Endoscopic ultrasound-guided portal pressure gradient with liver biopsy: 6 years of endo-hepatology in practice.

BACKGROUND AND AIM: The portal pressure gradient (PPG) is a useful predictor of portal hypertension (PH) related complications. We previously showed the feasibility and safety of endoscopic ultrasound guided PPG measurement (EUS-PPG). Now EUS-guided liver biopsy (EUS-bx) has been shown to be a safe and effective alternative to percutaneous or Interventional Radiology-guided liver biopsy for the diagnosis of chronic liver disease (CLD). We aimed to evaluate the correlation between PPG and clinical markers of PH, and assess the feasibility and safety of concomitant, single session EUS-PPG and EUS-bx. METHODS: This was a retrospective study of patients undergoing EUS-PPG for CLD at a single tertiary endoscopy center between February 2014 and March 2020. EUS-PPG was performed using a 25-gauge needle and compact manometer. Data analysis was performed with SAS version 9.4. RESULTS: Eighty-three patients underwent EUS-PPG with 100% technical success. The mean PPG was 7.06 mmHg (SD 6.09, range 0-27.3). PPG was higher in patients with (vs without) clinical features of cirrhosis (9.46 vs 3.61 mmHg, P < 0.0001), esophageal or gastric varices (13.88 vs 4.34 mmHg, P < 0.0001), and thrombocytopenia (9.25 vs 4.71 mmHg, P = 0.0022). In the 71 patients (85.5%) who underwent EUS-bx, 70 (98.6%) specimens were deemed adequate by the pathologist for histologic diagnosis. There were no early or late major adverse events. CONCLUSION: EUS-PPG correlates well with clinical markers of PH. EUS-bx can be performed safely during the same session as EUS-PPG, providing a comprehensive endoscopic evaluation of the patient with CLD.

Benefit, tolerance, and safety of hybrid argon plasma coagulation for treatment of Barrett's esophagus: US pilot study.

Background and study aims A novel technique for Barrett's esophagus (BE) ablation, termed hybrid APC, has recently been developed. The aims of this US pilot study were to evaluate the efficacy, tolerance and safety of hybrid APC for the treatment of BE. Patients and methods Patients with biopsy-proven BE referred to our tertiary care center over a 12-month period for mucosal ablation were eligible for this study. Efficacy of ablation was measured on follow-up endoscopy by demonstrating either a reduction of visible BE or biopsies proving complete resolution of intestinal metaplasia (CRIM). To evaluate tolerance and safety, patients were called on post-procedure days 1 and 7. Results Twenty-two patients with BE (4.5 % intramucosal carcinoma, 31.8 % high-grade dysplasia, 18.1 % low-grade dysplasia, 36.3 % non-dysplastic, 9.1 % indefinite for dysplasia) underwent 40 treatments with hybrid APC. All patients had endoscopic improvement of BE disease and 19 of 22 patients (86.4 %) achieved CRIM. With regard to tolerance, average pain scores (0 to 10 scale) on follow-up were 2.65 and 0.62 on days 1 and 7, respectively. With regards to safety, there were two treatment-related strictures (9.1 %) that required a single balloon dilation. Conclusions Hybrid APC appears to be promising in the treatment of BE. The ablation protocol used in this study demonstrated efficacy, tolerability, and a safety profile similar to radiofrequency ablation. Given the significant price difference between hybrid APC and other modalities for Barrett's ablation, this modality may be more cost-effective. These results warrant further study in a large prospective multicenter trial.

Comparison of Two Specialized Histology Needles for Endoscopic Ultrasound (EUS)-Guided Liver Biopsy: A Pilot Study.

BACKGROUND: EUS-guided liver biopsy (EUS-LB) has been shown to be a safe and effective alternative to percutaneous liver biopsy. The optimal needle device and technique for EUS-LB is still evolving. The aim of this study was to compare the efficacy of two second-generation 19G fine-needle biopsy (FNB) (Franseen- and Fork-tip) devices for EUS-LB. METHODS: This is a repeated-measure crossover study with a prospectively maintained cohort of patients. We performed EUS-LB with a one-pass and single-actuation method using two 19G FNB needles in 22 consecutive patients between 10/2018 and 9/2019. Patients were randomized to left vs right liver lobes to be biopsied as well as the needle sequence. The specimens obtained were evaluated for adequacy for histologic diagnosis. The primary outcome was number of complete portal tracts (CPTs), post-fix aggregate, and longest specimen length. Secondary outcomes were prefix aggregate specimen length and the specimen adequacy judged by two expert pathologists. RESULTS: A total of 44 liver biopsies were performed in 22 patients. The CPTs were higher in the Franseen-tip needle group compared to the Fork-tip needle group (14.4 vs 9.5, p = 0.043). Post-fix aggregate specimen length (44.9 mm vs 34.6 mm, p = 0.097), the post-fix longest specimen length (19.9 mm vs 13.7 mm, p = 0.175), and prefix aggregate specimen length (51.7 mm vs 45 mm, p = 0.265) were not significantly different. Both needles showed similarly high histologic adequacy (100% vs 95.5%, p = 0.312). Interestingly, the right of the liver showed higher yield of CPTs with both needles (Franseen, 16.2 vs. 12.8, p = 0.003, the Fork-tip, 12.8 vs. 7.0, p < 0.0001). CONCLUSION: EUS-guided liver biopsy using the 19G Franseen-tip needle may provide more CPTs than 19G Fork-tip needle on a single-pass, single-actuation comparison.

Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America.

BACKGROUND & AIMS: Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. METHODS: We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death. RESULTS: Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD. CONCLUSIONS: ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.

Endoscopic ultrasound guided hepatic interventions.

Intervention for liver disease has predominantly been performed through the percutaneous approach. However, as endoscopic ultrasound (EUS) applications have expanded, there have emerged various EUS-guided interventions for liver disease, a space we call "Endo-Hepatology". EUS-guided liver biopsy can be considered the "forerunner" of Endo-Hepatology and has become a clinical option for patients requiring histologic diagnosis and staging of their liver disease. EUS also enables direct access to the portal vein. Subsequently, many procedures are being explored, such as angiography, measurement of the portosystemic pressure gradient, portal vein sampling to detect cancer cell or DNA, and EUS-guided transhepatic intrahepatic portosystemic shunt creation. Since the transducer is close to the liver, especially the left and caudate lobes, EUS can be used as a rescue when the percutaneous approach is not favorable and EUS-guided treatments of liver tumor, cyst and abscess have been reported. This review summarizes the available studies of EUS-guided intervention in the liver.

Per oral endoscopic myotomy as salvage therapy in patients with achalasia refractory to endoscopic or surgical therapy is technically feasible and safe: Systematic review and meta-analysis.

BACKGROUNDS AND AIMS: Per oral endoscopic myotomy (POEM) has been reported as an effective and safe salvage therapy for achalasia but there is limited composite data. We performed a systematic review and meta-analysis of studies that reported the rates of clinical success and adverse events among patients who underwent POEM after failed conventional endoscopic or surgical therapy. METHODS: Electronic literature search was conducted from inception through December 2018 for articles reporting the efficacy and safety of POEM in patients with achalasia who failed endoscopic or surgical therapy. Primary outcome was the pooled estimated rates of clinical success, defined as Eckardt score ≤ 3 after POEM. Secondary outcomes were procedural time, the rates of POEM-related gastroesophageal reflux disease (GERD) and procedure-related adverse events. RESULTS: Seven studies reporting outcomes on 487 patients met our criteria. Pooled estimated rate of clinical success of POEM was 88% (95% confidence interval (CI) 79-94%). Mean procedural time was 64 minutes (95% CI 44-85 minutes). POEM-related GERD was found in 20% (95% CI 16-24%) of patients. Estimated incidence of overall adverse events was 10% (95% CI 5-18%) with individual risk of bleeding, mucosotomy, pneumothorax, pneumoperitoneum hydrothorax/mediastinitis, and subcutaneous emphysema ranging from 1 to 4%. CONCLUSIONS: Per oral endoscopic myotomy after failed endoscopic or surgical therapy in patients with achalasia is an effective and safe treatment. Further long-term follow-up studies in a larger number of patients are warranted to validate the sustainable efficacy of POEM for achalasia.

Artificial intelligence using convolutional neural networks for real-time detection of early esophageal neoplasia in Barrett's esophagus (with video).

BACKGROUND AND AIMS: The visual detection of early esophageal neoplasia (high-grade dysplasia and T1 cancer) in Barrett's esophagus (BE) with white-light and virtual chromoendoscopy still remains challenging. The aim of this study was to assess whether a convolutional neural artificial intelligence network can aid in the recognition of early esophageal neoplasia in BE. METHODS: Nine hundred sixteen images from 65 patients of histology-proven early esophageal neoplasia in BE containing high-grade dysplasia or T1 cancer were collected. The area of neoplasia was masked using image annotation software. Nine hundred nineteen control images were collected of BE without high-grade dysplasia. A convolutional neural network (CNN) algorithm was pretrained on ImageNet and then fine-tuned with the goal of providing the correct binary classification of "dysplastic" or "nondysplastic." We developed an object detection algorithm that drew localization boxes around regions classified as dysplasia. RESULTS: The CNN analyzed 458 test images (225 dysplasia and 233 nondysplasia) and correctly detected early neoplasia with sensitivity of 96.4%, specificity of 94.2%, and accuracy of 95.4%. With regard to the object detection algorithm for all images in the validation set, the system was able to achieve a mean average precision of .7533 at an intersection over union of .3 CONCLUSIONS: In this pilot study, our artificial intelligence model was able to detect early esophageal neoplasia in BE images with high accuracy. In addition, the object detection algorithm was able to draw a localization box around the areas of dysplasia with high precision and at a speed that allows for real-time implementation.

Endoscopic ultrasound-through-the-needle biopsy in pancreatic cystic lesions: A large single center experience.

BACKGROUND: Establishing a diagnosis of pancreatic cystic lesions (PCLs) preoperatively still remains challenging. Recently, endoscopic ultrasound (EUS)-through-the-needle biopsy (EUS-TTNB) using microforceps in PCLs has been made available. AIM: To assess the efficacy and safety of EUS-TTNB in the diagnosis of PCLs. METHODS: We retrospectively collected data of patients with PCLs who underwent both EUS-fine-needle aspiration (FNA) for cytology and EUS-TTNB at our institution since 2016. EUS-FNA for cytology was followed by EUS-TTNB in the same session. Evaluation of the cyst location, primary diagnosis, adverse events, and comparison between the cytologic fluid analyses and histopathology was performed. Technical success of EUS-TTNB was defined as visible tissue present after biopsy. Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis. RESULTS: A total of 56 patients (mean age 66.9 ± 11.7, 53.6% females) with PCLs were enrolled over the study period. The mean cyst size was 28.8 mm (12-85 mm). The EUS-TTNB procedure was technically successful in all patients (100%). The clinical success rate using EUS-TTNB was much higher than standard EUS-FNA, respectively 80.4% (45/56) vs 25% (14/56). Adverse events occurred in 2 patients (3.6%) who developed mild pancreatitis that resolved with medical therapy. Using TTNB specimens, 23 of 32 cases (71.9%) with intraductal papillary mucinous neoplasm were further differentiated into gastric type (19 patients) and pancreaticobiliary type (4 patients) based on immunochemical staining. CONCLUSION: EUS-TTNB for PCLs was technically feasible and had a favorable safety profile. Furthermore, the diagnostic yield for PCLs was much higher with EUS-TTNB than standard EUS-FNA cytology and fluid carcinoembryonic antigen. EUS-TTNB should be considered as an adjunct to EUS-FNA and cytologic analysis in the diagnosis and management of PCLs.

Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience.

Background and aims Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8-88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4-81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19-76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease.

Successful Curative Cryoablation of an Esophageal Gastrointestinal Stromal Tumor.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. The most common location of GIST is the stomach; however, occurrences of GIST in the esophagus are also possible albeit rare. Although the current standard of care for gastric and intestinal GIST involves surgery and tyrosine kinase inhibitors, this case report focuses on the potential of treating esophageal GIST through a novel means of cryoablation therapy.

EUS-guided through-the-needle biopsy for pancreatic cystic lesions.

BACKGROUND AND AIMS: Differentiating pancreatic cystic lesions remains a challenge when the current technique of EUS-guided FNA is used. Recently, a miniaturized biopsy forceps with an outer diameter of 0.8 mm has been developed, thus allowing it to be passed through the bore of a standard 19-gauge FNA needle to acquire tissue. METHODS: This study consisted of a retrospective review of all cases of EUS-guided through-the-needle forceps biopsy technique (TTNFB) performed for pancreatic cystic lesions at a single academic tertiary care center over a 12-month period. Technical success was defined as acquisition of adequate tissue for formal histologic analysis. Safety was assessed through the monitoring and recording of periprocedural and postprocedural adverse events. RESULTS: The technical success of EUS-guided TTNFB was 87% (13/15). EUS-guided TTNFB with histologic analysis yielded pancreatic cyst diagnoses in 11 of 15 (73%) patients, compared with 0 of 15 (0%) patients with the use of EUS-FNA and cytologic analysis (P < .001). Of the 15 cystic lesions, 8 were diagnosed as intrapapillary mucinous neoplasm based on EUS-TTNFB. CONCLUSION: This TTNFB technique has the potential to improve the diagnostic yield of EUS-FNA for pancreatic cystic neoplasms.

Impact of Urgent Double-Balloon Enteroscopy on the Short-Term and Long-Term Outcomes in Overt Small Bowel Bleeding.

BACKGROUND: Double-balloon enteroscopy (DBE) is a safe and useful procedure for managing small bowel bleeding. However, there are limited studies regarding the preferable timing of DBE and its impact on long-term outcomes. AIM: We aimed to evaluate the association between the timing of DBE and the long-term outcomes of patients suspected of having overt small bowel bleeding who underwent DBE. METHODS: We retrospectively reviewed a prospectively collected database of patients who underwent DBE procedures between May 2004 and April 2016. The electronic medical records were reviewed, and interviews were conducted via mail and telephone. RESULTS: One-hundred sixty-five patients could be followed up. The bleeding source was detected during the initial DBE (DBE-positive group) for 102 patients. Sixty-three patients had no definite lesion during the initial DBE (DBE-negative group). Urgent DBE (DBE within 24 h after the last bleeding episode) was performed more often for the DBE-positive group (50/102; 49.0%) than for the DBE-negative group (10/63; 16.1%) (p < 0.0001). Nine patients in the DBE-positive group underwent curative surgery after diagnosis. Among the remaining DBE-positive patients, 38 of 93 (40.9%) had recurrent bleeding during 2675 days of follow-up. Twenty-one of 63 patients (33.3%) in the DBE-negative group had recurrent bleeding during 2490 days of follow-up. There was no significant difference between the two groups in terms of intervals without rebleeding (p = 0.17). CONCLUSION: Urgent DBE at the initial bleeding episode was useful for detecting lesions. However, the rebleeding rate was not dependent on the initial DBE results.