Steven Zerbo

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.

Digital cholangioscopy: assessing the impact of radiofrequency ablation.

Radiofrequency ablation (RFA) has been shown to be an efficacious therapy that improves survival in patients with malignant biliary strictures [1]. Direct cholangioscopy can be useful in confirming a successful response to therapy. We present the case of a patient who underwent RFA of a distal malignant biliary stricture, with cholangioscopic images obtained before and after the procedure confirming successful ablation. A 66-year-old woman with an inoperable malignant biliary stricture presented for endoscopic retrograde cholangiopancreatography (ERCP). The duodenoscope (TGFQ180V; Olympus America, Center Valley, Pennsylvania, USA) was advanced to the ampulla. An occlusion cholangiogram showed a dilated biliary tree above a distal biliary stricture. A digital cholangioscope (SpyGlass; Boston Scientific, Natick, Massachusetts, USA) was inserted into the bile duct, and the stricture was visualized. Oozing, erythematous mucosa consistent with malignancy was seen in the distal portion of the duct. An RFA catheter (Habib EndoHPB; EMcision, Montreal, Canada) was advanced into the stricture, and RFA was performed at 8 effect and 10W for 90 seconds [2]. The cholangioscope was then reinserted, and visualization showed successfully ablated tissue with localized necrosis

Endoscopic ultrasound-guided gastrojejunostomy: a novel technique

Endoscopic ultrasound (EUS)-guided gastroenterostomy with placement of a lumen-apposing metal stent has emerged as a novel, minimally invasive therapeutic option for patients with gastric outlet obstruction (GOO) [1–3]. The most challenging aspect of the procedure is immobilizing the jejunal loop in order to create the fistulous tract and deploy the stent. Several different techniques have been described [1–3]. We present a novel approach involving the use of a second endoscope that is advanced through a previously placed percutaneous gastrostomy (PEG) site to within the target jejunal lumen in order to provide traction on the wire, and to facilitate fistula creation and stent placement. A 68-year-old man presented with GOO following surgical resection for pancreatic cancer. Enteral stenting and PEG-jejununostomy tube placement were unsuccessful for palliation. Therefore, EUSguided gastroenterostomy was performed using a novel rendezvous technique (▶Video1). The echoendoscope was used to identify and access the jejunum from within the gastric lumen, and a wire was advanced into the targeted jejunal loop. A concurrent small-diameter endoscope was advanced percutaneously through the PEG site and across the malignant obstruction into the jejunum, where the coiled guidewire was visualized and grasped by a pediatric biopsy forceps. This provided traction on the wire, which facilitated transgastric cautery-assisted fistula creation and stent placement with a lumen-apposing metal stent (▶Fig. 1). After stent placement, both endoscopes were removed and the PEG site was closed intragastrically with an over-the-scope clip. At 3-month followup, the patient was still able to tolerate a soft diet. In conclusion, EUS-guided gastroenterostomy using this rendezvous technique was safe and efficacious, and should be considered in patients with GOO who have a previously placed PEG tube.

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

Endoscopic management of a GI perforation

A 55-year-old woman with a Roux-en-Y gastric bypass presented for ERCP because of a biliary stricture. She previously had undergone an endoscopically created jejunogastric fistula with a lumen-apposing metal stent (LAMS) for ampullary access. The duodenoscope was advanced to the LAMS. Balloon dilation was performed up to 15 mm, but there was resistance to passage of the duodenoscope. After slight forward pressure, the duodenoscope slipped abruptly back, causing a jejunal perforation. This was managed by using 4 steps: (1) Stabilize the patient: The duodenoscope was advanced through the defect into the peritoneal cavity, and the carbon dioxide was suctioned. Antibiotics were administered. (2) Determine the best closure method: Because of the location of the defect, a 14-mm over-the-scope clip (OTSC) (Ovesco; Los Gatos, Calif) was selected. (3) Close the defect: The endoscope loaded with the OTSC was advanced to the defect. Tissue