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Endoscopic resection of GI stromal tumor using full-thickness resection device: tips and tricks
Gastrointestinal stromal tumor (GIST) is the most common type of subepithelial lesion (SEL) in the stomach. Management of gastric GISTs varies by size. While all gastric GISTs ≥2 cm should be resected, the need to resect gastric GISTs <2 cm is still controversial given that surgical resection may be too aggressive for small, low-risk GISTs. On the other hand, evidence suggests that even <2-cm GISTs can metastasize.1 In fact, the Canadian guidelines suggest that even GISTs <1 cm should be excised because of the risk of metastases.Novel simulator of endoscopic hemostasis with actual endoscope and devices
Endoscopic hemostasis is an essential skill for endoscopists and has been the first-line treatment.1 For example, we reported that 70% of bleeding ulcers were treated with endoscopic hemostasis.2 Endoscopic hemostasis, similar to most techniques, is currently acquired through on-the-job training with real patients. However, such high-risk situations are not preferable for trainees. To perform a hemostatic procedure safely, the operator needs skills such as maintaining an appropriate view, stabilizing the scope, and controlling hemostatic devices precisely.Underwater EMR for the diagnosis of diffuse infiltrative gastric cancer
A 75-year-old woman experienced nausea 7 months prior and had lost 9 kg over 3 months. She was referred to the university hospital for further examination. A CT scan showed circumferential wall thickening of the stomach. Endoscopic examination revealed markedly enlarged folds, redness, and poor extension of the gastric lumen. Advanced infiltrative gastric cancer was suspected. However, endoscopic forceps biopsy specimens did not reveal adenocarcinoma. Endoscopic examination and the forceps biopsy were repeated twice during the next 6 months.Rare solitary giant hamartomatous polyp of the stomach removed by endoscopic submucosal dissection
The incidence of solitary gastric hamartomatous polyps (SGHPs) is extremely low, with fewer than 12 cases reported in the literature.1 Common symptoms include abdominal pain, bleeding, and anemia. While most SGHPs are benign, dysplastic changes have been reported.1,2 Hence, large lesions are typically referred for resection.1 In this video, we present a case of an SGHP resected with endoscopic submucosal dissection (ESD) (Video 1, available online at www.giejournal.org ).Endoscopic subserosal dissection for a GI stromal tumor
With the advancements in endoscopic resection techniques, subepithelial tumors (SETs) can be removed by transnatural orifice endoscopy with minimal invasiveness. Currently, available endoscopic procedures include endoscopic submucosal dissection, endoscopic submucosal excavation, endoscopic full-thickness resection, and endoscopic submucosal tunneling dissection, which have all been applied for SET management.1-3 Endoscopic subserosal dissection (ESSD) is a novel method for removal of SETs with origin beyond the muscularis propria layer in the upper GI tract.Hybrid resection of GI stromal tumor with endoscopic submucosal dissection and the full-thickness resection device
GI stromal tumors (GISTs) typically arise from the muscularis propria layer and are commonly seen in the stomach, although they can occur anywhere along the GI tract. Lesions larger than 2 cm should undergo surgical resection, although endoscopic resection can be considered for gastric GISTs 2 to 4 cm in size without high-risk features.1,2 Smaller lesions are monitored conservatively with surveillance EUS examinations, or endoscopically resected in patients who prefer to avoid frequent examinations.Use of helical tack system for management of a high-risk fibrotic peptic ulcer
GI bleeding because of peptic ulcer disease is a well-described entity in its diagnosis and management. Although hemostatic clips and thermal therapy have been the primary tools in bleeding from peptic ulcer disease, some bleeds remain refractory. New data have shown that obliteration of the underlying arterial blood flow is needed to control refractory peptic ulcer bleeding. Although this has been shown with over-the-scope clips, we present a case where GI bleeding is controlled via a helical tack system.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 full-thickness resection of gastric ulceration with persistent low-grade dysplasia using full-thickness resection device
Endoscopic mucosal resection and endoscopic submucosal dissection (ESD) are well-established treatment methods for resection of precancerous gastric lesions and early gastric cancers.1 Ulcerated or scarred gastric lesions are challenging to resect with EMR or ESD because of submucosal fibrosis and scarring, and hence, carry increased risk for perforation.2Transpyloric 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.Novel articulating through-the-scope traction device
Endoscopic submucosal dissection (ESD) has become a standard approach for treating superficial GI neoplasia, but its adoption remains limited because of its steep learning curve and extensive resource utilization when performed by endoscopists in the earlier stages of the ESD learning curve.1,2 Furthermore, although traction strategy has emerged to improve clinical outcomes and increase procedural efficiency, current techniques and devices own inherent limitations such as technical complexity, lack of adjustability, or demanding preparation.Novel dual-action tissue through-the-scope clip for endoscopic closure
Third space endoscopy, also known as submucosal endoscopy, has continued to evolve and expand as a minimally invasive alternative to surgery for the management of various GI diseases. Safe and effective endoscopic mucosal defect closure during many of these procedures is crucial. Conventional through-the-scope (TTS) clips are the most used devices for defect closure given the familiarity and ease of use.1 However, large mucosal defects can be difficult to close by using conventional TTS clips alone, given the inherent restrictions in clip opening width and inability to approximate large gaps firmly and securely.Endoscopic ultrasound–guided embolization of refractory splenic pseudoaneurysm
Visceral arterial pseudoaneurysms are common sequelae of chronic pancreatitis, occurring in 10% of patients, and carry a non-negligible 50% risk of rupture and 14% to 50% mortality with rupture.1-4 Transcatheter arterial embolization (TAE) is an effective modality for treatment of visceral arterial pseudoaneurysms with high technical and clinical success rates (97%-100% and 94%-100%, respectively) but a variable adverse event rate of splenic infarction of 6% to 24%.1-4 However, in cases refractory to TAE, EUS embolization approaches have demonstrated clinical efficacy, with studies demonstrating up to 100% technical and clinical success in this setting when using thrombin or cyanoacrylate glue.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 ).Endoscopic submucosal dissection in the right lateral position for early gastric cancer in the fornix
Endoscopic submucosal dissection (ESD) of early gastric cancer located in the fornix is challenging because the lesion is difficult to approach. The lesion in the fornix, especially on the greater curvature side or the anterior wall side, tends to face vertically in the left lateral position (LLP) when in close proximity. Additionally, the lesion occasionally becomes immersed in gastric fluid and blood, which interferes with the procedure because of poor visibility (Fig. 1A). Despite the use of a multibending scope or clip traction techniques attempted previously,1,2 some technical difficulties remain.Low-magnification narrow-band imaging for small gastric neoplasm detection on screening endoscopy
Microsurface patterns of the gastric mucosa can be observed using magnifying narrow-band imaging (M-NBI). However, the efficacy of M-NBI at low-magnification (LM-NBI) screening for detecting small gastric neoplasms is unclear.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.Endoscopic full-thickness resection with through-the-scope suture closure for gastrointestinal stromal tumor
Gastrointestinal stromal tumors (GISTs) greater than 2 cm are considered for resection.1 Those with muscularis propria (MP) involvement, as seen on endoscopic ultrasound and/or radiology, require full-thickness resection (FTR), surgery, or a combined laparoscopic/endoscopic approach.2 Dedicated endoscopic FTR (EFTR) devices are available but limited to lesions less than 2 cm.3,4 We present a GIST resected by EFTR and through-the-scope suture (TTSS) defect closure (Video 1, available online at www.giejournal.org ).A novel approach to the removal of a silastic band via the peroral endoscopic tunneling–silastic bandectomy technique
Managing outlet stenosis in patients who have undergone vertical banded gastroplasty (VBG) can be challenging.1,2 Endoscopic band removal can provide a noninvasive method to manage this serious adverse event. Transgastric cutting of the band has been reported, but this can be challenging if the band is not easily visible.3 We report a novel method for bandectomy using the peroral endoscopic tunneling–silastic bandectomy (POET-S) technique in a patient without an exposed band (Video 1, available online at www.giejournal.org ).
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