Efficacy of a Novel Tapered Contrast Catheter for Endoscopic Ultrasound-Guided Hepaticogastrostomy: A Multicenter Study.

Background: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an alternative for failed endoscopic retrograde cholangiopancreatography (ERCP), with current success rates of 65-84% considered suboptimal. A novel ERCP catheter (SHOREN, Kaneka Corporation, Osaka, Japan) with a tapered 3.3-French tip may facilitate smoother insertion, potentially improving outcomes. Methods: This retrospective analysis encompassed EUS-HGS procedures conducted from January 2021 to August 2023 at four institutions. The aim of this study was to compare the performance of conventional and novel ERCP contrast catheters regarding the success rate of single-attempt catheter insertion, failure rates, technical success rates, and incidence of adverse events. Results: The study included 48 patients; 26 underwent EUS-HGS using conventional catheters and 22 with the novel catheter. The novel catheter achieved higher success rates in single-attempt insertions (96.5% vs. 80.8%) and lower failure rates (4.6% vs. 7.7%). The occurrence of bile peritonitis was comparable between the two groups. Conclusions: The novel ERCP contrast catheter with a tapered tip appears to contribute to successful catheter insertion and is useful for EUS-HGS.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions in the caudate lobe: a report of seven cases.

The caudate lobe of the liver is located deep within the body and surrounded by major blood vessels, such as inferior vena cava, portal vein, and hepatic veins. Thus, percutaneous biopsy is technically challenging. Herein, we report seven patients with focal liver lesions in the caudate lobe who underwent endoscopic ultrasound-guided tissue acquisition (EUS-TA). Their median age was 56 (25-79) years, consisting five males and two females, and the median lesion size was 44 (19-77) mm. Transgastric EUS-TA was performed in all patients. The needles used were 22G and 25G in six patients and one patient, and the median procedure time was 18 (13-30) min. In all patients, adequate specimens were collected, and pathological diagnosis was possible (three intrahepatic cholangiocarcinoma, two metastatic tumors from pancreatic cancer, one hepatocellular carcinoma, and one focal nodular hyperplasia). No adverse events associated with the procedure were observed. EUS-TA can be the first choice for tissue acquisition of the caudate lobe lesions.

A new surgical method to treat intracanal lumbar disc herniation using the unilateral biportal endoscopic transforaminal approach: patient series.

BACKGROUND: Unilateral biportal endoscopic lumbar discectomy (UBELD) is a new minimally invasive spine surgery. The purpose of this study is to describe a new surgical method to treat intracanal lumbar disc herniation (LDH) using the unilateral biportal endoscopic transforaminal approach (UBE-TFA). The first 15 patients who had undergone UBELD for single-level LDH were included in this study. Operative time, intraoperative blood loss, postoperative stay, and intraoperative complications were recorded. The Oswestry Disability Index (ODI), numeric rating scale (NRS) score for leg pain, and modified MacNab criteria were assessed at 3 months postoperatively. OBSERVATIONS: The mean operative time was 52.0 ± 13.8 minutes. The mean intraoperative blood loss was 10.5 ± 10.2 mL. The mean postoperative stay was 1.1 ± 0.3 days. There were no complications. The postoperative mean ODI was significantly improved from 44.9 ± 14.4 to 7.7 ± 11.2 at the final follow-up (p < 0.001). There was a significant decrease in the postoperative mean NRS score for leg pain, from 6.1 ± 1.9 to 0.8 ± 1.3 at the final follow-up (p < 0.001). Based on the modified MacNab criteria, good to excellent results were obtained in 86.7% of the patients. LESSONS: We considered UBELD-TFA as not only one of the promising surgical methods for UBELD, but also a new surgical implementation of the TFA.

Percutaneous transhepatic gallbladder drainage versus endoscopic gallbladder stenting for managing acute cholecystitis until laparoscopic cholecystectomy.

INTRODUCTION: Gallbladder drainage by methods such as percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic gallbladder stenting (EGBS) is important in the early management of moderate to severe acute cholecystitis. METHODS: In patients undergoing laparoscopic cholecystectomy (LC) for acute cholecystitis after a month or more of gallbladder drainage, the clinical course was compared between patients initially treated with PTGBD or EGBS. RESULTS: Among 331 patients undergoing LC for cholecystitis between 2018 and 2022, 43 first underwent 1 or more months of gallbladder drainage. The median interval between drainage initiation and LC was 89 days (range, 28-261) among 34 patients with PTGBD and 70 days (range, 62-188) among nine with EGBS (p = 0.644). During this waiting period, PTGBD was clamped in six patients and removed in five. Cholecystitis relapsed in three PTGBD patients (9%) and four EGBS patients (44%; p = 0.026). Relapses were managed with medications. Cholecystectomy duration (p = 0.022), intraoperative blood loss (p = 0.026), frequency of abdominal drain insertion (p = 0.023), and resort to bailout surgery such as fundus-first approaches (p = 0.030) were significantly greater in patients with EGBS. Postoperative complications were somewhat likelier (p = 0.095) and postoperative hospital stays were longer (p = 0.007) in the EGBS group. CONCLUSION: Among patients whose LC was performed 1 or more months after initiation of drainage, daily living during the waiting period associated with drainage was well supported by EGBS, but LC and the postoperative course were more complicated than in PTGBD patients.

Unilateral Biportal Endoscopic Laminectomy-Bilateral Decompression Using a Monoportal Scope and Bipolar Coagulator for Lumbar Spinal Stenosis: A Technical Report.

The purpose of this study was to introduce the application of a monoportal scope and bipolar coagulator used in full-endoscopic spine surgery (FESS) for unilateral biportal endoscopy-unilateral laminectomy bilateral decompression (UBE-ULBD) in those with central stenosis. A 68-year-old man who presented with cauda equina symptoms underwent UBE-ULBD to improve his central stenosis at the L2/3 level. In this technique, a FESS scope was attached to a camera portal in place of a common arthroscope. A decompression tool was subsequently inserted through the working portal, and the lower border of the vertebral lamina and the lower border of the contralateral lamina were resected. Additionally, the superior border of the L3 level was thinned using a high-speed drill, and the ligament flavum was excised. The operation time was 70 minutes, and his symptoms improved. The patient was discharged from the hospital four days postoperatively. We found three advantages of using a FESS scope and bipolar coagulator, including the ability to 1) stabilize the camera via placement of the sleeve against the bone, 2) minimize the wounded area by irrigating saline on the side of the scope, and 3) provide bipolar tissue hemostasis in an isolated area around the nerves. Therefore, among the UBE techniques, we believe that assisted full-endoscopic spine surgery (AFESS) is a viable option to offer a more minimally invasive surgery for patients with stenosis.

A multilocular discal cyst extending from the spinal canal to the extraforaminal region: A case report.

BACKGROUND: Lumbar discal cysts are intraspinal extradural cysts communicating with the intervertebral disc. The usual location and morphology are in the caudal ventrolateral epidural space of the spinal canal, without extension to the neural foramen or crossing the midline and described as a well-defined homogeneous oval or spherical cyst on low and high signal intensities observed in lumbar lesions on T1- and T2-weighted magnetic resonance imaging, respectively. We report an unusual lumbar discal cyst in terms of the lesion location and morphology. CASE PRESENTATION: A 33-year-old-man presented with lower back and right anterior thigh pain. Magnetic resonance imaging revealed multilocular cystic lesions in the cranial ventrolateral epidural space at L2-L3 with low and high signal intensities on T1- and T2-weighted magnetic resonance imaging, respectively. We performed a full-endoscopic transforaminal cystectomy under general anesthesia. CONCLUSION: Lumbar discal cysts should be considered a differential diagnosis for multilocular intraspinal cystic lesion.

A case of synchronous IgG4-associated pleuritis and type 1 autoimmune pancreatitis.

A 50-year-old man presented to the emergency department with left chest pain, epigastralgia, and low-grade fever for several days. A CT scan showed left pleural effusion, ground-glass opacities in the lower lobes of both lungs, and a capsule-like rim in the pancreas. ERCP showed narrowing of the main pancreatic duct. EUS-FNA was performed, but pathological findings showed no IgG4-positive cells. A thoracoscopic biopsy was performed, and pathological findings showed many IgG4-positive cells. A diagnosis of autoimmune pancreatitis and IgG4-associated pleurisy was made according to international diagnostic criteria. After that, oral steroid therapy was started, and left pleural effusion and pancreatic enlargement improved.

The Effectiveness of Unilateral Biportal Endoscopic Decompression for Radiculopathy After Vertebral Compression Fracture: A Case Report.

A 79-year-old woman was presented to our hospital with L3 radiculopathy due to excessive osteophyte formation following an osteoporotic vertebral compression fracture (OVCF). She underwent a unilateral biportal endoscopy (UBE)-assisted canal decompression via the interlaminar approach. The operation time was 101 minutes. Good results were observed at one-year postoperatively. We found that UBE may be useful to avoid the risks of facetectomy, especially when decompressing narrow interlaminar spaces after upper lumbar compression fractures. Improvement of radiculopathy after lumbar compression fractures remains challenging because the upper lumbar vertebrae are often affected by compression fractures. Even in normal cases, the interlaminar space can be narrow; furthermore, the space becomes narrower after compression fractures due to vertebral body collapse. When there is compression of the posterior wall nerve root due to thickening of the yellow ligament and posterior wall damage, decompression is needed to obtain a sufficient working space. With the UBE technique, the endoscope and portals are independent of each other, and the field of view and instrument can be moved separately. Therefore, in the upper lumbar spine with a narrow interlaminar space following OVCF, decompression can be achieved while avoiding the risk of facetectomy and is unnecessary if its purpose is to secure a field of view. This report presents a case where UBE was useful to improve the effectiveness of spinal decompression in a narrow interlaminar space to treat residual neurological symptoms.

Long-term Follow-up of Small Nonfunctioning Pancreatic Neuroendocrine Tumors Diagnosed Using Endoscopic Ultrasound-guided Fine-needle Aspiration.

Objective Clinical practice guidelines in Japan recommend surgery for all nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs), regardless of their size or associated symptoms. Because pancreatic resection is highly invasive, follow-up for small NF-PNETs is often chosen in clinical practice. However, the natural history of NF-PNET remains poorly understood. We aimed to examine the natural history of pathologically confirmed NF-PNET. Methods This single-center retrospective case series investigated NF-PNETs that were pathologically diagnosed using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) at our hospital between 2014 and 2018. Patients who were followed up without treatment due to their general condition or their wish were included in the study. Patients' background characteristics, imaging findings, pathological findings, and long-term prognoses were investigated using medical records. Results Overall, 26 patients were diagnosed with NF-PNET by EUS-FNA during the observation period. Of these, 9 patients (3 men and 6 women; median age: 64 years old) were followed up without treatment. All of these patients were asymptomatic, and localization was noticed in 3 cases in the head, body, and tail (1 each), with a median size of 12 (range: 4-18) mm. Neuroendocrine tumor (Grade 1 [G1]) was pathologically diagnosed in all patients with EUS-FNA. The median observation period was 63 (range: 26-90) months. Tumor growth and distant metastasis were not observed in any of the nine patients who remained asymptomatic. Conclusion Follow-up is a feasible option for asymptomatic NF-PNET ≤20 mm in size with a pathological grade of G1.

Covered self-expandable metallic stents versus plastic stents for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction.

BACKGROUND/AIMS: Covered self-expandable metallic stents (cSEMS) have become popular for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting (EUS-HGS). We compared the time to recurrent biliary obstruction (TRBO), complications, and reintervention rates between EUS-HGS using plastic stent (PS) and cSEMS in patients with unresectable malignancies at multicenter institutions in Japan. METHODS: Patients with unresectable malignant biliary obstruction who underwent EUS-HGS between April 2015 and July 2020 at any of the six participating facilities were enrolled. Primary endpoint: TRBO; secondary endpoints: rate of complications other than recurrent biliary obstruction and technical success rate of reintervention were evaluated. RESULTS: PS and cSEMS were used for EUS-HGS in 109 and 43 patients, respectively. The TRBO was significantly longer in the cSEMS group than in the PS group (646 vs. 202 days). Multivariate analysis identified two independent factors associated with a favorable TRBO: combined EUS-guided antegrade stenting with EUS-HGS and the use of cSEMS. No significant difference was observed in the rate of complications other than recurrent biliary obstruction between the two groups. The technical success rate of reintervention was 85.7% for PS and 100% for cSEMS (p=0.309). CONCLUSION: cSEMS might be a better option for EUS-HGS in patients with unresectable malignancies, given the longer TRBO.

A retrospective multicenter study comparing the punctures to B2 and B3 in endoscopic ultrasound-guided hepaticogastrostomy.

Objectives: In recent years, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been performed as an important salvage option for failed endoscopic retrograde cholangiopancreatography for biliary drainage. However, technical issues, such as puncture site (bile duct of segment 3 [B3] or bile duct of segment 2 [B2]), dilation method, stent selection, and procedural safety, need to be resolved for the optimization of EUS-HGS. The present study was to compare the safety, difficulty, and technical and functional success between biliary access via B2 and B3 during EUS-HGS. Methods: We conducted a retrospective investigation of 161 consecutive EUS-HGS cases across a total of 6 facilities, including those at our hospital. The patients were divided into two groups according to the successful drainage route: the puncture to B2 (P-B2) or the puncture to B3 (P-B3). We compared the technical and functional success rates, technical difficulty, and adverse events between the two groups. We also conducted a subgroup analysis to show the factors related to the procedure time. Results: There were 92 cases in the P-B2 group and 69 cases in the P-B3 group. There were no significant differences in the technical success, functional success, or adverse events between the groups; however, the procedure time was significantly shorter in P-B2 cases than in P-B3 cases. The multivariate analysis showed that the puncture site was the only factor related to the procedure time. Conclusions: Based on these findings, P-B2 appears useful and safe. P-B2 is as effective as P-B3 and was able to be performed in a shorter period of time. The B2 approach can be considered a useful option for EUS-HGS.

Full-Endoscopic Discectomy in an Adult Postoperative Spinal Dysraphism Patient: A Case Report.

A 52-year-old male patient presented with right lumbar pain and was diagnosed with a herniated disc using MRI. Based on his symptoms, a full-endoscopic discectomy via transforaminal approach (FED-TF) was planned. However, we focused on the possibility of an abnormal spinal anomaly due to a history of prior surgery for spina bifida during childhood that was identified through an interview. Although the FED-TF approach is sometimes used in the upper lumbar spine, this approach may damage the existing nerve in the Kambin's triangle due to an abnormal nerve root course; therefore, we changed the surgical approach to a full-endoscopic discectomy via interlaminar approach (FED-IL) and successfully completed the surgery. Despite the rarity of spinal dysraphism in children with an estimated incidence of 0.05-0.25 per 1000 live births, the probability of these patients undergoing spinal surgery in adulthood is unknown, and the total percentage of those requiring surgery is likely to be small. However, the possibility of abnormal nerve course should be considered when planning surgery for these patients. Therefore, it is important to pay attention to the route of the root and to obtain a preoperative coronal MRI in patients who have undergone spinal surgery during their childhood. Careful interviews and preoperative imaging are of critical importance for the safety and efficacy of spine surgery.

Influence of Graft Ureter Length, a Donor-Related Factor, on Urinary Tract Infections After Living-Donor Kidney Transplantation: A Single-Center Analysis of 211 Cases.

Urinary tract infection (UTI) occurs in 25% of recipients of living-donor kidney transplantation (LDKT). Female sex, age, and anatomical abnormalities have been reported as recipient-related risk factors for UTI after LDKT; few studies have reported donor-related factors. We retrospectively examined UTI occurrence within 5 years of transplantation in recipients (n = 211) who underwent LDKT at our hospital between April 2011 and April 2021. All nephrectomies were performed using a retroperitoneal pure laparoscopic approach. The ureter was dissected at the lower level of the common iliac artery and trimmed to the shortest length, enough to reach the bladder using extra vesicular ureterocystoneostomy with a 3 cm submucosal tunnel. Twenty-nine recipients (13.7%) developed UTI within 5 years, and the median time to onset was 40.0 days. After adjusting for the well-known factors, including recipient sex, graft ureter length was an independent factor for UTI occurrence (HR 1.25, 95% CI 1.02∼1.53, p = 0.028) in the multivariate Cox regression analysis. The long ureter is usually trimmed, and the widest part is used for anastomosis, which may increase the possibility of reflux from the bladder to the ureter in the standard technique. The ureter length may be associated with the incidence of UTI after LDKT.