Endoscopic Ultrasound Group Research Articles

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.

Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study

Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV. A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared. In this study, the patients' age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation. EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.

S37 The Impact of Early Detection of Malignant Biliary Obstruction by Endoscopic Ultrasound on Clinical Outcomes After Surgical Resection

Introduction: Computerized tomography (CT) scan and endoscopic ultrasound (EUS) are the main diagnostic tools for detecting periampullary cancers. EUS allows the detection of small tumors missed by CT scan in patients presenting with bile duct obstruction. However, the impact of EUS in diagnosing small tumors on clinical outcomes is yet to be explored. This study aimed to compare the tumor recurrence rate and survival benefit of patients following pancreaticoduodenectomy (PD) for periampullary cancers detected by abdominal CT vs. EUS after negative CT. Methods: A retrospective review of the EUS and surgery database from 2009 to 2021. The patients who underwent PD for periampullary cancer were recruited. The patients were divided into CT-guided surgery group (CT group) and EUS-guided surgery group (EUS group). The clinical outcomes between the 2 groups were compared. Results: 429 patients were enrolled. 372 patients were diagnosed by CT scan, and EUS diagnosed 57 patients after CT scans failed to detect the cause of bile duct obstruction. The mean age was 64.7+ 11.9 years. The common presentations included jaundice (79.0 %) and weight loss (66.9%). Pancreatic adenocarcinoma (PDAC) was the most common cancer (43.6%), followed by ampullary cancer (32.4%), distal cholangiocarcinoma (14.2%), and duodenal cancer (9.8%). There were no differences in patient demographics between the two groups regarding age, gender, and underlying diseases. Patients in the CT group had higher serum bilirubin (p=0.025), higher serum alkaline phosphatase (p=0.047), lower serum hematocrit (p=0.043), and larger CBD diameter (p=0.005) compared to the EUS group. The T and M staging were not different between the two groups; however, the percentage of patients with nodal metastasis was higher in the CT group (p=0.014). Multivariate analysis showed a trend towards higher recurrence and 5-year mortality rate in the CT group with odds ratios (OR) of 1.33 (95% CI, 0.82-2.13) and 1.43 (95% CI, 0.84-2.42), respectively. Subgroup analysis of PDAC and cholangiocarcinoma demonstrated a significantly higher mortality rate of patients in the CT group with an OR of 2.82 (95% CI, 1.14-6.99, p=0.026) and a trend toward a higher recurrence rate after surgery with the OR of 1.45 (95% CI, 0.80-2.66) compared to the EUS group. Conclusion: EUS added a diagnostic value in the early detection of periampullary cancers, which may lead to a survival benefit, especially in PDAC and cholangiocarcinoma.

Comparison of endoscopic ultrasound-guided drainage and percutaneous catheter drainage of postoperative fluid collection after pancreaticoduodenectomy.

Postoperative fluid collection is a common complication of pancreatic resection without clear management guidelines. This study aimed to compare outcomes of endoscopic ultrasound (EUS)-guided trans-gastric drainage and percutaneous catheter drainage (PCD) in patients who experienced this adverse event after pancreaticoduodenectomy (PD). Demographic and clinical data and intervention outcomes of 53 patients who underwent drainage procedure (EUS-guided, n = 32; PCD, n = 21) for fluid collection after PD between January 2015 and June 2019 in our tertiary referral center were retrospectively analyzed. Prior to drainage, 83.0% had leukocytosis and 92.5% presented with one or more of the following signs or symptoms: fever (69.8%), abdominal pain (69.8%), and nausea/vomiting (17.0%). Within 8 weeks of drainage, 77.4% showed a diameter decrease of more than 50% (87.5% in EUS vs. 66.7% in PCD, p = 0.09). Post-procedural intravenous antibiotics were used for an average of 8.1 ± 4.3 days and 12.4 ± 7.4 days for EUS group and PCD group, respectively (p = 0.01). The EUS group had a shorter post-procedural hospital stay than the PCD group (9.8 ± 1.1 vs. 15.8 ± 2.2 days, p < 0.01). However, the two groups showed no statistically significant difference in technical or clinical success rate, reintervention rate, or adverse event rate. EUS-guided drainage and PCD are both safe and effective methods for managing fluid collection after PD. However, EUS-guided drainage can shorten hospital stay and duration of intravenous antibiotics use.

The Value of Gastric Cancer Staging by Endoscopic Ultrasonography Features in the Diagnosis of Gastroenterology.

This research was aimed at exploring the application value of endoscopic ultrasonography (EUS) in the diagnosis of gastric cancer staging and the correlation between staging and clinical features of gastric cancer. A total of 72 patients with gastric cancer were selected and randomly divided into two groups. The patients in the pathological group underwent postoperative pathological examination, while those in the EUS group received preoperative EUS examination. The results showed that the staging accuracy of EUS was 73.33% for T1, 78.57% for T2, 27% for T3, and 100% for T4, compared with the pathological staging. The accuracy of N- and N+ was 42.5% and 82.3% in EUS, respectively, and the total accuracy was 55.7%. There was no considerable difference in the accuracy of T staging between early gastric cancer and advanced gastric cancer (P > 0.05), but there was a considerable difference in N staging (P < 0.05). Lymph node metastasis affected the accuracy of N staging (P < 0.05). The number and location of metastatic lymph nodes did not affect the judgment of metastatic lymph nodes (P > 0.05). In addition, the proportion of understaging and overstaging was greatly different among different lesion sizes and histological types of gastric cancer (P < 0.05). To sum up, the accuracy of EUS for T and N staging of gastric cancer needed to be improved. The location of gastric cancer lesions affected the accuracy of T staging, while the depth of invasion and lymph node metastasis affected the accuracy of N staging.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for the diagnosis of computed tomography-negative common bile duct stone: Prospective randomized controlled trial.

For suspected common bile duct stone (CBDS) missed on computed tomography (CT), there is no clear evidence on whether endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is the better diagnostic tool. We aimed to compare the diagnostic accuracy of EUS and MRCP for cases of missed CBDS on CT. Patients suspected of having CBDS were enrolled and randomly allocated to the EUS or MRCP group. Upon the initial examination, those having CBDS or sludge formation underwent endoscopic retrograde cholangiopancreatography (ERCP), while those who were CBDS-negative underwent a second examination with either MRCP or EUS, which was distinct from the initial diagnostic procedure. The primary outcome was diagnostic accuracy, and the secondary outcomes were diagnostic ability, detection rate and characteristics of CBDS in the second examination, and the frequency of adverse events. Between April 2019 and January 2021, 50 patients were enrolled in the study. The accuracy was 92.3% for EUS and 68.4% for MRCP (P = 0.055). EUS showed 100% sensitivity, 88.2% specificity, 81.8% positive predictive value, and 100% negative predictive value, and MRCP showed 33.3% sensitivity, 84.6% specificity, 50% positive predictive value, and 73.3% negative predictive value. The CBDS detection rate in the second examination was 0% for MRCP after a negative EUS and 35.7% for EUS after a negative MRCP (P = 0.041). No adverse events occurred in any of the patients. Endoscopic ultrasound may be a superior diagnostic tool compared to MRCP for the detection of CBDS that are undetected on CT. (UMIN000036357).

Drainage procedures for postoperative fluid collection after pancreaticoduodenectomy: A comparison of endoscopic ultrasound guided and percutaneous drainage

Postoperative fluid collection (POFC) is a common complication of pancreas resection with no clear management guidelines and high morbidity rates. This study aims to analyze clinical features of patients with POFC and compare outcomes of endoscopic ultrasound (EUS) guided and percutaneous drainage in patients with POFC after pancreaticoduodenectomy (PD). We analyzed demographic data, clinical data and intervention outcomes of 53 (EUS guided = 32, percutaneous = 21) patients who underwent PD between January 1, 2015 and June 30, 2019 at our center. Prior to drainage, 83.0% had leukocytosis and 92.5% presented with one or more of the following signs or symptoms: fever (69.8%), abdominal pain (79.2%), and nausea/vomiting (17.0%). Fluid collection diameters showed a mean of 95 mm (range, 33 to 191 mm), of which 77.4% showed a diameter decrease of more than 50% within 8 weeks of drainage (EUS = 87.5% vs. PCD = 61.9%, p = 0.085). Eighty-two percent of sampled fluid collections showed positive culture results and post procedural IV antibiotics were used for an average of 8.1 ± 4.3 and 12.4 ± 7.4 days for EUS group (EG) and PCD group (PG) respectively (p = 0.012). EG had a shorter post-procedural hospital stay than PG (9.8 ± 1.1 vs. 15.8 ± 2.2 days, p = 0.004) with no statistically significant differences in technical and clinical success rates, reintervention rates and adverse event rates. EUS guided drainage (EUSD) and percutaneous catheter drainage (PCD) are both equally safe and effective in managing POFC after PD. However, EUSD was associated with shorter IV antibiotic treatment and shorter hospital stay.

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.

Endoscopic Ultrasound in Borderline &amp; Locally Advanced Pancreatic: Leeds Experience

Introduction: Endoscopic ultrasonography (EUS) is an essential pancreatic cancer investigation which has picked up in the last decade and is commonly used in combination with more traditional cross-sectional imaging techniques. Up to 79% of all pancreatic malignancies are locally advanced (stage 3) or metastatic (stage 4) at initial presentation. Developments in technology, such as contrast enhancement, elastography and fine needle aspiration (EUS-FNA) have further increased EUS diagnostic yield. EUS-FNA is accepted as the optimal method of obtaining tissue for histological diagnosis prior to starting neoadjuvant treatment (NAT) and has a lower incidence of complications such as pancreatitis, bleeding and tumour seeding. The aim of this study was to evaluate the role of EUS in advanced pancreatic cancers. Methods: Patients with borderline and locally advanced pancreatic ductal adenocarcinoma between 2016 and 2020 were retrieved from institutional pancreatic tumour database. Patients with IPMN, MCN, periampullary cancers and metastatic pancreatic cancer were excluded. All patients with BRPC, LAPC received NAT. Data of patients undergoing EUS were retrieved and compared with cross-sectional imaging. Appropriate statistical analysis was performed where applicable. Results: 96 patients underwent EUS and FNB. Diagnosis of PDAC was confirmed in 81.25% (78) cases before starting neoadjuvant treatment. Mean tumour size on EUS was 2.7cm as compared to 3cm on CT. CT confirmed N1 disease was seen in 21.6% (26) patients however, in only 2.5% (3) cases local lymphadenopathy was detected using EUS. Vascular involvement was seen in 50.8% (61) cases on CT and only in 44.1% (53) in the EUS group. EUS induced pancreatitis was seen in 3.12% (3) patients. > 2 attempts to confirm tissue diagnosis was seen in 3.84% of patients. Dysplasia, IPMN, Pancreatitis and Suspicious lesions were detected in 1.04%, 2.08%, 1% and 15.62% is suspected PDAC on imaging. There were no EUS induced bleeding or other complications during the study period. Conclusion: EUS has a role in the evaluation of advanced pancreatic malignancies and in assessment of vascular involvement and local lymphadenopathy. It also provides cytological and histological confirmation prior to commencing NAT. EUS-guided therapeutic interventions also provide effective biliary drainage particularly in individuals where ERCP is not feasible.

Characteristics of Atrial Fibrillation Patients Suffering Esophageal Injury Caused by Ablation for Atrial Fibrillation

The close proximity of esophagus to the left atrial posterior wall predisposes esophagus to thermal injury during catheter ablation for atrial fibrillation (AF). In this retrospective study, we aimed to investigate risk factors of esophageal injury (EI) caused by catheter ablation for AF. Patients who underwent first-time AF ablation from July 2013 to June 2018 were included. The esophagus was visualized by oral soluble contrast during ablation for all patients and a subset of patients were selected to undergo endoscopic ultrasonography (EUS) to estimate EI post ablation. Degree of EI was categorized as Kansas City classification: type 1: erythema; type 2: ulcers (2a: superficial ulcers; 2b: deep ulcers); type 3: perforation (3a: perforation without communication with the atria; 3b: atrioesophageal fistula [AEF]). Of 3,852 patients, 236 patients (61.5 ± 9.7 years; male, 69%) received EUS (EUS group) and 3616 (63.2 ± 10.9 years; male, 61.1%) without EUS (No-EUS group). In EUS group, EI occurred in 63 patients (type 1 EI in 35 and type 2 EI in 28), and no type 3 EI was observed during follow up. In a multivariable logistic regression analysis, an overlap between the ablation lesion and esophagus was an independent predictor of EI (odds ratio, 21.2; 95% CI: 6.23–72.0; P < 0.001). In No-EUS group, esophagopericardial fistula (EPF; n = 3,0.08%) or AEF (n = 2,0.06%) was diagnosed 4–37 days after ablation. In 3 EPF patients, 2 completely recovered with conservative management and 1 died. Two AEF patients died. Ablation at the vicinity of the esophagus predicts risk of EI. EUS post ablation may prevent the progression of EI and should be considered in management of EI. It remains challenging to identify patients with high risk of EI.

Predicting common bile duct stones by non-invasive parameters

Common bile duct (CBD) stone affect about 10% of patients with symptomatic cholelithiasis. The American Society for Gastrointestinal Endoscopy (ASGE) published a strategy in 2010 for managing patients with suspected choledocholithiasis. This study aimed to assess the performance of different clinical parameters in predicting CBD stones. A total of 344 patients suspected to suffer from CBD stone and referred to endoscopic ultrasound (EUS) were included. Parameters were collected and their prediction power for CBD stones was assessed. One hundred and sixty-seven patients without CBD stone according to EUS (group A) were compared to 177 patients with CBD stones (group B). Several predictive factors for CBD stone were identified on univariate analysis. In multivariate regression analysis, CBD width by US (OR=1.224, 95% CI: 1.073-1.359; P=0.0026), age (OR=1.023, 95% CI: 1.011-1.035; P=0.0002) and gamma glutamyl transferase (GGT) level (OR=1.001, 95% CI: 1.000-1.002; P=0.0018) were significantly correlated with CBD stone, with receiver operator characteristics (ROC) of 0.7259. We generated a diagnostic equation [age (yr)×0.1+CBD width (mm) by US×1+GGT (U/L)×0.005] to predict CBD stone with ROC of 0.7287. We suggest this score as a very strong predictor for CBD stones, and to reduce the strength of total bilirubin and transaminases as predictors.

97 Performance Comparison Between Endoscopic Ultrasound/endoscopic Retrograde Cholangiopancreatography and Intraoperative Cholangiography for Detecting Choledocholithiasis

INTRODUCTION: The diagnosis and management of choledocholithiasis have been evolving given multiple diagnostic modalities. One of these diagnostic modalities is intraoperative cholangiogram (IOC) which is typically performed during laparoscopic cholecystectomy for evaluation of choledocholithiasis. Our aim is to compare endoscopic ultrasound (EUS) to IOC in the accurate detection of a common bile duct stone using endoscopic retrograde cholangiopancreatography (ERCP) as gold standard for diagnosis. METHODS: A five-year retrospective single center study was performed for patients diagnosed with choledocholithiasis due to a positive IOC during laparoscopic cholecystectomy. These patients subsequently were tested with EUS and ERCP (Group 1). Analysis was also performed in which patients underwent IOC with subsequent ERCP without EUS (Group 2). We used ERCP as the gold standard to ascertain a percentage of true positives, true negatives, sensitivity, specificity and corresponding 95% exact confidence intervals. Demographic data and laboratory values (bilirubin and liver enzymes) prior to endoscopic procedure were also described. RESULTS: All of the 24 IOC positive patients (Group 1) were subjected to EUS and the majority of these patients underwent an ERCP. EUS detected 80% (8/10, 95% CI: 48.1–96.5) true positives and 92.3% (12/13, 95% CI: 67.5–99.6) true negatives among these IOC positive patients (Figure 1). 52 patients who underwent IOC and subsequent ERCP without EUS (Group 2). 43 of the 52 patients were positive to IOC. Nine IOC negative patients were examined with ERCP and 6 were negative. IOC detected 69.7% (30/43, 95% CI: 54.9–82.0) of true positives and 66.7% (6/9, 95% CI: 33.2–90.7) true negatives (Figure 1). With a sensitivity of 90.9% (95% CI: 75.7–98.1) and specificity of 31.6% (95% CI: 12.6–56.6), IOC resulted 30.2% (13/43, 95% CI: 18.0–46.1) false positives and 33.3% (3/9, 95% CI: 9.27–66.8) false negatives. CONCLUSION: Test performance of EUS in IOC-positive patients compared to test performance of IOC in patients not tested with EUS were comparable. However, with about a third of patients exposed to unnecessary ERCP, clinical practicality of IOC as the screening test is questionable. Large proportion of false positives is not desirable for a screening test with less than perfect sensitivity. Thus, EUS can help risk stratify patients and presumably avoid or minimize unnecessary ERCP risks to patients. Additional studies with large patient populations will be more conclusive.

Position statement on EUS-guided ablation of pancreatic cystic neoplasms from an international expert panel.

Background and aim Recently, several guidelines with divergent recommendations on management of pancreatic cystic neoplasm have been published but the role of endoscopic ultrasound (EUS)-guided pancreatic cyst ablation has not been thoroughly addressed. The aim of the current paper is to explore the issues surrounding EUS-guided pancreatic cyst ablation by generating a list of clinical questions and providing answers based on best scientific evidence available. Methods An expert panel in EUS-guided pancreatic cyst ablation was recruited from members of the Asian EUS group and an international expert panel. A list of clinical questions was created and each question allocated to one member to generate a statement in response. The statements were then discussed in three Internet conference meetings between October 2016 and October 2017. The statements were changed until consensus was obtained. Afterwards, the complete set of statements was sent to all the panelist to vote on strength of the statements, classification of the statement sand grading of the evidence. Results Twenty-three statements on EUS-guided drainage of pancreatic cyst ablation were formulated. The statements addressed indications for the procedures, technical aspects, pre-procedure and post-procedure management, management of complications, and competency and training in the procedures. Conclusion The current set of statements on EUS-guided pancreatic cyst ablation are the first to be published by any endoscopic society. Clinicians interested in developing the technique should reference these statements and future studies should address the key issues raised in the document.

Endoscopic ultrasound-guided vs endoscopic retrograde cholangiopancreatography biliary drainage for obstructed distal malignant biliary strictures: A systematic review and meta-analysis.

BACKGROUNDFor palliation of malignant biliary obstruction (MBO), the gold-standard method of biliary drainage is endoscopic retrograde cholangiopancreatography (ERCP) with the placement of metallic stents. Endoscopic ultrasound (EUS)-guided drainage is an alternative that is typically reserved for cases of ERCP failure. Recently, however, there have been robust randomized clinical trials (RCTs) comparing EUS-guided drainage and ERCP as primary approaches to MBO.AIMTo compare EUS guidance and ERCP in terms of their effectiveness and safety in palliative biliary drainage for MBO.METHODSThis was a systematic review and meta-analysis, in which we searched the MEDLINE, Excerpta Medica, and Cochrane Central Register of Controlled Trials databases. Only RCTs comparing EUS and ERCP for primary drainage of MBO were eligible. All of the studies selected provided data regarding the rates of technical and clinical success, as well as the duration of the procedure, adverse events, and stent patency. We assessed the risk of biases using the Jadad score and the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation criteria.RESULTSThe database searches yielded 5920 records, from which we selected 3 RCTs involving a total of 222 patients (112 submitted to EUS and 110 submitted to ERCP). In the EUS and ERCP groups, the rate of technical success was 91.96% and 91.81%, respectively, with a risk difference (RD) of 0.00% (95%CI: -0.07, 0.07; P = 0.97; I2 = 0%). The clinical success was 84.81% and 85.53% in the EUS and ERCP groups, respectively, with an RD of −0.01% (95%CI: -0.12, 0.10; P = 0.90; I2 = 0%). The mean difference (MD) for the duration of the procedure was -0.12% (95%CI: -8.20, 7.97; P = 0.98; I2 = 84%). In the EUS and ERCP groups, there were 14 and 25 adverse events, respectively, with an RD of -0.06% (95%CI: -0.23, 0.12; P = 0.54; I2 = 77%). The MD for stent patency was 9.32% (95%CI: -4.53, 23.18; P = 0.19; I2 = 44%). The stent dysfunction rate was significantly lower in the EUS group (MD = -0.22%; 95CI:-0.35, -0.08; P = 0.001; I2 = 0%).CONCLUSIONEUS represents an interesting alternative to ERCP for MBO drainage, demonstrating lower stent dysfunction rates compared with ERCP. Technical and clinical success, duration, adverse events and patency rates were similar.

Esophageal cancer N staging study with endoscopic ultrasonography.

Esophageal cancer staging is important for the treatment of esophageal cancer. Endoscopic ultrasonography (EUS) is a common diagnostic tool for esophageal cancer prior to surgery. However, EUS is unable to accurately discriminate the N-staging of lymph nodes. In order to distinguish an optimized standard for malignant lymph node diagnosis, the present study compared lymph nodes detected by EUS and surgery. A total of 112 patients were preoperatively examined with EUS and staged according to the 7th Edition of the American Joint Committee on Cancer Staging Manual. The results of EUS were compared with surgical findings. The critical values of long diameter, short diameter and lymph node number detected by EUS were >7.5, >5.5 mm and >2, respectively; indexes, including long diameter >7.5 mm, short diameter >5.5 mm, round, low echo, edge smooth, near lesion and detected lymph node number (>2) and T3/4 staging, met significance in the EUS group compared with the surgical group (P<0.05). Furthermore, the area under curve (AUC) value of the EUS (0.801) was superior to the conventional, surgical method (0.779). Although EUS improved the diagnostic accuracy of esophageal N staging, it was not able to satisfactorily distinguish between N2 and N3 staging. Advancements in EUS may enhance its detection ability, further improving the diagnostic accuracy of lymph node metastasis.

Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel

ObjectivesInterventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac...

Use of Endoscopic Ultrasound to Guide Adalimumab Treatment in Perianal Crohn's Disease Results in Faster Fistula Healing.

Perianal disease is a manifestation of Crohn's disease (CD) that has poor long-term treatment outcomes. The aim was to determine if rectal endoscopic ultrasound (EUS)-guided therapy with adalimumab (ADA) can improve outcomes for patients with perianal fistulizing CD. This is a randomized prospective study comparing serial EUS guidance of fistula treatment versus standard of care in fistulizing perianal CD. At enrollment, all patients underwent a rectal EUS and an EUA with seton placement and/or I&D. Treatment was maximized with immunomodulators, antibiotics, and ADA induction. Surgical interventions were determined by the surgeon's discretion in the control group and assisted by every 12th week EUS in the intervention group. Primary and secondary endpoints where complete drainage cessation at week 48 was fistula status per EUS, respectively. Twenty patients were enrolled: 11 control and 9 EUS guidance. At 24 weeks, 7/9 (78%) in EUS group and 3/11 (27%) in control group had drainage cessation (P = 0.04). This significant difference was lost at week 48 (P = 0.44). Three patients in the EUS and 1 in the control group had additional surgical intervention. Those in the EUS group had more rapid escalation of ADA dosing (P = 0.003). There was no difference in the change in PDAI at week 48 versus baseline (P = 0.81). Rectal EUS-guided ADA therapy for CD perianal fistulas showed an initial benefit at 24 weeks, which was lost at week 48. This is likely due to small sample size and higher fistula closure in the controls. However, the faster rate of fistula resolution is a clinically significant finding.

A multi-institutional survey on the practice of endoscopic ultrasound (EUS) guided pseudocyst drainage in the Asian EUS group.

Background: There is a lack of consensus on how endoscopic ultrasound (EUS) guided pseudocyst drainage should be performed. This survey was carried out amongst members of the Asian Endoscopic Ultrasonography Group (AEG) to describe their practices in performing this procedure. Methods: This was an Asia wide multi-institutional survey amongst members of the Asian EUS group conducted between November and December 2013. The responses to a 19-question survey with regard to the practice of pseudocyst drainage were obtained. Results: In total, 19 endoscopists responded to the questionnaire and the mean (SD) number of procedures performed by each endoscopist was 87.95 (40); 42.2 % believed that prior endoscopic retrograde cholangiopancreatography (ERCP) is required and pancreatic duct stenting is indicated in patients with pancreatic duct disruption; 47.4 % used tapered catheters for track dilation and 42.1 % used the cystotome; 84.1 % would dilate the track up to 8 to 10 mm in size. Metallic stents were used by 10.5 % of the respondents and transcystic catheters were employed by 26.3 %. Those who were more experienced in the procedure tended to use the cystotome more frequently (P = 0.02) and removed the stents in less than 3 months after insertion (P = 0.011). Conclusion: This was the first Asia wide survey in the practice of pseudocyst drainage. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need for establishment of a consensus for safe practices.

Mo1407 Structured Endoscopic Ultrasound Training Program Improved Knowledge and Skills of Trainees - Results From the Asian EUS Group

While endoscopic ultrasound (EUS) is an established diagnostic modality, its use in some Asian countries remains limited. One of the main reasons is the lack of training availability. The Asian EUS Group was established to propagate the training of EUS to aspiring endosonographers through structured 2-day workshops with lectures, hands-on practice in animals, and/or Ikuma model, and live case demonstration.

Endoscopic Ultrasound–Guided Pancreatic Fiducial Placement

Image-guided radiation therapy allows precise tumor targeting using real-time tracking of radiopaque fiducial markers. To enable appropriate tracking, it is recommended to place fiducials with "ideal fiducial geometry" (IFG). Our objectives were to determine the proportion of patients in whom IFG can be achieved when fiducials are placed by endoscopic ultrasound (EUS) and surgery and to determine if attaining IFG is necessary for delivering radiation. This single-center retrospective cohort study included 77 patients with biopsy-proven advanced pancreatic cancer who underwent either EUS-guided or laparotomy/laparoscopy-assisted fiducial placement between September 2005 and July 2009. Gold fiducials were implanted by EUS in 39 patients (51%) and by surgery in 38 patients (49%). The proportion of patients with IFG was significantly higher for surgical placement [18/38, 47%; 95% confidence interval (CI), 32%-63%] compared with EUS-guided placement (7/39, 18%; 95% CI, 8%-32%), P = 0.0011. However, fiducial tracking was successfully used for Cyberknife therapy in 35 (90%) of 39 (95% CI, 77%-97%) patients in the EUS group compared with 31 (82%) of 38 (95% CI, 67%-92%) patients in the surgery group. There were 5 procedure-related complications in the EUS group. Achieving IFG appears unnecessary for successful tracking and delivery of radiation.