Endoscopic ultrasonography

304 Pages·2016·18.663 MB·English

by  Frank G. Gress, Thomas J. Savides

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Endoscopic Ultrasonography
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Endoscopic
Ultrasonography
Editedby
Frank G. Gress MD
DivisionofDigestiveandLiverDiseases,ColumbiaUniversityMedicalCenter,NewYork,NY,USA
Thomas J. Savides MD
DivisionofGastroenterology,UniversityofCalifornia,SanDiego,LaJolla,CA,USA
Third Edition
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Thiseditionfirstpublished2016©2001,2009,2016byJohnWiley&SonsLtd
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(cid:2) LibraryofCongressCataloging-in-PublicationData (cid:2)
Names:Gress,FrankG.,editor.|Savides,ThomasJ.,editor.
Title:Endoscopicultrasonography/editedbyFrankG.Gress,ThomasJ.
Savides.
Othertitles:Endoscopicultrasonography(Gress)
Description:Thirdedition.|Chichester,WestSussex;Hoboken,NJ:John
Wiley&SonsInc.,2016.|Includesbibliographicalreferencesandindex.
Identifiers:LCCN2015033567(print)|LCCN2015035077(ebook)|ISBN
9781118781104(cloth)|ISBN9781118781081(ePub)|ISBN9781118781098
(AdobePDF)
Subjects:|MESH:Endosonography.|DigestiveSystem
Diseases–ultrasonography.
Classification:LCCRC804.E59(print)|LCCRC804.E59(ebook)|NLMWN208|
DDC616.07/543–dc23
LCrecordavailableathttp://lccn.loc.gov/2015033567
AcataloguerecordforthisbookisavailablefromtheBritishLibrary.
Wileyalsopublishesitsbooksinavarietyofelectronicformats.Somecontentthatappearsinprintmaynotbeavailablein
electronicbooks.
Setin9/11pt,MinionProbySPiGlobal,Chennai,India.
1 2016
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Contents
Listofcontributors,vii 16 EUSofthestomachandduodenum,123
Preface,ix SarahA.Rodriguez&DouglasO.Faigel
Acknowledgments,xi 17 Gastrointestinalsubepithelialmasses,138
RaymondS.Tang&ThomasJ.Savides
1 Endoscopicultrasonographyatthebeginning:a
personalhistory,1 18 EUSforthediagnosisandstagingofsolidpancreatic
MichaelV.Sivak,Jr. neoplasms,151
BrookeGlessing&ShawnMallery
2 BasicprinciplesandfundamentalsofEUSimaging,5
JooHaHwang&MichaelB.Kimmey 19 EUSforpancreaticcysts,172
JohnScherer&KevinMcGrath
3 LearningEUSanatomy,15
JohnC.Deutsch 20 TheroleofEUSininflammatorydiseasesofthe
pancreas,182
4 EUSinstruments,roomsetup,andassistants,27
AmyTyberg&ShireenPais
PushpakTaunk&BrianC.Jacobson
21 Autoimmunepancreatitis,193
5 EUSprocedure:consentandsedation,34
LarissaL.Fujii,SureshT.Chari,ThomasC.Smyrk,
PavlosKaimakliotis&MichaelKochman
NaokiTakahashi&MichaelJ.Levy
6 TheEUSreport,40
22 EUSforbiliarydiseases,204
JoseG.delaMora-Levy&MichaelJ.Levy
NikolaPanic,FabiaAttili&AlbertoLarghi
7 RadialEUS:normalanatomy,47
23 EUSinliverdisease,217
ManuelBerzosa&MichaelB.Wallace
(cid:2) EmmanuelC.Gorospe&FergaC.Gleeson (cid:2)
8 Linear-arrayEUS:normalanatomy,54
24 ColorectalEUS,225
JamesT.Sing,Jr.
ManoopS.Bhutani,BrianR.Weston&PradermchaiKongkam
9 EUSelastography,61
25 TherapeuticEUSforcancertreatment,239
JulioIglesiasGarcia,JoseLariño-Noia&J.Enrique
KouroshF.Ghassemi&V.RamanMuthusamy
DominguezMuñoz
26 EUS-guidedbiliaryaccess,248
10 FundamentalsofEUSFNA,72
ChristineBoumitri,PrashantKedia&MichelKahaleh
LarissaL.Fujii,MichaelJ.Levy&MauritsJ.Wiersema
27 Pancreaticfluidcollectiondrainage,254
11 EUSFNAcytology:materialpreparationand
TiingLeongAng&StefanSeewald
interpretation,82
CynthiaBehling 28 EUS-guideddrainageofpelvicfluidcollections,261
JayapalRamesh,JiYoungBang&ShyamVaradarajulu
12 High-frequencyultrasoundprobes,88
NidhiSingh,AlbertoHerreros-Tejada&IrvingWaxman 29 EUShemostasis,267
EversonL.A.Artifon,FredO.A.Carneiro&DaltonM.Chaves
13 EUS:applicationsinthemediastinum,95
DavidH.Robbins 30 TraininginEUS,273
AdamJ.Goodman&FrankG.Gress
14 EBUSandEUSforlungcancerdiagnosisandstaging,102
L.M.M.J.Crombag,P.F.Clementsen&J.T.Annema 31 ThefutureofEUS,285
AbdurrahmanKadayifci&WilliamR.Brugge
15 EUSforesophagealcancer,116
ImadElkhatib&SyedM.AbbasFehmi Index,291
v
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List of contributors
TiingLeongAngMD SureshT.ChariMD KouroshF.GhassemiMD
DepartmentofGastroenterologyandHepatology DivisionofGastroenterologyandHepatology InterventionalEndoscopy
ChangiGeneralHospital MayoClinic UniversityofCalifornia
Singapore Rochester,MN,USA LosAngeles,CA,USA
J.T.AnnemaMD DaltonM.ChavesMD FergaC.GleesonMD
DepartmentofPulmonology UniversityofSãoPaulo DivisionofGastroenterology&Hepatology
AcademicMedicalCentre SãoPaulo,Brazil MayoClinic
UniversityofAmsterdam Rochester,MN,USA
Amsterdam,TheNetherlands P.F.ClementsenMD
DepartmentofPulmonology BrookeGlessingMD
EversonL.A.ArtifonMD GentofteHospital DivisionofGastroenterology
UniversityofCopenhagen HepatologyandNutrition
UniversityofSãoPaulo
Hellerup,Denmark UniversityofMinnesota
SãoPaulo,Brazil
Minneapolis,MN,USA
L.M.M.J.CrombagMD
FabiaAttiliMD DepartmentofPulmonology AdamJ.GoodmanMD
DigestiveEndoscopyUnit AcademicMedicalCentre DivisionofGastroenterologyandHepatology
CatholicUniversity UniversityofAmsterdam NewYorkUniversity
Rome,Italy Amsterdam,TheNetherlands LangoneMedicalCenter
NewYork,NY,USA
JiYoungBangMD JoseG.delaMora-LevyMD
DivisionofGastroenterology-Hepatology EndoscopyUnit EmmanuelC.GorospeMD
(cid:2) IndianaUniversity GastroenterologyDepartment MayoClinic (cid:2)
Indianapolis,IN,USA InstitutoNacionaldeCancerologia Rochester,MN,USA
MexicoCity,Mexico
CynthiaBehlingMDPhD FrankG.GressMD
PacificRimPathologyGroup JohnC.DeutschMD DivisionofDigestiveandLiverDiseases
SharpMemorialHospital EssentiaHealthSystems ColumbiaUniversityMedicalCenter
SanDiego,CA,USA Duluth,MN,USA NewYork,NY,USA
ManuelBerzosaMD J.EnriqueDominguezMuñozMD AlbertoHerreros-TejadaMD
MayoClinic GastroenterologyDepartment CenterforEndoscopicResearchandTherapeutics
Jacksonville,FL,USA FoundationforResearchinDigestiveDiseases (CERT)
(FIENAD) UniversityofChicago
UniversityHospitalofSantiagodeCompostela Chicago,IL,USA
ManoopS.BhutaniMD SantiagodeCompostela,Spain
DepartmentofGastroenterology JooHaHwangMD
HepatologyandNutrition ImadElkhatibMD DivisionofGastroenterology
UTMDAndersonCancerCenter
DivisionofGastroenterology UniversityofWashingtonSchoolofMedicine
Houston,TX,USA
UniversityofCalifornia,SanDiego Seattle,WA,USA
LaJolla,CA,USA
ChristineBoumitriMD JulioIglesiasGarciaMD
DepartmentofMedicine DouglasO.FaigelMD GastroenterologyDepartment
StatenIslandUniversityHospital TheMayoClinic FoundationforResearchinDigestiveDiseases
StatenIsland,NY,USA Scottsdale,AZ,USA (FIENAD)
UniversityHospitalofSantiagodeCompostela
WilliamR.BruggeMD SyedM.AbbasFehmiMD SantiagodeCompostela,Spain
PancreasBiliaryCenter DivisionofGastroenterology
MedicineandGastrointestinalUnit UniversityofCalifornia,SanDiego BrianC.JacobsonMD
MassachusettsGeneralHospital LaJolla,CA,USA BostonUniversitySchoolofMedicine
Boston,MA,USA Boston,MA,USA
LarissaL.FujiiMD
FredO.A.CarneiroMD DivisionofGastroenterologyandHepatology AbdurrahmanKadayifciMD
UniversityofSãoPaulo MayoClinic DivisionofGastroenterology
SãoPaulo,Brazil Rochester,MN,USA UniversityofGaziantep
Gaziantep,Turkey
vii
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viii Listofcontributors
MichelKahalehMD V.RamanMuthusamyMD MichaelV.Sivak,Jr.MD
DivisionofGastroenterologyandHepatology InterventionalEndoscopy UniversityHospitalsCaseMedicalCenter
WeillCornellMedicalCollege UniversityofCalifornia Cleveland,OH,USA
NewYork,NY,USA LosAngeles,CA,USA
ThomasC.SmyrkMD
PavlosKaimakliotisMD ShireenPaisMD DivisionofAnatomicalPathology
GastroenterologyDivision DivisionofGastrointestinalandHepatobiliaryDiseases MayoClinic
HospitaloftheUniversityofPennsylvania NewYorkMedicalCollege Rochester,MN,USA
Philadelphia,PA,USA WestchesterMedicalCenter
Valhalla,NY,USA NaokiTakahashiMD
PrashantKediaMD DivisionofRadiology
DivisionofGastroenterologyandHepatology NikolaPanicMD MayoClinic
WeillCornellMedicalCollege DigestiveEndoscopyUnit Rochester,MN,USA
NewYork,NY,USA CatholicUniversity
Rome,Italy RaymondS.TangMD
MichaelB.KimmeyMD InstituteofDigestiveDisease
FranciscanDigestiveCareAssociates JayapalRameshMD TheChineseUniversityofHongKong
Tacoma,WA,USA DivisionofGastroenterology-Hepatology PrinceofWalesHospital
UniversityofAlabamaatBirmingham HongKong,China
MichaelKochmanMD Birmingham,AL,USA
GastroenterologyDivision PushpakTaunkMD
HospitaloftheUniversityofPennsylvania DavidH.RobbinsMD BostonUniversitySchoolofMedicine
Philadelphia,PA,USA LenoxHillHospital Boston,MA,USA
NorthShore-LongIslandJewishHealthCareSystem
PradermchaiKongkamMD NewYork,NY,USA AmyTybergMD
EndoscopicUltrasoundSection DivisionofGastroenterologyandHepatology
DivisionofGastroenterology SarahA.RodriguezMD WeillCornellMedicalCollege
ChulalongkornUniversityandKingChulalongkorn TheOregonClinicandOregonHealth&Science NewYork,NY,USA
MemorialHospital University
ThaiRedCrossSociety Portland,OR,USA ShyamVaradarajuluMD
Bangkok,Thailand CenterforInterventionalEndoscopy
ThomasJ.SavidesMD FloridaHospital
AlbertoLarghiMD DivisionofGastroenterology Orlando,FL,USA
DigestiveEndoscopyUnit UniversityofCalifornia,SanDiego
CatholicUniversity LaJolla,CA,USA MichaelB.WallaceMD
(cid:2) Rome,Italy MayoClinicJacksonville (cid:2)
JohnSchererMD MayoCollegeofMedicine
JoseLariño-NoiaMD DivisionofGastroenterology Jacksonville,FL,USA
GastroenterologyDepartment HepatologyandNutrition
FoundationforResearchinDigestiveDiseases UniversityofPittsburghMedicalCenter IrvingWaxmanMD
(FIENAD) Pittsburgh,PA,USA CenterforEndoscopicResearchandTherapeutics
UniversityHospitalofSantiagodeCompostela (CERT)
SantiagodeCompostela,Spain StefanSeewaldMD UniversityofChicago
CenterofGastroenterology Chicago,IL,USA
MichaelJ.LevyMD KlinikHirslanden
DivisionofGastroenterologyandHepatology Zurich,Switzerland BrianR.WestonMD
MayoClinic DepartmentofGastroenterology
Rochester,MN,USA JamesT.Sing,Jr.MD HepatologyandNutrition
DivisionofGastroenterology UTMDAndersonCancerCenter
ShawnMalleryMD Scott&WhiteClinicandHospitalTexas Houston,TX,USA
DivisionofGastroenterology A&MHealthScienceCenter
HepatologyandNutrition Temple,TX,USA MauritsJ.WiersemaMD
UniversityofMinnesota LutheranMedicalGroup
Minneapolis,MN,USA NidhiSinghMD FortWayne,IN,USA
CenterforEndoscopicResearchandTherapeutics
KevinMcGrathMD (CERT)
DivisionofGastroenterology UniversityofChicago
HepatologyandNutrition Chicago,IL,USA
UniversityofPittsburghMedicalCenter
Pittsburgh,PA,USA
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Preface
EndoscopicUltrasonography(EUS)wasfirstconceptualizedmore EUS, elastography, therapeutic EUS, lung cancer, autoimmune
than 30 years ago, during the early years of endoscopy, and was pancreatitis, liver disease, biliary access, and pancreatic fluid
developed in an attempt to improve ultrasound imaging of the drainage. We have continued to emphasize a practical, “how-to”
pancreas.SincethefirstprototypeEUSscopeswerereleasedinthe approachtolearningEUS.
early1980s,EUShasevolvedintothe“standardofcare”fordiag- Mostofourcontributorsareeitherthe“first-generation”pioneers
nosisandstagingofavarietyofgastrointestinal(GI)pathologies. of endosonography or the protégés of those pioneers. They have
Inthelastfewyears,ithasalsobecomeanimportanttherapeutic contributedsignificantlytoclinicalpractice,research,andtraining
toolforassistingincomplexinterventionalendoscopictechniques. inGIendosonography.TheircollectiveexperienceinapplyingEUS
EUSisnowavailableatcommunityhospitalsthroughouttheword, to themanagement of GIdiseases is unsurpassed.A tremendous
andisnolongerconfinedtoacademicmedicalcenters. amountofeffortonthepartofeachindividualauthorhasledto
Our hope is that Endoscopic Ultrasonography improves the thisnewthirdedition.TheyarethetruemastersofEUS.We are
training and dissemination of EUS by providing interested GI deeplygratefultothemfortheiroutstandingcontributions.
endoscopists with an authoritative yet practical approach to the This book is meant to introduce the new learner to the field
roleofEUSinthemanagementofspecificdigestivedisorders.This ofGIendosonograpy,aswellastoupdatethecurrentendosono-
textallowsthelearnertounderstandthehistoryofEUS,thefun- grapher on recent cutting-edge advances. The chapters combine
damentalsofultrasound,andhowbesttoutilizeEUSindiagnostic well-referenced reviews with practical performance advice. We
andinterventionalprocedures. hopeyouenjoythethirdEditionofEndoscopicUltrasonography.
This third edition brings many new and exciting changes and
additions to the text, including new chapters on how to learn
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ix
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Acknowledgments
Wegiveourthanksandlovetoourparents,FrancisandEvelynGressandJohnandAnitaSavides,fortheguidance,support,andlovethat
createdtheopportunitieswearefortunatetohavehadinlife.Wecannotthankenoughourwives,DebraGressandWendyBuchi,fortheir
unendingsupport,understanding,andsacrificeduringthemanyhoursspentcompletingthistext.Wededicatethisbooktoourparents,
wives,andespeciallychildren,Travis,Erin,Morgan,andAbbyGress,andMichaelSavides,fortheirlove,kindnessandpatience,which
sustainuseveryday.
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xi
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CHAPTER 1
Endoscopic ultrasonography at the beginning:
a personal history
MichaelV.Sivak,Jr.
UniversityHospitalsCaseMedicalCenter,Cleveland,OH,USA
The first report of endoscopic ultrasonography (EUS), to my amongthoseofusmostcloselyinvolvedwithandcommittedtoits
knowledge,isthatofDiMagnoetal.,publishedin1980[1].These development. The ample tribulations facing the very small cadre
investigators described a prototype echoendoscope assembled of nascent endosonographers became strikingly evident with the
by attaching a transducer to a duodenoscope. Although images arrival of the first EUS system, a prototype in the truest sense.
wereobtainedonlyindogs,thisworkestablishedthefeasibilityof Despitetheobviousproblems,however,Idonotbelievethatanyof
EUS.Aswithnearlyallseminaladvancesinendoscopy,EUSwas uswereevertrulydiscouraged;thebestdescriptionofourmindset
basically an amalgamation of existing technologies. But in 1980, duringtheseformativeyearsmightbe“doggedlyenthusiastic.”
the potential of this hybrid technology was scarcely apparent to I began by writing a simple, all-encompassing protocol that
anyone–probablyincludingthesefirstendosonographers,whodid wouldallowmetousetheinstrumentasaninvestigationaldevice
notexpandontheirdemonstrationofthefeasibilityofEUS. inpatients.Theprotocol,essentially,hadnohypothesis,otherthan
Forpracticalpurposes,theinceptionofEUSasaclinicalentityin theassertionthatEUSwasgoingtobeagoodthing.Itlistedalmost
theUnitedStatescanbetracedtoameetingIhadwithMr.Hiroshi every possible indication I could conceive, and minimized the
(cid:2) Ichikawa of the Olympus Optical Company. Neither of us can risks–whichwereunknown,inanycase–tosuchadegreethatI (cid:2)
remember the exact date, but it was most likely 1981. Olympus doubtitwouldbeapprovedbyanyinstitutionalresearchcommittee
wasdevelopingseveralnewtechnologies,andHiroshiofferedmea today.
choicebetweenEUSandenteroscopy.TheonlyotherthingIrecol- Themajorproblemsthathadtobeaddressedinthebeginning
lectfromthatmeetingisthat,forsomeunknownreason,Ididnot dividedintofourcategories:thetechnicallimitationsanddeficien-
ponderthechoiceverylongbeforeIselectedEUS,largelybecause ciesoftheequipment,thedevelopmentofefficientandsafetech-
theideaofendosonographyseemedespeciallyintriguing;itoffered niquesfortheuseoftheechoendoscopeinpatients,interpretation
agreaterchallenge,butalsothepromiseofamuchwiderrangeof oftheultrasoundimages,andtheneedtodefineandestablishindi-
prospectiveapplications.Icertainlygavelittlethoughtto–indeed, cationsforEUSinclinicalpractice.Moreissues,someevenmore
did not appreciate – the formidable obstacles to the clinical real- complicated,becameevidentovertime.
izationofthispotential,nortotheinvestmentoftimeandeffortI Theprototypeechoendoscopeitselfwas,bymodernstandards,
wouldneedtoreachthisgoal,whichwasmuchmoredistantthanI incrediblycumbersome.Theelectronic(video)endoscopehadnot
realized.Hiroshidid,infact,layemphasisontheobstacles,warning beenintroducedintoclinicalpractice,sotheprototypeechoendo-
that the instrumentation was in the early stages of development scope was afiberoptic instrument;theoptical (endoscopic) com-
(aeuphemismforcrude,barelyusable).Becauseofthescopeand ponentconsistedofanocularlensandfocusingring,coupledtoa
difficulty of the project, Hiroshi advised that Olympus proposed coherent fiberoptic bundle, with another lens at the distal end of
to work with two investigators in the United States (actually, the theinsertiontubetofocusanimageonthebundle.Thelatterpro-
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westernhemisphere),theotherbeingDr.CharlesLightdaleinNew videdalimited,80 fieldofview,orientedobliquelyatanangleof
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YorkCity,aswellasafewindividualsinothercountries.Ialready 70 totheinsertiontube.Ofthesetwoparameters,thenarrowfield
knew Charlie, and thought him an excellent choice. As it turned ofviewwasmoreofalimitationthantheobliqueorientation,which
out, this was the beginning of a long and rewarding professional wasnotespeciallyproblematicforendoscopistsaccustomedtothe
association, for which EUS became the basis. Thus, EUS in the side-viewingduodenoscope.
UnitedStatesbeganwithmeandCharlieLightdale. The ultrasound component of early echoendoscopes consisted
Giventhetechnicalsophisticationofpresent-dayEUSsystems, ofatransducercoupledtoarotatingacousticmirroratthedistal
itisimportanttorecognizethatduringtheearlyyears,theviability tip of the insertion tube. The mirror was turned by means of an
of endosonography was far from certain. Until about 1985, there electricmotorwithinamotorhousingsituatedbetweenastandard
was substantial skepticism concerning the future of EUS, even designcontrolsectionandtheinsertiontube;thusthedesignation,
EndoscopicUltrasonography,ThirdEdition.EditedbyFrankG.GressandThomasJ.Savides.
©2016JohnWiley&Sons,Ltd.Published2016byJohnWiley&Sons,Ltd.
1
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2 EndoscopicUltrasonography
“mechanical,sector-scanningechoendoscope.”Becausethemirror Depending on the circumstances, including location within the
turnedaroundthelongaxisoftheinsertiontube,theultrasound gastrointestinaltract,oneortheotherwasusuallyabetterchoice.
scanningplanewasorientedperpendiculartotheinsertiontube.In Withtheballoonmethodinparticular,theendoscopicviewwaslost
retrospect,thiswasthebestchoice,becauseitseemedtosimplify astheballoonwasbroughtintocontactwiththegutwall,meaning
the problems of image interpretation. But this arrangement also that ultrasound imaging could only proceed by abandoning the
had its limitations; mainly that it was unsuitable for guiding a endoscopic view. For technical reasons, therefore, EUS imaging
needle to a target. Needle aspiration was, in fact, attempted with was, of necessity, endoscopically blind. Although this decoupling
thesector-scanninginstrument,albeitunsuccessfully,becausethe mightseeminconsequentialtoday,itwasamentalleapoffaithin
widthofthetissuewithinthecircularscanwasmuchtoonarrow. theearlydays,inasmuchasendoscopicdogmadeemed“blind”use
Unfortunately,theultrasoundimagingsectorprovidedbythefirst ofanendoscopehazardous.
∘ ∘
instrumentswasnotafull360 ,butonly180 .Toobtainacomplete, Useoftheballoonwithearly-modelechoendoscopeswassoexas-
circumferentialsectorscanofthesurroundingtissue–acircum- peratingthatitdeservesadigressiveparagraphofitsown.Thelatex
ferentialesophagealtumor,forexample–itwasnecessarytorotate material that constituted the balloon was not of uniform quality,
∘
theinsertiontube180 ,whilemaintainingthesamescanningplane. whichmadeitnearlyimpossibletoplacetheballoonontheechoen-
Thiswasaconsiderablefeat,especiallywiththeinstrumentdeeply doscope without tearing it. When expanded, the balloon had an
inserted,forexampleinthethirdpartoftheduodenum.Intruth, asymmetricbulge,andaccordingtotheinstructionsthebulgewas
itwaslargelyimpossible,becauseanyapplicationoftorquetothe to be placed over the transducer on the same side as the optical
insertiontubeinvariablyalteredthescanningplane.Thiswasbut component;thiswasneveraccomplished.Assumingthatthebal-
oneamongmanydifficulties. looncouldbemaneuveredintactintothecorrectposition,itwas
Owing to the mechanical components, principally the motor nextnecessarytotieitinplacewithsmallsutures.Thedesignof
anditshousing,theinstrumentwasmuchheavierthanastandard theinstrumentwassuchthattheproximalendoftheballoonsome-
endoscope. I don’t think I ever tried to weigh it, but it proba- timesoccludedtheopeningofthechannelforairinsufflationand
bly tipped the scale at more than one pound. Because EUS had waterirrigation,whichwouldnotbeevidentuntilitwassecurely
no established clinical purpose, the first procedures can only be tiedinplaceandtested.Subsequentattemptstonudgetheballoon
described as exploratory. Consequently, procedure length was intoproperpositionusuallyresultedintearing.Sincetheobjective
determined largely by patient endurance, and with an especially wastocreateawater–tissueinterface,itwasnecessarytoremoveall
tolerantpatient,theweightoftheinstrumentseeminglyincreased theairfromtheballoon(withoutbreakingit).Theballoon,ifnot
exponentially.Aftertwoorthreeexaminations,itwasoftendifficult placed exactly, could occlude the tiny-diameter channel provided
(andpainful)tostraightenyourleftarm. forthispurpose.Onceallofthedelicateparameterswereattained,
The combination of optical and acoustical components at the and the balloon was in gloriously correct position and function-
distalendoftheinsertiontubeconferredotherpenalties,including ingproperly,themostmaddeningoccurrence was ruptureofthe
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some potential hazards. The diameter of the insertion tube was ill-fatedbaginthemiddleofanexamination,usuallyatthemost
13mm;thatis,substantiallygreaterthanthatoftheupperendo- inopportunemoment.Idealtwithsomeofthesefrustrationsbyper-
scopesofthetime.Tomakemattersworse,thedistalendwasrigid suadingagentlemanfromthebiomedicalengineeringdepartment
overalengthof4.5cm;thatis,thedistancefromthetiptothebend- (designatedthe“balloonman”)totakeonthetaskofballoonplace-
ingsection.Togetherwiththelimitedfieldofview,thisincreased mentpriortoeachprocedure.
the difficulty of inserting the instrument through the mouth and Duringtheexamination,theballoonwasfilledwithwaterviaa
pharynx and into the esophagus. Although we assumed that the Luerlockfittinglocatedbetweenthecontrolsectionandthemotor
riskofcomplicationswithEUSwasnogreaterthanthatwithupper housing.Unfortunately,thisdesignmeantthattheattachedsyringe
endoscopy,andinformedourpatientsthesame,inrealitytherisk protrudedinperpendicularfashion.Accordingly,astheendosono-
of perforating the pyriform sinus was probably greater – a fact graphermovedhisrighthandfromthecontrolsectiontotheinser-
subsequentlysubstantiated.Moreover,attemptsatinsertionofthe tiontube,heinvariablybrokethesyringe.Inordertofilltheballoon,
large-diameter echoendoscope through a constricting tumor in itwasnecessarytosetasmallleveronthemotorhousingtothe
the esophagus were no doubt associated with an appreciable risk balloon-fillingposition,clearlylabeledas“B.”Theotherchoicewas
ofperforation. “G,”whichwhenselectedchanneledthewaterintothegut.Sinceit
Inadditiontodevelopingtechniqueforthesafeinsertionofthe wasnotpossibletoseethislever,itwasadvisabletorememberwhich
echoendoscope, the learning curve for EUS imaging can only be positionitwasin.Otherwise,theballoonmightbefilledwithwater
describedaslongandsteep,alinewithaslopeapproachingstraight beyonditscapacity.
up. According to Yogi Bera, “ninety percent of everything is half One of the most gratifying aspects of endosonography, readily
mental,”andthiswasdefinitelytrueofEUS.Thefirstquandarywas apparentattheveryfirstexamination,wastheabilitytoobtaina
the need to uncouple endoscopic imaging from ultrasonography. structuredimageofthegutwall.Believeme,allofusknewintu-
Thisrelatedtotheneedforacousticcoupling;thatis,thecreation itivelyandimmediatelythatthiswasgoingtobeverybig.Butthe
of a suitable interface between the tissue and the transducer (in interpretationoftheseimageswassomethingelseagain.Therewas
thiscase,theacousticmirror).Wediscoveredinshortorderthat anaturaltendencytoassume,tohope,thatthefive-layerstructure
ultrasound images can’t be obtained through air. The obvious correspondedinexactfashiontotheactuallayersofthegutwallas
solution: remove the air. But this proved impractical, for several seenmicroscopicallyinahistologicalsection.Thisbetraysanear
reasons. The alternative was to interpose water between tissue totalignoranceoftheprinciplesofultrasoundimaging,andover
and “transducer,” which could be accomplished in two ways: by time it became evident that the physical basis for the endosono-
placing a balloon over the transducer section of the instrument graphicrepresentationofthebowelwallismuchmorecomplex.For
andfillingitwithwater,orbyfillingthegutwithwater.However, reasonsunknowntome,themainultrasoundfrequencyselectedfor
itwasnotsimplyamatterofchoosingbetweenthesetwooptions. thefirstEUSsystemswas7.5MHz,afrequencythathappens,under
(cid:2)