13 & 14 december 2010, fourth annual course hotel okura amsterdam, the netherlands 13 & 14...

13 & 14 December 201013 & 14 December 2010, Fourth Annual Course, Fourth Annual Course

Hotel Okura Amsterdam, the NetherlandsHotel Okura Amsterdam, the Netherlands

13 & 14 December 201013 & 14 December 2010, Fourth Annual Course, Fourth Annual Course

Hotel Okura Amsterdam, the NetherlandsHotel Okura Amsterdam, the Netherlands

Paul Fockens, MD PhDPaul Fockens, MD PhDProfessor of Gastrointestinal Endoscopy,Academic Medical Center, University of

Amsterdam

Baltahasar Geeraerts Symposium 2010Baltahasar Geeraerts Symposium 2010

What is the role of What is the role of EUS in cholelithiasis?EUS in cholelithiasis?

EUS in cholelithiasis

• History

• Instruments

• EUS for cholecystolithiasis

• EUS for choledocholithiasis

• Conclusions and future of EUS in gallstones

History of EUS in clinical practice• Started as a technique to image organs

outside GI-tract (US, start of ERCP, no CT, no MR)

• Staging of luminal tumors quickly followed (esophagus, stomach, colorectum)

• Next major breakthrough: EUS-guided FNA

• 2009: non-invasive staging by excellent CT & MR

• 2010+: EUS for early diagnosis and guided Rx

EUS in cholelithiasis

• History

• Instruments

• EUS for cholecystolithiasis

• EUS for choledocholithiasis

• Conclusions and future of EUS in gallstones

Instruments & Accesories

High-end US processors (Aloka, Hitachi. ...)

• Elastography

• Tissue Harmonic Imaging

• Contrast Enhanced EUS

• .......

Instruments & Accesories• 360° Radial array

vs. Linear array

EUS in choledocholithiasis

EUS in cholelithiasis

• History

• Instruments

• EUS for cholecystolithiasis

• EUS for choledocholithiasis

• Conclusions and future of EUS in gallstones

EUS in cholecystolithiasis• Transabdominal US is standard for

galbladder stones

• EUS may be useful in case of:– Multiple very small stones (sludge)

– Poor imaging because of obesity

• Indication for EUS in cholecystolithiasis– Strong suspicion of gallbladder stones

with negative non-invasive imaging

EUS in cholecystolithiasis

• 35 pts with biliary type pain and negative US

• EUS showed suspicion of stones in 18pts (52%)

• 15/17 proven during surgery

• 13/15 symptomfree at one year FU

EUS in cholecystolithiasis

EUS in cholelithiasis

• History

• Instruments

• EUS for cholecystolithiasis

• EUS for choledocholithiasis

• Conclusions and future of EUS in gallstones

EUS in choledocholithiasis• Imaging of CBD is not so difficult

anymore with excellent new equipment

• Experience is important (50-100/year)

• EUS only in low-probablility for CBD-stones?

• Should every ERCP for stones be preceded by EUS?

• How about acute pancreatitis?

EUS in choledocholithiasis

EUS in choledocholithiasis

EUS in choledocholithiasis

• ERCP vs. EUS +/- ERCP• 65pts with elevated LFT’s or dilated

CBD (8 or 10mm)• ERCP: 7/32 pts (22%) with CBD-stones• EUS +/- ERCP: 9/33pts (27%) CBD-

stones• 1pt in each group recurrent symtoms

EUS in choledocholithiasis

• 4 trials selected (423pts)

• In EUS group, ERCP was avoided in 74%

• EUS significantly reduced risk of ERCP associated complications

EUS in choledocholithiasis

risk of acute pancreatitis

EUS in cholelithiasis

• History

• Instruments

• EUS for cholecystolithiasis

• EUS for choledocholithiasis

• Conclusions and future of EUS in gallstones

Conclusions & future use• EUS is most sensitive technique for

CBD-stones, more sensitive than MRCP

• EUS is invasive and requires expertise

• Restriction of ERCP to (very) experienced seems imminent (raise req/yr from 40100)

• Combine EUS with ERCP in:– Unexplained obstrcutive jaundice

– All pts referred for treatment of CBD-stones

13 & 14 December 201013 & 14 December 2010, Fourth Annual Course, Fourth Annual Course

Hotel Okura Amsterdam, the NetherlandsHotel Okura Amsterdam, the Netherlands

13 & 14 December 201013 & 14 December 2010, Fourth Annual Course, Fourth Annual Course

Hotel Okura Amsterdam, the NetherlandsHotel Okura Amsterdam, the Netherlands