Endoscopic ultrasound assessment and tissue acquisition of mediastinal and abdominal lymph nodes

The differential diagnosis between benign and malignant lymph nodes(LNs)has a fundamental role in the characterization and staging of malignant conditions,as well as in subsequent patients’management.All imaging modalities(i.e.computed tomography and magnetic resonance imaging)rely mainly on size;endoscopic ultrasound(EUS)criteria based on B-mode evaluation and Doppler features fail to adequately characterize with high specificity LNs nature.The introduction of EUS-elastography and contrast-enhanced harmonic EUS are useful techniques to increase the diagnostic yield in identifying metastatic LNs,to identify which suspicious LN should require pathological characterization and,finally,to target tissue acquisition.EUS-guided tissue acquisition(EUS-TA)is increasingly being used for diagnosing lymphadenopathy whenever the characterization modifies patients’subsequent management and when no superficial LN is accessible.Since target therapy are currently available(i.e.lung cancer,breast cancer),EUS-TA of malignant LNs could be required to identify tumor biology.In this field,both fine needle aspiration and biopsy needles are able to guarantee accurate results with almost perfect specificity and sub-optimal sensitivity.We finally propose a diagnostic algorithm based on most recent,high-level evidence for the diagnostic approach to suspected LNs assessment.

Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasoundguided gastroentero-anastomosis

Gastric outlet obstruction(GOO)is a clinical syndrome characterized by postprandial vomiting,abdominal pain,bloating and,in advanced cases,by weight loss secondary to inadequate oral intake.This clinical entity may be caused by mechanical obstruction,either benign or malignant,or by motility disorders.In this review we will focus on malignant GOO and on its endoscopic ultrasound(EUS)-guided palliative treatment.The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas;other causes include duodenal or ampullary neoplasms,gastric lymphomas,retroperitoneal lymphadenopathies and,more infrequently,gallbladder and bile duct cancers.Surgery represents the treatment of choice when radical and curative resection is potentially feasible;if the malignant cause is not likely to be completely resected,palliative treatments should be proposed.Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent.Both treatments are effective;however,endoscopic stent placement is less invasive and it is associated with good short-term results,while surgery provides longer-lasting effects with a lower frequency of reintervention.In the last few years,EUS-guided gastroenterostomy(GE)has been proposed as palliative treatment for malignant GOO.This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction,through the deployment of a lumen-apposing metal stent under EUS-view.EUS-GE has the advantage of being as minimally invasive as enteral stent placement,and of guaranteeing long-term results similar to those of surgery.