Endoscopic Ultrasound

EUS-directed transgastric access to the excluded stomach to facilitate pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy Robert A Moran, Saowanee Ngamruengphong, Omid Sanaei, Lea Fayad, Vikesk K Singh, Vivek Kumbhari, Mouen A Khashab Endoscopic Ultrasound 2019 8(3):139-145

Recent developments in hepatopancreatobiliary EUS Irina M Cazacu, Ben S Singh, Adrian Saftoiu, Manoop S Bhutani Endoscopic Ultrasound 2019 8(3):146-150 The last American College of Gastroenterology's (ACG) annual meeting was held in Philadelphia on October 5–10, 2018 and showcased a wide variety of the latest and upcoming research within the field of Gastroenterology. This article will present the advancements and research regarding endoscopic ultrasound (EUS) presented at this year's meeting with focus on hepatopancreatobiliary indications. Seventy studies related to EUS were presented; however, case reports and video forum presentations were excluded from this review. Many endosonographers investigated various aspects of EUS such as the tissue acquisition and diagnostic yields of fine-needle biopsies, the application of interventional EUS, and various novel techniques to advance the role of EUS. It would be very difficult to discuss all of the abstracts presented in details; however, we commend and encourage all endosonographers who presented at ACG to continue advancing research and development in EUS.

EUS-guided drainage: Summary of therapeutic EUS consortium meeting Michel Kahaleh, Everson L. A. Artifon, Manuel Perez-Miranda, Monica Gaidhane, Carlos Rondon, Martin Freeman, Rajeev Attam, Takao Itoi, Marc Giovannini Endoscopic Ultrasound 2019 8(3):151-160 EUS-guided drainage is a safe and efficacious endoscopic technique for biliary, pancreatic, and gallbladder decompression. Recent literature has described many successful procedural techniques and devices to achieve EUS-guided drainage. This consortium gathering advanced endoscopists with expertise in both ultrasonography and therapeutic endoscopy, discuss the introduction to learning several EUS-guided drainage approaches, devices, and technology involved, possible obstacles to certain procedural and all potential complications.

Imaging of infracolic and pelvic compartment by linear EUS Malay Sharma, Amol Patil, Avinash Kumar, Amit Pathak, Piyush Somani, Srijaya S Sreesh, Chittapuram Srinivasan Rameshbabu Endoscopic Ultrasound 2019 8(3):161-171 The peritoneal cavity is subdivided into supracolic and infracolic compartments by transverse mesocolon, which attaches the colon to the posterior abdominal wall. Infracolic compartment is subdivided into right and left compartment by small bowel mesentery. Left infracolic space freely communicates with pelvic compartment. The infracolic compartment contains the coils of small bowel which is separated from paracolic gutter on either side by ascending and descending colon. Pelvic compartment mainly contains bladder, rectum and genital organ (prostate, seminal vesicle in male and uterus in female). The evaluation of different compartments of peritoneum is gaining importance in multimodality imaging. It has become essential that clinicians and endosonographers thoroughly understand the peritoneal spaces and the ligaments and mesenteries that form their boundaries in order to localize disease to a particular peritoneal/subperitoneal space and formulate a differential diagnosis on the basis of that location. In this article we describe the applied EUS anatomy of peritoneal ligaments, infracolic and pelvic compartments of peritoneum and there technique of imaging from stomach, duodenum, sigmoid colon and rectum. Imaging from stomach images the infracolic compartment through transverse mesocolon, imaging from duodenum images the infracolic compartment through the mesentery and imaging from rectum and sigmoid images the infracolic and pelvic compartments through the sigmoid mesocolon and pelvic peritoneum.

Direct endoscopic necrosectomy at the time of transmural stent placement results in earlier resolution of complex walled-off pancreatic necrosis: Results from a large multicenter United States trial Linda Yan, Andrew Dargan, Jose Nieto, Reem Z Shariaha, Kenneth F Binmoeller, Douglas G Adler, Michael DeSimone, Tyler Berzin, Mandeep Swahney, Peter V Draganov, Dennis J Yang, David L Diehl, Lillian Wang, Asma Ghulab, Nausharwan Butt, Ali A Siddiqui Endoscopic Ultrasound 2019 8(3):172-179 Background and Objectives: EUS-guided drainage, and direct endoscopic necrosectomy (DEN) of walled-off necrosis (WON) using a lumen-apposing metal stent (LAMS) is safe and effective. Early debridement of WON may improve overall clinical outcomes. The aim of this study is to perform a multicenter retrospective study to compare the clinical outcomes and predictors of success for endoscopic drainage of WON with LAMS followed by immediate or delayed DEN performed at standard intervals. Methods: Patients with WON managed by EUS-guided drainage with LAMS were divided into 2 groups: (1) those that underwent immediate DEN at the time of stent placement and (2) those that underwent delayed DEN 1 week after stent placement. DEN was subsequently performed every 1–2 week (s). Technical success (successful placement of LAMS), adverse events (AEs), and clinical success (complete resolution of the WON) were evaluated. Results: Totally, 271 patients underwent WON drainage with LAMS: 69 who underwent immediate DEN and 202 who underwent delayed DEN. The technical success for LAMS placement was 100% in both groups. There was no significant difference in the overall procedural AEs between the immediate and delayed DEN groups (P = 7.2% vs. 9.4%; P = 0.81). Stent dislodgement during index endoscopy occurred in three patients in the immediate DEN group compared to zero in the delayed DEN group (P = 0.016); all three dislodgements occurred during necrosectomy. Clinical success for WON resolution in the immediate DEN group was 91.3% compared to 86.1% in the delayed DEN group (P = 0.3). The mean number of necrosectomy sessions for WON resolution was significantly lower in the immediate DEN group compared to the delayed DEN group (3.1 vs. 3.9, P < 0.001). Performing DEN at the time of stent placement was an independent predictor for resolution of WON with lesser number of DEN sessions (odds ratio 2.3; P = 0.004). Conclusions: DEN at the time of initial stent placement reduces the number of necrosectomy sessions required for successful clinical resolution of WON.

Performance characteristics of EUS-FNA biopsy for adrenal lesions: A meta-analysis Suhag Patel, Raxitkumar Jinjuvadia, Anupama Devara, Paul H Naylor, Mohammad Anees, Kartikkumar Jinjuvadia, Mohammad Al-Haddad Endoscopic Ultrasound 2019 8(3):180-187 Background and Objective: The role of EUS-FNA biopsy (EUS-FNAB) for detection of metastatic lesions (mets) to adrenals has not been evaluated systematically. Our aim is to systematically evaluate the performance characteristics of EUS-FNAB in detecting metastasis to the adrenal glands. Materials and Methods: We performed a systematic search on PubMed and OvidSP from January 1990 to July 2016 using various search terms for EUS and adrenal lesion. Only articles published in English literature were included in the study. Studies with fewer than 10 patients were excluded from the study. Publication bias was assessed using Begg-Mazumdar test and visual inspection of funnel plots. Results: Eight studies including 360 adrenal lesions that underwent EUS-FNAB were identified. Of these, 137 FNABs were conclusive for malignancy. Sensitivity of EUS-FNAB in detecting metastasis to the adrenals was 95% (95% confidence interval [CI]: 90%–98%) and specificity was 99% (95% CI: 96%–100%). Pooled positivity of EUS-FNAB in detecting lung cancer metastasis to the adrenals was 44% (95% CI: 31.5%–57.3%). No evidence of publication bias was noted. Conclusion: Our study demonstrates that EUS-FNAB is highly sensitive and specific in detecting metastasis to adrenals. It also shows that up to about half of the patients with lung cancer and adrenal lesions on imaging have metastasis, a finding with profound implications on lung cancer staging and treatment.

The underutilization of EUS-guided biliary drainage: Perception of endoscopists in the East and West Won Jae Yoon, Do Hyun Park, Jun Ho Choi, Sunguk Jang, Jason Samarasena, Tae Hoon Lee, Woo Hyun Paik, Dongwook Oh, Tae Jun Song, Joon Hyuk Choi, Kazuo Hara, Takuji Iwashita, Manuel Perez-Miranda, John G Lee, Enrique Vazquez-Sequeiros, Itaru Naitoh, Juan J Vila, William R Brugge, Mamoru Takenaka, Sang Soo Lee, Dong-Wan Seo, Sung Koo Lee, Myung-Hwan Kim Endoscopic Ultrasound 2019 8(3):188-193 Background and Objectives: EUS-guided biliary drainage (EUS-BD) is increasingly utilized to manage unresectable malignant biliary obstruction after a failed ERCP. However, there is no data on how endoscopists perceive EUS-BD. The aim of this study was to investigate the perception of endoscopists on EUS-BD. Patients and Methods: A survey questionnaire of six topics with 22 survey statements was developed. A total of 17 pancreatobiliary endoscopists (10 from East and 7 from West) were invited to survey. The participants were asked to answer the multiple choice questionnaire and give comments. The opinions of the participants for individual survey statements were assessed using 5-point Likert scale. Results: All participants completed the survey. The endoscopists had a trend to perceive EUS-BD as a procedure indicated after a failed ERCP. Various EUS-BD methods were regarded as having different efficacy and safety. The superiority of EUS-BD over percutaneous transhepatic BD (PTBD) with regard to efficacy, procedure-related adverse events, and unscheduled re-intervention was not in agreement. Conclusions: EUS-BD was not yet perceived as the initial procedure to relieve the unresectable malignant biliary obstruction. Various EUS-BD methods were regarded as having different efficacy and safety. The superiority of EUS-BD over PTBD was not in agreement. Refining the procedure, developing dedicated devices, and gaining expertise in the procedure are necessary to popularize EUS-BD.

Discontinuation of proton pump inhibitor use reduces the number of endoscopic procedures required for resolution of walled-off pancreatic necrosis Patrick C Powers, Ali Siddiqui, Reem Z Sharaiha, Grace Yang, Enad Dawod, Aleksey A Novikov, Amy Javia, Cynthia Edirisuriya, Arish Noor, Tayebah Mumtaz, Usama Iqbal, David E Loren, Thomas E Kowalski, Natalie Cosgrove, Yordano Alicea, Amy Tyberg, Iman Andalib, Michel Kahaleh, Douglas G Adler Endoscopic Ultrasound 2019 8(3):194-198 Background and Objectives: Endoscopic drainage/debridement of symptomatic walled off necrosis (WON) using lumen-apposing metal stents (LAMS) is both safe and effective. While endoscopic management of WON is the standard approach to treatment, the ideal concomitant medical therapy remains unclear. The purpose of this study was to further elucidate the effect of proton pump inhibitor (PPIs) therapy on the technical and clinical success of endoscopic treatment of WON. Methods: Two hundred and seventy-two patients in 8 centers with WON managed by endoscopic drainage using LAMS were evaluated. Patients were followed for at least 6 months following treatment. The patients were divided into two groups: Those that used PPIs continuously during the therapy and those not on PPIs continuously during the interval of therapy. Outcomes included but were not limited to technical success, clinical success, number of procedures performed, and adverse events. Results: From 2013 to 2016, 272 patients underwent WON drainage with successful transmural LAMS placement. The two groups were split evenly into PPI users and non-PPI users, and matched in regards to demographics, etiology of pancreatitis, WON size, and location. There was no difference in the technical success between the two groups (100% vs. 98.8%, P = 1), or in clinical success rates (78.7% vs. 77.9%). There was a significant difference in the required number of direct endoscopic necrosectomies to achieve clinical success in the PPI vs. non-PPI group (3.2 vs. 4.6 respectively, P < 0.01). There were significantly more cases of stent occlusion in the non-PPI group vs. PPI group (9.5% vs. 20.1% P = 0.012), but all other documented adverse events were not significantly different. Conclusion: Discontinuing PPIs during endoscopic drainage and necrosectomy of symptomatic WON appears to reduce the number of endoscopic procedures required to achieve resolution. Continuous PPI results in higher rates of early stent occlusion.

Drainage of the right liver under EUS guidance: A bridge technique allowing drainage of the right liver through the left liver into the stomach or jejunum Fabrice Caillol, Coline Bosshardt, Sylvia Reimao, Ellen Francioni, Christian Pesenti, Erwan Bories, Jean Philippe Ratone, Marc Giovannini Endoscopic Ultrasound 2019 8(3):199-203 Background and Objective: EUS-guided biliary drainage is now comparable to percutaneous drainage. This technique can be used in cases of complex drainage of the hilum, mainly for salvage therapy to drain the left liver. In cases of inaccessible papilla or altered anatomy, EUS-guided biliary drainage for hilar stenosis of the liver could be used as the first approach. However, this technique has limited applicability for the right liver. In this feasibility study, we reported drainage of the right liver using the bridge technique and hepaticogastrostomy. Patients and Methods: This retrospective study was based on a prospective registry from January 2013 to February 2017. Patients with inaccessible papilla due to altered anatomy or duodenal invasion and drainage under EUS guidance and bridge technique without previous biliary drainage were included in the study. The bridge technique was used to place an uncovered biliary stent between the right and left liver. The left liver was drained with a hepaticogastrostomy. Results: Twelve patients were included in the study. Stenosis was Type II for nine, IIIA for two, and Type IV for one patient. Technical and clinical success was 100% and 83%, respectively. Morbidity was 33% (four patients), including three with abdominal pain managed conservatively and one with a percutaneous salvage drainage. Postoperative mortality was 8% (uncontrolled sepsis). The mean survival was 6 months. Chemotherapy could be administered in 70% (seven) patients in cases of clinical success. Conclusion: The bridge technique under EUS guidance could be a first alternative for draining malignant hilar stenosis in cases of the inaccessible papilla.

Endobronchial ultrasound-guided transbronchial needle aspiration under general anesthesia versus bronchoscopist-directed deep sedation: A retrospective analysis Christian G Cornelissen, Johanna Dapper, Michael Dreher, Tobias Müller Endoscopic Ultrasound 2019 8(3):204-208 Background: Different sedation strategies are used during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnostic workup of lung cancer including general anesthesia (GA) and moderate sedation. However, no data are available about EBUS-TBNA under deep sedation (DS) with fiberoptic intubation directed by the investigator. Materials and Methods: A retrospective analysis of EBUS-TBNAs under GA (n = 160) or DS (n = 105) was performed. Results: Unadjusted diagnostic yield did not differ significantly between the groups (GA: 42.5% vs. DS: 53.3%P= 0.1018). Similar results were obtained when only patients with a final diagnosis of malignancy were analyzed (GA: 53.6% vs. DS: 61.5%P= 0.2675). Adverse events (AEs) occurred more often under DS (GA: 27.5% vs. DS: 59.1%P< 0.0001) due to more sedation-related problems whereas severe AEs tended to be higher under GA (GA: 7.5% vs. DS: 1.9%P= 0.0523). Conclusion: In summary, our data show that the diagnostic yield and the complication rate of EBUS-TBNA performed under DS are similar compared to GA. Hence, in an appropriate setting, EBUS-TBNA can be performed safely under DS.

Alexandros Sfakianakis
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alsfakia@gmail.com