Endoscopes

4 Endoscopes Arianna Massella and Paolo Bocus 4.1 Endoscopes Since its introduction more than 40 years ago, endoscopic retrograde cholangiopancreatography (ERCP) has changed the treatment of biliopancreatic diseases. At the beginning, it was a diagnostic procedure, but over time due to the development of noninvasive imaging, it evolved to a therapeutic procedure. Such an evolution has required developments in technology and training to bring us to present ERCP. Endoscopic ultrasound (EUS) was developed in the early 80s to overcome mainly difficulties by the radiological techniques of the time in visualizing the pancreas, located in retroperitoneal space and often covered by air. The first scope commercially available from 1986 was a fiberoptic radial device. In the early 1990s with the advent of the curved, linear-array echoendoscope began the era of interventional EUS (EUS-FNA). Over the years, many improvements have been achieved such as switchable frequencies, to allow more detailed visualization of GI wall layers and the conversion from a mechanical to a fully electronic instrument. This allowed to develop new A. Massella · P. Bocus (*) IRCCS “Sacro Cuore—Don Calabria”, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Classificato e Presidio Ospedaliero Accreditato—Regione Veneto, Negrar di Valpolicella, Verona, Italy functions such as Doppler, elastosonography, and the contrast enhanced echoendoscopy. 4.2 Duodenoscopes The standard endoscope for ERCP is the sideviewing duodenoscope, equipped with a tip with four-way angulation capability, a side-positioned air/water nozzle, an instrument channel, and a forceps elevator adjacent to the instrument channel outlet that allows fine linear instrument position changes facilitating cannulation and placement of various devices. Instrument channel diameter ranges from 2.2 to 5.5 mm. Duodenoscopes with 4.2 mm internal channel allowing to place biliary endoprostheses (10–11.5 Fr circumference) are the most used. Pediatric duodenoscopes with a 2.2 mm channel are available for examination in infants, while largest instrument channels (>5 mm) are found in so-called “mother/baby” scope system usedfor choledochoscopy and pancreatoscopy. However this system is difficult to manipulate and is now rarely used [1]. In certain situations where a traditional duodenoscope is not suitable (e.g., in patients with a Billroth II or a Roux-en-Y reconstruction), a forward-viewing endoscope may be tried instead [2]. Conventional endoscopes however provide a limited visualization of the ampullary region and are limited with respect to control of accessories during cannulation due to the absence of elevator. © Springer Nature Switzerland AG 2020 M. Mutignani et al. (eds.), Endotherapy in Biliopancreatic Diseases: ERCP Meets EUS, https://doi.org/10.1007/978-3-030-42569-2_4 27 28 A. Massella and P. Bocus In recent years, infections due to multidrugresistant organisms (MDROs) have become a concern in health care, including in gastrointestinal endoscopy. Cases and serial outbreaks of MDROs infections associated with ERCP have been published from different countries from 2010 [3]. All the processes of cleaning, disinfection, and sterilization of duodenoscopes have been analyzed featuring different issues [4]. Major manufacturers developed tools to prevent infections such as detachable disposable distal cap. Post-procedure reprocessing is performed by detaching the disposable distal cap and cleaning and disinfecting the tip of the scope [5]. In addition, new adaptors that can be attached to the tip of the duodenoscope to inject a cleaning solution have been developed (Figs. 4.1, 4.2, and 4.3). Four major manufacturers, Olympus (Olympus America, Center Valley, Pa), Pentax (Pentax of America, Montvale, NJ), Fujifilm endoscopy (Fujinon, Wayne, NJ), and Karl Storz Se & Co. (Tuttlingen, Germany—Fig. 4.4), produce duodenoscopes, and these are their major characteristics (Table 4.1). 4.3 Echoendoscopes Endoscopic ultrasonography (EUS) combines endoscopy and intraluminal ultrasonography. The new electronic instruments are connected with processors with considerable digital capabilities. Therefore, the technical peculiarities of the endoscopes of the same brand (i.e., NBI, FICE, Hi-scan) are contemporary available with the technical features of the most modern ultrasounds equipment (Doppler, power Doppler, color Doppler, tissue harmonic echo [THE], contrast harmonic EUS [CH-EUS], elastography, etc.). The instruments for endoscopic ultrasound evaluation can be divided in: – radial echoendoscopes purposes, for diagnostic – linear echoendoscopes for diagnostic and interventional purposes. Radial echoendoscopes consist of electronic radial-array transducers that orient the individual piezoelectric elements around the distal tip in a 360° radial array, producing an image in a plane perpendicular to the long axis of the echoendoscope that is very similar to the images provided by computed tomography. Radial-array echoendoscopes are used only for diagnostic EUS examinations because tissue sampling and therapeutic interventions are not possible due to the lack of visualization of needle or other devices track. Linear echoendoscopes provide a plane of imaging parallel to the long axis of the scope with an image format that is similar to that obtained with transabdominal ultrasonography; only this type of probe allows real-time visualization of needles and other accessories introduced through the operative channel of the echoendoscope [6–8]. It allows to perform fine-needle aspiration or biopsy (FNA or FNAB), stent delivering, drainage, and locoregional treatments (i.e., celiac plexus block and neurolysis). Three major manufacturers (Olympus, Pentax, Fujifilm) produce echoendoscopes. Their characteristics are summarized in the tables below (Figs. 4.5, 4.6, and 4.7, Tables 4.2 and 4.3). 4.4 EUS Processors EUS processors consist of two parts: the first for the endoscopic view and the second one for the ultrasound view. These devices allow to capture, manipulate, and store EUS images. These platforms may be exclusively dedicated to EUS or may be compatible with transabdominal probes. Traditionally, a strict partnership has been created between the echoendoscope companies and well-known ultrasound processors manufacturers: Pentax radial and linear scopes are driven by a Hitachi platform, whereas Olympus echoendoscopes run from Aloka systems. 4 Endoscopes Table 4.1 Duodenoscopes Distal end Insertion tube outer outer diameter diameter (mm) (mm) Channel inner diameter Working length (mm) 11.3 13.7 4.2 1240 11.3 13.5 4.2 1240 11.5 13.1 4.2 1250 11.5 13.1 4.2 1250 11.6 13 4.2 1250 Pentax ED34-i10T2 11.6 13.6 4.2 1250 Storz Silverscope 12.6 12.6 4.2 1260 Olympus TJF-Q180V Olympus TJF-Q190V Fujinon ED-530XT Fujinon ED-530XT8 Pentax ED34-i10T Single use distal tip Remarks Depth of field Electronic (mm) Angulation range capabilities Up Down Right Left 5–60 120° 90° 110° 90° NBI No V-System 5–60 120° 90° 110° 90° NBI Yes OT, HFT, V-System 4–60 130° 90° 110° 90° FICE No 4–60 130° 90° 110° 90° FICE Yes 4–60 120° 90° 105° 90° HISCAN No 100°/10° retro° 4–60 120° 90° 105° 90° HISCAN Yes 140° 2–60 120° 90° 110° 90° / No Field of view 100°/5° retro 100°/15° retro 100°/8° retro 100°/8° retro 100°/10° retro HD+, detachable cap, Pentax “CleanCapsystem” (OE-A55) HD+, DEC, Disposable Elevator Cap (OE-A63) OT One-Touch Connector, FHT High-Force Transmission, HD+ High Definition New Chip, DEC Allows simplified reprocessing and increased cleaning capability, Pentax “CleanCap-system” Detachable distal end cap for a safe and quick mechanical cleaning of air and water channels 29 30 Table 4.2 Radial echoendoscopes Radial Olympus GF-UE160-AL5 Pentax EG-3670URK Fujinon EG-580UR Distal end Insertion tube (mm) (mm) 11.8 Working length (mm) 1250 Channel inner diameter (mm) 2.2 12.1 10.3 1250 2.4 Direction of viewing field Forward oblique Forward 11.5 11.4 1250 2.8 Forward Ultrasound field of view 360° Depth Frequency of field (MHz) 3–100 5/6/7.5/10/12 CHEDoppler EUS Yes Yes 360° 4–100 5–10 Yes Yes System Elastography compatibility Yes Hitachi-Aloka Olympus Yes Hitachi-Aloka 360° 3–100 5/7.5/10/12 Yes No No Fuji A. Massella and P. Bocus 4 Endoscopes Table 4.3 Linear echoendoscopes Distal end Insertion tube (mm) (mm) 12.6 14.6 Working length (mm) 1250 Channel inner diameter (mm) 3.7 Olympus TGF-UC180J Pentax EG-3270UK 12.6 14.6 1245 3.7 10.8 12 1250 2.8 Pentax EG-3870UTK 12.8 14.3 1250 3.8 Fujinon EG-580UT 12.4 13.9 1250 3.8 Linear Olympus GF-UCT180 Direction of viewing field Forward oblique (55°) Forward Forward oblique (50°) Forward oblique (50°) Forward oblique (40°) Ultrasound field of view 180° Depth of field Frequency (mm) (MHz) 3–100 5/6/7.5/10/12 CHEDoppler EUS Yes Yes System Elastography compatibility Yes Hitachi-Aloka Olympus 90° 3–100 5/6/7.5/10/12 Yes Yes Yes 180° 5–100 5–10 Yes Yes Yes Hitachi-Aloka Olympus Hitachi-Aloka 180° 5–100 5–10 Yes Yes Yes Hitachi-Aloka 180° 3–100 5/7.5/10/12 Yes No No Fuji 31 32 4.5 A. Massella and P. Bocus ERCP Instruments Fig. 4.1 Olympus TJF-Q190V. The single-use distal cover allows better access for reprocessing accessories during manual cleaning. The cover is transparent and is destroyed during removal, preventing unintended reuse. The new flushing adapter reduces the number of required flushing steps and ensures controlled distribution of detergent and disinfectant solution to the distal tip of the endoscope during manual reprocessing Fig. 4.2 Pentax ED34-i10T2. This video duodenoscope combines a sterile disposable elevator cap (DECTM) for single-patient use and simple disposal that advances cleaning capability of the duodenoscope. This is to help reduce risk of cross contamination 4 Endoscopes 33 Tit-up mechanism part Fig. 4.3 Fujinon ED-530XT8. It is equipped with a disposable distal end cap that enables brushing of all channels and helps to improve the hygienic environment. A covered tilt-up mechanism of the forceps elevator maintains the elevator wire clean without any additional clearing procedure Fig. 4.4 Karl Storz 13885PKSK/NKSK duodenoscope. Removable and autoclavable Albarran module 34 4.6 a A. Massella and P. Bocus EUS Instruments b Fig. 4.5 The Olympus GF-UCT180 (a) delivers highquality ultrasound images with greater B-mode imaging depth, offering safe control with a round transducer design and a short rigid distal end. Olympus GF-UE160-AL5 (b) radial ultrasound endoscope is a 360° radial-array scan- a Fig. 4.6 Pentax EG-3870UTK (a) ultrasound video endoscope utilizes a curved, linear-array ultrasound transducer that provides a large 120° field of view. The EG-3670URK (b) features a 360°, electronic, radial-array ultrasound transducer, which generates high-resolution c ning endoscope. Olympus TGF-UC180J (c) linear ultrasound endoscope. The forward-viewing ultrasound gastrovideoscope pioneers new opportunities in endoscopic ultrasound-guided treatment b ultrasound images. Both are supported by various imaging modalities such as Hitachi Real-Time Tissue Elastography (HI-RTE) and Doppler function for a more accurate localization and targeting of lesions 4 Endoscopes 35 a Fig. 4.7 Fujifilm EG-580UT (a) ultrasound endoscope with forceps elevator assist which enables convex scanning, developed for therapeutic interventions. With a working channel of 3.8 mm and equipped with an Albarran lever, it is the former scope, which also allows passage of therapeutic devices and needle position guide on the ultrasound image. Fujifilm EG-580 UR (b) with the thin outer b diameter of 11.4 mm, the unique 190° bending, and the brilliant Super CCD image quality; the new EG-580UR allows to carry out endoscopic ultrasound examinations almost as simply as a traditional endoscopic examination. The 2.8 mm working channel enables a good suction ability and the use of a standard-size biopsy forceps. The electronic 360° radial scan ensures a reliable panoramic view References 1. 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