Endoscopic retrograde access to the biliary tree is not always possible and endoscopic ultrasound (EUA)-guided biliary drainage is increasingly used. EUS-guided hepaticogastrostomy has been proved to be feasible, although safety issues still need to be evaluated. There are few reports [1-5] with 90 %-100 % technical and 75 %-100 % clinical success rates. Major complications included stent migration, bile leaks, and cholangitis [4, 5]. An 81-year-old man with obstructive jaundice secondary to gallbladder adenocarcinoma and duodenal stricture was referred for endoscopic drainage. Magnetic resonance imaging (MRI) showed an infiltrative mass and biliary stenosis with dilated intrahepatic ducts (• " Fig. 1). The duodenal stricture was dilated with a balloon. Following failure of several attempts at transpapillary deep cannulation of the bile duct, a decision was taken to carry out transgastric EUS-guided drainage. A linear EUS scope positioned in the gastric lesser curvature disclosed a dilated intrahepatic biliary system (• " Fig. 2 a), and a 19-gauge needle was inserted inside a left intrahepatic branch (• " Fig. 2 b). After stylet removal, a cholangiogram was obtained (• " Fig. 3) and a 0.035-inch guide wire was introduced through the needle (• " Video 1). The guide wire was then positioned into an intrahepatic biliary branch. The transmural tract was enlarged by using a needle-knife. A partially covered self-expandable metal stent (SEMS), 10 × 60 mm in size (Wallstent, Boston Scientific International, La Garenne Colombes, France), was inserted (• " Fig. 4). At the end of the procedure, an enteral SEMS, 30 × 90 mm in size (Wallflex, Boston Scientific), was placed across the duodenal stenosis (• " Fig. 5 and• " Video 1).
The presumptive diagnosis of gastric submucosal tumors can be made by endoscopic ultrasonography (EUS) but histological confirmation is still required. A special guillotine biopsy device (Flexi-Temno) which enables collection of adequate submucosal samples by the endoscopic approach was therefore evaluated. After visualization by EUS the guillotine needle biopsy was performed in 21 patients with submucosal tumors of the stomach. There were 2 failures in 2 patients with leiomyomas. The diagnosis suggested by EUS was confirmed by guillotine biopsy in 17 cases. Guillotine biopsy detected 2 cases of unsuspected leiomyosarcoma which were confirmed surgically. In cases of solid submucosal tumors confirmed on EUS, the guillotine needle biopsy enables a definitive histologic diagnosis. Thus malignancies can be detected when EUS findings are not significant.
After an RIC-allo, FN and early SBI occurred mostly in patients with severe mucositis and early-onset neutropenia, while postengraftment high-dose steroid therapy for acute GVHD was the major RF.
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