Clinical Endoscopy

Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy for biliary drainage in hypervascular hepatocellular carcinoma: a retrospective study from Japan: Kenneth Tachi, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Ahmed Mohammed Sadek, Hossam El-Din Shaaban Mahmoud Ibrahim, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto; Received April 2, 2024 Accepted July 29, 2024 Published online November 11, 2024; DOI: https://doi.org/10.5946/ce.2024.079 [Epub ahead of print]

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/Aims: Biliary obstruction drainage in patients with hepatocellular carcinoma (HCC) is associated with symptom palliation, improved access to chemotherapy, and improved survival. Stent placement and exchange via endoscopic retrograde cholangiopancreatography biliary drainage risk traversing the HCC, a hypervascular tumor and causing bleeding. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) potentially prevents procedure-related bleeding. Therefore, we evaluated the efficacy and safety of EUS-HGS as an alternative treatment for biliary obstruction in patients with HCC.
Methods
This was a retrospective study of all EUS-HGS procedures performed in patients with HCC at the Aichi Cancer Center Hospital, Japan, from February 2017 to August 2023.
Results
A total of 14 EUS-HGS procedures (42.9% primary) were attempted in 10 HCC patients (mean age 71.5 years, 80.0% male). Clinical and technical success rates were 92.9% and 90.9%, respectively. The observed procedure details in the 13 successful procedures included B3 puncture (53.8%), 22-G needle (53.8%), fully covered self-expandable metal stent (100%), and mean procedure time (32.7 minutes). There was no bleeding. Mild complications occurred in 27.3%. All patients resumed oral intake within 24 hours.
Conclusions
EUS-HGS is a technically feasible and clinically effective initial or salvage drainage option for the treatment of biliary obstruction in patients with HCC.

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Safety and efficacy of trans-afferent loop endoscopic ultrasound-guided pancreaticojejunostomy for post pancreaticoduodenectomy anastomotic stricture using the forward-viewing echoendoscope: a retrospective study from Japan: Ahmed Sadek, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto, Kenneth Tachi; Received April 12, 2024 Accepted May 31, 2024 Published online August 26, 2024; DOI: https://doi.org/10.5946/ce.2024.089 [Epub ahead of print]

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Background
/Aims: Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is a well-established procedure for managing pancreaticojejunostomy anastomotic strictures (PJAS) post-Whipple surgery. In this study, we examined the effectiveness and safety of EUS-guided pancreaticojejunostomy (EUS-PJS).
Methods
This retrospective, single-arm study was performed at Aichi Cancer Center Hospital on 10 patients who underwent EUS-guided pancreaticojejunostomy through the afferent jejunal loop using a forward-viewing echoendoscope when endoscopic retrograde pancreatography failed. Our primary endpoint was technical success rate, defined as successful stent insertion. The secondary endpoints were early and late adverse events.
Results
A total of 10 patients underwent EUS-PJS between February 2019 and October 2023. The technical success rate was 100%. The median procedure time was 23.5 minutes. No remarkable early or late adverse events related to the procedure, except for fever, occurred in two patients. The median follow-up duration was 9.5 months, and the median number of stent exchanges was two. A stent-free state was achieved in three patients.
Conclusions
EUS-PJS for PJAS management after pancreaticoduodenectomy appears to be an effective and safe procedure with the potential advantages of fewer reinterventions and the creation of a permanent drainage fistula.

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Transanastomotic Forward-Viewing EUS-Guided Pancreatic Duct Drainage via Afferent Loop for Pancreaticojejunostomy Anastomotic Stricture After Pancreaticoduodenectomy
Tadahisa Inoue, Rena Kitano, Tomoya Kitada, Kazumasa Sakamoto, Satoshi Kimoto, Jun Arai, Kiyoaki Ito
Digestive Diseases and Sciences.2024;[Epub] CrossRef

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Hepatobiliary scintigraphy of bile excretion after endoscopic ultrasound-guided hepaticogastrostomy for malignant biliary obstruction: a retrospective study in Japan: Masanori Yamada, Kazuo Hara, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Tsukasa Yasuda, Toshitaka Fukui; Clin Endosc 2024;57(6):798-806. Published online August 20, 2024; DOI: https://doi.org/10.5946/ce.2023.291

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Hepatobiliary scintigraphy (HBS) is used to evaluate bile excretion. This study aimed to evaluate biliary excretion during endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using HBS.
Methods
We retrospectively evaluated 78 consecutive patients with malignant extrahepatic biliary obstruction, who underwent HBS after EUS-HGS between April 2015 and July 2022. The peak time and decay rate were scored with 0, 1, or 2 points based on thresholds of 20 and 35 minutes, and 10% and 50%, respectively. A total score of 4 or 3 was considered indicative of good bile excretion, whereas scores of 2, 1, or 0 indicated poor bile excretion.
Results
The good and poor bile excretion groups included 40 and 38 cases, respectively. The group with good bile excretion had a significantly longer time to recurrent biliary obstruction compared to the poor bile excretion group (not reached vs. 124 days, p=0.026). Multivariate analysis identified the site of obstruction as a significant factor influencing good bile excretion (odds ratio, 3.39; 95% confidence interval, 1.01–11.4, p=0.049), with superior bile excretion observed in cases involving upper biliary obstruction compared to middle or lower biliary obstruction.
Conclusions
In patients with malignant biliary obstruction who underwent HGS, the site of obstruction is significantly associated with stent patency.

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Safety and efficacy of endoscopic ultrasound-guided pancreatic duct drainage using a drill dilator: a retrospective study in Japan: Ahmed Sadek, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto, Kenneth Tachi; Clin Endosc 2024;57(5):666-674. Published online June 5, 2024; DOI: https://doi.org/10.5946/ce.2023.272

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Background
/Aims: Dilation of the tract before stent deployment is a challenging step in endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD). In this study, we examined the effectiveness and safety of a novel spiral dilator, Tornus ES (Asahi Intec), for EUS-PDD.
Methods
This was a retrospective, single-arm, observational study at Aichi Cancer Center Hospital. The punctured tract was dilated using a Tornus ES dilator in all EUS-PDD cases. Our primary endpoint was the technical success rate of initial tract dilation. Technical success was defined as successful fistula dilation using a Tornus ES followed by successful stent insertion. Secondary endpoints were procedure times and early adverse events.
Results
A total of 12 patients were included between December 2021 and March 2023. EUS-PDD was performed in 11 patients for post-pancreaticoduodenectomy anastomotic strictures and one patient with pancreatitis with duodenal perforation. The technical success rates of stent insertion and fistula dilation using a Tornus ES dilator was 100%. The median procedure time was 24 minutes. No remarkable adverse events related to the procedure were observed, apart from fever, which occurred in 2 patients.
Conclusions
Tract dilation in EUS-PDD using a Tornus ES is effective and safe.

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A novel spiral dilator for pancreatic duct drainage: catching two birds with one stone
Han Taek Jeong, Jimin Han
Clinical Endoscopy.2024; 57(5): 608. CrossRef
Technical outcomes between a drill dilator and ultra-tapered mechanical dilator during EUS-guided pancreaticogastrostomy: Comparative study
Takeshi Ogura, Saori Ueno, Atsushi Okuda, Nobu Nishioka, Jun Sakamoto, Jun Matsuno, Yuki Uba, Mitsuki Tomita, Nobuhiro Hattori, Junichi Nakamura, Kimi Bessho, Hiroki Nishikawa
Endoscopy International Open.2024;[Epub] CrossRef

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Safety and efficacy of novel oblique-viewing scope for B2-endoscopic ultrasound-guided hepaticogastrostomy: Sho Ishikawa, Kazuo Hara, Nozomi Okuno, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Yasuhiro Kuraishi, Takafumi Yanaidani, Masanori Yamada, Tsukasa Yasuda, Toshitaka Fukui, Teru Kumagi, Yoichi Hiasa; Clin Endosc 2024;57(4):527-533. Published online March 29, 2024; DOI: https://doi.org/10.5946/ce.2023.129

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Background
/Aims: Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) performed at the intrahepatic bile duct segment 3 (B3) is widely used for biliary drainage. Although performing post-puncture procedures is easier in the intrahepatic bile duct segment 2 (B2) when using a conventional oblique-viewing (OV) EUS scope, this method may cause transesophageal puncture and severe adverse events. We evaluated the safety and efficacy of B2 puncture using a novel OV-EUS scope.
Methods
In this single-center retrospective study, we prospectively enrolled and collected data from 45 patients who consecutively underwent EUS-HGS procedures with a novel OV-EUS scope between September 2021 and December 2022 at our cancer center.
Results
The technical success rates of B2-EUS-HGS and EUS-HGS were 93.3% (42/45) and 97.8% (44/45), respectively. The early adverse event rate was 8.9% (4/45) with no cases of scope changes or transesophageal punctures. The median procedure time was 13 minutes (range, 5–30).
Conclusions
B2-EUS-HGS can be performed safely with the novel EG-740UT (Fujifilm) OV-scope without transesophageal puncture and with a high success rate. B2-EUS-HGS using this novel OV scope may be the preferred strategy for EUS-HGS.

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Dedicated Echoendoscope for Interventional Endoscopic Ultrasound: Comparison with a Conventional Echoendoscope
Toshio Fujisawa, Shigeto Ishii, Yousuke Nakai, Hirofumi Kogure, Ko Tomishima, Yusuke Takasaki, Koichi Ito, Sho Takahashi, Akinori Suzuki, Hiroyuki Isayama
Journal of Clinical Medicine.2024; 13(10): 2840. CrossRef

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The role of needle-based confocal laser endomicroscopy in the diagnosis of pancreatic neuroendocrine tumors: Masanori Yamada, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Tsukasa Yasuda, Toshitaka Fukui; Clin Endosc 2024;57(3):393-401. Published online September 12, 2023; DOI: https://doi.org/10.5946/ce.2023.068

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Background
/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a highly accurate method for diagnosing pancreatic neuroendocrine tumors (PNETs); however, some PNETs are difficult to diagnose. Recently, the efficacy of needle-based confocal laser endomicroscopy (nCLE) in diagnosing solid pancreatic masses has been reported. However, the efficacy of nCLE in the diagnosis of PNETs remains unknown and only a small number of cases have been reported. Hence, this study aimed to evaluate the efficacy of nCLE in the diagnosis of PNETs.
Methods
This single-center retrospective study evaluated 30 consecutive patients with suspected PNETs on contrast-enhanced computed tomography, who consented to nCLE combined with EUS-FNA and were diagnosed using EUS-FNA or surgical resection. The diagnostic criteria for PNETs using nCLE were based on the nesting and trabecular and glandular arrangement of tumor cell clusters surrounded by capillary vessels and fibrosis, as reported in previous studies.
Results
The diagnosis using nCLE was classified into three categories: misdiagnosis in three cases (10%), non-diagnostic in six cases (20%), and diagnostic in 21 cases (70%). nCLE was able to diagnose PNET in one of the two cases with inconclusive EUS-FNA.
Conclusions
Although further development of the resolution and optimization of the diagnostic criteria are required, nCLE may constitute a useful diagnostic option in cases of inconclusive EUS-FNA for PNETs.

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Recent developments in the diagnosis of pancreatic neuroendocrine neoplasms
Anna Battistella, Matteo Tacelli, Paola Mapelli, Marco Schiavo Lena, Valentina Andreasi, Luana Genova, Francesca Muffatti, Francesco De Cobelli, Stefano Partelli, Massimo Falconi
Expert Review of Gastroenterology & Hepatology.2024; 18(4-5): 155. CrossRef
Advancements and challenges in gastrointestinal imaging
Eun Jeong Gong, Chang Seok Bang
World Journal of Clinical Cases.2024; 12(33): 6591. CrossRef

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Safety of endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction and ascites: Tsukasa Yasuda, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Masanori Yamada, Toshitaka Fukui; Clin Endosc 2024;57(2):246-252. Published online September 7, 2023; DOI: https://doi.org/10.5946/ce.2023.075

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Background
/Aims: Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) is useful for patients with biliary cannulation failure or inaccessible papillae. However, it can lead to serious complications such as bile peritonitis in patients with ascites; therefore, development of a safe method to perform EUS-HGS is important. Herein, we evaluated the safety of EUS-HGS with continuous ascitic fluid drainage in patients with ascites.
Methods
Patients with moderate or severe ascites who underwent continuous ascites drainage, which was initiated before EUS-HGS and terminated after the procedure at our institution between April 2015 and December 2022, were included in the study. We evaluated the technical and clinical success rates, EUS-HGS-related complications, and feasibility of re-intervention.
Results
Ten patients underwent continuous ascites drainage, which was initiated before EUS-HGS and terminated after completion of the procedure. Median duration of ascites drainage before and after EUS-HGS was 2 and 4 days, respectively. Technical success with EUS-HGS was achieved in all 10 patients (100%). Clinical success with EUS-HGS was achieved in 9 of the 10 patients (90 %). No endoscopic complications such as bile peritonitis were observed.
Conclusions
In patients with ascites, continuous ascites drainage, which is initiated before EUS-HGS and terminated after completion of the procedure, may prevent complications and allow safe performance of EUS-HGS.

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Management of iatrogenic perforations during endoscopic interventions in the hepato-pancreatico-biliary tract
Kirsten Boonstra, Rogier P. Voermans, Roy L.J. van Wanrooij
Best Practice & Research Clinical Gastroenterology.2024; 70: 101890. CrossRef
Is Endoscopic Ultrasound-Guided Hepaticogastrostomy Safe and Effective after Failed Endoscopic Retrograde Cholangiopancreatography?—A Systematic Review and Meta-Analysis
Saqr Alsakarneh, Mahmoud Y. Madi, Dushyant Singh Dahiya, Fouad Jaber, Yassine Kilani, Mohamed Ahmed, Azizullah Beran, Mohamed Abdallah, Omar Al Ta’ani, Anika Mittal, Laith Numan, Hemant Goyal, Mohammad Bilal, Wissam Kiwan
Journal of Clinical Medicine.2024; 13(13): 3883. CrossRef
Feasibility and safety of EUS-guided biliary drainage in inexperienced centers: a multicenter study in southwest Japan
Takehiko Koga, Yusuke Ishida, Shunpei Hashigo, Yuzo Shimokawa, Hirofumi Harima, Kazuhisa Okamoto, Akihisa Ohno, Tsukasa Miyagahara, Toshihiro Fujita, Satoshi Fukuchi, Kosuke Takahashi, Hiroki Taguchi, Norimasa Araki, Yuichiro Ohtsuka, Toshiyuki Uekitani,
Gastrointestinal Endoscopy.2024;[Epub] CrossRef
Endoscopic ultrasound-guided antegrade stenting combined with closure of the puncture route using self-assembling peptide solution in a jaundiced patient with ascites
Hirotsugu Maruyama, Kojiro Tanoue, Tatsuya Kurokawa, Yoshinori Shimamoto, Yuki Ishikawa-Kakiya, Akira Higashimori, Yasuhiro Fujiwara
Endoscopy.2024; 56(S 01): E953. CrossRef
The Role of Therapeutic Endoscopic Ultrasound in Management of Malignant Double Obstruction (Biliary and Gastric Outlet): A Comprehensive Review with Clinical Scenarios
Giuseppe Dell’Anna, Rubino Nunziata, Claudia Delogu, Petra Porta, Maria Vittoria Grassini, Jahnvi Dhar, Rukaia Barà, Sarah Bencardino, Jacopo Fanizza, Francesco Vito Mandarino, Ernesto Fasulo, Alberto Barchi, Francesco Azzolini, Guglielmo Albertini Petron
Journal of Clinical Medicine.2024; 13(24): 7731. CrossRef

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