IJGII Inernational Journal of Gastrointestinal Intervention

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< PreviousNext >Gastrointestinal Intervention 2017; 6(2): 85~150
  • Review Article 2017-07-31

    Comprehensive management of cholangiocarcinoma: Part I. Diagnosis

    Charilaos Papafragkakis, and Jeffrey H. Lee

    Abstract : Cholangiocarcinoma is the second most common primary hepatic malignancy and its incidence is increasing worldwide. Classification and staging of intrahepatic, perihilar, and distal cholangiocarcinomas provide useful prognostic information and further guide in their management. Establishing diagnosis is frequently challenging and may require a multi-modality approach that includes advanced radiological imaging studies and procedures for tissue acquisition; the endoscopic procedures that have been utilized in the management of cholangiocarcinoma comprise endoscopic retrograde cholangiopancreatography with brushing and biopsy, endoscopic ultrasound-guided fine needle aspiration, cholangioscopy with targeted biopsy, and intraductal confocal endomicroscopy. In this review, we will examine the strengths and limitations of each diagnostic tool and assess the serum and bile tumor markers.

    Cited By: 2

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  • Review Article 2017-07-31

    Comprehensive management of cholangiocarcinoma: Part II. Treatment

    Charilaos Papafragkakis, and Jeffrey H. Lee

    Abstract : Cholangioarcinoma is a rare but dreadful malignancy which poses much difficulties in the management. If detected early with only localized disease, curative resection is possible. However, most patients present in the late stages of the disease, which are managed with endoscopic biliary drainage and/or chemoradiation. Liver transplantation offers a possibility for cure in the distal and the perihilar tumors for selected candidates. Local treatments, such as hepatic artery-based therapies, brachytherapy, and photodynamic therapy, may offer some benefit in cases of the advanced disease. In this review, we will assess the role of preoperative biliary drainage, how best to drain biliary obstruction, and the intricate details of various treatments that are currently available.

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  • Review Article 2017-07-31

    Self-expandable metal stent placement for recurrent cancer in a surgically-altered stomach

    Jung-Hoon Park, Jiaywei Tsauo, and Ho-Young Song

    Abstract : Gastric cancer is one of the most common malignancies and most frequent causes of cancer-related death worldwide. Radical surgical resection accomplished by total or distal gastrectomy represents the mainstay of curative treatment for gastric cancer; however, recurrent cancer still occurs in a significant amount of cases. Patients with recurrent cancer are generally incurable and often experience debilitating symptoms, such as nausea, vomiting, dysphagia, dehydration, and malnutrition, because of malignant gastric-outlet, duodenal, and jejunal obstructions. Consequently, such patients experience progressive deterioration of quality of life. If bypass surgery has not already been performed, it is not usually appropriated in the context of recurrent cancer and is associated with a high risk of morbidity and mortality. Endoscopic or fluoroscopic self-expandable metal stent placement represents an effective and safe method for palliative treatment of recurrent cancer in patients with the surgically-altered stomach. Therefore, it should be considered as the first-line option. Importantly, accurate knowledge of the surgically-altered anatomy and stricture location are critical to achieve successful treatment outcomes.

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  • Review Article 2017-07-31

    Endoscopic ultrasound-guided biliary drainage: Complications and their management

    Hiroyuki Isayama, Yousuke Nakai, Natsuyo Yamamoto, Saburo Matsubara, Yukiko Ito, Hirfoumi Kogure, Tsuyoshi Hamada, and Kazuhiko Koike

    Abstract : Endoscopic ultrasound-guided biliary drainage (EUS-BD), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS) can effectively palliate obstructive jaundice, but have not been well established yet. The incidence of complications is about 30% in EUS-BD and higher for EUS-HGS. Several complications have been reported such as bleeding, perforation and peritonitis. Bleeding occurs due to puncture of portal vein, hepatic vein and artery, and we should use color Doppler. When a cautery dilator is used for fistula dilation, burn effects may cause delayed bleeding. Endoscopic hemostasis is only effective for anastomotic bleeding and embolization with interventional radiology technique is required for pseudo aneurysm. There are some types of perforation: failed stent placement after puncture or fistula dilation, double puncture during CDS procedure, and stent migration. Peritonitis with perforation requires surgery and can be fatal. Stent migration before mature fistula formation causes severe peritonitis because EUS-BD makes fistula between two unattached organs. Stents with flaps or long covered self-expandable metallic stents (cSEMSs) are effective to prevent migration. Recent development of lumen apposing stents may reduce early migration in EUS-CDS. Peritonitis without migration can be due to 1) leakage of bile juice or gastric/duodenal contents during EUS-BD or 2) leakage along the placed stent. We should make procedure time as short as possible, and cSEMSs reduce bile leak along the stent by occluding the dilated fistula. In summary, we should understand the mechanism of complications and the technique to prevent and manage complications. Development of dedicated devices to increase the success rate and reduce complications is required.

    Cited By: 1

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  • Review Article 2017-07-31

    Colonic cancer: The current role of stent insertion

    Katherine Newton, and James Hill

    Abstract : Acute colonic obstruction secondary to left-colonic malignancy remains a common emergency condition. Traditional management is emergency surgery and has high morbidity and mortality. Self expandable metallic stents (SEMS) promised to improve morbidity and mortality, stoma rates and hospital stay. SEMS use in the potentially curative setting, as a bridge to surgery, is associated with an improved stoma rate and morbidity, but has no mortality benefit. There are concerns about oncological safety with higher local recurrence rates, thus SEMS is not recommended in this setting unless the patient has increased surgical risk and would benefit from a period of recovery prior to surgery. SEMS has a definite role in the palliative setting, for both patients with incurable disease or those with a high surgical risk. SEMS is associated with improved morbidity, mortality, and stoma rates. The technique for SEMS insertion is now well established but it is still unclear whether covered or uncovered stents are better.

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  • Review Article 2017-07-31

    Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions

    László Madácsy, and Harry Kaltsidis

    Abstract : Endoscopic ultrasound (EUS)-guided management of abdominal fluid collections adjacent to the gastroduodenal lumen is a relatively new concept attracting a lot of interest in recent years. The ability of EUS to identify and drain these collections in the same session accounts for the surge of interest in these novel techniques. On the other hand, the complexity of these interventions and associated serious complications has moderated the enthusiasm of novice endoscopists to some extent and reiterated that focused research and technical innovations are needed to make EUS-guided drainage simpler and safer. Self-expandable metallic stents (SEMS) have emerged in the last decade in the endoscopic management of malignant luminal gastrointestinal strictures. The use of SEMS in the management of benign conditions (biliary, pancreatic, and colonic strictures) is also rapidly expanding. Recently, fully-covered (FC)-SEMS have been successfully used for drainage of peripancreatic and pericholecystic fluid collections. Here we will review the existing data and future directions in the use of FC-SEMS for such drainage procedures. We will also review the literature on novel “purpose-made” prostheses, such as the lumen-apposing metallic stents, which aim to address technical problems arising in EUS-guided drainage procedures when conventional SEMS are used. Further development of these and other similar devices may transform EUS-guided drainage procedures from an esoteric concept to “mainstream”, first-line intervention.

    Cited By: 0

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  • Review Article 2017-07-31

    Endoscopic ultrasound-guided vascular intervention for portal hypertension

    Raymond Shing-Yan Tang

    Abstract : As endoscopic ultrasound (EUS) equipment improves, the diagnostic and therapeutic applications of EUS in patients with portal hypertension (pHTN) have been increasingly explored. Various EUS-guided vascular interventions for pHTN have been evaluated in human or animal studies. EUS has been shown to be useful in variceal and perforating feeding veins identification, prediction of variceal recurrence/rebleeding, and assessment of response to pharmacological therapy for pHTN. When compared to conventional endoscopic therapies, EUS-guided therapy for varices and/or perforating feeding veins can ensure intra-variceal delivery of injection therapy, allow real-time monitoring of variceal obliteration, and provide injection therapy under pure EUS guidance when the target varix is endoscopically obscured. While the feasibility of EUS-guided assessment of portal hemodynamics and creation of intrahepatic portosystemic shunt has been evaluated, further studies would be needed to assess the long term outcomes before routine application.

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  • Review Article 2017-07-31

    Placement of feeding tubes using fluoroscopy guidance and over-the-wire technique: A technical review

    Jinoo Kim, and Ji Hoon Shin

    Abstract : Nutritional support is essential for improving the outcome in critically ill patients. Enteral nutrition possesses advantages over total parenteral nutrition in that it maintains the physiologic barrier function of the gastrointestinal mucosa. Short-term enteral nutrition can be achieved through transnasal feeding tubes. Traditionally, feeding tubes have been placed at bedside in a blind fashion. However, blind tube placement is unreliable as it may result in improper positioning of the tubes. Numerous complications arising from misplacement have been reported in the literature. A number of modalities may be used in order to improve the accuracy and safety of transnasal feeding tube placement. Fluoroscopy is widely accepted for this purpose. Together with the use of water-soluble contrast media and over-the-wire technique, fluoroscopy-guided placement of nasogastric or nasojejunal feeding tubes offers a higher rate of technical success while decreasing procedure time as well as the incidence of procedure-related complications.

    Cited By: 4

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  • Original Article 2017-07-31

    Complex biliary intervention: Percutaneous small bowel access confirmation with cone-beam computed tomography and retrograde biliary obstruction recanalization

    Jorge E. Lopera, Ryan Hegg, Eric Bready, Ghazwan Kroma, Andres Garza-Berlanga, and Rajeev Suri

    Abstract : BackgroundTo describe our experience with percutaneous small bowel access in patients with surgically altered anatomy for complex biliary intervention where cone-beam computed tomography (CBCT) was used to confirm appropriate small bowel access.MethodsRetrospective chart review from January 2012 to February 2016 identified 9 patients who underwent complex biliary procedures, which used CBCT assistance. Inclusion criteria were creation of percutaneous small bowel access, usage of CBCT, and biliary recanalization. Procedures were performed using percutaneous small bowel access to assist with antegrade or retrograde biliary recanalization using a variety of wire and catheter techniques. Non-contrast CBCT was used in all cases to confirm appropriate small bowel access.ResultsIn three patients with disconnected biliary systems and failed prior attempts at percutaneous recanalization, new bilio-enteric anastomoses were successfully created. In 6 patients with prior hepaticojejunostomy and biliary obstructions, percutaneous jejunostomy was used successfully to recanalize the biliary stenoses and place multiple internal biliary stents, which were then managed with percutaneous retrograde exchanges. Five patients are catheter free; two are currently managed with long-term biliary drainage. One patient eventually required liver transplantation and another required surgical revision of anastomotic restenosis. There was a single major complication in one patient where the jejunostomy tube resulted in small bowel obstruction requiring surgical revision. A minor complication occurred in another patient, with the development of cellulitis around the jejunostomy tube.ConclusionCBCT can effectively confirm appropriate percutaneous small bowel access in patients with surgically altered anatomy, and who require retrograde biliary recanalization. CBCT is also useful to guide percutaneous creation of new bilio-enteric anastomosis in patients with disconnected biliary systems.

    Cited By: 1

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  • Case Report 2017-07-31

    Biodegradable stent insertion for ischaemic colorectal strictures: Tiger country

    Pavan Singh Najran, Damian Mullan, and Hans-Ulrich Laasch

    Abstract : We describe our initial experience with the use of biodegradable (BD) stents in benign ischemic colorectal strictures with two cases. The first case is of a 40-year-old male with a history of retroperitoneal sarcoma who developed a benign stricture in the descending colon postsurgical and radiotherapy treatment. Balloon dilation was required in order to pass the delivery system. The patient experienced significant pain postdeployment and post procedure computed tomography scan demonstrated a small perforation requiring an emergency laparotomy. The second case is a 61-year-old male with a history of retroperitoneal sarcoma who also developed an ischemic stricture in the descending colon after surgical excision. Using a combined fluoroscopic and endoscopic approach 3 separate BD stents were inserted over a 17-month period improving clinical symptoms of intermittent obstruction. These symptoms reoccurred after stent disintegration and the patient was definitively managed surgically with colostomy formation. The use of BD stents, although appealing, does not provide an adequate long term result. Additionally, more flexible, smaller calibre systems are required for deployment in tortuous environments.

    Cited By: 1

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April, 2024
Vol.13 No.2

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