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Create a Free AccountAnatomy - Hepatopancreatobiliary
Endoscopic nasobiliary drainage tube placement through a periampullary perforation for management of intestinal leak and necrotizing pancreatitis
Periampullary perforation has a high mortality rate.1,2 Endoscopic management, including a biliary stent placement into the common bile duct (CBD) and hemostatic clips, can treat the periampullary perforation.3,4 However, it can be difficult to close the perforation and prevent the intestinal juice leakage in the case of the perforation with severe inflammation.EUS–guided choledochoduodenostomy using a lumen-apposing metal stent in a patient with preexisting duodenal stent and ascites
Endoscopic retrograde cholangiopancreatography in patients with a pre-existing duodenal stent is technically challenging with a low success rate.1 EUS-guided biliary drainage has emerged as a promising technique for patients with malignant biliary obstruction when conventional ERCP fails. Although combined placement of self-expanding metal biliary and duodenal stents can be performed for patients with simultaneous biliary and duodenal obstruction, reports on transduodenal EUS-guided biliary drainage in patients with an existing duodenal metal stent are limited.ERCP and EUS technique in situs inversus totalis: preparing for a left-sided plot twist
Situs inversus totalis (SIT) is the rare occurrence of a mirror image reversal of the entire internal visceral anatomy with a reported incidence of 1 out of 8000 to 1 out of 25,000.1,2 The altered anatomy in SIT imposes significant challenges to performing diagnostic and therapeutic endoscopy successfully. We describe in this case report a successful EUS and ERCP in a patient with SIT.Magnetic compression anastomosis for treatment of biliary stricture after cholecystectomy
Postcholecystectomy biliary stricture can be treated with endoscopic or percutaneous treatments. However, these conventional methods are not feasible if a guidewire cannot be passed through the stricture.1-6 We report magnetic compression anastomosis for the treatment of a biliary stricture after cholecystectomy that could not be treated with conventional methods (Video 1, available online at www.VideoGIE.org ).Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-guided gallbladder drainage is safe and feasible
Acute cholecystitis and choledocholithiasis in patients with altered anatomy and major contraindications to surgery represent a challenging clinical scenario.1Endoscopic ultrasonography-guided rendezvous technique for removal of a long biliary ascariasis: a challenging case
Biliary ascariasis is a well-known entity in tropical countries.1 ERCP is generally successful in removing them if they are causing cholangitis or obstruction.2 However, in the presence of anatomic distortion, an EUS-guided approach may be needed. To the best of our knowledge, this is the first reported case of the EUS-guided rendezvous technique being used to remove biliary ascaris.Cholangioscopy in primary sclerosing cholangitis: a case series of benign features
Cholangioscopy is useful in establishing a visual diagnosis of cholangiocarcinoma (CCA), but this is harder to achieve in primary sclerosing cholangitis (PSC) because of the stricture-forming nature of the disease. Furthermore, it can be harder to differentiate malignant from benign features of the underlying inflammation. This case series demonstrates the varied features of nonmalignant inflammatory findings in PSC.Electrohydraulic lithotripsy under the mother-baby cholangioscope system using a colonoscope for large common bile duct stones in a patient with Roux-en-Y reconstruction
Electrohydraulic lithotripsy (EHL) is useful for the treatment of common bile duct (CBD) stones (CBDSs) when stones are larger than 2 cm in diameter or conventional extraction methods have proven ineffective.1 However, EHL requires direct visualization of the CBD, which is often challenging in patients who have undergone Roux-en-Y reconstruction. There have been some reports of EHL under direct cholangioscopy using an enteroscope or ultra-slim upper endoscope for patients with a history of Roux-en-Y reconstruction.EUS-guided biliary rendezvous as an emergent rescue after failed choledochoduodenostomy using a lumen-apposing metal stent
A 60-year-old man with pancreatic cancer and liver metastases who had been referred previously for biliary drainage was recommended palliative oncologic treatment. After a failed transpapillary attempt via ERCP, same-session EUS-guided biliary drainage was chosen. On EUS examination, a minimally dilated common bile duct (CBD) up to 9 mm was identified from the duodenal bulb. An EUS-guided choledochoduodenostomy (CDS) using a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EC-LAMS) (8 × 8 mm, HotAxios; Boston Scientific, Marlborough, Mass) was performed from a long-scope position using a free-hand plus preloaded guidewire technique.Cholangioscopy in primary sclerosing cholangitis: a case series of dominant strictures and cholangiocarcinoma
Prompt and accurate differentiation of benign and malignant strictures in primary sclerosing cholangitis (PSC) is crucial. ERCP with brush cytology, the most common modality to achieve this, is hindered by a low diagnostic yield. Cholangioscopy can overcome this limitation by establishing a visual diagnosis based on the characteristic morphologic features of cholangiocarcinoma (CCA) and can aid in targeted biopsies of suspicious lesions. However, its role in PSC remains unclear. This case series demonstrates the performance of the latest generation of single-operator cholangioscope for this indication.EUS-guided choledochoduodenostomy creation using a biliary fully covered self-expanding metal stent after maldeployment of lumen-apposing metal stent
A 72-year-old man with stage IV renal cell carcinoma presented with obstructive jaundice secondary to a metastasis in the head of the pancreas. CT imaging demonstrated common bile duct dilation up to 15 mm secondary to a 6-cm pancreatic head mass (Fig. 1). ERCP was attempted but failed because of ampullary effacement from malignant invasion. Because the patient was not a surgical candidate, EUS-guided biliary drainage was attempted.Combined bridging and antegrade stent placement during transmural treatment for malignant hilar biliary obstruction in a patient with surgically altered anatomy
Recently, bilateral biliary drainage has been considered as the recommended approach for malignant hilar biliary obstruction (MHBO).1 Patients with surgically altered anatomy (SAA) usually represent a challenge for enteroscopy-assisted ERCP (E-ERCP), with its demanding procedure and dedicated technique. This challenge is greatly increased if SAA is combined with MHBO, especially with the limited availability of suitable metal stents for E-ERCP. EUS-guided hepaticogastrostomy (EUS-HGS) has become a feasible alternative approach for this group of patients, allowing bilateral drainage through the bridging technique using an uncovered self-expandable metal stent (SEMS) across the hilar malignant stricture joining the right and left hepatic ducts (RHDs and LHDs, respectively).Direct peroral cholangioscopy after dilation of distal common bile duct with a fully covered self-expandable metal stent for the assessment of indeterminate biliary stricture
An 82-year-old man presented with jaundice and evidence of a stricture in the mid common bile duct (CBD), with wall thickening detected on CT scan (Fig. 1). The patient underwent endoscopic ultrasound that showed a hypoechoic, endoductal, hypovascularized lesion of the mid CBD measuring 12.7 mm in diameter. EUS-guided fine-needle biopsy was performed in this area, and histocytopathologic evaluation results were inconclusive.Uncommon cause of cholangitis due to a migrated pancreatic stone into the common bile duct
A 62-year-old man was referred to our tertiary hospital for endoscopic therapy of previously diagnosed alcoholic chronic pancreatitis. In the previous year he had been admitted to the referring hospital every 2 months for flares of pancreatitis, which were all treated conservatively. He was using nonopioid analgesics. He had no history of a cholecystectomy. Routine laboratory tests did not show any abnormalities. Cross-sectional imaging studies demonstrated 2 obstructive pancreatic duct stones in the pancreatic head with upstream main pancreatic duct dilatation of 7.6 mm.Treatment of a proximally migrated plastic stent in a case of refractory distal biliary stricture
Proximal migration of a biliary plastic stent is an uncommon but important adverse event. The migrated stents can not only compromise bile drainage but also result in serious adverse events, such as fistulas.1 Although endoscopic retrieval could be an effective method of addressing migrated stents, surgery may be required if endoscopic retrieval is unsuccessful, especially in benign diseases.2-4EUS-guided rendezvous with a steerable access needle in choledocholithiasis
A 60-year-old man who had previously undergone cholecystectomy was seen for a 4-week history of abdominal pain and fever. Investigations revealed leukocytosis (12,000 cell/mm3) and deranged liver function test results (bilirubin 3 mg/dL, serum alkaline phosphatase 360 IU/L). An ultrasound of the abdomen showed a dilated common bile duct (CBD). EUS (UCT-180; Olympus Ltd, Tokyo, Japan) revealed a dilated CBD with multiple calculi without intrahepatic biliary radicle dilation (Fig. 1). Attempts at biliary access during ERCP were unsuccessful because of nonvisualized intradiverticular papilla and duodenal deformity (Fig. 2).Recanalization of the bile duct by using percutaneous and endoscopic methods after iatrogenic injury
Bile leaks are an uncommon adverse event after biliary surgery. Iatrogenic common bile duct (CBD) injuries are particularly uncommon. However, they lead to substantial morbidity and often require surgical intervention, possibly with the creation of Roux-en-Y hepaticojejunostomy. We describe a case demonstrating the successful combination of endoscopic and percutaneous methods to recanalize the bile duct after iatrogenic injury.Removal of proximally migrated biliary stents by using single-operator cholangioscopy
Migration is a late adverse event of biliary stent placement. It occurs in 1% to 20% of cases and is associated with a diverse array of adverse events. In this article, we report our take on endoscopic extraction of proximally migrated biliary stents by the use of single-operator cholangioscopy.EUS-guided drainage of a 20-cm biloma by use of a lumen-apposing metal stent
With the advent of laparoscopic surgery, postoperative bile-duct injuries have become more common over the past several decades.1 Recent studies have suggested that the incidence of bile-duct injury resulting from laparoscopic cholecystectomies ranges from 0.3% to 0.6%.2 Disruption of the biliary ductal anatomy can lead to intra-abdominal leakage of bile and the formation of a biloma. A biloma is defined as “any well-demarcated collection of bile outside the biliary tree.”3 If left untreated, bilomas can lead to significant morbidity and mortality.Cystic duct remnant syndrome: endoscopic approach to management
Postcholecystectomy syndrome (PCS) with recurrence of pain and dyspepsia can be caused by various biliary and extrabiliary conditions.1 Biliary causes of PCS include iatrogenic bile duct injury, bile leak, recurrent or retained choledocholithiasis, biliary dyskinesia, and biliary strictures.2 Here we describe a case of cystic duct remnant syndrome, which is a rare cause of PCS.3Stent-in-stent self-expandable metallic stent placement under direct cholangioscopy with the use of short double-balloon endoscope for a Roux-en-Y case
Managing consequent jaundice caused by malignant hilar biliary obstruction (MHBO) is important. Endoscopic biliary drainage is the treatment of choice because of its limited invasiveness. Bilateral self-expandable metallic stent (SEMS) placement for unresectable MHBO is a good option because of its high success rate and long-term stent patency. However, in patients with surgically altered anatomy, especially those who have undergone Roux-en-Y bypass surgery, ERCP is challenging because the endoscope needs to pass the long limb of the small intestine to reach the main papilla.Management of afferent limb obstruction by use of EUS-guided creation of a jejunojejunostomy and placement of a lumen-apposing metal stent
A 49-year-old woman presented with nausea, vomiting, and abdominal pain. Her medical history consisted of a diverting loop gastrojejunostomy performed because of an obstructing mesenteric desmoid tumor and a recent diagnosis of metastatic adenocarcinoma (Fig. 1). Treatment with different chemotherapy regimens had failed.Percutaneous transhepatic cholangioscopy with electrohydraulic lithotripsy in a patient with choledocholithiasis complicating a benign stricture
An 88-year-old woman with a history of orthotopic liver transplantation 25 years earlier for primary biliary cholangitis presented with jaundice and abdominal pain. Her initial post–liver transplantation course was complicated by choledocholithiasis and recurrent biliary strictures, requiring placement of a metal Wallstent (Boston Scientific, Natick, Mass, USA). She had done well for the previous 2 decades, with good allograft function. On admission, her laboratory results were notable for a bilirubin of 5.4 mg/dL (92 μmol/L) (previously 0.8 mg/dL [14 μmol/L] 4 months prior).Endoscopic resection of an unusual ampullary adenoma
A 40-year-old woman with no comorbidities presented with episodic postprandial bilious vomiting of 6 months’ duration and mild abdominal discomfort. Her liver function tests showed normal bilirubin with raised alkaline phosphatase and γ-glutamyltransferase. Abdominal US had shown dilatation of the common bile duct (CBD) and pancreatic duct (PD). She had previously undergone MRCP, which showed diffuse dilatation of the CBD, common hepatic duct, and intrahepatic biliary radicles with smooth tapering at the region of the ampulla, diffuse prominence of the main PD, and ectopic ampulla of Vater.Endoclip papilloplasty for a patulous and incompetent biliary papilla
A 78-year-old woman with choledocholithiasis (Fig. 1) underwent an extensive endoscopic sphincterotomy for large stone extraction. Concerned about the possibility of recurrent cholangitis and subsequent recurrent stone formation, we proceeded with a novel procedure, which we called endoclip papilloplasty: zipper closure of the patulous papilla with endoclips (Figs. 2-3; Video 1, available online at www.VideoGIE.org ).
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