EUS Examination Research Articles

Differential diagnosis of gastrointestinal stromal tumors versus leiomyomas by special stains

The objective of the study was to investigate whether special stains can differentiate gastrointestinal stromal tumors (GISTs) and gastrointestinal leiomyomas (GILs). In this retrospective study, 39 cases of GISTs (diameter, 0.2–8.8 cm) and 75 cases of GILs (diameter, 0.2–4.5 cm) were recruited, all biopsy specimens were obtained by endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) excision, and the depth of excision included the whole mucosa, mucosal myometria, and most submucosa. GISTs and GILs were the most common types of mesenchymal tumors found anywhere along the gastrointestinal (GI) tract, from the esophagus to the rectum. GISTs were often associated with a higher risk of malignancy. In this study, the gender, age of onset, size and sites of the lesions, together with the number of mucosal or lamina propria lesions all have significant differences, nevertheless, there was no significant difference in cell morphology of GISTs and GILs tested by hematoxylin eosin (H&E) stain, and all showed low echo areas by EUS examination. In this retrospective study, the GISTs and GILs had been diagnosed by immunohistochemistry combined with clinical morphology. Subsequently, special stains including Masson’s trichrome (MT) stain, Alcian blue periodic acid-Schiff (AB-PAS) stain (pH 2.5), Wright-Giemsa (W-G) stain and periodic acid-Schiff (PAS) combined with diastase periodic acid-Schiff (D-PAS) stains were also applied in the diagnosis, the retrospective study results showed that 92.3% GISTs were stained blue with MT stain, 97.3% GILs were stained red with MT stain (P < 0.01), almost all GISTs were PAS-negative (light purple), in contrast, all GILs were PAS-positive (rose red) (P < 0.01), all of these experiments set control using the blood vessels stained by MT and AB-PAS stains. Nevertheless, there was no significant difference between GISTs and GILs stained by W-G stain. These obvious and meaningful differential results were also confirmed in the detection of new GISTs and GILs cases using MT and AB-PAS stains. In conclusion, MT and AB-PAS stains could also identify GISTs and GILs cases, particularly, AB-PAS was more sensitive and more specific, providing a more cost-effective, simple, and high sensitivity and specificity inspection methods, which should be noticed and widely used in the future, especially in resource-limited grass-roots testing institution or in cases with inconclusive immunostains or insufficient material.

Role of macroscopic on-site evaluation of endoscopic ultrasound-guided fine-needle aspiration/biopsy: Results of a multicentric prospective study.

The concept of macroscopic on-site evaluation (MOSE) was introduced in 2015 when the endoscopist observed better diagnostic yield when the macroscopically visible core on MOSE was superior to 4 mm. Recent studies suggest that MOSE by the endoscopist may be an excellent alternative to rapid on-site evaluation, and some classifications have been published. Few studies have assessed the adequacy of histologic cores in MOSE during endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB). To evaluate the performance of MOSE during EUS-FNA/FNB. This multicentric prospective study was conducted in 16 centers in 3 countries (Egypt, Iraq, and Morocco) and included 1108 patients with pancreatic, biliary, or gastrointestinal pathology who were referred for EUS examination. We prospectively analyzed the MOSE in 1008 patients with available histopathological reports according to 2 classifications to determine the adequacy of the histological core samples. Data management and analysis were performed using a Statistical Package for Social Sciences (SPSS) version 27. A total of 1074 solid lesions were biopsied in 1008 patients with available cytopathological reports. Mean age was 59 years, and 509 patients (50.5%) were male. The mean lesion size was 38 mm. The most frequently utilized needles were FNB-Franseen (74.5%) and 22 G (93.4%), with a median of 2 passes. According to 2 classifications, 618 non-bloody cores (61.3%) and 964 good samples (95.6%) were adequate for histological evaluation. The overall diagnostic yield of cytopathology was 95.5%. The cytological examination confirmed the diagnosis of malignancy in 861 patients (85.4%), while 45 samples (4.5%) were inconclusive. Post-procedural adverse events occurred in 33 patients (3.3%). Statistical analysis showed a difference between needle types (P = 0.035) with a high sensitivity of FNB (97%). The analysis of the relationship between the MOSE-score and the final diagnosis showed a significant difference between the different scores of the MOSE (P < 0.001). MOSE is a simple method that allows endoscopists to increase needle passes to improve sample quality. There is significantly higher FNB sensitivity and cytopathology diagnostic yield with good MOSE cores.

The comparison of clinicopathological characteristics of two distinct manifestations of gastric signet ring cell carcinoma under EUS

ABSTRACT Background and Objectives There are two different endoscopic ultrasonographic manifestations of gastric signet ring cell carcinoma (GSRCC). No studies have been reported on the differences in the clinical profiles of patients based on EUS examination. We aim to study the variations in clinicopathological characteristics between two distinct endoscopic ultrasonographic manifestations of GSRCC. Methods A total of 302 patients with GSRCC confirmed by pathological examination who underwent EUS were enrolled in the study. Based on the endoscopic ultrasonographic features, patients were categorized into two groups: type 1, where the entire layer structure disappeared, and type 2, where the layer structure was still present and appeared lymphomatoid. Clinicopathologic features were collected retrospectively and analyzed. Results Compared with type 2 patients, type 1 patients tended to develop GSRCC at an older age (P = 0.033) and had higher serum levels of tumor markers and were more likely to experience anemia (P &lt; 0.001) and weight loss (P &lt; 0.001) during the disease progression. Significant increases in the tumor size (P &lt; 0.001), thickness of the affected gastric wall (P &lt; 0.001), and depth of tumor invasion (P &lt; 0.001) were observed in type 1 patients. Furthermore, type 1 patients had higher prevalence of affected blood vessels (P &lt; 0.001), nerves (P &lt; 0.001), lymph nodes (P &lt; 0.001), and peritoneal metastasis (P &lt; 0.001). However, no difference was found in the duration of disease between the two groups, and all deficient mismatch repairs were observed in type 1 patients. Conclusions The two distinct endoscopic ultrasonographic manifestations of GSRCC exhibited different clinicopathological characteristics, suggesting that they may represent different subtypes of the disease that require special attention in management strategies.

Role of Endoscopic Ultrasound and Endoscopic Ultrasound Guided Fine Needle Aspiration in Endoscopic Biopsy Negative Gastrointestinal Lesion

Abstract Introduction The rapidly growing incidence of gastrointestinal malignancies, makes early detection of such lesions a mandatory issue. EUS is a very sensitive modality in diagnosis of GIT wall lesions with superiority in diagnostic yield over conventional endoscopy, and non- invasive diagnostic modalities as CT and MRI. Aim To assess the feasibility, safety and accuracy of endoscopic ultrasound and endoscopic ultrasound guided fine needle aspiration in diagnosis of endoscopic biopsy negative gastrointestinal lesions. Material and Methods We conducted this prospective study over the period of 2 years that included 245 patients with mean age 46 years. All included patients had suspected GIT lesions with repeated negative endoscopic biopsies. All patients underwent EUS examination and EUS- FNA in the same session. Results EUS diagnosis SE, SP, PVP, PVN, LR+, LR-, and, DiAc were 0.94, 0.90, 0.93, 0.91, 9.11, 14.7, and 0.92 respectively, while EUS-FNA SE, SP, PVP, PVN, LR+, LR-, and DiAc were 0.86, 0.99, 0.99, 0.83, 83.89, 7.32, and 0.91respectively, with 100% technical success. Size of the lesion, size of the needle, and number of needle passes had no impact on diagnostic yield of EUS-FNA. No procedure related complications were reported. Conclusions EUS with EUS-FNA is a safe, feasible modality with high diagnostic accuracy in diagnosis of endoscopic biopsy negative gastrointestinal lesions irrespective to anatomical location of the lesion, layer of origin, lesion size, lesion echotecture, and no impact of needle size and number of needle passes on the diagnostic yield of EUS and EUS-FNA.

Endoscopic Ultrasound-based Shear Wave Elastography for Detection of Advanced Liver Disease.

Endoscopic ultrasound shear wave elastography (EUS-SWE) is a novel modality for liver stiffness measurement. The aims of this study are to evaluate the performance and reliability of EUS-SWE for detecting advanced liver disease in a prospective cohort. EUS-SWE measurements were prospectively obtained from patients undergoing EUS between August 2020 and March 2023. Liver stiffness measurements were compared between patients with and without advanced liver disease (ALD), defined as stage ≥3, to determine diagnostic accuracy for advanced fibrosis and portal hypertension. Logistic regression was performed to identify variables that impact the reliability of EUS-SWE readings. Select patients underwent paired magnetic resonance elastography (MRE) for liver fibrosis correlation. Patients with ALD demonstrated higher liver stiffness compared to healthy controls (left lobe: 17.6 vs. 12.7 kPa, P<0.001; median right lobe: 24.8 vs. 11.0 kPa, P<0.001). The area under the receiver operator characteristic (AUROC) for the detection of ALD was 0.73 and 0.80 for left and right lobe measurements, respectively. General anesthesia was associated with reliable EUS-SWE liver readings (odds ratio: 2.73, 95% CI: 1.07-7.39, P=0.040). Left lobe measurements correlated significantly with MRE with an increase of 0.11 kPa (95% CI: 0.05-0.17 kPA) for every 1 kPa increase on EUS-SWE. D. SWE is a promising technology that can readily be incorporated into standard EUS examinations for the assessment of ALD.

Exploring the utility of EUS in Budd-Chiari syndrome: a multicenter multiobserver prospective cohort study

Background and aimsThe diagnosis of Budd-Chiari syndrome (BCS) is essentially radiological and is needed to plan appropriate therapy. We therefore conducted this proof of concept study to assess the utility of EUS in assessing anatomy of BCS. MethodsA prospective multi-centre observational study including 50 consecutive patients with a diagnosis of BCS were enrolled. All patients underwent a detailed EUS examination by three independent endosonographers, blinded to the anatomical details of BCS and others’ findings. This was compared to each other and to conventional angiography (where available) or Magnetic resonance venography (MRV). Outcomes assessed include inter observer agreement, sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy in diagnosing pathological lesions of BCS. ResultsFifty BCS patients (Mean age 34 years ; range 13-65 years) underwent EUS. Results showed good agreement among endosonographers for diagnosing right hepatic vein (RHV) (kappa=0.716) and left hepatic vein (LHV) lesions (kappa=0.722), moderate agreement for middle hepatic vein (MHV) lesions (kappa=0.660) and very good agreement for inferior vena cava (IVC) lesions (kappa=0.823). EUS demonstrated high sensitivity, positive predictive value, low inter-observer variability, and overall diagnostic accuracy for BCS lesions. ConclusionsIn conclusion, EUS is a safe and accurate diagnostic tool for BCS. It can provide accurate mapping of hepatic veins, intrahepatic collaterals, and the IVC.

Linear Endoscopic Ultrasound Examination of the Biliary System and Its Clinical Applications

AbstractEndoscopic ultrasound (EUS) examination of the biliary system plays pivotal role in pancreatobiliary studies. EUS offers a safe and noninvasive method of the biliary tract disorder evaluation. Although radial EUS provides a straightforward orientation, practicing biliary system examination with a curvilinear echoendoscope is advisable because of its added therapeutic benefits. Linear EUS may pose challenge in understanding the orientation and tracing nondilated bile duct in the beginning. However, adopting a systematic station-wise approach can help in comprehending the orientation and effectively tracing the entire bile duct. In this review, we have discussed linear EUS examination of the bile duct and gallbladder from various stations and its clinical applications.

A deep learning-based system for mediastinum station localization in linear EUS (with video).

EUS is a crucial diagnostic and therapeutic method for many anatomical regions, especially in the evaluation of mediastinal diseases and related pathologies. Rapidly finding the standard stations is the key to achieving efficient and complete mediastinal EUS imaging. However, it requires substantial technical skills and extensive knowledge of mediastinal anatomy. We constructed a system, named EUS-MPS (EUS-mediastinal position system), for real-time mediastinal EUS station recognition. The standard scanning of mediastinum EUS was divided into 7 stations. There were 33 010 images in mediastinum EUS examination collected to construct a station classification model. Then, we used 151 videos clips for video validation and used 1212 EUS images from 2 other hospitals for external validation. An independent data set containing 230 EUS images was applied for the man-machine contest. We conducted a crossover study to evaluate the effectiveness of this system in reducing the difficulty of mediastinal ultrasound image interpretation. For station classification, the model achieved an accuracy of 90.49% in image validation and 83.80% in video validation. At external validation, the models achieved 89.85% accuracy. In the man-machine contest, the model achieved an accuracy of 84.78%, which was comparable to that of expert (83.91%). The accuracy of the trainees' station recognition was significantly improved in the crossover study, with an increase of 13.26% (95% confidence interval, 11.04%-15.48%; P < 0.05). This deep learning-based system shows great performance in mediastinum station localization, having the potential to play an important role in shortening the learning curve and establishing standard mediastinal scanning in the future.

Pictorial Essay of Linear Endoscopic Ultrasound Examination of Pancreas Anatomy

AbstractEndoscopic ultrasound (EUS) is a widely used imaging modality for both diagnostic and therapeutic purposes. Understanding the anatomy is crucial during a curved linear EUS examination. Compared with other advanced endoscopic techniques, the learning curve for EUS is longer, and the training facilities for EUS are also not widely available. The interest and enthusiasm for EUS among endoscopists is limited by the long learning curve and the scarcity of training programs. Imaging of the pancreas is the most common indication of EUS examination, and many endoscopist often face difficulty in understanding the anatomy and orientation of the pancreas on linear EUS examination. In this article, we will discuss the problems encountered during linear EUS examination and how to overcome each problem with a station-wise pancreas examination.

EUS-derived maximum tumor thickness and tumor shrinkage rate as independent prognostic factors in locally advanced esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy.

EUS-derived maximum tumor thickness (MTT) pre- and post-neoadjuvant chemoradiotherapy (NCRT) for locally advanced esophageal squamous cell carcinoma (LA-ESCC) indicates treatment response. However, the accuracy of predicting long-term survival remains uncertain. This study aimed to investigate the association between EUS-derived MTT pre- and post-NCRT and tumor shrinkage rate as well as long-term survival in patients with LA-ESCC receiving NCRT. We retrospectively enrolled patients with LA-ESCC who underwent EUS examination from 2017 to 2021. Tumor shrinkage rate was the ratio of the difference between pre- and post-MTT to pre-MTT. The most fitted cutoff values were determined by the receiver operating characteristic curve. Univariate and multivariate Cox regression analyses and Kaplan-Meier curves were used to calculate overall survival (OS) and progression-free survival. Data from another center were also used for external validation testing. Two hundred thirty patients were enrolled. Of the patients, 178 completed the first EUS pre-NCRT and obtained pre-MTT, 200 completed the reexamined EUS post-NCRT and obtained post-MTT, and 148 completed both EUS and achieved tumor shrinkage. For all the patients, the 1- and 3-year OS rates were 93.9% and 67.9%, and progression-free survival rates were 77.7% and 54.1%, respectively. The median follow-up period was 30.6 months. Thinner post-MTT (≤8.8 mm) and EUS responder (tumor shrinkage rate ≥52%) were independently associated with better OS. EUS-derived MTT and tumor shrinkage post-NCRT are independent prognostic factors for long-term survival and may be an alternative method for evaluating tumor response in patients with LA-ESCC after NCRT.

Factors Affecting the Learning Curve in the Endoscopic Ultrasound-Guided Sampling of Solid Pancreatic Lesions: A Prospective Study.

Endosonography is associated with a long learning curve. We aimed to assess variables that may influence the diagnostic outcomes in endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) of solid pancreatic tumors regarding the level of endoscopists' experience. Consecutive patients undergoing EUS-guided puncture of solid pancreatic tumors (eight endosonographers, including six trainees) were prospectively enrolled. An experienced endosonographer was defined as having performed at least 250 EUS examinations, including 75 FNA/Bs. The final diagnosis was determined by cytopathology, histopathology, or clinical follow-up. In total, 283 EUS-FNA/Bs of solid pancreatic tumors (75.6% malignant) in 239 patients (median age 69 years, 57.6% males) were enrolled. Trainees performed 149/283 (52.7%) of the interventions. Accuracy and sensitivity for detecting malignancy were significantly higher in the expert group than in the trainee group (85.8% vs 73.2%, p=0.01 and 82.5% vs 68.4%, p=0.02). Solid lesions evaluated by an expert using FNB needles showed the best odds for a correct diagnosis (odds ratio, 3.07; 95% confidence interval, 1.15 to 8.23; p=0.02). More experienced endoscopists achieved better accuracy in sampling via the transduodenal approach (86.7% vs 68.5%, p<0.001), in the sampling of malignant lesions (82.5 vs 68.4, p=0.02), and in the sampling of lesions located in the pancreatic head (86.1 vs 69.1, p=0.02). In cases involving these factors, we observed a moderate improvement in the diagnostic accuracy after 40 attempts. Transduodenal approach, pancreatic head lesions, and malignancy were recognized as the most important clinical factors affecting the learning curve in EUS-FNA/B of solid pancreatic lesions.

The value of contrast-enhanced harmonic endoscopic ultrasound in differential diagnosis and evaluation of malignant risk of gastrointestinal stromal tumors (

Objectives Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) has been used in the differential diagnosis of benign and malignant tumors by visualization of tumor microcirculation and perfusion. However, its diagnostic role in submucosal tumors (SMTs), especially leiomyomas and gastric submucosal tumors (GISTs) was rarely studied. The aim of this study was to analyze the diagnostic role of CEH-EUS for SMTs (<50 mm) and the value of assessing the malignant potential of GISTs. Materials and Methods We retrospectively included patients with tumors <50 mm in diameter who underwent preoperative EUS and CEH-EUS examination and had pathologically confirmed as leiomyomas and GISTs. To analyze the imaging features of CEH-EUS with pathological diagnosis as the gold standard and evaluate its diagnostic value. Results This study included 10 cases of leiomyomas and 38 cases of GISTs. Under CEH-EUS detection, 86.9% of GISTs showed hyper-enhancement, 89.5% showed diffuse enhancement, 39.5% showed non-enhancing spots, and 97.4% showed obvious capsule enhancement. In contrast, the leiomyoma cases mostly showed hypo-enhancement (50.0%) or non-enhancement (30.0%) (p < 0.05). Then, the value of CEH-EUS in the differential diagnosis of benign and malignant tumors based on blood flow is significantly higher than that of B-EUS. Signal appearance time was significantly faster in the intermediate-high risk GISTs than in the very low-low risk group (5.1 s versus 15.5 s, p < 0.05), and the AUROC values predicted the risk at this time to be 0.903 (0.763–0.975). Heterogeneous perfusion and non-enhancing spots were also more common in the intermediate-high risk group. Univariate and multivariate analysis revealed that intratumoral irregularitie was an independent predictor of moderate to high risk (OR 3.99, 95%CI 1.04–90.95), with sensitivity, specificity and accuracy of 73.33%, 91.30% and 84.21%, respectively. Conclusions Through this study, CEH-EUS has a good differential diagnostic ability for leiomyomas and GISTs, and has a high value in predicting the risk of GISTs.

Exploring Gap in Adherence to ASGE Quality Metrics of EUS Examination for Pancreatic Lesions: A Quality Improvement Initiative

ASGE proposed dedicated quality metrics for EUS examination. Overall adherence to this quality metrics remains unknown in both academic center as well as in community practice. We aimed to conduct retrospective analysis of EUS practice for pancreatic lesions in our hospital system that comprises of both academic tertiary care practice as well as community based EUS practice.

A computed tomography—negative pancreatic lesion diagnosed by endoscopic ultrasound imaging enhancement (with video)

A 50-year-old woman was admitted for slightly elevated serum carbohydrate antigen 19-9 (39 U/mL) and negative findings from 2 rounds of computed tomography (CT) scanning at a 6-month interval (A). The patient underwent EUS examination. In the initial scanning, the pancreatic parenchyma was normal, without ductal dilatation. To avoid missing a potential isoechoic lesion, we next performed imaging enhancement by adjusting the acoustic parameters in the US (HI VISION Preirus, Hitachi, Tokyo, Japan).

Clinical utility of linear endosonography in patients with unexplained biliary dilatation and negative MRCP, with predictors for detection of neoplastic lesions

Background and study aimsUnexplained biliary dilatation (UBD) frequently represents a diagnostic dilemma. Linear endosonography (EUS), with its close proximity to the pancreaticobiliary system and the ability for tissue acquisition, could have a role in revealing etiologies of UBD particularly in the context of negative other non-invasive modalities. However, in such patients, the decision for this semi-invasive procedure is usually debatable and often needs justification. Thus, we aimed to evaluate the diagnostic utility of linear EUS in patients with UBD after negative magnetic resonance cholangiopancreatography (MRCP) and to delineate predictors for EUS ability to detect neoplastic lesions.Patients and methodsThis was a prospective diagnostic observational study between 2018 and 2021. Included patients with evidence of biliary dilatation on abdominal ultrasound and negative MRCP underwent linear EUS examination. Results were compared to the final diagnosis relied on histopathology after EUS-guided biopsy or surgery for neoplastic lesions, while ERCP, diagnostic EUS criteria plus histopathology for autoimmune pancreatitis, Rosemont criteria for chronic pancreatitis, and/or follow-up for 6 months were the gold standard tests for non-neoplastic etiologies. Logistic regression was conducted to reveal predictors of neoplasm detection by EUS.ResultsSixty-one patients (mean age 60 years, 32 females) were enrolled; 13.1% of them were asymptomatic. The final diagnosis was categorized into 29 patients with and 32 without neoplasms. Sensitivity, specificity, positive, negative predictive values (PPV, NPV), and accuracy of EUS-positive findings were 98.3%, 100%, 100%, 66.7%, and 98.3%, respectively. Corresponding results for neoplasm identification were 100%, 93.8%, 93.5%, 100%, and 96.7%, respectively. The most common neoplastic etiologies were small pancreatic and ampullary masses. Common bile duct (CBD) diameter > 12.9mm and CA19-9 > 37.1 u/ML were independent predictors for pancreaticobiliary neoplasm at multivariate regression analysis.ConclusionLinear EUS appears to have a high accuracy in detecting etiologies of UBD, with higher sensitivity for small pancreatic, ampullary lesions, and CBD stones. CBD diameter > 12.9 mm and elevated CA19-9 > 37.1 u/ML should raise a concern about the presence of occult pancreaticobiliary neoplasm, and then, EUS may be warranted even in asymptomatic patients.

Pancreatic cystic neoplasms: Adherence to management recommendations and associated endosonographic cyst characteristics.

Background:The purpose of this study is to assess patients’ compliance to recommendations after evaluation of pancreatic cystic neoplasm (PCN) with EUS and investigate how the presence of “worrisome” characteristics including cyst's size, main pancreatic duct dilation and presence of mural nodules might affect the adherence rates of management recommendations.Methods:We performed a retrospective cohort study of patients at a private tertiary hospital who were referred for evaluation with EUS over a 5-year period (2015-2019), after the diagnosis of pancreatic cystic neoplasm during radiological imaging.Results:We included 111 patients (mean age 64.1 years, SD = 13.9) with PCN. After the EUS examination, 16 patients were referred for surgical resection, 4 patients needed no further follow up and 91 patients were recommended to follow imaging surveillance. In total, 70 (63.1%) subjects adhered to surveillance recommendations. In the group of subjects who adhered to surveillance, cyst size ≥3cm was found in 27 (38.6%) patients, main pancreatic duct diameter ≥5mm in 12 (17.1%) subjects and only 3 (4.3%) pancreatic cysts demonstrated mural nodules. However, none of the aforementioned cystic “worrisome features” was significantly correlated with increased adherence to follow up (p = 0.709, P = 0.642 and P = 0.630, respectively).Conclusions:Although the majority of patients with PCN adhered to given recommendations after EUS examination, the number of noncompliant subjects was noticeable. The presence of cystic “worrisome” features did not correlate with an increased compliance rate to suggested management plan. Further prospective studies are needed to elucidate the factors that may enhance patients’ adherence.

Ectopic fat deposition and its related abnormalities of lipid metabolism followed by nonalcoholic fatty pancreas.

The positive energy balance between caloric intake and caloric output increasing storage of triglycerides (TG) in adipocytes has made nonalcoholic fatty liver disease (NAFLD) one of the major public health problems in China. Excessive lipid deposition in the pancreas is referred to as nonalcoholic fatty pancreas disease (NAFPD). Early assessment of pancreatic fat infiltration will have an increasing role in the clinical management of the metabolic dysregulation and prevention pancreatic complications. We retrospectively collected data of inpatients with NAFPD from EUS database between September 2012 and August 2020 at our endoscopic center. The prevalence of NAFPD and factors associated with its development were statistically analyzed. The echogenicity of the pancreas was compared to that of the left renal cortex during the EUS examination by using an existing criterion. Four thousand, seven hundred and four consecutive individuals underwent EUS were enrolled. The prevalence of NAFPD was 1.2% (57/4704) . Factors independently associated with NAFPD on multivariate analysis were increasing TG (odds ratios [OR] 4.65, P = 0.014), NAFLD (OR 16.76, P = 0.005) and decreasing apolipoprotein A-1 (OR 0.002, P = 0.0127). We found no association between NAFPD and age, sex, total cholesterol or hypertension. We found a meaningful relationship between NAFLD, dyslipidemia, and NAFPD in Chinese. We hypothesized that NAFPD was strongly correlated with ectopic fat deposition and its related abnormalities of lipid metabolism. Early diagnosis of NAFLD provides opportunities to control the progression of NAFPD.

Clinical utility of directional eFLOW compared with contrast-enhanced harmonic endoscopic ultrasound for assessing the vascularity of pancreatic and peripancreatic masses

BackgroundContrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) can be used for the differential diagnosis of pancreatic lesions by evaluating microvascular circulation and patterns of contrast enhancement. However, routine use of CEH-EUS is limited by its high cost, the lack of contrast agent availability and the absence of expertise with this technique. Directional eFLOW (D-eFLOW) (Aloka Co., Ltd., Tokyo, Japan) was introduced as a new high-definition modality that detects blood flow in microvessels. Because it uses built-in functions, it entails no additional cost and reduces time for examination. The present study compared the usefulness of D-eFLOW and CEH-EUS for differential diagnosis of pancreatic and peripancreatic lesions. MethodsThis retrospective study analyzed 130 patients who underwent EUS and D-eFLOW examinations from January 2016 to March 2020 to evaluate pancreatic and peripancreatic masses. ResultsAll 130 patients underwent D-eFLOW and CEH-EUS examinations. Histological diagnoses were confirmed in 130 patients by EUS-FNA and/or surgery. D-eFLOW and CEH-EUS showed good correlation in evaluating the vascularity of pancreatic and peripancreatic tumors (Fisher's exact test, p < 0.05). ConclusionsIn evaluating the characteristics of tumorous lesions, vascularity detected by D-eFLOW showed good correlation with enhancement patterns of CEH-EUS. D-eFLOW can be considered a good alternative to CEH-EUS in diagnosing pancreatic and peripancreatic masses.

Utility of contrast-enhanced harmonic endoscopic ultrasonography for T-staging of patients with extrahepatic bile duct cancer.

The value of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for T-staging in patients with extrahepatic bile duct cancer was evaluated. This single-center, retrospective study included consecutive patients with extrahepatic bile duct cancer who underwent surgical resection after preoperative EUS, CH-EUS, and contrast-enhanced CT (CE-CT) examinations between June 2014 and August 2017. The capacity of these modalities for T-staging of extrahepatic bile duct cancer was evaluated by assessing invasion beyond the biliary wall into the surrounding tissue, gallbladder, liver, pancreas, duodenum, portal vein system (portal vein and/or superior mesenteric vein), inferior vena cava, and hepatic arteries (proper hepatic artery, right. and/or left. hepatic artery). Blind reading of EUS, CH-EUS, and CE-CT images was performed by two expert reviewers each. 38 patients were eligible for analysis, of which eight had perihilar bile duct cancer and 30 had distal bile duct cancer. Postoperative T-staging was T1 in 6, T2 in 16, and T3 in 16 cases. CH-EUS was superior to CE-CT for diagnosing invasion beyond the biliary wall into surrounding tissue (92.1% vs. 45.9%, P = 0.0002); the ability to detect invasion to other organs did not differ significantly between the two modalities. The accuracy of CH-EUS for T-staging of tumors was better than that of CE-CT (73.7% vs. 39.5%, P = 0.0059). CH-EUS tended to have a better accuracy than EUS for the diagnosis of invasion beyond the biliary wall into the surrounding tissue (92.1% vs. 78.9%, P = 0.074) and T-staging (73.7% vs. 60.5%, P = 0.074). CH-EUS is useful for T-staging of extra hepatic bile duct cancer, especially in terms of invasion beyond the biliary wall into the surrounding tissue.

Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy.

Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy.