The Case for Endoscopic Ultrasound in the ASC

EUS is a safe and powerful addition to any GI service line — if you can attract one of the few GI doctors qualified to perform it.

If your facility has room in its capital equipment budget and can procure the services of physicians who can perform endoscopic ultrasound (EUS) procedures, you can provide a profitable service that enables you to diagnose and treat patients for numerous conditions much less invasively than before.

What is EUS?

EUS is much like a colonoscopy or upper endoscopy, in that a flexible endoscope with a camera is inserted through the rectum or mouth. What’s different is the presence of an additional ultrasound probe that enables the endoscopist to look through the wall of the stomach and the intestines.

Shaffer Mok, MD, MBS, FASGE, a gastroenterologist at Moffitt Cancer Center in Tampa, Fla., co-authored a landmark 2016 study that found EUS safe to perform at ASCs. “Pretty much all the indications we see on a daily basis for EUS are related to cancer diagnosis and, in some instances, treatment,” he says. “However, there are numerous other indications for EUS, including chronic abdominal pain and ruling out chronic pancreatitis for people who have bowel dysfunction, bloating, gas pain or even diarrhea.”

Daniel Gelrud, MD, FACP, a gastroenterologist and advanced endoscopist with Gastro Health in Miami, says the majority of EUS patients he sees in an ASC arrive due to imaging studies or previous endoscopies that raised suspicion of the presence of a cancerous mass in the pancreas, stomach or esophagus.

“EUS allows you to see outside of the lumen of the intestines,” explains Dr. Gelrud. “During an upper endoscopy, we see the inside of the esophagus, stomach and small bowel, but with ultrasound we can see lesions that are outside of the stomach. With EUS, you can see a mass or tumor on the ultrasound, put a needle in it, and biopsy it. EUS has opened a whole new set of things we can do with endoscopy, such as looking at the pancreas.”

• New needles. Both doctors say the reason most EUS procedures were performed at hospitals until recently was not because of patient safety. “It’s not like an ERCP [endoscopic retrograde cholangiopancreatography] where you require radiology and it’s a high-risk procedure,” says Dr. Gelrud. “For most indications — such as taking a biopsy of a tumor — you can do EUS in an outpatient setting.”

The greatest leap we’ve had in EUS is the invention of better tissue acquisition needles. Now we can reliably get appropriate tissue without having a pathologist in the room, which really opened the door to do EUS in the outpatient setting.
Daniel Gelrud, MD, FACP

The true obstacle was the need for an on-site pathologist, which is no longer required. “In the past, a lot of the interpretation of EUS procedures had to be done in the hospital,” says Dr. Gelrud. “For example, if you had a mass in the pancreas, we did a fine needle aspiration (FNA), but the yield of those procedures was very low because we depended on very scant tissue that was inside of the needle. We would bring a pathologist to the room and look at the slides to see if we had enough tissue.” New needles have largely removed that concern. “The greatest leap we’ve had in EUS is the invention of better tissue acquisition needles,” says Dr. Gelrud. “Now we can reliably get appropriate tissue without having a pathologist in the room, which really opened the door to do EUS in the outpatient setting.”

Says Dr. Mok of new needles, “The way the tip is shaped and formed allows you to obtain core tissue, as opposed to a standard triangular-shaped needle that gets some cells that don’t necessarily correlate to a confined core piece of tissue. It really is a game-changer for the patient, because we get so much more information than a traditional FNA approach.”

• Anesthesia. Because MAC sedation is used, both doctors say CRNAs are perfectly adequate for EUS cases. However, patient selection based on ASA scores is still a qualifying factor for ASCs. “Assessing the anesthesia risk is an appropriate first step,” says Dr. Mok. “Those who have a higher anesthesia risk or who could be converted to general anesthesia really should be done in the hospital setting. But for most, EUS can be done in an ASC with a trained anesthetist administering MAC using propofol.”

• Personnel. Dr. Gelrud performs EUS with a nurse and a tech. “The nurse is usually charting, while the tech is usually helping me with biopsies,” he says. He notes, however, that nurses and techs need specialized training for EUS, much like physicians. “You need staff who know how to use the ultrasound machine and the needles,” he says. “The scopes are different, and you prepare them in a different way. For nurses and techs, it’s just a different technique.”

You’ll also likely need a relationship with a local hospital for review of EUS-derived samples. “Our own pathologists are used to getting polyps and biopsies from the stomach or the colon, but not tumors from the mediastinum or the pancreas,” says Dr. Gelrud. “We send that pathology to the hospitals, which requires a whole different workflow for the nurses and for the center.”

• Procedure length. As with many things both in surgery and in life, the length of an EUS procedure varies with experience. Veteran practitioners and supporting staff can perform many EUS procedures in 30 minutes or less, while less experienced teams often take longer. The key is the ability of the physician to use and interpret ultrasound imaging to safely navigate difficult anatomy and visualize abnormalities. This skill usually improves over time for most doctors who perform EUS procedures.

• Patient experience. EUS is similar to other endoscopic procedures. Both doctors say most EUS procedures are through the mouth, which simply requires standard preoperative fasting in preparation.

Dr. Mok notes there are other preoperative concerns with upper EUS, however. “You need to control blood thinners and oral hypoglycemic agents, and make sure very important heart or thyroid medications are taken in the morning with a sip of water,” he says. “Down below, on the other hand, if you really want to see a mass in the rectum, you either go with enemas or a bowel prep depending upon the extent of the things you need to see.”

While the safety of EUS is relatively high, risks do exist. “Some can be mitigated due to proper technique and training, and some are related to patient factors,” says Dr. Mok. Bleeding, as well as perforation or tearing in the esophagus or bowel can occur, although he says EUS provides physicians the ability to see blood vessels in real time and avoid them.

Pancreatitis is also a risk. “It’s more prevalent amongst young women, and it’s actually lower for people who have a pancreas mass than those who don’t,” says Dr. Mok. “In a patient population that you’d think would be relatively high risk with pancreatic cancer in question, most people have a relatively low risk of pancreatitis.”

• Investment. EUS scopes use the same camera heads as regular scopes, but a separate ultrasound machine is required. “They’re hybrid scopes,” explains Dr. Gelrud. “They have a camera like a regular scope but also an ultrasound probe at the tip. Those two separate heads connect to two different machines. You use the same machine you would use for a regular scope, but you also need to invest in a separate ultrasound machine.”

EXTRA EDUCATION In addition to physicians, nurses and techs need specialized training to perform EUS procedures.

Dr. Mok says the cost of the ultrasound machine is a limiting factor for many ASCs. “Most centers will already have standard power and a processor that allows you to convert the images into something that can be saved into a computer, but the big capital purchase is the ultrasound machine, which can cost as much as a Ferrari — just a lot slower and a lot less cool looking,” he says.

“In general, any place that does EUS needs a minimum of three scopes,” says Dr. Gelrud. “We use a radial scope for certain applications like staging tumors, but you can’t take biopsies with it. A linear scope allows you to do all the biopsies and most advanced EUS applications.” He recommends having at least two linear scopes on hand because of their extensive reprocessing protocol.

Looking ahead

Dr. Mok says EUS continues to evolve from its origins as a diagnostic procedure, first by adding the ability to perform biopsies with needles, and now by becoming a platform for introducing therapies. “Lumen-apposing metal stents have been a game changer in GI by allowing us to bridge the connection between an organ in the luminal GI tract to the area outside of it.”

That enables debridement of a damaged pancreas, which previously required surgery or placement of percutaneous drains. This technology also can be used to bypass blockages in the GI tract from cancer and in the bowels, he notes.

“We also now have all kinds of needle-based technologies that can actually deliver therapies,” says Dr. Mok. “EUS scopes are now able to perform ultrasound-guided chemoablation to treat pancreatic cysts; radiofrequency ablation to treat tumors; ultrasound-guided liver biopsies and ultrasound-guided portal pressure measurement to measure the degree of portal hypertension for diagnosis of cirrhosis; and even vascular interventions.”

The biggest hindrance to the adoption of outpatient EUS is a lack of qualified providers. “That is not changing, unfortunately,” says Dr. Gelrud, as the main barrier is the requirement of an extra year of special training. “You need to learn how to interpret ultrasound images to understand what you’re looking at, and we’re not trained in doing that.” In the Miami market, he estimates that only 20 people are qualified to perform EUS, with four at Gastro Health. “Each of us here will do probably around 200 per year,” he says.

Recruitment is a challenge for ASCs. “We’re always scrambling trying to recruit people who can do EUS,” says Dr. Gelrud. “We’re doing so many things now with EUS, and we really need more people who can do these procedures. We are overwhelmed with the number of EUS procedures we need to do, and we practice GI as well, so we’re still doing colonoscopies and all the other procedures.”

One heartening note for ASCs: You may have a competitive recruitment advantage against hospitals for EUS providers. “EUS is profitable in the outpatient setting, but not in the inpatient setting,” says Dr. Gelrud. “In general, it’s very difficult to make enough money as a gastroenterologist doing EUS at a hospital because at maximum you can do one procedure an hour, and the only thing you collect is a fee for the procedure. When you do EUS in an outpatient setting, it’s better for the physician from a reimbursement point of view.” OSM