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Endoscopic Ultrasonography-Guided Anastomosis, Drainage of Abdominopelvic Fluid Collections, and Vascular Interventions
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330
e use of the linear array echoendoscope has expanded the realm
of therapeutic interventions to include drainage of obstructive
biliary ductal system, peripancreatic uid collections and pelvic
abscesses, placement of coils or injection of sclerotic agents in vari-
ces, and more recently the creation of an anastomosis between the
stomach and small bowel for palliation of gastric outlet obstruc-
tion (GOO). In this chapter, the technique and outcomes of
endoscopic EUS-guided anastomosis, drainage of abdominal uid
collections and pelvic abscesses, and its role in the obliteration of
gastric varices are reviewed.
Endoscopic Ultrasonography-Guided
Anastomosis
Options for the treatment of GOO include open or laparoscopic
gastrojejunostomy and the endoscopic placement of self-expanding
metal stents (SEMS) across the luminal obstruction. Recently there
have been reports of successful creation of gastroenteric anastomo-
ses performed under endosonographic guidance.
1–3
e procedure
has the potential to oer long-lasting luminal patency without the
risk of stent obstruction by tumor ingrowth, and it also avoids the
morbidity of a surgical procedure.
Procedural Technique
EUS-guided gastroenterostomy (EUS-GE) can be performed by
adopting one of three techniques: direct EUS-GE, assisted EUS
GE, and EUS-guided balloon-occluded gastrojejunostomy bypass
(EPASS).
Direct Endoscopic Ultrasonography-Guided
Gastroenterostomy Technique
1. A 19-G needle is inserted transgastrically into the small-bowel
loop to distend the duodenum and jejunum by infusing saline
under EUS visualization.
2. An enterogram is then obtained by injecting a radiocontrast
agent and a 0.025/0.035-inch guidewire is passed through the
19-G needle into the small bowel.
3. e GE tract is dilated using a 40 mm long and 4 mm wide
over-the-wire dilating balloon followed by the placement of
a 15- by 10-mm lumen-apposing metal stent (LAMS) (Fig.
26.1A–F; Video 26.1). It may sometimes be necessary to create
a tract using a needle-knife catheter prior to performing bal-
loon dilation. Alternatively, the electrocautery-enhanced deliv-
ery system can be used to puncture the small bowel directly for
LAMS deployment.
4. e lumen of the LAMS may be dilated, if required, using a
radial expansion balloon to create a wider opening.
26
Endoscopic Ultrasonography-Guided
Anastomosis, Drainage of Abdominopelvic
Fluid Collections, and Vascular
Interventions
TAKAO ITOI AND SHYAM VARADARAJULU
KEY POINTS
• An anastomosis can be established between the stomach
and the jejunum under the guidance of endoscopic ultraso-
nography (EUS) in patients with gastric outlet obstruction. A
lumen-apposing metal stent (LAMS) can either be deployed
directly or with balloon assistance using uoroscopic and
sonographic guidance. Although experience is limited, the
preliminary data appear promising.
• EUS facilitates transmural drainage of postoperative ab-
dominal and pelvic uid collections adjacent to the stomach,
duodenum, rectum, or colonic lumen and within the reach of
an echoendoscope. Both procedures are safe, with a treat-
ment success rate greater than 90%. Adverse events are mild
and can be managed conservatively in most patients.
• Essentials for such procedures include a uoroscopy unit,
therapeutic echoendoscope, accessories such as 19-G needles,
endoscopic retrograde cholangiopancreatography cannula
or needle-knife catheters, guidewires, balloon dilators, LAMS,
double-pigtail plastic stents, and biliary drainage catheters.
• EUS-guided hemostasis in gastric varices can be attained
with coil embolization and/or glue injection. The technique
appears to be clinically eective, with promising treatment
outcomes.
331
CHAPTER 26 EUS-Guided Anastomosis, Drainage of Abdominopelvic Fluid Collections, and Vascular Interventions
A
C
EF
D
B
• Fig. . Placement of lumen-apposing stent during endoscopic ultrasonography-guided gastrojeju-
nostomy. (A) Endoscopic image of fistula tract dilation by using a 4-mm balloon. (B) Endoscopic image
of the proximal end of the stent deployed in the stomach. (C) Endoscopic image of balloon dilation of the
stent. (D) Fluoroscopic image of balloon dilation of the stent. (E) Coronal computed tomography image
demonstrating contrast material flowing through the stent into the distal small bowel. (F) Image from a
small-bowel series demonstrating contrast material flowing through the stent into the distal small bowel.
(Courtesy of Dr. Mouen Khashab.)
332
SECTION VI Endoscopic Ultrasonography-Guided Tissue Acquisition
Assisted Endoscopic Ultrasonography-Guided
Gastroenterostomy Technique
e assisted EUS-GE technique involves the passage of a retrieval/
dilating balloon or ultraslim endoscope across the stricture to the
duodenal-jejunal exure to assist in the placement of a LAMS.
4,5
e balloon serves as an anatomic marker for the creation of the
anastomosis (Video 26.2).
1. e retrieval or dilating balloon catheter is passed over a guide-
wire into the small bowel and then inated with uid (water
mixed with contrast) while it is being positioned in the duode-
num or jejunum.
2. e echoendoscope is then passed alongside the balloon cath-
eter into the stomach and the uid-lled balloon is localized by
sonography.
3. e balloon is punctured using a 19-G needle. Bursting of the
balloon indicates correct positioning of the needle tip within
the small-bowel lumen.
4. A guidewire is advanced through the needle and a LAMS
is subsequently deployed. It may be necessary to dilate the
transmural tract if a nonelectrocautery-based LAMS is being
deployed.
When an ultraslim endoscope-assisted EUS-GE is performed,
the small-caliber endoscope is passed perorally or through an
existing gastrostomy site into the stomach and then beyond the
stricture. Saline is injected through the ultraslim scope to distend
the bowel lumen. e echoendoscope is then advanced into the
stomach (alongside the ultraslim scope in cases where the ultraslim
scope is introduced perorally). A guidewire is advanced through
the needle and coiled within the bowel lumen. A biopsy forceps
is then passed through the ultraslim scope to grasp the guidewire,
thus providing traction in an internal rendezvous maneuver. A
stulous tract is then created for LAMS deployment. ere are
reports of using a nasobiliary catheter for saline and contrast injec-
tion into the duodenum-jejunum so as to facilitate uoroscopic
and sonographic visualization.
3
Endoscopic Ultrasonography-Guided Balloon-Occluded
Gastrojejunostomy Bypass Technique
1. A standard upper endoscope is advanced to the third portion
of the duodenum and a guidewire is advanced as far as possible
into the jejunum (Fig. 26.2A and B; Video 26.3).
2. e endoscope is removed, leaving the guidewire in place. An
overtube is helpful to facilitate passage of the preinated bal-
loon catheter to avoid looping in the fornix of the stomach as
it passes through the pyloric-duodenal stenosis.
3. A double-balloon tube (Tokyo Medical University type, Create
Medic Co., Ltd., Yokohama, Japan) is inserted perorally over
the guidewire and the two balloons are placed in the duode-
num and jejunum in an area adjacent to the stomach.
4. Both balloons are lled with saline and contrast material to
anchor the small intestine in place. A sucient quantity
of saline with contrast material is introduced into the space
between the two balloons to distend the small bowel lumen.
5. An echoendoscope is advanced to the stomach to identify the
distended duodenum or jejunum.
6. EUS-guided balloon-occluded gastrojejunostomy bypass
(EPASS) can then be undertaken by one of two techniques,
namely the “free style” or “standard” technique. e former is
performed using a direct electrocautery-enhanced tip delivery
system insertion without needle puncture, whereas the latter
involves placement of the LAMS over a guidewire, as described
previously.
Technical and Treatment Outcomes
ree case series have reported an overall technical success rate
of approximately 90% regardless of the technique adopted (Table
26.1). In the EPASS procedure, the success rate of the free-
style technique was higher than that of the standard technique
(100% vs. 82%).
2
Treatment success was observed in almost all
cases where the LAMS was successfully placed. Although there
was no mortality, adverse events such as peritonitis or bleeding
were encountered in several patients, although none were life-
threatening. One failed case of balloon-assisted EUS-GE required
conversion to a laparoscopic gastrojejunostomy. In two cases of
stent maldeployment using the EPASS procedure, both patients
responded well to conservative treatment measures.
Technical Limitations
Limitations of the EUS-guided gastroenteric anastomosis include
the following: (1) If the most proximal enteric lumen is located
farther from stomach, EUS-guided anastomosis may not be
appropriate unless alternate lumen-apposing devices such as
T-tags are used and (2) the procedure cannot be performed safely
when LAMS are not available due to the lack of adhesion between
the stomach and the enteric tract.
Endoscopic Ultrasonography-Guided
Drainage of Abdominopelvic Fluid
Collections
Abdominal and/or pelvic abscesses can occur postoperatively after
pancreatic, liver, and bariatric surgery or in patients with medical
conditions such as Crohn disease, diverticulitis, ischemic colitis,
sexually transmitted diseases, or septic emboli from endocarditis.
Management of postoperative uid collections (POFCs) and pel-
vic abscesses can be technically challenging due to the need for
navigation around multiple vital organs, including the bony pel-
vis, bowel loops, bladder, reproductive organs in females, prostrate
in men, rectum, and other neurovascular structures. Undrained
POFCs have a high morbidity and mortality. Historically these
collections have necessitated surgery, ultrasound-guided transrec-
tal or transvaginal intervention, or were drained percutaneously
under computed tomography (CT) guidance. Recent advances in
the eld of interventional EUS have opened a new avenue for the
management of POFCs
4–10
and pelvic abscesses.
11–18
Procedural Technique
In cases of abdominopelvic abscess drainage, all patients should
undergo dedicated CT or magnetic resonance imaging (MRI) of
the abdomen and pelvis to dene the anatomy and location of
the uid collection/abscess. If the POFC/pelvic abscess is mul-
tiloculated, measures less than 4 cm in size, has immature walls
(without a denitive rim), is located at the level of the dentate line
or greater than 2 cm from the EUS transducer, it should be man-
aged by alternative techniques. Commonly it is recommended
that patients be administered prophylactic antibiotics prior to the
procedure. In case of POFC drainage, the overall procedural tech-
nique is similar to that of conventional EUS-guided drainage of
peripancreatic uid collections. In cases of pelvic abscess drain-
age, patients should undergo local preparation with an enema to
optimize visualization and minimize contamination. Laboratory
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