Echotip procore

All patients provided written informed consent previous to the procedure. All EUS-guided TA were performed by an experienced endosonographer. Deep sedation was assisted by endoscopist or anesthesiologist, depending on the sedation protocol of each center. A linear array echoendoscope (Olympus GF-UCT140-AL5 or UCT-180, Pentax EG-3870UTK or EG-3270UK, Fujifilm EG-580UT) was used to identify and puncture the suspected AG. Left AGs were evaluated from the stomach, and right AGs from the duodenum. EUS-guided puncture was performed using a fine needle (25 or 22G in size), either cytological (EchoTipUltra, Cook; ExpectEndoscopic Ultrasound Aspiration Needle, BostonSC; BeaconFNA exchange system, Medtronic-Covidien) or cytohistopathological (EchoTip ProCore, Cook; SharkCoreFNB exchange system, Medtronic-Covidien). Color Doppler imaging was used to avoid interposal vessels. The suction technique applied, if any (stylet slow-pull vs. standard suction), and type and size of needle were items selected at the discretion of the endosonographer. In patients with antiplatelet or anticoagulant therapy, the recommendations of the international guidelines were followed (i.e., European Society of Gastrointestinal Endoscopy or British Society of Gastroenterology, 2008) [14 (link)]. EUS-guided FNA of a left AG example is shown in Fig 1.

EUS examinations were performed using linear echoendoscopes (GF-UCT 260, Olympus Medical Systems, Tokyo, Japan or EG 3870 UTK Pentax Medical Corporation, Tokyo, Japan) coupled with the corresponding US processor (Aloka Prosound Alpha-10, Aloka, Tokyo, Japan or Hitachi Preirus, Hitachi Medical Corporation, Tokyo, Japan). Commercially available 22 and 25-gauge FNA needles (EZ Shot 2 and EZ Shot 3 Plus Nitinol, Olympus, Tokyo, Japan; Expect, Boston Scientific, Natick, MA, USA; EchoTip Ultra, Cook Medical, Bloomington, IN, USA) or FNB needles (Acquire, Boston Scientific; EchoTip ProCore, Cook Medical) were used.

A linear echoendoscope (EG3870UTK, Pentax, Japan) and an ultrasound processor (HI VISON Ascendus, Hitachi, Tokyo, Japan) were used to examine the patients under deep sedation. The characteristics of target lesions were recorded. Before sampling, the echoendoscope was stabilized in the stomach or in the duodenum. Then, transmural puncture of the target lesion was performed by EUS-FNB using a 22 gauge reverse-bevel needle (EchoTip Procore®, Wilson-Cook Medical, Limerick, Ireland) and by applying fanning and standard suction^{21 (link)}. All EUS-procedures of the study were performed by either of two dedicated and experienced endosonographers (> 1000 procedures).
The yield of EUS-FNB was put into formalin tubes and the FNB-core was assessed macroscopically. Additional FNB-passes were performed if the cores were considered inadequate at gross examination. No fixed number of passes was performed. Routine EUS-FNA (EchoTip®, Wilson-Cook Medical), and not EUS-FNB, was preferred during some periods when diagnostics was performed by subspecialized cytopathologists or if no FNB-needle was available on-site.

In patients with extrinsic type, if malignancy was not detected on the initial TPB for suspected MBS, a follow‐up biopsy was performed by EUS‐FNAB (Fig. 1). EUS‐FNAB was performed in a standardized manner by two experienced investigators using a linear‐array echoendoscope (GF‐UCT240; Olympus Medical Systems) in patients under conscious sedation. FNAB was performed from the stomach using a standard 22 gauge (G), or from the duodenum with a 25G, FNAB device (Echotip ProCore; Wilson‐Cook Medical, Winston‐Salem, NC). After puncturing the lesion, the stylet was removed, and suction was applied using a 5–10 mL syringe. The needle was then moved to and fro 15–20 times and withdrawn from the lesion after suction was released. For specimen preparation and analysis, we used a triple approach comprising simultaneous cytopathologic and histologic evaluations with on‐site examination 14. In patients with intrinsic type, the follow‐up biopsy was performed by a second TPB using the same method as the initial TPB during ERCP.