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Therapeutic endoscopic ultrasound

Authors
Kenneth E Fasanella, MD
Michael K Sanders, MD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF

INTRODUCTION

Endoscopic ultrasound (EUS) was developed as a diagnostic modality but rapidly gained a role for a variety of therapeutic applications. EUS has been used increasingly for drainage of pancreatic pseudocysts, treatment of cystic lesions of the pancreas, EUS-guided cholangiopancreatography, localized therapy for pancreatic tumors, and treatment of subepithelial lesions and gastric varices.

DRAINAGE PROCEDURES

EUS is well-suited to safely drain fluid collections of various types in areas accessible from the stomach, duodenum, or rectum. The most abundant experience has been with drainage of pancreatic pseudocysts, but case reports have described a variety of drainage procedures, including a hepatic abscess [1], subphrenic abscesses [2], pelvic abscesses [3-5], bilomas [6-8], and infected gallbladders [9-11].

Pseudocysts — The traditional endoscopic approach to transmural drainage of pseudocysts relies on the presence of an intraluminal bulge and/or accurate cross-sectional imaging techniques to detect the location of the pseudocyst and determine the distance between the pseudocyst and gastric wall. Despite this information, avoidance of interposed vasculature can be challenging.

The technique of EUS-guided drainage starts with localization of the pseudocyst with EUS. A 19-gauge needle is then directed into the pseudocyst, with care being taken to avoid interposed vasculature. A guidewire is then introduced into the cavity under fluoroscopy (image 1), followed by transmural balloon dilation of the tract into the pseudocyst (image 2). It is often difficult to place a dilating balloon catheter across the stomach wall. When this occurs, creating a fistulous tract with a push dilating catheter, a needle-knife, or a cystenterostome may aid with balloon placement. Once the tract is dilated, one or more plastic stents are placed into the pseudocyst cavity (picture 1 and picture 2) for drainage.

EUS-guided drainage from the duodenum can be technically challenging because the oblique view from a linear echoendoscope makes endoscopic visualization more difficult than a standard side-viewing duodenoscope. Ongoing development of forward-viewing and side-viewing echoendoscopes may improve these technical limitations and improve endoscopic visualization.

                               

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Literature review current through: Nov 2016. | This topic last updated: Mon Sep 28 00:00:00 GMT+00:00 2015.
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