Background: Most diagnosed pancreatic neuroendocrine tumors (pNETs) are nonfunctioning tumors (90.8%); the remaining 9% are malignant functioning tumors. While surgical resection is the standard of care, alternative management options may be mandated in symptomatic patients who refuse or are ineligible for surgery. We present a case of endoscopic ultrasound (EUS)-guided ethanol ablation of symptomatic insulinoma in a patient who refused surgery. Case Presentation: A 35-year-old man was referred to our facility with suspected insulinoma for EUS evaluation. During a 48-h supervised fast, a plasma glucose of 30 mg/dl was obtained with a corresponding serum insulin level of 235 μIU/mL (normal: 20–80) and C-peptide level of 19.9 ng/mL (normal: 2.8–9.9). Computed tomography abdomen revealed a normal pancreas with no detected masses. On admission, he was on intravenous glucose 25% at an infusion rate of 250 mL/h and octreotide (150 mcg subcutaneously three times daily). EUS examination revealed a small hypoechoic pancreatic tail mass 2 cm ×1.5 cm with no vascular involvement or detected lymph nodes. EUS-fine needle aspiration was done using a 25G needle. Pathological examination was consistent with NET. The patient's family initially refused surgery; EUS-guided ethanol ablation was therefore considered. The lesion was injected with 3 mL of ethanol using 25G needle resulting in a hyperechoic blush within the center of the tumor. Following the procedure, there was partial clinical success with the patient's glucose infusion rate decreased to 100 mL/h. After 3 days, a second session was considered. The lesion was re-injected with 3 mL of ethanol using 22G needle resulting in a hyperechoic blush of the lesion. Again, there was partial clinical success with the patient's glucose infusion rate decreased to 50 mL/h. There were no postprocedural complications. The patient's family decided to do surgery and distal pancreatectomy was done. Discussion: EUS-guided ethanol ablation of functioning pNETs is a less common therapeutic tool. A recent literature review showed 19 patients who underwent EUS-guided ethanol ablation of functioning pNETs from 2006 to 2015 with technical and clinical success in 100% of cases. This case reports another EUS-guided ethanol ablation of functioning insulinoma added to the documented cases, with partial clinical success. Despite partial clinical success, EUS-guided ethanol ablation is feasible and safe when applied to symptom relief in functioning tumors in patients who refuse or are ineligible for surgery.

Background and Objectives: In the perspective of improving accuracy of endoscopic ultrasound (EUS)-guided sampling, the efforts of innovation have focused on needle design, with the development of micro-core acquisition technology, and puncture technique variations. Available studies have shown that fine needle biopsy (FNB) needles can achieve a satisfactory diagnostic yield after fewer passes when compared to fine needle aspiration (FNA) needles, without an overall diagnostic advantage. Limited data are available to explain these results. We compared FNA and side-beveled FNB needles for micro-core/cellular material retrieval and diagnostic performance in pancreatic solid lesions. Methods: This was a single-center retrospective study of 110 consecutive patients who underwent EUS-sampling for a solid pancreatic lesion. All cellular material was collected for cell-block construction. The cytological examination was performed according to Papanicolaou. KRAS analysis was used as an ancillary technique to resolve indeterminate cases. Sensitivity and specificity were calculated in FNA (EchoTip ^® Ultra) and in FNB (EchoTip ProCore ^®) categories. All cases were evaluated for cellularity and micro-core (fragment retaining tissue architecture) retrieval. We compared FNA and FNB needles of different diameter (FNA: 19, 22, and 25G and FNB: 20, 22, and 25G), as well as large (19–20G) and small bore needles (22–25G). Results: Considering only positive cytology as diagnostic for malignancy, FNB needles showed higher sensitivity than FNA needles (86.4% vs. 54.9%, P = 0.002). If KRAS-mutated indeterminate cases were considered as malignant, overall sensitivity was 94.7%. In subcategories (FNB vs. FNA), sensitivity was 97.7% versus 92.2%, P = 0.37. Micro-cores were present in 65.2% of FNB versus 15.1% of FNA samples (P < 0.0001), rising to 95.2% in 20G-FNB category, and in 88.5% of large bore versus 20.5% of small bore needles (P < 0.0001). Considering the overall amount of cellular material (micro-cores plus cellular aggregates), FNB needles were better than FNA (91.3% vs. 62.3%, P = 0.001). The needle diameter did not influence the overall amount of cellular material retrieval since a satisfactory amount could be retrieved in both categories (large vs. small bore needles: 88.5% vs. 71.2%, P = 0.063). Conclusions: FNB needles allowed a relevant improvement in positive cytology with reduced need of KRAS mutational assessment or ancillary techniques. Dedicating all cellular material to the construction of cell-blocks and high retrieval rate of micro-cores may explain these results.

Objectives: This study aims to evaluate endoscopic ultrasound (EUS) ability in detecting and puncturing lesion of inferior vena cava (IVC) located below renal veins. Methods: A 54-year-old female patient presented with periodic abdominal pain. US and computed tomography (CT) revealed retrocaval lesion, compressing IVC 3 cm below the right renal vein – a big lymph node (28 mm) was suspected. EUS purpose was to differentiate this lesion between lymph node and primary tumor. EUS was performed under endotracheal anesthesia, in the patient's left lateral position, using radial and convex echoendoscopes, ultrasound contrast agent, and 25G needle. Results: Not knowing whether we would be able to reach infrarenal IVC area, we started with radial echoendoscope. EUS revealed a 3 cm oval hypoechoic lesion arising from IVC wall or invasing it, partly pressed into the IVC lumen. Doppler obtained single doubtful signal. Contrast-enhanced EUS showed the arterial phase vascularization. Two fine needle aspirations (FNAs) were done with slim convex echoendoscope during apnea, at active aspiration (with syringe) because of the risk of IVC injury. There were no complications. Cytology excluded lymph node and suspected vascular origin of the tumor. The patient underwent laparoscopic wedge resection of the infrarenal IVC wall containing the tumor with the use of linear stapler. Morphology of surgery specimen detected IVC leiomyoma. Conclusion: Contrast-enhanced EUS with FNA showed successful result in preoperative detection of inferior vena cava lesion located below renal veins.

Background and Objectives: Different tissue entities can present as solid pancreatic lesions (SPLs). This study aimed to explore the diagnostic accuracy of endoscopic ultrasound-guided dual needle sampling (endoscopic ultrasound-guided fine needle aspiration/biopsy [EUS-FNA/B]) in SPLs. Methods: In 2012-2016, consecutive patients with SPLs were prospectively included in a single-center setting aiming at dual sampling with EUS-FNA (22/25-gauge) and reverse bevel EUS-FNB (22-gauge) in each lesion. Randomization decided if the first pass should be EUS-FNA or EUS-FNB. The primary outcome was the diagnostic accuracy including mandatory immunostaining of all tumors but pancreatic ductal adenocarcinoma (PDAC). The secondary outcome was the clinical impact of dual needle sampling EUS-FNA/B in comparison with single needle EUS-FNA of SPLs performed in the same center 2006-2011 (the comparison cohort). Results: In 108 study subjects, 68 dual needle sampling procedures were performed. The four most common entities were PDAC (32%), neuroendocrine tumor (34%), pancreatitis (15%), and metastasis (6%). EUS-FNA and EUS-FNB had comparable diagnostic accuracy. EUS-FNA/B, compared with EUS-FNA, had a higher sensitivity for malignancy (91% vs. 75%, P = 0.004), higher sensitivity for non-PDAC malignancy (89% vs. 69%, P=0.02), and higher overall accuracy (91% vs. 78%, P=0.004). The performance of an additional diagnostic procedure was less frequent after EUS-FNA/B compared with EUS-FNA of the comparison cohort (4% vs. 21%, P=0.007). Conclusions: Reverse bevel EUS-FNB is not superior to EUS-FNA in the sampling of solid pancreatic lesions. However, dual needle sampling with both modalities (EUS-FNA/B) seems to improve the diagnostic accuracy and facilitate the clinical management, especially in malignant entities other than ductal adenocarcinomas.

Background and Objectives: Pancreatic cystic lesions (PCLs) are increasingly found in the clinical practice because of the widespread use of imaging modalities. Although differential diagnosis of nonneoplastic and neoplastic pancreas cysts is not certain markers, endosonography which has been taken place in cyst management shows morphologic specialty of cyst and cyst fluids by fine needle aspiration (FNA). Endoscopic ultrasound (EUS) and EUS-FNA performed patients were evaluated to pancreas cyst features for the differentiation of neoplastic or nonneoplastic. Method: Between January and July 2016, sixty patients with PCLs were retrospectively evaluated. Patients were recorded with undergoing pancreatitis, diabetes mellitus, and hematologic and biochemical parameters. EUS evaluation of PCLs was noted according to size, focal irregularity, wall thickness, and echo-dens mucus or debris. EUS FNA fluid was evaluated with biochemical (amylase, carcinoembryonic antigen, carbohydrate antigen 19-9) and cytology. Results: Finally, 73.3% were nonneoplastic cases, whereas 26.7% were found to have malignant or premalignant. On comparing nonneoplastic and neoplastic groups, age (P = 0.002), alkaline phosphatase (P = 0.001), and g-glutamyl transferase (P = 0.004) were high and hematocrit (P = 0.001) and albumin (P = 0.001) were low in malignant groups. Of the non-neoplastic PCLs, 61.3% were atypical pseudocysts, 20.4% were serous cystadenomas, and 18.1% were simple cysts, whereas of the malignant PCLs, 26.7% was intraductal papillary mucinous neoplasms, 18% were mucinous cystic neoplasms, and 25% were adenocacinomas. The septation in the nonneoplastic group was 25% and in the neoplastic group was 56.2% (P = 0.023). Cyst lobulation was 25% in the nonneoplastic groups and 56.2% in the neoplastic group (P = 0.014). Mural nodularity was 2.5% in the nonneoplastic group and 26.7% in neoplastic group (P = 0.005). Conclusion: Majority of patients who needed EUS-FNA that EUS and clinical investigation were insufficient for final diagnosis were nonneoplastic. This situation is thought that the management of PCLs for clinician poses still problems. Although cholestasis findings in the malign PCLs are more common than the non-neoplastic group, EUS-FNA performed in this cholestasis group is thought helping to differentiation of between neoplastic and nonneoplastic situation. In our study, the presence of mural nodularity and cyst septation in PCLs were found effective in differentiation of pre-malign and benign as in other studies. In addition to, we think that cyst lobularity may help differentiation of neoplastic and nonneoplastic.

A 48-year-old woman was referred for the management of an excluded left hepatic lobe (LHL) with recurrent cholangitis after right hepatectomy extended to the segment 1 and wedge resection of the segment 2 for the treatment of an occlusive metastatic adenocarcinoma of the sigmoid colon previously treated with neoadjuvant chemotherapy and local resection. The crossing of the stricture of the left intrahepatic bile ducts (LIHBDs) was not successful with endoscopic retrograde cholangiopancreatography (ERCP). A permanent percutaneous external biliary drainage was performed through segment 3 biliary branch, complicated with pain and bile leakage around the drain. A first attempt by endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) did not succeed given the absence of dilation of the LIHBD and mostly due to an unstable position induced by a small size of the remnant LHL. Then, a hybrid procedure was performed after changing the percutaneous drain for a 5Fr Arrow-Flex introducer that permitted the puncture of the external part of the introducer with an EUS transgastric EchoTip ^® 19G needle and insertion of a 0.025-inch guidewire directly into the LIHBD around the introducer. The introducer was removed and the guidewire was caught in the hepatic segment 2 by a percutaneous lasso to stabilize the 0.025-inch guidewire. An EUS-HGS was done after fistulization of the transhepatic tract by 6Fr cystotome and placement of a partially-covered self-expandable metal stents. The clinical course was uncomplicated under vancomycin for an Enterococcus faecium bacteremia, and then chemotherapy was restarted. EUS-HGS is clearly established as an alternative technique for biliary drainage in case of unsuccessful ERCP or altered anatomy, based on decisional algorithm, with a pooled technical success rate of 82%, clinical success rate of 97%, and adverse event rate of 23%. The success of this procedure depends on several factors and tips like the kind and length of the intragastric part of the prosthesis, angulation of the LIHBD, oversized dilation of the transhepatic tract, access to the liver segment 3, and shearing of the guidewire. The low volume of the LHL may also be a cause of technical failure that can be resolved by new procedures as described in this case.

We present a 55-year-old male with recurrent attacks of fresh bleeding per rectum, 3 intermittent bouts per year for the last 2 years. The last attack was severe; hemoglobin dropped to 7 g/dl necessitating blood transfusion. Colonoscopy revealed a rectal polyp, 1 cm × 1.5 cm, with bluish intact covering mucosa, compressible on palpation by a biopsy forceps, highly impressive of rectal hemangioma. No biopsies were taken for fear of bleeding. Rectal endoscopic ultrasound (EUS) showed a soft tissue polyp, 5 cm above the anal verge originating from the submucosal layer (3^rd layer) with preserved deeper muscularis propria layer. Doppler study showed a feeding vessel at its base with venous color flow signal. The lesion was most probably localized rectal cavernous hemangioma. The treatment options for the localized type of GI hemangiomas include polypectomy with endoloop, ethanolamine oleate injection, cyanoacrylate (histoacryl) injection, or surgery. We avoided doing polypectomy with endoloop as it will carry a high risk of postprocedural bleeding after falling of the loop or band with exposure of the significant feeding vessel seen by EUS examination. As there was no role for vessel embolization by interventional radiology as the feeding vessel is vein and not an artery, we preferred to do ethanolamine oleate injection. Hence, EUS had direct implication on choosing the line of therapy of that case. 12 mL of 5% ethanolamine oleate were injected (4 injections, 3 mL each) by a usual sclerotherapy needle. No further bouts of bleeding per rectum for 3 months after the maneuver. Conclusion: Rectal EUS could help in choosing the line of management of vascular rectal polyps.

Background and Objectives: Many gastrointestinal tumors as diffuse circumferential malignancies as signet ring cell carcinoma and lymphoma may involve mainly the submucosal layer and hence are difficult to diagnose as they frequently yield negative endoscopic biopsies. This main aim of this study is to evaluate the accuracy of endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of diffuse gastrointestinal (GI) lesions with inconclusive endoscopic biopsies. Patients and Methods: This prospective study included 102 patients with diffuse or circumferential GI lesions with nonconclusive biopsies that were taken during upper or lower endoscopy. EUS and EUS-FNA were performed to all patients with cytopathological examination. Results: This study included 65 males (64%) and 37 females (36%), with the mean age of 54.6 years; 80 cases (78.4%) were proved to have malignant lesions; 22 cases (21.6%) were proved to be benign. EUS had a sensitivity of 95%, specificity of 65%, positive predictive value (PPV) of 91%, negative predictive value (NPV) of 45% with P < 0.0001 in diagnosing malignant lesions. EUS-FNA had a sensitivity of 83%, specificity of 100%, PPV of 100%, NPV of 62%, with P < 0.0001. Conclusion: EUS with EUS-FNA is an accurate procedure in the diagnosis of endoscopic biopsy negative diffuse or circumferential GI lesions.

Solid pseudopapillary neoplasm (SPPN) of the pancreas is a rare tumor entity that arises from different pancreatic parts constitutes up to 2.5% of all pancreatic neoplasms. We addressed special focus on the general descriptive features of SPPNs regarding age, gender, symptoms, diagnostic tools, pathological features, surgery, and outcome. SPPN has low malignant potential. It usually discovered incidentally with great predilection to occur in young women in about 90% of reported cases. SPPNs exhibit benign characteristics in most of cases reported with low tendency toward malignant behavior. Tumor size may reach up to 10 cm and the prevalent sites of tumor occurrence are the head and tail of the pancreas comprising 40% and 30%, respectively. SPPNs tend to arise as single pancreatic mass, but some reported cases of multicentric SPPN. Endoscopic ultrasound (EUS)-guided fine needle aspiration (EUS-FNA) is used as a preoperative diagnostic tool with sensitivity and specificity of 90% and 94%, respectively. Surgical resection is the standard of care for treatment of such neoplasms as it achieves cure and prolongs patient survival. Long-term prognosis is evidently excellent with 5-year survival rates ranging 95%–97%. In addition, 10-year survival may be as high as 90%, but these data are limited. Nonresectable tumors are treated by surgical debulking. In our series, we identified 18 cases of SPPN confirmed by histopathological examination. Female to male ratio is 9:1, and mean age was 29 with an average of 5.5 years. The oldest of our patients was a 70-year-old male. All patients presented with abdominal pains; some presented with anorexia and weight loss. EUS showed a soft tissue mass with multiple cystic areas that represented areas of internal hemorrhage. The size ranged from 2 cm up to 10 cm. Eight masses were located in the body, 7 in the head, 2 in the tail, and only one case in the uncinate process. The cytopathological study demonstrated single cells, small loose clusters, and scattered intact papillary structures with delicate fibrovascular cores, finely granular cytoplasm, and nuclei with fine chromatin. No distant metastasis was observed. EUS-FNA was done in all cases using a 22G needle and revealed SPPN in all cases. Distal pancreatectomy or modified Whipple operation was done and final histopathology confirmed the diagnosis. Only one patient operated by Whipple resection complicated by postoperative abdominal sepsis and died 2 weeks later. Follow-up for at least 2 years for the rest of the patients revealed no recurrence.

Background and Objectives: Pancreatic schwannomas are a rare disease. They consist of a tumor originating from Schwann cells, and usually, the diagnosis comes from a surgical resection since the image alone is not characteristic. The endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can provide a tissue sample of the tumor by minimal invasive examination. This study shows the diagnosis of three cases of pancreatic schwannomas by EUS-FNA. Methods: This retrospective study shows the diagnosis of three consecutive pancreatic schwannomas by EUS-FNA in patients that had an incidentalome. Results: Three patients were diagnosed with schwannoma in a private clinic in Rio de Janeiro. One of the lesions was solid, situated in the head and neck of the pancreas, hypoechoic, with anechoic areas of cystic degeneration. The second lesion was cystic, hypoechoic, situated in the neck of the pancreas, with exophytic growing. The third lesion was cystic and solid, situated in the body of the pancreas. Fine-needle aspirations were made with a standard 19G needle and revealed cells that expressed S-100 protein, suggestive for schwannoma. Conclusion: The EUS-FNA can provide tissue sample of the tumor by minimal invasive examination and make this rare diagnose in the pancreas. It should be considered in the differential diagnosis of solid and cystic lesions of the pancreas.

Background and Objectives: Pancreatic calculi (PCs) are sequelae of chronic pancreatitis (CP) and may obstruct and produce ductal hypertension leading to pain, the cardinal feature of CP. Indications for endotherapy include stones <5 mm size, stones in the head of pancreas which are not impacted and absence of downstream strictures. The assessment before the procedure is done by magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT). However, problems are encountered during endoscopic retrograde cholangiopancreatography (ERCP) clearance which are not anticipated despite MRCP/CT. The problems are possible impacted stones, hard stones, indeterminate stricture, and change of finding during ERCP. Hence, controversy exists. Endoscopic ultrasound (EUS) can help by providing concordance or discordance with MRCP images and may help in further clarification. The aim of this study is to evaluate the role, feasibility, and management changes of EUS before ERCP in patients planned for endotherapy in CP. Another objective was to evaluate whether EUS features of pancreatic duct (PD) stones can serve as a predictor of successful removal during ERCP. Methods: The data of 412 patients during the study period (2009–2016) with CP were retrospectively analyzed. A total of 143 were associated with stones in head/papillary region of pancreas. Out of these, 75 were excluded and remaining 68 were evaluated by EUS using a linear/radial echoendoscope before ERCP. Results: Out of 68 cases, 48 were associated with hard stones with acoustic shadowing while 20 were associated with soft stones without acoustic shadowing. In 20 soft stones cases, ERCP was successful in 18 patients. In 48 with hard stones, there was failure of endotherapy in 40 which required extracorporeal shock wave lithotripsy (ESWL)/surgery. The presence of large (≥5mm), hard, immobile stones were negative predictors of successful endotherapy. Small, ampullary/papillary stones were positive predictors. Conclusion: The present study suggests that EUS can differentiate “soft PD stones” (without an acoustic shadow) from “hard PD stones”(with acoustic shadow). “Hard PD stones” are better managed by ESWL. An EUS can influence important therapeutic decisions before endotherapy and can prevent unsuccessful attempts at ERCP and thus improve overall success/prognosis. An EUS has an additional advantage of making a diagnosis of ampullary/papillary stones and biliary obstruction which can be treated endoscopically. It can guide whether endotherapy needs to be performed through major or minor papilla. EUS by diagnosing pancreatic tumor/strictures missed on other imaging modalities allows early surgical reference and hence improves long term prognosis.

Background and Objectives: Although uncommon in the West, Ascaris lumbricoides is a common cause of acute pancreatitis in developing countries. The mechanism of acute pancreatitis in ascariasis may be due to obstruction of papilla of Vater, invasion of common bile duct (CBD), or pancreatic duct (PD). The invasion of PD occurs rarely owing to its smaller caliber. Ultrasonography (USG) is an effective tool for the diagnosis of biliary and pancreatic ascariasis; however, the diagnosis may be false negative in up to 30% of cases. Pancreatic ascariasis is a rare entity. We present our retrospective data of last 10 years of 15 cases of pancreatic ascariasis. Methods: During a study period of 10 years, 15 cases of pancreatic ascariasis were diagnosed by USG/endoscopic ultrasonography (EUS). EUS was performed with a linear or radial echoendoscope. Thirteen patients presented with symptoms of acute pancreatitis. Out of 13 patients, nine presented with first episode of idiopathic pancreatitis while four presented with idiopathic recurrent acute pancreatitis. One patient had biliary colic and one patient presented with acute cholangitis. Twelve patients had mild pancreatitis while only one had moderate pancreatitis. Only two cases were diagnosed with USG while 13 patients were diagnosed with EUS. Out of 15 patients, 14 underwent side viewing endoscopy with removal of live single/multiple worms with rat tooth forceps/biopsy forceps/dormia basket in 13 patients. Two patients were managed conservatively with repeat USG showing absence of ascariasis. There were no complications. Results: Two patients had associated bile duct ascariasis. EUS features were single or multiple linear hyperechoic structure without acoustic shadowing in the PD or CBD or with central hypoechoic tube, representing alimentary canal of the worm and movements of worms inside the duct. Live roundworms were removed from CBD and PD without undertaking sphincterotomy. In endemic areas, sphincterotomy facilitates the risk of migration of worms into the CBD. Conclusion: Ascariasis-induced acute pancreatitis is mild and EUS is the investigation of choice. The recurrence is rare and treatment is side viewing endoscopy with removal of worms. Although USG is quite sensitive for diagnosing biliary and pancreatic ascariasis, its sensitivity significantly falls when the worm is thin, in the PD, or the CBD is non-dilated. EUS should be used early in the workup of idiopathic acute pancreatitis after the first episode.

Background and Objectives: Thoracocentesis is the first diagnostic procedure for pleural effusion (PE). If diagnosis after thoracocentesis remains uncertain, pleural biopsy either computed tomography (CT)/ultrasonography (USG)-guided or thoracoscopy is required for definitive diagnosis. Overall, access to thoracoscopy is limited in many parts of the world as significant resources and expertise are required. We present the data about evaluation of undiagnosed PE by endoscopic ultrasound (EUS)-guided pleural aspiration or fine needle aspiration cytology (FNAC) of the lymph nodes/pleural deposits. This is first case series regarding EUS-guided FNAC of pleural deposits. Methods: During 2 years, 11 patients of undiagnosed PE were evaluated by EUS. Aspiration of PE was done if fluid sampling was required and EUS-FNA with rapid on-site evaluation (ROSE) was done if FNAC from PE deposit or lymph node was required. Results: Seven patients had right sided and four had left PE. Three cases had unsuccessful attempts/complications at US-guided aspiration. A single pass was successful in diagnostic aspiration in these cases and the aspirated fluid was suggestive of tuberculosis. The remaining eight cases had nondiagnostic aspiration and FNAC with ROSE (average two passes) was done from mediastinal lymphadenopathy or pleural deposits. Four cases with mediastinal lymphadenopathy had granulomatous lesions. Four cases with pleural deposits had malignancy. In this series, EUS was selected as the last diagnostic option for three indications: nontappable PE (3 cases), PE with mediastinal nodes (4 cases) and PE with pleural deposits (4 cases). Conclusion: EUS-guided imaging introduces a totally different path/technique of imaging for inspection of the pleural space. EUS-FNA can be performed as safe procedure in undiagnosed PE. At present, it appears that EUS-guided evaluation is an alternative modality for the evaluation of undiagnosed PE, in the cases who are unfit for thoracoscopy and as an alternative or adjunct to USG/CT-guided aspiration or biopsy.

The most efficient and cost-effective approach to undiagnosed exudative pleural effusion remains uncertain. Both closed pleural biopsy and thoracoscopy may be utilized for the acquisition of pleural tissue. The cumulative yield of image-assisted (either ultrasound or computed tomography [CT]) repeat thoracocentesis and pleural biopsy has been reported to approach that of thoracoscopy. Thoracoscopy, either medical (pleuroscopy) or surgical (video-assisted thoracoscopic surgery [VATS]), remains gold standard in undiagnosed pleural effusion with or without pleural thickening/nodularity or mass. However, thoracoscopy has its own limitations and contraindications. Image-guided pleural biopsy by endoscopic ultrasound (EUS) has never been explored in the past. We describe case series of EUS-guided FNA of pleural deposits in four patients. Case 1: A 50-year-old man, chronic smoker, presented with cough and weight loss. A CT scan of chest revealed a 5 cm × 4 cm size lesion near the apex of lung with pleural effusion. Family was unwilling for thoracoscopy. Linear EUS was performed from esophagus. EUS revealed a well-defined hypoechoic mass above the aorta between esophagus and chest wall. Fine needle aspiration FNAC showed non-small cell lung cancer. Case 2: A 58-year-old man, a smoker for 34 years, was evaluated for breathlessness and chest pain. CT scan revealed a pleural effusion and a nodule on the mediastinal aspect of pleura. He was unfit for bronchoscopy/thoracoscopy. EUS revealed 1.7 cm × 1 cm hypoechoic deposit on mediastinal pleura with pleural effusion. FNAC was diagnostic of nonsmall cell lung cancer. Case 3: A 65-year-old man, a smoker for 40 years, presented with breathlessness. A CT chest showed a mass above right lobe of liver and right-sided pleural effusion. He had low baseline oxygen saturation and could not be stabilized even after supportive therapy. An EUS-guided examination was done without sedation. Hypoechoic deposit was seen extending from diaphragmatic aspect to mediastinal aspect of pleura. FNAC was diagnostic of nonsmall cell lung cancer. Case 4: A 60-year-old morbidly obese (weight 124 kg) female presented with recurrent undiagnosed exudative pleural effusion. CT scan showed a mass close to right bronchus with massive right side pleural effusion. She was unfit for bronchoscopy or thoracoscopy. An EUS examination was done without any sedation. EUS revealed 5 cm × 6 cm hypoechoic mass (deposit) on mediastinal pleura with pleural effusion. FNAC showed multiple caseating granulomas suggestive of tuberculosis.

Background and Objectives: Obtaining a tissue diagnosis from lung tumor or mediastinal lymph node located lateral to the aorta (para-aortal) is a diagnostic challenge because of the interposition of the aorta. Invasive surgical procedures such as mediastinotomy, thoracotomy, or video-assisted thoracic surgery are required for the diagnosis of these lesions. Lymph nodes on the “far-side” of major blood vessels can be visualized by endoscopic ultrasound (EUS); however, fine needle aspiration (FNA) is avoided due to concern for bleeding complications. Tumors and mediastinal lymph nodes located in the para-aortic region can easily be visualized by esophageal EUS, because the aorta provides an excellent medium to transfer ultrasound waves. The objective of the study is to evaluate the feasibility, yield, and safety of EUS-guided transaortic FNA of lung tumors and para-aortic lymph nodes. Methods: A retrospective case series of 12 consecutive patients with suspected lung cancer or tuberculosis who underwent transaortic FNAC during a study period of 7 years. Based on computed tomography/positron-emission tomography imaging, a transesophageal FNAC performed through the aorta was considered as the only option to diagnose or stage these patients by means of a minimally invasive procedure. Seven patients had left-sided lung mass. Four patients has enlarged para-aortic lymph node, suspicious for IASLC Stations 5 (n = 1) and 6 (n = 3). EUS was performed with a linear echoendoscope. All aspirates were obtained under real-time US-guided FNA by using a 22/25-gauge needle. A single real-time FNA of the lung mass or lymph node was performed. Results: The final diagnosis was known in 11 patients (5 non-small cell lung carcinoma [SCLC], 2 SCLC, 3 tuberculosis, and 1 thymolipoma). EUS-FNA established diagnosis in 9 of 12 patients (75%). One procedure was abandoned due to complication. Conclusion: This case series demonstrates the feasibility and probable safety of single EUS guided transaortic aspiration in para-aortic lesions. The diagnostic yield is 75%. Clearly, further study and very careful selection by expert EUS operators are needed before this procedure can be routinely recommended. Advantages of this procedure include day care procedure, less invasive than surgical procedures, low-cost, good diagnostic yield and can be performed in poor surgical candidate. Limitations includes single-center study, requires EUS expertise, more data are required. At present, transaortic FNA should only be performed in the absence of alternative minimally invasive diagnostic procedures.

Background and Objectives: The cause of acute pancreatitis (AP) remains elusive even after extensive work up in 10%–30 % of cases. It is important to determine the cause of AP as it helps for early treatment and limits unnecessary tests and to prevent recurrence which may improve a patient's long-term prognosis. Our study aimed to evaluate the diagnostic yield, feasibility, and management changes of early endoscopic ultrasound (EUS), performed within 24–48 h of admission in patients with idiopathic acute pancreatitis (IAP). Methods: During the study period (2010–2016), 850 cases of AP were admitted. Out of these, etiology was determined in 666 (78.35%). There were 184 cases of IAP. EUS examination was done using a linear/radial echoendoscope. Results: Out of 158 cases (90 males; age range: 15–70 years) of IAP (26 were excluded), EUS was able to clinch the diagnosis in 110 patients (69.6 %). The most common causes of IAP included biliary stone disease (gallbladder microlithiasis, common bile duct microlithasis/stone/sludge) (n = 60) followed by chronic pancreatitis (CP) (n = 25), pancreatic tumor (n = 11), and pancreaticobiliary ascariasis (n = 10). Other etiologies included hydatid cyst rupture of bile duct, opium addiction, and duplication cyst. No cause was found in 48 (31.4%) patients. Conclusions: Early EUS establishes diagnosis in about 70% cases of IAP and changes the short-term management in IAP. Biliary stone disease was the predominant cause for IAP followed by CP. EUS is a safe investigation with a high diagnostic yield. An early EUS can influence important therapeutic decisions and prevent further attacks of AP which may occur if a delayed EUS is performed and thus improve long term prognosis. An early EUS has an additional advantage of making an early diagnosis of pancreatic tumors/pancreaticobiliary ascariasis and ampullary/papillary stones which can be treated endoscopically. It also prevents making the wrong diagnosis of sludge as etiological factor for AP which may occur in patients undergoing a delayed EUS since sludge may be secondary to AP due to prolonged fasting, total parenteral nutrition or antibiotics such as ceftriaxone.

Background and Objectives: Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. The most common etiology is acute or chronic pancreatitis. The most common clinical presentation is gastrointestinal (GI) hemorrhage secondary to rupture of the aneurysm. Such a complication is not always related to the size of the aneurysm, and therefore, treatment should be planned as soon as a diagnosis is made. Surgical, endovascular, percutaneous, and endoscopic ultrasound (EUS)-guided interventions are used in the treatment of visceral artery pseudo-aneurysms. Methods: A 50-year-old male had an episode of alcohol induced acute moderate severe pancreatitis 1 month back. He presented with melena, requiring six units of blood transfusions for hemodynamic stabilization. After hemodynamic resuscitation, the patient underwent upper GI endoscopy to know the etiology of massive upper GI bleeding. Upper GI endoscopy showed a bulge with overlying ulceration in the second part of the duodenum. Side viewing endoscopy showed a pulsatile bulge with overlying large ulcer. Ultrasound abdomen showed pseudo-aneurysm of size 3.8 cm × 5.6 cm arising from GDA artery. Contrast-enhanced computed tomography abdomen with angiography showed a saccular pseudo-aneurysm of size 4 cm × 6 cm in relation to GDA. EUS from duodenal bulb showed a pseudo-aneurysm of size 4.1 cm × 5.8 cm arising from GDA. Radiological or EUS-guided interventions were considered. The advantages and disadvantages of both procedures were explained. The patient selected the option of EUS-guided coil embolization. Results: Under EUS and fluoroscopy guidance, five coils of 10 mm size were placed within pseudo-aneurysm through 19-gauge EUS needle. After coil embolization, contrast injection into the pseudo-aneurysm showed partial filling of pseudo-aneurysm. Review EUS 1 day after coil embolization showed high flow in the pseudo-aneurysm. Around 30% of pseudo-aneurysm was obliterated. On the 3^rd day, 6 mL of human thrombin was (3000 IU) injected during second session of intervention in six boluses of 500 unit each. After thrombin injection, high-velocity flow was confined to the neck and periphery of pseudo-aneurysm. Further 2 mL of thrombin was injected. Immediately after thrombin injection, color Doppler EUS showed complete obliteration of pseudo-aneurysm. Two weeks later, repeat EUS showed completely obliterated pseudo-aneurysm with no flow. Conclusions: This case shows the practical problems of EUS-guided coil embolization of pseudo-aneurysms.

Background: Hepatic artery pseudo-aneurysms are rare and have been reported after abdominal trauma and after abdominal surgery. Hepatic artery pseudo-aneurysms constitute 20% of all visceral artery aneurysms. It carries very high risk of rupture with severe bleeding into peritoneal cavity, bile duct, or portal vein. Essentially, all pseudo-aneurysms, whether symptomatic or not symptomatic, require early treatment to prevent lethal complications. Surgical treatment consists of ligation or revascularization of the hepatic artery but is associated with higher morbidity compared to endovascular treatment. The goal of endovascular treatment of hepatic aneurysms is to obtain a complete, stable exclusion of the sac from arterial circulation with preservation of the parent vessel. Endovascular, percutaneous, and endoscopic ultrasound (EUS)-guided interventions are used in the treatment of visceral artery pseudo aneurysms. Case Report: A 20-year-old male presented with abdomen pain in right upper quadrant for two months. He had undergone ultrasound-guided aspiration of liver abscess two months ago. Ultrasound abdomen showed an aneurysm arising from hepatic artery. Computed tomography angiography of the abdomen confirmed a saccular pseudo-aneurysm arising from proximal part of hepatic artery. The lesion was not considered feasible for percutaneous intervention. Interventional radiologist suggested hepatic artery stenting across the neck of aneurysm to block the flow of blood into the aneurysm and explained the associated risk of ischemia, infarction due to stent stenosis, thrombosis, and distal migration of the stent. After discussing the pros and cons of EUS-guided procedure, the patient chose EUS-guided coil embolization. The sack packing with helical coils was planned. Packing with one coil of 10 mm and five coils of 6mm size through a 19-gauge needle caused 80% obliteration of the sac. Five days later, EUS assessment showed the injected coils were collected into the most distal part of the aneurysm but the flow into a smaller cavity continued with high velocity. During the second attempt, four coils of 10 mm size were deployed. Postcoiling EUS assessment still showed flow into the aneurysm. Three more coils of 8 mm size were placed and complete obliteration of aneurysm was confirmed by contrast injection and EUS. One week later, follow-up color Doppler abdomen showed no flow in the pseudo-aneurysm. Conclusion: This case showed the practical problems of EUS-guided coil embolization of hepatic artery aneurysm. Initial attempt resulted in 80% obliteration of aneurysm cavity but did not cause progressive thrombosis of rest of the cavity of the aneurysm. However, successful and complete obliteration of pseudo-aneurysm was achieved in second attempt of coiling.

Background: Malignant tracheoesophageal fistula (TEF) is a devastating complication of esophageal cancer, lung cancer, or other carcinoma associated with high mortality, short survival, and poor quality of life. Covered metallic stents placement either in trachea/esophagus or both are used for the palliative treatment. Other endoscopic modalities rarely attempted for benign and malignant TEF include use of over the scope clip, transesophageal glue injection, electrocautery, and laser. Case Description: A 56-year-old man presented with complaint of intractable cough on swallowing for last 3 months. He had completed a course of chemo-radiotherapy for carcinoma of middle one-third of the esophagus 4 months back. The upper gastrointestinal endoscopy showed a stricture with superficial ulceration at 23 cm from lower incisor in the esophagus. A small (~4 mm diameter) fistula was noted just above the stricture. Application of over-the-scope clip was failed. A hydrophilic guide wire (0.032″ diameter) was placed through the ERCP cannula into the fistula. Bronchoscopy revealed the presence of guidewire coming out from a fistulous tract in the posterior wall of the trachea above the tracheal bifurcation. The guide wire was grasped with a biopsy forceps. The guidewire was removed along with the scope from the mouth. The fluoroscopic image showed a curved course (length of the fistula was about 2.5 cm) of the guidewire. After assessment of the fistula by the track of the guidewire, two routes of glue injection were considered, transtracheal and transesophageal. Transesophageal route was considered risky due to an expected spillage of the glue within the trachea. Hence, the option of transtracheal glue injection was selected. The cannula and the scope were reintroduced through the trachea. The presence of the markers on the cannula was used to assess the depth of insertion of cannula within the fistula and to plan the site of injection of the glue. 1 mL of cyanoacrylate glue was injected while pulling the cannula out. 1 mL of distilled water was injected while pulling out the rest of the cannula to the tip of the fistula. After one hour, the patient started swallowing liquids without any cough. The patient has remained asymptomatic till now. Conclusion: Transtracheal glue placement may be safer than transesophageal glue placement. This appears to be the first report of transtracheal glue injection of malignant TEF.

Background and Objectives: Endoscopic ultrasound (EUS) elastography is a noninvasive ultrasound technique that measures the stiffness of tissues. Both a qualitative score and a quantitative method (strain ratio [SR]) can be used to study the hardness of solid pancreatic lesions (SPLs). This single-center prospective cohort study aimed to evaluate the efficacy of the combination of EUS elastography and SR for the diagnosis of SPL using the elastography software on the new Olympus echo-processor EU-ME2. Methods: Two different areas were selected: area A included the tumor; area B was placed in a soft peri-tumoral normal (parenchymal SR [pSR]) and in the gastrointestinal wall (wall SR [wSR]). The quantitative score of elastography was calculated by the SR method (area B/area A). Elasticity measurements were performed 3 times in each procedure. Means of pSR and of wSR were calculated and used as final results for each patient. Final diagnosis was made on the basis of EUS-guided fine needle aspiration, surgical specimens, or follow-up of at least 6 months. Results: Study population included 100 patients and a total of 102 SPLs. Mean lesion (standard deviation) size was 27.1 mm (12.4). The final diagnosis classified SPL into adenocarcinoma (ADC, n = 69) or benign lesions (n = 33). Benign lesion group included 19 neuroendocrine tumors. ROC analysis identified a cutoff of SR of 9.1 as the best value for the detection of malignancy. Sensitivity, Specificity, positive predictive value, negative predictive value, and accuracy with their cutoff value for malignancy are shown in the full article. Univariate logistic regression analysis showed that both pSR and wSR were significant discriminators for ADC and benign SPL. The overall area under the characteristic curve was 88.6% (81.2%–96.0%), indicating good ability in discriminating between cancers and benign lesions. The major limitation of this study is the low number of benign masses, but these preliminary data showed the feasibility of the SR calculated with the Olympus EU-ME2 echo-processor and the higher SR values in ADC. Conclusions: EUS-elastography may be helpful in the diagnosis of SPLs, especially in the identification of those suspected for ADC. Further studies are needed to assess its diagnostic accuracy and reproducibility.

Malignant melanoma is reported to metastasize to all organs of the human body. Although pancreatic metastases are rare, they range from 2% to 5% of pancreatic malignancies. Differentiating a primary pancreatic malignancy from a metastasis can be difficult due to similarities on imaging findings, but it is crucial to ensure proper treatment. Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is often needed to provide a cytologic diagnosis. We present a case of a 48-year-old man who had 4 years later surgical treatment for a skin melanoma located in the right axillary region. Abdominal computed tomography showed two round masses in the body of the pancreas. He was referred to our Clinic for EUS-FNA. EUS-FNA was performed with a 22G Pro-Core ^® Needle (Cook Medical Inc., Limerick, Ireland) and cytology material was obtained after three needle passes. The slides and cell-block were stained and analyzed by cytopathologists, showing pancreatic metastases of malignant melanoma.

Paracoccidioidomycosis, or South American blastomycosis, or Lutz disease, is a granulomatous infection caused by fungus. Pancreatic infection with mass formation is very uncommon. We report a case of a 72-year-old man with abdominal pain and weight loss for the past 4 months. Abdominal computed tomography (CT) showed masses in the pancreatic head and body. He was referred to our Clinic for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), with suspicious of pancreatic adenocarcinoma. EUS-FNA was performed with a 22G Pro-Core ^® needle (Cook Medical In., Limerick, Ireland) and cytology material was obtained after three needle passes. The slides were stained and analyzed by a cytopathologist, showing numerous Paracoccidioides forms. It seems to be the first report of this diagnostic issue made by EUS-FNA.

Background and Objectives: Pancreatic cystic tumors are detected with increasing frequency globally. One large cross-sectional imaging study showed a prevalence of 25.5% for multifocal cystic tumors. A surgical series showed that single cysts within multifocal disease exhibit independent behavior in molecular and histological analyses. Our study describes the endoscopic ultrasound (EUS) appearance and prevalence of cystic tumors in multifocal disease, which has not previously been studied. Methods: We report a retrospective analysis of 545 consecutive patients with pancreatic cystic lesions who underwent EUS from January 2010 to July 2015. The patient demographics were 63% females and 37% males, mean age of 67 years, range 21–94. Results: On initial EUS, 315 (58%) of 545 patients had single lesions. 100 (32%) of 315 patients with single lesions had EUS follow-up, and the 11 patients who later developed multifocal disease were not included in our analyses. 230 (42%) of 545 had multiple cystic lesions on initial EUS and comprised our primary analysis. These patients (mean age 71.3) were significantly older (P < 0.05) than patients with single lesions (mean age 64.3). Of the 230 patients with multiple cystic tumors on initial EUS, 145 (63%) were women and 85 (37%) were men. Before EUS, computed tomography (CT) imaging only detected multiple cystic lesions in 16 (7%) of these patients in whom multiple lesions were later diagnosed on EUS. 83 (36%) of patients with multifocal disease had both simple and multilobulated cysts. 154 (67%) of patients with multifocal disease had cysts scattered throughout both the proximal region (uncinate, head, and neck) as well as in the distal region (body/tail) of the pancreas. 34 (15%) of patients with multifocal disease had solid internal nodules. Conclusion: Multifocal disease was seen in 42% of patients with cystic tumors evaluated by EUS, due to the increased sensitivity of EUS compared to CT. As cystic tumors are more common in females, multiple cystic tumors are also more common in female patients. The cystic lesions were both complex and simple in appearance on EUS in these patients, with 15% having a solid internal nodule, which has a predisposition for malignancy. As the majority of these patients had cystic lesions scattered throughout the pancreas, we recommend a complete pancreatic examination when performing EUS for pancreatic cysts detected on CT.

We present advances in multiphoton and coherent Raman microscopy and endoscopy for gastrointestinal cancer detection. We use stimulated Raman scattering combined with second harmonic generation to reveal cell nuclei, cytoplasm, and collagen simultaneously in human tissues. For the first time, cell nuclei, cytoplasm, and extracellular matrix can be visualized in real time with image quality similar to histology.

Objective: The objective of the study is to investigate the application of endoscopic ultrasound-guided needle-based confocal laser endomicroscopy (EUS-nCLE) in the diagnosis of pancreatic neoplasms. Methods: Patients with pancreatic neoplasms were diagnosed by endoscopic ultrasound and punctured by 19G needle; Cellvizio AQ-Flex19 confocal microprobe was implanted through the needle. The diagnostic yield and complication were evaluated and compared with pathology. Results: A total of 28 patients successfully underwent EUS-nCLE examination, including serous cystadenoma (n = 5), mucinous cystadenoma (n = 3), intraductal papillary mucinous neoplasms (n = 3), pseudocyst (n = 1), ductal adenocarcinoma (n = 10), neuroendocrine tumors (1), solid pseudopapillary tumor (n = 2), chronic pancreatitis (n = 2), and lymphoma (n = 1). High-quality images were obtained in all the patients. The diagnostic yield in 26 patients with pathology was 73.1% (19/26) and the specificity of serous cystic neoplasm (SCN) and intraductal papillary mucinous neoplasm (IPMN) was 100% (7/7). The complications, mostly pancreatitis and intracystic hemorrhage, were occurred in 10.7% (3/28) patients. Conclusion: EUS-nCLE is a safe and feasible method in the diagnosis of pancreatic neoplasms and shows high specificity in SCN and IPMN.