EUS-guided transesophageal, transgastric, and transcolonic drainage of intra-abdominal fluid collections and abscesses

Clinical outcomes of EUS-guided transluminal drainage with a novel lumen-apposing metal stent for postoperative pancreatic fluid collection after pancreatic surgery

BACKGROUND AND AIMS

EUS-guided transluminal drainage (EUS-TD) is increasingly used for the treatment of postoperative pancreatic fluid collections (POPFCs). A novel lumen-apposing metal stent (LAMS) was recently developed and used for the drainage of POPFCs. This study aimed to evaluate the efficacy and safety of a novel LAMS in patients with POPFCs.

METHODS

Forty-seven patients with symptomatic POPFCs who underwent EUS-TD with a novel LAMS (Niti-S SPAXUS; Taewoong Medical Co, Ltd, Ilsan, South Korea) between April 2019 and July 2020 were included in this study. Clinical outcomes, including technical success, clinical success, and adverse events, were retrospectively evaluated.

RESULTS

EUS-TD was technically successful in 41 of 47 patients (87.2%). Clinical success was achieved in 37 of 41 patients (90.2%). The mean procedure time was 13.7 ± 3.5 minutes. The mean POPFC size was 59 ± 18.9 mm. The mean time interval from surgery to EUS-TD was 24.2 ± 37.6 days. Five patients experienced 6 procedural adverse events (12.8%): 4 (8.5%) POPFC infections and 2 (4.3%) distal stent migrations. The 4 patients with POPFC infection underwent additional endoscopic interventions. Of the 2 patients with stent migration, 1 underwent laparoscopic exploration and surgical extraction of the stent and 1 (2.1%) experienced POPFC recurrence, which was managed with percutaneous drainage.

CONCLUSIONS

EUS-TD for symptomatic POPFCs with a novel LAMS is technically feasible and effective, with an acceptable adverse event rate. Further larger-scale prospective studies are required to confirm the findings of this study.

Extrapancreatic Advanced Endoscopic Interventions

As the field of interventional endoscopy advances, conditions that were once treated with surgery are increasingly being treated with advanced endoscopy. Endoscopy is now used for treatment of achalasia, bariatric procedures for obesity; resection of early-stage malignancies in the gastrointestinal tract; and placement of lumen-apposing metal stents in the treatment of biliary obstruction, gastric outlet obstruction, cholecystitis, and drainage of nonpancreatic-related fluid collections or abscesses. Knowledge of the novel terminology, procedural details, expected postintervention imaging findings, and potential complications is vital for radiologists because these procedures are rapidly becoming more mainstream in daily practice. These procedures include peroral endoscopic myotomy for the treatment of achalasia and other esophageal motility disorders; endoscopic sleeve gastroplasty and placement of an intragastric balloon for weight loss; endoscopic submucosal dissection in the resection of tumors of the gastrointestinal tract; and therapeutic endoscopic-guided procedures for the treatment of biliary obstruction, gastric outlet obstruction, acute cholecystitis, and drainage of nonpancreatically related fluid collections. Patients benefit from these minimally invasive procedures, with potential improvement in morbidity and mortality rates, decreased length of hospital stay, and decreased health care costs when compared with the surgical alternative. Complications of these procedures include leaks or perforations, infections or abscesses, fistulas, and occlusion and migration of stents. An invited commentary by Pisipati and Pannala is available online. ^©RSNA, 2022.

More than Just a Hole in the Wall: Evolving Management and Treatment Paradigms of Suppurative Gastritis

Suppurative gastritis is an uncommon lesion and often an occult cause of upper abdominal pain without florid signs of a septic focus. There are two main phenotypic forms: (1) localized, also referred to as gastric abscess; and (2) diffuse, in which the differential diagnosis includes a more diverse range of benign and malignant lesions. Cross-section imaging such as CT allows for rapid diagnosis and demonstrates the location and extent, but not the specific etiology, of the lesion. High-frequency endoscopic ultrasound (EUS) and fine needle aspiration (FNA) have greatly improved the safety and diagnostic accuracy of suppurative gastritis. EUS/FNA provides an opportunity to arbitrate among infectious and malignant or benign tumors, to identify specific pathogens, and in cases of localized gastric abscesses, for resolution by decompression. More advanced endoscopic procedures are rapidly emerging to supplement EUS/FNA, which already demonstrate the promise of improved, minimally-invasive diagnosis and effective management for the diverse range of lesions causing suppurative gastritis.

EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series

Background and Aims

Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes. The aim of this study was to evaluate the safety and efficacy of EUS-TRD with LAMSs in patients with PFCs.

Methods

A retrospective analysis of a prospectively maintained database on therapeutic EUS was conducted. All EUS-TRD procedures were included.

Results

Five patients (2 male, age 44-89 years) were included. Four patients had postoperative PFCs, and 1 presented with a pelvic abscess complicating acute diverticulitis. Two of 5 had fecal diversion; the remaining 3 had unaltered large-bowel anatomy. One case had a concomitant abdominal collection, treated with percutaneous drainage in the same session. An electrocautery-enhanced LAMS delivery system (15 × 10 mm) was used in all cases. EUS-TRD was performed with the direct-puncture technique and lasted less than 10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required, and the procedure length was 14 minutes. The clinical success rate was 100%. LAMSs were removed after a median of 14 (range, 12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed.

Conclusion

EUS-TRD with LAMSs is a safe and effective technique for treatment of PFCs. The use of 15- × 10-mm LAMSs allows rapid PFC resolution. EUS-TRD could be performed not only in patients with fecal diversion but also in cases of unaltered anatomy.

EUS anatomy of the pancreatobiliary system in a swine model: The WISE experience

Background and Objectives

EUS training is recognized to have a substantial learning curve. To date, few dedicated training programs for EUS have been described. The swine model has been highlighted as a realistic tool to enhance EUS training. Studies extensively describing EUS swine anatomy are lacking in the current literature. The article aims to describe both radial and linear EUS pancreatobiliary swine anatomy.

Materials and Methods

Four live pigs were endoscoped under general anesthesia using both radial and linear array echoendoscopes. Relevant images and videos were recorded.

Results

It was possible to effectively image aorta, crus of the diaphragm, celiac trunk, superior mesenteric artery, pancreas, common bile duct, gallbladder, portal vein, kidneys, spleen, and hepatic hilum. Images were comparable to human EUS findings, with some remarkable differences. The pancreas was relatively larger in swine and in contrast to humans has three segments (duodenal, splenic, and connecting lobe).

Conclusions

The swine model was a highly realistic teaching model for linear and radial pancreatobiliary EUS and a useful tool for training in the setting of in vivo hands-on sessions.

Case Report: Biloma gastrostomy after failed sonogram-guided percutaneous aspiration, pigtail catheter insertion and surgical drainage

Bilomas are rare abnormal extrabiliary accumulation of bile.  This can be either intrahepatic or extrahepatic following traumatic or spontaneous rupture of the biliary tree. The commonest causes of biloma are surgery, percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage, transcatheter arterial embolization and abdominal trauma. We report here a 15 year old patient whom we followed for over 10 years. His chief complaints were right hypochondriac pain, loss of appetite and vomiting. Initial clinical presentation, sonographic as well as laboratory findings suggested a liver abscess, which was drained, but the definitive diagnosis of biloma was entertained after sonographically guided percutaneous aspirations and percutaneous transhepatic cholangiography 7 years later. We also discuss the role of imaging and surgical challenges encountered that culminated into bilomo-gastrostomy. The patient is now enjoying a peaceful life.

EUS-guided drainage of postsurgical fluid collections using lumen-apposing metal stents: a multicenter study

BACKGROUND AND AIMS

Postsurgical fluid collections (PSFCs) are traditionally drained either percutaneously or surgically. Endoscopic drainage offers several advantages compared with either percutaneous or surgical approaches, including avoiding repeat surgery or the need to have a percutaneous drain in place for weeks. There are very little data regarding the use of lumen-apposing metal stents (LAMSs) in the drainage of PSFCs. We aim to study the technical and clinical success and adverse events (AEs) of using LAMSs in the drainage of PSFCs.

METHODS

Collaborators from 8 centers retrospectively reviewed their endoscopic databases to find procedures using LAMSs for drainage of PSFCs. Technical success (successful placement of LAMSs into the fluid collection), clinical success (complete resolution of the fluid collection on repeat imaging or endoscopy), and intraprocedure and postprocedure AEs were measured.

RESULTS

Forty-seven patients were identified with PSFCs after various surgeries. Thirteen patients had failed previous percutaneous or surgical drainage attempts. Fluid collections averaged 78.6 mm (range, 47-150 mm) in size. The most common site of stent placement was transgastric, followed by rectum and duodenum. Technical success rate was 93.6% and clinical success rate 89.3%. The intraprocedural AE rate was 4.25% and postprocedural AE rate 6.4%. There was 1 death unrelated to the procedure.

CONCLUSIONS

The use of LAMSs to drain PSFCs has a high technical and clinical success rate with low AEs. For collections that are favorably located adjacent to the stomach, duodenum, or rectum, LAMS placement is a viable alternative to repeat surgery or percutaneous drainage.

Endoscopic ultrasound-guided transmural drainage for subphrenic abscess: report of two cases and a literature review

BACKGROUND

An intra-abdominal abscess can sometimes become serious and difficult to treat. The current standard treatment strategy for intra-abdominal abscess is percutaneous imaging-guided drainage. However, in cases of subphrenic abscess, it is important to avoid passing the drainage route through the thoracic cavity, as this can lead to respiratory complications. The spread of intervention techniques involving endoscopic ultrasonography (EUS) has made it possible to perform drainage via the transmural route.

CASE PRESENTATION

We describe two cases of subphrenic abscess that occurred after intra-abdominal surgery. Both were treated successfully by EUS-guided transmural drainage (EUS-TD) without severe complications. Our experience of these cases and a review of the literature suggest that the drainage catheters should be placed both internally and externally together into the abscess cavity. In previous cases there were no adverse events except for one case of mediastinitis and pneumothorax resulting from transesophageal drainage. Therefore, we consider that the transesophageal route should be avoided if possible.

CONCLUSIONS

Although further studies are necessary, our present two cases and a literature review suggest that EUS-TD is feasible and effective for subphrenic abscess, and not inferior to other treatments. We anticipate that this report will be of help to physicians when considering the drainage procedure for this condition. As there have been no comparative studies to date, a prospective study involving a large number of patients will be necessary to determine the therapeutic options for such cases.

Paediatric pancreaticobiliary endoscopy: a 21-year experience from a tertiary hepatobiliary centre and systematic literature review

Background

In adults ERCP and endoscopic ultrasound (EUS) are standard methods of evaluating and treating many hepatopancreaticobiliary (HPB) conditions. HPB disease is being diagnosed with increasing frequency in children but information about role of ERCP and EUS and their outcomes in this population remain limited. Therefore the aims of this study were to describe the paediatric ERCP and EUS experience from a large tertiary referral HPB centre, and to systematically compare outcomes with those of other published series.

Methods

All patients <18 years undergoing an ERCP or EUS between January 1992–December 2014 were included. Indications for the procedure, rates of technical success, procedural adverse events and reinterventions were recorded in all cases.

Results

Ninety children underwent 111 procedures (87 ERCPs and 24 EUS). 53% (48) were female with a median age of 14 years (range: 3 months - 17 years). Procedures were performed under general anaesthesia (n = 48) or conscious sedation (n = 63). Common indications for ERCP included chronic or recurrent pancreatitis and biliary obstruction. Patients frequently had multiple comorbidities, with a median ASA grade of 2 (range 1–4). Therapeutic procedures performed included biliary or pancreatic sphincterotomy, common bile duct or pancreatic duct stone removal, biliary or pancreatic stent insertion, EUS-guided fine needle aspiration and endoscopic transmural drainage of pancreatic fluid collections. No adverse events were reported following ERCP but there was one complication requiring surgery following EUS guided cystenterostomy.

Conclusion

ERCP and EUS in children and adolescents have high technical success rates and low rates of adverse events when performed in high volume HPB centres.

Endoscopic Ultrasound-Guided Drainage of Pelvic Fluid Collections

Pelvic fluid collections can be challenging and often inaccessible because of their location and close proximity to adjacent organs and spine. This causes an increased risk for morbidity and poor outcomes. Recent advances in endoscopic ultrasound and therapeutic devices provide an effective, safe, and minimally invasive option to surgery or interventional radiology. These devices offer a relatively pain-free method that has shown good outcomes with minimal risk in recent case series, and has increasingly become the first-line treatment of choice. This article summarizes the current literature and the technique and considerations for successful drainage of these collections.

Recent developments in the surgical management of complex intra-abdominal infection

BACKGROUND

Current guidance on the management of sepsis often applies to infection originating from abdominal or pelvic sources, which presents specific challenges and opportunities for efficient and rapid source control. Advances made in the past decade are presented in this article.

METHODS

A qualitative systematic review was undertaken by searching standard literature databases for English-language studies presenting original data on the clinical management of abdominal and pelvic complex infection in adults over the past 10 years. High-quality studies relevant to five topical themes that emerged during review were included.

RESULTS

Important developments and promising preliminary work are presented, relating to: imaging and other diagnostic modalities; antimicrobial therapy and the importance of antimicrobial stewardship; the particular challenges posed by fungal sepsis; novel techniques in percutaneous and endoscopic source control; and current issues relating to surgical source control and managing the abdominal wound. Logistical challenges relating to rapid access to cross-sectional imaging, interventional radiology and operating theatres need to be addressed so that international benchmarks can be met.

CONCLUSION

Important advances have been made in the diagnosis, non-operative and surgical control of abdominal or pelvic sources, which may improve outcomes in the future. Important areas for continued research include the diagnosis and therapy of fungal infection and the challenges of managing the open abdomen.

Therapeutic endoscopic ultrasound

Endoscopic ultrasound (EUS) is now firmly established as one of the essential tools for diagnosis in most gastrointestinal MDTs across the UK. However, the ability to provide therapy with EUS has resulted in a significant impact on the management of the patients. These include drainage of peripancreatic collections, EUS-guided endoscopic retrograde cholangiopancreatogram, EUS-guided coeliac plexus blocks, etc. The rapid development of this area in endoscopy is a combination of newer tools and increasing expertise by endosonographers to push the boundaries of intervention with EUS. However, the indications are limited and we are at the start of the learning curve for these high-risk procedures. These therapies should, therefore, be confined to centres with a robust multidisciplinary team, including interventional endoscopists, radiologists and surgeons.

Endoscopic Ultrasound-Guided Biliary Access, with Focus on Technique and Practical Tips

In 1980, endoscopic ultrasound (EUS) was introduced as a diagnostic tool for evaluation of the pancreas. Since the introduction of curvilinear-array echoendoscopy, EUS has been used for a variety of gastrointestinal interventions, including fine needle aspiration, tumor ablation, and pancreatobiliary access. One of the main therapeutic roles of EUS is biliary drainage as an alternative to endoscopic retrograde biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD). This article summarizes three different methods of EUS-guided biliary access, with focus on technique and practical tips.

Transrectal drainage of pelvic collections: Experience of a single center

BACKGROUND AND OBJECTIVE

Pelvic abscesses are a well-known complication of intestinal diseases or abdominal surgery. We report our case series concerning transrectal drainage by endoscopic ultrasound (EUS).

METHODS

Between January 2010 and august 2014, seven patients received transrectal drainage by endoscopic ultrasound (EUS) were selected and analyzed.

RESULTS

Two pigtails was positioned under fluoroscopic and EUS control. The success rate was 100% and complication rate was 0%. The median time of hospitalization was 10 days [range 4-25].

CONCLUSIONS

The technique appears to be safe and feasible in all etiologies. In our experience, we can considerate transrectal drainage by EUS like a first-line technique in experienced hands.

EUS-guided drainage of hepatic abscess and infected biloma using short and long metal stents (with videos)

BACKGROUND

Currently, few reports exist on EUS-guided hepatic abscess drainage (EUS-HAD) and EUS-guided biloma drainage (EUS-BLD) using a metal stent.

OBJECTIVE

We evaluated the technical success rate and efficacy of EUS-HAD and EUS-BLD for patients with hepatic abscess (HA) and infected biloma.

DESIGN

Retrospective case series.

SETTING

Single tertiary referral medical center.

PATIENTS

We evaluated 7 HA and 6 infected biloma patients who were treated between August 2013 and August 2014 at Tokyo Medical University Hospital.

INTERVENTIONS

EUS-HAD or EUS-BLD using a short (length, 2 or 3 cm) or long (length, 6 or 8 cm) self-expandable fully covered metal stent.

MAIN OUTCOME MEASUREMENTS

Technical success, clinical success, and adverse event.

RESULTS

The overall technical success rate was 100% in both EUS-HAD and EUS-BLD. The clinical success rates of EUS-HAD and EUS-BLD at the first session were 71.4% and 83.3%, respectively. Direct endoscopic necrosectomy was required in 1 case each of HA and infected biloma. The final clinical success rate was 100%. There were no procedure-related adverse events or cases of recurrence during the follow-up period (median, 83.5 days; range, 24-396 days).

LIMITATIONS

Small sample size and no control group.

CONCLUSIONS

EUS-HAD and EUS-BLD using a metal stent can be performed safely and effectively for HA and infected biloma.

Endoscopic ultrasound-guided drainage of pancreatic pseudocysts

Pancreatic pseudocysts are fluid collections in the peripancreatic tissues associated with acute or chronic pancreatitis. Endoscopic ultrasound (EUS)-guided drainage has become an established indication, having better results as compared to percutaneous drainage, nonguided endoscopic drainage, or surgical drainage. The aim of this review is to assess critically the current literature concerning EUS-guided pseudocyst drainage and to review the place of the procedure in the clinical decision management algorithms of these patients.

Could Transgastric Endoscopic Ultrasound-Guided Aspiration Alone Be Effective for the Treatment of Pancreatic Abscesses?

Drainage of pancreatic abscesses is required for effective control of sepsis. Endoscopic ultrasound (EUS)-guided endoscopic drainage is less invasive than surgery and prevents local complications related to percutaneous drainage. Endoscopic drainage with stent placement in the uncinate process of the pancreas is a technically difficult procedure. We report a case of pancreatic abscess treated by repeated EUS-guided aspiration and intravenous antibiotics without an indwelling drainage catheter or surgical intervention.

Diagnostic and Therapeutic Roles of Endoscopic Ultrasound in Pediatric Pancreaticobiliary Disorders

OBJECTIVES

The diagnostic role of endoscopic ultrasound (EUS) in children has only recently been demonstrated, and that also to a lesser extent than in adults. Data on the technique's therapeutic indications remain scarce. We therefore sought to evaluate diagnostic and interventional EUS indications, safety, and impact in children with pancreaticobiliary disorders.

METHODS

We retrospectively reviewed our single pediatric center records, covering a 14-year period.

RESULTS

From January 2000 to January 2014, 52 EUS procedures were performed in 48 children (mean age: 12 years; range: 2-17 years) with pancreaticobiliary disorders for the following indications: suspected biliary obstruction (n = 20/52), acute/chronic pancreatitis (n = 20), pancreatic mass (n = 3), pancreatic trauma (n = 7), and ampullary adenoma (n = 2). EUS was found to have a positive impact in 51 of 52 procedures, enabling us to avoid endoscopic retrograde cholangiopancreatography (ERCP) (n = 13 biliary; n = 6 pancreatic), focusing instead on endotherapy (n = 7 biliary; n = 14 pancreatic) or reorienting therapy toward surgery (n = 7). EUS-guided fine-needle aspiration was carried out on 12 patients for pancreatic tumor (n = 4), pancreatic cyst fluid analysis (n = 4), autoimmune pancreatitis (n = 2), and suspicion of biliary tumor (n = 2). A total of 13 therapeutic EUS procedures (11 children) were conducted, including 9 combined EUS-ERCP procedures (7 children, mean age: 8 years, range: 4-11 years), 3 EUS-guided pseudocyst drainage (2 children), and 1 EUS-guided transgastric biliary drainage.

CONCLUSIONS

Our study reports on a large pediatric EUS series for diagnostic and therapeutic pancreaticobiliary disorders, demonstrating the impact of diagnostic EUS and affording insights into novel EUS and combined EUS-ERCP therapeutic applications. We suggest considering EUS as a diagnostic and therapeutic tool in the management of pediatric pancreaticobiliary diseases.

Endoscopic ultrasonography-guided transmural drainage of an infected hepatic cyst due to Edwardsiella tarda: a case report

Infected hepatic cysts are very rare compared to simple liver cysts and abscesses. We treated a 77-year-old man with an infected hepatic cyst in the lateral segment caused by Edwardsiella tarda, which has not been previously reported as a pathogenic organism associated with infected hepatic cysts. Percutaneous drainage was temporarily effective, but infection recurred after the drainage tube was removed. We then inserted two drainage tubes into the cyst using an endoscopic ultrasonography (EUS)-guided technique, which was developed from EUS-guided fine needle aspiration (EUS-FNA). The internal drainage tube was a 7 Fr double pigtail stent, and the external tube was a 6 Fr nasobiliary drainage tube. Lavage through the external drainage tube was carried out for one week. The external drainage tube was discontinued when the patient's condition improved significantly. Sixteen days after tube insertion, he was discharged with the internal tube draining the hepatic cyst into the stomach. Fifteen months after EUS-guided drainage, CT examination showed no recurrence of the hepatic cyst. EUS-guided drainage is an effective treatment for infected hepatic cysts.

Endoscopic ultrasound-guided pelvic abscess drainage (with video)

Pelvic abscesses present a serious and challenging management problem. Endoscopic ultrasound (EUS)-guided drainage provides a safe and effective minimally invasive treatment option. The likelihood of a successful outcome is dependent on appropriate patient selection, drainage technique and postoperative management. This review outlines the evidence behind and procedural steps required for EUS-guided pelvic abscess drainage.

Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.

Comparison of outcomes between endoscopic ultrasound-guided transcolonic and transrectal drainage of abdominopelvic abscesses

BACKGROUND

Transrectal endoscopic ultrasound (EUS)-guided pelvic abscess drainage has been reported, but data on transcolonic drainage are scant.

AIM

To compare outcomes in patients undergoing transcolonic and transrectal drainage of abdominopelvic abscesses.

METHODS

Retrospective study of all patients who underwent EUS-guided drainage of abdominopelvic abscesses over a 7-year period. Abscesses were drained by a standard single-step EUS-guided technique with deployment of double-pigtail stents ± catheters. Technical success was defined as successful placement of stents or drainage catheters within the abscess cavity. Treatment success was defined as resolution of abscess on follow-up computed tomography at 2 weeks with symptom improvement.

RESULTS

Of 38 patients, 11 underwent transcolonic and 27 transrectal drainages. There was no difference in patient demographics, laboratory values, and median abscess size (65 vs 70 mm, P = 0.85) between the two cohorts. Etiology of abscess was postsurgical in 65.7%, diverticulitis in 13.1%, perforated viscus in 10.5%, and other causes in 10.5%. There was no difference in rates of technical success (100% in each cohort), treatment success (70% vs 96.3%, P = 0.052), or complications (none). Three patients in the transcolonic and one in the transrectal cohort underwent surgery for failed endoscopic drainage (27.3% vs 3.7%, P = 0.06). When evaluated by etiology, treatment success for diverticular abscess was significantly lower compared with others (25% vs 97%, P = 0.002). At a median follow-up of 1228.5 days (interquartile range = 131-1660), all patients with treatment success were doing well with no recurrence.

CONCLUSION

Except for patients with diverticular etiology, treatment of abdominopelvic abscess under EUS guidance is highly effective and safe for both routes.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recognized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, percutaneous and non-EUS-guided endoscopic drainage. EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to percutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct access to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the subsequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in “one step”, EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.

Successful endoscopic treatment of iatrogenic biloma as a complication of endosonography-guided hepaticogastrostomy: The first case report

Endosonography (EUS)-guided biliary drainage is a novel therapeutic option for patients with biliary obstruction after failed endoscopic retrograde cholangiopancreatography (ERCP). Many case reports and series worldwide have shown satisfactory clinical outcomes in terms of technical and clinical success rates, which approach 80%-100%. However, these procedures need to be performed by experts to minimize the possible complications, which have been reported in as many as 14-35% of patients. The most common complications encountered in these procedures are bile leakage, pneumoperitoneum, peritonitis, and stent related complications such as stent migration. Here, we report the case of a female patient who had cholangiocarcinoma and underwent EUS-guided hepaticogastrostomy after failed ERCP; stent malposition occurred during the procedure, leading to biloma formation that was successfully treated with EUS-guided biloma drainage.

Endoscopic ultrasound-guided abscess drainage

Abdominal and pelvic abscesses have traditionally been drained by percutaneous techniques or surgery. While surgical drainage is associated with considerable morbidity and mortality, percutaneous techniques are associated with the need for multiple interventions, increased length of hospital stay, and an indwelling external catheter for prolonged periods. Endoscopic ultrasound (EUS) is a minimally invasive but highly effective technique that enables internal drainage of the abscess. Although data are limited, evidence supporting its clinical efficacy is increasing rapidly. This article summarizes the current status of EUS-guided approach for drainage of gastrointestinal abscess collections.

EUS-guided drainage and stent placement for postoperative intra-abdominal and pelvic fluid collections in oncological surgery

OBJECTIVES

The objective of this study was to evaluate the role and benefits of endoscopic ultrasonography (EUS) in the management of postoperative intra-abdominal fluid collections after attempted curative surgery for abdominal cancer.

METHODS

The authors retrospectively analysed the Endobase from 1 July 2007 to 30 January 2011 for patients with a postoperative intra-abdominal fluid collection who had undergone EUS-guided drainage and the placement of a stent. The data analysed included the demographics, type of surgery and clinical indications of each patient as well as their clinical and radiological findings.

RESULTS

Six patients (three men and three women; mean age, 61.8 years [range, 38-78 years]) with intra-abdominal and pelvic fluid collections after abdominal surgery for cancer had undergone EUS-guided internal drainage. All procedures had been performed using linear EUS guidance and 8-Fr stent drainage catheters ('one step device', Giovannini, NWOA system Needle-Wire, Cook). The collection types included perigastric abscess (n = 3), perigastric hematoma and rectal hematoma (n = 1), perirectal biloma (n = 1), and perirectal abscess (n = 1). Patients had undergone the following types of surgery: lower-anterior rectal resection (n = 2), Whipple's duodenopancreatectomy type (n = 1), total gastrectomy (n = 1), splenectomy (n = 1), and distal pancreatectomy (n = 1). The number of stents inserted for each collection was one (five patients) and two (one patient).

CONCLUSIONS

EUS-guided drainage and stenting provide another option for the management of postoperative collections. It allows access to areas that are difficult to reach with the CT-guided approach and it can be performed accurately, efficiently and safely. In addition to this, the internal nature of the drainage offers patients more comfort.

Interventional EUS

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of new or emerging endoscopic technologies that have the potential to have an impact on the practice of GI endoscopy. Evidence-based methodology is used by performing a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched through August 2009 by using the keywords "interventional endoscopic ultrasound," "EUS," and "interventional endoscopy." Reports on Emerging Technologies are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. These reports are scientific reviews provided solely for educational and informational purposes. Reports on Emerging Technologies are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encouraging results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.

[Diagnostic and interventional endoscopy in gastroenterology : from high-resolution chips and procedures for endoscopic resection to NOTES]

In the past 10 years endoscopic diagnostics has benefited from technologies such as big chips, high-definition television (HDTV) and narrow band imaging (NBI). Video capsule endoscopy and double balloon enteroscopy have facilitated visualization of the entire small bowel. A number of studies on mucosal Barrett's and gastric cancers could prove that endoscopic mucosal resection (EMR) is oncologically equivalent to surgical resection when certain criteria are respected. However, EMR is less invasive and carries a substantially lower complication risk and mortality compared to surgery. Endoscopic submucosal dissection (ESD) facilitates en bloc resection with thorough histopathologic evaluation of the specimen, e.g. for mucosal lesions in the stomach and rectum. Endosonography (EUS) guided transgastric necrosectomy using a flexible gastroscope has set a milestone in the treatment of infected pancreatic necroses and has replaced open surgery in many centers. Natural orifice transluminal endoscopic surgery (NOTES) uses natural body openings as minimally invasive access to the abdomen and mediastinum. Interventional GI endoscopists and minimally invasive surgeons have profited from these innovations in micromechanics and microelectronics.