- A 56-year-old woman with multiple comorbidities presented with dysphagia and endoscopic examination revealed an esophageal mass with associated Barrett’s esophagus. The mass was 6 cm long (Fig. 1A), and histologic examination showed adenocarcinoma. Echoendoscopic staging showed a T2 lesion, but staging was incomplete because the radial echoendoscope could not traverse the malignant stricture. The patient was referred for oncology, surgical, and radiation oncology evaluation, but given her comorbidities she was determined not to be a candidate for those therapies.
- A 69-year-old man presented with an incidental finding of a diffusely dilatated pancreatic duct to 18 mm on CT performed for evaluation of emphysema. Magnetic resonance imaging showed an additional 12-mm mural nodule in a side branch duct in the tail of the pancreas. A multidisciplinary tumor board agreed during discussion that performing a segmental distal pancreatectomy to remove the nodule might not be of benefit if there were high-risk lesions in the proximal pancreatic duct, given the diffusely dilatated pancreatic duct without obvious lesions of the proximal main duct.
- An 81-year-old woman was transferred to our hospital after an unsuccessful ERCP for Escherichia coli bacteremia, abnormal liver function test results, and right upper-quadrant pain. At ERCP, attempted cannulation of the bile duct using the traditional route was unsuccessful. Thus, EUS-guided biliary access was achieved with a 19-gauge access needle into a 13-mm bile duct in a transduodenal approach. A 450-cm 0.025-inch wire was passed in a transpapillary fashion; this was technically difficult but successful (Fig. 1A).
- A 64-year-old woman underwent an EGD that revealed esophageal erythema from 21 cm from the incisors to 36 cm. Biopsy specimens taken from every centimeter revealed multifocal high-grade squamous neoplasia/superficial cancer. The patient was referred for endoscopic staging. EGD showed subtle irregular mucosa in the upper esophagus at 21 cm (Fig. 1A, arrow) and erythema from 23 to 36 cm. Echoendoscopic examination showed intact esophageal layers and no lymphadenopathy. Involvement of the muscularis mucosa, which is essential to determine eligibility for endoscopic therapy, could not be determined.
- A 47-year-old woman recently underwent an ERCP with mechanical lithotripsy for a symptomatic stone. The stone was cleared per the endoscopist, but because of ampullary edema a stent was placed. The patient continued to experience right upper-quadrant abdominal pain, and thus the clinical picture suggested a retained stone. A subsequent ERCP was performed for stent removal and re-evaluation. The stent was removed, and multiple balloon sweeps that started at the hilum yielded no stones. An occlusion cholangiogram showed a bile duct dilated to 15 mm and no filling defects (Fig. 1A).
- A 60-year-old woman was referred with a chronic gastrocutaneous fistula resulting from failure of a gastrostomy-tube site closure. The patient had been experiencing persistent, large-volume leakage of gastric contents since her gastrostomy tube was dislodged 3 years prior. Her albumin level was 3.3 g/dL. The patient had been seen by the surgical department and was deemed a poor surgical candidate for closure of the surgical fistula. The decision was made to attempt closure with an over-the-scope clip.
- A 57-year-old woman with metastatic breast cancer presented with jaundice and decreased oral intake secondary to vomiting. A CT scan showed a large, pancreatic mass causing biliary and duodenal obstruction. Given the duodenal obstruction, conventional ERCP could not be performed. EUS-guided choledochoduodenostomy was accomplished by using a lumen-apposing metal stent (Axios; Xlumena Inc, Mountain View, Calif) for biliary drainage, followed by placement of a duodenal stent. Because of its saddle-shape design, the lumen-apposing stent appears to be ideal in the setting of dual stenting.
- A 64-year-old man presented with painless jaundice. ERCP showed a stricture at the proximal common hepatic duct, and a 10F × 15-cm biliary stent was placed. Examination of biopsy specimens revealed cholangiocarcinoma. The patient was deemed a nonsurgical candidate, and repeat ERCP was performed for revision to metal stent. During ERCP the plastic stent was noted to have migrated proximally into the left intrahepatic system, and it was embedded (Fig. 1A). Multiple attempts to remove the stent were unsuccessful despite the use of rat-tooth and alligator forceps, extraction and dilating balloons, snares, and various baskets.
- An 83-year-old woman was admitted to the medical intensive care unit (ICU) for septic shock caused by bacteremia from cholangitis. Owing to the patient’s unstable condition, emergent ERCP without fluoroscopy was performed at the bedside with the patient in the left lateral decubitus position. Endoscopy revealed a bulging and ulcerated ampulla consistent with an impacted stone (Fig. 1A). Bile duct cannulation was performed; however, it was unclear whether bile duct access was obtained because bile aspirate from the sphincterotome was minimal.