Relief of jaundice in malignant biliary obstruction:When should we consider endoscopic ultrasonography-guided hepaticogastrostomy as an option?

Background:Since it was first described in 2001,endoscopic ultrasonography-guided biliary drainage(EUS-BD)has emerged as an alternative procedure for achieving an endoscopic internal drainage in case of endoscopic retrograde cholangiopancreatography(ERCP)failure.Biliary drainage can be achieved by either a transduodenal extrahepatic approach through EUS-guided choledochoduodenostomy(EUS-CDS),or a transgastric intrahepatic approach,namely EUS-guided hepaticogastrostomy(EUS-HGS)which already holds a remarkable place in the treatment of patients with malignant biliary obstruction.Data sources:For this review we did a comprehensive search of PubMed/MEDLINE from inception to May 31,2021 for papers with a significant sample size(at least 20 patients enrolled)dealing with EUS-HGS.Data on technical success,clinical success and rate of adverse events were collected.Results:A total of 22 studies with different design,com prising 874 patients,were included.Technical success was achieved in about 96% of cases(ranging from 65% to 100%).Clinical success was obtained in almost 91% of cases(ranging from 76% to 100%).Overall rate of adverse events was 19%(ranging from 0% to 35%).Abdominal pain,self-limiting pneumoperitoneum,bile leak,cholangitis,bleeding,perforation and intraperitoneal migration of the stent were the most common.Conclusions:Despite both safety and efficacy profile,at the moment HGS still remains a challenging procedure at every single step and must therefore be conducted by a very experienced endoscopist in interventional EUS and ERCP procedures,who is able to deal with the possible severe adverse events of this procedure.A rapid introduction in clinical practice of dedicated devices is desiderable.

Endoscopic ultrasonography for gastric submucosal lesions

Gastric submucosal tumors(SMTs) are a rather frequent finding,occurring in about 0.36%of routine upper GIendoscopies.Endoscopic ultrasonography(EUS) has emerged as a reliable investigative procedure for evaluation of these lesions.Diagnostic EUS has the ability to differentiate intramural tumors from extraluminal compressions and can also show the layer of origin of gastric SMTs.Tumors can be further characterized by their layer of origin,echo pattern and margin.EUS-risk criteria of their malignant potential are presented,although the emergence of EUS-FNA has opened new indications for transmural tissue diagnosis and expanded the possibilities of EUS in SMTs of the stomach.Tissue diagnosis should address whether the SMT is a Gastrointestinal stromal tumour(GIST) or another tumor type and evaluate the malignant potential of a given GIST.However,there seems to be a lack of data on the optimal strategy in SMTs suspected to be GISTs with a negative EUS-FNA tissue diagnosis.The current management strategies,as well as open questions regarding their treatment are also presented.

Diagnosis of pancreatic tumors by endoscopic ultrasonography

Pancreatic tumors are highly diverse, as they can be solid or cystic, and benign or malignant. Since their imaging features overlap considerably, it is often difficult to characterize these tumors. In addition, small pancreatic tumors, especially those less than 2 cm in diameter, are difficult to detect and diagnose. For characterizing pancreatic tumors and detecting small pancreatic tumors, endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available. This technique also provides good results in terms of the preoperative staging of pancreatic tumors. EUS-guided fine needle aspiration (EUS-FNA) has also proved to be a safe and useful method for tissue sampling of pancreatic tumors. Despite these advantages, however, it is still difficult to differentiate between be-nign and malignant, solid or cystic pancreatic tumors, malignant neoplasms, and chronic pancreatitis using EUS, even when EUS-FNA is performed. Recently, contrast-enhanced EUS with Doppler mode (CE-EUS) employing ultrasound contrast agents, which indicate vascularization in pancreatic lesions, has been found to be useful in the differential diagnosis of pancreatic tumors, especially small pancreatic tumors. However, Doppler ultrasonography with contrast-enhancement has several limitations, including blooming artifacts, poor spatial resolution, and low sensitivity to slow flow. Consequently, an echoendoscope was developed recently that has a broad-band transducer and an imaging mode that was designed specifically for contrastenhanced harmonic EUS (CEH-EUS) with a secondgeneration ultrasound contrast agent. The CEH-EUS technique is expected to improve the differential diagnosis of pancreatic disease in the future. This review describes the EUS appearances of common solid and cystic pancreatic masses, the diagnostic accuracy of EUS-FNA, and the relative efficacies and advantages of CE-EUS and CEH-EUS along with their relative advantages and their complementary roles in clinical practice.

Safety of endoscopic ultrasound-guided ethanol ablation for pancreatic cystic lesions: A single-center experience of 214 patients

Background:Endoscopic ultrasound-guided ethanol ablation(EUS-EA)for pancreatic cystic lesions(PCLs)has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients considered high-risk for surgery.The present study aimed to confirm the safety of EUS-EA and to find predictive factors for adverse event(AE).Methods:A retrospective review was performed from the prospectively maintained database of patients who underwent EUS-EA for PCLs from June 2006 to April 2018 at Seoul National University Hospital.The primary outcomes of the study were the rates of AEs and severe AEs by EUS-EA.The secondary outcome was the predictive factors of AEs including acute pancreatitis and abdominal pain.Results:A total of 214 patients were evaluated and the diagnoses of PCLs according to cystic fluid analysis and clinical features were as follows:serous cystic neoplasm(32.2%),mucinous cystic neoplasm(26.6%),branch duct type intraductal papillary mucinous neoplasm(BD-IPMN)(29.4%),and pseudocyst(11.7%).Three patients(1.4%)experienced severe AEs.Overall,AEs occurred in 71(33.2%)patients.BD-IPMN(OR:2.87;95%CI:1.05–7.84;P=0.040),multilocular cysts(OR:3.59;95%CI:1.09–11.85;P=0.036),suspected ethanol leakage during procedure(OR:10.68;95%CI:1.98–57.53;P=0.006),and sticky cystic fluid(OR:3.83;95%CI:1.20–12.24;P=0.024)were predictive factors for post-procedural acute pancreatitis.PCLs of uncinate process(OR:2.99;95%CI:1.22–7.35;P=0.017)and PCLs with exophytic portion(OR:3.70;95%CI:1.96–7.01;P<0.001)were predictive factors for post-procedural abdominal pain.Conclusions:EUS-EA is a safe procedure with a very low rate of severe AEs.It seems possible to predict the AEs according to the features of the procedure and PCLs.

Endoscopic Ultrasound-Guided Biliary Drainage with a Fully Covered Self-Expandable Metal Stent for Malignant Obstructive Jaundice

Objective: To study the therapeutic effect of Endoscopic ultrasound-guided biliary drainage (EUS-BD) with a nitinol fully covered self-expandable metal stent in patients with malignant obstructive jaundice when endoscopic retrograde cholangiopancreatography (ERCP) fails. Methods: From January 2016 January 2018, all patients with malignant obstructive jaundice during hospitalization underwent EUS-guided biliary drainage with a nitinol fully covered self-expandable metal stent, and the operation success rate, the clinical success rate, complications, length of hospital stay and survival time were observed. Results: Of 36 patients, 34 cases had successful operation;the operation success rate was 94.44% (34/36). The clinical success rate was 88.89% (32/36). Hemobilia occurred in 1, acute cholangitis in 1, and bile peritonitis in 1;improved after conservative treatment, the complication rate is 8.33% (3/36). Hospital stay and survival time was 21.54 ± 4.73 days and 220.54 ± 54.76 days, respectively. Conclusion: EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.