A sleeve within a sleeve

  • A sleeve within a sleeve Figure 1


A 57-year-old woman with obesity class III (body mass index: 42 kg/m2) and a history of open cholecystectomy secondary to gangrenous cholecystitis presents for weight regain of 25 kg from nadir weight loss after surgical sleeve gastrectomy 7 years ago. An upper GI series demonstrates gastric sleeve dilation. Given her poor surgical candidacy, she is offered endoscopic sleeve gastroplasty (ESG) with argon plasma coagulation-reinforced suturing (Figure). Which of the following is true about primary ESG for weight loss?

The entire stomach is imbricated, so that the fundus and antrum are significantly restricted in size. The dissemination of ESG is hampered by increasing rates of gastroesophageal reflux disease compared with laparoscopic sleeve gastrectomy. ESG with lifestyle modifications is an U.S. Food and Drug Administration (FDA)-approved intervention for primary therapy of obesity classes 1 and 2. The long-term weight-loss durability of ESG has been firmly established.
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Hard to swallow

A 74-year-old woman undergoes an upper endoscopy because of symptoms of dysphagia and weight loss. A giant fibrovascular polyp is seen filling the esophageal lumen and estimated to be 17 cm. During EGD, forceful retching and vomiting result in disgorgement of the polyp from the mouth (Figure). Given the inability to reduce this lesion without the risk of airway obstruction, the decision is made to proceed with emergent endoscopic submucosal dissection after nasotracheal intubation. Which of the following is true about giant fibrovascular polyps?
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The GIST of it

During screening colonoscopy, a 45-year-old man is found to have a rectal submucosal lesion. EUS reveals a 2.5-cm hypoechoic lesion emanating from the adventitial layer with an intact muscularis propria. EUS-guided core biopsy shows a GI stromal tumor (GIST), and the patient is referred for endoscopic adventitial dissection (Figure). Which of the following is true regarding GISTs?
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An ooze diffuse

A 67-year-old patient presents with melena and shortness of breath culminating over the last few weeks. Laboratory test results show a hemoglobin level of 7 mg/dl from a baseline of 13 mg/dl and a blood urea nitrogen/creatinine ratio >40. CT scan results reveal a fundal mass with hyper-enhancing locules consistent with a GI stromal tumor. Upper endoscopy finds a 5-cm ulcerated submucosal mass diffusely bleeding in the gastric fundus. To control this bleed, hemostatic powder therapy is chosen, and the injection catheter is modified to prevent clogging of the system during deployment (Figure). After successful hemostasis, the patient undergoes definitive therapy with surgical resection. Which of the following is true regarding upper GI bleeding?
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The underwater leather bottle

A 70-year-old man presents with weight loss, anorexia, and nausea. A CT scan shows a significantly thickened gastric wall. Upper endoscopy and mucosal biopsies are performed from hyperemic, “angry-looking” areas, but malignancy is not discerned. A repeat endoscopy is performed, and the lumen is submerged in water. A specialized stiff cold snare is used to obtain sampling underwater. Histopathologic evaluation also is performed (Figure). Which of the following is true about this condition?
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Pesky pearls

A 73-year-old man presents with right upper quadrant pain 19 months after cholecystectomy. A CT scan shows perihepatic fluid collection extending to the gallbladder fossa suspicious for biloma. Percutaneous drainage is performed, and evidence of dropped gallstones is found during placement. After multidisciplinary discussion, cholangioscopy is completed through the percutaneous tract with removal of the dropped gallstones. Which of the following is true?
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