Video Journal and Encyclopedia of GI Endoscopy最新文献

Introduction

Gastric arteriovenous malformation (AVM) is an uncommon cause of upper gastrointestinal (GI) bleeding.

Methods and results

We describe a case of gastric AVM which was diagnosed endoscopically and successfully managed by endoclip application and percutaneous transarterial coil embolization.

Conclusions

We propose that these two minimally invasive technologies can be used to manage AVM in the gut: endoscopic therapy to control luminal bleeding and interventional radiology to define the full extent of the malformation and to decrease arterial pressure and flow to the point that hemostasis can occur, without creating symptomatic ischemia.

Background

The change in lithogenicity of bile, increased stasis of bile and decreased gall bladder emptying are the possible reasons for an increased risk of gall stones during pregnancy. However, biliary interventions during pregnancy are associated with risks to both the pregnancy and developing fetus. ERC under fluoroscopic control as gold standard is associated with higher risk of premature labor and teratogenity.

Methods and patient

We performed transabdominal ultra-sound guided ERC in one patient in the second trimenon with gall stones. While the hilus area is observed by ultrasound, the papilla is carefully cannulated with a guidewire. A contrast agent is applied in the common bile duct (CBD) via the guide-wire of conventional duodenoscope.

Results

A rather small stone obstructing the common bile duct was visualized. To keep the invasiveness of this procedure to an absolute minimum at this time sphincterotomy with subsequent stone extraction were postponed after delivery and we decided to decompress the bile duct with a plastic stent. There were no complications due to the procedure. Bile flow was observed.

Conclusion

The exposure to radiation raises a problem in pregnant women because radiation is a possible risk for fetal disorders or premature labor, depending of the trimenon. For pregnant patients with symptomatic obstruction current guidelines recommend treatment by ERCP but with minimal exposure to radiation. This case report demonstrates a feasible alternative without fluoroscopy to the conventional fluoroscopic ERC in pregnant woman.

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.

Patients and methods

In this video manuscript, we demonstrate the complete PEG procedure (pull method) in a 65 year old patient and placement of PEG jejunal extension tube in another patient who needed post-pyloric enteral feeding.

Conclusions

PEG-pull method is the most widely used PEG technique. Appropriate patient selection, timing of the procedure, informed consent, antibiotic prophylaxis, adequate endoscopic air insufflation during PEG site selection, and optimal PEG site localization are the keys in this procedure.

Background

Endoscopic ultrasound (EUS) is an important tool in the evaluation of idiopathic or recurrent acute pancreatitis and prior to high-risk endoscopic retrograde cholangiopancreatography (ERCP), such as ampullectomy and sphincter of Oddi manometry. Linear-array EUS provides detailed imaging of the pancreas in a non-invasive manner and can accurately identify pancreas divisum in most patients.

Patient and methods

Linear-array EUS is used to demonstrate the normal pancreatic ductal anatomy. Three clinical cases are then presented to demonstrate the endosonographic findings in pancreas divisum. (1) A 64 year-old female with history of pancreatitis undergoes an MRI, which shows an irregular calcified area in the head/uncinate of the pancreas and pancreas divisum. (2) A 55 year-old female undergoes EUS prior to ERCP for evaluation of sphincter of Oddi dysfunction. Pancreas divisum is noted on EUS and later confirmed with ERCP. (3) A 50 year-old female with abdominal pain undergoes an MRI, which shows a peri-ampullary cystic structure and pancreas divisum.

Results

Pancreas divisum can be detected with linear EUS by the inability to follow the main pancreatic duct (PD) from the major ampulla to the body of the pancreas, or from the relatively hypoechoic ventral pancreas to the more echogenic dorsal pancreas. Often in cases of pancreas divisum, the main PD can be seen merging with the duodenal wall at the minor papilla.

Conclusions

Linear-array EUS is an effective way to detect pancreas divisum, which is important in the work-up of idiopathic pancreatitis and in defining pancreatic ductal anatomy prior to ERCP.

Background

Endoscopic submucosal dissection (ESD) has been increasingly used for en bloc resection of gastrointestinal lesions. One of the main difficulties during ESD is to mobilize the partially resected lesion, leading to increased procedure time and complication rates. We developed a new “yo-yo technique”, that allows a fast, cheap and easy way for, not only pulling, but also pushing the lesion during ongoing ESD.

Aims

To describe the feasibility and safety of the “yo-yo technique” for ESD.

Procedure

After marking and lifting the lesion, incision and partial dissection are performed. Then, a hemoclip is placed in the already dissected edge of the lesion. Afterwards, a conventional snare is introduced through the nose into the stomach. Using a forceps, the hemoclip is grabbed with the snare. Due to the moderate stiffness of the snare, the edge of the lesion can be pulled or pushed during ongoing ESD, independently from the endoscope's movements. This increases the visualization of the dissection plane, reducing complications rate and procedure time.

Results

The pull and push movements of the snare allow easier ESD with better access to the submucosal space and to the lesions' distal margins. Lesions can be successfully and safely removed and en block resection achieved using the “yoyo technique”. The presence of the hemoclip in the resected specimen permits a precise anatomopathological orientation.

Conclusion

The “yo-yo technique” for ESD is feasible, cheap and safe allowing full mobilization of the lesion.

Histological diagnosis of upper gastrointestinal submucosal tumors (SMT) is a prerequisite for selecting the proper therapeutic approach. EUS-FNA has improved the evaluation of SMT. Endoscopic biopsy by mucosal incision (EBM) is a diagnostic procedure developed by Yokohata et al. The principal aim of this study was to examine the potential of EBM, as an alternative to the more expensive and technically-demanding EUS-FNA, in diagnosing SMT. This retrospective study included a consecutive series of 27 patients (15 males and 12 females, mean age 60.1 years) undergoing EBM and 11 patients (7 males and 4 females, mean age 65.7 years) undergoing EUS-FNA. The tumors had diameters of 15 mm or more, and were suspicious for continuity with the fourth layer as determined by EUS. We compared the diagnostic accuracy and the operating time of EBM with those of EUS-FNA.

Results

The diagnostic accuracies of EBM and EUS-FNA were 85.2% (23/27) and 90.0% (9/10) respectively. The average operating time of EBM and EUS-FNA was 20 min and 41.0 min respectively. During our investigation no major complications were encountered in either group.

Conclusion

EBM matches EUS-FNA in diagnostic accuracy of SMT and is more time and cost-efficient.