Tomas DaVee

Is endoscopic ultrasound examination necessary in the management of esophageal cancer

Despite substantial efforts at early diagnosis, accurate staging and advanced treatments, esophageal cancer (EC) continues to be an ominous disease worldwide. Risk factors for esophageal carcinomas include obesity, gastroesophageal reflux disease, hard-alcohol use and tobacco smoking. Five-year survival rates have improved from 5% to 20% since the 1970s, the result of advances in diagnostic staging and treatment. As the most sensitive test for locoregional staging of EC, endoscopic ultrasound (EUS) influences the development of an optimal oncologic treatment plan for a significant minority of patients with early cancers, which appropriately balances the risks and benefits of surgery, chemotherapy and radiation. EUS is costly, and may not be available at all centers. Thus, the yield of EUS needs to be thoughtfully considered for each patient. Localized intramucosal cancers occasionally require endoscopic resection (ER) for histologic staging or treatment; EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of ER. Although positron emission tomography (PET) has been increasingly utilized in staging EC, it may be unnecessary for clinical staging of early, localized EC and carries the risk of false-positive metastasis (over staging). In EC patients with evidence of advanced disease, EUS or PET may be used to define the radiotherapy field. Multimodality staging with EUS, cross-sectional imaging and histopathologic analysis of ER, remains the standard-of-care in the evaluation of early esophageal cancers. Herein, published data regarding use of EUS for intramucosal, local, regional and metastatic esophageal cancers are reviewed. An algorithm to illustrate the current use of EUS at The University of Texas MD Anderson Cancer Center is presented.

Biliary Obstruction: Endoscopic Approaches

Painless jaundice is a harbinger of malignant biliary obstruction, with the majority of cases due to pancreatic adenocarcinoma. Despite advances in treatment, including improved surgical techniques and neoadjuvant (preoperative) chemotherapy, long-term survival from pancreatic cancer is rare. This lack of significant improvement in outcomes is believed to be due to multiple reasons, including the advanced stage at diagnosis and lack of an adequate biomarker for screening and early detection, prior to the onset of jaundice or epigastric pain. Close attention is required to select appropriate patients for preoperative biliary decompression, and to prevent morbid complications from biliary drainage procedures, such as pancreatitis and cholangitis. Use of small caliber plastic biliary stents during endoscopic retrograde cholangiopancreatography should be minimized, as metal stents have increased area for improved bile flow and a reduced risk of adverse events during neoadjuvant therapy. Efforts are underway by translational scientists, radiologists, oncologists, surgeons, and gastroenterologists to augment lifespan for our patients and to more readily treat this deadly disease. In this review, the authors discuss the rationale and techniques of endoscopic biliary intervention, mainly focusing on malignant biliary obstruction by pancreatic cancer.

Endoscopic ultrasound-guided sclerosant injection and coil embolization of bleeding gastric varices

The usefulness of endoscopic ultrasound (EUS) as a diagnostic tool is well known; however, its therapeutic implications are upcoming. There are data for the use of cyanoacrylate glue (CYA) as a temporary measure to control bleeding in gastric varices, followed either by a transjugular intrahepatic portosystemic shunt (TIPS) procedure or by balloon-occluded retrograde transvenous obliteration (BRTO). A 44-year-old Asian man with hepatitis B virus cirrhosis complicated by hepatocellular cancer causing portal vein thrombosis presented with melena and bright red blood per rectum with associated dizziness, hemodynamic instability, and an initial hemoglobin of 6.5 g/dL. He had a history of bleeding esophageal varices that had been banded in the past, with prior EGD showing non bleeding gastric varices. An emergent repeat esophagogastroduodenoscopy showed no residual esophageal varices and the stomach was filled with blood clots and fresh blood that were preventing identification of the bleeding source, but he had known prior gastric varices making that to be the most likely source of bleeding. An emergent EUS showed multiple gastric varices with active blood flow (▶Fig. 1). CYA was unavailable and, in view of the patient’s hemodynamic instability, a decision was made to emergently inject 3% sodium tetradecyl sulfate (STS), a sclerosing agent, under EUS guidance. Doppler ultrasound confirmed a significant decrease in the blood flow to the gastric varices. Following this an interventional radiology opinion was sought, but the patient was deemed a poor candidate for TIPS and BRTO because of his portal vein thrombosis and advanced cirrhosis. The following day, on repeat EUS, two deep gastric varices were therefore identified and injected with two tornado 4-mm× 30-mm coils, followed by a further 3mL E-Videos