Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) using oblique-view EUS in patients with a surgically altered anatomy (SAA) of the upper gastrointestinal tract is limited because of difficult scope insertion due to the disturbed anatomy. This study aimed to investigate the efficiency of forward-view (FV)-EUS in performing FNA in patients with a SAA.
We retrospectively investigated 32 patients with a SAA of the upper gastrointestinal tract who visited Aichi Cancer Center Hospital in Nagoya, Japan, between January 2014 and December 2020. We performed-upper gastrointestinal EUS-FNA using FV-EUS combined with fluoroscopic imaging to confirm tumor recurrence or to make a decision before chemotherapy or after a failure of diagnosis by radiology.
We successfully performed EUS-FNA in all studied patients (100% technical success), with the specificity, sensitivity, and accuracy of 100%, 87.5%, and 87.8%, respectively, with no complications.
EUS-FNA using FV-EUS combined with fluoroscopic imaging is an effective and safe technique for tissue acquisition in patients with a SAA.
Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) have valid diagnostic and therapeutic roles in gastrointestinal and extra-gastrointestinal lesions.
Forward-view EUS (FV-EUS) has many advantages over OV-EUS. One crucial advantage is that it allows the use of needles and other devices in the straight direction, providing high penetration force into the target lesions.
We retrospectively investigated 32 patients treated at the Gastroenterology Department, Aichi Cancer Center Hospital, Nagoya, Japan, between January 2014 and December 2020. First, EUS-FNA was performed to obtain evidence from patients with suspected cancer recurrence during the follow-up based on the findings of imaging examinations, including abdominal computed tomography (CT), positron emission tomography/CT, and magnetic resonance imaging. Second, EUS-FNA was performed to obtain evidence before cancer chemotherapy and in cases in which imaging was not conclusive. EUS-FNA using FV-EUS was performed under fluoroscopic guidance in all cases. All patients had mass lesions, swollen lymph nodes, or peritoneal dissemination.
All patients had undergone upper gastrointestinal surgery, either pancreaticoduodenectomy (PD), PD+left lobe hepatectomy (left HPD) total pancreatectomy, total gastrectomy, or both esophagectomy and total gastrectomy.
We examined all study participants using a FV-EUS scope (TGF-UC260J; Olympus Medical Systems, Tokyo, Japan), either at the outset or after the failure of OV-EUS insertion.
As shown in
We examined the patients after conscious sedation with intravenous pethidine and midazolam. The procedures were performed with the patients lying in the left lateral position.
We performed FNA using a 22- to 25-gauge Expect needle (Boston Scientific) or a 22-gauge Acquire needle (Boston Scientific) and a 22-gauge Ez-Shot needle (Olympus Medical Systems). After each puncture, the specimens were sent for rapid onsite evaluation (ROSE), cytology, or tissue cell block. The number of punctures ranged from one to six, depending on the ROSE results (
The study protocol was approved by the Institutional Review Board (IRB No: 2021-0-017). The EUS-FNA procedure was performed after obtaining written informed consent from the patients.
Of the 32 studied patients, 26 underwent EUS-FNA using FV-EUS combined with fluoroscopic guidance to evaluate for tumor recurrence suspected on the basis of abdominal CT, magnetic resonance imaging, or positron emission tomography results; five patients underwent the procedure to help the clinicians make informed decisions before chemotherapy; and one patient underwent the procedure after the failure of diagnosis by imaging.
In our study, the specificity, sensitivity, and accuracy of EUS-FNA using FV-EUS were 100%, 87.5%, and 87.8%, respectively. Of the 32 patients, four could not be evaluated with EUS-FNA because of insufficient specimens, and one patient was finally diagnosed radiologically. In this latter patient, the lesion was difficult to diagnose by FNA although the specimen was reported to be sufficient and confirmed to be nonmalignant by cell block and cytology techniques.
FV-EUS was performed for FNA under fluoroscopic guidance either at the outset (24 patients) or after the failure of OV-EUS (eight patients). FV-EUS was technically successful in all studied patients (100%).
The patients who underwent postoperative assessment with FV-EUS had a previous history of pancreatic cancer (19 patients), cholangiocarcinoma (eight patients), intraductal papillary mucinous cancer (one patient), duodenal cancer (one patient), gastric cancer (one patient), ampulla of Vater cancer (one patient), and both gastric and esophageal cancers (one patient) (
The patients had undergone either PD (26 patients), total pancreatectomy (three patients), left HPD (one patient), total gastrectomy with Roux-en-Y reconstruction (one patient), or both esophagectomy and total gastrectomy (one patient) (
The lesions targeted in our study included peritoneal dissemination (14 patients), lymph node swelling (nine patients), anastomotic mass (four patients), liver metastasis (two patients), mass around the celiac artery (one patient), mass around the superior mesenteric artery (one patient), and pelvic mass (one patient) (
FNA was performed in all patients using a FV-EUS scope through the trans-jejunum route in 27 patients, from the stomach in three patients, from both the trans-jejunum and trans-stomach in one patient, and from the Y-leg anastomosis in one patient (
The site of puncture differed according to the cases, as shown in
In this retrospective study, we evaluated the efficacy and technical success of EUS-FNA using FV-EUS in patients with a SAA. Vilmann et al.
To overcome these limitations, we attempted FV-EUS guided by fluoroscopic imaging in performing EUS-FNA in patients with suspected recurrent tumors, either as a first-line procedure in 24 patients (75%) or after a failed EUS-FNA using OV-EUS in eight patients (25%). FV-EUS has some advantages over OV-EUS. First, owing to its FV orientation, the FV-EUS scope could be easily advanced into the surgically altered small bowel (
To our knowledge, only three studies have reported the feasibility of EUS-FNA in patients with a SAA. First, Wilson et al.
FV-EUS scanning and tissue sampling vary according to the type of patients and whether they have a residual stomach or have undergone subtotal or total gastrectomy. Before FNA in patients with a SAA, we carefully assessed the altered anatomy to determine how to reach the target lesion. In our study, the FV-EUS scope passed smoothly through the jejunal limb and was easier to insert into the afferent loop in 27 patients, into the stomach in three patients, from both the trans-jejunum and trans-stomach in one patient, and from the Y-leg in one patient.
Our team previously examined the efficacy of FNA using FV-EUS in tissue acquisition from pericolonic lesions under fluoroscopic guidance. We reported that the specificity, sensitivity, and accuracy of EUS-FNA for detecting malignant lesions were 100%, 91%, and 92%, respectively.
In four of the 32 patients, FNA using FV-EUS failed to obtain sufficient samples (one patient with a history of total pancreatectomy and three patients with a history of PD), which could be attributed to low tumor cellularity after chemotherapy (
Our study had some limitations. First, it was based on a retrospective review of a single-center experience. Second, the equipment limitation of FV-EUS is its narrow scanning range (90°) compared with that of OV-EUS (180°). To overcome this limitation, we used fluoroscopy to help localize the target lesions by approaching the scope tip closer to the target lesions previously detected with CT. In addition, we used a detachable cap (endoscopic distal attachment cap; Olympus Medical Systems) over the scope tip to hold the scope in place and for effective air suction to obtain a clearer ultrasound image (
In conclusion, FV-EUS is safe and effective for performing EUS-FNA in patients with a SAA of the upper gastrointestinal tract.
The authors have no potential conflicts of interest.
None.
Conceptualization: KH, SH, TK, NO, SZ, HO; Data curation: NO, DF, TY; Investigation: AB, MEl; Methodology: AB, KH, ME; Project administration: KH, NO; Software: AB, ME; Supervision: AB, KH, ME, SH, TK, NO; Writing–original draft: AB, ME; Writing–review & editing: all authors.
(A) Oblique-view endoscopic ultrasound scope with maximum angulation in retroflexion with the use of an elevator. It is usually difficult to advance the needle in this position. (B) Forward-view endoscopic ultrasound scope in full retroflexion with no elevator. Note that this position facilitates smooth needle advancement compared with oblique-view endoscopic ultrasound. Courtesy of Prof. Pietro Fusaroli at the University of Bologna, Italy. Endosc Ultrasound 2013;2:64–70.
(A) Forward-view endoscopic ultrasound image showing lymph node swelling around the hepatic hilum and the needle inserted inside the lesion for fine-needle aspiration. (B) Forward-view endoscopic ultrasound image showing lymph node swelling around the portal vein and the needle inserted inside the lesion for fine-needle aspiration.
Tip of the forward-view endoscopic ultrasound scope under fluoroscopy, passing through the afferent loop toward the lesion.
Picture of the detachable cap (endoscopic distal attachment cap; Olympus Medical Systems).
Demographic and surgical features of the studied cases
Patient data | Value |
---|---|
Sex | |
Female | 21 (65.6) |
Male | 11 (34.3) |
Age (yr) | 68.5 (46–82) |
Type of surgical operation | |
Pancreatoduodenectomy | 26 (81.2) |
Total pancreatectomy | 3 (9.3) |
Left HPD | 1 (3.1) |
Total gastrectomy Roux-en-Y | 1 (3.1) |
Esophagectomy and total gastrectomy | 1 (3.1) |
Indication for surgery | |
Pancreatic cancer | 19 (59.3) |
Cholangiocarcinoma | 8 (25.0) |
Intraductal papillary mucinous cancer | 1 (3.1) |
Duodenal cancer | 1 (3.1) |
Ampulla of Vater cancer | 1 (3.1) |
Gastric cancer | 1 (3.1) |
Gastric and esophageal cancer | 1 (3.1) |
Values are presented number (%) or mean (range).
PD, pancreatoduodenectomy; HPD, PD and left lobe hepatectomy.
Details of the EUS-FNA procedure
Lesion assessment | Value |
---|---|
Lesion-diameters (mm) | 15.7 (8–23) |
Target lesion for FNA | |
Peritoneal dissemination | 14 (43.7) |
Lymph node swelling | 9 (28.1) |
Anastomotic mass | 4 (12.5) |
Liver metastasis | 2 (6.2) |
Mass around the celiac | 1 (3.1) |
Mass around superior mesenteric artery | 1 (3.1) |
Pelvic mass | 1 (3.1) |
Pass insertion | |
Trans-jejunum | 27 (84.3) |
Stomach | 3 (9.3) |
Trans-jejunum and trans-stomach | 1 (3.1) |
Y legged | 1 (3.1) |
Site of puncture | |
Around superior mesenteric artery | 7 (21.8) |
Para aortic | 4 (12.5) |
Bile duct jejunal anastomosis | 4 (12.5) |
Around the portal vein | 4 (12.5) |
Trans-jejunum | 2 (6.2) |
Wisteria jejunal anastomosis | 1 (3.1) |
Near the right renal artery | 1 (3.1) |
Liver segment 5 | 1 (3.1) |
Right loop of the liver | 1 (3.1) |
In relation to superior mesenteric vein | 1 (3.1) |
Y legged anastomosis | 1 (3.1) |
In relation to the hepatic hilum | 1 (3.1) |
Lymph node 12 | 1 (3.1) |
Head of the pancreas | 1 (3.1) |
Celiac surroundings | 1 (3.1) |
Abdominal disseminating nodules | 1 (3.1) |
EUS procedure time (min) | 51 (18–135) |
Values are presented median (range) or number (%).
EUS-FNA, endoscopic ultrasound-guided fine-needle aspiration.
Adverse events of EUS-FNA (
Adverse event | % |
---|---|
Perforation | 0 |
Bleeding | 0 |
Mild abdominal pain and discomfort | 0 |
Aspiration pneumonia | 0 |
Anesthesia-related | 0 |
EUS-FNA, endoscopic ultrasound-guided fine-needle aspiration.
Unsuccessful cases by FV-EUS
Case | EUS-FNA (cytology) | EUS-FNA (cell block) | Final diagnosis |
---|---|---|---|
1 | Insufficient specimen | Insufficient specimen | No malignancy |
2 | Insufficient specimen | Insufficient specimen | No malignancy |
3 | Insufficient specimen | Insufficient specimen | Suspected recurrence after surgery for bile duct cancer |
4 | Insufficient specimen | Insufficient specimen | No malignancy |
FV-EUS, forward-view endoscopic ultrasound; EUS-FNA, EUS-guided fine-needle aspiration.