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Introduction and Aim: Pancreatobiliary tumours are challenging to diagnose exclusively by imaging methods. Although the optimum moment for carrying out the EUS is not well defined, it has been suggested that the presence of biliary stents may interfere with the proper staging of tumours and the acquisition of samples. We performed a meta-analysis to evaluate the impact of biliary stents on EUS-guided tissue acquisition yield., Material and Methods: We conducted a systematic review in different databases, such as PubMed, Cochrane, Medline, and OVID Database. A search was made of all studies published up to February 2022., Results: Eight studies were analyzed. A total of 3185 patients were included. The mean age was 66.9±2.7 years; 55.4% were male gender. Overall, 1761 patients (55.3%) underwent EUS guided tissue acquisition (EUS-TA) with stents in situ, whereas 1424 patients (44.7%) underwent EUS-TA without stents. The technical success was similar in both groups (EUS-TA with stents: 88% vs EUS-TA without stents: 88%, OR=0.92 [95% CI 0.55-1.56]). The type of stent, the needle size and the number of the passes were similar in both groups., Conclusions: EUS-TA has similar diagnostic performance and technical success in patients with or without stents. The type of stent (SEMS or plastic) does not seem to influence the diagnostic performance of EUS-TA. Future prospectives and RCT studies are needed to strengthen these conclusions., (Copyright © 2023 Elsevier España, S.L.U. All rights reserved.)

Background: Curvilinear array ultrasound transducers enable tissue sampling and have therapeutic capabilities. Nevertheless, colonic intubation and maneuvering with these transducers is technically challenging and is therefore typically limited to the rectosigmoid area. This retrospective cohort study aimed to evaluate the safety, feasibility, and diagnostic yield of colonoscopic ultrasound-guided fine-needle aspiration in deep colonic intubation., Impact of Innovation: The impact of this innovation is to enable tissue sampling of colonic and extracolonic lesions guided by endoscopic ultrasound., Technology, Materials, and Methods: Curvilinear array ultrasound is used in the evaluation of luminal and extraluminal colonic diseases. Thirteen patients underwent colonoscopic ultrasound with a curvilinear array ultrasound endoscope in a single center for subepithelial lesions, cancer staging, and extracolonic lesions from July 2015 to February 2021. Endosonography was performed using an Olympus EU-ME1 and GF-UCT 180 with a 5-12MHz curvilinear array transducer. The primary outcome was the percentage of patients who were successfully scanned with the endoscopic ultrasound. The secondary outcomes included the success rate of fine-needle aspiration, the diagnostic yield of the tissue samples, and the adverse events related to the procedure., Preliminary Results: A total of 13 female patients underwent colonoscopic ultrasound. All patients (100%, 13/13) were successfully scanned. Fine-needle aspiration was deemed necessary and successfully performed in 100% (5/5) of the patients. Tissue samples collected by fine-needle aspiration resulted in a diagnostic yield of 60%, and no adverse events resulted from this intervention., Conclusions: This study demonstrates the feasibility of performing colonoscopic ultrasound with a curvilinear array transducer. Fine-needle aspiration for subepithelial, colonic, and extracolonic lesions is feasible and safe in this setting with no adverse events reported in our study., Future Directions: Future research should be directed toward validating colonoscopic ultrasound with a curvilinear array transducer technique in prospective randomized trials. Studies evaluating the feasibility and safety of endoscopic ultrasound-guided interventions in the colon, such as abscess drainage and enteral anastomosis, should be considered., (Copyright © The ASCRS 2021.)

Endobronchial ultrasound has revolutionized the field of bronchoscopy and has become one of the most important tools for the diagnosis of intrathoracic lymphadenopathy and para-bronchial structures. The reach of this technique has not been limited to these structures and pleural lesions have been at times accessible. To our knowledge, pleural fluid collections have not been accessed with endobronchial ultrasound (EBUS) through oesophageal approach and rationale behind using this approach. We report a case of 70 years old man who has been referred from physician for the EBUS in view of hilar mass with mediastinal lymphadenopathy with pleural effusion. The endobronchial ultrasound through oesophagus (EUS-B) was done for thoracocentesis and lymph node cytology evaluation and ultimately endobronchial biopsy of hilar mass was done as rapid on-site (ROSE) analysis of lymph node was suggestive of necrotic tissue. The cytology report of lymph node and pleural effusion was positive for malignant cells. The final diagnosis was metastatic poorly differentiating adeno-squamous carcinoma.

Introduction: Adequate sampling by endobronchial ultrasound (EBUS)-transbronchial needle aspiration to meet the demands of precision medicine or histologic evaluation is challenging. There is increasing demand for core biopsy specimens with advances in therapy. Franseen enodoscopic ultrasound needles have shown promising results in gastroenterology application for obtaining core biopsies and same design has recently been extended for pulmonary use. We evaluated Franseen needles with EBUS to assess its utility, safety and ability to provide core biopsy specimens., Materials and Methods: Retrospective analysis of our database at the University of Utah of patients undergoing EBUS with a Franseen needle was performed to ascertain the performance characteristics of this needle in the first 100 patients after its implementation. Medical records were also reviewed to identify any immediate procedure-related complications., Results: One hundred seventy locations were sampled in 100 patients. A total of 152 lymph nodes and 18 masses were sampled. Core biopsies, as per pathology report, were seen in 87% of patients. A clinically concordant pathological diagnosis was established in 97% of patients. Diagnostic yield for granulomatous lymphadenopathy was 95.6% (22 of 23). No patient-related adverse events were noted., Conclusion: The Franseen needle evaluated in this study can safely procure core tissue samples during EBUS bronchoscopy that are adequate for histopathological diagnosis in benign and malignant lesions. Its ability to provide adequate tissue in patients with granulomatous inflammation is encouraging., (Copyright © 2020 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved.)

Introduction: Endobronchial biopsy using forceps is generally performed with a standard bronchoscope, while a needle is used with an endobronchial ultrasound (EBUS) bronchoscope. An EBUS video bronchoscope, such as the EB-530US instrument (Fujifilm, Tokyo, Japan), provides good visibility and may, therefore, enable both forceps biopsies and needle aspirations to be performed., Objectives: The aim of this study was to investigate the feasibility of performing forceps biopsies and needle aspirations using the EBUS video bronchoscope for diagnosing endobronchial lesions., Methods: Seventy patients with suspected endobronchial lesions based on a computed tomography scan were recruited and underwent forceps biopsy using the EB-530US EBUS bronchoscope. If the result of a rapid on-site cytological evaluation was negative, an additional needle aspiration of the same lesion or other target lesions was performed. The primary outcome was the completion rate of bronchoscopy, using only the EBUS bronchoscope without removal., Results: In the 70 patients, forceps biopsies and/or needle aspirations using the EBUS video bronchoscope were performed and completed without removing the EBUS bronchoscope in 67 patients (95.7%). The remaining three patients required the removal of the EBUS bronchoscope from the trachea (blood clot obstruction of the working channel in one patient and change to a thin bronchoscope to sample an EBUS bronchoscope-inaccessible lesion in two others). The EBUS bronchoscope provided diagnostic material in 66 patients (94.3%). One case each of bleeding and pneumonia were observed (1.4%)., Conclusion: Both forceps biopsy and needle aspiration are feasible using a Fujifilm EB-530US EBUS video bronchoscope., (© 2020 John Wiley & Sons Ltd.)

Background: Recently, a novel 22-gauge needle with three symmetric needle points and crown-shaped cutting heels, known as a Franseen needle, has been developed for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB)., Aim: To assess the histological material acquisition rate and histological diagnostic capability of the 22-gauge Franseen needle (AC22) during EUS-FNB for solid lesions., Methods: This study was designed as an open-label, multicenter, prospective, single-arm pilot study of EUS-FNB using AC22 for the diagnosis of solid lesions. Three passes of FNB using AC22 were performed for all lesions. The primary endpoints were the histological material acquisition rate and histological diagnostic capability. The secondary endpoints were the technical success rate, quality of histological samples, number of passes for diagnosis, and safety., Results: Between September 2017 and May 2018, 75 patients were enrolled. The final diagnoses were malignancy in 65 and benign in 10. Three passes of FNB were technically successful in all patients. The sensitivity, specificity, and accuracy for the malignancy of histological analyses were 92.3% (60/65), 100% (10/10), and 93.3% (70/75), respectively, for the first pass and 95.4% (62/65), 100% (10/10), and 96% (72/75), respectively, for combined three passes. The diagnostic yield plateaued after the second pass. Sufficient tissue samples for histological interpretation were obtained in 96% (72/75) and 100% (75/75) patients for the single pass and combined three passes, respectively. Two patients (2.7%) developed mild pancreatitis as an adverse event., Conclusion: EUS-FNB using AC22 showed high histological diagnostic capability with the high first pass yield., Clinical Trials Registry: UMIN Clinical Trials Registry (UMIN ID: UMIN000036641).

Background: There are different techniques for obtaining tissue using a fine needle guided by endoscopic ultrasound (EUS); all aim to obtain the most appropriate material, free of defects, of good quality and in sufficient quantity., Objective: The objective of the study was to determine which of the two EUS-guided techniques (capillary and wet) provides better quality samples for cytopathological analysis and which should be used for obtaining tissue from pancreatic, bile duct, liver, and lymph node tumors., Material and Methods: We conducted a pilot prospective study that included 26 patients with evidence of pancreatic tumor, liver tumor, and/or lymph node metastasis of primary tumor. All patients were subjected to two different tissue sampling techniques, the capillary technique and the wet technique, during the same procedure. Both techniques relied on EUS guidance. The samples obtained for the cytopathological analysis were evaluated in blinded manner by two different pathologists., Results: Pathologist A was able to make a diagnosis using the capillary technique in 96.15% of the cases and in 88.46% of the cases using the wet technique. Pathologist B was able to make a diagnosis using the capillary technique in 96.15% of the cases and in 92.30% of the cases using the wet technique. The kappa coefficient between observers for histopathological diagnosis was 1 for capillarity and 0.948 for wet technique., Conclusion: The capillary technique yielded better results than the wet technique in terms of sample quality and cellularity., (Copyright: © 2020 Permanyer.)

Background: Endoscopic ultrasound-guided liver biopsy (EUS-LB) is a safe and effective method for accomplishing parenchymal liver biopsy. The aim of this study was to compare a 19 G aspiration needle (FNA) with a 19 G Franseen-tip core biopsy needle (FNB) for EUS-LB., Methods: This was a prospective, parallel group, randomized trial comparing the tissue yields and adequacy of a 19 G FNA needle vs. a 19 G FNB needle for EUS-LB. The primary outcome was length of the longest piece of liver core specimen. Secondary outcomes were aggregate specimen length, number of complete portal triads (CPTs), and adverse events. One transgastric pass and one transduodenal pass were performed with the same needle in each patient. Specimen lengths were measured before and after histological processing., Results: 40 patients referred for EUS-LB were randomized to either the FNA group (n = 20) or the FNB group (n = 20). Both groups had similar patient characteristics. FNB biopsies yielded longer mean (standard deviation) specimen lengths (pre-processing mean 2.09 cm [0.41] vs. mean 1.47 cm [0.46], and post-processing mean 1.78 cm [0.66] vs. mean 1.05 cm [0.42]; both P  < 0.001), a longer aggregate specimen length (pre-processing mean 15.78 cm [5.19] vs. 10.89 cm [4.38]; P  = 0.003), and more CPTs (mean 42.6 25 vs 18.1 [9.3]; P  < 0.001) compared with the FNA needle. There were no severe adverse events or difference in adverse event rate between the two needles. Post-biopsy pain was noted in 37.5 %., Conclusion: EUS-LB using the FNB needle delivered longer liver biopsy specimens with more CPTs than the regular (non-core) needle., Competing Interests: Dr. Diehl is a consultant for Boston Scientific, Olympus America, Medtronic, and Cook (all manufacturers of needles used for endoscopic ultrasound)., (Owner and Copyright © Georg Thieme Verlag KG 2019.)

The endobronchial ultrasound is a minimally invasive technique that simultaneously associates ultrasound and bronchoscopy, to visualize lung nodule or masses, airway wall, and structures adjacent to the tracheobronchial tree. Endobronchial ultrasound has been incorporated into clinical practice all over the world because of its low risk and high diagnostic yield in neoplastic and non-neoplastic disease.

Competing Interests: None

Background: Liver biopsy through endoscopic ultrasound (EUS) has become a novel approach for tissue acquisition. We aim to evaluate the adequacy of EUS-guided liver biopsies in comparison to those obtained through interventional radiology (IR) techniques., Methods: A retrospective single-center analysis was performed of all IR (transjugular or image-guided percutaneous) and EUS-guided liver biopsies performed at an academic medical center from January 2016 to January 2018. Patient demographics, histologic characteristics, and clinical outcomes were collected., Results: 152 procedures were included for analysis. 45% of liver biopsies were performed through EUS-guidance. The most common indication for liver biopsy was NASH fibrosis staging (n = 64). IR-guided biopsies contained a higher number of complete portal triads (13.6 vs. 10.8 p ≤ 0.01) while EUS-guided biopsies produced an increased total specimen length (4.6 cm vs. 3.6 cm p ≤ 0.01).47% of biopsy samples were fragmented with the majority of these (72%) occurring with EUS-guided procedures (p ≤ 0.01). IR-guided biopsies led to more complications in comparison to EUS-guided procedures (p = 0.03) CONCLUSION: Liver biopsies performed through EUS-guidance are comparable to IR-guided liver biopsies and may have an enhanced safety profile with acceptable tissue acquisition characteristics. Standardization of techniques and needles is needed for optimization of tissue sampling., (Copyright © 2019 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: A forward-viewing linear (FVL) echoendoscope has been developed with the aim of overcoming some of the limitations of standard curved linear-array (CLA) echoendoscopes. There are no existing studies comparing the performance of the two echoendoscopes for endoscopic ultrasound-guided tissue acquisition (EUS-TA) of solid lesions other than subepithelial lesions., Methods: This was a prospective, multicenter, randomized trial with a noninferiority design comparing FVL vs. CLA echoendoscopes in patients with solid lesions of the gastrointestinal tract or adjacent organs. Primary outcomes were successful identification of the lesion and success of EUS-TA. Secondary outcomes were safety, sensitivity, specificity, and diagnostic accuracy of the two different scopes for EUS-TA., Results: 126 patients with solid lesions were randomly assigned to the CLA group (63 patients) or the FVL group (63 patients). The two groups were homogeneous with no differences in terms of needle type used, mean number of passes, and site of EUS-TA. No differences were observed between the FVL vs. CLA scopes in identification of the lesion (96.8 % vs. 98.4 %; P  > 0.99) and technical success of EUS-TA (92.1 % vs. 96.8 %; P  = 0.44). No adverse events occurred. Overall, diagnostic accuracy (77.8 % vs. 84.1 %), sensitivity (76.6 % vs. 84.1 %), and specificity (81.3 % vs. 84.2 %) did not differ between the two groups., Conclusions: Our results strongly suggest that the FVL echoendoscope is noninferior to the CLA scope for the detection and performance of EUS-TA in patients with solid lesions of the gastrointestinal tract and adjacent organs. In addition, the FVL scope has the same diagnostic yield, accuracy, and safety as the CLA scope., Competing Interests: Prof. Fockens is a consultant for Olympus Medical. Prof. Deviere has received research support for IRB-approved studies from Olympus Medical. Prof. Costamagna is a consultant for Olympus Medical and has received research grants from Olympus Medical., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: To overcome the limitations of using cytological specimen alone for the diagnosis of challenging pancreatic lesions, biopsy needles have been developed to procure histological specimens during EUS, especially for the discrimination of several specific pancreatic tumors requiring adequate histological samples. The aim of this study was to compare the diagnostic yield of EUS-guided 22-gauge (G) fine needle aspiration (FNA) needles and 22G fine needle biopsy (FNB) needles for sampling pancreatic masses., Methods: We conducted a retrospective study of all EUS-guided sampling performed between November 2012 and April 2016. 422 cases sampled with a 22G FNA needle (N = 254) or a 22G FNB needle (N = 168) were recruited for this study. The specimen quality analyses, technical characteristics, accuracy, sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) for the pancreatic masses were reviewed and compared., Results: There was no significant difference in the procurement of adequate histological specimens (75.0% vs. 79.5%; p = .277) or the presence of diagnostic histological specimens (71.3% vs. 77.4%; p = .155) between FNA and FNB groups, respectively. There were also no significant differences in the accuracy, sensitivity, specificity, PPVs, or NPVs of the cytological, histological, and overall analyses for FNA and FNB groups in the diagnosis of pancreatic malignancy. However, 22G biopsy needles demonstrated a better histological diagnostic yield in the discrimination of pancreatic adenocarcinoma and non-adenocarcinoma pancreatic neoplasms than 22G FNA needles (69.8% vs. 57.9%, p = .033)., Conclusions: 22G FNB needle demonstrated a better histological diagnostic yield in the differentiation between pancreatic adenocarcinoma and non-adenocarcinoma pancreatic neoplasms.

In the everyday practice of respiratory physicians, ultrasound techniques play a key role by enabling several diagnostic and interventional procedures. The application of ultrasound to endoscopic procedures allows both a visualization and a guided sampling of mediastinal and hilar lymph nodes. Endobronchial ultrasound can be combined with transbronchial needle aspiration, and, similarly, endoscopic ultrasound can be combined with fine-needle aspiration to sample virtually all mediastinal nodal stations from the airways and the esophagus. Endobronchial ultrasound-transbronchial needle aspiration and endoscopic ultrasound-fine needle aspiration showed a complementary diagnostic yield, and, recently, endoscopic ultrasound with bronchoscope was introduced in clinical practice to perform a transesophageal needle aspiration by using an ultrasound bronchoscope. This technique allows a single operator to perform both transbronchial and transesophageal needle sampling with the same instrument during a single bronchoscopic procedure. Mediastinal staging impacts the management of patients affected by lung cancer, and the most recent guidelines clearly state that endobronchial ultrasound and endoscopic ultrasound should be the initial tissue sampling procedure over surgical staging. In addition, endoscopic ultrasound techniques demonstrated an excellent yield in diagnosing lymphoma and benign diseases, for example, sarcoidosis. The aim of this review was to discuss the current role and future perspectives of endosonography techniques available for the evaluation of the mediastinum. Special emphasis was placed on equipment and technical aspects, the diagnostic role, and future directions of development., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2018 by Daedalus Enterprises.)

Background: Endoscopic ultrasound (EUS)-guided tissue acquisition has become the most effective method of obtaining specimens from a solid lesion adjacent to the gastrointestinal tract. No data exist regarding the use of a stylet in the core biopsy needle during EUS-guided tissue acquisition. The aims of this study were to evaluate the feasibility, safety, and diagnostic yield of a 25-gauge core biopsy needle without (S-) a stylet and to compare its performance with that of a 25-gauge core biopsy needle with (S+) a stylet in patients with solid lesions adjacent to the gastrointestinal tract., Methods: From November 2013 to January 2016, we performed 114 EUS-guided tissue acquisitions for the diagnosis of solid lesions adjacent to the gastrointestinal tract in a randomized controlled trial. Patients were randomly assigned to the S+ group (n = 57) or the S- group (n = 57). EUS-guided tissue acquisition was performed using a 25-gauge core biopsy needle without an on-site cytopathologist., Results: There were no significant differences in technical success (100 vs. 100%, p = 1.000), the mean number of needle passes (7.0 ± 1.6 vs. 6.8 ± 1.5, p = 0.556), needle malfunction (0 vs. 1.8%, p = 1.000), or complications (1.8 vs. 0%, p = 1.000) between the S+ and S- groups. Both groups exhibited comparable outcomes with respect to cytological diagnostic accuracy (93.0 vs. 91.2%, p = 1.000) and histological diagnostic accuracy (86.0 vs. 87.7%, p = 1.000) for malignancy. The procedure time was significantly shorter in the S- group than in the S+ group (32.4 ± 11.7 vs. 39.7 ± 8.6 min, p < 0.001)., Conclusions: EUS-guided tissue acquisition using a 25-gauge core biopsy needle without a stylet did not decrease the diagnostic yield for malignancy and was associated with a shorter procedure time than that associated with a stylet.

Introduction and Objectives: Endosonography has become standard of care in the diagnostic work-up of mediastinal lymphadenopathy and peribronchial lung lesions, but its success rate in some specific settings/conditions may be hampered by limited needle flexibility and size. We report on our initial experience with the 19G Flex needle, characterized by larger size and greater flexibility as compared with the currently available cytology needles., Methods: Retrospective review of prospectively collected data on the first 13 consecutive patients submitted to endosonography with the 19G Flex needle. Patients were included if they had: (a) suspicion of a histologically complex disease (ie, lymphoma); (b) suspicion of an advanced lung cancer possibly requiring extensive genotyping; (c) a lesion whose sampling with a 22G needle had failed because of lack of visibility when the needle was loaded into the scope., Results: The 13 patients enrolled had a mean age of 58.15 ± 17 years and a male to female ratio of 8:5. Target lesions (mean size 18.6 ± 6.4 mm) were lymphadenopathies (9 patients), lung lesions (3 patients) and a pleural nodule (1 patient). Histology core/s and a definite diagnosis (adenocarcinoma, 4 cases; lymphoma, 2; mesothelioma, 2, metastases from extrathoracic tumors, 2; non-small-cell lung cancer not otherwise specifiable, 1; small cell carcinoma, 1; sarcoidosis, 1) were obtained in 100% of patients. A single case of self-resolving bleeding was the only complication we observed., Conclusions: Preliminary results obtained with the dedicated Flex 19G needle are promising, as sample size/quality is satisfactory and the needle influence on scope flexibility is minimal., (© 2017 John Wiley & Sons Ltd.)

Background and Aim: Recently, a 22-gauge (G) needle with a Franseen tip design was developed for endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB). The present study evaluated the performance of the Franseen biopsy needle in EUS-guided tissue acquisition., Methods: This is a retrospective study of patients who underwent EUS-FNB using the Franseen needle. Lesions were sampled using either the Franseen needle only or after failed diagnostic fine-needle aspiration (FNA). After rapid onsite evaluation (ROSE), two dedicated passes were carried out for histological assessment using the cell block technique. Main outcomes were: (i) rates of diagnostic adequacy for ROSE and histological diagnosis; and (ii) quality of histology as determined by total tissue area and tumor percentage in tissue., Results: Thirty patients underwent EUS-FNB of pancreatic or other masses over a 3-month period. Twenty-four lesions were sampled using the Franseen needle only and six after failed diagnostic FNA. Final diagnosis was pancreatic cancer in 12, gastrointestinal stromal cell tumor in five, other tumors in four and benign disease in nine. Diagnostic adequacy for ROSE was 96.6% and histological diagnosis was established in 96.7% of patients. Median tissue area was 2.9 mm 2 (IQR = 0.68-8.71 mm 2 ) and median tumor percentage in tissue was 73.9% (IQR = 44-97.6). Rates of technical success and adverse events were 96.7 and 3.3%, respectively., Conclusion: Preliminary data suggest that the Franseen needle yields diagnostic material for ROSE and histology in >95% of patients., (© 2016 Japan Gastroenterological Endoscopy Society.)

Objective: Three- and four-dimensional transrectal ultrasound transducers are now available from most major ultrasound equipment manufacturers, but currently are incorporated into only one commercial prostate biopsy guidance system. Such transducers offer the benefits of rapid volumetric imaging, but can cause substantial measurement distortion in electromagnetic tracking sensors, which are commonly used to enable 3-D navigation. In this paper, we describe the design, development, and validation of a 3-D-ultrasound-guided transrectal prostate biopsy system that employs high-accuracy optical tracking to localize the ultrasound probe and prostate targets in 3-D physical space., Methods: The accuracy of the system was validated by evaluating the targeted needle placement error after inserting a biopsy needle to sample planned targets in a phantom using standard 2-D ultrasound guidance versus real-time 3-D guidance provided by the new system., Results: The overall mean needle-segment-to-target distance error was 3.6 ± 4.0 mm and mean needle-to-target distance was 3.2 ± 2.4 mm., Conclusion: A significant increase in needle placement accuracy was observed when using the 3-D guidance system compared with visual targeting of invisible (virtual) lesions using a standard B-mode ultrasound-guided biopsy technique.

Isolated hilar and mediastinal recurrence (IMHR) following external beam radiation therapy (EBRT) in patients with lung cancer is common. These patients do not have many treatment options and are usually offered palliative chemotherapy or best supportive care. Endobronchial ultrasound (EBUS)-guided intratumoral injection of cisplatin (ITC) is a novel approach for these patients. The procedure is performed under conscious sedation. The lesion is located with a bronchoscopy using EBUS, and a 22-gauge EBUS needle is advanced through the working channel of the scope and locked in position. Under ultrasound guidance, the wall of the tracheobronchial tree is punctured and the needle is moved into the target lesion. The needle stylet is then removed and cisplatin (40 mg/40 mL) is injected into the lesion. One to two sites are treated per session. Details of the procedure are described in the protocol section of paper. At our center, 50 sites were treated in 36 patients (19 males, 17 females). The mean age of our cohort was 61.9 ±8.5 years. We performed final analyses on 35 patients and 41 sites. 24/35 (69%) had complete or partial response (responders), whereas 11/35 (31%) had stable or progressive disease (non-responders). Overall, survival in our group was 8 months (95% CI of 6-11 months), with patients who responded having significantly better survival than the ones who did not.

Background and Aims: EUS-guided liver biopsy sampling using FNA and, more recently, fine-needle biopsy (FNB) needles has been reported with discrepant diagnostic accuracy, in part due to differences in methodology. We aimed to compare liver histologic yields of 4 EUS-based needles and 2 percutaneous needles to identify optimal number of needle passes and suction., Methods: Six needle types were tested on human cadaveric tissue: one 19G FNA needle, one existing 19G FNB needle, one novel 19G FNB needle, one 22G FNB needle, and two 18G percutaneous needles (18G1 and 18G2). Two needle excursion patterns (1 vs 3 fanning passes) were performed on all EUS needles. Primary outcome was number of portal tracts. Secondary outcomes were degree of fragmentation and specimen adequacy. Pairwise comparisons were performed using t tests, with a 2-sided P < .05 considered to be significant. Multivariable regression analysis was performed., Results: In total, 288 liver biopsy samplings (48 per needle type) were performed. The novel 19G FNB needle had significantly increased mean portal tracts compared with all needle types. The 22G FNB needle had significantly increased portal tracts compared with the 18G1 needle (3.8 vs 2.5, P < .001) and was not statistically different from the 18G2 needle (3.8 vs 3.5, P = .68). FNB needles (P < .001) and 3 fanning passes (P ≤ .001) were independent predictors of the number of portal tracts., Conclusions: A novel 19G EUS-guided liver biopsy needle provides superior histologic yield compared with 18G percutaneous needles and existing 19G FNA and core needles. Moreover, the 22G FNB needle may be adequate for liver biopsy sampling. Investigations are underway to determine whether these results can be replicated in a clinical setting., (Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Aim: To compare the aspiration needle (AN) and core biopsy needle (PC) in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of abdominal masses., Methods: Consecutive patients referred for EUS-FNA were included in this prospective single-center trial. Each patient underwent a puncture of the lesion with both standard 22-gauge (G) AN (Echo Tip Ultra; Cook Medical, Bloomington, Indiana, United States) and the novel 22G PC (EchoTip ProCore; Cook Medical, Bloomington, Indiana, United States) in a randomized fashion; histology was attempted in the PC group only. The main study endpoint was the overall diagnostic accuracy, including the contribution of histology to the final diagnosis. Secondary outcome measures included material adequacy, number of needle passes, and complications., Results: Fifty six consecutive patients (29 men; mean age 68 years) with pancreatic lesions ( n = 38), lymphadenopathy ( n = 13), submucosal tumors ( n = 4), or others lesions ( n = 1) underwent EUS-FNA using both of the needles in a randomized order. AN and PC reached similar overall results for diagnostic accuracy (AN: 88.9 vs PC: 96.1, P = 0.25), specimen adequacy (AN: 96.4% vs PC: 91.1%, P = 0.38), mean number of passes (AN: 1.5 vs PC: 1.7, P = 0.14), mean cellularity score (AN: 1.7 vs PC: 1.1, P = 0.058), and complications (none). A diagnosis on the basis of histology was achieved in the PC group in 36 (64.3%) patients, and in 2 of those as the sole modality. In patients with available histology the mean cellularity score was higher for AN (AN: 1.7 vs PC: 1.0, P = 0.034); no other differences were of statistical significance., Conclusion: Both needles achieved high overall diagnostic yields and similar performance characteristics for cytological diagnosis; histological analysis was only possible in 2/3 of cases with the new needle., Competing Interests: Conflict-of-interest statement: None to declare.

Background: Convex probe endobronchial ultrasound (CP-EBUS) has proven safe and accurate for identifying malignancy and granulomatous disease affecting the mediastinum and hilum. For the diagnosis of parenchymal lung lesions, conventional techniques such as transbronchial biopsy, brush and lavage are useful, particularly when an airway leads directly to the lesion. For centrally located intraparenchymal lesions, CP-EBUS has been shown to be efficacious., Objective: To expand on the existing literature in an effort to highlight the important diagnostic role of CP-EBUS in centrally located lesions, particularly those without a bronchus sign., Methods: In our cohort of 430 patients undergoing CP-EBUS between 03/2009-03/2012, we retrospectively identified 32 who underwent transbronchial needle aspiration (TBNA) of a centrally located parenchymal lung lesion. All lesions were completely surrounded by lung parenchyma and not visualized during white light bronchoscopy. Diagnostic yield was determined and compared to conventional bronchoscopic biopsy techniques, when performed., Results: The mean lesion size was 25.6 mm and 24/32 (75%) lesions were located in the lower lobes. A definitive diagnosis was obtained in 27/32 (84.4%) of parenchymal lesions without a bronchus sign biopsied using CP-EBUS. CP-EBUS provided the exclusive method of diagnosis in 15/32 (46.9%) patients in this cohort. Most lesions (26/32) were diagnosed as non-small cell carcinoma. There were no procedural complications., Conclusion: CP-EBUS is useful for diagnosing parenchymal lung abnormalities without a bronchus sign, extending its scope beyond mediastinal and hilar lymph nodes. It is imperative that physicians performing EBUS maintain this tool as a complement to conventional bronchoscopic techniques., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background and Study Aims: To overcome the limitations associated with cytology, a uniquely designed needle (ProCore) was introduced in an effort to obtain a core of tissue under endoscopic ultrasound (EUS) guidance. However, studies comparing the sample quality between ProCore and standard-design fine-needle aspiration (FNA) needles have yielded varying results. A systematic review and meta-analysis was therefore conducted to compare the performance of the ProCore and standard FNA needles when performing EUS-guided tissue acquisition., Patients and Methods: MEDLINE and EMBASE were searched to identify all published manuscripts that compared the ProCore needle with standard FNA needles. Noncomparative and technical feasibility studies were excluded. The main outcome measures were diagnostic adequacy, diagnostic accuracy, acquisition of histological core tissue, and mean number of passes required to achieve a diagnosis when sampling solid lesions., Results: Nine studies (total 576 patients) met the inclusion criteria. There was no significant difference in diagnostic adequacy (75.2 % vs. 89.0 %, odds ratio [OR] 0.39, P = 0.23), diagnostic accuracy (85.8 % vs. 86.2 %, OR 0.88, P = 0.53) or rate of histological core specimen acquisition (77.7 % vs. 76.5 %, OR 0.94, P = 0.85) between the ProCore and standard FNA needles, respectively. The mean number of passes required for diagnosis, however, was significantly lower when using the ProCore needle (standardized mean difference - 1.2, P < 0.001)., Conclusions: Current data do not demonstrate a significant difference between the ProCore and standard FNA needles for sample adequacy, diagnostic accuracy or acquisition of a core specimen. However, the ProCore needle establishes the diagnosis with fewer passes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Ever since the invention of the flexible bronchoscope, perhaps no other innovation in the field of interventional pulmonology has caused so much excitement the world over, as the convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA). While it took over a decade from 1992 to 2004 for the radial EBUS to evolve into the commercial convex probe EBUS scope, another exciting decade has gone by with the technology being thoroughly researched and appraised. The current evidence suggests that EBUS-TBNA can replace mediastinoscopy as the first investigation in the mediastinal staging of lung cancer. The use of EBUS-TBNA has been extended to several other areas including the diagnosis of undefined mediastinal lymphadenopathy, evaluation of intra-parenchymal lesions and others. In fact, EBUS-TBNA is the preferred modality for accessing mediastinal lesions in contact with the airways. The procedure not only has a high diagnostic efficiency (80%-90% for most indications) but is also safe compared to alternative options, such as image-guided fine needle aspiration and mediastinoscopy in the diagnosis of mediastinal lymphadenopathy. Apart from the traditional use of EBUS to perform TBNA, the last decade has seen the evolution of its transoesophageal use, development of novel EBUS-TBNA needles to obtain better histological specimens and a smaller EBUS scope. This review summarises the developments made in this field over the years since its inception.

Background: Recent advances in bronchoscopy, such as transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS), have improved the diagnostic yield of small-sized peripheral lung lesions. In some cases, however, it is difficult to obtain adequate biopsy samples for pathological diagnosis. Adequate prediction of the diagnostic accuracy of TBB with EBUS-GS is important before deciding whether bronchoscopy should be performed., Methods: We retrospectively reviewed 149 consecutive patients who underwent TBB with EBUS-GS for small-sized peripheral lung lesions (≤30 mm in diameter) from April 2012 to March 2013. We conducted an exploratory analysis to identify clinical factors that can predict an accurate diagnosis by TBB with EBUS-GS. All patients underwent thin-section chest computed tomography (CT) scans (0.5-mm slices), and the CT bronchus sign was evaluated before bronchoscopy in a group discussion. The final diagnoses were pathologically or clinically confirmed in all studied patients (malignant lesions, 110 patients; benign lesions, 39 patients)., Results: The total diagnostic yield in this study was 72.5% (95% confidence interval: 64.8-79.0%). Lesion size, lesion visibility on chest X-ray, and classification of the CT bronchus sign were factors significantly associated with the definitive biopsy result in the univariate analysis. In the multivariate analysis, only the CT bronchus sign remained as a significant predictive factor for successful bronchoscopic diagnosis. The CT bronchus sign was also significantly associated with the EBUS findings of the lesions., Conclusion: Our results suggest that the CT bronchus sign is a powerful predictive factor for successful TBB with EBUS-GS.

Background: Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) and biopsy (FNB) is considered a very accurate and safe tool for sampling extra-intestinal tumors. Standard echoendosocopes for FNA/FNB are large with a sharpened tip that can be associated with complications. A new slim linearechoendoscope have been developed trying to overcome this limitation., Aim: Of the present study was to evaluate the feasibility; safety and diagnostic yield of this newly developed slim echoendoscope for performing EUS-guided FNA/FNB., Methods: A pilot observational study was performed. Consecutive patients submitted for a EUS-FNA/FNB were prospectively included in the study. Patients underwent EUS procedure using the new slim linear PENTAX-echoendoscope. Tissue acquisition was done with standard and histology needles. Feasibility and diagnostic yield were evaluated. A descriptive analysis was performed., Results: 87 patients were included (mean age 66.7 years (range 24-90 years), 45 male. Mean size was of lesions sampled were 33.43 +/- 20.8 mm. Esophagus intubation and access to the second portion of the duodenum (D2) were considered easy in all 87 cases (100%). Nineteen procedures (21.8%) were performed from the esophagus, 42 (48.3%) from the stomach, 22 (25.3%) cases from duodenal bulb, and 4 (4.6%) cases from D2. EUS-FNB was feasible in 85 cases (97.7%), failed in 2 pancreatic lesions accessed from D2. Diagnostic yield was 86.21% (95%CI 77.4- 91.9) in the intention-to-treat analysis and 88.24% (95%CI 79.7- 93.5) in per-protocol analysis. There were no complications related to the technique., Conclusion: Performing a EUS-FNA/FNB with the newly designed slim scope is feasible and safe for cyto-histopathology diagnosis of intra-intestinal and extra-intestinal mass lesions.

The forward-viewing linear echoendoscope (FV-EUS) has been developed with the aim of overcoming limitations of standard curved linear-array echoendoscopes (CLA-EUS) and to further expand interventional applications of EUS. The main characteristic of the FV-EUS is a shifting in the orientation of both endoscopic and ultrasound views from oblique to forward, with the exit of the working channel at the tip of the instrument. This allows exit of the devices parallel to the longitudinal axis of the endoscope, thus resulting in a more direct and stable access to the lesion while increasing the precision and force applied to the target. Accumulating evidence has shown that the FV-EUS can be used instead of the standard CLA-EUS scope for routine fine needle aspiration, with extremely good performance for subepithelial lesions and for difficult to reach locations. Several areas of use of this echoendoscope are yet to be better defined, such as its potential for therapeutic and interventional procedures, as well as for natural orifice transluminal endoscopic surgery. The current report provides an updated overview of the available evidence for both diagnostic and interventional uses of the FV-EUS., (© 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration is widely used for mediastinal and hilar lesions. Histologic specimens from this procedure are important for specific diagnosis and targeted therapy. Studies on the traditional endobronchial ultrasound-guided transbronchial needle aspiration needles reported yields of only 50-60% for diagnostic histologic specimens. Recently, a new needle has become available in Europe, USA and Asia. The investigators aimed to evaluate the histologic specimen retrieval yields of the two needles., Methods: Patients who underwent endobronchial ultrasound-guided transbronchial needle aspiration with the new 22 G needle (M group, n = 94) were compared with a historical control group who underwent endobronchial ultrasound-guided transbronchial needle aspiration with the traditional 22 G needle (O group, n = 82). The quality of needle aspirates from both groups was evaluated., Results: There were no significant differences between the two groups in terms of demographics, lesion characteristics, primary disease and examiner experience. The M group had a significantly shorter procedure time than the O group (P = 0.049). Of the 214 punctures by the M group, 159 (74.3%) were diagnostic, 28 (13.1%) were non-diagnostic and 27 (12.6%) had no histologic specimen. The 235 punctures by the O group were diagnostic in 144 (61.3%), non-diagnostic in 60 (25.5%) and had no histologic specimen in 31 (13.2%). The yield for diagnostic histologic specimens of the M group was significantly higher than the O group (P = 0.0035). There were no major complications observed., Conclusions: The yield for diagnostic histologic specimens by the new 22 G endobronchial ultrasound-guided transbronchial needle aspiration needle was high. Further technical improvements of histologic sampling yields are very important when selecting targeted therapy., (© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Endoscopic ultrasound (EUS) continues to present a rich source of innovation, allowing it to evolve from a diagnostic procedure to a therapeutic modality. This was obvious from the numerous high-quality presentations at the 2014 Digestive Disease Week (DDW) held in Chicago, Illinois. This review discusses several of the presented abstracts of innovations in the field of EUS., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: The overall diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for subepithelial lesions (SELs) is suboptimal. The aim of this study was to evaluate the diagnostic accuracy, defined as the proportion of correct diagnoses, obtained using the EUS-guided fine-needle tissue acquisition (FNTA) sampling technique performed with the newly developed forward-viewing EUS scope (FV-EUS)., Patients and Methods: This was a retrospective analysis of a prospectively collected database including all consecutive patients with SELs who underwent EUS-FNTA using the FV-EUS scope from 2007 to 2011 in a tertiary referral center. All procedures were performed by a single expert endoscopist., Results: A total of 121 consecutive patients with SELs (13 in the esophagus, 96 in the stomach, 10 in the duodenum, 2 in the rectum) underwent sampling of the lesion using the FV-EUS scope. The procedure was technically feasible in all but one patient, and no complication related to EUS-FNTA occurred. Full histological assessment including immunostaining could be completed in 93.4% (113/121) of the patients. Considering neoplastic vs. non-neoplastic diseases, the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 92.8% (95%CI 86.3-96.8), 100% (95%CI 69.0-100%), infinity, and 0.07 (95%CI 0.04-0.14), respectively., Conclusions: EUS-FNTA performed in conjunction with the FV-EUS scope for sampling SELs of the gastrointestinal tract was safe and provided a very high diagnostic accuracy. Studies comparing FV-EUS with standard curved linear echoendoscopes are needed to clarify whether these results are due to the sampling technique or the type of scope utilized., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Histological examination of core tissue samples may have advantages over cytology in endoscopic ultrasound (EUS)-guided sampling. We aimed to evaluate the feasibility and efficiency of a new 22G core biopsy needle., Patients and Methods: Consecutive patients with a pancreatic mass lesion or peri-intestinal lymphadenopathy sequentially underwent fine needle biopsy with both a newly developed 22G core needle (the FNB needle) and a standard 22G fine needle aspiration (FNA) needle, in randomized order., Results: In 144 patients, mean age 48 years (± standard deviation [SD] 14; range 18 - 82), with 145 lesions (mean lesion size 39 ± 15 mm, range 15 - 99), EUS-guided sampling was technically feasible with both needles in all patients. Mean number of passes to obtain sufficient tissue was 1.2 ± 0.5 with the core needle vs. 2.5 ± 0.9 with the standard needle (P < 0.001). FNB specimens were adequate for evaluation in 125 (86.2 %) vs. 127 (87.6 %) with FNA (P = 0.72). Among 139 patients available for follow-up, FNB provided a correct diagnosis in 110 (79.1 %) and FNA in 112 (80.6 %) (P = 0.73). Sensitivity, specificity, positive and negative predictive values, and accuracy for diagnosis of malignancy were 90 %, 100 %, 100 %, 93 %, 96 % for FNB and 77 %, 100 %, 100 %, 85 %, 92 % for FNA, respectively (P > 0.05)., Conclusion: FNB with the new 22G core needle was technically feasible, efficient and comparable to FNA with a standard needle. The core needle required fewer passes to provide an adequate sample, offering potentially shorter procedure time., (© Georg Thieme Verlag KG Stuttgart · New York.)

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration has become an invaluable tool for thoracic physicians. Along with medical complications, it is also important to understand the equipment-related malfunctions. The EBUS scope is delicate and requires dedicated needle assembly for performing the needle aspirates. EBUS scope damage could be expensive and has been well described. We report 2 rare cases of Olympus EBUS needle assembly malfunction (model NA-201SX-4021/4022). The first case describes needle breakage and the second case reports the separation of shaft of sheath-sliding mechanism.

Background: Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (EBUS-TBNA) is performed with a dedicated 22- or 21-gauge needle while suction is applied. Fine-needle sampling without suction (capillary sampling) has been studied for endoscopic ultrasound and for biopsies at various body sites and has resulted in similar diagnostic yield and fewer traumatic samples. However, the role of EBUS-guided transbronchial needle capillary sampling (EBUS-TBNCS) is still to be determined., Methods: Adults with suspicious hilar or mediastinal lymph nodes (LNs) were included in a single-blinded, prospective, randomized trial comparing EBUS-TBNA and EBUS-TBNCS. The primary end point was the concordance rate between the two techniques in terms of adequacy and diagnosis of cytologic samples. The secondary end point was the concordance rate between the two techniques in terms of quality of samples., Results: A total of 115 patients and 192 LNs were studied. Concordance between EBUS-TBNA and EBUS-TBNCS was high, with no significant difference in adequacy (88% vs 88%, respectively [P ± .858]; concordance rate, 83.9% [95% CI, 77.9-88.8]); diagnosis (36% vs 34%, respectively [P ± .289]; concordance rate, 95.8% [95% CI, 92-92.8]); diagnosis of malignancy (28% vs 26%, respectively [P ± .125]; concordance rate, 97.9% [95% CI, 94.8-99.4]); or sample quality (concordance rate, 83.3% [95% CI, 73.3-88.3]). Concordance between EBUS-TBNA and EBUS-TBNCS was high irrespective of LN size (≤ 1 cm vs > 1 cm)., Conclusions: Regardless of LN size, no differences in adequacy, diagnosis, or quality were found between samples obtained using EBUS-TBNA and those obtained using EBUS-TBNCS. There is no evidence of any benefit derived from the practice of applying suction to EBUS-guided biopsies., Trial Registry: ClinicalTrials.gov; No.: NCT00886847; URL: www.clinicaltrials.gov

Aim: A number of potential variables are associated with the diagnostic accuracy of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA). The aim of this study was to evaluate factors affecting the diagnostic accuracy of EUS-FNA for upper gastrointestinal submucosal or extraluminal solid lesions., Methods: Patients with such lesions who underwent EUS-FNA between January 2009 and December 2010 were studied retrospectively. Needles of 22, 25 and 19 gauge were used. The associations between the EUS-FNA results and factors such as mass location, mass size, needle size, number of needle passes, combined histologic-cytologic analysis and final diagnosis were analyzed., Results: A total of 170 EUS-FNA procedures were performed in 158 patients with upper gastrointestinal submucosal or extraluminal solid lesions. The overall accuracy of EUS-FNA was 86.5% (147/170). The diagnostic accuracy with three or more needle passes was higher than with less than 3.0 needle passes (90.0%, 108/120 vs 78.0%, 39/50; P < 0.05). Mass location, mass size, and final diagnosis were not associated with EUS-FNA accuracy. Combined cytologic-histologic analysis had significantly higher diagnostic accuracy than either cytologic or histologic analysis alone (P < 0.001). In a subgroup of 90 patients, both 22 and 25 gauge needles were used for EUS-FNA. The overall diagnostic accuracy was similar for 25 gauge needles and 22 gauge needles (80.0% vs 78.9% P = 1.000) in this subgroup., Conclusion: Overall, 25 and 22 gauge needles have a similar diagnostic accuracy. Our results suggest that 3.0 or more needle passes and combined cytologic-histologic analysis enhance the diagnostic accuracy of EUS-FNA., (© 2012 The Authors. Digestive Endoscopy © 2012 Japan Gastroenterological Endoscopy Society.)