The exact prevalence of endometriosis is unknown, but estimates range from 2% to 10% within the general female population and up to 50% in infertile women [1, 2]. Despite its high prevalence, it takes an average of 8–12 years from the onset of symptoms to receive a diagnosis [3]. The clinical case presented here demonstrates a rare example of the diagnosis of colorectal endometriosis through endoscopy.

A 41-year-old woman was under observation by a gynecologist due to infertility issues. Upon the gynecologist's recommendation, a colonoscopy was performed. A submucosal lesion was revealed up to 3 cm in diameter, located 30 cm from the anus. Single foci of hyperemia with pit pattern I-II types corresponding to Kudo were observed on the surface of the lesion.

Considering the patient's medical history, the decision was made to perform EUS-FNA. The lesion was identified as hypoechoic, non-homogeneous, measuring up to 25 mm, primarily located in the muscular layer. In some areas, neoplasm penetrated the intestinal wall. Histological findings revealed areas of glandular tissue, accompanied by a non-abundant stroma resembling secretory phase endometrial tissue. Intense expressions of ER, PR, and CD10 were also observed. Thus, the diagnosis of endometriosis was confirmed.

The patient was referred to a surgeon to determine the appropriate surgical treatment. Colorectal involvement is not rare in cases of deep endometriosis, and it has been reported in up to 12% of women affected by endometriosis [4]. For lesions on the sigmoid colon, segmental resection is recommended as radical treatment of deep endometriosis also has a positive impact on fertility outcomes [5]. Therefore, in rare cases, EUS-FNA can be used as a diagnostic tool for endometriosis.

References

1. Eskenazi B, Warner ML. Epidemiology of endometriosis.Obstet Gynecol Clin North Am 1997;24:235-258

2. Meuleman C, Vandenabeele B, Fieuws S, Spiessens C, Timmerman D, D'Hooghe T. High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners.Fertil Steril 2009;92:68-74

3. Becker C. M. et al. ESHRE guideline: endometriosis //Human reproduction open.– 2022.–Т.2022.–№.2.–С.hoac009.

4. Wills HJ, Reid GD, Cooper MJ, Morgan M. Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: a review. Aust N Z J Obstet Gynaecol 2008;48:292-295.

5. Daraï E, Cohen J, Ballester M. Colorectal endometriosis and fertility.Eur J Obstet Gynecol Reprod Biol 2017;209:86-94.

Introduction

Extrahepatic biliary obstruction can rapidly induce secondary biliary cirrhosis(SBC). If Endoscopic Retrograde Cholangiopancreatography (ERCP) is not possible, transplant remains the only salvage. We present a series of successful biliary drainage via endoscopic ultrasound (EUS) guided bilioenterostomy(EUS-BE) in this high risk subgroup.

Methods

Patients with benign biliary strictures and secondary biliary cirrhosis who presented with symptomatic biliary obstruction were included if they couldnot undergo ERCP due to anatomical constraints, were high surgical risk due to clinically significant portal hypertension, and not candidates for transplant due to socioeconomic factors. These patients were then offered the option of EUS-BE.

Results

EUS-BE was done for five patients with secondary biliary cirrhosis (2 compensated, 3 decompensated). Anatomy and procedure details are enclosed in table 1(attachment)

All showed decompression of biliary system, decline in bilirubin, improvement in liver functions and transient elastography scores over 3 months. All 5 tolerated the procedure well with no immediate major adverse events. One patient succumbed to cholangitis after 4 months of procedure, likely due to stent block. Rest patients are doing well with a minimum followup of 5 months  

Conclusion

EUS-guided bilioenterostomy maybe a potential salvage strategy for benign biliary strictures leading to secondary biliary cirrhosis, even in patients with decompensated cirrhosis

Refractory anastomotic stenosis from colorectal surgery is unusual and may require reconstructive surgery. A 67 y-old male developed a complete anastomotic stricture following rectosigmoidectomy. Magnetic compression recanalization was sucessfully performed at first, which became again stenotic and refractory for endoscopic treatment after 3 months. A procedure using LAMS under EUS-guidance was carried out and followed by 2 sessions of stricturoplasty, allowing colorectal transit reconstruction. 

Unresectable biliary strictures are generally managed by stenting, however major following problem is stent patency. Recent studies show the advantages of endoscopic retrograde cholangiopancreatography - guided intraductal radiofrequency ablation (ID-RFA) as adjunctive therapeutic modality in reducing the rate of stent occlusion. We present our initial experience with the procedure in patients who were diagnosed with unresectable malignant biliary stenosis or were poor surgical candidates over two year preiod. Seventeen procedures in sixteen patients were performed followed by stenting with plastic or metal stents. Our primary endpoints were: evaluating the period of stent patency and overall survival; secondary endpoints: adverse events. A temperature-controlled ID-RFA catheter (ELRA, STARmed, Taewoond Medical) and generator  VIVA combo (STARmed) were used.  The mean period of stent patency (defined as time between the date of the procedure and the last follow up without signs of stent occlusion) was 144,36 ± 89.3 days. In this period all the patients were asymptomatic with good quality of life and without any signs of cholangitis. The indications were as follows: 10 patients with cholangiocarcinoma (CCA), 2 patients with intraductal extension of papillary adenoma after endoscopic papillectomy, 2 patients with gallbladder cancer, 2 patients with hilar metastasis of extrahepatic origin. We experienced two stent occlusions- both treated with second session RFA. In 9 of the patients with CCA chemotherapy was initiated  with no interruption during the period of treatment. In three of the patients/18.75%/ we performed ID-RFA in order to  prolong  stent patency in occluded by tumor ingrowth metalic stent. Overall the rate of the adverse events was 18.75%/n=3/ - one patient with self limited bleeding; one patient with postprocedural cholangitis and one patient with liver abscess (managed with percutaneous drainage). There were no deaths or ICU admissions.

Conclusion: Endobiliary RFA is a promising new tool which provides improved outcomes in patients with malignant biliary obstruction both in stent patency and symptom free survival. It has many advantages – easy delivery and good safety profile with few local and systemic adverse events. Therefore ID-RFA can be proposed as adjunctive treatment in patients with malignant biliary strictures although more randomized controlled trials are needed.

Background: Cholangiocarcinoma (CC) has an incidence of around 2/100.000 and a 5-year survival of 2-16%. When occluding hepatic hilum, a palliative treatment is often the only option. Hilar biliary strictures are responsible of obstructive jaundice and/or cholangitis, requiring placement of endoscopic and/or percutaneous stents. Uncovered self-expandable metal stent (SEMS) are currently the favorite type of stent used in these setting, because of their larger diameter and presumed longer patency. However, neoplastic and/or inflammatory ingrowth and overgrowth are frequent complications. Due to a pour diagnostic accuracy, re-do biopsy of hilar stricture are often needed, so requiring placement of removable stents. Advances in oncological treatment is leading to better responses and to frequent follow up imaging, impaired by the presence of SEMS. In this new oncological setting, using multiple plastic stent (MPS) could be a better option.

Method&Results: We report our initial experience from February 2021 to April 2023 with 3 patients (A,B,C) having a hilar CC (type II, type IIIa, type I according to Bismuth-Corlette classification, respectively), treated with MPS. Histological diagnosis was obtained along with molecular profile (MSS/pMMR). A total of 5 endoscopic retrograde cholangiopancreatographies (ERCP) performed for each patient. For A, according to clinical setting, ERCP were performed every 7 months (median) and for B every 3.5 months (median). In A, MPS started with 2 stents (10Fr+7Fr) and a progressive increase till 5 stents (10Fr). In B, MPS started with 2 (7Fr) stents, increased to 5 (10Fr) + 2 (7Fr) stents. A and B had at least 18 months follow-up, without procedure related adverse events. For C, from August 2022 till March 2023, 4 ERCP were performed with placement of 3 (7Fr) to 5 stents (4 7Fr+1 10Fr). This case was complicated by recurrent occlusion due to tumor bleeding (patient anticoagulated) and disease progression, requiring SEMS placement at the 5th ERCP.

Conclusion: We report our initial experience with MPS in 3 hilar CC. Evolving oncological treatments, as well as the need of a correct diagnosis and the need of follow-up imaging will probably push us to perform biliary drainage using MPS instead of SEMS, at least for a certain time. Further study comparing these two types of stents in malignant hilar biliary stricture should be encouraged.

Subphrenic abscess is an uncommon complication in Roux-en-Y gastroplasty, and its treatment traditionally involves percutaneous or surgical drainage. A 46 y-old female had recurrent left subphrenic abscess due to a Roux-en-Y gastroplasty GI fistula requiring urgent laparotomy and drainage on admission, without success. She undergone several endoscopic treatment approaches resulting in a successful EUS-guided transmural drainage through the excluded stomach using a lumen-apposition metal stent.

Introduction:

Endoscopic ultrasound (EUS) biliary drainage is an alternative after the failure of the trans-papillary

endoscopic approach. We reported 5 cases of echo-endoscopic biliary drainage performed for biliary

obstructions of malignant nature after failure or impossibility of ERCP.

patients and Methods:

This was a monocentric descriptive and analytical retrospective study over a period from June 2019

to April 2023. Our work aimed to report the cases having benefited from biliary drainage by EUS for

biliary obstructions of malignant nature after failure or impossibility of ERCP.

Results:

Five patients (4F/1M) were collected with a median age of 63 years (36;76). The indication for biliary

drainage was the occurrence of acute cholangitis in 2 cases, palliative treatment in 2 cases, and

chronic cholestasis in 1 case. ERCP was unsuccessful due to duodenal stenosis by tumor invasion of

adenocarcinoma of the pancreatic head in 2 cases, 1 case of attempted papillotomy complicated by

severe bleeding in a patient with pancreatic head ADK, and 1 case of afferent loop syndrome in a

patient with a history of head duodenal pancreatectomy and 1 case of antral ADK with a history of

the gastrojejunal anastomosis with distal common bile duct involvement. Clinical success was

defined by the absence of recurrence of acute cholangitis and improvement of biological parameters

especially total bilirubin (TB) by more than 75% in one-week post-drainage. We performed one

transgastric and 4 transbulbar approaches. All procedures were performed with an Olympus

therapeutic linear EUS. The targeted bile duct is punctured with a 19G needle and the creation of the

anastomosis was made by a 6Fr cystotome. The pathway was then fitted with a fully covered metallic

stent. We performed 4 biliary choledocobulbar anastomosis and 1 hepatico-gastric anastomosis.

Three patients died: two due to multi-organ failure and one due to septic shock related to pulmonary

origin. One patient with choledocobulbar anastomosis had a favorable evolution with food

resumption and normalization of the TB and he died 03 months later due to tumor recurrence, the

patient with an ADK of the antrum had a favorable evolution with normalization of the TB and food

resumption and was sent for palliative chemotherapy.

Conclusion :

Biliary drainage EUS guided in cases of malignant biliary obstruction appears feasible, effective, and

safe. This type of procedure could be an alternative to percutaneous or surgical drainage after failure

of ERCP.

Introduction: Loco-regional ablative treatments are increasingly being considered for oncologic diseases. Endoscopic ultrasound (EUS) guided locally ablative options using radiofrequency ablation (RFA) or alcohol has been demonstrated to be safe for locally advanced inoperable pancreatic cancers or even operable PNET (1). Percutaneous Microwave Ablation (MWA) is beneficial and hence preferred over RFA for HCC (liver tumors) by interventional radiologists in the recent past (2). The aim of this paper is to determine the feasibility and safety of a new EUS guided treatment for liver and pancreatic tumors.

Aims & Methods: A cohort study of patients having localized pancreatic or liver tumours or locally advanced pancreatic cancers after neoadjuvant treatment was retrospectively reviewed. The new CREO Medical Microwave 5.8 GHz ablation system together with the 19G antenna was used under EUS guidance.

Results: A total of 12 patients (male 6; mean age 64.7 years (range 42-81 years) were enrolled between 2020 to 2022. The cohort included: 3 pancreatic ductal adenocarcinoma (PDAC), 4 pancreatic neuroendocrine tumors (pNET), 3 pancreatic metastases from renal cell carcinoma (RCC), and 2 liver metastases (Table). Six of the subjects had previous treatment by EUS RFA with sub-optimal response. The mean diameter of the tumor was 23.3 mm. Trans-gastric approach was used in 11 and trans-duodenal approach in 2 patients. The number of applications per session was 3.38 with a mean duration of 1.9 minutes per site. There was no major adverse event. Few (n=2) minor adverse events observed were minimal hemosuccus pancreaticus (n=1) and mild ooze in the stomach (n=1) that spontaneously subsided. A follow-up CT scan was performed in all patients at 1 month that demonstrated the presence of necrosis in all cases. At up to 12 months follow-up period was documented. Complete radiological response was encountered in patients with liver tumors; partial and complete response in patients with pNET and pancreatic metastases and stable and progressive disease at 4 and 6 months in the cases of PDAC.

Conclusion: EUS-guided MWA is a safe and feasible procedure for localized pancreatic tumors (PNETs or RCC), locally advanced pancreatic adenocarcinoma, or isolated liver metastases. Further randomized studies are needed to demonstrate local control, progression-free and overall survival.

Introduction

A 47-year-old female patient presented with symptomatic iron deficiency anaemia(IDA) (haemoglobin 75 g/L, ferritin 4 ug/L) following an episode of melaena.  She had a strong family history of breast cancer, was positive for BRCA gene mutation and had previously undergone bilateral salphingo-oophorectomy. An initial oesophago gastro duodenoscopy (OGD) and a subsequent colonoscopy did not identify any abnormality. CT scan identified two slightly prominent mesenteric lymph nodes adjacent to superior mesenteric vein with largest one measuring 8 mm in diameter. Patient was referred a year later with blood tests showing recurrence of IDA.  A repeat OGD identified a large pedunculated  6 cm polypoidal mass arising from the junction of first and second parts of the duodenum with a thick pedicle. The previously noted lymph nodes had reduced in size to 6mm in diameter. An endoscopic ultrasound was done which demonstrated a homogenous hypoechoic submucosal tumour with a thick vascular pedicle.  Biopsies taken at endoscopy suggested a neural origin of the tumour. PET CT scan confirmed a moderately hypermetabolic tumour without any metastasis.

A lateral duodenotomy was performed and the tumour which was attached to a thick stalk was resected. Following removal of the tumour, a frozen section was performed and it was confirmed that there was no evidence of tumour in the stalk. Histology showed a circumscribed tumour based in the lamina propria, submucosa and muscularis propria. The tumour was noted to have mixture of epithelioid cells arranged in a nested pattern surrounded by spindled stromal cells with scattered ganglion. The epithelioid cells stained positive to AE1/A3, cam5.2, chromogranin, synaptophysin, NSE, and CD56 and stained negative to CK7, CK20, Sox10 and S100. The spindled stromal cells stained positive to S100 and Sox10. The tumour showed approximately 2 mitosis /high power field The morphological findings and immunohistochemical profile confirmed a diagnosis of gangliocytic paraganglioma.

Discussion

Gangliocytic paraganglioma is a relatively rare tumour of the duodenum.  Most of them are localised to the duodenum with the tumour usually showing benign features and are managed by resection, either endoscopic or surgical. 5–7% of cases show regional lymph node metastasis. The most common clinical presentation includes melaena and abdominal pain. In most instances these can be removed either endoscopically or surgically. 

Background: In our institution, biological therapy for inflammatory bowel diseases has been used since 1998. Zadar County has about 170,000 inhabitants. According to the dataAccording to the Health and statistical yearbook for the year 2020, there are 302 patients with Mb. Crohn and 147 with Ulcerative Colitis. Among them, are 98 patients on biological therapy. In a period of 25 years, we recorded 3 rare malignancies in our patients, one of which ended in death. Indication for EUS are: staging of GI malignancies, evaluating pancreaticobiliary disease, valuating subepithelial abnormalities, evaluating extraluminal abnormalities, staging of lung cancer and therapeutic EUS.Methods: During regular check-ups, a patient examination, laboratory diagnostics, endoscopic treatment and radiological imaging would be performed depending on the patient's condition. We recruited three patients with rare malignant diseases, but one of them was diagnosed using the EUS FNB technique.Results: Patient at the age of 23 was diagnosed with UC. At the age of 30, adalimumab was included for the next 4 years. Due to the relapse, a switch was made to estrasimod. After 8 months, he had severe pain in the lumbosacral spine and abdomen. An extensive treatment was performed, as well as EUS FNB of enlarged nodes in the abdomen. The diagnosis is - NET carcinoma, ki67 index 80%. He died 2 weeks after the diagnosis. According to Siegel et al. NET could develop from multipotential cells in the dysplastic epithelium, suggesting that long-term inflammation could be involved in its pathogenesis. Conclusion: Biological drugs, due to their composition and many times larger molecules than classic drug molecules, have the potential to the human body recognizes it as an "attacker" and can trigger various unwanted immune reactions. EUS has become the standard in the diagnosis of abdominal and retroperitoneal neoplasms.

Introduction.

 Kidney cancer accounts for 5% and 3% of all adult malignancies in men and women. The most common histological subtype is clear cell renal cell carcinoma (1).The most common metastatic sites are lung (45.2%), bone (29.5%), lymph nodes (21.8%), liver (20.3%), adrenal (8.9%) and brain (8.1%) (2).Pancreatic metastasis of RCC are rare, and often finded in asymptomatic patients (3).

Method.

We are describing case reports of four patients with late pancreatic metastases from RCC .

Results. 

The first patient, 59 years old woman after nefrectomy of right kidney because of RCC in 2016 was referred to our department according to 16 mm pancreatic lesion on CT scan in 2022. We performed endoscopic ultrasound with FNB. Histology showed RCC metastasis in pancreas. Patient underwent distal pancreatectomy, definitive histology was in accord with FNB result.The second patient, 70 years old man after right nefrectomy for RCC in 2007 was referred to our department because of 16 mm pancreatic lesion on CT scan in 2022. We performed EUS FNB, which confirmed RCC  pancreatic metastasis. Patient was operated (central pancreatectomy) with good outcome.Definitive histology was in agreement with FNB histology.The third patient, 60 years old man after left nefrectomy for RCC in 4/2020 was refferod to EUS because of CT scan in 5/2022, which showed 20 mm lesion of pancreatic tail. FNB was performed , histology confirmed pancreatic MTS from RCC. Patient underwent left pancreatectomy. Definitive histology was RCC.The fourth patient, 74 years old man after left nefrectomy for RCC in 2018, with pancreatic lesion on CT scan in 12/2022, was referred to EUS with FNB. Pancreatic metastasis from RCC was confirmed. Patient underwent distal pancreatectomy. Definitive histology was in agreement with FNB histology.

Conclusion.

Patients with RCC need long oncologic follow up. In case of pancreatic lesion and history of RCC endoscopic ultrasound and FNB should be considered. Pancreatic metastasis from RCC can occur a long time after neprectomy.

1. Renal Cell Carcinoma: ESMO Clinical Practice Guidelines. Published in 2019.2. Bianchi M, Distribution of metastatic sites in renal cell carcinoma: a population-based analysis. Ann Oncol. 2012;23:973–803. Tosoian JJ, Cameron JL, Allaf ME, Hruban RH, Nahime CB, Pawlik TM, et al. Resection of isolated renal cell carcinoma metastases of the pancreas: outcomes from the Johns Hopkins Hospital. J Gastrointest Surg. 2014;18:542–8

Retroperitoneal tumours are uncommon and often present symptoms in advanced stages or become noticeable after significant growth. Among these tumours, lymphoma is a particularly prevalent condition.

We present a case of a 67-year-old female patient who was admitted to the emergency department with a 3-month history of worsening fatigue, postprandial vomiting, abdominal pain and involuntary weight loss. Physical examination revealed diminished breath sounds on the right hemithorax and epigastric discomfort to deep palpation.

CT scan revealed an extensive retroperitoneal mass with areas of necrosis involving the mesenteric vessels; a significant right-sided pleural effusion; mesenteric lymphadenopathies and diffuse peritoneal thickening. A diagnostic thoracentesis confirmed the presence of chylothorax in the drained fluid.

Endoscopic ultrasound (EUS) examination documented an heterogeneous mass extending to the lower portion of the head of the pancreas. EUS-guided fine-needle biopsy (EUS-FNB) was performed using a 22 Gauge needle, obtaining a tissue sample through 3 transgastric passages.

Pathological examination revealed lymphocyte proliferation and immunohistochemical testing showed: CD20 +, Bcl2 +, CD3 -, CD5 -, CD10 -. The diagnosis was consistent with diffuse large B-cell lymphoma.

This case highlights the increasing role of EUS in the diagnosis of retroperitoneal tumours. EUS-FNB is crucial for precise tissue sampling, aiding in management, including chemotherapy treatment.

 Introduction : 

La ponction biopsie sous écho-endoscopie (PBEE) des lésions pancréatiques est d’introduction récente dans notre centre, nous proposons ainsi de rapporter notre expérience et d’évaluer sa valeur diagnostique.

Méthodes : 

 Il s’agit d’une étude monocentrique, descriptive sur une période de 2 ans (Janvier 2021- Juin 2023) incluant les patients adressés pour PBEE de lésions pancréatiques au service de gastroentérologie de l’Hôpital habib Thameur. Nous avons utilisé un écho endoscope de type FUGIFILM ® linéaire EG-580 UT. Une aiguille de type FNA était utilisée pour les ponctions et FNB 22 G pour les biopsies (méthode slow-pull sous aspiration). Nous avons confronté les données cliniques, endoscopiques, morphologiques et histologiques des patients.

Résultats : 

Seize ponctions ont été effectuées chez douze patients (âge moyen 63 ans [39-77] et sexe ratio F/H  3). La symptomatologie était dominée par les épigastralgies chez 33 % des cas, accompagnées d’une altération de l’état général chez 33 %, l’ictère et le prurit étaient présents chez un seul patient, l’hypoglycémie était révélatrice chez un cas. Une cholestase  était notée chez 66% des cas (n=8) et une élévation de la CA 19-9  chez sept patients.  Sur le plan radiologique, il s’agissant d’une lésion de la tête chez 33 % (n=4), de l’uncus (16,7%, n=2) du corps chez 33 % (n=4) et corporéocaudale chez 16.7% (n=2), de type tissulaire dans 66% (n=8), kystique dans 16% (n=2), solidokystique chez un patient.

En EE, la taille minimale était de 9 mm et maximale de 50 mm. Les deux lésions kystiques étaient anéchogènes, les autres lésions étaient hypoéchogènes et hétérogènes, vascularisées dans 33 % des cas, avec extension vasculaire chez 58% des patients et hypertension portale segmentaire dans 50 %. Le nombre de passage de l’aiguille était de 2,8 [2-3]. En anatomopathologie, il s’agissait d’un adénocarcinome (n=5), permettant la réalisation d’une chimiothérapie, d’une pancréatite chronique (n=2) et d’un insulinome (n=1) avec indication opératoire. Un deuxième jeu de biopsies a été nécessaire dans 2 cas. La rentabilité de la PBEE était de 69% des cas (n= 9). Concernant les deux lésions kystiques, l’étude cytologique était en faveur d’un cystadénome séreux dans un cas, et non contributive dans l'autre. Aucune complication n'a été notée.

Conclusion : 

La PBEE est  un examen performant pour déterminer la nature des lésions pancréatiques, évaluer l'extension afin de guider la prise en charge thérapeutique.

Introduction:

Post-orthotropic liver transplant (OLT) cholangiopathies are a group of biliary complications that can occur after liver transplantation. These complications can lead to significant morbidity and mortality if not detected and treated early.

Methods: A comprehensive review of the literature comparing the accuracy of Endoscopic Ultrasound
(EUS) in assessing and monitoring post OLT cholangiopathies was conducted. A search of various databases including PubMed, Embase, and Cochrane Library was performed for relevant articles published up to February 2023 was done. The search terms used were "endoscopic ultrasound," "post-orthotopic liver transplantation," "primary sclerosing cholangitis," and "cholangiopathy." Relevant articles were selected and included in this review.

Results: EUS has a high sensitivity and specificity in diagnosing primary sclerosing cholangitis (PSC) [1]. In the meta-analysis that included 22 articles, comprising 1,227 patients with PSC, and demonstrated that EUS had an overall sensitivity of 90% (95% CI: 85%-94%) and specificity of 96% (95% CI: 94%-98%). In a study of 27 patients with suspected PSC recurrence after OLT, EUS had a sensitivity of 86% and a specificity of 100% for the detection of biliary abnormalities, with a positive predictive value of 100% and a negative predictive value of 90%. Another study found that EUS-FNA had a diagnostic yield of 80% in the evaluation of suspected PSC recurrence after OLT. Larghi et al., evaluated the role of EUS in the surveillance of patients with PSC and demonstrated that EUS-guided cholangiography was safe and effective in detecting biliary strictures. In patients with PSC, EUS can aid in the early
detection of biliary strictures and primary tumors, and can also guide therapeutic interventions such as ERCP and biliary drainage.

Conclusion: This review shows that EUS has a superior diagnostic accuracy compared to other imaging modalities such as MRCP and
CT in detecting biliary complications after OLT. EUS has emerged as a state-of-the-art modality for the assessment and surveillance
of post-OLT cholangiopathies, with high success rates in the diagnosis and treatment of biliary complications.

References:
1. Wang K, Zhu J, Xing L, et al. Diagnostic value of endoscopic ultrasound for bile duct strictures after liver transplantation: a
systematic review and meta-analysis. J Gastroenterol Hepatol. 2020;35(2):165-73.

Spontaneous biliary fistulas are observed in 0.3% of patients with biliary pathology . Cholecystoduodenal fistulas are the most frequent and are often revealed by a complication such as chronic cholecystitis or cholangitis. Our study aimed to identify the clinical, para-clinical, and therapeutic profiles of spontaneous biliary digestive fistulas .

Materials and methods:

This was a monocentric retrospective study over 42 months, between June 2019 and September 2022, including all patients diagnosed with spontaneous biliary digestive fistula as revealed on imaging or during ERCP (Endoscopic retrograde cholangiopancreatography). Iatrogenic fistulas secondary to surgery or instrumental exploration of the bile ducts were excluded.

Results:

we enrolled seven patients, the average age was 63 years with a male predominance, and the sex ratio M/F was 6. Clinically, three patients presented with acute cholangitis classified as grade 2 in two patients and grade 3 in one patient, one patient was admitted with liver abscesses associated with cholecystitis, one patient presented with upper gastrointestinal bleeding, and two patients were clinically asymptomatic at the time of diagnosis with a history of spontaneously resolved jaundice.

The fistula was suspected on imaging by the presence of aerobilia on ultrasound, and on CT scan in all patients.

The diagnosis was confirmed by duodenoscopy in six patients and with upper endoscopy in one patient. The endoscopic aspect showed an orifice with bile liquid flow at the distal bulbar in five cases, on the papilla infundibulum in two cases, and at the duodenal genius superius in one case. Opacification with contrast medium at the level of the biliary fistula showed choledochoduodenal communication in all cases.

Etiologically, lithiasis was found in 4 cases associated with acute pancreatitis in 2 cases and chronic pancreatitis in 1 case, a distal cholangiocarcinoma in 2 cases, and adenocarcinoma of the head of the pancreas in 1 case. 

Conclusion:

Our study has objectified that spontaneous biliary digestive fistulas are not uncommon. The most finding was choledchoduonal fistula, and these fistulas were mostly developed in the context of cholangitis.

introduction:

Our work aimed to describe the evolution of pancreatic collections in acute pancreatitis.

Methods :

This was a retrospective descriptive monocentric study spread over a period of 5 years, including all patients admitted for acute pancreatitis (AP) with collections defined as stages D and E of Balthazar. The diagnosis of AP was based on the Atlanta criteria.

Result :

Out of 86 patients with acute pancreatitis (AP), 44 were classified as grade E and D,representing an incidence of 51.1%. The mean age was 58.6 years +/- 14.7, with a sex ratio of 0.69. Abdominal CT scan showed acute AP stage E of Balthazar in 81.8% of cases (n=36), with parenchymal necrosis in 50% of cases, and AP stage D of Balthazar in 18.1% of cases . The etiologies of these acute pancreatitis were biliary in 61.3% (n=27) of the cases, metabolic in 9% (n=4), alcoholic in 4.5% (n=2), iatrogenic (post-ERCP) in 4.5% (n=2), pancreas divisum in 2.27% (n=1) and idiopathic in 18.1% of the cases.

The clinical outcome was good in 59% of the cases and 22.72 % had local complications , of which 2 patients had an early necrotic flow infection and a recurrence of another episode of acute pancreatitis in 15.9% of the cases. The abdominal CT scan performed at 6 weeks later in 36 patients showed a regression of the size of the collections in 55.5% of the patients (n=20), an increase in the size of the collections in 27.7% of the patients (n=10) of whom 60% (n=6) had developed a walled-off necrosis and stability of the appearance of the collections in 16.6% of the patients

Therapeutically, the symptomatic patients benefited from drainage whose principal indications were superinfection and compression of the adjacent organs, and the asymptomatic patients did not benefit from any treatment.

Symptomatic collections were drained endoscopically in 4 patients, with the placement of two double stents in 3 patients and of a metallic LAMS stent in one patient with 2 sessions of necrosectomy, surgical drainage in 3 patients, and radiological drainage in 2 patients .

The evolution after drainage was noted by the disappearance of symptoms in 6 patients, and death in 3 patients .

Conclusion:

Our work has shown a favorable evolution in the majority of patients who benefited from an adapted therapeutic management. Endoscopic drainage of symptomatic pancreatic collections is effective and less invasive and should be preferred whenever possible.

  Duodenal obstruction is not a classic complication of pancreatic cancer, that is manifested by gastric outlet obstruction (GOO). Endoscopic treatment is indicated as first-line treatment, particularly with significant surgical risk and a short life expectancy. Our work aimed to determine the incidence of duodenal strictures in pancreatic tumors

Methods

   This was a monocentric descriptive retrospective study over 3.5 years, from May 2019 to August 2022, including all patients with pancreatic tumors complicated with a duodenal stricture.

Results

Out of 51 patients with pancreatic tumors, 11 patients had duodenal stricture, with an incidence of 21.5%.

    The median age of our patients was 61.63 years [46-78]. A female predominance was observed with an M/F sex ratio of 0.57.

   The risk factors for pancreatic cancer in our patients were diabetes in 3 patients (27.2%) and smoking in 2 patients (18.1%).

    Clinically, 6 patients presented a GOO manifested by early post-prandial vomiting. The general condition classified as World Health Organization (WHO) was 2 in 54.5%, WHO 1 in 36.3%, and WHO 3 in 9% of cases. 

The upper endoscopy showed a duodenal stricture caused by luminal tumor invasion in 9 patients (81.8%) and a duodenal stricture caused by extrinsic compression in 2 patients (18.1%).

    CA19-9 and CEA were increased in 90.9% and 36.3% of patients respectively. the means values of 4883.4 and 12.95 for CA19-9 and CEA respectively.   

   The location of the tumor was cephalic in 63.6%, cervico-isthmic in 18.1%, and uncus in 18.1% of the cases. The histological type was adenocarcinoma in 10 patients [90.9%] and neuroendocrine in one patient.

   Nine patients (81.8%) were diagnosed as metastatic and two patients (18.1%) with locally advanced pancreatic tumors.

All patients underwent endoscopic drainage with the insertion of metallic biliary stents. Two patients benefited from a gastro-jejunal bypass and two others from a duodenal prosthesis.

Conclusion

The incidence of duodenal stenosis in pancreatic cancer is not rare (21%), especially in patients with locally advanced or metastatic tumors. The treatment consists of the placement of endoscopic stents or the realization of surgical intestinal anastomosis.

Introduction :
endoscopic ultrasound associated with fine-needle biopsy (EUS-FNB) and histopathological study of lymph nodes (LN) located in the mediastinal or/and abdominal area carries valuable diagnostic and therapeutic value. The study aimed to evaluate the diagnostic yield of EUS-FNB for the diagnosis of mediastinal and abdominal LN.
patients and methods :
This was a retrospective descriptive study over 4 years from January 2019 to April 2023 in a hepato-gastroenterology department, including all patients in whom a EUS-FNB of LN was performed.
Results :
Of 21 patients in whom LN was found on EUS, LN FNB was performed in 10 patients, the median age was 59.5 [50.5-64.8] with a sex ratio of M/F of 1.5. The circumstances of finding were cholestatic jaundice in 60% (6) of cases, abdominal pain in 30%, and dysphagia in one case. the location of the localization of LN was mediastinal and abdominal at 50% each.
The size of these ADPs had a median of 15.5mm [15-20].
The diagnosis retained was granulomatosis in 2 cases (20%) including 1 case of tuberculosis and one case of sarcoidosis. two cases (20%) associated with an ADK of the head of the pancreas, including 1 poorly differentiated and 1 moderately differentiated and infiltrating.
In 4 patients, the biopsy was of a reactive lymphoid nature. In 3 patients, the biopsy was of a hemorrhagic and non-specific inflammatory nature.
The patients benefited from a treatment specific to their pathology.
It should be noted that no complications related to EUS-FNB were observed.
Conclusion :
EUS-FNB is positioned at the forefront for the diagnosis of deep lymphadenopathy, whether mediastinal or abdominal. It is a technique that remains minimally invasive and efficient, allowing not only to rule out a neoplastic origin but also to establish a specific treatment when the pathology is documented .

Introduction :

the histopathological confirmation of bile duct strictures is desirable to define the patient

subsequent treatment and prognosis. Intraductal biopsy by forceps (IDBF) under ERCP is

one of the options to determine the nature of biliary strictures. Our work aimed to evaluate the yield of IDBF for the diagnosis of biliary strictures.

Methods :

 we enrolled, over 3 years, all patients who underwent ERCP due to indeterminate bile duct

stenosis. The type of biliary stricture was classified according to the Bismuth-corlette

classification. 

Results :

We registered 10 patients with biliary stenosis who underwent IDBF. The mean age was 62

years. The sex ratio F/M was 0.4. Thirty percent had a history of cholecystectomy. Clinically,

90% of patients had jaundice and 80% (n=8) had cholangitis classified as stage 1 in 75%

(n=6) and stage 2 in 25% (n=2) according to the Tokyo classification 2018. Biologically, the

mean total bilirubin level was 151.3 mg/l.

The localization of the biliary stenosis was hilar in 60% (n=6) classified bismuth-corlette type

2 in 40% (n=4), type 3a in 10% (n=1), and type 3b in 10% (n=1); it involved the whole

common bile duct in 20% (n=2) and the median and distal bile duct in 10% (n=1) each. 

IDBF was performed for all patients with a positive result in 60% of cases of which 66.6% of

cases (n=4) returned in favor of adenocarcinoma and one patient whit a high-grade papillary

intraductal neoplasm and 16.6% of cases it was IGg4 cholangitis with a significant blood level

of IGg4 at 6.3 g/l.

Conclusion :

IDBF of biliary strictures after sphincterotomy is a specific method for pathological diagnosis.

In our work, histopathology was conclusive in 60% of cases.

Introduction: Large rectal lesions can conceal submucosal invasion and cancer nodules. Despite the increasing diffusion of high-definition endoscopes and the importance of an accurate morphological evaluation, a complete assessment in this setting can be challenging. Endoscopic ultrasound (EUS) plays an established role in the locoregional staging of rectal cancer although with a tendency to an over-estimation of the loco-regional (T) staging. However, there are still few data on contrast-enhanced endoscopic ultrasound (CH-EUS), especially if this ancillary technique may increase the accuracy for predicting invasive nodules among large rectal lesions. 

Material and Methods: Consecutive large (≥20 mm) superficial rectal lesions with high-definition endoscopy, characterized by focal areas suggestive for invasive cancer/2B type according to JNET classification were considered for additional standardized evaluation by CH-EUS with Sonovue ©.

Results: From 2020 to 2023, we evaluated 12 consecutive superficial rectal lesions with size ranging from 20 to 180 mm. In 3 cases the CH-EUS showed invasive pattern and patients were submitted to surgical approach, mainly represented by anterior resection. In 8 cases CH-EUS confirmed early stage (uTis or uT1) and curative endoscopic resection was performed. In 9 among 12 patients (75%), the definitive pathological diagnosis corresponded to the initial CH-EUS staging. A single case of understaging was observed for a voluminous lesion of the rectum: an initial indication was placed for ESD, which was later converted to surgery during the resection. In two other cases of adenoma of the distal rectum, evaluation with CH-EUS resulted in overstaging. 

Conclusion: Contrast-enhanced endoscopic ultrasound can provide additional evaluation for large and difficult-to-classify rectal lesions. In our experience CH-EUS staging corresponded to final pathological stage in 9/12 (75%) lesions, improving the distinction between T1 and T2 lesions. Larger prospective studies and randomized trials should be conducted to support and standardize this approach.