Endoscopic ultrasound-fine needle injection for oncological therapy

The minimal invasiveness and precision of endoscopicultrasound(EUS) has lead to both its widespread use as a diagnostic and staging modality for gastrointestinal and pancreaticobiliary malignancies, and to its expand-ing role as a therapeutic modality. EUS-guided celiac plexus neurolysis is now a well-accepted modality for palliation of pain in patients with pancreatic cancer. EUS-guided ablation, brachytherapy, fiducial marker placement, and antitumor agent injection have been described as methods of performing minimally invasive oncological therapy. EUS-fine needle injection may be performed as adjunctive, alternative, or palliative treatment. This review summarizes the studies to date that have described these methods. A literature search using the Pub Med/MEDLINE databases was performed. While most published studies to date are limited with disappointing outcomes, the concept of a role of EUS in oncological therapy seems promising.

Long-term efficacy and safety of cap-assisted endoscopic sclerotherapy with long injection needle for internal hemorrhoids

BACKGROUND Hemorrhoids are a common anal condition and can afflict an individual at any age.Epidemiological survey results in China show that the prevalence of anorectal diseases is as high as 50.1%among which 98.08%of patients have hemorrhoid symptoms.AIM To assess long-term efficacy and safety of cap-assisted endoscopic sclerotherapy(CAES)with long injection needle for internal hemorrhoids.METHODS This study was retrospective.Data from patients with symptomatic internal hemorrhoids treated with CAES using endoscopic long injection needle from April 2016 to December 2019 were collected.Patients were telephoned and followed at two time points,December 2020 and 2021,to evaluate the improvements in symptoms,complications,recurrence,and satisfaction.RESULTS Two hundreds and one patients with internal hemorrhoids underwent CAES with the long needle.The first median follow-up was performed 33 mo postoperatively.Symptoms improved in 87.5%of patients after the first CAES.Efficacy did not decrease with treatment time extension.Fifty-four patients underwent colonoscopy after the first CAES treatment of which 21 underwent CAES again,and 4 underwent hemorrhoidectomy.At the first follow-up,62.7%of patients had both improved hemorrhoid grades and symptoms,and 27.4%had a significant improvement in both parameters.At the second follow-up,61.7%of the patients showed satisfactory improvement in their hemorrhoid grade and symptoms when compared with pre-surgery values.90%of patients reported CAES was painless,and 85%were satisfied/very satisfied with CAES treatment outcomes.CONCLUSION The present study based on the largest sample size reported the long-term follow-up of the treatment for internal hemorrhoid with the CAES using endoscopic long injection needle.Our findings demonstrate that CAES should be a micro-invasive endoscopic technology yields satisfactory long-term efficacy and safety.

Endoscopic ultrasound-guided intraportal injection of autologous bone marrow in patients with decompensated liver cirrhosis:A case series

BACKGROUND Recently,stem cell therapy has been extensively studied as a promising treatment for decompensated liver cirrhosis(DLC).Technological advances in endoscopic ultrasonography(EUS)have facilitated EUS-guided portal vein(PV)access,through which stem cells can be precisely infused.AIM To investigate the feasibility and safety of fresh autologous bone marrow injection into the PV under EUS guidance in patients with DLC.METHODS Five patients with DLC were enrolled in this study after they provided written informed consent.EUS-guided intraportal bone marrow injection with a 22G FNA needle was performed using a transgastric,transhepatic approach.Several parameters were assessed before and after the procedure for a follow-up period of 12 mo.RESULTS Four males and one female with a mean age of 51 years old participated in this study.All patients had hepatitis B virus-related DLC.EUS-guided intraportal bone marrow injection was performed in all patients successfully without any complications such as hemorrhage.The clinical outcomes of the patients revealed improvements in clinical symptoms,serum albumin,ascites,and Child-Pugh scores throughout the 12-mo follow-up.CONCLUSION The use of EUS-guided fine needle injection for intraportal delivery of bone marrow was feasible and safe and appeared effective in patients with DLC.This treatment may thus be a safe,effective,non-radioactive,and minimally invasive treatment for DLC.

Endoscopic ultrasound-guided treatments: Are we getting evidence based- a systematic review

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound(EUS)-guided treatments.These include EUS-guided drainage of pancreatic fluid collections,EUS-guided necrosectomy,EUS-guided cholangiography and biliary drainage,EUSguided pancreatography and pancreatic duct drainage,EUS-guided gallbladder drainage,EUS-guided drainage of abdominal and pelvic fluid collections,EUS-guided celiac plexus block and celiac plexus neurolysis,EUSguided pancreatic cyst ablation,EUS-guided vascular interventions,EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy.However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy,such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting.We undertook a systematic review to record the entire body of literature accumulated over the past 2decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles,based on the classification of studies according to levels of evidence,in order to assess the scientific progress made in this field.

Interventional endoscopic ultrasound:Therapeutic capability and potential

The linear echoendoscope,introduced in the 1990s,opened the era of interventional endoscopic ultrasound(IEUS).The linear echoendoscope enabled EUS guided Fine Needle Aspiration(EUS-FNA) allowing the path of the needle to be traced during the puncture process.After EUS-FNA,other interventional procedures were introduced in clinical practice.Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established.After EUS-FNA,Celiac plexus neurolysis(CPN) and block(CPB),pancreatic pseudocyst drainage,abdominal and mediastinal collections/abscesses drainage,and in selected cases,pancreatic and biliary ductal system drainage,were introduced in clinical practice.EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality.We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.

Endoscopic ultrasound in gastroenterology:From diagnosis to therapeutic implications

Since its advent in 1980,the scope of endoscopic ultrasound(EUS)has grown to include a wide range of indications,and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology.Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders.EUS was first used to visualize remote organs,such as the pancreas and abdominal lymph nodes.When fine needle aspiration was introduced,the indications for EUS expanded to include tissue sampling for diagnostic purposes.At the same time,the needle can be used to convey a potential therapy to the internal organs,allowing access to remote sites.In this review,we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.

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.

Role of endoscopic ultrasound in anticancer therapy:Current evidence and future perspectives

The digestive system is one of the most common sites of malignancies in humans.Since gastrointestinal tumors represent a massive global health burden both in terms of morbidity and health care expenditures,scientists continuously develop novel diagnostic and therapeutic methods to ameliorate the detrimental effects of this group of diseases.Apart from the well-established role of the endoscopic ultrasound(EUS)in the diagnostic course of gastrointestinal and hepatobiliary malignancies,we have recently become acquainted with a vast array of its therapeutic possibilities.A multitude of previously established,evidence-based methods that might now be guided by the EUS emerged:Radiofrequency ablation,brachytherapy,fine needle injection,celiac plexus neurolysis,and endoscopic submucosal dissection.In this review we endeavored to provide a comprehensive overview of the role of these methods in different malignancies of the digestive system,primarily in the treatment and symptom control in pancreatic cancer,and additionally in the management of hepatic,gastrointestinal tumors,and pancreatic cysts.

Possibilities of interventional endoscopic ultrasound

Since endoscopic ultrasound (EUS) was developed in the 1990s, EUS has become widely accepted as an imaging tool. EUS is categorized into radial and linear in design. Radial endoscopes provide cross-sectional imaging of the mediastinum, gastrointestinal tract, liver, spleen, kidney, adrenal gland, and pancreas, which has highly accuracy in the T and N staging of esophageal, lung, gastric, rectal, and pancreatic cancer. Tumor staging is common indication of radial-EUS, and EUSstaging is predictive of surgical resectability. In contrast, linear array endoscope uses a side-viewing probe and has advantages in the ability to perform EUSguides fine needle aspiration (EUS-FNA), which has been established for cytologic diagnosis. For example, EUS-FNA arrows accurate nodal staging of esophageal cancer before surgery, which provides more accurate assessment of nodes than radial-EUS imaging alone. EUS-FNA has been also commonly used for diagnose of pancreatic diseases because of the highly accuracy than US or computed tomography. EUS and EUS-FNA has been used not only for TNM staging and cytologic diagnosis of pancreatic cancer, but also for evaluation of chronic pancreatitis, pancreatic cystic lesions, and other pancreatic masses. More recently, EUS-FNA has developed into EUS-guided fine needle injection including EUS-guided celiac plexus neurolysis, celiac plexus block, and other "interventional EUS" procedures. In this review, we have summarized the new possibilities offered by "interventional EUS".

Endoscopic ultrasound in the evaluation of pancreatic neoplasms-solid and cystic: A review

Pancreatic neoplasms have a wide range of pathology, from pancreatic adenocarcinoma to cystic mucinous neoplasms. Endoscopic ultrasound(EUS) with or without fine needle aspiration(FNA) is a helpful diagnostic tool in the work-up of pancreatic neoplasms. Its utility in pancreatic malignancy is well known. Over the last two decades EUS-FNA has become a procedure of choice for diagnosis of pancreatic adenocarcinoma. EUS-FNA is highly sensitive and specific for solid lesions, with sensitivities as high as 80%-95% for pancreatic masses and specificity as high as 75%-100%. Multiple aspects of the procedure have been studied to optimize the rate of diagnosis with EUS-FNA including cytopathologist involvement, needle size, suctioning and experience of endoscopist. Onsite pathology is one of the most important elements in increasing diagnostic yield rate in EUS-FNA. EUS-FNA is valuable in diagnosing rare and atypical pancreatic neoplasms including neuroendocrine, lymphoma and metastatic disease. As more and more patients undergo cross sectional imaging, cystic lesions of the pancreas are becoming a more common occurrence and EUS-FNA of these lesions can be helpful for differentiation. This review covers the technical aspects of optimizing pancreatic neoplasm diagnosis rate, highlight rare pancreatic neoplasms and role of EUS-FNA, and also outline the important factors in diagnosis of cystic lesions by EUS-FNA.

Diagnosis of intraductal papillary mucinous neoplasm using endoscopic ultrasound guided microbiopsies:A case report

Pancreatic cysts are increasingly diagnosed due to expanding use of cross-sectional imaging,but current diagnostic modalities have limited diagnostic accuracy.Recently,a novel through-the-needle microbiopsy forceps has become available,offering the possibility of obtaining cyst-wall biopsies.We present a case of 41-year-old male with chronic pancreatitis and a 2-cm pancreatic cyst,initially considered a pseudocyst.Subsequently,endoscopic ultrasou-nd guided microbiopsies were successfully obtained,which surprisingly revealed an intraductal papillary mucinous neoplasm of mixed subtype with low grade dysplasia.In conclusion,obtaining biopsies from the wall of the pancreatic cystic lesions with this novel instrument is feasible and,as demonstrated in this case,can possibly alter the clinical outcome.Microbiopsies offered enough cellular material,allowing supplemental gene mutation analysis,which combined with other modalities could lead to a more individual approach when treating pancreatic cysts.However,prospective studies are warranted before routine clinical implementation.

根据MRI体积测量咽喉部血管瘤平阳霉素瘤内定量介入治疗

目的探讨在电子喉镜及内窥镜专用注射小针双重辅助下,根据瘤体体积(MRI测量),精确定位定量瘤内注射平阳霉素混合液治疗咽喉部血管瘤的方法及疗效。方法收集5年来咽喉部血管瘤25例,MRI增强扫描,测量瘤体体积,电子喉镜明确定位后,利用内镜专用注射小针头(奥林帕斯WF-1816PN),根据瘤体体积,按比例瘤内精确定量注射平阳霉素混合液。结果治愈的20例,显效5例。经2年以上的随访,未见复发。结论根据瘤体MRI体积测量,定量控制平阳霉素瘤内介入治疗,方法安全可靠,简单有效。

自制内镜注射针经喉镜注射氢氧化钠构建兔食管良性狭窄模型

目的探讨一种新的兔食管良性狭窄模型构建方法——自制内镜注射针经喉镜注射氢氧化钠（NaOH）构建食管良性狭窄模型，为支架置入体内相关介入研究提供实验基础。方法自制注射针：将一次性胃镜注射针外层导管去除，取含针头端长约70mm内芯导管。将针头剪至2mm长并磨成斜坡状，去除针柄及部分塑料管，然后接上内芯导管无针头端。选择2—3奴健康兔10只，3％戊巴比妥（1ml/kg）经耳缘静脉注射麻醉，左侧卧位固定于DSA操作台；透视下将泥鳅导丝插入胃腔，8mm×40mm球囊置于食管下段贲门处，喉镜下距球囊近端约1cm处选取环周4个点，经自制内镜注射针分别注入1．5％NaOH0．25ml。术后2周和4周分别作喉镜及造影检查；术后4周处死实验兔，取材作组织病理学检查。结果术后2周喉镜检查显示食管中下段溃疡形成。无明显狭窄；造影显示食管中下段管壁不光整。术后4周喉镜显示食管中下段瘢痕形成、食管狭窄；造影显示食管中下段局部狭窄：组织病理学检查提示局部溃疡、黏膜下层增厚、瘢痕形成。食管管径狭窄率为平均49．54％（44．89％～56.65%）；狭窄长度造影测量为平均18．0mm（14．6-22．8mm），标本测量为平均16．3mm（13．1-21．1mm）。结论自制内镜注射针经喉镜注射1．5％NaOH可成功构建兔食管良性狭窄模型,方法简单易行,狭窄程度和部位易控。

超声内镜引导下胰腺疾病诊断与治疗的研究进展

胰腺属于腹膜后位器官,传统影像学方法诊断胰腺疾病的准确度不高,恶性肿瘤发现时往往已是晚期,患者失去手术机会。超声内镜引导下细针穿刺抽吸活检对于胰腺占位性疾病具有较高的诊断价值,现已广泛应用于胰腺疾病的诊断,一些新兴的超声内镜下影像技术(如弹性成像和共聚焦激光显微内镜等)也逐渐成为重要的诊断工具。超声内镜引导下引流是胰腺内引流治疗的首选方式,超声内镜引导下射频消融和腹腔神经丛阻滞等技术作为新型的治疗手段,在胰腺癌新辅助和姑息治疗中也开始发挥重要作用。内镜超声的发展和普及将为胰腺疾病的诊疗提供新的途径。

超声内镜引导下穿刺抽吸联合硬化剂注射术治疗肝囊肿的疗效

目的探讨超声内镜(EUS)引导下穿刺抽吸联合硬化剂注射术对肝囊肿患者炎症因子的影响。方法2020年6月-2022年6月安阳市第三人民医院收治的肝囊肿患者90例,随机数字表法分为对照组和观察组各45例,依次行硬化剂注射术或者EUS引导下穿刺抽吸联合硬化剂注射术,观察48周。比较两组治疗前及治疗后7 d血生化指标及炎因子水平,分析两组治疗后12周总有效率及不良反应发生率,并观察两组治疗后48周肝囊肿复发率。结果观察组治疗后12周末总有效率为95.56%,高于对照组的82.22%(P<0.05)。两组治疗后7 d ALT、AST、ALP及TBil无显著差异(P>0.05)。观察组治疗后7 d血清CRP、TNF-α和IL-1β水平分别为(53.83±6.24)mg/L、(260.80±18.40)ng/L和(91.04±5.10)ng/L,显著低于对照组[(56.67±5.96)mg/L、(268.92±16.93)ng/L和(93.22±4.87)ng/L,P<0.05]。观察组不良反应发生率为2.22%,低于对照组的17.78%(P<0.05)。观察组治疗后48周末肝囊肿复发率为2.27%,低于对照组的17.95%(P<0.05)。结论相较于硬化剂注射术,EUS引导下穿刺抽吸联合硬化剂注射术治疗肝囊肿临床疗效更为确切,可缓解机体炎症反应,减少并发症及复发,对患者肝功能并无明显影响。

Clinical update on the management of pseudopapillary tumor of pancreas

Solid pseudopapillary neoplasm(SPN) is a rare tumor with malignant potential which is generally located in the tail of pancreas.The prevalence of SPN has increased with widespread use of cross sectional imaging.SPN is often misdiagnosed due to nonspecific clinical presentation and accurate diagnosis is essential for optimal management.Endoscopic ultrasound-FNA with immunohistochemistry can help in preoperative diagnosis.Surgery is the treatment of choice and a successful R0 resection is curative.Overall,SPN has a good prognosis.This review article focuses on pathogenesis,diagnosis and management of SPN.

Direct therapeutic intervention for advanced pancreatic cancer

Currently,chemotherapy is an accredited,standard treatment for unresectable,advanced pancreatic cancer(PC). However,it has been still showed treatmentresistance and followed dismal prognosis in many cases. Therefore,some sort of new,additional treatments are needed for the better therapeutic results for advanced PC. According to the previous reports,it is obvious that interventional endoscopic ultrasonography(EUS) is a well-established,helpful and low-risky procedure in general. As the additional treatments of the conventional therapy for advanced PC,many therapeutic strategies,such as immunotherapies,molecular biological therapies,physiochemical therapies,radioactive therapies,using si RNA,using autophagy have been developing in recent years. Moreover,the efficacy of the other potential therapeutic targets for PC using EUS-fine needle injection,for example,intra-tumoral chemotherapeutic agents(paclitaxel,irinotecan),several ablative energies(radiofrequency ablation and cryothermal treatment,neodymiumdoped yttrium aluminum garnet laser,high-intensity focused ultrasound),etc.,has already been showed in animal models. Delivering these promising treatments reliably inside tumor,interventional EUS may probably be indispensable existence for the treatment of locally advanced PC in near future.

一次性使用内窥镜注射针注册技术审评关注点

从医疗器械注册技术审评角度,简述内窥镜注射针申报文件风险管理资料、产品技术要求、研究资料、毒性物质残留、生物相容性评价、临床评价资料等章节的关注点。规定了技术要求常见条款,风险管理、研究资料列举了针对产品特性的项目要求,以便准确判断产品质量,提高审评和监管效率,推动行业发展。

超声内镜引导下细针注射治疗胰腺以外腹腔脏器囊肿的初步疗效

2017年8月至2022年8月间,在中南大学湘雅二医院消化内科共8例胰腺以外腹腔脏器组织囊肿患者接受了超声内镜引导下细针注射治疗,其中2例肝囊肿、2例脾囊肿、3例肾囊肿、1例胃胰间隙囊肿,8例患者共行11例次注射治疗,其中无水乙醇注射2例次、聚桂醇注射9例次,注射成功率100.0%(11/11)。随访3个月至5年,5例患者囊肿完全消失,其余3例患者囊肿缩小50%或以上。以上结果初步证实,对于胰腺以外腹腔脏器组织囊肿,超声内镜引导下细针注射治疗具有较好的临床疗效。

经尿道内镜下注射针黏膜下剥离后整块切除非肌层浸润性膀胱肿瘤63例报告

目的:探讨利用经尿道内镜下注射针行膀胱肿瘤黏膜下剥离后再行经尿道膀胱肿瘤整块电切术治疗非肌层浸润性膀胱肿瘤的安全性和有效性。方法:收集2017年1月~2018年12月我院收治的63例影像学或膀胱镜检查考虑为非肌层浸润性膀胱肿瘤患者,先在膀胱镜下利用经尿道内镜下注射针行膀胱肿瘤黏膜下剥离后,再改电切镜行经尿道膀胱肿瘤整块切除治疗膀胱肿瘤病灶。记录患者手术时间、术中出血量、膀胱冲洗时间、尿管留置时间、术后住院时间、术后病理分级和6个月及12个月肿瘤复发率。结果:其中61例顺利完成,2例因黏膜下剥离后出血,视野不清行常规电切。肿瘤直径1.0~4.0 cm,完整取出肿瘤58例,切开取出5例。手术时间(46.0±18.2)min,膀胱冲洗时间(23±8)h,尿管留置时间(4.8±1.8)d,术后住院时间(6.1±1.8)d。无一例需要输血,1例发生闭孔神经反射,无穿孔及术后出血等并发症。术后病理:Ta期47例,T1期14例,T2期2例。48例随访6个月,均未见复发;其中29例随访至12个月,2例复发。结论:利用经尿道内镜下注射针行膀胱肿瘤黏膜下剥离后整块电切治疗非肌层浸润性膀胱肿瘤是一种安全有效的方式。肿瘤的完整切除有利于病理学的评估,对肿瘤的后续治疗具有更精确的指导意义。完整切除膀胱肿瘤的方法更符合肿瘤外科治疗原则。虽然我们的手术方式需分步进行,但本手术的设备常规,易于开展,尤其在基层医院,这是本手术的一大优点。