Search Results (42)

Background: Peripancreatic collections (PPCs) are a frequent and severe complication of acute and chronic pancreatitis, as well as pancreatic surgery, often requiring interventions to treat and prevent infection, gastric obstruction, and other complications. Endoscopic ultrasound (EUS)-guided drainage has emerged as a minimally invasive alternative to surgical and percutaneous approaches, offering reduced morbidity and shorter recovery times. However, the effectiveness of EUS-guided drainage in post-surgical PPCs remains underexplored. Methods: This retrospective, single-center study evaluated the technical and clinical outcomes of EUS-guided drainage in patients with PPCs between October 2021 and December 2024. Patients were categorized as having post-pancreatitis or post-surgical PPCs. Technical success, clinical success, complications, recurrence rates, and the need for reintervention were assessed. Results: A total of 50 patients underwent EUS-guided drainage, including 42 (84%) with post-pancreatitis PPCs and 8 (16%) with post-surgical PPCs. The overall technical success rate was 100%, with clinical success achieved in 96% of cases. Lumen-apposing metal stents (LAMSs) were used in 84% of patients, including 7.1% as a dual-gate salvage strategy after the failure of double-pigtail drainage. The complication rate was 24%, with infection being the most common (16%). The recurrence rate was 25%, with no significant difference between post-pancreatitis and post-surgical cases. Patients with walled-off necrosis had a significantly higher reintervention rate (35%) than those with pseudocysts (18%; p = 0.042). Conclusions: EUS-guided drainage is a highly effective and safe intervention for PPCs, including complex post-surgical cases. The 100% technical success rate reinforces its reliability, even in anatomically altered post-surgical collections. While recurrence rates remain a consideration, EUS-guided drainage offers a minimally invasive alternative to surgery, with comparable outcomes in both post-pancreatitis and post-surgical patients. Future multi-center studies should focus on optimizing treatment strategies and reducing recurrence in high-risk populations. Full article

Background/Objectives: Pancreatic fluid collections (PFCs) in acute pancreatitis require drainage when symptomatic or infected. Walled-off necrosis (WON) is difficult to drain with plastic stents alone. A lumen-apposing metal stent (LAMS) offers larger calibre drainage, lower migration risk than conventional methods, and the option of direct endoscopic necrosectomy through the stent. However, the paediatric literature on LAMSs is sparse. We report our institutional experience, and summarise current evidence on the feasibility, efficacy and safety of LAMSs for PFC drainage in children. Methods: We performed a retrospective study at the National University Hospital (NUH) and a full review of the literature on LAMS use in children for endoscopic trans-gastric drainage of PFCs from April 2012 to September 2024. Results: There were, respectively, 2 (males, 10 and 17 years) and 18 children who underwent endoscopic trans-gastric LAMS insertion for drainage of PFCs in acute pancreatitis in the NUH and across the nine included studies, which were published between 2015 and 2024. The technical and clinical success was 100%. There were no complications during insertion or indwell time (28 and 50 days in the NUH and 40 days, range of 7–100 days in the systematic review, respectively). Endoscopic removal of LAMSs was uneventful. There were no recurrent PFCs over a 4-month (1,7 months) and 12-month (range, 2–44 months) follow-up, respectively. Migration of LAMSs to colon following the collapse of the WON was reported in one case. Conclusions: An transgastric LAMS (with trans-stent necrosectomy) is a technically feasible method of drainage of WON following acute pancreatitis in children with minimal complications. Full article

Pancreatic cancer is an aggressive malignancy, with a current 5-year survival rate in the United States of approximately 13.3%. Although the current standard for resectable pancreatic cancer most commonly includes neoadjuvant chemotherapy prior to a curative resection, surgery, in the majority of patients, has historically been palliative. The latter interventions include open or laparoscopic bypass of the bile duct or stomach in cases of obstructive jaundice or gastric outlet obstruction, respectively. Non-surgical interventional therapies started with percutaneous transhepatic biliary drainage (PTBD), both as a palliative maneuver in unresectable patients with obstructive jaundice and to improve liver function in patients whose surgery was delayed. Likewise, interventional radiologic techniques included the placement of plastic and ultimately self-expandable metal stents (SEMSs) through PTBD tracts in patients with unresectable cancer as well as percutaneous cholecystostomy in patients who developed cholecystitis in the context of malignant obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) and stent placement (plastic/SEMS) were subsequently used both preoperatively and palliatively, and this was followed by, or undertaken in conjunction with, endoscopic gastro-duodenal SEMS placement for gastric outlet obstruction. Although endoscopic ultrasound (EUS) was initially used to cytologically diagnose and stage pancreatic cancer, early palliation included celiac block or ablation for intractable pain. However, it took the development of lumen-apposing metal stents (LAMSs) to facilitate a myriad of palliative procedures: cholecystoduodenal, choledochoduodenal, gastrohepatic, and gastroenteric anastomoses for cholecystitis, obstructive jaundice, and gastric outlet obstruction, respectively. In this review, we outline these procedures, which have variably supplanted surgery for the palliation of pancreatic cancer in this rapidly evolving field. Full article

Objective: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as a promising alternative for biliary decompression in patients with malignant distal biliary obstruction (MDBO), used either as a first-line approach or after other interventions have failed. This study aimed to evaluate the aggregated efficacy and safety of EUS-GBD in this patient population. Methods: A comprehensive literature search was carried out across PubMed/Medline, Embase, and Cochrane databases up to 9 January 2024, to identify studies reporting outcomes of EUS-GBD in MDBO cases. The primary endpoint assessed was clinical success, while secondary endpoints included technical success and the incidence of adverse events (AEs). Pooled outcomes were calculated using a random-effects model and presented with 95% confidence intervals (CIs). Results: Seven studies encompassing a total of 193 patients were included in the analysis. The combined clinical success rate for EUS-GBD was 88.1% [95% CI: 78.9–94.9%], while the technical success rate was 99.2% [95% CI: 97.5–100%]. The overall AE rate was 13.7% [95% CI: 9.3–18.8%], with the majority being mild to moderate in severity; no fatal complications were reported. Subgroup analyses indicated that use of smaller lumen-apposing metal stents (LAMS) (<15 mm) was associated with slightly higher clinical success (93.3% [95% CI: 72.4–99.9%]) compared to larger stents (≥15 mm) (87.1% [95% CI: 78.8–93.5%]), and a marginally lower rate of AEs (12.3% [95% CI: 6.4–19.7%] vs. 15.2% [95% CI: 6.5–26.6%]). Conclusions: EUS-GBD demonstrates excellent technical performance, high clinical efficacy, and a manageable safety profile in patients with MDBO and a patent cystic duct. Full article

Technological advances have greatly expanded the diagnostic and therapeutic capabilities of endoscopic ultrasound (EUS). The integration of cutting-edge imaging techniques, including tissue harmonic echo, contrast-enhanced harmonic EUS, elastography, and needle-based confocal laser endomicroscopy, have significantly enhanced lesion characterization and diagnostic accuracy. Additionally, developments in stent design and the introduction of new accessories have broadened the therapeutic applications of EUS. Ongoing innovations in clinical practice have transformed procedures such as drainage, tumor ablation, EUS-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), the placement of fiducial markers, advancements in endohepatology, lesion characterization, and treatment. These developments continue to expand the role of EUS in delivering precise and effective therapeutic interventions. Full article

Anastomotic strictures are a common complication following esophagogastric surgery, with prevalence varying depending on the type of surgery and anatomical site. These strictures can lead to debilitating symptoms such as dysphagia, pain, and malabsorption, significantly impacting patients’ quality of life. Endoscopic treatment of anastomotic strictures has established a role as the first-line strategy in this setting instead of revision surgery, offering benefits in terms of lower morbidity. Various endoscopic methods are available for anastomotic stricture management, including balloon dilation, stent placement, the new lumen-apposing metal stent, and endoscopic incision techniques. However, there is currently no strong evidence and established guidelines for the optimal treatment strategy. Available data suggest that endoscopic treatments, when performed in tertiary referral centers, can provide favorable outcomes in terms of symptom relief and reduced need for rescue surgical intervention. Nonetheless, challenges remain regarding the management of recurrent strictures and procedural complications, underscoring the need for a personalized, multidisciplinary approach to optimize clinical outcomes. This review aims to provide an updated overview of endoscopic techniques and available evidence with a focus on the most recent technologies, supporting clinicians in effectively managing anastomotic strictures in complex clinical settings. Full article

This multicenter retrospective study included patients undergoing EUS-guided GI anastomoses from 2016 to 2023. Indications for EUS-guided anastomosis were GOO, ALS or patients with altered anatomy needing endoscopic interventions. The primary outcome was technical success, while secondary outcomes included clinical success, safety, lumen-apposing metal stent (LAMS) patency, and the need for reinterventions. A total of 216 patients (mean age 64.5 [±13.94] years; 49.1% males) were included. In total, 149 cases (69%) were GOO, 44 (20.4%) cases were bilioenteric anastomotic strictures or lithiasis in altered anatomy, 14 cases (6.5%) were ALS, and 9 patients (4.2%) were for ERCP in altered anatomy after EUS-GG. Overall, EUS-GE was performed in 181 patients (83.8%), EUS-JJ in 44 cases (20.4%), and EUS-GG in 10 (4.6%). Technical success was 94.91%, and clinical success was 93.66%. The adverse event (AE) rate was 11.1%. The reintervention rate was 7.69%. The median follow-up was 85 days. In conclusions, EUS-guided GI anastomoses are technically feasible and safe in both malignant and benign diseases. Full article

Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications. Full article

Background: Lumen-apposing metal stents (LAMS) are utilized in a wide range of therapeutic gastrointestinal applications. We present our experience with LAMS-assisted drainage of complex pelvic abscesses at a large safety-net hospital. Methods: EUS-guided LAMS placements for pelvic abscesses from July 2020 to June 2024 were analyzed. Data were collected on patient demographics, procedure indications, fluid collection size, stent characteristics, stent dwell time, and complications. All cases underwent multidisciplinary review with Surgery and Interventional Radiology (IR) prior to LAMS-assisted drainage; all were deemed not amenable to drainage by IR. Results: Eleven patients underwent EUS-guided drainage of complex pelvic abscesses with cautery-enhanced LAMS. Diverticulitis was the most common cause of abscesses (n = 6; 55%). The average time from presentation to drainage was 7 days (1–18). The average abscess size was 7.2 cm (3.9–12.0 cm). The most common LAMS size was 15 mm × 10 mm; each was placed through the left colon and rectum with both technical and clinical success. All abscesses completely resolved with a mean stent dwell time of 28 days (17–42 days). After stent removal, the fistula was not routinely closed. No complications such as stent migration, bleeding, or perforation occurred. There were no recurrences and no patients required additional surgical or IR procedures with a mean follow-up of 25 weeks (SD 35.6). Conclusions: Adequate drainage is the cornerstone of pelvic abscess management, but IR or surgical access can be challenging, with inadequate drainage and prolonged hospitalization leading to significant morbidity. In our experience, EUS-guided, LAMS-assisted drainage provides a safe and effective alternative for managing pelvic abscesses. Full article

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life. Full article

Background: Endoscopic cysto-gastrostomy (ECG) has become the treatment of choice for pancreatic pseudocysts (PPCs). Endoscopic drainage of PPCs requires the creation of an anastomosis between the lumen of the PPCs and the lumen of the gastrointestinal tract. Various types of stents are used for this purpose. The aim of the study is to compare the indications, quantity, and results of using double pigtail plastic stents (DPPSs) and lumen-apposing fully covered metal stents (LAMSs) in ECG. Methods: A retrospective analysis was conducted of 39 patients (24 men, 15 women) treated for PPCs in the Department of Digestive Tract Surgery and the Department of Gastroenterology and Hepatology between October 2018 and February 2023. The mean age of patients was 51.13 (28–77). Data about etiology, cyst diameter, type, and complications of the stents were collected. Results: DPPSs were placed in smaller cysts (108 vs. 140 millimeters, p = 0.04) and were maintained for a longer duration compared to LAMSs (106 vs. 34 days, p = 0.001). Cyst recurrence was reported less frequently in patients with a LAMS (0 (0%) vs. 4 (19.05%), p = 0.05) and the therapeutic success was non-significantly higher in the LAMS group compared to the DPPS group (100% vs. 85.71%), p = 0.095. Conclusions: Both DPPSs and LAMSs are characterized by high therapeutic success and low complication rates in patients undergoing ECG for PPCs. Full article

Background: This study aimed to assess the effectiveness and safety of endoscopic management in patients with walled-off necrosis and additionally explore the results of a stepwise approach for combining percutaneous intervention in cases where endoscopic management was inadequate. Methods: We included cases of endoscopic management for walled-off necrosis between February 2019 and December 2023. Results: Endoscopic management was performed in 11 patients. The median largest dimension was 150 mm. Multiple cavities were present in four patients. Technical success was 90.9%, while clinical success with only endoscopic management was 36.3%. Clinical success could not be achieved with only endoscopic management in patients with a large diameter (≥125 mm) or multi-lobulated walled-off necrosis. Combining percutaneous intervention resulted in success for all patients. Two patients experienced major complications: one suffered from major bleeding, while the other experienced perforation, necessitating surgical intervention. The patient with perforation died due to multi-organ failure. Conclusions: Endoscopic management is recommended as the primary treatment method for walled-off necrosis due to its less invasive and higher safety profile. In cases involving large or multi-lobulated walled-off necrosis where clinical success cannot be achieved, combining percutaneous intervention is highly successful and safe. Ultimately, this approach can minimize the need for more invasive surgery. Full article

Pancreatic fluid collections (PFCs) are a well-known complication of pancreatitis. PFCs operative management includes percutaneous, endoscopic or surgical drainage. Even if in adult patients, endoscopic drainage is a well-established treatment, few data are available in pediatric setting. We report our single-center experience of EUS-guided cystogastrostomy and lumen-apposing metal stent (LAMS) positioning in children with PFCs; this, at the best of our knowledge, has never been reported before. All consecutive children with PFCs between April 2020 and November 2022 were enrolled in this retrospective study. PFCs were preoperatively evaluated with MRI or CT scan. All the procedures were performed under general anesthesia. A LAMS Hot-Axios^TM 10 × 15 mm was placed in all patients. We evaluated technical feasibility and clinical outcomes, including complications and recurrence rates. Follow-up included clinical observation, blood tests and US. EUS-guided cystogastrostomy was performed in 3 children (2 males; median age 13.2 years). Median maximum cyst diameter was 14.7 cm (range 10–22 cm). Technical and clinical success rates were 100%. No intra or post-operative complications occurred. Our experience suggests that this can be considered a safe and feasible treatment of PCFs even in the pediatric population, as long as the procedure is performed by an expert Endoscopist in a pediatric tertiary-level Center. Full article

Background and Objectives: Pancreatic pseudocysts often arise as complications of pancreatitis and present unique challenges in clinical management, encompassing considerations for both technical aspects and financial implications. Before the advancements of invasive gastroenterology, pancreatic pseudocysts have been drained surgically for many years. Nowadays, we have less invasive techniques with higher efficiency and lower mortality rates, however, they remain cost-challenging for most countries. Materials and Methods: We present four patients (two males and two females) with pancreatic pseudocysts who underwent endoscopic ultrasound-guided transgastric drainage using plastic stents accompanied by a standard lavage protocol using a nasocystic catheter. Results: All four patients had successful outcomes, and a follow-up at 6 months revealed no traces of the pseudocysts or any significant long-term complications. One acute complication (arterial bleeding) and one late complication (stent migration) were observed. As the study aimed to present a cheaper option for draining pancreatic pseudocysts, we investigated and compared costs for the materials we utilized and those associated with lumen-apposing metal stents. Upon compiling the data, a notable advantage was evident in favour of our method. Conclusions: While EUS-guided drainage of pancreatic pseudocysts using lumen-apposing metal stents (LAMSs) represents a high-end strategy for treating pancreatic pseudocysts, our method demonstrates better cost-effectiveness without compromising efficacy. Full article