Pancreaticobiliary Endoscopic Ultrasound (EUS)

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Information about Pancreaticobiliary Endoscopic Ultrasound (EUS)

Published on September 30, 2015

Author: Apollo_Hospitals

Source: slideshare.net

1. Pancreaticobiliary Endoscopic Ultrasound (EUS): Current Status at Delhi Apollo Hospital

2. Original Article INTRODUCTION Since its development in the 1980’s, EUS has dramatically expanded the reach of the gastrointestinal endoscope especially into the pancreaticobiliary system. Its limitations have been overcome with the adjunctive capabilitiesofEUSguidedFNAandotherinterventionalEUS procedures. More than 2000 publications have shown EUS to be a safe and accurate method for diagnosing, staging and samplingavarietyofbenignandmalignantlesionswithinthe GI tract, NSCLC, mediastinal masses, celiac lymph nodes, Pancreas, Gall bladder and CBD lesions. METHODS All cases of endoscopic ultrasound were performed using either the new electronic radial array or the electronic linear array echoendoscopes manufactured by Olympus Corporation, Japan. We utilized the new EU-ME1 ultrasound processor with a CLV-180 lightsource/ processor. Most diagnostic cases were conducted using the radial or linear echoendoscope and FNA cases were performed utilizing the linear echoendoscope. FNA was conducted in all cases using the Olympus EZ shot 22G needle or the Wilson Cook 22/25G needle. Most patients were given Propofol by consultant Anesthesiologists; however a few diagnostic cases were performed under Fortwin and Midazolam moderate sedation. Cytopathology technicians were available onsite for each of the cases and an average of 3-5 passes were made to obtain adequate material. 303 Apollo Medicine, Vol. 7, No. 4, December 2010 PANCREATICOBILIARY ENDOSCOPIC ULTRASOUND (EUS): CURRENT STATUS AT DELHI APOLLO HOSPITAL Sandeep Bhargava Senior Consultant Gastroenterology, Hepatology and Endoscopic Ultrasound, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Objective: To evaluate the results of EUS in patients having pancreaticobiliary lesions. Methods: EUS was performed in 45 patients (CBD lesions in 20, pancreatic in 19 and periampullary in 6 patients using EUS equipment. Results: Final diagnosis was achieved by either diagnostic and or FNA in al patients. None had any complications. Conclusions: Results are very similar to what has been reported from established centers. Key words: Endoscopic Ultrasound (EUS); Fine needle aspiration (FNA). No procedure, sedation or FNA related complications were observed. EUS was performed in 67 patients (March 2010 to November, 2010) which included Esophageal (7 patents), Gastric (4 patients), Mediastinal (3 patients), Duodenal 2 patients), Colon (3 patients), CBD (20 patients), Pancreatic (19 patients), Periampullary (6 patients) and Miscellaneous (3 patients). This observational study details my initial experience of EUS atApollo Hospital, Delhi in pancreatico- biliary lesions.All referred patients with pancreatico-biliary lesions attending Indraprastha Apollo Hospital were enrolled and diagnosis of different types was made based on ultra-sonography (USG) or computed tomography (CT) or MRI/MRCP. These patients showed pancreatic mass lesions or cysts, pancreatic duct dilatation, presence of stones or sludge in the CBD, CBD mass/stricture and periampullary lesions. RESULTS Pancreas There were 11 patients showing pancreatic mass lesions 1 to 4 cm in size (on USG/CT Scan) upon which EUS was performed. FNA was performed in all of them except one. Final diagnosis included adenocarcinoma (4), acute on chronic pancreatitis (2), cystadenoma (1), pancreatic cyst (1) (Fig 1), normal (2). Eight patients had pancreatic cyst measuring 1 to 4 cm in size on (USG/CT Scan). EUS confirmed diagnosis as cyst alone in 3 patients, cyst with sludge in CBD in 2 patients and two patients had normal pancreas. One patient was diagnosed to have a pancreatic duct stone on MRCP however; EUS revealed only a dilated PD but no stone.

3. Apollo Medicine, Vol. 7, No. 4, December 2010 304 Original Article Fig 1. Pancreatic cyst. Fig 3. Common bile-duct stones. Fig 2. Periampullory lesions. (a) (b) Fig 4. Cholelithiasis Periampullary lesions There were six patients in this group. The lesions were detected on (USG, CT/MRCP). EUS with FNA revealed adenocarcinoma in 2, neuroendocrine tumor in 1, tuberculosis in 1, benign polyp in 1 and in one patient EUS could not detect any abnormality (Fig 2). COMMON BILE DUCT LESIONS Fifteen patients had suspected CBD stones (on USG/ MRCP). EUS showed a normal CBD (9 patients). CBD stones and CBD sludge (3 patients). EUS was also evaluated in CBD mass/stricture in five patients. Final diagnosis on the basis of EUS & FNA revealed adenocarcinoma in two patients, two had cholangiocarcinoma and 1 had CBD stone (Fig 3 & 4).

4. Original Article 305 Apollo Medicine, Vol. 7, No. 4, December 2010 DISCUSSION EUS is the most sensitive diagnostic procedures for detecting pancreatic lesions and has been shown to be superior to other imaging modalities. It is particularly superior in the detection of pancreatic tumors, based on multiple studies comparing the sensitivity of various techniques in the detection of pancreatic cancer. With EUS it was 98%, ultrasound (75%), CT (80%), ERCP (86 %) and angiography (89%). A recent study comparing EUS to helical CT showed superiority of EUS to helical CT in detection of pancreatic tumors (97% vs. 73%) and sensitivity for vascular invasion of (91% vs. 64%) [1]. Ability to obtain cytological specimens by EUS guided FNA which differentiates between benign vs. malignant lesions was at a sensitivity of 83% and a specificity of 90%, diagnostic accuracy of 85%, negative predictive values of 80 % and positive predictive value of 100%. These were significantly superior to CT. EUS also has been found to be more accurate than CT in assessing vascular invasion and define tumor resectability.Another advantage includes accurate assessment of peripancreatic nodal disease [2-5]. The advantages of EUS guided FNA includes tissue diagnosis along with TNM staging. EUS guided FNA of pancreas unlike CT guided FNA can be performed during initial EUS procedure. All patients thought to have operable disease based on initial CT imaging should undergo EUS and FNA prior to surgical intervention [6]. The overall complication rate of EUS-FNA is a low 0.5 to 2.9%. EUS guided FNA of head of pancreas is usually performed from the bulb of the duodenum which eliminates the risk of malignant seeding when compared with percutaneous approach. The ability to detect vascular structures around the targeted lesion by Doppler flow analysis is another advantage to minimize bleeding [7, 8]. EUS with or without biopsy is clearly the procedure of choice for staging and diagnosis of periampullary neoplasms. EUS is especially helpful in smaller lesions not well characterized by CT or MRI. MRCP is a noninvasive technique; however has the disadvantage of not being able to make perform FNA and tissue diagnosis. At times, it is difficult to delineate lesions or stones at the distal end of CBD [9]. EUS can identity septations and cyst wall nodules in more detail than MRI or CT and allows cyst wall biopsy & cyst fluid aspirations for analysis. Cystic fluid analysis of a premalignant lesion will generally reveal thick and mucoid material; low fluid amylase, elevated CEA and mucinous epithetical cells by cytology as in one of our patients of mucinous cystadenoma [10]. EUS with FNA has an emerging role in the diagnosis and staging of suspected cholangiocarcinoma when brush cytology and other methods fail to yield a diagnosis. The sensitivity and specificity, positive predictive value, negative predictive value and accuracy were 86%, 100%, 97% and 88% respectively but the sensitivity of brush biopsy approach was only 50 to 60% at best. EUS has been shown to have role in the pre-operative diagnosis and staging of gallbladder carcinoma and polyps. EUS is highly accurate for detecting choledocholithiasis. It has the advantage of being able to visualize the bile duct from within the GI lumen and is reported to be comparable if not better than ERCP. Endoscopic imaging provides several advantages over USG including closer proximity to the bile duct, higher resolution and lack of interference by bowel gas. It has a positive predictive value of 99% and accuracy rate of 97% for the diagnosis of bile duct stones as compared with ERCP. EUS is also safer than ERCP in detecting stones and avoids complications related to ERCP. EUS is also superior to MRCP in detecting the presence or absence of bile duct stones especially at the distal end of CBD. EUS is also highly sensitive for detection of unrecognized gall baldder and CBD microlithiasis in patients with acute pancreatitis [11,12]. EUS is highly accurate in the diagnosis of chronic pancreatitis. There are 9 criterion defined that help assist in the diagnosis [5]. CONCLUSION Thus EUS has markedly expanded the diagnostic role of endoscopy. EUS is much less invasive than ERCP and has no associated radiation or contrast exposure. EUS combined with fine needle aspiration provides tissue diagnosis of masses and lymph nodes and excellent staging of GI malignancies. This article describes the initial experience at Apollo Hospital where this is now a well established service. REFERENCES 1. Hunt GC, Faigel DO. Assessment of EUS for diagnosing, staging and determining resectability of pancreatic cancers: A review. Gastrointestinal Endoscopy 2002; 55: 232-237. 2. Gress FG, Haives RN, Savidas TJ. Role of EUS in preoperative staging of pancreatic cancers. Gastrointes Endos. 1999; 500-786-791.

5. Apollo Medicine, Vol. 7, No. 4, December 2010 306 Original Article 3. Micames with Jowell P.S. White R, et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS guided FNA versus percutaneous FNA. Gastrointestinal Endos. 2003; 58- 690-695. 4. Brugge WR, Lewandrowski K, Lewandrowski E, et al. Diagnosis of Pancreatic cystic neoplasm a report of the cooperative pancreatic cyst study. Gastroentrol 2004; 126:1330-1336. 5. Bhargava S, et al. EUS of the Pancreas Endoscopic ultrasonography published by Black well Science, 2001. 6. Chang KJ. Endoscopic ultrasound and FNA. Gastroenterology & liver diseases 2005; 29-35. 7. Palazzo L, et al. EUS in the diagnosis and staging of pancreatic adenocarcinoma. Results of a prospective study with comparison to USG and CT Scan. Endoscopy. 1993; 143-150. 8. Kochman ML. EUS in pancreatic cancer. Gastrointestinal Endoscopy. 2002; S6 - S12. 9. Burtin P, et al. Diagnostic strategies for extrahepatic cholestasis of indefinite origin, EUS or ERCP. Results of a prospective study. Endoscopy: 1997; 349-355. 10. Brugge W. et al. Cystic neoplasm of the pancreas. NEJM. 2004; 1218-1226. 11. Amouyal P, et al. Diagnosis of choledocholithiasis by EUS. Gastroenterology. 1994; 1062-1067. 12. Norton S, Alderson D. Prospective comparison of EUS and ERCP in the detection of CBD stones. British Journal of Surgery. 1997; 1366-1369.

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