Symptomatic hepatic cyst treated with endoscopic ultrasound-guided drainage and minocycline hydrochloride injection: a case report.

A 72 year-old male patient with a history of a hepatic cyst presented to our hospital with epigastric pain. The cyst had enlarged to approximately 130 mm and was diagnosed as a symptomatic hepatic cyst. Percutaneous cyst drainage was deemed challenging because of the risk of intestinal perforation; therefore, transgastric endoscopic ultrasound-guided hepatic cyst drainage was performed with external nasal cyst drainage. After cyst shrinkage was confirmed, minocycline hydrochloride was injected into the cyst through the nasal drainage tube, and the nasal cyst drainage was removed. Nine months after treatment, the cyst diameter markedly reduced to 12 mm on computed tomography, and the symptoms improved. In cases where surgery is complex or it is difficult to secure a percutaneous puncture line, endoscopic ultrasound-guided drainage and minocycline hydrochloride injection may be effective if a puncture route can be secured under endoscopic ultrasound.

Endoscopic ultrasound-guided pancreatic fluid collection drainage: Where are we?

Pancreatic fluid collections (PFCs) result from injury to the pancreas from acute or chronic pancreatitis, surgery, or trauma. Management of these collections has evolved over the last 2 decades. The choice of interventions includes percutaneous, endoscopic, minimally invasive surgery, or a combined approach. Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract. In this editorial, we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.

Tardive Peritonitis After Endoscopic Ultrasound-Guided Pancreatic Pseudocyst Drainage: A Case Report.

Here, we report a case of tardive peritonitis after endoscopic ultrasound (EUS)-guided transmural pancreatic pseudocyst drainage. A 50-year-old man was diagnosed with acute pancreatitis and a pancreatic pseudocyst measuring 5 cm. Ten months later, his pancreatic pseudocyst was 10 cm. We performed EUS-guided transmural drainage using a lumen-apposing metal stent. After two months, the stent was replaced with a double-pigtail plastic stent. Two months later, the patient developed fever and abdominal pain, and computed tomography revealed abdominal free air. He was diagnosed with peritonitis due to free air caused by a fistula rupture. The double-pigtail plastic stent was removed, and clipping was performed at the fistula site to achieve closure. The patient's symptoms subsequently improved. Long-term placement of a plastic stent for pancreatic pseudocysts makes recurrence less likely, but late adverse events due to stent placement can occur. Notably, fistula rupture can occur even when the fistula is well-formed several months after the initial drainage.

Endoscopic management of malignant biliary obstructions.

Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field.

Current trends of minimally invasive therapy for cholecystocholedocholithiasis.

Introduction: The minimally invasive approach of endoscopic ultrasound (EUS)-guided procedures for cholecystocholedocholithiasis, such as EUS-guided gallbladder drainage (EUS-GBD), EUS-guided rendezvous (EUS-RV), and EUS-guided biliary drainage (EUS-BD), is affirmed as an effective treatment for patients with acute cholecystitis (AC) who are unfit for surgery and for patients with common bile duct stones (CBDSs) who have experienced a previous ERCP failure. Furthermore, in cases of difficult CBDS extraction during endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy-guided electrohydraulic lithotripsy (CS-EHL) has showed optimal results. The main objective of our study was to evaluate the effectiveness of EUS-GBD and percutaneous gallbladder drainage (PT-GBD) in patients with AC who are unfit for surgery. We also aimed to evaluate the efficacy of EUS-GBD, EUS-BD, and EUS-RV following ERCP failure and the effectiveness of CS-EHL for difficult CBDS extraction in our hospital. The secondary aim was to examine the safety of these procedures. Materials and methods: We conducted a retrospective evaluation of all the EUS-GBD, PT-GBD, EUS-BD, EUS-RV, and CS-EHL procedures, which were prospectively collected in the gastroenterology and digestive endoscopy unit and the general surgery unit from January 2020 to June 2023. The efficacy was expressed in terms of technical and clinical success rates, while safety was assessed based on the rate of adverse events (AEs). Results: We enrolled 83 patients with AC and high surgical risk. Among them, 57 patients (68.7%, 24/57 male, median age 85 ± 11 years) underwent EUS-GBD, and 26 (31.3%, 19/26 male, median age 83 ± 7 years) underwent PT-GBD. The technical and clinical success rates were 96.5 and 100% for EUS-GBD, and 96.1 and 92% for PT-GBD. The AEs for EUS-GBD were 1.7%, and for PT-GBD, it was 12%. ERCP for CBDS extraction failed in 77 patients. Among them, 73 patients (94.8%) underwent EUS-RV with technical and clinical success rates of 72.6% (53/73) and 100%, respectively. No AEs were reported. Four out of 77 patients were directly treated with EUS-BD for pyloric inflammatory stenosis. In 12 patients (16.4%), following unsuccessful EUS-RV with a CBD diameter ≥ 12 mm, an EUS-BD was performed. Both technical and clinical success rates for EUS-BD were 100%, and no AEs were reported. EUS-GBD was the treatment of choice for the remaining 8 (10.9%) patients after failure of both ERCP and EUS-RV. The procedure had high technical and clinical success rates (both at 100%), and no AEs were reported. The 12 difficult CBDS extraction treated with CS-EHL also showed high technical and clinical success rates (both at 100%), with no reported AEs. Conclusion: The minimally invasive approach for cholecystocholedocholithiasis, especially EUS-guided procedures, had high efficacy and safety in treating AC in high-risk surgical patients and CBDS extraction after a previously unsuccessful ERCP.

A case of bladder and pelvic dead space inflammation successfully treated with endoscopic ultrasound drainage.

Key Clinical Message: Interventional endoscopic ultrasound (EUS) is effective not only for biopsy, but also for abscess drainage. We report the first use of EUS to drain inflammation of the bladder and pelvic dead space through the ileal conduit. EUS-guided drainage is effective in treating postoperative abscesses and should be employed more routinely. Abstract: The patient was a 77-year-old man with a vesicoureteral fistula. An ileal conduit was placed after abdominoperineal resection and partial bladder resection for local, postoperative recurrence of rectal cancer. During postoperative chemotherapy, the patient developed a high-grade fever and after a thorough examination, he was diagnosed with bladder and pelvic dead-space inflammation. All urine flowed through the ileal conduit, and it was assumed that secretions from the residual bladder and prostate gland had accumulated in the bladder and pelvic cavity, resulting in infection. A transcutaneous drain was inserted through the perineum and the infection was controlled, but it flared up again after the drain was removed. We concluded that long-term drainage was necessary and successfully controlled the infection by placing a plastic stent through the ileal conduit into the bladder and pelvic dead space under ultrasound endoscopy. This is the first report of ultrasound endoscopic drainage of an abscess through the ileal conduit.

Endoscopic Ultrasound in Pancreatology: Focus on Inflammatory Diseases and Interventions.

Background: Endoscopic ultrasound (EUS) is a main tool in pancreatology for both diagnosis and therapy. It allows minimally invasive differentiation of various diseases, with a minimal degree of inflammation or anatomic variations. EUS also enables interventional direct access to the pancreatic parenchyma and the retroperitoneal space, the pancreatic duct, the pancreatic masses, cysts, vascular structures for diagnostic and therapeutic purposes. Summary: This review aimed to summarize the new developments of EUS in the field of pancreatology, with special interest on inflammation and interventions. EUS enables way to perform pseudocyst drainage, necrosectomy, transenteral drainage and transenteric access of the main pancreatic duct, or the direct visualization or therapy of vascular structures adjacent to the pancreas. Key Messages: EUS has a deep impact on pancreatology, and the development of new diagnostic and interventional approaches to the retroperitoneal space and the pancreas has increased in the last years exponentially, allowing minimal invasive diagnostics and therapy and avoiding surgery and percutaneous therapy.

Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management.

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 EUS-CDS, 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.

Efficacy and safety of endoscopic ultrasound guided drainage of pseudocysts and walled-off necrosis after failure of percutaneous drainage.

BACKGROUND: Endoscopic Ultrasound (EUS) represents the gold standard for initial drainage of pancreatic fluid collections (PFC) due to various etiologies. However, data concerning salvage EUS drainage after initial percutaneous drainage are limited. The purpose of our study was to evaluate the clinical outcomes and safety of EUS-guided drainage of pancreatic collections after failure of percutaneous drainage. METHODS: This retrospective study was conducted in a single, tertiary university center from August 2013 to January 2020. Indication was pancreatic collection after acute pancreatitis with PFC requiring EUS-guided drainage after failure of percutaneous drainage. RESULTS: Twenty-two patients with PFC after acute pancreatitis were included (mean age 64.1 ± 11.3 years) of which 4/22 (18.2%) had pancreatic pseudocyst and 18/22 (81.8%) presented with a walled-off necrosis. Seventy-six interventions were performed among the 22 patients. Lumen-Apposing Metal Stent (LAMS) were used in 5/22 (22.7%) and double pigtail plastic stents in 17/22 (77.3%) of interventions with a median number intervention of 3 per patient (range 1 to 7). Technical success rate was 98.7% (75/76) with an overall clinical success of 81.8% (18/22). Procedure related adverse events rate was 9.1% (2/22) including one bleeding and one pancreatic fistula. Two non-procedure related deaths were observed. CONCLUSION: EUS-guided pancreatic collection drainage is clinically effective and safe after clinical/technical failure of radiological percutaneous management.

Management of severe acute pancreatitis in 2019.

Pancreatic fluid collections (PFCs) are frequent complications in severe acute pancreatitis that are the result of damage to the pancreas to include but not limited to trauma, surgery, autoimmune diseases, alcohol abuse, infections, medications, gallstones, metabolic disorders, and premalignant or malignant conditions. The majority of these collections resolve spontaneously; however, if the collection is infected or causes symptoms to include abdominal pain, nausea, vomiting, diarrhea, fevers, and tachycardia, drainage is indicated. Drainage of PFCs can be accomplished surgically, percutaneously, or endoscopically and should be approached in a multidisciplinary fashion for best overall patient care and outcomes. Before the introduction of endoscopic procedures, surgical and percutaneous drainage was the preferred modality. Today a minimally-invasive "step-up" approach is generally accepted depending upon the specific characteristics of the PFC and clinical presentation. Endoscopic ultrasound-guided PFC drainage is favored due to high success rates, shorter hospital stays, and lower cost. Direct debridement of walled-off pancreatitis can now be performed endoscopically with higher success rates with larger caliber fully covered metal stents. At large, the field of endoscopic techniques has evolved, and more specifically, the management of PFCs continues to evolve with increasing experience and with the advent of new stents and accessories, leading to increased efficacy with less adverse events.

Endoscopic versus percutaneous drainage for pancreatic fluid collection after pancreatic surgery: An up-to-date meta-analysis and systematic review.

Endoscopic ultrasound-guided drainage (EUSD) and percutaneous drainage (PD) have reportedly been used for postoperative pancreatic fluid collection (PFC). However, there is limited evidence regarding safety and efficacy in a comparison of EUSD and PD for postoperative PFC. We conducted a search of the databases PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov, to August 2020. Studies comparing EUSD and PD for postoperative PFC were included. The outcomes included technical success, clinical success, adverse events, and recurrence of PFC.We included a total of 6 studies involving 247 patients in the current study. There was no significant difference between EUSD and PD in terms of technical success (odds ratio [OR] = 0.95; 95% confidence interval [CI]: 0.29-3.12; p = 0.94) and clinical success (OR = 1.36; 95% CI: 0.68-2.72; p = 0.39). PFC recurrence and adverse events were similar between the two groups (OR = 1.82; 95% CI: 0.75-4.37; p = 0.18 and OR = 0.78; 95% CI: 0.31-1.92; p = 0.58, respectively).This meta-analysis confirmed that EUSD has comparable safety and efficacy to PD for postoperative PFC. Additional high-quality studies are required in the future.

Subdiaphragmatic abscess due to penetration of a duodenal ulcer successfully treated with endoscopic transgastric drainage: a case report.

BACKGROUND: Subdiaphragmatic abscesses are sometimes caused by intraabdominal infections. We report a case of endoscopic ultrasound-guided transgastric drainage. CASE PRESENTATION: A 75-year-old Asian man was referred to our hospital for treatment for upper gastrointestinal bleeding. On admission, blood tests showed a marked inflammatory response, and abdominal computed tomography showed free air in the abdominal cavity and a left subdiaphragmatic abscess. Therefore, the patient was diagnosed with an intraabdominal abscess associated with a perforated duodenal ulcer. Because he did not have generalized peritonitis, fasting and antibiotic treatment were the first therapies. However, because of the strong pressure on the stomach associated with the abscess and difficulty eating, we performed endoscopic ultrasound-guided transgastric drainage. After treatment, the inflammatory response resolved, and food intake was possible. The patient's condition remains stable. CONCLUSIONS: Drainage is the basic treatment for subdiaphragmatic abscesses; however, percutaneous drainage is often anatomically difficult, and surgical drainage is common. We suggest that our success with endoscopic ultrasound-guided transgastric drainage in this patient indicates that this approach can be considered in similar cases and that it can be selected as a minimally invasive treatment method.

A Rare Case of Delayed Perigastric Abscess after Curative Resection of Early Gastric Cancer by Uncomplicated Endoscopic Submucosal Dissection: Successful Treatment with Endoscopic Ultrasound-guided Drainage.

A 72-year-old man had undergone uncomplicated endoscopic submucosal dissection (ESD) with en bloc resection of a localized 20-mm IIc lesion in the anterior wall of the gastric angle. Twenty-eight days later, he was re-admitted with epigastric pain of one-week duration. Contrast-enhanced computed tomography (CT) revealed a 60-mm mass bordered by viscera; repeat endoscopy confirmed a smooth elevated submucosal tumor at the greater curvature on the oral side of the post-ESD ulcer. We diagnosed him with a perigastric abscess as a complication of ESD and performed endoscopic ultrasound-guided drainage. Subsequently, the symptoms and blood inflammatory parameters improved, and follow-up CT showed the disappearance of the abscess.

Endoscopic ultrasonography-guided drainage for spontaneous rupture of a pancreatic pseudocyst into the peritoneal cavity in a patient with autoimmune pancreatitis.

A 75-year-old man was referred to our hospital due to a huge pancreatic cyst. Computed tomography revealed a monocular cyst 15 cm in size without a solid mass lesion nearby. He was diagnosed with pancreatic pseudocyst. Endoscopic ultrasound (EUS)-guided drainage was planned for the next day due to abdominal distension; however, the pseudocyst ruptured into the peritoneal cavity before treatment could be applied. To prevent the progression of peritonitis, EUS-guided drainage of the pseudocyst was performed. A nasocystic tube and plastic stent were placed into the ruptured cyst via the gastric wall through the same puncture tract. After the treatment, the cyst rapidly decreased in size, and the peritonitis improved without surgery. The patient's serum IgG4 level was found to be elevated to 820 mg/dL. Endoscopic retrograde cholangiopancreatography revealed main pancreatic duct stricture without obstruction. No communication between the main pancreatic duct and the pseudocyst was found. An EUS-guided fine-needle aspiration biopsy of the hypoechoic site was performed, revealing IgG4-positive plasma cell infiltration. He was finally diagnosed with AIP associated with the rupture of a pseudocyst. Oral corticosteroid (30 mg/day) treatment was started and gradually tapered. There has been no recurrence in the 28 months since the initiation of treatment.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections.

Pancreatic and peripancreatic collections (PPC) are a known complication of acute pancreatitis. They are categorized into four types of collection: (1) acute peripancreatic fluid collection, (2) pseudocyst, (3) acute necrotic collection and (4) walled-off necrosis. Most PPC resolve spontaneously or are persistent but asymptomatic. Intervention is needed in a minority of patients with infected or symptomatic collection. Endoscopic ultrasound-guided transmural drainage is currently the first-line treatment option for PPC management. It has shown great technical and clinical success, similar to percutaneous or surgical approaches, but with lower morbidity and costs and better quality of life. In this review article, the GRUPUGE presents an updated perspective on the potential role of endoscopic ultrasound-guided drainage of peripancreatic collections, addressing the selection criteria and the technical issues of different techniques and analysing emerging data on their efficacy and safety.

As coleções pancreáticas e peripancreáticas constituem uma complicação conhecida de pancreatite aguda. As coleções são classificadas em quatro tipos: (1) coleção líquida peripancreática aguda, (2) pseudoquisto, (3) coleção necrótica aguda e (4) coleção necrótica encapsulada (walled-off necrosis). A maioria das coleções peripancreáticas resolvem espontaneamente ou mantém-se assintomáticas. A drenagem está indicada numa minoria de doentes em que a coleção infecta ou se torna sintomática. A drenagem de coleções peripancreáticas guiada por ecoendoscopia é atualmente considerada a primeira linha de tratamento. Os procedimentos guiados por ecoendoscopia têm mostrado uma elevada taxa de sucesso técnico e clínico, semelhante às abordagens cirúrgica e percutânea, mas está associada a menor morbilidade e custos e a melhor qualidade de vida. Neste artigo de revisão, o GRUPUGE apresenta uma perspetiva atualizada do papel da ecoendoscopia na drenagem de coleções peripancreáticas, abordando critérios de seleção e questões técnicas relativas aos diferentes procedimentos, e analisando os dados disponíveis sobre a sua eficácia e segurança.

Effectiveness of endoscopic ultrasound-guided drainage for noncapsulated postoperative pancreatic collection.

BACKGROUND: Postoperative pancreatic collection (POPC) is a frequent complication after pancreatectomy. Although percutaneous drainage (PD) has been the treatment of choice for POPC with encapsulation, endoscopic ultrasound-guided transmural drainage (EUS-TD) was recently reported effective for this condition. The main aim of this retrospective study was to compare EUS-TD and PD in terms of effectiveness and safety as the first procedure in patients with noncapsulated POPC. METHODS: Consecutive patients who underwent pancreatectomy and developed noncapsulated POPC requiring EUS-TD or PD between April 2003 and May 2018 were enrolled. Noncapsulated POPC was defined as pancreatic collection appearing within 28 days postoperatively and lacking a thick encapsulating inflammatory wall on contrast-enhanced computed tomography. The effectiveness of drainage was compared between the two groups before and after propensity-score matching of patient characteristics. Outcomes of interest included re-intervention rate, number of re-interventions, immediate complication, remote complication, and time to clinical resolution after the procedure. RESULTS: A sum of 81 patients were included: 14 underwent EUS-TD, and 67 underwent PD. There were significant differences between groups in POPC size and type of surgery. Propensity-score matching selected 13 patients who underwent EUS-TD and 28 who underwent PD. Re-intervention rate (p = 0.045), and number of re-interventions (p = 0.026) were significantly lower in the matched EUS-TD group than in the matched PD group. There were no significant between-group differences in immediate complication and remote complication. The time to clinical resolution after the procedure was significantly shorter in the matched EUS-TD than in the matched PD group (14 versus 26 days; p < 0.0001). CONCLUSION: EUS-TD is more effective than PD for drainage of noncapsulated POPC. EUS-TD should be considered as the first treatment of choice for noncapsulated POPC visible on EUS.

Radical treatment for walled-off necrosis: Transmural nasocyst continuous irrigation.

BACKGROUND AND AIM: Treatment efficiency of walled-off necrosis (WON) using endoscopic ultrasound-guided drainage (EUS-D) with a double pigtail stent (DPS) is limited. Endoscopic necrosectomy is often carried out if EUS-D fails. However, endoscopic necrosectomy is associated with significant morbidity and mortality. Thus, we developed transmural nasocyst continuous irrigation (TNCCI) as an alternative therapeutic option for WON. This study aimed to evaluate the usefulness of TNCCI therapy for WON. METHODS: Between April 2009 and March 2018, 19 of 39 patients admitted with WON underwent EUS-D. Ten consecutive patients also received TNCCI therapy (TNCCI group) between May 2015 and March 2018. TNCCI was carried out by inserting an external tube from the gastroduodenal lumen into the WON under endoscopic ultrasonography guidance and then continuously irrigating the WON with saline at a rate of 40 ml/h. Nine consecutive patients who underwent EUS-D without TNCCI therapy between April 2009 and April 2015 were used for comparison (control group). Various parameters were compared between the TNCCI and control groups. RESULTS: Time taken to reduce WON (6 vs 32 days, P = 0.001), implementation rate of endoscopic necrosectomy (0% vs 55.6%, P = 0.01), and number of endoscopic necrosectomy sessions per patient (0 vs 0.8 ± 1.0, P = 0.008) were significantly lower in the TNCCI group than in the control group. CONCLUSIONS: Walled-off necrosis can be effectively and safely treated by endoscopic drainage with a DPS and TNCCI. This technique can be an alternative therapeutic option before carrying out endoscopic necrosectomy.

Present status and perspectives of endosonography 2017 in gastroenterology.

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.