A kit for eus-guided access and drainage of pancreatic pseudocysts: efficacy in a porcine model

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography for patients with Roux-en-Y gastric bypass anatomy: technical overview

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass anatomy is a well-documented challenge. Traditionally, this problem has been overcome with adjunctive techniques, such as device-assisted ERCP, including double-balloon or single-balloon enteroscopy and laparoscopy-assisted transgastric ERCP. Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a novel technique that enables access to the ampulla using a duodenoscope without surgical intervention and has shown high clinical and technical success rates in recent studies. However, this approach is technically demanding, necessitating a thorough understanding of the gastrointestinal anatomy as well as high operator experience. In this review, we provide a technical overview of EDGE in parallel with our personal experience at our center and propose a simple algorithm to select patients for its appropriate application. In conjunction, the outcomes of EDGE compared with those of device-assisted and laparoscopy-assisted transgastric ERCP will be discussed.

Evaluation of an all-in-one hybrid model (EUS Magic Box) for stepwise teaching and training in multiple interventional EUS procedures

Background and study aims  While multiple interventional endoscopic ultrasound (EUS)-guided procedures have evolved over the past two decades, there is no model that allows for training in all of these procedures. We aimed to develop and validate an all-in-one hybrid model for stepwise learning in multiple EUS interventions. Methods  A hybrid model was created utilizing a pig esophagus and stomach, a silicon-based duodenum and pancreato-biliary system, a pseudocyst, and biopsy targets. This model was designed to provide hands-on training in multiple interventional EUS procedures, such as EUS-guided fine-needle biopsy (EUS-FNB), biliary drainage (BD), pancreatic duct drainage (PD), pseudocyst drainage (PSD), and gastro-enterostomy (GE). Thirty-six trainees underwent training on this model over 6 days, in two batches. Lumen apposing metal stents were used for PSD and GE. Trainees were assessed for objective criteria of technical difficulties. Subjective assessment by trainees was done via a questionnaire. Results  All the trainees were able to complete the requisite steps for all the procedures under supervision. On subjective assessment, 30 trainees (83 %) graded the model as good or excellent. A total of 107 technical difficulties were noted (scope position 55, duct puncture 27, guidewire-related problems 25). Time taken to complete the requisite steps of biopsy, PSD, and GE (10.5 minutes; range 3.5 to 22) was significantly less than that for BD and PD (28 minutes; range 17 to 40) ( P  < 0.001). Conclusions  The hybrid model provided training for multiple EUS interventions with good acceptance by trainees. Stepwise mentoring with the possibility of performing multiple procedures in a single model with or without X-ray could prove useful in conference as well as institutional settings.

The Evolution of Endoscopic Cystgastrostomy

The lumen-apposing metal stent is the first stent specifically designed for endoscopic ultrasound-guided transluminal drainage of extraintestinal fluid collections. With the "hot" electrocautery-enhanced delivery system, this platform marks the most recent evolutionary stage of endoscopic therapy of pancreatic fluid collections. The lumen-apposing metal stent platform has made endoscopic drainage of pancreatic fluid collections easier and safer, while serving as a port for safe entry into the cyst cavity to extend the reach of endoscopic diagnosis and therapy. Tools conceived for endoscopic ultrasound-guided transluminal intervention have emerged and are opening the door to new frontiers of endoscopic transluminal therapy.

Future Directions for Endoscopic Ultrasound: Where Are We Heading?

Endoscopic ultrasound (EUS) plays an important role as a diagnostic and therapeutic modality in gastroenterology. New developments have emerged, especially in the last decade, and are being introduced to endoscopists. The ability to readily visualize and access organs in the gastrointestinal tract has allowed endoscopists to perform new interventional procedures. EUS procedures have taken the place of conventional approaches for the treatment of various gastrointestinal diseases, including pancreatic cystic lesions. This article focuses on the advances and future of diagnostic and therapeutic EUS.

Endoscopic extra-cavitary drainage of pancreatic necrosis with fully covered self-expanding metal stents (fcSEMS) and staged lavage with a high-flow water jet system

AIM

To present a novel, less-invasive method of endoscopic drainage (ED) for walled-off pancreatic necrosis (WON).We describe the feasibility, success rate, and complications of combined ED extra-cavitary lavage and debridement of WON using a biliary catheter and high-flow water jet system (water pump).

PATIENTS AND METHODS

Endoscopic ultrasound (EUS)-guided drainage was performed with insertion of two 7-Fr, 4-cm double pigtail stents. Subsequently a fully covered self-expanding metal stent (fcSEMS) was placed. The key aspect of the debridement was the insertion of a 5-Fr biliary catheter through or along the fcSEMS into the cavity, with ensuing saline lavage using a high-flow water jet system. The patients were then brought back for repeated, planned endoscopic lavages of the WON. No endoscopic intra-cavitary exploration was performed.

RESULTS

A total of 17 patients (15 men, 2 women; mean age 52.6, range 24 - 69; mean American Society of Anesthesiologists [ASA] score of 3) underwent ED of WON with this new method. The mean initial WON diameter was 9.5 cm, range 8 to 26 cm. The total number of ED was 84, range 2 to 13. The mean stenting period was 42.5 days. The mean follow-up was 51 days, range 3 to 370. A resolution of the WON was achieved in 14 patients (82.3 %). There were no major complications associated with this method.

CONCLUSION

ED of complex WON with fcSEMS followed by repeated endoscopic extra-cavitary lavage and debridement using a biliary catheter and high-flow water jet system is a minimally invasive, feasible method with high technical and clinical success and minimal complications.