Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography(ERCP)is the preferred modality for drainage of the obstructed biliary tree.In patients with surgically altered anatomy,ERCP using standard techniques may not be feasible.Enteroscope assisted ERCP is usually employed with variable success rate.With advent of endoscopic ultrasound(EUS),biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective.In this narrative review,we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography(SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76(90%) procedures and clinical success rate of 30/34(88%) patients. Mild adverse event rate was 8/76(11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30(80%) procedures( P = 0.194 vs. biliary SBEERCP) and clinical success rate of 11/17(65%) patients( P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30(20%)( P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Volumetric comparative analysis of anatomy through far-lateral approach:surgical space and exposed tissues

Background:The three-dimensional(3D)visualization model has ability to quantify the surgical anatomy of farlateral approach.This study was designed to disclose the relationship between surgical space and exposed tissues in the far-lateral approach by the volumetric analysis of 3D model.Methods:The 3D skull base models were constructed using MRI and CT data of 15 patients(30 sides)with trigeminal neuralgia.Surgical corridors of the far-lateral approach were simulated by triangular pyramids to represent two surgical spaces exposing bony and neurovascular tissues.Volumetric comparison of surgical anatomy was performed using pair t test.Results:The morphometric results were almost the same in the two surgical spaces except the vagus nerve(CN X)exposed only in one corridor,whereas the volumetric comparison represented the statistical significant differences of surgical space and bony and neurovascular tissues involved in the two corridors(P<0.001).The differences of bony and neurovascular tissues failed to equal the difference of surgical space.Conclusions:For far-lateral approach,the increase of exposure for the bony and neurovascular tissues is not necessarily matched with the increase of surgical space.The volumetric comparative analysis is helpful to provide more detailed anatomical information in the surgical design.

Feasibility of orthotopic fetal liver transplantation:an experimental study

BACKGROUND:The use of livers from nonviable fetuses is particularly attractive for its potential to solve the current limitations of organ availability for the pediatric recipient.Therefore,it is essential to study the feasibility of orthotopic fetal liver transplantation.METHOD:We measured the hepatic and extra-hepatic anatomical structures of fetal and neonatal lambs and established an orthotopic liver transplantation model of the fetal lamb.RESULTS:Mean weight of the liver of fetal lambs at 142 to 145 days gestation was 34.75 g and the mean diameter of the portal vein was 3.03 mm,the supra-hepatic vena cava was 5.88 mm,and the infra-hepatic vena cava was 4.00 mm,which matched the corresponding sizes in neonatal lambs aged up to 2 weeks.Using standard surgical procedures we completed the vascular inosculation of fetal liver.However,all the newborn lamb recipients survived less than 24 hours.CONCLUSIONS:Orthotopic transplantation of the fetal liver is anatomically and technically feasible.However,perioperative issues need to be resolved prior to clinical application.

Anatomic relationship of extensor indicis propius and extensor digitorum communis: Implications for tendon transfer

BACKGROUND The extensor indicis proprius(EIP)tendon is a frequently used donor for a variety of tendon transfers,most commonly for reconstruction of the extensor pollicis longus(EPL).EIP is known to have frequent anatomic variants including split tendons and variations in tendon arrangement.AIM To characterize the anatomy of the EIP at the level of the extensor retinaculum,where tendon harvest is often performed,and share our preferred technique for EIP to EPL transfer.METHODS Twenty-nine fresh-frozen cadaveric forearms without history of forearm or hand injury or surgery were dissected.Tendon circumference and relationship of the EIP and extensor digitorum communis to the index(EDCI)at the metacarpophalangeal(MCP)joint and the distal extensor retinaculum were recorded.Distance from the distal extensor retinaculum to the EIP myotendinous junction was measured.RESULTS EIP was ulnar to the EDCI in 96.5%of specimens(28/29)at the distal edge of the extensor retinaculum.In the remaining specimen,EIP was volar to EDCI.Tendon circumference at the distal extensor retinaculum averaged(9.3 mm±1.7 mm)for EDCI and 11.1 mm(±2.7 mm)for EIP(P=0.0010).The tendon circumference at the index MCP joint averaged 11.0 mm(±1.7 mm)for EDCI and 10.6 mm(±2.1 mm)for EIP(P=0.33).EIP had a greater circumference in 76%(22/29)of specimens at the distal extensor retinaculum whereas EIP had a greater circumference in only 31%(9/29)of specimens at the MCP joint.CONCLUSION The EIP tendon is frequently ulnar to and greater in circumference than the EDCI at the distal extensor retinaculum,which can be taken into consideration for tendon transfers involving EIP.

Endoscopic retrograde cholangiopancretography in modified double tracks anastomosis with anastomotic stenosis

A 63-year-old man presented at our hospital with right upper abdomen pain and fever for 4 d.The patient's magnetic resonance cholangiopancreatography revealed dilated common bile duct and choledocholithiasis.In his past history,he received proximal gastrectomy and modified double tracks anastomosis.Endoscopic retrograde cholangiopancretography in modified double tracks anastomosis,especially accompanied with anastomotic stenosis,has been rarely reported.In the present case,the duodenoscope was successfully introduced over the guidewire and the stone taken out using a basket.The patient had good palliation of his symptoms after removal of the stone.