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   Table of Contents - Current issue
Coverpage
September-October 2019
Volume 8 | Issue 5
Page Nos. 283-355

Online since Tuesday, October 1, 2019

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EDITORIAL  

Rapid on-site evaluation (ROSE) with EUS-FNA: The ROSE looks beautiful p. 283
Fei Yang, Enshuo Liu, Siyu Sun
DOI:10.4103/eus.eus_65_19  
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TRAINING COURSES Top

Radial-scanning flexible EUS of the anorectum and pelvis p. 288
Vikram Bhatia, Masahiro Tajika, Susumu Hijioka
DOI:10.4103/eus.eus_33_19  PMID:31249168
Standard upper gastrointestinal flexible radial EUS probes are well suited for imaging of anorectum and pelvic pathologies. They offer multiple advantages over conventional rigid rectal probes. The current transducers allow imaging at variable frequencies and are Doppler capable. The flexible shaft of the endoscope and optics allow easy probe insertion to upper sigmoid. Flexible radial EUS probes allow evaluation of anal sphincter complex, rectosigmoid mural pathologies, and paraluminal pelvic disorders. A thorough understanding of pelvic anatomy and image orientation is the key to appropriate image interpretation. In this review, we describe the principles and methodology for anorectal EUS imaging using a flexible radial EUS probe.
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REVIEW ARTICLES Top

EUS versus percutaneous management of postoperative pancreatic fluid collection: A systematic review and meta-analysis p. 298
Babu P Mohan, Mohammed Shakhatreh, Sushma Dugyala, Vaishali Geedigunta, Ashwini Gadalay, Parul Pahal, Suresh Ponnada, Kapil Nagaraj, Ravishankar Asokkumar, Douglas G Adler
DOI:10.4103/eus.eus_18_19  PMID:31249160
Postoperative pancreatic fluid collection (POPFC) is an important complication following abdominal surgery. POPFC causes significant morbidity and mortality. Management options are time-consuming and severely affect patient's quality of life. Surgical and/or percutaneous drainage (PCD) is the traditional mainstay of treatment. Studies have shown that EUS could have a role to play in the management of POPFC. Data are limited in the comparison of clinical outcomes with EUS as compared to PCD to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, LILACS, and Web of Science databases (earliest inception through September 2018) to identify studies that reported on the clinical outcomes of EUS and PCD in the management of POPFC. The goals were to estimate and compare the pooled rates of technical success, clinical success, adverse events, and POPFC recurrence with EUS and PCD. A total of 13 studies were included in the analysis. Ten studies (239 patients) used EUS and 6 studies (267 patients) used PCD in the management of POPFC. The pooled rate of clinical success with EUS was 93.2% (95% confidence interval [CI] 88.2–96.2, I2 = 0) and with PCD was 79.8% (95% CI 70–87, I2 = 74). The difference was statistically significant, P = 0.002. Recurrence rate was significantly lower with EUS as compared to PCD (9.4%: 95% CI 5.2–16.5 vs. 25.7%: 95% CI 24.3–41.7; P = 0.02). Pooled rates of technical success and adverse events were similar with EUS and PCD. Our meta-analysis shows that EUS has significantly better clinical outcomes, in terms of clinical success and disease recurrence, in the management of POPFC as compared to PCD.
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The incremental benefit of EUS for the identification of malignancy in indeterminate extrahepatic biliary strictures: A systematic review and meta-analysis p. 310
Albert Chiang, Martin Theriault, Misbah Salim, Paul Damien James
DOI:10.4103/eus.eus_24_19  PMID:31249170
This systematic review aims to assess the literature to determine the impact of EUS for diagnosing malignancy among indeterminate extrahepatic biliary strictures. A systematic review was performed using MEDLINE, EMBASE, Cochrane, and conference proceedings from inception to July 2016. Pooled results were calculated using random-effects model, and heterogeneity was explored using stratified meta-analysis and meta-regression. The main outcome was the incremental benefit of EUS (IBEUS) for the diagnosis of malignancy among patients who have undergone ERCP with brushing cytology for extrahepatic biliary strictures. Of 3131 identified citations, ten met the inclusion criteria and were included in the final analyses (study periods from 1998 to 2014). Pooled IBEUS estimate with the adjustment for publication bias was 14% (95% confidence interval, 7%–20%). Individual studies demonstrate that the IBEUS is greater for distal biliary strictures or when an extrinsic mass is identified on cross-sectional imaging. EUS increases the identification of malignancy for indeterminate biliary strictures following a nondiagnostic ERCP, particularly those that are distal or related to extrinsic compression.
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ORIGINAL ARTICLES Top

An assessment of the yield of EUS in patients referred for dilated common bile duct and normal liver function tests p. 318
Matthew S Kaspy, Galab M Hassan, Sarto C Paquin, Anand V Sahai
DOI:10.4103/eus.eus_21_19  PMID:31249161
Objective: This study aims to determine the yield of EUS in patients with common bile duct (CBD) dilation and normal liver function tests (LFTs). Materials and Methods: Between October 2000 and December 2016, all patients referred for EUS for unexplained CBD dilatation (CBD ≥7 mm), with normal aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin and no history of sphincterotomy, were eligible. Linear-array EUS was performed by one of the two experienced endosonographers. Data were extracted from a prospectively maintained database. Results: Of 29,920 upper gastrointestinal EUS procedures performed, 840/29,920 (3%) were for unexplained CBD dilation. Of 840 patients, 199 (24%) had normal LFTs, 99% were Caucasian, 46% had biliary-type abdominal pain, and 41% were postcholecystectomy. EUS diagnosed choledocholithiasis (CDL) or sludge in 18/199 (9%) patients (7/18 had CBD sludge only). No other pathology was diagnosed. Of 18 CDL patients, 15 (83%) had an intact gallbladder, and all 15 patients had cholelithiasis. The frequency of CDL or sludge in postcholecystectomy patients was only 3.7% (3/82); none of these patients were younger than 69 years of age. Regression analyses showed no associations between EUS diagnosis of CDL or sludge and biliary-type abdominal pain, other symptoms, sex, or race. Each additional year of age was associated with an increase in the risk of CDL or sludge by a factor of 1.05 (odds ratio: 1.05; P = 0.034). Summary: In patients with CBD dilation and normal LFTs, the only significant pathology identified is CBD stones or sludge (almost exclusively in elderly patients with cholelithiasis). Conclusion: EUS should be avoided in patients with dilated bile ducts and normal LFTs, especially if under 65 years of age and postcholecystectomy.
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Prospective, multicenter, observational study of tissue acquisition through EUS-guided fine-needle biopsy using a 25G Franseen needle p. 321
Ryo Sugiura, Masaki Kuwatani, Kei Yane, Yoko Taya, Hideyuki Ihara, Manabu Onodera, Kazunori Eto, Itsuki Sano, Taiki Kudo, Tomoko Mitsuhashi, Akio Katanuma, Naoya Sakamoto, Hokkaido Interventional EUS/ERCP study (HONEST) group
DOI:10.4103/eus.eus_66_18  PMID:30880724
Background: Recently, EUS-guided fine-needle biopsy (EUS-FNB) using a Franseen needle was developed for histological tissue acquisition. However, the yield of a 25G Franseen needle when acquiring histological core tissue has been unclear. Patients and Methods: We performed a prospective, multicenter, and observational cohort study that included 100 solid lesions scheduled for EUS-FNB using a 25G Franseen needle at eight centers in Hokkaido, Japan. Only EUS-FNB specimens acquired at the first pass were evaluated without a rapid on-site evaluation. The tissue acquisition rate, acquisition rate of an adequate specimen for histological assessment, the quality of tissue sample, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, and adverse events were evaluated. Results: We analyzed a total of 100 solid lesions in 100 patients. The patients were 57 males and 43 females with a median age of 70 years. The technical success rate was 100%. The tissue acquisition rate was 95.0%. The acquisition rate of an adequate specimen for histological assessment was 82.0%. The sensitivity, specificity, PPV, NPV, and diagnostic accuracy were 87.0%, 100%, 100%, 40.0%, and 88.0%, respectively. The adverse event rate was 1.0%, and it was reported in only one patient who had a moderate pancreatic fistula. Conclusions: EUS-FNB using the 25G Franseen needle was feasible, and adequate histological core tissue samples were acquired with this method.
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Evaluation of a new slim radial echoendoscope: A better option for an aging population p. 329
Pietro Fusaroli, Marta Serrani, Andrea Lisotti
DOI:10.4103/eus.eus_3_19  PMID:30880720
Background and Objectives: The radial echoendoscope is still widely used for the investigation of abnormalities in the gastrointestinal wall and for stone detection in the extrahepatic biliary tree. Due to aging patient population, EUS is frequently performed in fragile and elderly individuals. We aimed to compare the maneuverability and image quality of a new thin radial echoendoscope to the current one. Patients and Methods: This evaluation was conducted at a referral academic EUS center. The new radial echoendoscope has a thinner shaft and distal tube and a shorter bending section compared to the previous one. Patients referred for diagnostic EUS with a radial echoendoscope were enrolled. Indications included pancreaticobiliary disease, esophagogastric abnormalities, and neoplasms and rectal cancer staging. Results: We enrolled 177 patients (122 pancreaticobiliary, 48 esophagogastric, and 7 rectal cases). Overall, the new echoendoscope performed better than the previous model in terms of maneuverability during esophageal intubation and transition from the duodenal bulb to the second portion. On the other hand, pylorus traversing was comparable to the current radial echoendoscope. No loss in image quality was appreciated at predefined stations (esophagus, stomach, and duodenum) compared to the current model. On the other hand, image penetration depth in tissue harmonic mode was significantly improved with the new echoendoscope. Conclusions: A new thinner radial echoendoscope showed improved maneuverability compared to the existing version. Image quality was also improved thanks to increased penetration depth in the tissue harmonic mode. We speculate that this new echoendoscope may allow for safer and faster EUS examination, which may prove useful in an aging patient population.
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Pseudo solid-appearing pancreatic serous microcystic adenomas: Histologic diagnosis with the EUS core biopsy fork-tip needle p. 334
Erminia Manfrin, Claudia Perini, Serena Di Stefano, Laura Bernardoni, Alice Parisi, Luca Frulloni, Sokol Sina, Andrea Remo, Armando Gabbrielli, Stefano Francesco Crinò
DOI:10.4103/eus.eus_11_19  PMID:30924447
Background and Objectives: Despite rarely, serous cystic adenoma (SCA) can assume a pseudo-solid aspect mimicking other pancreatic neoplasm as neuroendocrine tumor. EUS-FNA cytology has low diagnostic accuracy due to the scant cellularity of the collected samples. Histological diagnosis is usually made after resection. Recently, end-cutting needles for EUS-fine-needle biopsy (EUS-FNB), which obtain tissue cores by penetrating the lesions, have been developed. We aimed to assess the capability of EUS-FNB with SharkCore™ needles in the preoperative diagnosis of serous cystic adenoma pseudo-solid-appearing on imaging (Sa-SCA). Materials and Methods: Between January 2016 and January 2018, data from consecutive adult patients, who were referred for EUS-FNB of a solid pancreatic lesion and were diagnosed with having SCA, were retrieved from a single-center institutional database. Results: Two patients were excluded because of microcystic aspect at EUS. Histological diagnosis of SCA was made by EUS-FNB in the remaining 7 patients (5 females; mean age of 62.5 years). Lesions (mean size of 19.8 mm) were hypervascular on cross-sectional imaging, slightly hyperdense magnetic resonance imaging with T2-weighted images can, and negative at 68Ga-somatostatin receptor positron emission tomography and 18fluoro-deoxyglucose positron emission tomography. EUS-FNB samples were judged adequate for a definitive diagnosis in all cases, achieving specimens suitable for histological evaluation and several ancillary stains. Histochemical positivity for periodic acid-Schiff (PAS) and PAS with diastase digestion was observed in 7/7 cases. Immunohistochemical positivity for α-inhibin (7/7), GLUT1 (6/6), MUC6 (5/5), and negativity for synaptophysin (7/7) and chromogranin A (2/2) favored SCA diagnosis. Conclusions: In the case of preoperative workup suspected for Sa-SCA, a “forward acquiring” needle could improve the rate of preoperative histological diagnosis.
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The impact of macroscopic on-site evaluation using filter paper in EUS-guided fine-needle biopsy p. 342
Dongwook Oh, Dong-Wan Seo, Seung-Mo Hong, Tae Jun Song, Do Hyun Park, Sang Soo Lee, Sung Koo Lee, Myung-Hwan Kim
DOI:10.4103/eus.eus_34_19  PMID:31268010
Background and Objectives: EUS-guided tissue acquisition with rapid on-site cytologic evaluation (ROSE) has been used to increase the diagnostic yield. However, ROSE is not available in many centers. To date, only a few studies have assessed the adequacy of histologic cores in macroscopic on-site evaluation (MOSE) during EUS-guided fine-needle biopsy (EUS-FNB). Blood contamination of histologic core specimens lowers the sample quality and the diagnostic yield. Therefore, we evaluated the efficacy of MOSE using filter paper to increase the adequacy of histologic core specimens while minimizing blood contamination. Materials and Methods: Seventy-nine consecutive patients with an intraabdominal mass underwent EUS-FNB between March 2017 and October 2018. Histologic specimens obtained using EUS-FNB were expelled onto filter paper, and the histologic procurement rate on MOSE was evaluated. Results: EUS-FNB using a 20-gauge Procore needle or a 22-gauge Acquire needle was successful in all patients. The mean number of needle passes was 2.8 ss0.8. Visible histologic cores were observed in 94.9% (75/79) of the patients. Blood-contaminated specimens with scanty histologic cores were obtained in 5.1% (4/79) of the patients. On microscopic examination, 92.4% (73/79) of the histologic samples were graded as optimal. The diagnostic accuracy, sensitivity, and specificity were 94.5%, 94.3%, and 100%, respectively. Mild postprocedural adverse events occurred in 2 patients (2.5%: n = 1, transient fever; n = 1, acute pancreatitis). Conclusions: MOSE using filter paper provided adequate histologic samples while minimizing blood contamination. MOSE can also increase the diagnostic accuracy when ROSE is not available.
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IMAGES AND VIDEOS Top

Successful retrieval of proximally migrated pancreatic duct stent by EUS-guided retrograde extrusion through the papilla p. 348
Surinder Singh Rana, Ravi Sharma, Rajesh Gupta
DOI:10.4103/eus.eus_30_19  PMID:31249166
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EUS-guided botulinum toxin injection into the pyloric sphincter for the treatment of gastroparesis p. 350
Manoop S Bhutani
DOI:10.4103/eus.eus_22_19  PMID:31249162
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Antegrade stenting combined with hepaticogastrostomy using a 5.4-Fr novel ultra-slim metallic stent and dedicated stent under EUS guidance (with video) p. 352
Hiroshi Kawakami, Yoshimasa Kubota, Tesshin Ban
DOI:10.4103/eus.eus_40_19  PMID:31441449
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Primary pancreatic actinomycosis: A case report and literature review p. 354
Salvatore Magrž, Danilo Paduano, Mariangela Cappai, Valeria Pollino
DOI:10.4103/eus.eus_63_19  
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