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Relief of malignant gastric outlet obstruction with lumen-apposing metallic stent–assisted percutaneous endoscopic gastrostomy tube after Roux-en-Y gastric bypass
Accessing the bypassed portion of the stomach and small bowel for endoscopic interventions in Roux-en-Y gastric bypass (RYGB) is challenging. In the case of bowel obstruction distal to the Roux-en-Y limb, decompression of the gastric pouch and bypassed stomach can be achieved with percutaneous enterostomy/gastrostomy tube placement by interventional radiology, deep enteroscopy, or surgery.1,2 The venting tube is usually placed within the alimentary limb of the jejunum in these approaches. However, in certain patients with obstruction distal to the jejunojejunal anastomosis or within the biliopancreatic limb, decompression of the excluded stomach is required.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.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 ).Endoscopic submucosal dissection with ductotomy for the resection of a gastric duplication cyst with a communicating duct
A 40-year-old otherwise healthy woman with persistent upper abdominal pain was found to have a 3-cm subepithelial lesion in the prepyloric area and was referred to our center (Fig. 1). EUS showed an anechoic cyst in the submucosa with well-defined outer sonographic borders suggesting a gastric duplication cyst (GDC) (Fig. 2). The cyst was completely aspirated and yielded 40 mL of serous fluid with negative cytology for malignancy. The patient’s symptoms resolved for 3 weeks but then recurred. A CT scan showed the cystic lesion with diameters of 3.2 × 1.2 × 1.1 cm.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.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.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.Successful endoscopic full-thickness resection of an exophytic subepithelial lesion with double scope traction technique
Endoscopic resection of an exophytic subepithelial lesion (SEL) in the stomach is challenging. Exophytic lesions are more amenable to surgical resection and are a relative contraindication for endoscopic resection. However, endoscopic resection of gastric SELs is now technically feasible with advancements in endoscopic techniques, such as peroral endoscopic tumor resection,1 endoscopic subserosal dissection,2 and endoscopic full-thickness resection.3 Secure closure of gastrointestinal (GI) wall defects is another technical challenge.Persistent gastro-cutaneous fistula closure with tack suture system in the setting of a severe esophageal stricture
A 64-year-old man with a history of metastatic squamous cell carcinoma of the larynx underwent laryngopharyngectomy with good response to adjuvant combination of immunotherapy and chemotherapy. Postoperatively, the patient developed symptomatic esophageal stricture requiring serial sessions of endoscopic dilation, which resulted in improved nutritional status and the removal of a previously placed PEG tube. However, a gastro-cutaneous PEG fistula (GCF) persisted 5 months after PEG tube removal, significantly affecting the patient’s quality of life.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.3A successful case of endoscopic submucosal dissection using the water pressure method for early gastric cancer with severe fibrosis
The water pressure method (WPM) is an endoscopic submucosal dissection (ESD) technique that uses a water stream from the working channel of an endoscope.1-4 In addition to the floating force and magnification effect provided by underwater ESD, WPM allows us to flip up and get under the mucosal flap easily. Also, by vibrating the submucosa with the water stream, the submucosa and lateral edge that should be dissected can be precisely identified. Here, we report a case of gastric cancer with severe fibrosis due to previous ESD, which was successfully treated by ESD with WPM (Video 1, available online at www.giejournal.org ).Magnetic compression anastomosis for the treatment of complete gastric outlet obstruction due to corrosive injury
The use of magnets in endoscopy has been described for over 75 years.1 The first experimental study of magnetic compression gastrojejunostomy was described in 1995, with the magnets introduced by means of the endoscopic technique perorally or through a gastrostomy.2 Chopita et al3 demonstrated the results of magnetic endoscopic gastroenteric anastomosis in humans, with a success rate of 86.6%. Other authors achieved success creating a gastroenteric anastomosis formed by magnetic compression for palliation of malignant gastric outlet obstruction.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.Objective assessment of luminal diameter and distensibility by an impedance planimetry system before and after pneumatic dilation in gastric sleeve stenosis
Sleeve gastrectomy has increased in popularity in recent years. Despite its low adverse event rate, its increased prevalence has yielded an increase in the incidence of complications.1 One such complication is gastric sleeve stenosis (GSS), which occurs in up to 4% of patients, typically at the incisura.2 Depending on the severity of the stenosis, this complication commonly causes reflux, regurgitation, and obstructive symptoms such as nausea, vomiting, and abdominal pain.Endoscopically directed single-port intragastric fundoplication, sleeve gastroplasty, and myotomy: a preclinical study in a porcine model
The progress of endoscopic therapy in the upper GI tract is limited by the size of the endoscope working channel and by the need to achieve triangulation for instrumentation. A novel transgastric trocar (Endoscopic Trans-Abdominal Gastric Surgery System [Endo-TAGSS, LLC, Shawnee, Kansas, USA]; Kansas City, Mo, USA) has been developed to allow intraluminal therapy using a combined endoscopic and laparoscopic approach (Fig. 1).1,2 The device, not yet Food and Drug Administration approved, is deployed under endoscopic vision with a technique similar to a pull PEG (Fig. 2), and it has been shown to be safe in a preclinical study that evaluated tract closure upon trocar withdrawal.Successful endoscopic ultrasound-guided nasocavitary catheter drainage of abscess caused by delayed perforation after gastric endoscopic submucosal dissection
Delayed perforation after gastric endoscopic submucosal dissection (ESD) is a rare but serious adverse event often requiring emergency surgery.1,2 Here, we report the use of EUS-guided nasocavitary catheter drainage to treat an intra-abdominal abscess caused by delayed perforation after gastric ESD.Successful diagnosis and endoscopic submucosal dissection of a gastric gastrointestinal stromal tumor originating from the submucosal layer
A 77-year-old man was introduced to our institution because of a slow-growing gastric subepithelial tumor (SET). Esophagogastroduodenoscopy revealed an SET approximately 2 cm in size in the fundus of the stomach, which was covered with normal smooth mucosa (Fig. 1A). EUS using a 20-MHz miniature probe (UM-3R; Olympus, Tokyo, Japan) showed a uniform hypoechoic lesion, 21.4 mm in size, in the third layer of the stomach wall (Fig. 1B). The hypoechoic fourth layer was intact and could be observed below the tumor (Fig. 1C).If at first you don’t succeed… a complicated course of endoscopic reversal of a gastric bypass
Marginal ulcer remains a common adverse event after Roux-en-Y gastric bypass (RYGB). Despite treatment with antisecretory therapy, up to a third of patients with recalcitrant ulcers may require surgical revision.1-4 In suboptimal surgical candidates or in patients who have failed attempts at surgical intervention, endoscopic techniques may be a preferable or required approach. Case reports have described uncomplicated endoscopic bypass reversal to treat refractory marginal ulcers.5 Here, we describe a more complicated, protracted case of a refractory marginal ulceration requiring endoscopic reversal, highlighting the potential for an oscillating, yet salvageable, approach (Video 1, available online at www.giejournal.org ).Division of a long-term symptomatic tissue bridge for reversal of endoscopic sleeve gastroplasty
Endoscopic sleeve gastroplasty (ESG) induces weight loss through delayed gastric emptying through gastric remodeling.1 In the long term, this commonly manifests as tissue bridges seen on follow-up endoscopy.2,3 ESG’s clinical efficacy, long durability for weight loss,4 and minimal rate of severe adverse events5 have led to widespread adoption. Although “redo” ESG appears safe and effective,6 reversibility is not well described and is limited to the acute setting. There is a risk that cutting sutures acutely may result in microperforations that put a patient at risk for leak, perigastric fluid collection, abscess, and bleeding.Endoscopic through-the-scope suturing
There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine.Endoscopic submucosal dissection by using a new traction device
Several devices and techniques have been described to assist endoscopic submucosal dissection (ESD), but all have their limitations. Most enable only traction,1 some are invasive2 or complex,3 and others demand several steps.4 We describe the use of a new traction wire device (ProdiGi Traction Wire, Medtronic, Minneapolis, Minn, USA) that is easy to deploy and enables easier access to the submucosa during ESD.Navigational tunnel technique for gastric peroral endoscopic pyloromyotomy: getting straight to the point (pylorus)
Gastric peroral endoscopic pyloromyotomy (G-POEM) is emerging as a treatment option for patients with gastroparesis. The most technically difficult part of the procedure is creating a submucosal tunnel in the gastric antrum, which can be directionally challenging. We describe a novel navigational tunneling method that guides submucosal dissection in the direction of the pylorus and helps to identify the pyloric landmarks.Complete endoscopic removal of an eroded magnetic sphincter augmentation device
GERD is characterized by reflux of the gastric contents into the esophagus through the lower esophageal sphincter (LES), resulting in symptoms of heartburn and regurgitation.1 If left untreated, long-term adverse events consisting of esophageal ulcers and strictures, Barrett’s esophagus, and esophageal adenocarcinoma may arise.2 First-line treatment of GERD consists of lifestyle modification and use of proton pump inhibitors (PPIs). Although PPIs are effective in most patients with GERD, 30% to 40% of patients have persistent symptoms.Traction wire endoscopic submucosal dissection: tips and techniques from 4 institutions
Traction can make endoscopic submucosal dissection (ESD) easier to perform. The traction wire is a new technology that is easy to use and delivers continuous traction throughout the ESD procedure. It is a curved wire system that, when attached to a lesion, returns to its precurved shape, lifting the mucosa and exposing the submucosa for easier dissection. Here, we present tips and techniques for using the device from 4 institutions.The use of the cap and underwater technique as an aid in endoscopic diagnosis and treatment of upper gastrointestinal bleeding: case series
Upper GI bleeding (UGIB) is a medical emergency associated with elevated mortality and significant costs to the health care system. EGD is currently the method of choice for the diagnosis and management of these conditions. However, the location of bleeding lesions and technical difficulties in achieving endoscope stability may challenge even the most experienced endoscopists. Herein, we demonstrate the use of the cap and underwater technique as a helpful aid in these situations.A unique twist following treatment of a sleeve gastrectomy leak: a multidisciplinary approach
Sleeve gastrectomy (SG) is currently the most common bariatric surgery procedure performed.1 GI leak is a known adverse event of SG, reported in up to 3% of patients,2 and is often the result of increased intraluminal pressure exceeding the strength of tissue and/or the staple line. Although there is a growing endoscopic armamentarium to manage these adverse events, refractory leaks often require surgical intervention.3-6 We describe a complex case of a leak after SG that, despite operative management, required a multidisciplinary approach involving endoscopic and surgical treatment strategies (Video 1, available online at www.giejournal.org ).Freestyle endoscopic submucosal dissection using a multifunctional snare
Endoscopic submucosal dissection (ESD) is an excellent treatment for superficial GI neoplasms because it allows en bloc resection, regardless of the lesion size.1,2 Recently, a novel multifunctional snare (SOUTEN; Kaneka Medics, Tokyo, Japan) was introduced to enable successful hybrid ESD procedures.3,4 Although this multifunctional snare was introduced for hybrid ESD, hybrid ESD involves partial submucosal dissection. We hypothesized that conventional ESD using this multifunctional snare would be a successful technique.
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