Background
Endoscopic ultrasound (EUS) is proposed as an accurate diagnostic device for the locoregional staging of gastric cancer, which is crucial to developing a correct therapeutic strategy and ...ultimately to providing patients with the best chance of cure. However, despite a number of studies addressing this issue, there is no consensus on the role of EUS in routine clinical practice.
Objectives
To provide both a comprehensive overview and a quantitative analysis of the published data regarding the ability of EUS to preoperatively define the locoregional disease spread (i.e., primary tumor depth (T‐stage) and regional lymph node status (N‐stage)) in people with primary gastric carcinoma.
Search methods
We performed a systematic search to identify articles that examined the diagnostic accuracy of EUS (the index test) in the evaluation of primary gastric cancer depth of invasion (T‐stage, according to the AJCC/UICC TNM staging system categories T1, T2, T3 and T4) and regional lymph node status (N‐stage, disease‐free (N0) versus metastatic (N+)) using histopathology as the reference standard. To this end, we searched the following databases: theCochrane Library (the Cochrane Central Register of Controlled Trials (CENTRAL)), MEDLINE, EMBASE, NIHR Prospero Register, MEDION, Aggressive Research Intelligence Facility (ARIF), ClinicalTrials.gov, Current Controlled Trials MetaRegister, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), from 1988 to January 2015.
Selection criteria
We included studies that met the following main inclusion criteria: 1) a minimum sample size of 10 patients with histologically‐proven primary carcinoma of the stomach (target condition); 2) comparison of EUS (index test) with pathology evaluation (reference standard) in terms of primary tumor (T‐stage) and regional lymph nodes (N‐stage). We excluded reports with possible overlap with the selected studies.
Data collection and analysis
For each study, two review authors extracted a standard set of data, using a dedicated data extraction form. We assessed data quality using a standard procedure according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) criteria. We performed diagnostic accuracy meta‐analysis using the hierarchical bivariate method.
Main results
We identified 66 articles (published between 1988 and 2012) that were eligible according to the inclusion criteria. We collected the data on 7747 patients with gastric cancer who were staged with EUS. Overall the quality of the included studies was good: in particular, only five studies presented a high risk of index test interpretation bias and two studies presented a high risk of selection bias.
For primary tumor (T) stage, results were stratified according to the depth of invasion of the gastric wall. The meta‐analysis of 50 studies (n = 4397) showed that the summary sensitivity and specificity of EUS in discriminating T1 to T2 (superficial) versus T3 to T4 (advanced) gastric carcinomas were 0.86 (95% confidence interval (CI) 0.81 to 0.90) and 0.90 (95% CI 0.87 to 0.93) respectively. For the diagnostic capacity of EUS to distinguish T1 (early gastric cancer, EGC) versus T2 (muscle‐infiltrating) tumors, the meta‐analysis of 46 studies (n = 2742) showed that the summary sensitivity and specificity were 0.85 (95% CI 0.78 to 0.91) and 0.90 (95% CI 0.85 to 0.93) respectively. When we addressed the capacity of EUS to distinguish between T1a (mucosal) versus T1b (submucosal) cancers the meta‐analysis of 20 studies (n = 3321) showed that the summary sensitivity and specificity were 0.87 (95% CI 0.81 to 0.92) and 0.75 (95% CI 0.62 to 0.84) respectively. Finally, for the metastatic involvement of lymph nodes (N‐stage), the meta‐analysis of 44 studies (n = 3573) showed that the summary sensitivity and specificity were 0.83 (95% CI 0.79 to 0.87) and 0.67 (95% CI 0.61 to 0.72), respectively.
Overall, as demonstrated also by the Bayesian nomograms, which enable readers to calculate post‐test probabilities for any target condition prevalence, the EUS accuracy can be considered clinically useful to guide physicians in the locoregional staging of people with gastric cancer. However, it should be noted that between‐study heterogeneity was not negligible: unfortunately, we could not identify any consistent source of the observed heterogeneity. Therefore, all accuracy measures reported in the present work and summarizing the available evidence should be interpreted cautiously. Moreover, we must emphasize that the analysis of positive and negative likelihood values revealed that EUS diagnostic performance cannot be considered optimal either for disease confirmation or for exclusion, especially for the ability of EUS to distinguish T1a (mucosal) versus T1b (submucosal) cancers and positive versus negative lymph node status.
Authors' conclusions
By analyzing the data from the largest series ever considered, we found that the diagnostic accuracy of EUS might be considered clinically useful to guide physicians in the locoregional staging of people with gastric carcinoma. However, the heterogeneity of the results warrants special caution, as well as further investigation for the identification of factors influencing the outcome of this diagnostic tool. Moreover, physicians should be warned that EUS performance is lower in diagnosing superficial tumors (T1a versus T1b) and lymph node status (positive versus negative). Overall, we observed large heterogeneity and its source needs to be understood before any definitive conclusion can be drawn about the use of EUS can be proposed in routine clinical settings.
New technologies in endoscopic ultrasound(EUS) evaluation have been developed because of the need to improve the EUS and EUS-fine needle aspiration(EUS- FNA) diagnostic rate. This paper reviews the ...principle, indications, main literature results, limitations and future expectations for each of the methods presented. Contrast-enhanced harmonic EUS uses a low mechanical index and highlights slowflow vascularization. This technique is useful for differentiating solid and cystic pancreatic lesions and assessing biliary neoplasms, submucosal neoplasms and lymph nodes. It is also useful for the discrimination of pancreatic masses based on their qualitative patterns; however, the quantitative assessment needs to be improved. The detection of small solid lesions is better, and the EUS-FNA guidance needs further research. The differentiation of cystic lesions of the pancreas and the identification of the associated malignancy features represent the main indications. Elastography is used to assess tissue hardness based on the measurement of elasticity. Despite its low negative predictive value, elastography might rule out the diagnosis of malignancy for pancreatic masses. Needle confocal laser endomicroscopy offers useful information about cystic lesions of the pancreas and is still under evaluation for use with solid pancreatic lesions of lymph nodes.
Endoscopic ultrasound–guided pancreatic cyst chemoablation is safe and effective for appropriately selected patients; however, the proper frequency of radiographic surveillance after successful ...chemoablation is unknown. Here we report the long-term follow-up of 2 randomized prospective Chemotherapy for Ablation and Resolution of Mucinous Pancreatic Cysts (ChARM) clinical trials. In addition, the performance of a postablation-reduced radiographic surveillance protocol was evaluated according to clinical and economic outcomes and patient experience metrics.
Patients who successfully completed 1 of the 2 ChARM randomized control trials were evaluated for durability of response and clinical outcomes. Patients were eligible if 2 years or more of follow-up were available and complete. We calculated economic outcomes according to Medicare allowable costs applicable to endoscopic ultrasound, magnetic resonance imaging, and outpatient clinic visits. We modeled costs of a patient followed by the ChARM Post-treatment Reduced Radiographic Surveillance Protocol compared with a similar patient followed under Fukuoka or American College of Gastroenterology (ACG) guidelines over 5 years. In addition, patients under long-term surveillance in our clinic were interviewed via a 4-question Likert-type questionnaire.
A total of 52 patients were eligible and included in the study. At the most recent follow-up of the 52 patients, 36 (69.2%) achieved complete response, an additional 11 (21.2%) showed partial response, and only 5 (9.6%) showed nonresponse. All patients were successfully reduced to annual or less surveillance without recurrence or the development of cyst-associated malignancy. Compared with Fukukoa or ACG guidelines, a patient treated and followed under the ChARM Post-treatment Reduced Radiographic Surveillance Protocol incurred a Medicare allowable cost of $7200.00 versus $19,437.44 and $12,526.52 if untreated and observed under Fukukoa and ACG guidelines, respectively. The patient experience questionnaire was returned completed by 49 participants.
The ChARM Post-treatment Reduced Radiographic Surveillance Protocol safely allows a reduction in radiographic surveillance. A reduction in cost associated with cyst management under the ChARM protocol, compared with management following Fukukoa or ACG guidelines, was shown. According to the questionnaire, most patients reported a moderate level of logistical and emotional burden associated with magnetic resonance imaging surveillance, and a majority were in favor of reducing the frequency of radiographic surveillance if it could be done without a marked increase in oncologic risk.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
At present, clinicians routinely apply ultrasound endoscopy in a variety of interventional procedures that provide treatment solutions for diseased organs. Ultrasound endoscopy not only produces ...high-resolution images, but also is safe for clinical use and broadly applicable. However, for soft tissue imaging, its mechanical wave-based image contrast fundamentally limits its ability to provide physiologically specific functional information. By contrast, photoacoustic endoscopy possesses a unique combination of functional optical contrast and high spatial resolution at clinically relevant depths, ideal for imaging soft tissues. With these attributes, photoacoustic endoscopy can overcome the current limitations of ultrasound endoscopy. Moreover, the benefits of photoacoustic imaging do not come at the expense of existing ultrasound functions; photoacoustic endoscopy systems are inherently compatible with ultrasound imaging, thereby enabling multimodality imaging with complementary contrast. Here we present simultaneous photoacoustic and ultrasonic dual-mode endoscopy and show its ability to image internal organs in vivo, thus illustrating its potential clinical application.
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DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
The detection rate of gastrointestinal subepithelial lesions (SELs) has recently increased with the rise in screening endoscopies. Presumptive diagnoses can be made based on endoscopic features such ...as color, consistency, size, mobility, shape, and location, prior to definitive histologic diagnoses. For a more accurate differential diagnosis of SELs, endoscopic ultrasonography (EUS) may be necessary. EUS enables the identification of SEL characteristics like the layer of origin, exact size, depth of invasion, echogenicity, and borderline. It can also assess regional lymph node metastases. The behavior and treatment strategies for gastrointestinal SELs vary according to the characteristics of the tumor and the affected site. Neuroendocrine tumors (NETs), a type of SEL with malignant potential, can occur anywhere in the gastrointestinal tract, but are most commonly found in the rectum. Factors that increase the risk of local and distant metastases of rectal NETs include tumor size, involvement of the muscularis propria, differentiation index, and lymphovascular invasion. Therefore, EUS can assist in determining therapeutic strategies and predicting prognosis by measuring the size and depth of invasion of rectal NETs and regional lymph node metastases. However, its role in tissue acquisition is limited in the case of rectal NETs. This review focuses on the clinical applications of EUS imaging in diagnosing and treating rectal NETs.
Abstract Study objectives Recently, less invasive methods have emerged as potential alternatives for staging with tissue confirmation of suspected metastatic mediastinal lymph nodes in lung cancer. ...The objective of this review was to assess the overall diagnostic accuracy of EBUS-TBNA in detecting metastatic mediastinal lymph node in lung cancer with a meta-analysis. Methods The MEDLINE, EMBASE, Cancerlit and Cochrane Library database, from January 1995 to September 2008, were searched for studies evaluating EBUS-TBNA accuracy. Meta-analysis methods were used to pool sensitivity and specificity and to construct summary receiver-operating characteristic. Results A total of 11 studies with 1299 patients, who fulfilled all of the inclusion criteria, were considered for the analysis. No publication bias was found. EBUS-TBNA had a pooled sensitivity of 0.93 (95% CI, 0.91–0.94) and a pooled specificity of 1.00 (95% CI, 0.99–1.00). The subgroup of patients who were selected on the basis of CT or PET positive results had higher pooled sensitivity (0.94, 95% CI 0.93–0.96) than the subgroup of patients without any selection of CT or PET (0.76, 95% CI 0.65–0.85) ( p < 0.05). Study sensitivity was not correlated with the prevalence of lymph node metastasis. Only two complications occurred (0.15%). Conclusion EBUS-TBNA was an accurate, safe and cost-effective tool in lung cancer staging. The selection of patients who had positive results of suspected lymph node metastasis in CT or PET may improve the sensitivity of EBUS-TBNA. High-quality prospective studies regarding EBUS-TBNA in lung cancer staging are still needed to be conducted.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background: Patients may experience anxiety, discomfort, and pain during endoscopy, which cannot be tolerated without sedative drugs. Objectives: This study aimed to compare the sedative effects of ...dexmedetomidine and midazolam on patients undergoing endosonography outside the operating room. Methods: This randomized, double-blind clinical trial was conducted on 126 patients aged 18 - 65 years old with American Society of Anesthesiologists (ASA) physical status I - II undergoing elective endosonography. Patients were randomly divided into 2 groups. The dexmedetomidine group received dexmedetomidine (1 μg/kg) for 25 minutes with propofol (0.5 mg/kg) and fentanyl (1 μg/kg) at the start of the procedure. The midazolam group received midazolam (0.03 mg/kg) with propofol (0.5 mg/kg) and fentanyl (1 μg/kg). Heart rate, mean arterial pressure (MAP), and oxygen saturation (SpO2) were recorded before and 5, 10, and 15 minutes after starting the procedure. The Ramsay Sedation Scale (RSS) and the need for an additional dose of propofol were recorded during the procedure. The Numeric Pain Rating scale (Ambesh score) scores were recorded at the beginning, immediately after, and 1 hour after the procedure. Nausea and vomiting were assessed using the Visual Analogue Scale in cooperation with the patient. Results: The dexmedetomidine group had significantly higher SpO2 and RSS scores during sedation than the midazolam group (P = 0.02). Overall, specialist satisfaction was higher in the dexmedetomidine group than in the midazolam group. There was no clinically significant difference in pain score and nausea and vomiting frequencies between the 2 groups. Conclusions: Dexmedetomidine is more effective than midazolam for sedation during gastrointestinal endosonography.
Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with ...adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Stent misdeployment (SM) has hindered the dissemination of EUS-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction (GOO) management. We aimed to provide a classification system for SM ...during EUS-GE and study clinical outcomes and management accordingly.
This is a retrospective study involving 16 tertiary care centers (8 in the United States, 8 in Europe) from March 2015 to December 2020. Patients who developed SM during EUS-GE for GOO were included. We propose classifying SM into 4 types. The primary outcome was rate and severity of SM (per American Society for Gastrointestinal Endoscopy lexicon), whereas secondary outcomes were clinical outcomes and management of dislodgement according to the SM classification type, in addition to salvage management of GOO after SM.
From 467 EUS-GEs performed for GOO during the study period, SM occurred in 46 patients (9.85%). Most SMs (73.2%) occurred during the first 13 EUS-GE cases by the performing operators. SM was graded as mild (n = 28, 60.9%), moderate (n = 11, 23.9%), severe (n = 6, 13.0%), or fatal (n = 1, 2.2%), with 5 patients (10.9%) requiring surgical intervention. Type I SM was the most common (n = 29, 63.1%), followed by type II (n = 14, 30.4%), type IV (n = 2, 4.3%), and type III (n = 1, 2.2%). Type I SM was more frequently rated as mild compared with type II SM (75.9% vs 42.9%, P = .04) despite an equivalent rate of surgical repair (10.3% vs 7.1%, P = .7). Overall, 4 patients (8.7%) required an intensive care unit stay (median, 2.5 days). The median length of stay was 4 days after SM.
Although SM is not infrequent during EUS-GE, most are type I, mild/moderate in severity, and can be managed endoscopically with a surgical intervention rate of approximately 11%.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Despite substantial efforts at early diagnosis, accurate staging and advanced treatments, esophageal cancer(EC) continues to be an ominous disease worldwide. Risk factors for esophageal carcinomas ...include obesity, gastroesophageal reflux disease, hard-alcohol use and tobacco smoking. Five-year survival rates have improved from 5% to 20% since the 1970 s, the result of advances in diagnostic staging and treatment. As the most sensitive test for locoregional staging of EC, endoscopic ultrasound(EUS) influences the development of an optimal oncologic treatment plan for a significant minority of patients with early cancers, which appropriately balances the risks and benefits of surgery, chemotherapy and radiation. EUS is costly, and may not be available at all centers. Thus, the yield of EUS needs to be thoughtfully considered for each patient. Localized intramucosal cancers occasionally require endoscopic resection(ER) for histologic staging or treatment; EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of ER. Although positron emission tomography(PET) has been increasingly utilized in staging EC, it may be unnecessary for clinical staging of early, localized EC and carries the risk of false-positive metastasis(over staging). In EC patients with evidence of advanced disease, EUS or PET may be used to define the radiotherapy field. Multimodality staging with EUS, crosssectional imaging and histopathologic analysis of ER, remains the standard-of-care in the evaluation of early esophageal cancers. Herein, published data regarding use of EUS for intramucosal, local, regional and metastatic esophageal cancers are reviewed. An algorithm to illustrate the current use of EUS at The University of Texas MD Anderson Cancer Center is presented.
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