Digestive Endoscopy最新文献

With the recent development of interventional endoscopic ultrasound (EUS), EUS-guided vascular interventions have seen increased clinical and research focus. This modality can be used to diagnose portal hypertension and treat portal hypertension-related gastrointestinal varices and refractory gastrointestinal hemorrhage, including pseudoaneurysm. The vascular embolic materials used for treatment include tissue adhesives (cyanoacrylates), sclerosants, thrombin, and vascular embolic coils, all of which are associated with favorable results. The feasibility of EUS-guided procedures, including portal vein stenting and portosystemic shunt formation conventionally performed percutaneously and transvenously, has also been demonstrated, albeit in animal studies. As EUS-guided vascular intervention is a technique that may receive significant attention in the future, we provide a thorough review of the current evidence for its use.

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has emerged as an alternative to standard percutaneous or transpapillary approaches in fragile patients with acute cholecystitis.^1-3 Oblique-viewing linear endoscopic ultrasonography (OV-EUS) is used for biliary intervention. However, forward-viewing linear endoscopic ultrasonography (FV-EUS) is applied in certain settings.^{4, 5} Herein, we report salvaged EUS-GBD by using FV-EUS after failure of OV-EUS.

An 82-year-old man with clinical stage IV pancreatic cancer presented with severe vomiting and initially underwent implantation of a duodenal bulb-covered metallic stent. One week later, this patient underwent endoscopic ultrasonography-guided choledochoduodenostomy due to acute obstructive suppurative cholangitis without intrahepatic biliary dilation (Video S1). One month later, this patient developed antibiotic-refractory acute cholecystitis, which deteriorated into a pericholecystic abscess (Fig. 1). Prioritizing the internal drainage, we attempted EUS-GBD using OV-EUS (EG-580UT; Fujifilm, Tokyo, Japan). The gallbladder was depicted; however, the scope struggled to maneuver in the duodenal metallic stent, and a 19G lancet puncture needle could not advance from the scope channel into the gallbladder (Fig. 2a, Video S1). The following day, we retried EUS-GBD using FV-EUS (TGF-UC260J; Olympus, Tokyo, Japan), which quickly facilitated the gallbladder visualization, needle puncture, 0.025 inch hydrophilic guidewire advancement, electrocautery dilation (Cysto-Gastro-Sets; Endo-flex, Voerde, Germany), and a double-pigtailed plastic stent deployment (Advanix J, 7F, 7 cm; Boston Scientific, Marlborough, MA, USA) (Fig. 2b,c, Video S1). The clinical course was uneventful.

The maneuverability of the OV-EUS was limited inside the duodenal bulb stent. We needed to down-angle the scope steeply to depict the gallbladder, which obstructed the puncture needle. In this situation, FV-EUS in the long position easily depicted the gallbladder without an angle maneuver. In addition, all the devices showed excellent pushability and trackability, including the puncture needle, dilator, and gallbladder stent, because the target was located vertically in front of the long-positioned FV-EUS.⁵

Authors declare no conflict of interest for this article.

Endoscopic ultrasound (EUS)-guided drainage effectively treats difficult transpapillary drainage.^{1, 2} However, EUS-guided pancreatic duct drainage (EUS-PD) is technically challenging, as repuncture should be avoided to prevent pancreatic fluid leakage; we describe a technique for EUS-PD stent migration that enables us to avoid repuncture (Video S1).³ A 54-year-old woman, who underwent pancreaticoduodenectomy for pancreatic cancer, experienced recurrent cholangitis and pancreatic stones due to anastomotic stenosis. Endoscopic drainage using a single-balloon enteroscope (SIF-H290S; Olympus, Tokyo, Japan) was attempted, but identifying the pancreatic duct orifice was difficult. Therefore, EUS-PD was performed to secure the route for stone removal. A 19G needle (EZ shot 3 plus; Olympus) was used to puncture the dilated pancreatic duct at the tail. The drill dilator (Tornus ES; Olympus) could not pass the stone. A 4 mm dilating balloon (REN TYPE-IT; Kaneka, Osaka, Japan) was used. After adequate dilation, a 7Fr plastic stent (TYPE IT; Gadelius Medical, Tokyo, Japan) was deployed, but its tip failed to cross the stone and anastomosis, so the stent was placed in the main pancreatic duct proximal to the stone.⁴ Vomiting and fever occurred postprocedure, and radiography revealed stent migration into the esophagus. However, computed tomography revealed the stent tip barely lodged in the pancreatic duct owing to the large flap. Therefore, using a side-viewing duodenoscope (TJF-260 V; Olympus), a guidewire (VisiGlide II; Olympus) was successfully inserted through the stent flap and guided into the jejunum. The stent was removed using forceps (Figs 1, 2). The tract and anastomotic site were sufficiently dilated using a drill dilator, and a 6 mm fully covered self-expandable metal stent (EGIS biliary stent, 6 × 10 mm; SB-Kawsumi, Kanagawa, Japan) was successfully placed. One month later, the stone was successfully removed by the EUS-PD route. A plastic stent has two large flaps at its tip, and even if it migrates, the flap may remain in the pancreas.

Author T.I. received honoraria for his lectures from Olympus and Boston Scientific. The other authors declare no conflict of interest for this article.

The remarkable recent developments in image-enhanced endoscopy (IEE) have significantly contributed to the advancement of diagnostic techniques. Linked color imaging (LCI) is an IEE technique in which color differences are expanded by processing image data to enhance short-wavelength narrow-band light. This feature of LCI causes reddish areas to appear redder and whitish areas to appear whiter. Because most colorectal lesions, such as neoplastic and inflammatory lesions, have a reddish tone, LCI is an effective tool for identifying colorectal lesions by clarifying the redder areas and distinguishing them from the surrounding normal mucosa. To date, eight randomized controlled trials have been conducted to evaluate the effectiveness of LCI in identifying colorectal adenomatous lesions. The results of a meta-analysis integrating these studies demonstrated that LCI was superior to white-light endoscopy for detecting colorectal adenomatous lesions. LCI also improves the detection of serrated lesions by enhancing their whiteness. Furthermore, accumulating evidence suggests that LCI is superior to white-light endoscopy for the diagnosis of the colonic mucosa in patients with ulcerative colitis. In this review, based on a comprehensive search of the current literature since the implementation of LCI, the utility of LCI in the detection and diagnosis of colorectal lesions is discussed. Additionally, the latest data, including attempts to combine artificial intelligence and LCI, are presented.

Ruptured esophageal varices (EVs) lead to life-threatening events. Endoscopic injection sclerotherapy (EIS) can help prevent bleeding. Endoscopic ultrasound (EUS) is essential for evaluating EV hemodynamics to ensure their effective management. The gel immersion method (GIM), which is crucial for accurate diagnosis and management, provides a clear and stable medium in the gastrointestinal system.¹ Compared with traditional water immersion techniques, the GIM provides superior image quality and reduces the risk of aspiration and other complications.² A 75-year-old Japanese woman presented with an EV with enlarged and red color signs at risk of bleeding (Fig. 1a). Two consecutive EUS and EIS procedures were performed using the modified GIM (mGIM-EUS/EIS). During esophagoduodenoscopy, after general evaluation of the EV and deaeration of the stomach, gel (Viscoclear; Otsuka Pharmaceutical Factory, Tokushima, Japan) was injected into the esophagus. The EV was identified and the esophageal wall vessels (perforating veins) were penetrated using a 20 MHz ultrasonic mini probe (Fig. 1b) before mGIM-EIS. This method enabled a detailed hemodynamic evaluation of EV, including the assessment of perforating veins, to help estimate the difficulty of EIS.^{2, 3} mGIM-EIS was conducted without interruption. Filling the esophagus with intermittent gel supplementation prevented visual defects due to bleeding and improved procedural safety (Fig. 2a). The gel facilitated precise needle placement, effective delivery, and visualization of sclerosant agents into the varices, using balloon deployment to reduce the risk of aspiration (Fig. 2b–d, Video S1).³ The gel was injected through the working channel during the procedure. The absence of air in the esophagus and stomach reduced the patient burden. The gel used can be securely held in the esophagus, enabling mGIM-EUS/EIS procedures to be performed continuously and without stress. This method minimizes the risk of aspiration and ensures accurate and safe management during mGIM-EIS. Therefore, mGIM-EUS/EIS is more effective and safer than previous methods.

Authors declare no conflict of interest for this article.