Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography(ERCP)is the preferred modality for drainage of the obstructed biliary tree.In patients with surgically altered anatomy,ERCP using standard techniques may not be feasible.Enteroscope assisted ERCP is usually employed with variable success rate.With advent of endoscopic ultrasound(EUS),biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective.In this narrative review,we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Comparison of trans-gastric vs trans-enteric(trans-duodenal or trans-jejunal)endoscopic ultrasound guided gallbladder drainage using lumen apposing metal stents

BACKGROUND Endoscopic ultrasound guided gallbladder drainage(EUS-GBD)is being increasingly used in practice(either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients).Stents are used to create a conduit between the lumen of the gallbladder(GB)and the intestinal lumen through the gastric or enteric routes.Among the various types of stents used,cautery-enhanced lumen apposing metallic stents(LAMS)may be associated with fewer adverse events(AEs).AIM To compare the clinical success,technical success,and rate of AEs between transgastric(TG)and trans-enteric[transduodenal(TD)/transjejunal(TJ)]approach to GB drainage.Further,we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters.METHODS Study was registered in PROSPERO(CRD42022319019)and comprehensive literature review was conducted.Manuscripts were reviewed for the data collection:Rate of AEs,clinical success,and technical success.Random effects model was utilized for the analysis.RESULTS No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches(P>0.05)were noted.There was no statistically significant difference in the rate of AEs when comparing two-arm studies only.However,when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach.When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS,a statistically significant difference in the rate of AEs was observed when all the studies were included,with the rate being higher in non-cautery enhanced stents(14.0%vs 37.8%;P<0.01).CONCLUSION As per our study results,TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD.Additionally,use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS.Though the approach chosen depends on several patient and physician factors,the above findings could help in deciding the ideal drainage route when both TG and TD/TJ approaches are feasible.

Endoscopic ultrasound guided gastroenterostomy:Technical details updates,clinical outcomes,and adverse events

Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has been transformed from an innovative technique,into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction.Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed,giving patients more less invasive options.However,EUS-GE is still a technically challenging procedure.In order to improve EUS-GE,several techniques have been reported to improve the technical details.With EUS-GE widely performed,more data about EUS-GE’s clinical outcomes have been reported.The aim of the current review is to describe technical details updates,clinical outcomes,and adverse events of EUS-GE.

Endoscopic ultrasound guided fine needle tissue acquisition:Where we stand in 2013?

Since its introduction,endoscopic ultrasound(EUS)guided fine needle aspiration and fine needle biopsy have become an indispensable tool for the diagnosis of lesions within the gastrointestinal tract and surrounding organs.It has proved to be an effective diagnostic method with high accuracy and low complication rates.Several factors can influence the accuracy and the diagnostic yield of this procedure including experience of the endosonographer,availability of onsite cytopathology services,the method of cytopathology preparation,the location and physical characteristics of the lesion,sampling techniques and the type and size of the needle used.In this review we will outline the recent studies evaluating EUS-guided tissue acquisition and will provide practical recommendations to maximize tissue yield.

Endoscopic ultrasound guided gallbladder drainage - is it ready for prime time？

Management of acute cholecystitis includes initial sta-bilization and antibiotics. However, the most definitive treatment is cholecystectomy. A small percentage of patients who are not suitable for surgery due to the severity of cholecystitis or comorbidities will require a temporary measure as a bridge to surgery or permanent nonoperative management to decrease the mortality and morbidity. Most of these patients who require conservative management were managed with percutaneous transhepatic cholecystostomy or trans-papillary drainage of gallbladder drainage with cystic duct stenting through endoscopic retrograde cholangiopancreaticography （ERCP）. Although, these conservative measures are effective, they can cause signifcant discomfort to the patients especially if used as a long-term measure. In view of this, there is a need for further minimally invasive procedures, which is safe, effective and comfortable to patients. Endoscopic ultrasound （EUS） guided gallbladder drainage is a novel method of gallbladder drainage frst described in 2007[1]. Over the last decade, EUS guided gallbladder drainage has evolved as an effective alternative to percutaneouscholecystostomy and trans-papillary gallbladder drai-nage. Our goal is to review available literature regarding the scope of EUS guided gallbladder drainage as a viable alternative to percutaneous cholecystostomy or cystic duct stenting through ERCP among patients who are not suitable for cholecystectomy.

Endoscopic ultrasound guided liver biopsy: Recent evidence

Liver biopsy(LB)is an essential tool in diagnosing,evaluating and managing various diseases of the liver.As such,histopathological results are critical as they establish or aid in diagnosis,provide information on prognosis,and guide the appropriate selection of medical therapy for patients.Indications for LB include evaluation of persistent elevation of liver chemistries of unclear etiology,diagnosis of chronic liver diseases such as Wilson's disease,autoimmune hepatitis,small duct primary sclerosing cholangitis,work up of fever of unknown origin,amyloidosis and more.Traditionally,methods of acquiring liver tissue have included percutaneous LB(PCLB),transjugular LB(TJLB)or biopsy taken surgically via laparotomy or laparoscopy.However,traditional methods of LB may be inferior to newer methods.Additionally,PCLB and TJLB carry higher risks of adverse events and complications.More recently,endoscopic ultrasound guided LB(EUS-LB)has evolved as an alternative method of tissue sampling that has proven to be safe and effective,with limited adverse events.Compared to PC and TJ routes,EUS-LB may also have a greater diagnostic yield of tissue,be superior for a targeted approach of focal lesions,provide higher quality images and allow for greater patient comfort.These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue.Herein,we provide a review of the recent evidence of EUS-LB for liver disease.

Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction

Endoscopic ultrasound-guided biliary drainage(EUS-BD)directs bile flow into the digestive tract and has been mostly used in patients with malignant biliary obstruction(MBO)where endoscopic retrograde cholangiopancreatography-guided biliary drainage was unsuccessful or was not feasible.Lumen apposing metal stents(LAMS)are deployed during EUS-BD,with the newer electrocautery-enhanced LAMS reducing procedure time and complication rates due to the inbuilt cautery at the catheter tip.EUS-BD with electrocautery-enhanced LAMS has high technical and clinical success rates for palliation of MBO,with bleeding,cholangitis,and stent occlusion being the most common adverse events.Recent studies have even suggested comparable efficacy between EUS-BD and endosc-opic retrograde cholangiopancreatography as the primary approach for distal MBO.In this editorial,we commented on the article by Peng et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2024.

Endoscopic ultrasound-guided fine-needle aspiration pancreatic adenocarcinoma samples yield adequate DNA for next-generation sequencing:A cohort analysis

BACKGROUND Genetic tests are increasingly performed for the management of unresectable pancreatic cancer.For genotyping aimed samples current guidelines recommend using core specimens,although based on moderate quality evidence.However,in clinical practice among the endoscopic ultrasound(EUS) guided tissue acquisition methods,fine needle aspiration(FNA) is the most widely performed.AIM To assess the adequacy for next generation sequencing(NGS) of the DNA yielded from EUS-FNA pancreatic adenocarcinoma(PDAC) samples.METHODS Between November 2018 and December 2021,105 patients with PDAC confirmed by EUS-FNA were included in the study at our tertiary gastroenterology center.Either 22 gauge(G) or 19G FNA needles were used.One pass was dedicated to DNA extraction.DNA concentration and purity(A260/280,A260/230) were assessed by spectrophotometry.We assessed the differences in DNA parameters according to needle size and tumor characteristics(size,location) and the adequacy of the extracted DNA for NGS(defined as A260/280 ≥ 1.7,and DNA yield:≥ 10 ng for amplicon based NGS,≥ 50 ng for whole exome sequencing [WES],≥ 100 ng for whole genome sequencing [WGS]) by analysis of variance and ttest respectively.Moreover,we compared DNA purity parameters across the different DNA yield categories.RESULTS Our cohort included 49% male patients,aged 67.02 ± 8.38 years.The 22G needle was used in 71%of the cases.The DNA parameters across our samples varied as follows:DNA yield:1289 ng(inter quartile range:534.75-3101),A260/280 = 1.85(1.79-1.86),A260/230 = 2.2(1.72-2.36).DNA yield was > 10 ng in all samples and > 100 ng in 93% of them(one sample < 50 ng).There were no significant differences in the concentration and A260/280 between samples by needle size.Needle size was the only independent predictor of A260/230 which was higher in the 22G samples(P =0.038).NGS adequacy rate was 90% for 19G samples regardless of NGS type,and for 22G samples it reached 89% for WGS adequacy and 91% for WES and amplicon based NGS.Samples with DNA yield > 100 ng had significantly higher A260/280(1.89 ± 0.32 vs 1.34 ± 0.42,P = 0.013).Tumor characteristics were not corelated with the DNA parameters.CONCLUSION EUS-FNA PDAC samples yield DNA adequate for subsequent NGS.DNA amount was similar between 22G and 19G FNA needles.DNA purity parameters may vary indirectly with needle size.

Comparison of Transrectal Prostate Digital and Ultrasound-Guided Core Biopsies in 400 Men in a Low-and-Middle Income Country

Background: The diagnosis of prostate cancer (PCa) relies on clinical assessment with digital rectal examination, serum PSA and histological examination. Limitations in our technical facilities, high financial cost of ultrasound-guided biopsy often prevent us from implementing the guidelines on the practice of prostate biopsy. Methods: We conducted a retrospective and cross-sectional descriptive study comparing digital-guided and ultrasound-guided transrectal prostate biopsy of 400 patients over a period of 12 years in the Yaounde Central Hospital. We reviewed files of patients who underwent digital and ultrasound guided biopsy procedures. Data was analyzed using EPI info 7.0. Parametric variables were reported as means and standard deviations and percentages and counts were used to report categorical variables. Results: Out of the 400 patients, 292 digital-guided transrectal biopsies (73%) and 108 ultrasound-guided transrectal biopsies (27%) were performed in patients who were suspected of having prostate cancer (PCa). Patients were aged between 39 to 90 years. Both procedures were effective in identifying prostate cancer. Gleason score between 2 to 10 detected prostate adenocarcinoma for 301 patients (75.2%). The complications included anal pain, rectal bleeding, hematuria and urinary tract infections, with an occurrence rate similar for both ultrasound-guided (2.25%) and digitally-guided techniques (2.5%). Seven patients (1.75%) required hospitalization for management of complications. The mortality rate was null. Conclusion: Both techniques are effective in detecting PCa with the similar complication rates. Digital-guided trans-rectal prostate biopsy still has its place in a resource-limited setting like ours.

Update on endoscopic ultrasound-guided liver biopsy

Endoscopic ultrasound guided liver biopsy(EUS-LB)has emerged as a minimally-invasive alternative to the traditional(percutaneous or transjugular)liver biopsy techniques for the diagnosis of liver parenchymal diseases.Potentially,EUS-LB combines the advantages of percutaneous and transjugular liver biopsy in addressing focused sampling in addition to measuring portal pressure.Additionally,EUS-LB facilitates access to both the lobes of the liver which is not considered with the traditional percutaneous liver biopsy.Multiple studies have compared EUS-LB with conventional liver biopsy and reported comparable diagnostic yield,increased acquisition of complete portal tracts,and longer specimen length as compared to the traditional approaches.EUS-LB is associated with lesser post-procedural pain and shorter recovery time,while providing lower risk of complications when compared to traditional liver biopsy.Innovations in needle types,needle sizes and suction techniques have aimed at further optimizing the EUS-LB technique.This review article updates current literature with focus on the variations in the technique and equipment used for EUS-LB,and compares EUS-LB with traditional methods of liver biopsy.

Liu-stain quick cytodiagnosis of ultrasound-guided fine needle aspiration in diagnosis of liver tumors

AIM： To combine ultrasound-guided fine-needle aspiration （US-FNA） and Liu （Riu） stain to make a quick study on liver tumor lesions. METHODS： Two hundred and twenty-eight aspirations from 232 patients were completely studied. The operator himself made the quick cytodiagnosis of US-FNA smear stained by Liu method within thirty minutes. The US-FNA specimen was also sent to the pathological department for cytological study and cellblock histology. The result of our Uu-stain quick cytodiagnosis in each patient was confirmed by the final cytopathological diagnosis from pathological report. RESULTS： Among 228 samples, the quick cytodiagnosis revealed 146 malignancies, 81 benign lesions and one inadequate specimen. Cytopathological diagnosis from the pathological department revealed 150 malignancies, and 78 benign lesions. Four well-differentiated hepatocellular carcinomas （HCCs） were under-diagnosed by quick cytodiagnosis as benign and 3 benign lesions were over-diagnosed as well-differentiated HCCs. Compared with cytopathological diagnosis, quick cytodiagnosis correctly diagnosed 143 malignancies and 77 benign lesions. Except for the one inadequate specimen in quick cytodiagnosis, the accuracy of quick cytodiagnosis was 96.9% （220/227）, and its sensitivity, specificity and positive and negative predictive values were 97.9%, 95.1%, 97.3% and 96.3%, respectively. CONCLUSION： Liu-stain quick cytodiagnosis is a fast, convenient, safe and effective method for hepatologists in clinic practice to diagnose liver tumor. In few cases of well-differentiated HCC, Liu-stain quick cytodiagnosis has its limitation.

Ultrasound-guided percutaneous drainage of a traumatic abdominal wall hematoma in the emergency department

BACKGROUND:Abdominal wall hematoma is due to trauma,coagulation disorders or anticoagulation therapy complications.METHODS:in this report we present a case of a 44-year-old female who suffered from blunt abdominal trauma and presented to the emergency department with sharp abdominal pain and ecchymosis.FAST and abdominal computerized tomography(CT) revealed an abdominal wall hematoma.Treatment with an ultrasound-guided percutaneous drainage was performed successfully.RESULTS:The patient remained under observation for six hours with serial ultrasound scans,and no signs of hematoma recurrence were present.She was discharged the same day with clinical improvement.CONCLUSION:Complete history investigation and clinical examination help to make a correct diagnosis of abdominal wall hematoma,select a prompt treatment,and reduce complications.

Changes over time in treatment for obstructive jaundice

This editorial discusses an article by Peng et al.This study reviewed the efficacy and safety of a new approach for treating obstructive jaundice.Although the pathophysiology of obstructive jaundice has not yet been fully elucidated,pro-gress has been made in its management.There are two aspects of obstructive jaundice:Cholestatic status and absence of bile in the intestinal lumen.Internal biliary drainage resolved both the conditions.Clinically,endoscopic retrograde biliary drainage(ERBD)has replaced percutaneous transhepatic biliary drainage,and ERBD is transitioning to endoscopic ultrasound guided biliary drainage.This editorial briefly explains the mechanism and treatment of obstructive jaundice and the prospects of this new internal biliary drainage technique.

Applications of endoscopic ultrasound in pancreatic cancer

Since the introduction of endoscopic ultrasound guided fine-needle aspiration(EUS-FNA),EUS has assumed a growing role in the diagnosis and management of pancreatic ductal adenocarcinoma(PDAC).The objective of this review is to discuss the various applications of EUS and EUS-FNA in PDAC.Initially,its use for detection,diagnosis and staging will be described.EUS and EUS-FNA are highly accurate modalities for detection and diagnosis of PDAC,this high accuracy,however,is decreased in specific situations particularly in the presence of chronic pancreatitis.Novel techniques such as contrast-enhanced EUS,elastography and analysis of DNA markers such as k-ras mutation analysis in FNA samples are in progress and might improve the accuracy of EUS in the detection of PDAC in this setting and will be addressed.EUS and EUS-FNA have recently evolved from a diagnostic to a therapeutic technique in the management of PDAC.Significant developments in therapeutic EUS have occurred including advances in celiac plexus interventions with direct injection of ganglia and improved pain control,EUS-guided fiducial and brachytherapy seed placement,fine-needle injection of intra-tumoral agents and advances in EUS-guided biliary drainage.The future role of EUS and EUS in management of PDAC is still emerging.

Liver Abscesses in General Surgery at CsRef CI in Bamako Mali

Liver abscesses correspond to a newly formed cavity created by necrosis of the liver parenchyma induced by the pathogen. The aim of the present work was to study liver abscesses;determine the frequency;describe the clinical and paraclinical aspects, therapeutic and evolutionary modalities;determine the follow-up of treatment in order to assess the cost of treatment in the Reference Health Center of Commune I of Bamako in Mali. This prospective study, involving 30 cases of liver abscess, took place over a period of 24 months from January 2015 to December 2016 in the general surgery department of the Cs Ref of commune I. The liver abscess is very often the consequence of amoebiasis which is rampant in the underprivileged population and it remains topical in surgical practice in Mali. Our hospital frequency was 0.081% with an average age of 34.40 years and extremes of 16 and 61 years;a sex ratio of 2.3 in favor of men. The main clinical signs were fever (56.7%), hepatalgia (73.3%) and hepatomegaly (26.7%). Hepatic collections objectified on abdominal ultrasound were located in the right lobe in 70% of cases and unique in 62%. Amebic serology carried out in 100% was negative in 20%;10% of cases had undergone surgical treatment. The consequences were simple for all our patients. The average cost of care, approximately 100,000 FCFA, was significantly higher than the minimum wage (28,460 FCFA) in Mali.

Therapeutic Effect of Transcatheter Arterial Chemoembolization Combined with Percutaneous Ethanol Injection in Hepatocellular Carcinoma

Objective To evaluate the clinical efficacy of the combined treatment with transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) on hepatocellular carcinoma (HCC) .Methods 312 patients with moderate or advanced HCCs were divided into two groups; 170 cases underwent TACE treatment alone, 142 cases were treated with TACE and PEI under B-ultrasound guidance.Results The rates of reduction in tumor diameter and the decline in serum AFP level were 41.2% and 40.4% in the TACE group and 75.4% and 74.1 % in the TACE + PEI group respectively. The 6, 12 and 24 months survival rates in the TACE group were 77.1 % , 34.1% and 18.8% ,respectively and in the TACE + PEI group 87.3% , 62.0% and 38.0% , respectively. Overall, there was a significant difference between the two treatment groups ( P < 0.05). Conclusion Treatment on HCCs with TACE + PEI is convenient, safe and results in better survival rates than TACE alone.

Clinical management for malignant afferent loop obstruction

Afferent loop obstruction(ALO)is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy.With advances in chemotherapy,the incidence of malignant ALO is increasing.Malignant ALO can be complicated by ischemia,gangrenous bowel,pancreatitis,and ascending cholangitis.Moreover,the general condition of patients with recurrent cancer is often poor.Therefore,accurate and rapid diagnosis and minimally invasive treatments are required.However,no review articles on the diagnosis and treatment of malignant ALO have been published.Through literature searching,we reviewed related articles published between 1959 and 2020 in the PubMed database.Herein,we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives.Endoscopic transluminal self-expandable metal stent(SEMS)placement is considered the standard treatment for malignant ALO,as this procedure is well established and less invasive.However,with the development of interventional endoscopic ultrasound(EUS)in recent years,the usefulness of EUS-guided gastrojejunostomy has been reported.Moreover,through indirect comparison,this approach has been reported to be superior to transluminal SEMS placement.It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

Is there a difference between 19G core biopsy needle and 22G core biopsy needle in diagnosing the correct etiology?——A meta-analysis and systematic review

AIM To compare the accuracy of endoscopic ultra-sonography(EUS) 19 G core biopsies and 22 G core biopsies in diagnosing the correct etiology for a solid mass.METHODS Articles were searched in Medline, Pub Med, and Ovid journals. Pooling was conducted by both fixed and random effects models. RESULTS Initial search identified 4460 reference articles for 19 G and 22 G, of these 670 relevant articles were selected and reviewed. Data was extracted from 6 studies for 19G(n = 289) and 16 studies for 22G(n = 592) which met the inclusion criteria. EUS 19 G core biopsies had a pooled sensitivity of 91.6%(95%CI: 87.1-95.0) and pooled specificity of 95.9%(95%CI: 88.6-99.2), whereas EUS 22 G had a pooled sensitivity of 83.3%(95%CI: 79.7-86.6) and pooled specificity of 64.3%(95%CI: 54.7-73.1). The positive likelihood ratio of EUS 19 G core biopsies was 9.08(95%CI: 1.12-73.66) and EUS 22 G core biopsies was 1.99(95%CI: 1.09-3.66).The negative likelihood ratio of EUS 19 G core biopsies was 0.12(95%CI: 0.07-0.24) and EUS 22 G core biopsies was 0.25(95%CI: 0.14-0.41). The diagnostic odds ratio was 84.74(95%CI: 18.31-392.26) for 19 G core biopsies and 10.55(95% CI: 3.29-33.87) for 22 G needles. CONCLUSION EUS 19 G core biopsies have an excellent diagnostic value and seem to be better than EUS 22 G biopsies in detecting the correct etiology for a solid mass.

Castleman disease in the hepatic-gastric space: A case report

BACKGROUND Castleman disease, also known as giant lymph node hyperplasia, was first reported in 1956. It is a rare benign proliferative pathological change of the lymph nodes.CASE SUMMARY The patient, a 33-year-old woman, had epigastric distension for half a year.Examinations were performed in a local hospital. Computed tomography scan showed round soft tissue nodules, about 5.45 cm in diameter, in the hepaticgastric space. Endoscopic ultrasound and endoscopic ultrasound guided fine needle aspiration was performed on the patient. Rapid on-site evaluation,hematoxylin eosin staining and histopathology of the puncture smear was performed. According to the Diff-Quik staining and hematoxylin eosin staining results of preoperative endoscopic ultrasound guided fine needle aspiration puncture smears as well as the immunohistochemistry results, Castleman disease was highly suspected. A sufficient preoperative evaluation was made, and a precise surgical plan was developed. Postoperative pathology confirmed Castleman disease.CONCLUSION Endoscopic ultrasound guided fine needle aspiration can extract internal tissues of the tumor for histological and cytological examinations and provide accurate diagnosis as much as possible. Therefore, a sufficient preoperative evaluation can be made, and a precise surgical plan can be developed.