What are the current and potential future roles for endoscopic ultrasound in the treatment of pancreatic cancer?

Figure 1 Endoscopic ultrasound-guided injection into the celiac ganglion. A: Celiac ganglion visualized by linear endoscopic ultrasound as a hypoechoic structure anterior to the aorta (arrow); B: 19-gauge needle puncture into the celiac ganglia for neurolysis.

Figure 2 A 84 years old male with duodenal adenocarcinoma causing biliary obstruction underwent endoscopic ultrasound-guided choledochoduodenostomy following unsuccessful endoscopic retrograde cholangiopancreatography. A: Tumor involving the major papilla; B: Endoscopic ultrasound-guided puncture of the common bile duct through the duodenum with a 19-gauge needle; C: Guidewire insertion and balloon dilation of a choledochoduodenal fistula; D: Followed by the placement of a 10 mm × 10 mm lumen-apposing metal stent to create a choledochoduodenostomy; E and F: Endoscopic (E) and flouroscopic (F) view after the placement of a 7 Fr × 3 cm double pigtail stent into the common hepatic duct.

Figure 3 A 66 years old female with metastatic cholangiocarcinoma and gastric outlet obstruction undergoing endoscopic ultrasound-guided gastrojejunostomy. A: Tumor ingrowth into two previously placed duodenal stents; B: Endoscopic ultrasound visualization of a 20 mm balloon inflated in the proximal jejunum followed by a 19-gauge needle puncture (arrow); C and D: Balloon dilation of the gastrojejunal fistula over a 0.035 inch guidewire; E and F: Endoscopic (E) and fluoroscopic (F) demonstration of contrast flow across 10 mm × 15 mm lumen-apposing metal stent (arrow) into the jejunum.

Figure 4 Magnetic anastomosis device to create endoscopic gastrojejunostomy (Images courtesy of Cook Medical). A: Gastric magnent marked with an endoscopy clip; B: Mating of gastric and proximal jejunal magnets under fluoroscopic guidance to create a gastrojejunal fistula; C: Placement of a fully covered stent within the fistula with a proximal flanged edge positioned in the gastric lumen; D: The stent within the fistula functions as a gastrojejunostomy.

Figure 5 Images courtesy of Sanders et al[74]. A: Fiducial loaded into 19-gauge needle with sterile forceps; B: Fiducial within tip of needle; C: Sealing fiducial with sterile bonewax; D: Loaded fiducial ready for advancement down operating channel; E and F: Needle delivering fiducial into pancreatic mass (arrow).