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   Table of Contents - Current issue
Coverpage
January-February 2020
Volume 9 | Issue 1
Page Nos. 1-70

Online since Thursday, February 13, 2020

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EDITORIAL  

Evidence-based recommendations for establishing and implementing an EUS program: Recommendations for sustainable success and improved clinical outcomes across the continuum of care p. 1
Anand V Sahai, Paul D James, Michael J Levy, Gregory Monkewich, Jonathan Wyse
DOI:10.4103/eus.eus_2_20  
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REVIEW ARTICLES Top

Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis Highly accessed article p. 6
Thomas R McCarty, Ahmad Najdat Bazarbashi, Kelly E Hathorn, Christopher C Thompson, Marvin Ryou
DOI:10.4103/eus.eus_37_19  PMID:31417066
Cyanoacrylate (CYA), coil embolization, and/or combination thereof are available EUS-guided therapies for the treatment of†Š gastric varices (GV). The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the comparative effectiveness of EUS-guided interventions for the treatment of GV. Individualized search strategies were developed for PubMed, EMBASE, and Cochrane Library databases, from inception through November 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This cumulative meta-analysis was performed using calculating pooled proportions. Measured outcomes included technical success, clinical success, adverse events, and rate of rebleeding or reintervention. Comparative subgroup analyses were performed for three treatment cohorts (EUS-guided CYA injection, EUS-guided coil embolization + CYA injection, and EUS-guided coil injection alone). Heterogeneity was assessed with I2 statistics. Eleven studies (n = 536 patients; 62.20% of males) were included. The mean age was 58.21 ± 4.15 years with an average follow-up of 12.93 ± 7.69 months. Overall technical success, clinical success, and adverse events for EUS treatments was 100% ([95% confidence interval [CI] 98–100]; I2 = 30.54%), 97% ([95% CI 92–100]; I2 = 59.99%), and 14% ([95% CI 6–23]; I2 = 82.23%), respectively. On subgroup analysis, EUS-guided CYA + coil embolization resulted in a better technical and clinical success compared to CYA alone (100% vs. 97%; P < 0.001 and 98% vs. 96%; P < 0.001) and coil embolization alone (99% vs. 97%; P < 0.001 and 96% vs. 90%; P < 0.001). CYA + coil embolization also resulted in lower adverse event rates compared to CYA alone (10% vs. 21%; P < 0.001), and comparable rates to coil embolization alone (10% vs. 3%; P = 0.057). EUS-guided treatment overall appears to be an effective and safe modality for GV. Among a variety of EUS-therapies available, EUS combination therapy with coil embolization + CYA injection appears to be a preferred strategy for the treatment of GV over EUS-based monotherapy.
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EUS-guided gastroenterostomy for the management of gastric outlet obstruction: A systematic review and meta-analysis p. 16
Umair Iqbal, Harshit S Khara, Yirui Hu, Vikas Kumar, Kashif Tufail, Bradley Confer, David L Diehl
DOI:10.4103/eus.eus_70_19  PMID:31898587
Gastric outlet obstruction (GOO) is characterized by epigastric pain and postprandial vomiting secondary to mechanical obstruction. Management of GOO is usually focused on alleviating the symptoms of obstruction and can be achieved by surgical gastrojejunostomy or enteral stenting. Recent studies have shown success with EUS-guided gastroenterostomy (EUS-GE) in the management of GOO but data is limited. We, therefore, conducted a meta-analysis to evaluate the safety and efficacy of EUS-GE in the management of GOO. A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to January 2019 to identify all studies that evaluate the efficacy and safety of EUS-GE in GOO. Our primary outcome was to evaluate technical success and clinical success. Secondary outcomes were to evaluate the need for reintervention and adverse events of the procedure. Twelve studies including 285 patients were included in the meta-analysis. Technical success was achieved in 266 patients with a pooled technical success of 92% (95% confidence interval [CI]: 88%–95%). Clinical success was achieved in 90% of the patients (95% CI: 85%–94%). Recurrence of symptoms or unplanned reintervention was needed in 9% of the patients (95% CI: 6%–13%) and adverse events were reported in 12% of the patients (95% CI: 8%–16%). The heterogeneity tests among studies were nonsignificant with I2 = 0. EUS-GE is a safe and efficacious treatment modality for the management of benign and malignant GOO. Larger prospective studies are needed to further evaluate its utility in GOO.
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RAPID COMMUNICATION Top

An open-label, single-arm pilot study of EUS-guided brachytherapy with phosphorus-32 microparticles in combination with gemcitabine +/- nab-paclitaxel in unresectable locally advanced pancreatic cancer (OncoPaC-1): Technical details and study protocol p. 24
Manoop S Bhutani, Jason B Klapman, Richard Tuli, Ghassan El-Haddad, Sarah Hoffe, Franklin C. L. Wong, Beth Chasen, David R Fogelman, Simon K Lo, Nicholas N Nissen, Andrew E Hendifar, Gauri Varadhachary, Matthew H. G. Katz, William D Erwin, Eugene J Koay, Eric P Tamm, Ben S Singh, Rutika Mehta, Robert A Wolff, Ashish Soman, Irina M Cazacu, Joseph M Herman
DOI:10.4103/eus.eus_44_19  PMID:31670288
Current treatment options for patients with unresectable locally advanced pancreatic cancer (LAPC) include chemotherapy alone or followed by chemoradiation or stereotactic body radiotherapy. However, the prognosis for these patients remains poor, with a median overall survival <12 months. Therefore, novel treatment options are needed. Currently, there is no brachytherapy device approved for pancreatic cancer treatment. Hereby, we present the protocol of a prospective, multicenter, interventional, open-label, single-arm pilot study (OncoPac-1, Clinicaltrial.gov-NCT03076216) aiming to determine the safety and efficacy of Phosphorus-32 when implanted directly into pancreatic tumors using EUS guidance, for patients with unresectable LAPC undergoing chemotherapy (gemcitabine ± nab-paclitaxel).
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ORIGINAL ARTICLES Top

Long-term safety and efficacy of ethanol retention therapy via percutaneous approach and/or EUS guidance for symptomatic large hepatic cysts (with video) p. 31
Dong Seok Lee, Sung Koo Lee, Dong-Wan Seo
DOI:10.4103/eus.eus_42_19  PMID:31571618
Background and Objectives: Ethanol retention therapy (ERT) under EUS guidance or a percutaneous approach is a safe treatment for large symptomatic hepatic cysts. However, reports on the long-term outcomes after ERT are very rare. Therefore, we aimed to evaluate the long-term outcomes of ERT in symptomatic large hepatic cysts. Materials and Methods: A total of 47 consecutive patients with large symptomatic hepatic cysts treated at the Asan Medical Center from April 2009 to October 2017 were analyzed. Thirty patients with right hepatic cysts were treated with ERT through a percutaneous approach, and 14 patients with left hepatic cysts were treated with ERT under EUS guidance. Three patients were treated with ERT using both methods. Results: Of the 47 patients, 43 (91%) showed complete regression and four (9%) showed partial regression on abdominal computed tomography. Recurrence of the cysts was not observed during the follow-up surveillance of a median of 66 months. Conclusions: Percutaneous catheter drainage-guided ERT and EUS-guided ERT, based on their favorable long-term outcomes, may be considered as first-line treatments in patients with large symptomatic hepatic cysts.
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DNA sequencing of cytopathologically inconclusive EUS-FNA from solid pancreatic lesions suspicious for malignancy confirms EUS diagnosis p. 37
Julie Isabelle Plougmann, Pia Klausen, Anders Toxvaerd, Armita Armina Abedi, Bojan Kovacevic, John Gásdal Karstensen, Tim Svenstrup Poulsen, Evangelos Kalaitzakis, Estrid Høgdall, Peter Vilmann
DOI:10.4103/eus.eus_36_19  PMID:31552911
Background and Objectives: EUS-FNA is inconclusive in up to 10%–15% of patients with solid pancreatic lesions (SPLs). We aimed to investigate whether supplementary genetic analyses with whole-exome sequencing add diagnostic value in patients with SPLs suspicious of malignancy but inconclusive EUS-FNA. Patients and Methods: Thirty-nine patients, who underwent EUS-FNA of an SPL were retrospectively included. Three groups were defined: 16 (41.0%) had suspected malignancy on EUS confirmed by cytology (malignant), 13 (33.3%) had suspected malignancy on EUS but benign cytology (inconclusive), and 10 (25.6%) had benign EUS imaging and cytology (benign). Areas with the highest epithelial cell concentrations were macro-dissected from the FNA smears from each patient, and extracted DNA was used for whole-exome sequencing by next-generation sequencing of a selected gene panel including 19 genes commonly mutated in cancer. Results: Pathogenic mutations in K-RAS, TP53, and PIK3CA differed significantly between the three groups (P < 0.001, P = 0.018, and P = 0.026, respectively). Pathogenic mutations in KRAS and TP53 were predominant in the inconclusive (54% and 31%, respectively) and malignant groups (81.3% and 50%, respectively) compared to the benign group (0%). Malignant and inconclusive diagnoses correlated strongly with poor overall survival (P < 0.001). Conclusion: Whole-exome sequencing of genes commonly mutated in pancreatic cancer may be an important adjunct in patients with SPLs suspicious for malignancy on EUS but with uncertain cytological diagnosis.
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EUS-guided biliary drainage for the management of benign biliary strictures in patients with altered anatomy: A single-center experience p. 45
Margherita Pizzicannella, Fabrice Caillol, Christian Pesenti, Erwan Bories, Jean Philippe Ratone, Marc Giovannini
DOI:10.4103/eus.eus_55_19  PMID:31552913
Background and Objectives: The management of benign biliary stricture in patients with altered anatomy secondary to surgery is challenging. Percutaneous transhepatic biliary drainage (BD) represents the standard therapy for benign biliary stricture, but it is associated with nontrivial morbidity rates. Despite the increasing application of guided BD (EUS-BD) for the management of malignant obstruction, its role in patients with benign biliary stricture is limited. This retrospective study aimed to evaluate the feasibility, safety, and clinical effectiveness of EUS-BD with multiple transanastomotic plastic stent treatment in patients with benign biliary stricture. Materials and Methods: This study included consecutive patients who underwent EUS-BD for benign biliary stenosis at our center. EUS-BD with fully covered self-expandable metal stent placement was performed first. When feasible, the stricture was treated by balloon dilation with the placement of a transanastomotic double-pigtail plastic stent. Scheduled procedures were repeated to remove the metal stent and replace the plastic stent to treat the stenosis. Technical success and adverse events (AEs) were assessed. Results: Twelve patients underwent EUS-BD for benign biliary strictures. Procedural and clinical successes were achieved in all patients (100%). Multistenting treatment was performed in 10/12 patients (77%). The median number of stents inserted, maximum number of stents placed, and median time of retreatment were 2.4 (range: 1–4), 4, and 3.4 (range: 1–7), respectively. In total, 4/12 patients (33.3%) developed AEs that required endoscopic interventions (Clavien-Dindo Grade III). Conclusions: EUS-BD with the placement of multiple trans-stenosis plastic stents is a safe, feasible, and well-tolerated alternative for the management of benign biliary stricture in patients with surgery-altered anatomy. Long-term follow-up is necessary to support our results.
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Quality of life impact of EUS in patients at risk for developing pancreatic cancer p. 53
Irina M Cazacu, Adriana A Luzuriaga Chavez, Tito R Mendoza, Wei Qiao, Ben S Singh, Raza H Bokhari, Adrian Saftoiu, Jeffrey H Lee, Brian Weston, John R Stroehlein, Michael P Kim, Matthew H G. Katz, Anirban Maitra, Florencia McAllister, Manoop S Bhutani
DOI:10.4103/eus.eus_56_19  PMID:31552914
Background and Objectives: The current knowledge about the psychological impact of pancreatic cancer (PC) screening is limited. We aimed to assess the changes in quality of life (QOL) and level of distress after undergoing EUS in individuals with pancreatic cystic lesions (PCLs) and in patients at high risk for PC based on genetic and familial factors. Methods: Eighty patients with PCL and/or increased genetic or familial risk for PC who had undergone EUS were contacted. Fifty percent of those patients successfully completed the brief profile of mood states (POMS) and the linear analog scale assessment (LASA) QOL questionnaires to evaluate their pre/post-EUS overall QOL. The effect size (ES) method was used to assess clinically meaningful changes in the scores. Results: There was a significant difference in patients' overall QOL scores before and after the EUS procedure (LASA, mean difference 0.73, standard deviation (SD) 1.76, ES 0.58, P < 0.01; brief POMS, mean difference −5.46, SD −6.72, ES 0.81, P < 0.01). Conclusions: QOL of patients with PCL or increased risk factors for PC is significantly improved after a EUS/EUS-guided fine-needle aspiration (FNA) negative for malignancy.
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Transcutaneous partial pressure of carbon dioxide monitoring during EUS-guided drainage of peripancreatic fluid collections using carbon dioxide insufflation: A prospective study p. 59
Liu Xiang, Sun Jiayi, Wang Guoxin, Ge Nan, Wang Sheng, Guo Jintao, Sun Siyu
DOI:10.4103/eus.eus_32_19  PMID:31249167
Background: Carbon dioxide (CO2) insufflation has become more commonly used in EUS-guided interventions in recent years. However, there is a paucity of information regarding methods by which to monitor in vivo CO2 levels. This study aimed to assess the feasibility of a novel noninvasive method to monitor transcutaneous partial pressure of CO2 [INSIDE:1] levels during EUS-guided drainage of peripancreatic fluid collections (PFCs). The safety of CO2 insufflation in EUS-guided interventions was also investigated. Patients and Methods: Patients who underwent EUS-guided PFC drainage between September 2015 and December 2016 at Shengjing Hospital of China Medical University were prospectively enrolled in this study. [INSIDE:2] was measured in all patients using a noninvasive sensor throughout the procedure. Results: There were 25 patients eligible to be included in this study. The mean procedure time was 53.1 min. The mean [INSIDE:2] level was 40 ± 4 mmHg and 48 ± 5 mmHg before and after the procedure, respectively. The mean peak [INSIDE:2] during the procedure was significantly higher at 53 ± 6 mmHg (P < 0.0001). No complications associated with CO2 insufflation such as CO2 narcosis, gas embolism, or arrhythmias were encountered. Conclusions: [INSIDE:2] monitoring can accurately reflect the level of [INSIDE:3] continuously and noninvasively. CO2 insufflation is safe for patients undergoing relatively complicated EUS-guided drainage of PFCs.
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IMAGES AND VIDEOS Top

Endoscopic management of metal stent migration after walled-off necrosis drainage for 3 months (with video) p. 66
Chun-Ping Zhu, Jie-Fang Guo, Yun-Feng Wang, Tao Han, Yang-Yang Qian, Jie Chen, Zhao-Shen Li
DOI:10.4103/eus.eus_58_19  
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LETTER TO EDITOR Top

Contrast-enhanced EUS in the evaluation of peritoneum and omentum in undiagnosed ascites p. 69
Surinder Singh Rana, Ravi Sharma, Radhika Srinivasan, Manish Rohilla, Rajesh Gupta
DOI:10.4103/eus.eus_78_19  
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