The following protocol developed at our institution (Zealand University Hospital) follows the Danish national guidelines on human research ethics.Written and informed consent was obtained from the human subjects.
1. Preparation for EUS-B
NOTE: This procedure requires experience in performing bronchoscopy / EBUS, thus the following instruction will not include details on basic steps such as sedation, monitoring etc. which are common for bronchoscopy, EBUS and EUS-B.
<ol>
	<li>Evaluate available computed tomography (CT) or positron emission tomography (PET)-CT scans in order to locate target lesions reachable by EUS-B (see Figure 2). Make sure that antithrombotic therapy is paused according to guidelines. Obtain patient&#39;s informed consent.</li>
	<li>Exclude patients with increased risk of perforation (e.g., recent bowel surgery, bowel obstruction, esophageal stenosis), coagulopathy or impaired platelet function.</li>
	<li>Position the patient in a supine position and apply monitoring similar to bronchoscopy or EBUS according to institutional standards. Many sites continuously monitor 3-lead telemetry, oxygen saturation, pulse and intermittent blood pressure.</li>
	<li>Initiate conscious sedation similar to bronchoscopy or EBUS according to institutional standards, such as IV midazolam 2.5 mg (for sedation) and IV Fentanyl 25 &#181;g (for cough and pain).</li>
</ol>
2. Performing EUS-B
<ol>
	<li>Perform EUS-B using the EBUS echoendoscope, which is typically 60 cm long (EUS is 125 cm) and the average diameter of the regular scope is between 6 and 7 mm (EUS is 12 - 14 mm).</li>
	<li>Stand behind the patient&#180;s head who is in a supine position. Hold the handle of the endoscope with the left hand with the thumb on the lever and hold the distal end of the endoscope with the right hand.</li>
	<li>Apply local anesthetic gel (nasal route) or spray (oral route) on the mucosa 1-2 min before endoscopy.</li>
	<li>Introduce the endoscope into the oropharynx, either orally or through the nostril, after applying local anesthetic gel on the tip of the endoscope.</li>
	<li>Advance into the laryngopharynx while the epiglottis is in front of the scope and visualize the vocal cords using the bronchoscopic view.
	<ol>
		<li>Turn the scope left or right to direct the scope lateral to the arytenoids. Ask the patient to swallow and slowly bend the endoscope posteriorly and introduce it into the esophagus. Never use force but follow the downward direction of the patient&#39;s voluntary swallowing movement, where the esophageal lumen is widened. Patient-operator coordination is vital.</li>
		<li>Spray 2 mL of topical lidocaine in the oropharynx if the endoscope is not successfully introduced into the esophagus.</li>
	</ol>
	</li>
	<li>Shift to the ultrasonic image and introduce the endoscope into the stomach, and start identifying the six EUS landmarks in a stepwise and chronological order as described in19 and below (Figure 3).
	<ol>
		<li>The left liver lobe - turn the endoscope slightly counterclockwise (Landmark 1).</li>
		<li>The abdominal aorta with the celiac trunk and superior mesenteric artery - turn the scope clockwise (Landmark 2).</li>
		<li>The left adrenal gland - turn the scope further clockwise (Landmark 3).</li>
		<li>Mediastinal lymph node station 7 -retract the endoscope to the mediastinum. This is situated close to the left atrium and right pulmonary artery (Landmark 4).</li>
		<li>Mediastinal lymph node station 4L - retract the endoscope a few centimeters and notice the reflections from the trachea. Then, turn the endoscope counterclockwise and find 4L between the aortic arch and the left pulmonary artery (the mickey mouse sign; Landmark 5).</li>
		<li>Mediastinal lymph node station 4R - turn the endoscope clockwise, pass the trachea and find the azygos vein (confirm by retracting the scope and the vein should disappear into the superior vena cava). 4R is near the azygos vein (Landmark 6).</li>
	</ol>
	</li>
</ol>
3. Tissue sample collection
<ol>
	<li>Take tissue samples from suspected lesions under real-time ultrasonographic guidance using the FNA needle. The needles on the market are slightly different, but the principles for their use are the same.
	<ol>
		<li>Insert the sheath in the endosope and adjust the length so that the tip is 1 mm outside the endoscope and lock it.</li>
		<li>Move the needle with the stylet forward and retract the stylet a few millimeters (if the tip is rounded) to make the needle sharp. This step is not needed if the stylet is sharp.</li>
		<li>Hit the target, retract the stylet, and apply suction to the needle.</li>
		<li>Move the needle back and forth. Then remove suction, lock the needle in the upper position and remove the equipment from the endoscope.</li>
	</ol>
	</li>
	<li>Make sure that the biopsy order is M1b-M1a-N3-N2-N1-T (M = metastasis, N = lymph node, T = tumor) to avoid iatrogenic upstaging.</li>
</ol>

Integrating Transesophageal Ultrasound with an Echoendobronchoscope

<ol>
	<li>Crombag, L. M. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ebus+Versus+Eus-B+for+diagnosing+sarcoidosis:+The+International+Sarcoidosis+Assessment+(ISA)+randomized+clinical+trial.">Ebus Versus Eus-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial.</a> Respirology. 27 (2), 152-160 (2022).</li><li>Vilmann, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Combined+endobronchial+and+esophageal+endosonography+for+the+diagnosis+and+staging+of+lung+cancer:+European+Society+of+Gastrointestinal+Endoscopy+(ESGE)+Guideline,+in+cooperation+with+the+European+Respiratory+Society+(ERS)+and+the+European+Society+of+Thoracic+Surgeons+(ESTS).">Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS).</a> Endoscopy. 47 (6), 545-559 (2015).</li><li>Pais, F. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transesophageal+approach+to+lung,+adrenal+biopsy+and+fiducial+placement+using+endoscopic+ultrasonography+(EUS):+An+interventional+pulmonology+experience.+Initial+experience+of+the+UCSF-FRETOC+(fresno+tracheobronchial+&amp;+oesophageal+center)+study+group.">Transesophageal approach to lung, adrenal biopsy and fiducial placement using endoscopic ultrasonography (EUS): An interventional pulmonology experience. Initial experience of the UCSF-FRETOC (fresno tracheobronchial &amp; oesophageal center) study group.</a> Respair Med. 141, 52-55 (2018).</li><li>Bhatia, S., Puri, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+endoscopic+ultrasound+in+non-small+cell+lung+cancer.">Role of endoscopic ultrasound in non-small cell lung cancer.</a> Int J Gastrointest Interv. 5 (3), 187-192 (2016).</li><li>Clementsen, P. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosis+and+staging+of+lung+cancer+with+the+use+of+one+single+echoendoscope+in+both+the+trachea+and+the+esophagus:+A+practical+guide.">Diagnosis and staging of lung cancer with the use of one single echoendoscope in both the trachea and the esophagus: A practical guide.</a> Endosc Ultrasound. 10 (5), 325-334 (2021).</li><li>Christiansen, I. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Characterization+of+lung+tumors+that+the+pulmonologist+can+biopsy+from+the+esophagus+with+endosonography+(EUS-B-FNA).">Characterization of lung tumors that the pulmonologist can biopsy from the esophagus with endosonography (EUS-B-FNA).</a> Respiration. 100 (2), 135-144 (2021).</li><li>Bibi, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+ultrasound-guided+pleural+biopsy+in+the+hands+of+the+pulmonologist.">Endoscopic ultrasound-guided pleural biopsy in the hands of the pulmonologist.</a> Respirol Case Rep. 8 (2), e00517 (2020).</li><li>Christiansen, I. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aspiration+of+pericardial+effusion+performed+with+EUS-B-FNA+in+suspected+lung+cancer.">Aspiration of pericardial effusion performed with EUS-B-FNA in suspected lung cancer.</a> Respiration. 99 (8), 686-689 (2020).</li><li>Christiansen, I. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EUS-B-FNA+for+diagnosing+liver+and+celiac+metastases+in+lung+cancer+patients.">EUS-B-FNA for diagnosing liver and celiac metastases in lung cancer patients.</a> Respiration. 98 (5), 428-433 (2019).</li><li>Issa, M. A., Sidhu, J. S., Tehrani, S. G., Clementsen, P. F., Bodtger, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+ultrasound-guided+pancreas+biopsy+in+the+hands+of+a+chest+physician.">Endoscopic ultrasound-guided pancreas biopsy in the hands of a chest physician.</a> Respir Med Case Rep. 43, 101833 (2023).</li><li>Crombag, L. M. M. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EUS-B-FNA+vs+conventional+EUS-FNA+for+left+adrenal+gland+analysis+in+lung+cancer+patients.">EUS-B-FNA vs conventional EUS-FNA for left adrenal gland analysis in lung cancer patients.</a> Lung Cancer. 108, 38-44 (2017).</li><li>Christiansen, I. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EUS-B+for+suspected+left+adrenal+metastasis+in+lung+cancer.">EUS-B for suspected left adrenal metastasis in lung cancer.</a> J Thorac Dis. 12 (3), 258-263 (2020).</li><li>Crombag, L. M. M. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EUS-B-FNA+vs+conventional+EUS-FNA+for+left+adrenal+gland+analysis+in+lung+cancer+patients.">EUS-B-FNA vs conventional EUS-FNA for left adrenal gland analysis in lung cancer patients.</a> Lung Cancer. 108, 38-44 (2017).</li><li>Shen, Y., Qin, S., Jiang, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endobronchial+ultrasound-guided+transbronchial+needle+aspiration+combined+with+either+endoscopic+ultrasound-guided+fine-needle+aspiration+or+endoscopic+ultrasound+using+the+EBUS+scope-guided+fine-needle+aspiration+for+diagnosing+and+staging+mediastinal+diseases:+a+systematic+review+and+meta-analysis.">Endobronchial ultrasound-guided transbronchial needle aspiration combined with either endoscopic ultrasound-guided fine-needle aspiration or endoscopic ultrasound using the EBUS scope-guided fine-needle aspiration for diagnosing and staging mediastinal diseases: a systematic review and meta-analysis.</a> Clinics. 75, e1759 (2020).</li><li>Giri, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transesophageal+endoscopic+ultrasound-guided+tissue+acquisition+of+lung+masses:+a+case+series+with+systematic+review+and+meta-analysis.">Transesophageal endoscopic ultrasound-guided tissue acquisition of lung masses: a case series with systematic review and meta-analysis.</a> Ann Gastroenterol. 36 (2), 185-194 (2023).</li><li>Christiansen, I. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+feasibility+of+oesophageal+ultrasound+for+the+work-up+of+thoracic+malignancy+in+patients+with+respiratory+impairment.">Safety and feasibility of oesophageal ultrasound for the work-up of thoracic malignancy in patients with respiratory impairment.</a> J Thor Dis. , (2023).</li><li>Torii, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EUS-B-FNA+enhances+the+diagnostic+yield+of+EBUS+bronchoscope+for+intrathoracic+lesions.">EUS-B-FNA enhances the diagnostic yield of EBUS bronchoscope for intrathoracic lesions.</a> Lung. 200 (5), 643-648 (2022).</li><li>Kang, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Infectious+complications+of+EBUS-TBNA:+A+nested+case-control+study+using+10-year+registry+data.">Infectious complications of EBUS-TBNA: A nested case-control study using 10-year registry data.</a> Lung Cancer. 161, 1-8 (2021).</li><li>Konge, L., Colella, S., Vilmann, P., Clementsen, P. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+to+learn+and+to+perform+endoscopic+ultrasound+and+endobronchial+ultrasound+for+lung+cancer+staging:+A+structured+guide+and+review.">How to learn and to perform endoscopic ultrasound and endobronchial ultrasound for lung cancer staging: A structured guide and review.</a> Endosc Ultrasound. 4 (1), 4-9 (2015).</li><li>Dhooria, S., Aggarwal, A. N., Gupta, D., Behera, D., Agarwal, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Utility+and+safety+of+endoscopic+ultrasound+with+bronchoscope-guided+fine-needle+aspiration+in+mediastinal+lymph+node+sampling:+Systematic+review+and+meta-analysis.">Utility and safety of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration in mediastinal lymph node sampling: Systematic review and meta-analysis.</a> Respir Care. 60 (7), 1040-1050 (2015).</li><li>Cot&#233;, G. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+in+EUS-guided+fine+needle+aspiration:+Safety+and+diagnostic+yield+of+attending+supervised,+trainee-directed+FNA+from+the+onset+of+training.">Training in EUS-guided fine needle aspiration: Safety and diagnostic yield of attending supervised, trainee-directed FNA from the onset of training.</a> Diagn Ther Endosc. 2011, 378540 (2011).</li><li>Meena, N., Hulett, C., Patolia, S., Bartter, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Exploration+under+the+dome:+Esophageal+ultrasound+with+the+ultrasound+bronchoscope+is+indispensible.">Exploration under the dome: Esophageal ultrasound with the ultrasound bronchoscope is indispensible.</a> Endosc Ultrasound. 5 (4), 254-257 (2016).</li><li>Nielsen, A. O., Cold, K. M., Vamadevan, A., Konge, L., Clementsen, P. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+endobronchial+ultrasound+-+The+six+landmarks+approach.">Systematic endobronchial ultrasound - The six landmarks approach.</a> J Vis Exp. (198), 65551 (2023).</li><li>Konge, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulator+training+for+endobronchial+ultrasound:+a+randomised+controlled+trial.">Simulator training for endobronchial ultrasound: a randomised controlled trial.</a> Eur Respir J. 46 (4), 1140-1149 (2015).</li><li>Naur, T. M. H., Konge, L., Nayahangan, L. J., Clementsen, P. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+and+certification+in+endobronchial+ultrasound-guided+transbronchial+needle+aspiration.">Training and certification in endobronchial ultrasound-guided transbronchial needle aspiration.</a> J Thorac Dis. 9 (7), 2118-2123 (2017).</li><li>Nayahangan, L. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Developing+a+simulation-based+training+curriculum+in+transesophageal+ultrasound+with+the+use+of+the+endobronchial+ultrasound-endoscope.">Developing a simulation-based training curriculum in transesophageal ultrasound with the use of the endobronchial ultrasound-endoscope.</a> Endosc Ultrasound. 11 (2), 104-111 (2022).</li><li>El Hajj, I. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+assessment+of+the+performance+of+a+new+fine+needle+biopsy+device+for+EUS-guided+sampling+of+solid+lesions.">Prospective assessment of the performance of a new fine needle biopsy device for EUS-guided sampling of solid lesions.</a> Clin Endosc. 51 (6), 576-583 (2018).</li><li>Adler, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+multicenter+evaluation+of+a+new+EUS+core+biopsy+needle:+Experience+in+200+patients.">A multicenter evaluation of a new EUS core biopsy needle: Experience in 200 patients.</a> Endosc Ultrasound. 8 (2), 99-104 (2019).</li><li>Balwan, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Core+needle+biopsy+with+endobronchial+ultrasonography:+single+center+experience+with+100+cases.">Core needle biopsy with endobronchial ultrasonography: single center experience with 100 cases.</a> J Am Soc Cytopathol. 9 (4), 249-253 (2020).</li><li>Mangiavillano, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transesophageal+endoscopic+ultrasound+in+the+diagnosis+of+the+lung+masses:+a+multicenter+experience+with+fine-needle+aspiration+and+fine-needle+biopsy+needles.">Transesophageal endoscopic ultrasound in the diagnosis of the lung masses: a multicenter experience with fine-needle aspiration and fine-needle biopsy needles.</a> Eur J Gastroenterol Hepatol. 34 (7), 757-762 (2022).</li></ol>

EUS-B has significantly changed the field of interventional pulmonology2,5,6,13. EUS-B allows the pulmonologist to access lesions not reachable with EBUS, simply by using the EBUS endoscope in a new way. A patient with a central lung tumor, enlarged mediastinal lymph nodes and abnormal left adrenal gland can have all lesions sampled with one endoscope in a single interventional session, saving ...

Endoscopic ultrasound is a key procedure in the diagnosis and staging of lung cancer and allows safe sampling from mediastinal or hilar lymph nodes1,2. Endoscopic ultrasound comprises endobronchial (EBUS) and transesophageal ultrasound (EUS), are considered complementary procedures2.
Interventional pulmonologists are trained with the EBUS endoscope but are rarely familiar with the larger EUS endoscope (Figure 1), which requires special training to handle correctly3. EBUS and EUS are often performed by different departments and on separate sessions/days4. However, trained pulmonologists experienced with EBUS techniques can insert the smaller EBUS endoscope into the esophagus and perform safe examination and biopsy sampling from mediastinal lymph nodes and other lesions adjacent to the esophagus and stomach - a technique termed as EUS-B5. This leads to extension of pulmonologists&#39; ability to safely and conclusively sample lesions in many different anatomical sites such as lung6, pleura7, pericardial effusion8, mediastinal lymph nodes1,5, left liver lobe and retroperitoneal lymph nodes9, pancreas10 and the left adrenal gland11,12 (Figure 2).
The EUS-B procedure is a pulmonologist friendly version of the gastroenterologists&#180; EUS using an endoscope that the pulmonologist already masters. The EUS procedure is performed with a gastroendoscope which is both larger and heavier than the EBUS endoscope, has a different handle (with wheels, see Figure 1) and is unlike EBUS performed with the patient in left lateral decubitus. Learning EUS as a pulmonologist is challenging and requires a lot of training and supervision2.
EUS-B and EUS are so far very similar regarding diagnostic yield when performed in the field of pulmonology5,13,14,15. EUS-B is patient friendly since the endoscope is significantly thinner than that of EUS, and therefore less unpleasant for the pharynx and esophagus. Unlike EBUS, EUS-B does not cause direct airway irritation and is therefore safe to use in patients with suspected cancer resulting in severe respiratory impairment due to mediastinal tumor masses16.
The combination of EBUS and EUS-B is preferred over either test alone in any patient suspected of lung cancer, but EUS-B should especially be considered in patients with suspicious lesions out of reach by EBUS, but within range by transesophageal ultrasound (Figure 2). Adding EUS-B to EBUS in lung cancer work-up expands the interventional pulmonologists&#180; ability to perform diagnostic work-up during a single session using the same endoscope by one proceduralist, which is more convenient for the patient, saving both time and costs.
The complication risk of EUS-B is extremely low and is to our knowledge only limited to infectious complications17,18. EUS-B training should be easy and a natural continuation of EBUS, and the following protocol will describe how to perform EUS-B in mild sedation in an out-patient clinical setting.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>22 Gauge FNA needle system</td>
			<td>Olympus Medical Systems</td>
			<td>Vizishot</td>
			<td></td>
		</tr>
		<tr>
			<td>EBUS echoendoscope</td>
			<td>Olympus Medical Systems</td>
			<td>BF-UC190F</td>
			<td></td>
		</tr>
		<tr>
			<td>EVIS Exera II endoscopy tower with EVIS X1 video processor</td>
			<td>Olympus Medical Systems</td>
			<td>CV-1500&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Lidocaine gel</td>
			<td>Multiple (e.g. Aspen Pharma)</td>
			<td>Xylocain 2%</td>
			<td></td>
		</tr>
		<tr>
			<td>Lidocaine spray</td>
			<td>Multiple (e.g. Aspen Pharma)</td>
			<td>Xylocaine Pump Spray</td>
			<td></td>
		</tr>
	</tbody>
</table>

using the endoscope for endobronchial ultrasound in the esophagus

EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that pulmonologists can use to visualize and biopsy structures adjacent to the esophagus and stomach. EUS-B gives access to many structures of which some may also be reached by EBUS (mediastinal lymph nodes, lung or pleural tumors, pericardial fluid) while others cannot be reached such as retroperitoneal lymph nodes, ascites, and lesions in the liver, pancreas or left adrenal gland. The procedure is a pulmonologist- and patient- friendly version of the gastroenterologists' EUS using the thin EBUS endoscope that the pulmonologist already masters. Thus EUS-B training should be easy and a natural continuation of EBUS. With the patient under conscious sedation and in the supine position, the echoendoscope is introduced either through the nostril or mouth into the oropharynx. Then the patient is encouraged to swallow while the endoscope is slowly bent posteriorly and introduced into the esophagus and stomach. Using the ultrasonic image, the operator identifies the six landmarks by EUS-B and EUS: the left liver lobe, abdominal aorta (with the celiac trunk and superior mesenteric artery), left adrenal gland, and mediastinal lymph node stations 7, 4L, and 4R. Biopsies can be taken from suspected lesions under real-time ultrasonographic guidance- fine needle aspiration (EUS-B-FNA) using a technique similar to that used with EBUS-TBNA. The biopsy order is M1b-M1a-N3-N2-N1-T (M = metastasis, N = lymph node, T = tumor) to avoid iatrogenic upstaging. Pre- and post-procedural observation is similar to that of bronchoscopy. EUS-B is safe and feasible in the hands of experienced interventional pulmonologists and provides a significant expansion of the diagnostic possibilities in providing safe, fast, and thorough diagnosis and staging of lung cancer.

Author Spotlight: Advancing Biopsy Techniques with Transesophageal Ultrasound

Using the Endoscope for Endobronchial Ultrasound in the Esophagus

Our scope is to identify new ways to perform biopsies from otherwise difficult to access areas in the most patient-friendly way. Thus, conclusive biopsies with few adverse events, low patients discomfort, and low costs. EUS-B is a safe technique in the hands of respiratory physicians.Despite that biopsies are taken not from the lungs or airways, but from the esophagus or stomach, it allows for more complete investigation of patients with possible lung cancer or other cancer. We have contributed significantly to the field by exploring utility and safety of EUS-B, including identification of new targets that can be reached and sampled. The aspect of patient safety is of utmost importance, and EUS-B has no serious complications.EUS-B is an emerging technique, and there's still no simulators or phantoms that allows for safe learning of the technique. This protocol provides a clear and stepwise instruction to support beginners and mentors to improve the learning curve.

The described technique allows the EBUS-skilled pulmonologist to safely and efficiently sample lesions adjacent to the esophagus and stomach - above or below the diaphragm - using the EBUS echoendoscope (Figure 1 and Figure 2). Table 1 shows that diagnostic hit rates vary according to location, with slightly higher diagnostic success rates of intrathoracic lesions. 
The systematic six...

Read this Scientific Article Protocol about Author Spotlight: Advancing Biopsy Techniques with Transesophageal Ultrasound at JoVE.com

Transesophageal ultrasound (EUS-B) is a safe and feasible procedure using the echoendobronchoscope (EBUS) in esophagus and stomach. After identifying six anatomical landmarks, additional structures can be identified and biopsied, sparing subsequent diagnostic sessions. Thus, EUS-B is an ideal continuation of bronchoscopy and EBUS in diagnosing lung cancer and other diseases.

EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that ...

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Research

JoVE Journal

Medicine

Performing Transesophageal Ultrasound Using the Six Landmarks Approach and Tissue Sampling

To begin, position the patient in a supine and apply monitoring equipment. Continuously monitor 3-lead telemetry, oxygen saturation, pulse, and intermittent blood pressure. While standing behind the patient's head, hold the handle of the echo endobronchoscope with the left hand, thumb in the lever, and distal end in the right hand.Apply local anesthetic gel on the tip of the endoscope, then orally or through the nostril, introduce the endoscope into the oropharynx of the anesthetized patient. Advance the endoscope into the laryngopharynx while the epiglottis in front of the scope. Visualize the vocal cords using the bronchoscopic view.Next, turn the scope left or right to direct it lateral to the adenoids. Ask the patient to swallow and slowly bend the endoscope posteriorly, introducing it into the esophagus following the patient's swallowing movement. If required, spray two milliliters of topical lidocaine in the oropharynx.To identify six endoscopic ultrasound landmarks, shift to the ultrasonic image and introduce the endoscope into the stomach. At landmark one, turn the endoscope slightly counterclockwise to visualize the left liver lobe. At landmark two, turn the scope clockwise to visualize the abdominal aorta with the celiac trunk in superior mesenteric artery.Turn the scope further clockwise at landmark three to visualize the left adrenal gland. At landmark four, retract the endoscope to the mediastinum to locate the mediastinal lymph station 7. Next, retract the endoscope a few centimeters and observe the reflections from the trachea.Now turn the endoscope counterclockwise and at landmark five find mediastinal lymph node station 4L between the aortic arch and the left pulmonary artery. At landmark six, turn the endoscope clockwise and pass the trachea to find the azygos vein and mediastinal lymph node station 4R. Insert the sheath in the endoscope and adjust the length such that the tip is one millimeter outside the endoscope.Then lock the sheath in place. Move the FNA needle with the stylet forward and retract the stylet a few millimeters to sharpen the needle. Under realtime ultrasonographic guidance, hit the target lesions.Then retract the stylet and apply suction to the needle. Move the needle back and forth. Remove the suction and lock the needle in the upper position before removing the equipment from the endoscope.The transesophageal ultrasound tissue sampling technique shows that diagnostic hit rates vary according to location with slightly higher diagnostic success rates of intrathoracic lesions.

204 Views.  Zealand University Hospital.  Transesophageal ultrasound (EUS-B) is a safe and feasible procedure using the echoendobronchoscope (EBUS) in esophagus and stomach. After identifying six anatomical landmarks, additional structures can be identified and biopsied, sparing subsequent diagnostic sessions. Thus, EUS-B is an ideal continuation of bronchoscopy and EBUS in diagnosing lung cancer and other diseases.

Integrating Transesophageal Ultrasound with an Echoendobronchoscope

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