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 17 October 2017

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Endoscopic ultrasound

Editor: Ian Penman


2. EUS equipment and technique

Anne Marie Lennon & Koji Matsuda

Fig. 1 (A) Olympus GF-UM2000 mechanical radial echoendoscope (distal tip). Note the transducer is distal to the oblique-forward viewing optics. (B) Proximal end of the same instrument (left)—in comparison to earlier models (right) the motor has been removed from the proximal end to make the instrument lighter.

Fig. 2 Wire-guided, 6.9 mm non-optical radial mechanical instrument (Olympus MH-908). This is particularly useful for traversing stenotic esophageal lesions.

Fig. 3 (A) Radial mechanical EUS processor for the instruments shown in Figs 1 and 2 (Olympus UM2000). (B) Hitachi processor for all available Pentax–Hitachi echoendoscopes (model EUB-6500).

Fig. 4 Electronic radial echoendoscopes. (A) Pentax–Hitachi EG3630UR has forward-viewing video optics and provides a 270° radial image. (B) Olympus GF-UE260-AL5. This has forward-oblique optics but provides a 360° radial image.

Fig. 5 Curved linear array echoendoscopes. (A) Olympus GF-UC240P. (B) Pentax–Hitachi FG-38X. This provides a linear array view parallel with the instrument shaft, allowing real-time imaging of a needle for interventional procedures. This model has a 3.7 mm instrument channel capable of taking 7 Fr stents for pseudocyst drainage.

Fig. 6 Examples of commonly available instruments for EUS. See [1] for further details.

Fig. 7 High-frequency catheter probes ('miniprobes') for EUS. (A) A variety of probes is available with varying imaging frequencies, diameters, and need for balloon sheaths. Wire-guided probes for pancreatico-biliary ductal imaging are also available. (B) Drive motor for Olympus catheter probes (MAJ-935).

Fig. 8 Catheter probes for EUS.

Fig. 9 A 2.8 mm wire-guided catheter probe for imaging in the biliary and pancreatic ducts (Olympus UM-G20-29R).

Fig. 10 Needles available for EUS.

Fig. 11 Needles for EUS. Handle of Echotip Ultra needle (Cook Endoscopy) showing adjustable guard to prevent excessive insertion of the needle.

Fig. 12 Distal tips of several EUS needles (Cook Endoscopy). From left to right: 19 G 'Quickcore' core biopsy needle (EUSN-19-QC), 22 G FNA needle (EUSN-3), and 20 G spray needle for celiac plexus neurolysis (EUSN-20-CPN).

Fig. 13 19 G 'Quickcore' needle after extension of tissue tray into target lesion. Upon fully depressing the plunger the spring-loaded outer sheath closes rapidly over the tray, trapping a tissue core in the tray.

Fig. 14 Low-power view of EUS-guided 19 G core ('Quickcore') biopsy from mediastinal lymph nodes in a patient with non-small cell lung cancer.

Fig. 15 Sonelastography. A developing technique which attempts to differentiate benign from malignant masses, especially in the pancreas, by differences in elasticity and deformity when gently compressed.

Fig. 16 'Virtual sonography' (Hitachi). Software developments may allow linkage of real-time EUS with CT data from the same patient, allowing scrolling images of the corresponding CT to be displayed as the ultrasound probe is moved.

Fig. 17 Endobronchial ultrasound. This echoendoscope has an outer diameter of 6.9 mm and a 2.0 mm instrument channel for FNA of transbronchial EBUS-FNA (Olympus BF-UC160F).

Copyright © Blackwell Publishing, 2006

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Introduction
History
Current applications
Therapeutic EUS
Teaching and training EUS
Synopsis
Introduction
Radial and linear endosonographic probes
Contrast-enhanced ultrasonography
Catheter-based EUS probes (miniprobes)
  Miniprobe technique
  Miniprobes in cancer
  Other uses of miniprobes
  Miniprobe limitations
Needles and accessories for EUS
  Fine-needle aspiration
   Different types of needles
   FNA technique
   Accuracy and safety
  Core tissue biopsies
   Technique
   Accuracy and safety
Outstanding issues and future trends
References
Synopsis
EUS for cancer staging
Esophageal cancer staging with EUS
  Esophageal cancer TNM staging
  Technique for performing EUS staging of esophageal cancer
  EUS of stenotic esophageal tumors
  EUS evaluation of superficial tumors
  EUS evaluation of lymph nodes
  EUS-FNA of peri-esophageal lymph nodes
  Accuracy and limitations of EUS staging of esophageal cancer
  EUS re-staging of esophageal cancer after chemoradiation
  Impact of EUS staging on esophageal cancer management
Gastric cancer staging with EUS
  Gastric cancer TNM staging
  EUS staging of advanced gastric adenocarcinoma
  EUS staging of early gastric adenocarcinoma
  EUS staging of gastric MALT lymphoma
Rectal cancer staging with EUS
  Rectal cancer TNM staging
  Pathologic staging of rectal cancer
  Surgical management of rectal cancer
  Management algorithm for rectal cancer (Fig. 17)
  Technique for performing EUS rectal cancer staging
  EUS staging of rectal cancer
  Accuracy of EUS in staging rectal cancer
  EUS vs. CT and MRI for rectal cancer staging
  EUS/FNA for rectal cancer lymph node staging
  Stenotic rectal tumors
  Rectal EUS staging after radiation therapy
  Colon cancer staging with EUS
Anal cancer staging with EUS
Pancreatic cancer
  Staging of pancreatic cancer
  EUS staging of pancreatic cancer (Figs 12,13)
  Combination of EUS and CT/MRI for pancreatic cancer staging and determining resectability
  EUS-FNA for staging pancreatic cancer
  Recommendations for EUS staging of pancreatic cancer
Ampullary cancer
Extrahepatic bile duct cancer
Future trends and outstanding issues
References
Synopsis
Introduction
Endoscopic and EUS examination
GISTs
  Origin and development of GISTs
  Molecular biology of GIST: c-kit
  CD34 and other immunohistochemistry
  Clinical features
  Pathology
  Predicting malignant behavior: role of molecular markers
  Predicting malignant behavior: role of EUS
  Tissue sampling of GISTs
  EUS-guided fine-needle aspiration
  Therapy: surgery
  Therapy: imatinib
Leiomyomas
  Clinical features and diagnosis
  EUS features
Lipomas
  Clinical features and diagnosis
  EUS features
Granular cell tumors
  Clinical features
  Pathology
  Endoscopic and EUS features
  Treatment of granular cell tumors
Duplication cysts
  Clinical features
  EUS features
  Treatment of duplication cysts
Carcinoid tumors
  Clinical features and pathology
  Biochemistry
  Endoscopic and EUS features
  Appendiceal carcinoids
  Ileal carcinoids
  Rectal carcinoids
  Gastric and duodenal carcinoids
Ectopic pancreas ('pancreatic rest')
  Clinical features
  EUS features
Extrinsic compressions
Varices
Future trends and outstanding issues
References
Synopsis
Morbid anatomy
  Pancreas
  Portal vein
  Common bile duct
Endosonographic anatomy
Performing EUS of the pancreas and biliary tree
  Body and tail of pancreas
   Radial EUS
   Linear EUS
  Head and uncinate process of pancreas
   Radial EUS
   Linear
Benign biliary disease
  Choledocholithiasis
  Choledochal cysts
  Primary sclerosing cholangitis (PSC)
Malignant biliary disease
  Ampullary carcinoma
  Cholangiocarcinoma
  Carcinoma of the gallbladder
Benign pancreatic disease
  Pancreatitis
   Acute pancreatitis
   Chronic pancreatitis
   Autoimmune pancreatitis
Cystic lesions of the pancreas
  Pseudocysts
  Cystadenomas
   Serous cystadenoma
   Mucinous cystadenoma
   Solid-cystic pseudopapillary tumor
   Intraductal mucin-producing tumor/neoplasm (IPMT/N)
   Mucinous cyst adenocarcinoma
Solid tumors of the pancreas
  Adenocarcinoma
   Screening for adenocarcinoma
  Neuroendocrine tumors
  Metastases
Training in pancreatico-biliary EUS
Outstanding issues and future trends
References
Synopsis
Non-invasive imaging modalities
  Chest CT
  Positron emission tomography
Invasive staging
Endoscopic ultrasound-guided fine-needle aspiration
  Accuracy for diagnosing malignancy
  EUS and identification of metastatic disease
  EUS technique
  Limitations of EUS-FNA
Combined minimally invasive staging with endoscopic ultrasound and endobronchial ultrasound
Outstanding issues and future trends
  EUS-FNA and molecular markers in lung cancer
References

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