News in EUS - Oct - Dec 2017

News in EUS (Oct-Dec 2017)


EUS-guided celiac ganglia neurolysis: a clinical and human cadaver study (with video)
Kappelle W et al. Gastrointest Endosc 2017


Key points:
- Several techniques of EUS-guided celiac plexus neurolysis have been tried over time
- Feasibility of injecting a neurolytic agent directly into the celiac ganglia (EUS-guided celiac ganglia neurolysis) was previously reported.
- This study provides important information regarding the pattern of ethanol spread after various techniques of EUS-guided celiac ganglia neurolysis and celiac plexus neurolysis in human cadavers.
- The key findings of this study were that targeting ganglia injection is not feasible (because ethanol spreads well beyond the targeted ganglion) and that unidentified celiac ganglia are better reached with high-volume injection (by celiac plexus neurolysis or ganglia neurolysis, whether central or bilateral).
- On the basis of this study and the available literature, high volume bilateral celiac plexus neurolysis (not celiac ganglia neurolysis) appears to be the most effective technique (most likely to distribute sclerosant to the most ganglia, at the highest concentration, and without the potential for added pain – which may be associated with targeted ganglia injection).


Background and Aims
There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN).
First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echoendoscope next to the celiac trunk and removing the underlying tissue for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in 1 ganglion, 1 mL per ganglion (both low volume), and 4 mL per ganglion (high volume). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 μm) were obtained and photographed to allow visualization of the spread of ethanol.
A total of 204 ganglia were detected in 83 patients. Mean (± standard deviation) size of the long axis was 8.1 mm (± 7.4 mm). Histology of the removed region in the cadaver showed only nerve cell bodies. After low-volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable to the spread after EUS-CPN.
Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.


EUS-guided lauromacrogol ablation of insulinomas: a novel treatment
Qin S et al. Scand J Gastroenterol 2017


Key points:
• EUS-guided ablation of pancreatic lesions using ethanol is described for solid and cystic lesions;
• Functional insulinoma is a type of pancreatic endocrine tumor that results in intractable hypoglycemia;
• Chinese researchers evaluated the outcomes of EUS–guided polidocanol injection into symptomatic insulinomas (citologically confirmed) in seven patients who refused surgery;
• In this pilot study, the volume of injected sclerosant was determined by tumor size and patients were followed-up for at least 1 month.
• Tumor diameter ranged from <1 cm to over 3 cm. After the procedure, all patients had blood markers of hypoglycemia and hyperinsulinemia normalized. There were no adverse events.
• In this small case series EUS-guided polidocanol injection of insulinomas was found feasible and safe. This may be an inexpensive way to treat these lesions in a nonsurgical manner.



EUS-guided ablation with ethanol has been used to treat insulinoma since 2006 as a minimally invasive alternative for those who are unwilling or unsuitable for surgeries. However, pancreatic fistula, pancreatitis and other adverse effects were found after the procedure in these patients. Herein, we aimed to find a novel feasible injection.

METHODS: Seven patients with different chief complaints were diagnosed with insulinoma by symptoms, lab results and pathology results from EUS fine needle aspiration. All the patients refused to have surgeries and were treated by EUS-guided ablation with lauromacrogol. The injection volume was calculated by tumor size. All the patients were followed up by at least 1 month to see if there is any adverse effect. Blood glucose (BG), insulin and C-peptide levels were monitored before and after the procedure.

RESULTS: Insulinoma size ranged from 0.76 cm×0.84 cm to 3.39 cm×1.84 cm. With a mean injection volume of 1.9 ml (range from 0.9 to 3.9 ml), all the patients showed relief in symptoms after the procedure. During the follow up, their BG, insulin and C-peptide levels went back to normal. None of the patients had any adverse effect.

EUS-guided ablation with lauromacrogol showed good treatment results and received no adverse effect after the procedure. Hence, we consider it as an effective and safe method to treat insulinoma.


Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial
van Brunschot S et al Lancet 2017


Key points:
• Surgery was the treatment of choice for infected pancreatic necrosis in the past. Recently endoscopic drainage and pancreatic necrosectomy was developed;
• This Dutch multicenter randomized trial compared the rate of adverse events or death during 6 months (primary endpoint) following endoscopic versus surgical step-up therapy in patients with infected pancreatic necrosis;
• Ninety-eight patients were randomized. Major adverse event or death were similar between groups (43% in the endoscopy group and 45% in the surgery group). Pancreatic fistulas were fewer and hospital stays were shorter among patients treated by endoscopy (secondary endpoints);
• The authors conclude that these results will likely make the endoscopic step-up approach the preferred treatment for infected pancreatic necrosis;
• Surgery should be reserved for patients who are not candidates for primary endoscopic therapy;



BACKGROUND: Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes.

METHODS: In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711.

FINDINGS: Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine patients in the endoscopy group vs six patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint.

INTERPRETATION: In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference.


Agreement between endoscopic ultrasound-guided fine-needle aspiration and endobiliary brush cytology in suspected pancreaticobiliary malignancies.
Endosc Int Open 2017


Key points:
• Endobiliary brush cytology during ERCP and EUS-FNA are the most widely used endoscopic techniques for pancreatobiliary sampling;
• Cytology using a traditional short segment design brush has a poor sensitivity leading to false negative results;
• In this retrospective study, American researchers looked if the use of a special brush with two types of bristles with different stiffness’s (Infinity brush – US Endoscopy) would provide more adequate samples improving cancer detection and compared the agreement between brush sampling and EUS-FNA results in 41 patients.
• Infinity sampling brush provided a suitable sample for analysis in 97.6% of the cases and a moderate agreement with EUS-FNA samples.




For suspected pancreaticobiliary malignancies, endobiliary brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) remains the diagnostic test of choice despite historically poor and variable sensitivity. This has led to increased use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as an initial test. Recently, our institution began using a cytology brush that was designed specifically to collect a more substantial and higher-quality sample. The aim of this study was to investigate whether this brush design would provide more adequate samples and have high agreement with EUS-FNA in patients who underwent both procedures.


A retrospective chart review was conducted of all patients who underwent both EUS-FNA and endobiliary brush cytology for suspicion of pancreaticobiliary malignancy from January 2013 to May 2015. A total of 41 patients met the inclusion criteria. Initially, sample quality was evaluated. Final cytology results were then assessed for agreement with EUS-FNA using Cohen's kappa. The effect of considering atypical cytology as negative was also uniquely evaluated by running separate analyses.


Brush cytology provided an adequate sample in 95.1 % of cases. Cohen's Kappa demonstrated moderate agreement between brush cytology and EUS-FNA: κ = 0.42 ( P  = 0.001). When atypical results were excluded, agreement increased: κ = 0.60 ( P  = 0.02), but remained moderate. If atypical results were considered "positive," the two procedures demonstrated equal cancer detection rates of 80.8 %.

The studied brush provided more adequate samples compared with historical rates for brush cytology and had moderate agreement with EUS-FNA. If this brush truly increases sample adequacy, it could potentially provide results comparable