Marta Serrani

Contrast Harmonic-Endoscopic Ultrasound Is Useful to Identify Neoplastic Features of Pancreatic Cysts (With Videos).

Objectives To evaluate the potential role of contrast harmonic endoscopic ultrasound (CH-EUS) in the differential diagnosis of pancreatic cysts and detection of malignancy. Methods Patients who underwent CH-EUS for evaluation of cyst wall, septae, and solid components of pancreatic cysts were included. The findings were compared to fine needle aspiration and surgery. Results Seventy-six patients were included. Serous and mucinous cysts were both hyperenhanced (86% and 89%, respectively; P = ns), whereas pseudocysts were hypoenhanced in 90% of the cases (P = 0.000004 vs serous cysts and P = 0.000005 vs mucinous cysts). Patients showing hyperenhanced solid components were finally diagnosed with malignancy (2 malignant intraductal papillary mucinous neoplasms, 2 cystic neuroendocrine tumors), in contrast to the patients with nonenhanced solid components who resulted to have either benign cysts with internal mucus clots (n = 10) or pseudocysts with internal debris (n = 8). Conclusions CH-EUS allowed differentiation between pseudocysts and other pancreatic cysts but not mucinous versus serous cysts. Malignant vegetations inside pancreatic cystic lesions were clearly shown by CH-EUS as solid components with features of hyperenhancement, directing EUS-fine needle aspiration of potential neoplastic areas and avoiding puncture of debris and mucus plugs.

Contrast harmonic endoscopic ultrasonography in the characterization of pancreatic metastases (with video).

Objective The differential diagnosis between primary pancreatic neoplasms versus pancreatic metastases (PM) is challenging. Endoscopic ultrasonography with fine-needle aspiration can be used to differentiate primary versus metastatic tumors although with a suboptimal accuracy. Recently, contrast harmonic EUS (CH-EUS) has been reported as an adjunct in the diagnosis of pancreatic neoplasms. We evaluated the potential role of CH-EUS in the differential diagnosis of PM. Methods This study is a retrospective analysis of a prospectively maintained database. Of the 266 patients, 4.1% were diagnosed with PM. Endoscopic ultrasonography with fine-needle aspiration and/or surgical pathology represented our criterion standard. Results The origins of PM were renal cancer (3 patients), colon cancer (2 patients), breast cancer (2 patients), ovarian cancer (1 patient), melanoma (1 patient), lymphoma (1 patient), and sarcoma (1 patient). All lesions appeared hypoechoic at standard EUS. At CH-EUS, of the 11 lesions, 6 appeared hypoenhancing (colon cancer, sarcoma, and breast and ovarian cancer), 4 were hyperenhancing (renal cancer and lymphoma), and 1 was isoenhancing (melanoma). Conclusions In our population, standard EUS features of PM were unremarkable. At CH-EUS, most of the PM appeared hypoenhancing suggesting a possible malignant origin. However, a subset of PM showed hyperenhancing pattern. In the appropriate context, particularly when cancer history is present, CH-EUS may add to the differential diagnosis and potentially spare endoscopic ultrasonography with fine-needle aspiration.

Performance of the forward-view echoendoscope for pancreaticobiliary examination in patients with status post-upper gastrointestinal surgery

Background and Objectives: Failures of endoscopic ultrasound (EUS) imaging of the head of the pancreas (HOP) and the common bile duct (CBD) have been reported in up to 50% of patients with status postsurgery (e.g., Billroth II and Roux-en-Y). This is attributable to inability to intubate the afferent limb or the duodenum. Recently, a forward-view (FV) echoendoscope has become available. The frontal endoscopic and ultrasound field of view theoretically allow easier manipulation throughout the gastrointestinal tract compared to the traditional echoendoscopes. The aim of our study was to evaluate the safety and performance of the FV echoendoscope for the investigation of the biliary tree and the pancreas, including fine-needle aspiration (FNA), in patients with surgically altered upper gastrointestinal anatomy. Patients and Methods: This was a retrospective evaluation of a prospectively maintained database. All EUS procedures were performed at our institution by one experienced endosonographer from March to September 2009 under conscious sedation. The FV echoendoscope was used for all procedures. Results: Twenty-five (25) out of 37 presented status post-Billroth II and 12 out of 37 with status post-Roux-en-Y surgery. Overall, HOP and CBD were adequately visualized in 28 out of 37 (75.7%). All the failures occurred in the Roux-en-Y patients. EUS-FNA was successfully performed in 16 patients. No adverse events were observed. Conclusions: The FV echoendoscope proved to be safe and effective in reaching the periampullary area in patients with previous Billroth II, allowing complete exploration of the HOP and the CBD and performance of EUS-FNA. However, FV EUS was unsuccessful in the majority of patients with Roux-en-Y, which still remains a challenging condition.

Role of contrast harmonic-endoscopic ultrasound in pancreatic cystic lesions

Incidental pancreatic cysts (PCs) are frequently encountered in the general population often in asymptomatic patients who undergo imaging tests to investigate unrelated conditions. The detection of a PC poses a significant clinical dilemma, as the differential diagnosis is quite broad ranging from benign to malignant conditions. Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) has been reported to be an accurate tool in the differential diagnosis; however, its sensitivity is suboptimal and false negative results do occur. Contrast harmonic EUS (CH-EUS) was demonstrated to be a useful tool to investigate pancreatic solid lesions to differentiate between benign and malignant ones. In the setting of PCs, CH-EUS could help identify areas of malignant growth inside the cystic cavities. Several studies have reported promising results showing malignant areas in PCs as hyperenhanced lesions. Confirmation of malignancy can then be obtained by FNA, which should be precisely targeted according to the findings of the contrast harmonic study.

Elective cholecystectomy after reversal of septic shock using multimodality endoscopic gallbladder drainage

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is considered an effective therapy for acute cholecystitis in patients who are unfit for surgery [1– 3]. We describe the case of a 90-year-old woman admitted for septic shock due to acute cholecystitis, who underwent EUS-GBD after being considered unfit for surgery because of advanced age and comorbidities (obesity, coronary heart disease) (▶Video1). Transgastric EUSGBD with a lumen-apposing metal stent (Hot-Axios, 10×10mm, Boston Scientific, Marlborough, Massachusetts, USA) was performed using a forward-view echoendoscope (TGF-UC180J; Olympus, Tokyo, Japan) after failure in identifying a safe window with a curvilinear-array echoendoscope [4]. Subsequently, the patient recovered and returned home after 1 week. However, she was readmitted after 2 weeks because of recurrence of cholangitis and severe sepsis. Computed tomography showed cholecystitis despite the stent still being in place. Almost complete stent occlusion due to tissue overgrowth was observed endoscopically. The gallbladder lumen contained a large amount of pus, which was drained using a nasobiliary tube, leading to a temporary clinical improvement. At multidisciplinary discussion, surgery was still contraindicated due to sepsis and hemodynamic instability, and therefore an endoscopic rescue strategy was planned. We placed a fully covered biliary metal stent over a guidewire through the obstructed Axios, achieving good biliary drainage [5]. Two months later, due to the persistence of biliary pain and ultrasound signs of mild cholecystitis, without systemic sepsis, the patient was considered suitable for elective cholecystectomy. Surgery was not impeded by the presence of the stents. In particular, disconnecting the gallbladder and suturing the gastric wall were undemanding. We speculate that the suboptimal clinical outcome of EUS-GBD in our patient might have been due to the greater distance between the gallbladder and the antrum, as opposed to the duodenum, leading to traction on the stent and subsequent tissue overgrowth. We showed that surgery could be an effective rescue strategy, even after failure of EUS-GBD.

EUS liver assessment using contrast agents and elastography

Transabdominal-US is the first-line imaging modality used to assess the whole liver parenchyma and vascularization; EUS assessment of the liver is incomplete and is not sufficient to rule out the presence of focal liver lesions. On the other hand, due the high diagnostic yield in detecting very small (< 1 cm) lesions, EUS is considered complementary to radiological imaging techniques for the investigation of liver parenchyma. Scarce data are available regarding the investigation of liver parenchyma using both EUS-elastography (EUS-E) and CH-EUS. The aim of this review is to evaluate the clinical role of image enhancement techniques, namely EUS-E and contrast harmonic-EUS (CH-EUS), for the evaluation liver diseases. Despite a potential interest for the application of EUS-E in the assessment of liver diseases, available evidence relegates this technique only to research areas, such as the differential diagnosis between benign and malignant focal liver lesions and the quantification of liver fibrosis in diffuse parenchymal diseases. With the future introduction of EUS shear-wave elastography, interesting data can be obtained for the assessment of liver fibrosis during real-time EUS evaluation. The usefulness of CH-EUS for the evaluation of liver disease is limited by the intrinsic EUS ability to explore only the left lobe and a small part of the right lobe. CH-EUS could be used to increase the diagnostic ability of EUS for the detection and characterization of small lesions and for guiding tissue sampling. Targeting EUS-guided treatments with either EUS-E or CH-EUS might represent potential future applications.

Basics in Endoscopic Ultrasound Part 2: EUS-guided sampling and therapeutic applications

BACKGROUND Endoscopic ultrasound (EUS) has been used in the clinical arena for almost 35 years and it is now well-integrated in everyday hospital practice. METHOD We conducted a systematic review of the available English-language articles. OBJECTIVE The purpose of this review is to summarize the relevant applications of operative EUS. RESULTS More than 5000 scientific papers published in the literature have demonstrated its high accuracy for the diagnosis and staging of a variety of benign and malignant conditions. The main indications of operative EUS, both diagnostic and therapeutic, are related to its ability to combine ultrasound imaging and safe and effective needle insertion into lesions originating from the gut wall and from organs nearby. In addition, technologic advancements of echoendoscopes with a therapeutic working-channel have allowed to perform several EUS-guided interventions, i.e. celiac plexus neurolysis, drainage of fluid collections, drainage of dilated biliary and pancreatic ducts, and vascular interventions.

Basics in Endoscopic Ultrasound Part 1: Diagnostic Indications and Tissue Sampling

BACKGROUND Endoscopic Ultrasound has been used in the clinical arena for almost 35 years and it is now well-integrated in everyday hospital practice. METHOD We conducted a systematic review of the available English-language articles. OBJECTIVE The purpose of this review is to summarize all the relevant indications to endoscopic ultrasound and analyze its relevant data in terms of accuracy and clinical outcomes. RESULTS More than 5000 scientific papers published in the literature have demonstrated its high accuracy for the diagnosis and staging of a variety of benign and malignant conditions. Staging indications include gastroesophageal and rectal cancers. Diagnostic, staging and therapeutic indications include diseases of the pancreaticobiliary area. Finally, differential diagnosis of submucosal tumors represents another important indication to this technique.