Linear Echoendoscope Research Articles

PTH-186 Accuracy of standard 7.5–10 mhz endoscopic ultrasound for loco-regional staging of oesophageal malignancy – a retrospective analysis: Abstract PTH-186 Table 1

Introduction Systematic reviews have reported wide variations in locoregional – ‘T’ and ‘N’ staging – accuracy of EUS1for oesophageal cancer. This is attributed to multiple factors including the frequency of the echoendoscope (5–20 MHz), operator technique, non-traversibility of tumour and use of miniprobes. Method Retrospective review of oesophageal cancer cases registered in the local upper GI cancer database and Somerset Cancer registry for the Lancashire and South Cumbria cancer network (January 2008–December 2013). Staging EUS was performed at a single centre (Blackpool Teaching Hospitals) by four operators using Olympus prosound alpha 5 radial (13.8 mm outer diameter) and linear (14.6 mm outer diameter) echoendoscopes. Demographic, endoscopic and histopathological data were analysed and EUS staging was compared with final histopathological (p) staging of tumours. View this table: Abstract PTH-186 Table 1 Results 405 patients with oesophageal cancer identifed, 141 had EUS staging. 47 [39 male, mean age 70 (age range 45–85)] had final pathological staging available – surgical resection in 42 (89%) and endoscopic mucosal resection (EMR) in 5 (11%). The remaining 94 patients were unfit for resection or had palliative treatment only. Final ‘p’ staging confirmed adenocarcinoma in 38 (81%), sqaumous cell carcinoma in 7 (15%) and poorly differentiated in 2 patients (4%). 30 (64%) patients had neoadjuvant chemotherapy. 10 patients (21%) had endoscopically non-traversible tumours. Overall sensitivity and diagnostic accuracy of EUS for ‘T’ staging was 87% and 70% respectively, which falls to 67% and 49% respectively following neoadjuvant chemotherapy. Overall sensitivity and diagnostic accuracy of EUS for ‘N’ staging was 61% and 49% respectively, which falls to 40% and 38% respectively following neoadjuvant chemotherapy. None of the patients had FNA of local lymph nodes. Conclusion These results confirm that EUS has an acceptable overall accuracy for locoregional staging. Accuracy for T4 is diminished, often due to non-traversable tumours (no dilatation pre-EUS or use of mini-probes). Overall accuracy of ‘N’ staging is less than that of published literature as routine FNA of suspicious nodes were not performed. Limitations of study include time lag (mean 16.4 weeks) between EUS and resection and neo-adjuvant chemotherapy down staging of tumours. Disclosure of interest None Declared. Reference 1. Puli SR, Reddy JBK, Bechtold ML, Antillon D, Ibdah JA, Antillon MR. Staging accuracy of esophageal cancer by endoscopic ultrasound: A meta-analysis and systematic review. World J Gastroenterol. 2008;14(10):1479–1490

PTU-295 Endoscopic ultrasound: changing trends over a decade

<h3>Introduction</h3> Endoscopic Ultrasound (EUS) is a well established modality, in particular, fine needle aspiration (FNA) is used to sample suspicious lesions. The uptake in EUS is not well documented with the number of procedures performed and their indication unknown. Understanding demand for a procedure is essential for allocating resources in an endoscopy service. Our primary aim was to examine the trends in EUS in our unit and to examine EUS-FNA sensitivity and specificity in pancreatic and non-pancreatic lesions. <h3>Method</h3> Retrospective review of all EUS procedures from 2002 until 2013 was performed. Data collected included patient demographics, indication for EUS procedure (oesophago-gastric (OG) or pancreatobiliary (PB)) and obtained FNA samples. Pathology results of FNA specimens from 2011–2013 (n = 143) were analysed further with reference to number of passes into any lesion sampled. Sensitivity and specificity rates of FNA were calculated for pancreatic and non-pancreatic lesions respectively. <h3>Results</h3> The number of EUS procedures rose from 54 in 2002 to 287 in 2013. EUS FNA started in 2006 with the purchase of a linear echoendoscope which was associated with increasing number of EUS. There was a further increase in numbers in 2011 with the appointment of an additional consultant with an interest in EUS. There was a dip in total numbers 2008–2009 due to technical issues. Overall, there was a significant increase in the number of PB EUS comparing 2002 with 2013 (9/54 vs. 207/287, p &lt; 0.0001). There was a significant increase in the number of FNA performed comparing 2002 with 2013 (0/54 vs 48/287, p = 0.0006). EUS-FNA sensitivity for solid pancreatic lesions was 61.5%, for non-pancreatic lesions it was 66% but specificity was 100% in both groups of lesions. In solid pancreatic masses, diagnostic cytology was associated with increased numbers of passes into the lesion compared to non-diagnotic cytology (median 4 passes vs. median 2 passes, p = 0.001). There was no difference number of passes for non-pancreatic lesions with respect to diagnostic cytology rates. <h3>Conclusion</h3> There has been a significant increase in the utility of EUS in our unit, particularly PB EUS. Our current EUS FNA sensitivity is not good enough but will change practice to have a minimum number of passes for each lesion type. Reassessment of this service will then be conducted to determine whether any other improvements are required. <h3>Disclosure of interest</h3> None Declared.

EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach

ERCP is challenging in patients with Roux-en-Y gastric bypass. Using EUS to gain access to the excluded stomach and subsequently performing transcutaneous ERCP was described recently. We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). Single-center case series. Tertiary center with expertise in EUS-guided procedures. Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. A linear echoendoscope was used to access the excluded stomach. A LAMS was deployed over a wire to create a gastrogastric or jejunogastric fistula. A duodenoscope was then passed through the LAMS and conventional ERCP was performed. Technical and clinical success rates as well as adverse events. EUS-guided creation of a gastrogastric or jejunogastric fistula via placement of a LAMS was successful in all cases (100%). The ability to perform ERCP through the fashioned fistula during the index procedure was successful in 3 of 5 cases (60%). Two LAMS dislodgments requiring restenting were observed. No major adverse events were observed. No weight regain occurred. The median procedure time was 68.0 minutes. Small sample, single-institution experience. The internal EDGE procedure may offer a cost-effective, minimally invasive option for a common problem in a growing patient demographic. Further refinement of the technique is required to minimize adverse events. ( NCT01522573.).

Tu1650 Feasibility and Diagnostic Yield of a New EUS Guided Histology 20-Gauge Needle in the Evaluation of Intraintestinal and Extraintestinal Lesions

Tu1650 Feasibility and Diagnostic Yield of a New EUS Guided Histology 20-Gauge Needle in the Evaluation of Intraintestinal and Extraintestinal Lesions

Endoscopic Ultrasonography-Guided Fine Needle Aspiration of Kidney Masses

Scan the quick response (QR) code to the left with your mobile device to watch this article's video abstract and others. Don't have a QR code reader? Get one by searching 'QR Scanner' in your mobile device's app store. clinical management strategy is based on imaging features. A solid, contrast-enhancing renal mass seen on CT or MRI is considered malignant until proven otherwise, and operative resection is undertaken in appropriate candi- dates. A histologic diagnosis remains necessary in selected patients, such as those with radiographically indetermi- nate lesions, in those considering partial nephrectomy, and to confirm malignancy in patients unfi tf or surgery. Tissue diagnosis is critical to discern appropriate treat- ment in this subgroup. Renal biopsies are usually per- formed percutaneously under transabdominal ultrasound (US) or CT guidance. Percutaneous fine needle aspiration (FNA) can discriminate benign from malignant neoplasms in 91% of cases with histologic classification of tumor type possible in 87% of tumors. 2 Nondiagnostic/inade- quate specimens are largely owing to sampling error and occur in about 30% of cases. Data from case reports and series suggest endoscopic ultrasound (EUS)-guided FNA may provide an additional diagnostic technique for tissue acquisition of renal mass lesions.

Improvements and innovations in endoscopic ultrasound guided fine needle aspiration.

Keywords: Algorithm; Core histology needle; Cytology; Endoscopic ultrasound guided fine needle aspiration fine needle biopsy; Histology

EUS is superior for detection of pancreatic lesions compared with standard imaging in patients with multiple endocrine neoplasia type 1

In multiple endocrine neoplasia type 1 (MEN1), pancreatic neuroendocrine tumors (pNETs) are the leading MEN1-related cause of death. To evaluate EUS and (11)C-5-hydroxytryptophan positron emission tomography ((11)C-5-HTP PET), compared with the recommended screening techniques in MEN1 patients for early detection of pNETs. Cross-sectional study. Tertiary-care university medical center. This study involved 41 patients with a proven MEN1 mutation or with one MEN1 manifestation and a mutation carrier as a first-degree family member, with recent screening by abdominal CT or magnetic resonance imaging (MRI) and somatostatin receptor scintigraphy (SRS). EUS by using a linear Pentax echoendoscope and Hitachi EUB-525 and (11)C-5-HTP PET. Patient-based and lesion-based positivity for pNET was calculated for all imaging techniques. The McNemar test was used to compare the yield of the 4 imaging techniques. In 35 of 41 patients, 107 pancreatic lesions were detected in total. EUS detected 101 pancreatic lesions in34 patients, (11)C-5-HTP PET detected 35 lesions in 19 patients, and CT/MRI+ SRS detected 32 lesions in 18patients (P< .001). (11)C-5-HTP PET performed similarly to CT/MRI+ SRS and better compared with SRS only (13 lesions in 12 patients), both at a patient-based and lesion-based level (P< .05). Single-center study. EUS is superior to CT/MRI+ SRS for pancreatic lesion detection in patients with MEN1. In thissetting, (11)C-5-HTP PET is not useful. We recommend EUS as the first-choice pancreas imaging technique in patients with MEN1. ( NTR1668.).

Endoscopic ultrasonography-guided gallbladder drainage for acute cholecystitis: from evidence to practice.

With the evolution of the linear echoendoscope and the improved ability to direct a needle within the field of interest, the therapeutic potential of endoscopic ultrasonography (EUS) has greatly expanded. Endoscopic ultrasonography-guided transmural gallbladder drainage (EUS-GBD) may be the next frontier for therapeutic EUS. Since EUS-GBD was first described in 2007, recent reports have suggested it as an alternative to external gallbladder drainage for acute cholecystitis. EUS-GBD includes EUS-guided transmural nasogallbladder drainage, EUS-guided gallbladder aspiration, and EUS-guided transmural gallbladder stenting. Indications for the EUS-GBD technique as currently practiced, including equipment, technical details, complications, and efficacy are herein reviewed.

An 'omental patch' created during over-the-scope clipping completely sealed a duodenal perforation after endoultrasonography.

Perforation of the inferior knee of the duodenum is a rare complication during endoscopic maneuvers and, in particular, during endoscopic ultrasonography (EUS). A recent study by Carrara and colleagues reported a duodenal perforation rate of 0.09% in a series of 3296 patients who underwent EUS with fine-needle aspiration [Carrara et al. 2010]. The data in the literature on surgical management of these perforations are not currently comforting. An 82-year-old woman was referred to our center after computed tomography had shown a 7 cm diameter pseudocyst and a suspected malignant neoplasia of the proximal third of the common bile duct, causing jaundice. The patient underwent EUS with a linear echoendoscope (Pentax Hamburg, Germany). During retraction of the scope in the duodenum, we observed a full-thickness break of about 12 mm diameter, at the inferior duodenal knee (Figure 1). With an operative gastroscope we immediately placed a sharp-toothed, 10 mm/6 diameter over-the-scope clip (OTSC; OVESCO, Endoscopy, Tubingen, Germany) on the perforation. We preferred a therapeutic endoscope instead of the standard one because of the possibility of mounting a bigger diameter OTSC. During the aspiration we placed the omentum inside the cap. After releasing the OTSC we obtained immediate closure of the perforation, creating an ‘omental patch’ (Figure 2). The correct positioning of the OTSC and the complete closure of the perforation were subsequently confirmed by X-ray, the day after, when the patient underwent transhepatic biliary drainage (percutaneous transhepatic cholangiography). After releasing the drainage across the papilla, contrast was injected to check the correct closure of the defect. CO2 was not used in this case. Figure 1. Perforation of the inferior duodenal genu by endoscopic ultrasonography (EUS). Figure 2. Duodenal perforation sealed by OTSC creating an “omental-patch”. The patient developed peritonitis and died 12 days later of respiratory failure despite fasting, antibiotic therapy, nasogastric tube placement and parenteral nutrition support. As shown in a few reports in the literature [Donatelli et al. 2013; Meduri et al. 2014; Diez-Redondo et al. 2012], given the high rate of morbidity and mortality associated with post-surgical treatment of iatrogenic duodenal perforations, the OTSC should be considered the first option for immediate resolution of this adverse event, taking into account the possible risk of failure. OTSC may play a part in the armamentarium for the acute management of perforations and other such conditions [Bingener and Ibrahim-zada, 2014].

Forward-viewing linear echoendoscope: a new option in the endoscopic ultrasound armamentarium (with video).

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.

EUS-guided transesophageal drainage of a mediastinal abscess using a diabolo-shaped lumen-apposing metal stent

A 51-year-old man underwent laser vocal cord surgery for lysis of synechiae secondary to previous surgery for vocal cord cancer. After 1 month of postoperative healing, the patient developed fever. A chest CT scan demonstrated a 6 × 5-cm mediastinal abscess adjacent to the esophagus and the upper right paratracheal region (Fig. 1A). There was no clinical improvement with antibiotic therapy, and an EUS-guided transesophageal drainage of the lesion was considered. A linear echoendoscope was situated in the upper thoracic esophagus, and a well-defined mediastinal collection with isoechoic pattern was identified (Fig. 1B).

Tu1159 Risk and Outcomes of Reversal Agent Use in Moderate Sedation During Endoscopies and Colonoscopies

G A A b st ra ct s from 0 (no visualization) to 3 (visualized well without difficulty, easy to reproduce). Results: 175 patients from four tertiary care academic centers participated in the study. There was no difference in mean procedure times between EGD and the luminal endoscopic portion of the L-EUS (4:32 vs. 4:13, p=0.051). Similarly, there was no difference in the proportion of patients with clinically meaningful lesions identified on EGD and EUS (29.7% vs. 28%, p=0.72) (Table 1). There was also no significant difference in the miss-rate of clinically meaningful lesions between the two modalities (EGD: 10 (5.7%) patients vs. EUS: 14 (8%) patients, p= 0.37). The quality of visualization was better with EGD than L-EUS in the upper esophagus (mean 3.00 vs. 2.49) but worse when evaluating the ampulla (mean 1.38 vs. 2.32) (Table 2). However, no differences in clinically meaningful lesions were seen between the modalities at either of these locations. Conclusions: The endoscopic evaluation of the luminal upper gastrointestinal tract can be adequately achieved using the linear echoendoscope. Our findings suggest that the routine performance of EGD using a gastroscope at the time of linear EUS may be avoided, reducing procedure time and scope reprocessing costs. Table 1: Clinically Meaningful Findings on EGD and EUS

Mo1348 Endobronchial Ultrasound (EBUS) in Esophageal and Esophagogastric Malignant Stenosis: an Added Value

Accurate staging is critical in esophageal and esophago-gastric junction cancer, to select the appropriate management algorithm. Endoscopic ultrasound (EUS) is widely accepted as the gold standard technique to approach mediastinal diseases, providing an accurate assessment of local staging of both tumor infiltration (T stage) and lymph node status (N stage). However, in up to 30% of cases, failure in crossing the tumor narrowing with the EUS standard scope has been reported, resulting in a less accurate staging assessment. Endoscopic bronchial ultrasound (EBUS) with its smaller caliber, can be passed through obstructive tumors, allowing both T and N staging, and fine needle aspiration of lymph nodes or tumor masses (FNA). Aim To assess the feasibility of EBUS in stricturing esophageal and esophago-gastric junction tumors and to evaluate the staging yield of this technique for selecting the appropriate treatment. Patients and Methods Between January 2013 and October 2013, all consecutive patients referred to our tertiary referral center for EUS staging of esophageal cancer, with tumor stenosis, prohibiting the passage of the linear standard echoendoscope were enrolled in the study. After a first EGD evaluation and attempt with standard linear echoendoscope (EG3870UTK, Pentax Medical, Tokyo, Japan), in case of stenosis, the Pentax EB1670UK broncho-videoechoendoscope was used, to complete the tumor staging. Fine needle aspiration of peri-lesional lymph nodes, was performed, when indicated. Results 81 consecutive patients (65 M, mean age 67.4 years) with esophageal or esophago-gastric junction cancer underwent EUS for tumor staging at our center. In 31/81 (38%) patients (22 M, mean age 66.6 years) due to stricturing lesions, the linear echoendoscope could not pass the tumor. In these cases, we used the EBUS scope to overcome the stricture and complete the T and N staging. We reported 21/31 (68%) cases of stricturing esophageal cancer, 8/31 (26%) esophago-gastric junction cancer and 2/31 (6%) cases of post-surgical anastomotic recurrence. The EBUS T-stage was: 2/31 (6%) uT1sm, 2/31 (6%) uT2, 15/31(49%) uT3, 12/31 (39%) uT4. The EBUS N-stage was: 4/31 (13%) N0, 10/31 (32%) N1, 17/31 (55%) N+. In 2 cases, we performed FNA of per-lesional limph nodes, to complete diagnosis. 5/31 patients underwent surgery. The pathological staging confirmed the EBUS staging in 4/5 (80%) cases, whereas in 1 case EBUS over-staged the lesion (uT2 vs pT1a). Conclusions The use of EBUS scope in esophageal and esophagogastric malignant stenosis is feasible and effective, allowing an accurate T and N staging of all lymphovascular stations. Furthermore, FNA complete the local staging, and address the patient to the appropriate treatment.

Mo1458 Endosonography-Guided Gallbladder Drainage With a Lumen Apposing Stent Reduced Recurrent Biliary Events After Acute Cholecystitis As Compared to Percutaneous Cholecystostomy

Area under the ROC curve was 0.68 (95% CI 0.540.82), p-value 0.05 Mo1457 Endoscopic Ultrasound Correlates With Histology in Patients With Chronic Pancreatitis Undergoing Total Pancreatectomy Elham Afghani*, Amitasha Sinha, Michael Cruise, Mahya Faghih, Martin a. Makary, Kenzo Hirose, Marcia I. Canto, Mouen Khashab, Anne Marie Lennon, Vikesh K. Singh GI, Johns Hopkins, Baltimore, MD; Pathology, Johns Hopkins Hospital, Baltimore, MD; Surgery, Johns Hopkins Hospital, Baltimore, MD Background: Endoscopic ultrasound (EUS) is commonly used to diagnose chronic pancreatitis (CP). However, there have been few studies which have evaluated EUS with histology. Aims: To evaluate the association between EUS scoring with the degree of fibrosis in patients with CP who have undergone total pancreatectomy (TP). Methods: All consecutive adult patients with CP (ageR18 years) who underwent preoperative EUS followed by TP from 8/2011 to 10/2013 were included. EUS criteria were defined by the 9 ductal and parenchymal features. Surgical wedge biopsies were obtained from the head and body/tail during TP and histology was evaluated by a pathologist blinded to the results of EUS. Perilobular and intralobular fibrosis scores were determined from the wedge biopsy specimen for each patient and averaged. Mild fibrosis was defined as a fibrosis score (FS) of 0-6 and severe fibrosis was defined as FS of 7-12. The association between FS and EUS criteria was evaluated using Pearson’s correlation coefficient. The diagnostic accuracy of EUS for predicting severe fibrosis was assessed using the area under receiver operating characteristic curve (AUROC). Results: There were 29 patients (68.9% females, mean age of 44 12 years). All patients underwent EUS at mean time of 27.6 15.3 weeks prior to TP. There were 8 (27.5%) patients with calcifications. There were 13 (44.8%) patients with mild and 16 (55.2%) with severe fibrosis. There was a significant correlation between FS and EUS criteria (rZ0.57, 95% CI 0.28, 0.78, p!0.001) as seen in Figure 1. The diagnostic accuracy of EUS for predicting severe fibrosis by AUROC was 0.65 (95% CI 0.45, 0.85). An EUS cut-off of R6 criteria had a sensitivity of 37.5% but specificity and positive predictive value of 100% for severe fibrosis. Conclusion: EUS correlates with fibrosis but no criteria threshold is accurate enough to predict severe fibrosis. AB444 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 Mo1458 Endosonography-Guided Gallbladder Drainage With a Lumen Apposing Stent Reduced Recurrent Biliary Events After Acute Cholecystitis As Compared to Percutaneous Cholecystostomy Anthony Y. Teoh*, Takao Itoi, Philip W. Chiu, Raymond S. Tang, Charing C. Chong, Enders K. NG, Francis K.L. Chan, James Y. Lau Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong; Tokyo Medical University Hospital, Tokyo, Japan; Institute of Digestive Disease, Hong Kong, Hong Kong Background: Endosonography-guided gallbladder drainage (EGBD) has been shown to be feasible in previous studies. However, how the approach compares to percutaneous cholecystostomy (PTC) in patients who were unsuitable for surgery is uncertain. Methods: This was a retrospective case-controlled study of all patients who suffered from acute cholecystitis and were deemed high-risk for surgery, that were admitted to the Prince of Wales Hospital between January 2010 and November 2013. The patients that received EGBD were matched with those that received PTC based on sex, age and American society of anesthesiology grading. EGBD was performed using a linear echoendoscope (GF-UCT180 Olympus, Japan) and a lumen apposing stent (AXIOS, Xlumena, CA, USA) was used to drain the gallbladder in to the stomach or duodenum. Outcome measurements included technical and clinical success, morbidities, mortalities, the number of device-related events and unplanned admissions. Results EGBD was performed in 18 patients and they were case-matched with 18 patients who received PTC. There were no significant differences in background demographics between the EGBD and PTC groups(Table 1). All procedures were technically successful and clinical success was obtained in 88.9% and 94.4% of the patients respectively. 11 patients in the EGBD group underwent cholecystoscopy and all stones were removed in 81.8% of the patients. There were no differences in morbidities (33% vs 33.3%, P Z 1) and mortalities (11.1% vs 5.6%, P Z 1). Patients who underwent PTC suffered from significantly more device related events (61.1% vs 16.7%, P Z 0.015) and required more unplanned admissions (2.11 +/2.32 vs 0.11 +/0.47, P Z 0.002). The causes of device-related events in the PTC group included dislodgement, slipping of anchoring sutures and peri-tubal leak. Conclusion: EGBD and PTC were both effective means of obtaining gallbladder drainage. In the absence of a percutaneous tubing, EGBD was associated with reduced number of device-related events and unplanned admissions. Furthermore, EGBD allowed for removal of gallstones after the procedure. Comparison of outcomes between EGBD and PTC. EGBD N [ 18 PTC N [ 18

Mo1366 "One-Step" EUS-Guided Drainage of Pelvic Collections: a Single-Center Experience

EUS is a valuable imaging method that offers an excellent and non-invasive approach to the pelvic area. Moreover, the advent of linear echoendoscopes has allowed the endosonographer to perform fine-needle aspiration and therapeutic procedures such as EUS-guided drainage. As demonstrated by the literature, there is no standard technique to drain pelvic collections and the published series are quite short, so no solid conclusions can be obtained. We report our experience with "one-step" EUS-guided drainage in pelvic collections.

V.02.7 INCIDENTAL ENDOSONOGRAPHIC FINDING OF AN INTRA-CARDIAC MASS IN AN ASYMPTOMATIC PATIENT (VIDEO)

Background and aim: The patient, C.A., is a 75 years old male, referred to our centre for abdominal pain and a CT finding of a pancreatic cystic lesion. No cardiac or pulmonary symptoms. The previous medical history was mute except for arterial hypertension. Material and methods: The procedure was performed in deep sedation (Propofol e.v.), with a linear echoendoscope (Olympus GF-UCT 140 AL5). Results: The endosonographic finding was consistent with a small (2 cm) Intraductal Papillary Mucinous Neoplasia in the pancreatic head. On withdrawing the echoendoscope in the mediastinum, a homogeneous hyperechoic, 17 x 14 mm lesion was observed adherent to the left atrium wall. To distinguish between atrial thrombus and myxoma, the patient underwent Magnetic Resonance Imaging that diagnosed the presence of an atrial myxoma. Conclusions: Endoscopic Ultra Sound can sometimes incidentally discover diseases outside the gastro-intestinal tract that can significantly impact on patient management. In this subject the exploration of the mediastinum allowed to diagnose an otherwise undetected pathologic cardiac condition.

Treatment of complete esophageal stenosis using endoscopic ultrasound-guided puncture: a novel technique for access to the distal lumen

Treatment of locally advanced esophageal cancers with high-dose definitive concomitant chemoradiotherapy can lead to high-grade esophageal strictures, or, rarely, total obliteration of the lumen. Strictures can be successfully treated with various endoscopic techniques; however, complete obstruction is a technically challenging problem. Anterograde endoscopic techniques carry the risk of perforation or bleeding. A combined anterograde–retrograde dilation technique, described in a few reports, is another option but requires retrograde access through a prior ostomy [1–4]. We report a novel method for managing complete esophageal obstruction using endoscopic ultrasound (EUS)-guided puncture for access to the distal lumen, previously described only in a case of total colonic stricture using a prototype forward-view echoendoscope [5]. A 62-year-old woman had received highdose chemoradiation for a squamous cell esophageal carcinoma (stage IIIC) and her esophagus had completely occluded, with severe compromise to her quality of life (● Fig.1). Several attempts to pass a guide wire though the stricture were unsuccessful. We decided to attempt recanalization of the lumen using an EUS-guided access. The linear echoendoscope (GF-UCT140AL5;Olympus, Tokyo, Japan)wasadvanced 24cm from the incisors and the distal esophageal lumenwas identified from the proximal endon theEUSimage (● Fig.2a). A 19G needle (Expect Flex; Boston Scientific Corp, Natick, Massachusetts, USA) was used to puncture the obstructed lumen under EUS guidance (● Fig.2b). Contrast filling was visualized under fluoroscopy and a 0.035-inch guide wire (Microvasive Jagwire; Boston Scientific) was advanced through the EUS needle (● Fig.3a,b). An 8-mm biliary balloon (Hurricane RX; Boston Scientific) was used to perform a first dilation under endoscopic and fluoroscopic guidance (● Fig.3c). The endoscopic appearance after dilation was satisfactory, with reestablishment of luminal continuity (● Video 1). The patient underwent four additional endoscopic balloon dilations of up to 15mm (● Fig.4). She respondedwell, gaining the ability to swallow secretions, drinks, and soft food, andwithout evidence of delayed complications. Fig.2 a,b EUS images of the esophageal total stricture. a A thickened esophageal wall (arrows) continues through the stenosis. b EUS image of the 19G needle through the stricture (arrow).

Performance of the forward-viewing linear echoendoscope for fine-needle aspiration of solid and cystic lesions throughout the gastrointestinal tract: a large single-center experience

A newly developed forward-viewing linear echoendoscope (FV-EUS) has recently become available. To date, however, only scanty data on the performance of the FV-EUS scope for fine-needle aspiration (FNA) of lesions throughout the gastrointestinal (GI) tract are available. This study aimed to evaluate the technical performance of the FV-EUS scope for FNA of solid and cystic lesions located throughout the GI tract in a large cohort of patients referred to a tertiary care center. All patients who underwent endoscopic ultrasound (EUS)-guided FNA using the FV-EUS scope between January 2007 and December 2008 were included in this retrospective study. The performance of the FV-EUS scope for FNA was evaluated. During the study period, 285 patients with solid or cystic lesions throughout the GI tract underwent the procedure with the FV-EUS scope. A total of 300 FNAs were attempted, 6 (2%) of which could not be performed. Of the 294 successful EUS-FNA procedures, 130 (44.2%) were performed using a 22-gauge needle, 89 (30.3%) using a 25-gauge needle, and 75 (25.5%) using a 19-gauge needle. In all 67 cases of pancreatic cyst or dilated pancreatic duct, a specimen for cystic fluid analysis or cytologic examination could be obtained. Among the remaining 217 patients with solid lesion, a definitive diagnosis could be established for 211 patients (97.2%). The FV-EUS scope had a sensitivity of 74.7% (95% confidence interval [CI] 68.1-80.6%), a specificity of 100% (95% CI 89.9-100%), a positive likelihood ratio of infinity, and a negative likelihood ratio of 0.251 (95% CI 0.196-0.323). The FV-EUS scope is highly effective for FNA of solid and cystic lesions throughout the GI tract. Prospective studies comparing the FV-EUS scope and a curved linear scope are needed.

Metallic stent in the endoscopic treatment of pancreatic fluid collections

The endoscopic treatment of pancreatic fluid collections (PFCs) has become the preferred first-line approach. Fully covered self-expandable metal stents (FCSEMS) were considered as an alternative to multiple double pigtail stents. The aim of this study was to evaluate the results of the endosonography guided drainage (EUS-GD) of PFCs with FCEMS. A total of 33 consecutive patients were included. Cystogastrostomy and cystoduodenostomy were created with a linear echoendoscope under endosonographic and fluoroscopic control. Procedures were performed in a standard way of, puncture with a 19 gauge needle, bougie dilation and insertion of FCSEMS. A total of 33 patients (mean age 52 years, 21 men, range: 18-77 years), were included. PFCs were 22 non-infected symptomatic pseudocyst and 11 walled-off necrosis or abscess. EUS-GD was successful in 30 (90.9%) patients. Stent insertion failed in one patient. Two patients needed surgery. Complications were observed in 8 (25%) patients (stent dislocation in 3, perforation in 2, bleeding in 2 and pneumoperitoneum in 1 patient). Procedure related mortality was not seen. The mean cyst size was 11.3 cm (5-22). FCSEMS were successful in the treatment of pseudocysts (after 1 month mean cyst size is 6.2 cm, range: 0-15 cm, with 54.8% decrement rate). During a mean follow-up of 15 months complete resolution was 66.6% (20 patients) and recurrence due to stent malfunction was 10%. All these cases were submitted to a new session of endoscopic drainage. EUS-GD, FCSEMS insertion provides an effective, minimally invasive, and safe approach in the management of PFCs.

Imaging of peritoneal ligament by endoscopic ultrasound

Double layered peritoneal folds, variously named as ligaments, omenta and mesenteries connect the intraperitoneal organs to the abdominal wall. Some of these ligaments contain blood vessels and lymph nodes while others are avascular. The peritoneal folds not only act as conduits for the passage of blood vessels from the retroperitoneum to reach intraperitoneal organs, but also provide a pathway for the spread of disease processes. It is difficult to identify these normal peritoneal folds at imaging. Computed tomography is the most common imaging modality used to detect diseases of the peritoneum to fully delineate peritoneal anatomy and the extent of disease. The endoscopic ultrasound (EUS) can be used to image peritoneal ligaments with the advantage of lack of ionizing radiation and lower cost. Though EUS is being increasingly used both for diagnostic and interventional purposes in the abdomen, it has not been used to assess the peritoneal ligaments till now. We did this study in 50 patients using linear echo endoscope to delineate various peritoneal ligaments. The technique of evaluation of ligament has been described in this review. The peritoneal ligaments can be delineated with accuracy by EUS.