|Year : 2021 | Volume
| Issue : 4 | Page : 275-281
Interventional endoscopic ultrasound: An update
Department of Gastroenterology, Institute of Gastrosciences and Liver, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
|Date of Submission||11-Nov-2021|
|Date of Decision||25-Nov-2021|
|Date of Acceptance||29-Nov-2021|
|Date of Web Publication||23-Dec-2021|
Institute of Gastrosciences and Liver, Apollo Multispeciality Hospitals, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Endoscopic ultrasound (EUS) has come a long way in the field of interventional gastroenterology. Majority of the advancements in the field of EUS over the past 20 years has been done by the group of endoscopist who are looking to break the convention. At this time both diagnostic and interventional EUS has become the standard of care in the management of large number pancreatic, biliary, luminal gastro-intestinal, and mediastinal diseases. It is now widely available as the large number of medical institutions, have added it to their endoscopic armamentarium. Scope of interventional EUS in clinical practice is rapidly expanding. Here in the current review, we highlight the key concepts of various interventional EUS procedures like-EUS guided drainage of pancreatic fluid collection; EUS guided vascular therapy; EUS guided enteral anastomosis; EUS guided biliary drainage; Role of EUS in hepatology; EUS guided celiac plexus neurolysis and neurolysis. We also discuss the indications, technical aspects, adverse events, and future directions of each of these procedures. If looking into future, we can predict an evolution of these techniques into an exciting newer horizon in the form of EUS-guided minimally invasive surgery.
Keywords: Biliary drainage, endoscopic ultrasound-guided tumor therapy, interventional endoscopic ultrasound
|How to cite this article:|
Sonthalia N. Interventional endoscopic ultrasound: An update. Apollo Med 2021;18:275-81
| Introduction|| |
For the previous 20 years, endoscopic ultrasound (EUS) has been in use in the field of interventional endoscopy. The development of EUS and its related procedure has resulted in a significant shift towards endoscopic management of complex diseases which was not possible earlier endoscopically. Although these techniques have been reported in the literature long back, with further improvement in techniques and the discovery of new devices there is potential for expanding the application of interventional EUS to a larger group of the endoscopist.
There are few reasons for the slow development of interventional EUS like lack of supervised training, well-designed instruments, and large amount of prospectively published literature. EUS allows trans-luminal assessment of organs within the peritoneal cavity without the need for entering it., It may play a useful role in the field of natural orifice trans-luminal endoscopic surgery (NOTES).
Advancements have been made in various aspects of EUS. However, in this review, we focus on the key concepts in the field of therapeutic EUS. We herein discuss the use of EUS in drainage of pancreatic fluid collections (PFC), its role in celiac plexus blocks (CPBs) and neurolysis, EUS-guided biliary drainage, EUS-guided vascular therapy, EUS-guided anastomosis, and the development of endo-hepatology [Table 1].
|Table 1: The following table summarizes various endoscopic ultrasound guided interventions that are used in clinical practice|
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| Endoscopic Ultrasound Guided Drainage of Pancreatic Fluid Collections|| |
The clinical course of acute pancreatitis as well as chronic pancreatitis (CP) can be complicated by PFC which are classified according to the nature of the content and maturity of the wall surrounding it. The contents of the collections complicating acute pancreatitis generally change with time and the amount of solid necrotic debris also reduces with time. Indications for drainage of PFC are if the collection is symptomatic, resulting in gastric outlet obstruction, biliary obstruction, significant pain or is infected. Depending on the maturity of the wall, duration of disease, clinical condition of the percutaneous approach, surgical approach, endoscopic approach, or combination of them are used to drain these collections.,
At some centers pancreatic pseudocyst drainage is still being done by the endoscopic method. However, there is enough literature to suggest that EUS-guided drainage is always safer and more preferable. At least two randomized clinical trials have shown a better technical and clinical success when using EUS guided approach specifically in collections without intraluminal bulge., EUS-guided drainage is also needed in other clinical conditions like in presence of (a) portal hypertension, (b) large number of collaterals around the collection, and (c) presence of calcification in the wall to select the appropriate site of puncture.,
When comparing EUS guided drainage and only endoscopic drainage, median hospital stay was similar to the two modalities in of the previous studies. Both studies indicated that the procedure time was not significantly different with either of the techniques, however complication rates are significantly less with the EUS-guided approach.
Steps of EUS-Guided drainage: (a) First linear echoendoscope is used which is advanced into the stomach or duodenum. The window is assessed using color Doppler for any loco-regional vascularity. Then, the distance between the gastrointestinal tract wall and the cyst is measured, (b) Then, a 19G EUS fine-needle aspiration (FNA) is used to puncture into the cyst and contents are aspirated for visual assessment and sent for analysis (cultures, amylase, and carcinoembryonic antigen levels), (c) After this, a guidewire is coiled into the cyst cavity and the tract is dilated using a cystotome and balloon. (d) Once the fistula is formed there are various options available for the drainage of PFCs including single or multiple plastic stentings, multistep procedure with initial nasocystic drain followed by placement of stent or insertion of fully covered lumen apposing metal stent (LAMS).
Another important thing to consider is that after the resolution of the collection, when the stents are removed after 3–6 weeks, there may be chances of recurrence. Adequate imaging either by MRCP or EUS is required and then long-term indwelling plastic stents, especially in patients with disconnected duct, placed in these sub-group of patients.
Various advancements include:
- Nonfluoroscopic drainage: Use of Hot-axios system can enable completely nonfluoroscopic drainage. It is a single instrument system where access, dilatation, and deployment are all done without any device exchange completely under EUS guidance
- Multi-gateway technique-Multiple access is sometimes required for a large collection. Different puncture sites are chosen and a combination of plastic stent, LAMS, nasocystic drains are used
- Use of forward-viewing endoscope-Forward viewing echoendoscope may be better in certain antral and duodenal approaches due to its perpendicular position in relation to the collection. A multicenter study showed the use of a forward-viewing echoendoscope for drainage of PFCs had similar technical success rates, mean procedure times, ease of access, and complication rates like the oblique viewing echoendoscope.
| Endoscopic Ultrasound-Guided Coiling and Glue Injection for Gastric Varices|| |
The key advantage of the use of EUS for Gastric varices treatment are (a) detection (b) real-time visualization cessation of flow, (c) lacks dependency on direct varix visualization, which may be impaired by retained food or blood in the stomach, (d) Enables accurate delivery of the hemostatic agent into the varix lumen, (e) avoiding Para variceal injection, which can occur in up to 60% of injections. (f) The main deep “feeder” vessel may be visualized, and (g) Reducing the amount of glue needed.,,
The main indication for EUS-guided treatment of gastric varices is – (a) active or recent bleeding attributed to gastric fundal varices (GFV), (b) high-risk GFV for primary prophylaxis, (c) poor candidates for or previously failed transjugular intrahepatic portosystemic shunt, and (d) patient preference for EUS-guided therapy.,
The coils used are-metal alloy (platinum) and contain radially extending synthetic fibers, which induce clot formation and hemostasis. Coils are 2–15 mm in length and loops are 2–20 mm in diameter. Coil selection is based on the size and diameter of the varix. Coils can be deployed through a 22-gauge needle (0.018” coil) or a 19-gauge needle (0.035” coil). The needle stylet is used to push and deploy the coil into varix.
Advantage of combining glue with coil: (a) the contribution of each method to hemostasis and varix obliteration may be additive; (b) the coil may concentrate the glue at the coil site, thus reducing the glue volume needed for obliteration; (c) the coil can act as a scaffold to retain CYA within varix, thus reducing the risk of embolization.
In a randomized study, the overall obliteration rate achieved was 96.7%; however, 47.4% required repeat therapy in the glue group, whereas 36.4% in the coil group either required additional coil or glue placement. Rate of glue embolization-1/152 or 0.7% in combined group versus 2/19 or 10.5%, in glue only group, respectively.
[Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d shows a large gastric varix treated with EUS guided glue and coil and satisfactory obliteration of varix.
|Figure 1: (a-d) It shows a large gastric fundal varix (a), with endoscopic ultrasound guided coil (arrow) and glue injection done (b). A follow up image after 3 months shows coil in situ (c) and obliteration of varices (d)|
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| Endoscopic Ultrasound Guided Celiac Plexus Block and Neurolysis|| |
The main mechanism of EUS-guided CPB/neurolysis is disruption of signal transmission to the spinal cord and central nervous system, hence interfering with the perception of pain. In neurolysis, the mixture of 0.25% bupivacaine and 98% ethanol are used.
In block mixture of 0.25% bupivacaine and triamcinolone (40 mg/5 ml) is used.
Meta-analysis of 9 studies (376 patients) shows overall efficacy of 59% pain relief (range 50%–80%) in CP. Results are inferior as compared to pancreatic cancer (80% in 283 patients in 8 studies)., Duration of response is variable (range 12–24 weeks). The role of neurolysis is controversial in CP. Factors associated with improved response are not clear. The ESGE recommends considering CPB only as a second-line treatment for pain in CP; EUS-guided CPB should be preferred over percutaneous CPB.
As per ASGE guidelines – (a) EUS-CPB offered to patients with severe pain that markedly impairs their quality of life after failing aggressive, closely monitored pharmacologic therapy. (b) for hospitalized patients with refractory pain.
[Figure 2]a graphical demonstration of EUS needle at the site of celiac plexus and [Figure 2]b shows real-time EUS image with needle at the base of the celiac axis and injection being performed.
|Figure 2: (a) Shows graphic demonstration showing anatomy of celiac plexus, and endoscopic ultrasound needle accurately placed over the celiac plexus. (b) Shows real time endoscopic ultrasound image with injection being performed at the base of the celiac axis in the region of celiac plexus|
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Factors associated with improved response include (a) Timing of procedure - The timing of the block relative to pain onset may predict response. In pancreatic cancer, early EUS-CPN results in improved response. No such trials in CP are available. (b) Age >45 years has a better response (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.06, 2.43), (c) those with no prior surgery has better response, (d) those who had response to 1st session has better responses in subsequent sessions (OR 6.7,95%CI 2.25–19.72).
Various types of techniques are (a) celiac ganglion block/neurolysis, (b) central CPB/neurolysis, (c) bilateral CPB/neurolysis, (d) broad plexus neurolysis/block.
There is no clear evidence that CGN is more superior to bilateral or broad plexus EUS-CPN (with needle advancement caudal to the base of the celiac axis). Therefore, EUS-guided CGN is not necessary. Bilateral versus unilateral CPB-also showed conflicting results.
In a study by Levy MJ et al. - 160 patients (71 central, 89 bilateral)-both pancreatic cancer and CP, mean percentage pain reduction score-70.4% in bilateral compared to 45.9% in central (P = 0.0016)., Bilateral injection was only predictor of response. However in another study by Leblanc et al. - no statistical differences, pain relief in 65% central injection versus 59% in the bilateral group (P - 0.67) was seen. No difference in duration of relief was also seen. Ganglia are numerous and can be found adjacent to the aorta extending from the origin of the celiac artery down to the origin of the superior mesenteric artery. In bilateral technique-more ganglion and nerve fibers are targeted because of the broad distribution of the agents and hence may be more effective. However, it has more complex steps with increased risk of adverse events (mainly bleeding in high-risk patients). Hence, even central injection is acceptable. Adverse events rate is 7% of 481 EUS-CPB procedures and in 21% of 661 EUS-CPN procedures., Key adverse events include-mainly minor including diarrhea in 7%–18%, hypotension in 11%–20%, and transient increase in pain in 9%. Major adverse events rate is around 0.2%, being more common in neurolysis as compared to block. Major events include retroperitoneal bleed, retroperitoneal abscess, paraplegia, gastric ulceration, pancreatic, splenic, bowel infarction.
Infectious complications more in the block where steroids are used hence antibiotics should be given for 5 days after procedure.
| Endoscopic Ultrasound Guided Biliary Access|| |
Endoscopic retrograde cholangiopancreatography (ERCP) is usually the first preferred method to drain an obstructed biliary system. However, it may not be successful due to various reasons like inaccessible papilla due to obstruction or due to surgical alteration in the postoperative stomach or a failure of cannulation. In these situations, either percutaneous or surgical drainage has been traditionally used. EUS guided biliary drainage has been established as alternative to a failed ERCP nowadays.
EUS-guided biliary drainage can be: (1) transmural drainage-hepatic gastrostomy or choledochoduodenostomy, (2) a rendezvous procedure, or an (3) antegrade approach. EUS-guided transluminal drainage is achieved by either intra-hepatic or extra-hepatic bile duct puncture from the proximal stomach or the duodenum., The steps for EUS guided biliary drainage are – (a) EUS-FNA needle is punctured in the bile duct, (b) after obtaining a cholangiogram a guidewire is placed into the biliary system, and (c) the tract is dilated by cystotome, balloon followed by insertion of the stent which is usually a fully covered or a partially covered metal stent. Puncture site is the duodenum to achieve access into the common bile duct, and it is the stomach to allows access to the intrahepatic biliary radicals in the left lobe., Less commonly used, access to the right-sided intrahepatic biliary system creating hepatico-duodenostomy has also been reported in the literature.
In the EUS-guided rendezvous technique at first, temporary access to the biliary tree using EUS guided approach is created. This is followed by guidewire manipulation across the obstruction into the duodenum through the papilla. After this, the guidewire exiting the papilla is grasped using a snare and retrieved. This provides a conduit for further ERCP. This approach is used in patients with failed ERCP, but the papilla is accessible. EUS guided antegrade approach involves first achieving a temporary EUS guided access created from the duodenum or stomach, then placing the stents or doing balloon dilatation without the scope reaching the papilla. The success rate reported for this procedure is 77% and the complication rate is around 15%.
Complications associated with EUS-guided biliary drainage include perforation, bile leak, bleeding, and stent dysfunction or migration. In cases of malignant gastric outlet obstruction, he EUS-biliary drainage has been reported to have a higher stent patency rate as compared to transpapillary stenting. SEMS is most used for EUS-guided biliary drainage as they provide a larger diameter and therefore are likely to remain patent for longer periods and the risk of bile leaks is less as compared to plastic stents. When a SEMS is placed, reinsertion of stents in cases of blockage is easier as the new stent can be placed into the previous SEMS.
| Endoscopic Ultrasound Guided Interventions for Malignant Diseases|| |
Endoscopic ultrasound guided tumour ablation
Radiofrequency ablation (RFA) is used which involves thermal injury leading to coagulation necrosis. RFA has been used for the treatment of solid tumors like hepatocellular carcinoma and liver metastases. RFA traditionally has been done by either percutaneous, open, or laparoscopic approach. But these approaches have been associated with morbidity and mortality. EUS guided RFA has been used recently for inoperable pancreatic cancer, pancreatic neuroendocrine tumor, pancreatic solid pseudopapillary neoplasms. Both porcine model studies and human pilot studies have been published. Key complications include-pancreatitis, bleeding, perforation, pancreatic duct stricture formation. Data are still emerging.
Fiducial marker placement
In various gastro-intestinal malignancies, fiducial markers are placed inside the tumor for guiding radiotherapy. These are made of radioactive spheres or seeds. Conentionally, fiducials were placed under radiologic or surgical guidance. But now these can be placed by EUS guided approach as well. In their study, Pishvaian et al. showed EUS guided fiducial placement in 13 patients with technical success 84.56%. There have been few studies where EUS-guided fiducials have been placed successfully in pancreatic cancers, and oesophageal cancers.,,,
Delivery of antitumor agents
Pancreatic carcinoma has a poor prognosis because of less favorable response to chemotherapy. Neoadjuvant chemotherapy is used in locally advanced disease and borderline resectable disease, but it carries a poor response rate. Hence, instillation of local antitumor agents using EUS guidance have been attempted in patients with advanced pancreatic carcinoma and in locally advanced lesions. The role of this technique is still in experimental stage.,
Endoscopic ultrasound-guided anastomosis
EUS-guided gastro-jejunostomy (EUS-GJ) to bypass malignant obstruction was first attempted 6 years ago. EUS-guided enteral anastomoses have become possible with the introduction of LAMS, specifically cautery assisted LAMS – the hot-axios, as these stents allow for a single step procedure for access, dilatation, stent deployment, and anastomosis creation [Figure 3]a, [Figure 3]b, [Figure 3]c. These stents permit the creation of new anastomoses in malignant and benign gastric outlet obstruction, drainage of obstructed small bowel limbs after surgery, and creation of gastro-gastric fistulae after Roux-en-Y gastric bypass to facilitate ERCP.,
|Figure 3: (a-c) The hot-axios system with electro-cautery ring at the tip and markings for step-wise deployment of the axios stent|
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Key steps are
(a) EUS-GJ for malignant gastric outlet obstruction requires passing a catheter beyond obstruction with instillation of fluid to distend duodenal or jejunal lumen beyond obstruction, (b) Then, after identifying an accurate window by EUS for the anastomosis creation, a cutting electrosurgical current is applied via the tip of the hot axios catheter between the gastric wall and the adjacent distended bowel wall, (c) The catheter is then advanced into the bowel lumen and the stent is deployed.,,
| Role of Endoscopic Ultrasound in Endo-Hepatology|| |
Indications for use of EUS in hepatology are increasing. This application of EUS for liver indications is now termed “Endo-hepatology.“, It includes the following:
- EUS-guided liver biopsy
- EUS guided portal pressure gradient measurement
- EUS guided paracentesis
- EUS guided shear wave elastography.
As the prevalence of non-alcoholic fatty liver disease and nonalcoholic steatohepatitis is increasing all around the world, there is an unmet need to establish efficient and accurate information regarding liver inflammation and fibrosis. With the expansion of EUS to the liver and the emergence of this new field of “Endo-Hepatology,” there is now potential for “one-stop-shop” diagnosis and staging of liver disease.
| Endoscopic Ultrasound-Guided Gall Bladder Drainage|| |
With the emergence of interventional EUS and lumen apposing stent it is now possible to drain the gall bladder intraluminally. Indications include severe acute cholecystitis in patients who are not suitable for surgery due to comorbidities and have not responded to conservative management. Previously published systematic review has shown success rate of 96% for gallbladder stenting with complication rates of 6.3% in around 127 patients.
In one of the randomized controlled studies for comparison of percutaneous gall bladder drainage vs EUS-Guided drainage in patients of acute cholecystitis, it was found that technical success was similar and even the complication rates were similar. However, the re-intervention rate was significantly less in the EUS group.
EUS guided gall bladder drainage can be done from the antrum or duodenum; however, the duodenum is preferred. Hot-axios should be used as it is imperative to minimize the time between puncture and stent deployment to avoid the leakage of bile. Key complications of this procedure include bile leak, stent migration, perforation, pneumo-peritoneum.
| Endoscopic Ultrasound-Guided Pancreatic Duct Drainage|| |
EUS guided pancreatic duct drainage is indicated in patients with CP and failed cannulation during ERCP due to nonnegotiable stricture and the patient is not an appropriate candidate for surgery.
It is also indicated in patients as a primary approach in postsurgical cases with surgically altered anatomy with pancreaticogastrostomy or pancreaticojejunostomy with stricture. Both antegrade and rendezvous approaches can be used once the access to the pancreatic duct is made under EUS guidance.
Plastic stents are used instead of metal stents due to the risk of obstructive pancreatitis using metal stents. It is an extremely technically demanding procedure which required expertise. Complications include pancreatic duct leak, acute pancreatitis, bleeding, perforation, stent migration. Published literature is not extensive but the overall clinical success rate is around 74%, with complication rate of around 20%.
| Interventional Endoscopic Ultrasound, Devices and Accessories|| |
As mentioned, interventional EUS requires dedicated devices including needles, stents, other accessories, etc.
Stents [Figure 4] – (1) used in biliary drainage: (a) For hepaticogastrostomy-partially covered self-expanding metal stent-like Giobor stent or Bona stents are used. They have one-third part uncovered to be placed inside the liver which prevents the blockage of the segmental intrahepatic ducts and the other 2/3rd covered part which helps in bridging between the stomach and liver to prevent bile leak. They also have anti-migratory flare at its ends. The diameter available is 8 mm and 10 mm with the length of 10 cm and 12 cm (b) For choledochoduodenostomy – (a) the hot-axios system as previously described can be used if the ducts are dilatated enough, or (b) the standard fully covered self-expanding biliary metal stent can be used.
|Figure 4: The images show the various types of lumen apposing stents used in interventional endoscopic ultrasound. The axios stent, the spaxus stent and the NAGI stent are shown with their various sizes that are available|
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(2) For pancreatic fluid drainage – (i) the NAGI stent-which is a dumbbell-shaped stent with flares at both ends. Commonly used size is 16 mm diameter with 3 cm length. (ii) the HOT axios which is a true lumen apposing stent. Various sizes include 10 mm, 15 mm, 20 mm diameter. The most used size for PFC is 15 mm.
Needle: 19 g FNA needle is most widely used.
Wire: 0.25 visiglide (Olympus) is most commonly used. Occasionally, terumo guidewire is used.
Other accessories: Cystotome is an electrocautery-enabled dilating catheter which comes in 6 Fr, 8 Fr, 10 Fr sizes.
| Summary and Conclusions|| |
The field of interventional EUS has evolved and will continue to grow as specific newer equipment and devices are being developed for its applications. Furthermore, widespread implementation of interventional EUS is going to increase as more and more physicians are getting trained in this field. It is obvious that the expansion of interventional EUS has allowed gastroenterologists to enter into the areas which conventionally has remained the domain of surgeons. With further improvements in accessories and the development of EUS NOTES, the endosonologist will have multiple roles to play in future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]