Aspiring to new levels of achievement: eus in the therapeutic endoscopy olympics

Single-step versus 2-step management of huge pancreatic pseudocysts: a prospective randomized trial with long-term follow-up

OBJECTIVES

Single-step endoscopic ultrasonography-guided puncture through the stomach to insert a double-pigtail stent to drain a pseudocyst usually resulted in a high infection rate. The 2-step method, which combines the single-step method with a nasocystic drain, was created to help alleviate infections. Our study compared the 2 management strategies.

METHODS

Between January 2007 and December 2011, patients with huge pancreatic pseudocysts were randomized into either a single-step or a 2-step treatment. Complications from infections and long-term results assessed during follow-up for the 2 groups were compared.

RESULTS

Forty-seven patients were enrolled-23 in the single-step group and 24 in the 2-step group. There were significant differences in the infection rates (56.52 vs 20.83, P < 0.05), the average days of hospitalization (22.96 ± 2.82 days vs 10.38 ± 1.35 days, P < 0.05), postoperative hospital stay (15.31 ± 3.82 days vs 7.21 ± 1.61 days, P < 0.05), and the disappearance time of the pseudocyst (14.10 ± 2.33 weeks vs 11.70 ± 2.21 weeks, P < 0.05) between the 2 groups; however, there was no significant difference in the pseudocyst recurrence rate.

CONCLUSIONS

The preferred treatment of a huge pancreatic pseudocyst is a combined endoscopic ultrasonography method using 2 double-pigtail stents and a nasocystic drain.

Forward-view Endoscopic Ultrasound: A Systematic Review of Diagnostic and Therapeutic Applications

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and therapeutic procedures have been performed by a curved linear array (CLA) echoendoscope since the early 1990's. This particular echoendoscope, allowing real time visualization of aspiration needles and of other devices, has substantially remained unchanged since its introduction to the market. In a context of rapidly expanding indications for EUS-guided procedures, a dedicated forward view (FV) echoendoscope has been developed and tested under different clinical conditions. The FV echoendoscope is equipped with front endoscopic and EUS view, allowing deployment of needles and other devices through the working channel in straight direction. Several new diagnostic and therapeutic applications may thereby potentially be feasible with the FV echoendoscope and the established ones may prove easier to accomplish. The published literature with the FV echoendoscope has been systematically reviewed and the results are presented analytically and discussed in detail. EUS-FNA and therapeutic procedures, including pancreatic pseudocyst drainage, treatment of gastric fundal varices, celiac plexus neurolysis, and duct drainage were reported. The FV echoendoscope showed some unique advantages, opening new possibilities such as EUS-FNA in difficult gastrointestinal tracts and combined endoscopic/EUS treatment with frontal approach. However, no statistically significant evidence of superiority of the FV echoendoscope vs. the CLA echoendoscope was found in pancreatic pseudocyst drainage. No complications specifically attributable to the use of the FV echoendoscope were reported.

Skull metastasis revealing a papillary thyroid carcinoma

Although thyroid carcinoma is a relatively common form of malignancy, metastatic spread to the skull is rare. Here, we report a case of papillary thyroid carcinoma with frontal and parietal metastasis. A 61-year-old Chinese woman presented with a one year history of a growing mass on the center of the frontal and parietal bone, initially thought to be meningioma. Biopsy of the skull base mass after intracalvarium excision, indicated a tumor of thyroid origin. One month later the patient underwent a total thyroidectomy. Pathological examination confirmed a diagnosis of papillary thyroid carcinoma with frontal and parietal bone metastasis. Based on this experience, the key to successful management of the skull metastasis of thyroid carcinoma is prompt diagnosis and appropriate treatment. Skull metastasis should be considered at the outset of the clinical course of papillary thyroid cancer. To facilitate this, patients should be meticulously investigated by a multidisciplinary team to improve quality of life.

Combined EUS-Guided Abdominal Cavity Drainage and Cystogastrostomy for the Ruptured Pancreatic Pseudocyst

Background. Endoscopic-Ultrasonography- (EUS-) guided puncture and drainage of pancreatic pseudocyst is currently one of the most widely accepted nonsurgical treatments. To date, this technique has only been used for pancreatic pseudocysts adhesive to the gastric wall. This study introduces the technique of EUS-guided pseudocyst drainage and additional EUS-guided peritoneal drainage for the ruptured pseudocyst. Methods. Transmural puncture and drainage of the cyst were performed with a 19 G needle, cystotome, and 10 Fr endoprosthesis. Intraperitoneal drainage was performed with a nasobiliary catheter when rupture of pseudocyst occurred. The entire procedure was guided by the echoendoscope. Results. A total of 21 patients, 8 men and 13 women, with a mean age of 36 years, were included in this prospective study. All of the pseudocysts were successfully drained by EUS. Peritoneal drainage was uneventfully performed in 4 patients. There were no severe complications. Complete pseudocyst resolution was established in all patients. Conclusion. The technique of EUS-guided transmural puncture and drainage, when combined with abdominal cavity drainage by a nasobiliary catheter, allows successful endoscopic management of pancreatic pseudocysts without adherence to gastric wall.