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   Table of Contents - Current issue
Coverpage
July-August 2020
Volume 9 | Issue 4
Page Nos. 209-276

Online since Friday, August 14, 2020

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EDITORIAL  

The use of EUS-microforceps biopsies to evaluate patients with pancreatic cystic lesions p. 209
Arcelia Guerson, Sammy Ho
DOI:10.4103/eus.eus_32_20  PMID:32594027
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CONSENSUS Top

Expert panel consensus statement on the applications and precaution strategies of bronchoscopy in patients with COVID-19 p. 211
Huizhen Yang, Huidong Chen, Baoan Gao, Weining Xiong, Xiaoju Zhang, D Kyle Hogarth, Jiayuan Sun, Mingyao Ke, Felix J. F. Herth
DOI:10.4103/eus.eus_45_20  PMID:32769235
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus with higher transmissibility compared with SARS coronavirus (SARS-CoV) and Middle East respiratory distress syndrome coronavirus. Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is an unprecedented global crisis that has not been experienced, which is still disrupting health systems, economies, and societies around the world by the rapid spread. Bronchoscopy plays an important role in diagnosis and therapy of pulmonary diseases, especially in patients with severe pulmonary infection, however, application of bronchoscopy in patients suspected or confirmed SARS-CoV-2 infection is extremely limited for the potential airborne transmission from aerosol generated during the procedure. This consensus statement was completed by expert panel of Interventional & Minimally Invasive Respiratory Committee of China Medical Education Association, and the issues were summarized as seven key topics to define the indications of bronchoscopy and matters needing attentions on the bronchoscopy procedures in patients with COVID-19, as well as the protective precaution strategies to avoid nosocomial SARS-CoV-2 infection.
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REVIEW ARTICLES Top

EUS-guided through-the-needle microbiopsy of pancreatic cysts: Technical aspects (with video) p. 220
Bojan Kovacevic, Evangelos Kalaitzakis, Pia Klausen, Lene Brink, Hazem Hassan, John G Karstensen, Peter Vilmann
DOI:10.4103/eus.eus_12_20  PMID:32611847
Pancreatic cystic lesions are frequently encountered and diagnostically challenging as some of the cysts may have malignant potential (mucinous) while others are completely benign (serous). EUS-guided through-the-needle biopsy (EUS-TTNB) of the cyst wall has recently been introduced as an alternative to cyst fluid cytology. Several studies have shown that microbiopsies outperform cytology in terms of distinction between mucinous and nonmucinous lesions, but also in determining the specific cyst diagnosis. However, little is known about the technical aspects of tissue sampling with TTNB. Herein, we summarize our experience with the procedure in a tertiary referral center and discuss indications, technical aspects, and safety of the procedure. Most adverse events (AEs) associated with the procedure are mild, but there is emerging evidence that the rate of postprocedural pancreatitis is higher compared to standard fine-needle aspiration. The added diagnostic yield should therefore be placed in perspective with an increased risk of AEs. Prospective studies are warranted to fully identify which patient groups could benefit from EUS-TTNB.
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EUS tissue acquisition: From A to B p. 225
Bojan Kovacevic, Peter Vilmann
DOI:10.4103/eus.eus_21_20  PMID:32655082
EUS-guided tissue acquisition (EUS-TA) has made rapid development since its introduction in the early 1990s. The technique is widely accepted and invaluable for staging and diagnosis of a variety of upper gastrointestinal and mediastinal lesions. Fine-needle aspiration (FNA) has long been the gold standard, but due to its limitations such as the inability to retain stroma and associated cellular architecture, novel biopsy needles (FNB) were designed. Overall, FNA and FNB needles perform seemingly equally in terms of diagnostic accuracy, however, the second-generation FNB needles require less passes. The third-generation FNB needles (crown-cut needle types) seem to be preferable to FNA needles as well as to the second-generation FNB needles, when larger histological specimens and preserved tissue architecture are required. EUS-TA is constantly under development, and new applications of this technique include tumor risk stratification according to its genetic profile as well as minimally invasive creation of patient-derived organoids, hallmarks of personized medicine. It remains yet to be shown, whether these applications will lead to a decisive shift from aspiration to biopsy, i.e., from A to B.
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ORIGINAL ARTICLES Top

Validation of a novel swine model for training in EUS-FNA (with videos) p. 232
Jun Li, Jun Yao, Shiyu Li, Shimin Wang, Wei Zhou, Zhendong Jin, Kaixuan Wang
DOI:10.4103/eus.eus_13_20  PMID:32675460
Background and Objectives: EUS-FNA is applied widely in clinical practice, but there remains a lack of authentic training models. The present study aimed to develop a novel swine training model and to perform a preliminary assessment of its feasibility and efficacy. Materials and Methods: To create an internal lesion-like target, empty shells of iodine-125 seeds were implanted into the caudate lobe of the liver in Bama minipigs. A training program involving 10 trainees was subsequently carried out, in which a total of 60 needlings were performed, composed of 6 for each trainee obtained during two training steps. Comparisons of procedure-related variables were conducted between the two. Trainees completed a questionnaire to assess their basic endoscopic experiences and reasonability of the model. Results: A target region of 2.0 cm × 2.0 cm in diameter was successfully established on the caudate lobe in all implanted pigs. In the training program, the average procedure time decreased from the first to the second step and the average time for the total 30 needlings' obtainment was significantly shorter for the second training step (23.8 ± 4.5 min vs. 40.9 ± 9.0 min, P < 0.001). For the second step, there was also a significant improvement in total success rate (86.7% vs. 56.7%, P = 0.020) and accuracy rate (76.7% vs. 43.3%, P = 0.017). All trainees scored the effectiveness of the model highly and all reported improved confidence after the training. Conclusion: This novel swine training model could authentically mimic clinical EUS-FNA, providing an effective in vivo practice tool for novices before clinical practice.
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Sarcopenia represents a negative prognostic factor in pancreatic cancer patients undergoing EUS celiac plexus neurolysis p. 238
Antonio Facciorusso, Matteo Antonino, Nicola Muscatiello
DOI:10.4103/eus.eus_24_20  PMID:32611849
Background and Objectives: Increasing evidence suggests a prognostic role of sarcopenia in pancreatic cancer patients. The aim of this study was to assess the influence of sarcopenia on treatment outcomes after EUS-guided celiac plexus neurolysis (CPN). Materials and Methods: Data regarding 215 patients treated with EUS CPN between 2004 and 2019 were reviewed. Determination of body composition was conducted on contrast-enhanced CT scan, and pain response was considered as the primary outcome. Univariate and multivariate logistic regression was performed to identify the independent predictors of pain response. Results: Treatment was successful in 187 patients (86.9%). The median age was 62 (range 39–84) years, and most patients were male (61.8%). Of the whole study population, 139 patients (64.6%) were defined as sarcopenic, of which 116 (83.4%) responded to the treatment and 5 (3.5%) experienced a complete response. Among 76 nonsarcopenic participants, 71 (93.4%) responded to the treatment and 22 (28.9%) obtained a complete response (P = 0.03 and <0.001, respectively). The median duration of pain relief was 8 (2–10) and 15 (8–16) weeks in sarcopenic and nonsarcopenic patients, respectively (P = 0.01). The median overall survival after neurolysis was 4 months (3–5) in sarcopenic participants and 7 months (6–8) in nonsarcopenic participants (P = 0.05). Tumoral stage, interval from the diagnosis to treatment, and sarcopenia resulted as significant prognostic factors for treatment response both in univariate and multivariate regression analyses. No severe treatment-related adverse events were reported in the whole study population, with no difference between the two groups. Conclusions: Sarcopenia represents a predictor of poorer response to EUS CPN.
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Novel swine biliary dilatation model with temperature-controlled endobiliary radiofrequency ablation: An effective tool for training in EUS-guided biliary drainage p. 245
Dongwook Oh, Dario Ligresti, Dong-Wan Seo
DOI:10.4103/eus.eus_34_20  PMID:32675461
Background and Objectives: EUS-guided biliary drainage (EUS-BD) is used as a rescue method after failed endoscopic retrograde cholangiography. However, it is considered a technically challenging procedure. Phantoms and ex vivo biliary dilatation models have been used to enhance the learning of EUS-BD, but they provide a limited level of realism. The aim of this study was to develop a swine biliary dilatation model that uses temperature-controlled endobiliary radiofrequency ablation (EB-RFA) for training in EUS-BD. Materials and Methods: Target temperature-controlled (80°C at 7 or 10 W for 60–120 s) EB-RFA was performed on seven pigs. Two weeks after the EB-RFA, EUS examination was performed to confirm biliary dilatation, and EUS-BD was then attempted by performing a hepaticogastrostomy (HGS) or cholecystogastrostomy (CGS). Results: Twelve sessions of EB-RFA (11 at the distal common bile duct [CBD] and one at the proximal CBD) were successfully performed on the seven pigs. There were no immediate postprocedural adverse events. Two weeks after the procedures, clinical signs of jaundice were observed in all the pigs. EUS examination revealed massive intrahepatic and extrahepatic biliary dilatations in all the pigs, and EUS-BD was attempted in the same session. HGS was performed on six pigs. Technical success was achieved in five of the six pigs (83.3%). Technical failure in HGS occurred during the stent deployment, and CGS was successfully performed on one pig. Conclusions: Our study shows that EB-RFA is an effective minimally invasive method for creating biliary dilatation models. It may be considered suitable for training in EUS-BD.
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The relationship between the interruption of the lower esophageal sphincter and relief of dysphagia after per-oral endoscopic myotomy for achalasia p. 252
Sheng Wang, Xiang Liu, Nan Ge, Guoxin Wang, Jintao Guo, Wen Liu, Jinlong Hu, Siyu Sun
DOI:10.4103/eus.eus_30_20  PMID:32611850
Background and Objectives: We investigated the relationship between the interruption of the muscularis propria of the lower esophageal sphincter (LES) measured by EUS and the relief of dysphagia in patients with esophageal achalasia treated by per-oral endoscopic myotomy (POEM). Patients and Methods: Patients with achalasia treated by POEM at our endoscopy center between January 2015 and August 2016 were included in the study. Preoperative clinical characteristics and dysphagia and Eckardt scores, operative and postoperative complications, dysphagia and Eckardt scores at 3- and 7-months postoperatively, and the incidence of postoperative gastroesophageal reflux disease (GERD) were recorded. Patients were divided into two groups according to the degree of separation of the muscularis propria at the LES, as measured by EUS: Group A, separation distance 2–5 mm and Group B, separation distance 5–9 mm, for comparison. Results: Preoperative clinical characteristics, Eckardt scores, and dysphagia scores were similar in the two groups. Patients in both groups had significant symptom relief postoperatively, with significant decreases in Eckardt scores and dysphagia scores. On the comparison between the groups, there was no significant difference in postoperative Eckardt score, but the dysphagia score was statistically significantly lower in Group B as compared to Group A (P < 0.05). There was no significant difference between the groups in the incidence of gas-related complications or in the incidence of postoperative GERD. Conclusions: POEM was largely effective in the treatment of esophageal achalasia in this study. Patients with larger defects of the muscularis propria at the LES after myotomy had greater relief of dysphagia without an increased incidence of postoperative complications.
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Predicting pediatric esophageal wall thickness: An EUS study p. 259
Simon S Rabinowitz, Evan Grossman, Lisa Feng, Nonyelum Ebigbo, Bo Lin, Raavi Gupta, Rachel Sklar, Steven M Schwarz, Jeremy Weedon, Frank Gress
DOI:10.4103/eus.eus_15_20  PMID:32801228
Background and Objective: EUS has been shown in two small series to be capable of documenting increases in the total esophageal wall thickness (TWT) in children and adults with eosinophilic esophagitis (EoE). To apply EUS-derived TWT in clinical situations or in scientific investigations in pediatric EoE, measurements of esophageal TWT in children of differing ages and heights are required. Materials and Methods: Thirty patients (18M: 12F, 7 months to 20 years and 10 months) with a history of esophageal symptoms, but no endoscopic or histologic criteria of EoE were studied using a through the scope 20 MHZ Olympus Ultrasound miniprobe UM-3R (Olympus America, Center Valley Pa 18034) through a GIF Q180 or 160 (Olympus) standard pediatric upper endoscope. The mucosa, the mucosa plus submucosa, and the TWT were measured in the mid- and distal esophagus immediately before taking diagnostic biopsies. Results: Measurements from both sites showed a statistically significant increase in TWT as a function of age (P < 0.001) and height (P < 0.001), as did the individual layers. The width of the mucosa and the submucosa were equivalent and together, they contributed more than half of the entire TWT. There were no significant differences between the means of the mid- and distal esophageal measurements. A multiple regression equation that can predict TWT based on age, with 95% confidence limits, is presented. Conclusions: EUS has demonstrated that esophageal TWT in a cohort of control children correlates with height and with age and has provided insights into the organization of the esophageal wall. Esophageal TWT values obtained by EUS can now be interpreted to recognize esophageal wall thickening throughout childhood.
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IMAGES AND VIDEOS Top

One-step stent deployment of EUS-guided hepaticogastrostomy using a novel covered metal stent with a fine-gauge stent delivery system (with video) p. 267
Takeshi Ogura, Masanori Yamada, Nobu Nishioka, Tadahiro Yamada, Kazuhide Higuchi
DOI:10.4103/eus.eus_38_20  PMID:32687071
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Extra-hepatic portal vein aneurysm diagnosed by EUS p. 270
Surinder Singh Rana, Lovneet Dhalaria, Ravi Sharma, Rajesh Gupta
DOI:10.4103/eus.eus_40_20  PMID:32687073
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LETTERS TO EDITOR Top

Potential pitfalls in diagnostic EUS of the esophagus p. 272
Simon S Rabinowitz, Evan Grossman, Frank Gress
DOI:10.4103/eus.eus_22_20  PMID:32801229
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EUS-guided transmural pancreatic duct interventions for relief of pain in patients with chronic pancreatitis and failed ERCP p. 274
Surinder Singh Rana, Ravi Sharma, Rajesh Gupta
DOI:10.4103/eus.eus_46_20  PMID:32769236
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NEWS Top

The 3rd session of EUS editorial board established p. 276
Siyu Sun, Editorial Team of Endoscopic Ultrasound
DOI:10.4103/2303-9027.292178  PMID:32801230
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