Diagnostic Endoscopic Ultrasound Research Articles

Curriculum for diagnostic endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in diagnostic endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in diagnostic EUS. This curriculum is set out in terms of the prerequisites prior to training; the recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1: Trainees should have achieved competence in upper gastrointestinal endoscopy before training in diagnostic EUS. 2: The development of diagnostic EUS skills by methods that do not involve patients is advisable, but not mandatory, prior to commencing formal training in diagnostic EUS. 3: A trainee's principal trainer should be performing adequate volumes of diagnostic EUSs to demonstrate maintenance of their own competence. 4: Training centers for diagnostic EUS should offer expertise, as well as a high volume of procedures per year, to ensure an optimal level of quality for training. Under these conditions, training centers should be able to provide trainees with a sufficient wealth of experience in diagnostic EUS for at least 12 months. 5: Trainees should engage in formal training and supplement this with a range of learning resources for diagnostic EUS, including EUS-guided fine-needle aspiration and biopsy (FNA/FNB). 6: EUS training should follow a structured syllabus to guide the learning program. 7: A minimum procedure volume should be offered to trainees during diagnostic EUS training to ensure that they have the opportunity to achieve competence in the technique. To evaluate competence in diagnostic EUS, trainees should have completed a minimum of 250 supervised EUS procedures: 80 for luminal tumors, 20 for subepithelial lesions, and 150 for pancreaticobiliary lesions. At least 75 EUS-FNA/FNBs should be performed, including mostly pancreaticobiliary lesions. 8: Competence assessment in diagnostic EUS should take into consideration not only technical skills, but also cognitive and integrative skills. A reliable valid assessment tool should be used regularly during diagnostic EUS training to track the acquisition of competence and to support trainee feedback. 9: A period of supervised practice should follow the start of independent activity. Supervision can be delivered either on site if other colleagues are already practicing EUS or by maintaining contacts with the training center and/or other EUS experts. 10: Key performance measures including the annual number of procedures, frequency of obtaining a diagnostic sample during EUS-FNA/FNB, and adverse events should be recorded within an electronic documentation system and evaluated.

THE IMPACT OF THE COVID-19 PANDEMIC ON ENDOSCOPIC ULTRASOUND PROCEDURES IN A HIGH-VOLUME ENDOSCOPY UNIT IN BRAZIL.

•In pancreatic neoplasms the EUS plays a key role in the management. •During the pandemic period, lockdown measures prevented patients with comorbidities from performing EUS. •The D-EUS decreased during COVID-19, while I-EUS increased and EUS-TA was the most commonly I-EUS procedure performed, with no increase in adverse events. •Despite the moderate impact of the pandemic period in endoscopic services around the world, EUS-TA of solid and cystic tumors of the pancreas was the main indication. Background - Reports of the impact of the 2020 COVID-19 pandemic period/2020 on endoscopic ultrasound (EUS) are scarce. Objective - We analyzed the impact of the pandemic period/2020 on the demographics, indications, and number of diagnostic EUS (D-EUS) and interventional EUS (I-EUS) procedures performed in a high-volume endoscopy unit compared with the previous non-pandemic period/2019. Methods - We retrospectively reviewed the medical records of all patients undergoing D-EUS or I-EUS from March 1, 2019, to February 29, 2020 (non-pandemic period/2019) and from March 1, 2020, to February 28, 2021 (pandemic period/2020). Data compared between the study periods included sex, age, comorbidities, EUS findings and diagnosis, need for interventional procedures during EUS, and adverse events (AEs). Results were significant at P<0.05. Results - EUS procedures decreased from 475 in the non-pandemic period/2019 to 289 in the pandemic period/2020, accounting for a 39% reduction. In non-pandemic period/2019, 388 (81.7%) D-EUS and 88 (18.5%) I-EUS were performed, against 206 (71.3%) D-EUS and 83 (28.7%) I-EUS in pandemic period/2020 (P=0.001). Only 5/289 (1.7%) patients had COVID-19. Fewer patients with comorbidities underwent EUS during pandemic period/2020 due to lockdown measures (P<0.001). D-EUS decreased, whereas I-EUS increased (P<0.001). EUS-guided tissue acquisition (EUS-TA) was the most common I-EUS, performed in 83/289 (28.7%) patients in pandemic period/2020, against 88/475 (18.5%) in non-pandemic period/2019 (P=0.001). AEs did not differ significantly between the study periods. Conclusion - Pandemic Period/2020 had a moderate impact on reducing EUS procedures due to the risks involved. Although I-EUS increased, EUS-related AEs did not. Solid and cystic pancreatic tumors remained a major indication for EUS-TA even during the pandemic period/2020.

Proposal and Validation of New Diagnostic Criteria for Diagnostic Weights of Endoultrasonographic Findings for Early Chronic Pancreatitis.

[Background and study aim] A commonly applied method for diagnosing chronic pancreatitis (CP) uses endoscopic ultrasonography (EUS), assigning weights to each EUS diagnostic finding. It is the Rosemont classification (RC). In 2019, to improve EUS diagnostic specificity, Japanese diagnostic criteria for early chronic pancreatitis (ECP) were revised. Nevertheless, the criteria use no weighting of EUS diagnostic findings, as the RC does. This study was undertaken to propose diagnostic criteria that would weight each EUS finding of ECP and that would be more specific than the RC. [Methods] By EUS of the pancreas, 773 patients underwent detailed observation from January 2018 to March 2019 at our institution. An expert finalized all cases when patients were diagnosed. Using data from the medical records, 97 consecutive patients with EUS diagnostic findings of ECP based on the Japanese diagnostic criteria of ECP2009 (JDCECP2009) were selected. The definition under the RC of "Indeterminate for CP" was equivalent to ECP. Each case was diagnosed using (1) JDCECP2009 and (2) the Japanese diagnostic criteria of ECP2019 (JDCECP2019). Moreover, the four diagnostic EUS findings in JDCECP2019 were applied to the RC, weighted (modified-JDCECP2019), and subsequently compared with the earlier diagnostic criteria. As Modified-JDCECP2019, we suggested (3) RC-A-the current four items scored related to the RC, and (4) RC-B-the five items scored by dividing lobularity with and without honeycombing. [Results] Diagnoses produced based on each criterion were normal: ECP = (1) 20:77, (2) 46:51, (3) 52:42, and (4) 60:35. [Conclusions] Modified-JDCECP2019 may provide EUS diagnoses for ECP with higher specificity.

The Endoscopic Ultrasound Molecular Analysis of Pancreatic Cancer (EUMEPC) study.

751 Background: Pancreatic cancer carries a dismal prognosis and limited treatment options. Attempts to implement precision therapies have proved difficult to date, in part due to challenges obtaining high quality genetic material from pancreatic biopsies. Endoscopic ultrasound (EUS) is a common diagnostic procedure, but limited data is available on the clinical utility of these biopsies for comprehensive molecular profiling (CMP) to inform therapeutic choices. Methods: This study aimed to enrol up to 150 patients undergoing EUS biopsies for pancreatic cancer, in order to complete targeted DNA/RNA sequencing on 100. The primary outcome was to characterise the proportion of patients able to undergo CMP on their diagnostic EUS biopsies, with fresh-frozen biopsies preferred but FFPE specimens accepted if there was no alternative. Secondary endpoints included the proportion of patients with clinically relevant molecular findings as determined by Molecular Tumour Board (MTB) discussion, proportion of patients initiating targeted therapies, and quantitative/qualitative analysis on molecular material derived from fresh-frozen versus FFPE EUS biopsies. Results: 109 patients have been enrolled since May 2020, and molecular profiling has been completed for 102 patients. 2 patients (1.8%) were excluded due to having no available biopsies, and 5 biopsies (4.7%) were unable to be sequenced due to inadequate quality metrics. Common oncogenes were detected at roughly expected frequencies, with mutations in KRAS occurring in 91 (89.2%), TP53 in 67 (65.7%), SMAD4 in 11 (10.8%) and CDKN2A in 7 (6.8%). Median tumour mutation burden (TMB) in this cohort was low at 3.1Mut/Mb although 7 patients (6.9%) had a high TMB (defined as &gt;10Mut/Mb), of which 3 (2.9%) had markedly hypermutated tumours (&gt;200Mut/Mb). All processed samples were microsatellite stable. Therapeutically relevant mutations were detected in 21 (20.6%) including RNF43 in 7 patients (6.9%), KRAS G12C and BRCA in 3 patients each (2.9%), in addition to BRAF V600E in 2 (1.9%), and CHEK2 and BARD1 mutations in 1 each (0.9%). High TMB was observed in 7 patients (6.9%). To date, 5 patients (4.9%) have commenced on targeted therapies, with one patient notably experiencing a complete response to targeted therapy which has now been sustained for &gt;12 months. Conclusions: This real-world study confirms the utility of endoscopic biopsies as a valuable and reliable source of genetic material for clinically relevant molecular tumour profiling. Secondary analyses are underway to further characterise treatment and survival implications in this cohort.

Chronic follicular pancreatitis: a space occupying lesion with spontaneous resolution.

Follicular pancreatitis (FP) is an extremely odd entity characterized by the presence of a pseudotumor that histologically presents lymphoid aggregates and germinal centers. The authors present the case of a 67-year-old woman with epigastric pain and jaundice. Endoscopic ultrasonography (EUS) was performed, revealing a 14x15 mm hypoechoic area with irregular edges in the head of the pancreas. The in situ cytological study showed polymorphic lymphoid cellularity, without atypia suggesting neoplasia. The cell block and the immunohistochemical study showed a polyclonal population with a pattern suggestive of FP. The patient presented spontaneous clinical improvement. The EUS follow up three months later shown pancreatic parenchyma with homogeneous echogenicity and no space occupying lesions were indentified. Since the diagnosis of FP has been reached after surgery in most cases, the treatment is not well established. However, no recurrences have been reported after surgery and spontaneous resolution has been observed in incomplete resections, which suggests the indication for conservative management. Diagnostic EUS has a fundamental role in the differential diagnosis between FP and pancreatic neoplasms, two entities with very different prognosis, and makes it possible to avoid, in the case of FP, unnecessary surgeries with the associated morbidity and mortality.

IMPACT OF DIAGNOSTIC AND INTERVENTIONAL ENDOSCOPIC ULTRASONOGRAPHY IN CHILDREN.

Endoscopic ultrasonography is used in the diagnosis and treatment of digestive diseases in adults. In children, its use is limited due to a lack of available expertise. This study aimed to evaluate the clinical impact of endoscopic ultrasonography on diagnostic and therapeutic strategy changes in pediatric patients. Over ten years, this study retrospectively and consecutively analyzed children aged ≤18 years who underwent endoscopic ultrasonography because of inconclusive imaging or laboratory tests. The indications, results, occurrence of adverse events, and clinical impact of the procedures were analyzed. The clinical impact was classified as major (when the findings led to changes in diagnosis and management), minor (change in diagnosis but not in management), or none (no change in diagnosis or management). Overall, 107 children [77 (72%) of whom were female; mean age: 11.7 ± 4 years] underwent upper [102 (95.3%)] and lower [5 (4.7%)] endoscopic ultrasonography; 64 (58%) patients underwent diagnostic endoscopic ultrasonography, and 43 (42%) underwent interventional endoscopic ultrasonography. Endoscopic ultrasonography was used to investigate pancreaticobiliary, gastric, rectal, esophageal, duodenal, and mediastinal diseases in 81 (76%), 14 (13%), 5 (4.6%), 3 (2.8%), 2 (1.8%), and 2 (1.8%) patients, respectively. The clinical impact was significant in 81% of the children. Major and no clinical impact on pancreaticobiliary, gastrointestinal diseases, and mediastinal masses occurred in 50 (62%) and 13 (16%), 13 (54%) and 9 (37%), and 2 (100%) and 0 (0%) of the patients, respectively. This study evaluated the impact of diagnostic and interventional endoscopic ultrasonography in pediatric patients. When clinically and appropriately indicated, these procedures are safe and effective diagnostic or therapeutic interventions in pediatric patients with gastrointestinal or pancreaticobiliary disorders.

Technical Performance, Overall Accuracy and Complications of EUS-Guided Interventional Procedures: A Dynamic Landscape.

Endoscopic ultrasound (EUS) gained wide acceptance as the diagnostic and minimally invasive therapeutic approach for intra-luminal and extraluminal gastrointestinal, as well as various non-gastrointestinal lesions. Since its introduction, EUS has undergone substantial technological advances. This multi-centric study is a retrospective analysis of a prospectively maintained database of patients who underwent EUS for the evaluation of lesions located within the gastrointestinal tract and the proximal organs. It aimed to extensively assess in dynamic the dual-center EUS experience over the course of the past 20 years. Hence, we performed a population study and an overall assessment of the EUS procedures. The performance of EUS-FNA/FNB in diagnosing pancreatic neoplasms was evaluated. We also investigated the contribution of associating contrast-enhanced ultrasound imaging (CE-EUS) with EUS-FNA/FNB for differentiating solid pancreatic lesions or cystic pancreatic lesions. A total of 2935 patients undergoing EUS between 2002–2021 were included, out of which 1880 were diagnostic EUS and 1052 EUS-FNA/FNB (80% FNA and 20% FNB). Therapeutic procedures performed included endoscopic transmural drainage of pancreatic fluid collections, celiac plexus block and neurolysis, while diagnostic EUS-like CE-EUS (20%) and real-time elastography (12%) were also conducted. Most complications occurred during the first 7 days after EUS-FNA/FNB or pseudocyst drainage. EUS and the additional tools have high technical success rates and low rates of complications. The EUS methods are safe, cost effective and indispensable for the diagnostic or therapeutic management in gastroenterological everyday practice.

Endoscopic ultrasound in diagnosis and management of some gastrointestinal - pancreaticobiliary diseases at Hue University of Medicine and Pharmacy Hospital

Background: Gastrointestinal - pancreaticobiliary diseases is a major pathology relating to organs from the mouth to the anus and biliary tree. Endoscopic ultrasound (EUS) helps to assess deeper organs in the abdomen such as pancreas, biliary tree, lesions inside and outside the alimentary tract as well as regional lymph nodes. We proceeded this study to: (1) To examine some characteristics of patients, indications and safety of EUS, (2) To evaluate roles of EUS in diagnosis and management of gastrointestinal - pancreaticobiliary diseases. Materials and method: A cross-sectional study was conducted on 1615 patients undergoing endoscopic ultrasound at Hue University of Medicine and Pharmacy Hospital. Results: Male:female ratio = 1.4:1. Average age was 56.1 ± 15.1. Patients living in Hue was 79.9%, not living in Hue was 20.1%. Indications of EUS: in biliary diseases 37.1%, in pancreatic diseases 31.3%, in stomach 11.8%, in colon 9.0%, in esophagus 8.6%, and in duodenum 2.2%. Complications rates were very low. Lesions in gastrointestinal tract: Subepithelial lesions in stomach 57.9%, in esophagus 23.7%, in duodenum 13.6%, in colo-rectum 4.8%; cancer in colo-rectum 48.8%, in esophagus 33.2%, in stomach 16.3%, and in duodenum 1.7%. Lesions in biliary tree: gallstones 76%, common bile duct cyst 9.5%, bile duct parasitic lesions 4.3%, Vater tumor 3.8%, unknown causes biliary tract dilation 3.4% and cholangiocarcinoma 3.0%. Lesions in pancreas: chronic pancreatitis40.6%, pancreatic cancer 24.6%, acute pancreatitis 18.4%, pancreatic cyst 10.9% and lymph nodes 5.5%. EUSfine needle aspiration and EUS-guided drainage of pancreatic pseudocysts: FNA for 18 pancreatic tumors, 3 pancreatic cysts and 7 lymph nodes; drainage for 4 pancreatic pseudocysts. Conclusions: Diagnostic and interventional EUS were effectively and relatively safe in assessing lesions in alimentary tract and biliary diseases, as well as supporting to achieve samples through fine needle aspiration, and to drain pancreatic pseudocysts. Key words: endoscopy, endosonography

Landscape of Pediatric Endoscopic Ultrasound in a United States Tertiary Care Medical Center.

Endoscopic ultrasound (EUS) is a commonly used radiation-sparing procedure in adult patients for diagnostic sampling of gastrointestinal lesions and fluid collections, gastric variceal hemostasis, biliary/pancreatic duct drainage, and endo-surgical interventions. Integration of EUS in pediatrics is still in its infancy with limited data regarding its use. The present study analyzes utilization, diagnostic and therapeutic roles of pediatric EUS and evolution in these parameters over time. Records of patients 18 years or younger from 2009 to 2020 at our tertiary pediatric care center were retrospectively identified. Patient demographics, symptoms, laboratory studies, EUS indications and interventions, and clinical outcomes of the procedures were analyzed. Statistical analysis was performed using Student t-test, Pearson's chisquare and Fisher exact tests. 306 EUS procedures were performed during the study period, for 279 pediatric patients. These included 287 (93.8%) upper EUS and 19 (6.2%) lower EUS. Two hundred and twenty-nine procedures were diagnostic (74.8%) and 77 were therapeutic (25.2%). EUS indications included evaluation and therapy of the pancreaticobiliary region (231, 75.5%), subepithelial or regional lesion (54, 17.8%), celiac plexus block (19, 6.2%) and hemostasis (14, 4.5%). Diagnostic sampling was performed in 52 of these EUS procedures, with a 96.2% diagnostic yield. 98.7% of therapeutic procedures were technically successful and there were no associated adverse events. The diagnostic and therapeutic role for EUS in adults has expanded dramatically, however the role of EUS in pediatrics is not well-defined. In this, the largest pediatric EUS study to date, our data support the safety and utility of diagnostic and therapeutic EUS in pediatrics.

Therapeutic endoscopic ultrasound.

Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.

Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

The role of endoscopic ultrasound (EUS) as a diagnostic and therapeutic modality for the management of various gastrointestinal diseases has been expanding. The imaging or intervention for various liver diseases has primarily been the domain of radiologists. With the advances in EUS, the domain of endosonologists is rapidly expanding in the field of hepatology. The ability to combine endoscopy and sonography in one hybrid device is a unique property of EUS, together with the ability to bring its probe/transducer near the liver, the area of interest. Its excellent spatial resolution and ability to provide real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS, have facilitated the growth of EUS. The concept of “Endo-hepatology” encompasses the wide range of diagnostic and therapeutic procedures that are now gradually becoming feasible for managing various liver diseases. Diagnostic advancements can enable a wide array of techniques from elastography and liver biopsy for liver parenchymal diseases, to CE-EUS for focal liver lesions to portal pressure measurements for managing various liver conditions. Similarly, therapeutic advancements range from EUS-guided eradication of varices, drainage of bilomas and abscesses to various EUS-guided modalities of liver tumor management. We provide a comprehensive review of all the different diagnostic and therapeutic EUS modalities available for the management of various liver diseases. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1: Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended. 2: Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee's procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice. 3: Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice). 4: The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies [FNA/FNBs]), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %. ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.

Changing perspectives in the training of endoscopic ultrasonography in Asia.

Training of endoscopic ultrasound (EUS) in Asia faces challenges of the ever‐increasing demand for skills to handle a growing range of both diagnostic and interventional EUS procedures, and a continual shortage of EUS training programs. To keep up with the pace of development in EUS, more short‐term EUS programs have been conducted across Asia in recent years. In this aspect, the Asian EUS Group (AEG) has taken the lead to fast‐track the dissemination of EUS knowledge and skills across Asia through its multinational network of training centers. AEG's programs are brought to wherever there is demand. Its versatile modular structure allows the program to be easily customized and scaled up or down to align to local needs, making it highly adaptable to the changing and varying needs in different countries. Even with the current pandemic situation, it has been able to continue its training efforts through the use of technology, including webinars, and live case demonstration.

The Role of Endoscopic Ultrasound in Patients with Choledocholithiasis: A pilot study

Background and study aim. Endoscopicultrasound (EUS) is a diagnostic modality that continuesto expand its clinical applications. The aim of this studyis to evaluate the diagnostic role of EUS in commonbile duct stones. Patients and methods: This study wascarried on 29 patients with suspected CBD stones fromthem only 15 patients were diagnosed as Common BileDuct stone(s). Endoscopic retrograde cholangiopancreatography(ERCP) is considered as gold standard fordiagnosis of CBD stones and compare EUS findingswith that of ERCP. Results: The diagnostic performanceof EUS shows that the sensitivity, specificity, PPV, NPVand accuracy of 100%, 92.8%, 93.7%, 100% and 96.5%respectively. It can catch 15 true positive cases withonly one false positive case and 13 of 14 true negativecases. EUS is considered as a minimally invasivemethod with low incidence of complications, allowingexact determination of the site and size of stones. SoEUS aid in better planning for CBD stone removal.Conclusion: EUS is considered as a minimally invasivemethod with low incidence of complications, allowingexact determination of the site and size of stones withgood diagnostic performance.

Water-filled technique for therapeutic pancreato-biliary EUS in patients with surgically altered anatomy.

One of the main challenges encountered by endosonographers is performing diagnostic and interventional pancreato-biliary endoscopic ultrasound (EUS) procedures in the presence of surgically altered upper gastrointestinal anatomy. We describe the water-filled technique (WFT) for EUS examination and treatment of the pancreato-biliary region in patients with surgically altered upper gastrointestinal anatomy. Using the WFT, the scope is advanced up to the gastro-jejunal anastomosis and, after placing the tip of the scope 2 cm beyond it, enlargement of the jejunal lumen is obtained by water instillation of the jejunal loop. An enlargement of more than 1.5 cm allows advancement of the tip of the scope under EUSguidance up to the duodenum, in a retrograde way. The WFT is useful for reaching the ampullary area and performing diagnostic and therapeutic EUS in patients with surgically altered anatomy. The technique is also reproducible and can be easily used by endoscopists who regularly perform EUS.

Impact of endoscopist experience, patient age and comorbidities on dose of sedation and sedation-related complications by endoscopic ultrasound.

The aim of the study is to investigate the influence of endosonographer experience and patient-related factors on the dose of sedation and sedation-related complications during endoscopic ultrasound (EUS). Our retrospective analysis included EUS investigations performed between 2015 and 2018 at our institution. Sedation-related complications were defined as cardiorespiratory instability with oxygen saturation drop below 90% or prolonged low blood pressure or bradycardia. In total, 537 EUS examinations were analyzed (37.3% interventional). The median dose of propofol and midazolam were: 140 (30-570) and 3(1-7) mg, respectively. Sedation-related complications were documented in 1.8% of cases. All patients had transient, nonfatal respiratory insufficiency. Totally, 60% of the patients who developed complications were >75 years and 70% were male. The presence of cardiac and/or pulmonary comorbidities was associated with an OR = 8.77 [95% confidence interval (CI), 1.8-41.7] and American Society of Anesthesiologists class III with an OR = 7.64 (95% CI, 1.60-36.3) for the occurrence of sedation-related complications. Endosonographer experience did not influence the rate of sedation-related complications. In both diagnostic and interventional EUS, patients with comorbidities and older age received significantly less sedation. Experienced endosonographers used less sedation than trainees. Endosonographer experience, patient age and the presence of comorbidities had a significant influence on sedation dose. Sedation-related complications occurred only in 1.8% of cases.

Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study.

IntroductionIdiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP.Methods and analysisPICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months.Ethics and disseminationPICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal.Trial registration numberNetherlands Trial Registry (NL7066). Prospectively registered.

International consensus guidelines on the role of diagnostic endoscopic ultrasound in the management of chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BackgroundChronic pancreatitis (CP) is a complex inflammatory disease with variable presentations and outcomes. This statement is part of the international consensus guidelines on CP, specifically on the diagnostic role of endoscopic ultrasound (EUS). MethodsAn international working group with experts on the role of diagnostic EUS in the management of CP from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated two key statements generated from evidence on two questions deemed to be the most clinically relevant. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on each statement for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach’s alpha reliability coefficient. ResultsStrong consensus was obtained for both of the following statements [1]. The ideal threshold number of EUS criteria necessary to diagnose CP has not been firmly established, but the presence of 5 or more and 2 or less strongly suggests or refutes the diagnosis, respectively. The Rosemont scoring system standardizes the reporting of EUS signs indicative of chronic pancreatitis, but further studies are needed to demonstrate an overall improvement of its diagnostic accuracy over conventional scoring [2]. Specificity, inter- and intra-observer variability and pre-test probability limit the reliability and utility of EUS to help diagnose CP especially early stages of the disease. ConclusionsThe presence of 5 or more and 2 or less EUS criteria strongly suggests or refutes the diagnosis of CP, respectively. Intra-observer variability still limits the role of EUS in diagnosing CP especially early stage disease.

The role of endoscopic ultrasound in patients with choledocholithiasis: A pilot study

Background and study aim. Endoscopicultrasound (EUS) is a diagnostic modality that continuesto expand its clinical applications. The aim of this studyis to evaluate the diagnostic role of EUS in commonbile duct stones. Patients and methods: This study wascarried on 29 patients with suspected CBD stones fromthem only 15 patients were diagnosed as Common BileDuct stone(s). Endoscopic retrograde cholangiopancreatography(ERCP) is considered as gold standard fordiagnosis of CBD stones and compare EUS findingswith that of ERCP. Results: The diagnostic performanceof EUS shows that the sensitivity, specificity, PPV, NPVand accuracy of 100%, 92.8%, 93.7%, 100% and 96.5%respectively. It can catch 15 true positive cases withonly one false positive case and 13 of 14 true negativecases. EUS is considered as a minimally invasivemethod with low incidence of complications, allowingexact determination of the site and size of stones. SoEUS aid in better planning for CBD stone removal.Conclusion: EUS is considered as a minimally invasivemethod with low incidence of complications, allowingexact determination of the site and size of stones withgood diagnostic performance.

Diagnostic performance of the current risk-stratified approach with computed tomography for suspected choledocholithiasis and its options when negative finding

BackgroundSeveral studies evaluated the current guideline of the American Society for Gastrointestinal Endoscopy (ASGE) and reported only suboptimal accuracy. This study evaluated the diagnostic performance of the ASGE guideline based on computed tomography (CT) and role of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in patients with suspected choledocholithiasis but negative CT finding. MethodsPatients with suspected choledocholithiasis undergoing ERCP between January 2016 and January 2017 were retrospectively analyzed. All patients underwent CT to detect choledocholithiasis. EUS or MRCP was performed when the CT scan showed negative findings. Patients were classified into the high and intermediate-risk groups, based on predictors from the ASGE criteria. ResultsOf 583 patients with suspected choledocholithiasis, 340 (58.3%) had stones on ERCP (65.9% in the high-risk group and 40.6% in the intermediate-risk group). The accuracy of ASGE guideline for CT was 63.98% (79.12% sensitivity, 42.80% specificity) and 36.02% (20.88% sensitivity, 57.20% specificity) in the high-risk and intermediate-risk groups, respectively. In 103 patients in the high-risk group underwent both CT and US, the accuracy of CT was higher than that of US for detecting choledocholithiasis (78.64% vs. 53.40%), with a significant difference in area under the curve (AUC) (0.78 vs. 0.59, P < 0.001). Of 339 with negative CT finding, the accuracy of EUS was higher than that of MRCP (90.91% vs. 82.76%), but with no significant difference in AUC (0.91 vs. 0.83, P = 0.347). ConclusionsCT-based ASGE guideline showed superior diagnostic performance than US for predicting choledocholithiasis. The diagnostic options, EUS or MRCP, with negative CT finding showed comparable performance. Therefore, the diagnostic modality should be selected based on availability, experience, cost, and contraindications.