1. 13 & 14 December 2010, Fourth Annual Course Hotel Okura Amsterdam, the Netherlands 13 & 14 December 2010, Fourth Annual Course Hotel Okura Amsterdam, the Netherlands

3. Paul Fockens, MD PhD Professor of Gastrointestinal Endoscopy, Academic Medical Center, University of Amsterdam Baltahasar Geeraerts Symposium 2010 What is the role of EUS in cholelithiasis?

4. EUS in cholelithiasis History Instruments EUS for cholecystolithiasis EUS for choledocholithiasis Conclusions and future of EUS in gallstones

5. History of EUS in clinical practice Started as a technique to image organs outside GI-tract (US, start of ERCP, no CT, no MR) Staging of luminal tumors quickly followed (esophagus, stomach, colorectum) Next major breakthrough: EUS-guided FNA 2009: non-invasive staging by excellent CT & MR 2010+: EUS for early diagnosis and guided Rx

6. EUS in cholelithiasis History Instruments EUS for cholecystolithiasis EUS for choledocholithiasis Conclusions and future of EUS in gallstones

7. Instruments & Accesories High-end US processors (Aloka, Hitachi....) Elastography Tissue Harmonic Imaging Contrast Enhanced EUS.......

8. Instruments & Accesories 360° Radial array vs. Linear array

9. EUS in choledocholithiasis

10. EUS in cholelithiasis History Instruments EUS for cholecystolithiasis EUS for choledocholithiasis Conclusions and future of EUS in gallstones

11. EUS in cholecystolithiasis Transabdominal US is standard for galbladder stones EUS may be useful in case of: –Multiple very small stones (sludge) –Poor imaging because of obesity Indication for EUS in cholecystolithiasis –Strong suspicion of gallbladder stones with negative non-invasive imaging

12. EUS in cholecystolithiasis 35 pts with biliary type pain and negative US EUS showed suspicion of stones in 18pts (52%) 15/17 proven during surgery 13/15 symptomfree at one year FU

13. EUS in cholecystolithiasis

14. EUS in cholelithiasis History Instruments EUS for cholecystolithiasis EUS for choledocholithiasis Conclusions and future of EUS in gallstones

15. EUS in choledocholithiasis Imaging of CBD is not so difficult anymore with excellent new equipment Experience is important (50-100/year) EUS only in low-probablility for CBD-stones? Should every ERCP for stones be preceded by EUS? How about acute pancreatitis?

16. EUS in choledocholithiasis

18. ERCP vs. EUS +/- ERCP 65pts with elevated LFT’s or dilated CBD (8 or 10mm) ERCP: 7/32 pts (22%) with CBD-stones EUS +/- ERCP: 9/33pts (27%) CBD-stones 1pt in each group recurrent symtoms

19. EUS in choledocholithiasis 4 trials selected (423pts) In EUS group, ERCP was avoided in 74% EUS significantly reduced risk of ERCP associated complications

20. EUS in choledocholithiasis risk of acute pancreatitis

21. EUS in cholelithiasis History Instruments EUS for cholecystolithiasis EUS for choledocholithiasis Conclusions and future of EUS in gallstones

22. Conclusions & future use EUS is most sensitive technique for CBD- stones, more sensitive than MRCP EUS is invasive and requires expertise Restriction of ERCP to (very) experienced seems imminent (raise req/yr from 40  100) Combine EUS with ERCP in: –Unexplained obstrcutive jaundice –All pts referred for treatment of CBD-stones

24. 13 & 14 December 2010, Fourth Annual Course Hotel Okura Amsterdam, the Netherlands 13 & 14 December 2010, Fourth Annual Course Hotel Okura Amsterdam, the Netherlands