EUS-FNB has been introduced in clinical practice as a less invasive diagnostic approach with respect to surgery. We performed a single-center retrospective study on the diagnostic efficacy of EUS-guided FNB, including 171 patients with lymph nodes, splenic, and extranodal lesions that underwent EUS for FNB at our institution. Excluding 12 patients who did not undergo FNB and 25 patients with a previous diagnosis of a solid tumor, we included 134 patients with clinical/radiological suspect of a lymphoproliferative disease, including 20 patients with a previous history of lymphoma. Out of the 134 biopsies, material of diagnostic quality was obtained in 111 procedures (84.3%). Histological examination of the EUS-FNB samples produced an actionable diagnosis in 100 cases (74.6%). Among the patients without an actionable diagnosis, a second, different diagnostic procedure produced a further eight diagnoses of lymphoma. Therefore, the sensitivity of EUS-FNB for diagnosing lymphomas was calculated to be 86.4% (51/59). Assignment of lymphomas to WHO classification subtypes was possible in 47/51 (92%) of the cases. In conclusion, EUS-FNB is an effective procedure for the histological characterization of lesions that are suspected to be lymphoproliferative disease, allowing for an actionable diagnosis in 75% of cases.

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.

Our aim was to record pancreaticobiliary endoscopic ultrasound (EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence (LE). Original research articles (randomized controlled trials, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS were included. All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities, anatomical subdivisions and therapeutic applications of EUS. The North of England evidence-based guidelines were used to determine LE. A total of 1089 pertinent articles were reviewed. Published research focused primarily on solid pancreatic neoplasms, followed by disorders of the extrahepatic biliary tree, pancreatic cystic lesions, therapeutic-interventional EUS, chronic and acute pancreatitis. A uniform observation in all six categories of articles was the predominance of LE III studies followed by LE IV, II b, II a, I b and I a, in descending order. EUS remains the most accurate method for detecting small (< 3 cm) pancreatic tumors, ampullary neoplasms and small (< 4 mm) bile duct stones, and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms. Detailed EUS imaging, along with biochemical and molecular cyst fluid analysis, improve the differentiation of pancreatic cysts and help predict their malignant potential. Early diagnosis of chronic pancreatitis appears feasible and reliable. Novel imaging techniques (contrast-enhanced EUS, elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis. Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy. Despite the ongoing development of extra-corporeal imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, EUS still holds a leading role in the investigation of the pancreaticobiliary area. The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.

A prolific trend currently designates endoscopic ultrasonography (EUS) literature. We aimed to record all EUS-studies published during the past decade and evaluate them in terms of scientific quality, creating a stratification based on levels of evidence (LE).

All articles on EUS published between January 2001 and December 2010 were retrieved using a Pubmed and Cochrane Library search. Inclusion criteria were: original research papers (randomized controlled trials-RCTs, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS. Levels of evidence (LE) were assessed using the North of England evidence-based guidelines.

Overall, 1,832 eligible articles were reviewed. The majority (46.1%) of reports comprised retrospective descriptive studies (LE III). Expert reviews and committee reports (LE IV) accounted for 28.9%, well-designed quasi-experimental studies (LE IIb) for 20.1%, RCTs (LE Ib) for 2.4%, prospective controlled trials (LE IIa) for 1.4%, and meta-analyses (LE Ia) for 1.1% of the total. High LE (Ia-Ib) were assigned to loco-regional staging of luminal gastrointestinal cancers; mediastinal staging of lung cancer; diagnostic work-up of solid pancreatic tumors, suspected biliary obstruction and choledocholithiasis; celiac plexus neurolysis; and pancreatic pseudocysts drainage. Intermediate to low LE (IIa-IV) were assigned to submucosal tumors, pancreatic cysts, chronic pancreatitis and novel therapeutic applications (pancreato-biliary drainage, tumor ablation).

Diagnostic and staging EUS has matured and has proven its clinical impact on patient management. Therapeutic or interventional EUS is still evolving and more quality research and data are needed to establish EUS as the best next intervention to perform once firm evidence is available.

Practitioners and researchers from China, the largest user of complementary and alternative medicine (CAM), have been publishing an increasing number of scientific articles in world-famous CAM journals in recent years. However, the status of CAM research in the three major regions of China, the Mainland, Taiwan and Hong Kong has, until now, not been reported. In this study, we compared articles from these three regions published in international CAM journals from 2000 to 2009 using PubMed database and the Journal Citation Reports. The study results showed that the number of published articles from Mainland China increased significantly from 2000 to 2009, particularly since 2005. Meanwhile, the number of published articles from Taiwan also increased, whereas those from Hong Kong remained steady. Clinical trials and randomized controlled trials from Chinese authors both took a small percentage of the total. The impact factors of the journals in which these articles were published suggested similar academic levels whereas the average number of citation of articles from the Mainland was less than those from the other two regions. Journal of Ethnopharmacology, American Journal of Chinese Medicine, Journal of Alternative and Complementary Medicine and Evidence-based Complementary and Alternative Medicine were the most popular journals for Chinese authors.

To quantify the additional non-suspected new diagnoses made on upper endosonography (EUS) which were unknown before the procedure, and to analyse their influence on the management of patients. A further objective was to evaluate the influence that previous radiological or endoscopic explorations have on the capacity of EUS to diagnose these unsuspected lesions.

During a 2-year period every patient sent to our unit for upper EUS underwent a complete investigation, after signing an informed consent document. An upper EUS was considered as complete whenever the gut wall, pancreas, biliary tract, ampulla, large abdominal vessels, liver, spleen, left adrenal gland, posterior mediastinum and thyroid lobes had been explored. An additional diagnosis (AD) was defined as a diagnosis made on EUS that was previously unknown and not suspected. A significant additional diagnosis (SAD) was defined as an AD that required further study. The results of complementary explorations carried out before EUS were registered.

A total of 239 patients were included in the study. ADs were found in 92 patients (38.5%), which were considered to be SADs in 27 patients (11.3%). Those patients had previously undergone computed tomography (CT) and those who underwent more than one exploration had fewer incidences of ADs on EUS (p=0.03 and p=0.02, respectively). No exploration alone or in combination with others showed any influence on the capacity of EUS to find a SAD (p >0.05).

In our series, an AD was found on upper endosonography in 38.5% of the patients studied, and a SAD in 11.3%. The probability of finding a SAD on EUS is not influenced by previous endoscopic or radiologic explorations.

Implementation of electronic image technology in endoscopic ultrasonography (EUS) should improve image quality, but systematic data are scarce. The purpose of this study was to compare the image quality and performance of an electronic and a mechanical radial echoendoscope.

Eighty consecutive patients (42 M, mean age 56 years) in a tertiary referral center, without gross pathology (advanced tumors excluded), were prospectively randomized to EUS with the mechanical or electronic echoendoscope. Images from five standardized positions (pancreatobiliary and upper gastrointestinal (GI) tract) were taken by two examiners of differing experience. Time to acquire images was noted. Penetration depth was also measured. Image quality variables (overall quality, contrast, and structure discrimination) were assessed blindly on the basis of randomly shuffled images during three independent evaluations by the same experienced examiner (mean values were taken), using a visual analogue scale (VAS) from 1 (excellent) to 10 (inadequate).

Time needed to achieve visualization of the distal common bile duct (CBD) was significantly shorter with the electronic scope (49.7+/-8.6 versus 97.4+/-8.5 s; p<0.001). Image quality with the electronic scope was rated significantly better for all variables assessed, whereas EUS penetration depth was similar in both groups. There were no differences in examiner experience.

Electronic EUS provided better quality images according to the examiner's subjective assessment. An objective advantage was faster identification of the distal CBD.

Endosonography (EUS) is widely used for locoregional staging of malignant GI tumors. Delineation of a tumor's margins with a long-lasting fluoroscopically visible material will facilitate subsequent surgical and radiation therapy.

To assess the feasibility of EUS-guided submucosal implantation of a radiopaque marker in a porcine model.

Survival experiments on four 50-kg pigs.

A linear array echoendoscope was introduced into the esophagus and advanced to the stomach. With a 19-gauge FNA needle, a submucosal bleb was created by injecting 3 mL of normal saline solution into the gastric and esophageal wall followed by injection of 1 mL of tantalum suspension under fluoroscopic observation. Fluoroscopy was repeated after 1, 2, and 4 weeks followed by euthanasia and necropsy.

Long-term depositions of the marker in the injection sites.

Submucosal injections of tantalum were easily performed through the 19-gauge FNA needle, resulting in good fluoroscopic opacification of injected material. Follow-up fluoroscopy in 1, 2, and 4 weeks demonstrated stable deposition of the tantalum at the sites of injection. There were no complications during and after the tantalum implantation. Histologic examination of the injection sites demonstrated submucosal tantalum depositions without signs of infection, inflammation, tissue damage, or necrosis.

Animal experiments with 4 weeks' follow-up.

EUS-guided implantation of tantalum as a radiopaque marker into the submucosal layer of the GI tract in a porcine model is technically feasible and safe. Long-lasting fluoroscopically visible tantalum markings could facilitate subsequent surgical and radiation therapy.

People of Chinese ethnicity are one of the groups at most risk of gastrointestinal and liver diseases in the world. The research status in gastroenterology and hepatology (gastrointestinal [GI]) among Chinese individuals in the three major regions of China-the mainland (ML), Hong Kong (HK), and Taiwan (TW)-are unknown. The outputs of articles published in international GI journals from the three regions were compared in this study.

Articles published in 52 journals related to GI originating from the ML, TW, and HK from1996-2005 were retrieved from the PubMed database. The numbers of total articles, clinical trials, randomized controlled trials, case reports, impact factors (IF), citation reports, and articles published in the top general medical journals were conducted for quantity and quality comparisons.

The number of articles from the three regions increased significantly from 1996 to 2005. There were 5170 articles from the ML (2969), TW (1551), and HK (650). However, nearly 90% of articles from the ML were published in World Journal of Gastroenterology (WJG), a controversial Chinese journal. Following the exclusion of WJG, the ML had published the least number of articles and had the least total citations. The accumulated IF of the articles from TW (3747.893) was much higher than the ML (775.084) and HK (2272.972). HK had the highest average IF of articles in GI journals and the most articles published in the top, general medical journals among the three regions.

The difference between the number of GI research articles published in the ML, TW, and HK still appears to be considerable, particularly when assessed by IF, although the gap appears to be narrowing.

Endoscopic ultrasonography, both conventional and interventional, has been used increasingly during the past 20 years and is deemed a safe technique. Its complication rate, however, has been studied to only a limited extent. This multicentre investigation sought to establish the complication rate for a large number of endoscopic ultrasonography procedures.

By means of a questionnaire, we collected data from six centres on the number of endoscopic ultrasonography examinations performed and divided them into conventional and interventional examinations of the upper and lower gastrointestinal tract. Information was obtained on technical modalities such as instruments and sedation and, for interventional endoscopic ultrasonography, indications, pre-procedural exams and technical details (needle calibre, number of passes) had to be specified. Complications were classified as mild, moderate, severe or fatal and their onset as immediate, early or late. Variables that entered into the analysis of complication rate included type of endoscopic ultrasonography instrument used, type and site of lesion biopsied, number of needle passes and operator experience.

Eleven thousand five hundred thirty nine endoscopic ultrasonographic procedures were reported, of which 10,731 were conventional and 808 interventional. No deaths occurred; there were 14 (0.12%) complications, 5 (0.046%) of them following conventional endoscopic ultrasonography and 9 (1.11%) after interventional endoscopic ultrasonography. Seven complications were mild, four moderate and three severe.

Both conventional and interventional endoscopic ultrasonography were confirmed to be acceptably safe techniques.

This study assessed the value of high-resolution magnetic resonance imaging (MRI) of the distal colon by means of a dedicated endoluminal magnetic resonance receiver coil on a 1.5-T clinical scanner.

To this end, single-loop, receive-only radio-frequency coils, housed in 18 F sheaths, were built. A 1.5-T clinical imager was used. A 18 French diameter internal MRI receiver coil was inserted into the distal colon in 15 New Zealand rabbits to obtain high-resolution magnetic resonance images by using T1-weighted Flash sequences with and without Fat Saturation (FS), T2-weighted True-Fisp, turbo spin-echo, and T1-weighted Flash FS after contrast media injection. Images were compared to histological sections.

An adequate image quality was obtained in all specimens without significant artefacts. Based on histological reports, a five-layer structure of the wall was considered normal. On different MR sequences, only two layers were identified on the images of all rabbits specimens. The nearest layer to the mucosal surface was usually seen as a hyper intense layer and likely corresponds to the mucosa. The highest difference of signal value between internal and external layers was performed on 2D Fat saturation T1 weighted gradient echo. Comparison of mean signal value between the internal and external layers was statistically different in for each sequence used in our protocol (P < 0.05).

Dedicated endoluminal RF coil provides good spatial resolution at the region of interest. On this prospective study of in vivo rabbit, evaluation of colon walls allowed to provide detailed information.

Preoperative assessment of gastro-esophageal junction (GEJ) adenocarcinoma stage and its location according to Siewert are essential for planning the therapeutic approach. The present study was aimed at analyzing the utility of endoscopic ultrasonography (EUS) in evaluating GEJ adenocarcinoma stage and whether this modality added to EGD improves assessment of Siewert type.

The results of 51 patients studied by EGD plus EUS (EGD/EUS group) were compared with the results of 54 patients studied by EGD only (EGD group).

A differentiation of pT1 tumors was attempted by measurement of the tumor length using 4 cm as a criterion. This goal was not achieved because of a high rate of advanced tumors less than 4 cm (sensitivity and specificity were 81.3% and 34.2%, respectively). Conversely EUS ability in pT1 assessment was very reliable (92%). The accuracy in defining the Siewert type was 72.5% and 64.8% for EGD/EUS and EGD groups, respectively (P = 0.394). Some difficulties in distinguishing between type II and III tumors were observed in both groups with an extremely low specificity (44%) in classifying type II tumors by EGD group.

EUS seems to be essential in differentiating pT1 from advanced tumors. It shows an accuracy in defining the Siewert type of 72.5%, with some difficulties in distinguishing from type II and III tumors.

There are limited data evaluating the clinical impact of endoscopic ultrasonography (EUS). We assessed the impact of EUS on management of known or suspected malignancies.

Physicians requesting EUS were contacted before the examination and asked: "How would you manage this patient if EUS were not available?" Pre-EUS responses were recorded on standardized forms, and compared with management recommendations as determined by the same requesting physician after EUS. Endosonographers performing the study were blinded to the pre-EUS responses.

Responses were obtained from requesting physicians before and after EUS in 90 patients. Requesting physicians were composed of surgeons (33%), non-EUS-performing gastroenterologists (58%), oncologists (3%), internists (4%), and a pulmonologist (1%). After EUS, referring clinicians altered management plans in 46 of 90 patients (51%). By anatomic site, management changes occurred in 12 of 22 patients (56%) undergoing esophageal EUS, 9 of 15 (60%) undergoing gastric EUS, 21 of 43 (49%) undergoing pancreatic EUS, and 4 of 10 (40%) undergoing rectal EUS. There were no significant differences in the frequency of post-EUS management changes with respect to examination site (P = .76). EUS fine-needle aspiration (FNA) altered management in 9 of 20 (45%) patients. Management changes involved less complex or decreased risk-associated approaches in the majority (70%), and included 14 of 50 (28%) patients in whom surgical procedures were no longer planned.

Based on EUS examination findings, clinicians requesting EUS alter patient management in one half of cases, and more often pursue a less-complicated approach. EUS substantially impacts clinical care, and should be used in appropriate settings to guide patient management.

Despite improvements, spatial resolution and image quality with routine surface coils are too limited when detailed information about the gastrointestinal layers is requested. The objective of our feasibility study was to evaluate the potential of a dedicated endoluminal coil to depict different layers of the colonic wall in an in vitro small animal model.

A single-loop coil (40 mm length, 5 mm width) was built using IC (printed circuit) technology. The coil was tuned to a frequency of 63.7 MHz and matched at 50 Omega for this frequency. The coil was housed in a biocompatible tube with an outer diameter of 18 F (6 mm). Ten segments of rat colon, surgically excised 5 hours earlier, were completely immersed in an isotonic solution. The coil was introduced through the lumen of colonic specimens. MRI experiments were performed on a 1.5 T MR Symphony system (Siemens, Erlangen, Germany) using imaging protocol combining high-resolution 2D Flash, fast imaging employing steady-state acquisition (TrueFISP), turbo spin echo (TSE), and 3D FastLow-Angle Shot (FLASH) sequences. After a 24-hour period of fixation in 10% formalin, colonic specimens were excised along the longitudinal axis for histologic analysis.

The endoluminal coil provided high SNR allowing for the visualization of different layers of rat colonic walls. All the performed sequences made it possible to identify at least two different layers. On T1-weighted gradient-echo sequences, the mucosa was of high signal intensity, whereas the muscle layers had an intermediate to low signal intensity. The signal intensity of different wall layers was similar in different sequences. Histologic analysis identified three main layers.

These results are well correlated with histologic findings and suggest that endoluminal MR imaging may have potential for accurate staging of colonic tumor or inflammatory process.