Sarto C. Paquin

A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma

Tumor seeding along a needle tract is an established complication of percutaneous sampling of pancreatic masses under CT or transcutaneous US guidance. The risk of peritoneal carcinomatosis appears to be lower with EUS-guided FNA (EUS-FNA) compared with transcutaneous sampling methods. This is a potential advantage often cited for EUS-FNA because, to date, there is no case reported of tumor seeding from a pancreatic adenocarcinoma secondary to EUS-FNA. This report describes a case of apparent gastric-wall tumor seeding that occurred during EUS-FNA of a mass in the tail of the pancreas.

Randomized, Double-Blind, Controlled Trial of Early Endoscopic Ultrasound–Guided Celiac Plexus Neurolysis to Prevent Pain Progression in Patients With Newly Diagnosed, Painful, Inoperable Pancreatic Cancer

PURPOSE Celiac plexus neurolysis (CPN) is currently used as salvage therapy for morphine-resistant pancreatic cancer pain. Endoscopic ultrasound-guided CPN (EUS-CPN) can be performed early, at the time of EUS. We hypothesized that early EUS-CPN would reduce pain and morphine consumption, increase quality of life (QOL), and prolong survival. PATIENTS AND METHODS Patients were eligible if referred for EUS for suspected pancreatic cancer with related pain. If EUS and EUS-guided fine-needle aspiration cytology confirmed inoperable adenocarcinoma, patients were randomly assigned to early EUS-CPN or conventional pain management. Pain scores (7-point Likert scale), morphine equivalent consumption, and QOL scores (Digestive Disease Questionnaire-15) were assessed at 1 and 3 months. RESULTS Five hundred eighty eligible patients were seen between April 2006 and December 2008. Ninety-six patients were randomly assigned (48 patients per study arm). Pain relief was greater in the EUS-CPN group at 1 month and significantly greater at 3 months (difference in mean percent change in pain score = -28.9 [95% CI, -67.0 to 2.8], P = .09, and -60.7 [95% CI, -86.6 to -25.5], P = .01, respectively). Morphine consumption was similar in both groups at 1 month (difference in mean change in morphine consumption = -1.0 [95% CI, -47.7 to 49.2], P = .99), but tended toward lower consumption at 3 months in the neurolysis group (difference in mean change in morphine consumption = -49.5 [95% CI, -127.5 to 7.0], P = .10). There was no effect on QOL or survival. CONCLUSION Early EUS-CPN reduces pain and may moderate morphine consumption in patients with painful, inoperable pancreatic adenocarcinoma. EUS-CPN can be considered in all such patients at the time of diagnostic and staging EUS.

Central vs. Bilateral Endoscopic Ultrasound-Guided Celiac Plexus Block or Neurolysis: A Comparative Study of Short-Term Effectiveness

OBJECTIVES:Endoscopic ultrasound (EUS)-guided celiac plexus block/neurolysis (CPB/N) can be performed by injecting at the base (central) or on either side (bilateral) of the celiac axis. Central CPB/N is easier and possibly safer. Bilateral CPB/N is more difficult but may be more effective as it reaches more ganglia. The aim of this study was to compare the short-term safety and efficacy of central and bilateral CPB/N.METHODS:Consecutive patients referred for CPB/N to a quaternary EUS center were eligible for this study. Central CPB/N was used in the first half of the study period and bilateral CPB/N in the last half. The primary outcome was the percent reduction in visual analog pain scores at day 7.RESULTS:A total of 184 patients were eligible. Out of them, 24 (13%) were excluded for incomplete data. A total of 160 were left (71 central, 89 bilateral). The groups were similar for all cogent variables. Bilateral CPB/N was more effective than central CPB/N (mean percent pain reduction 70.4% (61.0–80.0) vs. 45.9% (32.7–57.4); P=0.0016). The only predictor of a>50% pain reduction was bilateral CPB/N (odds ratio 3.55, 1.72–7.34). Only one complication was noted: self-limited bleeding because of laceration of the adrenal artery following bilateral celiac plexus (CP) block in an anticoagulated patient.CONCLUSIONS:(i) Bilateral CPB/N is more effective than central CPB/N; (ii) bilateral CPB/N is safe, but on rare occasions can cause trauma to the left adrenal artery; it should therefore be avoided in patients with a bleeding diathesis.

Comparison of endoscopic ultrasonography‐guided fine‐needle aspiration cytology results with and without the stylet in 3364 cases

Endoscopic ultrasound‐guided fine‐needle aspiration cytology (EUS‐FNA) is traditionally carried out with the stylet, as it is believed to prevent blockage or contamination of the needle by tissue coming from the gastrointestinal wall. However, this recommendation has not been demonstrated on an empirical basis. The aim of the present study was to compare the yield of EUS‐FNA in a very large series of patients with (S+) and without (S–) the stylet.

Randomized controlled trial comparing stylet‐free endoscopic ultrasound‐guided fine‐needle aspiration with 22‐G and 25‐G needles

Previous studies comparing endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) results with different gauge needles have all been carried out with the stylet in place and show no clear advantage to the larger 22‐G needle. Similar data for stylet‐free EUS‐FNA (SF‐EUS‐FNA) are unavailable. The aim of the present study was to determine whether diagnostic yield and specimen adequacy is superior with the 22‐G needle as compared to the 25‐G needle.

Endoscopic ultrasound-guided fine needle aspiration cytology and biopsy in the evaluation of lymphoma.

Accurate diagnosis and subtyping of lymphoma have important prognostic implications and are generally required for treatment planning. Histological assessment, immunophenotyping, and genetic studies are usually necessary. Endoscopic ultrasound guided-fine needle aspiration cytology (EUS-FNAC) is a minimally invasive technique widely used for the evaluation of deep-seated benign and malignant lesions. However, the value of cytological samples in lymphoma diagnosis is still a matter of debate. Endoscopic ultrasound guided-fine needle biopsy (EUS-FNAB) can provide tissue core samples that may help overcome the limitations of cytology. The aim of this review is to summarize the available literature regarding EUS-FNAC and EUS-FNAB for the diagnosis and subtyping of lymphoma. In addition, we discuss its usefulness in the management of primary extra-nodal lymphomas, as well as technical issues that may influence sample quality.

Usefulness of endoscopic ultrasonography in hepatology

Endoscopic ultrasonography (EUS) is used to evaluate patients with hepatobiliary diseases. The technique is useful for the diagnosis of esogastric varices in selected cases of portal hypertension, and to evaluate the pathogenic role and prognostic value of the collateral circulation in patients with this condition. When coupled with the Doppler technique, EUS can be used to guide injection sclerotherapy and to verify the obliteration of varices (particularly fundal varices) after endoscopic treatment. Hemodynamic changes induced in the collateral circulation by vasoactive drugs can also be measured with Doppler-EUS. Fine-needle aspiration under EUS guidance is useful in the diagnosis of focal liver lesions and perihepatic adenopathy, and in the evaluation of biliary tract diseases. New indications can be developed in the future after adequate experimental validation.

Credentialing for endoscopic ultrasound: A proposal for Canadian guidelines.

Wang et al. evaluated EUS trainees’ evolution prospectively. Compared with pretraining, the proportion of trainees who succeeded in locating each structure after the training were, respectively, celiac axis (36% vs. 80.5%), pancreatic body and tail (51.5% vs. 80.5%), splenic vein and artery (48.5% vs. 84%), left kidney (60% vs. 83%), and spleen (47% vs. 83%). They concluded that a structured training program signifi cantly improved the successful localization of structures.[3]

In Patients Referred for Investigation Because Computed Tomography Suggests Thickened Gastric Folds, Endoscopic Ultrasound Is Superfluous If Gastroscopy Is Normal

BACKGROUND AND OBJECTIVE: Endoscopic ultrasound (EUS) is often requested in patients in whom computed tomography (CT) shows gastric wall thickening. It is unclear if EUS is useful if upper endoscopy is normal. The aim of this study was to prospectively compare the yield of upper endoscopy and EUS for this indication.METHODS:All patients referred for endoscopic ultrasound because of thickened gastric folds on CT from May 2001 and June 2003 were included. A single physician, questioned, examined, and performed upper endoscopy followed by EUS in all patients. Data were recorded prospectively. The main outcome measures were: upper endoscopy and EUS findings and predictors of abnormal EUS.RESULTS:Sixty-nine patients were enrolled. The average age was 57.9, 49% were male, 51% were asymptomatic, 57% had normal upper endoscopy, and 70% had normal EUS. If upper endoscopy was abnormal, EUS was abnormal in 70% of cases (95% CI 62%–78%). If upper endoscopy was normal, the EUS was normal in 100% of cases (95% CI 92%–100%). Multivariate analysis revealed that neither age, gender, presence of abdominal symptoms nor alarm symptoms predicted abnormal EUS.CONCLUSIONS:When CT shows gastric wall thickening: (a) Nnormal upper endoscopy is strongly associated with normal EUS; (b) abnormal upper endoscopy is associated with abnormal EUS in 70% of cases; (c) clinical variables such as age, sex, and the presence of symptoms do not predict or increase the likelihood of abnormal EUS. Therefore, in patients with thickened gastric wall on CT, upper endoscopy should be used to select patients for EUS.

Training in endoscopic ultrasound-guided fine needle aspiration.

Like any other technique, fine needle aspiration (FNA) proficiency requires adequate experience. Although this technique is not difficult to master, formal training will allow endosonographers to achieve better results. The following article is derived in two parts: (1) To review current knowledge on endoscopic ultrasound (EUS)-FNA training, discuss the current recommendations on training guidelines, explore other training adjuncts and review the latest studies evaluating the validity of current recommendations; and (2) to provide some basic grounds on the EUS-FNA technique. EUS-FNA can be broken down into a series of steps. Proper execution of each step will make FNA easier and likely increase its diagnostic yield. Adequate positioning of the lesion in regards to the ultrasound probe is a key factor to obtain best results. The following will discuss useful tips in order to achieve maximal success rates.