Utility of Forward-View Echoendoscopy for Transcolonic Fine-Needle Aspiration of Extracolonic Lesions: An Institutional Experience

Consensus statements on endoscopic ultrasound-guided tissue acquisition. Guidelines from the Asian Endoscopic Ultrasound Group

OBJECTIVES

This consensus was developed by the Asian EUS Group (AEG), who aimed to formulate a set of practice guidelines addressing various aspects of endoscopic ultrasound-guided tissue acquisition (EUS-TA).

METHODS

The AEG initiated the development of consensus statements and formed an expert panel comprising surgeons, gastroenterologists, and pathologists. Three online consensus meetings were conducted to consolidate the statements and votes. The statements were presented and discussed in the first two consensus meetings and revised according to comments. Final voting was conducted at a third consensus meeting. The Grading of Recommendations, Assessment, Development, and Evaluation system was adopted to define the strength of the recommendations and quality of evidence.

RESULTS

A total of 20 clinical questions and statements regarding EUS-TA were formulated. The committee recommended that fine-needle biopsy (FNB) needles be preferred over conventional fine-needle aspiration (FNA) needles for EUS-TA of subepithelial lesions. For solid pancreatic masses, rapid on-site evaluation is not routinely recommended when FNB needles are used. For dedicated FNB needles, fork-tip and Franseen-tip needles have essentially equivalent performance.

CONCLUSION

This consensus provides guidance for EUS-TA, thereby enhancing the quality of EUS-TA.

Diagnosis by Endoscopic Ultrasonography-Guided Sampling through the Lower Gastrointestinal Tract

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) is very safe and has a high diagnostic rate for upper gastrointestinal lesions, especially pancreatic lesions, but its application in the lower gastrointestinal tract has rarely been reported. Due to the tortuous course of the colorectum, with the sigmoid colon particularly prone to perforation, most endoscopists are reluctant to perform lateral-sector endoscopic ultrasound scanning without a water-bag protection for the puncture. The ultrasonic endoscopy and flexible puncture needle techniques recently introduced into clinical practice have made ultrasound-guided puncture safer and more convenient. In addition, endoscopists have carefully tested various protective measures to improve the safety of the lower gastrointestinal puncture, substantially increasing its clinical feasibility. In this article, we review the iterations of endoscopic ultrasound equipment introduced in recent years and the many ingenious ideas proposed by endoscopists regarding lower gastrointestinal puncture.

EUS of a submucosal lesion at the appendiceal orifice using a double-balloon endoluminal intervention platform

Video 1Video demonstrating the use of a DEIP to facilitate both radial and linear EUS in the proximal colon.

Metastatic undifferentiated pleomorphic sarcoma diagnosed by endoscopic ultrasound-guided fine-needle aspiration

Pathological differentiation is important for suspected lesions of metastatic undifferentiated pleomorphic sarcoma (UPS) because no reliable imaging criteria exist for this entity yet. In the present case, transgastric endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the pancreatic tumor and transcolonic EUS-FNA for the intraabdominal tumor contributed to the definitive diagnosis of metastatic UPS, leading to appropriate treatment selection.

Colonoscopic Ultrasound-Guided Fine-Needle Aspiration Using a Curvilinear Array Transducer: A Single-Center Retrospective Cohort Study

BACKGROUND

Curvilinear array ultrasound transducers enable tissue sampling and have therapeutic capabilities. Nevertheless, colonic intubation and maneuvering with these transducers is technically challenging and is therefore typically limited to the rectosigmoid area. This retrospective cohort study aimed to evaluate the safety, feasibility, and diagnostic yield of colonoscopic ultrasound-guided fine-needle aspiration in deep colonic intubation.

IMPACT OF INNOVATION

The impact of this innovation is to enable tissue sampling of colonic and extracolonic lesions guided by endoscopic ultrasound.

TECHNOLOGY, MATERIALS, AND METHODS

Curvilinear array ultrasound is used in the evaluation of luminal and extraluminal colonic diseases. Thirteen patients underwent colonoscopic ultrasound with a curvilinear array ultrasound endoscope in a single center for subepithelial lesions, cancer staging, and extracolonic lesions from July 2015 to February 2021. Endosonography was performed using an Olympus EU-ME1 and GF-UCT 180 with a 5-12MHz curvilinear array transducer. The primary outcome was the percentage of patients who were successfully scanned with the endoscopic ultrasound. The secondary outcomes included the success rate of fine-needle aspiration, the diagnostic yield of the tissue samples, and the adverse events related to the procedure.

PRELIMINARY RESULTS

A total of 13 female patients underwent colonoscopic ultrasound. All patients (100%, 13/13) were successfully scanned. Fine-needle aspiration was deemed necessary and successfully performed in 100% (5/5) of the patients. Tissue samples collected by fine-needle aspiration resulted in a diagnostic yield of 60%, and no adverse events resulted from this intervention.

CONCLUSIONS

This study demonstrates the feasibility of performing colonoscopic ultrasound with a curvilinear array transducer. Fine-needle aspiration for subepithelial, colonic, and extracolonic lesions is feasible and safe in this setting with no adverse events reported in our study.

FUTURE DIRECTIONS

Future research should be directed toward validating colonoscopic ultrasound with a curvilinear array transducer technique in prospective randomized trials. Studies evaluating the feasibility and safety of endoscopic ultrasound-guided interventions in the colon, such as abscess drainage and enteral anastomosis, should be considered.

Enterolith at the ileocecal valve mimicking a subepithelial mass

A 32-year-old woman presented with chronic constipation for three years. Colonoscopy revealed a 2.5 cm subepithelial tumor-like lesion at the ileocecal (IC) valve with protrusion of the lesion into the lumen. A CT scan of the abdomen showed an oval-shape laminated calcified lesion adhered to the IC valve and several gallstones. An exploratory laparotomy to enterotomy with stone extraction and open cholecystectomy was performed. Operative findings showed stone erosion into the ileal wall with the lesion being covered with colonic mucosa. Pathologic examination of stones from the intestinal wall revealed an enterolith. The case exemplifies the infrequent cause of a subepithelial lesion of the gastrointestinal tract and a rare presentation of an enterolith as a subepithelial lesion within the terminal ileal wall.

Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower gastrointestinal tract approaches

BACKGROUND

Combining upper and lower gastrointestinal tract (GI) approaches allows expansion of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) indications for pelvic lesions. The upper GI approach has been used for pelvic lesions around the level of the aortoiliac bifurcation in our institution. The aim of this study is to evaluate the feasibility and safety of EUS-FNA for pelvic lesions via the upper and lower GI approaches.

METHODS

All consecutive patients who underwent EUS-FNA for the pelvic lesion between January 2008 and December 2018 were retrospectively analyzed. Pelvic lesions were defined as lesions located around and below the aortoiliac bifurcation level. The primary outcome was technical success rate, and the secondary outcomes were the diagnostic capability of EUS-FNA for malignancy and the safety.

RESULTS

EUS-FNA for pelvic lesions was performed in 49 patients: upper and lower GI approaches were used in 28 and 21 patients, respectively. The technical success rates were 91.8% (45/49) in all patients: 89.3% (25/28) and 95.2% (20/21) with the upper and lower GI approaches, respectively. Among patients who achieved technical success, the diagnostic accuracy for malignancy was 97.8% (44/45) in all patients: 100% (25/25) and 95.0% (19/20) with the upper and lower GI approaches, respectively. One (2.0%) patient developed an adverse event of sigmoid colon perforation.

CONCLUSIONS

EUS-FNA for pelvic lesions via the upper and lower GI approaches was a safe, feasible, and effective method, although careful endoscopic manipulation is required to avoid perforation, especially with the lower GI approach. Further large-scale, well-designed studies are needed to validate our findings.