Acute left-sided malignant colonic obstruction:Is there a role for endoscopic stenting?

The therapy of left-sided malignant colonic obstruction continues to be one of the largest problems in clinical practice.Numerous studies on colonic stenting for neoplastic colonic obstruction have been reported in the last decades.Thereby the role of self-expandable metal stents(SEMS)in the treatment of malignant colonic obstruction has become better defined.However,numerous prospective and retrospective investigations have highlighted serious concerns about a possible worse outcome after endoscopic colorectal stenting as a bridge to surgery,particularly in case of perforation.This review analyzes the most recent evidence in order to highlight pros and cons of SEMS placement in left-sided malignant colonic obstruction.

Post-trans-arterial chemoembolization hepatic necrosis and biliary stenosis: Clinical charateristics and endoscopic approach

Liver cancer is the fifth most common tumor and the second highest death-related cancer in the world.Hepatocarcinoma(HCC)represents 90%of liver cancers.According to the Barcelona Clinic Liver Cancer group,different treatment options could be offered to patients in consideration of tumor burden,liver function,pa-tient performance status and biochemical marker serum concentration such as alpha-fetoprotein.Trans-arterial chemoembolization(TACE)is the treatment of choice in patients with diagnosis of unresectable HCC not eligible for liver trans-plantation,and preserved arterial supply.TACE is known to be safe and its com-plications are generally mild such as post-TACE syndrome,a self-resolving adverse event that occurs in about 90%of patients after the procedure.However,albeit rarely,more severe adverse events such as biloma,sepsis,hepatic failure,chemoagents induced toxicities,and post-TACE liver necrosis can occur.A prompt diagnosis of these clinical conditions is fundamental to prevent further complications.As a result,biliary stenosis could be a rare post-TACE necrosis complication and can be difficult to manage.Complications from untreated biliary strictures include recurring infections,jaundice,chronic cholestasis,and secon-dary biliary cirrhosis.

Cholangiocarcinoma and malignant bile duct obstruction: A review of last decades advances in therapeutic endoscopy

In the last decades many advances have been achieved in endoscopy, in the diagnosis and therapy of cholangiocarcinoma, however blood test, magnetic resonance imaging, computed tomography scan may fail to detect neoplastic disease at early stage, thus the diagnosis of cholangiocarcinoma is achieved usually at unresectable stage. In the last decades the role of endoscopy has moved from a diagnostic role to an invaluable therapeutic tool for patients affected by malignant bile duct obstruction. One of the major issues for cholangiocarcinoma is bile ducts occlusion, leading to jaundice, cholangitis and hepatic failure. Currently, endoscopy has a key role in the work up of cholangiocarcinoma, both in patients amenable to surgical intervention as well as in those unfit for surgery or not amenable to immediate surgical curative resection owing to locally advanced or advanced disease, with palliative intention. Endoscopy allows successful biliary drainage and stenting in more than 90% of patients with malignant bile duct obstruction, and allows rapid reduction of jaundice decreasing the risk of biliary sepsis. When biliary drainage and stenting cannot be achieved with endoscopy alone, endoscopic ultrasound-guided biliary drainage represents an effective alternative method affording successful biliary drainage in more than 80% of cases. The purpose of this review is to focus on the currently available endoscopic management options in patients with cholangiocarcinoma.

Single balloon enteroscopy: Technical aspects and clinical applications

The small bowel has long been considered a black box for endoscopists because of its long length and the presence of multiple complex loop. Most of the small bowel is inaccessible by traditional endoscopic means. In addition, radiographic studies have significant limitations with regard to diagnostic yield, and surgery is an invasive alternative. This limitation was overcome through the development of balloon enteroscopy that becomes established throughout the world for diagnostic and therapeutic examinations of the small bowel. The single-balloon enteroscope (SBE) system (Olympus, Tokyo, Japan) was introduced into the commercial market in 2007. Several study demonstrated its efficacy and safety. Early reports on the use of singleballoon enteroscopy have suggested a high diagnostic yield and similar therapeutic potential to that of the double-balloon endoscope. SBE is viable technique for in the management of small bowel disease. Technically, it is easy to perform, may be efficient, and in the literature data available, seems to provide high diagnostic and therapeutic yield.

Linear endoscopic ultrasonography vs magnetic resonance imaging in ampullary tumors

AIM:To assess linear endoscopic ultrasound (L-EUS) and magnetic resonance imaging (MRI) in biliary tract dilation and suspect small ampullary tumor.METHODS:L-EUS and MRI data were compared in 24 patients with small ampullary tumors;all with subsequent histological confirmation.Data were collected prospectively and the accuracy of detection,histological characterization and N staging were assessed retrospectivelyusing the results of surgical or endoscopic treatment as a benchmark.RESULTS:A suspicion of ampullary tumor was present in 75% of MRI and all L-EUS examinations,with 80% agreement between EUS and histological findings at endoscopy.However,L-EUS and histological TN staging at surgery showed moderate agreement (κ=0.54).CONCLUSION:L-EUS could be a useful adjunct as a diagnostic tool in the evaluation of patients with sus-pected ampullary tumors.

Needle-based confocal endomicroscopy in the discrimination of mucinous from non-mucinous pancreatic cystic lesions

BACKGROUND Pancreatic cystic lesions(PCLs)are considered a precursor of pancreatic cancer.Needle-based confocal endomicroscopy(nCLE)is an imaging technique that enables visualization of the mucosal layer to a micron resolution.Its application has demonstrated promising results in the distinction of PCLs.This study evaluated the utility of nCLE in patients with indeterminate PCLs undergoing endoscopic ultrasound fine-needle aspiration(EUS-FNA)to distinguish mucinous from non-mucinous lesions.AIM To evaluate the accuracy of nCLE in indeterminate PCLs undergoing EUS-FNA to distinguish mucinous from non-mucinous lesions.METHODS Patients who required EUS-FNA between 2015 and 2017 were enrolled prospectively.During EUS-FNA,confocal imaging,analyses of the tumor markers carcinoembryonic antigen and amylase,and cytologic examination were conducted.All patients were followed for at least 12 mo and underwent laboratory testing and computed tomography scanning or magnetic resonance imaging.nCLE videos were independently reviewed by 6 observers to reach a final diagnosis(mucinous vs non-mucinous)based on criteria derived from previous studies;if there was disagreement>20%,a final diagnosis was discussed after consensus re-evaluation.The sensitivity,specificity,and accuracy of nCLE were calculated.Adverse events were recorded.RESULTS Fifty-nine patients were included in this study.Final diagnoses were derived from surgery in 10 patients,cytology in 13,and imaging and multidisciplinary team review in 36.Three patients were excluded from final diagnosis due to problems with nCLE acquisition.Fifty-six patients were included in the final analysis.The sensitivity,specificity,and accuracy of nCLE were 80%[95%confidence interval(CI):65-90],100%(95%CI:72-100),and 84%(95%CI:72-93),respectively.Postprocedure acute pancreatitis occurred in 5%.CONCLUSION EUS-nCLE performs better than standard EUS-FNA for the diagnosis of indeterminate PCL.

Common bile duct lesions-how cholangioscopy helps rule out intraductal papillary neoplasms of the bile duct:A case report

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)is a rare variant of bile duct tumors,characterized by an exophytic growth exhibiting a papillary mass within the bile duct lumen and it can be localized anywhere along the biliary tree,with morphological variations and occasional invasion.CASE SUMMARY We present a patient with obstructive jaundice who was diagnosed with IPNB using cholangioscopy during endoscopic retrograde cholangio-pancreatography.Using the SpyGlass DS Ⅱ technology,we were able to define tumor extension and obtain targeted Spy-byte biopsies.After multidisciplinary evaluation,the patient was scheduled for surgical resection of the tumor,which was radically removed.CONCLUSION Cholangioscopy appears to be crucial for the rapid and clear diagnosis of lesions in the bile duct to achieve radical surgical resection.

Dilation assisted stone extraction for complex biliary lithiasis:Technical aspects and practical principles

Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography.Endoscopic sphincterotomy(EST)has been used for the removal of bile duct stones for the past 40 years,providing a wide opening to allow extraction.Up to 15%of patients present with complicated choledocholithiasis.In this context,additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy,intraductal or extracorporeal lithotripsy,or endoscopic papillary large balloon dilation(EPLBD).EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter.EPLBD without EST was introduced as a simplified technique in 2009.Dilation-assisted stone extraction(DASE)is the combination of two techniques:EPLBD and sub-maximal EST.Several studies have reported this technique as safe and effective in patients with large bile duct stones,without any increased risk of adverse events such as pancreatitis,bleeding,or perforation.Nevertheless,it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies.The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE,based on current literature and daily clinical experience in biliary referral centers.