PubMed · 8566648
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P B Cotton, J Cunningham. 1995. A sphincterotome with variable-length wire.. https://doi.org/10.1016/s0016-5107(95)70060-9
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The role of endoscopic ultrasound (EUS) in the detection and staging of pancreatic cancer is well established in medical literature. The development of EUS-guided fine needle aspiration (FNA) and subsequently EUS-guided fine needle injection (FNI) has expanded the clinical utility of EUS. These newer techniques made "interventional" EUS possible. Several recent applications of EUS-guided FNI include celiac nerve block, pseudocyst drainage, and drug delivery into pancreatic tumors. EUS is also gaining acceptance as an alternative diagnostic modality in the management of choledocholithiasis. The value of EUS in the diagnosis of early chronic pancreatitis is still being actively studied. This article reviews a number of recent developments in EUS-guided diagnosis and therapy with an emphasis on EUS-guided FNA and EUS-guided FNI.
OBJECTIVES: Transthoracic echoguided puncture of the pericardium can be an alternative to surgical drainage. We report our experience with this technique acquired over the last 11 years. PATIENTS AND METHODS: From January 1984 to September 1995, 34 consecutive patients in the cardiology intensive care unit (mean age 56.5 +/- 13 years) underwent echoguided pericardial puncture for poorly tolerated pericardial effusion. The underlying cause was neoplasia (n = 22), idiopathic disease (n = 5), autoimmune disease (n = 2), post-surgical complication (n = 2 including 1 on hemodialysis), infection (n = 1), antivitamin K therapy (n = 1) and disseminated vascular coagulation (n = 1). The subxyphoid (n = 33) or left parasternal (n = 1) route was used under echographic guidance. Intrapericardial contrast allowed verification of the catheter position. The mean quantity of fluid removed was 585 +/- 390 ml. The fluid was hemorrhagic (n = 19), clear (n = 10) or serohematic (n = 4). Aspiration was continued in 16 patients after the initial puncture for a mean 64 hours. The mean total volume of fluid was 750 +/- 330 ml. RESULTS: There was one death during puncture which was found to be unrelated to the procedure after anatomic verification. In two cases, the left ventride was punctured without any consequence. Collapsus occurred during puncture in 2 patients with pulmonary sepsis. Minor incidents were: 6 vasovagal syndromes at puncture with paroxysmal supraventricular rhythm disorder during aspiration. Prior to 1988, surgical drainage was required in 5 patients for persistent or recurrent effusion. Since that time, continuous aspiration has been used in all patients and no surgical drainage has been required. Short-term prognosis depends on the underlying cause (6 deaths at 1 month). CONCLUSION: Echoguided pericardial puncture is a simple procedure which rapidly improves cardiac hemodynamics in these particularly fracle patients. Continuous aspiration avoids subsequent surgical drainage for persistent or recurrent effusion.
The only valid criterion for comparing surgical (or medical) techniques is the extent of the beneficial effect compared with the risk of the underlying disease. The paper on echoguided pericardial puncture published in this issue of La Presse Médicale offers an excellent opportunity to apply this criterion in an area of clinical therapeutics where the temptation to promote "minimally invasive" techniques is so great. For pericardial effusion, as for all medical conditions, it is the underlying disease which determines the long-term outcome and not the pericardial effusion itself, even in emergency situations. The objective should then go beyond symptom relief and include, when possible, a search for an etiological diagnosis. Pericardial biopsy is one element which can be contributive in a significant number of cases further adding to the beneficial effect of the surgical technique. Consequently, indications for echoguided pericardial puncture cannot be broadened beyond patients suffering from compressive pericardial effusion secondary to a perfectly recognized cause. In other less urgent situations, and when the etiology has not been identified, videoscopic techniques appear to be indicated rather than conventional surgical drainage or echoguided puncture. Other cases, such as infected or recurrent effusions, also raise specific problems requiring a careful evaluation of the expected benefit and risk of each technique. After videosurgery and videoscopy, conventional pericardial drainage, a particularly simple, rapid and effective procedure, is once again challenged by a new, more "medical" technique, emphasizing that the ever renewed story of progress in medicine must not avert our attention from the fundamental goal of combating disease.