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Create a Free AccountProcedures - Upper endoscopy (EGD)
Endoscopic 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.Endoscopic submucosal dissection using an integrated needle-type knife and insulated-tip knife in a single device
Endoscopic submucosal dissection (ESD) allows for en bloc endoscopic resection of superficial lesions throughout the GI tract and is the first-line therapy for the endoscopic management of early gastric neoplasia.1,2 ESD requires familiarity with various specialized endoscopic knives that have been developed for mucosal incision and submucosal dissection.3 Currently, the most common knives used for ESD include the needle-type knife and the insulated-tip knife.4-6Management 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 ).Single-session EUS-guided gastrogastrostomy to facilitate cystgastrostomy in Roux-en-Y gastric bypass
Patients with surgically altered anatomy present unique challenges to traditional endoscopic management of foregut pathology, such as drainage of peripancreatic fluid collections. Recent advances in endoscopic techniques have enabled less-invasive access with EUS-directed transgastric intervention or gastric access temporary for endoscopy.1-4 Here we present a case of same session EUS-guided transgastric intervention to facilitate cystgastrostomy (Video 1, available online at www.giejournal.org ).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.Peroral endoscopic myotomy using an endoscopic dissector: another novel device in our toolbox
Peroral endoscopic myotomy (POEM) is a safe and effective technique for the management of achalasia and other nonachalasia motility disorders.1 However, it is technically challenging and time consuming with the use of multiple instruments often required for performing various steps associated with the procedure. While the procedural technique has remained homogeneous, various electrosurgical knives continue to evolve to prevent injuries to the surrounding structures and reduce the need for device changes.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.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 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.Endoscopic submucosal dissection of a gigantic gastric polyp aided by a novel retraction device and complicated by upper esophageal sphincter laceration during retrieval
An 87-year-old woman with chronic renal insufficiency and coronary artery disease on clopidogrel was found to have a sizable adenomatous gastric polyp. She was referred for endoscopic resection after declining surgery. On endoscopy, a gigantic polypoid lesion was found measuring 11 × 8 cm (Fig. 1) with a broad short stalk (Fig. 2). The surface pattern was irregular without ulceration. For the most part, the vascular pattern was a mesh of well-connected vessels. However, it contained an area of irregular vascular patterns worrisome for high-grade dysplasia.With a little help from my friends: percutaneously assisted internalization of a biliary drain
EUS-guided hepaticogastrostomy (EUS-HG) provides endoscopic biliary drainage when conventional techniques are not feasible.1 While comparable to percutaneous transhepatic drainage in regard to safety and efficacy,2 endoscopic drainage forgoes the need for cumbersome external drain hardware and promotes physiologic enterohepatic circulation of bile.3 In the absence of biliary dilation, the procedure can be technically challenging because access to the biliary tree is commonly obtained transgastrically with EUS-guided puncture of the left intrahepatic ducts.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.Endoscopic approach for management of dropped gallstones using percutaneous cholangioscopy
Dropped gallstones (DGS) are unable to be retrieved in 2% of cholecystectomy cases.1 While mostly asymptomatic, adverse events such as abscess formation have been described.2 Data on management are limited and most abscess cases in the literature required open laparotomy and surgical exploration.2The interventional direct peroral cholangioscopy toolbox for endoscopic snare resection of a high-grade biliary intraductal neoplasia
Direct peroral cholangioscopy (DPOC) is a valuable diagnostic and therapeutic tool for various biliary disorders because it allows direct endoscopic visualization of biliary lumen and mucosal abnormalities. Direct cholangioscopy carries several benefits, including high-definition imaging with the availability of narrow-band imaging, lower operating expenses and cost, and the ability to use a wide range of accessories through the working channel.1,2 In this article, we demonstrate endoscopic techniques for performing biliary intraductal polypectomy using the ultra-slim pediatric gastroscope (GIF-H190N; Olympus America, Center Valley, Pa) and showcase the various endoscopic accessories available for use.Emergent endoscopic submucosal dissection for a polypoid fibroadipose tumor accidentally disgorged from the mouth: an organ-preserving minimally invasive treatment
A 74-year-old woman presented with dysphagia. EGD at a previous hospital showed a giant pedunculated polyp from the entrance of the esophagus to the esophagogastric junction. She was referred to our hospital for treatment. On EGD, the polyp was covered with normal epithelium with a swollen and ulcerated head, measuring 17 cm in length. A CT scan revealed an intraluminal tumor in the esophagus with low density and no findings of metastasis (Fig. 1A). Positron emission tomography–CT revealed a highly concentrated area in the esophagus (Fig. 1B).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.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.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 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.
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