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Therapeutic endoscopic ultrasonography

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 and neuroendocrine neoplasms 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 [3,4], bilomas [5-7], and infected gallbladders [8-10].

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 still be a challenge.

The technique of EUS-guided drainage involves localization of the pseudocyst via EUS, avoidance of interposed vasculature while directing a 19-gauge needle into the pseudocyst, advancement of a guidewire into the cavity under fluoroscopy (picture 1), transmural balloon dilation (picture 2), and placement of one or multiple plastic stents into the pseudocyst cavity (picture 3 and picture 4).

It is often difficult to place a dilating balloon catheter across the stomach wall without first creating a fistulous tract with a push dilating catheter, needle-knife, or cystenterotome. Furthermore, the oblique view from a linear echoendoscope makes endoscopic visualization more difficult than a standard side-viewing duodenoscope. As a result, EUS-guided drainage from the duodenum can be technically challenging. Ongoing development of forward-viewing and side-viewing echoendoscopes may improve these technical limitations and improve endoscopic visualization. (See "Endoscopic management of pseudocysts of the pancreas: Efficacy and complications" and "Endoscopic management of pseudocysts of the pancreas: Technique".)
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