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REVIEW ARTICLE
Duplication cysts: Diagnosis, management, and the role of endoscopic ultrasound
Roy Liu, Douglas G Adler
July-September 2014, 3(3):152-160
DOI:10.4103/2303-9027.138783  
Gastrointestinal tract duplication cysts are rare congenital gastrointestinal malformation in young patients and adults. They consist of foregut duplication cysts, small bowel duplication cysts, and large bowel duplication cysts. Endoscopic ultrasound (EUS) has been widely used as a modality for the evaluation and diagnosis of duplication cysts. EUS is the diagnostic tool of choice to investigate duplication cysts since it can distinguish between solid and cystic lesions. The question of whether or not to perform EUS-fine needle aspiration (EUS-FNA) on a lesion suspected of being a duplication cyst is controversial as these lesions can become infected with significant consequences, although EUS-FNA is often required to obtain a definitive diagnosis and to rule out more ominous lesions. This manuscript will review the literature on duplication cysts throughout the body and will also focus on the role of EUS and FNA with regards to these lesions.
  43 18,004 1,735
ORIGINAL ARTICLES
A two-center comparative study of plastic and lumen-apposing large diameter self-expandable metallic stents in endoscopic ultrasound-guided drainage of pancreatic fluid collections
Tiing Leong Ang, Pradermchai Kongkam, Andrew Kwek, Piyachai Orkoonsawat, Rungsun Rerknimitr, Kwong Ming Fock
September-October 2016, 5(5):320-327
DOI:10.4103/2303-9027.191659  PMID:27803905
Background and Objectives: Endoscopic ultrasound-guided drainage of walled-off pancreatic fluid collections (PFCs) (pseudocyst [PC]; walled-off necrosis [WON]) utilizes double pigtail plastic stents (PS) and the newer large diameter fully covered self-expandable stents (FCSEMS) customized for PFC drainage. This study examined the impact of type of stent on clinical outcomes and costs. Patients and Methods: Retrospective two-center study. Outcome variables were technical and clinical success, need for repeat procedures, need for direct endoscopic necrosectomy (DEN), and procedure-related costs. Results: A total of 49 (PC: 31, WON: 18) patients were analyzed. Initially, PS was used in 37 and FCSEMS in 12. Repeat transmural drainage was required in 14 (PS: 13 [9 treated with PS, 4 treated with FCSEMS]; FCSEMS: 1 [treated with PS]) due to stent migration (PS: 3; FCSEMS: 1) or inadequate drainage (PS: 10). Technical success was 100%. Initial clinical success was 64.9% (25/38) for PS versus 91.7% (11/12) for FCSEMS (P = 0.074). With repeat transmural stenting, final clinical success was achieved in 94.6% and 100%, respectively (P = 0.411). Compared to FCSEMS, PS was associated with greater need for repeat drainage (34.2% vs. 6.3%, P = 0.032). The need for and frequency of DEN was similar between both groups, but PS required more frequent balloon dilatation. PS was significantly cheaper for noninfected PC. Costs were similar for infected PC and WON. Conclusion: PS was associated with a higher need for a second drainage procedure to achieve clinical success. The use of FCSEMS did not increase procedural costs for infected PC and WON.
  28 1,512 372
Pancreatic cystic lesions: The value of contrast-enhanced endoscopic ultrasound to influence the clinical pathway
Michael Hocke, Xin-Wu Cui, Dirk Domagk, Andre Ignee, Christoph F Dietrich
April-June 2014, 3(2):123-130
DOI:10.4103/2303-9027.131040  PMID:24955342
Background and Objectives: Cystic pancreatic lesions are a growing diagnostic challenge. The aim of this study was to proof a new diagnostic concept based on contrast-enhanced endoscopic ultrasound (CE-EUS) for differential diagnosis. Patients and Methods: A total of 125 patients with unclear cystic pancreatic lesions were included. The initial diagnostic was made by CE-EUS dividing the lesions in a group without contrast enhancing effect in the cystic wall, septae or nodule indicating pseudocysts or dysontogenetic cysts and a group with contrast enhancing effect in the described structures indicating cystic neoplasias. The investigations were performed using a Pentax echoendoscope and Hitachi Preirus ultrasound machine. The contrast enhancer used was 4.8 mL SonoVue ® (Bracco, Italy). The group with suspected cystic neoplasia was referred for endoscopic fine-needle puncture for further diagnostic or treatment decisions. Results: The dividing of the groups by contrast-enhanced ultrasound was feasible because all (n = 56) suspected cystic neoplasias showed a contrast enhancing effect, whereas in only 4 from 69 pseudocystic or dysontogenetic cystic lesions a contrast enhancing effect in the wall could be observed. Endoscopic fine-needle puncture could diagnose all malignant neoplasias and relevant premalignant conditions. The long-term follow-up did not show any development of malignant cystic lesions. Conclusion: Using CE-EUS and endoscopic fine-needle puncture as diagnostic criteria seemed to be a feasible method to deal with different cystic lesions in daily practice.
  26 3,466 667
Do the morphological features of walled off pancreatic necrosis on endoscopic ultrasound determine the outcome of endoscopic transmural drainage?
Surinder Singh Rana, Deepak Kumar Bhasin, Ravi Kumar Sharma, Jeyashree Kathiresan, Rajesh Gupta
April-June 2014, 3(2):118-122
DOI:10.4103/2303-9027.131039  PMID:24955341
Background and Objective: Endoscopic transmural drainage is an effective, but technically demanding treatment modality for walled off pancreatic necrosis (WOPN). The factors that determine the outcome of endoscopic treatment for WOPN have been infrequently studied. We aim to retrospectively correlate the morphological features of WOPN on endoscopic ultrasound (EUS) with the outcome of endoscopic transmural drainage. Patients and Methods: Over the last 3 years, 43 patients (36 males; mean age 36.04 ± 10.06 years) with symptomatic WOPN were treated by an attempted endoscopic drainage. The correlation between the morphological features of WOPN and the type of treatment offered as well as the number of endoscopic procedures undergone by the patient was assessed. Results: The mean size of WOPN was 9.95 ± 2.75 cm with <10%, 10-40% and >40% solid debris being present in 6, 33, and 4 patients, respectively. Patients with <10% necrotic debris needed only single session of endoscopic drainage, whereas patients with 10-40% solid debris needed two or more sessions. Patients with >40% solid debris either needed direct endoscopic debridement or surgical necrosectomy. The extent of necrosis correlated significantly (r = 0.703, P < 0.001) with the type of treatment received by the patient. With increasing size of the collection (r = 0.320, P = 0.047) and the amount of the solid debris (r = 0.800, P < 0.001), there was a significant increase in the number of endoscopic procedures required for successful outcome by the patient. Conclusions: The morphological features of WOPN on EUS have important therapeutic implications with collections having large size and more solid debris needing more aggressive therapeutic method for the successful outcome.
  20 2,941 505
REVIEW ARTICLES
Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis
Diogo Turiani Hourneaux De Moura, Eduardo Guimarães Hourneaux De Moura, Wanderlei Marques Bernardo, Eduardo Turiani Hourneaux De Moura, Felipe I Baraca, André Kondo, Sérgio Eijii Matuguma, Everson Luis Almeida Artifon
January-February 2018, 7(1):10-19
DOI:10.4103/2303-9027.193597  PMID:27824027
Background and Aims: There are no systematic reviews comparing the use of endoscopic retrograde cholangiopancreatography (ERCP)-based brush cytology and forceps biopsy and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of malignant biliary stricture; so in this revision, we will compare ERCP against EUS-FNA for tissue diagnosis of malignant biliary stricture. Design: A systematic review was conducted of comparative studies (prospective or retrospective) analyzing EUS and ERCP for tissue diagnosis of malignant biliary stricture. Materials and Methods: The databases Medline, EMBASE, Cochrane, LILACS, CINAHL, and Scopus were searched for studies dated previous to November 2014. We identified three prospective studies comparing EUS-FNA and ERCP for the diagnosis of malignant biliary stricture and five prospective studies comparing EUS-FNA with the same diagnosis of the other three studies. All patients were subjected to the same gold standard method. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values, and accuracy) and performed a meta-analysis using the Review Manager (RevMan) 5.3 software. Results: A total of 294 patients were included in the analysis. The pretest probability for malignant biliary stricture was 76.66%. The mean sensitivities of ERCP and EUS-FNA for tissue diagnosis of malignant biliary stricture were 49% and 75%, respectively; the specificities were 96.33% and 100%, respectively. The posttest probabilities positive predictive value (98.33% and 100%, respectively) and negative predictive value (34% and 47%, respectively) were determined. The accuracies were 60.66% and 79%, respectively. Conclusion: We found that EUS-FNA was superior to ERCP with brush cytology and forceps biopsy for diagnosing malignant biliary strictures. However, a negative EUS-FNA or ERCP test may not exclude malignant biliary stricture because both have low negative posttest probabilities.
  20 4,254 739
ORIGINAL ARTICLES
Pathologic evaluation of a new endoscopic ultrasound needle designed to obtain core tissue samples: A pilot study
Douglas G Adler, Benjamin Witt, Barbara Chadwick, Jason Wells, Linda Jo Taylor, Christopher Dimaio, Robert Schmidt
May-June 2016, 5(3):178-183
DOI:10.4103/2303-9027.183976  PMID:27386475
Background and Objectives: Standard endoscopic ultrasound-fine-needle aspiration (EUS-FNA) needles are in widespread use. Meaningful differences between the available needles have been difficult to identify. Recently, a new EUS needle (Shark Core®, Covidien, Dublin, Leinster, Ireland), has been introduced in an attempt to improve diagnostic accuracy, tissue yield, and to potentially obtain a core tissue sample. We performed a pilot study prospectively to evaluate this new needle when compared to a standard EUS-FNA needle. Materials and Methods: Analysis of the first 15 patients undergoing EUS-FNA with the Shark Core needle was performed and it was compared to EUS-FNA in 15 patients who underwent EUS-FNA with a standard needle. Results: The Shark Core needle required fewer needle passes to obtain diagnostic adequacy than the standard needle [(χ2(1) = 11.3, P < 0.001]. The Shark Core needle required 1.5 passes to reach adequacy, whereas the standard needle required three passes. For cases with cell blocks, the Shark Core needle produced diagnostic material in 85% of cases [95% confidence interval (CI): 54–98], whereas the standard needle produced diagnostic material in 38% of the cases (95% CI: 9-76). The Shark Core needle produced actual tissue cores 82% of the time (95% CI: 48–98) and the standard needle produced no tissue cores (95% CI: 0-71) (P = 0.03). Conclusion: This pilot study found that the Shark Core needle had a high rate of producing adequate cytologic material for the diagnosis of pancreatic and peri-pancreatic lesions sampled by EUS with fewer passes required to obtain a definitive diagnosis and with a high rate of tissue cores being obtained when compared to a standard FNA needle.
  19 2,226 367
REVIEW ARTICLES
Endoscopic ultrasound-guided liver biopsy
Parth J Parekh, Raj Majithia, David L Diehl, Todd H Baron
April-June 2015, 4(2):85-91
DOI:10.4103/2303-9027.156711  PMID:26020041
Liver biopsy remains the cornerstone in the diagnosis and management of liver disorders. Results of liver biopsy can often drive therapeutic decision-making. Unfortunately, studies have shown conventional biopsy techniques to carry significant sampling variability that can potentially impact patient care. Endoscopic ultrasound (EUS) is gaining traction as an alternative method of biopsy. For parenchymal disease, it can decrease sampling variability. It offers a more targeted approach for focal lesions. Its diagnostic yield and limited adverse event profile make it a promising approach for liver biopsy.
  19 2,722 820
Endoscopic ultrasound: Elastographic lymph node evaluation
Christoph F Dietrich, Christian Jenssen, Paolo G Arcidiacono, Xin-Wu Cui, Marc Giovannini, Michael Hocke, Julio Iglesias-Garcia, Adrian Saftoiu, Siyu Sun, Liliana Chiorean
July-September 2015, 4(3):176-190
DOI:10.4103/2303-9027.162995  PMID:26374575
Different imaging techniques can bring different information which will contribute to the final diagnosis and further management of the patients. Even from the time of Hippocrates, palpation has been used in order to detect and characterize a body mass. The so-called virtual palpation has now become a reality due to elastography, which is a recently developed technique. Elastography has already been proving its added value as a complementary imaging method, helpful to better characterize and differentiate between benign and malignant masses. The current applications of elastography in lymph nodes (LNs) assessment by endoscopic ultrasonography will be further discussed in this paper, with a review of the literature and future perspectives.
  18 3,871 685
ORIGINAL ARTICLES
Contrast-enhanced (endoscopic) ultrasound and endoscopic ultrasound elastography in gastrointestinal stromal tumors
Andre Ignee, Christian Jenssen, Michael Hocke, Yi Dong, Wen-Ping Wang, Xin-Wu Cui, Matthias Woenckhaus, Sevastita Iordache, Adrian Saftoiu, Gudrun Schuessler, Christoph F Dietrich
January-February 2017, 6(1):55-60
DOI:10.4103/2303-9027.200216  PMID:28218202
Background and Objectives: Gastrointestinal stromal tumors (GISTs) represent the largest group of subepithelial tumors (SET) of the upper gastrointestinal (GI) tract. They may show malignant behavior, in contrast to other SET. Endoscopic ultrasound (EUS) is frequently used to characterize SET. With the introduction of contrast-enhanced ultrasound (CEUS) into EUS (CE-EUS), distinct enhancement patterns can be detected. In the presented study, the characteristic features of CE-EUS in GIST are analyzed and compared with those of other SET. Materials and Methods: Consecutive patients from four centers with SET of the upper and middle GI tract were included and received endoscopic or transcutaneous CEUS. The results were compared with EUS-guided tissue acquisition, forceps biopsy, or surgical resection. Results: Forty-two out of 62 (68%) patients had SET of the stomach, 17/62 (27%) of the small intestine, 2/62 (3%) of the esophagus, and 1/62 (2%) extraintestinal. Eighty-one percent underwent surgery. Leiomyoma was found in 5/62 (8%) and GIST in 57/62 patients (92%). Thirty-nine out of 57 (68%) patients had GIST lesions in the stomach, 17/57 (30%) had GIST of the small intestine, and 1/57 (2%) patients had extraintestinal GISTs. GIST size was 62.6 ± 42.1 (16–200) mm. Hyperenhancement had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 98%, 100%, 100%, 93%, and 98% for the diagnosis of GIST. Fifty out of 57 patients with GIST (88%) showed avascular areas in the center of the lesions. Conclusion: CE-EUS and CEUS show hyperenhancement and avascular areas in a high percentage of GIST but not in leiomyoma. Thus, GIST and leiomyoma can be discriminated accurately.
  17 2,278 536
REVIEW ARTICLES
The safety of endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions
Won Jae Yoon, William R Brugge
October-December 2015, 4(4):289-292
DOI:10.4103/2303-9027.170408  PMID:26643695
Endoscopic ultrasound (EUS) is widely used in the evaluation of various pancreatic diseases including pancreatic cystic lesions (PCLs). EUS-guided fine-needle aspiration (EUS-FNA) of PCLs provides cyst fluid, which is used for the differentiation of PCLs. EUS-FNA of PCLs is a safe procedure with a low complication rate. Contrary to the concerns expressed by some investigators, preoperative EUS-FNA of mucinous PCLs is unlikely to increase the frequency of postoperative peritoneal seeding.
  17 1,674 519
Ultrasound contrast agents
Andre Ignee, Nathan S. S. Atkinson, Gudrun Schuessler, Christoph F Dietrich
November-December 2016, 5(6):355-362
DOI:10.4103/2303-9027.193594  PMID:27824024
Endoscopic ultrasound (EUS) plays an important role in imaging of the mediastinum and abdominal organs. Since the introduction of US contrast agents (UCA) for transabdominal US, attempts have been made to apply contrast-enhanced US techniques also to EUS. Since 2003, specific contrast-enhanced imaging was possible using EUS. Important studies have been published regarding contrast-enhanced EUS and the characterization of focal pancreatic lesions, lymph nodes, and subepithelial tumors. In this manuscript, we describe the relevant UCA, their application, and specific image acquisition as well as the principles of image tissue characterization using contrast-enhanced EUS. Safety issues, potential future developments, and EUS-specific issues are reviewed.
  17 3,475 572
REVIEWS
Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors
Jintao Guo, Zhijun Liu, Siyu Sun, Sheng Wang, Nan Ge, Xiang Liu, Guoxin Wang, Wen Liu
July-September 2013, 2(3):125-133
DOI:10.4103/2303-9027.117655  
Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.
  17 5,568 965
ORIGINAL ARTICLES
Endoscopic ultrasound-guided drainage of pancreatic pseudocysts: Medium-term assessment of outcomes and complications
Pui Yung Ng, Ditlev Nytoft Rasmussen, Peter Vilmann, Hassem Hassan, Victor Gheorman, Daniela Burtea, Valeriu Surlin, Adrian Saftoiu
October-December 2013, 2(4):199-203
DOI:10.4103/2303-9027.121245  PMID:24949396
Objective: Endoscopic ultrasound (EUS)-guided drainage is a widely used treatment modality for pancreatic pseudocysts (PPC). However, data on the clinical outcome and complication rates are conflicting. Our study aims to evaluate the rates of technical success, treatment success and complications of EUS-guided PPC drainage in a medium-term follow-up of 45 weeks. Materials and Methods: A retrospective review was conducted for 55 patients with symptomatic PPC from December 2005 to August 2010 drained by EUS. Medium-term follow-up data were obtained by searching their medical history or by telephonic interview. Results: A total of 61 procedures were performed. The symptoms that indicated drainage were abdominal pain (n = 43), vomiting (n = 7) and jaundice (n = 5). The procedure was technically successful in 57 of the 61 procedures (93%). The immediate complication rate was 5%. At a mean follow-up of 45 weeks, the treatment success was 75%. The medium term complications appeared in 25% of cases, which included three cases each of stent clogging, stent migration, infection and six cases of recurrence. There was no mortality. Conclusion: EUS-guided drainage is an effective treatment for PPC with a successful outcome in most of patients. Most of the complications require minimal invasive surgical treatment or repeated EUS-guided drainage procedures.
  16 4,009 775
Clinical evaluation of endoscopic ultrasonography-guided drainage using a novel flared-type biflanged metal stent for pancreatic fluid collection
Shuntaro Mukai, Takao Itoi, Atsushi Sofuni, Takayoshi Tsuchiya, Takuji Gotoda, Fuminori Moriyasu
April-June 2015, 4(2):120-125
DOI:10.4103/2303-9027.156738  PMID:26020046
Background and Objectives: Endoscopic ultrasonography (EUS)-guided transluminal drainage for pancreatic fluid collections (PFCs) has become the standard therapy worldwide as a minimally invasive therapy compared with surgical drainage. Recently, a novel flared-type biflanged metal stent (BFMS) designed specifically for the treatment of PFCs has been developed. The aim of this study was to retrospectively assess the feasibility and safety of EUS-guided drainage and direct endoscopic necrosectomy (DEN) for PFCs using the novel flared-type BFMS. Patients and Methods: Twenty-one patients were treated by EUS-guided drainage using a flared-type BFMS for PFCs (pancreatic pseudocyst, 2 patients; walled-off necrosis, 19 patients). Results: The present study showed a technical success rate of 100%, a final clinical success rate of 100%, a procedure-related adverse event (AE) rate of 0%, an early AE rate of 28.6% (moderate and severe AE rate of 9.5%), a mortality rate of 0%, and a recurrence rate of 9.5%. DEN (mean, 2.3 sessions) was required in 38% of the patients. Conclusion: The present study clarified that the EUS-guided drainage using the flared-type BFMS is an effective and safe treatment approach for PFCs. Further studies using randomized controlled multicenter trials are warranted.
  16 2,149 390
The diagnostic value of EUS in pancreatic cystic neoplasms compared with CT and MRI
Xuejia Lu, Shu Zhang, Chao Ma, Chunyan Peng, Ying Lv, Xiaoping Zou
October-December 2015, 4(4):324-329
DOI:10.4103/2303-9027.170425  PMID:26643701
Background and Objectives: Pancreatic cystic neoplasms (PCNs) are being increasingly identified. Recent reports have described the utility of endoscopic ultrasound (EUS) in the characterization of PCNs. This study presents the diagnostic value of EUS in PCNs. Materials and Methods: A total of 108 patients (78 women and 30 men; average age, 50 years) who were confirmed pathologically to have PCNs were analyzed retrospectively. We analyzed the clinical characteristics of 108 patients and compared the diagnostic performance of computed tomography (CT), magnetic resonance imaging (MRI), and EUS with or without fine-needle aspiration (FNA). Results: EUS with or without FNA significantly increased the accuracy for diagnosing PCNs compared with CT (P = 0.002) and MRI (P = 0.006). According to the tumor size, the further analysis of these impacts was provided. EUS was superior to CT in the characterization of PCNs in small (< 3 cm) lesions (P = 0.003), similarly superior to MRI in large (>3 cm) lesions (P = 0.030). Furthermore, EUS is valuable for precisely characterizing internal structures, for example, septa (P = 0.004, compared with CT; P = 0.033, compared with MRI) and mural nodules (P = 0.028, compared with CT). Conclusions: In our study, EUS with or without FNA is the ideal tool for providing detailed imaging of PCNs and performed better than MRI and CT.
  16 2,050 420
REVIEWS
Forward-view endoscopic ultrasound: A systematic review of diagnostic and therapeutic applications
Pietro Fusaroli, Liza Ceroni, Giancarlo Caletti
April-June 2013, 2(2):64-70
DOI:10.4103/2303-9027.117689  PMID:24949367
Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and therapeutic procedures have been performed by a curved linear array (CLA) echoendoscope since the early 1990's. This particular echoendoscope, allowing real time visualization of aspira­tion needles and of other devices, has substantially remained unchanged since its introduction to the market. In a context of rapidly expanding indications for EUS-guided procedures, a dedicated forward view (FV) echoendoscope has been developed and tested under different clinical conditions. The FV echoendoscope is equipped with front endoscopic and EUS view, allowing deployment of needles and other devices through the working channel in straight direction. Several new diagnostic and therapeutic applica­tions may thereby potentially be feasible with the FV echoendoscope and the established ones may prove easier to accomplish. The published literature with the FV echoendoscope has been systematically reviewed and the results are presented analytically and discussed in detail. EUS-FNA and therapeutic procedures, including pancreatic pseudocyst drainage, treatment of gastric fundal varices, celiac plexus neurolysis, and duct drainage were reported. The FV echoendoscope showed some unique advantages, open­ing new possibilities such as EUS-FNA in difficult gastrointestinal tracts and combined endoscopic/EUS treatment with frontal approach. However, no statistically significant evidence of superiority of the FV echoendoscope vs. the CLA echoendoscope was found in pancreatic pseudocyst drainage. No complications specifically attributable to the use of the FV echoendoscope were reported.
  16 2,790 520
REVIEW ARTICLE
The role of endoscopic ultrasound in pancreatic cancer screening
Manoop S Bhutani, Pramoda Koduru, Virendra Joshi, Payal Saxena, Rei Suzuki, Atsushi Irisawa, Kenji Yamao
January-February 2016, 5(1):8-16
DOI:10.4103/2303-9027.175876  PMID:26879161
Pancreatic cancer (PC) is a highly lethal cancer. Despite a significant advancement in cancer treatment, the mortality rate of PC is nearly identical to the incidence rates. Early detection of tumor or its precursor lesions with dysplasia may be the most effective approach to improve survival. Screening strategies should include identification of the population at high risk of developing PC, and an intense application of screening tools with adequate sensitivity to detect PC at an early curable stage. Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) seem to be the most promising modalities for PC screening based on the data so far. EUS had an additional advantage over MRI by being able to obtain tissue sample during the same examination. Several questions remain unanswered at this time regarding the age to begin screening, frequency of screening, management of asymptomatic pancreatic lesions detected on screening, timing of resection, and extent of surgery and impact of screening on survival. Novel techniques such as needle-based confocal laser endomicroscopy (nCLE), along with biomarkers, may be helpful to identify pancreatic lesions with more aggressive malignant potential. Further studies will hopefully lead to the development of strategies combining EUS with other technological/biological advancements that will be cost-effective and have an impact on survival.
  15 2,616 716
REVIEW ARTICLES
EUS-guided biliary drainage: A comprehensive review of the literature
Judith E Baars, Arthur J Kaffes, Payal Saxena
January-February 2018, 7(1):4-9
DOI:10.4103/eus.eus_105_17  PMID:29451164
EUS-guided biliary drainage (EUS-BD) has emerged as a technique for gaining biliary access when ERCP fails. This article gives a comprehensive review on the role and technique of EUS-BD. Moreover, we propose an algorithm guiding the clinician when to consider EUS-BD after failed ERCP or in anticipated difficult cannulations.
  15 2,319 749
ORIGINAL ARTICLES
Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure
Everson L. A. Artifon, Jarbas F Loureiro, Todd H Baron, Kaie Fernandes, Michel Kahaleh, Fernando P Marson
July-September 2015, 4(3):235-243
DOI:10.4103/2303-9027.163010  PMID:26374583
Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP. Patients and Methods: A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively. Results: Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days). Conclusion: Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.
  14 2,326 473
Diagnostic potency of EUS-guided FNA for the evaluation of pancreatic mass lesions
Amir Houshang Mohammad Alizadeh, Shabnam Shahrokh, Mohammad Hadizadeh, Maryam Padashi, Mohammad Reza Zali
January-February 2016, 5(1):30-34
DOI:10.4103/2303-9027.175879  PMID:26879164
Background and Objectives: Diagnosis of pancreatic lesions remains a clinical challenge. This study aimed to evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic mass lesions. Patients and Methods: Clinical data, laboratory tests, and cytopathological and imaging reports were collected from 185 pancreatic EUS cases performed from March 2010 to January 2014. The final diagnosis was based on surgical findings, EUS-FNA or computed tomography (CT)-guided biopsy. Results: A total of 100 pancreatic FNAs were obtained by EUS. Most positive diagnoses of malignancy were pancreatic adenocarcinomas (n = 61). The site of pancreatic adenocarcinoma was the head in 50 (82.0%), body in seven (11.5%), and tail in four (6.5%). The sensitivity, specifi city, and positive and negative predictive values of EUS-FNA for diagnosing adenocarcinoma were 80.3%, 92.3%, 94.2%, and 75.0%, respectively. Discussion: We concluded that EUS-FNA of pancreatic lesion accurately diagnoses pancreatic adenocarcinoma and should be considered for the standard management of pancreatic adenocarcinoma.
  14 1,750 354
Effectiveness of contrast-enhanced endoscopic ultrasound for detecting mural nodules in intraductal papillary mucinous neoplasm of the pancreas and for making therapeutic decisions
Mitsuru Fujita, Takao Itoi, Nobuhito Ikeuchi, Atsushi Sofuni, Takayoshi Tsuchiya, Kentaro Ishii, Kentaro Kamada, Junko Umeda, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Shuntaro Mukai, Fuminori Moriyasu
November-December 2016, 5(6):377-383
DOI:10.4103/2303-9027.190927  PMID:28000629
Background and Objectives: There have been few studies to date evaluating the effectiveness of contrast-enhanced endoscopic ultrasound (CE-EUS) for detecting mural nodules in patients with branch duct-type intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas. We aim to evaluate the effectiveness of CE-EUS for detecting mural nodules in BD-IPMN. Patients and Methods: Of the 427 BD-IPMN patients, 21 patients (4.9%) in whom the presence of mural nodules was suggested by CE computed tomography (CT) or magnetic resonance imaging (MRI), or in whom the presence of nodule-like lesions as shown by fundamental EUS, were examined by CE-EUS. Results: The mean diameter of cystic lesions was 29.8 ± 12.8 mm. The mean diameter of mural nodules was 9.5 ± 5.7 mm. BD-IPMN was detected in the pancreatic head in 16 cases, pancreatic body in 2 cases, and pancreatic tail in 3 cases. The mean follow-up period was 17.2 ± 11.9 months. The detection rates of mural nodule-like lesions in BD-IPMN patients on CT, MRI, and fundamental EUS were 36.8%, 63.2%, and 100%, respectively. The detection rates of true mural nodules in BD-IPMN patients on CT, MRI, and fundamental EUS were 85.7%, 71.4%, and 100%, respectively. The echo levels of mural nodule-like lesions on fundamental EUS were hyperechoic in 6 patients, isoechoic in 9 patients, and hypoechoic in 6 patients. The final diagnosis was mucus lumps in 14 patients and mural nodules in 7 patients. The contrast patterns observed were avascular, isovascular, and hypervascular in 14, 3, and 4 patients, respectively. No patients showed a hypovascular pattern. Fourteen patients showing an avascular pattern were diagnosed as having mucus lumps, and they were able to avoid surgical resection. Of the 7 patients who were diagnosed as having mural nodules, 5 underwent surgical resection. The pathological findings were adenocarcinoma in 2 patients and adenoma in 3 patients. Of the 3 adenoma patients, fundamental EUS demonstrated a hypoechoic area in 1 patient and an isoechoic area in 2 patients. Of the 2 adenocarcinoma patients, 1 each showed a hypoechoic area and a hyperechoic area. It was difficult to distinguish between patients with adenoma and patients with adenocarcinoma using the echo levels obtained from fundamental EUS. Conclusions: CE-EUS may be useful for avoiding the overdiagnosis of BD-IPMN with mural nodule-like lesions. However, it has difficulty in distinguishing between clearly benign and malignant lesions in BD-IPMN.
  14 2,155 353
CONSENSUS
A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy
Jintao Guo, Adrian Saftoiu, Peter Vilmann, Pietro Fusaroli, Marc Giovannini, Girish Mishra, Surinder S Rana, Sammy Ho, Jan-Werner Poley, Tiing Leong Ang, Evangelos Kalaitzakis, Ali A Siddiqui, Jose G De La Mora-Levy, Sundeep Lakhtakia, Manoop S Bhutani, Malay Sharma, Shuntaro Mukai, Pramod Kumar Garg, Linda S Lee, Juan J Vila, Everson Artifon, Douglas G Adler, Siyu Sun
September-October 2017, 6(5):285-291
DOI:10.4103/eus.eus_85_17  PMID:29063871
There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-off necrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peri-pancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus.
  13 2,199 699
ORIGINAL ARTICLES
Central is as effective as bilateral endoscopic ultrasound-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer
Felix I Téllez-Ávila, Adriana Fabiola Romano-Munive, Jose de Jesús Herrera-Esquivel, Miguel Angel Ramírez-Luna
July-September 2013, 2(3):153-156
DOI:10.4103/2303-9027.117664  
Objective: The objective of this study is to compare the efficacy of central (single) vs bilateral (2-injections) endoscopic ultrasound (EUS)-celiac plexus neurolysis (CPN) for palliation of patients with pain related to pancreatic cancer. Materials and Methods: Patients with unresectable pancreatic cancer were included. Central EUS CPN was used in the first group and bilateral EUS CPN in the second. The measurement of pain was made with a visual analog pain scale (VAPS) applied before and after the procedure. Follow-up was made at weeks 2 and 4 after the procedure. The use of morphine before and after EUS CPN was evaluated. Complications related to the procedure were recorded. Results: A total of 53 patients underwent EUS CPN, 21 (39.6%) with the central technique and 32 (60.4%) with bilateral injection; 29 were women (54.7%) and the median age was 59 (30-85) years. The tumor was located in the head of the pancreas in 24 (45.3%) patients, the neck in 14 (26.4%), the body in 26 (49.1%) and in the tail of the pancreas in 8 (15.1%). Nearly, 14 (26.4%) patients had more than one pancreatic segment involved. There was no difference in the median (range) percent pain reduction from baseline-4 weeks later was 50% (0-100) vs 60% (0-100), for central and bilateral techniques, respectively; P = 0.18. In total, 60.4% of patients had a reduction of 50% punctuation in the VAPS. No major complications were detected. Conclusions: EUS CPN is useful for the management of pain in patients with unresectable pancreatic cancer, but there is no significant difference between central vs bilateral techniques.
  13 430 131
REVIEW ARTICLES
Can elastography replace fine needle aspiration?
Alexandru Popescu, Adrian Saftoiu
April-June 2014, 3(2):109-117
DOI:10.4103/2303-9027.123009  PMID:24955340
Endoscopic ultrasound (EUS) is one of the best diagnostic methods for diseases of the digestive tract and surrounding organs. Whereas EUS-guided fine needle aspiration (FNA) has been very useful for providing histological confirmation for previously hard to reach lesions, elastography is aiming to obtain a "virtual biopsy" by assessing differences in elasticity between the normal and pathological - usually malignant - tissue. A question that arises is whether EUS-elastography has reached a stage where it might successfully supplant the use of EUS-FNA in some of its clinical indications. The main indications of EUS-guided FNA are listed in this article and published data on the usage of elastography in these settings is reviewed for each one. In some of the indications, a plethora of studies have been published, notably for the evaluation of solid pancreatic masses and lymph nodes, while in others there is little relevant data (submucosal masses, left liver lesions, left adrenal masses), or elastography simply is not suitable as a diagnostic means (cystic lesions). Our conclusion is that elastography is not yet ready to replace EUS-FNA in its indications, but should complement it in various settings, especially for the assessment of lymph nodes. It can only be considered an alternative on a case-by-case basis, in situations where FNA is regarded as a contraindication. Furthermore, it could be used in conjunction with other imaging techniques, such as contrast-enhanced EUS, in order to further improve the accuracy of non-invasive EUS assessment, possibly making the case for a more limited or targeted use of EUS-FNA in selected cases.
  13 3,607 689
REVIEWS
Endoscopic ultrasound-guided fine needle aspiration: From the past to the future
Madalin-Ionut Costache, Sevastita Iordache, John Gásdal Karstensen, Adrian Saftoiu, Peter Vilmann
April-June 2013, 2(2):77-85
DOI:10.4103/2303-9027.117691  PMID:24949369
Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a technique which allows the study of cells obtained through aspiration in different locations near the gastrointestinal tract. EUS-FNA is used to acquire tissue from mucosal/submucosal tumors, as well as peri-intestinal structures including lymph nodes, pancreas, adrenal gland, gallbladder, bile duct, liver, kidney, lung, etc. The pancreas and lymph nodes are still the most common organs targeted in EUS-FNA. The overall accuracy of EUS is supe­rior to computed tomography scan and magnetic resonance imaging for detecting pancreatic lesions. In most cases it is possible to avoid unnecessary surgical interventions in advanced pancreatic cancer, and EUS is considered the preferred method for loco-regional staging of pancreatic cancer. FNA improved the sensitivity and specificity compared to EUS imaging alone in detection of malignant lymph nodes. The negative predictive value of EUS-FNA is relatively low. The presence of a cytopathologist during EUS-FNA improves the diagnostic yield, decreasing unsatisfactory samples or need for additional passes, and consequently the procedural time. The size of the needle is another factor that could modify the diagnostic accuracy of EUS-FNA. Even though the EUS-FNA technique started in early nineteen's, there are many remarkable progresses culminating nowadays with the discovery and performance of needle-based confocal laser endomicroscopy. Last, but not least, identification and quantification of potential molecular markers for pancreatic cancer on cellular samples obtained by EUS-FNA could be a promising approach for the diagno­sis of solid pancreatic masses.
  13 3,800 831
* Source: CrossRef
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