Endoscopic Ultrasound Guidance Research Articles

Outcomes and Post-removal Course of Lumen-Apposing Metal Stent Placement for Peripancreatic Fluid Collections: A Comparative Study of Pancreatic Pseudocysts and Walled-Off Necrosis.

Pancreatic fluid collections (PFCs) are common local complications of pancreatitis that may require interventional therapy. Endoscopic ultrasound (EUS)-guided transluminal drainage from the digestive tract, particularly with lumen-apposing metal stents (LAMS), is the first-line therapy due to its safety and efficacy. However, adverse events and post-removal courses remain uncertain. This study aimed to clarify the characteristics of LAMS placement and its removal, comparing pancreatic pseudocysts (PPC) and walled-off necrosis (WON). This single-center retrospective study included 23 patients who underwent transgastric LAMS placement for PFCs under EUS guidance. The patients were categorized into the PPC group (n = 14) and the WON group (n = 9). Backgrounds and clinical outcomes were analyzed and compared. The mean procedure time was 19 minutes in the PPC group and 25 minutes in the WON group, with no significant difference (p = 0.11). The overall incidence of adverse events during LAMS placement was 14.3% in the PPC group and 33.3% in the WON group, with no significant difference (p = 0.28), but the incidence of infection of noninfected fluid collections was 0% in the PPC group and 55.5% in the WON group, significantly higher in the WON group (p = 0.0016). At the time of LAMS removal, a double-pigtail plastic stent (DPS) was replaced in 53.8% of the PPC group and 57.1% of the WON group. Within one year, 57.1% of the replaced DPS in the PPC group and 25.0% in the WON group became dislocated. There were no adverse events due to the dislocation of the replaced DPS. Adverse events occurred in one patient in each group after LAMS removal: 7.7% in the PPC group and 14.3% in the WON group (p = 0.64), which consisted of peritonitis in the PPC group and recurrent infection of fluid collection in the WON group, and both of these events occurred when the replaced DPS was still in place after LAMS removal. Although there was no significant difference in the overall incidence of adverse events between PPC and WON, the incidence of infection after LAMS placement was significantly higher in WON. Regarding the replaced DPS, there were some cases of dislocation within one year, but there were no related adverse events. Adverse events occurred even after the removal of LAMS and replacement with DPS, so careful follow-up is required.

7360 An Overlooked Cause of Hypoglycemia and Weight Loss: Phosphodiesterase-4 Inhibitors

Abstract Disclosure: J. Aurora: None. K. Cappetta: None. R.M. Lechan: None. Background: Phosphodiesterase-4 (PDE-4) inhibitors, apremilast and roflumilast, are anti-inflammatory agents used to treat psoriasis, psoriatic arthritis, and COPD. These agents are commonly associated with gastrointestinal intolerance. However, patients may also experience profound weight loss (>10%). We present a case of a patient with T2DM who developed significant hypoglycemia and weight loss on apremilast. Clinical Case: A 57-year-old female with T2DM, obesity, psoriasis, and postsurgical hypothyroidism due to papillary thyroid cancer developed symptoms of hypoglycemia and weight loss over 1 month. Prior to this, her A1c was 7.8% and weight 104 kg on stable doses of metformin, repaglinide, and insulin glargine. Insulin glargine and repaglinide were both discontinued given her symptoms, yet hypoglycemia persisted, and she continued to lose weight. Further investigations into the cause of this sudden change were carried out. Initial fasting labs: BG 53 mg/dL, C-peptide 4.48 ng/mL (RR 0.8-3.85 ng/mL), insulin 12.8 uIU/mL (RR <18.4 uIU/mL), proinsulin 29.8 pmol/L (RR <18.8 pmol/L), A1c 6.8%, cortisol 24.9 mcg/dL (RR 4-22 mcg/dL), IGF-1 95 ng/mL (Z-score -0.7), and IGF-2 434 ng/mL (RR 267-616 ng/mL). 1 month later, hypoglycemia symptoms improved but she continued to lose weight. Fasting labs were repeated: BG 84 mg/dL, C-peptide 5.62 ng/mL, insulin 24.3 uIU/mL, proinsulin 35 pmol/L, and beta-hydroxybutyrate (BHB) 0.17 mmol/L (RR <0.28 mmol/L); metformin was subsequently stopped. A MR abdomen revealed a 2 cm cystic pancreatic lesion that showed atypical mucinous epithelium by biopsy under endoscopic ultrasound guidance. Gallium-68 DOTATATE-PET scan was unremarkable for an insulin-producing tumor. Two months off metformin, she had no further episodes of hypoglycemia, but her weight loss continued. Fasting labs were repeated: BG 129 mg/dL, C-peptide 5.15 ng/mL, insulin 18.2 uIU/mL, proinsulin 40.5 pmol/L, and BHB 0.27 mmol/L. Review of her medications identified apremilast as a potential culprit contributing to both her hypoglycemia and weight loss, as her symptoms started 1 month after starting apremilast. Over 9 months using apremilast, her A1c decreased by 1% and weight decreased by 27%. Hypoglycemia resolved off all glucose-lowering agents. Conclusion: Significant weight loss with apremilast may be explained by PDE-4 inhibition increasing cyclic AMP, which triggers the release of GLP-1 with subsequent effects on pancreatic beta cells. Apremilast has also been shown to significantly increase fasting insulin levels in patients without insulin resistance, as seen in our patient (1). Given these effects, patients may be at higher risk of hypoglycemia with concurrent glucose-lowering agents, particularly secretagogues. BG and weight need careful monitoring for patients with T2DM using PDE-4 inhibitors. Reference: 1. Ikumi K, et al. J Dermatol. 2022;49(4):e125-e126. Presentation: 6/3/2024

EUS-Guided Radiofrequency Ablation Therapy for Pancreatic Neoplasia.

Radiofrequency ablation (RFA) under endoscopic ultrasound (EUS) guidance has been developed and utilized over the last decade to provide the loco-regional treatment of solid and cystic pancreatic neoplastic lesions. The advantage of this approach relies on the close proximity of the EUS transducer to the target pancreatic lesion, which, coupled with the development of specifically designed RFA ablation devices, has made the procedure minimally invasive, with a clear reduction in adverse events as compared to the high morbidity of the surgical approach. EUS-RFA has been applied so far to pancreatic functional and non-functional neuroendocrine neoplasms, pancreatic ductal adenocarcinoma or metastases to the pancreas, and pancreatic neoplastic cysts. Excluding neuroendocrine tumors, for other indications, most of these procedures have been performed in patients who refused surgery or were at high surgical risk. More studies evaluating EUS-RFA in selected patients, not at surgical risk, are gradually becoming available and will pave the road to extend the indications for this therapeutic approach, also in association with other oncological therapies. The present manuscript will critically review the available evidence in the field of the EUS-guided RFA of solid and cystic pancreatic neoplasms.

Outcomes of pediatric endoscopic ultrasound-guided celiac plexus block: A single center pilot study.

Celiac plexus blocks (CPBs) using endoscopic ultrasound (EUS) guidance provide significant pain relief in adults with chronic pancreatitis. We present on EUS-guided CPB for pediatric patients with abdominal pain from chronic pancreatitis or severe functional dyspepsia necessitating clinically assisted nutrition and hydration. Patients who underwent EUS-CPB were included and followed prospectively at 2-, 4-, and 8-weeks postprocedure about pain, enteral tolerance, and school/activity attendance. Thirteen patients underwent EUS-guided CPB with a total of 21 procedures. In the pancreatitis cohort, mean pain relief was 11.7 weeks for those who responded. In the functional dyspepsia cohort, mean improvement (in either pain or enteral tolerance) was 4.8 weeks. Symptom improvement varied between the two cohorts. Acute recurrent/chronic pancreatitis patients demonstrated more sustained relief than the functional dyspepsia cohort. This study adds to the limited data investigating the utility of EUS-CPB as part of a multimodal treatment plan in pediatrics.

Endoscopic pancreatogastric anastomosis in the treatment of symptoms associated with inflammatory diseases of the pancreas.

The outflow of pancreatic juice into the duodenum is often impaired in pancreatic inflammatory diseases. The basis of interventional treatment in these cases is anatomical transpapillary access of the main pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP), which ensures the physiological outflow of pancreatic juice into the lumen of the digestive tract. However, in some patients, anatomical changes prevent transpapillary drainage of the main pancreatic duct. Surgery is the treatment of choice in such cases. To evaluate the effectiveness and safety of endoscopic pancreaticogastrostomy under endoscopic ultrasound (EUS) guidance. Retrospective analysis of treatment outcomes of all patients with acute or chronic pancreatitis who underwent endoscopic pancreatogastric anastomosis under EUS guidance in 2018-2023 at the Department of General, Gastroenterological and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland. In 9 patients [7 men, 2 women; mean age 53.45 (36-66) years], endoscopic pancreatogastric anastomosis under EUS guidance was performed because of the lack of transpapillary access during ERCP. Narrowing of the main pancreatic duct at the head of the pancreas was observed in 4/9 patients (44.44%). Pancreatic fragmentation (disconnected pancreatic duct syndrome) was diagnosed in 3/9 patients (33.33%). In 2/9 patients (22.22%), narrowing of the pancreatoenteric anastomosis was observed after pancreaticoduodenectomy. Technical success of endoscopic pancreaticogastrostomy was observed in 8/9 patients (88.89%). Endotherapeutic complications were observed in 2/9 patients (22.22%). Clinical success was achieved in 8/9 patients (88.89%). The mean follow-up period was 451 (42-988) d. Long-term success of endoscopic pancreatogastric anastomosis was achieved in 7/9 patients (77.78%). Endoscopic pancreaticogastrostomy under EUS guidance is an effective and safe treatment method, especially in the absence of transpapillary access to the main pancreatic duct.

EUS-guided hydrogel injection to separate pancreatic head carcinoma from duodenum for enhanced radiotherapy: Multi-site feasibility study.

Background and study aims The proximity of a pancreas head tumor to the duodenum often limits delivery of an ablative dose of radiation therapy. This study evaluated the feasibility and safety of using an injectable polyethylene glycol (PEG) hydrogel between the head of the pancreas and duodenum. Patients and methods In a multi-site feasibility cohort study of patients with localized pancreatic cancer, PEG hydrogel was injected under endoscopic ultrasound guidance to temporarily position the duodenum away from the pancreas. Procedure characteristics were recorded, including hydrogel volume and space created. Patients were monitored for adverse events (AEs) and radiotherapy toxicity. Results In all six intent-to-treat patients (four with borderline resectable, two with locally advanced disease), the ability to place and visualize PEG hydrogel and create space between the duodenum and the head of the pancreas was successful. There were no procedure-related AEs resulting in radiotherapy delay. There were no device-related AEs and no reports of pancreatitis. Conclusions PEG hydrogel was successfully placed, created space between the duodenum and the head of the pancreas, and was not associated with major toxicity. Enhancing radiotherapy for pancreatic cancer by using PEG hydrogel to create peri-duodenal space could have beneficial implications for treatment and warrants more exploration.

Fine-needle aspiration technique under endoscopic ultrasound guidance: A technical approach for RNA profiling of pancreatic neoplasms.

Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) has been a longstanding challenge. The prognosis of patients with PDAC depends on the stage at diagnosis. It is necessary to identify biomarkers for the detection and differentiation of pancreatic tumors and optimize PDAC sample preparation procedures for DNA and RNA analysis. Most molecular studies are done using paraffin-embedded blocks; however, the integrity of DNA and RNA is often compromised in this format. Moreover, RNA isolated from human pancreatic tissue samples is generally of low quality, in part, because of the high concentration of endogenous pancreatic RNAse activity present. To assess the potential of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to obtain specimens from pancreatic neoplasms for subsequent RNA molecular profiling, including next-generation sequencing (NGS). Thirty-four EUS-FNA samples were included in this study: PDAC (n = 15), chronic pancreatitis (n = 5), pancreatic cysts (n = 14), mucinous cysts (mucinous cystic neoplasia/intraductal papillary mucinous neoplasia) n = 7, serous cystic neoplasms n = 5, and pseudocysts n = 2. Cyst material consisted of cyst fluid and cyst wall samples obtained by through-the-needle biopsy (TTNB). Samples were stored at -80 °C until analysis. RNA purity (A260/230, A260/280 ratios), concentration, and integrity (RIN) were assessed. Real-time polymerase chain reaction was conducted on all samples, and small RNA libraries were prepared from solid mass samples. RNA was successfully extracted from 29/34 (85%) EUS-FNA samples: 100% pancreatic adenocarcinoma samples, 100% chronic pancreatitis samples, 70% pancreatic fluid cyst samples, and 50% TTNB samples. The relative expression of GAPDH and HPRT were obtained for all successfully extracted RNA samples (n = 29) including low-quality RNA specimens. Low concentration and nonoptimal RIN values (no less than 3) of RNA extracted from EUS-FNA samples did not prevent NGS library preparation. The suitability of cyst fluid samples for RNA profiling varied. The quality of RNA extracted from mucinous cyst fluid had a median RIN of 7.7 (5.0-8.2), which was compatible with that from solid neoplasms [6.2 (0-7.8)], whereas the quality of the RNA extracted from all fluids of serous cystic neoplasms and TTNB samples had a RIN of 0. The results demonstrate the high potential of EUS-FNA material for RNA profiling of various pancreatic lesions, including low-quality RNA specimens.

Role of imaging in evaluating the complications of endoscopic management of pancreatic fluid collections in acute pancreatitis.

Acute pancreatitis is associated with local and systemic complications. Pancreatic fluid collection (PFC) is the most common local complication. Infected or symptomatic PFCs need drainage. Endoscopic drainage (ED) is the first-line procedure for accessible PFCs adjacent to the stomach and duodenum. ED is performed under endoscopic ultrasound (EUS) guidance. The technical and clinical success rates of EUS-guided ED in well-encapsulated PFCs are high. ED of poorly encapsulated PFCs is associated with complications. Bleeding and perforation are the most common complications. Contrast-enhanced computed tomography is critical in planning ED and early detection and management of complications. With the increasing utilization of ED for PFC, the radiologist must be familiar with the ED techniques, types of stents, and the complications related to ED. In this review, we discuss the technical aspects of the ED as well as the imaging findings of ED-related complications.

Current status of endoscopic ultrasound-guided antitumor treatment for pancreatic cancer.

Endoscopic ultrasound (EUS) was developed in the 1990s and has significantly transformed pancreatic tumor diagnosis. Subsequently, EUS has rapidly shifted from being a purely diagnostic procedure to being used in a wide range of interventional procedures. Recently, new therapeutic techniques, such as EUS-guided fine needle injection (EUS-FNI) or radiofrequency ablation (RFA), have been developed to deliver various antitumor agents. Despite technological advancements, pancreatic cancer (PC) has a poor prognosis and improvements in treatment outcomes are urgently required. One of the reasons for the limited response to antitumor agents in PC is the abundant desmoplasia and hypovascular nature of the tumor, complicating drug delivery into the tumor. Thus, changing the tumor microenvironment may be important to enhance the effectiveness of chemotherapy, and direct injection of antitumor agents into the tumor under EUS guidance can help overcome treatment challenges in PC. Treatment approaches using the EUS-FNI or RFA technique are expected to further improve the prognosis of PC. Therefore, this study reviewed the existing literature on EUS-guided antitumor therapy, specifically highlighting its application in PC to address the current challenges and to identify potential advancements in the field.

Safety and effectiveness of consecutive 191 endoscopic ultrasonography-guided biliary drainage procedures: a single-center experience.

<b>Introduction:</b> The development of endoscopic ultrasonography (EUS) has enabled extra-anatomical transmural access to the bile ducts, thus making it possible to perform endoscopic biliary anastomoses with the gastrointestinal (GI) tract and obtain extra-anatomical transpapillary access. EUS provides an alternative to the existing methods of biliary drainage (BD) for cases in which endoscopic retrograde cholangiopancreatography (ERCP) is ineffective.<b>Aim:</b> This study aimed to evaluate the efficacy and safety of extraanatomical endoscopic biliary access methods for the treatment of benign and malignant biliary strictures.<b>Material and methods:</b> This retrospective analysis included treatment results of all patients with obstructive jaundice and biliary strictures who were treated endoscopically in our department between 2016 and 2023. The study group comprised patients in whom EUS-guided transmural access was used during ERCP because of biliary strictures and the lack of transpapillary access.<b>Results:</b> Twenty-eight patients (14.66%) underwent endoscopic transpapillary biliary stenting via a transmural approach under EUS guidance. The remaining 163 patients (85.34%) underwent extraanatomical transmural biliodigestive anastomosis. Technical success was achieved in 186 of 191 (97.38%) patients. Clinical success was achieved in 170 of 191 (89.01%) patients. Complications were reported for 32 of 191 (16.75%) patients, including fatal complications for 6 of 191 (3.14%) patients.<b>Conclusions:</b> Advanced endoscopic techniques involving EUS-guided transmural access are effective and safe for biliary strictures. They provide an alternative to other drainage techniques when ERCP is ineffective and improve the quality of life of patients undergoing palliative treatment for biliary strictures with unresectable cancer of the biliopancreatic area.

Endoscopic stenting for malignant gastric outlet obstruction: focusing on comparison of endoscopic stenting and surgical gastrojejunostomy.

Malignant gastric outlet obstruction (GOO) is a condition characterized by blockage or narrowing where the stomach empties its contents into the small intestine due to primary malignant tumors or metastatic diseases. This condition leads to various symptoms such as nausea, vomiting, abdominal pain, and weight loss. To manage malignant GOO, different treatment options have been employed, including surgical gastrojejunostomy (SGJ), gastroduodenal stenting (GDS) using self-expandable metallic stent (SEMS), and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ). This review focuses on comparing the clinical outcomes of endoscopic stenting (GDS and EUS-GJ) with SGJ for malignant GOO. Studies have shown that GDS with SEMS provides comparable clinical outcomes and safety for the palliation of obstructive symptoms. The choice between covered and uncovered SEMS remains controversial, as different studies have reported varying results. EUS-GJ, performed via endoscopic ultrasound guidance, has shown promising efficacy and safety in managing malignant GOO, but further studies are needed to establish it as the primary treatment option. Comparative analyses suggest that GDS has higher recurrence and reintervention rates compared to EUS-GJ and SGJ, with similar overall procedural complications. However, bleeding rates were lower with GDS than with SGJ. Randomized controlled trials are required to determine the optimal treatment approach for malignant GOO.

EUS-guided laser lithotripsy for pancreatic duct stones after failed conventional pancreatic endotherapy.

The central dogma of pain in patients with chronic pancreatitis revolves around the pathophysiology of ductal hypertension owing to stones that obstruct the pancreatic duct. Conventional modalities available to decompress the pancreatic duct are occasionally limited by failed selective pancreatic duct cannulation during endoscopic retrograde cholangiopancreatography. We describe a novel endoscopic approach of EUS-guided laser lithotripsy to assist in pancreatic duct (PD) stone fragmentation in two symptomatic patients with underlying chronic pancreatitis who had failed PD cannulation and extracorporeal shock wave lithotripsy (ESWL). In both cases, a 365-micrometer LightTrail TracTip Holmium laser fiber was advanced within a 19G endoscopic ultrasound aspiration needle (Expect Slimline (SL), Boston Scientific, Marlborough, Massachusetts, United States) under endoscopic ultrasound (EUS) guidance to fragment the PD stones. There were no procedure-related complications encountered and follow-up after 1 month of the procedure revealed significant reduction in abdominal pain scores. To the best of our knowledge, these are the first reported cases of EUS-guided laser lithotripsy performed for PD stones. Our approach of performing laser lithotripsy under EUS guidance obviates the need for an ESWL procedure; however, it is technically more challenging and requires precision to avoid injury to the pancreas. Further prospective studies are required to evaluate the safety and efficacy of this novel approach and its applicability as either a rescue procedure or in tandem with conventional pancreatic endotherapy modalities.

Obstructive jaundice: epidemiology, diagnosis and choice of optimal method of biliary decompression

Aim. To analyze epidemiological features and morbidity structure in obstructive jaundice, to estimate the results of diagnosis and treatment of this category of patients and to evaluate factors affecting the effectiveness of the treatment and diagnostic program.Materials and methods. The study was based on four-year experience of treatment of 484 patients with mechanical jaundice. Ultrasound, CT, MRI, endoscopic ultrasound, and cholangioscopy were used to diagnose the level of the obstruction and the causes of obstructive jaundice. The main method of decompression involved transpapillary interventions in 365 patients. Two patients underwent choledochoduodenostomy under endoscopic ultrasound guidance. Percutaneous transhepatic interventions and “rendezvous” method were applied in 82 cases.Results. The efficacy of transpapillary endoscopic retrograde procedures in obstructive jaundice accounted for 93.4%. Complications developed in 33 patients (8.4%) including postmanipulation pancreatitis – in 19 patients (4.9%), pancreatonecrosis – in 2 patients (0.5%), bleeding – in 9 patients (2.3%), retroduodenal perforation – in 2 patients (0.5%), Mallory–Weiss syndrome – in 1 patient (0.3%). The efficacy of antegrade percutaneous transhepatic interventions comprised 95.1%, while liver parenchyma bleeding developed in 3.7% of patients. In-hospital mortality amounted to 0.8% (malignant tumor progression).Conclusion. The increasing share of patients with mechanical jaundice in the structure of general surgical emergencies, as well as the need to use high-tech equipment for diagnosis and treatment, necessitate creating centers for treatment of patients with mechanical jaundice. Retrograde and antegrade minimally invasive surgeries for specific indications are considered to be the main methods of biliary decompression.

Endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: a comprehensive review.

Advancements in diagnostic radiology have amplified the incorporation of these techniques into routine clinical practice. Concurrently, the frequency of incidentally identifying pancreatic cystic lesions (PCLs) has surged. PCLs encompass diverse categories contingent upon their origin. Among them, branch duct-intraductal papillary mucinous neoplasms (BD-IPMN) and mucinous cystic neoplasms (MCN) are categorized as mucinous cystic lesions that have malignant potential. Even solid neoplasms occasionally show cystic degeneration. Therefore, precise differential PCL diagnosis is crucial to optimize clinical management strategies and detect malignant transformations. Endoscopic ultrasound (EUS) affords comprehensive visualization of the pancreas with high-resolution ultrasound, complemented by fine-needle aspiration (FNA) under real-time EUS guidance, which is a minimally invasive procedure for obtaining pathological samples. This synergy has established EUS and EUS-FNA as vital procedures in the management of PCLs, enabling differentiation of PCLs. Cyst fluid analysis has played a pivotal role in deciding the optimal management strategy. The efficacy of cytological analysis is limited by scant cytologic material. The "string sign" test evaluates fluid viscosity, and its simplicity warrants initial consideration. Amylase and tumor markers, such as CEA, have been studied, but they yield varied sensitivity and specificity. Glucose and genetic mutations (KRAS, GNAS) exhibit promise, while comprehensive genomic profiling underscores genetic insights. Through-the-needle biopsy and needle-based confocal laser endomicroscopy also show high diagnostic yield. EUS-FNA, however, entails risks like infection and needle tract seeding, emphasizing the need for proper utilization. Pancreatic cyst fluid analysis augments diagnostic accuracy and informs clinical decisions, making it a valuable adjunct to imaging.

Interventional vs surgical procedures in localized/nonmetastatic insulinomas (ablation vs surgery).

Localized insulinoma is an uncommon entity that can result in substantial morbidity due to the associated hypoglycemia. Recent studies have suggested an increase in the incidence of insulinoma in recent decades that may possibly be secondary to increased awareness, incidental diagnoses, and better diagnostic methods. Diagnosing and localizing insulinoma within the pancreas can be challenging, but advances in nuclear imaging may improve diagnostic accuracy. Delays in diagnosis are common, but once a localized insulinoma is diagnosed and appropriately treated, the long-term prognosis is excellent. Surgical resection is considered the standard of care management option for localized insulinoma, but tumor ablation with endoscopic ultrasound guidance has also been shown to be an effective and safe method for therapy.

A130 ENDOSCOPIC ULTRASOUND GUIDED THROMBIN INJECTION: A NOVEL TECHNIQUE IN THE MANAGEMENT OF RECURRENT UPPER GASTROINTESTINAL BLEEDING CAUSED BY GASTRODUODENAL ARTERY PSEUDOANEURYSMS

Abstract Background Gastroduodenal artery (GDA) aneurysm is a rare vascular condition that is potentially life-threatening. It is associated with significant morbidity and mortality and most often encountered in patients with chronic pancreatitis. Other etiologies including atherosclerosis, peptic ulcer disease, alcohol abuse, cholecystectomy and absence of celiac axis, have been reported. False and true GDA aneurysms account for about 1.5% of all visceral artery aneurysms however are associated with a risk of rupturing and hemorrhage up to 75%. Mainstay of GDA aneurysm management involves aneurysm repair with open surgery with vessel ligation or endovascular repair with coil embolization or stent placement, depending on the patient’s comorbidities and overall hemodynamic stability. The use of percutaneous thrombin injection via computed tomography (CT) and ultrasound has also been described in the literature and is being increasingly used to promote clot formation and pseudoaneurysm occlusion as a less invasive option. Purpose To present a case of endoscopic ultrasound guided thrombin injection as an effective and safe management strategy for GDA pseudoaneurysms. Method At this time, there are limited data in the literature on endoscopic ultrasound guided thrombin injection for pseudoaneurysms. To our knowledge, this is the first case report describing a patient with recurrent gastrointestinal bleeding from a duodenal ulcer, who had undergone multiple endoscopic and angiographic procedures, with subsequent development of a gastroduodenal pseudoaneurysm unrelated to pancreatitis which was successfully managed by occluding the pseudoaneurysm with thrombin injection under endoscopic ultrasound guidance. EUS guided thrombin injection is a viable alternative to traditional interventional radiology guided thrombin injection for management of pseudoaneurysms. Result(s) In clinic follow-up three weeks after thrombin injection, our patient continued to do clinically well, without abdominal pain or symptoms. Repeat CT angiogram demonstrated the GDA pseudoaneurysm had remained thrombosed, indicating successful endoscopic obliteration. He had no further signs of gastrointestinal bleeding. Conclusion(s) EUS guided thrombin injection is a novel approach that has been presented as an option in the management of bleeding gastroduodenal pseudoaneurysms, especially when radiology guided or surgical options are higher risk or have previously failed. The paucity of available data highlights the need for ongoing clinical studies comparing the different therapeutic strategies that can effectively and safely manage these rare but life-threatening vascular entities. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Endoscopic ultrasound-guided tissue acquisition beyond the pancreas.

Endoscopic ultrasound (EUS) offers the ability to obtain tissue material via a fine needle under direct visualization for cytological or pathological examination. Prior studies have looked at EUS tissue acquisition; however, most reports have been centered around lesions of the pancreas. This paper aims to review the literature on EUS tissue acquisition in other organs (beyond the pancreas) such as the liver, biliary tree, lymph nodes, and upper and lower gastrointestinal tracts. Furthermore, techniques for obtaining tissue samples under EUS guidance continue to evolve. Specifically, some of the techniques that endoscopists employ are suction techniques (i.e., dry heparin, dry suction technique, wet suction technique), the slow pull technique, and the fanning technique. Apart from acquisition techniques, the type and size of the needle utilized play a major role in the quality of samples. This review describes the indications for tissue acquisition for each organ, and also describes and compares the various tissue acquisition techniques, as well as the different needles used according to their shape and size.

Comparison of the Effects of Alcohol and Phenol Used for Celiac Neurolysis with Endoscopic Ultrasound in Patients with Pancreas Cancer: Retrospective Analysis

Objective: In this study we aimed to compare the efficacy of ethanol and phenol used in the EUS-guided celiac plexus neurolysis procedure on pain scores and complications. Material and Methods: Between January 2009 and June 2022, 28 patients who underwent celiac neurolysis underwent sedation via EUS (endoscopic ultrasonography) guidance in the endoscopy unit were included. We retrospectively analyzed the data of the EUS-guided celiac neurolysis procedures for pain management of patients with pancreatic cancer. Results: Patients in the alcohol group had lower pain scores. Conclusion: When alcohol and phenol-based neurolytic techniques were compared, better analgesic effect was obtained in the alcohol group.

Endoscopic ultrasound-guided gallbladder endoscopic mucosal resection: a pilot porcine study

Introduction Endoscopic ultrasound (EUS)-guided natural orifice transluminal gallbladder polypectomy provides a minimally invasive alternative to cholecystectomy. The study aimed to investigate the feasibility and safety of protocol for gallbladder endoscopic mucosal resection (gEMR) under EUS guidance using a porcine model. Material and methods Fifteen Bama mini pigs were randomly divided into the control (CG, n = 3) and experimental (EG, n = 12) groups. EUS-guided fine needle aspiration was performed in the CG and used to establish a gallbladder pathway for polyp resection under EUS guidance in the EG. Procedural safety was evaluated using routine blood and biochemical tests, microbial bile cultures, histopathological tests, and enzyme-linked immunosorbent assays for inflammatory adhesion factors. Results EUS-guided metal stents were successfully deployed in all 12 pigs. Two cases of stent displacement occurred postoperatively, and one pig died of infectious peritonitis on the first day after stent implantation. In 11 surviving experimental animals, mature gallbladder paths were formed at 7–14 days after gastro-cholecystostomy, through which gEMR of gallbladder polyps was successfully performed. There were no significant changes in levels of inflammatory and adhesion factors during the postoperative process. Conclusions EUS-gEMR may be a safe and effective minimally invasive treatment approach for gallbladder polyps.

Current uses of electro-cautery lumen apposing metal stents in endoscopic ultrasound guided interventions.

The electro-cautery lumen apposing metal stent (EC-LAMS) is a newly developed device that integrates the electro-cautery cyctotome with the one-step metal stent delivery and releasing system in recent years. LAMS was first designed to complete the drainage of pancreatic fluid collection under endoscopic ultrasound guidance, and the technological innovation of EC-LAMS has made more off-labeled indications of endoscopic intervention for gastrointestinal diseases realized, such as abdominal fluid drainage, bile duct, or gallbladder drainage through stomach or duodenum, gastrointestinal anastomosis, and the establishment of fistulous channel for further endoscopic operation when necessary. The unique feature of this metal stent is that it has the design of a saddle shape and a large lumen, and can almost connect the adjacent structures to minimize the risk of perforation and leakage. Compared with traditional LAMS, EC-LAMS, an advanced integrated device, can greatly simplify the endoscopic process, shorten the procedure time and reduce the technical difficulty, thus it can help endoscopists complete more complex endoscopic interventions. In this review, we discuss the state of art with regard to EC-LAMS and its endoscopic process, current indications, outcomes, adverse events, and future application prospects.