Copyright
©The Author(s) 2021.
World J Hepatol. Nov 27, 2021; 13(11): 1459-1483
Published online Nov 27, 2021. doi: 10.4254/wjh.v13.i11.1459
Published online Nov 27, 2021. doi: 10.4254/wjh.v13.i11.1459
| Pre-procedure requirements |
| (1) No recommendations exist for EUS-P, although most studies have been performed under the cover of pre/peri-procedural antibiotics; and (2) Patient is usually fasted for 4-6 h before the procedure |
| Technical aspects |
| (1) EUS-P is usually performed using a 22 G/25 G FNA needle. A specialized spring-loaded 22 G FNA needle can also be used for the same; (2) The approach can be transgastric or transduodenal. The tip of the needle is visualized under EUS guidance in the ascites; (3) At the time of puncture, care is taken to avoid a trajectory involving any tumor/vessels to avoid peritoneal seeding or bleeding; (4) For therapeutic paracentesis, a suction tube attached to a vacuum canister can be used; (5) Repositioning of the needle is carried out in case it gets blocked by the tumor or omentum; (6) Two and fro motion is usually not needed; (7) CE-EUS followed by FNA of the peritoneal/omental nodules can also be done for added diagnostic value; and (8) The sample aspirated is sent for routine cytological assessment and for any additional tests that might be needed |
| Post procedure |
| The administration of albumin post 5 L of paracentesis and post procedure observation are carried out as per standard recommendations (EASL, AASLD) |
Table 2 Studies on endoscopic ultrasound guided paracentesis
| Ref. | Study design | Patient population | Imaging | Age (yr) | Gender (M/F) | Needle | Route (TG/TD) | Amount of fluid aspirated | Diagnosis on EUS | Actual diagnosis | Complications |
| Chang et al[12], 1995 | Case report | 2 cases | CT (pleural effusion and ascites) | - | - | - | - | - | - | Malignant effusion and ascites | - |
| Romero-Castro et al[14], 2017 | Case series | 3 cases | DLBCL (1 case), HCC (2 cases) | 60/74/55 | 3/- | 19 G FNA (all cases) | TG (3 cases) | Double Pigtail placement (3 cases) | - | Malignant ascites (3 cases) | None |
| Wardeh et al[16], 2011 | Retrospective study | 101 | Ascites not detected in 6/9 cases on CT | 68.3 | 54/47 | 19 G FNA | NA | 10 mL (max) in 90 cases, 2 smears in 11 cases | 74 negative | 84 malignant | None |
| Suzuki et al[11], 2014 | Retrospective study | 11 cases | CT (no ascites in 4) | 66.4 | 7/4 | 22 G (automatedspring-loaded) | NA | 14.1 mL (range 0.5-38 mL) | Benign 5; malignant 6 | NA | None |
| Kaushik et al[10], 2006 | Retrospective study | 25 | NA | 66-70 | 16/9 | 22/25 G FNA | Both | 6.8 mL (range, 1-20 mL) | 64% malignant (benign 9; malignant 16) | Benign 8; malignant 17 | 1 cases (4%) (bacterial peritonitis) |
| Lee et al[4], 2005 | Retrospective study | 250 cases | CT in all | 60.3 | 160/90 | NA | NA | NA | 37% ascites, 28% peritoneal metastasis | All malignant | None |
| Dewitt et al[5], 2007 | Retrospective study | 60 | CT/MRI/USG in all (ascites 31 cases (51%) | 67 | 33/27 | 22 G | 55 (TG), 5 (TD) | 8.9 (1-40) mL | Benign 42; malignant/atypical 18 | Benign 15; malignant 45 | 2 cases fever |
| Köck et al[13], 2018 | Case report | 2 cases | Rectal cancer, ovarian cancer | 36, 56 | -/2 | 19 G | Both TG | Pigtail (plastic) placed | - | - | None |
| Nguyen and Chang[2], 2001 | Retrospective study | 31 cases (of 85) | CT had ascites in 14/79 (18%) | NA | NA | NA | NA | 7.9 (1-40 mL) | Malignant 5; benign 26 | NA | None |
| Varadarajulu and Drelichman[3], 2008 | Case report | 1 | SCC anus | 31 | -/1 | 19 G | TG (1) | 10 mL (diagnostic); 5 L (therapeutic) | Malignant ascites | NA | None |
Table 3 Structures visualized with endoscopic ultrasound in the liver
| Structure | Features | Doppler |
| Portal vein branches | Thick and hyperechoic walls | Positive signal |
| Hepatic vein branches | Thin, non-reflective walls, straight course | Positive signal |
| Biliary radical | Hyperechoic walls, irregular course | Negative signal |
| Ligaments (teres and venosum) | Thick, hyperechoic (no lumen) (between vessels and Glisson’s capsule) | Negative signal |
| Gallbladder | Cystic structure, hyperechoic walls, anechoic content | Negative signal |
| Falciform ligament | Thick, hyperechoic (no lumen); on the left anterior to segment III, on the right anterior to segment IVa and IVb | Negative signal |
| Hepatic artery | Thick with reflective walls | Positive signal |
Table 4 Studies on endoscopic ultrasound guided fine needle aspiration/fine needle biopsy of focal liver lesions
| Ref. | Design | Patients | Diagnostic yield (%) | Needle passes (median) | Complications |
| EUS-FNA | |||||
| Nguyen et al[32] | Prospective | 14 | 100 | 2 | 0 |
| TenBerge et al[33] | Retrospective | 26 | 88.6 | - | 3.8% (fever) |
| DeWitt et al[34] | Retrospective | 77 | 91 | 3.4 (mean) | 0 |
| Hollerbach et al[35] | Prospective | 33 | 94 | 1.4 ± 0.6 | 6.1% (self-limited bleeding) |
| McGrath et al[36] | Prospective | 7 | 100 | 2 | 0 |
| Singh et al[26] | Prospective | 9 | 88.9 | 2 | 0 |
| Singh et al[27] | Prospective | 26 | 96 | 2.1 | 0 |
| Crowe et al[37] | Retrospective | 16 | 75 | 3 (minimum) | 0 |
| Prachayakul et al[38] | Retrospective | 14 | 100 | 0 | |
| Oh et al[39] | Prospective | 47 | 90.5 | 3 | 0 |
| Ichim et al[25] | Prospective | 48 | 98 | 2 | 0 |
| EUS-FNB | |||||
| Lee et al[40] | Prospective | 21 | 90.5 | 2 | 0 |
| Chon et al[41] | Retrospective | 58 | 89.7 | 2 | 1.7% (bleed) |
| Pre-biopsy: The following workup is needed in all cases of liver biopsy |
| (1) Coagulation work up including platelet count, PT/INR and BT/CT; (2) Prior to the biopsy, the medications should be stopped as follows: anti-platelet medications 7 d, warfarin 5 d, heparin and related products discontinued 12-24 h prior to biopsy; and (3) Use of conscious sedation such as midazolam and nalbuphine or propofol as per operator’s preference or patient comfort |
| Procedural details of EUS-LB |
| (1) A linear array echoendoscope (Olympus GF-UCT180, Center Valley, United States) is generally used for the procedure; (2) Prior to the procedure, Doppler imaging is done to ensure that no vascular structures are present along the expected trajectory of the needle; (3) The EUS-LB can be performed using a 19 G EUS-FNA/FNB needle; (4) The left lobe is identified first, as that liver parenchyma which is a few centimeters below the gastro-esophageal junction with the scope torqued clockwise. The right lobe if needed to be biopsied, is accessed from the duodenal bulb. Two site biopsy can be undertaken at the discretion of the endosonographer; (5) A preferably long vessel free trajectory allowing free passage of the needle to a depth of at least 3 cm or more is usually selected; (6) For wet heparin suction, the stylet is removed and the needle is primed with a heparin flush and the suction syringe is reattached to the needle hub; (7) The needle is then introduced into the echoendoscope channel; (8) Once liver parenchymal penetration is achieved with the needle (around 1-2 cm), full suction is applied with the 20 mL vacuum syringe with fluid column; (9) One pass consists of a total of 4-5 to-and-fro needle motions using the fanning technique under direct EUS guided visualization of the tip of the needle. Two such passes are usually taken (maximum 10 actuations); and (10) The specimen is pushed from the needle directly into the formalin solution using the stylet or saline flush |
| Post-liver biopsy: The following instructions are to be followed in all cases post liver biopsy |
| (1) The patient post biopsy, irrespective of the type of procedure, is transferred to the post procedure recovery room and monitored as per the AASLD protocol[69]; (2) The minimum observation period is 2-4 h; (3) Post-procedure pain and need for analgesics to be noted and provided; and (4) Patient is asked to report adverse events at specific time intervals (as per institute policy) |
Table 6 Studies on endoscopic ultrasound guided fine needle aspiration guided and endoscopic ultrasound guided fine needle biopsy guided liver biopsy in patients with chronic liver disease
| Ref. | Design of the study | Patients | Technical success (%) | Diagnostic yield (%) | Specimen length (median, range) (mm) | CPT (median, range) | Needle used for EUS-LB | Needle passes (median) | Complications, n (%) |
| EUS-FNA guided liver biopsy | |||||||||
| Pineda et al[57] | Retrospective | 110 | 100 | 98 | 38 (24-81) | 14 (9-27) | 19 G | - | 0 |
| Shuja et al[58] | Retrospective | 69 | 100 | 100 | 45.8 (mean) | 10.84 (mean) | 19 G | 3 | 0 |
| Stavropoulos et al[50] | Prospective case series | 22 | 100 | 91 | 36.9 (2-184.6) | 9 (1-73) | 19 G | 2 (1-3) | 0 |
| Diehl et al[59] | Prospective non randomized | 110 | 100 | 98 | 38 (0-203) | 14 (0-68) | 19 G | 1.5 (1-2) | 1 (0.9) (mild bleeding) |
| Gor et al[60] | Retrospective case series | 10 | 100 | 100 | 13 (6-23) | 8 (6-15) | 19 G | - | 0 |
| EUS-FNB guided liver biopsy | |||||||||
| Shah et al[61] | Retrospective | 24 | 100 | 96 | 65.6 (17-167.4) | 32.5 (5-85) | 19 G (SharkCore) | 2 (1-3) | 2 (8.3) |
| Nieto et al[62] | Retrospective | 165 | 100 | 100 | 60 (43-80) | 18 (13-24) | 19 G (SharkCore) | 1 | 3 (1.8) |
| Mathew[63] | Case report | 2 | 100 | 100 | - | - | 19 G (QuickCore) | - | 0 |
| Ching et al[55] | Prospective (RCT) | 20; 20 | 100; 100 | 100; 100 | 114 (mean); 153.2 (mean) | 16.5 (6-38); 38 (0-81) | 19 G (FNA); 19 G (Acquire) | -- | 8 (40); 7 (35) |
| Mok et al[56] | Prospective (RCT) | 40; 40 | 100; 100 | 88; 68 | -; - | -; - | 19 G (FNA); 22 G (SharkCore) | -; - | 0; 1 (2.5) |
| Patel et al[64] | Retrospective | 30; 50; 28; 27 | 100; 100; 100; 100 | 66.7; 46; 82.1; 81.5 | 1.8 (mean); 4.7 (mean); 1.9 (mean); 8.4 (mean) | 6.9 (mean); 3 (mean); 7.3 (mean); 16.9 (mean) | Acquire 22 G; QuickCore 19 G; ProCore 19 G; Expect 19 G | -; -; -; - | -; -; -; - |
| Gleeson et al[65] | Retrospective | 9 | 100 | 100 | 13 (8-28) | 7 (5-8) | 19 G (QuickCore) | 2 (1-3) | 0 |
| DeWitt et al[66] | Prospective case series | 21 | 100 | 90.5 | 9 (1-23) | 2 (0-10) | 19 G (QuickCore) | 3 (1-4) | 0 |
| Nakai et al[67] | Case report | 1 | 100 | 100 | 15 | 8 | ProCore 19 G | 0 | |
| Sey et al[68] | Prospective cross sectional study | 45; 30 | 100; 100 | 73.3; 96.7 | 9 (0-25); 20 (5-60) | 2 (0-15); 5 (0-24) | QuickCore 19 G; ProCore 19 G | 3; 2 | 2 (4.4); 0 |
| Hasan et al[69] | Prospective (RCT) | 40 | 100 | 100 | 55 (44.5-68) | 42 (28.5-53) | Acquire 22 G | - | 6 (15) |
Table 7 Studies in humans demonstrating the role of endoscopic ultrasound guided therapies for liver lesions
| EUS guided treatment | Study design | Patients | Location of the lesion | Technical success (%) | Response to therapy | Complications |
| Ethanol ablation in HCC | ||||||
| Nakaji et al[84] | Case report | 1 | Segment 8 | 100 | Complete | 0 |
| Lisotti et al[85] | Case report | 1 | Segment 2 | 100 | Complete | 0 |
| Nakaji et al[86] | Case report | 1 | Segment 3 | 100 | Complete | 0 |
| Nakaji et al[87] | Retrospective | 12 | Caudate lobe | 100 | Complete | 2 (16.7%) |
| Jiang et al[88] | RCT | 10 | Left lobe | 92 | Partial (30%) | 0 |
| Alcohol ablation in liver metastasis | ||||||
| Barclay et al[89] | Case report | 1 | Left lobe | 100 | Complete | Self-limited sub-capsular hematoma |
| Hu et al[103] | Case report | 1 | Left lobe | 100 | Complete | Low grade fever |
| RFA (radiofrequency ablation) in HCC | ||||||
| Armellini et al[91] | Case report | 1 | Left lobe | 100 | Complete | None |
| Attili et al[92] | Case report | 1 | Segment 3 | 100 | Complete | None |
| de Nucci et al[93] | Case report | 1 | Segment 2-3-4b | 100 | 70% reduction | None |
| Ablation by Nd-YAG | ||||||
| Di Matteo et al[95] | Case report | 1 | Caudate lobe | 100 | Complete | 0 |
| Jiang et al[96] | Prospective | 10 | Left lobe | 100 | Complete | 0 |
| Brachytherapy (Iodine-125) | ||||||
| Jiang et al[88] | RCT | 13 | Left lobe | 92 | Near complete | 0 |
Table 8 Steps of endoscopic ultrasound guided coil and glue placement for gastric varices obliteration
| Pre-procedure requirements |
| (1) All procedures are done under the cover of pre/peri-procedural antibiotics; (2) Patient is usually fasted for 4-6 h before the procedure; and (3) Adequate resuscitation of the patient, in case of active bleeding is ensured, prior to the procedure |
| Technical aspects |
| (1) The echoendoscope is usually positioned either in the distal esophagus or the gastric fundus; (2) Water is filled intra-luminally in the fundus. This enables a good acoustic coupling for better visualization of the gastric varices. Adequate examination of the fundus, the intramural varices and the feeder vessels is carried out; (3) The approach can be trans-esophageal or transgastric, wherein the trans-esophageal route is given preference; (4) EUS-guided coil and glue embolization is usually performed using a 22 G/19 G (gauge) FNA needle. The size of the coil is determined by the short axis of the diameter of the varix; (5) After puncture of the varix, blood is aspirated to confirm the location. This is followed by flushing of the needle with saline; (6) The coils are then deployed into the varix using the stylet as a pusher. Once the coils are deployed, flushing of the needle is done with normal saline; (7) After coil deployment, 1-2 mL of cyanoacrylate glue is injected over 30-45 s followed by rapid flushing with saline; and (8) Once, the varix is obliterated, visualized by absence of flow on color Doppler, the sheath of the needle is advanced beyond the endoscope tip for 2-3 cm before withdrawing the scope. This avoids contact of glue with the endoscope tip. The sample aspirated is sent for routine cytological assessment as well as for any additional tests that might be needed |
| Post procedure |
| (1) The patients are kept under observation for 12 h; (2) Repeat EUS can be done after 2 d to look for residual varices; and (3) Follow-up EUS can be performed at 1- and 3-mo intervals |
- Citation: Dhar J, Samanta J. Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends. World J Hepatol 2021; 13(11): 1459-1483
- URL: https://www.wjgnet.com/1948-5182/full/v13/i11/1459.htm
- DOI: https://dx.doi.org/10.4254/wjh.v13.i11.1459