Transjugular intrahepatic portosystemic shunt creation for portal hypertension in patients with hepatocellular carcinoma: A systematic review

He Zhao,Jiaywei Tsauo,Tao Gong,Jinggui Li,Xiao Li 소화기인터벤션의학회 2018 Gastrointestinal Intervention Vol.7 No.3

Background: To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for the management of portal hypertension in patients with hepatocellular carcinoma (HCC). Methods: A literature search of the MEDLINE/PubMed and Embase databases was conducted. All articles reporting the outcomes of TIPS creation for variceal bleeding and refractory ascites and hepatic hydrothorax in patients with HCC were included. Exclusion criteria were non-English language, sample size < 5, data not extractable, and data reported in another article. Results: A total of 280 patients (mean age, 48–58; male gender, 66%) from five articles were included. TIPS creation was performed for variceal bleeding in 79% and refractory ascites and/or hepatic hydrothorax in 26% of patients. Technical and clinical success was achieved in 99% and 64% of patients, respectively. Clinical failure occurred in 36% of patients due to rebleeding or recurrent bleeding (n = 77) or no resolution or improvement of refractory ascites and hepatic hydrothorax (n = 24). One percent of patient had major complications, including accelerated liver failure (n = 1) and multi-organ failure resulting from hemorrhagic shock (n = 1), all of which resulted in early (i.e., within 30 days) death. Hepatic encephalopathy occurred in 40% of patients after TIPS creation. Lung metastasis was found 1% of patient 5 months (n = 1) and 72 months (n = 1) after TIPS creation. Conclusion: TIPS creation seems to be safe and effective for the management of portal hypertension in patients with HCC.

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.

Recent development of endoscopic ultrasonography-guided drainage of pancreatic fluid collections

Dong Kee Jang,Jun Kyu Lee 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.4

Peripancreatic fluid collections (PFCs) usually occur as a local complication of acute pancreatitis. In the Atlanta classification revised in 2012, local complications are categorized into acute PFC, acute necrotic collection, pancreatic pseudocyst, and walled-off necrosis. The latter two are indications for drainage. With the development of endoscopic ultrasonography (EUS)-guided interventions, EUS-guided drainage of PFCs is now established as a standard treatment due to the advantages of lower cost, shorter hospital stay, and faster recovery. This article provides a brief introduction of PFCs and information on EUS-guided drainage of PFCs with a review of literature.

Recent topics on endoscopic ultrasonography-guided celiac plexus neurolysis

Ichiro Yasuda,Tatsuyuki Hanaoka,Kosuke Takahashi,Yasuhiro Araki,Shinpei Doi,Takuji Iwashita,Keisuke Iwata,Tsuyoshi Mukai 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.4

Endoscopic ultrasonography-guided celiac plexus neurolysis (EUS-CPN) is a widely practiced technique. Three sets of guidelines have recently been published and this procedure has become a major EUS technique. However, there are still several unanswered questions. The purpose of this manuscript is to review the recent literature pertaining to EUS-CPN. Currently, the main indication of EUS-CPN is pancreatic cancer pain. It is also performed for patients with chronic pancreatitis, but the indication is controversial due to its limited efficacy and a high incidence of infectious complications. Various techniques, such as central and bilateral EUS-CPN, and EUS-guided direct celiac ganglia neurolysis (EUS-CGN) have been performed. However, the efficacies of these techniques remain controversial. Complications related to the procedures are generally not serious, but major adverse events, such as paraplegia and ischemic complications, have been reported. The impacts of EUS-CPN on survival have also been evaluated. Although increased survival was expected via improvements in the quality of life, data suggests that EUS-CPN related procedures, especially EUS-CGN, might reduce the survival time. However, precise mechanisms have not been elucidated. In addition to conventional techniques, new techniques, such as EUS-guided celiac ganglion radiofrequency ablation (EUS-RFA) and the use of highly viscous phenol-glycerol, dexmedetomidine, and contrast-enhanced agents, have been introduced. However, these techniques are still in experimental stages. Additional studies need to be conducted to address these gaps in the literature.

Recent development of endoscopic ultrasound-guided gallbladder drainage

Brian Kin Hang Lam,Anthony Yuen Bun Teoh 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.4

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has emerged as a promising alternative treatment to high-risk patients suffering from acute cholecystitis and are unfit for surgery. EUS-GBD has similar rates of technical and clinical success compared to other alternative treatments, but the procedure has been shown to reduce adverse event rates and the need for repeated interventions. This review aims to provide a summary of the recent development in the EUS-GBD technique with various devices employed in the procedure.

Recent developments in endoscopic ultrasonography-guided gastroenterostomy

Kenjiro Yamamoto,Takao Itoi 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.4

Gastric outlet obstruction (GOO) can be caused by benign and malignant diseases. GOO often leads to a decreased quality of life, because of nausea, vomiting, and problems with oral food intake. Traditionally, surgical gastrojejunostomy (SGJ) has been the primary treatment for GOO. Endoscopic enteral stenting (EES) has also been carried out for the treatment of malignant GOO. In recent years, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen apposing metal stent has emerged as a procedure to treat patients with GOO, as an alternative to surgery or to standard endoscopy when EES is not possible. Various techniques, such as direct EUS-GE, assisted EUS-GE, and EUS-guided balloon-occluded gastrojejunostomy bypass have been established to perform EUS-GE safety and accurately. Previous reports of EUS-GE with lumen apposing metal stent demonstrated that the technical and clinical success rates were 87% to 100% and 84% to 100%, respectively, without differentiating the various procedural techniques. The adverse events rate ranged from 0% to 18.1%, and included stent misdeployment, bleeding, peritonitis, leakage, abdominal pain, etc. In addition, the reintervention rate ranged from 0% to 15.1%. Moreover, a comparison of EUS-GE and SGJ showed that there was no significant difference in clinical success, rate of adverse events, or need for reintervention between these procedures. On the other hand, studies comparing EUS-GE with EES showed that EUS-GE may have higher clinical success and a lower rate of stent failure requiring repeated intervention than EES. Furthermore, EUS-GE has been used in several clinical scenarios, such as the management of endoscopic retrograde cholangiopancreatography in patients who underwent Roux-en-Y gastric bypass, or for the treatment of afferent loop syndrome. The present review describes the presently available EUS-GE techniques and introduces the recent clinical advances in the treatment of GOO.

‘Radial force’ of colonic stents: A parameter without consistency, definition or standard

Hans-Ulrich Laasch,Graham D. Milward,Derek W. Edwards 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.3

Background: To investigate the expansion force of current colonic stents and to match these to industry standards. Methods: Samples of all colonic stents were requested from manufactures world-wide. Expansion forces were tested with an RX650 compression tool (MSI, Flagstaff, AZ, USA). Measurements were averaged over three cycles of compression and expansion, independently performed at 37°C by specialist engineers of MSI. In parallel, a survey was undertaken on standards, and tests used by manufacturers in their production process. As a labbased study, Institutional Review Board approval was not required. Results: A literature search did not identify any industry standards for testing expansion force or a suggested range for this primary stent function. Median expansion force of all stents was 24.4 N, (35.1 N for braided, 20.7 N for knitted stents) with a vast range from 5.6–130.8 N. Covering braided stents in liquid silicone increased their median force 5.5-fold, separate membranes attached to knitted stents only had a minor effect on expansion force. Five of eight manufacturers replied, describing three different test methods with three different units for expansion force. Conclusion: There are no standards on assessing expansion force, or what the ideal range should be. Consequently, the variation is remarkable, but values are not published, and even if they were, they could not be compared. Consequently, interventionists are unable to discriminate between different stents and to select the most suitable device for their patients, and no recommendation can be made on the ‘best stent’. The industry needs an agreed test standard and an acceptable range of stent forces.

The diagnostic yield of specimens obtained from endoscopic ultrasound guided fine needle biopsy of solid masses with the AcquireTM needle

Mark Bonnichsen,Ellie Skacel,James Kench,Arthur Kaffes,Payal Saxena 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.3

Background: Recent developments in the design of needle tips used for fine needle biopsy via endoscopic ultrasound (EUS) allows for the procurement of core tissue for histological assessment in addition to cytology. Core tissue provides tissue architecture as well as the ability to perform molecular profiling investigations. We present a single centre study of experience with a new EUS needle with a Franseen tip (AcquireTM; Boston Scientific, Natick, MA, USA). The aim of the study was to assess the diagnostic yield of biopsies from solid lesions throughout the gastrointestinal tract. Methods: We performed a retrospective study of consecutive patients undergoing EUS biopsy between January 2017 and November 2018. Cystic lesions with no solid component were excluded or if samples were not sent for both cytology and histology. Rapid onsite evaluation (ROSE) was performed and the core tissue obtained was sent for histology. Results: Forty-six patients underwent EUS biopsy of solid lesions with specimens sent for both cytology and histology. Lesions included solid pancreatic masses (n = 31), lymph node (n = 3), gastric subepithelial lesion (n = 3), other (n = 9). The mean number of passes per lesion was 1.9 (range 1–4). In 43/46 (93%) of cases, a core specimen was obtained. Tissue obtained by EUS biopsy was adequate for evaluation by ROSE in 39/46 cases (85%). Histological diagnosis was confirmed in 41/46 (89%) cases compared to 31/46 (67%) cases with cytology (P = 0.011). Subgroup analysis of pancreatic lesions showed histological diagnosis was superior to cytology (90% vs 61%, P = 0.007). There were no adverse events. Conclusion: Histological analysis of specimens obtained via EUS biopsy was superior to cytology, particularly in assessment of solid pancreatic lesions.

An extremely rare coexistence of achalasia cardia with esophageal leiomyoma: An endoscopic treatment approach

Pankaj Desai,Chintan Patel,Mayank Kabrawala,Subhash Nandwani,Rajiv Mehta,Ritesh Prajapati,Nisharg Patel,Krishna Parekh 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.3

The coexistence of an esophageal leiomyoma with an achalasia cardia is extremely rare and poses a diagnostic dilemma as the clinical presentation of an esophageal leiomyoma strongly resembles to an achalasia cardia. Moreover, at most of the time, an esophageal leiomyoma exist with absence of leiomyoma specific symptoms or findings. It could be the reason why the diagnosis of esophageal leiomyoma is missed while the patient has the coexistence of the both. Here, we present a case series of an unusual coexistence of an esophageal leiomyoma with achalasia in three patients who were presented with dysphagia and had an initial diagnosis of achalasia. Even endoscopic evaluation couldn’t reveal esophageal leiomyoma; it became apparent during the peroral endoscopic myotomy.

Angiographic diagnosis and treatment of a splenic artery pseudoaneurysm following endoscopic cystogastrostomy for a pancreatic pseudocyst

Ji Eun Kim,Ji Hoon Shin 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.4

Summary of the Event: A 57-year-old male with chronic pancreatitis presented with an enlarging pseudocyst which was treated with endoscopic ultrasound (EUS)-guided cystogastrostomy. Three days later, he presented with massive hematemesis, and abdominal computed tomography (CT) revealed hemorrhage within both the pseudocyst and the stomach. Endoscopic evaluation was impossible due to the massive amount of hematemesis. Angiography delineated a small pseudoaneurysm with contrast extravasation involving the branch of the splenic artery. Embolization using nbutyl- 2 cyanoacrylate was performed leading to the immediate cessation of bleeding. Teaching Point: The risk of delayed hemorrhage after EUS-guided cystogastrostomy for a pancreatic pseudocyst should always be kept in mind. Angiography should be considered for the diagnostic and therapeutic purpose when hemostasis is not possible using an endoscope.