Mistakes in ... 2021 - 14

ueg education
Mistakes in... 2021
a
Mistake 2 Choosing the incorrect
echoendoscope
b
Examination of the hepatic hilum, which contains
the portal triad (formed by the main portal vein,
proper hepatic artery and common hepatic duct),
is mandatory for exploration of hilar strictures.
Most hilar strictures are a concern for underlying
malignancy, such as hilar cholangiocarcinoma,
gallbladder carcinoma, portal hepatic lymph
nodes, and less frequently benign conditions, such
as primary sclerosing cholangitis or postsurgical
complications.11
EUS has been used for imaging hilar
cholangiocarcinoma;12-14
however, although
imaging of the CBD can be done by both radial
and linear techniques, depending on the
operator's expertise, imaging of the hepatic
hilum is difficult, and sometimes even impossible
with a radial scope. The imaging capability of the
curved linear array is superior to radial scanning
for interrogating the area between the hepatic
portal region and the superior bile duct.15
EUS
Figure 2 | False-positive diagnosis of pancreatic
tumour. a | Hypoechoic appearance of the ventral
anlage of the pancreatic uncinate process suggesting
a focal lesion with a nondilated upstream pancreatic
duct. b | The parenchyma is enhanced
homogeneously, excluding the focal lesion.
exploration of the hepatic hilum with a linear
scope is possible and this should be the choice
when investigating cases of hilar obstruction
(figure 3).16
Pancreatic tail lesions are traditionally
accessed through the gastric fundus by
a
following the aorta until the coeliac take-off is
seen, at which point it bifurcates into the hepatic
and splenic artery. Once the splenic artery
is detected, it can be followed with a slightly
clockwise rotation and pulling out of the scope
movement. This movement allows complete
examination of the pancreatic body and tail up to
the splenic hilum. However, in some cases (about
20%), the pancreatic tail is distant from the gastric
wall and cannot be fully explored, especially with a
radial scope. Several studies show that the lowest
sensitivity of EUS for detecting pancreatic lesions
is in the tail (37-40%) compared with the body
(79%) and the head (83-92%).17-19
Thus, in
some clinical situations (unexplained acute
pancreatitis, intraductal papillary mucinous
neoplasm [IPMN] follow-up, secretory syndrome
with normal conventional imaging or screening for
a genetic predisposition for pancreatic neoplasia
syndrome), a linear scope should be chosen for
pancreatic body-tail exploration (figure 4).
Mistake 3 Having the incorrect position to
reach the target lesion during EUS-guided
tissue acquisition
c
b
When performing EUS-FNA or FNB (fine needle
biopsy) the EUS transducer should be placed as
close as possible to the target lesion. The uncinate
process is difficult to reach when excessive
torqueing of the echoendoscope in the second
part of the duodenum is necessary. Another
difficult location to reach is near the fornix and
greater curvature from the stomach, in which
case the long position of the echoendoscope
in the stomach can be helpful-the needle can
push the stomach wall and a rapid and strong
push of the needle is needed to pass the gastric
wall. Diverticula or interposing vessels should be
avoided by slight modification of the transducer
position to puncture the gastrointestinal wall
outside the vessels, followed by changing the
needle direction towards the direction of the
target lesion. In such awkward duodenal
positions, the use of thinner FNA needles
represents a technical advantage.
Previous surgery, especially gastrectomy or
Figure 3 | Cholangitis with dilated left hepatic duct and no evident cause of biliary obstruction at imaging. a | An
impacted bile stone in left hepatic duct invisible with EUS radial scope. b | The stone is diagnosed with a linear
scope. c | Fragmentation of the impacted stone by Spyglass-guided electrohydraulic lithotripsy.
2
pancreatectomy, can make the detection of
pancreatic lesions difficult. The surgical procedure
and type of gastrointestinal anastomosis should
be well documented before starting the EUS
procedure. Scanning of the pancreas should be
as extensive as possible, following the splenic
vein and the pancreatic duct. For body/tail
pancreatic lesions, the puncture is done easily
from the remnant stomach or from the level of
esophagojejunal anastomosis without passing
the anastomosis. Lesions situated in the head
of the pancreas are more challenging in case
of previous surgery. In patients with a Billroth
type I gastroduodenal anastomosis, they can be
targeted from the duodenum after passing the
anastomosis. In patients who have undergone

Mistakes in ... 2021

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