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Create a Free AccountProcedures - Endoscopic ultrasound (EUS) - therapeutic
Endoscopic pyloric exclusion—EUS-guided gastrojejunostomy combined with endoscopic suturing and closure of the pylorus: a novel approach to failed surgical repair of a perforated duodenal ulcer
An 82-year-old woman with metastatic breast cancer was admitted with an acute abdomen. She was found to have a duodenal bulb perforation, for which she underwent emergent surgical repair using an omental patch. Postoperatively, the patient developed a large-volume enteric output from the Jackson-Pratt drains, and she was found to have a persistent duodenal leak on a CT scan. She was referred to our center in her third postoperative week.Management of an iatrogenic duodenal perforation with a helical tack system in a patient with pancreatic cancer complicated by gastric outlet obstruction
Although endoscopic procedures are safe, they carry a risk of perforation, which can manifest severe adverse events for patients if not managed expediently. Endoscopic methods of closure include clips, injectable agents, and suturing devices.1,2 Occasionally, perforations occur in difficult locations. Recently, a through-the-scope tacking system, X-tack Endoscopic HeliX Tacking System 160 cm (HTS) (Apollo Endosurgery Inc, Austin, Tex, USA), has been made available for mucosal defect closure, providing endoscopists with another tool to manage adverse events.Iatrogenic perforation during lumen-apposing metal stent deployment closed using an over-the-scope stent fixation clip device
EUS-guided gastrojejunostomy (EUS-GJ) has emerged as a safe and effective alternative for the palliative management of malignant gastric outlet obstruction.1,2 Although rare, perforation is a known adverse event of EUS-GJ seen in 1.6% of patients.3 We present a case of endoscopic closure of an iatrogenic perforation caused while performing EUS-GJ using an over-the-scope (OTS) stent fixation clip device (Video 1, available online at www.giejournal.org ).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 ).Relief of malignant gastric outlet obstruction with lumen-apposing metallic stent–assisted percutaneous endoscopic gastrostomy tube after Roux-en-Y gastric bypass
Accessing the bypassed portion of the stomach and small bowel for endoscopic interventions in Roux-en-Y gastric bypass (RYGB) is challenging. In the case of bowel obstruction distal to the Roux-en-Y limb, decompression of the gastric pouch and bypassed stomach can be achieved with percutaneous enterostomy/gastrostomy tube placement by interventional radiology, deep enteroscopy, or surgery.1,2 The venting tube is usually placed within the alimentary limb of the jejunum in these approaches. However, in certain patients with obstruction distal to the jejunojejunal anastomosis or within the biliopancreatic limb, decompression of the excluded stomach is required.EUS-guided gastroenterostomy for proximal jejunal obstruction: technique modification for more distal upper GI tract obstruction
EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has emerged as a safe, minimally invasive modality for the treatment of gastric outlet obstruction (GOO).1 Several techniques have been described, including anterograde, retrograde, and balloon-assisted approaches.1-3 The “direct” anterograde method of EUS-GE using a nasobiliary catheter to instill contrast material within the target jejunal loop distal to the obstruction uses fewer steps than other approaches and does not require use of a balloon.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.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 ).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.Point blank: an endoscopic retrieval of an extraluminal bullet
A 36-year-old man with no medical history presented with multiple gunshot wounds to the right neck, left axilla, and pelvis. An entry wound in the right buttocks was noted without a corresponding exit wound. A CT scan identified the bullet near the rectum, and a leak from an administered barium enema further demonstrated the location. (Figs. 1 and 2) A laparoscopic diverting colostomy was performed, and advanced endoscopy was consulted for retrieval of the bullet for ballistics and closure of the subsequent rectal defect.Endoscopic ultrasound–guided embolization of refractory splenic pseudoaneurysm
Visceral arterial pseudoaneurysms are common sequelae of chronic pancreatitis, occurring in 10% of patients, and carry a non-negligible 50% risk of rupture and 14% to 50% mortality with rupture.1-4 Transcatheter arterial embolization (TAE) is an effective modality for treatment of visceral arterial pseudoaneurysms with high technical and clinical success rates (97%-100% and 94%-100%, respectively) but a variable adverse event rate of splenic infarction of 6% to 24%.1-4 However, in cases refractory to TAE, EUS embolization approaches have demonstrated clinical efficacy, with studies demonstrating up to 100% technical and clinical success in this setting when using thrombin or cyanoacrylate glue.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.EUS-guided gastrojejunostomy for management of malignant gastric outlet obstruction in a patient with Roux-en-Y anatomy
Gastric outlet obstruction is a complication of advanced gastrointestinal malignancies and contributes significantly to patient morbidity. Surgical gastrojejunostomy (GJ) and enteral stenting have been traditionally employed for management in these patients. Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) with a lumen-apposing metal stent (LAMS) provides an alternative to luminal stenting and surgical GJ. We present a case of EUS-GJ performed in a patient with Roux-en-Y anatomy.Transjejunal drainage of an infected postsurgical fluid collection using a 6-mm lumen-apposing metal stent
Postsurgical fluid collections (PSFCs) can be a marked source of morbidity for patients, but advances in therapeutic endoscopy have allowed for endoscopic modalities of drainage to become more accessible.1 Prior studies have established the efficacy and safety of lumen-apposing metal stents (LAMSs) in PSFCs.1-4 In the video accompanying this case report (Video 1, available online at www.giejournal.org ), we demonstrate the transjejunal placement of a 6-mm LAMS for drainage of an infected postsurgical fluid collection.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 ultrasound-guided gastrojejunostomy with lumen-apposing metal stent in a boy with neurological impairment requiring jejunal feeding
Significant undernutrition is reported in 13% to 52% of children with neurodevelopmental disabilities (NPDC).1,2 Oropharyngeal dysphagia (90%), gastroesophageal reflux (50%-75%), delayed gastric emptying (67%), and/or ineffective esophageal peristalsis (61%) are associated with undernutrition. Moreover, nearly all NPDC have 1 or more comorbidity that negatively affects feeding and worsens GI symptoms such as retching and bloating, requiring prompt gastric decompression.3-5EUS-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.A case of cystic paraduodenal pancreatitis with gastric outlet obstruction: technical pitfalls in EUS-guided gastroenteroanastomosis
Cystic paraduodenal pancreatitis is part of a spectrum of diseases, collectively gathered under the term “paraduodenal pancreatitis,” which involves the area between the duodenum, the pancreatic head, and the common bile duct.1 Although common clinical presentation is constituted by abdominal pain, weight loss, and jaundice, association with gastric outlet obstruction (GOO) has been reported.2 In recent years, the introduction of lumen-apposing metal stents (LAMSs) led to the diffusion of a novel technique to manage GOO.A case of endoscopic minor duodenal papillectomy after pancreatic stent placement using an endoscopic ultrasonography-guided rendezvous method
Endoscopic papillectomy is a minimally invasive procedure for duodenal papillary tumors. However, it is often associated with adverse events, such as postprocedural pancreatitis, bleeding, and duodenal perforation. Although postprocedural pancreatitis is a major problem, the placement of a pancreatic plastic stent (p-PS) can reduce the risk of pancreatitis. Generally, a p-PS is inserted after endoscopic papillectomy; however, the procedure can be unsuccessful.1 We used the inside pancreatic stenting papillectomy method to insert a p-PS.Combined EUS-guided gallbladder drainage with rendezvous ERCP for treatment of concomitant cholecystitis, cholelithiasis, and choledocholithiasis
In recent years, interventional EUS has opened new doors for the management of biliary diseases that would otherwise not be amenable to traditional endoscopic methods. EUS-guided gallbladder drainage (GBD) for cholecystitis represents one such example; studies have demonstrated its safety and efficacy to be equivalent to that of traditional percutaneous drainage and laparoscopic cholecystectomy in patients at high operative risk.1,2 EUS-GBD also offers an alternative biliary drainage modality in cases of malignant biliary obstruction and may even be safe for patients with coagulopathy or on anticoagulation.Endoscopic management of recurrent cholangitis following EUS-guided choledochoduodenostomy
A 74-year-old man who previously underwent a Roux-en-Y gastro-jejunostomy for duodenal stenosis due to an inoperable pancreatic adenocarcinoma was admitted at our institution for obstructive jaundice. Considering the duodenal stenosis, biliary drainage via EUS-guided choledochoduodenostomy was performed using a 6 × 8 mm electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific, Natick, Mass, USA), with subsequent resolution of jaundice (Fig. 1). After 2 months, the patient was readmitted for acute cholangitis: CT scan showed marked dilation of the biliary tracts, with the LAMS in its proper position (Fig. 2).Endoscopic ultrasound-guided ileosigmoidostomy using a lumen-apposing metal stent for palliation of malignant small-bowel obstruction
High-grade malignant small-bowel obstruction (SBO) is typically managed with surgical diversion (ileostomy) or palliative decompression via nasogastric tube or venting gastrostomy. These approaches have a significant impact on quality of life. Endoscopic palliation of malignant luminal obstruction by lumen-apposing metal stent (LAMS) placement is well established for duodenal obstruction. Distal SBO, however, is challenging to manage endoscopically. We present the case of a novel EUS-guided ileosigmoidostomy technique for the palliation of malignant distal SBO.Novel EUS-guided microwave ablation of an unresectable pancreatic neuroendocrine tumor
Pancreatic neuroendocrine tumors have an incidence of ≤1 case per 100,000 individuals, accounting for up to 2% of all pancreatic neoplasms in the United States. The 5-year overall survival rate ranges from 37.6% to 50%.1 Curative surgical interventions are not feasible for most patients because most cases are detected in advanced unresectable stages, mainly in elderly patients with several comorbidities.2 Therefore, developing safe and effective alternatives for patients unfit for surgery is imperative for clinical practice.
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