EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V - EUS-Guided Therapeutic Interventions (short version).

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided interventions: General Aspects and EUS-guided Sampling (Short Version).

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided Interventions: General aspects and EUS-guided sampling (Long Version).

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V.

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation in clinical practice (long version).

German Survey on EUS-Guided Diagnosis and Management of Gastrointestinal Stromal Tumors (GISTs) - Evidence or "Gut-Feeling"?

PURPOSE: To examine practice patterns of endosonographers in diagnosing and managing gastrointestinal stromal tumors (GISTs) in Germany. MATERIALS AND METHODS: A modified published survey (Ha et al., Gastrointest Endosc 2009) was sent to endosonographic ultrasound (EUS) customers in Germany. The survey was also publicized on the homepage of an EUS interest group. To avoid duplicate opinions, participants were asked to return one survey per institution. RESULTS: 142 centers of roughly 850 German EUS centers responded. 25 % were from University hospitals and 74 % from community hospitals. 61 % performed > 2 EUS scans for suspected subepithelial lesions/week. Although 97 % of respondents believed that tissue acquisition with CD117 immunohistochemistry best predicts a GIST, 11 % do not perform EUS-FNA when suspecting a GIST, 68 % perform it occasionally and 18 % perform it regularly. The main EUS criteria used for a suspected GIST are the typical layer (85 %), hypoechoic appearance (80 %) and gastric location (51 %). 69 % would diagnose a GIST with negative CD117 if the EUS criteria and spindle cells are present. FNA was rated helpful in < 50 % by 55 % of participants. Size was the primary criterion for suspecting malignancy. 95 % of respondents would perform surveillance ≥ 1x/year of GISTs that are not resected. CONCLUSION: There is significant variability in the diagnosis and management of GISTs in Germany. Diagnostic certainty of EUS-FNA is suboptimal in many centers and EUS is frequently used for guidance. The diagnosis of a GIST is often guided by a "gut feeling" rather than evidence. Efforts should be made to unify existing guidelines.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

[EUS-FNA: how to improve biopsy results? An evidence based review]. / EUS-geführte Feinnadelbiopsie (EUS-FNP): Wie gelingen gute Biopsien? Eine evidenzbasierte Analyse.

Endosonography with fine-needle aspiration biopsy (EUS-FNA) has become a widespreadly available clinical tool to diagnose numerous different lesions in humans. EUS-FNA is frequently used for tissue-based diagnoses such as lymphatic diseases (ranging from tuberculosis / sarcoidosis to malignant lymphoma) or solid tumors (such as pancreatic carcinoma, neuroendocrine tumors, sub-epithelial gastrointestinal tumors and others). Outcomes of EUS-FNA results, however, vary which is caused by several different factors ranging from experience of the endoscopist over technical factors such as use of stylet or suction for puncture through the skills of the cyto-pathologist who takes care of the specimen obtained by EUS-FNA. Though introduced since more than 20 years ago EUS-FNA has still not yet been perfectionized and several issues remain controversial among endoscopist. These issues include needle size and type (FNA versus TNB needles), use of a stylet and suction for FNA sampling, pure cytologic assessment versus cyto-histologic techniques, grading of the investigator´s and pathologist´s experience and improvement of EUS training for novices. In this report we briefly review the actual literature and summarize the available evidence on some controversely discussed issues. The results support the view that use of a stylet rarely aids to increase the amount of tissue obtained during EUS-FNA, whereas use of suction can be helpful in certain situations. Novel cutting needles may potentially improve number and size of core biopsies that can be rendered for special histologic tissue processing techniques. An in-room-cytopathologist not necessarily improves outcome of EUS-FNA results but may have a role during build-up of EUS units to become more successful. EUS-FNA education requires skilled endoscopists on both sides and can presumably be improved by objective testing of practical expertise by peer review and introducing objective sampling parameters. Novel techniques and equipment are about to evolve in the near future.

[How safe is sedation in gastrointestinal endoscopy? A multicentre analysis of 388,404 endoscopies and analysis of data from prospective registries of complications managed by members of the Working Group of Leading Hospital Gastroenterologists (ALGK)]. / Wie sicher ist die Sedierung in der gastrointestinalen Endoskopie? Eine multizentrische Auswertung von 388 404 Endoskopien und Auswertung der Daten aus prospektiv geführten Komplikationsregistern von Mitgliedern der Arbeitsgemeinschaft leitender Gastroenterologen im Krankenhaus (ALGK).

BACKGROUND: Gastrointestinal endoscopies are increasingly being carried out with sedation. All of the drugs used for sedation are associated with a certain risk of complications. Data currently available on sedation-associated morbidity and mortality rates are limited and in most cases have substantial methodological limitations. The aim of this study was to record severe sedation-associated complications in a large number of gastrointestinal endoscopies. METHODS: Data on severe sedation-associated complications were collected on a multicentre basis from prospectively recorded registries of complications in the participating hospitals (median documentation period 27 months, range 9 - 129 months). RESULTS: Data for 388,404 endoscopies from 15 departments were included in the study. Severe sedation-associated complications occurred in 57 patients (0.01 %). Forty-one percent of the complications and 50 % of all complications with a fatal outcome (10/20 patients) occurred during emergency endoscopies. In addition, it was found that 95 % of the complications and 100 % of all fatal complications affected patients in ASA class ≥ 3. CONCLUSIONS: Including nearly 400,000 endoscopies, this study represents the largest prospective, multicenter record of the complications of sedation worldwide. The analysis shows that sedation is carried out safely in gastrointestinal endoscopy. The morbidity and mortality rates are much lower than previously reported in the literature in similar groups of patients. Risk factors for the occurrence of serious complications include emergency examinations and patients in ASA class ≥ 3.

[Malignant neoplasias of the gastrointestinal tract--endosonographic staging revisited]. / Maligne Neoplasien des Verdauungstrakts--neue Aspekte zum endosonografischen Staging.

On January 1st, 2010 the 7th edition of TNM classification was released. There are several consequences of this new classification for the staging of gastrointestinal malignancies by endoscopic ultrasound. This review discusses important changes in the TNM classification as well as new aspects in endosonographic staging investigations of cancers of the esophagus, stomach, and rectum.

EUS Meets Voxel-Man: three-dimensional anatomic animation of linear-array endoscopic ultrasound images.

Endoscopic ultrasonography (EUS) is a widely used imaging modality in gastroenterology. The development of linear-array endoscopic ultrasound transducers, with facilities for EUS-guided diagnostic and therapeutic procedures, led to increasingly widespread use in different areas of the body. Examiners need to have excellent knowledge of anatomy. Orientation in linear EUS is more difficult and the learning curve is long. In an effort to shorten the training, reducing the risk to the patient and to allow a faster learning of the basic anatomic structures EUS meets VOXEL-MAN, an interactive three-dimensional anatomic simulation program has been developed for linear EUS for the purposes of private and independent study.

Treatment of unresectable carcinoma of the esophagus or the gastroesophageal junction by mesh stents with or without radiochemotherapy.

The palliative treatment of malignant stenoses of the upper gastrointestinal tract by self-expanding metal stents is a novel procedure with effective relief of dysphagia in most patients. There is little follow-up information with respect to the factors influencing clinical outcome and survival rates. Survival rates of 40 consecutive patients treated with 53 mesh stents were analyzed with regard to their degree of dysphagia (grades 0-3), quality of life (Karnofsky score), and the effect of additional radiation and chemotherapy. Following stent placement dysphagia improved in 36 of 40 patients. Endoscopic reinterventions for worsening of dysphagia were necessary in 23 patients during a median follow-up period of 74 days (range 51-149). There was a trend towards superior survival time in younger patients (<60 years) with high Karnofsky score ( 70). Patients receiving concurrent radiation and chemotherapy (n=12) experienced prolonged survival (median 318 days after diagnosis, 225 days after stent) compared with patients of equal tumour staging, but without additional therapy (n=17; median 157 days after diagnosis, p<0.001; 138 days after stent, p<0.05). The combination of endoscopic stenting with additional radiation and chemotherapy was associated with improved survival. A randomized trial is warranted.

[CT diagnosis of the elbow joint]. / CT-Diagnostik des Ellbogengelenkes.

The normal anatomy of the elbow joint is described. Diverse pathologic joint alterations, e.g. fractures and dislocations, osteochondritis, inflammatory changes, and ulnar nerve lesion are demonstrated. Particular attention is paid to three-dimensional (3D-) reconstruction of demonstrable pathologic findings.

[Analysis of dynamic CT curves in kidney transplants with rejection reaction and cyclosporin A poisoning]. / Analyse von dynamischen CT-Kurven bei Nierentransplantaten mit Abstossungsreaktion und Cyclosporin-A-Intoxikation.

The early differential diagnosis between transplant rejection and cyclosporin intoxication is often difficult, although it is important for treatment. We carried out dynamic CT on 48 occasions in patients with normal function, with acute tubular necrosis, rejection and cyclosporin A intoxication. Analysis of the time-density curve of the cortex showed significantly slower enhancement with cyclosporin A intoxication than during rejection. The peak and the arterial curve were also delayed in cyclosporin A intoxication. This evidence of reduced cortical perfusion during cyclosporin A intoxication can be explained by the results of modern pathophysiological studies. In principle, it is possible to distinguish between cyclosporin A intoxication and rejection by means of dynamic CT, but for its routine use the nephrotoxicity of the contrast medium must be taken into account.