Hospital Universitario La Zarzuela Madrid


Eco-endoscopy Unit

ECO-ENDOSCOPY, also known as ENDOSCOPIC ULTRASONOGRAPHY, is a procedure performed with an instrument (an eco-endoscope) that makes it possible to a television camera into the body through the mouth or the anus. This instrument then transmits live images of the walls of the digestive tract to a monitor, together with an ultrasonograph that uses ultrasound to the tissues and organs located beyond the walls of the digestive tract.

Thus when the eco-endoscope is ed through the mouth, it can explore not only the oesophagus, stomach and the duodenum, but also the lymph nodes, arteries and veins of the chest and upper abdomen, and, part or all of the heart, liver, gallbladder and bile ducts, pancreas, kidneys and adrenal glands. When ed anally, in addition to the rectum-sigma, it can also the bladder, the prostate, the internal female genitalia, and the blood vessels and lymph nodes in the pelvis. The eco-endoscope also has a work canal into which instruments can be ed to perform surgical manoeuvres (for example a needle to pierce lesions and obtain samples to be analysed by microscope).

An eco-endoscopy is not a painful procedure, but it is technically complex, laborious, and prolonged. This is why they are always performed with the patient under more or less deep intravenous sedation. Still, most cases do not a post-operation hospital stay. There are two phases to an eco-endoscopy which if necessary are performed consecutively. The first is exploratory and the second involves intervention.

This consists of an endoscopic examination of the oesophagus, stomach and duodenum for upper eco-endoscopies, or of the rectum-sigma in lower eco-endoscopies. This is followed by an ultrasound of the adjacent organs in the chest and upper abdomen (upper) or pelvis (lower). This phase is always performed, and its purpose is to determine which illness is producing the patient's symptoms that the doctor suspects are affecting the organs that will be explored. Eco-endoscopies are often performed when there is already a diagnosis. Here the objective is to confirm the status and prognosis of the illness that was already diagnosed in order to decide which treatment would be best if there would be several options. In these circumstances an eco-endoscopy is preferable to conventional endoscopic studies, external ultrasounds, computed tomographies, and magnetic resonance imaging, which are other alternatives.

This will depend on the results of the exploratory phase, on whether a lesion was confirmed (a tumour or a lymph node) that would need to have a biopsy taken for diagnostic analysis. This is done by puncturing the lesion with a needle and aspirating fluid or tissue to obtain cells that will be studied under a microscope. Sometimes the intervention is therapeutic: to drain (empty) a cyst or abscess, or to access a duct (biliary or pancreatic) that would be inaccessible from its natural orifice. There are times, however, when another alternative treatment would be preferable, either percutaneous interventional radiology or surgery.

An eco-endoscopy is an invasive procedure that exposes the patient to risks. Fortunately, these risks are statistically low, and the doctor ordering the eco-endoscopy and the surgeon performing it will feel that the potential benefits of the eco-endoscopy for the patient's health outweigh these risks, and that it is thus the best option. If not they would not recommend it. Risk is a statistical concept applicable to the population, but it is impossible to predict the risk for each person, basically because it depends on numerous factors, many of which cannot be controlled. This is why any complications are almost always accidental and unexpected. In spite of this, the surgeon performing the eco-endoscopy will always be alert of any complications that might possibly occur, and will try to anticipate them by terminating the exploration before they happen, but this is not always possible.

The potential complications of an eco-endoscopy are so varied and have such a wide range of severity that it is practically impossible to list them in their entirety. Thus only the most common complications are mentioned here, but if there are other specific ones that you are worried about, do not hesitate to check with your doctor before the procedure. While all the complications appear during the course of the eco-endoscopy or afterwards, only some of them are exclusively due to the operation, and others appear due to factors related to the patient's condition before the procedure. For example, the risk of hypoexemia during an eco-endoscopy is higher for patients with a pre-existing lung condition than it is for patients with healthy lungs, although even for healthy patients the risk is still not zero. This is why it is extremely important to notify your doctor prior to the eco-endoscopy regarding any illnesses you have or may have had, and regarding any medications you have taken currently or over the previous week. For technical reasons, it is very important to tell your doctor if you have undergone any type of surgery on your oesophagus, stomach, duodenum, gallbladder, bile ducts, liver or pancreas, and to provide all the information you have about it in the form of written reports or x-rays.

The most common complications caused directly by an eco-endoscopy are perforations, haemorrhaging and infection. When operating on the pancreas there is also a risk of pancreatitits. In all, it occurs less than ten percent of the time. Perforation is a severe complication that nearly always s emergency surgical intervention. It usually occurs when the stiff point of the eco-endoscope needs to get around a curve in the gastrointestinal tract. The most dangerous areas are the pharynx, the duodenal bulb and recto-sigmoid junction, although perforation can occur at any point in the gastrointestinal tract.

Having had prior surgeries or large tumours that distorted the normal anatomy increases the risk of perforation. Another risk of perforation occurs when a stenosis is dilated so that the eco-endoscope can pass through it. Therefore this manoeuvre is only performed when it is necessary in order to make an important clinical decision, or if there are no alternatives. Haemorrhaging and infection generally occur when a puncture is made with a needle, and are more likely when puncturing a cyst than with solid lesions. The severity in these cases may vary. Usually an infection can be controlled conservatively, with antibiotics.

In some cases, though, the haemorrhaging may be severe, making a blood transfusion or an emergency intervention by the radiologist or surgeon necessary. Infections may also be complicated by the formation of an abscess that would need to be drained radiologically or surgically. Pancreatitis is a potential complication of puncturing a solid lesion, a cystic lesion or a duct in the pancreas. The risk is greater when a portion of the healthy pancreatic tissue needs to be crossed to reach the objective. Another potential but infrequent complication is bile peritonitis, when the bile duct or gallbladder are intentionally or unintentionally punctured.

One special therapeutic intervention is celiac plexus neurolysis, the abdominal nerve ganglia in the area are injected to treat pancreatic pain that does not respond to medication. Specific complications may occur with this procedure, such as arterial hypotension and exacerbation of pain. They are usually slight and temporary, disappearing within a few days. Occasionally though, serious complications do occur, such as muscle weakness and/or numbness, and even paralysis of the lower limbs.

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