Transjejunal endoscopic ultrasound-guided pancreatic drainage for pancreatic jejunostomy stricture using a forward-viewing echoendoscope in a patient with altered anatomy

The Role and Appropriate Selection of Guidewires in Biliopancreatic Endoscopy

Guidewires are indispensable tools in biliopancreatic endoscopy, playing a critical role in facilitating access and enabling the advancement of various devices during interventions such as Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Ultrasound (EUS)-guided procedures. These devices are primarily used to achieve and maintain access to lumens, ensuring the success of complex therapeutic maneuvers. Guidewires vary widely in terms of material, structure, length, diameter, and tip shape, offering distinct advantages depending on the clinical context. Therefore, selecting the appropriate guidewire is crucial and must be tailored to the specific requirements of each procedure. This article provides a comprehensive review of the current landscape of guidewire use in biliopancreatic endoscopy, emphasizing their importance, characteristics, and best practices for selection to optimize patient outcomes. By reviewing existing guidelines and the literature, this paper aims to enhance the endoscopist's understanding of guidewire technology and its application in biliopancreatic endoscopy.

Transanastomotic Forward-Viewing EUS-Guided Pancreatic Duct Drainage via Afferent Loop for Pancreaticojejunostomy Anastomotic Stricture After Pancreaticoduodenectomy

BACKGROUND

Although balloon enteroscopy-assisted ERCP and transgastric EUS-guided pancreatic duct drainage (EUS-PD) are treatment option for pancreaticojejunostomy anastomotic stricture (PJAS), they are often challenging with several limitations. This study aimed to examine the feasibility of transanastomotic forward-viewing EUS-PD (FVEUS-PD) via the afferent loop for PJAS after pancreaticoduodenectomy.

METHODS

Ten consecutive patients with symptomatic PJAS who underwent FVEUS-PD between 2015 and 2021 were retrospectively evaluated. Study outcomes included technical and clinical success, adverse events, and recurrence rates associated with FVEUS-PD. A short dumbbell-shaped, fully covered metal stent was deployed in all cases, and the stent was removed 3 month after placement, after which it became stent-free.

RESULTS

The technical success rate was 80% (8/10), and the scope could not reach the PJAS in two patients. Clinical success was achieved in all technically successful patients. No procedure-related adverse events observed. All patients were followed up for over three years after metal stent removal and becoming stent-free; the median follow-up period was 63 month. One patient developed symptomatic stricture recurrence 36 month after removal, with a stricture recurrence rate of 13% (1/8). The remaining patients did not experience any recurrence or late adverse events during the study period.

CONCLUSIONS

This study is the first to investigate FVEUS-PD, demonstrating promising technical feasibility with low adverse event and recurrence rates, potentially becoming a useful treatment option for PJAS.

Endoscopic Ultrasonography-Guided Drainage of the Pancreatic Duct (EUS-PD)-Indications and Results with a Literature Review

Background/Objectives: Drawing upon over twenty years of clinical experience in endoscopic and endosonographic procedures, along with comprehensive literature research, we present an overview on EUS-guided pancreatography and pancreatic duct drainage (EUS-PD) as an alternative approach, encompassing indications, procedural methods, and outcomes, including complications and the success rate. Methods: Narrative review. Results: (corner points): EUS-PD is indicated for cases, for which conventional methods are ineffective due to altered abdominal anatomy of the upper gastrointestinal (GI) tract, such as congenital or postoperative conditions that prevent access to the papilla or pancreatoenteric anastomosis. It is also considered if there is symptomatic retention of the pancreatic duct due to pathological changes in the papillary region or stenosis of the pancreatic duct or anastomosis, especially if surgery is not feasible or poses higher risks. EUS-PD has a technical success rate ranging from 25 to 92%, albeit with a complication rate spanning from 14 to 40%, primarily comprising bleeding, perforation, pancreatitis, and pain. Long-term clinical success, measured by pain and symptom relief, falls within a range of 65-85%. Conclusions: The method offers advantages such as minimal invasiveness, enhanced quality of life, the potential for endoscopic revision in the case of complications, and compatibility with most conventional endoscopic instruments requiring extensive expertise in interventional endoscopy and endosonography.

A balloon-assisted endoscopic submucosal dissection using long colonoscope and guidewire

Balloon-assisted endoscopy enables stable endoscopic maneuverability. Balloon-assisted endoscopic submucosal dissection (BA-ESD) is useful in the treatment of proximal colorectal tumors where scope maneuverability is poor. Herein, we reported a case in which BA-ESD was successfully performed using a long colonoscope with a guidewire, although the lesion could not be reached using the balloon-assisted endoscopy technique with a therapeutic colonoscopy. A 50-year-old man underwent a colonoscopy that revealed a tumor in the ascending colon. BA-ESD was performed using a conventional therapeutic endoscope due to excessive intestinal elongation and poor endoscopic maneuverability. However, the transverse colon loop could not be reduced, and the total colonoscopy failed despite using balloon-assisted endoscopy. The scope was then changed from a conventional colonoscope to a long colonoscope, inserted into the terminal ileum, and the loop was reduced. After the guidewire was placed at the terminal ileum and the long colonoscope was removed, a therapeutic colonoscopy with an overtube was inserted into the ascending colon without reforming the colonic loop, allowing safe BA-ESD.

Forward viewing liner echoendoscopy for therapeutic interventions

Therapeutic endoscopic ultrasonography (EUS) procedures using the forward-viewing convex EUS (FV-EUS) have been reviewed based on the articles reported to date. The earliest reported procedure is the drainage of pancreatic pseudocysts using FV-EUS. However, the study on drainage of pancreatic pseudocysts focused on showing that drainage is possible with FV-EUS rather than leveraging its features. Subsequently, studies describing the characteristics of FV-EUS have been reported. By using FV-EUS in EUS-guided choledochoduodenostomy, double punctures in the gastrointestinal tract can be avoided. In postoperative modified anatomical cases, using the endoscopic function of FV-EUS, procedures such as bile duct drainage from anastomosis, pancreatic duct drainage from the afferent limb, and abscess drainage from the digestive tract have been reported. When a perpendicular puncture to the gastrointestinal tract is required or when there is a need to insert the endoscope deep into the gastrointestinal tract, FV-EUS is considered among the options.