EUS-guided therapy: Current status and future directions

Introduction: EUS-guided therapies were 1st described in 1996. Progress has been slow but some procedures are now firmly established. This presentation will provide an update on the current status of the most important EUS guided interventions as well as a view of the future for EUS guided therapies.

EUS guided drainage of pancreatic fluid collections: The superiority of EUS guided- drainage of pseudocysts is now well-established. Future research will be directed toward the role of EUS guidance in the management of walled off pancreatic necrosis (WOPN).

EUS guided biliary drainage: EUS-guided biliary drainage can be accomplished via trans-duodenal or trans-hepatic rendezvous or stent placement. Initial studies demonstrated safely and efficacy and randomized trials are now underway. Improving outcomes will require optimizing techniques and devices.

EUS guided pancreatic cyst ablation: EUS guided pancreatic cyst ablation is an attractive intervention because surgery is the only alternative. Initial attempts used absolute alcohol while later studies have shown improved outcomes when mixing alcohol with paclitaxel. For this technique to advance, three issues must be addressed: 1) establish an accurate diagnosis before therapy, 2) finding a material or technology that will achieve complete ablation, and 3) determining the optimal method of surveying patients after therapy.

Other EUS guided therapies: Celiac guided neurolysis is now a well-established procedure and has performed favorably in randomized trials. There it been several reports of EUS guided drainage of pelvic abscesses. While the series or small,this appears to be a promising technique in selected patients. EUS guided inplantation therapy has included both implantation of radiation seeds as well as fiducials. The utilization and application of these procedures is completely dependent on developing effective implantation therapies and advances in radiation therapy. EUS guided injection therapy (FNI) has been tried with multiple different substances but none have proven effective to date. EUS guided pancreatic duct drainage has been reported in cases were endoscopic access to the pancreatic duct has been unsuccessful. This procedures quite difficult and will require technical and device advances before it becomes prime time.