• A 55 yrs old female was referred to us for the favor of ERC and metal biliary stenting for an advanced metastatic pancreatic cancer invading the duodenum leading to cholestatic symptoms
  • Duodenoscopy revealed large ulcerating mass in the second part of duodenum extending up to D3
  • The ampullary anatomy was completely distorted and despite several attempts selective cannulation of CBD failed
  • EUS was then performed which revealed a massively dilated CBD with a block at the lower end on color doppler and EUS guided puncture of the CBD was done
  • A guidewire was placed and sequential dilatation of the CD was carried out
  • A 4 cms completely covered metal stent was then deployed on endoscopy with the guidance of fluoroscopy

Large ulcerating mass in the second part of duodenum extending up to D3

Attempts at selective cannulation of the CBD transpapillary failed

 

 

 

 

 

 

 

 

A massively dilated CBD with a block at the lower end on color doppler

EUS GUIDED puncture of the CBD

 

 

 

 

 

 

 

 

A guidewire was placed and sequential dilatation of the CD

Fully covered metal stent passed through the duodenal bulb

 

 

 

 

 

 

 

 

A 4 cms completely covered metal stent was then deployed and free flow of bile was seen.

Fluoroscopy showed a 4 cms covered metal stent was deployed.

  • A 30 yrs old 7 months pregnant female patient was referred to us for the favour of EUS to evaluate the exact etiology of recurrent episodes of acute pancreatitis since 2012 and patient has been treated with conservative medication.
  • Patient has been in pain almost every day for the last few week requiring injectable analgesics and antispasmodic and hence after explaining all the risks of the procedure, EUS sos Endotherapy was considered once the relatives gave the informed consent.
  • EUS showed A 7.0mm stone and few concrements were seen in the Prepapillary portion of the MPD
  • MPD appeared dilated and irregular in the genu and body
  • Selective cannulation of MPD, Pancreatogram confirmed the EUS findings
  • Pancreatic sphincterotomy was performed.
  • Prepapillary Stones and concrements from the pancreatic duct was extracted with balloon catheter and complete ductal clearance was achieved.
  • A 7 fr stent was then placed in the MPD.

A 7.0mm Stones and few concrements were seen in the prepapillary portion of the MPD.

MPD appeared dilated (8 mm) in the head region with soft stones

 

 

 

 

 

 

 

 

MPD appeared dilated and irregular in the genu and body

Selective cannulation of MPD

 

 

 

 

 

 

 

 

Pancreatogram confirmed the EUS findings

Pancreatic Sphincterotomy was performed

 

 

 

 

 

 

 

 

Prepapillary Stones and concrements from the pancreatic duct was extracted with balloon catheter.

A 7 fr stent was then placed in the MPD

  • An 84 yrs old female referred to us for the favor of OGD scopy sos EUS sos Duodenal stenting for a suspected mitotic lesion in the pyloric antrum leading to gastric outlet obstruction.
  • A large ulcerostenotic lesion in the pyloric antrum extending upto the pyloric opening
  • Scope could be passed with difficulty into the duodenum.
  • Multiple biopsies were taken from the lesion for HPE.
  • EUS revealed hypoechoic lesion in the antrum which has breached the serosa.
  • Few subcentimeter nodes were seen in the peritumorous region. Minimal free fluid was also noted in the perigastric region, suggestive of peritoneal dissemination.
  • A 9 cms uncovered pyloroduodenal stent was then placed across the stricture under fluoroscopic control
  • Optimal stent deployment was confirmed both on endoscopy and fluoroscopy.

 

Take Home Message:

As we can see in this case that an advanced mitotic lesion of the antrum leading to gastric outlet obstruction who has comorbidities, nodes and ascites was an ideal indication for one stage procedure of detection, diagnosis, staging and palliation secondary to a malignant gastric adenocarcinoma. Hence with this protocol, patient avoided any further imaging or intervention. Surgical palliation can be avoided with this approach. Recently EUS guided Gastrojejunostomy has been described with a success rate of 90%. Hence, the future of luminal obstruction palliation will be the domain of Endoscopists.

A large ulcerostenotic lesion in the pyloric
antrum

Scope could be passed with difficulty into the duodenum

 

 

 

 

 

 

 

Multiple biopsies were taken from the lesion for HPE.

EUS revealed hypoechoic lesion in the antrum which has breached the serosa.

 

 

 

 

 

 

 

Minimal free fluid was also noted in the perigastric region.

Few subcentimeter nodes were seen in the peritumorous region.

 

 

 

 

 

 

 

Optimal stent deployment was confirmed on endoscopy.

Optimal stent deployment was confirmed on fluoroscopy

A 51 yrs male patient was referred to us for the favor of endoscopic evaluation, eus sos erc for suspected mass in the mid cbd region / gall bladder on other imaging studies with porta nodes and cholestatic symptoms. Patient has significant wt loss and now sr bil of 35 mg%

  • OGD scopy revealed a massively dilated esophagus with candidiasis, a very tight les
  • EUS scope passage was possible only after a 15 mm cre balloon dilatation
  • An irregular hypoechoic lesion in the region of upper cbd with few hypoechoic nodes in the porta.
  • The mass seems to have invaded the gastroduodenal artery, no evidence of any hypoechoic lesions in the left lobe of liver or nodes in the mediastinum
  • Eus guided fna was performed- cytological diagnosis was metastatic adenocarcinoma
  • Selective cannulation of cbd, cholangiogram showed bismuth type 1 stricture with communication of lt and rt ductal system
  • Biliary brushing was taken from the stricture- was inconclusive on cytology
  • A self expandable uncovered metal stent (10.0 cms) was then placed into the lt ductal system

Take Home Message:

As you can see in this patient who turned out to be advanced metastatic gall bladder cancer with multiple nodes leading to obstructive jaundice as well as secondary achalasia cardia. Now that balloon dilatation followed by EUS guided FNA from the nodal mass allowed us final tissue diagnosis of metastatic adenocarcinoma (gall bladder origin). Definitive palliation of severe cholestatic symptoms was achieved with ERCP and Metal Biliary Stenting. Surgical resection was ruled out due to metastatic disease process. Hence, any patient with suspected malignant obstructive jaundice a combination of EUS and ERCP will provide the most optimal diagnosis and effective palliation.

A massively dilated esophagus with candidiasis

Tight les seen on retroflexion

 

 

 

 

 

 

 

Balloon dilatation of les performed to facilitate eus and ercp

An irregular hypoechoic lesion in the region of upper cbd / gall bladder

 

 

 

 

 

 

 

EUS guided fna was performed

Selective cannulation of CBD

 

 

 

 

 

 

 

Cholangiogram showed bismuth type 1 stricture with communication of lt and rt ductal system

A self expandable uncovered metal stent (10.0 cms) was then placed into the lt ductal system

  • A 49 yrs female patient was sent to us for the favor of endoscopic palliation of obstructive jaundice. Patient is a known operated case of ca stomach in the past with Roux-en-y anastomosis.
  • Now patient has severe cholangitis and cholestatic symptoms hence endoscopic palliation was considered.
  • Endoscopic evaluation of the stomach showed oedematous stomach with patent g-j.
  • Scope could be passed across all the loops of roux-en-y anastomosis, but due to a very long afferent loop even enteroscopic ERC was not feasible and hence EUS guided approach was considered.
  • EUS showed extensive ascites and few liver mets and large mass and massively dilated system.
  • In view of these findings, EUS -guided Hepatico-Gastrostomy was performed.
  • EUS  showed a dilated left hepatic duct and hence EUS guided needle puncture of the Left hepatic duct was performed. The tract was sequentially dilated with cystotomes to facilitate stent placement.
  • A self expandable partially covered Giobor stent 10 cms and free flow of infected bile was seen from the stent in the stomach.

Take Home Message:

In cases where traditional ERC and biliary stenting is not feasible due to altered anatomy due to surgery or when PTC drainage too is not feasible due to ascites and liver mets, this unique technique of EUS guided Hepatico-gastrostomy allows us to decompress the obstructed biliary system and palliate cholestatic symptoms. First EUS guided Choledochoduodenostomy was performed by us was in 2001 and since then the technology and techniques have evolved.

Stomach showed edematous with patent G-J

Stomach showed edematous with patent G-J

Scope could be passed across all the loops of Roux-en-y anastomosis

Scope could be passed across all the loops of Roux-en-y anastomosis

 

 

 

 

 

 

 

EUS showed extensive ascites and few liver mets

EUS showed large mass and massively dilated system

 

 

 

 

 

 

 

EUS -guided hepatico-gastrostomy was performed

EUS -guided hepatico-gastrostomy was performed

Fluoroscopy showed dilated left hepatic duct

 

 

 

 

 

 

 

 

Left hepatic duct was punctured and sequentially dilated with cystotome

A self expandable partially covered Giobor stent 10 cms and free flow of infected bile was seen from the stent.

 

  • 43/M patient with symptoms of dyspepsia – tobacco chewer and smoker.
  • OGD Scopy revealed abnormal vascular pattern in the middle third of esophagus at 29cm from incisura. As per KUDO’s pit pattern classification it appears like IPCL – type III. Biopsy was taken from it for HPE; which is suggestive of an intraepithelial lesion – low grade squamous dysplasia.
  • EMR performed with saline adrenaline injection and snare technique.
  • Complete resection of the affected area was confirmed on post resection evaluation of the area.

Take home message:

Patient with risk factors such as tobacco consumption with dysplastic lesions in the esophagus are at very high risk of developing invasive cancers. Timely detection for intraepithelial lesions such as this case, will enable endoscopic curative resection.  Importance of magnification and electronic chromoendoscopy can be appreciated in this case.

Abnormal vascular pattern in the middle lower third of esophagus

Biopsy was taken for HPE middle lower third of esophagus

 

 

 

 

 

 

 

EMR performed with saline adrenaline injection and snare technique

Complete resection of the affected area was confirmed