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   2015| April-June  | Volume 4 | Issue 2  
    Online since May 8, 2015

 
 
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TRAINING COURSE
Techniques of imaging of the aorta and its first order branches by endoscopic ultrasound (with videos)
Malay Sharma, Praveer Rai, Varun Mehta, CS Rameshbabu
April-June 2015, 4(2):98-108
DOI:10.4103/2303-9027.156722  PMID:26020043
Endoscopic ultrasonography (EUS) is a useful modality for imaging of the blood vessels of the mediastinum and abdomen. The aorta acts as an important home base during EUS imaging. The aorta and its branches are accessible by standard angiographic methods, but endosonography also provides a unique opportunity to evaluate the aorta and its branches. This article describes the techniques of imaging of different part of the aorta by EUS.
  4,002 941 2
REVIEW ARTICLES
Endoscopic ultrasound-guided liver biopsy
Parth J Parekh, Raj Majithia, David L Diehl, Todd H Baron
April-June 2015, 4(2):85-91
DOI:10.4103/2303-9027.156711  PMID:26020041
Liver biopsy remains the cornerstone in the diagnosis and management of liver disorders. Results of liver biopsy can often drive therapeutic decision-making. Unfortunately, studies have shown conventional biopsy techniques to carry significant sampling variability that can potentially impact patient care. Endoscopic ultrasound (EUS) is gaining traction as an alternative method of biopsy. For parenchymal disease, it can decrease sampling variability. It offers a more targeted approach for focal lesions. Its diagnostic yield and limited adverse event profile make it a promising approach for liver biopsy.
  1,912 729 15
CASE REPORTS
Endoscopic ultrasound-assisted cholecystogastrostomy by a novel fully covered metal stent for the treatment of gallbladder stones
Nan Ge, Shupeng Wang, Sheng Wang, Guoxin Wang, Xiang Liu, Jintao Guo, Fei Yang, Wen Liu, Siyu Sun
April-June 2015, 4(2):152-155
DOI:10.4103/2303-9027.156749  PMID:26020052
An 85-year-old male patient with common bile duct stones and gallbladder stone was admitted to the hospital. Endoscopic ultrasound (EUS)-guided cholecystogastrostomy and the placement of a novel covered mental stent was performed after the endoscopic sphincter ectomy procedure. Two weeks later the stents were removed, and an endoscope was advanced into the gallbladder via the fistula, and cholecystolithotomy was performed. For weeks later gallbladder was assessed by abdominal ultrasound. EUS-guided cholecystogastrostomy with mental stent deployment was successfully performed. Two weeks after the procedure, the fistulas had formed, and the stent were removed. Endoscopic cholecystolithotomy was successfully performed through the fistula. The ultrasound exam of gallbladder 4 weeks later showed no stone remain and satisfactory function. The EUS-guided placement of a novel metal stent was a safe and simple approach to performing an endoscopic cholecystogastrostomy, which can subsequently allow procedures for treating biliary disease, including cholecystolithotomy.
  1,731 300 3
EDITORIAL
Preoperative endoscopic ultrasound-guided fine needle aspiration for diagnosis of pancreatic cancer in potentially resectable patients: Is this safe?
Natalie D Cosgrove, Linda Yan, Ali Siddiqui
April-June 2015, 4(2):81-84
DOI:10.4103/2303-9027.156708  PMID:26020040
  1,312 508 4
ORIGINAL ARTICLES
Role of endoscopic ultrasound-guided fine needle aspiration and ultrasound-guided fine-needle aspiration in diagnosis of cystic pancreatic lesions
Hussein Hassan Okasha, Mahmoud Ashry, Hala M. K. Imam, Reem Ezzat, Mohamed Naguib, Ali H Farag, Emad H Gemeie, Hani M Khattab
April-June 2015, 4(2):132-136
DOI:10.4103/2303-9027.156742  PMID:26020048
Background and Objective: The addition of fine-needle aspiration (FNA) to different imaging modalities has raised the accuracy for diagnosis of cystic pancreatic lesions. We aim to differentiate benign from neoplastic pancreatic cysts by evaluating cyst fluid carcinoembryonic antigen (CEA), carbohydrate antigen (CA19-9), and amylase levels and cytopathological examination, including mucin stain. Patients and Methods: This prospective study included 77 patients with pancreatic cystic lesions. Ultrasound-FNA (US-FNA) or endoscopic ultrasound-FNA (EUS-FNA) was done according to the accessibility of the lesion. The aspirated specimens were subjected to cytopathological examination (including mucin staining), tumor markers (CEA, CA19-9), and amylase level. Results : Cyst CEA value of 279 or more showed high statistical significance in differentiating mucinous from nonmucinous lesions with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 73%, 60%, 50%, 80%, and 65%, respectively. Cyst amylase could differentiate between neoplastic and nonneoplastic cysts at a level of 1043 with sensitivity of 58%, specificity of 75%, PPV of 73%, NPV of 60%, and accuracy of 66%. CA19-9 could not differentiate between neoplastic and nonneoplastic cysts. Mucin examination showed a sensitivity of 85%, specificity of 95%, PPV of 92%, NPV of 91%, and accuracy of 91% in differentiating mucinous from non-mucinous lesions. Cytopathological examination showed a sensitivity of 81%, specificity of 94%, PPV of 94%, NPV of 83%, and accuracy of 88%. Conclusion: US or EUS-FNA with analysis of cyst CEA level, CA19-9, amylase, mucin stain, and cytopathological examination increases the diagnostic accuracy of cystic pancreatic lesions.
  1,235 550 4
Clinical evaluation of endoscopic ultrasonography-guided drainage using a novel flared-type biflanged metal stent for pancreatic fluid collection
Shuntaro Mukai, Takao Itoi, Atsushi Sofuni, Takayoshi Tsuchiya, Takuji Gotoda, Fuminori Moriyasu
April-June 2015, 4(2):120-125
DOI:10.4103/2303-9027.156738  PMID:26020046
Background and Objectives: Endoscopic ultrasonography (EUS)-guided transluminal drainage for pancreatic fluid collections (PFCs) has become the standard therapy worldwide as a minimally invasive therapy compared with surgical drainage. Recently, a novel flared-type biflanged metal stent (BFMS) designed specifically for the treatment of PFCs has been developed. The aim of this study was to retrospectively assess the feasibility and safety of EUS-guided drainage and direct endoscopic necrosectomy (DEN) for PFCs using the novel flared-type BFMS. Patients and Methods: Twenty-one patients were treated by EUS-guided drainage using a flared-type BFMS for PFCs (pancreatic pseudocyst, 2 patients; walled-off necrosis, 19 patients). Results: The present study showed a technical success rate of 100%, a final clinical success rate of 100%, a procedure-related adverse event (AE) rate of 0%, an early AE rate of 28.6% (moderate and severe AE rate of 9.5%), a mortality rate of 0%, and a recurrence rate of 9.5%. DEN (mean, 2.3 sessions) was required in 38% of the patients. Conclusion: The present study clarified that the EUS-guided drainage using the flared-type BFMS is an effective and safe treatment approach for PFCs. Further studies using randomized controlled multicenter trials are warranted.
  1,425 332 12
REVIEW ARTICLES
Nonfluoroscopic endoscopic ultrasound-guided transmural drainage of pseudocysts: A pictorial technical review
Surinder Singh Rana, Deepak Kumar Bhasin
April-June 2015, 4(2):92-97
DOI:10.4103/2303-9027.156719  PMID:26020042
Pancreatic pseudocysts (PP) are one of the important local complications of pancreatitis and can be treated by surgical, laparoscopic, percutaneous, or endoscopic methods. The endoscopic methods of drainage include transpapillary or transmural drainage or a combination of these two routes. The transmural drainage can be done using conventional duodenoscope without endoscopic ultrasound (EUS) guidance or under EUS guidance. The EUS-guided transmural drainage of PP is done under EUS and fluoroscopic guidance. We have earlier reported nonfluoroscopic EUS-guided transmural drainage of walled-off pancreatic necrosis. In this pictorial technical review, we will discuss in detail this method of nonfluoroscopic EUS-guided drainage of PP.
  1,205 426 4
ORIGINAL ARTICLES
High risk of acute pancreatitis after endoscopic ultrasound-guided fine needle aspiration of side branch intraductal papillary mucinous neoplasms
Ali A Siddiqui, Haroon Shahid, Apeksha Shah, Tanvi Khurana, William Huntington, Saad S Ghumman, David E Loren, Thomas E Kowalski, Sobia Laique, Umar Hayat, Mohamad A Eloubeidi
April-June 2015, 4(2):109-114
DOI:10.4103/2303-9027.156728  PMID:26020044
Background and Objectives: Data on the risk of acute pancreatitis following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic cystic lesions are limited. The aim of our study was to evaluate the frequency of acute pancreatitis after EUS-FNA of pancreatic cysts and solid lesions, and determine whether there was a difference in pancreatitis risk in patients with side branch intraductal papillary mucinous neoplasms (SB-IPMN). Patients and Methods: A retrospective review of patients who underwent EUS-FNA of pancreatic cysts and solid lesions was performed. The primary outcome measure was development of acute pancreatitis after EUS-FNA. Factors associated with acute pancreatitis were examined by statistical analysis to determine independent predictors of acute pancreatitis. Statistical significance was determined at a P ≤ 0.05. Results: We identified 186 patients with pancreatic cystic lesions and 557 with solid lesions in which EUS-FNA was performed. The median size of the cysts was 19 mm (range: 10-66 mm). There were 37 IPMNs, 33 mucinous cystic neoplasms, 58 serous cysts and 46 pseudocysts and 12 solid-cystic ductal carcinomas. The majority of patients (75%) with solid lesions were diagnosed with adenocarcinoma. Patients with pancreatic cysts had a statistically greater frequency of developing pancreatitis after EUS-FNA when compared to those with solid lesions (2.6% vs. 0.36% respectively; P = 0.13). In patients with cysts, there were no statistically significant differences between the two groups (with and without pancreatitis) with regard to a cyst location, size of the cyst, and number of needle passes or trainee involvement. Patients with SB-IPMN had a statistically higher frequency of pancreatitis after EUS-FNA compared to those with other cyst types (8% vs. 1.3% respectively; odds ratio = 6.4, 95% confidence intervals = 1.0-40.3, P = 0.05). Discussion: Patients with SB-IPMN are at a higher risk of developing acute pancreatitis after a EUS-FNA. Alternative means of diagnosis such as magnetic resonance cholangiopancreatogram might be necessary to avoid risk of EUS-FNA.
  1,141 403 8
CASE REPORTS
Multiple pancreatic metastases from malignant melanoma: Conclusive diagnosis with endoscopic ultrasound-guided fine needle aspiration
Tanima Jana, Nancy P Caraway, Atsushi Irisawa, Manoop S Bhutani
April-June 2015, 4(2):145-148
DOI:10.4103/2303-9027.156746  PMID:26020050
Pancreatic metastases are rare, ranging from 2% to 5% of pancreatic malignancies. Differentiating a primary pancreatic malignancy from a metastasis can be difficult due to similarities on imaging findings, but is crucial to ensure proper treatment. Although transabdominal ultrasound, computed tomography, and magnetic resonance imaging provide useful images, endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is often needed to provide a cytologic diagnosis. Here, we present a unique case of malignant melanoma with pancreatic metastases. It is important for clinicians to recognize the possibility of melanoma metastasizing to the pancreas and the role of EUS with FNA in providing cytological confirmation.
  1,226 270 3
ORIGINAL ARTICLES
Comparison of cytologic accuracy of endobronchial ultrasound transbronchial needle aspiration using needle suction versus no suction
Kassem Harris, Rabih Maroun, Kristopher Attwood, Michel Chalhoub
April-June 2015, 4(2):115-119
DOI:10.4103/2303-9027.156737  PMID:26020045
Background and Objectives: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new procedure initially used for lung cancer diagnosis, staging and re-staging and extended to benign diseases such as sarcoidosis and other mediastinal lesions. Previously, multiple studies evaluated the use of needle biopsy with no aspiration that did not change the diagnostic accuracy compared with needle biopsy aspiration. Materials and Methods : All adult subjects who were scheduled to undergo EBUS-TBNA to sample mediastinal lesions were eligible. We evaluated two methods of sampling mediastinal lesions. The first method was the application of negative pressure syringe for needle suction aspiration. The second was with no suction. For every patient and every biopsy site in the same patient, we had two samples using each method. Results : Among the 26 participants, 24 patients had adequate tissue using both methods (92.3%, P = 1.00). Among the 24 patients with adequate tissue using both methods, 14 patients (58.3%) had benign pathology using both methods, whereas ten patients (41.7%) had malignant pathology using both methods (P = 1.00). Among the 32 sites that were sampled, 30 sites had adequate tissue using both methods (93.8%, P = 1.00). Among the thirty sites with adequate tissue using both methods, 17 (56.7%) had benign pathology using both methods; 12 (40.0%) had malignant pathology using both methods; and one site (3.3%) had malignant pathology using suction, but benign pathology using no suction (P = 1.00). Conclusion : In patients undergoing EBUS-TBNA to sample mediastinal lesions, the diagnostic yield with the application of suction to needle biopsy was not statistically significant compared to no suction.
  914 223 2
LETTER TO EDITOR
Pericardial recess through the eyes of endobronchial ultrasound
Abdul Hamid Alraiyes, Francisco A Almeida, Atul C Mehta
April-June 2015, 4(2):162-163
DOI:10.4103/2303-9027.156764  PMID:26020056
  977 158 -
ORIGINAL ARTICLES
The application of linear endoscopic ultrasound in the patients with esophageal anastomotic strictures
Sheng Wang, Shupeng Wang, Wen Liu, Siyu Sun, Xiang Liu, Nan Ge, Jintao Guo, Guoxin Wang, Linlin Feng
April-June 2015, 4(2):126-131
DOI:10.4103/2303-9027.156740  PMID:26020047
Objectives: To evaluate the role of linear endoscopic ultrasound (EUS) in the diagnosis and treatment of the anastomotic stricture after esophagectomy for locally advanced esophageal cancer (EC). Materials and Methods: A retrospective analysis was performed in patients undergone EUS assessment and endoscopic treatment for anastomotic stricture after esophagectomy for locally advanced EC from January 2010 to December 2014 at Shengjing Hospital. The linear EUS was performed in all the patients to assess the thickness of the esophageal wall, the length and width of the lesion, and to evaluate the severity of anastomotic stricture. According to the EUS features of the lesion, different endoscopic therapy were performed. Results: There were 92 patients enrolled in this study. All the lesions of the patients were assessed by EUS. Eighty-six patients had cicatricial stricture of the esophagus confirmed by EUS, and were treated by endoscopic balloon dilation. Five patients were suspected to have tumor relapses, and the other one had lymphatic metastasis. All the six patients were undergone endoscopic metal stent implantation. The EUS diagnoses of all the patients were confirmed by pathological biopsy. Conclusion: Linear EUS is safe and effective for distinguishing the nature of the anastomotic stricture, and should be performed before endoscopic or surgical treatment.
  949 179 2
Utility of EUS following endoscopic polypectomy of high-risk rectosigmoid lesions
Leticia P Luz, Gregory A Cote, Mohammad A Al-Haddad, Lee McHenry, Julia K LeBlanc, Stuart Sherman, Daniel M Moreira, Ihab I El Hajj, Kathleen McGreevy, John DeWitt
April-June 2015, 4(2):137-144
DOI:10.4103/2303-9027.156744  PMID:26020049
Background: The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy (WLE) following recent polypectomy of high-risk colorectal polyps is unknown. Objective: To assess the incremental yield of EUS after endoscopic polypectomy of a high-risk rectal lesion. Design: Retrospective cohort. Setting: Tertiary referral center. Materials and Methods: Patients referred for EUS following attempted endoscopic resection of a high-risk rectal neoplasm, defined as a tubulovillous adenoma, tubular adenoma with high-grade dysplasia, carcinoid, carcinoma in-situ or adenocarcinoma (CA). Interventions: Sigmoidoscopy ± mucosal biopsy and EUS ± fine-needle aspiration (FNA) to evaluate for: (1) Residual polyp/tumor in the rectal wall or (2) peritumoral adenopathy. Main Outcome: Sensitivity and specificity for detection of residual neoplasia for WLE ± biopsy (WLE/BX) and EUS ± FNA for cancer (CA group) or benign disease (non-CA group). The incremental yield of EUS defined as: (1) Residual intramural neoplasia not present on WLE ± BX and; (2) abnormal peritumoral adenopathy. Results: A total of 70 patients (mean age 64 ± 11 years, 61% male) with a final diagnosis of CA (n = 38) and non-CA (n = 32) were identified. There was no difference between the sensitivity and specificity of WLE alone (65% and 84%), WLE with biopsy (71% and 95%), and EUS (59% and 84%), for the detection of residual neoplasia (P > 0.05 for all). EUS identified 3 masses missed by WLE, all in the CA group. A malignant (n = 2) or benign (n = 3) node was identified in 5 (13%) CA patients; EUS-FNA in two showed residual malignancy in one and a reactive lymph node (LN) in one. No LNs were identified in the non-CA patients. Limitations: Retrospective design, incomplete follow-up in some patients. Conclusion: Following endoscopic polypectomy of high-risk rectal neoplasia, the incremental yield of EUS compared with WLE/BX for evaluation of residual disease appears limited, especially in patients with benign disease.
  900 219 2
IMAGES IN EUS
Convex probe endobronchial ultrasound placement of fiducial markers for central lung nodule (with video)
Kassem Harris, Jorge Gomez, Samjot Singh Dhillon, Abdul Hamid Alraiyes, Anthony Picone
April-June 2015, 4(2):156-157
DOI:10.4103/2303-9027.156757  PMID:26020053
  771 174 2
Pancreatic cancer with portal vein invasion diagnosed by endoscopic ultrasound
Augusto P. C. Carbonari, Juliana Bonfim, Rogerio Colaiacovo, Lucio G.B. Rossini
April-June 2015, 4(2):158-159
DOI:10.4103/2303-9027.156758  PMID:26020054
  713 229 -
CASE REPORTS
Gossypiboma diagnosed by a forward-view endoscopic ultrasound fine-needle aspiration out of the sigmoid colon
Masayuki Kato, Yosuke Kawahara, Koji Matsuda, Hisao Tajiri
April-June 2015, 4(2):149-151
DOI:10.4103/2303-9027.156748  PMID:26020051
Gossypiboma is a term used to describe a foreign mass within the body that is composed of a cotton matrix. Gossypiboma can cause infection or abscess formation from an early stage, or it can remain clinically silent for many years. Gossypiboma can be diagnosed using several methods including abdominal X-ray films, US of the abdomen, contrast-enhanced computed tomography of the abdomen, and during surgery. However, the variable appearance of gossypiboma can lead to diagnostic misinterpretations. Here, we report a successful diagnosis of gossypiboma using a novel method, that is, endoscopic ultrasound-fine-needle aspiration.
  719 141 1
IMAGES IN EUS
Contrast-enhanced harmonic endoscopic ultrasound in the diagnosis of primary pancreatic B-cell non-Hodgkin's lymphoma
Hui Jer Hwang, Carlos Robles-Jara, Monserrate Largacha, Carlos Robles-Medranda
April-June 2015, 4(2):160-161
DOI:10.4103/2303-9027.156762  PMID:26020055
  663 175 -
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