Video Journal and Encyclopedia of GI Endoscopy最新文献

Pancreatic fluid collections (PFCs) represent a complication of acute pancreatitis. Endoscopic management of PFCs is an alternative to surgery [1]. Classic strategies include access to the collection under endoscopic ultrasound (EUS)-guidance and placement of several double-pigtail stents. PFCs containing organized necrosis are classified as walled-off necrosis (WON). In those cases necrosis is hardly evacuated and will require necrosectomy in most cases. Every necrosectomy session needs prior removal of the stents, dilatation of the tract, debridement and placement of new stents adding up a considerable overall cost to the intervention. A novel double-flanged lumen-apposing fully-covered self-expandable metal stent (FC-SEMS) with a 15 mm diameter accelerates exit of the necrosis and facilitates multiple necrosectomy sessions.

We present a 60 year old patient admitted to the intensive care unit for severe acute pancreatitis that developed WON with superinfection. The intensivists and surgeons indicated endoscopic cystgastrostomy to evacuate the collection. Using the echoendoscope we found a large collection adherent to the gastric wall. The collection was accessed under EUS-guidance using the Hot AXIOS^™ catheter that features a cautery tip, then a 15 mm AXIOS^™ stent was deployed through the cystgastrostomy orifice to keep it patent. The patient required two necrosectomy sessions to clean the cavity. The WON resolved in 6 weeks and the stent was removed unevently. The patient was discharged.

A double flange lumen apposing FC-SEMS used as a port for necrosectomy significantly improves management of walled-off pancreatic necrosis. Placement of this stents should be considered when multiple necrosectomy sessions are anticipated. Procedure time can be significantly decreased using a catheter that combines a cautery tip and stent delivery system.

Background

Ampullary adenoma can be incidental or syndromic and is generally tubular, villous, or tubulovillous in histology. Pyloric gland adenoma (PGA) is uncommon, especially at extra-gastric locations.

Patient & methods

In this video manuscript, we present a case of 2 cm ampullary PGA with high-grade dysplasia (HGD), its endoscopic features, and endoscopic ampullectomy for complete resection.

Results

Under endoscopy, this ampullary PGA displayed a smooth mucosal surface with minimal pit patterns, unlike those pit patterns observed in tubular and villous adenomas. Pathologically, there was complete excision of PGA with HGD. The MUC6 immunostaining performed was positive, confirming the diagnosis of PGA.

Conclusions

Endoscopists and pathologists should be aware of PGA. Endoscopic resection should be performed for complete removal.

Background and aims

Endoscopic mucosal resection (EMR) is a well-established method for the removal of neoplastic polyps throughout the GI tract. EMR typically involves insufflation of the lumen using air or CO₂, followed by submucosal lifting of a polyp to minimize the risk of deep tissue injury and perforation, followed by hot-snare polypectomy. Underwater endoscopic mucosal resection (UEMR) is a new technique that uses water to enable lesion visualization in a lumen that is not distended by air or CO₂, followed by piecemeal hot-snare resection of large mucosally-based neoplasms. UEMR does not require submucosal injection to create a fluid cushion. Very few published examples of UMER in the duodenum exist. This video case series describes the use of UEMR for the resection of several large duodenal adenomas.

Procedure

Underwater endoscopic mucosal resection was utilized for the removal of several large duodenal adenomas.

Results

Three duodenal lesions ranging from 1.8 cm to 5 cm were successfully resected by UEMR. The mean time for resection was 18 min. There were no adverse events.

Conclusions

UEMR is an efficacious technique for the resection of large mucosally-based neoplasms of the duodenum.

Granular cell tumors are rare but benign submucosal tumors of the esophagus. Usually tumors are rather small and do not cause symptoms. We demonstrate a case with typical macroscopic appearance at endoscopy and endosonography. Important differential diagnoses are leiomyoma, and gastrointestinal stroma tumors. Although the patient had no symptoms, he insisted on a complete removal of this tumor. After careful inspection of the submucosal tumor with high-definition white light endoscopy and endosonography we performed endoscopic resection. No post-procedural complications were observed.

Background

Sarcoidosis is a multisystem non-caseating granulomatous disease, which commonly affects the skin, joints, heart, and nervous system. Gastrointestinal sarcoidosis is rare. Likewise, only a few cases of gastric melanosis and pseudomelanosis have been reported.

Patient and methods

In this video manuscript, the authors demonstrate endoscopic and pathological findings of gastrointestinal sarcoidosis and gastric melanosis in a 53-year-old African American woman with known systemic sarcoidosis who presented with recurrent gastrointestinal bleeding.

Conclusions

Internists and gastroenterologists need to be aware of potential gastrointestinal involvement in patients with sarcoidosis. Gastric melanosis is very rare and has unknown clinical significance or implications.

Background

Enteral feeding should be considered for patients with an intact and functional gastrointestinal tract. Percutaneous endoscopic gastrostomy (PEG) tube placement is indicated in patients requiring medium to long term enteral feeding (>30 days) and with impaired swallowing. Previously placed PEG tube can dislodge or be inadvertently removed, blocked, or damaged. Gastrostomy tube replacement is not infrequently performed.

Patients and methods

In this video manuscript, the author demonstrates step-by-step PEG tube replacement in several clinical scenarios: standard gastrostomy feeding tube (with internal retention balloon or with internal collapsible bumper) removal and replacement; low-profile feeding tube replacement; and feeding tube replacement over a wire guide.

Conclusions

PEG tube replacement can be easily replaced at bed-side in most cases. Occasionally, in difficult cases gastrostomy feeding tube replacement needs endoscopic guidance and assistance.

Endoscopic retrograde cholangiopancreatography (ERCP) offers an effective interventional option for treating symptomatic chronic pancreatitis. Endoscopic pancreatic sphincterotomy is performed to facilitated endoscopic treatment. Pancreatic duct strictures can be treated by inserting plastic stents, and a 10 Fr endoprosthesis is adequate in many cases. Before stent insertion, hydrostatic balloon dilation is needed in some cases. Pancreatic stones can be removed with a dormia basket, but combining ERCP and extracorporeal shockwave lithotripsy (ESWL) is often most effective.

Standard and advanced endoscopic treatment approaches are delineated in this article and include stricture dilation with a Soehendra retriever, cSEMS placement and multi-stenting.

Delayed esophageal metallic stent migration after a neo-adjuvant therapy of advanced esophageal cancer is a relatively frequent event, which is sometimes due to tumor response to chemotherapy.

Stent migration in the stomach is usually asymptomatic but it can cause potentially life-threatening complications as bowel obstruction or perforation.

Most gastric migrations can be managed endoscopically; however endoscopic stent removal could also be a risky procedure due to hemorrhage or esophageal perforation.

This case report describes a safe and quick endoscopic method to remove a migrated esophageal metallic stent from the stomach using a protection hood mounted on the tip of the endoscope.

EUS is highly accurate in the diagnosis of chronic pancreatitis. Pancreatic calcifications or five or more endosonographic criteria are consistent with chronic pancreatitis. Less than three criteria essentially rules out chronic pancreatitis. Three or four criteria are the best overall cutoffs. The number of criteria is used to estimate the likelihood of pancreatitis (i.e. low/medium/high), and is not recommended to stage the severity (i.e. mild/moderate/severe) of disease. Obtaining histology by FNA is not recommended in all patients with chronic pancreatitis changes. EUS is useful in distinguishing inflammatory from malignant masses in the pancreas. FNA is often not required as the EUS appearance of inflammatory changes alone or bulkiness without any perceptible mass has good negative predictive value. In indeterminate masses, FNA for cytology is recommended. Follow-up imaging after one to two months can be performed to catch the rare EUS false-negatives, and confirm resolution or stability of inflammatory masses.

Background

In adults, non-food foreign body ingestions occur more in denture users, incarcerated individuals, and in patients with psychiatric disorders or alcohol intoxication. The majority of the ingested foreign body will pass spontaneously. Sharp or pointed foreign body, animal or fish bones, and magnets increase the risk of perforation.

Patient

An incarcerated patient with bipolar disorder swallowed a 14 cm in length needle attached with a syringe three months prior to presentation. The needle penetrated the distal esophagus leading to mediastinitis.

Methods

In this video manuscript, we demonstrated endoscopic techniques on how to remove this 14 cm long sharp object.

Results

The foreign body was removed uneventfully and mediastinitis resolved with antibiotic treatment.

Conclusions

Emergent endoscopy is indicated in (1) esophageal obstruction and the patient are unable to swallow secretions and (2) disk batteries and sharp-pointed foreign body in the esophagus.