STAGED HEPATICOGASTROSTOMY AND RETROPERITONEOSCOPY TO RECONNECT A TRANSECTED BILE DUCT (TBD)

Background:
Two main reasons for a failed EUS- guided hepaticogastrostomy (EUS-HG) are, inability to access the bile ducts due to non-dilated intrahepatic ducts (IHD), and failure of tract dilation due to cirrhosis/ductal scarring or stent passage from misaligned vector forces. We present 5 cases that failed traditional EUS-HG, treated with EUS-rendezvous-HG.
RESULTS: 5 non-surgical patients, median age 52, (3 M) who failed conventional EUS-HG were treated successfully using 3 techniques. There were no adverse events over a median follow up of 28 months. (Tables 1 and 2)
Technique 1: EUS to IR balloon rendezvous. N=3.
Case 1: A 53 year old female with multiple surgeries and a Whipple procedure, presented with cholangitis and leakage around 2 long standing percutaneous biliary drains (PTBD) due to an afferent limb syndrome. EUS-HG into segment 2 failed to resolve the leak around the PTBD (in segment 3) not easily identifiable at EUS despite contrast injection. However, inflating an IR balloon allowed successful access and creation of an EUS-rendezvous-HG.
Technique 2: IR to IR rendezvous followed by endo-IR rendezvous. N=1.
Case 2: A 55 year old male with multiple comorbidities, prior Whipple procedure and R hepatectomy developed a perihepatic abscess from chronic dehiscence of his hepatico-jejunostomy. Having failed every other attempt to close this leak, an attempt was made for EUS-HG to divert bile from the leak site. Conventional EUS-HG failed due to non-dilated ducts as did an attempt to inflate an IR balloon. So, he underwent an IR to IR rendezvous. A peripheral branch of the L IHD closest to the gastric wall was accessed via the drain, dilated with a 4mm balloon, allowing opening of a loop snare. A transhepatic percutaneous needle puncture of this L IHD was then performed through the loop snare with subsequent puncture of the gastric lumen allowing placement of a guidewire and a successful rendezvous-HG.
Technique 3: EUS to Endo rendezvous. N=1.
Case 3: A 36 year old male with prior severe pancreatitis, benign biliary stricture, gastric outlet, and cirrhosis, had undergone a surgical gastrojejunostomy and hepaticoduodenostomy. He presented with recurrent cholangitis from food occluding his bile duct at the hepaticoduodenostomy (just proximal to the duodenal stricture). He had failed double pigtail biliary stents to keep the food out. So, he was taken for an EUS-HG to provide a more proximal diversion of his biliary tree. Although the L IHD was successfully punctured and a guidewire passed downstream, dilation of the tract failed due to dense scarring. However, after a successful rendezvous with the guidewire, we were able to create an EUS Rendezvous-HG in a retrograde fashion.
Conclusion:
When conventional EUS-HG fails, an EUS-rendezvous-HG with IR or oneself could successfully allow internal drainage rather than a long term PTBD.

Bouveret syndrome is a rare complication of cholelithiasis in which gallstone ileus occurs secondary to an acquired cholecysto-enteric fistula. The gallstone may migrate through the fistula and enter the gastrointestinal tract, causing gastric outlet obstruction. Given the rarity of the condition, there are no standardized treatment guidelines for the management of Bouveret syndrome.

We report a case of a 77-year-old male who presented to the emergency department with a 5-day history of gradual onset epigastric pain associated with nausea and vomiting after meals. His laboratory evaluation was significant for leukocytosis without left shift. Liver biochemistries were normal. Abdominal computed tomography (CT) demonstrated a large approximately 5cm calculus impacted in the proximal duodenum with marked gastric distention. The imaging findings confirmed the presence of a cholecysto-duodenal fistula with associated gastric outlet obstruction.

After multidisciplinary discussions involving surgical colleagues and considering patient preference, we proceeded with endoscopic management. During the endoscopy procedure, a large calculus was found wedged in the duodenal bulb immediately distal to the pylorus with near-total obstruction of the duodenal lumen. Extensive electrohydraulic lithotripsy was performed with delivery of over 15,500 pulses over the course of two prolonged procedures, yielding minimal fragmentation of the large stone. The decision was then made to utilize the submucosal dissection knife with electrosurgical energy. In a cautious and systematic method, stone fragmentation was performed by grasping the stone with the knife tip and delivering electrosurgical energy while retracting the knife into a distal attachment fitted onto our endoscope. Great care was undertaken to avoid mucosal contact and resultant bleeding. This approach yielded large stone fragments which were grasped and withdrawn into the stomach using a retrieval net and large-caliber snare.

After stone fragmentation and removal, a large cholesysto-duodenal fistula was identified with additional multiple large, pigmented stones visualized within the remaining gallbladder body. These stones were able to be retrieved into the stomach with a snare. Next, a 7Fr x 12cm double pigtail plastic stent was advanced antegrade into the duodenal lumen where it was deployed successfully. The proximal pigtail was placed within the gallbladder.

Our patient did well following the final procedure with minimal pain. He was subsequently reviewed by the surgical service and underwent laparoscopic cholecystectomy and fistula closure. Our case demonstrates that Bouveret’s syndrome, in particular gallstone fragmentation, was successfully managed utilizing a submucosal dissection knife with electrosurgical energy.Further evaluation is necessary before this approach can be widely accepted.

A 53 year old patient was referred because of a 3.5 cm obstructing submucosal esophageal tumor at the level of the aortic arch. The tumor was partially calcified. An interdisciplinary decision on an attempt of endoscopic removal using the SET submucosal endoscopic tunneling technique was made. The intervention was carried out with bi-hilar ventilation in the thoraco-surgical OR. The tumor originated form the circular muscular layer and could be enucleated using a 1.5 mm ESD flushknife. When an attempt of endoscopic removal via the enterance tract in the cervical esophagus was made the tumor proved to big to enter through the incision and upper esophageal sphincter. As the patient had an esophageal hernia a second caudal tunnel was created form the tumor bed and a second incision at the level of the preacardial esophagus was created. The tumor could then be pushed through the incision and via the hernia to the gastric lumen. The lesion was then cut into six pieces with a snare and removed from the stomach using a Roth net. Histology showed a calcified leiomyoma without maligancy. Both tunnel enterances were closed by standard and OTSC macro clips and two vacuum sponges were placed in to the esophageal lumen to reduce the local infection risk. The further course was uneventful. Sponges and clip matrial was removed and a control after three month is shown with a smooth esophagus. Only a discrete retraction of the mucosa at the level of the distal mucosal incision was found.
Conclusion: The double tunnel technique may be a helpful new strategy for retrieval of submucosal esophageal tumors to big to be removed via the cervical esophageal sphincter during a SET procedure.

Introduction
Pregnancy is associated with increased tendency to form biliary sludge and stones due to effect of estrogen and progesterone. Upto a third of pregnant women develop biliary sludge and about 12%, gallstones. These usually spontaneously resolve after pregnancy. About 1 in 1200 may develop symptomatic choledocholithiasis during pregnancy, necessitating biliary drainage. However, there are major concerns regarding fetal exposure to radiation. Lead shields, beam collimation and limited fluoroscopy use minimises exposure, still the fetus remains at risk of harm. Fluoroscopy free biliary drainage may be attempted, but has its own limitations. There is thus a need for better therapeutic options for biliary drainage during pregnancy.

Case details
We here report a case of a 31 year old primigravida who presented with moderate cholangitis due to biliary obstruction of unclear etiology. Diagnostic echoendoscopy revealed choledocholithiasis. Luminal endoscopic view of the echoendoscope showed a bulky papilla with orifice at an angle convenient for cannulation. We performed a biliary cannulation in the same setting with the echoendoscope, confirmed biliary placement of sphincterotome on endosonographic view at the same station, and placed a biliary stent. We then confirmed the proper placement of biliary stent crossing the obstructive calculi on the endosonographic view. The entire procedure (diagnosis of etiology, biliary drainage, and confirmation of proper stent placement) was completed in a single setting with the echoendoscope, without the use of fluoroscopy.

The patient had rapid resolution of symptoms, and continued the remained of her pregnancy uneventfully. She delivered a healthy child. Three months later, she returned for bile duct clearance. Cholangiogram showed large calculi in lower and mid common bile duct, which were not amenable to balloon extraction and could not be captured in a mechanical lithotripsy basket. She is now planned for laser lithotripsy.

Conclusion
Biliary drainage during pregnancy can be a difficult prospect. An echoendoscope can potentially facilitate same-session diagnostic and therapeutic transpapillary biliary drainage, avoiding fluoroscopy use. However, this may be applicable only when papillary morphology is conducive, and operator is aware of the technical challenges. In this video, we demonstrate the potential for a fluoroscopy-free single session diagnostic and therapeutic echoendoscopy for transpapillary biliary drainage in pregnancy.

Background

Ampullary adenomas have malignant potential and resection should be considered. Endoscopic papillectomy has gained popularity over surgery due to lower periprocedural risks. Conventional EP carries risk of incomplete resection with local recurrence rate up to 33%. Therefore we are in need of a better endoscopic resection method. Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal epithelial tumors had been proven to be safe with high curative resection rate, and can be applied to ampullary lesions.

Case Presentation

48 years old lady, who had history of hemorrhoidectomy in 2019, had chronic epigastric discomfort. Upper endoscopy found prominent papilla and biopsy confirmed adenoma with low grade dysplasia. She was referred to us for further management.
Upper endoscopy was repeated in our center showed 2cm pale sessile lesion at papilla. Magnifying NBI reveals the presence of demarcation line and there is regular white opaque substances over the entire lesion. Features are compatible with bx proven adenoma. EUS showed no intraductal extension. Therefore, endoscopic resection was decided after discussion with patient

Endoscopic Methods

A therapeutic upper GI endoscope with a transparent hood was used. We begin with submucosal injection with mixture of saline and indigo carmine. Mucosal incision was first started at distal part of the lesion with a water jet needle type endoscopic knife, then extended circumferentially. Submucosal dissection was performed and biliary pancreatic orifice was observed. Lesion was retrieved per oral. Integrity of muscle layer was checked and haemostasis was achieved with monopolar haemostatic forceps. Mucosal defect was partially closed with endoclips.
We then changed to a side-view endoscope. Pancreatic duct was cannulated with wire-guided sphincterotome and pancreatic stent was inserted. Rectal indomethacin was administered.
Patient recovered well after procedure. Pathology was pyloric gland adenoma (PGA) and resection margins were clear.

Clinical Implication

En-bloc resection of ampullary adenoma by ESD is technically feasible and safe. ESD can be applied to large size lesion or laterally-spreading adenoma with extra-papillary extension and has the potential advantage of higher complete resection rate.
Sporadic PGA at duodenal major papilla is extremely rare. The endoscopic appearance of PGA remains elusive and can mimic as tubovillous adenoma.

Conclusion

En-bloc resection of ampullary adenoma could be achieved with ESD in a safe manner, and ESD should be considered as a viable alternative to the conventional endoscopic papillectomy.

Conflicts of interest: none.

Background
Endoscopic Ultrasound (EUS)-directed Trans-Enteric Endoscopic Retrograde Cholangiopancreatography (EDEE) is one emerging alternative for biliary interventions in patients with Roux-en-Y hepaticojejunostomy (RY-HJ).

Case presentation
A 80-year-old women, with a former surgical RY-HJ for complex choledocholithiasis (2004) was admitted for cholangitis. Magnetic Resonance showed a 40mm stone above the biliodigestive anastomosis. After discussion of alternatives, EDEE was proposed.

Endoscopic Methods
Under EUS guidance, the “biliary” loop was punctured with a 19g needle through the stomach, and distended with contrast medium; an over-the-wire 15x10mm electrocautery-enhanced Lumen Apposing Metal Stent (LAMS) was released and dilated to 15mm.
After introducing a therapeutic gastroscope, the distal flange of the LAMS was misdeployed in the peritoneal cavity, with the jejunal loop with a large enterotomy clearly visible through the LAMS. The enterotomy was intubated with the gastroscope and a new over-the-wire 20x10mm LAMS-in-LAMS was placed under endoscopic vision and dilated to 12mm. Contrast injection showed no leak and the patient remained asymptomatic under prophylactic antibiotics.
48 hours later a gastroscope was easily passed through the LAMS and directed towards the biliodigestive anastomosis. The giant stone was managed by electrohydraulic lithotripsy, with fragments extracted by basket and balloon swipes, saline injection and suction.
Final cholangiography confirmed complete biliary clearance.
A second procedure was required for recurrent stones after 5 months.

Conclusions
EDEE represents an effective alternative for repeated biliary interventions in RY-HJ.
LAMS misdeployment is a serious complication, but a larger LAMS-in-LAMS rescue might allow to uneventfully complete the anastomosis and perform through-the-LAMS therapeutics.

Obesity is a public health issue for most countries worldwide. Bariatric surgery remains the most effective and durable therapy in terms of weight loss and metabolic control. The number of surgical procedures has increased exponentially, and Roux-en-Y gastric bypass (RYGB) is still considered the gold standard procedure. Although low, leaks may occur in about 0.5 to 1.5% of patients, and a multidisciplinary treatment including endoscopic intervention is key to success. Endoscopic techniques including closure, cover, and internal drainage are among the available options for the management of post-bariatric surgical leaks. Selecting the best endoscopic approach depends on several factors, and this video discusses the endoscopic options to manage post-RYGB leaks, including advantages, disadvantages, and mechanism of action for each technique.
Case Description
A 50-year-old man with class II obesity underwent revisional laparoscopic RYGB with resection of the excluded stomach, ring removal, resizing of the gastric pouch and gastrojejunal anastomosis (GJA). On the 8th postoperative day, he presented with abdominal pain and a computed tomography (CT) scan demonstrated a leak at the GJA associated with a contained collection.
An esophagogastroduodenoscopy (EGD) was performed and diagnosed a dehiscence of the GJA associated with an infected collection. We performed endoscopic internal drainage with two pigtail stents (EID-PS) and an intraluminal modified endoscopic vacuum therapy (EVT) manufactured in a double lumen tube allowing drainage (“bridge therapy”) and nutrition with one tube.
Six days later, after clinical improvement, EGD revealed a second leak at the pouch staple line, connected to the collection previous drained with the PS. There were no more signs of infection, and formation of granulation tissue was observed. Additionally, a large remnant gastric pouch wall like a septum was identified between the two leaks orifices. Therefore, a septotomy was performed and an intraluminal modified EVT manufactured in a double lumen tube was kept in place.
Patient had no symptoms and after 1 week, EGD showed an exuberant granulation tissue, without signs of infection, allowing removal of the EVT. Two days later, he was discharged from the hospital without any symptoms and remains in good clinical condition after 3-month follow-up.
Conclusion
knowledge of the mechanism of action of each endoscopic therapy is key to success for post-RYGB leaks. As drainage is a basic principle for the management of intraperitoneal collections, endoscopic draining techniques should be the preferred option for post-surgical leaks with associate collections.

Introduction
Bile duct transection is a dreaded AE of cholecystectomy. Standard management involves surgical repair, often with interval external biliary drainage. Extraluminal percutaneous rendezvous (Schreuder; PMID:29351705) or interventional EUS-based approaches (De-Benito-Sanz; PMID:34816304) can reconnect TBDs, but technical success is unpredictable and long-term repair uncertain.

Case presentation
A 32 year-old woman presented a high output (>800cc/day) bile leak on postoperative day 1 after laparoscopic cholecystectomy. She underwent emergent laparotomy with Jackson-Pratt drain placement. At ERCP a complete bile duct cut-off was noted with massive contrast extravasation into a right subhepatic biloma.

Endoscopic methods
No retrograde guidewire passage or contrast filling proximal to the TBD was possible at ERCP. EUS-guided hepaticogastrostomy (HGS) to liver segment III was performed using an anti-migration covered biliary metal stent. Bile output dropped to <100cc/day in 24h and gradually dried out. Two weeks later, the intrahepatic bile duct was accessed through the hepatogastric fistula with a duodenoscope under fluoroscopy. A guidewire was coiled into the biloma from the left intrahepatic duct. The duodenoscope was removed leaving the wire in place, and reintroduced alongside it to the papilla. A Spyglass™ cholangioscope was then passed through the papilla from the distal TBD into the biloma. The antegrade wire coiling within the biloma was grasped with a forceps passed through the cholangioscope, pulled out into the duodenum, and retrieved up the scope working channel. Following antegrade-retrograde TBD recanalization, parallel wire was placed into the biloma for double pig-tail stenting. A 10 Fr plastic biliary stent was placed across the TBD into the left hepatic duct. Ongoing residual (5-10cc/day) leakage ceased. The Jackson-Pratt drain was removed. Outpatient ERCP 4 weeks later showed a reconnected bile duct with a stricture and no leakage. The pig-tail and plastic biliary stents were removed. Bilateral stenting across the former TBD site with a right 8.5F-12cm plastic and a left 6x100mm covered metal stent was performed. The HGS stent was removed. Four months later, ERCP revealed a completely remodeled bile-duct. Prior bilateral stents were exchanged for a single 10-mm covered metal stent to consolidate duct repair, with scheduled definitive removal in 6 months.

Conclusions
HGS appears feasible in TBDs with intrahepatic biliary dilatation and convenient for acute leakage control. Staged antegrade access through mature HGS combined with retroperitoneoscopy can reliably facilitate TBD recanalization. Prompt aggressive TBD splinting with covered metal stents may favor effective remodeling. The impact on patient morbidity and mortality of this novel EUS-based approach could be significant. Long-term outcomes warrant further scrutiny.