Technique of endoscopic ultrasonography‐guided pancreatic duct intervention (with videos)

To date, several endoscopic ultrasonography (EUS)‐guided interventions have been reported. Of these interventions, EUS‐guided pancreatic duct (PD) intervention seems to be the most difficult and challenging procedure to accomplish. We provide suggestions for EUS‐guided PD intervention, which includes PD stenting and the rendezvous technique following EUS‐guided pancreatography. PD stenting is performed between the PD and the gastrointestinal tract (stomach, duodenum, or jejunum). The rendezvous technique is performed using a guidewire across the papilla or anastomotic site for retrograde stent insertion. EUS‐guided PD intervention is still challenging because it is not established yet. Thus, although EUS‐guided PD intervention seems to be promising, it should be performed in selected patients such as those of failed standard endoscopic retrograde cholangiopancreatography.     

Endoscopic ultrasonography‐guided transhepatic antegrade stone removal in patients with surgically altered anatomy: case series and technical review (with videos)

Recently, endoscopic ultrasonography (EUS)‐guided transhepatic antegrade interventions have been introduced in patients with a surgically altered anatomy. Herein, we focused on and reviewed EUS‐guided transhepatic antegrade stone removal (EUS‐TASR) in patients with a surgically altered anatomy and native papilla. The basic technique of EUS‐TASR involves the following steps: (1) EUS‐guided needle puncture; (2) guidewire placement; (3) tract dilation; (4) balloon sphincteroplasty; (5) stone removal; and (6) stent placement if needed. Based on reports in the literature including our cases, the complete stone extraction rate is 71.4% (10/14) including five of our cases (60% success rate) at one session without serious complications. In conclusion, EUS‐TASR appears to be feasible and useful in selected patients although its application may be limited depending on anatomical factors and current devices used.     

Endoscopic ultrasonography‐guided gallbladder drainage for acute cholecystitis: From evidence to practice

With the evolution of the linear echoendoscope and the improved ability to direct a needle within the field of interest, the therapeutic potential of endoscopic ultrasonography (EUS) has greatly expanded. Endoscopic ultrasonography‐guided transmural gallbladder drainage (EUS‐GBD) may be the next frontier for therapeutic EUS. Since EUS‐GBD was first described in 2007, recent reports have suggested it as an alternative to external gallbladder drainage for acute cholecystitis. EUS‐GBD includes EUS‐guided transmural nasogallbladder drainage, EUS‐guided gallbladder aspiration, and EUS‐guided transmural gallbladder stenting. Indications for the EUS‐GBD technique as currently practiced, including equipment, technical details, complications, and efficacy are herein reviewed.     

Endoscopic ultrasonography‐guided pancreatic duct access: Techniques and literature review of pancreatography,transmural drainage and rendezvous techniques

Endoscopic ultrasonography‐guided (EUS)‐guided pancreatic interventions have gained increasing attention. Here we review EUS‐guided pancreatic duct (PD) access techniques and outcomes. EUS‐guided PD intervention is divided into two types, antegrade and rendezvous techniques, following EUS‐guided pancreatography. In the antegrade technique, pancreaticoenterostomy is carried out by stent placement between the PD and the stomach, duodenum, or jejunum. Transenteric antegrade PD stenting is conducted by stent placement, advancing anteriorly into the PD through the pancreatic tract. The rendezvous technique is carried out by using a guidewire through the papilla or anastomotic site for retrograde stent insertion. In terms of EUS‐guided PD stenting, 11 case reports totaling 75 patients (35 normal anatomy, 40 altered anatomy) have been published. The technical success rate was greater than 70%. Early adverse events, including severe hematoma and severe pancreatitis,occurred in seven (63.6%) of 11 reports. Regarding the rendezvous technique, 12 case reports totaling 52 patients (22 normal anatomy, 30 altered anatomy) have been published. The technical success rate ranged from 25% to 100%. It was 48% in one report that involved more than 20 cases. Once stents were placed, all patients became free of symptoms. Early mild adverse events occurred in four (36.4%) of 11 reports. In conclusion, although it can be risky because of possible serious or even fatal adverse events, including pancreatic juice leakage, perforation and severe acute pancreatitis, EUS‐PD access seems to be promising for treating symptomatic pancreatic diseases caused by PD stricture and pancreaticoenterostomy stricture.     

Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography‐guided biliary drainage: 2018

Endoscopic ultrasound/ultrasonography‐guided biliary drainage (EUS‐BD) is a relatively new modality for biliary drainage after failed or difficult transpapillary biliary cannulation. Despite its clinical utility, EUS‐BD can be complicated by severe adverse events such as bleeding, perforation, and peritonitis. The aim of this paper is to provide practice guidelines for safe performance of EUS‐BD as well as safe introduction of the procedure to non‐expert centers. The guidelines comprised patient–intervention–comparison–outcome‐formatted clinical questions (CQs) and questions (Qs), which are background statements to facilitate understanding of the CQs. A literature search was performed using the PubMed and Cochrane Library databases. Statement, evidence level, and strength of recommendation were created according to the GRADE system. Four committees were organized: guideline creation, expert panelist, evaluation, and external evaluation committees. We developed 13 CQs (methods, device selection, supportive treatment, management of adverse events, education and ethics) and six Qs (definition, indication, outcomes and adverse events) with statements, evidence levels, and strengths of recommendation. The guidelines explain the technical aspects, management of adverse events, and ethics of EUS‐BD and its introduction to non‐expert institutions.     

Endoscopic ultrasonography‐guided cholecystogastrostomy in patients with unresectable pancreatic cancer using anti‐migratory metal stents: A new approach

Cholecystectomy is contraindicated in patients with comorbidities or unresectable cancer. Percutaneous transhepatic gallbladder drainage (PTGBD) is typically offered with response rates ranging from 56% to 100%, but has several risks such as bleeding, pneumothorax, pneumoperitoneum, bile leak, and/or catheter migration. Endoscopic transpapillary gallbladder drainage (ETGD) and endoscopic ultrasound‐guided transmural gallbladder drainage (EUS‐GBD) are alternative endoscopic modalities that have a technical feasibility, efficacy and safety profile comparable with PTGBD. In this report, we present the first case series of transgastric EUS‐GBD with placement of a fully covered self‐expandable metal stent with anti‐migratory fins. In three pancreatic cancercases with acute cholecystitis when ETGD was unsuccessful, there were no bile leaks or procedurally related complications. There were no acute cholecystitis recurrences. In conclusion, EUS‐GBD is a promising, minimally invasive treatment for acute cholecystitis. Additional comparative studies are needed to validate the benefit of this technique.     

Factors affecting the diagnostic accuracy of endoscopic ultrasonography‐guided fine‐needle aspiration (EUS‐FNA) for upper gastrointestinal submucosal or extraluminal solid mass lesions

Aim: A number of potential variables are associated with the diagnostic accuracy of endoscopic ultrasonography‐guided fine‐needle aspiration (EUS‐FNA). The aim of this study was to evaluate factors affecting the diagnostic accuracy of EUS‐FNA for upper gastrointestinal submucosal or extraluminal solid lesions. Methods: Patients with such lesions who underwent EUS‐FNA between January 2009 and December 2010 were studied retrospectively. Needles of 22, 25 and 19 gauge were used. The associations between the EUS‐FNA results and factors such as mass location, mass size, needle size, number of needle passes, combined histologic‐cytologic analysis and final diagnosis were analyzed. Results: A total of 170 EUS‐FNA procedures were performed in 158 patients with upper gastrointestinal submucosal or extraluminal solid lesions. The overall accuracy of EUS‐FNA was 86.5% (147/170). The diagnostic accuracy with three or more needle passes was higher than with less than 3.0 needle passes (90.0%, 108/120 vs 78.0%, 39/50; P < 0.05). Mass location, mass size, and final diagnosis were not associated with EUS‐FNA accuracy. Combined cytologic‐histologic analysis had significantly higher diagnostic accuracy than either cytologic or histologic analysis alone (P < 0.001). In a subgroup of 90 patients, both 22 and 25 gauge needles were used for EUS‐FNA. The overall diagnostic accuracy was similar for 25 gauge needles and 22 gauge needles (80.0% vs 78.9% P = 1.000) in this subgroup. Conclusion: Overall, 25 and 22 gauge needles have a similar diagnostic accuracy. Our results suggest that 3.0 or more needle passes and combined cytologic‐histologic analysis enhance the diagnostic accuracy of EUS‐FNA.     

Endoscopic ultrasonography‐guided pancreatic cyst ablation (with video)

Pancreatic cystic lesions are being diagnosed with increasing frequency owing to the widespread use of cross‐sectional imaging. Although most pancreatic cysts are detected incidentally, they represent a wide spectrum of histopathology, and neoplastic cysts appear to be more prevalent than previously estimated. Some histologic types have malignant potential. Considering the perioperative morbidity associated with surgical resection, deciding whether to operate or observe an indeterminate pancreatic cyst is challenging, and there is a strong clinical need to develop a minimally invasive approach. EUS‐guided pancreatic cyst ablation has been investigated in several clinical trials, and may represent a viable alternative to surgical resection.     

Endoscopic ultrasound‐guided intravascular therapy

The gastrointestinal tract provides a unique “window” to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with a standard fine‐needle aspiration (FNA) needle. Sclerosants, cyanoacrylate, and coils can be delivered through the lumen of the FNA needle. EUS‐guided treatment of gastric varices has theoretical advantages over conventional endoscopy‐guided treatment. Controlled studies are needed to determine the role of EUS‐guided treatment for primary and secondary prevention of variceal bleeding. There is a growing list of novel indications for EUS‐guided vascular therapy that include portal vein angiography and pressure measurements, intrahepatic portosystemic shunt placement, and micro coil embolization of vascular structures. Additionally, access and therapy of the heart and surrounding structures appears feasible.     

Recent advances in endoscopic ultrasound‐guided biliary drainage

Endoscopic ultrasound‐guided biliary drainage (EUS‐BD) is increasingly used as an alternative in patients with biliary obstruction who fail standard endoscopic retrograde cholangiopancreatography (ERCP). The two major endoscopic approach routes for EUS‐BD are the transgastric intrahepatic and the transduodenal extrahepatic approaches. Biliary drainage can be achieved by three different methods, transluminal biliary stenting, transpapillary rendezvous technique, and antegrade biliary stenting. Choice of approach route and drainage method depends on individual anatomy, underlying disease, and location of the biliary stricture. Recent meta‐analyses have revealed that cumulative technical success and adverse event rates were 90–94% and 16–23%, respectively. Development of new dedicated devices for EUS‐BD would help refine the technical aspects and minimize the possibility of complications, making it a more promising procedure.     

Combination of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography‐guided biliary drainage in malignant hilar biliary obstruction

Adequate biliary drainage (BD), defined as more than 50% of liver volume drained, is an ideal BD method in patients with advanced and unresectable malignant hilar biliary obstruction (MHBO). Endoscopic retrograde cholangiopancreatography (ERCP) with multi‐segmental BD is technically challenging. ERCP with percutaneous biliary drainage (PTBD) or PTBD alone has cumbersome maintenance of PTBD line and external bag. The utility of EUS‐guided BD (EUS‐BD) has risen significantly over last 5 years mostly in the clinical setting of distal bile duct obstruction. Information on EUS‐BD for malignant hilar biliary obstruction (MHBO) is thus far limited to only two small studies. This review suggests a new concept of a combination of ERCP and EUS‐BD (CERES) for BD in MHBO as a primary BD method whereby ERCP with a single self‐expandable metal stent (SEMS) is placed into either the right or the left intrahepatic bile duct (IHD). If SEMS is placed in the right biliary system, EUS‐guided hepaticogastrostomy (EUS‐HGS) can subsequently be carried out. However, if the stent is placed into the left biliary system, EUS‐guided hepaticoduodenostomy (EUS‐HDS) is done. For MHBO with non‐functioning right lobe of the liver, EUS‐HGS is carried out after failed ERCP, or primary HGS can be carried out in the left lobe of liver. For MHBO with non‐functioning left lobe of the liver, EUS‐HDS is carried out after failed transpapillary stenting of the right lobe by ERCP. Based on our experience, CERES is promising as it can fulfil gaps of both PTBD and ERCP by allowing internal drainage that can circumvent the inconvenience associated with PTBD and offer higher technical success rate compared to ERCP with bilateral SEMS placement.     

Endoscopic ultrasound guided biliary drainage

Endoscopic retrograde cholangio-pancreatography is the most appropriate technique for treating common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Even if the procedure is performed by skillful endoscopist, there are patients in whom endoscopic stent placement is not possible. Common causes of failure include complex peripapillary diverticula, prior surgery procedures, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones. Percutaneous trans-hepatic biliary drainage (PTBD) and surgical intervention carry morbidity and mortality. Recently endoscopic ultrasonography-guided biliary drainage has been reported as an alternative technique. Endoscopic ultrasonography- guided biliary drainage using either direct access or a rendezvous technique has attracted attention as an alternative procedure to PTBD, with a technical success between 75%-100% and with low complication rate. We have reviewed published data on EUS guided biliary drainage procedures with the aim of summarizing the efficacy and safety of this promising method.     

Endoscopic ultrasound‐guided gallbladder drainage for the management of acute cholecystitis (with video)

Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) has been introduced as an alternative to percutaneous transhepatic gallbladder drainage for the treatment of acute cholecystitis in non‐surgical candidates. A systematic review of the English language literature through PubMed search until June 2014 was conducted. One hundred and fifty‐five patients with acute cholecystitis treated with EUS‐GBD in eight studies and 12 case reports, and two patients with EUS‐GBD for other causes were identified. Overall, technical success was obtained in 153 patients (97.45%) and clinical success in 150 (99.34%) patients with acute cholecystitis. Adverse events developed in less than 8% of patients, all of them managed conservatively. EUS‐GBD has been performed with plastic stents, nasobiliary drainage tubes, standard or modified tubular self‐expandable metal stents (SEMS) and lumen‐apposing metal stents (LAMS) by different authors with apparently similar outcomes. No comparison studies between stent types for EUS‐GBD have been reported. EUS‐GBD is a promising novel alternative intervention for the treatment of acute cholecystitis in high surgical risk patients. Feasibility, safety and efficacy in published studies from expert centers are very high compared to currently available alternatives. Further studies are needed to establish the safety and long‐term outcomes of this procedure in other practice settings before EUS‐GBD can be widely disseminated.     

Endoscopic ultrasound‐guided fine‐needle aspiration of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding: A case series

The major gastrointestinal endoscopy society guidelines list endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) as a high‐risk procedure for bleeding. However, there are no studies evaluating the risk of bleeding for EUS‐FNA of solid organs while patients continue to take clopidogrel. The aim of the present case series was to evaluate the rate of bleeding in a cohort of patients who underwent EUS‐FNA for solid lesions while on clopidogrel. Bleeding was measured at the time of the procedure by bleeding seen on EUS, endoscopic visualization of blood, or drop in hemoglobin after the procedure. From 2013 to 2015, 10 patients were identified for this case series. Lesions that underwent EUS‐FNA included gastric and rectal subepithelial lesions, pancreas masses, and liver masses. No immediate or delayed bleeding was observed in any of the patients. EUS‐FNA of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding. Larger studies are needed to confirm this finding.     

Endoscopic ultrasound‐guided pancreatic duct drainage

Endoscopic ultrasound (EUS) has evolved from a purely diagnostic procedure to one with therapeutic capabilities. One of the most challenging therapeutic intervention for endosonographers is EUS‐guided pancreatic drainage. The development of this technique has allowed access and drainage of the main pancreatic duct after failed endoscopic retrograde pancreatography and can avoid invasive procedures such as surgical and percutaneous interventions. This review discusses the indications, technique, challenges, and an algorithmic approach to EUS‐guided pancreatic drainage.     

Endoscopic ultrasonography‐guided fine‐needle aspiration biopsy: A safe method for accurate diagnosis

Endoscopic ultrasonography‐guided fine‐needle aspiration biopsy (EUS FNAB) is a relatively new technique for obtaining specimens with excellent imaging power. The convex type of echoendoscope used with EUS FNAB provides images perpendicular to the endoscope, which differ from those of popular radial echoendoscopes and, hence, require different usage techniques. Color flow imaging is used to avoid the vessels in and around the mass during puncturing. EUS FNAB for submucosal tumors is sometimes difficult because the needle slips easily, and the gastrointestinal wall tends to be stretched when pushing the needle, which can be solved by making a dimple on the wall before puncturing. Lesions of the pancreas head, especially those at the uncus, and lymph nodes near the superior mesenteric artery are also difficult because of their distance from the endoscope and the resultant bending of the needle. Tissue sampling is more successful when the angle between the endoscope and the needle is kept at just less than 45 degrees, as this helps to transmit the hand force to the needle effectively. The complication rate of EUS FNAB is reportedly 1–2%, and so the technique is considered a safe modality, except for cystic lesions of the pancreas. Recent histological evidence is needed before applying medical therapies, such as chemoradiation and surgery, especially when imaging modalities alone cannot supply the evidence of malignancy; hence increasing importance of EUS FNAB is expected.     

以家猪作为超声内镜引导下腹腔神经节穿刺术模型的实验研究

【摘要】目的通过在健康家养猪进行超声内镜引导下腹腔神经节穿刺操作训练探讨其可行性和应用价值。方法选择6只健康家养猪用于研究。术前肌内注射盐酸氯胺酮10mg／kg镇静,动物安静后给予静脉缓慢注射3％戊巴比妥钠0．8mL／kg。麻醉稳定后进行穿刺操作并植入空粒子,术后行CT增强扫描以辅助判断穿刺是否成功。结果试验动物均无死亡,除1只家猪穿刺后CT扫描发现粒子在胃腔内,隔日再行穿刺种植粒子成功,其余均一次性穿刺成功。行CT增强扫描发现粒子定位准确,均匀分布于腹主动脉腹腔干起始部的两侧。结论家猪的解剖结构与人类相似,可作为初学者进行超声内镜引导下腹腔神经丛穿刺术培训的理想动物模型。     

Endoscopic ultrasound‐guided endoluminal drainage of the gallbladder

For patients with acute cholecystitis who are not suitable for surgery, endoscopic ultrasound‐guided endoluminal drainage of the gallbladder (EUS‐GBD) has been developed to overcome the limitations of percutaneous transhepatic gallbladder drainage when endoscopic transpapillary gallbladder drainage is not feasible. In the present review we have summarized the studies describing EUS‐GBD. Indications, techniques, accessories, endoprostheses, limitations and complications reported in the different studies are discussed. There were 90 documented cases in the literature. The overall reported technical success rate was 87/90 (96.7%). All patients with technical success were clinically successful. A total of 11/90 (12.2%) patients had complications including pneumoperitoneum, bile peritonitis and stent migration. The advantage of EUS‐GBD is its ability to provide gallbladder drainage especially in situations where percutaneous or transpapillary drainage is not feasible or is technically challenging. It also provides the option of internal drainage and the ability to carry out therapeutic maneuvers via cholecystoscopy.     

线阵式超声内镜引导下细针穿刺活检对粘膜下病变的诊断价值

目的 通过内镜超声检查(EUS)结合细针穿刺活检来确定粘膜下病变的起源和性质,并评价这种方法对粘膜下病变诊断的意义。方法 经胃镜发现28例食管胃实质性粘膜下病变的患,对他们进行超声内镜检查,以明确其来源的层次、病变的位置,观察有无淋巴结转移。排除腔外正常组织压迫,在超声内镜导引下对病变行细胞针穿刺活检。结果 28例患中,2例经EUS证实为腔外正常组织压迫,余26例患均行EUS导此下的细针穿刺活组织检查。3例患穿刺取材失败。23例患经细胞学分析显示4例恶性肿瘤(淋巴瘤2例,平滑肌肉瘤2例)及19例良性病变(平滑肌瘤18例,脂肪瘤1例)。全部病例20例经手术、1例经内镜电切及7例经临床随访验证。结论 EUS结合细针穿刺活检是诊断粘膜下病变安全、有效的方法。     

Endoscopic ultrasound guided hepatic interventions

Intervention for liver disease has predominantly been performed through the percutaneous approach. However, as endoscopic ultrasound (EUS) applications have expanded, there have emerged various EUS‐guided interventions for liver disease, a space we call “Endo‐Hepatology”. EUS‐guided liver biopsy can be considered the “forerunner” of Endo‐Hepatology and has become a clinical option for patients requiring histologic diagnosis and staging of their liver disease. EUS also enables direct access to the portal vein. Subsequently, many procedures are being explored, such as angiography, measurement of the portosystemic pressure gradient, portal vein sampling to detect cancer cell or DNA, and EUS‐guided transhepatic intrahepatic portosystemic shunt creation. Since the transducer is close to the liver, especially the left and caudate lobes, EUS can be used as a rescue when the percutaneous approach is not favorable and EUS‐guided treatments of liver tumor, cyst and abscess have been reported. This review summarizes the available studies of EUS‐guided intervention in the liver.