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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_775_Библиотеки_им_академика_М_И_Перельмана.pdf
a
16 Endoscopic Ultrasound forHepato-Pancreato-Biliary Diseases
137
b
c
nography (CH-EUS) ndings of pancreatic solid lesions. (a) Typical
case of hypo-enhancement (a pancreatic cancer). CH-EUS image:
CH-EUS (right) shows that the lesion (arrowhead) has a lower intensity
echo signal than that of the surrounding pancreatic tissue. (b) Typical
case of iso-enhancement (an inammatory mass). CH-EUS image:
CH-EUS (right) shows that the lesion (arrowhead) has signals of isointensity compared to that of the surrounding pancreatic tissue. (c)
Typical case of hyper- enhancement (a neuroendocrine tumor). CH-EUS
image: CH-EUS (right) shows that the lesion (arrowhead) has a higher
intensity echo signal than that of the surrounding pancreatic tissue
138
a b
(b) Cytology of EUS-FNA sample: Papanicolaou staining revealed
(EUS-FNA) for a small pancreatic lesion. (a) Image during EUS-FNA:
EUS-FNA was performed for the diagnosis of small pancreatic lesion
of 6mm in size (arrowhead). The arrow indicates the EUS-FNA needle.
adenocarcinoma with high nuclear-to-cytoplasmic ratio and irregular
nuclear contours
Y. Yamashita and M. Kitano
staging with EUS in patients with pancreatic cancers [12].
Minaga et al. reported that the diagnostic accuracy of CT,
conventional EUS, and CH-EUS for staging metastasis in the
left hepatic lobe was 90.6%, 93.4%, and 98.4%, respectively,
and showed that the sensitivity and accuracy of CH-EUS for
diagnosing metastasis in the left hepatic lobe were signicantly higher than those of conventional EUS or CT.In particular, the sensitivity of CH-EUS for the detection of small
liver metastasis (<10mm) was considerably higher than that
of CT or conventional EUS (P<0.001). In 2.1% of patients,
only CH-EUS could detect a single distant metastasis in the
left hepatic lobe, thereby upgrading tumor staging and altering clinical management [13]. With respect to resectability, a
meta-analysis of eight studies enrolling 4903 patients indicated that EUS alone identied unresectable diseases in 19%
of patients after they were diagnosed with resectable pancreatic cancer by CT [14]. Hence, EUS is an important tool for
the determination of pancreatic cancer stage.
Mural nodules (MNs) in IPMNs are important factors for the
determination of surgical indications and have a positive predictive value of 62.2% for malignancy according to a metaanalysis of 70 studies involving 2297 resected IPMNs. The
MN size also has a considerable effect on the prediction of
IPMNs with both invasive cancer and high-grade dysplasia,
with a standardized mean difference of 0.79. However, no
reliable cut-off value for the MN size was identied owing to
the heterogeneity of proposed thresholds. Multivariate analysis revealed that MN was the only independent predictor of
invasive cancer and high-grade dysplasia for all IPMN types
[15]. Additionally, all studies included in the meta-analysis
used CH-EUS for MN assessment. Therefore, CH-EUS is
the best tool for characterizing size and has the best accuracy
for predicting malignancy in IPMNs.
Kamata etal. followed up 102 patients with branch-duct
IPMNs for a median of 42months and concluded that EUS
was useful for the early detection of newly developed concomitant pancreatic carcinomas, reporting 3- and 5-year
rates of 4% and 8.8%, respectively. In their study, the sensitivity and specicity for pancreatic cancer detection in
patients with IPMNs were 100%, 100% on EUS and 39%,
99% on abdominal ultrasound and 56%, 100% on CT and
50%, 100% on MRI, respectively. EUS was signicantly
superior to other modalities [16].
EUS-FNA is also performed to diagnose cystic lesions. A
meta-analysis of eight studies including a total of 1438
patients evaluated the diagnostic accuracy of EUS-FNA for
distinguishing mucinous from non-mucinous cystic lesions
with cyst-uid analysis for cytology and carcinoembryonic
antigen (CEA). The most promising cystic uid biomarker
was CEA level, which was increased in mucinous cysts but
was low in serous cystadenomas and benign lesions. The
optimum threshold for cyst-uid CEA level was 192ng/mL
in this study, indicating high discriminatory accuracy.
Furthermore, the pooled sensitivity and specicity were 54%
and 93% for cytology and 63% and 88%, for CEA level,
respectively [17]. EUS-FNA, when used in conjunction with
16 Endoscopic Ultrasound forHepato-Pancreato-Biliary Diseases
cross-sectional imaging, is a useful diagnostic tool for the
correct identication of mucinous cysts.
Ampullary cancers without submucosal or ductal inltration
that are conned to the ampulla are considered amenable to
endoscopic resection [18–22] because neither vascular invasion, lymphatic permeation, nor lymph node metastasis is
observed in patients when the lesions are restricted to the duodenal mucosa [22, 23]. A meta-analysis of 14 studies investigating ampullary cancer staging by EUS in 422 patients
reported a pooled sensitivity and specicity of 77% and 78%
for T1 staging, 73% and 76% for T2 staging, 79% and 76% for
T3 staging, 84% and 74% for T4 staging, and 70% and 74%
for N staging, respectively [24]. Therefore, EUS is important
for prognostic prediction and determination of the most appropriate therapeutic approach for ampullary cancers.
A comparison of different diagnostic tools for the detection
of cholangiocellular carcinomas indicated the following
accuracy rates: 92% for endoscopic retrograde cholangiopancreatography (ERCP)/intraductal ultrasound (IDUS),
74% for endoscopic transpapillary forceps biopsy (ETP),
92% for IDUS + ETP, 70% for EUS, and 79% for CT.An
analysis of accuracy rates with respect to localization of bile
duct stenosis revealed that the accuracy rate of EUS for proximal versus distal stenosis was signicantly higher than that
for distal stenosis (79% vs. 57%; P<0.0001) [25]. ERCP/
IDUS is superior to EUS and CT in establishing accurate
diagnoses of bile duct strictures of uncertain etiology. Hence,
multimodal diagnostic imaging is recommended for bile
duct cancers.
139
Transpapillary drainage with ERCP is generally performed
for malignant biliary obstruction. Nonetheless, some previous studies have reported difculty in biliary cannulation in
15–22% of patients [29, 30], occurrence of post-ERCP pancreatitis (PEP) in 3–15% of patients [31], and an inaccessible
biliary orice due to duodenal stenosis in 7–13% of patients
with pancreatic head cancers [32].
Percutaneous transhepatic biliary drainage is conventionally performed when ERCP fails; however, this procedure
has several disadvantages, including tube dislocation, external drainage, and cosmetic problems. The recently developed EUS-BD is carried out when endoscopic transpapillary
drainage fails in patients with distal malignant biliary
obstruction. Important advantages of this method over other
procedures include internal drainage and prevention of PEP
(Fig. 16.4). A meta-analysis of four studies enrolling 302
patients revealed no difference in technical success (risk
ratio [RR], 1.00; 95% CI, 0.93–1.08), clinical success (RR,
1.00; 95% CI, 0.94–1.06), and total adverse events (RR,
0.68; 95% CI, 0.31–1.48) between EUS-BD and ERCP
drainage as primary treatment for distal malignant biliary
obstruction. EUS-BD was associated with lower rates of PEP
(RR, 0.12; 95% CI, 0.02–0.62), stent dysfunction (RR, 0.54;
95% CI, 0.32–0.91), and tumor ingrowth and overgrowth
(RR, 0.22; 95% CI, 0.07–0.76). No differences in reinterventions (RR, 0.59; 95% CI, 0.21–1.69), procedural duration
(weighted mean difference, −2.11; 95% CI, −9.51–5.29),
stent patency (hazard ratio, 0.61; 95% CI, 0.34–1.11), and
overall survival (hazard ratio, 1.00; 95% CI, 0.66–1.51) were
observed [33]. With adequate expertise in endoscopy,
EUS-BD can show the same efcacy and safety as ERCP for
the primary palliation of distal malignant biliary obstruction
and exhibits several clinical advantages with respect to
complications.
Diagnosis using imaging modalities is important because
preoperative pathological diagnosis is difcult in gallbladder
cancers. Malignancy diagnosis with conventional EUS and
CH-EUS for 36 gallbladder wall thickening lesions had been
reported to have an overall sensitivity of 61–87% and
90–97%, specicity of 65–83% and 56–98% (P < 0.001),
and accuracy of 73–86% and 94–96%, respectively [26–28].
An inhomogeneous enhanced pattern on CH-EUS was a
strong predictive factor for malignant gallbladder wall thickening. CH-EUS has the potential to improve preoperative
diagnostic accuracy in the differential diagnosis of gallbladder wall thickening.
EUS-PD is considered a feasible alternative to percutaneous
drainage (PCD) or surgical drainage when endoscopic retrograde pancreatography is unsuccessful in patients with pancreatic ductal obstruction (Fig.16.5). The overall technical
and clinical success rates of EUS-PD had been reported to be
85% (339/401; range, 63–100%) and 88% (328/372; range,
76–100%), respectively. Additionally, 25% (102/401) of
cases experienced short-term adverse events, including
abdominal pain (n=45), acute pancreatitis (n=17), bleeding
(n=10), and problems associated with pancreatic juice leakage such as perigastric or peripancreatic uid collection
140
cd
Y. Yamashita and M. Kitano
a
b
showing a guidewire inserted into the dilating bile duct. (c) Fluoroscopic
denostomy. (a) EUS showing a 19-gauge needle (arrows) inserted into
the dilating extrahepatic bile duct (arrowhead). (b) Fluoroscopic image
(PFC; n =9) [34]. EUS-PD continues to be a challenging
procedure associated with a high risk of adverse events;
nonetheless, it is an alternative tool for pancreatic duct drainage in patients with altered anatomy or selected patients for
whom ERCP conducted by experts at high-volume centers is
unsuccessful.
image showing stent placement. (d) Endoscopic image showing the
fully opened stent in duodenum
were developed to overcome these limitations (Fig.16.6). A
meta-analysis that included 15 studies (1746 patients) identied no signicant difference in clinical success between
LAMSs and DPPSs (RR, 1.04; 95% CI, 0.99–1.11) or
between LAMSs and FCSEMSs (RR, 0.96; 95% CI, 0.91–
1.03). FCSEMSs were superior to DPPSs with respect to
clinical success (RR, 1.09; 95% CI, 1.02–1.15). Furthermore,
no signicant difference in PFC recurrence was observed
EUS-guided drainage has become a widely accepted treatment option for PFC. In the early days, EUS-guided PFC
drainage was performed using double-pigtail plastic stents
(DPPSs) to minimize migration risk. However, endoscopists
eventually recognized the limitations of DPPSs.
Consequently, fully covered self-expanding metal stents
(FCSEMSs) and lumen-apposing metal stents (LAMSs)
among the groups. As for adverse events, LAMSs exhibited
a higher bleeding risk than FCSEMSs (RR, 6.70; 95% CI,
1.77–36.27) and tended to have a higher bleeding risk than
DPPSs (RR, 2.67; 95% CI, 0.71–9.28) [35]. LAMSs were
considered a breakthrough in the endoscopic management of
walled-off necrosis (WON), as their larger drainage diameter
was expected to result in effective necrotic material drainage.
16 Endoscopic Ultrasound forHepato-Pancreato-Biliary Diseases
141
a
b
d
c
drainage. (a) EUS showing a 19-gauge needle inserted into the dilating
main pancreatic duct (arrows). EUS showing pancreatic stone (arrow
head) in main pancreatic duct. (b) Fluoroscopic image showing dilating
Rana et al. reported that LAMSs were associated with a
signicantly shorter time to resolution; however, with respect
to technical success, the WON resolution and complication
rates were similar between patients treated with multiple
plastic stents and LAMSs [36]. Moreover, large WON or
WON with a high proportion of solid debris may be a good
indication for direct endoscopic necrosectomy through
LAMS with large inner diameter [37] (Fig.16.7).
POPFC is an important complication following abdominal
surgery. While PCD is the traditional mainstay of treatment,
main pancreatic duct and stone (arrowhead). (c) Fluoroscopic image
showing stent placement. (d) Endoscopic image showing the plastic
stent in stomach
EUS-guided drainage for POPFC has recently been performed. EUS and PCD were used in the management of
POPFC in 10 (239 patients) and 6 (267 patients) out of 13
studies included in a meta-analysis. The pooled clinical success rate was signicantly higher with EUS than with PCD
(93.2% vs. 79.8%; P= 0.002). Furthermore, the recurrence
rate was signicantly lower with EUS than with PCD (9.4%
vs. 25.7%) [38]. The pooled technical success and adverse
event rates were similar between EUS and PCD.EUS has
signicantly better clinical outcomes in terms of clinical success and disease recurrence than PCD in the management of
POPFC.Therefore, EUS-guided drainage plays a role in the
management of POPFC.
142
cd
Y. Yamashita and M. Kitano
a
b
area. (b) EUS image: EUS shows electrocautery-enhanced delivery sys-
scopic necrosectomy through lumen-apposing metal stent (LAMS) for
walled-off necrosis. (a) MDCT showing large walled-off necrosis
(WON) with a high proportion of solid debris (arrow) in peripancreatic
tem (arrow) was inserted into WON with a high proportion of solid
debris. (c) Fluoroscopic image showing stent placement (arrowhead).
(d) Endoscopic image showing the fully opened stent in stomach
eral approach. A meta-analysis extracted data from eight
EUS-CPN is widely employed to reduce pain originating
from upper abdominal organs. In particular, EUS-CPN
using the central or bilateral approach is accepted as a common pain control measure for patients with pancreatic cancer and chronic pancreatitis. Some of its advantages include
real- time guidance; short puncture distance; use of anterior
pathway, thereby avoiding puncture through the posterior
diaphragm space; and color Doppler, thus preventing vascular damage. Absolute ethanol is injected through the
FNA needle at the base of the celiac artery in the central
approach and on both sides of the celiac artery in the bilat-
studies (238 patients) evaluating EUS-CPN for the relief of
pain due to pancreatic cancer and from nine studies (376
patients) investigating EUS-CPN for the relief of pain due
to chronic pancreatitis. Overall, 80.12% of patients with
pancreatic cancer (95% CI, 74.47–85.22) and 59.45% of
patients with chronic pancreatitis (95% CI, 54.51–64.30)
showed pain relief [39]. Wyse etal. reported that the relief
of pain due to pancreatic cancer was signicantly greater at
three months in the EUS- CPN group than in the morphine
group [40]. Hence, EUS- CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or
pancreatic cancer.
16 Endoscopic Ultrasound forHepato-Pancreato-Biliary Diseases
ab
of necrotic tissue. (b) Necrotic tissues are removed from inside of WON
(LAMS) for walled-off necrosis (WON). (a) Endoscopic image:
Endoscopy is inserted into WON via LAMS and shows a large amount
by endoscopic necrosectomy
143
EUS-guided ablation therapy is considered a safe alternative
treatment for patients deemed unsuitable to undergo surgery. According to a meta-analysis of 14 studies that
included 158 patients, the major types of solid pancreatic
tumors were nonfunctional pancreatic neuroendocrine
tumors (n=78, 49.4%), pancreatic cancers (n=48, 30.4%),
and insulinomas (n=26, 16.5%). Overall, the pooled clinical success and complication rates were 85.9% (95% CI,
75.4–92.4%) and 29.1% (95% CI, 18.6–42.3%), respectively. A subgroup analysis of ablation methods indicated
clinical success rates of 83.5% (95% CI, 67.9–92.4%) and
87.9% (95% CI, 66.2–96.4%) and complication rates of
32.2% (95% CI, 19.4–48.4%) and 21.2% (95% CI, 6.8–
49.9%) for radiofrequency ablation and ethanol ablation,
respectively [41]. EUS-guided ablation therapy may be an
alternative treatment for solid pancreatic tumors, particularly neuroendocrine tumors and insulinomas <2 cm with
rarely severe complications. Further prospective studies
with long-term follow-up are warranted in the future owing
to the small number of studies.
EUS plays an important role in the diagnosis and staging of
pancreaticobiliary lesions, offers advantages over other
imaging methods in the detection of small lesions, and is
superior to any other modality with respect to spatial resolution. With a high accuracy rate and a low complication rate,
EUS-FNA can be regarded as the nal tool for decisionmaking regarding the therapeutic strategy and is extensively
applied as treatment for hepato-pancreato-biliary diseases.
EUS-guided drainage for PFC is a widely accepted treatment
option, and EUS-guided pancreatobiliary duct drainage has
become an alternative to conventional drainage in difcult
cases. Further studies investigating the role of EUS ablation
in solid pancreatic lesions are required in the future.
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Intraoperative Imaging Techniques
inLiver Surgery
FlorinBotea, AlexandruBarcu, andIrinelPopescu
17
Abstract
Despite tremendous development of preoperative imaging techniques in liver tumors, the high complexity liver
surgery, including techniques to increase resectability and
the minimal invasive approach, as well as the signicant
intraoperative risk, demand the development and implementation of intraoperative imaging techniques, such as
intraoperative cholangiography, intraoperative ultrasound, intraoperative uorescence, and intraoperative
navigation.
Despite tremendous development of preoperative imaging
techniques in liver tumors, the high complexity liver surgery,
including techniques to increase resectability and the minimal invasive approach, as well as the signicant intraoperative risk, demand the development and implementation of
intraoperative imaging techniques, such as intraoperative
cholangiography, intraoperative ultrasound, intraoperative
uorescence, and intraoperative navigation.
17.1 Intraoperative Cholangiography
The rst report on depiction of the biliary ducts was published in 1918 by Reich [1], who used bismuth and petrolatum to dene a biliary stula. Mirizzi advanced the eld by
reporting in 1932 the rst series of routine intraoperative
cholangiography (IOC) is using lipiodol during cholecystectomy [2]. Berci, Shore, Hamlin, and Morgenstern [3]
reported in 1978 a series of patients in whom a C-arm mobile
image intensier was used for IOC, obtaining high-denition
X-rays.
Intraoperative cholangiography (IOC) is currently the
most frequently used technique for intraoperative assess-
F. Botea (*) · A. Barcu · I. Popescu
“Dan Setlacec” Center of General Surgery and Liver
Transplantation, Fundeni Clinical Institute, Bucharest, Romania
ment of the biliary anatomy. Being safe, effective, and helpful in evaluating the biliary anatomy and guiding the surgical
procedures that involves the bile ducts.
The diagnostic accuracy of a static X-ray method is
50–70%, but the digitized image intensier uoroscopic
method increases the accuracy to 95–100%. The time
decreased from 20–30 min for a static cholangiogram to
3–5min with uoroscopic IOC.Dynamic uoroscopy speeds
up the IOC and provides high-resolution images that more
accurately depict the biliary anatomy [4].
The advantages of IOC are [4]:
– identication of the anatomy and aberrant anatomy of the
extrahepatic bile ducts,
– identication of pathology and injuries of the common
bile duct or Oddi’s sphincter,
– data storage for documentation and review,
– landmarks for further surgical dissection.
However, IOC has several drawbacks, preventing the routine
use of IOC:
– does not allow 3-dimensional (3D) anatomical viewing;
– the spatial relationships between the bile ducts and liver
parenchyma, as well as the location of the bile ducts pass-
ing through the liver, are difcult to understand because
only the bile duct can be imaged [5].
– the caudate bile ducts, that may cause biliary leakage after
bile duct division, are not always clearly delineated;
– poor detection of variants of intrahepatic biliary anatomy
[6],
– risk of false positive results,
– risk of iatrogenic bile duct injuries.
– time consuming procedure;
– a large C-arm uoroscopy device and additional human
resources are required,
– the patient and medical staff are exposed to radiation.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_17
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F. Botea et al.
However, in the era of laparoscopy and of no tolerance for
complications in living donor, IOC is extremely important in
case of unclear or aberrant biliary anatomy [4].
17.2 Intraoperative Ultrasound
Intraoperative ultrasonography (IOUS) was introduced in
liver surgery in 1980′ by Makuuchi [7] and had proven to be
fundamental for making a complete diagnosis during liver
surgery, but also for guiding the liver resection (LR), with a
low rate of intraoperative incidents and postoperative complications, while increasing the resectability [8].
IOUS usually uses high-frequency probes (7.5–10MHz),
due to the high resolution and, therefore, the highest detection
rate, especially in case of small relatively supercial lesions.
The low-frequencies probes (3.5–5MHz) may be used for
initial exploration, allowing a panoramic view of the liver and
the detection of deep located structures and lesion (such as
segment 1). They also are used for contrast-enhance IOUS.
It is worth mentioning that IOUS has difculties in detecting small subcapsular lesions; however, these are usually
easily detected at inspection and palpation. If IOUS is
intended to be used for detecting such lesions, especially in
case of a brotic liver that impedes lesion palpation, a surgi-
cal glove lled with sterile saline solution can be used as an
interface between the probe and the liver surface, making the
lesion visible.
IOUS is performed using specic devices, either in open
approach or in laparoscopy (Fig.17.1), after partial mobilization of the liver by sectioning the round and falciform
ligaments, and the triangular and coronary ligaments. It
involves four main steps:
1. evaluation of liver anatomy: exploration of vessels and
bile ducts at hilum and intrahepatic levels, establishing
the liver segmentation;
2. diagnosis: detection, diagnosis and mapping (according
to liver segmentation and relation to major intrahepatic
structures) of all liver lesions; Contrast-enhanced IOUS
may detect additional lesions and/or ensure a positive
diagnosis of the detected lesions [9]. Additionally, IOUS
evaluates the background liver, assessing its impairments,
such as cirrhosis and steatosis,
3. guidance of liver resection: resection planning, and real-
time guidance of the transection plane using specic
techniques, such as the hooking technique for vessel
identication during transection [10],
4. control of post-resection results in terms of tumor clear-
ance, including the control of the specimen for very small
Fig. 17.1 BK 5000
ultrasound machine designed
for intraoperative ultrasound.
of the liver, with various
probes: T-shaped convex
intraoperative probe (1);
I-shaped convex
intraoperative probe (2);
biplane convex intraoperative
probe (3); laparoscopic 4-way
convex probe (4); convex
probe for (5)