Endoscopic Guided Biliary Drainage: How Can We Achieve Efficient Biliary Drainage?

Prashant Kedia,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2013 Clinical Endoscopy Vol.46 No.5

Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

Technical Advances in Endoscopic Ultrasound(EUS)-Guided Tissue Acquisition for Pancreatic Cancers: How Can We Get the Best Results with EUS-Guided Fine Needle Aspiration?

Prashant Kedia,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2013 Clinical Endoscopy Vol.46 No.5

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.

Review : Advances in Endoscopic Ultrasound-Guided Biliary Drainage; A Comprehensive Review

( Savreet Sarkaria ),( Ho Su Lee ),( Monica Gaidhane ),( Michel Kahaleh ) 대한간학회 2013 Gut and Liver Vol.7 No.2

Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapy for bile duct drainage. In the hands of experienced endoscopists, conventional ERCP results in a failed cannulation rate of 3% to 5%. This failure can occur more commonly in the setting of altered anatomy or technically difficult cases due to either duodenal or biliary obstruction. In cases of ERCP failure, patients have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. However, both PTBD and surgery have higher than desirable complication rates. Within the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an attractive alternative to PTBD after failed ERCP. Many groups have reported on the feasibility, efficacy and safety of this technique. This article reviews the indications for ERCP and the currently practiced EUS-BD techniques, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy. (Gut Liver 2013;7:129-136)

Reverse Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Superior Mesenteric Artery Syndrome: A New Concept

Ming-ming Xu,Enad Dawod,Monica Gaidhane,Amy Tyberg,Michel Kahaleh 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.1

Superior mesenteric artery syndrome (SMAS) causes compression and partial or complete obstruction of the duodenum, resulting inabdominal pain, nausea, vomiting, and weight loss. If conservative therapy fails, the patient is typically referred for enteral feeding orlaparoscopic gastrojejunostomy. The last few years have seen increasing use of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for gastric obstructionindications. EUS-GJ involves the creation of a gastric bypass via an echoendoscope in cases in which the small intestine can bepunctured under ultrasonographic visualization, resulting in an incision-free, effcient, and safe procedure. In this case report, we present the first case of SMAS treated using a reverse EUS-GJ, and describe the steps and advantages of theprocedure in this particular case.

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.

Endoscopic Therapy for Pancreatic Fluid Collections: A Definitive Management Using a Dedicated Algorithm

Ming Ming Xu,Iman Andalib,Aleksey Novikov,Enad Dawod,Moamen Gabr,Monica Gaidhane,Amy Tyberg,Michel Kahaleh 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.3

Background/Aims: Endoscopic ultrasonography (EUS)-guided drainage is the preferred approach for infected or symptomaticpancreatic fluid collections (PFCs). Here, we developed an algorithm for the management of pancreatitis complicated by PFCs andreport on its effcacy and safety. Methods: Between September 2011 and October 2017, patients were prospectively managed according to the algorithm. PFCs wereclassified as poorly organized fluid collections (POFCs), pancreatic pseudocysts (PPs), or walled-off pancreatic necrosis (WOPN). Clinical success was defined as a decrease in PFC size by ≥50% of the maximal diameter or to ≤2 cm. Results: A total of 108 patients (62% male; mean age, 53 years) were included: 13 had POFCs, 43 had PPs, and 52 had WOPN. Seventytwopatients (66%) required a pancreatic duct (PD) stent, whereas 65 (60%) received enteral feeding. A total of 103 (95%) patientsachieved clinical success. Eight patients experienced complications including bleeding (n=6) and surgical intervention (n=2). Patientswith enteral feeding were 3.4 times more likely to achieve resolution within 60 days (p=0.0421), whereas those with PD stenting was fivetimes more likely to achieve resolution within 90 days (p=0.0069). Conclusions: A high PFC resolution rate can be achieved when a dedicated algorithm encompassing EUS-guided drainage, PDstenting, and early enteral feeding is adopted.

Photodynamic Therapy in Unresectable Cholangiocarcinoma: Not for the Uncommitted

Jayant P. Talreja,Marisa DeGaetani,Kristi Ellen,Timothy Schmitt,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2013 Clinical Endoscopy Vol.46 No.4

Background/Aims: Photodynamic therapy (PDT) in unresectable cholangiocarcinoma has been associated with improved survival. We report a single tertiary care center experience over the past 6 years. Methods: Fifty-five patients with unresectable cholangiocarcinoma received PDT between 2004 and 2010. Plastic stents were placed after PDT to prevent cholangitis. Results: Twenty-seven patients (49%) showed Bismuth type IV, 22 (41%) showed Bismuth type III, and six (10 %) showed Bismuth type I and II. Twenty patients (37%) received chemotherapy and radiation therapy, five (9%) received chemotherapy only; and one (2%) received radiation therapy only. Mean number of PDT sessions was 1.9±1.5 sessions (range, 1 to 9). Mean survival duration was 293±266 days (median 190; range, 25 to 1,332). PDT related complications included three (5%) facial burn, three (5%) photosensitivity, and two (3%) rash. Kaplan-Meier analysis comparing the survival means of patients who received PDT and chemotherapy/radiation therapy (median survival 257 days; 95% confidence interval [CI], 166 to 528) versus who received PDT only (median survival 183 days; 95% CI, 129 to 224) showed no significant difference (log-rank p=0.20). Conclusions: PDT has a measurable impact on survival in unresectable cholangiocarcinoma but requires aggressive stenting post therapy.

Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure

Amy Tyberg,Jose Nieto,Sanjay Salgado,Kristen Weaver,Prashant Kedia,Reem Z. Sharaiha,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.2

Background/Aims: Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Roux-en-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS. Methods: All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection. Results: Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg. Conclusions: EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

Peroral Endoscopic Myotomy: Establishing a New Program

Nikhil A. Kumta,Shivani Mehta,Prashant Kedia,Kristen Weaver,Reem Z. Sharaiha,Norio Fukami,Hitomi Minami,Fernando Casas,Monica Gaidhane,Arnon Lambroza,Michel Kahaleh 대한소화기내시경학회 2014 Clinical Endoscopy Vol.47 No.5

Achalasia is an esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Treatment of achalasia is aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM), derived from natural orifice transluminal endoscopic surgery (NOTES) and advances in endoscopic submucosal dissection (ESD), presents a novel, minimally invasive, and curative endoscopic treatment for achalasia. POEM involves an esophageal mucosal incision followed by creation of a submucosal tunnel crossing the esophagogastric junction and myotomy before closure of the mucosal incision. Although the procedure is technically demanding and requires a certain degree of skill and competency, treatment success is high (90%) with low complication rates. Since the first described POEM in humans in 2010, it has been used increasingly at centers worldwide. This article reviews available published clinical studies demonstrating POEM efficacy and safety in order to present a proposal on how to establish a dedicated POEM program and reach base proficiency for the procedure.

The Learning Curve for Peroral Endoscopic Myotomy in Latin America: A Slide to the Right?

Michel Kahaleh,Amy Tyberg,Supriya Suresh,Arnon Lambroza,Fernando Rodriguez Casas,Mario Rey,Jose Nieto,Guadalupe Ma Martínez,Felipe Zamarripa,Vitor Arantes,Maria G Porfilio,Monica Gaidhane,Pietro Fami 대한소화기내시경학회 2021 Clinical Endoscopy Vol.54 No.5

Background/Aims: Peroral endoscopic myotomy (POEM) has been increasingly used for achalasia in Latin America, where Chagasdisease is prevalent, and this makes POEM more challenging. The aim of this study was to determine the learning curve for POEMin Latin America. Methods: Patients undergoing POEM in Latin America with a single operator were included from a prospective registry over 4 years. Non-linear regression and cumulative sum control chart (CUSUM) analyses were conducted for the learning curve. Results: A total of 125 patients were included (52% male; mean age, 59 years), of which 80 had type II achalasia (64%), and 38 hadChagas disease (30%). The average pre-procedure and post-procedure Eckardt scores were 6.79 and 1.87, respectively. Technicalsuccess was achieved in 93.5% of patients, and clinical success was achieved in 88.8%. Adverse events occurred in 27 patients (22%)and included bleeding (4 patients), pneumothorax (4 patients), mucosal perforation (13 patients), mediastinitis (2 patients), andleakage (4 patients). The CUSUM chart showed a median procedure time of 97 min (range, 45-196 min), which was achieved at the 61st procedure. Procedure duration progressively decreased, with the last 10 procedures under 50 min approaching a plateau (p-value <0.01). Conclusions: Mastering POEM in Latin America requires approximately 61 procedures for both POEM efficiency and to accomplishthe procedure within 97 minutes.