The research The update: Endoscopic ultrasound in diagnosis and treatment of treatment

THE FIRST NATIONAL ULTRASOUND CONFERENCE

THE UPDATE: ENDOSCOPIC ULTRASOUND IN

THE DIAGNOSIS AND TREATMENT OF

GASTROENTEROLOGY DISEASES

Prof.Tran Van Huy - Dr.Vinh Khanh

Department of Internal Medicine - Hue University of Medicine and Pharmacy

OBJECTIVES

Overview of endoscopic ultrasound

The role of EUS in the diagnosis

The role of EUS in the treatment

Conclusion

5 4

OBJECTIVES

Overview of endoscopic ultrasound

The role EUS in the diagnosis

The role EUS in the treatment

Conclusion

5 4

ENDOSCOPIC ULTRASOUND The way to progress

1st TTS EUS Probe (1976)

• Integrated EUS scopes (1980)

• Single frequency scopes (1980)

• Variable frequency scopes (1985)

• 1st EUS – FNA (1991)

• Color Doppler

• 1st EUS guided cholangiography (1996)

• Large Channel Scopes

• 1st EUS guided CD-stomy (2002)

Interventional Endosonography (2017)

ENDOSCOPIC ULTRASOUND

Radial For diagnosis

Linear Diagnosis and intervention

Mini probe 12MHz – 20 MHz

RADIAL - LINEAR

Radial EUS

L

Linear EUS

Imaging perpendicular to the endoscope

L

Imaging parallel to the endoscope

GI Atlas, Wiley

Radial EUS

Linear EUS

OBJECTIVES

Overview of endoscopic ultrasound

The role of EUS in the diagnosis

The role of EUS in the treatment

Conclusion

5 4

1. SUBMUCOSA TUMORS

• Approximately 1 in 300 patients.

• Diagnosed by endoscopy.

• EUS: location, layer, size, contour, echogenicity, vascularity.

- Follow up

1. Alexander J. Eckardt, Christian Jenssen (2015), Current endoscopic ultrasound-guided approach to incidental subepithelial lesions: optimal or optional?, Annals

of Gastroenterology 28, 1-13.

2. Hwang JH1, Saunders MD, Rulyak SJ, et al. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest

Endosc 2005;62:202-208.

- Accuracy: 90%.

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

SUBMUCOSA TUMORS

CYST

2. GASTROINTESTINAL CANCER

EUS

Prognosis

Observe of chemo- radiotherapy

Staging

THE ROLE OF EUS IN TMN STAGING

N EUS - FNA

Accuracy: 74- 92%

TMN

ACCURACY OF EUS v. CT BY STAGE OF ESOPHAGEAL CANCER

100 )

%

(

80

60

40 y c a r u c c A g n

i

20 g a t S

0 EUS

CT

T1 or T2

T3

T4 N0 N1

ACCURACY OF EUS v. CT IN THE STAGING OF GASTRIC CANCER

90

85

78

80

70

60

48

50

42

40 EUS CT

30

20

10

0 T STAGE

N STAGE

ESOPHAGUS CANCER

T3N1Mx

3. COMMON BILE DUCT STONE

Ultrasound

CT-Scanner

DIAGNOSIS

MRCP

ERCP

EUS

EUS v. MRCP IN THE DIAGNOSIS CBDs

EUS (%)

MRCP (%)

RCP

EUS

100 95,4 90,9

100 72,7 62,5

100

100% 95.4% 90.9% 100% 96.9%

Sensitivity Specificity Positive predictive value Negative predictive value Accuracy

96,9

82,2

De Ledinghen V GIE 1999

4. CHRONIC PANCREATITIS

Function

Difficulties

Morphology Early chronic pancreatitis

Chronic pancreatitis

DIAGNOSIS OF CHRONIC PANCREATITIS

(cid:1) Diagnosis of chronic pancreatitis on EUS

Conventional classification

Rosemont classification

(cid:1) Rosemont classification detect early chronic pancreatitis.

5. PANCREATIC CANCER

Staging

Diagnosis

Related pain

PANCREATIC CANCER

EUS STAGING OF PANCREATIC CANCER

TomislavDragovich, et al. Medscape

EUS STAGING OF PANCREATIC CANCER

T staging

- EUS more accurate than CT/MRI - Vascular invasion; EUS more sensitive than CT; CT

more specific than EUS

N staging

- EUS similar to CT

- EUS stages smaller tumors (< 3cm) more accurately

Jose Manuel Ramia. World J GastrointestOncol 2014

than larger tumors.

EUS – TUMOR VASCULAR INVASION

Vascular invasion

Irregular vascular wall

Absence of invasion

OBJECTIVES

Overview of endoscopic ultrasound

The role of EUS in the diagnosis

The role of EUS in the treatment

Conclusion

5 4

1. EUS - FNA

• EUS-FNA: 1991. • The obtainment of a tissue biopsy specimen for histologic

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.

examination

PREPARATION

EUS-FNA Pancreatic cancer

• 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.

1. Michael JH, Mark JW, Lucia P, Panagiotis V, et al (2012), EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis, Gastrointest endosc, 75 (1).

EUS-FNA

2. EUS DRAINAGE

EUS-Guided Pancreatic Pseudocyst Drainage

EUS guided Cholangiography and

drainage.

EUS-Guided Pancreatic Pseudocyst Drainage

Follow up

No symptom

Pseudocyst

Symptom

Therapy

STRONG POINTS OF EUS

• 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.

EUS-Guided Pancreatic Pseudocyst Drainage

• Villa (2010): The success rate of endoscopic drainage ranges from

87%-97%, mortality rate of 1% and the mortality rate of 10%

associated with the surgical treatment.

• Varadarajalu (2007): The successful rate of endoscopic drainage

ranges 100% and treatment 95%. The successful rate of

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.

endoscopic drainage without EUS 57% and treatment 90%.

EUS-Guided Pancreatic Pseudocyst Drainage

EUS guided Pancreatico- billiary drainage

EUS guided hepaticogastrostomy

EUS guided choledochoduodenostomy

EUS GUIDED ANTEGRADE STENTING

EUS GUIDED BILIARY DRAINAGE Stenting / Bilio-enterostomy

• 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

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)

Alternative to PTC when ERCP fails

EUS GUIDED BILIARY ACCESS

EUS-BD vs. PTBD Improved rate of internal stenting, fewer complications

Bapaye et al , UEGJ 2013

EUS-CDS or EUS-HGS ? No significant difference by either approach

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

EUS guided stenting vs. ERCP stenting Similar outcomes in both groups

Dhir et al, GIE 2015

EUS GUIDED PANCREATIC STENTING

• Situations when Papillary access is not possible (Post op situations, Tight PD stricture)

(Francois, Giovannini, Deviere (2002, 2005)

• 75-80% success

3. EUS-guided Celiac Plexus Neurolysis (CPN)

Gastrointest Endosc 2003; 57:923-930

Gastrointest Endosc 2011;73:267-74

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)

CONCLUSION

• Endoscopic Ultrasound is an essential technique in

gastroenterology diseases.

• Endoscopic Ultrasound is a new medical procedure

which is highly qualified in diagnosis of the

gastrointestinal and pancreatico- biliary diseases.

THANK YOU AND HAPPY NEW YEAR!

The research The update: Endoscopic ultrasound in diagnosis and treatment of treatment