Masatoshi Mabuchi

Endoscopic Ultrasound-Guided Antegrade Treatments for Biliary Disorders in Patients with Surgically Altered Anatomy

IntroductionEndoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy is challenging. Several endoscopic ultrasound (EUS)-guided biliary access techniques have been reported as effective alternatives. EUS-guided antegrade treatments (AG) have been developed more recently but have not yet been studied well.AimsTo evaluate the feasibility and safety of EUS-AG for biliary disorders in patients with surgically altered anatomies.MethodsWe retrospectively identified all the patients who underwent EUS-AG. The left intrahepatic bile duct (IHBD) was initially punctured from the intestine followed by cholangiography, antegrade guidewire manipulation, and bougie dilation of the fistula. Either antegrade biliary stenting (ABS) or antegrade balloon dilation (ABD) was performed depending on the biliary disorders. In stone cases, the stones were antegradely pushed out using a balloon. After ABD, a nasobiliary drainage tube was placed to prevent possible bile leak and to keep an access route for any possible repeat procedures.ResultsEUS-AG was attempted in seven patients including choledocholithiasis in five, malignant biliary obstruction in one, and bilioenteric anastomosis stricture in one. EUS-AG was not performed in one patient because EUS-cholangiography did not indicate the presence of stones. In the remaining six patients, the IHBD was successfully punctured, followed by cholangiography, guidewire insertion, and bougie dilation. ABS and ABD were successfully performed in one and five patients, respectively. Antegrade procedures with ABD were repeated twice in one patient. Mild complications were observed in two patients.ConclusionsEUS-AG for biliary disorders in patients with surgically altered anatomy is feasible. Further studies are warranted.

EUS-guided rendezvous for difficult biliary cannulation using a standardized algorithm: a multicenter prospective pilot study (with videos)

BACKGROUND AND AIMS Biliary cannulation is necessary in therapeutic ERCP for biliary disorders. EUS-guided rendezvous (EUS-RV) can salvage failed cannulation. Our aim was to determine the safety and efficacy of EUS-RV by using a standardized algorithm with regard to the endoscope position in a prospective study. METHODS EUS-RV was attempted after failed cannulation in 20 patients. In a standardized approach, extrahepatic bile duct (EHBD) cannulation was preferentially attempted from the second portion of the duodenum (D2) followed by additional approaches to the EHBD from the duodenal bulb (D1) or to the intrahepatic bile duct from the stomach, if necessary. A guidewire was placed in an antegrade fashion into the duodenum. After the guidewire was placed, the endoscope was exchanged for a duodenoscope to complete the cannulation. RESULTS The bile duct was accessed from the D2 in 10 patients, but from the D1 in 5 patients and the stomach in 4 patients because of no dilation or tumor invasion at the distal EHBD. In the remaining patient, biliary puncture was not attempted due to the presence of collateral vessels. The guidewire was successfully manipulated in 80% of patients: 100% (10/10) with the D2 approach and 66.7% (6/9) with other approaches. The overall success rate was 80% (16/20). Failed EUS-RV was salvaged with a percutaneous approach in 2 patients, repeat ERCP in 1 patient, and conservative management in 1 patient. Minor adverse events occurred in 15% of patients (3/20). CONCLUSIONS EUS-RV is a safe and effective salvage method. Using EUS-RV to approach the EHBD from the D2 may improve success rates.

Endoscopic ultrasound-guided antegrade biliary stenting for unresectable malignant biliary obstruction in patients with surgically altered anatomy: Single-center prospective pilot study

Endoscopic retrograde cholangiography (ERCP) with biliary stenting for the treatment of unresectable malignant biliary obstruction (MBO) is challenging among patients with surgically altered anatomy. Endoscopic ultrasound‐guided antegrade biliary stenting (EUS‐ABS) was introduced as an alternative biliary drainage method, although it has not yet been well studied. In this single‐center prospective pilot study, we aimed to evaluate the feasibility and safety of EUS‐ABS for MBO in patients with surgically altered anatomy.

Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy

Abstract Introduction. Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy (SAA) is generally challenging despite the use of enteroscopy. After failed biliary cannulation, rendezvous technique (RV) can be an option to assist the biliary access. However, proper needle puncture of biliary ducts, which is critical in the RV procedure, can be difficult because of insufficient biliary dilation. By contrast, the gallbladder can be punctured as a possible access route for RV. Aim. To evaluate the feasibility and safety of percutaneous transgallbladder (PTGB)-RV in patients with SAA. Patients and methods. Six patients who underwent PTGB-RV were included. PTGB drainage was performed in cases without sufficient biliary duct dilation. A guidewire was inserted through the PTGB route with antegrade passage through the cystic duct, common bile duct and duodenal papilla. An enteroscope was inserted up to the papilla, at the guidewire exit site. The guidewire was pulled out through the accessory channel followed by biliary cannulation over the guidewire and endoscopic papillary balloon dilation (EPBD) for stone removal. Results. Six patients with SAA (Roux-en-Y in 4 and Billroth-II in 2) underwent PTGB-RV for removal of bile duct stones. In all patients, a guidewire was successfully inserted into the duodenum followed by insertion of the enteroscope and biliary cannulation. EPBD was then performed, but subsequent stone removal failed in 1 patient. Stone removal was successful in 5 patients without complication, except 1 case of mild pancreatitis. Conclusion. PTGB-RV seems to be a feasible and relatively safe salvage technique in patients with SAA.

Endoscopic Papillary Large Balloon Dilation as a Salvage Procedure for Basket Impaction During Retrieval of Common Bile Duct Stones

Endoscopic management of common bile duct stones (CBDSs) is an effective and minimally invasive procedure. CBDSs are retrieved using either a balloon or basket catheter after managing the major papilla with endoscopic sphincterotomy (ES) or endoscopic papillary balloon dilation (EPBD). However, this procedure is associated with complications such as pancreatitis, hemorrhage, perforation, and cholangitis [1, 2]. Although basket impaction at the papilla during stone retrieval is a rare complication with a reported incidence rate of 0.8 % [3], it can cause serious complications such as biliary obstruction and secondary cholangitis. Furthermore, attempts to release the basket impaction by forceful manipulation can lead to perforation of the duodenum or CBD that will eventually require surgery to resolve the complication. Generally, mechanical lithotripsy is initially attempted to release the impaction but may occasionally fail because of fracture of the basket wire at the cranking handle. Recently, endoscopic papillary large balloon dilation (EPLBD) has been reported as an effective papillary intervention for managing large or multiple CBDSs [4–7]. In this study, we evaluated the efficacy and safety of EPLBD as a salvage procedure for basket impaction at the ampulla.

Hybrid procedure combining endoscopic gallbladder lavage and internal drainage with elective cholecystectomy for acute cholecystitis: A prospective pilot study (The BLADE study)

Percutaneous transhepatic drainage is the most common method for non‐operative gallbladder drainage, but the technique does have several disadvantages because of its invasive nature and requirement for continuous drainage. To overcome these disadvantages, we developed a novel procedure, endoscopic gallbladder lavage followed by stent placement, carried out in a single endoscopic session. Our aim was to prospectively evaluate the efficacy and safety of this procedure in patients with acute cholecystitis.

Retrograde pancreatic stent extrusion through the EUS-guided pancreaticogastrostomy route

A 57-year-old man with alcohol-related chronic pancreatitis presented to us with a history of repeated endoscopic pancreatic duct (PD) stent placement over 2 years. At the last instance of ERCP for stent replacement, during stent removal, the stent fragmented at the site of PD stenosis, and 1 stent fragment migrated proximally. Because all attempts to remove the fragment by the transpapillary approach with the use of various accessories such as forceps, snare, balloon, and basket, were unsuccessful (Fig. 1), we recommended surgical removal of the migrated stent fragment. However, because the patient was asymptomatic and his blood tests revealed normal serum amylase levels, and owing to an absence of inflammatory response, he refused consent for surgical intervention and was discharged with the stent fragment in situ.

EUS-Guided Celiac Plexus Neurolysis

EUS-guided celiac plexus neurolysis (EUS–CPN) can be performed for alleviating pain originating from the upper abdominal organs and, particularly, when the primary indication for pain is pancreatic cancer pain. Two different techniques are currently used when applying EUS–CPN. The classic approach, known as the central technique, involves injection of a neurolytic agent at the base of the celiac axis, and the second approach, the bilateral technique, involves injection of the neurolytic agent on both sides of the celiac axis. Moreover, it was recently established that celiac ganglia can be examined and visualized by EUS. Therefore, EUS-guided direct celiac ganglia neurolysis (EUS–CGN) has been introduced as a new promising method. These techniques are performed with real-time imaging and with Doppler assessment of the interposing vessels. Therefore, they are more accurate, safe, and convenient than other classic approaches such as radiographic, fluoroscopic, or CT guidance. The effective rates reportedly vary from 50 to 90%. Common complications included transient diarrhea, transient pain exacerbation, transient hypotension, and inebriation, but they are not serious.