Tips and Thought Processes to Overcome Difficult Situations in Third Space Endoscopy

PURPOSE OF REVIEW

Third space endoscopy (TSE) offers diverse treatment options for a variety of conditions of the gastrointestinal tract and motility disorders. Accuracy and precise dissection have helped treat complex conventional surgeries with TSE. Despite over a decade of its presence, difficult situations are routinely encountered.

RECENT FINDINGS

The first challenging situation is decision-making (before the procedure), the second is tackling procedure-induced pulmonary / insufflation-related adverse events and intra-operative complications (during the procedure), and the third is post-operative complications and morbidity (post-procedure). The performance of TSE procedures is not without risk. Patients should receive enough time to weigh their options, considering that attitudes toward risk impact decision-making. Continuous basic patient monitoring and the micro-movements of endoscopic and electrosurgical equipment is crucial to avoid accidental injury. Anaesthetists should be mindful of anticipated complications and closely monitor, diagnose, and treat them. Demanding situations need careful consideration, problem-solving, or persistence to overcome challenges. This brief review provides inputs on preventing and tackling difficult situations in TSE.

Oesophageal perforation by migrated Ryles tube

A 72-year woman with a history of multiple cerebrovascular accidents presented with severe epigastric pain. An oesophageal perforation by the tip of a Ryles tube, which had migrated into the mediastinum, was diagnosed by radiography. An attempt at pushing the nasogastric tube into the stomach resulted in increasing the rupture to about 6 cm in size. Replacement by a triple-lumen nasojejunal feeding tube and subsequent feeding with c.1,400 calories per day enabled the perforation to close without further intervention.

Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy

Background and study aims The utility of stone density at non-contrast computed tomography (NCCT) for predicting the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis (CCP) is relatively unexplored. Patients and methods This was a prospective observational study of patients with CCP. Hounsfield units (HU) were determined for the largest pancreatic ductal stone during pretreatment NCCT. All patients underwent ESWL until the largest stone was fragmented to <3mm, followed by endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The predictive factors following ESWL for successful stone extraction were studied and the receiver operating characteristic (ROC) curve determined the HU optimal cut-point. Results Eighty-two patients with a median (interquartile range) age of 36 years (range, 29-55); majority male 45 (54.9%), were included. Idiopathic CCP was noted in 78 patients (95.1%). The median stone density (SD) was 1095 HU (range, 860.7-1260.7) and the number of ESWL sessions was 2 (range, 2-3). Complete stone removal at index ERCP was achieved in 55 patients (67.1%). Those with partial clearance (n=27) needed a repeat ERCP, which was successful in 26 (96.3%); one patient (3.7%) underwent surgery. There was a significant, positive correlation between number of ESWL sessions and SD (r=0.797; P <0.001). On bivariate analysis, SD and the number of ESWL sessions revealed a significant association with complete ductal clearance. The optimal cut-point for complete stone removal by the ROC curve was 1106.5 HU (Youden index 0.726), with a sensitivity of 93% and a specificity of 80%. Conclusions The SD is a significant predictor of ESWL success followed by ductal clearance at ERCP, and <1106.5 HU is a predictor of good candidates for ESWL therapy.

Comparison of diagnostic outcomes, safety, and cost of Franseen-tip 19G versus 22G needles for endoscopic ultrasound-guided liver biopsies

Background and study aims Favorable outcomes were noted with refinement in newer endoscopic ultrasound-guided liver biopsy (EUS-LB) needle tips. Still, the overall usefulness and benefit are yet to be well explored. Patients and methods This was a retrospective analysis of patients with EUS-LB (Franseen-tip 19G versus 22G FNB needle) over 2 years. EUS-LB was obtained in a one-pass, two-actuation, modified wet suction technique. Diagnostic yield, fragmentation rate, aggregate specimen length (AL), number of complete portal tracts (CPT), length of longest intact core (LIC), adverse events (AEs) (early), and cost of the procedure (1USD = 82 INR) were compared. Results Fifty-four patients (33 [61.1%], female) successfully underwent EUS-LB with a median age of 46 years (interquartile range [IQR] 34-54); the majority 32 (59.2%) underwent 19G biopsies. There was a significantly increased median (IQR) AL in the 19G compared with 22G (20 mm [19-21] vs. 15 [14-15], P < 0.001), respectively. Similarly, significantly lengthier median LIC and CPT were seen, respectively. A nonsignificant diagnostic yield was noted (100% vs. 90.9%, P = 0.082), respectively. The fragmentation rate was higher in 22G FNB needles (36.4% [95% CI 16-56] vs. 12.5% [95% CI 1-24], respectively; P = 0.038). Seven patients (12.9%) had mild AEs with no difference between groups. The average procedure cost with 19G was INR 63000 (768$), and with 22G needle was INR 54500 (664$). Conclusions The Franseen-tip 19G outperforms 22G with a significantly lower fragmentation rate, longer AL, LIC, and a higher number of CPT with a marginal increase in the procedure cost, without any difference in diagnostic yield and safety.

Advances in the Management of Pain in Chronic Pancreatitis

PURPOSE OF REVIEW

The data on recent advances in managing chronic pancreatitis (CP) pain is limited. This review highlights the role of endotherapy and the advances in the overall management of pain in CP.

RECENT FINDINGS

Of late, pancreatic biodegradable stents have been used in endotherapy with appreciable success. These include slow, medium, and fast degrading stents, which optimize the overall management of CP and could prevent the need for multiple procedures. Endoscopic ultrasound-guided celiac plexus block is reserved in selected patients to treat debilitating pain. Total pancreatectomy with islet autotransplantation in small duct disease has shown promising results. The indications for treating pain in CP with endoscopy and surgery need to be better defined. The complexity of pain control due to the incomplete understanding of pathomorphology makes the management of CP challenging. The current treatment methods are still evolving. Therapy aims to reduce pain, optimize recovery, maintain quality of life, and meet postoperative needs. Initial management includes lifestyle modification, nutrition optimization, risk factor reduction with abstinence from alcohol, cessation of tobacco and smoking. Supportive medical management involves the judicial use of analgesics, neuromodulators, antioxidants, pancreatic enzyme replacement for insufficiency, and diabetes management. Patients with intractable pain are ideal for therapeutic intervention. Being less invasive with an acceptable complication rate makes endotherapy the preferred first-line treatment. If found to be cost-effective, biodegradable stents can reduce the overall cost. Unfortunately, if patients remain symptomatic, surgery is preferred in case of failure or recurrence. For optimal results, appropriate patient selection is vital to maximizing outcomes.

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux after peroral endoscopic myotomy: a randomized sham-controlled study

BACKGROUND : Endoscopic full-thickness plication (EFTP) has shown promising results in gastroesophageal reflux disease (GERD), but its efficacy in GERD after peroral endoscopic myotomy (POEM) is unclear. METHODS : In a prospective, randomized trial of post-POEM patients dependent on proton pump inhibitors (PPIs) for documented GERD, patients underwent EFTP (plication to remodel the gastroesophageal flap valve) or an endoscopic sham procedure (positioning of the EFTP device, but no stapling). The primary end point was improvement in acid exposure time (AET) < 6 % (3 months). Secondary end points included improvement in esophagitis (3 months), GERD Questionnaire (GERDQ) score (3 and 6 months), and PPI usage (6 months). RESULTS : 60 patients were randomized (30 in each group). At 3 months, a significantly higher proportion of patients achieved improvement in AET < 6 % in the EFTP group compared with the sham group (69.0 % [95 %CI 52.1-85.8] vs. 10.3 % [95 %CI 0-21.4], respectively). EFTP was statistically superior to sham (within-group analysis) in improving esophageal AET, DeMeester Score, and all reflux episodes (P < 0.001). A nonsignificant improvement in esophagitis was noted in the EFTP group (P = 0.14). Median GERDQ scores (3 months) were significantly better (P < 0.001) in the EFTP group, and the same trend continued at 6 months. A higher proportion of patients in the sham group continued to use PPIs (72.4 % [95 %CI 56.1-88.7] vs. 27.6 % [95 %CI 11.3-43.8]). There were no major adverse events in either group. CONCLUSION : EFTP improved post-POEM GERD symptoms, 24-hour pH impedance findings with normalization in one-third, and reduced PPI usage at 6 months.

Endoscopic Submucosal Dissection for Esophageal Squamous Cell High-grade Dysplasia in a Patient with Plummer Vinson Syndrome

A 35-year female with Plummer Vinson syndrome (PVS) presented with a history of progressive dysphagia over six months, not responding to iron therapy and endoscopic dilatations. Her upper gastrointestinal endoscopy showed a post-cricoid web dilated using a Savary-Gilliard dilator. On NBI, a long segment circumferential lesion with abnormal microvascular architecture was noted in the mid esophagus. Biopsy showed high-grade dysplastic squamous epithelium. The patient underwent minimally invasive, circumferential endoscopic submucosal dissection (ESD) and received oral prednisolone to prevent stricture formation. Resected margins were free of dysplasia. At follow-up there was no evidence of recurrence or stricture formation. To our knowledge, this is the first case of PVS with squamous proliferation with high-grade dysplasia that was successfully treated with circumferential ESD. Screening endoscopy helps in the downstaging of early cancer, and timely intervention helps to treat this with a minimally invasive approach like ESD.

Achalasia Cardia: Balloon, Tunnel, or Knife?

Achalasia cardia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter during swallowing and aperistalsis of the esophageal smooth muscles. The treatment approaches to achalasia include nonsurgical treatment with medications (nitrates, calcium channel blockers), endoscopic treatment (balloon pneumatic dilation [PD], botulinum toxin injection [BTI], peroral endoscopic myotomy [POEM]), and surgery (laparoscopic Heller's myotomy [LHM]). The subtype of achalasia (the Chicago Classification) governs the ideal treatment. For the commonly encountered achalasia subtype I and II, PD, LHM, and POEM all have similar efficacy. However, for type III achalasia, POEM seems to be the best line of treatment. Among high-risk elderly patients or those with comorbidities, BTI is preferred. The choice of treatment should be minimally invasive therapy with good short-term and sustained long-term effects with negligible adverse events. POEM seems to be evolving as a first-line therapy among the available therapies. Here, we review the treatment options among achalasia cardia patients with special attention to post-POEM gastroesophageal reflux disease and its management.

Usefulness of endoscopic ultrasound in children with pancreatobiliary and gastrointestinal symptoms

Background and study aims  Endoscopic ultrasound (EUS) is useful in diagnosing and treating childhood pancreatobiliary and gastrointestinal diseases. However, there are limited data on its effectiveness for various indications. Patients and methods  This was a retrospective analysis of prospectively collected data of patients who underwent EUS for upper gastrointestinal tract disorders from January 2018 to December 2020 to assess its indications, findings, interventions, and complications. Results  Ninety-two procedures were performed in 85 children, (70.5 % male; mean [SD] age 12.1 years [3.9] years) with a mean (SD) symptom duration of 1.1 (0.5) years. The procedures were technically successful in all patients. The primary indication for EUS was abdominal pain in 45(52.9%) and jaundice/cholangitis in 15 patients (17.6 %). General anesthesia was used in 12 (13 %) and TIVA in 80 patients (87 %). The most common diagnostic findings were choledocholithiasis in 21 (24.7 %) and cholelithiasis in 12 patients (14.1 %). Among interventions, EUS-guided cystogastrostomy for pancreatic pseudocyst was done in four patients (4.7 %), and EUS-guided rendezvous for failed ERCP in one patient (1.2 %) with cholangitis. There were no immediate post-procedural complications. Overall, EUS had a meaningful impact on the subsequent clinical management in 69 cases (81.2 %). Conclusions  EUS in the pediatric population is safe, effective, and has a meaningful impact in appropriately selected cases. It can act as a rescue in major therapeutic procedures, but adequate care should be taken at the procedural level and during anesthesia.

Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography

BACKGROUND

Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes.

METHODS

Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied.

RESULTS

As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage.

CONCLUSION

Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

Impact of Mobile Endoscopy Unit for Rendering Gastrointestinal Endoscopy Services at Two Community Health Centers in Western India

Background Patients with gastrointestinal (GI) symptoms in remote areas do not have access to standard medical care with the issues related to cost of medical care, transportation, health literacy, lack of healthcare insurance—all preventing healthcare access in a timely manner. To overcome this, we designed a mobile endoscopy van with the intent to provide free essential medical services to the rural population.

Methods This is a retrospective study of patients with predominantly upper GI symptoms at two community health centers (each 2 days camp). This is an audit of endoscopy findings in a community set up using a Mobile Endoscopy Unit (MEU). Patients' details were collected in a pre-designed questionnaire. Only those patients with alarm symptoms and suspicion of any pathological state underwent esophagogastroduodenoscopy (EGD) in MEU. Data analysis was done using descriptive statistics.

Results A total of 724 patients (424 [58.5%] males; mean [SD] age 48.5 [5.2] years) were included. The commonest presenting symptom was heartburn in 377 (52.1%) patients. The median duration of symptoms was 6.5 (range: 2–36) months. Gastroesophageal reflux disease was seen in 16 (6.8%) patients, ulceroproliferative growth was noted in the stomach in 3 (1.3%) patients. Eighteen (7.6%) patients had a positive rapid urease test and received Helicobacter pylori eradication therapy. The most commonly prescribed drugs were proton-pump inhibitors in 692 (95.6%) patients. Nine (1.2%) patients had chronic liver disease secondary to alcoholism and were counseled for abstinence. All procedures were safely performed without any immediate adverse events.

Conclusions Community outreach strategies such as the use of mobile endoscopy unit were found to be very useful in the diagnosis of GI symptoms. More research is needed in low-income countries to treat complex pathological states in rural patients.

Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture

BACKGROUND

Indeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures.

METHODS

The international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement.

RESULTS

Nine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties.

CONCLUSION

Evidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.

Endoscopic Retroperitoneal Necrosectomy for Infected Pancreatic Necrosis Using a Self-Expandable Metal Stent

Infected walled-off pancreatic necrosis (WOPN) is a severe complication of acute pancreatitis. Surgery in these critically ill patients can be associated with increased morbidity and mortality. Hence, minimally invasive therapies have emerged as an alternative to surgery. Herein, we report a case of severe acute pancreatitis with WOPN which was treated percutaneously with a flexible endoscope through an esophageal self-expanding metal stent using a total retroperitoneal approach. Percutaneous direct endoscopic necrosectomy (p-DEN) using the retroperitoneal route improved the patient's parameters dramatically with resolution of sepsis without the need for surgery. p-DEN using a flexible endoscope passed through a large bore metal stent shows promise in selected patients with WOPN and can be used in patients who are not ideal candidates for transmural or surgical drainage.

Utility of the Novel SpyGlass^TM DS II System and Laser Lithotripsy for Choledocholithiasis in Pregnancy

<b><i>Background and Aim:</i></b> Endoscopic retrograde cholangiopancreatography (ERCP) is considered a safe therapeutic modality even in pregnant women; however, adequate care needs to be taken. The utility of the SpyGlass^TM DS II system in choledocholithiasis among pregnant women is unexplored. <b><i>Methods:</i></b> We retrospectively analyzed patients who underwent<b><i></i></b>ERCP for choledocholithiasis in the absence of fluoroscopy using the SpyGlass DS II system from October 2019 to November 2020. Depending on the size and location of the stones, we used laser lithotripsy (LL) for large impacted stones, the balloon extraction technique for multiple stones, and the SpyGlass retrieval basket for single solitary stones. <b><i>Results:</i></b> A total of 10 (100% female) patients with a mean (±SD) age of 29.5 (±2.5) years underwent ERCP. Abdominal pain was the commonest presenting symptom in all patients. Four (40%) patients had cholangitis and 3 (30%) had pancreatitis. The majority of the patients (9; 90%) were in the second trimester. MRCP was the commonest radiological entity, used in 9 (90%) patients. ERCP was technically successful and the stones were removed from all of the patients in a mean (±SD) time of 30 (±3.5) min. LL was used successfully in 4 (40%) patients, balloon extraction in 3 (30%) patients, and the SpyGlass retrieval basket in 3 (30%) patients. There were no pre- or post-procedural complications. All of the patients had an uneventful childbirth, after which they underwent cholecystectomy and subsequent stent removal 2 weeks later. <b><i>Conclusions:</i></b> Use of the SpyGlass DS II system and LL during ERCP appears safe and effective for the treatment of choledocholithiasis among pregnant women.

Early outcomes of peroral endoscopic myotomy with fundoplication for achalasia cardia - Is it here to stay?

BACKGROUND

Peroral endoscopic myotomy with fundoplication (POEM-F) has garnered widespread attention since it tries to achieve an appropriate antireflux procedure during the same setting. The outcomes of POEM-F are currently unexplored.

METHODS

Patients who underwent POEM-F at our center were retrospectively studied to assess its safety and early outcomes.

RESULTS

Twenty patients [70% male; median age 32 years (range 25-41)], with a median symptom duration of 2.1 years (range 1.5-3.7) with achalasia were included. POEM-F procedure was completed in a median of 118 min (range 90-160), with 17/20 (85%) technical success. The median hospitalization was 4 days (range 2-7). Capnothorax (n = 3), resolved spontaneously (n = 2) in 4-6 h, while in one patient (n = 1) the endoscope inadvertently entered into the thoracic cavity for which prophylactic intercostal drain was required. Capnoperitoneum was seen in 17/17 (100%) patients who underwent fundoplication, subcutaneous emphysema in 8/17 (47%) patients. At 1-month follow-up endoscopy, 5/17 (29.4%) patients had loosening of the fundal wrap, 3/17 (17.6%) patients had ulceration in fundus and in gastroesophageal junction due to underlying hemoclips. At 3 months, loosening of the fundal wrap was seen in 7/17 (41.2%) patients. A 24-h pH-metry revealed abnormal esophageal acid exposure in 7/17 (41.2%) patients, while it was normal in those patients in whom the fundal wrap was maintained. 10/17 (58.8%) patients were off proton pump inhibitors.

CONCLUSION

POEM-F is technically feasible with reasonable short term success. However, the durability, early success and safety of POEM-F need reassessment in long-term studies before being applied in clinical practice.

The Usefulness of an Endoscopic OverStitch Suturing System for Managing Anastomotic Dehiscence - A Case Report

Anastomotic dehiscence (AD) after colorectal surgery contributes to poor outcomes resulting in multiple postoperative complications. Conventional management would be a repeat laparotomy and tension suturing. But owing to the unhealthy vicinities near the suture lines, there is a significant risk of technical failure which further increases postoperative morbidity and mortality. A 60-year-old male, with a history of hypertension, ischemic heart disease, and previous percutaneous transluminal coronary angioplasty, underwent sigmoid colectomy with colorectal anastomosis for complicated sigmoid diverticulitis. He then developed anastomotic site leak for which an ileostomy was done. Prior to the ileostomy revision, he was referred for colonoscopic evaluation which showed the persistence of a partial AD. We decided to close the defect endoscopically with the Apollo OverStitch device. Initial tissue preparation was done by creating a surgical surface using argon plasma coagulation at the perimeter of the leak site. A double channel therapeutic endoscope with the OverStitch assembly was passed to take full-thickness running sutures across the rent to facilitate full closure. The area examined showed good suture approximation and complete closure. The procedure was successful with no immediate or delayed postprocedural complications. Repeat endoscopic evaluation at about two weeks showed well-approximated edges with intact suture lines, and there was complete resolution of the leak. The patient subsequently underwent revision surgery after a month. The patient is under close follow-up and doing well. The Apollo OverStitch device has certainly opened new avenues in flexible endoscopic surgery which need further exploratory studies to add to existing promising results.

An Indian Experience of Endoscopic Treatment of Obesity by Using a Novel Technique of Endoscopic Sleeve Gastroplasty (Accordion Procedure)

INTRODUCTION

Endoscopic Sleeve gastroplasty (ESG) is a novel minimally invasive endoscopic restrictive bariatric procedure. We studied the safety, effectiveness, 6-month weight loss outcomes of ESG.

METHODS

We prospectively collected data for patients undergoing ESG at a tertiary care referral center. Laboratory investigations were performed preoperatively, and at 6 months post-operatively. Anthropometric measurements were noted pre and post-operatively at a frequency of 3 months for a 6-month follow-up. Patients with BMI ≥28 kg/m2 who were ready for multidisciplinary follow up for at least 6 months were part of the study. Weight was evaluated at 1, 3 and 6 months' post procedure, and percent of total weight loss (%TWL) and percent of extra weight loss (% EWL) was calculated. Adverse events and new-onset symptoms were recorded.

RESULTS

This prospective study included 58 patients, [55(94.8%)females] who underwent ESG (Jun 2018 - July 2019) using the Over Stitch device (Apollo Endosurgery, Inc., Austin, Texas, US). Mean age was 42.1 years (range 23-53) and mean BMI (kg/m2) was 37.88 (range 28.4-42.9). A median of 5 plications (range 4-6) were used to provide a tubular restriction to the gastric cavity. Mean procedural time (min) was 55 (Range 45 - 86). The mean (±SD) weight reduced significantly from baseline of 98.3±20.4 to 81.8±19.1 at 6 months (p<0.001). The mean BMI reduced significantly from baseline of 37.88±5.76 to 31.37±5.23 at 6months (p<0.001). The mean % of TWL was 8.8 (5.6-16.1), 12.6(10.4-19.1) and 17.1 (11.2-24.1) at 1, 3 and 6 months respectively. The % of EWL was 21.3(12.3-34.3), 30.5(17.7-45.6) and 42.8 (24.5-61.9) at 1, 3 and 6 months respectively. No major complications developed, and patients were discharged on postoperative day 2 (+4 days). Nausea 29 (50%) and moderate to severe abdominal pain 14 (24.1%) were the most common adverse events, treated conservatively. Stitch loosening was noted in 1(1.7%) patient at third month who underwent resuturing.

CONCLUSIONS

ESG appears safe and effective in treating obesity at our center. Mindfulness to reduction in %TWL, %EWL and BMI are critical in evaluating the initial success of ESG. Long term follow-up is required to assess for its sustained effect. Further research into dietary and behavioral modifications with ESG is warranted.

Outcomes of Double Balloon Enteroscopy for Managing Overt Small Bowel Bleeding

Background The commonest therapeutic indications for double balloon enteroscopy (DBE) includes removal of retained video capsules, dilatation of strictures, polypectomy, and managing obscure small bowel bleeding. We review our experience in managing active small bowel bleeding with DBE.

Methods A retrospective review was done for all the cases undergoing DBE from August 2017 to July 2019. Patient follow-up data was collected.

Results Among 25 cases with a median age of 46.8 (range 25–65 years), 17 males (68%) underwent DBE for suspected small bowel bleeding. The commonest presenting complaint was melena 19 (76%). The findings were positive (diagnostic yield) in 18 (72%) patients with an antegrade approach. Active bleeding was associated with Dieulafoy's lesion (n = 6), gastrointestinal stromal tumors (GIST) (n = 4), jejunal varices (n = 3), angioectasia (n = 3), and ulcer (n = 2), who then underwent successful intervention. The rest of the patients underwent both antegrade and retrograde approach but failed to immediately identify an alternative diagnosis. Mean (standard deviation [SD]) time taken for antegrade enteroscopy was 96.7 (15.3) mins and 67.8 (13.6) mins for retrograde enteroscopy. The median duration between the last bleeding episode and timing of DBE was 9 (range 6–15 hours). No major complications were seen during or immediately postprocedure.

Conclusion DBE is useful in identifying and treating active small bowel bleeding. Being invasive and time-intensive, it is easy to miss lesions and, therefore, needs appropriate expertise. DBE does appear to be relatively cheaper, with better patient acceptance and time saving.

Feasibility and outcomes of anti-reflux mucosectomy for proton pump inhibitor dependent gastroesophageal reflux disease: First Indian study (with video)

BACKGROUND

Anti-reflux mucosectomy (ARMS) is a newfangled minimally invasive technique, with successful outcomes for the management of gastroesophageal reflux (GER). We present our initial experience (success rate) and safety profile for this procedure.

METHODS

Consecutive patients with daily dependence on proton pump inhibitor (PPI) for GER were prospectively enrolled from September 2016 to August 2019 and underwent ARMS using a cap assisted endoscopic mucosal resection. Severity was assessed by gastroesophageal reflux disease questionnaire. Gastroscopy and 24-h pH-metry was done pre and post procedure. Patient characteristics, PPI requirement, adverse events and follow-up were documented.

RESULTS

Sixty-two patients [44 (71%) male] underwent successful ARMS with a mean age (SD) of 36 (9.9) years. Technical success was achieved in 100 % of patients. Intraoperative bleeding was noted in 62 (100%) patients, endoscopic hemostasis was successfully achieved. At follow-up dysphagia was seen in 5 (8%) patients which needed a single session of endoscopic dilation. At 2 months, mean (SD) DeMeester score normalized in 45 (72.5%) patients from 76.8 (18.3) to 14.3 (6.1) (P < 0.001). PPI could be stopped in 43 (69.4%) patients. The mean (SD) GERD-Q score reduced from 10.6 (1.9) to 3.4 (1.5) (P < 0.001). However, in 12 (19.3%) patients low dose of PPIs was continued, while 7 (11.3%) patients continued full dose. Thirty-eight (61.3%) patients telephonically reported symptomatic improvement and were off PPIs at 12 months.

CONCLUSIONS

Anti-reflux mucosectomy is safe and effective for treatment of GER. The long term outcomes are favorable, response is durable and promising at our center. Appropriate patient selection still remains primal to the overall success of ARMS.

Six-year retrospective analysis of endoscopic ultrasonography-guided pancreatic ductal interventions at a tertiary referral center

BACKGROUND AND AIM

Endoscopic ultrasonography-guided pancreatic ductal intervention (EUS-PDI) serves as a rescue therapy in patients with failure of retrograde access to the pancreatic duct (PD) at the time of endoscopic retrograde pancreatography (ERP). We review our experience of this procedure.

METHODS

This is a retrospective study of patients who underwent EUS-PDI for an unsuccessful ERP and altered anatomy.

RESULTS

A total of 44 (65.9% male) patients underwent EUS-PDI with a mean age of 43.5 years, (range: 23-67). Transgastric rendezvous technique was carried out in 23/44 (52.3%), transgastric pancreaticogastrostomy in 18/44 (40.9%) and transduodenal pancreaticobulbostomy in 3/44 (6.8%). Overall technical and clinical success was seen in 88.6% (39/44) and 81.8% (36/44), respectively. Technical success of transgastric rendezvous was 95.6% and that of transgastric pancreaticogastrostomy was 77.8%. Two of seven patients with failure to access the PD had successfully undergone EUS-PD stenting at subsequent attempt. Ten immediate adverse events (AE) were noted which included abdominal pain (n = 4), pancreatitis (n = 2), fever (n = 2), minor bleeding (n = 1), and stripping of wire (n = 1). Delayed AE included stent blockage in 12/39 (30.8%) and spontaneous stent migration in 5/39 (12.8%) which were managed with stent exchange at follow up. The rendezvous technique was associated with fewer AE than transgastric pancreaticogastrostomy.

CONCLUSIONS

Endoscopic ultrasonography-PDI is an effective treatment modality and salvage therapy in patients with unsuccessful ERP. Technical and clinical success seen with this study is comparable to studies conducted across the world. EUS-PDI needs to show cost-effectiveness in future studies.

Operative technical tricks and 12-month outcomes of diverticular peroral endoscopic myotomy (D-POEM) in patients with symptomatic esophageal diverticula

BACKGROUND

Submucosal tunneling diverticular septotomy by diverticular peroral endoscopic myotomy (D-POEM) has emerged as an alternative to surgery for symptomatic esophageal diverticula, but its medium to long-term outcomes are currently unexplored.

METHODS

D-POEM for patients with symptomatic esophageal diverticula was prospectively studied to assess its safety and the 12-month outcomes.

RESULTS

25 patients (72 % male; median age 61 years [range 48 - 88]) with a Zenker's diverticulum (n = 20) or epiphrenic diverticulum (n = 5) were included. Major indications were dysphagia, recurrent bronchoaspiration, and foreign body sensation in 20 patients (80 %), with a mean symptom duration of 2.5 years (range 1 - : 4). Complete submucosal tunneling septotomy was achieved in a mean of 36 minutes (range 25 - : 45), with 100 % technical success. The median hospitalization was 5 days (range 4 - : 10). The mean (standard deviation) Eckardt Score improved significantly from 13.2 (1.0) at baseline to 3.2 (1.4) at 12 months (P < 0.001) with clinical success in 19/22 patients (86 %) and no long-term adverse events.

CONCLUSIONS

D-POEM appears safe and durable in patients with esophageal diverticula. Further multicenter studies with a larger patient cohort are warranted.

Antireflux mucosectomy for managing reflux symptoms in an obese patient post laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment modality for obesity. Commonest delayed complication post LSG is gastroesophageal reflux disease (GER). The prevalence of GER among obese patients is higher than normal individuals. Such patients need long term Proton pump inhibitors (PPI) or antireflux procedures to manage reflux. Antireflux mucosectomy (ARMS) uses techniques of endoscopic mucosal resection to treat reflux for PPI refractory GER. However, it can be technically challenging to perform ARMS with a restricted stomach in patients who have undergone LSG. A 40-year-old female, hypertensive who had previously undergone LSG was treated for GER by a multidimensional approach with ARMS utilizing hypotensive anesthesia. The patient underwent the procedure successfully without any complication. She was discharged and at follow up visit, her reflux symptoms had improved and endoscopy was unremarkable. We describe this unusual case which was treated effectively with ARMS.

A rare case of intraductal tubulopapillary neoplasm of the pancreas - case report (with video)

Intraductal tubulopapillary neoplasm (ITPN) is a premalignant epithelial tumor of the pancreas. We report a case of ITPN detected incidentally during histopathology examination (HPE) from a specimen taken at the time of endosonography in a patient with pancreatitis. A 53-year-old man presented with severe recurrent epigastric pain, associated with episodic nonbilious vomiting, with a weight loss of about 7 Kg since 15 days. He underwent Magnetic resonance cholangiopancreatography which showed an ovoid soft tissue lesion in the Pancreatic duct (PD) reported as possible intraductal neoplasm. Patient underwent Endoscopic Ultrasound, whereby the PD was dilated and a large hypoechoic lesion was noted in the PD (head region) causing upstream dilatation. Lesion did not show any vascularity on Doppler. Fine needle biopsy was sent from the intraductal lesion for histopathology examination (HPE). Patient then underwent an ERCP. After performing a pancreatic sphincterotomy, pancreaticoscopy was done using SPYGLASS DS system which showed a nodular intraluminal lesion in the head region with irregular and abnormal vascularity and papillary fronds. Biopsies were taken from this lesion using SpyBite biopsy forceps. To our surprise this HPE report came out to be ITPN. Patient was then referred for surgery. There is often a difference of opinion in distinguishing and classifying such tumors when compared to the subtypes of mucinous neoplasm. Identification of this neoplasm is often challenging for pathologists as well as radiologists. We present this case since it is infrequent and atypical in routine medical practice.

Early removal of biflanged metal stents in the management of pancreatic walled-off necrosis: a prospective study

BACKGROUND AND STUDY AIMS

Dedicated stents placed under endoscopic ultrasound (EUS) guidance have shown promise for the management of pancreatic walled-off necrosis (WON). A long duration of stent placement may increase the risk of adverse events. We prospectively evaluated the effects of (i) early removal of biflanged metal stents (BFMSs) and (ii) additional stenting of the pancreatic duct with plastic stents in patients with ductal leaks, on the risk of WON recurrence.

PATIENTS AND METHODS

Symptomatic patients with pancreatic WON underwent EUS-guided BFMS placement, followed by necrosectomy, when required, from Day 3. A 5 Fr plastic stent was placed in patients with ductal leak. BFMS was removed when the WON cavity had collapsed completely. Patients were followed up at 3-month intervals.

RESULTS

BFMS placement was successful in all 88 patients. A total of 64 patients (72.7 %) underwent necrosectomy (median 3 sessions). All BFMSs were removed at a median of 3.5 weeks (range 3 - 17 weeks). Ductal disconnection and leak occurred in 53/87 (60.9 %) and 61/87 (70.1 %) patients, respectively. A 5 Fr stent was placed in 56/61 patients (91.8 %) with ductal leak. Overall, 22 patients (25.0 %) had adverse events (17 mild, 1 moderate, 3 severe, 1 fatal). Recurrence was noted in 8/88 (9.1 %) at a median follow-up of 22 months. The recurrence rate was higher in patients with ductal disconnection than in those without (13.2 % vs. 2.9 %; P = 0.08), and was similar in patients with vs. without pancreatic duct stenting (7.1 % vs. 12.9 %; P = 0.44). Seven recurrences (87.5 %) partially regressed on follow-up and did not require therapy; in one case, drainage with a plastic stent was performed.

CONCLUSIONS

Short-term BFMS placement is an effective therapy for pancreatic WON. The majority of recurrences developed in patients with ductal disconnection and did not require therapy. Additional pancreatic duct stents probably do not influence the recurrence rate.

Feasibility of a complete pancreatobiliary linear endoscopic ultrasound examination from the stomach

BACKGROUND AND STUDY AIMS

Linear endoscopic ultrasound (EUS) evaluation of the pancreaticobiliary system usually requires scanning from both the stomach and the duodenum. The feasibility of assessing the complete pancreaticobiliary system from the stomach alone has not been studied. We aimed to conceptualize a system-based approach (the railroad approach) for linear pancreaticobiliary EUS (PB-EUS) and evaluate whether the pancreaticobiliary anatomy could be assessed from the stomach alone.

PATIENTS AND METHODS

Three maneuvers were conceptualized and evaluated (the alpha maneuver in the stomach, and sigma and xi maneuvers in the duodenum). The maneuvers were prospectively evaluated in 100 consecutive patients requiring PB-EUS.  RESULTS:  The median procedure time for the three maneuvers was significantly higher than that for the alpha maneuver alone (12 vs. 6 minutes; P ≤ 0.001). The visualization rate of the hilum and common hepatic duct was significantly higher from the stomach than from the duodenum (100 % vs. 83.5 %; P ≤ 0.001), while rates for the head of the pancreas (100 % vs 100 %) and uncinate process (100 % vs 100 %) did not differ. The suprapancreatic common bile duct (CBD; 92 % vs 100 %; P = 0.006), retropancreatic CBD (95 % vs 100 %; P = 0.06), and pancreatic duct in the head (94 % vs 100 %; P = 0.03) were not completely visualized from the stomach, because of pancreatic calcification or shadow from the ligaments. The EUS diagnosis made from the stomach and duodenum did not differ after excluding body and tail lesions (pancreatic head neoplasms, 100 % vs 100 %; CBD stone, 100 % vs 84.6 %; pancreatic cysts in the head, 83.3 % vs 83.3 %, respectively).

CONCLUSIONS

Adequate anatomical and diagnostic information on the pancreaticobiliary system may be acquired by EUS scanning from the stomach alone and with a shorter procedure time.

Life-threatening upper gastrointestinal bleeding due to gastric Dieulafoy's lesion: Successful minimally-invasive management

Dieulafoy's lesion (DL) is a relatively rare, but potentially life-threatening condition. It accounts for 1-2% of acute gastrointestinal bleedings. Its serious nature makes it necessary for early diagnosis and treatment. This is a case report of a patient who presented with life-threatening haematemesis due to gastric Dieulafoy's that was successfully treated laparoscopically after failed endotherapy.

Usefulness of single-operator cholangioscopy-guided laser lithotripsy in patients with Mirizzi syndrome and cystic duct stones: experience at a tertiary care center

BACKGROUND AND AIMS

ERCP is an established technique for the management of bile duct stones. Large bile duct stones (>1.2 cm) require additional techniques such as mechanical lithotripsy and balloon sphincteroplasty for ductal clearance. The literature on endoscopic management of cystic duct stones (CDSs) and Mirizzi syndrome (MS) is limited. We report our experience with cholangioscopy-assisted extraction of CDSs and MS in patients in whom conventional endoscopic and surgical techniques failed.

METHODS

Between August 2011 and August 2014, 50 patients (15 males) diagnosed with MS (n = 40) and CDSs (n = 10) were recruited for the study. MRCP was the preferred diagnostic modality to outline the biliary anatomy. ERCP was performed by using an Olympus TJF 160/180 duodenoscope (Olympus, Tokyo, Japan). Cholangioscopy was performed by using the Spyglass system (Boston Scientific, Marlborough, Mass). Holmium laser lithotripsy (LL) was performed when conventional stone extraction techniques failed.

RESULTS

Cholangioscopy-guided LL was required in 34 of 50 patients (68%) with MS and CDSs. Stone extractions using conventional endoscopy techniques were successful in 8 patients and with surgery in another 8 patients, and these patients were excluded from the final statistical analysis. The mean stone size for MS was 21 mm (range 15-41 mm), and the CDS size was 8 mm (range 6-12 mm). Single-session ductal clearance could be achieved in 32 patients (94%). Adverse events were mild and included fever (2 patients), transient abdominal pain (2 patients), and self-limited pancreatitis (2 patients).

CONCLUSIONS

Cholangioscopy-guided LL is a useful technique for extraction of CDSs and in MS with high single-session success rates. It is also a rescue technique in patients in whom surgical stone extraction failed.

Percutaneous endoscopic management of intrahepatic stones in patients with altered biliary anatomy: A case series

Incidence of primary intrahepatic stones (IHS) in India is very less as compared to the Far East. However patients with altered biliary anatomy are prone for IHS formation secondary to anastomotic stricture formation. Indian data on percutaneous endoscopic management of IHS is scare. Five patients with IHS were managed percutaneously. All patients had undergone Roux-en-Y hepaticojejunostomy and were not suitable for direct endoscopic intervention. All patients underwent percutaneous biliary drainage followed by cholangioscopy-guided laser lithotripsy. Crushed stones were pushed across the anastomotic site using basket/balloon and ductal clearance was achieved. Good stone pulverization could be achieved in five patients (100 %). Complete ductal clearance could be achieved in all patients (100 %). Cholangioscopy-guided treatment of IHS can be valuable alternative to surgery in select group of patients especially those having dilated biliary tree with absence of intrahepatic strictures. However long-term follow up studies are required to see for recurrence of stone formation.

Endoscopic management of internally migrated pancreatic duct stents (with video)

BACKGROUND AND AIMS

Spontaneous intestinal migration of pancreatic stents is a known phenomenon. However, retrieval of a proximally migrated pancreatic stent (PMPS) poses a therapeutic challenge. The primary aim of this study was to evaluate technical success of endoscopic retrograde of cholangiopancreatography (ERCP) for extraction of PMPS, including number of sessions, need of surgery for failures and intervention-induced adverse events. The secondary outcome was to evaluate long-term effects of PMPS on the ductal morphology.

METHODS

Data of patients undergoing pancreatic stenting since January 2007 was reviewed. Fourteen patients were found to have PMPS. The level of stent migration was divided into two categories: level 1: retropapillary migration of the stent, the distal end seen till the genu (n = 6). Level II: PMPS with distal end seen beyond genu (n = 8). The stents were placed due to following reasons, prophylactic pancreatic stenting after common bile duct stone extraction (n = 6), pancreatic endotherapy for chronic pancreatitis (n = 7), and recurrent acute pancreatitis with incomplete pancreas divisum (n = 1). ERCP was done using Olympus TJF 160/180 duodenoscope. Stent extraction was initially attempted using rat tooth forceps, snare with or without wire, wire-guided basket, and in case of failures, pancreatoscope was used (Boston Scientific, USA).

RESULTS

PMPS could successfully be retrieved in 13 out of 14 patients (92.8 %). Stents were retrieved using stone extraction balloon in two (14.2 %), modified angiography balloon in one (7 %), rat tooth in three patients (21.4 %), over-the-wire snare in three patients (21.4 %), lasso technique in one (7 %), and under pancreatoscope guidance in three patients (21.4 %). Adverse events encountered were mild pancreatitis (n = 2, 14 %) and self-limited bleeding (n = 2, 14 %).

CONCLUSIONS

Endotherapy of PMPS could be complex and associated with adverse events. Level II-migrated stents may require specialized methods like pancreatoscopy for stent retrieval.

Endoscopic management of radio-opaque bile duct stones

BACKGROUND

Majority of the bile duct stones (BDS) are radiolucent (RL) and are amenable to conventional endoscopic extraction techniques. There is no publication that specifically discusses the optimal management of radio-opaque (RO) BDS and makes a distinction from the strategy followed for RL BDS.

METHODS

Data of patients with BDS managed endoscopically from January 2009 till June 2015 were retrospectively reviewed. Diagnosis of RO stone was established during initial fluoroscopy, just prior to obtaining a cholangiogram. Endoscopic retrograde cholangiopancreatography (ERCP) was done using therapeutic duodenoscope. Stone extraction was attempted initially using conventional techniques. Balloon sphincteroplasty or mechanical lithotripsy (ML) or both were done if conventional techniques failed. Cholangioscopy-guided intracorporeal holmium laser lithotripsy (LL) was done when all the above techniques failed.

RESULTS

Fifteen patients were found to have RO stones in the bile duct during the study period. ERCP was successful in all patients. Discrepancy of the stone size in relation to the lower CBD diameter was seen in eight patients (53.34 %). Stone extraction with conventional techniques was successful in 2/15 patients (13 %). Successful controlled radial expansion (CRE) balloon sphincteroplasty/ML was possible in 5/15 patients (33 %). Cholangioscopy guided LL was done in eight patients (53.34 %) with successful pulverization of RO BDS (100 %).

CONCLUSIONS

RO bile duct stones provide unique challenges for endoscopic management with success of conventional techniques in only about half of them (46 %). RO stones detected on fluoroscopy are extremely hard and difficult to crush with lithotripsy basket probably due to high calcium content. Cholangioscopy guided LL provides an excellent alternative management strategy.