Pancreatic Fluid Collection Drainage by Endoscopic Ultrasound: An update

Shashideep Singhal,Stephen R. Rotman,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2013 Clinical Endoscopy Vol.46 No.5

Endoscopic management of symptomatic pancreatic fluid collections (PFCs) is now considered to be first line therapy. Expanded use of endoscopic ultrasound (EUS) techniques has resulted in increased applicability, safety, and efficacy of endoscopic transluminal PFC drainage. Steps include EUS-guided trangastric or transduodenal fistula creation into the PFC followed by stent placement or nasocystic drain deployment in order to decompress the collection. With the remarkable improvement in the available accessories and stents and development of exchange free access device; EUS drainage techniques have become simpler and less time consuming. The use of self-expandable metal stents with modifications to drain PFC has helped in overcoming some previously encountered challenges. PFCs considered suitable for endoscopic drainage include collection present for greater than 4 weeks, possessing a well-formed wall, position accessible endoscopically and located within 1 cm of the duodenal or gastric walls. Indications for EUS-guided drainage have been increasing which include unusual location of the collection, small window of entry, nonbulging collections, coagulopathy, intervening varices, failed conventional transmural drainage, indeterminate adherence of PFC to the luminal wall or suspicion of malignancy. In this article, we present a review of literature to date and discuss the recent developments in EUS-guided PFC drainage.

Esophageal Stricture Prevention after Endoscopic Submucosal Dissection

Deepanshu Jain,Shashideep Singhal 대한소화기내시경학회 2016 Clinical Endoscopy Vol.49 No.3

Advances in diagnostic modalities and improvement in surveillance programs for Barrett esophagus has resulted in an increase in the incidence of superficial esophageal cancers (SECs). SEC, due to their limited metastatic potential, are amenable to non-invasive treatment modalities. Endoscopic ultrasound, endoscopic mucosal resection, and endoscopic submucosal dissection (ESD) are some of the new modalities that gastroenterologists have used over the last decade to diagnose and treat SEC. However, esophageal stricture (ES) is a very common complication and a major cause of morbidity post-ESD. In the past few years, there has been a tremendous effort to reduce the incidence of ES among patients undergoing ESD. Steroids have shown the most consistent results over time with minimal complications although the preferred mode of delivery is debatable, with both systemic and local therapy having pros and cons for specific subgroups of patients. Newer modalities such as esophageal stents, autologous cell sheet transplantation, polyglycolic acid, and tranilast have shown promising results but the depth of experience with these methods is still limited. We have summarized case reports, prospective single center studies, and randomized controlled trials describing the various methods intended to reduce the incidence of ES after ESD. Indications, techniques, outcomes, limitations, and reported complications are discussed.

Transoral Incisionless Fundoplication for Refractory Gastroesophageal Reflux Disease: Where Do We Stand?

Deepanshu Jain,Shashideep Singhal 대한소화기내시경학회 2016 Clinical Endoscopy Vol.49 No.2

Gastroesophageal reflux disease (GERD) is a chronic, progressive, and costly medical condition affecting a substantial proportion of the world population, predominantly the Western population. The available treatment options for patients with refractory GERD symptoms are limited to either laparoscopic surgery with significant sequelae or potentially lifelong, high-dose proton pump inhibitor therapy. The restoration of the antireflux competence of the gastroesophageal junction at the anatomic and physiologic levels is critical for the effective long-term treatment of GERD. Transoral incisionless fundoplication (TIF) surgery is a safe, well-tolerated, and effective treatment that has yielded significant symptomatic improvement in patients with medically refractory GERD symptoms. In this review article, we have summarized case series and reports describing the role of TIF for patients with gastroesophageal reflux symptoms. The reported indications, techniques, complications, and success rates are also discussed.

Endoscopic Sleeve Gastroplasty - A New Tool to Manage Obesity

Deepanshu Jain,Bharat Singh Bhandari,Ankit Arora,Shashideep Singhal 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.6

Obesity is a growing pandemic across the world. Dietary restrictions and behavior modifications alone have a limited benefit. Bariatric surgery, despite being the current gold standard, has limited acceptance by patients due to cost and associated morbidity. In our review, we have discussed nine original studies describing endoscopic sleeve gastroplasty (ESG). A total of 172 subjects successfully underwent ESG. Of 65 subjects with follow up data, 95.4% (62/65) had intact gastric sleeve confirmed via esophagogastroduodenoscopy or oral contrast study at the end of study specific follow up interval (the longest being 6 months). Individual studies reported a technical success rate for intact gastric sleeve from as low as 50% to as high as 100%. A statistically significant (p<0.05) weight loss was reported in seven of the eight studies with available data. None of the patients experienced any intra-procedure complications, and approximately 2.3% (4/172) of patients experienced major post-procedure complications; however, no mortality was reported. Majority of the studies reported relatively high incidence of minor post-procedure complications, which improved with symptomatic treatment alone. Good patient tolerance with comparable clinical efficacy in achieving and sustaining desired weight loss makes ESG an attractive option to consider among other bariatric therapies.

De-novo Gastrointestinal Anastomosis With Lumen Apposing Metal Stent

Deepanshu Jain,Ankit Chhoda,Abhinav Sharma,Shashideep Singhal 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.5

Gastric outlet obstruction, afferent or efferent limb obstruction, and biliary obstruction among patients with altered anatomy oftenrequire surgical intervention which is associated with significant morbidity and mortality. Endoscopic dilation for benign etiologiesrequires multiple sessions, whereas self-expandable metal stents used for malignant etiologies often fail due to tumor in-growth. Lumenapposing metal stents, placed endoscopically with the intent of creating a de-novo gastrointestinal anastomosis bypassing the site ofobstruction, can potentially achieve similar effcacy, with a much lower complication rate. In our study cohort (n=79), the compositetechnical success rate and clinical success rate was 91.1% (72/79) and 97.2% (70/72), respectively. Five different techniques were used:43% (34/79) underwent the balloon-assisted method, 27.9% (22/79) underwent endoscopic ultrasound-guided balloon occludedgastro-jejunostomy bypass, 20.3% (16/79) underwent the direct technique, 6.3% (5/79) underwent the hybrid rendezvous technique,and 2.5% (2/79) underwent natural orifice transluminal endoscopic surgery (NOTES)-assisted procedure. All techniques required anechoendoscope except NOTES. In all, 53.2% (42/79) had non-cautery enhanced Axios stent, 44.3% (35/79) had hot Axios stent, and2.5% (2/79) had Niti-S spaxus stent. Symptom-recurrence was seen in 2.8%, and 6.3% had a complication (bleeding, abdominal pain orperitonitis). All procedures were performed by experts at centers of excellence with adequate surgical back up.

Endoscopic ultrasound guided gallbladder drainage by using Lumen apposing metal stent for acute cholecystitis: systematic review

Deepanshu Jain,Bharat Singh Bhandari,Nikhil Agrawal,Shashideep Singhal 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.5

Surgery remains the standard treatment for acute cholecystitis except in high-risk candidates where percutaneous transhepatic gallbladderdrainage (PT-GBD), endoscopic transpapillary cystic duct stenting (ET-CDS), and endoscopic ultrasound-guided gallbladder drainage(EUS-GBD) are potential choices. PT-GBD is contraindicated in patients with coagulopathy or ascites and is not preferred by patientsowing to aesthetic reasons. ET-CDS is successful only if the cystic duct can be visualized and cannulated. For 189 patients whounderwent EUS-GBD via insertion of a lumen-apposing metal stent (LAMS), the composite technical success rate was 95.2%, which increasedto 96.8% when LAMS was combined with co-axial self-expandable metal stent (SEMS). The composite clinical success rate was96.7%. We observed a small risk of recurrent cholecystitis (5.1%), gastrointestinal bleeding (2.6%) and stent migration (1.1%). Cauteryenhanced LAMS significantly decreases the stent deployment time compared to non-cautery enhanced LAMS. Prophylactic placementof a pigtail stent or SEMS through the LAMS avoids re-interventions, particularly in patients, where it is intended to remain in situ indefinitely. Limited evidence suggests that the effcacy of EUS-GBD via LAMS is comparable to that of PT-GBD with the former showingbetter results in postoperative pain, length of hospitalization, and need for antibiotics. EUS-GBD via LAMS is a safe and effcaciousoption when performed by experts.

Contrast Enhanced Harmonic Endoscopic Ultrasound: A Novel Approach for Diagnosis and Management of Gastrointestinal Stromal Tumors

Ankit Chhoda,Deepanshu Jain,Venkateswar R Surabhi,Shashideep Singhal 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.3

The histologic analysis of gastrointestinal stromal tumors (GISTs) is a common method to detect the mitotic activity and to subsequentlydetermine the risk of GISTs for malignancy. The potential false negative error due to inadequate yield of specimens and actualdetermination of malignancy risk requires analysis of the whole tumor. We aimed to assess the role of contrast enhanced endoscopicultrasound (CE-EUS) in the management of GISTs. Two authors individually did review of English literatures to identify nine peerreviewedoriginal articles using keywords- contrast endoscopic ultrasound, GIST and submucosal tumor. Studies were heterogeneousin their aims looking either at differentiating submucosal lesions from GISTs, estimating malignant potential of GISTs with histologiccorrelation or studying the role of angiogenesis in malignant risk stratification. CE-EUS had moderate to high efficacy in differentiatingGISTs from alternative submucosal tumors. CE-EUS had a higher sensitivity than EUS-guided fine needle aspiration, contrast computedtomography and Doppler EUS for detection of neo-vascularity within the GISTs. However, the evidence of abnormal angiogenesiswithin GIST as a prognostic factor needs further validation. CE-EUS is a non-invasive modality, which can help differentiate GISTs andprovide valuable assessment of their perfusion patterns to allow better prediction of their malignant potential but more experience isneeded.

Review of Simultaneous Double Stenting Using Endoscopic Ultrasound-Guided Biliary Drainage Techniques in Combined Gastric Outlet and Biliary Obstructions

Hao Chi Zhang,Monica Tamil,Keshav Kukreja,Shashideep Singhal 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.2

Concomitant malignant gastric outlet obstruction and biliary obstruction may occur in patients with advanced cancers affecting theseanatomical regions. This scenario presents a unique challenge to the endoscopist in selecting an optimal management approach. Wesought to determine the effcacy and safety of endoscopic techniques for treating simultaneous gastric outlet and biliary obstruction(GOBO) with endoscopic ultrasound (EUS) guidance for biliary drainage. An extensive literature search for peer-reviewed publishedcases yielded 6 unique case series that either focused on or included the use of EUS-guided biliary drainage (EUS-BD) withsimultaneous gastroduodenal stenting. In our composite analysis, a total of 51 patients underwent simultaneous biliary drainagethrough EUS, with an overall reported technical success rate of 100% for both duodenal stenting and biliary drainage. EUS-guidedcholedochoduodenostomy or EUS-guided hepaticogastrostomy was employed as the initial technique. In 34 cases in which clinicalsuccess was ascribed, 100% derived clinical benefit. The common adverse effects of double stenting included cholangitis, stent migration,bleeding, food impaction, and pancreatitis. We conclude that simultaneous double stenting with EUS-BD and gastroduodenal stentingfor GOBO is associated with high success rates. It is a feasible and practical alternative to percutaneous biliary drainage or surgery forpalliation in patients with associated advanced malignancies.

Closing the Gaps: Endoscopic Suturing for Large Submucosal and Full-Thickness Defects

Keshav Kukreja,Suma Chennubhotla,Bharat Bhandari,Ankit Arora,Shashideep Singhal 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.4

This article is a systematic review of relevant literature on endoscopic suturing as a primary closure technique for large submucosaland full-thickness defects after endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic fullthicknessresection (EFTR). A comprehensive literature search was conducted through 2016 by using PubMed, to find peer-reviewedoriginal articles. The specific factors considered were the procedural indications and details, success rates, clinical outcomes includingcomplications, and study limitations. Six original articles were included in the final review: two with non-human subjects and fourwith human subjects. The mean success rate of endoscopic suturing was 97.4% (100% for human subjects and 95.4% for non-humansubjects). The procedural time ranged from 7 to 89 min. The average size and depth of lesions were 2.71 cm (3.74 cm [human] and1.96 cm [non-human]) and 1.52 cm, respectively. The technique itself had no reported impact on mortality. In conclusion, endoscopicsuturing is a minimally invasive technique for the primary closure of defects caused by EMR, ESD, and EFTR, with a high success andlow complication rate.