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Create a Free AccountProcedures - Endoscopic ultrasound (EUS) - diagnostic
Fluorescence confocal microscopy for rapid evaluation of EUS fine-needle biopsy in pancreatic solid lesions
Fluorescence confocal laser microscopy (FCM) allows imaging of tissues in the fresh state, with minimal preparation and without any damage, distortion, or loss of tissue.1-4 It requires a fluorescent dye applied to the unfixed tissue sample. Two lasers of different wavelengths create 2 distinct images: a fluorescence image and a reflectance image. The device’s software uses an algorithm to translate the acquired image information into colors that resemble hematoxylin and eosin. The pseudo-colored images contain similar information to conventional histology and can be examined at any magnification up to 550-fold (Fig. 1).EUS of a submucosal lesion at the appendiceal orifice using a double-balloon endoluminal intervention platform
The use of curved linear array (CLA) and radial EUS in the lower GI tract has largely been limited to the sigmoid colon and rectum, as their oblique optics present a challenge in advancement to the right side of the colon. While catheter-based miniprobes are available for endosonographic assessment of lesions in the right side of the colon, they are limited by the inability to perform fine-needle biopsies (FNBs). Recently, a double-balloon endoluminal intervention platform (DEIP) has become available to aid in EMR and endoscopic submucosal dissection.EUS-guided liver biopsy using a novel hydrostatic stylet technique
EUS-guided liver biopsy (EUS-LB) has become increasingly used for the diagnostic evaluation and staging of hepatic pathologies. Compared to alternatives such as percutaneous or transjugular liver biopsy, EUS-LB produces samples of similar or superior quality while offering additional advantages because of its minimally invasive nature, broader access to all hepatic lobes, and the ability to be performed simultaneously alongside other endoscopic procedures.1 Despite these advantages, EUS-LB is largely limited to tertiary care centers and its use is not yet widespread.Endoscopic full-thickness resection with retroperitoneal dissection for duodenal myogenic cyst with adjustable traction from an independently controlled snare
A 58-year-old man was coincidentally found to have a duodenal subepithelial lesion in the bulb. Endoscopic ultrasonography revealed a 20-mm anechoic lesion with suspicious echogenic content or a hypoechoic lesion from the muscular propria (Figs. 1 and 2; Video 1, available online at www.giejournal.org ). Computed tomography revealed a lesion close to the hepatic hilum (Fig. 3). After a multidisciplinary discussion with endoscopists and surgeons, we decided to perform endoscopic full-thickness resection (EFTR) of the lesion with acceptable risk.EUS–guided biopsy of an intraventricular mass in a patient with ventricular tachycardia
Endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) is a minimally invasive procedure commonly used for diagnostic purposes. Because of the accuracy and safety of EUS, both intraluminal and extraluminal lesions can be sampled. Traditional methods of cardiac biopsy, typically through an endovascular approach, are well established. However, few EUS-guided cardiac interventions have been published,1-3 as they are rarely performed. Potential risks for cardiac biopsy, regardless of modality, include hemorrhage, perforation, arrhythmia, and valvular damage.EUS-guided liver biopsy using a modified wet heparin suction technique
The field of endohepatology has been evolving recently with multiple studies describing the success and safety of EUS-guided liver biopsy (EUS-LB) in obtaining liver parenchymal tissue. Although the supporting evidence embracing the use of this technique is convincing, variabilities in techniques are still an ongoing field for research.1 There is no consensus on the type of needle, depth of needle insertion, number of passes and actuations, or suction technique.Purely endoscopic appendectomy
Surgical/laparoscopic appendectomy requires abdominal wall incisions/punctures that can subsequently cause hernias, pain, and delayed return to work and regular physical activity after surgical/laparoscopic removal of the appendix.1 Natural orifice transluminal endoscopic surgery interventions were often performed with laparoscopic assistance and required advancement of an endoscope into the peritoneal cavity through gastric or vaginal wall with increased risk of infection and abdominal adhesions.A novel and effective EUS training program that enables visualization of the learning curve: Educational Program of Kindai system (EPOK)
EUS is currently regarded as a tool that enables not only observation but also diagnosis and treatment. The basis of all EUS-related procedures is the EUS screening technique. However, it can be challenging for trainees to master the technique. Several studies have investigated training methods for EUS screening that are based on memorization of typical EUS images.1 Hands-on training also is considered useful.2-5 The American Society for Gastrointestinal Endoscopy guidelines suggest that at least 225 hands-on EUS procedures are required to achieve competency in biliopancreatic EUS.Endoscopic full-thickness resection of well-differentiated T2 neuroendocrine tumors in the duodenal bulb: a case series
Endoscopic therapies have moved to the forefront in the removal of small, well-differentiated duodenal neuroendocrine tumors (NETs). Classic procedures used to address small tumors, especially those less than 1 cm in diameter, are banding without resection, ligation endoscopic mucosal resection, or endoscopic submucosal dissection. Endoscopic full-thickness resection (EFTR) is a procedure developed recently that allows for sealing off of the tissue surrounding the tumor before full-thickness removal.Intrahepatic aneurysmal portosystemic venous shunt diagnosed on EUS
A 76-year-old woman presented to an outside hospital for evaluation of persistent headache for 2 weeks. On laboratory assessments, she was found to have elevated erythrocyte sedimentation rate. Biopsy from the temporal artery was negative for temporal arteritis. An abdominal CT scan was performed and demonstrated a 25- × 24-mm mass lesion in the left liver lobe with enhancement in the portal venous phase (Fig. 1). Liver enzymes and tumor markers were unremarkable. She was referred for EUS examination at our center for further evaluation of the liver lesion.Successful diagnosis and endoscopic submucosal dissection of a gastric gastrointestinal stromal tumor originating from the submucosal layer
A 77-year-old man was introduced to our institution because of a slow-growing gastric subepithelial tumor (SET). Esophagogastroduodenoscopy revealed an SET approximately 2 cm in size in the fundus of the stomach, which was covered with normal smooth mucosa (Fig. 1A). EUS using a 20-MHz miniature probe (UM-3R; Olympus, Tokyo, Japan) showed a uniform hypoechoic lesion, 21.4 mm in size, in the third layer of the stomach wall (Fig. 1B). The hypoechoic fourth layer was intact and could be observed below the tumor (Fig. 1C).Ampullary cyst with papillary orifice distal to bulge: Not always a choledochocele!
A 9-year-old girl presented with recurrent episodes of epigastric pain for the past 3 months. Investigations suggested recurrent acute pancreatitis with significantly elevated amylase and lipase levels on several occasions. Contrast-enhanced CT of the abdomen revealed a 3.1- × 1.8- × 3.9-cm thick-walled nonenhancing cystic lesion along the third part of the duodenum (Fig. 1). MRCP revealed a cyst communicating with the common biliopancreatic channel (Fig. 2). A side-viewing examination using a duodenoscope (Olympus TJF Q180V, Olympus Corp, Tokyo, Japan) revealed a smooth extrinsic bulge extending from the second to the third part of the duodenum on the medial wall.Autoimmune pancreatitis masquerading as pancreatic cancer
A 77-year-old man presented with a history of painless jaundice, loss of weight, and anorexia for 3 weeks. He had a significant history of atrial fibrillation on warfarin. His physical examination revealed icteric sclera. Murphy's sign was negative. Initial laboratory markers showed increased bilirubin (169 umol/L) with elevated Ca 19-9 (144 u/mL).Endoscopic ultrasound–guided liver biopsy: needle types and suction methods
Endoscopic ultrasound−guided liver biopsy (EUS-LB) is gaining traction among hepatologists and endosonographers. It is safe and effective at delivering excellent liver biopsy cores and can be time saving if another endoscopic procedure is required at the same time.1 Although the first EUS-guided biopsy of a liver lesion was described in 1997, EUS-LB for routine assessment of elevated liver biochemistries or evidence of cirrhosis was later reported in 2008.2,3 There is no clear consensus on the optimal tools and techniques used in EUS-LB.EUS-guided blood patch delivery during liver biopsy: nature’s gel foam
EUS-guided liver biopsy is emerging as an alternative form of tissue acquisition to percutaneous or interventional radiology–guided liver biopsy. Recent studies have shown adequate specimen acquisition and an enhanced safety profile. EUS-guided liver biopsy has been found to be extremely safe. The most common adverse events are mainly due to bleeding events. Unfortunately, there are limited endoscopic interventions available to prevent bleeding during liver biopsy.Management of a postoperative fistula after pancreatic left resection using percutaneous endoscopy-assisted transpapillary pancreatic duct drainage via its stump
Postoperative pancreatic fistula is a potential adverse event after pancreatic resection. Pancreatic duct drainage (endoscopic, percutaneous) is a therapeutic option.1-11 We describe a new approach via percutaneous endoscopy.Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy
Endoscopic papillectomy is an alternative to surgery for tumors of the ampulla of Vater. Adverse effects of the procedure, however, include pancreatitis, bleeding, and papillary stenosis, as well as occasional perforations,1 which are sometimes challenging to treat endoscopically. A novel endoscopic closure device, the Over-the-Scope Clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) System, has increased the ability of the therapeutic endoscopist to close gastrointestinal luminal defects and treat gastrointestinal bleeding.Postfundoplication submucosal prolapse syndrome
Surgical fundoplication is an established treatment for refractory symptomatic esophageal hiatal hernia. Dysphagia after surgery is not uncommon.1-5 Different etiologies include fundoplication hiatal stenosis, twisted and/or slipped fundoplication, and paraesophageal herniation. We report and describe a previously unrecognized pathology called postfundoplication submucosal prolapse syndrome (PFSPS); we coined this term based on the imaging and pathological findings.Leiomyomatosis masquerading as sigmoid achalasia: a rare occurrence
A 34-year-old man presented with an 8-year history of dysphagia to solids and regurgitation. Evaluation by using timed barium swallow and esophageal manometry suggested a diagnosis of type I achalasia with a sigmoid configuration of the esophagus (Fig. 1). Gastroscopy revealed a dilated and tortuous esophagus with no significant resistance at the gastroesophageal junction. Peroral endoscopic myotomy was performed in this case via the posterior route (5 o’clock) using the standard technique.EUS diagnosis of asymptomatic type III choledochal cyst
Choledochal cysts occur in approximately 0.007% of live births in the United States, compared with 0.1% in Asia.1-3 There are 6 types of choledochal cysts, with type I being the most common (Fig. 1). A type III cyst, accounting for 1% to 5% of biliary cysts, involves dilation of the intraduodenal part of the distal common bile duct; these cysts are further subclassified into type IIIA, in which both the bile and pancreatic ducts terminate in the cyst, and type IIIB, in which an intra-ampullary or intraduodenal diverticulum is formed.EUS diagnosis of rectal endometriosis
Endometriosis usually occurs in women of childbearing age. Deep pelvic endometriosis can infiltrate the intestinal wall, with up to 93% of reported cases involving the rectum and sigmoid colon.1,2 Patients may be asymptomatic or may present with dysmenorrhea, hematochezia, lower abdominal pain, constipation, diarrhea, tenesmus, and even bowel obstruction.“One stop” liver-focused endoscopy: EUS-guided portal pressure gradient measurement technique
Referral for abnormal liver chemistry is one of the most frequently encountered reasons for visits to gastroenterologists and hepatologists, particularly given the versatility and vulnerability of the liver.1 Here, we present a 40-year-old man with class III obesity, essential hypertension, and hyperlipidemia who was referred for further diagnostic workup of his abnormal liver chemistry. Despite periods of significant weight loss, his liver transaminases had remained elevated over the prior 10 years (alanine aminotransferase 20-93 U/L, aspartate aminotransferase 20-71 U/L).Adaptation for endoscopy of a ventilation mask using a glove finger like a filter: trying to reduce aerosols
The name of the COVID-19 pandemic is derived from the coronavirus disease that started in 2019. It is caused by coronavirus 2 virus of severe acute respiratory syndrome. It was first identified in December 2019 in Wuhan City, the capital of Hubei Province in the People’s Republic of China. A group of sick people with an unknown type of pneumonia were reported. Most affected individuals were linked to workers at the Wuhan South China Wholesale Seafood Market. The World Health Organization recognized it as a pandemic on March 11, 2020.A fluke catch: biliary obstruction and pancreatitis from dicrocoeliasis
An 82-year-old woman presented with 3 days of epigastric and right upper quadrant abdominal pain, nausea, and vomiting. She was afebrile and had a bilirubin level of 2.9 mg/dL without leukocytosis or eosinophilia. Peak aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lipase levels were 675, 708, 236, and 7366 U/L, respectively. CT with contrast showed mild gallbladder wall thickening and no stones or pericholecystic fluid. Bile ducts and pancreas appeared normal.Use of a new face shield for patients of the endoscopy unit to avoid aerosol exchange in the COVID-19 era
In December 2019, a new coronavirus called SARS-CoV-2 emerged from a zoonotic source in Wuhan, China. One of its main characteristics is its easy propagation through airborne droplets from symptomatic and asymptomatic patients. SARS-CoV-2 thus has spread quickly, infecting 2 million people in more than 200 countries. It is the first coronavirus to be considered a pandemic. Its mortality rate ranges from 1% to 10%.1,2 Unfortunately, health workers have a 3 times greater chance of acquiring the virus compared with the general population, with almost 20% infected in some regions.
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