Taking a shortcut to the cecum, endoscopic ultrasound of a submucosal lesion at the appendiceal orifice using a double-balloon endoluminal intervention platform. EUS using curved linear array echoendoscopes is an established tool in the evaluation of submucosal lesions in the GI tract. By allowing endoscopists to distinguish between the different layers and perform fine-needle biopsy, the exam is often able to yield an accurate diagnosis. However, the use of curved linear array echoendoscopes in the colon has largely been limited to the sigmoid colon and rectum. Recently, a double-balloon endoscopic intervention platform has become available to aid in CEQL intubation. The double-balloon endoscopic intervention platform consists of a sheath equipped with two manually inflatable balloons that allow for the advancement of an endoscope while shortening the colon. We present a novel use of the double-balloon endoscopic intervention platform to facilitate curved linear array endoscopic ultrasound of a submucosal lesion at the appendiceal orifice. An asymptomatic 56-year-old male was referred after being found to have a 20-millimeter submucosal lesion at the appendiceal orifice. CT imaging noted an ill-defined mixed soft tissue density just inferior to the CEQM of unclear etiology and clinical significance. The patient underwent general surgery evaluation who recommended endoscopic evaluation with endoscopic ultrasound. A discussion regarding the possible endoscopic options were held. First, a catheter-based mini-probe sonographic examination was considered. However, this was considered a poor option due to the limited sonographic quality and the inability to perform fine-needle biopsy under sonographic guidance. Next, overtube-assisted EOS was considered. However, this was felt to be a poor option given the risk of perforation and submucosal injury associated with overtube use in the colon. Finally, a decision was made to proceed with double-balloon endoluminal intervention platform-assisted endoscopic ultrasound. The double-balloon endoluminal intervention platform consists of a soft, flexible sheath that fits over standard diameter colonoscopes. The sheath is equipped with two balloons, the foreballoon, denoted in the green circle, and the aftballoon, denoted in the red circle. On inflation of the aftballoon, the sheath and endoscope can be retracted to reduce the left colon, and then the endoscope can be advanced further into the right colon. First, a double-balloon endoluminal intervention platform equipped with a standard colonoscope was advanced into the ascending colon, as seen here. Next, the colonoscope was advanced and the appendiceal orifice was identified. On further inspection, there appeared to be a 20mm submucosal lesion at the appendiceal orifice, as seen by the red arrow. Next, the aftballoon was inflated and the colonoscope was withdrawn. On withdrawal, the inflated aftballoon is seen and is demonstrated by the red arrow. Once the colonoscope is completely withdrawn, a curved linear array echoendoscope is then reintroduced to the double-balloon endoluminal intervention platform and advanced into the right colon. The echoendoscope is then able to be advanced to the level of the appendiceal orifice, and endoscopic ultrasound of the lesion is able to be performed. The extraluminal portion of the appendiceal orifice appeared thickened and appeared to lead to an irregular 33x16mm hypoechoic mass. Fine needle biopsy was then performed using a 22-gauge ultrasound biopsy needle using a transcolonic approach. A total of four passes were obtained, and the procedure was then terminated. Through use of a double-balloon endoluminal intervention platform, sequel intubation with a curved linear array echoendoscope was successfully and safely achieved. High-quality sonographic assessment of the submucosal lesion and sonographic fine needle biopsy was able to be performed. Final pathology revealed a leiomyoma. The patient avoided an unnecessary surgery and is now in a surveillance imaging protocol. In conclusion, high-quality EUS using curved linear array echoendoscopes has enabled accurate diagnoses of submucosal lesions in the GI tract. However, lesions in the right colon have often remained out of reach. Our case demonstrates that the use of a double-balloon endoluminal intervention platform facilitates safe passage of a curved linear array echoendoscope into the right colon, allowing for high-quality endoscopic ultrasound and safe fine needle biopsy.

double-balloon endoluminal intervention platform

endoscopic ultrasound (EUS)

submucosal lesion

appendiceal orifice

curved linear array echoendoscopes