Showing papers by "Todd H. Baron published in 2020"

Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using 20-mm versus 15-mm lumen-apposing metal stents: an international, multicenter, case-matched study.

Abstract: Backgrounds Endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMSs) has gained popularity for the treatment of pancreatic walled-off necrosis (WON). We compared the 20-mm and 15-mm LAMSs for the treatment of symptomatic WON in terms of clinical success and adverse events. Methods We conducted a retrospective, case-matched study of 306 adults at 22 tertiary centers from 04/2014 to 10/2018. A total of 102 patients with symptomatic WON who underwent drainage with 20-mm LAMS (cases) and 204 patients who underwent drainage with 15-mm LAMS (controls) were matched by age, sex, and drainage approach. Conditional logistic regression analysis was performed to compare clinical success (resolution of WON on follow-up imaging without reintervention) and adverse events (according to American Society for Gastrointestinal Endoscopy criteria). Results Clinical success was achieved in 92.2 % of patients with 20-mm LAMS and 91.7 % of patients with 15-mm LAMS (odds ratio 0.92; P = 0.91). Patients with 20-mm LAMS underwent fewer direct endoscopic necrosectomy (DEN) sessions (mean 1.3 vs. 2.1; P Conclusions The 20-mm LAMS showed comparable clinical success and safety profile to the 15-mm LAMS, with the need for fewer DEN sessions for WON resolution.

An international, multi-institution survey on performing EUS-FNA and fine needle biopsy.

Abstract: Background and Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and fine needle biopsy (FNB) are effective techniques that are widely used for tissue acquisition. However, it remains unclear how to obtain high-quality specimens. Therefore, we conducted a survey of EUS-FNA and FNB techniques to determine practice patterns worldwide and to develop strong recommendations based on the experience of experts in the field. Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS Task Force (ISEUS-TF). The survey was administered by E-mail through the SurveyMonkey website. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Another questionnaire about the level of recommendation was designed to assess the respondents' answers. Results: ISEUS-TF members developed a questionnaire containing 17 questions that was sent to 53 experts. Thirty-five experts completed the survey within the specified period. Among them, 40% and 54.3% performed 50–200 and more than 200 EUS sampling procedures annually, respectively. Some practice patterns regarding FNA/FNB were recommended. Conclusion: This is the first worldwide survey of EUS-FNA and FNB practice patterns. The results showed wide variations in practice patterns. Randomized studies are urgently needed to establish the best approach for optimizing the FNA/FNB procedures.

Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography.

Abstract: Endoscopic ultrasound (EUS) was originally devised as a novel diagnostic technique to enable endoscopists to stage malignancies and acquire tissue. However, it rapidly advanced toward therapeutic applications and has provided gastroenterologists with the ability to effectively treat and manage advanced diseases in a minimally invasive manner. EUS-guided biliary drainage (EUS-BD) has gained considerable attention as an approach to provide relief in malignant and benign biliary obstruction for patients when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible. Such instances occur in those with surgically altered anatomy, gastroduodenal obstruction, periampullary diverticulum or prior transampullary duodenal stenting. While ERCP remains the gold standard, a multitude of studies are showing that EUS-BD can be used as an alternative modality even in patients who could successfully undergo ERCP. This review will shed light on recent EUS-guided advancements and techniques in malignant and benign biliary obstruction.

A newly designed over-the-scope-clip device to prevent fully covered metal stents migration: A pilot study

Abstract: Background Fully covered self-expandable metal stents (FCSEMS) have increasingly been used in the endoscopic management of malignant and benign gastrointestinal diseases. The main limitation of FCSEMS is the risk of migration, occurring in at least one-third of patients. Different methods have been employed for anchorage of esophageal stent, as external fixation with endoscopic snare and internal fixation using both through-the-scope (TTS) and over-the scope (OTS) clips to fix the upper flared end of the FCSEMS to the esophageal mucosa. A new designed over-the-scope device called Stentfix OTSC® System (AG-Tuebingen– Germany), has been developed to avoid migration. It consists in a Nitinol clip preloaded on the applicator cap used to clip the flared end of FCSEMS to the gastrointestinal mucosal layer Aims To evaluate the clinical outcomes of patients treated with Stentfix device. Methods Five consecutive patients (median age: 58 years; males, 80%) were enrolled. All patients had experienced FCSEMS migration. The OTSC device was placed to prevent further stent migration. Results Technical and clinical success was achieved in all patients. In one patient with a benign rectal anastomotic stricture long-term luminal patency was achieved after stent placement. One patient died of causes unrelated to endoscopic procedures. The other patients are still being followed. Dysphagia improvement of at least 1 point was seen in these patients. Conclusions The StentfixOTSC® System appears to be a useful and safe device in the preventing FCSEMS migration in a variety of clinical scenarios.

Removal of a proximally migrated 5-Fr pancreatic stent with a 5-4-3-Fr catheter using a wedge technique.

Abstract: A 44-year-old woman underwent pancreatic sphincterotomy with placement of a 5-Fr, 3-cm pancreatic duct stent (Geenen Sof-Flex; Cook Endoscopy, Winston-Salem, NC, USA). The stent did not pass spontaneously and migrated upstream (▶Fig. 1). Attempts to grasp the stent with a pediatric biopsy forceps failed (▶Fig. 2), but inadvertently advanced the stent toward the pancreatic tail. A 0.018-inch wire was advanced through the stent lumen. A 5-Fr stent retriever was not available. Attempts to retrieve the stent with over-the-wire snare and basket failed (▶Fig. 3). Finally, a 5–4–3-Fr biliary catheter (Contour; Boston Scientific, Marlborough, MA, USA) was forcefully wedged into the stent lumen (▶Fig. 4). The stent was withdrawn (▶Video 1). Retrieval of proximally migrated pancreatic duct stents can be technically difficult despite the variety of accessories available [1–3]. Pancreatoscopy-assisted removal is limited when the pancreatic duct is small [4]. Endoscopic ultrasound-guided transgastric pancreatic puncture is also an option [5]. We believe our technique was successful because the stent material was pliable and expandable, allowing the catheter to wedge into the stent. This provided sufficient axial tension to securely retrieve the stent.

Luminal-apposing stents for benign intraluminal strictures: a large United States multicenter study of clinical outcomes.

Abstract: Background The use of fully covered lumen-apposing metal stents (LAMS) for benign short gastrointestinal (GI) strictures has been reported. This study aimed to evaluate the safety and efficacy of LAMS for refractory GI strictures. Methods A retrospective analysis was performed of patients who underwent LAMS placement for benign GI strictures in 8 United States centers. The primary outcomes were technical success and initial clinical response. Secondary outcomes were reintervention rate and adverse events. Results A total of 51 patients underwent 61 LAMS placement procedures; 33 (64.7%) had failed previous treatments. The most common stricture location was the pylorus (n=17 patients). Various sizes of stents were used, with 15-mm LAMS placed in 45 procedures, 20-mm LAMS in 14 procedures, and 10-mm LAMS in 2 procedures. The overall technical success, short-term clinical response and reintervention rate after stent removal were 100%, 91.8% and 31.1%, respectively. Adverse events were reported in 17 (27.9%) procedures, with stent migration being the most common (13.1%). In subgroup analysis, both 15 mm and 20 mm stents had comparable short-term clinical response and adverse event rates. However, stent migration (15.6%) was the most common adverse event with 15-mm LAMS while pain (14.3%) was the most common with 20-mm LAMS. The reintervention rate was 80% at 200-day follow up after stent removal. Conclusions Using LAMS for treatment of short benign GI strictures is safe and effective. Larger LAMS, such as the new 20 mm in diameter, may have a lower stent migration rate compared to smaller diameter LAMS.

EUS-Guided Gallbladder Drainage

Abstract: The interventional capabilities of endoscopic ultrasound (EUS) have considerably advanced in recent years, most importantly in techniques for EUS-guided biliary drainage. EUS allows visualization of gallbladder, and provides the ability for drainage techniques [1, 2]. Cholecystectomy remains the standard of care for patients with acute calculous cholecystitis and symptomatic gallbladder disease [3]. Some patients are poor surgical candidates due to significant medical comorbidities, prior abdominal surgery causing dense adhesions, underlying liver disease, or due to the severity of cholecystitis [4, 5]. Percutaneous cholecystostomy (PC) is often performed for gallbladder decompression, either as permanent (destination) therapy or as a bridge to cholecystectomy. Percutaneous drainage catheters require routine maintenance and catheter exchange, and are also limited by inadvertent dislodgement and patient discomfort.