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Praktiknjo M, Dollinger M, Braden B, Laleman W, Trebicka J. [Endo-Hepatology: New Endoscopic Solutions for Old Hepatological Problems]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2025. [PMID: 40306648 DOI: 10.1055/a-2590-9998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2025]
Abstract
With the rapid development of endoscopic ultrasound (EUS), diagnostic and therapeutic platforms have emerged that are applicable in hepatology. New tools such as EUS-guided portal pressure measurement (in combination with EUS-guided liver biopsy) or EUS-guided variceal obliteration using coils and glue present attractive procedures that can potentially overcome the limitations of current gold standards. In this review article, we provide an overview of these new 'endo-hepatology' techniques and highlight their current role in the treatment of liver diseases.
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Affiliation(s)
| | - Matthias Dollinger
- Medizinische Klinik I Gastroenterologie, Nephrologie und Diabetologie, Klinikum Landshut gGmbH, Landshut, Germany
- Innere Medizin I, University Hospital Ulm, Ulm, Germany
| | - Barbara Braden
- Medizinische Klinik B, Universitätsklinikum Münster, Munster, Germany
| | - Wim Laleman
- Medizinische Klinik B, Universitätsklinikum Münster, Munster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Munster, Germany
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Bruni A, Dell’Anna G, Samanta J, Fanizza J, Mandarino FV, Dhar J, Facciorusso A, Annese V, Massironi S, Malesci A, Marasco G, Dajti E, Eusebi LH, Barbara G, Donatelli G, Danese S, Fuccio L. Advances in Endo-Hepatology: The Role of Endoscopic Ultrasound in the Management of Portal Hypertension. Diagnostics (Basel) 2025; 15:967. [PMID: 40310390 PMCID: PMC12025765 DOI: 10.3390/diagnostics15080967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2025] [Revised: 04/06/2025] [Accepted: 04/08/2025] [Indexed: 05/02/2025] Open
Abstract
Portal hypertension (PH) is a complication of advanced liver diseases, including cirrhosis and hepatocellular carcinoma, often leading to unfavorable outcomes. Endo-hepatology, particularly endoscopic ultrasound (EUS) has revolutionized the assessment of PH. Notably, EUS-guided portal pressure gradient (EUS-PPG) enables measurement of portal and hepatic venous pressures, offering diagnostic precision for both cirrhotic and non-cirrhotic forms of PH, including porto-sinusoidal vascular disorder (PSVD). EUS-based assessment of PH in advanced liver disease can refine diagnostic workup and prognostication, supporting therapeutic decisions. Additionally, EUS-guided liver biopsy (EUS-LB) achieves high-quality histological samples with fewer complications compared to percutaneous techniques, enabling thorough evaluation of chronic liver diseases and vascular abnormalities. EUS-shear wave elastography (EUS-SWE) further refines stiffness measurements where standard imaging fails. Moreover, EUS plays a major role in controlling variceal hemorrhage, a severe PH complication. EUS-guided coil and cyanoacrylate injection for gastric varices demonstrate a great efficacy, often surpassing conventional endoscopy. Similarly, EUS-based identification and treatment of perforator vessels feeding esophageal varices reduce rebleeding risks, particularly in challenging patients. The combination of these state-of-the-art interventions supports a "one-stop strategy", integrating variceal screening, biopsy, and portal pressure measurement within a single procedure. Despite these advancements, refinements in sedation protocols, patient selection, and cost-effectiveness data are necessary. While noninvasive tools remain central in guidelines, EUS-based methods continue to expand their role, especially in complex cases. This review summarizes the applications and impact of EUS in evaluating PH, emphasizing its importance in contemporary hepatology and its potential as a pivotal diagnostic modality in cirrhosis complicated by PH.
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Affiliation(s)
- Angelo Bruni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola, 40138 Bologna, Italy; (A.B.); (G.M.); (E.D.); (L.H.E.); (G.B.); (L.F.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Giuseppe Dell’Anna
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (G.D.); (J.F.); (F.V.M.); (S.M.); (A.M.)
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, 20097 Milan, Italy;
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, 75013 Paris, France;
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.S.); (J.D.)
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (G.D.); (J.F.); (F.V.M.); (S.M.); (A.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (G.D.); (J.F.); (F.V.M.); (S.M.); (A.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.S.); (J.D.)
- Department of Gastroenterology and Hepatology, Punjab Institute of Liver and Biliary Sciences, Mohal 160062, India
| | - Antonio Facciorusso
- Gastroenterology Unit, Faculty of Medicine and Surgery, University of Salento, 73100 Lecce, Italy;
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, 20097 Milan, Italy;
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Sara Massironi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (G.D.); (J.F.); (F.V.M.); (S.M.); (A.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Alberto Malesci
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (G.D.); (J.F.); (F.V.M.); (S.M.); (A.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola, 40138 Bologna, Italy; (A.B.); (G.M.); (E.D.); (L.H.E.); (G.B.); (L.F.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Elton Dajti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola, 40138 Bologna, Italy; (A.B.); (G.M.); (E.D.); (L.H.E.); (G.B.); (L.F.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Leonardo Henry Eusebi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola, 40138 Bologna, Italy; (A.B.); (G.M.); (E.D.); (L.H.E.); (G.B.); (L.F.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola, 40138 Bologna, Italy; (A.B.); (G.M.); (E.D.); (L.H.E.); (G.B.); (L.F.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Gianfranco Donatelli
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, 75013 Paris, France;
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80138 Naples, Italy
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (G.D.); (J.F.); (F.V.M.); (S.M.); (A.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Lorenzo Fuccio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola, 40138 Bologna, Italy; (A.B.); (G.M.); (E.D.); (L.H.E.); (G.B.); (L.F.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
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AbiMansour J, Yung-Lun Chin J, Kaur J, Vargas EJ, Abu Dayyeh BK, Law R, Garimella V, Levy MJ, Storm AC, Dierkhising R, Allen A, Venkatesh S, Chandrasekhara V. Endoscopic Ultrasound-based Shear Wave Elastography for Detection of Advanced Liver Disease. J Clin Gastroenterol 2025; 59:256-261. [PMID: 38648501 PMCID: PMC11496376 DOI: 10.1097/mcg.0000000000002013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/17/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound shear wave elastography (EUS-SWE) is a novel modality for liver stiffness measurement. The aims of this study are to evaluate the performance and reliability of EUS-SWE for detecting advanced liver disease in a prospective cohort. METHODS EUS-SWE measurements were prospectively obtained from patients undergoing EUS between August 2020 and March 2023. Liver stiffness measurements were compared between patients with and without advanced liver disease (ALD), defined as stage ≥3, to determine diagnostic accuracy for advanced fibrosis and portal hypertension. Logistic regression was performed to identify variables that impact the reliability of EUS-SWE readings. Select patients underwent paired magnetic resonance elastography (MRE) for liver fibrosis correlation. RESULTS Patients with ALD demonstrated higher liver stiffness compared to healthy controls (left lobe: 17.6 vs. 12.7 kPa, P <0.001; median right lobe: 24.8 vs. 11.0 kPa, P <0.001). The area under the receiver operator characteristic (AUROC) for the detection of ALD was 0.73 and 0.80 for left and right lobe measurements, respectively. General anesthesia was associated with reliable EUS-SWE liver readings (odds ratio: 2.73, 95% CI: 1.07-7.39, P =0.040). Left lobe measurements correlated significantly with MRE with an increase of 0.11 kPa (95% CI: 0.05-0.17 kPA) for every 1 kPa increase on EUS-SWE. D. CONCLUSIONS SWE is a promising technology that can readily be incorporated into standard EUS examinations for the assessment of ALD.
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Affiliation(s)
- Jad AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jerry Yung-Lun Chin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jyotroop Kaur
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric J. Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vishal Garimella
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ross Dierkhising
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Alina Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Dhar J, Yadav A, Mitra S, Nabi Z, Aggarwal M, Gupta P, Facciorusso A, Crinò SF, Trikudanathan G, Samanta J. Endoscopic ultrasound guided liver biopsy and portal pressure gradient: when, why and how? Can it become the standard of care in endo-hepatology? Expert Rev Gastroenterol Hepatol 2025; 19:1-18. [PMID: 39980174 DOI: 10.1080/17474124.2025.2469838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 02/14/2025] [Accepted: 02/17/2025] [Indexed: 02/22/2025]
Abstract
INTRODUCTION The armamentarium of 'Endo-hepatology' is proliferating with the advancements in techniques and availability of new devices in the field of endoscopic ultrasound (EUS). This has resulted in the merger of multitude of diagnostic and therapeutic interventions, such as EUS-liver biopsy (LB), EUS-angioembolization of gastric varices, EUS-portal pressure gradient (PPG) measurement, and others into a 'one-stop-shop' for efficient patient management. Lack of standardization of these techniques forms a major hinderance in their widespread adoption. AREAS COVERED A comprehensive literature search was undertaken across various databases on EUS-LB and EUS-PPG till November 2024 for reviews, observational studies, and randomized trials on EUS-LB and EUS-PPG, describing its indications, technique, and data of safety and efficacy, detailing its role in day-to-day clinical practice. EXPERT OPINION EUS-LB and EUS-PPG have shown promise in the ever-growing field of endo-hepatology. EUS-LB has exhibited excellent safety profile and comparable tissue yield compared to its percutaneous counterpart. On the other hand, EUS-PPG seems to be a viable alternative although it needs to be standardized further. From a patient and hospital perspective, they might prove to be convenient and cost-effective. Nevertheless, more evidence is warranted before they can be labeled as the new standard of care.
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Affiliation(s)
- Jahnvi Dhar
- Department of Gastroenterology and Hepatology, Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India
| | - Amit Yadav
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Suvradeep Mitra
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manik Aggarwal
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Antonio Facciorusso
- Department of Experimental Medicine, Section of Gastroenterology, University of Salento, Lecce, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Laleman W, Peiffer KH, Tischendorf M, Ullerich HJ, Praktiknjo M, Trebicka J. Role of endoscopy in hepatology. Dig Liver Dis 2024; 56:1185-1195. [PMID: 38151452 DOI: 10.1016/j.dld.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany.
| | - Kai-Henrik Peiffer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Hans-Joerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Praktiknjo
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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Selvanderan SP, Lam E, Shahidi N. Endohepatology: Arrival at the frontier of interventional endosonography. World J Gastroenterol 2024; 30:2397-2401. [PMID: 38764768 PMCID: PMC11099394 DOI: 10.3748/wjg.v30.i18.2397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/16/2024] [Accepted: 04/19/2024] [Indexed: 05/11/2024] Open
Abstract
Endohepatology describes the emerging field where diagnostic and therapeutic endoscopic ultrasound (EUS) are used for the diagnosis and management of liver disease and its sequelae. In this editorial we comment on the article by Gadour et al. The spectrum of EUS-guided procedures includes liver parenchymal and lesional biopsy, abscess drainage, treatment of focal liver lesions, diagnosis of portal hypertension and management of gastric varices. The data suggest that the application of EUS to hepatology is technically feasible and safe, heralding the arrival at a new frontier for EUS. More data, specifically randomised trials comparing EUS to interventional radiology techniques, and continued partnership between endoscopy and hepatology are required to see this field establish itself outside expert tertiary centres.
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Affiliation(s)
- Shane P Selvanderan
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Eric Lam
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
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Chang KJ, Ge PS. The gift of foresight: interventional endoscopy, 30 years after the first EUS-guided FNA. IGIE 2024; 3:132-149. [DOI: 10.1016/j.igie.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
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Alwassief A, Al-Busafi S, Abbas QL, Al Shamusi K, Paquin SC, Sahai AV. Endohepatology: The endoscopic armamentarium in the hand of the hepatologist. Saudi J Gastroenterol 2024; 30:4-13. [PMID: 37988109 PMCID: PMC10852142 DOI: 10.4103/sjg.sjg_214_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 11/22/2023] Open
Abstract
ABSTRACT Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.
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Affiliation(s)
- Ahmed Alwassief
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Said Al-Busafi
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Qasim L. Abbas
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Khalid Al Shamusi
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Sarto C. Paquin
- Division of Gastroenterology, Hopital Saint Luc, Centre Hospitaliér de l’Universite de Montréal, Montreal, Quebec, Canada
| | - Anand V. Sahai
- Division of Gastroenterology, Hopital Saint Luc, Centre Hospitaliér de l’Universite de Montréal, Montreal, Quebec, Canada
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Laleman W, Vanderschueren E, Mehdi ZS, Wiest R, Cardenas A, Trebicka J. Endoscopic procedures in hepatology: Current trends and new developments. J Hepatol 2024; 80:124-139. [PMID: 37730125 DOI: 10.1016/j.jhep.2023.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Abstract
Gastrointestinal endoscopy has long been a reliable backbone in the diagnosis and management of hepatobilary disorders and their complications. However, with evolving non-invasive testing, personalised medicine has reframed the utility and necessity of endoscopic screening. Conversely, the growing interest and use of endoscopic ultrasound (EUS) and advanced endoscopy within gastrointestinal units has also opened novel diagnostic and therapeutic avenues for patients with various hepatobiliary diseases. The integration of "advanced endoscopy" within the practice of hepatology is nowadays referred to as "endo-hepatology". In essence, endo-hepatology consists of two pillars: one focusing primarily on disorders of the liver parenchyma, vascular disorders, and portal hypertension, which is mainly captured via EUS, while the other targets the hepatobiliary tract via endoscopic retrograde cholangiopancreatography and advanced imaging. Applications under the umbrella of endo-hepatology include, amongst others, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, coil and glue embolisation of gastric varices as well as cholangioscopy. As such endo-hepatology could become an attractive concept wherein advanced endoscopy might reinforce the medical management of patients with hepatobiliary disorders and their complications after initial basic work-up. In this review, we discuss current trends and future developments within endo-hepatology and the remaining hurdles to overcome.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium; Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany.
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Zain Seyad Mehdi
- Department of Mechanical Engineering, KU LEUVEN, Leuven, Belgium
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain; Institute of Digestive Disease and Metabolism, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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Laleman W, Mertens J, Vanderschueren E, Praktiknjo M, Trebicka J. Advances in Endohepatology. Am J Gastroenterol 2023; 118:1756-1767. [PMID: 37610016 DOI: 10.14309/ajg.0000000000002482] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/18/2023] [Indexed: 08/24/2023]
Abstract
Over the past decade, the number of endoscopic procedures relevant to patients with liver disease not only increased but also altered and expanded in terms of indications and applications. "Endohepatology" refers to the integration of advanced endoscopy within the practice of hepatology with endoscopic ultrasound as one of the main pillars. Current applications under the umbrella of endohepatology focus on advanced diagnostics and oncological, vascular, and metabolic interventions. These involve, among others, endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided coil and glue embolization of gastric varices. In addition to its conceptually attractive technical and innovative characteristics, endohepatology is also an appealing practical option for daily practice because it can be offered as a "one-stop clinic" intervention where comprehensive endoscopic diagnostic and/or therapeutic testing is performed in a single outpatient visit. In this review, we will discuss current trends and future developments within endohepatology and the remaining hurdles to overcome.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
| | - Joachim Mertens
- Department of Gastroenterology & Hepatology, Klinik Hirslanden, Zurich, Switzerland
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Michael Praktiknjo
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
- European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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11
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Lesmana CRA. Endoscopic ultrasound-guided portal pressure gradient measurement in managing portal hypertension. World J Gastrointest Surg 2023; 15:1033-1039. [PMID: 37405096 PMCID: PMC10315130 DOI: 10.4240/wjgs.v15.i6.1033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/30/2022] [Accepted: 04/24/2023] [Indexed: 06/15/2023] Open
Abstract
Portal hypertension (PH) is still a challenging clinical condition due to its silent manifestations in the early stage and needs to be measured accurately for early detection. Hepatic vein pressure gradient measurement has been considered as the gold standard measurement for PH; however, it needs special skill, experience, and high expertise. Recently, there has been an innovative development in using endoscopic ultrasound (EUS) for the diagnosis and management of liver diseases, including portal pressure measurement, which is commonly known as EUS-guided portal pressure gradient (EUS-PPG) measurement. EUS-PPG measurement can be performed concomitantly with EUS evaluation for deep esophageal varices, EUS-guided liver biopsy, and EUS-guided cyanoacrylate injection. However, there are still major issues, such as different etiologies of liver disease, procedural training, expertise, availability, and cost-effectiveness in several situations with regard to the standard management.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta 10430, DKI, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta 12950, DKI, Indonesia
- Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta 12930, DKI, Indonesia
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12
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Vanderschueren E, Trebicka J, Laleman W. Endoscopic Advances in Hepatology. Semin Liver Dis 2023; 43:176-188. [PMID: 37192654 DOI: 10.1055/s-0043-1769009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Endoscopy is and remains an indispensable tool in diagnosing and managing liver disease and its complications. Due to the progress in advanced endoscopy, endoscopy has become an alternative route for many surgical, percutaneous, and angiographic interventions, not only as a backup tool when conventional interventions fail but increasingly as a first-line choice. The term endo-hepatology refers to the integration of advanced endoscopy in the practice of hepatology. Endoscopy is key in the diagnosis and management of esophageal and gastric varices, portal hypertensive gastropathy, and gastric antral vascular ectasia. Endoscopic ultrasound (EUS) can be used for the evaluation of the liver parenchyma, liver lesions, and surrounding tissues and vessels, including targeted biopsy and complemented with new software functions. Moreover, EUS can guide portal pressure gradient measurement, and assess and help manage complications of portal hypertension. It is crucial that each present-day hepatologist is aware of the (rapidly increasing) full spectrum of diagnostic and therapeutic tools that exist within this field. In this comprehensive review, we would like to discuss the current endo-hepatology spectrum, as well as future directions for endoscopy in hepatology.
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Affiliation(s)
- Emma Vanderschueren
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
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13
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Laleman W, Vanderschueren E, Van der Merwe S, Chang KJ. The use of endoscopic ultrasound in the diagnosis and management of portal hypertension. Best Pract Res Clin Gastroenterol 2022; 60-61:101811. [PMID: 36577537 DOI: 10.1016/j.bpg.2022.101811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
The role of endoscopic ultrasound in the diagnosis and management of chronic liver disease is rapidly increasing. It forms one of the major backbones of endo-hepatology and brings us a step closer to personalized medicine. This review will focus on the particular use of EUS in the diagnosis and management of cirrhotic portal hypertension and potential complications hereof, such as ascites and gastrooesophageal varices. More specifically, EUS-guided Porto-systemic Pressure Gradient (EUS-PPG) measurement, EUS-guided coil and glue embolization of gastric varices, EUS-guided paracentesis and EUS-guided intrahepatic portosystemic shunt creation (IPSS) will be discussed in-depth with regard to clinical status, available data and technical considerations.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium; Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany.
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Kenneth J Chang
- Digestive Health Institute, University of California, Irvine, CA, 92868, USA
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14
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Téllez-Ávila FI, García-Saenz-de-Sicilia M. Endohepatology: current status and perspectives. Ann Hepatol 2022; 27:100730. [PMID: 35786448 DOI: 10.1016/j.aohep.2022.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Félix I Téllez-Ávila
- Division of Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, United States
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15
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Rudnick SR, Conway JD, Russo MW. Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound. World J Hepatol 2021; 13:887-895. [PMID: 34552695 PMCID: PMC8422923 DOI: 10.4254/wjh.v13.i8.887] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/18/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of cirrhosis and portal hypertension (PH) with its complications including variceal hemorrhage, ascites, and hepatic encephalopathy continues to evolve. Although there are established “standards of care” in liver biopsy and measurement of PH, gastric varices remain an area without a universally accepted therapeutic approach. The concept of “Endo Hepatology” has been used to describe of the applications of endoscopic ultrasound (EUS) to these challenges. EUS-liver biopsy (EUS-LB) offers an alternative to percutaneous and transjuglar liver biopsy without compromising safety or efficacy, and with added advantages including the potential to reduce sampling error by allowing biopsies in both hepatic lobes. Furthermore, EUS-LB can be performed during the same procedure as EUS-guided portal pressure gradient (PPG) measurements, allowing for the collection of valuable diagnostic and prognostic data. EUS-guided PPG measurements provide an appealing alternative to the transjugular approach, with proposed advantages including the ability to directly measure portal vein pressure. In addition, EUS-guided treatment of gastric varices (GV) offers several possible advantages to current therapies. EUS-guided treatment of GV allows detailed assessment of the vascular anatomy, similar efficacy and safety to current therapies, and allows the evaluation of treatment effect through doppler ultrasound visualization. The appropriate selection of patients for these procedures is paramount to ensuring generation of useful clinical data and patient safety.
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Affiliation(s)
- Sean R Rudnick
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Jason D Conway
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Mark W Russo
- Department of Hepatology, Atrium Health, Carolinas Medical Center, Charlotte, NC 28204, United States
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16
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Hogan DE, Ma M, Kadosh D, Menon A, Chin K, Swaminath A. Endo-hepatology: An emerging field. World J Gastrointest Endosc 2021; 13:296-301. [PMID: 34512877 PMCID: PMC8394184 DOI: 10.4253/wjge.v13.i8.296] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/13/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroenterologists have long been spearheading the care of patients with various forms of liver disease. The diagnosis and management of liver disease has traditionally been a combination of clinical, laboratory, and imaging findings coupled with percutaneous and intravascular procedures with endoscopy largely limited to screening for and therapy of esophageal and gastric varices. As the applications of diagnostic and therapeutic endoscopic ultrasound (EUS) have evolved, it has found a particular niche within hepatology now coined endo-hepatology. Here we discuss several EUS-guided procedures such as liver biopsy, shear wave elastography, direct portal pressure measurement, paracentesis, as well as EUS-guided therapies for variceal hemorrhage.
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Affiliation(s)
- Daniel E Hogan
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - Michael Ma
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - David Kadosh
- Department of Internal Medicine, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - Alisha Menon
- Department of Internal Medicine, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - Kana Chin
- Department of Internal Medicine, Long Island Jewish Forest Hills, Northwell Health, Forest Hills, NY 11375, United States
| | - Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
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17
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Hashimoto R, Lee DP, Samarasena JB, Chandan VS, Guo W, Lee JG, Chang KJ. Comparison of Two Specialized Histology Needles for Endoscopic Ultrasound (EUS)-Guided Liver Biopsy: A Pilot Study. Dig Dis Sci 2021; 66:1700-1706. [PMID: 32556821 DOI: 10.1007/s10620-020-06391-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/03/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND EUS-guided liver biopsy (EUS-LB) has been shown to be a safe and effective alternative to percutaneous liver biopsy. The optimal needle device and technique for EUS-LB is still evolving. The aim of this study was to compare the efficacy of two second-generation 19G fine-needle biopsy (FNB) (Franseen- and Fork-tip) devices for EUS-LB. METHODS This is a repeated-measure crossover study with a prospectively maintained cohort of patients. We performed EUS-LB with a one-pass and single-actuation method using two 19G FNB needles in 22 consecutive patients between 10/2018 and 9/2019. Patients were randomized to left vs right liver lobes to be biopsied as well as the needle sequence. The specimens obtained were evaluated for adequacy for histologic diagnosis. The primary outcome was number of complete portal tracts (CPTs), post-fix aggregate, and longest specimen length. Secondary outcomes were prefix aggregate specimen length and the specimen adequacy judged by two expert pathologists. RESULTS A total of 44 liver biopsies were performed in 22 patients. The CPTs were higher in the Franseen-tip needle group compared to the Fork-tip needle group (14.4 vs 9.5, p = 0.043). Post-fix aggregate specimen length (44.9 mm vs 34.6 mm, p = 0.097), the post-fix longest specimen length (19.9 mm vs 13.7 mm, p = 0.175), and prefix aggregate specimen length (51.7 mm vs 45 mm, p = 0.265) were not significantly different. Both needles showed similarly high histologic adequacy (100% vs 95.5%, p = 0.312). Interestingly, the right of the liver showed higher yield of CPTs with both needles (Franseen, 16.2 vs. 12.8, p = 0.003, the Fork-tip, 12.8 vs. 7.0, p < 0.0001). CONCLUSION EUS-guided liver biopsy using the 19G Franseen-tip needle may provide more CPTs than 19G Fork-tip needle on a single-pass, single-actuation comparison.
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Affiliation(s)
- Rintaro Hashimoto
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - David P Lee
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - Vishal S Chandan
- Pathology Department, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - Wenchang Guo
- Pathology Department, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - John G Lee
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA, 92868, USA.
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18
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Improved detection of liver metastasis using Kupffer-phase imaging in contrast-enhanced harmonic EUS in patients with pancreatic cancer (with video). Gastrointest Endosc 2021; 93:433-441. [PMID: 32592778 DOI: 10.1016/j.gie.2020.06.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Kupffer-phase imaging visualized by perfluorobutane (Sonazoid) distribution into normal liver tissues upon phagocytosis by Kupffer cells potentially aids in improving detection of liver metastasis compared with fundamental B-mode EUS (FB-EUS). However, the diagnostic performance of Kupffer-phase imaging in contrast-enhanced harmonic EUS (CH-EUS) remains unclear. Hence, this study aimed to evaluate the usefulness of CH-EUS-based Kupffer-phase imaging for diagnosing liver metastasis from pancreatic cancer. METHODS We retrospectively analyzed consecutive patients with pancreatic cancer who underwent contrast-enhanced CT (CE-CT) and FB-EUS, followed by CH-EUS, from 2011 to 2017. The diagnostic ability of CH-EUS against that of CE-CT and FB-EUS for metastasis in the left liver lobe was compared. Subsequently, the influences of CH-EUS on the determination of clinical stage and patient management for pancreatic cancer were assessed. RESULTS We enrolled 426 patients with pancreatic cancer. Metastasis in the left liver lobe was present in 27.2% of patients. The diagnostic accuracy of CE-CT, FB-EUS, and CH-EUS was 90.6%, 93.4%, and 98.4%, respectively. The sensitivity and diagnostic accuracy of CH-EUS for metastasis in the left liver lobe were significantly higher than those of FB-EUS or CE-CT. The sensitivity of CH-EUS for detecting small liver metastasis (<10 mm) was considerably higher than that of CE-CT or FB-EUS (P < .001). In 2.1% of patients, only CH-EUS could detect a single distant metastasis of the left liver lobe, thereby upgrading the tumor staging and altering the clinical management. CONCLUSIONS CH-EUS-based Kupffer-phase imaging increased the detectability of metastasis in the left liver lobe. This technique could be a reliable pretreatment imaging modality for clinical decision-making in patients with pancreatic cancer.
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DeWitt JM, Arain M, Chang KJ, Sharaiha R, Komanduri S, Muthusamy VR, Hwang JH. Interventional Endoscopic Ultrasound: Current Status and Future Directions. Clin Gastroenterol Hepatol 2021; 19:24-40. [PMID: 32950747 DOI: 10.1016/j.cgh.2020.09.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
The evolution of endoscopic ultrasound (EUS) from a diagnostic to a therapeutic procedure has resulted in a paradigm shift toward endoscopic management of disease states that previously required percutaneous or surgical approaches. The past few years have seen additional techniques and devices that have enabled endoscopists to expand its diagnostic and therapeutic capabilities. Some of these techniques initially were reported more than a decade ago; however, with further device development and refinement in techniques there is potential for expanding the application of these techniques and new technologies to a broader group of interventional gastroenterologists. Lack of formalized training, devices, and prospective data regarding their use in addition to a scarcity of guidelines on implementation of these technologies into clinical practice are contributing factors impeding the growth of the field of interventional EUS. In April 2019, the American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology conducted its annual Tech Summit and a key session focused on interventional EUS. This article is a White Paper generated from the conference, discusses the published literature pertaining to the topic of interventional EUS, and outlines a proposed framework for the implementation of interventional EUS techniques into clinical practice. Three primary areas of interventional EUS are addressed: (1) EUS-guided access; (2) EUS-guided tumor ablation; and (3) endohepatology. There was general agreement among participants on several key components. The introduction of these novel interventions requires better tools, more data on safety/outcomes, and improved training for endoscopists. Participants also agreed that widespread implementation and use of these techniques will require support from Gastrointestinal Societies and other key stakeholders including payers. Continued work by the Gastrointestinal Societies and manufacturers to provide training programs, appropriate equipment/work environments, and policies that motivate endoscopists to adopt new techniques is essential for growing the field of interventional EUS.
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Affiliation(s)
- John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana
| | - Mustafa Arain
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Kenneth J Chang
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, California
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Sri Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California.
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Ma ZH, Wang YP, Zheng WH, Ma J, Bai X, Zhang Y, Wang YH, Chi D, Fu XB, Hua XD. Prognostic factors and therapeutic effects of different treatment modalities for colorectal cancer liver metastases. World J Gastrointest Oncol 2020; 12:1177-1194. [PMID: 33133385 PMCID: PMC7579728 DOI: 10.4251/wjgo.v12.i10.1177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/18/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is one of the most common malignant tumors in China, and the liver is the most common metastatic site in patients with advanced CRC. Hepatectomy is the gold standard treatment for colorectal liver metastases. For patients who cannot undergo radical resection of liver metastases for various reasons, ablation therapy, interventional therapy, and systemic chemotherapy can be used to improve their quality of life and prolong their survival time.
AIM To explore the prognostic factors and treatments of liver metastases of CRC.
METHODS A retrospective analysis was conducted on 87 patients with liver metastases from CRC treated at the Liaoning Cancer Hospital and Institute between January 2005 and March 2011. According to different treatments, the patients were divided into the following four groups: Surgical resection group (36 patients); ablation group (23 patients); intervention group (15 patients); and drug group (13 patients). The clinicopathological data and postoperative survival of the four groups were analyzed. The Kaplan-Meier method was used for survival analysis, and the Cox proportional hazards regression model was used for multivariate analysis.
RESULTS The median survival time of the 87 patients was 38.747 ± 3.062 mo, and the 1- and 3-year survival rates were 87.5% and 53.1%, respectively. The Cox proportional hazards model showed that the following factors were independent factors affecting prognosis: The degree of tumor differentiation, the number of metastases, the size of metastases, and whether the metastases are close to great vessels. The results of treatment factor analysis showed that the effect of surgical treatment was better than that of drugs, intervention, or ablation alone, and the median survival time was 48.83 ± 4.36 mo. The drug group had the worst prognosis, with a median survival time of only 13.5 ± 0.7 mo (P < 0.05). For patients with liver metastases of CRC near the great vessels, the median survival time (27.3 mo) of patients undergoing surgical resection was better than that of patients using other treatments (20.6 mo) (P < 0.05).
CONCLUSION Patients with a low degree of primary tumor differentiation, multiple liver metastases (number of tumors > 4), and maximum diameter of liver metastases > 5 cm have a poor prognosis. Among drug therapy, intervention, ablation, and surgical treatment options, surgical treatment is the first choice for liver metastases. When liver metastases are close to great vessels, surgical treatment is significantly better than drug therapy, intervention, and ablation alone.
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Affiliation(s)
- Zuo-Hong Ma
- Department of Hepatopancreatobiliary Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Yong-Peng Wang
- Department of Hepatopancreatobiliary Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Wen-Heng Zheng
- Department of Medical Imaging, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Ji Ma
- Department of Pathology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Xue Bai
- Department of Hepatopancreatobiliary Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Yong Zhang
- Department of Pathology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Yuan-He Wang
- Department of Hepatopancreatobiliary Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Da Chi
- Department of Hepatopancreatobiliary Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Xi-Bo Fu
- Department of Hepatopancreatobiliary Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Xiang-Dong Hua
- Department of Hepatopancreatobiliary Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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Origins of Portal Hypertension in Nonalcoholic Fatty Liver Disease. Dig Dis Sci 2018; 63:563-576. [PMID: 29368124 DOI: 10.1007/s10620-017-4903-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 12/26/2017] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) advanced to cirrhosis is often complicated by clinically significant portal hypertension, which is primarily caused by increased intrahepatic vascular resistance. Liver fibrosis has been identified as a critical determinant of this process. However, there is evidence that portal venous pressure may begin to rise in the earliest stages of NAFLD when fibrosis is far less advanced or absent. The biological and clinical significance of these early changes in sinusoidal homeostasis remains unclear. Experimental and human observations indicate that sinusoidal space restriction due to hepatocellular lipid accumulation and ballooning may impair sinusoidal flow and generate shear stress, increasingly disrupting sinusoidal microcirculation. Sinusoidal endothelial cells, hepatic stellate cells, and Kupffer cells are key partners of hepatocytes affected by NAFLD in promoting endothelial dysfunction through enhanced contractility, capillarization, adhesion and entrapment of blood cells, extracellular matrix deposition, and neovascularization. These biomechanical and rheological changes are aggravated by a dysfunctional gut-liver axis and splanchnic vasoregulation, culminating in fibrosis and clinically significant portal hypertension. We may speculate that increased portal venous pressure is an essential element of the pathogenesis across the entire spectrum of NAFLD. Improved methods of noninvasive portal venous pressure monitoring will hopefully give new insights into the pathobiology of NAFLD and help efforts to identify patients at increased risk for adverse outcomes. In addition, novel drug candidates targeting reversible components of aberrant sinusoidal circulation may prevent progression in NAFLD.
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23
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Ge PS, Ryou M. EUS-guided tissue acquisition of liver and hepatobiliary masses. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2017.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Han J, Chang KJ. Endoscopic Ultrasound-Guided Direct Intervention for Solid Pancreatic Tumors. Clin Endosc 2017; 50:126-137. [PMID: 28391669 PMCID: PMC5398363 DOI: 10.5946/ce.2017.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 03/23/2017] [Accepted: 03/23/2017] [Indexed: 12/13/2022] Open
Abstract
Development and use of linear-array echoendoscope and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) have made endoscopic ultrasound (EUS) more of an interventional procedure than a purely diagnostic procedure. This is a literature review of previously published clinical studies on EUS-guided direct intervention for solid pancreatic tumors, including EUS-guided fine needle injection (EUS-FNI) of antitumor agents, EUS-guided fiducial marker placement, EUS-guided brachytherapy and EUS-guided tumor ablation.
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Affiliation(s)
- Jimin Han
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Kenneth J. Chang
- Division of Gastroenterology and Hepatology, H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine, Orange, CA, USA
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