What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment modality for bile duct obstruction. When ERCP is unsuccessful, percutaneous transhepatic biliary drainage can be an alternative method. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a treatment option for biliary obstruction, especially after ERCP failure. EUS-BD offers transluminal intrahepatic and extrahepatic drainage through a transgastric and transduodenal approach. EUS-guided hepaticogastrostomy (EUS-HGS) is an excellent choice for patients with hilar strictures or those with a surgically altered anatomy. The optimal steps in EUS-HGS are case selection, bile duct visualization, puncture-site selection, wire insertion and manipulation, tract dilation, and stent placement. Caution should be taken at each step to prevent complications. Dedicated devices for EUS-HGS have been developed to improve the technical success rate and reduce complications. This technical review focuses on the essential practical points at each step of EUS-HGS.

What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment modality for bile duct obstruction. When ERCP is unsuccessful, percutaneous transhepatic biliary drainage can be an alternative method. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a treatment option for biliary obstruction, especially after ERCP failure. EUS-BD offers transluminal intrahepatic and extrahepatic drainage through a transgastric and transduodenal approach. EUS-guided hepaticogastrostomy (EUS-HGS) is an excellent choice for patients with hilar strictures or those with a surgically altered anatomy. The optimal steps in EUS-HGS are case selection, bile duct visualization, puncture-site selection, wire insertion and manipulation, tract dilation, and stent placement. Caution should be taken at each step to prevent complications. Dedicated devices for EUS-HGS have been developed to improve the technical success rate and reduce complications. This technical review focuses on the essential practical points at each step of EUS-HGS.

Endoscopic Ultrasound-Guided Vascular Therapy for Portoduodenal Fistula

Portoenteric fistula is a rare cause of massive upper gastrointestinal bleeding. Most cases can be treated with radiointervention or surgery, but portoenteric fistula is associated with a high mortality. We reported a case of intermittent massive upper gastrointestinal bleeding in a 33-year-old man with cholangiocarcinoma who underwent surgical resection followed by chemoradiation. A portoduodenal fistula due to chronic duodenal ulceration was identified. The bleeding was successfully controlled by endoscopic ultrasound-guided coil placement through the duodenal bulb using the anchoring technique. Follow-up endoscopy and computed tomography scan showed multiple coil placements between a part of the portal vein and the duodenal bulb without any evidence of portal vein thrombosis. There were no complications, and bleeding did not recur during the 8-month follow-up period.

Successful Closure of a Benign Refractory Tracheoesophageal Fistula Using an Over-the-Scope Clip after Failed Esophageal Stent Placement and Surgical Management

Tracheoesophageal fistulas (TEFs) have traditionally been managed surgically, but the endoscopic approach is widely performed as a less invasive alternative. Different closure techniques have been proposed with inconsistent results. An over-the-scope clip (OTSC) appears to be a reasonable option, but long-term results have not been well defined. We report the long-term outcomes of a complex case of successful closure of a benign refractory TEF using an OTSC after failed surgical management and esophageal stent placement.

Endoscopic Ultrasound-Guided Vascular Therapy for Portoduodenal Fistula

Portoenteric fistula is a rare cause of massive upper gastrointestinal bleeding. Most cases can be treated with radiointervention or surgery, but portoenteric fistula is associated with a high mortality. We reported a case of intermittent massive upper gastrointestinal bleeding in a 33-year-old man with cholangiocarcinoma who underwent surgical resection followed by chemoradiation. A portoduodenal fistula due to chronic duodenal ulceration was identified. The bleeding was successfully controlled by endoscopic ultrasound-guided coil placement through the duodenal bulb using the anchoring technique. Follow-up endoscopy and computed tomography scan showed multiple coil placements between a part of the portal vein and the duodenal bulb without any evidence of portal vein thrombosis. There were no complications, and bleeding did not recur during the 8-month follow-up period.

Usefulness of stent placement above the papilla, so-called, ‘inside stent’

Stent occlusion and cholangitis are common complications after endoscopic biliary stenting caused by duodenobiliary refluxes and food impaction. To prolong the stent patency, the concept of stenting above the papilla, so-called inside stent, has been developed. Various studies of the inside stent in the treatment of both benign and malignant biliary obstruction have been published, with a promising result. However, most studies were retrospective, with wide variation of stent type and the etiology of biliary obstruction. This review aims to summarize the principle, evidence, and the usefulness of inside biliary stent.

Groove Pancreatitis: Endoscopic Treatment via the Minor Papilla and Duct of Santorini Morphology

BACKGROUND/AIMS: Groove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published. METHODS: Seven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed. RESULTS: There were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP. CONCLUSIONS: Disconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.