线阵超声内镜对直肠子宫内膜异位症的诊断价值

目的:探讨线阵超声内镜对直肠子宫内膜异位症(rectal endometriosis,RE)的诊断价值.方法:对20例子宫内膜异位症患者于外科手术前行线阵超声内镜检查直肠,超声扫描频率为7.5MHz,根据直肠壁内有无边界不规则的低回声结节或团块判断直肠是否受累,并将超声内镜检查结果与手术中所见及术后病理进行比较.结果:20例患者中有12例经线阵超声内镜检查发现直肠壁内有异位子宫内膜病灶,其余8例患者的直肠壁正常.超声内镜诊断为RE的12例患者术中均见盆腔异位子宫内膜病灶与肠壁粘连紧密,手术切除的直肠病灶送检均见子宫内膜组织.超声内镜下未见直肠受累的8例患者盆腔子宫内膜异位病灶与肠壁无粘连或轻度粘连,易分离,分离缘组织送检未见子宫内膜组织.线阵超声内镜检查结果与手术中所见及术后病理完全一致.结论:线阵超声内镜检查是诊断RE的可靠方法,可对子宫内膜异位症患者是否伴有直肠受累做出准确的术前评估.     

Endoluminal ultrasound diagnosis and operative management of rectal endometriosis

PURPOSE: Endorectal ultrasound was performed in patients with endometriosis to evaluate the role of this technique for rectal wall involvement and to evaluate the position of preoperative diagnosis in the operative management of rectal endometriosis. METHODS: Sixteen patients with suspected fixation of endometriomas to the rectal wall during bimanual examination were included in the study. Endorectal ultrasound was performed using a real time unit with a 7.5 MHz endorectal transducer. The probe was introduced via a rectoscope into the rectum up to the rectosigmoid. RESULTS: Endometriosis was confirmed histopathologically in all patients. In six patients rectal wall involvement was diagnosed, in two patients endometriomas were adjacent to the rectal wall, and in eight patients rectal wall involvement could be excluded. Preoperative diagnosis was confirmed in all patients during operation. Laparotomy was performed in those patients with preoperatively diagnosed rectal wall involvement, whereas the remaining patients were treated laparoscopically. Endometriomas with rectal wall involvement were treated in five of six patients with resection of the affected bowel predominantly by low anterior resection. CONCLUSIONS: Preoperative endorectal ultrasound is a reliable technique to visualize perirectal endometriomas and to assess rectal wall involvement. Based on preoperative endosonographic diagnosis, an operative management was established with laparotomy and resection of the affected bowel in cases of rectal wall involvement.     

Usefulness of EUS-guided fine needle aspiration (EUS-FNA) in the diagnosis of functioning neuroendocrine tumors

BACKGROUND: Localization of neuroendocrine tumors may be challenging. The role of EUS-FNA in this setting is unknown. METHODS: Ten patients with clinically suspected functioning neuroendocrine tumors (hormonal disturbances) underwent EUS-FNA to determine the location and to confirm the diagnosis cytologically. OBSERVATIONS: EUS identified 14 tumors in these 10 patients. In all but one patient CT did not demonstrate the tumor or missed at least one of multiple lesions. Mean tumor size was 12 mm (range 4-25 mm). Tumor locations were pancreas (n = 13) and duodenal wall (n = 1). Eleven of the 14 detected lesions were aspirated under EUS with accurate diagnosis in all cases. Surgical confirmation of EUS-FNA findings was available in 7 patients. There was no complication of EUS-FNA. CONCLUSIONS: EUS is a highly accurate technique for visualization of small functioning neuroendocrine tumors not evident on CT and for identification of patients with multiple lesions. EUS-FNA safely provides cytologic confirmation with high accuracy in these patients.     

EUS-guided fine needle aspiration in mediastinal lymphadenopathy of unknown etiology

BACKGROUND: EUS-guided fine needle aspiration (EUS-FNA) has significantly expanded the diagnostic capability of GI EUS. FNA technology can also be helpful in the diagnosis of non-GI disorders. The role of EUS-guided FNA in the diagnosis of mediastinal lymphadenopathy of unknown etiology has not been described. The aim of this study was to evaluate the diagnostic accuracy and impact on subsequent evaluation and therapy of EUS-FNA in mediastinal lymphadenopathy of unknown cause. METHODS: Sixty-two patients (40 men, 22 woman; mean age 56 years, range 16-91 years) with mediastinal lymphadenopathy of unknown etiology underwent EUS-FNA at 6 tertiary referral centers. Presenting symptoms included the following: dysphagia, 6 patients; night sweats, 14; cough, 8; chest pain, 10; odynophagia, 10; fever, 6; weight loss, 8; and asymptomatic/abnormal radiograph, 12. A final diagnosis by EUS-FNA, surgery, autopsy, or long-term follow-up was available for all patients. EUS-FNA results were classified under 3 disease categories: (1) benign/infectious; (2) malignant pulmonary; and (3) malignant mediastinal (e.g., lymphoma, metastatic malignancy). Four EUS features were used as criteria for lymph node metastases: size greater than 1 cm, round shape, sharp border, and homogeneous/hypoechoic echo pattern. RESULTS: Final diagnoses included benign/infectious lymph nodes, 26; malignant pulmonary, 24; and malignant mediastinal, 12. EUS-FNA established a tissue diagnosis in 56 of 62 patients (90%). EUS criteria for malignant lymph nodes were more frequently present in malignant pulmonary (mean 2.6 features) and malignant mediastinal (mean 2.8) than benign/infectious (mean 1.9) lymph nodes. EUS results influenced subsequent evaluation in 87% and therapy in 87% of patients. There was no complication of EUS-FNA. CONCLUSIONS: EUS-FNA in patients with mediastinal lymphadenopathy is safe and guides subsequent therapy in the great majority of cases. Transesophageal EUS-FNA of mediastinal lymph nodes provides minimally invasive tissue sampling, obviating the need for mediastinoscopy or bronchoscopy.     

EUS features of recurrent transitional cell bladder cancer metastatic to the GI tract

BACKGROUND: Recurrent transitional cell bladder cancer (TCBC) can metastasize to the GI tract albeit uncommonly. This is the first report of the EUS appearance of metastatic TCBC to the GI tract. In addition to describing the EUS features of recurrent metastatic TCBC, this study determined the number of patients referred for evaluation of a primary GI luminal cancer in which EUS instead established the diagnosis of metastatic recurrent TCBC. METHODS: Patients referred from July 2000 through April 2004 for EUS evaluation of a suspected primary GI luminal cancer were retrospectively reviewed. For patients with an established diagnosis of recurrent metastatic TCBC, EUS images were retrospectively reviewed to identify characteristic features. RESULTS: Of 2216 patients undergoing EUS to evaluate a suspected primary GI luminal cancer, 3 men (0.14%: 95% confidence interval [0.02%, 0.29%]) (mean age 67 years, range 54-74 years) were found instead to have recurrent metastatic TCBC involving the duodenum (n = 1) or rectum (n = 2). The patients presented a mean of 32 months after diagnosis of the primary TCBC with change in bowel habit (n = 1) and symptoms of bowel obstruction (n = 2). In each patient, initial endoscopy revealed circumferential luminal stenosis and mucosal erythema, but mucosal biopsy specimens revealed normal tissue. EUS demonstrated hypoechoic, symmetric, circumferential wall thickening, loss of deep wall layers, and pseudopodia-like extensions into the peri-intestinal tissues. In the two patients with rectal involvement, no evidence of direct infiltration from the bladder bed was seen. EUS-guided FNA was diagnostic of metastatic TCBC in all patients. CONCLUSIONS: Although most cases of hypoechoic bowel-wall thickening and stenosis are from primary GI neoplasia, recurrent TCBC should be considered in patients with a history of this tumor. Correct diagnosis is important, because this allows selection of appropriate therapeutic interventions. Although firm EUS criteria for TCBC cannot be established based on findings in 3 patients, certain features may prove useful. EUS-guided FNA can confirm the diagnosis.     

Evaluation of a new curved linear array echoendoscopy system for EUS

BACKGROUND: EUS-FNA can be used to accurately diagnose and stage GI and pulmonary neoplasms. This study evaluated the performance characteristics of a new compact linear EUS system during EUS-FNA. METHODS: A total of 37 patients enrolled in this prospective pilot study underwent clinically indicated EUS-FNA and/or celiac plexus neurolysis with the compact EUS system. RESULTS: The mean time to perform a radial and linear array EUS with FNA and/or celiac plexus neurolysis was 24 minutes shorter with the compact EUS system compared with that for an historical control procedure in which a conventional linear EUS unit was used (p = 0.0007). The EUS images and visualization of the needle during EUS-FNA were rated good to excellent in greater than 95% of the patients. With respect to ease of esophageal intubation, duodenal intubation, and general maneuverability, the performance of the new linear echoendoscope, compared with a radial scanning videoechoendoscope, was the same or better in, respectively, 85%, 87%, and 100% of procedures. The video image quality of the new linear array echoendoscope was superior to that of the radial scanning videoechoendoscope in all patients. No complications were encountered. CONCLUSIONS: EUS-FNA and celiac plexus neurolysis can be performed safely with the new compact EUS system. The efficiency of this procedure is enhanced compared with historical experience with other instruments. Although image quality is sufficient for EUS-FNA and celiac plexus neurolysis, the compact unit cannot be used as a "stand-alone" system for routine diagnostic EUS, and its use must be complemented by standard radial imaging.     

Utility of a repeated EUS at a tertiary-referral center

BACKGROUND: The utility of a repeated EUS by experts is not known. OBJECTIVE: To define the utility of a repeated EUS for the same indication. DESIGN: A retrospective case series. SETTING: Tertiary-referral hospital in Indianapolis, Indiana. PATIENTS: Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital. INTERVENTIONS: A repeated EUS. MAIN OUTCOME MEASUREMENTS: Clinical impact of a repeated EUS. RESULTS: Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed. LIMITATIONS: A retrospective design; a small number of nonpancreatic indications. CONCLUSIONS: In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.     

超声内镜对常规内镜活检阴性胃壁增厚病变的诊断价值

目的评价超声内镜对常规内镜活检阴性胃壁增厚病变的诊断价值。方法回顾性分析57例常规内镜活检阴性胃壁增厚病变行超声内镜检查患者的诊断结果和随访情况,以手术病理和随访结果为最终诊断,统计内镜超声检查术（EUS）的诊断符合率以及内镜超声引导下细针穿刺抽吸术（EUS—FNA）、内镜超声定位下活检的阳性发现率。结果57例最终诊断为胃癌19例、胃淋巴瘤10例、不典型增生1例、Menetrier’s病1例、炎性改变26例。EUS对胃癌的诊断符合率为53．8％（14／26）,对胃淋巴瘤的诊断符合率为50．0％（10／20）;EUS．FNA阳性发现率为47．4％（9／19）;内镜超声定位下活检阳性发现率为66．7％（20／30）。结论EUS结合EUS—FNA尚不能作为鉴别诊断常规内镜活检阴性胃壁增厚病变病因的金标准,但超声内镜对诊断有一定帮助。     

Opinion: How to manage subepithelial lesions of the upper gastrointestinal tract?

Subepithelial lesions (SELs) in the upper gastrointestinal (GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound (EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor (GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration (EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions (size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.     

Diagnostic accuracy of endoscopic ultrasonography for rectal neuroendocrine neoplasms

AIM:To investigate the diagnostic accuracy of endoscopic ultrasonography(EUS)for rectal neuroendocrine neoplasms(NENs)and the differential diagnosis of rectal NENs from other subepithelial lesions(SELs).METHODS:The study group consisted of 36 consecutive patients with rectal NENs histopathologically diagnosed using biopsy and/or resected specimens.The control group consisted of 31 patients with homochronous rectal non-NEN SELs confirmed by pathology.Epithelial lesions such as cancer and adenoma were excluded from this study.One EUS expert blinded to the histological results reviewed the ultrasonic images.The size,original layer,echoic intensity and homogeneity of the lesions and the perifocal structures were investigated.The single EUS diagnosis recorded by the EUS expert was compared with the histological results.RESULTS:All NENs were located at the rectum 2-10 cm from the anus and appeared as nodular(n=12),round(n=19)or egg-shaped(n=5)lesions with a hypoechoic(n=7)or intermediate(n=29)echo pattern and a distinct border.Tumors ranged in size from 2.3 to 13.7 mm,with an average size of 6.8 mm.Homogeneous echogenicity was seen in all tumors except three.Apart from three patients(stage T2 in two and stage T3 in one),the tumors were located in the second and/or third wall layer without involvement of the fourth and fifth layers.In the patients with stage T1 disease,the tumors were located in the second wall layer only in seven cases,the third wall layer only in two cases,and both the second and third wall layers in27 cases.Approximately 94.4%(34/36)of rectal NENs were diagnosed correctly by EUS,and 74.2%(23/31)of other rectal SELs were classified correctly as nonNENs.Eight cases of other SELs were misdiagnosed as NENs,including two cases of inflammatory lesions and one case each of gastrointestinal tumor,endometriosis,metastatic tumor,lymphoma,neurilemmoma,and hemangioma.The positive predictive value of EUS for rectal NENs was 80.9%(34/42),the negative predictive value was 92.0%(23/25),and the diagnostic accuracy was85.1%.CONCLUSION:EUS has satisfactory diagnostic accuracy for rectal NENs with good sensitivity,but unfavorable specificity,making the differential diagnosis of NENs from other SELs challenging.     

EUS-guided fine needle aspiration of the liver: indications,yield, and safety based on an international survey of 167 cases

BACKGROUND: The liver is a common site of metastases for various malignancies. EUS-guided fine needle aspiration (EUS-FNA) of liver masses has only been reported in small series from single centers. METHODS: A retrospective questionnaire was sent by e-mail to 130 EUS-FNA centers around the world regarding indications, complications, and findings of EUS-FNA of the liver. RESULTS: Twenty-one centers reported 167 cases of EUS-FNA of the liver. A complication was reported in 6 (4%) of 167 cases including the following: death in 1 patient with an occluding biliary stent and biliary sepsis, bleeding (1), fever (2), and pain (2). EUS-FNA diagnosed malignancy in 23 of 26 (89%) cases after nondiagnostic fine needle aspiration under transabdominal US guidance. EUS localized an unrecognized primary tumor in 17 of 33 (52%) cases in which CT had demonstrated only liver metastases. EUS image characteristics were not predictive of malignant versus benign lesions. CONCLUSION: EUS-guided FNA of the liver appears to be a safe procedure with a major complication rate of approximately 1%. EUS-FNA should be considered when a liver lesion is poorly accessible to US-, or CT-guided FNA should be considered when US- or CT-guided FNA fail to make a diagnosis, when a liver lesion(s) is detected (de novo) by EUS, and for investigation of possible upper GI primary tumors in the setting of liver metastases.     

Pelvic endometriosis simulating colonic malignant neoplasm

Three women had endometriosis that involved the rectosigmoid colon; their clinical presentation suggested primary colonic malignant neoplasm. Intestinal obstruction, weight loss, and, in two patients, rectal bleeding with radiologic evidence of a mass lesion that involved the rectosigmoid were present at initial evaluation. All patients eventually underwent colonic resection as definitive therapy. Endometriosis of the pelvic colon may mimic primary intestinal disease, mistakenly suggesting malignant neoplasm. Such symptoms in a young woman should prompt a search for endometriosis, which is a more likely diagnosis. Adequate therapy frequently requires surgical intervention.     

内镜超声及其引导下的细针穿刺活检在胰腺疾病中的诊断价值

目的:探讨内镜超声(EUS)及其引导下的细针穿刺活检(EUS-FNA)在胰腺疾病诊断中的价值.方法:回顾性分析2008-03/2010-03经EUS检查的62例胰腺疾病,其中有32例行细针穿刺活检.结果:(1)62例胰腺疾病中胰腺癌26例、慢性胰腺炎20例、胰腺囊肿10例、胰岛细胞瘤2例;(2)B超、CT、EUS/EU...     

Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma

BACKGROUND: Preoperative identification of lymph node metastases associated with esophageal carcinoma may influence treatment. EUS is the most accurate method for locoregional staging of these tumors. The impact of EUS-guided fine-needle aspiration (EUS-FNA) on lymph node staging in esophageal carcinoma is unclear. METHODS: From May 1996 to May 1999, 74 patients with esophageal carcinoma underwent preoperative EUS. After October 1998 EUS-guided FNA was performed on nonperitumoral lymph nodes greater than 5 mm in width. The results of EUS with and without FNA were retrospectively reviewed and compared. Final diagnosis was based on surgical results or EUS-guided FNA malignant cytology. Ten of the 74 patients had to be excluded for lack of lymph node stage confirmation. Final diagnosis was obtained in the remaining 64 patients (33 from the EUS only group and 31 from the EUS-FNA group). RESULTS: The results of EUS versus EUS-FNA for lymph node staging were sensitivity 63% versus 93% (p = 0.01), specificity 81% versus 100% (not significant), and accuracy 70% versus 93% (p = 0.02), respectively. Complications comprised 1 patient who developed self-limited bleeding after dilation that did not preclude completion of the EUS (1%, 95% CI [0%, 7%]). CONCLUSIONS: EUS-FNA is more sensitive and accurate than EUS alone for preoperative staging of locoregional and celiac lymph nodes associated with esophageal carcinoma. EUS-FNA of nonperitumoral lymph nodes in patients with esophageal carcinoma is safe and should be routinely performed when treatment decisions will be affected by nodal stage.     

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".     

A descriptive analysis of EUS-FNA for mediastinal lymphadenopathy: an emphasis on clinical impact and false negative results

OBJECTIVES: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been shown to accurately diagnose mediastinal lymph node pathology. We investigated the clinical impact of EUS-FNA in the management of patients with mediastinal lymphadenopathy, and determined the nature and clinical consequences of false negative results. METHODS: We analyzed a cohort of patients who were found to have mediastinal lymph nodes by EUS and underwent FNA. The diagnostic standard included FNA cytology, histopathology, and clinical follow-up. RESULTS: Sixty EUS-FNAs of mediastinal lymph nodes were performed on 59 patients (mean age 61 years old, 74.5% men) over a 24-month period. Prior to EUS, 20 (34%) patients had known malignancy. The most frequent indication for EUS was failed diagnosis by bronchoscopy (54%). EUS-FNA of lymph nodes showed malignant cells in 38%. The diagnostic accuracy of EUS-FNA was 84%. Among the 47 patients who were available for follow-up, EUS-FNA provided new information by changing the clinical diagnosis, and subsequently changed the management in 18 (38%) patients. The false negative rate was 20% (95% exact CI, 8.4-31.6%). Two of the 7 false negative cases received empiric chemoradiation without tissue diagnosis, and 4 received palliative treatment for advanced malignancy. CONCLUSION: The most common indication for EUS-FNA of the mediastinum in our institution is nondiagnostic transbronchial FNA. EUS-FNA is a valuable diagnostic method for sampling mediastinal lymph nodes and affecting management. False negative results do not appear to delay appropriate treatment or adversely affect clinical outcome.     

The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience.

BACKGROUND: The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients. METHODS: The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses. RESULTS: EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement. CONCLUSION: EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.     

Endometriosis recti — Wertigkeit der Endosonographie in der präoperativen Diagnostik

36 women with suspected rectal endometriosis were examined by endorectal sonography to evaluate the role of this technique for rectal wall involvement and to evaluate the position of preoperative diagnosis in the operative management. In 13 patients rectal wall involvement was detected by endorectal sonography. Those 13 women were operated by laparotomy and anterior rectal resection (n=9), particular excision of the involved wall (n=4) in the surgical department. In two cases the endometrial tumor was localized directly beyond the M. propria without infiltration. In 21 women rectal involvement could be excluded. All 23 patients without rectal involvement were treated laparoscopically in the gynecological department. Preoperative diagnosis was confirmed in all patients during operation. Endorectal sonography is able to visualize perirectal endometriomas and to access rectal wall involvement. Based on these preoperative findings operative management can be changed to laparotomy and resection of rectal wall or laparoscopic coagulation of endometriomas without rectal involvement.     

Advances in endoscopic ultrasound imaging of colorectal diseases

The development of endoscopic ultrasound(EUS) has had a significant impact for patients with digestive diseases, enabling enhanced diagnostic and therapeutic procedures, with most of the available evidence focusing on upper gastrointestinal(GI) and pancreaticobiliary diseases. For the lower GI tract the main application of EUS has been in staging rectal cancer, as a complementary technique to other cross-sectional imaging methods. EUS can provide highly accurate indepth assessments of tumour infiltration, performing best in the diagnosis of early rectal tumours. In the light of recent developments other EUS applications for colorectal diseases have been also envisaged and are currently under investigation, including beyond-rectum tumour staging by means of the newly developed forward-viewing radial array echoendoscope. Due to its high resolution, EUS might be also regarded as an ideal method for the evaluation of subepithelial lesions. Their differential diagnosis is possible by imaging the originating wall layer and the associated echostructure, and cytological and histological confirmation can be obtained through EUS-guided fine needle aspiration or trucut biopsy. However, reports on the use of EUS in colorectal subepithelial lesions are currently limited. EUS allows detailed examination of perirectal and perianal complications in Crohn’s disease and, as a safe and less expensive investigation, can be used to monitor therapeutic response of fistulae, which seems to improve outcomes and reduce the need for additional surgery. Furthermore, EUS image enhancement techniques, such as the use of contrast agents or elastography, have recently been evaluated for colorectal indications as well. Possible applications of contrast enhancement include the assessment of tumour angiogenesis in colorectal cancer, the monitoring of disease activity in inflammatory bowel disease based on quantification of bowel wall vascularization, and differentiating between benign and malignant subepithelial tumours. Recent reports suggest that EUS elastography enables highly accurate discrimination of colorectal adenocarcinomas from adenomas, while inflammatory bowel disease phenotypes can be distinguished based on the strain ratio calculation. Among EUS-guided therapies, the drainage of abdominal and pelvic collections has been regarded as a safe and effective procedure to be used as an alternative for the transcutaneous route, while the placing of fiducial markers under EUS guidance for targeted radiotherapy in rectal cancer or the use of contrast microbubbles as drug-delivery vehicles represent experimental therapeutic applications that could greatly impact the forthcoming management of patients with colorectal diseases, pending on further investigations.     

The utility and the safety of EUS-guided FNA in the evaluation of duplication cysts

BACKGROUND: Diagnosis of a foregut duplication cyst is of great clinical impact. A definitive diagnosis of a foregut duplication cyst can avert the need for major thoracic surgery in the otherwise asymptomatic individual. This study sought to evaluate the safety and the utility of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of foregut duplication cysts. METHODS: Over a period of 4 years, 4771 patients underwent EUS for various indications at two EUS referral centers. EUS findings were consistent with a mediastinal cyst in 30 cases. EUS-FNA was performed in 22 patients. A definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up. FNA was done with 22-gauge needles and antibiotic prophylaxis. RESULTS: The appearance of cyst contents on EUS ranged from completely anechoic (23 cases) to hypoechoic (7 cases). Hypoechoic cystic lesions contained echogenic foci. All anechoic lesions were confirmed as benign duplication cysts based on cytology, pathology, and clinical follow-up. Hypoechoic cystic lesions were confirmed to be benign duplication cysts in 4 cases. Three cases proved to be malignant or granulomatous necrotizing lymph nodes. No periprocedural complications occurred. CONCLUSIONS: Variation exists in the EUS appearance of benign mediastinal cysts. EUS-FNA of mediastinal cysts with smaller-gauge needles, and antibiotic prophylaxis appears safe and can provide a definitive diagnosis in atypical mediastinal cystic lesions.