Abstract Background Foreign body (FB) ingestion is a common pediatric problem with the majority of these occurring in children younger than 3 years. Management varies depending on the age of the patient, ingested object(s), its location along the digestive tract, and the available expertise. We aim to report our experience with endoscopic management of FB ingestions in children (<18 years). Materials and Methods We retrospectively reviewed and analyzed endoscopic and medical records from our hospital database of all pediatric patients (<18 years) who presented with FB ingestion between January 2011 and December 2021. Results Our analysis included a total of 368 patients. FB ingestions and/or food bolus impactions were noted in 242 and 11 children, respectively while 115 (31.25%) had spontaneously passed off FB from the digestive tract. Most common FB was coin (28.5%) followed by animal bones (26.2%). Endoscopic management of FBs and food bolus impaction was successful in 247 children (97.63%), while endoscopic FB retrieval failed in 6 children including 1 with fish bone and 5 with button batteries. A total of 9 out of 11 children with food bolus impaction had underlying esophageal pathology, the commonest being corrosive stricture ( n = 7). No mortality related to endoscopic intervention was reported. Conclusions Endoscopic retrieval of ingested FBs and food bolus impaction in children is a safe and effective approach when performed by experienced endoscopists and is associated with a high success rate and a lower incidence of complications with reduced hospital stay.
{"title":"Endoscopic Management of Pediatric Foreign Body Ingestions and Food Bolus Impactions: A Retrospective Study from a Tertiary Care Center","authors":"S. Shafiq, H. Devarbhavi","doi":"10.1055/s-0043-1771009","DOIUrl":"https://doi.org/10.1055/s-0043-1771009","url":null,"abstract":"Abstract Background Foreign body (FB) ingestion is a common pediatric problem with the majority of these occurring in children younger than 3 years. Management varies depending on the age of the patient, ingested object(s), its location along the digestive tract, and the available expertise. We aim to report our experience with endoscopic management of FB ingestions in children (<18 years). Materials and Methods We retrospectively reviewed and analyzed endoscopic and medical records from our hospital database of all pediatric patients (<18 years) who presented with FB ingestion between January 2011 and December 2021. Results Our analysis included a total of 368 patients. FB ingestions and/or food bolus impactions were noted in 242 and 11 children, respectively while 115 (31.25%) had spontaneously passed off FB from the digestive tract. Most common FB was coin (28.5%) followed by animal bones (26.2%). Endoscopic management of FBs and food bolus impaction was successful in 247 children (97.63%), while endoscopic FB retrieval failed in 6 children including 1 with fish bone and 5 with button batteries. A total of 9 out of 11 children with food bolus impaction had underlying esophageal pathology, the commonest being corrosive stricture ( n = 7). No mortality related to endoscopic intervention was reported. Conclusions Endoscopic retrieval of ingested FBs and food bolus impaction in children is a safe and effective approach when performed by experienced endoscopists and is associated with a high success rate and a lower incidence of complications with reduced hospital stay.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42927624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Jain, Sudesh Sharda, Suchita Jain, A. Singh, Shohini Sircar, Priyanka Bhagat, Tasvir Balar
Abstract Intussusception rarely occurs among adult patients; however, gastroduodenal intussusception is the most infrequent form of intussusception in adults. Almost all these patients present with abdominal pain and vomiting with or without associated gastrointestinal bleed. But none of the patients reported in the literature have presented with gastrointestinal bleed alone. We report a case of gastroduodenal intussusception who presented with melena alone without abdominal pain and vomiting.
{"title":"Gastroduodenal Intussusception Due to Gastric GIST Presenting with Melena","authors":"A. Jain, Sudesh Sharda, Suchita Jain, A. Singh, Shohini Sircar, Priyanka Bhagat, Tasvir Balar","doi":"10.1055/s-0042-1757471","DOIUrl":"https://doi.org/10.1055/s-0042-1757471","url":null,"abstract":"Abstract Intussusception rarely occurs among adult patients; however, gastroduodenal intussusception is the most infrequent form of intussusception in adults. Almost all these patients present with abdominal pain and vomiting with or without associated gastrointestinal bleed. But none of the patients reported in the literature have presented with gastrointestinal bleed alone. We report a case of gastroduodenal intussusception who presented with melena alone without abdominal pain and vomiting.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41672746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Learning endoscopic ultrasound (EUS) can be challenging as the technology combines the disciplines of flexible endoscopy and diagnostic radiology. In the early days of evolution, radiographers performed EUS independently and taught gastroenterologists the basic principles of ultrasound. Lok Tio developed the first learning tool—an atlas of EUS—by correlating EUS images with computed tomography, surgery, and pathology. Robert Hawes is creditedwith developing the “station-based approach” whereby a gastroenterologist learnt how to position the EUS transducer at specific anatomical locations in the gastrointestinal tract and then identify the surrounding organs sonographically. This was the sentinel step that simplified learning and training in EUS. Diagnostic EUS is mostly practiced for staging tumors and performing tissue acquisition. These carry significant implications for patient management and clinical outcomes. To achieve optimal outcomes, it is not sufficient to just know how to do EUS; one needs to be proficient. However, learning a technology is very different from mastering the discipline. Societies such as the ASGE (United States) and FOCUS (Canadian) have developed minimum thresholds to assess competency, and the number of procedures vary from 225 to 250. However, there is significant subjectivity between learners and one rule does not fit all. More importantly, learning EUS has two components: technical and cognitive. In addition to performing the procedure independently, the endoscopist must possess sufficient cognitive skills to formulate the derived information to executable treatment plan. Both components are not mutually exclusive—they are complimentary/mandatory. New training tools such as TEESAT (The EUS and ERCP Skills Assessment Tool) emphasize these principles in EUS learning. In this edition of the journal, Chavan and Rajput have proposed a pictorial essay to make EUS examination of the pancreas easier for the novice endosonographer. They have focused on the most difficult aspect of EUS—pancreatic anatomy—and have simplified it. The authors have expanded on the station-based approach by paying particular attention to technical nuances that can facilitate better interrogation of various parts of the pancreas, surrounding vasculature, and adjacent organs. The imagesandaccompanying videosare thoroughand easy to comprehend. This should enable precise detection and accurate staging of pancreatic diseases. This pictorial essaywill be of significant relevance to novices, particularly those bereft of hands-on training opportunities. The onus is now on apprentices to apply this knowledge clinically and develop the requisite cognitive skills so that theycangainproficiency in the immediate future and attain mastery with time.
{"title":"Endoscopic Ultrasound Made Easy","authors":"S. Varadarajulu","doi":"10.1055/s-0043-1772235","DOIUrl":"https://doi.org/10.1055/s-0043-1772235","url":null,"abstract":"Learning endoscopic ultrasound (EUS) can be challenging as the technology combines the disciplines of flexible endoscopy and diagnostic radiology. In the early days of evolution, radiographers performed EUS independently and taught gastroenterologists the basic principles of ultrasound. Lok Tio developed the first learning tool—an atlas of EUS—by correlating EUS images with computed tomography, surgery, and pathology. Robert Hawes is creditedwith developing the “station-based approach” whereby a gastroenterologist learnt how to position the EUS transducer at specific anatomical locations in the gastrointestinal tract and then identify the surrounding organs sonographically. This was the sentinel step that simplified learning and training in EUS. Diagnostic EUS is mostly practiced for staging tumors and performing tissue acquisition. These carry significant implications for patient management and clinical outcomes. To achieve optimal outcomes, it is not sufficient to just know how to do EUS; one needs to be proficient. However, learning a technology is very different from mastering the discipline. Societies such as the ASGE (United States) and FOCUS (Canadian) have developed minimum thresholds to assess competency, and the number of procedures vary from 225 to 250. However, there is significant subjectivity between learners and one rule does not fit all. More importantly, learning EUS has two components: technical and cognitive. In addition to performing the procedure independently, the endoscopist must possess sufficient cognitive skills to formulate the derived information to executable treatment plan. Both components are not mutually exclusive—they are complimentary/mandatory. New training tools such as TEESAT (The EUS and ERCP Skills Assessment Tool) emphasize these principles in EUS learning. In this edition of the journal, Chavan and Rajput have proposed a pictorial essay to make EUS examination of the pancreas easier for the novice endosonographer. They have focused on the most difficult aspect of EUS—pancreatic anatomy—and have simplified it. The authors have expanded on the station-based approach by paying particular attention to technical nuances that can facilitate better interrogation of various parts of the pancreas, surrounding vasculature, and adjacent organs. The imagesandaccompanying videosare thoroughand easy to comprehend. This should enable precise detection and accurate staging of pancreatic diseases. This pictorial essaywill be of significant relevance to novices, particularly those bereft of hands-on training opportunities. The onus is now on apprentices to apply this knowledge clinically and develop the requisite cognitive skills so that theycangainproficiency in the immediate future and attain mastery with time.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49665565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Endoscopic necrosectomy (EN) in acute necrotizing pancreatitis has mortality benefits and may avert the requirement for surgery. However, bleeding is a common adverse event during EN. There is limited knowledge about the risk factors predicting this adverse event and the measures for its management. In this news and views, we discuss recently published studies that evaluated the risk factors for bleeding during EN.
{"title":"Risk Factors for Bleeding during Endoscopic Necrosectomy: Are We Wiser Now?","authors":"Anurag Sachan, S. Rana","doi":"10.1055/s-0043-1766121","DOIUrl":"https://doi.org/10.1055/s-0043-1766121","url":null,"abstract":"Abstract Endoscopic necrosectomy (EN) in acute necrotizing pancreatitis has mortality benefits and may avert the requirement for surgery. However, bleeding is a common adverse event during EN. There is limited knowledge about the risk factors predicting this adverse event and the measures for its management. In this news and views, we discuss recently published studies that evaluated the risk factors for bleeding during EN.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42166367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Endoscopic ultrasound (EUS) is a widely used imaging modality for both diagnostic and therapeutic purposes. Understanding the anatomy is crucial during a curved linear EUS examination. Compared with other advanced endoscopic techniques, the learning curve for EUS is longer, and the training facilities for EUS are also not widely available. The interest and enthusiasm for EUS among endoscopists is limited by the long learning curve and the scarcity of training programs. Imaging of the pancreas is the most common indication of EUS examination, and many endoscopist often face difficulty in understanding the anatomy and orientation of the pancreas on linear EUS examination. In this article, we will discuss the problems encountered during linear EUS examination and how to overcome each problem with a station-wise pancreas examination.
{"title":"Pictorial Essay of Linear Endoscopic Ultrasound Examination of Pancreas Anatomy","authors":"R. Chavan, S. Rajput","doi":"10.1055/s-0043-1770924","DOIUrl":"https://doi.org/10.1055/s-0043-1770924","url":null,"abstract":"Abstract Endoscopic ultrasound (EUS) is a widely used imaging modality for both diagnostic and therapeutic purposes. Understanding the anatomy is crucial during a curved linear EUS examination. Compared with other advanced endoscopic techniques, the learning curve for EUS is longer, and the training facilities for EUS are also not widely available. The interest and enthusiasm for EUS among endoscopists is limited by the long learning curve and the scarcity of training programs. Imaging of the pancreas is the most common indication of EUS examination, and many endoscopist often face difficulty in understanding the anatomy and orientation of the pancreas on linear EUS examination. In this article, we will discuss the problems encountered during linear EUS examination and how to overcome each problem with a station-wise pancreas examination.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"57981405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Introduction Primary achalasia is an idiopathic motility disorder of the esophagus characterized by esophageal aperistalsis and incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing. The gold standard diagnostic method in adults is high-resolution manometry (HRM). Diagnostic criteria in adults are also used in children, but some HRM normal values may change depending on age. Case Report A 15-month-old girl was admitted to the hospital for evaluation due to persistent vomiting since birth. Vomiting included what she ate regardless of the amount of food she consumed. Barium esophagography revealed barium retention, esophageal dilatation, and a “bird's beak appearance” in the distal esophagus. Esophagogastroduodenoscopy revealed stenosis in the lower esophagus and bubbles at the esophagogastric junction. In HRM, the resting LES pressure was 43.4 mm Hg, there was pan-esophageal pressurization with 60% of swallows and no normal peristalsis. The patient was diagnosed with type II achalasia based on the Chicago 3.0 classification. First, the tube was inserted to ensure adequate nutrition of the patient, and approximately 4 months later, when the patient was 10 kg, the peroral endoscopic myotomy (POEM) procedure was performed. No complications developed during and after the procedure. At the 6th month after treatment, the patient was completely asymptomatic and her weight was within normal limits for her age. Conclusion POEM is an effective and safe method in the treatment of pediatric patients with idiopathic achalasia.
{"title":"Peroral Endoscopic Myotomy (POEM) in a 19-Month-Old Girl with Primary Achalasia","authors":"Serkan Duman, A. Yurçi, J. Cho","doi":"10.1055/s-0043-1769926","DOIUrl":"https://doi.org/10.1055/s-0043-1769926","url":null,"abstract":"Abstract Introduction Primary achalasia is an idiopathic motility disorder of the esophagus characterized by esophageal aperistalsis and incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing. The gold standard diagnostic method in adults is high-resolution manometry (HRM). Diagnostic criteria in adults are also used in children, but some HRM normal values may change depending on age. Case Report A 15-month-old girl was admitted to the hospital for evaluation due to persistent vomiting since birth. Vomiting included what she ate regardless of the amount of food she consumed. Barium esophagography revealed barium retention, esophageal dilatation, and a “bird's beak appearance” in the distal esophagus. Esophagogastroduodenoscopy revealed stenosis in the lower esophagus and bubbles at the esophagogastric junction. In HRM, the resting LES pressure was 43.4 mm Hg, there was pan-esophageal pressurization with 60% of swallows and no normal peristalsis. The patient was diagnosed with type II achalasia based on the Chicago 3.0 classification. First, the tube was inserted to ensure adequate nutrition of the patient, and approximately 4 months later, when the patient was 10 kg, the peroral endoscopic myotomy (POEM) procedure was performed. No complications developed during and after the procedure. At the 6th month after treatment, the patient was completely asymptomatic and her weight was within normal limits for her age. Conclusion POEM is an effective and safe method in the treatment of pediatric patients with idiopathic achalasia.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44259078","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Samanta, P. Udawat, S. Chowdhary, D. Gunjan, P. Rai, V. Bhatia, Vikas Singla, Saurabh S. Mukewar, Nilay Mehta, C. Achanta, A. Dalal, M. Sahu, A. Balekuduru, Abhijith Bale, Jahangir Basha, M. Philip, S. Rana, R. Puri, S. Lakhtakia, V. Dhir
Abstract Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined, and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreatography (ERCP). However, even in expert hands, the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or, more commonly, percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreaticobiliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD, and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, however, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories, making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, Society of Gastrointestinal Endoscopy of India (SGEI) deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.
{"title":"Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part II (Technical Aspects)","authors":"J. Samanta, P. Udawat, S. Chowdhary, D. Gunjan, P. Rai, V. Bhatia, Vikas Singla, Saurabh S. Mukewar, Nilay Mehta, C. Achanta, A. Dalal, M. Sahu, A. Balekuduru, Abhijith Bale, Jahangir Basha, M. Philip, S. Rana, R. Puri, S. Lakhtakia, V. Dhir","doi":"10.1055/s-0043-1768043","DOIUrl":"https://doi.org/10.1055/s-0043-1768043","url":null,"abstract":"Abstract Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined, and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreatography (ERCP). However, even in expert hands, the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or, more commonly, percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreaticobiliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD, and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, however, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories, making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, Society of Gastrointestinal Endoscopy of India (SGEI) deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43334125","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Percutaneous endoscopic gastrostomy (PEG) has become the standard nutrition access with well-established procedural and long-term safety data. Yet, buried bumper syndrome (BBS) remains a major concern and complicates up to 5% of PEGs. Albeit poorly standardized, endoscopicmanagement is possible in most internal disc migrations with variable tractionor dissection-based techniques available. Most advanced BBS stages>Cyrany stage 2 call for incision of hyperplastic tissue overgrowth due to insufficient traction forces for nondissection extraction.1 A 54-year-old institutionalized male patient suffering from cerebral palsy dependent on enteral nutrition presented with suspicion of BBS due to insufficient PEG forward mobility, with tube patency maintained. BBS was confirmed using computed tomography, in addition and compatible with laboratory signs of systemic inflammation, suggesting a small intramural abscess. After institution of broad-spectrum antibiotics, the patient underwent upper endoscopy the following day with the internal disc not visible. Instead, an elevated lesion reminiscent of a submucosal tumor with central putrid discharge emerged (►Fig. 1A). However, given adequate internal drainage, no specific treatment was needed beyond antibiotic treatment. After adequate washing, the abscess cavity could be entered with the scope tip with gentle pressure and the disc was visualized (►Fig. 1B). Next, the external tube length was reduced, and a standard biopsy forceps advanced through the tube (►Fig. 1C). A polypectomy snare was advanced through the endoscope, opened and grasped by the forceps (►Fig. 1D). An estimated 3-cm piece, the fashioned T-piece, was cut from the tube and externally grasped by the snare (compare ►Fig. 1E). Beforehand, a nylon thread from a commercially available PEG tube set was tied to the tube and pulled into the stomach along with the tube system withdrawn into the stomach. Alternatively, the nylon thread might have been placed through the indwelling PEG tube beforehand. After repeat endoscopy of the intramural cavity, a new PEG was inserted in the pull technique (►Fig. 1F; ►Video 1). Concerning chances of migration of the newly placed PEG tube as it has been placed in the same area, in fact, there are no specific data available for this critical issue. However, in the author’s opinion, migration and/or BBS are rather a question of proper PEG care by well-trained nurses rather than a question of endoscopy technique and/or tactics.
{"title":"T-piece Traction Removal for Buried Bumper Syndrome","authors":"V. Zimmer","doi":"10.1055/s-0043-1768044","DOIUrl":"https://doi.org/10.1055/s-0043-1768044","url":null,"abstract":"Percutaneous endoscopic gastrostomy (PEG) has become the standard nutrition access with well-established procedural and long-term safety data. Yet, buried bumper syndrome (BBS) remains a major concern and complicates up to 5% of PEGs. Albeit poorly standardized, endoscopicmanagement is possible in most internal disc migrations with variable tractionor dissection-based techniques available. Most advanced BBS stages>Cyrany stage 2 call for incision of hyperplastic tissue overgrowth due to insufficient traction forces for nondissection extraction.1 A 54-year-old institutionalized male patient suffering from cerebral palsy dependent on enteral nutrition presented with suspicion of BBS due to insufficient PEG forward mobility, with tube patency maintained. BBS was confirmed using computed tomography, in addition and compatible with laboratory signs of systemic inflammation, suggesting a small intramural abscess. After institution of broad-spectrum antibiotics, the patient underwent upper endoscopy the following day with the internal disc not visible. Instead, an elevated lesion reminiscent of a submucosal tumor with central putrid discharge emerged (►Fig. 1A). However, given adequate internal drainage, no specific treatment was needed beyond antibiotic treatment. After adequate washing, the abscess cavity could be entered with the scope tip with gentle pressure and the disc was visualized (►Fig. 1B). Next, the external tube length was reduced, and a standard biopsy forceps advanced through the tube (►Fig. 1C). A polypectomy snare was advanced through the endoscope, opened and grasped by the forceps (►Fig. 1D). An estimated 3-cm piece, the fashioned T-piece, was cut from the tube and externally grasped by the snare (compare ►Fig. 1E). Beforehand, a nylon thread from a commercially available PEG tube set was tied to the tube and pulled into the stomach along with the tube system withdrawn into the stomach. Alternatively, the nylon thread might have been placed through the indwelling PEG tube beforehand. After repeat endoscopy of the intramural cavity, a new PEG was inserted in the pull technique (►Fig. 1F; ►Video 1). Concerning chances of migration of the newly placed PEG tube as it has been placed in the same area, in fact, there are no specific data available for this critical issue. However, in the author’s opinion, migration and/or BBS are rather a question of proper PEG care by well-trained nurses rather than a question of endoscopy technique and/or tactics.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42382285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
P. Rai, P. Udawat, S. Chowdhary, D. Gunjan, J. Samanta, V. Bhatia, Vikas Singla, Saurabh S. Mukewar, Nilay Mehta, C. Achanta, A. Dalal, M. Sahu, A. Balekuduru, Abhijith Bale, Jahangir Basha, M. Philip, S. Rana, R. Puri, S. Lakhtakia, V. Dhir
Abstract Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.
{"title":"Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part I (Indications, Outcomes, Comparative Evaluations, Training)","authors":"P. Rai, P. Udawat, S. Chowdhary, D. Gunjan, J. Samanta, V. Bhatia, Vikas Singla, Saurabh S. Mukewar, Nilay Mehta, C. Achanta, A. Dalal, M. Sahu, A. Balekuduru, Abhijith Bale, Jahangir Basha, M. Philip, S. Rana, R. Puri, S. Lakhtakia, V. Dhir","doi":"10.1055/s-0043-1761591","DOIUrl":"https://doi.org/10.1055/s-0043-1761591","url":null,"abstract":"Abstract Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49171267","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mayur G. Gattani, S. Mukewar, A. Kulkarni, Bhushan Bhaware, Saurabh S. Mukewar
Abstract Endoscopic interventions have become increasingly popular in the management of obstructive jaundice. In this case study, we present a case of complex Bismuth type 4 hilar stricture in an elderly lady presenting with obstructive jaundice. Complete endoscopic biliary drainage was accomplished successfully by placement of three metal stents – two with ERCP and one with Endoscopic Ultrasound (EUS) guided hepatico-gastrostomy. She developed cholecystitis later, which was successfully addressed by EUS guided gallbladder drainage using a cautery enhanced lumen apposing metal stent. Thus, a complete internal biliary drainage was achieved with endoscopic interventions.
{"title":"Endoscopic Management of a Complex Biliary Problem","authors":"Mayur G. Gattani, S. Mukewar, A. Kulkarni, Bhushan Bhaware, Saurabh S. Mukewar","doi":"10.1055/s-0043-1762575","DOIUrl":"https://doi.org/10.1055/s-0043-1762575","url":null,"abstract":"Abstract Endoscopic interventions have become increasingly popular in the management of obstructive jaundice. In this case study, we present a case of complex Bismuth type 4 hilar stricture in an elderly lady presenting with obstructive jaundice. Complete endoscopic biliary drainage was accomplished successfully by placement of three metal stents – two with ERCP and one with Endoscopic Ultrasound (EUS) guided hepatico-gastrostomy. She developed cholecystitis later, which was successfully addressed by EUS guided gallbladder drainage using a cautery enhanced lumen apposing metal stent. Thus, a complete internal biliary drainage was achieved with endoscopic interventions.","PeriodicalId":43098,"journal":{"name":"Journal of Digestive Endoscopy","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48660417","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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