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Review
. 2022 Apr 25:7:20.
doi: 10.21037/tgh-2020-12. eCollection 2022.

Therapeutic endoscopic ultrasound

Rodrigo Duarte-Chavez  1 , Michel Kahaleh  2
Affiliations
Review

Therapeutic endoscopic ultrasound

Rodrigo Duarte-Chavez et al. Transl Gastroenterol Hepatol. .

Abstract

Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.

Keywords: Gallbladder drainage; biliary drainage; endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography procedure (EDGE procedure); gastroenterostomy (GE); pancreatic duct drainage.

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Conflict of interest statement

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2020-12/coif). The series “Innovation in Endoscopy” was commissioned by the editorial office without any funding or sponsorship. MK reports Research Grant support from Boston Scientific, Apollo Endosurgery, Cook Endoscopy, NinePoint Medical, Merit Medical, Olympus, and Interscope Med. Consultant for Boston Scientific, Concordia Laboratories Inc, ABBvie and ERBE. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Distended gallbladder targeted under ultrasonography.
Figure 2
Figure 2
Puncture of the gallbladder under EUS with the cautery enhanced lumen-apposing metal stent. EUS, endoscopic ultrasound.
Figure 3
Figure 3
Deployment of the LAMS into the gallbladder. LAMS, lumen-apposing metal stent.
Figure 4
Figure 4
Puncture of the pancreatic duct under ultrasonography.
Figure 5
Figure 5
Contrast injection of the pancreas under EUS and fluoroscopy guidance. EUS, endoscopic ultrasound.
Figure 6
Figure 6
Antegrade advancement of the guidewire into the pancreatic duct and transpapillary.
Figure 7
Figure 7
Dilated intrahepatic biliary tree targeted under ultrasonography.
Figure 8
Figure 8
EUS guided puncture of the dilated left hepatic duct. EUS, endoscopic ultrasound.
Figure 9
Figure 9
Transgastric deployment of a fully covered metal stent with fins realizing a hepaticogastrostomy, with a double pigtail placed within.
Figure 10
Figure 10
Distended loop of bowel using saline mixed with methylene blue targeted under ultrasonography.
Figure 11
Figure 11
Deployment of the LAMS with methylene blue drainage confirming appropriate position of the gastrojejunostomy. LAMS, lumen-apposing metal stent.
Figure 12
Figure 12
Dilation of the LAMS with small bowel visualization. LAMS, lumen-apposing metal stent.
Figure 13
Figure 13
Puncture of the excluded stomach under ultrasonography guidance.
Figure 14
Figure 14
Deployment of the distal flange of the LAMS in the excluded stomach under EUS. LAMS, lumen-apposing metal stent; EUS, endoscopic ultrasound.
Figure 15
Figure 15
Deployment of the proximal flange of the LAMS in the pouch. LAMS, lumen-apposing metal stent.
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