ERCP is challenging in patients with gastric bypass due to altered anatomy. We report a case of symptomatic choledocholithiasis requiring temporary placement of EUS-guided hepaticogastrostomy with a fully covered metal stent and electrohydraulic lithotripsy. This is a 71-year-old female with a history of multiple abdominal surgeries, including Roux-en-Y gastric bypass with Fobi pouch, appendectomy, cholecystectomy, and adhesiolysis who presented with 4 months right upper quadrant abdominal pain and a 1 week hx of jaundice. MRCP revealed intra and extrahepatic ductal dilatation with a 1.1cm obstructing stone in a tortuous CBD. A double balloon enteroscopy assisted ERCP was considered but initial endoscopy revealed a stricture at the GJ anastomosis thought to be related to complications from the fobi pouch. Given the complex anatomy, surgery was consulted to coordinate a laparoscopic-assisted ERCP. However, due to her extensive surgical history and multiple repeated open abdominal surgeries, they strongly advocated for a non-surgical approach. Interventional radiology was then consulted for a percutaneous approach, but explained that they would require multiple procedures for percutaneous tract dilation before the point that stone extraction could be attempted. As a result, an EUS guided approach was performed via creation of a hepaticogastrostomy. The procedure was performed by puncturing a dilated radical of the left intrahepatic system with a 19G FNA needle. A 0.035mm guidewire was passed antegrade down into the tortuous bile duct. A 6mm balloon catheter was passed into the bile duct and used to dilate the tract. A 10mmx8cm fully covered metal biliary stent was placed from the gastric pouch to the intrahepatic ducts with confirmation made with cholangiogram. A pediatric gastroscope was then passed through the stent and eventually into the distal CBD where the stone was seen. Under direct visualization saline assisted electrohydraulic shockwave lithotripsy was performed to fragment the stone. The stone pieces were pushed and flushed through the ampulla. Two months later, patient underwent repeat EGD. The stent was subsequently removed without any complications and today she continues to do well. This case illustrates that lithotripsy through a temporarily placed EUS-guided hepaticogastrostomy may be safe and effective approach for altered anatomy patients who cannot undergo more traditional approaches for management of complex choledocholithiasis.Figure: MRCP Showing 10.4mm CBD Stone.Figure. CBD: Stone Before Lithotripsy.Figure. CBD: Stone After Lithotripsy.
Introduction: Differentiating pancreatic cystic neoplasms remains a challenge using the current technique of Endoscopic Ultrasound-guided fine needle aspiration (EUS-FNA). Recently, a miniaturized biopsy forceps with an outer diameter of 0.8mm has been developed. This through-the-needle forceps biopsy technique (TTNFB) has the potential to increase the diagnostic yield of EUS-FNA for pancreatic cystic neoplasms. This video demonstrates the technique of EUS guided TTNFB technique using two case examples as well as device setup. The video also summarizes findings from our single center retrospective study in pancreatic cystic lesions. Methods: The primary aim of our single center retrospective study was to evaluate the technical success and safety of EUS-guided TTNFB for pancreatic cystic lesions.This was a retrospective review over a 12-month period. Technical success=acquisition of adequate tissue for histologic analysis. Safety was assessed by post procedural adverse events. Using the Moray® forceps (US Endoscopy, Mentor, OH) through a standard 19G FNA needle, biopsy of the cyst wall or septum was performed. FNA of cyst fluid for fluid analysis was performed on each patient. When intraductal papillary mucinous neoplasms (IPMN) was suspected, mucin (MUC) staining was performed to subtype IPMN. Results: The study included 15 cystic lesions (mean size 26.6mm) in 15 patients. Technical success was 87% (13/15). There was 1 adverse event of intracystic bleeding with no clinical sequelae (6.7%). No episodes of pancreatitis. EUS-guided TTNFB with histologic analysis yielded a cyst diagnosis in 11/15 patients (73%) as compared to 0/15 (0%) using EUS-FNA and cytologic analysis (P<0.001). Of the 15 cystic lesions, 1 was a neuroendocrine tumor, 2 were serous cystadenoma, and 8 were diagnosed as IPMN based on EUS TTNFB. 7 of 8 IPMNs were able to be subtyped based on histologic analysis and MUC staining (7 gastric/1 indeterminate). Conclusion: This study demonstrates that EUS-TTN forceps biopsy of pancreatic cystic lesions appears safe and can be performed with high technical success. TTN forceps biopsy with histologic analysis demonstrated a significantly higher diagnostic yield for pancreatic cystic lesions compared to EUS-FNA and cytologic analysis. Furthermore, in this study, subtyping of IPMN was feasible. EUS-guided through the needle forceps biopsy is a novel approach that should be considered in the diagnostic algorithm for patients with pancreatic cystic lesions. Watch the video: https://goo.gl/MKzwcG.
Multiple computer-aided techniques utilizing artificial intelligence (AI) have been created to improve the detection of polyps during colonoscopy and thereby reduce the incidence of colorectal cancer. While adenoma detection rates (ADR) and polyp detection rates (PDR) are important colonoscopy quality indicators, adenoma miss rates (AMR) may better quantify missed lesions, which can ultimately lead to interval colorectal cancer. The purpose of this systematic review and meta-analysis was to determine the efficacy of computer-aided colonoscopy (CAC) with respect to AMR, ADR, and PDR in randomized controlled trials.A comprehensive, systematic literature search was performed across multiple databases in September of 2022 to identify randomized, controlled trials that compared CAC with traditional colonoscopy. Primary outcomes were AMR, ADR, and PDR.Fourteen studies totaling 10 928 patients were included in the final analysis. There was a 65% reduction in the adenoma miss rate with CAC (OR, 0.35; 95% CI, 0.25-0.49, P < 0.001, I2 = 50%). There was a 78% reduction in the sessile serrated lesion miss rate with CAC (OR, 0.22; 95% CI, 0.08-0.65, P < 0.01, I2 = 0%). There was a 52% increase in ADR in the CAC group compared with the control group (OR, 1.52; 95% CI, 1.39-1.67, P = 0.04, I2 = 47%). There was 93% increase in the number of adenomas > 10 mm detected per colonoscopy with CAC (OR 1.93; 95% CI, 1.18-3.16, P < 0.01, I2 = 0%).The results of the present study demonstrate the promise of CAC in improving AMR, ADR, PDR across a spectrum of size and morphological lesion characteristics.
The oral contraceptive pill (OCP) is a widely used method of contraception. There have been conflicting studies linking the use of OCPs to the development of inflammatory bowel disease (IBD). The intent of this meta-analysis is to better define the association between OCP exposure and the risk for development of IBD.A thorough search of multiple databases, including Scopus, Cochrane, MEDLINE/PubMed, and CINAHL, and abstracts from major gastroenterology meetings was performed (October, 2016). Studies reporting the development of IBD in patients with or without previous exposure to OCP, compared with healthy controls, were included. A meta-analysis was completed using the Mantel-Haenszel model to evaluate the risk of developing IBD in the setting of previous OCP exposure.In a complete analysis of 20 studies, there appeared to be over a 30% increased risk for the development of IBD in patients exposed to OCP compared with patients not exposed to OCP [odds ratio (OR): 1.32, 95% confidence interval (CI): 1.17-1.49, P<0.001, I=14%]. More specifically, there was a 24% higher risk for developing Crohn's disease (OR: 1.24, 95% CI: 1.09-1.40, P<0.001; I=38%) and a 30% higher risk for developing ulcerative colitis (OR: 1.30, 95% CI: 1.13-1.49, I=26%) in patients exposed to OCP compared with those not exposed to the medication.The use of OCP is associated with an increased risk for development of Crohn's disease and ulcerative colitis in the genetically susceptible host. The total duration, dose of OCP exposure, and the risk for development of IBD need to be better characterized.
