Evolving Role of Interventional Endoscopic Ultrasound (EUS)

Abstract

Background: EUS is established in the diagnosis and staging of GI malignancies. Therapeutic EUS is evolving and includes celiac plexus block and pseudocyst (PC) drainage. We report our experience with 6 indications for therapeutic EUS. Results: (1) Hematoma drainage: 47 yo F with pain and fever 3-1/2 wk post-LOA. CT: peri-rectal fluid collection. EUS: 50 × 43 mm cystic mass with septations. EUS-guided needle evacuation obtained fluid consistent with old hematoma. Cytology and cultures - negative. Fever and pain subsided. CT at 4 wk - resolved. (2) Choledochoduodenostomy: 61 yo M with jaundice and pancreatic mass on CT. EUS/FNA - 68 × 40 mm adenocarcinoma invading duodenum, superior mesenteric vein, splenoportal confluence. Transpapillary stenting failed due to mass in ampulla/duodenum. Guidewire (GW) placed through echoendoscope from bulb into bile duct (BD) above obstruction. GW would not pass antegrade across the stricture/papilla for rendezvous. EUS-guided choledochoduodenostomy and stenting was done at the same session, with excellent biliary drainage. (3) Pancreatic rendezvous: 63 yo F with pain, chronic pancreatitis, and stones obstructing the ventral pancreatic duct (PD). Cannulation of major/minor orifices failed. EUS-guided transgastric access into main PD was followed by advancement of GW across the minor papilla. The GW was retrieved using the duodenoscope, followed by minor papillotomy and pancreatoscopy-electrohydraulic lithotripsy. ERP at 6 months confirmed stone clearance. (4) Cyst-esophagostomy: 60 yo M with symptomatic 20 × 10 cm PC. Anatomic considerations led to EUS-guided cystesophagostomy and stenting, with complete drainage and no recurrence at 5 months. (5) Gastropancreatic stenting: 58 yo M with symptomatic 58 × 48 mm PC and amylase-rich pleural effusion. EUS cyst gastrostomy successful but after 6 wk pt returned with dyspnea, effusion and pancreatic ascites. ERP - stenosis in the head and contrast leak into pleural space. ERP transpapillary GW and EUS-guided transgastric GW failed to traverse PD stricture. Pancreaticogastrostomy and stenting was performed. Effusion and ascites nearly completely resolved on CT at 2 months and pt has been symptom-free for 13 months. (6) Pelvic abscess drainage: 61 yo M with 70 × 50 mm diverticular abscess near rectosigmoid. EUS-guided drainage and stenting performed, followed by sigmoid colectomy with primary anastomosis 23 days later, avoiding a 2-stage surgery. Conclusion: EUS has an expanding therapeutic role. Background: EUS is established in the diagnosis and staging of GI malignancies. Therapeutic EUS is evolving and includes celiac plexus block and pseudocyst (PC) drainage. We report our experience with 6 indications for therapeutic EUS. Results: (1) Hematoma drainage: 47 yo F with pain and fever 3-1/2 wk post-LOA. CT: peri-rectal fluid collection. EUS: 50 × 43 mm cystic mass with septations. EUS-guided needle evacuation obtained fluid consistent with old hematoma. Cytology and cultures - negative. Fever and pain subsided. CT at 4 wk - resolved. (2) Choledochoduodenostomy: 61 yo M with jaundice and pancreatic mass on CT. EUS/FNA - 68 × 40 mm adenocarcinoma invading duodenum, superior mesenteric vein, splenoportal confluence. Transpapillary stenting failed due to mass in ampulla/duodenum. Guidewire (GW) placed through echoendoscope from bulb into bile duct (BD) above obstruction. GW would not pass antegrade across the stricture/papilla for rendezvous. EUS-guided choledochoduodenostomy and stenting was done at the same session, with excellent biliary drainage. (3) Pancreatic rendezvous: 63 yo F with pain, chronic pancreatitis, and stones obstructing the ventral pancreatic duct (PD). Cannulation of major/minor orifices failed. EUS-guided transgastric access into main PD was followed by advancement of GW across the minor papilla. The GW was retrieved using the duodenoscope, followed by minor papillotomy and pancreatoscopy-electrohydraulic lithotripsy. ERP at 6 months confirmed stone clearance. (4) Cyst-esophagostomy: 60 yo M with symptomatic 20 × 10 cm PC. Anatomic considerations led to EUS-guided cystesophagostomy and stenting, with complete drainage and no recurrence at 5 months. (5) Gastropancreatic stenting: 58 yo M with symptomatic 58 × 48 mm PC and amylase-rich pleural effusion. EUS cyst gastrostomy successful but after 6 wk pt returned with dyspnea, effusion and pancreatic ascites. ERP - stenosis in the head and contrast leak into pleural space. ERP transpapillary GW and EUS-guided transgastric GW failed to traverse PD stricture. Pancreaticogastrostomy and stenting was performed. Effusion and ascites nearly completely resolved on CT at 2 months and pt has been symptom-free for 13 months. (6) Pelvic abscess drainage: 61 yo M with 70 × 50 mm diverticular abscess near rectosigmoid. EUS-guided drainage and stenting performed, followed by sigmoid colectomy with primary anastomosis 23 days later, avoiding a 2-stage surgery. Conclusion: EUS has an expanding therapeutic role.