Revolution of hands-on model for interventional EUS: How to make a training model.

EUS interventions have an increasing role in the treatment for hepatobiliary-pancreatic diseases. However, the procedure itself is not frequently performed, needs expertise, and carries a high risk of complications. With these limitations, the hands-on practice model is very important for the endoscopist in training for EUS intervention. There have been various hands-on models for EUS interventions, ranging from in vivo living pig model to all-synthetic model. Although a living model provides realistic sensation, the preparation is complex and increases concerns for zoonotic issues. All-synthetic models are easier to prepare and store but not realistic and still need the room for improvement. Hybrid ex vivo model is more widely available and provides various training procedures but still needs special preparation for the porcine tissue.

Three-year evaluation of a novel, nonfluoroscopic, all-artificial model for EUS-guided biliary drainage training for the impact to practice: A prospective observational study (with videos).

Background and Objectives: EUS-guided biliary drainage (EUS-BD) required a dedicated training. We developed and evaluated a nonfluoroscopic, all-artificial training model known as Thai Association for Gastrointestinal Endoscopy Model 2 (TAGE-2) for the training of EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). We hypothesize that trainers and trainees would appreciate the ease of the nonfluoroscopy model and increase their confidence to start their real procedures in humans. Materials and Methods: We prospectively evaluated the TAGE-2 launched in two international EUS hands-on workshops and have followed trainees for 3 years to see long-term outcomes. After completing the training procedure, the participants answered questionnaires to assess their immediate satisfaction of the models in and also the impact of these models on their clinical practice 3 years after the workshop. Results: A total of 28 participants used the EUS-HGS model and 45 participants used the EUS-CDS model. The EUS-HGS model was rated as excellent by 60% of beginners and 40% by experienced and the EUS-CDS model was rated as excellent by 62.5% of beginners and 57.2% of experienced. The majority of trainees (85.7%) have started the EUS-BD procedure in humans without additional training in other models. Conclusion: Our nonfluoroscopic, all-artificial model for EUS-BD training is convenient to be used with good-to-excellent satisfaction scored by the participants in most aspects. It can help the majority of trainees start their procedures in humans without additional training in other models.

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.

Simple Clinical Score to Predict 24-Week Survival Times in Patients with Inoperable Malignant Distal Biliary Obstruction as a Tool for Selecting Palliative Metallic or Plastic Stents.

BACKGROUND AND AIM: Endoscopic biliary drainage (EBD) is the mainstay treatment for inoperable malignant distal biliary obstruction (MDBO). Some authorities suggest that metallic stents are more cost-effective than plastic stents in patients with expected survival of at least 6 months. However, studies attempting to define the predictive factors for such survival times are limited. This study aims to develop a scoring system for predicting a survival time of <24 weeks in these patients. METHOD: Patients with MDBO from inoperable periampullary cancers who underwent EBD at Songklanagarind Hospital during 2004-2009 were retrospectively analyzed. Baseline clinical, laboratory, and imaging data were retrieved. The survival time data were retrieved from the medical records and Thailand's civil registration database. Multivariate Cox regression model coefficients were used in the development of a survival time prediction scoring system. RESULTS: Ninety-eight patients were included. The overall median survival was 17.6 weeks. Fifty-seven (58.1%) survived <24 weeks. By multivariate analysis, cancer type and liver metastasis were significant predictive factors. The Simple Clinical Score (SCS) was calculated from (2× liver metastasis) + (1× pancreatic cancer) - (2× ampullary cancer) - (1× cholangiocarcinoma), when 1 and 0 were used for the presence and absence of each factor, respectively. The cutoff value of the score ≥0 had a sensitivity and specificity of 0.77 and 0.63, respectively, for predicting a survival time of <24 weeks, with AUC of 0.76. The median survival of patients with SCS <0 and ≥0 was 36.6 and 13.1 weeks, respectively. CONCLUSION: The scoring system from this study may be beneficial for clinicians to select the appropriate stents in endoscopic biliary drainage in inoperable MDBO patients.

Prospective randomized trial of EUS-assisted ERCP without fluoroscopy versus ERCP in common bile duct stones.

BACKGROUND AND AIMS: ERCP with stone removal is the standard treatment for common bile duct stones (CBDSs). Radiation exposure is a risk to the endoscopist and patient. EUS-guided ERCP without fluoroscopy (EGEWF) in patients with CBDSs is feasible, but the efficacy and safety compared with ERCP is unknown. We aimed to compare the efficacy and safety of EGEWF with ERCP in CBDS removal. METHODS: A prospective randomized study was done in 114 patients with CBDSs who met inclusion criteria. These patients were equally randomized into the EGEWF and ERCP groups. In the EGEWF group, ERCP was performed by cannulation without fluoroscopy. Balloon sweeping was done after sphincterotomy to clear the stones until the number of stones matched the number detected by EUS and the stone clearance (SC) was confirmed by cholangiography. In the ERCP group, ERCP was performed in the standard manner. The cannulation rates, SC rates, total procedure and fluoroscopic times, and adverse event rates were analyzed. RESULTS: After exclusion of 3 patients, 55 were in the EGEWF group and 56 in the ERCP group. Demographic data, laboratory data, stone characteristics, CBD diameter, and number of patients with periampullary diverticulum were not different between the 2 groups. The cannulation success rates in the EGEWF (96.35%) and ERCP (100%) groups were similar (P = .243). The SC rate in the EGEWF group (85.5%) was inferior to the ERCP group (100%) (P = .002). The SC rate based on the number of stones retrieved that matched the number by EUS was correct in 94%. More than 2 stones may increase the failure rate of SC in EGEWF. The adverse event rates and the total procedure times were not different between the groups. CONCLUSIONS: EGEWF was inferior to ERCP in terms of SC; however, no radiation exposure is beneficial for selected patients. (Clinical trial registration number: NCT02870686.).

Endoscopic ultrasonography-guided biliary and pancreatic duct interventions.

Drainage of obstructed bile duct and pancreatic duct under endoscopic ultrasonography (EUS) guidance has evolved into viable techniques suitable for patients with failed endoscopic retrograde cholangiopancreatography (ERCP) and/or altered surgical anatomy. One of the major advantages of EUS guidance is the possibility of multiple access points depending upon patient and ductal anatomy. Unlike ERCP, an approachable papilla is not a requisite for successful EUS-guided biliary or pancreatic ductal drainage. Moreover, as the access is away from the papilla, there is the possibility of reduced pancreatitis. A variety of procedures have become available for EUS-guided drainage, and it is important to develop standard terminology and procedural details. EUS-specific stents, including lumen-apposing metal stents have recently become available, and are likely to impact the outcomes of these procedures. Available data show a high success rate and acceptable adverse event rate for EUS-guided biliary drainage. Success rate appears to be low for pancreatic duct drainage because of a variety of reasons. Outcomes of EUS-guided biliary drainage appear equivalent to percutaneous drainage and ERCP. EUS-guided gallbladder drainage appears promising for patients requiring gallbladder drainage but unfit for surgery. Further large controlled studies are needed to evaluate the exact role of these procedures.

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy.

AIM: To evaluate the efficacy of endoscopic ultrasound guided biliary drainage (EUS-BD) in patients with surgically altered anatomies. METHODS: We performed a search of the MEDLINE database for studies published between 2001 to July 2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only full-text English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth I; group 2, Billroth II; group 4, Roux-en-Y with gastric bypass; and group 3, all other types. RESULTS: Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion. CONCLUSION: EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrograde-cholangiography in centers with expertise in EUS-BD procedures in a research setting.