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   2018| January-February  | Volume 7 | Issue 1  
    Online since February 15, 2018

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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.
  4,082 721 17
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.
  2,156 730 13
EUS elastography: How to do it?
Christoph F Dietrich, Ellison Bibby, Christian Jenssen, Adrian Saftoiu, Julio Iglesias-Garcia, Roald F Havre
January-February 2018, 7(1):20-28
DOI:10.4103/eus.eus_49_17  PMID:29451165
Strain elastography as used in EUS (EUS-real-time tissue elastography [RTE]) is a qualitative technique and provides information on the relative stiffness between one tissue and another. This article reviews the principles, technique, and interpretation of EUS-RTE in various organs. It includes information on how to optimize the technique as well as a discussion on pitfalls and artifacts. We also refer to the article describing RTE using conventional ultrasound transducers.
  1,915 586 8
EUS-guided gallbladder drainage: Current status and future prospects
Douglas G Adler
January-February 2018, 7(1):1-3
DOI:10.4103/eus.eus_3_18  PMID:29451163
  1,860 366 6
Molecular analysis of pancreatic cyst fluid changes clinical management
David M Arner, Brooke E Corning, Ali M Ahmed, Henry C Ho, Bradley J Weinbaum, Uzma Siddiqui, Harry Aslanian, Reid B Adams, Todd W Bauer, Andrew Y Wang, Vanessa M Shami, Bryan G Sauer
January-February 2018, 7(1):29-33
DOI:10.4103/eus.eus_22_17  PMID:29451166
Background and Objectives: DNA molecular analysis has been suggested as a tool to evaluate pancreatic cysts. This study assesses whether the addition of DNA molecular analysis alters clinical management. Methods: This is a retrospective review of 46 consecutive patients who underwent EUS-FNA of pancreatic cysts with DNA molecular analysis at two major academic institutions. Cases were presented to two pancreaticobiliary surgeons first without and then with DNA molecular analysis data. The primary outcome was the frequency with which clinical management was altered with the addition of DNA molecular analysis. Results: Forty-six patients with a mean age of 62.0 (±13.4) years and mean cyst size of 3.2 (±2.3) cm were included in the study. Cyst carcinoembryonic antigen (CEA) was available in 30 patients and ranged from 0.4 to 15,927 ng/mL. DNA molecular analysis was described as benign in 23 (50%), statistically indolent in 13 (28%), statistically higher risk in 9 (20%), and indeterminate in 1 (2%). Surgeon #1 changed the management in 13/46 cases (28%) and surgeon #2 changed the management in 12/46 cases (26%) with the addition of DNA molecular analysis. When organized by CEA concentration, those with an intermediate CEA (45–800 ng/mL) or without a CEA concentration had a management changed more frequently (40%) compared to all others (P < 0.05). Conclusions: The addition of DNA molecular analysis alters the clinical management of pancreatic cystic lesions most often when CEA levels are intermediate (45–800 ng/mL) or when no CEA concentration is available. Use of DNA molecular analysis can be considered in this cohort. Further study of molecular markers in pancreatic cystic lesions is recommended.
  1,579 308 2
Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy for treatment of infected pancreatic necrosis in early phase of illness
Surinder Singh Rana, Rajesh Gupta, Mandeep Kang, Vishal Sharma, Ravi Sharma, Ujjwal Gorsi, Deepak K Bhasin
January-February 2018, 7(1):41-47
DOI:10.4103/eus.eus_94_17  PMID:29451168
Background and Objectives: Infected pancreatic necrosis (IPN) in the early phase is treated with “step up approach” involving initial percutaneous catheter drainage (PCD) followed by necrosectomy. There is a paucity of data on a combined approach of initial PCD followed by endoscopic drainage and necrosectomy. A retrospectively study on safety and efficacy of initial PCD followed by endoscopic transluminal drainage and necrosectomy in IPN. Methods: Retrospective analysis of data of 23 patients with IPN who were treated with a combined approach. Patients were divided into two groups as follows: patients with central necrosis in whom PCD and endoscopic drainage were done in the same collection (n = 11) and patients with combined central and peripheral necrosis where PCD was placed in peripheral necrosis, and endoscopic drainage was done for central necrosis (n = 12). Results: Endoscopic drainage could be done successfully in all 23 patients with mean time for the resolution being 4.0 ± 0.9 weeks. Fifteen (65.2%) patients were successfully treated using multiple plastic stents while direct endoscopic necrosectomy (DEN) was needed in 8 (34.8%) patients and fully covered self-expanding metal stent was inserted in 6 (26%) patients. The number of endoscopic sessions needed were 3 in 3 (13%), 4 in 9 (39%) patients, 5 in 5 (22%), 6 in 3 (13%), and 7 in 3 (13%) patients, respectively. Patients of central walled-off pancreatic necrosis (WOPN) with PCD catheter in situ needed more endoscopic sessions for resolution as well as more frequently needed DEN in comparison to patients with central WOPN with no PCD catheter. Conclusion: The combined approach of initial PCD followed by endoscopic drainage and necrosectomy is safe and effective treatment alternative for patients with IPN.
  1,569 264 6
Patient perception and preference of EUS-guided drainage over percutaneous drainage when endoscopic transpapillary biliary drainage fails: An international multicenter survey
Kwangwoo Nam, Dong Uk Kim, Tae Hoon Lee, Takuji Iwashita, Yousuke Nakai, Ahmed Bolkhir, Lara Aguilera Castro, Enrique Vazquez-Sequeiros, Carlos de la Serna, Manuel Perez-Miranda, John G Lee, Sang Soo Lee, Dong-Wan Seo, Sung Koo Lee, Myung-Hwan Kim, Do Hyun Park
January-February 2018, 7(1):48-55
DOI:10.4103/eus.eus_100_17  PMID:29451169
Background and Objectives: EUS-guided biliary drainage (EUS-BD) is a feasible procedure when ERCP fails, as is percutaneous transhepatic BD (PTBD). However, little is known about patient perception and preference of EUS-BD and PTBD. Patients and Methods: An international multicenter survey was conducted in seven tertiary referral centers. In total, 327 patients, scheduled to undergo ERCP for suspected malignant biliary obstruction, were enrolled in the study. Patients received decision aids with visual representation regarding the techniques, benefits, and adverse events (AEs) of EUS-BD and PTBD. Patients were then asked the choice between the two simulated scenarios (EUS-BD or PTBD) after failed ERCP, the reasons for their preference, and whether altering AE rates would influence their prior choice. Results: In total, 313 patients (95.7%) responded to the questionnaire and 251 patients (80.2%) preferred EUS-BD. The preference of EUS-BD was 85.7% (186/217) with EUS-BD expertise, compared to 67.7% (65/96) without EUS-BD expertise (P < 0.001). The main reason for choosing EUS-BD was the possibility of internal drainage (78.1%). In multivariate analysis, the availability of EUS-BD expertise was the single independent factor that influenced patient preference (odds ratio: 3.168; 95% of confidence interval, 1.714–5.856; P < 0.001). The preference of EUS-BD increased as AE rates decreased (P < 0.001). Conclusions: In this simulated scenario, approximately 80% of patients preferred EUS-BD over PTBD after failed ERCP. However, preference of EUS-BD declined as its AE rates increased. Further technical innovations and improved proficiency in EUS-BD for reducing AEs may encourage the use of this procedure as a routine clinical practice when ERCP fails.
  1,313 261 7
A Multicenter comparative trial of a novel EUS-guided core biopsy needle (SharkCore) with the 22-gauge needle in patients with solid pancreatic mass lesions
Mariam Naveed, Ali A Siddiqui, Thomas E Kowalski, David E Loren, Ammara Khalid, Ayesha Soomro, Syed M Mazhar, Joseph Yoo, Raza Hasan, Silpa Yalamanchili, Nicholas Tarangelo, Linda J Taylor, Douglas G Adler
January-February 2018, 7(1):34-40
DOI:10.4103/eus.eus_27_17  PMID:29451167
Background and Objectives: The ability to obtain adequate tissue of solid pancreatic lesions by EUS-guided remains a challenge. The aim of this study was to compare the performance characteristics and safety of EUS-FNA for evaluating solid pancreatic lesions using the standard 22-gauge needle versus a novel EUS biopsy needle. Methods: This was a multicenter retrospective study of EUS-guided sampling of solid pancreatic lesions between 2009 and 2015. Patients underwent EUS-guided sampling with a 22-gauge SharkCore (SC) needle or a standard 22-gauge FNA needle. Technical success, performance characteristics of EUS-FNA, the number of needle passes required to obtain a diagnosis, diagnostic accuracy, and complications were compared. Results: A total of 1088 patients (mean age = 66 years; 49% female) with pancreatic masses underwent EUS-guided sampling with a 22-gauge SC needle (n = 115) or a standard 22-gauge FNA needle (n = 973). Technical success was 100%. The frequency of obtaining an adequate cytology by EUS-FNA was similar when using the SC and the standard needle (94.1% vs. 92.7%, respectively). The sensitivity, specificity, and diagnostic accuracy of EUS-FNA for tissue diagnosis were not significantly different between two needles. Adequate sample collection leading to a definite diagnosis was achieved by the 1st, 2nd, and 3rd pass in 73%, 92%, and 98% of procedures using the SC needle and 20%, 37%, and 94% procedures using the standard needle (P < 0.001), respectively. The median number of passes to obtain a tissue diagnosis using the SC needle was significantly less as compared to the standard needle (1 and 3, respectively; P< 0.001). Conclusions: The EUS SC biopsy needle is safe and technically feasible for EUS-FNA of solid pancreatic mass lesions. Preliminary results suggest that the SC needle has a diagnostic yield similar to the standard EUS needle and significantly reduces the number of needle passes required to obtain a tissue diagnosis.
  1,238 247 12
Stent release within scope channel technique to prevent stent migration during EUS-guided hepaticogastrostomy (with video)
Takeshi Ogura, Atsushi Okuda, Akira Miyano, Nobu Nishioka, Kazuhide Higuchi
January-February 2018, 7(1):67-68
DOI:10.4103/eus.eus_57_17  PMID:29451173
  901 132 2
A case of gastric wall implantation caused by EUS-FNA 22 months after pancreatic cancer resection
Makiko Yasumoto, Yoshinobu Okabe, Hiroto Ishikawa, Jyunya Kisaki, Jun Akiba, Yoshiki Naito, Yusuke Ishida, Tomoyuki Ushijima, Osamu Tsuruta, Takuji Torimura
January-February 2018, 7(1):64-66
DOI:10.4103/eus.eus_58_17  PMID:29451172
  857 126 1
EUS-guided fine-needle biopsy for histological examination: Is it time to change our sampling technique?
Giulia Gibiino, Alberto Larghi
January-February 2018, 7(1):71-72
DOI:10.4103/eus.eus_56_17  PMID:29451175
  831 114 4
EUS-FNA using 22G nitinol or ProCore needles without on-site cytopathology
Charing Ching Ning Chong, Anthony Yuen Bun Teoh, Raymond Shing Yan Tang, Anthony Wing Hung Chan, Enders Kwok Wai Ng, Paul Bo San Lai
January-February 2018, 7(1):56-60
DOI:10.4103/eus.eus_113_17  PMID:29451170
Objectives: The project is aimed to compare the tissue sampling rate and the diagnostic accuracy rate of EUS-FNA using 22G nitinol and reverse bevel-tipped needles. Subjects and Methods: This was a prospective, randomized, crossover study in a tertiary academic hospital. All consecutive adult patients undergoing EUS-guided FNA for lesions > 2 cm were recruited. Patients fulfilling the inclusion and exclusion criteria underwent EUS-guided FNA using both needles in sequence. They were randomized on a 1:1 basis to determine whether EUS-FNA would be performed first using the 22G reverse bevel-tipped (ProCore) needle followed by the nitinol needle or vice versa. The patients and the pathologists were blinded to the type of needle used. Results: Forty patients with suspected malignant neoplasms were recruited to the study. No significant differences were found in the diagnostic yield (76.9% vs. 84.6%, P = 0.389), accuracy (71.8% vs. 84.6%, P = 0.170), sensitivity (77.8% vs. 86.1%, P = 0.358), specificity (100% vs. 100%, P = 1), positive predictive value (100% vs. 100%, P = 1), and negative predictive value (20.0% vs. 28.6%, P = 1). The percentage of obtained tissue for histological assessment was also similar (41.0% vs. 46.2%, P = 0.648). In terms of the quantity of tissue obtained with the needles, a larger proportion of patients in the nitinol group obtained more tissue for assessment (P = 0.003). Conclusion: The tissue-sampling rate and the diagnostic accuracy of the new 22G ProCore needle were comparable to the conventional 22G FNA needle in the absence of an on-site cytopathologist.
  787 121 1
Stent Tracker app: Novel method to track patients with indwelling lumen-apposing metal stents
Ji Young Bang, Shyam Varadarajulu
January-February 2018, 7(1):69-70
DOI:10.4103/eus.eus_50_17  PMID:29451174
  779 94 1
An unusual complication of cardia occlusion with lumen-apposing metal stent therapy for pancreatic pseudocyst
Yan Chen, Huiyun Zhu, Zhendong Jin, Zhaoshen Li, Yiqi Du
January-February 2018, 7(1):61-63
DOI:10.4103/eus.eus_99_17  PMID:29451171
  623 94 1