Rare adult gastric duplication cyst mimicking a gastrointestinal stromal tumor

Gastric duplication cyst is a very rare gastrointestinal tract malformation that accounts for 2%-4%of alimentary tract duplications.Most cases are diagnosed within the first year of life,following presentation of abdominal pain,vomiting,and weight loss and clinical discovery of an abdominal palpable mass.This case report describes a very uncommon symptomatic gastric duplication cyst diagnosed for the first time in adulthood.Only a few other case reports of similar condition exist,and all were identified by endosonography.The current case involves a 52-year-old male who presented with a onemonth history of progressive iron deficiency anemia without overt gastrointestinal bleeding.The patient underwent esophagogastroduodenoscopy,which revealed a 2.0 cm pinkish subepithelial lesion,suspected to be a gastrointestinal stromal tumor(GIST)and source of gastrointestinal bleeding.The endosonography showed inhomogeneous hypoechoic lesions with focal anechoic areas arising from a second and third layer of the gastric wall.Differential diagnoses of GIST,neuroendocrine tumor,or pancreatic heterotopia were made.The lesion was removed using an endoscopic submucosal resection technique.Histopathology revealed an erosive gastric mass composed of a complex structure of dilated gastric glands surrounded by fibro-muscular tissue,fibroblasts,and smooth muscle bundles,which led to the diagnosis of gastric duplication.

Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention

Endoscopic retrograde cholangiopancreatography(ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation re-sults in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.

A novel technique for endoscopic ultrasound-guided biliary drainage

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates. METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients' baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient's overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student's t -test and the χ 2 test were used to assess the significance of inter-group differences. RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The technical success and clinical success rates of this technique were 95.2% and 90.5%, respectively. Complications included bile leakage and pneumoperitoneum, occurred at a rate of 9.5%. None of the patients died from the procedure. One patient presented with a biloma, a major complication that was successfully treated by another endoscopic procedure. CONCLUSION: We present a highly effective EUS-guided biliary drainage technique that does not require cauterization or balloon dilation.

Endoscopic ultrasound-guided biliary drainage as an alternative to percutaneous drainage and surgical bypass

Endoscopic retrograde cholangiopancreatography had been a treatment modality of choice for both benign and malignant biliary tract obstruction for more than half century, with a very high clinical success rate and low complications. But in certain circumstances, such as advanced and locally advanced pancreatobiliary malignancies(pancreatic cancer, cholangiocarcinoma, ampullary tumor) and tight benign strictures, endoscopic retrograde cholangiopancreatography(ERCP) fails. Up to this point, the only alternative interventions for these conditions were percutaneous transhepatic biliary drainage or surgery. Endoscopic ultrasound guided interventions was introduced for a couple decades with the better visualization and achievement of the pancreatobiliary tract. And it's still in the process of ongoing development. The inventions of new techniques and accessories lead to more feasibility of high-ended procedures. Endoscopic ultrasound guided biliary drainage was a novel treatment modality for the patient who failed ERCP with the less invasive technique comparing to surgical bypass. The technical and clinical success was high with acceptable complications. Regarded the ability to drain the biliary tract internally without an exploratory laparotomy, this treatment modality became a very interesting procedures for many endosonographers, worldwide, in a short period. We have reviewed the literature and suggest that endoscopic ultrasoundguided biliary drainage is also an option, and one with a high probability of success, for biliary drainage in the patients who failed conventional endoscopic drainage.

Massive gastric antral vascular ectasia successfully treated by endoscopic band ligation as the initial therapy

Gastric antral vascular ectasia(GAVE) accounted for 4% of non-variceal gastrointestinal hemorrhage.Even though unclear pathogenesis,GAVE often associated with chronic renal failure,autoimmune diseases and cirrhosis.Asymptomatic lesions were reasonably not to treated.The treatment options for GAVE are nonendoscopic and endoscopic treatments.For the pharmacological treatment,some success were reported for the use of octreotide,thalidomide and tranexamic acid.While the endoscopic treatment is the mainstay for treatment of symptomatic lesions.The endoscopic ablative therapies such as argon plasma coagulation was reported with good clinical outcomes.However,these treatment options had some limitation due to the need of special equipment and multiple sessions needed to control the bleeding.We reported another treatment option using the routine-achievable instrument such as endoscopic band ligation as an initial treatment which also provided a good treatment outcome and less sessions.

Endoscopic ultrasound-guided biliary drainage:Bilateral systems drainage via left duct approach

Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed,thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage,both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently,only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma,and thus can be used as an alternative to percutaneous biliary drainage.

Endoscopic ultrasound-guided interventions in specialsituations

Endoscopic ultrasound(EUS) was introduced in 1982 and has since become a popular advanced procedure for diagnosis and therapeutic intervention. Initially, EUS was most commonly used for the diagnosis of pancreatobiliary diseases and tissue acquisition. EUS was first used for guided cholangiography in 1996, followed by EUS-guided biliary drainage in 2001. Advancements in equipment and endoscopic accessories have led to an expansion of EUS-guided procedures, which now include EUS-guided drainage of intra-abdominal abscesses or collections, intravascular treatment of refractory variceal and nonvariceal bleeding, transmural pancreatic drainage, common bile duct stone clearance, enteral feeding tube placement and entero-enteric anastomosis. Patients with surgically altered upper gastrointestinal anatomies have greatly benefited from EUS also. This systematic review describes and discusses EUS procedures performed in uncommon diseases and conditions, as well as applications on more vulnerable patients such as young children and pregnant women. In these cases, routine approaches do not always apply, and thus may require the use of innovative and unconventional techniques. Increased knowledge of such special applications will help increase the success rates of these procedures and provide a foundation for additional advances and utilizations of the technique.

Factors influencing clinical outcomes of Histoacryl~ glue injection-treated gastric variceal hemorrhage

AIM: To determine the factors associated with clinical outcomes and complications of Histoacryl glue injection for acute gastric variceal hemorrhage. METHODS: Patients who presented to the Siriraj Gastrointestinal Endoscopy Center with active gastric variceal bleeding and were admitted for treatment between April 2008 and October 2011 were selected retrospectively for study inclusion. All bleeding varices were treated by injection of Histoacryl tissue glue (B. Braun Melsungen AG, Germany) through a 21G or 23G catheter primed with lipiodol to prevent premature glue solidification. Data recorded for each patient included demographic and clinical characteristics, endoscopic findings, clinical outcomes in terms of early and late re-bleeding, mortality, and procedure-related complications. Data from admission (baseline) and posttreatment were comparatively analyzed using stepwise logistic regression analysis to determine the correlation between factors and clinical outcomes.RESULTS: A total of 90 patients underwent Histoacryl injection to treat bleeding gastric varices. The mean age was 55.9 ± 13.9 (range: 15-88) years old, and 74.4% of the patients were male. The most common presentations were hematemesis (71.1%), melena (12.2%), and coffee ground emesis (8.9%). Initial hemostasis was experienced in 97.8% of patients, while re-bleeding within 120 h occurred in 10.0%. The presence of ascites was the only factor associated with early and late re-bleeding [odds ratio (OR)=10.67, 95%CI: 1.27-89.52, P=0.03 and OR=4.15, 95%CI: 1.34-12.86, P=0.01, respectively]. Early procedure-related complications developed in 14.4% of patients, and were primarily infections and non-fatal systemic embolization. Late re-bleeding was significantly correlated with early procedure-related complications by univariate analysis (OR=4.01, 95%CI: 1.25-12.87, P=0.04), but no factors were significantly correlated by multivariate analysis. The overall mortality rate was 21.1%, the majority of which were related to infections. The factors showing strong association with higher mortality risk were elevated total bilirubin (OR=16.71, 95%CI: 3.28-85.09, P < 0.01), a large amount of transfused fresh frozen plasma (OR=1.001, 95%CI: 1.000-1.002, P=0.03), and late re-bleeding (OR=10.99, 95%CI: 2.15-56.35, P=0.02).CONCLUSION: Histoacryl injection is a safe and effective hemostatic method for treating gastric variceal hemorrhage. Patients with compromised liver, including ascites, have a higher risk of re-bleeding.

Feasibility and safety of using Soehendra stent retriever as a new technique for biliary access in endoscopic ultrasoundguided biliary drainage

AIM:To assess the feasibility and safety of the use of soehendra stent retriever as a new technique for biliary access in endoscopic ultrasound-guided biliary drainage.METHODS:The medical records and endoscopic reports of the patients who underwent endoscopic ultrasound-guided biliary drainage(EUS-BD) owing to failed endoscopic retrograde cholangiopancreatography in our institute between June 2011 and January 2014 were collected and reviewed.All the procedures were performed in the endoscopic suite under intravenous sedation with propofol and full anaesthetic monitoring.Then we used the Soehendra stent retriever as new equipment for neo-tract creation and dilation when performing EUS-BD procedures.The patients were observed in the recovery room for 1-2 h and transferred to the regular ward,patients' clinical data were reviewed and analysed,clinical outcomes were defined by using several different criteria.Data were analysed by using SPSS 13 and presented as percentages,means,and medians.RESULTS:A total of 12 patients were enrolled.The most common indications for EUS-BD in this series were failed common bile duct cannulation,duodenal obstruction,failed selective intrahepatic duct cannulation,and surgical altered anatomy for 50%,25%,16.7%,and 8.3%,respectively.Seven patients underwent EUS-guided hepaticogastrostomy(58.3%),and 5 underwent EUS-guided choledochoduodenostomy(41.7%).The technical success rate was 100%,while the clinical success rate was 91.7%.Major and minor complications occurred in 16.6% and 33.3% of patients,respectively,but there were no procedurerelated death.CONCLUSION:Soehendra stent retriever could be used as an alternative instrument for biliary access in endoscopic ultrasound guided biliary drainage.

Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type pain.Obstruction of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches,ranging from pharmacologic,endoscopic and radiologic treatments to surgical interventions.When the conservative treatment approaches fail to resolve symptomatic cases,however,endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach,despite its well-recognized drawbacks.When the conventional transpapillary approach fails to achieve the necessary drainage,the patients may benefit from application of the less invasive endoscopic ultrasound(EUS)-guided pancreatic duct interventions.Here,we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 mo.Computed tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at genu.After conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms,EUS-guided pancreaticogastrostomy(PGS)was applied using a fully covered,self-expandable,10-mm diameter metallic stent.The treatment resolved the case and the patient experienced no adverse events.EUS-guided PGS with a regular biliary fully covered,self-expandable metallic stent effectively and safely treated pancreatictype pain in chronic pancreatitis.

Mediastinal small cell carcinoma with liver and bone marrow metastasis, mimicking lymphoma

Primary mediastinal neuroendocrine tumors are a rare malignancy that accounts for < 10% of all mediastinal tumors. The case presented here involves a 52-yearold man who had been suffering for 3 mo from chronic cough, anorexia and substantial weight loss, as well as 2 wk of jaundice prior to his admission. A computed tomography scan showed a 4.3 cm × 6.6 cm mediastinal mass with multiple liver nodules scattered along both hepatic lobes. Endoscopic ultrasound showed a large heterogeneous hypoechoic mass at the mediastinum with multiple target-like nodules in the liver. Fine-needle aspiration specimens revealed numerous, small, round cells with hyperchromatic nuclei, scarce cytoplasm, and frequent mitotic features. Immunohistochemical study revealed positive results for AE1/AE3, CD56 and chromogranin A, with negative findings for synaptophysin, CK20, vimentin, CK8/18 and CD45. The patient was subsequently diagnosed with a poorly differentiated neuroendocrine carcinoma, small cell type. A bone marrow biopsy also revealed extensive involvement by the carcinoma.

Uncommon complications of therapeutic endoscopic ultrasonography: What, why, and how to prevent

There is an increasing role for endoscopic ultrasound(EUS)-guided interventions in the treatment of many conditions. Although it has been shown that these types of interventions are effective and safe, they continue to be considered only as alternative treatments in some situations. This is in part due to the occurrence of complications with these techniques, which can occur even when performed by experienced endosonographers. Although common complications have been described for many procedures, it is also crucial to be aware of uncommon complications. This review describes rare complications that have been reported with several EUS-guided interventions. EUS-guided biliary drainage is accepted as an alternative treatment for malignant biliary obstruction. Most of the uncommon complications related to this procedure involve stent malfunction, such as the migration or malposition of stents. Rare complications of EUS-guided pancreatic pseudocyst drainage can result from air embolism and infection. Finally, a range of uncommon complications has been reported for EUS-guided celiac plexus neurolysis, involving neural and vascular injuries that can be fatal. The goal of this review is to identify possible complications and promote an understanding of how they occur in order to increase general awareness of these adverse events with the hope that they can be avoided in the future.