Digestive Endoscopy最新文献

Endoscopic ultrasound (EUS) is increasingly used as a therapeutic approach for gastrointestinal diseases, especially with the advent of lumen-apposing metal stents (LAMS). This has led to a rise in of EUS-guided gastrointestinal anastomosis procedures. Due to the reliability of intestinal conduits with LAMS, indications for EUS-guided gastrointestinal anastomosis are becoming more common and trend to potentially be standard care for gastric outlet obstruction, afferent loop syndrome, and EUS-directed transgastric interventions such as EUS-directed endoscopic retrograde cholangiopancreatography. Retrospective and prospective data indicate that the procedure is becoming widely adopted with promising outcomes. This article aims to review the existing literature on EUS-guided gastrointestinal anastomosis and predict its future developments.

Although endoscopic enteral metal stent placement (EMSP) is an effective treatment for afferent loop obstruction (ALO)^{1, 2} and gastrointestinal obstruction,³ only limited studies have focused on the placement method. In the conventional EMSP approach, the stent is deployed with the stent delivery system fully out of the endoscope, and its proximal end, the yellow marker, is monitored on the endoscopic image.⁴ However, because the endoscope must be withdrawn to some extent, its position can become unstable, dislodging the stent delivery system. We report on EMSP using a single-balloon enteroscope (SBE) for ALO with a “half-and-half technique” that applies the intrachannel stent release technique in interventional endoscopic ultrasound (EUS) to facilitate correct stent placement.

A 90-year-old male patient who underwent pylorus-preserving pancreatoduodenectomy for distal cholangiocarcinoma approximately 5 years prior presented to our hospital with bile duct stone-induced acute cholangitis. Because SBE endoscopic retrograde cholangiopancreatography failed due to ALO, EUS-guided hepaticogastrostomy was performed (Fig. 1). Although acute cholangitis improved, the patient developed afferent loop syndrome 3 weeks later, prompting the decision to perform EMSP. The SBE was advanced to the afferent loop's stenotic site, and a contrast medium was injected through the catheter to confirm the stenosis range. Subsequently, the stent delivery system was advanced through the stenosis to ensure the central marker aligned with the stenosis. Stent deployment was initiated with approximately half of the stent positioned within the endoscopic working channel. Subsequently, the remaining half was deployed by pushing out the delivery system while simultaneously withdrawing the endoscope, ensuring it was not deployed entirely within the endoscope (Fig. 2; Video S1). The “half-and-half technique” uses the endoscopic working channel to enable endoscope stabilization even in difficult situations, including EMSP using a balloon enteroscope, thereby preventing stent jumping and facilitating correct stent positioning. This method is expected to be applicable to other EMSPs.

Authors declare no conflict of interest for this article.

Endoscopic pancreatic duct stenting is useful for recurrent chronic obstructive pancreatitis.^{1, 2} However, approaching the caudal pancreatic duct is challenging in patients with severe stenosis or a spiral (loop type) or hairpin (reverse-Z type) curve of the main pancreatic duct.³ Recently, a drill dilator (Tornus ES; Olympus, Tokyo, Japan; Fig. 1) has been reported as useful for opening obstructions caused by pancreatic stone impaction.^{4, 5} We encountered a case of pancreatic stone disease in a tortuous main pancreatic duct that was difficult to pass through using conventional devices; a pancreatic stent was successfully implanted using a drill dilator.

A 68-year-old man with alcoholic chronic pancreatitis was admitted to our hospital with complaints of abdominal pain. Computed tomography showed a large amount of ascites effusion, high amylase level in the ascites, a 7 mm sized pancreatic stone in the main pancreatic duct of the pancreatic head, and caudal pancreatic duct dilatation, suggesting pancreatic duct collapse (Fig. 2a,b). We performed endoscopic retrograde cholangiopancreatography (ERCP), but the device could not pass through because of the reverse-Z type main pancreatic duct and severe stenosis caused by the pancreatic stone (Fig. 2c). The patient improved with conservative treatment alone, but his symptoms flared approximately 6 months later. When we performed ERCP after extracorporeal shock wave lithotripsy for the pancreatic stone disease, the guidewire penetrated the stenosis, but the other devices could not. We used a drill dilator, which easily broke through the stenosis caused by the meandering main pancreatic duct and pancreatic stone (Fig. 2d–f). Afterward, an ERCP cannula (MTW-Endoskopie, Wesel, Germany) could pass through the stenosis, and a pancreatic stent was successfully implanted (Video S1). No adverse events occurred postoperatively.

The drill dilator, newly designed to advance by rotational manipulation to dilate stenoses, proved valuable by preventing instrument pushing and may inhibit further bend steepening in pancreatic ducts with strong meandering.

Authors declare no conflict of interest for this article.

The purpose of preoperative biliary drainage (PBD) is to reduce complications during the perioperative period. The extrahepatic bile duct comprises distal and hilar bile ducts and assessing the need for PBD must be considered separately for each duct, as surgical procedures and morbidities vary. The representative disease-causing distal bile duct obstruction is pancreatic cancer. A randomized controlled trial has revealed that PBD carries the risk of recurrent cholangitis and pancreatitis before surgery, thus eliminating the need for PBD when early surgery is feasible. However, neoadjuvant therapy has seen a rise in recent years, resulting in longer preoperative waiting periods and an increased demand for PBD. In such cases, metal stents are preferable to plastic stents due to their lower stent occlusion rates. When endoscopic transpapillary biliary drainage (EBD) is not viable, endoscopic ultrasound-guided biliary drainage may be a suitable substitute. In the hilar bile duct, the representative disease-causing obstruction is hilar cholangiocarcinoma. PBD's necessity has long been a subject of contention. In spite of earlier criticisms of routine PBD, recent views have emerged recommending PBD, particularly when major hepatectomy is required, to prevent postoperative liver failure. Given the risk of tumor seeding associated with percutaneous transhepatic biliary drainage, EBD is preferable. Nevertheless, as its shortcomings involve recurrent cholangitis until surgery due to stent or tube obstruction, it is necessary to seek out novel approaches to circumvent complications. In this review we summarize the current evidence for PBD in patients with distal and hilar biliary obstruction.

Intestinal ultrasound (IUS) for inflammatory bowel disease (IBD) was described as early as 1979. However, it was not widely adopted, possibly due to the lack of proper training and concern about accuracy as compared to standard cross-sectional imaging or endoscopy. There is now renewed interest in gastroenterologist-led point-of-care ultrasound as a noninvasive, sensitive monitoring tool to assess IBD activity that is associated with excellent patient satisfaction. Current indications include suspected IBD, assessment of IBD activity and complications, monitoring therapeutic response, assessment of postoperative recurrence, and prediction of clinical outcomes.

An ultrasound machine with a low frequency curvilinear probe and a high frequency linear probe (frequency ≥7 MHz) is required to perform IUS. The low frequency probe (depth of penetration 15–22 cm) helps to detect complications such as deep-seated abscess whereas high frequency probes evaluate the bowel wall (depth 8–10 cm). The higher frequency allows higher resolution at the expense of lower penetration. Dedicated bowel ultrasound probes use single-crystal technology that, compared to the multiple Piezoelectric crystals material in conventional probes, provides higher clarity, contrast, penetration, and uniform resolution across depth.

The ultrasound machine should have dials to adjust the depth, focus, color doppler gain, contrast (dynamic range), and flow, along with the facility to measure and store still images and cine loops (Fig. 1). Increasing the depth helps to delineate deeper structures at the expense of reduced frame rate and line density. The focus dial helps to focus on a particular depth. The gain dial allows uniform amplification of the ultrasound signal by increasing the brightness of the image, and the dynamic range adjusts the shades of gray/contrast. Although increasing the contrast makes the image sharper, the smooth gradation of B (brightness)-mode imaging is compromised.

The abdomen should be exposed up to the inguinal ligament. The colon is examined starting from the left iliac fossa, identifying the iliac vessels over the left psoas muscle where the sigmoid colon is visualized (Video S1). Then the colon is traced towards the left flank to examine the descending colon and splenic flexure. Then tracing is started below the xiphisternum from the liver. The first luminal structure seen is the stomach/duodenum followed by the wavy cloud-like transverse colon with haustrations. Then the right colon can be visualized either downwards starting from the hepatic flexure just below the liver or tracing upwards from the right iliac fossa above the right iliac vessels from the terminal ileum. The small bowel is differentiated from the large bowel by the presence of peristalsis. Valvulae conniventes are seen in the jejunum which is seen in the left upper quadrant of the abdomen. The small bowel is traced using the “lawn mowing” method, in “stripes” screening

A new endoscopic system (EVIS X1; Olympus, Tokyo, Japan) is currently available for photodynamic therapy (PDT) in patients with esophageal squamous cell carcinoma (ESCC).^{1, 2} The endoscope, GIF-H190 (Olympus), allows observation through a simultaneous display system and uses an electronic shutter function that automatically adjusts the image sensor's exposure time (shutter speed). With these systems, images can be obtained with preserved color information even when a diode laser light is used during PDT, thereby suppressing whiteout of the screen. This allows patients to be treated while viewing the location of the markings, lesions, and laser irradiation field. EVIS X1 also has a novel image-enhanced endoscopic modality, texture, and color enhancement imaging (TXI) mode 1, which enhances the surface texture, brightness, and color tone compared with that obtained via white light imaging (WLI).³ Observation using TXI mode 1 may improve the visibility of the irradiated area by enhancing the laser light and the visibility of ischemic changes in the irradiated area.

A 79-year-old woman underwent chemoradiotherapy for advanced ESCC. Surveillance endoscopy revealed metachronous ESCC with suspected submucosal invasion, and PDT was performed (Fig. 1, Video S1). In TXI mode 1, the laser light's irradiation area was visible, and any misalignment in the irradiation position could be immediately corrected. Additionally, ischemic and edematous mucosal changes, which indicate a treatment effect, were easier to evaluate using TXI mode 1 than WLI, even on treatment day. TXI mode 1 was useful for determining the need for additional treatment during endoscopy the day after PDT. Endoscopy performed 10 weeks after PDT confirmed the absence of ESCC, and local complete response (L-CR) was achieved (Fig. 2).

Prospective studies focusing on L-CR rates are needed to verify the true benefit of PDT using GIF-H190 and TXI mode 1.

Authors declare no conflict of interest for this article.

A basket impaction during stone extraction or plastic stent (PS) migration is a well-known complication of endoscopic retrograde cholangiopancreatography (ERCP). However, a basket impaction with a PS is rare. A 66-year-old woman with a 7F biliary inside stent (IS) for the anastomotic biliary stricture after a living donor liver transplantation underwent ERCP for IS exchange. The nylon thread attached to the IS was not found on the endoscopic image. Therefore, we inserted a rotatable 8-wire basket (RASEN; Kaneka Medical, Osaka, Japan) to retrieve the migrated IS.¹ The IS's distal flange was easily caught by the basket, and we intended to remove it. However, when attempting to extract the IS into the duodenum, the stent's distal end penetrated the oral protrusion of the duodenal papilla, apart from the orifice of the bile duct. We could not open the basket or push it upward into the common bile duct, resulting in its impaction with the PS (Fig. 1). After removing the endoscope and leaving the basket in place, we reinserted the endoscope and recannulated the bile duct. Subsequently, we performed endoscopic sphincterotomy (EST) in the direction of the impacted PS. Although there was post-EST bleeding, we grasped it with forceps after hemostasis and finally succeeded in retrieving the impacted PS (Video S1).

Various techniques, such as a basket catheter, snare, forceps, balloon catheter, or stent retriever, have been used to retrieve a migrated PS.² However, a rescue technique for an impacted PS has not been established, and complicated procedures such as mechanical lithotripsy or electrohydraulic lithotripsy with a cholangioscope³ that have been used for basket impaction with a biliary stone cannot be employed for PS impaction. Endoscopists should carefully align the PS with the direction of stent removal, and additional EST may be a treatment option for PS impaction.

Author N.F. has received consulting fees from Kaneka Medical, and payment for lectures from Gadelius Medical and Kaneka Medical. The other authors declare no conflict of interest for this article.

A novel integrated biliary stent and nasobiliary drainage catheter system (UMIDAS NB stent [UMIDAS]; Olympus Medical Systems, Tokyo, Japan) was recently renewed.^{1, 2} The renewed UMIDAS consists of a 7F or 8.5F outside biliary stent with a large flap on the distal side to prevent migration and a 5F nasobiliary catheter (Fig. 1). The advantage of the UMIDAS is that additional endoscopic retrograde cholangiopancreatography is not required because internal drainage can be achieved by simply removing the nasobiliary catheter.^{3, 4} However, because of the large 8.5F diameter of the stent pushing sheath, it is impossible to deploy two UMIDASs through the scope channel. Here, we present a technique demonstrating the placement of two UMIDASs (Video S1).

External drainage of the right anterior and posterior bile ducts was planned before left hepatic lobectomy for hilar biliary stricture resulting from cholangiocarcinoma. Endoscopic retrograde cholangiopancreatography was performed using a duodenoscope (TJF-Q290V; Olympus Medical Systems). After bile duct cannulation, 0.025 inch guidewires were inserted into the anterior and posterior branches, followed by endoscopic sphincterotomy. Next, a UMIDAS with a 7F biliary stent was inserted into the anterior branch across the papilla. Because a second UMIDAS could not be inserted through the 4.2 mm diameter scope channel, pushing sheath and nasocatheter of the first UMIDAS were temporarily removed while retaining the biliary stent and guidewire in place (Fig. 2a). This allowed the second UMIDAS to be inserted through the channel and placed in the posterior branch (Fig. 2b). After removing the pushing sheath of the second UMIDAS, the nasocatheter of the first UMIDAS was reinserted through the lumen of the biliary stent and placed in the anterior branch (Fig. 2c,d).

A week later, the nasobiliary catheters were successfully extracted under fluoroscopic guidance while the biliary stents were retained in place.

Authors declare no conflict of interest for this article.