The update: Endoscopic ultrasound in the diagnosis and treatment of gastroenterology diseases

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 OBJECTIVES 1 2 Overview of endoscopic ultrasound 1 The role of EUS in the diagnosis 2 3 The role of EUS in the treatment 3 Conclusion5 4 6 hinhanhykhoa.com OBJECTIVES 1 2 Overview of endoscopic ultrasound 1 The role EUS in the diagnosis 2 3 The role EUS in the treatment 3 Conclusion5 4 6 Interventional Endosonography (2017) 1st TTS EUS Probe (1976) ENDOSCOPIC ULTRASOUND The way to progress • Integrated EUS scopes (1980) • Color Doppler • Single frequency scopes (1980) • 1st EUS guided cholangiography (1996) • Variable frequency scopes (1985) • 1st EUS – FNA (1991) • Large Channel Scopes • 1st EUS guided CD-stomy (2002) hinhanhykhoa.com ENDOSCOPIC ULTRASOUND Radial For diagnosis Linear Diagnosis and intervention Mini probe 12MHz – 20 MHz LL GI Atlas, Wiley Imaging perpendicular to the endoscope Imaging parallel to the endoscope Radial EUS Linear EUS RADIAL - LINEAR hinhanhykhoa.com Radial EUS Linear EUS OBJECTIVES 1 2 Overview of endoscopic ultrasound 1 The role of EUS in the diagnosis 2 3 The role of EUS in the treatment 3 Conclusion5 4 6 hinhanhykhoa.com hinhanhykhoa.com 1. SUBMUCOSA TUMORS hinhanhykhoa.com 1. SUBMUCOSA TUMORS • Approximately 1 in 300 patients. • Diagnosed by endoscopy. • EUS: location, layer, size, contour, echogenicity, vascularity. - Follow up - Accuracy: 90%. 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. 1.Kazuya Akahoshi (2012),Practical Handbook of Endoscopic Ultrasonography. hinhanhykhoa.com SUBMUCOSA TUMORS CYST 2. GASTROINTESTINAL CANCER Staging Prognosis Observe of chemo- radiotherapy EUS hinhanhykhoa.com THE ROLE OF EUS IN TMN STAGING TMN T N EUS - FNA M Accuracy: 74- 92% ACCURACY OF EUS v. CT BY STAGE OF ESOPHAGEAL CANCER 0 20 40 60 80 100 EUS CT S t a g i n g A c c u r a c y ( % ) T1 or T2 T3 T4 N0 N1 hinhanhykhoa.com ACCURACY OF EUS v. CT IN THE STAGING OF GASTRIC CANCER 85 78 42 48 0 10 20 30 40 50 60 70 80 90 T STAGE N STAGE EUS CT ESOPHAGUS CANCER T3N1Mx hinhanhykhoa.com 3. COMMON BILE DUCT STONE Ultrasound CT-Scanner ERCP MRCP DIAGNOSIS EUS EUS v. MRCP IN THE DIAGNOSIS CBDs EUS 100% 95.4% 90.9% 100% 96.9% RCP EUS (%) MRCP (%) Sensitivity 100 100 Specificity 95,4 72,7 Positive predictive value 90,9 62,5 Negative predictive value 100 100 Accuracy 96,9 82,2 De Ledinghen V GIE 1999 hinhanhykhoa.com 4. CHRONIC PANCREATITIS Chronic pancreatitis Morphology Function Difficulties Early chronic pancreatitis hinhanhykhoa.com DIAGNOSIS OF CHRONIC PANCREATITIS
Diagnosis of chronic pancreatitis on EUS Conventional classification Rosemont classification
Rosemont classification detect early chronic pancreatitis. hinhanhykhoa.com 5. PANCREATIC CANCER PANCREATIC CANCER Diagnosis Staging Related pain EUS STAGING OF PANCREATIC CANCER TomislavDragovich, et al. Medscape hinhanhykhoa.com 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 than larger tumors. Jose Manuel Ramia. World J GastrointestOncol 2014 EUS STAGING OF PANCREATIC CANCER EUS – TUMOR VASCULAR INVASION Absence of invasion Irregular vascular wall Vascular invasion hinhanhykhoa.com OBJECTIVES 1 2 Overview of endoscopic ultrasound 1 The role of EUS in the diagnosis 2 3 The role of EUS in the treatment 3 Conclusion5 4 6 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. hinhanhykhoa.com 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. 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 Pancreatic cancer hinhanhykhoa.com EUS-FNA 2. EUS DRAINAGE EUS-Guided Pancreatic Pseudocyst Drainage EUS guided Cholangiography and drainage. hinhanhykhoa.com EUS-Guided Pancreatic Pseudocyst Drainage Pseudocyst No symptom Follow up Symptom Therapy • 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 hinhanhykhoa.com 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 endoscopic 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 hinhanhykhoa.com EUS guided Pancreatico- billiary drainage EUS guided hepaticogastrostomy hinhanhykhoa.com EUS guided choledochoduodenostomy EUS guided choledochoduodenostomy hinhanhykhoa.com 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 hinhanhykhoa.com 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 • Situations when Papillary access is not possible (Post op situations, Tight PD stricture) • 75-80% success (Francois, Giovannini, Deviere (2002, 2005) hinhanhykhoa.com Gastrointest Endosc 2011;73:267-74Gastrointest 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) hinhanhykhoa.com • 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. CONCLUSION THANK YOU AND HAPPY NEW YEAR! hinhanhykhoa.com