Prospective study of the clinical impact of EUS

Technical Performance, Overall Accuracy and Complications of EUS-Guided Interventional Procedures: A Dynamic Landscape

Endoscopic ultrasound (EUS) gained wide acceptance as the diagnostic and minimally invasive therapeutic approach for intra-luminal and extraluminal gastrointestinal, as well as various non-gastrointestinal lesions. Since its introduction, EUS has undergone substantial technological advances. This multi-centric study is a retrospective analysis of a prospectively maintained database of patients who underwent EUS for the evaluation of lesions located within the gastrointestinal tract and the proximal organs. It aimed to extensively assess in dynamic the dual-center EUS experience over the course of the past 20 years. Hence, we performed a population study and an overall assessment of the EUS procedures. The performance of EUS-FNA/FNB in diagnosing pancreatic neoplasms was evaluated. We also investigated the contribution of associating contrast-enhanced ultrasound imaging (CE-EUS) with EUS-FNA/FNB for differentiating solid pancreatic lesions or cystic pancreatic lesions. A total of 2935 patients undergoing EUS between 2002–2021 were included, out of which 1880 were diagnostic EUS and 1052 EUS-FNA/FNB (80% FNA and 20% FNB). Therapeutic procedures performed included endoscopic transmural drainage of pancreatic fluid collections, celiac plexus block and neurolysis, while diagnostic EUS-like CE-EUS (20%) and real-time elastography (12%) were also conducted. Most complications occurred during the first 7 days after EUS-FNA/FNB or pseudocyst drainage. EUS and the additional tools have high technical success rates and low rates of complications. The EUS methods are safe, cost effective and indispensable for the diagnostic or therapeutic management in gastroenterological everyday practice.

The impact of endoscopic ultrasound on the management and outcome of patients with oesophageal cancer: an update of a systematic review

AIM

To provide an updated systematic review concerning the impact of endoscopic ultrasound (EUS) in the modern era of oesophageal cancer staging.

MATERIALS AND METHODS

To update the previous systematic review, databases including MEDLINE and EMBASE were searched and studies published from 2005 onwards were selected. Studies reporting primary data in patients with oesophageal or gastro-oesophageal junction cancer who underwent radiological staging and treatment, regardless of intent, were included. The primary outcome was the reported change in management after EUS. Secondary outcomes were recurrence rate and overall survival. Two reviewers extracted data from included articles. This study was registered with PROSPERO (CRD42021231852).

RESULTS

Eighteen studies with 11,836 patients were included comprising 2,805 patients (23.7%) who underwent EUS compared to 9,031 (76.3%) without EUS examination. Reported change of management varied widely from 0% to 56%. When used, EUS fine-needle aspiration precluded curative treatment in 37.5%-71.4%. Overall survival improvements ranged between 121 and 639 days following EUS intervention compared to patients without EUS. Smaller effect sizes were observed in a randomised controlled trial, compared to larger differences reported in observational studies.

CONCLUSION

Current evidence for the effectiveness of EUS in oesophageal cancer pathways is conflicting and of limited quality. In particular, the extent to which EUS adds value to contemporary cross-sectional imaging techniques is unclear and requires formal re-evaluation.

Endoscopic Ultrasound Quality Metrics in Clinical Practice

Recent advances in endoscopic ultrasound (EUS), particularly EUS-guided tissue acquisition, may have affected EUS procedural performance as measured by current American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) quality indicators. Our study aims to assess how these quality metrics are met in clinical practice. We retrospectively analyzed 732 EUS procedures; data collected were procedural indications, technical aspects and outcomes, completeness of documentation, and malignancy staging. EUS was performed in 660 patients for a variety of indications. All ASGE/ACG EUS procedural quality metrics were met or exceeded. Intervention was successful in 97.7% (715/732) of cases, with complication rate of 0.4% (3/732). EUS outcomes changed clinical management in 58.7% of all cases and in 91.2% of malignancy work-up cases; in 26.0% of suspected choledocholithiasis cases, endoscopic retrograde cholangiopancreatography (ERCP) was avoided after EUS. Locoregional EUS staging was accurate in 61/65 (93.8%) cases of non-metastatic disease and in 15/22 (68.2%) cases of metastatic disease. Pancreatic mass malignancy detection rate with EUS-guided fine needle aspiration (FNA) or fine needle biopsy (FNB) was 75.8%, with a sensitivity of 96.2%; a significant increase in detection rate from 46.2% (6/13) to 95.0% (19/20) (p = 0.0026) was observed with a transition to the predominant use of FNB for tissue acquisition. All ASGE/ACG EUS quality metrics were met or exceeded for EUS procedures performed for a wide variety of indications in a diverse patient population. EUS was instrumental in changing clinical management, with a low complication rate. The malignancy detection rate in pancreatic masses significantly increased with FNB use.

Advances in endoscopic ultrasound imaging of colorectal diseases

The development of endoscopic ultrasound (EUS) has had a significant impact for patients with digestive diseases, enabling enhanced diagnostic and therapeutic procedures, with most of the available evidence focusing on upper gastrointestinal (GI) and pancreatico-biliary diseases. For the lower GI tract the main application of EUS has been in staging rectal cancer, as a complementary technique to other cross-sectional imaging methods. EUS can provide highly accurate in-depth assessments of tumour infiltration, performing best in the diagnosis of early rectal tumours. In the light of recent developments other EUS applications for colorectal diseases have been also envisaged and are currently under investigation, including beyond-rectum tumour staging by means of the newly developed forward-viewing radial array echoendoscope. Due to its high resolution, EUS might be also regarded as an ideal method for the evaluation of subepithelial lesions. Their differential diagnosis is possible by imaging the originating wall layer and the associated echostructure, and cytological and histological confirmation can be obtained through EUS-guided fine needle aspiration or trucut biopsy. However, reports on the use of EUS in colorectal subepithelial lesions are currently limited. EUS allows detailed examination of perirectal and perianal complications in Crohn’s disease and, as a safe and less expensive investigation, can be used to monitor therapeutic response of fistulae, which seems to improve outcomes and reduce the need for additional surgery. Furthermore, EUS image enhancement techniques, such as the use of contrast agents or elastography, have recently been evaluated for colorectal indications as well. Possible applications of contrast enhancement include the assessment of tumour angiogenesis in colorectal cancer, the monitoring of disease activity in inflammatory bowel disease based on quantification of bowel wall vascularization, and differentiating between benign and malignant subepithelial tumours. Recent reports suggest that EUS elastography enables highly accurate discrimination of colorectal adenocarcinomas from adenomas, while inflammatory bowel disease phenotypes can be distinguished based on the strain ratio calculation. Among EUS-guided therapies, the drainage of abdominal and pelvic collections has been regarded as a safe and effective procedure to be used as an alternative for the transcutaneous route, while the placing of fiducial markers under EUS guidance for targeted radiotherapy in rectal cancer or the use of contrast microbubbles as drug-delivery vehicles represent experimental therapeutic applications that could greatly impact the forthcoming management of patients with colorectal diseases, pending on further investigations.

Advanced EUS imaging for early detection of pancreatic cancer

Endoscopic ultrasound (EUS)-fine needle aspiration remains the gold standard for diagnosing pancreatic malignancy. However, in a subset of patients, limitations remain in regards to image quality and diagnostic yield of biopsies. Several new devices and processors have been developed that allow for enhancement of the EUS image. Initial studies of these modalities do show promise. However, cost, availability, and overall incremental benefit to EUS-fine needle aspiration have yet to be determined.

State-of-the-art imaging techniques in endoscopic ultrasound

Endoscopic ultrasound (EUS) has recently evolved through technological improvement of equipment, with a major clinical impact in digestive and mediastinal diseases. State-of-the-art EUS equipment now includes real-time sono-elastography, which might be useful for a better characterization of lesions and increased accuracy of differential diagnosis (for e.g. lymph nodes or focal pancreatic lesions). Contrast-enhanced EUS imaging is also available, and is already being used for the differential diagnosis of focal pancreatic masses. The recent development of low mechanical index contrast harmonic EUS imaging offers hope for improved diagnosis, staging and monitoring of anti-angiogenic treatment. Tridimensional EUS (3D-EUS) techniques can be applied to enhance the spatial understanding of EUS anatomy, especially for improved staging of tumors, obtained through a better assessment of the relationship with major surrounding vessels. Despite the progress gained through all these imaging techniques, they cannot replace cytological or histological diagnosis. However, real-time optical histological diagnosis can be achieved through the use of single-fiber confocal laser endomicroscopy techniques placed under real-time EUS-guidance through a 22G needle. Last, but not least, EUS-assisted natural orifice transluminal endoscopic surgery (NOTES) procedures offer a whole new area of imaging applications, used either for combination of NOTES peritoneoscopy and intraperitoneal EUS, but also for access of retroperitoneal organs through posterior EUS guidance.

EUS and survival in patients with pancreatic cancer: a population-based study

BACKGROUND

There is no direct evidence that EUS improves patient outcome.

OBJECTIVE

To study the association of undergoing EUS with survival in patients with pancreatic adenocarcinoma.

DESIGN

Population-based study.

PATIENTS

Persons aged 65 years and older with a diagnosis of pancreatic cancer who were captured in the linked Surveillance Epidemiology and End Results-Medicare database between 1994 and 2002 were identified.

INTERVENTIONS

Demographic, cancer-specific, and EUS procedural information was extracted, and survival curves were compared for patients who underwent EUS in the peridiagnostic period (1 month before the diagnosis to 3 months after the date of diagnosis: group I) with those who had not undergone EUS (group II).

MAIN OUTCOME MEASUREMENTS

Relative hazard ratios for survival.

RESULTS

A total of 8616 patients with pancreatic adenocarcinoma were identified. Only 610 (7.1%) patients underwent EUS evaluation. In patients with locoregional cancer, the median survival (interquartile range) in group I and II patients was 10 (5-17) and 6 (2-12) months, respectively, P < .0001. There were more patients with early-stage disease in group I than group II (69.3% vs 36.2%, P < .001). Curative-intent surgery, chemotherapy, and radiation therapy were also performed more frequently in the patients in group I. Undergoing EUS, adjusted for age, race, sex, tumor stage, curative-intent surgery, chemotherapy, radiation therapy, and comorbidity score, was an independent predictor of improved survival (relative hazard, 0.71; 95% CI, 0.63-0.79).

LIMITATIONS

Retrospective design.

CONCLUSIONS

EUS evaluation is independently associated with improved outcome in patients with locoregional pancreatic cancer, possibly because of detection of earlier cancers and improved stage-appropriate management including more selective performance of curative-intent surgery.

Downstream hospital charges generated from endoscopic ultrasound procedures are greater than those from colonoscopies

BACKGROUND & AIMS

Endoscopic ultrasound is a clinically valuable endoscopic platform, although a potential barrier to its widespread use is the modest reimbursement to the hospital, compared with that of standard endoscopy. However, the downstream procedures generated by endoscopic ultrasound findings might offset its modest procedural reimbursement for a hospital or health care system. We compared the number of hospital procedures that resulted from endoscopic ultrasound findings with those from colonoscopy findings and also compared the downstream hospital charges generated by endoscopic ultrasounds with those from colonoscopies.

METHODS

We retrospectively reviewed data from 920 consecutive endoscopic ultrasounds and 920 consecutive colonoscopies performed at University Hospital in Cincinnati, Ohio to determine the downstream procedures generated within 18 months of the index procedure. Total hospital charges were determined for the index procedures, as well as all downstream surgeries, endoscopic procedures, and radiation therapy, chemotherapy, and interventional radiology procedures.

RESULTS

Endoscopic ultrasounds led to a greater number of downstream procedures than colonoscopies (198 vs 34). Hospital charges for downstream procedures that arose from endoscopic ultrasounds were 2.63-fold greater than those of colonoscopies ($4,068,115 vs $1,546,291). Hospital charges that resulted from the 920 index endoscopic ultrasounds were 1.34-fold greater than those of the index colonoscopies ($3,194,715 vs $2,381,745). Thus, the total hospital charges (index procedures plus downstream procedures) that arose from endoscopic ultrasounds were 1.85-fold greater than those of colonoscopies ($7,262,830 vs $3,928,036).

CONCLUSIONS

Endoscopic ultrasounds generate greater downstream hospital charges than colonoscopies. These downstream charges attenuate the higher procedure-related charges of colonoscopy for a hospital.

Systematic review of the impact of endoscopic ultrasound on the management of patients with esophageal cancer

OBJECTIVES

Although endoscopic ultrasound (EUS) staging of esophageal cancer is established in clinical practice, high-quality evidence about its impact on patient outcomes is not available. This study aims to determine the impact of EUS for esophageal cancer staging on patient management and survival.

METHODS

A systematic review was conducted using Medline, PreMedline, Embase, and The Cochrane Library. Included studies were (i) comparative studies reporting survival following EUS esophageal cancer staging, (ii) therapeutic impact studies reporting change in patient management following EUS. The quality of included studies was critically appraised.

RESULTS

One systematic review, five studies reporting therapeutic impact, and two studies reporting patient survival were identified. The design and quality of the therapeutic impact studies varied widely. Management changed in 24-29 percent of patients following EUS staging of esophageal cancer (two studies). No studies provided data on the avoidance of surgery for this indication. One retrospective cohort study with historical control found EUS staging of esophageal cancer improved patient survival; a second study with similar design limitations did not find a survival benefit for EUS staging in patients undergoing resection. These studies had a high potential for bias, limiting the value of these findings.

CONCLUSIONS

Two studies provided evidence of a change in patient management following EUS for staging esophageal cancer, a higher level of evidence for a clinical benefit than can be obtained from accuracy studies alone. This evidence contributed to a recommendation for public funding of EUS in staging esophageal cancer in Australia.

Current utilization and performance status of endoscopic ultrasound in a community hospital

OBJECTIVE

Endoscopic ultrasound (EUS) is an essential tool for cancer staging and investigating gastrointestinal diseases. Although it is not a widespread skill, as its expanded indications became much more advanced so did its popularity and hospital acceptance. We aimed to study the utilization and indications of upper EUS in a Hong Kong community hospital. The secondary aim was to assess our accuracy in staging of esophageal and gastric cancer and in evaluating submucosal tumors.

METHODS

All patients who had undergone upper EUS in Tuen Mun Hospital from January 2002 to December 2006 were recruited. Their background data, indications, radiological investigations, upper endoscopy and operation records and histopathologic results were retrieved for analysis. The accuracy of EUS in esophageal cancer staging, gastric cancer staging and evaluating submucosal tumors was assessed by comparing surgical and histopathologic findings.

RESULTS

A total of 645 upper EUS examinations were performed and there has been a steady increase in EUS utilization in our hospital. The most common indications were evaluating submucosal tumors and staging esophageal and gastric cancer. The accuracy of T and N staging of esophageal cancer was 71.2 and 79.7%, respectively and for gastric cancer was 64.0 and 74.7%, respectively. Endoscopic ultrasound was 70% accurate in identifying lesions arising from the submucosal layer and 100% accurate in identifying lesions from the muscularis propria.

CONCLUSION

Endoscopic ultrasound is an accurate method and its demand is increasing. The performance in a community hospital can be further improved and its utilization should expand to other indications.

Endosonography- vs. endoscopic retrograde cholangiopancreatography-based strategies in the evaluation of suspected common bile duct stones in patients with normal transabdominal imaging

BACKGROUND

Endosonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are highly accurate techniques for evaluating common bile duct stones.

AIM

To compare the clinical impact and costs of EUS- and ERCP-based strategies for evaluating patients with suspected common bile duct stones but normal transabdominal imaging.

METHODS

The costs of EUS- vs. ERCP-based strategies were compared in patients with suspected acute biliary obstruction from common bile duct stones but normal transabdominal imaging.

RESULTS

Over a 15-month period, 110 patients were recruited. EUS detected a common bile duct lesion in 73% (common bile duct stones: 68%; pancreatic cancer: 2%; ampulla tumour: 2%; cholangiocarcinoma: 1%). The sensitivity, specificity, positive predictive value and negative predictive value of EUS were 98%, 100%, 100% and 93%, respectively. EUS prevented 30% unnecessary ERCP. The mean difference in cost per patient between EUS- and ERCP-based strategies was US$166. When stratified according to clinical indications, an EUS-based strategy was costlier only in suspected biliary sepsis. Costs were similar when the indications were cholestatic jaundice, acute pancreatitis and cholestasis.

CONCLUSION

EUS prior to biliary interventions in patients with suspected common bile duct stones prevented unnecessary ERCP. It allowed a definitive diagnosis to be made prior to more invasive procedures.

Experience of endoscopic ultrasound in an Australian tertiary hospital

BACKGROUND

There is minimal prospective data on endoscopic ultrasound (EUS) experience in Australia. This study aimed to review the recent EUS experience of a single Australian tertiary hospital.

METHODS

Data of all EUS carried out at St Vincent's Hospital, Melbourne, Australia were prospectively collected from August 2002 to September 2005. Patient demographics, indications, anatomical sites of EUS and fine-needle aspiration (FNA) were extracted from the database. A subset of 231 patients were involved in a prospective study to assess the clinical effect of EUS: with accuracy and outcomes data derived from surgical histology and pre-EUS and post-EUS questionnaires.

RESULTS

Five hundred and sixty-one procedures were carried out for 526 patients. Men comprised 57% (n = 300). Mean age was 60 years (range, 19-92 years). The indications were (i) oesophageal 30.7% (n = 172); (ii) pancreaticobiliary 29.6% (n = 166); (iii) mediastinal and lung 20.7% (n = 116); (iv) gastric 15.9% (n = 89); and (v) duodenal 3.2% (n = 18). Endoscopic ultrasound-guided FNA was carried out in 30.3% procedures (170/561). Overall EUS accuracy was 84% (55/67 patients) and EUS-guided FNA accuracy was 88% (28/32 patients). There were no major complications.

CONCLUSIONS

This is the largest reported Australian experience of EUS to date. Overall EUS was accurate, safe with no major complications or mortality and had useful outcomes. The role, expertise and accessibility of EUS in the Australian clinical setting are anticipated to continue to increase.

CURRENT CLINICAL APPLICATIONS OF ENDOSCOPIC ULTRASOUND

Endoscopic ultrasound (EUS) has been developed since the early 1980s. Its clinical role in the diagnosis of gastrointestinal wall lesions and staging of gastrointestinal and lung cancer has evolved over the last two decades. Initially, it was either used as an imaging tool for gastrointestinal wall lesions or for staging of gastrointestinal tumours. However, in combination with fine-needle aspiration under real-time scanning, EUS is now being used in tissue sampling for diagnosis. In addition, EUS may be used therapeutically in coeliac plexus neurolysis or pseudocyst drainage. This review concentrates on the current applications of EUS.

Imaging in the diagnosis and treatment of non-small cell lung cancer

The available tools for diagnosing and staging lung cancer patients can be broadly categorized into non-invasive, minimally invasive and invasive (surgical) modalities. Non-invasive modalities include CT and PET. Minimally invasive modalities are endoscopic approaches, including endoscopic ultrasound, endobronchial ultrasound and transbronchial fine needle aspiration without ultrasound guidance. This review focuses on the non-invasive and minimally invasive techniques involving imaging. Application of Bayesian principles indicates that tests with a high sensitivity and specificity for detection of both systemic metastases and mediastinal nodal involvement are required for treatment selection and planning in patients with non-small cell lung cancer who would be considered for treatment with curative intent. Combined PET/CT using the glucose analogue fluorine-18 fluorodeoxyglucose currently provides the best diagnostic performance for this purpose and should now be considered the standard of care for staging non-small cell lung cancer. Endoscopic ultrasound and endobronchial ultrasound have important complementary roles to allow further evaluation of equivocal nodal abnormalities on PET or CT and to allow pathological samples to be obtained. Diagnostic CT has an important role in defining tumour relations for patients deemed suitable for surgical resection and as the initial investigation for patients with potential symptoms of lung cancer or proven lung cancer that would not be considered for curative treatment on medical grounds.