Endoscopic ultrasound guided interventional procedures

Training and quality indicators in interventional endoscopic ultrasound

Endoscopic ultrasound (EUS) has transformed the landscape of minimally invasive gastrointestinal procedures, necessitating specialized training for proficiency in interventional EUS (iEUS). This study evaluates the effectiveness of iEUS training, focusing on learning curves, success rates, and the associated risks in various procedures, aiming to recommend practices for standardizing training and ensuring competency. Key metrics such as procedure type, learning curve for proficiency, success rates, and risk of adverse events were analyzed to establish benchmarks for training programs. Proficiency in pancreatic fluid collection drainage was achieved after 20-30 procedures, with a 100% success rate and a complication rate ranging from 1.5 to 80%. Gallbladder drainage required 19 cases to reach an 86% success rate, with adverse events reported in 19% of cases. Choledocoduodenostomy mastery was observed after approximately 100 cases, with postintervention pancreatitis affecting 5.3-6.6% of all cases. Hepaticogastrostomy showed a 93% success rate after 33 cases, with a 24.8% adverse event rate. Hepaticoenterostomy reached 100% success beyond the 40th patient, with a 20% rate of postsurgical strictures. Pancreatic duct drainage achieved 89% technical and 87% clinical success after 27 cases, with 12-15% adverse events. Gastro-enteric anastomosis required 25 cases for proficiency and approximately 40 cases for mastery, with 5.5% immediate and 1% late adverse events. iEUS training outcomes vary significantly across different procedures, highlighting the importance of structured, procedure-specific training programs to achieve proficiency. These findings provide a foundation for developing universal competency benchmarks in iEUS, facilitating consistent and effective training worldwide.

A New Step-Up Dual Endoscopic Approach for Large-Size Infected Pancreatic Necrosis: Percutaneous Endoscopic Necrosectomy Followed by Transluminal Endoscopic Drainage/Necrosectomy

BACKGROUND

Acute pancreatitis in 10% to 20% of cases can be associated with necrosis of the pancreatic gland, peripancreatic tissue, or both. We report a case series of a new endoscopic approach to treat infected pancreatic necrosis (IPN).

PATIENTS AND METHODS

Consecutive patients with IPN, extending from the perigastric area up to the paracolic gutters or into the pelvis, were prospectively studied from January 2017 to June 2022. The treatment protocol was radiologic percutaneous drainage as the first step, followed by fully covered metal stent placement (FC-SEMS) in the track of the catheter. Percutaneous endoscopic necrosectomy (PEN) was performed 2 to 4 days later using a flexible endoscope through the percutaneous tract. About 2 to 4 weeks later, when a matured sac was visible, EUS-guided endoscopic transluminal drainage (ETD) with lumen-apposing metal stents (LAMS) was performed. Control of sepsis with resolution of collection(s) was the primary outcome measure.

RESULTS

We included 18 patients, males in 50% of cases with age 60±12 years old. Most frequent cause of pancreatitis was biliary (7 cases) followed by alcoholic in 6 cases; in 3 cases pancreatitis was caused by hyperlipemia and in 2 cases was idiopathic. Mean size of WON was 18±2 cm. For PEN, SEMSs used were esophageal FC-SEMS. LAMS used for ETD were Hot Axios, Hot Spaxus and Nagistent. Mean time of endoscopic intervention for PEN and ETD was 18±3 and 37±4 days, respectively. In 5 cases adverse events occurred: 3 cases of overinflations resolved with introduction of Verres needles in abdomen. In 2 cases postprocedural GI bleeding required endoscopic intervention. In all cases control of sepsis was reached together with resolution of collections. No cases of deaths were observed.

CONCLUSIONS

Step-up percutaneous and transluminal endoscopic necrosectomy therapy is an effective strategy for large-size IPN with combined central and peripheral necrosis.

International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process

INTRODUCTION

The study aimed to develop international consensus recommendations on the safe use of lumen-apposing metal stents (LAMSs) for on- and off-label indications.

METHODS

Based on the available literature, statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections, endoscopic ultrasound (EUS)-biliary drainage, EUS-gallbladder drainage, EUS-gastroenterostomy, and gastric access temporary for endoscopy. The evidence level of each statement was determined using the Grading of Recommendations Assessment, Development, and Evaluation methodology.International LAMS experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback. Statements were rejected if no consensus was reached after the third Delphi round.

RESULTS

Fifty-six (93.3%) of 60 formulated statements were accepted, of which 35 (58.3%) in the first round. Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and essential safety measures during the procedure, such as the use of Doppler, and measurement of the distance between the gastrointestinal lumen and the target structure. Specific consensus recommendations were generated for the different LAMS indications, covering, among others, careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement, and the appropriate management of LAMS-related adverse events.

DISCUSSION

Through a modified international Delphi process, we developed general and indication-specific experience- and evidence-based recommendations on the safe use of LAMS.

Endoscopic ultrasonography-guided trans-afferent loop drainage of liver abscess using forward-viewing echoendoscope

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EUS-guided FNAC in intra-abdominal lesions: Technique of tissue acquisition, ancillary testing, pearls and perils, and prospects

Endoscopic ultrasound enables visualization of lesions within and in the vicinity of the gastrointestinal tract. Endoscopic ultrasound guided fine needle aspiration cytology (EUS-FNAC) helps in targeting various luminal and extraluminal lesions both diagnostically and therapeutically. Various intra-abdominal organs amenable to EUS-FNA include the gastrointestinal tract (GIT), pancreas, kidney, adrenal gland, liver, bile duct, gallbladder, spleen, and lymph nodes. EUS-FNAC is mostly done for pancreatic and intra-abdominal lymph nodal lesions. In the present review, we have discussed various aspects of EUS-FNAC.

Role of interventional endoscopic ultrasound in a developing country

BACKGROUND/AIMS

Endoscopic ultrasound (EUS) has become an essential diagnostic and therapeutic tool. EUS was introduced in 2013 in Indonesia and is considered relatively new. This study aimed to describe the current role of interventional EUS at our hospital as a part of the Indonesian tertiary health center experience.

METHODS

This retrospective study included all patients who underwent interventional EUS (n=94) at our center between January 2015 and December 2020. Patient characteristics, technical success, clinical success, and adverse events associated with each type of interventional EUS procedure were evaluated.

RESULTS

Altogether, 94 interventional EUS procedures were performed at our center between 2015 and 2020 including 75 cases of EUS-guided biliary drainage (EUS-BD), 14 cases of EUS-guided pancreatic fluid drainage, and five cases of EUS-guided celiac plexus neurolysis. The technical and clinical success rates of EUS-BD were 98.6% and 52%, respectively. The technical success rate was 100% for both EUS-guided pancreatic fluid drainage and EUS-guided celiac plexus neurolysis. The adverse event rates were 10.6% and 7.1% for EUS-BD and EUS-guided pancreatic fluid drainage, respectively.

CONCLUSION

EUS is an effective and safe tool for the treatment of gastrointestinal and biliary diseases. It has a low rate of adverse events, even in developing countries.

Evaluating the role of endoscopic ultrasound in pancreatitis

INTRODUCTION

Endoscopic ultrasound (EUS) provides high-resolution images of both pancreatic parenchyma and duct and therefore is an integral component of evaluating and treating patients with pancreatitis and its complications. The development of enhanced EUS imaging techniques and newer EUS-specific accessories has expanded the diagnostic and therapeutic role of EUS in patients with acute and chronic pancreatitis (CP).

AREAS COVERED

This review discusses the current diagnostic and therapeutic role of EUS in acute pancreatitis (AP), CP, and autoimmune pancreatitis (AIP).

EXPERT OPINION

EUS plays a vital role in patients with AP by confirming the presence of common bile duct (CBD) stones in patients with acute biliary pancreatitis and intermediate probability of CBD stones. It plays an important role in the etiological evaluation of patients with idiopathic acute and recurrent pancreatitis. EUS is also an essential modality for diagnosing and managing pancreatico-biliary as well as gastroduodenal complications associated with CP. EUS-guided FNB using newer generation core biopsy needles has made possible accurate diagnosis of AIP by providing tissue samples with preserved architecture.

Endoscopic step up: When and how

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

Advances in Pediatric Diagnostic Endoscopy: A State-of-the-Art Review

Pediatric endoscopy has revolutionized the way we diagnose and treat gastrointestinal disorders in children. Technological advances in computer processing and imaging continue to affect endoscopic equipment and advance diagnostic tools for pediatric endoscopy. Although commonly used by adult gastroenterologists, modalities, such as endomicroscopy, image-enhanced endoscopy, and impedance planimetry, are not routinely used in pediatric gastroenterology. This state-of-the-art review describes advances in diagnostic modalities, including image-enhanced endoscopy, confocal laser endomicroscopy, optical coherence tomography, endo functional luminal imaging probes, wireless motility/pH capsule, wireless colon capsule endoscopy, endoscopic ultrasound, and discusses the basic principles of each technology, including adult indications and pediatric applications, safety cost, and training data.

Various innovative roles for 3-Fr microcatheters in pancreaticobiliary endoscopy

With the development of newer devices and technical innovations, pancreaticobiliary endoscopy is expanding to assume more advanced therapeutic roles. As with other devices, slimmed-down "3-Fr microcatheters" are considered to be opening new windows toward entirely new therapeutic techniques for various purposes. Our practical experience with a total of 34 consecutive patients in whom 3-Fr microcatheters were applied during pancreaticobiliary endoscopic procedures clarified the potential roles of this instrument in pancreaticobiliary endoscopy. The major benefits of 3-Fr microcatheters involve their slimness and flexibility. Applications of 3-Fr microcatheters could be categorized into three groups according to the characteristics of usage: (1) utilization as a cannulation catheter for peroral digital cholangioscopy (n = 15); (2) selective advancement through deep flexures or severely stenotic ducts (n = 11); or (3) two-devices-in-one-channel technique (n = 8). The microcatheter worked successfully for cannulation of cholangioscopy in all but one case (14/15, 93.3%). For selective advancement, the microcatheter worked for troubleshooting in 9 of 11 cases (81.8%). With the two-devices-in-one-channel technique, the microcatheter proved satisfactory in all cases (8/8, 100%). In total, the microcatheter was successfully maneuvered in 31 of 34 cases (91.1%), following the failure of procedures using conventional endoscopic techniques. In terms of adverse events, cystic duct injury was only observed in two cases (5.8%), who recovered under conservative observation, because its slimness could minimize the damage. We believe that 3-Fr microcatheters offer effective and safe salvage troubleshooting during various endoscopic pancreaticobiliary procedures that face troublesome situations with conventional strategies.

Extrapancreatic Advanced Endoscopic Interventions

As the field of interventional endoscopy advances, conditions that were once treated with surgery are increasingly being treated with advanced endoscopy. Endoscopy is now used for treatment of achalasia, bariatric procedures for obesity; resection of early-stage malignancies in the gastrointestinal tract; and placement of lumen-apposing metal stents in the treatment of biliary obstruction, gastric outlet obstruction, cholecystitis, and drainage of nonpancreatic-related fluid collections or abscesses. Knowledge of the novel terminology, procedural details, expected postintervention imaging findings, and potential complications is vital for radiologists because these procedures are rapidly becoming more mainstream in daily practice. These procedures include peroral endoscopic myotomy for the treatment of achalasia and other esophageal motility disorders; endoscopic sleeve gastroplasty and placement of an intragastric balloon for weight loss; endoscopic submucosal dissection in the resection of tumors of the gastrointestinal tract; and therapeutic endoscopic-guided procedures for the treatment of biliary obstruction, gastric outlet obstruction, acute cholecystitis, and drainage of nonpancreatically related fluid collections. Patients benefit from these minimally invasive procedures, with potential improvement in morbidity and mortality rates, decreased length of hospital stay, and decreased health care costs when compared with the surgical alternative. Complications of these procedures include leaks or perforations, infections or abscesses, fistulas, and occlusion and migration of stents. An invited commentary by Pisipati and Pannala is available online. ^©RSNA, 2022.

Novel Resection System for Direct Endoscopic Necrosectomy of Walled-Off Pancreas Necrosis: Have We Conquered the Final Frontier?

Surgical necrosectomy has been the traditional management for pancreatic necrosis and is done using blunt dissection. However, lack of dedicated endoscopic accessories has been a major limitation in direct endoscopic necrosectomy (DEN). Standard endoscopic accessories cannot effectively remove large necrotic material. Also, diameter of instrument channel of the endoscope limits the ability to use large-diameter graspers that can remove large chunks of necrotic material. In this news, we discuss a recent study that has evaluated a new powered endoscopic debridement system for DEN.

Value of neutrophil-lymphocyte ratio in evaluating response to percutaneous catheter drainage in patients with acute pancreatitis

BACKGROUND

Early prediction of response to percutaneous catheter drainage (PCD) of necrotic collections in acute pancreatitis (AP) using simple and objective tests is critical as it may determine patient prognosis. The role of white blood cell (WBC) count and neutrophil-lymphocyte ratio (NLR) has not been assessed as a tool of early prediction of PCD success and is the focus of this study.

AIM

To assess the value of WBC and NLR in predicting response to PCD in AP.

METHODS

This retrospective study comprised consecutive patients with AP who underwent PCD between June 2018 and December 2019. Severity and fluid collections were classified according to the revised Atlanta classification and organ failure was defined according to the modified Marshall Score. WBC and NLR were monitored 24 h prior PCD (WBC-0/NLR-0) and 24 h (WBC-1/NLR-1), 48 h (WBC-2/NLR-2) and 72 h (WBC-3/NLR-3) after PCD. NLR was calculated by dividing the number of neutrophils by the number of lymphocytes. The association of success of PCD (defined as survival without the need for surgery) with WBC and NLR was assessed. The trend of WBC and NLR was also assessed post PCD.

RESULTS

One hundred fifty-five patients [median age 40 ± 13.6 (SD), 64.5% males, 53.5% severe AP] were included in the final analysis. PCD was done for acute necrotic collection in 99 (63.8%) patients and walled-off necrosis in 56 (36.1%) patients. Median pain to PCD interval was 24 ± 69.89 d. PCD was successful in 109 patients (group 1) and 46 patients (group 2) who failed to respond. There was no significant difference in the baseline characteristics between the two groups except the severity of AP and frequency of organ failure. Both WBC and NLR showed an overall decreasing trend. There was a significant difference between WBC-0 and WBC-1 (P = 0.0001). WBC-1 and NLR-1 were significantly different between the two groups (P = 0.048 and 0.003, respectively). The area under the curve of WBC-1 and NLR-1 for predicting the success of PCD was 0.602 and 0.682, respectively. At a cut-off value of 9.87 for NLR-1, the sensitivity and specificity for predicting the success of PCD were calculated to be 75% and 65.4% respectively.

CONCLUSION

WBC and NLR can be used as simple tests for predicting response to PCD in patients with acute necrotizing pancreatitis.

Safety and efficacy of a novel electrocautery-enhanced lumen-apposing metal stent in interventional EUS procedures (with video)

BACKGROUND AND AIMS

Electrocautery-tip lumen-apposing metal stents (EC-LAMSs) have extended the indications of therapeutic EUS. We aimed to retrospectively evaluate safety and technical and clinical success of a newly developed EC-LAMS, the Hot-Spaxus (Taewoong Medical Co, Gimpo, Korea), for various EUS-guided procedures.

METHODS

We included and retrospectively analyzed consecutive patients at 8 tertiary care referral centers who had undergone EUS interventional procedures using the Hot-Spaxus between October 2018 and February 2021.

RESULTS

Of 58 included patients (male-to-female, 36:22; mean age, 63.5 ± 14.9 years), 29 had undergone pancreatic fluid collection drainage (50%), 22 (37.9%) biliary drainage for malignant distal obstruction, 3 (5.1%) gallbladder drainage for acute cholecystitis, 3 gastroenteroanastomoses, and 1 (1.7%) pelvic collection drainage. Technical success was achieved in 54 of 58 patients (93.1%) and clinical success in all 58. Adverse events occurred in 6 patients (11.1%): 2 early (3.7%), 1 late (1.8%), and 3 long term (5.6%). The outcomes were similar to those observed in a control group of patients treated with the Hot-Axios (Boston Scientific, Marlborough, Mass, USA), the other available EC-LAMS.

CONCLUSIONS

Our study showed that the novel EC-LAMS has high technical and clinical success rates for various interventional EUS indications. Future multicenter prospective studies will better clarify the role of this new EC-LAMS for different indications.

Advances in gastrointestinal surgical endoscopy

Surgeons have a role in observing, detect abnormalities, disease, and other deficiencies in function which could be treated. Diagnosing and treating back days were challenging for many reasons. However, technology's innovation enhances surgeons' ability to treat their patients. The term endoscopy refers to the Greek prefix endo- ("within") and the verb skopein ("to view or observe"). Endoscopy is practical both in the diagnosis and treatment of various pathologies. Technological advances, especially in endoscopy, gradually progress and discover many possibilities which allow rapid advancement. Endoscopy development aims to assess human orifice that has not been inspected, probed, and examined over the centuries. Endoscopy over these decades is improving, which led to new problem solving using advanced technological approaches. Thus, a surgeon can solve any issues from examination, diagnosis, and treatment using progressive endoscopy evolution. This review delivers a brief history of advances in surgical endoscopy and describes current endoscopy development.

Newly Designed Laser-Cut Metal Stent with an Anchoring Hook and Thin Delivery System for Endoscopic Ultrasound–Guided Hepaticogastrostomy: Is It a Dream Stent?

Endoscopic ultrasound–guided hepaticogastrostomy (EUS-HGS) involves creation of an anastomosis between two intra-abdominal mobile organs, namely, liver and the stomach, with no intervening stricture. Therefore, the risk of stent migration in EUS-HGS is very high and the stent migration can lead on to severe life-threatening complications like biliary peritonitis. During last few years, there have been increased efforts to design a safe and effective stent for EUS-HGS that obviates the risk of stent migration and can also be inserted quickly, preferably, in a single-step procedure. In this news and views, we discuss an experimental study from Japan that has evaluated a new partially covered self-expandable laser cut metal stent with a thin delivery system (7.2 F) and antimigration anchoring hooks for single-step EUS-HGS in phantom and animal models.

Safety and Efficacy of Early (<4 Weeks of Illness) Endoscopic Transmural Drainage of Post-acute Pancreatic Necrosis Predominantly Located in the Body of the Pancreas

BACKGROUND

Endoscopic transmural drainage is usually not performed for pancreatic necrotic collection (PNC) < 4 weeks after onset of acute necrotizing pancreatitis (ANP) because of lack of encapsulating wall and increased risk of complications.

OBJECTIVE

Study safety and efficacy of early (<4 weeks) endoscopic transluminal drainage in patients with symptomatic PNC.

METHODS

Retrospective analysis of data base of patients with PNC treated with endoscopic transmural drainage within 4 weeks of onset of ANP (early drainage) was done. The outcomes and complications were compared with patients with PNC who underwent delayed endoscopic drainage (≥4 weeks of onset of ANP).

RESULTS

Thirty-four patients (26 males; mean age: 35.9 ± 8.6 years) underwent early and 136 patients (115 males; mean age: 37.9 ± 9.4 years) underwent delayed endoscopic drainage. The PNC was significantly larger (12.3 ± 2.1 cm vs 10.5 ± 2.7 cm, p <0.001) with increased solid component (47.7 ± 8.9% vs 28.3 ± 11.7%, p <0.001) in the early group. Clinical success was achieved in 94% patients in the early group and all patients in the delayed group. Direct endoscopic necrosectomy was performed more frequently in the early group (50% vs 7.4%; p<0.001). There was increased mortality (5.7% vs 0%), need for rescue surgical necrosectomy (5.7% vs 0%), and clinically significant bleeding (20% vs 1.5%, p<0.001) in the early group as compared to the delayed group.

CONCLUSION

Early endoscopic drainage of PNC is feasible and seems to be safe as well as effective but is associated with increased risk of complications as compared to delayed drainage.

Management of walled-off necrosis with nasocystic irrigation with hydrogen peroxide versus biflanged metal stent: randomized controlled trial

Background and study aims  Walled-off necrosis (WON) is a known complication of acute necrotizing pancreatitis (ANP). There is no study comparing nasocystic irrigation with hydrogen peroxide (H ₂ O ₂ ) versus biflanged metal stent (BMS) in the management of WON. The aim of this study was to compare the clinical efficacy of both the treatment strategies. Patients and methods  This study was conducted on patients with symptomatic WON who were randomized to nasocystic irrigation with H ₂ O ₂ (Group A) and BMS placement (Group B). Primary outcomes were clinical and technical success while secondary outcomes were procedure time, adverse events, need for additional procedures, duration of hospitalization, and mortality. Results  Fifty patients were randomized into two groups. Group A (n = 25, age 37.8 ± 17.6 years, 16 men) and Group B (n = 25, age 41.8 ± 15.2 years, 17 men). There were no significant differences in baseline characteristics between the two groups. The most common etiology of pancreatitis was alcohol, observed in 27 (54 %) patients. Technical success (100 % vs 96 %, P  = 0.98), clinical success (84 % vs 76 %, P  = 0.76), requirement of additional procedures (16 % vs 24 %, P  = 0.70) and adverse events (4 vs 7, P  = 0.06) were comparable in both the groups. The duration to clinical success (34.4 ± 12 vs 14.8 ± 10.8 days, P  = 0.001) and procedure time (36 ± 15 vs 18 ± 12 minutes, P  = 0.01) were longer in Group A compared to Group B. Conclusions  Nasocystic irrigation with H ₂ O ₂ and BMS are equally effective in the management of WON but time to clinical success and procedure time is longer with nasocystic irrigation.

Endoscopic Ultrasound-Guided Gallbladder Drainage

The mainstay of management of acute cholecystitis is surgical. Despite the advances in anesthesia and laparoscopic surgery, there is a significant pool of patients that are not candidates for surgery given their significant comorbidities and limited functional reserve. Historically percutaneous gallbladder drainage has been utilized to temporize these patients. Recently, endoscopic approaches are being explored with transpapillary and transmural drainage. In this article, we discuss the background, current status, technical challenges, adverse events, and outcomes of endoscopic ultrasound-guided gallbladder drainage for management of acute cholecystitis.

Endoscopic ultrasound-guided gallbladder drainage: a technical review

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as a safe and effective minimally invasive alternative to both percutaneous and endoscopic transpapillary GBD in patients with acute cholecystitis. Over the last few years, the technique, as well as the indications for EUS-GBD have been gradually evolving, and the procedure has become simpler and safer as the accepted indications have expanded. The development of lumen-apposing metal stents (LAMS) has allowed us to realize the dream of creating endoscopic gastrointestinal anastomoses, and has thus paved the way for a safer EUS-GBD. Single step EUS-guided LAMS delivery systems have obviated the use of other endoscopic accessories and thus made EUS-GBD simpler and safer. However, EUS-GBD can be associated with potentially serious complications, and therefore should be performed by expert interventional endosonologists at centers with surgical and radiological back up. EUS-GBD is a relatively new procedure still in its infancy, but continued improvement in EUS accessories and dedicated stents will make this procedure safer and also expand its current indications. This review focuses on the technical aspects, including procedural details, as well as the complications of EUS-GBD.

EUS-guided Gastroenterostomy: Assessing the Competence of the Endoscopist

Assessing competence is of utmost importance for complex EUS procedures like EUS-guided gastroenterostomy (EUS-GE) that are associated with higher risk of procedural complications. It is a matter of intense debate on what is the training needed to carry out these interventions, how to judge for competence, and who can perform these newer interventions. The procedure has several variations including the methods to identify the jejunal loops on EUS like direct puncture, balloon-assisted, and hybrid rendezvous with ultrathin endoscope. Therefore, there is lack of clarity on the role and ways of assessing the learning curve for EUS-GE. In this news and views, we are discussing two studies that assessed the learning curve for EUS-GE.

Transrectal Endoscopic Ultrasound-Guided Drainage of a Tubo-Ovarian Abscess Via a Lumen-Apposing Metal Stent

Tubo-ovarian abscess (TOA) is a potentially lethal condition, often requiring a combination of medical and surgical interventions. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic fluid collections, but its role for the treatment of TOA is not well documented. We report the first known case of successful treatment of a large TOA with EUS-guided transrectal drainage using a lumen-apposing metal stent.

Current Status of Needles in the Optimization of Endoscopic Ultrasound-Guided Procedures

Endoscopic ultrasound (EUS) is among the most important tools for the evaluation of gastrointestinal tumors and affected areas around the gastrointestinal tract. It enables the acquisition of material from abnormal lesions via the gastrointestinal wall for tissue confirmation via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA has played a vital role in oncological care and has become the standard method for tissue sampling. The choice of needle type is an important factor determining tissue acquisition and has been evaluated by many researchers. New needles are introduced into the market almost every year, and opinions vary regarding proper needle selection. While there are diverse opinions but no definitive recommendations about the use of one particular device, fine-needle biopsy needles may provide detailed information on a tissue’s architecture based on greater sample yields. This permits additional analyses, including genetic sequencing and phenotyping, thereby enabling the provision of more personalized treatment plans. Furthermore, other EUS-guided procedures have been developed, including interventional EUS and through-the-needle devices. Given the continued attempts to improve the diagnostic ability and therapeutic techniques, we review in detail the available types of puncture needles to provide guidance on the selection of the appropriate needle types.

Advanced Endoscopic Procedures: An Update for Radiologists

OBJECTIVE. The purposes of this article are to familiarize radiologists with endoscopic techniques currently in use and to improve identification of clinically relevant imaging findings and procedural complications related to common endoscopic interventions. CONCLUSION. The frequency of performance of therapeutic endoscopic ultrasound-guided procedures has risen precipitously in the last decade. These procedures are replacing surgical and percutaneous approaches to a variety of disease entities. Recent advances include endoscopic bariatric procedures, endoscopic myotomies, and endoscopic ultrasound-guided drainage procedures.

Endoscopic ultrasound guided liver biopsy for parenchymal liver disease

Liver biopsy plays an essential role in the diagnosis, evaluation and management of a vast proportion of liver diseases. Conventionally, percutaneous and trans-jugular approaches have been used to obtain liver biopsies. Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a safe and effective alternate in the past two decades. EUS-LB carries a role in evaluation of both benign and malignant diseases of the liver. It can offer higher resolution imaging of the liver and can detect smaller lesions than computed tomography scan of the abdomen or ultrasound scans with the option for doppler assistance to reduce complications. Current evidence demonstrates the superiority of EUS-LB for a targeted approach of focal lesion and there is also evidence of less sampling variability in heterogeneous parenchymal pathologies. These advantages combined with an improved safety profile had led to the rapid progress in the development of new techniques, equipment and procedures for EUS-LB. We provide a comprehensive review of EUS-LB for parenchymal liver disease.

An overview of walled-off pancreatic necrosis for clinicians

Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.

Endoscopic Ultrasound-Guided Vascular Interventions: From Diagnosis to Treatment

The development of endoscopic ultrasound was driven by the need to develop less invasive alternatives to surgical and radiologic interventions for a wide variety of gastrointestinal conditions. During the past decade, there has been a very rapid growth in the clinical role and capabilities of endoscopic ultrasound-guided therapeutic interventions. Endoscopic ultrasound offers both real-time imaging and access to structures within and adjacent to the gastrointestinal tract. The proximity of the gastrointestinal system to vascular structures throughout the abdomen and the mediastinum allows for endoscopic ultrasound-guided vascular access and therapy. The recent development of endoscopic ultrasound-guided vascular interventions has relied both on finding new applications for standard endoscopic accessories and on commandeering tools originally developed for use in interventional radiology. This article provides a review of the literature regarding the current state of endoscopic ultrasound for the management of variceal and nonvariceal bleeding, portal vein angiography and pressure measurements, intrahepatic portosystemic shunts, endoscopic ultrasound-guided fine-needle aspiration for portal vein sampling, drug administration and embolization as well as endoscopic ultrasound-guided cardiac access and treatment.

Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy for treatment of infected pancreatic necrosis in early phase of illness

Background and Objectives:

Infected pancreatic necrosis (IPN) in the early phase is treated with “step up approach” involving initial percutaneous catheter drainage (PCD) followed by necrosectomy. There is a paucity of data on a combined approach of initial PCD followed by endoscopic drainage and necrosectomy. A retrospectively study on safety and efficacy of initial PCD followed by endoscopic transluminal drainage and necrosectomy in IPN.

Methods:

Retrospective analysis of data of 23 patients with IPN who were treated with a combined approach. Patients were divided into two groups as follows: patients with central necrosis in whom PCD and endoscopic drainage were done in the same collection (n = 11) and patients with combined central and peripheral necrosis where PCD was placed in peripheral necrosis, and endoscopic drainage was done for central necrosis (n = 12).

Results:

Endoscopic drainage could be done successfully in all 23 patients with mean time for the resolution being 4.0 ± 0.9 weeks. Fifteen (65.2%) patients were successfully treated using multiple plastic stents while direct endoscopic necrosectomy (DEN) was needed in 8 (34.8%) patients and fully covered self-expanding metal stent was inserted in 6 (26%) patients. The number of endoscopic sessions needed were 3 in 3 (13%), 4 in 9 (39%) patients, 5 in 5 (22%), 6 in 3 (13%), and 7 in 3 (13%) patients, respectively. Patients of central walled-off pancreatic necrosis (WOPN) with PCD catheter in situ needed more endoscopic sessions for resolution as well as more frequently needed DEN in comparison to patients with central WOPN with no PCD catheter.

Conclusion:

The combined approach of initial PCD followed by endoscopic drainage and necrosectomy is safe and effective treatment alternative for patients with IPN.

The role of endoscopic ultrasound in children with Pancreatobiliary and gastrointestinal disorders: a single center series and review of the literature

BACKGROUND

The role of endoscopic ultrasound (EUS) in the management of pancreatobiliary and digestive diseases is well established in adults, but it remains limited in children. The aim of this study was to evaluate the feasibility, safety, and clinical impact of EUS use in children.

METHODS

This is a retrospective analysis of a prospectively acquired database of consecutive pediatric (< 18 years) patients presenting an indication for EUS for pancreatobiliary and gastrointestinal disorders.

RESULTS

Between January 2010 and January 2016, 47 procedures were performed in 40 children (mean age of 15.1 ± 4.7 years; range 3-18). The majority of EUS (n = 32; 68.1%) were performed for pancreatobiliary and upper gastrointestinal pathologies, including suspected common bile duct stones (CBDs), acute biliary pancreatitis, recurrent/chronic pancreatitis, cystic pancreatic mass, recurrent hypoglycemia, duodenal polyp, gastric submucosal lesion, and perigastric abscess. In only 2 out of 18 children with suspected CBDs or acute biliary pancreatitis, EUS confirmed CBDs. EUS-guided fine needle aspiration was performed in 3 (6.4%) patients. Fifteen (31.9%) procedures were performed for lower gastrointestinal tract disorders, including suspected anal Crohn's disease, fecal incontinence, and encopresis. Overall, EUS had a significant impact on the subsequent clinical management in 87.2% of patients.

CONCLUSION

The present findings were consistent with results observed in the current relevant literature and support EUS as a safe and feasible diagnostic and therapeutic tool, which yields a significant clinical impact in children with pancreatobiliary and gastrointestinal disorders.

Endoscopic ultrasound-guided fine-needle aspiration from ascites and peritoneal nodules: A scoping review

The peritoneum is involved in many diseases such as primary malignancy (mesothelioma), infectious disease (tuberculosis), and disseminated malignancy (peritoneal carcinomatosis). The peritoneal disease may manifest as ascites and/or peritoneal masses or nodules. Endoscopic ultrasound (EUS), due to its ability to provide high-resolution images, has revolutionized the imaging and diagnosis of pancreaticobiliary diseases among other gastrointestinal conditions. EUS can not only help in imaging of various lesions close to the gastrointestinal lumen but also aspirate/biopsy them. We conducted a systematic search to identify published literature on the value of EUS in detection and diagnosis of peritoneal disorders. This review aims to summarize the available literature on the use of EUS-guided paracentesis and fine-needle aspiration from peritoneal nodules.

Endoscopic ultrasound: Current roles and future directions

Endoscopic ultrasound (EUS), developed in the 1980s, was initially predominantly used for guidance of fine needle aspiration; the last 25 years, however, have witnessed a major expansion of EUS to various applications, both diagnostic and therapeutic. EUS has become much more than a tool to differentiate different tissue densities; tissue can now be characterized in great detail using modalities such as elastography; the extent of tissue vascularity can now be learned with increasing precision. Using these various techniques, targets for biopsy can be precisely pinpointed. Upon reaching the target, tissue can then be examined microscopically in real-time, ensuring optimal targeting and diagnosis. This article provides a comprehensive review of the various current roles of EUS, including drainage of lesions, visualization and characterization of lesions, injection, surgery, and vascular intervention. With EUS technology continuing to develop exponentially, the article emphasizes the future directions of each modality.

A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review

In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.

Safety and utility of endoscopic ultrasound-guided fine-needle aspiration of focal splenic lesions: a retrospective analysis

BACKGROUND

Fine-needle aspiration (FNA) of focal splenic lesions (FSL) is usually done under ultrasound (US) or computed tomography guidance. Endoscopic US (EUS), because of its ability to provide high-resolution images, can be used for aspirating FSL. We studied the safety and efficacy of EUS-guided FNA of FSL.

METHODS

We performed a retrospective analysis of patients with FSL undergoing EUS-guided FNA over the last six years.

RESULTS

EUS-guided FNA was performed in 16 patients (age: 28-43 years; male: 11). A 22-G needle was used in 13 patients, a 25-G needle in 2 patients, and a 19-G needle in 1 patient. All patients had abdominal pain, with 6 patients also having fever. On EUS, 8 patients had focal hypoechoic lesion/lesions, whereas 8 patients had focal cystic lesion/lesions. The size of the focal lesions ranged from 0.8-10 cm. EUS-guided aspiration was performed successfully in all patients. The cytology was adequate in all patients and a diagnosis was established in 13 (81%) patients. The final diagnosis in patients with hypoechoic lesions was tuberculosis in 6 patients and sarcoidosis in 2 patients. The final diagnosis in patients with cystic lesions was pseudocyst in 5 patients and simple cyst in 3 patients. One patient with splenic pseudocyst had a massive hemorrhage from a splenic artery pseudoaneurysm 7 days after FNA. No other major complication was encountered.

CONCLUSION

EUS-guided FNA of FSL is safe and provides adequate material for cytological examination, even in the case of small lesions.

Current Practices in the Management of Antithrombotic Therapy During the Periendoscopic Period for Patients With Cardiovascular Disease

The management of antithrombotics during the periendoscopic period is traditionally represented as a doubleedged sword for cardiologists and endoscopists. Appropriate administration prevents thromboembolic events, whereas excessive administration provokes bleeding events. Therefore, cardiologists and endoscopists must consider the risks of bleeding and thromboembolism in individual cases, before deciding whether to continue antithrombotic use. Several guidelines exist concerning antithrombotic management in Asian and Western countries. These guidelines generally classify procedural bleeding risk and thromboembolic risk into high risk and low risk groups and recommend that the two risks be weighed when managing a given patient. Moreover, they generally do not recommend interrupting antithrombotics during the periendoscopic period unless absolutely necessary; however, the details surrounding this point differ among the guidelines after several revisions. In this review, we describe the present state, problems, and future perspectives concerning the management of antithrombotics in patients with cardiovascular disease undergoing gastrointestinal endoscopy.

Endoscopic computerized tomography guided percutaneous trans-gastric drainage: A case report on this hybrid approach

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Comparisons of endoscopic Computerized tomography guided percutaneous trans-gastric drainage and EUS-guided drainage reveal that endoscopic Computerized tomography guided percutaneous trans-gastric drainage is easier for surgeons to perform, takes less time, and causes less discomfort to the patient.

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Percutaneous transgastric drainage is more comfortable than EUS-guided drainage.

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The puncture can be performed safely because space is eliminated by fixation of the gastric and abdominal walls.

Percutaneous drainage, percutaneous transgastric drainage, and endoscopic ultrasound (EUS)-guided transgastric drainage are primarily utilized for drainage of fluid collections dorsal to the stomach. Percutaneous transgastric drainage is performed with computed tomography (CT) guidance, but it requires inflation of a balloon in the stomach, and gastric peristalsis makes it difficult to ensure a reliable puncture route via the stomach. Using endoscopy-assisted CT-guidance, we were able to safely and effectively perform percutaneous transgastric drainage.

A 69-year-old man underwent a pancreaticoduodenectomy for cancer of the inferior section of the common bile duct. Postoperative day 5, the amylase value of the drainage fluid was 1,232 IU/L, we diagnosed a pancreatic fistula developed as a result of pancreaticojejunal anastomotic failure and we performed drainage at the drain which was placed in the foramen of Winslow intraoperatively, however fluid collection dorsal to the stomach was detected on a follow-up abdominal CT scan, and the fluid was a high value of amylase, we judged the drain was not working well and the pancreatic fistula occured. Endoscopy-assisted, CT-guided percutaneous transgastric drainage was therefore performed, and the pancreatic fistula was successfully closed the fistula.

Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type pain. Obstruction of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches, ranging from pharmacologic, endoscopic and radiologic treatments to surgical interventions. When the conservative treatment approaches fail to resolve symptomatic cases, however, endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach, despite its well-recognized drawbacks. When the conventional transpapillary approach fails to achieve the necessary drainage, the patients may benefit from application of the less invasive endoscopic ultrasound (EUS)-guided pancreatic duct interventions. Here, we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 mo. Computed tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at genu. After conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms, EUS-guided pancreaticogastrostomy (PGS) was applied using a fully covered, self-expandable, 10-mm diameter metallic stent. The treatment resolved the case and the patient experienced no adverse events. EUS-guided PGS with a regular biliary fully covered, self-expandable metallic stent effectively and safely treated pancreatic-type pain in chronic pancreatitis.