Indications For Endoscopic Ultrasound Research Articles

Indications and Results of Endoanal Ultrasonography in Anal Pathology

Anal disease encompasses a diverse array of disorders, including conditions such as sphincter defects, anorectal fistulas and abscesses, unexplained chronic anal pain. The objective of this study is to assess the diagnostic value of endoscopic ultrasound (EUS) in the context of anal diseases. A total of 58 patients who benefited from an EUS, over a period between January 2018 and april 2023. Mean age was 43,4 years with a sex ratio (M: F) of 0.4. The main indication for EUS is dominated by fecal incontinence (FI) in 53% of patients, followed by the anoperineal manifestations of Crohn's disease in 22%. Among patients with perineal Crohn's disease (CD), fistulas were observed in 47% of CD cases. anovaginal or rectovaginal fistulas (ARVFs) were visualized in 9% of all cases. In patients presenting with fecal incontinence (FI), EUS identified defects in the internal and external anal sphincters. EUS is a highly sensitive technique for assessing anal anatomy and diagnosing of anal diseases.

Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children

Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.

Development of devices for interventional endoscopic ultrasound for the management of pancreatobiliary diseases.

A variety of devices have been developed for interventional endoscopic ultrasound (EUS). EUS-guided drainage of the bile duct and pancreatic duct, as well as fluid collection adjacent to the gastrointestinal tract, is performed by a procedure involving puncture, guidewire manipulation, tract dilation, and stent placement. Devices specialized for interventional EUS are being developed for each step of the procedure. Mechanical dilators such as bougie, balloon, and electrocautery dilators are used for tract dilation. Various types of plastic stents, self-expandable metal stents, and lumen-apposing metal stents specifically designed for interventional EUS are now available, including one-step devices developed to improve the efficacy and safety of interventional EUS. In addition, radiofrequency ablation and the placement of fiducial markers and radioactive seeds under EUS guidance are now becoming established for pancreatic neoplasms. Such development of specialized devices has expanded the indications for interventional EUS, increased the success rate, and lowered the adverse event rate.

S1119 Safety and Efficacy of Pediatric Endosonography: A Multi-Center Retrospective Cohort Study

Introduction: Endoscopic ultrasound (EUS) is widely used in the adult population for a wide range of diagnostic and therapeutic purposes. In the pediatric population, the use of EUS has been historically diagnostic, however, EUS-guided therapy is increasing. In this retrospective study, we aim to describe the safety and efficacy profiles of EUS in pediatric patients across a spectrum of EUS procedures. Methods: This is a retrospective multi-center cohort study of pediatric patients who underwent EUS procedures for diagnostic or therapeutic purposes between January 2011 and March 2022. Data including demographics, procedural details, and adverse events (AE) were collected. Outcomes were diagnostic success, defined as successful diagnosis using only EUS without any additional diagnostic tools, and therapeutic success, defined as using only EUS without additional therapeutic interventions. Results: 61 pediatric patients between the age of 0 to 18 years underwent 77 EUS procedures, of which 35 were females (56.5%). The mean age at the procedure was 16.2 ± 4.2 years and the median weight was 70.2 kg (IQR 49.7-91.2). The indications for EUS were gastrointestinal lumen evaluation ± fine needle biopsy/aspiration (FNB/A), pancreaticobiliary tree evaluation ±FNB/A, surveillance for tumor syndrome, suspected lymph node (LN), or gastrointestinal (GI) mass, celiac plexus block and cyst gastrostomy creation (Table). The median procedure time was 35 minutes (IQR 18 – 49). The diagnostic success rate was 98.7% and the therapeutic success rate was 100%. The complication rate was 2.6% which included 2 cases of pancreatitis after fine-needle aspiration of the pancreas. No case had any anesthesia-related complications. Conclusion: In this multicenter retrospective cohort study, the use of EUS in pediatrics has shown to be safe and effective in a wide range of diagnostic and therapeutic intents. Table 1. - Baseline characteristics, procedural and clinical outcomes of pediatric patient EUS procedures N=77 (%) Females 35 (56.5) Weight (n=66) 70.2 [49.7 – 91.2] Age at procedure (years) 16.2 ± 4.2 Indication Diagnostic GI lumen Evaluation 9 (11.7) GI lumen Evaluation with FNB/A 5 (6.5) Pancreaticobiliary tree evaluation 37 (48.1) Pancreaticobiliary tree evaluation with FNB/A 6 (7.8) Surveillance for tumor syndrome 7 (9.1) Suspected LN or mass 8 (10.4) Therapeutic Celiac Plexus Block 1 (1.3) Cystgastrostomy 4 (5.2) Anesthesia Type Monitored Anesthesia Care (MAC) 48 (62.3) General Anesthesia 29 (37.7) Mean procedure Time in minutes (N= 59) 35.0 [18.0 - 49.0] Diagnostic Success 76 (98.7) Therapeutic Success (n=5) 5 (100) EUS related complications 2 (2.6) Anesthesia complications 0 (0) EUS = endoscopic ultrasound, FNA/B = fine needle aspiration/biopsy, LN = lymph node.Continuous variables presented as mean ± SD or median (IQR).Categorical variables presented as n (%).

Diagnostic and Therapeutic Indications for Endoscopic Ultrasound (EUS) in Patients with Pancreatic and Biliary Disease-Novel Interventional Procedures.

There is growing evidence supporting the substantial, essential and indispensable role of endoscopic ultrasound (EUS) as a key diagnostic armamentarium for upper GI oncologic surgery. Well described in countless publications, EUS holds that position in gastroenterological expert centers all over Europe. Despite its undisputable contributions to oncologic upper GI surgery, the availability of this technique at the expert level shows up in an irregular spread pattern. Endoscopic ultrasound’s primary use during the first few years after its creation was the detection of pancreatic cancer. From then on, EUS developed in different directions, becoming a diagnostic tool that increasingly better defines its status as a method of minimally invasive therapeutic applications and a useful addition to surgical options. As a result, several surgical interventions could even be replaced by ultrasound-targeted interventions. This process took place in just a few years and was made possible by technical development that sensibly combined high-resolution ultrasound with therapeutic endoscopy. The present article will serve to cover the most prevalent uses with supporting data considering the growing list of suggested indications for EUS while also examining cutting-edge initiatives that might soon become the standard of clinical practice. Endoscopic centers with high expertise are needed to train future experts in the growing field of EUS interventions.

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

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

Usefulness of endoscopic ultrasound in children with pancreatobiliary and gastrointestinal symptoms.

Background and study aims Endoscopic ultrasound (EUS) is useful in diagnosing and treating childhood pancreatobiliary and gastrointestinal diseases. However, there are limited data on its effectiveness for various indications. Patients and methods This was a retrospective analysis of prospectively collected data of patients who underwent EUS for upper gastrointestinal tract disorders from January 2018 to December 2020 to assess its indications, findings, interventions, and complications. Results Ninety-two procedures were performed in 85 children, (70.5 % male; mean [SD] age 12.1 years [3.9] years) with a mean (SD) symptom duration of 1.1 (0.5) years. The procedures were technically successful in all patients. The primary indication for EUS was abdominal pain in 45(52.9%) and jaundice/cholangitis in 15 patients (17.6 %). General anesthesia was used in 12 (13 %) and TIVA in 80 patients (87 %). The most common diagnostic findings were choledocholithiasis in 21 (24.7 %) and cholelithiasis in 12 patients (14.1 %). Among interventions, EUS-guided cystogastrostomy for pancreatic pseudocyst was done in four patients (4.7 %), and EUS-guided rendezvous for failed ERCP in one patient (1.2 %) with cholangitis. There were no immediate post-procedural complications. Overall, EUS had a meaningful impact on the subsequent clinical management in 69 cases (81.2 %). Conclusions EUS in the pediatric population is safe, effective, and has a meaningful impact in appropriately selected cases. It can act as a rescue in major therapeutic procedures, but adequate care should be taken at the procedural level and during anesthesia.

Safety and efficacy of endoscopic ultrasound as a diagnostic and therapeutic tool in pediatric patients: a multicenter study.

Despite the well-established diagnostic and therapeutic applications of endoscopic ultrasound (EUS) in adults, data about its use in children are limited. In this study, we tried to assess the feasibility, safety, and clinical impact of EUS in pediatric patients. Data of pediatric patients (<18 years) referred for EUS over a 3-year period to the endoscopy units of four Egyptian tertiary centers were retrospectively analyzed. Significant impact was defined as a new diagnosis or treatment attributed to the EUS procedure. Twenty-four diagnostic and five therapeutic EUS procedures were conducted in 29 children with a median age of 9 years. Indications for EUS included assessment of solid pancreatic mass (n = 3), pancreatic cyst (n = 2), suspected chronic pancreatitis (n = 9), pancreatic pseudocyst (PPC) (n = 5), recurrent hypoglycemia (n = 1), bile duct mass (n = 1), subepithelial lesion (esophageal, duodenal or anorectal) (n = 4), mediastinal mass (n = 1), pelvic mass (n = 3), and mass at splenic hilum (n = 1). Therapeutically, five patients underwent cystogastrostomy for symptomatic PPC with 100% technical and clinical success. EUS was able to diagnose 21 out of the other 24 patients. EUS-guided tissue acquisition was performed in 11 patients with definitive histopathological diagnosis in 10 patients (91%). There was no procedure-related major complication, while minor complications occurred in two cases (transient pain in one case, temporary fever, and vomiting in two cases). Standard linear EUS equipment and accessories can be used safely and effectively in selected pediatric patients for diagnostic and therapeutic purposes.

ID: 3524391 NON-STANDARD INDICATIONS FOR ENDOSCOPIC ULTRASOUND FOR IN CLINICAL PRACTICE: FREQUENCY, CLASSIFICATION, AND COMPLICATION RATES

Endoscopic Ultrasound (EUS) is a widely utilized diagnostic and therapeutic procedure in gastroenterology. The American Society of Gastrointestinal Endoscopy (ASGE) has published 11 standard indications for EUS and recommends: i) inclusion of an indication in the procedure documentation for all cases, and ii) >80% of EUS performed for standard indications. We aim to characterize the frequency, type, contributing factors, and post-procedural complication rates for non-standard indications for EUS in clinical practice.

Comparing accuracy of high-risk features for detecting advanced neoplasia in pancreatic cystic lesions: a systematic review and meta-analysis.

BackgroundThe American Gastroenterological Association recommends endoscopic ultrasound (EUS) for evaluating pancreatic cystic lesions (PCL) with ≥2 high-risk features (HRF), whereas the American College of Gastroenterology recommends EUS for ≥1 HRF. This systematic review and meta-analysis compared the diagnostic accuracy of using ≥1 vs. ≥2 HRF for assessing the risk of advanced neoplasia (AN) and performing EUS in PCL.MethodsAn electronic database search was performed for eligible studies. AN was defined as pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm or mucinous cystadenoma with high-grade dysplasia, pancreatic intraepithelial neoplasia and pancreatic neuroendocrine tumors. HRF included cyst size ≥3 cm, solid component, and dilated pancreatic duct ≥5 mm. The primary outcome was the sensitivity and specificity of using ≥1 vs. ≥2 HRF as an indication for EUS to detect AN in PCL.ResultsOf 38 studies initially screened, 8 were included in the final analysis. Seven studies assessed the accuracy of ≥2 HRF and 4 studies assessed ≥1 HRF. The pooled sensitivity, specificity, positive and negative predictive values of EUS for detecting AN were 41.7% (95% confidence interval 19.5-67.8%), 90.8% (81.9-95.5%), 30.4% (19.4-44.2%) and 94.3% (89.6-97.0%) with ≥2HRFs, and 77.1% (66.1-85.3%), 72.7% (50.4-87.5%), 17.95% (10.3-29.4%), 98.1% (90.8-99.6%), respectively, with ≥1 HRF.ConclusionPerforming EUS for PCL with ≥1 HRF could offer greater sensitivity in detecting AN compared to ≥2 HRF, with a similar negative predictive value.

Indications and Outcomes of Endoscopic Ultrasound in Tanta-Egypt: Initial experience

Background: Endoscopic ultrasound (EUS) is valuable in the diagnosis and staging of gastrointestinal tumors and some extra-luminal malignancies. Aim: This study aimed to describe the initial experience with EUS and fine-needle aspiration (FNA) and the indications and outcomes of patients at the Tanta University Teaching Hospital. Subjects and Methods: This is a cross-sectional descriptive survey study analyzing 70 EUS cases seen at Tanta University Teaching Hospital from January to December 2019. FNA was performed for 61 patients. A provisional cytopathology diagnosis was made by on-site and the final cytology/histopathology report was given after immunostaining and review of slides. Results: The major indications for EUS were pancreatic, gastric, and ampulla of Vater lesions. EUS revealed pancreatic masses in 27, cysts in 1, and chronic pancreatitis in 1 case. Gastric masses were seen in 13, polyps in 5, and varices in 3 cases. Ampulla of Vater lesions were masses in 5, common bile duct (CBD) distal end stones in 3 cases, and one case proved normal. The final diagnosis of pancreatic lesions was adenocarcinoma in 25, cyst in 1 case, mucoepidermoid tumour in 1 case, neuroendocrine tumour in 1 case and chronic pancreatitis in 1 case. Gastric lesions were gastrointestinal stromal tumors (GIST) in 8, and adenocarcinoma in 5 cases, while 3 cases of polyps were hyperplastic, one inflammatory and one tubulovillous adenomatosis. Celiac axis block was done for 6 cases. No major complications were recorded. Conclusion: The major indications for EUS were pancreatic, gastric and ampulla of Vater lesions, while the main outcomes were pancreatic adenocarcinoma, gastric GIST, adenocarcinoma and ampullary adenocarcinoma. .

Su1297 ENDOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE BIOPSY: DIAGNOSTIC ACCURACY OF CYTOLOGY AND HISTOLOGY

Endoscopic ultrasound (EUS)-guided fine needle aspiration/biopsy (EUS-FNA/FNB) to obtain cytological aspirates and histological core samples have been the standard of care for diagnosis of solid or cystic lesions in or nearby upper and lower gastrointestinal tract. Due to lack of standardization of tissue processing, it is unclear as to whether core sample should be sent only for histology (in formalin), or for cytology (in cytolyte) or for both. The aim of this study is to investigate the concordance rates observed between cytology compared with histology on samples obtained using EUS-FNA/FNB. Out of 226 patients who underwent EUS-FNA/FNB using a 22-gauge needle between October 2017 and February 2019 by a single therapeutic endoscopist, 46 patients were selected for final evaluation, in whom equal number of passes were sent for both histology and cytology. Patient's demographics, medical history, imaging (prior computed tomography /magnetic resonance imaging), indication for EUS, EUS findings, and cytology/histology results were analyzed. The main outcome measures were diagnostic accuracy for malignancy and concordance between cytology and histology. In 46 patients, the acquired core samples were placed alternately in cytolyte (for cytology) and formalin (for histology), with equal number of passes into each, to best achieve proportionate amount of samples. These samples were obtained from solid masses in 78% (36/46), lymph nodes in 13% (6/46) and from cystic lesions in 8.6% (4/46) of cases. Analysis was remarkable for diagnosis consistency in 42 out of 46 samples (91.3%). Cytology and histology were found to be discordant in four cases. Cytology was reported inconclusive in 1 and negative in 3 of these cases, but definitive diagnosis was achieved with histology, which was positive for neoplasm in all 4 cases. These samples were obtained from two pancreatic masses, one gastric subepithelial lesion, and one lymph node; and histology confirmed pancreatic adenocarcinoma, gastrointestinal stromal tumor, and follicular lymphoma, respectively. Our study observed an 8% diagnostic discordance between cytology and histology on core samples obtained using EUS-FNB, when it was sent for both cytology and histology in equal proportions. Diagnostic yield of histology was noted to be superior to cytology, especially in cases with cytological diagnostic uncertainty. Further large, randomized and prospective studies are needed to ascertain a best and universally acceptable practice to make the diagnostic process more efficient, accurate, and cost-effective.

Accuracy of endoscopic ultrasound-guided biopsy of focal liver lesions.

Endoscopic ultrasound (EUS) has become an indispensable method for diagnosis in gastroenterology and new indications for EUS continue to emerge. However, there are limited data regarding the accuracy of EUS-guided biopsy of hepatic focal lesions. The aim of this study was to assess the diagnostic yield of EUS-guided fine needle aspiration (FNA) of focal liver lesions. We conducted a prospective study in which patients with focal liver lesions, detected by transabdominal ultrasound and computed tomography or magnetic resonance imaging, underwent EUS-guided FNA to determine the diagnostic yield of the procedure. In 47/48 of patients, the results of EUS-FNA were positive for malignancy, while in one case the acquired fragment was insufficient for appropriate histological analysis. Diagnostic yield was 0.98. In 83% of the cases biopsies were taken from the left lobe and in 17% from the right lobe with the same technical success rate. The most common diagnosis was metastatic adenocarcinoma of the pancreas (26% cases) followed by cholangiocarcinoma (17% cases). Concurrent sampling of other sites in addition to the liver and/or primary tumor was realized in 35% of the cases, with results that correlated with the liver biopsy and with the primary tumor biopsy. We reported no immediate or long-term complications in any of the patients. EUS guided fine needle aspiration/biopsy of focal liver lesions is safe, provides a very high diagnostic accuracy and should not be considered only as a rescue method after failure of percutaneous guided biopsies.

912 Comparison of Diagnostic Yield of Cytology versus Histology on Samples Obtained During Endoscopic Ultrasound-Guided Fine-Needle Biopsy (EUS-FNB)

INTRODUCTION: The advent of endoscopic ultrasound (EUS) has vastly improved access to several gastrointestinal lesions, thereby leading to increased diagnostic capability. Moreover, improved core tissue sampling is now possible with fine needle biopsy (EUS-FNB) needle, as opposed to aspiration (FNA) alone. However, the practice of sample handling is highly individualized due to lack of standardization as to whether core sample should be sent only in histology (in formalin), or cytology (in cytolyte) or both. This study was abstracted to compare the diagnostic yield of cytology versus histology on core tissue obtained from the same lesion, using the same EUS-FNB needle. METHODS: Single endoscopist at a large tertiary referral center conceptualized a prospective EUS database between October 2017 and February 2019, where a 22-gauge FNB needle was used to obtain core tissue samples, which were sent for cytology and histology. After IRB approval, retrospective analysis of this database was performed. Patient’s demographics, medical history, imaging, indication for EUS, EUS findings, and cytology/histology results were analyzed. RESULTS: Out of 226 therapeutic EUS' performed by single endoscopist during study period, 103 samples were collected using 22-gauge FNB needle [solid masses (62), lymph nodes (18) &amp; solid-cystic lesions (23)]. 28 samples were sent for cytology, 29 for histology, and 46 for both (passes equally divided). Out of these 46 samples, 42 were consistent between cytology and histology, but 4 were discordant; in all 4 cases, histology provided the conclusive information. In 3 cases, histology provided the diagnosis of cancer while cytology was reported negative. In the fourth case, cytology was inconclusive while histology was definitely negative for carcinoma. These samples were obtained from 2 pancreatic masses, one gastric subepithelial lesion, and one lymph node, and pathology showed pancreatic adenocarcinoma, GIST, and persistent follicular lymphoma, respectively. 22-gauge needles were used for all these procedures, and no complications were noted. CONCLUSION: Our study demonstrates 8% inconsistency between cytology and histology on core samples obtained using EUS-FNB. In all discordant cases, histology provided more accurate information than cytology. Larger, multi-centric and prospective studies are needed to ascertain the best practice to make the diagnostic process more efficient, accurate, and cost-effective.

2810 Endoscopic Ultrasound in Diabetics: Is There a Protective Role of Metformin Therapy for Pancreatic Ductal Adenocarcinoma?

INTRODUCTION: The relationship between diabetes mellitus (DM) and pancreatic ductal adenocarcinoma (PDAC) is a field of immense interest. Studies have proposed that metformin therapy (MT) could play a protective role in risk reduction for PDAC; however, the prevalence of pancreatic structural abnormalities in patients on MT is unknown. We aimed to identify the prevalence and distribution of pancreatic parenchymal and ductal changes during endoscopic ultrasound (EUS) of diabetic patients on MT, compared to patients non-MT. METHODS: We performed a retrospective chart review of diabetic patients who underwent EUS at the University of Miami Health System between 2010-2018. Patients with known history of chronic pancreatitis (CP), pancreatic mass/PDAC or pancreatic surgery were excluded. RESULTS: Seventy-eight patients were identified (mean age = 65 ± 13.6 years; M:F = 31:47): 18 (23%) African-American, 17 (22%) Caucasian and 43 (55%) Hispanic. Mean BMI was 31.55 ± 9.8. Four patients (5%) had DM type 1 and 74 (95%) had type 2, with mean hemoglobin A1c of 6.45 ± 2%. Diabetic complications were seen in 44 patients (56.4%): nephropathy = 25, neuropathy = 26 and retinopathy = 6. Forty-four (56.7%) patients were on MT and 34 (43.5%) patients were on either insulin (n = 20) or insulin secretagogue (n = 14), defined as non-MT group (Table 1) Indications for EUS included abdominal pain (24), submucosal esophageal (2), gastric (11) or duodenal (3) lesion, common biliary narrowing or dilation (18), abnormal hepatic panel (3), lymphadenopathy on imaging (5), suspected choledocholithiasis (3), jaundice (2), and elevated CA-19-9 (2). Parenchymal or ductal endosonographic findings were present in 34% (n = 15) of the patients on MT versus 53% (18) of patients non-MT (Table 2). Among the 44 patients on MT, 2 patients met criteria for chronic pancreatitis (CP), 1 was indeterminate and 41 (93.2%) were classified as normal pancreas, according to the Rosemont classification. In non-MT patients, 32 (94.11%) were classified as having normal pancreas, 2 were indeterminate and no patients met criteria for CP. Following EUS examination, PDAC was diagnosed in 1 (2.2%) patient in MT group, versus 3 patients (8.8%) in the non-MT group. CONCLUSION: Pancreatic structural abnormalities occurred equally in diabetic patients in MT (6.8%) versus non-MT (5.8%) groups (P = ns). Higher number of PDAC were diagnosed in non-MT group; however, whether or not this finding could explain the proposed protective role of MT on the risk of developing PDAC is yet unclear.

Rectal Endoscopic Ultrasound in Clinical Practice.

Endoscopic ultrasound (EUS) is routinely utilized for evaluation of disorders of the lower gastrointestinal tract. In this review, we summarize the current status of rectal EUS in clinical practice and describe recent developments in diagnostic and therapeutic rectal EUS. Recent guidelines recommend rectal EUS for rectal cancer staging as a second line modality in cases where MRI is contraindicated. Forward-viewing echoendoscopes and through the scope EUS miniprobes allow for EUS imaging of lesions through the entire colon and for evaluation beyond stenoses or luminal narrowings. EUS can be used to assess perianal disease and drain pelvic abscess associated with IBD, along with newer applications currently under investigation. For rectal varices, EUS can confirm the diagnosis, assess the optimal site for banding, guide therapy placement with sclerotherapy and/or coils, and assess response to treatment by confirming absence of flow. Therapeutic rectal EUS is emerging as a promising modality for drainage of pelvic fluid collection drainage and fiducial placement for rectal or prostatic cancer. Drug delivery mechanisms and substances that may increase the scope of therapy with rectal EUS are in varying stages of development. Rectal EUS continues to be an important modality for evaluation of benign and malignant disorders of the lower gastrointestinal tract, although its use as a cancer staging modality has declined due to improvements in MRI technology. Various technologies to enhance ultrasound imaging and for therapeutics have been developed that have or may contribute to expanded indications for rectal EUS.

Cross-Sectional Study to Assess Endoscopic Ultrasound Practice in Portugal

Background: Despite the increasing number of national departments performing endoscopic ultrasound (EUS), there are no official data regarding clinical EUS practice in Portugal. Objectives: We aimed to evaluate the current practice of EUS in Portugal. Methods: By email, we invited 1 physician of each one of the 26 national Gastroenterology Departments which perform EUS to complete a survey questionnaire available on the Google Forms platform. The online questionnaire was available from September 2017 until February 2018 and was answered only by physicians who perform EUS. Results: A total of 21/26 (80.8%) national Gastroenterology Departments answered the questionnaire. In Portugal, there are 42 echoendoscopes in total; most of the echoendoscopy units have only 1 EUS processor (81%), 1 radial echoendoscope (66.7%), 1 linear echoendoscope (76.2%), 1 anorectal probe (57.1%), but no miniprobes (85.7%). About 81% have histological core acquisition needles. In 81% of the units, there are at least 2 ultrasonographers who perform echoendoscopy together (at least 2 ultrasonographers per EUS) in 47.6% of these departments. The ultrasonographers also performed abdominal ultrasound (US), anal US, and endoscopic retrograde cholangiopancreatography in 71.4, 66.7, and 42.9%, respectively. The echoendoscopy units have 2.4 ± 1.1 periods of echoendoscopy per week and 4 ± 1.5 EUS per period (499.2 ± 416.8 EUS per year). Subepithelial lesions and biliopancreatic lesion evaluation as well as gastrointestinal neoplasia staging were the most common EUS indications. The number of FNA (fine-needle aspirations) ranges from 10 to 160/year. Rapid on-site evaluation (ROSE) is available in 60% of units and is performed by the cytopathologist (66.7%) in the majority of cases. The main reason for omitting ROSE is the limited pathology staff. Cytopathological material is prepared by the ultrasonographer in 25% of the units. Air drying (50%) and formalin (50%) are most frequently used to fix and preserve smears, respectively. Pancreatic pseudocyst drainage (66.7%), celiac plexus neurolysis (52.4%) and pancreatic necrosectomy (42.9%) are the most widespread therapeutic procedures. Conclusions: This survey provides the first insight into the current status of digestive echoendoscopy in Portugal. There is a great variability in diagnostic and therapeutic echoendoscopy practice.

Esophagogastroduodenoscopy With Every Endoscopic Ultrasound Study - Is It Necessary? A Single Center Experience

Introduction: Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (EUS-FNA) have been used increasingly as a safe, accurate and diagnostic as well as therapeutic tool for a variety of gastrointestinal (GI) as well as non-GI conditions. In 2015, the ASGE and ACG released standard quality indicators for GI endoscopic procedures including EUS. Performing an EUS for an “appropriate” indication and having adequate photo documentation of structuresof interest were among the key indicators with different grades for the clarity of benefit. However, there was no mention for the utility of preprocedure esophagogastroduodenoscopy (EGD). Purpose: To see if an EGD prior to EUS in asymptomatic patients changes management or patient outcomes. Methods: A retrospective chart review of asymptomatic patients who underwent EGD prior to EUS over the last 4 years was conducted. Patients with symptoms that warranted an EGD were excluded. We estimated a sample size of 150 for 80% power and significance level of 0.05. Chi-Square analysis was used. Results: 1100 charts were reviewed, and 158 patients were included. Mean age was 60.5 years. 63 patients were males. It was noted that 23.4% and 35.4% were using alcohol or tobacco respectively, while 30% were on antiplatelet therapy. Most patients underwent EUS due to a pancreatic indication followed by a biliary indication (figure 1). Among all EGDs, only 33 were completely normal. 125 were associated with benign mucosal findings; 11 cases of Barrett’s esophagus and 4 cases of GI malignancy were detected as well. These findings lead to changes in patient management (figure 2). Overall, 67% of patients had some changes in their managment. There was a statistically significant association between male gender and detection of malignant lesions (P 0.013). Alcohol use was associated with findings on EGD as well as a need for an intervention, as a medication modification (P 0.05), tissue sampling (P 0.034) and schedule a follow procedure (P 0.046) (figure 3). Finally, EGD prior to EUS was safe and not associated with increased complications compared to EUS alone. Conclusion: Our study showed that performing an EGD prior to EUS in the absence of luminal or mucosal symptoms is safe and changed management in 67% of asymptomatic individuals.479_A Figure 1. Pie graph showing the percentages of EUS indications (Pancreatic and biliary indications represent the majority of cases)479_B Figure 2. Different intervention and change in management done as a result of the EGD findings479_C Figure 3. Alcohol’s association with change in management

The role of endoscopic ultrasound in children with Pancreatobiliary and gastrointestinal disorders: a single center series and review of the literature

BackgroundThe role of endoscopic ultrasound (EUS) in the management of pancreatobiliary and digestive diseases is well established in adults, but it remains limited in children. The aim of this study was to evaluate the feasibility, safety, and clinical impact of EUS use in children.MethodsThis is a retrospective analysis of a prospectively acquired database of consecutive pediatric (< 18 years) patients presenting an indication for EUS for pancreatobiliary and gastrointestinal disorders.ResultsBetween January 2010 and January 2016, 47 procedures were performed in 40 children (mean age of 15.1 ± 4.7 years; range 3–18). The majority of EUS (n = 32; 68.1%) were performed for pancreatobiliary and upper gastrointestinal pathologies, including suspected common bile duct stones (CBDs), acute biliary pancreatitis, recurrent/chronic pancreatitis, cystic pancreatic mass, recurrent hypoglycemia, duodenal polyp, gastric submucosal lesion, and perigastric abscess. In only 2 out of 18 children with suspected CBDs or acute biliary pancreatitis, EUS confirmed CBDs. EUS-guided fine needle aspiration was performed in 3 (6.4%) patients. Fifteen (31.9%) procedures were performed for lower gastrointestinal tract disorders, including suspected anal Crohn’s disease, fecal incontinence, and encopresis. Overall, EUS had a significant impact on the subsequent clinical management in 87.2% of patients.ConclusionThe present findings were consistent with results observed in the current relevant literature and support EUS as a safe and feasible diagnostic and therapeutic tool, which yields a significant clinical impact in children with pancreatobiliary and gastrointestinal disorders.

Pancreatic Cysts in Pancreatitis: Does EUS-FNA Add Value Over Baseline EUS or MRI?

Introduction: Endoscopic Ultrasound (EUS) and MRI are the images of choice in the evaluation of pancreatic cysts. The majority of cysts in pancreatitis are pseudocysts. Fine needle aspiration (EUS-FNA) is considered when there are high risk or unusual features or diagnostic uncertainty. Aims: To evaluate the role of FNA in characterizing pancreatic cysts in pancreatitis. Methods: A retrospective analysis was performed on 27 patients who underwent EUS guided aspiration of pancreatic cysts between January and December 2016. All patients had a baseline MRI/MRCP. Demographics including age, sex and alcohol intake was noted. Indication for aspiration, cyst characteristics were documented and the presence of single or multiple cysts was included. Change of diagnosis, if any and post-procedural complications at 30 days were noted. Results: Demographics are shown in Table 1. 27 patients underwent FNA. Mean age was 65.4 years with male predominance (51.8% vs. 48.1%). Indication for EUS was for evaluation of pancreatic cyst (74.1%), suspected chronic pancreatitis (11.1%), pseudocyst (7.4%) and mass (7.4%). Of the 12 patients who had a history of pancreatitis, 6 (50%) had pseudocysts, 5 (41.6%) had mucinous cysts, and one (8.3%) had a benign serous cyst. Of the ones with pseudocysts, 2 (33.3%) had underlying malignancy causing pseudocysts to be drained. The final diagnosis following FNA was Intraductal Papillary Mucinous Neoplasm (IPMN- 37.0%), pseudocyst (25.9%), benign lesion (22.2%) and malignancy (14.8%). A change of initial diagnosis was noted in 12 (44.4%). There was a change in management in all twelve patients, with the need for surgery in 18%. No immediate or 30-day post-procedure complications were noted.Table: Table. Pancreatic cyst characteristicsConclusion: EUS guided aspiration should be considered in selected cysts irrespective of the preliminary clinical and radiologic diagnosis. In our study, a change of initial diagnosis was noted in 44%. Only 50% of cysts in pancreatitis were pseudocysts. Larger multicenter studies are needed to confirm the findings from our study and to validate the role of EUS-FNA in the role of pancreatic cysts in pancreatitis patients with atypical or high-risk features.