Transcolonic endoscopic ultrasound-guided fine-needle biopsy to diagnose a pancreatic tail adenocarcinoma in a patient with surgically altered anatomy

Previous studies have demonstrated that endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) is an efficient method for diagnosing pancreatic masses in patients with surgically altered anatomy [1], but it is sometimes difficult to visualize the target organs from the reconstructed route [2]. Echoendoscope manipulation challenges have restricted the approaches for EUS-FNA/B to the lower gastrointestinal tract, through the sigmoid colon and rectum [3]. Meanwhile, transcolonic EUS-FNA/B using forward-viewing echoendoscope or guidewire-assisted techniques have been reported [4] [5]. Herein, we report a case of pancreatic tail adenocarcinoma diagnosed by transcolonic EUS-FNB from the splenic flexure using an overtube method.

A 70-year-old woman who had previously undergone esophagectomy with retrosternal gastric tube reconstruction for esophageal carcinoma presented with abdominal pain. Contrast-enhanced computed tomography revealed a 25-mm hypovascular tumor at the pancreatic tail, which was suggestive of pancreatic cancer ([Fig. 1]). Because of the distance between the gastric tube and the pancreas along the postoperative reconstruction, a puncture through the gastric tube was not possible. Therefore, we attempted transcolonic EUS-FNB in order to obtain a biopsy ([Video 1]).

Fig. 1 Computed tomography scan showing a 25-mm hypovascular tumor at the pancreatic tail (yellow arrowhead) and the significant distance between the gastric tube and the pancreatic tail (two-headed arrow).

Video 1 Transcolonic endoscopic ultrasound-guided fine-needle biopsy via an overtube is used to diagnose a pancreatic tail adenocarcinoma in a patient with surgically altered anatomy.

First, we inserted a colonoscope with an overtube (ST-C7; Olympus Co., Tokyo, Japan) ([Fig. 2]) up to the splenic flexure. We then placed the overtube at the sigmoid colon, pulled out the colonoscope, and inserted an echoendoscope (GF-UCT260; Olympus Co.) through the overtube to reach the splenic flexure ([Fig. 3 a]). A hypoechogenic tumor was visualized at the pancreatic tail from the splenic flexure, and the lesion was punctured twice with a 22-gauge Franseen needle (Acquire; Boston Scientific Corp., Natick, Massachusetts, USA) under EUS guidance ([Fig. 3 b]).

Fig. 2 Photograph of the overtube ST-C7, which has an inner cylinder diameter of 18.4 mm and an effective length of 32 cm.

Fig. 3 Images during transcolonic endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) showing: a the echoendoscope in position at the splenic flexure after its insertion through the overtube; b a hypoechogenic tumor in the pancreatic tail being punctured with a 22-gauge Franseen needle.

The patient received prophylactic antibiotics and no procedure-related adverse events were observed. Histopathological examination revealed adenocarcinoma ([Fig. 4]) and we diagnosed the patient as having a resectable pancreatic ductal adenocarcinoma. She received two cycles of neoadjuvant chemotherapy with gemcitabine and S-1, before undergoing distal pancreatectomy.

Fig. 4 Histopathological appearance, which revealed an adenocarcinoma.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Tanaka K, Hayashi T, Utsunomiya R. et al. Endoscopic ultrasound-guided fine needle aspiration for diagnosing pancreatic mass in patients with surgically altered upper gastrointestinal anatomy. Dig Endosc 2020; 32: 967-973
• 2 Katanuma A, Hayashi T, Kin T. et al. Interventional endoscopic ultrasonography in patients with surgically altered anatomy: Techniques and literature review. Dig Endosc 2020; 32: 263-274
• 3 Mita N, Iwashita T, Senju A. et al. Endoscopic ultrasound‑guided fine‑needle aspiration of pelvic lesions via the upper and lower gastrointestinal tract approaches. BMC Gastroenterol 2021; 21: 18
• 4 Thinrungroj N, Hara K, Mizuno N. et al. Utility of forward-view echoendoscopy for transcolonic fine-needle aspiration of extracolonic lesions: An institutional experience. Clin Endosc 2020; 53: 60-64
• 5 Kawakami H, Ban T, Kubota Y. et al. Endoscopic ultrasonography-guided fine-needle biopsy from ascending colon using a novel curved linear echoendoscope. Endoscopy 2020; 52: E24-E26

Publication History

Article published online:
19 December 2022