Technical tips for endoscopic ultrasound-guided hepaticogastrostomy

Interventional procedures using endoscopic ultrasound (EUS) have recently been developed. For biliary drainage, EUS-guided trans-luminal drainage has been reported. In this procedure, the transduodenal approach for extrahepatic bile ducts is called EUS-guided choledochoduodenostomy, and the transgastric approach for intrahepatic bile ducts is called EUS-guided hepaticogastrostomy (EUS-HGS). These procedures have several effects, such as internal drainage and avoiding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and they are indicated for an inaccessible ampulla of Vater due to duodenal obstruction or surgical anatomy. EUS-HGS has particularly wide indications and clinical impact as an alternative biliary drainage method. In this procedure, it is necessary to dilate the fistula, and several devices and approaches have been reported. Stent selection is also important. In previous reports, the overall technical success rate was 82% (221/270), the clinical success rate was 97% (218/225), and the overall adverse event rate for EUS-HGS was 23% (62/270). Adverse events of EUS-biliary drainage are still high compared with ERCP or PTCD. EUS-HGS should continue to be performed by experienced endoscopists who can use various strategies when adverse events occur.     

ERCP结合EPT对胆囊切除术后患者诊治价值的探讨

目的 回顾性研究逆行性胰胆管造影（ERCP）结合乳头肌切开术（EPT）对胆囊切除术后患者的诊治价值。方法 170例胆囊切除术后症状再发或反复发作患者，接受ERCP检查和EPT等治疗，诊断结果与B超作对照。同时动态观察内镜下介入诊治术后临床表现的改变。不良反应及血清淀粉酶的变化及高淀粉酶血症的分布情况。结果 经ERCP结合EPT等术后患者临床症状显著改善；与B超对照ERCP对胆囊切除术后胆总管残余结石的诊断率显著提高（P＜0．001），对胆总管扩张程度的诊断价值显著优于B超（P＜0．05），并能发现许多B超检查不能发现的胆胰病变；术后主要不良反应表现为出血、高淀粉酶血症，ERCP结合EPT等治疗组高淀粉酶的发生率显著高于单纯ERCP操作组（P＜0．01）。经积极地处理后短期内出血控制，血清淀粉酶多在3日内转为正常。结论 对胆囊切除术后患者，ECRP结合EPT不失为一项非常有价值、安全的诊治措施。     

Stent displacement in endoscopic pancreatic pseudocyst drainage and endoscopic management

A pancreatic pseudocyst(PPC)is a collection of pancreatic fluid enclosed by a non-epithelialized,fibrous or granulomatous wall.Endoscopic pancreatic pseudocyst drainage(PPD)has been widely used clinically to treat PPCs.The success and complications of endoscopic PPD are comparable with surgical interventions.Stent displacement is a rare complication after endoscopic PPD.Almost all the complications of endoscopic PPD have been managed surgically,and there is rare report involving the endoscopic treatment of intraperitoneal stent displacement.We report here a case of stent displacementafter endoscopic ultrasound-and fluoroscopy-guided PPD in a 41-year-old female patient with a PPC in the tail of the pancreas.The endoscopic treatment was successfully performed to remove the displaced stent.The clinical course of the patient was unremarkable.The cyst had significantly reduced and disappeared by 12 wk.We found that both endoscopic ultrasound and fluoroscopy should be used during endoscopic PPD to avoid stent displacement.The displaced stent can be successfully treated by endoscopic removal.     

Current applications of endoscopic suturing

Endoscopic suturing had previously been considered an experimental procedure only performed in a few centers and often by surgeons. Now, however, endoscopic suturing has evolved sufficiently to be easily implemented during procedures and is more commonly used by gastroenterologists. We have employed the Apollo OverStitch suturing device in a variety of ways including closure of perforations, closure of full thickness defects in the gastrointestinal wall created during endoscopic full thickness resection, closure of mucosotomies during peroral endoscopic myotomy, stent fixation, fistula closure, post endoscopic submucosal dissection, endoscopic mucosal resection and Natural Orifice Transluminal Endoscopic Surgery defect closures, post-bariatric surgery gastrojejunal anastomosis revision and primary sleeve gastroplasty.     

帽状息肉病临床和内镜特征及内镜下切除治疗效果

为了探讨帽状息肉病的临床、内镜特征,并评价其内镜下切除治疗效果,对2017年6月—2021年2月首都医科大学附属北京友谊医院行内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）或内镜黏膜切除术（endoscopic mucosal resection,EMR）结直肠息肉切除治疗,经术后病理证实为帽状息肉病的14例病例（共56枚息肉）进行了回顾性分析。结果显示：男8例,女6例;年龄14岁～74岁,其中<60岁7例,≥60岁7例;7例（50.0%）伴消化道症状;息肉多发4例,单发10例（71.4%）;息肉位于直肠42枚（75.0%）,乙状结肠13枚（23.2%）,横结肠1枚;山田分型Ⅰ型44枚（78.6%）,Ⅱ型3枚,Ⅲ型5枚,Ⅳ型4枚;内镜下息肉表面可见明显白色帽状覆盖物41枚（73.2%）、明显充血发红23枚,其中两者均可见8枚;2例行ESD治疗、12例行EMR治疗,均完全切除,均未出现出血、穿孔、感染等并发症;7例伴消化道症状者术后临床症状均获得缓解;11例（78.6%）随访期间完成肠镜复查,均未见息肉复发。由此可见,帽状息肉病无性别、年龄发病差异,息肉多单发,直肠及乙状结肠多见,形态以山田Ⅰ型为主,表面多有白色帽状覆盖物,患者可无明显消化道症状,内镜下切除治疗安全、有效。     

Wire-guided endoscopic snare retrieval of proximally migrated pancreatic stents after endoscopic papillectomy for ampullary adenoma

With the increasing use of pancreatic duct (PD) stents after endoscopic papillectomy (EP), complications such as proximal migration of the stent have become increasingly prevalent. A PD stent that migrates within a nondilated PD may be difficult to remove endoscopically. We performed endoscopic retrieval of proximally migrated PD stents after EP in 5 patients. Endoscopic retrieval was performed immediately after EP in one patient, the next day in 3 patients, and 2 weeks later in one patient. Wire-guided endoscopic retrieval was attempted in 4 patients, and the migrated stents were removed successfully in these 4 patients. No significant procedure-related complications occurred, other than mild pancreatitis in a single patient. In one patient, endoscopic retrieval performed immediately after EP failed when using the conventional method, and the migrated stent was removed using a minisnare without a guidewire the next day; this patient developed severe pancreatitis. Wire-guided endoscopic snare retrieval seems to be a safe and effective method for removing proximally migrated PD stents after EP.     

Meta-analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy

AIM: To assess endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy (EST) for common bile duct (CBD) stone removal using a meta-analysis. METHODS: Randomized controlled trials published from 1990 to 2012 comparing EPBD with EST for CBD stone removal were evaluated. This meta-analysis was performed to estimate short-term and long-term com-plications of these two treatments. The fixed random effect model or random effect model was established to analysis the data. Results were obtained by analyz-ing the relative risk, odds ratio, and 95%CI for a given comparison using RevMan 5.1. Statistical significance was defined asP < 0.05. Risk of bias was evaluated us-ing a funnel plot. RESULTS: Of the 1975 patients analyzed, 980 of them were treated with EPBD and 995 were treated with EST. Of the patient population, patients in the EPBDgroup were younger (OR=-1.16, 95%CI:-1.49 to 0.84, P<0.01). There were no significant differences in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the incidence of duodenal diverticulum, CBD diameter or the total follow-up time between EST and EPBD groups. Com-pared with EST, the total stone clearance in the EPBD group decreased (OR=0.64, 95%CI: 0.42 to 0.96,P=0.03), the use of stone extraction baskets significantly increased (OR=1.91, 95%CI: 1.41 to 2.59, P<0.01), and the incidence of pancreatitis significantly increased (OR=2.79, 95%CI: 1.74 to 4.45, P<0.0001). The incidence of bleeding (OR=0.12, 95%CI: 0.04 to 0.34, P<0.01) and cholecystitis (OR=0.41, 95%CI: 0.20 to 0.84, P=0.02) significantly decreased. The stone re-currence rate also was significantly reduced in EPBD (OR=0.48, 95%CI: 0.26 to 0.90, P=0.02). There were no significant differences between the two groups with the incidence of stone removal at first attempt, hours of operation, total short-term complications and infection, perforation, or acute cholangitis. CONCLUSION: Although the incidence of pancreatitis was higher, the overall stone     

内镜超声检查在上消化道黏膜下肿瘤微创治疗中的价值研究

目的评价超声内镜检查对上消化道黏膜下肿瘤的诊断价值及指导内镜下微创治疗黏膜下肿瘤的疗效及安全性。方法经超声内镜诊断上消化道黏膜下肿瘤82例,根据黏膜下肿瘤的起源层次、大小及性质分别选择不同的内镜治疗方案,内镜治疗包括高频电凝电切术、内镜下黏膜切除术、皮圈套扎术等。标本行常规病理学及免疫组化检查。术后定期内镜随访。结果26例超声判断起源于黏膜肌层的上消化道黏膜下肿瘤行高频电凝电切术;17例起源于黏膜肌层的平坦型上消化道黏膜下肿瘤行内镜下黏膜切除术;38例起源于固有肌层和1例起源于黏膜肌层的上消化道黏膜下肿瘤行皮圈套扎术。内镜超声诊断与术后病理符合率为91．4％。术后1例出血,其余无严重并发症发生。79例术后随访3—24个月无复发。结论超声内镜能够对消化道黏膜下肿瘤进行起源和定性诊断,超声内镜为内镜微创治疗选择消化道黏膜下肿瘤适应证具有良好的指导作用,内镜治疗是消化道黏膜下肿瘤治疗的安全、有效的手段。     

Experimental model standardizing polyvinyl alcohol hydrogel to simulate endoscopic ultrasound and endoscopic ultrasound-elastography

BACKGROUND Endoscopic ultrasound(EUS) and endoscopic ultrasound elastography(EUS-E) simulation lessens the learning curve; however, models lack realism, diminishing competitiveness.AIM To standardize the mechanical properties of polyvinyl alcohol(PVA) hydrogel for simulating organs and digestive lesions.METHODS PVA hydrogel(Sigma Aldrich, degree of hydrolysis 99%) for simulating EUS/EUS-E lesions was investigated in Unidad de Investigación y Desarrollo Tecnológico at Hospital General de México "Dr. Eduardo Liceaga", Mexico City. We evaluated physical, contrast, elasticity and deformation coefficient characteristics in lesions, applying Kappa's concordance and satisfaction questionnaire(Likert 4-points).RESULTS PVA hydrogel showed stable mechanical properties. Density depended on molecular weight(MW) and concentration(C). PVA bblocks with the greatest density showed lowest tensile strength(r =-0.8, P = 0.01). Lesions were EUSgraphically visible. Homogeneous and heterogeneous examples were created from PVA blocks or PVA phantoms, exceeding(MW_2 = 146000-186000, C_9 = 15% and C_(10) = 20%) with a density under(MW_1 = 85000-124000, C_1 = 7% and C_2 = 9%). We calculated elasticity and deformation parameters of solid(blue) areas, contrasting with the norm(Kappa = 0.8; high degree of satisfaction).CONCLUSION PVA hydrogels were appropriate for simulating organs and digestive lesions using EUS/EUS-E, facilitating practice and reducing risk. Repetition amplified skills, while reducing the learning curve.     

Technical tips of endoscopic ultrasound-guided choledochoduodenostomy

Endoscopic ultrasound(EUS) is clinically useful not only as a diagnostic tool during EUS-guided fine needle aspiration,but also during interventional EUS.EUS-guided biliary drainage has been developed and performed by experienced endoscopists.EUS-guided choledocoduodenostomy(EUS-CDS) is relatively well established as an alternative biliary drainage method for biliary decompression in patients with biliary obstruction.The reported technical success rate of EUS-CDS ranges from 50% to 100%,and the clinical success rate ranges from 92% to 100%.Further,the over-all technicalsuccess rate was 93%,and clinical success rate was 98%.Based on the currently available literature,the overall adverse event rate for EUS-CDS is 16%.The data on the cumulative technical and clinical success rate for EUS-CDS is promising.However,EUS-CDS can still lead to several problems,so techniques or devices that are more feasible and safe need to be established.EUS-CDS has the potential to become a first-line biliary drainage procedure,although standardizing the technique in multicenter clinical trials and comparisons with endoscopic biliary drainage by randomized clinical trials are still needed.     

Prior minimal endoscopic sphincterotomy to prevent pancreatitis related to endoscopic balloon sphincteroplasty

AIMTo investigate the efficacy of prior minimal endoscopic sphincterotomy (EST) to prevent pancreatitis related to endoscopic balloon sphincteroplasty (EBS).METHODSAfter bile duct access was gained and cholangiogram confirmed the presence of stones < 8 mm in the common bile duct at endoscopic retrograde cholangiography, patients were subjected to minimal EST (up to one-third of the size the papilla) plus 8 mm EBS (EST-EBS group). The incidence of pancreatitis and the difference in serum amylase level after the procedure were examined and compared with those associated with 8-mm EBS alone in 32 patients of historical control (control group).RESULTSOne hundred and five patients were included in the EST-EBS group, and complete stone removal was accomplished in all of them. The difference in serum amylase level after the procedure was - 25.0 (217.9) IU/L in the EST-EBS group and this value was significantly lower than the 365.5 (576.3) IU/L observed in the control group (P < 0.001). The incidence of post-procedure pancreatitis was 0% (0/105) in the EST-EBS group and 15.6% (5/32) in the control group (P < 0.001).CONCLUSIONPrior minimal EST might be useful to prevent the elevation of serum amylase level and the occurrence of pancreatitis related to EBS.     

Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones

Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy(EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.     

Recent advances in endoscopic management of gastric neoplasms

The development and clinical application of new diagnostic endoscopic technologies such as endoscopic ultrasonography with biopsy, magnification endoscopy, and narrow-band imaging, more recently supplemented by artificial intelligence, have enabled wider recognition and detection of various gastric neoplasms including early gastric cancer (EGC) and subepithelial tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors. Over the last decade, the evolution of novel advanced therapeutic endoscopic techniques, such as endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection, along with the advent of a broad array of endoscopic accessories, has provided a promising and yet less invasive strategy for treating gastric neoplasms with the advantage of a reduced need for gastric surgery. Thus, the management algorithms of various gastric tumors in a defined subset of the patient population at low risk of lymph node metastasis and amenable to endoscopic resection, may require revision considering upcoming data given the high success rate of en bloc resection by experienced endoscopists. Moreover, endoscopic surveillance protocols for precancerous gastric lesions will continue to be refined by systematic reviews and meta-analyses of further research. However, the lack of familiarity with subtle endoscopic changes associated with EGC, as well as longer procedural time, evolving resection techniques and tools, a steep learning curve of such high-risk procedures, and lack of coding are issues that do not appeal to many gastroenterologists in the field. This review summarizes recent advances in the endoscopic management of gastric neoplasms, with special emphasis on diagnostic and therapeutic methods and their future prospects.     

Safety of same-day endoscopic ultrasound and endoscopic retrograde cholangiopancreatography under conscious sedation

AIM: To assess the tolerability and safety of same-day tandem procedures, endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation. METHODS: A retrospective review was conducted at Loma Linda University Medical Center, a tertiary-care center. All 54 patients who underwent EUS followed by ERCP (group A) from 2004 to 2006 were included in the study. A second group of 56 patients who underwent EUS only (group B), and a third group of 53 patients who...     

内镜下黏膜切除术和内镜黏膜下剥离术治疗直肠类癌的对照研究

目的 评估内镜下黏膜切除术(EMR)和内镜黏膜下剥离术(ESD)治疗直肠类癌的有效性及安全性.方法 回顾性总结24例26处EMR治疗(EMR组)和19例20处ESD治疗(ESD组)的直肠类癌患者的临床资料,对比分析两组在病灶大小、手术时间、病灶整块切除率、组织病理学治愈性切除率、并发症及随访结果方面的差异.结果 ESD组术前超声内镜测量的直径大小为(7.4 ±5.3)mm,明显大于EMR组的(5.6 ±2.1)mm(P ＜0.05);ESD组手术时间为(32.6±10.5)min,明显长于EMR组的(8.9±6.3)min(P ＜0.05);EMR组和ESD组病灶均一次性完整切除,整块切除率均为100.0％;EMR组的组织病理学治愈性切除率为100.0％(26/26),略高于ESD组的95.0％ (19/20) (P＞0.05);EMR术后出血、穿孔并发症发生率为15.3％ (4/26),明显高于ESD组的5.0％ (1/20) (P＜0.05);两组在术后复查随访,均未发现局部复发.结论 对于直径小于7 mm的病灶应用EMR方法可以有效完整地切除病灶,并缩短手术时间;而对于直径大于7 mm和经过多次活检或局部切除后内镜下注射抬举征阴性的病灶,采取ESD的手术方式,方能得到比较满意的治疗效果.     

Dehiscence following successful endoscopic closure of gastric perforation during endoscopic submucosal dissection

Gastric perforation is one of the most serious complications that can occur during endoscopic submucosal dissection (ESD). In terms of the treatment of such perforations, we previously reported that perforations immediately observed and successfully closed with endoclips during endoscopic resection could be managed conservatively. We now report the first case in our medical facility of a gastric perforation during ESD that was ineffectively treated conservatively even after successful endoscopic closure. In December 2006, we performed ESD on a recurrent early gastric cancer in an 81-year-old man with a medical history of laparotomy for cholelithiasis. A perforation occurred during ESD that was immediately observed and successfully closed with endoclips so that ESD could be continued resulting in an en-bloc resection. Intensive conservative management was conducted following ESD, however, an endoscopic examination five days after ESD revealed dehiscence of the perforation requiring an emergency laparotomy.     

胃镜活检联合超声内镜对胃底隆起性病变的诊断价值

目的研究胃底隆起性病变的性质,为临床治疗方式的选择提供依据。方法常规胃镜检查发现胃底隆起性病变的病例同时行活检及超声内镜检查,将接受超声内镜检查者的诊断结果与活检组织病理检查结果进行对比,指导临床治疗。结果137例胃底隆起性病变中,7例为胃癌,76例为胃溃疡,27例为胃炎,10例为胃息肉,4例为平滑肌瘤,3例为脂肪瘤,10例为胃壁外脏器压迫。结论胃镜活检联合超声内镜检查对胃底隆起性病变性质的鉴别有重要意义,为临床治疗方式提供有力依据。     

十二指肠乳头切开术联合球囊扩张术在肝外胆管结石内镜治疗中的作用

目的 探讨十二指肠乳头切开术(EST)联合十二指肠乳头球囊扩张术(EPBD)在肝外胆管结石内镜治疗中的安全性及其疗效.方法 164例肝外胆管结石患者接受内镜取石治疗,其中78例取石前进行EST联合EPBD治疗(EST+ EPBD组),其余86例取石前进行单一EST治疗(EST组),对比分析2组并发症发生率、结石取净率和碎石发生率.结果 EST+ EPBD组出现高淀粉酶血症3例、轻症急性胰腺炎2例,EST组出现高淀粉酶血症5例、轻症急性胰腺炎3例、出血2例,2组均未出现重症急性胰腺炎、穿孔等严重并发症.EST+ EPBD组并发症发生率为6.4％( 5/78),略低于EST组的11.6％ (10/86)(x2=1.340,P=0.288);结石取净率为100.0％ (78/78),明显高于EST组的93.0％( 80/86)(x2=5.649,P=0.030);碎石发生率为33.3％( 26/78),明显低于EST组的60.5％(52/86)(x2=12.073,P=0.001).结论 EST联合EPBD应用肝外胆管结石内镜治疗中安全、有效,对于结石大、乳头条件差的患者效果尤其明显.