Kunal Karia

EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach

BACKGROUND ERCP is challenging in patients with Roux-en-Y gastric bypass. Using EUS to gain access to the excluded stomach and subsequently performing transcutaneous ERCP was described recently. OBJECTIVE We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). DESIGN Single-center case series. SETTING Tertiary center with expertise in EUS-guided procedures. PATIENTS Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. INTERVENTIONS A linear echoendoscope was used to access the excluded stomach. A LAMS was deployed over a wire to create a gastrogastric or jejunogastric fistula. A duodenoscope was then passed through the LAMS and conventional ERCP was performed. MAIN OUTCOME MEASUREMENTS Technical and clinical success rates as well as adverse events. RESULTS EUS-guided creation of a gastrogastric or jejunogastric fistula via placement of a LAMS was successful in all cases (100%). The ability to perform ERCP through the fashioned fistula during the index procedure was successful in 3 of 5 cases (60%). Two LAMS dislodgments requiring restenting were observed. No major adverse events were observed. No weight regain occurred. The median procedure time was 68.0 minutes. LIMITATIONS Small sample, single-institution experience. CONCLUSION The internal EDGE procedure may offer a cost-effective, minimally invasive option for a common problem in a growing patient demographic. Further refinement of the technique is required to minimize adverse events. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01522573.).

Management of pancreatic fluid collections: A comprehensive review of the literature

Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.

Probe-based confocal laser endomicroscopy for indeterminate biliary strictures: refinement of the image interpretation classification.

Background. Accurate diagnosis and clinical management of indeterminate biliary strictures are often a challenge. Tissue confirmation modalities during Endoscopic Retrograde Cholangiopancreatography (ERCP) suffer from low sensitivity and poor diagnostic accuracy. Probe-based confocal laser endomicroscopy (pCLE) has been shown to be sensitive for malignant strictures characterization (98%) but lacks specificity (67%) due to inflammatory conditions inducing false positives. Methods. Six pCLE experts validated the Paris Classification, designed for diagnosing inflammatory biliary strictures, using a set of 40 pCLE sequences obtained during the prospective registry (19 inflammatory, 6 benign, and 15 malignant). The 4 criteria used included (1) multiple thin white bands, (2) dark granular pattern with scales, (3) increased space between scales, and (4) thickened reticular structures. Interobserver agreement was further calculated on a separate set of 18 pCLE sequences. Results. Overall accuracy was 82.5% (n = 40 retrospectively diagnosed) versus 81% (n = 89 prospectively collected) for the registry, resulting in a sensitivity of 81.2% (versus 98% for the prospective study) and a specificity of 83.3% (versus 67% for the prospective study). The corresponding interobserver agreement for 18 pCLE clips was fair (k = 0.37). Conclusion. Specificity of pCLE using the Paris Classification for the characterization of indeterminate bile duct stricture was increased, without impacting the overall accuracy.

A Review of Probe-Based Confocal Laser Endomicroscopy for Pancreaticobiliary Disease

Confocal laser endomicroscopy (CLE) is a novel in vivo imaging technique that can provide real-time optical biopsies in the evaluation of pancreaticobiliary strictures and pancreatic cystic lesions (PCLs), both of which are plagued by low sensitivities of routine evaluation techniques. Compared to pathology alone, CLE is associated with a higher sensitivity and accuracy for the evaluation of indeterminate pancreaticobiliary strictures. CLE has the ability to determine the malignant potential of PCLs. As such, CLE can increase the diagnostic yield of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound, reducing the need for repeat procedures. It has been shown to be safe, with an adverse event rate of ≤1%. Published literature regarding its cost-effectiveness is needed.

Endoscopic Ultrasonography-Guided Jejunojejunostomy to Facilitate Endoscopic Retrograde Cholangiopancreatography: A Minimally Invasive Option

1. Investigations of the molecular properties of membrane proteins and serum lipoporoteins have for the most part required the use of detergents as solubilizing agents and as probes for hydrophobic binding sites, z 2. The popular technique of identifying and cataloging polypeptides on the basis of their mobilities in sodium dodecyl sulfate-polyacrylamide gel electrophoresis is based on a specific type of detergent-protein interaction. 3 3. Two-dimensional polyacrylamide gel electrophoresis using sodium dodecyl sulfate in one direction and the nonionic detergent, Triton X-100, in the other has been used to identify polypeptides containing long hydrophobic sequences or regions. 4 This technique relies on differences in binding characteristics between water-soluble and intrinsic membrane proteins in that the former do not in general bind nonionic detergents.

Endoscopic management of recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis (RPC) can be challenging to manage. The case presented illustrates all the endoscopic techniques available to us to manage this difficult entity. A 54-year-old man with RPC presented with recurrent abdominal pain, fever, and jaundice. Magnetic resonance cholangiopancreatography (MRCP) showed an extensive stone burden. A conventional endoscopic retrograde cholangiopancreatography (ERCP) confirmed the magnetic resonance imaging (MRI) findings, but was unable to clear the extensive stone burden. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy placement was performed to allow drainage of the left biliary system. After the tract had been allowed to mature, a repeat transgastric ERCP with cholangioscopic assistance was performed. Fluoroscopic and cholangioscopic visualization showed inflammation in the bile duct, but there were no stones visualized. A fully covered self-expandable metal stent (FCSEMS; 10mm×6cm) with an anchoring double-pigtail stent (7 Fr, 10 cm) were deployed, and the patient was discharged home. After 3 months, the patient returned for stent revision. The fistulous tract was cannulated with a sphincterotome and a hydrophilic guidewire. The wire was advanced across the ampulla into the duodenum with a swing-tip catheter. The duodenoscope was removed over the wire to perform a rendezvous procedure. The hepaticogastrostomy stent was revised, and the patient was again discharged home. He re-presented a few months later with cholecystitis and underwent a successful ERCP with placement of a transcystic biliary drain (10 Fr, 15 cm) (▶Fig. 1; ▶Video1). His condition then improved with antibiotics, and he was again discharged home. He went on to undergo liver transplantation (▶Fig. 2), and was recovering at home at the time of writing. RPC is a disease characterized by intrabiliary pigment stone formation that results in stricturing of the biliary tree and biliary obstruction with recurrent bouts of cholangitis [1]. Its etiology is thought to arise from bile stasis, transient portal bacteremia, and abnormal phospholipid metabolism. Stone clearance is the mainstay of therapy, and this can be accomplished invasively either through surgical resection, surgical T-tube placement, or non-invasively through ERCP [2]. Previous reports have indicated complete clearance of stones in 66% of cases [3]. E-Videos

Cholangioscopy and Biliary Confocal Laser Endomicroscopy

The evaluation of indeterminate biliary strictures is challenging due to the low sensitivity of routine sampling at the time of endoscopic retrograde cholangiopancreatography (ERCP). Cholangioscopy allows for direct visualization of the biliary mucosa. Confocal laser endomicroscopy is an in vivo imaging technique that provides real-time optical biopsies. Both modalities have the potential to increase diagnostic yields at the time of ERCP. This chapter will focus on the current data available for those two technologies.

Successful decompression of a massively dilated bile duct by use of a through-the-scope esophageal stent

A 65-year-old man with a history of unresectable pancreatic cancer with associated biliary obstruction and previous biliary stent placement was referred for abdominal pain and elevated liver enzymes. Imaging studies showed distal migration of the previously placed biliary stent with worsened biliary dilation and absence of pneumobilia. ERCP was performed for stent revision and biliary decompression. The duodenoscope was advanced to the ampulla, which revealed a migrated biliary stent. The stent was removed with a rat-toothed forceps. Extensive tissue overgrowth involving the distal bile duct was noted. A biliary balloon was advanced over a guidewire into the biliary tree, and an occlusion cholangiogram revealed a severely dilated common bile duct (CBD) to 18 mm with dilated intrahepatic ducts and a distal CBD stricture. Given the degree of biliary dilation, a decision was made to place a through-the-scope, fully covered, metal esophageal stent (Taewoong Medical, Korea) 18 mm in diameter and 60 mm long. The stent was successfully deployed under