Tài liệu Hội thảo Quốc tế về Nội soi và Phẫu thuật nội soi

bilateral endoscopic ultrasound-guided celiac plexus block or neurolysis: a comparative study of short-term. effectiveness[r]

THAWEE Ratanachu-ek, M.D Surgical Endoscopy Unit,

Department of Surgery, Rajavithi Hospital

EUS

Endoscopic Ultrasonography In clinical practice

EndoUltraSonography

Endoscopic ultrasound(EUS)

Endoscopy Ultrasonography

Mucosal lesion

Submucosal lesion

Extraluminal lesion

Endo Ultra Sonography

Why it is developped?

Endoultrasonoprobe

Radial EUS

Convex (Longitudinal) EUS Miniprobe

EUS: Basic principle

Mucosa

Muscularis mucosae Submucosa Proper muscle Sub-,serosa

Border echo Border echo 7.5-12 MHz : 5-layer

20-30 MHz: layer

Endoscopic ultrasound(EUS)

Radial type

Linear (convex) type

1980 2005

Modified from E Burmester, EURO EUS 2005 Diagnosis

EUS-FNA

Therapeutic procedure

EUS: Technical Development

 Cancer staging (T,N,M?)

 Lung cancer, GI cancer

 Giant Gastric folds

 Subepithelial tumor

 HBP lesions

 Retroperitoneal lesions

 Colon & Rectum

 etc……

EUS: Clinical Practice

Diagnostic applications

 Pseudocyst drainage

 Pancreatic necrosectomy

 Celiac plexus neurolysis/block

 Biliary-enteric bypass

 Drainage of collection Intervention EUS

EUS: Clinical Practice

Absolute contraindication

Uncorrectable coagulopathy with INR>1.5 Uncorrectable thrombocytopenia with platelet count<50,000/ul

Relative contraindication: Precaution

Biliary obstrcution without prior decompression Bronchogenic duplication cyst

Trajectory to vessel Luminal stenosis Tumor spreading

EUS: Complications

 Bleeding

 Pancreatitis

 Infection

 Perforation

 Air embolism

 Cancer staging (T,N,M?)

 Lung cancer, GI cancer

 Giant Gastric folds

 Subepithelial tumor

 HBP lesions

 Retroperitoneal lesions

 Colon & Rectum

 etc……

EUS: Clinical Practice

Diagnostic applications

EUS-FNA is possible in lymph node station :

1, 2, 3, 4, (5 ), 7, 8 and

Remember the adrenal glands !

Cancer staging (T,N,M?)

T4,N1 esophageal cancer

Liver metastasis Panc.head mass FNA

Metastasis liver celiac LN Mass@panc

abutment invasion

encasement

EUS: Pancreatic cancer; Assessment of vascular invasion

Subepithelial Tumor

mucosa

Owens D, Savides T Endoscopicn untrasound, 2009:98-119

SET based on site of origin

DDx of SMT based on

site of origin & Echo pattern: rd

Lipoma

Glomus tumor Panc rest

Goldblum J R et al.; Ann Thorac Surg 1996;62:860-865

DDx of SMT based on

site of origin & Echo pattern: 2nd/4th

Leiomyoma

GIST

GIST

Garcea G, Ong SL, Rajesh A, et al.Cystic Lesions of the Pancreas Pancreatology 2008;8:236-251 Features of common pancreatic cysts

Microcystic with macrocystic varients

Macrocystic with microcystic varients Branches type

P-cyst: Over-lapping Images

Macrocystic Microcystic Oligocystic

MCN SCN IPMN

EUS: aspiration

antibiotic EUS guided pancture 19, 22 G needle

Wash-out the wall

Levy MJ, Wiersema MJ Pancratic neoplasm.Gastrointest Endoscopy Clin N Am 2005;15:117-142

 Pseudocyst drainage

 Pancreatic necrosectomy

 Celiac plexus neurolysis/block

 Biliary-enteric bypass

 Drainage of collection Intervention EUS

i-EUS: How often?

Siriraj 5.0% Chula 4.8% NKC-Songkla 4.6% Rajavithi 7.4%

i-EUS 204/ total EUS (N) 3807= 5.3%

(N=1300) (N=471)

(N=1253) (N=783)

% of i-EUS:d-EUS/YEAR

Courtesy: Dr.Siriboon,Dr Bancha, Dr.Tassanee,Dr.Thawatchai,Dr.Nonthalee,Dr,Varayut, Dr.Pradermchai

i-EUS: What procedures?

64 (31.3%) 76

(37.0%) 42

(20.5%)

11 11

CGN: Ganglia injection CPN: Single/ Bilateral injection

Celiac plexus Neurolysis(CPN) Block (CPB)

Gunaratnam NT, Sarma AV, Norton ID, et al A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain GIE 2001;54:316–324 Sahai AV, Lemelin V, Lam E, Paquin PC Central vs bilateral endoscopic ultrasound-guided celiac plexus block or neurolysis: a comparative study of short-term

effectiveness Am J Gastroenterol 2009 Feb;104(2):326-9 Epub 2009 Jan

Sakamoto H, Kitano M, Komaki T, et al Endoscopic ultrasound-guided neurolysis in pancreatic cancer Pancreatology 2011;11Suppl 2:52-8 Epub 2011 Apr Sakamoto H, Kitano M, Komata K, et al Am J Gastroenterol 2010;105:2599-2606

Levy MJ, Topazian MD, Wiersema MJ, et al Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block Am J Gastroenterol 2008;103:98–103

BPN (Broad Plexuse Neurolysis)

Covered areas CPN(%) BPN (%)

42

28

34 15

1-3 57 15

Gleeson FC, Levy MJ, Papachristou GI Frequency of visualization of presumed celiac ganglia by endoscopic ultrasound Endoscopy 2007;39:620-4

Not possible up to 20%

Achieve 70%

Choledochoduodenostomy Hepaticogastrostomy

EUS Guided HPB Drainage

Gall bladder drainage*

Bile duct drainage

Biloma drainage