Endoscopic ultrasound-guided fine-needle aspiration of ascites

Antibiotic prophylaxis in digestive endoscopy: Guidelines from the French Society of Digestive Endoscopy

Digestive endoscopy is a highly dynamic medical discipline, with the recent adoption of new endoscopic procedures. However, comprehensive guidelines on the role of antibiotic prophylaxis in these new procedures have been lacking for many years. The Guidelines Commission of the French Society of Digestive Endoscopy (SFED) convened in 2023 to establish guidelines on antibiotic prophylaxis in digestive endoscopy for all digestive endoscopic procedures, based on literature data up to September 1, 2023. This article summarizes these new guidelines and describes the literature review that fed into them.

Current perspectives on the diversification of endoscopic ultrasound-guided fine-needle aspiration and biopsy

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has undergone significant advancements since it was first reported in 1992. Initially focused on the pancreas, EUS-guided fine-needle aspiration (FNA) has now been extended to encompass all organs proximal to the gastrointestinal system. Recently, a novel fine-needle biopsy (FNB) needle with an end-cut tip was developed, allowing for the collection of specimens suitable for histological assessment, a feat hard to achieve with traditional needles. The FNB needle holds promise for applications in immunohistochemistry staining and genetics evaluation, and it has the potential to yield specimens of comparable quality to core needle biopsy during percutaneous puncture, especially for lesions beyond the pancreas, such as lymph nodes. This review focuses on the efficacy of EUS-FNA/FNB for extended target regions, specifically lymph nodes, spleen, adrenal gland, and ascites. The indications for EUS-FNA have greatly expanded beyond the pancreas over the years, and future improvements and innovations in puncture needles will allow for the collection of higher-quality specimens, which is expected to play a significant part in personalized cancer treatment.

Endoscopic Diagnosis of Extra-Luminal Cancers

The last 2 decades have seen an emergence of endoscopic technologies and techniques allowing for minimally invasive modalities for assessing and sampling lesions outside of the gastrointestinal lumen, including the chest, abdomen, and pelvis. Incorporating these new endoscopic approaches has revolutionized the diagnosis and staging of extra-luminal malignancies and has enabled more accessible and safer tissue acquisition.

Changing Trends in Liver Biopsy Practices: A Single-Center Analysis

Introduction To assess the trends for liver biopsy (LB) indications, technique, and histopathologic diagnosis, we retrospectively evaluated liver biopsies in two one-year periods, separated by a decade. Methods A pathology database query was performed for all parenchymal LB in patients over 18 years (11/2017 to 10/2018) and compared to those performed over a one-year period, a decade ago. We identified 427 parenchymal liver biopsies in the recent group and 166 in the decade-old group. Results Elevated liver enzymes are the most common indication for LB. Non-alcoholic fatty liver disease (NAFLD) has become the most common diagnosis compared to 10 years ago, when it was viral hepatitis. Routes of LB were significantly different between the two groups, endoscopic ultrasound-guided liver biopsy (EUS-LB) (80.3% vs 0; p<0.0001), computed tomography-guided (0 vs 42.8%, p<0.0001), percutaneous by gastroenterologists (0% vs 29.5%, p<0.0001), and transjugular-LB (15.1% vs 17.6%, p<0.0001). The adequacy of the tissue for pathological diagnosis was similar, and there was no difference in adverse events. Conclusion At our institution, practice patterns have changed significantly for liver biopsy. There has been an increase in liver biopsy volume, and EUS guidance has become the most common approach for liver biopsy.

Role of therapeutic endoscopic ultrasound in gastrointestinal malignancy- current evidence and future directions

Endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to an advanced therapeutic modality. With the advent of better technologies and accessories, EUS has found ground in the management of gastrointestinal (GI) malignancies, not only for diagnosis but also for therapeutic purposes. EUS can tackle a host of conditions, including hepato-pancreatico-biliary malignancies. Advances and experience in various EUS-guided biliary drainage techniques have enabled the endosonologist to tackle biliary obstruction when conventional techniques of endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD) fails. More and more emerging data not only establishes the safety of EUS-BD but also demonstrates superior efficacy over PTBD and sometimes even ERCP. Malignant gastric outlet obstruction can now be safely managed with EUS-guided gastroenterostomy. Starting from pain management in malignant tumors through celiac plexus neurolysis to various tumor ablative therapies, EUS has forged ahead over percutaneous treatment or surgical options in the management of GI malignancies. Additional data is now coming up on the prospects of EUS-guided immunotherapy and biological therapy for tumor management. The future of EUS therapeutics in the field of GI malignancies is bright. With increasing evidence, this modality becoming a key player in management of a host of complex clinical conditions arising out of GI malignancies is in the offing. This review focuses on elucidating the role of therapeutic EUS in the management of GI malignancies, a synopsis of various techniques, data on its safety and efficacy as well as future advancements in this domain.

Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

The role of endoscopic ultrasound (EUS) as a diagnostic and therapeutic modality for the management of various gastrointestinal diseases has been expanding. The imaging or intervention for various liver diseases has primarily been the domain of radiologists. With the advances in EUS, the domain of endosonologists is rapidly expanding in the field of hepatology. The ability to combine endoscopy and sonography in one hybrid device is a unique property of EUS, together with the ability to bring its probe/transducer near the liver, the area of interest. Its excellent spatial resolution and ability to provide real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS, have facilitated the growth of EUS. The concept of "Endo-hepatology" encompasses the wide range of diagnostic and therapeutic procedures that are now gradually becoming feasible for managing various liver diseases. Diagnostic advancements can enable a wide array of techniques from elastography and liver biopsy for liver parenchymal diseases, to CE-EUS for focal liver lesions to portal pressure measurements for managing various liver conditions. Similarly, therapeutic advancements range from EUS-guided eradication of varices, drainage of bilomas and abscesses to various EUS-guided modalities of liver tumor management. We provide a comprehensive review of all the different diagnostic and therapeutic EUS modalities available for the management of various liver diseases. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

Endoscopic ultrasound guided fine needle biopsy (EUS-FNB) from peritoneal lesions: a prospective cohort pilot study

Background

Diagnostic laparoscopy is often a necessary, albeit invasive, procedure to help resolve undiagnosed peritoneal diseases. Previous retrospective studies reported that EUS-FNA is feasible on peritoneal and omental lesions, however, EUS-FNA provided a limited amount of tissue for immunohistochemistry stain (IHC).

Aim

This pilot study aims to prospectively determine the effectiveness of EUS-FNB regarding adequacy of tissue for IHC staining, diagnostic rate and the avoidance rate of diagnostic laparoscopy or percutaneous biopsy in patients with these lesions.

Methods

From March 2017 to June 2018, patients with peritoneal or omental lesions identified by CT or MRI at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand were prospectively enrolled in the study. All Patients underwent EUS-FNB. For those with negative pathological results of EUS-FNB, percutaneous biopsy or diagnostic laparoscopy was planned. Analysis uses percentages only due to small sample sizes.

Results

A total of 30 EUS-FNB passes were completed, with a median of 3 passes (range 2–3 passes) per case. For EUS-FNB, the sensitivity, specificity, PPV, NPV and accuracy of EUS-FNB from peritoneal lesions were 63.6%, 100%, 100%, 20% and 66.7% respectively. Adequate tissue for IHC stain was found in 25/30 passes (80%). The tissues from EUS results were found malignant in 7/12 patients (58.3%). IHC could be done in 10/12 patients (83.3%). Among the five patients with negative EUS results, two underwent either liver biopsy of mass or abdominal paracentesis, showing gallbladder cancer and adenocarcinoma. Two patients refused laparoscopy due to advanced pancreatic cancer and worsening ovarian cancer. The fifth patient had post-surgical inflammation only with spontaneous resolution. The avoidance rate of laparoscopic diagnosis was 58.3%. No major adverse event was observed.

Conclusions

EUS-FNB from peritoneal lesions provided sufficient core tissue for diagnosis and IHC. Diagnostic laparoscopy can often be avoided in patients with peritoneal lesions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01953-9.

Endo-hepatology: An emerging field

Gastroenterologists have long been spearheading the care of patients with various forms of liver disease. The diagnosis and management of liver disease has traditionally been a combination of clinical, laboratory, and imaging findings coupled with percutaneous and intravascular procedures with endoscopy largely limited to screening for and therapy of esophageal and gastric varices. As the applications of diagnostic and therapeutic endoscopic ultrasound (EUS) have evolved, it has found a particular niche within hepatology now coined endo-hepatology. Here we discuss several EUS-guided procedures such as liver biopsy, shear wave elastography, direct portal pressure measurement, paracentesis, as well as EUS-guided therapies for variceal hemorrhage.

Endoscopic Ultrasound-Guided Random Omental Fine Needle Aspiration: A Novel Technique for the Diagnosis of Peritoneal Carcinomatosis

Background/Aims

Diagnostic abdominal paracentesis has been described in literature to have variable sensitivity of 50%–75% for the detection of peritoneal carcinomatosis (PC). We believe that random needle aspirates from the omentum, even in the absence of obvious deposits by endoscopic ultrasound (EUS), could prove malignancy in patients with PC.

Methods

Consecutive patients who underwent EUS for diagnosis and staging of cancer and found to have ascites were included after obtaining informed consent. EUS-guided fine needle aspiration (EUS-FNA) from random sites in the omentum was performed through the transgastric route using a linear echoendoscope.

Results

Fifty-four patients underwent EUS during October 2015 to April 2017 for detection, staging, or FNA of a suspected malignant lesion. Ascites was seen in 17 patients and 15 patients who fulfilled the criteria were included. The procedure was successful in all patients. Cytology was suggestive of malignancy in 12 (80%) but not suggestive of malignancy in 3 (20%) patients. Three patients who tested negative had hyperbilirubinemia with biliary obstruction. Their ascitic fluid analysis result was also negative.

Conclusions

Random FNA of the omentum in patients with malignancy-related ascites is highly effective in the diagnosis of PC and could be employed during EUS evaluation of malignancies.

Successful use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) on a pancreatic lesion in a peritoneal dialysis patient without interrupting treatment

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), a well-established minimally invasive gastrointestinal procedure, has been used to diagnose and stage cancers of the pancreas. We describe the successful use of EUS-FNA in a peritoneal dialysis (PD) patient to evaluate a pancreatic cyst. The patient continued on PD immediately after the procedure without using hemodialysis. The patient did not experience any complication such as infection, bleeding, or peritoneal fluid leakage.

Predictive Factors for Inaccurate Diagnosis of Swollen Lymph Nodes in Endoscopic Ultrasound-Guided Fine Needle Aspiration

Background/Aims

This study aimed to identify the predictive factors for inaccurate endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnosis of swollen lymph nodes without rapid on-site cytopathological evaluation.

Methods

Eighty-three consecutive patients who underwent EUS-FNA for abdominal or mediastinal lymph nodes from January 2008 to June 2017 were included from a prospectively maintained EUS-FNA database and retrospectively reviewed. The sensitivity, specificity, and accuracy of EUS-FNA for the detection of neoplastic diseases were calculated. Candidate factors for inaccurate diagnosis (lymph node size and location, needle type, puncture route, number of passes, and causative disease) were evaluated by comparison between accurately diagnosed cases and others.

Results

The final diagnosis of the punctured lymph node was classified as neoplastic (65 cases: a metastatic lymph node, malignant lymphoma, or Crow-Fukase syndrome) or non-neoplastic (18 cases: a reactive node or amyloidosis). The sensitivity, specificity, and accuracy were 83%, 94%, and 86%, respectively. On multivariate analyses, small size of the lymph node was the sole predictive factor for inaccurate EUS-FNA diagnosis with a significant difference (odds ratios, 19.8; 95% confidence intervals, 3.15–124; p=0.0015).

Conclusions

The lymph node size of <16 mm was the only independent factor associated with inaccurate EUS-FNA diagnosis of swollen lymph nodes.

Endoscopic ultrasound-guided fine needle aspiration for pancreatic cancer

Since the development of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the early 1990s, its application has been extended to various diseases. For pancreatic cancer (PC), EUS-FNA can obtain specimens from the tumor itself with fewer complications than other methods. EUS-FNA can also be more useful for TNM staging than other imaging modalities. Furthermore, EUS-FNA can contribute to precision medicine by obtaining tissue for immunohistochemical or genetic studies from primary or metastatic sites of diseases. This paper will focus on the role of EUS-FNA in PC.

Gastroenterology and pancreatic adenocarcinoma: what the radiologist needs to know

In this article, we review the information that radiologists need to know regarding the endoscopic approach to the diagnosis and management of pancreatic cancer. This includes a review of the indications, techniques, and complications of endoscopic ultrasound. We also review information regarding endoscopic retrograde cholangiopancreatography, including the various biliary drainage techniques and the use of endoscopic palliation for patients with pancreatic cancer.

Endoscopic ultrasound-guided fine-needle aspiration from ascites and peritoneal nodules: A scoping review

The peritoneum is involved in many diseases such as primary malignancy (mesothelioma), infectious disease (tuberculosis), and disseminated malignancy (peritoneal carcinomatosis). The peritoneal disease may manifest as ascites and/or peritoneal masses or nodules. Endoscopic ultrasound (EUS), due to its ability to provide high-resolution images, has revolutionized the imaging and diagnosis of pancreaticobiliary diseases among other gastrointestinal conditions. EUS can not only help in imaging of various lesions close to the gastrointestinal lumen but also aspirate/biopsy them. We conducted a systematic search to identify published literature on the value of EUS in detection and diagnosis of peritoneal disorders. This review aims to summarize the available literature on the use of EUS-guided paracentesis and fine-needle aspiration from peritoneal nodules.

Diagnostic performance of endoscopic ultrasound for detection of pancreatic malignancy following an indeterminate multidetector CT scan: a systemic review and meta-analysis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis in part due to delayed diagnosis. Even with advances in cross-sectional imaging, small pancreatic malignancies can be missed. We sought to determine the performance of endoscopic ultrasound (EUS) in those without an obvious mass on multi-detector CT scan (MDCT), but with clinical suspicion for pancreatic malignancy.

METHODS

Multiple databases were systematically searched to identify studies that assessed the diagnostic performance of EUS after negative or inconclusive pancreatic protocol MDCT for detection of pancreatic malignancy when clinically suspected. A total of four studies met the inclusion criteria. The point estimates in each study were compared to the summary pooled estimates of sensitivity and specificity with the aid of forest plots. Funnel plots and Egger's test were employed to evaluate possible publication bias.

RESULTS

EUS-guided fine needle aspiration was performed in all studies. EUS was performed in 206 subjects with a clinical suspicion of a pancreatic mass but with an indeterminate MDCT. A pancreatic mass (mean size 21 ± 1.2 mm) was identified in 70% (n = 144) of the subjects, and 42.2% (n = 87) were diagnosed with PDAC. The pooled estimates of EUS for diagnosing pancreatic malignancy in the setting of an indeterminate MDCT were a sensitivity of 85% (95% CI 69-94%), specificity of 58% (95% CI 40-74%), positive predictive value of 77% (69-84%), negative predictive value of 66% (95% CI 53-77%), and an accuracy of 75% (95% CI 67-82). The summary area under the ROC curve was 0.80 (95% CI 0.52-0.89). The funnel plots and Egger's test did not show a significant publication bias.

CONCLUSIONS

The yield of EUS is comparatively higher for the diagnosis of a pancreatic malignancy in patients with suspected cancer, but a non-diagnostic MDCT. Importantly, the majority of the lesions missed on CT represent PDAC, in which early diagnosis is essential.

Diagnosis of Pseudomyxoma peritonei via endoscopic ultrasound guided fine needle aspiration: a case report and review of literature

INTRODUCTION

Pseudomyxoma peritonei (PMP) is a rare condition caused by mucinous adenocarcinoma cancerous cells that produce abundance of mucin or gelatinous ascites. This cancer can cause tissue fibrosis and can impair normal organ function. Diagnosis can involve multiple imaging modalities including CT scan. There have been few cases of endoscopic ultrasound (EUS) being used as a means for diagnosis of this condition. Here we report a second case of PMP with a previous history of appendectomy diagnosed with EUS guided fine needle aspiration (FNA) biopsy.

CASE STUDY

A 66-year-old male with a history of an appendectomy presented with intermittent abdominal pain for two years and weight loss of 40 pounds over two months. EGD and colonoscopy performed at an outside hospital was unremarkable. CT abdomen revealed perigastric ascities and lesions of the liver. ESR was elevated at 75. At our facility, EUS was performed revealing a peri-gastric and omental mass measuring 36.6 mm × 25.5 mm. FNA performed of both mass and ascetic fluid revealed low grade mucinous adenocarcinoma with mucinous deposits in the peritoneum consistent with PMP.

CONCLUSIONS

Endoscopic ultrasound guided FNA, although very rarely used, can be a reliable and safe technique in diagnosis of PMP.

A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review

In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.

A specimen volume of ≥80 mL improves cytologic sensitivity for malignant ascites: a retrospective analysis of 2665 cases

INTRODUCTION

Although paracentesis simultaneously allows cytologic evaluation of peritoneal fluid and symptomatic relief, its utility is limited by a paltry 50% to 60% sensitivity for malignancy. Specimen volume has recently been shown to affect cytologic diagnosis in other body fluids, but its role has never been examined in ascites. This study evaluates how specimen volume impacts cytologic diagnosis of malignant ascites.

MATERIALS AND METHODS

We identified 2665 consecutive paracentesis specimens with documented numeric volumes collected at our institution between 1994 and 2013. We separated the cases into 10 bins of roughly equivalent sample size and compared the percentage of cases that received malignant diagnoses across each cutoff volume. When follow-up pathology was available, we also compared the sensitivity of cytology with the gold standard of surgical pathology.

RESULTS

The peritoneal fluids had a mean volume of 760.2 mL (range: 1-10,000). Just 11.3% of specimens with volumes <80 mL were diagnosed as malignant, while 20.1% were malignant at volumes ≥80 mL (P < 0.001, OR = 0.51, 95% CI = 0.39-0.64). Lower volume specimens also had more indeterminate and nondiagnostic results. Cytologic sensitivity increased from 56.7% for specimens <80 mL to 75.4% for volumes ≥80 mL (P = 0.03, OR = 0.43, 95% CI = 0.19-0.94).

CONCLUSIONS

A specimen volume of ≥80 mL is associated with increased cytologic sensitivity for malignant ascites and a higher rate of malignant diagnoses. The disparate sensitivity at lower volumes likely stems from inadequate sampling of larger specimens. Although fluids should not be summarily rejected based on volume, a specimen volume of ≥80 mL minimizes the influence of specimen size on diagnostic adequacy in paracentesis specimens.

Bench-top testing of suction forces generated through endoscopic ultrasound-guided aspiration needles

BACKGROUND

Adequate needle size and tissue acquisition techniques for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) need further elucidation. Moreover, the actual negative pressure and suction forces of FNA needles remain unknown. We evaluated the suction forces of 19-gauge, 22-gauge, and 25-gauge conventional FNA needles and side hole aspiration needles using conventional negative pressure and the slow pull technique.

METHODS

Using a manometer, we determined the mean (SD) negative pressure and suction force for needle gauge, aspiration volume, and aspiration technique. We also evaluated the time to reach the maximum negative pressure.

RESULTS

Suction force was comparatively higher in the 19-gauge needle when 50 ml of negative pressure was applied. Suction force using the slow pull method was very weak at 5% of pressure found with conventional methods. With the use of a 20-ml syringe, the time to reach the maximum negative pressure was 4 s in the 19-gauge needle, 11 s in the 22-gauge needle, and 80 s in the 25-gauge needle.

CONCLUSIONS

Bench-top testing showed that suction force increases with a larger gauge needle and larger aspiration volume. The slow pull method produces a very weak suction force. The time to reach the maximum negative pressure was longest in the 25-gauge needle.

Usefulness of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of hepatic, gallbladder and biliary tract Lesions

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of the liver is a safe procedure in the diagnosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for liver lesions poorly accessible to other imaging modalities of the liver. EUS-guided FNA of biliary neoplasia and malignant biliary stricture is superior to the conventional endoscopic brushing and biopsy.

Endoscopic ultrasound and paracentesis in the evaluation of small volume ascites in patients with intra-abdominal malignancies

The evaluation of ascites in patients with known or suspected malignancy is a critical aspect of preoperative staging. Endoscopic evaluation by ultrasound of low volume ascites and sampling of the ascitic fluid by endoscopic ultrasound guided paracentesis (EUS-P) is both a sensitive and specific modality for the determination of peritoneal implants, which is not only an important prognostic indicator but a crucial factor in determining treatment strategy. It is common practice to utilize EUS for gastrointestinal malignancies such as pancreatic or gastric masses, with the performance of paracentesis during the same procedure for the purpose of imaging the abnormality and possibly performing fine needle aspiration for biopsy of the neoplasm itself. However, given the ability of EUS-P to adequately sample even minimal ascites, detecting much smaller volumes than traditional computed tomography or magnetic resonance imaging, EUS-P may be a useful modality for the standard metastatic workup of any newly diagnosed or suspected malignancy. In this “Field of Vision” commentary, we discuss the role of EUS-P, including the article by Suzuki et al reporting their experience with EUS-P using an automated spring-loaded needle device. We also review the utility of EUS-P for non-gastrointestinal malignancies, such as ovarian cancer, which has a high incidence of malignant ascites.

When to puncture, when not to puncture: Pancreatic masses

Endoscopic ultrasound (EUS) has evolved to become a crucial tool for the evaluation of pancreatic diseases, among them solid pancreatic lesions. However, its ability to determine whether a lesion is malignant or not is difficult to establish based only in the endosonographic image. EUS-guided fine needle aspiration (EUS-FNA) allows obtaining a cytological and/or histological sample from pancreatic lesions, with a high overall accuracy and low complication rates. Although the clinical usefulness of EUS-FNA for pancreatic diseases is widely accepted, the indications for tissue diagnosis of pancreatic lesions suspected to be malignant is still controversial. This review highlights the diagnostic accuracy and complications of EUS-FNA, focusing on its current indications.

How good is fine needle aspiration? What results should you expect?

Tissue acquisition plays a key role before treatment decision in most of oncological pathologies but also in several benign diseases. By offering tissue sampling, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become an essential tool in the diagnostic processes. One of the reasons for the success of the technique is related to its excellent diagnostic performance. The diagnostic accuracy of EUS-FNA is above 80% for most of the usual indications. These performances are however dependent on some factors related to both the disease and patient's medical history but also related to medical staff expertise. Endoscopist needs to know how to reach a lesion but also how to efficiently acquire good tissue samples. This review aims to report general recommendations available in the literature for high quality EUS-FNA. Sample processing and sample interpretation also influence diagnostic accuracy of FNA. This paper includes a discussion on sample processing and benefits of the on-site pathology examination. It also provides the results reported in the literature of sample adequacy and diagnostic performance of EUS-FNA for most common indications: Pancreatic diseases, sub-mucosal lesion, mucosal thickenings, lymph nodes, cystic lesion and free fluids.

Technical Advances in Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition for Pancreatic Cancers: How Can We Get the Best Results with EUS-Guided Fine Needle Aspiration?

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.

Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical practice

Since its initial report in 1992, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has now been incorporated into the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of adjacent organs. Its introduction constitutes a major breakthrough in the endoscopic field and has gradually transformed EUS from a pure imaging modality into a more interventional. In addition, the possibility of collecting samples, providing a definitive cytological and/or histological evidence of the presence of malignancy, has strongly contributed to changing EUS from a subjective, highly operator dependant procedure into a more objective one. This article will review the instrumentation, technique and the most important clinical applications of EUS-FNA.

Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.

Endo-hepatology: a new paradigm

Recent advances in hepatology have included a new and effective treatment of viral hepatitis, with an increased need for the assessment of liver function and histology. At the same time, there have been a growing number of endoscopic procedures that are pertinent to patients with liver disease. It would be ideal if the assessment and treatment of liver disease and portal hypertension could be performed and assimilated by the liver/gastrointestinal specialist. The authors like to consider this area of integration or overlap of endoscopic procedures within the practice of hepatology as endo-hepatology.

Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review

BACKGROUND

EUS-guided FNA (EUS-FNA) permits both morphologic and cytologic analysis of lesions within or adjacent to the GI tract. Although previous studies have evaluated the accuracy of EUS-FNA, little is known about the complications of EUS-FNA. Moreover, the frequency and severity of complications may vary from center to center and may be related to differences in individual experience.

OBJECTIVE

To systematically review the morbidity and mortality associated with EUS-FNA.

DESIGN

MEDLINE and EMBASE were searched to identify relevant English-language articles.

MAIN OUTCOME MEASUREMENTS

EUS-FNA-specific morbidity and mortality rates.

RESULTS

We identified 51 articles with a total of 10,941 patients who met our inclusion and exclusion criteria; the overall rate of EUS-FNA-specific morbidity was 0.98% (107/10,941). In the small proportion of patients with complications of any kind, the rates of pancreatitis (36/8246; 0.44%) and postprocedure pain (37/10,941; 0.34%) were 33.64% (36/107) and 34.58% (37/107), respectively. The mortality rate attributable to EUS-FNA-specific morbidity was 0.02% (2/10,941). Subgroup analysis showed that the morbidity rate was 2.44% in prospective studies compared with 0.35% in retrospective studies for pancreatic mass lesions (P=.000), whereas it was 2.33% versus 5.07% for pancreatic cysts (P=.036).

LIMITATIONS

Few articles reported well-designed, prospective studies and few focused on overall complications after EUS-FNA.

CONCLUSIONS

EUS-FNA-related morbidity and mortality rates are relatively low, and most associated events are mild to moderate in severity.

Endoscopic ultrasound-guided paracentesis of ascitic fluid: a morphologic study with ultrasonographic correlation

BACKGROUND

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) has been widely used for the diagnosis of primary and metastatic gastrointestinal (GI) and non-GI malignancies. Few studies have been published to evaluate the accuracy and the cytologic features of EUS-guided paracentesis in the diagnosis and staging of malignant neoplasms.

METHODS

All EUS-guided paracenteses of ascitic fluid performed at the University of California Irvine Medical Center (UCIMC) from January 2003 to February 2006 were retrospectively retrieved. Corresponding EUS findings, cytology and histology slides, and follow-up information were reviewed.

RESULTS

One hundred one (101) cases were found. Two smears were submitted in 11 cases because of the scanty amount of fluid aspirated. In the remaining cases, 5 mL or less of fluid were aspirated in 56 patients, and, of 9 who had prior computed tomography (CT), ascitic fluid was not seen in 6. The cytologic diagnoses were as follows: 17 were positive for adenocarcinoma, 1 positive for metastatic small-cell carcinoma of the lung, 1 positive for diffuse large-cell lymphoma, 3 suspicious for adenocarcinoma, 1 suspicious for plasmacytoma, 4 atypical epithelial cells, and 74 negative. Cell block was available in 80 cases and immunohistochemical stains were performed in 71 cases to confirm the diagnosis. Six patients had peritoneal biopsy. The sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were 80%, 100%, 100%, 95%, and 96%, respectively.

CONCLUSIONS

EUS-guided paracentesis is a valuable aid in the cytologic diagnosis of malignant ascites. It is particularly useful when no abnormality is identified by CT.

Survival in patients with pancreatic cancer after the diagnosis of malignant ascites or liver metastases by EUS-FNA

BACKGROUND

The expected survival after the EUS-FNA diagnosis of malignant ascites or liver metastases from pancreatic cancer is not known.

OBJECTIVE

To report overall and 1-year survival in these patients.

DESIGN

Retrospective cohort series.

SETTING

Tertiary referral hospital.

PATIENTS

Consecutive subjects with newly diagnosed pancreatic cancer from June 1998 and March 2008 in whom EUS-FNA of the liver or ascitic fluid confirmed hepatic metastases or malignant ascites.

INTERVENTIONS

Calculation of survival after diagnosis by using the Social Security Death Index.

MAIN OUTCOME MEASUREMENTS

Survival after EUS-FNA diagnosis of stage IV pancreatic cancer.

RESULTS

EUS-FNA identified liver metastases and malignant ascites from primary pancreatic cancer in 75 and 13 patients, respectively, and all 88 died during follow-up. For all 88 patients, the 1-year survival rate and median survival were 3.4% (95% CI, 1.1%-10.4%) and 82 days (range 2-754 days), respectively. The 1-year survival rates for those with liver metastases (4.0% [95% CI, 1.3%-12.1%]) and for those with malignant ascites (0% [95% CI, 0-24.7%]) were similar (P = 1.0). The median survival for patients with liver metastases of 83 days (range 2-754 days) was similar to that for those with malignant ascites (64 days; range 2-153 days) (P = .13). No clinical variable considered predicted survival of more than, less than, or 3 months.

LIMITATIONS

Retrospective series with variable treatment for malignancy.

CONCLUSIONS

In patients with pancreatic cancer, identification of malignant ascites or liver metastases by EUS-FNA is associated with a very poor prognosis.

EUS-guided FNA of peritoneal carcinomatosis in patients with unknown primary malignancy

BACKGROUND

EUS-guided FNA is a well-recognized technique for sampling the pancreas, peri-intestinal lymph nodes, and mass lesions. The role of EUS-guided FNA in the diagnosis of peritoneal carcinomatosis has not been well studied.

OBJECTIVE

We aimed to determine the feasibility and success in sampling lesions in the peritoneum suspicious for carcinomatosis without a primary source.

DESIGN

An observational study.

SETTING

A tertiary referral center.

PATIENTS

Consecutive patients who underwent EUS-guided FNA of peritoneal deposits.

RESULTS

During a span of 3 years, 4 patients underwent transgastric or transduodenal EUS-guided FNA of peritoneal lesions with a curvilinear echoendoscope. All of these lesions were imaged by abdominal CT scan. The EUS findings of the nodules appeared round, relatively hypoechoic to the surrounding tissue, but hyperechoic when compared with the surrounding low-volume ascites where the lesions floated. Four passes were performed per case, and the diagnosis was achieved on a median of 2 passes (range 1-4). All patients received intravenous antibiotics during the procedure. Two patients had metastatic adenocarcinoma, 1 patient had lymphoma, and 1 patient had metastatic breast carcinoma. Diagnostic laparoscopy/laparotomy was avoided in all patients. No complications, particularly peritonitis, were encountered.

LIMITATIONS

Observational study with a small sample size.

CONCLUSIONS

Transgastric or transduodenal EUS-guided FNA for peritoneal carcinomatosis is feasible and safe. In the setting of an unknown primary cancer, EUS-guided FNA facilitates acquisition of tissues for treatment allocation, thus avoiding the need for laparoscopy or laparotomy.

Prognostic significance of endoscopic ultrasound-defined pleural, pericardial or peritoneal fluid in oesophageal cancer

BACKGROUND

Endoscopic ultrasound (EUS) is known to detect smaller effusion volumes than computerised tomography (CT), yet the outcomes for patients diagnosed with oesophageal carcinoma and EUS-defined pleural, pericardial or ascitic fluid effusions (EDFE) are unknown. The aim of this study was to determine the outcome of multidisciplinary stage directed treatment for such patients.

METHODS

Forty-nine (9.2%) out of a consecutive 527 patients diagnosed with oesophageal cancer from a single regional upper gastrointestinal (GI) cancer network were found to have evidence of EDFE undetected by CT. Thirty-nine (79.6%) patients had pleural effusions, eight (16.3%) pericardial effusions, and two (4.1%) ascites.

RESULTS

Twelve (24.4%) underwent surgery, 3 (6.1%) received neoadjuvant chemotherapy without subsequent surgery, 12 (24.5%) received definitive chemoradiotherapy (dCRT), and 22 (44.9%) received palliative treatment. Survival in patients with EDFE was significantly shorter (median and 2-year survival 15.6 months and 24%, respectively) when compared with patients without EDFE (26.7 months and 40%, respectively, p = 0.001), and was unrelated to EDFE type (p = 0.192). Two-year survival after oesophagectomy with or without neoadjuvant therapy was 45% in patients with EDFE compared with 42% in patients without EDFE (p = 0.668).

CONCLUSIONS

EDFE was an important adverse prognostic indicator, but patients deemed to have operable tumours should still be treated with radical intent.