Endoscopic Ultrasound Research Articles

Safety and Efficacy of Novel Cost-Effective EUS Coiling and Glue Technique for the Management of Large Gastric Varices: A Long-Term Follow-up Study

Abstract Aims and Objective Mortality by gastric variceal bleeding can reach up to 30%. Gastric varices can be treated by either direct endoscopic glue or endoscopic ultrasound (EUS) coiling + glue injection. Now, enough data show that EUS coil + glue is an effective option for large varices. However, it is a costlier option than direct endoscopic glue injection. In our study, after putting the coil under EUS guidance, direct endoscopic glue injection is done with a 21G sclerotherapy needle. Since the EUS needle was not used for the glue injection, it can be reused for up to three cases for deployment of the EUS coil, hence reducing the cost of the whole procedure. In short, our study aims to find the safety and efficacy of a cost-effective method of EUS coiling + glue injection in a cohort of the Indian population. Material and Methods Retrospective review of prospectively collected data on EUS coiling + direct endoscopic glue injection over a period spanning from July 2017 to December 2023 from a tertiary care center in North India. Results A total of 103 patients (gastroesophageal varices type 2, GOV2 [n = 82] and isolated gastric varices type 1, IGV1 [n = 21]) were taken up for the study. Among the 103 patients, 74 patients were males and 29 were females. The mean follow-up duration of the study population was 34.2 ± 21 months. The average size of the varix was 2.3 cm. The average number of coils was 3.3 and the volume of injected glue was 3.1 mL. In our study, 4 out of 103 patients had rebleeding, but the cause of rebleeding turned out to be nonvariceal. Regarding the intraprocedural and postprocedural adverse events, 1 out of 103 patients in our study experienced abdominal pain and fever, which responded to oral analgesics and antipyretics. There was no active bleeding from the puncture site or evidence of systemic embolization. Technical success was 100% in our study. Reuse of needles was not associated with any increment in risk of infection. Conclusion EUS coiling + direct endoscopic glue injection is a safe and effective endoscopic therapy for large gastric varices with sustainable long-term beneficial effects with a negligible amount of rebleeding. Direct endoscopic injection of glue following EUS coiling with a 21G sclerotherapy needle can significantly reduce the cost of the procedure without any risk of infection.

The Role of Therapeutic Endoscopic Ultrasound in Management of Malignant Double Obstruction (Biliary and Gastric Outlet): A Comprehensive Review with Clinical Scenarios

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life.

Stent misdeployment and factors associated with failure in endoscopic ultrasound-guided choledochoduodenostomy: analysis of the combined datasets from two randomized trials.

Stent misdeployment (SMD) is a feared and poorly characterized technical challenge of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) using lumen-apposing stents. We aimed to ascertain the rate of stent misdeployment in EUS-CDS for malignant distal biliary obstruction (MDBO) and describe its outcomes while identifying variables associated with its occurrence. This was a post hoc analysis of two randomized controlled trials comparing EUS-CDS vs. endoscopic retrograde cholangiopancreatography in MDBO. The primary end point was rate of SMD, classified as misdeployment of the distal flange (type I), proximal flange (type II), contralateral bile duct wall injury (type III), or double mucosal puncture (type IV). Multivariable analysis was performed to identify variables associated with SMD and/or technical failure, and with clinical failure or stent dysfunction. 152 patients were included. Technical success was 93.4 %. SMD occurred in 11 patients (7.2 %; 95 %CI 3.1 %-11.4 %): 8 type I, 1 type II, and 2 type III. Endoscopic salvage of SMD was successful in 81.8 %. Misdeployment led to adverse events in four patients (two mild, two moderate), giving an overall SMD-related adverse event rate of 2.6 % (95 %CI 0.7 %-6.6 %). On multivariable analysis, extrahepatic bile duct diameter of ≤ 15 mm was associated with increased odds of SMD and/or technical failure. SMD was relatively common in EUS-CDS and was associated with an extrahepatic bile duct diameter of ≤ 15 mm. The majority of misdeployments could be rescued endoscopically with low risk for adverse events.

Fasciola hepatica Diagnosed with Endoscopic Ultrasound and Treated with Endoscopic Retrograde Cholangio Pancreatography: A Case Report

This article discusses Fasciola hepatica infection, a zoonotic parasite that lives in the liver bile ducts. A 31-year-old female patient was diagnosed with symptoms such as nausea, increased liver enzymes, and right upper quadrant pain for about a year. The parasite was detected in the common bile duct by Endoscopic Ultrasound (EUS) and removed by Endoscopic Retrograde Cholangio Pancreatography (ERCP). Treatment was performed with 10 mg/kg triclabendazole. Eosinophilia, abdominal pain, and dietary history are important clues in the diagnosis of infection. Imaging methods, especially EUS, play a critical role in diagnosis. With this method, parasites can be seen as mobile hyperechogenic structures. If untreated, parasites can survive in their hosts for many years, therefore early diagnosis and treatment are important in preventing complications. It is recommended to monitor the eosinophil levels and serological test results of patients after treatment. As a result, EUS is a very valuable diagnostic tool in suspected cases.

Endoscopic Ultrasound-Guided Pancreatic Tissue Sampling: Lesion Assessment, Needles, and Techniques

Endoscopic ultrasound (EUS)-guided tissue sampling includes the techniques of fine needle aspiration (FNA) and fine needle biopsy (FNB), and both procedures have revolutionized specimen collection from the gastrointestinal tract, especially from remote/inaccessible organs. EUS-FNB has replaced FNA as the procedure of choice for tissue acquisition in solid pancreatic lesions (SPLs) across various society guidelines. FNB specimens provide a larger histological tissue core (preserving tissue architecture) with fewer needle passes, and this is extremely relevant in today’s era of precision and personalized molecular medicine. Innovations in needle tip design are constantly under development to maximize diagnostic accuracy by enhancing histological sampling capabilities. But, apart from the basic framework of the needle, various other factors play a role that influence diagnostic outcomes, namely, sampling techniques (fanning, aspiration or suction, and number of passes), collection methods, on-site evaluation (rapid, macroscopic, or visual), and specimen processing. The choice taken depends strongly on the endoscopist’s preference, available resources at the disposal, and procedure objectives. Hence, in this review, we explicate in detail the concepts and available literature at our disposal on the topic of EUS-guided pancreatic tissue sampling to best guide any practicing gastroenterologist/endoscopist in a not-to-ideal set-up, which EUS-guided tissue acquisition technique is the “best” for their case to augment their diagnostic outcomes.

Case report: Esophageal bulge with white patch: endoscopic removal of leiomyoma and high-grade intraepithelial neoplasia

Esophageal leiomyoma is the most common benign intramural tumor of the esophagus. Despite being the most common benign tumor in its category, esophageal leiomyomas constitute only 1.2% of all esophageal tumors. While esophageal leiomyoma itself is uncommon, the occurrence of multiple esophageal leiomyomas is even rarer, and the coexistence of high-grade squamous intraepithelial neoplasia (HGIN), involving both epithelial and mesenchymal tissues, is exceedingly rare. This case report describes a patient with multiple esophageal leiomyomas and localized HGIN, diagnosed using endoscopic ultrasonography, which identified a submucosal lesion within the muscularis mucosae. The lesion was successfully treated using endoscopic high-frequency electrocoagulation resection. This minimally invasive approach proved to be precise, safe, and effective, offering therapeutic outcomes comparable to those of traditional surgical resection, as confirmed by postoperative pathological analysis. As a primary goal, the abstract should render the general significance and conceptual advance of the work clearly accessible to a broad readership. References should not be cited in the abstract. Leave the Abstract empty if your article does not require one – please see the “Article types” on every Frontiers journal page for full details.

Biliary sphincterotomy resets pancreaticobiliary pain refractory to intrasphincteric Botox injections in functional biliary pain.

The management of Type III sphincter of Oddi dysfunction or functional biliary pain (FBP) is challenging. A strategy of intermittent intrasphincteric botulinum toxin (Botox) injections into the sphincter of Oddi can alleviate pancreaticobiliary pain. In patients who lose response to intermittent Botox injections, endoscopic biliary sphincterotomy (ES) could potentially reset pain facilitating ongoing management of symptoms. A retrospective review of case notes over a seven-year period (2014-2021) was performed. All patients underwent blood tests, gastroscopy, trans-abdominal ultrasonography, cross-sectional imaging withmagnetic resonance cholangiopancreatography (MRCP)/computed tomography (CT) and endoscopic ultrasound (EUS)to rule out alternative causes for their symptoms of pancreaticobiliary pain. A diagnosis of FBP was made in patients with typical post-cholecystectomy pain and normal liver function tests and bile duct size on imaging. Patients with symptomatic FBP underwent intermittent endoscopic Botox injections to the sphincter of Oddi. Patients who lost response to Botox injections underwent ES and were followed up in an outpatient setting to assess response. One hundred and thirty (128 female, 2 male) patients with FBP underwent a mean of four (2-8) Botox injections over the study period. Of 130 (90%) patients, 117 reported a significant improvement in pain on post procedure review with 81% of patients managing to discontinue opioid medication post procedure. Fifty-one out of 130 (39%) lost response to Botox injections after a median of six (range 5-11) sessions (median eightmonths between sessions [range 6-18months]) and continued to have ongoing pancreaticobiliary pain and subsequently underwent biliary ES. Forty-one out of 50 (82%) reported a clinical improvement in their symptoms of pancreaticobiliary pain following ES, with response persisting at follow-up for up to mean of eight (5-15) months and no further hospital attendances due to severe pancreaticobiliary pain. ES can reset pancreaticobiliary pain in FBP once Botox injection therapy to the sphincter of Oddi becomes ineffective and may provide ongoing relief of symptoms.

Interdigitating dendritic cell sarcoma presenting as retroperitoneal mass and obstructive jaundice. An uncommon entity of complex diagnosis.

A 60-year-old male was admitted for obstructive jaundice secondary to a 2 cm retroperitoneal lesion. Ultrasound endoscopy (UES) with fine needle biopsy (FNB) was performed, as well as endoscopic retrograde cholangiopancreatography (ERCP) with placement of a metal stent for bile duct drainage. Initially IgG4-related disease was suspected from FNB. After 8 months of treatment the patient attended with a progression evidenced in computed tomography (CT) with retroperitoneal adenopathies and liver metastasis, with involvement of duodenum and fistulation towards hepatic angle of colon. Upper endoscopy and colonoscopy was performed. The patient underwent a cephalic duodenopancreatectomy with antrectomy and right hemicolectomy. The histological study of the specimen revealed cells of fascicular distribution, fusiform aspect, with ovoid nuclei, accompanied by a polymorphic inflammatory infiltrate with mononuclear cells. Immunohistochemistry (IHQ) was positive for S100, CD21, CD23, D2-40 and Bcl-2 and negative for CD1a, CD2, CD3, CD4, CD5, CD8, CD20, CD79a, PD1, desmine, langherin, c-kit, PDGFR. These findings were suggestive of interdigitating dendritic cell sarcoma (IDCS). Systemic chemotherapy with R-CHOP was initiated and after the first 4 cycles of treatment, retroperitoneal adenopathies regressed, with stability of metastatic liver disease.

Validity evidence for endoscopic ultrasound competency assessment tools: Systematic review.

Background and study aims Competent endoscopic ultrasound (EUS) performance requires a combination of technical, cognitive, and non-technical skills. Direct observation assessment tools can be employed to enhance learning and ascertain clinical competence; however, there is a need to systematically evaluate validity evidence supporting their use. We aimed to evaluate the validity evidence of competency assessment tools for EUS and examine their educational utility. Methods We systematically searched five databases and gray literature for studies investigating EUS competency assessment tools from inception to May 2023. Data on validity evidence across five domains (content, response process, internal structure, relations to other variables, and consequences) were extracted and graded (maximum score 15). We evaluated educational utility using the Accreditation Council for Graduate Medical Education framework and methodological quality using the Medical Education Research Quality Instrument (MERSQI). Results From 2081 records, we identified five EUS assessment tools from 10 studies. All tools are formative assessments intended to guide learning, with four employed in clinical settings. Validity evidence scores ranged from 3 to 12. The EUS and ERCP Skills Assessment Tool (TEESAT), Global Assessment of Performance and Skills in EUS (GAPS-EUS), and the EUS Assessment Tool (EUSAT) had the strongest validity evidence with scores of 12, 10, and 10, respectively. Overall educational utility was high given ease of tool use. MERSQI scores ranged from 9.5 to 12 (maximum score 13.5). Conclusions The TEESAT, GAPS-EUS, and EUSAT demonstrate strong validity evidence for formative assessment of EUS and are easily implemented in educational settings to monitor progress and support learning.

Role of high-resolution magnetic resonance imaging in preoperative tumor-node-metastasis staging evaluation of esophageal cancer: a narrative review.

Esophageal cancer (EC) is an aggressive disease characterized by high mortality rates and a propensity for locoregional or distant recurrence. The treatment strategies and prognostic estimation for EC depend on accurate pre-treatment tumor-node-metastasis (TNM) staging. The objective of this review was to illustrate the role of various imaging modalities in achieving accurate preoperative TNM staging of EC, with a particular focus on the utilization of advanced high-resolution magnetic resonance imaging (MRI) sequences for T classification, which have shown promise in enhancing the delineation of tumor depth and extent. A comprehensive literature search was conducted in PubMed and Web of Science databases. The studies on imaging in preoperative TNM staging of EC published in English from inception of these databases to December 31, 2022 were reviewed. The review highlights the distinct advantages and inherent limitations of different imaging modalities for the preoperative staging of EC. Endoscopic ultrasound (EUS) provides real-time, high-resolution imaging of the esophageal wall but is operator-dependent. Computed tomography (CT) is widely available and non-invasive, but it may lack sensitivity for early T-stage identification. Positron emission tomography (PET)/CT offers accurate assessment of distant metastasis but has limited value in the evaluation of early-stage tumors. With improved techniques, MRI is particularly useful for visualization of tumor infiltration and the surrounding anatomical structures, gaining prominence in preoperative staging of EC. Various imaging modalities including EUS, CT, PET/CT, and MRI should be applied as complementary methods for preoperative TNM staging of EC. Notably, high-resolution MRI can overcome motion-related artifacts and provide high-quality images, which may play a more important role in the management of EC in the future.

Accuracy of endoscopic ultrasound (EUS) elastography for the diagnosis of malignancy of solid pancreatic tumors. A prospective registry from a reference center

Accuracy of endoscopic ultrasound (EUS) elastography for the diagnosis of malignancy of solid pancreatic tumors. A prospective registry from a reference center

Reliability of clinical examination for the assessment of obstetric anal sphincter injuries. A comparative study with 3D endoanal ultrasonography

Reliability of clinical examination for the assessment of obstetric anal sphincter injuries. A comparative study with 3D endoanal ultrasonography

Transjugular intrahepatic portosystemic shunt combined with endoscopic ultrasonography for portal vein recanalization and biopsy in malignant occlusion of the portal vein.

Transjugular intrahepatic portosystemic shunt combined with endoscopic ultrasonography for portal vein recanalization and biopsy in malignant occlusion of the portal vein.

Application Value of Endoscopic Ultrasonography in Diagnosis and Treatment of Inflammatory Bowel Disease.

Inflammatory bowel disease refers to a group of non-specific inflammatory illnesses affecting the gastrointestinal tract. According to pathogenic characteristics, it is divided into Ulcerative colitis and Crohn's disease. The exact cause and pathogenic mechanism of these disorders are not yet fully understood. Inaddition, there is currently no definitive diagnostic method for inflammatory bowel disease, which mainly depends on clinical symptoms, blood testing, imaging investigations, and endoscopic examination, which includes histology. Endoscopic Ultrasonography is a digestive tract examination technique that combines endoscopy and ultrasound. Compared to conventional endoscopy, it can visualize surface and deep lesions of the gastrointestinal wall, as well as provide information on the characteristics of the surrounding layers and nearby lymph nodes. Due to these advantages, Endoscopic Ultrasonography has played a significant role in the evaluation of inflammatory bowel disease in recent years. Through this work, we aim to identify the applications of this method in the case of patients with inflammatory bowel disease.

Safety and efficacy of lumen-apposing metal stents for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis.

Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) has variable outcomes according to the type of lumen-apposing metal stent (LAMS) used. We aimed to perform a systematic review and meta-analysis of the available data. Online databases, including EMBASE, PubMed, and SCOPUS, were searched from inception to 30 January 2024. The outcomes of interest were technical success, clinical success, adverse events (AEs), and the need for endoscopic necrosectomy. Pooled estimates stratified by the type of stent (Axios, Nagi, or Spaxus), severity of bleeding, and type of PFC were calculated using a random-effects model. Heterogeneity was assessed by I 2 values. 37 studies were included in the final analysis. The pooled outcomes (95%CIs) for PFC drainage using the Axios, Nagi, and Spaxus stents, respectively, were: technical success 97.7% (96.4%-98.8%), 96.9% (94.6%-98.5%), 98.2% (94.4%-99.9%); clinical success 90.9% (88.7%-92.8%), 88.5% (79.9%-95.0%), 93.5% (91.0%-95.6%); total AEs 20.4% (16.6%-24.6%), 17.1% (8.3%-28.3%), 7.6% (3.6%-13.0); migration 4.2% (2.9%-5.7%), 7.8% (4.1%-12.4%), 0.9% (0.1%-2.8%); overall bleeding 7.0% (4.9%-9.5%), 4.4% (2.2%-7.4%), 1.8% (0.8%-3.3%); and endoscopic necrosectomy 54.5% (38.9%-69.7%), 16.0% (11.4%-21.3%), 19.9% (6.6%-38.1%). In terms of severity, moderate-severe bleeding was most common with all three stents. AEs were higher in patients with walled-off necrosis compared with pseudocysts. Substantial-to-considerable heterogeneity (I 2 >60%) was present for total AEs for all of the stents. Our study shows good technical and clinical success rates with all three LAMSs for EUS-guided PFC drainage. Total AEs and bleeding were highest with the Axios stent and lowest with the Spaxus. Stent migration was highest with the Nagi stent and lowest with the Spaxus.

Enhanced dual-mode imaging: Superior photoacoustic and ultrasound endoscopy in live pigs using a transparent ultrasound transducer.

Dual-mode photoacoustic/ultrasound endoscopy (ePAUS) is a promising tool for preclinical and clinical interventions. To be clinically useful, ePAUS must deliver high-performance ultrasound imaging comparable to commercial systems and maintain high photoacoustic imaging performance at long working distances. This requires a transducer with an intact physical aperture and coaxial alignment of acoustic and optical beams within the probe, a challenging integration task. We present a high-performance ePAUS probe with a miniaturized, optically transparent ultrasonic transducer (TUT) called ePAUS-TUT. The 1.8-mm-diameter probe, fitting into standard endoscopic channels, aligns acoustic and optical beams efficiently, achieving commercial-level ultrasound and high-resolution photoacoustic imaging over long distances. These imaging capabilities were validated through in vivo imaging of a rat's rectum and a pig's esophagus. The ePAUS-TUT system substantially enhances feasibility and potential for clinical applications.

Adherence to the dietary approaches to stop hypertension (DASH) and risk of pancreatic steatosis

BackgroundThe Dietary Approach to Stop Hypertension (DASH) has shown positive effects on various health factors that may be related to pancreatic steatosis (PS). This study aimed to investigate the association between adherence to the DASH diet and the risk of developing PS.MethodsThis case-control study was conducted on 278 patients diagnosed with gallstone disease and referred to Taleghani Hospital (Tehran, Iran). Among the participants, 89 were diagnosed with PS based on an endoscopic ultrasound (EUS) examination, while 189 patients did not exhibit this condition. The dietary intake of patients was assessed using a validated food frequency questionnaire (FFQ). Participants were classified based on the DASH diet score. Multiple logistic regression models estimated crude and multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs).ResultsThe mean ± SD of DASH score in PS patients and controls was 23.68 ± 4.38 and 25.27 ± 4.2, respectively (P = 0.006). The risk of PS in the highest tertile of DASH score was 64% lower than the lowest tertile (OR = 0.36, 95%CI: 0.17–0.75, P = 0.005) after full adjustment for confounders. Also, more intake of vegetables and whole grains and less intake of sodium, red and processed meat were each significantly associated with reduced risk of PS.ConclusionsOur data prove that adherence to the DASH diet was associated with a lower risk of PS. Further prospective studies are warranted to confirm these associations and explore the underlying mechanisms.

Analytical modeling and non-dimensionalization study for endoscopic ultrasound acoustic field in tubular structure

The concept of endoscopic ultrasound (EUS) has been introduced to non-destructive testing for the internal inspection of tubular structure. It is a typical inspection application on layered media with a non-planar interface. Existing research in this area is hindered by two significant limitations: i) the absence of an EUS acoustic field model that is adaptable to the layered medium with non-planar interfaces; ii) the lack of a generalizable analysis and regularity of the EUS acoustic field distribution. This paper derives a refraction model for the tube interface and delay law. By combining these with the angular spectrum model, an analytical acoustic field model for EUS in tubular structure is developed, providing the theoretical framework for acoustic field analysis and interpretation. Subsequently, the geometric and acoustic parameters of the transducer and the tubular object are non-dimensionalized to normalize diverse EUS inspection scenarios. A parametric analysis is then conducted to identify and comprehend the regularity of the EUS acoustic field distribution, which is the main object of this study. The derived EUS acoustic field regularity is validated through an EUS inspection experiment of a tube using control variate method. The quantitative analysis result of the EUS imaging aligns with the expectations from beam analysis. The proposed analytical model is applicable to any scenarios with multi-layered media and with arbitrary interfaces. Its primary strength lies in its intuitive ability to demonstrate the impact of various parameters on the acoustic field distribution. The methodology of non-dimensionalization provides a paradigm for deriving generalizable regularities in the field of ultrasonic testing and imaging.

Impact of tumor type and size on macroscopic tissue core retrieval in endoscopic ultrasound-guided fine needle biopsy for pancreatic malignancies.

Endoscopic ultrasonography (EUS) is pivotal for diagnosing and sampling pancreatic tumor tissues. This study aimed to assess how the histological type and size of tumors influence the adequacy of macroscopic tissue cores acquired using EUS-guided fine needle biopsy (FNB). We conducted a retrospective study involving 180 patients with pathologically confirmed pancreatic malignancies at our hospital, a medical center, between July 2020 and June 2023. Personal and clinical data, EUS findings, and pathological results were extracted from the patient records. The macroscopic tissue core acquisition rate was 86.1%. Patients with tumors larger than 3cm had a higher sufficiency rate (93.3%) compared to those with tumors 3cm or smaller (78.9%, p = 0.005). It was more difficult to obtain sufficient tissue cores from neuroendocrine tumors than from adenocarcinomas (67.7% vs. 89.9%, p = 0.001). Interestingly, obtaining a sufficient tissue core only affected the diagnostic rate of adenocarcinoma (93.3% vs. 60%, p < 0.001) but did not significantly influence the diagnostic rate of neuroendocrine tumors. This study highlights that small tumors (< 3cm) and neuroendocrine tumors pose a challenge in obtaining sufficient tissue cores. However, obtaining sufficient tissue cores significantly influences the pathological diagnosis of FNB in adenocarcinoma but not in neuroendocrine tumors.

Application of EUS or MRCP prior to ERCP in patients with suspected choledocholithiasis in clinical practice

Background: Patients with symptomatic cholelithiasis can be stratified according to the 2019 European Society for Gastrointestinal Endoscopy (ESGE) guideline into low-, intermediate- and high-likelihood groups for the presence of choledocholithiasis. For the intermediate group, endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is recommended to assess whether an endoscopic retrograde cholangiopancreatography (ERCP) is necessary prior to cholecystectomy. Objective: The aim of the study is to investigate adherence to the guideline for diagnostic and treatment strategy for cholelithiasis in daily clinical practice. Patients and methods: Multicenter, retrospective cross-sectional observational study of the diagnostic pathway of patients with suspicion of choledocholithiasis between 2019 and 2021. Patients were stratified according to the ESGE guideline "Endoscopic management of common bile duct stones”. Results: A total of 305 patients were included in the analysis and stratified into low- (17%), intermediate- (40%) and high- (43%) likelihood of choledocholithiasis. In these three categories, 182 (60%) patients underwent ERCP. Adherence to the ESGE guideline recommendation was 59.7% overall and was the highest in the intermediate-likelihood group (83.6%), compared to 45.1% in the low- and 43.2% in the high-likelihood group, respectively (p &lt;.001). In the high-likelihood group, 49% underwent additional imaging. In 195 patients who underwent additional imaging, 55 ERCPs (28.2%) could be avoided. Conclusion: This study shows that stratification according to the ESGE guideline is useful to reduce the number of unnecessary additional imaging procedures and ERCPs in patients with a suspicion of choledocholithiasis. It seems worthwhile to perform EUS prior to the ERCP in the same session.