[Changes in mediastinal lymph node sampling practices]. / Évolution des pratiques concernant l'exploration ganglionnaire médiastinale.

INTRODUCTION: While mediastinoscopy is considered the gold standard for mediastinal node sampling, it is to some extent being superseded by endobronchial ultrasound. The objective of this study was to evaluate the different practices in our center regarding mediastinal lymph node sampling in lung cancer patients. METHODS: Data were collected from patients having undergone mediastinal lymph node sampling by video-assisted-mediastinoscopy (VM) or by endobronchial ultrasound (EBUS) in our center between August 2020 and July 2023. The modalities of the two procedures and their diagnostic accuracy were analyzed, as was their evolution over time. RESULTS: The 362 patients comprised 217 who were sampled by EBUS and 145 by VM. Overall, the procedures became more frequent, with EBUS tending to supersede VM. The number of harvested lymph nodes gradually grew, and less unforeseen lymph node invasion and upstaging occurred. CONCLUSION: The arrival in our center of endobronchial ultrasound yielded an overall increase of lymph node sampling despite a decrease in the number of mediastinoscopy procedures performed. Reinforced compliance with guidelines is needed to improve the diagnostic accuracy of these techniques and to better ensure quality of care.

The i-EUS consensus on the management of pancreatic fluid collections - Part 1.

Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches; however, it has later shifted toward an endoscopy-based approach. With the development of dedicated lumen-apposing metal stents (LAMS), interventional Endoscopic Ultrasound (EUS)-guided procedures have become the standard approach for PFC drainage. However, there is still limited consensus on several aspects of the multidisciplinary management of PFCs. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript describes the first part of the results of a consensus conference organized by i-EUS with the aim of providing evidence-based guidance on aspects such as indications for treating PFCs, the timing of intervention, and different technical strategies for managing patients with PFCs.

Using quality indicators to assess performance of endobronchial ultrasound in the staging and diagnosis of lung cancer: a pre/post study at a New Zealand centre.

AIM: There are no data on the performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the staging and diagnosis of lung cancer in New Zealand. We aimed to assess the performance of EBUS-TBNA for lung cancer staging and diagnosis at our institution before and after the commencement of regular performance monitoring with comparison to published EBUS quality indicators. METHODS: The performance of EBUS-TBNA in the staging and diagnosis of lung cancer was assessed in two phases. Phase 1 consisted of a retrospective review of all lung cancer EBUS performed over a 2-year period. Published quality indicators were determined from the literature with relevant indicators being extracted and used to determine EBUS performance. Local reporting and education were undertaken and prospective data collection was commenced. Phase 2 consisted of prospective assessment of all lung cancer EBUS over the subsequent year. Performance of EBUS was then compared between phases 1 and 2 in order to determine the effect of performance monitoring and identify areas for service improvement. RESULTS: A total of 115 staging EBUS and 117 diagnostic EBUS were performed during the study period. Staging EBUS demonstrated good performance across phases 1 and 2 with high sensitivity and negative predictive values (NPV) for the detection of N2/3 disease, meeting published quality standards. During phase 2 there was evidence of a transition towards more guideline-concordant practice evidenced by more detailed nodal sampling during staging EBUS; however, this did not affect overall sensitivity or NPV. Diagnostic EBUS resulted in high rates of pathological confirmation meeting published quality standards across both phases. Pathway times were similar between phases 1 and 2, with reporting of molecular profiling being the predominant factor in delayed pathway times. CONCLUSION: Monitoring and reporting of local performance allows critical assessment of practice and can identify areas for quality improvement. This review demonstrated good overall performance but prompted a move towards more guideline-concordant practice with increased mediastinal nodal sampling during staging procedures. Consideration should be given to the adoption of routine EBUS performance monitoring within local and/or regional networks, which could be incorporated alongside the newly proposed Lung Cancer Clinical Quality Registry.

Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE recommends endoscopic ultrasonography (EUS) as the best tool to characterize subepithelial lesion (SEL) features (size, location, originating layer, echogenicity, shape), but EUS alone is not able to distinguish among all types of SEL.Strong recommendation, moderate quality evidence. 2: ESGE suggests providing tissue diagnosis for all SELs with features suggestive of gastrointestinal stromal tumor (GIST) if they are of size > 20 mm, or have high risk stigmata, or require surgical resection or oncological treatment.Weak recommendation, very low quality evidence. 3: ESGE recommends EUS-guided fine-needle biopsy (EUS-FNB) or mucosal incision-assisted biopsy (MIAB) equally for tissue diagnosis of SELs ≥ 20 mm in size.Strong recommendation, moderate quality evidence. 4: ESGE recommends against surveillance of asymptomatic gastrointestinal (GI) tract leiomyomas, lipomas, heterotopic pancreas, granular cell tumors, schwannomas, and glomus tumors, if the diagnosis is clear.Strong recommendation, moderate quality evidence. 5: ESGE suggests surveillance of asymptomatic esophageal and gastric SELs without definite diagnosis, with esophagogastroduodenoscopy (EGD) at 3-6 months, and then at 2-3-year intervals for lesions < 10 mm in size, and at 1-2-year intervals for lesions 10-20 mm in size. For asymptomatic SELs > 20 mm in size that are not resected, ESGE suggests surveillance with EGD plus EUS at 6 months and then at 6-12-month intervals.Weak recommendation, very low quality evidence. 6: ESGE recommends endoscopic resection for type 1 gastric neuroendocrine neoplasms (g-NENs) if they grow larger than 10 mm. The choice of resection technique should depend on size, depth of invasion, and location in the stomach.Strong recommendation, low quality evidence. 7: ESGE suggests considering removal of histologically proven gastric GISTs smaller than 20 mm as an alternative to surveillance. The decision to resect should be discussed in a multidisciplinary meeting. The choice of technique should depend on size, location, and local expertise.Weak recommendation, very low quality evidence. 8: ESGE suggests that, to avoid unnecessary follow-up, endoscopic resection is an option for gastric SELs smaller than 20 mm and of unknown histology after failure of attempts to obtain diagnosis.Weak recommendation, very low quality evidence. 9: ESGE recommends basing the surveillance strategy on the type and completeness of resection. After curative resection of benign SELs no follow-up is advised, except for type 1 gastric NEN for which surveillance at 1-2 years is advised.Strong recommendation, low quality evidence. 10: For lower or upper GI NEN with a positive or indeterminate margin at resection, ESGE recommends repeating endoscopy at 3-6 months and another attempt at endoscopic resection in the case of residual disease.Strong recommendation, low quality evidence.

Endoscopic ultrasound-guided vs ERCP-guided biliary drainage for malignant biliary obstruction: A up-to-date meta-analysis and systematic review.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is being used increasingly as an alternative treatment for malignant biliary obstruction (MBO). However, few studies have compared EUS-BD and endoscopic retrograde cholangiopancreatography biliary drainage (ERCP-BD). We searched the PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases until 1 November 2020 for studies comparing EUS-BD versus ERCP-BD. The primary outcomes of interest in this study were technical and clinical success. Nine studies involving 634 patients were included in this meta-analysis. Regarding technical and clinical success, there were no significant differences between EUS-BD and ERCP-BD (odds ratio [OR], 0.76; 95% CI: 0.30-1.91; OR, 1.45, 95% confidence interval [CI], 0.66-3.16, respectively). EUS-BD was associated with significantly less reintervention vs ERCP-BD (OR, 0.36, 95% CI, 0.15-0.86). Regarding adverse events, the rates were similar for EUS-BD and ERCP-BD (OR: 0.75, 95% CI, 0.45-1.24). There were no significant differences in the types of adverse events (stent occlusion, stent migration, stent dysfunction, and duration of stent patency) between the two techniques. EUS-BD was associated with lower reintervention rates compared with ERCP-BD, with comparable safety and efficacy outcomes. However, more high-quality randomized trials are required.

A tug-of-war in intraductal papillary mucinous neoplasms management: Comparison between 2017 International and 2018 European guidelines.

BACKGROUND: 2017 International and 2018 European guidelines are the most recent guidelines for intraductal papillary mucinous neoplasms management. AIM: to evaluate the diagnostic accuracy of these guidelines in identifying malignant IPMN. METHODS: data from resected patients with IPMN were collected in two referral centers. Features of risk associated to cancerous degeneration described in International and European guidelines were retrospectively applied. Sensitivity, specificity, positive and negative predictive value in detecting malignant disease were calculated. RESULTS: the study includes 627 resected patients. European guidelines suggest resection in any patient with at least one feature of moderate-risk. International guidelines suggest that patients with moderate-risk features undergo endoscopic ultrasound before surgery. European guidelines had a higher sensitivity (99.2% vs. 83%) but a lower positive predictive value (59.5% vs. 65.8%) and Specificity (2% vs. 37.5%). European guidelines detected almost all malignancies, but 40% of resected patients had low-grade dysplasia. 297 patients underwent endoscopic ultrasound before surgery. 31/116 (26.7%) tumors radiologically classified as "worrisome features" were reclassified as "high-risk stigmata" by endoscopic ultrasound and 24/31 were malignant IPMN. CONCLUSIONS: European and International guidelines have a relatively low diagnostic accuracy, being European guidelines more aggressive. Endoscopic ultrasound can improve guidelines accuracy in patients with moderate-risk features.

The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) Guidelines for Contrast-Enhanced Endoscopic Ultrasound.

The Asian Federation of Societies for Ultrasound in Medicine and Biology aimed to provide information on techniques and indications for contrast-enhanced harmonic endoscopic ultrasound (CH-EUS), and to create statements including the level of recommendation. These statements are based on current scientific evidence reviewed by a Consensus Panel of 15 internationally renowned experts. The reliability of clinical questions was measured by agreement rates after voting. Six statements were made on techniques, including suitable contrast agents for CH-EUS, differences between contrast agents, setting of mechanical index, dual imaging and duration and phases for observation. Thirteen statements were made on indications, including pancreatic solid masses, pancreatic cancer staging, pancreatic cystic lesions and mural nodules, detection of subtle pancreatic lesions, gallbladder sludge and polyps, hepatic lesions, lymph nodes, subepithelial lesions, visceral vascular diseases, guidance of fine needle aspiration and evaluation for local therapy. These international expert consensus guidelines will assist endosonographers in conducting CH-EUS according to evidence-based information.

Quality in Endoscopy.

Quality improvement is a dynamic process that requires continuously monitoring quality indicators and benchmarking these with national and professional standards. Endoscopists have formed societal task forces to propose quality indicators and performance goals. Institutions are now incentivized by payers and value-based reimbursement agreements to have processes in place to measure, report, and act on these quality metrics. Nationwide registries, such as the Gastrointestinal Quality Improvement Consortium, are used to report quality data to these merit-based incentive payment systems. Quality improvement processes such as these are instrumental to improve patient safety, health, and satisfaction while decreasing costs and medical errors.

Endoscopic Ultrasound.

Endoscopic ultrasound provides high-resolution, real-time imaging of the gastrointestinal tract and surrounding extramural structures. In recent years, endoscopic ultrasound has played an increasing role as an adjunct or alternative method to conventional surgical therapies. The role of endoscopic ultrasound in diagnosis and management of gastrointestinal malignancy, pancreatic diseases, and biliary diseases continues to evolve. Therapeutic endoscopic ultrasound procedures for a variety of pancreatic and biliary indications shows a high technical and clinical success rate, with low rate of adverse events. Endoscopic ultrasound plays a key role in multidisciplinary management of complex surgical and oncology patients and those with pancreaticobiliary disorders.

Endoscopic Management of Pancreaticobiliary Disease.

The evolution of advanced pancreaticobiliary endoscopy in the past 50 years is remarkable. Endoscopic retrograde cholangiopancreatography (ERCP) has progressed from a diagnostic test to an almost entirely therapeutic procedure. The endoscopist must have a clear understanding of the indications for ERCP to avoid unnecessary complications, including post-ERCP pancreatitis. Endoscopic ultrasound initially was used as a diagnostic tool but now is equipped with accessary channels allowing endoscopic ultrasound-guided interventions in various pancreaticobiliary conditions. This review discusses the endoscopic management of common pancreatic and biliary diseases along with the techniques, indications, outcomes, and complications of pancreaticobiliary endoscopy.

A prospective analysis of the diagnostic accuracy of 3 T MRI, CT and endoscopic ultrasound for preoperative T staging of potentially resectable esophageal cancer.

BACKGROUND: Patients with esophageal cancer (EC) undergo endoscopic ultrasound and CT based cancer staging. Recent technical developments allow improved MRI quality with diminished motion artifact that may allow MRI to compare favorable to CT for noninvasive staging. Hence the purpose of the study was to assess image quality and diagnostic accuracy of 3 T MRI versus CT and EUS for preoperative T-staging of potentially resectable esophageal cancer. METHODS: Between October-2014 and December-2017, esophageal cancer patients with T-staging by EUS were enrolled in this prospective study. Post-operative histopathologic T-staging was the reference standard. All participants underwent MRI [T2- multi-shot turbo spin echo sequence (msTSE), diffusion-weighted imaging (DWI), and 3D gradient-echo based sequence (3D-GRE)] and CT [non-contrast and multiphase contrast-enhanced CT scanning] 5.6 + 3.6 days after endoscopy. Surgery was performed within 3.6 + 3.5 days after imaging. Two blinded endoscopists (reader 1 and 2) and radiologists (reader 3 and 4) independently evaluated EUS and CT/MRI, respectively. Considering the clinical relevance, patients were dichotomized into early (T1 and T2) vs late (T3 and T4) stage cancer before assessment. For statistical purpose, the binary decision was defined as the ability of the imaging technique to diagnose early stage/not early stage esophageal cancer. Diagnostic performance of EUS, MRI and CT was compared using McNemar's test with Bonferroni correction; kappa values were assessed for reader performance. RESULTS: 74 study participants (60 ± 8 yrs.; 56 men) with esophageal cancer were evaluated, of whom 85%(63/74) had squamous cell carcinoma, 61%(45/74) were at early stage and 39%(29/74) were at late stage cancer, as determined by histopathology. Intra- and Inter-reader agreement for pre-operative vs post-operative T-staging was excellent for all imaging modalities. Compared to CT, MRI showed significantly higher accuracy for both the readers (reader3: 96% vs 82%, p = 0.0038, reader4: 95% vs 80%, p = 0.0076, for MRI vs CT, respectively). Further, MRI outperformed EUS with higher specificity (reader 1 vs 3: 59% vs 93%, p = 0.0015, reader 2 vs 4: 66% vs 93%, p = 0.0081, for EUS vs MRI respectively), and accuracy (reader 1 vs 3: 81% vs 96%, p = 0.0022, reader 2 vs 4: 85% vs 95%, p = 0.057, for EUS vs MRI, respectively). CONCLUSION: For resectable esophageal cancer, MRI had better diagnostic performance for tumor staging compared to CT and EUS. TRIAL REGISTRATION: ChiCTR, ChiCTR-DOD, Registered 2nd October 2014, http://www.chictr.org.cn/showproj.aspx?proj=9620.

[Accuracy comparision of abdominal enhanced CT and endoscopic ultrasound in the staging of gastric cancer after neoadjuvant chemotherapy: a post hoc analysis of a randomized clinical trial].

Objective: To compare the accuracy of abdominal enhanced CT and endoscopic ultrasound in the staging of gastric cancer after neoadjuvant chemotherapy (yc stage). Methods: Clinic data of 86 locally advanced gastric cancer patients admitted in Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute from April 2015 to November 2017 were analyzed retrospectively. Totally 86 patients completed both abdominal enhanced CT and endoscopic ultrasound after neoadjuvant chemotherapy. There were 60 males and 26 females, aged (57.8±9.7) years (range: 32 to 76 years). The diagnostic accuracy of abdominal enhanced CT and endoscopic ultrasound for yc stage were calculated by the area under the multiclass receiver operation characteristic curve (M-AUC), retrospectively. McNemar test was used to compared the diagnostic sensitivity. Results: The M-AUC of ycT stage evaluated by abdominal enhanced CT (CT-ycT stage) and by endoscopic ultrasound (EUS-ycT stage) was 0.614 and 0.704, respectively. For middle and lower gastric cancer, the M-AUC of CT-ycT stage was 0.599 and 0.613, respectively, while EUS-ycT stage was 0.558 and 0.709, respectively. For tumor in the lesser and non-lesser curvature, the M-AUC of CT-ycT stage was 0.630 and 0.607, respectively, while EUS-ycT stage was 0.616 and 0.749, respectively. For patients in CT-ycT1-CT-ycT4, there was no statistically significant difference in the sensitivity between CT-ycT stage and EUS-ycT stage (2/18, 2/15, 52.8%(19/36), 8/13 vs. 0, 4/15, 55.6%(20/36), 7/13; χ(2)=2.00, P=0.157; χ(2)=2.00, P=0.157; χ(2)=0.08, P=0.782; χ(2)=0.33, P=0.564). The M-AUC of ycN stage evaluated by abdominal enhanced CT (CT-ycN stage) was 0.654, while ycN stage evaluated by endoscopic ultrasound (EUS-ycN stage) was 0.533. For patients in CT-ycN0, there was statistically significant difference in the sensitivity between CT-ycN stage and EUS-ycN stage (12.7%(7/55) vs. 5.5%(3/55); χ(2)=4.00, P=0.046). For patients in CT-ycN1, N2, and N3, there was no statistically significant difference in the sensitivity between CT-ycN stage and EUS-ycN stage (2/19, 1/10, 0 vs. 1/19, 1/10, 0; χ(2)=1.00, P=0.317; the other P cannot be estimated). Conclusions: There was no significant difference between the diagnostic efficacy of abdominal enhanced CT and endoscopic ultrasound for yc stage of gastric cancer. Considering the invasiveness of ultrasound gastroscopy, it should not be recommend for patients after neoadjuvant chemotherapy routinely.

Restarting gastrointestinal endoscopy in the deceleration and early recovery phases of COVID-19 pandemic: Guidance from the British Society of Gastroenterology.

Many non-emergency clinical services were suspended during COVID-19 pandemic peak. It is essential to develop a plan for restarting services following the peak. It is equally important to protect patients and staff and to use resources and personal protective equipment (PPE) efficiently. The British Society of Gastroenterology Endoscopy Committee and Quality Improvement Programme has produced guidance on how a restart can be safely delivered. Key recommendations include the following: all patients should have need for endoscopy assessed by senior clinicians and prioritised according to criteria we have outlined; once the need for endoscopy is confirmed, patients should undergo telephone screening for symptoms using systematic questionnaires; all outpatients should undergo RT-PCR testing for COVID-19 virus 1-3 days prior to endoscopy; and PPE should be determined by patient risk stratification, the nature of the procedure and the results of testing. While this guidance is tailored to endoscopy services, it could be adapted for any interventional medical discipline.

Review of the diagnosis and management of intraductal papillary mucinous neoplasms.

Intraductal papillary mucinous neoplasms are common lesions with the potential of harbouring/developing a pancreatic cancer. An accurate evaluation of intraductal papillary mucinous neoplasms with high-resolution imaging techniques and endoscopic ultrasound is mandatory in order to identify patients worthy either of surgical treatment or surveillance. In this review, the diagnosis and management of patients with intraductal papillary mucinous neoplasms are discussed with a specific focus on current guidelines. Areas of uncertainty are also discussed, as there are controversies related to the optimal indications for surgery, surveillance protocols and surveillance discontinuation.

Management of rectal cancer in Canada: an evidence-based comparison of clinical practice guidelines

Background: Rectal cancer requires a multidisciplinary and multimodality treatment approach. Clinical practice guidelines (CPGs) provide a framework for delivering consistent, evidence-based health care. We compared provincial/territorial CPGs across Canada to identify areas of variability and evaluate their quality. Methods: We retrieved CPGs from Canadian organizations responsible for cancer care oversight and evaluated their quality and developmental methodology using the AGREE-II instrument. Recommendations for diagnostic and staging investigations, treatment by stage, and post-treatment surveillance of stage I­III rectal cancers were abstracted and compared. Results: We identified 7 sets of CPGs for analysis, varying in content, presentation, quality, and year last updated. Differences were noted in locoregional staging: 4 recommended magnetic resonance imaging over endorectal ultrasonography, 2 recommended either modality, and 3 specified scenarios for one over the other. Recommendations also varied for use of staging computed tomography of the chest versus chest radiography and for surgical management and indications for transanal excision. Recommendations for neoadjuvant therapy in stage II/III disease also differed: 3 guidelines recommended long-course chemoradiation over short-course radiation therapy alone, while 3 others recommended short-course radiation in specific clinical scenarios. Adjuvant chemotherapy for stage II/III disease was uniformly recommended, with variable protocols. The use of proctosigmoidoscopy and interval/duration of endoscopic post-treatment surveillance varied among guidelines. Conclusion: Canadian CPGs vary in their recommendations for staging, treatment, and surveillance of rectal cancer. Some of these differences reflect areas with limited definitive evidence. Consistent guidelines with uniform implementation across provinces/territories may lead to more equitable care to patients.

Contexte: Le cancer rectal requiert une approche thérapeutique multidisciplinaire et multimodalité. Les guides de pratique clinique (GPC) procurent un cadre pour assurer la prestation de soins de santé constants reposant sur des données probantes. Nous avons comparé les GPC des provinces et des territoires canadiens pour identifier les secteurs où ils varient et pour en évaluer la qualité. Méthodes: Nous avons obtenu les GPC des organisations canadiennes responsables des soins oncologiques et nous avons évalué leur qualité et la méthodologie de leur élaboration au moyen de l'outil AGREE II (Appraisal of Guidelines for Research & Evaluation). Nous avons extrait et comparé les recommandations en ce qui concerne les épreuves diagnostiques et la stadification, les traitements en fonction du stade et la surveillance post-thérapeutique du cancer rectal de stade I à III. Résultats: Nous avons recensé 7 GPC aux fins de cette analyse; leur contenu, leur présentation, leur qualité et l'année de leur plus récente mise à jour variaient. Des différences ont été observées au plan de la stadification locorégionale : 4 recommandaient l'imagerie par résonnance magnétique plutôt que l'échographie endorectale, 2 recommandaient l'une ou l'autre et 3 précisaient des circonstances où utiliser l'une plutôt que l'autre. Les recommandations variaient aussi pour ce qui est de l'utilisation de la scintigraphie c. radiographie thoracique de stadification, de la prise en charge chirurgicale et des indications de l'excision transanale. Les recommandations variaient également en ce qui concerne le traitement néoadjuvant pour la maladie de stade II/III : 3 guides recommandaient un traitement par chimioradiothérapie à long terme plutôt qu'une brève radiothérapie seule, tandis que 3 autres recommandaient une radiothérapie brève dans certains cas particuliers. La chimiothérapie adjuvante pour la maladie de stade II/III était uniformément recommandée, mais les protocoles variaient. L'utilisation de la proctosigmoïdoscopie et l'intervalle/durée de la surveillance endoscopique post-thérapeutique variaient d'un guide à l'autre. Conclusion: Les GPC canadiens varient quant à leurs recommandations pour la stadification, le traitement et la surveillance du cancer rectal. Certaines de ces différences témoignent du manque de données probantes concluantes dans certains secteurs. L'uniformisation des guides et de leur application entre les provinces et les territoires pourrait faciliter une prestation plus équitable des soins aux patients.

Sensitivity of Radial Endobronchial Ultrasound-Guided Bronchoscopy for Lung Cancer in Patients With Peripheral Pulmonary Lesions: An Updated Meta-analysis.

BACKGROUND: Registry trials have found radial endobronchial ultrasound (r-EBUS) sensitivity to vary between institutions, suggesting that in clinical practice, r-EBUS sensitivity may be lower than reported in clinical trials. We performed a meta-analysis to update the estimates of r-EBUS sensitivity and to explore factors contributing to heterogeneity of results. METHODS: A systematic review using PubMed was performed through July 2018 to determine the sensitivity of r-EBUS for lung cancer, and to construct a summary receiver operating characteristic curve. The DerSimonian and Laird method was used to weight results. Subgroup analysis and meta-regression was used to identify sources of heterogeneity. Study quality was assessed using the QUADAS tool, and publication bias was tested using funnel plots. RESULTS: Fifty-one studies with a total of 7,601 patients were included. r-EBUS pooled sensitivity was 0.72 (95% CI, 0.70-0.75), and area under the sROC curve was 0.96 (95% CI, 0.94-0.97). Significant heterogeneity was observed (I2 = 76%; heterogeneity P < .01). We failed to demonstrate an association between sensitivity and air bronchus sign, average nodule size, use of fluoroscopy, virtual bronchoscopy, guide sheath, cancer prevalence, multicenter status, or consecutive enrollment. Rapid onsite cytology was associated with increased sensitivity (P = .01). The pooled pneumothorax rate was 0.7% (95% CI, 0.3%-1.1%). Funnel plots were asymmetrical, demonstrating sample size-related effects and possible publication bias. CONCLUSIONS: r-EBUS has an excellent safety profile, but there is significant between-study heterogeneity. Sample size-related effects and possibly publication bias have led to overly optimistic estimates of the sensitivity of r-EBUS.

Endoscopic Ultrasound-Guided Fine Needle Biopsy Using 22-Gauge Franseen Needle for the Histological Diagnosis of Solid Lesions: A Multicenter Prospective Pilot Study.

BACKGROUND: Recently, a novel 22-gauge needle with three symmetric needle points and crown-shaped cutting heels, known as a Franseen needle, has been developed for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). AIM: To assess the histological material acquisition rate and histological diagnostic capability of the 22-gauge Franseen needle (AC22) during EUS-FNB for solid lesions. METHODS: This study was designed as an open-label, multicenter, prospective, single-arm pilot study of EUS-FNB using AC22 for the diagnosis of solid lesions. Three passes of FNB using AC22 were performed for all lesions. The primary endpoints were the histological material acquisition rate and histological diagnostic capability. The secondary endpoints were the technical success rate, quality of histological samples, number of passes for diagnosis, and safety. RESULTS: Between September 2017 and May 2018, 75 patients were enrolled. The final diagnoses were malignancy in 65 and benign in 10. Three passes of FNB were technically successful in all patients. The sensitivity, specificity, and accuracy for the malignancy of histological analyses were 92.3% (60/65), 100% (10/10), and 93.3% (70/75), respectively, for the first pass and 95.4% (62/65), 100% (10/10), and 96% (72/75), respectively, for combined three passes. The diagnostic yield plateaued after the second pass. Sufficient tissue samples for histological interpretation were obtained in 96% (72/75) and 100% (75/75) patients for the single pass and combined three passes, respectively. Two patients (2.7%) developed mild pancreatitis as an adverse event. CONCLUSION: EUS-FNB using AC22 showed high histological diagnostic capability with the high first pass yield. CLINICAL TRIALS REGISTRY: UMIN Clinical Trials Registry (UMIN ID: UMIN000036641).

Robot-assisted partial nephrectomy with a standard laparoscopic ultrasound probe in treating endophytic renal tumor.

OBJECTIVE: To report our experience in treating endophytic renal tumor by robot-assisted partial nephrectomy (RPN) with a standard laparoscopic ultrasound probe and our original approach for separating renal mass. METHODS: All patients with endophytic renal tumor who underwent RPN in our department from January 2015 to December 2017 were retrospectively analyzed. All surgeries were performed by transperitoneally by a single, experienced surgeon. Baseline characteristics, tumor characteristics, operative profile and follow-up data were collected. RESULTS: Among these 29 patients, 23 patients were male. The mean age of patients was 47.42 years old. 69% (20/29) tumors were completely endophytic tumors. The average tumor size was 3.1 cm. The average R.E.N.A.L. score was 9.0. Tumors from 3 patients were pathologically confirmed to be renal angiomyolipomas. And the rest were malignant including 23 clear cell renal cell carcinoma and 3 chromophobe renal cell carcinoma. The mean operative time was 3.0 h. The mean warm ischemia time was 22.3 min. All tumor margins were pathologically confirmed negative. No patient needed blood transfusion. Two patients presented had Grade II complication. Both of them had a fever after surgery with body temperature over 38 °C, leading to a prolonged postoperative hospitalization time. The mean postoperative hospitalization time was 6.8 days. During mean 21.3-month follow-up, no patient was confirmed to relapse by CT scan. CONCLUSION: RPN with a standard laparoscopic ultrasound probe is safe, effective and feasible in treating endophytic renal tumor. Our original approach for separating renal mass can avoid some problems caused by the standard laparoscopic ultrasound probe.