Digestive Endoscopy最新文献

Postoperative bleeding and perforation are common complications of gastric endoscopic submucosal dissection (ESD),¹ and closure is a topic. However, closures are often complicated.^{2, 3} Nishiyama et al.⁴ described the use of novel thin grasping forceps for over-the-scope clip (OTSC) closure after endoscopic full-thickness resection. The grasping forceps (TechGrasper; Micro-Tech, Nanjing, China) offers two main advantages. The forceps' small diameter does not interfere with suction applied before the OTSC deployment, and the strong grasping power ensures reliable staple application to the muscle layer. Here, we report the first case of successful ulcer closure after gastric ESD using TechGrasper-assisted OTSC.

A 78-year-old man with lung adenocarcinoma underwent esophagogastroduodenoscopy for preoperative screening, which revealed a 30 mm gastric cancer. Although the patient was a candidate for ESD, lung resection was prioritized because of advanced-stage lung cancer (pT2aN2M0, pStage IIIA). Postoperative adjuvant chemotherapy including regimens associated with increased risk of perforation and thrombocytopenia was recommended. Therefore, before chemotherapy initiation, the patient underwent TechGrasper-assisted OTSC closure of the post-ESD ulcer, which measured 50 × 34 mm in diameter (Fig. 1a,b).⁵ Briefly, immediately after ESD, an OTSC (Ovesco Endoscopy GmbH, Tuebingen, Germany) was attached to the tip of a two channel endoscope (GIF-2TQ260M; Olympus Co., Tokyo, Japan). After grasping the edge of the post-ESD ulcer, the TechGraspers were pulled into the cap of the OTSC, which was then released with sufficient suction (Fig. 1c,d). The endoscopist pulled and adjusted one pair of forceps, and the assistant pulled the other pair of forceps. Four OTSCs were successfully applied to the post-ESD ulcer (Fig. 2a and Video S1). The patient underwent adjuvant chemotherapy 4 weeks after ESD, without subsequent adverse events (Fig. 2b–d). The present case illustrates the utility of TechGrasper-assisted OTSC as a simple technique to promote effective wound healing following gastric ESD.

Authors declare no conflict of interest for this article.

Gursimran S. Kochhar, MD, is a gastroenterologist, Division Chief of the Department of Gastroenterology and Hepatology, at Allegheny Health Network, Pittsburgh, Pennsylvania. He specializes in interventional inflammatory bowel disease (IBD) and advanced therapeutic procedures.

Dr. Kochhar completed his training in internal medicine at Cleveland Clinic Foundation, Cleveland, Ohio, where he subsequently received training in nutrition and finished a gastroenterology and hepatology fellowship focused on training in IBD. Dr. Kochhar then completed his advanced endoscopy fellowship at Mayo Clinic, Jacksonville, Florida.

Dr. Kochhar has been at the forefront of managing IBD and its complications with various advanced endoscopic procedures. His innovative research on the endoscopic management of IBD has been successfully published in leading gastroenterology journals, including Gastroenterology, Clinical Gastroenterology and Hepatology, and Gastrointestinal Endoscopy. He has more than 120 publications, including peer-reviewed articles and book chapters. He serves on the Editorial Board of the journal Inflammatory Bowel Diseases. His current research focuses on endoscopic management of IBD complications, artificial intelligence in health care, and newer endoscopic innovations.

Stricture formation is a common complication in Crohn's disease (CD) patients, resulting from the underlying disease process, surgical anastomosis, or strictureplasty. The true incidence of stricturing disease is hard to assess. However, some studies suggest the prevalence of strictures is up to 25% in patients with CD, and over 50% of patients with CD will need at least one surgery in their lifetime.

Endoscopic balloon dilation (EBD), first described by Dr. G.M. Heller in 1988 in a patient with CD,1 is a very important tool in our toolbox to manage strictures in such patients. EBD, if done well, can be very effective in mitigating or delaying surgeries in patients with CD (Fig. 1).

Endoscopic assessment of strictures is challenging, especially if they are impassable. Hence, we rely heavily on preprocedural imaging. Both computed tomography enterography (CTE) and magnetic resonance enterography (MRE) with contrast are acceptable preprocedural imaging techniques. These give us an idea of the length, number, severity, type of stricture (inflammatory versus fibrotic), presence of prestenotic dilation, and any associated fistula or abscess. All these details help us plan the procedure. Strictures longer than 5–7 cm or with significant prestenotic dilation (>5 cm in the small bowel) tend to be less responsive to EBD treatment. Avoid EBD in patients with an associated fistula or abscess. If there is a lot of inflammation on imaging, optimize medical therapy before performing an EBD.

Although there are not many scenarios where EBD is contraindicated, I recommend not performing it if there is an associated abscess or fistula with the stricture, as t