Paul Yeaton

Use of a novel through-the-needle biopsy forceps in endoscopic ultrasound.

Background and aims: Pancreatic cysts are becoming more common. Their differential diagnosis includes benign, premalignant, and malignant lesions. Distinguishing the type of cyst helps in the management decision making. We report on a novel tissue acquisition device for pancreatic cysts. Methods: Data on two patients who underwent endoscopic ultrasound (EUS) – guided fine-needle aspiration with a new micro forceps device are presented. Results: Two patients had large pancreatic cystic lesions in the pancreatic head. Linear EUS was performed, and tissue samples were obtained with the Moray micro forceps through a 19-gauge needle. In both patients, mucinous columnar epithelium lined the cystic walls. One patient underwent surgical resection, and the other elected surveillance. Examination of the surgical specimen from the first patient confirmed the cyst was a side-branch intraductal papillary mucinous neoplasm (IPMN), gastric type. Conclusions: The Moray micro forceps is a new tool that can be used to help determine the nature of pancreatic cysts and aid in their risk stratification and management.

Prevention of Post-ERCP Pancreatitis

Pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). A variety of patient-related and procedure-related factors have been identified to risk-stratify patients. Several measures can be undertaken in order to decrease the risk of post-ERCP pancreatitis in high-risk groups. These measures include pancreatic duct stenting and rectal indomethacin, amongst others.

Endoscopic Ultrasound Guided Embolization of a Pancreatic Pseudoaneurysm

Pseudoaneurysms are rare complications of chronic pancreatitis and are associated with a high mortality. In this article we demonstrate a novel utilization of endoscopic ultrasound (EUS) technology to embolize a large pancreatic pseudoaneurysm when gold standard therapies had proven futile.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMS The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

A Rare Cause of Colonic Stricture

68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 Question: A 57-year-old man presented to our hospital with a week of generalized weakness and abdominal pain. Relevant medications included diclofenac 75 mg twice daily, aspirin 81 mg, and clopidogrel 75 mg/d. Vital signs were normal. Physical examination showed mild diffuse abdominal tenderness. Admission blood work revealed a hemoglobin of 8.8 g/dL, decreased from a baseline hemoglobin of 12 g/dL. The patient did not have overt gastrointestinal bleeding, but tested positive for fecal occult blood. A computed tomography scan demonstrated luminal narrowing at the hepatic flexure without bowel wall thickening or obstruction (Figure A). Esophagogastroduodenoscopy was normal. Colonoscopy revealed a circumferential stricture in the right colon with an estimated diameter of 8 mm (Figure B). Biopsies of the stricture showed significant lamina propria fibrosis, eosinophilic infiltration, and mild crypt distortion (Figure C). What was the diagnosis? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 95 96 97 98 99 100 Conflicts of interest The authors disclose no conflicts.

ERCP through a gastrojejunal lumen-apposing stent

Figure 2. Fluoroscopic view showing passage of guidewire into the distal duodenum. We present a case of an 84-year-old man who had received a diagnosis of pancreatic head adenocarcinoma 2 years earlier. At that time, he had received bile and pancreatic duct stents with resolution of jaundice and improvement in diarrhea. Over the past month, the patient started experiencing epigastric pain, nausea, and vomiting. Cross-sectional imaging demonstrated no significant change in pancreatic mass size, with intact stents and stable pneumobilia. An upper endoscopy was then performed, demonstrating narrowing of the second portion of the duodenum with inability of the endoscope to traverse this segment. Contrast medium was injected into the duodenal bulb and showed evidence of severe narrowing of the second portion of the duodenum (Fig. 1). A long ERCP guidewire was advanced through the upper endoscope past the duodenal narrowing and looped in the distal duodenum (Fig. 2). The endoscope was then withdrawn while the guidewire was maintained in place. A dilation balloon was advanced over the guidewire into the distal duodenum and inflated to 18 mm (Fig. 3). A linear echoendoscope was then advanced into the stomach. The dilated balloon was identified and punctured with a 19-gauge needle and immediate dissipation of contrast medium into the small intestine was observed (Fig. 4). Another guidewire was advanced through the 19-gauge needle into the small intestine. A Boston-Scientific (Marlborough, Mass) electrocautery-enhanced Axios stent was then deployed over the guidewire into the lumen of the small intestine (Fig. 5). The stent was then dilated with a 13.5-mm dilation balloon (Fig. 6). The final endoscopic and fluoroscopic appearance appeared satisfactory. The patient did well after the procedure, with resolution of symptoms, and was discharged the next day after tolerating a regular diet. However, the patient presented about 2 weeks later with right upper-quadrant pain, fever, and an increase in bilirubin from 0.4 to 2.6 mg/dL. A transabdominal US showed worsening intrahepatic biliary dilatation. Intravenous antibiotics were started, with improvement in symptoms but persistence of laboratory abnormalities. We then discussed with the patient the options of percutaneous drainage, EUS-guided hepaticogastrostomy, or an attempt at exchanging the stent through the newly placed Axios stent. The patient opted for an endoscopic