New method
Experimental endoscopy
EUS-guided submucosal implantation of a radiopaque marker: a simple and effective procedure to facilitate subsequent surgical and radiation therapy

https://doi.org/10.1016/j.gie.2008.02.053Get rights and content

Background

Endosonography (EUS) is widely used for locoregional staging of malignant GI tumors. Delineation of a tumor's margins with a long-lasting fluoroscopically visible material will facilitate subsequent surgical and radiation therapy.

Objective

To assess the feasibility of EUS-guided submucosal implantation of a radiopaque marker in a porcine model.

Setting

Survival experiments on four 50-kg pigs.

Methods

A linear array echoendoscope was introduced into the esophagus and advanced to the stomach. With a 19-gauge FNA needle, a submucosal bleb was created by injecting 3 mL of normal saline solution into the gastric and esophageal wall followed by injection of 1 mL of tantalum suspension under fluoroscopic observation. Fluoroscopy was repeated after 1, 2, and 4 weeks followed by euthanasia and necropsy.

Main Outcome Measurements

Long-term depositions of the marker in the injection sites.

Results

Submucosal injections of tantalum were easily performed through the 19-gauge FNA needle, resulting in good fluoroscopic opacification of injected material. Follow-up fluoroscopy in 1, 2, and 4 weeks demonstrated stable deposition of the tantalum at the sites of injection. There were no complications during and after the tantalum implantation. Histologic examination of the injection sites demonstrated submucosal tantalum depositions without signs of infection, inflammation, tissue damage, or necrosis.

Limitations

Animal experiments with 4 weeks' follow-up.

Conclusions

EUS-guided implantation of tantalum as a radiopaque marker into the submucosal layer of the GI tract in a porcine model is technically feasible and safe. Long-lasting fluoroscopically visible tantalum markings could facilitate subsequent surgical and radiation therapy.

Section snippets

Methods

This study was approved by the Johns Hopkins University School of Medicine Animal Care Institutional Review Board. Four long-term survival experiments were performed on 50-kg pigs (Sus scrofus domesticus) that were under 1.5% to 2% isoflurane general anesthesia with 7.0-mm endotracheal intubation (Mallinckrodt, Juarez, Mexico). All pigs were fed with six 16-ounce cans of Ensure (Abbott Laboratories, North Chicago, Ill) 1 day before endoscopy and then fasted overnight. Preanesthesia medication

Results

All layers of the esophageal and gastric walls were clearly visualized with EUS in all animals. Submucosal injections of normal saline solution through the 19-gauge FNA needle were easily performed in all animals and created an endoscopically visible bleb at the sites of the injections. Subsequent injections of the tantalum suspension into this submucosal bleb through the same 19-gauge FNA needle were also technically easy and resulted in endoscopically visible depositions of black powder at

Discussion

EUS is currently widely used for local staging of GI malignant tumors, allowing very accurate determination of tumor borders.1, 2, 3, 4, 20 Injection of a radiopaque material to mark the borders of malignant lesions at the time of EUS will facilitate subsequent radiation therapy and surgery. Although submucosal injections of color markers (India ink, Spot [GI Supply, Camp Hill, Pa], methylene blue, indocyanine green) are widely used to facilitate a lesion's localization during repeat endoscopy

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    Copyright © 2008 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.