Alvaro Martínez-Alcalá

Emerging Endoscopic Treatments for Nonvariceal Upper Gastrointestinal Hemorrhage

Despite major improvements in endoscopic devices and therapeutic endoscopy, rebleeding rates and mortality have remained the same for several decades. Therefore, much interest has been paid to emerging therapeutic devices, such as the over-the-scope clip and hemostatic sprays. Other emerging technologies, such as radiofrequency ablation, endoscopic suturing devices, and ultrasound-guided angiotherapy, are also being investigated to improve therapeutic outcomes in specific situations. This narrative review details the technical aspects, clinical applications, outcomes, and potential limitations of these devices in the context of nonvariceal upper gastrointestinal hemorrhage.

ENDOSCOPIC FULL-THICKNESS RESECTION FOR DIAGNOSIS OF HIRSCHSPRUNG'S DISEASE

Endoscopic full-thickness resection (EFTR) is beneficial for treating a variety of conditions of the lower gastrointestinal tract such as early cancers, polyps, and fistulas [1, 2]. Whereas the role of EFTR in the therapy for these conditions has been proven to be effective and safe, there is a paucity of data about its potential utility as a diagnostic intervention in patients with gastrointestinal tract dysmotility disorders [3] In this report, we present a 19-year-old woman with chronic constipation since childhood, which remained severe, despite the use of multiples laxatives, along with dietary and lifestyle changes. Apart from the severe, recalcitrant constipation, the patient had no significant past medical history. The family history, however, was positive for achalasia in her mother. The patient underwent several diagnostic interventions. A colonoscopy was unrevealing, except for massive dilatation of the sigmoid and descending colon and stool retention despite aggressive bowel prep and intraprocedural bowel cleansing. Histology obtained using the biopsy-on-biopsy technique was unrevealing. Both anorectal manometry and barium enema were suggestive of Hirschsprung’s disease. To obtain a definitive diagnosis, a full-thickness tissue sample was required. Traditionally, surgery is mandatory to obtain such tissue. However, the advent of the EFTR device (Ovesco, Tübingen, Germany) allows for the retrieval of the entire wall of the gastrointestinal tract. The patient decided to E-Videos

Oxidized cellulose as hemostatic agent to prevent bleeding after high-risk endoscopic resection of rectal laterally spreading tumor overlying hemorrhoids

A 58-year-old man with a history of a hypertension, coronary heart disease, and diabetes mellitus type II was referred for evaluation of a rectal tumor. The patient had undergone coronary artery stenting and was taking dual antiplatelet therapy. On colonoscopy he was found to have a laterally spreading tumor, granular type. The polypoid lesion extended from the anal verge, continued on top of internal hemorrhoids, and extended proximally 5 cm into the rectum, covering about two-thirds of the rectal circumference. The patient preferred endoscopic resection to a transrectal surgery procedure. The endoscopic resection was carried out using a gastroscope and with an endoscopic submucosal dissection– endoscopic mucosal resection (ESD– EMR) hybrid technique. Post-resection inspection revealed a complete resection (endoscopic R0), several small vessels, and exposed haemorrhoids (▶Fig. 1). Prophylactic hemostasis was then achieved by applying oxidized regenerated cellulose. The oxidized cellulose was cut into 20×20mm pieces, grasped with a clip, which had been previously advanced through the scope and then pushed through an overtube onto the resection site. The cellulose was attached through clipping proximally (▶Video1). The patient had an uneventful recovery without any rectal bleeding. Oxidized cellulose can be considered to be a “topical” hemostatic agent, similar to Hemospray (Cook Medical, WinstonSalem, North Carolina, USA) [1]. The mechanism of action of cellulose is still unclear, but data show that it activates platelets and provides mechanical hemostasis by dehydrating or through “sponge-like’ mechanisms [2, 3]. Indeed, oxidized cellulose is generally used in heavy bleeding, including in liver surgery, because of its high absorptive capacity due to its dense fibrous composition. Oxidized cellulose can absorb up to seven times its physiological weight, and has E-Videos

Overtube-assisted EUS with FNA for esophageal stenosis

An 82-year-old woman presented to the hospital because of 3 weeks of abdominal pain, weight loss, and early satiety. CT imaging demonstrated a 3-cm pancreatic body mass. The patient was scheduled for EUS with general anesthesia. As practice for the endoscopist, an EGD was performed before the EUS (Video 1, available online at www.VideoGIE.org). This revealed a challenging esophageal intubation at the oropharynx, secondary to the body shape without any pathologic

Insertion of fully covered self-expandable metal stent during balloon-assisted ERCP in patient with surgically altered upper gastrointestinal anatomy

The presence of complex, surgically altered gastrointestinal (GI) anatomy poses a diagnostic and therapeutic challenge to the endoscopist treating patients with pancreaticobiliary disorders. Placing fully covered metal stents into the bile duct during endoscopic retrograde cholangiopancreatography (ERCP) through standard forward-viewing scopes, such as doubleand single-balloon enteroscopes and colonoscopes, is impossible as the working channel is too small, even with the new-generation short double-balloon enteroscopes [1, 2]. Herein, we present a novel technique to insert fully covered metal stents into the bile duct using balloon-assisted ERCP, whereby the overtube is used as a giant working channel. A 43-year male patient who had undergone Whipple operation with Roux-en-Y hepaticojejunostomy for a “pancreatic cyst” (or choledochal cyst) at age 3 years presented with choledocholithiasis and cholangitis. The magnetic resonance cholangiopancreatography showed a tight hepaticojejunostomy stricture and dilated bile ducts full of stones. ERCP failed at two different medical centers using traditional methods. We performed a double-balloon enteroscopy-assisted ERCP (▶Video1). The hepaticojejunostomy was very narrow. A long (650 cm) guidewire (Metro; Cook Medical, Bloomington, Indiana, USA) was advanced through the narrow opening of the hepatico-jejunal anastomosis. A catheter was advanced over the long wire. Cholangiography revealed a tight and short anastomotic stricture (▶Fig. 1, ▶Video1). The hepaticojejunostomy was dilated with a 6mm through-thescope balloon (Hercules; Cook Medical) (▶Fig. 1, ▶Video1). The guidewire was inserted deep into into the bile duct system and the enteroscope was withdrawn, leaving the overtube in place as a working channel. As the fully covered self-expandable metal stent (fcSEMS) delivery system is shorter than the length of the overtube, the overtube was incised on the side just before the mouthpiece, and the delivery system was inserted under fluoroscopic guidance (▶Video1). The wire was tightly grasped with a hemostat forceps. An fcSEMS 10×40mm (Evolution biliary SEMS; Cook Medical) was deployed, resulting in excellent bile duct drainage. A gastroscope was then inserted through the overtube to inspect the fully deployed stent and to remove stones during direct cholangioscopy. Multiple stones were extracted. Because there were several large stones inside the massively dilated bile duct, small plastic stents were inserted through the fcSEMS to guarantee bile flow. Cholangitis and cholestasis resolved, and the patient was discharged home 2 days later. To the best of our knowledge, this is the first video report on successful insertion of fully covered metal stents during balloon-assisted ERCP. Our case also highlights a case of “extreme endoscopy,” where multiple endoscopes, accessories, and instruments are used to solve a complex pancreaticobiliary problem. Not only did balloon-assisted ERCP reach the bile ducts, but the balloon-assisted enteroscopy overtube worked as a giant working channel, allowing the operator to adE-Videos

Safe technique for direct percutaneous endoscopic jejunostomy tube placement using single-balloon enteroscopy with fluoroscopy

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method for the delivery of nutrition in patients with a variety of gastrointestinal (GI) problems [1–3]. However, DPEJ using standard colonoscopes or the push technique remains a technically challenging procedure, with success rates of about 68% in expert hands [2]. Herein, we present the key steps to conducting a successful DPEJ using a single-balloon enteroscopy technique. A 62-year-old woman presented with severe necrotizing pancreatitis mandating intensive care therapy. The pancreas necrosis progressed into a huge collection, resulting in partial gastric outlet obstruction (▶Fig. 1 a). Despite endoscopic drainage, the patient remained nauseated and was unable to tolerate oral feeding. We were consulted to place a direct percutaneous jejunostomy (PEG) tube. The patient was placed in the supine position, and the therapeutic double-balloon enteroscope was used in single-balloon mode (i. e. no balloon was attached to the tip of the scope) (▶Video1). The scope and overtube were then advanced to about 80 cm distal to the pylorus. A jejunal loop was then carefully located using both endoscopic and fluoroscopic guidance (▶Video1). PEG tube placement was performed using the Ponsky method (pull-type technique using a 20 Fr PEG-kit; Cook Medical, Bloomington, Indiana, USA) (▶Video1). Once the string had been endoscopically grasped by the snare, the scope and string were pulled back out through the overtube (▶Fig. 1b, c, ▶Video1). A key element of the technique is the overtube, which is left in situ. The string was attached to the PEG tube and, as the string was pulled back out through the skin incision, the PEG tube was pulled through (i. e. inside) the overtube (▶Video1). The scope was advanced into the overtube and was used to help push the PEG button, and subsequently to inspect the jejunum for correctness of PEG tube placement (▶Fig. 1d, ▶Video1). An enteral diet was started 12 hours later. This new method of PEG tube placement focuses on three key components: 1) use of a balloon-assisted overtube, which provides endoscopic stabilization during the procedure; 2) use of fluoroscopy, leading to increased success of finding an adequate jejunal loop for puncture; 3) leaving the overtube in place during the entire procedure (and also for PEG tube removal), which decreases the risk of GI luminal damage during pulling of the PEG tube and during scope manipulation, as the overtube “shields” the inside of the GI tract. The combination of all these aspects may increase the safety and success of this technique.

A novel mechanical simulator for hands-on bariatric endoscopy training in intragastric balloon placement

Bariatric endoscopy is a novel and expanding field in gastrointestinal (GI) endoscopy [1]. The most common bariatric endoscopy procedure is intragastric balloon (IGB) placement [2]. Currently most training occurs with a proctor and a patient. Of course, this approach has potential ethical disadvantages [3], and obtaining the skills for IGB placement using an ex vivo hands-on model would be an ideal solution [4]. We developed a novel mechanical simulator for endoscopic hands-on training with the IGB procedure (LELLA model; EndoWorks LLC, Florida, USA). The model consists of a transparent polycarbonate resin phantom with a fully accessible upper GI tract (▶Fig. 1; ▶Video1). The IGB placement is carried out step by step with endoscopic, as well as external, visual control, which allows an extended comprehensive view of the physics applied in IGB placement and retrieval (▶Video1). The esophagus was developed from a plastic conduit of 3 cm in diameter. It connects proximally to a standard mouthpiece and distally to a red rubber ring, which simulates the gastroesophageal junction and cardia region, an important anatomical landmark for the IGB procedure. The stomachmodel is a round acrylic based chamber of 20 cm in diameter and supports all Food and Drug Administration (FDA)-approved single IGBs. For the purpose of this video, we used the Spatz 3 Adjustable Balloon System (Spatz FGIA, Inc., New York, USA) (▶Fig. 2). The IGB was filled with 600mL of purple isotonic drink (Gatorade) allowing several reuses of the device and thereby reducing the costs associated with training (▶Fig. 2). IGB systems that require drilling are an exception as they are ruptured after one use. In addition, the use of isotonic drinks avoids staining the prototype, which can be an issue when using a saline and methylene blue solution. Balloon emptying is carried out after retrieving the retractile drainage catheter with a rat-tooth forceps and aspirating the fluid using a negative pressure aspiration system (▶Fig. 2; ▶Video1). After endoscopically confirming complete shrinkage of the IGB, the decompressed balloon is withdrawn through the esophagus and mouthpiece. E-Videos