ENDOSCOPIC NECROSECTOMY UNDER DIRECT VISION AFTER ENDOSCOPIC ULTRASOUND‐GUIDED CYSTGASTROSTOMY FOR ORGANIZED PANCREATIC NECROSIS

A 56‐year‐old man was referred for an enlarging pancreatic pseudocyst that developed after severe acute pancreatitis with gallstones. Abdominal ultrasound showed a huge cystic lesion with a large amount of solid high echoic components. Arterial phase contrast‐enhanced computed tomography scan revealed arteries across the cystic cavity. Stents were placed after endoscopic ultrasound‐guided cystgastrostomy; however, the stents were obstructed by necrotic debris, and secondary infection of the pseudocyst occurred. Therefore, the cystgastrostomy was dilated by a dilation balloon, and a forward‐viewing endoscope was inserted into the cystic cavity. Many vessels and a large amount of necrotic debris existed in the cavity. Under direct vision, all necrotic debris was safely removed using a retrieval net and forceps. One year after this procedure, there was no recurrence. Our case indicates that peripancreatic fat necrosis can cause exposure of vessels across/along the cystic cavity, and blind necrosectomy should be avoided.     

Interventional EUS for the treatment of pancreatic cancer

Since the curved linear array echoendoscope (linear EUS) was developed in the 1990s, EUS has evolved from EUS imaging, to EUS-guided FNA, and now to EUS-guided fine needle injection (FNI), giving EUS even wider application. This advancement has brought “interventional EUS” into the pancreato-biliary field. Interventional EUS for pancreatic cancer includes delivery of contrast agents, drainage/anastomosis, celiac neurolysis (including ganglion neorolysis), radiofrequency ablation, photodynamic therapy, brachytherapy, and delivery of a growing number of anti-tumor agents. This review will focus on interventional EUS in the treatment of pancreatic cancer.     

ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED SIMULTANEOUS INTERNAL AND EXTERNAL DRAINAGE OF INFECTED PANCREATIC PSEUDOCYSTS

The procedure for endoscopic ultrasonography (EUS)‐guided cystodrainage of pancreatic pseudocysts has been established but, at times, we encounter difficult cases because of infected pseudocysts. We report successful simultaneous internal and external drainage performed in three patients with severely infectious pancreatic pseudocysts.     

EUS/IDUS AND ENDOSCOPIC PAPILLECTOMY

In our institute, the indication of endoscopic papillectomy is set for adenoma or early cancer without tumor growth in the bile duct or the pancreatic duct. The substantial complete excision rate was 78.8%. One out of 11 incomplete excision cases was removed surgically for tumor persistence, and, as for remaining the 10 cases without persistence had been under serial observations. One case out of the serial observations had local recurrence in 5 years 5 months after papillectomy and surgical resection was performed. Further cases and long‐term serial observations may be required to get evidence of an appropriate indication. In addition, for 60 cases experienced in our institute, the safety of this therapy was reviewed. We experienced bleeding (13.3%), pancreatitis (10%), and cholangitis (3.3%) as early complications, but all cases were successfully treated conservatively. There were no serious conditions as late complications, and endoscopic papillectomy was evaluated as a safe therapy.     

A CASE OF PANCREATIC PSEUDOCYST SUCCESSFULLY TREATED WITH ENDOSCOPIC CYSTGASTROSTOMY USING A NEW THERAPEUTIC ECHOENDOSCOPE

Aim: A case of an infected pancreatic pseudocyst in which cystgastrostomy was successfully performed with a new therapeutic echoendoscope and ?uoroscopic guidance is presented. Methods: A curved linear array echoendoscope (GF‐UCT240‐AL5; Olympus) with an instrument channel 3.7 mm in diameter was used in combination with the Aloka SSD‐5000 display unit. It enabled endoscopic video viewing. The cyst puncture was performed using a 1‐mm diathermic needle housed in a 5 Fr Te?on tube. Following the endoscopic ultrasound (EUS)‐guided puncture, a 10 Fr stent was placed in the pancreatic pseudocyst without an exchange of endoscope. Results: The procedure was well tolerated for the patient and there were no complications. The cyst was resolved and the stent was removed 8 weeks later. Conclusion: This new therapeutic echoendoscope may provide a more effective, safer and less time‐consuming method of endoscopic pseudocyst drainage.     

NEW DEVICES FOR EUS STUDY

It is likely that new endoscopic ultrasound (EUS)‐guided therapies, particularly those that aim to provide local therapy to a neoplastic lesion, will require more sophisticated instrumentation than currently available. In particular, current linear array echoendoscopes are able to image only in two dimensions. New EUS‐guided interventions to ablate tumors might benefit from the development of echoendoscopes which can provide three‐dimensional (3D) images of tumors or lymph nodes. This paper describes the development of such a system.     

ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE IN CASES WITH DIFFICULT TRANSPAPILLARY ENDOSCOPIC BILIARY DRAINAGE

Background: Recently, reports on a new endoscopic biliary drainage technique utilizing endosonographic guidance (endosonography‐guided biliary drainage [ESBD]) have been increasing. The aim of this study was to evaluate the efficacy of ESBD in cases with difficult transpapillary endoscopic biliary drainage (EBD). Patients and Methods: Sixteen patients with obstructive jaundice who underwent ESBD because of difficult EBD between January 2007 and September 2008 were included. The technical success, complications, and clinical efficacy of ESBD were prospectively evaluated. Results: ESBD was performed via the duodenum, stomach, and esophagus in eight, six and two patients, respectively. Stent placement was successful in all cases and excellent biliary decompression was achieved in all but one patient. One patient developed localized peritonitis following guidewire migration and re‐puncture of the bile duct. In another patient, stent migration was observed one week after ESBD and re‐ESBD was carried out. Three patients underwent surgery for their primary diseases, and stent exchange was carried out in 10 patients during the course. Conclusions: ESBD is an effective treatment for obstructive jaundice that will replace percutaneous transhepatic biliary drainage in cases of difficult EBD and is a possible alternative to EBD in selected cases.     

PANCREATIC TUBERCULOSIS AND ITS DIAGNOSIS BY ENDOSCOPIC ULTRASONOGRAPHY: REPORT OF TWO CASES AND REVIEW OF THE LITERATURE

Mass lesions in the head of the pancreas are generally malignant and it is difficult to diagnose benign lesions preoperatively. We describe two patients with pancreatic tuberculosis, who presented with abdominal pain, jaundice and a pancreatic head mass, mimicking cancer. The correct diagnosis could be made by endoscopic ultrasonography (EUS) and EUS‐guided fine‐needle aspiration (FNA) cytology in both patients, precluding the need for surgery. Both patients responded well to anti‐tuberculosis treatment. We conclude that EUS with guided FNA is a useful modality to diagnose pancreatic tuberculosis.     

Effects of long-term parenteral nutrition on the course of pancreatic pseudocyst

The benefit of total parenteral nutrition (TPN) for the non-operative treatment of acute pancreatic pseudocyst remains hypothetical benefit. We reviewed results for 40 patients with pancreatic pseudocyst treated with TPN who had had serial imaging studies. On presentation, mean cyst size was 7.4 cm and after non-operative treatment with TPN (mean 32.5 days) the cyst had decreased to 5.6 cm. After the non-operative period, 68% of the pseudocysts had regressed, completely in 14% and partially in 54% of the patients. Except for 1 patient with cyst-related obstructive jaundice, there were no complicated pseudocysts. Only 12 (28%) of the patients underwent cyst drainage. Fifteen patients (35%) sustained catheter-related complications, which included sepsis (26%), pneumothorax (9%), hydropneumothorax (2%), and septic right atrial thrombosis (2%), during the course of hospitalization. Most of the patients treated with TPN showed both clinical and radiographic regression of their pseudocysts. However, the risk of catheter-related complications in this group suggests that this therapy should be limited to those patients who are unable to sustain enteral nutrition.     

EUS may have limited impact on the endoscopic management of gastric carcinoids

Summary Background. Carcinoids are occasionally found during gastroscopy. Endoscopic ultrasonography (EUS) can determine the depth of invasion and vascularity of submucosal tumors, including carcinoid tumors. Thus, EUS can lead to an informed decision as to whether to attempt endoscopic or surgical excision of a carcinoid. The three cases described here were found by EUS to be amenable to endoscopic resection of submucosal carcinoid tumors. In each case, the margin of the specimen obtained led to uncertainty regarding the completeness of gastroscopic excision of the tumor. Guidelines for follow-up of gastric carcinoid are few. The incompleteness of endoscopic resection of submucosal tumors, with tumor found at the specimen margin, indicates that careful follow-up and/or consideration of other means of excision are indicated.     

EUS IN THE DIAGNOSIS OF ULCERATIVE COLITIS

The ultrasonograms of ulcerative colitis (UC) in active stage show hypoechoic changes of the colorectal wall from the mucosal layer to the deeper layers. These endoscopic ultrasound (EUS) changes of the wall recognized in active stage disappear or normalize in the stage of remission. When the stage of UC is exacerbated, the hypoechoic changes of the wall extend from the mucosal layer to the deeper layers with the increase of wall thickness. These EUS images of active UC are classified into the following types: UC‐M, thickening of the whole wall with the structure preserved; UC‐SM, hypoechoic changes reach the superficial portion of third layer with the thickening of whole wall; UC‐SM deep, hypoechoic changes reach the deeper portion of third layer with the thickening of whole wall; UC‐MP, hypoechoic changes reach the fourth layer with the thickening of whole wall; UC‐SS/SE, hypoechoic changes penetrate through the fourth layer with the thickening of whole wall. With the help of EUS we can demonstrate the severity of inflammation in UC. Moreover, in severe cases of UC, the treatment strategy including emergency surgery can be determined. EUS is a valuable method in the management of UC.     

经皮穿刺引流与吸刮治疗肝及腹腔包虫囊肿的临床应用

长期以来，包虫病经皮穿刺无论作为治疗或其它目的被看作禁忌。１９８６年始我们用经皮穿刺引流，吸刮囊腔，结合局部和全身用药对３０２例（３６１个囊肿）患者进行了治疗，仅１例出现明显过敏反应。对２１８例进行了随访，最长者已达５年。穿刺后６月，Ｂ超显示囊肿缩小停止生长者９７．２％（２１２／２１８）。１年后随访，Ｂ超显示８４．４％（１３０／１５４）囊肿已消失。５年后随访１８例，１４例囊肿消失。除２例因脱管导致复发外，均恢复顺利。随访未见异位复发及其它严重并发症发生。     

LIVER TRANSPLANTATION: AN UPDATE FOR PHYSICIANS

End-stage irreversible liver disease, previously treated only by partially-effective, symptomatic measures, can now be reversed by successful liver transplantation at reasonable cost and with comparatively little increase in resources. Three Australian liver transplant programs are now established with results comparable to those of more experienced overseas centres. New organ-preservation techniques and reduced-size orthotopic transplantation in children should significantly increase donor organ availability. Orthotopic liver transplantation should be considered as a therapeutic option once a patient has been diagnosed as suffering from intractable, non-malignant chronic liver disease.     

Outcome and complications of endoscopic ultrasound guided pancreatic pseudocyst drainage using combined endoprosthesis and naso-cystic drain

Background and Aim: Endoscopic ultrasound guided pancreatic pseudocyst drainage (EUS‐PPD) is increasingly being used for management of pancreatic pseudocysts. We evaluated the outcome and complications of EUS‐PPD with modified combined technique by inserting both endoprosthesis and naso‐cystic drain. Methods: Forty patients referred between August 2007 and January 2010 for EUS‐PPD were prospectively studied. EUS‐PPD was attempted for symptomatic pancreatic pseudocysts which were; (i) resistant to conservative treatment, (ii) in contact with the gastric or duodenal wall on EUS and (iii) having no bulge seen on endoscopy. Controlled radial expansion wire guided balloon dilation of the puncture tract was performed followed by insertion of a 10 French double pigtail stent and 7‐Fr naso‐biliary drain. The early and late outcome and complications of EUS‐PPD were analyzed. Results: Thirty‐two patients had non‐infected and eight had infected pseudocysts. EUS‐PPD was technically successful in all. Pseudocysts resolved completely in 39 patients, while one with infected pseudocyst underwent surgical resection for bleeding in the cyst. Naso‐cystic drain was removed in 39 patients after median duration of 13 days. Thereafter, the double pigtail stent was removed in all cases after median duration of 10 weeks. Pseudocyst recurred in one patient requiring a second session of EUS‐PPD. All 32 patients without cystic infection were successfully treated by EUS‐PPD. Seven out of eight patients (87%) with cystic infection were successfully treated by EUS‐PPD. Conclusion: Endoscopic ultrasound guided pancreatic pseudocyst drainage with modified combined technique is safe and is associated with high success rate.     

超声内镜对胰神经内分泌肿瘤的诊断价值

目的 评价超声内镜对胰神经内分泌肿瘤的诊断价值.方法 回顾性总结26例行内镜超声检查术(EUS)和内镜超声引导下针吸活检术(EUS-FNA)检查且最终确诊为胰神经内分泌肿瘤病例的资料.结果 胰神经内分泌肿瘤在EUS下表现为内部回声均匀或不均匀、边界清晰的低回声肿块,血流信号丰富;肿瘤位于胰腺头部3例,钩突部2例,胰腺颈部2例,胰腺体部11例,胰腺尾部8例;其中有功能的胰神经内分泌肿瘤16例,瘤体平均直径9 mm,无功能的内分泌肿瘤10例,瘤体平均直径29 mm.EUS-FNA检查22例结果阳性,4例结果阴性.23例患者进行了外科手术治疗,其术前EUS定位准确率为100％.结论 EUS能对病变进行准确的术前定位,还可以通过EUS-FNA提供病变的病理学资料,在胰神经内分泌肿瘤的诊断中具有一定优势.     

CASE REPORT: Pancreatic Ascites in an Infant: Lack of Symptoms and Normal Amylase

A 4-month-old boy presented with 9 days of abdominal distension. The abdomen was tense, distended, and nontender, with a fluid wave. Hypoalbuminemia, hyponatremia, high lipase, normal amylase, high ascitic fluid: lipase, amylase, and serum-ascites albumin gradient < 1.1 were present. Abdominal CT showed large ascites, edema, and pancreatic cyst. No improvement was noted with bowel rest, TPN, albumin, furosemide, octreotide, and paracentesis. Endoscopic retrograde cholangiopancreatography showed disrupted pancreatic duct and a cyst. Pancreatic duct stenting was complicated by early outward migration of the stent and was thus ineffective. An exploratory laporatomy revealed a cyst. Cystogastrostomy resolved the pancreatitis and ascites. The patient was discharged off TPN and tolerating enteral nutrition. Pancreatic ascites is rare, producing few or no symptoms in infants. In conclusion, our patient may have had viral pancreatitis, complicated by a disrupted duct and/or ruptured pseudocyst with ascites formation. Medical management was ineffective. Surgery appears to have been curative.