Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage

This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.

Evolution of interventional endoscopic ultrasound

Endoscopic ultrasound(EUS)has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s.Following the development of the linear echoendoscope,EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention,with numerous luminal,pancreaticobiliary,and hepatic applications.Broadly,these applications may be subdivided into three categories:transluminal drainage or access procedures,injection therapy,and EUS-guided liver interventions.Transluminal drainage or access procedures include management of pancreatic fluid collection,EUS-guided biliary drainage,EUS-guided bile duct drainage,EUS-guided pancreatic duct drainage,and enteral anastomosis formation.Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS.EUS-guided liver applications include EUS-guided liver biopsy,EUS-guided portal pressure gradient measurement,and EUS-guided vascular therapies.In this review,we discuss the origins of each of these EUS applications,evolution of techniques leading to the current status,and future directions of EUS-guided interventional therapy.

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.

Endoscopic ultrasound-guided fiducial marker placement for neoadjuvant chemoradiation therapy for resectable pancreatic cancer

BACKGROUND Preoperative neoadjuvant chemoradiation therapy(NACRT)is applied for resectable pancreatic cancer(RPC).To maximize the efficacy of NACRT,it is essential to ensure the accurate placement of fiducial markers for image-guided radiation.However,no standard method for delivering fiducial markers has been established to date,and the nature of RPC during NACRT remains unclear.AIM To determine the feasibility,safety and benefits of endoscopic ultrasound-guided(EUS)fiducial marker placement in patients with RPC.METHODS This was a prospective case series of 29 patients(mean age,67.5 years;62.1%male)with RPC referred to our facility for NACRT.Under EUS guidance,a single gold marker was placed into the tumor using either a 19-or 22-gauge fine-needle aspiration needle.The differences in daily marker positioning were measured by comparing simulation computed tomography and treatment computed tomography.RESULTS In all 29 patients(100%)who underwent EUS fiducial marker placement,fiducials were placed successfully with only minor,self-limiting bleeding during puncture observed in 2 patients(6.9%).NACRT was subsequently administered to all patients and completed in 28/29(96.6%)cases,with one patient experiencing repeat cholangitis.Spontaneous migration of gold markers was observed in 1 patient.Twenty-four patients(82.8%)had surgery with 91.7%(22/24)R0 resection,and two patients experienced complete remission.No inflammatory changes around the marker were observed in the surgical specimen.The daily position of gold markers showed large positional changes,particularly in the superior-inferior direction.Moreover,tumor location was affected by food and fluid intake as well as bowel gas,which changes daily.CONCLUSION EUS fiducial marker placement following NACRT for RPC is feasible and safe.The RPC is mobile and is affected by not only aspiration,but also food and fluid intake and bowel condition.

Clinical utility of treatment method conversion during single-session endoscopic ultrasound-guided biliary drainage

BACKGROUND Although several techniques for endoscopic ultrasound-guided biliary drainage(EUS-BD)are available at present,an optimal treatment algorithm of EUS-BD has not yet been established.AIM To evaluate the clinical utility of treatment method conversion during single endoscopic sessions for difficult cases in initially planned EUS-BD.METHODS This was a single-center retrospective analysis using a prospectively accumulated database.Patients with biliary obstruction undergoing EUS-BD between May 2008 and April 2016 were included.The primary outcome was to evaluate the improvement in EUS-BD success rates by converting the treatment methods during a single endoscopic session.Secondary outcomes were clarification of the factors leading to the conversion from the initial EUS-BD and the assessment of efficacy and safety of the conversion as judged by technical success,clinical success,and adverse events(AEs).RESULTS A total of 208 patients underwent EUS-BD during the study period.For 18.8%(39/208)of the patients,the treatment methods were converted to another EUSBD technique from the initial plan.Biliary obstruction was caused by pancreatobiliary malignancies,other malignant lesions,biliary stones,and other benign lesions in 22,11,4,and 2 patients,respectively.The reasons for the difficulty with the initial EUS-BD were classified into the following 3 procedures:Target puncture(n=13),guidewire manipulation(n=18),and puncture tract dilation(n=8).Technical success was achieved in 97.4%(38/39)of the cases and clinical success was achieved in 89.5%of patients(34/38).AEs occurred in 10.3%of patients,including bile leakage(n=2),bleeding(n=1),and cholecystitis(n=1).The puncture target and drainage technique were altered in subsequent EUSBD procedures in 25 and 14 patients,respectively.The final technical success rate with 95%CI for all 208 cases was 97.1%(95%CI:93.8%-98.9%),while that of the initially planned EUS-BD was 78.8%(95%CI:72.6%-84.2%).CONCLUSION Among multi-step procedures in EUS-BD,guidewire manipulation appeared to be the most technically challenging.When initially planned EUS-BD is technically difficult,treatment method conversion in a single endoscopic session may result in successful EUS-BD without leading to severe AEs.

Endoscopic approach to gastric remnant outlet obstruction after gastric bypass:A case report

BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery.Furthermore,acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously.Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach.Traditionally,this necessitates surgical intervention.Recently,however,the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.CASE SUMMARY A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension,nausea,and melena of two days duration.His imaging illustrated a massively distended stomach.A nasogastric tube did not result in drainage of fluid or decompression of his abdomen.His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended"fluid"-filled gastric remnant.An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant.Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum.The patient underwent emergent angiography with embolization of the gastroduodenal artery.He was discharged with a stable hemoglobin level and resolution of symptoms.Healing superficial gastric ulcers were visualized on a follow-up endoscopy.Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated,and successful eradication was achieved.CONCLUSION This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound directed transgastric intervention.