Alternative uses of lumen apposing metal stents

The advent of lumen apposing metal stents(LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design,LAMS provide more efficient drainage, serve as conduit for endoscopic access,are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures,creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.     

Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience?

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUSguided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and ECLAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.     

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis

Background and Aims

Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome).

Methods

We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with ≥ 10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model.

Results

Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I ² = 15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I ² = 50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P = 0.51). WPR for AE was 13% (9, 20%), (I ² = 64%). AE were 10% more in WON as compared to PP (P = 0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I ² = 50%). Pooled MD for number of endoscopic sessions was ? 0.84 (? 1.69, 0.01).

Conclusions

LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

     

EUS-guided drainage of pancreatic fluid collections using lumen apposing metal stents: An international,multicenter experience

IntroductionLumen apposing metal stents (LAMS) have been used increasingly for drainage of pancreatic fluid collections (PFC). We present an international, multicenter study evaluating the safety and efficacy of LAMS in PFCs.MethodsConsecutive patients undergoing LAMS placement for PFC at 12 international centers were included (ClinicalTrials.gov NCT01522573). Demographics, clinical history, and procedural details were recorded. Technical success was defined as successful LAMS deployment. Clinical success was defined as PFC resolution at three-month follow-up.Results192 patients were included (140 males (72.9%), mean-age 53.8 years), with mean follow-up of 4.2 months ± 3.8. Mean PFC size was 11.9 cm (range 2–25). The median number of endoscopic interventions was 2 (range 1–14). Etiologies for PFC were gallstone (n = 82, 42.7%), alcohol (n = 50, 26%), idiopathic (n = 26, 13.5%), and other (n = 34, 17.7%). Technical success was achieved in 189 patients (98.4%). Clinical success was observed in 125 of 135 patients (92.6%).Adverse events included bleeding (n = 11, 5.7), infection (n = 2, 1%), and perforation (n = 2, 1%). Three or more endoscopy sessions were a positive predictor for PFC resolution and the only significant predictor for AEs.ConclusionLAMS has a high technical and clinical success rate with a low rate of AEs. PFC drainage via LAMS provides a minimally invasive, safe, and efficacious procedure for PFC resolution.     

Early and long-term clinical outcomes of endoscopic interventions for benign pancreatic duct stricture/obstruction-the possibility of additional clinical effects of endoscopic ultrasonography-guided pancreatic drainage-

ObjectivesFor benign pancreatic duct strictures/obstructions (BPDS/O), endoscopic ultrasonography-guided pancreatic drainage (EUS-PD) is performed when endoscopic transpapillary pancreatic drainage (ETPD) fails. We clarified the clinical outcomes for patients with BPDS/O who underwent endoscopic interventions through the era where EUS-PD was available.MethodsForty-five patients with BPDS/O who underwent ETPD/EUS-PD were included. We retrospectively investigated overall technical and clinical success rates for endoscopic interventions, adverse events, and clinical outcomes after successful endoscopic interventions.ResultsThe technical success rates for ETPD and EUS-PD were 77% (35/45) and 80% (8/10), respectively, and the overall technical success rate using two drainage procedures was 91% (41/45). Among the 41 patients who underwent successful endoscopic procedures, the clinical success rates were 97% for the symptomatic patients (35/36). The rates of procedure-related pancreatitis after ETPD and EUS-PD were 13% and 30%, respectively. After successful endoscopic interventions, the cumulative 3-year rate of developing recurrent symptoms/pancreatitis was calculated to be 27%, and only two patients finally needed surgery. Continuous smoking after endoscopic interventions was shown to be a risk factor for developing recurrent symptoms/pancreatitis.ConclusionsBy adding EUS-PD to ETPD, the technical success rate for endoscopic interventions for BPDS/O was more than 90%, and the clinical success rate was nearly 100%. Due to the low rate of surgery after endoscopic interventions, including EUS-PD, for patients with BPDS/O, EUS-PD may contribute to their good clinical courses as a salvage treatment for refractory BPDS/O.     

What is the ideal indwelling time for metal stents after endoscopic ultrasound-guided gastrojejunostomy? Case report of delayed iatrogenic perforation with a review of the literature

Several recent studies have described the feasibility, efficacy and safety of the placement of lumen-apposing metal stents (LAMS) for the treatment of gastrointestinal strictures. However, the optimum stent indwelling time is unclear. We reviewed the literature on endoscopic gastroenterostomy (GE) with a focus on the stent indwelling time and we described the first reported case of iatrogenic perforation six months after Axios stent placement. In the literature review (n = 239), the composite technical success rate and clinical success rate were 93.7% and 87.9%, respectively. The mean follow-up period was 191 days, and the mean stent indwelling time was 88 days. Among 13 studies (n = 202), the mean rate of complications was 13.4%. The principal complication was mis-deployment of the stent (4.5%). We report a case report of delayed iatrogenic perforation. A 59-year-old male patient with cystic dystrophy of the duodenum has been followed for several years. He presented with anorexia following duodenal obstruction and underwent endoscopic ultrasound-guided gastrojejunostomy. Six months later, he was referred to our center due to septic shock, and abdominal computed tomography revealed peritonitis secondary to a perforation of the small intestine, opposite the Axios stent. The mean LAMS indwelling time after GE was 88 days. To minimise the rate of adverse events, such as ulceration and mucosal overgrowth, regular abdominal computed tomography and endoscopy can be performed to evaluate the local effect of the stent. When the disease has resolved, the LAMS must be removed as soon as possible.     

Over‐the‐scope clip for acute esophageal variceal bleeding

Over‐the‐scope clip (OTSC) has been reported to control non‐variceal bleeding; however, the use of this device for acute variceal hemorrhage (AVH) is very limited. We report our experience regarding the use of OTSC in patients with AVH in terms of technical success and safety. A retrospective clinical experience case series study was conducted from October 2017 to June 2019 at two tertiary care centers. Adult patients with AVH as a result of small varices managed with OTSC after endoscopic band ligation (EBL) failure were enrolled. Standard gastroscope and OTSC ‘type a’ with a cap of 11 mm in diameter were used in all procedures. Total of five patients with chronic liver disease (Child‐Pugh score ≤8) and portal hypertension (hepatic venous pressure gradient, mean 14.4 ± 1.3 mmHg) were included. Four of them presented collapse of the bleeding varix, and one had wall disruption associated with fibrosis secondary to prior banding. We were able to stop AVH in all patients without clip‐related adverse events during a 30‐day follow‐up period. Two patients developed solid food dysphagia after 3 months of clip deployment that resolved after removal using a bipolar cutting device. Twin grasper or anchor were not used to aid or facilitate the approximation of opposite edges in any patient. No additional local therapies or new endoscopic session for variceal eradication were required. This case series shows preliminary success controlling AVH with OTSC after EBL failure in patients with small varices. Esophageal dysphagia may appear as a complication during follow up but it can be resolved by clip removal.     

Economical effect of lumen apposing metal stents for treating benign foregut strictures

AIM To evaluate the clinical and economical efficacy of lumen apposing metal stent(LAMS) in the treatment of benign foregut strictures.METHODS A single center retrospective database of patients who underwent endoscopic treatment of benign foregut strictures between January 2014 and May 2017 was analyzed. A control group of non-stented patients who underwent three endoscopic dilations was compared to patients who underwent LAMS placement. Statistical tests performed included independent t-tests and fiveparameter regression analysis RESULTS Nine hundred and ninety-eight foregut endoscopic dilations were performed between January 2014 and May 2017. 15 patients underwent endoscopic LAMS placement for treatment of benign foregut stricture. Thirty-six patients with recurrent benign foregut strictures underwent three or more endoscopic dilations without stent placement. The cost ratio of endoscopic dilation to LAMS(stent, placement and retrieval) is 5.77. Cost effective analysis demonstrated LAMS to be economical after three endoscopic dilation overall.LAMS was cost effective after two dilations in the Postsurgical stricture subgroup. CONCLUSION Endoscopists should consider LAMS for the treatment of benign foregut strictures if symptoms persist past three endoscopic dilations. Post-surgical strictures may benefit from LAMS if symptoms persist after two dilations in a post-surgical. Early intervention with LAMS appears to be a clinically and economically viable option for durable symptomatic relief in patients with these strictures.     

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.     

Efficacy of traction‐assisted colorectal endoscopic submucosal dissection using a clip‐and‐thread technique: A prospective randomized study

Background and Aim

Colorectal endoscopic submucosal dissection (ESD) remains challenging because of technical difficulties, long procedure time, and high risk of adverse events. To facilitate colorectal ESD, we developed traction‐assisted colorectal ESD using a clip and thread (TAC‐ESD) and conducted a randomized controlled trial to evaluate its efficacy.

Methods

Patients with superficial colorectal neoplasms (SCN) ≥20 mm were enrolled and randomly assigned to the conventional‐ESD group or to the TAC‐ESD group. SCN ≤50 mm were treated by two intermediates, and SCN >50 mm were treated by two experts. Primary endpoint was procedure time. Secondary endpoints were TAC‐ESD success rate (sustained application of the clip and thread until the end of the procedure), self‐completion rate by the intermediates, and adverse events.

Results

Altogether, 42 SCN were analyzed in each ESD group (conventional and TAC). Procedure time (median [range]) for the TAC‐ESD group was significantly shorter than that for the conventional‐ESD group (40 [11–86] min vs 70 [30–180] min, respectively; P < 0.0001). Success rate of TAC‐ESD was 95% (40/42). The intermediates’ self‐completion rate was significantly higher for the TAC‐ESD group than for the conventional‐ESD group (100% [39/39] vs 90% [36/40], respectively; P = 0.04). Adverse events included one intraoperative perforation in the conventional‐ESD group and one delayed perforation in the TAC‐ESD group.

Conclusion

Traction‐assisted colorectal endoscopic submucosal dissection reduced the procedure time and increased the self‐completion rate by the intermediates (UMIN000018612).     

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 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.     

Clinical outcomes of lumen-apposing metal stent in the management of benign gastrointestinal strictures: a systematic review and meta-analysis

Background and aims: Lumen-apposing metal stent (LAMS) have been considered as a viable alternative to treat benign gastrointestinal (GI) strictures. We aimed to determine the efficacy and safety of LAMS for benign GI strictures.

Methods: Medline, Embase, Cochrane, and PubMed databases were searched using the keywords ‘benign stricture’, ‘gastrointestinal stricture’, ‘lumen-apposing metal stent’ and related terms on December 2018. Articles were selected for review by two authors independently according to predefined inclusion criteria and exclusion criteria. A meta-analysis using a random effects model was performed.

Results: Six studies with a total of 144 patients were included in the final analysis (60 males, 41.7%). Overall, the pooled technical success rate was 98.3% [95% confidence interval (CI): 0.962–1.004], clinical success rate was 73.8% (95% CI: 0.563–0.912) and adverse events rate was 30.6% (95% CI: 0.187–0.425). The most common complication associated with LAMS for benign GI strictures was migration, and the pooled events rate was 10.9% (95% CI: 0.058–0.160). According to locations of stricture, subgroup analysis was performed in terms of clinical success [Esophagogastric: 63.9% (95% CI: 0.365–0.914); Gastroduodenal: 67.4% (95% CI: 0.421–0.927); Gastrojejunal: 78% (95% CI: 0.638–0.922); Pylorus: 77.6% (95% CI: 0.551–1.002); Colonic: 85.3% (95% CI: 0.515–1.191)].

Conclusions: Although the safety of LAMS placement in benign GI strictures is not very satisfactory, it is associated with a low migration rate. LAMS can achieve clinical symptom improvement or resolution in most patients with benign GI strictures, and it might be an alluring prospect for treating patients with this difficult condition.     

Endoscopic management of complications of acute pancreatitis: an update on the field

ABSTRACT

Introduction: Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances.

Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed.

Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.     

Endoscopic transmural drainage tailored to quantity of necrotic debris versus laparoscopic transmural internal drainage for walled-off necrosis in acute pancreatitis: A randomized controlled trial

Background and aimsBoth endoscopic and laparoscopic transmural internal drainage are practiced for drainage of walled-off necrosis (WON) following acute pancreatitis (AP) but the superiority of either is not established. Our aim was to compare transperitoneal laparoscopic drainage with endoscopic drainage using either lumen apposing metal stents (LAMS) or plastic stents tailored to the amount of necrotic debris in WON.MethodsIn a randomized controlled trial, adequately powered to exclude the null hypothesis, patients with symptomatic WON were randomized to either endoscopic or laparoscopic drainage. In the endoscopy group, two plastic stents were placed if the WON contained <1/3rd necrotic debris and a LAMS was placed if it was >1/3rd. Primary outcome was resolution of WON within 4 weeks without re-intervention for secondary infection. Secondary outcome was overall success (resolution of WON at 6 months) and adverse events.ResultsForty patients were randomized: 20 to each group. Baseline characteristics were comparable between the groups. Primary outcome was similar between the groups [16 (80%) in laparoscopy and 15 (75%) in endoscopy group; p = 0.89]. The overall success was similar [18 (90%) in laparoscopy vs. 17 (85%) in endoscopy; p = 0.9]. Median duration of hospital stay was shorter in endoscopy group [4 (4–8) vs. 6 days (5–9); p = 0.03]. Adverse events were comparable between the groups.ConclusionLaparoscopic drainage was not superior to endoscopic transmural drainage with placement of multiple plastic stent or LAMS depending on the amount of necrotic debris for symptomatic WON in AP. The hospital stay was shorter with the endoscopic approach.     

EXPERIENCES OF BILIARY INTERVENTIONS USING SHORT DOUBLE‐BALLOON ENTEROSCOPY IN PATIENTS WITH ROUX‐EN‐Y ANASTOMOSIS OR HEPATICOJEJUNOSTOMY

Background: The efficacy of double‐balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux‐en‐Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux‐en‐Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.     

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.     

胰腺假性囊肿内引流及超声内镜引导新型蕈型覆膜金属支架治疗进展

内镜下胰腺假性囊肿(pancreatic pseudocyst,PPC)内引流已经成为PPC治疗重要方式之一,随着新型蕈型覆膜金属支架(lumen-apposing metal stents,LAMS)在假性囊肿引流中的不断应用,展现出较好的疗效和临床实用价值,本文就PPC内引流现状,特别是超声内镜引导LAMS治疗疗效、并发症及处理对策做一综述.     

Post‐dilatation trepidation: Post‐dil is “no big dil”

• Selective stent post‐dilatation (PD) in a cohort of STEMI patients did not affect major adverse cardiac events but it did decrease device‐oriented composite events, a secondary composite end point of less clear significance.
• This study suggests that selective stent PD in STEMI does not increase the incidence of acute no‐reflow or long‐term adverse clinical events.
• In primary PCI for STEMI, if the stent appears under‐expanded, then PD, perhaps guided by intravascular imaging (which was not reported in this study), is reasonable.