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Intraductal Ultrasonography (IDUS) for the Diagnosis of Biliopancreatic Diseases
S154
Ultrasound in Medicine and Biology
devices lead to expansion of its targets, such as bile duct, gallbladder, pancreatic duct, and so on. EUS-guided celiac plexus neurolysis (EUS-CPN) was reported as the first EUS-guided injection/ablation. During EUS-CPN, ethanol is injected into celiac plexus under the guide of EUS to relieve pain in patients with an upper abdominal cancer. EUS-CPN reportedly achieved more pain relief than using narcotic drugs alone. Modification of this technique such as ganglia neurolysis and broad plexus neurolysis further improved its efficacy. Ethanol injection recently expanded for ablation of cystic or solid tumors in the pancreas. EUS-guided radiofrequency ablation is currently applied to ablation of these tumors. Moreover, EUS-guided coiling has been used for embolization of gastric varices. In conclusion, interventional EUS became essential or rescue treatment of various digestive diseases. Its target is expected to expand to the other more fields in the future. T12-16-IN07 EUS-Guided Radiofrequency Ablation for the Management of Pancreatic Tumors Dong Wan Seo, MD, PhD Professor of Medicine, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Endoscopic ultrasound (EUS) became an indispensable tool not only for the diagnosis but also for the management of pancreatic tumors. With the modification of EUS-guided fine needle aspiration (EUS-FNA) technology, EUS-guided fine needle injection (EUS-FNI), EUS-guided ablation and other interventions can be applied for various solid or cystic lesions in the pancreas. Local ablative modalities such as radiofrequency ablation (RFA) or photodynamic therapy (PDT) are also applied to pancreas in animal studies. RFA is primarily delivered to liver percutaneously or intraoperatively. EUS-guided RFA in a pig model proved that this modality can also be delivered to the pancreas trans-gastrically and cause well-demarcated coagulation zone. This modality, however, should be improved and refined to reduce the possible complications such as pancreatitis, gastric burn or perforation. Our group conducted EUS-guide RFA human trial for unresectable pancreatic cancer and showed technical feasibility and safety of EUS-RFA for pancreatic cancer. Further studies are required to see the long-term efficacy and survival benefit of this adjunctive modality for pancreatic cancer. EUS-RFA can be applied for the management of small pancreatic or peripancreatic tumors such as neuroendocrine tumor, adrenal tumor and small lymph node metastasis. Initial studies using EUS-RFA for the treatment of pancreatic neuroendocrine tumor showed very promising result without any serious complication. EUS-RFA seems to be very useful especially for the management of insulinoma. Since the patient presents with recurrent hypoglycemic attack, insulinoma is generally small in size at the time of diagnosis. It can be easily ablated under EUS-RFA and the functionality can be controlled very effectively. EUS-RFA is also applied for the management of cystic tumor of the pancreas. However, only animal study are reported using GB and cystic duct of pig and more studies are required before direct human application. In conclusion, EUS-guided approach offers minimally invasive access for delivery of local ablation modalities including EUSRFA. This area is a continuously evolving field and many studies are currently undergoing. Although many of these approaches are still investigational but will play a key role in the treatment of benign and malignant pancreatic disease in the future.
Volume 43, Number S1, 2017 Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan In recent years, evidence suggests that a minimally invasive step-up approach is superior to conventional open necrosectomy, with decreased rates of the composite end point of major complications or death among patients with necrotizing pancreatitis and walled-off necrosis (WON). Since first described in 1992, EUSguided transluminal drainage for pancreatic fluid collection has played a pivotal role and spread worldwide as a minimally invasive alternative to surgical and percutaneous drainage with reportedly high technical and clinical success rates. However, the clinical response rate of the conventional single transluminal gateway technique with single stenting for treating WON is not satisfactory (described as 45%–63%). Recently, various techniques, such as the use of wide-caliber lumen-apposing metal stents, multiple transluminal gateway technique and direct endoscopic necrosectomy have improved the clinical success rate of endoscopic management of WON. When conventional EUS fails to depict the WON reflecting solid necrotic components, contrast-enhanced EUS may be useful to clearly visualize target lesions and to decisively puncture them. We evaluated the clinical outcomes of the algorithmic step-up approach based on EUS-guided drainage for WON. The result shows the step-up approach based on EUS-guided drainage is an effective strategy for the management of WON, particularly in patients with serious comorbid conditions or in those with WON cavity extending to the pelvis, who are difficult to manage with endoscopy alone. More options, such as surgical necrosectomy should be considered. In conclusion, EUS-guided intervention has become an essential treatment method of WON. The development of new dedicated devices for EUS-guided drainage would help make it a more sophisticated and promising procedure. T12-16-IN09 Intraductal Ultrasonography (IDUS) for the Diagnosis of Biliopancreatic Diseases Cheuk-Kay Sun, MD Division of Hepatology and Gastroenterology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Although endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic procedure of choice for patients with pancreatobiliary lesions, it is limited in diagnostic accuracy. Intraductal ultrasonography (IDUS) is an imaging modality having unique characteristics and suitable for imaging of a narrow ductal cavity, its wall and the neighbouring structures. As IDUS uses high-frequency ultrasound (20 MHz), its image quality is very high within approximately 2-cm range of radius. The bile duct and the pancreatic duct, and therefore are good targets for the assessment by IDUS. Biliopancreatic IDUS is mainly performed through the papilla of Vater in the same session as endoscopic retrograde cholangiopancreatography (ERCP). Technically easy, IDUS is a valuable adjunct to endoscopic retrograde cholangiography that increases the ability to distinguish malignant from benign pancreatobiliary lesions. T12-16-IN10
T12-16-IN08
EUS for Biliary Tract Stricture Meng-Shun Sun Gastroenterology, Internal medicine, Yuan’s General Hospital, Kaohsiung
EUS-Guided Interventions for Walled-off Pancreatic Necrosis Kosuke Minaga
Biliary and pancreatic diseases are common, but accurate image diagnosis are often challenging due to the complexities of structures and locations. There are wide ranges of possible diagnosis of biliary tract
Ultrasound in Medicine and Biology
devices lead to expansion of its targets, such as bile duct, gallbladder, pancreatic duct, and so on. EUS-guided celiac plexus neurolysis (EUS-CPN) was reported as the first EUS-guided injection/ablation. During EUS-CPN, ethanol is injected into celiac plexus under the guide of EUS to relieve pain in patients with an upper abdominal cancer. EUS-CPN reportedly achieved more pain relief than using narcotic drugs alone. Modification of this technique such as ganglia neurolysis and broad plexus neurolysis further improved its efficacy. Ethanol injection recently expanded for ablation of cystic or solid tumors in the pancreas. EUS-guided radiofrequency ablation is currently applied to ablation of these tumors. Moreover, EUS-guided coiling has been used for embolization of gastric varices. In conclusion, interventional EUS became essential or rescue treatment of various digestive diseases. Its target is expected to expand to the other more fields in the future. T12-16-IN07 EUS-Guided Radiofrequency Ablation for the Management of Pancreatic Tumors Dong Wan Seo, MD, PhD Professor of Medicine, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Endoscopic ultrasound (EUS) became an indispensable tool not only for the diagnosis but also for the management of pancreatic tumors. With the modification of EUS-guided fine needle aspiration (EUS-FNA) technology, EUS-guided fine needle injection (EUS-FNI), EUS-guided ablation and other interventions can be applied for various solid or cystic lesions in the pancreas. Local ablative modalities such as radiofrequency ablation (RFA) or photodynamic therapy (PDT) are also applied to pancreas in animal studies. RFA is primarily delivered to liver percutaneously or intraoperatively. EUS-guided RFA in a pig model proved that this modality can also be delivered to the pancreas trans-gastrically and cause well-demarcated coagulation zone. This modality, however, should be improved and refined to reduce the possible complications such as pancreatitis, gastric burn or perforation. Our group conducted EUS-guide RFA human trial for unresectable pancreatic cancer and showed technical feasibility and safety of EUS-RFA for pancreatic cancer. Further studies are required to see the long-term efficacy and survival benefit of this adjunctive modality for pancreatic cancer. EUS-RFA can be applied for the management of small pancreatic or peripancreatic tumors such as neuroendocrine tumor, adrenal tumor and small lymph node metastasis. Initial studies using EUS-RFA for the treatment of pancreatic neuroendocrine tumor showed very promising result without any serious complication. EUS-RFA seems to be very useful especially for the management of insulinoma. Since the patient presents with recurrent hypoglycemic attack, insulinoma is generally small in size at the time of diagnosis. It can be easily ablated under EUS-RFA and the functionality can be controlled very effectively. EUS-RFA is also applied for the management of cystic tumor of the pancreas. However, only animal study are reported using GB and cystic duct of pig and more studies are required before direct human application. In conclusion, EUS-guided approach offers minimally invasive access for delivery of local ablation modalities including EUSRFA. This area is a continuously evolving field and many studies are currently undergoing. Although many of these approaches are still investigational but will play a key role in the treatment of benign and malignant pancreatic disease in the future.
Volume 43, Number S1, 2017 Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan In recent years, evidence suggests that a minimally invasive step-up approach is superior to conventional open necrosectomy, with decreased rates of the composite end point of major complications or death among patients with necrotizing pancreatitis and walled-off necrosis (WON). Since first described in 1992, EUSguided transluminal drainage for pancreatic fluid collection has played a pivotal role and spread worldwide as a minimally invasive alternative to surgical and percutaneous drainage with reportedly high technical and clinical success rates. However, the clinical response rate of the conventional single transluminal gateway technique with single stenting for treating WON is not satisfactory (described as 45%–63%). Recently, various techniques, such as the use of wide-caliber lumen-apposing metal stents, multiple transluminal gateway technique and direct endoscopic necrosectomy have improved the clinical success rate of endoscopic management of WON. When conventional EUS fails to depict the WON reflecting solid necrotic components, contrast-enhanced EUS may be useful to clearly visualize target lesions and to decisively puncture them. We evaluated the clinical outcomes of the algorithmic step-up approach based on EUS-guided drainage for WON. The result shows the step-up approach based on EUS-guided drainage is an effective strategy for the management of WON, particularly in patients with serious comorbid conditions or in those with WON cavity extending to the pelvis, who are difficult to manage with endoscopy alone. More options, such as surgical necrosectomy should be considered. In conclusion, EUS-guided intervention has become an essential treatment method of WON. The development of new dedicated devices for EUS-guided drainage would help make it a more sophisticated and promising procedure. T12-16-IN09 Intraductal Ultrasonography (IDUS) for the Diagnosis of Biliopancreatic Diseases Cheuk-Kay Sun, MD Division of Hepatology and Gastroenterology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Although endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic procedure of choice for patients with pancreatobiliary lesions, it is limited in diagnostic accuracy. Intraductal ultrasonography (IDUS) is an imaging modality having unique characteristics and suitable for imaging of a narrow ductal cavity, its wall and the neighbouring structures. As IDUS uses high-frequency ultrasound (20 MHz), its image quality is very high within approximately 2-cm range of radius. The bile duct and the pancreatic duct, and therefore are good targets for the assessment by IDUS. Biliopancreatic IDUS is mainly performed through the papilla of Vater in the same session as endoscopic retrograde cholangiopancreatography (ERCP). Technically easy, IDUS is a valuable adjunct to endoscopic retrograde cholangiography that increases the ability to distinguish malignant from benign pancreatobiliary lesions. T12-16-IN10
T12-16-IN08
EUS for Biliary Tract Stricture Meng-Shun Sun Gastroenterology, Internal medicine, Yuan’s General Hospital, Kaohsiung
EUS-Guided Interventions for Walled-off Pancreatic Necrosis Kosuke Minaga
Biliary and pancreatic diseases are common, but accurate image diagnosis are often challenging due to the complexities of structures and locations. There are wide ranges of possible diagnosis of biliary tract