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A novel technique for endoscopic ultrasound-guided biliary drainage

World Journal of Gastroenterology 2013年第29期19卷 4758-4763页

作者： Varayu Prachayakul pitulak aswakul Division of Gastroenterology Department of Internal Medicine Faculty of Medicine Siriraj Hospital Mahidol University Bangkok 10700 Thailand Liver and Digestive Institute Samitivej Sukhumvit Hospital Bangkok 10110 Thailand

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates. METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients' baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient's overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student's t -test and the χ 2 test were used to assess the significance of inter-group differences. RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The

关键词： Endoscopic ultrasound Biliary drainage Hepaticogastrostomy Choledochoduodenostomy Endoscopic ultrasound-guided

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Feasibility and safety of using Soehendra stent retriever as a new technique for biliary access in endoscopic ultrasoundguided biliary drainage

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World Journal of Gastroenterology 2015年第9期21卷 2725-2730页

作者： Varayu Prachayakul pitulak aswakul Siriraj GI Endoscopy Center Division of GastroenterologyDepartment of Internal MedicineFaculty of MedicineSiriraj HospitalMahidol UniversityBangkok 10700Thailand Liver and Digestive Institute Samitivej Sukhumvit HospitalWattana Bangkok 10120Thailand

AIM:To assess the feasibility and safety of the use of soehendra stent retriever as a new technique for biliary access in endoscopic ultrasound-guided biliary ***:The medical records and endoscopic reports of the patients who underwent endoscopic ultrasound-guided biliary drainage(EUS-BD) owing to failed endoscopic retrograde cholangiopancreatography in our institute between June 2011 and January 2014 were collected and *** the procedures were performed in the endoscopic suite under intravenous sedation with propofol and full anaesthetic *** we used the Soehendra stent retriever as new equipment for neo-tract creation and dilation when performing EUS-BD *** patients were observed in the recovery room for 1-2 h and transferred to the regular ward,patients' clinical data were reviewed and analysed,clinical outcomes were defined by using several different *** were analysed by using SPSS 13 and presented as percentages,means,and ***:A total of 12 patients were *** most common indications for EUS-BD in this series were failed common bile duct cannulation,duodenal obstruction,failed selective intrahepatic duct cannulation,and surgical altered anatomy for 50%,25%,16.7%,and 8.3%,*** patients underwent EUS-guided hepaticogastrostomy(58.3%),and 5 underwent EUS-guided choledochoduodenostomy(41.7%).The technical success rate was 100%,while the clinical success rate was 91.7%.Major and minor complications occurred in 16.6% and 33.3% of patients,respectively,but there were no procedurerelated ***:Soehendra stent retriever could be used as an alternative instrument for biliary access in endoscopic ultrasound guided biliary drainage.

关键词： Soehendra stent retriever Endoscopic ultrasound-gu

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Endoscopic ultrasound-guided biliary drainage:Bilateral systems drainage via left duct approach

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World Journal of Gastroenterology 2015年第34期21卷 10045-10048页

作者： Varayu Prachayakul pitulak aswakul Siriraj GI Endoscopy Center Division of GastroenterologyDepartment of Internal MedicineSiriraj HospitalMahidol University Liver and Digestive Institute Samitivej Sukhumvit Hospital

Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed,thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage,both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently,only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma,and thus can be used as an alternative to percutaneous biliary drainage.

关键词： Biliary drainage Endoscopic ultrasound-guided Bila

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Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention

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World Journal of Clinical Cases 2014年第10期2卷 522-527页

作者： Varayu Prachayakul pitulak aswakul Siriraj GI Endoscopy Center Division of Gastroenterology Department of Internal Medicine Siriraj Hospital Faculty of Medicine Mahidol University Liver and Digestive Institute Samitivej-Sukhumvit Hospital

Endoscopic retrograde cholangiopancreatography(ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation re-sults in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.

关键词： Endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography Perforation Prevention Management Classification

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Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

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World Journal of Clinical Cases 2016年第4期4卷 112-117页

作者： Arunchai Chang pitulak aswakul Varayu Prachayakul Siriraj Gastrointestinal Endoscopy Center Division of Gastroenterology Department of Internal Medicine Siriraj Hospital Faculty of Medicine Mahidol University Liver and Digestive Institute Samitivej Sukhumvit Hospital

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type *** of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches,ranging from pharmacologic,endoscopic and radiologic treatments to surgical *** the conservative treatment approaches fail to resolve symptomatic cases,however,endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach,despite its well-recognized *** the conventional transpapillary approach fails to achieve the necessary drainage,the patients may benefit from application of the less invasive endoscopic ultrasound(EUS)-guided pancreatic duct ***,we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 *** tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at *** conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms,EUS-guided pancreaticogastrostomy(PGS)was applied using a fully covered,self-expandable,10-mm diameter metallic *** treatment resolved the case and the patient experienced no adverse ***-guided PGS with a regular biliary fully covered,self-expandable metallic stent effectively and safely treated pancreatictype pain in chronic pancreatitis.

关键词： Endoscopic ultrasound-guided Endoscopic ultrasound Pancreaticogastrostomy Pancreatic duct drainage Chronic pancreatitis Self-expandable metallic stent

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Factors influencing clinical outcomes of Histoacryl~ glue injection-treated gastric variceal hemorrhage

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World Journal of Gastroenterology 2013年第15期19卷 2379-2387页

作者： Varayu Prachayakul pitulak aswakul Tanyaporn Chantarojanasiri Somchai Leelakusolvong Division of Gastroenterology Department of Internal MedicineFaculty of MedicineMahidol UniversitySiriraj HospitaBangkok 10700Thailand Division of Gastroenterology Department of Internal MedicineFaculty of MedicineMahidol UniversitySiriraj HospitalBangkok 10700Thailand Liver and Digestive Institute Samitivej Sukhumvit HospitalBangkok 10700Thailand

AIM: To determine the factors associated with clinical outcomes and complications of Histoacryl glue injection for acute gastric variceal hemorrhage. METHODS: Patients who presented to the Siriraj Gastrointestinal Endoscopy Center with active gastric variceal bleeding and were admitted for treatment between April 2008 and October 2011 were selected retrospectively for study inclusion. All bleeding varices were treated by injection of Histoacryl tissue glue (B. Braun Melsungen AG, Germany) through a 21G or 23G catheter primed with lipiodol to prevent premature glue solidification. Data recorded for each patient included demographic and clinical characteristics, endoscopic findings, clinical outcomes in terms of early and late re-bleeding, mortality, and procedure-related complications. Data from admission (baseline) and posttreatment were comparatively analyzed using stepwise logistic regression analysis to determine the correlation between factors and clinical ***: A total of 90 patients underwent Histoacryl injection to treat bleeding gastric varices. The mean age was 55.9 ± 13.9 (range: 15-88) years old, and 74.4% of the patients were male. The most common presentations were hematemesis (71.1%), melena (12.2%), and coffee ground emesis (8.9%). Initial hemostasis was experienced in 97.8% of patients, while re-bleeding within 120 h occurred in 10.0%. The presence of ascites was the only factor associated with early and late re-bleeding [odds ratio (OR)=10.67, 95%CI: 1.27-89.52, P=0.03 and OR=4.15, 95%CI: 1.34-12.86, P=0.01, respectively]. Early procedure-related complications developed in 14.4% of patients, and were primarily infections and non-fatal systemic embolization. Late re-bleeding was significantly correlated with early procedure-related complications by univariate analysis (OR=4.01, 95%CI: 1.25-12.87, P=0.04), but no factors were significantly correlated by multivariate analysis. The overall mortality rate was 21.1%, the majority of which w

关键词： Histoacryl Gastric varices Clinical outcome Complications Hemorrhage

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Rare adult gastric duplication cyst mimicking a gastrointestinal stromal tumor

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World Journal of Gastroenterology 2013年第45期19卷 8445-8448页

作者： Morakod Deesomsak pitulak aswakul Pairoj Junyangdikul Varayu Prachayakul Liver and Digestive Institute Samitivej Sukhumvit Hospital Bangkok 10120Thailand Department of Pathology Samitivej Srinakarin Hospital Bangkok 10250 Thailand Siriraj GI Endoscopy Center Division of Gastroenterology Department of Internal Medicine Faculty of Medicine Siriraj Hospital Mahidol University Bangkok 10700Thailand

Gastric duplication cyst is a very rare gastrointestinal tract malformation that accounts for 2%-4%of alimentary tract *** cases are diagnosed within the first year of life,following presentation of abdominal pain,vomiting,and weight loss and clinical discovery of an abdominal palpable *** case report describes a very uncommon symptomatic gastric duplication cyst diagnosed for the first time in *** a few other case reports of similar condition exist,and all were identified by *** current case involves a 52-year-old male who presented with a onemonth history of progressive iron deficiency anemia without overt gastrointestinal *** patient underwent esophagogastroduodenoscopy,which revealed a 2.0 cm pinkish subepithelial lesion,suspected to be a gastrointestinal stromal tumor(GIST)and source of gastrointestinal *** endosonography showed inhomogeneous hypoechoic lesions with focal anechoic areas arising from a second and third layer of the gastric *** diagnoses of GIST,neuroendocrine tumor,or pancreatic heterotopia were *** lesion was removed using an endoscopic submucosal resection *** revealed an erosive gastric mass composed of a complex structure of dilated gastric glands surrounded by fibro-muscular tissue,fibroblasts,and smooth muscle bundles,which led to the diagnosis of gastric duplication.

关键词： Gastric duplication cyst Gastrointestinal bleeding Endoscopy Endoscopic ultrasonography Endoscopic mucosal resection Differential diagnosis Adult

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Mediastinal small cell carcinoma with liver and bone marrow metastasis, mimicking lymphoma

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World Journal of Clinical Cases 2015年第10期3卷 915-919页

作者： Napaporn Nawarawong Tawatchai Pongpruttipan pitulak aswakul Varayu Prachayakul Siriraj GI Endoscopy Center Division of GastroenterologyDepartment of Internal MedicineSiriraj HospitalMahidol University Division of Hematopathology Department of PathologyFaculty of MedicineSiriraj HospitalMahidol University Liver and Digestive Institute Samitivej Sukhumvit Hospital

Primary mediastinal neuroendocrine tumors are a rare malignancy that accounts for < 10% of all mediastinal tumors. The case presented here involves a 52-yearold man who had been suffering for 3 mo from chronic cough, anorexia and substantial weight loss, as well as 2 wk of jaundice prior to his admission. A computed tomography scan showed a 4.3 cm × 6.6 cm mediastinal mass with multiple liver nodules scattered along both hepatic lobes. Endoscopic ultrasound showed a large heterogeneous hypoechoic mass at the mediastinum with multiple target-like nodules in the liver. Fine-needle aspiration specimens revealed numerous, small, round cells with hyperchromatic nuclei, scarce cytoplasm, and frequent mitotic features. Immunohistochemical study revealed positive results for AE1/AE3, CD56 and chromogranin A, with negative findings for synaptophysin, CK20, vimentin, CK8/18 and CD45. The patient was subsequently diagnosed with a poorly differentiated neuroendocrine carcinoma, small cell type. A bone marrow biopsy also revealed extensive involvement by the carcinoma.

关键词： Bone marrow metastasis Liver metastasis Lymphoma Mediastinal mass Neuroendocrine tumor

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Endoscopic ultrasound-guided interventions in specialsituations

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World Journal of Gastrointestinal Endoscopy 2016年第2期8卷 104-112页

作者： Varayu Prachayakul pitulak aswakul Siriraj Gastrointestinal Endoscopy Center Division of GastroenterologyDepartment of Internal MedicineSiriraj HospitalFaculty of MedicineMahidol UniversityBangkok 10700Thailand Liver and Digestive Institute Samitivej Sukhumvit HospitalBangkok 10120Thailand

Endoscopic ultrasound(EUS) was introduced in 1982 and has since become a popular advanced procedure for diagnosis and therapeutic intervention. Initially, EUS was most commonly used for the diagnosis of pancreatobiliary diseases and tissue acquisition. EUS was first used for guided cholangiography in 1996, followed by EUS-guided biliary drainage in 2001. Advancements in equipment and endoscopic accessories have led to an expansion of EUS-guided procedures, which now include EUS-guided drainage of intra-abdominal abscesses or collections, intravascular treatment of refractory variceal and nonvariceal bleeding, transmural pancreatic drainage, common bile duct stone clearance, enteral feeding tube placement and entero-enteric anastomosis. Patients with surgically altered upper gastrointestinal anatomies have greatly benefited from EUS also. This systematic review describes and discusses EUS procedures performed in uncommon diseases and conditions, as well as applications on more vulnerable patients such as young children and pregnant women. In these cases, routine approaches do not always apply, and thus may require the use of innovative and unconventional techniques. Increased knowledge of such special applications will help increase the success rates of these procedures and provide a foundation for additional advances and utilizations of the technique.

关键词： Children Endoscopic ultrasonography Intraabdominalabscesses Pregnancy Special situation Surgically altered anatomy Therapeutic Uncommon

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Endoscopic ultrasound-guided biliary drainage as an alternative to percutaneous drainage and surgical bypass

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World Journal of Gastrointestinal Endoscopy 2015年第1期7卷 37-44页

作者： Varayu Prachayakul pitulak aswakul Siriraj GI Endoscopy Center Division of GastroenterologyDepartment of Internal MedicineSiriraj HospitalFaculty of MedicineMahidol UniversityBangkok 10700Thailand Liver and Digestive Institute Samitivej Sukhumvit HospitalBangkok 10120Thailand

Endoscopic retrograde cholangiopancreatography had been a treatment modality of choice for both benign and malignant biliary tract obstruction for more than half century, with a very high clinical success rate and low complications. But in certain circumstances, such as advanced and locally advanced pancreatobiliary malignancies(pancreatic cancer, cholangiocarcinoma, ampullary tumor) and tight benign strictures, endoscopic retrograde cholangiopancreatography(ERCP) fails. Up to this point, the only alternative interventions for these conditions were percutaneous transhepatic biliary drainage or surgery. Endoscopic ultrasound guided interventions was introduced for a couple decades with the better visualization and achievement of the pancreatobiliary tract. And it's still in the process of ongoing development. The inventions of new techniques and accessories lead to more feasibility of high-ended procedures. Endoscopic ultrasound guided biliary drainage was a novel treatment modality for the patient who failed ERCP with the less invasive technique comparing to surgical bypass. The technical and clinical success was high with acceptable complications. Regarded the ability to drain the biliary tract internally without an exploratory laparotomy, this treatment modality became a very interesting procedures for many endosonographers, worldwide, in a short period. We have reviewed the literature and suggest that endoscopic ultrasoundguided biliary drainage is also an option, and one with a high probability of success, for biliary drainage in the patients who failed conventional endoscopic drainage.

关键词： Endoscopic ultrasound Endoscopicultrasound Biliary drainage Choledochoduodenostomy Hepaticogastrostomy Technique

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