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Technical tips for endoscopic ultrasound-guided pancreatic duct access and drainage
Yousuke Nakai 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.4
Endoscopic ultrasound (EUS)-guided pancreatic duct access and drainage can be achieved by EUS-guided rendezvous (EUS-RV) or EUS-guided pancreatic duct drainage (EUS-PD) by transmural stent placement. Although the procedure is utilized for further complex treatment such as intraductal lithotripsy in obstructive pancreatic duct stones, the procedure is technically difficult compared to other EUS-guided interventions. Recently, some devices are developed for EUS-guided pancreatic duct intervention. In this review, technical tips are reviewed in a step-by-step fashion from puncture, guidewire insertion, tract dilation to drainage. Given the advantage of EUS-guided approach, treatment algorithm of endotherapy for pancreatic indications should be further established especially in cases with surgically altered anatomy.
Current Status of Endoscopic Ultrasound Techniques for Pancreatic Neoplsms
Yousuke Nakai,Naminatsu Takahara,Suguru Mizuno,Hirofumi Kogure,Kazuhiko Koike 대한소화기내시경학회 2019 Clinical Endoscopy Vol.52 No.6
Endoscopic ultrasound (EUS) now plays an important role in the management of pancreatic neoplasms. There are various types of pancreatic neoplasms, from benign to malignant lesions, and the role of EUS ranges from the imaging diagnosis to treatment. EUS is useful for the detection, characterization, and tissue acquisition of pancreatic lesions. Recent advancement of contrast-enhanced harmonic EUS and elastography enables better characterization of pancreatic lesions. In addition to these enhanced EUS imagingtechniques, EUS-guided tissue acquisition is now the standard procedure to establish the pathological diagnosis of pancreatic neoplasms. While these diagnostic roles of EUS have been established, EUS-guided interventions such as ablation and drainage are also increasingly utilized in the management of pancreatic neoplasms. However, most of these EUS-guided interventions are not yet standardized in terms of techniques and devices and thus need further investigations.
A Meta-Analysis of Slow Pull versus Suction for Endoscopic Ultrasound-Guided Tissue Acquisition
( Yousuke Nakai ),( Tsuyoshi Hamada ),( Ryunosuke Hakuta ),( Tatsuya Sato ),( Kazunaga Ishigaki ),( Kei Saito ),( Tomotaka Saito ),( Naminatsu Takahara ),( Suguru Mizuno ),( Hirofumi Kogure ),( Kazuhi 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2021 Gut and Liver Vol.15 No.4
Background/Aims: Endoscopic ultrasound (EUS)-guided tissue acquisition is widely utilized as a diagnostic modality for intra-abdominal masses, but there remains debate regarding which suction technique, slow pull (SP) or conventional suction (CS), is better. A meta-analysis of reported studies was conducted to compare the diagnostic yields of SP and CS during EUS-guided tissue acquisition. Methods: We conducted a systematic electronic search using MEDLINE/PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials to identify clinical studies comparing SP and CS. We meta-analyzed accuracy, sensitivity, blood contamination and cellularity using the random-effects model. Results: A total of 17 studies (seven randomized controlled trials, four prospective studies, and six retrospective studies) with 1,616 cases were included in the analysis. Compared to CS, there was a trend toward better accuracy (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.97 to 2.27; p=0.07) and sensitivity (OR, 1.67; 95% CI, 0.95 to 2.93; p=0.08) with SP and a significantly lower rate of blood contamination (OR, 0.48; 95% CI, 0.33 to 0.69; p<0.01). However, there was no significant difference in cellularity between SP and CS, with an OR of 1.28 (95% CI, 0.68 to 2.40; p=0.45). When the use of a 25-gauge needle was analyzed, the accuracy and sensitivity of SP were significantly better than those of CS, with ORs of 4.81 (95% CI, 1.99 to 11.62; p<0.01) and 4.69 (95% CI, 1.93 to 11.40; p<0.01), respectively. Conclusions: Compared to CS, SP appears to provide better accuracy and sensitivity in EUSguided tissue acquisition, especially when a 25-gauge needle is used. (Gut Liver 2021;15:625- 633)
Technical tips for endoscopic ultrasound-guided pancreatic duct access and drainage
Yousuke Nakai 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.4
Endoscopic ultrasound (EUS)-guided pancreatic duct access and drainage can be achieved by EUS-guided rendezvous (EUS-RV) or EUS-guided pancreatic duct drainage (EUS-PD) by transmural stent placement. Although the procedure is utilized for further complex treatment such as intraductal lithotripsy in obstructive pancreatic duct stones, the procedure is technically difficult compared to other EUS-guided interventions. Recently, some devices are developed for EUS-guided pancreatic duct intervention. In this review, technical tips are reviewed in a step-by-step fashion from puncture, guidewire insertion, tract dilation to drainage. Given the advantage of EUS-guided approach, treatment algorithm of endotherapy for pancreatic indications should be further established especially in cases with surgically altered anatomy.
Yousuke Nakai,Tatsuya Sato,Ryunosuke Hakuta,Kazunaga Ishigaki,Kei Saito,Tomotaka Saito,Naminatsu Takahara,Tsuyoshi Hamada,Suguru Mizuno,Hirofumi Kogure,Minoru Tada,Hiroyuki Isayama,Kazuhiko Koike 거트앤리버 소화기연관학회협의회 2020 Gut and Liver Vol.14 No.3
Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increasingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enteroscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disadvantages of each technique for better management of bile duct stones.
Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction
Yousuke Nakai,Hirofumi Kogure,Hiroyuki Isayama,Kazuhiko Koike 대한소화기내시경학회 2019 Clinical Endoscopy Vol.52 No.3
Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO)and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneoustranshepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasinglybeing reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary strictureand internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUSguidanceinclude a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. Theaim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches suchas endoscopic transpapillary biliary drainage and PTBD.
Ishigaki Kazunaga,Nakai Yousuke,Oyama Hiroki,Kanai Sachiko,Suzuki Tatsunori,Nakamura Tomoka,Sato Tatsuya,Hakuta Ryunosuke,Saito Kei,Saito Tomotaka,Takahara Naminatsu,Hamada Tsuyoshi,Mizuno Suguru,Kogu 거트앤리버 소화기연관학회협의회 2020 Gut and Liver Vol.14 No.6
Background/Aims: Recently, a three-plane symmetric needle with Franseen geometry was developed for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). In this retrospective study, tissue acquisition per pass was compared between 22-gauge Franseen FNB and standard fine needle aspiration (FNA) needles in patients with solid pancreatic lesions. Methods: Consecutive patients who underwent EUSFNA or EUS-FNB for solid pancreatic lesions between October 2014 and March 2018 were retrospectively studied. The tissue acquisition rate and the diagnostic performance per session, per pass, and at first pass were compared. Results: A total of 663 passes (300 by the FNB needle and 363 by the standard FNA needle) were performed in 154 patients (71 FNB and 83 FNA). The tissue acquisition rate per session and at first pass in the FNB and FNA groups was 100% and 95% (p=0.13) and 87% and 69% (p=0.007), respectively. The multivariate analysis revealed that among the patients, EUS-FNB (odds ratio, 3.07; p=0.01) was associated with a higher first-pass tissue acquisition rate. While the tissue acquisition rate reached a plateau after the 4th pass with FNA, it reached a plateau after the 2nd pass with FNB. Among the 129 malignant cases, the histological tissue acquisition rate per session was similar (100% and 94%), but the sensitivity by histology alone per session was higher for FNB than for FNA (93% and 73%, p<0.01). Conclusions: The results of our retrospective analysis indicated that compared with a standard FNA needle, a 22-gauge Franseen FNB needle was associated with a higher first-pass tissue acquisition rate.
Endoscopic ultrasound-guided biliary drainage: Complications and their management
Hiroyuki Isayama,Yousuke Nakai,Natsuyo Yamamoto,Saburo Matsubara,Yukiko Ito,Hirfoumi Kogure,Tsuyoshi Hamada,Kazuhiko Koike 소화기인터벤션의학회 2017 International journal of gastrointestinal interven Vol.6 No.2
Endoscopic ultrasound-guided biliary drainage (EUS-BD), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS) can effectively palliate obstructive jaundice, but have not been well established yet. The incidence of complications is about 30% in EUS-BD and higher for EUS-HGS. Several complications have been reported such as bleeding, perforation and peritonitis. Bleeding occurs due to puncture of portal vein, hepatic vein and artery, and we should use color Doppler. When a cautery dilator is used for fistula dilation, burn effects may cause delayed bleeding. Endoscopic hemostasis is only effective for anastomotic bleeding and embolization with interventional radiology technique is required for pseudo aneurysm. There are some types of perforation: failed stent placement after puncture or fistula dilation, double puncture during CDS procedure, and stent migration. Peritonitis with perforation requires surgery and can be fatal. Stent migration before mature fistula formation causes severe peritonitis because EUS-BD makes fistula between two unattached organs. Stents with flaps or long covered self-expandable metallic stents (cSEMSs) are effective to prevent migration. Recent development of lumen apposing stents may reduce early migration in EUS-CDS. Peritonitis without migration can be due to 1) leakage of bile juice or gastric/duodenal contents during EUS-BD or 2) leakage along the placed stent. We should make procedure time as short as possible, and cSEMSs reduce bile leak along the stent by occluding the dilated fistula. In summary, we should understand the mechanism of complications and the technique to prevent and manage complications. Development of dedicated devices to increase the success rate and reduce complications is required.
( Kei Saito ),( Yousuke Nakai ),( Hiroyuki Isayama ),( Ryuichi Yamamoto ),( Kazumichi Kawakubo ),( Yuzo Kodama ),( Akio Katanuma ),( Atsushi Kanno ),( Masahiro Itonaga ),( Kazuhiko Koike ) 대한소화기학회 2021 Gut and Liver Vol.15 No.1
Background/Aims: The aim of this study was to evaluate the safety and efficacy of partially covered self-expandable metallic stents (PCSEMS) in patients undergoing neoadjuvant chemo (radio) therapy (NAC) for pancreatic cancer (PC). Methods: This was a prospective multicenter study to evaluate the safety and efficacy of PC-SEMS in patients receiving NAC for resectable and borderline resectable PC. The primary endpoint was the rate of recurrent biliary obstruction (RBO). Results: Twenty-six patients with PC (three with resectable PC and 23 with borderline resectable PC) who underwent NAC at seven Japanese centers were included in the analysis. Both the technical and functional success rates of PCSEMS placement were 100%. Early stent-related complications were observed in three patients (11.5%): mild pancreatitis (n=2) and mild liver abscess (n=1). The median time to surgery or palliation was 4.0 months. Surgical resection was eventually performed in 73.1% of patients, and stent removal during surgery was successful in all patients. RBO was observed in nine patients (34.6%): seven with stent occlusion, one with kinking and one with migration. The RBO rates in resected cases and nonresected cases were 36.8% and 28.6%, respectively. Conclusions: Biliary drainage by PCSEMS was safe and feasible in patients undergoing NAC for resectable and borderline resectable PC. (Gut Liver 2021;15:135-141)