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.

Propensity score matching analysis for clinical impact of braided-type versus laser-cut-type covered self-expandable metal stents for endoscopic ultrasound-guided hepaticogastrostomy

Background:To prevent stent migration during endoscopic ultrasound-guided hepaticogastrostomy(EUS-HGS),intra-scope channel release technique is important,but is unfamiliar to non-expert hands.The self-expandable metal stent(SEMS)is an additional factor to prevent stent migration.However,no compara-tive studies of laser-cut-type and braided-type during EUS-HGS have been reported.The aim of this study was to compare the distance between the intrahepatic bile duct and stomach wall after EUS-HGS among laser-cut-type and braided-type SEMS.Methods:To evaluate stent anchoring function,we measured the distance between the hepatic parenchyma and stomach wall before EUS-HGS,one day after EUS-HGS,and 7 days after EUS-HGS.Also,propensity score matching was performed to create a propensity score for using laser-cut-type group and braided-type group.Results:A total of 142 patients were enrolled in this study.Among them,24 patients underwent EUS-HGS using a laser-cut-type SEMS,and 118 patients underwent EUS-HGS using a braided-type SEMS.EUS-HGS using the laser-cut-type SEMS was mainly performed by non-expert endoscopists(n=21);EUS-HGS using braided-type SEMS was mainly performed by expert endoscopists(n=98).The distance after 1 day was significantly shorter in the laser-cut-type group than that in the braided-type group[2.00(1.70-3.75)vs.6.90(3.72-11.70)mm,P<0.001].In addition,this distance remained significantly shorter in the laser-cut-type group after 7 days.Although these results were similar after propensity score matching analysis,the distance between hepatic parenchyma and stomach after 7 days was increased by 4 mm compared with the distance after 1 day in the braided-type group.On the other hand,in the laser-cut-type group,the distance after 1 day and 7 days was almost the same.Conclusions:EUS-HGS using a laser-cut-type SEMS may be safe to prevent stent migration,even in non-expert hands.

Endoscopic ultrasound-guided tissue sampling induced pancreatic duct leak resolved by the placement of a pancreatic stent:A case report

BACKGROUND Pancreatic ductal leaks complicated by endoscopic ultrasonography-guided tissue sampling(EUS-TS)can manifest as acute pancreatitis.CASE SUMMARY A 63-year-old man presented with persistent abdominal pain and weight loss.Diagnosis:Laboratory findings revealed elevated carbohydrate antigen 19-9(5920 U/mL)and carcinoembryonic antigen(23.7 ng/mL)levels.Magnetic resonance imaging of the pancreas revealed an approximately 3 cm ill-defined space-occupying lesion in the inferior aspect of the head,with severe encasement of the superior mesenteric artery.Pancreatic ductal adenocarcinoma was confirmed after pathological examination of specimens obtained by EUS-TS using the fanning method.Interventions and outcomes:The following day,the patient experienced severe abdominal pain with high amylase(265 U/L)and lipase(1173 U/L)levels.Computed tomography of the abdomen revealed edematous wall thickening of the second portion of the duodenum with adjacent fluid collections and a suspicious leak from either the distal common bile duct or the main pancreatic duct in the head.Endoscopic retrograde cholangiopancreatography revealed dye leakage in the head of the main pancreatic duct.Therefore,a 5F 7 cm linear plastic stent was deployed into the pancreatic duct to divert the pancreatic juice.The patient’s abdominal pain improved immediately after pancreatic stent insertion,and amylase and lipase levels normalized within a week.Neoadjuvant chemotherapy was then initiated.CONCLUSION Using the fanning method in EUS-TS can inadvertently cause damage to the pancreatic duct and may lead to clinically significant pancreatitis.Placing a pancreatic stent may immediately resolve acute pancreatitis and shorten the waiting time for curative therapy.When using the fanning method during EUSTS,ductal structures should be excluded to prevent pancreatic ductal leakage.

Percutaneous ultrasound-guided coaxial core needle biopsy for the diagnosis of multiple splenic lesions: A case report

BACKGROUND The overlap of imaging manifestations among distinct splenic lesions gives rise to a diagnostic dilemma.Consequently,a definitive diagnosis primarily relies on his-tological results.The ultrasound(US)-guided coaxial core needle biopsy(CNB)not only procures sufficient tissue to help clarify the diagnosis,but reduces the incidence of puncture-related complications.CASE SUMMARY A 41-year-old female,with a history of pulmonary tuberculosis,was admitted to our hospital with multiple indeterminate splenic lesions.Gray-scale ultrasono-graphy demonstrated splenomegaly with numerous well-defined hypoechoic ma-sses.Abdominal contrast-enhanced computed tomography(CT)showed an en-larged spleen with multiple irregular-shaped,peripherally enhancing,hypodense lesions.Positron emission CT revealed numerous abnormal hyperglycemia foci.These imaging findings strongly indicated the possibility of infectious disease as the primary concern,with neoplastic lesions requiring exclusion.To obtain the precise pathological diagnosis,the US-guided coaxial CNB of the spleen was ca-rried out.The patient did not express any discomfort during the procedure.CONCLUSION Percutaneous US-guided coaxial CNB is an excellent and safe option for obtaining precise splenic tissue samples,as it significantly enhances sample yield for exact pathological analysis with minimum trauma to the spleen parenchyma and sur-rounding tissue.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic bile duct drainage in the management of malignant obstructive jaundice

BACKGROUND Malignant obstructive jaundice(MOJ)is a condition characterized by varying degrees of bile duct stenosis and obstruction,accompanied by the progressive development of malignant tumors,leading to high morbidity and mortality rates.Currently,the two most commonly employed methods for its management are percutaneous transhepatic bile duct drainage(PTBD)and endoscopic ultrasound-guided biliary drainage(EUS-BD).While both methods have demonstrated favorable outcomes,additional research needs to be performed to determine their relative efficacy.To compare the therapeutic effectiveness of EUS-BD and PTBD in treating MOJ.METHODS This retrospective analysis,conducted between September 2015 and April 2023 at The Third Affiliated Hospital of Soochow University(The First People’s Hospital of Changzhou),involved 68 patients with MOJ.The patients were divided into two groups on the basis of surgical procedure received:EUS-BD subgroup(n=33)and PTBD subgroup(n=35).Variables such as general data,preoperative and postoperative indices,blood routine,liver function indices,myocardial function indices,operative success rate,clinical effectiveness,and complication rate were analyzed and compared between the subgroups.RESULTS In the EUS-BD subgroup,hospital stay duration,bile drainage volume,effective catheter time,and clinical effect-iveness rate were superior to those in the PTBD subgroup,although the differences were not statistically significant(P>0.05).The puncture time for the EUS-BD subgroup was shorter than that for the PTBD subgroup(P<0.05).Postoperative blood routine,liver function index,and myocardial function index in the EUS-BD subgroup were significantly lower than those in the PTBD subgroup(P<0.05).Additionally,the complication rate in the EUS-BD subgroup was lower than in the PTBD subgroup(P<0.05).CONCLUSION EUS-BD may reduce the number of punctures,improve liver and myocardial functions,alleviate traumatic stress,and decrease complication rates in MOJ treatment.

Endoscopic ultrasound-guided pancreatic fluid collection drainage: Where are we?

Pancreatic fluid collections(PFCs)result from injury to the pancreas from acute or chronic pancreatitis,surgery,or trauma.Management of these collections has evolved over the last 2 decades.The choice of interventions includes percu-taneous,endoscopic,minimally invasive surgery,or a combined approach.Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract.In this editorial,we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.

Endoscopic ultrasound-guided tissue acquisition for the diagnosis of focal liver lesion

In patients with liver tumors,the histopathology examination can assist in diagnosis,staging,prognosis,and therapeutic management strategy.Endoscopic ultrasound(EUS)-guided tissue acquisition using fine needle aspiration(FNA)or more newly fine needle biopsy(FNB)is a well-developed technique in order to evaluate and differentiate the liver masses.The goal of the EUS-FNA or EUS-FNB is to provide an accurate sample for a histopathology examination.Therefore,malignant tumors such as hepatocarcinoma,cholangiocarcinoma and liver metastasis or benign tumors such as liver adenoma,focal hyperplastic nodular tumors and cystic lesions can be accurately diagnosed using EUS-guided tissue acquisition.EUS-FNB using 19 or 22 Ga needle provide longer samples and a higher diagnostic accuracy in patients with liver masses when compared with EUS-FNA.Few data are available on the diagnostic accuracy of EUS-FNB when compared with percutaneously,ultrasound,computer tomography or transjugulary-guided liver biopsies.This review will discuss the EUS-guided tissue acquisition options in patients with liver tumors and its efficacy and safety in providing accurate samples.The results of the last studies comparing EUS-guided liver biopsy with other conventional techniques are presented.The EUS-guided tissue acquisition using FNB can be a suitable technique in suspected liver lesions in order to provide an accurate histopathology diagnosis,especially for those who require endoscopy.

Comparison of Cognitive Registration Transrectal Ultrasound-Guided Targeted Biopsy of Prostate to Systematic 12-Core Biopsy: A Retrospective, Multicentre Study

Introduction: Prostate cancer (PCa) is the third most prevalent cancer among Malaysian males, often diagnosed at advanced stages, leading to suboptimal outcomes. While transrectal ultrasound-guided systematic biopsy (TRUS-SB) is the primary diagnostic method, prebiopsy multiparametric magnetic resonance imaging (mpMRI) is gaining popularity in identifying suspicious lesions. This study addresses the lack of comprehensive investigations into the efficacy of cognitive registration TRUS targeted biopsy (COG-TB) compared to conventional TRUS-SB, considering the resource limitations of the Malaysian healthcare system. Materials and Methods: A retrospective cohort study was conducted in two Malaysian healthcare facilities. 116 adult patients with a prostate-specific antigen (PSA) level of more than 4 ng/mL who underwent both COG-TB and TRUS-SB between October 2020 and March 2022 were included. Primary outcomes were cancer detection rate and histopathological outcomes, including Gleason score. Results: COG-TB showed a higher overall cancer detection rate (50%) compared to TRUS-SB (44%). Clinically significant cancer detection rates were similar between COG-TB and TRUS-SB (37.1%). Further analysis revealed that both COG-TB and TRUS-SB detected clinically significant cancer in 30.2% of patients, did not detect it in 56.0%, and had conflicting findings in 16 patients (p Conclusion: COG-TB and TRUS-SB have comparable detection rates for clinically significant prostate cancer, with COG-TB showing a higher tendency to detect insignificant prostate cancer. Further studies comparing these methods are warranted.

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.

Stage IV malignant transformation of mature cystic teratoma palliatively treated with concurrent chemoradiotherapy:A case report

BACKGROUND Malignant transformation(MT)of mature cystic teratoma(MCT)has a poor prognosis,especially in advanced cases.Concurrent chemoradiotherapy(CCRT)has an inhibitory effect on MT.CASE SUMMARY Herein,we present a case in which CCRT had a reduction effect preoperatively.A 73-year-old woman with pyelonephritis was referred to our hospital.Computed tomography revealed right hydronephrosis and a 6-cm pelvic mass.Endoscopic ultrasound-guided fine-needle biopsy(EUS-FNB)revealed squamous cell carci-noma.The patient was diagnosed with MT of MCT.Due to her poor general con-dition and renal malfunction,we selected CCRT,expecting fewer adverse effects.After CCRT,her performance status improved,and the tumor size was reduced;surgery was performed.Five months postoperatively,the patient developed dis-semination and lymph node metastases.Palliative chemotherapy was ineffective.She died 18 months after treatment initiation.CONCLUSION EUS-FNB was useful in the diagnosis of MT of MCT;CCRT suppressed the disea-se and improved quality of life.

Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration

AIM： to evaluate the role of endoscopic ultrasonographyguided fine needle aspiration （EUS-FNA） in the preoperative diagnosis of gastrointestinal stromal tumor （GIST）.METHODS： From September 2002 to June 2006, Fiftythree consecutive EUS-FNAs of GI tract subepithelial hypoechoic tumors with continuity to proper muscle layer suspected as GIST by standard EUS were evaluated prospectively. The reference standards for the final diagnosis were surgery （n = 31）, or clinical follow-up （n = 22）. Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens were compared.RESULTS： In 2 cases puncture was not performed because of anatomical problems. The collection rate of adequate specimens from the GI tract subepithelial hypoechoic tumor with continuity to proper muscle layer was 82% （42/51）. The diagnostic rate for the tumor less than 2 cm, 2 to 4 cm, and 4 cm or more were 71% （15/21）, 86% （18/21）, and 100% （9/9）,respectively. In 29 surgically resected cases, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EUS-FNA using immunohistochemical analysis of GIST were 100%（24/24）, 80% （4/5）, 96% （24/25）, 100% （4/4）, and 97% （28/29）, respectively. No major complications were encountered.CONCLUSION： EUS-FNA with immunohistochemical analysis is a safe and accurate method in the pretherapeutic diagnosis of GIST. It should be taken into consideration in decision making, especially in early diagnosis following minimal invasive surgery for GIST.

Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis

Acute obstructive suppurative cholangitis(AOSC) due to biliary lithiasis is a life-threatening condition that requires urgent biliary decompression. Although endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the current gold standard for biliary decompression, it can sometimes be difficult because of failed biliary cannulation. In this retrospective case series, we describe three cases of successful biliary drainage with recovery from septic shock after urgent endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) was performed for AOSC due to biliary lithiasis. In all three cases, technical success in inserting the stents was achieved and the patients completely recovered from AOSC with sepsis in a few days after EUS-CDS. There were no procedure-related complications. When initial ERCP fails, EUS-CDS can be an effective life-saving endoscopic biliary decompression procedure that shortens the procedure time and prevents post-ERCP pancreatitis, particularly in patients with AOSC-induced sepsis.

Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction

AIM:To determine the utility of endoscopic ultrasoundguided biliary drainage(EUS-BD)with a fully covered self-expandable metal stent for managing malignant biliary stricture. METHODS:We collected data from 13 patients who presented with malignant biliary obstruction and underwent EUS-BD with a nitinol fully covered selfexpandable metal stent when endoscopic retrograde cholangiopancreatography(ERCP)fails.EUS-guided choledochoduodenostomy(EUS-CD)and EUS-guided hepaticogastrostomy(EUS-HG)was performed in 9 patients and 4 patients,respectively. RESULTS:The technical and functional success rate was 92.3%(12/13)and 91.7%(11/12),respectively. Using an intrahepatic approach(EUS-HG,n=4),there was mild peritonitis(n=1)and migration of the metal stent to the stomach(n=1).With an extrahepatic approach(EUS-CD,n=10),there was pneumoperitoneum(n=2),migration(n=2),and mild peritonitis (n=1).All patients were managed conservatively with antibiotics.During follow-up(range,1-12 mo),there was re-intervention(4/13 cases,30.7%)necessitated by stent migration(n=2)and stent occlusion(n=2). 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.

Percutaneous Removal of Benign Breast Lesions with an Ultrasound-guided Vacuum-assisted System:Influence Factors in the Hematoma Formation

Objective To explore the influence factors in hematoma formation after removing benign breast lesions with an ultrasound-guided vacuum-assisted system.Methods A total of 232 females with 312 benign breast masses received excisional biopsy with ultrasoundguided vacuum-assisted system.The pathology of patients,results of hematoma development and outcome,influence factors for hematoma occurrence(nodule size,nodule location,number of nodule,breast shape,menstrual period,efficacy time of bandage,and application of hemostatic agents during the procedure) were recorded.Results Pathologic examination revealed fibroadenomas in 138 lesions,fibroadenosis in 127 lesions,intraductal papillomas in 39 lesions,inflammatory change in 4 lesions,retention cyst of the breast in 3 lesions,and benign phyllodes tumor in 1 lesion.Thirty hematomas were observed in patients(9.6%).Finally,97.0%hematomas were absorbed completely within 6 months follow-up.The incidence rates of hematoma were increased by 24.7%,10.0%,63.2%,13.9%in the nodule diameter larger or equal to 25 mm group,removal of larger or equal to two nodules once time from one patient group,menstrual period group,and larger and loose breast group,respectively(all P<0.05).However,the incidences were decreased by 60.6%in the bandage performed for 12-24 hours or beyond 24 hours group(P<0.05).The multiple logistic regression models revealed that nodule size(x^2=15.227,P<0.001),number of nodule(x^2=7.767,P=0.005),menstrual period(x^2=24.530,P<0.001),and breast shape(x^2=9.559,P=0.002) were independent risk factors associated with hematoma occurrence,but efficacy time of bandage was a protective factor associated with hematoma occurrence.Conclusion The occurrence of hematoma after the minimally invasive operation was associated with nodule size,number of nodule,menstrual period,breast shape,and efficacy time of bandage.

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy

AIM: To evaluate the efficacy of endoscopic ultrasound guided biliary drainage(EUS-BD) in patients with surgically altered anatomies.METHODS: We performed a search of the MEDLINE database for studies published between 2001 to July2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only fulltext English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth Ⅰ; group 2, Billroth Ⅱ; group 4, Rouxen-Y with gastric bypass; and group 3, all other types. RESULTS: Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion. CONCLUSION: EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrogradecholangiography in centers with expertise in EUS-BD procedures in a research setting.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis: Long-term outcomes after removal of a self-expandable metal stent

AIM To assess the long-term outcomes of this procedure after removal of self-expandable metal stent(SEMS). The efficacy and safety of endoscopic ultrasoundguided gallbladder drainage(EUS-GBD) with SEMS were also assessed.METHODS Between January 2010 and April 2015, 12 patients with acute calculous cholecystitis, who were deemed unsuitable for cholecystectomy, underwent EUSGBD with a SEMS. EUS-GBD was performed under the guidance of EUS and fluoroscopy, by puncturing the gallbladder with a needle, inserting a guidewire, dilating the puncture hole, and placing a SEMS. TheSEMS was removed and/or replaced with a 7-Fr plastic pigtail stent after cholecystitis improved. The technical and clinical success rates, adverse event rate, and recurrence rate were all measured.RESULTS The rates of technical success, clinical success, and adverse events were 100%, 100%, and 0%, respectively. After cholecystitis improved, the SEMS was removed without replacement in eight patients, whereas it was replaced with a 7-Fr pigtail stent in four patients. Recurrence was seen in one patient(8.3%) who did not receive a replacement pigtail stent. The median follow-up period after EUS-GBD was 304 d(78-1492).CONCLUSION EUS-GBD with a SEMS is a possible alternative treatment for acute cholecystitis. Long-term outcomes after removal of the SEMS were excellent. Removal of the SEMS at 4-wk after SEMS placement and improvement of symptoms might avoid migration of the stent and recurrence of cholecystitis due to food impaction.

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 drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recog-nized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, per-cutaneous and non-EUS-guided endoscopic drainage.EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to per-cutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct ac-cess to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the sub-sequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in 'one step', EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.

Hemobilia and other complications caused by percutaneous ultrasound-guided liver biopsy

Hemobilia accounts for approximately 3%of all major percutaneous liver biopsy complications,and rarely results from arterioportal fistula.We report a patient who suffered from four complications over 11 d after ultrasound-guided percutaneous liver biopsy:hemobilia,acute pancreatitis,acute cholecystitis,and multiple stomach ulcers.Digital subtraction angiography was done after consultation with doctors,and showed obvious arteriovenous fistula of the right liver.The hepatic artery was selected and embolized by spring orbs.The active bleeding was stopped after embolization of the hepatic artery.The patient was discharged home on day 12 after embolization and remained well.

Comparative clinical study of ultrasound-guided A1 pulley release vs open surgical intervention in the treatment of trigger finger

AIM To investigate the effectiveness of ultrasound-guided release of the first annular pulley and compare results with the conventional open operative technique.METHODS In this prospective randomized, single-center, clinical study, 32 patients with trigger finger or trigger thumb, grade Ⅱ-Ⅳ according to Green classification system, were recruited. Two groups were formed; Group A(16 patients) was treated with an ultrasound-guided percutaneous release of the affected A1 pulley under local anesthesia. Group B(16 patients) underwent an open surgical release of the A1 pul ey, through a 10-15 mm incision. Patients were assessed pre- and postoperatively(follow-up:2,4 and 12 wk) by physicians blinded to the procedures. Treatment of triggering(primary variable of interest) was expressed as the "success rate" per digit. The time for taking postoperative pain killers, range of motion recovery, QuickD ASH test scores(Greek version), return to normal activities(including work), complications and cosmetic results were assessed.RESULTS The success rate in group A was 93.75%(15/16) and in group B 100%(16/16). Mean times in group A patients were 3.5 d for taking pain killers, 4.1 d for returning to normal activities, and 7.2 and 3.9 d for complete extension and flexion recovery, respectively. Mean Quick DASH scores in group A were 45.5 preoperatively and, 7.5, 0.5 and 0 after 2, 4, and 12 wk postoperatively. Mean times in group B patients were 2.9 d for taking pain killers, 17.8 d for returning to normal activities, and 5.6 and 3 d for complete extension and flexion recovery. Mean QuickD ASH scores in group B were 43.2 preoperatively and, 8.2, 1.3 and 0 after 2, 4, and 12 wk postoperatively. The cosmetic results found excellent or good in 87.5%(14/16) of group A patients, while in 56.25%(9/16) of group B patients were evaluated as fair or poor.CONCLUSION Treatment of the trigger finger using ultrasonography resulted in fewer absence of work days, and better cosmetic results, in comparison with the open surgery technique. It is a promising method that represents excellent results without major complications, so that it could be possibly be established as a first-line treatment in the trigger finger's disease.