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   Table of Contents - Current issue
November-December 2019
Volume 8 | Issue 6
Page Nos. 357-434

Online since Friday, December 13, 2019

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Artificial intelligence in pancreatic cancer: Toward precision diagnosis p. 357
Irina M Cazacu, Anca Udristoiu, Lucian Gheorghe Gruionu, Andreea Iacob, Gabriel Gruionu, Adrian Saftoiu
DOI:10.4103/eus.eus_76_19  PMID:31854344
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What should be known prior to performing EUS exams? (Part II) p. 360
Christoph F Dietrich, Paolo Giorgio Arcidiacono, Barbara Braden, Sean Burmeister, Silvia Carrara, Xinwu Cui, Milena Di Leo, Yi Dong, Pietro Fusaroli, Uwe Gottschalk, Andrew J Healey, Michael Hocke, Stephan Hollerbach, Julio Iglesias Garcia, André Ignee, Christian Jürgensen, Michel Kahaleh, Masayuki Kitano, Rastislav Kunda, Alberto Larghi, Kathleen Möller, Bertrand Napoleon, Kofi W Oppong, Maria Chiara Petrone, Adrian Saftoiu, Rajesh Puri, Anand V Sahai, Erwin Santo, Malay Sharma, Assaad Soweid, Siyu Sun, Anthony Yuen Bun Teoh, Peter Vilmann, Hans Seifert, Christian Jenssen
DOI:10.4103/eus.eus_57_19  PMID:31571619
In “What should be known prior to performing EUS exams, Part I,” the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?
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Therapeutic EUS: New tools, new devices, new applications Highly accessed article p. 370
Barbara Braden, Vipin Gupta, Christoph Frank Dietrich
DOI:10.4103/eus.eus_39_19  PMID:31417067
Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.
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Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: A systematic review and meta-analysis p. 382
Babu P Mohan, Mohammed Shakhatreh, Rajat Garg, Ravishankar Asokkumar, Mahendran Jayaraj, Suresh Ponnada, Udayakumar Navaneethan, Douglas G Adler
DOI:10.4103/eus.eus_27_19  PMID:31249163
Franseen-tip and Fork-tip needles have been widely used in EUS guided fine-needle biopsy (FNB) of solid organs. There is conflicting data on the performance of these needles and unanswered questions on the ideal number of needle-passes and the requirement of an onsite cytopathologist (ROSE). We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of Forktip and Franseen-tip needles in EUS-FNB of solid organs. The primary outcome was to estimate and compare the pooled rates of diagnostic-yield. A subgroup analysis compared the outcomes based on the number of needle-passes and the availability of ROSE. A total of 23 study-arms were available for analysis. The pooled rate of diagnostic yield with Fork-tip needle was 92.8% (95% CI 85.3 - 96.6, I2 = 73.1) and the pooled rate of diagnostic yield with Franseen-tip needle was 92.7% (95% CI 86.4 - 96.2, I2 = 88.4).
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Recognizing intrapancreatic accessory spleen via EUS: Interobserver variability p. 392
Grace E Kim, John D Morris, Naveen Anand, Fedele DePalma, Bruce D Greenwald, Raymond E Kim, Jeffery Laczek, Woo Jung Lee, Ioannis Papadopoulas, Lance Uradomo, Patrick Young, Peter E Darwin
DOI:10.4103/eus.eus_35_19  PMID:31417068
Background and Objective: Accessory spleen (AS) may be encountered as an intrapancreatic lesion on EUS. This can look similar to other pancreatic pathologies and may lead to unnecessary interventions. The goal of this study was to evaluate the accuracy of EUS in distinguishing intrapancreatic AS (IPAS) from other pancreatic lesions. Materials and Methods: Twelve sets of endoscopic images of the spleen and various pancreatic lesions confirmed on histology or cytology were gathered. Ten endosonographers were asked to characterize and identify the lesions. The responses were analyzed via Excel and the interobserver agreement was analyzed using Gwet's agreement coefficient statistic via Stata I/C v15. Results: In our sample, the interobserver agreement was 0.37 (−+1–1; 0–0.2 poor, 0.2–0.4 fair, 0.4–0.6 moderate, 0.6–0.8 substantial, and 0.8–1.0 almost perfect) for determining whether or not the pancreatic lesion is IPAS. The reviewers were able to correctly determine IPAS endosonographically with a sensitivity of 77%, specificity of 74%, and positive and negative predictive values of 50% and 92%, respectively. Conclusion: There is a moderate-to-substantial interobserver agreement in describing the sonographic characteristics of the pancreatic lesions, such as the shape, echogenicity compared to spleen, echotexture, and border of the lesions. However, the interobserver agreement is only fair when deciding if the pancreatic lesion is an IPAS. The similar profile of IPAS and pancreatic neuroendocrine tumor could confound the diagnosis of IPAS, thus contributing to the decreased interobserver agreement. This study demonstrates that EUS criteria alone are not accurate for IPAS diagnosis. Fine-needle aspiration (FNA) may be required for a confirmatory diagnosis.
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Long-term outcomes of EUS-guided transluminal stent deployment for benign biliary disease: Multicenter clinical experience (with videos) p. 398
Takeshi Ogura, Mamoru Takenaka, Hideyuki Shiomi, Daisuke Goto, Takashi Tamura, Takeshi Hisa, Hironari Kato, Nobu Nishioka, Kosuke Minaga, Atsuhiro Masuda, Takumi Onoyama, Masatoshi Kudo, Kazuhide Higuchi, Masayuki Kitano
DOI:10.4103/eus.eus_45_19  PMID:31552912
Background and Objectives: Biliary drainage (BD) under EUS guidance is usually indicated for malignant biliary obstruction. Recently, EUS-guided transluminal treatment has been applied to benign biliary disease (BBD). This multicenter retrospective study evaluated the clinical impact of EUS-guided transluminal stent deployment for BBD with long-term follow-up. Patients and Methods: This retrospective study investigated patients treated between September 2015 and October 2016 at participating hospitals in the therapeutic endoscopic group. The inclusion criteria comprised complications with BBD obstructive jaundice or cholangitis and failed endoscopic retrograde cholangiopancreatography or inaccessible ampulla of Vater. Results: Twenty-six patients underwent EUS-guided transluminal stent deployment. Indications for EUS-guided transluminal stent deployment comprised anastomotic biliary stricture (n = 17), bile duct stones (n = 5), inflammatory biliary stricture (n = 3), and acute pancreatitis prevention (n = 1). Thirteen of these 26 patients underwent scheduled reintervention, with technical success achieved in all 13 patients. None of the deployed stents became dysfunctional. Among the 13 patients who underwent reintervention on demand, stents had become dysfunctional in six patients (stent patency: 48, 90, 172, 288, 289, and 608 days). Reintervention was successfully performed in all patients. During follow-up (median, 749 days), severe adverse events were not seen in any patients. Conclusion: We concluded that EUS-guided transluminal stent deployment for BBD is feasible and safe. Because metal stent dysfunction was more frequent when deployed on demand, such stents should be exchanged for plastic stents in a scheduled manner if a metal stent is used.
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Determining factors of endobronchial ultrasound-guided transbronchial needle aspiration specimens for lung cancer subtyping and molecular testing p. 404
Yujun Zhang, Fangfang Xie, Xiaowei Mao, Xiaoxuan Zheng, Ying Li, Lei Zhu, Jiayuan Sun
DOI:10.4103/eus.eus_8_19  PMID:31670289
Objective: This study is to explore the determining factors for testing epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) fusion after subtyping by immunohistochemistry (IHC) using samples obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Materials and Methods: Patients suspected with advanced lung cancer were performed EBUS-TBNA without rapid on-site evaluation(ROSE) from January 2015 to March 2016 in Shanghai Chest Hospital. All samples diagnosed as lung cancer by histopathology underwent IHC to identify subtypes. EGFR mutation and ALK fusion were tested in adenocarcinoma and non-small-cell lung cancer-not otherwise specified (NSCLC-NOS) using remnant tissue samples. Results: A total of 453 patients were diagnosed with lung cancer, including 44.15% (200/453) with adenocarcinoma and 11.04% (50/453) with NSCLC-NOS. With the average passes of 3.41 ± 0.68, samples obtained from EBUS-TBNA were adequate for performing EGFR mutation and ALK fusion gene analysis in 80.4% (201/250) of specimens after routine IHC. On univariate analysis, successful molecular testing was associated with passes per lesion (P = 3.80E-05), long-axis diameters (P = 6.00E-06) and short-axis diameters (P = 4.77E-04), and pathology subtypes of lesions (P = 3.00E-03). Multivariate logistic regression revealed that passes per lesion (P = 1.00E-03), long-axis diameters (P = 3.50E-02), and pathology subtypes (P = 8.00E-03) were independent risk factors associated with successful molecular testing. Conclusions: With at least three passes of per lesion, EBUS-TBNA is an efficient method to provide adequate samples for testing of EGFR mutation and ALK gene arrangement following routine histopathology and IHC subtyping. Determining factors associated with successful pathology subtyping and molecular testing using samples obtained by EBUS-TBNA are passes of per lesion, long-axis diameter, and pathology subtypes. During the process of EBUS-TBNA, selecting larger lymph nodes and the puncturing at least 3 passes per lesion may result in higher success rate in lung cancer subtyping and molecular testing.
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Prospective comparison study of franseen needle and standard needle use for pancreatic lesions under EUS guidance p. 412
Jun Matsuno, Takeshi Ogura, Yoshitaka Kurisu, Akira Miyano, Miyuki Imanishi, Saori Onda, Atsushi Okuda, Nobu Nishioka, Kazuhide Higuchi
DOI:10.4103/eus.eus_38_19  PMID:31417069
Background and Objectives: A needle with Franseen geometry for fine needle aspiration is now available. However, no reports have described prospective evaluations of the Franseen needle or comparisons with the standard needle. The aim of this comparative prospective study was to evaluate the histological diagnostic yield of the Franseen needle and the standard needle using tissue obtained by a single pass of each for the same lesion. Patients and Methods: In this study, only tissue obtained by the first pass using the Franseen needle was used. As a comparison group, only tissue obtained from the same lesion by a second pass using the standard needle was used. Evaluation of the histological diagnostic yield of the needles was based on tissue obtained by each single pass with no additional passes. Results: A total of 56 patients were prospectively enrolled. The rate of adequate tissue obtained was significantly higher for the Franseen needle than for the standard needle (89.4% vs. 62.5%, respectively; P < 0.05). The sensitivity and accuracy of the Franseen needle were 80.7%, and 84.6%, respectively, while those for the standard needle were 59.6% and 63.5%, respectively. Conclusions: The Franseen needle offers a better rate of obtaining adequate tissue and higher diagnostic accuracy than the standard needle.
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An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions p. 418
Nan Ge, William R Brugge, Payal Saxena, Anand Sahai, Douglas G Adler, Marc Giovannini, Nonthalee Pausawasdi, Erwin Santo, Girish Mishra, William Tam, Mitsuhiro Kida, Jose G de la Mora-Levy, Malay Sharma, Muhammad Umar, Akio Katanuma, Linda Lee, Pramod Kumar Garg, Mohamad Ali Eloubeidi, Ho Khek Yu, Isaac Raijman, Brenda Lucia Arturo Arias, Manoop Bhutani, Silvia Carrara, Praveer Rai, Shuntaro Mukai, Laurent Palazzo, Christoph F Dietrich, Nam Q Nguyen, Mohamed El-Nady, Jan Werner Poley, Simone Guaraldi, Evangelos Kalaitzakis, Luis Carlos Sabbagh, Jose Lariño-Noia, Frank G Gress, Yuk-tong Lee, Surinder S Rana, Pietro Fusaroli, Michael Hocke, Vinay Dhir, Sundeep Lakhtakia, Thawee Ratanachu-ek, AS Chalapathi Rao, Peter Vilmann, Hussein Hassan Okasha, Atsushi Irisawa, Ryan Ponnudurai, Ang Tiing Leong, Everson Artifon, Julio Iglesias-Garcia, Adrian Saftoiu, Alberto Larghi, Carlos Robles-Medranda, Siyu Sun
DOI:10.4103/eus.eus_61_19  PMID:31552915
Background and Objectives: Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field. Methods: A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Results: Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year. Conclusion: Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.
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Difficult pyloric intubation during EUS: Forward viewing echoendoscope to the rescue (with videos) p. 428
Phonthep Angsuwatcharakon, Ben S Singh, Irina M Cazacu, Brian R Weston, Manoop S Bhutani
DOI:10.4103/eus.eus_64_19  PMID:31854345
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Thyroid ectopia of the liver: An unusual diagnosis with contrast-enhanced EUS (with video) p. 430
Dario Ligresti, Alberto Martino, Maria Barbaccia, Sergio Calamia, Ilaria Tarantino, Luca Barresi, Antonino Granata, Salvatore Gruttadauria, Rosa Liotta, Mario Traina
DOI:10.4103/eus.eus_71_19  PMID:31854346
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Macroscopic on-site evaluation during EUS-fine needle biopsy with combined cyto and histological analysis may overcome the need of rapid on-site evaluation p. 432
Pedro Costa-Moreira, Filipe Vilas-Boas, Pedro Moutinho-Ribeiro, Guilherme Macedo
DOI:10.4103/eus.eus_72_19  PMID:31854347
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Erratum: The borderline resectable/locally advanced pancreatic ductal adenocarcinoma staging with computed tomography/magnetic resonance imaging p. 434

DOI:10.4103/2303-9027.244803  PMID:31854348
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