Forward-viewing echoendoscope aids tissue acquisition via the afferent limb after pancreaticoduodenectomy

Abstract

Figures

Contrast-enhanced computed tomography showing a 30-mm hypovascular mass (arrow) behind the portal vein. a Axial image. b Coronal image.

Transgastric echoendoscopic image showing the obscure mass (arrow) with the intervening portal vein.

a Endoscopic ultrasound-guided tissue acquisition (EUS-TA) with an oblique-viewing echoendoscope was technically unfeasible due to positional difficulty. Hence, a decision was made to perform EUS-TA via the afferent limb using a forward-viewing echoendoscope instead. b Forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan). c Fluoroscopic image showing the forward-viewing echoendoscope inserted into the afferent limb.

Endoscopic ultrasound-guided tissue acquisition. a EUS view of the hypoechoic mass (arrow) with B mode. b EUS view of the hypoechoic mass (arrow) using the color Doppler function. RHA, right hepatic artery. c Puncture of the mass under EUS guidance using a 22-gauge fine-needle biopsy needle. d Fluoroscopic image during EUS-TA.

Histopathological appearance, revealing adenocarcinoma.

Full text

Endoscopic ultrasound-guided tissue acquisition (EUS-TA), commonly performed with an oblique-viewing echoendoscope, can be difficult in patients with surgically altered anatomy 1 . Recently, EUS-TA using an oblique-viewing echoendoscope inserted over a guidewire into the afferent limb has been reported 2 , but there is the risk of perforation. Although forward-viewing echoendoscopes can be safely inserted into the distal intestinal tract, there are few reports about EUS-TA via the afferent limb using them 3 4 . Here, we describe a patient with surgically altered anatomy who underwent EUS-TA using a forward-viewing echoendoscope for recurrent cancer of the distal bile duct.

The 85-year-old man had previously undergone pancreaticoduodenectomy with modified Child’s reconstruction for distal bile duct cancer. Two years later, computed tomography revealed a 30-mm intra-abdominal mass behind the portal vein ( Fig. 1 ), suggestive of bile duct cancer recurrence. We attempted EUS-TA using a transgastric approach. However, the mass puncture could not be performed because of the intervening portal vein ( Fig. 2 ). Therefore, a decision was made to perform EUS-TA via the afferent limb using a forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan) instead ( Fig. 3 a , b ). The colonoscope was inserted into the afferent limb, followed by a guidewire, and the colonoscope was removed. Next, the echoendoscope was inserted into the afferent limb over the guidewire under fluoroscopic guidance and endoscopic vision ( Fig. 3 c ). EUS successfully showed a hypoechoic mass adjacent to the portal vein ( Fig. 4 a , b ). EUS-TA was performed without complications using a 22-gauge Franseen needle ( Fig. 4 c , d , Video 1 ). The histopathological diagnosis was adenocarcinoma, consistent with bile duct cancer recurrence ( Fig. 5 ).

Contrast-enhanced computed tomography showing a 30-mm hypovascular mass (arrow) behind the portal vein. a Axial image. b Coronal image.

Transgastric echoendoscopic image showing the obscure mass (arrow) with the intervening portal vein.

a Endoscopic ultrasound-guided tissue acquisition (EUS-TA) with an oblique-viewing echoendoscope was technically unfeasible due to positional difficulty. Hence, a decision was made to perform EUS-TA via the afferent limb using a forward-viewing echoendoscope instead. b Forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan). c Fluoroscopic image showing the forward-viewing echoendoscope inserted into the afferent limb.

Endoscopic ultrasound-guided tissue acquisition. a EUS view of the hypoechoic mass (arrow) with B mode. b EUS view of the hypoechoic mass (arrow) using the color Doppler function. RHA, right hepatic artery. c Puncture of the mass under EUS guidance using a 22-gauge fine-needle biopsy needle. d Fluoroscopic image during EUS-TA.

Histopathological appearance, revealing adenocarcinoma.

Endoscopic ultrasound-guided tissue acquisition successfully performed via the afferent limb using a forward-viewing echoendoscope in a patient with previous pancreaticoduodenectomy with modified Child’s reconstruction.Video 1

In cases of hilar lesions after pancreaticoduodenectomy with Child’s reconstruction, EUS-TA using an oblique-viewing echoendoscope is often difficult because the lesion is far away since it is approached transgastrically. Use of a forward-viewing echoendoscope may enable safe insertion into the afferent limb and EUS-TA with a short puncture distance 5 .

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