• Users Online:2372
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 
REVIEW ARTICLE
Ahead of print publication  

What should be known prior to performing EUS exams? (Part II)


1 Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Neubrandenburg; Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
2 Pancreatico/Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Rozzano, Milan, Italy
3 Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford OX3 9DU, England
4 Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
5 Humanitas Clinical and Research Center- IRCCS- Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Milan, Italy
6 Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
7 Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
8 Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna/Imola Hospital, Imola, Italy
9 Medical Department, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
10 General and HPB Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
11 Medical Department, Helios Klinikum Meiningen, Meiningen, Germany
12 Department of Gastroenterology, Allgemeines Krankenhaus Celle, Celle, Germany
13 Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
14 Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Neubrandenburg, Germany
15 Department of Hepatology and Gastroenterology, Charite CCM, Berlin, Germany
16 Department of Gastroenterology, The State University of New Jersey, New Jersey, USA
17 Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
18 Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Department of Surgery and Department of Advanced Interventional Endoscopy, University Hospital Brussels, Brussels, Belgium, France
19 Digestive Endoscopy Unit, IRCCS Foundation University Hospital, Policlinico A. Gemelli, Rome, Italy
20 Medical Department I/Gastroenterology, SANA Hospital Lichtenberg, Berlin, Germany
21 Digestive Endoscopy Unit, Hopital Privé J Mermoz Ramsay Générale de Santé, Lyon, France
22 HPB Unit, Freeman Hospital, Newcastle Upon Tyne, England
23 Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
24 Interventional Gastroenterology, Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, Haryana, India
25 Center Hospitalier de l'Université de Montréal, Montreal, Canada
26 Department of Gastroenterology and Liver Diseases, Tel Aviv, Sourasky Medical Center, Tel Aviv, Israel
27 Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India
28 Division of Gastroenterology, Endosonography and Advanced Therapeutic Endoscopy, The American University of Beirut, Medical Center, Beirut, Lebanon
29 Endoscopy Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning, China
30 Department of Surgery, Division of Upper Gastrointestinal and Metabolic Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
31 Department of Surgery, GastroUnit, Copenhagen University Hospital Herlev, Herlev, Denmark
32 Department of Gastroenterology, Klinikum Oldenburg, Oldenburg, Germany
33 Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany

Date of Submission15-May-2019
Date of Acceptance15-Jul-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Christoph F Dietrich,
Medical Department, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany; Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_57_19

PMID: 31571619

  Abstract 


In “What should be known prior to performing EUS exams, Part I,” the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?

Keywords: Complication rate, EUS, screen orientation



How to cite this URL:
Dietrich CF, Arcidiacono PG, Braden B, Burmeister S, Carrara S, Cui X, Leo MD, Dong Y, Fusaroli P, Gottschalk U, Healey AJ, Hocke M, Hollerbach S, Garcia JI, Ignee A, Jürgensen C, Kahaleh M, Kitano M, Kunda R, Larghi A, Möller K, Napoleon B, Oppong KW, Petrone MC, Saftoiu A, Puri R, Sahai AV, Santo E, Sharma M, Soweid A, Sun S, Bun Teoh AY, Vilmann P, Seifert H, Jenssen C. What should be known prior to performing EUS exams? (Part II). Endosc Ultrasound [Epub ahead of print] [cited 2019 Nov 14]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=267994




  Does Equipment Design Influence Complication Rate? Top


Introduction and review of the literature

Detailed knowledge of the factors contributing to adverse events (AEs) that may occur during EUS and EUS-FNA is limited due to the retrospective nature of most studies. The major complication related to the echoendoscope itself is perforation, which typically occurs in the hypopharynx or the first portion of the duodenum. Perforation of the cervical esophagus is a rare but serious complication that appears to be more common among elderly female patients,[1],[2] likely related to hypertrophy and/or spasm of the cricopharyngeal muscle. It is most frequently associated with procedures performed by EUS operators with limited experience.[3],[4],[5] Initial reports linked the complication rate to the use of radial instruments;[3] however, this was reported at a time when radial echoendoscopes were far more commonly used than linear scopes and had a larger caliber. There are significant differences regarding the design of instrument tips of echoendoscopes by different manufacturers; these differences include scope diameter, length of bending, and profile of the tip, and, in case of radial echoendoscopes, the shape as forward-viewing instrument or standard side-view scope. The low number of reported serious AEs, however, does not allow comparison between different echoendoscopes in view of their potential for causing esophageal perforation.

Arguments in favor of equipment design influencing the complication rate

Anecdotally, it could be argued that large, rigid echoendoscopes with less tip angulation and long bending section could be prone to causing damage to the gastrointestinal (GI) wall, particularly during intubation and push movements. In contrast, it may be assumed that the use of smaller, more flexible, forward-viewing instruments may help reduce the number and severity of these AEs. Data from a large database suggest that longitudinal echoendoscopes may carry a higher risk of duodenal perforation compared to radial scopes.[5]

Arguments against equipment design influencing the complication rate

Other factors such as anatomical variations and experience of the endosonographer and his/her level of awareness of the potential risk of EUS procedures are likely to influence the rate of AE.

Conclusion

The reported relatively low number of serious endoscope-related complications combined with ongoing recent advances in echoendoscope design makes it difficult and of questionable relevance to focus on the role of instrument design in the development of these complications. As the risk of esophageal and duodenal perforation directly correlates with the level of technical experience of the EUS operator, appropriate supervision of trainees and mentoring of independent operators should become the priority of teaching courses and supervisory projects in the clinical setting. We also refer to the recently published paper discussing the consent form.[6]


  Screen Orientation Top


Orientation of the sonographic image obtained during longitudinal EUS is variable, with the “near point” or cranial end of the transducer in relation to the endoscope able to be located either on the left or right side of the ultrasound screen. By convention, transabdominal ultrasound is orientated in the longitudinal section, with the left side of the screen indicating the cranial position. Differences in utilization of screen orientation continue to exist among different endosongraphers, with preference typically determined by an individual's training.

Introduction and review of the literature

EUS was initially developed by combining resources and techniques utilized in both endoscopic and ultrasonographic procedures. Initially, it was performed mostly by GI endoscopists who used radial echoendoscopes. Because the screen orientation was similar to that of a computed tomography (CT) scan, interpretation and comparison were relatively easy. With the aorta placed in the screen at 6 o'clock position, the left side of the screen would equate to the patient's right side, while the right side of the screen would image the patient's left, as long as the echoendoscope was in a straight position. With longitudinal echoendoscopes, the orientation and image characteristics are quite different from other radiological modalities such as CT and magnetic resonance imaging (MRI). Thus, with the advent and increase in their use, screen orientation was largely determined randomly, by personal preference or according to institutional training. Over time, a greater number of practitioners trained in transabdominal ultrasound began to perform EUS. These operators tended to choose the left cranial position because of similarities in probe positioning and image characteristics, when compared with percutaneous ultrasound.

Points in favor of the “cranial to the right side” orientation

The “cranial to the right side” approach is based on the examiner's position to the right of the patient's bed from the examiner's perspective, as he/she approaches from the foot of the bed. The patient is in the left lateral position, and the tip of the echoendoscope is introduced into the mouth and upper esophagus from the right side. By pushing the scope gently forward, more distally located anatomical structures move into the screen from the left side. Needles and other instruments are introduced into the instrument channel from the right side, and the needle tip will consequently appear at the right side of the screen. Therefore, the orientation “cranial to the right side” reflects the natural course of movements by the endoscopist and the echoendoscope.

Points against the “cranial to the right side” orientation

Training and experience in percutaneous ultrasound is a major advantage for operators performing EUS and is considered by many to be mandatory. Because of the overlap in standard probe positions required to illustrate specific anatomical structures/relationships (e.g., aorta with celiac trunk and mesenteric artery) and to allow meaningful comparisons between percutaneously and endoscopically obtained images, the orientation of the longitudinal picture should be cranial to the left. This has the added benefit of facilitating initial training in EUS and avoids the challenges of interpreting mirrored images.

Conclusion

Screen orientation probably does not directly affect the performance of longitudinal EUS. Operators are trained differently because of institutional history in the procedure. Operators with long-standing experience in one of the two different screen orientations often experience difficulties in switching to the other. Therefore, there is no need to change the orientation in experienced operators. However, in the future, the cranial to the left position could be preferable because of the significant overlap in standard positions when compared with transcutaneous ultrasound (TUS) if we consider TUS knowledge is mandatory for EUS.[6] For training purposes, a standard orientation should be demanded.


  Radial EUS Versus Longitudinal (Linear) EUS Top


Introduction and review of the literature

Radial endosonography and longitudinal endosonography were invented at approximately the same time around 1978 and 1979. Linear echoendoscopes were first used by Eugene DiMagno in Rochester, NY, USA,[7],[8] whereas Meinhard Classen and his group in Erlangen, Bavaria, Germany, and a Japanese group developed the first radial echoendoscopes.[9],[10],[11] For several reasons, early longitudinal echoendoscopes using linear arrays proved to be clinically unsuitable. The very long rigid tip of the first instruments prevented passage into the duodenum in approximately half of the patients,[8] whereas the sonographic view was limited by the narrow aperture of the linear transducer, meaning that despite the high resolution of the linear-array transducers, anatomical orientation was difficult.[12],[13],[14]

The development of mechanically rotating transducers provided radial echoendoscopes with a 360° rotating US probe, which could scan perpendicular to the long axis of the endoscope.[15],[16],[17] Images of the mediastinum obtained within the esophagus were comparable with CT scans and radial echoendoscopy initially prevailed. For nearly 1 decade (1982–1990), only radial echoendoscopes manufactured by Olympus were commercially available and were used worldwide, particularly for staging of GI malignancies, diagnosis of subepithelial tumors, and a variety of pancreaticobiliary indications. The breakthrough for longitudinal EUS came with the prototype development of a forward-viewing gastroscope mounted with a 36-mm long 5-MHz curved-array US transducer behind the optical lens. Preliminary experience using this new type of longitudinal echoendoscope (Pentax and Hitachi) was reported in 1991 by Peter Vilmann.[18],[19],[20] The pivotal step in overcoming previous difficulties was to place the curved-array transducer in the long axis of a side-viewing endoscope with a working channel, thereby refining the direction of the ultrasound scanning planes. Now, endoscopic and sonographic views were congruent and fine-needle biopsy,[18],[19],[20] as well as transmural cholangiopancreatography[21] and one-step therapeutic interventions[22] under direct sonographic control, became feasible. To appreciate anatomical orientation with the new, unfamiliar longitudinal EUS systems, detailed descriptions of longitudinal EUS anatomy were published.[20],[23],[24],[25] However, despite the obvious advantage of the curved-array transducers introducing the most advanced ultrasound technology into the field of EUS,[26],[27],[28],[29],[30],[31] many traditional users of radial scanning echoendoscopes were reluctant for a long time to use the new longitudinal echoendoscopes for noninterventional diagnostic purposes. In 2000, electronic array radial echoendoscopes became available, resulting in consequent improvements in image quality over traditional mechanical radial scanning echoendoscopes.[32],[33],[34],[35] In addition, more advanced, noninvasive technologies for tissue characterization became available in the field of radial EUS (R-EUS).[36]

Echoendoscopes with mechanical radial scanners have been available with US frequencies varying between 7.5 and 20 MHz. Despite the fact that in some institutions mechanical radial scanners and 270° electronic radial scanners may still be in use,[37] currently only electronic array 360° scanners are on the market. Two of them are forward-viewing endoscopes (Pentax-Hitachi, Fujifilm), whereas the third has a forward 55° oblique endoscopic view (Olympus). Technical differences between different types of longitudinal scanners are more remarkable. The Hitachi-Pentax longitudinal echoendoscopes are equipped with curved arrays with a 120° insonation angle. The scanning angle of the Fujifilm longitudinal echoendoscope is 150°, and the most current Olympus longitudinal scanners have a 180° curved-array scanner. Longitudinal EBUS scopes have a smaller diameter of approximately only 6 mm and may be used as an alternative in the GI tract in patients with upper GI stenosis for EUS fine-needle sampling.[38],[39] The left adrenal gland, celiac trunk area, and parts of the left lobe of the liver may be successfully approached using an EBUS scope.[38],[40],[41] A dedicated type of longitudinal echoendoscope is the forward-viewing echoendoscope of Olympus, which is equipped with a 90° curved array. Both the optical lens and transducer are forward-viewing and coaxially orientated to the instrumental channel. This may facilitate evaluation and sampling of lesions that are not easily accessible using conventional longitudinal echoendoscopes.[42],[43],[44]

From these descriptions, it can be concluded that a number of factors including manufacturer, generation, diameters, and transducer orientation may impact on a specific echoendoscope's characteristics, resulting in differences with respect to sonographic field of view, ease of anatomical orientation, contact to the GI wall, reach, and spatial resolution. Furthermore, quality of imaging and technological capabilities may be considerably influenced by the type of ultrasound processor used.[36],[45],[46]

In most traditional indications for R-EUS, studies from the early 1990s have shown comparable results using longitudinal echoendoscopes, e.g., for staging of upper GI cancer,[47],[48],[49],[50],[51] evaluation of suspected pancreaticobiliary disease,[52],[53] detection of common bile duct stones,[54],[55],[56] staging of periampullary cancer,[57] classification of mediastinal lymph nodes,[58] and evaluation of adrenal glands.[59] Nevertheless, there is a paucity of studies prospectively comparing the accuracy of diagnostic procedures using both types of echoendoscope. In 1997, a small randomized study demonstrated that both types of echoendoscope were comparably accurate in staging of pancreatic cancer and assessing vascular invasion and resectability.[60] Two randomized comparative studies showed that longitudinal and R-EUS provided similar results in terms of T-staging of upper GI cancer.[61],[62] However, in one study, R-EUS detected a higher number of suspicious lymph nodes[61] while in the other longitudinal EUS took significantly longer time for staging.[62]

More recently, the imaging capabilities of modern radial and longitudinal electronic array EUS systems have been compared for visualization of specific pancreaticobiliary anatomical structures and to determine their sensitivity for the detection of focal pancreatic lesions and features of chronic pancreatitis. In a prospective randomized study, the overall imaging capability in assessing 11 specific pancreaticobiliary areas was superior with longitudinal EUS compared with R-EUS. Visualization of the pancreatic head, body and tail, and the middle and inferior bile duct did not differ between either EUS system, whereas longitudinal EUS performed better in delineation of the pancreatic neck, the structures within the liver hilum, and the origins of the coeliac and superior mesenteric vessels. R-EUS was the superior imaging tool for the papilla of Vater and the gallbladder.[63]

In a study focusing on the diagnosis of chronic pancreatitis, R-EUS was performed comparably to longitudinal EUS with no significant differences observed in terms of interobserver variability, sensitivity, specificity, or overall discriminative ability.[64]

A retrospective study showed that both electronic radial and longitudinal EUS facilitated similar accuracy in the detection of pancreatic malignancies.[65] To discriminate between radial and linear EUS (L-EUS) in the detection of diminutive focal pancreatic lesions, Shin et al. conducted a prospective randomized tandem study in asymptomatic, high-risk individuals for pancreatic cancer.[37] In this study, the overall prevalence of mostly small cystic lesions was 43.2% on a peer patient analysis, with a mean size of 0.55 cm noted from a previous analysis.[37],[66] Of 109 lesions, 73 (67%; miss rate 33%) were detected by R-EUS and 99 of 120 lesions (82.5%; miss rate 17.5%) by longitudinal EUS during the first examination, thus demonstrating the superiority of the curved-array echoendoscope[37] in this setting.

Advantages of radial-EUS over linear-EUS

R-EUS may be less time-consuming than L-EUS. Due to the smaller sector image of 120°–180° and orientation of the scanning plane in the long axis of the echoendoscope, longitudinal EUS may be more difficult to handle and interpret, which is mainly true for the examiner with limited experience in transabdominal ultrasound.

Due to comparability with CT and MRI and full circle delineation of the GI wall, interpretation of R-EUS images may be easier in particular for endoscopists trained in CT and MRI. The main advantage is that the GI wall is more easily visualized using radial scanners. EUS-guided sampling is seldom indicated in patients with upper GI and rectal cancer mainly due to the success of endoscopic biopsy and histological results, but also due to a high risk of false-positive findings.[67] Moreover, differentiating between GI stromal tumors[68] and benign types of subepithelial GI lesions (e.g., lipoma, leiomyoma, and ectopic pancreas) is possible in a high percentage of cases using endoscopic and endosonographic features.[69],[70] This has been aided by the development of new techniques in US such as elastography and contrast enhancement, which have improved tissue characterization.[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81] On the other hand, EUS-guided sampling in GI subepithelial tumors is only moderately accurate.[80] A recent meta-analysis showed a pooled diagnostic rate of only 59.9%.[82] However, a high diagnostic accuracy has been reported with the forward-viewing EUS scope using a 19-G needle in a sampling of subepithelial tumors.[83] Moreover, the utilization of newly commercially available FNB needles, which can also be used by nonexpert endosonographers, may overcome the limitation of EUS-tissue acquisition in this clinical setting.[84] Therefore, while radial echoendoscopes may be the preferred instrument for staging GI wall cancer and allow for examination of patients with subepithelial lesions, the diagnostic advantage of radial vs. linear echoendoscopes remains to be established.

The recent development of novel, dedicated biopsy needles (such as the “Acquire-,” “Trident,” or “Shark-core” needles produced by different manufacturers) has further improved the diagnostic capacity of FNA, due to these needles' ability to produce core samples suitable for histological analysis. Tissue yield is increased and samples may be obtained in greater numbers including in patients with subepithelial tumors and autoimmune pancreatitis. However, this topic remains to be carefully elucidated by prospective, controlled clinical studies. In patients presenting with abdominal pain of unknown origin, one advantage of forward-viewing radial echoendoscopes is that in principle it can offer the opportunity to combine complete endoscopic examination of the upper GI tract with endosonographic evaluation of the GI wall and surrounding organs, especially the pancreaticobiliary system.[85],[86] Therefore, R-EUS might be considered the first-line examination of patients with a suspicion of biliary origin for upper abdominal pain, in particular biliary calculi.

Advantages of L-EUS over R-EUS

Longitudinal echoendoscopes are essential for performing EUS-guided tissue sampling and EUS-guided therapeutic interventions. In the German prospective EUS registry, EUS-guided sampling has been performed in approximately 13% of all EUS examinations with EUS-guided therapeutic interventions performed in a further 3% of cases. This rate may be higher in countries that utilize CT/MRI earlier in the algorithmic workup of pancreaticobiliary disease, reserving EUS for targeted morphological assessment of specific conditions: fluid or tissue acquisition and therapeutic intervention.

With the ability to perform immunohistochemistry and up-to-date molecular techniques using small specimens obtained via EUS-guided sampling[87],[88],[89],[90],[91],[92],[93] together with the adoption of multimodal, personalized, and targeted treatments in the modern management of malignant disease, the role of EUS-guided sampling and other interventions is increasing. In pancreatic pathology practice, EUS-guided sampling has been described as “an example of disruptive innovation effect.”[94] Increasingly, very small solid and cystic pancreatic lesions measuring ≤15 mm are detected by various forms of imaging, typically incidentally.[[74],[77],[78],[95] The majority of these lesions are entities distinct from pancreatic ductal adenocarcinoma (PDAC), and malignancy can be ruled out with a high degree of accuracy using advanced ultrasound technologies for tissue characterization.[74],[78] Despite this, an increasing role for tissue diagnosis in small, incidentally detected lesions may be seen in coming years. This is particularly so considering evolving management strategies for both benign (small pancreatic neuroendocrine tumors, focal autoimmune pancreatitis) and malignant (neoadjuvant treatment for resectable PDAC) scenarios. However, in non-PDAC, tissue diagnosis is essential for clinical decision-making. Neoadjuvant treatment strategies might change this perspective rendering EUS-FNB mandatory also in patients with PDAC.

Therapeutically, a multitude of minimally invasive transmural EUS-guided procedures has emerged in recent years which successfully compete with conventional endoscopic and minimally invasive surgical techniques.[79],[81],[96] In specialized centers, EUS-guided sampling and treatment procedures are performed in more than one-third of EUS examinations.[97]

Conclusion

Longitudinal echoendoscopes can be safely and successfully used for all EUS indications without significant disadvantages. They are indispensable in all kinds of EUS-guided interventions including EUS-guided tissue sampling and EUS-guided therapeutic interventions. L-EUS is also first choice for staging of lung cancer, evaluation of mediastinal lymphadenopathy, and evaluation of pancreatic disease. The examination of the gallbladder and periampullary region depends on local experience and remains controversial.

R-EUS continues to have a role in the staging of luminal cancers and the assessment subepithelial tumors. In the future, radial echoendoscopy with high-definition endoscopic imaging and increased flexibility of the scope tip may emerge as a first-line diagnostic modality in patients with upper GI complaints instead of ultrasound or cross-sectional imaging combined with esophagogastroduodenoscopy.[85],[86]


  Should We Search for Incidental Findings Using EUS? Top


Introduction and review of the literature

Incidental findings are defined as unexpected and clinically silent lesions unknown prior to EUS examination. Considering the potential implications, the question should be rephrased: can we interpret unexpected findings correctly based on EUS alone and how should we respond to such unexpected findings? Literature on incidental findings during EUS examination is limited to small observational studies. One Spanish study involving 239 patients noted additional diagnoses in 38.5% of cases where examination included the gut wall, pancreas, biliary tract, ampulla of the pancreas, large abdominal vessels, liver, spleen, left adrenal gland, posterior mediastinum, and the thyroid gland. Significant findings that required further investigations were found in 11.3% of patients (approximately 1 in 10).[98] A second study from Iran of 552 prospectively collected EUS examinations noted incidental findings in only 7.1% of patients, with approximately half of those requiring further investigation. This study, however, did not specifically document or discriminate examination of the spleen, left adrenal, or thyroid gland.[99] Incidentally found cystic lesions of the pancreas have been extensively discussed elsewhere.[95],[100]

Advantages to examination of incidental lesions

Knowledge of a patient's diagnosis prior to EUS examination may influence the scheduling and conduct of the procedure.[6] Unexpected findings during such examinations may provide new perspectives to a known disease, such as previously undetected liver metastasis in a patient with pancreatic adenocarcinoma. EUS may also reveal previously undetected metastasis in unexpected locations, for instance, a patient with proximal squamous cell carcinoma of the esophagus could be found to have suspicious retroperitoneal lymph nodes at EUS staging, with subsequent EUS-FNA providing proof of abdominal metastasis and systemic disease. Equally important consequences may arise when focal liver lesions are unexpectedly detected by EUS, as can happen with conventional transabdominal ultrasound.[101],[102] The same implications are valid for splenic and adrenal incidentalomas.[59],[99],[103],[104],[105],[106],[107],[108],[109]

Very occasionally, purely incidental findings may lead to different or additional diagnoses in individual patients.[98],[99],[100],[110] Rarely, such findings may alter clinical management of the patient, for example, a patient found to have asymptomatic common bile duct stones while undergoing EUS staging of a gastric cancer, who should first undergo endoscopic retrograde cholangiography and biliary stone removal prior to having surgery.[111],[112]

Disadvantages to examination for incidental lesions

Complete examination of all accessible structures in the upper GI tract may entail certain risks in some patients. For instance, in a patient with esophageal carcinoma, complete EUS examination could include exclusion of abdominal lymphadenopathy or common bile duct stones. In such circumstances, the risk of duodenal passage may outweigh the potentials benefit and may expose the patient to unnecessary and time-consuming examinations of areas with a low probability of important findings. In addition, extended EUS procedures can put pressure on experienced high-level endoscopists for whom time is a scarce commodity. Hence, prior to EUS examination, it should always be assessed whether the benefit of the procedure outweighs the potential risks in each individual clinical scenario.

Conclusion

Be aware of the “beautiful flowers” or the “chirping of crickets by the wayside”. They can provide a new perspective on a known disease, influence patient management, or even lead to a new or additional diagnosis. To find them requires time, a systematic thorough examination, and solid knowledge of normal morphological findings. Prior to each and any EUS exam, the operator should always assess whether the benefit of “seeing it all” outweighs the potential procedural risks in each patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eloubeidi MA, Tamhane A, Lopes TL, et al. Cervical esophageal perforations at the time of endoscopic ultrasound: A prospective evaluation of frequency, outcomes, and patient management. Am J Gastroenterol 2009;104:53-6.  Back to cited text no. 1
    
2.
Jenssen C, Faiss S, Nürnberg D. Complications of endoscopic ultrasound and endoscopic ultrasound-guided interventions – Results of a survey among German centers. ZGastroenterol 2008;46:1177-84.  Back to cited text no. 2
    
3.
Das A, Sivak MV Jr., Chak A. Cervical esophageal perforation during EUS: A national survey. Gastrointest Endosc 2001;53:599-602.  Back to cited text no. 3
    
4.
ASGE Standards of Practice Committee, Early DS, Acosta RD, et al. Adverse events associated with EUS and EUS with FNA. Gastrointest Endosc 2013;77:839-43.  Back to cited text no. 4
    
5.
Jenssen C, Alvarez-Sánchez MV, Napoléon B, et al. Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications. World J Gastroenterol 2012;18:4659-76.  Back to cited text no. 5
    
6.
Dietrich CF, Arcidiacono PG, Braden B, et al. What should be known prior to performing EUS? Endosc Ultrasound 2019;8:3-16.  Back to cited text no. 6
    
7.
DiMagno EP, Buxton JL, Regan PT, et al. Ultrasonic endoscope. Lancet 1980;1:629-31.  Back to cited text no. 7
    
8.
Dimagno EP, Regan PT, Clain JE, et al. Human endoscopic ultrasonography. Gastroenterology 1982;83:824-9.  Back to cited text no. 8
    
9.
Strohm WD, Phillip J, Hagenmüller F, et al. Ultrasonic tomography by means of an ultrasonic fiberendoscope. Endoscopy 1980;12:241-4.  Back to cited text no. 9
    
10.
Strohm WD, Jessen K, Phillip J, et al. Endoscopic ultrasonic tomography of the upper digestive tract. Dtsch Med Wochenschr 1981;106:714-7.  Back to cited text no. 10
    
11.
Hisanaga K, Hisanaga A, Nagata K, et al. High speed rotating scanner for transgastric sonography. AJR Am J Roentgenol 1980;135:627-9.  Back to cited text no. 11
    
12.
Lutz H, Lux G, Heyder N. Transgastric ultrasonography of the pancreas. Ultrasound Med Biol 1983;9:503-7.  Back to cited text no. 12
    
13.
Asaki S, Ota K, Kanazawa N, et al. Ultrasonic endoscopy. Tohoku J Exp Med 1983;141:9-12.  Back to cited text no. 13
    
14.
Tanaka M, Bandou T, Watanabe A, et al. A new technique in endoscopic ultrasonography of the upper gastrointestinal tract. Endoscopy 1990;22:221-5.  Back to cited text no. 14
    
15.
DiMagno EP, DiMagno MJ. Endoscopic ultrasonography: From the origins to routine EUS. Dig Dis Sci 2016;61:342-53.  Back to cited text no. 15
    
16.
Yasuda K, Tanaka Y, Fujimoto S, et al. Use of endoscopic ultrasonography in small pancreatic cancer. Scand J Gastroenterol Suppl 1984;102:9-17.  Back to cited text no. 16
    
17.
Sivak MV. Endoscopic ultrasonography at the beginning: A personal history. In: Gress FG, Savides TJ, editors. Endoscopic Ultrasonography. Hoboken: Wiley-Blackwell; 2016. p. 1-4.  Back to cited text no. 17
    
18.
Vilmann P, Hancke S. Endoscopic ultrasound scanning of the upper gastrointestinal tract. Preliminary results. Ugeskr Laeger 1991;153:422-5.  Back to cited text no. 18
    
19.
Vilmann P, Hancke S. Endoscopic ultrasound scanning of the upper gastrointestinal canal. Ugeskr Laeger 1991;153:414-7.  Back to cited text no. 19
    
20.
Vilmann P, Khattar S, Hancke S. Endoscopic ultrasound examination of the upper gastrointestinal tract using a curved-array transducer. A preliminary report. Surg Endosc 1991;5:79-82.  Back to cited text no. 20
    
21.
Wiersema MJ, Sandusky D, Carr R, Wiersema LM, Erdel WC, Frederick PK. Endosonography-guided cholangiopancreatography. Gastrointest Endosc 1996;43:102-106.  Back to cited text no. 21
    
22.
Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUS-cholangio-drainage of the bile duct: report of 4 cases. Gastrointest Endosc 2003;57:246-251.  Back to cited text no. 22
    
23.
Chang KJ, Erickson RA. A primer on linear array endosonographic anatomy. Gastrointest Endosc 1996;43:S43-7.  Back to cited text no. 23
    
24.
Irisawa A, Yamao K. Curved linear array EUS technique in the pancreas and biliary tree: Focusing on the stations. Gastrointest Endosc 2009;69:S84-9.  Back to cited text no. 24
    
25.
Burmester E, Leineweber T, Hacker S, et al. EUS meets voxel-man: Three-dimensional anatomic animation of linear-array endoscopic ultrasound images. Endoscopy 2004;36:726-30.  Back to cited text no. 25
    
26.
Wiersema MJ, Chak A, Kopecky KK, et al. Duplex Doppler endosonography in the diagnosis of splenic vein, portal vein, and portosystemic shunt thrombosis. Gastrointest Endosc 1995;42:19-26.  Back to cited text no. 26
    
27.
Bhutani MS, Barde CJ. Contrast-enhanced gastrointestinal trans-abdominal and endoscopic ultrasonography: An idea whose time has come. Am J Gastroenterol 1997;92:1976-80.  Back to cited text no. 27
    
28.
Bhutani MS, Hoffman BJ, van Velse A, et al. Contrast-enhanced endoscopic ultrasonography with galactose microparticles: SHU508 A (Levovist). Endoscopy 1997;29:635-9.  Back to cited text no. 28
    
29.
Dietrich CF, Ignee A, Frey H. Contrast-enhanced endoscopic ultrasound with low mechanical index: A new technique. ZGastroenterol 2005;43:1219-23.  Back to cited text no. 29
    
30.
Giovannini M, Hookey LC, Bories E, et al. Endoscopic ultrasound elastography: The first step towards virtual biopsy? Preliminary results in 49 patients. Endoscopy 2006;38:344-8.  Back to cited text no. 30
    
31.
Săftoiu A, Vilmann P, Hassan H, et al. Analysis of endoscopic ultrasound elastography used for characterisation and differentiation of benign and malignant lymph nodes. Ultraschall Med 2006;27:535-42.  Back to cited text no. 31
    
32.
Anderson MA, Scheiman JM. Initial experience with an electronic radial array echoendoscope: Randomized comparison with a mechanical sector scanning echoendoscope in humans. Gastrointest Endosc 2002;56:573-7.  Back to cited text no. 32
    
33.
Niwa K, Hirooka Y, Itoh A, et al. Preclinical study of endoscopic ultrasonography with electronic radial scanning echoendoscope. JGastroenterol Hepatol 2003;18:828-35.  Back to cited text no. 33
    
34.
Niwa K, Hirooka Y, Niwa Y, et al. Comparison of image quality between electronic and mechanical radial scanning echoendoscopes in pancreatic diseases. JGastroenterol Hepatol 2004;19:454-9.  Back to cited text no. 34
    
35.
Hikichi T, Irisawa A, Takagi T, et al. An electronic radial scanning echoendoscope is superior to a mechanical radial scanning echoendoscope in ultrasound image quality for gastrointestinal tract and pancreaticobiliary lesions. Fukushima J Med Sci 2010;56:99-106.  Back to cited text no. 35
    
36.
Ishikawa H, Hirooka Y, Itoh A, et al. Acomparison of image quality between tissue harmonic imaging and fundamental imaging with an electronic radial scanning echoendoscope in the diagnosis of pancreatic diseases. Gastrointest Endosc 2003;57:931-6.  Back to cited text no. 36
    
37.
Shin EJ, Topazian M, Goggins MG, et al. Linear-array EUS improves detection of pancreatic lesions in high-risk individuals: A randomized tandem study. Gastrointest Endosc 2015;82:812-8.  Back to cited text no. 37
    
38.
Buxbaum JL, Eloubeidi MA. Transgastric endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with esophageal narrowing using the ultrasonic bronchovideoscope. Dis Esophagus 2011;24:458-61.  Back to cited text no. 38
    
39.
Holland HC, Gupta BD. Some correlated measures of activity and reactivity in two strains of rats selectively bred for differences in the acquisition of a conditioned avoidance response. Anim Behav 1966;14:574-80.  Back to cited text no. 39
    
40.
Crombag LM, Annema JT. Left adrenal gland analysis in lung cancer patients using the endobronchial ultrasound scope: A feasibility trial. Respiration 2016;91:235-40.  Back to cited text no. 40
    
41.
Crombag LM, Szlubowski A, Stigt JA, et al. EUS-B-FNA vs. conventional EUS-FNA for left adrenal gland analysis in lung cancer patients. Lung Cancer 2017;108:38-44.  Back to cited text no. 41
    
42.
Fusaroli P, Ceroni L, Caletti G. Forward-view endoscopic ultrasound: A systematic review of diagnostic and therapeutic applications. Endosc Ultrasound 2013;2:64-70.  Back to cited text no. 42
    
43.
Lee S, Seo DW, Choi JH, et al. Evaluation of the feasibility and efficacy of forward-viewing endoscopic ultrasound. Gut Liver 2015;9:679-84.  Back to cited text no. 43
    
44.
Fuccio L, Attili F, Larghi A. Forward-viewing linear echoendoscope: A new option in the endoscopic ultrasound armamentarium (with video). JHepatobiliary Pancreat Sci 2015;22:27-34.  Back to cited text no. 44
    
45.
Jeong SH, Yoon HH, Kim EJ, et al. High-resolution endoscopic ultrasound imaging and the number of needle passages are significant factors predicting high yield of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid masses without an on-site cytopathologist. Medicine (Baltimore) 2017;96:e5782.  Back to cited text no. 45
    
46.
Matsumoto K, Katanuma A, Maguchi H, et al. Performance of novel tissue harmonic echo imaging using endoscopic ultrasound for pancreatic diseases. Endosc Int Open 2016;4:E42-50.  Back to cited text no. 46
    
47.
Mortensen MB, Pedersen SA, Hovendal CP. Preoperative assessment of resectability in gastroesophageal carcinoma by linear array endoscopic ultrasonography. Scand J Gastroenterol 1994;29:341-5.  Back to cited text no. 47
    
48.
Giovannini M, Seitz JF, Thomas P, et al. Electronic sectorial ultrasound endoscopy in benign and malignant tumoral pathology of the stomach. Results in 30 patients. Gastroenterol Clin Biol 1993;17:26-32.  Back to cited text no. 48
    
49.
Natsugoe S, Yoshinaka H, Moringa T, et al. Assessment of tumor invasion of the distal esophagus in carcinoma of the cardia using endoscopic ultrasonography. Endoscopy 1996;28:750-5.  Back to cited text no. 49
    
50.
Hünerbein M, Dohmoto M, Rau B, et al. Endosonography and endosonography-guided biopsy of upper-GI-tract tumors using a curved-array echoendoscope. Surg Endosc 1996;10:1205-9.  Back to cited text no. 50
    
51.
Shimoyama S, Yasuda H, Hashimoto M, et al. Accuracy of linear-array EUS for preoperative staging of gastric cardia cancer. Gastrointest Endosc 2004;60:50-5.  Back to cited text no. 51
    
52.
Kochman ML, Elta GH, Bude R, et al. Utility of a linear array ultrasound endoscope in the evaluation of suspected pancreatic disease. JGastrointest Surg 1998;2:217-22.  Back to cited text no. 52
    
53.
Giovannini M, Seitz JF. Endoscopic ultrasonography with a linear-type echoendoscope in the evaluation of 94 patients with pancreatobiliary disease. Endoscopy 1994;26:579-85.  Back to cited text no. 53
    
54.
Kohut M, Nowakowska-Duława E, Marek T, et al. Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones. Endoscopy 2002;34:299-303.  Back to cited text no. 54
    
55.
Kohut M, Nowak A, Nowakowska-Dulawa E, et al. Endosonography with linear array instead of endoscopic retrograde cholangiography as the diagnostic tool in patients with moderate suspicion of common bile duct stones. World J Gastroenterol 2003;9:612-4.  Back to cited text no. 55
    
56.
Lachter J, Rubin A, Shiller M, et al. Linear EUS for bile duct stones. Gastrointest Endosc 2000;51:51-4.  Back to cited text no. 56
    
57.
Rivadeneira DE, Pochapin M, Grobmyer SR, et al. Comparison of linear array endoscopic ultrasound and helical computed tomography for the staging of periampullary malignancies. Ann Surg Oncol 2003;10:890-7.  Back to cited text no. 57
    
58.
Lee N, Inoue K, Yamamoto R, et al. Patterns of internal echoes in lymph nodes in the diagnosis of lung cancer metastasis. World J Surg 1992;16:986-93.  Back to cited text no. 58
    
59.
Dietrich CF, Wehrmann T, Hoffmann C, et al. Detection of the adrenal glands by endoscopic or transabdominal ultrasound. Endoscopy 1997;29:859-64.  Back to cited text no. 59
    
60.
Gress F, Savides T, Cummings O, et al. Radial scanning and linear array endosonography for staging pancreatic cancer: A prospective randomized comparison. Gastrointest Endosc 1997;45:138-42.  Back to cited text no. 60
    
61.
Matthes K, Bounds BC, Collier K, et al. EUS staging of upper GI malignancies: Results of a prospective randomized trial. Gastrointest Endosc 2006;64:496-502.  Back to cited text no. 61
    
62.
Siemsen M, Svendsen LB, Knigge U, et al. Aprospective randomized comparison of curved array and radial echoendoscopy in patients with esophageal cancer. Gastrointest Endosc 2003;58:671-6.  Back to cited text no. 62
    
63.
Kaneko M, Katanuma A, Maguchi H, et al. Prospective, randomized, comparative study of delineation capability of radial scanning and curved linear array endoscopic ultrasound for the pancreaticobiliary region. Endosc Int Open 2014;2:E160-70.  Back to cited text no. 63
    
64.
Stevens T, Zuccaro G Jr., Dumot JA, et al. Prospective comparison of radial and linear endoscopic ultrasound for diagnosis of chronic pancreatitis. Endoscopy 2009;41:836-41.  Back to cited text no. 64
    
65.
Kanazawa K, Imazu H, Mori N, et al. Acomparison of electronic radial and curvilinear endoscopic ultrasonography in the detection of pancreatic malignant tumor. Scand J Gastroenterol 2012;47:1313-20.  Back to cited text no. 65
    
66.
Canto MI, Hruban RH, Fishman EK, et al. Frequent detection of pancreatic lesions in asymptomatic high-risk individuals. Gastroenterology 2012;142:796-804.  Back to cited text no. 66
    
67.
Gleeson FC, Kipp BR, Caudill JL, et al. False positive endoscopic ultrasound fine needle aspiration cytology: Incidence and risk factors. Gut 2010;59:586-93.  Back to cited text no. 67
    
68.
Buscarini E, Pezzilli R, Cannizzaro R, et al. Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms. Dig Liver Dis 2014;46:479-93.  Back to cited text no. 68
    
69.
Kim GH, Park DY, Kim S, et al. Is it possible to differentiate gastric GISTs from gastric leiomyomas by EUS? World J Gastroenterol 2009;15:3376-81.  Back to cited text no. 69
    
70.
Eckardt AJ, Jenssen C. Current endoscopic ultrasound-guided approach to incidental subepithelial lesions: Optimal or optional? Ann Gastroenterol 2015;28:160-72.  Back to cited text no. 70
    
71.
Ignee A, Jenssen C, Hocke M, et al. Contrast-enhanced (endoscopic) ultrasound and endoscopic ultrasound elastography in gastrointestinal stromal tumors. Endosc Ultrasound 2017;6:55-60.  Back to cited text no. 71
    
72.
Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. JGastroenterol Hepatol 2017;32:1686-92.  Back to cited text no. 72
    
73.
Tsuji Y, Kusano C, Gotoda T, et al. Diagnostic potential of endoscopic ultrasonography-elastography for gastric submucosal tumors: A pilot study. Dig Endosc 2016;28:173-8.  Back to cited text no. 73
    
74.
Ignee A, Jenssen C, Arcidiacono PG, et al. Endoscopic ultrasound elastography of small solid pancreatic lesions: A multicenter study. Endoscopy 2018;50:1071-9.  Back to cited text no. 74
    
75.
Dietrich CF, Averkiou M, Nielsen MB, et al. How to perform contrast-enhanced ultrasound (CEUS). Ultrasound Int Open 2018;4:E2-15.  Back to cited text no. 75
    
76.
Dong Y, D'Onofrio M, Hocke M, et al. Autoimmune pancreatitis: Imaging features. Endosc Ultrasound 2018;7:196-203.  Back to cited text no. 76
    
77.
Braden B, Jenssen C, D'Onofrio M, et al. B-mode and contrast-enhancement characteristics of small nonincidental neuroendocrine pancreatic tumors. Endosc Ultrasound 2017;6:49-54.  Back to cited text no. 77
    
78.
Dietrich CF, Sahai AV, D'Onofrio M, et al. Differential diagnosis of small solid pancreatic lesions. Gastrointest Endosc 2016;84:933-40.  Back to cited text no. 78
    
79.
Fusaroli P, Jenssen C, Hocke M, et al. EFSUMB guidelines on interventional ultrasound (INVUS), part V. Ultraschall Med 2016;37:77-99.  Back to cited text no. 79
    
80.
Jenssen C, Hocke M, Fusaroli P, et al. EFSUMB guidelines on interventional ultrasound (INVUS), part IV – EUS-guided interventions: General aspects and EUS-guided sampling (Long version). Ultraschall Med 2016;37:E33-76.  Back to cited text no. 80
    
81.
Fusaroli P, Jenssen C, Hocke M, et al. EFSUMB guidelines on interventional ultrasound (INVUS), part V – EUS-guided therapeutic interventions (short version). Ultraschall Med 2016;37:412-20.  Back to cited text no. 81
    
82.
Zhang XC, Li QL, Yu YF, et al. Diagnostic efficacy of endoscopic ultrasound-guided needle sampling for upper gastrointestinal subepithelial lesions: A meta-analysis. Surg Endosc 2016;30:2431-41.  Back to cited text no. 82
    
83.
Larghi A, Fuccio L, Chiarello G, et al. Fine-needle tissue acquisition from subepithelial lesions using a forward-viewing linear echoendoscope. Endoscopy 2014;46:39-45.  Back to cited text no. 83
    
84.
Bang JY, Kirtane S, Krall K, et al. In memoriam: Fine-needle aspiration, birth: Fine-needle biopsy: The changing trend in endoscopic ultrasound-guided tissue acquisition. Dig Endosc 2019;31:197-202.  Back to cited text no. 84
    
85.
Jung A, Schlag C, Becker V, et al. Endosonography for right-sided and acute upper intestinal misery: The EFRAIM study: A prospective, randomized, controlled, blinded study. United European Gastroenterol J 2013;1:329-34.  Back to cited text no. 85
    
86.
Chang KJ, Erickson RA, Chak A, et al. EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain. Gastrointest Endosc 2010;72:967-74.  Back to cited text no. 86
    
87.
Gleeson FC, Kerr SE, Kipp BR, et al. Targeted next generation sequencing of endoscopic ultrasound acquired cytology from ampullary and pancreatic adenocarcinoma has the potential to aid patient stratification for optimal therapy selection. Oncotarget 2016;7:54526-36.  Back to cited text no. 87
    
88.
Trisolini E, Armellini E, Paganotti A, et al. KRAS mutation testing on all non-malignant diagnosis of pancreatic endoscopic ultrasound-guided fine-needle aspiration biopsies improves diagnostic accuracy. Pathology 2017;49:379-86.  Back to cited text no. 88
    
89.
Biermann K, Lozano Escario MD, Hébert-Magee S, et al. How to prepare, handle, read, and improve EUS-FNA and fine-needle biopsy for solid pancreatic lesions: The pathologist's role. Endosc Ultrasound 2017;6:S95-8.  Back to cited text no. 89
    
90.
Gleeson FC, Kipp BR, Voss JS, et al. Endoscopic ultrasound fine-needle aspiration cytology mutation profiling using targeted next-generation sequencing: Personalized care for rectal cancer. Am J Clin Pathol 2015;143:879-88.  Back to cited text no. 90
    
91.
Leong TL, Christie M, Kranz S, et al. Evaluating the genomic yield of a single endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer: Meeting the challenge of doing more with less. Clin Lung Cancer 2017;18:e467-72.  Back to cited text no. 91
    
92.
Hocke M, Braden B, Jenssen C, et al. Present status and perspectives of endosonography 2017 in gastroenterology. Korean J Intern Med 2018;33:36-63.  Back to cited text no. 92
    
93.
Hocke M, Topalidis T, Braden B, et al. “Clinical” cytology for endoscopists: A practical guide. Endosc Ultrasound 2017;6:83-9.  Back to cited text no. 93
    
94.
Eltoum IA, Alston EA, Roberson J. Trends in pancreatic pathology practice before and after implementation of endoscopic ultrasound-guided fine-needle aspiration: An example of disruptive innovation effect? Arch Pathol Lab Med 2012;136:447-53.  Back to cited text no. 94
    
95.
Beyer-Enke SA, Hocke M, Ignee A, et al. Contrast enhanced transabdominal ultrasound in the characterisation of pancreatic lesions with cystic appearance. JOP 2010;11:427-33.  Back to cited text no. 95
    
96.
van Brunschot S, van Grinsven J, van Santvoort HC, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: A multicentre randomised trial. Lancet 2018;391:51-8.  Back to cited text no. 96
    
97.
Noh KW, Woodward TA, Raimondo M, et al. Changing trends in endosonography: Linear imaging and tissue are increasingly the issue. Dig Dis Sci 2007;52:1014-8.  Back to cited text no. 97
    
98.
Vila JJ, Jiménez FJ, Irisarri R, et al. Prospective observational study of the incidental findings on endoscopic ultrasonography: Should a complete exploration always be performed? Scand J Gastroenterol 2009;44:1139-45.  Back to cited text no. 98
    
99.
Sotoudehmanesh R, Ali-Asgari A. Incidental findings on upper gastrointestinal endoscopic ultrasonography. JDiag Med Sonography 2013;29:73-7.  Back to cited text no. 99
    
100.
Jenssen C, Kahl S. Management of incidental pancreatic cystic lesions. Viszeralmedizin 2015;31:14-24.  Back to cited text no. 100
    
101.
Dietrich CF, Jenssen C. Focal liver lesion, incidental finding. Dtsch Med Wochenschr 2012;137:2099-116.  Back to cited text no. 101
    
102.
Dietrich CF, Sharma M, Gibson RN, et al. Fortuitously discovered liver lesions. World J Gastroenterol 2013;19:3173-88.  Back to cited text no. 102
    
103.
Sienz M, Ignee A, Dietrich CF. Reference values in abdominal ultrasound-biliopancreatic system and spleen. ZGastroenterol 2011;49:845-70.  Back to cited text no. 103
    
104.
von Herbay A, Barreiros AP, Ignee A, et al. Contrast-enhanced ultrasonography with SonoVue: Differentiation between benign and malignant lesions of the spleen. JUltrasound Med 2009;28:421-34.  Back to cited text no. 104
    
105.
Cui XW, Ignee A, De Molo C, et al. Littoral cell angioma of the spleen. ZGastroenterol 2013;51:209-12.  Back to cited text no. 105
    
106.
Ignee A, Cui X, Hirche T, et al. Percutaneous biopsies of splenic lesions – A clinical and contrast enhanced ultrasound based algorithm. Clin Hemorheol Microcirc 2014;58:529-41.  Back to cited text no. 106
    
107.
Trojan J, Schwarz W, Sarrazin C, et al. Role of ultrasonography in the detection of small adrenal masses. Ultraschall Med 2002;23:96-100.  Back to cited text no. 107
    
108.
Dietrich CF, Ignee A, Barreiros AP, et al. Contrast-enhanced ultrasound for imaging of adrenal masses. Ultraschall Med 2010;31:163-8.  Back to cited text no. 108
    
109.
Jenssen C, Dietrich CF. Ultrasound and endoscopic ultrasound of the adrenal glands. Ultraschall Med 2010;31:228-47.  Back to cited text no. 109
    
110.
Thomas A, Vamadevan AS, Slattery E, et al. Performing forward-viewing endoscopy at time of pancreaticobiliary EUS and ERCP may detect additional upper gastrointestinal lesions. Endosc Int Open 2016;4:E193-7.  Back to cited text no. 110
    
111.
Seifert H, Wehrmann T, Hilgers R, et al. Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities. Gastrointest Endosc 2004;60:61-7.  Back to cited text no. 111
    
112.
Moehler M, Al-Batran SE, Andus T, et al. German S3-guideline Diagnosis and treatment of esophagogastric cancer. ZGastroenterol 2011;49:461-531.  Back to cited text no. 112
    




 

 
Top
 
 
  Search
 
     Search Pubmed for
 
    -  Dietrich CF
    -  Arcidiacono PG
    -  Braden B
    -  Burmeister S
    -  Carrara S
    -  Cui X
    -  Leo MD
    -  Dong Y
    -  Fusaroli P
    -  Gottschalk U
    -  Healey AJ
    -  Hocke M
    -  Hollerbach S
    -  Garcia JI
    -  Ignee A
    -  Jürgensen C
    -  Kahaleh M
    -  Kitano M
    -  Kunda R
    -  Larghi A
    -  Möller K
    -  Napoleon B
    -  Oppong KW
    -  Petrone MC
    -  Saftoiu A
    -  Puri R
    -  Sahai AV
    -  Santo E
    -  Sharma M
    -  Soweid A
    -  Sun S
    -  Bun Teoh AY
    -  Vilmann P
    -  Seifert H
    -  Jenssen C
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
   Does Equipment D...
  Screen Orientation
   Should We Search...
   Radial EUS Versu...
   References

 Article Access Statistics
    Viewed283    
    PDF Downloaded15    

Recommend this journal