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INTRODUCTION: gastric varices hemorrhage is a severe complication of portal hypertension, with high mortality rates and few management alternatives, especially when there is a contraindication to transjugular intrahepatic portosystemic shunts (TIPS). The usual therapeutic options are the injection of cyanoacrylate, the insertion of coils or both. Hydrocoils are special coils coated with different types of expandable hydrogel polymers conventionally used in neurovascular interventionism. They allow rapid occlusion of vessel, forming a mesh that favors the local formation of thrombus and the development of a neointima on the gel cover. We consider the use of endoscopic ultrasound (EUS) guided hydrocoil insertion in gastric varices, without using cyanoacrylate. OBJECTIVE: this study aimed to evaluate the safety and effectivity of the application of EUS-guided hydrocoils in patients with gastric varices hemorrhage with TIPS contraindication. MATERIAL AND METHODS: this was a retrospective case series of four patients with TIPS contraindication after interventional radiologist evaluation. Linear echoendoscopes, fluoroscopy, 19G needles and hydrocoils (Azur®, Terumo) and Progreat® 3 Fr microcatheters were used. An interventional radiologist expert advised the procedures and endoscopic ultrasound confirmed the varix obliteration. RESULTS: technical and clinical success occurred in all patients involved in this study. There were no adverse effects related to the procedure or endoscopic equipment damage. CONCLUSIONS: the application of EUS-guided hydrocoils can be a safe and effective method in the short term for gastric varices bleeding in patients who are not candidates for TIPS. Besides, a complete obliteration of the vascular lumen could occur and thus, dispense with the use of cyanoacrylate. Further studies are needed to corroborate these preliminary results.

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Endoscopic retrograde cholangiography with biliary stenting is the generally recognized optimal treatment of malignant biliary obstruction. This procedure, though, is challenging in patients with surgically altered anatomy. Endoscopic ultrasound (EUS) enables tissue sampling by means of fine-needle aspiration and also represents an alternative recourse for biliary drainage in preference to a percutaneous approach. We aimed to report a case in which EUS enabled a definitive diagnosis of the recurrence of oncologic disease and the relief of biliary obstruction in a patient with a surgically altered anatomy.

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INTRODUCTION: splenomegaly and/or focal splenic lesions (FSL) have limited histopathologic studies due to the risk posed by splenic punctures. Percutaneous biopsies with a fine needle are difficult, especially due to interposition of gases, ascites, obesity or a history of abdominal surgery. On the other hand, endoscopic ultrasound (EUS) takes advantage of the proximity of the gastric wall to the spleen in order to puncture and visualize the needle and its movements in real time. OBJECTIVE: to describe the initial experience and results obtained with EUS-FNA in patients with splenomegaly or FSL. MATERIALS AND METHODS: this was a descriptive observational study. EUS-FNA of the spleen was performed with a slow-pull technique, which avoided fanning with an average of 3 needle passes. Biopsies were sent in Cytorich RedTM solution for analysis by cytology and cell block. RESULTS: punctures were performed in 15 patients (9 females) and the median age was 67 years (range 44-86). Patients studied due to an enlarged spleen or splenic FSL, in the context of fever of an unknown origin, adenopathies and abnormal weight loss were included. A conclusive diagnosis was achieved by EUS-FNA in 10 patients (66.7 %), 4 were large cell type B non-Hodgkin's lymphoma and one Hodgkin's lymphoma. There were no immediate or delayed complications related to the procedure. CONCLUSIONS: EUS-guided splenic punctures appear to be safe, effective and may be necessary in some clinical settings in order to complete the etiologic filiation of splenomegaly of an uncertain origin or FSL and to rule out malignancy.

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RESUMEN La colangiopancreatografía retrógrada endoscópica (CPRE) representa el tratamiento de primera línea para el drenaje biliar en pacientes con obstrucción biliar maligna avanzada. Sin embargo, este procedimiento representa un desafío en pacientes con anatomía alterada quirúrgicamente. El ultrasonido endoscópico (USE) permite la toma de muestras de tejido mediante punción aspiración con aguja fina y también representa una alternativa de drenaje biliar al abordaje percutáneo o quirúrgico. Nuestro objetivo es comunicar un caso en el que la ecoendoscopia permitió el diagnóstico definitivo de la recurrencia de la enfermedad oncológica de base y el alivio de la obstrucción biliar en un paciente con anatomía alterada quirúrgicamente.

ABSTRACT Endoscopic retrograde cholangiography with biliary stenting is the generally recognized optimal treatment of malignant biliary obstruction. This procedure, though, is challenging in patients with surgically altered anatomy. Endoscopic ultrasound (EUS) enables tissue sampling by means of fine-needle aspiration and also represents an alternative recourse for biliary drainage in preference to a percutaneous approach. We aimed to report a case in which EUS enabled a definitive diagnosis of the recurrence of oncologic disease and the relief of biliary obstruction in a patient with a surgically altered anatomy.

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Sump syndrome (SS) is associated with choledocho-duodenostomy (CDD) dysfunction, which occurs due to accumulation of detritus, biliary mud and food remains in the suprapapillary distal common bile duct. The prevalence is low after CDD. Currently, biliary drainage endoscopic ultrasound (EUS)-guided with a lumen-apposing metal stent (LAMS) is a new minimally invasive alternative for biliary stenosis for patients in whom endoscopy retrograde cholangial-pancreatography (ERCP) is not feasible. CDD via EUS-guided LAMS is increasing. Thus, SS has become a potential associated complication that was previously unreported in the literature.

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We present the case of a 79-year-old patient with multiple cardiovascular morbidities, classified as ASA III (American Society of Anesthesiology). An upper digestive endoscopy was performed due to chronic anemia and a subepithelial lesion was identified in the subcardial region of 30 x 25 mm, without other relevant findings.

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CONTEXT: To demonstrate a comprehensive review of published articles regarding EUS-guided biliary drainage. METHODS: Review of studies regarding EUS-guided biliary drainage including case reports, case series and previous reviews. RESULTS: EUS-guided hepaticogastrostomy, choledochoduodenostomy and choledochoantrostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is choledochoduodenostomy in distal lesions. Both procedures must be done only after unsuccessful ERCP. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. CONCLUSION: Hepaticogastrostomy and choledochoduodenostomy are feasible when performed by endoscopists with expertise in biliopancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

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The EUS-guided biliary drainage is a new tool for the palliation of distal obstructive biliary lesions. The EUS-guided access, which creates a fistulization between the duodenal bulb and distal common biliary duct, is an effective method to relieve jaundice and has low morbidity and mortality, in patients with distal biliary obstruction (pancreatic mass or papillary câncer). This technique is called choledochoduodenostomy and is presented promptly in this article. The EUS-guided biliary drainage should be made within protocol conditions and done by very experienced endosonographers.