Using the Endoscope for Endobronchial Ultrasound in the Esophagus
Summary
Transesophageal ultrasound (EUS-B) is a safe and feasible procedure using the echoendobronchoscope (EBUS) in esophagus and stomach. After identifying six anatomical landmarks, additional structures can be identified and biopsied, sparing subsequent diagnostic sessions. Thus, EUS-B is an ideal continuation of bronchoscopy and EBUS in diagnosing lung cancer and other diseases.
Abstract
EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that pulmonologists can use to visualize and biopsy structures adjacent to the esophagus and stomach. EUS-B gives access to many structures of which some may also be reached by EBUS (mediastinal lymph nodes, lung or pleural tumors, pericardial fluid) while others cannot be reached such as retroperitoneal lymph nodes, ascites, and lesions in the liver, pancreas or left adrenal gland. The procedure is a pulmonologist- and patient- friendly version of the gastroenterologists’ EUS using the thin EBUS endoscope that the pulmonologist already masters. Thus EUS-B training should be easy and a natural continuation of EBUS. With the patient under conscious sedation and in the supine position, the echoendoscope is introduced either through the nostril or mouth into the oropharynx. Then the patient is encouraged to swallow while the endoscope is slowly bent posteriorly and introduced into the esophagus and stomach. Using the ultrasonic image, the operator identifies the six landmarks by EUS-B and EUS: the left liver lobe, abdominal aorta (with the celiac trunk and superior mesenteric artery), left adrenal gland, and mediastinal lymph node stations 7, 4L, and 4R. Biopsies can be taken from suspected lesions under real-time ultrasonographic guidance- fine needle aspiration (EUS-B-FNA) using a technique similar to that used with EBUS-TBNA. The biopsy order is M1b-M1a-N3-N2-N1-T (M = metastasis, N = lymph node, T = tumor) to avoid iatrogenic upstaging. Pre- and post-procedural observation is similar to that of bronchoscopy. EUS-B is safe and feasible in the hands of experienced interventional pulmonologists and provides a significant expansion of the diagnostic possibilities in providing safe, fast, and thorough diagnosis and staging of lung cancer.
Introduction
Endoscopic ultrasound is a key procedure in the diagnosis and staging of lung cancer and allows safe sampling from mediastinal or hilar lymph nodes1,2. Endoscopic ultrasound comprises endobronchial (EBUS) and transesophageal ultrasound (EUS), are considered complementary procedures2.
Interventional pulmonologists are trained with the EBUS endoscope but are rarely familiar with the larger EUS endoscope (Figure 1), which requires special training to handle correctly3. EBUS and EUS are often performed by different departments and on separate sessions/days4. However, trained pulmonologists experienced with EBUS techniques can insert the smaller EBUS endoscope into the esophagus and perform safe examination and biopsy sampling from mediastinal lymph nodes and other lesions adjacent to the esophagus and stomach – a technique termed as EUS-B5. This leads to extension of pulmonologists' ability to safely and conclusively sample lesions in many different anatomical sites such as lung6, pleura7, pericardial effusion8, mediastinal lymph nodes1,5, left liver lobe and retroperitoneal lymph nodes9, pancreas10 and the left adrenal gland11,12 (Figure 2).
The EUS-B procedure is a pulmonologist friendly version of the gastroenterologists´ EUS using an endoscope that the pulmonologist already masters. The EUS procedure is performed with a gastroendoscope which is both larger and heavier than the EBUS endoscope, has a different handle (with wheels, see Figure 1) and is unlike EBUS performed with the patient in left lateral decubitus. Learning EUS as a pulmonologist is challenging and requires a lot of training and supervision2.
EUS-B and EUS are so far very similar regarding diagnostic yield when performed in the field of pulmonology5,13,14,15. EUS-B is patient friendly since the endoscope is significantly thinner than that of EUS, and therefore less unpleasant for the pharynx and esophagus. Unlike EBUS, EUS-B does not cause direct airway irritation and is therefore safe to use in patients with suspected cancer resulting in severe respiratory impairment due to mediastinal tumor masses16.
The combination of EBUS and EUS-B is preferred over either test alone in any patient suspected of lung cancer, but EUS-B should especially be considered in patients with suspicious lesions out of reach by EBUS, but within range by transesophageal ultrasound (Figure 2). Adding EUS-B to EBUS in lung cancer work-up expands the interventional pulmonologists´ ability to perform diagnostic work-up during a single session using the same endoscope by one proceduralist, which is more convenient for the patient, saving both time and costs.
The complication risk of EUS-B is extremely low and is to our knowledge only limited to infectious complications17,18. EUS-B training should be easy and a natural continuation of EBUS, and the following protocol will describe how to perform EUS-B in mild sedation in an out-patient clinical setting.
Protocol
Representative Results
Discussion
EUS-B has significantly changed the field of interventional pulmonology2,5,6,13. EUS-B allows the pulmonologist to access lesions not reachable with EBUS, simply by using the EBUS endoscope in a new way. A patient with a central lung tumor, enlarged mediastinal lymph nodes and abnormal left adrenal gland can have all lesions sampled with one endoscope in a single interventional session, saving …
Divulgazioni
The authors have nothing to disclose.
Acknowledgements
None.
Materials
| 22 Gauge FNA needle system | Olympus Medical Systems | Vizishot | |
| EBUS echoendoscope | Olympus Medical Systems | BF-UC190F | |
| EVIS Exera II endoscopy tower with EVIS X1 video processor | Olympus Medical Systems | CV-1500 | |
| Lidocaine gel | Multiple (e.g. Aspen Pharma) | Xylocain 2% | |
| Lidocaine spray | Multiple (e.g. Aspen Pharma) | Xylocaine Pump Spray |
Riferimenti
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