Doppler probe and unroofing in the management of gastrointestinal subepithelial lesions

Aims Subepithelial lesions (SELs) are common and their diagnosis is usually not possible through regular endoscopy and biopsies. As deep biopsies may be associated with severe bleeding, patients are usually referred for endoscopic ultrasound (EUS). EUS is performed to characterize the lesion, its size, structure, location in the wall and vascularity. EUS-fine needle aspiration or biopsy (FNA/FNB) may enable sampling and diagnosis. However, EUS is highly operator dependent, expensive and is only performed in specialized centers. EUS investigations of SEL represent a significant burden for EUS operations. This causes long waiting lists for EUS and increases patient’s anxiety. Additionally, diagnostic accuracy of EUS is usually dependent on tissue sampling, being poor in small or polypoid lesions. There is the need for another approach for the assessment of SELs. The ideal solution should be safe, easy to perform, cheaper, non-highly operator dependent and available at first endoscopy (at any center). The doppler endoscopic prove (DEP) can be inserted through a conventional endoscope and enables assessment of vascularity beneath the mucosa in 3 different depth cathegories (superficial/middle/deep). Some studies had proven its efficacy in the management of peptic ulcer.

Methods This was a prospective blind pilot study. Patients referred for EUS due to a gastrointestinal SEL were invited to participate. First, endoscopy was performed and the lesion was characterized using endoscopy and DEP. The results of DEP were classified as 4 negative/superficial/middle/deep. Then, EUS was performed, being the EUSscopist blinded to the previous endoscopic findings. If after EUS, the lesion was considered avascular or poorly vascular, unroofing with biopsies was performed. The primary endpoint was the diagnostic accuracy of DEP (highly vascular or non-highly vascular) and correlation between DEP and EUS findings in terms of SEL vascularization. Secondary endpoints were the accuracy rate and adverse events of unroofing in the histological characterization of SELs.

Results Twenty-eight SELs from twenty-seven patients were included, corresponding 1/14/10/3 SELs in the esophagus/stomach/duodenum/colon, respectively. Regarding the primary endpoints, highly vascular/non-highly vascular for DEP and EUS is 3/25 and 4/24, respectively. The positive predict value (PPV)/negative predict value (NPV) for DEP is 2/3 (67%) and 23/25 (92%), respectively. Regarding the secondary endpoints, unroofing enabled histological diagnosis in 24/26 (92%). Four patients (4/28 14%) reported pain in the throat. 2/3 high vascular cases for DEP were liver and gall bladder compressions and all 25 non-highly vascular were SELs.

Conclusions This method is safe, feasible and easy to perform and might be available at any center. DEP has a good NPV, being a good tool for the exclusion or vascular lesions. Unroofing is also safe and associated with high accuracy in the diagnosis of SEL. Prospective RCT are warranted before the dissemination of DEP and unroofing.

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Artikel online veröffentlicht:
15. April 2024