Keywords Pancreatobiliary (ERCP/PTCD) - Strictures - PTCD/PTCS - Endoscopic ultrasonography - Intervention EUS

We would like to thank Saito T and colleagues for their comments about and interest in our study about the timing of lumen-apposing metal stent (LAMS) removal during endoscopic ultrasound-guided treatment of pancreatic fluid collections (PFCs) [1]. We agree with the authors that a better understanding of which PFCs will require longer LAMS placement is needed to optimize patient care. Here are some details about our results.

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.

A 77-year-old man with a pancreatic head mass underwent EUS-guided choledochoduodenostomy with a 6- × 8-mm lumen-apposing metal stent (LAMS) (AXIOS, Boston Scientific, Malborough, Mass, USA) after a failed ERCP. Two years later, he presented to the emergency department with fever, jaundice, and vomiting.

Background and study aims Optimal timing for removal of lumen-apposing metal stents (LAMS) for effective drainage of pancreatic fluid collections (PFC) while minimizing adverse events (AE) is unknown. Outcomes of early (≤ 4 weeks) or delayed (> 4 weeks) LAMS removal on both clinical efficacy and the incidence of AE were assessed. Patients and methods This was a retrospective analysis of a prospectively maintained registry of PFC drainage between November 2016 and September 2021. Clinical success was defined as a 75% decrease in fluid collection volume with no need for reintervention at 6 months. AE were defined using the American Society for Gastrointestinal Endoscopy lexicon. Multiple logistic regression analysis was performed to determine variables associated with clinical success and AE. Results A total of 108 consecutive PFCs were included. LAMS deployment was technically successful in 103 of 108 cases (95.4%). Failure was associated with collection diameter ≤ 4 cm (odds ratio [OR] 24.0, P = 0.005) and presence of more than 50% necrotic material (OR 20.1, P = 0.01). Stents were left in place for a median of 48 days. Patients with early stent removal (< 4 weeks) had clinical success in 70.0% of cases, which was significantly less than in the group with delayed stent removal (96.4%, P = 0.03). On multiple regression analysis, clinical failure was associated with early stent removal (OR 25.5, P = 0.003). AEs occurred in 8.7% of cases (9/103). There were no predictors of AE. Notably, delayed stent removal did not predict the occurrence of AE. Conclusions Early LAMS removal (< 4 weeks) did not prevent AEs but did lead to increased clinical failure.

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.

Background and Objectives: EUS-guided biliary drainage (EUS-BD) is a promising alternative to ERCP in malignant distal biliary obstruction (MDBO). Despite accumulating data, however, its application in clinical practice has been impeded by undefined barriers. This study aims to evaluate the practice of EUS-BD and its barriers. Methods: An online survey was generated using Google Forms. Six gastroenterology/endoscopy associations were contacted between July 2019 and November 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers. The primary outcome was the uptake of EUS-BD as a first-line modality, without previous ERCP attempts, in patients with MDBO. Results: Overall, 115 respondents completed the survey (2.9% response rate). Respondents were from North America (39.2%), Asia (28.6%), Europe (20%), and other jurisdictions (12.2%). Regarding the uptake of EUS-BD as first-line treatment for MDBO, only 10.5% of respondents would consider EUS-BD as a first-line modality regularly. The main concerns were the lack of high-quality data, fear of adverse events, and limited access to EUS-BD dedicated devices. On multivariable analysis, lack of access to EUS-BD expertise was an independent predictor against the use of EUS-BD, odds ratio 0.16 (95% confidence interval, 0.04-0.65). In salvage situations following failed ERCP, most favored EUS-BD (40.9%) over percutaneous drainage (21.7%) in unresectable cancer. In borderline resectable or locally advanced disease, however, most favored the percutaneous approach due to fear of EUS-BD complicating future surgery. Conclusions: EUS-BD has not reached widespread clinical adoption. Identified barriers include lack of high-quality data, fear of adverse events, and lack of access to EUS-BD dedicated devices. Fear of complicating future surgery was also identified as a barrier in potentially resectable disease.

Centre Hospitalier de l'Universite de Montreal, Canada; Tanta University, Egypt.

Yen-I Chen: YES financial relationship with a commercial interest;Boston Scientific:Consulting;Boston Scientic:Grant/Research Support | Anand Sahai: YES financial relationship with a commercial interest;Boston Scientific:Consulting | Gianfranco Donatelli: NO financial relationship with a commercial interest | Eric Lam: NO financial relationship with a commercial interest | Sana Kenshil: NO financial relationship with a commercial interest | Fergal Donnellan: NO financial relationship with a commercial interest | Avijit Chatterjee: NO financial relationship with a commercial interest | Nauzer Forbes: YES financial relationship with a commercial interest;Boston Scientific:Advisory Committees or Review Panels;Boston Scientific:Consulting;Boston Scientific:Speaking and Teaching;Pentax Medical:Advisory Committees or Review Panels;Pentax Medical:Consulting;Pentax Medical:Grant/Research Support;Pentax Medical:Speaking and Teaching;Pendopharm:Advisory Committees or Review Panels | Jeffrey Mosko: NO financial relationship with a commercial interest | Etienne Desilets: NO financial relationship with a commercial interest | Sarto Paquin: NO financial relationship with a commercial interest | Jennifer Telford: YES financial relationship with a commercial interest;Pendopharm:Advisory Committees or Review Panels | Gary May: YES financial relationship with a commercial interest;Boston Scientific:Consulting;Medtronic:Speaking and Teaching;Olympus Canada:Consulting;Pentax canada:Speaking and Teaching;Fujifilm:Consulting;Vantage endoscopy:Speaking and Teaching | Gurpal Sandha: NO financial relationship with a commercial interest | Rachid Mohamed: NO financial relationship with a commercial interest | S. Ian Gan: YES financial relationship with a commercial interest;Romark:Stock Shareholder | Andre Roy: NO financial relationship with a commercial interest | Jad Abou Khalil: NO financial relationship with a commercial interest | Corey Miller: NO financial relationship with a commercial interest | Jeffrey Barkun: NO financial relationship with a commercial interest | George Zogopoulos: NO financial relationship with a commercial interest | Prosanto Chaudhury: YES financial relationship with a commercial interest;astellas:Speaking and Teaching;novartis:Advisory Committees or Review Panels;ipsen:Advisory Committees or Review Panels;astra zeneca:Advisory Committees or Review Panels | Peter Metrakos: NO financial relationship with a commercial interest | Ali Bessissow: YES financial relationship with a commercial interest;cook medical:Speaking and Teaching;boston scientific :Speaking and Teaching | Olivia Geraci: NO financial relationship with a commercial interest | Agnihotram Ramana-Kumar: NO financial relationship with a commercial interest | Myriam Martel: NO financial relationship with a commercial interest | Alan Barkun: YES financial relationship with a commercial interest;Olympus:Advisory Committees or Review Panels;Cook:Advisory Committees or Review Panels;Pendopharm:Consulting;Pendopharm:Advisory Committees or Review Panels;Imagia:Grant/Research Support

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.

Endoscopic Ultrasonography (EUS) in patients with suspected bile duct stones rules out the presence of stones in up to 65% of patients, thus preventing unnecessary Endoscopic Retrograde Cholangiography with Endoscopic Sphincterotomy (ERC with ES) and its complications in the majority of cases.1 Increased use of EUS for ruling out bile duct stones has led to more cases in which bile duct sludge is detected. Sludge is an ultrasound diagnosis usually described as layered, mobile, low-amplitude echoes without shadowing, representing bile precipitate out of solution.

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.

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.

Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) is an integral part of the diagnosis and management of many disease states. The goal is to obtain sufficient tissue for cytological analysis and/or for cell block, safely and effectively. There are numerous techniques and devices for EUS-guided FNA, but the most important predictor of success is the ability to move the needle within the target lesion in an effective manner. This chapter reviews current concepts related to all aspects of EUS-guided FNA.

BACKGROUND & AIMS:Endoscopic ultrasound guided-biliary drainage (EUS-BD) is a promising alternative to endoscopic retrograde cholangiopancreatography (ERCP); however, its growth has been limited by a lack of multicenter randomized controlled trials (RCT) and dedicated devices. A dedicated EUS-BD lumen- apposing metal stent (LAMS) has recently been developed with the potential to greatly facilitate the technique and safety of the procedure. We aim to compare a first intent approach with EUS-guided choledochoduodenostomy with a dedicated biliary LAMS vs. standard ERCP in the management of malignant distal biliary obstruction.METHODS:The ELEMENT trial is a multicenter single-blinded RCT involving 130 patients in nine Canadian centers. Patients with unresectable, locally advanced, or borderline resectable malignant distal biliary obstruction meeting the inclusion and exclusion criteria will be randomized to EUS-choledochoduodenostomy using a LAMS or ERCP with traditional metal stent insertion in a 1:1 proportion in blocks of four. Patients with hilar obstruction, resectable cancer, or benign disease are excluded. The primary endpoint is the rate of stent dysfunction needing re-intervention. Secondary outcomes include technical and clinical success, interruptions in chemotherapy, rate of surgical resection, time to stent dysfunction, and adverse events.DISCUSSION:The ELEMENT trial is designed to assess whether EUS-guided choledochoduodenostomy using a dedicated LAMS is superior to conventional ERCP as a first-line endoscopic drainage approach in malignant distal biliary obstruction, which is an important and timely question that has not been addressed using an RCT study design.TRIAL REGISTRATION:Registry name: ClinicalTrials.gov. Registration number: NCT03870386. Date of registration: 03/12/2019.

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.

Endoscopic ultrasound (EUS) has an established role in the diagnosis of pancreatic and biliary disease. CBD dilation is common amongst older people and those with previous cholecystectomy. Data are limited regarding the yield of EUS in patients with asymptomatic CBD dilation and normal LFTs. To determine the frequency and predictive factors of significant pathology in patients with CBD dilation and normal LFTs in whom EUS is requested. All patients referred to CHUM, a tertiary EUS referral center, between October 2000 and December 2016, for EUS for unexplained CBD dilatation (defined as CBD diameter ≥ 7mm at any place), with normal LFTs (AST, ALT, ALP, BILI) and no history of biliary sphincterotomy, were eligible for this retrospective study. EUS was performed using the linear echoendoscope (Pentax Medical, Melville NJ) by one of 2 experienced endosonographers. Data were extracted from a prospectively maintained database. Between 10/1/2000 and 12/31/2015, 29920 upper gastrointestinal EUS procedures were performed, 840/29920 (3%) for unexplained CBD dilation. 199/840 (24%) had normal LFTs, (99%) were Caucasian, 46% had abdominal pain, and 41% were post-cholecystectomy. EUS diagnosed CDL or sludge in 18/199 (9%) patients (7/18 had CBD sludge only). No other pathology was diagnosed. 15/18 [83%] CDL patients had an intact gallbladder, and all 15 had cholelithiasis. The frequency of CDL or sludge in post-cholecystectomy patients was only 3.7% (3/82); and none of these patients were younger than 69 years of age. Univariate, bivariate and multivariate logistic regression analyses showed no associations between EUS diagnosis of CDL or sludge and 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 (OR: 1,05; p = 0.034). In patients referred for EUS for CBD dilation and abnormal LFTs, the only significant pathology identified is CBD stones or sludge, and this almost exclusively in elderly patients with cholelithiasis. EUS should be avoided in patients with dilated bile ducts and normal LFTs – especially if under 65 years of age and post-cholecystectomy.

In selected difficult EUS tissue sampling cases, the 22g Franseen tip needle: 1) Provides samples adequate for histological analysis in 92%, 2) The sensitivity for malignancy is 91.7%. These results were obtained without ROSE.

Dear Editor, Endoscopic ultrasound-guided fiducial placement (EUS-FP), performed to facilitate stereotactic body radiation therapy, is feasible and safe.[12] Antibioprophylaxis is not recommended currently by existing guidelines.[3] We report the first case of a large liver abscess and sepsis after EUS-FP. A 67-year-old female with colon cancer and a single, metastatic, 3 cm left lobar liver lesion was referred for EUS-FP. A single fiducial was back-loaded into the 19-gauge needle (Cook, EchoTip®); the tip was then sealed with sterile bone wax [Figures 1 and 2]. After placement of the first fiducial, the needle was then withdrawn from the scope to back-load the next fiducial. Three fiducials were placed in total using this method. No prophylactic antibiotics were administered.Figure 1: Under sterile conditions, the fiducial is back-loaded into the needle tipFigure 2: The needle tip is then sealed with sterile bone waxSix weeks postprocedure, the patient was admitted to the intensive care unit with abdominal pain and septic shock. Computed tomography scan revealed a 10 cm intrahepatic/perigastric abscess in the region where the fiducials had been placed. All resolved with antibiotics and percutaneous drainage. Our institution has performed 43 EUS-FP to date, with only one reported infectious complication (Case #38). We now administer antibioprophylaxis to all patients undergoing EUS-FP. The role of prophylactic antibiotics for EUS-FP was unclear.[3] To the best of our knowledge, only two infectious complications have been reported previously; one cholangitis after EUS-FP of porta hepatis nodes and[4] one cholangitis after EUS-FP for pancreatic head cancer.[3] In both cases, it was uncertain if the infection was related to the procedure or to malignant biliary obstruction. Recent studies with EUS-FP did not systematically administer antibioprophylaxis.[45] In conclusion, postprocedural liver abscess is a possible complication of EUS-FP. Excessive manipulation of the needle, related to the “semi-sterile” back-loading technique, is probably responsible for our reported complication. Therefore, we believe that antibioprophylaxis pre- and post-EUS-FP in these conditions is a reasonable recommendation, and guidelines for prophylaxis should be amended appropriately. EUS-FP infectious risk could likely also be reduced using a needle that allows placement of multiple fiducials, without manual back-loading. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.