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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.Over-the-wire snare-assisted stent exchange in endoscopic retrograde cholangiopancreatography
ERCP is an important therapeutic tool to address pancreatobiliary pathology. At times, negotiating a stricture with a wire can be challenging, but the nature of these lesions often mandates the placement of a temporary stent and often requires the exchange or upsize of stents to adequately manage the stricture. In such cases, it is efficient to preserve the tract established by the stent in the index procedure rather than renegotiating the stricture upon exchange. Toward this end, we demonstrate the steps of a method that allows preservation of the tract by removing the stent over a wire left in adequate position with the tip situated proximal (upstream) to the stricture.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.Cholangiocarcinoma obscured by a large paraesophageal hernia causing traction compression of the common hepatic duct ultimately diagnosed with percutaneous cholangioscopy
A 75-year-old man presented to an outside hospital with a 1-month history of painless jaundice. Abdominal CT and magnetic resonance imaging with contrast showed severe intrahepatic biliary ductal dilation with an abrupt cutoff in the common bile duct at the entrance into a large type IV hiatal hernia that contained the entire stomach, proximal duodenum, and colon (Fig. 1). The proximal duodenum was being pulled into the hernia tightly, leading to compression of the common bile duct (Fig. 2). His lipase level was normal (65 U/L), and the pancreas appeared normal on cross-sectional imaging.Technique of straightening the guidewire using a balloon catheter for successful endoscopic transpapillary gallbladder stenting
Endoscopic transpapillary gallbladder stenting (EGBS) is useful for acute cholecystitis when cholecystectomy or percutaneous transhepatic gallbladder drainage is contraindicated because of coagulopathy, administration of antithrombotic drugs, and poor physical condition.1,2 Furthermore, EGBS is considered to be superior in terms of patient quality of life because internal drainage can be achieved. However, EGBS is technically challenging. In some patients, a stent cannot be placed into the fundus of the gallbladder because of the looped guidewire in the cystic duct or the neck of the gallbladder.EUS-guided gallbladder drainage and subsequent peroral endoscopic cholecystolithotomy: A tool to reduce chemotherapy discontinuation in neoplastic patients?
EUS-guided gallbladder drainage (EUS-GBD) is emerging as a valuable treatment for acute cholecystitis (AC) in patients unfit for surgery. When lumen-apposing metal stents are used, large-caliber access to the gallbladder allows for subsequent direct peroral endoscopic cholecystoscopy (POEC) and eventual cholecystolithotomy (CL), offering a potentially “curative” solution for frailer patients. The aim of this series was to evaluate the outcome of these procedures in oncologic patients experiencing AC, with a specific focus on chemotherapy continuity.Successfully combined therapy of Coca-Cola and endoscopic treatment for a giant diospyrobezoar in the duodenum using the electrosurgical endo-knife and ileus tube
A 71-year-old woman was admitted to our surgical department with the chief symptom of abdominal pain and vomiting. She had undergone a distal gastrectomy with Billroth 1 for early gastric cancer 20 years ago. CT showed 8-cm defects and duodenal dilation in the more proximal defect (Fig. 1A). The patient’s history and CT findings led us to suspect that a diospyrobezoar may have caused the obstruction.Cholangioscopy and double-balloon enteroscopy mediated “sandwich puncture” of a completely closed choledochojejunostomy
Postoperative stricture after choledochojejunostomy is usually treated by (1) a percutaneous transhepatic approach, (2) balloon-assisted enteroscopy, or (3) interventional EUS.1 However, if the anastomosis is completely closed, it cannot be endoscopically expanded and must be surgically reopened. Although blind puncture2 and magnetic compression3 have been proposed as nonsurgical alternatives, they are not yet common procedures, and both carry risks such as perforation and major bleeding.EUS-guided gastroenterostomy to treat gastric outlet obstruction in a patient with gastric lymphoma followed by pyloric recanalization using a rendezvous technique
The rendezvous technique was described to salvage a dislodged stent during EUS-guided gastrojejunostomy.1 We describe using this technique to perform endoscopic gastroenterostomy because of the unsafety of traditional methods2 in this case.Enteroscopy-assisted ERCP with needle-knife stricturoplasty of a strictured hepaticojejunostomy
A 66-year-old woman with a history of T3N2 pancreatic adenocarcinoma who had been previously treated with a Whipple procedure and adjuvant chemotherapy presented with jaundice and pruritus. A CT scan demonstrated marked intrahepatic biliary ductal dilation with a transition point at the level of the hepaticojejunostomy; marked nodular enhancement was concerning for a stricture, and findings were suggestive of cholangitis. She was referred for an attempt at ERCP (Video 1, available online at www.giejournal.org ).PEG J tube placement with optimization of J tube insertion
We present a case series of 5 patients who underwent placement of a PEG tube followed by a J extension tube (PEG-J). PEG-J placement is usually performed as a 2-step procedure and is used for a variety of conditions such as gastroparesis. First, the PEG tube is placed using endoscopic transillumination, followed by tube placement with the pull method, and trimming of the PEG tube to approximately 20 cm. This is followed by insertion of the J extension tube through the PEG tube; the J extension tube is grasped by an endoscope and guided through the pylorus to a position distal to the ligament of Treitz.Valsalva maneuver barrier mouthpiece during upper endoscopy
Endoscopists with inadequate access to standard personal protective equipment (PPE) are being exposed to droplets from patients, some of whom may be positive for COVID-19, during upper endoscopy. Herein, we describe how a ready-made mouthpiece with a barrier (Valsa-mouth [Fig. 1A]; Sumitomo Bakelite Co, Ltd, Shinagawa-ku, Japan) may help protect endoscopists during endoscopic procedures. The mouthpiece was designed for the Valsalva maneuver, a forceful attempted exhalation against a closed airway to allow observation of the hypopharynx.Overtube-guided electrohydraulic lithotripsy through digital cholangioscopy for difficult biliary stones in a postoperative patient: challenging points with salvage techniques
Enteroscopy-assisted ERCP (E-ERCP) in patients with surgically altered anatomy usually represents a challenge even within the hands of skilled operators, with a success rate ranging from 70% to 90%.1 Management of difficult hepatolithiasis in such patients, using overtube-assisted digital cholangioscopy (DC) with laser lithotripsy, was previously reported.2 We describe here the use of electrohydraulic lithotripsy (EHL) in a similar fashion; however, this case video focuses mostly on challenges we have faced during this demanding procedure.Use of a rigidizing overtube for altered-anatomy ERCP
ERCP is important in managing biliary and pancreatic disorders.1 However, the success of altered anatomy ERCP depends on overcoming challenges including traversing the variable length of the afferent jejunal limb, intubating the surgical anastomosis, cannulating the papilla, and restrictions of tools depending on the endoscope used.1,2Adaptation for endoscopy of a ventilation mask using a glove finger like a filter: trying to reduce aerosols
The name of the COVID-19 pandemic is derived from the coronavirus disease that started in 2019. It is caused by coronavirus 2 virus of severe acute respiratory syndrome. It was first identified in December 2019 in Wuhan City, the capital of Hubei Province in the People’s Republic of China. A group of sick people with an unknown type of pneumonia were reported. Most affected individuals were linked to workers at the Wuhan South China Wholesale Seafood Market. The World Health Organization recognized it as a pandemic on March 11, 2020.A spiraling journey into the small bowel: a case series of novel motorized power spiral enteroscopies
The small bowel has, to date, remained a difficult area to access via endoscopy. The novel motorized power spiral enteroscopy, recently introduced, has more depth of insertion and is of shorter duration. Presented here is a case series of motorized spiral enteroscopies.Motorized spiral enteroscope-assisted retrieval of video capsule in a patient with Crohn’s disease
A 36-year-old man with chronic kidney disease on maintenance hemodialysis was evaluated elsewhere for obscure GI bleeding requiring multiple blood transfusions. A capsule endoscopy (CE) performed at that center showed ileal stricture and poor progression of the capsule beyond the stricture. CT showed the CE device in the proximal ileal loop, with no signs of small-bowel obstruction. Laboratory test results showed highly sensitive C-reactive protein and fecal calprotectin levels (>500 μg/mg) suggestive of inflammatory bowel disease.Complete anterograde small-bowel exploration with the novel motorized spiral enteroscope
The advent of deep enteroscopy with the support of capsule endoscopy has given impetus to the diagnosis and therapy of small-bowel diseases, especially in relation to GI bleeding and Crohn’s disease.1 However, deep enteroscopy still has a few limitations, such as the difficulty of fully exploring the small bowel and inaccurate measure of the enteroscope insertion depth.2Endoscopic therapy for bleeding small-bowel venous malformations
An 84-year-old man was admitted to our inpatient ward with melena. He had a history of coronary artery disease treated with aspirin and clopidogrel and atrial fibrillation treated with apixaban. Initial laboratory analysis showed a hemoglobin level of 7.7 g/dL; hemoglobin level was normal 1 month before admission.Blue rubber bleb nevus syndrome in a 10-year-old child treated with loop ligation facilitated by double-balloon enteroscopy
Blue rubber bleb nevus syndrome is an extremely rare systemic vascular disorder (with only 200 cases published to date), characterized by multiple cutaneous and GI venous malformations.1 Patients present with fatigue, iron-deficiency anemia, and occult or overt obscure GI bleeding. Patients are usually managed conservatively with iron supplementation and/or blood transfusions. However, endoscopic (argon plasma coagulation, sclerotherapy, polypectomy, and ligation), radiologic, and surgical approaches are preferred for severe cases.Motorized spiral enteroscopy–assisted ERCP after Roux-en-Y reconstructive surgery and bilioenteric anastomosis: first clinical case
ERCP procedures in patients with surgically altered anatomy are often challenging because Roux-en-Y reconstructive surgery usually excludes the biliopancreatic system from a conventional endoscopic approach. The advent of device-assisted enteroscopy (DAE) using double- and single-balloon enteroscopy and spiral enteroscopy substantially improved the efficacy of endoscopic treatment after all types of Roux-en-Y reconstructions.1,2 However, insertion of the enteroscope is still often cumbersome and time consuming, and therapeutic success rates of ERCP are limited by reduced maneuverability of the endoscope and unstable position in front of the papilla, the limited diameter of the working channel, and availability of instruments with an appropriate length.New protection barrier for endoscopic procedures in the era of pandemic COVID-19
In December 2019, the World Health Organization office in China was informed of cases of pneumonia of unknown etiology detected in Wuhan.1 A new coronavirus called SARS-CoV-2 was identified in lower respiratory tract samples from several patients. The virus has spread worldwide and on March 11, 2020, was declared a pandemic by the World Health Organization. From the time of its detection to April 26, 2020, more than 2,900,000 cases have been confirmed worldwide with more than 203,000 deaths. In Colombia, 5379 cases have been confirmed, with 244 deaths reported.The structure and delivery of a novel training course on endoscope reprocessing and standard precautions in the endoscopy unit
The importance of knowing about endoscope reprocessing cannot be overemphasized. It is crucial to remember that keeping the endoscope disinfected and the endoscopy unit clean is everyone’s responsibility; all staff members must understand the principles of endoscope reprocessing and standard precautions in the endoscopy unit. For precleaning, the process can be simplified and summarized as follows: wipe the outside and then wash and dry the inside. The specific length of time, typically ranging from 10 to 30 seconds, required to wash and dry the individual channels must be followed.Preventing clogging of hemostatic powder during control of bleeding
Hemostatic powders are topical agents used in therapeutic and potentially prophylactic control of GI bleeding.1 When effectively applied to the site of bleeding, the powder allows for better visualization of the area and subsequent definitive therapy. These powders are generally composed of small mineral granules that stimulate hemostasis. In the United States, the inorganic powder TC-325 (Hemospray; Cook Medical, Bloomington, Ind, USA) was the first to be brought onto the market.2 It was approved by the United States Food and Drug Administration in May 2018 for treatment of nonvariceal bleeding.Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter
GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported.
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