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Recent Advance of Endoscopy Hsiu-Po Wang, MD. Department of Emergency Medicine National Taiwan University Hospital

ndoscopy in last decade of 20 th and beginning of 21 th century Diagnostic Therapeutic agnify endoscopy hromoendoscopy ble stiffness endoscopy doscopic Ultrasound ectronic baby scope le-balloon enteroscopy apsule endoscope Capsule EUS (?) Hemoclipping Detachable snare Argon plasma coagulatio Endoscopic mucosectom Endoscopic pseudocyst drai EUS-FNA EUS-true cut biopsy

Routine endoscopy for morphology( ) Dye endoscopy for spreading area( ) EUS for depth( )

Magnify endoscopy I endoscopy & colonoscopy pattern & vascular pattern pth & malignant potential

Why chromoendoscopy?

Enteroscopy

Double balloon enteroscopy

Endoscopic Ultrasound EUS

Ultrasound family

Why EUS?

Lymphangeal cyst

EUS 80 Miniprobe 90 Linear scan US IDUS Linear scan EGCP CD-EUS EUS-F

CBD microlithiasis detected by EUS Ghang YS, Wang HP,etc Gastroenterol J Taiwan 1998;15:246-250 250

IDUS

IDUS Cystic duct

---> --->

Mallory-Weiss

Mallory-Weiss syndrome Huang SP, Wang HP, Lee YC, Lin CC, Yang CS, Wu MS, Lin JT Endoscopic hemoclip placement and epinephrine injection for Mallory-Weiss syndrom with active bleeding Gastrointest Endosc.(2002) Jun;55(7 Pt 1):842-846

Hemoclipping for aneurysmal vessel

Lee YC, Wang HP et al. J Hemoclippin for bleeding marginal ulc

7000-13000/mm 3

,,,

Argon plasma coagulation First endoscopic application in Taiwan in July 1999 Non-contact

Early esophageal cancer - APC

SM cardia cancer -APC

- Endoscopic mucosectomy EMR

EMR-C

EMR for early esophageal cancer

EMR for early rectal cancer

Leiomyoma - EMRC

Lipoma LT

ndoscopic Submucosal Dissection IT Knife Flex Knife Hook Kni

ndoscopic Submucosal Dissection ( ESD )

Depth of invasion is very important for EMR EUS

m: mucosa sm: submucosa m1 m2 m3 sm1 sm2 sm3 For metastasis of lymph node

Esophageal cancer m: mucosa sm: submucosa m1 m2 For metastasis of lymph node

Gastric cancer m: mucosa sm: submucosa m1 m2 m3 sm1 For metastasis of lymph node

RBD Bile Bile

Materials of Stent Plastic endoprotheses # polyethelyne Metal endoprotheses # stainless steel # nitinol (nickel-titanium alloy)

roblems of Metal Biliary Stenting Unremovable Cholangitis due to reflux of duodenal content Duodenal ulcers or even bleeding Tumor ingrowth or overgrowth

roblems of biliary metallic stent Metalli stent Ulcer

roblems of biliary metallic stent or ingrowth New stent

Biliary Plastic Stents - NTUH Experience Post-procedure cholangitis 9% more in hilar lesions Procedure-related motality 8% Patency : 5-630 days mean 158 days

Biliary Plastic Stents - NTUH Experience ncy (%)

etallic stent for gastric cardia cancer

odenal stent

Duodenal Stent - NTUH Experience

Duodenal Stent - NTUH Experience Before After

Clinical Benefits for Duodenal Endoprotheses Relieves obstructive symptoms Eliminate need for gastrojejunostomy Allows food orally Reduces palliative morbidity Improves patient s quality of life

Metal stenting of colon Dr. Kochman Workshop in NTUH 1999 July

EUS- FNA needle Echo-tip GIP Olympus NA-10J-1 Olympus NA-11J-KB

Complications of EUS-FNA/FN Perforation Bleeding Infection Tumor seeding

astrointestinal stromal tumor

EUS-FNA Quick-core 19 gauge

EUS-related procedure EUS-FNA EUS guided & assisted US guided Tru-cut biopsy terventional EUS ( 21 st ) Mediastinal structure GI mural tumor Biliopancreatic lesion Adrenal tumor Spleen Lymph nodes Pseuodocyst darianage Abscess aspiration GI mural tumor Gastrojejunostomy Cholecystogastrostomy

EUS-Therapy Pancreatic pseudocyst drainage Plexus block/neurolysis Botulim toxin injection for achalasia Injection of chemotherapy, Cytoimplants Radiofrequency-ablation, etc

Puncture needle wire

EUS-assisted Cystgastrostomy pseudocyst

EUS-assisted Cystgastrostomy

EUS-guided celiac plexus block/neurolysis eliac nerve block CPB) Injection of orticosteroid for emporary bock eliac plexus eurolysis (CPN) Injection of absolute thanol to destroy the

EUS-guided CPN

EUS-guided Celiac Plexus Block Complications: Major: Retroperitoneal bleeding Peripancreatic abscess Minor: Increase in abdominal pain Diarrhea Transient hypotension ~J Clin Gastroenterol 2001; 32: 390-393

EUS-FNI minimally invasive delivery system educe tumor burden

Wire EUS