Mohan Ramchandani

Background and Objectives: Accurate pre-operative lymph node (LN) staging is essential for guiding treatment decisions in gallbladder cancer (GBC). This study evaluated the impact of endoscopic ultrasound (EUS) with tissue acquisition (EUS-TA) on LN staging in presumed resectable GBC. Methods: This retrospective, single-center study, included patients with potentially resectable GBC who underwent pre-operative EUS between January 2019 and November 2024. The primary outcome was the impact of EUS on clinical decision making, defined as preclusion from surgical exploration by identification of LN metastasis. Secondary outcomes were missed LN metastases and complications. Results: Fifty-six patients were included, undergoing 59 EUS procedures. Lymphadenopathy was reported on pre-operative cross-sectional imaging in 54.7% of patients. During EUS, 46 LN were identified and EUS-TA was performed on 24 LN in 21 patients. LN metastases were confirmed by EUS-TA in 10.7% of patients, leading to preclusion from surgical treatment. Among patients who underwent surgical exploration, regional LN metastases were identified in nine of 31 patients and extra-regional LN metastases in one patient. There were no complications. Conclusions: Pre-operative EUS influenced management in patients with presumed resectable GBC by detecting LN metastases altering the treatment approach. However, its non-systematic approach resulted in missed regional LN involvement. Standardized EUS protocols are warranted to enhance LN staging accuracy.

INTRODUCTION: Health care accounts for nearly 5% of global greenhouse gas emissions, and medical imaging is among its most energy-intensive activities. For intermediate-likelihood common bile duct stones, endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are both guideline-endorsed with comparable diagnostic accuracy, yet their environmental costs have never been directly compared. METHODS: In this prospective study, we measured the per-procedure carbon footprint of EUS and MRCP using the Greenhouse Gas Protocol and India's grid emission factor. We recorded EUS procedure times individually; MRCP emissions were derived from a validated power model that captures the continuous cryocooler load maintaining magnet superconductivity around the clock, with shared infrastructure allocated by real case volume. We performed sensitivity analyses across scanner utilization, energy-allocation method, scan duration, and grid carbon intensity. The study followed the European Society of Gastrointestinal Endoscopy Endoscopic Sustainability PrimAry Reporting Essentials reporting standard. RESULTS: EUS generated 4.53 kg CO ₂ e per procedure and MRCP 18.90 kg CO ₂ e per procedure, making MRCP 4.2 times more carbon-intensive. The continuously running cryocooler was the single largest fixed contributor to MRCP emissions (23.4% in standby alone), a 24/7 load absent in EUS. Choosing EUS for 108 patients saved 1,552 kg CO ₂ e, equivalent to the annual carbon uptake of 74 mature trees. EUS remained the lower-carbon option across sensitivity analyses, although the advantage narrowed and could reverse on low-carbon grids. DISCUSSION: For bile duct stone evaluation, EUS offers the same diagnostic answer at substantially lower carbon cost where grid electricity is carbon-intensive, adding environmental impact to accuracy, safety, and cost in the decision.

Background: Lymph node (LN) involvement is a negative prognostic factor for patients with cholangiocarcinoma (CCA). Preoperative assessment of the LN could potentially aid therapy decision making. Endoscopic ultrasound (EUS) can be used to sample suspicious LN. The aim of this study was to evaluate the clinical impact of EUS for suspicious LN in patients with presumed resectable CCA. Methods: In this single-center cohort study, patients with potentially resectable CCA who underwent preoperative linear EUS between 2019 and 2024 were retrospectively included. The primary aims were the percentage of malignant LN detected and the clinical impact of EUS, which was defined as the percentage of patients who were precluded from surgical exploration due to pathologically confirmed LN metastases found with EUS tissue acquisition (EUS-TA). The secondary aim was the complication rate of EUS-TA. Results: A total of 135 patients were included, of whom 12 (8.9%) had intrahepatic CCA (iCCA), 65 (48.1%) had perihilar CCA (pCCA), 13 had (9.6%) middle bile duct CCA (mCCA), and 45 (33.3%) had distal CCA (dCCA). Across 148 EUS procedures, 139 LNs were identified, and EUS-TA was performed on 63 LNs among 55 patients. LN metastases were detected by EUS-TA for iCCA, pCCA, mCCA, and dCCA, in 25%, 6.2%, 15.4%, and 4.4%, respectively. EUS and EUS-TA influenced surgical work-up for iCCA, pCCA, mCCA, and dCCA in 25%, 1.5%, 15.4%, and 0.0%, respectively. No complications associated with EUS were noted. Conclusions: Preoperative EUS for nodal staging had an important clinical impact in patients with presumed resectable iCCA and mCCA, but less for pCCA and dCCA. Further prospective studies should investigate whether systematic nodal staging with EUS could improve preoperative decision making even further.

Zeeshan Ahmed, Raviraj Tilloo, Monish Karunakaran, Shreeyash Modak, Prateek Arora, Sanjeev Patil, Anuradha Sekaran, Mohan Ramchandani, Mahesh Shetty, Rohit Dama, Pradeep Rebala, Guduru Venkat Rao. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.25-041

A 68-year-old man with type 2 diabetes and hypertension underwent upper gastrointestinal endoscopy for anemia, revealing an ulcerated subepithelial lesion on the anterior-superior wall of the duodenal bulb ([Fig. 1] a). Endoscopic ultrasound revealed a 25-mm hypoechoic lesion arising from the submucosa and extending into the muscularis propria, with increased vascularity ([Fig. 1] b, c). Computed tomography (CT) and positron emission tomography-CT confirmed a localized lesion without nodal or distant spread ([Fig. 2]). Based on these features, endoscopic full-thickness resection (EFTR) was planned. The procedure was performed under general anesthesia. Initial dissection with conventional EFTR using carbon dioxide insufflation was limited by poor maneuverability, presence of fibrosis, and bleeding. The approach was converted to saline-immersion therapeutic endoscopy (SITE). Swift Coagulation (effect 3.5) was used to safely coagulate vessels without a coagulation grasper, minimizing the risk of perforation. An intermuscular dissection technique was employed to target the space between the inner and outer muscularis propria, avoiding EFTR when possible. Only a <6-mm area required EFTR due to deep invasion. This approach minimized peritoneal exposure and avoided pneumoperitoneum ([Fig. 3], [Video 1]). The resection site was closed using the loop-and-clip technique. No complications occurred. Histology confirmed a well-differentiated neuroendocrine tumor, infiltrating the muscularis propria, with negative lateral and vertical margins and no lymphovascular invasion ([Fig. 4]). Endoscopic resection of duodenal lesions involving the muscularis propria is challenging due to the thin wall, narrow lumen, and proximity to important vessels [1]. While EFTR offers an alternative to surgery, it carries risks such as pneumoperitoneum and bleeding [2]. This video demonstrates a combined approach using the advantages of SITE-enhanced visualization, elimination of gas insufflation, buoyancy-assisted traction, and reduced thermal injury through gradual coagulation enabled by improved conductivity [3] [4] (“frozen tree” effect). Furthermore, intermuscular dissection [5] enabled a targeted approach, limiting EFTR to only the extent necessary for complete tumor removal, highlighting its value in anatomically challenging cases. Endoscopy_UCTN_Code_TTT_1AO_2AC Article published online: 04 July 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany