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FNA vs. TCB, EUS-TCB reduced the number of needle passes
compared with EUS-FNA, potentially reducing the cost and time
of the procedure [18].
L. C. Shipley and A. M. Ahmed
Evaluation ofDuplication Cysts andChildhood
Congenital Abnormalities oftheEsophagus
Duplication cysts arise from abnormal budding of the embryonic
foregut at 5–8weeks of gestation. They most commonly occur in
the ileum, esophagus, and colon with 50–70% enterogenic and
7–15% bronchogenic. These cysts can either be found within the
wall or extrinsic to the wall and usually present as an asymptomatic mediastinal mass with rare mass effect symptoms such as
dysphagia. EUS is the diagnostic modality of choice as it can differentiate cystic versus solid lesions and location with regard to
surrounding tissues [19]. EUS-FNA has been used to assist with
diagnosis, however should be performed with caution given the
increased risk of infection [20]. Denitive treatment is surgical
removal; however, if asymptomatic, surveillance with EUS may
be considered [21].
EUS has also proven to be effective in treating other types
of esophageal congenital abnormalities such as esophageal stenosis [22]. Congenital esophageal stenosis is further classied
into bromuscular thickening (54%), tracheobronchial remnants (TBR) (30%), and membranous web (16%). Current
management includes surgery and dilation, except for the TBR
subtype. EUS can identify TBR subtype, and thus, EUS-guided
case selection has been shown to be predictive of success rate
(90% vs. 29%) and decreases the rate of perforation (7% vs
24%) [22, 23].
Walled-O Pancreatic Necrosis
Walled-off pancreatic necrosis (WOPN) is associated with
high morbidity and mortality. Interventions for both diagnosis
and treatment have shifted toward a less-invasive strategy,
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121
EUS- guided methods. EUS allows for better visualization of
the contents, structure, and surrounding structures of the pseudocyst [24].
Evaluation andDiagnosis oftheLiver
EUS can sample liver lesions suspected of metastatic disease for
diagnosis and staging. An example is shown in the gure below
(Fig.10.2).
New developments in endoscopic ultrasound have expanded
evaluation from sampling liver lesions and liver parenchyma for
diagnosis to the measurement of portal pressure utilizing a novel
catheter. The rst EUS-guided liver biopsy was performed in
2007 utilizing the linear array echoendoscope. Since then, several
Fig. 10.2 Fine-needle biopsy of metastatic liver lesion
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studies have demonstrated the efcacy of the technique with
93.9% diagnostic yield [25] and a comparative study between
EUS-guided liver biopsy with percutaneous and transjugular techniques demonstrated lower complicates by EUS (p= 0.03) and
increased specimen length by EUS (p<0.01) but fewer complete
portal tracts (p < 0.01). NASH can present sporadically in the
liver, and sampling both the left and right hepatic lobes may better
assess the disease. This is more easily accomplished by EUS with
directed passes to the specic lobes. Additionally, patient recovery is faster than the traditional methods of liver biopsy [26].
A recently approved device has a manometer that attaches to a
needle that can be placed through the EUS and directly into
hepatic vessels. This permits EUS-guided portal pressure measurement. The brosis in cirrhosis manifests itself by portal
hypertension, which is best measured by portal venous pressure.
The eld of EUS hepatology is novel with many advances
expected in the coming years and includes EUS-guided portal
vein embolization/thrombolysis, EUS-guided portal vein stent
placement, EUS-guided therapy for liver lesions, and EUSdirected drainage of liver abscesses/cysts and bilomas [26].
L. C. Shipley and A. M. Ahmed
Role ofEUS inForegut Treatment
Treatment ofEsophageal, Gastric, andPancreatic
Cancer
Endoscopic ultrasound ne-needle injection (EUS-FNI) is currently used for palliative biliary drainage [27], palliative celiac
plexus blockade, and precise submucosal injection prior to endoscopic mucosal resection of neoplasia or other lesions [28].
Research efforts are currently focused on EUS-FNI as treatment
for cancer; however, they have not been successful thus far [29].
Ethanol, brachytherapy seeds, chemotherapeutic agents, immunomodulating cell cultures, and viral vectors have all been used in
research efforts for anti-tumor therapy; however, this is largely
limited to animal studies and a few small case series. Prospective
10 Endoscopic Ultrasound
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studies are needed to determine the utility of EUS in cancer management [28].
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Treatment ofDuplications Cysts andChildhood
Congenital Abnormalities oftheEsophagus
Treatment of duplication cysts is typically via surgical enucleation in symptomatic cases, while asymptomatic cases are commonly observed. EUS-guided needle aspiration has been proposed
for treatment but has only been used in a small number of case
reports, primarily in colonic duplication cysts [19].
Treatment ofWalled-O Pancreatic Necrosis
In addition to the ability to better visualize the contents, structure, and surrounding structures of the pseudocyst, current
EUS-guided strategies to treat WOPN include lumen-apposing metal stents (LAMS) and direct endoscopic necrosectomy
(DEN) [24]. Further, EUS-guided drainage is safe, can be performed at a lower cost and decreases hospital stay, [30] and
has a high success rate (Fig.10.3). In a randomized control
study of 60 patients with pseudocysts, EUS-guided drainage
showed a higher rate of technical success when compared to
conventional transmural drainage (CTD) (94% vs. 72%,
p=0.039); however, long-term outcomes showed no significant difference in EUD versus CTD (89% vs. 86%, p=0.696)
[31]. A recent multicenter randomized study compared endoscopic luminal drainage followed by endoscopic necrosectomy versus percutaneous drainage followed by minimally
invasive surgical necrosectomy, if needed. The primary end
point of mortality was equal in both groups, but the endoscopic group had fewer complications such as pancreatic fistulas (5% vs 32%, p=0.0011) and a shorter mean length of
hospitalization (53days vs 69days, p = 0.014) [32]. Larger
prospective studies are needed to study long-term outcome,
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Fig. 10.3 Pseudocyst, walled-off necrosis drainage
L. C. Shipley and A. M. Ahmed
but a paradigm shift toward endoscopic drainage is being seen
in the treatment of these patients.
Conclusion
EUS is currently utilized to evaluate and occasionally treat many
abnormalities of the foregut. It offers a safe, cost-effective, and
accurate diagnosis of malignancies, cysts, and tissue previously
not well-dened. There are exciting new frontiers for the advanced
endoscopist with regard to the treatment of foregut pathology;
however, further prospective studies are needed to evaluate more
recent advancements.
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18. Levy MJ, Jondal ML, Clain J, Wiersema MJ.Preliminary experience with
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19. Liu R, Adler DG.Duplication cysts: diagnosis, management, and the role
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20. Wildi SM, Hoda RS, Fickling W, Schmulewitz N, Varadarajulu S, Roberts
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22. Terui K, Saito T, Mitsunaga T, Nakata M, Yoshida H.Endoscopic management for congenital esophageal stenosis: a systematic review. World J
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management of pancreatic uid collections: update and review of the literature. Clin Endosc. 2017;50(2):117–25.
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Endoscopic ultrasound-guided versus conventional transmural drainage
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L. C. Shipley and A. M. Ahmed
Part III
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Diagnostic Testing
High-Resolution Esophageal
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Manometry
11
withandwithout
Impedance: Understanding
the“Chicago Classication”
MohanadR.Youssef, MeredithFreeman,
NatachaWathieu, DanuelLaan,
andCarlosGalvani
Introduction toHigh-Resolution Manometry
(HRM) without Impedance
High-resolution manometry is an updated version of conventional
manometry that provides a panoramic view of the proximal physiology of the gastrointestinal tract from the pharynx to the stomach. The modications introduced in the 90’s included decreasing
pressure sensors spacing from 3 to 5cm to 1-cm intervals, increasing the number of sensors and therefore lengthening the pressure
sensing of the catheter from the pharynx to the stomach [1]. This
allowed for simultaneous and continuous recording of motor
M. R. Youssef · D. Laan · C. Galvani (*)
Division of Minimally Invasive Surgery and Bariatric, Department of
Surgery, Tulane University, School of Medicine, New Orleans, LA, USA
e-mail: cgalvani@tulane.edu
M. Freeman · N. Wathieu
Tulane University, School of Medicine, New Orleans, LA, USA
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_11
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M. R. Youssef et al.
activity along the entire esophageal length (UES to LES) with
each swallow. In addition, as compared to conventional manometry, pull-through is not required, it is more comfortable and
faster, shifts of position do not affect the reliability and reproducibility of pressure recordings, and it reduces inter-observer variability [2]. The uniqueness of this revolutionary method lies in its
ability to convert pressure data onto a topographical plot [3]. The
esophageal pressure topography plots (EPT) or “Clouse Plots”
have the capacity to convert manometric pressure into a topographic (color contour) plot that illustrates the better spatial resolution of esophageal motor function [4].
Even though in its inception this work was only used for
research, over time these remarkable advances have led to the
development of new measurements and resulted in a new classication. The Chicago Classication (CC) of esophageal motility
disorders was developed to enable an objective analysis of HRM
metrics and topography, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies [5]. The
CC divides esophageal motility disorders according to the relaxation of the lower esophageal sphincter (LES) as characterized by
the integrated relaxation pressure (IRP) and motility of the esophageal body. Once LES relaxation has been characterized, motility
disorders may be further categorized by abnormalities of esophageal body peristalsis. The initial CC was modied [6], and the
most recent revision of the Chicago Classication (v3.0) was published in 2015 [4].
As a result of these advances, today HRM is a diagnostic
method that is considered the gold standard for the evaluation of
esophageal motor function. HRM supplements endoscopy and
radiologic studies not only to help elucidate numerous foregut
symptoms, but also to guide different therapeutic options such as
medical, endoscopic, surgical, and even behavioral therapy. The
purpose of this chapter was to explore high-resolution manometry
and the Chicago Classication v3.0 and its utilization in the characterization of esophageal motility disorders.
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