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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.The 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.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-guided liver biopsy using a modified wet heparin suction technique
The field of endohepatology has been evolving recently with multiple studies describing the success and safety of EUS-guided liver biopsy (EUS-LB) in obtaining liver parenchymal tissue. Although the supporting evidence embracing the use of this technique is convincing, variabilities in techniques are still an ongoing field for research.1 There is no consensus on the type of needle, depth of needle insertion, number of passes and actuations, or suction technique.Successful endoscopic resection by using gel immersion and the technique of endoscopic papillectomy for a tumor adjacent to the papilla of Vater
Superficial nonampullary duodenal epithelial tumors are rare, and the establishment of optimized strategies for their treatment is an area of active investigation.1 Endoscopic submucosal dissection (ESD) for superficial nonampullary duodenal epithelial tumors poses the risk of major adverse events (AEs), including a high rate of bleeding, intraoperative perforation, and delayed perforation.2,3 Lesions located in the duodenal flexure are associated with poor endoscope maneuverability.4 Moreover, endoscopic resection is particularly challenging for lesions on the descending duodenum’s medial wall, especially those adjacent to the papilla of Vater (POV).Endoscopic intermuscular dissection with intermuscular tunneling for local resection of rectal cancer with deep submucosal invasion
The introduction of population-based screening has resulted in an increased incidence of early-invasive (T1) rectal cancer.1 For these tumors, local treatment is considered curative when the resection margins are negative (R0) and histological high-risk factors for lymph node metastasis (LNM) are absent. Although deep submucosal invasion has long been considered a high-risk factor,2 recent reports showed that Kikuchi level (Sm) 2 to 3 lesions without other high-risk factors are associated with a negligible LNM risk (<2%).A specimen collection technique to ensure that the resected specimen is safely retrieved after duodenal ESD
In recent years, endoscopic submucosal dissection (ESD) has been applied for duodenal tumors.1-3 The advantage of en bloc excision in ESD is that it allows precise pathological examination.4 For this reason, it is important to ensure that the resected specimen is collected. However, there is no report on the collection method for duodenal specimens resected by ESD.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.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.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.Wide-field endoscopic mucosal resection of laterally spreading rectal tumors using a multiband ligation endoscopic mucosal resection technique
Advanced tissue resection techniques such as EMR and endoscopic submucosal dissection (ESD) have been established as therapeutic options for the management of advanced mucosal neoplasia of the colon. EMR has been found to safely and effectively remove sessile or flat neoplasms confined to the superficial layers of the GI tract.1Traction 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.Endoscopic ultrasound–guided liver biopsy: needle types and suction methods
Endoscopic ultrasound−guided liver biopsy (EUS-LB) is gaining traction among hepatologists and endosonographers. It is safe and effective at delivering excellent liver biopsy cores and can be time saving if another endoscopic procedure is required at the same time.1 Although the first EUS-guided biopsy of a liver lesion was described in 1997, EUS-LB for routine assessment of elevated liver biochemistries or evidence of cirrhosis was later reported in 2008.2,3 There is no clear consensus on the optimal tools and techniques used in EUS-LB.EUS-guided blood patch delivery during liver biopsy: nature’s gel foam
EUS-guided liver biopsy is emerging as an alternative form of tissue acquisition to percutaneous or interventional radiology–guided liver biopsy. Recent studies have shown adequate specimen acquisition and an enhanced safety profile. EUS-guided liver biopsy has been found to be extremely safe. The most common adverse events are mainly due to bleeding events. Unfortunately, there are limited endoscopic interventions available to prevent bleeding during liver biopsy.Rubber band-assisted closure of a mucosal defect following duodenal EMR
EMR of large duodenal adenomas is a technically challenging procedure. It carries a particularly high risk of perforation (5 % -10%) because of its relatively thin and fixed wall and delayed bleeding (15%) due to its rich vascular supply.1 Systematic closure of mucosal defects after duodenal endoscopic resection has been found to significantly reduce the risk of delayed adverse events (AEs) by 80%, specifically the risk of delayed bleeding and perforation.2 However, owing to the fixed retroperitoneal descending duodenum, apposition of the 2 mucosal edges is not always feasible, making closure using standard clips challenging.Bone wax-tipped catheter and 3-way stopcock to optimize hemostatic powder deployment
TC-325 Hemospray (Cook Medical, Winston-Salem, NC, USA) is a highly absorptive mineral powder used for endoscopic hemostasis in the setting of nonvariceal upper GI bleeding. The hemostatic powder is propelled by compressed CO2 through either a 7F or 10F catheter inserted through the working channel of the endoscope.Endoscopic resection of large Paris 0-Ip pedunculated polyps: video demonstration of recent U.S. Multi-Society Task Force recommendations on resection and removal for general endoscopists
Large pedunculated polyps have several unique features that contribute to the complexity of their removal. Pedunculated polyps typically have larger feeding blood vessels in their stalk, which increases the risk of immediate and delayed postpolypectomy bleeding. In addition, maneuvering instruments around the head of very large polyps can be difficult within the confined space of the colon lumen. The 2020 U.S. Multi-Society Task Force Recommendations on the Endoscopic Removal of Colorectal Lesions have offered best practice recommendations on the resection and removal of pedunculated lesions.The pocket-creation method facilitates gastric endoscopic submucosal dissection and overcomes challenging situations
Endoscopic submucosal dissection (ESD) is the criterion standard for resection of gastric superficial tumors. However, the stomach has a wide lumen that makes gastric ESD difficult in some locations. In difficult locations in the stomach, sometimes a distant or a vertical approach toward the muscularis is unavoidable and results in lengthy procedure times, the occurrence of adverse events, and a low-quality resected specimen. Unlike colorectal ESD, changing the patient’s position during the procedure is very difficult during gastric ESD when the patient is under conscious sedation.Endoscopic sleeve gastroplasty: the “cable” technique
Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure for the treatment of obesity whereby transmural sutures are placed to reduce gastric volume. An endoscopic suturing system (OverStitch, Apollo Endosurgery, Austin, Tex, USA) is used to create a running suture pattern that imbricates the greater curvature of the stomach, resulting in a reduction in functional volume by approximately 70%, in addition to 30% foreshortening.1-3Step-by-step instruction: using an endoscopic tack and suture device for gastrointestinal defect closure
Closure of mucosal and full-thickness defects in flexible endoscopy has become a major concern in interventional endoscopy.1 Multiple closure devices and techniques have been developed in the past years.2-6 However, the closure of large (>30 mm) tissue defects remains challenging, and over-the-scope clips and endoscopic suturing require removal of the endoscope for preparation of the device, which is not optimal, particularly for right-sided colon lesions.Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique
A 40-year-old man presented with a 1-year history of difficulty in swallowing liquids and solids. His Eckhart’s score was 6 of 12. EGD showed dilated esophagus with liquid stasis and mild resistance noted across the gastroesophageal junction. Esophageal manometry showed elevated integrated relaxation pressure with panesophageal pressurization (achalasia cardia type II). Peroral endoscopic myotomy (POEM) was planned and was performed using the novel Evis X1 endoscopy (Olympus Corporation, Tokyo, Japan) system.Use of cyanoacrylate glue in gastric variceal bleed: a modified technique without using lipiodol
We know that varices have the thinnest wall at the gastroesophageal (GE) junction and, with an increase in portal pressure beyond 12 mm Hg, they can rupture and cause a torrential bleed. To salvage this situation, we use injections of n-butyl-2-cyanoacrylate to achieve hemostasis.Small-bowel aspiration during upper esophagogastroduodenoscopy: Rao technique
Small-intestinal bacterial overgrowth (SIBO) and small-intestinal fungal overgrowth (SIFO) are characterized by high levels of bacteria or fungal organisms in the small intestine and are associated with GI symptoms such as bloating, abdominal distention, flatulence, abdominal discomfort, diarrhea, and weight loss. Diagnosis of SIBO and SIFO remain challenging. Although breath testing is noninvasive and used in clinical practice, its sensitivity and specificity remain poorly defined. Small-bowel aspiration and culture during upper endoscopy is generally regarded as the best method for the diagnosis of SIBO and SIFO.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.Mucosa-preserving Zenker’s diverticulotomy
Zenker’s diverticulum (ZD) is a rare condition, with prevalence ranging between 0.01% to 0.11%.1 The mainstay of treatment is cricopharyngeal myotomy. Recently, flexible endoscopic cricopharyngeal myotomy (FECM) (Fig. 1) has become increasingly popular as a safe and effective alternative to open surgery and the rigid endoscopic approach. However, reported recurrence rates range from 0% to 32%,2 likely owing to a lack of procedure standardization and difficulty in performing adequate myotomy for fear of perforation, given the absence of mucosa preservation.
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