Linear Echoendoscope Research Articles

Failed endoscopic ultrasound-guided gallbladder drainage across the duodenal covered metallic stent salvaged by using a forward-viewing linear echoendoscope.

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Impact of Slim Linear Echoendoscope on the Practice of EUS.

Standard linear echoendoscopes have a large distal tip and bending radius, which can preclude adequate examination in some patients. We examined the impact of having available slim linear echoendoscopes (SLE) on our endoscopic ultrasound (EUS) practice. As a quality improvement measure, data on the need for the use of SLE were documented in 2000 consecutive procedures performed over a 10-month period from February to November 2022. When examination using a standard size echoendoscope failed due to technical limitations, the procedure was reattempted in the same session using a SLE. The main outcome was the impact of SLE, which was defined as the establishment of a new diagnosis or if findings altered treatment plan. A complete EUS examination failed in 23 of 2000 procedures (1.15%, 95% CI, 0.73-1.72%) performed using standard size echoendoscope (14 male, median age 73y [IQR 66 to 79]). The examination was technically successful when using SLE in 22 of 23 (95.6%) patients. SLE impacted clinical management in all 22 patients (100%) by establishing tissue diagnosis in 19 and/or altering subsequent treatment plan in 5. Adverse event of transient hypoxia was observed in one patient (4.3%). A very experienced EUS team required SLE in 1.1% of consecutive examinations. Our findings suggest that when used, 95% of patients benefitted as it had a significant impact on their clinical management.

Beyond boundaries: Feasibility of curved linear array echoendoscope in appendiceal neoplasm detection

We recently read with great interest a study by Zhang et al in the World Journal of Gastroenterology . In our practice, we focus specifically on examining appendiceal mucinous neoplasms (AMNs) with endoscopic ultrasound (EUS) using different scopes. AMNs are rare neoplastic lesions characterized by an accumulation of mucin inside a cystic dilatation of the appendix. Clinically, they can present as nonspecific acute appendicitis. AMNs can turn into a life-threatening condition, termed pseudomyxoma peritonei, in which the ruptured appendix causes accumulation of mucin in the abdomen. Therefore, accurate and rapid diagnosis of AMN is essential. EUS is able to confirm and stage AMNs; although, EUS examination was once limited to the rectal and anal regions due to the conventional oblique-view scopes. With the emergence of new forward-view linear echoendoscopes and instruments like EUS miniprobes and overtubes, the scope of examination is changing. Herein, we discuss the feasibility of using the curved linear array echoendoscopes to examine cecal and appendiceal orifice lesions.

A130 RETROGRADE ENDOSCOPIC ULTRASOUND-GUIDED ENTERO-ENTEROSTOMY USING A LUMEN-APPOSING METAL STENT FOR THE MANAGEMENT OF A HIGH-OUTPUT ENTEROCUTANEOUS FISTULA AND ILEAL STRICTURE IN A COMPLEX SURGICAL ABDOMEN

Abstract Background A 26-year-old male sustained significant traumatic thoracoabdominal injuries following a gunshot. He underwent several laparotomies, small bowel resections, an extended left hemicolectomy with end-colostomy formation, and a flap to close the abdomen. He subsequently developed a high-output enterocutaneous fistula (ECF) and loss of colostomy output. CT imaging confirmed an ECF from the ileum to the anterior abdominal wall and a severe ileal stricture distal to the fistula. Aims In the context of his complex surgical abdomen and proximity of the ECF to the abdominal flap, surgical re-intervention was deemed high-risk. He was placed on total parenteral nutrition and referred for endoscopic management. Methods Under fluoroscopic guidance, we injected methylene blue & contrast dye from the skin side of the ECF. A dilated segment of small bowel was filled, with no downstream passage of contrast (Fig 1A). Retrograde ileoscopy was performed with an Olympus pediatric colonoscope via the patient’s colostomy. 90 cm from the ileocecal valve (ICV), we encountered a benign enteric stenosis that could not be traversed. Contrast was injected, with fluoroscopy revealing a 10 cm long tortuous stenosis (Fig 1B), extending to the previously filled loop of small bowel. Given the length and characterof the stricture, endoscopic balloon dilation and enteral stenting were technically infeasible. Results We proceeded to retrograde endoscopic ultrasound (EUS)-guided entero-enterostomy creation. With the aid of a guidewire, and under endoscopic, fluoroscopic and endosonographic guidance, a linear echoendoscope was advanced into the ileum via the colostomy, cecum and ICV. 50 cm from the ICV, we identified an adjacent dilated loop of small bowel (Fig. 1C). Water was instilled through the ECF, with the endosonographic view demonstrating filling, thus indicating this location to be upstream from the ECF. A 19-gauge needle was punctured through, with subsequent aspiration of methylene blue (Fig. 1D). We then created an EUS-guided entero-enterostomy using a 15mm lumen-apposing metal stent (Hot-AXIOS; Boston Scientific, Massachusetts, USA; Fig. 1E). Passage of methylene blue & contrast through the stent confirmed accurate deployment (Fig. 1F&G). With both the ECF & stricture bypassed, the patient’s colostomy output returned and ECF output diminished. Conclusions Electrocautery-enhanced lumen apposition with metal stenting is well established. It can facilitate the formation of an anchored anastomosis across non-adherent luminal structures in a single-step fashion. Herein, we have reported a novel application of this technique in the management of a complex post-surgical trauma patient with a high-output ECF and deep enteric stenosis. Figure 1: Retrograde EUS-guided entero-enterostomy Funding Agencies None

Role of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and Gene Xpert

BackgroundMediastinal tubercular lymphadenitis is form of extrapulmonary tuberculosis [EPTB]. Clinical presentations are non-specific and diagnosis remains great clinical challenge. Microbiological and or histopathological evidences need to be present in order make diagnosis secure before initiation of anti-tubercular therapy (ATT). Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) provides tissue samples and aids management of this difficult to diagnosed entity. Current study describe role of EUS-FNA and Gene Xpert (GXP) in mediastinal tubercular lymphadenitis. MethodsRetrospective analysis of 72 patients with mediastinal lymphadenopathy who underwent EUS-FNA were carried out. Linear echoendoscope was used for evaluation mediastinum. EUS echo features of LNs were studied. Twenty two-G needle used was for aspiration tissue sample from pathologic lymph nodes (LNs). FNA samples were analysed by cytology, Acid-Fast Bacilli (AFB) staining and GXP study. All procedures were uneventful without any complications. ResultsForty two patients were diagnosed as tuberculosis (TB) following first EUS-FNA setting. Six patients underwent repeat EUS-FNA procedure following which another 3 were diagnosed as TB while remaining 3 started on empirical ATT based on additional supportive evidences. Forty five patients showed granulomatous inflammation on cytological analysis, AFB positivity noted in 16 (33.33%) patients while GXP in 26 (57.78%) patients. Rifampicin resistance detected in 3 ((6.25%) patients. All patients were followed clinico-radiologically for response to treatment. ConclusionTuberculous lymphadenitis is the most common cause of mediastinal lymphadenopathy in TB endemic countries. EUS-FNA provides microbiological and histopathological/cytological evidences in this difficult to diagnosed EPTB and thereby avoids empirical ATT.

Successful endoscopic ultrasound-guided hepaticogastrostomy using "mirror image technique" for obstructive jaundice with complete situs inversus viscerum.

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A rare case of pancreatic acinar cell carcinoma presenting a submucosal tumor.

A 66-year-old man, who underwent distal gastrectomy with Billroth I reconstruction for gastric cancer, regularly underwent upper endoscopy as a routine examination. Unlike 1 year earlier [Figure 1a], a submucosal tumor-like lesion was identified near the minor papilla [Figure 1b], but the opening of the minor papilla could not be confirmed. Computed tomography revealed a mass (26 mm × 10 mm) protruding from the duodenal wall into the duodenal lumen [Figure 2] without pancreatic duct dilation. EUS using a linear array echoendoscope showed that the hypoechoic and smooth-marginal mass adjacent to the pancreatic head [Figure 3a] and the accessory pancreatic duct could not be recognized. EUS using a miniature probe showed that the mass was mainly located in the muscularis propria of the duodenal wall [Figure 3b]. The initial diagnosis was a duodenal gastrointestinal stromal tumor; however, EUS-guided fine-needle biopsy of the mass revealed suspicious pancreatic acinar cell carcinoma (PACC). A pancreaticoduodenectomy was performed. Macroscopically, a gray-white mass with a 25-mm maximum diameter was found in the duodenal submucosa on the cut surface [Figure 4a]. The boundary between the mass and the pancreatic parenchyma was unclear. Predominant growth of the tumor was observed within the accessory pancreatic duct by loupe image [Figure 4b]. No invasive growth or cystic formation was found. The tumor cells having irregular, hyperchromatic nuclei and eosinophilic cytoplasm proliferated mainly in an acinar or tubular pattern [Figure 4c]. The neoplastic cells were diffusely positive for anti-trypsin [Figure 4d] and bcl-10, whereas they were negative for a neuroendocrine marker, chromogranin or synaptophysin. Finally, the pathological diagnosis was a PACC at stage TisN0M0.Figure 1: (a) Endoscopic image showing no abnormality of the duodenal wall and minor papilla 1 year ago. (b) Endoscopic image showing a submucosal tumor-like lesion near the original minor papillaFigure 2: Contrast-enhanced computed tomography showing a mass (arrow) protruding from the duodenal wall into the duodenal lumen located in contact with the pancreatic headFigure 3: (a) EUS using a linear array echoendoscope showing a hypoechoic and smooth-marginated mass outside the pancreatic head. (b) EUS using a miniature probe showing the mass mainly located in the muscularis propria of the duodenal wallFigure 4: (a) Gross examination of resected specimen revealed a gray-white, solid lesion mainly occupying the duodenal submucosa on the cut surface. (b) A tumor with intraductal growth was observed by loupe image of histologic specimen (H and E). Normal pancreatic parenchyma (arrow). (c) Tumor cells having irregular, hyperchromatic nuclei and eosinophilic cytoplasm proliferated resembling acini of the pancreas (H and E, × 200). (d) Immunohistochemically, the neoplastic cells were positive for anti-trypsin (×40)PACC is a rare pancreatic tumor,[1] which is typically a solid tumor with expansive growth.[2] A PACC that predominantly grows within the main pancreatic ducts is extremely rare.[3] There has not been any reported case of PACC growing in the accessory pancreatic duct and presenting a submucosal tumor. In this case, there are some hypotheses regarding the specific tumor appearance: PACC originating from (1) pancreatic parenchyma near the accessory pancreatic duct and (2) ectopic pancreas[4] or submucosal pancreatic parenchyma.[5] However, it is a limitation that it was difficult to prove the hypotheses. Authors’ contributions R.S. treated the patient and wrote the manuscript; H.K., H.N., S.H., T.M., K.S., T.Y., H.A., M.K., M.F., T.M., M.F., K.O., E.T., T.U., A.T., and A.I. treated the patient and contributed writing the manuscript; T.T. performed pathological diagnosis and contributed writing the manuscript; all authors approved the final manuscript. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Masaki Kuwatani is an Editorial Board Member of the journal. This article was subject to the journal’s standard procedures, with peer review handled independently of the editor and his research group.

EUS-directed transgastric endoscopy for upper gastrointestinal bleeding.

A 64-year-old man who had undergone a Roux-en-Y gastric bypass presented because of massive upper gastrointestinal bleeding. The diagnostic and initial therapeutic approach included an upper-endoscopy and colonoscopy without finding the bleeding source. After blood transfusions and hemodynamic stability was reached, a computed tomography angiography was performed. Finding an active extravasation of contrast in the duodenal bulb. After discussion of options, a EUS-directed transgastric endoscopy was proposed. A linear echoendoscope (GF-UCT180; Olympus America, Center Valley, Pa, USA) was advanced into the gastric pouch. Under US guidance, the excluded stomach was located. Under fluoroscopic and US guidance, the remnant stomach was punctured with a 19-gauge EUS needle. As a safety measure; sterile water, methylene blue, and contrast material were injected. Through endosonographic vision a 15-mm × 10-mm cautery-enhanced, lumen-apposing metal stent (LAMS, Axios; Boston Scientific, Natick, Mass, USA) was inserted [Figure 1] creating a gastrogastric fistula between the pouch and the remnant stomach. A gastroscope (GIF-HQ190, Olympus America) was then inserted, followed by a 12 mm CRE balloon (CRE™ Single-Use WIREGUIDED Balloon Dilator) used for dilatation [Figure 2]. The scope was advanced to the duodenal bulb, finding a Forrest IIa ulcer. Conventional endoscopic treatment was performed with submucosal epinephrine injection and mechanical hemostasis with clips Figure 3. The LAMS was left until it was verified that there was no rebleeding risk. Bariatric surgery modifies patient’s anatomy and physiology, bleeding duodenal ulcer are usually treated with urgent laparotomy or interventional radiology.[1] EUS-directed transgastric procedures may offer a minimally invasive, effective option, with less resource utilization in modified anatomy patients that require endoscopic access to gastric remnant for therapeutic procedures.[2,3] To the best of our knowledge, this was the first edge procedure used as a therapeutic measure for bleeding in patients with modified anatomy.Figure 1: EUS gastro-gastric fistulaFigure 2: LAMS ballon dilatationFigure 3: Conventional endoscopic treatmentDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Temporary EUS-guided gastrojejunostomy for gastric outlet obstruction caused by severe acute pancreatitis (with videos).

Gastric outlet obstruction (GOO) due to duodenal stricture after acute pancreatitis occurs in 5.7%, with two peaks, during the early phase or after 4 weeks.[1] Patients may require enteral and parenteral nutrition or surgical therapy when conservative treatment fails.[1] EUS-guided gastrojejunostomy (EUS-GJ) has emerged as an alternative for malignant GOO and a bridge therapy for benign causes,[23] including after acute pancreatitis as an unusual indication.[24] We present the case of a 73-year-old male with a history of severe acute pancreatitis 8 weeks earlier, with percutaneous drainage of 70 mm × 50 mm pancreatic fluid collection. He complained of oral intolerance. A computed tomography scan revealed a large gastric retention with two small pancreatic fluid collections [Figure 1]. Gastroscopy confirmed impassable duodenal inflammatory stenosis leading to severe gastric outlet gastrointestinal edema (GOGE) [Figure 2]. A nasojejunal tube was inserted downstream the jejunum but failed to achieve enteral nutrition so parenteral nutrition was initiated. He was referred to our unit to address GOO. A 0.035 mm guidewire was inserted through the duodenal stenosis downstream the jejunum using a gastroscope. After exchange for linear echoendoscope and distension of jejunum with water and contrast, the gastric wall was punctured and free-hand deployment of a cautery-enhanced 15 mm × 10 mm lumen-apposing metal stent (LAMS) was performed [Video 1]. However, an unplanned procedure event occurred as free perforation due to distal flange misdeployment outside the jejunum [Figure 3]. The LAMS was removed using rat-tooth forceps [Figure 4] and the procedure was repeated without finding the previous puncture site. Hence, a 15 mm × 10 mm LAMS was inserted allowing the EUS-GJ [Video 2]. Oral feeding was tolerated the next day, and the patient was discharged 6 days after uneventfully. A barium-meal radiography performed 54 days after confirmed adequate gastric emptying [Figure 5]. The LAMS was removed 3 months later and the patient underwent cholecystectomy 9 months later. He remained with any GOO symptoms throughout a 12-month follow-up.Figure 1: A computed tomography scan showing a large gastric distension together with a small fluid collection in the pancreatic headFigure 2: Endoscopic view of impassable duodenal inflammatory stenosis due to severe acute pancreatitisFigure 3: Endoscopic view of the misdeployed distal lumen-apposing metal stent flange after the first EUS-guided gastrojejunostomy attempt. Notice that the peritoneum can be observed across the lumen-apposing stentFigure 4: Radiological view of lumen-apposing metal stent removal using a rat-tooth forceps after misdeployment of distal flangeFigure 5: Radiological view of barium meal. An adequate gastric emptying is observed as the first and second image are compared. (a) The arrow indicates the pylorus. Notice that only a small amount of contrast pass to the duodenum with a second and third portion stenosis. The asterisk refers to the EUS-guided gastro-jejunal anastomosis. (b) Also, the lumen-apposing metal stent can be observed in situ in the right imageThis case suggests that temporary EUS-GJ is feasible and safe in some patients with GOGE after acute pancreatitis[3] as an alternative to indefinite LAMS placement.[5] Distal flange misdeployement noted intraprocedurally was successfully managed by immediate LAMS removal and repeat LAMS insertion across a new puncture tract. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic and M.I.Tech. He is also an Editorial Board Member of the journal. This article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research group.

Evolution of interventional endoscopic ultrasound.

Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.

Endoscopic Ultrasound-Guided Botox Injection for Refractory Anal Fissure.

Background: Anal fissures cause severe pain and can be difficult to treat. Medical therapy is initially used, followed by sigmoidoscopy-guided botox injections if the medical therapy is not successful. With this technique, however, it is not clear whether botox is injected into the muscle layer or submucosa. Aim: To evaluate the efficacy of EUS-guided botox injection directly into the internal sphincter. Methods: Consecutive patients with chronic anal fissure refractory to conventional endoscopic botulinum toxin type A injection were enrolled in the study. EUS was performed using a linear array echoendoscope, and a 25 G needle was used to inject botox. All patients were followed up at one- and two-month intervals. Results: Eight patients with chronic anal fissures were included in the study. Six patients had an excellent response to botox at the two-month interval using a visual analog pain scale, while one patient had a moderate response with a pain score reduction of 40%. One patient had no response. No complications were noted. An improvement in visual analog scale (pre-score > post-score) was statistically significant at the p < 0.01 level. Conclusion: EUS-guided botox injection into the internal sphincter appears to be a promising technique for patients with refractory anal fissure with pain.

Use of an endoscopic attachment device for duodenal stricture dilation

A 75-year-old man with stage IV non–small–cell lung cancer was incidentally found to have a duodenal stricture during EUS to evaluate biliary dilation. The stricture was unable to be traversed with the linear echoendoscope or an adult upper endoscope despite through-the-scope balloon dilation from 8 to 12 mm. The results of analysis of stricture biopsy specimens were negative for malignancy and of gastric biopsy specimens were negative for Helicobacter pylori infection. Four months later, the patient experienced symptoms of gastric outlet obstruction.

S374 Endoscopic Coiling of Mesenteric Varices Causing Stomal Bleeding Caused by Extensive Portal Vein and Superior Mesenteric Thrombus

Introduction: Ectopic varices are collateral vessels located outside the gastro-esophageal area. Small bowel varices, while an uncommon result of portal hypertension can be a life-threatening cause of gastrointestinal bleeding. We present a case of refractory stomal bleeding secondary to mesenteric varices, treated with endoscopic ultrasound (EUS) guided coiling. Case Description/Methods: A 54-year-old male presented with history of ulcerative colitis status post proctocolectomy and ileostomy, primary sclerosing cholangitis (PSC), and auto-immune hepatitis (AIH) overlap syndrome treated with a deceased donor liver transplant in 2019. This was further complicated by portal hypertension secondary to portal vein and superior mesenteric vein thrombus. The patient presented with refractory stomal bleeding at this ileostomy site requiring multiple blood transfusions. On CT imaging, prominent mesenteric varices extending to the area of the stoma were noted. An interventional radiology (IR) approach from the portal system was not feasible given thrombosis in the portal vein and superior mesenteric vein. Percutaneous IR approach was also felt to be suboptimal given the depth of the peri-stomal varices. After a multidisciplinary discussion, the patient underwent ileoscopy with EUS guided coiling of the terminal/culprit branches of the mesenteric varices. The linear echoendoscope was introduced through the ileostomy and advanced approximately 5-10cm. Multiple tubal anechoic structures consistent with varices were noted with flow seen on doppler examination. This was confirmed on pulse wave doppler. A large feeding variceal vein towards the patient’s left side was punctured with a 22G needle. Saline was injected and it was visualized on EUS to confirm location. Next, embolization coils (8mm x 2, 10mm x1) were inserted for varix eradication. Reduced flow downstream of the coiling site was confirmed on doppler exam after embolization. Brief fluoroscopic images showed appropriate placement of coils in the patients right lower quadrant, without any migration. There was no significant flow toward the lumen on EUS after coiling. Since this procedure, the patient’s stomal bleeding resolved. (Figure) Discussion: Small bowel varices in the setting of significant portal hypertension are a rare but clinically significant cause of gastrointestinal bleeding. EUS-guided interventions such as coil embolization can be an effective treatment modality, especially in patients who are poor interventional radiology candidates. Watch the video at https://tinyurl.com/ACGAbstractS374Figure 1.: (1a) Prominent mesenteric varices extending into the ostomy (1b) EUS-guided coil embolization (1c) Status post successful endoscopic coil embolization

S2876 To the Duodenum, and Beyond! Using the BougieCap for Duodenal Stricture Dilation

Introduction: Benign duodenal strictures are typically caused by peptic ulcer disease, caustic ingestion, surgical anastomoses, or inflammatory bowel disease. Treatment of benign strictures usually involves endoscopic dilation using through-the-scope (TTS) balloon dilators with or without fluoroscopy. TTS balloon dilators allow visualization during dilation, but they do not provide haptic feedback. The BougieCap dilator is a newer device that attaches to the endoscope and allows direct visual and haptic feedback during dilation. While it is generally used for dilation of esophageal strictures, this report describes its use for dilation of a benign duodenal stricture. Case Description/Methods: A 75-year-old male with stage IV non-small cell lung cancer on immunotherapy was found to have biliary dilation on imaging. He subsequently underwent endoscopic ultrasound which incidentally revealed a duodenal stricture at the junction of the first and second portions of the duodenum. The stricture was unable to be traversed with the linear echoendoscope or an adult upper endoscope. TTS balloon dilation from 8 to 12 mm was performed, however, the adult upper endoscope was still unable to traverse the stricture. Biopsies of the stricture were obtained and were negative for malignancy and gastric biopsies did not reveal any evidence of Helicobacter pylori infection. Approximately 4 months later, the patient developed progressive nausea and vomiting. Upper endoscopy again showed the duodenal stricture which was unable to be traversed. The decision was made to use the BougieCap device for dilation. The stricture was then sequentially dilated from 10 to 12 mm using the BougieCap with direct visualization of mucosal disruption during dilation as expected (Figure). The adult upper endoscope was then able to traverse the stricture easily. There were no procedural complications or adverse effects and the patient reported improvement in his symptoms. Discussion: Benign duodenal strictures are typically treated with endoscopic dilation using TTS balloon dilators, although this method is limited by the lack of haptic feedback or complete visualization in some cases. In this case, TTS balloon dilation was ineffective for initial stricture dilation, thus the BougieCap was used for more precise dilation under direct visualization. While the BougieCap is generally used for esophageal stricture dilation, it may also serve as a safe and effective method to dilate refractory benign duodenal strictures.Figure 1.: Endoscopic image of BougieCap dilation of the duodenal stricture.

S2827 Endoscopic Full Thickness Resection of a Sigmoid Colon GIST Diagnosed by EUS FNA

Introduction: Subepithelial lesions of colon are often encountered during colonoscopy with lipoma being a common etiology, with other etiologies such as neuroendocrine tumors, leiomyoma, schwannoma, and GIST being rare. While a lipoma can be diagnosed by endoscopic appearance, pillow sign, and fat on biopsy; a diagnostic dilemma is presented if these findings are not present. EUS can be used for lesions that are within reach of an echoendoscope, but the sonographic appearance may still not be diagnostic without tissue sampling. This is a case of a subepithelial lesion in the sigmoid colon noted on colonoscopy that was diagnosed as a gastrointestinal stromal tumor by EUS FNA. Case Description/Methods: A 67 year old man was noted to have a one centimeter smooth round lesion in his sigmoid colon on screening colonoscopy. The endoscopic appearance was consistent with a subepithelial lesion. A pillow sign was negative, showing a firm mobile mass. He was referred for endoscopic ultrasound. A radial echoendoscope was used to localize the lesion. It was round, well demarcated, hypoechoic, and originated in the fourth layer (muscularis propria). The radial scope was exchanged for a linear echoendoscope and FNA was performed using a 20 gauge biopsy needle. Pathology showed a spindle cell lesion that was positive for CD 117 staining consistent with a gastrointestinal stromal tumor. Multidiscipline discussion with colorectal surgery was had, and the decision to proceed with endoscopic resection using an over the scope clip to perform full thickness resection. Following the resection the patient had some post-procedure pain and was hospitalized for observation, treated with antibiotics, and serial imaging. No perforation was noted. Final pathology showed a 1.7cm low grade GIST with positive microscopic margins. Multidiscipline discussion at tumor board recommends continued surveillance for the low grade GIST. (Figure) Discussion: Colonic GISTs are rare lesions with variable clinical courses. Full thickness endoscopic resection is an option using either an over the scope clip or dedicated full thickness resection device, or surgery are available options for management. Size, location, and multidiscipline discussion are needed to determine the best management strategy.Figure 1.: 4th layer hypoechoic lesion, sigmoid colon.

No relation between adenosine triphosphate after manual cleaning and presence of microorganisms on endoscopes after automated high-level disinfection.

Background and study aims Adenosine triphosphate (ATP) tests are increasingly used to detect biological material; however, their reliability to detect bacterial contamination in endoscopes is not proven. We investigated the predictive value of ATP tests after manual cleaning for presence or absence of microorganisms as shown by culture after automated high-level disinfection (HLD) in duodenoscopes and linear echoendoscopes (DLEs). Patients and methods After manual cleaning, ATP tests were performed on swab samples taken from the detachable cap and forceps elevator, and on flush samples of the DLE working channels. These results were compared to the growth of any microorganisms in cultures acquired after automated HLD. ATP tests with > 200 relative light units (RLU) were considered positive. Receiver operator characteristic (ROC) curves were used to compare the RLU levels with microbial presence in cultures. Results In total, 903 procedures were performed involving 26 distinct DLEs. Depending on sample site, 20.8 % (cap) to 63.8 % (channel brush) of the ATP negative samples were accompanied by positive post-HLD cultures. 54.4 % of the cap samples with a positive culture (growth of any kind of microorganism) and 91.8 % of the channel samples with a positive culture had a negative ATP test after manual cleaning. ROC curves per sample site, DLE type and microorganism type all had area under the curves below 0.6. Conclusions In our study, ATP tests performed after manual cleaning could not predict presence or absence of microorganisms after automated HLD as shown by culture. More than half of the positive cultures were preceded by a negative ATP test.

Impact of endoscopic ultrasound-guided gallbladder drainage on reducing costs of reintervention and unplanned readmission: a budget impact analysis.

Background and study aims Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is the preferred treatment for patients with acute calculous cholecystitis who are unfit for surgery. The aim of this study was to perform a cost-effective analysis (CEA) comparing EUS-GBD with percutaneous gallbladder drainage (PT-GBD). Patients and methods CEA was performed on patients recruited for our prior randomized controlled trial. A budget impact model was developed to compare the base-case and scenario of EUS-GBD applications. The costs including peri-procedure and intra-procedure, reinterventions, expenses associated with treatment of adverse events (AEs), costs of hospital stay, subsequent clinic follow-up, and unplanned readmission were included. Results PT-GBD had a lower total procedure cost per patient (USD$4,375.00) than EUS-GBD (USD$9,397.44). For EUS-GBD, the cost of cautery-enhanced lumen-apposing stent accounted for the major part of the expense (USD$4,910.26). EUS-GBD resulted in a lower expected cost (USD$108.26 vs USD$1,601.54) for a re-procedure. The expected cost per patient in unplanned readmissions in the EUS-GBD group (USD$450.00) was lower than that in the PT-GBD group (USD$1,717.56). Based on the budget impact analysis, the net budget impact per year of introducing EUS-GBD to replace PT-GBD was higher (USD$16,424.10 vs USD$11,433.08). The net budget impact was most sensitive to the cost of stent and linear echoendoscope used in EUS-GBD. Conclusions The net budget impact per year was higher for introducing EUS-GBD. The cost of the stent accounted for the major cost difference between the two procedures. EUS-GBD saved on the cost in management of AEs, reinterventions, and unplanned readmissions but these did not offset the cost of the stent.

Endoscopic ultrasound guided gastroenterostomy: literature review

Mantas Markauskas1 1Vilnius City Clinical Hospital, Vilnius, Lithuania Abstract Background. The first echoendoscope was introduced only as diagnostic tool in 1980 and it was mainly used to diagnose tumors, located in mediastinum, pancreas, liver or biliary tree. Therapeutic procedures using endoscopic ultrasound became possible only in 1991, when first linear echoendoscope and needle compatible with […]

Endoscopic ultrasound guided biliary drainage: literature review

Mantas Markauskas1 1Vilnius City Clinical Hospital, Vilnius, Lithuania Abstract Background. The first echoendoscope was introduced only as diagnostic tool in 1980 and it was mainly used to diagnose tumors, located in mediastinum, pancreas, liver or biliary tree. Therapeutic procedures using endoscopic ultrasound became possible only in 1991, when first linear echoendoscope and needle compatible with it were introduced. During past two decades echoendoscope and its accessories were improved, therefore complex therapeutic procedures using endoscopic ultrasound, such as gallbladder and biliary drainage, pancreatic duct and peripancreatic fluid drainage, pancreatic tumor ablation, brachytherapy, celiac plexus neurolysis, gastroenterostomy and many others, became possible. Aim. To discuss the recent literature describing endoscopic ultrasound guided biliary drainage. Procedure is discussed in terms of its indications, technique, results and adverse events. Methods. The literature search was performed in the PubMed database by entering relevant keywords in various combinations into the regular and advanced search fields, as well as using the bibliographies of the articles found. A total of 38 publications were found during the review, with 24 scientific publications based on the inclusion criteria. Conclusion. Literature indicates that endoscopic ultrasound guided biliary drainage can be safely performed on patients with biliary obstruction after failed endoscopic retrograde cholangiopancreatography. Present studies allow to conclude that endoscopic ultrasound guided biliary drainage is safe and efficient. However, in order to confirm endoscopic ultrasound guided biliary drainage as first-line treatment on patients with biliary obstruction after failed endoscopic retrograde cholangiopancreatography, further large prospective multicenter studies are needed. Keywords: endoscopic ultrasound, therapeutic procedures, biliary drainage.

Impact of endoscopic ultrasound examination for deep esophageal collateral veins evaluation in liver cirrhosis patients prior to endoscopic treatment: A case series

AbstractAimThe presence of esophageal collateral veins (ECV) has been reported to be associated with the recurrence of esophageal varices (EV) and bleeding in liver cirrhotic (LC) patients. This study aimed to see the potential clinical value of deep collateral veins assessment using endoscopic ultrasound (EUS) in liver cirrhotic patients with EV.MethodsDuring 6 months period, a prospective study is conducted, where we identified LC patients who were admitted for esophagogastroduodenoscopy (EGD) screening at the Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Jakarta. ECV was examined using EUS. Patients were excluded if they had (1) liver malignancy, (2) history of ligation or glue injection, or (3) portal or splenic vein thrombus. We collected demographic data, medical history, data pertaining to use of nonselective beta blocker (NSBB), and laboratory, imaging, and endoscopy results. EGD was performed using a gastroscope (EG29‐i10, 3.2 mm Pentax Medical) while EUS was performed using a linear array echoendoscope (EG‐3870UTK, 3.8 mm, Pentax Medical) before band ligation or glue injection.ResultsThere were 20 LC patients included in this study, where 15 (75%) of patients were classified with Child–Pugh (CP)‐A and five (25%) of patients with CP‐B. The most common aetiologies were hepatitis B in seven (35%) patients and hepatitis C in nine (45%) patients. The EV with peri‐ or para‐esophageal veins (PEEV or PAEV) were detected in 65% of patients. None of the LC patients with no EV showed the presence of ECV. PEEV or PAEV were detected in grades 1–3 EV.ConclusionEUS examination can give a better evaluation before managing gastroesophageal varices through deep ECV detection in LC patients.