The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).

/pdf/efsumb-guidelines-on-interventional-ultrasound-invus-part-iv-1gi1slalya.pdf

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided Interventions: General aspects and EUS-guided sampling (Long Version).

Background Endoscopic ultrasound (EUS)-guided tissue acquisition is extensively used, but the optimal sampling device is still a matter of debate We performed meta-analyses on studies comparing fine-needle aspiration (FNA) with fine-needle biopsy (FNB) needles, and studies comparing different FNB needles Methods Online databases were searched for randomized controlled trials (RCTs) of at least 50 cases with a suspected solid pancreatic or nonpancreatic lesion that compared FNA with FNB needles Outcome measures included diagnostic accuracy, adequacy, number of passes, presence of tissue cores, and adverse events We also performed meta-regression analysis on the effect of FNB design on diagnostic accuracy Quality was assessed using the QUADAS-2 tool Results 18 RCTs comparing FNA with FNB needles were included FNB provided a higher pooled diagnostic accuracy (87 % vs 80 %; P = 002) and tissue core rate (80 % vs 62 %; P = 0002), and allowed diagnosis with fewer passes (P = 003), in both pancreatic and nonpancreatic lesions A total of 93 studies were included comparing different FNB devices Pooled diagnostic accuracy was higher for forward-facing bevel needles than for the reverse bevel needle In this analysis, study quality was low and heterogeneity was high (I2
  = 80 %) Conclusion FNB outperformed FNA when sampling pancreatic and nonpancreatic lesions Forward-facing bevel FNB needles seemed to outperform the reverse bevel FNB needle, but the low quality of evidence prevents us from making strong recommendations on the optimal FNB design

Comparison of fine-needle aspiration and fine-needle biopsy devices for endoscopic ultrasound-guided sampling of solid lesions: a systemic review and meta-analysis

Randomized trial comparing fork-tip and side-fenestrated needles for EUS-guided fine-needle biopsy of solid pancreatic lesions.

Peroral endoscopic myotomy (POEM) demonstrated similar efficacy to surgical myotomy in the management of achalasia. However, gastroesophageal reflux disease (GERD) is common after POEM. The aim of this study is to identify factors associated with GERD after POEM. After searching electronic databases, randomized trials and observational studies including patients with achalasia or other spastic esophageal disorders, treated by POEM, and providing GERD data were selected. GERD was evaluated by 3 methods: pH monitoring, endoscopic findings, and symptoms. For each method, an analysis was performed comparing the outcomes related to the following independent variables: full-thickness (FT) vs circular myotomy, anterior vs posterior, long myotomy vs short myotomy, naive vs previous treatment failure, previous Heller myotomy (HM) vs non-previous-HM, Type I vs II, Type I vs III, and Type II vs III. 2869 publications were identified, and 25 studies met criteria for inclusion in the qualitative analysis. Of these, 18 were included in the meta-analysis. According to the endoscopic findings, circular and anterior myotomy demonstrated a lower trend of GERD with borderline significance (p = 0.06; p = 0.07, respectively). In the pH monitoring and symptom analyses, circular myotomy, anterior myotomy, treatment naive, and non-HM patients were associated with a lower occurrence of GERD; however, no statistically significant difference was found. When comparing achalasia subtypes, no statistical difference was found in all analyses. This systematic review and meta-analysis suggest that a circular anterior approach may limit post-POEM GERD and should be considered in appropriate patients.

Risk factors for gastroesophageal reflux after POEM for achalasia: a systematic review and meta-analysis

Abstract The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV – EUS-guided Interventions: General aspects and EUS-guided sampling (Long Version)

Accuracy and inter-observer agreement of the Procore™ 25 gauge needle for endoscopic ultrasound-guided tissue core biopsy

Tu2041 Long vs Short POEM for the Treatment of Achalasia. Interim Analysis of a Randomized Controlled Trial

Endoscopic ultrasound (EUS)-guided fineneedle aspiration (FNA) is a safe procedure with a low complication rate [1]. To the best of our knowledge, there has only been one previous report of inadvertent fracturing of an FNA needle, which occurred during an attempted EUS-guided rendezvous for an inaccessible main pancreatic duct [2]. We present the case of a 75-year-old woman with an unresectable pancreatic head mass, who was referred to us for EUS-FNA after biliary stent placement. The procedure was performed by an experienced endosonographer from the duodenal bulb using a 22-gauge needle. The needle was inserted into the periphery of the mass to avoid passing through the plastic stent, and the fanning technique was used. At the end of the first pass, an unusual hyperreflecting line was observed, corresponding to the needle tract (●" Fig.1), which suggested that the needle may have broken during the sampling procedure. This was confirmed when the needle was advanced outside the external sheath to collect the specimen. The extremity of the broken needle was further identified protruding from the mucosa of the upper duodenal bulb (●" Fig.2). After various attempts at retrieval, the needle was grasped from the terminal end using a snare and was removed completely, without any consequences to the patient. The needle segment measured 4 cm (●" Fig.3,●" Video 1). There was no obvious cause of this incident. However, it is possible that the plastic stent could have been a relevant factor in the breaking of the needle. This case highlights the importance of ensuring that the correct EUS-FNA procedure is followed. After confirmation of a needle fracture, endoscopic removal can be accomplished with caution using the proper endoscopic accessories, in order to avoid potential damage to both the patient and the echoendoscope.

/pdf/fractured-needle-during-endoscopic-ultrasound-guided-fine-24phw4svvx.pdf

Fractured needle during endoscopic ultrasound-guided fine-needle aspiration of a pancreatic head mass.

One of the most common causes of external pancreatic fistula is the iatrogenic manipulation of a complex pancreatic fluid collection concomitantly associated with a disconnected pancreatic duct [1,2]. This situation can lead to the development of a high output (up to 400mL/d) external pancreatic fistula that is difficult to manage and sometimes requires surgery [3]. In 2012, a 40-year-old woman underwent laparoscopic cholecystectomy with a hepaticojejunal Roux-en-Y anastomosis for a congenital Todani’s type IV common bile duct cyst. Postoperative pancreatitis resulted in the development of a complex pancreatic fluid collection in the pancreatic head, which was drained percutaneously. Subsequently, an external pancreatic fistula formedwith an output of 200mL/d. In 2014, the patient was referred to us for further evaluation. Endoscopic retrograde cholangiopancreatography (ERCP) showed a normal main pancreatic duct that lacked a clear communication with the collection (●" Fig.1). The injection of contrast through the percutaneous catheter showed the presence of a 4-cm fluid collection (●" Fig.2). Endoscopic ultrasound (EUS)-guided drainage with the placement of plastic stentswas planned. At EUS, the collection was accessed from the duodenal bulbwith a 19-gauge needle, after which a 0.035-inch guidewire was placed. The needle was then exchanged for an 8.5-Fr cystotome, but the collection no longer appeared adjacent to the duodenal wall, probably because it had been pushed away by the guidewire, and major vesselswere interposed (●" Video1). Based on our previous experience, we decided to replace the cystotome with a novel cautery-tipped stent delivery system that allows the single-step EUS-guided placement of a lumen-apposing fully covered metal stent (Hot AXIOS System; Xlumena, Mountain View, California, USA) [4]. The lesionwas directly punctured and entered with the system, and an 8×8-mm lumenapposing fully covered metal stent was delivered under complete EUS guidance (●" Fig.3,●" Video 1). The output significantly dropped the following day, allowing removal of the external catheter 2 days after the procedure. The patient was discharged and remains well 3 months later, without any symptoms.

/pdf/external-pancreatic-fistula-treated-by-endoscopic-ultrasound-26i1myvvyu.pdf

External pancreatic fistula treated by endoscopic ultrasound-guided drainage with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system.

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Accuracy and inter-observer agreement of the Procore™ 25 gauge needle for endoscopic ultrasound-guided tissue core biopsy

Tu2041 Long vs Short POEM for the Treatment of Achalasia. Interim Analysis of a Randomized Controlled Trial

Fractured needle during endoscopic ultrasound-guided fine-needle aspiration of a pancreatic head mass.

External pancreatic fistula treated by endoscopic ultrasound-guided drainage with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system.