Interventional EUS for Pancreatobiliary Disordersmedicine.med.miami.edu/documents/InterventionalEUSforPancreatobiliary... · Interventional EUS for Pancreatobiliary Disorders Cyrus

Interventional EUS for Pancreatobiliary Disorders

Cyrus Piraka MDAssistant Professor Gastroenterology

Director of EndoscopyUniversity of Miami Hospital

Miami FL

Objectives

bull Understand and identify the role of Endoscopic Ultrasound (EUS) in diagnosis of pancreatobiliarydisorders ndash Where is EUS helpfulndash EUS pancreatobiliary anatomyndash Types of EUS scopes

bull Understand where EUS is used for therapy in pancreatobiliary disordersndash EUS‐directed therapyndash EUS complementing ERCPndash As an alternative to surgery and IR

Intro to EUS ndash Anatomy

bull What can we see and accessndash Entire pancreas

ndash Entire extrahepatic bile duct and bifurcation

ndash Left liver and much of the right liver

ndash Ampulla

ndash Adrenals bull Left is easier than right to access

NodesbullCeliacbullPeripancreaticbullPerigastricgastrohepaticbullHilum of liverbullMediastinal

Associated vesselsbullAorta and celiac trunkbullSuperior mesenteric artery and veinbullSplenic artery and veinbullHepatic artery left gastric artery and gastroduodenal arterybullPortal vein and confluencebullRenal arteries and veins

From Feldman Sleisenger amp Fordtrans Gastrointestinal and Liver Disease 8th edCopyright copy 2006 Saunders An Imprint of Elsevier

EUS ndash Scope types

bull Radial ndash more intuitive better for lumpsbumps and for esophagusrectum but cannot FNA

bull Linear ndash better for pancreatobiliary tree can perform FNA and injectionwire passage

bull Probe ndash through a therapeutic scope can access small spaces and evaluate biliary or pancreatic duct but limited depth of penetration and cannot FNA

Equipment ndash Radial EUS

Pros

bull 360 degree image

bull Cross‐sectional imaging

bull Better for mucosalsubmucosalimaging

Consbull Cannot as easily do therapy

bull Image quality not as good as linear

Source Olympus

Equipment ndash Linear EUS

Pros

bull High quality image

bull Can do directed therapybiopsies

bull Has elevator (like ERCP)

Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely

visualize mucosasubmucosa

Source Olympus

Equipment ndash AccessoriesToys

bull Mini‐probendash Intraductal ultrasound

ndash Evaluate stricture

Source Olympus

EUS ndash Basic Diagnostics

bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma

EUS ndash Basic Diagnostics

bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence

EUS in pancreatobiliary disorders ndashdiagnostic uses

bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis

ndash Look for biliary sludgestone and biliary dilation

ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD

ndash Look for ampullary polypcancer

bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances

EUS in pancreatobiliary disorders ndashdiagnostic uses

bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation

bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode

ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node

ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance

ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis

EUS in pancreatitis ‐ Diagnostic

bull Immediatendash Identification of bile duct stone in GS pancreatitis

bull Delayedndash Identify cause (especially in recurrent AP)

bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion

ndash Identify complications (pseudocyst)

Wilcox et al GIE 2006

Necrotic Pseudocyst ‐ EUS

EUS in pancreatitis ‐ Diagnostic

bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm

bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis

EUS in pancreatobiliary disorders ndashdiagnostic uses

bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones

ndash Look for strictures

ndash Look for dilated duct

bull Surveillance in family history of pancreatic cancer

Cancer

bull Diagnosis ndash FNAbull Staging

ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac

arterybull 4 ndash hits superior mesenteric artery or celiac artery

ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes

ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study

Cysts

bull May be pre‐malignantndash Mucinous cysts

bull IPMN

bull Mucinous cystadenoma

bull Cystadenocarcinoma

bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma

ndash Pseudocyst

Cysts

bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms

bull Weight lossbull Abdominal painbull Recurrent pancreatitis

EUS ndash Interventional

bull Celiac plexus block and neurolysisndash Pancreatic cancer

ndash Other intra‐abdominal cancer

ndash Chronic pancreatitis

ndash Chronic abdominal pain

Source top5pluscom

EUS ‐ Therapeutic

bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy

bull Abscess drainage

bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy

ndash Irrigation with nasocystic drain or via scope

ndash Debridement with Dormia basketother tools

EUS single step pseudocyst drainage

Other ‐ Therapeutic

bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)

bull Choledochoduodenostomybull Gastropancreatic stenting

ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy

Case

bull 54 yo man ho alcohol abuse

bull Admitted with one week of epigastric pain radiating to the back

bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred

bull Jejunal feeds continues sxs improved

ERCP ndash biliary stricture chronic pancreatitis no leak

bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm

bull CT angio excluded pseudoaneurysm

bull EUS pseudocyst gastrostomy performed

Pseudocyst

Pseudocyst ‐ EUS

Needle and wire ‐ fluoro

Balloon dilation of tract

Pseudocyst gastrostomy

4 weeks post‐procedure

bull 5 weeks later readmitted for abdominal pain and nv

bull ERCP ndash PD leak stented

PD leak

Follow‐up ndash leak resolved ongoing CBD stricture tx

Case

bull 60 yo man non‐alcoholic with single episode of pancreatitis

bull Weight loss

Cancer ‐ EUS

Pancreatic cancer nodes

Conclusions

bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders

bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders

Bibliography

bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797

bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6

bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5

bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92

bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175

bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45