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Create a Free AccountAnatomy - Small intestine
Over-the-scope clip to the rescue: solution for duodenal perforation from migrated biliary stent
Iatrogenic perforation of the duodenum caused by biliary stents is a rare adverse event of ERCP.1 While the only available definitive treatment option was previously surgery, the advancement in the minimally invasive endoscopic field led to the development of over-the-scope clips (OTSCs), which allow complete closure of full-thickness defects endoscopically.2Endoscopic pyloric exclusion—EUS-guided gastrojejunostomy combined with endoscopic suturing and closure of the pylorus: a novel approach to failed surgical repair of a perforated duodenal ulcer
An 82-year-old woman with metastatic breast cancer was admitted with an acute abdomen. She was found to have a duodenal bulb perforation, for which she underwent emergent surgical repair using an omental patch. Postoperatively, the patient developed a large-volume enteric output from the Jackson-Pratt drains, and she was found to have a persistent duodenal leak on a CT scan. She was referred to our center in her third postoperative week.Management of an iatrogenic duodenal perforation with a helical tack system in a patient with pancreatic cancer complicated by gastric outlet obstruction
Although endoscopic procedures are safe, they carry a risk of perforation, which can manifest severe adverse events for patients if not managed expediently. Endoscopic methods of closure include clips, injectable agents, and suturing devices.1,2 Occasionally, perforations occur in difficult locations. Recently, a through-the-scope tacking system, X-tack Endoscopic HeliX Tacking System 160 cm (HTS) (Apollo Endosurgery Inc, Austin, Tex, USA), has been made available for mucosal defect closure, providing endoscopists with another tool to manage adverse events.Duodenal stenting as a palliative approach to a malignant duodenocolonic fistula
Duodenocolonic fistulae may result as adverse events of malignancies, and their management is often challenging for nonsurgical patients. Our case demonstrates a palliative approach in the management of malignant duodenocolonic fistula by means of luminal stent placement.Endoscopic holmium laser lithotripsy for therapy of Bouveret syndrome
Bouveret syndrome is a rare condition characterized by the impaction of a gallstone in the stomach or duodenum via a fistulous tract resulting in gastric outlet obstruction or ileus in the setting of cholecystitis.1,2 This condition generally requires surgery to remove the impacted stone, repair the fistula, and remove the gallbladder. However, for patients who are unable to undergo surgery, laser lithotripsy can be an alternative therapy.3,4 For biliary stones, a holmium laser has yet to be widely adopted, partly because of the cost and limited availability of the equipment.Iatrogenic perforation during lumen-apposing metal stent deployment closed using an over-the-scope stent fixation clip device
EUS-guided gastrojejunostomy (EUS-GJ) has emerged as a safe and effective alternative for the palliative management of malignant gastric outlet obstruction.1,2 Although rare, perforation is a known adverse event of EUS-GJ seen in 1.6% of patients.3 We present a case of endoscopic closure of an iatrogenic perforation caused while performing EUS-GJ using an over-the-scope (OTS) stent fixation clip device (Video 1, available online at www.giejournal.org ).Modification of the endoscopic hemostatic powder application technique
EndoClot Polysaccharide Hemostatic System (EndoClot PHS; Micro-Tech Europe, Dusseldorf, Germany) is a starch-derived compound that consists of biocompatible absorbable hemostatic polysaccharides that absorb water when in contact with blood or liquids, creating a gelled matrix over the bleeding lesion. It also accelerates the in situ coagulation process through hyperconcentration of platelets and coagulation factors.1 Hemostatic powders are considered an endoscopic hemostatic option for upper and lower nonvariceal bleeding, which are easy to use and have a good safety profile.EUS-guided gastroenterostomy for proximal jejunal obstruction: technique modification for more distal upper GI tract obstruction
EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has emerged as a safe, minimally invasive modality for the treatment of gastric outlet obstruction (GOO).1 Several techniques have been described, including anterograde, retrograde, and balloon-assisted approaches.1-3 The “direct” anterograde method of EUS-GE using a nasobiliary catheter to instill contrast material within the target jejunal loop distal to the obstruction uses fewer steps than other approaches and does not require use of a balloon.Successful management of a duodenal perforation using a through-the-scope suturing device after failed attempt at closure with an over-the-scope clip
The X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery, Austin, Tex, USA) is a novel through-the-scope suture-based device approved for tissue approximation of mucosal defects. Initial case reports and case series have been encouraging on its efficacy for closure of mucosal defects.1-3 However, this device is not intended for full-thickness closure, and there are limited data on this approach.4,5 In this video, we present the successful use of the HeliX Tacking System for the management of a duodenal perforation after a same-session failed attempt at closure with an over-the-scope clip (OTSC).Endoscopic nasobiliary drainage tube placement through a periampullary perforation for management of intestinal leak and necrotizing pancreatitis
Periampullary perforation has a high mortality rate.1,2 Endoscopic management, including a biliary stent placement into the common bile duct (CBD) and hemostatic clips, can treat the periampullary perforation.3,4 However, it can be difficult to close the perforation and prevent the intestinal juice leakage in the case of the perforation with severe inflammation.Endoscopic full-thickness resection with retroperitoneal dissection for duodenal myogenic cyst with adjustable traction from an independently controlled snare
A 58-year-old man was coincidentally found to have a duodenal subepithelial lesion in the bulb. Endoscopic ultrasonography revealed a 20-mm anechoic lesion with suspicious echogenic content or a hypoechoic lesion from the muscular propria (Figs. 1 and 2; Video 1, available online at www.giejournal.org ). Computed tomography revealed a lesion close to the hepatic hilum (Fig. 3). After a multidisciplinary discussion with endoscopists and surgeons, we decided to perform endoscopic full-thickness resection (EFTR) of the lesion with acceptable risk.Successful endoscopic removal of foreign body lacerating into the duodenum
A 29-year-old woman with psychiatric history and multiple foreign body ingestions presented with a 1-day history of moderate to severe nonradiating central abdominal pain. She reported ingesting foreign objects 3 weeks prior to presentation. The patient was tachycardiac but afebrile and hemodynamically stable, and her abdominal examination showed right upper quadrant tenderness with negative Murphy sign. A CT scan showed a foreign body identified as a ballpoint pen laceration in the second part of the duodenum, projecting at the subhepatic region with adjacent free fluid but no free intraperitoneal air (Fig. 1).Endoscopic rescue of anastomotic dehiscence after urgent gastric bypass revision
Adverse events are rare after bariatric surgery; however, leaks can lead to high morbidity. A large population study demonstrated a rare need for endoscopic management, most commonly endoluminal stent therapy. Unfortunately, many patients eventually needed surgical intervention and patients with stents had a notable rate of readmissions.1 Although stents are a valuable tool, newer technologies have expanded the toolbox to address difficult gastrointestinal adverse events.2,3 We present a challenging case of a gastrojejunal anastomotic disruption in a Roux-en-Y patient after recent urgent surgical revision that was rescued with total endoscopic therapy.Endoscopic management of gastrojejunocolic fistula after endoscopic gastrojejunostomy
Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) is an alternative to endoscopic stent placement alone and surgical gastrojejunostomy for the management of gastric outlet obstruction (GOO). Similar technical and clinical success rates have been shown with EUS-GJ and endoscopic stent placement alone with lower rates of reintervention in the EUS-GJ group.1 When compared to the more invasive surgical GJ, EUS-GJ has shown similar rates of clinical success and lower adverse event rates.2,3 Rare EUS-GJ adverse events include perforation, peritonitis, bleeding, stent misdeployment, and migration.Endoscopic submucosal dissection with reinforcement using a laparoscopic approach for a duodenal cavernous hemangioma
Duodenal cavernous hemangiomas are rare; however, when they occur, they may require hemostasis.1 Hemangiomas are classified into cavernous, capillary, or mixed tumors; the cavernous type is the most common.2 Cavernous hemangiomas are defined as congenital benign vascular lesions that are venous malformations. Because cavernous hemangiomas are derived from the submucosa, even minimally invasive endoscopic procedures—such as polyp resection, endoscopic mucosal resection, and argon plasma coagulation—may cause heavy bleeding or perforation.The Double-Max method: a novel method for gallbladder epithelial biopsy
A 75-year-old woman with no medical history presented to her previous physician complaining of weight loss. The patient was referred to our hospital after abdominal ultrasonography revealed a gallbladder lesion. There was irregular thickening of the gallbladder wall on a contrast-enhanced CT scan (Fig. 1A) and multiple broad-based polyps on EUS (Fig. 1B). Endoscopic retrograde cholangiopancreatography was performed to determine whether the gallbladder lesion was malignant.EUS-directed transenteric ERCP–assisted internalization of a percutaneous biliary drain in Roux-en-Y anatomy
Endoscopic ultrasound–directed transenteric ERCP (EDEE) has recently been described as a safe, effective procedure to obtain biliary access in patients with Roux-en-Y anatomy.1,2 Here, we present a video case report of EDEE-assisted biliary drain internalization in a patient with prior liver transplant and Roux-en-Y hepaticojejunostomy (HJ), presenting with HJ anastomotic stricture (Video 1, available online at www.giejournal.org ).EUS-guided gastrojejunostomy for management of malignant gastric outlet obstruction in a patient with Roux-en-Y anatomy
Gastric outlet obstruction is a complication of advanced gastrointestinal malignancies and contributes significantly to patient morbidity. Surgical gastrojejunostomy (GJ) and enteral stenting have been traditionally employed for management in these patients. Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) with a lumen-apposing metal stent (LAMS) provides an alternative to luminal stenting and surgical GJ. We present a case of EUS-GJ performed in a patient with Roux-en-Y anatomy.The use of water immersion technique during device-assisted (single-balloon) enteroscopy to treat actively bleeding jejunal Dieulafoy's lesion
Dieulafoy’s lesion (DL) is an uncommon but potentially life-threatening condition, which can result in sudden, massive gastrointestinal bleeding. The water immersion technique can be helpful in localizing the source of active bleeding during an endoscopy. Herein, we present a case of gastrointestinal bleeding due to jejunal DL found on a video capsule endoscopy (VCE). We describe the use of the water immersion technique in localization and treatment of actively bleeding DL during single-balloon enteroscopy.Transjejunal drainage of an infected postsurgical fluid collection using a 6-mm lumen-apposing metal stent
Postsurgical fluid collections (PSFCs) can be a marked source of morbidity for patients, but advances in therapeutic endoscopy have allowed for endoscopic modalities of drainage to become more accessible.1 Prior studies have established the efficacy and safety of lumen-apposing metal stents (LAMSs) in PSFCs.1-4 In the video accompanying this case report (Video 1, available online at www.giejournal.org ), we demonstrate the transjejunal placement of a 6-mm LAMS for drainage of an infected postsurgical fluid collection.Endoscopic ultrasound-guided gastrojejunostomy with lumen-apposing metal stent in a boy with neurological impairment requiring jejunal feeding
Significant undernutrition is reported in 13% to 52% of children with neurodevelopmental disabilities (NPDC).1,2 Oropharyngeal dysphagia (90%), gastroesophageal reflux (50%-75%), delayed gastric emptying (67%), and/or ineffective esophageal peristalsis (61%) are associated with undernutrition. Moreover, nearly all NPDC have 1 or more comorbidity that negatively affects feeding and worsens GI symptoms such as retching and bloating, requiring prompt gastric decompression.3-5Endoscopic management of magnet ingestion and its adverse events in children
Magnet ingestion has recently increased among children. Multiple magnets can lead to serious adverse events owing to pressure necrosis of trapped bowel wall; therefore, urgent removal of the magnet is recommended. However, awareness of magnet ingestion and adverse events associated with it are lacking among the general population and some healthcare professionals. Herein, we demonstrate the adverse events associated with prolonged retention of ingested magnets and endoscopic management of ingested magnets in children.EUS-directed transgastric ERCP in Roux-en-Y gastric bypass revision of sleeve gastrectomy
EUS-directed transgastric ERCP (EDGE) is an effective approach for the treatment of biliary adverse events of patients who have undergone Roux-en-Y gastric bypass (RYGB).1 Through deployment of a lumen-apposing metal stent (LAMS) from the gastric pouch into the excluded stomach, EDGE allows access to the bypassed stomach and duodenum in patients who have undergone RYGB (Fig. 1). However, patients who have undergone sleeve gastrectomy (SG) who undergo revision to RYGB have limited working space within both the gastric pouch and excluded stomach (Fig. 2), making therapeutic endoscopic procedures such as EDGE technically challenging.A case of cystic paraduodenal pancreatitis with gastric outlet obstruction: technical pitfalls in EUS-guided gastroenteroanastomosis
Cystic paraduodenal pancreatitis is part of a spectrum of diseases, collectively gathered under the term “paraduodenal pancreatitis,” which involves the area between the duodenum, the pancreatic head, and the common bile duct.1 Although common clinical presentation is constituted by abdominal pain, weight loss, and jaundice, association with gastric outlet obstruction (GOO) has been reported.2 In recent years, the introduction of lumen-apposing metal stents (LAMSs) led to the diffusion of a novel technique to manage GOO.Successful endoscopic resection by using gel immersion and the technique of endoscopic papillectomy for a tumor adjacent to the papilla of Vater
Superficial nonampullary duodenal epithelial tumors are rare, and the establishment of optimized strategies for their treatment is an area of active investigation.1 Endoscopic submucosal dissection (ESD) for superficial nonampullary duodenal epithelial tumors poses the risk of major adverse events (AEs), including a high rate of bleeding, intraoperative perforation, and delayed perforation.2,3 Lesions located in the duodenal flexure are associated with poor endoscope maneuverability.4 Moreover, endoscopic resection is particularly challenging for lesions on the descending duodenum’s medial wall, especially those adjacent to the papilla of Vater (POV).
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