Endoscopic Ultrasonography-Specific Stents

The evolution of the endoscopic ultrasonography (EUS) technique has necessitated the development of EUS-specific accessories and stents. In the earlier period, EUS-guided interventions mostly relied on borrowed accessories and stents from therapeutic endoscopy in particular ERCP. Traditional stents do not serve the purpose of EUS-guided transluminal stenting in all cases due to the length of the stent, no anchoring mechanism, and chance of migration. From 2011 onward, several EUS-specific stents became available, bringing a paradigm shift in interventional EUS. This article reviews current EUS-specific stents, indications, strengths, and weaknesses.

The Role of Contrast-Enhanced Harmonic Endoscopic Ultrasound in Interventional Endoscopic Ultrasound

Over the last decades, contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) has emerged as an important diagnostic tool for the diagnosis and differentiation of several gastrointestinal diseases. The key advantage of CH-EUS is that the influx and washout of contrast in the target lesion can be observed in real time, accurately depicting microvasculature. CH-EUS is established as an evidence-based technique complementary to B-mode EUS to differentiate solid appearing structures, to characterize mass lesions, and to improve the staging of gastrointestinal and pancreatobiliary cancer. In the last few years, interest has increased in the use of CH-EUS in interventional procedures such as tissue acquisition, tumor ablation, biliary drainage, and the management of pancreatic fluid collections. The aim of this narrative review is to evaluate the available evidence and future expectations of CH-EUS in interventional EUS.

The Role of Interventional Endoscopic Ultrasound in Liver Diseases: What Have We Learnt?

Chronic liver disease (CLD) is still a major problem, where the disease progression will lead to liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Portal hypertension (PH) management and loco-regional therapy for HCC have become the cornerstones in advanced liver disease management. Recently, there are studies looking at the potential role of interventional endoscopic ultrasound (EUS) in liver diseases. EUS may be useful in vascular changes of the digestive wall evaluation, performing dynamic assessment of hemodynamic changes, predicting variceal bleeding and rebleeding risk, and assessing the pharmacological effects. In PH management, EUS-guided vascular therapy—which revolves around glue injection, endovascular coil placement/embolization, and combination of both—has shown promising results. As a diagnostic modality for liver cancer, the implementation of EUS in liver diseases is currently not only limited to liver biopsy (EUS-LB) but also in shear-wave elastography (SWE) and portal pressure gradient measurement, as well as portal vein sampling. The application of EUS-guided radiofrequency ablation (EUS-RFA) and tumor injection can also overcome the limitations shown by both modalities without EUS. Nevertheless, establishing EUS as a firm diagnostic and therapeutic modality is still challenging since the performance of interventional EUS requires high expertise and adequate facilities.

Recent Advances of Interventional Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound for Patients with Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the gold standard for diagnosis and interventions in biliopancreatic diseases. However, ERCP in patients with surgically altered anatomy (SAA) appears to be more difficult compared to cases with normal anatomy. Since the production of a balloon enteroscope (BE) for small intestine disorders, BE had also been used for biliopancreatic diseases in patients with SAA. Since the development of BE-assisted ERCP, the outcomes of procedures, such as stone extraction or drainage, have been reported as favorable. Recently, an interventional endoscopic ultrasound (EUS), such as EUS-guided biliary drainage (EUS-BD), has been developed and is available mainly for patients with difficult cases of ERCP. It is a good option for patients with SAA. The effectiveness of interventional EUS for patients with SAA has been reported. Both BE-assisted ERCP and interventional EUS have advantages and disadvantages. The choice of procedure should be individualized to the patient’s condition or the expertise of the endoscopists. The aim of this review article is to discuss recent advances in interventional ERCP and EUS for patients with SAA.

Personalized Approach to the Role of Endoscopic Ultrasound in the Diagnosis and Management of Pancreaticobiliary Malignancies

Pancreaticobiliary malignancies arise from different areas within the pancreas and biliary tree. Endoscopic ultrasound (EUS) is a well-recognized diagnostic and therapeutic modality in the treatment of pancreaticobiliary diseases, and more specifically, pancreaticobiliary malignancies. Traditionally used for diagnostic purposes, EUS plays a critical role in tissue sampling and cancer staging. The emergence of the new field of interventional EUS has allowed EUS to also play a critical role in therapeutic management. Novel interventional EUS procedures such as EUS-guided gastrojejunostomy (EUS-GE), EUS-guided biliary drainage (EUS-BD), and EUS-guided gallbladder drainage (EUS-GLB) can be utilized to treat complications of pancreaticobiliary malignancies such as gastric outlet obstruction, obstructive jaundice, and cholecystitis. In addition, interventional EUS procedures can be utilized for the palliation of unresectable malignancies both for source control with EUS-radiofrequency ablation (EUS-RFA) and for the treatment of abdominal pain refractory to opioid medications with EUS-guided celiac axis neurolysis. However, patient selection remains a critical component in both diagnostic and therapeutic interventions and must be tailored to individual patient wishes, disease pathology, and overall prognosis.