Digestive Endoscopy最新文献

WEO Newsletter Editor: Nalini M Guda MD, MASGE, AGAF, FACG, FJGES

Surinder Singh Rana MD, D.M, FAMS, AGAF, FASGE, Master ISG, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India

Dr. Surinder Rana is a Professor of Gastroenterology at the Post Graduate Institute of Medical Education and Research, which is a premier Medical Education Institute in India. Dr. Rana has over 500 publications in peer-reviewed journals. He is a well-known researcher, endoscopist and educator who is involved in several international and national educational conferences and endoscopy workshops.

Gastric peroral endoscopic myotomy (G-POEM) is an emerging treatment modality for gastroparesis. This technique involves mucosal incision, submucosal tunneling, and pyloric myotomy followed by closure of the mucosal incision.

There are multiple closure methods described in the literature, including through-the-scope (TTS) clips,¹ over-the-scope clips, and endoscopic suturing.² TTS clips are the easiest and most economical of the above methods. However, mucosal closure after G-POEM with TTS clips can by difficult due to the thicker gastric mucosa and widening of the mucosal entry site, resulting in difficulty of apposition of mucosal edges.

Clip and snare traction is well described in the literature to assist endoscopic submucosal dissection.³ An internal traction method has been previously described for full-thickness mucosal defect closure.⁴

I describe an adaptation of the above methods to assist clip deployment for mucosal closure.

Once the myotomy is complete, the scope is withdrawn and a snare is attached to the end of the scope by closing the snare over the distal attachment cap. Then the scope is reinserted and a TTS clip is closed just distal to the distal edge of the mucosal incision. Prior to full deployment of the clip, the snare is opened to disengage from the scope and closed over the stem of the clip.

The snare is then used to apply gentle traction to pull the mucosa upwards, creating a mucosal “tent.” The next clip is then deployed, closing the mucosal edges together. Another clip is then introduced through the channel and is used to transfer the snare to the stem of the last deployed clip. This process is repeated until the mucosal incision is completely closed. In this case, the final clip is deployed without the assistance of the snare.

This case illustrates a novel method of gastric mucosal incision closure using inexpensive, widely available devices.

Author declares no conflict of interest for this article.

Approval of the research protocol by an Institutional Review Board: N/A.

Informed consent: Informed consent was obtained from the patient to publish deidentified endoscopic images and videos.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has emerged as an alternative to standard percutaneous or transpapillary approaches in fragile patients with acute cholecystitis.^1-3 Oblique-viewing linear endoscopic ultrasonography (OV-EUS) is used for biliary intervention. However, forward-viewing linear endoscopic ultrasonography (FV-EUS) is applied in certain settings.^{4, 5} Herein, we report salvaged EUS-GBD by using FV-EUS after failure of OV-EUS.

An 82-year-old man with clinical stage IV pancreatic cancer presented with severe vomiting and initially underwent implantation of a duodenal bulb-covered metallic stent. One week later, this patient underwent endoscopic ultrasonography-guided choledochoduodenostomy due to acute obstructive suppurative cholangitis without intrahepatic biliary dilation (Video S1). One month later, this patient developed antibiotic-refractory acute cholecystitis, which deteriorated into a pericholecystic abscess (Fig. 1). Prioritizing the internal drainage, we attempted EUS-GBD using OV-EUS (EG-580UT; Fujifilm, Tokyo, Japan). The gallbladder was depicted; however, the scope struggled to maneuver in the duodenal metallic stent, and a 19G lancet puncture needle could not advance from the scope channel into the gallbladder (Fig. 2a, Video S1). The following day, we retried EUS-GBD using FV-EUS (TGF-UC260J; Olympus, Tokyo, Japan), which quickly facilitated the gallbladder visualization, needle puncture, 0.025 inch hydrophilic guidewire advancement, electrocautery dilation (Cysto-Gastro-Sets; Endo-flex, Voerde, Germany), and a double-pigtailed plastic stent deployment (Advanix J, 7F, 7 cm; Boston Scientific, Marlborough, MA, USA) (Fig. 2b,c, Video S1). The clinical course was uneventful.

The maneuverability of the OV-EUS was limited inside the duodenal bulb stent. We needed to down-angle the scope steeply to depict the gallbladder, which obstructed the puncture needle. In this situation, FV-EUS in the long position easily depicted the gallbladder without an angle maneuver. In addition, all the devices showed excellent pushability and trackability, including the puncture needle, dilator, and gallbladder stent, because the target was located vertically in front of the long-positioned FV-EUS.⁵

Authors declare no conflict of interest for this article.

Endoscopic ultrasound (EUS)-guided drainage effectively treats difficult transpapillary drainage.^{1, 2} However, EUS-guided pancreatic duct drainage (EUS-PD) is technically challenging, as repuncture should be avoided to prevent pancreatic fluid leakage; we describe a technique for EUS-PD stent migration that enables us to avoid repuncture (Video S1).³ A 54-year-old woman, who underwent pancreaticoduodenectomy for pancreatic cancer, experienced recurrent cholangitis and pancreatic stones due to anastomotic stenosis. Endoscopic drainage using a single-balloon enteroscope (SIF-H290S; Olympus, Tokyo, Japan) was attempted, but identifying the pancreatic duct orifice was difficult. Therefore, EUS-PD was performed to secure the route for stone removal. A 19G needle (EZ shot 3 plus; Olympus) was used to puncture the dilated pancreatic duct at the tail. The drill dilator (Tornus ES; Olympus) could not pass the stone. A 4 mm dilating balloon (REN TYPE-IT; Kaneka, Osaka, Japan) was used. After adequate dilation, a 7Fr plastic stent (TYPE IT; Gadelius Medical, Tokyo, Japan) was deployed, but its tip failed to cross the stone and anastomosis, so the stent was placed in the main pancreatic duct proximal to the stone.⁴ Vomiting and fever occurred postprocedure, and radiography revealed stent migration into the esophagus. However, computed tomography revealed the stent tip barely lodged in the pancreatic duct owing to the large flap. Therefore, using a side-viewing duodenoscope (TJF-260 V; Olympus), a guidewire (VisiGlide II; Olympus) was successfully inserted through the stent flap and guided into the jejunum. The stent was removed using forceps (Figs 1, 2). The tract and anastomotic site were sufficiently dilated using a drill dilator, and a 6 mm fully covered self-expandable metal stent (EGIS biliary stent, 6 × 10 mm; SB-Kawsumi, Kanagawa, Japan) was successfully placed. One month later, the stone was successfully removed by the EUS-PD route. A plastic stent has two large flaps at its tip, and even if it migrates, the flap may remain in the pancreas.

Author T.I. received honoraria for his lectures from Olympus and Boston Scientific. The other authors declare no conflict of interest for this article.