EUS-guided Transmural Drainage Research Articles

Endoscopic ultrasound-guided transmural drainage by cautery-tipped lumen-apposing metal stent: exploring the possible indications.

BackgroundThe recently introduced Hot AXIOS™ system for endoscopic ultrasound (EUS)-guided transenteric drainage has the potential to change interventional endoscopy significantly. The aim of our study was to assess the effectiveness and safety of this new type of lumen-apposing metal stent (LAMS) with cautery system for pancreatic collection, and gallbladder and biliary tree drainage.MethodsWe retrospectively reviewed consecutive patients undergoing EUS-guided drainage by LAMS with cautery system in a tertiary-care academic medical center between March 2014 and March 2017. All patients were included in our prospectively maintained institutional EUS database. The main outcome measures were technical success, clinical effectiveness, and adverse events.ResultsA total of 45 patients (20 men, mean age 69.6 years) underwent LAMS placement. Indications were pancreatic fluid collections (19 patients, 42.2%), acute cholecystitis (10 patients, 22.2%), and biliary drainage (16 patients, 35.5%). Technical success was achieved in all patients except one (97.7%). Clinical success was achieved in 86.4% (38/44) of cases and adverse events occurred in 5 (11.4%) of patients.ConclusionsIn our experience, EUS-guided LAMS placement performed by expert endoscopists was feasible and effective in the endoscopic management of pancreatic fluid collection, and biliary and gallbladder drainage. Optimization of transmural drainage by new dedicated devices could improve efficacy and safety in appropriately selected patients.

Fluoroscopy-assisted vs fluoroless endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections: A comparative study

Fluoroscopy-assisted vs fluoroless endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections: A comparative study

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis.

Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome). We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with≥10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model. Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I 2=15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I 2=50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P=0.51). WPR for AE was 13% (9, 20%), (I 2=64%). AE were 10% more in WON as compared to PP (P=0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I 2=50%). Pooled MD for number of endoscopic sessions was -0.84 (-1.69, 0.01). LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

Endoscopic ultrasound-guided pancreatic fluid collections' transmural drainage outcomes in 100 consecutive cases of pseudocysts and walled off necrosis: a single-centre experience from the United Kingdom

Background and aim: Endoscopic ultrasound-guided drainage is a minimally invasive first-line modality for the drainage of pancreatic fluid collection (PFC) resulting in a shorter hospital stay and less morbidity compared with surgical cystogastrostomy. Our aim is to evaluate potential differences in the outcomes of endoscopic ultrasound (EUS) guided transmural drainage (EUS-TD) drainage of pancreatic pseudocyst (PP) and walled-off necrosis (WON).Method: We retrospectively reviewed 100 consecutive EUS-guided drainages of PFC utilising EUS reports; clinical notes and imaging with follow-up (FU) to 12 months. All procedures were undertaken under conscious sedation with EUS guidance alone (without fluoroscopy) and placement of plastic double pigtail stents.Results: In these 100 sequential cases, there were 78 cases of PP and 22 cases of WON. All 22/22(100%) cases of WON had successful EUS-guided stent placement. In 2/22(9%), there was little or no clinical improvement. These two patients required further computed tomography (CT)–guided drainage and one of these patients (1/22) (4.5%) developed recurrence within 12 months FU after removal of stents.In case of PP, overall stent placement was successful in 76/78 (97%) patients, but 6/78(8%) required 2nd EUS procedure after failure to show clinical improvement; 3/78(2.5%) required further CT-guided drainage. The overall complication rate was 9%(9/100) with 4%(4/100) requiring endoscopic or CT-guided intervention with no overall 30-day mortality.Conclusion: This is the largest series from a single UK centre demonstrating that EUS-guided cystogastrostomy of PFC drainage using plastic double pigtail stents is sufficient in majority of cases with PFC including that of WON, with or without infection.

Short- and long-term results of endoscopic ultrasound-guided transmural drainage for pancreatic pseudocysts and walled-off necrosis.

AIMTo evaluate the short- and long-term results of endoscopic ultrasound-guided transmural drainage (EUS-GTD) for pancreatic fluid collection (PFC) and identify the predictive factors of treatment outcome for walled-off necrosis (WON) managed by EUS-GTD alone.METHODSWe investigated 103 consecutive patients with PFC who underwent EUS-GTD between September 1999 and August 2015. Patients were divided into four groups as follows: WON (n = 40), pancreatic pseudocyst (PPC; n = 11), chronic pseudocyst (n = 33), and others (n = 19). We evaluated the short- and long-term outcomes of the treatment. In cases of WON, multiple logistic regression analyses were performed to identify the predictor variables associated with the treatment success. In addition, PFC recurrence was examined in patients followed up for more than 6 mo and internal stent removal after successful EUS-GTD was confirmed.RESULTSIn this study, the total technical success rate was 96.1%. The treatment success rate of WON, PPC, chronic pseudocyst, and others was 57.5%, 90.9%, 91.0%, and 89.5%, respectively. Contrast-enhanced computed tomography using the multivariate logistic regression analysis revealed that the treatment success rate of WON was significantly lower in patients with more than 50% pancreatic parenchymal necrosis (OR = 17.0; 95%CI: 1.9-150.7; P = 0.011) and in patients with more than 150 mm of PFC (OR = 27.9; 95%CI: 3.4-227.7; P = 0.002).The recurrence of PFC in the long term was 13.3% (median observation time, 38.8 mo). Mean amylase level in the cavity was significantly higher in the recurrence group than in the no recurrence group (P = 0.02).CONCLUSIONThe reduction of WON by EUS-GTD alone was associated with the proportion of necrotic tissue and extent of the cavity. The amylase level in the cavity may be a predictive factor for recurrence of PFC.

Fluoroscopy-assisted vs fluoroless endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections: A comparative study

IntroductionThe need for fluoroscopy guidance in patients undergoing endoscopic ultrasound-guided transmural drainage (EUS-TMD) of peripancreatic fluid collections (PFCs) remains unclear. AimsThe aim of this study was to compare general outcomes of EUS-TMD of PFCs under fluoroscopy (F) vs fluoroless (FL). MethodsThis is a comparative study with a retrospective analysis of a prospective and consecutive inclusion database at a tertiary centre, from 2009 to 2015. All patients were symptomatic pseudocyst (PSC) and walled-off pancreatic necrosis (WON). Two groups were assigned depending on availability of fluoroscopy. The groups were heterogeneous in terms of their demographic characteristics, PFCs and procedure. The main outcome measures included technical and clinical success, incidences, adverse events (AEs), and follow-up. ResultsFifty EUS-TMD of PFCs from 86 EUS-guided drainages were included during the study period. Group F included 26 procedures, PSC 69.2%, WON 30.8%, metal stents 61.5% (46.1% lumen-apposing stent) and plastic stents 38.5%. Group FL included 24 procedures, PSC 37.5%, WON 62.5%, and metal stents 95.8% (lumen-apposing stents). Technical success was 100% in both groups, and clinical success was similar (F 88.5%, FL 87.5%). Technical incidences and intra-procedure AEs were only described in group F (7.6% and 11.5%, respectively) and none in group FL. Procedure time was less in group FL (8min, p=0.0341). ConclusionsFluoroless in the EUS-TMD of PFCs does not involve more technical incidences or intra-procedure AEs. Technical and clinical success was similar in the two groups.

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals.

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals. Retrospective analysis of collected database of patients (n=18; age 40.94±8.43years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals. Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3±0.79 and time to resolution was 4.4±1.3weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2weeks. EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

The use of clip anchoring to ensure safe transgastric puncture during endoscopic ultrasound-guided transmural drainage

The use of clip anchoring to ensure safe transgastric puncture during endoscopic ultrasound-guided transmural drainage

212 Endoscopic Ultrasound-Guided Transmural Gallbladder Drainage Using Lumen-Apposing Metal Stents Versus Endoscopic Transpapillary Drainage Versus Percutaneous Cholecystostomy for Gallbladder Drainage in High-Risk Surgical Patients With Acute Cholecystitis: Clinical Outcomes and Success in an International, Multicenter, Comparative Trial

212 Endoscopic Ultrasound-Guided Transmural Gallbladder Drainage Using Lumen-Apposing Metal Stents Versus Endoscopic Transpapillary Drainage Versus Percutaneous Cholecystostomy for Gallbladder Drainage in High-Risk Surgical Patients With Acute Cholecystitis: Clinical Outcomes and Success in an International, Multicenter, Comparative Trial

Endoscopic recovery of multiple migrated plastic stents during EUS-guided transmural drainage of pancreatic fluid collections

Endoscopic recovery of multiple migrated plastic stents during EUS-guided transmural drainage of pancreatic fluid collections

Clinical outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts: a large multicenter study.

Background and study aims Data on clinical outcomes of endoscopic drainage of debris-free pseudocysts (PDF) versus pseudocysts containing solid debris (PSD) are very limited. The aims of this study were to compare treatment outcomes between patients with PDF vs. PSD undergoing endoscopic ultrasound (EUS)-guided drainage via transmural stents. Patients and methods Retrospective review of 142 consecutive patients with pseudocysts who underwent EUS-guided transmural drainage (TM) from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TM technical success, treatment outcomes (symptomatic and radiologic resolution), need for endoscopic re-intervention at follow-up, and adverse events (AEs). Results TM was performed in 90 patients with PDF and 52 with PSD. Technical success: PDF 87 (96.7 %) vs. PSD 51 (98.1 %). There was no difference in the rates for endoscopic re-intervention (5.5 % in PDF vs. 11.5 % in PSD; P = 0.33) or AEs (12.2 % in PDF vs. 19.2 % in PSD; P = 0.33). Median long-term follow-up after stent removal was 297 days (interquartile range [IQR]: 59 – 424 days) for PDF and 326 days (IQR: 180 – 448 days) for PSD (P = 0.88). There was a higher rate of short-term radiologic resolution of PDF (45; 66.2 %) vs. PSD (21; 51.2 %) (OR = 0.30; 95 % CI: 0.13 – 0.72; P = 0.009). There was no difference in long-term symptomatic resolution (PDF: 70.4 % vs. PSD: 66.7 %; P = 0.72) or radiologic resolution (PDF: 68.9 % vs. PSD: 78.6 %; P = 0.72) Conclusions There was no difference in need for endoscopic re-intervention, AEs or long-term treatment outcomes in patients with PDF vs. PSD undergoing EUS-guided drainage with transmural stents. Based on these results, the presence of solid debris in pancreatic fluid collections does not appear to be associated with a poorer outcome.

Endoscopic recovery of multiple migrated plastic stents during EUS-guided transmural drainage of pancreatic fluid collections.

Endoscopic recovery of multiple migrated plastic stents during EUS-guided transmural drainage of pancreatic fluid collections.

Nonfluoroscopic endoscopic ultrasound-guided transmural drainage of pancreatic pseudocysts at atypical locations

Abstract Background: Pancreatic pseudocysts (PP) at atypical locations are a therapeutic challenge and are usually managed surgically. Objective: We evaluated safety and efficacy of nonfluoroscopic endoscopic ultrasound (NF-EUS)-guided transmural drainage in the management of PP at atypical locations. Patients and Methods: Retrospective analysis of 11 patients (all males; age range: 28–46 years) with PP at atypical locations who were treated with NF-EUS-guided transmural drainage during the last 18 months was done. Results: Four patients had intra/peri-splenic, three patients had mediastinal, three patients had intrahepatic, and one patient had renal PP. Nine patients had chronic pancreatitis whereas two patients had acute pancreatitis. Alcohol was the etiology of pancreatitis in ten patients. The size of PP ranged from 4 to 10 cm. All patients had abdominal pain, and two patients had fever whereas one patient with mediastinal PP also had dysphagia. NF-EUS-guided transmural drainage could be done successfully in all patients. 7 Fr transmural stent(s) was/were placed in six patients whereas single-time complete aspiration of PP was done in five patients. On endoscopic retrograde pancreatography, six patients had partial duct disruption whereas five patients had complete disruption. Bridging transpapillary stent (5 Fr) was placed in all patients with partial disruption. All PP healed in 10/11 (91%) patients within 2–4 weeks, and there has been no recurrence in 9 of these patients during a follow-up period of 4–18 months. One patient with splenic PP needed surgery for gastrointestinal bleed. Conclusion: PP at atypical locations can be effectively and safely treated with NF-EUS-guided transmural drainage.

Endoscopic Treatment of Walled-off Necrosis in Children: Clinical Experience and Treatment Outcomes.

Data on the endoscopic treatment outcomes for walled-off necrosis (WON) in children are limited. The aim of the present study was to evaluate the efficacy and safety of endoscopic approach for the treatment of WON in children. A retrospective study was conducted of all children with symptomatic WON treated endoscopically over 6 years. Treatment consisted of endoscopic ultrasound-guided transmural drainage using either a lumen-apposing metal stent or multiple 7Fr double pigtail plastic stents with or without percutaneous drainage. Main outcome measures were technical success, treatment success, recurrence, reinterventions, and adverse events. Six children (5 girls, median age 12 years) underwent endoscopic ultrasound-guided WON drainage by creation of a single transmural tract in 5 patients and multiple transmural tracts in 1. Stents placed were plastic in 5 patients and lumen-apposing metal stent in 1. One patient underwent concomitant percutaneous drainage. Treatment success was achieved in all of the 6 patients (100%) following a single intervention in 4 patients and 2 interventions in 2. No procedure-related adverse events were encountered. At 8-week follow-up, the transmural stents were retrieved in all but 1 patient who had a disconnected pancreatic duct. At a median follow-up of 781 days (interquartile range 336-869 days), no WON or symptom recurrence was encountered in any patient. Endoscopic treatment is effective, safe, and when available should be the first-line modality for the management of WON in children.

EUS-guided insertion of self-expandable metal stent and direct endoscopic necrosectomy in the management of infected walled-off pancreatic necrosis.

Fully covered self-expandable metal stents (FCSEMSs) have larger diameters than plastic stents and can provide more effective drainage for pancreatic collections. Enteral or biliary FCSEMSs are suboptimal for drainage of pancreatic collections because of the higher risk of migration, excessive length, and lack of lumen apposition. FCSEMSs customized for drainage are characterized by short lengths and biflanged designs that allow apposition and prevent migration. Examples include the NAGI stent (Taewoong, Seoul, Korea) and the Axios stent (Boston Scientific, Natick, Mass). The NAGI stent comes in lengths of 10, 20, and 30 mm with lumen diameters of 10, 14, 12, and 16 mm, and flared ends of 20 mm. In comparison with the NAGI stent, the Axios stent is 10 mm long with lumen diameters of 10 mm (flange, 21 mm) or 15 mm (flange, 24 mm). The delivery catheter of the NAGI stent is 9F (10-mm and 12-mm stents) or 10F (14-mm and 16-mm stents), whereas that of the Axios stent is 10.8F. Radiopaque markers to guide placement are present for both stents. The NAGI stent is deployed by simple retraction of the catheter sheath, whereas deployment of the Axios stent is characterized by a Luer lock mechanism that allows independent deployment of the distal and proximal stent anchors. The estimated cost of the Axios stent is 3-fold to 4-fold that of the NAGI stent. This case illustrates the use of a NAGI stent in the management of infected walled-off necrosis (WON). A 68-year-old man with recent severe gallstone pancreatitis presented with fever and abdominal pain. CT revealed WON measuring 15.5 cm by 10.3 cm. He was treated with intravenous antibiotics, and EUS-guided transmural drainage was performed. The collection was punctured with a 19G needle, and a 0.035-inch guidewire was inserted. Sequential dilation of the puncture tract was performed with use of a 6F biliary dilator and a 10-mm balloon dilator. A 16-mm × 20-mm NAGI stent was then successfully deployed (Fig. 1A). The patient’s symptoms resolved promptly; interval CT at 7 days demonstrated a reduction in size of the WON, and he was discharged from the hospital. He experienced fever and abdominal pain 24 days later. Intravenous antibiotics were restarted. Repeated CT showed an increase in the size of the WON despite the presence of the FCSEMS (Fig. 1B). Endoscopy revealed solid debris blocking the opening of the FCSEMS. Direct endoscopic necrosectomy was performed with the patient under sedation (Video 1), and 4 sessions were required (Fig. 1C). All necrotic debris was removed. Follow-up CT revealed resolution of the WON. The FCSEMS was removed. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3MGRjODBmNGM1ZGY0NmM4NTMzOWRlOWI1ZWYzMGZjMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3ODA5MzcyfQ.HB7mqYc7xg02qAta1O8BgcbRRVTowj76FnNv4P6-wQ89p6NU5SRQGbsBby8CxGqyd00bOasBO0w5surEmqH8C0Zk7mQAcwvEBBu4RAavWRFLqG7KPtr0Fw6Na81YxS8rioH0Vgd2V2Z2ZFsbvaVDVjM4pkDV0YqxlqQIJ7zPG_rofUEC-evizGPBAooM336ADMuFe96duZ8_sJgw5yr1IOUlflCniuI7OVtMRoRn2V-7JGvFX-5giqTlrnnZ3bzFb7OAjVWPAyJxrVnobgbz7o_cJp-rATIOL8JkuURh5DD8GOO9uLWPcVGydhNEUDJd3kA2iyUU-nSKEw_WM4l6lA Download .mp4 (25.81 MB) Help with .mp4 files Video 1EUS-guided insertion of self-expandable metal stent and direct endoscopic necrosectomy. Download .docx (.01 MB) Help with docx files Video Script

International collaborative study on EUS-guided gallbladder drainage: Are we ready for prime time?

BackgroundCholecystectomy remains the gold standard treatment of cholecystitis. Endoscopic treatment of cholecystitis includes transpapillary gallbladder drainage. Recently, endoscopic ultrasound-guided transmural drainage of the gallbladder (EUS-GBD) has been reported. This study reports the cumulative experience of an international group performing EUS-GBD. MethodsCases of EUS-GBD from January 2012 to November 2013 from 3 tertiary-care institutions were captured in a registry. Patient demographics, disease characteristics, procedural and clinical outcomes were recorded. Results35 patients (15 malignant, 20 benign) were included. Median age was 81 years (SD=13.76 years), sixteen (46%) were males. Median follow-up was 91.5 days (SD=157 days). Transmural access was obtained from the stomach (n=17) or duodenum (n=18). Stents placed included plastic (n=6), metal (n=20), or combination (n=7). Technical success was achieved in 91.4% (n=32). Immediate adverse events (14%) included: bleeding, stent migration, cholecystitis and hemoperitoneum. Delayed adverse events (11%) included abscess formation and recurrence of cholecystitis. Long-term clinical success rate was 89%. Stent type and puncture site were not associated with immediate (p=0.88, p=0.62), or long-term (p=0.47, p=0.27) success. ConclusionsEUS-GBD appears to be feasible, safe, and effective. Prospective studies are needed to confirm these findings and identify the best technique to use. Clinical trial registrationNCT01522573.

Endoscopic Therapy With Lumen-apposing Metal Stents Is Safe and Effective for Patients With Pancreatic Walled-off Necrosis.

Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n= 78), pancreatic duct stent placement for leak (n= 19), hydrogen peroxide-assisted necrosectomy (n= 38), and nasocystic irrigation (n= 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.

273 Similar Efficacies of Endoscopic Ultrasound-Guided Transmural and Percutaneous Drainage for Malignant Distal Biliary Obstruction

273 Similar Efficacies of Endoscopic Ultrasound-Guided Transmural and Percutaneous Drainage for Malignant Distal Biliary Obstruction

Continuing Medical Education Exam: April 2016

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Yang D, Amin S, Gonzalez S, et al. Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 2016;83:720-9. Costamagna G, Iacopini F, Bizzotto A, et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker’s diverticulum. Gastrointest Endosc 2016;83:765-73. Kumar N, Thompson C. Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc 2016;83:776-9. Naravadi V, Gupta N, Early D, et al. Prevalence of advanced histological features and synchronous neoplasia in patients with flat adenomas. Gastrointest Endosc 2016;83:795-9. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Electrocautery vs non-electrocautery dilation catheters in endoscopic ultrasonography-guided pancreatic fluid collection drainage.

To investigate the safety and utility of an electrocautery dilation catheter for endoscopic ultrasonography (EUS)-guided pancreatic fluid collection drainage. A single-center, exploratory, retrospective study was conducted between August 2010 and August 2014. This study was approved by the Medical Ethics Committee of our institution. Informed, written consent was obtained from each patient prior to the procedure. The subjects included 28 consecutive patients who underwent EUS-guided transmural drainage (EUS-TD) for symptomatic pancreatic and peripancreatic fluid collections (PFCs) by fine needle aspiration using a 19-gauge needle. These patients were retrospectively divided into two groups based on the use of an electrocautery dilation catheter as a fistula dilation device; 15 patients were treated with an electrocautery dilation catheter (electrocautery group), and 13 patients were treated with a non-electrocautery dilation catheter (non-electrocautery group). We evaluated the technical and clinical successes and the adverse events associated with EUS-TD for the treatment of PFCs between the two groups. There were no significant differences in age, sex, type, location and diameter of PFCs between the groups. Thirteen patients (87%) in the electrocautery group and 10 patients (77%) in the non-electrocautery group presented with infected PFCs. The technical success rates of EUS-TD for the treatment of PFCs were 100% (15/15) and 100% (13/13) for the electrocautery and the non-electrocautery groups, respectively. The clinical success rates of EUS-TD for the treatment of PFCs were 67% (10/15) and 69% (9/13) for the electrocautery and the non-electrocautery groups, respectively (P = 0.794). The procedure time of EUS-TD for the treatment of PFCs in the electrocautery group was significantly shorter than that of the non-electrocautery group (mean ± SD: 30 ± 12 min vs 52 ± 20 min, P < 0.001). Adverse events associated with EUS-TD for the treatment of PFCs occurred in 0 patients and 1 patient for the electrocautery and the non-electrocautery groups, respectively (P = 0.942). EUS-TD using an electrocautery dilation catheter as a fistula dilation device for the treatment of symptomatic PFCs appears safe and contributes to a shorter procedure time.