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Wide-field ESD for Barrett's adenocarcinoma at the gastroesophageal junction: technical approaches to facilitate en bloc R0 resection
Endoscopic submucosal dissection (ESD) for Barrett's esophagus (BE) neoplasia is associated with high en bloc resection and an acceptable safety profile but with suboptimal curability rates (range, 56%-59%).1 Two large Western studies showed that low R0 resection rates resulted from the high rate of positive lateral margins in ESD specimens (range, 82%-86%), which prompted either salvage ESD or additional surgical treatment.2,3 A U.S. multicenter ESD study found positive lateral margins in up to 70% of Barrett's adenocarcinoma (BA) at the gastroesophageal junction (GEJ) because of the increased technical complexity, poor maneuverability, and difficulty in evaluating the lesion’s margin.Transpyloric lumen-apposing metal stent for management of persistent post-esophagogastrectomy leak
Anastomotic leaks are an adverse event complication of GI surgery that contribute to increased hospital stays, morbidity, and mortality. Endoscopic therapy via endoscopic closure techniques or covered metal stent placement has increasingly been used for primary therapy of anastomotic leaks.Recurrence after Zenker’s peroral endoscopic myotomy despite complete septotomy: how far to go with myotomy on the esophageal side
Zenker’s diverticulum (ZD) is the most common diverticular disease found in the pharyngo-esophageal region.1 Zenker’s peroral endoscopic myotomy (Z-POEM) has been used incrementally for ZD with good efficacy and safety.2 Although Z-POEM provides the platform of submucosal tunneling that ensures a complete septotomy, recurrence to the tune of 14.7% are still reported after Z-POEM.3 Here we present a case of ZD that had recurrence after Z-POEM because of incomplete myotomy on the esophageal side, which was subsequently tackled with flexible endoscopic division of the residual esophageal muscular bridge.EUS–guided biopsy of an intraventricular mass in a patient with ventricular tachycardia
Endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) is a minimally invasive procedure commonly used for diagnostic purposes. Because of the accuracy and safety of EUS, both intraluminal and extraluminal lesions can be sampled. Traditional methods of cardiac biopsy, typically through an endovascular approach, are well established. However, few EUS-guided cardiac interventions have been published,1-3 as they are rarely performed. Potential risks for cardiac biopsy, regardless of modality, include hemorrhage, perforation, arrhythmia, and valvular damage.An endoscopic approach to therapy for spontaneous esophageal rupture
Boerhaave syndrome is among the most lethal GI tract disorders with a reported mortality rate of up to 40%.1-3 Spontaneous perforations are caused by sudden intraesophageal pressure elevations leading to transmural injury and subsequent mediastinal inflammation, subcutaneous emphysema, and/or necrosis secondary to spillage of gastric contents. Management was historically surgical, but stable patients may benefit from the reduced morbidity and mortality associated with less invasive percutaneous and endoscopic approaches.Antireflux band mucosectomy: a novel minimally invasive approach for the treatment of refractory gastroesophageal reflux disease
Endoscopic therapies in the treatment of refractory GERD have largely been regarded as inferior as surgical intervention. Procedures such as the transoral endoscopic incisionless fundoplication (TIF), Stretta, and antireflux mucosectomy (ARMS) are less invasive but produce outcomes that are middling to lackluster, with many patients having to continue proton pump therapy without resolution of symptoms. Antireflux band mucosectomy (ARBM), in which the cardia is banded, may provide more effective relief.Helix tack suspension for esophageal stent fixation
Fully covered self-expanding metal stents were developed as a removable prosthesis for esophageal obstruction. They are highly effective at relieving dysphagia and are covered with an impermeable membrane to prevent tissue ingrowth. Unfortunately, these stents carry a significant risk of migration,1 with risk for subsequent adverse events including intestinal obstruction2 and, rarely, perforation.3 If the esophageal stricture is endoscopically nonpassable, there is also a risk of requiring surgical removal.Endoscopic suturing for repair of an obstructing Zenker’s diverticulum using a bidirectional endoscopic approach for lumen delineation
Endoscopic suturing is a technique that can be applied to several disease processes, such as repair of fistulae or perforations, endoluminal stent anchoring, and for endobariatric procedures. We describe a case of suturing to repair an obstructing Zenker's diverticulum (Video 1, available online at www.giejournal.org ).Successful D-POEM after failed surgical myotomy and diverticulectomy
Peroral endoscopic myotomy with diverticulotomy (D-POEM) is feasible for management of achalasia with an epiphrenic diverticulum (ED).1-3 In a study of 14 patients with ED and underlying motility disorders with isolated lower esophageal sphincter (LES) POEM, all had postoperative Eckardt score improvement.4 Diverticulotomy is second-line treatment.4-7Peroral endoscopic myotomy (POEM) for achalasia developing after vertical banded gastroplasty with asymptomatic gastro-gastric fistula
Peroral endoscopic myotomy (POEM) has revolutionized the treatment landscape for achalasia. Randomized trials and meta-analyses have shown that its efficacy is comparable to the traditional reference-standard surgical approach represented by laparoscopic Heller’s myotomy (LHM), with an outstanding safety profile1,2; higher postoperative reflux rates seem to be associated with POEM over LHM, owing to the absence of an antireflux procedure. POEM has consequently been proposed as a first-line option over LHM, which may carry higher perioperative and postoperative risk, for patients with previous abdominal surgery or obesity.Gauze extension method for specimens resected by endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) is a standard and reliable procedure for resection of GI neoplasms. Although ESD allows en bloc resection of large GI neoplasms,1 ESD specimens tend to contract because of burning and scarring of the margins during ESD (Fig. 1). When preparing ESD specimens for pathologic examination, including evaluation of the margins, specimens should be extended and pinned on a fixing board as quickly as possible.2,3 However, in most cases, the normal marginal mucosa from ESD specimens is thin and fragile, especially from the colon.A novel and effective EUS training program that enables visualization of the learning curve: Educational Program of Kindai system (EPOK)
EUS is currently regarded as a tool that enables not only observation but also diagnosis and treatment. The basis of all EUS-related procedures is the EUS screening technique. However, it can be challenging for trainees to master the technique. Several studies have investigated training methods for EUS screening that are based on memorization of typical EUS images.1 Hands-on training also is considered useful.2-5 The American Society for Gastrointestinal Endoscopy guidelines suggest that at least 225 hands-on EUS procedures are required to achieve competency in biliopancreatic EUS.Modified submucosal tunneling endoscopic resection for postcricoid esophageal subepithelial tumor
Submucosal tunneling endoscopic resection (STER) has been described as a technique for endoscopic resection of GI subepithelial tumors (SETs) arising from the muscularis propria layer1 and is an accepted treatment modality for these SETs.2 The standard STER technique involves submucosal elevation 3 to 5 cm proximal to the SET along its longitudinal axis, mucosotomy, submucosal tunneling, dissection of the SET within the tunnel, enucleation from the deep muscle layer, and specimen delivery followed by mucosal closure.Septal wall divides esophagus into double lumen: successful endoscopic septotomy
Intraluminal esophageal diverticulum is a rare condition identified by a collection of intraluminal barium with surrounding radiolucent halo on barium swallow.1-3 Historically, management has comprised proton pump inhibitor therapy, lifestyle modification, and esophageal dilation.1,2 Limited literature exists on the endoscopic management of this condition. Our case highlights the use of minimally invasive endoscopic techniques to manage intraluminal esophageal diverticulum.Endoscopic submucosal dissection and tunneling procedures using novel image-enhanced technique
Recent innovations in image-enhanced endoscopy allow early detection and management of GI lesions. In this study, we aim to analyze the utility of texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) during endoscopic submucosal dissection (ESD) and submucosal tunneling procedures.
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