EUS-guided endoscopic internal drainage with lumen-apposing metal stent for symptomatic hepatic cysts: a case series (with video).

Background and study aims Simple hepatic cysts (SHCs) are usually asymptomatic and detected incidentally. However, larger cysts may present with clinical signs and require treatment such as percutaneous aspiration or surgery with non negligeable rate of recurrence. We report a series of 13 consecutive patients who underwent EUS-guided lumen-apposing metal stent (LAMS) drainage of SHCs of the right and left liver. Patients and methods Nine men and four women, average age 71.9 years, underwent EUS-guided LAMS cyst drainage because of significant symptoms. At 1 month, LAMS was exchanged for a double pigtail stent (DPS), which was left in place for 3 months. Nine of the SHCs were located in the right liver and four in the left. The average diameter was 22.2 cm. Results Thirteen LAMS were successful delivered in all patients. However only 12 of 13 (92.3 %) remained in place. In one case, the LAMS slipped out immediately and was promptly removed and the cyst treated percutaneously. One of 12 patients experienced bleeding, which was treated conservatively. In seven patients, the LAMS was exchanged for a DPS; in the other five, it was successfully left in place until the patients died, given their comorbidities. At 10.5 months of follow-up, none of the SHCs had recurred. Conclusions EUS-guided LAMS drainage permits treatment of symptomatic SHCs without recurrence and with few adverse events. Comparative studies are needed to consider this approach as first intention.

Long-term Outcomes of Combined Endoscopic-Radiological Approach for the Management of Complete Transection of the Biliary Tract.

BACKGROUND: Complete transection of the main bile duct (CTMD) is a major complication during hepato-bilio-pancreatic (HBP) surgery and is associated with high morbidity and mortality. In recent years, a combined endoscopic-radiological approach (CERA) for minimally invasive treatment of CTMD has been introduced, but evidence on its long-term outcomes is limited. Our aim is to report efficacy, safety, and long-term outcomes of CERA for the management of post-surgical CTMD in a tertiary referral center. METHODS: All consecutive patients referred for CTMD after HBP surgery between February 2012 and January 2021 were included in this study. CERA was first performed to re-establish biliary tree continuity, and then multiple biliary plastic stents were deployed to guarantee biliary tree reconstruction. Anthropometric, clinical, procedural (endoscopic/radiologic/surgical), and follow-up data were collected and analyzed. Each lesion was classified according to Strasberg classification. RESULTS: Overall, 60 patients (age 60.5 years, range 28-91), 38 F (61.7%), underwent CERA. Mean interval from surgery to endoscopic treatment was 13.2 days. Mean treatment duration was 526 days (SD ± 415) with a median number of 8 endoscopic sessions (range 1-33). Mean length of the biliary defect was 17.6 mm (SD ± 11.5). Long-term clinical success was achieved in 33/49 (67.3%) of patients. Treatment failure was experienced in 16/49 (32.7%) patients, while after an average follow-up of 41 months, stricture recurrence was observed in 3/36 (8.3%) patients. CONCLUSIONS: CERA is a minimally invasive and effective technique to re-establish the continuity of the biliary tract after CTMD, achieving permanent restoration in over half of treated patients.

Endoscopic Management of Bariatric Surgery Complications According to a Standardized Algorithm.

BACKGROUND AND AIMS: Endoscopy is effective in management of bariatric surgery (BS) adverse events (AEs) but a comprehensive evaluation of long-term results is lacking. Our aim is to assess the effectiveness of a standardized algorithm for the treatment of BS-AE. PATIENTS AND METHODS: We retrospectively analyzed 1020 consecutive patients treated in our center from 2012 to 2020, collecting data on demographics, type of BS, complications, and endoscopic treatment. Clinical success (CS) was evaluated considering referral delay, healing time, surgery, and complications type. Logistic regression was performed to identify variables of CS. RESULTS: In the study period, we treated 339 fistulae (33.2%), 324 leaks (31.8%), 198 post-sleeve gastrectomy twist/stenosis (19.4%), 95 post-RYGB stenosis (9.3 %), 37 collections (3.6%), 15 LAGB migrations (1.5%), 7 weight regains (0.7%), and 2 hemorrhages (0.2%). Main endoscopic treatments were as follows: pigtail-stent positioning under endoscopic view for both leaks (CS 86.1%) and fistulas (CS 77.2%), or under EUS-guidance for collections (CS 88.2%); dilations and/or stent positioning for sleeve twist/stenosis (CS 80.6%) and bypass stenosis (CS 81.5%). After a median (IQR) follow-up of 18.5 months (4.29-38.68), complications rate was 1.9%. We found a 1% increased risk of redo-surgery every 10 days of delay to the first endoscopic treatment. Endoscopically treated patients had a more frequent regular diet compared to re-operated patients. CONCLUSIONS: Endoscopic treatment of BS-AEs following a standardized algorithm is safe and effective. Early endoscopic treatment is associated with an increased CS rate.

Long-term placement of lumen-apposing metal stent after endoscopic ultrasound-guided duodeno- and jejunojejunal anastomosis for direct access to excluded jejunal limb.

BACKGROUND: Management of biliary disorders in patients with altered anatomy may be challenging. Endoscopic ultrasound (EUS)-guided gastrointestinal anastomosis using a lumen-apposing metal stent (LAMS) was introduced to allow endoscopic retrograde cholangiography (ERC) in such cases. However, the appropriate stent indwelling time remains uncertain. We report long-term LAMS deployment after duodenojejunal or jejunojejunal anastomosis (EUS-DJA) to allow endoscopic reinterventions in cases of recurrences. METHODS: 11 consecutive patients underwent EUS-DJA with long-standing LAMS between January 2017 and December 2018. Over a 12-month period, ERC treatment was carried out with multiple endoscopic sessions across the DJA. RESULTS: Technical success was 91 % (10/11) for EUS-DJA and 100 % for ERC. Four patients presented stricture recurrence at a mean of 489 days (standard deviation [SD] 31.7) after the end of ERC treatment. A novel ERC across the LAMS anastomosis was feasible in all cases. At a mean of 781 days (SD 253.1), all LAMS remained in place with no evidence of complications. CONCLUSION: Long-term LAMS placement after EUS-DJA may be feasible and safe for direct access to the excluded limb.

Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study.

BACKGROUND AND STUDY AIMS: Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures. PATIENTS AND METHODS: This retrospective study included 66 consecutive patients presenting with a duodenal stricture impeding the ability to perform an ERCP. Provisional duodenal stenting was performed as a bridge to ERCP. A second endoscopic session was performed to remove the provisional stent and to perform an ERCP. Afterward, a permanent duodenal stent was delivered if necessary. RESULTS: Sixty-six duodenal stents (17 pcSEMS and 49 fcSEMS) were delivered with a median indwelling time of 3.15 (1 - 7) days. Two migrations occurred in the pcSEMS group, 1 of which required lower endoscopy for retrieval. No other procedure-related complications were observed. At second endoscopy a successful ERCP was performed in 56 patients (85 %); 10 patients (15 %) with endoscopic failure underwent PTBD or EUS-BD. Forty patients needed permanent duodenal stenting. CONCLUSIONS: Provisional removable covered duodenal stenting as a bridge to ERCP for duodenal obstruction is safe procedure and in most cases allows successful performance of therapeutic ERCP. This technique could be a sound option as a step up approach before referring such cases for more complex techniques such as EUS-BD or PTBD.

Endoscopic Internal Drainage with Enteral Nutrition (EDEN) for treatment of leaks following sleeve gastrectomy.

BACKGROUND: Endoscopic treatment of gastric leaks (GL) following sleeve gastrectomy (SG) involves different techniques; however, standard management is not yet established. We report our experience about endoscopic internal drainage of leaks using pigtail stents coupled with enteral nutrition (EDEN) for 4 to 6 weeks until healing is achieved. METHODS: In 21 pts (18 F, 41 years), one or two plastic pigtail stents were delivered across the leak 25.6 days (4-98) post-surgery. In all patients, nasojejunal tube was inserted. Check endoscopy was done at 4 to 6 weeks with either restenting if persistent leak, or removal if no extravasation of contrast in peritoneal cavity, or closure with an Over-the-Scope Clip® (OTSC®) if contrast opacifying the crossing stent without concomitant peritoneal extravasation. RESULTS: Twenty-one out of 21 (100 %) patients underwent check endoscopy at average of 30.15 days (26-45) from stenting. In 7/21 (33.3 %) patients leak sealed, 2/7 needed OTSC®. Second check endoscopy, 26.7 days (25-42) later, showed sealed leak in 10 out 14; 6/10 had OTSC®. Four required restenting. One patient, 28 days later, needed OTSC®. One healed at 135 days and another 180 days after four and seven changes, respectively. One patient is currently under treatment. In 20/21 (95.2 %), GL have healed with EID treatment of 55.5 days (26- 180); all are asymptomatic on a normal diet at average follow-up of 150.3 days (20-276). CONCLUSIONS: EDEN is a promising therapeutic approach for treating leaks following SG. Multiple endoscopic sessions may be required.