Background A single session of EUS-guided biliary drainage (EUS-BD) may be a viable alternative to ERCP in patients with malignant distal common bile duct (CBD) obstruction. There is no study ...comparing EUS-BD and ERCP for the relief of distal malignant biliary obstruction. Objective To compare the outcomes of self-expandable metal stent (SEMS) placement for malignant distal biliary obstruction by using ERCP and EUS-BD. Study Design Multicenter, retrospective analysis. Setting Tertiary referral centers. Patients Patients with malignant distal CBD obstruction requiring SEMS placement. Interventions Patients in the EUS-BD group underwent EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade (EUS-AG) procedures after 1 or more failed ERCP attempts. Patients in the ERCP group underwent retrograde SEMS placement. Main Outcome Measurements Composite success (the ability to complete the intended therapeutic procedure in a single session and resulting in a greater than 50% decrease in bilirubin over 2 weeks). Results The study included 208 patients, 104 treated with ERCP and 104 treated with EUS-BD (68 EUS-CDS, 36 EUS-AG). SEMS placement was successful in 98 patients in the ERCP group and 97 in the EUS-BD group (94.23% vs 93.26%, P = 1.00). The frequency of adverse events in the ERCP and EUS-BD groups was 8.65% and 8.65%, respectively. Postprocedure pancreatitis rates were higher in the ERCP group (4.8% vs 0, P = .059). The mean procedure times in the ERCP and EUS-BD groups were similar (30.10 and 35.95 minutes, P = .05). Limitations Retrospective analysis. Conclusions In patients with malignant distal CBD obstruction requiring SEMS placement, the short-term outcome of EUS-BD is comparable to that of ERCP.
Background Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy. Objective To report ...the largest combined experience of DEN performed for WOPN. Design Retrospective chart review. Setting Six U.S. tertiary medical centers. Patients A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003. Interventions DEN for WOPN. Main Outcome Measurements Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications. Results Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN. Limitations Retrospective, highly specialized centers. Conclusions This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile.
Background Contemporary EUS-guided FNA techniques involve the use of a needle, with an air column within the lumen, with or without suction. We describe a novel technique with an aim to improve the ...quality of the aspirate. Objective To compare a novel “wet suction” technique (WEST) with the conventional FNA technique (CFNAT) of EUS-guided FNA using a 22-gauge FNA needle. Design Prospective, single-blind, and randomized trial. Setting Two large tertiary-care hospitals. Patients All consecutive adult patients presenting for EUS with possible FNA of solid lesions were offered the chance to participate in the study. Methods All lesions were sampled with the same needle by using alternating techniques. Patients were randomized to the WEST versus the CFNAT for the first pass. If the first pass was made with the WEST, the second pass was made with the CFNAT, and subsequent passes were made in an alternating manner by using the same sequence. All FNAs were performed using 22-gauge needles. Main Outcome Measurements Specimen adequacy, cellularity, and blood contamination of EUS-guided FNA aspirates graded on a predefined scale. Results The WEST yielded significantly higher cellularity in a cell block compared with the CFNAT, with a mean cellularity score of 1.82 ± 0.76 versus 1.45 ± 0.768 ( P < .0003). The WEST cell block resulted in a significantly better specimen adequacy of 85.5% versus 75.2% ( P < .035). There was no difference in the amount of blood contamination between the 2 techniques. Limitations Lack of cross check and grading by a second cytopathologist. Conclusion The novel WEST resulted in significantly better cellularity and specimen adequacy in cell blocks of EUS-guided FNA aspirate of solid lesions than the CFNAT.
Background and Aims The option for performing ERCP and laparoscopic cholecystectomy (LC) for the management of choledocholithiasis in the same operative session is often overlooked. We compared the ...success, safety, and cost of ERCP and LC when performed in either a single session or in separate sessions. Methods We conducted a retrospective cohort study at a U.S. tertiary care hospital. We identified patients undergoing ERCP and LC between April 2011 and August 2014 in either a single operative session (n = 33) or in 2 separate sessions within a 30-day period (n = 80). Technical success, total anesthesia duration, operative time, length of hospitalization, cost of care, and morbidity and mortality were evaluated. Results Bile duct clearance was achieved in all patients at ERCP in the same-session cohort. The separate versus single-session groups, respectively, did not differ in terms of total procedure times (mean ± SD = 142 ± 64 vs 142 ± 58 min; t test, P =.98), anesthesia duration (251 ± 64 vs 225 ± 69 min; P =.06), or overall cost (49.3 ± 24.5 vs 42.3 ± 23.2 ×1000 USD; P =.167), but hospitalization was longer in the separate-sessions group (6.2 ± 3.3 vs 4.8 ± 2.6 days; P =.03). The rates of adverse events were similarly low (7% vs 2%, P =.70). Conclusions Performing single-session ERCP and LC is safe, effective, economically viable, and reduces hospital stay compared with performing ERCP and LC during separate sessions.
Background Access to the excluded gastric remnant in patients after Roux-en-Y gastric bypass for gastrostomy tube placement or therapeutic endoscopy is a technical challenge. Available techniques ...include interventional radiology–placed gastrostomy, deep enteroscopy, and surgical gastrostomy; however, these techniques are hampered by complications, technical complexity, or invasiveness. Objective To describe a novel technique that uses EUS to insufflate the excluded gastric remnant for fluoroscopically guided percutaneous gastrostomy placement. Design Retrospective study. Setting University hospital. Patients Ten patients who required gastrostomy placement after Roux-en-Y gastric bypass. Interventions EUS was used to puncture the excluded stomach through the gastric pouch or jejunum. The stomach was insufflated, and a direct percutaneous gastrostomy placed under fluoroscopic guidance in the distended stomach. Main Outcome Measurements Feasibility, safety, and efficacy of EUS-assisted, fluoroscopically guided gastrostomy tube placement. Results Technical success of EUS-assisted gastrostomy was achieved in 9 of 10 patients(90%). There were no complications. Limitations Single-institution study, small sample size. Conclusions EUS-assisted, fluoroscopically guided gastrostomy tube placement may be a safe and feasible technique to obtain enteral access to the excluded gastric remnant in patients after Roux-en-Y gastric bypass at specialized centers.
Background Interventions for necrotizing pancreatitis have undergone a recent paradigm shift toward minimally invasive techniques, including endoscopic transluminal necrosectomy (ETN). The optimal ...stent for endoscopic transmural drainage remains unsettled. Objective To evaluate a novel large-bore, fully covered metal through-the-scope (TTS) esophageal stent for cystenterostomy in large walled-off necrosis (WON). Design Retrospective case series. Setting Single tertiary care academic center. Patients Ten patients with large (>10 cm) WON collections who underwent endoscopic transmural drainage and ETN. Intervention Initial cystenterostomy was performed by using EUS, and in the same session, a TTS (18 × 60 mm), fully covered esophageal stent was placed to create a wide-bore fistula into the cavity. In 1 or more later sessions, the stent was removed, and ETN was performed as needed. Main Outcome Measurements Technical and clinical success rates and adverse events. Results The TTS stent was successfully deployed at the initial cystogastrostomy in all 10 patients. All patients had large WON (median size 17 cm, range 11-30 cm) and underwent intervention at a median of 30 days (range 12-117 days) after onset of acute pancreatitis. Resolution of WON was achieved in 9 of the 10 patients (90%) after a median of 3 endoscopic sessions. There were no early adverse events. Late adverse events occurred in 3 patients (30%); worsening of infection from stent migration and occlusion of cystogastrostomy (2 patients), and fatal pseudoaneurysmal bleeding from erosion of infected necrosis into a major artery distant from the stent (1 patient). The stent was easily removed in all the cases after resolution or improvement of the necrotic cavity. Limitations Retrospective, single-center evaluation of a small number of cases. No comparative arm to determine the relative efficacy or cost-effectiveness of these stents compared with conventional plastic stents. Conclusions Endoscopic therapy using a large-bore TTS, fully covered esophageal stent is feasible for use in the treatment of large WON. Further studies are needed to validate these findings.
