Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy

AIM:To compare small sphincterotomy combined with endoscopic papillary large balloon dilation(SES+ ELBD)and endoscopic sphincterotomy(EST)for large bile duct stones. METHODS:We compared prospectively SES+ELBD (group A,n=27)with conventional EST(group B, n=28)for the treatment of large bile duct stones(≥ 15 mm).When the stone could not be removed with a normal basket,mechanical lithotripsy was performed. We compared the rates of complete stone removal with one session and application of mechanical lithotripsy. RESULTS:No significant differences were observed in the mean largest stone size(A:20.8 mm,B:21.3 mm), bile duct diameter(A:21.4 mm,B:20.5 mm),number of stones(A:2.2,B:2.3),or procedure time(A:18 min, B:19 min)between the two groups.The rates of complete stone removal with one session was 85%in group A and 86%in group B(P=0.473).Mechanical lithotripsy was required for stone removal in nine of 27 patients(33%)in group A and nine of 28 patients (32%,P=0.527)in group B.CONCLUSION:SES+ELBD did not show significant benefits compared to conventional EST,especially for the removal of large(≥15 mm)bile duct stones.

Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents

AIM:To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) with a fully covered self-expandable metallic stent(FCSEMS).METHODS:From April 2009 to August 2010,15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography(ERCP) were included.These 15 patients consisted of 8 men and 7 women and had a median age of 61 years(range:30-91 years).The underlying causes of the distal malignant biliary obstruction were pancreatic cancer(n = 9),ampulla of Vater cancer(n = 2),renal cell carcinoma(n = 1),advanced gastric cancer(n = 1),lymphoma(n = 1),and duodenal cancer(n = 1).RESULTS:The technical success rate of EUS-CDS with an FCSEMS was 86.7%(13/15),and functional success was achieved in 100%(13/13) of those cases.In two patients,the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct.The mean duration of stent patency was 264 d.Early adverse events developed in three patients(3/13,23.1%),including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient.During the follow-up period(median:186 d,range:52-388 d),distal stent migration occurred in four patients(4/13,30.8%).In 3 patients,the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.CONCLUSION:EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.

Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography(EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation,precut fistulotomy,and transpancreatic septostomy are reviewed.Prophylactic pancreatic stent placement,which is the best-known prophylactic method,is reviewed with reference to the ideal stent type,adequate duration of stent placement,and stentrelated complications.Finally,we comment on other treatment alternatives,and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.

Diagnostic performance of the current risk-stratified approach with computed tomography for suspected choledocholithiasis and its options when negative finding

Background:Several studies evaluated the current guideline of the American Society for Gastrointestinal Endoscopy(ASGE)and reported only suboptimal accuracy.This study evaluated the diagnostic performance of the ASGE guideline based on computed tomography(CT)and role of endoscopic ultrasonography(EUS)and magnetic resonance cholangiopancreatography(MRCP)in patients with suspected choledocholithiasis but negative CT finding.Methods:Patients with suspected choledocholithiasis undergoing ERCP between January 2016 and January 2017 were retrospectively analyzed.All patients underwent CT to detect choledocholithiasis.EUS or MRCP was performed when the CT scan showed negative findings.Patients were classified into the high and intermediate-risk groups,based on predictors from the ASGE criteria.Results:Of 583 patients with suspected choledocholithiasis,340(58.3%)had stones on ERCP(65.9%in the high-risk group and 40.6%in the intermediate-risk group).The accuracy of ASGE guideline for CT was 63.98%(79.12%sensitivity,42.80%specificity)and 36.02%(20.88%sensitivity,57.20%specificity)in the high-risk and intermediate-risk groups,respectively.In 103 patients in the high-risk group underwent both CT and US,the accuracy of CT was higher than that of US for detecting choledocholithiasis(78.64%vs.53.40%),with a significant difference in area under the curve(AUC)(0.78 vs.0.59,P<0.001).Of 339 with negative CT finding,the accuracy of EUS was higher than that of MRCP(90.91%vs.82.76%),but with no significant difference in AUC(0.91 vs.0.83,P=0.347).Conclusions:CT-based ASGE guideline showed superior diagnostic performance than US for predicting choledocholithiasis.The diagnostic options,EUS or MRCP,with negative CT finding showed comparable performance.Therefore,the diagnostic modality should be selected based on availability,experience,cost,and contraindications.

A pilot proof-of-concept study of a modified device for one-step endoscopic ultrasound-guided biliary drainage in a new experimental biliary dilatation animal model

AIM:To evaluate the technical feasibility of a modified tapered metal tip and low profile introducer for onestep endoscopic ultrasound(EUS)-guided biliary drainage(EUS-BD)in a new experimental biliary dilatation porcine model.METHODS:A novel dedicated device for one-step EUS-guided biliary drainage system(DEUS)introducer has size 3F tapered catheter with size 4F metal tip for simple puncture of the intestinal wall and liver parenchyma without graded dilation.A self-expandable metal stent,consisting of both uncovered and nitinol-covered portions,was preloaded into DEUS introducer.After establishment of a biliary dilatation model using endoscopic hemoclips or band ligation with argon plasma coagulation in 9 mini-pigs,EUS-BD using a DEUS was performed following 19-G needle puncture without the use of fistula dilation devices.RESULTS:One-step EUS-BD was technically successful in seven pigs[7/9(77.8%)as intention to treat]without the aid of devices for fistula dilation from the high body of stomach or far distal esophagus to the intrahepatic(n=2)or common hepatic(n=5)duct.Primary technical failure occurred in two cases that did not show adequate biliary dilatation.In seven pigs with a successful bile duct dilatation,the technical success rate was 100%(7/7 as per protocol).Median procedure time from confirmation of the dilated bile duct to successful placement of a metallic stent was 10 min(IQR;8.9-18.1).There were no immediate procedure-related complications.CONCLUSION:Modified tapered metal tip and low profile introducer may be technically feasible for onestep EUS-BD in experimental porcine model.

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model. METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope. RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to sixstitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.

Endoscopic transcystic stent placement for an intrahepatic abscess due to gallbladder perforation

Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.

Forward-viewing endoscopic ultrasound-guided NOTES interventions: A study on peritoneoscopic potential

AIM:To evaluate the feasibility of diagnostic and therapeutic transgastric(TG)peritoneoscopic interventions with a forward-viewing endoscopic ultrasound(FV-EUS).METHODS:This prospective endoscopic experimental study used an animal model.Combined TG peritoneoscopic interventions and EUS examination of the intraabdominal organs were performed using an FV-EUS on 10 animal models(1 porcine and 9 canine).The procedures carried out include EUS evaluation and endoscopic biopsy of intraperitoneal organs,EUS-guided fine needle aspiration(EUS-FNA),EUS-guided radiofrequency ablation(EUS-RFA),and argon plasma coagulation(APC)for hemostatic control.The animals were kept alive for 7 d,and then necropsy was performed to evaluate results and complications.RESULTS:In all 10 animals,TG peritoneoscopy,followed by endoscopic biopsy for the liver,spleen,abdominal wall,and omentum,was performed successfully.APC helped control minor bleeding.Visualization of intra-abdominal solid organs with real-time EUS was accomplished with ease.Intraperitoneal EUS-FNA was successfully performed on the liver,spleen,and kidney.Similarly,a successful outcome was achieved with EUSRFA of the hepatic parenchyma.No adverse events were recorded during the study.CONCLUSION:Peritoneoscopic natural orifice transluminal endoscopic surgery(NOTES)interventions through FV-EUS were feasible in providing evaluation and performing endoscopic procedures.It promises potential as a platform for future EUS-based NOTES.

Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy

Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However,up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula,which remains a serious problem and usually requires prolonged hospitalization,or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage,which were endoscopically closed with fibrin glue injection via the necrotic cavity.

Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy

AIM:To evaluate the success rates,procedural time and adverse event rates of the modified methods in endoscopic ultrasonography-guided hepaticogastrostomy(EUS-HGS).METHODS:Twenty-eight patients in a prospective case series who underwent EUS-HGS(phaseⅠ).Fortysix patients in a matched case-control study(phaseⅡ).The simplified technique for fistula dilation was the primary use of a 4 mm balloon catheter with a stainless steel stylet.The stent deployment was modified by deploying the metal stent inside a bile duct(half of the stent)under EUS and fluoroscopic guidance and gently pulling the echoendoscope after full deployment of the stent inside the echoendoscope channel(remaining portion of the stent)under fluoroscopic guidance.This cohort was compared with a matched historical cohort.RESULTS:In phaseⅠ,the technical and clinical success with the modified method was 96%(27/28)and89%(24/27 as per-protocol analysis).The overall adverse event rate was 7%.In phaseⅡ,there was no difference in technical and clinical success,stent patency and overall adverse events in each group.However,the procedural time(15.3±5.2 min vs 22.3±6.0 min,P<0.001)and early adverse events(0%vs 26%,P=0.02)were statistically improved in case cohort compared with control cohort.CONCLUSION:Compared with the conventional EUSHGS technique,the procedural time was shorter and early adverse events were less frequent with our simplified and modified technique.

Metal stents placement for refractory pancreatic duct stricture in children

AIM To evaluate the use of fully covered self-expandable metal stents(FCSEMSs) for pancreatic duct strictures in children with chronic pancreatitis.METHODS Eight patients with refractory benign dominant stricture of the main pancreatic duct(MPD) were enrolled through chart reviews between December 2014 and June 2017 in a single center. Endoscopic retrograde cholangiopancreatography(ERCP) with placement of a 6-mm FCSEMS with dual flaps was performed. Endoscopic removal of FCSEMSs was performed with a snare or rat-tooth forceps. All procedures were performed by a pediatric gastroenterologist. For the assessment of outcomes, technical and clinical success, adverse events, and stent patency were evaluated retrospectively.RESULTS The placement and removal of the FCSEMSs were successful in all 8 patients. Five patients were boys and 3 were girls. The median age at initial FCSEMS placement was 12 years(range, 5-18 years). The diameters of all the inserted stents were 6 mm, and the lengths were 4-7 cm. The median indwelling time was 6 mo(range, 3-10 mo). No pancreatic sepsis, pancreatitis, cholestasis, or mortality occurred. There was no proximal and distal migration. All subjects showed a patent stent. On follow-up ERCP, the mean diameter of the stricture improved from 1.1 mm to 2.8 mm(P < 0.05), whereas that of upstream dilation improved from 8.4 mm to 6.3 mm(P < 0.05).CONCLUSION This initial experience showed that temporary FCSEMS placement is feasible and safe for the management of refractory benign MPD stricture in children.

Ampullary adenomyoma presenting as acute recurrent pancreatitis

Adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. Despite its benign nature,ampullary adenomyoma is usually presented as biliary obstruction. Most cases are misdiagnosed as carcinoma or adenoma by preoperative endoscopic or radiologic procedure. Therefore,it is frequently treated with extensive surgery. To our knowledge,this is the first reported case in English literature of adenomyoma located in the peripancreatic orifice resulting in intermittent pancreatic duct obstruction and recurrent pancreatitis diagnosed by the endoscopic piecemeal resection.

Aortoduodenal fistula and aortic aneurysm secondary to biliary stent-induced retroperitoneal perforation

Duodenal perforations caused by biliary prostheses are not uncommon, and they are potentially life threatening and require immediate treatment. We describe an unusual case of aortic aneurysm and rupture which occurred after retroperitoneal aortoduodenal fistula formation as a rare complication caused by biliary metallic stent-related duodenal perforation. To our knowledge, this is the first report describing a lethal complication of a bleeding, aortoduodenal fistula and caused by biliary metallic stent-induced perforation.