BACKGROUND Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced(ECE)delivery of lumen-apposing metal stent(LAMS)is gradually being re-cognized as a viable palliative technique for malignant bili...BACKGROUND Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced(ECE)delivery of lumen-apposing metal stent(LAMS)is gradually being re-cognized as a viable palliative technique for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography(ERCP)failure.However,most of the studies that have assessed its efficacy and safety were small and hetero-geneous.Prior meta-analyses of six or fewer studies that were published 2 years ago were therefore underpowered to yield convincing evidence.AIM To update the efficacy and safety of ECE-LAMS for treatment of biliary ob-struction after ERCP failure.METHODS We searched PubMed,EMBASE,and Scopus databases from the inception of the ECE technique to May 13,2022.Primary outcome measure was pooled technical success rate,and secondary outcomes were pooled rates of clinical success,re-intervention,and adverse events.Meta-analysis was performed using a random-effects model following Freeman-Tukey double-arcsine transformation in R soft-ware(version 4.1.3).RESULTS Fourteen eligible studies involving 620 participants were ultimately included.The pooled rate of technical success was 96.7%,and clinical success was 91.0%.Adverse events were reported in 17.5%of patients.Overall reinter-vention rate was 7.3%.Subgroup analyses showed results were generally consistent.CONCLUSION ECE-LAMS has favorable success with acceptable adverse events in relieving biliary obstruction when ERCP is impossible.The consistency of results across most subgroups suggested that this is a generalizable approach.展开更多
In this editorial,we comment on the article by Peng et al.Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage.The procedures of biliary dra...In this editorial,we comment on the article by Peng et al.Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage.The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound,endoscopic ultrasound(EUS),or both.Endoscopic retrograde cholangiopancreatography(ERCP)has been primarily recommended for the management of biliary obstruction,while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage(PTBD)are alternative choices for cases where ERCP has failed or is impossible.PTBD is limited by shortcomings of a higher rate of adverse events,more reinterventions,and severe complications.EUS-guided biliary drainage has a lower rate of adverse events than PTBD.EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)enables EUS-guided biliaryenteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire.The present meta-analysis showed that ECELAMS has a high efficacy and safety in relieving biliary obstruction in general,although the results of LAMS depending on the site of biliary obstruction.This study has highlighted the latest advances with a larger sample-based comprehensive analysis.展开更多
This editorial delves into Peng et al's article,published in the World Journal of Gastrointestinal Surgery.Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing me...This editorial delves into Peng et al's article,published in the World Journal of Gastrointestinal Surgery.Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing metal stents(ECE-LAMS)in ultrasound-guided biliary drainage for alleviating malignant biliary obstruction.Examining 14 studies encompassing 620 participants,the research underscores a robust technical success rate of 96.7%,highlighting the efficacy of ECE-LAMS,particularly in challenging cases which have failed endoscopic retrograde cholangio pancreatography.A clinical success rate of 91.0% underscores its impact on symptom alleviation,while a reasonably tolerable adverse event rate of 17.5% is observed.However,the 7.3% re-intervention rate stresses the need for post-procedural monitoring.Subgroup analyses validate consistent outcomes,bolstering the applicability of ECE-LAMS.These findings advocate for the adoption of ECELAMS as an appropriate approach for biliary palliation,urging further exploration in real-world clinical contexts.They offer valuable insights for optimizing interventions targeting malignant biliary obstruction management.展开更多
BACKGROUND The introduction of lumen-apposing metal stents(LAMS)for endoscopic ultrasound(EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffus...BACKGROUND The introduction of lumen-apposing metal stents(LAMS)for endoscopic ultrasound(EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings.Nevertheless,the procedure may conceal unexpected pitfalls.LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences.Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure.To date,no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.AIM To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy(EUS-CDS),gallbladder drainage(EUS-GBD)and pancreatic fluid collections drainage(EUS-PFC)and to describe the endoscopic rescue strategies adopted under the circumstance.METHODS We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022.The search was carried out using the exploded medical subject heading terms“lumen apposing metal stent”,“LAMS”,“endoscopic ultrasound”and“choledochoduodenostomy”or“gallbladder”or“pancreatic fluid collections”.We included in the review on-label EUS-guided procedures namely EUS-CDS,EUS-GBD and EUS-PFC.Only those publications reporting EUS-guided LAMS positioning were considered.The studies reporting a technical success rate of 100%and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment,while studies not reporting the causes of technical failure were excluded.Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques.The following data were collected from each study:Author,year of publication,study design,study population,clinical indication,technical success,reported number of misdeployment,stent type and size,flange misdeployed and type of rescue strategy.RESULTS The overall technical success rate of EUS-CDS,EUS-GBD and EUS-PFC was 93.7%,96.1%,and 98.1%respectively.Significant rates of LAMS misdeployment have been reported for EUS-CDS,EUS-GBD and EUS-PFC drainage,respectively 5.8%,3.4%,and 2.0%.Endoscopic rescue treatment was feasible in 86.8%,80%,and 96.8%of cases.Non endoscopic rescue strategies were required only in 10.3%,16%and 3.2%for EUS-CDS,EUS-GBD,and EUS-PFC.The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%,8%and 64.5%and stent-in-stent in 23.5%,60%,and 12.9%,respectively for EUSCDS,EUS-GBD,and EUS-PFC.Further therapeutic option were endoscopic rendezvous in 11.8%of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1%of EUS-PFC.CONCLUSION LAMS misdeployment is a relatively common adverse event in EUS-guided drainages.There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario,anatomical characteristics,and local expertise.In this review,we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used,with the aim of providing useful data for endoscopists and to improve patient outcomes.展开更多
In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic inter...In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUSguided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and ECLAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.展开更多
Background:Endoscopic ultrasound(EUS)-guided transmural drainage for pancreatic fluid collections(PFCs)has become the first-line treatment with quicker recovery and more minor injury compared with surgery and percutan...Background:Endoscopic ultrasound(EUS)-guided transmural drainage for pancreatic fluid collections(PFCs)has become the first-line treatment with quicker recovery and more minor injury compared with surgery and percutaneous drainage.The efficacy of stents implantation and drainage for different PFCs remains controversial,especially lumen-apposing metal stents(LAMS).This study aimed to compare the efficacy and safety of LAMS drainage for pancreatic pseudocysts(PPC)and walled-off necrosis(WON).Methods:A meta-analysis was performed for LAMS drainage for WON and PPC by systematically searching PubMed,Cochrane,and Embase databases from January 2010 to January 2020.From 2017 to 2019,12 patients who were treated with LAMS drainage for PFCs in our medical center were also reviewed and included in this study.Results:Combining 11 copies of documents with the data from our medical center,a total of 585 patients with PFCs were enrolled in this meta-analysis,including 343 patients with WON and 242 with PPC.The technical success rate in WON is not significantly different from that of PPC(P=0.08>0.05).The clinical success of LAMS placement was achieved in 99%vs 89%in PPC and WON,respectively(RR=0.92,95%CI:0.86-0.98,P=0.01<0.05).The further intervention of direct endoscopic necrosectomy was required by 60%of patients in WON group.There was no significant difference in the incidence of adverse events,including infection,bleeding,stent migration and stent occlusion,after LAMS placement between WON and PPC.Conclusions:Endoscopic ultrasound-guided LAMS for PFCs are feasible,effective with preferable technical and clinical success rates.The clinical effect of LAMS on PPC is slightly better than that of WON,but its adverse reactions still need to be verified in a large-sample prospective study.展开更多
Background:Fluoroscopy is often used during the endoscopic drainage of pancreatic-fluid collections(PFCs).An electrocautery-enhanced coaxial lumen-apposing,self-expanding metal stent(ELAMS)facilitates a single-step pr...Background:Fluoroscopy is often used during the endoscopic drainage of pancreatic-fluid collections(PFCs).An electrocautery-enhanced coaxial lumen-apposing,self-expanding metal stent(ELAMS)facilitates a single-step procedure and may avoid the need for fluoroscopy.This study compares the treatment outcomes using ELAMS with and without fluoroscopy.Methods:Patients with PFCs who had cystogastrostomy from January 2014 to February 2017 were enrolled.Two groups were studied based on fluoroscopy use.Technical success was defined as uneventful insertion of ELAMS at time of procedure.Clinical success was defined as(i)clinical resolution of symptoms after the procedure and(ii)>75%reduction in cyst size on computed tomography 8 weeks after stent placement.Adverse events including bleeding,stent migration,and infection were recorded.Results:A total of 21 patients(13 males)had PFCs drainage with ELAMS in the study period.The mean age was 51.6614.2 years.Thirteen patients had walled-off necrosis while eight had a pancreatic pseudocyst.The mean size of the PFCs was 11.363.3 cm.Fluoroscopy was used in seven cases(33%)and was associated with a longer procedure time compared to non-fluoroscopy(43.1610.4 vs 33.3610.5 min,P=0.025).This association was independent of the size,location,or type of PFCs.Fluoroscopy had no effect on the technical success rates.In fluoroless procedures,the clinical resolution was 91%as compared to 71%in fluoroscopy procedures(P=0.52)and the radiologic resolution was 57%as compared to 71%in fluoroscopy procedures(P=0.65).Three cases of stent migration/displacement occurred in the fluoroless procedures.Conclusions:ELAMS may avoid the need for fluoroscopy during cystogastrostomy.Procedures without fluoroscopy were significantly shorter and fluoroscopy use had no impact on the technical or clinical success rates.展开更多
This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally ...This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.展开更多
The role of endoscopy in pathologies of the bile duct and gallbladder has seen notable advancements over the past two decades.With advancements in stent technology,such as the development of lumen-apposing metal stent...The role of endoscopy in pathologies of the bile duct and gallbladder has seen notable advancements over the past two decades.With advancements in stent technology,such as the development of lumen-apposing metal stents,and adoption of endoscopic ultrasound and electrosurgical principles in therapeutic endoscopy,what was once considered endoscopic failure has transformed into failure of an approach that could be salvaged by a second-or third-line endoscopic strategy.Incorporation of these advancements in routine patient care will require formal training and multidisciplinary acceptance of established techniques and collaboration for advancement of experimental techniques to generate robust evidence that can be utilized to serve patients to the best of our ability.展开更多
Commentary on the article written and published by Peng et al,investigating the role of endoscopic ultrasound(EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrog...Commentary on the article written and published by Peng et al,investigating the role of endoscopic ultrasound(EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiopan-creatography(ERCP).For 40 years endoscopic biliary drainage was synonymous with ERCP,and EUS was used mainly for diagnostic purposes.The advent of therapeutic EUS has revolutionized the field,especially with the development of a novel device such as electrocautery-enhanced lumen-apposing metal stents.Complete biliopancreatic endoscopists with both skills in ERCP and in interven-tional EUS,would be ideally suited to ensure patients the best drainage technique according to each individual situation.展开更多
Endoscopic ultrasound-guided biliary drainage(EUS-BD) has been developed as an alternative means of biliary drainage for malignant biliary obstruction(MBO).Compared to percutaneous transhepatic biliary drainage,EUS-BD...Endoscopic ultrasound-guided biliary drainage(EUS-BD) has been developed as an alternative means of biliary drainage for malignant biliary obstruction(MBO).Compared to percutaneous transhepatic biliary drainage,EUS-BD offers effective internal drainage in a single session in the event of failed endoscopic retrograde cholangiopancreatography and has fewer adverse events(AE). In choosing which technique to use for EUS-BD,a combination of factors appears to be important in decision-making; technical expertise,the risk of AE,and anatomy. With the advent of novel all-in-one EUS-BD specific devices enabling simpler and safer techniques,as well as the growing experience and training of endosonographers,EUS-BD may potentially become a first-line technique in biliary drainage for MBO.展开更多
BACKGROUND Endoscopic drainage of walled-off necrosis(WON) is still a challenge due to stentassociated problems. We explored endoscopic gastric fenestration(EGF) as an innovative alternative intervention.AIM To assess...BACKGROUND Endoscopic drainage of walled-off necrosis(WON) is still a challenge due to stentassociated problems. We explored endoscopic gastric fenestration(EGF) as an innovative alternative intervention.AIM To assess the feasibility, efficacy and safety of EGF for WON.METHODS Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound(EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.RESULTS EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min(EUS assessment, 32.3 min;initial fenestration, 28.8 min;expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent(LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.CONCLUSION EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.展开更多
Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-sta...Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-standard therapy for these patients, as simultaneous endoscopic biliary and duodenal stenting is currently a feasible and widely used technique, with a high technical success in expert hands. In recent years, endoscopic ultrasonography(EUS) has evolved from a diagnostic to a therapeutic procedure, and is now increasingly used to guide biliary drainage, especially in cases of failed endoscopic retrograde cholangiopancreatography(ERCP). The advent of lumen-apposing metal stents(LAMS) has expanded EUS therapeutic options, and changed the management of synchronous bilioduodenal stenosis. The most recent literature regarding endoscopic treatments for synchronous biliary and duodenal malignant stenosis has been reviewed to determine the best endoscopic approach, also considering the advent of an interventional EUS approach using LAMS.展开更多
Gastric outlet obstruction(GOO)is a clinical syndrome characterized by postprandial vomiting,abdominal pain,bloating and,in advanced cases,by weight loss secondary to inadequate oral intake.This clinical entity may be...Gastric outlet obstruction(GOO)is a clinical syndrome characterized by postprandial vomiting,abdominal pain,bloating and,in advanced cases,by weight loss secondary to inadequate oral intake.This clinical entity may be caused by mechanical obstruction,either benign or malignant,or by motility disorders.In this review we will focus on malignant GOO and on its endoscopic ultrasound(EUS)-guided palliative treatment.The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas;other causes include duodenal or ampullary neoplasms,gastric lymphomas,retroperitoneal lymphadenopathies and,more infrequently,gallbladder and bile duct cancers.Surgery represents the treatment of choice when radical and curative resection is potentially feasible;if the malignant cause is not likely to be completely resected,palliative treatments should be proposed.Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent.Both treatments are effective;however,endoscopic stent placement is less invasive and it is associated with good short-term results,while surgery provides longer-lasting effects with a lower frequency of reintervention.In the last few years,EUS-guided gastroenterostomy(GE)has been proposed as palliative treatment for malignant GOO.This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction,through the deployment of a lumen-apposing metal stent under EUS-view.EUS-GE has the advantage of being as minimally invasive as enteral stent placement,and of guaranteeing long-term results similar to those of surgery.展开更多
BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)is an alternative method for the surgical treatment of gastric outlet obstruction,but it is regarded as a challenging technique for endoscopists as the ...BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)is an alternative method for the surgical treatment of gastric outlet obstruction,but it is regarded as a challenging technique for endoscopists as the bowel is highly mobile and can tent away.Thus,the technique requires superb skill.In order to improve EUS-GE,we have developed a retrievable puncture anchor traction(RPAT)device for EUSGE to address the issue of bowel tenting.AIM To evaluate the feasibility of RPAT-assisted EUS-GE using an animal model.METHODS Six Bama mini pigs each weighing between 15 and 20 kg underwent the RPATassisted EUS-GE procedure.Care was taken to ensure that the animals experienced minimal pain and discomfort.Two days prior to the procedure the animals were limited to a liquid diet.No oral intake was allowed on the day before the procedure.A fully covered metal stent was placed between the stomach and the intestine using the RPAT-assisted EUS-GE method.Infection in the animals was determined.Four weeks after the procedure,a standard gastroscope was inserted into the pig’s intestine through a previously created fistula in order to check the status of the stents under anesthesia.The pig was euthanized after examination.RESULTS The RPAT-assisted EUS-GE method allowed placement of the stents with no complications in all six animals.All the pigs tolerated a regular diet within hours of the procedure.The animals were monitored for four weeks after the RPATassisted EUS-GE,during which time all of the animals exhibited normal eating behavior and no signs of infection were observed.Endoscopic imaging performed four weeks after the RPAT-assisted EUS-GE showed that the stents remained patent and stable in all the animals.No tissue overgrowth or ingrowth was observed in any case.Each animal had a mature fistula,and the stents were removed without significant bleeding.Autopsies of all six pigs revealed complete adhesion between the intestine and the stomach wall.CONCLUSION The RPAT method helps reduce mobility of the bowel.Therefore,the RPATassisted EUS-GE method is a minimally invasive treatment modality.展开更多
BACKGROUND The endoscopic management of benign short post-anastomotic ileocolonic stricture(PAICS) that is refractory to primary and secondary treatment modalities remains challenging.The lumen-apposing metal stent(LA...BACKGROUND The endoscopic management of benign short post-anastomotic ileocolonic stricture(PAICS) that is refractory to primary and secondary treatment modalities remains challenging.The lumen-apposing metal stent(LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy.LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents(FCSEMSs).CASE SUMMARY This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature.We report a life-saving technique not previously documented and the use of technology to improve patient outcomes.The six patients(median age,75 years) suffered from vomiting,constipation and recurrent abdominal pain,with symptoms starting 23-25 wk post-surgery.The median stricture length was 1.83 cm.All six patients underwent successful and uneventful bi-flanged metal stent(BFMS)-LAMS placement for benign PAICS.All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal.According to the literature,the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding.Conversely,FCSEMS has a high migration rate(15%-50%).CONCLUSION The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options,allowing them to avoid more invasive surgical interventions.The BFMS(NAGI stent) is longer and larger than the prototype AXIOS-LAMS,which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.展开更多
BACKGROUND A recent expert panel issued recommendations about the technical aspects of direct endoscopic necrosectomy(DEN) for pancreatic walled-off necrosis(WON).However, significant technical heterogeneity still exi...BACKGROUND A recent expert panel issued recommendations about the technical aspects of direct endoscopic necrosectomy(DEN) for pancreatic walled-off necrosis(WON).However, significant technical heterogeneity still exists among endoscopists.AIM To report the outcomes of our DEN technique and how it differs from a recent expert consensus statement and previous studies.METHODS Medical records of patients with WON who underwent DEN from September2016-May 2019 were queried for the following information: Age, gender,ethnicity, etiology of acute pancreatitis, WON location and size, DEN technical information, adverse events(AEs) and outcomes. Adverse events were graded according to the American Society of Gastrointestinal Endoscopy Lexicon grading system. Technical success was defined as adequate lumen apposing metal stent(LAMS) deployment plus removal of ≥ 90% of necrosum. Clinical success was defined as complete resolution of WON cavity by imaging and resolution of symptoms at ≤ 3 months(mo) after last DEN. Data analysis was performed using mean and standard deviation for continuous variables,frequency and proportion for categorical variables, and median and range for interval data.RESULTS A total of 21 patients underwent DEN. Most of them were Hispanic and their mean age was 51 ± 17 years. The majority of the collections were located in the body of the pancreas and the mean size was 13 cm ± 5 cm. The most common indication was persistent vomiting. Antibiotics were administered only in cases of infected necrosis. All LAMS were placed without radiological guidance,dilated the same day of deployment and removed after a mean of 27 ± 11 d.Routine cross-sectional imaging immediately after drainage was not performed.The mean interval between DEN sessions was 7 ± 4 d and the mean number of DEN/patient was 3 ± 2. Technical and clinical success rates were both 95%. AEs were seen in 5 patients and included: Sepsis(2), stent migration(1), stent maldeployment(1), perforation(1). The sensitivity and positive predictive value of an occluded LAMS leading to sepsis was 50% and 0.11 respectively. No fatalities were observed.CONCLUSION Our DEN technique differed significantly from the one recommended by a recent expert panel and the one published in previous studies. Despite these differences excellent clinical outcomes were obtained.展开更多
Afferent loop obstruction(ALO)is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy.With advances in chemotherapy,the incidence of malignant ALO is increasing...Afferent loop obstruction(ALO)is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy.With advances in chemotherapy,the incidence of malignant ALO is increasing.Malignant ALO can be complicated by ischemia,gangrenous bowel,pancreatitis,and ascending cholangitis.Moreover,the general condition of patients with recurrent cancer is often poor.Therefore,accurate and rapid diagnosis and minimally invasive treatments are required.However,no review articles on the diagnosis and treatment of malignant ALO have been published.Through literature searching,we reviewed related articles published between 1959 and 2020 in the PubMed database.Herein,we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives.Endoscopic transluminal self-expandable metal stent(SEMS)placement is considered the standard treatment for malignant ALO,as this procedure is well established and less invasive.However,with the development of interventional endoscopic ultrasound(EUS)in recent years,the usefulness of EUS-guided gastrojejunostomy has been reported.Moreover,through indirect comparison,this approach has been reported to be superior to transluminal SEMS placement.It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.展开更多
基金The authors have read the PRISMA 2009 Checklist,and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
文摘BACKGROUND Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced(ECE)delivery of lumen-apposing metal stent(LAMS)is gradually being re-cognized as a viable palliative technique for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography(ERCP)failure.However,most of the studies that have assessed its efficacy and safety were small and hetero-geneous.Prior meta-analyses of six or fewer studies that were published 2 years ago were therefore underpowered to yield convincing evidence.AIM To update the efficacy and safety of ECE-LAMS for treatment of biliary ob-struction after ERCP failure.METHODS We searched PubMed,EMBASE,and Scopus databases from the inception of the ECE technique to May 13,2022.Primary outcome measure was pooled technical success rate,and secondary outcomes were pooled rates of clinical success,re-intervention,and adverse events.Meta-analysis was performed using a random-effects model following Freeman-Tukey double-arcsine transformation in R soft-ware(version 4.1.3).RESULTS Fourteen eligible studies involving 620 participants were ultimately included.The pooled rate of technical success was 96.7%,and clinical success was 91.0%.Adverse events were reported in 17.5%of patients.Overall reinter-vention rate was 7.3%.Subgroup analyses showed results were generally consistent.CONCLUSION ECE-LAMS has favorable success with acceptable adverse events in relieving biliary obstruction when ERCP is impossible.The consistency of results across most subgroups suggested that this is a generalizable approach.
文摘In this editorial,we comment on the article by Peng et al.Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage.The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound,endoscopic ultrasound(EUS),or both.Endoscopic retrograde cholangiopancreatography(ERCP)has been primarily recommended for the management of biliary obstruction,while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage(PTBD)are alternative choices for cases where ERCP has failed or is impossible.PTBD is limited by shortcomings of a higher rate of adverse events,more reinterventions,and severe complications.EUS-guided biliary drainage has a lower rate of adverse events than PTBD.EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)enables EUS-guided biliaryenteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire.The present meta-analysis showed that ECELAMS has a high efficacy and safety in relieving biliary obstruction in general,although the results of LAMS depending on the site of biliary obstruction.This study has highlighted the latest advances with a larger sample-based comprehensive analysis.
文摘This editorial delves into Peng et al's article,published in the World Journal of Gastrointestinal Surgery.Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing metal stents(ECE-LAMS)in ultrasound-guided biliary drainage for alleviating malignant biliary obstruction.Examining 14 studies encompassing 620 participants,the research underscores a robust technical success rate of 96.7%,highlighting the efficacy of ECE-LAMS,particularly in challenging cases which have failed endoscopic retrograde cholangio pancreatography.A clinical success rate of 91.0% underscores its impact on symptom alleviation,while a reasonably tolerable adverse event rate of 17.5% is observed.However,the 7.3% re-intervention rate stresses the need for post-procedural monitoring.Subgroup analyses validate consistent outcomes,bolstering the applicability of ECE-LAMS.These findings advocate for the adoption of ECELAMS as an appropriate approach for biliary palliation,urging further exploration in real-world clinical contexts.They offer valuable insights for optimizing interventions targeting malignant biliary obstruction management.
文摘BACKGROUND The introduction of lumen-apposing metal stents(LAMS)for endoscopic ultrasound(EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings.Nevertheless,the procedure may conceal unexpected pitfalls.LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences.Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure.To date,no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.AIM To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy(EUS-CDS),gallbladder drainage(EUS-GBD)and pancreatic fluid collections drainage(EUS-PFC)and to describe the endoscopic rescue strategies adopted under the circumstance.METHODS We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022.The search was carried out using the exploded medical subject heading terms“lumen apposing metal stent”,“LAMS”,“endoscopic ultrasound”and“choledochoduodenostomy”or“gallbladder”or“pancreatic fluid collections”.We included in the review on-label EUS-guided procedures namely EUS-CDS,EUS-GBD and EUS-PFC.Only those publications reporting EUS-guided LAMS positioning were considered.The studies reporting a technical success rate of 100%and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment,while studies not reporting the causes of technical failure were excluded.Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques.The following data were collected from each study:Author,year of publication,study design,study population,clinical indication,technical success,reported number of misdeployment,stent type and size,flange misdeployed and type of rescue strategy.RESULTS The overall technical success rate of EUS-CDS,EUS-GBD and EUS-PFC was 93.7%,96.1%,and 98.1%respectively.Significant rates of LAMS misdeployment have been reported for EUS-CDS,EUS-GBD and EUS-PFC drainage,respectively 5.8%,3.4%,and 2.0%.Endoscopic rescue treatment was feasible in 86.8%,80%,and 96.8%of cases.Non endoscopic rescue strategies were required only in 10.3%,16%and 3.2%for EUS-CDS,EUS-GBD,and EUS-PFC.The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%,8%and 64.5%and stent-in-stent in 23.5%,60%,and 12.9%,respectively for EUSCDS,EUS-GBD,and EUS-PFC.Further therapeutic option were endoscopic rendezvous in 11.8%of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1%of EUS-PFC.CONCLUSION LAMS misdeployment is a relatively common adverse event in EUS-guided drainages.There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario,anatomical characteristics,and local expertise.In this review,we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used,with the aim of providing useful data for endoscopists and to improve patient outcomes.
文摘In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUSguided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and ECLAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.
基金This study was supported by National Natural Science Foundation of China(81570507)National Key Research and Development Program of China(2017YFC0113600)。
文摘Background:Endoscopic ultrasound(EUS)-guided transmural drainage for pancreatic fluid collections(PFCs)has become the first-line treatment with quicker recovery and more minor injury compared with surgery and percutaneous drainage.The efficacy of stents implantation and drainage for different PFCs remains controversial,especially lumen-apposing metal stents(LAMS).This study aimed to compare the efficacy and safety of LAMS drainage for pancreatic pseudocysts(PPC)and walled-off necrosis(WON).Methods:A meta-analysis was performed for LAMS drainage for WON and PPC by systematically searching PubMed,Cochrane,and Embase databases from January 2010 to January 2020.From 2017 to 2019,12 patients who were treated with LAMS drainage for PFCs in our medical center were also reviewed and included in this study.Results:Combining 11 copies of documents with the data from our medical center,a total of 585 patients with PFCs were enrolled in this meta-analysis,including 343 patients with WON and 242 with PPC.The technical success rate in WON is not significantly different from that of PPC(P=0.08>0.05).The clinical success of LAMS placement was achieved in 99%vs 89%in PPC and WON,respectively(RR=0.92,95%CI:0.86-0.98,P=0.01<0.05).The further intervention of direct endoscopic necrosectomy was required by 60%of patients in WON group.There was no significant difference in the incidence of adverse events,including infection,bleeding,stent migration and stent occlusion,after LAMS placement between WON and PPC.Conclusions:Endoscopic ultrasound-guided LAMS for PFCs are feasible,effective with preferable technical and clinical success rates.The clinical effect of LAMS on PPC is slightly better than that of WON,but its adverse reactions still need to be verified in a large-sample prospective study.
文摘Background:Fluoroscopy is often used during the endoscopic drainage of pancreatic-fluid collections(PFCs).An electrocautery-enhanced coaxial lumen-apposing,self-expanding metal stent(ELAMS)facilitates a single-step procedure and may avoid the need for fluoroscopy.This study compares the treatment outcomes using ELAMS with and without fluoroscopy.Methods:Patients with PFCs who had cystogastrostomy from January 2014 to February 2017 were enrolled.Two groups were studied based on fluoroscopy use.Technical success was defined as uneventful insertion of ELAMS at time of procedure.Clinical success was defined as(i)clinical resolution of symptoms after the procedure and(ii)>75%reduction in cyst size on computed tomography 8 weeks after stent placement.Adverse events including bleeding,stent migration,and infection were recorded.Results:A total of 21 patients(13 males)had PFCs drainage with ELAMS in the study period.The mean age was 51.6614.2 years.Thirteen patients had walled-off necrosis while eight had a pancreatic pseudocyst.The mean size of the PFCs was 11.363.3 cm.Fluoroscopy was used in seven cases(33%)and was associated with a longer procedure time compared to non-fluoroscopy(43.1610.4 vs 33.3610.5 min,P=0.025).This association was independent of the size,location,or type of PFCs.Fluoroscopy had no effect on the technical success rates.In fluoroless procedures,the clinical resolution was 91%as compared to 71%in fluoroscopy procedures(P=0.52)and the radiologic resolution was 57%as compared to 71%in fluoroscopy procedures(P=0.65).Three cases of stent migration/displacement occurred in the fluoroless procedures.Conclusions:ELAMS may avoid the need for fluoroscopy during cystogastrostomy.Procedures without fluoroscopy were significantly shorter and fluoroscopy use had no impact on the technical or clinical success rates.
文摘This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.
文摘The role of endoscopy in pathologies of the bile duct and gallbladder has seen notable advancements over the past two decades.With advancements in stent technology,such as the development of lumen-apposing metal stents,and adoption of endoscopic ultrasound and electrosurgical principles in therapeutic endoscopy,what was once considered endoscopic failure has transformed into failure of an approach that could be salvaged by a second-or third-line endoscopic strategy.Incorporation of these advancements in routine patient care will require formal training and multidisciplinary acceptance of established techniques and collaboration for advancement of experimental techniques to generate robust evidence that can be utilized to serve patients to the best of our ability.
文摘Commentary on the article written and published by Peng et al,investigating the role of endoscopic ultrasound(EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiopan-creatography(ERCP).For 40 years endoscopic biliary drainage was synonymous with ERCP,and EUS was used mainly for diagnostic purposes.The advent of therapeutic EUS has revolutionized the field,especially with the development of a novel device such as electrocautery-enhanced lumen-apposing metal stents.Complete biliopancreatic endoscopists with both skills in ERCP and in interven-tional EUS,would be ideally suited to ensure patients the best drainage technique according to each individual situation.
文摘Endoscopic ultrasound-guided biliary drainage(EUS-BD) has been developed as an alternative means of biliary drainage for malignant biliary obstruction(MBO).Compared to percutaneous transhepatic biliary drainage,EUS-BD offers effective internal drainage in a single session in the event of failed endoscopic retrograde cholangiopancreatography and has fewer adverse events(AE). In choosing which technique to use for EUS-BD,a combination of factors appears to be important in decision-making; technical expertise,the risk of AE,and anatomy. With the advent of novel all-in-one EUS-BD specific devices enabling simpler and safer techniques,as well as the growing experience and training of endosonographers,EUS-BD may potentially become a first-line technique in biliary drainage for MBO.
文摘BACKGROUND Endoscopic drainage of walled-off necrosis(WON) is still a challenge due to stentassociated problems. We explored endoscopic gastric fenestration(EGF) as an innovative alternative intervention.AIM To assess the feasibility, efficacy and safety of EGF for WON.METHODS Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound(EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.RESULTS EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min(EUS assessment, 32.3 min;initial fenestration, 28.8 min;expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent(LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.CONCLUSION EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.
文摘Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-standard therapy for these patients, as simultaneous endoscopic biliary and duodenal stenting is currently a feasible and widely used technique, with a high technical success in expert hands. In recent years, endoscopic ultrasonography(EUS) has evolved from a diagnostic to a therapeutic procedure, and is now increasingly used to guide biliary drainage, especially in cases of failed endoscopic retrograde cholangiopancreatography(ERCP). The advent of lumen-apposing metal stents(LAMS) has expanded EUS therapeutic options, and changed the management of synchronous bilioduodenal stenosis. The most recent literature regarding endoscopic treatments for synchronous biliary and duodenal malignant stenosis has been reviewed to determine the best endoscopic approach, also considering the advent of an interventional EUS approach using LAMS.
文摘Gastric outlet obstruction(GOO)is a clinical syndrome characterized by postprandial vomiting,abdominal pain,bloating and,in advanced cases,by weight loss secondary to inadequate oral intake.This clinical entity may be caused by mechanical obstruction,either benign or malignant,or by motility disorders.In this review we will focus on malignant GOO and on its endoscopic ultrasound(EUS)-guided palliative treatment.The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas;other causes include duodenal or ampullary neoplasms,gastric lymphomas,retroperitoneal lymphadenopathies and,more infrequently,gallbladder and bile duct cancers.Surgery represents the treatment of choice when radical and curative resection is potentially feasible;if the malignant cause is not likely to be completely resected,palliative treatments should be proposed.Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent.Both treatments are effective;however,endoscopic stent placement is less invasive and it is associated with good short-term results,while surgery provides longer-lasting effects with a lower frequency of reintervention.In the last few years,EUS-guided gastroenterostomy(GE)has been proposed as palliative treatment for malignant GOO.This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction,through the deployment of a lumen-apposing metal stent under EUS-view.EUS-GE has the advantage of being as minimally invasive as enteral stent placement,and of guaranteeing long-term results similar to those of surgery.
基金Supported by the China Postdoctoral Science Foundation,No.2019M661174National Natural Science Foundation of China,No.81770655the Natural Science Foundation of Liaoning Province,No.2019-MS-359.
文摘BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)is an alternative method for the surgical treatment of gastric outlet obstruction,but it is regarded as a challenging technique for endoscopists as the bowel is highly mobile and can tent away.Thus,the technique requires superb skill.In order to improve EUS-GE,we have developed a retrievable puncture anchor traction(RPAT)device for EUSGE to address the issue of bowel tenting.AIM To evaluate the feasibility of RPAT-assisted EUS-GE using an animal model.METHODS Six Bama mini pigs each weighing between 15 and 20 kg underwent the RPATassisted EUS-GE procedure.Care was taken to ensure that the animals experienced minimal pain and discomfort.Two days prior to the procedure the animals were limited to a liquid diet.No oral intake was allowed on the day before the procedure.A fully covered metal stent was placed between the stomach and the intestine using the RPAT-assisted EUS-GE method.Infection in the animals was determined.Four weeks after the procedure,a standard gastroscope was inserted into the pig’s intestine through a previously created fistula in order to check the status of the stents under anesthesia.The pig was euthanized after examination.RESULTS The RPAT-assisted EUS-GE method allowed placement of the stents with no complications in all six animals.All the pigs tolerated a regular diet within hours of the procedure.The animals were monitored for four weeks after the RPATassisted EUS-GE,during which time all of the animals exhibited normal eating behavior and no signs of infection were observed.Endoscopic imaging performed four weeks after the RPAT-assisted EUS-GE showed that the stents remained patent and stable in all the animals.No tissue overgrowth or ingrowth was observed in any case.Each animal had a mature fistula,and the stents were removed without significant bleeding.Autopsies of all six pigs revealed complete adhesion between the intestine and the stomach wall.CONCLUSION The RPAT method helps reduce mobility of the bowel.Therefore,the RPATassisted EUS-GE method is a minimally invasive treatment modality.
文摘BACKGROUND The endoscopic management of benign short post-anastomotic ileocolonic stricture(PAICS) that is refractory to primary and secondary treatment modalities remains challenging.The lumen-apposing metal stent(LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy.LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents(FCSEMSs).CASE SUMMARY This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature.We report a life-saving technique not previously documented and the use of technology to improve patient outcomes.The six patients(median age,75 years) suffered from vomiting,constipation and recurrent abdominal pain,with symptoms starting 23-25 wk post-surgery.The median stricture length was 1.83 cm.All six patients underwent successful and uneventful bi-flanged metal stent(BFMS)-LAMS placement for benign PAICS.All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal.According to the literature,the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding.Conversely,FCSEMS has a high migration rate(15%-50%).CONCLUSION The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options,allowing them to avoid more invasive surgical interventions.The BFMS(NAGI stent) is longer and larger than the prototype AXIOS-LAMS,which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.
文摘BACKGROUND A recent expert panel issued recommendations about the technical aspects of direct endoscopic necrosectomy(DEN) for pancreatic walled-off necrosis(WON).However, significant technical heterogeneity still exists among endoscopists.AIM To report the outcomes of our DEN technique and how it differs from a recent expert consensus statement and previous studies.METHODS Medical records of patients with WON who underwent DEN from September2016-May 2019 were queried for the following information: Age, gender,ethnicity, etiology of acute pancreatitis, WON location and size, DEN technical information, adverse events(AEs) and outcomes. Adverse events were graded according to the American Society of Gastrointestinal Endoscopy Lexicon grading system. Technical success was defined as adequate lumen apposing metal stent(LAMS) deployment plus removal of ≥ 90% of necrosum. Clinical success was defined as complete resolution of WON cavity by imaging and resolution of symptoms at ≤ 3 months(mo) after last DEN. Data analysis was performed using mean and standard deviation for continuous variables,frequency and proportion for categorical variables, and median and range for interval data.RESULTS A total of 21 patients underwent DEN. Most of them were Hispanic and their mean age was 51 ± 17 years. The majority of the collections were located in the body of the pancreas and the mean size was 13 cm ± 5 cm. The most common indication was persistent vomiting. Antibiotics were administered only in cases of infected necrosis. All LAMS were placed without radiological guidance,dilated the same day of deployment and removed after a mean of 27 ± 11 d.Routine cross-sectional imaging immediately after drainage was not performed.The mean interval between DEN sessions was 7 ± 4 d and the mean number of DEN/patient was 3 ± 2. Technical and clinical success rates were both 95%. AEs were seen in 5 patients and included: Sepsis(2), stent migration(1), stent maldeployment(1), perforation(1). The sensitivity and positive predictive value of an occluded LAMS leading to sepsis was 50% and 0.11 respectively. No fatalities were observed.CONCLUSION Our DEN technique differed significantly from the one recommended by a recent expert panel and the one published in previous studies. Despite these differences excellent clinical outcomes were obtained.
文摘Afferent loop obstruction(ALO)is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy.With advances in chemotherapy,the incidence of malignant ALO is increasing.Malignant ALO can be complicated by ischemia,gangrenous bowel,pancreatitis,and ascending cholangitis.Moreover,the general condition of patients with recurrent cancer is often poor.Therefore,accurate and rapid diagnosis and minimally invasive treatments are required.However,no review articles on the diagnosis and treatment of malignant ALO have been published.Through literature searching,we reviewed related articles published between 1959 and 2020 in the PubMed database.Herein,we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives.Endoscopic transluminal self-expandable metal stent(SEMS)placement is considered the standard treatment for malignant ALO,as this procedure is well established and less invasive.However,with the development of interventional endoscopic ultrasound(EUS)in recent years,the usefulness of EUS-guided gastrojejunostomy has been reported.Moreover,through indirect comparison,this approach has been reported to be superior to transluminal SEMS placement.It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.
