Juan J. Vila

Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey.

BACKGROUND EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown. OBJECTIVE To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist. DESIGN Multicenter retrospective study. SETTING Public health system hospitals with experience in ESCP in Spain. PATIENTS A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures. INTERVENTION ESCP. MAIN OUTCOME MEASUREMENTS Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed. RESULTS A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula. LIMITATIONS Retrospective study. CONCLUSION Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

Multicenter study on endoscopic ultrasound-guided expandable biliary metal stent placement: Choice of access route, direction of stent insertion, and drainage route

Endoscopic ultrasonography‐guided biliary drainage (EUS‐BD) using expandable biliary metal stents has emerged as an acceptable alternative in patients with failed endoscopic retrograde cholangiopancreatography for malignant biliary obstruction. However, there is no consensus over the preferred access route (transhepatic or extrahepatic), direction of stent insertion (antegrade or retrograde) or drainage route (transluminal or transpapillary) in patients potentially suitable for multiple methods. The present study compares success and complication rates in patients undergoing EUS‐BD via different methods.

Endosonography-guided cholangiopancreatography as a salvage drainage procedure for obstructed biliary and pancreatic ducts

Endoscopic ultrasound allows transmural access to the bile or pancreatic ducts and subsequent contrast injection to provide ductal drainage under fluoroscopy using endoscopic retrograde cholangiopancreatography (ERCP)-based techniques. Differing patient specifics and operator techniques result in six possible variant approaches to this procedure, known as endosonography-guided cholangiopancreatography (ESCP). ESCP has been in clinical use for a decade now, with over 300 cases reported. It has become established as a salvage procedure after failed ERCP in the palliation of malignant biliary obstruction. Its role in the management of clinically severe chronic/relapsing pancreatitis remains under scrutiny. This review aims to clarify the concepts underlying the use of ESCP and to provide technical tips and a detailed step-by-step procedural description.

Role of endoscopic ultrasound in the diagnosis of pancreatic cancer.

Endoscopic ultrasonography (EUS) with or without fine needle aspiration has become the main technique for evaluating pancreatobiliary disorders and has proved to have a higher diagnostic yield than positron emission tomography, computed tomography (CT) and transabdominal ultrasound for recognising early pancreatic tumors. As a diagnostic modality for pancreatic cancer, EUS has proved rates higher than 90%, especially for lesions less than 2-3 cm in size in which it reaches a sensitivity rate of 99% vs 55% for CT. Besides, EUS has a very high negative predictive value and thus EUS can reliably exclude pancreatic cancer. The complication rate of EUS is as low as 1.1%-3.0%. New technical developments such as elastography and the use of contrast agents have recently been applied to EUS, improving its diagnostic capability. EUS has been found to be superior to the recent multidetector CT for T staging with less risk of overstaying in comparison to both CT and magnetic resonance imaging, so that patients are not being ruled out of a potentially beneficial resection. The accuracy for N staging with EUS is 64%-82%. In unresectable cancers, EUS also plays a therapeutic role by means of treating oncological pain through celiac plexus block, biliary drainage in obstructive jaundice in patients where endoscopic retrograde cholangiopancreatography is not affordable and aiding radiotherapy and chemotherapy.

Diagnostic yield and reliability of endoscopic ultrasonography in patients with idiopathic acute pancreatitis

Abstract Objectives. To evaluate the diagnostic yield of endoscopic ultrasonography (EUS) in patients with idiopathic acute pancreatitis (IAP), find factors predictive of a positive EUS finding in these patients and investigate whether these etiological findings are maintained during follow-up. Material and methods. We performed EUS in patients with IAP between July 2004 and August 2007. We recorded epidemiological data, the number and severity of previous bouts of pancreatitis and gallbladder status. Results. A total of 44 patients were included in the study. EUS was normal in seven patients (16%). In the remaining 37 patients (84%) we found cholelithiasis (n = 3), microlithiasis (n = 20), chronic pancreatitis (n = 14), pancreas divisum (n = 3), pancreatic mass (n = 1), apudoma (n = 1), cystic tumor of the pancreas (n = 2) and choledocholithiasis (n = 2). Positive EUS findings were not influenced by sex, severity of pancreatitis or recurrent disease. Patients aged < 65 years (age > or < 65 years: 73.9% versus 95.2%; P = 0.097) and patients with gallbladder in situ (cholecystectomy versus non-cholecystectomy: 63.6% versus 90.9%; P = 0.054) showed a tendency to have positive EUS findings. Mean follow-up was 28.95 ± 10.86 months (range 12–64 months; median 28 months). During follow-up the etiological diagnosis was changed in two patients, lowering the diagnostic yield to 79%. Conclusions. EUS identified the cause of IAP in 79% of patients. Patients with gallbladder in situ and patients aged < 65 years showed a tendency to have positive EUS findings. The majority of the diagnoses provided by EUS are maintained during follow-up and seem to be reliable.

Endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) enables en bloc resection of certain types of early gastrointestinal neoplasias with the help of different knives, of which the insulated-tip, or IT, knife is the most frequently used. The IT knife is a variant of the needle knife, tipped with a ceramic ball to prevent cutting through muscularis propria. ESD is applied throughout the gastrointestinal tract, mostly in the stomach and colon. Although widely used in Japan, reports on ESD from western countries are infrequent. A total of six cases of ESD from two Czech gastroenterology centers are presented here.

Pancreatic pseudocyst drainage guided by endoscopic ultrasound

Pancreatic pseudocysts can be managed conservatively in the majority of patients but some of them will require surgical, endoscopic or percutaneous drainage. Endoscopic drainage represents an efficient modality of drainage with a high resolution rate and lower morbidity and mortality than the surgical or percutaneous approach. In this article we review the endoscopic pseudocyst drainage procedure with special emphasis on technical details.

Endoscopic ultrasound-guided drainage of pelvic collections and abscesses.

Pelvic abscesses are usually the end stage in the progression of an infection. They may occur from surgical complications, generalized abdominal infections such as appendicitis or diverticulitis, or from localized infections such as pelvic inflammatory disease or inflammatory bowel disease. Although surgery has been considered as the treatment of choice by some authors, pelvic abscesses can be managed by non-invasive methods such as ultrasound and computed tomography-guided drainage. The development of therapeutic linear echoendoscopes has allowed the endoscopist to perform therapeutic procedures. Recently, endoscopic ultrasonography (EUS)-guided drainage of pelvic collections has been demonstrated to be feasible, efficient and safe. It allows the endoscopist to insert stents and drainage catheters into the abscess cavity which drains through the large bowel. This article reviews technique, current results and future prospects of EUS-guided drainage of pelvic lesions.

Endoscopic ultrasonography and idiopathic acute pancreatitis

Idiopathic acute pancreatitis is a diagnostic challenge for gastroenterologists. The possibility of finding a cause for pancreatitis usually relies on how far the diagnostic study is taken. Endoscopic explorations such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography can help to determine the cause of pancreatitis. Furthermore, microscopic bile examination and magnetic resonance cholangiopancreatography can also be helpful in the work up of these patients. In this article an approximation to the diagnostic approach to patients with idiopathic acute pancreatitis is made, taking into account the reported evidence with which to choose between the different available explorations.

Endoscopic and anesthetic feasibility of EUS and ERCP combined in a single session versus two different sessions.

AIM To discuss the feasibility of single session endoscopic ultrasonography (EUS) to discuss and endoscopic retrograde cholangiopancreatography (ERCP) execution. METHODS Retrospective endoscopic and anesthetic outcome comparison of performing both EUS and ERCP in a single endoscopic session (Group I) versus performing each procedure in two different sessions (Group II) was made. The following variables were evaluated: epidemiological variables, American Society of Anesthesiologists Physical Status Classification (ASA) level, procedural time, propofol dose, anesthetic complications, endoscopic complications and diagnostic yield, and therapeutic procedures on both groups. T-student, Chi-Square and Fisher test were used for comparison. RESULTS We included 39 patients in Group I (mean age: 69.85 ± 9.25; 27 men) and 46 in Group II (mean age: 67.46 ± 12.57; 25 men). Procedural time did not differ significantly between both groups (Group Ivs Group II: 93 ± 32.78 vs 98.98 ± 38.17; P >0.05) but the dose of propofol differed (Group I vs Group II: 322.28 ± 250.54 mg vs 516.96 ± 289.06 mg; P = 0.001). Three patients had normal findings on both explorations. Three anesthetic complications [O(2) desaturation (2), broncoaspiration (1)] and 9 endoscopic complications [pancreatitis (6), bleeding (1), perforation (1), cholangitis (1)] occurred without significant differences between both groups (P > 0.05). We did not find any significant difference regarding age, sex, ASA scale level, diagnostic yield or therapeutic maneuvers between both groups. CONCLUSION The performance of EUS and ERCP in a single session offers a similar diagnostic and therapeutic yield, does not entail a higher complication risk and requires a significantly smaller dose of propofol for sedation compared with performing each exploration in a different session.