Frontier
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
Table 1 Technique of endoscopic ultrasound guided paracentesis[1-3,9-11]
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], 1995Case report2 casesCT (pleural effusion and ascites)------Malignant effusion and ascites-
Romero-Castro et al[14], 2017Case series3 casesDLBCL (1 case), HCC (2 cases)60/74/553/-19 G FNA (all cases)TG (3 cases)Double Pigtail placement (3 cases)-Malignant ascites (3 cases)None
Wardeh et al[16], 2011Retrospective study101Ascites not detected in 6/9 cases on CT68.354/4719 G FNANA10 mL (max) in 90 cases, 2 smears in 11 cases74 negative84 malignantNone
Suzuki et al[11], 2014Retrospective study11 casesCT (no ascites in 4)66.47/422 G (automatedspring-loaded)NA14.1 mL (range 0.5-38 mL)Benign 5; malignant 6NANone
Kaushik et al[10], 2006Retrospective study25NA66-7016/922/25 G FNABoth6.8 mL (range, 1-20 mL)64% malignant (benign 9; malignant 16)Benign 8; malignant 171 cases (4%) (bacterial peritonitis)
Lee et al[4], 2005Retrospective study250 casesCT in all60.3160/90NANANA37% ascites, 28% peritoneal metastasisAll malignantNone
Dewitt et al[5], 2007Retrospective study60CT/MRI/USG in all (ascites 31 cases (51%)6733/2722 G55 (TG), 5 (TD)8.9 (1-40) mLBenign 42; malignant/atypical 18Benign 15; malignant 452 cases fever
Köck et al[13], 2018Case report2 casesRectal cancer, ovarian cancer36, 56-/219 GBoth TGPigtail (plastic) placed--None
Nguyen and Chang[2], 2001Retrospective study31 cases (of 85)CT had ascites in 14/79 (18%)NANANANA7.9 (1-40 mL)Malignant 5; benign 26NANone
Varadarajulu and Drelichman[3], 2008Case report1SCC anus31-/119 GTG (1)10 mL (diagnostic); 5 L (therapeutic)Malignant ascitesNANone
Table 3 Structures visualized with endoscopic ultrasound in the liver
Structure
Features
Doppler
Portal vein branchesThick and hyperechoic wallsPositive signal
Hepatic vein branchesThin, non-reflective walls, straight course Positive signal
Biliary radicalHyperechoic walls, irregular courseNegative signal
Ligaments (teres and venosum)Thick, hyperechoic (no lumen) (between vessels and Glisson’s capsule)Negative signal
GallbladderCystic structure, hyperechoic walls, anechoic content Negative signal
Falciform ligamentThick, hyperechoic (no lumen); on the left anterior to segment III, on the right anterior to segment IVa and IVbNegative signal
Hepatic arteryThick with reflective wallsPositive 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]Prospective1410020
TenBerge et al[33]Retrospective2688.6-3.8% (fever)
DeWitt et al[34]Retrospective77913.4 (mean)0
Hollerbach et al[35]Prospective33941.4 ± 0.66.1% (self-limited bleeding)
McGrath et al[36]Prospective710020
Singh et al[26]Prospective988.920
Singh et al[27]Prospective26962.10
Crowe et al[37]Retrospective16753 (minimum)0
Prachayakul et al[38]Retrospective141000
Oh et al[39]Prospective4790.530
Ichim et al[25]Prospective489820
EUS-FNB
Lee et al[40]Prospective2190.520
Chon et al[41]Retrospective5889.721.7% (bleed)
Table 5 Technique of endoscopic ultrasound guided liver biopsy[50,51]
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]Retrospective1101009838 (24-81)14 (9-27)19 G-0
Shuja et al[58]Retrospective6910010045.8 (mean)10.84 (mean)19 G30
Stavropoulos et al[50]Prospective case series221009136.9 (2-184.6)9 (1-73)19 G2 (1-3)0
Diehl et al[59]Prospective non randomized1101009838 (0-203)14 (0-68)19 G1.5 (1-2)1 (0.9) (mild bleeding)
Gor et al[60]Retrospective case series1010010013 (6-23)8 (6-15)19 G-0
EUS-FNB guided liver biopsy
Shah et al[61]Retrospective241009665.6 (17-167.4)32.5 (5-85)19 G (SharkCore)2 (1-3)2 (8.3)
Nieto et al[62]Retrospective16510010060 (43-80)18 (13-24)19 G (SharkCore)13 (1.8)
Mathew[63]Case report2100100--19 G (QuickCore)-0
Ching et al[55]Prospective (RCT)20; 20100; 100100; 100114 (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; 40100; 10088; 68-; --; -19 G (FNA); 22 G (SharkCore)-; -0; 1 (2.5)
Patel et al[64]Retrospective30; 50; 28; 27100; 100; 100; 10066.7; 46; 82.1; 81.51.8 (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]Retrospective910010013 (8-28)7 (5-8)19 G (QuickCore)2 (1-3)0
DeWitt et al[66]Prospective case series2110090.59 (1-23)2 (0-10)19 G (QuickCore)3 (1-4)0
Nakai et al[67]Case report1100100158ProCore 19 G0
Sey et al[68]Prospective cross sectional study45; 30100; 10073.3; 96.79 (0-25); 20 (5-60)2 (0-15); 5 (0-24)QuickCore 19 G; ProCore 19 G3; 22 (4.4); 0
Hasan et al[69]Prospective (RCT)4010010055 (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 report1Segment 8100Complete0
Lisotti et al[85]Case report1Segment 2100Complete0
Nakaji et al[86]Case report1Segment 3100Complete 0
Nakaji et al[87]Retrospective12Caudate lobe100Complete2 (16.7%)
Jiang et al[88]RCT10Left lobe92Partial (30%)0
Alcohol ablation in liver metastasis
Barclay et al[89]Case report1Left lobe100CompleteSelf-limited sub-capsular hematoma
Hu et al[103]Case report1Left lobe100CompleteLow grade fever
RFA (radiofrequency ablation) in HCC
Armellini et al[91]Case report1Left lobe100CompleteNone
Attili et al[92]Case report1Segment 3100CompleteNone
de Nucci et al[93]Case report1Segment 2-3-4b10070% reductionNone
Ablation by Nd-YAG
Di Matteo et al[95]Case report1Caudate lobe100Complete0
Jiang et al[96]Prospective10Left lobe100Complete0
Brachytherapy (Iodine-125)
Jiang et al[88]RCT13Left lobe92Near complete0
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