WFUMB Course Book 34.

ENDOSCOPIC ULTRASOUND

34. Endoscopic ultrasound

Remember
Adrian Săftoiu, Christian Jenssen
• EUS examinations can be performed with radial or longitudinal echoendoscopes
Keywords: endoscopic ultrasound, fine needle aspiration biopsy, contrast-
• EUS-guided interventions require longitudinal echoendoscopes
enhacement, elastography

34.1. Preparation
Endoscopic ultrasound (EUS) is a high-performance imaging method which combines
endoscopy and ultrasound, using small transducers placed at the end of a modified
endoscope. EUS is used for the evaluation of the digestive tract wall, but also
neighboring organs, including the performance of EUS-guided fine needle aspiration
/ biopsy (FNA / FNB) for cytology or microhistology. Furthermore, EUS can be used
for guidance or assistance of therapeutic procedures, especially for the drainage of
pseudocysts or walled-off panreatic necrotic collections (WOPN), but also obstructed
bile ducts or gallbladder.
The preparation for the examination can be summarized as follows.
• Fasting (8h) prior to EUS is recommended to ensure that the stomach is empty.
Small amounts of clear fluids are allowed until 4 hours before the examination (e.g.
for medication is allowed).
34.3. Structured examination
For conventional EUS examinations, the wall of the digestive tract appears to consist
of five layers with alternating echogenicity (Fig 34.1):
Layers of the digestive tract by US:
• hyperechoic layer 1 formed by the interface with the superficial mucosa
• hypoechoic layer 2 comprising the deep mucosa
• hyperechoic layer 3 corresponding to the submucosa
• hypoechoic layer 4 represented by muscle
• hyperechoic layer 5 which represents serous / adventitious

• Antiplatelets and/or anticoagulants should not be stopped prior to diagnostic EUS.

Except aspirin, they have to be stopped (or switched with low-molecular weight View enlarged image
heparin) before therapeutic EUS (including EUS-FNA / FNB), according to ESGE and
EFSUMB guidelines. Fig 34.1
Wall layers of the stomach
as shown using a radial
34.2. Methodology echoendoscope (1st
echogenic layer, internal
Two types of dedicated flexible endoscopes, radial and longitudinal, are used in the interface echo; 2nd
hypoechoic level; mucosa;
clinical practice. Radial echoendoscopes have an examination field perpendicular
3rd hyperechoic layer;
to the long axis of the endoscope, thus yielding images similar to those from CT / submucosa; 4th hypoechoic
MR. Most initial studies have used such radial scopes, especially useful for staging level; muscularis propria; 5th
procedures in esophageal, gastric, and rectal cancer. hyperechoic level, external
Longitudinal scopes have the examination field in the long axis, thus allowing the interface echo corresponding
performance of EUS-FNA/FNB, but also other therapeutic procedures. Both elastography to serosal layer)
and contrast-enhancement are available with state-of-the-art EUS platforms.

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34.4. Indications
Clearly established indications for EUS include diagnosis of pancreatico-biliary
lesions, mediastinal lesions (including diagnosis and staging of lung cancer and
LN), as well as staging of digestive tract cancer (esophageal, gastric, rectal), etc.
Remember
• EUS is targeted for diagnosis of pancreatico-biliary or mediastinal lesions, as
well as staging of GI tract cancers
34.5. Digestive tract cancers
34.5.1. Esophageal diseases
EUS staging of esophageal and esogastric junction cancers should be performed
according to the 8th AJCC staging system. EUS is considered the best staging
method for T and N stage, whilst (PET)-CT is used for M stage. EUS appearance
consists of a hypoechoic, inhomogenous tumor, which invades the layers of the
esophageal wall, starting from the superficial mucosa towards profound mucosa,
submucosa and muscularis propria. Accuracy for T staging is around 90%, being
higher in advanced stages (T3 and T4). EUS is also useful for the assessment of
N stage, as it can clearly depict cervical, mediastinal and abdominal LN, although
with variable accuracy for the differential diagnosis benign-malignant. The lower
percentages are due to poor staging in stenotic tumors that cannot be crossed, in
small adenopathies with micrometastases or large inflammatory ones, for example
in smokers. Conventional EUS criteria (size > 10 mm, round, distinct margins,
hypoechoic appearance) have low accuracy of around 80%, although only 25%
have all 4 criterias. Nevertheless, EUS-FNA increases sensitivity and specificity of
N stage diagnosis. These procedures have a high clinical impact provided that the
LN indicate metastatic disease (stage M1). EUS (with EUS-FNA for the evaluation
of LN) represents the best option for the staging of patients with carcinoma in the
setting of Barrett’s esophagus, being superior to CT for both T and N staging,
especially when endoscopic mucosal resection (EMR) is considered.
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34. ENDOSCOPIC ULTRASOUND
34.5.2. Stomach
Similar to esophageal pathology, EUS examination of the stomach allows
visualization of individual layers of the wall and evaluation of adjacent structures.
Thus, resectable patients should be referred to curative surgeries, patients with
advanced local disease to neo-adjuvant treatment, and those with advanced
metastatic cancer to palliative treatment. Gastric adenocarcinoma can be evaluated
by EUS for the assessment of stage T and N, the method being clearly superior to
CT evaluations, with an accuracy of approximately 85% for stage T and 70% for
stage N. EUS and CT are considered complementary methods, with EUS used
for locoregional staging and CT for metastatic disease. Moreover, in patients with
diffuse thickening of the gastric wall (Fig 34.2), performing histological punctures
has an accuracy of over 90%, compared to the accuracy of FNA of only 60%. EUS-
FNA / FNB is also useful as it confirms metastatic diease in more than 40%, for
e.g. in mediastinal LN. The technique can be useful for confirmation of ascites and
peritoneal carcinomatosis, as well as metastasis of the left adrenal or left liver lobe.
Another indication for EUS staging is extranodal non-Hodgkin lymphoma, used for
the assessment of T and N staging with a sensitivity and specificity of over 85-90%,
higher than CT.
View enlarged image
Fig 34.2a
Scirrhous gastric cancer.
Endoscopic image showing
thickened and flat gastric
folds)
WFUMB Course Book
View enlarged image
Fig 34.2b
Scirrhous gastric cancer. With radial EUS marked thickening of gastric wall (between
markers) with partial loss of layering and a small amount of perigastric fluid are visible (1st
echogenic layer, internal interface echo; 2nd hypoechoic level; mucosa; 3rd hperechoic
layer; submucosa; 4th hypoechoic level; muscularis propria; 5th hyperechoic level, external
interface echo corresponding to serosal layer)
Moreover, MALT (mucosa-associated lymphoid tissue) gastric lymphomas
response to Helicobacter pylori eradication therapy can be assessed by EUS,
with a complementary value to endoscopy with biopsies. Thus, patients with low
malignancy lymphomas of the MALT type, limited to the mucosa and submucosa
(stage IE1, respectively T1m and T1sm in the Ann Arbor and TNM stages),
generally respond to H. pylori eradication treatment, while other patients require
more aggressive surgical and / or chemotherapeutic treatment.
Giant gastric folds can be assessed by EUS, as they have several potential
causes: infectious (chronic gastritis with Helicobacter pylori, secondary siphilis,
citomegalovirus infection, etc.), inflammatory (alcoholic gastropathy, Crohn’s
disease, sarcoidosis, amiloidosis, etc.) and neoplastic (plastic linitis, gastric
lymphoma, etc.), as well as Ménétrier disease. EUS-guided FNB can be used in
difficult cases for the differential diagnosis.
Subepithelial lesions incude various extrinsec compressions or intramural lesions,
including vascular lesions or benign tumors (lipoma, heterotopic pancreas, granular
cell tumors, etc.).
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34. ENDOSCOPIC ULTRASOUND
Gastrointestinal stromal tumors (GIST) are frequently encountered, being
mesenchymal neoplasms with uncertain malignant potential, in direct relation with
Cajal interstitial cells, and having a series of common immunohistochemical markers
(CD-117 and CD-34). EUS is the examination of choice, showing hypoechoic
formations with origin in the 2nd hypoechoic layer (deep mucosa) or most commonly
in the 4th hypoechoic layer (muscularis propria). EUS characteristics suggestive
of malignancy are: size over 3 cm, inhomogeneous appearance, irregular edges,
lymphadenopathy, metastases or ascites. The possibility of performing EUS-
FNA/FNB, with histopathological and immunohistochemical examination of cell
blocks should be considered, although the mitotic index is difficult to determine as
compared to surgical resection pieces.
34.6. Mediastinum
Mediastinum can be completely examined by combined EUS and EBUS, allowing
a complete “medical mediastinoscopy”. EUS allows the differential diagnosis of
mediastinal tumors through EUS-guided FNA / FNB, including negative endoscopic
/ transbronchial / transthoracic biopsies, mediastinoscopies or thoracoscopies. The
sensitivity of EUS-FNA / FNB is higher than 90-95% and allows the differentiation of
benign (sarcoidosis, tuberculosis, leyomioma, etc.) and malignant (lung carcinoma,
lymphoma, metastatic tumors, etc.) (Fig 34.3).
View enlarged image
Fig 34.3a
Mediastinal LN as shown
using longitudinal EUS.
Large lymph node with a
benign phenotype (flat-oval;
hyperechoic hilum) in a
patient with sarcoidosis
WFUMB Course Book 34. ENDOSCOPIC ULTRASOUND

View enlarged image

34.7. Pancreas and biliary tract

Together with magnetic resonance cholangiopancreatography (MRCP), EUS

was established as the most sensitive diagnostic tool for the examination of the
extrahepatic bile ducts and the pancreas. In case of suspected bile duct stones,
dilatation of the common bile duct of unknown etiology, biliary pancreatitis, idiopathic
acute pancreatitis and chronic pancreatitis, it has a sensitivity equally or even
Fig 34.3b superior to endoscopic retrograde cholangiopancreatography (ERCP) with a much
Mediastinal LN as shown better safety profile. The combination of high-resolution imaging, elastography,
using longitudinal EUS. contrast-enhanced techniques and sampling in one EUS examination makes EUS
Large LN with a malignant the ideal one-stop shopping tool for diagnosis of focal pancreatic lesions.
phenotype (round-oval,
hypoechoic with loss of
echogenic hilum) in a patient
with small cell lung cancer Remember
• EUS is the reference imaging tool for the examination of bile ducts and the
Performance of EUS-guided FNA / FNB has an important clinical impact as it pancreas
determines avoidance of thoracotomy / thoracoscopy, as well as mediastinoscopy
in a lot of patients. For patients with lung cancer, EUS-FNA/FNB has a dual role,
because it can confirm the diagnosis in patients with negative biopsies, but also View enlarged image
allows a complete mediastinal staging, with an overall accuracy over 90-95%. The
differential diagnosis between non-small cell (NSCLC) and small cell (SCLC) types
can be made on smears, but especially on cell blocks, with the new histological
needles being nowadays preferred.

EUS can also detect LN located in stations 4L (inferior paratracheal), 5 (aorto-

pulmonary window), 6 (para-aortic), 7 (subcarinal), 8 (inferior paraesophageal)
and 9 (pulmonary ligament). As the accuracy of EUS criteria is low, EUS-FNA can
be used for sampling of the LN with an overall accuracy of over 95%, especially
when using histological needles. EUS can be used for the assessment of portal
Fig 34.4
hypertension, for detection of varices and collateral circulation, but also for the Common bile duct stone
assessment of response to therapy or for EUS-guided therapeutic procedures (between markers, 5 x 2.9
(cyanoacrilate glue and/or coil obliteration of gastric varices). mm; longitudinal EUS)

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The most important clinical applications of EUS for diagnosis of pancreatic and
biliary diseases are listed in table 34.1.
Table 34.1
Indication
Detection / exclusion of bile duct stones in
patients with low or moderate probability
(Fig 34.4)
Biliary pancreatitis: exclusion of persistent
bile duct stone to prevent ERCP
Acute idiopathic pancreatitis: diagnosis of
etiology
Obstructive jaundice: diagnosis of etiology
(Fig 34.5)
Tissue diagnosis of biliary strictures of
unknown etiology
(Suspected) pancreatic ductal
adenocarcinoma (PDAC): Staging and
resectability assessment
Pancreatic solid lesions: further
characterisation and tissue diagnosis
(Fig 34.6, 34.7)
Pancreatic cystic lesions: further
characterisation, risk assessment and fluid
aspiration (Fig. 34.8)
(Suspected) chronic pancreatitis:
grading, detection of complications, treat-
ment planning
Suspected autoimmune pancreatitis: tissue
diagnosis
34. ENDOSCOPIC ULTRASOUND
View enlarged image
Clinical role
Recommended in guidelines, clinical
routine, in meta-analyses sensitivity slightly
superior in comparison to MRCP
Recommended in guidelines, clinical Fig 34.5a
routine Dilated intrahepatic bile
ducts (left liver love) in
Clinical routine a patient with primary
sclerosing cholangitis and
Clinical routine extrahepatic bile duct cancer
(longitudinal EUS)
Superior sensitivity compared to ERCP
with brush cytology and forceps biopsy
Suggested in guidelines, complementary to
CT, clinical routine
Recommended in guidelines before
chemotherapy of PDAC, clinical routine;
Under discussion before surgical treatment
of PDAC;
suggested in guidelines and clinical routine View enlarged image
in case of suspected etiology other than
PDAC
Recommended in guidelines in addition to
magnetic resonance imaging; fluid
aspiration and biochemical, cytoilogical
and molecular examination useful in Fig 34.5b
selected cases Irregular hypoechoic
thickened wall of the
Recommended in guidelines, clinical
common hepatic duct
routine
(wall between markers)
in a patient with primary
Alternative to percutaneous image-guided sclerosing cholangitis and
biopsy; limited sensitivity extrahepatic bile duct cancer
(longitudinal EUS)
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View enlarged image
Fig 34.6a
Longitudinal EUS in a
patient with a pancreatic
tumor. B-Mode EUS shows
a well circumscribed large
hypoechoic pancreatic body
tumor
View enlarged image
Fig 34.6b
Longitudinal EUS in a
patient with a pancreatic
tumor. With Color Doppler
(CD) EUS many irregular
branching vessels are visible
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34. ENDOSCOPIC ULTRASOUND
View enlarged image
Fig 34.6c
Longitudinal EUS in a
patient with a pancreatic
tumor. EUS-FNA (22 Gauge
needle, markers) confirmed
diagnosis of pancreatic
neuroendocrine tumor
View enlarged image
Fig 34.7a
Longitudinal EUS in a
patient with a pancreatic
tumor. B-Mode EUS shows
a well circumscribed large
hypoechoic pancreatic head
tumor
WFUMB Course Book
View enlarged image
Fig 34.7b
Longitudinal EUS in a
patient with a pancreatic
tumor. With EUS
elastography the tumor is
markedly (x 126) harder
compared to surrounding
pancreatic parenchyma
View enlarged image
Fig 34.7c
Longitudinal EUS in a
patient with a pancreatic
tumor. In contrast to the
pancreatic neuroendocrine
tumor shown in figure 4,
CD EUS shows only a few
peripheral vessels
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34. ENDOSCOPIC ULTRASOUND
View enlarged image
Fig 34.7d
Longitudinal EUS in a
patient with a pancreatic
tumor. EUS-FNA (22 Gauge
needle, markers) confirmed
diagnosis of pancreatic
ductal adenocarcinoma
View enlarged image
Fig 34.8
Microcystic serous
cystadenoma of the
pancreas (longitudinal EUS).
Note the multiple small and
larger cysts and echogenic
septae
WFUMB Course Book 34. ENDOSCOPIC ULTRASOUND

34.8. EUS-guided sampling Table 34.2 continued ...

34.8.1. Diagnostic yield and safety Established indications Other useful indications Contraindications
EUS-guided sampling (including endobronchial ultrasound-guided transbronchial Peri-intestinal and Solid splenic lesions Mediastinal cysts
needle aspiration, EBUS-TBNA) has not only considerably increased the clinical mediastinal LN (absolute
value of endoscopic ultrasound, but has also opened up completely new horizons, contraindication)
especially in the diagnosis of solid and cystic pancreatic tumours, the tissue Subepithelial gastrointestinal Small amounts of ascitis or Therapeutic anticoagu-
diagnosis of suspicious LN and subepithelial tumours as well as the staging of tumours pleural effusion and lation and, (combined)
lung cancer and other tumour diseases. peritoneal/ pleural nodules antiplatelet treatment
Diagnostic yield and sensitivity mainly depend on the type of target lesion, but
Solid mediastinal tumours Gastrointestinal mural Severe coagulopathy or
also on the needle type and the experience and collaboration of the examiner and central lung cancer tumors (suspicion of thrombcytopenia
and the cytopathologist. With sufficient experience, diagnostic adequate material scirrhous gastric cancer)
can be obtained in > 85% of cases. Today, cytopathologists can not only reliably
Biliary tract tumors and Adrenal tumors/ Interposition of large
differentiate between malignant and benign disease on the very small tissue
strictures metastases vessels in the needle path
samples and smears, but also further characterise malignant tumours using
immunohistochemical and molecular techniques enabling specific treatment
approaches (“targeted therapy”).
EUS-guided sampling is a very safe procedure with a total rate of adverse events Remember
below 2% and major adverse events being very rare In comparison to solid lesions,
• EUS-guided sampling is highly effective and very safe and facilitates tissue
sampling of cystic lesions is associated with a higher risk of infection and bleeding.
There are almost no absolute contra-indications. diagnosis of lesions that are not or poorly accessible to percutaneous US
guided sampling

34.8.2. Indications and (relative) contra-indications of EUS-guided sampling

Table 34.2
Established indications
Solid pancreatic lesions
(diagnosis of pancreatic
ductal adenocarcinoma in
particular before
chemotherapy and
differentiation from other
pancreatic tumors)
Cystic pancreatic lesions
(for differentiation and risk
stratification)
Other useful indications
Solid hepatic lesions (poorly
accessible for
percutaneous
image-guided sampling)
Parenchymal liver disease
Contraindications
Cytological/histological
result probably without
influence on patient
management
Lack of informed consent
(absolute
contraindication)
34.8.3. Needles and sampling techniques
A large variety of needles with diameters between 25 Gauge and 19 Gauge is
available for EUS- and endobronchial ultrasound (EBUS)- guided sampling. In
addition to the traditional standard aspiration needles, which are mainly used to
obtain material that can be examined cytologically (smears, cell block; EUS-FNA),
needles with a special bevel have also been available for some years, which
facilitate the procurement of small tissue cores with the possibility of histological
examination (EUS-FNB).
Comparative studies show an advantage of EUS-FNB needles in terms of number
of needles passes required to obtain adequate specimen, as well as for lesions
requiring immunohistochemistry for differentiation.

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We recommend limiting oneself to a manageable range of needle systems View enlarged image
with which all examiners and assistants should be well acquainted. Besides an
aspiration needle for standard sampling of solid lesions (e.g. 22 Gauge), an EUS-
FNB needle should be available for special indications (e.g. suspected lymphoma,
submucosal tumour, suspected autoimmune pancreatitis). An 19 Gauge aspiration
needle should also be on hand to aspirate viscous (mucinous, purulent) contents
of fluid collections. Fig 34.9a
Just as numerous studies have so far failed to demonstrate the clear advantage of EUS-FNA of a small liver
one specific needle over another, no specific puncture technique has yet been able nodule (10 mm) suspected
to demonstrate its superiority. Countless variations are practised: puncture with or to be a metastasis of ductal
without a stylet, with a fluid-filled needle, with or without suction, with few needle pancreatic carcinoma (same
movements in the target lesion or even with numerous ones. Fanning within the patient as Fig 34.7). The
nodule (between markers)
lesion (i.e. to and fro needle movements within the lesion several times at variable
is hypoechoic and hard by
angles) increases the diagnostic yield.
elastography
The way in which the material is processed depends primarily on whether you
are working with a cytologist (high-quality smears, air-drying or wet fixation) or
a pathologist (cell-block or cores for histology). An interesting alternative is to
place all the material into a preservative solution (CytoRichTM), which leaves
the cytopathologist free to examine the material cytologically, histologically,
immunohistochemically or using molecular techniques as required.
View enlarged image

34.9. EUS-guided therapy Fig 34.9b

EUS-FNA of a small liver
Starting with drainage of pancreatic fluid collections in the early ‘90ies, the clinical nodule (10 mm) suspected
role and variety of EUS-guided interventions has increased considerably in recent to be a metastasis of ductal
years. New technical developments, in particular lumen-apposing metal stents pancreatic carcinoma
(same patient as Fig 34.7).
(LAMS) and needle-based radiofrequency ablation probes have advanced the
The nodule (between
clinical applications, efficiency and safety of therapeutic interventions. markers) is hypoechoic
and EUS-FNA confirmed
Compared to percutaneous image-guided interventions or surgery, transluminal diagnosis of metastasis
EUS-guided application of plastic or self-expanding metal stents for drainage of of adenocarcinoma
fluid collections and obstructed ducts is often advantageous in terms of technical (pancreatobiliary
success, clinical outcome, and cost-efficiency. immunotype)

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View enlarged image
Fig 34.10a
Subepithelial rectal tumor
1 year after endoscopic
resection of a T1a rectal
cancer. Radial EUS; 1st
echogenic layer, internal
interface echo; 2nd
hypoechoic level; mucosa;
3rd hperechoic layer;
submucosa; 4th hypoechoic
level; muscularis propria)
View enlarged image
Fig 34.10b
Subepithelial rectal tumor
1 year after endoscopic
resection of a T1a
rectal cancer. EUS-FNA
(longitudinal EUS; 22
Gauge needle, markers)
revealed diagnosis of
adenocarcinoma (intestinal
immunotype)
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Table 34.3
EUS-guided intervention
Drainage of pancreatic fluid
collections (pseudocyst,
walled off pancreatic necrosis) procedures
Drainage of abscesses
(mediastinum, pelvis, liver, ...)
Gallbladder drainage
Biliary drainage (extrahepatic,
intrahepatic)
Pancreatic duct drainage
Tumour ablation treatment
(radio frequency ablation,
Injection of cytotoxic agents)
Gastroenterostomy
34. ENDOSCOPIC ULTRASOUND
Particular indications
Symptoms, Infection; First
line access option in step-up
Poor or no access for
percutaneous image-guided
drainage
Acute cholecystitis, high
surgical risk
Obstructive jaundice (in
particular of malignant
etiology) with failed ERC
Symptomatic pancreatic duct
obstruction (chronic
pancreatitis; anastomotic)
stricture
Alternative to surgical
resection in symptomatic
neuroendocrine pancreatic
tumors (e.g. insulinoma);
Treatment of neoplastic
pancreatic cysts
Treatment of other solid
(pancreatic) tumors
Symptomatic gastric outlet
obstruction or afferent loop
syndrome as an alternative
to surgery or endoscopic
stenting
Clinical role
Recommended in
guidelines
Routine procedure in
experienced centres
Suggested in guidelines,
routine procedure in
experienced centres
Suggested in guidelines,
routine procedure in
experienced centres;
increasing use in
experienced centres also
in benign conditions
Rescue technique, expert
intervention
Rescue technique
Experimental
Experimental
Expert intervention,
increasing use in
experienced centre
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Table 34.3 continued ...
EUS-guided intervention
Fiducial placement
Celiac plexus neurolysis (local
anesthetics plus ethanol;
radiofrequency ablation)
Celiac plexus block (local
anesthetics; glucocorticoids)
Gastric varices embolisation
(coils, glue)
Treatment of non-variceal
bleeding
Particular indications
To guide stereotactic
radiation therapy
Palliative treatment of
pancreatic cancer as part of
multimodal pain therapy
Treatment of otherwise
intractable pain in chronic
pancreatitis
Recurrent variceal
bleeding if standard
treatment (endoscopy) fails;
alternative to transjugular
intrahepatic stent shunt
Recurrent non-variceal
bleeding if standard
treatment (endoscopy,
angiography, surgery) fails, is
not available or not possible
Clinical role
Routine procedure in
experienced centres
Recommended in
guidelines
Decreasing clinical use
Increasing use in
experienced centres
Rescue technique
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34. ENDOSCOPIC ULTRASOUND
Recommended reading
• Cazacu IM, Singh BS, Saftoiu A, Bhutani MS. Recent developments in
hepatopancreatobiliary EUS. Endosc Ultrasound 2019; 8: 146-150
• Dietrich CF, Burmeister S, Hollerbach S, et al. Do we need elastography for
EUS? Endosc Ultrasound 2020; 9: 284-290
• Dietrich CF. Endoscopic Ultrasound-an introductory manual and atlas. Georg
Thieme Verlag 2006
• Dumonceau J-M, Deprez PH, Jenssen C, et al. Indications, results, and clinical
impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology:
European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline –
Updated January 2017. Endoscopy 2017; 49: 695-714
• Fusaroli P, Jenssen C, Hocke M, et al. EFSUMB Guidelines on Interventional
Ultrasound (INVUS), Part V - EUS-guided therapeutic interventions (long
version). Ultraschall Med 2016; 37: E77-99
• Hawes RH, Fockens P, Varadarajulu S. Endosonography 4th Ed. Elsevier inc
2019
• Jenssen C, Hocke M, Fusaroli P et al. EFSUMB Guidelines on Interventional
Ultrasound (INVUS), Part IV - EUS-guided Interventions: General aspects and
EUS-guided sampling. Ultraschall Med 2016; 37(2):E33-76
• Polkowski M, Jenssen C, Kaye P, et al. Technical aspects of endoscopic
ultrasound (EUS)-guided sampling in gastroenterology: European Society of
Gastrointestinal Endoscopy (ESGE) Technical Guideline – Updated February
2017. Endoscopy 2017; 4: 989-1006
• Saftoiu A, Napoleon B, Arcidiacono PG, et al. Do we need contrast agents for
EUS? Endosc Ultrasound. 2020; 9: 361-368
• Vilmann P, Seicean A, Săftoiu A. Tips to overcome technical challenges in EUS-
guided tissue acquisition. Gastrointest Endosc Clin N Am 2014; 24: 109-24