title: Endoscopic ultrasound (EUS)-guided fiducial placement allows localization of small neuroendocrine tumors during parenchymal-sparing pancreatic surgery.
abstract: BACKGROUND
  Parenchymal-sparing pancreatic surgery is ideal for lesions such as small pancreatic neuroendocrine tumors (PanNET). However, precise localization of these small tumors at surgery can be difficult. The placement of fiducials under endoscopic ultrasound (EUS) guidance (EUS-F) has been used to direct stereotactic radiation therapy for pancreatic adenocarcinoma. This report describes two cases in which placement of fiducials was used to guide surgical resection. This study aimed to assess the feasibility, safety, and efficacy of using EUS-F for intraoperative localization of small PanNETs.
  
  
  METHODS
  A retrospective study analyzed two consecutive patients with small PanNETs who underwent EUS-F followed by enucleation in a tertiary-care referral hospital. The following features were examined: technical success and complication rates of EUS-F, visibility of the fiducial at the time of surgery, and fiducial migration.
  
  
  RESULTS
  In the study, EUS-F was performed for two female patients with a 7-mm and a 9-mm PanNET respectively in the uncinate process and neck of the pancreas. In both patients, EUS-F was feasible with two Visicoil fiducials (Core Oncology, Santa Barbara, CA, USA) placed either within or adjacent to the tumors using a 22-gauge Cook Echotip needle. At surgery, the fiducials were clearly visible on intraoperative ultrasound, and both the tumor and the fiducials were successfully enucleated in both cases. No complications were associated with EUS-F, and no evidence of pancreatitis was shown either clinically or on surgical pathology. This investigation had the limitations of a small single-center study.
  
  
  CONCLUSIONS
  For patients undergoing enucleation, EUS-F is technically feasible and safe and aids intraoperative localization of small PanNETs.
authors: Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA, jlaw8@jhmi.edu.
authors: Joanna K
authors: JK
authors: Law
authors: Vikesh K
authors: VK
authors: Singh
authors: Mouen A
authors: MA
authors: Khashab
authors: Ralph H
authors: RH
authors: Hruban
authors: Marcia Irene
authors: MI
authors: Canto
authors: Eun Ji
authors: EJ
authors: Shin
authors: Payal
authors: P
authors: Saxena
authors: Matthew J
authors: MJ
authors: Weiss
authors: Timothy M
authors: TM
authors: Pawlik
authors: Christopher L
authors: CL
authors: Wolfgang
authors: Anne Marie
authors: AM
authors: Lennon
mesh_terms: D019072:Antibiotic Prophylaxis; D002939:Ciprofloxacin / Q000008:administration & dosage / Q000627:therapeutic use; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration / Q000295:instrumentation / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D057918:Fiducial Markers; D005548:Foreign-Body Migration; D006801:Humans; D021621:Imaging, Three-Dimensional; D007340:Insulinoma / Q000000981:diagnostic imaging* / Q000601:surgery; D008875:Middle Aged; D009339:Needles; D018358:Neuroendocrine Tumors / Q000000981:diagnostic imaging* / Q000601:surgery; D059351:Organ Sparing Treatments; D010180:Pancreatectomy / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery; D013653:Tattooing / Q000379:methods; D018084:Ultrasonography, Interventional / Q000295:instrumentation*
chemical_list: D002939:Ciprofloxacin
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