Digestive Diseases and Sciences

, Volume 61, Issue 3, pp 890–899 | Cite as

Eliminating the Residual Negative Pressure in the Endoscopic Ultrasound Aspirating Needle Enhances Cytology Yield of Pancreas Masses

  • A. Aziz Aadam
  • Young S. Oh
  • Vinod B. Shidham
  • Abdul Khan
  • Bryan Hunt
  • Nagarjun Rao
  • Ying Zhang
  • Sergey Tarima
  • Kulwinder S. DuaEmail author
Original Article



Prior to withdrawing the EUS-FNA needle from the lesion, the stopcock of the suction syringe is closed to reduce contamination. Residual negative pressure (RNP) may persist in the needle despite closing the stopcock.


To determine whether neutralizing RNP before withdrawing the needle will improve the cytology yield.


Bench-top testing was done to confirm the presence of RNP followed by a prospective, randomized, cross-over study on patients with pancreas mass. Ten milliliters of suction was applied to the FNA needle. Before withdrawing the needle from the lesion, the stopcock was closed. Based on randomization, the first pass was done with the stopcock either attached to the needle (S+) or disconnected (S−) to allow air to enter and neutralize RNP and accordingly the second pass was crossed over to S+ or S−. On-site cytopathologist was blinded to S+/S−.


Bench tests confirmed the presence of RNP which was successfully neutralized by disconnecting the syringe (S−) from the needle. Sixty patients were enrolled, 120 samples analyzed. S+ samples showed significantly greater GI tract contamination compared to S− samples (16.7 vs. 6.7 %, p = 0.03). Of the 53 patients confirmed to have pancreas adenocarcinoma, FNA using S− approach was positive in 49 (93 %) compared to 40 using the S+ approach (76 %, p = 0.02).


Despite closing the stopcock of the suction syringe, RNP is present in the FNA needle. Neutralizing RNP prior to withdrawing the needle from the target lesion significantly decreased GI tract contamination of the sample thereby improving the FNA cytology yield.

Clinical Trials Registration Number



Endoscopic ultrasound (EUS) Tissue acquisition Fine needle aspiration (FNA) Pancreas mass Pancreas adenocarcinoma 



Endoscopic ultrasound


Fine needle aspiration


Syringe-on; the suction syringe with its stopcock closed still attached to the needle handle


Syringe-off; the suction syringe with its stopcock closed disconnected from the needle handle

Minus (negative pressure)



This publication was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Number 8UL1TR000055. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

Supplementary material 1 (WMV 49176 kb)

Supplementary material 2 (WMV 26989 kb)


  1. 1.
    Dumonceau J-M, Polkowski M, Larghi A, et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2011;43:897–912.CrossRefPubMedGoogle Scholar
  2. 2.
    Hewitt MJM, McPhail MJWM, Possamai LL, Dhar AA, Vlavianos PP, Monahan KJK. EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis. Gastrointest Endosc. 2012;75:319–331.CrossRefPubMedGoogle Scholar
  3. 3.
    Mertz H, Gautam S. The learning curve for EUS-guided FNA of pancreatic cancer. Gastrointest Endosc. 2004;59:33–37.CrossRefPubMedGoogle Scholar
  4. 4.
    Yusuf TET, Ho SS, Pavey DAD, Michael HH, Gress FGF. Retrospective analysis of the utility of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic masses, using a 22-gauge or 25-gauge needle system: a multicenter experience. Endoscopy. 2009;41:445–448.CrossRefPubMedGoogle Scholar
  5. 5.
    Song TJ, Kim JH, Lee SS, et al. The prospective randomized, controlled trial of endoscopic ultrasound-guided fine-needle aspiration using 22G and 19G aspiration needles for solid pancreatic or peripancreatic masses. Am J Gastroenterol. 2010;105:1739–1745.CrossRefPubMedGoogle Scholar
  6. 6.
    Klapman Logrono, Dye Waxman. Clinical impact of on-site cytopathology interpretation on endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol. 2003;98:1289–1294.CrossRefPubMedGoogle Scholar
  7. 7.
    Wani S, Early D, Kunkel J, et al. Diagnostic yield of malignancy during EUS-guided FNA of solid lesions with and without a stylet: a prospective, single blind, randomized, controlled trial. Gastrointest Endosc. 2012;76:328–335.CrossRefPubMedGoogle Scholar
  8. 8.
    Puri RR, Vilmann PP, Săftoiu AA, et al. Randomized controlled trial of endoscopic ultrasound-guided fine-needle sampling with or without suction for better cytological diagnosis. Scand J Gastroenterol. 2009;44:499–504.CrossRefPubMedGoogle Scholar
  9. 9.
    Lee JK, Choi JH, Lee KH, et al. A prospective, comparative trial to optimize sampling techniques in EUS-guided FNA of solid pancreatic masses. Gastrointest Endosc. 2013 Feb 21.Google Scholar
  10. 10.
    Savides TJ. Tricks for improving EUS-FNA accuracy and maximizing cellular yield. Gastrointest Endosc. 2009;69:S130–S133.CrossRefPubMedGoogle Scholar
  11. 11.
    Mitsuhashi T, Ghafari S, Chang CY, Gu M. Endoscopic ultrasound-guided fine needle aspiration of the pancreas: cytomorphological evaluation with emphasis on adequacy assessment, diagnostic criteria and contamination from the gastrointestinal tract. Cytopathology. 2006;17:34–41.CrossRefPubMedGoogle Scholar
  12. 12.
    Fujii LL, Levy MJ. Pitfalls in EUS FNA. Gastrointest Endosc Clin N Am. 2014;24:125–142.CrossRefPubMedGoogle Scholar
  13. 13.
    Gleeson FC, Kipp BR, Caudill JL, et al. False positive endoscopic ultrasound fine needle aspiration cytology: incidence and risk factors. Gut. 2010;59:586–593.CrossRefPubMedGoogle Scholar
  14. 14.
    Eloubeidi MA, Jhala D, Chhieng DC, et al. Yield of endoscopic ultrasound-guided fine-needle aspiration biopsy in patients with suspected pancreatic carcinoma. Cancer. 2003;99:285–292.CrossRefPubMedGoogle Scholar
  15. 15.
    Kliment M, Urban O, Cegan M, et al. Endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: the utility and impact on management of patients. Scand J Gastroenterol. 2010;45:1372–1379.CrossRefPubMedGoogle Scholar
  16. 16.
    Woolf KMW, Liang H, Sletten ZJ, Russell DK, Bonfiglio TA, Zhou Z. False-negative rate of endoscopic ultrasound-guided fine-needle aspiration for pancreatic solid and cystic lesions with matched surgical resections as the gold standard: one institution’s experience. Cancer Cytopathol. 2013;121:449–458.CrossRefPubMedGoogle Scholar
  17. 17.
    Wallace MB, Kennedy T, Durkalski V, et al. Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy. Gastrointest Endosc. 2001;54:441–447.CrossRefPubMedGoogle Scholar
  18. 18.
    Storch IM, Sussman DA, Jorda M, Ribeiro A. Evaluation of fine needle aspiration vs. fine needle capillary sampling on specimen quality and diagnostic accuracy in endoscopic ultrasound-guided biopsy. Acta Cytol. 2007;51:837–842.CrossRefPubMedGoogle Scholar
  19. 19.
    Bang JY, Ramesh J, Trevino J, Eloubeidi MA, Varadarajulu S. Objective assessment of an algorithmic approach to EUS-guided FNA and interventions. Gastrointest Endosc. 2013;77:739–744.PubMedCentralCrossRefPubMedGoogle Scholar
  20. 20.
    Nakai Y, Isayama H, Chang KJ, et al. Slow pull versus suction in endoscopic ultrasound-guided fine-needle aspiration of pancreatic solid masses. Dig Dis Sci. 2014;59:1578–1585.CrossRefPubMedGoogle Scholar
  21. 21.
    Polkowski M, Larghi A, Weynand B, et al. Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline. Endoscopy. 2012;44:190–206.CrossRefPubMedGoogle Scholar
  22. 22.
    Wani S, Muthusamy VR, Komanduri S. EUS-guided tissue acquisition: an evidence-based approach (with videos). Gastrointest Endosc. 2014;80:939–959.e7.CrossRefPubMedGoogle Scholar
  23. 23.
    Rastogi A, Wani S, Gupta N, et al. A prospective, single-blind, randomized, controlled trial of EUS-guided FNA with and without a stylet. Gastrointest Endosc. 2011;74:58–64.CrossRefPubMedGoogle Scholar
  24. 24.
    Kudo T, Kawakami H, Hayashi T, et al. High and low negative pressure suction techniques in EUS-guided fine-needle tissue acquisition by using 25-gauge needles: a multicenter, prospective, randomized, controlled trial. Gastrointest Endosc. 2014;80:1030–1031.CrossRefPubMedGoogle Scholar
  25. 25.
    Iglesias-Garcia J, Dominguez-Munoz JE, Abdulkader I, et al. Influence of on-site cytopathology evaluation on the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solid pancreatic masses. Am J Gastroenterol. 2011;106:1705–1710.CrossRefPubMedGoogle Scholar
  26. 26.
    Hayashi T, Ishiwatari H, Yoshida M, et al. Rapid on-site evaluation by endosonographer during endoscopic ultrasound-guided fine needle aspiration for pancreatic solid masses. J Gastroenterol Hepatol. 2013;28:656–663.CrossRefPubMedGoogle Scholar
  27. 27.
    Wani S, Mullady D, Early DS, Rastogi A, Collins B. Clinical impact of immediate on-site cytopathology (CyP) evaluation during endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic mass: Interim analysis of a multicenter randomized con- trolled trial. Gastrointest Endosc. 2013;77:2. (Abstract supplement).CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Digestive DiseasesRush University Medical CenterChicagoUSA
  2. 2.Division of Gastroenterology and Hepatology, Department of MedicineMedical College of WisconsinMilwaukeeUSA
  3. 3.Department of PathologyMedical College of WisconsinMilwaukeeUSA
  4. 4.Department of BiostatisticsMedical College of WisconsinMilwaukeeUSA

Personalised recommendations