Successful endoscopic ultrasound-guided fine-needle biopsy of a recurrent paraganglioma using a forward-viewing echoendoscope in a patient who had undergone the Whipple procedure

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is useful for the diagnosis of retroperitoneal lesions and pancreatic diseases. However, the usefulness of EUS-FNB for tissue acquisition from retroperitoneal lesions in patients with surgically altered anatomy has not been established [1] [2] [3] [4] [5]. Herein, we report successful tissue acquisition from a recurrent lymph node lesion of a retroperitoneal paraganglioma by EUS-FNB using a forward-viewing echoendoscope (FV-EUS) in a patient who had undergone the Whipple procedure.

A 60-year-old man underwent the Whipple procedure for a retroperitoneal paraganglioma adjacent to the head of the pancreas ([Fig. 1]). Follow-up computed tomography 2.5 years after surgery revealed a 15-mm swelling of the lymph node on the right side of the inferior vena cava ([Fig. 2]). The lesion was located near the afferent loop, and we expected that it could be visualized using an FV-EUS (TGF-UC260J; Olympus, Tokyo, Japan).

Fig. 1 Computed tomography image of a retroperitoneal paraganglioma. The tumor was located adjacent to the head of the pancreas.

Fig. 2 Computed tomography image of a recurrent lymph node lesion (arrowheads) of the retroperitoneal paraganglioma.

To insert the FV-EUS into the afferent loop safely, a short-type single-balloon enteroscope (SIF-H290; Olympus) was first inserted into the hepaticojejunostomy anastomosis ([Fig. 3]), and a guidewire was placed. Then, under wire guidance, the FV-EUS was inserted up into the afferent loop, and the target lesion was visualized. EUS-FNB was performed transjejunally using a 22-gauge FNB needle ([Fig. 4]). The histopathological diagnosis was consistent with lymph node recurrence of the retroperitoneal paraganglioma ([Fig. 5]). Finally, open retroperitoneal tumor resection was performed, and complete resection was achieved ([Video 1]).

Fig. 3 A balloon enteroscope was inserted into the afferent loop.

Fig. 4 Endoscopic ultrasound-guided fine-needle biopsy was performed using a 22-gauge needle.

Fig. 5 The pathological specimen obtained by endoscopic ultrasound-guided fine-needle biopsy.

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Successful endoscopic ultrasound-guided fine-needle biopsy of a recurrent paraganglioma using a forward-viewing echoendoscope in a patient who had undergone the Whipple procedure.Video 1

This case demonstrates that EUS-FNB using an FV-EUS and assisted by balloon enteroscope insertion is a safe and effective method for tissue acquisition in patients with surgically altered anatomy, and can prevent adverse events, such as gastrointestinal perforation.

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Publication History

Article published online:
17 December 2024

• References

• 1 Katanuma A, Hayashi T, Kin T. et al. Interventional endoscopic ultrasonography in patients with surgically altered anatomy: techniques and literature review. Dig Endosc 2020; 32: 263-274
• 2 Larghi A, Fuccio L, Chiarello G. et al. Fine-needle tissue acquisition from subepithelial lesions using a forward-viewing linear echoendoscope. Endoscopy 2014; 46: 39-45
• 3 Tanaka K, Hayashi T, Utsunomiya R. et al. Endoscopic ultrasound-guided fine needle aspiration for diagnosing pancreatic mass in patients with surgically altered upper gastrointestinal anatomy. Dig Endosc 2020; 32: 967-973
• 4 Gong TT, Zhang MM, Zou DW. EUS-FNA of a lesion in the pancreatic head using a forward-viewing echoendoscope in a patient with Billroth II gastrectomy (with video). Endosc Ultrasound 2022; 11: 243-245
• 5 Akdamar MK, Eltoum I, Eloubeidi MA. Retroperitoneal paraganglioma: EUS appearance and risk associated with EUS-guided FNA. Gastrointest Endosc 2004; 60: 1018-1021