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Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent
This video demonstrates a case of EUS-guided choledochoduodenostomy, emblematic of the latest cutting-edge technology.
A 86-year-old woman with recent abdominal pain and jaundice underwent a CT-scan, which showed an enlarged tumor of the second portion of the duodenum with biliary tree dilatation. Gastroscopy with biopsy confirmed the diagnosis of duodenal adenocarcinoma of the 2nd duodenum.
First, endoscopic retrograde cholangiopancreatography (ERCP) failed to achieve biliary drainage because of an inability to cannulate the papilla due to tumor infiltration. EUS-guided hepatogastrostomy (EUS-HGS) was not attempted because the left intra-hepatic bile ducts were minimally dilated (3mm). However, the common bile duct (CBD) was largely dilated (20 mm). A Hot AXIOS™ Stent and Electrocautery Enhanced Delivery System (stent of 8 by 6mm) was advanced through the bulb. Pure cut electrocautery current was then applied, allowing the device to reach the CBD. Next, the distal flange was opened and retracted towards the EUS transducer, and once a biliary and bulbar tissue apposition had been noted, the proximal flange was released. Good drainage of purulent bile was observed and no complications occurred during the procedure and one month afterwards.
A Sportes, G Airinei, R Kamel, R Benamouzig
Surgical intervention
1 year ago
262 views
7 likes
0 comments
03:09
Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent
This video demonstrates a case of EUS-guided choledochoduodenostomy, emblematic of the latest cutting-edge technology.
A 86-year-old woman with recent abdominal pain and jaundice underwent a CT-scan, which showed an enlarged tumor of the second portion of the duodenum with biliary tree dilatation. Gastroscopy with biopsy confirmed the diagnosis of duodenal adenocarcinoma of the 2nd duodenum.
First, endoscopic retrograde cholangiopancreatography (ERCP) failed to achieve biliary drainage because of an inability to cannulate the papilla due to tumor infiltration. EUS-guided hepatogastrostomy (EUS-HGS) was not attempted because the left intra-hepatic bile ducts were minimally dilated (3mm). However, the common bile duct (CBD) was largely dilated (20 mm). A Hot AXIOS™ Stent and Electrocautery Enhanced Delivery System (stent of 8 by 6mm) was advanced through the bulb. Pure cut electrocautery current was then applied, allowing the device to reach the CBD. Next, the distal flange was opened and retracted towards the EUS transducer, and once a biliary and bulbar tissue apposition had been noted, the proximal flange was released. Good drainage of purulent bile was observed and no complications occurred during the procedure and one month afterwards.
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
I Boškoski, RA Ciurezu, I Crisan, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
1458 views
68 likes
0 comments
09:31
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
I Boškoski, RA Ciurezu, M Morar, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
1008 views
66 likes
0 comments
11:04
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
I Boškoski, M Morar, I Crisan, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
855 views
83 likes
0 comments
18:14
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.
I Boškoski, I Crisan, RA Ciurezu, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
504 views
92 likes
0 comments
09:17
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.
Removal of large biliary stones
Biliary stones can be easy or difficult to remove, depending on their dimensions. Understanding bile ducts anatomy, choosing the appropriate devices/extraction technique, developing confidence with biliary lithotripsy, choosing the appropriate size of the sphincterotomy, performing large balloon biliary dilation in appropriate cases and management of failed stones extraction are the basic key issues in the management of biliary stones. Here, we present the case of a 96-year-old female patient who had an episode of cholangitis one week ago and ERCP was performed with a biliary precut to access the bile duct. Since the biliary stones were large, a biliary plastic stent was placed and after unintentional pancreatic duct cannulation, a pancreatic stent was also placed to prevent pancreatitis. ERCP was repeated. The biliary stent was removed since the stones were approximately 12mm in diameter. A biliary balloon dilation was carried out to facilitate the removal. At the end, the pancreatic stent was also removed.
I Boškoski, M Morar, RA Ciurezu, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
1011 views
84 likes
0 comments
12:52
Removal of large biliary stones
Biliary stones can be easy or difficult to remove, depending on their dimensions. Understanding bile ducts anatomy, choosing the appropriate devices/extraction technique, developing confidence with biliary lithotripsy, choosing the appropriate size of the sphincterotomy, performing large balloon biliary dilation in appropriate cases and management of failed stones extraction are the basic key issues in the management of biliary stones. Here, we present the case of a 96-year-old female patient who had an episode of cholangitis one week ago and ERCP was performed with a biliary precut to access the bile duct. Since the biliary stones were large, a biliary plastic stent was placed and after unintentional pancreatic duct cannulation, a pancreatic stent was also placed to prevent pancreatitis. ERCP was repeated. The biliary stent was removed since the stones were approximately 12mm in diameter. A biliary balloon dilation was carried out to facilitate the removal. At the end, the pancreatic stent was also removed.
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
I Boškoski, I Crisan, M Morar, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
1 year ago
656 views
54 likes
0 comments
18:35
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
Percutaneous nephrolithotomy
This is the case of a 60-year-old man with a large left kidney stone (>3cm) taking up the entire renal pelvis and lower calyceal cavities. Under general anesthesia, the patient is placed in a supine modified lithotomy position, with a 3L water bag underneath the left lumbar fossa to raise it. The left leg is straight whereas the right leg is put on a leg brace flexed.
A cystoscopy is performed in order to identify the left ureteral orifice and introduce a 7 French beveled ureteral stent. This stent is connected to a Foley catheter. A contrast agent is injected into the ureteral stent.
The kidney’s lower pole is punctured with an 18 Gauge hypodermic needle, making sure to stay in contact with the stone. A rigid Lunderquist® guidewire is passed into the needle. The pathway is dilated using metallic coaxial dilators and with a dilation balloon until an Amplatz® renal sheath is placed. The sheath will then be extended.
A nephroscopy is performed to identify the stone, fragment and aspirate it partially with the LithoClast Master® intracorporeal lithotripter. Some large fragments will be withdrawn with crocodile forceps. The lithotripter system fails to remove the residual stone. A Malecot®-type nephrostomy tube is used and the ureteral stent is replaced by means of a double J catheter.
C Saussine
Surgical intervention
1 year ago
1907 views
88 likes
0 comments
34:10
Percutaneous nephrolithotomy
This is the case of a 60-year-old man with a large left kidney stone (>3cm) taking up the entire renal pelvis and lower calyceal cavities. Under general anesthesia, the patient is placed in a supine modified lithotomy position, with a 3L water bag underneath the left lumbar fossa to raise it. The left leg is straight whereas the right leg is put on a leg brace flexed.
A cystoscopy is performed in order to identify the left ureteral orifice and introduce a 7 French beveled ureteral stent. This stent is connected to a Foley catheter. A contrast agent is injected into the ureteral stent.
The kidney’s lower pole is punctured with an 18 Gauge hypodermic needle, making sure to stay in contact with the stone. A rigid Lunderquist® guidewire is passed into the needle. The pathway is dilated using metallic coaxial dilators and with a dilation balloon until an Amplatz® renal sheath is placed. The sheath will then be extended.
A nephroscopy is performed to identify the stone, fragment and aspirate it partially with the LithoClast Master® intracorporeal lithotripter. Some large fragments will be withdrawn with crocodile forceps. The lithotripter system fails to remove the residual stone. A Malecot®-type nephrostomy tube is used and the ureteral stent is replaced by means of a double J catheter.
Large intradiverticulum endoscopic biliary sphincterotomy
Periampullary duodenal diverticula are observed in 10-20% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and could well increase ampulla cannulation failure risk, as well as potential complications related to endoscopic sphincterotomy.
Here we report two successful cases of large intradiverticular endoscopic biliary sphincterotomy in the treatment of two different kinds of benign biliary pathologies. The first case was that of a woman with multiple large stones in the common bile duct (CBD). The second case was one of a male patient with cholestasis due to a compression of the distal common bile duct caused by a diverticulum – this condition being known as Lemmel’s syndrome.
Gf Donatelli, L Marx, J Marescaux
Surgical intervention
2 years ago
1352 views
77 likes
0 comments
05:09
Large intradiverticulum endoscopic biliary sphincterotomy
Periampullary duodenal diverticula are observed in 10-20% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and could well increase ampulla cannulation failure risk, as well as potential complications related to endoscopic sphincterotomy.
Here we report two successful cases of large intradiverticular endoscopic biliary sphincterotomy in the treatment of two different kinds of benign biliary pathologies. The first case was that of a woman with multiple large stones in the common bile duct (CBD). The second case was one of a male patient with cholestasis due to a compression of the distal common bile duct caused by a diverticulum – this condition being known as Lemmel’s syndrome.
LIVE INTERACTIVE SURGERY: Endoscopic Submucosal Dissection (ESD) for colonic polyp
Colorectal polyps are the most common type of polyps. Early resection before the polyp undergoes malignant transformation is key to long-term survival and to a favorable prognosis.
Endoscopic submucosal dissection (ESD) has been developed based on endoscopic mucosal resection (EMR) techniques. ESD can be used to resect lesions regardless of size, location, and fibrosis.

Indications for ESD:
- colorectal tumors when EMR is not feasible;
- tumors >20mm in size;
- lateral spreading tumors (non-granular) type;
- lateral spreading tumors (granular type) with a nodule;
- residual and recurrent tumors.

Technique:
- to accurately define the margins;
- to mark the borders;
- to perform a circumferential incision;
- to perform a submucosal dissection.

Complications:
- perforations – 2.4% in colonic ESD;
- bleeding – may be immediate or delayed, occurring after the procedure.
The overall rate of complications is 1.5%.

Endoscopic ultrasound (EUS):
The use of high-frequency EUS is useful to determine the depth of invasion of colorectal lesions. According to some studies, the efficacy of EUS is found to be superior to chromoendoscopy in determining the depth of the tumor.
N Fukami
Surgical intervention
3 years ago
781 views
34 likes
0 comments
32:29
LIVE INTERACTIVE SURGERY: Endoscopic Submucosal Dissection (ESD) for colonic polyp
Colorectal polyps are the most common type of polyps. Early resection before the polyp undergoes malignant transformation is key to long-term survival and to a favorable prognosis.
Endoscopic submucosal dissection (ESD) has been developed based on endoscopic mucosal resection (EMR) techniques. ESD can be used to resect lesions regardless of size, location, and fibrosis.

Indications for ESD:
- colorectal tumors when EMR is not feasible;
- tumors >20mm in size;
- lateral spreading tumors (non-granular) type;
- lateral spreading tumors (granular type) with a nodule;
- residual and recurrent tumors.

Technique:
- to accurately define the margins;
- to mark the borders;
- to perform a circumferential incision;
- to perform a submucosal dissection.

Complications:
- perforations – 2.4% in colonic ESD;
- bleeding – may be immediate or delayed, occurring after the procedure.
The overall rate of complications is 1.5%.

Endoscopic ultrasound (EUS):
The use of high-frequency EUS is useful to determine the depth of invasion of colorectal lesions. According to some studies, the efficacy of EUS is found to be superior to chromoendoscopy in determining the depth of the tumor.