Minimally invasive management of sleeve gastrectomy collection with a nasobiliary drainage tube

A staple line leak is a feared complication of sleeve gastrectomy. Endoscopic methods have superseded surgical management of small leaks, however large collections often require surgical intervention. Here, we describe endoscopic management of large collection adjacent to the staple line with an 8Fr nasobiliary tube.

Dieulafoy's Lesion in a Duodenal Diverticulum: A Case Report and Literature Review

This report presents a case of Dieulafoy's lesion (DL), a rare and serious gastrointestinal condition, which occurred unusually in a duodenal diverticulum and highlights the diagnostic and management complexities associated with it. A literature review of six similar cases revealed commonalities in presentation, diagnosis, and management, emphasizing the complexities in identifying and handling this rare manifestation of DL. The findings emphasize the need for clinical vigilance and further research into optimizing strategies for diagnosing and managing this rare condition.

Extra-hepatic portal vein thrombosis in children: Single center experience

Aim of the study

We aimed to discuss our experience in management of children with extra-hepatic portal vein thrombosis (EHPVT).

Material and methods

This retrospective cohort study included 62 children with EHPVT. All patients' records were reviewed. The patients' socio-demographic data, post-natal history, disease presentation and clinical examination were collected. Data from laboratory investigations - complete blood count, liver function tests, renal function tests, abdominal ultrasound/Doppler studies, upper endoscopic findings and treatment regimens - were collected whenever available.

Results

Of the 62 patients, 62.9% were male and 37.1% were female. The mean age at disease presentation was 3.5 ±2.7 years. The main initial clinical presentation of the disease was hematemesis and/or melena (30 cases; 48.4%). History of umbilical catheterization (UVC) was present in 60% of cases. The thrombophilia profile was assessed in 17 patients, of whom 12 (70.6%) were found to have a coagulation disorder. Splenomegaly was present in 91.7% of the patients. Hematological abnormalities in the form of cytopenias were present in most cases. Ultrasound revealed the presence of collaterals in 76.2%. Upper endoscopy showed the presence of varices in 45 cases, all of which needed endoscopic intervention, while in 11 cases the varices were either low grade or absent and thus were subjected only to medical treatment with propranolol and 6 cases were lost to follow-up. Splenectomy was done in only one case and 2 cases underwent the Rex operation.

Conclusions

Variceal bleeding is the most common clinical presentation of EHPVT in children. UVC is still the main etiological factor of EHPVT in our cohort especially with presence of thrombophilic disorder.

Endoluminal Vacuum Therapy (EVT) for the Treatment of Rectal Perforation Following Cleansing Enema Application

Traumatic rectal injuries (TRIs) are challenging for surgeons because of their high morbidity and mortality. Considering the well-known predisposing factors, enema-associated rectal perforation seems to be the most overlooked entity that leads to devastating rectal injuries. A 61-year-old man with a three-day history of painful swelling around his perirectal area after enema application was referred to the outpatient clinic. CT demonstrated the presence of a left posterolateral rectal abscess compatible with an extraperitoneal rectal injury. Sigmoidoscopy revealed the perforation started 2 cm above the dentate line with a diameter of 10 cm and a depth of 3 cm. Endoluminal vacuum therapy (EVT) and laparoscopic sigmoid loop colostomy was performed. The patient was discharged after removing the system on postoperative Day 10. On his follow-up, the perforation side was totally closed and pelvic abscess was completely resolved two weeks after his discharge. EVT appears to be a simple, safe, well-tolerated and cost-effective therapeutic procedure in the management of delayed extraperitoneal rectal perforations (ERPs) with large defects. To our knowledge, this is the first case that reveals the potency of EVT in the management of a delayed rectal perforation associated with an uncommon entity.

Complication of Hepatic Hydatid Cyst Surgery Presenting as Obstructive Jaundice

The liver is the commonest organ affected by hydatid disease. We report a rare case of a 25-year-old female patient who was treated surgically for hepatic echinococcosis two weeks ago with laparoscopic excision of hepatic hydatid cyst with marsupialization and omentoplasty. She then presented with features of obstructive jaundice, which is a known complication following hydatid endocystectomy. Cholangiogram revealed a communication of the residual hydatid cyst with right segmental intrahepatic biliary radicals. She was treated with endoscopic retrograde cholangiopancreatography (ERCP)-guided stenting. ERCP is regarded as an important therapeutic strategy for hydatid cysts occurring in the extra biliary tree either as primary or as complications of liver cysts. It facilitates the clearing of hydatid debris from the biliary tree, and the closure of fistulas and bile leaks followed by laparoscopic cholecystectomy when the hydatid cysts are also located in the gallbladder.

Brunner Gland Hamartomas-Uncommon Presentations and Endoscopic Management

Brunner gland hamartoma (BGH) is a rare condition that requires a high clinical suspicion to diagnose. Large hamartomas may initially present with iron deficiency anemia (IDA) or symptoms suggesting intestinal obstruction. Barium swallow may demonstrate the lesion, but endoscopic evaluation is the acceptable first line management unless a concern for underlying malignancy. The present case report and literature review highlight the uncommon presentations and endoscopic role in large BGHs management. Internists should consider BGH in their differential, especially in patient with occult bleeding, IDA, or obstruction, which can be treated with endoscopic resection of large sized tumors by trained experts.

Minimally invasive ureteral reimplantation or endoscopic management for primary obstructive megaureter: a narrative review of technical modifications and clinical outcomes

Background and Objective

Primary obstructive megaureter (POM) has various courses in different age populations. Although open ureteral reimplantation (OUR) remains the standard treatment for symptomatic POM, it is highly invasive with potential complications. In recent years, minimally invasive ureteral reimplantation (MIUR), including laparoscopic ureteral reimplantation (LUR) and robotic-assisted laparoscopic ureteral reimplantation (RALUR), and endoscopic management, such as double-J stent insertion, endoureterotomy and endoscopic balloon dilatation (EBD), have been utilized for POM in selected patients. However, few comparable studies between MIUR and endoscopic management have been published to date, and it remains unclear which surgical management is the optimal choice for POM in different age groups. This review provides a comprehensive perspective on technical development and clinical outcomes of MIUR and endoscopic management for POM in pediatric and adult populations.

Methods

The PubMed and Web of Science databases were used to comprehensively search English language articles related to MIUR and endoscopic management for POM in pediatric and adult populations up to March 2022. The technical modifications and the relevant clinical outcomes were reviewed.

Key Content and Findings

MIUR with various technical modifications related to intracorporeal suturing and ureteroneocystostomy with anti-reflux techniques appears to be as safe and effective for POM in different age groups as the open procedure. Double-J stent insertion should be regarded as a temporary option for infants by achieving internal urinary drainage, as it may present limited success rates and various complications. Endoureterotomy using pure cutting current or laser appears to be a safer, easier, and less invasive alternative to open surgical management. While EBD has emerged as a definite treatment for POM in the pediatric population, it is debatable whether EBD can substitute for MIUR in adult patients.

Conclusions

The safety and feasibility of MIUR and endoscopic management in patients from all age groups still need further investigation.

Endoscopic Management of a Post-Traumatic Internal Maxillary Artery Pseudoaneurysm: Case Report and Review of the Literature

Internal maxillary artery (IMA) pseudoaneurysms are rare, and typically occur following trauma or orthognathic surgery. Pseudoaneurysms are life-threatening conditions, and expeditious workup and treatment is critical. Endoscopic treatment of an IMA pseudoaneurysm is a feasible option and should be considered when IR embolization is not available. The objective of this study is to review the literature on IMA pseudoaneurysms and present the first reported case of an IMA pseudoaneurysm successfully treated endoscopically.

Cryptogenic massive hemoptysis caused by bronchial artery-pulmonary artery fistula in a 12-year-old boy: A case report and literature review

BACKGROUND

Hemoptysis is a frequently encountered symptom of the respiratory system in adult but is rare in children. Bronchial artery-pulmonary artery fistula (BPF) is one of the most important and life-threatening cause in pediatric hemoptysis patients. Although the severity of BPF has been proved in previous studies, details about clinical diagnosis and treatment of BPF in children have been rarely reported.

CASE PREPARATION

A 12-year-old boy presented to the hospital with hematemesis after coughing, without any other symptoms. After admission, he had repeated hemoptysis, 20-30 ml each time, and on the 11th night of admission a massive hemoptysis (about 100 ml bright red blood) occurred suddenly. Chest computed tomography demonstrated patchy ground glass opacities in the right lung, suggestive of pulmonary hemorrhage. Bronchial arteriography showed an apparent BPF in the right lobe bronchial artery. Therefore, bronchial artery embolization was performed, following which a thrombus in the bronchial lumen was removed by bronchoscopy. After these interventions, the patient recovered quickly and no recurrence was noted in the following year.

CONCLUSION

We believe that this case should raise awareness of cryptogenic massive hemoptysis caused by BPF. In the event of hemoptysis in a child, it is important to clarify the source of the bleeding. If common etiologies have been excluded, the presence of pulmonary and bronchial vascular malformations should be considered. Moreover, multidisciplinary collaboration is crucial in the diagnosis and management of cryptogenic hemoptysis.

Endoscopic laser treatment for urine leakage caused by an isolated calyx after robot-assisted partial nephrectomy

INTRODUCTION

An isolated calyx is a rare complication in which the renal calyx and pelvis are disconnected. The treatment is often complicated.

CASE PRESENTATION

An 81-year-old man underwent robot-assisted partial nephrectomy for the treatment of renal cell carcinoma (cT1bN0M0). Postoperatively, urine leakage was observed and did not improve with conservative measures. Retrograde pyelography and computed tomography revealed that urine leakage originated from the isolated calyx caused by infundibular stenosis. Endoscopic treatment via the transurethral approach was selected to preserve renal function. Ureteroscopy showed that the upper calyx was completely obstructed by the sutures. Therefore, we cut the suture thread using laser, and a ureteral stent was placed in the upper renal calyx. Fluid drainage immediately disappeared after the procedure, and the patient did not lose renal function.

CONCLUSION

Endoscopic management might be an option for isolated calyx after robot-assisted partial nephrectomy.

Endoscopic management of duodenal adenomatosis in familial adenomatous polyposis-A case-based review

Adenomatous polyposis (AP) diseases, including familial adenomatous polyposis (FAP), attenuated FAP (AFAP), and MUTYH‐associated polyposis (MAP), are the second most common hereditary causes of colorectal cancer. A frequent extra‐colonic manifestation of AP disease is duodenal polyposis, which may lead to duodenal cancer in up to 18% of AP patients. Endoscopic surveillance is recommended at 0.5‐ to 5‐year intervals depending on the extent of polyp growth and histological progression. Although the Spigelman classification is traditionally used to determine surveillance intervals, it lacks information on the (peri‐)ampullary site, where 50% of duodenal carcinomas are located. Hence, information on the papilla has recently been added as a prognostic marker. Patients with duodenal adenoma(s) ≥10 mm and ampullary adenomas of any size are suggested to be referred to an expert center for endoscopic therapy, particularly endoscopic mucosal resection and endoscopic ampullectomy. Nonetheless, despite the logic of this approach, the long‐term efficacy of endoscopic therapy is still to be demonstrated.

Endoscopic management of anastomotic leak after esophageal or gastric resection for malignancy: a multicenter experience

BACKGROUND

Most anastomotic leaks after surgical resection for esophageal or esophagogastric junction malignancies are treated endoscopically with esophageal stents. Internal drainage by double pigtail stents has been used for the endoscopic management of leaks following bariatric surgery, and recently introduced for anastomotic leaks after resections for malignancies. Our aim was to assess the overall efficacy of the endoscopic treatment for anastomotic leaks after esophageal or gastric resection for malignancies.

METHODS

We conducted a multicenter retrospective study in four digestive endoscopy tertiary referral centers in France. We included consecutive patients managed endoscopically for anastomotic leak following esophagectomy or gastrectomy for malignancies between January 2016 and December 2018. The primary outcome was the efficacy of the endoscopic management on leak closure.

RESULTS

Sixty-eight patients were included, among which 46 men and 22 women, with a mean ± SD age of 61 ± 11 years. Forty-four percent had an Ivor Lewis procedure, 16% a tri-incisional esophagectomy, and 40% a total gastrectomy. The median time between surgery and the diagnosis of leak was 9 (6-13) days. Endoscopic treatment was successful in 90% of the patients. The efficacy of internal drainage and esophageal stents was 95% and 77%, respectively (p = 0.06). The mortality rate was 3%. The only predictive factor of successful endoscopic treatment was the initial use of internal drainage (p = 0.002).

CONCLUSION

Endoscopic management of early postoperative leak is successful in 90% of patients, preventing highly morbid surgical revisions. Internal endoscopic drainage should be considered as the first-line endoscopic treatment of anastomotic fistulas whenever technically feasible.

Simultaneous Endoscopic Management of Urethral Duplication and Postposterior Sagittal Anorectoplasty Urethral Diverticulum in a Boy with Anorectal Malformation

We report a case of urethral duplication with high anorectal malformation (ARM). A 12-year-old boy who had undergone transverse colostomy on day 2 of life and posterior sagittal anorectoplasty (PSARP) for ARM (rectobulbar fistula) at 8 years and also had urinary dribbling from a midscrotal opening in addition to normal voiding, presented with recurrent urinary tract infections and dysuria. Midscrotal dribbling had continued postoperatively. Colostomy had been closed 3 months after PSARP. Investigations revealed a large urethral diverticulum at the site of rectourethral fistula due to a segment of the gut being left behind during fistula closure. In addition, he had a sagittal urethral duplication originating at bulbar urethra and opening externally at midscrotum. The highlight of this report is successful endoscopic management of both the urethral duplication and the diverticulum.

Efficacy of Office-Based Intralesional Steroid Injections in the Management of Subglottic Stenosis: A Systematic Review

OBJECTIVE

To determine the efficacy of office-based intralesional steroid injections (ILSI) as a management therapy for adult subglottic stenosis (SGS).

DATA SOURCES

A systematic review was completed using PubMed and Science Direct for office-based management of SGS due to various etiologies.

REVIEW METHODS

The primary end point measured was a change in surgery free interval (SFI) between endoscopic procedures due to office-based serial ILSI. The secondary end point was to determine what percentage of patients did not require further operative intervention for SGS maintenance therapy after changing management to office-based serial ILSI.

RESULTS

We identified 187 abstracts, 4 of which were included in the analysis. The total number of participants was 55. The mean age was 50.4, and 78.1% were women. The etiologies were as follows: idiopathic (58.2%), postintubation/tracheotomy (29.1%), and autoimmune (12.7%). The SFI was reported in 3 of the 4 studies. The reported mean pre-ILSI SFI was 362.9 days and the post-ILSI SFI was 582.2 days. The secondary outcome was reported in 3 of the 4 studies. Forty-one of the 55 patients (74.5%) did not require further operative intervention during the duration of the study.

CONCLUSION

This review explored office-based ILSI as a potential treatment option for patients with SGS. The limited data presented found ILSI significantly lengthened SFI, potentially reducing surgical burden. In addition, ILSI was found to be safe with few reported side effects.

Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12-24 hours

Background: Acute oesophageal variceal haemorrhage (AOVH) is a medical emergency. The American Association for the Study of Liver Diseases recommends endoscopy management as soon as possible and not more than 12 hours after presentation. The United Kingdom guidelines recommended endoscopy for unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and within 24 hours of admission. We aimed to evaluate the outcome of endoscopic management of AOVH in less than 12 hours compared to 12-24 hours post admission.Methods: 297 patients with AOVH were divided into groups depending on the timing of the endoscopic management: 180 within 12 h of admission and 117 patients at 12-24 hours of admission. Routine clinical and laboratory data were collected.Results: Compared to patients with endoscopic management at 12-24 hours (mean 16 hours), patients with endoscopic management within 12 hours (mean 8.3 hours) of admission had fewer hospital stay days (P = 0.001), significant reduction of ammonia levels (P < 0.0001) and significant improvement in associated hepatic encephalopathy grade 25 (p = 0.048). There were no major clinical events in the 12-hour group, but 8 events in the 12-24 hour group (p < 0.01).Conclusion: Endoscopic management of acute variceal bleeding within 12 hours of admission is superior to endoscopic management at 12-24 hours of admission regarding reduction of hospital stay, ammonia levels, correction of hepatic encephalopathy, re-bleeding and mortality rate, hence, reducing the cost of treatment benefiting patient satisfaction and improving hospital bed availability.

Conservative Treatment of Chronic Pancreatitis: A Practical Approach

BACKGROUND

Chronic pancreatitis is a long-standing, inflammatory condition of the pancreas that leads to the progressive damage and loss of function of pancreatic parenchyma and to the development of possible locoregional and systemic medical complications.

MATERIALS AND METHODS

In this review, we tried to summarize the current evidence on non-surgical treatment trying to suggest a practical approach to the management of chronic pancreatitis.

RESULTS

Besides the unclear pathophysiological mechanism and a poorly unknown epidemiology, chronic pancreatitis is a complex syndrome that displays different possible challenges for physicians. Despite being traditionally considered as a benign disease, chronic pancreatitis encompasses 10-year mortality rates which are superior to the ones reported for some of the most common cancers.

CONCLUSIONS

Chronic pancreatitis encompasses the management of multiple and complex medical co-morbidities that needs to be understood and addressed in a multidisciplinary specialist context.

Outcomes of endoscopic management of upper tract urothelial carcinoma

While radical nephroureterectomy (RNU) remains the gold-standard treatment for upper tract urothelial carcinoma (UTUC), a growing volume of literature surrounding endoscopic, organ-sparing procedures has developed over the past few decades. Based on this, endoscopic management of UTUC has gained acceptance as a standard of care approach, particularly among those with low-risk disease or with imperative indications for organ preservation. As a rare disease, however, data is mostly restricted to retrospective single institution series with relatively small numbers. Therefore, comparative outcomes of endoscopic management to RNU remain incompletely defined. Furthermore, the comparative utility of endoscopic approaches (ureteroscopy versus percutaneous resection) and topical therapy following resection lacks prospective analysis. In this article we review the available literature on endoscopic management of UTUC.

Endoscopic Management of Malignant Biliary Stricture

A biliary stricture is an area of narrowing in the extrahepatic or intrahepatic biliary system. The majority of biliary strictures are caused by malignancies, particularly cholangiocarcinoma and pancreatic adenocarcinoma. Most malignant biliary strictures are unresectable at diagnosis. Treatment of these diseases historically required surgical procedures, however, the development of endoscopic techniques has provided alternative minimally invasive treatment options to improve patient quality of life and survival with unresectable disease. While endoscopic retrograde cholangiopancreatography with stent placement has been the cornerstone of biliary drainage for decades, cutting edge endoscopic developments, including radiofrequency ablation and endoscopic ultrasound-guided biliary drainage, offer new therapy options to patients that historically have a poor quality of life and a grim prognosis. In this review, we explore the endoscopic techniques that have contributed to revolutionary advancements in the endoscopic management of malignant biliary strictures.

Endoscopic management of stricturing Crohn's disease

The natural history of Crohn's disease (CD) usually begins with primary intestinal inflammation, which progresses gradually to stricturing lesions. Stricture is a complicated, intractable but very common clinical problem in the management of CD. Difficulties remain in treating stricturing CD because of the limited efficacy of drug therapy and relapse of stricturing lesions cannot be completely avoided by surgery. Endoscopic management is a bridging therapy between drug therapy and surgical intervention, mainly including endoscopic balloon dilatation and endoscopic stricturotomy, and has been found to be effective for treating stricturing CD. Its explicit curative effect, less invasiveness and high safety performance make endoscopic management more acceptable by both the physician and patient. Although some patients require repeated endoscopic treatment and ultimately cannot avoid surgery, yet it can significantly delay the time to surgery and improve the quality of life. Physicians carrying out the endoscopic procedure need to be trained for performing this procedure. In this review we summarized the diagnosis and endoscopic treatment of stricturing CD.

Fertility after Endoscopic Surgery for Ectopic Pregnancy Management in Point "G" Teaching Hospital, Bamako-Mali

Endoscopic surgery of ectopic pregnancy is actually the gold standard for the management of fallopian tubal diseases. A survey was conducted to evaluate fertility in patients who underwent endoscopic management for ectopic pregnancy. A retrospective study was conducted at the department of general and endoscopic surgery of the Point "G" teaching hospital, in Bamako, Mali, from January 1st 2007 to December 31, 2016. Forty-eight (48) patients who underwent endoscopic management of tubal ectopic pregnancy and who have been followed up for fertility were included in this study. Statistical tests used were X2 or Fisher test and their confident interval, p <1 % has been considered as statistically significant. The therapeutic score of Pouly was less than 4 in 25.0% (n = 12). The return to fertility was observed among 48.0% of patients (n = 23). The chance of conception was less than 80.0% after the fourth postoperative year (p=0.001). The outcome of pregnancies has been seventeen full-term pregnancies, three ectopic pregnancies and three miscarriages. The occurrence of pregnancy after endoscopic management indicated for ectopic pregnancy is possible. However, many factors can influence the future conception.

Current Endoscopic Management of Malignant Biliary Stricture

Biliary and pancreatic cancers occur silently in the initial stage and become unresectable within a short time. When these diseases become symptomatic, biliary obstruction, either with or without infection, occurs frequently due to the anatomy associated with these cancers. The endoscopic management of these patients has changed, both with time and with improvements in medical devices. In this review, we present updated and integrated concepts for the endoscopic management of malignant biliary stricture. Endoscopic biliary drainage had been indicated in malignant biliary obstruction, but the concept of endoscopic management has changed with time. Although routine endoscopic stenting should not be performed in resectable malignant distal biliary obstruction (MDBO) patients, endoscopic biliary drainage is the treatment of choice for palliation in unresectable MDBO patients. Self-expanding metal stents (SEMS) have better stent patency and lower costs compared with plastic stents (PS). For malignant hilum obstruction, PS and uncovered SEMS yield similar short-term outcomes, while a covered stent is not usually used due to a potential unintentional obstruction of contralateral ducts.

Management of spontaneous and iatrogenic perforations, leaks and fistulae of the upper gastrointestinal tract

Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.

Surgery of Inverted Papilloma of the Maxillary Sinus via Translacrimal Approach-Long-Term Outcome and Literature Review

There are several differential diagnoses of unilateral sinus disease. One of these is inverted papilloma (IP) of the maxillary sinus, which is a common benign tumor with a substantial rate of malignant transformation. In general, endoscopic endonasal techniques for addressing the tumor are favored nowadays instead of classical external approaches. The aim of this retrospective study was to investigate the long-term outcome of inverted papilloma treated endoscopically via the prelacrimal approach. We reviewed 17 patients with primary or recurrent IP of the maxillary sinus that were treated via the prelacrimal endoscopic endonasal technique. After a median follow-up period of 45.9 months (3.8 years), none of the 17 included patients showed signs of recurrent disease and no serious complications were reported. Hypoesthesia of the incisors was reported by four patients and was resolved with time in one. All of the maxillary sinuses could be fully visualized with the flexible endoscope. IP is an important differential diagnosis in the clinical finding of unilateral nasal polypoid lesions. The prelacrimal approach is an effective and safe method in the treatment of IP with limited patient morbidity.

A Primary Clival Defect: Endoscopic Binostril Approach With Nasal Septal Flap Closure and Preservation of Septal Integrity

Primary spontaneous cerebrospinal fluid (CSF) rhinorrhea is an unusual phenomenon that may occur anywhere along the skull base. However, CSF leaks originating from clival defects are rarely reported in the literature. The majority of reported cases were managed with microscopic techniques, using free grafts. The present study discusses a case of spontaneous CSF rhinorrhea from a clival defect closed with our transnasal operative approach using endoscopic techniques. The skull base defect was successfully managed with an endoscopic binostril approach to create a nasal septal flap pedicled at the sphenopalatine artery, while also preserving the integrity of the nasal septum.

Advances in the management of upper tract urothelial carcinoma: improved endoscopic management through better diagnostics

As a rare disease, the management of upper tract urothelial carcinoma (UTUC) continues to evolve. While radical nephroureterectomy remains the gold standard, there is a growing desire to pursue nephron-sparing approaches through endoscopic management, particularly for low-risk disease or in the setting of imperative indications. A particular challenge for those undertaking endoscopic management is appropriate grading and staging of tumors, and thereby appropriate patient selection. In this review we will cover the current state of diagnostics for UTUC as well as highlight the challenges in accurate diagnosis. Additionally, we will focus on emerging technologies to aid in optimizing diagnostic accuracy in UTUC. This will include discussion of narrow band imaging, photodynamic diagnosis, optical coherence tomography, and confocal laser endomicroscopy.

Alternative treatments for prophylaxis of colorectal cancer in familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is a rare, hereditary disease characterized by the presence of 100 or more adenomas distributed throughout the colon and rectum. If untreated, colorectal cancer develops in almost 100% of FAP patients. As prophylactic treatment, proctocolectomy with ileal pouch-anal anastomosis remains the surgical treatment of choice. High rates of postoperative complications, however, have been reported with this procedure, including bowel dysfunction, incontinence, and reduced female fecundity. Some novel strategies for preventing hereditary colon cancers have been reported. This review summarizes alternative treatments, including the laparoscopic approach, chemoprevention, endoscopic management, and subtotal colectomy combined with endoscopic treatment, for prophylaxis of colorectal cancer in FAP patients.

Endoscopic Management of Primary Obstructive Megaureter: A Systematic Review

BACKGROUND

The gold standard treatment for primary obstructive megaureter (POM) with declining renal function, worsening obstruction, or recurrent infections is ureteral reimplantation with or without tapering. In infants, open surgery can be technically demanding and associated with significant morbidity. We conducted a systematic review of the literature with special interest in endoscopic management of POM and its outcomes.

MATERIALS AND METHODS

A search was conducted of the MEDLINE/Ovid, PubMed, Embase, and Web of Science databases. Only full-text articles written in the English language and involving greater than one reported pediatric case per publication were included. Two authors independently extracted data and assessed strength of evidence for each study.

RESULTS

We found 11 retrospective and 1 prospective, single institution case series that met selection criteria, describing 222 patients with 237 obstructed renal units. Mean age at time of surgery was 24.6 months. The most common endoscopic approaches were cystoscopy+high-pressure balloon dilation+Double-J ureteral stent placement (49.5%), cystoscopy+incisional ureterotomy+Double-J ureteral stent placement (27.8%), and cystoscopy+Double-J ureteral stent placement (18.9%). For all approaches and age groups, anatomic and functional success rates were 79.3% (146/184) and 76.7% (132/172), respectively. Anatomic success rates were highest in children ≥12 months of age (82.3%, 117/142). Endoscopic retreatment was performed in 15.1% of cases with a 36.7% overall surgical reintervention rate. Forty-one ureters progressed to ureteral reimplantation. Complications were generally mild (Clavien-Dindo Grades I-II), but 12 ureters did develop vesicoureteral reflux. Mean follow-up period was 3.2 years.

CONCLUSIONS

Endoscopic management for persistent or progressive POM in children ≥12 months of age is a minimally invasive alternative to ureteral reimplantation with modest success rates. In infants, it may best be utilized as a temporizing procedure. Approximately one-third of patients require surgical reintervention.

Recent advances in the management of large and complex colonic polyps

The endoscopic management of large colonic polyps is a rapidly changing field. Rapid evolution in endoscopic techniques and skills has resulted in diminishing the role of surgery in the management of larger and complex polyps. This is resulting in organ preservation for many who otherwise would have undergone surgery. However, it also poses new challenges. This article reviews these new advances and the developments which are overcoming these difficulties.

Management of neobladder complications: endoscopy comes first

OBJECTIVE

The aim of this study was to report the functional outcome after endoscopic management of neobladder complications.

MATERIALS AND METHODS

Out of 197 patients who underwent radical cystectomy and orthotopic ileal neobladder reconstruction between 2007 and 2013, 30 patients with delayed postoperative complications were enrolled in this study. Complications were in the form of: eight patients with outflow obstruction, 12 with ureteroenteric stricture, nine with neobladder calculi and one with an isolated recurrent papillary tumor inside the neobladder. Patients were followed up regularly to assess the outcomes of endoscopic treatment.

RESULTS

The mean maximum flow rate and postvoiding residual urine after endoscopic treatment of outflow obstruction were 18.2 ± 3.9 ml/s and 28.7 ± 11 ml, respectively. Ten patients with ureteroenteric stricture showed resolution of hydronephrosis after antegrade dilatation and JJ-stent fixation, with two patients requiring open surgery owing to impassable strictures. Complete clearance of neobladder calculi occurred after endoscopic neocystolithotripsy, with two patients requiring two sessions owing to large calculi. Transurethral resection of the neobladder for isolated tumor recurrence was performed in one patient over two sessions, followed by adjuvant chemoirradiation.

CONCLUSIONS

Endourological management of orthotopic neobladder problems is the safest choice. It avoids the difficulties and complications of open surgery and has durable results.

Results of a Tailored Approach to Zenker's Diverticulum: A Single VA Experience

The transoral division of the esophageal-diverticula septum with a linear stapler, with CO₂ laser, or with harmonic scalpel under rigid endoscopy has revolutionized the surgical management of Zenker's diverticula. Nevertheless, the open approach still plays a role in select cases. Our goals are to illustrate the techniques and the results of our tailored approach to the surgical management of Zenker's diverticula in U.S. veterans.

Psammomatoid Ossifying Fibroma of the Ethmoid Sinus with Secondary Intracranial Aneurymal Bone Cyst: A Case Report and Literature Review

Juvenile psammomatoid ossifying fibroma (JPOF) is a rare, slowly progressive tumor of the extragnathic craniofacial bones, with a tendency toward locally aggressive behavior and recurrence. The pathognomonic histopathologic feature is the presence of spherical ossicles, which are similar to psammoma bodies. Very few cases in association with secondary aneurysmal bone cyst (ABC) formation have been reported in literature. Treatment consists of complete surgical removal. However, incomplete excision has been associated with a high local recurrence rate. The prognosis is good because malignant change and metastasis have not been reported. The authors are reporting a case of JPOF of the ethmoid bones with secondary ABC in a 7-year-old female patient.

Endoscopic management of a chronic ureterocutaneous fistula using cyanoacrylic glue

Ureterocutaneous fistula is a rare complication of renal surgery. Cyanoacrylate glue is a tissue adhesive, used primarily for the endoscopic control of bleeding from gastric varices. A female aged 33 presented to our facility with a ureterocutaneous fistula after surgery. We used a retrograde endoscopic approach for the instillation of 2 ml of sealant into the ureteral lumen to seal the ureter and fistulous tract. The fistulous opening healed spontaneously a week after the procedure, and the patient remained dry and symptom free for 5 months following the procedure. Endoscopic delivery of cyanoacrylate sealant was a feasible and effective way in treating a ureterocutaneous fistula in our patient.

Current status and future perspectives of endoscopic diagnosis and treatment of diminutive colorectal polyps

During colonoscopy, small and diminutive colorectal polyps are commonly encountered. It is estimated that at least one adenomatous polyp is detected in almost half of all patients undergoing screening colonoscopy. In contrast, the 'predict, resect, and discard' strategy for diminutive and small colorectal polyps is a current topic especially in Western countries. 'Is this an acceptable policy in Japan?' Herein, we report the results of a questionnaire survey with regard to the management of diminutive colorectal polyps, including the thoughts of Japanese endoscopists regarding the 'predict, resect, and discard' strategy. At the moment, we propose that this strategy should be used by skilled endoscopists only.

Non-operative Management of Gallbladder Perforation After Blunt Abdominal Trauma

Isolated gallbladder perforations following blunt abdominal trauma are very rare. They often present with insidious onset of symptoms a few days after the initial insult and an operative course of management ensues. This is in the form of a cholecystectomy and peritoneal lavage; more often via laparotomy rather than laparoscopically. Conservative management, in the form of cholecystostomy, percutaneous intraperitoneal drainage or cholecystorraphy has been described; however, these cases have invariably resulted in cholecystectomy eventually. The case uniquely highlights the successful non-operative management of isolated traumatic gallbladder perforation.

Factors impacting treatment outcomes in the endoscopic management of walled-off pancreatic necrosis

BACKGROUND

Treatment outcomes are suboptimal for patients undergoing endoscopic treatment of walled-off pancreatic necrosis (WOPN). The objective of this study is to identify factors that impact treatment outcomes in this patient subset.

METHODS

This is a retrospective study of patients with WOPN treated endoscopically over 10 years. Patients underwent placement of stents and nasocystic catheters within the necrotic cavity. In select patients, the multiple transluminal gateway technique (MTGT) was adopted to create several openings in the stomach or duodenum to facilitate drainage of necrosis. In patients with disconnected pancreatic duct syndrome (DPDS), the transmural stents were left in place indefinitely to decrease pancreatic fluid collection (PFC) recurrence.

RESULTS

Endoscopic treatment was successful in 53 of 76 (69.7%) patients. Treatment success was higher in patients undergoing MTGT than in those in whom conventional drainage was used (94.4% vs. 62.1%, P = 0.009). On multivariate logistic regression analysis, only MTGT (OR 15.8, 95% CI 1.77-140.8; P = 0.01) and fewer endoscopic sessions being needed (OR 4.0, 95% CI 1.16-14.0; P = 0.03) predicted treatment success. PFC recurrence was significantly lower in patients with indwelling transmural stents than in patients in whom the stents were removed (0 vs. 20.8%; P = 0.02).

CONCLUSIONS

Creating multiple gateways for drainage of necrotic debris improves treatment success, and not removing the transmural stents decreases PFC recurrence in patients undergoing endoscopic drainage of WOPN.

Endoscopic management of blue rubber bleb nevus syndrome: A case report

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by multiple recurrent vascular malformations, including hemangioma, which primarily locate on the skin and gastrointestinal (GI) tract. The present study reports a 22-year-old female with iron-deficiency anemia and recurrent episodes of melena. The patient also exhibited characteristic venous malformations of the skin. Endoscopy revealed several hemangiomas in the GI tract. The hemangiomas were treated by ligation using a nylon cord, while small blue mucosal polypoid lesions were treated using a sclerosing agent during colonoscopy and double-balloon enteroscopy. The patient was reviewed regularly for three years following surgery and no further bleeding episodes were noted.

Repeated endoscopic treatments of multiple recurrent ureteral tumors following 15-year-long history of bladder tumors in the patient from endemic nephropathy region

Ureteral urothelial tumors (UUT) are uncommon; their incidence is higher in areas affected by Balkan endemic nephropathy (BEN), with low–grade lesions prevalent. In these patients, the efficacy of conservative surgery is comparable to that of nephroureterectomy. Endoscopic treatment is indicated for single, small and low grade UUT, in older patients with significant comorbidity.

The case of an 84–year–old lady from an area affected by BEN is presented. Over 20 years, the patient underwent five endoscopic interventions for multiple UUT, and numerous endoscopic interventions for recurrent bladder tumors.

Among a highly select group of patients, endoscopic treatment of multiple small superficial low–grade ureteral tumors may prove successful.

Endoscopic management of impacted esophageal foreign bodies

There are many reports on the endoscopic management of ingested foreign bodies in the upper gastrointestinal tract, however, little is known about the management of a specific subset of esophageal foreign bodies - impacted esophageal foreign bodies (IEFBs), especially perforating esophageal foreign bodies (PEFBs). The aim of this retrospective study on 78 cases was to report experience and outcome in the endoscopic management of the IEFBs in Chinese patients. From January 2006 to July 2011, a total of 750 patients with suspected upper gastrointestinal foreign bodies were admitted to the endoscopy center. Among these 750 patients, 78 cases that met the defined criteria of IEFBs were retrospectively enrolled in the present study, including 12 cases (12/78, 15.4%) with PEFBs. The major types of IEFBs were poultry bones (35.9%) and fish bones (17.9%). Most of the IEFBs (80.8%) were located in the upper esophagus, as were two thirds (66.7%) of the PEFBs. Foreign-body retrieval forceps were the most frequently used accessory devices. Extraction of IEFBs failed in eight patients (10.3%) during the endoscopic procedure. The difficult points in endoscopic management were PEFBs, IEFBs with sharp points, and those with impaction for more than 24 hours. IEFBs should be treated as early as possible, and their endoscopic management is safe and effective. Endoscopic management is the first choice for PEFBs when the duration of impaction is less than 24 hours and there are no abscesses outside of the esophageal tract as determined by a computed tomography scan.

Endoscopic management for delayed diagnosis of a foreign body penetrating the esophagus into the lung

A 31-year-old male presented with chest pain started after eating chicken about 2 weeks earlier. Upper endoscopy and Computed tomography scan of the chest revealed a sharp chicken bone penetrating the esophageal wall into the right lung. The foreign body was removed endoscopically using a rat-tooth forceps, followed by prophylactic placement of a metal stent across the esophageal perforation site. Foreign body-induced perforation is one of the common etiologies of benign esophageal perforations. Although the primary treatment is surgery, endoscopic therapy may be appropriate in individualized cases like our patient.

Endoscopic management of acute colorectal anastomotic complications with temporary stent

Acute postoperative anastomotic complications following colorectal resection include leak and obstruction. Often an operation is necessary to treat these complications. The role of endoluminal procedures to treat these complications has been limited. This article illustrates that such an approach is technically feasible and can be used to treat some colorectal anastomotic complications.