Login to your account
Don’t have an account?
Create a Free AccountProcedures - Drainage of pancreatic fluid
Single-session EUS-guided gastrogastrostomy to facilitate cystgastrostomy in Roux-en-Y gastric bypass
Patients with surgically altered anatomy present unique challenges to traditional endoscopic management of foregut pathology, such as drainage of peripancreatic fluid collections. Recent advances in endoscopic techniques have enabled less-invasive access with EUS-directed transgastric intervention or gastric access temporary for endoscopy.1-4 Here we present a case of same session EUS-guided transgastric intervention to facilitate cystgastrostomy (Video 1, available online at www.giejournal.org ).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.Transabdominal self-expandable metal stent placement as a rescue therapy for drainage of walled-off necrosis
The current management for intervention in necrotizing pancreatitis consists of a step-up approach with percutaneous drainage as the first choice for infected necrotic collections that are not in contact with the stomach or the duodenum wall.1 However, the presence of large solid necrotic areas often requires direct debridement for complete resolution.Extracorporeal rendezvous technique combining endoscopic retrograde pancreatography with endoscopic ultrasound for main pancreatic duct disconnection arising from acute necrotizing pancreatitis: a case report
A 45-year-old man with a history of heavy alcohol consumption presented with hematemesis and abdominal pain. Serum amylase and C-reactive protein levels were elevated in his biochemical examination. A CT of his abdomen demonstrated an acute necrotic collection around the pancreas (Fig. 1), and EGD demonstrated fistula in the duodenal bulb. Therefore, he was diagnosed with acute pancreatitis with duodenal fistula. He underwent emergency Billroth II gastrectomy and had a percutaneous drainage tube placed near the head of the pancreas.EUS-guided natural orifice transluminal endoscopic surgery for the removal of a toothpick embedded in the liver
A 75-year-old man with diabetic end-stage renal disease requiring hemodialysis presented with 1 week of progressive abdominal pain and fever. Laboratory examination showed an alkaline phosphatase level of 140 IU/L and white blood cell count of 15.7 × 109/L. Noncontrast abdominal CT revealed a 2.9-cm × 3.3-cm air/fluid collection in the left hepatic lobe with a linear foreign body extending from the collection into the duodenum (Fig. 1). An upper endoscopy was performed and was notable for 2 pustular lesions and edema in the second portion of the duodenum (Fig. 2).Endoscopic management of symptomatic walled-off omental fat necrosis
Omental infarction has been described as a rare adverse event of various abdominal surgeries, including pancreatic resection; it occasionally can lead to a walled-off omental fat necrosis (WOFN) collection. With only 1 case report describing WOFN after pancreatic resection, the incidence and appropriate management are unclear. However, a study of post–distal pancreatectomy patients found the incidence of WOFN to be much higher than previously thought, with reports of 2 presentation patterns: asymptomatic patients with incidental findings on imaging and symptomatic patients presenting with the chief symptom of abdominal pain.EUS-guided duodenojejunostomy by use of a 2-cm lumen-apposing metal stent to treat proximal jejunal stricture in a patient with chronic pancreatitis
EUS-guided gastrojejunostomy has been increasingly used to treat patients with gastric outlet and duodenal obstruction, particularly in patients with many comorbidities prohibiting surgery.1,2 We describe a case of a proximal jejunal stricture treated by EUS-guided duodenojejunostomy with use of a 2-cm lumen-apposing metal stent (LAMS).Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible
Walled-off pancreatic necrosis is a well-known serious adverse event of severe acute pancreatitis. EUS-guided transluminal access followed by direct endoscopic necrosectomy is increasingly used to remove necrosis, with good efficacy and a superior safety profile when compared with surgery. However, a percentage of patients is too critically ill to undergo this procedure or lack an appropriate transluminal window for access. Here we describe the use of percutaneous flexible endoscopic necrosectomy (PEN) with use of standard-sized upper endoscopes and accessories in a retrospective single-institution experience with a video demonstration of 1 patient in the series.A novel diathermy knife with suction function capable of keeping clear visibility while controlling bleeding
Innovative endoscopic devices have been developed and are now commercially available, which have contributed to the spread of the endoscopic submucosal dissection (ESD) technique for superficial neoplastic lesions.1 In particular, needle-type diathermy knives with a waterjet function enable injection into the submucosal area from the tip of the knife immediately after the cutting maneuver.2,3 This may reduce the number of times the knife is moved through the working channel, leading to a shorter procedure time.The evolution of EUS-guided cystogastrostomy for pancreatic fluid collections
Endoscopic drainage of pancreatic fluid collections has conventionally been a tedious procedure. Endoscopic drainage may be performed with or without the use of EUS. Conventionally, EUS-guided cystogastrostomy involved EUS-guided needle puncture, repurposed devices, and multiple exchanges over a guidewire. A simple single-device technique can facilitate the procedure.Polyloop anchor technique to close large gastric fistula
A 60-year-old woman presented with acute pancreatitis complicated by the development of acute pancreatic fluid collection, which later organized into a large peripancreatic pseudocyst (Fig. 1). This was drained endoscopically with a lumen-apposing metal stent inserted under EUS guidance (Fig. 2). The patient experienced a gastric perforation after the procedure, possibly resulting from an immature cyst wall, which required surgical repair (Fig. 3). Two months later, she had a residual gastric fistula along the posterior gastric wall communicating with the pancreatic bed (Figs.Reusing an electrocautery-enhanced stent deployment catheter to place additional pigtail stents for walled-off necrosis with disconnected duct
The development of an electrocautery-enhanced delivery system for lumen-apposing metal stents (Axios; Boston Scientific, Natick, Mass, USA) has simplified creation of a cystgastrostomy tract for the management of pancreatic walled-off necrosis. These larger-caliber transgastric metal stents are beneficial in terms of allowing for digestion and lavage of necrotic debris and to permit direct endoscopic necrosectomy.1,2 When disruption of the pancreatic duct is suspected, there remains a question of how to best manage the collection because there is a risk of recurrence of the collection, as well as highly morbid percutaneous fistulization if percutaneous drainage is attempted.Endoscopic drainage of pancreatic fluid collections by use of a novel biflanged stent with electrocautery-enhanced delivery system
Endoscopic drainage is currently the preferred modality of drainage for pancreatic fluid collections (PFCs) because of the ease of the procedure, reduced cost, shorter hospital stay, and the reduced morbidity and mortality compared with traditional surgical drainage.1 Plastic stents used for endoscopic drainage may become blocked with the passage of time, leading to adverse events requiring reinterventions, especially in PFCs with significant debris (ie, walled-off necrosis [WON]). Novel large-caliber metal stents (LCMSs) are less prone to spontaneous occlusions and therefore, provide efficient drainage of PFCs.EUS-guided cystesophagostomy using a lumen-apposing metal stent for drainage of a pancreatic fluid collection in a pediatric patient
An 8-year-old boy was referred because of abdominal pain, dysphagia, and failure to thrive (weight loss/poor growth). He had made multiple visits to the emergency department over a 5-year period for abdominal pain of unclear etiology. His abdominal pain was thought to be related to constipation, and he was treated accordingly. His amylase/lipase levels were previously elevated but were nondiagnostic for acute pancreatitis. The results of colonoscopy and upper endoscopy were negative for any obvious cause.Endoscopic management of pancreatic duct disruption with large mediastinal pseudocyst
A 47-year-old woman with schizophrenia and a history of chronic pancreatitis, alcohol use disorder, chronic portal vein thrombosis, and chronic left-sided pleural effusion presented with a 1-day history of fever, shortness of breath, dysphagia, and abdominal pain. On admission, she was febrile, tachypnic, and tachycardic. She had shortness of breath and dysphagia. Her physical examination results were significant for diaphoresis, sclera icterus, diffuse abdominal pain, and exquisite back tenderness.Transluminal drainage with a cautery-assisted 20-mm lumen-apposing metal stent
A 21-year-old woman presented with severe alcoholic necrotizing pancreatitis and was treated with maximal supportive care. Anticoagulant therapy for a superior mesenteric vein thrombosis was initiated, and ultimately she was discharged in stable condition. She was readmitted in hemorrhagic shock from retroperitoneal bleeding. Emergent laparotomy with evacuation of the hematoma and stabilization was performed. Her abdomen was left open, and a series of abdominal washouts followed. Persistent fever and tachycardia prompted CT with contrast which showed a large, maturing, left-sided collection away from the surgical site (Fig. 1A).Pancreatic duct rendezvous with pancreatoscopy through the minor papilla
An 18-year-old woman presented to our hospital with diffuse abdominal pain and visible distention. She reported a history of acute pancreatitis 2 months earlier. Physical examination revealed diffuse abdominal tenderness without rebound and an abdominal fluid wave. CT of the abdomen and pelvis (Figs. 1 and 2) showed a large volume of ascites and marked dilation of the pancreatic duct to 16 mm, with a hypodense filling defect within the pancreatic duct near the head of the pancreas.Endoscopic retrieval of a buried lumen-apposing metal stent through an indwelling lumen-apposing metal stent
A 43-year-old woman presented with worsening epigastric abdominal pain and postprandial nausea and vomiting, occurring 1 month after hospitalization for post-ERCP necrotizing pancreatitis. CT of the abdomen revealed an 11-cm × 13-cm walled-off necrosis (WON) compressing the posterior wall of the stomach (Fig. 1A). An EUS-guided cystgastrostomy was created by use of an electrocautery-enhanced 15-mm × 10-mm lumen-apposing metal stent (LAMS) (Hot Axios stent and delivery system; Boston Scientific Corp, Marlborough, Mass).Adverse events of pancreatic fluid collections
In this video (Video 1, available online at www.VideoGIE.org ), we present 3 similar cases in patients who presented to our hospital over 3 consecutive weeks.Massive bleeding after EUS-guided walled-off necrosis drainage
A 58-year-old man with a history of necrotizing pancreatitis of biliary causes 8 weeks previously presented with a 20-pound weight loss and daily epigastric pain. Abdominal magnetic resonance imaging (MRI) demonstrated a 12.3-cm collection surrounding the pancreatic body with a large amount of debris, consistent with walled-off necrosis (WON) (Fig. 1A). Given the collection size and the patient’s symptoms, we proceeded with EUS-guided drainage using a lumen-apposing metal stent (LAMS).EUS-guided drainage of hepatic abscess in the right side of the liver of a patient with Chilaiditi syndrome
Recently, the usefulness of EUS-guided hepatic abscess drainage (EUS-HAD) has been reported. However, EUS-HAD in the right lobe of the liver is not always easy and is challenging because it needs a long and angulated endoscope position, and the target is sometimes a long distance away. We describe EUS-HAD in the right side of the liver of a patient with Chilaiditi syndrome. A 65-year-old man visited our hospital because of fever and malaise for the previous 10 days. He had received a diagnosis of advanced cholangiocarcinoma 1 year previously.Cap-assisted necrosectomy: a novel technique increasing safety and efficiency
A 76-year-old man underwent EUS for the evaluation of intermittent elevation of liver enzymes; EUS revealed cholelithiasis with choledocholithiasis. Successful stone extraction was accomplished with biliary sphincterotomy and balloon extraction. A pancreatic duct stent was placed for post-ERCP prophylaxis of pancreatitis. The procedures were performed with the patient under propofol anesthesia without an esophageal overtube.The incredible shrinking waistline: lumen-apposing metal stent treatment of massive ascites
Ascites is an uncommon presentation after pancreatitis. The usual causes include pancreatic duct leaks, portal vein thrombosis, and overly aggressive fluid resuscitation in the acute setting of pancreatitis.Think opposite: biliary guidewire-assisted pancreatic cannulation in chronic pancreatitis for transpapillary pseudocyst drainage
Pancreatic duct cannulation in chronic pancreatitis fails in up to 10% to 30% of cases because of difficult guidewire or catheter manipulation.1 Synthetic porcine secretin2 and more challenging techniques such as EUS-guided drainage or dorsal duct cannulation have been proposed.1-3 Pancreatic guidewire-assisted biliary cannulation, also known as the double-guidewire (DGW) technique, after failure of deep cannulation of the common bile duct (CBD) was first described in 1998 by Dumonceau et al.3,4 The aim of the DGW technique is to obstruct the pancreatic orifice and facilitate deep biliary cannulation.EUS-guided insertion of self-expandable metal stent and direct endoscopic necrosectomy in the management of infected walled-off pancreatic necrosis
Fully covered self-expandable metal stents (FCSEMSs) have larger diameters than plastic stents and can provide more effective drainage for pancreatic collections. Enteral or biliary FCSEMSs are suboptimal for drainage of pancreatic collections because of the higher risk of migration, excessive length, and lack of lumen apposition. FCSEMSs customized for drainage are characterized by short lengths and biflanged designs that allow apposition and prevent migration. Examples include the NAGI stent (Taewoong, Seoul, Korea) and the Axios stent (Boston Scientific, Natick, Mass).A comprehensive examination of the novel techniques used for in vivo and ex vivo confocal laser endomicroscopy of pancreatic cystic lesions
Confocal laser endomicroscopy (CLE) is a new technique for the evaluation of pancreatic cystic lesions (PCLs). To our knowledge, there are no studies validating in vivo EUS-guided needle-based CLE (nCLE) images by ex vivo CLE and surgical histopathologic examination. This video presents the technique of in vivo and ex vivo CLE for the evaluation of PCLs. For in vivo imaging, an AQ-Flex nCLE miniprobe (Cellvizio, Mauna Kea Technologies, Paris, France) was preloaded into a 19-gauge Flex needle (Boston Scientific, Natick, Mass).
