Video Journal and Encyclopedia of GI Endoscopy最新文献

Endoscopic placement of esophageal Self-Expandable Metal Stents (SEMS) is a therapeutic option for post-surgical esophageal leaks. Partially covered SEMS are mainly designed for malignant esophageal strictures, but are used off-label to close post-surgical leaks due to their lower migration rate than fully covered SEMS, and better adherence to the esophageal wall. Partially covered esophageal SEMS can achieve post-surgical fistula healing, but their removal is difficult due to tissue ingrowth through the uncovered part. A challenging case of a difficult removal of a partially covered esophageal SEMS (remove the indefinite article) is (below) presented.

Early lesion detection and characterisation is vital to ensure accurate management in patients with gastrointestinal neoplasia. Endoscopic Tri-modal Imaging (ETMI) technology has been shown to improve the targeted detection of early dysplastic lesions in Barrett's Oesophagus, but these results were not confirmed in non-expert hands [1]. This technology incorporates high resolution while light endoscopy (HRE), Auto Fluorescence Imaging (AFI) and Narrow Band Imaging (NBI) in one endoscope. The mucosa is first inspected with HRE, and then AFI is switched on to help in highlighting any suspicious areas in the mucosa [2]. These areas can be further examined by switching to NBI mode with magnification which helps to characterise mucosal patterns and identify early neoplasia [3].

Endoscopic submucosal tunnel dissection (ESTD) was recently described for the resection of upper gastrointestinal submucosal tumors, namely leiomyomas, GISTs and aberrant pancreas. Granular cell tumors (GCT) are usually benign, but should be removed when symptomatic, significantly increase in size or have atypical histological or ultrasonographic features.

We aim to describe the role of ESTD for the resection of an esophageal GCT. A 51 year-old patient was referred to us due to the presence of an esophageal submucosal lesion with increased size in the follow-up. Deep biopsy specimens were positive for granular cell tumor. Suboptimal submucosal lifting precluded conventional endoscopic submucosal dissection (ESD). In this context an ESTD was performed. First, a submucosal tunnel was created starting 5 cm above the tumor. Afterwards, the GCT was carefully dissected from the overlying submucosa and muscularis propria using TT knife and IT knife2. The ESTD procedure was possible and en bloc resection achieved, being the 25 mm long lesion retrieved. The mucosal orifices were closed using conventional clips. The patient started oral diet 1 day after ESTD and was discharged at day 4 without any complications. In this first report of ESTD for esophageal GCT resection, this technique shown to be feasible, reliable and safe, enabling complete resection, even in this case with poor submucosal lifting.

Background/aim

Image enhanced endoscopy including narrow band imaging, flexible spectral imaging color enhancement and i-scan is useful for detailed examination of upper gastrointestinal lesions. We aimed to clarify the usefulness of blue laser imaging (BLI) method, a new endoscopic system, to image upper gastrointestinal lesions.

Procedure

We observed upper gastrointestinal lesions including early gastric cancer and early esophageal cancer using white light images and subsequently BLI bright images and BLI images.

Results

In gastric cancer, irregular microvessels on the tumor surface are clearly identified for both differentiated and undifferentiated lesions with high magnification, similar to those using narrow band imaging. In addition, irregular surface patterns are seen in differentiated lesions by enhanced white circles, which form white zones on the tumor surface. Finding these circles allow us to rule out undifferentiated lesions. Another advantage is to enhance gastric intestinal metaplasia as green-colored mucosa in both distant and close-up views, leading to higher color contrast with brown gastric cancers. This leads to early detection of gastric cancers and shows a demarcation line between the cancer and areas of metaplasia. In squamous cell carcinoma of the esophagus, BLI produces a higher color contrast between brown lesions with intraepithelial papillary capillary loops and the surrounding area without magnification. The extent of Barrett׳s esophagus is easily shown as a high color contrast with the brown gastric mucosa.

Conclusions

Blue laser imaging produces excellent images useful for detection and detailed examination of upper gastrointestinal lesions.

In colonoscopy, even a complete examination has little diagnostic accuracy when the endoscopic view of the mucosa was impaired by residual stool. Therefore, an assessment of the visibility of the mucosa is important, in order to be able to judge the reliability of positive, but even more importantly, negative findings during colonoscopy.

Insufficient visualization can result in lesions, especially small or flat ones, being missed. Poor bowel preparation may also result in difficult progression, an increased risk of complications, prolonged procedure duration and an increase in the amount of sedatives and analgetics required. Poor bowel preparation is also a frequent cause for incomplete procedures.

The optimal grading scale uses objective terminology, is validated, and informs both on segmental as overall bowel preparation quality. The Boston bowel preparation scale fulfils all these criteria, making it the most uses bowel preparation scale in colorectal cancer screening programs.

Conventional mother–baby cholangioscopy systems have significant limitations including poor image resolution, limited maneuverability and fragile cholangioscopes. We propose the novel short-access mother–baby-(SAMBA) cholangioscopy system that involves a very short and flexible cholangioscope that is introduced in a dedicated mother duodenoscope with an extra distal side port. Clinical feasibility of this device is demonstrated in three complex cases with cholangiopathies. The strengths of SAMBA cholangioscopy are improved imaging quality and excellent maneuverability of the baby that allows access of small intrahepatic ducts. Evaluation of suspected intrahepatic biliary disease is an excellent indication for SAMBA.

Mucormycosis is a rare invasive fungal infection with high mortality. It usually affects patients with poorly controlled diabetes, immunosuppression, or hematological malignancies. Gastroenterologists need to be aware of this rare infection because endoscopy can facilitate early diagnosis and prompt appropriate therapy. Here we describe a case of invasive esophageal mucormycosis that developed in a 63-year-old man with diabetes, acute promyelocytic leukemia, and prolonged leukopenia after chemotherapy. Upper endoscopy showed distal circumferential esophageal wall thickening with devitalization. The mucosa did not bleed after endoscopic biopsy. Histopathology confirmed mucormycosis. He was treated with various antifungal agents including echinocandins, fluconazole, and liposomal amphotericin B. Despite aggressive antifungal therapy and supportive care, the patient died 24 days later.

Introduction

The overall risk of clinically significant post-papillotomy bleeding is 1–4%, most of them manifest as a delayed hemorrhage 2–5 days after ERCP. Injection method with diluted epinephrine is the standard first line therapy of endoscopic hemostasis in these patients. In therapy resistant cases endoscopic hemocliping is effective, but optimal positioning of the hemoclips is difficult and sometimes impossible. Thermal coagulation method with coagulation forceps combined with prophylactic pancreatic duct stenting could be an alternative in these cases.

Patients and methods

We present 2 cases of recurrent post-papillotomy bleeding, both were detected in 1–6 days after the successful ERCP and EST. Standard endoscopic therapy with local injection of diluted epinephrine and/or application of hemoclips were ineffective. As a second line endoscopic therapy we used thermal coagulation of the bleeding vessels with coagulation forceps similarly to ESD. At the time of the thermal coagulation a 5F, 3–5 cm prophylactic pancreatic stent was applied to prevent pancreatitis.

Results

We achieved complete hemostasis in all patients without signs of further rebleeding or need for surgery. None of our patients developed post-procedure pancreatitis or perforation. Prophylactic pancreatic stents were safely removed after a few days.

Conclusion

We presented a new, effective and safe second line endoscopic hemostatic method in patients with therapy resistant post-papillotomy bleeding. Combination of prophylactic pancreatic stenting and thermal coagulation with coagulation forceps might be suggested as a rescue treatment in patients with severe post-papillotomy bleeding, resistant to standard endoscopic therapy.