Successful endoscopic ultrasound-guided fine-needle biopsy of a recurrent paraganglioma using a forward-viewing echoendoscope in a patient who had undergone the Whipple procedure

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is useful for the diagnosis of retroperitoneal lesions and pancreatic diseases. However, the usefulness of EUS-FNB for tissue acquisition from retroperitoneal lesions in patients with surgically altered anatomy has not been established ^{1 2 3 4 5} . Herein, we report successful tissue acquisition from a recurrent lymph node lesion of a retroperitoneal paraganglioma by EUS-FNB using a forward-viewing echoendoscope (FV-EUS) in a patient who had undergone the Whipple procedure.

A 60-year-old man underwent the Whipple procedure for a retroperitoneal paraganglioma adjacent to the head of the pancreas ( Fig. 1 ). Follow-up computed tomography 2.5 years after surgery revealed a 15-mm swelling of the lymph node on the right side of the inferior vena cava ( Fig. 2 ). The lesion was located near the afferent loop, and we expected that it could be visualized using an FV-EUS (TGF-UC260J; Olympus, Tokyo, Japan).

Fig. 1.

Computed tomography image of a retroperitoneal paraganglioma. The tumor was located adjacent to the head of the pancreas.

Fig. 2.

Computed tomography image of a recurrent lymph node lesion (arrowheads) of the retroperitoneal paraganglioma.

To insert the FV-EUS into the afferent loop safely, a short-type single-balloon enteroscope (SIF-H290; Olympus) was first inserted into the hepaticojejunostomy anastomosis ( Fig. 3 ), and a guidewire was placed. Then, under wire guidance, the FV-EUS was inserted up into the afferent loop, and the target lesion was visualized. EUS-FNB was performed transjejunally using a 22-gauge FNB needle ( Fig. 4 ). The histopathological diagnosis was consistent with lymph node recurrence of the retroperitoneal paraganglioma ( Fig. 5 ). Finally, open retroperitoneal tumor resection was performed, and complete resection was achieved ( Video 1 ).

Fig. 3.

A balloon enteroscope was inserted into the afferent loop.

Fig. 4.

Endoscopic ultrasound-guided fine-needle biopsy was performed using a 22-gauge needle.

Fig. 5.

The pathological specimen obtained by endoscopic ultrasound-guided fine-needle biopsy.

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Successful endoscopic ultrasound-guided fine-needle biopsy of a recurrent paraganglioma using a forward-viewing echoendoscope in a patient who had undergone the Whipple procedure.

Video 1

This case demonstrates that EUS-FNB using an FV-EUS and assisted by balloon enteroscope insertion is a safe and effective method for tissue acquisition in patients with surgically altered anatomy, and can prevent adverse events, such as gastrointestinal perforation.

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