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Create a Free AccountProcedures - ERCP/Cholangioscopy
Over-the-scope clip to the rescue: solution for duodenal perforation from migrated biliary stent
Iatrogenic perforation of the duodenum caused by biliary stents is a rare adverse event of ERCP.1 While the only available definitive treatment option was previously surgery, the advancement in the minimally invasive endoscopic field led to the development of over-the-scope clips (OTSCs), which allow complete closure of full-thickness defects endoscopically.2Impacted gallstone within a cholecystoduodenal fistula: endoscopic laser lithotripsy to the rescue
We share here the case of a 67-year-old man who presented to the emergency department for evaluation of bloating, chills, and dyspepsia for 2 weeks. He was admitted 3 years earlier for similar symptoms, attributed to symptomatic cholelithiasis. Because his symptoms resolved, elective cholecystectomy was not pursued at that time. A CT scan on admission demonstrated pneumobilia with a large stone within the gallbladder and the question of emphysematous cholecystitis versus biliary enteric fistula (Fig. 1).A new connection: management of disconnected segments 5 and 6 bile leak via the cystic duct remnant
Iatrogenic adverse events following cholecystectomy can lead to bile leaks in up to 1.1% of cases.1 Management of disconnected bile leaks often requires multidisciplinary management, especially because they are often complex injuries associated with high morbidity and mortality.2 ERCP with sphincterotomy and stenting has emerged as a reliable treatment modality even in refractory or complex leaks with a resolution rate over 90%.3 Nonetheless, type C biliary segments 5 and 6 injuries are rare and account for 9.7% of leaks that make it to surgery.Flexible fiber cholangioscope for detection of near-infrared fluorescence
Cholangiocarcinoma is a cancer of the bile ducts and is characterized by a high mortality rate and a steadily rising incidence.1 This disease is usually diagnosed at an advanced stage when the prognosis is poor. Biliary intraepithelial neoplasia represents a precursor condition that can result in excellent patient outcomes with surgical resection if detected early. This condition is often suspected in patients with indeterminate biliary strictures.2 Because the bile ducts are small in caliber, conventional biopsy and brushings often do not produce an adequate number of cells for either cytology or histology to make a definitive diagnosis.With a little help from my friends: percutaneously assisted internalization of a biliary drain
EUS-guided hepaticogastrostomy (EUS-HG) provides endoscopic biliary drainage when conventional techniques are not feasible.1 While comparable to percutaneous transhepatic drainage in regard to safety and efficacy,2 endoscopic drainage forgoes the need for cumbersome external drain hardware and promotes physiologic enterohepatic circulation of bile.3 In the absence of biliary dilation, the procedure can be technically challenging because access to the biliary tree is commonly obtained transgastrically with EUS-guided puncture of the left intrahepatic ducts.Endoscopic approach for management of dropped gallstones using percutaneous cholangioscopy
Dropped gallstones (DGS) are unable to be retrieved in 2% of cholecystectomy cases.1 While mostly asymptomatic, adverse events such as abscess formation have been described.2 Data on management are limited and most abscess cases in the literature required open laparotomy and surgical exploration.2The interventional direct peroral cholangioscopy toolbox for endoscopic snare resection of a high-grade biliary intraductal neoplasia
Direct peroral cholangioscopy (DPOC) is a valuable diagnostic and therapeutic tool for various biliary disorders because it allows direct endoscopic visualization of biliary lumen and mucosal abnormalities. Direct cholangioscopy carries several benefits, including high-definition imaging with the availability of narrow-band imaging, lower operating expenses and cost, and the ability to use a wide range of accessories through the working channel.1,2 In this article, we demonstrate endoscopic techniques for performing biliary intraductal polypectomy using the ultra-slim pediatric gastroscope (GIF-H190N; Olympus America, Center Valley, Pa) and showcase the various endoscopic accessories available for use.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.Laparoscopic intraoperative pancreatoscopy for main duct intraductal papillary mucinous neoplasms assessment
Intraductal papillary mucinous neoplasms of the pancreas (IPMNs) are increasingly diagnosed tumors that are characterized by endoluminal papillary projections of mucin-producing ductal epithelium, leading to a dilatation of the ducts it develops within. IPMNs carry a high risk of malignancy when the main pancreatic duct is involved (MD-IPMNs). When feasible, surgical resection of the pancreatic segment involved is the therapeutic option of choice. Complete resection of IPMN lesions is essential and requires precise diagnosis of the extent of the disease.Cognitive ERCP: decision making during successful retrieval of proximally migrated biliary stent
A 56-year-old man presented with painless jaundice. An outside CT scan reported a pancreatic head mass. The patient underwent ERCP with a 10F plastic biliary stent placement, and an EUS-guided biopsy confirmed the mass to be a pancreatic ductal adenocarcinoma. Subsequent staging CT chest/abdomen scans showed significant migration of the pre-existing plastic biliary stent, which was abutting the liver margin of the left hepatic lobe and the distal end was above the biliary stricture in the area of the hepatic hilum.EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy
A 67-year-old man with a history of total gastrectomy followed by Roux-en-Y esophagojejunostomy reconstruction in the setting of gastric adenocarcinoma presented with right-upper-quadrant pain and an abnormal liver function test (LFT) (aspartate aminotransferase 389, alanine aminotransferase 273, alkaline phosphatase 297, total bilirubin 8.70). A liver CT scan was consistent with dilation of the intrahepatic and extrahepatic bile ducts (Figs. 1 and 2; Video 1, available online at www.giejournal.org ).Pancreatoscopy-guided retrieval of a migrated pancreatic duct stent
A 26-year-old woman presented to an outside hospital with symptomatic cholelithiasis and underwent a laparoscopic cholecystectomy that was complicated by bile leak and intra-abdominal fluid collections. She underwent intraabdominal drain placement and an ERCP with biliary sphincterotomy and biliary stent placement. The ERCP was technically challenging and required a prophylactic pancreatic duct (PD) stent that was complicated by upstream migration and was unable to be retrieved. She was referred to our center for stent retrieval.A case of pancreatic duct stones treated with electrohydraulic lithotripsy through a duodenal ulcer
Pancreatic duct stone is a common adverse event associated with chronic pancreatitis. Asymptomatic pancreatic stones can be followed-up by observation, although some cases with severe symptoms require radical treatment, including extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy (EHL), and surgical treatment.1,2 Among these options, EHL is effective, less invasive, and can be performed through a duodenal papilla under pancreatoscopy.3,4 Here, we present a rare case of pancreatic duct stones that were directly treated by an EHL device through a duodenal ulcer.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.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.The Double-Max method: a novel method for gallbladder epithelial biopsy
A 75-year-old woman with no medical history presented to her previous physician complaining of weight loss. The patient was referred to our hospital after abdominal ultrasonography revealed a gallbladder lesion. There was irregular thickening of the gallbladder wall on a contrast-enhanced CT scan (Fig. 1A) and multiple broad-based polyps on EUS (Fig. 1B). Endoscopic retrograde cholangiopancreatography was performed to determine whether the gallbladder lesion was malignant.Successful minimally invasive management of adverse events following EUS-guided gallbladder drainage in a suboptimal surgical patient
Endoscopic ultrasound guided gallbladder drainage (EUS-GB) is increasingly being used for patients who cannot undergo a cholecystectomy.1,2 However, the procedure can be associated with adverse events, including pneumoperitoneum, biliary peritonitis, and perforation.3 We present a case in which 2 adverse events—cholecystogastrostomy tract disruption and gallbladder wall perforation—were successfully treated with endoscopic interventions (Video 1, available online at www.giejournal.org ).EUS-directed transenteric ERCP–assisted internalization of a percutaneous biliary drain in Roux-en-Y anatomy
Endoscopic ultrasound–directed transenteric ERCP (EDEE) has recently been described as a safe, effective procedure to obtain biliary access in patients with Roux-en-Y anatomy.1,2 Here, we present a video case report of EDEE-assisted biliary drain internalization in a patient with prior liver transplant and Roux-en-Y hepaticojejunostomy (HJ), presenting with HJ anastomotic stricture (Video 1, available online at www.giejournal.org ).EUS-Guided hepaticogastrostomy in a pregnant patient with Roux-en-Y hepaticojejunostomy anatomy
Endoscopic ultrasound–guided hepaticogastrostomy (EUS-HGS) is a therapeutic biliary drainage procedure that can be utilized as an alternative procedure in patients who fail conventional ERCP and have sufficiently dilated left-sided biliary ducts. Herein, we describe an EUS-HGS to obtain biliary drainage in a pregnant patient with previous Roux-en-Y hepaticojejunostomy (RYHJ) reconstruction.Combination of a 19-gauge needle and 0.018-inch guidewire with a Y-connector during endoscopic ultrasound-guided hepaticogastrostomy
Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) can be performed by either first injecting the contrast medium or inserting the guidewire. Each method has its advantages and disadvantages. When the contrast medium is injected first, the guidewire can be advanced along the correct pathway by using the obtained image. However, the guidewire is inserted into the needle after imaging, which makes its insertion into the bile duct time consuming. Furthermore, the tip of the needle may shift because of body movement or respiratory fluctuations; therefore, even if contrast administration is successful, guidewire placement might not be accurate.Endoscopic treatment of a refractory benign biliary stricture using cholangioscopy-guided thulium laser stricturoplasty
ERCP with balloon dilation and placement of multiple plastic stents or covered metal stents for distal biliary strictures has been established as the standard of care in the management of benign biliary strictures.1,2 Etiologies include chronic pancreatitis, chronic inflammation from biliary stone disease, postsurgical injury following cholecystectomy, primary sclerosing cholangitis, and biliary anastomotic strictures.1 Some biliary strictures, especially at the bifurcation and above, remain refractory to standard endoscopic therapies, with successful stricture resolution reported only in approximately 75% of patients.EUS-directed transgastric ERCP in Roux-en-Y gastric bypass revision of sleeve gastrectomy
EUS-directed transgastric ERCP (EDGE) is an effective approach for the treatment of biliary adverse events of patients who have undergone Roux-en-Y gastric bypass (RYGB).1 Through deployment of a lumen-apposing metal stent (LAMS) from the gastric pouch into the excluded stomach, EDGE allows access to the bypassed stomach and duodenum in patients who have undergone RYGB (Fig. 1). However, patients who have undergone sleeve gastrectomy (SG) who undergo revision to RYGB have limited working space within both the gastric pouch and excluded stomach (Fig. 2), making therapeutic endoscopic procedures such as EDGE technically challenging.Successful endoscopic resection by using gel immersion and the technique of endoscopic papillectomy for a tumor adjacent to the papilla of Vater
Superficial nonampullary duodenal epithelial tumors are rare, and the establishment of optimized strategies for their treatment is an area of active investigation.1 Endoscopic submucosal dissection (ESD) for superficial nonampullary duodenal epithelial tumors poses the risk of major adverse events (AEs), including a high rate of bleeding, intraoperative perforation, and delayed perforation.2,3 Lesions located in the duodenal flexure are associated with poor endoscope maneuverability.4 Moreover, endoscopic resection is particularly challenging for lesions on the descending duodenum’s medial wall, especially those adjacent to the papilla of Vater (POV).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 ).
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