Combined use of a two-channel endoscope and a flexible tip catheter for difficult biliary cannulation

A 69-year-old woman with jaundice was referred to our hospital. After a final diagnosis of pancreatic cancer with liver metastasis, we performed transpapillary biliary drainage with a covered self-expandable metal stent (SEMS). Three months later, we also placed an uncovered duodenal stent for duodenal stricture in a side-to-end fashion. Another month later, for biliary SEMS obstruction, we attempted a transpapillary approach. A duodenoscope was advanced and a guidewire was passed through the mesh of the duodenal stent into the bile duct with a flexible tip catheter, but the catheter was not. Thus, we exchanged the duodenoscope for a forward-viewing two-channel endoscope and used the left working channel with a flexible tip catheter. By adjusting the axis, we finally succeeded biliary cannulation and accomplished balloon cleaning for recanalization of the SEMS. This is the first case with successful biliary cannulation by combined use of a two-channel endoscope and a flexible tip catheter.

A Prospective Multicenter Study Evaluating Bleeding Risk after Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients Prescribed Antithrombotic Agents

BACKGROUND/AIMS: Although the risk of bleeding after endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is low, the safety of EUS-FNA in patients prescribed antithrom-botic agents is unclear. Therefore, this study evaluated the incidence of bleeding after EUS-FNA in those patients. METHODS: Between September 2012 and September 2015, patients who were prescribed antithrombotic agents underwent EUS-FNA at 13 institutions in Japan were prospectively enrolled in the study. The antithrombotic agents were managed according to the guidelines of the Japanese Gastrointestinal Endoscopy Society. The rate of bleeding events, thromboembolic events and other complications within 2 weeks after EUS-FNA were analyzed. RESULTS: Of the 2,629 patients who underwent EUS-FNA during the study period, 85 (62 males; median age, 74 years) patients were included in this stduy. Two patients (2.4%; 95% confidence interval [CI], 0.6% to 8.3%) experienced bleeding events. One patient required surgical intervention for hemothorax 5 hours after EUS-FNA, and the other experienced melena 8 days after EUS-FNA and required red blood cell transfusions. No thromboembolic events occurred (0%; 95% CI, 0.0% to 4.4%). Three patients (3.5%; 95% CI, 1.2% to 10.0%) experienced peri-puncture abscess formation. CONCLUSIONS: The rate of bleeding after EUS-FNA in patients prescribed antithrombotic agents might be considerable.

Impact of Franseen needle on rapid onsite evaluation and histological examination following endoscopic ultrasonography-guided tissue acquisition in patients with splenic malignant lymphoma

Rapid onsite evaluation [ROSE] following endoscopic ultrasonography [EUS]-guided fine-needle aspiration contributes to the establishment of a diagnosis for various organs. Newly designed three-plane symmetric needles for EUS-guided fine-needle biopsy [EUS-FNB], such as the Franseen needle, have been developed to enable histological core tissue acquisition. However, EUS-guided tissue acquisition for hypervascular splenic lesions remains challenging. Tissue acquisition in cases of splenic malignant lymphoma by using a conventional needle with multiple strokes and suction may result in indeterminate ROSE due to blood contamination and tiny fragments of lymphoma tissue, whereas EUS-FNB by using the Franseen needle with a minimal number of strokes with suction demonstrates qualified specimens for the ROSE as well as histological examination. For splenic malignant lymphomas, EUS-FNB by using the Franseen needle with a limited number of strokes may facilitate qualified specimen acquisition

Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy

The SpyGlass DS system is currently used as a direct video cholangioscope for biliarydiagnostic and therapeutic procedures. In general, the SpyGlass DS cholangioscope is passed through the working channel of a duodenoscope and inserted into a bile duct via duodenal papilla. However, the procedure has been challenging in patients with altered gastrointestinal anatomy due to the retrograde route through a potentially tortuous afferent limb. A therapeutic colonoscope with variable stiffness can offer alternative guidance for SpyGlass DS cholangioscope in patients with surgically altered gastrointestinal anatomy