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Endoscopic ultrasound (EUS) has a prolonged learning curve. Essential components include mastery of new endoscopic and radiographic skills as well as becoming familiar with anatomic relationships and variables. Additionally, providers must help train technicians and nurses, refine sedation strategies, and create productive relationships with cytopathologists. Aims of this chapter are to provide practical advice, hopefully to speed progression through the learning curve and to help improve safety and exam quality. Common EUS pitfalls and simple solutions are organized and presented in the following categories: sedation, endoscopic intubation and passage, orientation, technical issues, potential problem indications, choosing the right equipment for each case, and fine needle aspiration. Pitfalls are particularly salient for beginners, but many have pertinence for advanced endosonographers, including those moving to a new practice site. Selected take home points are highlighted with case examples and figures.

Background & Aims: Recent studies have claimed long neoplasia-free survival rates with endoscopic mucosal resection of high-grade dysplasia (HGD) in Barrett's esophagus (BE). However, reports have contended that approximately 40% of patients who have esophagectomy for HGD have occult invasive cancer. The aim of this study was to use explicit criteria to determine the true prevalence of invasive adenocarcinoma in reports of patients who had esophagectomy for HGD in BE. Methods: Studies reporting rates of esophageal cancer in patients who underwent esophagectomy for HGD in BE were gathered using MEDLINE and PUBMED. We defined invasive esophageal adenocarcinoma (IEAC) as tumor with submucosal invasion or beyond. Intramucosal carcinoma (IMC) was not considered IEAC. Results: Twenty-three articles were selected for analysis. Most investigators reported rates of invasive cancer in the esophagectomy specimen, and the pooled average was 39.9% among the 441 patients who underwent an esophagectomy for HGD. Reported rates varied from 0% to 73%. A total of 267 patients had American Joint Committee on Cancer stage 0 postoperatively, 132 patients had stage I, 23 patients had stage IIa, 10 patients had stage IIb, and 9 patients had stage III. Fourteen studies provided differentiation between intramucosal and submucosal invasion. Among 213 patients, only 12.7% had IEAC, whereas 87.3% had HGD or IMC. The IEAC rate of 11% among patients with visible lesions is greater than the rate of 3% among patients with no visible lesion. Conclusions: By using strict pathologic definitions of invasive disease, the present study indicates the true prevalence of IEAC in BE and HGD may have been overestimated significantly. Separating IMC from IEAC is clinically relevant because endoscopic techniques potentially may treat IMC.

Background: Mucinous pancreatic cystic lesions have the propensity to progress into pancreatic cancer. Currently radiographic surveillance or surgical resection is recommended for this premalignant type of cyst, both of which have significant limitations. Recently, endoscopic ultrasound-guided cyst ablation has emerged as an innovative and promising alternative treatment approach. Previous studies have shown that EUS-guided ethanol lavage of pancreatic cysts is safe and results in complete cyst resolution in 1/3 of patients. Subsequent studies demonstrated marked increases in rates of ablation with infusion of paclitaxel following ethanol lavage, which raises the question of whether alcohol is necessary for effective ablation. This is important, since ethanol extravasation is felt to have caused two complications in previous trials, abdominal pain and pancreatitis. This study hypothesizes that the removal of alcohol lavage prior to chemotherapy infusion will not impair ablation rates and will decrease complication rates. A secondary aim of this study is to assess whether a custom chemoablation cocktail tailored to pancreatic neoplasia (paclitaxel+gemcitabine) will improve ablation rates overall. Gemcitabine was chosen because it dilutes paclitaxel for injection and has been the standard in pancreatic cancer chemotherapy. Recently, the combination of paclitaxel and gemcitabine was shown to improve response rates and progression-free survival when compared with gemcitabine alone. Methods: Patients with mucinous or indeterminate type pancreatic cysts of 1-5cm’s without signs of malignancy were randomized to undergo either EUS-guided lavage with 80% alcohol or normal saline followed by infusion of 3 mg/ml paclitaxel + 19mg/ml gemcitabine (both arms). 9 patients were enrolled in this initial pilot study and evaluated post op, at 72 hours, with two week lab tests and by CT scan at 3, 6, and 12 months to assess response rates and for any complications. Results: The initial 9 patients of this trial (expected to have an N of 78 when complete) were randomized for this pilot study with 8 patients then able to be treated. Pancreatic cysts ranged in maximum diameter from 2.2cm to 3.8 cm (mean 2.9 cm). Location included body (n=4), head (n=2), neck (n=1) and tail (n=1). The overall reduction in cyst surface area was 67% at 3 months and 82% at 6 months. At 6 months size reduction was 81% in the alcohol infusion arm and 83% in the alcohol-free arm. Complications were mild abdominal pain (1) in the alcohol free arm (12.5%), moderate abdominal pain (1), and mild pancreatitis (1) in the alcohol arm (25%). Conclusion: The treatment of mucinous type pancreatic cysts with either alcohol or saline lavage followed by gemicitabine-paclitaxel infusion is feasible and safe in this limited pilot study. Initial results indicate that alcohol-free ablation does not impair ablation efficacy and is associated with fewer complications although the full sample size will be required to prove this hypothesis with any certainty. Citation Format: Matthew T. Moyer, Setareh Sharzehi, Charles E. Dye, Wafik El-Deiry, Thomas J. McGarrity, Abraham Mathew, Niraj Gusani, Raquel E. Davila, Brooke Ancrile. Is ethanol required for cyst ablation in patients with premalignant type pancreatic cysts? [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Innovations in Research and Treatment; May 18-21, 2014; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2015;75(13 Suppl):Abstract nr B95.

Dilation of malignant esophageal strictures often is required to complete staging by endoscopic ultrasound (EUS). This study was designed to determine the successful dilation rate (ability to complete staging) and complication rate of through-the-scope (TTS) balloon dilation for malignant esophageal strictures during EUS. We retrospectively reviewed EUS reports for all cases of primary esophageal cancer staged at five centers between January 2002 and October 2004. All dilations were performed with TTS balloons. Among 272 endoscopic ultrasounds, dilation was required in 77 (28%) and was successful in 73 cases (95%). There was one esophageal perforation after dilation (1.3%; 95% confidence interval (CI), 0.2-7) and one esophageal perforation after EUS without dilation (0.5%; 95% CI, 0.1-2.8; P = 0.48 by two-sided Fisher exact test). There were no other major complications. TTS balloon dilation is highly successful in permitting complete staging of obstructing tumors. The rate of complications after dilation with a TTS balloon dilator is low and similar to the baseline rate of EUS in this setting.

Background Because of postoperative complications, patients who have undergone Roux-en-Y gastric bypass (RYGB) for weight loss may require radiographic investigation of the pancreaticobiliary limb or enteral feeding. Gastrostomy-tube placement into the excluded stomach for these indications is typically performed surgically or via fluoroscopic or US guidance; PEG has not been reported as being performed for this purpose. Successful examination of the excluded stomach after RYGB has been reported when using double-balloon enteroscopy (DBE). Objective To perform PEG in the excluded stomach by using DBE. Design Retrospective review. Setting Single, North American tertiary-care center. Patients Individuals with postoperative complications after RYGB that requires radiographic examination of the excluded stomach and the pancreaticobiliary limb, or enteral feeding. Interventions Performance of PEG within the excluded stomach by using DBE. Main Outcome Measurements Ability to perform PEG-procedure–related complications and resultant management changes. Results PEG was successfully performed by using DBE in 3 of 4 patients with postoperative complications after RYGB. In 2 of the cases, the results of radiographic studies performed with contrast administration through the gastrostomy tube led to significant operative management changes. In the third case, preoperative enteral nutrition was provided by using a gastrostomy tube. PEG placement was not possible in the fourth case because of the lack of abdominal transillumination. Major complications were not observed. Limitations Small sample size, single-center experience. Conclusions PEG placement in the excluded stomach after RYGB by using DBE was safe, technically feasible, and led to management changes in patients in whom it was performed. This procedure should be added to the growing list of indications for DBE.

Small bowel obstruction (SBO) is a common complication of malignant disease. Because of the technical limitations posed by conventional endoscopes and delivery systems, palliation of malignant SBO by the endoscopic placement of expandable metal stents is usually performed only for obstruction of the gastric outlet and proximal duodenum. We present a case of malignant distal duodenal obstruction palliated by enteral stent placement using the doubleballoon enteroscope (DBE).

Increased population longevity as well as an emphasis on earlier diagnosis and more effective treatment of cancer have created an environment for new technologies and techniques to flourish. Some of the endoscopic entities discussed in this article have not been fully validated in clinical practice. Innovative spectroscopic modalities hold a great deal of promise, but are years away from general applicability. In contrast, many interventional endoscopic techniques are currently available and confer heightened levels of diagnostic and staging accuracy for gastric and esophageal malignancies. Earlier diagnosis can identify patients who may be eligible for less-invasive treatment options such as EMR. Minimally invasive treatment options and maximum staging accuracy are more important for patients who are marginal surgical candidates and for accurate comparison of clinical trials studying treatment options. Our challenge for the future is to properly integrate these technologic advances with the science of good medical practice.

Double balloon enteroscopy (DBE) was introduced into the US in 2004. Potential complications include perforation, pancreatitis, and gastrointestinal bleeding. Prevalence and risk factors for complications have not been described in a US population.We conducted a retrospective study of DBE complications in 9 US centers. We obtained detailed information for each complication including patient history, maneuvers performed during the DBE, and presence of altered surgical anatomy.We collected data from 2478 DBE examinations performed from 2004 to 2008. The dataset included 1691 (68%) anterograde DBE, 722 (29%) retrograde DBE (including 5 per-stomal DBEs), and 65 (3%) DBE-facilitated endoscopic retrograde cholangiopancreatography ERCP cases. There were a total of 22 (0.9%) major complications including perforation in 11 (0.4%), pancreatitis in 6 (0.2%), and bleeding in 4 (0.2%) patients. One of 6 cases of pancreatitis occurred post retrograde DBE. Perforations occurred in 3/1691 (0.2%) anterograde examinations and 8/719 (1.1%) retrograde DBEs (P = .004). Eight (73%) perforations occurred during diagnostic DBE examinations. Four of 8 retrograde DBE perforations occurred in patients with prior ileoanal or ileocolonic anastomoses. In the subset of 219 examinations performed in patients with surgically altered anatomy, perforations occurred in 7 (3%), including 1/159 (0.6%) anterograde DBE examinations, 6/60 (10%) retrograde DBEs, and 1 of 5 (20%) peristomal DBE examinations (P.005 compared with patients without surgically altered anatomy).DBE is associated with a higher complication rate compared with standard endoscopic procedures. The perforation rate was significantly elevated in patients with altered surgical anatomy undergoing diagnostic retrograde DBE examinations.