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EUS-guided transluminal drainage (EUS-TD) is increasingly used for the treatment of postoperative pancreatic fluid collections (POPFCs). A novel lumen-apposing metal stent (LAMS) was recently developed and used for the drainage of POPFCs. This study aimed to evaluate the efficacy and safety of a novel LAMS in patients with POPFCs.Forty-seven patients with symptomatic POPFCs who underwent EUS-TD with a novel LAMS (Niti-S SPAXUS; Taewoong Medical Co, Ltd, Ilsan, South Korea) between April 2019 and July 2020 were included in this study. Clinical outcomes, including technical success, clinical success, and adverse events, were retrospectively evaluated.EUS-TD was technically successful in 41 of 47 patients (87.2%). Clinical success was achieved in 37 of 41 patients (90.2%). The mean procedure time was 13.7 ± 3.5 minutes. The mean POPFC size was 59 ± 18.9 mm. The mean time interval from surgery to EUS-TD was 24.2 ± 37.6 days. Five patients experienced 6 procedural adverse events (12.8%): 4 (8.5%) POPFC infections and 2 (4.3%) distal stent migrations. The 4 patients with POPFC infection underwent additional endoscopic interventions. Of the 2 patients with stent migration, 1 underwent laparoscopic exploration and surgical extraction of the stent and 1 (2.1%) experienced POPFC recurrence, which was managed with percutaneous drainage.EUS-TD for symptomatic POPFCs with a novel LAMS is technically feasible and effective, with an acceptable adverse event rate. Further larger-scale prospective studies are required to confirm the findings of this study.

Background and Aims Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) using microbiopsy forceps is performed for the accurate diagnosis of pancreatic cystic lesions (PCLs). However, there are no standardized protocols for this procedure, and the amount of data on its efficacy is limited. Here, we evaluated the feasibility, efficacy, and safety of EUS-TTNB in categorizing the types of PCLs, and identified the factors associated with diagnostic failure. Methods The prospectively collected and maintained EUS-TTNB database at Asan Medical Center was reviewed to identify patients with PCL who underwent EUS-TTNB between January 2019 and January 2021. The primary outcomes were technical success, diagnostic yield, and adverse events. Factors contributing to diagnostic failure, and the discrepancies in the diagnosis made by conventional modalities (ie, EUS-morphology, cross-sectional imaging, and cystic fluid analysis) were also evaluated. Results A total of 45 patients were analyzed. EUS-TTNB was successfully performed in all patients (technical success = 100%). Histologic diagnosis of PCL was made in 37 patients (diagnostic yield = 82%). When comparing EUS-TTNB with presumptive diagnosis, EUS-TTNB changed the diagnosis in 10 patients in terms of the categorization of the types of PCLs. The diagnostic yield was significantly higher in those who had 4 or more visible biopsy specimens per session (93%) than in those with less than 4 visible biopsy specimens per session (67%; P = .045). During follow-up, 3 (7%) patients experienced adverse events (2 acute pancreatitis, 1 intracystic bleeding), and no life-threatening adverse event occurred. Conclusions EUS-TTNB showed high technical feasibility, diagnostic yield, and good safety profile. EUS-TTNB may improve the categorization of the types of PCLs. Studies with standardized procedure protocols are needed to reduce the diagnostic failure for the types of PCLs.

Background and Aims Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using an anti-migrating tubular self-expandable metal stent (ATSEMS) is performed in high surgical risk patients with acute cholecystitis. The newly introduced lumen-apposing metal stent (LAMS) is expected to reduce the risk of tubular self-expandable metal stent–related adverse events such as stent migration, but no comparative studies have been carried out between LAMSs and ATSEMSs for EUS-GBD. Methods We reviewed the prospectively collected EUS-GBD database at Asan Medical Center and Bucheon Soonchunhyang hospital to analyze consecutive patients with acute cholecystitis who underwent EUS-GBD with LAMSs or ATSEMSs between January 2015 and December 2017. Technical success, clinical success, adverse events, and recurrence of cholecystitis were evaluated. Results A total of 71 patients (36 with LAMSs, 35 with ATSEMSs) were analyzed. The LAMS group had longer median procedure time (15.5 minutes) than the ATSEMS group (11 minutes; P = .017). The 2 groups did not show significant differences in terms of technical success (LAMS, 94% vs ATSEMS, 100%; P = .49), clinical success (94% vs 100%; P = .49), procedure-related adverse events (0% vs 2.9%; P = .99), and stent-related late adverse events (11.8% vs 5.8%; P = .43). During follow-up, the 2 groups had similar rates of cholecystitis recurrence at 6 months (LAMS, 3.4% vs ATSEMS, 3.1%, P = .99) and 12 months (8.3% vs 3.1%, P = .56). Conclusions In high surgical risk patients with acute cholecystitis, LAMSs and ATSEMSs for EUS-GBD showed similar rates of technical success, clinical success, procedure-related adverse events, stent-related late adverse events, and recurrence of cholecystitis.

Background and Aims Recently, a newly designed lumen-apposing metal stent (LAMS) with a conventional delivery system was developed. The purpose of this study was to evaluate the effectiveness and safety of a newly designed LAMS for EUS-guided drainage to treat symptomatic pancreatic pseudocysts. Methods This prospective multicenter cohort study included 34 patients with symptomatic pancreatic pseudocysts from 2016 to 2017. The patients underwent EUS-guided drainage with the newly designed LAMS (Niti-S SPAXUS; Taewoong Medical Co, Ltd, Ilsan, South Korea). Effectiveness outcome measurements included technical success rate, clinical success rate, successful stent removal rate, and procedural time. Safety outcome measurements included procedure and/or stent-related adverse events (AEs) and overall AEs. Patients were prospectively followed, and consecutive data were collected at discharge, at stent removal, and 20 days after stent removal. Results Thirty-four patients (mean age 51.7 ± 13.3 years, 26 men) were enrolled. The mean pseudocyst size was 9.23 ± 3.54 cm. The technical success rate was 97.1% (33/34). The clinical success rate was 94.1% (32/34). All stents were successfully removed. The mean procedural time from needle puncture to stent deployment was 10.3 ± 5.7 minutes. Four patients (11.8%) experienced procedure and/or stent-related AEs, including stent maldeployment (n = 1) and pseudocyst infection (n = 3). All patients completely recovered from the AEs. Bleeding caused by the stent or buried LAMS syndrome was not observed. No unplanned endoscopic procedures were required. Conclusions This study showed that EUS-guided drainage using the newly designed LAMS is technically feasible and effective for the treatment of symptomatic pancreatic pseudocysts. (Clinical trial registration number: NCT02730663.)

Endoscopic gallbladder drainage (GBD) has been performed as an alternative to percutaneous drainage for acute cholecystitis. To date, there has been no comparative study between EUS-guided cholecystostomy (EUSC) and endoscopic transpapillary cholecystostomy (ETC). The aim of this study was to compare the outcomes of EUSC and ETC.A retrospective review of an endoscopic GBD database prospectively collected at the Asan Medical Center (between July 2010 and December 2014) was performed to identify consecutive patients with acute cholecystitis who underwent attempted endoscopic GBD. Procedural and long-term outcomes were evaluated using inverse probability of treatment weighting (IPTW).A total of 172 patients (76 in the EUSC group and 96 in the ETC group) were included in this study. Seven patients who failed to undergo ETC crossed over to the EUSC group. After adjustment with the IPTW method, technical success (99.3% vs 86.6%, P .01) and clinical success (99.3% vs 86%, P .01) rates were significantly higher in the EUSC group than in the ETC group. The procedure-related adverse event rate was significantly higher in the ETC group (7.1% vs 19.3%, P = .02). The cholecystitis or cholangitis recurrence rate (12.4% vs 3.2%) was also higher in the ETC group than in the EUSC group, as identified using Cox analysis (hazard ratio, 3.01; 95% confidence interval, .73-12.9; P = .04).In patients with acute cholecystitis who are unfit for surgery, EUSC may be a more suitable treatment method than ETC.

Background and Aims Although fully covered self-expandable metal stents (FCSEMSs) have been commonly used for EUS-guided biliary drainage (EUS-BD), FCSEMS migration is a main limitation of this procedure. In the present study we evaluated the technical and clinical success rates, adverse events, and long-term outcomes of a newly developed hybrid stent that has been customized for EUS-BD. Methods From September 2011 to May 2015, 54 consecutive patients with biliary obstruction were enrolled in this prospective, observational study. These patients were candidates for alternative BD techniques because of failed ERCP. The hybrid metal stent used for EUS-BD in this study was partially covered, had anchoring flaps, and is commercially available in Korea. Results EUS-guided hepaticogastrostomy (EUS-HGS) was performed in 21 patients and EUS-guided choledochoduodenostomy (EUS-CDS) in 33 patients. The technical and clinical success rates of EUS-BD were 100% (54/54) and 94.4% (51/54), respectively. Immediate adverse events developed after EUS-BD in 9 patients (16.6%; cholangitis in 3, bleeding in 2, self-limited pneumoperitoneum in 3, and abdominal pain in 1). Proximal or distal stent migration was not observed during the follow-up period (median, 148.5 days; IQR, 79.7-244), and the mean stent patency duration was 166.3 days and 329.1 days in the EUS-HGS and EUS-CDS groups, respectively. Conclusions EUS-BD with the hybrid metal stent is technically feasible and can effectively treat biliary obstruction after failed ERCP. EUS-BD with the hybrid metal stent can reduce stent-related adverse events, especially stent migration.

Background and Aims Preoperative biliary drainage (PBD) with stent placement has been commonly used for patients with malignant biliary obstruction. In PBD, the placement of fully covered self-expandable metal stents (FCSEMSs) may provide better patency duration and a lower incidence of cholangitis compared with plastic stents. We aimed to evaluate which type of stent showed better outcomes in PBD. Methods In this multicenter, prospective randomized trial, we compared PBD with FCSEMSs versus plastic stents in 86 patients with malignant biliary obstruction between January 2012 and December 2014. Patients with obstructive jaundice were randomly assigned to undergo PBD either with plastic stents or FCSEMS placement. Results Baseline characteristics were not significantly different between the 2 groups. Endoscopic stent placement was technically successful in all patients. Procedure-related adverse events were not significantly different between the 2 groups (plastic vs FCSEMS group; 16.3% vs 16.3%, P = 1.0). Reintervention was required in 16.3% of the plastic stent group and 14.0% of the FCSEMS group ( P = .763). The interval to surgery after PBD (plastic vs FCSEMS group; 14.2 ± 8.3 vs 12.3 ± 6.9 days, P = .426) was not significantly different between groups. Surgery-related adverse events occurred in 43.6% of the plastic stent group and 40.0% of the FCSEMS group ( P = .755). Conclusions In patients with resectable malignant biliary obstruction, the outcomes of PBD with plastic stents and FCSEMSs were similar. Considering the cost-effectiveness, PBD with plastic stents may be preferable to FCSEMS placement. (Clinical trial registration number: NCT01789502.)

Background and Aims ERCP is a difficult procedure to perform in Billroth II gastrectomy patients because of altered anatomy. We investigated the outcomes and risk factors for adverse events with ERCP using a cap-fitted forward-viewing endoscope with endoscopic papillary balloon dilation (EPBD) in Billroth II gastrectomy patients. Methods The records for Billroth II gastrectomy patients who underwent ERCP using a cap-fitted forward-viewing endoscope with EPBD at 5 institutions between August 2008 and April 2014 were retrospectively reviewed. The outcomes and risk factors for adverse events resulting from this treatment were analyzed. Results In total, 165 patients were identified. ERCP was technically successful in 144 patients (87.3%) and clinically successful in 141 patients (85.5%). Adverse events occurred in 38 patients (23.0%): perforation in 3 cases (1.8%), pancreatitis in 13 cases (7.9%), and asymptomatic hyperamylasemia in 22 patients (13.3%). In univariate analysis, ≥2 ERCP sessions, periampullary diverticulum, and common bile duct (CBD) stone size ≥ 12 mm were found to be associated with ERCP-related adverse events. In multivariate analysis, ≥2 ERCP sessions (odds ratio [OR], 4.762; 95% confidence interval [CI], 1.472-15.402; P = .009) and a CBD stone size ≥ 12 mm (OR, 3.213; 95% CI, 1.140-9.057; P = .027) were significant. Conclusions ERCP using a cap-fitted forward-viewing endoscope with EPBD is feasible in Billroth II gastrectomy patients. In patients with ≥2 ERCP sessions or a CBD stone size ≥ 12 mm, special attention should be paid to the possible occurrence of significant adverse events.

Background and Aims Radiofrequency ablation (RFA) has been used as a valuable treatment modality for various unresectable malignancies. EUS-guided radiofrequency ablation (EUS-RFA) of the porcine pancreas was reported to be feasible and safe in our previous study, suggesting that EUS-RFA may be applicable as an adjunct and effective alternative treatment method for unresectable pancreatic cancer. This study aimed to assess the technical feasibility and safety of EUS-RFA for unresectable pancreatic cancer. Methods An 18-gauge endoscopic RFA electrode and a radiofrequency generator were used for the procedure. The length of the exposed tip of the RFA electrode was 10 mm. After insertion of the RFA electrode into the mass, the radiofrequency generator was activated to deliver 20 to 50 W ablation power for 10 seconds. Depending on tumor size, the procedure was repeated to sufficiently cover the tumor. Results EUS-RFA was performed successfully in all 6 patients (median age 62 years, range 43-73 years). Pancreatic cancer was located in the head (n = 4) or body (n = 2) of the pancreas. The median diameter of masses was 3.8 cm (range 3cm-9cm). Four patients had stage 3 disease, and 2 patients had stage 4 disease. After the procedure, 2 patients experienced mild abdominal pain, but there were no other adverse events such as pancreatitis or bleeding. Conclusions EUS-RFA could be a technically feasible and safe option for patients with unresectable pancreatic cancer.

Small ampullary tumors and inflammatory lesions have similar endoscopic findings and are difficult to differentiate. Narrow-band imaging (NBI) can visualize microvessels and mucosal microstructure clearly and is widely used to diagnose early gastric and colon cancer.To evaluate the usefulness of NBI for differentiating ampullary tumors from benign diseases.Retrospective cohort study.Tertiary-care hospital.All 45 patients who had suspicious ampullary lesions (enlarged or protruded morphology) during duodenoscopy and underwent NBI between March 2010 and January 2011.NBI.NBI images were assessed for irregular villous arrangement, irregular villous size, ridge disappearance, demarcation with normal villi, and abnormal microvasculature. Histology of NBI-guided lesion biopsy specimens provided the final diagnoses. Agreement between NBI images and histologic findings was analyzed.Of the 60 ampullary lesions, 11, 26, and 23 were adenocarcinomas, adenomas, and benign inflammatory diseases, respectively. Irregular villous arrangement, irregular villous size, ridge disappearance, demarcation with normal villi, and abnormal microvasculature were observed in 45%, 63%, 50%, 48%, and 58% of the lesions, respectively. Multivariate analysis revealed that irregular villous arrangement (odds ratio [OR] 15.76; 95% confidence interval [CI], 3.38-64.12; P .001) and abnormal microvasculature (OR 86.63; 95% CI, 14.56-515.41; P .001) were significant independent factors for identifying ampullary adenomas and adenocarcinoma. All tumors had at least one abnormal NBI feature.Retrospective design.The NBI findings of irregular villous arrangement and/or abnormal microvasculature were useful for differentially diagnosing ampullary tumors. NBI may complement the accurate diagnosis of ampullary lesions by white-light imaging.

Background EUS-guided and percutaneous lavage therapy for large hepatic cysts can replace surgical drainage. EUS-guided therapy can especially enable the alcohol lavage to be done with a 1-step approach. Objective To evaluate the utility of EUS-guidance and percutaneous ethanol lavage therapy. Design Retrospective cohort study. Setting Tertiary-care referral teaching hospital. Patients Adult patients with large liver cysts who underwent cyst drainage and alcohol ablation between 2009 and 2012. Interventions Ethanol lavage via percutaneous and/or EUS-guided approaches. Main Outcome Measurements Feasibility, efficacy, and safety of ethanol lavage. Results Seventeen patients with 19 hepatic cysts were enrolled. The median cyst volume before therapy was 368.9 mL (interquartile range, 195.3-795.9 mL). Ten cysts were drained by the percutaneous approach with a pigtail catheter, and 8 cysts underwent EUS-guided aspiration and lavage treatment. In 1 case, both the percutaneous approach and EUS-guided puncture were used. During the median 11.5-month follow-up of the percutaneous approach group, the cysts showed 97.5% reduction. During the median 15-month follow-up of the EUS-guided group, the cysts showed nearly 100% reduction. Percutaneous catheter drainage ethanol lavage was more feasible for right-sided larger cysts, whereas the EUS-guided approach was useful for left-sided lobe cysts. Limitations Single-center retrospective study. Conclusion Excellent symptomatic and radiologic responses and long-term results were achieved with percutaneous catheter–guided and EUS-guided ethanol lavage. Ethanol lavage could be considered a primary method of treatment for hepatic cysts given its high degree of technical feasibility and safety.

Background The differential diagnosis between benign and malignant polyps of the gallbladder (GB) is often challenging. Objectives To evaluate whether contrast-enhanced harmonic EUS (CEH-EUS) might be an accurate method for discriminating malignant GB polyps from benign polyps. Design Observational study. Setting Tertiary care medical center. Patients Ninety-three patients with GB polyps larger than 10 mm in diameter that were detected by conventional EUS underwent CEH-EUS for evaluation of microvasculature. Intervention CEH-EUS was performed using a radial echoendoscope and the extended pure harmonic detection mode. Main Outcome Measurements The abilities of conventional EUS and CEH-EUS to diagnose malignant polyp were compared. Two blinded reviewers classified the perfusion images into 3 categories: diffuse enhancement, perfusion defect, or nonenhancement. The vessel images were categorized as having a regular spotty vessel, an irregular vessel, or no vessels. Results An irregular vessel pattern determined by CEH-EUS aided in the diagnosis of malignant polyps with a sensitivity and specificity of 90.3% and 96.6%, respectively. The presence of perfusion defects, determined by CEH-EUS, was calculated to diagnose malignant polyps with a sensitivity and specificity of 90.3% and 94.9%, respectively. Based on the definitely determined diagnosis, sensitivity and specificity for CEH-EUS were 93.5% and 93.2% versus 90.0% and 91.1% for conventional EUS. In 8 cases, management changed after CEH-EUS. Limitations A tertiary medical center with a limited number of patients. Conclusions The presence of irregular intratumoral vessels or perfusion defects seen on CEH-EUS may be sensitive and accurate predictors of malignant GB polyps. CEH-EUS offers slightly improved diagnostic accuracy compared with EUS.

Background EUS-guided radiofrequency ablation (EUS-RFA) could be used as an adjunct and effective alternative mode of treatment for unresectable locally advanced and nonmetastatic pancreatic adenocarcinoma. However, its translation into clinical practice has been restricted because of limited data and high procedure-related risk. Objective To evaluate the feasibility, efficacy, and safety of EUS-RFA in the normal porcine pancreas. Design Prospective, endoscopic, experimental study in a porcine model. Setting Tertiary-care referral center animal laboratory. Patients Animal study. Intervention EUS-RFA of the pancreas was attempted on 10 adult mini pigs. An 18-gauge endoscopic RFA electrode was used to puncture the body and tail of the pancreas, with an output power of 50 W for 5 minutes. Main Outcome Measurements The feasibility, efficacy, and safety of EUS-RFA. Results A spherical necrotic lesion surrounded by fibrous tissue localized in the pancreatic parenchyma was observed on histopathologic examination. The mean diameter of the ablated tissue was 23.0 ± 6.9 mm. No major procedure-related complications were noted, and all pigs survived without any distress behavioral pattern for 7 days until autopsy. Limitations Small sample size with short-term observation and the lack of evaluation of the head of the pancreas. Conclusion EUS-RFA of the pancreatic body and tail was feasible, effective, and relatively safe in a porcine model. More animal studies to assess damage to adjacent organs are required before human trials can be conducted.

Background Although early laparoscopic cholecystectomy is the treatment of choice for patients with acute cholecystitis, percutaneous cholecystostomy has been performed in patients unsuitable for cholecystectomy. EUS-guided transgastric/transduodenal gallbladder drainage by using a plastic stent and/or nasobiliary drainage may be an alternative effective treatment for these patients, but bile leakage into the peritoneal space causing bile peritonitis is not uncommon during placement of a plastic stent. Objective To evaluate the technical feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent (CSEMS) in patients with acute cholecystitis who are unsuitable for cholecystectomy. Design Prospective feasibility study. Setting Tertiary-care referral center. Patients This study involved 15 patients with acute cholecystitis who did not respond to initial medical treatment and were unsuitable for cholecystectomy. Intervention EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified CSEMS. Main Outcome Measurements Technical success, functional success, complications associated with the placement of a metal stent, and recurrence of acute cholecystitis. Results Modified CSEMSs were successfully placed in all patients through the stomach (n = 10) or duodenum (n = 5). All patients achieved functional success within 3 days of metal stent placement. Pneumoperitoneum occurred in two patients during or after the procedure, but both patients improved with conservative management. During follow-up (median 145 days, range 60-297 days), no patient experienced recurrent cholecystitis. Limitations Small patient population without long-term follow-up. Conclusion Placement of a modified CSEMS after EUS-guided transgastric/transduodenal gallbladder drainage may be a feasible and safe alternative to treatments such as percutaneous cholecystostomy in patients with acute cholecystitis who are unsuitable for cholecystectomy.

Background Recently, placement of fully covered self-expandable metal stents (FCSEMSs) has been proposed as an alternative treatment for the management of benign biliary strictures. However, the major limitations of FCSEMSs are frequent migration and removal complications. Objective We conducted this study to compare the antimigration effects, complication rates, and short-term efficacy of 2 FCSEMSs with either an anchoring flap (AF) or a flared end (FE) at the proximal end of the stent. Design A multicenter, prospective comparative pilot study. Setting Two tertiary referral centers. Patients A total of 43 patients with benign biliary stricture who were candidates for placement of FCSEMSs were assigned to the AF (n = 22) or the FE group (n = 21). Interventions Predefined duration of placement and removal of FCSEMSs. Results After a median period of placement of 6 months (interquartile range 4-6), no patients in the AF group and 33% of patients (7 of 21, 1 in proximal and 6 in distal) in the FE group had stent migration ( P = .004). The removal rate of the FCSEMSs was 100% in both groups (per protocol, n=22 in the AF group and n=17 in the FE group). Immediate improvement of biliary stricture was 91% (20/22, per protocol) in the AF group and 88% (15/17, per protocol) in the FE group. All stents were removed without difficulty. Limitations Short-term follow-up after the removal of FCSEMSs. Conclusions With regard to the antimigration effect of FCSEMSs for benign biliary stricture, the AF design may be superior to the FE. For up to 6 months, both FCSEMSs can be endoscopically removed without complications. (Clinical trial registration number: NCT00945516.)

Background EUS-guided FNA (EUS-FNA) or trucut biopsy (TCB) is indispensible in the diagnosis of mediastinal malignancies. Less is known, however, about the usefulness of EUS-guided sampling for nonmalignant, mediastinal tuberculosis (TB), despite the increase in the incidence of TB. Objective To assess the diagnostic yields of EUS-FNA/TCB in patients with mediastinal TB. Design Retrospective study. Setting Tertiary-care referral hospital in a geographic region with an intermediate TB burden. Patients This study involved 24 consecutive patients with mediastinal TB, who underwent EUS-FNA/TCB from July 2005 to September 2008. Intervention EUS-FNA/TCB. Main Outcome Measurements Technical success and diagnostic yields of EUS-FNA/TCB. Results Mediastinal lesions (mean diameter, 28.6 mm; range 17.0-49.5 mm) were targeted by using 22-gauge-needle FNA in 10 patients and 19-gauge-needle TCB in 14 patients. Before EUS, only 10 of the 24 patients had a presumptive diagnosis of mediastinal TB, whereas 11 patients were suspected of having malignancies. Six patients showed mass-like lung parenchymal lesions mimicking lung cancer, and 7 patients had a history of malignancy. Pathologic examination showed granulomatous inflammation in 16 patients (66.7%), including 10 patients with caseating granulomas. Positive microbiologic results were obtained in 10 patients (41.7%): 3 by Ziehl-Neelsen staining, 5 by Mycobacterium tuberculosis culture, and 5 by TB polymerase chain reaction (PCR) assay. EUS-FNA/TCB confirmed mediastinal TB in 20 of the 24 patients and directed 11 patients clinically suspected of having malignancies to anti-TB treatment. The diagnostic yields of FNA and TCB were similar (90.0% vs 78.6%). Limitations Retrospective design in a tertiary-care referral hospital. Conclusion EUS-FNA/TCB is sufficiently useful to confirm mediastinal TB and can exclude suspected malignancies in TB patients.

Background Autoimmune pancreatitis (AIP) is now considered to be part of an immunoglobulin G4 (IgG4)-related systemic fibroinflammatory disease. Objective We evaluated whether IgG4 immunostaining of duodenal papillary biopsy specimens is useful for supporting a diagnosis of AIP. Design A prospective study. Setting A tertiary academic center. Patients/Interventions We obtained 2 forceps biopsy specimens from the major duodenal papilla (MDP) of 19 symptomatic AIP patients during ERCP before steroid administration. As a control, biopsy specimens were obtained from the MDP of patients with pancreatic cancer (n = 35), cholangiocarcinoma (n = 20), ampullary cancer (n = 11), ordinary chronic pancreatitis (n = 18), and AIP in remission (n = 16) and immunohistochemically examined. Main Outcome Measurements Specimens were considered positive for IgG4 immunostaining if there were more than 10 IgG4-positive plasma cells per high-power field. Results Positive IgG4 immunostaining of the MDP was found in 10 (53%) of 19 symptomatic AIP patients, but was absent in the control groups. Among symptomatic AIP patients (n = 19), 5 (83%) of 6 AIP patients with elevated serum IgG4 levels exhibited positive IgG4 staining of the MDP, whereas 5 (38%) of 13 AIP patients with normal serum IgG4 levels showed positive IgG4 staining of the MDP. Nine of 19 symptomatic AIP patients also underwent pancreatic biopsy, and positive IgG4 immunostaining of the MDP was observed in patients with positive pancreas IgG4 staining (4/6, 67%), but not in patients with negative pancreas IgG4 staining (0/3). Limitations Small symptomatic AIP patient population. Conclusions Positive IgG4 immunostaining of the MDP was an extremely specific and moderately sensitive tool for the diagnosis of AIP. IgG4 immunostaining of the MDP may be useful for supporting a diagnosis of AIP, especially when AIP is suspected clinically but serum IgG4 levels are normal or pancreatic tissue is not available.

Background Percutaneous transhepatic biliary drainage (PTBD) may be the last resort for an occluded biliary metal stent when the ERCP was unsuccessful. Objective Because an EUS-guided biliary drainage has been proposed as an effective alternative for PTBD after a failed ERCP, we conducted this study to determine the feasibility and usefulness of an EUS-guided hepaticogastrostomy (EUS-HG) with a fully covered self-expandable metal stent (FCSEMS) for an occluded biliary metal stent after a failed ERCP. Design A case study. Setting A tertiary referral center. Patients and Interventions Five patients who had an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion and for whom reinterventional ERCP was unsuccessful underwent an EUS-HG with an FCSEMS for alternative PTBD. Main Outcome Measurements Technical and functional success, procedural complications, reinterventional rate after EUS-HG with an FCSEMS, and short-term stent patency. Results In all 5 patients, an EUS-HG with an FCSEMS was technically successful. No procedural complications, such as bile peritonitis, cholangitis, and pneumoperitoneum, were observed. Functional success was also 100% (5/5). During the follow-up period (median 152 days, range 64-184 days), no late complications, such as stent migration and occlusion, were observed. Thus, no biliary reintervention was performed during the follow-up period. Limitations A small series of patients without a control group. Conclusions The EUS-HG with an FCSEMS may be feasible, effective, and an alternative PTBD for an occluded biliary metal stent after a failed ERCP.

Background Endoscopic management of malignant hilar biliary strictures is difficult even for an experienced endoscopist. Moreover, endoscopic placement of bilateral metal stents is considered very difficult and complicated. Objective We explored the feasibility and efficacy of the placement of a newly designed metal stent for an endoscopic bilateral stent-in-stent procedure for the management of malignant hilar biliary strictures. Design Multicenter prospective feasibility study. Setting Five academic tertiary referral centers. Patients Thirty-five patients with malignant hilar biliary strictures of Bismuth type II or higher were enrolled. Interventions Bilateral stent placement by an endoscopic stent-in-stent procedure. Main Outcome Measurements Technical success, functional success, early and late complications, stent patency. Results The overall technical success rate of the newly designed metal stent was 94.3% (33/35). The success rate of the stent-in-stent procedure in a single session was 82% (27/33) per protocol and 77% (27/35) as intent to treat. In cases in which the initial stent-in-stent procedure failed, patients underwent the endoscopic stent-in-stent procedure for contralateral stent placement at 2 days (6%, 2/33) or 4 days (12%, 4/33) after the initial stent placement. There was no percutaneous insertion of a contralateral stent in these patients. There was no stent-related early or late complication in any enrolled patient. Functional success was 100% (33/33). Reintervention because of stent malfunction was 6% (2/33). These 2 patients showed sludge formation in the stent. During follow-up, there was no stent tumor ingrowth or overgrowth in the placed stent in any enrolled patient. According to the Kaplan-Meier analysis, median survival and stent patency were 180 days and 150 days, respectively. Limitations An uncontrolled feasibility study with a small patient population and a limited follow-up period. Conclusion The newly designed metal stent for the endoscopic bilateral stent-in-stent procedure may be feasible and effective for malignant hilar biliary strictures.

Background Cystic tumors of the pancreas are frequently detected and encompass a wide pathologic spectrum, ranging from benign to malignant. A substantial proportion of cystic tumors cannot be histologically classified, even after extensive diagnostic evaluation, and, therefore, ultimately require surgical resection. Recently, complete resolution of cystic tumors by EUS-guided ethanol lavage was reported in a pilot study. Objectives The aim of this study was to evaluate the safety, feasibility, and response after EUS-guided ethanol lavage with paclitaxel injection (EUS-EP) for cystic tumors of the pancreas. Design A prospective study. Setting A tertiary care, academic medical center, from July 2005 to November 2006. Patients Fourteen patients who underwent EUS-EP were observed for more than 6 months. They were analyzed in terms of procedure safety, feasibility, and response. Intervention EUS-EP. Main Outcome Measurements To compare changes of cyst volume before and after an EUS-EP. Results An EUS-EP was successfully performed in all cases except one patient in whom the cyst fluid was so viscous that it could not be sufficiently aspirated. Acute pancreatitis occurred in one patient, and minor complications, including hyperamylasemia (n = 6) and vague abdominal pain (n = 1), were observed. Complete resolution of a cystic tumor was observed in 11 patients and partial resolution in two patients, and a cyst persisted in one patient. Limitations A small patient number, a short follow-up time, a single treatment arm. Conclusions EUS-EP appears to be a safe, feasible, and effective method for treating cystic tumors of the pancreas. Further studies that involve larger populations and longer follow-ups are warranted.

Background and Aims Recently, EUS-guided pancreatic duct drainage (EUS-PD) has been used for patients in whom endoscopic retrograde pancreatography (ERP) has failed. Stent-related adverse events such as stent migrations, failures in stent placement, or pancreatic fluid leakages have been of concern in transmural plastic stenting procedures. The aim of this study is to evaluate the feasibility and safety of EUS-PD with a fully covered self-expandable metal stent (FCSEMS) for patients with obstructive pancreatitis who failed ERP. Methods Twenty-five consecutive patients with painful obstructive pancreatitis underwent EUS-PD with a FCSEMS after failed ERP. Technical and clinical success, adverse events, and stent patency were assessed. Results EUS-PD was successful in all 25 patients (technical success rate, 100%), and symptoms improved in all patients (clinical success rate, 100%). EUS-guided pancreaticogastrostomy (n = 23), pancreaticoduodenostomy (n = 1), and pancreaticojejunostomy (n = 1) were performed. Pain scores improved significantly after FCSEMS placement ( P = .001). Early mild grade adverse events occurred in 5 patients (20%), 4 with self-limited abdominal pain and 1 with minor bleeding. No other adverse events related to FCSEMS, including stent migration, stent clogging, pancreatic sepsis, and stent-induced ductal stricture, were observed during follow-up periods. Mean stent patency duration was 126.9 days during mean follow-up periods (221.1 days). Conclusions EUS-PD with an FCSEMS may be technically feasible and relatively safe for patients who fail conventional ERP. Further randomized trials comparing EUS-PD with long-term FCSEMS and plastic stents for patients with painful obstructive pancreatitis after failed ERCP should be encouraged.

Background MRCP is rapidly replacing diagnostic ERCP in various pancreaticobiliary diseases. This study was designed to evaluate the accuracy of MRCP in detecting and determining the extent of choledochal cysts, as well as associated ductal anomalies or lesions. Methods The study design was an 8-year retrospective survey conducted at a tertiary referral center, Asan Medical Center (University of Ulsan College of Medicine, Seoul, Korea). There were 72 patients with choledochal cysts. All patients underwent both MRCP and ERCP. MRCP findings were compared with those of ERCP as the criterion standard. Results The overall detection rate of MRCP for choledochal cysts was 96% (69/72). The sensitivity, the specificity, the positive predictive value, and the negative predictive value of MRCP for classifying choledochal cysts according to Todani's classification were 81%, 90%, 86%, and 86% in type I, respectively; 73%, 100%, 100, and 95% in type III, respectively; 83%, 90%, 80%, and 91% in type IVa, respectively; 100%, 100%, 100%, and 100% in type IVb, respectively; and 100%, 100%, 100%, and 100% in type V, respectively. The sensitivity, the specificity, and the accuracy of MRCP for detecting ductal anomalies were 83%, 90%, and 86%, respectively. The detection rate of MRCP for concurrent cholangiocarcinoma and choledocholithiasis was 87% (13/15) and 100% (8/8), respectively. Conclusions MRCP showed overall good accuracy in the detection and the classification of choledochal cysts and revealed associated cholangiocarcinoma and choledocholithiasis with excellent accuracy. MRCP, therefore, may supersede the diagnostic role of ERCP for the patients with choledochal cysts. However, MRCP showed limited capacity to detect minor ductal anomalies or small choledochocele.

The differential diagnosis in pancreatic cystic lesions is often difficult despite the availability of various modern imaging modalities. This study assessed the role of EUS in the following: (1) discrimination of pseudocysts from pancreatic cystic tumors, (2) differential diagnosis between serous cystadenoma and mucinous cystic tumor, and (3) prediction of accompanying malignancy in intraductal papillary mucinous tumor.EUS findings in 75 patients with pancreatic cystic lesions (58 cystic tumors, 17 pseudocysts) were evaluated. In the comparison of pseudocysts and cystic tumors, the latter included intraductal papillary mucinous tumor, mucinous cystic tumors, and serous cystadenomas, but not solid-pseudopapillary tumors.In univariate analysis, pseudocysts exhibited echogenic debris and parenchymal changes more often than cystic tumors did (respectively, 29% vs. 6%, p0.05; and 65% vs. 4%, p0.001). In contrast, septa and mural nodules were found more frequently in cystic tumors than pseudocysts (respectively, 69% vs. 12%, p0.001; 56% vs. 12%, p0.01). Multivariate analysis revealed that parenchymal changes (odds ratio [OR] = 83.59; p0.01); septa (OR = 30.75; p0.05); and mural nodules (OR = 21.38; p0.05) were independent predictors of differentiation between pseudocysts and cystic tumors. Serous cystadenoma exhibited diverse EUS features, as well as a honeycomb appearance. Mural nodules were found more often in mucinous cystic tumors than in serous cystadenomas (p0.05). There were no factors that predicted malignancy in intraductal papillary mucinous tumor.EUS is a useful complementary imaging method for differentiation of pancreatic cystic lesions.

Background: An ectopic opening of the common bile duct in the duodenal bulb is extremely rare, and the clinical significance of this anomaly has not been clarified. This study analyzed the clinical implications and cholangiographic findings of this anomaly. Methods: A total of 18 patients (15 men, 3 women; median age, 51 years) with an ectopic opening of the common bile duct in the duodenal bulb were studied. Medical records, endoscopic findings, and cholangiographic and other radiographic findings were reviewed. Results: All 18 patients had biliary pain; 7 had fever and chills. Fifteen (83%) had diffuse dilatation of the extrahepatic bile ducts with or without intrahepatic bile duct dilation. Associated bile duct stones were found in 10 (56%) patients. The papilla in the bulb had an orifice stained with bile at endoscopy, which was associated with duodenal ulcer disease found in 13 (72%) patients. The distal end of the common bile duct was tapered and narrowed and had a hook shape in all patients. Conclusion: An ectopic opening of the common bile duct in the duodenal bulb may be associated with clinical entities such as recurrent or intractable duodenal ulcer, choledocholithiasis, or acute cholangitis. Although these openings are rare, knowledge of the endoscopic and radiographic findings of an ectopic opening of the common bile duct in the duodenal bulb may help to clarify the cause of chronic recurrent duodenal ulcer disease in some patients and prevent damage to the bile duct during surgery. (Gastrointest Endosc 2003;57:679-82.)

Background: The utility of magnetic resonance cholangiography for assessment of longitudinal tumor extension of hilar cholangiocarcinoma was investigated with reference to findings by percutaneous transhepatic cholangioscopy. Methods: Ninety-nine patients with hilar cholangiocarcinoma underwent both magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy. Longitudinal tumor extension was described with the Bismuth-Corlette classification. Hilar cholangiocarcinoma was classified morphologically into stenotic, diffuse sclerosing, and polypoid types based on selective cholangiographic findings obtained during percutaneous transhepatic cholangioscopy. Agreement between percutaneous transhepatic cholangioscopy and magnetic resonance cholangiography according to the Bismuth-Corlette classification was compared. The degree of agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy according to each morphologic type was also compared in each subgroup without reference to Bismuth-Corlette type. Results: The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy with regard to Bismuth-Corlette types was 87.9% (kappa = 0.832, p < 0.01). The agreement of magnetic resonance cholangiography for each Bismuth-Corlette type with reference to percutaneous transhepatic cholangioscopy was as follows: type I (n = 18), 16/18 (88.9%); type II (n = 16), 14/16 (87.5%); type IIIa (n = 23), 19/23 (82.6%); type IIIb (n = 14), 14/14 (100%); and type IV (n = 28), 24/28 (85.7%). The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy for Bismuth-Corlette type according to selective cholangiographic findings was as follows: stenotic type, 58/61 (95.1%, kappa = 0.929, p < 0.01); diffuse sclerosing type, 12/16 (75%, kappa = 0.619, p < 0.01); and polypoid type, 17/22 (77.3%, kappa = 0.696, p < 0.01). Conclusion: There is good overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy on longitudinal extension of hilar cholangiocarcinoma. Especially for the stenotic type of hilar cholangiocarcinoma (based on selective cholangiographic findings), magnetic resonance cholangiography may replace percutaneous transhepatic cholangioscopy in the determination of longitudinal tumor extension. For polypoid or diffuse sclerosing types, however, percutaneous transhepatic cholangioscopy is required for accurate evaluation of longitudinal tumor extension. (Gastrointest Endosc 2002;56:25-32.)

This study investigated the clinical significance of papillitis of the major duodenal papilla and analyzed the correlation between endoscopic and histologic papillitis in patients with biliary or pancreatic disorders.Eighty-seven patients and 12 healthy control subjects were enrolled. The endoscopic appearance of papillitis was classified by two blinded endoscopists, and biopsy specimens were taken of the papilla. Various factors were prospectively analyzed to identify any relationship with the endoscopic severity of the papillitis.By univariate analysis, a clinically acute inflammatory condition and elevation of serum transaminase levels were significantly associated with moderate and severe endoscopic papillitis (p0.05). However, by multivariate analysis, only a clinically acute inflammatory condition was significantly associated with moderate and severe endoscopic papillitis (p0.001). The endoscopic severity of papillitis was poorly correlated with monocyte infiltration, but there was a good correlation with neutrophil infiltration. Moderate and severe papillitis were not observed in healthy volunteers.Moderate and severe endoscopic papillitis were significantly more common in patients with biliary or pancreatic disorders plus a clinically acute inflammatory condition, whereas moderate and severe papillitis were not observed in healthy volunteers. Moderate and severe endoscopic papillitis are characteristic of biliary or pancreatic disorders.