Endoscopic resection in subepithelial lesions of the upper gastrointestinal tract: Experience at a tertiary referral hospital in The Netherlands.

Background and study aims Histological confirmation of subepithelial lesions (SELs) in the upper gastrointestinal tract remains challenging. Endoscopic resection of SELs is increasingly used for its excellent diagnostic yield and opportunity to do away with continued surveillance. In this study, we aimed to evaluate the indications, success rates and complications of different endoscopic resection techniques for SELs at a large, tertiary referral hospital in Rotterdam, The Netherlands. Patients and methods Data between October 2013 and December 2021 were retrospectively collected and analyzed. Main outcomes were R0-resection rate, en bloc resection rate, recurrence rate, and procedure-related adverse events (AEs) (Clavien-Dindo). Secondary outcomes were procedure time, need for surgical intervention, and clinical impact on patient management. Results A total of 58 patients were referred for endoscopic resection of upper gastrointestinal SELs. The median diameter of lesions was 20 mm (range 7-100 mm). Median follow-up time was 5 months (range 0.4-75.7). Forty-eight procedures (83%) were completed successfully leading to en bloc resection in 85% and R0-resection in 63%. Procedure-related AEs occurred in six patients (13%). Severe complications (CD grade 3a) were seen in three patients. The local recurrence rate for (pre)malignant diagnosis was 2%. Additional surgical intervention was needed in seven patients (15%). A total of 32 patients (67%) could be discharged from further surveillance after endoscopic resection. Conclusions Endoscopic resection is a safe and effective treatment for SELs and offers valuable information about undetermined SELs for which repeated sampling attempts have failed to provide adequate tissue for diagnosis.

Comparison of stent patency between EUS-guided hepaticogastrostomy with bridging and endoscopic transpapillary biliary drainage for hilar obstruction.

Background and study aims Endoscopic ultrasound-guided hepaticogastrostomy with bridging between the left and right bile ducts is an alternative to endoscopic transpapillary drainage for malignant hilar biliary obstruction. We aimed to analyze the long-term stent patency of endoscopic ultrasound-guided hepaticogastrostomy with bridging. Patients and methods Patients who underwent endoscopic ultrasound-guided hepaticogastrostomy with bridging between April 2018 and July 2023 were retrospectively analyzed. We retrospectively compared the stent patency of these patients with that of the individuals who underwent endoscopic transpapillary drainage-multi-stenting using unmatched (entire) and propensity score-matched cohorts. Results Endoscopic ultrasound-guided hepaticogastrostomy with bridging had a technical success rate of 90% (18/20). Adverse events were minimal. The number of clinical success cases was 17 and 82 for endoscopic ultrasound-guided hepaticogastrostomy with bridging using metallic stent and endoscopic transpapillary drainage-multi-stenting, respectively. The recurrent biliary obstruction rate was 17.6% and 58.5% for endoscopic ultrasound-guided hepaticogastrostomy with bridging and endoscopic transpapillary drainage-multi-stenting, respectively; the median time to recurrent biliary obstruction (days) was significantly longer for endoscopic ultrasound-guided hepaticogastrostomy with bridging in the entire (not reached vs. 104, P =0.03) and propensity score-matched (183 vs. 79, P =0.05) cohorts. The non-recurrent biliary obstruction rate for endoscopic ultrasound-guided hepaticogastrostomy with bridging was 91.6% at 3 and 6 months and 57% at 12 months. Multivariate analyses revealed that endoscopic ultrasound-guided hepaticogastrostomy with bridging contributed to a lower recurrent biliary obstruction incidence (hazard ratio, 0.31, P =0.05) without significant difference. Conclusions Stent patency was significantly better for endoscopic ultrasound-guided hepaticogastrostomy with bridging. However, future prospective studies are needed.

EUS-guided hydrogel injection to separate pancreatic head carcinoma from duodenum for enhanced radiotherapy: Multi-site feasibility study.

Background and study aims The proximity of a pancreas head tumor to the duodenum often limits delivery of an ablative dose of radiation therapy. This study evaluated the feasibility and safety of using an injectable polyethylene glycol (PEG) hydrogel between the head of the pancreas and duodenum. Patients and methods In a multi-site feasibility cohort study of patients with localized pancreatic cancer, PEG hydrogel was injected under endoscopic ultrasound guidance to temporarily position the duodenum away from the pancreas. Procedure characteristics were recorded, including hydrogel volume and space created. Patients were monitored for adverse events (AEs) and radiotherapy toxicity. Results In all six intent-to-treat patients (four with borderline resectable, two with locally advanced disease), the ability to place and visualize PEG hydrogel and create space between the duodenum and the head of the pancreas was successful. There were no procedure-related AEs resulting in radiotherapy delay. There were no device-related AEs and no reports of pancreatitis. Conclusions PEG hydrogel was successfully placed, created space between the duodenum and the head of the pancreas, and was not associated with major toxicity. Enhancing radiotherapy for pancreatic cancer by using PEG hydrogel to create peri-duodenal space could have beneficial implications for treatment and warrants more exploration.

[Endoscopic ultrasound-guided liver biopsy: current status and prospects].

Liver biopsy is an important means of clinical diagnosis and treatment of liver diseases, but it is not easily accepted by patients because of its invasiveness. The most commonly employed liver biopsy approaches are percutaneous or transjugular. Endoscopic ultrasound-guided liver biopsy (EUS-LB), a newly emerging transjugular technique, has been widely studied and applied in recent years, but its application in China is less common. The EUS-LB has the advantages of high safety and comfort, simultaneous sampling of both liver lobes, and adequate sampling volume; however, it also has the disadvantages of high requirements for hardware, operators, and cost. This article reviews the clinical application of EUS-LB in accordance with pertinent research findings from recent years and discusses its advantages, disadvantages, and implementation feasibility.

Endoscopic ultrasonography-based intratumoral and peritumoral machine learning radiomics analyses for distinguishing insulinomas from non-functional pancreatic neuroendocrine tumors.

Objectives: To develop and validate radiomics models utilizing endoscopic ultrasonography (EUS) images to distinguish insulinomas from non-functional pancreatic neuroendocrine tumors (NF-PNETs). Methods: A total of 106 patients, comprising 61 with insulinomas and 45 with NF-PNETs, were included in this study. The patients were randomly assigned to either the training or test cohort. Radiomics features were extracted from both the intratumoral and peritumoral regions, respectively. Six machine learning algorithms were utilized to train intratumoral prediction models, using only the nonzero coefficient features. The researchers identified the most effective intratumoral radiomics model and subsequently employed it to develop peritumoral and combined radiomics models. Finally, a predictive nomogram for insulinomas was constructed and assessed. Results: A total of 107 radiomics features were extracted based on EUS, and only features with nonzero coefficients were retained. Among the six intratumoral radiomics models, the light gradient boosting machine (LightGBM) model demonstrated superior performance. Furthermore, a peritumoral radiomics model was established and evaluated. The combined model, integrating both the intratumoral and peritumoral radiomics features, exhibited a comparable performance in the training cohort (AUC=0.876) and achieved the highest accuracy in predicting outcomes in the test cohorts (AUC=0.835). The Delong test, calibration curves, and decision curve analysis (DCA) were employed to validate these findings. Insulinomas exhibited a significantly smaller diameter compared to NF-PNETs. Finally, the nomogram, incorporating diameter and radiomics signature, was constructed and assessed, which owned superior performance in both the training (AUC=0.929) and test (AUC=0.913) cohorts. Conclusion: A novel and impactful radiomics model and nomogram were developed and validated for the accurate differentiation of NF-PNETs and insulinomas utilizing EUS images.

Multiple intraductal papillary neoplasms of bile duct diagnosed based on endoscopic ultrasonography and peroral cholangioscopy findings.

A man in his 30s was referred to our department for evaluation of bile duct stricture and removal of an intrahepatic bile duct stone. Five years before his presentation, he underwent left hepatectomy for a giant hepatic hemangioma. There were no abnormalities in blood biochemical tests. Magnetic resonance cholangiopancreatography showed one 5 mm oval defect in region B6 and two 8 mm semicircular defects in the hilar bile duct. Endoscopic ultrasound revealed a 3.5 mm hypoechoic focal raised lesion in the hilar bile duct. Oral cholangioscopy revealed his two lesions in the hilar bile duct as white papillary elevations with mucus production. The pathological diagnosis of intraductal papillary neoplasm was determined (low-grade dysplasia, type 1, gastric type). After 1 and a half years, no expansion of the bile duct lesion was observed. Initially, it was thought to be a benign stenosis after liver resection, but based on the results of endoscopic ultrasound, we suspected a tumorous lesion, and we were able to make an accurate diagnosis, including histological type, using transoral cholangioscopy.

Role of endoscopy in eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease involving inflammation of the esophagus. Endoscopy is essential in the diagnosis and treatment of EoE and shows typical findings, including esophageal edema, rings, exudates, furrows, and stenosis. However, studies involving pediatric and adult patients with EoE suggest that even a normally appearing esophagus can be diagnosed as EoE by endoscopic biopsy. Therefore, in patients with suspected EoE, biopsy samples should be obtained from the esophagus regardless of endoscopic appearance. Moreover, follow-up endoscopies with biopsy after therapy initiation are usually recommended to assess response. Although previous reports of endoscopic ultrasonography findings in patients with EoE have shown diffuse thickening of the esophageal wall, including lamina propria, submucosa, and muscularis propria, its role in EoE remains uncertain and requires further investigation. Endoscopic dilation or bougienage is a safe and effective procedure that can be used in combination with medical and/or dietary elimination therapy in patients with esophageal stricture for the management of dysphagia and to prevent its recurrence.

Diagnostic Assessment of Endoscopic Ultrasonography-Fine Needle Aspiration Cytology in the Pancreas: A Comparison between Liquid-Based Preparation and Conventional Smear.

Background and Objectives: This study aimed to elucidate the cytologic characteristics and diagnostic usefulness of endoscopic ultrasonography-fine needle aspiration cytology (EUS-FNAC) by comparing it with liquid-based preparation (LBP) and conventional smear (CS) in pancreas. Methods: The diagnostic categories (I through VII) were classified according to the World Health Organization Reporting System for Pancreaticobiliary Cytopathology. Ten cytologic features, including nuclear and additional features, were evaluated in 53 cases subjected to EUS-FNAC. Nuclear features comprised irregular nuclear contours, nuclear enlargement, hypochromatic nuclei with parachromatin clearing, and nucleoli. Additional cellular features included isolated atypical cells, mucinous cytoplasm, drunken honeycomb architecture, mitosis, necrotic background, and cellularity. A decision tree analysis was conducted to assess diagnostic efficacy. Results: The diagnostic concordance rate between LBP and CS was 49.1% (26 out of 53 cases). No significant differences in nuclear features were observed between categories III (atypical), VI (suspicious for malignancy), and VII (malignant). The decision tree analysis of LBP indicated that cases with moderate or high cellularity and mitosis could be considered diagnostic for those exhibiting nuclear atypia. Furthermore, in CS, mitosis, isolated atypical cells, and necrotic background exerted a more significant impact on the diagnosis of EUS-FNAC. Conclusions: Significant parameters for interpreting EUS-FNAC may differ between LBP and CS. While nuclear atypia did not influence the diagnosis of categories III, VI, and VII, other cytopathologic features, such as cellularity, mitosis, and necrotic background, may present challenges in diagnosing EUS-FNAC.

SSM-Net: Semi-supervised multi-task network for joint lesion segmentation and classification from pancreatic EUS images.

Pancreatic cancer does not show specific symptoms, which makes the diagnosis of early stages difficult with established image-based screening methods and therefore has the worst prognosis among all cancers. Although endoscopic ultrasonography (EUS) has a key role in diagnostic algorithms for pancreatic diseases, B-mode imaging of the pancreas can be affected by confounders such as chronic pancreatitis, which can make both pancreatic lesion segmentation and classification laborious and highly specialized. To address these challenges, this work proposes a semi-supervised multi-task network (SSM-Net) to leverage unlabeled and labeled EUS images for joint pancreatic lesion classification and segmentation. Specifically, we first devise a saliency-aware representation learning module (SRLM) on a large number of unlabeled images to train a feature extraction encoder network for labeled images by computing a contrastive loss with a semantic saliency map, which is obtained by our spectral residual module (SRM). Moreover, for labeled EUS images, we devise channel attention blocks (CABs) to refine the features extracted from the pre-trained encoder on unlabeled images for segmenting lesions, and then devise a merged global attention module (MGAM) and a feature similarity loss (FSL) for obtaining a lesion classification result. We collect a large-scale EUS-based pancreas image dataset (LS-EUSPI) consisting of 9,555 pathologically proven labeled EUS images (499 patients from four categories) and 15,500 unlabeled EUS images. Experimental results on the LS-EUSPI dataset and a public thyroid gland lesion dataset show that our SSM-Net clearly outperforms state-of-the-art methods.

Controversies in endoscopic ultrasonography-guided management of walled-off necrosis.

Walled-off necrosis (WON) develops as local complications after acute necrotizing pancreatitis. Although less invasive interventions such as endoscopic ultrasonography (EUS)-guided drainage and endoscopic necrosectomy are selected over surgical interventions, delayed and step-up interventions are still preferred to avoid procedure-related adverse events. However, there is a controversy about the appropriate timing of drainage and subsequent necrosectomy. The advent of large-caliber lumen-apposing metal stents has also brought about potential advantages of proactive interventions, which still needs investigation in future trials. When step-up interventions of necrosectomy and additional drainage are necessary, a structured or protocoled approach for WON has been reported to improve safety and effectiveness of endoscopic and/or percutaneous treatment, but has not been standardized yet. Finally, long-term outcomes such as recurrence of WON, pancreatic endocrine, and exocrine function are increasingly investigated in association with disconnected pancreatic duct syndrome. In this review we discuss current evidence and controversy on EUS-guided management of WON.

Construction and validation of an endoscopic ultrasonography-based ultrasomics nomogram for differentiating pancreatic neuroendocrine tumors from pancreatic cancer.

Objectives: To develop and validate various ultrasomics models based on endoscopic ultrasonography (EUS) for retrospective differentiating pancreatic neuroendocrine tumors (PNET) from pancreatic cancer. Methods: A total of 231 patients, comprising 127 with pancreatic cancer and 104 with PNET, were retrospectively enrolled. These patients were randomly divided into either a training or test cohort at a ratio of 7:3. Ultrasomics features were extracted from conventional EUS images, focusing on delineating the region of interest (ROI) for pancreatic lesions. Subsequently, dimensionality reduction of the ultrasomics features was performed by applying the Mann-Whitney test and least absolute shrinkage and selection operator (LASSO) algorithm. Eight machine learning algorithms, namely logistic regression (LR), light gradient boosting machine (LightGBM), multilayer perceptron (MLP), random forest (RF), extra trees, k nearest neighbors (KNN), support vector machine (SVM), and extreme gradient boosting (XGBoost), were employed to train prediction models using nonzero coefficient features. The optimal ultrasomics model was determined using a ROC curve and utilized for subsequent analysis. Clinical-ultrasonic features were assessed using both univariate and multivariate logistic regression. An ultrasomics nomogram model, integrating both ultrasomics and clinical-ultrasonic features, was developed. Results: A total of 107 EUS-based ultrasomics features were extracted, and 6 features with nonzero coefficients were ultimately retained. Among the eight ultrasomics models based on machine learning algorithms, the RF model exhibited superior performance with an AUC= 0.999 (95% CI 0.9977 - 1.0000) in the training cohort and an AUC= 0.649 (95% CI 0.5215 - 0.7760) in the test cohort. A clinical-ultrasonic model was established and evaluated, yielding an AUC of 0.999 (95% CI 0.9961 - 1.0000) in the training cohort and 0.847 (95% CI 0.7543 - 0.9391) in the test cohort. Subsequently, the ultrasomics nomogram demonstrated a significant improvement in prediction accuracy in the test cohort, as evidenced by an AUC of 0.884 (95% CI 0.8047 - 0.9635) and confirmed by the Delong test. The calibration curve and decision curve analysis (DCA) depicted this ultrasomics nomogram demonstrated superior accuracy. They also yielded the highest net benefit for clinical decision-making compared to alternative models. Conclusions: A novel ultrasomics nomogram was proposed and validated, that integrated clinical-ultrasonic and ultrasomics features obtained through EUS, aiming to accurately and efficiently identify pancreatic cancer and PNET.

Utility of Contrast-Enhanced Harmonic Endoscopic Ultrasonography to Diagnose Pancreaticobiliary Maljunction.

BACKGROUND: Detection of a common channel outside the duodenal wall is important in diagnosing pancreaticobiliary maljunction (PBM). The present study evaluated the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) in diagnosing PBM. METHODS: This single-center retrospective study enrolled 45 patients who were diagnosed with PBM or high confluence of pancreatobiliary ducts (HCPBD) between January 2007 and December 2021. The diagnostic sensitivities of contrast-enhanced computed tomography (CE-CT), magnetic resonance imaging (MRI), and CH-EUS for diagnosing PBM were analyzed. Imaging findings were evaluated by two reviewers blinded to the clinicopathological results. RESULTS: Based on diagnostic criteria, 33 patients were diagnosed with PBM and 12 with HCPBD. Compared with the patients with HCPBD, those with PBM had significantly longer common channel (12.5 mm vs. 8.1 mm, P = 0.018) and common bile duct (13.0 mm vs. 8.6 mm, P = 0.049) lengths. The κ-coefficients for differentiating PBM and HCPBD were 0.871 between CE-CT and MRI, 0.330 between CE-CT and CH-EUS, and 0.611 between MRI and CH-EUS. The diagnostic sensitivity of CH-EUS (95.2%) was higher than that of CE-CT (83.3%) and MRI (82.8%), although the differences were not statistically significant. CONCLUSION: CH-EUS may be useful for the diagnosis of PBM.

Endoscopic ultrasound-guided fine-needle aspiration in the diagnostic value of focal liver lesions: A systematic analysis of 88 cases (with video).

BACKGROUND AND AIMS: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions in the gastrointestinal tract and adjacent organs. Our study aimed to evaluate the safety and effectiveness of EUS-FNA in focal liver lesions (FLLs). METHOD: Data from 88 patients diagnosed with FLLs by imaging who underwent EUS-FNA from 1 January 2017 to 31 August 2022 were reviewed in our retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of the School of Medicine of Shanghai Jiao Tong University. The EUS-FNA biopsy results were compared with the final diagnosis to evaluate diagnostic value. The relevant factors were analysed to determine their influence on EUS-FNA biopsy results. RESULTS: The 88 patients analysed in this study resulted in a final diagnosis of 86 malignant and two benign cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18 % (82/88; 95 % Confidence Interval [CI], 87.9-98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02 % (80/86; 95 %CI, 87.6-98.4), 100 % (2/2; 95 %CI, 100-100), 100 % (80/80; 95 %CI, 100-100), and 25 % (2/8; 95 %CI, -5-55.0), respectively. The parameters related to lesion and procedure were not significantly different between these two groups (p > 0.05). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001). CONCLUSION: Our data revealed that EUS-FNA is a safe and reliable diagnostic method for FLLs that shows high accuracy.

Comprehensive analysis of adverse events associated with transmural use of LAMS in patients with liver cirrhosis: International multicenter study.

Background and study aims Endoscopic ultrasound (EUS)-guided transmural (TM) deployment of lumen-apposing metal stents (LAMS) is considered relatively safe in non-cirrhotic patients and is cautiously offered to cirrhotic patients. Patients and methods This was a retrospective, multicenter, international matched case-control study to study the safety of EUS-guided TM deployment of LAMS in cirrhotic patients. Results Forty-three cirrhotic patients with model for end-stage liver disease score 12.5 ± 5, with 23 having ascites and 16 with varices underwent EUS-guided TM LAMS deployment, including 19 for pancreatic fluid collection (PFC) drainage, 13 gallbladder drainage, six for endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), three for EDGI, one for endoscopic ultrasound-directed transenteric ERCP, and one postsurgical collection drainage. Technical failure occurred in one LAMS for PFC drainage. Clinical failure was encountered in another PFC. Nine adverse events (AEs) occurred. The most common AE was LAMS migration (3), followed by non-bleeding mucosal erosion (2), delayed bleeding (2), sepsis (1), and anesthesia-related complication (pulseless electrical activity) (1). Most AEs were graded as mild (6), followed by severe (2), and moderate (1); the majority were managed conservatively. On univariable comparison, risk of AE was higher when using a 20 × 10 mm LAMS and the absence of through-the-LAMS plastic stent(s). Conditional logistic regression of matched case-control patients did not show any association between potential predicting factors and occurrence of AEs. Conclusions Our study demonstrated that mainly in patients with Child-Pugh scores A and B cirrhosis and despite the presence of mild-to-moderate ascites in over half of cases, the majority of AEs were mild and could be managed conservatively. Further studies are warranted to verify the safety of LAMS in cirrhotic patients.

Feasibility and safety of a novel plastic stent designed specifically for endoscopic ultrasound-guided pancreatic duct drainage.

Background and study aims Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) is emerging as an effective alternative treatment for obstructive pancreatitis after unsuccessful endoscopic retrograde pancreatography (ERP). However, the high incidence of adverse events associated with EUS-PD (approximately 20%) remains an issue. Recently, we developed a novel plastic stent for EUS-PD, with a radiopaque marker positioned at approximately one-third of the length from the distal end of the stent and side holes positioned exclusively distal to the marker. This study aimed to evaluate the feasibility and safety of using this stent in EUS-PD. Patients and methods We retrospectively reviewed data from 10 patients who underwent EUS-PD with the novel plastic stent at the National Cancer Center Hospital between March 2021 and October 2023. Technical and clinical success, procedure times, adverse events (AEs), recurrent pancreatic duct obstruction (RPO), and time to RPO were assessed. Results Of the 10 patients, five had postoperative benign pancreaticojejunal anastomotic strictures and five had malignant pancreatic duct obstruction. The technical and clinical success rates were both 100% (10/10). An AE (self-limited abdominal pain) occurred in one patient (10.0%). Two patients (20.0%) died of their primary disease during the follow-up period (median, 44 days; range, 25-272 days). The incidence of RPO was 10.0% (1/10), and the 3-month non-RPO rate was 83.3%. Conclusions The novel plastic stent shows potential as a useful and safe tool in EUS-PD.

The role of endoscopic ultrasonography for diagnosis of residual rectal neuroendocrine tumor.

BACKGROUND: Endoscopic ultrasonography (EUS) is useful for assessing the depth and regional lymph node involvement in rectal neuroendocrine tumors (NETs). However, evidence regarding the effectiveness of EUS in identifying residual lesions in patients with incompletely resected NET is limited. We aimed to evaluate the efficacy of EUS in identifying residual rectal NETs and the clinical outcomes of salvage endoscopic treatment. METHODS: We retrospectively reviewed the records of patients who were transferred to Chosun University Hospital and received salvage treatment for incompletely resected rectal NETs between January 2012 and October 2021. RESULTS: This study included 68 incompletely resected rectal NET, of which 59 were margin-positive and 9 were margin-indeterminate. EUS detection (odds ratio (OR), 8.44; 95% confidence interval (CI), 1.18-41.35) and visual detection (OR, 7.00; 95% CI, 1.50-47.48) were associated with residual lesion in patients with incompletely resected NET. EUS detection of residual lesions showed a sensitivity of 94%, specificity of 71%, positive predictive value of 88%, negative predictive value of 83%, and accuracy of 87%. All patients underwent salvage treatment with band-ligation endoscopic mucosal resection (58.8%) and endoscopic submucosal dissection (41.2%). Residual NETs were diagnosed in 47 of 68 patients (69.1%), and no recurrence was noted during the follow-up period of 51.8 ± 22.9 months. CONCLUSIONS: EUS is a more sensitive method than visual detection for evaluating residual rectal NETs. Salvage endoscopic treatment for incompletely resected NETs is safe and effective.