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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.Combined extracorporeal shockwave lithotripsy and ERCP for chronic calcific pancreatitis with the patient under general anesthesia in one session: an introduction to extracorporeal shockwave lithotripsy and a case example
The role of extracorporeal shockwave lithotripsy (ESWL) in the management of patients with chronic calcific pancreatitis is evolving. The European Society of Gastrointestinal Endoscopy recommends ESWL for the clearance of radiopaque obstructive main pancreatic duct (PD) stones larger than 5 mm located in the head or body of the pancreas because standard ERCP methods are less likely to result in successful stone clearance.1 However, although it is known to improve pain and quality of life in chronic calcific pancreatitis according to case studies and meta-analyses,2 ESWL is not currently widely available in the United States because of a lack of randomized controlled trials or lack of equipment, as well as difficulty in setting up such a procedure.Dual purpose easily assembled aerosol chamber designed for safe endoscopy and intubation during the COVID pandemic
GI endoscopy, particularly when performed through the oral route, is considered an aerosol-generating procedure. Such procedures may put endoscopists, anesthetists, and other healthcare personnel at risk.1,2 Transmission of infection can be interrupted by the proper use of personal protective equipment and by performing endoscopy in a negative pressure room.3 However, these rooms may not always be readily available. Aerosol chambers have been used recently to reduce the spread of COVID-19 during endotracheal intubation4 and as endoscopic shields during endoscopy.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.2Evaluation of sling fibers and two penetrating vessels for guiding extent of the tunnel and myotomy during posterior peroral endoscopic myotomy in a Western cohort
Peroral endoscopic myotomy (POEM) was performed first in 2008 by Professor Inoue. Its use is now widespread as a first-line treatment for achalasia, with similar efficacy to Heller’s myotomy.1Essentials of donning, doffing, and changes in endoscopy practice to reduce the risk of spreading COVID-19 during endoscopy
The COVID-19 pandemic has resulted in a significant disruption to normal endoscopy practice in the United Kingdom and around the world.1 Clinical manifestations of this infection are broad spectrum and can be very subtle; thus, a high degree of clinical suspicion and risk stratification are essential.2Pneumatic dilation for achalasia: new techniques to improve an old procedure
Pneumatic dilation (PD) remains an important treatment for achalasia (Fig. 1). PD has similar effectiveness compared with surgery (Heller’s myotomy) and is a very cost-effective treatment option. PD causes circumferential stretching of the lower esophageal sphincter (LES) with subsequent controlled tearing of its muscle fibers. PD is done under fluoroscopic guidance by inflating a noncompliant polyethylene balloon at the level of the LES. The goal of treatment is symptomatic relief characterized by a postdilation reduction of the Eckardt symptom score to 3 or less.A novel teaching tool for visualizing the invisible bile duct axis in 3 dimensions during biliary cannulation (Compact Disc method)
Selective biliary cannulation is difficult to master, even in cases with normal papillae.1 In the case of a papilla with a long oral protrusion (LOP), the difficulty is greatly increased.2 In such cases, visualization of the invisible bile duct axis in 3 dimensions is required, but this is difficult to master, even for experienced endoscopists. Individual trainers must commit to developing their teaching skills3; however, there is no dedicated teaching tool for this difficult task. Therefore, we developed a novel and simple teaching tool for visualizing the invisible bile duct axis in 3 dimensions, called the compact disc (CD) method.EUS-guided celiac plexus radiofrequency ablation using a novel device
The incidence of pancreatic cancer in the U.S. population was estimated to be 53,670 in 2017.1 Abdominal pain is common in patients with pancreatic cancer and can be intense, debilitating, and refractory to medical treatment.2 EUS celiac plexus neurolysis (CPN) is considered efficacious in the management of pancreatic cancer pain and can be used early at the time of diagnosis of inoperable disease.3Dynamic and multifocal clip and band countertraction for endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) is a challenging technique that bears a significant risk of perforation. Given that standard endoscopy, unlike laparoscopy, does not permit traction, the difficulty of ESD is augmented. Countertraction techniques have been shown to improve the speed of dissection, the rate of R0 resection, and the safety of the procedure.1-3Sterile disposable elevator cap in the reduction of cross-contamination
Flexible duodenoscopes play a pivotal role in GI endoscopy, allowing various diagnostic and therapeutic procedures. The estimated number of ERCP procedures performed annually exceeds 450,000 in the United States.1 However, flexible duodenoscopy is associated with the development of patient-to-patient cross-contamination and outbreaks of infection with multidrug-resistant organisms during ERCP procedures.2-4 In a nationwide study, the standard duodenoscope disinfection process yields a persistent bacterial contamination rate of up to 20%.Cholangioscopy-guided basket retrieval of impacted stones
ERCP remains the primary method of removing bile duct stones.1 Standard ERCP techniques, including endoscopic sphincterotomy with balloon sweeping or basket extraction, carry a >90% success rate in removing stones; however, large or impacted stones may present a particularly challenging scenario for the endoscopist.2 Alternative solutions include the use of mechanical lithotripsy or cholangioscopy-guided methods, such as electrohydraulic or laser lithotripsy. However, stones may be in a position in which extraction by conventional balloon or basket under fluoroscopic guidance may be difficult (eg, in the intrahepatic ducts).Endoscopic submucosal tunneling dissection: use of a novel bipolar radiofrequency and microwave-powered device for colorectal endoscopic submucosal dissection
A 57-year-old man with no significant medical history was referred for colonoscopy after positive multitarget stool DNA testing (FIT-DNA testing) as part of routine screening for colorectal cancer. The patient was asymptomatic with no family history of colorectal cancer. An initial colonoscopy revealed a large, 60-mm, laterally spreading tumor granular-type lesion in the rectum, approximately 3 cm from the anal verge (Fig. 1A). Examination of the lesion via image-enhanced endoscopy with narrow-band imaging revealed a type 2 noninvasive pattern per the narrow-band imaging international colorectal endoscopic classification (Fig. 1B).Endoscopic submucosal dissection using a new super-soft hood and the multipoint traction technique
Endoscopic submucosal dissection (ESD) is considered the standard of care for resection of early gastric cancers.1 To perform this technique in a safe and effective manner, visualization of the submucosal layer and appropriate tissue tension are required. To achieve this, a hood and a countertraction method may be used.2-6 Here, we introduce ESD using a new super-soft hood7 and the advanced multipoint traction technique.8Endoscopic shield: barrier enclosure during the endoscopy to prevent aerosol droplets during the COVID-19 pandemic
Coronavirus disease 19 (COVID-19) refers to human infection with severe acute respiratory syndrome coronavirus 2. The World Health Organization declared COVID-19 a pandemic on March 11, 2020. By April 21, 2020, the number of confirmed COVID-19 cases had increased to more than 2,397,000 globally, with an overall mortality rate of 6.8%.1Management of a COVID-19 patient in the endoscopy suite
Since the COVID-19 pandemic started in December 2019, gastroenterologists have had to rapidly evolve their endoscopy practice to ensure the safety of endoscopy team members and their patients. Because the virus is transmitted via droplets and potentially via airborne inhalation of aerosolized particles, endoscopic procedures performed on patients with confirmed or suspected COVID-19 increase the risk of transmission to healthcare providers.A simple and cost-effective method: piecemeal cold snare polypectomy without injection for a large sessile serrated lesion ≥20 mm
Cold snare polypectomy (CSP) has become a common treatment for small polyps, but a size limitation exists because some lesions are insufficient for precise histologic examinations. If the lesion measures 10 mm or more, its possibility of having malignant potential increases1; this is the reason why the limitation exists for CSP.2 Although sessile serrated lesions (SSLs) are important precursors of colorectal cancer, it is not known whether treatment is safer and more effective particularly for large SSLs (≥10 mm).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.A novel clip-band traction device to facilitate colorectal endoscopic submucosal dissection and defect closure
Endoscopic submucosal dissection (ESD) allows for en bloc resection of large superficial lesions throughout the GI tract.1,2 Adequate visualization of the submucosal dissection plane is critically important for both safety and efficacy in ESD. In traditional surgery, an assistant provides effective countertraction. However, this is not feasible with endoscopic resection, wherein countertraction is naturally absent, aside from the effects of gravity acting on the partially resected lesion.Usefulness of a handmade distal endoscope attachment with a transparent tape
Distal attachments placed on the endoscope tip can improve visualization of the endoscopic field and have been applied for a variety of endoscopic procedures (eg, colonic insertion, detection, diagnosis, and treatment).1 Although manufactured distal attachments are commercially available, it may be necessary to prepare different types to suit different endoscopes because the distal outer diameters of endoscopes vary widely. In addition, cost-effectiveness leads to hesitation about the use of commercially available distal attachments in daily practice.Simulation-based mastery learning (SBML) for rapid acquisition of upper endoscopy knowledge and skills–initial observation
At present, most endoscopy training during fellowship is based on the apprenticeship method, wherein trainees learn directly through patient cases in the endoscopy unit. In this method, trainees need to perform a high volume of cases and undergo a long training period to achieve competency. For example, it takes approximately 250 upper endoscopies before trainees attain minimum competence1 and 450 colonoscopies to achieve an adenoma miss rate of less than 25%.2 Unfortunately, many trainees may never reach this number of procedures during their fellowship.Endoscopic sleeve gastroplasty by use of a novel suturing pattern, which allays concerns for revisional bariatric surgery
Endoscopic sleeve gastroplasty (ESG) is a safe and effective minimally invasive procedure that has been gaining traction to treat patients with obesity.1-3 Because obesity is a chronic disease, revisional bariatric surgery may be beneficial if adverse events, inadequate weight loss, or weight regain have occurred.4Closure of mucosal defect with a micro-ring technique: simple, cheap, and effective
Effective closure methods of mucosal leakage are a paramount tool for every endoscopist. They are crucial in reducing the need for surgery and allowing us to stretch the limits of interventional endoscopy. The aim of these videos is to share a simple and cheap solution to close large mucosal defects (Videos 1, available online at www.VideoGIE.org ).Modified primary obesity surgery endoluminal (POSE-2) procedure for the treatment of obesity
The minimally invasive endoluminal approach has evolved to become a mainstream treatment option for obesity.1 Particularly, endoscopic remodeling of the stomach and restricting the gastric lumen by placing multiple, internal, full-thickness suture plication has been shown to affect hunger and appetite and to induce effective and sustained weight loss.2Suction marking method: a novel technique to prevent overlooking of polyps detected upon endoscope insertion
It has been established that removal of adenomas reduces the prevalence and mortality of colorectal cancers.1,2 Because the miss rate of polyps in colonoscopy remains high, an appropriate approach for all polyps, even for lesions detected upon endoscope insertion, plays an important role in achieving high-quality colonoscopy.Thoughts on an academic endoscopy career
My reasons for pursuing an academic career as an endoscopic investigator are several (Video 1, available online at www.VideoGIE.org ). I have an opportunity to work with both my hands and my mind; I have been able to collaborate with bright engineers to invent devices; I have developed some great friendships in the American Society for Gastrointestinal Endoscopy. Sometimes I feel like a child who has gotten to play with cutting-edge technology, but most importantly, I have had a chance to care for patients while experiencing the sheer joy of endoscopy.EUS-guided gastroenterostomy: techniques from East to West
Gastric outlet obstruction (GOO) can result from benign and malignant causes.1 Surgical gastroenterostomy has been the treatment of choice for patients with benign and malignant GOO with a good functional status.2 Placement of luminal self-expandable metal stents is currently accepted as the endoscopic treatment of choice for malignant GOO because of its effectiveness and minimally invasive nature.3 The main limitation of luminal stents is the high incidence of recurrent GOO resulting from tumor/tissue ingrowth/overgrowth.Endoluminal vacuum therapy of esophageal perforations
Acute esophageal perforations are traditionally managed surgically, although minimally invasive approaches, including esophageal clipping, stent placement, suturing, and endoluminal vacuum therapy (EndoVAC), have been reported.1-3 The EndoVAC approach, which relies on a modification of the wound-VAC technique, has been used to treat esophageal perforations and leaks with success.4-9 These cases, often reported in the surgical literature, have demonstrated healing of the perforation or leak while avoiding the morbidity and mortality associated with surgery.Authorship of articles in scholarly publications
The complete and accurate listing of authors on articles in scholarly publications is an ethical issue that deserves attention. In addition to ensuring the precise data, conflicts of interest, and other elements of your article, making sure that your author list is correct is an important part of publication ethics. Transparency in all areas is critical, and that includes the naming of authors. Readers must be able to count on your list being accurate; every person on it contributed and no one was omitted.Acetic acid spray for better delineation of recurrent sessile serrated adenoma in the colon
Sessile serrated lesions (SSLs) have a high risk of incomplete endoscopic resection.1 The benefit of using acetic acid spray has been reported for SSLs in the colon.2,3 Our previous experience has demonstrated that acetic acid spray, along with indigo carmine, is of substantial benefit for the delineation of SSLs.2 Similarly, the use of acetic acid for a single case of sessile serrated polyposis syndrome was reported and showed clinical usefulness.3Private practice career after GI training
Moving to the next phase, your career after fellowship, involves big decisions and sometimes an overwhelming number of questions. Here are some tips on organizing your thoughts around them.Step-by-step approach to endoscopic gastroplasty by a novel single-channel endoscopic suturing system
Endoscopic gastroplasty (EG) reduces gastric volume by use of a series of full-thickness internal plications and mimics the surgical sleeve gastrectomy.1 EG with use of the Overstitch device (Apollo Endosurgery, Austin, Tex, USA) is shown to be safe and effective in achieving weight loss.2,3 However, the device has certain limitations: (1) it requires a dual-channel endoscope, which is not widely available; (2) the endoscope is stiff and less maneuverable; (3) the field of vision gets impaired when the device is mounted; and (4) the suction ability decreases with the accessories in the working channel.Sit-stand endoscopic workstations equipped with a wearable chair
Endoscopists spend significant amounts of time standing during endoscopic examinations and procedures. Recently, endoscopy-related musculoskeletal injuries such as thumb, lower-back, hand, and neck pains have been recognized increasingly among endoscopists.1,2Duodenal endoscopic submucosal dissection for a large protruded lesion located just behind the pyloric ring with a scissor-type knife
Recently, endoscopic submucosal dissection (ESD) has been applied to the treatment of GI lesions to enable en bloc curative resection.1,2 Generally, large tumor size, protruded lesion, poor endoscope maneuverability, and other procedural factors may contribute to the technical difficulties of ESD and periprocedural perforation.3,4 Among ESD procedures for GI lesions, duodenal ESD is the most technically challenging procedure because of the thin wall and narrow lumen of the duodenum, as well as poor maneuverability of the endoscope in the duodenum.EUS-guided placement of fiducial markers for the treatment of pancreatic cancer
Radiation therapy plays an increasingly important role in the treatment of pancreatic cancer (PC). Studies have shown that aggressive local treatment with radiation dose escalation can improve local control.1,2 Stereotactic body radiation therapy (SBRT) uses advanced imaging technology to verify the target lesion setting before and during radiation therapy and allows for the accurate delivery of high-dose radiation to pancreatic tumors.3Endoscopic suturing for closure of endoscopic submucosal dissection defects
Endoscopic submucosal dissection (ESD) allows for en bloc resection of tumors within the GI tract, typically leaving a large mucosal defect, which can result in postprocedure adverse events such as delayed perforation or bleeding.1 Different techniques have been described for the closure of mucosal defects after ESD, including the use of a variety of clips (with or without an Endoloop or string) to close these defects, which may reduce the risk of adverse events.2-5 Endoscopic suturing may be another method to effectively close these defects.Colorectal endoscopic submucosal dissection with use of a bipolar and insulated tip knife
The bipolar needle-knife (B-knife) was originally developed by Doi et al in collaboration with the Zeon Medical Company (Tokyo, Japan) in 2002. The main advantage of the B-knife is safety. The electric current is limited to the needle, and the highest density of current stays near the sheath pole. The risks of both perforation and coagulation effect to the muscle layer are, therefore, significantly reduced.1,2 Several clinical studies have demonstrated the safety of the B-knife.3,4Robotic-assisted surgical endoscopy: a new era for endoluminal therapies
Minimally invasive endoscopic procedures are associated with lower adverse events and shorter hospital stays compared with conventional open surgery.1,2 However, some advanced endoscopic procedures, including endoscopic submucosal dissection (ESD), natural orifice transluminal endoscopic surgery (NOTES), and suturing, have typically required specialized training and a certain amount of experience to achieve competency. Therefore, these procedures are not widely performed in nonspecialized centers.Standardized examination procedure of magnetically controlled capsule endoscopy
Magnetically controlled capsule endoscopy (MCE), a painless noninvasive screening tool for gastric diseases, has been an emerging diagnostic modality in clinical practice.1-7 Because the magnetic capsule in the stomach can be accurately controlled through multidimensional rotation and adaptive matching of an external C-arm robot, the diagnostic accuracy of MCE for detecting gastric focal lesions is comparable with that of conventional EGD.2,3Assisted line to visualize endoscopic screen for endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) has been established as the general treatment for early GI cancer in Japan; however, ESD is considered a very difficult procedure to perform by those who are inexperienced with endoscopy.1-3 The direction of the accessory channel differs according to the type of upper and lower endoscope used. For ESD that requires an accurate tip for endoscopic manipulation, imaging in the direction in which the attached channel emerges is important. We previously discovered an approach to train individuals in the performance of ESD by attaching a transparent sheet to the endoscope4 and devised an approach for an assistance line to appear on the actual endoscope screen.How to perform water exchange colonoscopy, with tips and tricks
Water exchange (WE) colonoscopy is a standardized insertion technique entailing gasless insertion to the cecum, maximizing cleanliness during insertion, and avoiding distension of the colon through removal of excess water and residual air.1 In essence, through infusion and nearly simultaneous suction of water, with the use of WE all colon content is substituted by a layer of clear water, facilitating insertion of the instrument into the cecum (Figures 1 to 9).1 The colon is less elongated, and its bends and flexures are smoother and easier to negotiate.Endoclip line-assisted traction to control cardial postpolypectomy bleeding
Bleeding is the most common adverse event associated with gastric endoscopic resection.1“Posterior-like” anterior per-oral endoscopic myotomy
Per-oral endoscopic myotomy (POEM) can be performed by an anterior or a posterior approach to the esophageal wall, depending on the operator's preference. Recent data, however, show that posterior POEM is faster in accomplishing myotomy and in mucosal closure time, with less risk for inadvertent mucosal injury. These advantages are attributed to the axis of the dissection plane, which naturally parallels the endoscope working channel.A novel diathermy knife with suction function capable of keeping clear visibility while controlling bleeding
Innovative endoscopic devices have been developed and are now commercially available, which have contributed to the spread of the endoscopic submucosal dissection (ESD) technique for superficial neoplastic lesions.1 In particular, needle-type diathermy knives with a waterjet function enable injection into the submucosal area from the tip of the knife immediately after the cutting maneuver.2,3 This may reduce the number of times the knife is moved through the working channel, leading to a shorter procedure time.Modified attachment method using an S-O clip for gastric endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) has been an established treatment for gastric neoplasms.1 However, gastric ESD is still challenging because of its technical difficulties.2 Many traction methods have been developed to overcome the technical difficulties of gastric ESD.3-5 The traction method provides good visualization of the submucosa and appropriate tension for the lesion. However, in most traction methods, the direction of traction is limited to the oral side, and interference between the endoscope and the traction device in the cardia is unavoidable.Bite-on-bite technique for removal of a gastric subepithelial lipoma
A 55-year-old man with no relevant medical history underwent EGD for the evaluation of dysphagia. A submucosal nodule was found in the gastric antrum, and he was referred to our center for further evaluation and treatment. EGD at our facility found a 1-cm subepithelial lesion in the gastric antrum (Fig. 1). The mucosa overlying the lesion appeared normal, with a "yellowish" hue; the remainder of the stomach and duodenum appeared normal.Minimal water exchange colonoscopy
Conventional colonoscopy uses air to inflate the lumen. However, excessive air may lengthen the bowel, cause angulations and loop formation, and increase patients’ discomfort. Although carbon dioxide may be superior to room air,1 it is not always available, and unintentional insufflation still occurs during the procedure.The evolution of EUS-guided cystogastrostomy for pancreatic fluid collections
Endoscopic drainage of pancreatic fluid collections has conventionally been a tedious procedure. Endoscopic drainage may be performed with or without the use of EUS. Conventionally, EUS-guided cystogastrostomy involved EUS-guided needle puncture, repurposed devices, and multiple exchanges over a guidewire. A simple single-device technique can facilitate the procedure.Simultaneous detection and characterization of diminutive polyps with the use of artificial intelligence during colonoscopy
The application of artificial intelligence (AI) in colonoscopy is attracting a growing amount of attention because it has the potential to improve the quality of colonoscopy.1,2 The main focuses of research in this field comprise automated polyp detection3,4 and characterization5,6 (ie, pathologic prediction), which may respectively contribute to a higher rate of adenoma detection and a reduction of the costs related to unnecessary polypectomy. However, there has not yet been any report of technology capable of simultaneous polyp detection and characterization, which is the optimal situation for fully automated colonoscopic observation.Multiloop method for traction during colorectal endoscopic submucosal dissection
Colorectal endoscopic submucosal dissection (ESD) is one of the most challenging procedures. Traction methods for colorectal ESD have been devised to simplify the procedure and reduce the risks of adverse events.1-5 However, several problems remain, especially in terms of versatility and convenience. Therefore, we have devised a multiloop (M-loop) method, which is a traction method using silk thread and clips.Step-by-step use of hemostatic powder: treatment of a bleeding GI stromal tumor
Hemostatic powder (Hemospray; Cook Medical, Winston-Salem, NC, USA) was recently granted clearance for clinical use by the U.S. Food and Drug Administration for endoscopic therapy of nonvariceal GI hemorrhage (Fig. 1). This device has been in use internationally for more than 5 years, since it became available in 2011, and has been used in more than 70,000 procedures.1 The powder is an inert, nontoxic material called bentonite, and it is aerosolized with the use of a carbon dioxide canister to deliver the powder through a 7F or 10F delivery catheter.Gastric plications for weight loss: distal primary obesity surgery endoluminal through a belt-and-suspenders approach
A 40-year-old woman with lifelong obesity presented for consultation regarding a weight-loss procedure. Despite trying several weight-loss programs, she had been able to lose only 10 to 15 pounds and was unable to maintain this weight loss. Her medical history included polycystic ovary syndrome, hyperlipidemia, gallstone disease, and cholecystectomy. Her family history was notable for obesity, type 2 diabetes, and hypertension. Her physical examination results were notable for a weight of 228 pounds, height of 62 inches, and body mass index of 41.7 kg/m2.Polyglycolic acid sheet fibrin glue filling method for esophageal fistula
Esophageal fistula is difficult to treat. A few reports have described successful closure of esophageal fistula with polyglycolic acid (PGA) sheets and fibrin glue.1-3 PGA promotes the formation of granulation tissue and is a reinforcing material that is naturally absorbed by the body. We describe the details of a PGA sheet fibrin glue filling method (Video 1, available online at www.VideoGIE.org ).Creating effective titles for your scientific publications
You work for months, maybe years, to plan and conduct your study. You write it up carefully, reporting every piece of data accurately. You get the approval of your co-authors and double-check everyone’s conflicts of interest for the disclosure form. You are ready to submit it when you remember that your work needs a title. “No problem,” you say. “I’ll just throw something together.”
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