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EUS Guided Treatment: New Frontiers
Michel Kahaleh, M.D. Chief of Endoscopy
Professor of Medicine Division of Gastroenterology and Hepatology
EUS-guided drainage Fine Needle Injection and Ablation
Hemostasis Access
Anastomosis
Current Advances in Interventional Endosonograpy
Background
-Pancreatic fluid collection drainage -Inaccessible Pancreatic or bile duct, next
logical target
-Then GLB -Then Anastomosis
Wiersema MF: Gastrointest Endos 1996 Bataille L: Gastrointest Endosc 2002 Francois E: Gastrointest Endosc 2002
Prerequisites ➢ Cross Sectional Imaging: “Road Map”
➢ Repeat ERCP: “ Expertise”
➢ Skills in ERCP and EUS: “Training”
➢ Multidisciplinary approach: “Backup”
➢ General anesthesia: “Complexity”
Techniques ➢ Prophylactic antibiotherapy ➢ Use CO2 ➢ Linear array instrument (3 mm channel) ➢ Puncture with 19 gauge needle (Preferably) ➢ Placement of a 0.035-inch wire ➢ Dilation with creation a fistula with
-Bougie (6 or 7 Fr) -Balloon (4-6 mm) -Cystenterostome
➢ Placement of a stent with or without rendezvous technique ➢ Transluminal or transpapillary drainage
EUS Guided Biliary Drainage
- Transgastric-transhepatic or Intrahepatic
Burmester E: Gastrointest Endos 2003
EUS Guided Biliary Drainage
Transenteric- transcholedochal or Extrahepatic
Gupta K. Rev Gastroenterol Disord 2007
New ERCP related Procedure
UVA 2008
New Design Stent ?
Choledochoenteral Anastomosis
Case 2
■ 79 y old caucasian lady ■ Ampullary stricture ■ Failed ERCP x 2 ■ Early cholangitis
EUS-Guided Extrahepatic Drainage
EUS-Guided Extrahepatic Drainage
EUS-Guided Extrahepatic Drainage
EUS-Guided Extrahepatic Drainage
RDV
■ Access into D2 or biliary orifice require ■ Snare recommended to extract wire ■ Hydrophilic wire required ■ Dilation or sphincterotomy once access
recommended ■ Multiple plastic stents or metal stent
EUS Guided Drainage: RDV
A comprehensive search of several databases from each database’s earliest inception to November 1st, 2014 The databases included Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Scopus, and PUBMED Studies that reported outcomes of at least 4 EUS-BD procedures.
Results
■ According to the meta analysis of 27 independent cohorts (479 success out of 541) the pooled technical success rate under fixed effects model was 95% (95% CI -93-97)
■ The adverse event rate was 14% (95% CI -11-18).
Results
■ Of the technically successful procedures, the site of biliary drainage was transduodenal (50.3%) and transgastric (48.7%) .
■ The most common adverse event was pneumoperitoneum which constituted 36.7% of the total
EUS Guided Drainage vs. PTBD ?
Artifon E et al : J Clin Gastroenterol 2012;46:768–774
! No difference TB decrease in the two arms. ! Hospitalization time was significatively
shorter in the Arm B (6 days range 3-30 days) than the Arm A (12 days range 2-52 days) p < 0,02.
! Complication rate was higher in the Arm A (60%) vs Arm B (35%)
Limitations
■ Tortuous ducts (failure to advance wire) ■ High grade obstruction ■ Right hepatic duct drainage ??
EUS guided GLB
■ Easy access from stomach or duodenum ■ Allow placement of larger diameter stent ■ Avoid the percutaneous route -------------------------------------------------- ■ Risk of peritonitis ■ Risk of perforation ■ Risk of migration
EUS guided GLB: Series
-8 series -Total of 86 patients -Success between 86-100 % - Complications: 4 Pneumoperitoneum 2 UGI bleeding 1 migration 1 bile peritonitis
EUS-Guided Gallbladder Drainage - Methods
Jang JW, et al. Gastroenterology 2012;142:805-811.
All patients sedated with midazolam/meperidine 19g needle used for puncture Antrum or duodenal bulb – dilate or needle knife 5 French nasobiliary tube
EUS PTH Number treated 30 29 NS Technical success 97% 97% NS Clinical success 100% 96% NS Complications 7% 3% NS Convert to open CCx 9% 12% NS
EUS-Guided Gallbladder Drainage - Results
Jang JW, et al. Gastroenterology 2012;142:805-811.
EUS-Guided Gallbladder Drainage - Results
Jang JW, et al. Gastroenterology 2012;142:805-811.
Median post-procedure pain score significantly lower in the EUS group when compared with the PTH group
-All patients included were deemed unfit for surgery -Lumen apposing stent (AXIOS, Xlumena, CA, USA), draining the gallbladder to the stomach or duodenum
GIE 2015: In press
EUS guided GLB: Key concept
■ Not a replacement for surgery ■ Need cross sectional imaging prior ■ Performance by skilled endoscopist ■ Antimigratory system or pigtail ? ■ Transbulbar vs Transgastric ? ■ Removal or not ? ■ Longevity ?
ACCESS for RYGB
Bypass: EDGE procedure: Step 1
EDGE: Step 1
EDGE Step 2
EDGE step 2
Anastomosis
Training
Conclusions
■ Novel EUS guided procedure are safe and feasible techniques in expert hands
■ Choice between this approach and other -Level of expertise -Access to expertise
Conclusions
■ Progress are needed to permit safer and easier access
■ Further multicenter studies and training are required in order to standardize these techniques
Interventional EUS: Shift in Paradigm?
“The Future is ours, if we are willing to seize it ”
Thank you