【JDDW2023で実感した
EUS-BD関連デバイスの進化について】まず、前提としてEUS-BDは19GのFNA針で穿刺し、
0.025inchのワイヤーを通し、ステントを留置するという手技であり、それが常識であり、多くの報告はハイボリュームセンターからでした。
また、
①穿刺
②ワイヤー留置
③瘻孔の拡張…— しゅん euschannel (@eusmania_shun) November 5, 2023
目次
目次
The evolution of EUS-BD and related devices in JDDW2023
First of all, the premise of EUS-BD is to puncture with a 19G FNA needle, pass a 0.025inch wire, and place a stent,
The procedure is to pass a 0.025inch wire through the needle and implant a stent, which is common practice, and many reports were from high-volume centers.
Also,
(1) Puncture
(2) wire placement
(3) Fistula dilation
(iv) stent placement
These four problems used to increase the difficulty of EUS-BD,
However, the evolution of devices has gradually reduced the difficulty of the procedure.
For example, Sonotip pro control (MEDICOS), which is soft and flexible and has high puncture performance for deeper puncture, EndoSelector (BOSTON) for wires with extremely high ultrasound visibility, REN (KANEKA) for fistula dilation, and Type IT stent through and pass
The big news is that the Niti-S (EUS-BD system) metal stent is now covered by insurance in Japan.
In addition, this time, the status quo is changing with the evolution of several devices and the proliferation of procedures. I’m going to PICK a few abstracts that I found particularly informative and that I was very impressed with.
1. The advent of Tornus, a non-adherent, highly penetrating device (compatible with both 0.018 inch and 0.025) (reference abstract: Nai W20-13 11/4 9:00-11:30)
The introduction of Tornus has greatly advanced 22G EUS-HGS. Specifically, not only has the problem of fistula dilation (3) been solved, but it is also compatible with 0.018-inch devices, which has the advantage of making it easier to perform (1) puncture with a 22G.
Until the year before last or the year before that, it was possible to perform puncture and insertion of 0.018-inch wire with 22G, but the subsequent dilatation was difficult; although there were devices compatible with 0.018 inch, I think there were many reports of procedures from limited facilities due to various problems. I did not want to choose the 22G puncture needle too aggressively from the standpoint of cost, as the 19G had more contrast and devices afterward and ultimately used fewer devices.
This time, however, there was a report of the usefulness of 22G puncture for EUS-HGS from a somewhat smaller institution. They said that all cases are dilated with 22G, 0.018inch, Tornus, or ES dilator.
The greatest advantage of using a 22G needle is bile duct puncture,
role in reducing puncture difficulty even in smaller facilities.
The 22G allows for deeper bile duct puncture and is easier than the 19G for ideal puncture in HGS.
(Another report states that the needle stands about 30 degrees with the 19G and about 40 degrees with the 22G. This 10-degree difference appears to be significant in guiding the wire toward the hepatic portal. The shallower the angle at which it points, the more the guidewire is guided in the direction of the peripheral bile duct.)
He said 22G is better than 19G in training facilities because proper bile duct puncture facilitates subsequent procedures. Dilation is fine with Tornus 0.025; after fistula dilation, the wire is replaced with 0.025 inches for stability, and the stent IT stent is then placed as usual.
In fact, in HGS, the puncture is important, and the degree of difficulty varies greatly depending on the site of the puncture. In advanced facilities, experience, the accuracy of FNA, and even if the puncture line is a little bad, it was probably covered by subsequent withdrawals.
There are still some problems, such as the need for two wires and the fact that the initial guidewire is 0.018 inches, which makes it somewhat unstable, but it is a fact that there are patients in the world for whom EUS-HGS is absolutely necessary. I believe that Tornus has become a strong supporter of EUS-HGS.
2. Introduction of Fuji’s new ultrasonic endoscope, EG-740UT, and its connection to ARIETTA
This has improved (1) puncture and (4) stent placement. The angle at which the up-angle is applied has changed significantly, increasing the number of options for bile ducts that can be punctured. In particular, the fact that B2 puncture becomes easier may be very good as it increases the choices of puncture sites. It is also useful that the stent is easily visible with a wide viewing angle during stent release. This is the advantage of (4). It is no exaggeration to say that this camera was developed to encourage EUS-BD strongly.
Some doctors have also reported the usefulness of FNA in postoperative reconstructed intestinal tracts such as B-2 because of the better up-angle and easier frontal view.
Furthermore, the ARIETTA is now connected to the latest FUJI scope, which was introduced at the exhibition booth, but FUJI’s EUS has not yet caught up to the Olympus system in terms of image quality, a problem that has also been resolved.
However, since FUJI’s trolley is not widely used in fluoroscopy rooms of many facilities, it may be some time before this evolution will spread to training facilities. However, we expect to see a gradual increase in FUJI’s EUS-BD results over the next year.
3. Possibility of Seek Master (PIOLAX): EUS-GBD (Reference Presentation: W20-12 11/4 9:00-11:30)
This is a report of EUS-GBD using a 0.035 inch guidewire through a 19G.
It is common knowledge that a 0.035 inch wire cannot be passed through a 19G puncture needle.
I have looked into this in detail because I am an OTAKU,
0.035inch is 0.89mm, so the gap is too small to fit into the 1.07mm lumen of a 19G puncture needle.
But if it does, the gap between the device and the 0.035inch will be smaller, and the device will follow the 0.035inch better.
Actually,
PIOLAX seekmaster (0.035 former REVOWAVE) somehow goes through 19G needle. It is 0.032inch (?) thinner than 0.035. I don’t remember if it was 0.032inch (?), which is thinner than 0.035.
Anyway, a guidewire thicker than the conventional one will pass through a 19G needle. It may be a little less selective, though,
EUS-GBD has a large target, so it is not a problem. The report says that a stent is placed after puncture without dilatation.
If a metal stent can be inserted without dilatation, it would be useful!