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Anatomy of Thoracic Duct: A Study By Linear Endoscopic Ultrasound
Abstracts
M1217 Anatomy of Thoracic Duct: A Study By Linear Endoscopic Ultrasound Vinod K. Parasher Introduction: The thoracic duct begins as the cisterna chyli, ascends through the mediastinum and drains into the left juglosubclavian angle. It functions as a conduit, transporting lymph, proteins, lipids, immunologically activated cells from gastrointestinal tract, liver, pancrease and chest. The anatomy of the thoracic duct has been described by radial endoscopic ultrasonography; however, the anatomy by linear endoscopic ultrasound has not been previously described. Such description is relevant before a systematic approach can be developed to institute fine needle aspiration (FNA) of the thoracic duct for lymph sampling and/or potential thoracic duct interventional therapy (Parasher et al G.I.E. 2004:59:564-567). Aim: The aim of the study was to describe thoracic duct anatomy by linear endoscopic ultrasound. Method: Thoracic duct was studied in 20 patients undergoing routine endoscopic ultrasound (EUS) for variety of indications. Olympus linear echo endoscope (GF-UC30P) was used. Results: There were 12 males and 8 females, age range 32-86 years (mean 61.2 years). Technique: Beginning at 25-30 cm., the endoscope was rotated until a longitudinal view of the aorta was achieved. The endoscope was next rotated to the left until the azygos vein was brought into the view. The area between the aorta and azygos vein was scanned with slow right and left movements of the wrist. The thoracic duct was identified as a linear anechoic structure lying on the vertebral body, between the aorta and the azygos vein. It had no Doppler flow. The thoracic duct was best seen between 25-30 cm (mean 27.5 cm) from the incisors. Thoracic duct could be followed cranially and caudally to varying distances. However, the entire length of the duct, including the cisterna chyli, was not seen. This was possibly related to the natural anatomy of the thoracic duct, whereby it moves away from the esophagus. The diameter of the duct was 1.6 mm to 2.5 mm (mean 1.6 mm). Intercostal tributaries were seen draining into the duct. Thoracic duct was widest at its’ junction with the tributaries. Single duct was usually seen. No rhythmic contractions, pulsations or valves were seen. Conclusion: Thoracic duct can be readily identified by linear endoscopic ultrasound. It is best seen as a longitudinal anechoic structure with tributaries and without Doppler flow located between 25-30 cm adjacent to the aorta and azygos vein.
M1218 A Prospective, Randomized, Controlled Trial of EUS-FNA with and Without a Stylet: No Stylet Is Better Sarto C. Paquin, Gilles Gariepy, Anand V. Sahai Background: Current thinking is that the use of the stylet for EUS-FNA improves the quality of specimens. It is therefore currently recommended to re-insert the stylet before each FNA pass. However, there is no data comparing effectiveness of FNA with stylet (Sþ) to FNA without the stylet (S-). Aim: To compare the adequacy, the bloodiness, and the yield for malignancy of FNA samples obtained with a stylet (Sþ) versus without a stylet (S-). Patients & Methods: Prospective, single center study of all patients undergoing EUS-FNA for solid lesions within a 3 month period. FNA was performed with a 22g needle (Olympus) by a single experienced operator (AVS). Passes were performed with or without a stylet in a 1:2 ratio. All slides were read by a single, experienced, blinded cytopathologist. Adequate samples were defined as passes providing representative tissue from the sampled organ. Presence of blood was independently assessed regardless of specimen adequacy. Positive result was defined as presence of malignancy amongst adequate samples. Results: 111 patients (mean age 62.9 years, range 30-86) were included. Most patients were referred for cancer (77.5%, n Z 86). Most commonly assessed cancers (%, n) were: pancreatic (57%, 49), lung (17%, 15), esophageal (7%, 6), cholangiocarcinoma (5%, 4). Patients without cancer (22.5%, 25) were mainly evaluated for focal pancreatitis (60%, 15) or non-specific lymphadenopathy (24%, 6). Adequate samples were obtained in 98.1% (n Z 109) of patients. A total of 309 needle passes (mean 2.8 passes/patient, range 1-5) were performed, with stylet (Sþ) in 38% (n Z 118) and without stylet (S) in 62% (n Z 191). Lymph nodes (LN) were sampled in 42% (n Z 131) of passes, and masses in 58% (n Z 178) (of these, pancreatic lesions in 79% (n Z 140)). Sþ needles provided adequate samples in 74.6% of passes, compared to 86.9% in S- needles (p Z 0.0088). Bloody specimens were noted in 75.4% of Sþ passes compared to 51.8% in S- passes (p ! 0.0001). Amongst adequate samples, a positive diagnosis was obtained in 45.5% of Sþ passes compared to 45.8% in S- passes (p Z ns). Subgroup analysis of FNA passes restricted to LN showed similar results for adequacy between techniques used (Sþ 79.2%, S- 85.9% (p Z ns)). Analysis of FNA confined to pancreatic masses showed better adequacy with S- needles (Sþ 66.0%, S- 86.7% (p Z 0.0081). Summary: Use of the stylet for EUS-FNA was associated with reduced specimen adequacy and more bloody passes. Conclusion: The value of the stylet for EUS-FNA is questionable and requires further investigation.
AB198 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
M1219 Prospective Assessment of the Risk of Bacteremia in Cirrhotic Patients After EUS with and without FNA Gloria Fernandez-Esparrach, Angels Gines, Antonio Z. Gimeno-Garcia, Maria Pellise, Manel Almela, Oriol Sendino, Michel Zabalza, Josep Llach, Andres Cardenas, Josep M. Bordas, Antoni Castells Background: The incidence of bacteremia after endoscopic ultrasonography (EUS) or EUS-guided fine-needle aspiration (EUS-FNA) is low, but no data exists on this subject in cirrhotic patients. Aim: To prospectively assess the incidence of bacteremia in cirrhotic patients undergoing EUS and EUS-FNA. Patients and Methods: a total of 41 cirrhotic patients were enrolled. Sixteen of them underwent also FNA. Blood cultures were obtained before and at 5 and 30 minutes after the procedure. In case of EUS-FNA, an extra blood culture was obtained after the conclusion of radial EUS and before the introduction of the sectorial echoendoscope. Factors that could potentially influence the occurrence of bacteremia were recorded. All patients were clinically followed during 7 days for signs of infection. Results: Blood cultures were positive in 17 patients. Culture of blood from 12 tests in 11 patients grew coagulase negative Staphylococcus, Corynebacterium species, Propionibacterium species or Acinetobacterium Lwoffii wich were considered contaminants (contamination rate, 9%, 95% CI: 4% to 14%). The remaining 6 patients had true positive blood cultures and were considered to have had veritable bacteremia (15%, 95% CI: 4% to 26%). Five patients had positive blood cultures after diagnostic EUS (4 in samples obtained 5 minutes after the procedure and only 1 in the sample obtained 30 minutes after the procedure) whereas only one after EUS-FNA (in the sample obtained at 5 minutes after the procedure). Bacteria recovered were: 2 Streptococcus mitis, 2 Streptococcus viridis, 1 Staphylococcus aureus and 1 Peptostreptococcus. Thus, the frequency of bacteremia after EUS and EUS-FNA was 12% and 6%, respectively (95% CI: 2% to 22% and 0.2% to 30%, respectively). Only one of the patients who developed bacteremia after EUS presented self-limited fever with no other signs of infection within the 24 h after the procedure. Risk factors for bacteremia could not be identified. Conclusion: transient Gram-positive bacteremia develops in cirrhotic patients after EUS (with or without FNA) at a rate higher than that reported in immunocompetent patients. However, since there is no clinical impact, antibiotic prophylaxis seems not to be warranted except in those patients at high risk for endocarditis.
M1220 EUS-Guided FNA with Immunocytochemical Staining Is An Accurate Method of Diagnosing GI Mesenchymal Neoplasms Without Requiring Core Biopsy: A Comparison Study of EUS-Guided FNA Cytologic Diagnosis to Histologic Diagnosis of Resected Specimens Faris M. Murad, Steven M. Debol, Rebecca Lai, Mary Lynne Lucido, Edward B. Stelow, Shawn Mallery Background: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) allows for sampling and diagnosis of lesions of the GI tract and adjacent tissues. Submucosal GI mesenchymal neoplasms are uncommon and represent a small percentage of GI neoplasms. These neoplasms may be benign or malignant. Cytology alone cannot differentiate the type of mesenchymal lesion, and immunocytochemical staining is required for diagnosis. We have previously shown that adequate material for immunocytochemical staining is obtained via EUS-guided FNA in 80% of cases (Mallery, et al., GIE Abstract 2004). The accuracy of immunocytochemical staining of FNA obtained specimens has not been addressed. EUS-guided FNA with immunocytochemical staining may be an accurate method of diagnosing lesions without requiring core biopsy. Design: The cytology database was searched for all submucosal GI mesenchymal neoplasms sampled by EUSguided FNA between 1999 and 2006. All samples were collected by EUS trained gastroenterologists with on-site interpretation by our cytopathologists who triaged tissue towards cell block preparation. Patients in the database were contacted for consent and charts were reviewed to identify all cases with subsequent resection. The cytologic diagnosis was compared to the histologic diagnosis of the resected specimens when available. Results: Aspirates from 85 submucosal GI mesenchymal lesions contained sufficient cell block material for ancillary immunocytochemical studies. The majority of cases were GISTs (44), smooth muscle tumors (SMTs) (35), and peripheral nerve sheath tumors (PNSTs) (6). Of these, 23 cases with subsequent surgical resection were identified. In all the cases of surgically resected specimens, there was 100% correlation between the cytologic diagnosis at EUS and the histologic diagnosis. Conclusions: EUS-guided FNA with immunocytochemical staining allows for accurate diagnosis of submucosal mesenchymal neoplasms. When sufficient tissue for cell block is obtained, this is a reliable method for diagnosis without having to obtain intact solid tissue (i.e. core biopsy) of the lesion.
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M1217 Anatomy of Thoracic Duct: A Study By Linear Endoscopic Ultrasound Vinod K. Parasher Introduction: The thoracic duct begins as the cisterna chyli, ascends through the mediastinum and drains into the left juglosubclavian angle. It functions as a conduit, transporting lymph, proteins, lipids, immunologically activated cells from gastrointestinal tract, liver, pancrease and chest. The anatomy of the thoracic duct has been described by radial endoscopic ultrasonography; however, the anatomy by linear endoscopic ultrasound has not been previously described. Such description is relevant before a systematic approach can be developed to institute fine needle aspiration (FNA) of the thoracic duct for lymph sampling and/or potential thoracic duct interventional therapy (Parasher et al G.I.E. 2004:59:564-567). Aim: The aim of the study was to describe thoracic duct anatomy by linear endoscopic ultrasound. Method: Thoracic duct was studied in 20 patients undergoing routine endoscopic ultrasound (EUS) for variety of indications. Olympus linear echo endoscope (GF-UC30P) was used. Results: There were 12 males and 8 females, age range 32-86 years (mean 61.2 years). Technique: Beginning at 25-30 cm., the endoscope was rotated until a longitudinal view of the aorta was achieved. The endoscope was next rotated to the left until the azygos vein was brought into the view. The area between the aorta and azygos vein was scanned with slow right and left movements of the wrist. The thoracic duct was identified as a linear anechoic structure lying on the vertebral body, between the aorta and the azygos vein. It had no Doppler flow. The thoracic duct was best seen between 25-30 cm (mean 27.5 cm) from the incisors. Thoracic duct could be followed cranially and caudally to varying distances. However, the entire length of the duct, including the cisterna chyli, was not seen. This was possibly related to the natural anatomy of the thoracic duct, whereby it moves away from the esophagus. The diameter of the duct was 1.6 mm to 2.5 mm (mean 1.6 mm). Intercostal tributaries were seen draining into the duct. Thoracic duct was widest at its’ junction with the tributaries. Single duct was usually seen. No rhythmic contractions, pulsations or valves were seen. Conclusion: Thoracic duct can be readily identified by linear endoscopic ultrasound. It is best seen as a longitudinal anechoic structure with tributaries and without Doppler flow located between 25-30 cm adjacent to the aorta and azygos vein.
M1218 A Prospective, Randomized, Controlled Trial of EUS-FNA with and Without a Stylet: No Stylet Is Better Sarto C. Paquin, Gilles Gariepy, Anand V. Sahai Background: Current thinking is that the use of the stylet for EUS-FNA improves the quality of specimens. It is therefore currently recommended to re-insert the stylet before each FNA pass. However, there is no data comparing effectiveness of FNA with stylet (Sþ) to FNA without the stylet (S-). Aim: To compare the adequacy, the bloodiness, and the yield for malignancy of FNA samples obtained with a stylet (Sþ) versus without a stylet (S-). Patients & Methods: Prospective, single center study of all patients undergoing EUS-FNA for solid lesions within a 3 month period. FNA was performed with a 22g needle (Olympus) by a single experienced operator (AVS). Passes were performed with or without a stylet in a 1:2 ratio. All slides were read by a single, experienced, blinded cytopathologist. Adequate samples were defined as passes providing representative tissue from the sampled organ. Presence of blood was independently assessed regardless of specimen adequacy. Positive result was defined as presence of malignancy amongst adequate samples. Results: 111 patients (mean age 62.9 years, range 30-86) were included. Most patients were referred for cancer (77.5%, n Z 86). Most commonly assessed cancers (%, n) were: pancreatic (57%, 49), lung (17%, 15), esophageal (7%, 6), cholangiocarcinoma (5%, 4). Patients without cancer (22.5%, 25) were mainly evaluated for focal pancreatitis (60%, 15) or non-specific lymphadenopathy (24%, 6). Adequate samples were obtained in 98.1% (n Z 109) of patients. A total of 309 needle passes (mean 2.8 passes/patient, range 1-5) were performed, with stylet (Sþ) in 38% (n Z 118) and without stylet (S) in 62% (n Z 191). Lymph nodes (LN) were sampled in 42% (n Z 131) of passes, and masses in 58% (n Z 178) (of these, pancreatic lesions in 79% (n Z 140)). Sþ needles provided adequate samples in 74.6% of passes, compared to 86.9% in S- needles (p Z 0.0088). Bloody specimens were noted in 75.4% of Sþ passes compared to 51.8% in S- passes (p ! 0.0001). Amongst adequate samples, a positive diagnosis was obtained in 45.5% of Sþ passes compared to 45.8% in S- passes (p Z ns). Subgroup analysis of FNA passes restricted to LN showed similar results for adequacy between techniques used (Sþ 79.2%, S- 85.9% (p Z ns)). Analysis of FNA confined to pancreatic masses showed better adequacy with S- needles (Sþ 66.0%, S- 86.7% (p Z 0.0081). Summary: Use of the stylet for EUS-FNA was associated with reduced specimen adequacy and more bloody passes. Conclusion: The value of the stylet for EUS-FNA is questionable and requires further investigation.
AB198 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
M1219 Prospective Assessment of the Risk of Bacteremia in Cirrhotic Patients After EUS with and without FNA Gloria Fernandez-Esparrach, Angels Gines, Antonio Z. Gimeno-Garcia, Maria Pellise, Manel Almela, Oriol Sendino, Michel Zabalza, Josep Llach, Andres Cardenas, Josep M. Bordas, Antoni Castells Background: The incidence of bacteremia after endoscopic ultrasonography (EUS) or EUS-guided fine-needle aspiration (EUS-FNA) is low, but no data exists on this subject in cirrhotic patients. Aim: To prospectively assess the incidence of bacteremia in cirrhotic patients undergoing EUS and EUS-FNA. Patients and Methods: a total of 41 cirrhotic patients were enrolled. Sixteen of them underwent also FNA. Blood cultures were obtained before and at 5 and 30 minutes after the procedure. In case of EUS-FNA, an extra blood culture was obtained after the conclusion of radial EUS and before the introduction of the sectorial echoendoscope. Factors that could potentially influence the occurrence of bacteremia were recorded. All patients were clinically followed during 7 days for signs of infection. Results: Blood cultures were positive in 17 patients. Culture of blood from 12 tests in 11 patients grew coagulase negative Staphylococcus, Corynebacterium species, Propionibacterium species or Acinetobacterium Lwoffii wich were considered contaminants (contamination rate, 9%, 95% CI: 4% to 14%). The remaining 6 patients had true positive blood cultures and were considered to have had veritable bacteremia (15%, 95% CI: 4% to 26%). Five patients had positive blood cultures after diagnostic EUS (4 in samples obtained 5 minutes after the procedure and only 1 in the sample obtained 30 minutes after the procedure) whereas only one after EUS-FNA (in the sample obtained at 5 minutes after the procedure). Bacteria recovered were: 2 Streptococcus mitis, 2 Streptococcus viridis, 1 Staphylococcus aureus and 1 Peptostreptococcus. Thus, the frequency of bacteremia after EUS and EUS-FNA was 12% and 6%, respectively (95% CI: 2% to 22% and 0.2% to 30%, respectively). Only one of the patients who developed bacteremia after EUS presented self-limited fever with no other signs of infection within the 24 h after the procedure. Risk factors for bacteremia could not be identified. Conclusion: transient Gram-positive bacteremia develops in cirrhotic patients after EUS (with or without FNA) at a rate higher than that reported in immunocompetent patients. However, since there is no clinical impact, antibiotic prophylaxis seems not to be warranted except in those patients at high risk for endocarditis.
M1220 EUS-Guided FNA with Immunocytochemical Staining Is An Accurate Method of Diagnosing GI Mesenchymal Neoplasms Without Requiring Core Biopsy: A Comparison Study of EUS-Guided FNA Cytologic Diagnosis to Histologic Diagnosis of Resected Specimens Faris M. Murad, Steven M. Debol, Rebecca Lai, Mary Lynne Lucido, Edward B. Stelow, Shawn Mallery Background: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) allows for sampling and diagnosis of lesions of the GI tract and adjacent tissues. Submucosal GI mesenchymal neoplasms are uncommon and represent a small percentage of GI neoplasms. These neoplasms may be benign or malignant. Cytology alone cannot differentiate the type of mesenchymal lesion, and immunocytochemical staining is required for diagnosis. We have previously shown that adequate material for immunocytochemical staining is obtained via EUS-guided FNA in 80% of cases (Mallery, et al., GIE Abstract 2004). The accuracy of immunocytochemical staining of FNA obtained specimens has not been addressed. EUS-guided FNA with immunocytochemical staining may be an accurate method of diagnosing lesions without requiring core biopsy. Design: The cytology database was searched for all submucosal GI mesenchymal neoplasms sampled by EUSguided FNA between 1999 and 2006. All samples were collected by EUS trained gastroenterologists with on-site interpretation by our cytopathologists who triaged tissue towards cell block preparation. Patients in the database were contacted for consent and charts were reviewed to identify all cases with subsequent resection. The cytologic diagnosis was compared to the histologic diagnosis of the resected specimens when available. Results: Aspirates from 85 submucosal GI mesenchymal lesions contained sufficient cell block material for ancillary immunocytochemical studies. The majority of cases were GISTs (44), smooth muscle tumors (SMTs) (35), and peripheral nerve sheath tumors (PNSTs) (6). Of these, 23 cases with subsequent surgical resection were identified. In all the cases of surgically resected specimens, there was 100% correlation between the cytologic diagnosis at EUS and the histologic diagnosis. Conclusions: EUS-guided FNA with immunocytochemical staining allows for accurate diagnosis of submucosal mesenchymal neoplasms. When sufficient tissue for cell block is obtained, this is a reliable method for diagnosis without having to obtain intact solid tissue (i.e. core biopsy) of the lesion.
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