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Pancreatic cancer produces disabling abdominal pain, and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics (major opioids). However, opioids often provide suboptimal pain relief, and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients. Endosonography-guided celiac plexus neurolysis (EUS-CPN) is an alternative for pain control in patients with nonsurgical pancreatic cancer; EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue. EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach. We have reviewed most of the studies that evaluate the efficacy of EUS-CPN and that have compared the different approaches that have been performed by endosonographers. The efficacy of EUS-CPN varies from 50% to 94% in the different studies, and EUS-CPN has a pain relief duration of 4–8 wk. Several factors are involved in its efficacy, such as the onset of pain, previous use of chemotherapy, presence of metastatic disease, EUS-CPN technique, type of needle or neurolytic agent used, etc. According to this review, injection into the ganglia may be the best technique, and a good visualization of the ganglia is the best predictor for a good EUS-CPN response, although more studies are needed. However, any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques, but more studies are needed. The effect of EUS-CPN on pain improvement, patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials. Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.

Metastatic cancersmake up fewer than 2% of pancreaticmalignancies, and themajority of them mimic a primary adenocarcinoma [1]. Limited data are available concerning the assessment of pancreatic secondary cancers using endoscopic ultrasound-guided fine needle biopsy (EUSFNB) [2]. In this study we report the first case of metastatic pancreatic melanoma to be diagnosed by combining EUS with biopsy sampling using the SharkCore needle (SharkCore Fine Needle Biopsy System, Covidien IIc, NewtonMassachusetts, USA). A 57-year-old woman presented with evidence of a pancreatic mass. Her past medical history included a choroidal melanoma in 2009, which had been treated by iodine-125 brachytherapy. At the time of treatment no metastatic lesions had been documented. In May 2015, a magnetic resonance imaging (MRI) scan performed for clinical surveillance demonstrated a nodular liver consistent with metastasis. The patient underwent transarterial chemoembolization with irinotecan. A subsequent MRI scan showed a nodular lesion of the pancreatic tail (20×17mm), which was a mixture of isointense and hyperintense on T1-weighted images (●" Fig.1), and was hypointense on T2-weighted images, compatible with either primary cancer or metastatic disease. The patient was asymptomatic, with no suspicious skin lesions and no palpable lymphadenopathy. Laboratory test results were within normal limits. The patient was referred to our institution for EUS evaluation. The EUS (Olympus UCT 140 linear arrayechoendoscope) showed a 2-cm hypoechoic mass in the pancreatic tail (●" Fig.2). Five transduodenal FNB passes (22-gauge SharkCore needle) into the mass resulted in multiple tissue samples (maximum diameter 0.08–0.1cm) (●" Video1). Histological examination showed malignant pigmented epithelioid lesions, which were immunohistochemically confirmed as metastatic melanoma (●" Fig.3). The patient underwent chemotherapy and has currently completed her induction cycleswith fotemustine.

Purpose. The authors compared multidetector-row computed tomography (MDCT) and endoscopic ultrasound (EUS) in the identifi cation of pancreaticoduodenal endocrine tumours (PETs) in patients with multiple endocrine neoplasia type 1 (MEN 1). Materials and methods. Fourteen consecutive patients (eight men and six women, aged 26–54 years) with MEN 1 underwent MDCT performed with a 4- (n=5) or 64- (n=9) detector-row system and EUS done with a radial transducer (7.5–20 MHz) within 7–28 days of each other. Prior to MDCT examination, patients were given 750 cc of water and asked to lie down in the right lateral decubitus for 15 min. Multiphase MDCT images were acquired both before and after the injection of nonionic iodinated contrast material (2 cc/kg) at an injection rate of 4 ml/s, with technical parameters and scan delay varying in relation to the system used. Images were all reconstructed at 3-mm intervals for the three phases (arterial, pancreatic and portal) and evaluated on a dedicated workstation. Results. MDCT detected a total of 25 PETs (3–18 mm) in nine patients. Of these lesions, nine were situated within the duodenal wall and 16 in either the pancreatic head (n=3), body (n=7), or tail (n=6). Three additional lesions were detected retrospectively after EUS imaging. Most (18/22,81%) were hypervascular nodules, and four appeared as either hypoattenuating or cystic lesions. EUS detected a total of 32 PETs (2–18 mm) in 11 patients. Most lesions (29/32, 90%) appeared hypoechoic and were situated in the duodenal wall (n=15) or in either the pancreatic head (n=10), body (n=6) or tail (n=1). Conclusions. Our preliminary data indicate that MDCT is complementary to EUS in the identifi cation of PETs in MEN-1 patients.

O diagnóstico das lesões císticas pancreáticas pelos métodos de imagem, especialmente as de pequeno tamanho, é cada vez mais freqüente. Em alguns casos, ele representa um dilema em relação à terapêutica, podendo ser pseudocistos inflamatórios, neoplasias primárias ou secundárias. Para a decisão terapêutica, é necessário definir se a neoplasia é benigna, maligna ou potencialmente maligna. Hoje, a ecoendoscopia é considerada o exame padrão-ouro para a investigação do pâncreas, fornecendo dados sobre a morfologia destas lesões e possibilitando, por meio da punção guiada em tempo real, a colheita de material para avaliação citológica e dos marcadores tumorais. Este procedimento é considerado seguro e eficiente e apresenta taxas de sensibilidade e especificidade altas e de morbidade e de complicações baixas. No diagnóstico das lesões mucinosas do pâncreas, os fatores preditivos mais significativos para o diagnóstico diferencial são a presença de septos, os nódulos murais e as alterações parenquimatosas, para o qual as taxas de sensibilidade, especificidade e grau de exatidão são, respectivamente, 94%, 85% e 88%. Os autores têm por objetivo revisar as principais neoplasias císticas primárias do pâncreas, enfatizando a aplicação da ecoendoscopia no diagnóstico definitivo dessas neoplasias.Pancreatic cystic lesions, particularly small lesions, are more easily diagnosed nowadays with the use of imaging methods. In some cases, the diagnosis represents a challenge to establish the treatment, as it can range from inflammatory pseudocysts to primary or metastatic cystic neoplasms. In order to choose the treatment, it is necessary to determine if the lesion is benign, borderline, or malignant. Currently, echoendoscopy is considered the gold standard procedure for pancreatic evaluation as it clearly shows the morphology of the lesion, and also allows the acquisition of pancreatic material for cytological and tumor markers studies using fine needle aspiration biopsy. This procedure is considered safe and efficient with high rates of sensibility and specificity and low rates of complications and morbidity. The presence of septa, mural nodules and irregularities in the parenchyma are the most significant predictive factors for the differential diagnosis of mucinous pancreatic-cystic lesions for which sensibility, specificity and accuracy rates are 94%, 85% and 88%, respectively. The aim of the authors in this study is to review the major primary-cystic-pancreatic neoplasms with emphasis in the application of echoendoscopy for the definite diagnosis of these lesions.

Los lipomas gástricos representan el 5% de los lipomas gastrointestinales y entre el 1 a 3% de los tumores gástricos benignos. Suelen cursar asintomáticos y ser hallazgos incidentales o pueden manifestarse de distintas maneras, presentando desde dispepsia y dolor abdominal hasta hemorragia digestiva e intususcepción. La gastroscopia, TC y la endosonografía son útiles para el diagnóstico de estos lipomas. En caso de existir síntomas, se puede considerar la enucleación quirúrgica o endoscópica de la lesión. Presentamos el caso de una femenina de 39 años con un lipoma gástrico, que fue evaluado endosonográficamente y resecado endoscópicamente. Gastric lipomas represent 5% of gastrointestinal lipomas, and between 1-3% of benign gastric tumors. They use to be asymptomatic and incidentally found, or may be manifested in different manners, presenting even dyspepsia and abdominal pain and up to digestive hemorrhage and intussusception. Gastroscopy, CT, and endosonography are useful for diagnosing these lipomas. In case of existing symptoms, surgical or endoscopic enucleation of the lesion might be considered. The case presented here is of a 39-year old female with a gastric lipoma that was endosonography-assessed and an endoscopic resection was performed.

Objective: almost 30% of gastroenteropancreatic neuroendocrine tumors (GEPET) escape preoperative identification using standard imaging techniques. The goal of this retrospective study is to present our cumulative experience in the assessment of GEPET by preoperative endoscopic ultrasonography (EUS), and to compare it with a literature review. Patients and methods: thirty-seven patients with suspected specific hormonal syndromes were sequentially examined with US, CT, MRI, angiography, OctreoScan, and radial and sectorial EUS. Sixteen were males (43%) and 21 were females (57%), with a mean age of 61 years (interval: 40-84 a). Of all 37 patients, 27 had 19 endocrine tumors in the pancreas and 14 tumors in their gastrointestinal tract. No tumors were demonstrated in 10 patients, hence they were used as a control group. Of all 37 patients, 24 were operated on or had histological samples collected, with the presence of 26 GEPET (10 carcinoids) being confirmed in 22 patients. Results: EUS sensitivity and diagnostic accuracy were 81% and 78%. Specificity was 80%. All these values were similar to the mean values obtained from the literature review. Three pancreatic rumors smaller than or equal to 1 cm (insulinomas) were detected, which had escaped diagnosis with previous US, CT, and MRI studies. An echoendoscopic examination of the pancreas could not be completed in two cases (5%), a pancreas carcinoid and an already gastrectomized double pancreatic gastrinoma. Conclusion: EUS is a good preoperative technique for GEPET detection, and may likely be superior to other imaging techniques in the assessment of small tumors. The usefulness of EUS as a primary exploration after US or HCT has been posited for tumor diagnosis and localization before surgery.

Patients who are undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for suspected pancreatic tumors frequently undergo endoscopic retrograde cholangiopancreatography (ERCP) for palliation of their symptoms. Performing EUS-FNA and ERCP in tandem may be cost-effective and may reduce procedure time, but the potential risks associated with this approach have not been clearly defined in the literature. We report two patients who underwent same-day therapeutic ERCP after transduodenal EUS-FNA for pancreatic tumors. Endoscopic biliary manipulation during ERCP aggravated an inadvertent and subclinical needle puncture injury to the bile duct sustained during the preceding EUS-FNA. This resulted in leakage of bile into the retroperitoneal space, and both patients required laparotomy and surgical drainage. Additional clinical evidence is needed to clarify these issues and to determine whether it would be prudent to perform therapeutic ERCP prior to diagnostic transduodenal EUS-FNA when these two procedures are planned as sequential or same-day procedures.

Objective: almost 30% of gastroenteropancreatic neuroendocrine tumors (GEPET) escape preoperative identification using standard imaging techniques. The goal of this retrospective study is to present our cumulative experience in the assessment of GEPET by preoperative endoscopic ultrasonography (EUS), and to compare it with a literature review. Patients and methods: thirty-seven patients with suspected specific hormonal syndromes were sequentially examined with US, CT, MRI, angiography, OctreoScan, and radial and sectorial EUS. Sixteen were males (43%) and 21 were females (57%), with a mean age of 61 years (interval: 40-84 a). Of all 37 patients, 27 had 19 endocrine tumors in the pancreas and 14 tumors in their gastrointestinal tract. No tumors were demonstrated in 10 patients, hence they were used as a control group. Of all 37 patients, 24 were operated on or had histological samples collected, with the presence of 26 GEPET (10 carcinoids) being confirmed in 22 patients. Results: EUS sensitivity and diagnostic accuracy were 81% and 78%. Specificity was 80%. All these values were similar to the mean values obtained from the literature review. Three pancreatic rumors smaller than or equal to 1 cm (insulinomas) were detected, which had escaped diagnosis with previous US, CT, and MRI studies. An echoendoscopic examination of the pancreas could not be completed in two cases (5%), a pancreas carcinoid and an already gastrectomized double pancreatic gastrinoma. Conclusion: EUS is a good preoperative technique for GEPET detection, and may likely be superior to other imaging techniques in the assessment of small tumors. The usefulness of EUS as a primary exploration after US or HCT has been posited for tumor diagnosis and localization before surgery.

Introduction Endoscopic ultrasonography (EUS) has already proven useful in the assessment of submucosal lesions, and the staging of gastrointestinal cancer, particularly gastric MALT-type lymphoma. The goal of this paper was EUS staging. Patients and method 24 patients (10 females, 14 males) with a median age of 56 years and possibly gastric MALT lymphoma (25 cases) were studied using videoendoscopy, biopsies, and echoendoscopy with 7.5- and 20-MHz radial EUS, and also with 12- and 20-MHz miniprobes (MPs). Nineteen patients were definitely evaluated (7 females, 12 males) as having 20 MALT-type lymphomas, as five patients were post-hoc disregarded when an invasive, high-grade gastric lymphoma (3c) or plasmocytoma (2c) was subsequently demonstrated. Of these 19 patients, all had T1 lesions except for two with T2 lesions; one patient had a gastroduodenal T1 lymphoma. Echographic findings with MPs were compared to EUS (gold standard) and histology both before and after eradication. Then, patients were followed up every 1-3-6 months using videoendoscopy and MPs. Results Echoendoscopy correctly identified T stages in 90% of cases. MPs identified T stages in 88% of cases, and N stages in 33% of cases, with results being slightly inferior to those obtained with conventional EUS (91 vs. 45%); they were consequently used for follow-up. After eradication, all but two patients are in complete remission and have been followed every 1-3-6 months using MPs without echographic abnormalities, except for a patient who relapsed.

O diagnóstico das lesões císticas pancreáticas pelos métodos de imagem, especialmente as de pequeno tamanho, é cada vez mais freqüente. Em alguns casos, ele representa um dilema em relação à terapêutica, podendo ser pseudocistos inflamatórios, neoplasias primárias ou secundárias. Para a decisão terapêutica, é necessário definir se a neoplasia é benigna, maligna ou potencialmente maligna. Hoje, a ecoendoscopia é considerada o exame padrão-ouro para a investigação do pâncreas, fornecendo dados sobre a morfologia destas lesões e possibilitando, por meio da punção guiada em tempo real, a colheita de material para avaliação citológica e dos marcadores tumorais. Este procedimento é considerado seguro e eficiente e apresenta taxas de sensibilidade e especificidade altas e de morbidade e de complicações baixas. No diagnóstico das lesões mucinosas do pâncreas, os fatores preditivos mais significativos para o diagnóstico diferencial são a presença de septos, os nódulos murais e as alterações parenquimatosas, para o qual as taxas de sensibilidade, especificidade e grau de exatidão são, respectivamente, 94%, 85% e 88%. Os autores têm por objetivo revisar as principais neoplasias císticas primárias do pâncreas, enfatizando a aplicação da ecoendoscopia no diagnóstico definitivo dessas neoplasias. Pancreatic cystic lesions, particularly small lesions, are more easily diagnosed nowadays with the use of imaging methods. In some cases, the diagnosis represents a challenge to establish the treatment, as it can range from inflammatory pseudocysts to primary or metastatic cystic neoplasms. In order to choose the treatment, it is necessary to determine if the lesion is benign, borderline, or malignant. Currently, echoendoscopy is considered the gold standard procedure for pancreatic evaluation as it clearly shows the morphology of the lesion, and also allows the acquisition of pancreatic material for cytological and tumor markers studies using fine needle aspiration biopsy. This procedure is considered safe and efficient with high rates of sensibility and specificity and low rates of complications and morbidity. The presence of septa, mural nodules and irregularities in the parenchyma are the most significant predictive factors for the differential diagnosis of mucinous pancreatic-cystic lesions for which sensibility, specificity and accuracy rates are 94%, 85% and 88%, respectively. The aim of the authors in this study is to review the major primary-cystic-pancreatic neoplasms with emphasis in the application of echoendoscopy for the definite diagnosis of these lesions.

Objective: the applications of endoscopic ultrasonography have diversified over recent years. The possibility of reaching cardiac territory has been successfully explored in experimental models, opening up a new field of possibilities for diagnostic and therapeutic interventions that were unthinkable until very re cently. The aims set out in this study are to evaluate cardiac anatomy, its approach, the safety of the experimental procedure and the resulting morphological and histological changes after the procedure. Material and methods: the study has been performed on two adult pigs. They have undergone different surgical approach es to the cardiac cavities and descending thoracic aorta with excel lent results. Results: different cardiac structures have been identified and operated upon (right auricle, left auricle, left ventricle, cardiac valves), as well as major vessels. The use of contrast, both intra cavitary and from a peripheral vein, enabled us to verify the anatomical spaces studied. During the procedures we monitored for arrhythmias, hemodynamic behavior, possibility of infection by obtaining sample hemocultures before and after procedures, and response to punctures. Conclusions: the present study has enabled us to evaluate ac cess to the heart from the esophageal lumen using endoscopic ul trasonography, with results that are very similar to those described in the current bibliography. However, we offer two novelties: puncture of the right auricle through the interauricular partition and puncture of the descending thoracic aorta, both performed with ease and apparent safety.