Annette Fritscher-Ravens

EUS-Guided Fine-Needle Aspiration of Suspected Hilar Cholangiocarcinoma in Potentially Operable Patients with Negative Brush Cytology

BACKGROUND:Despite improvements of diagnostic modalities differentiation between benign and malignant hilar strictures remains a challenge. Hilar neoplasia requires preoperative tissue diagnosis to avoid risk of inappropriate extensive surgery. This is commonly attempted using various techniques at ERCP, which have variable sensitivity and accuracy. We used endosonography-guided fine-needle aspiration (EUS-FNA) for the preoperative diagnosis of hilar cholangiocarcinoma (HC).METHODS:Prospective evaluation of 44 patients (31 male, mean age: 59 yr) with strictures at the liver hilum were diagnosed by CT and/or ERCP. All were suspicious of HC but had inconclusive tissue diagnosis. They underwent EUS-FNA with linear echo endoscope and 22 gauge needles.RESULTS:Adequate material was obtained in 43 of 44 patients. Cytology revealed HC in 26 and other malignancies in 5 patients; 12 had benign results: sclerosing cholangitis (n = 4), primary sclerosing cholangitis (n = 4), inflammation (n = 3), sarcoid-like lesion (n = 1). There were no significant differences in age, lesion size, or echo features among patients with adenocarcinomas, other malignancies, or benign lesions. Thirty-two patients underwent surgery, 2 had autopsy, 10 were followed up clinically. Four of the benign results were false negatives. No complications occurred. Accuracy, sensitivity, and specificity were 91%, 89%, and 100%, respectively. EUS and EUS-FNA changed preplanned surgical approach in 27 of 44 patients.CONCLUSION:These results suggest that EUS-FNA is of value as a new, less-invasive approach for tissue diagnosis of hilar strictures of unknown cause. It was technically feasible without significant risks, when other diagnostic tests were inconclusive and was able to change preplanned management in about half of the patients.

Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model

BACKGROUNDnEndoluminal operations for gastroesophageal reflux currently are limited by the inability to visualize and manipulate structures outside the wall of the gut. This may be possible by using EUS. The aims of this study were the following: to define the EUS anatomy of structures outside the gut that influence reflux, to place stitches in the median arcuate ligament, to perform posterior gastropexy, and to test the feasibility of crural repair under EUS control in pigs.nnnMETHODSnIn survival experiments in 22 pigs, by using a linear-array echoendoscope, the median arcuate ligament and part of the right crus were identified and punctured with a needle, which served as a carrier for a tag and thread. These were anchored into the muscle. An endoscopic sewing device was used, allowing stitches to be placed through a 2.8-mm accessory channel to any predetermined depth. New methods allowed knot tying and thread cutting through the 2.8-mm channel of the echoendoscope.nnnRESULTSnStitches were placed through the gastric wall into the median arcuate ligament, and one stitch was placed just beyond the wall of the lower esophageal sphincter. The stitches were tied together and locked against the gastric wall. Median lower esophageal sphincter pressure, determined manometrically, was 11 mm Hg before surgery and 21 mm Hg after stitch placement (p=0.0002). The length of the lower esophageal sphincter increased from a median of 2.8 cm before the procedure to 3.5 cm after the procedure. At the postmortem, the median force required to pull the tags out of the median arcuate ligament was 2.8 kg.nnnCONCLUSIONSnThis study demonstrates that transgastric gastroesophageal reflux surgery, by using stitching under EUS control, can significantly increase lower esophageal sphincter pressure in pigs.

The wireless capsule: new light in the darkness.

The development of wireless capsule endoscopy offers the potential to examine the whole small intestine, with its 5-meter length, and has the advantage of being painless. Using a miniature CMOS camera and a short focal length lens, images are obtained, as the optical window of the capsule sweeps past the gut wall, without requiring air inflation of the gut lumen. The capsule endoscope is propelled by peristalsis through the gastrointestinal tract. The video images are transmitted using radiotelemetry to an array of aerials attached to the body which allows image capture. The images are stored on a small portable recorder carried on a belt and subsequently downloaded for analysis. The system allows more than 7 h of continuous recording of images of the gastrointestinal tract. The patients are free to continue their daily routine during the examination. The capsule endoscope has performed well in trials in patients with difficult gastrointestinal bleeding and in comparative studies with push enteroscopy. It has received both a CE mark and FDA approval for use in patients. It has been used to date in about 4,000 patients. The current clinical data are reviewed.

Endoscopic ultrasound evaluation in the diagnosis and staging of lung cancer.

The detection of mediastinal lymph node metastases in patients with lung cancer is most important. These nodes may be used for tissue diagnosis of the malignancy, if sampling techniques of the primary have failed. Their presence implies a stage III disease and may exclude a patient from surgery. CT is the standard imaging, but is relatively poor at staging the mediastinum (overall sensitivity: 50-70%), and is especially unreliable for lesions <1 cm. PET is a new physiological imaging technique, which seems to be superior to CT (sensitivity: 67-100%). Transesophageal EUS delivers high resolution imaging, offers the advantage of simultaneous tissue sampling (EUS-FNA sensitivity: 84-94%), but is limited to the posterior mediastinum. This review compares the diagnostic value of CT, PET and EUS as well as the different tissue sampling methods for mediastinal metastases with EUS-FNA. The technique of EUS and FNA is described, and a special interest is taken to stress out the different areas of the mediastinum accessible for each of the tissue sampling methods as well as the pros and cons for its use. Advantages and disadvantages of EUS-FNA are shown and the new efforts described to improve the outcome of EUS-FNA by adding molecular methods for the detection of micrometastases.

Endoscopic ultrasound–guided biopsy for the diagnosis of focal lesions of the spleen

OBJECTIVES:Needle biopsy of splenic lesions using computed tomography (CT) or ultrasound (US) is difficult if the size of the lesion is small. It may be dangerous if the lesion is adjacent to the splenic hilum or located peripherally. We used endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) to elucidate the tissue diagnosis of splenic abnormalities.METHODS:EUS-FNA was performed in 12 patients when US- or CT-guided biopsy was inconclusive (n = 5), was not attempted because of small tumor size (0.9–1.4 cm; n = 4), or was considered dangerous (n = 3). A linear echo-endoscope and 22-gauge needles were used for cytology and bacteriology.RESULTS:The age of the patients was 19–68 yr (median 32 yr). Seven patients were male and five female. The size of the lesions was 0.8–4.2 cm (median 1.4 cm). Cytology was inadequate in one patient. Bacteriology was positive for Staphylococcus aureus and Serratia in one patient each, and cultures were positive for Mycobacterium tuberculosis in two patients. A positive diagnosis was made in 10 of 12 patients (83%). Final diagnoses were tuberculosis in two patients, Hodgkins disease in two, sarcoidosis in two, abscesses in two, metastatic colon cancer in one, and infarction in one. Suspected recurrence of non-Hodgkins lymphoma was not confirmed in one case. One patient experienced pain after puncture, but no hematoma was demonstrated on subsequent US examination.CONCLUSIONS:EUS-FNA cytodiagnosis in patients with unknown splenic lesions seems feasible, even in very small foci, when CT- or US-guided biopsy fails. Additional material for bacteriology may show benign treatable diseases such as abscesses or tuberculosis.