Forward-viewing versus oblique-viewing echoendoscopes in the diagnosis of upper gastrointestinal subepithelial lesions with EUS-guided fine needle aspiration: a prospective, randomized, crossover study
چکیده
Background: The role of the forward-viewing echoendoscope compared with the oblique-viewing echoendoscope for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of upper gastrointestinal subepithelial lesions has not been defined. Objective: To compare the diagnostic yield and clinical efficacy of EUS-FNA using the two echoendoscopes in the same upper gastrointestinal subepithelial lesion. Design: Prospective, randomized, crossover study. Setting: Tertiary medical center. Patients: Forty-one patients with an upper gastrointestinal subepithelial lesion. Interventions: All patients first underwent EUS-FNA with a 19-gauge needle using both echoendoscopes based on random selection. When required, 22or 25-gauge needles were used additionally. Main outcome measurements: Comparison of diagnostic yield, tissue sample area, puncture success rates, procedure time, and adverse events. Results: Forty-one patients (median lesion size 22 mm; range 15-63 mm) were enrolled. Rates of histological diagnosis were 80.5% (33/41) and 73.2% (30/41) (P= 0.453) using forward and oblique-viewing echoendoscopes, respectively. Median tissue sample area in gastrointestinal stromal tumors (n=22) obtained with the forward-viewing echoendoscope was larger than with the oblique-viewing echoendoscope (2.46 mm2 vs. 1.00 mm2; P = 0.046). Puncture success rates were 39/41 (95.1%) and 35/41 (85.4%), (P = 0.289) with forward and oblique-viewing echoendoscopes, respectively. Median procedure time was 21 min with the forward-viewing echoendoscope and 27 min with the oblique-viewing echoendoscope (P = 0.009). An infectious adverse event occurred in a patient and was treated with antibiotics. Limitations: Small sample size. Conclusions: Diagnostic yield did not differ between the two echoendoscopes. However, tissue sample area and procedure time was superior with the forward-viewing echoendoscope. Main text Most subepithelial lesions harbor a very low risk of progression. However, gastrointestinal stromal tumors (GISTs) have malignant potential, and surgical resection is recommended [1-5]. Endoscopic ultrasonography (EUS) is considered the first choice for evaluating subepithelial lesions and is used to differentiate GISTs from other subepithelial lesions [6-8]. However, a definitive diagnosis based on imaging alone is insufficient and tissue sampling is necessary [9-11]. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become an accurate method for obtaining tissue samples from upper gastrointestinal subepithelial lesions. In several retrospective studies, the diagnostic yield of EUS-FNA in upper gastrointestinal subepithelial lesions ranged from 43 to 91% [10,12-16]. At present, the oblique-viewing echoendoscope is the standard instrument for EUS-FNA. Recently, a new forward-viewing echoendoscope was developed to overcome the major disadvantages of the former instrument: lack of a forward endoscopic view and difficulty in fixing the target. The advantages of the forward-viewing echoendoscope for the treatment of pancreatobiliary disease were noted in several reports [17-25]. A few reports described the diagnostic accuracy of forward-viewing echoendoscopes compared with oblique-viewing echoendoscopes [20,23,26]. More recently, Larghi et al. reported extraordinary results using the forward-viewing echoendoscope for subepithelial lesions [27]. To date, a comparative study of forward-viewing and oblique-viewing echoendoscopes has not been reported. We therefore hypothesized that the forward-viewing echoendoscope would increase the diagnostic yield and facilitate EUS-FNA. The aim of this study was to compare the diagnostic yield and clinical efficacy of EUS-FNA between the newly developed forward-viewing echoendoscopes and conventional oblique-viewing echoendoscopes for the same upper gastrointestinal subepithelial lesions. Patients and Methods This study was a prospective, randomized, crossover trial, and was conducted at the Nagoya University Hospital in Japan. Between January 2013 and May 2014, all 78 patients with upper gastrointestinal subepithelial lesions were examined with a radial scanner (GF-UM2000; Olympus Medical Systems Corp., Tokyo, Japan) before EUS-FNA. The inclusion criterion for the study was the presence of an upper gastrointestinal subepithelial lesion. Exclusion criteria were as follows: age >80 y; tumor size 1.5 or platelet count 80 y (n=3), lesion All authors had no financial relationships relevant to this publication. Acknowledgments We thank Olympus Medical System for loaning the forward-viewing echoendoscope to our unit. 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