1. Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees

Wani S. et al. Gastrointest Endosc 2019 Feb 7; [e-pub].

Key points:

  • The number of ERCP and EUS procedures a trainee needs to perform to become competent is not established;
  • The aim of this study was to define the number of procedures required by an “average” trainee to achieve competence in technical and cognitive EUS and ERCP tasks;
  • American researchers analyzed data from 37 trainees to assess the number of ERCP and EUS procedures required to achieve competence;
  • Median numbers of EUS and ERCP procedures performed by advanced trainees were 400 and 361, respectively;
  • The average trainee achieved core competence after performing 250 ERCPs and 225 endoscopic ultrasounds;


Background and Aims: Minimum EUS and ERCP volumes that should be offered per trainee in “high quality” advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an “average” advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure  AETPs.

Methods: ASGE-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system and learning curves (LCs) using cumulative sum (CUSUM) analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed effects models with a random intercept for each AET were used to generate aggregate LCs allowing us to use data from all AETs to estimate the average learning experience for trainees.

Results: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. The majority of AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed/AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 examinations were graded (EUS: 1277; ERCP-biliary: 1143; pancreatic: 196). The majority of graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for Grade 2 ERCP at about 300 cases.

Conclusions: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training.


2. Benefit of high negative pressure during endoscopic ultrasound-guided fine-needle aspirationwith standard 22 gauge needles for pancreatic lesions: a retrospective comparative study

Sato J et al. Scand J Gastroenterol 2019 Jan; [e-pub].

Key points:

  • ESGE recommends using 10-mL syringe suction for EUS-guided sampling of solid masses with 25G or 22G FNA needles;
  • Japanese investigators retrospectively evaluated the effectiveness of EUS-FNA of solid pancreatic lesions using suction created by a 10-cc syringe (normal negative pressure-NNP) versus a 50-cc syringe (high negative pressure-HNP);
  • Retrospective study; 200 patients with solid pancreatic masses underwent first two passes using NNP in 103 patients and HNP in 97.
  • The two techniques had the same diagnostic accuracy but HNP required fewer passes to reach a diagnosis (median, 2 vs. 3 passes) and samples contained a larger quantity of tissue.
  • This study reveals that High negative pressure from a 50-cc syringe may have benefits over normal negative pressure from a 10-cc syringe in terms of number of passes and tissue quantity.


Objectives: Few studies are available on high negative pressure (HNP) during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). This study compared the diagnostic yield between HNP and normal negative pressure (NNP) during EUS-FNA for solid pancreatic masses.

Methods: Consecutive patients with pancreatic masses who underwent EUS-FNA using a 22-G needle with either HNP or NNP for both the first and second passes were retrospectively examined for diagnostic yield. Rapid on-site evaluation (ROSE) was unavailable at our center. The main outcome measures were the number of passes, diagnostic accuracy and quantity of histological samples.

Results: Two hundred patients underwent EUS-FNA (n = 97, HNP; n = 103, NNP) over a 22-month period. A significantly lower median number of passes was required for HNP than for NNP (2 vs. 3; p < .001). There was no significant difference in diagnostic accuracy between the two groups. The rate of obtaining a histological sample larger than a 10× power field in length was significantly higher for HNP than for NNP (76.4% vs. 59.6%; p = .0019). In the multivariate analysis, a large tumor size (>20 mm) and HNP were identified as factors influencing the acquisition of a larger histological sample.

Conclusions: There was no significant difference in diagnostic accuracy between HNP and NNP. HNP required fewer passes without ROSE and was related to the acquisition of a larger histological sample. HNP may be useful when few samples are available for EUS-FNA with NNP or a larger histological sample is needed.


3. Effect of Pancreatic Mass Size on Clinical Outcomes of Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Sugiura R et al. Dig Dis Sci 2019 Jan 2; [e-pub].

Key points:

  • EUS-FNA is the standard tool to sample solid pancreatic lesions
  • The value of EUS-FNA for very small lesions is controversial; the diagnostic yield in the case of very small lesions is low and needs to be balanced with the risk of complications;
  • Researchers in Japan conducted an 8.5-year retrospective cohort study involving 761 patients with 788 lesions sorted into five groups based on size: group A (<10 mm), group B (10–20 mm), group C (20–30 mm), group D (30–40 mm), and group E (≥40 mm).
  • Needle gauge was decided by the endoscopist
  • Sensitivity and diagnostic accuracy increased significantly as mass size increased; Lesion size did not correlate to adverse event rates.


Background: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has high diagnostic accuracy for pancreaticdiseases. However, the effect of mass size on diagnostic accuracy has yet to be determined, especially for small pancreatic lesions. We aimed to determine the effect of pancreatic mass size on the diagnostic yield of EUS FNA.

Methods: We searched the database in Hokkaido University Hospital between May 2008 and December 2016 and identified solid pancreatic lesions examined by EUS-FNA. All lesions were stratified into five groups based on mass sizes: groups A (< 10 mm), B (10 20 mm), C (20-30 mm), D (30-40 mm) and E (≥ 40 mm). The sensitivity, specificity, diagnostic accuracy and adverse event rate were retrospectively evaluated.

Results: We analyzed a total of 788 solid pancreatic lesions in 761 patients. The patients included 440 males (57.8%) with a mean age of 65.7 years. The sensitivities in groups A (n = 36), B (n = 223), C (n = 304), D (n = 147) and E (n = 78) were 89.3%, 95.0%, 97.4%, 98.5% and 98.7%, respectively, and they significantly increased as the mass size increased (P < 0.01, chi-squared test for trend). The diagnostic accuracies were 91.7%, 96.4%, 97.7%, 98.6% and 98.7%, respectively, and they also significantly increased as the mass size increased (P = 0.03). Multivariate analysis showed that pancreatic mass size was associated with diagnostic accuracy. The adverse event rates were not significantly different among the five groups.

Conclusions: The sensitivities and diagnostic accuracies of EUS-FNA for solid pancreatic lesions are higher for lesions ≥ 10 mm in size, and they are strongly correlated with mass size.


4. Prospective assessment of the effectiveness of standard high-level disinfection for echoendoscopes

Becq A et al. Gastrointest Endosc 2019 Jan 14; [e-pub].

Key points:

  • Duodenoscopes contain an elevator mechanism that has been of specific concern for its potential to harbor multidrug-resistant organisms with risk for duodenoscope-related infections;
  • Linear echoendoscopes also contain an elevator mechanism
  • American researchers evaluated bacterial colonization of radial (50) and linear (51) echoendoscopes and compared the results with previously published data on duodenoscopes.
  • Echoendoscopes underwent high-level disinfection and were cultured at the beginning of each shift (two samples for each device)
  • No multidrug-resistant organisms were identified. Two linear echoendoscopes and one radial echoendoscope were found to harbor ≥10 colony-forming units (CFUs) in their working channels (3%).
  • Compared with published duodenoscope culture rates, echoendoscopes had a lower rate of elevator bacterial colonization (1% vs. 9%).
  • This study suggests echoendoscopes have a lower risk for transmitting infection compared with duodenoscopes.


Background and Aims: Duodenoscopes have been implicated in the transmission of multidrug-resistant organisms (MDROs). Echoendoscopes could potentially transmit infection. The aim of this study was to assess the effectiveness of standard high-level disinfection(HLD) for radial and linear echoendoscopes and to compare it with that of duodenoscopes.

Methods: We performed a prospective single-center study sampling echoendoscopes immediately before use, from the working channel (radial and linear echoendoscopes) and the transducer (radial echoendoscope) or elevator mechanism and transducer (linear echoendoscope). The primary outcome was the proportion of echoendoscopes with any culture showing ≥1 MDRO; secondary outcomes included bacterial growth >0 colony forming units (CFUs) and ≥10 CFUs on either sampling location. We compared these findings with duodenoscope cultures from the previously published DISINFECTS trial.

Results: During the study period, 101 echoendoscopes were sampled (n = 50 radial echoendoscopes, n = 51 linear echoendoscopes). No MDROs were recovered. Bacterial growth >0 CFUs was noted in 6% and ≥10 CFUs in 3% of all echoendoscopes. There was no significant difference in growth between radial and linear echoendoscopes (P = .4 for >0 CFU growth; P = .6 for ≥10 CFUs growth). The proportion of transducer and/or elevator mechanism positive for bacterial growth was significantly higher in duodenoscopes as compared with echoendoscopes (P = .02).

Conclusions: After standard HLD, no echoendoscope showed MDRO growth, 6% showed >0 CFUs, and 3% showed ≥10 CFUs bacterial growth. Bacterial growth was higher in duodenoscopes at the level of the transducer and/or elevator mechanism when compared with echoendoscopes.


5. Efficacy and safety of EUS-guided liver biopsy: a systematic review and meta-analysis

Mohan BP et al. Gastrointest Endosc 2019 Feb; [e-pub].

Key points:

  • EUS–guided liver biopsy (EUS-LB) has recently been shown to have a better safety profile than percutaneous or transjugular biopsy with similar diagnostic yield, but the results are inconsistent.
  • American researchers conducted a systematic review and meta-analysis to estimate diagnostic yield (primary outcome) and adverse events (secondary outcome) of EUS-guided liver biopsy
  • 8 studies comprising 437 patients; , 94% pooled estimate for successful histologic diagnosis; 10% insufficient specimen rate; 2% pooled adverse event rate
  • Subgroup analysis (needle type): fine-needle aspiration (FNA) with 19G needle had a numerically lower adverse event rate (1% vs. 3%), similar diagnostic yield (96% and 93%), and a significantly lower rate of insufficient specimen (4% vs. 20%).than core biopsy;
  • This meta-analysis showed EUS-LB has similar diagnostic yield and adverse event rates than percutaneous and transjugular biopsy
  • EUS-guided biopsy performed via FNA (specifically with 19G needle) seems to result in fewer adverse events with same diagnostic yield.


Background and Aims: EUS-guided liver biopsy (LB) is an emerging technique over conventional percutaneous (PC) or transjugular (TJ) approaches. Recent studies have reported that EUS-guided LB may have a better safety profile than PC LB or TJ LB without compromising diagnostic yield, and the outcomes are varied with respect to the types of biopsy needles. We performed a systematic review and meta-analysis to estimate the diagnostic yield, specimen adequacy, and adverse events associated with EUS-guided LB.

Background and Aims:We conducted a comprehensive search of multiple electronic databases and conference proceedings, including PubMed, EMBASE, and Web of Science databases (from inception to June 2018) to identify studies that reported on EUS-guided LB. The primary outcome was to estimate the pooled rates of successful diagnosis made and insuficiente specimen obtained. The secondary outcome was to estimate the pooled rate of adverse events. A subgroup analysis compared the outcomes based on the type of biopsy needle.

Results: A total of 9 study arms with 437 patients were included. The pooled rate of successful histologic diagnoses was 93.9% (95% confidence interval [CI], 84.9-97.7), with heterogeneity I2 of 75.3%. The pooled rate of insufficient specimen obtained was 10.1% (95% CI, 3.5-25.8), with I2 = 71.6%. The pooled rate of adverse events with EUS-guided LB was 2.3% (95% CI; 1.1-4.8, I2 = 0). On subgroup analysis, the adverse events rate with a 19-gauge FNA needle (vs other core biopsy needles) was 0.9% (vs 2.7%, P = .28), and the rate of diagnostic yield was 95.8% (vs 92.7%, P = .59). The rate of insufficient specimen was significantly lower with an FNA needle compared with the core needle (4% vs 20%, P = .03).

Conclusions: With a histologic diagnosis rate of 93.9% and adverse event rate of 2.3%, EUS-guided LB appears to be both effective and safe. A 19-gauge FNA needle provides significantly better biopsy specimens and seems to have better outcomes compared with other core biopsy needles.