Gastrointestinal and Pancreatico-Biliary Diseases: Advanced Diagnostic and Therapeutic Endoscopy

Description

This unique book is the first to focus on diagnostic and therapeutic endoscopy in gastrointestinal and pancreatico-biliary diseases. It provides an in-depth overview of the state of the art in diagnostic and therapeutic endoscopy of both the digestive tract and the pancreatico-biliary ductal system, and documents the latest innovations in the field. The first part of the book addresses advanced diagnostic and therapeutic endoscopy of the digestive tract, discussing bariatric endoscopic surgery, and the treatment of neoplasia and precancerous lesions of the upper and lower GI tract, motor disorders, GERD, strictures, fistulae and bleeding. The second part of the book is explores ERCP and EUS procedures, covering the diagnosis and therapy of biliary ductal system and pancreatic diseases. Each chapter includes an abundance of color images that document in detail the devices, operative techniques and outcomes. Written by leading internationally renowned experts, the book is a valuable resource for both specialists and residents in gastroenterology and surgery. Foreword Preface Contents About the Editors Contributors Part I: Diagnosis and Therapy of Upper G.I. Neoplasia and Precancerous Conditions 1 Advanced Imaging Techniques and In Vivo Histology: Current Status and Future Perspectives (Upper G.I.) Introduction High-Resolution and Magnifying Endoscopy Chromoendoscopy Digital or Virtual Chromoendoscopy Autofluorescence Imaging Optical Coherence Tomography Volumetric Laser Endomicroscopy Endomicroscopy Technique of Confocal Laser Endomicroscopy Principle of Confocal Endomicroscopy Endomicroscopy of Barrett´s Esophagus and Associated Neoplasia Gastritis, HP, and Gastric Cancer Duodenal Diseases: Celiac Disease and Atypical Food Allergies Molecular Imaging References 2 Role of Endoscopic Ultrasound in Pretreatment Staging of Upper Gastrointestinal Tract Cancers Introduction Esophageal Cancer Characteristics and Clinical Significance of EUS Evaluation of the Depth of Invasion (T Staging) Evaluation of the Lymph Node Involvement (N Staging) Cost Analysis Other Adjunctive Approaches to Endoscopic Ultrasound for Esophageal Cancers Limitations Gastric Cancer Characteristics and Clinical Significance of Endoscopic Ultrasound Evaluation of the Depth of Invasion (T Staging) Evaluation of the Lymph Node Involvement (N Staging) Limitations Gastric Lymphoma Ampullary Cancer Characteristics and Clinical Significance of Endoscopic Ultrasound Evaluation of the Depth of Invasion (T Staging) Evaluation of the Lymph Node Involvement (N Staging) References 3 Esophageal Neoplasia: Endoscopic Diagnosis and Treatment Introduction Epidemiology Screening and Detection Barrett´s Esophagus Characterization and Surveillance Squamous Neoplasia of Esophagus Cancer Prevention Treatment The Future Cross-References References 4 Endoscopic Resection of Squamous Cell Carcinoma: Techniques and Outcomes Introduction Clinical Pathway and Indications for Endoscopic Resection Resection Techniques Endoscopic Mucosal Resection (EMR) Endoscopic Submucosal Dissection (ESD) Suggestions for Safe and Effective Esophageal ESD Technical Tips and Tricks in Esophageal ESD Recent Technical Innovation in ESD Outcomes EMR Vs ESD ESD Vs Surgery Prevention of ESD-Related Stricture Combination of ESD and Other Oncological Treatments Conclusions References 5 Management of Barrett´s Esophagus: State of the Art Introduction Screening Who to Screen? How to Screen? Esophagogastroduodenoscopy (EGD) Unsedated Transnasal Endoscopy (UTNE) Esophageal Video Capsule Non-endoscopic Cell Collection Devices Oral Microbiome Exhaled Volatile Organic Compounds Surveillance Who to Survey? How to Survey? White Light Endoscopy Enhanced Imaging Technology Dye-Based Chromoendoscopy Optical or Virtual Chromoendoscopy Volumetric Laser Endomicroscopy (VLE) Probe-Based Confocal Laser Endomicroscopy(pCLE) Wide Area Transepithelial Sampling (WATS) Artificial Intelligence Posttreatment Surveillance Medical Therapy and Chemoprevention Proton Pump Inhibitors (PPI) Other Drugs for Chemoprevention Conclusions Cross-References References 6 Radiofrequency Ablation of Barrett´s Epithelium Introduction Indications for Radiofrequency Ablation Barrett´s Esophagus with Macroscopically Visible Neoplastic Lesions Barrett´s Esophagus with Flat High-Grade Dysplasia Barrett´s with Low-Grade Dysplasia Non-dysplastic Barrett´s Esophagus Ablation Procedures and Technical Aspects Circumferential Ablation Focal Ablation Posttreatment Management Follow-Up after Endoscopic Eradication Therapy Efficacy Outcomes of Radiofrequency Ablation Short-Term and Long-Term Outcomes Adverse Events Conclusion Cross-References References 7 Cryotherapy and Argon Ablation of Barrett´s Epithelium Introduction Argon Plasma Coagulation Rationale Background Technical Aspects Efficacy Short-Term Outcomes - Initial Experience (Table 1) Long-Term Outcomes (Table 2) Randomized Controlled Trials Efficacy: Discussion Buried Glands and APC Adverse Events Summary Cryotherapy Rationale Background Cryotherapy Technical Aspects Liquid Nitrogen Spray (LNS) Cryoballoon Focal Ablation System, CbFAS Cryoablation Efficacy LNS CO2 Results CbFAS Long-Term Follow-Up Pooled Analysis Comparison Cryotherapy Versus RFA Adverse Events Summary Cryotherapy Conclusion References 8 Resection Techniques in Barrett´s Esophagus Introduction Different Endoscopic Resection Techniques Endoscopic Resection with the ``Suck-and-Cut´´ Technique Cap-ER (ER-C) ER with a Ligation Device (ER-L) Endoscopic Submucosal Dissection (ESD) Different Steps of the ESD Procedure Complications Cross-References References 9 Endoscopic Characterization of Gastric Lesions and Resection Strategy Endoscopic Diagnosis of Early Gastric Epithelial Neoplasias and Therapeutic Strategy Introduction Detection and Characterization in Screening Endoscopy Technique Preparation EGD Technique Knowledge Background Mucosa Endoscopic Markers for Detecting EGC Characterization Conventional White Light Endoscopy (C-WLE) Magnifying Endoscopy (ME) with Image Enhanced Endoscopy (IEE) Technique Preoperative Endoscopic Diagnosis for Determining the Indications of Endoscopic Resection Histologic Type Size Invasion Depth Ulcer The Horizontal Extent of EGC Conclusion References 10 Endoscopic Submucosal Dissection of Gastric Lesions Epidemiology of Gastric Cancer Principle and Indication of ER for EGC Management After ER for EGC Curability Long-Term Outcome After ER Management in Elderly Patients with Curability C-2 After ER Appendix: Guidelines in the World Conclusion References 11 Endoscopic Resection of Submucosal Lesions of the Upper GI Tract: Full-Thickness Resection (EFTR) and Submucosal Tunneling ... Introduction Indications of Endoscopic Management Submucosal Tunneling Endoscopic Resection (STER) Indications of STER Absolute Indications Relative Indications Absolute Contraindications Pre-Procedure Assessment STER Procedure Equipment Required Procedure Steps (Fig. 1) STER at Different Situations Post-Procedure Care Adverse Events of STER Intra-Procedural Complications Post-Procedure Complications Patient Follow-Up Clinical Outcomes of STER Endoscopic Full-Thickness Resection (EFTR) Indications of EFTR Pre-Procedure Assessment and Equipment EFTR Techniques Free-Hand EFTR STEPS of EFTR [16] (Fig. 3) Full-Thickness Resection Device Assisted Post-Procedure Care Complications of EFTR Clinical Outcome of EFTR Comparing Different Modalities Summary and Conclusion References 12 POET and CLEAN-NET for Submucosal Tumor Introduction EMR and ESD Per-Oral Endoscopic Tumor Resection (POET) Concept Indication and Exclusion Criteria Technique Clinical Outcomes Technical Considerations and Limitations Summary Combination of Laparoscopic and Endoscopic Approaches for Neoplasia with Non-exposure Technique (CLEAN-NET) Concept of LECS Classification of LECS Indication Criteria Technique of CLEAN-NET Clinical Outcomes Considerations and Limitations Growth Pattern Appendix Summary Conclusions References 13 Vater´s Papilla Neoplasia: Endoscopic Ultrasonography for Preoperative Staging Introduction Benign Ampullary Neoplasms Ampullary Carcinoma Assessment of Ampullary Neoplasms Endoscopic Ultrasound and Intraductal Ultrasound Follow-Up of Post-Papillectomy Patients Summary References 14 Endoscopic Snare Papillectomy Introduction Papillectomy and Ampullectomy Diagnostic Work-Up Clinical Assessment Preoperative Evaluation and Staging Endoscopic Snare Papillectomy: Technique General Principles ERCP Endoscopic Resection Retrieval of the Specimen Pancreatic Stenting Biliary Stenting Bleeding Management Ablative Therapies Intraductal Extension Specimen Arrangement Surveillance Endoscopic Snare Papillectomy: Results Cross-References References 15 Endoscopic Diagnosis of Early Duodenal Epithelial Neoplasia and Therapeutic Strategy Introduction Differentiation Between Duodenal Neoplasms and Non-neoplasms Case Presentation Differentiation Between Duodenal Adenoma and Carcinoma Case Presentation Conclusion References Part II: Diagnosis and Therapy of Lower G.I. Neoplasia and Precancerous Conditions 16 Enteroscopy: Techniques and Small Bowel Therapy Introduction Principle of Balloon-Assisted Enteroscopy Distal Attachment Thin Wall How to Manage Bleeding A Polyp with Intussusception Looks Like a Pedunculated Polyp Endoscopic Reduction of Intussusception Endoscopic Management of Familial Adenomatous Polyposis Characteristics of Familial Adenomatous Polyposis Timing of Intervention in FAP CSP for Adenomas in FAP Follow-up After the Treatment in FAP Endoscopic Management of Peutz-Jeghers Syndrome Characteristics of Peutz-Jeghers Syndrome Retrograde BAE as First Approach Ligation Therapy For Huge Polyps For Incomplete Total Enteroscopy Patients BAE Assisted by Laparoscopic Adhesiolysis Follow-up After the Treatment in PJS Conclusion Cross-References References 17 Advanced Imaging Techniques and In vivo Histology: Current Status and Future Perspectives (Lower G.I.) Introduction High Definition Endoscopy (High-Definition White-Light Endoscopy-HD-WLE and Standard-Definition White Light Endoscopy-SD-WLE) Chromoendoscopy-Dye Based Advancement in Narrow Spectrum Imaging Technologies (High-Definition Narrow Band Imaging-HD-NBI, Flexible Spectral Imaging Col... Blue Light Imaging (BLI) and Linked Color Imaging (LCI) Autofluorescence Imaging (AFI) Confocal Laser Endomicroscopy (CLE) Future Direction Optical Diagnosis of Colorectal Polyp, Are We Ready? Barriers of Application of Optical Diagnosis of Colorectal Polyps Artificial Intelligence Role in Gastroenterology Conclusion Cross-References References 18 Endoscopic Characterization of Colorectal Lesions and Resection Strategy Part 1: Characterization of Colorectal Lesions Introduction Gross Morphology of Colorectal Lesions Paris Classification Laterally Spreading Type (LST) Classification Chromoendoscopy Dye-Based Chromoendoscopy Virtual Chromoendoscopy Kudo´s Classification of Colorectal Lesions NBI International Colorectal Endoscopic Classification (NICE) Japanese NBI Expert Team (JNET) Classification SMSA Small Colorectal Polyps Computer-Aided Diagnosis and Artificial Intelligence (AI) Workflow for the Endoscopic Characterization of Colorectal Lesions Part 2: Resection Strategy Introduction Resection Techniques Hot Snare Polypectomy (HSP) Cold Snare Polypectomy (CSP) Endoscopic Mucosal Resection (EMR) Underwater EMR (UEMR) Endoscopic Submucosal Dissection (ESD) Endoscopic Full Thickness Resection (EFTR) Resection Strategy (EMR Versus ESD) Endoscopic Resection for Early CRC (eCRC, pT1 Carcinoma) References 19 Endoscopic Mucosal Resection of Colorectal Lesions Introduction Lesion Assessment Morphology Surface Assessment Technique Patient Preparation Submucosal Injectate and Snares Resection Technique Submucosal Injection Snare Resection Electrosurgical Generator Settings Adjunctive Techniques Post-procedural Care Follow-Up Variant Techniques Piecemeal Cold Snare Polypectomy Underwater EMR Polyps for Special Considerations LSLs in the Anorectum Peri-appendiceal and Ileocecal Valve LSLs Large Pedunculated Polyps Lesions Previously Attempted for Resection Managing Complications Intra-procedural Bleeding Delayed Bleeding Perforation Post-polypectomy Electrocoagulation Syndrome and Delayed Perforation Stricturing Conclusion References 20 Endoscopic Submucosal Dissection of Colorectal Lesions Histologic Microstaging for Lymph Node Metastasis Risk Endoscopic Characterization of Superficial Colorectal Neoplasm Morphology, Size, and Additional Gross Features Surface Patterns Technical Issues: EMR Versus ESD Guidelines Comparison Technique Knives Lifting Solutions and Multifunction Knives Conventional Technique of Colorectal ESD Facilitations for SM Dissection Pocket Creation Method and Tunneling Traction Methods Traction Platforms Special Neoplasms Ileocecal Valve Cross-References Appendix Ano-Rectal Junction Nonlifting Lesions Inflammatory Bowel Disease References 21 Hybrid Technique for Difficult Colorectal Lesions Introduction Hybrid ESD Technique Factors Influencing the Outcome of H-ESD Complication of Hybrid ESD Hybrid ESD as Rescue Technique in Case of Failed ESD Knife-Assisted Resection EndoRotor Device Treatment of Scarred Recurrences Using Hybrid Technique Conclusions References 22 Piecemeal EMR Versus ESD for Large Colorectal Lesions: Pros and Cons Introduction Piecemeal EMR Versus ESD: Pros and Cons Piecemeal Resection Versus En Bloc Resection Learning Curve and Length of Procedure Recurrence and Follow-Up Complications: Delayed Bleeding and Perforation Cost-Effectiveness Conclusions Cross-References References 23 Resection of Submucosal Lesions of the Lower GI Tract: Full-Thickness Resection (EFTR), OVESCO Introduction Full-thickness Resection Device of Colorectal Submucosal Lesions The Full-thickness Resection Device (FTRD) Technique for performing FTRD Clinical evidence of the FTRD for lower GI submucosal lesions Over-the-scope clip-assisted method for full-thickness resection of submucosal lesions The over-the-scope clip device Technique for performing EFTR OTSC-assisted Clinical evidence of the EFTR OTSC-assisted EFTR resection with OTSC closure Conclusion References 24 Endoscopic Ultrasonography for Preoperative Staging of Rectal Lesions Introduction Useful Assessment Pearls for Primary Rectal Cancer Clinical Staging Anorectal Anatomy TNM Staging System for Rectal Cancer EUS Technique T Staging Pitfalls Nodal Staging Pitfalls Placement of Fiducials Utility of EUS Compared to Other Staging Modalities MRI Versus EUS Assessment CT and PET-CT Versus EUS Assessment Molecular EUS Utility of EUS Assessment Following Neoadjuvant Therapy Role for EUS Surveillance Following Radical or Local Surgery in Rectal Cancer EUS for Rectal Linitis Plastica References 25 Colonoscopy Surveillance After Adenoma Removal: Current Guidelines Introduction Important Principles for Appropriate Colonoscopy Surveillance After Polypectomy Lesion Related Risk Factors Form the Basis for Most Surveillance Recommendations Patient Related Risk Factors Not Included in Most Surveillance Recommendations Risk Stratification When Should Surveillance Stop Ongoing Initiatives to Improve the Current Guidelines on Colonoscopy Surveillance After Polypectomy Conclusions References 26 Uptake of Colorectal Cancer Screening and Cost-Effectiveness Introduction Uptake of CRC Screening Cost-Effectiveness Cross-References References 27 Advanced Techniques in Colonoscopy in Inherited Cancer Conditions Introduction Lynch Syndrome HD Endoscopy Chromoendoscopy AFI Device-Assisted Colonoscopy Serrated Polyposis Syndrome Familial Adenomatous Polyposis Cross-References References 28 Advanced Colonoscopy Techniques in Inflammatory Bowel Diseases Introduction New Endoscopic Techniques Available to Assess Inflammation and MH in IBD High Definition (HD) Endoscopy Virtual Electronic Chromoendoscopy (VCE) and Magnification Endoscopic Techniques Available in Surveillance Colonoscopy in IBD Dye-Based Chromoendoscopy (DCE) Virtual Electronic Chromoendoscopy (VCE) Characterization of Colonic IBD Lesions by Advanced Endoscopic Technologies New Advanced Endoscopic Technologies in Evolution Confocal Laser Endomicroscopy Clinical Application to Assess Inflammation and Functional Mucosal Barrier CLE Molecular Imaging Clinical Application to Detect and Characterize Colonic Lesions Using CLE Endocytoscopy (EC) Clinical Assessment of Mucosal Healing in IBD Using EC Clinical Role of EC for Colonic Lesion Characterization The Future at the Horizon and Artificial Intelligence Conclusions References 29 Future Technologies for Treatment of G.I. Tract Lesions Introduction Notes Robots in Endoscopy Robotic Driven Endoscope Locomotion Aer-O-Scope Invendoscope Endotics NeoGuide Endoscopy System Robotic Driven Instrumentation The Master System Flex Robotic System Medical Capsule Robots Capsule Robots for Surgical Treatment Conclusions References 30 Artificial Intelligence for Diagnosing G.I. Tract Lesions Introduction Gastric Pathology Gastric Neoplasia Detection Gastric Cancer Screening Depth of Gastric Cancer Invasion Helicobacter Pylori Assessment Esophageal Pathology Barrett´s Esophagus (BE) and Early Esophageal Adenocarcinoma (EAC) Esophageal Squamous Cell Carcinoma (ESCC) Esophageal Cancer Depth of Invasion Colorectal Pathology Polyp Detection Polyp Characterization Simultaneous Polyp Detection and Characterization Inflammatory Bowel Disease Small Bowel Pathology Using Capsule Endoscopy (CE) Regulatory, Privacy, and Ethical Issues References Part III: Therapy of Motor Disorders of Gastrointestinal Tract 31 Endoscopic Myotomy and Septotomy for Zenker´s Diverticulum (Z-POEM) Introduction References 32 Peroral Endoscopic Myotomy (POEM) for Achalasia: Indications, Techniques, and Outcomes Introduction Indications Treatment Naïve Vs. Patients with Prior Treatment Patients with Type III Achalasia Patients with Nonachalasia Esophageal Motility Disorders Technique Mid- to Long Term Efficacy Adverse Events Perioperative Adverse Events Reflux After POEM Comparative Data on POEM Vs. Conventional Treatments POEM Vs. Heller Myotomy POEM Vs. Pneumatic Dilation (PD) Conclusion References 33 Stenting and Endoscopic Techniques Alternative to POEM for Achalasia Introduction Injection Therapy Pneumatic Balloon Dilation Self-expanding Metal Stents Cross-References References 34 Peroral Endoscopic Myotomy (Poem) for Esophageal Motility Disorders: Indications, Techniques, and Outcomes Introduction Pathophysiology of Spastic Esophageal Motor Disorders (SED) Clinical Presentation and Diagnosis of Spastic Esophageal Disorders (SED) Esophagogastric Junction Outflow Obstruction (EGJOO) Distal Esophageal Spasm (DES) Jackhammer Esophagus General Treatment of SED Pharmacological Treatment Endoscopic Treatment Surgical Treatment Esophageal Peroral Endoscopic Myotomy (E-Poem) in SED Treatment Before E-POEM Position of the Patient Incision and Tunnel Creation Myotomy Type Length Site (Anterior Vs. Posterior) Full Thickness Vs. Circular Muscle Myotomy Entry Site Closure Outcomes E-Poem in SED E-POEM Vs. LHM in SEDs Adverse Events (AE) of E-Poem GERD After E-POEM Indications and E-Poem Role in Spastic Esophageal Disorders (SED) Conclusion References 35 Endoscopic Pyloromyotomy (G-POEM): Indications, Techniques, and Outcomes Introduction Diagnosis Management Endoscopic Pyloromyotomy (G-POEM) Indications Anesthesia Prerequisites for Procedure Technical Tips Outcomes Adverse Events Limitations Conclusion References 36 Perrectal Endoscopic Myotomy (PREM) Introduction Evolution, Philosophy, and Development of PREM Patient Selection and Pre-Procedure Workup Clinical Profile Diagnosis Colonoscopy Colonoscopic Mapping of the Aganglionic Segment The PREM Procedure Pre-Procedure Preparation Instrumentation Technique of PREM (Videos 3 and 4) Post-Procedure Care and Instructions Status of PREM Cross-References References Part IV: Therapy of Gastroesophageal Reflux Disease 37 Transoral Fundoplication for Treatment of Gastroesophageal Reflux Disease Introduction Indications for TIF Techniques for TIF Pre-procedure Evaluation TIF by EsophyX Z Device TIF by MUSE Device Postoperative Care Complications Outcomes of TIF Efficacy of TIF in Controlling GERD-Related Symptoms Efficacy of TIF in Controlling Gastro-Esophageal Reflux Efficacy of TIF in Controlling GERD in the Long-Term Period Efficacy of TIF Compared with Surgical Fundoplication Factors Affecting Outcomes After TIF Potential Limitation to Treat GERD by Surgery After TIF Failure and Vice Versa Conclusions References 38 Antireflux Mucosectomy and Antireflux Mucosal Ablation: Techniques and Outcomes Introduction Concept of ARMS and ARMA Indication and Exclusion Criteria Evaluation Before ARMS/ARMA Upper Gastrointestinal Endoscopy Hiatal Hernia (HH) Esophageal Manometry Esophageal pH Testing With/Without Impedance Barium Esophagram Techniques in Antireflux Mucosectomy (ARMS) ARMS Technique Management and Follow-Up Post-ARMS Outcomes of ARMS Efficacy Safety Techniques in Antireflux Mucosal Ablation (ARMA) ARMA Techniques Postoperative Management Outcomes of ARMA Efficacy Safety Conclusion References 39 Endoscopic Radiofrequency (Stretta) in the Management of Gastroesophageal Reflux Disease (GERD) Introduction The Stretta The Technique Mechanism of Action Patients The Role of Stretta in GERD Stretta in Nonerosive Reflux Disease (NERD) Stretta in Elderly Patients Durability of Stretta Comparative Trials Stretta for GERD Postsurgery Cost Analysis Safety Conclusions Cross-References References Part V: Therapy of Metabolic Disorders 40 Endoscopic Treatment for Obesity and Weight Management: State of the Art The Obesity Epidemic and Endobariatric Therapies The Role of Endobariatric Therapies and Appropriate Candidates Gastric Endobariatric Therapies Intragastric Balloons Endoscopic Suturing and Plication Procedures TransPyloric Shuttle Aspiration Therapy Potential Future Technologies Full Sense Device EndoZip Device Small Bowel Endobariatric Therapies Duodenal-Jejunal Bypass Liner Gastroduodenojejunal Bypass Liner Duodenal Mucosal Resurfacing Incisionless Magnetic Anastomosis System Future Directions Cross-References References 41 Intragastric Occupying Space Devices Introduction Intragastric Balloons IGB: Action Mechanisms IGB: Indications for Treatment IGB: Contraindications IGB: Pre-procedure Assessment and Multidisciplinary Follow-Up IGB: Post-placement Management Pharmacological Treatment of Symptoms Post-placement Diet IGB: Patient Follow-Up ORBERA Intragastric Balloon System RESHAPE DUO Integrated Dual Balloon System OBALON Balloon System TransPyloric Shuttle The Future References 42 Endoscopic Sleeve Gastroplasty Introduction Indications and Technique Indication Endoscopic Technique Outcome and Adverse Events Conclusions References 43 Aspiration Therapy for Obesity Indications and Contraindications for the Procedure AspireAssist Device Technique of Implantation Clinical Follow-Up Complications Outcomes References 44 Duodenal Resurfacing for Treatment of Type 2 Diabetes Introduction Endoscopic Duodenal Mucosal Resurfacing Proof-of-Concept in Animal Models Duodenal Mucosal Resurfacing Procedure Safety and Effectiveness of Duodenal Mucosal Resurfacing Using the Revita System in Treatment of Type 2 Diabetes Conclusion References 45 Endoscopic Management of Complications of Bariatric Therapy Introduction General Considerations and Recommendations Anatomy of Bariatric Procedures Complications Following Bariatric Surgery Ulcers and Bleeding Strictures Leaks and Fistulas Exclusion Closure To Provide Internal Drainage Weight Regain Procedure-Specific Complications Gastrogastric Fistula Candy Cane Syndrome Conclusions Cross-References References 46 Endoscopic Management of Weight Regain Introduction Endoscopic Suturing Endoscopic Plication Thermal (Heat/Cold) Therapy Cap-Mounted Clips Conclusion References Part VI: Therapy of Gastrointestinal Strictures 47 Self-Expanding Stents: Present and Future Introduction Present Devices Esophagus Gastric and Small Bowel Colon Future Conclusions Cross-References References 48 Endoscopic Management of Malignant Esophageal Strictures Introduction Esophageal Stenting Stent-Related Adverse Events Stent Placement as Bridge to Surgery Other Palliative Endoscopic Techniques Conclusions References 49 Endoscopic Management of Cervical Esophageal Strictures Introduction Anatomy Cause and Assessment Treatment of Benign Strictures Dilation Steroid Injection Topical Mitomycin Stents Incisional Therapies Submucal Tunneling Summary References 50 Endoscopic Management of Benign Esophageal Strictures Introduction Dilation Corticosteroids Mitomycin C Incision Temporary Stenting Self-Bougienage Therapeutic Algorithm Cross-References References 51 Biodegradable Self-Expandable Stents for Benign Strictures: Indications and Outcomes Introduction The History of Biodegradable Stent Development The First Steps Further Development Currently Available Biodegradable Stents Indications and Outcomes Refractory Benign Esophageal Stricture The SX-ELLA Biodegradable Stent in the Clinical Practice Conclusion Cross-References References 52 Endoscopic Stenting for Gastric Outlet Obstruction Introduction Stenting for Malignant Gastric Outlet Obstruction Introduction to Self-Expandable Metal Stents Indications and Contraindications Preprocedural Evaluation Patient Evaluation Patient Preparation Equipment Steps of Stent Placement Evaluation of the Stricture Choice of Stent Stent Deployment Troubleshooting Outcomes Technical Success and Clinic Success Complications Stent Obstruction Stent Migration Stent Fracture Perforation Bleeding Cholangitis Abdominal Pain Predictors of Resumption of Oral Intake and Stent Patency Double Stentings for Combined Malignant Biliary Obstruction and Gastric Outlet Obstruction Stenting at Surgical Anastomosis Site of Gastrojejunostomy Stenting for Benign Gastric Outlet Obstruction Self-Expandable Metal Stents Lumen-Apposing Metal Stents Innovation Specifically Designed Metal Stents Anti-migration Stents Drug-Eluting Stents Shape-Modified Stents Conclusion Cross-References References 53 Endoscopic Ultrasound (EUS)-Guided Gastroenterostomy (EUS-GE) Introduction Pre-procedure Preparation Endoscopic Equipment Techniques Antegrade EUS-GE (Gastroenterostomy) Direct Method (Fig. 2) EUS-Guided Balloon-Occluded Gastrojejunostomy Bypass (EPASS) Traditional Method (Fig. 3) Rendezvous Method Retrograde EUS-GE (Enterogastrostomy) Post-procedure Care Adverse Events Outcomes Future Perspectives and Conclusions References 54 Enteroscope-Assisted Small Bowel Stenting Introduction Endoscopic Therapy Alternative Methods of Stent Placement References 55 Endoscopic Management of Malignant Colorectal Strictures Introduction Initial Considerations Clinical Criteria for Colonic Obstruction Radiological Evaluation of Colonic Obstruction Endoscopic Evaluation of Colonic Obstruction Oncological Setting (Curative/Palliative Intent) Stenting Experience Chemotherapy with or Without Anti-Angiogenic Treatment Choosing the Appropriate Stent Covered Versus Uncovered SEMS Stent Length Stent Diameter Stent Material (Pre-)endoscopic Considerations Bowel Preparation with Enema Prophylactic Antibiotics Pre-procedural Treatment of Ileus Sedation Fluoroscopy, Endoscopy, or Combination Stricture Dilation Post-endoscopic Considerations Adverse Events and How to Handle Them Insufficient Relief of Ileus Perforation Migration Recurrent Obstruction Cross-References References 56 Colorectal Stenting as Bridge to Surgery Introduction Emergency Surgical Treatment Right-Sided Colonic Obstruction: Surgical Procedures Left-Sided Colonic Obstruction: Surgical Procedures Hartmann´s Procedure Resection and Primary Anastomosis Subtotal Colectomy Decompressing Stoma Stent as a Bridge to Elective Surgery Preprocedural Preparation Operative Technique Stent´s Related Complications Stent as a Bridge to Elective Surgery Versus Emergency Surgery Right-Sided Malignant Colonic Obstruction Left-Sided Malignant Colonic Obstruction Stent as a Bridge to Elective Surgery Versus Diverting Stoma as a Bridge to Surgery Conclusion Cross-References References 57 Endoscopic Management of Benign Colorectal Strictures Introduction Etiology and Risk Factors Colorectal Anastomosis Crohn´s Disease Diverticular Disease Large Mucosal Resection Endometriosis Radiotherapy Ischemia Bowel Preparation Endoscopic Treatment Digital and Instrumental Dilation Balloon Dilation Balloon Dilation and Intramural Corticosteroid Injection Electrosurgical Radial Incision Metal Stents Conclusion Cross-References References Part VII: Therapy of Fistulae, Wall Defects, and Bleeding 58 Techniques for Fistula Repair in the G.I. Tract Introduction Endoscopic Therapy Enteral Stents Endoscopic Clips Suturing Tissue Sealants Endoscopic Vacuum Therapy or Endo-Sponge Cardiac Septal Occluders (CSO) Approach to the Management Cross-References References 59 Stem Cells for Tissue Repair of the GI Tract Acronyms Introduction Renerative Medicine Techniques Regenerative Medicine as Applied for Partial-Thickness Defects Regenerative Medicine as Applied for Full-Thickness Patch Defects Regenerative Medicine as Applied for Long-Segment, Full-Thickness, Circumferential Defects Regenerative Medicine for Some Other GI Indications Perianal Fistulizing Crohn´s Disease Short Bowel Syndrome Hirschsprung Disease Regulations: Tissue Engineering for Human Application Summary Cross-References References 60 Endoscopic Management of Acute Non-variceal Upper Gastrointestinal Hemorrhage Introduction Section I: Pre-endoscopy Management Hemodynamic Resuscitation and Monitoring Risk Stratification Role of Blood Transfusion Nasogastric Tube Aspirate/Lavage Proton Pump Inhibitor Prior to Upper Endoscopy Promotility Agents Management of Antithrombotic Medications (Anticoagulants and Antiplatelet Agents) Anticoagulants Vitamin K Antagonists Direct Oral Anticoagulants (DOACs) Antiplatelet Agents Timing of Upper Endoscopy Section II: Intra-Endoscopy Management Endoscopic Diagnosis/Stigmata of Recent Hemorrhage Endoscopic Hemostasis Treatment Options High-Risk Stigmata (FIa, FIb, FIIa) Adherent Clot (FIIb) Second-Line/Salvage Endoscopic Hemostasis Treatment Options Doppler Ultrasound Tips and Tricks in Endoscopic Hemostasis Injection Therapy Thermal Therapy Mechanical Therapy Topical Therapy Section III: Post-Endoscopy Management PPI Therapy Scheduled Second-Look Endoscopy Persistent and Recurrent Ulcer Bleeding H. pylori Diagnosis and Treatment Management of Antithrombotic Agents (Anticoagulants and Antiplatelet Medications) Anticoagulants Antiplatelet Agents References 61 Endoscopic Management of Variceal Bleeding Introduction Esophageal Varices Endoscopic Band Ligation (EBL) Pre-procedural Preparation EBL: Procedure Complications Tissue Adhesive Injection Procedure Complications Primary Prophylaxis of Variceal Bleeding EBL Versus NSBBs EBL Versus No Treatment EBL Versus Placebo IsMn Versus EBL NSBBs + IsMn Versus EBL EBL+ NSBBs Versus NSBBs EBL+ NSBBs Versus EBL Conclusion Management of Acute Variceal Bleeding Endoscopic Therapy + Vasoactive Drugs Versus Endoscopic Therapy EST Versus Vasoactive Drugs EST Versus EST + Vasoactive Drugs EST + Vasoactive Drugs/Balloon Tamponade Versus Vasoactive Drugs/Balloon Tamponade EST Versus EBL Conclusion Secondary Prophylaxis of Variceal Bleeding EBL Versus EST EBL Versus EST + EBL TIPS Versus ET ET + NSSBs Versus ET EBL Versus NSBBs EBL+ NSBBs Versus EBL EBL+ NSBBs Versus NSBBs NSBBs ± IsMn Versus EBL NSBBs + IsMn Versus ET NSBBs ± IsMn Versus NSBBs ± IsMn + EBL NSBBs + IsMn + EBL Versus EBL NSBBs + IsMn Versus TIPS EBL Versus NSBBs + IsMn EBL + NSBBs Versus Monotherapy EBL+ NSBBs Versus TIPS Surgical Portosystemic Shunts Versus ET Conclusion Gastric Varices New Approaches General Conclusions References 62 Endoscopic Management of Colonic Angiodysplasias Introduction Definition Epidemiology Aortic Stenosis Von Willebrand Disease (vWD) Chronic Renal Failure (CRF) Pathogenesis Diagnosis Endoscopy Imaging Techniques Radionuclide Scanning CT Enterography and MR Enterography Catheter Angiography Treatment Endoscopic Treatment Argon Plasma Coagulation (APC) Electrocoagulation: Heather Probe and Bipolar Electrocautery Laser Photocoagulation Endoscopic Clipping Devices Endoscopic Ligation Thulium Laser Coagulation Pharmacologic Treatment Somatostatin Analogues Thalidomide Percutaneous Embolization Surgery References 63 Full-Thickness Closure of Iatrogenic or Post-Interventional Gastrointestinal Defect by the Use of Flexible Endoluminal Sutu... Introduction Endoscopic Suturing Device Iatrogenic Endoscopic Perforations Post-Endoscopic Full-Thickness Resection Wall Defect Closure Post-Endoscopic Submucosal Dissection Defect Closure References Part VIII: ERCP Technique 64 Difficult Biliary Cannulation and Sphincterotomy: What to Do Introduction Definition of Difficult Biliary Cannulation Risk Factors for Difficult Cannulation Patient Factors (Anatomy) Operator Factors (Experience) Normal Technique for Inserting the Duodenoscope to Identify the Papilla Problems with Intubation Inability to Intubate the Esophagus Looping of Duodenoscope in the Stomach Problems Identifying the Papilla Choosing Accessories for Biliary Cannulation: Catheters Choosing Accessories for Biliary Cannulation: Guidewires Initial Technique for Biliary Cannulation Strategies for Biliary Cannulation Following Pancreatic Duct Cannulation Use of Precut or Needle-Knife Papillotomy Transpancreatic Biliary Sphincterotomy Options for Cannulation When Wire Passes Through Wall of Intraduodenal Bile Duct Biliary Cannulation in the Presence of Periampullary Diverticulum Pancreatic Stent Insertion Followed by Pre-Cut Papillotomy/Fistulotomy Reverse Guidewire Method Endoclip-Assisted Cannulation Two Devices in One-Channel Method Balloon Dilatation of Narrow Diverticular Neck Cap Assisted Cannulation Double Endoscope Method Saline Injection Failed Biliary Cannulation Evidence-Based Approach for Achieving Biliary Cannulation Introduction to Biliary Sphincterotomy Things to Consider Prior to Biliary Sphincterotomy Patient Tolerance Implanted Electrical Devices Coagulopathy Previous Upper Gastrointestinal Surgery Recommended Initial Technique for Biliary Sphincterotomy Wire Guided Cannulation Choice of Current Direction and Length of Cut Specific Clinical Scenarios Performing Sphincterotomy in Patients with Stone Impaction Performing Sphincterotomy in Patients with Duodenal Diverticulae and Other Variants of Normal Anatomy Balloon Dilation as Alternative to Biliary Sphincterotomy Immediate Management of Visible Bleeding Cross-References References 65 Pancreatic Sphincterotomy Indications Major Papillotomy Pancreatic Strictures Pancreatic Stone Extraction Pancreatic Duct Disruptions/Leaks Idiopathic Recurrent Acute Pancreatitis (RAP) and Pancreatic Sphincter of Oddi Dysfunction Pancreatic Ductal Diagnostics Endoscopic Technique Pull-Type Needle-Knife Pancreatic Sphincterotomy Precut Access Papillotomy Use of Pancreatic Duct Stents Minor Papillotomy Endoscopic Technique Complications Associated with Pancreatic Sphincterotomy Cross-References References 66 Minor Papilla Cannulation and Papillotomy Introduction Anatomic Considerations for Endoscopic Therapy Involving the Minor Papilla Indications for Minor Papilla Cannulation, Papillotomy, and Dorsal Duct Therapy Minor Papillotomy in the Setting of Pancreas Divisum and Recurrent Acute Pancreatitis (RAP) Dorsal Duct Therapies in the Setting of Painful Chronic Pancreatitis Minor Papilla and Dorsal Duct Therapy in the Setting of Abdominal Pain Locating and Recognizing the Minor Papilla Preparation for Cannulation Cannulation Technique Minor Papillotomy Techniques Adverse Events Associated with Minor Papilla Cannulation and Papillotomy Conclusion Cross-References References 67 Biliary Balloon Sphincteroplasty Introduction Technique of Large Balloon Dilation of Postsphincterotomy Papilla Why Do We Perform Minor EST Before Dilation? The Extent of Sphincterotomy Before Performing EPLBD Optimal Large Balloon Dilation Technique Without a Sphincterotomy Determination of the Diameter of Dilating Balloon Optimal Duration of Balloon Inflation Adverse Events Factors Predictive of Adverse Events After EPLBD Lessons from These Fatal Cases Recommendations for Safe and Successful EPLBD Patient-Related Factors Related to Adverse Events References 68 Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Introduction Diagnosis Disease Severity Pathophysiology Prevention of Post-ERCP Pancreatitis Pre-ERCP Risk-Reducing Strategies Patient Selection Risk Stratification Intra-ERCP Risk-Reducing Strategies Risk Stratification Procedural Technique Prophylactic Pancreatic Stent Placement Pharmacoprevention Rectal NSAIDs Aggressive Lactated Ringer´s Solution Other Promising Agents Post-ERCP Risk-Reducing Strategies Aggressive LR Post-Procedure Hospital Observation References 69 ERCP in Surgically Altered Anatomy Introduction Equipment Endoscopes Accessories Others Preparations Specific Surgery Billroth II Whipple Surgery Hepaticojejunostomy Gastric Resection Roux-Y Gastric Bypass Specific Cannulation Issues Hepaticojejunostomy Intact Papilla Other Anastomoses Alternative Access Transhepatic Access Laparoscopy-Assisted Hybrid Procedures References 70 EUS- and Enteroscopy-Assisted ERCP Introduction Endoscopic Ultrasound-Guided Rendezvous Technique EUS-RV Puncture Route Detailed Methods Conclusion References 71 EUS-Guided Pancreatic Duct Cannulation Introduction Indications and Contraindications Accessories Procedure Outcomes Success Adverse Events Algorithm of Management of PD Obstruction Conclusion Cross-References References 72 Choledochoscopy: Techniques and Innovation Introduction Systems and Innovation Mother-Baby Systems Direct Peroral Cholangioscopy Systems DPOCS Ultrathin Endoscopes Double-Bending DPOCS Prototype Single-Operator Cholangioscopy (SOC) Percutaneous Cholangioscopy Indications Diagnostic Indications (Visual Impression and Classifications) Therapeutic Indications Preventing and Managing Complications Conclusion and Future References 73 Pancreatoscopy: Techniques and Innovations Introduction Equipment and Technique Video Pancreatoscope Two-Operator ``Mother-Baby´´ Method Single-Operator Cholangiopancreatoscopy Other Techniques Diagnostic Indications Intraductal Papillary Mucinous Neoplasm Indeterminate Pancreatic Duct Strictures (Benign or Malignant) Sampling Therapeutic Indications Intraductal Lithotripsy in Patients with Chronic Pancreatitis Adverse Events and Management Conclusions Cross-References References Part IX: Advanced Diagnosis and Therapy of Biliary Ductal System Diseases 74 Advanced Intraductal Biliary Imaging Introduction Indications For Cholangioscopy Diagnostic Therapeutic Cholangioscopy Systems Direct Peroral Cholangioscopy Freehand Technique Tandem Technique Balloon-Assisted Technique Hybrid Balloon Catheter Anchoring Devices Reusable Guiding Probe of Kautz Double-Bending Cholangioscope Indirect Cholangioscopy Dual-Operator System Single-Operator System Visualization Adjunctive Imaging Modalities Narrow-Band Imaging Chromocholangioscopy Autofluorescence Imaging (AFI) Confocal Laser Endomicroscopy (CLE) Intraductal Ultrasonography (IDUS) Optical Coherence Tomography Conclusion References 75 Treatment of Sphincter of Oddi Dysfunction Introduction Epidemiology Pathogenesis, Symptomatology, and Types Functional Biliary Sphincter Disorder (Previously Biliary SOD Type 2) Functional Pancreatic Sphincter Disorder Diagnosis Sphincter of Oddi Manometry (SOM) Management Endoscopic Therapy Benign Papillary Stenosis (Formerly Biliary SOD Type 1) Functional Biliary Sphincter Disorder (Previously Biliary SOD Type 2) Functional Biliary Abdominal Pain (Formerly Biliary SOD Type 3) Functional Pancreatic Sphincter Disorder Botulinum Toxin Injection Surgery Summary/Key Issues References 76 Treatment of Benign Biliary Stricture Introduction Causes General Principles Diagnosis Classification Treatment Endoscopic Therapy Biliary Access Dilatation Stent Choice Plastic Stents Metal Stents EUS-Guided Biliary Drainage (EUS-BD) Surgical Interventions New Techniques Treatment of Specific Disorders Postoperative Benign Biliary Strictures Post-Liver Transplant Biliary Stricture Chronic Pancreatitis Primary Sclerosing Cholangitis IgG4-Sclerosing Cholangitis HIV Cholangiopathy Biliary-Enteric Anastomotic Stricture Complications Bibliography 77 Treatment of Post-liver Transplant Strictures Introduction Strictures Non-anastomotic Strictures (NASs) Living-Related Donor Transplants Retained Surgical Stents Summary References 78 Endoscopic Management of Primary Sclerosing Cholangitis Introduction PSC and Rationale for Surveillance of Hepatobiliary Malignancy The ``Dominant´´ Stricture and Its Evaluation Role of ERCP in Evaluation of a Dominant Stricture ERCP with Brushings for Cytology ERCP with Stricture Biopsies and Use of Single-Operator Cholangioscopy (SOC) In Vivo Microscopy Next-Generation Sequencing (NGS) to Find Genetic Alterations Related to Biliary Strictures Our Practice Endoscopic Therapy of PSC Choledocholithiasis in PSC Risk of ERCP in PSC Our Practice References 79 Treatment of Malignant Hilar Strictures Introduction Clinical Features Role of Palliative Drainage for MHS Endoscopic Intervention Percutaneous Versus Endoscopic Approach Plastic Versus Metal Stents Unilateral (Single) Versus Bilateral (Multi-sectoral) Drainage Endoscopic Bilateral Metal Stents Deployment Self-Expandable Metal Stents for Bilateral Stenting Endoscopic Bilateral Stent-in-Stent Versus Stent-by-Stent (Side-by-Side) Deployment Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) Reintervention After Stent Malfunction Local Ablation Therapies Summary of Endoscopic Treatment References 80 Treatment of Malignant Biliary Distal Strictures Introduction Preoperative Biliary Drainage UNRESECTABLE Distal Malignant Biliary Obstruction How to Drain? - ERCP X EUS-CD X Surgery Plastic Stent X SEMS Covered SEMS X Uncovered SEMS Complications Stent Disfunction Conclusions References 81 Treatment of Concomitant Malignant Biliary Stricture and Gastric Outlet Obstruction Introduction Endoscopic Bilioduodenal Bypass Classification of Bilioduodenal Strictures Techniques Biliary Stenting First Other Dilation Techniques have been described Duodenal Stenting First 1. Combined Endoscopic Stent Insertion 2. Temporary Placement of Covered Enteral Metal Stent Outcomes of Endoscopic Bilioduodenal Bypass Conclusions Cross-References References 82 Treatment of Biliary Leaks and Fistulas Introduction Physiopathology of Biliary Fistulas How to Treat Biliary Fistulas Biliary Fistula from Isolated Transected Ducts Biliary Fistula in Surgically Altered Anatomy Post-Liver Transplantation (LT) Biliary Fistulas Primary Biliary Fistulas References 83 Management of Complications of Biliary Stenting Introduction Biliary Stents Fixed Diameter Plastic Stents Self-Expandable Metal Stents (SEMS) Indications for Biliary Stent Insertion Complications Occlusion Cholangitis Pancreatitis Cholecystitis Migration Perforation Conclusion References 84 Intraductal Ablation Therapy in the Biliary Ductal System Introduction Intraductal Ablation Devices Radiofrequency Ablation: Device and Technique Photodynamic Therapy: Device and Technique Intraductal Ablation: Adverse Events Outcomes of Intraductal Ablation Radiofrequency Ablation Photodynamic Therapy Outcomes of Ablation in Combination with Chemotherapy Radiofrequency Ablation Versus Photodynamic Therapy Intraductal Ablation: Indications Beyond Biliopancreatic Malignancies Ampullary Adenoma Occlusion of Metal Stents Benign Biliary Strictures Recent Advances in the Intraductal Ablation Therapies Radiofrequency Ablation Photodynamic Therapy Summary and Future Directions Cross-References References 85 Endoscopic Ultrasound (EUS)-Guided Biliary Drainage Introduction Material Interventional Echoendoscopes Needles and Accessories for Drainage Technique for Biliary Duct Drainage Under EUS Guidance Technique of Left Hepaticogastrostomy Under EUS Guidance (HGE) (Fig. 3) EUS-Choledocoduodenostomy (Fig. 4) EUS-Guided Rendezvous Technique Endoscopic Ultrasonography-Guided Transhepatic Anterograde Self-Expandable Metal Stent (SEMS) Placement (Fig. 5) Place of the Biliodigestive Anastomosis Guided by EUS in Comparison with ERCP What Stent Should Be Used? What Technique to Use to Drain the CBD in Patient with a Malignant Stenosis of the Lower Part of the CBD? ERCP, or EUS-BD? Conclusion References 86 EUS-Guided Bilio-enteric Anastomosis Introduction EUS-Assisted Versus EUS-Guided Drainage EUS-Guided Hepaticogastrostomy (EUS-HG) Technique and Tools Outcomes and Adverse Events EUS-HG with Anterograde Downstream Stenting Technique and Tools EUS-guided Choledochoduodenostomy (CDS) Technique and Tools Outcomes and Adverse Events EUS-Guided CDS as Primary Therapy EUS-Guided Cholecysto-enterostomy (Gallbladder Drainage) Technique and Tools Acute Cholecystitis in the Surgically Unfit Patient Internalization of Percutaneous Cholecystostomy Salvage Bile Duct Drainage After Failed ERCP EUS-Guided BD for Gastric Bypass Patients Comparative Data on Traditional Paradigm EUS-BD Versus PTCD Operator Skill and Training in EUS-BD Conclusion Cross-References References Part X: Advanced Diagnosis and Therapy of Pancreatic Diseases 87 Advanced Intraductal Pancreatic Imaging Introduction Pancreatography Pancreatography of Pancreatic Neoplasms Pancreatography in Cases of Pancreatitis Pancreatography of Ductal Disruption Pancreatography Risks Peroral Pancreatoscopy Pancreatoscopy of IPMN Pancreatoscopy of Pancreatic Duct Stones Pancreatoscopy Risks Intraductal Ultrasound IDUS of IPMN IDUS of Pancreatic Strictures IDUS of Pancreatic Neuroendocrine Tumors Probe-Based Confocal Laser Endomicroscopy Optical Coherence Tomography Conclusion References 88 Treatment of Acute Biliary Pancreatitis Introduction Diagnosis of Acute Pancreatitis Suspicion/Confirmation of Biliary Origin Prediction of Severity of Acute Pancreatitis Indication for Endoscopic Treatment Diagnosis of Cholangitis Timing of ERCP in Case of Cholangitis Diagnosis of Ongoing Biliary Obstruction Timing of ERCP in Case of Ongoing Biliary Obstruction Conservative Versus Endoscopic Treatment Pancreatic Duct Stent in Acute Biliary Pancreatitis? Timing of Cholecystectomy Special Settings Pregnancy References 89 Treatment of Symptomatic Pancreas Divisum Introduction Assumption Definition of Symptomatic Pancreas Divisum What Does Symptomatic PD Mean? Endotherapy Potential Predictors of Successful Endotherapy Does Endotherapy Reduce the Progression to CP in Patients ARP and PD? Endotherapy Techniques and Their Success Rate Post-ERCP Pancreatitis Incomplete Pancreas Divisum Santorinicele Therapeutic Flowchart Summary Box Symptomatic PD Cross-References References 90 Treatment of Pancreatic Leaks and Fistulae Introduction Definition and Classification Diagnosis Grading Treatment Traditional Management: Conservative Versus Surgical Endoscopic Treatment Internal Fistula External Fistula Predictors of Success and Failure Acute Necrotizing Pancreatitis Adverse Events Cross-References References 91 Trans-papillary Drainage of Fluid Collections Introduction Classification of Pancreatic Fluid Collections Indications for Drainage of Pancreatic Fluid Collections Imaging Evaluation for PFCs Management of PFCs Endoscopic Therapeutic Approach Pancreatic Duct Disruption Transpapillary Drainage Transpapillary Drainage in the Management of Pancreatic Pseudocyst Transpapillary Drainage in the Management of WON Conclusion: Individualized Transpapillary Approach Case Presentation Cross-References References 92 EUS-Guided Drainage of Fluid Collections Introduction and Definitions Treatment Prerequisites Endoscopic Ultrasound-Guided Transmural Drainage (EUS-TD) Discussion of Material and Procedure Techniques Which Needle? Cystotome Versus Needle-Knife Pure Cut Versus Endocut Bougie or Balloon Dilatation? Plastic Versus Self-Expandable Metal Stents Multimodality Treatment and Step-up Approaches Endoscopy-Guided Transmural Drainage (ETD) Procedure Endoscopy-Guided, Transpapillary Stent Placement and Drainage Failure and Adverse Events Antibiotic Treatment Postprocedural Recommendations and Management The Difficult Patient Differential Diagnosis Pseudocyst Versus Neoplasia Rare Diseases, Including Tuberculosis, Autoimmune Pancreatitis (AIP), and Ascariasis Lost Tail, Trauma Complications Treatment of Biliary Obstruction Prognosis and Follow-Up Cross-References References 93 Treatment of Walled-Off Necrosis Introduction Definition of Walled-Off Necrosis Timing of Intervention Important Considerations Choice of Intervention Special Considerations Post-Procedure Care Conclusions References 94 Treatment of Chronic Obstructive Pancreatitis Introduction Epidemiology Clinical Features Diagnosis Management Patient Selection Stenting Treatment Duration Multiple Pancreatic Stents Metal Pancreatic Stents Endoscopic Ultrasound-Guided Pancreatic Drainage Adverse Events Endotherapy Versus Surgery Summary Cross-References References 95 Treatment of Pancreatic Intraductal Stones Introduction Indication of Treatment Extracorporeal Shock Wave Lithotripsy (ESWL) Endoscopic Treatment Endoscopic Retrograde Cholangiopancreatography (ERCP) ERCP Alone Combination of ESWL and ERCP Pancreatoscopy-Guided Lithotripsy: EHL/LL Surgical Treatment Conclusion Cross-References References 96 Complications of Pancreatic Stents Introduction Plastic Stent Complications Abdominal Pain and Pancreatitis Sepsis Migration Stent Fracture Stent-Induced Ductal Lesions Fully Covered Self-Expandable Metal Stent (FC-SEMS) Abdominal Pain Cholestasis Induced Stenosis Stent Migration Biodegradable Stent Conclusion Cross-References References 97 Treatment of Pancreatic Cancer Introduction Endoscopic Palliation of Malignant Biliary Obstruction ERCP vs. Surgical Therapy ERCP vs. PTBD Plastic or Metal Stents? Endoscopic Ultrasound-Guided Biliary Drainage Endoscopic Therapy of Biliary Obstruction in Patients Undergoing Surgery Indications for ERC in Pancreatic Carcinoma-Patients Planed for Surgery Plastic or Metal for Preoperative Stenting? Endoscopic Ablation in Pancreatic Neoplasms EUS-Guided Celiac Plexus Ablation EUS-Guided Marking of Pancreatic Lesions EUS-Guided Fiducial Placement EUS-Guided Fine-Needle Tattooing Endoscopic Palliation of Gastric Outlet Obstruction Endoscopic Placement of Duodenal SEMS EUS-Guided Gastro-Enterostomy Cross-References References 98 Innovation in Pancreatic Stents Introduction Main TEXT Surgical vs Endoscopic Approach for MPD Stricture Endoscopic Approach for MPD Stricture Using Plastic Stent Endoscopic Approach for MPD Stricture Using Metal Stent Plastic vs Metal Stent Deployment for MPD Stricture Endoscopic Ultrasound-Guided Pancreatic Duct Drainage Cross-References References 99 EUS-Guided Pancreatico-Digestive Anastomosis Introduction Techniques Indications Results Alternative to EUS Approach Perspectives Conclusions References 100 Innovation in Lumen Apposing Metal Stents Introduction Available Designs AXIOS stent (Boston Scientific Marlborough, MA) (Fig. 1) Spaxus stent (Taewoong Medical Co., Ltd., Ilsan, Korea) (Fig. 2) NAGI stent (Taewoong Medical Co., Ltd., Ilsan, Korea) (Fig. 3) Plumber stent (MI Tech, Seoul, Korea) (Fig. 4) Aixstent (Leufen Medical, Aachen, Germany) Comparison of Lumen-Apposing Properties Current Applications and Data EUS-Guided PFC Drainage EUS-Guided Gallbladder Drainage (EUS-GBD) EUS-CDS EUS-Guided Entero-Enteric Anastomoses Challenges and Future Perspective Conclusion Cross-References References 101 Endoscopic Management and Follow-Up of Intraductal Papillary Mucinous Neoplasia (IPMN) Introduction Diagnostic Workup Classification Malignant Progression Diagnostic Endoscopic Management of IPMN IPMN Morphology Contrast-Enhanced Harmonic EUS EUS-Guided Fluid and Tissue Acquisition Fine Needle Aspiration Technical Process Cyst Fluid Analysis Cytology Biochemical Markers Molecular Testing Adverse Events Ancillary Novel Techniques Therapeutic Endoscopic Management Surveillance Surgery and Surveillance After Resection Conclusion Cross-References References 102 EUS-Guided Pancreatic Sampling Introduction EUS Sampling in the Management of Pancreatic Diseases Solid Pancreatic Lesions Needle Type Rapid On-Site Evaluation (ROSE) Number of Needle Passes Sampling Technique: Needle Stylet Use Sampling Technique: Dry Suction Technique Sampling Technique: Wet Suction Technique Sampling Technique: Stylet Slow-Pull Technique Sampling Technique: Fanning Technique Cystic Pancreatic Lesions Conclusion References 103 EUS Characterization of Focal Pancreatic Masses Introduction Pancreatic Mass Lesions: Disease Burden and Diagnostic Challenges Sensitivity of EUS for Detection of Pancreatic Mass Lesions Characterization of Solid Pancreatic Lesions EUS B-Mode EUS-Elastography Contrast-Enhanced EUS Characterization of Pancreatic Cystic Lesions EUS B-Mode Diagnostic Criteria Basic Facts: FLAG(S) Criteria EUS Morphology of Common PCL Elastography Contrast-Enhanced EUS EUS-Based Algorithm for Diagnostic Classification and Risk Assessment of PCL Visual Inspection Biochemical Analysis Molecular Testing Cyst Fluid Cytology Cross-References References 104 EUS-Guided Thermal Ablation of Pancreatic Neoplasia Introduction Technique Patient Selection and Contraindications Adverse Events Overall Efficacy and Safety Pancreatic Ductal Adenocarcinoma Pancreatic Neuroendocrine Tumors Pancreatic Cystic Neoplasms Other Types of Malignancy Summary Cross-References References 105 EUS-Guided Crio-thermal Ablation of Pancreatic Neoplasia Introduction Main Text Ablative Therapy Rationale Endoscopic Ultrasound-Guided Approach Conventional Ablative Therapies Radiofrequency Ablation Endoscopic Ultrasound Radiofrequency Ablation: Technical Aspects Cryoablation New Ablative Therapy: The Hybridtherm Ablation Physical Aspects Technical Aspects In Vivo Animal Study Ex Vivo Human Study In Vivo Human Study EUS-Guided HybridTherm Ablation Technique Technical Considerations and New Perspectives Conclusions References 106 EUS-Guided Celiac Plexus Neurolysis Introduction EUS-CPN Timing: Early or Salvage Therapy Obstacles to Adoptions of Early EUS-CPN Safety of EUS-CPN Benefits of Repeated EUS-CPN Celiac Ganglia Neurolysis Unilateral (Central) Versus Bilateral Injection Non-ethanol Based EUS-CPN Summary References Index