Introduction of Endoscopic Ultrasonography (EUS)

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1 Introduction of Endoscopic Ultrasonography (EUS) Dr. Yuk Tong LEE MBChB, MD(CUHK), FRCP (Edin), FRCP(Lond), FHKCP, FHKAM Specialist in Gastroenterology and Hepatology

2 Endoscopic Ultrasonography (EUS) ª Combines both endoscopic and ultrasonic examination in one ª High frequency USG transducer used ª Close proximity to the GIT and surrounding organs ª Highly accurate in diagnosing both mural and extramural structural abnormality ª EUS guided fine needle aspiration and intervention

3 Electronic radial echoendoscope GF-UE260 Color and Power Doppler study Contrast study

4 Linear echoendoscope Fine needle aspiration to obtain cytology

5 Miniature probes UM-G20-26R UM-G20-29R UM2R / 3R

6 Clinical practice ª Endoscopic diagnostician (Upper GI, pancreatobiliary) ª Electronic radial EUS ª Olympus (forward oblique) ª Fujinon / Pentax (forward end viewing) ª Miniprobe ª 12MHz (most commonly used) ª 20MHz, IDUS highly specialized. ª Practice related to oncology centre linear EUS for both diagnosis and staging, FNA and tumour therapy. ª Pulmonary physician and cardiothoracic surgery EBUS + FNA ª Colorectal surgery miniprobe, rectal probe

7 Diagnostician Colorectal Pulmonary The ECHO-ENDOSCOPIST Oncology

8 Diagnostic EUS Mural and extramural lesions Diagnosis of cyst, GIST, submucosal mass (assessment before mucosectomy, ESD) Thickened gastric fold Determine cause of GI tract stricture (anastomotic, reflux, extrinsic compression, achalasia) Staging of GI tract malignancies Oesophageal and gastric cancer Gastric lymphoma / MALToma Detection of malignant ascites and peritoneal metastases Restaging after chemotherapy Staging of non-gi tract malignancies Non-small cell lung cancer Mediastinal tumour / lymph node (Gynaecological cancer) Biliary diseases Common bile duct stones, sludge and cancer GB tumour, stone, polyps and other pathologies Pancreatic diseases Pancreatic and ampullary cancer Endocrine tumour, cystic tumour, IPMT Acute, chronic and idiopathic pancreatitis Assessment of pseudocyst (before drainage) Colorectal diseases Colorectal cancer and large polyps Colorectal submucosal mass and carcinoid IBD (CD, UC) Fistula-in-ano, incontinence, pelvic floor dysfunction Early detection of rectal tumour recurrence Pelvic diseases (abscess, prostate, endometriosis, etc) Portal hypertension Diagnosis of gastroesophageal varices and collaterals Monitoring drug and endoscopic therapy Haemodynamic study Dyspepsia and unexplained abdominal pain New methods EUS harmonic contrast study EUS elastography

9 Indications for EUS (EBUS) - FNA and trucut biopsy EUS-FNA of tumours GIT stromal tumour (GIST, leiomyoma, linitus plastica, etc) Lung tumour and metastases Liver metastases Adrenal metastases Pancreatic lesion Solid pancreatic mass Cystic lesion - FNA for fluid analysis, EUS guided brush cytology, EUS guided direct intra-cystic biopsy EUS tattoo of small neuroendocrine tumour EUS-FNA of lymph node in GIT cancer Peri-esophageal, celiac axis lymph node Peri-gastric Peri-pancreatic Peri-rectal EUS (EBUS) - FNA of mediastinal lymph node for staging of NSCLC EUS (EBUS) - FNA of other mediastinal lymph nodes and masses Metastases Lymphoma TB, Sarcoidosis, Histoplasmosis, etc EUS-FNA of other lesions Ascites Pleural effusion Pericardial effusion

10 Therapeutic and Interventional EUS (investigational) EUS-guided injection therapy Celiac plexus neurolysis Broad plexus neurolysis (around SMA) (Hypogastric plexus neurolysis) Botox injection for achalasia Sclerotherapy of OV and GV Lavage (alcohol, paclitaxel) of pancreatic cystic tumour EUS-guided tumour therapy Iodine 125 seeds placement for brachytherapies Fiducial placement for stereotactic radiation (Tumour ablation thermal probe, cryo probe, photodynamic probe, laser probe, radiofrequency (High intensity focused ultrasound, HIFU) ) (EUS-guided tumour injection therapy) Injection of cytoimplant, gene therapy, chemotherapeutic agents, immune modulators Alcohol ablation of liver metastases, small pancreatic neuroendocrine tumour, etc. EUS-guided abscess drainage Liver abscess Sub-phrenic abscess Peri-rectal abscess EUS-guided ERCP Pancreatic ductal cannulation CBD rendezvous cannulation EUS-guided drainage Pancreatic pseudocyst drainage Pancreatico-gastrostomy (EPG) Choledocho-duodenostomy Cholecysto-duodenostomy Hepatico-gastrostomy EUS guide vascular therapy Cyanoacrylate injection for bleeding varices and aneurysm Endocoil placement for varices and aneurysm (TIPS placement) (EUS guided anastomotic surgery) Gastro-jejunostomy Choledocho-duodenostomy EUS-guided angiography EUS guided needle confocal endomicroscopy