Interventional Endoscopic Ultrasound (EUS)

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Information about Interventional Endoscopic Ultrasound (EUS)

Published on September 30, 2015

Author: Apollo_Hospitals

Source: slideshare.net

1. Interventional Endoscopic Ultrasound (EUS): Current Status

2. Review Article Endoscopic ultrasound combines the concept of endoscopy and intraluminal ultrasonography. Interventional EUS started off in 1992, when Vilmann, et al., reported the first case of EUS guided FineNeedle Aspiration Cytology (FNAC) of pancreatic mass with a linear array echo- endoscope [1]. It has grown in scope gradually over the next two decades. This article will review the indications, accu- racy, complications and limitations of interventional EUS. EUS GUIDED FNA A fundamental principle of EUS-fineNeedle is that the information obtained should have the potential to affect patient management. In addition, the indications for EUS- FNA should be guided by its diagnostic accuracy, cost effectiveness, and patient comfort and safety. EUS guided FNAis used for evaluation of esophageal cancer, pancreatic mass, celiac lymphnode, submucosal lesion, lung cancer, mediastinal mass, liver mass and left adrenal mass. Diagnostic yield of EUS guided FNAis listed in Table 1. In esophageal cancer,EUS FNA is useful in determining therapy in whom distant metastasis has been excluded by CECT.Two important factors determining respectability are spread to adjacent organs (T4) and involvement of celiac lymph node. The involvement of celiac lymph node in esophageal cancer portends a bad prognosis with a 5 year survival of less than 10%. EUS FNA is superior to multislice CT scans in assessing celiac node involvement [2-5]. The sensitivity and specificity of malignant lymph node involvement by EUS FNA is 83-90% and 93-100% respectively [5,6]. CT combined with EUS has been shown to be cost effective staging evaluation for esophageal cancer [7]. Early diagnosis and resection alone provides hope of long term survival in pancreatic cancer. The overall prognosis of pancreatic cancer is poor . EUS is more 289 Apollo Medicine, Vol. 7, No. 4, December 2010 INTERVENTIONAL ENDOSCOPIC ULTRASOUND (EUS): CURRENT STATUS Piramanayagam P* and Palaniswamy KR** *Junior Consultant, **Senior Consultant, Department of Gastroenterology, Apollo Hospitals, Greames Raod, Chennai 600 006, India. Correspondence to: Dr K R Palaniswamy, Senior Consultant, Department of Gastroenterology, Apollo Hospitals, Greames Raod, Chennai 600 006, India. Key words: EUS-FNA, Diagnostic accuracy, EUS-guided procedures, Tumour localisation, Tumour therapy. sensitive in detecting pancreatic tumors less than 2 cm than other imaging modalities [8]. In evaluating solid pancreatic masses, the result of EUS-FNA is excellent, with a sensitivity of 64-94.7% and specificity of 97-100%. Routine pre-operative FNA may be valuable in establishing alternate diagnosis like pancreatic lymphoma, tuberculosis, autoimmune pan-creatitis which may also present as focal pancreatic mass lesions. Some centres attempt at biopsy only if the lesion is unresectable. EUS FNA has a lower risk of peritoneal carcinomatosis than CT guided FNA [9]. Pancreatic cysts may be pseudocysts, cystic neoplasm of pancreas or simple cysts of pancreas. The management varies and correct diagnosis becomes imperative. EUS provides detailed images of pancreas, septations, nodule, surrounding pancreatic parenchyma, relation to pancreatic duct, nearby vessels, bile duct. EUS FNA of cystic lesion provides with fluid for cytology, tumor markers (CEA, CA 19-9) , amylase, lipase. Fluid CEA level of more than 192 Table 1. Diagnosticyieldof EUSguidedFNAC Author (year) Sensitivity Specificity (%) (%) Pancreas mass Dewitt, et al.(2003) [11] 82 Liver SOL Eloubeidi, et al. (2003) [12] 94.7 100 Bhutani, et al. (1997) [13] 64 100 Mediastinal node Wallace, et al. (2001) [14] 87 100 Annema, et al. (2003) [15] 75 100 Hilar stricture Fritscher-Ravens, et al. [16] 89 100

3. Apollo Medicine, Vol. 7, No. 4, December 2010 290 Review Article ng/mL had an accuracy of 79% in correctly identifying cysts which require surgery [10]. Erickson, et al. reported that failure to have a cytopathologist in attendance increases the number of passes, reduces definitive cytological diagnoses, prolongs procedure time, increases risk and consumes additional needles. If a cytopathologist or a cytotechnician is not in attendance, three passes should be taken through lymph nodes and five to six passes through pancreatic masses to ensure adequate cellularity in >90% of cases [17]. EUS FNA has an overall complication rate of <1%. The complications include scope associated perforations, hemorrhage following aspiration of pseudocyst, bacteremia following aspiration of cystic lesion. The risk of acute pancreatitis following EUS FNA of pancreatic mass lesions is 0.64%. Thus, EUS FNA is a safe and well tolerated procedure [18,19]. EUS GUIDED MANAGEMENT OF PSEUDOCYST EUS enables assessment of pseudocyst wall thickness, confirmation of size, delineates contents (clear fluid vs. walled off pancreatic necrosis), checks distance from the gastrointestinal (GI) lumen, evaluates for intervening vasculature. Only 50% ofpancreatic fluid collections cause luminal compression [20]. EUS guided pseudocyst drainage has added advantage of not needing luminal compression as needle could be guided under sonographic guidance. EUS also has the added advantage of having Doppler which will help avoid major vessels on the wall of pseudocyst thus Fig 1. EUS guided FNAC of celiac lymph node. Fig 2. EUS guided aspiration of pancreatic fluid collection. minimising risk of bleeding. It has been shown in randomised trial that endoscopic drainage (12%) is associated with more complications that EUS guided drainage (0%). The technical success and complication rate , reinterventions were not significantly different for EUS guided pseudocyst drainage as compared to surgical intervention with added benefit of less hospitalisation time and improved QOL [22]. EUS GUIDED CELIAC PLEXUS BLOCK/ NEUROLYSIS Celiac plexus is localised anterior to the celiac trunk take off from aorta. EUS guided celiac plexus neurolysis involves injection of bupivacaine (3-10 mL) followed by dehydrated absolute alcohol (10 mL). It provides pain relief in upto 80% in pancreatic cancer patients at 10 weeks. Celiac plexus block involves use of triamcinolone (40 mg) in place of alcohol [23,24]. It provides temporary relief in patients with chronic pancreatitis. It has been reported to be successful in 55-80% of patients with chronic pancreatitis who report improvement in pain scores and reduction in opioid medicine requirements. Complications of celiac plexus block or neurolysis are infrequent and mostly self-limited. The most common side- effects are transient diarrhea and hypotension; these can be seen in up to 38% and 44% of patients, respectively [25]. Sympathetic blockade can manifest as diarrhea and hypotension due to a relative unopposed visceral parasympathetic activity. In most patients, the diarrhea is mild and self-limiting and lasts less than 48hrs [26].

4. Review Article 291 Apollo Medicine, Vol. 7, No. 4, December 2010 Medium term pain relief is reported to be upto 70% [39]. Technical failures may be due to acute angle at which linear EUS accesses pancreatic duct, difficulty in trasmural dilation due to dense fibrosis. Stent migration and block are observed in 5-44% on medium term follow up [40-41]. TUMOR LOCALISATION EUS guided gold fiducial placements have been used to localise pancreatic tumors planned for stereotactic radiotherapy [42]. Localising small neuroendocrine tumours at surgery may become difficult. Preoperative tattooing or fiducial placement by EUS has been shown to reduce operative time. TUMOR THERAPY EUS guided ethanol ablation with or without addition of antitumor agents of pancreatic cysts has been reported in case series. EUS-guided injection has been reported in pancreatic neuroendocrine tumors,adrenal metastases and GIST. EUS guided radioactive iodine seed implantation has been studied in animal models [43]. EUS guided photodynamic therapy is another exciting development whereby light source can be passed through a large bore EUS needle. EUS guided radiofrequency ablation has been studied in porcine models [44]. SUMMARY EUS guided FNA, pseudocyst aspiration, celiac plexus neurolysis are all common interventional EUS procedures done worldwide. EUS guided bile duct drainage and pancreatic duct drainage are options to be considered when access to desired duct is not achieved. Exciting new developments like EUS guided tumor localisation and ablation techniques are in clinical studies and will become available in future. REFERENCES 1. Wiersema MJ, Hawes R2H, Tao LC, et al. Endoscopic ultrasonography as an adjunct to fine needle aspiration cytology of the upper and lower gastrointestinal tract. Gastrointest. Endosc. 1992; 38: 35-39. 2. Reed CE, Mishra G, Sahai AV, Hoffman BJ, Hawes RH. Esophageal cancer staging: improved accuracy by endoscopic ultrasound of celiac lymph nodes. Ann. Thorac. Surg. 1999; 67: 319-321 3. Parmar KS, Zwischenberger JB, Reeves AL, Waxman I. Clinical impact of endoscopic ultrasound-guided fine needle aspiration of celiac axis lymph nodes (M1a disease) in esophageal cancer. Ann. Thorac. Surg. 2002; 73: 916-920 4. Romagnuolo J, Scott J, Hawes RH, et al. Helical CT versus EUS with fine needle aspiration for celiac nodal assessment in patients with esophageal cancer. EUS GUIDED BILE DUCT DRAINAGE Malignant biliary obstruction is managed endoscopically in upto 90% of patients. In those patients in whom access to CBD is not possible due to altered duodenal anatomy, tightness of stricture EUS guided bile duct drainage from duodenal bulb has been done with overall technical success rate of 92% . It may be either by rendezvous procedure [27-31] or by formation of choledochoduodenostomy. The stent patency rates of plastic biliary stent reported with choledochoduodenostomy is a mean of 211 days, which is longer than conventional transpapillary biliary stenting. The major complication is biliary peritonitis reported in upto 8% with overall complication rate of 19% [32-36]. EUS GUIDED HEPATICOGASTROSTOMY The left lobe of liver is well visualised from stomach. In patients whom ERCP has failed, hepaticogastrostomy can be performed. The technical success varies from 73- 100%. Serious complications include bile leak,bleeding, pneu-moperitoneum, infection and death may occur in upto 12.5% -30% of patients [37-39]. Contraindications include coagulopathy and ascites. EUS GUIDED PANCREATIC DUCT DRAINAGE Pancreatic endotherapy by ERCP is the first line of therapy for pain in select patients of chronic pancreatitis with strictures, stones. In patients with duodenal obstruction or tight strictures in pancreatic duct through which guidewire cannot be negotiated, EUS guided pancreatic duct drainage from the stomach is an option. Fig 3. EUS guided FNAC of liver SOL

5. Apollo Medicine, Vol. 7, No. 4, December 2010 292 Review Article Gastrointest. Endosc. 2002; 55: 648-654. 5. Williams DB, Sahai AV, Aabakken L, et al. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut 1999; 44: 720-726. 6. Vazquez-Sequeiros E, Norton ID, Clain JE, et al. Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma. Gastrointest. Endosc. 2001; 53: 751-757. 7. Wallace MB, Nietert PJ, Earle C, et al. An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy. Ann. Thorac. Surg. 2002; 74: 1026-1032. 8. Legmann P, Vignaux O, Dousset B, et al. Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography. AJR Am. J. Roentgenol. 1998; 170: 1315-1322. 9. Micames C, Jowell PS, White R, et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA versus percutaneous FNA. Gastrointest. Endosc. 2003; 58: 690- 695. 10. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastro- enterology 2004; 126: 1330-1336. 11. DeWitt J, LeBlanc J, McHenry L, et al. Endoscopic ultrasound-guided fine needle aspiration cytology of solid liver lesions: a large single-center experience. Am. J. Gastroenterol. 2003; 98: 1976-1981. 12. 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. 13. Bhutani MS, Hawes RH, Baron PL, et al. Endoscopic ultrasound guided fine needle aspiration of malignant pancreatic lesions. Endoscopy 1997; 29: 854-858. 14. Wallace MB, Silvestri GA, Sahai AV, et al. Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung. Ann. Thorac. Surg. 2001; 72: 1861-1867. 15. Annema JT, Veselic M, Versteegh MI, Willems LN, Rabe KF. Mediastinal restaging: EUS-FNA offers a new perspective. Lung Cancer 2003; 42: 311-318. 16. Fritscher-RavensA, Broering DC, Knoefel WT, et al. EUS- guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. Am. J. Gastroenterol. 2004; 99: 45-51. 17. Erickson RA, Sayage-Rabie L, Beissner RS. Factors predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies. Gastrointest. Endosc. 2000; 51: 184-190. 18. Bhutani MS. Endoscopic ultrasound guided fine needle aspiration of pancreas. In: Bhutani MS, eds. Interventional Endoscopic Ultrasonography. Amsterdam: Harwood Academic Publishers, 1999; 65-72. 19. O’Toole D, Palazzo L, Arotcarena R, et al. Assessment of complications of EUS-guided fine-needle aspiration. Gastrointest. Endosc. 2001; 53: 470-474. 20. Kahaleh M, Shami VM, Conaway MR, et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy. 2006; 38(4): 355-359. 21. Varadarajulu S, Christein JD, Tamhane A, et al. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with video). Gastrointest Endosc. 2008 Jul 18. [Epub ahead of print]. 22. Varadarajulu S, Trevino JM, Wilcox CM, et al. Randomized Trial Comparing EUS and Surgery for Pancreatic Pseudocyst Drainage. DDW 2010. 23. Levy MJ, Wiersema MJ. EUS-guided celiac plexus neulolysis and celiac plexus block. Gastrointest. Endosc. 2003; 57: 923-930. 24. Gress F, Schmitt C. Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am. J. Gastroenterol. 2001; 96: 409-416. 25. Gunaratnam NT, Wong GY, Wiersema MJ. EUS-guided celiac plexus block for the management of pancreatic pain. Gastrointest. Endosc. 2000; 52: S28-S34. 26. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta- analysis. Anesth. Analg. 1995; 80: 290-295. 27. Lai R, Freeman ML. Endoscopic ultrasound-guided bile duct access for rendezvous ERCP drainage in the setting of intradiverticular papilla. Endoscopy 2005; 37: 487-489. 28. Kahaleh M, Yoshida C, Kane L, et al. Interventional EUS cholangiography: a report of five cases. Gastrointest. Endosc. 2004; 60: 138-142. 29. Kahaleh M, Wang P, Shami VM, et al. EUS-guided transhepatic cholangiography: report of 6 cases. Gastrointest Endosc 2005; 61: 307-313. 30. Kahaleh M, Hernandez AJ, Tokar J, et al. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest. Endosc. 2006; 64: 52-59. 31. Tarantino I, Barresi L, Repici A, et al. EUS-guided biliary drainage: a case series. Endoscopy 2008; 40: 336-339. 32. Puspok A, Lomoschitz F, Dejaco C, et al. Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series. Am. J. Gastroenterol. 2005; 100: 1743-1747. 33. Yamao K, Sawaki A, Takahashi K, et al. EUS-guided choledochoduodenostomy for palliative biliary drainage in case of papillary obstruction: report of 2 cases. Gastrointest Endosc 2006; 64: 663-667.

6. Review Article 293 Apollo Medicine, Vol. 7, No. 4, December 2010 34. Ang TL, Teo EK, Fock KM. EUS-guided transduodenal biliary drainage in unresectable pancreatic cancer with obstructive jaundice. JOP 2007; 9: 438-443. 35. Fujita N, Noda Y, Kobayashi G, et al. Histological changes at an endosonography-guided biliary drainage site: a case report. World J. Gastroenterol. 2007; 13: 5512-5515. 36. Yamao K, Bhatia V, Mizuno N, et al. EUS-guided choledochoduodenostomy for palliative biliary drainage in patients with malignant biliary obstruction: results of long-term follow-up. Endoscopy 2008; 40: 340-342. 37. Bories E, Pesenti C, Caillol F, et al. Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy 2007; 39: 287-291. 38. Will U, Thieme A, Fueldner F, et al. Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage. Endoscopy 2007; 39: 292. 39. Perez-Miranda M, Saracibar E, Mata L, et al. EUS-guided pancreatic and biliary ductal drainage as a first line strategy after unsuccessful ERCP drainage. Gastrointest. Endosc. 2007; 65: AB106. 40. Tessier G, Bories E, Arvanitakis M, et al. EUS-guided pancreatogastrostomy and panctreatobulbostomy for the treatment of pain in patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy. Gastrointest. Endosc. 2007; 65: 233-241. 41. Kahaleh M, Hernandez AJ, Tokar J, et al. EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts. Gastrointest. Endosc. 2007; 65: 224-230. 42. Varadarajulu S, Trevino JM, Shen S, et al. EUS-guided gold markers for image guided radiation therapy of pancreatic cancer: A case series. Endoscopy 2010 (Epub ahead of print). 43. Sun S, Xu H, Xin J, et al. Endoscopic ultrasound-guided interstitial brachytherapy of unresectable pancreatic cancer: results of a pilot trial. Endoscopy 2006; 38: 399- 403. 44. Varadarajulu S, Jhala N, Drelichman ER. Experimental Study Evaluating EUS-guided RFA using a Prototype Retractable Needle Electrode Array. Gastrointest Endosc 2009; 7(2): 372-376.

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