For example, fine-needle aspirates in pancreatic cancer are now being used to assess biomarkers such as S100A2, ribonucleotide reductase subunit N2 and heat shock protein 27 that have been associated with gemcitabine resistance and short survival.29–31 Another potential application of EUS is the screening and surveillance of patients at high risk for pancreatic

cancer such as those with familial pancreatic cancer and hereditary chronic pancreatitis. As EUS can identify and sample lesions as small as 2 mm, it may become the surveillance procedure of choice in this small group of patients.32 In the future, it seems likely that echo-endoscopes will be smaller and lighter and will scan at higher frequencies XL765 purchase with improvements in image quality and reliability.

It may also be possible to design endoscopes with radial and linear imaging in the one instrument as well as 3-dimensional reconstruction of linear EUS. Another potential diagnostic and therapeutic procedure is that of natural orifice transluminal Selinexor cost endoscopic surgery (NOTES). With this procedure, rigid trocars or flexible endoscopes are passed into various parts of the abdominal and thoracic cavities through the esophagus, stomach, colon, vagina or bladder. This topic is discussed in detail elsewhere33 but, at present, it is unclear whether various NOTES procedures will be superior to conventional laparoscopic techniques. There is also the issue of training through gastroenterological or surgical programs although one option is surgical training with additional exposure to therapeutic endoscopy creating the ‘gastrointestinal interventionalist’.34 Impressive progress has been made in endoscopic therapies since the first descriptions of colonic polypectomy and biliary sphincterotomy. Procedures commonly performed by ‘typical’ and specialized

endoscopists are shown in Table 2 along with a short-list of evolving technologies. While most endoscopists are now familiar with hemostatic techniques, variceal ablation and mucosal resection, there is now an emerging group of therapeutic endoscopists with responsibility for insertion of metal stents and for the more challenging areas of submucosal dissection and drainage of pancreatic pseudocysts. This more specialized group is also likely to take responsibility for those procedures in Table 2 that do not, as yet, have an established click here role. Techniques that require EUS guidance include celiac plexus neurolysis, drainage of pancreatic pseudocysts and procedures that involve transgastric or transduodenal puncturing of either the bile duct or main pancreatic duct. One procedure of broad interest is the use of endoscopic techniques for the treatment of early gastrointestinal cancers.35,36 One approach is endoscopic mucosal resection but larger lesions are often removed in pieces, histological assessment is difficult and recurrence rates are significant, at least in some settings.