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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.EUS of a submucosal lesion at the appendiceal orifice using a double-balloon endoluminal intervention platform
The use of curved linear array (CLA) and radial EUS in the lower GI tract has largely been limited to the sigmoid colon and rectum, as their oblique optics present a challenge in advancement to the right side of the colon. While catheter-based miniprobes are available for endosonographic assessment of lesions in the right side of the colon, they are limited by the inability to perform fine-needle biopsies (FNBs). Recently, a double-balloon endoluminal intervention platform (DEIP) has become available to aid in EMR and endoscopic submucosal dissection.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 ).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.Endoscopic adventitial dissection of a rectal GI stromal cell tumor
Endoscopic adventitial dissection (EAD) is a novel resection technique that involves dissection in the “fourth space,” the space between the outer longitudinal muscle and the tunica adventitia of the rectum. EAD is the retroperitoneal equivalent of endoscopic subserosal dissection (ESSD), which involves dissection between the serosa and muscularis propria. The space between these 2 layers mainly consists of loose connective tissue, similar to the submucosa. The submucosal layer has been coined as the “third space” in which endoscopic procedures can be performed.A new connection: management of disconnected segments 5 and 6 bile leak via the cystic duct remnant
Iatrogenic adverse events following cholecystectomy can lead to bile leaks in up to 1.1% of cases.1 Management of disconnected bile leaks often requires multidisciplinary management, especially because they are often complex injuries associated with high morbidity and mortality.2 ERCP with sphincterotomy and stenting has emerged as a reliable treatment modality even in refractory or complex leaks with a resolution rate over 90%.3 Nonetheless, type C biliary segments 5 and 6 injuries are rare and account for 9.7% of leaks that make it to surgery.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).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).Wide-field ESD for Barrett's adenocarcinoma at the gastroesophageal junction: technical approaches to facilitate en bloc R0 resection
Endoscopic submucosal dissection (ESD) for Barrett's esophagus (BE) neoplasia is associated with high en bloc resection and an acceptable safety profile but with suboptimal curability rates (range, 56%-59%).1 Two large Western studies showed that low R0 resection rates resulted from the high rate of positive lateral margins in ESD specimens (range, 82%-86%), which prompted either salvage ESD or additional surgical treatment.2,3 A U.S. multicenter ESD study found positive lateral margins in up to 70% of Barrett's adenocarcinoma (BA) at the gastroesophageal junction (GEJ) because of the increased technical complexity, poor maneuverability, and difficulty in evaluating the lesion’s margin.Pancreatoscopy-guided retrieval of a migrated pancreatic duct stent
A 26-year-old woman presented to an outside hospital with symptomatic cholelithiasis and underwent a laparoscopic cholecystectomy that was complicated by bile leak and intra-abdominal fluid collections. She underwent intraabdominal drain placement and an ERCP with biliary sphincterotomy and biliary stent placement. The ERCP was technically challenging and required a prophylactic pancreatic duct (PD) stent that was complicated by upstream migration and was unable to be retrieved. She was referred to our center for stent retrieval.EUS–guided choledochoduodenostomy using a lumen-apposing metal stent in a patient with preexisting duodenal stent and ascites
Endoscopic retrograde cholangiopancreatography in patients with a pre-existing duodenal stent is technically challenging with a low success rate.1 EUS-guided biliary drainage has emerged as a promising technique for patients with malignant biliary obstruction when conventional ERCP fails. Although combined placement of self-expanding metal biliary and duodenal stents can be performed for patients with simultaneous biliary and duodenal obstruction, reports on transduodenal EUS-guided biliary drainage in patients with an existing duodenal metal stent are limited.Use of a novel dual-action clip for closure of complex endoscopic resection defects
While there continues to be debate surrounding indications for closure, use of clips following endoscopic mucosal resection of large nonpedunculated polyps has been found to reduce risk of postprocedural bleeding,1-3 and clinically has also been performed to reduce risk of perforation because of muscularis propria injuries. While standard clips are effective for closure of 2- to 3-cm endoscopic mucosal resection sites in the colon, closure of endoscopic submucosal dissection (ESD) wounds is more technically challenging as the deeper dissection plane in ESD tends to result in a larger separation between the wound edges.Point blank: an endoscopic retrieval of an extraluminal bullet
A 36-year-old man with no medical history presented with multiple gunshot wounds to the right neck, left axilla, and pelvis. An entry wound in the right buttocks was noted without a corresponding exit wound. A CT scan identified the bullet near the rectum, and a leak from an administered barium enema further demonstrated the location. (Figs. 1 and 2) A laparoscopic diverting colostomy was performed, and advanced endoscopy was consulted for retrieval of the bullet for ballistics and closure of the subsequent rectal defect.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.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 ).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.Endoscopic submucosal dissection to treat squamous cell carcinoma in situ of the anal canal
The standard treatment for invasive squamous cell anal cancer is chemoradiation treatment. However, treatment options for high-grade dysplasia (squamous cell cancer in situ) are either surgical excision or topical treatment modalities. There are a few case reports, mainly from Japan, about resecting early squamous cell anal cancer (high-grade dysplasia/carcinoma in situ) by endoscopic submucosal dissection. We present a case series of 3 patients from a western hemisphere population with squamous carcinoma in situ of the anal canal resected with endoscopic submucosal dissection (ESD).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.3Magnetic 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.Utility of red dichromatic imaging for identifying the bleeding point in endoscopic hemostasis of colonic diverticular bleeding
An 82-year-old woman was admitted to our hospital because of hematochezia without pain. She had been admitted to our hospital several times in the previous year for colonic diverticular bleeding (CDB) and had already undergone multiple hemostatic treatments for the CDB. A previous plain computed tomography scan had showed multiple colonic diverticula in the ascending colon and sigmoid colon (Fig. 1), so recurrent colonic diverticular hemorrhage was the primary differential diagnosis.Quit screwing around: magnetic retrieval of an appendiceal foreign body
Appendiceal foreign bodies are uncommon but can lead to serious adverse events such as appendicitis and perforation. Patients can remain asymptomatic for many years before these adverse events develop. Data on incidence and optimal management are limited and largely restricted to case reports in both adults and children.1-6 In a review spanning 100 years with 250 identified case reports, objects that were sharp, thin, stiff, and pointed increased the risk of adverse events.7 Timely intervention is recommended before the development of localized inflammation or perforation.Pancreatoscopy-guided laser dissection of obstructing pancreatic duct stricture: pancreas-preserving endotherapy
Pancreatic duct (PD) stones and strictures remain challenging sequelae of chronic calcific pancreatitis and contribute to ductal hypertension, which may manifest as abdominal pain, exocrine pancreatic insufficiency, or biliary obstruction.1,2 Standard ERCP techniques may be insufficient for complex lesions such as severe stricture(s) or extensive stone burden, whereby the degree of obstruction or ductal tortuosity may not permit passage of the wire or catheter.3 Peroral pancreatoscopy (POP) promotes direct ductal visualization and use of additional devices to treat such advanced pathology, which includes laser therapy that can be used for stone fragmentation or tissue dissection as a means of stricturoplasty.Endoscopic ultrasound-guided ileosigmoidostomy using a lumen-apposing metal stent for palliation of malignant small-bowel obstruction
High-grade malignant small-bowel obstruction (SBO) is typically managed with surgical diversion (ileostomy) or palliative decompression via nasogastric tube or venting gastrostomy. These approaches have a significant impact on quality of life. Endoscopic palliation of malignant luminal obstruction by lumen-apposing metal stent (LAMS) placement is well established for duodenal obstruction. Distal SBO, however, is challenging to manage endoscopically. We present the case of a novel EUS-guided ileosigmoidostomy technique for the palliation of malignant distal SBO.Novel EUS-guided microwave ablation of an unresectable pancreatic neuroendocrine tumor
Pancreatic neuroendocrine tumors have an incidence of ≤1 case per 100,000 individuals, accounting for up to 2% of all pancreatic neoplasms in the United States. The 5-year overall survival rate ranges from 37.6% to 50%.1 Curative surgical interventions are not feasible for most patients because most cases are detected in advanced unresectable stages, mainly in elderly patients with several comorbidities.2 Therefore, developing safe and effective alternatives for patients unfit for surgery is imperative for clinical practice.
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