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

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]).

Fig. 1 Contrast-enhanced computed tomography showing a 30-mm hypovascular mass (arrow) behind the portal vein. a Axial image. b Coronal image.

Fig. 2 Transgastric echoendoscopic image showing the obscure mass (arrow) with the intervening portal vein.

Fig. 3 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.

Fig. 4 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.

Fig. 5 Histopathological appearance, revealing adenocarcinoma.

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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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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 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
• 2 Ban T, Kawakami H, Kubota Y. et al. Endoscopic ultrasonography-guided fine-needle biopsy from the pancreatic head of a patient with Roux-en-Y reconstruction. Endoscopy 2018; 50: E202-E204
• 3 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
• 4 Ohno A, Kaku T, Kawabe K. Fine-needle-aspiration using forward-viewing echoendoscope for the recurrence of intraductal tubulopapillary neoplasm. Dig Endosc 2020; 32: e102-e103
• 5 Iwashita T, Nakai Y, Lee JG. et al. Newly-developed, forward-viewing echoendoscope: a comparative pilot study to the standard echoendoscope in the imaging of abdominal organs and feasibility of endoscopic ultrasound-guided interventions. J Gastroenterol Hepatol 2012; 27: 362-367

Publication History

Article published online:
29 April 2024