Learning in therapeutic EUS

Training and quality indicators in interventional endoscopic ultrasound

Endoscopic ultrasound (EUS) has transformed the landscape of minimally invasive gastrointestinal procedures, necessitating specialized training for proficiency in interventional EUS (iEUS). This study evaluates the effectiveness of iEUS training, focusing on learning curves, success rates, and the associated risks in various procedures, aiming to recommend practices for standardizing training and ensuring competency. Key metrics such as procedure type, learning curve for proficiency, success rates, and risk of adverse events were analyzed to establish benchmarks for training programs. Proficiency in pancreatic fluid collection drainage was achieved after 20-30 procedures, with a 100% success rate and a complication rate ranging from 1.5 to 80%. Gallbladder drainage required 19 cases to reach an 86% success rate, with adverse events reported in 19% of cases. Choledocoduodenostomy mastery was observed after approximately 100 cases, with postintervention pancreatitis affecting 5.3-6.6% of all cases. Hepaticogastrostomy showed a 93% success rate after 33 cases, with a 24.8% adverse event rate. Hepaticoenterostomy reached 100% success beyond the 40th patient, with a 20% rate of postsurgical strictures. Pancreatic duct drainage achieved 89% technical and 87% clinical success after 27 cases, with 12-15% adverse events. Gastro-enteric anastomosis required 25 cases for proficiency and approximately 40 cases for mastery, with 5.5% immediate and 1% late adverse events. iEUS training outcomes vary significantly across different procedures, highlighting the importance of structured, procedure-specific training programs to achieve proficiency. These findings provide a foundation for developing universal competency benchmarks in iEUS, facilitating consistent and effective training worldwide.

Endoscopic ultrasound drainage of pancreatic fluid collections: do we know enough about the best approach?

Pancreatic fluid collection often occurs as a local complication of acute pancreatitis, and drainage is indicated in symptomatic patients. The drainage may be surgical, percutaneous, or endoscopic ultrasound (EUS) guided. In symptomatic collections older than 4 weeks and localized in the upper abdomen, EUS-guided drainage is the first choice of treatment. Lumen-apposing metal stents are useful in cases of walled-off necrosis, facilitating access to the cavity; however, they do not reduce the number of necrosectomy sessions required. In most pancreatic pseudocysts requiring drainage, plastic stents remain the first choice of treatment. This review aimed to summarize the principles and techniques of step-up therapy of pancreatic fluid collections, including preprocedural and postprocedural assessment and practical approaches of drainage and necrosectomy, making available evidence more accessible to endoscopists aiming to train for this procedure. Successful and safe EUS drainage connotes early recognition and treatment of complications and the presence of a multidisciplinary team for optimal patient management. However, the best time for necrosectomy, modality of drainage method (lumen-apposing metal stents or plastic stents), and duration of antibiotherapy are still under evaluation.

The ultrasound use of simulators, current view, and perspectives: Requirements and technical aspects (WFUMB state of the art paper)

Simulation has been shown to improve clinical learning outcomes, speed up the learning process and improve learner confidence, whilst initially taking pressure off busy clinical lists. The World Federation for Ultrasound in Medicine and Biology (WFUMB) state of the art paper on the use of simulators in ultrasound education introduces ultrasound simulation, its advantages and challenges. It describes different simulator types, including low and high-fidelity simulators, the requirements and technical aspects of simulators, followed by the clinical applications of ultrasound simulation. The paper discusses the role of ultrasound simulation in ultrasound clinical training, referencing established literature. Requirements for successful ultrasound simulation acceptance into educational structures are explored. Despite being in its infancy, ultrasound simulation already offers a wide range of training opportunities and likely holds the key to a broader point of care ultrasound education for medical students, practicing doctors, and other health care professionals. Despite the drawbacks of simulation, there are also many advantages, which are expanding rapidly as the technology evolves.

Percutaneous transhepatic cholangiography vs endoscopic ultrasound-guided biliary drainage: A systematic review

BACKGROUND

Percutaneous transhepatic cholangiography is a diagnostic and therapeutic procedure that involves inserting a needle into the biliary tree, followed by the immediate insertion of a catheter. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a novel technique that allows BD by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract.

AIM

To compare the technical aspects and outcomes of percutaneous transhepatic BD (PTBD) and EUS-BD.

METHODS

Different databases, including PubMed, Embase, clinicaltrials.gov, the Cochrane library, Scopus, and Google Scholar, were searched according to the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses to obtain studies comparing PTBD and EUS-BD.

RESULTS

Among the six studies that fulfilled the inclusion criteria, PTBD patients underwent significantly more reinterventions (4.9 vs 1.3), experienced more postprocedural pain (4.1 vs 1.9), and experienced more late adverse events (53.8% vs 6.6%) than EUS-BD patients. There was a significant reduction in the total bilirubin levels in both the groups (16.4-3.3 μmol/L and 17.2-3.8 μmol/L for EUS-BD and PTBD, respectively; P = 0.002) at the 7-d follow-up. There were no significant differences observed in the complication rates between PTBD and EUS-BD (3.3 vs 3.8). PTBD was associated with a higher adverse event rate than EUS-BD in all the procedures, including reinterventions (80.4% vs 15.7%, respectively) and a higher index procedure (39.2% vs 18.2%, respectively).

CONCLUSION

The findings of this systematic review revealed that EUS-BD is linked with a higher rate of effective BD and a more manageable procedure-related adverse event profile than PTBD. These findings highlight the evidence for successful EUS-BD implementation.

Ex vivo comparison of electrocautery-enhanced delivery of lumen-apposing metal stents matching electrosurgical workstations during EUS-guided gallbladder drainage

Background and Objectives

EUS-guided gallbladder drainage (EUS-GBD) has become one of the recommended treatments for patients with high-risk acute cholecystitis. However, the gallbladder reportedly collapsed due to bile leakage, which was a disadvantage that affects the surgical success rate. Different electrocautery-enhanced delivery of the lumen-apposing metal stents (ECE-LAMSs) using suitable power levels in electrosurgical workstations can increase the surgical success rate and reduce trauma. Therefore, we proposed the use of the ECE-LAMSs and electrosurgical workstations for the first time through ex vivo experiments to adjust the different power levels and select the most suitable electrosurgical power for each ECE-LAMS type.

Methods

We compared three types of ECE-LAMS (9Fr, 10.5Fr, and 10.8Fr) with three types of electrosurgical workstations during EUS-GBD. GBD was simulated ex vivo under the guidance of an ultrasound endoscope. We performed various power tests to elucidate the ideal electric power for different ECE-LAMS combined with the different types of electrosurgical workstations.

Results

For the 10.8Fr ECE-LAMS matched with the Martin, Erbe, and Olympus electrosurgical workstations, the ideal power levels were 200 W, 200 W, and 250W. For the 10.5Fr and 9Fr ECE-LAMS matched with the Martin, Erbe, and Olympus electrosurgical workstations, the ideal power levels were 150 W, 200 W, and 200 W.

Conclusion

During the operations, due to low-power levels in the electrosurgical workstations increased the number of cuts, the EUS images were obviously unclear, which affected the success rates of the operations. We suggested different power levels for the different types of LAMS and their matching electrosurgical workstations, which can increase the surgical success rates and reduce surgical injuries.