EUS. Endoscopic Ultrasonography In clinical practice. THAWEE Ratanachu-ek, M.D. Surgical Endoscopy Unit, Department of Surgery, Rajavithi Hospital

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1 EUS Endoscopic Ultrasonography In clinical practice THAWEE Ratanachu-ek, M.D. Surgical Endoscopy Unit, Department of Surgery, Rajavithi Hospital Endoscopic ultrasound(eus) What is endoscopic ultrasonography? EndoUltraSonography Endoscopy Ultrasonography 1

2 Endo Ultra Sonography Why it is developped? Mucosal lesion Extraluminal lesion.... Submucosal lesion Endoultrasonoprobe Radial EUS Convex (Longitudinal) EUS Miniprobe Intraductal US (IDUS) Intravascular US (IVUS) 2

3 EUS: Basic principle MHz : 5-layer Mucosa Muscularis mucosae Submucosa Proper muscle Sub-,serosa MHz: 9 layer Border echo Border echo Emerging technology: EBUS/EUS/FNA 3

4 Endoscopic ultrasound(eus) Radial type Linear (convex) type EUS: Technical Development Therapeutic procedure Diagnosis EUS-FNA Modified from E. Burmester, EURO EUS

5 EUS: Clinical Practice Diagnostic applications Cancer staging (T,N,M?) Lung cancer, GI cancer Giant Gastric folds Subepithelial tumor HBP lesions Retroperitoneal lesions Colon & Rectum etc EUS: Clinical Practice Intervention EUS Pseudocyst drainage Pancreatic necrosectomy Celiac plexus neurolysis/block Biliary-enteric bypass Drainage of collection 5

6 EUS: Clinical Practice Absolute contraindication Uncorrectable coagulopathy with INR>1.5 Uncorrectable thrombocytopenia with platelet count<50,000/ul Relative contraindication: Precaution Biliary obstrcution without prior decompression Bronchogenic duplication cyst Trajectory to vessel Luminal stenosis Tumor spreading EUS: Complications Bleeding Pancreatitis Infection Perforation Air embolism Tumor seeding % 6

7 EUS: Clinical Practice Diagnostic applications Cancer staging (T,N,M?) Lung cancer, GI cancer Giant Gastric folds Subepithelial tumor HBP lesions Retroperitoneal lesions Colon & Rectum etc EUS-FNA is possible in lymph node station : 1, 2, 3, 4, (5 ), 7, 8 and 9 +EBUS Remember the adrenal glands! 7

8 Cancer staging (T,N,M?) T4,N1 esophageal cancer Panc.Cancer: EUS-get tissue & staging Liver metastasis Panc.head mass FNA Metastasis liver celiac LN 8

9 EUS: Pancreatic cancer; Assessment of vascular invasion abutment invasion encasement Subepithelial Tumor mucosa Muscularis mucosae submucosa muscularis propria serosa/adeventitia 9

10 SET based on site of origin Owens D, Savides T. Endoscopicn untrasound, 2009: DDx. of SMT based on site of origin & Echo pattern: 3 rd Lipoma Granular cell Glomus tumor Panc. rest Goldblum J. R. et al.; Ann Thorac Surg 1996;62:

11 DDx. of SMT based on site of origin & Echo pattern: 2 nd /4 th Leiomyoma GIST GIST Tbc Pancreas Anti TB drugs 11

12 Features of common pancreatic cysts Branches type Macrocystic with microcystic varients Microcystic with macrocystic varients Garcea G, Ong SL, Rajesh A, et al.cystic Lesions of the Pancreas. Pancreatology 2008;8: P-cyst: Over-lapping Images Macrocystic Microcystic Oligocystic MCN SCN IPMN Federle MP.,McGrath KM., Gastroenterol Clin N Am 2007;36:

13 EUS: aspiration Wash-out the wall Levy MJ, Wiersema MJ. Pancratic neoplasm.gastrointest Endoscopy Clin N Am. 2005;15: antibiotic EUS guided pancture 19, 22 G needle EUS: Clinical Practice Intervention EUS Pseudocyst drainage Pancreatic necrosectomy Celiac plexus neurolysis/block Biliary-enteric bypass Drainage of collection 13

14 i-eus: How often? % of i-eus:d-eus/year (N=1300) (N=471) (N=1253) (N=783) i-eus 204/ total EUS (N) 3807= 5.3% Siriraj 5.0% Chula 4.8% NKC-Songkla 4.6% Rajavithi 7.4% Courtesy: Dr.Siriboon,Dr Bancha, Dr.Tassanee,Dr.Thawatchai,Dr.Nonthalee,Dr,Varayut, Dr.Pradermchai i-eus: What procedures? N= (20.5%) 64 (31.3%) 76 (37.0%) 14

15 Celiac plexus Neurolysis(CPN) Block (CPB) Achieve 70% Covered areas CPN(%) BPN (%) CPN: Single/ Bilateral injection CGN: Ganglia injection Not possible up to 20% BPN (Broad Plexuse Neurolysis) Gunaratnam NT, Sarma AV, Norton ID, et al. A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain. GIE. 2001;54: Sahai AV, Lemelin V, Lam E, Paquin PC. Central vs. bilateral endoscopic ultrasound-guided celiac plexus block or neurolysis: a comparative study of short-term effectiveness. Am J Gastroenterol 2009 Feb;104(2): Epub 2009 Jan 6. Levy MJ, Topazian MD, Wiersema MJ, et al. Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block. Am J Gastroenterol. 2008;103: Sakamoto H, Kitano M, Komaki T, et al. Endoscopic ultrasound-guided neurolysis in pancreatic cancer. Pancreatology 2011;11Suppl 2:52-8. Epub 2011 Apr 5. Sakamoto H, Kitano M, Komata K, et al. Am J Gastroenterol 2010;105: Gleeson FC, Levy MJ, Papachristou GI. Frequency of visualization of presumed celiac ganglia by endoscopic ultrasound. Endoscopy 2007;39: EUS Guided HPB Drainage Bile duct drainage Gall bladder drainage* Hepaticogastrostomy Choledochoduodenostomy Pancreaticogastrostomy Pseudocyst drainage Biloma drainage Courtesy: Takao Itoi Itoi T, Binmoeller KF, et al. Gastrointestinal Endoscopy 2012;75:

16 Thank you for your attention 16