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.

Pancreatico-biliary endoscopic ultrasound:A systematic review of the levels of evidence,performance and outcomes

Our aim was to record pancreaticobiliary endoscopic ultrasound(EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence(LE).Original research articles(randomized controlled trials,prospective and retrospective studies),meta-analyses,reviews and surveys pertinent to gastrointestinal EUS were included.All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities,anatomical subdivisions and therapeutic applications of EUS.The North of England evidencebased guidelines were used to determine LE.A total of 1089 pertinent articles were reviewed.Published research focused primarily on solid pancreatic neoplasms,followed by disorders of the extrahepatic biliary tree,pancreatic cystic lesions,therapeutic-interventional EUS,chronic and acute pancreatitis.A uniform observation in all six categories of articles was the predominance of LE Ⅲ studies followed by LE Ⅳ,Ⅱb,Ⅱa,Ⅰb and Ⅰ a,in descending order.EUS remains the most accurate method for detecting small(< 3 cm) pancreatic tumors,ampullary neoplasms and small(< 4 mm) bile duct stones,and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms.Detailed EUS imaging,along with biochemical and molecular cyst fluid analysis,improve the differentiation of pancreatic cysts and help predict their malignant potential.Early diagnosis of chronic pancreatitis appears feasible and reliable.Novel imaging techniques(contrast-enhanced EUS,elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis.Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy.Despite the ongoing development of extra-corporeal imaging modalities,such as computed tomography,magnetic resonance imaging,and positron emission tomography,EUS still holds a leading role in the investigation of the pancreaticobiliary area.The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.