Abstract : Endoscopic ultrasound (EUS)-guided tissue acquisition is an established method for the pathologic diagnosis of solid pancreatic masses due to its high accuracy and safety. Currently, EUS-guided biopsy is applied to any lesions adjacent to the gastrointestinal tract that can be visualized with EUS. In this review, conventional and novel types of needles for EUS-guided tissue acquisition are introduced and their diagnostic performance is compared. In addition, technical issues and sampling handling methods to improve diagnostic accuracy are discussed.
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Abstract : Endoscopic retrograde cholangiopancreatography is the standard therapeutic approach for malignant distal biliary obstruction (MDBO). However, it can be challenging in patients with surgically altered anatomy, pyloric/duodenal obstruction, or failed biliary cannulation. Since the development of endoscopic ultrasound (EUS), EUS-guided biliary drainage (EUS-BD) has been increasingly performed. The current article provides a concise review of the latest practices and techniques of EUS-BD procedures for MDBO including EUS-assisted rendezvous, EUS-guided antegrade stenting, EUS-guided choledochoduodenostomy, and EUS-guided hepaticogastrostomy.
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Abstract : Endoscopic retrograde cholangiopancreatography (ERCP) has been established as a standard modality for the palliation of malignant hilar biliary obstruction (MHBO). However, endoscopic stent placement is not possible in some patients because of failed biliary cannulation or tumor invasion that limits transpapillary approaches. In this situation, percutaneous transhepatic biliary drainage (PTBD) can be a reasonable alternative for failed ERCP. However, PTBD has a relatively high rate of adverse events and is frequently associated with patient inconvenience related to the external drainage catheter. Endoscopic ultrasound (EUS)-guided biliary drainage (BD) has therefore been introduced as a reliable alternative modality to PTBD in cases of failed ERCP due to an inaccessible papilla, gastric outlet obstruction, or surgically altered anatomy for MHBO. Although the field of dedicated stents for EUS-BD is rapidly advancing with increasing innovations, the debate on the most appropriate stent for EUS-guided drainage has resurfaced. Furthermore, some important questions remain unaddressed, such as which stent best improves clinical outcomes and safety in EUS-BD for MHBO. This review summarizes the fundamental principles of BD in MHBO, basic technique, technical challenges, clinical outcomes, safety profiles, comparison with other modalities, and the future perspectives of EUS-BD, especially EUS-guided hepaticogastrostomy or hepaticoduodenostomy, for MHBO.
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Abstract : Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a promising minimally invasive technique for patients with gastric outlet obstruction (GOO), regardless of whether a benign or malignant condition impedes gastric emptying. EUS-GE involves creating a bypass from the stomach to the small bowel distally to the obstruction, which is similar to the surgical gastroenteric anastomosis. In fact, EUS-GE has been reported to have longer stent patency in patients with malignant GOO than conventional self-expandable metal stents deployed across a malignant obstruction. Although surgical treatment is still considered the gold-standard treatment for patients with malignant GOO, the results of recent studies have shown not only similar rates of technical and clinical success with EUS-GE, but also lower rates of adverse events. In this review, we aimed to appraise the current status of EUS-GE, describe the multiple techniques to perform this procedure, compare the outcomes of EUS-GE with those of other therapeutic modalities, and discuss the related adverse events and the future perspectives of EUS-GE.
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Abstract : Endoscopic ultrasound (EUS)-guided ablation procedures are emerging as minimally invasive therapeutic methods that address unmet needs in treatment methods for pancreatic cystic lesions (PCLs). Several studies have been published on the feasibility and efficacy of EUS-guided chemical ablation for PCLs, but further research on the actual treatment effects and real clinical benefits is needed. EUS-guided radiofrequency ablation for PCLs has recently been introduced. This review aimed to describe the broad framework of EUS-guided ablation treatments for PCLs and to present a blueprint for the future of these treatment methods.
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Abstract : Cancer associated abdominal pain, as typified by pancreatic cancer, has conventionally been treated with narcotic drugs, but often the severe abdominal pain is difficult to control. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) is commonly performed for abdominal pain that is difficult to control. EUS-CPN can be performed more safely and reliably than other conventional procedures on the celiac plexus, and good outcomes of pain relief have been reported. Although a variety of endoscopic techniques are available for EUS-CPN, the choice varies among institutions, and evidence on the efficacy and safety of each procedure is limited. In this review, we summarize the indications for treatment, specific endoscopic techniques, therapeutic efficacy for pain relief, and complications from previous reports on EUS-CPN.
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Abstract : In the modern era, endoscopic retrograde cholangiopancreatography (ERCP) and therapeutic endoscopic ultrasound (EUS) are increasingly being performed in day-care settings. The safety of these procedures in elderly admitted patients has been established in previous studies, but evidence for the safety of day-care ERCP/therapeutic EUS is limited. We retrospectively analyzed the outcomes of day-care ERCP/EUS in patients more than 80 years of age. All procedures were done under total intravenous anesthesia (ketamine- and propofol-based) and the intra-procedural and immediate postprocedural complications (within 6 hours) were noted. Thirty patients (24 male and 6 female) were enrolled. The most common indication for the procedure was choledocholithiasis (46.6%), followed by malignant stenosis (30.0%) and benign strictures (20.0%). One patient had transient desaturation during the procedure and two patients had hypotension. The dreaded complications of bleeding, perforation, or pancreatitis did not occur in any patients, and none required admission. In conclusion, day-care therapeutic ERCP/EUS is safe and cost-effective in the oldest old patients.
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Abstract : Jejunal Dieulafoy lesion (DL) is an exceedingly rare, life-threatening cause of gastrointestinal bleeding. Due to its rarity, intermittent bleeding symptoms that often necessitate prompt clinical intervention, variability in detection and treatment methods, and the risk of rebleeding, this condition frequently presents a diagnostic and therapeutic conundrum. We report a case of severe, intermittent, recurrent hematochezia due to a jejunal DL that was difficult to localize. In this case, the metallic coils used as a radiopaque marker allowed surgeons to accurately identify the bleeding site during intraoperative enteroscopy and successfully manage the lesion with minimally invasive laparoscopic surgery.
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Abstract : Peroral endoscopic myotomy (POEM) can be safely performed for achalasia. During POEM, gas is insufflated via the endoscope inside the submucosal tunnel. Gas-related complications often cannot be avoided because of the lack of serosa in the esophagus and the inability of the adventitia to function as a resistant barrier to gas. However, tension pneumothorax causing respiratory failure is a rare complication of POEM. Herein, we describe a 32-year-old female who developed tension pneumothorax after POEM. She showed respiratory compromise after POEM, and emergency chest radiography revealed pneumothorax with mediastinal shift. Tension pneumothorax was managed by chest tube drainage with the application of negative-suction pressure via the tube, after which her vital signs stabilized. On post-procedural day 4, the tube was removed. Our case suggests the importance of considering tension pneumothorax if respiratory compromise occurs despite oxygen administration after POEM even in the absence of immediate complications during the procedure, and performing chest radiography promptly.
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Abstract : Radiologically inserted gastrostomy (RIG) is performed in patients who cannot safely or sufficiently receive oral nutrition; however, postoperative complications are not uncommon. The risk of major complications such as peritonitis, migration, infection, malposition, and bleeding is small but appreciable, although mortality as a direct consequence of gastrostomy placement is rare. In this case series, we describe the major gastrostomy complications (arterial haemorrhage, gastric fluid leak, peritonitis, RIG site infection, ileus and colon perforation) that occurred in four patients at our hospital over a 27-month period in which 152 RIG procedures were performed (an incidence rate of 2.6%). Herein, we describe the gastrostomy procedures, clinical course, and surgical corrections required for these patients before discussing the complication risks for common gastrostomy procedures and potential methods to reduce and prevent such complications.
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Nozomi Okuno, Kazuo Hara, Nobumasa Mizuno, Susumu Hijioka, Takamichi Kuwahara, Masahiro Tajika, Tsutomu Tanaka, Makoto Ishihara, Yutaka Hirayama, Sachiyo Onishi, and Yasumasa Niwa
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