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   2015| July-September  | Volume 4 | Issue 3  
    Online since August 17, 2015

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Imaging of the pancreatic duct by linear endoscopic ultrasound
Malay Sharma, Praveer Rai, Chittapuram Srinivasan Rameshbabu, Shalini Arya
July-September 2015, 4(3):198-207
DOI:10.4103/2303-9027.162997  PMID:26374577
The current gold standard investigation for anatomic exploration of the pancreatic duct (PD) is endoscopic retrograde cholangiopancreatography. Magnetic resonance cholangiopancreatography is a noninvasive method for exploration of the PD. A comprehensive evaluation of the course of PD and its branches has not been described by endoscopic ultrasound (EUS). In this article, we describe the techniques of imaging of PD using linear EUS.
  3,338 1,256 1
Endoscopic ultrasound: Elastographic lymph node evaluation
Christoph F Dietrich, Christian Jenssen, Paolo G Arcidiacono, Xin-Wu Cui, Marc Giovannini, Michael Hocke, Julio Iglesias-Garcia, Adrian Saftoiu, Siyu Sun, Liliana Chiorean
July-September 2015, 4(3):176-190
DOI:10.4103/2303-9027.162995  PMID:26374575
Different imaging techniques can bring different information which will contribute to the final diagnosis and further management of the patients. Even from the time of Hippocrates, palpation has been used in order to detect and characterize a body mass. The so-called virtual palpation has now become a reality due to elastography, which is a recently developed technique. Elastography has already been proving its added value as a complementary imaging method, helpful to better characterize and differentiate between benign and malignant masses. The current applications of elastography in lymph nodes (LNs) assessment by endoscopic ultrasonography will be further discussed in this paper, with a review of the literature and future perspectives.
  3,641 672 16
Endobronchial ultrasound-guided transbronchial needle aspiration of pulmonary artery tumors: A systematic review (with video)
Kassem Harris, Kush Modi, Abhishek Kumar, Samjot Singh Dhillon
July-September 2015, 4(3):191-197
DOI:10.4103/2303-9027.162996  PMID:26374576
Convex probe endobronchial ultrasound (CP-EBUS) was originally introduced as a diagnostic and staging tool for lung cancer and subsequently utilized for diagnosis of other malignant and benign mediastinal diseases such as melanoma, lymphoma, and sarcoidosis. More recently, CP-EBUS has been successfully used for the visualization and diagnosis of pulmonary emboli and other vascular lesions including primary and metastatic pulmonary artery (PA) tumors. In this review, we will underline the role of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of pulmonary arterial tumors such as sarcomas and tumor emboli. We will concisely discuss the clinical applications of EBUS-TBNA and the types of pulmonary arterial tumors and their different diagnostic modalities. We searched the Cochrane Library and PubMed from 2004 to 2014 to provide the most comprehensive review. Only 10 cases of EBUS-TBNA for intravascular lesions were identified in the literature. Although many cases of EBUS and EUS-guided transvascular tumor biopsies were described in the literature, there were no reported cases of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for intravascular tumor biopsies. Except for one paper, all cases were published as case reports.
  2,253 487 11
Endoscopic ultrasound guided vascular access and therapy (with videos)
Payal Saxena, Sundeep Lakhtakia
July-September 2015, 4(3):168-175
DOI:10.4103/2303-9027.162994  PMID:26374574
The continued need to develop minimally invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. EUS has now stepped into the therapeutic arena. EUS provides the unique advantage of both real-time imaging and access to structures within and adjacent to the gastrointestinal (GI) tract. Hence, EUS-guided therapeutic techniques continue to evolve in several directions enabling a variety of minimally invasive therapies for pancreatic and biliary pathologies. Furthermore, the close proximity of the GI tract to vascular structures in the mediastinum and abdomen permits EUS-guided vascular access and therapy. Studies have demonstrated several EUS-guided vascular interventions by using standard endoscopic accessories and available tools from the interventional radiology armamentarium. This article provides an overview of the literature including clinical and nonclinical studies for the management of nonvariceal and variceal GI bleeding, formation of intrahepatic portosystemic shunts (IPSS), and EUS-guided cardiac access and therapy.
  2,025 574 5
Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure
Everson L. A. Artifon, Jarbas F Loureiro, Todd H Baron, Kaie Fernandes, Michel Kahaleh, Fernando P Marson
July-September 2015, 4(3):235-243
DOI:10.4103/2303-9027.163010  PMID:26374583
Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP. Patients and Methods: A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively. Results: Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days). Conclusion: Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.
  2,131 467 14
Endoscopic ultrasound-guided pancreatic pseudocyst cystogastrostomy using a novel self-expandable metal stent with antimigration system: A case series
Eric M Nelsen, Eric A Johnson, Andrew J Walker, Patrick Pfau, Deepak V Gopal
July-September 2015, 4(3):229-234
DOI:10.4103/2303-9027.163007  PMID:26374582
Background and Objectives: Development of symptomatic pseudocysts after acute pancreatitis is a common occurrence. Endoscopic ultrasound (EUS)-guided transmural drainage has become the treatment of choice for symptomatic pseudocysts. Following this procedure, stent migration can occur. A recently developed fully covered biliary metal stent with antimigration system has shown promise as an alternative endoprosthetic option for cystogastrostomy. The aim of this study is to describe the success and complications of using covered metal stents with antimigration system to drain pseudocysts at a single tertiary care center. Materials and Methods: The patients undergoing cystogastrostomy using the biliary metal stent with antimigration system over the course of a 10-month period (January-November, 2014) were retrospectively reviewed and all the pertinent information including length of the follow-up, age and sex of the patient, pseudocyst size, pseudocyst size at follow-up, and symptom improvement were recorded. Results: Five patients underwent endoscopic cystogastrostomy using a biliary metal stent with antimigration system. The average age of the patients was 57 years, with all the patients being males. The average size of the largest dimension of pseudocyst was 9 cm. The average follow-up time to repeat imaging was 30 days. All the patients had a significant improvement in their pseudocyst size, with two patients having complete resolution, one patient with a residual 2 cm cyst, and another with a residual 5 cm pseudocyst at follow-up. The average size at follow-up was 2 cm. No complications occurred during the follow-up period. No episodes of stent migration occurred. All the patients had symptom improvement at follow-up. Conclusion: Using a novel biliary covered self-expandable metal stent with antimigration system with EUS guidance to drain pseudocysts appears to be a safe and effective procedure in certain settings. Our experience shows rapid cyst resolution with no complications and no stent migration. This stent gives the providers another option when performing cystogastrostomy.
  1,816 347 2
A duodenal gastrointestinal stromal tumor with a large central area of fluid and gas due to fistulization into the duodenal lumen, mimicking a large duodenal diverticulum
Hussein Hassan Okasha, Hoda Mahmoud Amin, Mostafa Al-Shazli, Ahmed Nabil, Hossam Hussein, Reem Ezzat
July-September 2015, 4(3):253-256
DOI:10.4103/2303-9027.163018  PMID:26374586
Gastrointestinal stromal tumors (GISTs) can occur anywhere along the gastrointestinal tract especially the stomach and upper small bowel. They are usually solid, but cystic degeneration, necrosis, and focal hemorrhage have been described in larger tumors leading to central necrotic cavitation. The most sensitive marker of GIST is CD117 (c-kit). In computed tomography (CT) scan, it is often difficult to decide the origin of the primary tumor, especially in large GISTs. We report an incidental case of a large duodenal GIST fistulizing into the second part of the duodenum with a large amount of fluid and gas inside, mistaken for a cystic pancreatic neoplasm by CT and mistaken for a duodenal diverticulum by endoscopic ultrasound.
  1,670 225 1
Missed lesions in endoscopic ultrasound
Douglas G Adler, David L Diehl
July-September 2015, 4(3):165-167
DOI:10.4103/2303-9027.162993  PMID:26374573
  1,368 464 2
Endoscopic ultrasound-guided transmural drainage of infected pancreatic necrosis developing 2 years after acute pancreatitis
Kyle Eliason, Douglas G Adler
July-September 2015, 4(3):260-265
DOI:10.4103/2303-9027.163020  PMID:26374588
This is a case report of endoscopic ultrasound guided transmural drainage of a large infected pancreatic necrosis. The infected necrosis was treated by placement of a fully covered metal stent with subsequent endoscopic necrosectomy to remove solid debris. The case is notable for the fact that the patient developed infection of a long-standing and previously stable area of walled-off pancreatic necrosis 2 years after it formed. We believe this is the longest time ever reported between necrotizing pancreatitis and the development of infected pancreatic necrosis.
  1,600 218 2
Prevalence of extra-pancreatic cysts in patients with cystic pancreatic lesions detected by endoscopic ultrasound
Mehmet Bektas, Somashekar G Krishna, William A Ross, Brian Weston, Matthew H Katz, Jason B Fleming, Jeffrey H Lee, Manoop S Bhutani
July-September 2015, 4(3):219-224
DOI:10.4103/2303-9027.163001  PMID:26374580
Background and Objectives: Extra-pancreatic cysts (EPCs) are incidentally found in patients with pancreatic cystic lesions (PCLs). The aim of this study is to find the prevalence of concurrent EPC in patients with PCLs, investigate associations with neoplastic lesions, and compare the prevalence of EPC to a control population. Materials and Methods: A retrospective study of patients who underwent endoscopic ultrasound (EUS) over a 3-year period. The study group consisted of patients with PCLs. The control group included equal number of matched (age and sex) patients who had undergone EUS for reasons other than evaluation of PCLs. All patients had undergone computed tomography (CT) that was reviewed for EPCs. Results: A total of 191 patients were found to have PCLs. One patient with Von Hippel-Lindau (VHL) disease was excluded. Majority of the patients were female (60%); most PCLs were solitary (68.9%), unilocular (56.8%), predominantly located in the head of the pancreas (37.4%); and mean PCL diameter was 28.12 ± 18.4mm. EUS-guided fine-needle aspiration (FNA) was performed in 171 (90%) patients with 73 (42.7%) PCLs demonstrating cysts with benign epithelial cells, 37 (21.6%) mucinous cysts, 18 (10.5%) mucinous adenocarcinomas, 11 (6.4%) neuroendocrine tumors, nine intraductal papillary mucinous cystic neoplasms (IPMNs), six pseudocysts, five serous cyst adenomas (SCAs), and five with inadequate sampling. An EPC was observed in 97 of 190 (51.18%) patients with PCLs and in 67 of 190 (35.3%) controls (P < 0.001). The distribution of EPCs in PCL patients and controls (n = 190) were 32.1% vs. 15.8% (P < 0.001) for liver cysts, 30.0% vs. 20.5% (P = 0.04) for renal cysts, and 3.7% vs. 1.6% (P = 0.34) for cysts in other organs. Mean liver cyst diameter (15.6 mm vs. 10.1 mm, P = 0.23) and renal cyst diameter (20.4 mm vs. 20.1 mm, P = 0.95) were not statistically different in PCL patients compared to controls. Multivariate analysis demonstrated that among patients with PCLs, EPCs increased with age (mean age 69.6 vs. 62.4 years, P ≤ 0.001, odds ratio (OR) 1.06, 95% confidence interval (CI) 1.03, 1.09), and male gender was associated with higher chance of finding renal cysts (OR 2.17, P = 0.021, 95% CI 1.13, 4.19). There was no association between FNA result and prevalence or type of EPC. Conclusion: The prevalence of EPCs in patients with PCLs was significantly higher than in a matched control group. Among patients with PCLs, a liver cyst is the most common EPC. Increasing age is associated with higher prevalence of EPCs.
  1,477 260 4
Endoscopic drainage of pancreatic fluid collections using a fully covered expandable metal stent with antimigratory fins
Isaac Raijman, Paul R Tarnasky, Sandeep Patel, Douglas S Fishman, Sri Naveen Surapaneni, Laura Rosenkranz, Jayant P Talreja, Dang Nguyen, Monica Gaidhane, Michel Kahaleh
July-September 2015, 4(3):213-218
DOI:10.4103/2303-9027.163000  PMID:26374579
Background and Objectives: Endoscopic drainage is the first consideration in treating pancreatic fluid collections (PFCs). Recent data suggests it may be useful in complicated PFCs as well. Most of the available data assess the use of plastic stents, but scarce data exists on metal stent management of PFCs. The aim of our study to evaluate the efficacy and safety of a metal stent in the management of PFCs. Patients and Methods: Data were collected prospectively on 47 patients diagnosed with PFCs from March 2007 to August 2011 at 3 tertiary care centers. These patients underwent endoscopic transmural placement of a fully covered self-expanding metal stent (FCSEMS) with antimigratory fins of 10 mm diameter. Results: The stent was successfully placed in all patients, and left in place an average of 13 weeks (range 0.4-36 weeks). Etiology of the PFC was biliary pancreatitis (23), pancreas divisum (2), trauma (4), hyperlipidemia (3), alcoholic (8), smoking (2), idiopathic (4), and medication-induced (1). PFCs resolved in 36 patients, for an overall success rate of 77%. Complications included fever (3), stent migration (2) and abdominal pain (1). Conclusions: The use of FCSEMS is successful in the majority of patients with low complication rates. A large sample-sized RCT is needed to confirm if the resolution of PFCs is long-standing.
  1,261 240 6
Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome
Surinder Singh Rana, Deepak Kumar Bhasin, Ravi Sharma, Rajesh Gupta
July-September 2015, 4(3):208-212
DOI:10.4103/2303-9027.162999  PMID:26374578
Background and Objectives: Long-term indwelling transmural stents in patients with walled off pancreatic necrosis (WOPN) and disconnected pancreatic duct syndrome (DPDS) decreases risk of recurrence of pancreatic fluid collection (PFC). However, stents can spontaneously migrate causing recurrence of PFC in some patients whereas some patients may have asymptomatic migration of stents. We aim to retrospectively evaluate profile of patients with recurrent PFC following migration of transmural stents in patients with WOPN and DPDS and compare it with patients who had asymptomatic migration of stents. Patients and Methods: Records of consecutive patients who underwent endoscopic transmural drainage of WOPN over last 4 years were analyzed and patients with DPDS identified. Results: Thirty-five patients (29 M; mean age 37.0 ± 7.6 years) were followed-up for mean of 28.2 ± 14.0 months (range: 6-50 months). Eight patients (22.8%) had spontaneous migration of stents. It led to recurrence of PFC in three patients, whereas in five patients it was asymptomatic. The patients with recurrent PFC had early stent migration (2, 4, and 5 months respectively) whereas patients with asymptomatic migration had their stents migrating >6 months of resolution. Patients with recurrent PFC had duct disruption in pancreatic head (100% vs. 20%), and low frequency of diabetes (nil vs. 40%), steatorrhea (nil vs. 20%) as well as pancreatic atrophy (nil vs. 80%). Conclusion: Early migration of stents, ductal disruption in pancreatic head as well as absence of diabetes, steatorrhea, and pancreatic atrophy seem to increase risk of recurrent PFC following migration of transmural stents in patients with DPDS.
  1,119 244 10
Starry sky sign: A prevalent sonographic finding in mediastinal tuberculous lymph nodes
Ibrahim Onur Alici, Nilgün Yilmaz Demirci, Aydin Yilmaz, Jale Karakaya, Yurdanur Erdogan
July-September 2015, 4(3):225-228
DOI:10.4103/2303-9027.163004  PMID:26374581
Background and Objectives: We report a prevalent finding in tuberculous lymphadenitis (TL): Starry sky sign, hyperechoic foci without acoustic shadows over a hypoechoic background. Materials and Methods: We retrospectively searched the database for a possible relationship of starry sky sign with a specific diagnosis and also the prevalence and accuracy of the finding. Results: Starry sky sign was found in 16 of 31 tuberculous lymph nodes, while none of other lymph nodes (1,015 lymph nodes) exhibited this finding; giving a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 51.6%, 100%, 100%, 98.5%, and 98.5%, respectively. Conclusion: Bacteriologic and histologic findings are gold standard in the diagnosis of tuberculosis, but this finding may guide the bronchoscopist in choosing the more pathologic node within a station and increase the diagnostic yield as it may relate to actively dividing mycobacteria.
  1,173 179 1
Interobserver agreement of EUS elastography in the evaluation of solid pancreatic lesions
João-Bruno Soares, Julio Iglesias-Garcia, Bruno Gonçalves, Björn Lindkvist, Jose Lariño-Noia, Pedro Bastos, Ana Célia Caetano, Aníbal Ferreira, Pedro Pimentel-Nunes, Luís Lopes, Pedro Moutinho-Ribeiro, J Enrique Dominguez-Muñoz
July-September 2015, 4(3):244-249
DOI:10.4103/2303-9027.163016  PMID:26374584
Background and Objectives: Previous reports assessing the reproducibility of endoscopic ultrasound elastography (EUS-E) in evaluation of solid pancreatic lesions (SPL) involved only experienced endosonographers. We aimed to assess the interobserver agreement (IOA) of EUS-E in the evaluation of SPL by endoscopists with different levels of experience in EUS and EUS-E. Materials and Methods: A cross-sectional observational multicenter study was designed and included 11 endoscopists who were divided into four groups: Group A (long experience in EUS and EUS-E); Group B (short experience in EUS and EUS-E); Group C (long experience in EUS and no experience in EUS-E); and Group D (no experience in EUS or EUS-E). The observers independently classified the patterns of 60 video sequences of EUS-E, after a 20-min training session. For each group, we calculated IOA (kappa statistic, k) of EUS-E and the diagnostic accuracy of EUS-E for pancreatic malignancy, by comparing the pattern of EUS-E indicative of malignancy (heterogeneous or homogenous blue) with the final diagnosis. Results: The overall IOA was moderate (k = 0.42; 95% confidence interval (CI) 0.33-0.52). The IOA of Group A (k = 0.80; 95% CI 0.65-1.00) was significantly higher than that of Groups B (k = 0.54; 95%CI 0.40-0.71), C (k = 0.54; 95%CI 0.39-0.68), and D (k = 0.28; 95%CI 0.14-0.40). IOA of Groups B and C was not significantly different, but it was significantly higher than that of Group D. The diagnostic accuracy of Group A (area under the curve under summary receiver operating characteristic (AUROC) = 0.83; 95%CI 0.75-0.90) was not significantly different from that of Group B (AUROC = 0.77; 95%CI 0.71-0.83), but it was significantly higher than that of Groups C (AUROC = 0.74; 95%CI 0.67-0.81) and D (AUROC = 0.74; 95%CI 0.67-0.81). No significant difference was seen between Groups B, C, and D for diagnostic accuracy. Conclusion: EUS-E is reproducible in the evaluation of SPL, even between endoscopists with no or limited experience in EUS and/or EUS-E. Reproducibility and diagnostic accuracy increase with experience in EUS and EUS-E.
  1,024 268 8
Creation of multiple transluminal gateway during endoscopic ultrasound-guided drainage of pancreatic necrosis by enlarging tract of impending rupture in duodenum
Surinder Singh Rana, Vishal Sharma, Suresh Gorka, Ravi Sharma, Deepak Kumar Bhasin
July-September 2015, 4(3):257-259
DOI:10.4103/2303-9027.163019  PMID:26374587
Necrotic pancreatic collections are difficult to treat endoscopically due to a concern for inadequate drainage of the necrotic debris. Multiple techniques including the use of metallic stents, endoscopic necrosectomy and use of hybrid approaches utilizing endoscopic and percutaneous approaches have been described for the management of pancreatic necrotic collections. Furthermore, multiple transluminal gateway technique has been used to create endosonography guided multiple tracts to drain a perigastric or periduodenal collection. We hereby report about a patient with walled off necrosis resulting as a complication of alcohol related acute pancreatitis that was drained using endoscopic ultrasound-guided approach. However, a spontaneous cystoduodenal fistula was used to create another tract and place transmural stents resulting in a quick resolution of symptoms.
  956 160 2
Hepatogastrostomy by EUS for malignant afferent loop obstruction after duodenopancreatectomy
Jean-Philippe Ratone, Fabrice Caillol, Erwan Bories, Christian Pesenti, Sebastien Godat, Marc Giovannini
July-September 2015, 4(3):250-252
DOI:10.4103/2303-9027.163017  PMID:26374585
One of the most difficult biliary drainages is the recurrence and stenosis on afferent loop after surgery. We report an original case of hepaticogastrostomy (HGE) in a patient who had malignant stenosis of afferent loop after cephalic duodenopancreatectomy (CDP). After failure of the gastrointestinal stent, two metal self-expandable stents were placed by endoscopic ultrasound (EUS) after puncture of the dilated left hepatic duct. On clinical improvement and disappearance of jaundice, palliative chemotherapy was started.
  916 173 1
Endoscopic ultrasonography-guided drainage of a pancreatic pseudocyst one week after formation
Shupeng Wang, Wen Liu, Siyu Sun, Xiang Liu, Sheng Wang, Nan Ge, Guoxin Wang, Jintao Guo
July-September 2015, 4(3):271-272
DOI:10.4103/2303-9027.163024  PMID:26374592
  824 207 1
An unusual case of large symptomatic Brunner's gland adenoma: Endoscopic ultrasound imaging
Melissa A Martinez, Nicholas J Zyromski, Leticia P Luz
July-September 2015, 4(3):266-267
DOI:10.4103/2303-9027.163021  PMID:26374589
  873 147 2
Mediastinal sarcoidosis diagnosed by endobronchial ultrasound in a patient with Sjögren's syndrome
Augusto Carbonari, Marco Camunha, Fabio Marioni, Mauro Saieg, Lucio Rossini
July-September 2015, 4(3):268-269
DOI:10.4103/2303-9027.163022  PMID:26374590
  819 122 -
Are rigid probes sufficient to provide reliable data for rectal cancer staging?
Yucel Ustundag, Pietro Fusaroli
July-September 2015, 4(3):270-270
DOI:10.4103/2303-9027.163023  PMID:26374591
  660 100 1