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VideoGIE : An Official Video Journal of... Jan 2024Definitive peroral endoscopic treatment of pancreaticobiliary pathology in patients with surgically altered anatomy has recently been made more feasible by the use of... (Review)
Review
BACKGROUND AND AIMS
Definitive peroral endoscopic treatment of pancreaticobiliary pathology in patients with surgically altered anatomy has recently been made more feasible by the use of lumen-apposing metal stents (LAMS) to create bowel-to-bowel anastomoses. We aim to demonstrate 4 cases of non–gastric bypass Roux-en-Y anatomy for which an enteroenterostomy was created under EUS guidance to facilitate complex peroral ERCP.
METHODS
Akin to EUS-directed transgastric ERCP, the approach to EUS-directed transenteric ERCP involves identification and expansion of the target bowel before transmural puncture and stent placement. Bowel irrigation is used to opacify and distend the pancreaticobiliary limb in reasonable proximity to the papilla or biliary-enteric anastomosis, which facilitates enteroenterostomy creation via LAMS placement. Peroral ERCP can be performed through anastomosis, generally using a therapeutic gastroscope, once the transmural tract has matured.
RESULTS
In 4 cases of biliary obstruction, peroral ERCP was successfully performed after creation of an enteroenterostomy. In 3 of the 4 cases, target bowel opacification and distention were achieved by continuous irrigation through a previously placed percutaneous transhepatic cholangiography tube. In one case, a gastro-jejunostomy was created after irrigation of the target bowel loop via antegrade catheter advanced through a prior hepaticogastrostomy. No major adverse events occurred. In 2 of the 4 patients, the endoscopic objective (stone clearance) was met and the transenteric LAMS was removed. The other 2 patients are still undergoing serial ERCP.
CONCLUSIONS
EUS-guided enteroenterostomy permits safe and effective peroral ERCP, allowing for more efficient and effective treatment of pancreaticobiliary pathology in patients with surgically altered anatomy.
PubMed: 38239185
DOI: 10.1016/j.vgie.2023.09.007 -
Cureus Oct 2023Pregnancy in rudimentary horn is an uncommon presentation of an ectopic pregnancy. It needs a very high degree of suspicion for diagnosis and the diagnosis becomes...
Pregnancy in rudimentary horn is an uncommon presentation of an ectopic pregnancy. It needs a very high degree of suspicion for diagnosis and the diagnosis becomes difficult in cases with previous vaginal deliveries. A 25-year-old female patient with two spontaneous vaginal deliveries and a history of spontaneous abortion at five months visited the obstetric emergency department with a history of five months of amenorrhea with pain abdomen and breathlessness for one day. On abdominal examination abdomen was distended, and rigid, and tenderness was present. Paracentesis was done where blood was present. On bimanual examination, cervical motion tenderness was present, and left-sided fornices fullness was present. The patient was admitted, and her sonography was done for suspicion of a ruptured uterus or ectopic pregnancy. The sonography report showed a bulky uterus with decidual reactions and a well-defined pregnancy of 21 weeks and 6 days in the right adnexal region with hemoperitoneum suggesting suspicion of ruptured ectopic pregnancy. After initial treatment and arrangement of two units of packed red blood cells after proper grouping and cross-matching for the patient, laparotomy was done. At the time of surgery, there was a right-sided rupture of non-communicating rudimentary horn pregnancy with a unicornuate uterus. A dead fetus of 600 grams lies in the peritoneal cavity with two liters of hemoperitoneum. Timely diagnosis and laparotomy saved the life of the patient.
PubMed: 38034141
DOI: 10.7759/cureus.48015 -
Communications Biology Dec 2023The mechanisms leading to changes in mesoscale chromatin organization during cellular aging are unknown. Here, we used transcriptional activator-like effectors, RNA-seq...
The mechanisms leading to changes in mesoscale chromatin organization during cellular aging are unknown. Here, we used transcriptional activator-like effectors, RNA-seq and superresolution analysis to determine the effects of genotoxic stress on oocyte chromatin structure. Major satellites are organized into tightly packed globular structures that coalesce into chromocenters and dynamically associate with the nucleolus. Acute irradiation significantly enhanced chromocenter mobility in transcriptionally inactive oocytes. In transcriptionally active oocytes, irradiation induced a striking unfolding of satellite chromatin fibers and enhanced the expression of transcripts required for protection from oxidative stress (Fermt1, Smg1), recovery from DNA damage (Tlk2, Rad54l) and regulation of heterochromatin assembly (Zfp296, Ski-oncogene). Non-irradiated, senescent oocytes exhibit not only high chromocenter mobility and satellite distension but also a high frequency of extra chromosomal satellite DNA. Notably, analysis of biological aging using an oocyte-specific RNA clock revealed cellular communication, posttranslational protein modifications, chromatin and histone dynamics as the top cellular processes that are dysregulated in both senescent and irradiated oocytes. Our results indicate that unfolding of heterochromatin fibers following acute genotoxic stress or cellular aging induced the formation of distended satellites and that abnormal chromatin structure together with increased chromocenter mobility leads to chromosome instability in senescent oocytes.
Topics: Animals; Heterochromatin; Oocytes; Chromatin; Histones; Chromatin Assembly and Disassembly; Mammals
PubMed: 38086992
DOI: 10.1038/s42003-023-05641-0 -
VideoGIE : An Official Video Journal of... Mar 2024EUS-guided gastroenterostomy (EUS-GE) is effective in relieving gastric outlet obstruction. Several techniques used to create EUS-GEs have been described. However, these... (Review)
Review
BACKGROUND AND AIMS
EUS-guided gastroenterostomy (EUS-GE) is effective in relieving gastric outlet obstruction. Several techniques used to create EUS-GEs have been described. However, these techniques are dependent on passing a guidewire beyond the obstruction. We describe a direct needle-puncture technique that allows for successful EUS-GE creation without a guidewire.
METHODS
The direct antegrade EUS-GE method often involves passing a guidewire and tube beyond the obstruction to distend the small bowel. An oblique echoendoscope is then positioned in the stomach to locate the distended small bowel. An electrocautery-enhanced lumen-apposing metal stent (LAMS) is used to create the anastomosis. However, in cases when neither endoscope nor guidewire can be passed across the obstruction, the direct needle-puncture technique can be used. With the oblique echoendoscope positioned in the stomach, a collapsed loop of small bowel is located adjacent to the gastric wall. A 19-gauge needle is used to puncture the gastric and small bowel wall. The small bowel is distended with a mixture of saline, methylene blue, and contrast via a standard water pump connected to the needle. An antispasmodic is administered, and an electrocautery-enhanced LAMS is then introduced into the working channel to create a gastroenterostomy using the freehand method.
RESULTS
The direct needle-puncture technique was performed in 4 patients for these indications: postsurgical inflammation causing gastric outlet obstruction (case 1), tumor infiltration causing gastric outlet obstruction (cases 2A and 2B), and pancreaticobiliary limb access in a duodenal switch (case 3). The video shows the technique performed in a patient with postsurgical inflammation and a patient with duodenal tumor infiltration.
CONCLUSIONS
The direct needle-puncture technique is useful for performing gastroenterostomy when the guidewire cannot be passed beyond the obstruction. It can also be used to gain access to a targeted bowel limb in altered anatomy for diagnostic and therapeutic purposes.
PubMed: 38482479
DOI: 10.1016/j.vgie.2023.10.014