Pancreatic hyperechogenicity on endoscopic ultrasound examination

There is an ongoing discussion on how to diagnose a hyperechogenic pancreas and what is the clinical significance of diffusely hyperechogenic pancreas. Computerized tomography and magnetic resonance imaging are the more appropriate methods to diagnose pancreatic hyperechogenicity when compared with transcutaneous or endoscopic ultrasound examination. More importantly, pancreatic hyperechogenicity may not be a certain indicator of pancreatic fat infiltration. Even if it is true, we do not know the clinical s...     

Pancreatic parenchymal changes seen on endoscopic ultrasound are dynamic in the setting of fatty pancreas: A short-term follow-up study

ObjectivesThe impact of fatty pancreas on pancreatic parenchymal changes is unclear. The aim of this study is to assess parenchymal alterations over time in patients with fatty pancreas (FP).MethodsThis is a retrospective study (2014–2021) of patients with FP identified on endoscopic ultrasound (EUS). Subjects with follow up imaging studies including Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI), and EUS at least two years after the initial EUS were included.ResultsA total of 39 patients with a mean age of 51.21 ± 12.34 years were included. Mean initial weight was 80.17 ± 17.75 kg. Diabetes, hepatic steatosis, and EPI were present in 15%, 46% and 33% of the patients at baseline, respectively. In 25 patients with available follow up EUS over 2.4 ± 0.76 years, 16% progressed to chronic pancreatitis (CP) and 24% had progressive parenchymal changes without meeting the criteria for CP. One patient progressed from focal to diffuse FP, while one patient had resolution of FP. In multivariate analysis, progressive parenchymal changes on EUS were associated with an increase in weight over time (p-value 0.04), independent of the effects of gender, alcohol, or tobacco.ConclusionProgressive parenchymal changes were noted in 44%. Our result suggests that FP is a dynamic process with the possibility of progression or regression over time.     

Diagnosis of ectopic pancreas by endoscopic ultrasound with fine-needle aspiration

AIM:To study the clinical,endoscopic,sonographic,and cytologic features of ectopic pancreas(EP).METHODS:This was a retrospective study performedat an academic referral center including two hospitals.Institutional review board approval was obtained.Patients referred to the University Hospital or Denver Health Medical Center Gastrointestinal Endoscopy Lab for gastroduodenal subepithelial lesions(SEL)with a final diagnosis of EP between January 2009and December 2013 were identified.Patients in this group were selected for the study if they underwent endoscopic ultrasound(EUS)with fine-needle aspiration(FNA)or deep biopsy.A review of the medical record was performed specifically to review the following information:presenting symptoms,endoscopic and EUS findings,computed tomography or magnetic resonance imaging findings,pathology results,procedure-related adverse events,and subsequent treatments after EUSFNA.EUS with FNA or deep submucosal biopsy was performed in all patients on an outpatient basais by one of two physicians(Attwell A,Fukami N).Review of all subsequent clinic notes and operative reports was performed in order to determine follow-up and final diagnoses.RESULTS:Between July 2009 and December 2013,10patients[3 males,7 females,median age 52(26-64)years]underwent EUS for a gastroduodenal SEL and were diagnosed with EP.One patient was symptomatic.Six(60%)lesions were in the antrum,3(30%)in the body,and 1(10%)in the duodenum.A mucosal dimple was noted in 6(60%).Mean lesion size was 17(8-25)mm.Gastrointestinal wall involvement:muscularis mucosae,10%;submucosa,70%;muscularis propria,60%;and serosa,10%.Nine(90%)lesions were hypoechoic and 5(50%)were homogenous.A duct was seen in 5(50%).FNA was attempted in 9(90%)and successful in 8(80%)patients after 4(2-6)passes.Cytology showed acini or ducts in 7 of 8(88%).Superficial biopsies in 7 patients(70%)showed normal gastric mucosa.Deep endoscopic biopsies were taken in 2 patients and diagnostic in one.One patient(10%)developed pancreatitis after EUS-FNA.Two patients(20%)underwent surgery to relieve symptoms or confirm the diagnosis.The main limitation of the study was the fact that it was retrospective and performed at a single medical center.CONCLUSION:EUS features of EP include antral location,mucosal dimple,location in layers 3-4,and lesional duct,and FNA or biopsy is accurate and effective.     

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目的提高对胃异位胰腺的诊断及治疗水平。方法2000-2004年对解放军总医院消化科241例胃黏膜下肿物进行超声内镜(EUS)检查,回顾分析胃异位胰腺的图像特征。结果EUS诊断良性间质瘤105例,恶性间质瘤23例,脂肪瘤48例,异位胰腺45例,囊肿20例。异位胰腺EUS图像特点:(1)黏膜下层病变39例,6例与固有肌层无分界;(2)边界清37例;(3)42例为不均匀、形状不规则中强回声,3例为不均匀低回声;(4)32例中心有小的不规则液性回声。内镜电切26例,无出血穿孔等并发症。结论超声内镜对胃异位胰腺的诊断有一定价值,内镜切除是安全有效的治疗方法。     

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue. Treatment of heterotopic pancreas may include expectant observation, endoscopic resection or surgery. The aim of this report was to describe the technique of ligationassisted endoscopic mucosal resection （EMR） for resection of heterotopic pancreas of the stomach. Two patients （both female, mean age 32 years） were referred for management of gastric subepithelial tumors. Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa. Band ligation-assisted EMR was performed in both cases without complications. Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa. Margins were free of pancreatic tissue. Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.     

内镜黏膜下剥离术和内镜隧道技术对胃异位胰腺的诊治价值

目的 探讨内镜黏膜下剥离术(ESD)和内镜隧道技术(STER)在胃异位胰腺诊断及治疗中的临床价值.方法 2009年10月至2013年3月胃镜疑诊为胃异位胰腺并强烈要求内镜切除的患者40例住院接受ESD或STER,切除标本行病理学检查明确诊断,随访观察治疗效果和安全性.结果 术后病理确诊胃异位胰腺25例,其中位于胃窦20例,胃底体交界3例,胃体2例;胰腺组织成团块状20例,散在分布状5例;25例中21例施行ESD术,4例行STER术,完整切除率88％ (22/25),余3例剥离后有少许组织残留.术后迟发性出血1例(4％),予多枚钛铗止血成功无需另加手术,无术中及术后穿孔.术后随访1 ～30个月未见复发.结论 ESD能完整大块的切除病变组织,不仅能提供标本获得准确的病理学诊断,同时起到微创治疗的作用,是胃异位胰腺有效且安全的诊治手段,内镜隧道剥离切除术可能为胃异位胰腺的诊治提供一种新的方法.     

Endoscopic removal of gastric ectopic pancreas: An initial experience with endoscopic submucosal dissection

AIM:To evaluate the therapeutic usefulness and safety of endoscopic resection in patients with gastric ectopic pancreas.METHODS:A total of eight patients with ectopic pancreas were included.All of them underwent endoscopic ultrasonography before endoscopic resection.Endo-scopic resection was performed by two methods:endo-scopic mucosal resection(EMR)by the injection-and-cut technique or endoscopic mucosal dissection(ESD).RESULTS:We planned to perform EMR in all eight cases but EMR was successful in only four cases.In the other four cases,saline spread into surrounding normal tissues and the lesions becameattened,which made it impossible to remove them by EMR.Inthose four cases,we performed ESD and removed the lesions without any complications.CONCLUSION:If conventional EMR is difficult to remove gastric ectopic pancreas,ESD is a feasible alternative method for successful removal.     

内镜超声诊断胃异位胰腺20例临床分析

目的探讨内镜下超声检查胃异位胰腺的诊断特点,分析其诊断价值。方法总结2007年7月～2008年11月武汉大学人民医院消化内镜中心623例超声胃镜（EUS）检查结果及相关病理检查结果,嘲顾性分析胃异位胰腺的图像特征及其诊断正确率。结果623例EUS检查中,诊断胃异位胰腺20例,间质瘤91例,息肉81例。胃异位胰腺网像特点：好发于胃窦,多为隆起性病变,表面光滑,形态差异很大,中间顶端可见导管开口;EUS下可见黏膜下层或肌层低回声、中等回声或混合回声团。结论超声内镜诊断胃异位胰腺有一定价值,并可进一步选择相应的治疗措施。     

Endoscopic ultrasound in the diagnosis and management of carcinoma pancreas

Endoscopic ultrasound(EUS) has become an important component in the diagnosis and treatment of carcinoma pancreas. With the advent of advanced imaging techniques and tissue acquisition methods the role of EUS is becoming increasingly important. Small pancreatic tumors can be reliably diagnosed with EUS. EUS guided fine needle aspiration establishes diagnosis in some cases. EUS plays an important role in staging of carcinoma pancreas and in some important therapeutic methods that include celiac plexus neurolysis, EUS guided biliary drainage and drug delivery. In this review we attempt to review the role of EUS in diagnosis and management of carcinoma pancreas.     

Acute inflammation occurring in gastric aberrant pancreas followed up by endoscopic ultrasonography

We describe a case of gastric aberrant pancreas with acute pancreatitis followed up with subsequent endoscopic ultrasound. A 20-year-old woman known to have aberrant pancreas in the stomach was admitted to our hospital because of severe epigastralgia. Laboratory tests showed slight C reactive protein elevation without hyperamylasemia. Esophagogastroduodenoscopy revealed a swollen submucosal lesion (SML) to a greater degree compared with the previous findings. Subsequent endoscopic ultrasonography (EUS) revealed a swollen lesion of 35 mm in diameter. The internal echo-pattern was more hypoechoic than in the previous EUS. The border between the fourth layer (muscularis propria) and the SML was unclear. The anechoic lumen in the mass, considered as the ductal lumen, was dilated. Based on these results, we diagnosed the patient as having acute inflammation, resembling pancreatitis, in the aberrant pancreas.     

胃异位胰腺的内镜诊治

目的探讨胃异位胰腺胃镜和超声内镜的表现及内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)对胃异位胰腺的疗效与安全性。方法经胃镜及超声内镜诊断为胃异位胰腺患者17例,总结其临床症状、胃镜和超声内镜下表现,将有临床症状的16例患者行ESD治疗,另1例患者随访观察。结果胃镜下多表现为隆起性病变,顶部可见导管开口呈脐样凹陷;14例患者行超声内镜检查,病灶以累及黏膜下层为主,可累及固有肌层,多数为低回声、等回声或混合回声改变;16例患者接受ESD治疗,术中发现2例患者累及固有肌层,术中、术后无出血、穿孔等并发症。术后病检提示累及固有肌层3例,随访发现1例患者病灶存在,1例未行手术患者病灶无明显变化。结论胃镜及超声内镜检查是诊断胃异位胰腺及指导治疗的重要手段。ESD可安全、有效地应用于胃异位胰腺的治疗,并发症发生率低,无症状患者可随访观察。     

Impact of endoscopic ultrasound quality assessment on improving endoscopic ultrasound reports and procedures

AIM: To evaluate the impact of endoscopic ultrasonography (EUS) quality assessment on EUS procedures by comparing the most recent 2013-2014 local EUS procedural reports against relevant corresponding data from a 2009 survey of EUS using standardized quality indicators (QIs).METHODS: Per EUS exam, 27 QIs were assessed individually and by grouping pre-, intra-, and post-procedural parameters. The recorded QI frequencies from 200 reports (2013-2014) were compared to corresponding data of 100 reports from the quality control study of EUS in 2009. Data for QIs added after 2009 to professional guidelines (added after 2010) were also tabulated.RESULTS: Significant differences (P-value < 0.05) were found for 13 of 20 of the relevant QIs examined. 4 of 5 pre-procedural QIs, 6 of 10 intra-procedural QIs, and 3 of 5 post-procedural QIs all demonstrated significant upgrading with a P-value < 0.05.CONCLUSION: Significant improvements were demonstrated in QI adherence and thus EUS reporting and delivery quality when the 2013-2014 reports were compared to 2009 results. QI implementation facilitates effective high-quality EUS exams by ensuring comprehensive documentation while limiting error.     

Ectopic pancreas at the ampulla of Vater diagnosed with endoscopic snare papillectomy: A case report and review of literature

BACKGROUND Ectopic pancreas is a rare developmental anomaly that results in a variety of clinical presentations. Patients with ectopic pancreas are mostly asymptomatic,and if symptomatic, symptoms are usually nonspecific and determined by the location of the lesion and the various complications arising from it. Ectopic pancreas at the ampulla of Vater(EPAV) is rare and typically diagnosed after highly morbid surgical procedures such as pancreaticoduodenectomy or ampullectomy. To our knowledge, we report the first case of confirmed EPAV with a minimally invasive intervention.CASE SUMMARY A 71-year-old male with coronary artery disease, presented to us with new-onset dyspepsia with imaging studies revealing a ‘double duct sign' secondary to a small subepithelial ampullary lesion. His hematological and biochemical investigations were normal. His age, comorbidity, poor diagnostic accuracy of endoscopy,biopsies and imaging techniques for subepithelial ampullary lesions, and suspicion of malignancy made us acquire histological diagnosis before morbid surgical intervention. We performed balloon-catheter-assisted endoscopic snare papillectomy which aided us to achieve en bloc resection of the ampulla for histopathological diagnosis and staging. The patient's post-procedure recovery was uneventful. The en bloc resected specimen revealed ectopic pancreatic tissue in the ampullary region. Thus, the benign histopathology avoided morbid surgical intervention in our patient. At 15 mo follow-up, the patient is asymptomatic.CONCLUSION EPAV is rare and remains challenging to diagnose. This rare entity should be included in the differential diagnosis of subepithelial ampullary lesions.Endoscopic en bloc resection of the papilla may play a vital role as a diagnostic and therapeutic option for preoperative histological diagnosis and staging to avoid morbid surgical procedures.     

Interventional endoscopic ultrasound: Therapeutic capability and potential

The linear echoendoscope, introduced in the 1990s, opened the era of interventional endoscopic ultrasound (IEUS). The linear echoendoscope enabled EUS guided Fine Needle Aspiration (EUS-FNA) allowing the path of the needle to be traced during the puncture process. After EUS-FNA, other interventional procedures were introduced in clinical practice. Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established. After EUS-FNA, Celiac plexus neurolysis (CPN) and block (CPB), pancreatic pseudocyst drainage, abdominal and mediastinal collections/abscesses drainage, and in selected cases, pancreatic and biliary ductal system drainage, were introduced in clinical practice. EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality. We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.     

Role of endoscopic ultrasound during hospitalization for acute pancreatitis

Endoscopic ultrasound(EUS)is often used to detect the cause of acute pancreatitis(AP)after the acute attack has subsided.The limited data on its role during hospitalization for AP are reviewed here.The ability of EUS to visualize the pancreas and bile duct,the sonographic appearance of the pancreas,correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies.The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis.Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications.The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.     

中国肥胖症消化内镜治疗专家共识

消化内镜减重手术是近年来在减重领域逐渐兴起的一项新兴学科，以其创伤小、恢复快、可逆性好、并发症少、性价比高的诸多优势为肥胖患者的治疗提供了一项新的解决方案，有望成为外科减重代谢手术的并行和补充疗法。基于现有的临床循证医学依据，中华医学会消化内镜学分会微创减重治疗协作组、中国医师协会消化医师分会减重专业委员会和国家消化系统疾病临床医学研究中心（北京）组织相关专家，对其适应证、禁忌证、技术操作规范和围手术期处理策略等方面进行讨论，并达成共识，旨在为消化内镜减重技术的规范开展提供参考和指导，促进中国减重学科的健康发展。     

Possibilities of interventional endoscopic ultrasound

Since endoscopic ultrasound (EUS) was developed in the 1990s, EUS has become widely accepted as an imaging tool. EUS is categorized into radial and linear in design. Radial endoscopes provide cross-sectional imaging of the mediastinum, gastrointestinal tract, liver, spleen, kidney, adrenal gland, and pancreas, which has highly accuracy in the T and N staging of esophageal, lung, gastric, rectal, and pancreatic cancer. Tumor staging is common indication of radial-EUS, and EUSstaging is predictive of surgical resectability. In contrast, linear array endoscope uses a side-viewing probe and has advantages in the ability to perform EUSguides fine needle aspiration (EUS-FNA), which has been established for cytologic diagnosis. For example, EUS-FNA arrows accurate nodal staging of esophageal cancer before surgery, which provides more accurate assessment of nodes than radial-EUS imaging alone. EUS-FNA has been also commonly used for diagnose of pancreatic diseases because of the highly accuracy than US or computed tomography. EUS and EUS-FNA has been used not only for TNM staging and cytologic diagnosis of pancreatic cancer, but also for evaluation of chronic pancreatitis, pancreatic cystic lesions, and other pancreatic masses. More recently, EUS-FNA has developed into EUS-guided fine needle injection including EUS-guided celiac plexus neurolysis, celiac plexus block, and other "interventional EUS" procedures. In this review, we have summarized the new possibilities offered by "interventional EUS".     

Experimental model standardizing polyvinyl alcohol hydrogel to simulate endoscopic ultrasound and endoscopic ultrasound-elastography

BACKGROUND Endoscopic ultrasound(EUS) and endoscopic ultrasound elastography(EUS-E) simulation lessens the learning curve; however, models lack realism, diminishing competitiveness.AIM To standardize the mechanical properties of polyvinyl alcohol(PVA) hydrogel for simulating organs and digestive lesions.METHODS PVA hydrogel(Sigma Aldrich, degree of hydrolysis 99%) for simulating EUS/EUS-E lesions was investigated in Unidad de Investigación y Desarrollo Tecnológico at Hospital General de México "Dr. Eduardo Liceaga", Mexico City. We evaluated physical, contrast, elasticity and deformation coefficient characteristics in lesions, applying Kappa's concordance and satisfaction questionnaire(Likert 4-points).RESULTS PVA hydrogel showed stable mechanical properties. Density depended on molecular weight(MW) and concentration(C). PVA bblocks with the greatest density showed lowest tensile strength(r =-0.8, P = 0.01). Lesions were EUSgraphically visible. Homogeneous and heterogeneous examples were created from PVA blocks or PVA phantoms, exceeding(MW_2 = 146000-186000, C_9 = 15% and C_(10) = 20%) with a density under(MW_1 = 85000-124000, C_1 = 7% and C_2 = 9%). We calculated elasticity and deformation parameters of solid(blue) areas, contrasting with the norm(Kappa = 0.8; high degree of satisfaction).CONCLUSION PVA hydrogels were appropriate for simulating organs and digestive lesions using EUS/EUS-E, facilitating practice and reducing risk. Repetition amplified skills, while reducing the learning curve.