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Prachayakul V.,Mahidol University | Aswakul P.,Liver and Digestive Institute
World Journal of Gastroenterology | Year: 2015

Endoscopic ultrasound (EUS)-guided biliary drainage is accepted as a less invasive, alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen- Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed, thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage, both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently, only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma, and thus can be used as an alternative to percutaneous biliary drainage. © The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved. © 2015 Baishideng Publishing Group Inc. All rights reserved. Source


Prachayakul V.,Mahidol University | Aswakul P.,Liver and Digestive Institute | Bhunthumkomol P.,Thammasat University | Deesomsak M.,Liver and Digestive Institute
BMC Gastroenterology | Year: 2014

Background: Diagnosis of choledocholithiasis requires clinical manifestations and imaging examination findings suggesting a stone in the common bile duct (CBD), but these factors are not highly sensitive or specific. The choledocholithiasis management algorithm proposed by the American Society for Gastrointestinal Endoscopy (ASGE) may not be appropriate for patients who fulfill the clinical criteria for a high likelihood of choledocholithiasis. Endoscopic ultrasonography (EUS) may replace endoscopic retrograde cholangiopancreatography (ERCP) for the detection of CBD stones in all patients. The aims of this study were to determine the diagnostic yield and optimal timing of EUS in patients with an intermediate or high likelihood of choledocholithiasis requiring therapeutic ERCP.Methods: Patients with suspected choledocholithiasis who underwent EUS between June 2009 and January 2012 were retrospectively reviewed. The patients were divided into two groups based on the likelihood of choledocholithiasis according to the clinical predictors described by the ASGE guidelines: an intermediate likelihood group and a high likelihood group. The demographic data, clinical manifestations at presentation, blood test results, EUS and ERCP findings, and clinical manifestations during the follow-up period were recorded and analyzed.Results: Ninety-three patients were enrolled in the study (52.7% in the intermediate likelihood group and 47.3% in the high likelihood group). CBD stones were detected in 22.44% of patients in the intermediate likelihood group and 38.63% of patients in the high likelihood group. EUS had a sensitivity of 100% and specificity of 80% for detection of CBD stones. An alkaline phosphatase level of >133 mg/dL (area under the curve, 0.576) was the only factor that was significantly associated with detection of CBD stones in patients who underwent EUS >7 days after the initial clinical presentation (odds ratio 4.87, p = 0.01).Conclusions: EUS is an accurate diagnostic tool for the detection of CBD stones, and can prevent the unnecessary use of ERCP. This study found that use of clinical criteria alone might not provide a good prediction of the presence of CBD stones, even in patients who fulfill the criteria for a high likelihood of choledocholithiasis. © 2014 Prachayakul et al.; licensee BioMed Central Ltd. Source


Deesomsak M.,Liver and Digestive Institute | Aswakul P.,Liver and Digestive Institute | Junyangdikul P.,Samitivej Srinakarin Hospital | Prachayakul V.,Mahidol University
World Journal of Gastroenterology | Year: 2013

Gastric duplication cyst is a very rare gastrointestinal tract malformation that accounts for 2%-4% of alimentary tract duplications. Most cases are diagnosed within the first year of life, following presentation of abdominal pain, vomiting, and weight loss and clinical discovery of an abdominal palpable mass. This case report describes a very uncommon symptomatic gastric duplication cyst diagnosed for the first time in adulthood. Only a few other case reports of similar condition exist, and all were identified by endosonography. The current case involves a 52-year-old male who presented with a onemonth history of progressive iron deficiency anemia without overt gastrointestinal bleeding. The patient underwent esophagogastroduodenoscopy, which revealed a 2.0 cm pinkish subepithelial lesion, suspected to be a gastrointestinal stromal tumor (GIST) and source of gastrointestinal bleeding. The endosonography showed inhomogeneous hypoechoic lesions with focal anechoic areas arising from a second and third layer of the gastric wall. Differential diagnoses of GIST, neuroendocrine tumor, or pancreatic heterotopia were made. The lesion was removed using an endoscopic submucosal resection technique. Histopathology revealed an erosive gastric mass composed of a complex structure of dilated gastric glands surrounded by fibro-muscular tissue, fibroblasts, and smooth muscle bundles, which led to the diagnosis of gastric duplication. © 2013 Baishideng Publishing Group Co., Limited. All rights reserved. Source


Prachayakul V.,Mahidol University | Aswakul P.,Liver and Digestive Institute
World Journal of Gastroenterology | Year: 2013

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates. METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients' baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient's overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student's t-test and the χ 2 test were used to assess the significance of inter-group differences. RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The technical success and clinical success rates of this technique were 95.2% and 90.5%, respectively. Complications included bile leakage and pneumoperitoneum, occurred at a rate of 9.5%. None of the patients died from the procedure. One patient presented with a biloma, a major complication that was successfully treated by another endoscopic procedure. CONCLUSION: We present a highly effective EUS-guided biliary drainage technique that does not require cauterization or balloon dilation. © 2013 Baishideng. All rights reserved. Source


Prachayakul V.,Mahidol University | Aswakul P.,Liver and Digestive Institute
Case Reports in Gastroenterology | Year: 2015

Spontaneous bilo-enteric fistula is a rare complication following surgery or some therapeutic interventions such as transarterial chemoembolization (TACE). The present case was a young man, a known case of chronic hepatitis B with multiple recurrent hepatocellular carcinoma, who presented with clinical sepsis and jaundice. Computed tomography showed dilated proximal left intrahepatic ducts which suspected anastomotic stricture. He underwent endoscopic retrograde cholangiopancreatography, but the endoscopic view showed a deep ulcer covered by yellowish debris tissue. After re-evaluation it was found to be hepaticoduodenostomy and choledochoduodenostomy tracts. In the present case the fistula was suspected to be related to a previous TACE procedure. © 2015 S. Karger AG, Basel. Source

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