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

Endoscopic ultrasound

10.1155/2013/508082Gastroenterology Research and Practice201350808

Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound

Thoracic duct dilation has been demonstrated in portal hypertension and hepatic cirrhosis by lymphangiography and laparotomy and at autopsy. It is thought to be secondary to increased hepatic lymph flow and has been described in the absence of ascites or esophageal varices. The aim of the present study was to observe thoracic duct morphology by endoscopic ultrasound in various subsets of patients with portal hypertension and hepatic cirrhosis and also to validate existing radiologic/surgical data. METHODS: The thoracic duct of 33 patients with cirrhosis and portal hypertension was studied by endoscopic ultrasound. Patients were divided into four groups: 1, patients with ascites and esophageal varices; 2, esophageal varices without ascites; 3, without esophageal varices or ascites; 4, extrahepatic portal hypertension due to pancreatic malignancy. The thoracic duct diameter was also measured in 14 control subjects (group 5). RESULTS: When the thoracic duct diameter for the five groups was compared with analysis of variance, significance was p < 0.0001; by pairwise comparison, group 1 differed from the other four groups (p < 0.05). Thoracic duct dilation (5.61 mm) was seen in group 1 patients, whereas no dilation was present in groups 2 through 4. Additionally, thoracic duct diameter in 33 portal hypertensive and/or cirrhotic patients was significantly different from that in the 14 control subjects (p = 0. 003). CONCLUSION: The thoracic duct can be reliably identified by EUS in patients with hepatic cirrhosis and portal hypertension. Dilation of the duct is seen only in patients with hepatic cirrhosis, ascites, and esophageal varices. No thoracic duct dilation is present in extrahepatic portal hypertension. Contrary to existing radiologic/surgical data, thoracic duct dilation is not seen in all patients with hepatic cirrhosis and portal hypertension signifying advanced disease. A dilated thoracic duct by endoscopic ultrasound should be considered yet another sign of portal hypertension