A Tailgut Cyst Diagnosed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Tailgut cysts are rare developmental cysts. Surgery has been the primary method of diagnosis and treatment of these cysts, but endoscopic ultrasound (EUS) has recently been used to establish diagnosis. Only 2 cases of tailgut cyst diagnosed by EUS-guided FNA have been reported. We present a woman in her fourth decade who presented for evaluation of perirectal mass. EUS-guided fine-needle aspiration (FNA) helped establish the diagnosis of tailgut cyst. The patient opted for observation rather than surgery

Radical approach to traumatic tracheoesophageal fistula: Use of a biliary stent for esophageal repair in an infant

Background: The incidence of button battery ingestion has increased over time along with its most alarming complications including tracheoesophageal fistula. Historically this issue has been treated with sternotomy and closure of the fistula. However, morbidity and mortality of this invasive approach can be improved upon. Methods: This is an expert report from a tertiary care center, utilizing an adult biliary stent for closure of a giant 2 cm traumatic TEF secondary to a button battery ingestion in a 9 month old. Results: The patient's fistula healed with this radical approach and demonstrated a full return to swallowing, without invasive operative interventions. Conclusion: We present a radical approach with successful treatment of a TEF. This is the first study of its kind to utilize adult biliary stents for closure of a traumatic TEF in an infant. Level of evidence: V

A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era

Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections

EUS-directed transgastric interventions in Roux-En-Y Gastric Bypass anatomy: a multicenter experience

Background and Aims Placement of a Lumen Apposing Metal Stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS Guided Transgastric Interventions (EDGI) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS guided transgastric ERCP (EDGE) outcomes have been reported, there is a paucity of data on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGI. Methods This is a retrospective study involving 9 centers (8 USA, 1 Europe) and included patients with RYGB who underwent EDGI between 06/2015 and 09/2021. The primary outcome was the technical success of EDGI. Secondary outcomes included adverse events, length of hospital stay, and fistula follow-up and management. Results 54 EDGI procedures were performed in 47 patients (mean age 61yr, F 72%), most commonly for the evaluation of a pancreatic mass (n=16) and management of pancreatic fluid collections (n=10). A 20mm LAMS was utilized in 26 patients and a 15mm LAMS in 21, creating a gastrogastrostomy (GG) in 37 patients and jejunogastrostomy (JG) in 10. Most patients (n=30, 64%) underwent a dual-session EDGI, with a median interval of 17d between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (+/-FNA/B) (n=28) and EUS-guided cystgastrostomy (n=8). The mean procedural time was 97.6 ± 78.9 mins. Technical success was achieved in 52 (96%). AEs occurred in 5 (10.6%) patients, of which only 1 (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), while delayed spontaneous LAMS migration occurred in 2 (4.3%). 4 of the 5 LAMS migration events were managed endoscopically, and one required surgical repair. LAMS anchoring was found to be protective against LAMS migration (p=0.001). The median duration of hospital stay was 2.1 ± 3.7d. Of the 17 patients who underwent objective fistula assessment endoscopically/radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In one case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. Conclusion EDGI is effective and safe for the diagnosis and management of pancreatobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems effective

Factors predictive of persistent fistulas in EUS-Directed transgastric ERCP: A multicenter matched case-control study

BACKGROUND: EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However widespread adoption of the technique has been limited due to concerns about the development of persistent gastrogastric (GG) or jejunogastric (JG) fistulas. GG/GJ fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management/outcomes are lacking. AIMS: To assess (1) factors associated with the development of persistent fistulas; (2) technical success of endoscopic fistula closure. PATIENTS AND METHODS: This is a case-control study involving 9 centers (8 USA, 1 Europe) from 02/2015 to 09/2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Controls were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined/graded according to ASGE lexicon. RESULTS: 25 patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (controls) based on age and sex. Mean LAMS dwell time was 74.7±106.2d. Following LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 (61.3%). Primary closure of the fistula was performed in 26.7% (n=20, endoscopic suturing in 17, endoscopic tacking in 2 and over-the-scope clips + endoscopic suturing in 1). When comparing cases to controls, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the two groups (p\u3e0.05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 d vs 48 d, p=0.02), and more patients had ≥5% total body weight gain (33.3% vs 10.3%; p=0.03). LAMS dwell time was a significant predictor of persistent fistula (OR=4.5 after \u3e40 days in situ, p=0.01). The odds of developing a persistent fistula increased by 9.5% for every 7 days that the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 76% (n=19) with successful resolution in 14 (73.7%). CONCLUSIONS: Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which if present, can be effectively managed through endoscopic closure in most cases