We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

BACKGROUND:Ultrasound guidance is commonly used for accessing difficult peripheral veins.For successful access,a tourniquet is required for venodilation.Tourniquets decrease the compressibility and increase the diameter of veins;they also obfuscate artery-vein differentiation on ultrasound.We aimed to establish the upper limit of sphygmomanometer cuff pressure that facilitates artery-vein differentiation during ultrasound-guided peripheral intravenous access. METHODS:We employed the sphygmomanometer cuff as a tourniquet for venodilation and tested it on seven participants at six different levels as follows:0 mmHg,DBP/2,DBP,(DBP+SBP)/2,SBP,and SBP+20 mmHg.We used an ultrasound probe attached to a pressure-measuring instrument to record cross-sectional images of the cubital artery and vein.During ultrasonography,compression was applied to the blood vessels through the skin.The following day,we measured the wrist pulse pressure and observed the oximeter pulse wave at six different tourniquet pressure levels.Repeated-measures analysis of variance(ANOVA)on ranks and Tukey's post-hoc analysis were used for multiple comparisons. RESULTS:Arterial pulsation was maintained at tourniquet pressures between 0 mmHg and(DBP+SBP)/2.However,arterial pulsation decreased or disappeared when the tourniquet pressure reached or exceeded the SBP.Moreover,at this pressure level,the superior compressibility of veins compared to that of arteries was no longer observed.Compression of the artery to 75%and 50%of its original diameter increased arterial pulsation. CONCLUSION:Arterial pulsation and the superior compressibility are useful indicators for differentiating veins from arteries until the tourniquet pressure reaches(DBP+SBP)/2.However,these indicators are not reliable once the tourniquet pressure exceeds the SBP.

BACKGROUND:Ultrasound guidance is commonly used for accessing difficult peripheral veins.For successful access,a tourniquet is required for venodilation.Tourniquets decrease the compressibility and increase the diameter of veins;they also obfuscate artery-vein differentiation on ultrasound.We aimed to establish the upper limit of sphygmomanometer cuff pressure that facilitates artery-vein differentiation during ultrasound-guided peripheral intravenous access. METHODS:We employed the sphygmomanometer cuff as a tourniquet for venodilation and tested it on seven participants at six different levels as follows:0 mmHg,DBP/2,DBP,(DBP+SBP)/2,SBP,and SBP+20 mmHg.We used an ultrasound probe attached to a pressure-measuring instrument to record cross-sectional images of the cubital artery and vein.During ultrasonography,compression was applied to the blood vessels through the skin.The following day,we measured the wrist pulse pressure and observed the oximeter pulse wave at six different tourniquet pressure levels.Repeated-measures analysis of variance(ANOVA)on ranks and Tukey's post-hoc analysis were used for multiple comparisons. RESULTS:Arterial pulsation was maintained at tourniquet pressures between 0 mmHg and(DBP+SBP)/2.However,arterial pulsation decreased or disappeared when the tourniquet pressure reached or exceeded the SBP.Moreover,at this pressure level,the superior compressibility of veins compared to that of arteries was no longer observed.Compression of the artery to 75%and 50%of its original diameter increased arterial pulsation. CONCLUSION:Arterial pulsation and the superior compressibility are useful indicators for differentiating veins from arteries until the tourniquet pressure reaches(DBP+SBP)/2.However,these indicators are not reliable once the tourniquet pressure exceeds the SBP.

BACKGROUND:Ultrasound guidance is commonly used for accessing difficult peripheral veins.For successful access,a tourniquet is required for venodilation.Tourniquets decrease the compressibility and increase the diameter of veins;they also obfuscate artery-vein differentiation on ultrasound.We aimed to establish the upper limit of sphygmomanometer cuff pressure that facilitates artery-vein differentiation during ultrasound-guided peripheral intravenous access. METHODS:We employed the sphygmomanometer cuff as a tourniquet for venodilation and tested it on seven participants at six different levels as follows:0 mmHg,DBP/2,DBP,(DBP+SBP)/2,SBP,and SBP+20 mmHg.We used an ultrasound probe attached to a pressure-measuring instrument to record cross-sectional images of the cubital artery and vein.During ultrasonography,compression was applied to the blood vessels through the skin.The following day,we measured the wrist pulse pressure and observed the oximeter pulse wave at six different tourniquet pressure levels.Repeated-measures analysis of variance(ANOVA)on ranks and Tukey's post-hoc analysis were used for multiple comparisons. RESULTS:Arterial pulsation was maintained at tourniquet pressures between 0 mmHg and(DBP+SBP)/2.However,arterial pulsation decreased or disappeared when the tourniquet pressure reached or exceeded the SBP.Moreover,at this pressure level,the superior compressibility of veins compared to that of arteries was no longer observed.Compression of the artery to 75%and 50%of its original diameter increased arterial pulsation. CONCLUSION:Arterial pulsation and the superior compressibility are useful indicators for differentiating veins from arteries until the tourniquet pressure reaches(DBP+SBP)/2.However,these indicators are not reliable once the tourniquet pressure exceeds the SBP.

BACKGROUND:Ultrasound guidance is commonly used for accessing difficult peripheral veins.For successful access,a tourniquet is required for venodilation.Tourniquets decrease the compressibility and increase the diameter of veins;they also obfuscate artery-vein differentiation on ultrasound.We aimed to establish the upper limit of sphygmomanometer cuff pressure that facilitates artery-vein differentiation during ultrasound-guided peripheral intravenous access. METHODS:We employed the sphygmomanometer cuff as a tourniquet for venodilation and tested it on seven participants at six different levels as follows:0 mmHg,DBP/2,DBP,(DBP+SBP)/2,SBP,and SBP+20 mmHg.We used an ultrasound probe attached to a pressure-measuring instrument to record cross-sectional images of the cubital artery and vein.During ultrasonography,compression was applied to the blood vessels through the skin.The following day,we measured the wrist pulse pressure and observed the oximeter pulse wave at six different tourniquet pressure levels.Repeated-measures analysis of variance(ANOVA)on ranks and Tukey's post-hoc analysis were used for multiple comparisons. RESULTS:Arterial pulsation was maintained at tourniquet pressures between 0 mmHg and(DBP+SBP)/2.However,arterial pulsation decreased or disappeared when the tourniquet pressure reached or exceeded the SBP.Moreover,at this pressure level,the superior compressibility of veins compared to that of arteries was no longer observed.Compression of the artery to 75%and 50%of its original diameter increased arterial pulsation. CONCLUSION:Arterial pulsation and the superior compressibility are useful indicators for differentiating veins from arteries until the tourniquet pressure reaches(DBP+SBP)/2.However,these indicators are not reliable once the tourniquet pressure exceeds the SBP.

BACKGROUND:Ultrasound guidance is commonly used for accessing difficult peripheral veins.For successful access,a tourniquet is required for venodilation.Tourniquets decrease the compressibility and increase the diameter of veins;they also obfuscate artery-vein differentiation on ultrasound.We aimed to establish the upper limit of sphygmomanometer cuff pressure that facilitates artery-vein differentiation during ultrasound-guided peripheral intravenous access. METHODS:We employed the sphygmomanometer cuff as a tourniquet for venodilation and tested it on seven participants at six different levels as follows:0 mmHg,DBP/2,DBP,(DBP+SBP)/2,SBP,and SBP+20 mmHg.We used an ultrasound probe attached to a pressure-measuring instrument to record cross-sectional images of the cubital artery and vein.During ultrasonography,compression was applied to the blood vessels through the skin.The following day,we measured the wrist pulse pressure and observed the oximeter pulse wave at six different tourniquet pressure levels.Repeated-measures analysis of variance(ANOVA)on ranks and Tukey's post-hoc analysis were used for multiple comparisons. RESULTS:Arterial pulsation was maintained at tourniquet pressures between 0 mmHg and(DBP+SBP)/2.However,arterial pulsation decreased or disappeared when the tourniquet pressure reached or exceeded the SBP.Moreover,at this pressure level,the superior compressibility of veins compared to that of arteries was no longer observed.Compression of the artery to 75%and 50%of its original diameter increased arterial pulsation. CONCLUSION:Arterial pulsation and the superior compressibility are useful indicators for differentiating veins from arteries until the tourniquet pressure reaches(DBP+SBP)/2.However,these indicators are not reliable once the tourniquet pressure exceeds the SBP.

BACKGROUND:Ultrasound guidance is commonly used for accessing difficult peripheral veins.For successful access,a tourniquet is required for venodilation.Tourniquets decrease the compressibility and increase the diameter of veins;they also obfuscate artery-vein differentiation on ultrasound.We aimed to establish the upper limit of sphygmomanometer cuff pressure that facilitates artery-vein differentiation during ultrasound-guided peripheral intravenous access. METHODS:We employed the sphygmomanometer cuff as a tourniquet for venodilation and tested it on seven participants at six different levels as follows:0 mmHg,DBP/2,DBP,(DBP+SBP)/2,SBP,and SBP+20 mmHg.We used an ultrasound probe attached to a pressure-measuring instrument to record cross-sectional images of the cubital artery and vein.During ultrasonography,compression was applied to the blood vessels through the skin.The following day,we measured the wrist pulse pressure and observed the oximeter pulse wave at six different tourniquet pressure levels.Repeated-measures analysis of variance(ANOVA)on ranks and Tukey's post-hoc analysis were used for multiple comparisons. RESULTS:Arterial pulsation was maintained at tourniquet pressures between 0 mmHg and(DBP+SBP)/2.However,arterial pulsation decreased or disappeared when the tourniquet pressure reached or exceeded the SBP.Moreover,at this pressure level,the superior compressibility of veins compared to that of arteries was no longer observed.Compression of the artery to 75%and 50%of its original diameter increased arterial pulsation. CONCLUSION:Arterial pulsation and the superior compressibility are useful indicators for differentiating veins from arteries until the tourniquet pressure reaches(DBP+SBP)/2.However,these indicators are not reliable once the tourniquet pressure exceeds the SBP.

BACKGROUND:Ultrasound guidance is commonly used for accessing difficult peripheral veins.For successful access,a tourniquet is required for venodilation.Tourniquets decrease the compressibility and increase the diameter of veins;they also obfuscate artery-vein differentiation on ultrasound.We aimed to establish the upper limit of sphygmomanometer cuff pressure that facilitates artery-vein differentiation during ultrasound-guided peripheral intravenous access. METHODS:We employed the sphygmomanometer cuff as a tourniquet for venodilation and tested it on seven participants at six different levels as follows:0 mmHg,DBP/2,DBP,(DBP+SBP)/2,SBP,and SBP+20 mmHg.We used an ultrasound probe attached to a pressure-measuring instrument to record cross-sectional images of the cubital artery and vein.During ultrasonography,compression was applied to the blood vessels through the skin.The following day,we measured the wrist pulse pressure and observed the oximeter pulse wave at six different tourniquet pressure levels.Repeated-measures analysis of variance(ANOVA)on ranks and Tukey's post-hoc analysis were used for multiple comparisons. RESULTS:Arterial pulsation was maintained at tourniquet pressures between 0 mmHg and(DBP+SBP)/2.However,arterial pulsation decreased or disappeared when the tourniquet pressure reached or exceeded the SBP.Moreover,at this pressure level,the superior compressibility of veins compared to that of arteries was no longer observed.Compression of the artery to 75%and 50%of its original diameter increased arterial pulsation. CONCLUSION:Arterial pulsation and the superior compressibility are useful indicators for differentiating veins from arteries until the tourniquet pressure reaches(DBP+SBP)/2.However,these indicators are not reliable once the tourniquet pressure exceeds the SBP.