SUMMARY OF EVENT: Persistent greenish discharge with abdominal pain and fever were developed in the patient who had undergone laparoscopic cholecystectomy. For the endoscopic treatment of postoperative bile leak, endoscopic biliary sphincterotomy (EBST) with endoscopic retrograde biliary drainage (ERBD) was done and patient's symptoms and persistent discharge via surgical drain were resolved. TEACHING POINT: A high grade bile leak suggests a large defect and EBST alone may be insufficient to allow healing of the defect, and thus, ERBD with or without EBST is proposed as the preferred initial endoscopic treatment.
Abdominal Pain ; Bile* ; Cholecystectomy* ; Cholecystectomy, Laparoscopic ; Drainage ; Fever ; Humans

Coil occlusion of colonic vessels is uncommon due to a risk of colonic ischemia and perforation, and should only be performed as a bridge to emergent surgery. Colonic haemorrhage can occur in haemorrhoidal disease which is managed conservatively in most cases. Endovascular management of haemorrhoids has been described in a non acute setting with effective results and little complications. We present a case of a 46-year-old male admitted with haemorrhage secondary to abnormal vascular rests within the anal cushions, similar to that described in haemorrhoidal disease. Both clinical and endoscopic examination did not identify haemorrhoids; however, catheter angiogram identified ectatic distal rectal arteries with arterial blush demonstrating a haemorrhagic focus. This was subsequently embolised. The patient experienced no ischemic complications or further haemorrhage. Endovascular management in this setting has both a diagnostic and therapeutic benefit allowing rapid effective management of the patient.
Arteries ; Catheters ; Colon ; Humans ; Ischemia ; Male ; Middle Aged

BACKGROUND: Both endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) and tumor ablation using ethanol are very common procedures, and the utility of these therapies has already been reported in prominent journals. However, their effectiveness appears temporary and insufficient, especially EUS-CPN. We therefore have to consider new reagents for improving the results. The present study examined the best concentration of ethanol and povidone iodine mixed with atelocollagen for more effective therapies. METHODS: The effects of the new reagents were confirmed in three live pigs. At first, we injected three kinds of reagents (including indigo carmine) in three separate areas of para-aortic tissue under EUS guidance in one pig. At more than 4 hours after injection, we checked ethanol injection sites after dissection. In next study, we performed EUS-guided injection of a total of six kinds of reagents (two kinds of ethanol, three kinds of povidone iodine, and control atelocollagen) into the livers of two living pigs. After 2 weeks, we examined tissue damage to the liver in the two pigs. RESULTS: The 75% ethanol (absolute ethanol 3.75 mL + 1% atelocollagen 1.25 mL + a very small amount of indigo carmine) was seen like blue gel, and still remained in the para-aortic tissue. Brownish areas of povidone iodine mixed with 3% atelocollagen exhibited clear, regular borders with greatly reduced infiltration into surrounding tissue compared to others. CONCLUSION: We concluded that 75% ethanol mixed with 1% atelocollagen appears optimal for EUS-CPN. Povidone iodine mixed with 3% atelocollagen may be suitable for small tumor ablation therapy.
Celiac Plexus* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Endosonography ; Ethanol ; Indicators and Reagents ; Indigo Carmine ; Liver ; Povidone-Iodine ; Swine

An accurate diagnosis of solid pancreatic lesions (SPLs) is important because pancreatic cancer cannot be ignored if curative treatment is possible. Prompt and reliable diagnostic procedures are greatly needed for patients presenting with SPLs, particularly where resection is possible for a malignant mass. Several endoscopic ultrasound (EUS)-related technologies including a novel EUS-guided needle-based confocal laser endomicroscopy (EUS-nCLE) can provide real-time images at the cellular level (1,000-fold magnification). A 19-gauge EUS-guided fine needle aspiration (EUS-FNA) needle is recommended because its channel is large enough for the 0.85-mm diameter nCLE miniprobe. The procedure is performed by standard EUS-FNA techniques with either pre- or post-loading technique. Ten percent fluorescein sodium (2.5–5 mL) is used as an enhancing agent and is intravenously injected immediately before puncturing the lesion. Only a few studies have used the technique and reported results. A recent study from 19 malignant and 3 benign SPLs classified EUS-nCLE findings according to 4 signs: dark clumps, and dilated vessels (predominantly seen in malignant SPLs) and fine white fibrous bands and normal acini (predominantly seen in benign SPLs). Using these criteria, researchers correctly diagnosed 18 of the malignant SPLs (94.7%). Another study described 2 lesions as having “dark cells aggregates with pseudo-glandular aspects, and straight hyperdense elements more or less thick corresponding to tumoral fibrosis” in 17 of 18 malignant SPLs. Thus far, no large and systematic study has been performed to evaluate the potential clinical use of EUS-nCLE for diagnosing SPLs. However, based on available information from a few studies and the current limitations of EUS-FNA, EUS-nCLE can potentially provide a complementary role in diagnosing such lesions. Nevertheless, more studies are certainly needed.
Biopsy, Fine-Needle ; Diagnosis* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Fluorescein ; Humans ; Needles ; Pancreatic Neoplasms ; Ultrasonography

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is emerging as a safe and effective alternative for endoscopic BD. The advantage of multiple access points from stomach and duodenum allows EUS-BD in patients with altered surgical anatomy and duodenal stenosis. EUS-BD is also useful in patients with failed endoscopic retrograde cholangiopancreatography or difficult biliary cannulation. Depending on the access and exit route of the stent, a variety of EUS-BD procedures have been described. Trans-papillary as well as trans-luminal stent placements are possible with EUS-BD. Recent studies have shown a clinical success rate in excess of 90% and complication rates of < 15%. Prospective studies are needed to know the long-term results and relative efficacy of this technique.
Bile Duct Diseases ; Biliary Tract Neoplasms ; Catheterization ; Cholangiopancreatography, Endoscopic Retrograde ; Constriction, Pathologic ; Drainage* ; Duodenum ; Endosonography ; Humans ; Jaundice, Obstructive ; Prospective Studies ; Stents ; Stomach

Drainage of pseudocyst and walled-off pancreatic necrosis has traditionally been achieved by surgical means. Recently, there has been a progressive shift in paradigm to performing endoscopic drainage for these conditions. Endoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic pseudocyst. However, many controversies still exist on the optimal management and wide variations in techniques exist. There is a pressing need for establishment of a consensus for safe practices in EUS-guided pseudocyst drainage.
Asian Continental Ancestry Group* ; Consensus* ; Drainage* ; Humans ; Necrosis ; Pancreatic Pseudocyst* ; Ultrasonography

Pancreatic necrosis with the formation of walled-off collections is a known complication of severe acute pancreatitis. Infected necrotic pancreatic collections are associated with a high mortality rate. Open necrosectomy and debridement with closed drainage has traditionally been the gold standard for treatment of infected pancreatic necrosis, but carries a high risk of perioperative complications. Direct endoscopic necrosectomy has emerged as a safe and effective modality of treatment for this condition. Careful patient selection and gentle meticulous debridement is important to optimize clinical success. Bleeding is the commonest associated complication with the procedure but most cases can be managed conservatively. Air embolism, although rare, is potentially fatal. The use of fully covered large diameter lumen apposing self-expandable metal stents has further simplified the procedure. These stents optimize drainage, and facilitate endoscopic necrosectomy because repeat insertion of the endoscope into the necrotic cavity can be easily achieved.
Debridement ; Drainage ; Embolism, Air ; Endoscopes ; Endosonography ; Hemorrhage ; Mortality ; Necrosis ; Pancreatitis ; Patient Selection ; Stents

Lung carcinoma is a common cause of mortality and morbidity worldwide. Non-small cell lung cancer (NSCLC) accounts for majority of cases worldwide. Accurate staging of NSCLC is of paramount importance due to marked difference in survival and management strategies between stage II and III of the disease. The staging methods have evolved from invasive thoracotomies and mediastinoscopies to relatively non-invasive complete mediastinal staging by combination of endoscopic ultrasound (EUS) and endoscopic bronchial ultrasound (EBUS). EUS also provides information about mediastinal invasion and liver/adrenal metastasis. Future role of EUS include providing tissue for molecular targeted therapy.
Carcinoma, Non-Small-Cell Lung* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Lung ; Mediastinoscopy ; Molecular Targeted Therapy ; Mortality ; Neoplasm Metastasis ; Thoracotomy ; Ultrasonography*

Endoscopic ultrasound (EUS), with or without fine needle aspiration (FNA), has become an essential tool in the evaluation of pancreatobiliary diseases. Although conventional EUS is superior to multidetector computed tomography in tumor detection and staging, there are situations when characterization of various pancreatobiliary lesions remains difficult. Contrast-enhanced EUS (CE EUS) can further improve the detection and characterization of pancreatic solid lesions such as ductal adenocarcinoma, neuroendocrine tumor, or mass-forming autoimmune pancreatitis based on differences in the enhancement pattern of the target lesions. It is also useful in differentiating between mural nodules and mucous clots in pancreatic cystic neoplasms, and characterizing various lesions in the gallbladder and bile duct. CE EUS is complementary to FNA and has the potential to increase the diagnostic yield on the first FNA needle pass.
Adenocarcinoma ; Bile Ducts ; Biopsy, Fine-Needle ; Gallbladder ; Multidetector Computed Tomography ; Needles ; Neuroendocrine Tumors ; Pancreatic Cyst ; Pancreatitis ; Ultrasonography*

Accurate diagnosis of pancreatic solid lesions is often difficult using conventional imaging modalities. With the recent introduction of contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS), it is now possible to evaluate the microvascular environment and dynamic enhancement of a variety of pancreatic lesions. With CEH-EUS, three patterns of pancreatic lesion enhancement compared with the normal pancreatic tissue (fast, simultaneous, or slow), two washout patterns (fast or slow) and two distribution patterns (homogeneous, inhomogeneous) can be described. By evaluating the microvasculature, enhancement speed, and washout pattern, CEH-EUS may help to differentiate pancreatic adenocarcinoma from other masses and differentiate between pancreatic neuroendocrine tumor (pNET) and inflammatory masses. The finding of a hyperenhancing lesion on CEH–EUS, both with homogeneous and inhomogeneous patterns, was a strong predictor of histology different from adenocarcinoma (94% positive predictive value). pNET was the most common hyperenhancing lesions overall. Although CEH-EUS is useful for ruling out pancreatic ductal adenocarcinoma, making the differential diagnosis between pNETs and pseudotumoral pancreatic masses is difficult because both may share an isovascular or hypervascular appearance. Currently the interpretation of CEH-EUS findings is examiner-dependent. In the future, digital image analysis by image-processing techniques should allow more objective interpretation.
Adenocarcinoma ; Diagnosis ; Diagnosis, Differential ; Microvessels ; Neuroectodermal Tumors, Primitive ; Neuroendocrine Tumors ; Pancreatic Ducts ; Ultrasonography*