JoséCelso Ardengh -...

ECOENDOSCOPIA: ECOENDOSCOPIA:

DiagnDiagnóóstica e Terapêutica stica e Terapêutica

JosJoséé Celso ArdenghCelso Ardengh

IndicaIndicaçções da Ecoendoscopiaões da Ecoendoscopia

InvestigaInvestigaçção de Lesão Subepitelial ão de Lesão Subepitelial

Krstic M, Pesko P, Pavlovic A, Tomic D, Micev M, Krstic S, Lausevic Z, Jovanovic D, Spuran M. The role of endoscopic ultrasound (EUS) in differential diagnosis of

subepithelial esophago-gastric lesions. Acta Chir Iugosl. 2005;52:101-8.

Motoo Y, Okai T, Ohta H, Satomura Y, Watanabe H, Yamakawa O, Yamaguchi Y, Mouri I, Sawabu N. Endoscopic ultrasonography in the diagnosis of extraluminal

compressions mimicking gastric submucosal tumors. Endoscopy. 1994;26:239-42

Rosch T, Kapfer B, Will U, Baronius W, Strobel M, Lorenz R, Ulm K, German EUS Club Endoscopic Ultrasonography. Accuracy of endoscopic ultrasonography in

upper gastrointestinal submucosal lesions: a prospective multicenter study. Scand J Gastroenterol. 2002;37:856-62.

Compressão extrCompressão extríínseca X LSEnseca X LSE

EstEstáádio do Câncer do TGIdio do Câncer do TGI

May A, Gunter E, Roth F, Gossner L, Stolte M, Vieth M, Ell C. Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high

resolution endosonography: a comparative, prospective, and blinded trial. Gut. 2004;53:634-40.

Vazquez-Sequeiros E, Wiersema MJ, Clain JE, Norton ID, Levy MJ, Romero Y, Salomao D, Dierkhising R, Zinsmeister AR. Impact of lymph node staging on

therapy of esophageal carcinoma. Gastroenterology. 2003;125:1626-35.


Chu KM, Kwok KF, Law S, Wong KH. A prospective evaluation of catheter probe EUS for the detection of ascites in patients with gastric carcinoma.

Gastrointest Endosc.2004;59:471-4.

Ginès A, Pellisé M, Fernández-Esparrach G, Soria MT, Mata A, Membrillo A, Martinez-Palli G, Sole MM, Llach J, Bordas JM, Pique JM. Endoscopic-ultrasonogra-

phy in patients with large gastric folds at endoscopy and biopsies negative for malignancy: predictors of malignant disease and clinical impact. Am J

Gastroenterol. 2006;101:64-9.


FischBach W, Dragosics B, Kolve-Goebeler ME, Ohmann C, Greiner A, Yang Q, The German-Austrian Gastrointestinal Lymphoma Study Group. Primary gastric

B-cell lymphoma: results of a prospective multicenter study. Gastroenterology. 2000;119:1191-202.

Nobre-Leitão C, Lage P, Cravo M, Cabecadas J, Chaves P, Alberto-Santos A, Correia J, Soares J, Costa-Mira F. Treatment of gastric MALT lymphoma by

Helicobacter pylori eradication: a study controlled by endoscopic ultrasonography. Am J Gastroenterol. 1998;91:732-6.

Câncer do PâncreasCâncer do Pâncreas

•Legmann P, Vignaux O, Dousset B, Baraza AJ, Palazzo L, Dumontier I, et al. Pancreatic tumors: comparison of dual-phase helical CT and endoscopic

sonography. AJR Am. J. Roentgenol. 1998;170:1315-22. •**Volmar KE, Vollmer RT, Jowell PS, Nelson RC, Xie HB. Pancreatic FNA in 1000 cases: a comparison of imaging modalities. Gastrointest Endosc. 2005

Jun;61(7):854-61.

Câncer do PâncreasCâncer do Pâncreas

*Aslanian H, Salem R, Andersen D, Robert M, Topazian M. EUS diagnosis of vascular invasion in pancreatic cancer: surgical and histologic correlates. Am

J Gastroenterol. 2005 Jun;100(6):1381-5.

EstEstáádio (TNM)dio (TNM)

Ardengh JC, Malheiros CA, Pereira V, Coelho DE, Coelho JF, Rahal F. Endoscopic ultrasound-guided fine-needle aspiration using helical computerized

tomography for TN staging and vascular injury in operable pancreatic carcinoma. Journal of the Pancreas 2009;10:310-7

EstEstáádio (TNM)dio (TNM)


Harewood GC. Assessment of publication bias in the reporting of EUS performance in staging rectal cancer. Am J Gastroenterol. 2005;100:808-16.

DiagnDiagnóósticostico

Thorboll J, Vilmann P, Jacobsen B, Hassan H. Endoscopic ultrasonography in detection of cholelithiasis in patients with biliary pain and negative transabdominal

ultrasonography. Scand J Gastroenterol. 2004;39:267-9.

Ardengh JC. Pancreatite Aguda sem causa Aparente. In: Ecoendoscopia na Prática da Gastroenterologia. SARVIER, 2007; 345-62.

Napoleon B, Dumortier J, Keriven-Souquet O, Pujol B, Ponchon T, Souquet JC. Do normal findings at biliary endoscopic ultrasonography obviate the need for endoscopic

retrograde cholangiography in patients with suspicion of common bile duct stone? A prospective follow-up study of 238 patients. Endoscopy. 2003;35:411-5.

Lachter J, Kornizki J, Ardengh JC. Cálculos da Via Biliar Principal. In Ecoendoscopia na Prática da Gastroenterologia. SARVIER 2007; 382-402.

DiagnDiagnóósticostico

Wallace MB, Kennedy T, Durkalski V, Eloubeidi MA, Etamad R, Matsuda K, Lewin D, Van Velse A, Hennesey W, Hawes RH, Hoffman BJ. Randomized

controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy. Gastrointest Endosc. 2001;54:441-7.

Thuler FP, Costa PP, Paulo GA, Nakao FS, Ardengh JC, Ferrari AP. Endoscopic ultrasonography and alcoholic patients: can one predict early

pancreatic tissue abnormalities? Jop 2005;6(6):568-74.

Pancreatite CrônicaPancreatite Crônica

Pancreatite Crônica X CâncerPancreatite Crônica X Câncer

Ardengh JC, Lopes CV, Campos AD, Pereira de Lima LF, Venco F, Modena JL. Endoscopic ultrasound and fine needle aspiration in chronic pancreatitis:

differential diagnosis between pseudotumoral masses and pancreatic cancer. Jop 2007;8(4):413-21.

Tumor CTumor Cíístico do Pâncreasstico do Pâncreas

Brugge WR, Lewandrowski K, Lee-Lewandrowski E, Centeno BA, Szydlo T, Regan S, del Castillo CF, Warshaw AL. Diagnosis of pancreatic

cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology. 2004;126:1330-6.

Tumor CTumor Cíístico do Pâncreasstico do Pâncreas

PunPunçção Aspirativa com ão Aspirativa com

Agulha FinaAgulha Fina

Ardengh JC, Lopes CV, de Lima LF, de Oliveira JR, Venco F, Santo GC, et al. Diagnosis of pancreatic tumors by endoscopic ultrasound-guided fine-

needle aspiration. World J Gastroenterol 2007;13(22):3112-6.

Tumor STumor Sóólido do Pâncreaslido do Pâncreas

Carcinoma acinar neuroendócrino

Não funcionante

Tumor STumor Sóólido do Pâncreaslido do Pâncreas

Sensibilidade Acurácia

Geral (611) 78,4 % 87,2 %

TU< 3,0 cm (225) 82,4 % 87,8 %

TU>3,0 cm (180) 78,8 % 83,1 %

Cistos (206) 72,2 % 92,2 %

Ardengh JC, Lopes CV, de Lima LF, de Oliveira JR, Venco F, Santo GC, et al. Diagnosis of pancreatic tumors by endoscopic ultrasound-guided fine-

needle aspiration. World J Gastroenterol 2007;13(22):3112-6.

NeurNeuróólise do plexo cellise do plexo celííacoaco


NPCb NPCc

N 89 71

Acurácia (95% i.c.) 70.4% (61-80%) 45.9% (32.7-57.4%)

Sahai AV et al. Am J Gastroenterol 2009;104:326-9.

30 dias 60 dias 90 dias

Controle da dor 88.4% 87% 74%


N Pâncreas (uT4N1M1)N Pâncreas (uT4N1M1)

PAAF + Neurólise PC

Escleroterapia guiada por EEEscleroterapia guiada por EE

Romero-Castro R, et al. Gastrointest Endosc 2007;66:402-7

de Paulo GA & Ardengh JC. Gastrointest Endosc 2006;63:396-402

EE-Esc EGD-Esc P

N pacientes 24 24 -

Seguimento médio (m) 22,6 + 6,9 22,6 + 6,9 -

No de sessões 4,1 + 1,2 4,3 + 1,5 0.52

Esclerosante (ml) 22,2 19,7 -

Sucesso 100% 96% -

Tempo de erradicação 59,2 + 18,7 63,2 + 21,7 0.50

Complicações

Dor (%) 16,6 8,6 0.67

Sangramento (%) 4,2 16,7 0.35

Recurrencia (%) 16,7 8,3 0.32


Primeiro exame Escleroterapia



Depois da erradicação



InjeInjeçção ecoguiada deão ecoguiada de

etanol e paclitaxel etanol e paclitaxel Resultados n %

Sucesso 13/14 92.8

Complicações

Dor abdominal 1/14 7.1

Pancreatite aguda 1/14 7.1

Hiperamilasemia 6/14 42.8

Resolução do cisto

Completa 11/14 78.5

Parcial 2/14 14.2

Persistência do cisto 1/14 7.1

Sucesso 13/14 92.8

Oh HC, et al. Gastrointest Endosc 2008;67:636-42

Wallace MB, et al. Gastrointest Endosc. 2000 (W 1234)

InserInserçção de marcadores ão de marcadores

radioativos para braquiterapiaradioativos para braquiterapia

AspiraAspiraçção Ecoguiadaão Ecoguiada

Ardengh JC, et al. Dig Dis 2008;26:370-6

Comparativo EE X EndoscopiaComparativo EE X EndoscopiaEndoscópica Ecoguiada p

Pacientes (n = 49)/ 53 drenagens 25 28

Abscesso ou necrose 2/25 10/28 0,016

Sucesso (%) 56 96 <0,001

Próteses inseridas (média) 1 3 <0,001

Taxa de resolução (%) 81 42 <0,003

Complicações (%) 28 7 0,04

Poley et al. Gastrointest Endosc. 2006 DDW (W1320)

Tratamento do PseudocistoTratamento do Pseudocisto

AspiraAspiraçção e Drenagem Ecoguiadaão e Drenagem Ecoguiada

Ardengh JC, et al. Dig Dis 2008;26:370-6

Jan/02 - Dec/05 Grupo I* Grupo II** Total P

Pacientes (n) 44 33 77 -

Total de procedimentos 50 41 91 -

Tamanho (mm) 48 28 -- <0,001

Sucesso (%) 84 100 90.9 -

Vol. médio (ml) -- 25 (18-65) -- -

Complicações (%) 9 0 9 <0,001

Recorrência (%) 4,5 18,1 22,6 <0,001

*Prótese de 10F; ** Aspiração (agulha de 19G); Follow-up = 64 +15,6 sem.

AspiraAspiraçção de pseudocistoão de pseudocisto

Drenagem EcoguiadaDrenagem Ecoguiada

Drenaje EcoguiadaDrenaje Ecoguiada

Autor (ano) n Sucesso (%)

Pfaffenbach (1998) 11 91,0

Giovannini (2001) 35 90,0

Vosoghi (2002) 14 93,0

Seewald (2005) 13 76,9

Kahaleh (2006) 99 84,0

Hookey (2006) 116 87.9

Weckman (2006) 170 86.1

Kruger (2006) 35 88,0

Seewald (2006) 8 100

Ahlawat (2006) 11 82,0

Autor (ano) n Sucesso (%)

Charnley (2006) 13 69,0

Lopes (2007) 51 94,0

Papachristou (2007) 53 81,0

Voermans (2007) 25 93,0

Lopes (2008) 31 93,5

Ardengh (2008) 77 90.9

Hocke (2008) 30 83.4

Varadarajulu (2008) 29 100

Ang (2009) 15 100

Ang et al. J Digest Dis. 2009; 10(3):213-24

Abscesso RetalAbscesso Retal

Giovannini M, et al. Endoscopy 2003;35:511-4


Agulha Prótese


Antes da drenagemAntes da drenagem ApApóós a drenagems a drenagem

Abscesso de PâncreasAbscesso de Pâncreas

Necrosectomia EcoguiadaNecrosectomia Ecoguiada

N %

Total de pacientes 8 --

Tempo médio da 1ª intervenção 33d (17-62d) --

Falência por sepsis 2/8 25

Sucesso 8/8 100

Média de sessões 4 (2-6) --

Cirurgia 2/8 25

Óbito 1/2 50

Melhora clínica 6/8 75

Follow-up médio 12 m (8-60m)

Schrover IM, et al. Pancreatology 2008;8:271-6

Necrosectomia EcoguiadaNecrosectomia Ecoguiada

Drenagem EcoguiadaDrenagem Ecoguiada

Kahaleh M, et al. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest

Endosc 2006;64:52-9

Drenagem biliar ecoguiadaDrenagem biliar ecoguiada

Kahaleh M, et al. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest

Endosc 2006;64:52-9

Colangiografia EcoguiadaColangiografia Ecoguiada

ColedocoduodenostomiaColedocoduodenostomia

InserInserçção de prão de próótesesteses

HepaticogastrostomiaHepaticogastrostomia

Drenagem Ecoguiada Drenagem Ecoguiada

BiliopancreBiliopancreááticatica

n Intervenções Sucesso técnico Sucesso Clínico Complicações Reintervenções Follow-up

Kahaleh, 2006 28 -- 82% 91.3% 17,3% -- 6m

Will, 2007 8 10 90% 88.9% 12,5% 20% 1 a 360m

Brauer, 2009 20 90% 70.0% 10.0% 7% 6m

Park do, 2009 14 100% 100% 14,2% 7% 6m

Total

Global

70 -- 90.5% 87.5% 13.5% 11.3% 94m

Kahaleh M, et al. Interventional EUS-guided cholangiography: evaluation of a technique in evolution.

Gastrointest Endosc 2006;64:52-9

Park do H, et al. EUS-guided biliary drainage with one-step placement of a fully covered metal stent for

malignant biliary obstruction: a prospective feasibility study. Am J Gastroenterol 2009;104:2168-74

Will U, et al. Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-

guided transluminal biliary drainage. Endoscopy 2007;39:292-5

Brauer BC, et al.EUS-guided cholangiopancreatography for difficult pancreaticobiliary access (with video).

Gastrointest Endosc 2009;70:471-9

Pancreatografia EcoguiadaPancreatografia Ecoguiada

Estenose de anastomoseEstenose de anastomose

(Whipple)(Whipple)

PancreaticogastrostomiaPancreaticogastrostomia

Pancreaticogastrostomia Pancreaticogastrostomia

EcoguiadaEcoguiada

n Sucesso técnico Sucesso Clínico Complicações Follow-up

Kahaleh, 2007 13 76.9% 100% 15.3% 14m

Tessier , 2007 36 91.6% 69% 5.5% 14.5m

Will, 2007 12 69.0% 69% 42.9% 4 s – 3 a

Total Global 61 79.1% 79.3% 21.2% 93m

Kahaleh M, et al. EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible

pancreatic ducts. Gastrointest Endosc 2007;65:224-30.

Tessier G, et al. EUS-guided pancreatogastrostomy and pancreatobulbostomy for the treatment of pain in

patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy. Gastrointest

Endosc 2007;65:233-41

Will U, et al. Transgastric pancreatography and EUS-guided drainage of the pancreatic duct. J

Hepatobiliary Pancreat Surg 2007;14:377-82

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