Endohepatology: The endoscopic armamentarium in the hand of the hepatologist.

ABSTRACT: Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.

Protocol for a randomized controlled trial of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN) with vs without bupivacaine.

BACKGROUND: Pancreatic cancer is a devastating disease with less than 5% 5-year survival. Inoperable patients often present with pain. Randomized controlled trial have shown that endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) improves pain control. It is usually performed by injecting bupivacaine followed by absolute alcohol around the celiac axis. STUDY DESIGN: Single center, randomized, double blind controlled trial of EUS-CPN with and without bupivacaine in patients with inoperable malignancy (pancreatic or other) involving the celiac plexus. The study was approved by research ethics board with approval number of 2022-9969, 21.151 and registered on ClinicalTrials.gov (NCT04951804). DISCUSSION: We hypothesize that bupivacaine is superfluous and may actually reduce pain control by diluting the neurolytic effect of alcohol. Bupivacaine is also potentially dangerous in that it may produce serious adverse events such as arrythmias and cardiac arrest if inadvertently injected intravascularly. CONCLUSION: This randomized trial is designed to assess whether bupivacaine is of any value during EUS-CPN.

Safety and clinical efficacy of EUS-guided pelvic abscess drainage.

Background and Objectives: EUS is a potential alternative for the drainage of abscesses. The aim of this study was to determine if EUS-guided pelvic abscess drainage is technically feasible, safe, and a valid option for abscess resolution. Methods: We conducted a retrospective review from 2002 to 2020 at a single quaternary institution. EUS-guided pelvic abscess drainage via the transrectal route was performed in all patients with or without drain/stent placement. Technical and clinical success of EUS-guided pelvic abscess drainage was analyzed. Descriptive analyses and Fisher exact test were performed. Results: Sixty consecutive patients were included in the study (53.5% male; mean age, 53.8 ± 17.9 years). Pelvic abscesses occurred mainly postoperatively (33 cases; 60.0%) and from complicated diverticulitis (14 cases; 23.3%). Mean diameter was 6.5 ± 2.4 cm (80% unilocular). Drainage was performed with EUS-guided stent placement (double-pigtail plastic or lumen-apposing metal) in 74.5% of cases and with aspiration alone for the remainder. Technical success occurred in 58 cases (97%). Of those with long-term follow-up after EUS-guided pelvic abscess drainage (n = 55; 91.7%), complete abscess resolution occurred in 72.7% of all cases. Recurrence occurred in 8 cases (14.5%) and persisted in 7 patients (12.5%), 7 of which were successfully retreated with EUS-guided pelvic abscess drainage. Accounting for these successful reinterventions, the overall rate of abscess resolution was 85.5%. Abscess resolution rate improved with drain placement (83%). Accounting for 7 repeat EUS-guided pelvic abscess drainages, overall abscess resolution improved. Two deaths occurred (3.4%) because of sepsis from failed source control in patients who had previously failed medical, radiological, and surgical treatment. Conclusions: EUS-guided pelvic abscess drainage is technically feasible, safe, and an effective alternative to radiological or open surgical drainage. It also offers favorable clinical outcomes in different clinical situations.

Endoscopic Ultrasound Guided Fine Needle Aspiration versus Endoscopic Ultrasound Guided Fine Needle Biopsy for Pancreatic Cancer Diagnosis: A Systematic Review and Meta-Analysis.

INTRODUCTION: One of the most effective diagnostic tools for pancreatic cancer is endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or biopsy (EUS-FNB). Several randomized clinical trials have compared different EUS tissue sampling needles for the diagnosis of pancreatic cancer. OBJECTIVE: To compare the diagnostic accuracy of EUS-guided FNA as EUS-FNB needles for the diagnosis of pancreatic cancer using a systematic review and meta-analysis. METHOD: A literature review with a meta-analysis was performed according to the PRISMA guide. The databases of PubMed, Cochrane and Google Scholar were used, including studies published between 2011-2021 comparing the diagnostic yield (diagnostic accuracy or probability of positivity, sensitivity, specificity, predictive value) of EUS-FNA and EUS-FNB for the diagnosis of pancreatic cancer. The primary outcome was diagnostic accuracy. Random effect models allowed estimation of the pooled odds ratio with a confidence interval (CI) of 95%. RESULTS: Nine randomized control trials were selected out of 5802 articles identified. Among these, five studies found no statistically significant difference between the EUS-FNA and EUS-FNB, whereas the other four did. The meta-analysis found EUS-FNB accuracy superior to EUS-FNA for the diagnosis of pancreatic cancer with a pooled odds ratio of 1.87 (IC 95%: 1.33-2.63). CONCLUSION: As compared to EUS-FNA, EUS-FNB seems to improve diagnostic accuracy when applied to suspicious pancreatic lesions.

EUS-guided celiac plexus neurolysis for pancreas cancer - Finally established or still under review?

Patients with pancreas cancer must deal frequently with intractable and refractory pain. Endoscopic ultrasound guided-celiac plexus neurolysis (EUS-CPN) has been the most studied and used therapeutic technique aimed to destroy the pain fibres that allow the pancreas to communicate with the central nervous system. A neurolytic agent, most commonly ethanol, is optimally spread around the celiac axis in order to reduce pain and mitigate narcotic requirements. This can be performed early to prevent the spiral of pain and medication use, or more historically as salvage therapy. Different techniques to best administer the ethanol for effective EUS-CPN are still being debated. New EUS-guided injection techniques with radiofrequency, radioactive, and/or chemotherapeutic agents need more study.

Controversies in EUS: Do we need miniprobes?

This is the fifth in a series of papers entitled "Controversies in EUS." In the current paper, we deal with high-resolution catheter probes, otherwise known as EUS miniprobes (EUS-MPs). The application of miniprobes for early carcinomas in the entire intestinal tract, for subepithelial lesions, and for findings in the bile duct and pancreatic duct as well as endobronchial use is critically discussed. Submucous lesions, especially in the colon, but also early carcinomas in special cases are considered the most important indications. The argument is illustrated by numerous examples.

Standard reporting elements for the performance of EUS: Recommendations from the FOCUS working group.

BACKGROUND AND OBJECTIVES: Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. To support the incorporation of these indicators and standardize EUS documentation, we propose standard EUS reporting elements for endosonographers and endoscopy units. METHODS: A comprehensive literature search and review was performed to identify EUS quality indicators and key components of high-quality standardized EUS reporting. Guidance statements regarding standard EUS reporting elements were developed and reviewed at the Forum for Canadian Endoscopic Ultrasound (FOCUS) 2019 Annual Meeting. RESULTS: EUS reporting elements can be divided into preprocedural, intraprocedural, and postprocedural items. Preprocedural components include the type, indication, and urgency of the procedure and patient clinical information and consent. Intraprocedural components include the adequacy and extent of examination, relevant landmarks, lesion characteristics, sampling method, specimen quality, and intraprocedural adverse events. Postprocedural components include a summary and synthesis of relevant findings as well as recommended management and follow-up. CONCLUSIONS: Standardizing reporting elements may help improve the care of patients undergoing EUS procedures. Our review provides a practical guide and compilation of recommended reporting elements to ensure ongoing best practices and quality improvement in EUS.

A randomized noninferiority trial comparing the diagnostic yield of the 25G ProCore needle to the standard 25G needle in suspicious pancreatic lesions.

BACKGROUND AND OBJECTIVES: The aim of the study was to perform the first randomized trial comparing the diagnostic yield, bloodiness, and cellularity of the 25G standard needle (25S) and the 25G ProCore™ needle (25P). MATERIALS AND METHODS: All patients referred to the tertiary care referral center for EUS guided fine-needle aspiration (EUS-FNA) of suspicious solid pancreatic lesions were eligible. EUS-FNA was performed in each lesion with both 25S and 25P needles (the choice of the first needle was randomized), using a multipass sampling pattern, without stylet or suction. Rapid on-site evaluation was used when possible. Pap-stained slides were read by a single experienced cytopathologist, blinded to the needle type. RESULTS: One hundred and forty-three patients were recruited. Samples were positive for cancer in 122/143 (85.3%) with the 25S needle versus 126/143 (88.1%) with the 25P needle, negative in 17/143 (11.9%) with the 25S needle versus 13/143 (9.1%) with the 25P needle, and suspicious in 4/143 (2.8%) with each needle. There was no difference in any outcome based on the type of the first needle. No carryover effect was detected (P = 0.214; NS). Cumulative logistic regression analyses showed no associations between the type of needle and diagnostic yield for cancer, cellularity, or bloodiness. The difference in the yield for cancer was 2.9% (-4.2; 10.1%); with the confidence interval upper within the predetermined noninferiority margin of 15%. CONCLUSION: The 25S needle is noninferior to the 25P needle for diagnosing cancer in suspicious pancreatic lesions.

An international, multi-institution survey on performing EUS-FNA and fine needle biopsy.

BACKGROUND AND OBJECTIVES: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and fine needle biopsy (FNB) are effective techniques that are widely used for tissue acquisition. However, it remains unclear how to obtain high-quality specimens. Therefore, we conducted a survey of EUS-FNA and FNB techniques to determine practice patterns worldwide and to develop strong recommendations based on the experience of experts in the field. METHODS: This was a worldwide multi-institutional survey among members of the International Society of EUS Task Force (ISEUS-TF). The survey was administered by E-mail through the SurveyMonkey website. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Another questionnaire about the level of recommendation was designed to assess the respondents' answers. RESULTS: ISEUS-TF members developed a questionnaire containing 17 questions that was sent to 53 experts. Thirty-five experts completed the survey within the specified period. Among them, 40% and 54.3% performed 50-200 and more than 200 EUS sampling procedures annually, respectively. Some practice patterns regarding FNA/FNB were recommended. CONCLUSION: This is the first worldwide survey of EUS-FNA and FNB practice patterns. The results showed wide variations in practice patterns. Randomized studies are urgently needed to establish the best approach for optimizing the FNA/FNB procedures.

How to perform EUS-guided tattooing?

Recently, we introduced a series of papers describing on how to perform certain techniques and controversies in EUS. In the first paper, "What should be known before performing EUS examinations, Part I," the authors discussed clinical information and whether other imaging modalities should be needed before embarking in EUS examination. In Part II, some technical controversies on how EUS is performed are discussed from different points of view by providing the relevant available evidence. Herewith, we describe on how to perform EUS-guided fine needle tattooing (FNT) in daily practice. The aim of this paper is to discuss pros and cons for several issues including historical remarks, injecting material, technical approach, and how to perform EUS-FNT including argues in favor and against.

Do we need elastography for EUS?

We recently introduced a series of papers "What should be known prior to performing EUS exams." In Part I, the authors discussed which clinical information and whether other imaging modalities are needed before embarking EUS examinations. In Part II, technical controversies on how EUS is performed were discussed from different points of view. In this article, important practical issues regarding EUS elastography will be raised and controversially discussed from very different points of view.

Do we need contrast agents for EUS?

We recently introduced a series of articles that dealt with controversies in EUS. In Part I, the authors discussed which clinical information is necessary prior to EUS and whether other imaging modalities are required before embarking on EUS examinations. Part II focuses on technical details and controversies about the use of EUS in special situations. In this article, important practical issues regarding the application of contrast-enhanced EUS in various clinical settings are raised and controversially discussed from different points of view.

A proposal for the ideal algorithm for the diagnosis, staging, and treatment of pancreas masses suspicious for pancreatic adenocarcinoma: Results of a working group of the Canadian Society for Endoscopic Ultrasound.

Numerous clinical pathways exist for patients presenting with a suspicious pancreatic mass. These range from direct surgical intervention following staging, with preoperative cross-sectional imaging, EUS with or without fine-needle aspiration or fine-needle core biopsy; neoadjuvant chemotherapy and/or radiation therapy; or palliation. Although international guidelines exist for pancreas cancer management, the ideal workup and treatment for a suspicious pancreas mass is unclear. During its annual meeting in September 2017 (The Forum for Canadian Endoscopic Ultrasonography), the Canadian Society of Endoscopic Ultrasound organized a working group of experienced endosonographers and hepatobiliary surgeons from across Canada to achieve this goal.

What should be known prior to performing EUS exams? (Part II).

In "What should be known prior to performing EUS exams, Part I," the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?

An assessment of the yield of EUS in patients referred for dilated common bile duct and normal liver function tests.

OBJECTIVE: This study aims to determine the yield of EUS in patients with common bile duct (CBD) dilation and normal liver function tests (LFTs). MATERIALS AND METHODS: Between October 2000 and December 2016, all patients referred for EUS for unexplained CBD dilatation (CBD ≥7 mm), with normal aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin and no history of sphincterotomy, were eligible. Linear-array EUS was performed by one of the two experienced endosonographers. Data were extracted from a prospectively maintained database. RESULTS: Of 29,920 upper gastrointestinal EUS procedures performed, 840/29,920 (3%) were for unexplained CBD dilation. Of 840 patients, 199 (24%) had normal LFTs, 99% were Caucasian, 46% had biliary-type abdominal pain, and 41% were postcholecystectomy. EUS diagnosed choledocholithiasis (CDL) or sludge in 18/199 (9%) patients (7/18 had CBD sludge only). No other pathology was diagnosed. Of 18 CDL patients, 15 (83%) had an intact gallbladder, and all 15 patients had cholelithiasis. The frequency of CDL or sludge in postcholecystectomy patients was only 3.7% (3/82); none of these patients were younger than 69 years of age. Regression analyses showed no associations between EUS diagnosis of CDL or sludge and biliary-type abdominal pain, other symptoms, sex, or race. Each additional year of age was associated with an increase in the risk of CDL or sludge by a factor of 1.05 (odds ratio: 1.05; P = 0.034). SUMMARY: In patients with CBD dilation and normal LFTs, the only significant pathology identified is CBD stones or sludge (almost exclusively in elderly patients with cholelithiasis). CONCLUSION: EUS should be avoided in patients with dilated bile ducts and normal LFTs, especially if under 65 years of age and postcholecystectomy.