Feasibility Study of EUS-NOTES as a Novel Approach for Peroral Cholecysto-Gastrostomy

Rezumat Studiu de fezabilitate al procedurilor de chirurgie endoscopicã transluminalã prin orificii naturale (NOTES) ghidate prin endoscopie ultrasonograficã (EUS) pentru efectuarea de colecisto-gastrostomii perorale Introducere: Colecisto-gastrostomia ghidata prin endoscopie ultrasonograficã (EUS) poate reprezenta o procedurã miniminvazivã folositã pentru drenajul colecistului, fie la pacienåi cu cancere pancreatico-biliare avansate, fie la pacienåi cu colecistitã acutã care nu sunt consideraåi candidaåi pentru o posibilã intervenåie chirurgicalã laparoscopicã. Obiectiv: Colecisto-gastrostomie directã ghidatã ecoendoscopic prin plasarea unui stent metalic expandabil dublu. Design: Studiu de fezabilitate pilot la un model experimental animal. Material aei metode: Studiul a testat fezabilitatea colecistogastrostomiei ghidate ecoendoscopic prin abord transgastric la un model experimental porcin. Au fost folosite dispozitive speciale pentru accesul transgastric al colecistului prin abord ecoendoscopic prin canalul de biopsie, respectiv un stent metalic expandabil cu capete proeminente. Rezultate: Rezultatele au indicat cã procedura este dificilã dar fezabilã, pe baza unor dispozitive prototip pentru accesul transgastric al colecistului, prin plasarea transgastricã a unui stent metalic expandabil. Limitãri: Studiu de fezabilitate de supravieåuire folosind dispositive prototip pentru drenaj ecoendoscopic al colecistului la un numãr mic de animale (5 porci). Concluzii: Colecisto-gastrostomia ghidatã ecoendoscopic prin abord transgastric la un model experimental porcineste o procedurã fezabilã, dar dificilã tehnic datoritã limitãrilor anatomice ale modelului experimental porcin, dar în special datoritã complexitãåii procedurii aei a stadiului preliminar de dezvoltare al accesoriilor endoscopice. Cuvinte cheie: chirurgie endoscopicã transluminalã prin orificii naturale (NOTES), endoscopie ultrasonograficã (EUS), colecisto-gastrostomie, anastomoze bilio-digestive Abstract Background: EUS-guided cholecysto-gastrostomy might be a useful minimally invasive procedure used for salvage drainage in advanced pancreaticobiliary cancers, but also for drainage of the gallbladder in acute cholecystitis in patients deemed unfit for laparoscopic surgery. Objective: Direct EUS-guided cholecysto-gastrostomy with placement of a double flanged expandable metal stents. Design/Setting: This was an animal pilot/feasibility study. Interventions: The feasibility of EUS-guided cholecystogastrostomy through a transgastric approach was tested in five pigs. Specially designed EUS-guided devices for initial access in the gallbladder and a double flanged expandable metal stent were used in this study. Feasibility Study of EUS-NOTES as a Novel Approach for Peroral Cholecysto-Gastrostomy Result: The results showed the feasibility of EUS-guided cholecysto-gastrostomy based on prototype devices for access in the gallbladder and transgastric stent placement. Limitations: Survival feasibility study with prototype devices in a small number of animals. Conclusions: EUS guided cholecysto-gastrostomy in a porcine model is feasible but technically demanding due to anatomical limitations of the pig and/or complexity of the procedure and the preliminary stage of development of the accessory devices. Abbreviations: NOTES -Natural Orifice Translumenal Endoscopic Surgery; EUS -Endoscopic Ultrasound; EUS-FNA -Endoscopic Ultrasound Fine Needle Aspiration

A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy

There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-offnecrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peripancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus

Practice guidelines for endoscopic ultrasound-guided celiac plexus neurolysis

Objectives: The objective of guideline was to provide clear and relevant consensus statements to form a practical guideline for clinicians on the indications, optimal technique, safety and efficacy of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN). Methods: Six important clinical questions were determined regarding EUS-CPN. Following a detailed literature review, 6 statements were proposed attempting to answer those questions. A group of expert endosonographers convened in Chicago, United States (May 2016), where the statements were presented and feedback provided. Subsequently a consensus group of 35 expert endosonographers voted based on their individual level of agreement. A strong recommendation required 80% voter agreement. The modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria were used to rate the strength of recommendations and the quality of evidence. Results: Eighty percent agreement was reached on 5 of 6 consensus statements, 79.4% agreement was reached on the remaining one. Conclusions: EUS-CPN is efficacious, should be integrated into the management of pancreas cancer pain, and can be considered early at the time of diagnosis of inoperable disease. Techniques may still vary based on operator experience. Serious complications exist, but are rare