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ABSTRACT Background: In the past decades, endoscopic ultrasound has developed from a diagnostic tool to a platform for many therapeutic interventions. Various technological advancements have emerged since the last Brazilian Consensus, demanding a review and update of the recommendations based on the best scientific evidence. Methods: A group of 32 renowned echoendoscopists selected eight relevant topics to be discussed to generate clinical questions. After that, a literature review was conducted to answer these questions based on the most updated evidence. Results: Thirty-three statements were formulated and voted on by the experts to reach a consensus. The Oxford System was used to grade the level of evidence. Conclusion: There is moderate evidence to support that the needle shape, gauge, or aspiration technique does not influence the yield of endoscopic ultrasound (EUS)-guided tissue sampling of pancreatic solid lesions. There is moderate evidence to support using EUS-TTNB of the cyst wall to differentiate between mucinous and non-mucinous cystic neoplasms. There is little evidence to support the EUS-guided treatment of gastric varices. There is a high level of evidence to support that EUS-guided biliary drainage and ERCP present similar outcomes in patients with distal malignant biliary obstruction. There is a high level of evidence for using EUS to diagnose neoplastic pancreatic cysts and detect necrosis before indicating drainage. There is moderate evidence to support EUS-GE over duodenal stent for malignant gastric outlet obstruction in patients with a life expectancy higher than 2 months. There is a high level of evidence to support the use of RFA in treating both functioning and non-functioning types of NET.

Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evaluation. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP and assessing its accuracy, timing, safety, and future technological improvement. In this review, we investigate the role of EUS in identifying the actual cause of IAP by examining the available literature. We aim to assess possible existing evidence regarding EUS accuracy, timing, and safety and explore potential trends of future technological improvements in EUS for diagnostic purposes. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a crucial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visualization of the pancreas, biliary system, and adjacent structures. Microlithiasis, biliary sludge, chronic pancreatitis, and small pancreatic tumors seem to be much more accurately identified with EUS in the setting of IAP. The optimal timing for EUS is post-resolution of the acute phase of the disease. With a low rate of complications, EUS poses minimal safety concerns. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in the cytological analysis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicentre prospective studies. This review underscores EUS as a transformative tool in unraveling IAP’s enigma and advancing diagnostic and therapeutic strategies.

Objective: The aim of this study was to compare predictive factors and Radial Echoendoscopy (EUS) in the diagnosis of choledocholithiasis. Materials and Methods: Patients with suspected choledocholithiasis were recruited from April 2011 to January 2018. All patient characteristics, findings of EUS and findings of ERCP were recorded and analyzed. Results: Eighty patients were enrolled in this study. Clinical symptoms, blood chemistry and liver function test were similar in patients with and without choledocholithiasis. Using the findings of ERCP as the gold standard, Radial EUS had sensitivity and specificity for the detection of choledocholithiasis at 90.2% and 97.4%, and for choledocholithiasis and/or common bile duct sludge at 92.7% and 100%, respectively. For patients with intermediate likelihood and high likelihood from predictive factors (33 and 45), Radial EUS was positive for choledocholithiasis in 51.5% (17/33) and 46.7% (21/45), and ERCP was positive for choledocholithiasis in 54.5% (18/33) and 48.9% (22/45), respectively. Conclusion: Predictive factors, for both intermediate and high likelihood groups, were not accurate to diagnose these patients. Radial EUS is a good diagnostic tool and should done in both groups of patients to avoid unnecessary ERCP.

Background: Despite the increasing number of national departments performing endoscopic ultrasound (EUS), there are no official data regarding clinical EUS practice in Portugal. Objectives: We aimed to evaluate the current practice of EUS in Portugal. Methods: By email, we invited 1 physician of each one of the 26 national Gastroenterology Departments which perform EUS to complete a survey questionnaire available on the Google Forms platform. The online questionnaire was available from September 2017 until February 2018 and was answered only by physicians who perform EUS. Results: A total of 21/26 (80.8%) national Gastroenterology Departments answered the questionnaire. In Portugal, there are 42 echoendoscopes in total; most of the echoendoscopy units have only 1 EUS processor (81%), 1 radial echoendoscope (66.7%), 1 linear echoendoscope (76.2%), 1 anorectal probe (57.1%), but no miniprobes (85.7%). About 81% have histological core acquisition needles. In 81% of the units, there are at least 2 ultrasonographers who perform echoendoscopy together (at least 2 ultrasonographers per EUS) in 47.6% of these departments. The ultrasonographers also performed abdominal ultrasound (US), anal US, and endoscopic retrograde cholangiopancreatography in 71.4, 66.7, and 42.9%, respectively. The echoendoscopy units have 2.4 ± 1.1 periods of echoendoscopy per week and 4 ± 1.5 EUS per period (499.2 ± 416.8 EUS per year). Subepithelial lesions and biliopancreatic lesion evaluation as well as gastrointestinal neoplasia staging were the most common EUS indications. The number of FNA (fine-needle aspirations) ranges from 10 to 160/year. Rapid on-site evaluation (ROSE) is available in 60% of units and is performed by the cytopathologist (66.7%) in the majority of cases. The main reason for omitting ROSE is the limited pathology staff. Cytopathological material is prepared by the ultrasonographer in 25% of the units. Air drying (50%) and formalin (50%) are most frequently used to fix and preserve smears, respectively. Pancreatic pseudocyst drainage (66.7%), celiac plexus neurolysis (52.4%) and pancreatic necrosectomy (42.9%) are the most widespread therapeutic procedures. Conclusions: This survey provides the first insight into the current status of digestive echoendoscopy in Portugal. There is a great variability in diagnostic and therapeutic echoendoscopy practice.

Echoendoscopy, endoscopic ultrasound or endosonography is an examination that combines endoscopic and ultrasound images in order to evaluate the lesions found not only in the gastrointestinal tract wall but also around it. This investigation also allows staging patients with gastrointestinal cancer, tumors of the pancreas and lung. Therefore, the indications for endoscopic ultrasound are very broad (some more supported by the literature than others) and their utilities are multiple. The current trend is to move from diagnostic echoendoscopy to a therapeutic one, since it is being used for multiple purposes, such as guiding minimally invasive surgical procedures. A concise review of the literature was made to summarize the applications of endoscopic ultrasound, in order to familiarize gastroenterologists with their indications and possible therapeutic applications. Endoscopic ultrasound (EUS), also known as endosonography (ES) and endoscopic ultrasound (UE), is an examination that combines the endoscopic image with the ultrasound image to evaluate lesions located in and around the wall of the gastrointestinal tract. Although it was described more than 20 years ago, its indications, both diagnostic and therapeutic, remain unknown by the majority of medical specialists or general practitioners. Every day more and more publications about EUS are published, describing new indications of this interesting examination and ratifying those previously described, making it an indispensable tool within a gastroenterology service.

BACKGROUND: Echoendoscopy is a mixed technique which adds the advantages of endoscopy to those of transabdominal ultrasonography through an endoscope with transductor in its distal extremity, allowing for the evaluation of the abdominal organs reached by the endoscope and in contact with the intestinal wall. AIM: To verify the positivity rate of the echoendoscopy with puncture with thin needle (EEPTN) or (EE-PAF) in solid pancreatic mass based on the technique used in the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, University of São Paulo. METHODS: Retrospective evaluation - cohort study - of 138 patients who were submitted to echoendoscopy through aspiration puncture between May 2004 and June 2007. The data were collected through the medical charts present in the medical files of Hospital das Clínicas (Clinical Hospital) of the University of São Paulo, having as inclusion criterion the presence of solid pancreatic mass in computerized tomography and as exclusion criterion the presence of non solid pancreatic tumor. The routine technique was the one used in the Gastrointestinal Endoscopy Unit focusing the following variables: mass characteristics (size, location, presence of peripancreatic lymph node, presence of lymph node in celiac trunk); number of punctures to obtain microfragment for cytology, and experience of the professional in charge. The equipment used was an echoendoscopy device model Olympus EUS (EYES) Exera EU - C60, with electronic sectorial transductor and 22 gauges Wilson-Cook needles. RESULTS: Seventy six (55,4 %) male patients and 61 (44.5 %) female were enrolled. Age ranged from 16 to 87 years and means 59,9 years. The lesions were cephalic in 94 (68,1 %). Mass larger than 4 cm had a higher percentage of positivity reaching 40%, but lesions smaller than 2 cm had a percentage of 43% of inconclusive. Microfragments were obtained in 100% of the positive cases and only 73,1 % when negative (P=0,004). There was no statistic difference regarding the experience of the endoscopy professional. Only 80 patients had the number of punctures written down and it was noticed that there is better performance as the number of punctures was increased. The definitive histopathologycal diagnosis of pancreatic neoplasia occurred in only 41(29,7 %) patients. CONCLUSIONS: Regarding mass characteristics, when larger is the mass, larger is the positivity of the method; the location didn't correlate with higher positivity; when the lymph nodes were present, there was a tendency to positivity; concerning the number of punctures, the higher number, higher positivity; in relationship to the professional experience in endoscopy, there was no difference in the rate of positivity of the puncture of the solid pancreatic mass.RACIONAL: Ecoendoscopia é técnica mista que adiciona as vantagens da endoscopia àquelas da ecografia, somente que o procedimento ecográfico é realizado do interior dos órgãos para fora deles, no sentido centrífugo. OBJETIVO: Verificar a positividade da ecoendoscopia na punção com agulhas (EEPTN) ou (EE-PAF) em tumores sólidos pancreáticos baseados na técnica utilizada pelo Serviço de Endoscopia Digestiva do Hospital de Clínicas da Universidade de São Paulo. MÉTODOS: Cohorte retrospectiva de 138 pacientes que realizaram ecoendoscopia com punção aspirativa por agulha fina (EE-PAAF) no período de maio de 2004 a junho de 2007. Os dados foram coletados por meio de consulta aos prontuários, constantes do arquivo médico. O critério de inclusão foi a presença de massa pancreática sólida à tomografia computadorizada e o critério de exclusão a presença de tumor pancreático não sólido. Foram utilizadas as seguintes variáveis: característica da massa (tamanho, localização, presença de linfonodo peripancreático, presença de linfonodo em tronco celíaco); número de punções para obtenção de microfragmento; citologia e experiência do profissional executante. O aparelho utilizado foi um ecoendoscópio da marca Olympus, modelo OLYMPUS EUS (EYS) EXERA EU-C60, com transdutor setorial eletrônico e agulhas de 22 gauges da marca Boston Scientific. RESULTADOS: Setenta e seis (55,4 %) deles eram do sexo masculino e 61 (44,5 %) do feminino. A idade variou de 16 a 87 anos, com média de 59,9 anos. As lesões foram cefálicas em 94 (68,1 %) dos casos. Massas maiores que 4 cm tiveram percentual de positividade maior, chegando a 40%, mas as lesões menores que 2 cm obtiveram percentual de 43 % de inconclusivo. A obtenção de microfragmentos foi conseguida em 100% dos casos positivos e apenas 73,1 %, quando negativo (P=0,004). Não houve diferença estatística em relação à experiência do endoscopista. Apenas 80 pacientes tiveram anotado o número de punções e notou-se que existe melhor desempenho quanto maior for o número delas. O diagnóstico anatomopatológico definitivo de neoplasia pancreática ocorreu em apenas 41 (29,7 %) indivíduos. CONCLUSÕES: Em relação às características da massa, quanto maior ela era maior a positividade do método; a localização não correlacionou com maior positividade; há tendência de positividade quando presentes os linfonodos peripancreáticos; em relação ao número de punções, quanto maior o número delas, maior a positividade do método; em relação à experiência do profissional, não houve diferença no índice de positividade da punção da massa pancreática sólida.

Objective: the applications of endoscopic ultrasonography have diversified over recent years. The possibility of reaching cardiac territory has been successfully explored in experimental models, opening up a new field of possibilities for diagnostic and therapeutic interventions that were unthinkable until very recently. The aims set out in this study are to evaluate cardiac anatomy, its approach, the safety of the experimental procedure and the resulting morphological and histological changes after the procedure. Material and methods: the study has been performed on two adult pigs. They have undergone different surgical approaches to the cardiac cavities and descending thoracic aorta with excellent results. Results: different cardiac structures have been identified and operated upon (right auricle, left auricle, left ventricle, cardiac valves), as well as major vessels. The use of contrast, both intracavitary and from a peripheral vein, enabled us to verify the anatomical spaces studied. During the procedures we monitored for arrhythmias, hemodynamic behavior, possibility of infection by obtaining sample hemocultures before and after procedures, and response to punctures. Conclusions: the present study has enabled us to evaluate access to the heart from the esophageal lumen using endoscopic ultrasonography, with results that are very similar to those described in the current bibliography. However, we offer two novelties: puncture of the right auricle through the interauricular partition and puncture of the descending thoracic aorta, both performed with ease and apparent safety.Objetivo: las aplicaciones de la ultrasonografía endoscópica se han diversificado en los últimos tiempos. La posibilidad de acceder al territorio cardiaco se ha explorado en modelos experimentales con buenos resultados, abriendo un campo de nuevas posibilidades de intervencionismo diagnóstico y terapéutico hasta hace poco impensables. Los objetivos planteados en este trabajo pretenden evaluar la anatomía cardiaca, su abordaje, la seguridad del procedimiento experimental y los cambios morfológicos e histológicos derivados. Material y métodos: se ha trabajado con dos animales adultos de la especie porcina a los que se han practicado diversos abordajes a cavidades cardiacas y aorta torácica descendente con excelentes resultados. Resultados: se han identificado y abordado diversas estructuras cardiacas (aurícula derecha, aurícula izquierda, ventrículo izquierdo, válvulas cardiacas) y grandes vasos. El uso de contraste intracavitario y desde una vía venosa periférica ha permitido asegurar los espacios anatómicos estudiados. Durante los procedimientos se ha monitorizado la aparición de arritmias, el comportamiento hemodinámico, la posibilidad de infección mediante la obtención de hemocultivos antes y después de aquellos y la respuesta a las punciones. Conclusiones: el presente trabajo nos ha permitido evaluar el acceso al corazón desde la luz esofágica mediante ultrasonografía endoscópica, con unos resultados muy similares a los observados en la literatura, ofreciendo dos novedades como la punción de la aurícula derecha a través del tabique interauricular y de la aorta torácica descendente, de forma fácil y aparentemente segura.

Introducción: el insulinoma es el tumor endocrino pancreático más frecuente. Su diagnóstico preoperatorio ha sido motivo de controversia durante muchos años. El objetivo del trabajo es evaluar la experiencia del Hospital Ramón y Cajal en el manejo diagnóstico y terapéutico de este tipo de tumores. Material y métodos: en el periodo comprendido entre enero de 1999 y julio de 2006 fueron intervenidos en nuestro hospital 12 pacientes (9 mujeres y 3 varones) con el diagnóstico de insulinoma, con una edad media de 56 años (16-72 años). Resultados: la gammagrafía con octreótido nos permitió realizar el diagnóstico en el 33,3% de los casos, el TAC abdominal en el 83,3% y la ecoendoscopia en el 100%. El 100% de los insulinomas fue diagnosticado durante la cirugía gracias al uso de la ecografía intraoperatoria. En todos los casos se realizó la excisión completa del tumor, mediante 9 enucleaciones y 3 pancreatectomías distales. Dos pacientes presentaron una fístula pancreática y otro un pseudoquiste pancreático que se resolvieron de forma conservadora. La tasa de curación fue del 100%. El seguimiento fue de 48 meses, no encontrándose ningún caso de recidiva. Conclusión: en nuestra experiencia, creemos aconsejable la realización de TAC abdominal y ecoendoscopia como pruebas previas a la cirugía. Sin embargo, la técnica de elección sería la palpación del páncreas y la realización de una ecografía intraoperatoria. La cirugía es curativa en el 100% de los casos, y la técnica efectuada dependerá del tamaño, localización y distancia del tumor al conducto pancreático, así como su relación con el síndrome MEN-1.Introduction: insulinoma is the most frequent pancreatic endocrine tumor. Its preoperative diagnosis has been controversial for many years. The aim of this study was to evaluate the experience in the management and treatment of this kind of tumor at Hospital Ramón y Cajal. Material and methods: between January 1999 and July 2006, 12 patients were operated on in our hospital (9 females and 3 males) who had been diagnosed with insulinoma, with a mean age of 56 years (16-72 years). Results: octreotide scintigraphy allowed a diagnosis in 33.3% of cases, abdominal CT in 83.3%, and echoendoscopy in 100%. Intraoperative ultrasonography confirmed the presence of an insulinoma in 100% of cases. In all cases a complete excision was possible, with 9 enucleations and 3 distal pancreatectomies. Two patients developed a pancreatic fistula, and one a pancreatic pseudocyst that healed spontaneously without surgery. The overall cure rate was 100%. After a mean follow-up of 48 months no recurrences have been reported. Conclusion: in our experience, we consider advisable that abdominal CT and echoendoscopy be performed before surgery. However, the initial procedure of choice would be pancreas palpation and intraoperative ultrasonography. Surgery cured 100% of cases, and the procedure selected depends on size, location, distance from the main pancreatic duct, and relation to multiple endocrine neoplasm 1 (MEN-1).

Objective: almost 30% of gastroenteropancreatic neuroendocrine tumors (GEPET) escape preoperative identification using standard imaging techniques. The goal of this retrospective study is to present our cumulative experience in the assessment of GEPET by preoperative endoscopic ultrasonography (EUS), and to compare it with a literature review. Patients and methods: thirty-seven patients with suspected specific hormonal syndromes were sequentially examined with US, CT, MRI, angiography, OctreoScan, and radial and sectorial EUS. Sixteen were males (43%) and 21 were females (57%), with a mean age of 61 years (interval: 40-84 a). Of all 37 patients, 27 had 19 endocrine tumors in the pancreas and 14 tumors in their gastrointestinal tract. No tumors were demonstrated in 10 patients, hence they were used as a control group. Of all 37 patients, 24 were operated on or had histological samples collected, with the presence of 26 GEPET (10 carcinoids) being confirmed in 22 patients. Results: EUS sensitivity and diagnostic accuracy were 81% and 78%. Specificity was 80%. All these values were similar to the mean values obtained from the literature review. Three pancreatic rumors smaller than or equal to 1 cm (insulinomas) were detected, which had escaped diagnosis with previous US, CT, and MRI studies. An echoendoscopic examination of the pancreas could not be completed in two cases (5%), a pancreas carcinoid and an already gastrectomized double pancreatic gastrinoma. Conclusion: EUS is a good preoperative technique for GEPET detection, and may likely be superior to other imaging techniques in the assessment of small tumors. The usefulness of EUS as a primary exploration after US or HCT has been posited for tumor diagnosis and localization before surgery.

Introduction: endoscopic ultrasonography (EUS) has already proven useful in the assessment of submucosal lesions, and the staging of gastrointestinal cancer, particularly gastric MALT-type lymphoma. The goal of this paper was EUS staging. Patients and method: 24 patients (10 females, 14 males) with a median age of 56 years and possibly gastric MALT lymphoma (25 cases) were studied using videoendoscopy, biopsies, and echoendoscopy with 7.5- and 20-MHz radial EUS, and also with 12- and 20-MHz miniprobes (MPs). Nineteen patients were definitely evaluated (7 females, 12 males) as having 20 MALT-type lymphomas, as five patients were post-hoc disregarded when an invasive, high-grade gastric lymphoma (3c) or plasmocytoma (2c) was subsequently demonstrated. Of these 19 patients, all had T1 lesions except for two with T2 lesions; one patient had a gastroduodenal T1 lymphoma. Echographic findings with MPs were compared to EUS (gold standard) and histology both before and after eradication. Then, patients were followed up every 1-3-6 months using videoendoscopy and MPs. Results: echoendoscopy correctly identified T stages in 90% of cases. MPs identified T stages in 88% of cases, and N stages in 33% of cases, with results being slightly inferior to those obtained with conventional EUS (91 vs. 45%); they were consequently used for follow-up. After eradication, all but two patients are in complete remission and have been followed every 1-3-6 months using MPs without echographic abnormalities, except for a patient who relapsed.Introducción: la ultrasonografía endoscópica (USE) ha demostrado ya su utilidad en la evaluación de las lesiones submucosas, en la estadificación del cáncer digestivo en general, y del linfoma gástrico tipo MALT en particular. El objetivo de este trabajo fue la estadificación por USE. Pacientes y método: veinticuatro enfermos (10 mujeres y 14 varones) con edad media de 56 años y con posible linfoma gástrico tipo MALT (25 casos) fueron estudiados con videoendoscopia, biopsias y ecoendoscopia con USE radial de 7,5 y 20 MHz, y con minisondas (MS) de 12 y 20 MHz. Se evaluaron definitivamente 19 pacientes (7 mujeres y 12 varones) con 20 MALT, ya que cinco enfermos se desestimaron por demostrarse a posteriori que presentaban un linfoma gástrico invasivo de alto grado (3c) o un plasmocitoma (2c). De los 19 pacientes todos eran T1 menos dos pacientes que eran T2, y otra presentaba un linfoma T1 gastroduodenal. Los hallazgos ecográficos de las MS fueron comparados con la USE (gold standard) y con la histología antes y después de la erradicación. Después, fueron seguidos cada 1, 3 y 6 meses mediante videoendoscopia y MS. Resultados: la ecoendoscopia identificó el estadio T correcto en el 90% de los casos. Las MS identificaron el estadio T en el 88% de los casos y la N en el 33% de los casos, con resultados discretamente inferiores a los obtenidos con la USE convencional (91 y 45%), por lo que se utilizaron en el seguimiento. Después de la erradicación, todos menos dos están en remisión completa y han sido seguidos cada 1, 3 y 6 meses con las MS sin observar anomalías ecográficas, excepto una paciente que hizo una recidiva.