EUS-Guided Biliary Drainage

The echoendoscopic biliary drainage is an option to treat obstructive jaundices when ERCP drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear setorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimenion on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonographic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampulary diverticula, and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Dilatation is required before stent introduction, and a plastic or metallic stent is introduced. This phrase should be replaced by: diathermic dilatation of the puncturing tract is required using a 6F cystostome. The technical success of hepaticogastrostomy is near 98%, and complications are present in 36%: pneumoperitoneum, choleperitoneum, infection, and stent disfunction. To prevent bile leakage, we have used the 2 stent techniques, the first stent introduced was a long uncovered metallic stent (8 or 10 cm), and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92% and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 19%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution

Echoendoscopic biliary drainage: which place in 2017?

Le drainage biliaire sous échoendoscopie représente une alternative au drainage percutané ou à la chirurgie lorsque la CPRE a échouée. Ces techniques ont été rendues possible par le développement depuis les années 1990 des écho-endoscopes électroniques linéaires permettant la réalisation des ponctions écho-guidées. Malgré un taux de réussite appréciable, la CPRE est mise en échec notamment en raison d’une obstruction duodénale ou d’une chirurgie préalable (gastrectomie, duodénopancréatectomie céphalique). Ce drainage des voies biliaires par échoendoscopie, repose sur la ponction « échoguidée » soit de la voie biliaire principale, soit du canal hépatique gauche (segment III). Techniquement, il s’agit de créer une anastomose bilio-digestive entre les voies biliaires intra-hépatiques gauches ou le cholédoque, et l’estomac ou le duodénum en utilisant généralement un cystostome de 6F pour créer l'anastomose bilio-digestive et d’une prothèse biliaire métallique le plus souvent pour maintenir ouverte cette anastomose. Le taux de réussite de l’hépatico-gastrostomie est 80 % à 100 % (moyenne 84 %) et un taux moyen de complication de 13 %, pour la cholédoco-duodénostomie de 75 % à 100 % (moyenne 90 %) et un taux de complication de 18 %. Depuis une dizaine d’années, ces techniques sont réalisées en routine dans des centres spécialisés en drainage biliaire complexe.Echoendoscopic biliary drainage is an option to treat obstructive jaundice when ERCP drainage fails. These procedures represent alternatives to surgery and percutaneous transhepatic biliary drainage and have been made possible through the continuous development and improvement of echoendoscopes and accessories. The development of linear sectorial array echoendoscopes in early 1990 brought a new approach to the diagnostic and therapeutic dimensions of echoendoscopy capabilities, opening the possibility to perform puncture over a direct ultrasonographic view. Despite the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty can arise with an ingrown stent tumor, tumor gut compression, periampullary diverticula and anatomic variation. The echoendoscopic technique requires puncture and contrast of the left biliary tree. When performed from the gastric wall, access is obtained through hepatic segment III. Direct common bile duct puncture is achieved from the duodenum. Diathermic dilation of the puncturing tract is performed using a 6F cystotome and a metallic stent. The technical success of hepaticogastrostomy is near 80 to 100% (mean 84%), and complications are present in 13% of cases. The most common complications include pneumoperitoneum, bilioperitoneum, infection and stent dysfunction. To prevent bile leakage, we used the two-stent techniques. The overall success rate for choledochoduodenostomy is 75 to 100% (mean 90%). The described complications include, in decreasing order of frequency: pneumoperitoneum and focal bile peritonitis, present in 18% of cases. Over the last 10 years, the technique has typically been performed in reference centers, by groups experienced with ERCP. This seems to be a general guideline for safer execution of the procedure

Miniprobe confocal endomicroscopy for biliary stenosis: which place in 2012?

"L’endomicroscopie confocale est une technique émergeante qui permet la réalisation de véritables biopsies optiques au niveau du tractus digestif. Le diagnostic histologique pré-opératoire du cholangiocarcinome reste toujours très difficile avec une fiabilité très basse. Pour essayer d’améliorer cette situation, certaines équipes ont évalué la microscopie confocale pour la détection in vivo du cholangiocarcinome. Récemment des mini-sondes de microscopie confocale ont été développées permettant d’obtenir une histologie in vivo. Les images sont obtenues après injection de fluoroscéine qui permet une meilleure visualisation des vaisseaux sanguins. Etant donné que la néoangiogénèse est un des premiers évènements de la cancérogenèse, la mise en évidence d’une néo-vascularisation anarchique serait fortement évocatrice d’une transformation maligne. Cet article va essayer de faire le point sur les données de la littérature concernant cette nouvelle technique appliquée aux sténoses biliaires d’origine indéterminée. Des critères de la malignité ont déjà été établis en 2009 et publiés en 2011 sous le nom des critères de Miami. Depuis, deux études comparatives (Confocal I vs Brossage et biopsies biliaires per CPRE) ont montré la supériorité de la microscopie confocale avec une fiabilité de 83 à 86 % pour le diagnostic de malignité versus 50 à 53 % pour l’histologie standard. L’endomicroscopie confocale biliaire représente un progrès incontestable dans le diagnostic de malignité des sténoses biliaires indéterminées ; néanmoins, d’autres études restent nécessaires notamment pour définir les critères de sténoses inflammatoires afin de pouvoir différencier cholangite sclérosante primitive et cholangiocarcinome. "Confocal endomicroscopy is an emergent technique allowing for real optical biopsies in the GI tract. The preoperative diagnosis of cholangiocarcinoma is associated with a low sensitivity. To overcome this limitation, a new imaging modality was evaluated to detect neoplasia in vivo in the biliary tract. Recently, confocal miniprobes have been introduced, enabling in vivo histopathology.Images can be acquired after intravenous application of fluorescein. This approach has the further benefit to make blood vessels clearly visible. Because angiogenesis has been mentioned as an essential step in the development of cancers, documentation of blood flow, vessel density, and configuration might be relevant. This paper refers to the literature data regarding this new diagnostic technique for undetermined biliary strictures. Malignancy criteria were described during a meeting in Miami in 2009 and published on the same year as Miami’s criteria. Two studies reported the superiority of confocal microscopy versus the conventional brush cytology orERCP guided biopsies with an accuracy of 83 to 86% vs. 50-53%. The last study has reported a high negative predictive value of the confocal microscopy around 93%.Intraductal confocal microscopy represents a huge progress in the diagnostic of undetermined biliary strictures, but a better definition of benign criteria will be necessary to differentiate cholangiocarcinoma from primary sclerosing cholangitis

MUCOSECTOMIE ENDOSCOPIQUE POUR LES LESIONS SESSILES COLO-RECTALES (DES HEPATO-GASTRO-ENTEROLOGIE)

AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts

BACKGROUND: Surgery is the traditional treatment for symptomatic pancreatic pseudocysts, but the morbidity is still too high. Minimally invasive endoscopic approaches have been encouraged. AIMS: To evaluate the efficacy of endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts. METHODS: From January, 2003 to August, 2006, 31 consecutive symptomatic patients submitted to 37 procedures at the same endoscopic unit were retrospectively analysed. Chronic and acute pancreatitis were found in, respectively, 17 (54.8%) and 10 (32.3%) cases. Bulging was present in 14 (37.8%) cases. Cystogastrostomy or cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control. By protocol, only a single plastic stent, without nasocystic drain, was used. Straight or double pigtail stents were used in, respectively, 22 (59.5%) and 15 (40.5%) procedures. RESULTS: Endoscopic ultrasound-guided transmural drainage was successful in 29 (93.5%) patients. Two cases needed surgery, both due to procedure-related complications. There was no mortality related to the procedure. Twenty-four patients were followed-up longer than 4 weeks. During a mean follow-up of 12.6 months, there were six (25%) symptomatic recurrences due to stent clogging or migration, with two secondary infections. Median time for developing complications and recurrence of the collections was 3 weeks. These cases were successfully managed with new stents. Complications were more frequent in patients treated with straight stents and in those with a recent episode of acute pancreatitis. CONCLUSIONS: Endoscopic transmural drainage provides an effective approach to the management of pancreatic pseudocysts

Case report Endoscopic Ultrasound Guided Biliopancreatic Diversion: Case Description and Literature Review

Abstract In this paper we present the fi rst reported case of endoscopic ultrasound-guided hepatic-gastrostomy, performed on a patient with a history of bariatric surgery (gastric banding). We review the patient's clinical history and the technology and accessories used. This case report is supplemented with a detailed and updated review of the medical literature regarding endoscopic ultrasound-guided biliary-pancreatic diversions. These procedures are rapidly developing in a way that is increasing the therapeutic armory for patients who require biliary or pancreatic derivations but who do not meet the requirements for endoscopic retrograde cholangiopancreatography (ERCP), and who are not candidates for, or who reject, the option of percutaneous biliary bypass. These procedures include the hepatic gastrostomy guided by endoscopic ultrasound, biliary-pancreatic rendezvous guided by endoscopic ultrasound, endoscopic ultrasound-guided choledochoduodenostomy, endoscopic ultrasonography-guided cholecystogastrostomy and endoscopic ultrasound-guided pancreatic gastrostomy. This article provides a technical description of each of these procedures and the accessories required. Finally, we present patient management following the guide of the most experienced pioneers of these techniques in the world. These procedures already have a well-recognized place in the therapeutic armory for patients who require this kind of diversion