Abstract : Endoscopic ultrasound (EUS)-guided fine-needle aspiration was introduced in the early 1990s. EUS has evolved from a diagnostic modality to a therapeutic tool for patients with various pancreatic neoplasms. Recent advances in EUS-guided interventions include drainage and ablation. EUS-guided treatment provides a minimally invasive option for patients with pancreatic neoplasms instead of surgery or the percutaneous approach. This review aimed to provide an overview of the current EUS-guided ablation treatments, such as ethanol ablation and radiofrequency ablation, for treating various pancreatic tumors.
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Abstract : Endoscopic ultrasound (EUS)-guided drainage of bile ducts is experiencing widespread introduction into clinical algorithms and utilization of its benefits on regular basis. Various types of procedures, including EUS-guided choledochoduodenostomy, EUS-guided hepaticogastrostomy, EUS-guided antegrade drainage facilitate biliary interventions particularly in those cases when endoscopic retrograde cholangiopancreatography fails or is not possible at all, for example in cases with surgically altered anatomy. Available clinical data are encouraging, but prospective and randomized controlled trials are warranted. The need for development of special tools and accessories seems to be essential for safer spreading of these procedures into algorithms of clinical care.
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Abstract : Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has emerged as a promising alternative treatment to high-risk patients suffering from acute cholecystitis and are unfit for surgery. EUS-GBD has similar rates of technical and clinical success compared to other alternative treatments, but the procedure has been shown to reduce adverse event rates and the need for repeated interventions. This review aims to provide a summary of the recent development in the EUS-GBD technique with various devices employed in the procedure.
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Abstract : Endoscopic ultrasound (EUS)-guided pancreatic duct access and drainage can be achieved by EUS-guided rendezvous (EUS-RV) or EUS-guided pancreatic duct drainage (EUS-PD) by transmural stent placement. Although the procedure is utilized for further complex treatment such as intraductal lithotripsy in obstructive pancreatic duct stones, the procedure is technically difficult compared to other EUS-guided interventions. Recently, some devices are developed for EUS-guided pancreatic duct intervention. In this review, technical tips are reviewed in a step-by-step fashion from puncture, guidewire insertion, tract dilation to drainage. Given the advantage of EUS-guided approach, treatment algorithm of endotherapy for pancreatic indications should be further established especially in cases with surgically altered anatomy.
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Abstract : Peripancreatic fluid collections (PFCs) usually occur as a local complication of acute pancreatitis. In the Atlanta classification revised in 2012, local complications are categorized into acute PFC, acute necrotic collection, pancreatic pseudocyst, and walled-off necrosis. The latter two are indications for drainage. With the development of endoscopic ultrasonography (EUS)-guided interventions, EUS-guided drainage of PFCs is now established as a standard treatment due to the advantages of lower cost, shorter hospital stay, and faster recovery. This article provides a brief introduction of PFCs and information on EUS-guided drainage of PFCs with a review of literature.
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Abstract : Endoscopic ultrasonography-guided celiac plexus neurolysis (EUS-CPN) is a widely practiced technique. Three sets of guidelines have recently been published and this procedure has become a major EUS technique. However, there are still several unanswered questions. The purpose of this manuscript is to review the recent literature pertaining to EUS-CPN. Currently, the main indication of EUS-CPN is pancreatic cancer pain. It is also performed for patients with chronic pancreatitis, but the indication is controversial due to its limited efficacy and a high incidence of infectious complications. Various techniques, such as central and bilateral EUS-CPN, and EUS-guided direct celiac ganglia neurolysis (EUS-CGN) have been performed. However, the efficacies of these techniques remain controversial. Complications related to the procedures are generally not serious, but major adverse events, such as paraplegia and ischemic complications, have been reported. The impacts of EUS-CPN on survival have also been evaluated. Although increased survival was expected via improvements in the quality of life, data suggests that EUS-CPN related procedures, especially EUS-CGN, might reduce the survival time. However, precise mechanisms have not been elucidated. In addition to conventional techniques, new techniques, such as EUS-guided celiac ganglion radiofrequency ablation (EUS-RFA) and the use of highly viscous phenol-glycerol, dexmedetomidine, and contrast-enhanced agents, have been introduced. However, these techniques are still in experimental stages. Additional studies need to be conducted to address these gaps in the literature.
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Abstract : Radiofrequency ablation (RFA) has been regarded as an established technique to treat various diseases such as hepatocellular carcinoma, renal cell carcinoma and Barret’s esophagus. Although the application of RFA in the pancreas has been limited due to increased risk of adverse events, endoscopic ultrasound-guided RFA (EUS-RFA) has generated interest as a novel minimally invasive treatment modality which combines real-time visualization with a precise localization of the treatment procedure. For over a decade, the optimization of RFA devices have made EUS-RFA relatively safe, and several studies have supported its feasibility. However, there is insufficient evidence to suggest the appropriate indications and to describe long-term outcomes of EUS-RFA for various pancreatic neoplasms such as pancreatic neuroendocrine tumor, ductal adenocarcinoma, and cystic lesions. Therefore, this review focuses on the technical aspects and clinical applications of EUS-RFA for each pancreatic disease.
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Abstract : Gastric outlet obstruction (GOO) can be caused by benign and malignant diseases. GOO often leads to a decreased quality of life, because of nausea, vomiting, and problems with oral food intake. Traditionally, surgical gastrojejunostomy (SGJ) has been the primary treatment for GOO. Endoscopic enteral stenting (EES) has also been carried out for the treatment of malignant GOO. In recent years, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen apposing metal stent has emerged as a procedure to treat patients with GOO, as an alternative to surgery or to standard endoscopy when EES is not possible. Various techniques, such as direct EUS-GE, assisted EUS-GE, and EUS-guided balloon-occluded gastrojejunostomy bypass have been established to perform EUS-GE safety and accurately. Previous reports of EUS-GE with lumen apposing metal stent demonstrated that the technical and clinical success rates were 87% to 100% and 84% to 100%, respectively, without differentiating the various procedural techniques. The adverse events rate ranged from 0% to 18.1%, and included stent misdeployment, bleeding, peritonitis, leakage, abdominal pain, etc. In addition, the reintervention rate ranged from 0% to 15.1%. Moreover, a comparison of EUS-GE and SGJ showed that there was no significant difference in clinical success, rate of adverse events, or need for reintervention between these procedures. On the other hand, studies comparing EUS-GE with EES showed that EUS-GE may have higher clinical success and a lower rate of stent failure requiring repeated intervention than EES. Furthermore, EUS-GE has been used in several clinical scenarios, such as the management of endoscopic retrograde cholangiopancreatography in patients who underwent Roux-en-Y gastric bypass, or for the treatment of afferent loop syndrome. The present review describes the presently available EUS-GE techniques and introduces the recent clinical advances in the treatment of GOO.
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Abstract : Summary of the Event: A 57-year-old male with chronic pancreatitis presented with an enlarging pseudocyst which was treated with endoscopic ultrasound (EUS)-guided cystogastrostomy. Three days later, he presented with massive hematemesis, and abdominal computed tomography (CT) revealed hemorrhage within both the pseudocyst and the stomach. Endoscopic evaluation was impossible due to the massive amount of hematemesis. Angiography delineated a small pseudoaneurysm with contrast extravasation involving the branch of the splenic artery. Embolization using n-butyl-2 cyanoacrylate was performed leading to the immediate cessation of bleeding. Teaching Point: The risk of delayed hemorrhage after EUS-guided cystogastrostomy for a pancreatic pseudocyst should always be kept in mind. Angiography should be considered for the diagnostic and therapeutic purpose when hemostasis is not possible using an endoscope.
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