Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.

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Objective: The objective of this study is to compare the efficacy of central (single) vs bilateral (2-injections) endoscopic ultrasound (EUS)-celiac plexus neurolysis (CPN) for palliation of patients with pain related to pancreatic cancer. Materials and Methods: Patients with unresectable pancreatic cancer were included. Central EUS CPN was used in the first group and bilateral EUS CPN in the second. The measurement of pain was made with a visual analog pain scale (VAPS) applied before and after the procedure. Follow-up was made at weeks 2 and 4 after the procedure. The use of morphine before and after EUS CPN was evaluated. Complications related to the procedure were recorded. Results: A total of 53 patients underwent EUS CPN, 21 (39.6%) with the central technique and 32 (60.4%) with bilateral injection; 29 were women (54.7%) and the median age was 59 (30-85) years. The tumor was located in the head of the pancreas in 24 (45.3%) patients, the neck in 14 (26.4%), the body in 26 (49.1%) and in the tail of the pancreas in 8 (15.1%). Nearly, 14 (26.4%) patients had more than one pancreatic segment involved. There was no difference in the median (range) percent pain reduction from baseline-4 weeks later was 50% (0-100) vs 60% (0-100), for central and bilateral techniques, respectively; P = 0.18. In total, 60.4% of patients had a reduction of 50% punctuation in the VAPS. No major complications were detected. Conclusions: EUS CPN is useful for the management of pain in patients with unresectable pancreatic cancer, but there is no significant difference between central vs bilateral techniques.

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At present, the European Society of Gastrointestinal Endoscopy (ESGE) guidelines on endoscopic ultrasound-guided sampling are almost complete and express state of the art developments. However, future developments are anticipated. This editorial focuses on a few recently published papers with some additional information and on two important additional techniques, elastography and contrast enhanced ultrasound (CEUS), which are mentioned, but not explained in detail in the current ESGE guidelines. Elastography and CEUS might be of importance in the near future to improve the biopsy techniques.

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Ectopic pancreas is the relatively uncommon presence of pancreatic tissue outside the normal location of the pancreas. We report a case of abdominal pain due to retroperitoneal neuroendocrine tumor arising from heterotopic pancreatic tissue between the duodenal wall and the head of the pancreas. Patient underwent surgical enucleation of the tumor.

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Standard imaging of pancreas is generally obtained by computed tomography and magnetic resonance imaging. However endoscopic ultrasound (EUS) has become an indispensable tool for the diagnosis of various pancreatic diseases. Because of the close proximity of the EUS probe to the pancreas, EUS provides excellent images of the pancreas. In this review, we discuss the role of EUS in the clinical management of patients with benign pancreatic diseases, i.e., various forms of pancreatitis.

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Endoscopic ultrasonography is the best modality for pancreatic lesion evaluation as its superior spatial resolution allows small lesions to be identified and fine needle aspiration (FNA) cytology performed under ultrasound-guidance. Despite this, differentiating benign from malignant lesions remains a challenge as conventional ultrasound imaging is unable to differentiate lesions accurately and tissue yield is poorly diagnostic or limited in patients with the chronic inflammation. Contrast-harmonic technology uses a wide-band transducer capable of inducing sufficient acoustic energy to create harmonic microbubble oscillations of the newer second-generation ultrasound contrast agents (UCAs). These microbubbles are more stable, remaining within the intravascular component longer and emit significantly more harmonic content than surrounding tissue, thus allowing pancreatic parenchymal differentiation and microvascular architecture visualization. The use of UCAs is generally safe, but should be especially avoided in patients with unstable ischemic heart disease. During CH endosonography, pancreatic adenocarcinoma is commonly seen as an inhomogenous hypoenhancing lesion, focal pancreatitis as a hypo- or iso-enhancing lesion and neuroendocrine tumor as a hyperenhancing lesion. The presence of hyperenhancement is a strong predictor of non-adenocarcinoma etiology. Furthermore, in patients with the chronic pancreatitis or biliary stents that may obscure pancreatic inspection, the addition of contrast-harmonic endosonography to guide FNA cytology improves its diagnostic yield and accuracy. Quantitative analysis of perfusion through the time intensity curve is promising as an objective and accurate method to differentiate pancreatic lesions. Furthermore, studies are required to fully determine the role of contrast harmonic endosonography in the differential diagnosis of solid pancreatic lesions.

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Objective: Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma. Materials and Methods: Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France. Results: A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma. Conclusion: EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

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Gastrointestinal duplications usually manifest in children and may involve the esophagus in 20% cases. Esophageal duplication cysts are a rare cause of dysphagia in adults. We report the case of a 35-year-old male who presented to us with progressive dysphagia of 6 months duration. Contrast enhanced computed tomography showed a soft-tissue lesion in right lateral wall of distal thoracic esophagus. On endoscopic ultrasound, a heterogeneously echotextured lesion with anechoic component present at intramural location in the lower esophagus was noted. The patient underwent surgical excision of the lesion and histopathology confirmed the diagnosis of esophageal duplication cyst.

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We report a 56-year-old lady presented with cholangitis due to post-surgical clip migration associated choledocholithiasis. She under­went laparoscopic cholecystectomy 2 years ago. Endoscopic ultrasound revealed linear nature of hyper-echoic lesion casting acoustic shadow in the distal common bile duct suggestive of metallic surgical clip, which was later confirmed by endoscopic cholangiography.

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Heterotopic pancreas is usually asymptomatic and does not change throughout the patient's life, but sometimes it can present symp­toms and complications, which are rarely discrete in the literature. We present here a case of heterotopic pancreas in the gastric wall complicated with pseudocyst, and suggest that heterotopic pancreatic pseudocyst should be included in the differential diagnosis of gastric wall cysts.

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Endoscopic ultrasound (EUS) was one of the leading topics in 2013 Digestive Disease Week meeting and some new progresses were highlighted at the EUS monothematic symposium during the period. Although EUS-fine needle aspiration has increased the accuracy of EUS in the diagnosis of pancreatic and biliary diseases, controversies still exit in its application such as safety, cost-effectiveness and the choice of needle. Meanwhile, EUS may also function as a therapeutic approach and more and more digestive diseases could be treated with interventional EUS. This report will focus on the above aspects and some progresses of interventional EUS discussed in the meeting

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Hyperparathyroidism is an uncommon cause of pancreatitis and one should look for its telltale evidence on history (renal stone disease) and investigations (hypercalcemia). Endosonography has an upcoming role in the management of acute pancreatitis, especially in the presence of fluid collection. We report a case of parathyroid adenoma related acute pancreatitis complicated with pseudocyst, which was managed with percutaneous drainage and endosonographic localization of the adenoma to the left parathyroid gland. This patient underwent sestamibi scanning, which confirmed its presence and underwent surgical excision of the adenoma. Endosonography should be included in the work up of patients with unclear etiology and thyroids should be routinely scanned for parathyroid adenomas. One should always look outside the box to get clues for diseases inside the box.

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