Radial Endoscopic Ultrasonography Research Articles

Multiple Esophageal Leiomyomas: Case Report

Esophageal leiomyoma is uncommon. It is the most common benign tumor of the esophagus accounting for 0.4% of esophageal neoplasms and approximately two-thirds of benign esophageal tumors. About 90% of them are reported to be solitary and intramural lesions, and multiple or diffuse lesions seem to be very rare. We report the observation of a 75 years old male patient who was evaluated for chronic epigastric pain, Physical examination findings were typically normal, the patient underwent upper GI endoscopy. In esophagus, many submucosal tumor covered with intact mucosa, varying between 5mm and 20mm in size and located in the middle and lower part of oesophagus were noted. The radial endoscopic ultrasonography showed multiple (>10 masses), homogenous hypoechoic masses with clear margins, originated from the submucosa layer with normal surrounding structures, located in the middle and lower part of the oesophagus, and their size was < 2 cm, these lesions are followed periodically as they have a slow growth rate and negligible risk of malignant transformation. Multiple esophageal leiomyomas seems to be very rare, EUS is a valuable technique for the diagnosis of the disease and for making treatment decisions.

Linear EUS Accuracy in Preoperative Staging of Gastric Cancer: A Retrospective Multicenter Study.

Preoperative gastric cancer (GC) staging is the most reliable prognostic factor that affects therapeutic strategies. Contrast-enhanced computed tomography (CECT) and radial endoscopic ultrasound (R-EUS) scans are the most commonly used staging tools for GC. The accuracy of linear EUS (L-EUS) in this setting is still controversial. The aim of this retrospective multicenter study was to evaluate the accuracy of L-EUS and CECT in preoperative GC staging, with regards to depth of tumor invasion (T staging) and nodal involvement (N staging). 191 consecutive patients who underwent surgical resection for GC were retrospectively enrolled. Preoperative staging had been performed using both L-EUS and CECT, and the results were compared to postoperative staging by histopathologic analysis of surgical specimens. L-EUS diagnostic accuracy for depth of invasion of the GC was 100%, 60%, 74%, and 80% for T1, T2, T3, and T4, respectively. CECT accuracy for T staging was 78%, 55%, 45%, and 10% for T1, T2, T3, and T4, respectively. L-EUS diagnostic accuracy for N staging of GC was 85%, significantly higher than CECT accuracy (61%). Our data suggest that L-EUS has a higher accuracy than CECT in preoperative T and N staging of GC.

Endoscopic Ultrasound Images of Normal Anatomy of the Pancreas and Biliary Tree

Since the development of endoscopic ultrasound (EUS), the importance in the using EUS in pancreas and biliary tree has gradually increased. In order to properly observe the pancreas and biliary tree in EUS, it is necessary to learn landmark structures at each location, such as the stomach and duodenum, and to learn the positional relationship between them and normal structures. In this article, we will deal with the examination method at each position of the linear and radial EUS and reveal the normal EUS image.

Oesophageal wall thickness assessment at endoscopic ultrasound in children and adolescents with eosinophilic oesophagitis: a case-control study.

Eosinophilic oesophagitis (EoE) is a chronic immune-mediated disease, and an endosonographic evaluation may help the diagnosis. The main objectives of this study were to measure the thickness of the oesophageal wall using a radial endoscopic ultrasound (EUS), mucosa/submucosa (MSM), muscularis propria (MP) and mucosa to muscularis propria (MMP); to compare these measurements between patients with and without EoE; to correlate them with the Endoscopic Reference Score (EREFS); and to evaluate the diagnostic accuracy of these measurements. Children and adolescents (aging from 4 to 17years) were evaluated in this prospective cross-sectional study. A radial EUS at 12MHz frequency was used, and EREFS was employed to grade macroscopic findings. Accuracy of the measurements for the diagnosis of EoE was assessed by receiver operating characteristics (ROC) curve. Twenty-six (19M/7 F) patients (median age 10.83years, range 5.65-17.46) were evaluated. EoE was diagnosed in 6 patients. The mean (and SD) oesophageal wall thicknesses in the distal oesophagus in millimetres in groups with and without EoE, respectively, were: MSM 1.07 (0.44) and 1.11 (0.33); MP 0.67 (0.25) and 0.60 (0.19); and MMP 1.73 (0.46) and 1.72 (0.32). Mid-oesophagus: MSM 1.16 (0.34) and 1.15 (0.34); MP 0.63 (0.16) and 0.60 (0.2); and MMP 1.79 (0.41) and 1.74 (0.34). In the ROC curve, the distal MP layer thickness presented better discriminative performance, with an area under the curve of 0.61 (95% CI 0.28-0.93) at 0.73mm cut-off (66.67% sensitivity, 80% specificity, likelihood ratios of 3.33 for positive and 0.42 for negative test). The evaluation of oesophageal thickness measurements by EUS is not useful for diagnosing EoE.

Depictability of the upper gastrointestinal tract on forward-viewing radial endoscopic ultrasonography versus standard upper esophagogastroduodenoscopy.

ObjectivesEsophagogastroduodenoscopy (EGD) is a widely used modality for investigating the upper gastrointestinal (GI) tract, similar to endoscopic ultrasonography (EUS) for the pancreaticobiliary system. A recent and novel forward‐viewing radial EUS has potential as an EGD. However, this potential has not yet been evaluated and reported in the literature. We compared the depictability of the upper GI tract on EUS using a standard EGD.MethodsThis was a prospective study in a single session in an identical patient and it was conducted at a single center.ResultsSixty‐nine participants were enrolled in this study. A forward‐viewing radial EUS revealed equivalent visualizing performance compared with the standard EGD, except for the retroflex view of the three angular areas. Depiction scores of the anterior wall, lesser curvature, and posterior wall of the angulus in the retroflex view in the forward‐viewing radial EUS were 1.94 (95% confidence interval [CI], 1.36–2.52), 2.03 (95% CI, 1.48–2.58), and 1.93 (95% CI, 1.35–2.50), respectively. These scores were significantly lower compared with those of standard EGD scores of 2.97 (95% CI, 2.86–3.08), 2.97 (95% CI, 2.86–3.78), and 2.96 (95% CI, 2.83–3.09], respectively; p < 0.001). The rate of full‐mark score in these three angular areas was significantly lower in the forward‐viewing radial EUS than in the standard EGD (21/69, 30.4%; 23/69, 33.3%; 21/69, 30.4% vs. 67/69; 97.1%, 67/69; 97.1%, 66/69; 95.7%, p < 0.001 for all).ConclusionsAlthough forward‐viewing radial EUS has the potential to simultaneously investigate the upper GI and pancreaticobiliary systems, it is too early to introduce it for this purpose.

Simultaneous observation of the upper gastrointestinal tract and pancreas with direct forward viewing radial endoscopic ultrasonography

Simultaneous observation of the upper gastrointestinal tract and pancreas with direct forward viewing radial endoscopic ultrasonography

S2948 Long-Term Proton Pump Inhibitor-Induced Gastric Microcystic Glandular Changes Leading to Gastric Wall Thickening

INTRODUCTION: Long term (LT) proton pump inhibitor (PPI) induced gastric microcystic glandular mucosal changes could lead to significant gastric wall thickening which must be further evaluated to exclude underlying neoplastic process. CASE DESCRIPTION/METHODS: An 81-year-old male with GERD and Barrett’s esophagus (BE) on chronic omeprazole 40mg BID was evaluated by endoscopic ultrasound (EUS) for 1cm gastroesophageal junction (GEJ) sub epithelial lesion (SEL) seen on EGD and thickened gastric mucosa (2.6 cm) normalizing just proximal to GEJ identified on an otherwise negative CT abdomen done to evaluate for epigastric pain. EGD showed irregular carpet-like thickened gastric folds with cobble stoning sparing the gastric antrum. EUS showed a small cystic SEL at GEJ and marked diffuse thickening of gastric body mucosa (16 mm) with intact muscularis propria and absence of regional lymphadenopathy. Endoscopic biopsies revealed no H. pylori but gastric mucosa with microcystic glandular changes consistent with gastric mucosal trophic changes secondary to chronic PPI use. Due to BE however, patient was continued on PPI. DISCUSSION: PPIs remain the cornerstone for GERD treatment. Adverse effects from inappropriate PPI use are more clinically manifested in the elderly population. These include drug-drug interactions and increased risk of LT PPI adverse effects on digestive and extra-digestive organs (such as dementia, decreased bone density, and community acquired pneumonia). LT PPI use can lead to fundic gland polyp formation, small intestinal bacterial overgrowth, and collagenous colitis. Gastric trophic changes were found to occur secondary to LT PPI use in the form of parietal cell protrusion into the gastric lumen and fundic gland polyp formation resulting from increased serum gastrin level. Hypertrophic changes due to LT PPI induce gastric mucosal changes that can be appreciated endoscopically as gastric cobblestone-like lesions (GCLL). Sparing of the antrum in our patient of such changes can be explained by parietal cells being anatomically present in gastric fundic glands located primarily in the gastric fundus and body. Histopathology of gastric biopsies in these cases show fundic microcystic glandular change, parietal cell hyperplasia, and cytoplasmic vacuolation. A gastroenterologist should be familiar with such changes due to LT PPI use and, yet, must biopsy the gastric mucosa to exclude any underlying gastric infiltrative and neoplastic process.Figure 1.: Endoscopic view of gastric corpus showing thickened folds, carpet like polypoid lesions.Figure 2.: Radial EUS showing markedly thickened gastric mucosa and intact muscularis propria.Figure 3.: Histopathology of gastric corpus biopsies showing microcystic glandular conformation.

Role of Radial Endoscopic-ultrasound (EUS) to Establish Diagnosis of Undetermined Causes of Obstructive Jaundice: A Case Series

Identification the causes of obstructive jaundice are challenging. Recent radiologic imaging techniques improve diagnostic yield to determine jaundice causes. However, small lesions particularly in pancreas or periampullary area that lead to jaundice, often unrecognize with conventional radiologic imaging. Radial endoscopic-ultrasound (EUS) is the most sensitive modality to identify the lesions-related obstructive jaundice, remarkably in the lack of high-resolution radiologic facilities. We presented four cases of obstructive jaundice, without obvious obstruction causes from conventional radiologic imaging or abdominal ultrasound. All patients underwent radial EUS, pancreatic head mass revealed in 2 patients, and distal stenosis of the common bile duct without evidence of mass was found in 2 other patients. The masses size were 16 mm and 39 mm in diameter. Due to linear EUS and EUS guided fine needle were unavailable in our center, confirmation biopsy was undone. Three patients were performed endoscopic retrograde cholangiopancreatography (ERCP) for dilatation and inserting stents, and one patient referred to the surgeon. In conclusion, radial EUS aided to diagnose the definite causes of jaundice despite in the less-equipped of high-resolution radiologic imaging.

Impact of balloon inflation on the insertion of endoscopic ultrasound: a prospective, randomized controlled trial.

Background and study aims During endoscopic ultrasound (EUS), patients may experience severe discomfort. The radial echoendoscope has a balloon around its tip. Balloon inflation prior to insertion may reduce contact injury and pharyngeal pain. The purpose of this study was to investigate the effect of balloon inflation on pharyngeal pain during insertion. Patients and methods Patients who underwent radial EUS for pancreatobiliary disease were randomized into standard insertion or balloon-inflated insertion. The primary outcome was the proportion of moderate-to-severe pharyngeal pain. Secondary outcomes were the degree of pharyngeal pain, risk factors for moderate pharyngeal pain, procedure-related adverse events, and pharyngeal pain depending on the experience of the endoscopist. Results A total of 481 patients were randomized into two groups: standard insertion (238) and balloon inflation (243). No statistically significant differences in proportion of moderate-to-severe pain were found (26.5 % vs. 20.2 %, P = 0.107). Balloon inflation (HR 0.65; 95 % CI (0.42–0.98, P = 0.041) was a protective factor against moderate pain. Balloon inflation reduced the proportion of patients with moderate-to-severe pain when performed by physicians with less than 3months of experience with EUS (44.7 % vs. 25.3 %, P = 0.012). Conclusion Balloon inflation did not reduce the absolute degree of post-procedural pain with EUS, but it reduced the number of patients with moderate-to-severe pain when performed by physicians with less than 3 months of experience.

Endoscopic ultrasound and fine-needle aspiration for the detection of residual nodal disease after neoadjuvant chemoradiotherapy for esophageal cancer.

Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are potential tools for the detection of residual disease after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. This study investigated yield of EUS and FNA for detection of malignant lymph nodes (LNs) after nCRT. This was a post hoc analysis of the preSANO trial. EUS was performed 10 - 12 weeks after nCRT. 18F-fluorodeoxyglucose positron emission tomography - computed tomography (18F-FDG PET-CT) was used to guide targeting of suspicious LNs. Consecutive FNA sampling was performed for suspicious LNs identified on EUS and/or PET-CT. EUS nodal staging was compared with histopathological examination of the resection specimen. The primary outcome was the proportion of correctly identified patients with malignant LNs by radial EUS. 101 consecutive patients were included: 79 patients had no malignant LNs, of whom 62 were classified correctly by EUS (specificity 78 %); 22 patients had malignant LNs, of whom 11 were identified (sensitivity 50 %). Six of these patients had ≥ 1 suspicious LN not fulfilling EUS criteria (round, hypoechogenic, > 5 mm). Malignant LNs in falsely negative patients were predominantly located at distal LN stations. Specificity and sensitivity of conclusive FNA outcomes were 100 % (7/7) and 75 % (3/4), respectively. FNA outcome was uncertain in eight patients, half of whom appeared to have malignant LNs. EUS only detected 50 % of patients with malignant LNs 10 - 12 weeks after nCRT. To optimize sensitivity and minimize the risk of missing residual disease, FNA of LNs should be performed even in cases of low endosonographic suspicion.

Cholangiopathy in children with extrahepatic portal venous obstruction.

Portal cavernoma cholangiopathy (PCC), a surgical-endoscopic dilemma, has not been studied comprehensively, more so in children. Our study aimed to evaluate PCC in children using a combination of magnetic resonance cholangiography-portovenography (MRC-MRPV) and endoscopic ultrasonography (EUS). In this prospective cross-sectional study, recruited children with extrahepatic portal venous obstruction (EHPVO) underwent MRC-MRPV and radial array EUS. PCC was categorized as asymptomatic PCC, symptomatic and no-PCC. Modified Llop grading was used to grade the MRC changes. Sixty-six of 72 (92%) children had PCC (85% asymptomatic; 7% symptomatic) on MRC. Age at study and duration of disease had significant correlation (r = 0.588, P < 0.001). 63% had grade III MRC changes. MRC grades and superior mesenteric vein block (64%) on MRPV significantly corresponded with EUS changes (intracholedochal varices, choledochal perforators, intramural cholecystic collaterals and biliary calculi). Superior mesenteric vein non-patency was a strong predictor of MRC biliary changes (P = 0.003, odds ratio 46.4, 95% confidence interval 4.91-623.6). A majority of EHPVO children have asymptomatic cholangiopathy and should be routinely evaluated for PCC at the time of first presentation by MRC-MRPV. Additional superior mesenteric vein block with portal cavernoma results in significantly higher changes of cholangiopathy on MRC and EUS.

Clinical efficacy of endoscopic ultrasonography for decision of treatment strategy of gastric cancer

Accurate preoperative tumor staging of gastric cancer is indispensable with expansion of indications for laparoscopic surgery and endoscopic resection. It is important to distinguish mucosal cancer (T1a) in smaller lesion and differentiate early gastric cancer (EGC) in larger lesion considering endoscopic resection indication and laparoscopic surgery indication. We evaluated the clinical outcomes of endoscopic ultrasonography (EUS) for the decision of treatment strategy of gastric cancer compared with pathological staging. The patients who underwent EUS and surgical or endoscopic resection for gastric cancer were retrospectively reviewed between September 2005 and February 2016. The depth of tumor invasion (T staging) by EUS was compared with the pathological staging after endoscopic or surgical resection. A total of 6084 patients were finally analyzed. The accuracy rates for T1a and EGC were 75.0 and 89.4%, respectively. The overall accuracy of T staging by EUS was 66.3% when divided by T1a, T1b, and over T2. The accuracy of EUS prior to endoscopic resection was 75.1% in absolute indication and 73.1% in expanded criteria, respectively. The accuracy rates for T1a with lesion ≤ 2cm in miniprobe EUS and EGC with lesion > 2cm in conventional EUS were 84.6 and 83.2%, respectively. In multivariate analysis, presence of ulcer, large tumor size, and radial EUS were associated with overestimation, and small tumor size and miniprobe were associated with underestimation in T staging. EUS showed the high accuracy of 84.6% for T1a in lesion ≤ 2cm in miniprobe EUS and 83.2% for EGC in lesion > 2cm in conventional EUS, respectively. EUS can be a complementary diagnostic method to determine endoscopic or surgical treatment modality.

Capability of Radial- and Convex-Arrayed Echoendoscopes for Visualization of the Pancreatobiliary Junction.

Background/AimsAlthough both radial- and convex-arrayed endoscopic ultrasonography (EUS) scopes are widely used for observational EUS examinations, there have been few comparative studies on their power of visualization. The aim of this study was to evaluate the capability of these EUS scopes for observation of the pancreatobiliary junction. MethodsThe rate of successful visualization of the pancreatobiliary junction was retrospectively compared between a radial-arrayed and a convex-arrayed echoendoscope, from a prospectively maintained database. Study periods were defined as January 2010 to December 2012 for the radial group, and February 2015 to October 2016 for the convex group because the respective scope was mainly used during those periods. ResultsDuring the study period, 1,660 cases with radial EUS and 1,984 cases with convex EUS were recruited. The success rates of observation of the pancreatobiliary junction were 80.0% and 89.5%, respectively (p<0.0001). ConclusionsThe capability of visualization of the pancreatobiliary junction in observational EUS was found to be better with a convex-arrayed than with a radial-arrayed echoendoscope.

Clinical application of radial endoscopic ultrasonography on preoperative T and N staging for advanced gastric cancer

Objective To assess the value of endoscopic ultrasonography (EUS) and abdominal CT scan on preoperative T and N staging of advanced gastric cancer. Methods A total of 188 patients with advanced gastric cancer received EUS and CT scan to evaluate the T and N staging and lymphatic metastasis before surgical operation. The postoperative pathologic results acted as gold standard for comparison of the two methods. The results consistent with pathologic results were considered as correct otherwise were incorrect. The accuracy of EUS and CT and the each consistency of two methods with pathology were analyzed. Results For T staging, the accuracy of EUS and CT was 87.2%(164/188), 76.6%(144/188), respectively, and Kappa value of EUS and CT was 0.726 and 0.509, respectively. There was a statistical difference between the two methods(χ2=7.181, P=0.007). For lymph node metastasis, the accuracy of EUS and CT was 72.9%(137/188) and 79.8%(150/188), respectively, and Kappa value of EUS and CT was 0.397 and 0.487, respectively. No statistical difference was found between them(χ2=0.963, P=0.326). The consistency test between the two methods for T and N staging and lymph node metastasis revealed that the Kappa value was 0.507 and 0.649, respectively. The accuracy of EUS on T staging was 93.0%, 93.3%, 96.8% and 91.5% in cardiac cancer, gastric fundus cancer, gastric corpus cancer, and gastric antrum cancer, respectively. Corresponding Kappa value in the 4 different positions were 0.843, 0.881, 0.940 and 0.710, respectively according to consistency tests. The accuracy of gastric antrum cancer with pylorus invasion was 63.2% and the consistency test Kappa value was 0.340. Conclusion EUS is an accurate method for T staging and lymphatic metastasis of advanced gastric cancer, but there is a lower accuracy for T staging of gastric antrum cancer with pylorus invasion. Key words: Endoscopic ultrasonography; Advanced gastric cancer; Neoplasm staging

Endoscopic ultrasound-guided cyanoacrylate glue injection for treatment of ano-urethral fistula

Background:Perianal fistulas are a frequent cause of morbidity and occur due to cryptoglandular infection, Crohn’s disease, radiotherapy, and malignancy. Perianal fistula occurring as a complication of anal canal surgery is an infrequent cause. We report endoscopic ultrasound (EUS)-guided management of a case of postsurgical perianal fistula with cyanoacrylate glue injection.Case Report:A 35-year-old man presented with recurrent urinary tract infection requiring multiple courses of antibiotics for the past 15 years. He was operated for imperforate anus at birth and developed anal stricture requiring repeated bougienage dilation till 4 years of age. After anal dilatation, he had intermittent passing of urine through anal opening and was diagnosed to have ano-urethral fistula. He underwent multiple surgeries (three times) for the repair of fistula till the age of 16 and remained well till the age of 33. He presented with recurrent urinary tract infection. Radial EUS showed a tortuous fistula in anal canal communicating with prostatic urethra which was visualized due to air bubbles. A linear EUS-guided glue injection was planned. The patient was catheterized. Glue was injected into the middle part of fistula with successful closure. While injecting glue, the Foley’s catheter was rotated to avoid sticking of glue to the catheter. The patient is symptom-free on follow-up for 1 year. To conclude, we can say that EUS-guided cyanoacrylate glue can be safely attempted to treat postsurgical ano-urethal fistula.

The Role of Endoscopic Ultrasound in the Diagnostic Assessment of Subepithelial Lesions of the Upper Gastrointestinal Tract

IntroductionThe identification of subepithelial lesions is a relatively frequent finding at endoscopy however their natural history is not well known. Our aim was to analyze the role of endoscopic ultrasound (EUS) in the diagnostic approach of subepithelial lesions of the upper gastrointestinal tract. MethodsRetrospective study which included 324 patients undergoing upper radial EUS for evaluation of subepithelial lesions from 2008 to 2014. The EUS features, presumptive diagnosis and management decision were analyzed. Results324 patients included, 60% with gastric subepithelial lesions, 28% oesophageal and 12% from the duodenum. Based on EUS features the presumptive diagnosis was: 25% gastrointestinal stromal tumor, 21% lipoma, 19% leiomyoma, 17% pancreatic rest, 7% submucosa cysts, 1% granular cell tumors, 1% carcinoids, 1% mucosa lesions and 8% not defined. After EUS the suggested approach was no follow-up in 45%, follow-up with re-examination with EUS in 35% and additional tissue sampling or endoscopic/surgical resection in 20%. The latter was based on EUS features of risk at the diagnosis (53%), such as size ≥2cm, hypoechogenicity, heterogeneity, lobulation, calcifications, cystic component and regional adenopathies; impossibility to define a presumptive diagnosis (39%) or EUS features change at follow-up (8%). The combination of multiple features correlated with a higher probability of this recommended strategy (p<0.001), in 100% when 4 or more features were present. Among the 33 patients who underwent fine needle aspiration, in 66% the result was inconclusive. During follow-up, none of the patients who were managed with surveillance radial EUS presented complications. ConclusionEUS is the method of choice in the study of subepithelial lesions of the upper gastrointestinal tract, in most cases defining a diagnosis. The need for a definitive diagnosis or therapeutic approaches can be based on ultrasound risk features, presented, in the majority, at presentation. This study shows that EUS is capable of safely and accurately define those subepithelial lesions that can be managed only with surveillance ultrasound while waiting for better results with fine needle aspiration.

The value of CA 19 – 9 and endoscopic ultrasonography (EUS) in the detection of Pancreatic Ductal Adenocarcinoma (PDAC)

Introduction: EUS has been recommended when computer tomography (CT) is inconclusive for PDAC. CA19 – 9 has been suggested as a potential marker in the detection of PDAC. Aims: The aim of our study was to assess the utility of CA19 – 9 and EUS in PDAC detection after a negative abdominal CT in a selected population of pancreatic EUS referrals. Methods: A retrospective study of patients who underwent radial EUS between 2012 and 2015 in our institution, with the aim to confirm the presence or absence of PDAC subsequent to no tumor detection by abdominal CT compared normal with elevated Ca 19 – 9 level. Results: 46 patients (20 male, 26 female, mean age 63.54 ± 18 years) were recruited in the study. 24 patient had abdominal pain, 3 fever, 9 weight lost and 18 patients were asymptomatic. EUS revealed 18 PDAC and 28 EUS were negative. The CA 19 – 9 level was normal in 8 and elevated in 10 patients with PDAC, and it was normal in 23 and elevated in 5 patients with negative EUS. Sensitivity, specificity and positive and negative predictive value of CA19 – 9 were 55.5%, 82.1%, 66.6% and 74.1%, respectively. Conclusions: EUS is recommended to be performed, when PDAC is suspected, but CT is negative. Ca 19 – 9 is not a reliable diagnostic tool for PDAC.

Complete Endoscopic Resection and Perforation Closure of a T1 Rectal Carcinoid Tumor

SymbolIntroduction:Rectal carcinoid tumors are typically incidentally found and can be managed endoscopically or surgically. Although rectal carcinoids are often indolent, they can metastasize with a 5-year survival rate of 86% for all stages combined. Endoscopic management by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) versus trans-anal endoscopic microsurgery (TEMS) are the preferred management options depending on the size and clinical features of the lesion.SymbolMethods: A 74-year-old female, with history of hypertension and hyperlipidemia, was found to have an 8 mm submucosal rectal lesion on screening colonoscopy at an outside center. This was biopsied, and the site was tattooed with ink. Pathology revealed a carcinoid lesion. She was referred to our center for further management. Both endoscopic and surgical options were discussed with the patient in detail. She opted for endoscopic resection, due to her concern for sphincter injury with the TEMS approach. Flexible sigmoidoscopy with endoscopic ultrasound (EUS) and endoscopic resection were planned. Sigmoidoscopy showed a 5-6 mm submucosal lesion in the distal rectum with a tattoo mark at the base. Radial EUS exam did not reveal any involvement of the muscularis propria or any perirectal adenopathy. EMR of the lesion was successful using the band ligation EMR device. The entire lesion was resected en bloc and retrieved. Post retrieval, the resection site revealed a focal perforation of the inner circular muscle layer with an adjacent non-bleeding pulsatile vessel. Given the focal perforation and potential for delayed bleeding, seven endoclips were used to completely close the resection defect. The patient recovered uneventfully and was discharged home the same day. Pathology of the resected lesion revealed a well differentiated low grade neuroendocrine tumor with focal submucosal involvement, but without lymphovascular invasion, with negative deep and circumferential margins and a low Ki-67 index. Endoscopic surveillance is planned. Conclusion: Our case illustrates the utility of the band ligation EMR technique for complete en-bloc resection of a T1 rectal carcinoid lesion. The tattoo ink within the resection site likely created focal inflammation and scarring, resulting in involvement of the muscle layer as part of the band-based resection. This increases the risk for perforation at the EMR site. Endoclips allow complete defect closure and also help prophylactically treat vessels within the resection site to prevent delayed bleeding.

Assessing the Imaging Capabilities of Radial Mechanical and Electronic Echo-endoscopes Using the Resolution Integral

Over the past decade there have been significant advances in endoscopic ultrasound (EUS) technology. Although there is an expectation that new technology will deliver improved image quality, there are few methods or phantoms available for assessing the capabilities of mechanical and electronic EUS systems. The aim of this study was to investigate the possibility of assessing the imaging capability of available EUS technologies using measurements of the resolution integral made with an Edinburgh Pipe Phantom. Various radial EUS echo-endoscopes and probes were assessed using an Edinburgh Pipe Phantom. Measurements of the resolution integral (R), depth of field (LR) and characteristic resolution (DR) were made at all operating frequencies. The mean R value for Fuji miniprobes was 16.0. The GF-UM20 and GF-UM2000 mechanical radial scopes had mean R values of 24.0 and 28.5, respectively. The two electronic radial echo-endoscopes had similar mean R values of 34.3 and 34.6 for the Olympus GF-UE260 and Fujinon EG-530 UR scopes, respectively. Despite being older technology, the mechanical GF-UM2000 scope had superior characteristic resolution (DR), but could not compare with the depths of field (LR) delivered by the current generation of electronic radial scopes, especially at the standard operating frequencies of 7.5 and 12 MHz.

Incidence of bacteremia in cirrhotic patients undergoing upper endoscopic ultrasonography

BackgroundThe incidence of bacteremia after endoscopic ultrasonography (EUS) or EUS-guided fine-needle aspiration (EUS-FNA) is between 0% and 4%, but there are no data on this topic in cirrhotic patients. AimTo prospectively assess the incidence of bacteremia in cirrhotic patients undergoing EUS and EUS-FNA. Patients and methodsWe enrolled 41 cirrhotic patients. Of these, 16 (39%) also underwent EUS-FNA. Blood cultures were obtained before and at 5 and 30min after the procedure. When EUS-FNA was used, an extra blood culture was obtained after the conclusion of radial EUS and before the introduction of the sectorial echoendoscope. All patients were clinically followed up for 7 days for signs of infection. ResultsBlood cultures were positive in 16 patients. In 10 patients, blood cultures grew coagulase-negative Staphylococcus, Corynebacterium species, Propionibacterium species or Acinetobacterium Lwoffii, which were considered contaminants (contamination rate 9.8%, 95% CI: 5.7–16%). The remaining 6 patients had true positive blood cultures and were considered to have had true bacteremia (15%, 95% CI: 4–26%). Blood cultures were positive after diagnostic EUS in five patients but were positive after EUS-FNA in only one patient. Thus, the frequency of bacteremia after EUS and EUS-FNA was 12% and 6%, respectively (95% CI: 2–22% and 0.2–30%, respectively). Only one of the patients who developed bacteremia after EUS had a self-limiting fever with no other signs of infection. ConclusionAsymptomatic Gram-positive bacteremia developed in cirrhotic patients after EUS and EUS-FNA at a rate higher than in non-cirrhotic patients. However, this finding was not associated with any clinically significant infections.