Endoscopic Ultrasound-guided Interventions Research Articles

ANTEGRADE METHODS OF BILIARY DECOMPRESSION IN TUMOR OBSTRUCTION OF THE BILIARY TRACT

Percutaneous transhepatic endoscopic ultrasound-guided intervention is a crucial method for addressing mechanical jaundice. This technique for restoring bile outflow enables the resolution of several medical and diagnostic issues with minimal invasiveness and fewer complications compared to traditional open surgical treatments. Most often, antegrade cholangiostomy is used in oncological practice, where the variety of clinical situations determines the indications for performing this intervention in different variants and with different goals. According to the world literature, at the moment, sufficient experience of transdermal technologies has been accumulated, their application in clinical practice has been worked out, which allows to recognize them, to a certain extent, as routine. The purpose of this work is to optimize biliary decompression in patients with tumor obstruction of the biliary tract, to improve the prevention of complications, to enhance the immediate results of treatment and the quality of life for this group of population. The study analyzed the examination and surgical treatment outcomes of 64 patients with tumor-related mechanical jaundice treated in surgical hospitals from 2017 to 2023. All patients underwent antegrade biliary drainage procedures, specifically percutaneous transhepatic cholangiostomy and bile duct stenting under ultrasound guidance, to achieve biliary decompression. Percutaneous transhepatic endoscopic interventions have become the primary method for biliary decompression in cases of bile duct obstruction due to tumors. These procedures, particularly for malignant tumors, are associated with relatively few complications and low mortality rates.

Disconnected pancreatic duct syndrome in acute necrotising pancreatitis and outcomes of endoscopic ultrasound-guided interventions: a decade’s experience from a tertiary centre

Disconnected pancreatic duct syndrome in acute necrotising pancreatitis and outcomes of endoscopic ultrasound-guided interventions: a decade’s experience from a tertiary centre

Risk factors for adverse outcomes at various phases of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Data from a multi-institutional consortium.

No comprehensive study has examined short- and long-term adverse outcomes of endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs) including walled-off necrosis (WON) and pseudocysts. In a multi-institutional cohort of 357 patients receiving EUS-guided treatment of PFCs (228 with WON and 129 with pseudocysts), we examined PFC type-specific risk factors for procedure-related adverse events (AEs), clinical failure, and recurrence. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the logistic and Cox regression models, respectively, adjusting for potential confounders. Adverse events were observed predominantly in WON, and risk factors were WON extension to the pelvis (OR 2.49; 95% CI 1.00-6.19) and endoscopic necrosectomy (OR 5.15; 95% CI 1.61-16.5). Risk factors for clinical failure in WON treatment included higher Charlson Comorbidity Index (OR for ≥3 vs. ≤2, 2.58; 95% CI 1.05-6.35), extension to the pelvis (OR 3.63; 95% CI 1.57-8.43), nonuse of a lumen-apposing metal stent (OR 2.88; 95% CI 1.10-7.54), and percutaneous drainage (OR 3.73; 95% CI 1.27-10.9). Patients with pseudocysts extending to the paracolic gutter and the need for more than two endoscopic/percutaneous procedures had ORs for clinical failure of 5.28 (95% CI 1.10-25.3) and 5.52 (95% CI 1.61-18.9), respectively. Pseudocysts requiring the multigateway approach were associated with a high risk of recurrence (HR 4.00; 95% CI 1.11-11.6). The adverse outcomes at various phases of EUS-guided PFC treatment may be predictable based on clinical parameters. Further research is warranted to optimize treatment strategies for high-risk patients.

Clinical characteristics and predictive factors of postoperative intra-abdominal abscess after distal pancreatectomy.

The postoperative mortality rate of distal pancreatectomy is lower than that of pancreaticoduodenectomy, although persistent complications may occur after distal pancreatectomy. Fluid collection (FC) is frequently observed after distal pancreatectomy; however, FC may occasionally progress to postoperative intra-abdominal abscess (PIAA), which requires conservative or progressive interventional treatment. This study aimed to compare the status between patients with or without PIAA, identify predictive factors for PIAA and clinically relevant postoperative pancreatic fistula, and investigate the clinical characteristics of patients with PIAA with interventional drainage. We retrospectively reviewed data of patients who underwent distal pancreatectomy between January 2012 and December 2019 at two high-volume centers, where hepatobiliary-pancreatic surgeries were performed by expert specialist surgeons. Logistic regression analysis was performed to determine the predictive factors for PIAA. Overall, 242 patients were analyzed, among whom 49 (20.2%) had PIAA. The median postoperative period of PIAA formation was 9 (range: 3-49) days. Among the 49 patients with PIAA, 25 (51.0%) underwent percutaneous ultrasound, computed tomography, or endoscopic ultrasound-guided interventions for PIAA. In the univariate analysis, preoperative indices representing abdominal fat mass (i.e., body mass index, subcutaneous fat area, and visceral fat area) were identified as predictive factors for PIAA; in the multivariate analysis, C-reactive protein (CRP) level (continuous variable) on postoperative day (POD) 3 (odds ratio: 1.189, 95.0% confidence interval: 1.111 - 1.274; P < 0.001) was the only independent and significant predictive factor for PIAA. CRP level on POD 3 was an independent and significant predictive factor for PIAA after distal pancreatectomy.

Endoscopic ultrasound-guided intervention for inaccessible papilla in advanced malignant hilar biliary obstruction.

Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.

Usefulness of a laser-cut covered metal stent with a 7F delivery sheath in endoscopic ultrasound-guided biliary drainage without fistula dilation.

Background and study aims Recently, the utility of endoscopic ultrasound-guided intervention without fistula dilation (EUS-IV WoD) has been reported to prevent adverse events. We clinically evaluated cases in which EUS-IV WoD was attempted using a novel self-expandable metallic stent (SEMS); this is a fully covered, laser-cut SEMS that has a tapered and stiff tip specifically designed for a 0.025-inch guidewire and a relatively thin, 7F delivery system. Patients and methods We retrospectively evaluated cases wherein EUS-IV WoD was attempted using the novel SEMS between March and December 2021. Results Treatment of 11 patients by EUS-IV WoD with the novel SEMS was attempted. The technical success rate for EUS-IV was 100 % and the clinical success rate was 100 %; the success rate for EUS-IV WoD was 72.8 %. Of these, the procedural success rate for EUS-IV WoD was 100 % in EUS-biliary drainage (BD) and 57.1 % in non-EUS-BD. Early adverse events were observed in 27.3 % of patients (3/11): mild abdominal pain in two patients and moderate bleeding in one patient. The abdominal pain cases were both cases of EUS-IV WoD failure and required fistula dilation. Conclusions The novel stent may be useful for EUS-IV WoD, especially in EUS-BD.

Colonoscopic Ultrasound-Guided Fine-Needle Aspiration Using a Curvilinear Array Transducer: A Single-Center Retrospective Cohort Study.

Curvilinear array ultrasound transducers enable tissue sampling and have therapeutic capabilities. Nevertheless, colonic intubation and maneuvering with these transducers is technically challenging and is therefore typically limited to the rectosigmoid area. This retrospective cohort study aimed to evaluate the safety, feasibility, and diagnostic yield of colonoscopic ultrasound-guided fine-needle aspiration in deep colonic intubation. The impact of this innovation is to enable tissue sampling of colonic and extracolonic lesions guided by endoscopic ultrasound. Curvilinear array ultrasound is used in the evaluation of luminal and extraluminal colonic diseases. Thirteen patients underwent colonoscopic ultrasound with a curvilinear array ultrasound endoscope in a single center for subepithelial lesions, cancer staging, and extracolonic lesions from July 2015 to February 2021. Endosonography was performed using an Olympus EU-ME1 and GF-UCT 180 with a 5-12MHz curvilinear array transducer. The primary outcome was the percentage of patients who were successfully scanned with the endoscopic ultrasound. The secondary outcomes included the success rate of fine-needle aspiration, the diagnostic yield of the tissue samples, and the adverse events related to the procedure. A total of 13 female patients underwent colonoscopic ultrasound. All patients (100%, 13/13) were successfully scanned. Fine-needle aspiration was deemed necessary and successfully performed in 100% (5/5) of the patients. Tissue samples collected by fine-needle aspiration resulted in a diagnostic yield of 60%, and no adverse events resulted from this intervention. This study demonstrates the feasibility of performing colonoscopic ultrasound with a curvilinear array transducer. Fine-needle aspiration for subepithelial, colonic, and extracolonic lesions is feasible and safe in this setting with no adverse events reported in our study. Future research should be directed toward validating colonoscopic ultrasound with a curvilinear array transducer technique in prospective randomized trials. Studies evaluating the feasibility and safety of endoscopic ultrasound-guided interventions in the colon, such as abscess drainage and enteral anastomosis, should be considered.

Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments.

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)–guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy’s lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.

Simultaneous endoscopic ultrasound-guided treatment of intestinal and biliary obstruction due to massive lymphoma of the duodenal papilla.

Simultaneous endoscopic ultrasound-guided treatment of intestinal and biliary obstruction due to massive lymphoma of the duodenal papilla.

Lumen-apposing metals stents in advanced endoscopic ultrasound-guided interventions: novel applications, potential complications and radiologic assessment.

Endoscopic ultrasound (EUS)-guided drainage procedures are an increasingly utilized minimally invasive alternative to percutaneous or surgical management strategies, having been shown to decrease recovery time, cost, and duration of hospital stay. The current mainstay of EUS-guided drainage procedures is in pancreatic and peripancreatic collections in pancreatitis. Recent technological advancements and the development of specialized stents have allowed for novel applications in a growing variety of clinical scenarios, including biliary obstruction, cholecystitis and gastrointestinal obstruction. An overview is provided of standard EUS-guided lumen-apposing metal stent (LAMS) management in pancreatic collections, including the expected radiologic findings and appropriate post-treatment sequelae. Relevant parameters to report include presence of a walled-off collection, collection contents, proximity of the target collection to the gastrointestinal lumen, intervening vascular structures or vascular malformations, and presence of regional cystic structures. Novel stent applications in biliary and gastrointestinal drainage are summarized and examples are provided, including choledochoduodenostomy in biliary obstruction, cholecystogastrostomy in cholecystitis, and jejunogastrostomy in focal gastrointestinal obstruction. Finally, a pictorial review of imaging findings of complications including perforation, hemorrhage, displacement, occlusion, migration and mistargeting is provided. Minimally invasive EUS-guided endoluminal stenting is utilized in a growing variety of clinical applications. Radiologist familiarity with common and novel applications of EUS-guided stenting is invaluable in determining suitability for endoscopic management, evaluating treatment response and identifying potential complications.

Endoscopic Ultrasound-Guided Treatment of Pancreatic Cancer

The aim of this review is to evaluate the emerging role of endoscopic ultrasound (EUS) in the guidance of tumor-targeted therapies for patients with pancreatic cancer (PC). EUS-guided ablation, brachytherapy, fiducial marker placement, and antitumor agent injection have been described to date. EUS-guided fiducial placement for SBRT in pancreatic cancer has entered the clinical practice and is performed at many centers clinically without a research protocol. EUS-guided brachytherapy and RFA have been shown to be feasible and safe procedures, and potentially offer local disease control. Other potential techniques of EUS-guided treatment of pancreatic cancer are still considered experimental, with many of them appearing to be safe and reasonably well tolerated. However, their effectiveness and exact role in oncological treatment have yet to be established. Clinical trials with many of the techniques/agents described are underway and multicentric randomized trials with prospective design are eagerly awaited.

Endoscopic Ultrasound-Guided Treatments for Non-Variceal Upper GI Bleeding: A Review of the Literature.

Endoscopic injection of glues, clotting factors, or sclerosing agents is a well-known therapy for the treatment of non-variceal upper gastrointestinal bleeding (NVUGIB), but less is known about endoscopic ultrasound (EUS)-guided treatments. In this setting, literature data are scarce, and no randomized controlled trials are available. We performed a review of the existing literature in order to evaluate the role of EUS-guided therapies in the management of NVUGIB. The most common treated lesions were Dieulafoy’s lesions, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors (GISTs). Mostly, the treatments were performed as a salvage option after failure of conventional endoscopic hemostatic attempts, showing good efficacy and a good safety profile, also documented by Doppler monitoring of treated lesions. EUS-guided therapies may be an effective option in the treatment of refractory NVUGIB, thus avoiding radiological or surgical management. Nevertheless, available literature still lacks robust data.

Endoscopic ultrasound-guided treatment of gastric varices with coil embolization and absorbable hemostatic gelatin sponge: a novel alternative to cyanoacrylate.

Background and study aims Bleeding from gastric varices (GV) carries high morbidity and mortality. Current endoscopic therapies are premised on cyanoacrylate injection which is technically challenging and carries risk of embolization. We present a case series of endoscopic ultrasound (EUS)-guided coil injection in combination with hemostatic absorbable gelatin sponge (AGS) for treatment of bleeding gastric varices. Patients and methods This was a retrospective review of EUS-guided coil injection for bleeding GV since November 2017. After EUS-guided needle puncture, hemostatic coils were serially injected until significant reduction of Doppler flow. Under fluoroscopic guidance, test contrast was injected to confirm absence of run-off, at which time AGS, converted into a liquid slurry, was injected as hemostatic reinforcement. Results Ten consecutive patients underwent EUS-guided coil embolization reinforced by AGS. Technical success, defined as uncomplicated injection of coils and sponge was achieved in 100 % (10/10). Mean follow-up was 6 months 73–397 days; No patients rebled or required reintervention on GV. The complication rate was 10 % (1/10; severe abdominal pain without radiographic findings); otherwise, there were no cases of systemic embolization. Nine of 10 patients (90 %) had follow-up EUS (mean 80 days); 100 % (9/9) revealed near-obliteration of GV. Conclusion EUS-guided coil embolization in combination with hemostatic AGS is a novel method for management of bleeding GV with high clinical and technical success rates, low risk for complications and favorable safety profile when compared to cyanoacrylate. This technique theoretically minimizes embolic complications and need for re-intervention. Further studies are required to compare this modality.

Endoscopic management of local complications of chronic pancreatitis.

Endoscopic treatment of local complications in patients with chronic pancreatitis has gained ground over the surgical alternative in the last few years. The lower aggressiveness of endoscopic treatment, as well as the possibility to use it repeatedly in high-risk patients, has favored this development. In addition, the incorporation of new, highly accurate endoscopic therapeutic options such as pancreatoscopy-guided lithotripsy and endoscopic ultrasound-guided treatments make endoscopic treatment the first choice in many cases, despite discordant data in the literature. This article reviews the endoscopic treatment of the most common local complications of chronic pancreatitis, such as pancreatolithiasis, pseudocysts, and pancreatic, biliary, and duodenal ductal stenosis.

Endoscopic Ultrasound-Guided Treatment of Gastric Varices Using Coils and Cyanoacrylate Glue Injections: Results after 1 Year of Experience.

Background and Aims: Gastric varices (GVs) occur in 20% of patients with portal hypertension. GVs are associated with a 65% risk of bleeding over the course of 2 years and have a mortality rate of up to 20%. The standard treatment for GVs is obliteration with cyanoacrylate (CYA). This study presents our experience with combined therapy (vascular coils and CYA) under endoscopic ultrasound (EUS) guidance. Methods: 16 patients (9 male and 7 female) were included into our study. Etiology of portal hypertension included: portal vein thrombosis (PVT) (31.0%), isolated splenic vein thrombosis (SVT) (25.0%), alcoholic cirrhosis (12.5%), hepatitis C cirrhosis (19.0%), and alcoholic cirrhosis with PVT (12.5%). Varices type GOV-2 were diagnosed in 8 patients, type IGV-1 and IGV-2 in 6 and 2 patients, respectively. Indications for treatment were based on endoscopic and endosonographic evaluations of GVs. Inclusion and exclusion criteria were also specified. Technique depended on the size of varices (different size of coils + CYA additionally). The results were based on the achievement of technical success, therapeutic effects, and number of adverse events. Average follow-up period was 327 days. Results: From January to August 2017, 16 patients were treated with EUS-guided obliteration of GVs using vascular coils only or coils with CYA injections. 6 (37.5%) and 10 (62.5%) patients underwent primary and secondary prophylaxis for hemorrhage, respectively. Technical success was achieved in 15 patients (94.0%). Mean numbers of implanted coils and CYA volume during one procedure were 1.7 and 2 mL, respectively. Therapeutic success was achieved in all patients treated with the combination. There were no serious complications such as embolization or death due to the procedure. Three patients (19.0%) had transient abdominal pain and two (12.5%) had transient fever. 1 patient had clinical symptoms of gastrointestinal bleeding. Conclusions: Based on our retrospective research we have concluded, that EUS-guided implantation of intravascular coils combined with cyanoacrylate injections is an effective method of treatment with an acceptable number of complications.

594 – Endoscopic Ultrasound-Guided Treatment of Gastric Varices with Coil Embolization and Absorbable Gelatin Sponge: A Novel Alternative to Cyanoacrylate

594 – Endoscopic Ultrasound-Guided Treatment of Gastric Varices with Coil Embolization and Absorbable Gelatin Sponge: A Novel Alternative to Cyanoacrylate

Initial Experience of Endoscopic Ultrasound-Guided Interventions at a Large Tertiary Care Centre in a Developing Country

Initial Experience of Endoscopic Ultrasound-Guided Interventions at a Large Tertiary Care Centre in a Developing Country

Endoscopic Ultrasound-Guided Treatment of Gastric Varices With Coil Embolization and Absorbable Hemostatic Gelatin Sponge

Endoscopic Ultrasound-Guided Treatment of Gastric Varices With Coil Embolization and Absorbable Hemostatic Gelatin Sponge

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V - EUS-Guided Therapeutic Interventions (short version).

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).

Endoscopic ultrasound-guided interventions in special situations

Endoscopic ultrasound (EUS) was introduced in 1982 and has since become a popular advanced procedure for diagnosis and therapeutic intervention. Initially, EUS was most commonly used for the diagnosis of pancreatobiliary diseases and tissue acquisition. EUS was first used for guided cholangiography in 1996, followed by EUS-guided biliary drainage in 2001. Advancements in equipment and endoscopic accessories have led to an expansion of EUS-guided procedures, which now include EUS-guided drainage of intra-abdominal abscesses or collections, intra-vascular treatment of refractory variceal and nonvariceal bleeding, transmural pancreatic drainage, common bile duct stone clearance, enteral feeding tube placement and entero-enteric anastomosis. Patients with surgically altered upper gastrointestinal anatomies have greatly benefited from EUS also. This systematic review describes and discusses EUS procedures performed in uncommon diseases and conditions, as well as applications on more vulnerable patients such as young children and pregnant women. In these cases, routine approaches do not always apply, and thus may require the use of innovative and unconventional techniques. Increased knowledge of such special applications will help increase the success rates of these procedures and provide a foundation for additional advances and utilizations of the technique.