Alberto Murino

Small bowel obstruction caused by a migrated Obalon gastric bariatric balloon: nonsurgical management by antegrade double-balloon panenteroscopy

A 46-year-old woman presented with small-bowel obstruction (SBO) 2 months after placement of two Obalon gastric balloons (Obalon Therapeutics, California, USA) for weight loss [1]. A computed tomography (CT) scan confirmed SBO caused by a partially deflated balloon that had migrated into the ileum; the other balloon remained inflated and in situ within the stomach (● Fig.1 and ● Fig.2). After 72 hours of conservative management, a sudden worsening of her symptoms warranted intervention. For avoidance of surgery, we performed an antegrade double-balloon enteroscopy (DBE) with the patient under general anesthesia. The first (intragastric) balloon was deflated and extracted to enable friction-free DBE. The enteroscope was then inserted down to the distal ileum to an estimated depth of 6.4m from the pylorus, where the second partially deflated retained balloon was identified approximately 20cm proximal to the ileocecal valve (ICV). The retained balloon was then completely deflated by aspirating through an endoscopic injection needle before the balloon was carefully pushed through the ICV into the ascending colon with endoscopic graspers (● Fig.3). No strictures were encountered during the uncomplicated panenteroscopy. The patient’s symptoms of obstruction resolved completely and the balloon was passed in the stools 2 days later (● Fig.4). Migration of partially deflated gastric balloons into the small bowel is a recognized but uncommon complication that may warrant surgical intervention [2]. Although DBE has been shown to be useful for retrieval of foreign objects retained within the small bowel [3,4], to the best of our knowledge, this is only the second reported case of management of gastric balloon-related SBO by DBE [5]. Ours is the first report of this being achieved through antegrade panenteroscopy with endoscopic deflation of the impacted balloon and advancement of this through the ICV into the ascending colon. The antegrade route was the only DBE approach possible in this patient with SBO and an unprepared colon. Our case highlights the usefulness of DBE for the potential avoidance of surgery in such cases.

Effectiveness of Endoscopic Ultrasonography during Double Balloon Enteroscopy for characterization and management of small bowel submucosal tumours.

BACKGROUNDnCharacterization of small bowel submucosal tumours is challenging, requiring additional investigations. Endoscopic Ultrasonography performed during Double Balloon Enteroscopy, appeared a promising technique although it has not been fully evaluated. The aim was to determine the effectiveness of this technique for characterization and management of sub mucosal tumours in a large cohort of patients.nnnMETHODSnPatients with suspected small bowel tumours, who underwent Endoscopic Ultrasonography performed during Double Balloon Enteroscopy in our Institution between 2005 and 2013, were reviewed. Demographic data, clinical, endoscopic and radiological findings, therapeutic management, final diagnosis and follow-up were analyzed.nnnRESULTSn30 patients (19 male; median age 61.5) affected by submucosal tumours were included in the study. Endoscopic Ultrasonography performed during Double Balloon Enteroscopy was successfully performed in all cases providing a correct characterization of 19 submucosal tumours (63%). Based on the ultrasonographic characteristics 8 patients were treated endoscopically, 16 were referred to surgery, and 6 were managed conservatively.nnnCONCLUSIONnOur results suggest that Endoscopic Ultrasonography performed during Double Balloon Enteroscopy is a safe and useful technique for submucosal tumours characterization. This procedure may be applied in clinical practice when small bowel tumours are encountered, to confirm the diagnosis and provide the most appropriate management.

Management of a rare cause of significant acute upper gastrointestinal bleeding: gastric lipoma resected by hybrid endoscopic submucosal dissection

Gastric lipomas are rare, benign, slowgrowing subepithelial tumors. Most lipomas remain asymptomatic and are detected incidentally at endoscopy. Large lipomas, however, may very rarely cause significant upper gastrointestinal (GI) bleeding and warrant removal [1]. For the management of large gastric lipomas, laparoscopic excision may be required, but endoscopic techniques such as endoscopic submucosal dissection (ESD) and unroofing have also been described [1, 2]. This endoscopic video case highlights this rare cause of upper GI bleeding and its definitive management by hybrid ESD. A 66-year-old man presented with melena, pallor, and fatigue. On admission, his hemoglobin level was 89g/L. He underwent an upper GI endoscopy during which a 3 cm ulcerated submucosal lesion was identified at the greater curvature (▶Fig. 1). An endoscopic clip and Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) were applied, and hemostasis was achieved. Computed tomography imaging revealed an ovoid (fat-dense) lesion measuring 25×15mm, consistent with a lipoma (▶Fig. 2). Endoscopic ultrasound assessment of the lesion was subsequently performed, and showed the presence of a homogeneous and slightly hyperechoic lesion, 25×15mm, arising from the hyperechoic submucosal layer. A 22g needle was used to obtain core biopsies but unfortunately the sample was inadequate for diagnostic assessment. Endoscopic management of the lesion was agreed and the lesion was success-

A rare cause of small-bowel bleeding: haemorrhagic small-bowel lymphangioma diagnosed by antegrade double-balloon enteroscopy

Small-bowel lymphangiomata (SBLs) are benign and relatively uncommon tumors of the lymphatic system [1]. Although SBLs are usually clinically silent, they may rarely present with significant small-bowel bleeding, protein-losing enteropathy, and intussusception [2, 3]. A 54-year-old-man with a past medical history of stable chronic lymphocytic leukemia presented with transfusion-dependent obscure-overt gastrointestinal (GI) bleeding. Upper and lower GI endoscopies and small-bowel cross-sectional imagining were unremarkable. A smallbowel video capsule endoscopy (VCE) showed a white-speckled congested lesion, with active oozing (▶Fig. 1). The lesion was estimated to be about 2 cm in diameter and was deemed to be located within the jejunum. Antegrade double-balloon enteroscopy (DBE) was subsequently performed. The enteroscope was advanced to an estimated insertion depth of 240 cm post-pylorus, where the lesion seen at VCE was identified (▶Fig. 2, ▶Video1). This had a white–yellow appearance with overlying severely congested villi giving a “strawberry-like” mucosal pattern. The lesion was not deemed to be endoscopically resectable; multiple biopsies were taken and a reference tattoo was placed proximal to it. Histopathological exam confirmed a lymphangiomatous etiology without any evidence of dysplasia or malignancy (▶Fig. 3). Minimally invasive tattooguided laparoscopic resection has been planned. This case highlights the key, complementary role of small-bowel VCE and DBE for the diagnosis and minimally invasive management of clinically significant SBLs.

Small bowel endoluminal imaging (capsule and enteroscopy)

Over the last 16u2005years, the disruptive technologies of small bowel capsule endoscopy and device-assisted enteroscopy have revolutionised endoluminal imaging and minimally invasive therapy of the small bowel. Further technological developments continue to expand their indications and use. This brief review highlights the state-of-the-art in this arena and aims to summarise the current and potential future role of these technologies in clinical practice.

Specific characteristics of hemorrhagic Meckel’s diverticulum at double-balloon endoscopy

Background and study aimsu2003Diagnosis of Meckel’s diverticulum (MD) before surgery may be challenging; double-balloon endoscopy (DBE) facilitates identification of MD in the setting of a gastrointestinal bleeding; however, MD can be found incidentally without this condition. The purpose of this research was to determine specific characteristic of hemorrhagic MD and incidental MD at DBE. Patients and methodsu2003Ectopic gastric mucosa enclosed in the MD and/or ulceration were defined as “major findings”; ring-like scar surrounding the MD was defined as “minor finding”. We retrospectively reviewed the medical records of patients affected by MD and analyzed the findings that significantly affected the characterization of MD. Resultsu2003MD was diagnosed in 33 patients. The axis of the diverticulum was longer in hemorrhagic MD compared to incidental MD (Pu200a=u200a0.031). The amount of transfusion was significantly higher (Pu200a=u200a0.018) in the hemorrhagic MD group.u200aHemorrhagic MD was significantly more correlated with major findings (Pu200a=u200a0.01) and minor findings (Pu200a<u200a0.01). The specificity of major finding was 100u200a% while the sensitivity of major and/or minor findings was 96u200a%. Conclusionsu2003The combination of major and minor findings appears to improve the diagnostic ability of hemorrhagic MD avoiding unnecessary diverticulectomy.

The role of salvage ERCP for the treatment of post-ERCP pancreatitis.

We read with great interest the article by Kerdsirichairat et al. titled “Urgent ERCP with pancreatic stent placement or replacement for salvageofpost-ERCPpancreatitis” [1]. The authors reported their experience of performing an urgent endoscopic retrograde cholangiopancreatography (ERCP) to place a pancreatic stent in patients who developed post-ERCP pancreatitis (PEP). PEP was defined by abdominal pain (using the revised Atlanta criteria), serum amylase level at least three times greater than the upper limit of normal, andmore than one night of hospitalization (the so-called “Cotton criteria” [2]). Salvage ERCP was attempted 2 hours or more after clinical onset of pain. Comparedwith before salvage ERCP, themedianpain score (P<0.001), andmedian amylase (P=0.003) and lipase (P=0.001) levels significantly improved 24 hours after the procedure. In addition, systemic inflammatory response syndrome (SIRS) resolved in 24 hours (P< 0.001). However, possible bias and methodological shortcomings limit the validity of the study and the conclusion. Although not clearly stated in the text, we believe that this study was a retrospective analysis of a prospectively collected database. In addition, out of 3216 patients, 64 (2%) developed PEP, but 7 of them were excluded because of incomplete information. Only 14 (25%) of the remaining 57 patients were treated with salvage ERCP, and no information regarding the other 43 patients (75%) included in the study were given, representing a potential bias. Unexpectedly, the authors did not introduce any comparison group, focusing the analysis instead on internal data (i.e. improvement of PEP after salvage ERCP). We would be interested to know the following: What were the main characteristics of the 14 included patients compared with the remaining 43 patients? Why were these 43 patients not considered for salvage ERCP? What were the selection criteria? Would it be possible for the authors to state whether the outcome of the 14 patients was significantly different from that of the remaining 43 patients who did not undergo salvage ERCP? This information is essential in order to understand whether, and towhat extent, the information acquired on the 14 cases can be generalized to the remaining patients. Most interestingly, the diagnosis of PEP was established according to Cotton consensus criteria (i. e. amylase at least three times the normal level at more than 24 hours after the procedure and requiring admission or prolongation of planned admission to 2–3 days) [2]. However, the median onset of PEP was 5 hours after ERCP in patients with a prophylactic pancreatic stent and 2 hours after ERCP in patients without a prophylactic pancreatic stent. According to these data, the onset of PEP did not meet the Cotton criteria for the diagnosis of PEP in almost all of the included cases. Furthermore, the salvage ERCP was performed at a median of 10 hours after the clinical onset of PEP. In other words, most of the patients underwent a so-called “salvage” ERCP before a Letters to the editor 468