Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage

EUS-guided cholecystenterostomy: a new technique (with videos)

BACKGROUND

The cornerstone of management for acute cholecystitis is cholecystectomy. However, surgical intervention is contraindicated in the occasional patient. EUS-guided transduodenal gallbladder drainage may represent an effective minimally invasive alternative.

OBJECTIVES

To describe a new technique, EUS-guided cholecystenterostomy.

DESIGN AND SETTING

A single-center retrospective case series.

PATIENTS

Three patients with severe acute cholecystitis unresponsive to conservative management who were deemed unfit for cholecystectomy.

INTERVENTIONS

Under combined EUS and fluoroscopic guidance, cholecystenterostomy was performed via needle puncture, guidewire insertion, cystoenterostome passage, and stent placement.

MAIN OUTCOME MEASURES

Technical success, clinical progress, immediate and long-term complications, and recurrence of cholecystitis.

LIMITATIONS

Pilot series.

RESULTS

Cholecystenterostomy was performed successfully in all patients. Rapid improvement in clinical status and inflammatory parameters ensued. A minor intraprocedural bile leak occurred in 1 patient, without significant clinical sequelae. Cholecystitis did not recur in any patient.

CONCLUSIONS

EUS-guided cholecystenteric drainage is technically feasible and appears to be a safe and effective procedure. Via this technique, gallbladder drainage and resolution of related sepsis may be achieved in patients with acute cholecystitis who are unfit for surgery.

Endoscopic evaluation and palliation of pancreatic adenocarcinoma: current and future options

PURPOSE OF REVIEW

To analyze the role of endoscopy in the diagnosis and treatment of pancreatic adenocarcinoma. New developments, including molecular analysis of endoscopic tissue samples and injection of antitumor agents, are discussed.

RECENT FINDINGS

Endoscopic ultrasound is superior to multidetector computed tomography for detection of smaller than 3-cm pancreatic tumors, and for T staging, while they are equivalent for nodal staging and assessment of resectability. Molecular analysis of endoscopic ultrasound-guided fine-needle aspiration samples has the potential to improve cancer detection. Placement of biliary self-expanding metal stents prior to Whipple resection appears to be an option to reduce stent obstruction and allow neo-adjuvant therapy. Endoscopic ultrasound-guided biliary drainage is a new approach to patients who failed to have a biliary stent placed by endoscopic retrograde cholangiopancreatography. Contrast-enhanced endoscopic ultrasound may be useful to differentiate focal inflammation from pancreatic carcinoma. Optical coherence tomography was shown to distinguish nonneoplastic from neoplastic main pancreatic duct tissue. Finally, endoscopic ultrasound-guided interstitial brachytherapy and injection of therapeutic agents into tumors have shown exciting preliminary results.

SUMMARY

Endoscopic approaches for diagnosis and palliation of pancreatic adenocarcinoma are rapidly expanding. These new techniques show promise in the diagnosis, staging, and treatment of pancreatic malignancy.

Endoscopic ultrasonography (EUS)-guided access and therapy of pancreatico-biliary disorders: EUS-guided cholangio and pancreatic drainage

Endoscopic ultrasonography (EUS)-guided cholangio pancreatic drainage (ECPD) has been reported as an alternative to surgery or percutaneous transhepatic cholangiography if endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. With the development of EUS and the ability to direct a puncture within the field of vision, ECPD has been used increasingly in tertiary centers. Its concept includes EUS-guided access into a dilated biliary tree or main pancreatic duct, creation of a transenteric fistula deployment of a stent across the fistula or the ampulla after a rendezvous-type procedure. EUS-guided cholangio-drainage may be performed in a transhepatic or extrahepatic fashion, whereas EUS-guided pancreatic drainage can be antegrade or retrograde. Their respective efficacy can be measured by resolution of biliary obstruction or pain improvement in case of pancreatic drainage. The current literature, including our own data, shows that ECPD has an acceptable success and complication rate and might be considered as first-line therapy in centers offering expertise in EUS and ERCP. The techniques, efficacy, and complication of ECPD are discussed.

Endosurgery: what do we need?

A paradigm shift in therapeutic endoscopy occurred with the advent of mucosectomy for the treatment of mucosal neoplasms and suture plication for gastroesophageal reflux disease. The objectives changed from finding simple, easy, and quick alternatives to surgery to reproducing surgical results. A radical version of flexible endoscopy has emerged to meet new goals of full-thickness resections, creation of anastomoses, and lumen reconfiguration. This will require a new generation of endosurgical tools that cut, stitch, and staple with added dimensions of multiaxis orientation and triangulation.

Endoscopic ultrasound of the upper gastrointestinal tract and mediastinum: diagnosis and therapy

Endoscopic ultrasound (EUS) has developed significantly over the last two decades and has had a considerable impact on the imaging and staging of mass lesions within or in close proximity to the gastrointestinal (GI) tract. In conjunction with conventional imaging such as helical computed tomography and magnetic resonance imaging, the indications for EUS include (1) differentiating between benign and malignant lesions of the mediastinum and upper GI tract, (2) staging malignant tumors of the lung, esophagus, stomach, and pancreas prior to surgery or oncological treatment, (3) excluding common bile duct stones before laparoscopic cholecystectomy, thereby avoiding the need for endoscopic retrograde cholangiopancreatography (ERCP) in some patients, and (4) assessing suspected lesions that are either equivocal or not seen on conventional imaging. In recent years, EUS has charted a course similar to that taken by ERCP, evolving from a purely diagnostic modality to one that is interventional and therapeutic. These indications include (5) obtaining a tissue diagnosis by EUS-guided fine-needle aspiration or trucut-type needle biopsy and (6) providing therapy such as coeliac plexus neurolysis and pancreatic pseudocyst drainage--in many cases, more accurately and safely than conventional techniques. Emerging investigational techniques include EUS-guided enteric anastomosis formation and fine-needle injection therapy for malignant disease.

Interventional pancreaticojejunostomy after pancreatoduodenectomy

BACKGROUND

Leakage from the pancreaticoenteric anastomosis after pancreatoduodenectomy (PD) is closely associated with intra-abdominal hemorrhage with ensuing high mortality.

METHODS

Interventional pancreaticojejunostomy was performed in 10 patients with external drainage of pancreatic juice after two-staged PD or leakage from pancreaticojejunostomy after PD. The jejunum was punctured using a 22-gauge needle into the pancreatic fistula during endoscopic observation of the jejunal lumen, followed by the insertion of two 0.35-inch guide-wires into the jejunum and pancreatic fistula. Finally, a stenting tube was placed between the jejunum and pancreatic fistula.

RESULTS

No severe complications developed. Oral intake was instituted the following day in 8 of 10 patients, and on the 7th day in the remaining two patients.

CONCLUSION

This interventional procedure is considered to be safe and easy to perform, and in the future, it may permit a reduction in the number of second laparotomies in pancreatic fistula.

Interventional EUS-guided cholangiography: evaluation of a technique in evolution

BACKGROUND

Interventional EUS-guided cholangiography (IEUC) has been increasingly used as an alternative to percutaneous transhepatic cholangiography (PTC) in cases of biliary obstruction when ERCP is unsuccessful.

OBJECTIVE

We reviewed our experience and technique used for this procedure.

DESIGN

Over a 3-year period, ending July 2005, patients with a failed ERCP were offered an IEUC.

SETTING

Tertiary care center offering ERCP and interventional EUS.

PATIENTS

Twenty-eight patients were candidates for IEUC. Two patients had bleeding masses and were referred to interventional radiology, 1 patient had a large mass occupying the duodenal lumen, and 2 patients refused IEUC.

INTERVENTION

EUS was used to access the biliary system after which a guidewire was advanced antegrade across the obstruction. Either rendezvous with retrograde or antegrade drainage was then accomplished.

MAIN OUTCOME MEASUREMENTS

Efficacy and safety of IEUC for biliary decompression.

RESULTS

IEUC was successfully performed in 23 patients, with a transgastric-transhepatic (intrahepatic) approach in 13 cases and transenteric-transcholedochal (extrahepatic) approach in 10 cases. Therapeutic benefit was achieved in 21 patients: 18 underwent successful stent deployment across the stricture, whereas 3 patients required a choledochoenteric fistula formation. Complications included 1 case of bile leak, 2 cases of self-limited pneumoperitoneum, and 1 case of minor bleeding.

LIMITATIONS

Single-center experience of 2 operators.

CONCLUSIONS

IEUC appears efficacious in patients in whom ERCP is unsuccessful and is evolving as an attractive alternative to PTC. Intrahepatic access to the biliary system appears safer than the extrahepatic approach.

Interventional endoscopic ultrasound in pancreatic diseases

During the last 15 years, endoscopic ultrasound (EUS) has become an important imaging procedure for diagnosis and management of pancreatic diseases. The clinical interest of EUS is now enhanced by interventional procedures. Noteworthy, fine-needle aspiration biopsy is one of the most important contributions of EUS, in particular for the investigation of patients with pancreatic cancer and cystic tumors. EUS-guided fine-needle aspiration appears to be a safe and reliable technique to obtain tissue from pancreatic masses with a low risk of complications. EUS became also a therapeutic procedure, especially applied for celiac plexus neurolysis, pseudocyst drainage, and pancreaticogastrostomy. Further developments are expected by improvement of needle devices such as pancreatic pseudocyst drainage kits. In the future, EUS might be also a support for local application of new treatments of pancreatic tumors, such as gene or cellular therapy products. In this review, we discuss the current clinical applications of interventional EUS and the future development for diagnosis and management of pancreatic diseases.

Interventional applications of endoscopic ultrasound

Endoscopic ultrasound, which was developed more than 20 years ago, is currently a valuable investigative tool for endoscopists. It began as a diagnostic instrument and in the short span of a decade made a clinical impact as a therapeutic tool with a promising potential for various interventional applications. The introduction of the curved linear array echoendoscope in the 1990s enabled a whole range of interventional applications of endoscopic ultrasound ranging from fine needle aspiration of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This review article outlines the current interventional applications of endoscopic ultrasound and discusses potential future procedures. These procedures include endoscopic ultrasound guided creation of communication between the gastrointestinal tract and adjacent organs, such as hepaticogastrostomy and choledochoduodenostomy.

Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series

OBJECTIVES

Endoscopic retrograde cholangiography is an established method for treatment of common bile duct stones as well as for palliation of patients with malignant pancreaticobiliary strictures. It may be unsuccessful in the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic biliary drainage and surgery are alternative methods with a higher morbidity and mortality in these cases. Recently, endoscopic ultrasound (EUS) guided biliary stent placement has been described in patients with malignant biliary obstruction. We describe our experience with this method that was also used for the treatment of cholangiolithiasis for the first time.

METHODS

The EUS guided transduodenal puncture of the common bile duct with stent placement was performed in 5 patients. In 2 of these patients, the stents were removed after several weeks and common bile duct stones were extracted. In another patient with gastrectomy, the left intrahepatic bile duct was punctured transjejunally and a metal stent was introduced transhepatically to bridge a distal common bile duct stenosis.

RESULTS

Biliary decompression was successful in all 6 patients. No immediate complications occurred. One patient developed a subacute phlegmonous cholecystitis.

CONCLUSIONS

Interventional EUS guided biliary drainage is a new technique that allows drainage of the biliary system in benign and malignant diseases when the bile duct is inaccessible by conventional ERCP.

EUS-guided transhepatic cholangiography: report of 6 cases

BACKGROUND

This report describes a novel application of EUS-guided cholangiography in which a transhepatic approach was used to alleviate perihilar and distal biliary obstructions when this could not be accomplished at ERCP.

METHODS

EUS-guided transhepatic cholangiography was used to alleviate symptoms of biliary obstruction in 6 patients. In 4 cases, after transgastric puncture of an intrahepatic branch of the obstructed bile duct with a 19- or a 22-gauge EUS needle, a guidewire was advanced antegrade across both the biliary stricture and the papilla. Subsequently, a rendezvous procedure was performed, allowing ERCP and stent placement.

OBSERVATIONS

EUS-guided transhepatic cholangiography was performed in 6 patients, with successful rendezvous ERCP and stent placement in 4, and transduodenal stent placement in another patient. Stent placement was unsuccessful in one patient, because of the inability to advance a guidewire into the common hepatic duct. There was no immediate complication of the procedures.

CONCLUSIONS

EUS-guided transhepatic cholangiography can be used to access and to drain bile ducts that are obstructed by proximal, as well as distal lesions when ERCP is unsuccessful.

Future therapeutic indications for endoscopic ultrasound

Attempts to perform therapy guided by endoscopic ultrasound (EUS) are rare. Some new indications for interventional and therapeutic endoscopic procedures performed under EUS control have been developed in areas that have been purely surgical for many years. Indications, procedures, and related tools for EUS-guided endosurgery are described, all of which are experimental but may open a new corridor for endoscopists to enter a variety of transluminal procedures in real time without soiling the peritoneal or mediastinal cavity.

Endoscopic ultrasonography

Endoscopic ultrasound (EUS) was introduced in the early 1980s in an attempt to improve sonographic imaging of the pancreas. Its uses have been expanded to include examination of the upper and lower gastrointestinal tracts, hepatobiliary and portal systems,and the anal sphincter; diagnosis and staging of esophageal, gastric,and pancreaticobiliary tumors; and evaluation of mediastinal nodes in lung cancer. Although EUS has its limitations and is greatly dependent on operator skill, it has wide-ranging interventional and therapeutic applications that can be expected to increase in the future with technologic advances and greater educational opportunities for physicians.

Interventional EUS cholangiography: A report of five cases

BACKGROUND

ERCP may be unsuccessful because of the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic cholangiography is a classic technique for accessing the bile duct and remains the primary alternative when biliary ERCP is unsuccessful. With the evolution of interventional EUS, additional options are available for management of biliary obstruction.

METHODS

EUS cholangiography was performed, after which the puncture was enlarged to form an enterocholedochal fistula that was used for interventions that resulted in biliary decompression in 5 patients with obstructive jaundice.

OBSERVATIONS

Cholangiography was readily performed in all 5 patients. In one patient, a guidewire could not be manipulated across the papilla via the enterocholedochal fistula, necessitating percutaneous intervention. Biliary decompression was achieved in the other 4 patients, in the last two, as a single procedure.

CONCLUSIONS

Interventional EUS cholangiography is a new technique that allows drainage of a dilated biliary system when the bile duct is inaccessible by conventional ERCP.

Ultrasound-guided endoscopic surgery

Ten years' development of sectorial linear endoscopic ultrasound (EUS) has allowed us to perform guided biopsies of lymph nodes, mediastinal masses and pancreatic tumours. Furthermore, biopsy guided by EUS has been the first step in the development of interventional EUS. This development, in turn, has been made possible by the appearance of the interventional echoendoscope with a large working channel. EUS-guided biopsy obtains the best results for lymph nodes, anastomotic relapses and extrinsicz compression as well as for pancreatic tumours. Results in the literature show a global sensitivity of the technique that varies between 76 and 91%, a specificity of 84-100% and an accuracy of 78-94%. Using alcohol injection of the plexus nerves, the coeliac block guided by EUS is a simple technique. It will replace percutaneous access under US or CT scan guidance. Data from the literature show a significant reduction in pain of the order of 85-90% of cases-results that would have been good for percutaneous techniques. The technique of cystoenterostomy guided by EUS allows more accurate drainage of the cysts with a lower risk of perforation and haemorrhage. With regard to haemorrhage it should be emphasized that colour Doppler and power Doppler assessment of the punctures rules out the risk of vascular perforation during puncture but the risk of haemorrhage due to decompression of a vascular lesion in the vicinity of the cyst remains. The new ultrasound echoendoscope EG 38X, with a large working channel (3.8 mm), is now available. This system allows more effective drainage and also enables the placement of cystodigestive stents.

EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases

BACKGROUND

Only a few cases have been reported of EUS-guided drainage of obstructed pancreatic or bile ducts. An initial experience with EUS-guided rendezvous drainage after unsuccessful ERCP is reported.

METHODS

EUS-guided transgastric or transduodenal needle puncture and guidewire placement through obstructed pancreatic (n=4) or bile (n=2) ducts was attempted in 6 patients. Efforts were made to advance the guidewire antegrade across the papilla or surgical anastomosis. If guidewire passage was successful, rendezvous ERCP with stent placement was performed immediately afterward.

RESULTS

EUS-guided duct access and intraductal guidewire placement was accomplished in 5 of 6 cases, with successful traversal of the obstruction, and rendezvous ERCP, with stent placement in 3 of 6 cases (two biliary, one pancreatic). The procedure was clinically effective in all successful cases (two patients with malignant obstructive jaundice, one with relapsing pancreatitis after pancreaticoduodenectomy). There was one minor complication (transient fever) but no pancreatitis or duct leak after successful or unsuccessful procedures.

CONCLUSIONS

EUS is a feasible technique for allowing rendezvous drainage of obstructed biliary or pancreatic ducts through native papillae or anastomoses after initially unsuccessful ERCP.

EUS antegrade pancreatography with gastropancreatic duct stent placement: Review of two cases

BACKGROUND

Endoscopic retrograde pancreatography is an established procedure for palliation of patients with pain caused by chronic pancreatitis associated with pancreatic ductal stricture. Some patients may not be candidates for endoscopic retrograde pancreatography because of surgically altered anatomy. Two cases are presented in which endoscopic retrograde pancreatography was unsuccessful and EUS-guided antegrade pancreatography with gastropancreatic stent placement was performed.

METHODS

EUS-guided antegrade pancreatography was performed in both patients by creating a gastropancreatic fistula through which dilation and stent placement were performed over a guidewire.

RESULTS

Stent insertion was successful in both cases. Both patients experienced rapid improvement in symptoms.

CONCLUSIONS

EUS-guided antegrade pancreatography with stent placement may be an alternative to endoscopic retrograde pancreatography when surgical reconstruction precludes access to the major and minor papillae.

EUS-cholangio-drainage of the bile duct: report of 4 cases

BACKGROUND

Endoscopic retrograde cholangiography with stent insertion is an established procedure for palliation of patients with malignant pancreaticobiliary strictures. In some patients, however, placement of a stent by means of a duodenoscope is not possible. Percutaneous transhepatic biliary drainage is an alternative method that has a complication rate of up to 15%. Four cases of successful EUS-guided-cholangio-drainage are presented in which the major papilla could not be cannulated at endoscopic retrograde cholangiography.

METHODS

For puncture of the intrahepatic or extrahepatic bile duct, a modification of the one-step technique for the drainage of pancreatic pseudocysts was used.

RESULTS

Stent insertion was successful in 3 of the 4 patients. In these 3 patients cholestasis resolved promptly.

CONCLUSIONS

EUS-guided cholangio-drainage is a potential alternative to percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiography in the therapy of malignant pancreaticobiliary strictures, especially in patients who have undergone gastrectomy or partial gastrectomy with Billroth II reconstruction.

Endoscopic ultrasound of the pancreas: tissue acquisition and intervention

Endoscopic ultrasound is an established modality for staging gastrointestinal and pancreatic malignancies. Since the development of the linear array echoendoscope, the field of interventional endoscopy has continued to evolve as an adjunctive method to standard endosonography. The ability to sample extraluminal lesions or lymph nodes has overcome the initial limitations of endoscopic ultrasound and provided a list of attractive endoscopic ultrasound-guided therapeutic applications.This review focuses on recent advancements in the field of interventional endosonography related to the diagnosis and therapy of pancreatic diseases. In particular, the article reviews the role of endoscopic ultrasound-guided fine-needle aspiration in diagnosing various pancreatic diseases; the role of endoscopic ultrasound-guided fine-needle injection in delivering neurolytic, chemotherapeutic, or biologic agents; and emerging procedures like endoscopic ultrasound-assisted biliary bypass in the setting of malignant biliary obstruction.