Endoscopic ultrasound (EUS) guidance is a safe and effective technique for sampling
mediastinal lesions [1]
[2]
[3]. We report a case where an EUS was done in retrograde fashion through a gastrostomy
because of the patient’s limited degree of mouth opening due to trismus.
We present the case of a 42-year-old man with oropharyngeal squamous cell carcinoma
(SCC) who had had a suboptimal response to chemoradiation and was therefore undergoing
evaluation for surgery. A positron emission tomography (PET) scan showed a hypermetabolic
mediastinal lesion. If this mediastinal lesion was a metastatic focus, the patient
would not benefit from surgery and therefore sampling was required. An initial EUS-guided
fine needle aspiration (FNA) failed as the echoendoscope could not be passed through
the patient’s mouth because of his radiation-induced trismus. After multidisciplinary
discussion, we proceeded with retrograde EUS-FNA of the mediastinal mass performed
through the patient’s pre-existing gastrostomy ([Video 1]).
Video 1 Video demonstrating retrograde endoscopic ultrasound-guided fine needle aspiration
(EUS-FNA) through an existing gastrostomy for sampling of a mediastinal mass in a
patient with radiation-induced trismus.
The procedure was performed with the patient under general anesthesia. The existing
gastrostomy tube was removed and, after serial dilation of the gastrostomy tract,
was replaced with a 15-mm laparoscopic trocar. A standard gastroscope was passed through
the trocar and two hemoclips were placed in the gastric cardia to aid identification
of the gastroesophageal junction (GEJ) during echoendoscope passage. A radial echoendoscope
(GF-UE160-AL5; Olympus, Tokyo, Japan) was inserted through the trocar and advanced
in retrograde fashion through the GEJ until the mediastinal mass was identified ([Fig. 1]). The radial echoendoscope was then exchanged for a linear echoendoscope (UC140P-AL5;
Olympus) to perform the EUS-FNA ([Fig. 2]). Two passes with a 22G needle were diagnostic for carcinoma by on-site cytology.
The linear echoendoscope and trocar were removed and a balloon-type gastrostomy tube
was placed.
Fig. 1 The mediastinal mass is shown: a by the radial echoendoscope first used to locate it; b on a computed tomography (CT) scan, which produces a similar image.
Fig. 2 Tissue sampling from the mediastinal mass was obtained by endoscopic ultrasound-guided
fine needle aspiration (EUS-FNA). a Schematic showing the linear echoendoscope inserted through the existing gastrostomy.
b EUS image during tissue acquisition with a 22G needle.
Final pathology confirmed metastasis of the SCC. The patient was discharged on the
same day without complications and was later started on palliative immunotherapy.
Retrograde EUS-FNA through a gastrostomy for mediastinal mass sampling seems to be
safe and feasible, and offers a novel solution for patients in whom the antegrade
route is not available.
Endoscopy_UCTN_Code_TTT_1AS
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
