Endosonography

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Endosonography
Copyright
Dedication
Contributors
Preface
Acknowledgments
Contents
Video Contents
Section I Basics of Endoscopic Ultrasonography
1 Principles of ultrasound
Key points
Basic ultrasound physics
Wavelength, frequency, and velocity
Density, compressibility, and bulk modulus
Ultrasound interactions in tissue
Reflection
Refraction
Scattering
Absorption
Ultrasound intensity
Basics of ultrasound instrumentation
Transducers
Processors
Transmit/receive
System gain and time gain compensation
Signal processor
Imaging principles
Resolution
Axial resolution
Lateral resolution
Elevation resolution
A-mode scanning
B-mode imaging
Doppler
Continuous-wave doppler
Pulsed-wave doppler
Color doppler
Power doppler
Imaging artifacts
Reverberation
Reflection (mirror image)
Acoustic shadowing
Through transmission
Tangential scanning
Side lobe artifacts
Endoscopic ultrasound elastography
Harmonic imaging
High-intensity focused ultrasound
Summary
References
Key References
References
2 Equipment
Key points
Introduction
Equipment
Radial scopes
Linear scopes
Processors
Endoscopic ultrasound with elastography and shear wave measurement
Miniprobes
Accessories
Fine-needle aspiration needles
Fine-needle biopsy needles
Endoscopic ultrasound-guided fiducial placement
Endohepatology
Confocal laser endomicroscopy
Radiofrequency ablation
Endoscopic ultrasound-guided lumen-apposing stents
3 Training and simulators
Key points
Introduction
Training in EUS
Current status of EUS training in the United States
Guidelines for competency assessment
Learning curves and competence in EUS
Toward competency-based medical education
Credentialing, recredentialing, and renewal of privileges in EUS
EUS training using simulators
Quality metrics in EUS
Future directions
Conclusions
Key References
References
4 Indications, preparation, and adverse effects
Key points
Indications
Diagnostic imaging
Tumor staging
Tissue acquisition
Therapy
Contraindications
Patient preparation
General measures
Laboratory studies
Medications
Daily medications
Antithrombotic drugs
Resuming antithrombotic therapy
Prophylactic antibiotics
Risks and adverse effects
Perforation
Bleeding
Infection
Pancreatitis
Other adverse effects of EUS and EUS FNA
Adverse effects of therapeutic endoscopic ultrasound
References
Key References
References
5 New techniques in EUS: Multiparametric endoscopic ultrasound imaging
Key points
Introduction
Real-time EUS elastography
Technical details
Clinical applications
Lymph nodes
Pancreatic masses
Other applications
Future techniques
Contrast-enhanced EUS
Technical details
Clinical applications
Pancreatic diseases
Gallbladder diseases
Other applications
Future techniques
Fusion imaging
Confocal laser endomicroscopy
Artificial intelligence
Key References
References
Section II Mediastinum
6 How to perform an EUS examination of the esophagus and mediastinum
Esophagus
Mediastinum
Radial echoendoscope
Linear array echoendoscope
How to examine the adrenal glands
Summary
Key Reference
7 Endoscopic ultrasonography in esophageal and gastric cancer
Esophageal and gastric cancer
Background
AJCC staging of esophageal and gastric cancer
Workup of newly diagnosed esophageal and gastric cancer
The role of EUS-FNA or FNB in staging
EUS examination technique and staging
Scope selection
TNM staging
T stage
N stage
M stage
Obstructing tumors
Cancer management pathway according to stage
Esophageal cancer
Gastric cancer
Restaging after neoadjuvant therapy
Esophageal cancer
Gastric cancer
The role of EUS in surveillance
Cost-effectiveness of EUS in esophageal and gastric cancer
Impact of EUS on patient management and survival
Learning curve and procedural volume
Summary
Primary gastric non-Hodgkin lymphoma
Background
Staging of non-Hodgkin lymphoma
Diffuse large B-cell lymphoma
Mucosa-associated lymphoid tissue (MALT) lymphoma
Thickened gastric folds
Gastric linitis plastica
Ménétrier’s disease
Further evaluation of thickened gastric folds
Key References
References
8 Endoscopic ultrasound in the evaluation of posterior mediastinal lesions and lung cancer
Key points
Introduction
EUS evaluation of enlarged posterior mediastinal lymph nodes
EUS appearance of posterior mediastinal lymph nodes
Appearance of benign posterior mediastinal lymph nodes
Appearance of malignant posterior mediastinal lymph nodes
Technique for EUS and EUS FNA of posterior mediastinal lesions
Performing EUS of the posterior mediastinum
Performing EUS FNA of posterior mediastinal lymph nodes and lesions
Endobronchial ultrasound
Accuracy of EUS FNA for diagnosing posterior mediastinal lesions
Risks of EUS FNA of posterior mediastinal lesions
EUS FNA compared with other modalities for evaluation and biopsy of posterior mediastinal lymph nodes or masses
Differential diagnosis of enlarged posterior mediastinal lymph nodes
Malignant posterior mediastinal lymph nodes
Metastatic disease from thoracic tumors
Lung cancer
Mesothelioma
Metastatic disease from extrathoracic malignancy
Lymphoma
Benign posterior mediastinal lymph nodes
Reactive lymph nodes
Granulomatous lymph nodes
Sarcoid
Histoplasmosis
Tuberculosis
Other infections
Impact of EUS FNA of mediastinal lymph nodes on subsequent thoracic surgery rates
Mediastinal masses
Malignant posterior mediastinal masses
Neurogenic tumors
Leiomyoma and gastrointestinal stromal tumors
Mesothelioma
Benign posterior mediastinal masses
Mediastinal cysts
Drainage of mediastinal pseudocysts and abscesses
Pleural effusions
Non–small cell lung cancer
Approach to endosonography in lung cancer
Diagnosis and staging of lung cancer
Intrapulmonary tumors (T)
Mediastinal nodal (N) staging and stations
Distant metastases (M1)
Position of EUS and EBUS in lung cancer staging algorithms
Summary
Key References
References
Section III Stomach
9 How to perform an EUS examination of the stomach
Stomach
Summary
10 Subepithelial lesions
Key points
Introduction
Comparison of accuracy between EUS and other imaging modalities
Extramural lesions
Evaluation of subepithelial lesions
Gastrointestinal stromal tumor
Aberrant pancreas
Lipoma
Carcinoid tumor
Granular cell tumor
Cysts including duplication cyst
Varices
Inflammatory fibroid polyps
Glomus tumor
Rare lesions
Tissue sampling for histologic assessment of subepithelial lesions
Management of subepithelial lesions
Summary
References
Section IV Pancreas and Biliary Tree
11 How to perform an endoscopic ultrasonography examination of the pancreas, bile duct, and liver
Pancreas
Evaluation of the body and tail of the pancreas
Radial echoendoscopes
Linear echoendoscope
Evaluation of the head and uncinate regions of the pancreas
Head of the pancreas
Radial echoendoscope
Linear echoendoscope
Papilla
Radial echoendoscope
Linear echoendoscope
Uncinate
Radial echoendoscope
Linear echoendoscope
Bile duct
Liver
12 EUS in inflammatory diseases of the pancreas
Key points
Introduction
EUS in the nondiseased pancreas
Chronic pancreatitis
Brief overview
Role of EUS
EUS imaging characteristics
EUS criteria for CP
Comparison of conventional and rosemont classification
Correlation of EUS findings and surgical histopathology
Interobserver variability
EUS sampling
Image-enhancing techniques in EUS
EUS elastography
EUS shear-wave measurement
Advanced EUS techniques
EUS-guided celiac plexus block
Acute pancreatitis
Brief overview
Role of EUS
Acute biliary pancreatitis
Acute idiopathic pancreatitis
Recurrent acute pancreatitis
EUS imaging characteristics
Advanced EUS techniques
Autoimmune pancreatitis
Brief overview
Role of EUS
EUS imaging characteristics
EUS sampling
Fine-needle aspiration
Tru-cut biopsy
Other EUS fine-needle biopsy techniques
Image-enhancing techniques in EUS
EUS elastography
Contrast-enhanced EUS
Artificial intelligence
Benign pancreatic masses
Brief overview
EUS sampling
EUS fine-needle aspiration
EUS-guided core biopsy
Image-enhancing techniques in EUS
EUS elastography
Contrast-enhanced EUS
Summary
Key References
References
13 Endoscopic ultrasound and pancreatic tumors
Key points
Examination checklist for evaluation of a suspected pancreatic tumor
Tumor
Vascular invasion
Lymph nodes
Liver
Ascites
Endoscopic ultrasound-guided tissue acquisition
Staging
Pancreatic ductal adenocarcinoma
Background
Detection of pancreatic ductal adenocarcinoma
Endoscopic ultrasound versus computed tomography
Endoscopic ultrasound versus magnetic resonance imaging
Contrast-enhanced endoscopic ultrasound
Endoscopic ultrasound elastography
Assessment of resectability and cancer staging
Staging
Tumor classification and local vascular invasion
Nodal classification
Presence of distant metastases
Tumor resectability
Endoscopic ultrasound-guided tissue acquisition
Fine-needle aspiration techniques/accessories for tissue acquisition
Needle size
Route of fine-needle aspiration
Sampling maneuver
Suction
Stylet
Specimen interpretation and processing
Challenges in endoscopic ultrasound-guided fine-needle aspiration of pancreatic mass lesions
Uncinate mass lesions
Mass size
Chronic pancreatitis
Adverse events of fine-needle aspiration
Endoscopic ultrasound-guided fine-needle biopsy
Sampling maneuver
Role of rapid onsite evaluation in era of FNB
Recent developments
Summary
Pancreatic neuroendocrine tumor
Background
Diagnosis
Imaging modalities in pancreatic neuroendocrine tumor
Endoscopic ultrasound versus other imaging modalities
Endoscopic ultrasound-guided tissue acquisition
Metastatic lesions to the pancreas
Pancreatic lymphoma
Personalized cancer therapy
References
Key References
References
14 Endoscopic ultrasonography in the evaluation of pancreatic cysts
Key points
Introduction
Types of pancreatic cysts
Diagnostic approach
Clinical history and imaging
Endoscopic ultrasound
Confocal laser endomicroscopy
Endoscopic ultrasound-guided tissue sampling of pancreatic cysts
Fine-needle aspiration (FNA)
Through-the-needle biopsy forceps
Through-the-needle cytology brush
Needle choice for EUS-guided cyst sampling
Adverse events of EUS-guided cyst sampling
Analysis of cyst fluid
Appearance of the aspirate and the string test
Cytology
Protein markers
Carcinoembryonic antigen
Other markers
Cyst fluid amylase
Glucose
Molecular markers
When to perform endoscopic ultrasound-guided fine-needle aspiration and what to send it for
Pancreatic cyst guidelines
Pancreatic cysts overview
Pseudocysts
Serous cystadenoma
Mucinous cystic neoplasm
Intraductal papillary mucinous neoplasia
Solid pseudopapillary neoplasm
Cystic neuroendocrine tumors
Cystic pancreatic ductal adenocarcinoma
Future developments
Analysis of molecular markers in pancreatic juice
Cyst ablation
Examination checklist
Key References
References
15 EUS in bile duct, gallbladder, and ampullary lesions
Key points
EUS and biliary stones
A Bile duct stones
EUS technique for detecting choledocholithiasis
The use of EUS, MRCP, and ERCP in the management of choledocholithiasis
B Gallstones
Summary
EUS in bile duct strictures
EUS-FNA considerations in biliary strictures and tumors
The performance of IDUS in biliary strictures
Cholangioscopy in biliary strictures
Multimodality approach to bile duct strictures
Staging of cholangiocarcinoma
EUS in gallbladder disease (excluding stones)
A Gallbladder polyps
B Gallbladder tumors
C. Other gallbladder disorders presenting with wall thickening
Summary
Ampullary tumors
Key References
References
Section V Anorectum
16 How to perform anorectal endoscopic ultrasonography
The perianal area
The rectum
Key Reference
17 Endoscopic ultrasonography in rectal cancer
Key points
Relevant anorectal anatomy and the American joint committee on cancer 2010 staging system for rectal cancer
Anorectal anatomy
Rectal cancer tumor-node-metastasis staging
Rectal endoscopic ultrasonography in the setting of de novo rectal cancer
T-staging considerations
N-staging considerations
Magnetic resonance imaging assessment versus endoscopic ultrasonography
Computed tomography and positron emission tomography–computed tomography evaluation versus endoscopic ultrasonography
Endoscopic ultrasonography evaluation following neoadjuvant therapy
Endoscopic ultrasonography for recurrent rectal cancer following radical and local surgery
Endoscopic ultrasonography for rectal wall metastases
Innovative interventions and adverse event profile for lower gastrointestinal endoscopic ultrasonography
Translational medicine
Conclusion
References
Key Reference
Reference
18 Evaluation of the anal sphincter by anal endosonography
Key points
Introduction
Equipment and examination technique
Anal sphincter anatomy
Normal endosonographic findings
Anal sphincter function
Anorectal physiologic testing
Manometry
Pudendal nerve latency
Electromyography
Sonographic findings in anal incontinence
Obstetric injury
Idiopathic internal anal sphincter degeneration and external anal sphincter atrophy
Iatrogenic sphincter injury and anal trauma
Sonographic findings in other anal disorders
Recent developments
Key Reference
Reference
Section VI Endoscopic Ultrasonography-Guided Tissue Acquisition
19 How to perform endoscopic ultrasonography-guided fine-needle aspiration and fine-needle biopsy
Key points
A brief history of EUS-guided needle sampling
Choosing the correct needle
How to perform EUS-FNA and FNB?
Indications and contraindications
Steps for EUS-guided FNA or FNB
Verify the indication
Localize the lesion and position the echoendoscope
Insert the EUS needle into the echoendoscope
Position the lesion in the needle path
Puncture the lesion and move the needle within the lesion
Withdraw the needle and evaluate the sample
Prepare the needle for subsequent passes
Evolving trends in EUS-FNA/B
Use of the stylet
Use of suction
Tissue sampling particularities according to site
Esophagus
Stomach
Duodenal bulb
Duodenal sweep (D2)
EUS-FNA of cystic lesions
Conclusion
References
Reference
20 Cytology primer for endosonographers
Key points
Technical aspects of EUS that improve diagnostic yield
Preliminary planning
Fine-needle aspirates
Choice of needles
Needle core biopsy versus fine-needle aspiration
To apply or not to apply suction
Number of passes
Immediate cytologic evaluation
Factors associated with improved cytologic preparation
Cytology smears and cell block
Air-dried or alcohol-fixed smears
Transport media and liquid-based preparations
Cytology interpretation
Adequacy
Diagnostic evaluation of the slide
EUS fine-needle aspiration of specific sites
Pancreas
Global approach to diagnosis
Pancreatic adenocarcinoma and chronic pancreatitis
Pitfalls
Causes of false-negative diagnosis.
Causes of false-positive diagnosis.
Pancreatic neuroendocrine tumors
Major differential diagnosis
Solid pseudopapillary neoplasm of the pancreas.
Cystic pancreatic lesions
Intraductal papillary mucinous neoplasia (IPMN)
Causes of false diagnosis.
Mucinous cystic neoplasm
Causes of false diagnosis.
Ancillary studies that can help distinguish neoplastic mucinous from nonmucinous cysts of the pancreas (Table 20.9)
Biochemical estimations.
Molecular analysis of cyst fluid.
Newer markers.
Lymph nodes
Sample collection
Algorithmic approach to interpretation of lymph node aspirates
How to confirm lymph nodes
Differential diagnosis
Monomorphous lymphoid population
Pitfalls
Nonhematopoietic cells in background of lymphoid cells
Pitfalls
Nonhematopoietic cells without the background of lymphoid cells
Spleen
Gastrointestinal tract
Detection of foregut cysts
Gastrointestinal stromal tumors
Hepatobiliary tree
Liver
Adrenal glands
Summary
Key Reference
Reference
Section VII Interventional Endoscopic Ultrasound
21 EUS-guided drainage of pancreatic and intraabdominal fluid collections and pelvic abscesses
Key points
Pancreatic fluid collections
Definitions
Indications for and timing of intervention
Types of interventions for drainage of PFC
Pseudocysts
WON
EUS-guided drainage
Preprocedure checklist
Cautions prior to EUS-guided PFC drainage
Procedural techniques
Single-gate technique
Plastic stent insertion
Accessories
Technique
1) PFC puncture and guidewire insertion
2) Transmural tract creation and dilation
3) Plastic stents
Double-wire technique
Lumen-apposing metal stent (LAMS) insertion
Accessories
Technique
LAMS versus plastic stents
Pseudocysts
WON
Multi-gate technique
Irrigation of WON cavity
Dual modality technique
Endoscopic necrosectomy
Disconnected pancreatic duct syndrome (DPDS)
Adverse events
Follow-up
Intraabdominal fluid collections and pelvic abscesses
Procedural technique
Additional drainage
Postdrainage follow-up
Technical and treatment outcomes
POFC drainage
Pelvic abscess drainage
Technical limitations
Summary
Key Reference
Reference
22 Endoscopic ultrasonography-guided drainage of the biliary-pancreatic ductal systems
Key points
Introduction
Endoscopic ultrasonography-guided biliary drainage
Indications
Nomenclature
General considerations for endoscopic ultrasonography-guided drainage of biliary-pancreatic ductal systems
Procedural considerations and equipment
General preprocedural and postprocedural precautions
Echoendoscope
Needles and guidewires
Tract dilation
Stents
Techniques of EUS-guided biliary drainage
Technique of endoscopic ultrasonography-rendezvous (biliary)
Considerations
Site of needle puncture
The procedure (Fig. 22.4 and Video 22.1)
Troubleshooting
Technique of endoscopic ultrasonography-guided antegrade biliary
Considerations
The procedure (Fig. 22.5 and Video 22.2)
Troubleshooting
Technique of endoscopic ultrasonography-choledochoduodenostomy
Considerations
The procedure (Fig. 22.6, Video 22.3)
Troubleshooting
Technique of endoscopic ultrasonography-guided hepaticogastrostomy
Considerations
The procedure (Fig. 22.7 and Video 22.4)
Troubleshooting
Learning curve in EUS-guided biliary drainage
Outcomes of the endoscopic ultrasonography-guided biliary drainage procedures
Endoscopic ultrasonography-rendezvous endoscopic retrograde cholangiopancreatography (biliary)
Endoscopic ultrasonography-guided choledochoduodenostomy
Endoscopic ultrasonography-guided antegrade stenting
Endoscopic ultrasonography-guided hepaticogastrostomy
Is one EUS-BD technique preferred over the other?
Comparison of endoscopic ultrasonography-guided biliary drainage with percutaneous transhepatic biliary drainage
Comparison of endoscopic ultrasonography-guided biliary drainage with endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction
Comparison of endoscopic ultrasonography-guided biliary drainage with enteroscopy-assisted ERCP
Algorithm for biliary drainage and choice of procedure
Endoscopic ultrasonography-guided pancreatic duct drainage
Indications for endoscopic ultrasonography-guided pancreatic duct drainage
Nomenclature
Technique of endoscopic ultrasonography-guided pancreatic duct drainage
Considerations
The procedure
Troubleshooting
Outcomes of endoscopic ultrasonography-guided pancreatic duct drainage procedures
Algorithm for endoscopic ultrasonography-guided pancreatic duct drainage procedures
Key Reference
Reference
23 Endoscopic ultrasonography-guided gallbladder drainage
Key points
Introduction
Indications for endoscopic ultrasonography-guided transmural gallbladder drainage
Technical aspects of EUS-GBD
Choice of endoprosthesis
Procedural steps for EGBD using LAMS
Noncautery-enhanced LAMS
Cautery-enhanced LAMS
Postprocedural management
Long-term management
Outcomes of endoscopic ultrasonography-guided transmural gallbladder drainage
EUS versus percutaneous gallbladder drainage
EUS versus transpapillary gallbladder drainage
EUS versus percutaneous versus transpapillary treatment approaches for gallbladder drainage
Future directions
Key Reference
Reference
24 Endoscopic ultrasonography-guided celiac plexus interventions and fiducial placement
Key points
Endoscopic ultrasonography-guided celiac plexus injections
EUS-guided celiac plexus block
Direct ganglia injection
Endoscopic ultrasonography-guided radiofrequency ablation of the celiac ganglia
Brachytherapy
Endoscopic ultrasonography-guided fiducial placement
Procedural technique
Celiac ganglion irradiation
Summary
Key Reference
Reference
25 EUS-guided bowel anastomosis
Key points
EUS-guided gastroenterostomy
Procedural technique
I. Antegrade EUS-GE: The traditional/downstream method
II. Antegrade EUS-GE: The rendezvous method
III. Retrograde EUS-GE
IV. EUS-guided balloon-occluded gastrojejunostomy bypass (Fig. 25.1 and Video 25.1)
V. Antegrade EUS-GE: The direct method (Video 25.2)
VI. Wireless EUS-GE simplified technique (Video 25.3)
Technical and treatment outcomes
Technical limitations
Conclusions
EUS-directed transgastric ERCP
Procedural technique
Step 1. Creation of gastrogastric or jejunogastric (GG/JG) fistula using a LAMS
Step 2. Anchoring of the LAMS
Step 3. ERCP
Technical and treatment outcomes
Management of adverse events
1. Stent dislodgement
2. Bleeding
3. Buried LAMS
4. Closed remnant stomach syndrome
5. Marginal ulcers
6. Persistent and refractory JG/GG fistula
Tips, tricks, and troubleshooting
Conclusion
Reference
26 EUS-guided pancreatic cyst chemoablation, EUS-guided radiofrequency ablation, and EUS-guided fine-needle injection
Key points
EUS-guided pancreatic cyst chemoablation
Patient selection
Indications and contraindications
Cyst ablation technique
Postoperative care and follow-up
Summary and areas of uncertainty
Conclusions
EUS-guided radiofrequency ablation
Equipment
Technique
Checklist for EUS RFA
EUS-guided ablation of pancreatic solid tumors
EUS-RFA for pancreatic net
EUS-RFA for pancreatic cancer
EUS-RFA for pancreatic mucinous cysts
EUS-RFA-related adverse events
Endoscopic ultrasound-guided injection therapies
Ethanol or chemotherapy injection for solid tumors
Novel and biologic antitumor EUS-FNI agents for pancreatic and esophageal cancer
Key Reference
Reference
27 Endoscopic ultrasonography-guided vascular interventions
Key points
Endoscopic ultrasonography-guided variceal obliteration
Procedural technique
Technical and treatment outcomes
Technical limitations and complications
Technical variations
EUS-guided therapy for ectopic variceal bleeding and nonvariceal bleeding
EUS-guided portal venous access and therapy
Portal pressure measurement
Portal vein thrombus sampling
Experimental interventions
EUS-guided portal vein embolization
EUS-guided cancer therapy
EUS-guided intrahepatic portosystemic shunting
Key Reference
Reference
28 Endo-hepatology
Key points
Introduction
EUS-guided shear-wave elastography
Technical considerations
EUS-guided liver biopsy
Technical considerations
Contrast-enhanced (CE)-EUS
EUS-guided portosystemic pressure gradient measurement
Technical considerations
Future directions
Conclusion
Key Reference
Reference
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
R
S
T
U
V
W
X
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