REVIEW Therapeutic endoscopic ultrasoundTo cite: Venkatachalapathy S, Nayar MK. Frontline...
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REVIEW Therapeutic endoscopic ultrasound Suresh Venkatachalapathy, 1 Manu K Nayar 2 1 Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK 2 HPB Unit, Freeman Hospital, Newcastle Upon Tyne, UK Correspondence to Dr Manu K Nayar, Hepato- Pancreato-Bilairy Unit, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; [email protected] Received 5 November 2016 Revised 13 December 2016 Accepted 15 December 2016 To cite: Venkatachalapathy S, Nayar MK. Frontline Gastroenterology 2017;8:119–123. ABSTRACT Endoscopic ultrasound (EUS) is now firmly established as one of the essential tools for diagnosis in most gastrointestinal MDTs across the UK. However, the ability to provide therapy with EUS has resulted in a significant impact on the management of the patients. These include drainage of peripancreatic collections, EUS-guided endoscopic retrograde cholangiopancreatogram, EUS-guided coeliac plexus blocks, etc. The rapid development of this area in endoscopy is a combination of newer tools and increasing expertise by endosonographers to push the boundaries of intervention with EUS. However, the indications are limited and we are at the start of the learning curve for these high-risk procedures. These therapies should, therefore, be confined to centres with a robust multidisciplinary team, including interventional endoscopists, radiologists and surgeons. BACKGROUND Endoscopic ultrasound (EUS) was devel- oped as a diagnostic modality in the early 1980s for diagnosis of various gastro- intestinal (GI) benign and malignant con- ditions. It is widely used to diagnose/ stage malignancies and acquire tissue for diagnosis from pancreas, biliary tree, liver and mediastinum. It has now become an integral part of patient management in multidisciplinary teams across the UK. However, in the last decade, it has rapidly gained a role for providing therapy. Close proximity and relatively safe access to GI and retroperitoneal structures provide opportunity for min- imally invasive treatment of various con- ditions which would otherwise have been treated with other forms of intervention, that is, surgery or interventional radiology. Due to the wide range of applications, the remit of this paper is to summarise the therapeutic applications of EUS and discuss the future of interventional EUS including training. EUS-GUIDED DRAINAGE OF INTRA-ABDOMINAL COLLECTIONS Drainage of peripancreatic fluid collections Pancreatic fluid collections (PFCs) develop due to injury to the pancreatic duct in acute or chronic pancreatitis. PFCs are divided into acute peri-PFCs, pancreatic pseudocyst, acute necrotic col- lection and walled-off necrosis (WON). Pseudocysts and WON usually develop after 4 weeks and if the patient is symp- tomatic, they would benefit from inter- vention, that is, drainage which could be surgical, percutaneous or endoscopic route. Historically, PFCs were drained through surgical cyst gastrostomy and percutaneous drainage either under CT or ultrasound guidance. Endoscopy- guided transmural drainage was first reported in 1975. 1 It involved identifying PFC bulge in the gastric wall and creating a fistulous tract using the Seldinger tech- nique. A guide wire is then advanced in to the cyst cavity, and one or multiple stents were deployed to secure the pos- ition. EUS-guided drainage of pancreatic pseudocyst was first reported in 1992. 2 It allowed the endosonographers to visual- ise the collection without bulge, avoid blood vessels and ensure adequate appos- ition for deployment of the stent and was, therefore, thought to be safer. Since 1992, several studies have reported a success rate of 80%–100% with a complication rate of 10% for pan- creatic pseudocysts. A randomised control trial reported that EUS-guided drainage of PFC is associated with reduced length of stay, low morbidity and mortality when compared with surgical cyst gastrostomy. 3 However, the complication rate rose sig- nificantly from 5% to 30% for infected pseudocysts. 4 On the other hand, drainage of WON plastic stents is associated with lower rates of collection resolution and higher adverse event rates. This has been ENDOSCOPY Venkatachalapathy S, Nayar MK. Frontline Gastroenterology 2017;8:119–123. doi:10.1136/flgastro-2016-100774 119 on September 29, 2020 by guest. Protected by copyright. http://fg.bmj.com/ Frontline Gastroenterol: first published as 10.1136/flgastro-2016-100774 on 10 February 2017. Downloaded from
Transcript of REVIEW Therapeutic endoscopic ultrasoundTo cite: Venkatachalapathy S, Nayar MK. Frontline...
REVIEW
Therapeutic endoscopic ultrasound
Suresh Venkatachalapathy,1 Manu K Nayar2
1Department of Gastroenterologyand Hepatology, NottinghamUniversity Hospitals NHS Trust,Nottingham, UK2HPB Unit, Freeman Hospital,Newcastle Upon Tyne, UK
Correspondence toDr Manu K Nayar, Hepato-Pancreato-Bilairy Unit, FreemanHospital, Freeman Road,Newcastle upon Tyne NE7 7DN,UK; [email protected]
Received 5 November 2016Revised 13 December 2016Accepted 15 December 2016
To cite: Venkatachalapathy S,Nayar MK. FrontlineGastroenterology2017;8:119–123.
ABSTRACTEndoscopic ultrasound (EUS) is now firmlyestablished as one of the essential tools fordiagnosis in most gastrointestinal MDTs acrossthe UK. However, the ability to provide therapywith EUS has resulted in a significant impact onthe management of the patients. These includedrainage of peripancreatic collections,EUS-guided endoscopic retrogradecholangiopancreatogram, EUS-guided coeliacplexus blocks, etc. The rapid development of thisarea in endoscopy is a combination of newertools and increasing expertise byendosonographers to push the boundaries ofintervention with EUS. However, the indicationsare limited and we are at the start of thelearning curve for these high-risk procedures.These therapies should, therefore, be confined tocentres with a robust multidisciplinary team,including interventional endoscopists, radiologistsand surgeons.
BACKGROUNDEndoscopic ultrasound (EUS) was devel-oped as a diagnostic modality in the early1980s for diagnosis of various gastro-intestinal (GI) benign and malignant con-ditions. It is widely used to diagnose/stage malignancies and acquire tissue fordiagnosis from pancreas, biliary tree, liverand mediastinum. It has now become anintegral part of patient management inmultidisciplinary teams across the UK.However, in the last decade, it hasrapidly gained a role for providingtherapy. Close proximity and relativelysafe access to GI and retroperitonealstructures provide opportunity for min-imally invasive treatment of various con-ditions which would otherwise have beentreated with other forms of intervention,that is, surgery or interventionalradiology.Due to the wide range of applications,
the remit of this paper is to summarisethe therapeutic applications of EUS anddiscuss the future of interventional EUSincluding training.
EUS-GUIDED DRAINAGE OFINTRA-ABDOMINAL COLLECTIONSDrainage of peripancreatic fluid collectionsPancreatic fluid collections (PFCs)develop due to injury to the pancreaticduct in acute or chronic pancreatitis.PFCs are divided into acute peri-PFCs,pancreatic pseudocyst, acute necrotic col-lection and walled-off necrosis (WON).Pseudocysts and WON usually developafter 4 weeks and if the patient is symp-tomatic, they would benefit from inter-vention, that is, drainage which could besurgical, percutaneous or endoscopicroute.Historically, PFCs were drained
through surgical cyst gastrostomy andpercutaneous drainage either under CTor ultrasound guidance. Endoscopy-guided transmural drainage was firstreported in 1975.1 It involved identifyingPFC bulge in the gastric wall and creatinga fistulous tract using the Seldinger tech-nique. A guide wire is then advanced into the cyst cavity, and one or multiplestents were deployed to secure the pos-ition. EUS-guided drainage of pancreaticpseudocyst was first reported in 1992.2 Itallowed the endosonographers to visual-ise the collection without bulge, avoidblood vessels and ensure adequate appos-ition for deployment of the stent andwas, therefore, thought to be safer.Since 1992, several studies have
reported a success rate of 80%–100%with a complication rate of 10% for pan-creatic pseudocysts. A randomised controltrial reported that EUS-guided drainageof PFC is associated with reduced lengthof stay, low morbidity and mortality whencompared with surgical cyst gastrostomy.3
However, the complication rate rose sig-nificantly from 5% to 30% for infectedpseudocysts.4
On the other hand, drainage of WONplastic stents is associated with lowerrates of collection resolution and higheradverse event rates. This has been
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traditionally performed with the insertion of double-pigtail stents and subsequent necrosectomies.However, the patients needed more repeat proceduresfor complete resolution of the necrotic cavity.5 Newerfully covered self-expanding metals stents (FCSEMS)and lumen-apposing metal stents (LAMS) have nowbeen used for the drainage of PFCs (figure 1).Huggett et al6 reported the use of a novel double
flanged type of FCSEMS in 19 patients with WONand concluded that the use of this stent is feasible andsafe for the drainage of WON. However, stent dis-placement rates were high, and improvements to thestent design were required before it could be advo-cated for routine use in WON.A newer LAMS has been used for the drainage of
WON due to its antimigratory properties. A retro-spective analysis of 124 patients who had endoscopicdrainage of WON by using LAMS concluded that it issafe and highly effective minimally invasive treatmentmodality for these patients.7
In conclusion, it appears that the minimally invasiveapproach is associated with an overall decreased mor-tality rate, fewer major and long-term complicationscompared with surgery, especially in patients withpseudocysts. However, we need more data on cost-effectiveness and randomised trials to firmly establishthe role of metal stents in WON.
Gall bladder drainageCholecystectomy is the treatment of choice in patientswith acute cholecystitis. However, in certain group ofpatients, this is not an option due to multiplecomorbidities. Traditionally, these patients have beentreated with either a permanent percutaneous drain ora cystic duct biliary stent until the patients are fit forsurgery. Since it was first reported in 2007, there havebeen a number of small case series on this form ofintervention.8 The recent introduction of LAMS hasfacilitated ease of insertion (figure 2A, B).9 However,this continues to be a rare indication which should
only be considered after careful discussion in a MDMsetting.
Other intraabdominal collectionsThere have also been case reports/series on the drain-age of hepatic abscesses, bilomas, subphrenic andpelvic abscesses.10 These are very rare indications forEUS-guided therapy.
EUS-GUIDED BILIARY DRAINAGEEndoscopic retrograde cholangiopancreatogram(ERCP) is a widely accepted mode of establishingbiliary drainage. However, it is not always possible toachieve biliary drainage in 3%–5% of patients becauseof malignant duodenal obstruction, awkward ampul-lary position or presence of a diverticulum.Percutaneous transhepatic cholangiogram (PTC) is theestablished alternative to gain access into the bileduct. A retrospective UK study on 16 363 patientsassessing the outcomes of PTC for the palliative reliefof malignant jaundice reported that PTC is associatedFigure 1 Endoscopic necrosectomy.
Figure 2 Endoscopic ultrasound-guided gall bladder drainage—lumen apposing metal stents in GB—endoscopic view and CTview—8 days after insertion.
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with a high morbidity and mortality (30-day mortality23%). The emergency readmission rate following theprocedure was 20% and 35% experienced seriousadverse event.11 EUS-guided biliary drainage seems tobe an alternative method in achieving biliary drainagein patients who failed ERCP or who are unfit forradiological intervention.The three options include:1. EUS-guided biliary drainage—transduodenal—for distal
biliary strictures.2. EUS-guided biliary drainage—transgastric—for proximal
biliary strictures, accessed through the left lobe of theliver (figure 3A, B).
3. EUS-guided rendezvous—for patients who have diver-ticulum or the ampulla is not clearly visible.
A recent systematic review of 42 studies involving1192 patients, assessing the safety and efficacy ofEUS-guided biliary drainage, reported a cumulativetechnical success rate of 95%, functional success rateof 92% and complication rate of 23%. There was nosignificant difference in the technical success rate andadverse event rate between transduodenal and trans-gastric approach.12 The common adverse events arebleeding, bile leakage, pneumoperitoneum, stentmigration and cholangitis.EUS-guided biliary drainage provides an alternative
to drain biliary tree but despite its success rates, highmorbidity such as bile leak, perforation and pneumo-peritoneum exists. Hence, these patients should becarefully assessed and should be managed by a multi-disciplinary team and should be performed only byexperts skilled in both EUS and ERCP.13 In addition,this mode of intervention should not be an alternativein units with a poor ERCP cannulation rates.
EUS-GUIDED COELIAC PLEXUS NEUROLYSIS/BLOCK)Coeliac plexus neurolysis (CPN) has been done underEUS guidance, and it has advantage over percutaneousapproach because the scope can be placed close to thecoeliac axis which facilitates coeliac plexus localisa-tion. This helps to place the needle accurately andenhances the spread of injection. A meta-analysis ofnine studies involving 221 patients reported that inpatients with inoperable pancreatic cancer EUS-guidedCPN alleviates pain in 70%–80% of patients at8 weeks. The pain relief was higher in patients whoreceived injections on both sides of coeliac artery. Inpatients with chronic pancreatitis, the pain relief was50%–60% at 8 weeks. In clinical practice, the painrelief is not permanent and it recurs after 8–12 weeks,and therefore it is important to involve the pain teamin the early stages to optimise pain before consideringCPB.14
EUS-GUIDED TREATMENT OF TUMOURSEUS allows accurate targeting for the delivery ofvarious substances directly into pancreas, liver or sub-epithelial lesions.EUS-guided fine-needle injection (FNI) has been
reported for the treatment of GI stromal tumours,insulinomas, hepatic metastases, oesophageal cancer,cystic neoplasms of the pancreas and pancreaticadenocarcinoma.Various biological antitumour agents have been
introduced into pancreatic and oesophageal cancersunder EUS-guided FNI for control of locally advanceddisease. Although long-term results are not wellstudied, preliminary results suggest that theseapproaches are generally safe and may prove to be anadjunct or alternative to traditional chemoradiationtherapies.
Figure 3 Endoscopic ultrasound (EUS)-guidedhepaticogastrostomy—EUS-guided cholangiogram andEUS-guided stent insertion of the intrahepatic ducts.
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Cyber knife stereotactic radiotherapy has been usedto treat lung, mediastinal and pancreatic tumours. Itdelivers precise directed beams of radiation to thetumour using real-time image guidance. The radio-graphic markers are placed around the tumour eithersurgically or using transabdominal ultrasound.However, EUS-guided fiducial placement for locallyadvanced or recurrent pancreatic cancer seems to bea successful alternative.15 However, this is still in theearly stages of being established as a mode of deliver-ing treatment and is only being used in researchtrials.
EUS IN THE MANAGEMENT OF GI BLEEDINGUpper GI bleeding is a common medical emergencywith a mortality of 10%, and therapeutic endoscopyis the main modality of treatment. In clinical practice,it is sometimes difficult to achieve haemostasis, espe-cially in gastric variceal bleeds. If endoscopy fails,then they are often referred for transjugular intrahepa-tic portosystemic shunt. It is contraindicated inpatients with encephalopathy and right heart failure.EUS may be used as an alternative to achieve haemo-stasis in this group of patients.The utility of EUS in the setting of GI bleeding has
been evaluated in a few small series for specific situa-tions, including refractory bleeding lesions (eg,Dieulafoy’s and pancreatic pseudoaneurysm) andoesophageal and gastric varices.16 However, endos-copy should be the mainstay of treatment as thequality of evidence for EUS-guided therapy is low andmore research is needed to assess the safety andfeasibility.
EUS-GUIDED TISSUE ABLATIONThere is accumulating data on the EUS-guided abla-tion of cystic and solid pancreatic tumours but the useof these techniques should be within research proto-cols until results from larger, prospective clinical trialsare available.
OTHER INDICATIONSThe other indications for interventional EUS, whichare in very preliminary stages, include EUS-guidedfine-needle tattoo injection for small tumours,EUS-guided angiography, EUS-guided Botox injectionand EUS-guided gastroenterostomy.
Training in therapeutic EUSTherapeutic EUS is one of the most advanced formsof GI endoscopy. It needs excellent spatial orientation,dexterity, accurate interpretation of sonographyimages and echoendoscope control. To achieve theabove competencies, one should be competent indiagnostic EUS. It needs dedicated focused training inthe above modalities. In the UK, with the demands ofGI training and acute medicine service provision, it isimpossible to deliver adequate supervised training in
diagnostic EUS, during their 5 years of training.Although there is now a JAG approved format fordiagnostic EUS training, the logistics of providingtraining in therapeutic EUS has not been addressed.
CONCLUSIONTherapeutic applications of EUS have exponentiallyincreased over the past decade due to the introductionof newer accessories and echoendoscopes. In addition,the evidence is slowly gathering the role of interven-tional EUS as the first mode of treatment in certainconditions. This development will continue to growin the coming years with newer techniques and equip-ments in the pipeline. However, many of the applica-tions mentioned in this paper are associated withsignificant risk. It is imperative that these cases are dis-cussed in a multidisciplinary meeting before decidingon the optimum mode of intervention. As training inthese procedures is limited, these should be restrictedto tertiary centres with experienced endoscopists com-petent in EUS and ERCP, HPB surgeons and interven-tional and diagnostic radiologists.
Competing interests None declared.
Provenance and peer review Not commissioned; externallypeer reviewed.
Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
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