Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey

Figure 30 Endoscopic aultrasound guided portosystemic pressure gradient measurement in a patient with suspected cirrhosis. A: Diagram showing fine needle aspiration (FNA) needle within the middle hepatic vein; B: Endoscopic ultrasound (EUS) image of middle hepatic vein with Doppler wave form demonstrating 4 phases (ASVD); C: 25G needle placed directly through liver parenchyma into the middle hepatic vein; compact hand-held manometer showing a pressure of 13 mmHg; D: Diagram FNA needle within the left portal vein; E: EUS image of left portal vein (umbilical portion); typical Doppler waveform showing venous hum; F: 25G needle placed directly through liver parenchyma into the left portal vein; compact hand-held manometer showing a pressure of 15 mmHg. Thus, the EUS-portosystemic pressure gradient measurement is 2 mmHg, which is within normal range.