Feasibility of a complete pancreatobiliary linear endoscopic ultrasound examination from the stomach

Abstract

Background and study aims Linear endoscopic ultrasound (EUS) evaluation of the pancreaticobiliary system usually requires scanning from both the stomach and the duodenum. The feasibility of assessing the complete pancreaticobiliary system from the stomach alone has not been studied. We aimed to conceptualize a system-based approach (the railroad approach) for linear pancreaticobiliary EUS (PB-EUS) and evaluate whether the pancreaticobiliary anatomy could be assessed from the stomach alone.

Patients and methods Three maneuvers were conceptualized and evaluated (the alpha maneuver in the stomach, and sigma and xi maneuvers in the duodenum). The maneuvers were prospectively evaluated in 100 consecutive patients requiring PB-EUS. 

Results The median procedure time for the three maneuvers was significantly higher than that for the alpha maneuver alone (12 vs. 6 minutes; P ≤ 0.001). The visualization rate of the hilum and common hepatic duct was significantly higher from the stomach than from the duodenum (100 % vs. 83.5 %; P ≤ 0.001), while rates for the head of the pancreas (100 % vs 100 %) and uncinate process (100 % vs 100 %) did not differ. The suprapancreatic common bile duct (CBD; 92 % vs 100 %; P = 0.006), retropancreatic CBD (95 % vs 100 %; P = 0.06), and pancreatic duct in the head (94 % vs 100 %; P = 0.03) were not completely visualized from the stomach, because of pancreatic calcification or shadow from the ligaments. The EUS diagnosis made from the stomach and duodenum did not differ after excluding body and tail lesions (pancreatic head neoplasms, 100 % vs 100 %; CBD stone, 100 % vs 84.6 %; pancreatic cysts in the head, 83.3 % vs 83.3 %, respectively).

Conclusions Adequate anatomical and diagnostic information on the pancreaticobiliary system may be acquired by EUS scanning from the stomach alone and with a shorter procedure time.

• References

• 1 ASGE training committee. EUS Core curriculum. Gastrointest Endosc 2012; 76: 476-481
• 2 Azad JS, Verma D, Kapadia AS. et al. Can U.S. GI fellowship programs meet American Society for Gastrointestinal Endoscopy recommendations for training in EUS? A survey of U.S. GI fellowship program directors. Gastrointest Endosc 2006; 64: 235-241
• 3 Wani S, Coté GA, Keswani R. et al. Learning curves for EUS by using cumulative sum analysis: implications for American Society for Gastrointestinal Endoscopy recommendations for training. Gastrointest Endosc 2013; 77: 558-565
• 4 Irisawa A, Yamao K. Curved linear array EUS technique in the pancreas and biliary tree: focusing on the stations. Gastrointest Endosc 2009; 69: S84-S89
• 5 Hawes RH, Fockens P, Varadarajulu S. How to perform EUS in the pancreas, bile duct, and liver. In: Endosonography. 3rd edn Philadelphia (PA): Saunders; 2015: 152-164
• 6 Erickson RA. Linear array EUS: Normal anatomy. In: Gress F, Savides T. , eds. Endoscopic ultrasonography. 2nd edn Oxford (UK): Wiley-Blackwell; 2009: 42-48
• 7 Yamao K, Irisawa A, Inoue H. et al. Standard imaging techniques of endoscopic ultrasound-guided fine needle aspiration using a curved linear array echoendoscope. Dig Endosc 2007; 19: S180-S205
• 8 Sharma M, Rai P, Rameshbabu CS. et al. Imaging of the pancreatic duct by linear endoscopic ultrasound. World J Gastrointest Endosc 2015; 4: 198-207
• 9 Wilson JA, Hoffman B, Hawes R. et al. EUS in patients with surgically altered upper GI anatomy. Gastrointest Endosc 2010; 72: 947-953
• 10 Noh KW, Woodward TA, Raimondo M. et al. Changing trends in endo- sonography: linear imaging and tissue are increasingly the issue. Dig Dis Sci 2007; 52: 1014-1018
• 11 Carrara S, Arcidiacono PG, Mezzi G. et al. Pancreatic endoscopic ultrasound-guided fine needle aspiration: complication rate and clinical course in a single centre. Dig Liver Dis 2010; 42: 520-523