monthly focus

surgical intervention video

Insulinomas are rare pancreatic neuroendocrine neoplasms (panNENs) with an incidence of 1 to 3 cases per million per year. Most of them are solitary and do not show signs of malignant spread. Multiple synchronous or metachronous panNENs / insulinomas may occur in multiple endocrine neoplasia type 1 (MEN-1). The diagnosis of an insulinoma requires demonstration of inappropriately high insulin, proinsulin or C-peptide levels for the prevailing hypoglycemia in a 72-hour fast. Localization of the tumor and exclusion or confirmation of metastatic disease via computed tomography is still the preferred initial option followed by endoscopic ultrasonography (EUS) or MRI. Glucagon-like peptide receptor 1 (GLP-1R) receptor positron emission tomography (PET) CT or MRI is a highly sensitive localization technique for indolent localized (“benign”) insulinomas. For single solitary tumors, surgical excision or radiofrequency ablation (RFA) represents the treatment(s) of choice.

EUS-guided radiofrequency ablation (EUS-RFA) is a novel and promising technique, which induces tissue necrosis of localized lesions (1).

Crino *et al.* (2) has recently published a comparison between EUS-RF ablation versus surgery for sporadic insulinoma. Eighty-nine patients were allocated in each group (1:1), and were evenly distributed in terms of age, sex, Charlson comorbidity index, American Society of Anesthesiologists score, body mass index, distance between lesion and main pancreatic duct, lesion site, size, and grade. The adverse event (AE) rate was 18.0 and 61.8% after EUS-RFA and surgery, respectively (p \< .001). No severe AEs were observed in the EUS-RFA group as compared to 15.7% after surgery (p \< .0001). Clinical efficacy was 100% after surgery and 95.5% after EUS-RFA (P = .160). However, mean duration of follow-up time was shorter in the EUS-RFA group (median: 23 months; interquartile range: 14-31 months vs. 37 months; interquartile range: 17.5-67 months in the surgical group; p \< .0001). Hospital stay was significantly longer in the surgical group (11.1 ± 9.7 vs. 3.0 ± 2.5 days in the EUS-RFA group; p \< .0001). Fifteen lesions (16.9%) recurred after EUS-RFA and underwent a successful repeat EUS-RFA (11 patients) or surgical resection (4 patients).

EUS-RFA is safer than surgery and highly effective for the treatment of pancreatic insulinomas (PI). If confirmed in a randomized study, EUS-RFA treatment can become first-line therapy for sporadic PI.

Bibliography:

1\. Mariola Marx, Toni Trosic-Ivanisevic, Fabrice Caillol, Nicolas Demartines, Alain Schoepfer, Christian Pesenti, Jean-Philippe Ratone, Maxime Robert, Marc Giovannini, Sébastien Godat. EUS-guided radiofrequency ablation for pancreatic insulinoma: experience in 2 tertiary centers. Gastrointest Endosc 2022 Jun;95(6):1256-1263. doi: 10.1016/j.gie.2021.11.045. Epub 2021 Dec 10. PMID: 34902374 DOI: 10.1016/j.gie.2021.11.045

2\. Stefano Francesco Crinò, Bertrand Napoleon, Antonio Facciorusso, Sundeep Lakhtakia, Ivan Borbath, Fabrice Caillol, Khanh Do-Cong Pham, Gianenrico Rizzatti, Edoardo Forti, Laurent Palazzo , Arthur Belle, Peter Vilmann, Jean-Luc van Laethem, Mehdi Mohamadnejad, Sebastien Godat, Pieter Hindryckx, Ariel Benson, Matteo Tacelli, Germana De Nucci, Cecilia Binda, Bojan Kovacevic, Harold Jacob, Stefano Partelli, Massimo Falconi, Roberto Salvia, Luca Landoni; ERASING study collaborators; Alberto Larghi. Endoscopic Ultrasound-guided Radiofrequency Ablation Versus Surgical Resection for Treatment of Pancreatic Insulinoma. Clin Gastroenterol Hepatol 2023 Oct;21(11):2834-2843.e2. doi: 10.1016/j.cgh.2023.02.022. Epub 2023 Mar 4. PMID: 36871765 DOI: 10.1016/j.cgh.2023.02.022

EUS-guided radiofrequency ablation (RFA) of an insulinoma located in the uncinate process of the pancreas 

Ablation par radiofréquence (RFA) écho-guidée d’un insulinome situé dans le processus unciforme du pancréas

video lecture

The primary focus of video capsule endoscopy (VCE) remains the evaluation of overt or occult small bowel (SB) bleeding. Additional indications include small bowel Crohn’s disease, complicated celiac disease, and polyposis syndromes.

Most platforms transmit images via radiofrequency, while others use low-power electrical conduction or onboard image storage (requiring capsule retrieval). Recording time is at least 8 hours but often exceeds 13 hours.

Patients are required to follow a clear liquid diet for at least 12 hours before the procedure. Additional intake of laxatives and simethicone is recommended. Real-time viewing is used to confirm proper passage into the small bowel.

After data transfer to a workstation with dedicated software, videos are reviewed and stored. Several platforms also offer AI-assisted reading with high accuracy; however, these systems cannot yet replace physicians.

The most frequent findings in cases of bleeding are angioectasias. Various conditions can cause small bowel ulcers, particularly Crohn’s disease and NSAID enteropathy. Small bowel polyps, tumors, diverticula, and villous atrophy are less common.

Typical small bowel transit time is approximately 4 hours, although there is considerable variation. The proportion of small bowel transit time at which a lesion is detected helps guide the choice of insertion route for subsequent enteroscopy.

Capsule retention (defined as persistence for more than 2 weeks) is rare. In at-risk patients (e.g., those with established Crohn’s disease, radiation enteritis, or obstructive symptoms), prior testing with a self-dissolving patency capsule is recommended.

In patients with swallowing disorders, the capsule can be placed endoscopically.

Patients with an ingested capsule should not undergo magnetic resonance imaging. Cardiac pacemakers are not a contraindication for VCE.

Small bowel capsule endoscopy (SBCE)

Esophagogastroduodenoscopy (EGD) represents the gold standard for the evaluation of the upper gastrointestinal (GI) tract. Despite its widespread use, the quality of the examination remains highly operator-dependent. 

A systematic step-by-step approach is required for the intubation of the upper esophagus under direct vision, following the clear identification of the larynx and hypopharyngeal structures. As the endoscope explores the esophagus, several landmarks must be identified, particularly at the level of the esophagogastric junction. Here, the identification of the Z-line (squamocolumnar junction) and the diaphragmatic pinch is crucial for accurately assessing the presence of hiatal hernias or Barrett’s esophagus (BE).

Upon entering the stomach, a rigorous "no-blind-spot" strategy requires the endoscopist to visualize the entire gastric antrum, body, and fundus. Key maneuvers include a meticulous antral survey to identify the prepyloric area and the incisura angularis, followed by the retroflexion maneuver. This retroflexion is vital to inspect the gastric cardia and the fundus from below—areas that are frequently missed during standard forward-viewing. Finally, the transpyloric passage allows the exploration of the duodenal bulb and the second portion of the duodenum, including the identification of the major duodenal papilla.

Mastering the technical nuances of EGD is not merely about "seeing" but about "looking" systematically. This video serves as a fundamental pedagogical resource for trainees and a valuable refresher for experienced clinicians. It reinforces the fact that a high-quality EGD relies on three pillars: ergonomic instrument control, a deep understanding of endoscopic anatomy, and a disciplined repetitive sequence of maneuvers.

Esophagogastroduodenoscopy (EGD): instrumentation, technique, and identification of landmarks

Cholelithiasis is a very common condition worldwide. The coexistence of cholelithiasis and choledocholithiasis occurs in approximately 15% of cases. In addition, about 10% of patients with choledocholithiasis present with so-called “difficult stones,” for which endoscopic management is ineffective, making a surgical approach necessary. In this educational video, the authors present a case of transductal bile duct exploration using a laparoscopic approach.

Bibliography:

1\. Long Pan, Mingyu Chen, Lin Ji, Longbo Zheng, Peijian Yan, Jing Fang, Bin Zhang, Xiujun Cai. The Safety and Efficacy of Laparoscopic Common Bile Duct Exploration Combined with Cholecystectomy for the Management of Cholecysto-choledocholithiasis: An Up-to-date Meta-analysis. Ann Surg 2018 Aug;268(2):247-253. doi: 10.1097/SLA.0000000000002731. PMID: 29533266 DOI: 10.1097/SLA.0000000000002731

2\. Alison Bradley, Sharukh Sami, Niroshini Hemadasa, Anne Macleod, Leo R Brown, Jeyakumar Apollos. Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis. Surg Endosc 2020 Dec;34(12):5211-5222. doi: 10.1007/s00464-020-07816-w. Epub 2020 Jul 24. PMID: 32710213 DOI: 10.1007/s00464-020-07816-w

3\. Jisheng Zhu, Guiyan Wang, Bin Xie, Zhengying Jiang, Weidong Xiao, Yong Li. Minimally invasive management of concomitant gallstones and common bile duct stones: an updated network meta-analysis of randomized controlled trials. Surg Endosc 2023 Mar;37(3):1683-1693. doi: 10.1007/s00464-022-09723-8. Epub 2022 Oct 24. PMID: 36278995 DOI: 10.1007/s00464-022-09723-8

4\. Wangcheng Xie, Zhilong Ma, Jieliang Zuo, Jian Gong, Weidi Yu, Ping Wang, Wei Han, Zhenshun Song, Tingsong Yang. The efficacy and safety of laparoscopic common bile duct exploration and cholecystectomy for the treatment of difficult common bile duct stones combined with gallstones: a multicenter retrospective study. Langenbecks Arch Surg 2023 May 15;408(1):195. doi: 10.1007/s00423-023-02923-3. PMID: 37188992 DOI: 10.1007/s00423-023-02923-3

Laparoscopic cholecystectomy and bile duct revision

Cholécystectomie laparoscopique et révision des voies biliaires

Pancreatic pseudocysts (PPs) arise as a complication of acute pancreatitis, chronic pancreatitis, pancreatic trauma, including post-surgical trauma, or neoplasia. PPs include acute and chronic pancreatic pseudocysts. Acute PPs are believed to form due to the limited pancreatic necrosis, which produces a pancreatic ductal leak whereas the formation of chronic PPs is attributed to downstream pancreatic obstruction from fibrotic strictures and/or stones resulting in a pancreatic ductal blowout (leak) and accumulation of pancreatic fluid. In addition, pancreatic trauma may disrupt the pancreatic duct or its side branches, resulting in fluid collection there. Consequently, pancreatic ductal leak is major in the formation of PPs due to limited pancreatic necrosis, pancreatic ductal strictures and/or stones, and pancreatic trauma.

The transpapillary approach may be used for pseudocyst drainage when the cyst communicates with the main pancreatic duct, especially for PPs associated with pancreatic duct abnormalities. Endoscopic drainage of such PPs could be achieved via the transpapillary placement of endoprostheses. Many studies have reported transpapillary drainage of PPs, and experience has been widely obtained, with compelling results. There are also rare studies reporting prognostic factors associated with successful endoscopic transpapillary drainage of PPs.

The endoscopic transpapillary approach is probably the least traumatic procedure for PPs. Nealon and Walser classified ductal abnormalities in PPs patients as:

\- type I, with normal duct/no communication with the cyst,

\- type II, with normal duct with duct-cyst communication,

\- type III, with otherwise normal duct with stricture and no duct-cyst communication,

\- type IV, with otherwise normal duct with stricture and duct-cyst communication,

\- type V, with otherwise normal duct with complete cut-off,

\- type VI, with chronic pancreatitis without duct-cyst communication,

\- type VII, with chronic pancreatitis and duct-cyst communication.

Accordingly, when a pancreatic pseudocyst is found to have a connection to Wirsung’s duct, the preferred treatment is often the transpapillary insertion of a stent for internal drainage. Endoscopic transpapillary drainage is the least traumatic approach for drainage of PPs and is also effective for patients with no communicating pseudocysts. Clinical success for pancreatic body or tail pseudocyst drainage is higher than that for pancreatic head pseudocyst drainage. We found that the location of PPs is the factor predicting the success of endoscopic transpapillary pseudocyst drainage.

This video shows the case of a 53-year-old female patient with a history of alcohol use disorder presented with epigastric pain since July 2024. In September 2024, a CT scan revealed a cyst in the pancreatic head causing common bile duct compression, main pancreatic duct rupture, and a large communication with the cyst. The patient subsequently developed severe abdominal pain associated with hyperleukocytosis. Follow-up CT imaging demonstrated an increased size of the pseudocyst with evidence of bleeding, portal vein thrombosis (PVT) involving the portal vein, superior mesenteric vein (SMV), and splenic vein (SV), right-sided ischemic colitis, and ascites. CT angiography showed no visible pseudoaneurysm. The patient was started on heparin therapy, and serum chemistries revealed a prothrombin time of 19%, cholestasis, and persistent hyperleukocytosis. Given the clinical and radiological findings, the patient has been scheduled for pseudocyst drainage.

In this video, a 7cm 7 French plastic stent was inserted into the pancreatic duct and collection. A 7cm 10 French plastic stent was also inserted for biliary drainage.

Bibliography:

1\. Paolo Soliani, Christian Franzini, Stefanie Ziegler, Paolo Del Rio, Paolo Dell'Abate, Davide Piccolo, Gioacchino Giovanni Japichino, Giulia Martina Cavestro, Francesco Di Mario, Mario Sianesi. Pancreatic pseudocysts following acute pancreatitis: risk factors influencing therapeutic outcomes. JOP 2004 Sep 10;5(5):338-47.

2\. Todd H Baron. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis. Gastrointest Endosc Clin N Am 2003 Oct;13(4):743-64. doi: 10.1016/s1052-5157(03)00100-4. PMID: 14986796 DOI: 10.1016/s1052-5157(03)00100-4

3\. Edoardo Rosso, Nicholas Alexakis, Paula Ghaneh, Martin Lombard, Howard L Smart, Johnathan Evans, John P Neoptolemos. Pancreatic pseudocyst in chronic pancreatitis: endoscopic and surgical treatment. Dig Surg 2003;20(5):397-406. doi: 10.1159/000072706. Epub 2003 Jul 31. PMID: 12900529 DOI: 10.1159/000072706

4\. William H Nealon, Eric Walser. Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis. Ann Surg 2003 May;237(5):614-20; discussion 620-2. doi: 10.1097/01.SLA.0000064360.14269.EF. PMID: 12724627 PMCID: PMC1514521 DOI: 10.1097/01.SLA.0000064360.14269.EF

5\. Deepak Kumar Bhasin, Surinder Singh Rana, Chalapathi Rao, Rajesh Gupta, Ganga Ram Verma, Mandeep Kang, Birinder Nagi, Kartar Singh. Endoscopic management of pancreatic injury due to abdominal trauma. JOP 2012 Mar 10;13(2):187-92. PMID: 22406599

6\. Deepak Kumar Bhasin, Surinder Singh Rana, Mohit Nanda, Vijant Singh Chandail, Ibrahim Masoodi, Mandeep Kang, Navin Kalra, Saroj Kant Sinha, Birinder Nagi, Kartar Singh. Endoscopic management of pancreatic pseudocysts at atypical locations. Surg Endosc 2010 May;24(5):1085-91. doi: 10.1007/s00464-009-0732-8. Epub 2009 Nov 14. PMID: 19915913 DOI: 10.1007/s00464-009-0732-8

Transpapillary drainage of an infected pancreatic pseudocyst (PP) in a patient with chronic pancreatitis, portal vein thrombosis (PVT), and ascites

Hépaticogastrostomie guidée par échographie endoscopique avec prothèse biliaire souple (métallique auto-expansible dite SEMS chez un patient présentant un ictère obstructif

Biliary drainage is an essential therapeutic strategy for patients with obstructive jaundice, particularly those with malignant biliary obstruction. The first-line approach for biliary drainage is typically endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP can be unsuccessful in cases with altered surgical anatomy, tumor infiltration of the papilla, or duodenal obstruction. In such situations, alternative drainage routes become necessary.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained increasing attention as a minimally invasive alternative to percutaneous transhepatic biliary drainage (PTBD), which has traditionally been used in ERCP-failed cases. Among various EUS-BD techniques, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is particularly useful when access to the left intrahepatic bile ducts (segments B2 or B3) is possible. EUS-HGS involves the creation of a fistula between the stomach and the intrahepatic bile duct using a stent to allow internal drainage.

EUS-HGS may be performed using either self-expandable metal stents (SEMSs) or plastic stents (PSs). As compared to PSs, SEMSs provide superior patency, lower occlusion rates, and greater long-term durability. Fully covered SEMSs (FCSEMSs) are particularly effective in preventing bile leakage. However, their use may result in obstruction of the intrahepatic bile duct (IHD), especially in branched segments, potentially leading to segmental cholangitis or insufficient biliary drainage.

Residual contrast medium is sometimes observed in the IHD on computed tomography (CT) the day after EUS-HGS. Partially covered SEMSs (PCSEMSs) have recently been introduced to address some of these limitations. Although these stents allow for endoscopic reintervention through their lumen, they are difficult to remove due to tissue ingrowth and hyperplasia.

A recent study (1) has compared FCSEMSs versus PCSEMSs. This study has reviewed the EUS database to analyze consecutive patients with MBO who underwent EUS‐HGS between November 2017 and March 2023. The authors performed a 1:1 matching using propensity score matching (PSM) based on potential confounding factors. Stent patency, technical success, clinical success, adverse events, reintervention, and overall survival were assessed.

The technical success rate of EUS‐HGS was 92% (123/134). A total of 80 patients with technical success (40 FCSEMSs, 40 PCSEMSs) were selected after propensity score matching. The two groups showed similar rates of clinical success (90 vs. 88%, p=0.999), early adverse events (15 vs. 20%, p=0.556), late adverse events (18 vs. 33%, p=0.121), reintervention (20 vs. 38%, p=0.084), and median overall survival (4.1 months \[95% confidence interval (CI) 2.6-5.5] vs. 3.8 months \[95% CI: 1.9-5.7], p=0.609). During follow‐up, the FCSEMS group showed higher patency rates (85 vs. 60% at 6 months; 76 vs. 43% at 12 months, p=0.030).

FCSEMSs and PCSEMSs for EUS‐HGS in patients with unresectable MBO showed similar rates of clinical success, as well as early and late adverse events. However, the FCSEMS group showed a higher cumulative stent patency rate as compared to the PCSEMS group.&#x20;

Bibliography:

1\. Sung Hyun Cho, Seong Je Kim, Tae Jun Song, Dongwook Oh, Dong‐Wan Seo. Comparison of fully versus partially covered metal stents in endoscopic ultrasound‐guided hepaticogastrostomy for malignant biliary obstruction (with video). Dig Endosc 2025 May;37(5):532-540. doi: 10.1111/den.14952. Epub 2024 Nov 28. PMID: 39605291 PMCID: PMC12062555 DOI: 10.1111/den.14952

2\. Ren Kuwabara, Kazuo Hara, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Hiroki Koda, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto, Keigo Oshiro, Tomoki Ogata. Multiple Self-Made Side Holes in a Fully Covered Metal Stent Prevent Intrahepatic Bile Duct Occlusion Following Endoscopic Ultrasound-Guided Hepaticogastrostomy: A Retrospective Study in Japan. J Clin Med 2025 May 28;14(11):3773. doi: 10.3390/jcm14113773. PMID: 40507535 PMCID: PMC12156069 DOI: 10.3390/jcm14113773

Endoscopic ultrasound-guided hepaticogastrostomy using a fully covered self-expandable metal stent (SEMS) in a patient with obstructive jaundice

Laparoscopic cholecystectomy is accountable for 80 to 85% of bile duct injuries (BDIs), and it is twice as frequent as compared to open cholecystectomy. Injuries affect the quality of life and overall survival of the patient. The management of such injuries is complex and challenging. Traditionally, biliary injuries have been classified using the Bismuth classification. This classification, which originated from the era of open surgery, is intended to help surgeons to select the appropriate technique for the repair, and it has a good correlation with final outcomes after surgical repair. However, the Bismuth classification does not encompass the whole spectrum of injuries that may occur. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. The Strasberg classification made the Bismuth classification much more comprehensive by including various other types of extrahepatic BDIs.

The cornerstones for the initial management of BDIs are early recognition, followed by modern imaging and evaluation of injury severity. The availability of a tertiary hepatobiliary care center with a multidisciplinary approach is crucial. The diagnosis of BDI starts with a multi-phase abdominal CT-scan, and when the biloma is drained or a surgical drain is put in place, the diagnosis is established with the help of bile drain output. To visualize the leakage site and biliary anatomy, the diagnosis is supplemented with contrast-enhanced magnetic resonance imaging (MRI). The location and severity of the bile duct lesion and concomitant injuries to the hepatic vascular system are evaluated. Most often, a combination of percutaneous and endoscopic methods is used for control of contamination and bile leakage. Generally, the next step is endoscopic retrograde cholangiography (ERC) for downstream control of the bile leak. Endoscopic retrograde cholangiography with insertion of a stent is the treatment of choice in most mild bile leaks. The surgical option of reoperation and its timing should be discussed in cases where an endoscopic and percutaneous approach is not sufficient. The patient’s failure to properly recover in the first days after a laparoscopic cholecystectomy should immediately raise the suspicion of BDI, and this merits immediate investigation. Early consultation and referral to a dedicated hepatobiliary unit are essential for best outcomes.

This video demonstrates an endoscopic repermeabilization of a common bile duct (CBD) transection after laparoscopic cholecystectomy in a 21-year-old female patient.

Key operating steps include the following: failure of recanalization using a transjugular biopsy needle and an extraction balloon, introduction of a pediatric bronchoscope in intrahepatic right bile ducts, introduction of a cholangioscope, successful passage of a guide wire through the right bile duct into the common bile duct. The video also clearly demonstrates the rendezvous technique, which allowed for the dilatation of the stenosis and the introduction of a 10.2 French internal-external biliary drain.

Bibliography:

D Pencev, P G Brady, H Pinkas, J Boulay. The role of ERCP in patients after laparoscopic cholecystectomy. Am J Gastroenterol 1994 Sep;89(9):1523-7. PMID: 8079931

Bobby V M Dasari, Chuan Jin Tan, Kurinchi Selvan Gurusamy, David J Martin, Gareth Kirk, Lloyd McKie, Tom Diamond, Mark A Taylor. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013 Sep 3:(9):CD003327. doi: 10.1002/14651858.CD003327.pub3. PMID: 23999986 DOI: 10.1002/14651858.CD003327.pub3

Haim Pinkas, Patrick G Brady. Biliary leaks after laparoscopic cholecystectomy: time to stent or time to drain. Hepatobiliary Pancreat Dis Int 2008 Dec;7(6):628-32. PMID: 19073409

Mubashir H Khan, Thomas J Howard, Evan L Fogel, Stuart Sherman, Lee McHenry, James L Watkins, David F Canal, Glen A Lehman. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc 2007 Feb;65(2):247-52. doi: 10.1016/j.gie.2005.12.037. PMID: 17258983 DOI: 10.1016/j.gie.2005.12.037

Young Ook Eum, Joo Kyung Park, Jaeyoung Chun, Sang-Hyub Lee, Ji Kon Ryu, Yong-Tae Kim, Yong-Bum Yoon, Chang Jin Yoon, Ho-Seong Han, Jin-Hyeok Hwang. Non-surgical treatment of post-surgical bile duct injury: clinical implications and outcomes. World J Gastroenterol 2014 Jun 14;20(22):6924-31. doi: 10.3748/wjg.v20.i22.6924. PMID: 24944484 PMCID: PMC4051933 DOI: 10.3748/wjg.v20.i22.6924

Yunxiao Lyu, Yunxiao Cheng, Ting Li, Bin Cheng, Xin Jin. Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis. Surg Endosc 2019 Oct;33(10):3275-3286. doi: 10.1007/s00464-018-06613-w. Epub 2018 Dec 3.PMID: 30511313 DOI: 10.1007/s00464-018-06613-w

Suprabhat Giri, Sridhar Sundaram, Harish Darak, Sanjay Kumar, Shobna Bhatia. Outcomes of Endoscopic Management among Patients with Bile Leak of Various Etiologies at a Tertiary Care Center. Clin Endosc 2020 Nov;53(6):727-734. doi: 10.5946/ce.2020.017. Epub 2020 Aug 21. PMID: 32819052 PMCID: PMC7719417 DOI: 10.5946/ce.2020.017

Endoscopic repermeabilization of a common bile duct (CBD) transection after laparoscopic cholecystectomy

Reperméabilisation endoscopique d'une transection de la voie biliaire principale après cholécystectomie laparoscopique

Un cas d'ablation par radiofréquence intrabiliaire d'un adénome résiduel après papillectomie endoscopique

The first snare endoscopic papillectomy (ESP) was described in 1983 (1). This procedure is the gold standard for the management of benign tumors of the papilla of Vater and it is acceptable for adenocarcinomas strictly limited to the mucosa.

This technical endoscopic procedure has a high resection rate of up to 90%, considering the need for subsequent endoscopic sessions; in fact, positive margins and relapse are common, occurring in up to 30% of patients. Most of the time, positive lateral margins can be monitored and managed endoscopically with standard tools such as snare resection (SR) or Argon plasma coagulation (APC), whereas deep positive margins are more challenging to manage. In fact, their treatment depends on histology and on the length of intraductal extension.

In the case of adenocarcinoma in deep positive margins and because of node risk, surgery is indicated, with morbidity and mortality rates of up to 49 and 9%, respectively.

For many years, biliary and pancreatic intraductal benign tissue involvement was considered a failure criterion for EP, and because endoscopic tools do not permit complete intraductal ablation, a length greater than 1cm was considered a surgical indication (11, 12).

Recently, procedure improvements which involve radiofrequency probes consisted in applying such probes to the lower part of the biliary and pancreatic ducts to induce coagulative necrosis of the surrounding tissue. Several case reports and more recent series of intraductal ablation techniques using cystostomes or radiofrequency probes (14) have been published and showed promising results, with a clinical success rate of approximately 70%. Adverse events (AEs) occurred in 11 to 50% of cases and mostly consisted of mild acute pancreatitis or duct stenosis. However, such outcomes have mainly been observed over short-term follow-up periods.

Bibliography:

(1) Suzuki K, Kantou U, Murakami Y. Two cases with ampullary cancer who underwent endoscopic excision. Prog Dig Endosc 1983;23:236-9.

(2) Geoffroy Vanbiervliet, Marin Strijker, Marianna Arvanitakis, Arthur Aelvoet, Urban Arnelo, Torsten Beyna, Olivier Busch, Pierre H Deprez, Lumir Kunovsky, Alberto Larghi, Gianpiero Manes, Alan Moss, Bertrand Napoleon, Manu Nayar, Enrique Pérez-Cuadrado-Robles, Stefan Seewald, Marc Barthet, Jeanin E van Hooft. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021 Apr;53(4):429-448. doi: 10.1055/a-1397-3198. Epub 2021 Mar 16. PMID: 33728632 DOI: 10.1055/a-1397-3198

(3) ASGE Standards of Practice Committee; Krishnavel V Chathadi, Mouen A Khashab, Ruben D Acosta, Vinay Chandrasekhara, Mohamad A Eloubeidi, Ashley L Faulx, Lisa Fonkalsrud, Jenifer R Lightdale, John R Salztman, Aasma Shaukat, Amy Wang, Brooks D Cash, John M DeWitt. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2015 Nov;82(5):773-81. doi: 10.1016/j.gie.2015.06.027. Epub 2015 Aug 7. PMID: 26260385 DOI: 10.1016/j.gie.2015.06.027

(4) Bertrand Napoleon, Rodica Gincul, Thierry Ponchon, Julien Berthiller, Jean Escourrou, Jean-Marc Canard, Jean Boyer, Marc Barthet, Philippe Ponsot, René Laugier, Thierry Helbert, Dimitri Coumaros, Jean-Yves Scoazec, François Mion, Jean-Christophe Saurin; Sociéte Française d’Endoscopie Digestive (SFED, French Society of Digestive Endoscopy). Endoscopic papillectomy for early ampullary tumors: long-term results from a large multicenter prospective study. Endoscopy 2014 Feb;46(2):127-34. doi: 10.1055/s-0034-1364875. Epub 2014 Jan 29. PMID: 24477368 DOI: 10.1055/s-0034-1364875

(5) Sung Hoon Kang, Kook Hyun Kim, Tae Nyeun Kim, Min Kyu Jung, Chang Min Cho, Kwang Bum Cho, Ji Min Han, Ho Gak Kim, Hyun Soo Kim. Therapeutic outcomes of endoscopic papillectomy for ampullary neoplasms: retrospective analysis of a multicenter study. BMC Gastroenterol 2017 May 30;17(1):69. doi: 10.1186/s12876-017-0626-5. PMID: 28558658 PMCID: PMC5450406 DOI: 10.1186/s12876-017-0626-5

(6) Sophia E van der Wiel, Jan-Werner Poley, Arjun D Koch, Marco J Bruno. Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study. Surg Endosc 2019 Apr;33(4):1180-1188. doi: 10.1007/s00464-018-6392-9. Epub 2018 Aug 23. PMID: 30167949 PMCID: PMC6430826 DOI: 10.1007/s00464-018-6392-9

(7) Arata Sakai, Masahiro Tsujimae, Atsuhiro Masuda, Takao Iemoto, Shigeto Ashina, Kohei Yamakawa, Takeshi Tanaka, Shunta Tanaka, Yasutaka Yamada, Ryota Nakano, Yu Sato, Manabu Kurosawa, Takuya Ikegawa, Seiji Fujigaki, Takashi Kobayashi, Hideyuki Shiomi, Yoshifumi Arisaka, Tomoo Itoh, Yuzo Kodama. Clinical outcomes of ampullary neoplasms in resected margin positive or uncertain cases after endoscopic papillectomy. World J Gastroenterol 2019 Mar 21;25(11):1387-1397. doi: 10.3748/wjg.v25.i11.1387. PMID: 30918431 PMCID: PMC6429348 DOI: 10.3748/wjg.v25.i11.1387

(8) C Mattevi, J Garnier, U Marchese, J Ewald, M Gilabert, F Poizat, G Piana, J R Delpero, O Turrini. Has the nonresection rate decreased during the last two decades among patients undergoing surgical exploration for pancreatic adenocarcinoma? BMC Surg 2020 Aug 5;20(1):176. doi: 10.1186/s12893-020-00835-3. PMID: 32758203 PMCID: PMC7430808 DOI: 10.1186/s12893-020-00835-3

(9) Junmin Song, Hongxiang Liu, Zhen Li, Chao Yang, Yuling Sun, Chaojie Wang. Long-term prognosis of surgical treatment for early ampullary cancers and implications for local ampullectomy. BMC Surg 2015 Mar 22:15:32. doi: 10.1186/s12893-015-0019-z. PMID: 25888004 PMCID: PMC4375931 DOI: 10.1186/s12893-015-0019-z

(10) Olivier Farges, Noelle Bendersky, Stéphanie Truant, Jean Robert Delpero, François René Pruvot, Alain Sauvanet. The theory and practice of pancreatic surgery in France. Ann Surg 2017 Nov;266(5):797-804. doi: 10.1097/SLA.0000000000002399. PMID: 28885506 DOI: 10.1097/SLA.0000000000002399

(11) Sabine Bohnacker, Uwe Seitz, Dzung Nguyen, Frank Thonke, Stefan Seewald, Andreas deWeerth, Ryan Ponnudurai, Salem Omar, Nib Soehendra. Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth. Gastrointest Endosc 2005 Oct;62(4):551-60. doi: 10.1016/j.gie.2005.04.053. PMID: 16185970 DOI: 10.1016/j.gie.2005.04.053

(12) Wiriyaporn Ridtitid, Damien Tan, Suzette E Schmidt, Evan L Fogel, Lee McHenry, James L Watkins, Glen A Lehman, Stuart Sherman, Gregory A Coté. Endoscopic papillectomy: risk factors for incomplete resection and recurrence during long-term follow-up. Gastrointest Endosc 2014 Feb;79(2):289-96. doi: 10.1016/j.gie.2013.08.006. Epub 2013 Oct 1. PMID: 24094466 PMCID: PMC4413454 DOI: 10.1016/j.gie.2013.08.006

(13) Enrique Pérez-Cuadrado-Robles, Hubert Piessevaux, Tom G Moreels, Ralph Yeung, Tarik Aouattah, Mina Komuta, Hélène Dano, Anne Jouret-Mourin, Pierre H Deprez. Combined excision and ablation of ampullary tumors with biliary or pancreatic intraductal extension is effective even in malignant neoplasms. United European Gastroenterol J 2019 Apr;7(3):369-376. doi: 10.1177/2050640618817215. Epub 2019 Jan 12. PMID: 31019705 PMCID: PMC6466754 DOI: 10.1177/2050640618817215

(14) Marine Camus, Bertrand Napoléon, Ariane Vienne, Marc Le Rhun, Sarah Leblanc, Maximilien Barret, Stanislas Chaussade, Françoise Robin, Nadira Kaddour, Frederic Prat. Efficacy and safety of endobiliary radiofrequency ablation for the eradication of residual neoplasia after endoscopic papillectomy: a multicenter prospective study. Gastrointest Endosc 2018 Sep;88(3):511-518. doi: 10.1016/j.gie.2018.04.2332. Epub 2018 Apr 13. PMID: 29660322 DOI: 10.1016/j.gie.2018.04.2332

(15) Tarun Rustagi, Shayan Irani, D Nageshwar Reddy, Barham K Abu Dayyeh, Todd H Baron, Christopher J Gostout, Michael J Levy, John Martin, Bret T Petersen, Andrew Ross, Mark D Topazian. Radiofrequency ablation for intraductal extension of ampullary neoplasms. Gastrointest Endosc 2017 Jul;86(1):170-176. doi: 10.1016/j.gie.2016.11.002. Epub 2016 Nov 17. PMID: 27866907 DOI: 10.1016/j.gie.2016.11.002

(16) Andrea Tringali, Maria Valeria Matteo, Beatrice Orlandini, Federico Barbaro, Vincenzo Perri, Qianqian Zhang, Riccardo Ricci, Guido Costamagna. Radiofrequency ablation for intraductal extension of ampullary adenomatous lesions: proposal for a standardized protocol. Endosc Int Open 2021 May;9(5):E749-E755. doi: 10.1055/a-1387-7880. Epub 2021 Apr 22. PMID: 33937517 PMCID: PMC8062240 DOI: 10.1055/a-1387-7880

(17) Sung Hyun Cho, Dongwook Oh, Tae Jun Song, Do Hyun Park, Dong-Wan Seo, Sung Koo Lee, Myung-Hwan Kim, Sang Soo Lee. Long-term outcomes of endoscopic intraductal radiofrequency ablation for ampullary adenoma with intraductal extension after endoscopic snare papillectomy. Gut Liver 2023 Jul 15;17(4):638-646. doi: 10.5009/gnl220201. Epub 2022 Dec 6. PMID: 36472069 PMCID: PMC10352061 DOI: 10.5009/gnl220201

(18) Karlijn J Nass, Liselotte W Zwager, Manon van der Vlugt, Evelien Dekker, Patrick M M Bossuyt, Srivathsan Ravindran, Siwan Thomas-Gibson, Paul Fockens. Novel classification for adverse events in GI endoscopy: the AGREE classification. Gastrointest Endosc 2022 Jun;95(6):1078-1085.e8. doi: 10.1016/j.gie.2021.11.038. Epub 2021 Dec 8. PMID: 34890695 DOI: 10.1016/j.gie.2021.11.038

(19) Jung Won Chun, Sang Myung Woo, Mira Han, Min Woo Lee, Jin Ho Choi, In Rae Cho, Woo Hyun Paik, Woo Jin Lee, Ji Kon Ryu, Yong-Tae Kim, Sang Hyub Lee. Prolonged patency of fully covered self-expandable metal stents with an externally anchored plastic stent in distal malignant biliary obstruction. Endoscopy 2023 Jun;55(6):563-568. doi: 10.1055/a-2013-2034. Epub 2023 Feb 3. PMID: 36736351 DOI: 10.1055/a-2013-2034

A case of intrabiliary radiofrequency ablation (RFA) of a residual adenoma after endoscopic papillectomy

Ablation par radiofréquence guidée par écho-endoscopie d'une tumeur neuroendocrine du pancréas

Nowadays, endoscopic ultrasound-guided radiofrequency ablation has become increasingly accepted for the treatment of different precancerous and neoplastic lesions of the pancreas, particularly in patients who are unfit for surgery. However, thermal ablation has long been suspected to induce pancreatitis or to injure adjacent structures. Published case reports and case series on this topic are of limited size and are often based on a heterogeneous study population, reporting on functional and nonfunctional pancreatic neuroendocrine tumors (pNETs). Nevertheless, the overall results are promising, with high technical success and relatively low complication rates.

Recently, there has been growing interest in investigating endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for the management of small non-functional pancreatic neuroendocrine tumors (nf pNETs).

A bicentric retrospective study was performed. It included patients with histologically confirmed nonfunctional pNETs who were consecutively treated by means of EUS-RFA at two tertiary referral centers between December 2015 and March 2021. In 27 patients (mean age: 65.0 years, 52% male), EUS-RFA was successfully performed. All patients had sporadic G1 lesions (mean size: 14.0 plus-minus 4.6mm, 7% uncinated process, 22% head, 11% body, 19% body/tail junction, and 41% tail). Overall, 9/27 lesions (33%) were cystic. Mean hospital stay was 3.2 days. Complete treatment response was confirmed in 25/27 patients (93%) on cross-sectional imaging (mean follow-up: 15.7 plus-minus 12.2 months, range: 2-41 months). Two patients had two EUS-RFA sessions until complete necrosis was observed. Periprocedural acute pancreatitis occurred in 4/27 patients (14.8%), three of them were treated by means of endoscopic cystogastrostomy (11.1%). One patient underwent secondary surgery. The histopathology of the resected specimen revealed 3mm of residual tumor tissue.

EUS-RFA seems to be a promising treatment strategy for the management of small nonfunctional pNETs with excellent efficacy. Further evidence focusing on long-term survival, safety profile, and recurrence is required.

Bibliography:

1\. Elia Armellini, Antonio Facciorusso, Stefano Francesco Crinò. Efficacy and Safety of Endoscopic Ultrasound-Guided Radiofrequency Ablation for Pancreatic Neuroendocrine Tumors: A Systematic Review and Metanalysis. Medicina (Kaunas) 2023 Feb 14;59(2):359. doi: 10.3390/medicina59020359. PMID: 36837560 PMCID: PMC9963038 DOI: 10.3390/medicina59020359

2\. Fadi Younis, Dana Ben-Ami Shor, Nir Lubezky, Ravit Geva, Esther Osher, Oren Shibolet, Adam Phillips, Erez Scapa. Endoscopic ultrasound-guided radiofrequency ablation of premalignant pancreatic-cystic neoplasms and neuroendocrine tumors: prospective study. Eur J Gastroenterol Hepatol 2022 Nov 1;34(11):1111-1115. doi: 10.1097/MEG.0000000000002422. Epub 2022 Sep 10. PMID: 36170679 DOI: 10.1097/MEG.0000000000002422

3\. Mihai Rimbaș, Giulia Tripodi, Alberto Larghi. Endoscopic ultrasound-guided radiofrequency ablation for nonfunctional pancreatic neuroendocrine tumors: Put the gun away or keep shooting? Dig Endosc 2022 Sep;34(6):1257. doi: 10.1111/den.14349. Epub 2022 Jun 27. PMID: 35545866 DOI: 10.1111/den.14349

4\. Mihai Rimbaş, Mihaela Horumbă, Gianenrico Rizzatti, Stefano Francesco Crinò, Antonio Gasbarrini, Guido Costamagna, Alberto Larghi. Interventional endoscopic ultrasound for pancreatic neuroendocrine neoplasms. Dig Endosc 2020 Nov;32(7):1031-1041. doi: 10.1111/den.13635. Epub 2020 Mar 20. PMID: 31995848 DOI: 10.1111/den.13635

5\. Tawfik Khoury, Wisam Sbeit, Pietro Fusaroli, Davide Campana, Nicole Brighi, Bertrand Napoleon, Andrea Lisotti. Safety and efficacy of endoscopic ultrasound-guided radiofrequency ablation for pancreatic neuroendocrine neoplasms: Systematic review and meta-analysis. Dig Endosc 2024 Apr;36(4):395-405. doi: 10.1111/den.14681. Epub 2023 Oct 11. PMID: 37702096 DOI: 10.1111/den.14681

6\. Radhika Chavan, Nirav Thosani, Shivangi Kothari. Role of Endoscopic Ultrasound-Guided Radiofrequency Ablation in Pancreatic Lesions: Where Are We Now and What Does the Future Hold? Cancers (Basel) 2024 Oct 30;16(21):3662. doi: 10.3390/cancers16213662. PMID: 39518100 PMCID: PMC11544980 DOI: 10.3390/cancers16213662

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) of pancreatic neuroendocrine tumor (pNET)

In this key lecture, Professor Petko Karagyozov, MD, PhD, FASGE (Sofia, Bulgaria) addresses the advances in diagnostic and therapeutic endoscopy, which have increased the need for effective management of post-resection defects and accurate lesion localization. Recent technological developments in resection devices have expanded clinicians’ ability to remove large lesions and have driven the evolution of closure tools, thereby improving the safety of endoscopic procedures.

This presentation provides a comprehensive overview of contemporary strategies for endoscopic defect closure and gastrointestinal tattooing. Indications for defect closure are discussed, including perforation, deep resection, prophylactic closure in high-risk patients, and third-space endoscopic procedures. The presentation also reviews the available evidence on when closure reduces the risk of delayed bleeding and perforation, alongside recent guideline recommendations, emphasizing individualized decision-making based on patient- and lesion-specific risk factors.

Current closure techniques and devices are reviewed, including conventional through-the-scope clips, newer clips with larger jaws and enhanced grasping capability, dual-action tissue approximation devices, over-the-scope clips, and suturing systems. Practical tips and technical nuances are provided to optimize tissue capture, defect approximation, and overall procedural success.

The second part of the presentation focuses on endoscopic tattooing, outlining its indications, appropriate anatomical sites, ink types, and standardized techniques. Particular attention is given to preventing adverse events such as transmural injection, peritoneal staining, and fibrosis. Best practices for saline-assisted injection, optimal tattoo placement in relation to lesions, and proper documentation are emphasized.

The lecture integrates guideline-based evidence with practical experience to support safe, effective, and reproducible approaches to endoscopic defect closure and tattooing in routine clinical practice.

Tattooing and defect closure

Tatouage et fermeture des brèches

Endoscopic suturing remains one of the most technically demanding skills in therapeutic endoscopy, requiring precision, stability, and efficient knot management. This presentation delivered by Prof. Dariusz Patkowski, MD, PhD focuses on practical strategies to simplify and optimize the suturing process through a stepwise approach. Key technical aspects include establishing the basis for perfect suturing, precise needle positioning, controlled needle passage through tissue, and effective loop creation around an instrument. Special emphasis is placed on mastering the sliding knot technique, which is one of the most practical and useful knots in almost every situation, including suturing under tension. The double-knot technique is also demonstrated. The advantages of these standardized maneuvers are discussed, highlighting how they can enhance procedural efficiency, facilitate learning, and improve overall suturing performance in advanced endoscopic interventions.

Endoscopic suturing is a challenge: how to make it easier

EUS-guided biliary drainage is an option to treat obstructive jaundice when ERCP drainage fails. Such a procedure represents an alternative to surgery and to percutaneous transhepatic biliary drainage. It has also been made possible through the continuous development and improvement of endoscopic ultrasound (EUS) scopes and accessories. The development of linear sectorial array EUS scopes in the early 1990s brought a new approach to the diagnostic and therapeutic dimensions of endoscopic ultrasound capabilities, opening the possibility to perform a puncture over a direct ultrasonographic view. Despite the high success rate and the low morbidity of biliary drainage obtained via ERCP, difficulty may arise with an ingrown stent tumor, tumor gut compression, periampullary diverticula, and anatomic variations. The EUS-guided technique requires puncture and contrast of the left biliary tree. When performed from the gastric wall, access is obtained through liver segment III. Direct common bile duct puncture is achieved from the duodenum. Diathermic dilation of the puncturing tract is performed using a 6 French cystotome and a plastic or metallic stent. The technical success of hepaticogastrostomy nears 98%, and complications are present in 20% of cases. The most common complications include pneumoperitoneum, bilioperitoneum, infection and stent dysfunction. To prevent bile leakage, the authors used a special partially covered stent (70% covered and 30% uncovered). The overall success rate for choledochoduodenostomy is 92%. The described complications include, in decreasing order of frequency, the following: pneumoperitoneum and focal bile peritonitis, present in 14% of cases. Over the last 15 years, the technique has typically been performed in reference centers, by groups experienced with ERCP. This seems to be a general guideline guaranteeing the safer execution of the procedure.

Bibliography:

1\. Giovannini M. EUS-guided hepaticogastrostomy. Endosc Ultrasound. 2019 Nov 28;8(Suppl 1):S35-S39. doi: 10.4103/eus.eus\_47\_19. eCollection 2019 Nov. PMID: 31897377. PMCID: PMC6896433 DOI: 10.4103/eus.eus\_47\_19

2\. Koutlas NJ, Pawa S, Russell G, Ferris T, Ponnatapura J, Pawa R. EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis. Endosc Int Open 2024 Jan 19;12(1):E108-E115. doi: 10.1055/a-2220-2740. eCollection 2024 Jan. PMID: 38250165 PMCID: PMC10798845 DOI: 10.1055/a-2220-2740

3\. Ishiwatari H, Ogura T, Hijioka S, Iwashita T, Matsubara S, Ishikawa K, Niiya F, Sato J, Okuda A, Ueno S, Nagashio Y, Maruki Y, Uemura S, Notsu A. EUS-guided hepaticogastrostomy versus EUS-guided hepaticogastrostomy with antegrade stent placement in patients with unresectable malignant distal biliary obstruction: a propensity score-matched case-control study. Gastrointest Endosc 2024 Jul;100(1):66-75. doi: 10.1016/j.gie.2024.02.012. Epub 2024 Feb 19. PMID: 38382887 DOI: 10.1016/j.gie.2024.02.012

4\. Ogura T, Ishiwatari H, Hijioka S, Takeshita K, Sato J, Takenaka M, Fukunaga T, Omoto S, Fujimori N, Ohno A, Hatamaru K, Tamura T, Imai H, Yamada M, Hakoda A, Nishikawa H, Kitano M. Multicenter study comparing EUS-guided hepaticogastrostomy and ERCP for malignant biliary obstruction in patients with accessible papillae. J Hepatobiliary Pancreat Sci 2024 Sep;31(9):680-687. doi: 10.1002/jhbp.12055. Epub 2024 Jul 18.. PMID: 39022838 DOI: 10.1002/jhbp.12055

5\. Takeshita K, Hijioka S, Nagashio Y, Maruki Y, Ohba A, Kawasaki Y, Takasaki T, Yagi S, Agarie D, Hara H, Hagiwara Y, Yamashige D, Okamoto K, Fukuda S, Kuwada M, Chatto M, Kondo S, Morizane C, Ueno H, Saito Y, Okusaka T. Comparison of stent patency between EUS-guided hepaticogastrostomy with bridging and endoscopic transpapillary biliary drainage for hilar obstruction. Endosc Int Open 2024 Jul 10;12(7):E875-E886. doi: 10.1055/a-2333-7898. eCollection 2024 Jul. PMID: 38989254 PMCID: PMC11236478 DOI: 10.1055/a-2333-7898

EUS-guided biliary drainage for obstructive jaundice due to advanced pancreatic cancer in a patient with a previous duodenal stent for duodenal tumoral obstruction: EUS hepaticogastrostomy

Drainage biliaire sous échoendoscopie pour le traitement d'un ictère obstructif dû à un cancer pancréatique de stade avancé chez un patient pris en charge par prothèse biliaire pour obstruction duodénale tumorale : hépaticogastrostomie guidée sous échoendoscopie

Drainage d’un pseudokyste pancréatique guidé par échoendoscopie

A true cyst is a localized fluid collection, which is contained within an epithelial lined capsule. In contrast, a pseudocyst is a fluid collection, surrounded by a non-epithelialized wall made up of fibrous and granulation tissue, hence the name ‘pseudocyst’. A pancreatic pseudocyst is an encapsulated collection of homogeneous fluid with little or no necrotic tissue within it. It is usually well-circumscribed and located outside of the pancreas, often in the lesser sac. Pancreatic pseudocysts are often seen as a complication of chronic pancreatitis and less commonly originating from acute pancreatitis. They occur when the damage of the pancreatic ducts, frequently from biliary stones or alcohol, causes extravasation and collection of the pancreatic fluid. Regardless of the cause, the overall incidence of pseudocysts is low, namely 0.5 to 1 per 100,000 adults per year.

 

From a technical standpoint, the EUS-guided approach has two crucial steps. The first step consists in the identification of an optimal point to puncture without intervening vessels and with a short distance between the cyst and the gut wall. Once this point has been identified, the endoscope should be straightened as much as possible in a stable position. The second critical step is that once the puncture has been performed and the guide wire has been curled inside the cyst cavity, the wall dilator (i.e., a 10 French cystostome) must be introduced without losing the endoscope position under ultrasonographic and X-ray views. Once the dilator has been inserted through the parietal fistula, the ultrasonographic view is no longer needed. A second guide wire is then inserted. Two plastic pigtail stents are inserted under endoscopic and X-ray views.

This video includes clinical case presentation, pseudocyst evaluation and puncturing tract selection, puncture of pseudocyst with the needle knife of a 10 French cystostome, aspiration of pseudocyst fluid sample and insertion of a first 0.035 inch guide wire, insertion of the 10 French part of the cystostome using pure cutting and insertion of a second 0.0035 inch guide wire, dilation of puncturing tract with an 8mm balloon, insertion of two 7 French, 5cm plastic pigtail stents, postoperative outcomes, and take-home messages.&#x20;

Bibliography:

1\. Vanessa Falk, Sana Kenshil, Simrat Sandha, Christopher Teshima, Pernilla D'Souza, Gurpal Sandha. The Evolution of EUS-Guided Transluminal Drainage for the Treatment of Pancreatic Fluid Collections: A Comparison of Clinical and Cost Outcomes with Double-Pigtail Plastic Stents, Conventional Metal Stents and Lumen-Apposing Metal Stents. J Can Assoc Gastroenterol 2018 Sep 12;3(1):26-35. doi: 10.1093/jcag/gwy049. eCollection 2020 Feb. PMID: 34169224 PMCID: PMC8218535 DOI: 10.1093/jcag/gwy049

2\. Tomotaka Saito, Mamoru Takenaka, Masaki Kuwatani, Shinpei Doi, Hiroshi Ohyama, Toshio Fujisawa, Atsuhiro Masuda, Takuji Iwashita, Hideyuki Shiomi, Nobuhiko Hayashi, Keisuke Iwata, Akinori Maruta, Tsuyoshi Mukai, Saburo Matsubara, Tsuyoshi Hamada, Tadahisa Inoue, Kazuyuki Matsumoto, Sumio Hirose, Nao Fujimori, Kosuke Kashiwabara, Hideki Kamada, Shinichi Hashimoto, Toshiyasu Shiratori, Reiko Yamada, Hirofumi Kogure, Kazunari Nakahara, Takeshi Ogura, Masayuki Kitano, Ichiro Yasuda, Hiroyuki Isayama, Yousuke Nakai, WONDERFUL study group in Japan and collaborators. WONDER-02: plastic stent vs. lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic pseudocysts-study protocol for a multicentre randomised non-inferiority trial. Trials 2024 Aug 24;25(1):559. doi: 10.1186/s13063-024-08373-6. PMID: 39182137 PMCID: PMC11344301 DOI: 10.1186/s13063-024-08373-6

3\. Kaveh Khodakaram, Svein Olav Bratlie, Per Hedenström, Riadh Sadik. Equivalent efficacy and safety of plastic stents and lumen-apposing metal stents in the treatment of peripancreatic fluid collections: a prospective cohort study. Ann Gastroenterol 2024 May-Jun;37(3):362-370. doi: 10.20524/aog.2024.0873. Epub 2024 Apr 5. PMID: 38779636 PMCID: PMC11107401 DOI: 10.20524/aog.2024.0873

Focus on endoscopic surgery and digestive endoscopy