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Purpose The role of EUS before or after neoadjuvant chemotherapy (nCTX) in advanced esophagogastric cancer (EGC) is still unclear. The phase II NEOPECX trial evaluated perioperative chemotherapy with or without panitumumab in this setting. The aim of this sub-study was to investigate the prognostic value of EUS-guided preoperative staging before and after nCTX.Materials and Methods Preoperative yuT/yuN stages by EUS were compared with histopathological ypT/ypN stages after curative resection. Reduction in T-stage from baseline to preoperative EUS was defined as downstaging (DS+) and compared to progression-free (PFS) and overall survival (OS) of patients without downstaging (DS-). In addition, preoperative EUS N-stages (positive N+ or negative N-) were correlated with clinical data.Results The preoperative yuT-stage correlated with the ypT-stage in 48% of cases (sensitivity 48%, specificity 52%), while the preoperative yuN-stage correlated with the ypN-stage in 64% (sensitivity 76%, specificity 52%). Within DS+ patients who were downstaged by ≥ 2 T-categories, a trend towards improved OS was detected (median OS DS+: not reached (NR), median OS DS-: 38.5 months (M), p=0.21). Patients with yuN+ at preoperative EUS had a worse outcome than yuN- patients (median OS yuN-: NR, median OS yuN+: 38.5 M, p = 0.013).Conclusion The diagnostic accuracy of EUS to predict the response after nCTX in patients with advanced EGC is limited. In the current study the endosonographic detection of lymph node metastasis after nCTX indicates a poor prognosis. In the future, preoperative EUS with sectional imaging procedures may be used to tailor treatment for patients with advanced EGC.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of bacterial infections are discussed. Improved detection and characterization of common focal liver lesions (FLL) are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper on infectious (bacterial) focal liver lesions is on their appearance on B-mode and Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

ZusammenfassungDie Ultraschalldiagnostik ist in vielen klinischen Situationen das Verfahren der ersten Wahl für die abdominelle Bildgebung. Neben dem Graustufenbild (B-Modus) und den klassischen Dopplerverfahren ermöglichen die kontrastmittelverstärkte Sonografie (CEUS), die Elastografie und die Fettquantifizierung eine multimodale Charakterisierung von Organen und Gewebestrukturen. Panorama- und 3D-Verfahren sowie Bildfusion haben die Befunddarstellung erweitert. Die Entwicklung tragbarer Kleingeräte führt zu einer Erweiterung der Einsatzmöglichkeiten der konventionellen Ultraschalldiagnostik.In dieser Übersichtsarbeit werden moderne sonografisch relevante Verfahren diskutiert sowie Geräteklassen und Stufenkonzepte beschrieben und anhand der wissenschaftlichen Evidenz bewertet. Ferner werden Hinweise zu Qualitätsstandards für die abdominelle Ultraschalldiagnostik vermittelt.

Sclerosing cholangitis (SC) represents a spectrum of chronic progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system characterized by patchy inflammation, fibrosis, and stricturing. Primary and secondary SC must be distinguished given the different treatment modalities, risks of malignancy, and progression to portal hypertension, cirrhosis, and hepatic failure. This review focuses on secondary SC and the pathogenic mechanisms, risk factors, clinical presentation, and novel imaging modalities that help to distinguish between these conditions. We explore the detailed use of cholangiography and ultrasound imaging techniques.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of non-infectious and non-neoplastic focal liver lesions (FLL) are discussed. Improved detection and characterization of common FLL are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper is on non-infectious and non-neoplastic FLL and their appearance on B-mode, Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

A definite pathologic diagnosis of intrapancreatic metastasis is crucial for the management decision, i.e., curative or palliative surgery versus chemotherapy or conservative/palliative therapy. This review focuses on the appearance of intrapancreatic metastases on native and contrast-enhanced transabdominal ultrasound and endoscopic ultrasound. Differences and similarities in relation to the primary tumor, and the differential diagnosis from pancreatic carcinoma and neuroendocrine neoplasms are described. The frequency of intrapancreatic metastases in autopsy studies and surgical resection studies will be discussed. Further emphasis is placed on endoscopic ultrasound-guided sampling to confirm the diagnosis.

With the development of modern EUS, multiple imaging functions, transducer settings, and examination modes have become available for clinical settings. While the major determinants of the ultrasound beam are still comprised of the signal wavelength, its frequency range, and its amplitude, other modifications and calculations have gained more interest for advanced users, such as tissue harmonic imaging (THI), spatial and frequency compounding, certain versions of speckle reduction, and various Doppler/duplex settings. The goal of such techniques is a better, perhaps more realistic image, with reduced artifacts (such as speckle), better image contrast, and an improved signal-to-noise ratio. In addition, 'add-ons' such as THI, which is based on the phenomenon of nonlinear distortion of acoustic signals as they travel through tissues, provide greater contrast and an enhanced spatial resolution than conventional EUS. Finally, optimization of spectral and color Doppler imaging in EUS requires experience and knowledge about the basic principles of Doppler/duplex phenomena. For these purposes, factors such as adjustment of Doppler controls, Doppler angle, color gain, spectral wall filters, and others require special attention during EUS examinations. Incorporating these advanced techniques in EUS examinations may be time-consuming and cumbersome. Hence, practical guidelines enabling endosonographers to steer safely through the large quantity of technological properties and settings (knobology) are appreciated. This review provides an overview of the role of important imaging features to be adjusted before, during, and after EUS procedures.

In "What should be known prior to performing EUS exams, Part I," the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?

This manuscript describes the use of ultrasound elastography, with the exception of liver applications, and represents an update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography.Diese Arbeit beschreibt den Einsatz der Ultraschall-Elastografie mit Ausnahme der Leberanwendungen und ist eine Aktualisierung der Leitlinien und Empfehlungen der EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) von 2013 zum klinischen Einsatz der Elastografie.

ZusammenfassungAufgrund der relativ hohen Komplikationsrate wird die Notwendigkeit einer Milzbiopsie kontrovers diskutiert. Bei der Indikationsstellung sind der klinische Hintergrund und die bereits erfolgte Diagnostik zu berücksichtigen. Anhand der Anamnese, der bildgebenden Verfahren und des sonografischen Verlaufs sind unterschiedliche klinische Szenarien vorstellbar. Das Ziel der Arbeit ist es, die Indikation einer Milzbiopsie unter Beachtung unterschiedlicher klinischer Szenarien zu beschreiben.

ZusammenfassungFür eine optimale sonografische Dopplerbildgebung müssen die Geräteeinstellungen an die spezielle Anwendung, patientenindividuelle Gegebenheiten und die Sehgewohnheiten des Untersuchers adaptiert werden. Dieser Beitrag ermöglicht dem Anwender, „sein“ Gerät vom Einschalten über die Dopplerbildoptimierung bis zur Speicherung immer gut handhaben zu können – ohne alle technischen oder physikalischen Details hinter den „Knöpfen“ zu kennen.

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

This review gives an overview of different techniques in the treatment of post-acute complications of acute pancreatitis. The endoscopic treatment of those complications is currently standard of care. EUS opened up the broad implementation of internal drainage methods to make them safe and effective. Due to different endoscopic approaches worldwide, controversies have arisen that are pointed out in this paper. The main focus was placed on weighing up evidence to find the optimal approach. However, if no evidence can be provided, the authors, experienced in the field, give their personal advice.

EUS-guided biliary drainage (EUS-BD) has recently gained widespread acceptance as a minimally invasive alternative method for biliary drainage. Even in experienced endoscopy centers, ERCP may fail due to inaccessibility of the papillary region, altered anatomy (particularly postsurgical alterations), papillary obstruction, or neoplastic gastric outlet obstruction. Biliary cannulation fails at first attempt in 5%-10% of cases even in the absence of these factors. In such cases, alternative options for biliary drainage must be provided since biliary obstruction is responsible for poor quality of life and even reduced survival, particularly due to septic cholangitis. The standard of care in many centers remains percutaneous transhepatic biliary drainage (PTBD). However, despite the high technical success rate with experienced operators, the percutaneous approach is more invasive and associated with poor quality of life. PTBD may result in long-term external catheters for biliary drainage and carry the risk of serious adverse events (SAEs) in up to 10% of patients, including bile leaks, hemorrhage, and sepsis. PTBD following a failed ERCP also requires scheduling a second procedure, resulting in prolonged hospital stay and additional costs. EUS-BD may overcome many of these limitations and offer some distinct advantages in accessing the biliary tree. Current data suggest that EUS-BD is safe and effective when performed by experts, although SAEs have been also reported. Despite the high number of clinical reports and case series, high-quality comparative studies are still lacking. The purpose of this article is to report on the current status of this procedure and to discuss the tools and techniques for EUS-BD in different clinical scenarios.

Background The prevalence of malignancy in patients with small solid pancreatic lesions is low; however, early diagnosis is crucial for successful treatment of these cases. Therefore, a method to reliably distinguish between benign and malignant small solid pancreatic lesions would be highly desirable. We investigated the role of endoscopic ultrasound (EUS) elastography in this setting. Methods Patients with solid pancreatic lesions ≤ 15 mm in size and a definite diagnosis were included. Lesion stiffness relative to the surrounding pancreatic parenchyma, as qualitatively assessed and documented at the time of EUS elastography, was retrospectively compared with the final diagnosis obtained by fine-needle aspiration/biopsy or surgical resection. Results 218 patients were analyzed. The average size of the lesions was 11 ± 3 mm; 23 % were ductal adenocarcinoma, 52 % neuroendocrine tumors, 8 % metastases, and 17 % other entities; 66 % of the lesions were benign. On elastography, 50 % of lesions were stiffer than the surrounding pancreatic parenchyma (stiff lesions) and 50 % were less stiff or of similar stiffness (soft lesions). High stiffness of the lesion had a sensitivity of 84 % (95 % confidence interval 73 % – 91 %), specificity of 67 % (58 % – 74 %), positive predictive value (PPV) of 56 % (50 % – 62 %), and negative predictive value (NPV) of 89 % (83 % – 93 %) for the diagnosis of malignancy. For the diagnosis of pancreatic ductal adenocarcinoma, the sensitivity, specificity, PPV, and NPV were 96 % (87 % – 100 %), 64 % (56 % – 71 %), 45 % (40 % – 50 %), and 98 % (93 % – 100 %), respectively. Conclusions In patients with small solid pancreatic lesions, EUS elastography can rule out malignancy with a high level of certainty if the lesion appears soft. A stiff lesion can be either benign or malignant.

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

Due to the relatively high complication rate, the necessity of a spleen biopsy is controversially discussed. In establishing its indication, the clinical background and performed diagnostics must be considered. Based on the medical history, imaging procedures and sonographic course, different clinical scenarios are conceivable. The aim of this review is to describe the indications of splenic biopsy considering various clinical scenarios.Aufgrund der relativ hohen Komplikationsrate wird die Notwendigkeit einer Milzbiopsie kontrovers diskutiert. Bei der Indikationsstellung sind der klinische Hintergrund und die bereits erfolgte Diagnostik zu berücksichtigen. Anhand der Anamnese, der bildgebenden Verfahren und des sonografischen Verlaufs sind unterschiedliche klinische Szenarien vorstellbar. Das Ziel der Arbeit ist es, die Indikation einer Milzbiopsie unter Beachtung unterschiedlicher klinischer Szenarien zu beschreiben.