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An unexpected complication during EUS-FNA


1 Division of Gastroenterology, Hepatology and Endoscopy, Theodor Bilharz Research Institute, Giza, Egypt
2 Division of Gastroenterology, Hepatology and Endoscopy, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
3 Department of Internal Medicine, Hepatology and Gastroenterology Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
4 Department of Internal Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt

Date of Submission09-Jan-2021
Date of Acceptance06-May-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Hussein Hassan Okasha,
Division of Gastroenterology, Hepatology and Endoscopy, Kasr Al-ainy School of Medicine, Cairo University
Egypt
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00017

PMID: 34494583



How to cite this URL:
Ragab K, Elmeligui AM, Atalla H, Okasha HH. An unexpected complication during EUS-FNA. Endosc Ultrasound [Epub ahead of print] [cited 2021 Oct 24]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=325245

A 73-year-old diabetic and hypertensive male patient presented with progressive dysphagia and marked weight loss. There is no intake of antiplatelets or anticoagulants. Upper endoscopy revealed distal esophageal stricture with inconclusive biopsy results, so he was referred for EUS evaluation.

First, a linear echoendoscope was advanced into the distal esophagus where a short esophageal stricture was encountered at 33 cm from the incisors. There was an esophageal wall circumferential hypovascular mass in the most distal 4 cm with loss of wall layer differentiation, raising the possibility of a malignant neoplasm [Figure 1]. EUS-FNA was done using a 22G needle (EchoTip, Wilson-Cook) by conventional tissue actuation method with the aid of stylet and suction [Figure 2]. Instantaneous bleeding inside the lesion was evident endosonographically by observing a dense turbid fluid collection within the lesion [Figure 3] and endoscopically by further narrowing of the lumen as a result of newly formed hematoma [Figure 4]. A forward-viewing endoscopy was then introduced, and a Savary guidewire was passed through the narrowed lumen. An 11 cm/18 mm partially covered metal stent (self-expandable metal stents) was deployed at the site of stricture [Figure 5], and then, a second similar one was inserted proximal to the first one (stent-in-stent technique) with its proximal end above the upper level of the hematoma to act as a hemostatic scaffold and to dilate the partially obstructed lumen by the hematoma [Figure 6]. Follow-up period after the procedure was uneventful and the patient was discharged after 2 days. Cytopathological analysis revealed esophageal adenocarcinoma.
Figure 1: A soft tissue lesion is infiltrating the distal esophageal wall with loss of wall layer structure

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Figure 2: EUS-FNA of the distal esophageal wall lesion

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Figure 3: Post-EUS-FNA wall hematoma as seen by EUS (left panel). Post-EUS-FNA wall hematoma (another view, right panel)

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Figure 4: Post-EUS-FNA wall hematoma as seen by upper endoscopy

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Figure 5: The proximal end of the first deployed self-expandable metal stents

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Figure 6: The proximal end of the second deployed self-expandable metal stents

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EUS-FNA is an established standard method for tissue acquisition from different gastrointestinal tumors and strictures. Reported overall adverse event from EUS-FNA was 0.98% that included a bleeding rate of 0.13% in recent meta-analysis.[1] EUS-FNA is considered a high-risk procedure according to the guidelines of the European and American Society of Gastrointestinal Endoscopy,[2],[3] especially in patients taking antithrombotic agents which should be stopped before the procedure. However, bleeding is still possible even after these drugs had been stopped.[4] Although very uncommon, we have demonstrated that bleeding is a potential adverse event of EUS-FNA and attention should be taken during and after this procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

Hussein Hassan Okasha is an Editorial Board Member of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of this Member and his research groups.



 
  References Top

1.
Wang KX, Ben QW, Jin ZD, et al. Assessment of morbidity and mortality associated with EUS-guided FNA: A systematic review. Gastrointest Endosc 2011;73:283-90.  Back to cited text no. 1
    
2.
Veitch AM, Vanbiervliet G, Gershlick AH, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy 2016;48:385-402.  Back to cited text no. 2
    
3.
ASGE Standards of Practice Committee; Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016;83:3-16.  Back to cited text no. 3
    
4.
Kawakubo K, Yane K, Eto K, et al. A prospective multicenter study evaluating bleeding risk after endoscopic ultrasound-guided fine needle aspiration in patients prescribed antithrombotic agents. Gut Liver 2018;12:353-9.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

 
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