Endoscopic ultrasound in diagnosis and treatment of treatment

THE UPDATE: ENDOSCOPIC ULTRASOUND IN THE DIAGNOSIS AND TREATMENT OF GASTROENTEROLOGY DISEASES THE FIRST NATIONAL ULTRASOUND CONFERENCE Prof.Tran Van Huy - Dr.Vinh Khanh Department of In

THE UPDATE: ENDOSCOPIC ULTRASOUND IN

THE DIAGNOSIS AND TREATMENT OF GASTROENTEROLOGY DISEASES

THE FIRST NATIONAL ULTRASOUND

CONFERENCE

Prof.Tran Van Huy - Dr.Vinh Khanh Department of Internal Medicine - Hue University of Medicine and Pharmacy

Interventional Endosonography (2017)

1st TTS EUS Probe (1976)

ENDOSCOPIC ULTRASOUND

The way to progress

• Integrated EUS scopes (1980)

• Color Doppler

• Single frequency scopes (1980)

• 1 st EUS guided cholangiography (1996)

• Variable frequency scopes (1985)

• 1 st EUS – FNA (1991)

• Large Channel Scopes

• 1 st EUS guided CD-stomy (2002)

ENDOSCOPIC ULTRASOUND

Radial

For diagnosis

Linear Diagnosis and intervention

Mini probe 12MHz – 20 MHz

Radial EUS

Linear EUS

1 SUBMUCOSA TUMORS

1.Kazuya Akahoshi (2012),Practical Handbook of Endoscopic Ultrasonography.

SUBMUCOSA TUMORS

CYST

2 GASTROINTESTINAL CANCER

Staging

Prognosis

Observe of chemo- radiotherapy EUS

THE ROLE OF EUS IN TMN

STAGING

TMN

T

N EUS - FNA

M

Accuracy:

74-92%

ACCURACY OF EUS v CT BY STAGE

ACCURACY OF EUS v CT IN THE STAGING OF GASTRIC CANCER

ESOPHAGUS CANCER

T3N1Mx

3 COMMON BILE DUCT STONE

EUS

EUS v MRCP IN THE DIAGNOSIS CBDs

4 CHRONIC PANCREATITIS

Chronic pancreatitis

EUS STAGING OF PANCREATIC

CANCER

TomislavDragovich, et al Medscape

T staging

- EUS more accurate than CT/MRI

- Vascular invasion; EUS more sensitive than CT; CT more specific than EUS

EUS – TUMOR VASCULAR INVASION

1 EUS - FNA

• EUS-FNA: 1991

• The obtainment of a tissue biopsy specimen for histologic

examination

1 Tharian B, Tsiopoulos F, George N, Pietro SD et al, (2012), Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical

practice,World J Gastrointest Endosc, 4(12): 532–544.

PREPARATION

• Sensitivity of up to 85%.

• Specificity of up to 100%.

• On-site cytopathologist; improves diagnostic yield by

10-15%.

• Complicated rate of 0.5-2%; bleeding, pancreatitis

• Rarely, tumor seeding.

• Michael: 4983 patients EUS-FNA sensitivity 85%

and specificity 98% for pancreas tumor.

EUS-FNA Pancreatic cancer

EUS-FNA

EUS-Guided Pancreatic Pseudocyst Drainage

Pseudocyst

No

• Puncture do not depend on the pseudocyst depression into

the wall of the stomach

• Avoid vessels by doppler

• Preventing perforation

• Observing characteristics of lesion before pseudocyst drainage

STRONG POINTS OF EUS

EUS-Guided Pancreatic Pseudocyst Drainage

• Villa (2010): The success rate of endoscopic drainage ranges from87%-97%, mortality rate of 1% and the mortality rate of 10%associated with the surgical treatment

• Varadarajalu (2007): The successful rate of endoscopic drainageranges 100% and treatment 95% The successful rate ofendoscopic drainage without EUS 57% and treatment 90%

1 Vila JJ, Carral D, Fernández-Urien I (2010), Pancreatic pseudocyst drainage guided by endoscopic ultrasound World J Gastrointest Endosc; 2(6): 193-197.

2 Varadarajulu S, Wilcox CM, Tamhane A, Eloubeidi MA et al (2007), Role of EUS in drainage of peripancreatic fluid collections not

amenable for endoscopic transmural drainage, Gastrointest Endosc 66: 1107-1119.

EUS-Guided Pancreatic Pseudocyst Drainage

EUS guided

Pancreatico-billiary drainage

EUS guided hepaticogastrostomy

EUS guided choledochoduodenostomy

EUS guided choledochoduodenostomy

EUS GUIDED ANTEGRADE

STENTING

EUS GUIDED BILIARY DRAINAGE

Stenting / Bilio-enterostomy

Alternative to PTC when ERCP fails

Giovannini et al, Burmester et al (2003), Puspok et al, Kahaleh et al (2010, 2005), Kitano (2010),

Gupta (2011), Vila (2011), Bapaye (2013), Dhir (2014), Hara (2014)

• 1st report – Giovannnini (2002)

• Duodenal / Gastric / Extra / Intra hepatic approaches

• Direct stenting / rendezvous / antegrade stenting

• Large case series – multicenter study of 241 patients

• 85-90% success, ~10% complications

EUS GUIDED BILIARY ACCESS

EUS-BD vs PTBD

Improved rate of internal stenting, fewer complications

Bapaye et al , UEGJ 2013

EUS guided stenting vs ERCP stenting

Similar outcomes in both groups

Dhir et al, GIE 2015

EUS-CDS or EUS-HGS ?

No significant difference by either approach

Bapaye et al , UEGJ 2013; Dhir et al GIE 2014

EUS GUIDED PANCREATIC STENTING

(Post op situations, Tight PD stricture)

(Francois, Giovannini, Deviere (2002, 2005)

Gastrointest Endosc 2011;73:267-74 Gastrointest Endosc 2003; 57:923-930

3 EUS-guided Celiac Plexus

Neurolysis (CPN)

EUS GUIDED CELIAC PLEXUS NEUROLYSIS- CPN

EUS-CPN safer, direct & under visual control

For Cancer pancreas EUS vs CT guided CPN : 78% vs 26%, p = 0.0001,

effect sustained for 24 weeks For chronic pancreatitis EUS guided vs CT guided CPN – 43% > 25%, p < 0.05

Complication Transient diarrhea (20-30%), orthostatic hypotension

(10-60%), abdominal pain Most are mild and transient

Gunaratnam et al (2001), Gress et al (1999)

• Endoscopic Ultrasound is an essential technique ingastroenterology diseases.

• Endoscopic Ultrasound is a new medical procedure

gastrointestinal and pancreatico- biliary diseases

CONCLUSION

THANK YOU AND HAPPY NEW YEAR!