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   2017| March-April  | Volume 6 | Issue 2  
    Online since April 20, 2017

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Endoscopic ultrasound of peritoneal spaces
Malay Sharma, Jayan Gopinath Madambath, Piyush Somani, Amit Pathak, Chittapuram Srinivasan Rameshbabu, Raghav Bansal, Kovil Ramasamy, Amol Patil
March-April 2017, 6(2):90-102
DOI:10.4103/2303-9027.204816  PMID:28440234
The peritoneal cavity is subdivided into supracolic and infracolic compartments by transverse colon and its mesocolon. The supracolic compartment contains the liver, spleen, stomach, and lesser omentum. The infracolic compartment contains the coils of small bowel surrounded by ascending, transverse, and descending colon and the paracolic gutters. The imaging of different compartments is possible by various methods such as ultrasound (US) and computerized tomography. The treating physicians should be familiar with the relevant radiological anatomy of different compartments and spaces as accurate localization of fluid collection/lymph node in peritoneal cavity greatly aids in selection of a treatment strategy. The role of endoscopic US (EUS) is emerging for detail evaluation of all parts of peritoneal cavity as it provides an easy access for fine-needle aspiration from different compartments of peritoneal cavity. In this review, we describe the techniques of evaluation of different parts of supracolic compartments of peritoneum by EUS.
  7,060 639 1
Clinical use of endoscopic ultrasound-guided fine-needle aspiration: Guidelines and recommendations from Chinese Society of Digestive Endoscopy
Nan Ge, Shutian Zhang, Zhendong Jin, Siyu Sun, Aiming Yang, Bangmao Wang, Guiqi Wang, Guoqiang Xu, Jianyu Hao, Liang Zhong, Ning Zhong, Peng Li, Qi Zhu, Weidong Nian, Wen Li, Xiaofeng Zhang, Xiaoping Zhou, Xiujiang Yang, Yi Cui, Zhen Ding
March-April 2017, 6(2):75-82
DOI:10.4103/eus.eus_20_17  PMID:28440232
  2,097 548 7
New criteria to differentiate between mucinous cystic neoplasm and serous cystic neoplasm in pancreas by endoscopic ultrasound: A preliminarily confirmed outcome of 41 patients
Wengang Zhang, Enqiang Linghu, Ningli Chai, Huikai Li
March-April 2017, 6(2):116-122
DOI:10.4103/eus.eus_8_17  PMID:28440237
Background and Objectives: The ability to distinguish between mucinous cystic neoplasm (MCN) and serous cystic neoplasm (SCN) in the pancreas preoperatively by endoscopic ultrasound (EUS) remains a clinical challenge. To address this problem, we have developed new criteria using EUS findings and cyst fluid carcinoembryonic antigen (CEA) in the clinic. In this study, the validity and reliability of these criteria were assessed. Materials and Methods: Between April of 2015 and May of 2016, a total of 59 patients with pancreatic cystic neoplasms underwent EUS and ultimately received surgery in our hospital. Of the 59 patients, 21 were pathologically verified to have MCN while 20 were verified to have SCN in the pancreas. For these 41 patients with MCN or SCN, EUS findings and cyst fluid CEA were reviewed. Results: For the 41 patients reviewed, the new criteria were found to identify MCN with 85.71% sensitivity (95% confidence interval [CI], 64%–97%), 80.00% specificity (CI, 56%-94%), and 82.93% accuracy (CI, 68%–93%). Conclusion: These new criteria were preliminarily found to produce excellent results, with 82.93% accuracy determined for the differential diagnosis between MCN and SCN by EUS. However, a further prospective study with a larger population must be carried out to fully assess these new criteria.
  2,099 394 2
“Clinical” cytology for endoscopists: A practical guide
Michael Hocke, Theodoros Topalidis, Barbara Braden, Christoph F Dietrich
March-April 2017, 6(2):83-89
DOI:10.4103/eus.eus_21_17  PMID:28440233
Clinical cytology was originally used by clinicians to provide rapid diagnosis. However, with advancing medical subspecialization, few clinicians interpret cytology themselves these days, for example, gynecologists, hematologists, urologists, and occasional gastroenterologist (mainly in Asian countries). Cytological assessment enjoyed a renaissance with the development of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). Subsequently, pathologists, most of them more experienced in histology, had to take over. Recently, it has been shown that in-room cytology can be easily performed by the endoscopist themselves for initial evaluation of the quality of the EUS-FNA specimen and an initial diagnosis distinguishing benign or malignant cells. Bringing cytology back to the clinician has some advantages but does not substitute the professional cytopathologist. This report has written to lower the threshold for the clinician to find his way back to the microscope, which may improve both their diagnostic yield and assessment of EUS-FNA sample quality.
  1,764 400 -
The effect of solid pancreatic mass lesions on pancreatic duct diameter at endoscopic ultrasound
Anand C Baxi, Qingwei Jiang, Jinghua Hao, Zhuo Yang, Kevin Woods, Steven Keilin, Field F Willingham, Qiang Cai
March-April 2017, 6(2):103-108
DOI:10.4103/2303-9027.204812  PMID:28440235
Objectives: To evaluate the effect of solid pancreatic masses on the pancreatic duct (PD) at the endoscopic ultrasound (EUS) and the relationship of the location/size of a mass and PD dilation. Materials and Methods: Patients who underwent EUS for pancreatic indications from 2011 to 2013 at a single center were retrospectively identified. Those with biopsies that revealed adenocarcinoma or neuroendocrine tumors in the pancreas were identified and PD size was ascertained from EUS, computed tomography, or magnetic resonance imaging. Results: Of the 475 patients who had a pancreatic EUS, 239 had a dilated PD and 236 had a normal PD. Patients with a dilated PD had a significantly higher incidence of pancreatic malignancy than those with a normal PD diameter (106/239, 44.4% vs. 32/236, 13.6%, P< 0.001). Of the 138 patients with a pancreatic malignancy, 106 (76.8%) had a dilated PD at some location in the pancreas. Over 80% of patients with a mass within the head, neck, or body had a dilated PD. For a mass located at the uncinate process or the tail, PD dilation was 65% and 23%, respectively. Fifty-six (80.0%) of the masses in the head, 11 (78.6%) masses in the neck, and 16 (76.2%) masses in the body had a dilated PD upstream of the mass. In addition, a step-wise increase in the incidence of PD dilation was correlated with an increase in mass size. About 67.6% of patients with masses measuring in the 1st quartile had dilated a PD, while 77.8%, 91.0%, and 71.4% of those with masses measuring in the 2nd, 3rd, and 4th quartiles, respectively, had a dilated PD. Conclusion: PD dilation is a warning sign for pancreatic malignancies, however, small masses or masses at the uncinate process or the tail of the pancreas may not affect the size of the PD.
  1,859 241 3
Endoscopic ultrasound-guided fine-needle aspiration can target right liver mass
Dongwook Oh, Dong-Wan Seo, Seung-Mo Hong, Tae Jun Song, Do Hyun Park, Sang Soo Lee, Sung Koo Lee, Myung-Hwan Kim
March-April 2017, 6(2):109-115
DOI:10.4103/2303-9027.204813  PMID:28440236
Background and Objectives: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been established as a safe and accurate method for diagnosing and staging intra-abdominal mass. However, few studies investigated its feasibility, efficacy, and safety for targeting liver mass. We evaluated the efficacy and safety of EUS-FNA in patients with liver masses including the right lobe. Patients and Methods: The technical feasibility, safety, and diagnostic yield were determined in 47 patients (30 in the left lobe and 17 in the right lobe) presenting with liver masses between September 2010 and February 2016. Results: Thirty-eight patients (80.9%) had malignancies whereas nine patients (19.1%) had benign liver masses. Technical success rate was 97.9% (46/47). EUS-FNA was diagnostic in 38 of 42 patients (90.5%). When the outcomes of EUS-FNA between right liver mass and left mass were accessed, the technical success rates were similar in both lobes (100% vs. 94.1%, P= 0.2). The median tumor size on EUS (25.5 mm, interquartile range [IQR] 13.8–30.3 vs. 28 mm, IQR 18.5–43.5, P= 0.24) and number of needle passes (3, IQR 3–4 vs. 3, IQR 3–3, P= 0.24) were not significantly different. Adequate specimen obtained was statistically higher in the left lobe (28/30, 93.3% vs. 14/17, 82.4%, P= 0.04). However, diagnostic accuracy for liver masses was not different (25/28, 89.3% vs. 13/14, 92.9%, P= 0.86). No complications developed after procedure. Conclusions: EUS-FNA can be a safe and efficient method for the diagnosis of liver mass and it is technically feasible even for those in the right lobe.
  1,417 288 8
Feasibility, safety, and outcomes of a single-step endoscopic ultrasonography-guided drainage of pancreatic fluid collections without fluoroscopy using a novel electrocautery-enhanced lumen-apposing, self-expanding metal stent
Joseph Yoo, Linda Yan, Raza Hasan, Saana Somalya, Jose Nieto, Ali A Siddiqui
March-April 2017, 6(2):131-135
DOI:10.4103/2303-9027.204814  PMID:28440239
Background and Objectives: There are currently limited data available regarding the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) using the lumen-apposing metal stent without fluoroscopic guidance. This study aims to evaluate clinical outcomes and safety of EUS-guided drainage of PFC using the electrocautery-enhanced lumen-apposing metal stents (EC-LAMSs) without fluoroscopic guidance. Methods: We conducted a retrospective study on patients with symptomatic PFC who underwent EUS-guided drainage using EC-LAMS without fluoroscopy. All patients were followed clinically until resolution of their PFC. Technical success (successful placement of EC-LAMS), number of patients who achieved complete resolution of PFC without additional intervention and adverse events were noted. Results: We evaluated 25 patients, including three with pancreatic pseudocysts and 22 with walled-off necrosis (WON). The etiology of the patient's pancreatitis was gallstones (42%), alcohol (27%), and other causes (31%). The mean cyst size was 82 mm (range, 60–170 mm). The indications for endoscopic drainage were abdominal pain, infected WON, or gastric outlet obstruction. Technical success with placement of the EC-LAMS was achieved in all 25 patients. There were no procedure-related complications. The mean patient follow-up was 7.8 months. PFCs resolved in 24 (96%) patients; the one failure was in a patient with WON. Stent occlusion was seen in one patient. There was a spontaneous migration of one stent into the enteral lumen after resolution of WONs. The EC-LAMS were successfully removed using a snare in all the remaining patients. The median number of endoscopy sessions to achieve PFCs resolution was 2 (range, 2–6). Conclusions: Single-step EUS-guided drainage of PFCs without fluoroscopic guidance using the novel EC-LAMS is a safe and effective endoscopic technique for drainage of PFCs with excellent technical and clinical success rates and no complications. Due to its ease of use, EC-LAMS may simplify and streamline EUS-guided management of PFC and help in its widespread adoption as an alternative to surgery.
  1,327 271 11
Cystic pancreatic lymphangioma diagnosed with endoscopic ultrasound-guided fine needle aspiration
Ikram Hussain, Tiing Leong Ang
March-April 2017, 6(2):136-139
DOI:10.4103/2303-9027.204807  PMID:28440240
Pancreatic lymphangiomas are rare, but benign neoplasms. Historically, the diagnoses in various case reports were mostly made after surgical resection. There are emerging data concerning the utility of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to differentiate it from more sinister pancreatic cystic neoplasms. A confident preoperative diagnosis with EUS-FNA is crucial to avoid unnecessary workup or surgery, especially for small and asymptomatic lesions. Here, we present a rare case of asymptomatic pancreatic lymphangioma which was diagnosed with EUS-FNA. The case highlights that a preoperative diagnosis of pancreatic lymphangioma can be made with certainty.
  1,229 160 4
Thermal ablation of pancreatic cyst with a prototype endoscopic ultrasound capable radiofrequency needle device: A pilot feasibility study
Maria Moris, Mustafa Atar, Abdurrahman Kadayifci, Murli Krishna, Ariston Librero, Eugene Richie, William Brugge, Michael B Wallace
March-April 2017, 6(2):123-130
DOI:10.4103/eus.eus_6_17  PMID:28440238
Background and Objectives: Pancreatic cysts are evaluated by endoscopic ultrasound and fine needle aspiration (EUS). The only accepted treatment is pancreatectomy, which is associated with morbidity and mortality. This study evaluated the optimal thermal dosimetry of a novel radiofrequency ablation device using a standard electrosurgical unit in ex vivo cyst models. Methods: A modified EUS 22-gauge monopolar needle prototype with a tip electrode connected to a standard electrosurgical unit (Erbe USA, Marietta, GA, USA) was used to induce a subboiling point temperature. A cyst model was created using 2-cm sections of porcine small intestine ligated and filled with saline. After ablation, the cyst models were prepared for pathological evaluation. The epithelial layers were measured in at least two different sites with a micrometer and compared with the corresponding control sample. Results: Thirty-two cyst models were ablated with maximum temperatures of 50°C, 60°C, 90°C, and 97°C in 8, 11, 11, and 2 cysts, respectively. Longer ablation times were required to induce higher temperatures. A trend in the reduction in thickness of the measured layers was observed after exposure to higher temperatures. A temperature over 50°C was required for the ablation of the muscularis, submucosa, and villi, and over 60°C was required to ablate the mucosal crypts. Conclusions: In a preclinical model, a novel radiofrequency EUS-capable needle connected to a standard electrosurgical unit using standard low-voltage coagulation provided ablation in a temperature-dependent fashion with a threshold of at least 60°C and a safe cyst margin below 97°C. This potentially will allow low-cost, convenient cyst ablation.
  1,142 221 2
Esophageal adenocarcinoma metastasis in the left adrenal gland diagnosed by endoscopic ultrasound-guided fine needle aspiration
Everton Hadlich, Augusto P. C Carbonari, Maurício S Assef, Osvaldo M Araki, Frank S Nakao, Mauro T. A Saieg, Lúcio G. B Rossini
March-April 2017, 6(2):142-144
DOI:10.4103/2303-9027.204809  PMID:28440242
  1,125 118 -
Endoscopic ultrasound-guided choledochoduodenostomy for obstructive jaundice with venous collaterals around the bile duct wall (with video)
Takeshi Ogura, Saori Onda, Wataru Takagi, Toshihisa Takeuchi, Shinya Fukunishi, Kazuhide Higuchi
March-April 2017, 6(2):140-141
DOI:10.4103/2303-9027.204811  PMID:28440241
  929 182 -
A case of biliary fascioliasis mimicking a common bile duct tumor (with video)
Hyung Ku Chon, Tae Hyeon Kim
March-April 2017, 6(2):145-146
DOI:10.4103/eus.eus_5_17  PMID:28440243
  968 128 3