1. Endoscopic ultrasound-guided liver biopsy using a 22-G fine needle biopsy needle: a prospective study.

Hasan MK, et al. Endoscopy. 2019 Sep;51(9):818-824 (doi: 10.1055/a-0967-3640).

KEY POINTS

  • The aim of this study was to evaluated the efficacy and safety of a 22-G EUS fine needle biopsy (FNB) needle for performing EUS-guided liver biopsy (EUS-LB).
  • Prospective study; 40 patients referred for evaluation of elevated liver enzymes and without obstructive disease requiring ERCP; EUS-LB was performed using a 22-G FNB needle (2 passes from the left lobe; 1 from the right).
  • The median cumulative core length per patient was 55 mm and the median cumulative number of complete portal triads (CPTs) per patient was 42; the adequacy of the specimen for histology interpretation was 100% (40/40).
  • Self-limiting abdominal pain was reported in 6 patients (15 %).
  • EUS-LB using a 22-G FNB needle is a safe and viable alternative to the use of larger gauge needle.

ABSTRACT

Background Endoscopic ultrasound-guided liver biopsy (EUS-LB) using a 19-gauge (19-G) EUS needle is becoming increasingly popular. We evaluated the efficacy and safety of a 22-G EUS fine needle biopsy (FNB) needle for performing EUS-LB.

Methods Patients referred for evaluation of elevated liver enzymes and without obstructive disease requiring endoscopic retrograde cholangiopancreatography (ERCP) were included. Using a 22-G FNB needle, two passes were made from the left lobe and one from the right. The main outcome measure was adequacy of the specimen for histology interpretation, and the secondary outcome was the safety of EUS-guided liver biopsy with a 22-G FNB needle. Patients were followed for post-procedure complications for 30 days.

Results 40 patients (median age 61 years; 26 women) underwent EUS-LB. Analyzing by needle passes, the median longest core fragment was 12 mm (1st quartile – 3rd quartile 10 mm – 16.25 mm, interquartile range [IQR] 6.25 mm) from the left lobe and 11 mm (10 mm – 15.75 mm, IQR 5.75 mm) from the right lobe. The median cumulative core length per patient was 55 mm (44.5 mm – 68 mm, IQR 23.5 mm). The median cumulative number of complete portal triads (CPTs) per patient was 42 (28.5 – 53, IQR 24.5). The specimen was considered adequate in all 40 patients (100 %). Self-limiting abdominal pain was reported in 6 patients (15 %).

Conclusions EUS-LB using a 22-G FNB needle is a safe and viable alternative to the use of larger gauge needles, yielding adequate tissue for evaluation of parenchymal disease in 100 % of the patients.

 

2. EUS versus percutaneous management of postoperative pancreatic fluid collection: A systematic review and meta-analysis.

Mohan BP, et al. Endosc Ultrasound. 2019 Jun 20 (doi: 10.4103/eus.eus_18_19).

KEY POINTS

  • The aim of this systematic review and meta-analysis was to evaluate the clinical outcomes of EUS and percutaneous drainage (PCD) in the management of postoperative pancreatic fluid collection (POPFC).
  • 13 studies included: 10 studies (239 patients) used EUS and 6 studies (267 patients) used PCD.
  • The clinical success rate was significantly superior for EUS (93% vs 80%, P=0.002); the recurrence rate was significantly lower for EUS (9% vs 26%, P=0.02). The rates of technical success and adverse events were similar for EUS and PCD. 
  • EUS had significantly better clinical outcomes, in terms of clinical success and disease recurrence, in the management of POPFC as compared to PCD.

ABSTRACT

Postoperative pancreatic fluid collection (POPFC) is an important complication following abdominal surgery. POPFC causes significant morbidity and mortality. Management options are time-consuming and severely affect patient’s quality of life. Surgical and/or percutaneous drainage (PCD) is the traditional mainstay of treatment. Studies have shown that EUS could have a role to play in the management of POPFC. Data are limited in the comparison of clinical outcomes with EUS as compared to PCD to this end. 

We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, LILACS, and Web of Science databases (earliest inception through September 2018) to identify studies that reported on the clinical outcomes of EUS and PCD in the management of POPFC. The goals were to estimate and compare the pooled rates of technical success, clinical success, adverse events, and POPFC recurrence with EUS and PCD. 

A total of 13 studies were included in the analysis. Ten studies (239 patients) used EUS and 6 studies (267 patients) used PCD in the management of POPFC. The pooled rate of clinical success with EUS was 93.2% (95% confidence interval [CI] 88.2–96.2, I2 = 0) and with PCD was 79.8% (95% CI 70–87, I2 = 74). The difference was statistically significant, P = 0.002. Recurrence rate was significantly lower with EUS as compared to PCD (9.4%: 95% CI 5.2–16.5 vs. 25.7%: 95% CI 24.3–41.7; P = 0.02). Pooled rates of technical success and adverse events were similar with EUS and PCD. 

Our meta-analysis shows that EUS has significantly better clinical outcomes, in terms of clinical success and disease recurrence, in the management of POPFC as compared to PCD.

 

3. Non-superiority of lumen apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomizes trial.

Bang JY, et al. Gut. 2019 Jul;68(7):1200-1209 (doi: 10.1136/gutjnl-2017-315335).

KEY POINTS

  • The aim of this study was to compare the efficacy of lumen-apposing metal stents (LAMS) and plastic stents for walled-off necrosis (WON) drainage.
  • Prospective randomized trial; 60 patients: LAMS n=31; plastic stents n=29.
  • There was no significant difference in total number of procedures performed, treatment success, clinical adverse events, readmissions, length of hospital stay and overall treatment costs between cohorts. 
  • Procedure duration was shorter (15 vs 40 min, p<0.001), stent-related adverse events (32% vs 7%, p=0.01) and procedure costs (US$12155 vs US$6609, p<0.001) were higher with LAMS.
  • Adverse events were observed ≥3 weeks postintervention in LAMS cohort; after protocol amendment where CT scan was obtained at 3 weeks postintervention followed by LAMS removal if WON had resolved, there was no significant difference in adverse events between cohorts.
  • Except for procedure duration, there was no significant difference in treatment outcomes between LAMS and plastic stents.

ABSTRACT

Objective Although lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off necrosis (WON), their advantage over plastic stents is unclear. We compared efficacy of LAMS and plastic stents for WON drainage.

Design Patients with WON were randomised to endoscopic ultrasound-guided drainage using LAMS or plastic stents. Primary outcome was comparing total number of procedures to achieve treatment success defined as symptom relief in conjunction with WON resolution on CT at 6 months. Secondary outcomes were treatment success, procedure duration, clinical/stent-related adverse events, readmissions, length of hospital stay (LOS) and costs.

Results 60 patients underwent LAMS (n=31) or plastic stent (n=29) placement. There was no significant difference in total number of procedures performed (median 2 (range 2–7) LAMS vs 3 (range 2–7) plastic, p=0.192), treatment success, clinical adverse events, readmissions, LOS and overall treatment costs between cohorts. Although procedure duration was shorter (15 vs 40 min, p<0.001), stent-related adverse events (32.3% vs 6.9%, p=0.01) and procedure costs (US$12 155 vs US$6609, p<0.001) were higher with LAMS. Significant stent-related adverse events were observed ≥3 weeks postintervention in LAMS cohort. Interim audit resulted in protocol amendment where CT scan was obtained at 3 weeks postintervention followed by LAMS removal if WON had resolved. After protocol amendment, there was no significant difference in adverse events between cohorts.

Conclusion Except for procedure duration, there was no significant difference in treatment outcomes between LAMS and plastic stents. To minimise adverse events with LAMS, patients should undergo follow-up imaging and stent removal at 3 weeks if WON has resolved.

 

4. Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.

Luk SW, et al. Endoscopy. 2019 Aug;51(8):722-732 (doi: 10.1055/a-0929-6603).

KEY POINTS

  • The aim of this systematic review and meta-analysis was to compare EUS-guided gallbladder drainage (EUS-GBD) and percutaneous drainage (PT-GBD) in high risk surgical patients with acute cholecystitis. 
  • 5 comparative studies included: 206 patients in the EUS-GBD group and 289 patients in the PT-GBD group.
  • There were no statistically significant differences in technical success and clinical success between the two procedures. 
  • EUS-GBD was associated with fewer post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions than PT-GBD.

ABSTRACT

Background Recent evidence suggests that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD). We conducted a systematic review and meta-analysis to compare these two procedures in high risk surgical patients with acute cholecystitis. 

Methods A comprehensive electronic literature search was conducted for all articles published up to October 2017 to identify comparative studies between EUS-GBD and PT-GBD. A meta-analysis was performed on outcomes including technical success, clinical success, post-procedure adverse events, length of hospital stay, unplanned hospital readmission, need for reintervention, recurrent cholecystitis, and disease- or treatment-related mortality for these two procedures.

Results Five comparative studies (206 patients in the EUS-GBD group vs. 289 patients in the PT-GBD group), were included in the final analysis. There were no statistically significant differences in technical success (odds ratio [OR] 0.43, 95 % confidence interval [CI] 0.12 to 1.58; P = 0.21; I 2 = 0 %) and clinical success (OR 1.07, 95 %CI 0.36 to 3.16; P = 0.90; I 2 = 44 %) between the two procedures. EUS-GBD had fewer adverse events than PT-GBD (OR 0.43, 95 %CI 0.18 to 1.00; P = 0.05; I 2 = 66 %). Moreover, patients undergoing EUS-GBD had shorter hospital stays, with pooled standard mean difference of – 2.53 (95 %CI – 4.28 to – 0.78; P = 0.005; I 2 = 98 %), and required significantly fewer reinterventions (OR 0.16, 95 %CI 0.04 to 0.042; P <  0.001; I 2 = 32 %) resulting in significantly fewer unplanned readmissions (OR 0.16, 95 %CI 0.05 to 0.53; P = 0.003; I 2 = 79 %). 

Conclusions EUS-GBD was associated with lower rates of post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions compared with PT-GBD in patients with acute cholecystitis who were unfit for surgery.