Endoscopic Ultrasound Research Articles

Traditional Biomarkers in Patients with Pancreatic Cancer Staged by Computed Tomography and Endoscopic Ultrasound: Is There Still a Role in the Molecular Era?

Serum carbohydrate antigen 19-9 (Ca19-9) is the only approved biomarker approved for the screening and diagnosis of pancreatic cancer (PC), but its value remains controversial. The aim of our study is to evaluate the role of CA 19-9 in the management of PC patients in jaundiced patients staged by both Computed Tomography (CT) and Endoscopic Ultrasound (EUS). Additionally, we evaluated traditional cholestasis marker behavior. Medical records of 73 patients have been retrospectively reviewed. We considered tumor size, tumor stage, CA 19-9, cytolysis, and cholestasis biomarkers. All patients underwent CT scan for staging. EUS +/− fine-needle biopsy (FNB) was performed in doubtful cases. Median alkaline phosphatase (ALP) and y-glutamyltransferase (GGT) levels were significantly lower compared to baseline after the biliary drainage (204 vs. 465 U/L, p < 0.0001, 204. U/L vs. 608.5, p < 0.0001, respectively), whilst no differences were observed for CA 19-9 levels. CA 19-9 showed significant association with the tumor stage in the pre-drainage setting. CT and EUS showed a low agreement in estimating tumor size (mean difference 4.8 mm 95% LoA −10.82–20.38). We did not find any significant correlation between CA 19-9 and bilirubin levels (r = −0.05, p = 0.7). In our cohort, survival rate was lower in patients with higher CA 19-9 levels (log rank p = 0.007). CA 19-9 has some limitations as a biomarker in the PC setting, thus it cannot address the treatment strategy alone. Nonetheless, it provides valuable information, and is not replaceable for the time being.

Risk factors of negative diagnosis of MRCP in acute biliary pancreatitis patients with choledocholithiasis.

Assessment of the presence of choledocholithiasis is crucial among acute biliary pancreatitis (ABP). Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are widely used to identify the gallstones of common bile duct (CBD). EUS provides better diagnostic accuracy and sensitivity than MRCP but carries a certain risk due to sedation. We investigated the risk factors of negative diagnosis of MRCP in ABP patients with choledocholithiasis for better selection of MRCP or EUS. A total of 2321 ABP patients were retrospectively included in this study. Based on the exclusion criteria, 337 ABP patients with negative MRCP results were ultimately included. Among these patients, 75 patients had positive EUS findings. Univariate and multivariate logistic regression models were used to screen the risk factors of negative diagnosis of MRCP in ABP patients with choledocholithiasis. Patients with positive EUS findings were older (62.0 vs. 55.0) and had higher rate of cholecystectomy history (18.7% vs. 7.3%) than those with negative EUS findings. The result of univariate logistic regression showed that the history of cholecystectomy, age and sex were potential risk factors (all p < 0.05). Then after adjusting the other potential risk factors (Direct bilirubin (DBIL), alanine transaminase (ALT), gamma-glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP)), a history of cholecystectomy (OR = 2.859 [1.312,6.23]), older age (1.03 [1.009,1.052]) and male (2.016 [1.152,3.528]) were independent risk factors of negative diagnosis of MRCP in ABP patients with choledocholithiasis. The history of cholecystectomy, older age and male are independently associated with an increased risk of negative diagnosis of MRCP in ABP patients with choledocholithiasis. We suggest that patients with these risk factors should undergo EUS first, rather than MRCP.

EUS for the evaluation of esophageal injury after catheter ablation for atrial fibrillation

Background & AimAtrial fibrillation (AF) ablation is an increasingly utilized rhythm control strategy that can damage adjacent structures in the mediastinum including the esophagus. Atrioesophageal fistulas and esophagopericardial fistulas are life-threatening complications that are thought to progress from early esophageal mucosal injury (EI). Endoscopic ultrasound (EUS) has been proposed as a superior method than EGD to survey EI and damage to deeper structures. We aim to evaluate the safety of EUS in categorizing post-ablation EI and quantify EUS-detected lesions and their correlation with injury severity and clinical course. Methods234 consecutive patients between 2006-2020 who underwent AF ablation followed by EUS for the purpose of EI screening were retrospectively reviewed. Kansas City Classification (KCC) was used to classify EI (Type 1, Type 2a/b, Type 3a/b). ResultsEUS identified pleural effusions (31.6%) of patients, mediastinal adventitia changes (22.2%), mediastinal lymphadenopathy (14.1%), pulmonary vein changes (10.6%), and esophageal wall changes (7.7%). EGD revealed 175 (75%) patients without and 59 (25%) with EI. Patients with Type 2a/b EI and no EI were compared with multivariate logistic regression, and the presence of esophageal wall abnormality on EUS with OR 72.85 (95% CI 13.9-380.7), female sex with OR 3.97 (95% CI 1.3-12.3), and number of energy deliveries with OR 1.01 (95% CI 1.003-1.03), were associated with the presence EI type 2a or 2b. Pre-ablation PPI use was not associated with decreased risk of EI. ConclusionsEUS safely assesses mediastinal damage after ablation for atrial fibrillation and may excel over EGD in evaluating mucosal lesions of uncertain significance, with reduced risk of gas embolization in the setting of a full thickness injury (entero-vascular fistula). We propose an EUS-first guided approach to post-AF ablation examination, followed by EGD if it is safe to do so.

Uneventful salvage for partial deployment of a coil via endoscopic ultrasound in the treatment of rebleeding gastric varices.

A 72-year-old female who had received emergent endoscopic cyanoacrylate (CYA) injection for bleeding gastric varices (GV) two month before was readmitted due to recurrence of melena. Current gastroscopy verified the type-2 GV (GOV-2) according to Sarin's classification with stigmata of recent bleeding. Endoscopic ultrasound (EUS) identified the largest varix of 8.7mm in diameter, which prompted us to consider EUS-guided coiling combined with CYA injection as an alternative therapeutic strategy, considering the short interval between prior injection and rebleeding. Via trans-esophageal route, the abovementioned varix was punctured using a 19-gauge FNA needle preloaded with a 0.035-inch coil with diameter of 10mm and length of 14cm (Nester, Cook Medical, Bloomington, IN). Initially, the stylet used as a pusher was advanced smoothly and part of the coil was visualized to have been pushed out of the needle tip. However, the stylet could not be fully advanced to place the entire coil into the varix due to substantial resistance, which, regardless of the endeavor to adjust the needle, was not diminished.

Clinical impact of esophageal muscle thickness on peroral endoscopic myotomy patients.

Peroral endoscopic myotomy (POEM) is a standard procedure for achalasia, an esophageal motility disorder, characterized by a thickened lower esophageal sphincter muscularis propria (LEMP). Visualization of this anatomical stratification has been made possible by the advent of endoscopic ultrasound (EUS). However, the effect of LEMP thickness on treatment outcomes remains unclear. The objective of this study was to investigate whether LEMP thickness affects treatment response post-POEM. This was a single-center, prospective cohort study of patients who underwent POEM between 2014 and 2021. Patients who underwent EUS to evaluate the LEMP before POEM were included in the study. We divided the patients into two groups according to muscle thickness measured by EUS (≥ 2.80mm; group 1, < 2.80mm; group 2). The pre- and post-procedural clinical parameters were compared between the two groups. Among 278 patients, 189 were enrolled. There were no significant differences in the pre- and post-Eckardt scores, integrated relaxation pressure, and distensibility index between the two groups divided by muscle thickness. Furthermore, there was no statistically significant difference in symptom recurrence, as measured by an Eckardt score > 3, post-procedural complications, or post-POEM GERD symptoms. However, patients with thicker lower esophageal sphincter muscle showed a greater decrease in Eckardt scores (ΔES ≥ 3) which was statistically significant (P = 0.002). POEM is an effective and safe treatment method for achalasia, regardless of LES muscle thickness. There was a statistically significant difference in the decrease of Eckardt scores of 3 or greater (ΔES ≥ 3) after POEM in the thicker LEMP group suggesting greater alleviation of symptoms in POEM patients with thicker lower esophageal muscle.

Successful thoracoscopic enucleation of a calcifying fibrous tumor of the lower mediastinum in a young woman

BackgroundCalcifying fibrous tumor (CFT) arising from the pleura is a relatively rare benign lesion in young and middle-aged adults. We report a 31-year-old woman with pleural CFT who underwent successful complete thoracoscopic enucleation.Case presentationAn asymptomatic woman presented with a mass in the right lower lung field that was incidentally detected on a chest X-ray during a routine medical checkup. Chest computed tomography showed a well-defined mass in the lower mediastinum, with a maximum diameter of approximately 5.5 cm. Esophagogastroduodenoscopy showed no abnormal findings in the esophagus. An endoscopic ultrasonography (EUS) revealed a well-defined tumor with no internal blood flow. EUS-fine needle aspiration failed to establish a definitive diagnosis. Therefore, thoracoscopic tumor enucleation was performed for diagnostic and therapeutic purposes. Based on the histopathological findings of the resected specimen, the presence of a tumor with a high fibrous component in a young woman, and the identification of granulomatous calcifications, a diagnosis of CFT was established.ConclusionsComplete thoracoscopic tumor enucleation was successfully performed for CFT arising from the pleura in a young adult woman.

Pre-Cut Papillotomy Versus Endoscopic Ultrasound-Rendezvous for Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis.

Various endoscopic techniques are employed to achieve biliary cannulation when confronted with difficult biliary access. Every procedure carries its own risk in terms of bleeding, infection, pancreatitis, and cholangitis. Our meta-analysis aimed to compare pre-cut papillotomy and endoscopic ultrasound (EUS)-rendezvous in terms of technical success rates, and post-procedure pancreatitis and bleeding. We conducted a systematic review and meta-analysis of studies that compared pre-cut papillotomy and EUS-rendezvous. The primary outcome was technical success by achieving biliary cannulation. Secondary outcomes were postoperative pancreatitis and bleeding. A random-effects model was used to calculate the risk ratios (RRs) and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Our meta-analysis included four studies comparing pre-cut papillotomy and EUS-rendezvous. The studies included 13,659 total endoscopic retrograde cholangiopancreatography (ERCP) procedures, of whom 1,004 patients underwent alternate biliary cannulation procedures due to difficult biliary cannulation. The mean age of the study population was noted to be 49.5 years and males represented 53.3% of the total participants. Both procedures were similar in terms of technical success (RR: 0.95, 95% CI (0.88, 1.02)). No difference was found between rates of post procedure pancreatitis (RR: 1.82, 95% CI (0.80, 4.15)) and post procedure bleeding (RR: 2.80, 95% CI (0.67, 11.66)). There was no difference in technical success of procedure or post-procedure complications such as pancreatitis and bleeding between pre-cut papillotomy and EUS-rendezvous technique. More randomized controlled trials (RCTs) are needed to compare both procedural techniques and complications rates. However, currently, both procedures are equally effective and safe during difficult biliary cannulation in the hands of experienced endoscopists.

Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group, Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines.

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40 % of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past few years the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques such as endoscopic ultrasound-guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Different Etiologies of Dilated Pancreatic Duct Based on Endoscopic Ultrasonography Findings.

Pancreatic duct (PD) dilation could be presented in both benign and malignant diseases. Endoscopic ultrasonography (EUS) is a sensitive modality that provides both structural assessment and tissue sampling. This study aims to explore the importance of PD dilation as a potential indicator related to various pancreatobiliary pathologies identified via EUS. Among 3109 subjects who underwent EUS, 599 had evidence of dilated PD and met the inclusion criteria of this retrospective study. Also, the patients underwent EUS fine needle aspiration (EUS-FNA) to evaluate the etiology when required. All data were extracted from patients' medical records to perform statistical analysis. The study sample revealed 64% being male with a median age was 65-years. Pancreatic adenocarcinoma was the most common etiology diagnosed in 236 patients (39.4%), followed by sphincter of Oddi dysfunction (SOD) in 13% of subjects. Ampullary carcinoma, common bile duct stone, and cholangiocarcinoma were found at 9.5%, 8.8%, and 6.8%, respectively. Abdominal pain was the most common symptom seen in 440 (73.4%) patients. Opium consumption was reported in 170 (28.4%) subjects. Opium consumption was significantly more prevalent in patients with SOD (P<0.05). We suggest that PD dilation could be associated with a wide range of pancreaticobiliary pathologies, especially pancreatic neoplasms. In this regard, PD dilation should be considered as a crucial indicator of pancreatic neoplasm despite it may be associated with no clear etiologies.

Endoscopic resection for non-ampullary duodenal subepithelial lesions: a retrospective cohort study

PurposeThis study aimed to assess the safety and efficacy of endoscopic submucosal dissection (ESD) and pre-cutting endoscopic mucosal resection (pEMR) in treating non-ampullary duodenal subepithelial lesions (NADSELs) and to evaluate the clinical utility of endoscopic ultrasound (EUS) before endoscopic resection (ER).MethodsIn this retrospective single-centre cohort study, we compared the clinical outcomes of patients with NADSELs who underwent ESD or pEMR between January 2014 and June 2023. The accuracies of EUS in determining the pathological type and origin of the lesions were evaluated using postoperative histopathology as the gold standard.ResultsOverall, 56 patients with NADSELs underwent ER in this study, including 16 and 40 treated with pEMR and ESD, respectively. There were no significant differences between the two groups in terms of en bloc resection rate, complete (R0) resection rate, perioperative complication rate, and postoperative hospital length of stay (P > 0.05). However, the pEMR group had significantly shorter median operational (13.0 min vs. 30.5 min, P < 0.001) and mean fasting (1.9 days vs. 2.8 days, P = 0.006) time and lower median hospital costs (¥12,388 vs. ¥19,579, P = 0.002). The accuracies of EUS in determining the pathological type and origin of the lesions were 76.8% and 94.6%, respectively, compared with histopathological evaluation.ConclusionsEUS can accurately predict the origin of NADSELs. Suitable lesions determined to originate from the submucosa or more superficial layers using EUS can be treated using pEMR as it shortens the operational and recovery time, reduces hospitalisation costs, and achieves an R0 resection rate similar to ESD.

Clinical Perspectives on the Histomolecular Features of the Pancreatic Precursor Lesions: A Narrative Review.

Pancreatic cancer (PC) is a lethal cancer with poor prognoses. Identifying and characterizing pancreatic cystic lesions (PCLs) in the early detection and follow-up plans is thought to help detect pancreatic malignancy. Besides, the molecular features of PCLs are thought to unravel potentials for targeted therapies. We present a narrative review of the existing literature on the role of PCLs in the early detection, risk stratification, and medical management of PC. High-grade intraductal papillary mucinous neoplasms (IPMN) and pancreatic intraepithelial neoplasia (PanIN) stage III are high-risk lesions for developing PC. These lesions often require thorough histomolecular characterization using endoscopic ultrasound (EUS), before a surgical decision is made. EUS is also useful in the risk assessment of PCLs with tentative plans-for instance, in branch-duct IPMNs (BD-IPMN)- where the final decision might change. Besides the operative decisions, recent improvements in the application of targeted therapies are expected to improve survival measures. Knowledge of molecular features has helped develop targeted therapies. In summary, the histomolecular characterization of PCLs is helpful in optimizing management plans in PC. Further improvements are still needed for the broad application of this knowledge in the clinical setting.

Linear-Array Endoscopic Ultrasound and Narrow-Band Imaging Measure the Invasion Depth of Nonpedunculated Rectal Lesions With Comparable Accuracy Based on a Randomized Controlled Trial.

Linear-array endoscopic ultrasound (EUS) and narrow-band imaging (NBI) are both used to estimate the invasion depth of nonpedunculated rectal lesions (NPRLs). However, it is unclear which procedure is more accurate. This randomized controlled trial aimed to compare the diagnostic accuracy of linear EUS and NBI for estimating the invasion depth of NPRLs. This study is a single-center, randomized, tandem trial. Eligible patients with NPRLs were randomly assigned to A group (assessment with EUS followed by NBI) or B group (assessment with NBI followed by EUS). The invasion depth of each lesion was independently measured by each procedure and categorized as mucosal to slight submucosal (M-SM s , invasion depth <1,000μm) or deep submucosal (SM d , invasion depth ≥1,000μm) invasion, with postoperative pathology as the standard of measurement. The primary outcome was diagnostic accuracy, and secondary outcomes included sensitivity, specificity, and procedure time. Eighty-six patients with NPRLs were enrolled, and 79 patients were finally analyzed, including 39 cases in the A group and 40 cases in the B group. Comparable diagnostic accuracies were observed between EUS and NBI (96.2% vs 93.7%, P = 0.625). EUS identified lesions with deep submucosal invasion with 81.8% sensitivity while that of NBI was 63.6% ( P = 0.500). The specificity of both EUS and NBI was 98.5%. The procedure time was also similar between EUS and NBI (5.90 ± 3.44 vs 6.4 ± 3.94minutes, P = 0.450). Furthermore, the combined use of EUS and NBI did not improve diagnostic accuracy compared with EUS or NBI alone (94.9% vs 96.2% vs 93.7%, P = 0.333). Linear EUS and NBI measure the invasion depth of NPRLs with comparable accuracy. The combination of the 2 methods does not improve the diagnostic accuracy. Single NBI should be preferred, considering its simplicity and convenience in clinical practice.

Comparison of bispectral index-guided endoscopic ultrasonography with continuous versus intermittent infusion of propofol: a retrospective study in Japan.

This study aimed to evaluate the safety and efficacy of continuous propofol infusion for anesthesia during endoscopic ultrasonography (EUS). A total of 427 consecutive patients who underwent EUS between May 2018 and February 2019 were enrolled in this study. The patients were divided into two propofol infusion groups: continuous (n=207) and intermittent (n=220). The following parameters were compared: (1) propofol dose, (2) respiratory and circulatory depression, (3) body movement requiring discontinuation of the examination, (4) awakening score, and (5) patient satisfaction. The median total maintenance dose of propofol was significantly higher in the continuous group than in the intermittent group (160.0 mg vs. 130.0 mg, respectively); however, the reduction in SpO2 was significantly lower in the continuous group (2.9% vs. 13.2%). Body movements occurred less frequently in the continuous group than in the intermittent group (40.1% vs. 49.5%, respectively). The rate of complete awakening was significantly higher in the continuous group than in the intermittent group. Finally, there was a significant difference in the percentage of patients who answered "absolutely yes" when asked about receiving EUS again: 52.7% in the continuous group vs. 34.3% in the intermittent group. Continuous infusion resulted in stable sedation and reduced propofol-associated risks.

Endoscopic ultrasound-guided bite-on-bite biopsy and endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of gastric tumors with negative malignant endoscopy biopsies: a retrospective cohort study

Background Specific types of gastric tumors, including gastric linitis plastica and lymphoma, may cause extensive deep-layer infiltration, impeding an accurate diagnosis with endoscopic biopsy. This study aims to evaluate the efficacy of endoscopic ultrasound (EUS)-guided bite-on-bite biopsy and EUS-guided fine-needle aspiration (EUS-FNA) in diagnosing gastric malignancies with negative endoscopic biopsies. Methods We retrospectively analyzed suspicious malignant gastric lesion cases in our hospital from October 2017 to August 2023. Clinical manifestations, radiographical examinations, endoscopic examinations, histopathological results, and therapeutic strategies were recorded and analyzed. Results Forty malignant gastric tumor cases with negative endoscopic biopsies were incorporated into our study. EUS-guided bite-on-bite biopsy was performed in 16 cases exclusively, whereas 17 patients received EUS-FNA exclusively, and seven patients underwent both simultaneously. Among the 23 patients who received the EUS-guided bite-on-bite biopsy, 22 (95.7%) were diagnosed with malignancies. Among the 24 patients who received EUS-FNA, a total of 19 cases with malignancies (79.2%) were confirmed by EUS-FNA (p = 0.11): 13 gastric adenocarcinomas, five metastatic malignancies, and one malignant stromal tumor. No adverse events were observed in any of the cases. Conclusions EUS-guided bite-on-bite biopsy and EUS-FNA possess their advantages and disadvantages. EUS-guided bite-on-bite biopsy could serve as a reliable diagnostic method for shallow lesions with negative malignant endoscopic biopsies.

Current status of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms.

The new Kyoto guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) provide evidence-based recommendations for the diagnosis and treatment of IPMN. Endoscopic ultrasonography (EUS) is a diagnostic modality with a high spatial resolution that allows detailed observation and obtaining cyst fluid or tissue samples via EUS-guided fine needle aspiration (EUS-FNA). Currently, EUS is an indispensable examination method for the diagnosis of pancreatic diseases. On the other hand, there have been concerns that EUS imaging tends to be highly operator-dependent, and may lack objectivity. Previous guidelines have assigned EUS as an option for patients with worrisome features. However, recent reports indicate that the sensitivity of EUS for the diagnosis of mural nodules (MNs) is more than 90%, comparable or superior to that of contrast-enhanced computed tomography or magnetic resonance cholangiopancreatography. The specific advantages of EUS in the diagnosis of IPMN are: (1) high spatial resolution imaging for the diagnosis of MNs, (2) contrast-enhanced EUS for differentiation of intra-cystic MNs from mucous clots, and (3) pathological diagnosis using EUS-FNA and differential diagnosis of a pancreatic cystic tumor by cystic fluid analysis. In order to utilize EUS in the diagnosis of IPMN, endoscopists are required to have the skills to provide sufficiently objective imaging findings.

Pancreatic cancer screening is effective in individuals at risk with predisposing germline gene variants, but not in gene variant-negative familial pancreatic cancer families.

To evaluate the diagnostic yield of pancreatic cancer screening in individuals at risk (IAR) from familial pancreatic cancer (FPC) families with respect to the presence or absence of pathogenic germline variants predisposing to pancreatic adenocarcinoma (PDAC). In a 20 years period, IAR from FPC families were enrolled in a prospective screening program of the national case collection for FPC of Germany, including magnet resonance imaging (MRI) and endoscopic ultrasound (EUS). The diagnostic yield was analyzed regarding significant pancreatic lesions such as PDAC, high-grade pancreatic-intraepithelial-neoplasia (PanIN3) and intraductal-papillary-mucinous-neoplasia (IPMN) with high-grade dysplasia. Screening results were compared between carriers of pathogenic variants and variant-negative IAR. 337 IAR, including 74 (22%) variant-carriers and 263 IAR of variant-negative FPC families (mean age 49; standard deviation [SD]+8.9) were followed 64 (SD+55) months. IAR underwent 5.1 (SD+3.9) screening visits with 1733 MRI (5.1,SD+3.9 per IAR) and 728 EUS (2.2,SD+1.7 per IAR). In 12 (4%) cases, significant pancreatic lesions were detected, including 4 PDAC, 3 PanIN3 and 5 high-grade IPMN. Three of 4 IAR with PDAC died after a mean of 27months postoperatively, and one IAR is alive without evidence of disease after 31months. The diagnostic yield for significant lesions was 13.5% (10/74) for variant carriers compared to 0.8% (2/263) for IAR of variant-negative FPC families (p<0.001). Logistic regression analysis revealed that a negative variant status was almost always accompanied by the absence of a significant lesion over time with a negative predictive value of 99.2% (95% CI 97.3%-99.9%). The diagnostic yield seems to justify PDAC screening in IAR of FPC-families with pathogenic germline variants in PDAC predisposing genes, not in IAR of variant-negative families.

Training and quality indicators in interventional endoscopic ultrasound.

Endoscopic ultrasound (EUS) has transformed the landscape of minimally invasive gastrointestinal procedures, necessitating specialized training for proficiency in interventional EUS (iEUS). This study evaluates the effectiveness of iEUS training, focusing on learning curves, success rates, and the associated risks in various procedures, aiming to recommend practices for standardizing training and ensuring competency. Key metrics such as procedure type, learning curve for proficiency, success rates, and risk of adverse events were analyzed to establish benchmarks for training programs. Proficiency in pancreatic fluid collection drainage was achieved after 20-30 procedures, with a 100% success rate and a complication rate ranging from 1.5 to 80%. Gallbladder drainage required 19 cases to reach an 86% success rate, with adverse events reported in 19% of cases. Choledocoduodenostomy mastery was observed after approximately 100 cases, with postintervention pancreatitis affecting 5.3-6.6% of all cases. Hepaticogastrostomy showed a 93% success rate after 33 cases, with a 24.8% adverse event rate. Hepaticoenterostomy reached 100% success beyond the 40th patient, with a 20% rate of postsurgical strictures. Pancreatic duct drainage achieved 89% technical and 87% clinical success after 27 cases, with 12-15% adverse events. Gastro-enteric anastomosis required 25 cases for proficiency and approximately 40 cases for mastery, with 5.5% immediate and 1% late adverse events. iEUS training outcomes vary significantly across different procedures, highlighting the importance of structured, procedure-specific training programs to achieve proficiency. These findings provide a foundation for developing universal competency benchmarks in iEUS, facilitating consistent and effective training worldwide.

Endoscopic pancreatogastric anastomosis in the treatment of symptoms associated with inflammatory diseases of the pancreas.

The outflow of pancreatic juice into the duodenum is often impaired in pancreatic inflammatory diseases. The basis of interventional treatment in these cases is anatomical transpapillary access of the main pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP), which ensures the physiological outflow of pancreatic juice into the lumen of the digestive tract. However, in some patients, anatomical changes prevent transpapillary drainage of the main pancreatic duct. Surgery is the treatment of choice in such cases. To evaluate the effectiveness and safety of endoscopic pancreaticogastrostomy under endoscopic ultrasound (EUS) guidance. Retrospective analysis of treatment outcomes of all patients with acute or chronic pancreatitis who underwent endoscopic pancreatogastric anastomosis under EUS guidance in 2018-2023 at the Department of General, Gastroenterological and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland. In 9 patients [7 men, 2 women; mean age 53.45 (36-66) years], endoscopic pancreatogastric anastomosis under EUS guidance was performed because of the lack of transpapillary access during ERCP. Narrowing of the main pancreatic duct at the head of the pancreas was observed in 4/9 patients (44.44%). Pancreatic fragmentation (disconnected pancreatic duct syndrome) was diagnosed in 3/9 patients (33.33%). In 2/9 patients (22.22%), narrowing of the pancreatoenteric anastomosis was observed after pancreaticoduodenectomy. Technical success of endoscopic pancreaticogastrostomy was observed in 8/9 patients (88.89%). Endotherapeutic complications were observed in 2/9 patients (22.22%). Clinical success was achieved in 8/9 patients (88.89%). The mean follow-up period was 451 (42-988) d. Long-term success of endoscopic pancreatogastric anastomosis was achieved in 7/9 patients (77.78%). Endoscopic pancreaticogastrostomy under EUS guidance is an effective and safe treatment method, especially in the absence of transpapillary access to the main pancreatic duct.

Esophagogastroscopy for predicting endoscopic ultrasonography T-stage by utilizing deep learning methods in esophageal cancer

Endoscopic ultrasonography (EUS) is commonly utilized in preoperative staging of esophageal cancer, however with additional pain and cost as well as adverse events. Meanwhile, the accuracy of EUS is highly depend on the training and practice of operators and not universally available. Different operators would lead to high inter-observer variability. Therefore, it is desirable to explore an alternative way to determine preoperative T stage in esophageal cancer. Whether conventional endoscopy possess the ability to predict EUS T stage has never been investigated yet. In current study, with the assistance of Artificial intelligence, we have developed a deep learning model to predict EUS T stage based on 9,714 images collected from 3,333 patients. ResNet-152 pre-trained on the ImageNet dataset was trained with the appropriate transfer learning and fine-tuning strategies on the conventional endoscopic images and their corresponding labels (e.g., T1, T2, T3, T4 and Normal). Meanwhile, augmentation strategies including rotation and flipping were performed to increase the number of images to improve the prediction accuracy. Finally, 4,382 T1, 243 T2, 3,985 T3, 1,102 T4, 14,302 controls images were obtained and split into training dataset, validation dataset and independent testing dataset with the ratio of 4:1:1. Our model could achieve a satisfied performance with an area under the receiver-operating curve (AUC) were 0.9767, 0.9637, 0.9597 and 0.9442 for T1, T2, T3 and T4, respectively in independent testing dataset. In conclusion, conventional gastroscopy combined with artificial intelligence have the great potential to predict EUS T stage.

Outcome of Endoscopic Resection of Rectal Neuroendocrine Tumors ≤ 10 mm.

Guidelines suggest endoscopic resection for rectal neuroendocrine tumors (rNETs) < 10 mm, but the most appropriate resection technique is unclear. In real-life clinical practice, the endoscopic removal of unrecognized rNETs can take place with "simple" techniques and without preliminary staging. The aim of the current study is to report our own experience at a referral center for both neuroendocrine neoplasms and endoscopy. Retrospective analyses of polypectomies were performed at the Humanitas Research Hospital for rNETs (already diagnosed or previously unrecognized). A total of 19 patients were included, with a median lesion size of 5 mm (range 3-10 mm). Only five lesions were suspected as NETs before removal and underwent endoscopic ultrasound (EUS) before resection, being removed with advanced endoscopic techniques. Unsuspected rNETs were removed by cold polypectomy in eleven cases, EMR in two, and biopsy forceps in one. When described, the margins were negative in four cases, positive in four (R1), and indeterminate in one. The median follow-up was 40 months. A 10 mm polypoid lesion removed with cold snare polypectomy (G2 R1) needed subsequent surgery. Eighteen patients underwent EUS after a median time of 6.5 months from resection. The EUS identified local recurrence after 14 months in a 7 mm polypoid lesion removed with cold snare polypectomy (G1 R1); the lesion was treated with cap-assisted EMR. For all the other lesions, the follow-up was negative. When rNETs are improperly removed without prior staging, caution must be exercised. The data from our cohort suggest that even if inappropriate resection had happened, patients may be safely managed with early EUS evaluation.