Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Table 1 Frequency of upper gastrointestinal tract perforations caused by radial and longitudinal echoendoscopes in the German survey of endoscopic ultrasonography complications (2004-2006, data from Jenssen, Faiss and Nürnberg[31]) n (%)

Perforation location	Radial EUS (n = 47 417)	Longitudinal EUS (n = 37 667)	Radial and longitudinal EUS1 (n = 85 084)
Esophageal	3 (0.087)	5 (0.013)	8 (0.009)
Duodenal	8 (0.017)	11 (0.029)	19 (0.022)a
Gastric	0	1 (0.003)	1 (0.001)
Total	11 (0.023)	17 (0.045)	28 (0.033)

¹Without endoscopic ultrasonography (EUS)-guided fine-needle biopsy or EUS-guided therapeutic interventions.

^aP < 0.05 vs esophageal perforations.

Table 2 Possible risk factors for endoscopic ultrasonography-related gastrointestinal perforations (adapted from Jenssen, Mayr, Nuernberg and Faiss[40])

Risk factor	References
Operator inexperience	Das et al[27], Jenssen et al[31], Lachter[38]
Esophagus
Stenosing cancer of the esophagus and esophagogastric junction	Das et al[27], Mortensen et al[30], Rösch et al[28]
Dilatation of esophageal stricture prior to EUS	Das et al[27], Mortensen et al[30], Rösch et al[28]
Advanced patient age	Das et al[27]
Difficult previous endoscopic esophageal intubation	Das et al[27]
Large cervical osteophytes	Das et al[27]
Duodenum
Diverticula	Jenssen et al[31], Lachter[38]
Stenosis, pancreatic head tumor	Raut et al[34]
Longitudinal echoendoscope (long, rigid tip)	Lachter[38]

EUS: Endoscopic ultrasonography.

Table 3 Complications of diagnostic endoscopic ultrasonography in 67 German centers (2004-2006, data from Jenssen, Faiss and Nürnberg[31]) n (%)

Complications	Non-interventional diagnostic EUS (n = 85 084)	EUS-FNB (n = 13 223)	Total (n = 98 307)
Total	29 (0.034)	38 (0.29)	104 (0.10)
Major	29 (0.034)	23 (0.17)	52 (0.053)
Conservative treatment	2	15	17
Interventional treatment	0	4	4
Surgical treatment	27	4	31
Mortality	4 (0.005)	0 (0.000)	4 (0.004)
Minor (no treatment necessary)	0	15 (0.11)	16 (0.016)

EUS: Endoscopic ultrasonography; EUS-FNB: Endoscopic ultrasonography-guided fine-needle biopsy.

Table 4 Procedural risk of endoscopic ultrasonography

First author (yr)	Study features	Frequency of complications (%)
		EUS1	EUS-FNB	EUS-I
Prospective, single-center
Williams et al[52]	333 EUS-FNA	-	0.3	-
Mortensen et al[30]	2518 EUS; 670 EUS-FNA; 136 EUS-I	0.22	0.3	0.74
Bournet et al[36]	3207 EUS; 224 EUS-FNA	0.093	2.2	-
Eloubeidi et al[53]	355 pancreatic EUS-FNA	-	2.542	-
Al-Haddad et al[54]	483 EUS-FNA	-	1.4	-
Eloubeidi et al[55]	656 EUS-FNA	-	1.12	-
Thomas et al[56]	247 EUS-TCB	-	2.43	-
Gerke et al[57]	44 EUS-TCB; 36 EUS-FNA4	-	2.3 (EUS-TCB);2.8 (EUS-FNA)	-
Prospective, multicenter (registry)
Gottschalk et al[32]	11 889 EUS; 2099 EUS-FNB; 438 EUS-I	0.14	2.1	4.1
Retrospective, single-center
O'Toole et al[41]	322 EUS-FNA	-	1.6	-
Carrara et al[37]	1034 pancreatic EUS-FNA	-	1.25	-
Retrospective, multicenter
Rösch et al[28]	42 105 EUS (34 EUS centers)	0.05	-	-
Wiersema et al[58]	457 EUS-FNA (4 EUS centers)	-	1.1	-
Buscarini et al[59]	11 539 EUS; 787 EUS-FNA; 21 EUS-I (6 EUS centers)	0.046	0.88	9.5
Jenssen et al[31]	85 084 EUS; 13 223 EUS-FNB; 2297 EUS-I (67 EUS centers)	0.034	0.29	1.61

Results of large single-center and multicenter studies on complications of non-interventional diagnostic endoscopic ultrasonography (EUS), endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) [endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) plus endoscopic ultrasonography-guided trucut biopsy (EUS-TCB)] and endoscopic ultrasonography-guided therapeutic interventions (EUS-I).

¹Without EUS-guided fine-needle biopsies and EUS-guided therapeutic interventions;

²major complications only; 1 fatality due to pulmonary embolism;

³EUS-guided trucut-biopsy (19 Gauge);

⁴randomized controlled trial.

Table 5 Contraindications to endoscopic ultrasonography and endoscopic ultrasonography-guided fine needle biopsy

Contraindications to EUS and EUS-FNB
Lack of informed consent1
Lack of cooperation or insufficient sedation1
Results of examination are unlikely to have a significant clinical impact1
Anticoagulation treatment or non-substituted coagulopathy (international normalized ratio > 1.5; platelet count < 50 000/mL; heparin administration at therapeutic doses)2
Inhibition of platelet aggregation by clopidogrel and other thienopyridines2
Failure of ultrasonographic needle control2
EUS-FNB of lesions upstream of a bile duct stricture which is insufficiently drained2
Cystic mediastinal and pelvic lesions23
Interposition of vessels24

¹Contraindication to endoscopic ultrasonography (EUS) and endoscopic ultrasonography-guided fine needle biopsy (EUS-FNB);

²contraindication to EUS-FNB;

³relative contraindication, peri-interventional antibiotic treatment is mandatory;

⁴relative contraindication, benefit has to be weighed carefully against risk. Transaortic endoscopic ultrasonography-guided fine needle aspiration of mediastinal lymph nodes and tumors[184,185] of the pericardium and a left atrial mass[186], and of intravascular tumors[187,188] have been reported without any major complications.

Table 6 Morbidity of diagnostic endoscopic ultrasonography compared to other endoscopic procedures (%)

Complications	Total	Bleeding	Perforation
Diagnostic esophagogastroduodenoscopy	0.009-0.2	0.002-0.06	0.0009-0.04
Diagnostic colonoscopy	0.02-0.25	0-0.03	0.005-0.2
Colonoscopy + polypectomy	0.36-9.7	0.26-8.6	0.06-1.1
Diagnostic ERCP	1.38	0	0.11
Therapeutic ERCP	5.0-9.8	0.49-2.0	0.3-0.8
EUS	0.03-0.15	0-0.03	0.03-0.15
EUS-FNB	0.3-6.3	0.15-3.7	0-0.86

Complication risk of non-interventional diagnostic endoscopic ultrasound (EUS) and endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB): compared to other endoscopic examinations and interventions (pooled data from literature, table adapted from: Jenssen, Mayr, Faiss and Nuernberg[40]). ERCP: Endoscopic ultrasonography-guided trucut biopsy.