Endoscopic Ultrasound Research Articles

Pancreatic cystic neoplasms

Pancreatic cystic lesions represent achallenging heterogeneous entity with a potential risk of malignant transformation. The diagnostics include in particular medical history taking with collection of relevant clinical information and high-resolution imaging, preferably using magnetic resonance imaging (MRI) with MR cholangiopancreatography (MRCP) and/or endoscopic ultrasonography. A differentiation between different cystic entities and identification of risk factors are crucial for making appropriate treatment decisions. Only a small proportion of pancreatic cystic neoplasms require surgery. Pancreatic cystic lesions with a relevant risk of malignancy, such as main duct intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and general cystic pancreatic lesions with risk factors regardless of the entity, should be resected, whereas an individualized approach is required for branch duct IPMN and serous cystic neoplasms (SCN) and dysontogenetic cysts require no treatment. Parenchyma-sparing and minimally invasive resection techniques should be preferred whenever possible for resecting pancreatic cystic tumors. Approximately 10% of patients develop recurrences over time.

Endo-hepatology: Why should we do endoscopic ultrasound-guided interventions to the liver that we could do through the skin?

Endoscopic ultrasound (EUS)-guided interventions on the liver such as diffuse biopsy and portal pressure gradient measurement are emerging as potential alternatives to percutaneous procedures. The purpose of this editorial was to address all the indications that could potentially make an EUS-guided approach a possible alternative to the percutaneous procedures with respect to the proce-dures that could join the EUS examination such as upper endoscopy for gastro-esophageal varices, pancreaticobiliary investigation with EUS, and other potential advantages in terms of patient safety. The issue of a holistic gastroenterologist approach was also discussed along with the potential for developing clinical research.

Management of Fecal Incontinence: Etiology, Diagnostic Approach, and Conservative Therapy

Background: Fecal incontinence is a common problem especially in the elderly resulting in a reduced quality of life. Summary: The etiology of fecal incontinence is often multifactorial with little options for a causal therapy. The mechanisms causing incontinence can be detected by sophisticated methods in most of the patients. Using therapeutic algorithms, incontinence can be improved or even continence restored in many patients. Key Messages: Diagnostic work-up starts with history, digital investigation, and anoproctoscopy. The specialist will further investigate with anorectal manometry, anal endosonography, and electromyography of the external anal sphincter muscle. Nonoperative therapy comprises hygienic methods, medical therapy, intraanal electrostimulation, and training methods like pelvic floor exercises or biofeedback. Second-line conservative therapies are tibial nerve stimulation, transanal irrigation, or anal inserts.

Assessment of Endoscopic Ultrasound for Predicting Preoperative T Staging in Patients With Gastric Adenocarcinoma.

Endoscopic ultrasound (EUS) is an imaging modality that can be applied to predict preoperative T staging. It is important for the patient to decide whether to receive endoscopic therapy, surgical intervention, or neoadjuvant therapy. The objectives of our study were to (1) identify if EUS could precisely predict T1-stage tumor, which is suitable for endoscopic treatment and (2) identify if EUS could precisely predict tumors more advanced than T3, which would mandate neoadjuvant therapy. A retrospective study of patients who received gastrectomy was conducted from March 2017 to December 2021 at Taichung Veterans General Hospital. Those who received preoperative EUS, with final pathology showing gastric adenocarcinoma were included. Consistency of EUS prediction and pathology, accuracy, and parameters impacting accuracy were analyzed. The κ value was 0.6 if the T stage was not grouped, indicating moderate agreement. Overall accuracy was 52.8%. Overestimation and underestimation rates were 17.6% and 29.5%, respectively. The accuracy of T stages is highest in T1 (85.23%). The κ value of T1-stage was 0.67, and those of T2, T3, and T4 were below 0.5. Regarding parameters affecting accuracy, we found longitudinal portion, Borrmann type, ulcer presentation, early gastric cancer, and size of tumor could influence the accuracy. Our study showed that EUS was a good tool for precisely predicting T1-stage of gastric adenocarcinoma preoperatively. For this situation, endoscopic treatment would be enough. However, for predicting more advanced gastric adenocarcinoma, EUS should be combined with other modalities to achieve better accuracy.

Endoscopic ultrasound-guided biliary rendezvous after failed cannulation, and comparison between benign vs malignant biliopancreatic disorders: outcomes at a single tertiary-care centre

Background Endoscopic ultrasound (EUS)-guided biliary rendezvous (RV) is an EUS-assisted technique described as a rescue method in cases of failed biliary cannulation via endoscopic retrograde cholangiography (ERC). Current literature remains unclear regarding its current role. The study aim was to evaluate the effectiveness for biliary EUS-RV, and comparison between benign vs malignant biliopancreatic disorders. Methods Retrospective observational study with prospective consecutive inclusion in a specific database from a tertiary-center. All patients with biliopancreatic diseases that underwent a EUS-assisted ERC between October-2010 and November-2022 for failed ERC were included. Main outcomes were technical/overall success. Secondary outcomes were safety, potential factors related to failure/success or safety; and a comparative analysis between EUS-RV and EUS-guided transmural drainage (TMD) in malignant cases. Results A total of 69 patients who underwent EUS-RV procedures, with benign and malignant pathologies (n = 40 vs n = 29), were included. Technical / overall success and related-adverse events (AEs) were 79.7% (95%CI, 68.3-88.4) / 74% (95%CI, 61-83.7) and 24% (95%CI, 15.1-36.5), respectively. Failed cases were mainly related with guidewire manipulation. Seven failed RV were successfully rescued by EUS-TMD. On multivariable analysis, EUS-RV and malignant pathology was associated with a greater failure rate (technical success: OR,0.21; 95%CI,0.05-0.72; p = 0.017), and higher AEs rate (OR,3.46; 95%CI,1.13-11.5; p = 0.034). Also, the EUS-TMD group had greater technical success (OR,16.96; 95%CI,4.69-81.62; p < 0.001) and overall success (OR, 3.09; 95%CI,1.18-8-16; p < 0.026) with a lower AEs rate (OR,0.30; 95%CI,0.11-0.78; p = 0.014) than EUS-RV in malignant disorders. Conclusions EUS-RV is a demanding technique with better outcomes in benign than in malignant biliopancreatic diseases. Comparison of the EUS-TMD group on malignant disorders showed worse outcomes with EUS-RV. Given these findings, maybe EUS-RV is not the best option for malignant biliopancreatic disorders.

Gallbladder Polyps: A Literature Review of Basic Concepts, Diagnosis and Treatment Options

Gallbladder polyps (GP) are projections of the mucosa toward the light, most of them are benign caused by cholesterol deposits, focal adenomatosis, or hyperplastic lesions secondary to a local infection. It has an estimated prevalence of 5% of the world population. Cholesterol polyps are usually formed by an asymptomatic process, rarely obstructive jaundice or cholangitis due to the blockage of distal bile ducts by detached fragments of polyps. A small number of patients may be symptomatic; cholesterolosis and adenomatosis can also cause chronic dyspeptic abdominal pain, nausea, and vomiting. Ultrasound is the main imaging modality to diagnose polyps of the gallbladder, endoscopic ultrasonography can be a useful tool in patients with clinical pictures suggestive of vesicular pathology and non-invasive imaging studies, and inconclusive. In a patient aged less than 50 years with GP, the likelihood of malignancy is minimal and does not require cholecystectomy. However, those with a size greater than or equal to 10 mm should be resected by cholecystectomy for high risk of malignancy, and those with a size less than 10 mm should be submitted to ultrasound monitoring, observing the risk characteristics during follow-up, to provide timely treatment.

Development of an intraductal papillary mucinous neoplasm malignancy prediction scoring system.

Despite the presence of various guidelines, diagnosing malignant intraductal papillary mucinous neoplasm (IPMN) continues to pose challenges. Furthermore, although endoscopic ultrasonography (EUS) offers high-resolution images, it has not yet recognized as the primary tool for malignancy diagnosis. The study objective was to develop a simplified and user-friendly scoring system to improve the diagnostic accuracy of malignant IPMNs. Additionally, the utility of EUS and its effect on diagnostic accuracy were assessed. We retrospectively collected the clinical data on 160 cases of resected IPMN at Tokyo Medical and Dental University Hospital from January 2008 to December 2022. We examined clinical features, computed tomography (CT) and magnetic resonance imaging (MRI) findings, and EUS results if available. We then calculated the odds ratio of malignancy for these factors and developed an IPMN malignancy prediction (IMAP) scoring system. There were 89 (55.6%) cases of benign IPMNs and 71 (44.4%) of malignant IPMNs. Eight clinical and imaging findings, including age, diabetes mellitus status, jaundice, CA19-9 level, enhancing mural nodules ≥5mm, thickened wall, and main duct dilatation, were significantly associated with malignancy. The IMAP score was calculated by assigning 0 to 2 points to these factors based on the odds ratio. The area under the receiver operating characteristic curve for the IMAP score was 0.78 [95% confidence interval (CI): 0.71-0.85] based on CT/MRI alone and improved to 0.81 (95% CI: 0.74-0.87) when EUS was added. When the total exceeds 5 points, the positive predictive value becomes 100% (95% CI: 95.9-100). In conclusion, the IMAP scoring system has demonstrated promise as a clinically useful tool, offering both simplicity and sufficient accuracy. It holds potential as an important decision criterion for determining the treatment approach for IPMN. Additionally, EUS contributes to enhancing the diagnostic accuracy of the IMAP scoring system, thereby enabling more precise decision-making.

Propofol-alone sedative efficacy in observational biliopancreatic endoscopic ultrasound.

Appropriate sedative and analgesic selection is essential to reduce patient discomfort and body movement to safely conduct endoscopic ultrasonography (EUS). However, few cases have examined sedation with propofol in EUS, and few studies the need for combined analgesia. In this study, we retrospectively evaluated the usefulness and safety of propofol without analgesics for sedation in biliopancreatic observational EUS. This single-center retrospective study included 516 observational biliopancreatic EUS procedures using propofol alone performed between April 2021 and March 2023. The primary and secondary endpoints were the observational biliopancreatic EUS results obtained with propofol alone and adverse event occurrence, respectively. The median examination time and total propofol dose were 22 (range: 10-67) min and 186.5 (range: 50-501) mg, respectively. The median starting Richmond Agitation-Sedation Scale and Visual Analog Scale scores were -5 (range: -5-1) and 0 (range: 0-10), respectively. The median recovery time was 22 (range: 5-80) min. Adverse events occurred in 60 (11.6%) patients. Trainee-performed examination (odds ratio [OR] 3.52, 95% confidence interval [CI]: 1.63-7.60, p = 0.0014) and examination length (>22 min; OR 1.67, 95% CI: 0.95-2.92, p = 0.07) were risk factors for adverse events.High body mass index (OR 1.87, 95% CI: 1.10-3.16, p = 0.02) and extended examination time (OR 4.23, 95% CI: 2.08-8. 57, p < 0.001) were risk factors for delayed recovery. During observational biliopancreatic EUS, propofol is useful as a single sedative and offers high patient satisfaction and relative safety.

Endoscopic ultrasound-guided drainage for mediastinal abscess: first report of bridge to surgery for esophageal cancer.

Perforated esophageal cancer rarely results in the formation of mediastinal abscess. Endoscopic ultrasound (EUS)-guided abscess drainage (AD) has increasingly been used in the management of abscesses in locations that are difficult to treat percutaneously. We describe a case of EUS-AD for mediastinal abscess due to perforating esophageal cancer and successful bridge to surgery. A 71-year-old man with suspected esophageal issues was referred to our hospital. Computed tomography showed an esophageal cancer perforating the mediastinum, forming a mediastinal abscess. EUS-AD was planned before curative resection, because there was little improvement in inflammatory response with antimicrobial therapy. The mediastinal abscess cavity was confirmed on EUS and punctured using a 19-G needle, and then, a 0.025-inch guidewire was placed in the abscess cavity. The fistula was dilated with a 7-Fr dilator and a 6-Fr, single-pigtail nasobiliary tube was placed in the abscess cavity. One month later, clinical signs had improved and curative surgery was performed. Postoperative adjuvant therapy was administered using fluorouracil/cisplatin therapy. As of 2years postoperatively, the patient remains free of recurrence.

Gastric glomus tumor with a rare presentation: a case report and review of the literature

Introduction and Importance: Gastric glomus tumors (GGT) are rare soft tissue tumors of the gastrointestinal tracts (GIT). It is somewhat challenging to establish the diagnosis of GGT and differentiate it from the more common submucosal neoplasms. Case Presentation: A 34-year-old female patient presented with upper gastrointestinal bleeding. Extensive workup including endoscopic ultrasonography (EUS) revealed a well-circumscribed isoechoic mass arising from the muscularis propria. Based on fine needle biopsy (FNB) findings, with H&amp;E stains performed only initially, the mass was considered a neuroendocrine tumor (NET). Antrectomy with Billroth II anastomosis was performed. A microscopic and immunohistochemical studies of the resected specimen showed the cells to be positive for smooth muscle actin (SMA) making GGT the final diagnosis. Clinical Discussion: Of the 116 patients included in our analysis, 56.9% (n=66) were females and age group was between 41-64 years old in 63.8% (n=74) of the patients. About 55 cases (47.4%) had abdominal or epigastric pain or discomfort, which was the most frequent clinical symptom. In immunohistochemistry, SMA staining is present in 68.1% of the cases, underscoring its diagnostic significance. Laparotomy with wedge or partial gastrectomy was employed in 46.1% of the recorded cases. Due to malignant potential, long-term follow-up and monitoring are usually recommended. Conclusion: Despite the rarity of GGT, they should be included in the differential diagnosis of gastric submucosal tumors, with immunohistochemistry studies playing a major role in the diagnosis. Furthermore, a comprehensive evaluation of the literature in the past eight years was presented in a table.

Endoscopic Ultrasound and Gastric Sub-Epithelial Lesions: Ultrasonographic Features, Tissue Acquisition Strategies, and Therapeutic Management

Background and objectives: Subepithelial lesions (SELs) of the gastrointestinal (GI) tract present a diagnostic challenge due to their heterogeneous nature and varied clinical manifestations. Usually, SELs are small and asymptomatic; generally discovered during routine endoscopy or radiological examinations. Currently, endoscopic ultrasound (EUS) is the best tool to characterize gastric SELs. Materials and methods: For this review, the research and the study selection were conducted using the PubMed database. Articles in English language were reviewed from August 2019 to July 2024. Results: This review aims to summarize the international literature to examine and illustrate the progress in the last five years of endosonographic diagnostics and treatment of gastric SELs. Conclusions: Endoscopic ultrasound is the preferred option for the diagnosis of sub-epithelial lesions. In most of the cases, EUS-guided tissue sampling is mandatory; however, ancillary techniques (elastography, CEH-EUS, AI) may help in both diagnosis and prognostic assessment.

Effect of endoscopic ultrasound guided celiac plexus block on the palliation of pain in chronic pancreatitis (EPOCH Trial): study protocol for a randomized multicenter sham-controlled trial {1}

BackgroundCeliac plexus block has been commonly utilized for the treatment of chronic pancreatitis-associated abdominal pain. Prospective studies suggest efficacy in 30 to 50% of patients, although no randomized sham-controlled trials have been performed. The objective of this study is to assess the effect of endoscopic ultrasound (EUS)-guided celiac plexus block on abdominal pain in patients with documented chronic pancreatitis. MethodsThis is a two-arm randomized sham-controlled trial with blinded evaluators. The study will be conducted at multiple academic sites in the United States who are members of the United States Pancreatic Disease Study Group (USPG). Patients referred for EUS to exclude chronic pancreatitis as a cause of abdominal pain as well as those with established painful chronic pancreatitis undergoing EUS for another indication will be eligible. At the time of EUS with confirmation of chronic pancreatitis by standard EUS diagnostic criteria, patients will be randomized to either celiac plexus block or sham whereby an anesthetic and steroid combination will be injected into the celiac plexus or saline will be injected into the gastric lumen with the same type of needle as used for celiac plexus block, respectively. The main outcome measure will be a 50% reduction in abdominal pain using the Brief Pain Inventory Short Form (BPI-SF) at 1 month post-intervention. A number of secondary outcomes will be measured including visual analog scale (VAS), Comprehensive Pain Assessment Tool Short Form (COMPAT-SF) pain scores, and quality of life using a pancreas-specific validated measure (PANQOLI).DiscussionIn this study, the effect of celiac plexus block on abdominal pain in patients with chronic pancreatitis will be compared to a sham intervention. This randomized trial will offer a definitive assessment of the role of celiac plexus block for the treatment of abdominal pain in this setting.Trial registration {2}ClinicalTrials.gov NCT 06178315. Registered on December 21, 2023

Value of image enhancement of endoscopic ultrasound for diagnosis of gastrointestinal subepithelial lesions.

Among subepithelial lesions (SELs), gastrointestinal stromal tumors (GISTs) should be identified and surgically treated at an early stage. However, it is difficult to diagnose SELs smaller than 20 mm. In recent years, endoscopic ultrasound (EUS) elastography (EUS-EG) and contrast-enhanced harmonic EUS (CH-EUS) have been reported to be useful for the diagnosis of SELs, although the diagnostic accuracy of a combination of EUS techniques with image enhancement is unknown. Patients with SELs who underwent EUS-guided tissue acquisition, EUS shear-wave elastography (EUS-SWE), EUS strain elastography (EUS-SE), and CH-EUS from January 2019 to June 2023 were enrolled. To assess the diagnostic accuracy for differentiating GISTs from other SELs, shear-wave velocity on EUS-SWE, the strain ratio on EUS-SE, and vascularity on CH-EUS were determined and their diagnostic accuracies were compared. Forty-three patients were enrolled. When the cut-off value was set at 3.27 m/s, the sensitivity, specificity, and diagnostic accuracy of shear-wave velocity were 28.6%, 86.2%, and 34.9%, respectively. When the cut-off value was set at 3.79, the sensitivity, specificity, and diagnostic accuracy of the strain ratio were 93.1%, 64.3%, and 83.7%, respectively. The sensitivity, specificity, and diagnostic accuracy of CH-EUS were 79.3%, 92.3%, and 83.7%, respectively. When EUS-SE was combined with CH-EUS, the sensitivity and diagnostic accuracy were the highest among binary combinations of image enhancement modalities. EUS-SE and CH-EUS are useful for differentiating GISTs from other SELs. Furthermore, the use of both modalities may further improve the identification of GISTs.

Informative value of diagnostic imaging methods in the detection of subepithelial formations of the stomach: a clinical case

INTRODUCTION: Subepithelial formations (SubEO) of the upper gastrointestinal tract (GI tract) are asymptomatic in most cases, and are a diagnostic finding in routine studies. Given the risk of malignancy of some SubEO, the question of treatment tactics remains relevant today: observation or surgical intervention.PURPOSE: To demonstrate diagnostic capabilities at the outpatient stage when choosing observational tactics in a patient with SubEO.MATERIALS AND METHODS: A dynamic observation of a 68-year-old woman with a randomly identified SubEO was demonstrated. The patient has been observed by a gastroenterologist since 2005 with a diagnosis of functional disorder of the gallbladder and sphincter of Oddi. In August 2022, when contacting the clinic with complaints of epigastric pain and heartburn, the following studies were performed: gastroscopy (FGDS), endoscopic ultrasound (EUS) with fine needle puncture, transabdominal ultrasound (TAUZI), computed tomography (CT) of the abdominal cavity, during which a submucosal formation of the stomach was diagnosed. The picture is more consistent with a gastrointestinal stromal tumor (GISO). Given the small size of the formation, the surveillance tactic was chosen. At the time of 12.2023, according to the results of control studies of the SubEO without dynamics.RESULTS: The follow-up period was 17 months, the results of the control studies justified the wait-and-see tactics and allowed avoiding unjustified surgical interventions and intraoperative complications.CONCLUSION: The combined use of TAUZI with endoscopy contributes to a better differential diagnosis and the choice of adequate treatment tactics.

Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study.

The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM. This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis. Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%). ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

Comparison of Endoscopic Ultrasound and CT Scan in the Diagnosis of Esophageal Duplication Cysts.

Esophageal duplication cysts (EDCs) are rare congenital malformations, often discovered incidentally during endoscopy or on computed tomography (CT) scans. The role of endoscopic ultrasound (EUS) and CT scan in the diagnosis of these lesions and indications for surgical treatment are underreported. The aim of this study was to investigate these topics in a cohort of patients. Between January 2001 and October 2020, 82 patients had a suspicion of esophageal duplication cyst on endoscopic ultrasound. Thirty four of these patients were referred for surgical enucleation of the lesion, but three patients were lost to follow-up. At the end, 31 patients, who underwent surgical treatment for their suspected EDC were included in this study. Clinical features, EUSfindings, CT images, surgical treatment, and outcome were collected from hospital health records. CT images were re-evaluated by a chest radiologist. Type of surgery, surgical complications, and final histological diagnosis were reported. The patients referred for surgery were younger (p = 0.0001) and had larger lesions (> 2cm; p = 0.005) than the patients who had non-operative follow-up. From thirty-one operated patients, eighteen (58%) had post-operative histological diagnosis of duplication cyst. On EUS the final histological diagnosis was correct in 58% (18/31) of all the operated cases and on CT scan 57% (17/30). CT scan misdiagnosed three of the EDCs but found two leiomyomas correctly. None of these patients developed malignancy. According to this study, neither EUS without fine-needle biopsy nor CT scan alone can differentiate EDCs from other mediastinal masses.

Endoscopic Ultrasound-Guided Drainage of Pelvic Fluid Collections with Lumen-Apposing Metal Stents

Introduction: A pelvic abscess is a potential life-threatening condition that should be managed conservatively whenever possible. Currently, computed tomography or ultrasound-guided percutaneous drainage is still the gold standard approach for pelvic fluid collections (PFCs) requiring intervention. More recently, endoscopic ultrasound (EUS) drainage using lumen-apposing metal stents (LAMSs) has been used off-label in PFCs with similar efficacy, a favorable safety profile, better quality of life, and generally a shorter duration of treatment when compared to the gold standard treatment. Methods: An observational retrospective analysis of 6 patients who underwent EUS-guided PFC drainage with LAMS at our institution was conducted. Records were reviewed to identify etiology, size of the collection, number of endoscopic procedures required until complete resolution, stent indwelling time, concomitant surgical or percutaneous associated procedures, successful removal and resolution. Results: The 6 patients included had an average age of 69 years old and 5 (83.3%) were male. The average size of the PFCs was 72.5 mm. All patients (100%) had successful drainage following LAMS placement, though 1 patient had an early recurrence. The mean stent indwelling time in our study was 6.7 days. An additional percutaneous or surgical drainage intervention was not required in any of the participants. Also, no adverse events related to the procedure were reported during the follow-up period. Conclusion: EUS-guided drainage of PFCs with LAMS is a safe and minimally invasive technique, which allows rapid PFC resolution, with no need for percutaneous or surgical drainage interventions.

The Impact of Combined Chemotherapy and Intra-Tumoural Injection of Phosphorus-32 Microparticles on Vascularity in Locally Advanced Pancreatic Carcinoma.

Poor intra-tumoural vascularity contributes to a lack of response to chemotherapy in pancreatic cancers. Preliminary data suggest that the addition of endoscopic ultrasound (EUS)-guided intra-tumoural injection of phosphorus-32 (32P) microparticles to standard chemotherapy is potentially beneficial in locally advanced pancreatic cancer (LAPC). We aimed to assess changes in pancreatic tumour vascularity following 32P implantation, using contrast-enhanced EUS (CE-EUS). This was a prospective single-centre trial from January 2022 to 2024 of patients with unresectable, non-metastatic LAPC undergoing standard FOLFIRINOX chemotherapy and 32P implantation. We performed CE-EUS pre-implantation after two chemotherapy cycles and 4 and 12 weeks after implantation. Time-intensity curves were analysed for 90 s after IV contrast bolus to ascertain peak intensity and intensity gain. A total of 20 patients underwent 32P implantation, with 15 completing 12-week follow-up. The technical success of 32P implantation was 100%. The median primary tumour size reduced from 32 mm (IQR 27.5-38.75) pre-implantation to 24 mm (IQR 16-26) 12 weeks post-implantation (p < 0.001). Five patients (25%) had tumour downstaging, and four underwent resections. The baseline (pre-implantation, post-chemotherapy) median intensity gain of contrast enhancement within the tumour was 32.15 (IQR 18.08-54.35). This increased to 46.85 (IQR 35.05-76.6; p = 0.007) and 66.3 (IQR 54.7-76.3; p = 0.001) at 4 weeks and 12 weeks post-implantation, respectively. Over a median follow-up of 11.2 months (IQR 7.8-12.8), 15/20 (75%) of patients remained alive, with 3/20 (15%) demonstrating local disease progression. Overall survival was not significantly different between patients with or without an increased intensity of 10 a.u. or more at 12 weeks post-implantation. This is the first clinical study to demonstrate treatment-induced increased vascularity within pancreatic primary tumours, which followed 32P implantation and FOLFIRINOX chemotherapy. Larger comparative trials are warranted.

Is endoscopic ultrasound-guided gastroenterostomy better than surgical gastrojejunostomy or duodenal stenting?

Gastrojejunostomy is a critical procedure for managing gastric outlet obstruction. While surgical gastrojejunostomy has traditionally been the standard approach, endoscopic ultrasound (EUS)-guided gastroenterostomy has emerged as a promising endoscopic alternative. This comprehensive review aims to explore the development, techniques, outcomes, and comparative effectiveness of EUS-guided gastroenterostomy in comparison to duodenal stenting and surgical gastrojejunostomy. A comprehensive literature search was conducted using electronic databases to identify relevant studies published up to April 2024. The search included keywords related to EUS-guided gastrojejunostomy, surgical gastrojejunostomy, and duodenal stenting. Studies reporting on technical success, clinical success, complications, recurrence rates, quality of life, and long-term outcomes were included for analysis. The development of EUS-guided gastroenterostomy has evolved significantly over the years, driven by device advancements and improved endoscopic techniques. Comparative studies have shown that the technique offers several advantages, including the ability to create an anastomosis without the need for surgery, reduced invasiveness, shorter hospital stays, and potentially improved patient outcomes as compared to duodenal stenting and surgical gastrojejunostomy. Endoscopic ultrasound-guided gastroenterostomy represents a promising alternative to surgical gastrojejunostomy and duodenal stenting for the management of gastric outlet obstruction. The technique has evolved significantly, offering a less invasive and more effective treatment option.

6666 Asymptomatic Fasting Hypoglycemia After Sleeve Gastrectomy

Abstract Disclosure: K. Mitrollari: None. H.K. Deveaux: None. A. Gundeti: None. A.P. Calimag: None. T. Yasmeen: None. Introduction: Post-bariatric surgery hypoglycemia (PBSH), though previously considered rare, is increasingly recognized, occurring not only after Roux-en-Y gastric bypass (RYGB,) but also following various bariatric procedures. PBSH can manifest as postprandial or fasting hypoglycemia, requiring thorough investigation and prevention due to potential asymptomatic presentations that may lead to severe consequences, including coma and death. Case Report A 45-year-old female with a history of type 2 DM, ESRD on HD, gastric sleeve surgery, bilateral trans-metatarsal amputations, coronary artery disease, and congestive heart failure presented with bilateral lower extremity wounds. On admission her venous blood glucose was 71 mg/dL. Glycohemoglobin was 3.9% and fructosamine was 225 (205-285 umol/L). Her glycohemoglobin levels consistently remained below 6.4% status post sleeve gastrectomy off diabetes medications. Throughout admission, she experienced almost daily episodes of fasting asymptomatic hypoglycemia correlated with venous sample with lowest blood glucose reading 38 mg/dL. Initially, these episodes were attributed to NPO status for procedures or decreased PO intake. Her diet consisted of fast food brought by her family, which she reported was similar to her diet at home. Workup during a hypoglycemic episode (glucose 51 mg/dL,) revealed insulin 4 mUnits/L, proinsulin 7.1 pmol/L (&amp;lt;=7.2 pmol/L), C-peptide 25.7 ng/mL (0.8-3.9 ng/mL), and beta-hydroxybutyrate 0.5 mmol/L (0.0-0.3 mmol/L). Negative insulin antibodies and sulfonylurea panel, normal cortisol, and ACTH levels were noted. The patient was placed on a 10% dextrose infusion to avoid further episodes of hypoglycemia. However, she continued to experience hypoglycemia and was started on oral diazoxide. A CT pancreas with and without contrast was unremarkable, and endoscopic ultrasonography only revealed a 10 mm accessory spleen. The patient was discharged with counseling on glucose monitoring, dietary changes, and follow-up with endocrinology. Conclusion: PBSH should be considered as a differential diagnosis in patients with unexplained hypoglycemia and a history of bariatric surgery. PBSH mimics insulinoma or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) with elevated insulin, proinsulin, C-peptide, and low beta-hydroxybutyrate during hypoglycemia, however NIPHS is exclusive to non-bariatric patients. Imaging is crucial to rule out insulinoma, and invasive tests such as endoscopic ultrasound aid diagnosis. PBSH is a diagnosis of exclusion; therefore, workup involves ruling out other causes of hypoglycemia. First-line treatment involves diet modification, with medications like diazoxide or acarbose considered if dietary changes prove insufficient. This case underscores the complexity of hypoglycemia, implicating bariatric surgery as a contributing factor. Presentation: 6/3/2024