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Create a Free AccountAnatomy - Small intestine
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).Duodenal subepithelial neuroendocrine tumor removed by endoscopic submucosal dissection using internal traction with magnets
We report the case of a 57-year-old woman with multiple endocrine neoplasia type 1 who was referred to us because of the presence of a 15-mm subepithelial lesion in the descendent duodenum. Earlier endoscopic ultrasound and biopsies confirmed the diagnosis of neuroendocrine tumor in the submucosa. The patient was asymptomatic, blood test results were unremarkable, and there were no metastases on positron emission tomography/CT.Follow-up outcomes of mucosal defect closures after endoscopic resection using a helix tacking system and endoclips
The X-Tack endoscopic HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) has recently been approved by the Food and Drug Administration and is slowly gaining popularity for the closure of large tissue defects. Despite its increasing use, outcome data of using the X-Tack system for mucosal defect closure after endoscopic resection (ER) are limited. Here, we report the follow-up outcomes of a series of cases that underwent ER and mucosal closure aided by the HeliX tacking system.A novel approach for weight regain after Roux-en-Y gastric bypass: Staged transoral outlet reduction (TORe) followed by surgical type 1 distalization
Roux en-Y gastric bypass (RYGB) is an effective modality for substantial long-term weight loss. Although patients experience 60% to 80% excess weight loss after RYGB, about one-third of these patients experience weight regain and relapse of obesity-related pathologies over time.1,2 This subset of patients presents a treatment challenge because lifestyle modifications and pharmacologic therapies may have limited efficacy.3Gauze 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 specimen collection technique to ensure that the resected specimen is safely retrieved after duodenal ESD
In recent years, endoscopic submucosal dissection (ESD) has been applied for duodenal tumors.1-3 The advantage of en bloc excision in ESD is that it allows precise pathological examination.4 For this reason, it is important to ensure that the resected specimen is collected. However, there is no report on the collection method for duodenal specimens resected by ESD.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.Endoscopic full-thickness resection of well-differentiated T2 neuroendocrine tumors in the duodenal bulb: a case series
Endoscopic therapies have moved to the forefront in the removal of small, well-differentiated duodenal neuroendocrine tumors (NETs). Classic procedures used to address small tumors, especially those less than 1 cm in diameter, are banding without resection, ligation endoscopic mucosal resection, or endoscopic submucosal dissection. Endoscopic full-thickness resection (EFTR) is a procedure developed recently that allows for sealing off of the tissue surrounding the tumor before full-thickness removal.Utilization of an overtube for placement of a lumen-apposing metal stent for removal of a capsule endoscope retained proximal to an ileal stricture
Capsule endoscopy is a noninvasive procedure used to evaluate the small bowel. Capsule retention remains a significant adverse event of capsule endoscopy, and endoscopic capsule extraction may be technically complicated when device-assisted enteroscopy is necessary to reach the retained capsule. The length and limited diameter of enteroscope working channels limit the endoscopic tools available and can make extraction of the capsule difficult. The presence of enteral strictures can also further complicate endoscopic extraction of a retained capsule.Endoscopic submucosal dissection for a laterally spreading ampullary carcinoma
Endoscopic papillectomy (EP) is not standard of care for early ampullary carcinoma but may be considered in select situations owing to its minimal invasiveness compared with pancreaticoduodenectomy and the low incidence of lymph node metastasis.1,2 However, the curative resection rate of EP with negative margins was limited to approximately 87% of patients with neoplastic ampullary lesions.3
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