Interventional EUSInterventional EUS

William R. Brugge, MDWilliam R. Brugge, MDMassachusetts General HospitalMassachusetts General Hospital

Boston, MABoston, MAUSAUSA

Therapeutic EUSTherapeutic EUSModes of ApproachModes of Approach

DrainagePseudocystsPhlegmonsAbscesses

InjectionEthanolGene therapyChemotherapeutic agents

DeliveryHeatColdBrachytherapyDevices

End Viewing EchoendoscopeEnd Viewing Echoendoscope

Moving towards Interventional Moving towards Interventional EUSEUS

Therapeutic EUS scopeTherapeutic EUS scope

Drainage TherapyDrainage Therapy

EUS guided biliary drainageEUS guided biliary drainage

Transgastric access to intrahepatic ductsTransgastric access to intrahepatic ducts

Transduodenal access to extrahepatic bile Transduodenal access to extrahepatic bile ductduct

FNA guidewire placementFNA guidewire placement

Stent placementStent placement

EUS Guided Biliary EUS Guided Biliary DrainageDrainage

n 8 pts (in 10 interventions) underwent this new 8 pts (in 10 interventions) underwent this new biliary drainage procedure. The routes were biliary drainage procedure. The routes were transesophageal (n = 1), transgastric (n = 4), transesophageal (n = 1), transgastric (n = 4), and transjejunal (n = 3, including a rendezvous and transjejunal (n = 3, including a rendezvous technique with ERCP [n = 1]). technique with ERCP [n = 1]).

n 5 pts (62.5%) received a metal stent, and 3 5 pts (62.5%) received a metal stent, and 3 (37.5%) had a plastic prosthesis (8.5-Fr double-(37.5%) had a plastic prosthesis (8.5-Fr double-pigtail). The technical success rate was 90% pigtail). The technical success rate was 90% (9/10) and the clinical success rate was 88.9% (9/10) and the clinical success rate was 88.9% (8/9). (8/9).

Will U, Thieme A, Fueldner F, Gerlach R, Wanzar I, Meyer F.Will U, Thieme A, Fueldner F, Gerlach R, Wanzar I, Meyer F.Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage.Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage.Endoscopy. 2007 Apr;39(4):292-5. Epub 2007 Mar 15. Endoscopy. 2007 Apr;39(4):292-5. Epub 2007 Mar 15.

Principles of EUS-directed Principles of EUS-directed Pseudocyst DrainagePseudocyst Drainage

•Cautery access•Wire placement•Contrast injection•Site dilation•Stent placement

Barthet M, Lamblin G, Gasmi M, Vitton V, Desjeux A, Grimaud JC.Clinical usefulness of a treatment algorithm for pancreatic pseudocysts.Gastrointest Endosc. 2008 Feb;67(2):245-52.

IntroducerIntroducer

Balloon dilationBalloon dilation

Pig Tail StentPig Tail Stent

Pancreatic Pseudocyst Pancreatic Pseudocyst Drainage: EUS vs EGDDrainage: EUS vs EGD

Thirty patients were randomized to undergo pseudocyst drainage by Thirty patients were randomized to undergo pseudocyst drainage by EUS (n = 15) or EGD (n = 15) over a 6-month period. EUS (n = 15) or EGD (n = 15) over a 6-month period. Pts (n = 14) randomized to an EUS underwent successful drainage Pts (n = 14) randomized to an EUS underwent successful drainage (100%), the procedure was technically successful in only 5 of 15 (100%), the procedure was technically successful in only 5 of 15 patients (33%) randomized to an EGD patients (33%) randomized to an EGD All 10 pts who failed drainage by EGD underwent successful All 10 pts who failed drainage by EGD underwent successful drainage of the pseudocyst on a crossover to EUS. There was no drainage of the pseudocyst on a crossover to EUS. There was no significant difference in the rates of treatment success between EUS significant difference in the rates of treatment success between EUS and EGD after stenting, either by intention-to-treat (ITT) analysis and EGD after stenting, either by intention-to-treat (ITT) analysis (100% vs 87%; P = .48) or as-treated analysis (95.8% vs 80%; P (100% vs 87%; P = .48) or as-treated analysis (95.8% vs 80%; P = .32). = .32). Major procedure-related bleeding was encountered in 2 patients in Major procedure-related bleeding was encountered in 2 patients in whom drainage by EGD was attempted; one resulted in death and whom drainage by EGD was attempted; one resulted in death and the other necessitated a blood transfusion. Technical success was the other necessitated a blood transfusion. Technical success was significantly greater for EUS than EGD significantly greater for EUS than EGD

Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM.Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM.Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos).Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos).Gastrointest Endosc. 2008 Jul 18. [Epub ahead of print]Gastrointest Endosc. 2008 Jul 18. [Epub ahead of print]

Imaging of EUS-guided Imaging of EUS-guided pseudocyst drainagepseudocyst drainage

Injection TherapyInjection Therapy(examples of drug delivery)(examples of drug delivery)

Ethanol therapyEthanol therapy Celiac neurolysisCeliac neurolysis

Ethanol for cyst ablationEthanol for cyst ablation

Retroviral therapiesRetroviral therapies Adenovirus Adenovirus

Chemotherapeutic agentsChemotherapeutic agents

Hemostatic agentsHemostatic agents

Celiac NeurolysisCeliac NeurolysisCeliac NeurolysisCeliac Neurolysis

Retrogastric orientation Localized injection into the celiac space Bupivacaine and/or ethanol are commonly used agents

Retrogastric orientation Localized injection into the celiac space Bupivacaine and/or ethanol are commonly used agents

needleneedle

Direct injection into gangliaDirect injection into ganglia

Levy MJ, Topazian MD, Wiersema MJ, Clain JE, Rajan E, Wang KK, de la Mora JG, Gleeson FC, Pearson RK, Pelaez MC, Petersen BT, Vege SS, Chari ST.Levy MJ, Topazian MD, Wiersema MJ, Clain JE, Rajan E, Wang KK, de la Mora JG, Gleeson FC, Pearson RK, Pelaez MC, Petersen BT, Vege SS, Chari ST.Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block.Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block.Am J Gastroenterol. 2008 Jan;103(1):98-103. Epub 2007 Oct 26.Am J Gastroenterol. 2008 Jan;103(1):98-103. Epub 2007 Oct 26.

Cyst fluid

epithelium

cyst

EUS-guided ethanol lavageEUS-guided ethanol lavagepancreatic cystadenomapancreatic cystadenoma

↓ ↓ cyst cyst fluidfluid

↓↓ DNA, DNA, ↓↓ CEACEA

Cell necrosis

Denuded epithelium

80% ethanol

TechniqueTechnique Cyst aspirationCyst aspiration Evacuation of cystEvacuation of cyst Cyst fluid for sampleCyst fluid for sample Lavage of 80% ethanolLavage of 80% ethanol 3-5 minutes3-5 minutes Evacuation cystEvacuation cyst

ContraindicationsContraindications PancreatitisPancreatitis Complex cystic lesionComplex cystic lesion Evidence of malignancyEvidence of malignancy

Principles of Ethanol LavagePrinciples of Ethanol Lavage

Saline LavageSaline Lavage

Ethanol LavageEthanol Lavage

Example of Ethanol LavageExample of Ethanol Lavage

Monitoring of EUS Monitoring of EUS Ethanol AblationEthanol Ablation

Ethanol injection caused focal necrosisEthanol injection caused focal necrosis

Subtle 1cm hypoechoic lesion Subtle 1cm hypoechoic lesion

Avascular by Doppler Avascular by Doppler

i.v. injection of microspheres enhanced the i.v. injection of microspheres enhanced the normal pancreatic parenchyma normal pancreatic parenchyma

Contrast-enhanced EUS with Contrast-enhanced EUS with microspheres improves visualizationmicrospheres improves visualization

Giday SA, Magno P, Gabrielson KL, Buscaglia JM, Canto MI, Ko CW, Clarke JO, Kalloo AN, Jagannath SB, Shin EJ, Kantsevoy SV.Giday SA, Magno P, Gabrielson KL, Buscaglia JM, Canto MI, Ko CW, Clarke JO, Kalloo AN, Jagannath SB, Shin EJ, Kantsevoy SV.The utility of contrast-enhanced endoscopic ultrasound in monitoring ethanol-induced pancreatic tissue ablation: a pilot study in a porcine model.The utility of contrast-enhanced endoscopic ultrasound in monitoring ethanol-induced pancreatic tissue ablation: a pilot study in a porcine model.Endoscopy. 2007 Jun;39(6):525-9.Endoscopy. 2007 Jun;39(6):525-9.

Ethanol Ablation of Pancreatic Ethanol Ablation of Pancreatic Neuroendocrine Tumor (NET)Neuroendocrine Tumor (NET)

Enhancing 1cm massEnhancing 1cm mass

BeforeBefore

After ethanol injectionAfter ethanol injection

Ethanol-ablated NET

Jürgensen C, Schuppan D, Neser F, Ernstberger J, Junghans U, Stölzel U.Jürgensen C, Schuppan D, Neser F, Ernstberger J, Junghans U, Stölzel U.EUS-guided alcohol ablation of an insulinoma.EUS-guided alcohol ablation of an insulinoma.Gastrointest Endosc. 2006 Jun;63(7):1059-62.Gastrointest Endosc. 2006 Jun;63(7):1059-62.

EUS-Guided Injection of EUS-Guided Injection of ChemotherapyChemotherapy

OncoGel is a novel depot formulation of paclitaxel designed OncoGel is a novel depot formulation of paclitaxel designed for intralesional injection with a sustained paclitaxel delivery for intralesional injection with a sustained paclitaxel delivery over approximately 6 weeksover approximately 6 weeksOncoGel was injected into 18 superficially accessible OncoGel was injected into 18 superficially accessible advanced solid cancerous lesions among 16 adult patients for advanced solid cancerous lesions among 16 adult patients for whom no curative therapy whom no curative therapy OncoGel injections were generally well tolerated. There was OncoGel injections were generally well tolerated. There was one report of grade 3 injection site pain.one report of grade 3 injection site pain.Systemic levels of paclitaxel were detectable only in 3.3% of Systemic levels of paclitaxel were detectable only in 3.3% of the samples analyzed (range: 0.53–0.71 ng/ml).the samples analyzed (range: 0.53–0.71 ng/ml).stable disease was noted among 6/14 patients and stable disease was noted among 6/14 patients and progressive disease among 8 patients. progressive disease among 8 patients.

Vukelja SJ, Anthony SP, Arseneau JC, Berman BS, Cunningham CC, Nemunaitis JJ, Samlowski WE, Fowers KD.Vukelja SJ, Anthony SP, Arseneau JC, Berman BS, Cunningham CC, Nemunaitis JJ, Samlowski WE, Fowers KD.Phase 1 study of escalating-dose OncoGel (ReGel/paclitaxel) depot injection, a controlled-release formulation of paclitaxel,Phase 1 study of escalating-dose OncoGel (ReGel/paclitaxel) depot injection, a controlled-release formulation of paclitaxel, for local management of superficial solid tumor lesions.for local management of superficial solid tumor lesions.Anticancer Drugs. 2007 Mar;18(3):283-9.Anticancer Drugs. 2007 Mar;18(3):283-9.

EUS-Guided OncoGel InjectionEUS-Guided OncoGel Injection

Matthes K, Mino-Kenudson M, Sahani DV, Holalkere N, Fowers KD, Rathi R, Brugge WR.Matthes K, Mino-Kenudson M, Sahani DV, Holalkere N, Fowers KD, Rathi R, Brugge WR.EUS-guided injection of paclitaxel (OncoGel) provides therapeutic drug concentrations in the porcine pancreas (with video).EUS-guided injection of paclitaxel (OncoGel) provides therapeutic drug concentrations in the porcine pancreas (with video).Gastrointest Endosc. 2007 Mar;65(3):448-53. Gastrointest Endosc. 2007 Mar;65(3):448-53.

EUS-Guided Oncogel Injection EUS-Guided Oncogel Injection

Matthes K, Mino-Kenudson M, Sahani DV, Holalkere N, Fowers KD, Rathi R, Brugge WR.Matthes K, Mino-Kenudson M, Sahani DV, Holalkere N, Fowers KD, Rathi R, Brugge WR.EUS-guided injection of paclitaxel (OncoGel) provides therapeutic drug concentrations in the porcine pancreas (with video).EUS-guided injection of paclitaxel (OncoGel) provides therapeutic drug concentrations in the porcine pancreas (with video).Gastrointest Endosc. 2007 Mar;65(3):448-53. Gastrointest Endosc. 2007 Mar;65(3):448-53.

Therapeutic concentrations of TaxolTherapeutic concentrations of Taxol Diffuse into normal tissueDiffuse into normal tissue 2-3cm area of therapeutic levels2-3cm area of therapeutic levels

Ethanol-Taxol LavageEthanol-Taxol Lavage

Taxol inhibits formation of cysts in Taxol inhibits formation of cysts in ADPKDADPKD

14 Patients with pancreatic cystic 14 Patients with pancreatic cystic lesions (3cm)lesions (3cm)

EUS guided lavage of 88% ethanolEUS guided lavage of 88% ethanol

EUS guided injection of Taxol 3 EUS guided injection of Taxol 3 mg/mlmg/ml

11/14 resolution of cyst11/14 resolution of cyst

2/14 partial resolution of cyst2/14 partial resolution of cyst

Oh HC, Seo DW, Lee TY, Kim JY, Lee SS, Lee SK, Kim MH.New treatment for cystic tumors of the pancreas: EUS-guided ethanol lavage with paclitaxel injection.Gastrointest Endosc. 2008 Apr;67(4):636-42.

Courtesy of Dr .Seo

EUS-Guided Brachytherapy of EUS-Guided Brachytherapy of the Pancreasthe Pancreas

Investigation of the feasibility and safety of Investigation of the feasibility and safety of EUS guided brachytherapyEUS guided brachytherapy

Modified 18 gauge needleModified 18 gauge needle

Radioactive seeds implanted into pig Radioactive seeds implanted into pig pancreaspancreas

Animal monitored for 14 daysAnimal monitored for 14 days

Pancreatic tissue changes: necrosis and Pancreatic tissue changes: necrosis and fibrosisfibrosis

Sun S, Xu H, Xin J, et al. Endoscopic ultrasound-guided interstitial brachytherapy of unresectable pancreatic cancer: results of a pilot trial. Endoscopy 2006; 38: 399-403.

EUS-Guided EUS-Guided BrachytherapyBrachytherapy

22 pts were successfully 22 pts were successfully implanted : ave 10 seeds implanted : ave 10 seeds and a maximum of 30 seeds and a maximum of 30 seeds per procedure. Partial per procedure. Partial remission was achieved in remission was achieved in three cases (13.6 %). three cases (13.6 %).

EUS19 ga Needle PlacementEUS19 ga Needle Placement

Seeds on XraySeeds on Xray

125 Iodine125 Iodine

Pain reliefPain reliefSurvival curveSurvival curve

Jin Z, Du Y, Li Z, Jiang Y, Chen J, Liu Y. Endoscopic ultrasonography guidedinterstitial implantation of iodine 125 seeds combined withchemotherapy in the treatment of unresectable pancreatic carcinoma: aprospective pilot study Endoscopy Feb 19 2008

Radio-frequency Ablation

RFA generator

EUS RF needle catheter

FNA needle with RFA catheter

Gastrointest Endosc. 1999 Sep;50(3):392-401EUS-guided radiofrequency ablation in the pancreas: results in a porcine model.Goldberg SN, Mallery S, Gazelle GS, Brugge WR.

RFA of the PancreasRFA of the Pancreas

Gross image of pancreasAfter RFA : note sharp border

CT scan of RFA lesionIn pancreas, 2 weeksafter RFA.

Histology of RFAP: intact pancC : dead tissue

Cryo-Therm Ablation of the Cryo-Therm Ablation of the PancreasPancreas

Flexible bipolar probe--RFA energy input (16 W) and Flexible bipolar probe--RFA energy input (16 W) and simultaneous cryogenic cooling with carbon dioxide (650 simultaneous cryogenic cooling with carbon dioxide (650 psi)psi)Application time range was 120 - 900 seconds in 14 pigsApplication time range was 120 - 900 seconds in 14 pigsGood correlation between RFA time and size of ablationGood correlation between RFA time and size of ablation2/14 pigs showed histochemical pancreatitis, which was 2/14 pigs showed histochemical pancreatitis, which was clinically overt in one. clinically overt in one. Necropsy additionally revealed one burn to the gastric Necropsy additionally revealed one burn to the gastric wall and four gut adhesions.wall and four gut adhesions.EUS – guided RFA provides pancreatic ablationEUS – guided RFA provides pancreatic ablation

Carrara S, Arcidiacono PG, Albarello L, Addis A, Enderle MD, Boemo C, Campagnol M, Ambrosi A, Doglioni C, Testoni PA.Endoscopic ultrasound-guided application of a new hybrid cryotherm probe in porcine pancreas: a preliminary study.Endoscopy. 2008 Apr;40(4):321-6.

ERBEERBE

Cryo-Therm AblationCryo-Therm AblationCourtesy of Dr. EnderleCourtesy of Dr. Enderle

Flexible fiberFlexible fiber

Carrara S, Arcidiacono PG, Albarello L, Addis A, Enderle MD, Boemo C, Neugebauer A, Campagnol M, Doglioni C, Testoni PA.Carrara S, Arcidiacono PG, Albarello L, Addis A, Enderle MD, Boemo C, Neugebauer A, Campagnol M, Doglioni C, Testoni PA.Endoscopic ultrasound-guided application of a new internally gas-cooled radiofrequency ablation probe in the liver and spleen of an animal model: a preliminary study.Endoscopic ultrasound-guided application of a new internally gas-cooled radiofrequency ablation probe in the liver and spleen of an animal model: a preliminary study.Endoscopy. 2008 Aug 13. [Epub ahead of print]Endoscopy. 2008 Aug 13. [Epub ahead of print]

PDT of the PancreasPDT of the Pancreas

Chan HH, Nishioka NS, Mino M, Lauwers GY, Puricelli WP, Collier KN, Brugge WR.Gastrointest Endosc. 2004 Jan;59(1):95-9.EUS-guided photodynamic therapy of the pancreas: a pilot study.

PDT of the PancreasPDT of the Pancreas

Yusuf TE, Matthes K, Brugge WR.Yusuf TE, Matthes K, Brugge WR.EUS-guided photodynamic therapy with verteporfin for ablation of normal pancreatic tissue: a pilot study in a porcine model (with video).EUS-guided photodynamic therapy with verteporfin for ablation of normal pancreatic tissue: a pilot study in a porcine model (with video).Gastrointest Endosc. 2008 May;67(6):957-61. Epub 2008 Feb 21. Gastrointest Endosc. 2008 May;67(6):957-61. Epub 2008 Feb 21.

Applications for PDT in the pancreasApplications for PDT in the pancreas

Neuroendocrine tumorsNeuroendocrine tumorsLocal ablation of adenocarcinomaLocal ablation of adenocarcinomaIntraductal papillary tumorsIntraductal papillary tumorsCystic lesionsCystic lesions

CT Guided PDTCT Guided PDT

TNFeradeTNFerade™ ™ BiologicBiologic

•TNFerade is a second-generation (E1-, partial E3-, and E4-deleted) group C adenovector carrying the transgene encoding for TNF

•A radiation-inducible promoter (Egr-1) is incorporated in the construct to optimize spatial and temporal gene expression following ionizing radiation

Chang KJ, Lee JG, Holcombe RF, Kuo J, Muthusamy R, Wu ML.Endoscopic ultrasound delivery of an antitumor agent to treat a case of pancreatic cancer.Nat Clin Pract Gastroenterol Hepatol. 2008 Feb;5(2):107-11.

     

Survival of Pancreatic Cancer Patients Survival of Pancreatic Cancer Patients Treated with TNFeradeTreated with TNFerade™ Biologic™ Biologic, by , by DoseDose

4x109 PU

4x1010 PU

4x1011 PU

1x1012 PU

0.00

0.25

0.50

0.75

1.00

Months since start of treatment

0 3 6 9 12 15 18 21 24 27 30 33 36

Pro

bab

ility

10.910.918%18%8.48.4

11.211.2

8.88.8

6.66.6

MedianMedian

34%34%

5%5%

0%0%

18-month 18-month raterate

15.215.2

8.88.8

8.08.0

MeanMean

Farrell et al. DDW 2006

EUS guided Lymph EUS guided Lymph Node Marker InjectionNode Marker Injection

Mediastinal and celiac lymph nodes were Mediastinal and celiac lymph nodes were identified and injected with 1 mL tantalum identified and injected with 1 mL tantalum suspension suspension

Excellent opacification Excellent opacification

Stable for 4 weeksStable for 4 weeks

No signs of infection, inflammation, tissue No signs of infection, inflammation, tissue damage, or necrosis. damage, or necrosis.

Gastrointest Endosc. 2007 Aug;66(2):387-92. Gastrointest Endosc. 2007 Aug;66(2):387-92. EUS-guided implantation of radiopaque marker into mediastinal and celiac lymph nodes is safe and effective.EUS-guided implantation of radiopaque marker into mediastinal and celiac lymph nodes is safe and effective.Magno P, Giday SA, Gabrielson KL, Shin EJ, Buscaglia JM, Clarke JO, Ko CW, Jagannath SB, Canto MI, Sedrakyan G, Kantsevoy SV.Magno P, Giday SA, Gabrielson KL, Shin EJ, Buscaglia JM, Clarke JO, Ko CW, Jagannath SB, Canto MI, Sedrakyan G, Kantsevoy SV.

EUS guided EUS guided LymphadenectomyLymphadenectomy

Gastrointest Endosc. 2006 Feb;63(2):302-6.Gastrointest Endosc. 2006 Feb;63(2):302-6.Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance.Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance.Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P.Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P.

Selected nodes were punctured with a 19-Selected nodes were punctured with a 19-gauge EUS needle. gauge EUS needle.

Traction applied using needle and threadTraction applied using needle and thread In 2 of 6 examinations, the entire In 2 of 6 examinations, the entire

sequence of the procedure, node tagging, sequence of the procedure, node tagging, gastric-wall incision, lymphadenectomy, gastric-wall incision, lymphadenectomy, and wall closure was performed. No and wall closure was performed. No serious complication occurred. serious complication occurred.

EUS guided hemostasisEUS guided hemostasisFive consecutive pts with gastric Five consecutive pts with gastric varices were enrolledvarices were enrolledInjection of cyanoacrylate-lipiodol in Injection of cyanoacrylate-lipiodol in gastric varices with 22-gauge gastric varices with 22-gauge needles by EUS guidance. needles by EUS guidance. EUS-guided injection of the EUS-guided injection of the perforating veins by using perforating veins by using cyanoacrylate-lipiodol was cyanoacrylate-lipiodol was successful in eradicating gastric successful in eradicating gastric varices in the 5 patients varices in the 5 patients No recurrent bleeding or other No recurrent bleeding or other complications during the study complications during the study follow-up. follow-up. EUS-guided injection of EUS-guided injection of cyanoacrylate at the level of the cyanoacrylate at the level of the perforating veins in the treatment of perforating veins in the treatment of gastric varices seems to be a safe, gastric varices seems to be a safe, efficient, and accurate approach efficient, and accurate approach

Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M, Marcos-Sanchez F, Ortiz-Moyano C, Gomez-Parra M, Herrerias-Gutierrez JM.Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M, Marcos-Sanchez F, Ortiz-Moyano C, Gomez-Parra M, Herrerias-Gutierrez JM.EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases.EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases.Gastrointest Endosc. 2007 Aug;66(2):402-7.Gastrointest Endosc. 2007 Aug;66(2):402-7.

ConclusionsConclusions

Interventional EUSInterventional EUS Ductal accessDuctal access Pseudocyst drainagePseudocyst drainage Tumor ablationTumor ablation