内镜超声引导下无水乙醇消融术治疗胰腺囊性肿瘤的初步研究(含视频)

目的 评价内镜超声引导下无水乙醇消融术（EUS-EA）治疗胰腺囊性肿瘤的可行性、安全性及有效性。方法 回顾性分析2013年7月至2017年4月在上海长海医院接受EUS-EA的10例胰腺囊性肿瘤患者的基本信息、EUS特征、术后并发症、随访情况等资料。根据术后随访的影像学资料评估EUS-EA疗效。结果 10例患者瘤体最长径平均为（2.95±1.56）cm,囊液分析结果显示6例浆液性囊腺瘤,3例黏液性囊腺瘤,1例未定型囊腺瘤。10例患者共行12次EUS-EA,手术均成功,未出现有临床意义的感染、胰腺炎、出血、胰瘘等严重并发症。术后中位随访时间4.0个月（3.0~12.0个月）,3例完全缓解,6例部分缓解,1例稳定,无进展病例。结论 EUS-EA治疗胰腺囊性肿瘤手术成功率高、并发症少、总体疗效较好。     

Current status and perspective of endoscopic ultrasonography‐guided gastrojejunostomy: endoscopic ultrasonography‐guided double‐balloon‐occluded gastrojejunostomy (with videos)

Surgical intervention and, more recently, endoscopic intervention have been performed for the treatment of malignant gastric outlet obstruction. Recently, endoscopic ultrasonography (EUS)‐guided gastrojejunostomy using special devices has been established. In line with this, we have developed a novel EUS‐guided double‐balloon‐occluded gastrojejunostomy (EBOG) using a lumen‐apposing biflanged metal stent. Herein, we describe the technique and outcome of EBOG.     

Endoscopic ultrasound-guided ethanol ablation therapy for tumors

Endoscopic ultrasonography (EUS) has evolved into a useful therapeutic tool for treating a broad range of tumors since being introduced into clinical practice as a diagnostic modality nearly three decades ago. In particular, EUS-guided fine-needle injection has proven a successful minimally invasive approach for treating benign lesions such as pancreatic cysts, relieving pancreatic pain through celiac plexus neurolysis, and controlling local tumor growth of unresectable malignancies by direct delivery of anti-tumor agents. One such ablative agent, ethanol, is capable of safely ablating solid or cystic lesions in hepatic tissues via percutaneous injection. Recent research and clinical interest has focused on the promise of EUS-guided ethanol ablation as a safe and effective method for treating pancreatic tumor patients with small lesions or who are poor operative candidates. Although it is not likely to replace radical resection of localized lesions or systemic treatment of metastatic tumors in all patients, EUS-guided ablation is an ideal method for patients who refuse or are not eligible for surgery. Moreover, this treatment modalitymay play an active role in the development of future pancreatic tumor treatments. This article reviews the most recent clinical applications of EUS-guided ethanol ablation in humans for treating pancreatic cystic tumors, pancreatic neuroendocrine tumors, and metastatic lesions.     

Endoscopic ultrasound guided tumor directed therapy and cyst ablation

Endoscopic ultrasonography (EUS) has become an interventional procedure for the diagnosis and treatment of various gastrointestinal and pancreatic tumors. Because of the unique anatomical location of the pancreas, EUS-guided therapies offer substantial promise for the delivery of targeted treatments. This article reviews the recent EUS-guided various therapeutic methods for pancreatic cyst and tumor ablation, especially focusing on cystic neoplasms.     

Endoscopic ultrasound-guided injective ablative treatment of pancreatic cystic neoplasms

With the development of cross-sectional imaging modalities and the increasing attention being paid to physical examinations, the prevalence of pancreatic cystic neoplasms(PCNs) has increased. PCNs comprise a broad differential spectrum with some PCNs having low or no malignant potential and others having high malignant potential. The morbidity and mortality rates related to major pancreatic surgical resection are high. Long-term surveillance may not only increase the financial burden and psychological stress for patients but also result in a missed malignancy. Minimally invasive endoscopic ultrasound(EUS)-guided ethanol ablation was first reported in 2005. Several other agents, such as paclitaxel, lauromacrogol, and gemcitabine, were reported to be effective and safe for the treatment of PCNs. These ablative agents are injected through a needle inserted into the cyst via transgastric or transduodenal puncture. This treatment method has been substantially developed in the last 15 years and is regarded as a promising treatment to replace surgical resection for PCNs. While several reviews of EUS-guided ablation have been published, no systematic review has evaluated this method from patient preparation to follow-up in detail. In the present review, we systematically describe EUS-guided injective ablation with regard to the indications, contraindications, preoperative treatment, endoscopic procedure, postoperative care and follow-up, evaluation method, treatment efficiency, safety profile, tips and tricks, and current controversies and perspectives.     

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 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 ethanol ablation of pancreatic neuroendocrine tumours: A case study and literature review

Here we offer a review of the literature regarding endoscopic ultrasound-guided ethanol ablation for pancreatic neuroendocrine tumours and describe the case of a cystic tumour completely ablated after a multisession procedure. A total of 35 PubM ed indexed cases of treated functioning and non-functioning pancreatic neuroendocrine tumours resulted from our search, 29 of which are well-documented and summarised. Endoscopic ultrasound-guided ethanol ablation appears as a local, minimally invasive treatment of pancreatic neuroendocrine tumours, suitable for selected patients. This technique appears feasible, relatively safe and efficient, especially when applied to symptom relief in functioning tumours, aiming at loss of endocrine secretion. For non-functioning tumours, where the goal is complete tissue ablation, eus guided ethanol ablation can provide good results for patients who are unfit for surgery or for those who refuse surgical resection. Its role in "fit for surgery" patients requires assessment through further studies.     

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 ultrasound guided radiofrequency ablation for pancreatic tumors: A critical review focusing on safety,efficacy and controversies

The role of endoscopic ultrasound (EUS) in the last two decades has shifted from a diagnostic tool to an important therapeutic tool treating mainly pancreato-biliary disorders. In recent years, its applications for treating pancreatic diseases have broadened, including the implementation of radiofrequency ablation (RFA), which has been traditionally used for treating solid tumors. In this critical in-depth review, we summarized all the papers throughout the literature regarding EUS-RFA for pancreatic neuroendocrine neoplasms, adenocarcinoma, and pancreatic cystic lesions. Overall, for pancreatic neuroendocrine neoplasms we identified 16 papers that reported 96 patients who underwent EUS-RFA, with acceptable adverse events that were rated mild to moderate and a high complete radiological resolution rate of 90%. For pancreatic adenocarcinoma, we identified 8 papers with 121 patients. Adverse events occurred in 13% of patients, mostly rated mild. However, no clear survival benefit was demonstrated. For pancreatic cystic lesions, we identified 4 papers with 38 patients. The adverse events were mostly mild and occurred in 9.1% of patients, and complete or partial radiological resolution of the cysts was reported in 36.8%. Notably, the procedure was technically feasible for most of the patients. Nevertheless, a long road remains before this technique finds its definite place in guidelines due to several controversies. EUS-RFA for pancreatic tumors seems to be safe and effective, especially for pancreatic neuroendocrine neoplasms, but multicenter prospective trials are needed to consider this treatment as a gold standard.     

内镜超声引导下射频消融治疗三例晚期胰腺癌的临床分析

目的 初步探讨内镜超声引导下射频消融(EUS-RFA)的可行性、安全性和短期疗效.方法 对3例晚期、无手术指征的胰腺癌患者进行EUS-RFA治疗.在EUS引导下以22G穿刺针穿刺入胰腺癌病灶,1 Fr的射频消融针通过穿刺针腔进入病灶,采用单极模式,以功率10 W消融2 min,之后再以15 W消融2 min.与前一针道相隔约1～1.5 cm选择另一针道,再次进针,重复消融.结果 3例患者的平均年龄为63岁.2例为胰尾癌,1例为胰体癌,肿瘤平均直径为3.6 cm.术前行EUS引导下细针穿刺活检均见到癌细胞.1例患者间隔2周分别行3次EUS-RFA,2例患者行1次EUS-RFA,平均每个病灶行EUS-RFA 3.67次.术后2周复查EUS,3例病灶直径平均缩小13.9％,病灶内均出现大小不等的空泡变性.术后血清CA19-9浓度平均下降46.5％,腹痛未见明显加重.治疗后48 h内均未出现出血、胰腺炎、穿孔等短期并发症.平均随访49 d,未见其他并发症.结论 EUS-RFA可使胰腺癌病灶直径缩小,可降低血清CA 19-9浓度,方便可行,安全性良好.     

Safety and efficacy of endoscopic ultrasound-guided radiofrequency ablation for pancreatic insulinoma: A single-center experience

Background/objectivesInsulinomas are rare, functioning pancreatic neuroendocrine neoplasms (pNEN), whose gold standard therapy is surgical resection. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is a recent technique that has emerged as a minimally invasive therapeutic option for patients with pancreatic lesions not eligible for surgery. In this study, we aimed to describe a series of patients with unresectable pancreatic insulinoma treated with EUS-RFA.MethodsThis is a single-center, retrospective study including all consecutive patients with functioning pancreatic insulinoma undergoing EUS-RFA for surgical unfitness or surgery refusal, between March 2017 and September 2021. Technical success (i.e., complete mass ablation), adverse event rate and severity, clinical and radiologic outcomes (i.e., symptom remission with a normal concentration of blood glucose, and the presence of intralesional necrosis), and post-procedural follow-up were assessed.ResultsA total of 10 patients (mean age: 67.1 ± 10.1years; F:M 7:3) were included. The mean size of insulinoma was 11.9 ± 3.3 mm. Technical success and clinical remission were achieved in 100% of patients. Only one (10%) patient was successfully treated with two RFA sessions. Two procedure-related early adverse events occurred, including two (20%) cases of mild abdominal pain. No major complications were observed. The complete radiologic response within 3 months after EUS-RFA was observed in all patients (100%). After a median follow-up of 19.5 (range12–59) months, symptom remission and persistent euglycemia were assessed in all the patients.ConclusionsData from this case series suggest that EUS-RFA is a feasible and safe therapeutic approach for pancreatic insulinomas in patients unwilling or unable to undergo surgery with medium-term efficacy.     

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 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 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.