Digestive Endoscopy最新文献

A 69-year-old woman with complex hilar strictures due to unresectable gallbladder cancer was admitted for plastic stents obstruction. Considering duodenal invasion, conversion to endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with bridging stenting after temporary naso-biliary drainage was planned.¹ After puncturing B2 with a 19 G needle (Fig. 1a), two 0.025 inch guidewires were inserted into B8 and B6 using a double-lumen catheter. Two uncovered self-expandable metal stents (SEMS) were placed in both branches in partially stent-in-stent configuration. Finally, an 8 mm × 12 cm partially covered SEMS (Spring Stopper; Taewoong Medical, Seoul, Korea) with a 15 mm uncovered portion at the distal end was placed in B2 as a transluminal drainage/anastomosis stent (T-DAS). However, the T-DAS was accidentally moved toward the stomach because the tip of the inner catheter was stuck during removal.² Since the uncovered portion was suspected to be exposed to the abdominal cavity (Fig. 1b), there was concern for persistent bile leakage. Coaxial insertion of a fully-covered SEMS (HANAROSTENT Benefit; M.I.Tech, Seoul, Korea) to seal the uncovered portion failed and the guidewire was dislodged. The T-DAS within the liver parenchyma was then punctured with the 19 G needle (Fig. 1c), followed by manipulation of the 0.025 inch guidewire to bring it out of the distal end of the T-DAS into the bile duct (Fig. 1d). The HANAROSTENT Benefit was successfully placed as a second T-DAS after passing through the mesh of the first T-DAS and stopped bile leakage by completely covering the uncovered portion of the first T-DAS in the bile duct (Fig. 2, Video S1). Although computed tomography on the next day showed fluoroscopic markers at the end of the uncovered portion of the first T-DAS were outside of the liver, the clinical course was uneventful. For dislocation of a partially covered SEMS in EUS-HGS, this rescue method could be useful when coaxial fully covered SEMS insertion fails.

Authors declare no conflict of interest for this article.

Closure of mucosal defects following colorectal endoscopic submucosal dissection (C-ESD) is often performed to prevent post-C-ESD adverse events. However, large mucosal defect closure using conventional clips remains technically challenging. Here, we evaluated the feasibility of the novel endoclip with anchor prongs, called the MANTIS Clip (Boston Scientific, Tokyo, Japan), for mucosal defect closure after C-ESD. This high-volume retrospective study was conducted at a single center. From March until December 2023, consecutive patients who underwent post-C-ESD mucosal defect closure using MANTIS Clip to achieve complete closure were enrolled. Patient clinical characteristics and outcomes were evaluated. Closure of the mucosal defect using the MANTIS Clip was attempted following C-ESD in 32 lesions. The median sizes of the resection specimens and the tumors were 32 mm (range, 17–100 mm) and 23.5 mm (range, 5–96 mm), respectively. The lesions were distributed between the cecum, ascending, transverse, descending, sigmoid, and rectum. Complete closure was achieved in 96.9% of cases (31/32). All lesions up to 61 mm in defect size were completely closed. The median closure time was 7.9 (range, 3.3–18.0) min. The median numbers of MANTIS Clip and additional conventional clips were 3 (range, 1–4) and 5 (range, 1–11), respectively. No adverse events associated with closure, post-ESD bleeding, and delayed perforation occurred. MANTIS Clip closure for large post-C-ESD mucosal defects was found to be feasible and reliable with a high complete closure rate and a short procedure time.

In recent years, antegrade treatment via an endosonographically created route (ESCR) for choledocholithiasis in patients with surgically altered anatomy (SAA) has emerged.^{1, 2} A self-expandable metal stent (SEMS) can form thicker ESCR to facilitate cholangioscopy-guided electrohydraulic lithotripsy (EHL).³ If repeat EHL is required, another SEMS should be placed to maintain ESCR, but at a cost. Herein, we present a method for reinserting a removed SEMS.

A 76-year-old man with a history of total gastrectomy was admitted for obstructive jaundice due to large common bile duct stones (Fig. 1a). First, endoscopic ultrasound-guided hepaticojejunostomy (EUS-HJS) was performed, using an 8 mm partially covered SEMS (Spring Stopper; Taewoong Medical, Seoul, Korea) (Fig. 1b) to prevent focal cholangitis. One week later, the stent was removed through the channel without resistance, suggesting an absence of tissue hyperplasia in the uncovered area due to the short indwelling time. Then a SpyGlass DS II (Boston Scientific, Natick, MA, USA) was inserted through the ESCR and EHL was performed. Since the stones could not be sufficiently crushed after 1 h, we decided to reinsert the stent for the next session. After attaching a looped nylon thread to the tip of the stent (Fig. 2a), a guidewire indwelling in the ESCR was inserted through the tip of the stent. A wire-guided forceps (Histoguide; STERIS, Mentor, OH, USA) (Fig. 2b) was inserted over the guidewire from the end of the stent to grasp the loop (Fig. 2c). The stent was then inserted into the channel with the lid removed, while being stretched and twisted together with the forceps. Following insertion of the stent into the bile duct, the guidewire and forceps were removed (Video S1). The stones were completely removed during the next cholangioscopy-guided EHL.

Reuse of a single SEMS with this method for multiple cholangioscopy-guided procedures via an ESCR would be cost beneficial.

Authors declare no conflict of interest for this article.

We appreciate Vanella et al.'s insightful letter regarding our GALLBLADEUS study.¹ They correctly noted that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) may have appeared as a third-line option. Due to our retrospective data, we lack specific details, but in our center, EUS-GBD is often preferred over endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) after failed endoscopic retrograde cholangiopancreatography, with many patients receiving EUS-GBD as a second-line treatment.

We fully agree with Vanella's remark that the presence of duodenal stenosis makes the use of EUS-CDS inappropriate. However, the patients included in this study were treated at a time when this information had not yet been published, particularly by the CABRIOLET trial² conducted by our correspondents. The proportion of patients with duodenal stenosis was significant but comparable in both groups (48.7% EUS-CDS vs. 41.5% EUS-GBD). However, despite this, our study still showed that dysfunctions seemed less frequent in the EUS-GBD group.

Emerging evidence suggests hepaticogastrostomy as a better route for duodenal stenosis,^{2, 3} although it has a longer learning curve compared to EUS-GBD, which is simpler for less-experienced centers. Our study suggests fewer dysfunctions with EUS-GBD vs. EUS-CDS in this context, a finding that needs confirmation from future prospective, comparative studies as suggested by Vanella et al. We agree that biliary drainage far from the tumor warrants comparing EUS-GBD to hepaticogastrostomy. The significant proportion of duodenal stenosis in our study favors EUS-GBD, suggesting fewer dysfunctions, although this needs confirmation by future studies. This question is of interest because EUS-GBD is simpler for less-experienced centers and could be more widely adopted than hepaticogastrostomy. Future prospective studies comparing EUS-CDS, EUS-GBD, and hepaticogastrostomy across various clinical scenarios are essential. We thank Vanella et al. for their valuable input and look forward to further dialogue and research in this evolving field.

Authors declare no conflict of interest for this article.

Postoperative pancreatic fistula (POPF) is one of the major complications following distal pancreatectomy (DP). With the increasing adoption of laparoscopic and robotic approaches, the rate of clinically relevant POPF is reported as between 18.2–26.7%.^{1, 2} When POPF does not improve with conservative treatment, interventions such as percutaneous drainage (PTD), endoscopic ultrasound-guided transluminal drainage (EUS-TD), and endoscopic transpapillary drainage (ETPD) are employed.^3-5 However, PTD and EUS-TD may not always be appropriate due to interfering blood vessels, the distance from the abdominal or gastrointestinal wall to the POPF, or an immature POPF wall. On the other hand, while ETPD may reduce leakage of pancreatic fluid from the main pancreatic duct into the POPF, it may sometimes be ineffective due to indirect drainage of the POPF.

For such cases, we performed ETPD through the pancreatic duct stump (PDS). A 59-year-old man developed POPF with fever and abdominal pain 23 days after DP. Pancreatography from near the PDS was performed to confirm the leakage into the POPF, followed by guidewire insertion into the POPF. An endoscopic nasopancreatic drainage (ENPD) tube was subsequently placed into the POPF. After confirming the shrinkage of POPF in 1–2 weeks, the ENPD tube was replaced with a pancreatic duct stent, without penetrating the PDS (Video S1). The ENPD tube over the PDS enabled direct drainage of the POPF, and the pancreatic duct stent could relieve the intrapancreatic high pressure because of Oddi.⁴ The stent was removed a few months later after confirming the absence of POPF recurrence by computed tomography (Fig. 1). This strategy was applied in four cases, with no cases with recurrent POPF (Table 1). This method provides an alternative option for PTD or EUS-TD, especially when the POPF has distance from the abdominal or gastrointestinal wall, or when the POPF wall is immature in the early postoperative period.

Authors declare no conflict of interest for this article.

A 73-year-old woman underwent pyloric resection and B-1 reconstruction for gastric cancer followed by duodenal bile duct anastomosis to treat common bile duct stones. The patient was later referred for bile duct dilation examination. Magnetic resonance imaging revealed intrahepatic gallstones in the posterior intrahepatic bile duct. Consequently, endoscopic retrograde cholangiopancreatography was performed.

Initially, direct peroral cholangioscopy (POCS) with an endoscope equipped with water-jet functionality was used to attempt stone fragmentation via electrohydraulic lithotripsy (EHL). However, this approach failed due to challenging angulation of the bile duct, which obstructed access to the posterior biliary duct. Subsequently, the mother–baby technique was employed using a duodenoscope and cholangioscope (SpyScope; Boston Scientific, Marlborough, MA, USA). However, advancing the SpyScope into the posterior biliary duct was unsuccessful due to the instability of the duodenoscope, which impeded the effective transmission of force and passage beyond the bend.

To address the need for greater scope stability and rigidity, a colonoscope (CF HQ290ZI, channel diameter 3.7 mm; Olympus Medical Systems, Tokyo, Japan) was introduced through the choledochoduodenal anastomosis, effectively serving as the mother endoscope. This combination of direct POCS and the mother–baby system, referred to as combined-POCS, significantly improved scope stability and enhanced the insertability of the choledochoscope. This rigidity of the colonoscope helped facilitate successful access to the posterior biliary branch (Figs 1,2). Complete stone removal was achieved using stone fragmentation with EHL (Video S1).

Generally, EHL is effective in treating intrahepatic stones,^{1, 2} but its success is often limited by the devices used in the postoperative intestinal tract.³ In this case, the sequential application of various treatment methods led to effective resolution. The therapeutic intervention proceeded without adverse events, demonstrating the efficacy of combined-POCS in the management of postoperative intrahepatic stones.

Authors declare no conflict of interest for this article.

Endoscopic procedures for large common bile duct stones in patients with altered anatomy remain challenging, despite reports on direct peroral cholangioscopy (POCS).^1-4 Recently, a novel slim cholangioscope (9F eyeMAX; Micro-Tech, Nanjing, China) facilitated balloon enteroscopy-assisted POCS (BE-POCS).⁵

An 83-year-old man, after Billroth II gastrectomy, was admitted with a large common bile duct stone. BE-POCS using a Holmium YAG (Ho:YAG) laser was employed for stone removal (Video S1). A balloon enteroscope (SIF-H290S; Olympus, Tokyo, Japan) was inserted into the afferent loop, and cholangiography revealed a large stone (15 mm) in the dilated common bile duct (20 mm). After papillary balloon dilation (15 mm), 9F eyeMAX was smoothly inserted via enteroscopy. A large stone was located in the hepatic hilum. Ho:YAG laser (LithoEVO; EDAP TMS, Lyon, France) lithotripsy effectively crushed the stone core under cholangioscope guidance (Fig. 1). The irrigation ability was sufficient to maintain a clear view because of a separate irrigation channel. A basket catheter (LithoCrush V; Olympus) was used to remove the fragments; however, the largest piece could not be extracted, and mechanical lithotripsy failed. A plastic stent was placed until the second session because of the procedure length (100 min). One month later, the largest fragment was completely crushed using the Ho: YAG laser to prevent basket impaction (Fig. 2). The green color of the laser helped detect the probe tip during the procedure. The fragmented stones were removed using a spiral basket catheter (KANEKA Medics, Tokyo, Japan). Cholangioscopy confirmed no residual stones in the intrahepatic bile ducts. Finally, small fragments were extracted using a microbasket catheter (ABIS, Hyogo, Japan) (60 min).

This is the first report of laser lithotripsy with BE-POCS for a patient with Billroth II gastrectomy. Ho:YAG laser lithotripsy using a slim cholangioscope is useful for treating difficult stones in patients with altered anatomy.

Authors declare no conflict of interest for this article.