Endoscopic ultrasound-guided gallbladder and bile duct drainage with lumen apposing metal stent: A large multicenter cohort (with videos).

BACKGROUND AND AIM: Cholecystectomy and endoscopic retrograde cholangiopancreatography are the gold standard for managing acute cholecystitis and malignant biliary obstruction, respectively. Recent advances in therapeutic endoscopic ultrasound (EUS) have provided alternatives for managing patients in whom these approaches fail, namely, EUS-guided gallbladder drainage (EUS-GB) and EUS-guided bile duct drainage (EUS-BD). We aimed to assess the technical and clinical success of these techniques in the largest multicenter cohort published to date. METHODS: A retrospective, multicenter, observational study involving 17 centers across Australia and New Zealand was conducted. All patients who had EUS-GB or EUS-BD performed in a participating center using a lumen apposing metal stent between 2016 and 2020 were included. Primary outcome was technical success, defined as intra-procedural successful drainage. Secondary outcomes included clinical success and 30-day mortality. RESULTS: One hundred and fifteen patients underwent EUS-GB (n = 49) or EUS-BD (n = 66). EUS-GB was technically successful in 47 (95.9%) while EUS-BD was successful in 60 (90.9%). All failed cases were due to maldeployment of the distal flange outside of the targeted lumen. Clinical success of EUS-GB was achieved in 39 (79.6%). No patients required subsequent cholecystectomy. Clinical success of EUS-BD was achieved in 52 (78.8 %). Thirty-day mortality was 14.3% for EUS-GB and 12.1% for EUS-BD. CONCLUSIONS: EUS-guided gallbladder drainage and EUS-BD are promising alternatives for managing nonsurgical candidates with cholecystitis and malignant biliary obstruction following failed endoscopic retrograde pancreatography. Both techniques delivered high technical success with acceptable clinical success. Further research is needed to investigate the gap between technical and clinical success.

Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system.

BACKGROUND AND AIM: Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice. METHODS: A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers. RESULTS: Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion. CONCLUSIONS: This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.

EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study.

BACKGROUND: Both EUS and ERCP sampling techniques may provide tissue diagnoses in suspected malignant biliary obstruction. However, there are scant data comparing these 2 methods. OBJECTIVE: To compare EUS-guided FNA (EUS-FNA) and ERCP tissue sampling for the diagnosis of malignant biliary obstruction. DESIGN: Prospective, comparative, single-blind study. SETTING: Tertiary center. PATIENTS: Fifty-one patients undergoing same-session EUS and ERCP for the evaluation of malignant biliary obstruction over a 1-year period. INTERVENTIONS: EUS-FNA and ERCP tissue sampling with biliary brush cytology and intraductal forceps biopsies. MAIN OUTCOME MEASUREMENTS: Diagnostic sensitivity and accuracy of each sampling method compared with final diagnoses. RESULTS: EUS-FNA was more sensitive and accurate than ERCP tissue sampling (P < .0001) in 51 patients with pancreatic cancers (n = 34), bile duct cancers (n = 14), and benign biliary strictures (n = 3). The overall sensitivity and accuracy were 94% and 94% for EUS-FNA, and 50% and 53% for ERCP sampling, respectively. EUS-FNA was superior to ERCP tissue sampling for pancreatic masses (sensitivity, 100% vs 38%; P < .0001) and seemed comparable for biliary masses (79% sensitivity for both) and indeterminate strictures (sensitivity, 80% vs 67%). LIMITATIONS: Single-center study. CONCLUSION: EUS-FNA is superior to ERCP tissue sampling in evaluating suspected malignant biliary obstruction, particularly for pancreatic masses. EUS-FNA appears similar to ERCP sampling for biliary tumors and indeterminate strictures. Given the superior performance characteristics of EUS-FNA and the higher incidence of pancreatic cancer compared with cholangiocarcinoma, EUS-FNA should be performed before ERCP in all patients with suspected malignant biliary obstruction. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01356030.).

Over-the-scope-clip system secured nasojejunal tube feeding in refractory hyperemesis gravidarum.

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. It complicates up to 2% of all pregnancies and can be associated with adverse outcomes. Its management commonly involves a combination pharmacotherapy, however, the efficacy of such treatment is limited. Supplemental nutrition is often required in refractory cases. Enteral route is preferred over parenteral, given the high rate of intravenous catheter-related complications. Enteral feeding tube placement can be challenging and is commonly thwarted by dislodgement. We present a pharmacotherapy refractory HG case where the over-the-scope-clip (OTSC) system was successfully used for durable mucosal fixation of the nasojejunal feeding tube.

Ambulatory oesophageal manometry and pH monitoring for investigation of chest pain: a New Zealand experience.

AIMS: Patients with chest pain of uncertain origin are often referred to gastroenterology to assess for possible oesophageal causes. Oesophageal spasm is difficult to ascertain with stationary manometry, as pain seldom occurs during this brief study. Twenty-four-hour ambulatory manometry and oesophageal pH recording (AMP) offers the opportunity to correlate pain symptoms with abnormal motility or acid reflux for more definitive diagnosis. AMP has been available at Christchurch Hospital since 2000 and we describe our experience. METHODS: Thirty-seven patients (23 female, 14 male) underwent AMP between January 2000 and January 2004. Tracings were analysed by automated software and manually by an experienced scientist and gastroenterologist. Case-notes were reviewed for history and drug data. RESULTS: Thirty-three patients (89%) experienced typical pain and/or dysphagia symptoms during AMP. Twenty-one had no correlation between symptoms and pH or manometric abnormalities, excluding reflux disease or an oesophageal hypercontractile disorder as a cause of symptoms. Only one patient had oesophageal spasm proven. One patient's pain correlated strongly with acid reflux. Seven others had reflux episodes during AMP with less consistent pain correlation. At least six patients required treatment for ischaemic heart disease after a negative AMP result. CONCLUSIONS: AMP has been a useful additional investigation for chest pain and was able to exclude oesophageal causes of pain in most patients studied. Oesophageal spasm appears to be a rare cause of chest pain in Christchurch. When a diagnosis was made on AMP, it was most often gastro-oesophageal reflux disease.