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Correspondence |

EndosonographyEndoscopic Ultrasound Is Superior: Esophagus Is Better! FREE TO VIEW

Nikhil Meena, MD; Wissam Abouzgheib, MD; Ziad Aboujaoude, MD; Thaddeus Bartter, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Drs Meena and Bartter), Department of Internal Medicine, University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System; and Division of Pulmonary and Critical Care (Drs Abouzgheib and Aboujaoude), Department of Internal Medicine Cooper University Hospital, Cooper University Health Care.

CORRESPONDENCE TO: Nikhil Meena, MD, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W Markham Mail Slot #555, Little Rock, AR 72205; e-mail: nkmeena@uams.edu


CONFLICT OF INTEREST: None declared.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(4):e129. doi:10.1378/chest.15-1262
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To the Editor:

We read with interest the article by Oki et al1 and the accompanying editorial by Mehta et al2 in a recent issue of CHEST (May 2015). Our perspective on endoscopic ultrasound (EUS) using the endobronchial ultrasound (EBUS) scope differs from that of Mehta et al.2 As background, we all serve as faculty at interventional pulmonary fellowship programs that include EUS in training and practice, our senior authors have performed > 1,000 EUS procedures each since 2008, and we all have performed more EUS than gastroenterology at our institutions.

The advantages of esophageal access to the mediastinum are intuitive but have now been redundantly confirmed.1,3 The bronchial tree defends against solid and liquid matter, while the esophagus accepts them on an ongoing basis. Esophageal access offers economies of sedation and time for a node accessible via esophagus or bronchial tree.1,3 Combining EUS with EBUS increases yield for mediastinal staging.

Mehta et al2 argue that gastroenterologists and surgeons are more competent to perform EUS because of their knowledge of esophageal anatomy. We would suggest that a single tube offers little complexity, and one can reasonably argue that the EBUS-trained pulmonologist has spent more time than a surgeon or a gastroenterologist studying mediastinal nodes and their surrounding structures with ultrasound and, thus, is at least as qualified as a surgeon or a gastroenterologist to study and biopsy the mediastinum via the esophagus in the evaluation of thoracic disease. Mehta et al2 also state, regarding the EBUS scope, “obviously, it cannot reach the adrenal glands.” In fact, some of us have been routinely accessing the left adrenal with the EBUS scope when it is suspect.4

We would like to challenge the argument that EBUS is needed whether EUS is performed, thus rendering EUS superfluous. Many cases do not require sampling of multiple sites. A single positive N2 or N3 node establishes not only diagnosis but also nonresectability. Cases in which multiple nodes need not be sampled include benign adenopathy, cancer recurrence, rebiopsy after neoadjuvant therapy, and parastructural masses. EUS may be the optimal diagnostic option for the intubated patient with an endotracheal tube < 8.0 mm or the patient with limited pulmonary reserve.

Patients are best served if one proceduralist can effectively perform EUS, EBUS, or both combined when indicated.5 Oki et al1 have strengthened the case for the pulmonologist in this role, and we thank them. In our opinion, all interventional pulmonary programs should incorporate access via the esophagus into their training.

References

Oki M, Saka H, Ando M, et al. Transbronchial vs transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions: a randomized study. Chest. 2015;147(5):1259-1266. [CrossRef] [PubMed]
 
Mehta AC, Cicenia J, Yasufuku K. The chef has a knife…: endoscopic ultrasound-guided fine-needle aspiration by a pulmonologist. Chest. 2015;147(5):1201-1203. [CrossRef] [PubMed]
 
Meena N, Bartter T. Endosonography for mediastinal disease: esophageal ultrasound vs endobronchial ultrasound [published online ahead of print May 21, 2015]. Endoscopy International Open. doi:10.1055/s-0034-1392092.
 
Meena N, Hulett C, Jeffus S, Bartter T. Left adrenal biopsy using the convex curvilinear ultrasound scope. Respiration. 2015;89(1):57-61. [CrossRef] [PubMed]
 
Szlubowski A, Soja J, Kocon P, et al. A comparison of the combined ultrasound of the mediastinum by use of a single ultrasound bronchoscope versus ultrasound bronchoscope plus ultrasound gastroscope in lung cancer staging: a prospective trial. Interact Cardiovasc Thorac Surg. 2012;15(3):442-446. [CrossRef] [PubMed]
 

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References

Oki M, Saka H, Ando M, et al. Transbronchial vs transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions: a randomized study. Chest. 2015;147(5):1259-1266. [CrossRef] [PubMed]
 
Mehta AC, Cicenia J, Yasufuku K. The chef has a knife…: endoscopic ultrasound-guided fine-needle aspiration by a pulmonologist. Chest. 2015;147(5):1201-1203. [CrossRef] [PubMed]
 
Meena N, Bartter T. Endosonography for mediastinal disease: esophageal ultrasound vs endobronchial ultrasound [published online ahead of print May 21, 2015]. Endoscopy International Open. doi:10.1055/s-0034-1392092.
 
Meena N, Hulett C, Jeffus S, Bartter T. Left adrenal biopsy using the convex curvilinear ultrasound scope. Respiration. 2015;89(1):57-61. [CrossRef] [PubMed]
 
Szlubowski A, Soja J, Kocon P, et al. A comparison of the combined ultrasound of the mediastinum by use of a single ultrasound bronchoscope versus ultrasound bronchoscope plus ultrasound gastroscope in lung cancer staging: a prospective trial. Interact Cardiovasc Thorac Surg. 2012;15(3):442-446. [CrossRef] [PubMed]
 
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