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• W2000218862 abstract "When high-frequency mini-probe ultrasound devices were first described in the late 1980s and early 1990s, much was made of their advantages over standard endoscopic ultrasound.1 Probes were easier to use, could be passed through tight strictures without dilation, and gave higher resolution images of the gut wall. The latter was of particular interest if one were to consider performing the newly described “strip biopsy” or endoscopic mucosal resection.2 Now, more than 10 years and numerous acronyms later, (mini-probe ultrasound has been variously referred to as EUS-P, for endoscopic ultrasound probe, C-EUS for catheter-based ultrasound, HFPE for high-frequency probe EUS, and now HFUS for high-frequency probe ultrasound), Hurlstone et al, in this month's issue of the Journal of Clinical Gastroenterology, again demonstrate the ease of use and versatility of catheter mini-probe ultrasound as well as its ability to allow the endoscopist to predict complete endoscopic resection of certain submucosal lesions.3 While Hurlstone et al provide an excellent prospective assessment of the effectiveness of high-frequency ultrasound-assisted EMR in the colon, questions remain. First, what does this study really tell us about this technology? What does it tell us about EMR? Also, if this is such a useful technology, why hasn't it received wider attention over the past decade? Why doesn't high-frequency ultrasound get any respect? But before discussing the article itself, this seems to be a reasonable time to assign high-frequency mini-probe ultrasound a consistent acronym. While HFUS seems as good as any-the catheter probe is in fact a high-frequency ultrasound device-it does not make any reference to the specific use of the device. HFUS could just as easily refer to any nonendoscopic high-frequency ultrasound. A Medline search of “HFUS” brings up three articles about high-frequency ultrasound for dermatologic conditions, one for breast biopsy localization, and one about the “hand-foot-uterus syndrome,” but none about endoscopic high-frequency ultrasound. We prefer C-EUS because it specifically refers to ultrasound performed via a catheter-type mini-probe during endoscopy. It is also an acronym used widely in English-language journals and the one used in the most comprehensive review of the topic.4 The current study describes 30 patients who underwent C-EUS prior to resection of small submucosal lesions (<20 mm). Most of the lesions were located in the left colon and rectum; however, a few nodules were found in the cecum. C-EUS prior to EMR identified 27 individuals in whom EMR resulted in complete resection. The submucosa failed to separate from muscularis propria after submucosal injection in 3 individuals. These 3 were deemed unsafe for EMR and went to transanal excision. All 27 who underwent EMR were disease-free at the 12-month follow-up. While this study reinforces the data supporting the safety of EMR for submucosal lesions,5 it adds only a small amount to what we already know about C-EUS. We already know that C-EUS can accurately identify the depth of invasion of mucosal lesions6 and the level of involvement of submucosal lesions.7 This study suggests that if C-EUS demonstrates that a lesion fails to separate from the muscularis propria after submucosal injection, it is not amenable to EMR. However, no attempt was made at endoscopically removing this group of lesions. No mention was made of final histology of “non-lifting” lesions that went for surgical resection, ie, was there histologic evidence of invasion of the muscularis propria that would have led to an incomplete resection or a complication if EMR had been attempted? How can we know that the failure to separate wasn't a misinterpretation of the C-EUS images or a misdirected submucosal injection? Further, since there was no control group-individuals who underwent EMR without C-EUS, using only the “lifting sign” as evidence of resectability-we cannot accurately say that C-EUS increases the accuracy and safety of EMR for submucosal colonic lesions. This is not a strictly academic question. Although C-EUS can be performed during the index endoscopy, all patients in this study (presumably even those with rectal lesions) underwent a second bowel prep and a second sedated procedure. This being said, we think that there is clear value to performing EUS before EMR. Further, we can probably generalize that, even without the support of a prospective, randomized trial, most endoscopists who perform EMR prefer to know the nature and extent of the tissue they are resecting before they apply current. Consider, for example, a gastric nodule that is in reality a varix or a GIST of the esophagus arising from the muscularis propria. Because of the wealth of information provided by C-EUS, as well as the ease of performing the study, C-EUS has become an invaluable adjunct to EMR for both mucosal and submucosal lesions. This leads to the second question: Why doesn't C-EUS get more respect? Although standard EUS has gained wide acceptance and utility among gastroenterologist, surgeons, and oncologists, C-EUS is still thought of in many circles (even among endosonographers) as an amusing accessory. A Medline search reveals more than 3,000 articles about EUS between January 1980 and February 2005. C-EUS (in all of its incarnations) appears fewer than 200 times. The truth is that C-EUS can stand alone as a versatile tool with myriad applications in everyday gastroenterology practice. While much of the original attention for C-EUS was for imaging tight strictures inaccessible by a standard echoendoscope without a potentially risky dilation, C-EUS has proven to be at least equal to and likely superior to standard ultrasound for a variety of other applications. C-EUS allows pinpoint targeting of mucosal lesions and can quickly identify and localize submucosal structures. The higher frequency of C-EUS can provide better resolution of superficial structures than standard EUS. C-EUS can frequently be accomplished in a few minutes, during the index endoscopy, and often without removing the endoscope. As the current study demonstrates, C-EUS be performed virtually anywhere an endoscope or colonoscope can reach. C-EUS has been used to image Barrett's mucosa before ablative therapy. It has been used to look for microlithiasis and image biliary and pancreatic duct structures. Lastly, as endoscopic mucosal resection techniques become more sophisticated and aggressive, C-EUS will play an increasingly important role, helping endoscopists avoid misadventures. Some endosonographers avoid using C-EUS because of problems with acoustic coupling. C-EUS is most often used without a water-filled balloon, requiring irrigation during the procedure. This can be problematic in the esophagus, as overfilling can lead to aspiration. Several innovations have helped, including a balloon sheath,8 a condom affixed to the endoscope,9 and a jelly-like transducing medium that lingers in the lumen longer than water.10 Others find the limited depth of penetration, well, limiting.11 However, when the target is a mucosal or submucosal lesion, what lies beyond the luminal wall is largely irrelevant. Finally, some find the technology expensive and fragile.10 While inexpensive endoscopy equipment remains a virtual oxymoron, a portable C-EUS system that can travel from room to room costs about as much as a duodenoscope. With proper care, an echo probe should last well beyond 100 uses and can reduce the incidence of expensive repairs of standard endoscopes. In addition, training requires only a few hours since the anatomy that is usually imaged is fairly simple and consistent. Numerous challenges remain for EUS, particularly C-EUS. The current article brings up the important limitation of predicting the histology of submucosal lesions. All of the lesions resected were benign and half represented lipomas, lymphangiomas, and fibrovascular polyps, which harbor no malignant potential. What we may need more than the ability to localization submucosal sublayers is a better ability to differentiate benign bumps from lesions that require resection. Even the highest frequency ultrasound probes currently available cannot consistently do this. For now, Hurlstone et al do provide a cushion of reassurance as well as a helpful guide for those willing to remove colonic submucosal lesions endoscopically. In addition, this study should help the oft-ignored mini-probe gain a bit more respect." @default.
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• W2000218862 title "High-Frequency Mini-Probe Ultrasound: The Rodney Dangerfield of Endoscopy?" @default.
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