Digestive Endoscopy最新文献

Endoscopic full-thickness resection (EFTR) is crucial in managing gastrointestinal submucosal tumors (GISTs).¹ Different traction methods have enhanced the safety and efficacy of EFTR,^{2, 3} such as floss-assisted traction, which is widely used in endoscopic submucosal dissection and EFTR.^{4, 5} However, these methods usually provide one-way traction and inconsistent force, making it challenging to address specific tumor locations. Therefore, we developed an innovative pulley traction technique successfully applied to EFTR of a GIST in the gastric fundus (Video S1).

A patient with a 20 mm × 15 mm GIST in gastric fundus was referred for EFTR (Fig. 1a). Initially, a clip linked with dental floss was used to bring a rubber band into the stomach (Fig. 1b). On releasing the rubber band, the clip was secured to the oral mucosal edge of the tumor. A second clip was used to anchor the rubber band to the normal mucosa on the opposite side of the tumor (Fig. 1c). As the pulley traction consistently lifted the tumor, we incised the mucosa and exposed the tumor without use of a transparent cap or submucosal injection (Fig. 1d). With sufficient traction force of the pulley device, the tumor was safely excavated with complete capsule. Because the defect was transformed to be linear by the pulley traction, it was easily closed using clips (Fig. 1e). Finally, the pulley device was removed from the normal mucosa and the lesion was extracted (Fig. 1f).

Dental floss with rubber band-assisted pulley traction delivers continuous multidirectional traction in difficult locations, thus promoting safe and effective EFTR of GISTs. This method ensures a clear surgical field, prevents hemorrhage, avoids tissue damage, reduces the risk of tumor spillage, provides easy closure of the surgical defect, minimizes tumor resection time, facilitates suturing, and minimizes the likelihood of intra-abdominal infection.

Authors declare no conflict of interest for this article.

Duodenal neuroendocrine tumors (dNETs) easily invade the deep submucosa, resulting in a low R0 resection rate (50%) with conventional endoscopic mucosal resection.¹ Endoscopic resection has recently seen the utilization of the over-the-scope clip (OTSC). Endoscopic muscularis resection with OTSC (EMRO) facilitated muscularis resection without perforation² and achieved a high R0 resection rate (92.9%) for dNETs.³ Nevertheless, electricity can flow toward the OTSC in employing a monopolar snare when the area constricted by the OTSC is smaller than that of the closed snare,^3-5 leading to coagulation damage to the duodenal mucosa and ultimately resulting in EMRO failure.

Here we present the case of an 80-year-old man with cT1 dNET located on the anterior wall of the bulb (Fig. 1), which was not successfully resected by EMRO but could be resected completely through endoscopic muscularis dissection with OTSC (EMDO) (Video S1). We decided to perform EMRO, deploying the OTSC during the process (Fig. 1). The lesion was ensnared above the OTSC without contact, and Endocut electrocoagulation (VIO300D; Erbe Elektromedizin, Tübingen, Germany) was employed. However, electricity flowed toward the OTSC, resulting in mild coagulation damage to the duodenal mucosa and rendering snare resection impossible. Therefore, we switched to an endoscopic dissection technique, named EMDO. The dissection proceeded above the OTSC, utilizing the ORISE ProKnife (Boston Scientific, Watertown, MA, USA). Endocut mode was primarily employed for mucosal incision and muscularis dissection, resulting in the resection of the lesion without any adverse events. The histopathological findings revealed a dNET confined to the deep submucosa with negative resection margins, confirming successful muscularis resection (Fig. 2).

To our knowledge, this is the first report of EMDO. Muscularis resection was achieved without perforation, similar to the outcomes of EMRO. EMDO could serve as an alternative when EMRO is not feasible due to the flow of electricity toward the OTSC.

Authors declare no conflict of interest for this article.

Endoscopic submucosal dissection (ESD) is an established endoscopic treatment for esophageal and stomach tumors, as well as colorectal tumors. The cure rate, operation time, and complication rate for colonic ESD have improved with standardization of the procedure.¹ However, colonic ESD is technically difficult due to factors such as the thinness of the intestinal wall, maneuverability of the endoscope, physiological bending, peristalsis, respiratory movements, and heartbeat.^{2, 3} Various training models have previously been reported to overcome these difficulties, such as a colonic ESD training model using an animal model⁴ and a model that simulates heartbeat using a motor device⁵; however, there are no reports of ESD training models that simulate respiratory movements. In this report, we introduce the first such ESD training model (Video S1). We use an accordion hose, battery-powered toy train, smartphone holder, turntable (20 cm diameter), plastic plate, a three-plate bolt assembly, two springs, two paper cups, an A4-size binder, and versatile training tissue (VTT; Kotobuki Medical, Saitama, Japan). VTT is a simulated mucosal model consisting of a food-quality konjac, which is readily obtainable and poses few hygiene issues. Moving the toy train fixed with a smartphone holder on the turntable automatically rotates the turntable (Fig. 1a). When the turntable and plastic plate are connected with the bolt plate, the plastic plate moves linearly back and forth (Fig. 1b). This model makes a reciprocating linear movement ~10 times per min. Placing the VTT on this plastic plate results in a movement on the monitor that is very similar to the respiratory movements experienced during colonoscopy (Fig. 2). This model enables training on handling respiratory movements, which pose a difficulty in colonic ESD. Two experts and four trainees at our hospital who trained with this model rated this model highly, suggesting that it could be useful as a colonic ESD training model.

Authors declare no conflict of interest for this article.

Intussusception accounts for 1–5% of the causes of intestinal obstruction in adults.¹ Surgical resection is a radical treatment for malignant colonic intussusception.² However, emergent endoscopy for assessing colonic obstruction is sometimes needed preoperatively.³ Endoscopy can be used to temporally resolve intussusception preoperatively, although a detailed procedure has not been reported. This video reports the use of carbon dioxide (CO₂) insufflation via colonoscopy to repair intussusception due to colorectal cancer.

A 58-year-old man presented with severe abdominal pain and constipation. Computed tomography (CT) revealed a large mass and a three-layer structure of the sigmoid colon wall with the mesentery wrapped over the rectum, suggesting intussusception of the sigmoid colon (Fig. 1a). No signs of intestinal ischemia or perforation were observed. Colonoscopy was performed without bowel preparations, revealing a large mass overlapping the normal mucosa in the rectum (Fig. 1b). The colonoscope could not access the oral side of the lesion. Insufflation was achieved using CO₂ through the colonoscope. The mass was moved toward the oral side, and the overlapping sigmoid colon wall was gradually released. Type I advanced cancer of the sigmoid colon was observed after intussusception repair (Fig. 2a). Postcolonoscopy CT revealed that the mass moved to the sigmoid colon and the three-layer structure of the colonic wall disappeared (Fig. 2b). Three weeks after colonoscopy, a laparoscopic-assisted sigmoid colon resection was performed, and the final pathological diagnosis was well-differentiated adenocarcinoma of the sigmoid colon (T3, N0, M0, stage IIa) according to the Japanese Classification.⁴

Although colonic intussusception repair by air insufflation has been reported previously,⁵ this is the first report of a video of colonic intussusception repair using CO₂ insufflation using a colonoscope. This procedure is simple, inexpensive, and effective for avoiding emergency surgery. Therefore, CO₂ insufflation using colonoscopy may be an alternative option for repairing malignant colonic intussusceptions.

Author S.S. is an Associate Editor of Digestive Endoscopy. Author S.S. received a speaker honorarium from FUJIFILM Corporation. The other authors declare no conflict of interest for this article.

In recent years, several suturing methods have been invented to prevent the adverse event of endoscopic submucosal dissection (ESD) such as delayed bleeding.¹

Furthermore, it is important to close the entire muscle layer without dead space for a strong suture.^{2, 3}

A 67-year-old female patient presented with a 30 mm 0-IIa lesion in the cecum, and underwent ESD (Video S1).

First, ESD was performed using an ORISE Proknife (Boston Scientific, Marlborough, MA, USA) from the anal side and en bloc resection was completed. After en bloc resection, a mucosal defect of ~5 cm was observed (Fig. 1), and suturing was performed. First, a clip with nylon thread was attached to the middle of the mucosal defect. The thread was then gently pulled to elevate the grasped muscle layers, while suturing it with a reopenable clip (SureClip; MicroTech, Nanjing, China). In this process, the clip was applied to the submucosal layer at the edge of the mucosal defect, not the mucosa, and sutured to the submucosal layer at the opposite edge along with the elevated muscle layer. The other area was sutured in the same way with a clip by pulling the thread. Once the mucosa on both sides has closed to some extent, additional clips were used to suture the mucosa tightly. Finally, the thread was cut and complete suture was possible (Fig. 2).

This suturing technique allows the mucosal defect to be reduced by clipping the middle region of the muscle layer. In addition, by hooking the clip not to the mucosa but to the submucosa at the edge of the mucosal defect, the clip is less likely to slip, and by pulling the thread to elevate the muscle layer, the middle muscle layer can be sutured together with both sides, eliminating dead space. This suturing technique is useful for mucosal defect of colorectal ESD.

Authors declare no conflict of interest for this article.

Duodenal endoscopic submucosal dissection (DESD) has a high incidence of delayed adverse events (AEs).¹ However, complete mucosal closure (CMC) can reduce the risk of AEs after DESD.² Conventional clip closure is a common technique,¹ but it poses challenges when used for CMC of large defects after DESD. This case shows a simple closure technique using anchor-pronged clips (MANTIS clip; Boston Scientific, Waltham, MA, USA) for CMC after DESD.

A 63-year-old man underwent DESD for a 40 mm flat elevated lesion in the descending duodenum (Fig. 1a). During the DESD, an intraprocedural perforation occurred, which was closed using a conventional clip (SureClip; Micro-tech, Nanjing, China). Then en bloc resection was performed on a 47 × 41 mm specimen (Fig. 1b). After resection, mucosal closure was initiated with the anchor-pronged clips for the approximately half circumferential defect (Fig. 2a,b). We grasped the oral edge of the defect using the anchor-pronged clip, allowing us to bring and grasp the opposite side (Video S1). The anchor-pronged clip closed the center of the defect (Fig. 2c), and CMC was achieved in 11 min using seven additional conventional clips (Fig. 2d). The patient was discharged 6 days later without AEs. Pathological examination revealed the lesion was an intramucosal well-differentiated adenocarcinoma with negative resection margins.

Although there are various techniques for CMC after DESD,¹ some of these methods require technical skills. Anchor-pronged clip closure is a simple technique that enables the closure of larger defects and overcomes the challenges of conventional clips during the closure procedure, such as tissue slippage when grasping the opposite side.^{3, 4} Furthermore, by applying the previously reported technique of anchor-pronged clip to grasp and suture the muscle layer, it may be possible to reduce suture-induced dead space even in the duodenum.⁵ Therefore, mucosal closure using anchor-pronged clips is a viable option for CMC of large defects after DESD.

Authors declare no conflict of interest for this article.

Braun reconstruction is effective in preventing afferent loop syndrome (ALS) after pancreatoduodenectomy.¹ Occlusion of a Braun anastomosis can lead to ALS, posing a risk of nonobstructive cholangitis.² In such circumstances, surgical reconstruction is highly invasive, and although endoscopic ultrasonography (EUS)-guided enterostomy offers a less invasive alternative,^{3, 4} challenging cases still exist. We hereby report the safer endoscopic recanalization for an occluded Braun anastomosis using an endoscopic needle (Video S1).

An 83-year-old man, with a history of pancreaticoduodenectomy and Child's reconstruction, developed recurrent cholangitis. Balloon-assisted enteroscopy showed no stenosis at the choledocojejunostomy site, but revealed complete closure of the Braun anastomosis (Fig. 1). To address the potential cause of recurrent cholangitis, an endoscopic attempt was made to recanalize the Braun anastomosis. We discovered that a 20G endoscopic injection needle (Varixer needle (01941); Top, Tokyo, Japan) designed for endoscopic injection sclerotherapy is compatible with a 0.018 inch guidewire (Fielder 18; Olympus, Tokyo, Japan). This needle has a slenderer outer sheath than the EUS-guided fine-needle aspiration needle. Unlike the latter, the metal needle is limited to the tip (Fig. 2a), enabling flexible adaptation to the steep bending angles of the endoscope (Fig. 2b). We aimed for safe recanalization using a rendezvous method, puncturing from the efferent loop to facilitate dilation from the afferent loop, where applying force was more feasible in this case. Despite the endoscope being deeply angulated, the puncture was easily performed, allowing for the placement of a 0.018 inch guidewire (Fig. 2c). As a result, we were able to grasp the guidewire from the afferent loop side, enabling subsequent fistula dilation and stent placement exceptionally easily (Fig. 2d). This technique can be used for the occluded choledocojejunostomy site⁵ and is a valuable method for recanalization of closed intestinal anastomoses.

Authors declare no conflict of interest for this article.

Distinguished Reviewers - Reviewers who have received DEN Best Reviewers Award 3 or more times -

Seiichiro Abe, Osamu Dohi, Mitsuru Esaki, Motohiro Esaki, Yoshihiro Furuichi, Waku Hatta, Takuto Hikichi, Kenichiro Imai, Hiroshi Kawakami, Hideki Kobara, Hiroki Kurumi, Kosuke Minaga, Hiroki Sato, Yuto Shimamura, Mitsushige Sugimoto, Yoji Takeuchi, Toshio Uraoka, Yasushi Yamasaki.