EUS-guided transgastric drainage of caudate lobe liver abscesses

Diagnostic and interventional EUS in hepatology: An updated review

EUS has become an increasingly used diagnostic and therapeutic modality in the armamentarium of endoscopists. With ever-expanding indications, EUS is being used in patients with liver disease, for both diagnosis and therapy. EUS is playing an important role in providing additional important information to that provided by cross-sectional imaging modalities such as computerized tomography and magnetic resonance imaging. Domains of therapy that were largely restricted to interventional radiologists have become accessible to endosonologists. From liver biopsy and sampling of liver lesions to ablative therapy for liver lesions and vascular interventions for varices, there is increased use of EUS in patients with liver disease. In this review, we discuss the various diagnostic and therapeutic applications of EUS in patients with various liver diseases.

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.

Endoscopic ultrasound-guided transgastric drainage of radiologically inaccessible left lobe liver abscess involving segment 4, caudate lobe, and left lateral segments using a modified technique

Liver abscess requiring drainage is conventionally managed by interventional radiology-guided percutaneous drainage (PCD). Radiologically inaccessible abscesses are managed with laparoscopic or open surgery, which carries high rates of morbidity and mortality. EUS-guided transluminal liver abscess drainage is minimally invasive and can be an alternative approach for caudate lobe, segment 4, and left lateral segment abscesses. We report on three consecutive patients with radiologically inaccessible left lobe liver abscess involving the caudate lobe, segment 4, and lateral segment in whom EUS-guided transluminal drainage using a modified technique was successful.

Endoscopic ultrasound-guided drainage of difficult-to-access liver abscesses

OBJECTIVES

Antibiotic therapy and percutaneous drainage have been the first-line treatments for liver abscesses. However, percutaneous drainage of abscesses may be challenging in difficult-to-access locations such as the caudate lobe. The aim of this review was to determine the indications, technical feasibility and efficacy of endoscopic ultrasound-guided drainage of difficult-to-access liver abscesses.

METHODS

A literature review of original articles, abstracts, case series and case reports describing endoscopic ultrasound-guided liver abscess drainage was performed. The indications, techniques and complications associated with endoscopic ultrasound-guided drainage were reviewed.

RESULTS

A total of 15 studies were identified. The main indications were failed antibiotic therapy and difficulty in gaining percutaneous access. The technique involved identification and puncturing of an abscess under endoscopic ultrasound guidance followed by placement of a prosthesis via a guide wire. The technique was 97.5% successful with no major complications reported.

CONCLUSION

Endoscopic ultrasound-guided drainage was feasible and safe and allowed complete drainage of liver abscesses not accessible by percutaneous drainage.

The role of EUS in diagnosis and treatment of liver disorders

Background and aim  Transabdominal ultrasound (US), computed tomographic scanning (CT) and magnetic resonance imaging (MRI) are established diagnostic tools for liver diseases. Percutaneous transhepatic cholangiography is used to perform hepatic interventional procedures including biopsy, biliary drainage procedures, and radiofrequency ablation. Despite their widespread use, these techniques have limitations. Endoscopic ultrasound (EUS), a tool that has proven useful for evaluating the mediastinum, esophagus, stomach, pancreas, and biliary tract, has an expanding role in the field of hepatology complementing the traditional investigational modalities. This review aimed to assess the current scientific evidence regarding diagnostic and therapeutic applications of EUS for hepatic diseases.

Endoscopic ultrasound-guided fine-needle aspiration can target right liver mass

Background and Objectives:

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been established as a safe and accurate method for diagnosing and staging intra-abdominal mass. However, few studies investigated its feasibility, efficacy, and safety for targeting liver mass. We evaluated the efficacy and safety of EUS-FNA in patients with liver masses including the right lobe.

Patients and Methods:

The technical feasibility, safety, and diagnostic yield were determined in 47 patients (30 in the left lobe and 17 in the right lobe) presenting with liver masses between September 2010 and February 2016.

Results:

Thirty-eight patients (80.9%) had malignancies whereas nine patients (19.1%) had benign liver masses. Technical success rate was 97.9% (46/47). EUS-FNA was diagnostic in 38 of 42 patients (90.5%). When the outcomes of EUS-FNA between right liver mass and left mass were accessed, the technical success rates were similar in both lobes (100% vs. 94.1%, P = 0.2). The median tumor size on EUS (25.5 mm, interquartile range [IQR] 13.8–30.3 vs. 28 mm, IQR 18.5–43.5, P = 0.24) and number of needle passes (3, IQR 3–4 vs. 3, IQR 3–3, P = 0.24) were not significantly different. Adequate specimen obtained was statistically higher in the left lobe (28/30, 93.3% vs. 14/17, 82.4%, P = 0.04). However, diagnostic accuracy for liver masses was not different (25/28, 89.3% vs. 13/14, 92.9%, P = 0.86). No complications developed after procedure.

Conclusions:

EUS-FNA can be a safe and efficient method for the diagnosis of liver mass and it is technically feasible even for those in the right lobe.

Clinical Outcome of Endoscopic Ultrasound-Guided Liver Abscess Drainage Using Self-Expandable Covered Metallic Stent (with Video)

BACKGROUND

Percutaneous drainage (PCD) is now the first-line drainage method for liver abscess because of its minimal invasiveness and high technical success rate. However, this procedure has several disadvantages, such as extra-drainage and self-tube removal. Recently, EUS-guided liver abscess drainage (EUS-AD) has been developed. However, only a few reports of EUS-AD have been reported. In addition, the clinical benefits of PCD and EUS-AD have not been reported.

AIMS

In the present study, the safety and feasibility of EUS-AD using fully covered SEMS (FCSEMS) and the clinical outcomes of EUS-AD and PCD were examined retrospectively.

METHODS

Twenty-seven consecutive patients who underwent PCD or EUS-AD between April 2012 and April 2015 were included in this study. EUS-AD was performed using FCSEMS. In addition, to prevent stent migration, 7-Fr pig tail plastic stent was placed within FCSEMS.

RESULTS

Technical success was achieved in all patients of both groups. Clinical success was 100 % in the EUS-AD group although it was 89 % in PCD group (P = 034). Three adverse events were seen in the PCD group (self-tube removal n = 1, tube migration n = 2), but no adverse events were seen in the EUS-AD group. The median hospital stay was significantly shorter in the EUS-AD group than in the PCD group (21 vs 41 days, P = 0.03).

CONCLUSION

Because of the short hospital stay, the high clinical success rate, and the low adverse event rate compared to PCD, EUS-AD has potential as a first-line treatment for liver abscess.