EUS Guided Treatment: New Frontiers

Michel Kahaleh, M.D. Chief of Endoscopy

Professor of Medicine Division of Gastroenterology and Hepatology

EUS-guided drainage Fine Needle Injection and Ablation

Hemostasis Access

Anastomosis

Current Advances in Interventional Endosonograpy

Background

-Pancreatic fluid collection drainage -Inaccessible Pancreatic or bile duct, next

logical target

-Then GLB -Then Anastomosis

Wiersema MF: Gastrointest Endos 1996 Bataille L: Gastrointest Endosc 2002 Francois E: Gastrointest Endosc 2002

Prerequisites ➢ Cross Sectional Imaging: “Road Map”

➢ Repeat ERCP: “ Expertise”

➢ Skills in ERCP and EUS: “Training”

➢ Multidisciplinary approach: “Backup”

➢ General anesthesia: “Complexity”

Techniques ➢ Prophylactic antibiotherapy ➢ Use CO2 ➢ Linear array instrument (3 mm channel) ➢ Puncture with 19 gauge needle (Preferably) ➢ Placement of a 0.035-inch wire ➢ Dilation with creation a fistula with

-Bougie (6 or 7 Fr) -Balloon (4-6 mm) -Cystenterostome

➢ Placement of a stent with or without rendezvous technique ➢ Transluminal or transpapillary drainage

EUS Guided Biliary Drainage

- Transgastric-transhepatic or Intrahepatic

Burmester E: Gastrointest Endos 2003

EUS Guided Biliary Drainage

Transenteric- transcholedochal or Extrahepatic

Gupta K. Rev Gastroenterol Disord 2007

New ERCP related Procedure

UVA 2008

New Design Stent ?

Choledochoenteral Anastomosis

Case 2

■ 79 y old caucasian lady ■ Ampullary stricture ■ Failed ERCP x 2 ■ Early cholangitis

EUS-Guided Extrahepatic Drainage

EUS-Guided Extrahepatic Drainage

EUS-Guided Extrahepatic Drainage

EUS-Guided Extrahepatic Drainage

RDV

■ Access into D2 or biliary orifice require ■ Snare recommended to extract wire ■ Hydrophilic wire required ■ Dilation or sphincterotomy once access

recommended ■ Multiple plastic stents or metal stent

EUS Guided Drainage: RDV

A comprehensive search of several databases from each database’s earliest inception to November 1st, 2014 The databases included Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Scopus, and PUBMED Studies that reported outcomes of at least 4 EUS-BD procedures.

Results

■ According to the meta analysis of 27 independent cohorts (479 success out of 541) the pooled technical success rate under fixed effects model was 95% (95% CI -93-97)

■ The adverse event rate was 14% (95% CI -11-18).

Results

■ Of the technically successful procedures, the site of biliary drainage was transduodenal (50.3%) and transgastric (48.7%) .

■ The most common adverse event was pneumoperitoneum which constituted 36.7% of the total

EUS Guided Drainage vs. PTBD ?

Artifon E et al : J Clin Gastroenterol 2012;46:768–774

! No difference TB decrease in the two arms. ! Hospitalization time was significatively

shorter in the Arm B (6 days range 3-30 days) than the Arm A (12 days range 2-52 days) p < 0,02.

! Complication rate was higher in the Arm A (60%) vs Arm B (35%)

Limitations

■ Tortuous ducts (failure to advance wire) ■ High grade obstruction ■ Right hepatic duct drainage ??

EUS guided GLB

■ Easy access from stomach or duodenum ■ Allow placement of larger diameter stent ■ Avoid the percutaneous route -------------------------------------------------- ■ Risk of peritonitis ■ Risk of perforation ■ Risk of migration

EUS guided GLB: Series

-8 series -Total of 86 patients -Success between 86-100 % - Complications: 4 Pneumoperitoneum 2 UGI bleeding 1 migration 1 bile peritonitis

EUS-Guided Gallbladder Drainage - Methods

Jang JW, et al. Gastroenterology 2012;142:805-811.

All patients sedated with midazolam/meperidine 19g needle used for puncture Antrum or duodenal bulb – dilate or needle knife 5 French nasobiliary tube

EUS PTH Number treated 30 29 NS Technical success 97% 97% NS Clinical success 100% 96% NS Complications 7% 3% NS Convert to open CCx 9% 12% NS

EUS-Guided Gallbladder Drainage - Results

Jang JW, et al. Gastroenterology 2012;142:805-811.

EUS-Guided Gallbladder Drainage - Results

Jang JW, et al. Gastroenterology 2012;142:805-811.

Median post-procedure pain score significantly lower in the EUS group when compared with the PTH group

-All patients included were deemed unfit for surgery -Lumen apposing stent (AXIOS, Xlumena, CA, USA), draining the gallbladder to the stomach or duodenum

GIE 2015: In press

EUS guided GLB: Key concept

■ Not a replacement for surgery ■ Need cross sectional imaging prior ■ Performance by skilled endoscopist ■ Antimigratory system or pigtail ? ■ Transbulbar vs Transgastric ? ■ Removal or not ? ■ Longevity ?

ACCESS for RYGB

Bypass: EDGE procedure: Step 1

EDGE: Step 1

EDGE Step 2

EDGE step 2

Anastomosis

Training

Conclusions

■ Novel EUS guided procedure are safe and feasible techniques in expert hands

■ Choice between this approach and other -Level of expertise -Access to expertise

Conclusions

■ Progress are needed to permit safer and easier access

■ Further multicenter studies and training are required in order to standardize these techniques

Interventional EUS: Shift in Paradigm?

“The Future is ours, if we are willing to seize it ”

Thank you