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Create a Free AccountProcedures - Stent placement
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.Duodenal stenting as a palliative approach to a malignant duodenocolonic fistula
Duodenocolonic fistulae may result as adverse events of malignancies, and their management is often challenging for nonsurgical patients. Our case demonstrates a palliative approach in the management of malignant duodenocolonic fistula by means of luminal stent placement.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 ).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.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.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.Endoscopic rescue of anastomotic dehiscence after urgent gastric bypass revision
Adverse events are rare after bariatric surgery; however, leaks can lead to high morbidity. A large population study demonstrated a rare need for endoscopic management, most commonly endoluminal stent therapy. Unfortunately, many patients eventually needed surgical intervention and patients with stents had a notable rate of readmissions.1 Although stents are a valuable tool, newer technologies have expanded the toolbox to address difficult gastrointestinal adverse events.2,3 We present a challenging case of a gastrojejunal anastomotic disruption in a Roux-en-Y patient after recent urgent surgical revision that was rescued with total endoscopic therapy.Endoscopic management of gastrojejunocolic fistula after endoscopic gastrojejunostomy
Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) is an alternative to endoscopic stent placement alone and surgical gastrojejunostomy for the management of gastric outlet obstruction (GOO). Similar technical and clinical success rates have been shown with EUS-GJ and endoscopic stent placement alone with lower rates of reintervention in the EUS-GJ group.1 When compared to the more invasive surgical GJ, EUS-GJ has shown similar rates of clinical success and lower adverse event rates.2,3 Rare EUS-GJ adverse events include perforation, peritonitis, bleeding, stent misdeployment, and migration.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.Transpyloric lumen-apposing metal stent for management of persistent post-esophagogastrectomy leak
Anastomotic leaks are an adverse event complication of GI surgery that contribute to increased hospital stays, morbidity, and mortality. Endoscopic therapy via endoscopic closure techniques or covered metal stent placement has increasingly been used for primary therapy of anastomotic leaks.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.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.An endoscopic approach to therapy for spontaneous esophageal rupture
Boerhaave syndrome is among the most lethal GI tract disorders with a reported mortality rate of up to 40%.1-3 Spontaneous perforations are caused by sudden intraesophageal pressure elevations leading to transmural injury and subsequent mediastinal inflammation, subcutaneous emphysema, and/or necrosis secondary to spillage of gastric contents. Management was historically surgical, but stable patients may benefit from the reduced morbidity and mortality associated with less invasive percutaneous and endoscopic approaches.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.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.Jailbreaking a metal biliary stent through a duodenal stent
Uncovered metal biliary stents have often been employed for malignant biliary strictures, and meta-analyses have shown decreased rates of stent migration compared to covered stents and prolonged patency compared to plastic stents.1-3 Despite their efficacy, uncovered metal stents that remain in situ are prone to obstruction by tissue ingrowth or stone formation over the long term, potentially leading to cholangitis.4 With improving chemotherapy and immunotherapy regimens, patients with malignant obstruction and uncovered metal stent placements are living longer than ever.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).Pancreatoscopy-guided laser dissection of obstructing pancreatic duct stricture: pancreas-preserving endotherapy
Pancreatic duct (PD) stones and strictures remain challenging sequelae of chronic calcific pancreatitis and contribute to ductal hypertension, which may manifest as abdominal pain, exocrine pancreatic insufficiency, or biliary obstruction.1,2 Standard ERCP techniques may be insufficient for complex lesions such as severe stricture(s) or extensive stone burden, whereby the degree of obstruction or ductal tortuosity may not permit passage of the wire or catheter.3 Peroral pancreatoscopy (POP) promotes direct ductal visualization and use of additional devices to treat such advanced pathology, which includes laser therapy that can be used for stone fragmentation or tissue dissection as a means of stricturoplasty.Over-the-wire snare-assisted stent exchange in endoscopic retrograde cholangiopancreatography
ERCP is an important therapeutic tool to address pancreatobiliary pathology. At times, negotiating a stricture with a wire can be challenging, but the nature of these lesions often mandates the placement of a temporary stent and often requires the exchange or upsize of stents to adequately manage the stricture. In such cases, it is efficient to preserve the tract established by the stent in the index procedure rather than renegotiating the stricture upon exchange. Toward this end, we demonstrate the steps of a method that allows preservation of the tract by removing the stent over a wire left in adequate position with the tip situated proximal (upstream) to the stricture.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.Utilization of an overtube for placement of a lumen-apposing metal stent for removal of a capsule endoscope retained proximal to an ileal stricture
Capsule endoscopy is a noninvasive procedure used to evaluate the small bowel. Capsule retention remains a significant adverse event of capsule endoscopy, and endoscopic capsule extraction may be technically complicated when device-assisted enteroscopy is necessary to reach the retained capsule. The length and limited diameter of enteroscope working channels limit the endoscopic tools available and can make extraction of the capsule difficult. The presence of enteral strictures can also further complicate endoscopic extraction of a retained capsule.
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