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Introduction: Selective cannulation fails in approximately 3 % of endoscopic retrograde cholangiography (ERC) procedures. An endoscopic ultrasound-guided rendezvous technique (EUS - RV) may salvage failed cannulation. The aims of the current study were to determine the safety and efficacy of EUS - RV. Methods: A total of 40 patients underwent salvage EUS - RV. EUS - RV was attempted immediately after failed biliary cannulation. A dilated intra- or extra-hepatic biliary duct (IHBD or EHBD) was punctured from the stomach or the small intestine under EUS guidance followed by cholangiography and antegrade manipulation of the guide wire into the small intestine. Finally, the echoendoscope was exchanged for an appropriate endoscope and biliary cannulation was achieved over or adjacent to the guide wire. Result: EUS-RV appears safe and effective and may be considered as a primary salvage technique after failed cannulation. Antegrade manipulation of the guide wire into the small intestine was achieved in 29 of 40 patients (73 %; EHBD 25 /31 and IHBD 4/9). The reasons for failure were inability to advance the guide wire through an obstruction or a native ampulla. Re-attempt at ERC immediately after failed EUS - RV was made in seven of the 11 patients, and was successful in four. The remaining seven patients underwent percutaneous drainage within 3 days. Complications occurred in five patients (13 %), including pancreatitis, abdominal pain, pneumoperitoneum, and sepsis/death, which was unlikely to be related to the procedure. Conclusion: EUS - RV is safe and effective and should be considered as a primary salvage technique after failed cannulation. Immediate re-attempt at ERC after failed EUS - RV is warranted, as EUS-guided cholangiogram can facilitate biliary cannulation in some cases. Finally, prompt alternative biliary drainage should be available. [ABSTRACT FROM AUTHOR]

Background: Recently, placement of fully covered self-expandable metal stents (FCSEMSs) has been proposed as an alternative treatment for the management of benign biliary strictures. However, the major limitations of FCSEMSs are frequent migration and removal complications. Objective: We conducted this study to compare the antimigration effects, complication rates, and short-term efficacy of 2 FCSEMSs with either an anchoring flap (AF) or a flared end (FE) at the proximal end of the stent. Design: A multicenter, prospective comparative pilot study. Setting: Two tertiary referral centers. Patients: A total of 43 patients with benign biliary stricture who were candidates for placement of FCSEMSs were assigned to the AF (n = 22) or the FE group (n = 21). Interventions: Predefined duration of placement and removal of FCSEMSs. Results: After a median period of placement of 6 months (interquartile range 4-6), no patients in the AF group and 33% of patients (7 of 21, 1 in proximal and 6 in distal) in the FE group had stent migration (P = .004). The removal rate of the FCSEMSs was 100% in both groups (per protocol, n = 22 in the AF group and n = 17 in the FE group). Immediate improvement of biliary stricture was 91% (20/22, per protocol) in the AF group and 88% (15/17, per protocol) in the FE group. All stents were removed without difficulty. Limitations: Short-term follow-up after the removal of FCSEMSs. Conclusions: With regard to the antimigration effect of FCSEMSs for benign biliary stricture, the AF design may be superior to the FE. For up to 6 months, both FCSEMSs can be endoscopically removed without complications. (Clinical trial registration number: NCT00945516.) [ABSTRACT FROM AUTHOR]

Background: EUS-guided biliary drainage (EUS-BD) with the use of a fully covered metal stent can result in a large-diameter fistula between the bile duct and the duodenum or stomach. This sustainable fistula may constitute a new endoscopic route to the bile duct. Objective: To assess the feasibility of performing endoscopic procedures through EUS-guided choledochoduodenostomy or hepaticogastrostomy with a fully covered self-expandable metal stent (FCSEMS). Design: Observational pilot study. Setting: Tertiary-care referral center. Patients: This study involved 3 consecutive patients who underwent EUS-BD with an FCSEMS for biliary decompression. Interventions: One to four weeks after EUS-BD with an FCSEMS, endoscopic procedures for the bile duct were performed through the sinus tract to evaluate and manage intrabiliary lesions. Main Outcome Measurements: Technical success and procedural complications of endoscopic procedures through EUS-BD with an FCSEMS. Results: Endoscopic procedures were completed through the sinus tract of EUS-BD. Two patients underwent photodynamic therapy for tumor bleeding in the common bile duct and argon plasma coagulation on the biliary intraductal papillary mucinous neoplasm repeatedly under direct visual guidance. In the other patient, photodynamic therapy was performed on the malignant hilar stricture through EUS-guided hepaticogastrostomy with an FCSEMS. Limitations: Small sample size, pilot study. Conclusions: EUS-BD with an FCSEMS may result in a large-diameter sustainable fistula. Endoscopic intervention through this fistula seems to be feasible and useful for the management of intrabiliary lesions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Currently, percutaneous drainage is the first treatment of choice for hepatic abscesses because of its high success and low mortality rates compared with other surgical procedures. However, percutaneous drainage of hepatic abscesses in the caudate lobe or gastrohepatic space may be difficult. OBJECTIVE: The aim of this study was to determine the technical feasibility and clinical implication of EUS-guided drainage for hepatic abscesses not accessible to percutaneous biliary drainage. DESIGN: Single-center prospective case series. SETTING: Academic tertiary referral center. PATIENTS: This study involved 3 consecutive patients with hepatic abscesses not accessible to percutaneous biliary drainage: 2 in the caudate lobe and 1 in the gastrohepatic extension from the posteromedial aspect of the lateral segment. INTERVENTIONS: EUS-guided drainage with a plastic stent and/or nasocystic tube was conducted using a therapeutic linear-array echoendoscope under endoscopic and fluoroscopic guidance. RESULTS: The EUS-guided transgastric approach was performed in 2 patients (1 in the caudate lobe, and 1 in the gastrohepatic space). In the other patient (caudate lobe), EUS-guided transduodenal drainage was conducted. EUS-guided drainage with the placement of a plastic stent and/or nasocystic tube was successful in all of the patients. Complete resolution of the hepatic abscesses and symptom relief were achieved in all of the patients (3 out of 3, 100%). No procedural complications were observed. Follow-up results were also favorable. LIMITATIONS: Small series of cases. CONCLUSIONS: For this case series, EUS-guided drainage of hepatic abscesses not accessible to percutaneous drainage, such as those in the caudate lobe or gastrohepatic space, is technically feasible, safe, and provides complete drainage, symptom relief, and favorable follow-up results. Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved. [ABSTRACT FROM AUTHOR]

AIM OF THE STUDY: The fruit of Euphoria longan (Lour.) Steud. (Sapindaceae) is sweet and edible. Dried Euphoria longan fruit is prescribed as a tonic and for the treatment of forgetfulness, insomnia, or palpitations caused by fright in traditional Chinese medicine. The effects of aqueous extract of Euphoria longan fruit (ELE) on learning and memory and their underlying mechanisms were investigated. MATERIALS AND METHODS: Aqueous extract of Euphoria longan fruit (ELE) was administered to ICR mice for 14 days. Piracetam was used as a positive control for its known memory-enhancing effects. Memory performances were assessed using the passive avoidance task. The expressions of phosphorylated extracellular signal-regulated kinase (pERK) 1/2, phosphorylated cAMP response element binding protein (pCREB), brain-derived neurotrophic factor (BDNF), doublecortin (DCX) and the incorporation of 5-bromo-2-deoxyuridine (BrdU) in hippocampal dentate gyrus and CA1 regions were investigated using immunohistochemical methods. RESULTS: The step-through latency in the ELE-treated group was significantly increased compared with that in the vehicle-treated controls (P<0.05) in the passive avoidance task. Piracetam-treated group also showed enhanced cognitive performaces in the passive avoidance task. Immunohistochemical studies revealed that the number of cells immunopositive for BDNF, pCREB, or pERK 1/2 was significantly increased in the hippocampal dentate gyrus and CA1 regions after ELE treatment for 14 days (P<0.05). DCX and BrdU immunostaining also revealed that ELE significantly enhanced immature neuronal survival, but not neuronal cell proliferation in the subgranular zone of the dentate gyrus. CONCLUSIONS: The present results suggest that subchronic administration of aqueous extract of Euphoria longan fruit enhances learning and memory, and that its beneficial effects are mediated, in part, by BDNF expression and immature neuronal survival. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although the definitive therapy of acute cholecystitis is cholecystectomy, nonsurgical treatment such as percutaneous cholecystostomy could be indicated in patients who are unsuitable candidates for cholecystectomy. EUS-guided cholecystoenterostomy with a plastic stent and/or nasobiliary drainage has been proposed as an alternative effective treatment for these patients. OBJECTIVE: We conducted this study to evaluate the technical feasibility, safety, usefulness, and follow-up results of EUS-guided cholecystoenterostomy with single-step placement of a plastic stent for patients with acute cholecystitis who are unsuitable candidates for cholecystectomy. DESIGN: A prospective feasibility study with a case series. SETTING: Tertiary teaching hospital. PATIENTS: Eight consecutive patients diagnosed with acute cholecystitis who were poor candidates for surgery. INTERVENTIONS: EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent. MAIN OUTCOME MEASUREMENTS: Technical success, clinical resolution of acute cholecystitis, procedure-related complications, and recurrence of cholecystitis. RESULTS: Technical success and clinical resolution were achieved in all patients (100% [8/8] as intent to treat). A transduodenal approach was used for 7 patients and a transgastric approach for 1 patient. One patient showed self-limited pneumoperitoneum, and bile peritonitis occurred in 1 patient. One patient showed distal stent migration without bile leakage 3 weeks after stent insertion. During follow-up periods (median 186 days; range 22-300 days), cholecystitis did not recur in any patients. LIMITATIONS: Small number of patients. CONCLUSION: EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent may be a feasible and useful alternative in patients with acute cholecystitis who are unsuitable candidates for cholecystectomy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Percutaneous transhepatic biliary drainage (PTBD) may be the last resort for an occluded biliary metal stent when the ERCP was unsuccessful. OBJECTIVE: Because an EUS-guided biliary drainage has been proposed as an effective alternative for PTBD after a failed ERCP, we conducted this study to determine the feasibility and usefulness of an EUS-guided hepaticogastrostomy (EUS-HG) with a fully covered self-expandable metal stent (FCSEMS) for an occluded biliary metal stent after a failed ERCP. DESIGN: A case study. SETTING: A tertiary referral center. PATIENTS AND INTERVENTIONS: Five patients who had an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion and for whom reinterventional ERCP was unsuccessful underwent an EUS-HG with an FCSEMS for alternative PTBD. MAIN OUTCOME MEASUREMENTS: Technical and functional success, procedural complications, reinterventional rate after EUS-HG with an FCSEMS, and short-term stent patency. RESULTS: In all 5 patients, an EUS-HG with an FCSEMS was technically successful. No procedural complications, such as bile peritonitis, cholangitis, and pneumoperitoneum, were observed. Functional success was also 100% (5/5). During the follow-up period (median 152 days, range 64-184 days), no late complications, such as stent migration and occlusion, were observed. Thus, no biliary reintervention was performed during the follow-up period. LIMITATIONS: A small series of patients without a control group. CONCLUSIONS: The EUS-HG with an FCSEMS may be feasible, effective, and an alternative PTBD for an occluded biliary metal stent after a failed ERCP. [ABSTRACT FROM AUTHOR]

BACKGROUND: Painful chronic pancreatitis with main pancreatic ductal strictures is usually managed with endotherapy with a plastic stent. To date, the role of placement of metallic stents, especially uncovered ones in benign pancreatic ductal stricture, has been unsatisfactory as a result of stent dysfunction related to mucosal hyperplasia. OBJECTIVE: We explored the feasibility and safety of temporary placement of a newly designed, fully covered self-expandable metal stent (FCSEMS) in painful chronic pancreatitis and refractory benign pancreatic ductal strictures. DESIGN: A prospective pilot and feasibility study. SETTING: A tertiary academic center. PATIENTS: Thirteen patients with chronic painful pancreatitis of alcoholic (8) or idiopathic (5) etiology. INTERVENTION: ERCP with temporary FCSEMS placement (2 months). Endoscopic removal of FCSEMSs was performed with a snare or rat-tooth forceps. MAIN OUTCOME MEASUREMENTS: End points were feasibility, safety, and morbidity. RESULTS: Successful FCSEMS placement was performed in all enrolled patients. After immediate placement of FCSEMS, 2 patients had mild acute pancreatitis related mainly to the stricture dilation procedure (Soehendra stent retriever or balloon dilation). Complications associated with stent placement included 5 migrations (39%, 1 proximal and 4 distal) and 2 incidents of cholestatic liver dysfunction associated with the compression of the bile duct orifice by expansion of FCSEMSs. In 1 patient with proximal migration, the stent was repositioned by an inflated retrieval balloon. Additional endoscopic biliary sphincterotomy with or without biliary stenting was performed in 2 patients with cholestatic liver dysfunction. There was no occurrence of pancreatic sepsis among any patients. FCSEMSs were removed from 9 of 9 patients without stent migration (100% [9/9] as per protocol, and 69% [9/13] as intention to treat, respectively). Improvement or resolution of the pancreatic ductal strictures was confirmed in all 13 patients on follow-up ERCP (2 months after stent placement), regardless of stent migration. LIMITATIONS: Small patient populations without long-term follow-up. CONCLUSIONS: Two-month placement of FCSEMSs in patients with refractory benign pancreatic ductal strictures may be feasible and relatively safe. However, stent migration was not uncommon. A further investigation with ideal stent design may therefore be needed before recommending FCSEMSs as a therapeutic option for refractory benign pancreatic ductal strictures. [ABSTRACT FROM AUTHOR]

BACKGROUND: Endoscopic treatment of a pedunculated submucosal tumor (SMT) has not been well established. In particular, endoscopic cautery snare resection of a large pedunculated SMT is discouraged because of the increased risk of bowel perforation. OBJECTIVE: To report the clinical outcome of endoloop ligation for the treatment of various pedunculated SMTs with a clip-marking technique. DESIGN: Prospective evaluation of 10 patients who, between June 2005 and May 2006, received endoloop ligation with a clip-marking technique. SETTING: At a tertiary-care, academic medical center. PATIENTS: Ten patients with various pedunculated SMTs with either symptomatic lesions or large-sized lesions (>4 cm). MAIN OUTCOME MEASUREMENTS: Clinical procedural success, reported adverse events. RESULTS: Nine cases were successfully treated, with tumor removal within 4 weeks. In contrast, only 1 patient needed a second session of loop ligation. Only 6 specimens were retrieved. There were no procedure-related complications, such as bleeding or perforation. LIMITATIONS: Retrieval by the patient of a specimen from stool was possible in only 60% of cases; a limited number of 10 patients; by oncology standards, not the correct treatment for nonlipomatous lesions, which limits its application to surgical risk candidates. CONCLUSIONS: Endoloop ligation of large pedunculated SMTs seemed to be technically feasible and appeared to be safe in this case series. Further controlled clinical trials have to be conducted before application of this technique to a large submucosal lipoma or other SMTs in surgical high-risk candidates can be generally recommended. [ABSTRACT FROM AUTHOR]

BACKGROUND: It is difficult to estimate the safe upper margin and the proper direction of endoscopic biliary sphincterotomy (EBS) in cases of choledocholithiasis complicated by periampullary diverticulum (PAD) or previous EBS. OBJECTIVE: This study evaluated the clinical usefulness of an inflated-balloon-pulling (IBP) technique for assessing the safe margin and the proper direction of EBS in affected patients. DESIGN: Prospective feasibility study. SETTING: Academic tertiary center. PATIENTS: From March 2003 to November 2003, the IBP technique was applied to patients with choledocholithiasis in whom EBS was difficult because of concomitant PAD or previous EBS. INTERVENTIONS AND MAIN OUTCOME MEASUREMENTS: After the endoscopically visible papillary roof of the ampulla of Vater was fully dissected, an inflated 11.5- or 15-mm retrieval balloon was inserted in the bile duct and was pulled toward the duodenal lumen, creating an artificial bulge. This bulge was considered an endoscopic landmark to indicate the residual intramural portion and the direction of the bile duct. RESULTS: A total of 19 patients (12 men, 7 women), with a mean age of 61.5 years, were consecutively enrolled. Of these patients, 7 had PAD, 7 had recurrent choledocholithiasis, and 5 had both conditions. The mean length of the IBP-induced residual intramural bile duct was 6.6 mm (range, 3-15 mm). The previous EBS was not oriented toward the bile duct in 4 of 12 patients with recurrent choledocholithiasis (33.3%). After EBS extended completely, choledocholithiases were successfully removed in all patients (1 by mechanical lithotripsy). Of the 19 patients, 2 had complications (11%; 1 mild hemorrhage, 1 mild pancreatitis), which were managed medically. There was no case of perforation. CONCLUSIONS: The IBP technique is a feasible and a reliable method for safe and effective EBS in patients with choledocholithiasis in whom EBS is difficult because of PAD or/and previous EBS. The clinical significance of the direction of previous EBS needs to be defined. [ABSTRACT FROM AUTHOR]