Role of Endoscopic Ultrasound in Staging and Vascular Assessment of Pancreatic Cancer.

Introduction Computed tomography (CT) of the abdomen with contrast stands as the gold standard for assessing pancreatic cancer, encompassing both staging and vascular analysis. However, not all patients are suitable candidates for contrast-enhanced CT (CECT) scans due to factors such as contrast agent allergies, pregnancy, renal impairment, radiation risks, and limited tissue sampling capability in CECT scans of the abdomen. In light of these challenges, this study evaluated the diagnostic capabilities of endoscopic ultrasound (EUS) compared to CECT for staging and vascular assessment of pancreatic cancer. Methods Fifty patients diagnosed with pancreatic cancer underwent evaluations using both CECT scans and EUS, focusing on staging and vascular invasion assessment. Vascular evaluation was carried out using a categorization system based on EUS findings, classifying them into three types based on the tumor-vessel relationship: Type 1 indicating clear invasion or encasement of a vessel by a tumor or contact with a vessel wall exceeding 180 degrees, Type 2 representing abutment, wherein a tumor contacts a vessel wall but at an angle less than 180 degrees, and Type 3 implying clear non-invasion, where a discernible distance exists between a tumor and a vessel. In this categorization, Type 1 and Type 2 indicated signs of vascular invasion, while Type 3 indicated vascular non-invasion. These findings were subsequently compared to the results from CECT scans. The endoscopist performing EUS was blinded to the CT outcomes prior to the examination. Results Regarding pancreatic cancer staging, EUS exhibited remarkable sensitivity, specificity, and accuracy rates of 100% according to the T criterion.As for vascular invasion assessment, EUS demonstrated sensitivity, specificity, and accuracy of 100%, 95.93%, and 96%, respectively, for venous invasion. For arterial invasion, the figures were 95.65% sensitivity, 100% specificity, and an overall accuracy of 99.5%. Conclusion EUS is an effective modality for evaluating both staging and vascular invasion in pancreatic cancer, boasting exceptional sensitivity, specificity, and accuracy rates. The findings are robust enough to consider EUS a viable alternative to CT scans in evaluation, with the added advantage of EUS offering tissue sampling capability.

Comparison of diagnostic outcomes, safety, and cost of Franseen-tip 19G versus 22G needles for endoscopic ultrasound-guided liver biopsies.

Background and study aims Favorable outcomes were noted with refinement in newer endoscopic ultrasound-guided liver biopsy (EUS-LB) needle tips. Still, the overall usefulness and benefit are yet to be well explored. Patients and methods This was a retrospective analysis of patients with EUS-LB (Franseen-tip 19G versus 22G FNB needle) over 2 years. EUS-LB was obtained in a one-pass, two-actuation, modified wet suction technique. Diagnostic yield, fragmentation rate, aggregate specimen length (AL), number of complete portal tracts (CPT), length of longest intact core (LIC), adverse events (AEs) (early), and cost of the procedure (1USD = 82 INR) were compared. Results Fifty-four patients (33 [61.1%], female) successfully underwent EUS-LB with a median age of 46 years (interquartile range [IQR] 34-54); the majority 32 (59.2%) underwent 19G biopsies. There was a significantly increased median (IQR) AL in the 19G compared with 22G (20 mm [19-21] vs. 15 [14-15], P < 0.001), respectively. Similarly, significantly lengthier median LIC and CPT were seen, respectively. A nonsignificant diagnostic yield was noted (100% vs. 90.9%, P = 0.082), respectively. The fragmentation rate was higher in 22G FNB needles (36.4% [95% CI 16-56] vs. 12.5% [95% CI 1-24], respectively; P = 0.038). Seven patients (12.9%) had mild AEs with no difference between groups. The average procedure cost with 19G was INR 63000 (768$), and with 22G needle was INR 54500 (664$). Conclusions The Franseen-tip 19G outperforms 22G with a significantly lower fragmentation rate, longer AL, LIC, and a higher number of CPT with a marginal increase in the procedure cost, without any difference in diagnostic yield and safety.

Impact and assessment of training models in interventional endoscopic ultrasound.

Interventional endoscopic ultrasound (IEUS) has gained significant popularity in recent years because of its diagnostic and therapeutic capabilities. The proper training of endoscopists is critical to ensure safe and effective procedures. This review study aims to assess the impact of different training models on the competence of trainees performing IEUS. Eight studies that evaluated simulators for IEUS were identified in the medical literature. Various training models have been used, including the EASIE-R, Mumbai EUS, EUS Magic Box, EndoSim, Thai Association for Gastrointestinal Endoscopy model, and an ex vivo porcine model (HiFi SAM). The trainees underwent traditional didactic lectures, hands-on training using simulators, and direct supervision by experienced endoscopists. The effectiveness of these models has been evaluated based on objective and subjective parameters such as technical proficiency, operative time, diagnostic success, and participant feedback. As expected, the majority of skills were improved after the training sessions concluded, although the risk of bias is high in the absence of external validation. It is difficult to determine the ideal simulator among the existing ones because of the wide variation between them in terms of costs, reusability, design, fidelity of anatomical structures and feedback, and types of procedures performed. There is a need for a standardized approach for the evaluation of IEUS simulators and the ways skills are acquired by trainees, as well as a clearer definition of the key personal attributes necessary for developing a physician into a skilled endoscopist capable of performing basic and advanced therapeutic EUS interventions.

Molecular characterization of Aeromonas hydrophila isolates from diseased fishes in district Kasur, Punjab, Pakistan / Caracterização molecular de isolados de Aeromonas hydrophila de peixes doentes no distrito de Kasur, Punjab, Paquistão

Abstract Pakistan is an agricultural country and fisheries play a very important role in the economic development of the country. Different diseases are prevalent in Pakistani fish but information related to the causative agents is not well-known. Keeping in view the significance of bacterial pathogens as the causative agents of multiple fish diseases, the present study was conducted for identification, characterization and analysis of virulence genes of Aeromonas spp. isolated from diseased fishes. A total of fifty fish samples having multiple clinical indications were collected from different fish farms of district Kasur, Punjab Pakistan. For isolation of Aeromonas spp. samples were enriched and inoculated on Aeromonas isolation medium. Isolates were identified and characterized by different biochemical tests, Analytical Profile Index (API) 20E kit and Polymerase Chain Reaction (PCR) assays. All isolates were screened for three putative virulence genes including aerolysin (aer), haemolysin (hyl) and heat labile cytotonic enterotoxin (alt). Seven isolates of Aeromonas (A.) hydrophila were retrieved and identified based on API 20E. These isolates were further confirmed as A. hydrophila on the basis of PCR assays. Three isolates were detected positive for the presence of virulence genes (alt and hyl). Whereas aerolysin (aer) gene was not present in any of A. hydrophila isolates. The present study confirmed A. hydrophila as the causative agent of epizootic ulcerative syndrome and motile Aeromonas septicemia in fish farms of district Kasur, Punjab Pakistan. Moreover, detection of two virulence genes (alt and hyl) in A. hydrophila isolates is a threat for fish consumers of study area.

Resumo O Paquistão é um país agrícola, onde a pesca desempenha um papel muito importante para o desenvolvimento econômico. Diferentes doenças são prevalentes em peixes do Paquistão, mas as informações relacionadas aos agentes causadores não são bem conhecidas. Tendo em vista a importância dos patógenos bacterianos como agentes causadores de múltiplas doenças em peixes, o presente estudo foi conduzido para identificação, caracterização e análise de genes de virulência de isolados de Aeromonas spp. de peixes doentes. Foram coletadas 50 amostras de peixes com múltiplas indicações clínicas em diferentes fazendas do distrito de Kasur, Punjab, Paquistão. Para isolar Aeromonas spp., as amostras foram enriquecidas e inoculadas em meio de isolamento. Os isolados foram identificados e caracterizados por diferentes testes bioquímicos, kit Analytical Profile Index (API) 20E, e ensaios de reação em cadeia da polimerase (PCR). Todos os isolados foram selecionados para três genes de virulência putativos, incluindo aerolisina (aer), hemolisina (hyl) e enterotoxina citotônica termolábil (alt). Sete isolados de Aeromonas hydrophila foram recuperados e identificados com base no API 20E. Esses isolados foram posteriormente confirmados como A. hydrophila de acordo com ensaios de PCR. Três isolados indicaram a presença de genes de virulência (alt e hyl), enquanto o gene aerolisina (aer) não esteve presente em nenhum dos isolados de A. hydrophila. O presente estudo confirmou A. hydrophila como o agente causador da síndrome ulcerativa epizoótica e septicemia móvel por Aeromonas em fazendas de peixes, no distrito de Kasur, Punjab, Paquistão. Além disso, a detecção de dois genes de virulência (alt e hyl) em isolados de A. hydrophila é uma ameaça para os consumidores de peixes da área de estudo.

Molecular characterization of Aeromonas hydrophila isolates from diseased fishes in district Kasur, Punjab, Pakistan

Abstract Pakistan is an agricultural country and fisheries play a very important role in the economic development of the country. Different diseases are prevalent in Pakistani fish but information related to the causative agents is not well-known. Keeping in view the significance of bacterial pathogens as the causative agents of multiple fish diseases, the present study was conducted for identification, characterization and analysis of virulence genes of Aeromonas spp. isolated from diseased fishes. A total of fifty fish samples having multiple clinical indications were collected from different fish farms of district Kasur, Punjab Pakistan. For isolation of Aeromonas spp. samples were enriched and inoculated on Aeromonas isolation medium. Isolates were identified and characterized by different biochemical tests, Analytical Profile Index (API) 20E kit and Polymerase Chain Reaction (PCR) assays. All isolates were screened for three putative virulence genes including aerolysin (aer), haemolysin (hyl) and heat labile cytotonic enterotoxin (alt). Seven isolates of Aeromonas (A.) hydrophila were retrieved and identified based on API 20E. These isolates were further confirmed as A. hydrophila on the basis of PCR assays. Three isolates were detected positive for the presence of virulence genes (alt and hyl). Whereas aerolysin (aer) gene was not present in any of A. hydrophila isolates. The present study confirmed A. hydrophila as the causative agent of epizootic ulcerative syndrome and motile Aeromonas septicemia in fish farms of district Kasur, Punjab Pakistan. Moreover, detection of two virulence genes (alt and hyl) in A. hydrophila isolates is a threat for fish consumers of study area.

Resumo O Paquistão é um país agrícola, onde a pesca desempenha um papel muito importante para o desenvolvimento econômico. Diferentes doenças são prevalentes em peixes do Paquistão, mas as informações relacionadas aos agentes causadores não são bem conhecidas. Tendo em vista a importância dos patógenos bacterianos como agentes causadores de múltiplas doenças em peixes, o presente estudo foi conduzido para identificação, caracterização e análise de genes de virulência de isolados de Aeromonas spp. de peixes doentes. Foram coletadas 50 amostras de peixes com múltiplas indicações clínicas em diferentes fazendas do distrito de Kasur, Punjab, Paquistão. Para isolar Aeromonas spp., as amostras foram enriquecidas e inoculadas em meio de isolamento. Os isolados foram identificados e caracterizados por diferentes testes bioquímicos, kit Analytical Profile Index (API) 20E, e ensaios de reação em cadeia da polimerase (PCR). Todos os isolados foram selecionados para três genes de virulência putativos, incluindo aerolisina (aer), hemolisina (hyl) e enterotoxina citotônica termolábil (alt). Sete isolados de Aeromonas hydrophila foram recuperados e identificados com base no API 20E. Esses isolados foram posteriormente confirmados como A. hydrophila de acordo com ensaios de PCR. Três isolados indicaram a presença de genes de virulência (alt e hyl), enquanto o gene aerolisina (aer) não esteve presente em nenhum dos isolados de A. hydrophila. O presente estudo confirmou A. hydrophila como o agente causador da síndrome ulcerativa epizoótica e septicemia móvel por Aeromonas em fazendas de peixes, no distrito de Kasur, Punjab, Paquistão. Além disso, a detecção de dois genes de virulência (alt e hyl) em isolados de A. hydrophila é uma ameaça para os consumidores de peixes da área de estudo.

Impact of Biopsy Attempts, Race, and Access on Time to Initiation of Treatment for Pancreatic Cancer.

BACKGROUND: Biopsy of suspected pancreatic cancer (PDAC) in surgical candidates is informative however not always necessary. Biopsies impact treatment options as histological diagnosis are presently required for neo-adjuvant therapy, but not surgical resection. We explored the impact of pursuing tissue diagnosis by endoscopic ultrasound (EUS) biopsy on time to treatment in patients with resectable and borderline resectable PDAC. METHODS: A retrospective review of surgical patients with ultimately proven PDAC was performed (2011-2021). Milestone dates (cancer suspected, biopsy(ies), surgical or neo-adjuvant treatment) were collected. Mann-Whitney-Wilcoxon tests, Pearson's chi-squared tests, Fisher's exact tests, linear regressions, and Cox proportional hazard models were used for data analysis. RESULTS: Among 131 resectable and 58 borderline resectable patients, the borderline resectable group underwent more biopsies (1.2 vs 0.7, p < 0.0001), were more likely to undergo biopsy at tertiary care centers (67.2% vs 30.5%, p < 0.0001), and trended toward longer time to treatment (49 vs 44 days, p = 0.070). Significant increases in days to treatment were seen in patients with Black race (29 days, p = 0.0002) and Medicare insurance (22 days, p = 0.038) and no biopsies at a tertiary care center (10 days, p = 0.039). After adjusting for covariates, additional biopsies significantly delayed treatment (1 biopsy: 21 days, p = 0.0001; 2 biopsies: 44 days, p < 0.0001; 3 biopsies: 68 days, p < 0.0001). CONCLUSIONS: EUS biopsy significantly impacts time between suspicion and treatment of PDAC. This may be exacerbated by clinical practices increasingly favoring neo-adjuvant therapy that necessitates biopsy-proven disease. Time to treatment may also be impacted by access to tertiary centers and racial disparities.

Real-world costs and dynamics of surveillance in patients who underwent surgery for low-risk branch duct intraductal papillary mucinous neoplasms.

Surveillance costs and appropriateness of surgery of "low-risk" BD-IPMNs are relevant issues. In this study we evaluated the rate of correct indication for pancreatectomy defined as high grade dysplasia (HGD) at histology in 961 patients who underwent surveillance for a median of 5.1 years. Undertreatment and overtreatment were defined as invasive cancer and low grade dysplasia (LGD) at histology, respectively. Of the 66 patients (6.9%) who were operated, only 16 (23.8%) had a HGD while 40 (59.7%) had a LGD and 10 (14.9%) an invasive cancer, without differences regarding timing of surgery. The mean surveillance cost was € 194.9 ± 107.6 per patient-year, with a median cost of € 277.1 ± 148.2 in the correct surgery group compared with € 222.7 ± 111.6 and € 197 ± 102.7 in the overtreatment and undertreatment groups. The surveillance mean cost from diagnosis to surgery was € 854.8. Rate of appropriate surgery in BD-IPMNs under surveillance is low.

Endoluminal ultrasound versus magnetic resonance imaging in assessment of rectal cancer after neoadjuvant therapy.

BACKGROUND: Accurate rectal tumor staging guides the choice of treatment options. EUS and MRI are the main modalities for staging. AIM OF THE WORK: To compare the performance of EUS and MRI for loco-regional staging of anorectal cancer after neo-adjuvant therapy. METHODS: Seventy-three (37 male, 36 female) patients with rectal cancer after neo-adjuvant chemoradiotherapy were enrolled. Histopathological staging after surgery were used as reference for comparing the yield of loco-regional staging for EUS and MRI. EUS and MRI were done 1 month after completion of neo-adjuvant therapy. RESULTS: Regarding post-surgical T staging, eight patients had early tumor (T2 = 16 and T1 = 9) and thirty six were locally advanced (T3 = 36), while N staging, forty patients with negative nodes and 33 were positive (N1 = 22 and N2 = 11). Comparing EUS to MRI, it showed a higher sensitivity (95.7% vs. 78.7%), specificity (84.6% vs. 68.0%) and accuracy (91.8% vs. 75.3%) for staging early and locally advanced tumor. Also, it had a higher sensitivity (78.8% vs. 69.7%), specificity (75.0% vs. 65.0%) and accuracy (76.7% vs. 67.1%) for detection of lymph nodes. CONCLUSION: EUS appears to be more accurate than MRI in loco-regional staging of rectal carcinoma after neo-adjuvant therapy.

Gastric Cancer Angiogenesis Assessment by Dynamic Contrast Harmonic Imaging Endoscopic Ultrasound (CHI-EUS) and Immunohistochemical Analysis-A Feasibility Study.

Tumor vascular perfusion pattern in gastric cancer (GC) may be an important prognostic factor with therapeutic implications. Non-invasive methods such as dynamic contrast harmonic imaging endoscopic ultrasound (CHI-EUS) may provide details about tumor perfusion and could also lay out another perspective for angiogenesis assessment. Methods: We included 34 patients with GC, adenocarcinoma, with CHI-EUS examinations that were performed before any treatment decision. We analyzed eighty video sequences with a dedicated software for quantitative analysis of the vascular patterns of specific regions of interest (ROI). As a result, time-intensity curve (TIC) along with other derived parameters were automatically generated: peak enhancement (PE), rise time (RT), time to peak (TTP), wash-in perfusion index (WiPI), ROI area, and others. We performed CD105 and CD31 immunostaining to calculate the vascular diameter (vd) and the microvascular density (MVD), and the results were compared with CHI-EUS parameters. Results: High statistical correlations (p < 0.05) were observed between TIC analysis parameters MVD and vd CD31. Strong correlations were also found between tumor grade and 7 CHI-EUS parameters, p < 0.005. Conclusions: GC angiogenesis assessment by CHI-EUS is feasible and may be considered for future studies based on TIC analysis.

Endosonography and endosonography guided needle aspiration for left adrenal gland assessment in lung cancer patients - 10 years' experience.

INTRODUCTION: Lung cancer patients (LCP) require invasive evaluation of left adrenal glands (LAG) if distant metastases (M1b/1c) are suspected in CT or PET-CT. Only few studies showed utility of endosonography and particularly EUS-b-FNA as minimally invasive endoscopic method of LAG analysis. MATERIAL AND METHODS: A retrospective study of consecutive LCP was conducted in two pulmonology centers between January 2010 and December 2019. Records of complete endosonographic staging with use of single ultrasound bronchoscope or two scopes were overviewed. The analysis included cases of enlarged LAG (body size or limbs > 10 mm) examined and sampled by EUS-b-FNA or EUS-FNA. RESULTS: 142 of 2596 LCP staged by complete endosonography (M: 88, F: 54 mean age 64.7) had enlarged LAG, which were biopsied by conventional EUS-FNA (52) and/or by EUS-b-FNA (90). Strong correlation with gland diameter (P < 0.001) was observed. The incidence of LAG metastases in analyzed group was 52.1% (74/142) and regarding histology: SCLC 76.9% (10/13), adenocarcinoma 66.7% (44/66), NSCLC 56.3% (9/16) and SCC 17.5% (7/40). A specificity and PPV for both methods were 100%. A sensitivity, accuracy and NPV for EUS-FNA were 91.7%, 96.2%, 93.3% and for EUS-b-FNA 88%, 93.3% and 87%, respectively and no significant differences for both methods were noted (P = 0.62, 0.44, 0.35). No severe complications afterall biopsies were observed. A six months clinical follow up included all negative LCP with enlarged LAG. CONCLUSIONS: After our study EUS-b-FNA seems to be a reasonable method of choice for LAG assesssment in LCP.

Diagnostic accuracy of endoscopic ultrasound and intraductal ultrasonography for assessment of ampullary tumors: a meta-analysis.

BACKGROUND: Accurate preoperative assessment of ampullary tumors (ATs) is critical for determining the appropriate treatment. The reported diagnostic accuracy of endoscopic ultrasound (EUS) and intraductal ultrasonography (IDUS) for detecting tumor depth (T-staging) and regional lymph node status (N-staging) varies across studies. METHOD: An electronic search of the MEDLINE and Embase databases was conducted to identify studies that assessed the diagnostic accuracy of EUS and IDUS for ATs. Sensitivities and specificities of eligible studies were summarized using either fixed effects or random-effects model. RESULTS: Twenty-one studies were included in the final analysis. The pooled sensitivity and specificity of EUS were 0.89 and 0.87 for T1, 0.76 and 0.91 for T2, 0.81 and 0.94 for T3 and 0.72 and 0.98 for T4, respectively. For IDUS, estimates from five studies were 0.90 and 0.88 for T1, 0.73 and 0.91 for T2 and 0.79 and 0.97 for T3, respectively. For N-staging, 16 studies using EUS were included with sensitivity and specificity of 0.61 and 0.77, respectively. Moreover, estimates of IDUS for N-staging were 0.61 and 0.92, respectively. CONCLUSION: Our results imply that EUS and IDUS have good diagnostic accuracy for T-staging of ATs. However, the accuracy of EUS or IDUS is less satisfactory for N-staging. More well-designed prospective studies are warranted to confirm our findings.

Randomized trial comparing the 25G and 22G Franseen needles in endoscopic ultrasound-guided tissue acquisition from solid pancreatic masses for adequate histological assessment.

BACKGROUND: The effects of the Franseen needle size in endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) of solid pancreatic masses remain unclear. This study aimed to compare 25G and 22G Franseen needles in terms of adequate tissue acquisition from solid pancreatic masses. METHODS: In this single-center, crossover, randomized noninferiority trial, eligible patients underwent EUS-FNB with both 25G and 22G Franseen needles in a randomized order between November 2018 and August 2020. Tissue specimens from each pass were separately evaluated based on the cellularity scoring system. The primary outcome was the proportion of acquired specimens allowing adequate histological assessment (cellularity score ≥3). A -15% noninferiority margin was assumed. RESULTS: Data from 88 patients were analyzed, which showed malignant and benign lesions in 84 (95.5%) and four (4.5%) patients, respectively. Of the 88 specimens, 62 (70.5%) and 69 (78.4%) acquired using 25G and 22G needles, respectively, allowed adequate histological assessment. The adjusted proportion difference was -6.6% (95% confidence interval -8.8% to -4.5%), indicating noninferiority of the 25G Franseen needle (P < 0.001). The diagnostic accuracies of the 25G and 22G needles were 86.4% and 89.8%, respectively, with no significant difference (P = 0.180). Adverse events occurred in one patient. CONCLUSIONS: The 25G Franseen needle showed a noninferior adequate tissue acquisition and similar diagnostic performance compared to that of the 22G Franseen needle. However, a 15% noninferiority margin was high for clinical use; thus, further consideration is needed (Clinical Trial Registry no. UMIN000034596).

EBUS versus EUS-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial.

BACKGROUND AND OBJECTIVE: Endosonography with intrathoracic nodal sampling is proposed as the single test with the highest granuloma detection rate in suspected sarcoidosis stage I/II. However, most studies have been performed in limited geographical regions. Studies suggest that oesophageal endosonographic nodal sampling has higher diagnostic yield than endobronchial endosonographic nodal sampling, but a head-to-head comparison of both routes has never been performed. METHODS: Global (14 hospitals, nine countries, four continents) randomized clinical trial was conducted in consecutive patients with suspected sarcoidosis stage I/II presenting between May 2015 and August 2017. Using an endobronchial ultrasound (EBUS) scope, patients were randomized to EBUS or endoscopic ultrasound (EUS)-B-guided nodal sampling, and to 22- or 25-G ProCore needle aspiration (2 × 2 factorial design). Granuloma detection rate was the primary study endpoint. Final diagnosis was based on cytology/pathology outcomes and clinical/radiological follow-up at 6 months. RESULTS: A total of 358 patients were randomized: 185 patients to EBUS-transbronchial needle aspiration (EBUS-TBNA) and 173 to EUS-B-fine-needle aspiration (FNA). Final diagnosis was sarcoidosis in 306 patients (86%). Granuloma detection rate was 70% (130/185; 95% CI, 63-76) for EBUS-TBNA and 68% (118/173; 95% CI, 61-75) for EUS-B-FNA (p = 0.67). Sensitivity for diagnosing sarcoidosis was 78% (129/165; 95% CI, 71-84) for EBUS-TBNA and 82% (115/141; 95% CI, 74-87) for EUS-B-FNA (p = 0.46). There was no significant difference between the two needle types in granuloma detection rate or sensitivity. CONCLUSION: Granuloma detection rate of mediastinal/hilar nodes by endosonography in patients with suspected sarcoidosis stage I/II is high and similar for EBUS and EUS-B. These findings imply that both diagnostic tests can be safely and universally used in suspected sarcoidosis patients.

Same day endoscopic retrograde cholangio-pancreatography immediately after endoscopic ultrasound for choledocholithiasis is feasible, safe and cost-effective.

BACKGROUND: Patients with suspected choledocholithiasis should undergo further confirmatory imaging test by endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) before performing definite extraction by endoscopic retrograde cholangiopancreatography (ERCP). Usually, those procedures are performed at a separate session. AIM: The aim of our study is to report the safety, efficacy and cost-effectiveness of same day EUS and ERCP. METHODS: A retrospective study including all patients who underwent EUS and ERCP for choledocholithiasis from 1st January 2020 through 1st January 2021. Patients were categorized into same day EUS and ERCP (group A) and separate day procedures (group B). Univariate descriptive analysis was done to compare between the groups and cost-effectiveness analysis was based on the length of hospitalization. RESULTS: Sixty-one patients (57.5%) underwent same day EUS and ERCP (group A), as compared to 45 patients (42.5%) who had separate sessions (group B). The average ages in groups A and B were 66.1 ± 20.7 years and 65.8 ± 19.3 years, respectively (p = .47). There was no difference in the mean doses of midazolam, propofol and fentanyl in EUS and ERCP examinations in both groups. Notably, group A had a significantly lower hospitalization length as compared to group B (7.4 ± 2.9 vs. 9.7 ± 3.9 days, p = .0003). Consequently, same day EUS and ERCP was associated with a significant cost saving as compared to group B (7680.9$ ± 3071.4$vs 10089.4$±4053.4$, p = .0003), respectively. There was no serious anesthesia related adverse events. CONCLUSION: Same day EUS and ERCP for choledocholithiasis was safe and cost-effective with significant lower hospitalization length.

Lumen-apposing metals stents in advanced endoscopic ultrasound-guided interventions: novel applications, potential complications and radiologic assessment.

Endoscopic ultrasound (EUS)-guided drainage procedures are an increasingly utilized minimally invasive alternative to percutaneous or surgical management strategies, having been shown to decrease recovery time, cost, and duration of hospital stay. The current mainstay of EUS-guided drainage procedures is in pancreatic and peripancreatic collections in pancreatitis. Recent technological advancements and the development of specialized stents have allowed for novel applications in a growing variety of clinical scenarios, including biliary obstruction, cholecystitis and gastrointestinal obstruction. An overview is provided of standard EUS-guided lumen-apposing metal stent (LAMS) management in pancreatic collections, including the expected radiologic findings and appropriate post-treatment sequelae. Relevant parameters to report include presence of a walled-off collection, collection contents, proximity of the target collection to the gastrointestinal lumen, intervening vascular structures or vascular malformations, and presence of regional cystic structures. Novel stent applications in biliary and gastrointestinal drainage are summarized and examples are provided, including choledochoduodenostomy in biliary obstruction, cholecystogastrostomy in cholecystitis, and jejunogastrostomy in focal gastrointestinal obstruction. Finally, a pictorial review of imaging findings of complications including perforation, hemorrhage, displacement, occlusion, migration and mistargeting is provided. Minimally invasive EUS-guided endoluminal stenting is utilized in a growing variety of clinical applications. Radiologist familiarity with common and novel applications of EUS-guided stenting is invaluable in determining suitability for endoscopic management, evaluating treatment response and identifying potential complications.

EUS-guided biliary drainage in patients with distal malignant biliary obstruction requires fewer interventions and has a lower cost compared to ERCP biliary drainage.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage is considered the reference standard in patients with biliary obstruction, but it is not free of complications. EUS-guided biliary drainage (EUS-BD) is considered an alternative in patients with failed ERCP; however, data are scarce as to whether EUS-BD could be considered a first option. OBJECTIVE: The aim of our study was to compare the need for reintervention and cost between ERCP biliary drainage vs. EUS-BD. MATERIAL AND METHODS: We conducted a retrospective and comparative study of patients with distal malignant biliary obstruction with biliary drainage with ERCP + plastic stent (ERCP-PS) vs. ERCP + metal stent (ERCP-MS) vs. EUS-BD. RESULTS: 124 patients were included, divided into three groups: ERCP-PS, 60 (48.3%) patients; ERCP-MS, 40 (32.2%) patients; and EUS-BD, 24 (19.3%) patients. The need for reinterventions (67 vs. 37 vs. 4%, respectively), the number of procedures [3 (1-10) vs. 2 (1-7) vs. 1 (1-2)], and the costs (4550 ± 3130 vs. 5555 ± 3210 vs. 2375 ± 1020 USD) were lower in the EUS-BD group. No differences in terms of complications were detected. CONCLUSION: EUS-BD requires fewer reinterventions and has a lower cost compared to drainage by ERCP with metal or plastic stents.

EUS assessment for intermediate risk of choledocholithiasis after a negative magnetic resonance cholangiopancreatography.

BACKGROUND AND AIMS: Guidelines recommend either EUS or magnetic resonance cholangiopancreatography (MRCP) for intermediate risk of choledocholithiasis. There is a lack of evidence that supports proceeding with EUS if the MRCP is negative and if clinical suspicion still exists. METHODS: This is a retrospective study of all patients who underwent EUS to assess for choledocholithiasis at a tertiary care referral center from July 2013 to October 2019. RESULTS: A total of 593 patients underwent EUS for evaluation for choledocholithiasis. Of the 593 patients, 35.2% (209/593) had an MRCP. 73.2% (153/209) had a negative MRCP while 26.8% (56/209) had a positive MRCP. Of the group of patients who underwent EUS with a negative MRCP, 15% (23/153) were positive for choledocholithiasis on EUS. Of these, 91% (21/23) were also positive for sludge or stones on endoscopic retrograde cholangiopancreatography and thus 14% (21/153) of the EUS were "true positives." There were no clinical or laboratory factors predictive of choledocholithiasis on univariate analysis in the EUS plus negative MRCP group. When further analyzing the MRCP negative group into MRCP-/EUS+ and MRCP-/EUS-subgroups, a total bilirubin >3 mg/dL predicted a bile duct stone (55% vs. 32%, P = 0.05). CONCLUSION: The diagnostic yield of EUS for suspected choledocholithiasis in the setting of a negative MRCP is 14% in our cohort. EUS should be considered in patients with intermediate risk of choledocholithiasis with a negative MRCP if the clinical suspicion is still present, and especially if the total bilirubin is above 3 mg/dL.

Assessment of preoperative pancreatic biopsy, cytological/histological review of cell-block-specimens obtained by endoscopic ultrasound-guided fine-needle aspiration: Laboratory-based study.

BACKGROUND: Pancreatic cancer is among the most lethal cancers worldwide due to the limited availability of techniques for early detection of signs and symptoms. Reportedly, it is the fourth-leading cause of cancer-related mortality among Japanese adults. With the advent of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosing pancreatic cancer, the rate of the cytological and histological diagnoses of cell-block-specimens has significantly increased in Japan. METHODS: The cytological specimens of 165 patients with pancreatic lesions obtained using EUS-FNA between January 2010 and July 2016 at the Kyorin University Hospital were investigated. The clinical course of 153 patients was assessed from their clinical records, which included information on their imaging diagnosis, laboratory data, final clinical diagnosis and treatment; moreover, the accuracy of the cytological/histological examination and clinical diagnosis at our hospital were analysed. RESULTS: The number of cells in cell-block-specimens was too small to estimate data. However, cytological specimens were sufficient to observe the findings of suspected malignancy such as necrosis. Biopsy was deemed necessary for diagnosis using both histological and cytological specimens. CONCLUSION: EUS-FNA can be used not only to diagnose benign or malignant types of pancreatic cancers but also to assess the sensitivity of molecular target drugs and chemotherapy methods. Therefore, both histological and cytological diagnoses are required to enhance diagnostic precision both in our hospital and at other institutions.

The implementation of European Union (EU) rules on cross-border care: moving towards convergence?

This article studies the implementation of the European Union (EU)'s Patients' Rights Directive in Germany and Norway. The objective of the Directive was to allow EU member states to have a say in the regulatory work, ensure predictability and uniformity in the application of EU rules on cross-border care, and enhance a move towards EU harmonisation in this area. So far, the implementation processes in Norway and Germany have mixed results regarding the likelihood of achieving uniformity and harmonisation. Although the Directive has had convergent effects on certain areas of cross-border care, such as setting up National Contact Points and providing patients with the basic right to treatment abroad, implementation also shows divergent patterns. In both countries, adapting to EU rules has strengthened patients' rights to choose freely among health-service providers in a wider European health-service market. However, due to legal discretion and country-specific institutions within which the new rules are applied, divergent patterns prevail.

Endoscopic ultrasound staging in patients with gastro-oesophageal cancers: a systematic review of economic evidence.

BACKGROUND: The sensitivity of endoscopic ultrasound (EUS) in staging gastro-oesophageal cancers (GOCs) has been widely studied. However, the economic evidence of EUS staging in the management of patients with GOCs is scarce. This review aimed to examine all economic evidence (not limited to randomised controlled trials) of the use of EUS staging in the management of GOCs patients, and to offer a review of economic evidence on the costs, benefits (in terms of GOCs patients' health-related quality of life), and economic implications of the use of EUS in staging GOCs patients. METHODS: The protocol was registered prospectively with PROSPERO (CRD42016043700; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016043700 ). MEDLINE (ovid), EMBASE (ovid), The Cochrane Collaboration Register and Library (including the British National Health Service Economic Evaluation Database), CINAHL (EBSCOhost) and Web of Science (Core Collection) as well as reference lists were systematically searched for studies conducted between 1996 and 2018 (search update 28/04/2018). Two authors independently screened the identified articles, assessed study quality, and extracted data. Study characteristics of the included articles, including incremental cost-effectiveness ratios, when available, were summarised narratively. RESULTS: Of the 197 articles retrieved, six studies met the inclusion criteria: three economic studies and three economic modelling studies. Of the three economic studies, one was a cost-effectiveness analysis and two were cost analyses. Of the three economic modelling studies, one was a cost-effectiveness analysis and two were cost-minimisation analyses. Both of the cost-effectiveness analyses reported that use of EUS as an additional staging technique provided, on average, more QALYs (0.0019-0.1969 more QALYs) and saved costs (by £1969-£3364 per patient, 2017 price year) compared to staging strategy without EUS. Of the six studies, only one included GOCs participants and the other five included oesophageal cancer participants. CONCLUSIONS: The data available suggest use of EUS as a complementary staging technique to other staging techniques for GOCs appears to be cost saving and offers greater QALYs. Nevertheless, future studies are necessary because the economic evidence around this EUS staging intervention for GOCs is far from robust. More health economic research and good quality data are needed to judge the economic benefits of EUS staging for GOCs. PROSPERO REGISTRATION NUMBER: CRD42016043700 .