Endoscopic Ultrasound (eBook)

Endosonographic Instrumentation 13
INTRODUCTION: BASICS OF ULTRASOUND AND RATIONALE FOR EUS 14
THE ULTRASOUND TRANSDUCER 15
RADIAL ARRAY VERSUS LINEAR ARRAY 15
BASIC ECHOENDOSCOPE DESIGN 18
LINEAR ARRAY ECHOENDOSCOPES 20
RADIAL ECHOENDOSCOPES 20
ENDOBRONCHIAL ULTRASOUND DEVICES 25
OTHER SPECIALIZED DEVICES 27
EUS MINIPROBES 31
ULTRASOUND CONSOLES 31
EUS NEEDLES 36
CONCLUSION 40
REFERENCES 41
Probe Ultrasonography 42
INTRODUCTION 43
INSTRUMENTS AND EXAMINATION TECHNIQUES 44
GASTROINTESTINAL WALL ANATOMY 45
CLINICAL INDICATIONS 47
Esophagus 47
Stomach 47
Small Bowel and Colon 51
INTRADUCTAL ULTRASOUND 55
TECHNICAL CONSIDERATIONS 55
BILIARY TRACT ANATOMY 55
CLINICAL INDICATIONS 56
Choledocholithiasis 56
Bile Duct Strictures 57
Cholangiocarcinoma 57
PANCREATIC INTRADUCTAL ULTRASOUND 59
Pancreatic Duct Strictures and Pancreatic Adenocarcinoma 59
Mucin-Producing and Islet-Cell Tumors 59
PAPILLA OF VATER INTRADUCTAL ULTRASOUND 60
FUTURE PROBE TECHOLOGY 60
CONCLUSION 61
REFERENCES 62
Radial Endoscopic Ultrasound 71
INTRODUCTION 72
EQUIPMENT 73
GASTROINTESTINAL TRACT WALL 77
MEDIASTINUM AND ESOPHAGUS 78
Distal Esophagus 78
Midesophagus 80
Proximal Esophagus 83
STOMACH 83
PANCREAS AND EXTRAHEPATIC BILE DUCT 87
RECTUM 92
SUMMARY 96
REFERENCES 97
Linear Endoscopic Ultrasound 98
INTRODUCTION 99
TECHNIQUE 99
Maneuvering the Linear Echoendoscope 99
Value of a Forward Viewing Endoscopy Prior to EUS 101
Mediastinum 101
Celiac Axis and Adjacent Structures 103
Liver and Gallbladder 105
Pancreas, Bile Duct, and Ampulla 106
Rectum 109
ACCESSORIES 109
Balloons 109
Buttons and Caps 109
Role of linear eus in Gi diseases 110
Esophageal Cancer 110
Stomach Cancer 111
Pancreatic Cancer 112
Chronic Pancreatitis and Pancreatic Ductal Anatomy 113
Common Bile Duct Stones 114
Rectal Cancer 115
SUMMARY 115
REFERENCES 115
The Cytopathology of Endoscopic Ultrasound-Guided Fine Needle Aspiration 118
INTRODUCTION 119
PRINCIPLES OF CYTOLOGY 119
Preparations 119
TERMINOLOGY 121
BIOPSY OF LUMINAL GUT 122
Epithelial Malignancy 122
Adenocarcinoma 122
Squamous cell carcinoma 124
Spindle cell (sarcomatoid) carcinoma 125
Carcinoid tumors and other well-differentiated neuroendocrine carcinomas 126
Mesenchymal Neoplasia 128
Lymphoma 132
Melanoma 135
Other Lesions 137
BIOPSY OF LYMPH NODES 138
The Staging of Malignancy 138
Adenopathy of Other Etiology 138
BIOPSY OF THE LUNG AND MEDIASTINUM 140
BIOPSY OF THE PANCREAS, EXTRAHEPATIC BILIARY SYSTEM, AND GALLBLADDER 144
Pancreas 144
Pancreatic ductal adenocarcinoma 146
Other primary pancreatic solid neoplasms 148
Solid lesions mimicking solid pancreatic neoplasia 152
Cystic lesions 154
Extrahepatic Biliary System and Gallbladder 159
BIOPSY OF THE LIVER 159
ADRENAL GLAND 161
CONCLUSION 162
REFERENCES 162
Pitfalls in Endoscopic Ultrasound 171
SEDATION 172
ENDOSCOPE INTUBATION AND PASSAGE 172
ORIENTATION 173
TECHNICAL ISSUES 177
EUS INDICATIONS 178
EQUIPMENT SELECTION 179
FNA CONSIDERATIONS 180
Sec8_6 181
CONCLUSION 184
REFERENCES 184
The Role of EUS in Esophageal Cancer 188
INTRODUCTION 189
DIAGNOSIS 189
STAGING ESOPHAGEAL CANCER 189
T STAGING 192
N STAGING 196
Staging in the Setting of Malignant Strictures 199
M STAGING 200
RESTAGING 201
DETECTING TUMOR RECURRENCE 202
BARRETT’S ESOPHAGUS 203
QUALITY INDICATORS 203
CONCLUSION 204
REFERENCES 204
Role of EUS in Mediastinal Nodes, Masses, Cysts, and Lung Cancer 209
INTRODUCTION 210
Mediastinal Cysts 211
ROLE OF FNA 212
THE LUNG MASS 212
LUNG CANCER 214
RATIONALE FOR EUS 214
BEFORE YOU START 215
WHICH TEST IS BEST? 217
CROSS-SECTIONAL IMAGING 218
FUNCTIONAL IMAGING 219
FAILED BRONCHOSCOPY AND EUS RESCUE 220
EUS AND MEDIASTINOSCOPY 220
MEDICAL MEDIASTINOSCOPY 220
ENDOBRONCHIAL ULTRASOUND 220
SHOULD EUS BE EMPLOYED IN SUSPECTED EARLY LUNG CANCER? 222
THE LINEAR EXAM 222
THE FNA TECHNIQUE 222
SELECTIVE NODAL TARGETING 224
DOES EUS PREDICT T4 DISEASE? 225
EUS AFTER INDUCTION THERAPY 225
NEW APPLICATIONS 226
COST EFFECTIVENESS OF EUS IN LUNG CANCER 226
TRAINING 226
CONCLUSION 227
References 227
The Role of Endoscopic Ultrasound in Gastric Cancer 231
INTRODUCTION 232
GASTRIC CANCER STAGING SYSTEMS 233
DIAGNOSIS AND STAGING OF GASTRIC CANCER 235
EUS TECHNIQUE 235
PRIMARY TUMOR ASSESSMENT (T-STAGE) OF GASTRIC CANCER BY EUS 237
LYMPH NODE ASSESSMENT (N-STAGING) OF GASTRIC CANCER BY EUS 240
ASSESSMENT OF DISTANT METASTASES (M-STAGING) OF GASTRIC CANCER BY EUS 242
TECHNICAL LIMITATIONS OF EUS FOR TNM STAGING OF GASTRIC CANCER 242
COMPARISON OF EUS TO OTHER IMAGING MODALITIES FOR STAGING OF GASTRIC CANCER 243
EUS IN THE EVALUATION OF EARLY GASTRIC CANCER 243
EUS IN THE EVALUATION OF LOCALLY ADVANCED GASTRIC CANCER 245
CONCLUSION 246
REFERENCES 247
The Role of EUS in Subepithelial Lesions 252
INTRODUCTION 252
EXTRAMURAL LESIONS 254
INTRAMURAL LESIONS 255
Benign 255
Lipoma 255
Leiomyoma 257
Varices 259
Pancreatic Rest 259
Duplication Cyst 261
Inflammatory Fibroid Polyp 261
Malignant or Premalignant 262
Gastrointestinal Stromal Tumor 262
Carcinoid Tumor 262
Lymphoma 264
Glomus Tumors 264
Granular Cell Tumors 264
Metastasis 265
CONCLUSIONS 265
REFERENCES 265
Endoscopic Ultrasound of Ampullary and Duodenal Lesions 270
INTRODUCTION 271
AMPULLA OF VATER 271
Benign Lesions of the Ampulla of Vater 271
Malignant Lesions of the Ampulla of Vater 272
Lesions Involving the Minor Duodenal Ampulla 273
TECHNIQUE OF EUS EXAMINATION 273
EUS-Guided FNA 274
Intraductal Ultrasound 274
STAGING ACCURACY OF EUS 277
TREATMENT 280
DUODENAL LESIONS 280
Benign Lesions of the Duodenum 281
CONCLUSIONS 281
REFERENCES 282
The Role of EUS in Pancreatic Cancer 286
Introduction 287
PRESENTATION AND INITIAL EVALUATION 287
RADIOGRAPHIC IMAGING STUDIES 292
ENDOSCOPIC ULTRASOUND (EUS) 292
REFERENCES 298
The Role of EUS in Cystic Lesions of the Pancreas 302
INTRODUCTION 303
EUS VERSUS OTHER IMAGING MODALITIES IN THE DIAGNOSIS OF CPLs 304
EUS-FNA of CPLs: TECHNIQUE 306
EUS-GUIDED TRUCUT BIOPSIES 307
CYST FLUID EVALUATION 308
Cytology 308
Tumor Markers 309
Genetic Markers 310
SEROUS CYSTIC NEOPLASMS 311
MUCINOUS CYSTIC NEOPLASMS 313
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS 316
OTHER RARE TYPES OF CPLs 320
TREATMENT OF CPLs 322
Expectant Management 322
Surgical Management 323
Alternate Nonsurgical Management and Future Developments 323
CONCLUSION 324
REFERENCES 324
The Role of EUS in the Biliary System 331
TECHNIQUE OF BILIARY IMAGING 332
Standard Endoscopic Ultrasonography 332
Intraductal Ultrasonography 335
Normal Findings 337
GALLSTONE DISEASE 338
Introduction 338
Technique 339
Results 340
Particular Case: “Idiopathic” Acute Pancreatitis 344
BILIARY STRICTURES 346
Standard Endoscopic Ultrasonography 346
Detection and Characterization of Biliary Strictures and Lymph Nodes 346
Sampling 347
Longitudinal Tumor Extent, TNM Stage, and Resectability 350
Impact of EUS-FNA on Patient Management 352
Intraductal Ultrasonography 354
Introduction 354
Distinction Between Benign and Malignant Strictures 354
Staging of Cholangiocarcinomas 355
Particular Case: Primary Sclerosing Cholangitis 356
Therapeutic EUS for Biliary Strictures 357
Preamble 357
Technique 358
Results 358
GALLBLADDER 358
Normal Findings 358
Stones 358
Polypoid Lesions 359
Description 359
Role of EUS in the Management of Gallbladder Polypoid Lesions 360
Carcinoma 361
REFERENCES 364
The Role of EUS in Rectal Cancer and Fecal Incontinence 373
EUS AND RECTAL CANCER 374
Background 374
EUS Technique 374
T Staging 374
N Staging 377
Fine Needle Aspiration 377
Clinical Significance of EUS in Rectal Cancer Staging 380
Factors Affecting EUS Accuracy 380
Tumor Recurrence 380
Future EUS Applications in Rectal Cancer 381
EUS AND FECAL INCONTINENCE 381
Background 381
Normal Anatomy of the Anal Sphincter 382
EUS Technique 382
EUS Accuracy in Identifying Sphincter Tears 383
EUS Compared to Other Modalities 384
Clinical Impact of EUS on Fecal Incontinence 384
Future EUS Applications in Fecal Incontinence 385
SUMMARY 385
References 386
Interventional Endoscopic Ultrasound-Guided Cholangiopancreatography 392
INTRODUCTION 393
Patient Selection 393
Endoscopist Selection 394
Patient Preparation 394
Techniques 394
EUS-guided Biliary Drainage 395
Intrahepatic Approach 395
Extrahepatic Approach 396
EUS-guided pancreatic drainage 398
LITERATURE REVIEW 399
EUS-Guided Biliary Drainage 399
EUS-Guided Pancreatic Drainage 401
SUMMARY 404
References 405
Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections 409
INTRODUCTION 410
MATERIALS AND METHODS 411
Appropriate Candidates 411
Appropriate Endoscopists 411
Patient Preparation 411
Instrumentation 412
Predrainage Evaluation 412
PROCEDURE DESCRIPTION 412
LITERATURE REVIEW 414
CONCLUSION 420
REFERENCES 420
Endoscopic Ultrasound-Guided Celiac Plexus Block and Celiac Plexus Neurolysis 424
INTRODUCTION 425
ANATOMICAL AND FUNCTIONAL CONSIDERATIONS 426
Pancreas 426
CELIAC PLEXUS 426
TECHNIQUE 427
CPN 431
Celiac plexus block 431
PREPARATION PREPROCEDURE 432
POSTPROCEDURE MONITORING 433
SIDE EFFECTS AND COMPLICATIONS OF THE PROCEDURE 433
PROCEDURE EFFICACY 434
REFERENCES 437
Fine Needle Injection Therapy 441
INTRODUCTION 441
TUMOR ABLATION 442
Injection Therapy 443
Biologics 443
Ethanol 445
Thermal/Energy Delivery 447
Radiofrequency Ablation 447
Cryoablation 450
Photodynamic Therapy 452
High-Intensity Focused Ultrasound 455
Implantable Therapy 455
Chemotherapy 455
Brachytherapy 457
PRETREATMENT TUMOR IDENTIFICATION 459
Fiducial Placement 459
Tumor Marking 461
PANCREATIC CYST ABLATION 461
SUMMARY 463
REFERENCES 464
Contrast-Enhanced Endoscopic Ultrasound 473
INTRODUCTION 474
GENERAL CONSIDERATIONS 474
COMMERCIALLY AVAILABLE UCA IN EUROPE 475
PANCREATIC EUS AND US CONTRAST AGENTS 476
CONTRAST-ENHANCED EUS IN DISCRIMINATION BETWEEN BENIGN AND MALIGNANT MEDIASTINAL AND ABDOMINAL LYMPH NODES 480
CONCLUSION 481
References 482
Endosurgical Applications of EUS 485
INTRODUCTION 486
ENDOLUMINAL ENDOSURGICAL METHODS 487
EUS-Guided Pancreatic Necrosectomy 487
EUS-Guided Drainage of the Biliary Tract 489
EUS-Guided Bilioma Drainage 491
EUS-Guided Pancreatic Duct Interventions 491
EUS-Guided Vascular Interventions 492
EXPERIMENTAL EUS-GUIDED ENDOSURGERY: TOWARD NOTES 494
EUS-Guided Anastomosis 498
EUS-Guided Cardiac Interventions 499
EUS-GUIDED ENDOSURGERY 501
EUS-Guided Transluminal (NOTES) Access 501
EUS-Guided Mediastinal Drainages and NOTES 502
Transluminal EUS 503
CONCLUSION 503
REFERENCES 504
The Future of EUS 510
INTRODUCTION 510
FUTURE EUS EQUIPMENT 511
EUS Scopes 511
Future EUS Ultrasound Processors 512
Future EUS Accessories 512
EUS INDICATIONS IN THE FUTURE 514
Mediastinal EUS 514
Luminal GI Tract Cancer 515
Pancreatic Cancer 515
Pancreatic Cysts 516
EUS Pseudocyst Drainage 517
EUS Celiac Plexus Neurolysis 517
CBD Stones 518
Biliary Drainage 518
Hemostasis and Vascular EUS 518
EUS and NOTES/Surgery 519
FUTURE TRAINING AND QUALITY ISSUES 519
CONCLUSIONS 520
REFERENCES 521