Ecoendoscopie (EUS)

Notiuni introductive

Dr. Mihai Ciocirlan

Principiile ultrasonografiei
Echipament
Indicatii generale
Principiile ultrasonografiei
Echipament
Indicatii generale
Principiile ultrasonografiei
 Principiile ultrasonografiei
(frecventa invers proportionala cu lungimea de unda)
lungimea de unda mare = penetranta mare, dar rezolutie mica
– lungime unda mica (frecventa mare) = penetranta mica si
rezolutie mare
– lungime de unda mare (frecventa mica) = penetranta mare si
rezolutie mica
avantaj EUS fata de ECO transabdominal
– distanta mai mica fata de organul explorat, nu necesita
penetranta mare (si nu se interpun alte structuri, ex. gaze)
– deci se folosesc lungimi de unda mici (frecvente mari) care
determina rezolutii mari
eco transabdominal – frecventa mica = 3,5 – 5 Mhz
EUS – frecventa mare = 5 – 30 Mhz
Principiile ultrasonografiei
Echipament
Indicatii generale
 Echipament
2 categorii : radial (sectorial) si linear (convex array)

Diagnostic / diagnostic sau/si interventional

Probe specializate : miniprobe tub digestiv, miniprobe intraductale, sonde rectale

Variabilitate tehnica : mecanice sau electronice; frecventa 5-30 MHz

Linear Radial
Ecoendoscop mecanic sau electronic
radial

Fujinon electronic
Olympus electronic mecanic
Pentax electronic
 FUJINON
Distal end diameter
5
4
3
Insertion portion Ultrasonic frequency
2
1
0

Forceps channel
Length of hard part OLYMPUS PENTAX
at the distal end

Bending capability EG-530UR

GF-UE160-AL5
EG-3630UR
 Ecoendoscop electronic radial
FUJINON OLYMPUS PENTAX

Model Name EG-530UT EG-530UR GF-UCT160-AT8 GF-UCT160- GF-UE160-AL5 EG-3830U Ｔ EG-3630UR

OL5

Display mode Color Doppler / Color Doppler / Color Doppler / Color Doppler / Color Color Color
Power Doppler / Power Doppler / Power Doppler / Power Doppler / Doppler / Doppler / Doppler /
PW Doppler / B PW Doppler / B PW Doppler / B PW Doppler / B Power Power Power
Ultrasound functions

mode / M mode / M mode / mode / M mode / mode / M Doppler / PW Doppler / PW Doppler / PW

mode / THI THI THI mode / THI Doppler / B Doppler / B Doppler / B
mode / M mode mode / M mode / M mode
/ THI mode / THI / THI

Scan system Convex Electronic radial Electronic Electronic Electronic Convex Radial
convex convex radial

Scan direction Scan angle 360° Parallel with the 150° 360° Parallel with Verticality
110°targetting inserting the inserting with the
Forward cross- direction direction inserting
eye 120° 120° direction
60°direction as
the center axis

Frequency 5MHz/ 5MHz/ 7.5MHz/ 5-12MHz 7.5MHz 5MHz/ 6MHz/ 5MHz/ 5-10MHz
7.5MHz/ 10MHz / 12MHz 7.5MHz / 7.5MHz/ switch
10MHz / 12MHz 10MHz 10MHz

Ultrasound image representing Balloon Balloon method / Balloon method / Balloon Balloon method Balloon method Balloon method
method method / degassed water degassed water method / / degassed / degassed / degassed
degassed water congestion congestion degassed water water water water
congestion method / method and congestion congestion congestion congestion
method / contacting using both method and method and method and method and
contacting method methods using both using both using both using both
method methods methods methods methods
 Ecoendoscop electronic radial
FUJINON OLYMPUS PENTAX

Model Name EG-530UT EG-530UR GF-UCT160- GF-UCT160- GF-UE160-AL5 EG-3830U Ｔ EG-3630UR

AT8 OL5
Functions of the Endoscope

Optical View angle 140° 140° 100° 100° 100° 120° 120°
system (Maximum
opponent angle ）

View direction 40° Forward cross- 55° 55° 55° 50° Direct view
eye

Observing depth 3-100mm 3-100mm 3-100mm 3-100mm 3-100mm 5-100mm 5-100mm

Inserting External Φ13.9mm Φ11.6mm Φ14.6mm Φ14.6mm Φ13.8mm Φ14.2mm Φ12mm

part diameter at the
distal end part

External Φ12.1mm Φ11.5mm Φ12.6mm Φ12.6mm Φ11.8mm Φ12.8mm Φ12.1mm

diameter of the
flexible part

Effective length 1254mm 1254mm 1260mm 1250mm 1250mm 1250mm 1250mm

Forceps Diameter of Φ3.8mm Φ2.2mm Φ3.7mm Φ3.7mm Φ2.2mm Φ3.8mm Φ2.4mm

channel forceps channel

Elevator ○ － ○ ○ － ○ －

Bending UP / DOWN 160° / 160° 180° / 90° 130° / 90° 130° / 90° 130° / 90° 130° / 130° 130° / 60°
part
RIGET / LEFT 120° / 120° 100° / 100° 90° / 90° 90° / 90° 90° / 90° 120° / 120° 60° / 60°

Entire length 1554mm 1554mm 1565mm 1555mm 1555mm 1575mm 1575mm

◆ Fujinon system : EG530UR

FUJINON
Fuji EG 530 UR
 Ecoendoscop Pentax

EG-3670URK :

Videoendoscop
Vedere frontala
 Electronic radial
 360°
 Doppler
 Noua generatie
 Video ecoendoscop mecanic
Olympus
Type  Chann MHz Unit
mm el
GF- 10,5 2,2 5 - 7,5 EUM-30
Echoendoscop
UM160 mm – 12 - EUM-60
mecanic radial
20
GF- 10,5 2,2 7,5 - 12 EUM-30
UM130 mm EUM-60
GF- 10,5 2,2 7,5 - EUM-30
UMQ130 mm 20 EUM-60

IC Fundeni
 Ecoendoscop mecanic radial cu 3
sau 4 frecvente US

GF-UM160

MAJ-935 GF-UM160 IC Fundeni

C5 C7.5 C12 C20

9 cm range 9 cm range 6 cm range 6cm range
 Ecoendoscop electronic radial
type  Chann MHz unit
mm el
GF- 11,8 2,2 5- 6- ALOKA
UE160- mm 7,5 -10
AL5
Ecoendoscop
Electronic radial
360°
 Econdoscoape Liniar

Fujinon electronic
Olympus electronic sau mecanic
Pentax electronic
 FUJINON
Distal end
diameter
5
4
Insertion 3 Ultrasonic
portion 2 frequency
1
0

Length of hard OLYMPUS PENTAX

Forceps channel part at the
distal end

Bending
capability EG-530T
GF-UCT160-OL5 OLYMPUS
EG-3830R

Forceps
Distal end Insertion Portion Bending Capability U/ Ultrasonic
Channnel
diameter diameter D/ R/L Frequency
diameter
EG-530UT φ13.9 φ12.1 φ3.8 160 160 120 120 5-12MHz
GF-UCT160-OL5 φ14.6 φ12.6 φ3.7 130,90,90,90 7.5MHz
EG-3830UT φ15.5 φ12.8 φ3.8 130,90,90,90 5-10MHz
 Ecoendoscoape electronice liniare
FUJINON OLYMPUS PENTAX

Model Name EG-530UT EG-530UR GF-UCT160-AT8 GF-UCT160- GF-UE160-AL5 EG-3830U Ｔ EG-3630UR

OL5

Display mode Color Doppler / Color Doppler / Color Doppler / Color Doppler / Color Color Color
Power Doppler / Power Doppler / Power Doppler / Power Doppler / Doppler / Doppler / Doppler /
PW Doppler / B PW Doppler / B PW Doppler / B PW Doppler / B Power Power Power
Ultrasound functions

mode / M mode / M mode / mode / M mode / mode / M Doppler / PW Doppler / PW Doppler / PW

mode / THI THI THI mode / THI Doppler / B Doppler / B Doppler / B
mode / M mode mode / M mode / M mode
/ THI mode / THI / THI

Scan system Convex Electronic radial Electronic Electronic Electronic Convex Radial
convex convex radial

Scan direction Scan angle 360° Parallel with the 150° 360° Parallel with Verticality
110°targetting inserting the inserting with the
Forward cross- direction direction inserting
eye 120° 120° direction
60°direction as
the center axis

Frequency 5MHz/ 5MHz/ 7.5MHz/ 5-12MHz 7.5MHz 5MHz/ 6MHz/ 5MHz/ 5-10MHz
7.5MHz/ 10MHz / 12MHz 7.5MHz / 7.5MHz/ switch
10MHz / 12MHz 10MHz 10MHz

Ultrasound image representing Balloon Balloon method / Balloon method / Balloon Balloon method Balloon method Balloon method
method method / degassed water degassed water method / / degassed / degassed / degassed
degassed water congestion congestion degassed water water water water
congestion method / method and congestion congestion congestion congestion
method / contacting using both method and method and method and method and
contacting method methods using both using both using both using both
method methods methods methods methods
 Ecoendoscoape electronice liniare
FUJINON OLYMPUS PENTAX

Model Name EG-530UT EG-530UR GF-UCT160- GF-UCT160- GF-UE160-AL5 EG-3830U Ｔ EG-3630UR

AT8 OL5
Functions of the Endoscope

Optical View angle 140° 140° 100° 100° 100° 120° 120°
system (Maximum
opponent angle ）

View direction 40° Forward cross- 55° 55° 55° 50° Direct view
eye

Observing depth 3-100mm 3-100mm 3-100mm 3-100mm 3-100mm 5-100mm 5-100mm

Inserting External Φ13.9mm Φ11.6mm Φ14.6mm Φ14.6mm Φ13.8mm Φ14.2mm Φ12mm

part diameter at the
distal end part

External Φ12.1mm Φ11.5mm Φ12.6mm Φ12.6mm Φ11.8mm Φ12.8mm Φ12.1mm

diameter of the
flexible part

Effective length 1254mm 1254mm 1260mm 1250mm 1250mm 1250mm 1250mm

Forceps Diameter of Φ3.8mm Φ2.2mm Φ3.7mm Φ3.7mm Φ2.2mm Φ3.8mm Φ2.4mm

channel forceps channel

Elevator ○ － ○ ○ － ○ －

Bending UP / DOWN 160° / 160° 180° / 90° 130° / 90° 130° / 90° 130° / 90° 130° / 130° 130° / 60°
part
RIGET / LEFT 120° / 120° 100° / 100° 90° / 90° 90° / 90° 90° / 90° 120° / 120° 60° / 60°

Entire length 1554mm 1554mm 1565mm 1555mm 1555mm 1575mm 1575mm

 Fujinon EG-530UT

◆ Super CCD Fujifilm, rezolutie inalta 410000

pixeli
FUJINON

Microminiature super CCD honeycomb

For linear and radial probes

◆ 5 to 12 MHz

5MHz 7.5MHz

10MHz 12MHz
 Ecoendoscop Pentax linear electronic
cu consola HITACHI

EG-3830UT :

Videoendoscop
Vedere frontala
Electronic 120°
elevator
canal 3,8mm
3.5 – 13 Mhz
Consola HITACHI
6005 - 8005

IC Fundeni, din martie 2007 (exista consola HITACHI 6005)

 Ecoendoscop Olympus linear electronic
cu consola EUM60 sau EU-C60
type  Chann MHz unit
mm el
GF- 12,6 3,7 7,5 EU-C60
UCT160- mm
OL5
GF- 11,8 2,8 7,5 EU-C60
UC160P- mm
OL5

IC Fundeni – din 2008

Ecoendoscop Olympus linear mecanic : GF-UMD240/140P

Ecoendoscop Olympus linear electronic
cu consola ALOKA

type  Chann MHz unit

mm el

GF- 12,6 3,7 5- 6- ALOKA

UCT140- mm 7,5
AL5 -10
GF- 11,8 2,8 5- 6- ALOKA
UC140P- mm 7,5
AL5 -10
Probe specializate
Proba oarba » : Olympus MH908
Sonda mecanica radiala introdusa pe fir ghid (8.5mm)
Pentru staging cancer esofagian stenozant

Fuji Torpedo 7.7 MHz miniprobe, similar, incarcata prin canalul

operator in sens invers

Miniprobe : Fujinon sau Olympus

2 - 2.6 mm
7.5-30 MHz
staging T parietal, intraductal (pancreatobiliar)
+/- balon
durata de viata 50-100 examinari

IC Fundeni, din 2008

 20 Mhz: 9 straturi 7.5-12 Mhz: 5 straturi

1-2-3: m T1m m
4: mm T1sm
5: sm T2 sm
6: mp: ci T3
mp
8: mp:le
a
Miniproba Fujinon

20 MHz

7.5 MHz

Cu consola Hitachi
Fuji PL2226B-7.5
Back-loaded Adenom vilos rectal Duct biliar
7.5 MHz
 15-20 MHz Fujinon probe

Gastric cancer, m invasion/ Osaka Police Hospital Dr. Kubo

 Probe endobronsice (Olympus)
Bronhoscop BF-UC260

Diametru 6.9 mm
Lungime 60 cm
2 mm canal accesor (ac special pt FNA)
C60 processor
 Sonde rigide anorectale

Hitachi U533 :
– mixta (radial or linear) electronic
– 5-10 MHz, 19 mm

Olympus
– radial mecanic RU-75M-RI and RU-12M-RI (7.5 or
12 MHz)
– electronic radial (10mm) ,
cu consola Aloka (7.5-10MHz)

IC Fundeni – din 2008

 EUP-U533

Fistula tract : radial and linear

INSULINOMA
 Elastografie

EUS

COLOR POWER DOPPLER ELASTOGRAPHY

 Echipament, in concluzie
Fujinon, Olympus, Pentax
electronic radial 360° si linear toti
– mecanic radial si linear doar Olympus, dar « moral depasite »
Fuji
– AV: consola unica endo/L/R (compact), endosc OK
– DEZAV: imag EUS, miniprobe, rigide
Pentax
– AV: imag Hitachi OK, rectal, miniprobe
– DEZAV: consola Hitachi R/L
Olympus
– AV: si consola R/L si Aloka R/L, in functie de preferinta
Principiile ultrasonografiei
Echipament
Indicatii generale
 Indicatii EUS
3 mari grupuri de indicatii

– A. oncologie de tub digestiv

– B. afectiuni biliopancreatice

– C. alte afectiuni
 Indicatii EUS
3 mari grupuri de indicatii

– A. oncologie de tub digestiv

– B. afectiuni biliopancreatice

– C. alte afectiuni
 A. Oncologie
(1) stadializare si decizie de tratament si
(2) follow-up

stadializare carcinom (si limfom)

esofag, stomac, duoden, rect, canal anal
– NU extensie M1 (CT/RMN/PET/scinti)*
– DA stadializare locoregionala (TN)
acuratete diagnostica ~ 85% pt stadiul T
acuratete diagnostica ~ 75% pt stadiul N
– cu FNA ssb 95%, specificitate 100%
!!! superioara oricarei alte tehnici de imagistica disponibila !!!

*uneori M1 dimeniuni mici lob stang hepatic sau grande suprarenale (+/- FNA)
 A. Oncologie
cand e indicat EUS pt stadializare si decizie
de tratament la un cancer digestiv ?
– cand nu exista metasaze la distanta (M0),
intotdeauna dupa efectuarea altor investigatii ce
evidentiaza M0 (CT/RMN/PET/scinti)
– si cand starea generala a pacientului permite
alegerea din mai multe optiuni terapeutice, in
functie de stadiul locoregional
excizie endoscopica mucozala
chirurgie
chimioterapie
radioterapie
 A. Oncologie
de reamintit
– T in stadiul TNM
T1 mucoasa sau submucoasa
T2 muscularis propria
T3 adventiatia/seroasa
T4 structuri adiacente

Indicat deci in:

– Neoplazie precoce de tub digestiv (stadiul I =
T1N0M0)
– Neoplazie avansata de tub digestiv (stadiul II-IV
≥T2)
Neoplazie precoce de tub digestiv
Risc invazie N1 depinde de stadiul T
– Daca riscul de invazie N1 este ~ 0% (sau
apropiat de 0% la cei cu
morbiditate/mortalitate mare chirurgicala)
atunci se poate face rezectie endoscopica
limitata (mucosectomie)
– in general risc N1 este ~ 0% la cei cu T1
mucos
Neoplazie precoce de tub digestiv
IND: EUS
– a) minisonde pot diferetia destul de bine T1m de T1sm, fata
de EUS standard care da over si understaging
– b) EUS standard diferetiaza doar T1 de T2 (submucosa de
musculara proprie) si evidentiaza N0/N1

In practica
– mucosectmie riscanta - esofag, cec - se prefera minisonde pt
stadializare T1m/T1sm si EMR doar pt T1m
– mucosectomie cu risc mai mic – rect, stomac - se preferea
EUS standard - daca T1 (m sau sm) N0M0 face EMR (se
poate decola submucosa de pe musculara), iar daca pe analiza
post mucosectomie doar invazie mucosa atunci curativ – se
supravegheaza, daca invazie submucosa atunci
chirurgie/radioterapie

*particularitati la squamous esofagian, grading, dimensiuni, etc

Neoplazie avansata de tub digestiv
ESOFAG
Stadializare loco-regionala EUS utila ?
indica N0/N1 +/- FNA
indica M1 daca adenopatie celiaca +/- FNA

Da, pt ca tratament in functie de stadiu:

– CHIRURGIE
stadiul I (T1N0M0)
stadiul II (T2T3N0M0)
– CHIMIO(RADIO)TERAPIE
stadiul III (N1), IV (M1)
Neoplazie avansata de tub digestiv
STOMAC
EUS mai putin util in stadializare CARCINOM
AVANSAT pentru ca nu modifica tratamentul,
chiar daca evaluarea locoregionala TN cea mai
buna

in final majoritatea sunt operati, cu exereza a

cel putin 15 ganglioni (nici CT-ul nu modifica
prea mult, ofera mai mult informatii de abord
chirurgical si magnitudine extensie)

ramane exterm de util pentru CARCINOM

PRECOCE in vederea rezectiei endoscopice
Neoplazie avansata de tub digestiv
STOMAC
EUS util pentru limfom gastric – non
Hodgkin extraganglionar sau MALT:
– diagnostic diferential cu alte leziuni ce
determina « pliuri gastrice largi »
– stadializare ce permite atitudine
terapeutica diferentiata – stadii initiale
MALT doar eradicare H pylori posibil
– follow-up post tratament
Neoplazie avansata de tub digestiv
STOMAC
Neoplazie avansata de tub digestiv
RECT
Stadializare loco-regionala EUS utila?
indica N0/N1 +/- FNA

Da, pt ca depinde decizia de tratament

– T1,T2, N0 chirurgie
– T3 (mezorect intact > 1mm*)N0 chirurgie
– T3 (mezorect intact < 1mm*)T4 / N1 radio
(chimio) terapie

* la RMN
 Indicatii EUS
3 mari grupuri de indicatii

– A. oncologie de tub digestiv

– B. afectiuni biliopancreatice

– C. alte afectiuni
B. Afectiuni bilio-pancreatice
colestaza extrahepatica
pancreatita acuta etiologie X
tumori endocrine de dimensuni mici
pancreas si duoden (insulinom,
gastrinom) clinic manifeste
cancer de pancreas nediagnosticat la CT
multi spiralat
diagnostic bioptic mase solide sau
chistice pancreas
 B. Afectiuni bilio-pancreatice
Colestaza extrahepatica
Litiaza coledoc
– EUS acuratete egala peste 10 mm, mai buna pentru
EUS sub 10mm diametru, biliRM nu detecteaza
nimic sub 5mm diametru
– EUS detecteaza si sludge
– ERCP poate fi realizat imediat dupa EUS, cu
aceeasi anestezie
Strictura biliara
– inalta: RMN+ERCP+ IDUS
– medie si joasa: EUS+FNA, ERCP+/- IDUS
 B. Afectiuni bilio-pancreatice
Colestaza extrahepatica
Tumora biliara
– Klatskin:
– RMN, angioRM caz rezecabil ERCP plsu IDUS
– joasa:
– EUS/IDUS

Tumori ampulare
– ampulectomie endoscopica posibila pentru
leziun T1m
fara ulceratie deasupra ampulei
fara extensie intraductala
– EUS esential pentru staging (si IDUS ideal)
 B. Afectiuni bilio-pancreatice
Pancreatita acuta etiologie X
EUS pentru etiologie

– la distanta de episodul de pancreatita acuta

evidentiaza microlitiaza biliara, imagini de « cer
instelat » la nivelul VB (ssb 100%)
evidentiaza TIPMP (ssb ~ RMN de buna calitate)
evidentiaza pancreatita cronica in stadiu
precoce (> ERCP, RMN) – vezi ulterior
 B. Afectiuni bilio-pancreatice
Pancreatita cronica incipienta
EUS pentru
diagnostic pozitiv
 B. Afectiuni bilio-pancreatice
Tumori endocrine de dimensuni mici pancreas si duoden
(insulinom, gastrinom) clinic manifeste
EUS examen de referinta in cazul
acestor tumori entitati clinice
– caz localizate, pot fi vindecate ulterior prin
rezectie chirurgicala
B. Afectiuni bilio-pancreatice
Cancer de pancreas

CT mutispiral, RMN de referinta pentru

staging T cancer de pancreas, EUS mai buna
doar la staging N, DAR...

Cancer de pancreas nediagnosticat la CT multi

spiralat
– 10% din cancerele pancreatice sunt izodense la CT
multispiral = 30% din cancerele cu dimensiuni < 20
mm (adica cele curabile chirurgical)!!!
Cancer de pancreas aparent curabil la CT
– poate gasi contraindicatii la exereza chirurgicala la
CT multispiral
B. Afectiuni bilio-pancreatice
Diagnostic bioptic mase solide sau chistice pancreas

De referinta pentru tumori chistice

pancreatice
– pseudochist
– chistadenom serom
– chistadenom mucinos
– chistadenocarcinom
– TIPMP
– alte tumori chistice rare
B. Afectiuni bilio-pancreatice
Diagnostic bioptic mase solide sau chistice pancreas

De referinta pentru diagnostic bioptic mase

solide pancreatice (pentru cancerele
nerezecabile, pentru a vedea tipul histologic
inainte de a incepe un tratament
chimioterapic; pot gasi tipuri histologice mai
favorabile: limfom, T neuroendoscrine, etc)

Nu se punctioneaza cancerele rezecabile (risc

diseminare – doar in anumite cazuri in care
riscul chirurgical este mare sau diagnostic
disputat)
 Indicatii EUS
3 mari grupuri de indicatii

– A. oncologie de tub digestiv

– B. afectiuni biliopancreatice

– C. alte afectiuni
 C. Alte afectiuni (alte)
Tumori bronsice

Tumori submucoase
– GIST foarte « la<moda » in prezent
– evaluare malignizare

Anorectal
– fistule (ex Crohn) ...
– endometrioza ... (rectovaginal si sigmoidian)
– rupturi sfincteriene ... (incontinenta anala)
– tulburari de motilitate anorectala ... (dischezie)