Atlas of Endoscopic Ultrasonography

Frank G. Gress, Thomas J. Savides, Brenna Casey, Everson L. A. Artifon, Frank G. Gress, Thomas J. Savides, Brenna Casey, Everson L. A. Artifon

• Publisher: Wiley-Blackwell
• Year: 2021
• ISBN:
  9781119523031
• Edition: 2
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Atlas of Endoscopic Ultrasonography

Atlas of Endoscopic Ultrasonography, Second Edition offers an outstanding visual guide to this very common diagnostic and therapeutic endoscopic tool. With contributions from noted experts in the field, the Atlas contains 400 high-quality color and black and white images obtained from real cases, each accompanied by detailed annotation to aid readers in their understanding of this popular technical procedure. In addition, there is a companion website featuring 50 video clips of real-life procedures in action, as well as the entire collection of images from within the book.

• Updated throughout to include the most recent advances in interventional Endoscopic Ultrasound (EUS) guided therapies
• Contains a large collection of color images obtained from both diagnostic and therapeutic procedures, also available on the companion website image bank
• Provides a highly integrated and accessible multimedia introduction to endoscopic ultrasonography
• Includes a companion website offering insightful videos

Written for gastroenterologists, students, residents, and radiologists, Atlas of Endoscopic Ultrasonography, Second Edition is an essential introduction to endoscopic ultrasonography.

1
Normal EUS Anatomy

1
Normal Human Anatomy

John C. Deutsch

Essentia Health Care Systems, Duluth, MN, USA

Introduction

The Visible Human Project at the University of Colorado has generated large volumes of human anatomy data. The original information is captured by slowly abrading away frozen human cadavers in a transaxial manner and capturing the anatomy by digital imaging. The digital data is compiled and then over the years is manipulated by scientists at the University’s Center for Human Simulation to allow access to identified cross‐sections in any plane as well as to models which can be lifted from the data set. Details regarding the Visible Human Project and its applications to gastroenterology and endosonography have been previously described.

This atlas is fortunate to be able to use the interactive anatomy resources developed by Vic Spitzer, Karl Reinig, David Rubenstein, and others to create movies that help explain what takes place during endoscopic ultrasound (EUS) evaluations. Since EUS is a “real‐time” examination, it seems reasonable to present this section primarily as “real‐time” videos. The videos can be viewed over and over, allowing endosonographers to look not only at the highlighted structures, but also at structures they might visualize during EUS that are not specifically identified on the selected video.

This chapter uses the terms “radial array orientation” to describe planar anatomy which would be found perpendicular to a line going through the digestive tract (as would be generated by a radial array echoendoscope, Figure 1.1) and “linear array orientation” for planar anatomy generated parallel to a line going through the digestive tract (as would be generated by a linear array echoendoscope, Figure 1.2).

Normal EUS anatomy from the esophagus

Radial array orientation (Video 1.1)

Video 1.1 starts with Visible Human Models of the left atrium (purple), trachea and bronchi (light blue), aorta and pulmonary arteries (red), vena cava (dark blue), and the esophagus (brown). A plane is shown passing through the esophagus. This plane contains the transaxial cross‐sectional anatomy images which then follow, starting in the oropharynx and going caudally. The upper esophageal sphincter (UES) is identified. As the images proceed distally, the trachea and esophagus can be followed to a point where the brachiocephalic left carotid and left subclavian arteries are evident just above the aortic arch. Below the aortic arch is the aortopulmonary window. The azygos arch can be seen exiting the superior vena cava (SVC). This occurs just above the tracheal bifurcation. The esophagus (labeled as “E”) is surrounded by the descending aorta, the vertebrae, and the trachea. The thoracic duct (not labeled) is visible between the aorta and vertebrae, inferior to the esophagus. Going distally, the pulmonary artery becomes prominent. The region between the right mainstem bronchus (RMB) and left mainstem bronchus (LMB) is the subcarinal space. The video progresses to a level where the left atrium surrounds the superior aspect of the esophagus and then the video ends as the esophagus passes the gastroesophageal junction.

An image plane cross‐section taken from a radial array orientation at the level of the subcarinal space is shown in Figure 1.3.

Linear array orientation (Video 1.2)

Video 1.2 starts with the same models as above (the left atrium [purple], trachea and bronchi [light blue], aorta and pulmonary arteries [red], vena cava [dark blue], and the esophagus [brown]). The plane shows potential ways that cross‐sectional anatomy can be generated. The video then shows a sagittal image with the descending aorta inferior to the esophagus, much as what is done during linear array EUS. In this orientation the pulmonary artery (PA) and left atrium are superior. The image plane is rotated to bring the left atrium and pulmonary artery to the inferior side of the esophagus. The models are then shown again, and the plane is moved in the caudal and cephalad directions, much as during EUS.

Figure 1.1 Visible Human Model of esophagus, stomach, and duodenum. The green circle shows a plane perpendicular to the axis and is similar to a plane developed during radial array endosonography.

Normal EUS anatomy from the stomach

Radial array orientation (Video 1.3)

Endoscopic ultrasound of the stomach differs from EUS at other sites since the stomach does not constrain the endoscope tightly. It is important to follow anatomical structures (such as in a station approach) to avoid getting lost.

The video shows models of the stomach, esophagus, duodenum, gallbladder, pancreas (brown), the aorta, splenic artery, hepatic artery a...