Critical care transesophageal endosonography and guided fine-needle aspiration for diagnosis and management of posterior mediastinitis

A quarter century of EUS-FNA: Progress, milestones, and future directions

Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.

Endoscopic ultrasound (with an echobronchoscope)-guided fine-needle aspiration for diagnosis of a mediastinal lesion in a mechanically ventilated patient: A case report and systematic review of the literature

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is routinely used for accessing mediastinal lymph nodes and masses. However, in patients with respiratory failure, who are being mechanically ventilated through an endotracheal tube, EBUS-TBNA may not be feasible due to several reasons. In such patients, the esophageal route offers a useful alternative for accessing mediastinal lesions. Herein, we describe a 50-year-old man with a mediastinal mass, who was being invasively ventilated for respiratory failure. Endoscopic ultrasound (with an echobronchoscope)-guided fine-needle aspiration was performed, which revealed a diagnosis of small cell carcinoma. Appropriate cancer chemotherapy resulted in successful liberation of the patient from mechanical ventilation. We have also performed a systematic review of literature for reports of endoscopic diagnostic procedures for mediastinal/hilar lesions in critically ill patients.

Diagnostic bedside EUS in the intensive care unit: a single-center experience

BACKGROUND

The knowledge of bedside diagnostic EUS in critically ill patients is limited.

OBJECTIVE

To investigate the indications, feasibility, safety, and clinical utility of diagnostic EUS in the intensive care unit (ICU).

DESIGN

Retrospective.

SETTING

Tertiary-care referral teaching hospital.

PATIENTS

All consecutive patients who had EUS done in the ICU within a 6-year period.

INTERVENTION

Bedside EUS and EUS-guided FNA.

MAIN OUTCOME MEASUREMENTS

EUS indications, complications, and impact on management.

RESULTS

A total of 64 EUS procedures were performed in 63 patients (38 men, 25 women; age range 27-78 years); 1 patient underwent 2 separate EUS procedures. EUS was performed while the patients were mechanically ventilated in 70% (45/64) of cases. Indications for EUS included jaundice (n = 24), mass of unknown etiology (n = 25), unexplained pancreatitis (n = 7), and staging of known cancer (n = 3). In 5 cases, EUS was used as an alternative to other imaging modalities because of morbid obesity (n = 3) or contraindication to intravenous contrast material (n = 2). Complications included reversible oxygen desaturation (n = 4), nonsustained ventricular tachycardia (n = 1), and transient hypotension (n = 1). Overall, EUS influenced management in 97% (62/64) of cases.

LIMITATIONS

Retrospective, single-center study.

CONCLUSION

ICU-based EUS can be performed with few intraprocedural complications and can be a valuable diagnostic modality in the ICU setting. It appears to be particularly useful for determining the etiology of jaundice, masses of unknown etiology, and pancreatitis. It may have particular value as a diagnostic technique on selected patients with unstaged cancer and when morbid obesity or the inability to use intravenous contrast material precludes the use of other imaging modalities in the critically ill patient.

Diagnosis of mediastinal tuberculosis by using EUS-guided needle sampling in a geographic region with an intermediate tuberculosis burden

BACKGROUND

EUS-guided FNA (EUS-FNA) or trucut biopsy (TCB) is indispensible in the diagnosis of mediastinal malignancies. Less is known, however, about the usefulness of EUS-guided sampling for nonmalignant, mediastinal tuberculosis (TB), despite the increase in the incidence of TB.

OBJECTIVE

To assess the diagnostic yields of EUS-FNA/TCB in patients with mediastinal TB.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral hospital in a geographic region with an intermediate TB burden.

PATIENTS

This study involved 24 consecutive patients with mediastinal TB, who underwent EUS-FNA/TCB from July 2005 to September 2008.

INTERVENTION

EUS-FNA/TCB.

MAIN OUTCOME MEASUREMENTS

Technical success and diagnostic yields of EUS-FNA/TCB.

RESULTS

Mediastinal lesions (mean diameter, 28.6 mm; range 17.0-49.5 mm) were targeted by using 22-gauge-needle FNA in 10 patients and 19-gauge-needle TCB in 14 patients. Before EUS, only 10 of the 24 patients had a presumptive diagnosis of mediastinal TB, whereas 11 patients were suspected of having malignancies. Six patients showed mass-like lung parenchymal lesions mimicking lung cancer, and 7 patients had a history of malignancy. Pathologic examination showed granulomatous inflammation in 16 patients (66.7%), including 10 patients with caseating granulomas. Positive microbiologic results were obtained in 10 patients (41.7%): 3 by Ziehl-Neelsen staining, 5 by Mycobacterium tuberculosis culture, and 5 by TB polymerase chain reaction (PCR) assay. EUS-FNA/TCB confirmed mediastinal TB in 20 of the 24 patients and directed 11 patients clinically suspected of having malignancies to anti-TB treatment. The diagnostic yields of FNA and TCB were similar (90.0% vs 78.6%).

LIMITATIONS

Retrospective design in a tertiary-care referral hospital.

CONCLUSION

EUS-FNA/TCB is sufficiently useful to confirm mediastinal TB and can exclude suspected malignancies in TB patients.

[An unusual mediastinal opacity]

A 36-year old immunocompetent male from Senegal with an uneventful history was admitted for exploration of a bullous collection in the posterior mediastinum. Multifocal tuberculosis was diagnosed. Computed tomography-guided drainage removed 600 cc of caseum. The diagnosis as rupture of intrathoracic Pott's abscess complicated by a probably esophageal fistula. The clinical course was rapidly favorable with later development of mediastinal fibrosis. This uncommon case illustrates the contribution of interventional radiology recently developed in the Principal Hospital in Dakar, Senegal.

Cytologic diagnosis of pancreatic endocrine tumors by endoscopic ultrasound-guided fine-needle aspiration: A review

Precise localization and diagnosis of pancreatic endocrine tumors (PETs) is important, because pancreatic PETs have different clinical and biological behavior and treatment modalities than do exocrine pancreatic tumors. In contrast to the much more common exocrine adenocarcinomas, cytologic studies of PET are relatively rare and many cytopathologists lack experience with the cytomorphologic features of these tumors.During the last 10 yr, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has matured into an accurate, highly sensitive, and cost-effective modality for the preoperative localization of pancreatic PETs. This has resulted in an increased number of PETs first sampled as cytology specimens. This manuscript focuses on the cytomorphologic features most suggestive of pancreatic PETs, differential diagnosis, and diagnostic pitfalls of PETs. The technical development of EUS-guided FNA and the ancillary studies for pancreatic PETs are also reviewed. The data summarized in this review indicate that EUS-FNA is a valuable method in the recognition of pancreatic PETs and in most cases cytopathologists could reach a correct diagnosis of these tumors, including their hormone producing capability on aspirated cytologic material.

[Fungi in the mediastinum: rare, but relevant]

Fungal infections of the mediastinum are rare. There are five forms to be differentiated: (i) hematogenous fungal infection of the mediastinum after fungemia; (ii) postoperative fungal infection after cardiosurgical sternotomy; (iii) as special form of a descending necrotizing fasciitis; (iv) infection of the mediastinum per continuitatem; (v) fungal infection of the posterior mediastinum after esophageal perforation. In the surgical department, University of Schleswig-Holstein, Campus Lübeck, five patients with a fungal mediastinitis were treated during a period of 10 years. Three patients suffered from a descending mediastinitis, one patient from a fungal infection after pseudarthrosis of the sternum (postoperatively after cardiosurgery). The section results of one other patient with pulmonary aspergillosis showed a complete invasion of the mediastinum by Aspergillus fumigatus.

Present and future of endoscopic ultrasonography

Endoscopic ultrasonography and endoscopic ultrasonography-guided fine needle aspiration are well-established techniques, encompassing a variety of diagnostic and therapeutic applications. Along with traditional indications that constitute everyday clinical practice in all endoscopic ultrasonography centres, new indications are emerging that resemble the continuing research carried on in this field. Some of these are innovative applications, developed by highly experienced endosonographers and with a putative role for clinical practice in the near future. Others are merely experimental applications, carried out on in animal models or in highly selected groups of patients, opening up new fascinating areas of research but not for imminent introduction in clinical practice. The purpose of this review, after summarising the present indications of endoscopic ultrasonography, is to focus on the future applications and try to establish their possible advent, either in the near or in the far future.

Source control in the management of severe sepsis and septic shock: An evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.