Endoluminal Ultrasound

Donald G. Kim and W. Douglas Wong

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Evaluation of the anal canal and rectum has traditionally relied on digital
examination, anoscopy, and rigid or flexible proctosigmoidoscopy. The introduction
of imaging methods, particularly endoluminal ultrasonography has brought a
greater degree of objectivity to the evaluation of the anorec- tum. Endoluminal
ultrasound has become the diagnostic proce- dure of choice in the evaluation of
many anorectal disorders. Endorectal ultrasound (ERUS) has evolved into the best
imag- ing modality for accurate staging of rectal neoplasms. The accurate
determination of tumor penetration depth and regional lymph node status has
become critical to guiding subsequent treatment of rectal malignancies. In addition,
endoanal ultrasound (EAUS) has become invaluable in the diagnostic workup of
fecal incontinence and anorectal suppu- rative conditions. This chapter will focus on
the use of endo- luminal ultrasound in the evaluation of patients with benign and
malignant conditions of the anorectum.
History
Endoluminal ultrasound of the rectum was first introduced by Wild and Reid1 in
1952. They were the first to develop an echoendo probe, but it was never used
clinically. Because of limitations in technology, it was not until 1983 that this type of
imaging was introduced into clinical practice by Dragsted and Gammelgaard.2 They
used a Bruel and Kjaer (Type 8901) ultrasound probe with a rigid rotating endosonic
probe with 4.5-MHz transducer initially designed for prostatic ultra- sound. Thirteen
primary rectal cancers were evaluated and invasion was correctly predicted in 11
cases when compared with the final histopathology. Two patients could not be adequately imaged because of stricture. Although successful, they did not define their
reporting criteria. In 1985, Hildebrandt and Feifel3 found that ultrasonography
correlated with pathologic finding in 23 of 25 rectal cancers. They pro- posed a
modification of the tumor-node-metastasis (TNM) classification4 for ultrasound
tumor staging (uTNM).3 The
prefix u indicated ultrasound staging as opposed to the pre- fix p representing
pathologic staging. Similar to Dragsted and Gammelgaard, they also made no
reference to the report- ing criteria used for degree of invasion. Further refinements
of the technique and improvement in the ultrasound equipment have made
endoluminal ultrasound routine in the evaluation of patients with anorectal
disorders.
Endorectal Ultrasound

As the treatment for rectal cancer has evolved, the importance of accurate
preoperative staging of the lesion has become paramount in determining the
patients treatment regimen. Radical surgery, either low anterior or
abdominoperineal resection is not always the initial or only therapy available for
patients diagnosed with rectal carcinoma. With the develop- ment of preoperative
neoadjuvant therapies for rectal cancer, accurate staging of these patients lesions
has become increasingly important. In addition, local excision has become an option
in highly selected early-stage rectal cancers necessitating accurate preoperative
staging. The goal of preoperatively staging the rectal lesion is an accurate
evaluation of the primary tumor, which includes the depth of tumor penetration and
an evaluation of regional lymph node disease. ERUS accomplishes these goals using
an intraluminal high-frequency sonographic transducer via a handheld rotating
probe to accurately image the rectal wall and adjacent structures. For this reason,
ERUS has become the preferred method used to stage the patient with rectal
cancer.
Equipment and Technique
Equipment used for endoluminal ultrasonography includes a handheld endocavitary
probe with rotating transducer which acquires a 360-degree image. Most
investigators use a B-K Medical scanner with a rigid handheld Type 1850 rotating
probe and a 7- or 10-MHz transducer (B-K Medical