News in EUS: April - June 2017

News in EUS

 

1. EUS-guided fine-needle core liver biopsy using a novel 19G needle with modified one pass, one actuation wet suction technique

Gastrointest Endosc. 2017 May 24

 

Key points:

  • - Endoscopic Ultrasound (EUS) has become a popular procedure for the investigation of suspected biliary obstruction;
  • - EUS has the opportunity to evaluate liver parenchymal disease potentially reducing the delay in achieving a diagnosis and preventing the need for a second procedure (such as percutaneous or transjugular biopsy)
  • - In this study the authors retrospectively evaluated outcomes in 165 consecutive patients who underwent EUS-guided liver biopsy (using a 19-gauge core needle and a single-pass technique) after an EUS excluded bile duct stones as the cause of liver test abnormalities;
  • - This study shows that EUS-guided liver biopsy can provide adequate tissue for analysis of liver specimens with a low rate of adverse events.

 

Abstract

BACKGROUND AND AIMS:

EUS-guided fine-needle core biopsy is a safe and effective technique for diagnosis of focal liver lesions. However, data are limited in its role in parenchymal disease. We evaluated the utility of EUS-guided parenchymal liver biopsies (EUS-LB) with a modified one pass wet suction technique (EUS-MLB) in patients with unexplained increase in liver associated tests.

METHODS:

We retrospectively evaluated the safety and efficacy of EUS-MLB in patients referred for EUS to evaluate for biliary obstruction and pancreatic disorders, but with associated unexplained liver tests. EUS-MLB was performed during the same session after biliary obstruction was excluded.

RESULTS:

One hundred sixty-five consecutive patients underwent EUS-MLB. The median (interquartile range ) age was 52 years (42, 65). Sixty-eight patients (41%) were male. The median (IQR) of the maximum intact core tissue length was 2.4 cm (1.8, 3.5). The median (IQR) total specimen length (TSL) was 6 cm (4.3, 8). The median (IQR) number of complete portal tracts (CPT) per TSL was 18 (13, 24). The mean number of CPT per sample length was 7.5 cm. Adverse events were uncommon (1.8%), and included abdominal pain and self-limited hematoma.

CONCLUSION:

EUS-guided fine-needle biopsy using a novel 19G core needle with a modified one pass one actuation wet suction technique (EUS-MLB) is a safe and effective way to evaluate patients with unexplained liver tests abnormalities who are undergoing EUS for exclusion of biliary obstruction.

 

2. The Use of a Stylet in Endoscopic Ultrasound With Fine-Needle Aspiration: A Systematic Review and Meta-Analysis

J Clin Gastroenterol 2017 Jun 21

 

Key points:

• While the use of an internal stylet during puncture is time consuming, controversy exists whether it is instrumental in improving diagnostic yield or quality of specimens;

• Several randomized controlled trials (RCTs) have been performed to test the paradigm of routine stylet usage. However, the results from these RCTs have been conflicting;

• In this meta-analysis, the authors demonstrate that stylet use during EUS-FNA confers no significant advantage with regard to diagnostic adequacy, accuracy, yield, contamination, bloodiness, or representative cellularity compared to not using a stylet.

• All 5 included studies individually found there was no significant difference or added advantage to using a stylet during EUS-FNA procedures.

 

Abstract

BACKGROUND:

Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is the most efficacious way to collect specimens from a solid lesion adjacent to the gastrointestinal tract and is performed with an internal stylet during puncture. However, its reinsertion into the needle is time-consuming. Controversy surrounds whether quality of cytology specimen improves with stylet use. We performed a meta-analysis comparing the use of stylet versus no stylet with EUS-FNA of gastrointestinal-related masses

METHODS:

Multiple databases were searched from inception until April 28, 2016. Discordant findings from independent extractions were reviewed by at least 2 investigators. Methods were executed as per the standards of the Cochrane Collaboration. Primary outcomes assessed were diagnostic adequacy of individual specimen samples, accuracy, and yield. Secondary outcomes included overall diagnostic accuracy of per-malignant lesion, cellularity, contamination, and bloodiness of the sample, and adverse events.

RESULTS:

Five randomized control trials were identified comparing stylet versus no stylet use, which enrolled 504 patients, evaluated 537 lesions, and 1914 distinct specimens. There was no difference in diagnostic adequacy , accuracy (RR=0.98; 95% CI, 0.90-1.06), or yield (RR=0.96; 95% CI, 0.89-1.03). No stylet use was favored in per-lesion malignant diagnosis (RR=0.85; 95% CI, 0.76-0.96). There was no difference in representative cellularity, contamination, or bloodiness of specimens obtained with or without stylet use.

CONCLUSIONS:

Stylet use confers no significant advantage in diagnostic adequacy, accuracy, yield, contamination, bloodiness, or cellularity over no stylet. We reinforce that no stylet use may be used preferentially in EUS-FNA as a more convenient technique and is favored with a higher per-lesion malignant diagnosis.

 

3. Prospective randomized trial of EUS-assisted ERCP without fluoroscopy versus ERCP in common bile duct stone.

Gastrointest Endosc 2017 Apr 7

 

Key points:

  • - ERCP is associated with radiation exposure to both the patients and staff personnel;

- ERCP without fluoroscopy can avoid radiation exposure and has been proved feasible for stone clearance in pregnant women;

- The aim of the study was to evaluate the effectiveness of EUS-assisted ERCP;

- 114 patients randomized to standard ERCP with fluoroscopy or EUS-assisted ERCP (biliary access confirmed by aspirating bile);

- Fluoroscopy was used at the end of the procedure just to confirm duct clearance.

- Cannulation rates were not significantly different but EUS-guided ERCP was inferior to standard ERCP for achieving stone clearance;

- Adverse event rates and total procedure times did not differ between the two groups.

 

Abstract

BACKGROUND AND AIMS:

ERCP with stone removal is the standard treatment for common bile duct stones (CBDSs). Radiation exposure is a risk to the endoscopist and patient. EUS-guided ERCP without fluoroscopy (EGEWF) in patients with CBDSs is feasible, but the efficacy and safety compared with ERCP is unknown. We aimed to compare the efficacy and safety of EGEWF with ERCP in CBDS removal.

METHODS:

A prospective randomized study was done in 114 patients with CBDSs who met inclusion criteria. These patients were equally randomized into the EGEWF and ERCP groups. In the EGEWF group, ERCP was performed by cannulation without fluoroscopy. Balloon sweeping was done after sphincterotomy to clear the stones until the number of stones matched the number detected by EUS and the stone clearance (SC) was confirmed by cholangiography. In the ERCP group, ERCP was performed in the standard manner. The cannulation rates, SC rates, total procedure and fluoroscopic times, and adverse event rates were analyzed.

RESULTS:

After exclusion of 3 patients, 55 were in the EGEWF group and 56 in the ERCP group. Demographic data, laboratory data, stone characteristics, CBD diameter, and number of patients with periampullary diverticulum were not different between the 2 groups. The cannulation success rates in the EGEWF (96.35%) and ERCP (100%) groups were similar (P = .243). The SC rate in the EGEWF group (85.5%) was inferior to the ERCP group (100%) (P = .002). The SC rate based on the number of stones retrieved that matched the number by EUS was correct in 94%. More than 2 stones may increase the failure rate of SC in EGEWF. The adverse event rates and the total procedure times were not different between the groups.

CONCLUSIONS:

EGEWF was inferior to ERCP in terms of SC; however, no radiation exposure is beneficial for selected patients.


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