Endoscopic drainage for pancreatic and peripancreatic fluid collections (PFCs) has been increasingly used as a minimally invasive alternative to surgical or percutaneous drainage. Recently, endoscopic ultrasound-guided transluminal drainage (EUS-TD) has become the standard of care and a safe procedure for nonsurgical PFC treatment. EUS-TD ensures a safe puncture, avoiding intervening blood vessels. Single or multiple plastic stents (combined with a nasocystic catheter) were used for the treatment of PFCs for EUS-TD. More recently, the use of covered self-expandable metallic stents (CSEMSs) has provided a safer and more efficient approach route for internal drainage. We focused our review on the best approach and stent to use in endoscopic drainage for PFCs. We reviewed studies of EUS-TD for PFCs based on the original Atlanta Classification, including case reports, case series, and previous review articles. Data on clinical outcomes and adverse events were collected retrospectively. A total of 93 patients underwent EUS-TD of pancreatic pseudocysts using CSEMSs. The treatment success and adverse event rates were 94.6% and 21.1%, respectively. The majority of complications were of mild severity and resolved with conservative therapy. A total of 56 patients underwent EUS-TD using CSEMSs for pancreatic abscesses or infected walled-off necroses. The treatment success and adverse event rates were 87.8% and 9.5%, respectively. EUS-TD can be performed safely and efficiently for PFC treatment. Larger diameter CSEMSs without additional fistula tract dilation for the passage of a standard scope are needed to access and drain for PFCs with solid debris.
Abdominal Abscess/surgery ; Drainage/*methods ; Endosonography/*methods ; Humans ; Necrosis/surgery ; Pancreas/*pathology/surgery ; Pancreatic Diseases/*surgery ; Pancreatic Pseudocyst/surgery ; *Stents ; Surgery, Computer-Assisted/*methods ; Ultrasonography, Interventional/methods

Magnetic compression anastomosis (MCA) is a minimally invasive method of performing choledochocholedochostomy without surgery in patients with biliary stricture or obstruction. We describe a successful case involving magnetic compression duct-to-duct biliary reconstruction in right-lobe living donor liver transplantation (RL-LDLT). Endoscopically, a samarium-cobalt (Sm-Co) rare-earth magnet was placed at the superior site of obstruction via the percutaneous transhepatic biliary drainage route, and another Sm-Co magnet was also placed at the inferior site of obstruction with the aid of an endoscope. MCA techniques enabled complete anastomosis without procedure-related complications. In conclusion, the MCA technique is a revolutionary method of performing choledochocholedochostomy in patients with biliary obstruction after LDLT.
Constriction, Pathologic ; Drainage ; Endoscopes ; Humans ; Liver ; Liver Transplantation ; Living Donors ; Magnetics ; Magnets

Irreversible electroporation (IRE) is a novel form of soft tissue ablation therapy that uses highcurrent electrical pulses to induce the formation of pores in the cell membrane, leading to cell death. Although outcome data for the ablation of hepatocellular carcinoma (HCC) by IRE are limited, early results are encouraging and may suggest equivalency to the outcomes achieved by thermal ablation methods such as radiofrequency ablation (RFA) and microwave ablation (MWA). However, IRE can be a challenging and very time-consuming procedure compared to RFA and MWA. In this review article, we not only evaluate the efficacy and safety of IRE for the treatment of HCC, but also discuss imaging guidance, ablation monitoring, and endpoint assessment, with a particular focus on ultrasonography.

Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.

BACKGROUND/AIMS: Propofol sedation for elderly patients during time-consuming endoscopic procedures is controversial. Therefore, we investigated the safety of using propofol in elderly patients during upper gastrointestinal therapeutic endoscopy. METHODS: The medical records of 160 patients who underwent therapeutic endoscopic procedures under gastroenterologist-guided propofol sedation at a single institution were retrospectively reviewed. The subjects were divided into two groups: a younger group, patients <75 years old; and an elderly group, patients > or =75 years old. The two groups were compared with respect to the therapeutic regimen, circulatory dynamics, and presence/absence of discontinuation of propofol treatment. RESULTS: Although the number of patients with liver dysfunction was higher in the elderly group, there were no other significant differences in the baseline characteristics, including the American Society of Anesthesiologists classification, between the elderly and younger groups. The average maintenance rate of continuous propofol infusion was lower in the elderly patients. No statistically significant differences were found in the occurrence of adverse events between the elderly and younger groups. None of the patients returned to a resedated state after the initial recovery from sedation. CONCLUSIONS: Gastroenterologist-guided propofol sedation in elderly patients can be safely achieved in the same manner as that in younger patients, even for time-consuming upper gastrointestinal therapeutic endoscopic procedures.
Age Factors ; Aged ; Aged, 80 and over ; Conscious Sedation/adverse effects/*methods ; *Endoscopy, Gastrointestinal/methods ; Female ; Humans ; *Hypnotics and Sedatives/adverse effects ; Male ; *Propofol/adverse effects ; Retrospective Studies

Shear wave (SW) dispersion imaging is a newly developed imaging technology for assessing the dispersion slope of SWs, which is related to tissue viscosity in diffuse liver disease. Our preclinical and preliminary clinical studies have shown that SW speed is more useful than dispersion slope for predicting the degree of fibrosis and that dispersion slope is more useful than SW speed for predicting the degree of necroinflammation. Thus, dispersion slope, which reflects viscosity, may provide additional pathophysiological insight into diffuse liver disease.

Background/Aims: Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD). Methods: We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes. Results: Resection time was significantly shorter in the following order: RH-ESD (149 [90–197] minutes) >C-ESD (90 [60–140] minutes) >SH-ESD (52 [29–80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%–30%]) than in the en bloc resection group (40% [20%–60%]). Conclusions RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.

Purpose: The study aimed to compare the diagnostic performance of washout-parametric imaging (WOPI) with that of conventional contrast-enhanced ultrasound (cCEUS) in differentiating focal liver lesions (FLLs). Methods: A total of 181 FLLs were imaged with contrast-enhanced ultrasound using Sonazoid, and the recordings were captured for 10 minutes in a prospective setting. WOPI was constructed from three images, depicting the arterial phase (peak enhancement), the early portal venous phase (1-minute post-injection), and the vasculo-Kupffer phase (5 or 10 minutes post-injection). The intensity variations in these images were color-coded and superimposed to produce a single image representing the washout timing across the lesions. From the 181 FLLs, 30 hepatocellular carcinomas (HCCs), 30 non-HCC malignancies, and 30 benign lesions were randomly selected for an observer study. Both techniques (cCEUS and WOPI) were evaluated by four off-site readers. They classified each lesion as benign or malignant using a continuous rating scale, with the endpoints representing "definitely benign" and "definitely malignant." The diagnostic performance of cCEUS and WOPI was compared using the area under the receiver operating characteristic curve (AUC) with the DeLong test. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). Results: The difference in average AUC values between WOPI and cCEUS was 0.0062 (95% confidence interval, -0.0161 to 0.0285), indicating no significant difference between techniques. The interobserver agreement was higher for WOPI (ICC, 0.77) than cCEUS (ICC, 0.67). Conclusion The diagnostic performance of WOPI is comparable to that of cCEUS in differentiating FLLs, with superior interobserver agreement.

Purpose: The study aimed to compare the diagnostic performance of washout-parametric imaging (WOPI) with that of conventional contrast-enhanced ultrasound (cCEUS) in differentiating focal liver lesions (FLLs). Methods: A total of 181 FLLs were imaged with contrast-enhanced ultrasound using Sonazoid, and the recordings were captured for 10 minutes in a prospective setting. WOPI was constructed from three images, depicting the arterial phase (peak enhancement), the early portal venous phase (1-minute post-injection), and the vasculo-Kupffer phase (5 or 10 minutes post-injection). The intensity variations in these images were color-coded and superimposed to produce a single image representing the washout timing across the lesions. From the 181 FLLs, 30 hepatocellular carcinomas (HCCs), 30 non-HCC malignancies, and 30 benign lesions were randomly selected for an observer study. Both techniques (cCEUS and WOPI) were evaluated by four off-site readers. They classified each lesion as benign or malignant using a continuous rating scale, with the endpoints representing "definitely benign" and "definitely malignant." The diagnostic performance of cCEUS and WOPI was compared using the area under the receiver operating characteristic curve (AUC) with the DeLong test. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). Results: The difference in average AUC values between WOPI and cCEUS was 0.0062 (95% confidence interval, -0.0161 to 0.0285), indicating no significant difference between techniques. The interobserver agreement was higher for WOPI (ICC, 0.77) than cCEUS (ICC, 0.67). Conclusion The diagnostic performance of WOPI is comparable to that of cCEUS in differentiating FLLs, with superior interobserver agreement.

Purpose: The study aimed to compare the diagnostic performance of washout-parametric imaging (WOPI) with that of conventional contrast-enhanced ultrasound (cCEUS) in differentiating focal liver lesions (FLLs). Methods: A total of 181 FLLs were imaged with contrast-enhanced ultrasound using Sonazoid, and the recordings were captured for 10 minutes in a prospective setting. WOPI was constructed from three images, depicting the arterial phase (peak enhancement), the early portal venous phase (1-minute post-injection), and the vasculo-Kupffer phase (5 or 10 minutes post-injection). The intensity variations in these images were color-coded and superimposed to produce a single image representing the washout timing across the lesions. From the 181 FLLs, 30 hepatocellular carcinomas (HCCs), 30 non-HCC malignancies, and 30 benign lesions were randomly selected for an observer study. Both techniques (cCEUS and WOPI) were evaluated by four off-site readers. They classified each lesion as benign or malignant using a continuous rating scale, with the endpoints representing "definitely benign" and "definitely malignant." The diagnostic performance of cCEUS and WOPI was compared using the area under the receiver operating characteristic curve (AUC) with the DeLong test. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). Results: The difference in average AUC values between WOPI and cCEUS was 0.0062 (95% confidence interval, -0.0161 to 0.0285), indicating no significant difference between techniques. The interobserver agreement was higher for WOPI (ICC, 0.77) than cCEUS (ICC, 0.67). Conclusion The diagnostic performance of WOPI is comparable to that of cCEUS in differentiating FLLs, with superior interobserver agreement.