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IMAGES AND VIDEOS
Year : 2018  |  Volume : 7  |  Issue : 6  |  Page : 420-421

EUS-FNA of gastric cancer metastatic to the head of pancreas using a forward oblique viewing echoendoscope in a case with Roux-en-Y anatomy


1 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
2 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo; Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan

Date of Submission17-Jul-2017
Date of Acceptance24-Oct-2017
Date of Web Publication12-Mar-2018

Correspondence Address:
Dr. Yousuke Nakai
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_107_17

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How to cite this article:
Mizuno S, Nakai Y, Isayama H, Suzuki T, Saito K, Uchino R, Takahara N, Kogure H, Tada M, Koike K. EUS-FNA of gastric cancer metastatic to the head of pancreas using a forward oblique viewing echoendoscope in a case with Roux-en-Y anatomy. Endosc Ultrasound 2018;7:420-1

How to cite this URL:
Mizuno S, Nakai Y, Isayama H, Suzuki T, Saito K, Uchino R, Takahara N, Kogure H, Tada M, Koike K. EUS-FNA of gastric cancer metastatic to the head of pancreas using a forward oblique viewing echoendoscope in a case with Roux-en-Y anatomy. Endosc Ultrasound [serial online] 2018 [cited 2018 Dec 18];7:420-1. Available from: http://www.eusjournal.com/text.asp?2018/7/6/420/227152



A 79-year-old man with a prior history of distal gastrectomy and Roux-en-Y anastomosis for gastric cancer 2 years ago was admitted to our department. Contrast-enhanced computed tomography revealed an ill-defined hypovascular lesion in the head of pancreas without upstream pancreatic duct dilation [Figure 1]. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (EUS-FNA) was attempted using a forward-oblique viewing curved linear echoendoscope (EG-580UT, Fujifilm Corp., Tokyo, Japan). Since the head of pancreas was not visualized on EUS from the remnant stomach, the echoendoscope was advanced to the jejunojejunal anastomosis using the assistance of the endoscopic view [Figure 2]. Although intubation into the afferent limb was difficult due to the sharp angulation, a 2-cm, ill-defined hypoechoic mass in the head of pancreas was visualized on EUS from the proximal jejunum before the anastomosis and EUS-FNA using a 22-gauge needle (EZ Shot 3 Plus, Olympus Corp., Tokyo, Japan) was successfully performed without complications [Figure 3]. Histological assessment of EUS-FNA specimen revealed adenocarcinoma similar to the surgical specimen of prior gastric cancer, which confirmed recurrent gastric cancer metastatic to the pancreas.
Figure 1: Contrast-enhanced computed tomography revealed an ill-defined hypovascular lesion in the head of pancreas (white arrow) without upstream pancreatic duct dilation (white arrowhead)

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Figure 2: The forward oblique viewing echoendoscope was advanced into the efferent jejunum limb under endoscopic guidance and reached the jejunojenunal anastomosis

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Figure 3: EUS-FNA was performed using a 22-gauge needle. A 2-cm, ill-defined hypoechoic mass (white arrow) in the head of pancreas was visualized on endoscopic ultrasonography from the jejunum. Ph: Pancreas head, Pb: Pancreas body

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Although feasibility of EUS and EUS-FNA was reported in cases with surgically altered anatomy, the head of pancreas and common bile duct in cases with Roux-en-Y anatomy are difficult to access on EUS due to the difficulty in scope insertion into the duodenum through the afferent limb.[1],[2] This is the first case report of EUS-FNA of the head of pancreas using a new forward-oblique echoendoscope in a patient with Roux-en-Y anatomy. This new forward-oblique viewing echoendoscope has advantages of forward endoscopic view and 150° EUS image. In addition, this echoendoscope has wider bending capacity up to 150°.[3] Those features helped scope insertion deep into the jejunum, EUS visualization, and EUS-FNA. In our case, intubation into the afferent limb was difficult even using this new echoendoscope. However, our case illustrated that EUS-FNA is sometimes possible from the jejunum, even if intubating the afferent limb is impossible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

Author Y.N. and H.I. have conducted collaborative research with Fujifilm Corp. (Tokyo, Japan). Other authors have no COI to disclose.



 
  References Top

1.
Wilson JA, Hoffman B, Hawes RH, et al. EUS in patients with surgically altered upper GI anatomy. Gastrointest Endosc 2010;72:947-53.  Back to cited text no. 1
[PUBMED]    
2.
Itoi T, Itokawa F, Sofuni A, et al. Endoscopic ultrasonography-guided fine needle aspiration biopsy in a patient with prior Billroth II gastrectomy. Dig Endosc 2011;23 Suppl 1:162-3.  Back to cited text no. 2
    
3.
Kawakami H, Kubota Y. New curved linear echoendoscope for endoscopic ultrasonography-guided fine-needle aspiration in patients with Roux-en-Y reconstruction (with videos). Endosc Ultrasound 2017;[Epub ahead of print].  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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