Top takeaways in endoscopic ultrasound from DDW

In this Peer Perspective Guest Commentary from Digestive Disease Week, Paul Sepe, MD, specialist in gastroenterology and advanced endoscopy at Hawthorn Medical Associates, Dartmouth, Mass., reviews the best of DDW in the area of endoscopic ultrasound.

Endoscopic ultrasound has come a long way from its inception decades ago. It has evolved from a pure diagnostic technique to a very powerful and useful therapeutic tool. I continue to be excited about the many new techniques and tools available currently and on the horizon that are serving to revolutionize this field. These novel approaches have substantially influenced both the diagnostic and therapeutic spaces and many of these were highlighted at DDW. It was difficult to put together a “Best of DDW” list, but below represents my attempt to summarize a very exciting week.

Paul Sepe

1. EUS-guided fine needle biopsy (EUS-FNB) has been increasingly used as an adjunct to or in place of EUS-FNA. Studies continue to examine the yield and diagnostic accuracy of EUS-FNB especially as newer needles have and continue to hit the market. Of particular interest is whether or not FNB needles obviate the need for rapid on-site evaluation (ROSE). Rao et al. compared FNA vs. FNB and found comparable safety and diagnostic accuracy. Importantly, FNB resulted in a shorter procedural time with fewer number of passes, and ROSE did not appear to significantly impact FNB results. This suggests that perhaps ROSE may not be necessary when using FNB which could offer the potential advantage of decreased time under anesthesia and lower overall cost without sacrificing diagnostic accuracy or risk. More studies need to be done especially as newer needle technologies and designs continue to become available. Several studies examining the newer Shark-core (Medtronic-Covidien) and Acquire (Boston Scientific) FNB needles demonstrated promising results in terms of safety and yield.

2. There has been much debate about the utility and limitations of EUS-guided liver biopsy. Research has shown promise although percutaneous or transjugular biopsy remains the standard at most institutions. As above, with the development of newer FNA and FNB needles significant gains have been made in our ability to acquire sufficient tissue via EUS-guided sampling. Two studies evaluated the use of EUS-guided liver biopsy vs. percutaneous and transjugular liver biopsy (Shahshahan et al and Foor-Pessin et al). These had similar findings demonstrating comparable diagnostic yield, tissue quality, and safety profile of all three approaches. While further studies need to be done to determine ideal needle type, gauge, and number of passes, this suggests that EUS-guided liver biopsy is a feasible alternative to the more standard percutaneous and transjugular approaches.

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3. Another exciting development in the diagnostic space is the advent of a novel through-the-needle forceps to sample pancreatic cystic lesions. We rely heavily on EUS-FNA utilizing fluid analyses and cytology to diagnose these commonly encountered lesions. However, even in the best circumstances sensitivity and diagnostic yield are limited. Barnardoni et al. assessed the feasibility, safety, and diagnostic yield of a micro-forceps (Moray, US Endoscopy) passed through a 19 g FNA needle. Technical success and a macroscopic specimen were achieved in all cases (29 of 29), with a histologic diagnosis made in 79.3%. Only one complication was seen which was a case of self-limited intra-cystic bleeding. While this was only a small, retrospective study, the concept of using micro-forceps through an FNA needle has tremendous potential and may serve to be useful in numerous disease states where tissue acquisition is needed.

Much of the excitement in the therapeutic space is centered around lumen apposing metal stents (LAMS). While originally used predominantly for pseudocyst and walled off necrosis (WON) drainage, multiple other uses have been proposed, including EUS-guided biliary drainage, EUS-guided gallbladder drainage, and EUS-guided bypass procedures.

1. Multiple studies were presented evaluating LAMS for pseudocyst and WON drainage, several of which compared LAMS to plastic stents (PS) and fully covered self-expanding metal stents (FCSEMS). A study by Chen et al. suggests that LAMS is superior to these other modalities in attaining successful drainage, while resulting in shorter procedure time and fewer recurrences. Two additional studies (Kumar et al. and Siddiqui et al.) found decreased overall endoscopy charges and an economic analysis suggesting that LAMS is the preferred strategy in managing pseudocysts and WON as it offers better health outcomes at lower total cost. Finally, a study by Adler et al. looked at whether or not LAMS to drain pseudocysts and WON can be safely performed on an outpatient basis. They found that stable patients who undergo successful LAMS placement and tolerate the procedure well can be safely discharged on the day of their procedure.

2. EUS-guided biliary drainage (EUS-BD) has been used more and more for cases of failed ERCP, in particular in cases of malignant obstruction. Khan et al. conducted a meta-analysis of available studies and found that EUS-BD is associated with significantly better clinical success, increased safety profile, and decreased re-intervention rates as compared to percutaneous biliary drainage (PTBD). Bories et al. conducted a multicenter, randomized, Phase II study comparing PTBD vs. EUS-BD. The latter group included either anterograde trans-papillary stenting, choledoco-duodenostomy, or hepatico-gastrostomy. This study showed similar technical and clinical success between EUS-BD and PTBD, but lower complication rate in the EUS-BD group. While these studies were not uniform in regards to approach or type of stent used, they suggest that EUS-BD should at least be considered first after failed ERCP in select patients, especially in patients with malignant obstruction.

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3. Several studies also evaluated EUS-guided gallbladder drainage (EUS-GBD) using LAMS. Traditionally, percutaneous cholecystostomy tubes have been used for gallbladder drainage in patients with acute cholecystitis who are poor surgical candidates. EUS-GBD is being used more in select patients as an alternative. Torres-Yuste et al. looked at long-term outcomes and found no migration and no recurrent episodes of acute cholecystitis after a mean stent indwelling time of 889 days (range 371-1872 days). Vanar et al. conducted a meta-analysis assessing efficacy and safety and determined that EUS-GBD using LAMS has good success with acceptable complication rates. Finally Kunda et al. studied LAMS vs. endoscopic transpapillary drainage vs. percutaneous cholecystostomy (PC) for gallbladder drainage. They found That EUS-GBD using LAMs had similar technical success rates to PC and superior success as compared to transpapillary drainage. There were also significant lower adverse events, hospital stay, and unplanned admissions as compared to PC. While further studies need to be done, this shows tremendous promise as an eventual modality that could supplant percutaneous cholecystostomy as a first line approach for gallbladder drainage in poor surgical candidates.

4. Last but not least, significant interest has been given recently to EUS-guided gastrojejunostomy and other bypass procedures using LAMS for malignant and even some benign diseases. Through literature search, H. Zhang describes several groups who may benefit from such procedures: 1) Patients undergoing EUS-guided gastrojejunostomy or gastroduodenostomy for malignant or benign gastric outlet obstruction; 2) Patients with afferent limb syndrome after whipple, gastric bypass, or Roux-en-Y hepaticojejunostomy managed with EUS-guided gastrojejunostomy, jejunojejunostomy, or duodenojejunostomy; 3) Patients with Roux-en-Y gastric bypass anatomy managed by EUS-directed ERCP through a gastro-gastric or jejuno-jejunal fistula creation; 4) Patients with simultaneous biliary obstruction and gastric outlet obstruction managed by dual EUS-guided bypass merging gastrojejunostomy with choledochoduodenostomy. In addition, Irani et al. presented a video at the ASGE video plenary on EUS-guided gastrojejunostomy for gastric outlet obstruction. They describe five techniques for gastrojejunostomy creation utilizing LAMS. While extensive further study needs to be done to determine the ideal patient, technique, and indication, this highlights some very exciting new modalities in therapeutic EUS.

We did not have an opportunity to discuss advances in EUS imaging modalities or progress in EUS-guided tumor ablation but there is much promise in these areas as well. Given the recent advances highlighted above in both diagnostic and therapeutic EUS it seems the sky is the limit. I am excited to see the clinical impact these will have in academic and community GI practice as well as the arrival of even newer modalities on the horizon.

References:

Rao B. Su1311. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Attili F. Su1338. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Adler DG. Su1319. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Al-Haddad M. Su1320. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Jovani M. Su1337. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Barnardoni L. Su1306. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Shahshahan M. Mo1285. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Foor-Pessin C. 1273. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Chen Y. Mo1240. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Kumar S. Su1377. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Siddiqui A. Su1300. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Adler DG. Su1310. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Bories E. Mo1237. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Khan MW. Mo1238. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Vanar V. Mo1235. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Torres-Yuste R. 213. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Kunda R. 212. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Zhang H. Su1336. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Irani SS. 865. Presented at Digestive Diseases Week; May 6-9, 2017; Chicago.

Disclosures: Sepe reports no relevant financial disclosures. For specific disclosures on presentations, please refer to DDW.org.