[EUS-guided therapy of cholangiolithiasis in surgically altered anatomy of the upper GI tract - a unicenter case study]. / Endosonografisch gestützteTherapie der Cholangiolithiasis bei chirurgisch veränderter Anatomie ­ eine monozentrische Fallstudie.

AIM: To investigate feasibility and outcome the novel and favorable option of an endoscopic ultrasonography(EUS)-guided antegrade or even retrograde gall stone extraction via a transhepatic route in patients (pats.) with no option for the usual gold standard, ERCP. MATERIAL/METHODS: All consecutive pats. with cholangiolithiasis and surgically altered anatomy of the upper GI tract with and without previous attempts of an ERCP were enrolled in this unicenter case study and were characterized with regard to the technical and clinical success of this approach. RESULTS: From 2004 to 03/2020, overall 449 pats. underwent EUS-guided cholangiodrainage (n = 37 pats. with cholangiolithiasis). In 8 of these 37 pats., gall stone extraction was achieved using EUS-ERCP rendezvous technique (not included in the study since there was no surgically altered anatomy of the upper GI tract). In 13 of the remaining 29 subjects (45 %), there was a failure of previous attempts to reach the papilla of Vater or biliodigestive anastomosis using balloon-enteroscopy-guided ERCP. EUS-guided access to the biliary system was achieved in all 29 pats. Stone extraction was performed in 26 individuals (90 %) by means of antegrade push-technique after balloon dilatation of the papilla of Vater and biliodigestive anastomosis, respectively, before. In 11/29 cases (42 %), double pigtail prostheses were subsequently placed to track papilla of Vater/biliodigestive anastomosis ("ring drainage"), which were removed with gastroscopy three months later after previous ultrasound- and lab parameter-based follow-up control. In two pats. (7 %), gall stones were extracted via a retrograde route using a transhepatic access site; in one patient (3 %), stones were removed by means of a combined ante-/retrograde technique. In two subjects (7 %), cholangioscopy with electrohydraulic lithotripsy was used.Technical as well as clinical success rate was 100 % (29 of 29 pats.). Re-interventions became necessary in 6/29 cases (21 %), complications occurred in 6 individuals (21 %). CONCLUSION: EUS-guided stone extraction in antegrade or retrograde technique for pats. with surgically altered anatomy of the upper GI tract can be considered a favorable and safe but challenging approach of interventional endoscopy/EUS. It can provide high technical and clinical success and low complication rates; it has the potential to substitute the time-consuming balloon-enteroscopy-guided ERCP as well as, in particular, PTCD and, thus, secundary and tertiary therapeutic alternatives.

Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct.

AIM: To evaluate the use of translumenal pancreatography with placement of endoscopic ultrasonography (EUS)-guided drainage of the pancreatic duct. METHODS: This study enrolled all consecutive patients between June 2002 and April 2014 who underwent EUS-guided pancreatography and subsequent placement of a drain and had symptomatic retention of fluid in the pancreatic duct after one or more previous unsuccessful attempts at endoscopic retrograde cannulation of the pancreatic duct. In all, 94 patients underwent 111 interventions with one of three different approaches: (1) EUS-endoscopic retrograde drainage with a rendezvous technique; (2) EUS-guided drainage of the pancreatic duct; and (3) EUS-guided, internal, antegrade drainage of the pancreatic duct. RESULTS: The mean duration of the interventions was 21 min (range, 15-69 min). Mean patient age was 54 years (range, 28-87 years); the M:F sex ratio was 60:34. The technical success rate was 100%, achieving puncture of the pancreatic duct including pancreatography in 94/94 patients. In patients requiring drainage, initial placement of a drain was successful in 47/83 patients (56.6%). Of these, 26 patients underwent transgastric/transbulbar positioning of a stent for retrograde drainage; plastic prostheses were used in 11 and metal stents in 12. A ring drain (antegrade internal drainage) was placed in three of these 26 patients because of anastomotic stenosis after a previous surgical intervention. The remaining 21 patients with successful drain placement had transpapillary drains using the rendezvous technique; the majority (n = 19) received plastic prostheses, and only two received metal stents (covered self-expanding metal stents). The median follow-up time in the 21 patients with transpapillary drainage was 28 mo (range, 1-79 mo), while that of the 26 patients with successful transgastric/transduodenal drainage was 9.5 mo (range, 1-82 mo). Clinical success, as indicated by reduced or absence of further pain after the EUS-guided intervention was achieved in 68/83 patients (81.9%), including several who improved without drainage, but with manipulation of the access route. CONCLUSION: EUS-guided drainage of the pancreatic duct is a safe, feasible alternative to endoscopic retrograde drainage when the papilla cannot be reached endoscopically or catheterized.

Endoscopic papillectomy: data of a prospective observational study.

AIM: To investigate the clinical value of endoscopic papillectomy indicated by feasibility and safety of the procedure in various diseases of the papilla in a representative number of patients in a setting of daily clinical and endoscopic practice and care by means of a systematic prospective observational study. METHODS: Through a defined time period, all consecutive patients with tumor-like lesions of the papilla, who were considered for papillectomy, were enrolled in this systematic bicenter prospective observational study, and subdivided into 4 groups according to endoscopic and endoscopic ultrasonography (EUS) findings as well as histopathological diagnosis: adenoma; carcinoma/neuroendocrine tumor (NET)/lymphoma; papilla into which catheter can not be introduced; adenomyomatosis, respectively. Treatment results and outcome were characterized by R0 resection, complication, recurrence rates and tumor-free survival. RESULTS: Over a 7-year period, 58 patients underwent endoscopic papillectomy. Main symptoms prompting to diagnostic measures were unclear abdominal pain in 50% and cholestasis with and without pain in 44%. Overall, 54/58 patients [inclusion rate, 93.1%; sex ratio, males/females = 25/29 (1:1.16); mean age, 65 (range, 22-88) years] were enrolled in the study. Prior to papillectomy, EUS was performed in 79.6% (n = 43/54). Group 1 (adenoma, n = 24/54; 44.4%): 91.6% (n = 22/24) with R0 resection; tumor-free survival after a mean of 18.5 mo, 86.4% (n = 19/22); recurrence, 13.6% (n = 3/22); minor complications, 12.5% (n = 3/24). Group 2 (carcinoma/NET/lymphoma, n = 18/54; 33.3%): 75.0% (n = 10/18) with R0 resection; tumor-free survival after a mean of 18.5 (range, 1-84) mo, 88.9% (n = 8/9); recurrence, 11.1% (n = 1/9). Group 3 (adenomyomatosis, n = 4/54; 7.4%). Group 4 (primarily no introducible catheter into the papilla, n = 8; 14.8%). The overall complication rate was 18.5% (n = 10/54; 1 subject with 2 complications): Bleeding, n = 3; pancreatitis, n = 7; perforation, n = 1 (intervention-related mortality, 0%). In summary, EUS is a sufficient diagnostic tool to preoperatively clarify diseases of the papilla including suspicious tumor stage in conjunction with postinterventional histopathological investigation of a specimen. Endoscopic papillectomy with curative intention is a feasible and safe approach to treat adenomas of the papilla. In high-risk patients with carcinoma of the papilla with no hints of deep infiltrating tumor growth, endoscopic papillectomy can be considered a reasonable treatment option with low risk and an approximately 80% probability of no recurrence if an R0 resection can be achieved. In patients with jaundice and in case the catheter can not be introduced into the papilla, papillectomy may help to get access to the bile duct. CONCLUSION: Endoscopic papillectomy is a challenging interventional approach but a suitable patient- and local finding-adapted diagnostic and therapeutic tool with adequate risk-benefit ratio in experienced hands.

A prospective study on endoscopic ultrasonography criteria to guide management in upper GI submucosal tumors.

UNLABELLED: Endoscopic ultrasonography (EUS) can differentiate between impression and submucosal tumor (SMT) but it is not known whether EUS criteria can reliably guide management. The aim of this prospective study was to assess an approach to recommend removal versus follow-up investigation based on clinical and EUS criteria, with respect to the predictive values to recognize malignancy versus benign lesions. MATERIAL AND METHODS: Over a 7-years time period, all patients referred for the EUS assessment of submucosal upper GI lesions were prospectively enrolled. Extraluminal impressions diagnosed with EUS were not further considered. If submucosal tumors seen with EUS were clearly symptomatic or one of several parameters (tumor size >3 cm, irregular margins, inhomogeneous echotexture and/or enlarged lymph nodes) were found, resection was recommended. The remaining cases were subjected to EUS follow-up. RESULTS: Of cases with 241 submucosal lesions, 65 had impressions and 176 had true submucosal lesions. Of the latter, 29 cases had non-neoplastic lesions (cysts, varices). In 59 cases, removal was deemed necessary due to clinical symptoms and suspicious findings in conventional endoscopy. These subjects underwent either surgical (originating layer, muscularis propria) or endoscopic resection (submucosal origin): 35.6% were malignant, more frequently in the surgical group (41.6% vs 20%). However, in 52.5% (n=31) of the 59 cases with no severe symptoms and true SMT, EUS suggested removal because of their additional criteria. Eighteen patients (12.2%) refused SMT removal and even regular EUS-based follow-up investigation. Clinical follow-up investigation by the family practitioner did not show frank malignancy in these cases (retransferal not registered). Follow-up investigation with EUS was recommended in 70 cases (mean follow-up period, 5 years; range, 1-7 years). The pattern remained unchanged in 67/70, and 2 of the 3 cases with changes underwent surgery for benign leiomyoma (patient refusal, n=1 with no change in the one-year follow-up MRI). CONCLUSIONS: An EUS strategy based on defined characteristics to remove SMT with no severe symptoms and suspicious finding in the conventional endoscopy shows a good adherence to the recommended approach and has a reasonable positive predictive value for malignancy (88%). Clinical symptoms alone or with endoscopic finding are frequently too vague to decide for a reasonable SMT resection. The chosen EUS criteria are valuable to: 1) achieve the primary resection of all potentially malignant SMT and 2) avoid to overlook them as shown by the results of the follow-up investigations with no detected malignant lesion.

Successful transgastric pancreaticography and endoscopic ultrasound-guided drainage of a disconnected pancreatic tail syndrome.

OBJECTIVES: We aim to demonstrate that endoscopic ultrasound (EUS)-guided transgastric pancreaticography/drainage of the pancreatic duct is feasible and successful in healing a persisting pancreaticocutaneous fistula. METHODS: By means of a case report, we describe the following alternative therapeutic procedure. A 76-year-old male had: (1) 10 surgical interventions because of necrotizing acute pancreatitis with a persisting pancreaticocutaneous fistula (volume 200-300 ml/day); (2) an unsuccessful attempt of transpapillary drainage (disrupted duct after necrosectomy). He then underwent a EUS-guided transluminal pancreaticography/drainage of the pancreatic duct. A transgastric puncture was performed followed by, insertion of a guide wire into the dilated tail segment, and expansion of the gastropancreaticostomy using a 10-Fr retriever. A 10-Fr Amsterdam prosthesis was then placed through the guide wire. RESULTS: The procedure was both a technical and clinical success as indicated by fistula occlusion and sufficient internal drainage of the pancreatic juice via the gastropancreaticostomy. No severe complications such as bleeding, perforation stent occlusion or migration were observed during the 15-month follow-up. CONCLUSIONS: Transgastric pancreaticography and EUS-guided drainage of the enlarged pancreatic duct are elegant and feasible alternative options for the treatment of specific pancreatic lesions such as persisting pancreaticocutaneous fistula (complication after necrotizing pancreatitis), after pancreatic resective surgery, chronic pancreatitis and anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy. Moreover, the procedure may represent a valid tool to avoid surgery and more invasive interventions.

Transgastric pancreatography and EUS-guided drainage of the pancreatic duct.

BACKGROUND/PURPOSE: Endoscopic transpapillary drainage of the retained pancreatic duct in symptomatic patients with chronic pancreatitis is considered an established treatment option. The aim of this study was to investigate, as an alternative, endoscopic ultrasound (EUS)-guided transgastric pancreatography and drainage of the pancreatic duct, in terms of their feasibility and outcome. METHODS: All consecutive symptomatic patients with failure of the traditional approach to catheterize and drain the pancreatic duct, over a 3-year time period, were enrolled in this prospective, observational single-center study (case series). Feasibility was characterized by success rate, outcome by complication rate (frequency of bleeding or perforation), mortality, and follow-up. RESULTS: Twelve patients underwent 14 interventions (sex ratio, M/F, 10:4; age range, 43-77 years) from November 2002 to October 2005. The main indication was retention of the pancreatic duct associated with pain, in particular: (i) papilla not reachable because of prior gastrointestinal surgery (n = 5); and (ii) not possible to introduce the catheter through the papilla in chronic pancreatitis or "pancreas divisum" (n = 7). Pancreatography was successful in all patients (normal finding with no therapeutic consequence, n = 1 [after pancreaticojejunostomy]), whereas drainage of the pancreatic duct was achieved in 9 patients (69%; attempts, n = 13). The transgastric route was used in 5 patients and the transpapillary route (rendezvous technique with endoscopic retrograde cholangiopancreatography [ERCP]) in 4. There was a complication rate of 42.9%, comprising postinterventional pain (n = 4; 28.6%); bleeding (n = 1); and perforation because of retriever problems (n = 1). The postinterventional pancreatitis rate was 0% and mortality was 0%. The follow-up investigation (range, 4 weeks - 3 years) revealed that 4 patients (28.6%) subsequently underwent surgical intervention, because of duodenal stenosis (n = 1; 7.1%), suspicious tumor growth (n = 1; 7.1%), and insufficient drainage of the pancreatic duct (n = 2; 14.3%). In 2 subjects (14.3%), endoscopic reinterventions became necessary, which were subsequently successful. There were the following technical problems: 1) Too dense stenosis (n = 3); 2) inadequate equipment (insufficient infeed of the endoscopic tool because of its bending), in each case. CONCLUSIONS: Transgastric pancreatography and EUS-guided drainage of the pancreatic duct are reasonable and feasible alternative options for diagnostic and therapeutic management for selected indications (chronic pancreatitis; anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy), with an acceptable periinterventional risk, which broaden the therapeutic spectrum and may avoid surgery but need further evaluation and follow-up investigation.