Andrew C. Storm

Similar Efficacies of Endoscopic Ultrasound Gallbladder Drainage With a Lumen-Apposing Metal Stent Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis

Background & Aims Acute cholecystitis in patients who are not candidates for surgery is often managed with percutaneous transhepatic gallbladder drainage (PT‐GBD). Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) with a lumen‐apposing metal stent (LAMS) is an effective alternative to PT‐GBD. We compared the technical success of EUS‐GBD versus PT‐GBD, and patient outcomes, numbers of adverse events (AEs), length of hospital stay, pain scores, and repeat interventions. Methods We performed a retrospective study to compare EUS‐GBD versus PT‐GBD at 7 centers (5 in the United States, 1 in Europe, and 1 in Asia), from 2013 through 2015, in management of acute cholecystitis in patients who are not candidates for surgery. A total of 90 patients (56 men) with acute cholecystitis (61 calculous, 29 acalculous) underwent EUS‐GBD (n = 45) or PT‐GBD (n = 45). Data were collected on technical success, clinical success (resolution of symptoms or laboratory and/or radiologic abnormalities within 3 days of intervention), and need for repeat intervention. Characteristics were compared using Student t tests for continuous variables and the chi‐square test, or the Fisher exact test, when appropriate, for categorical variables. Adverse events were graded according to American Society for Gastrointestinal Endoscopy definitions and compared using the Fisher exact test. Postprocedure pain scores were compared using the Mann‐Whitney U test. Results Baseline characteristics, type, and clinical severity of cholecystitis were comparable between groups. In the EUS‐GBD group, noncautery LAMS were used in 30 patients and cautery‐enhanced LAMS were used in 15. Technical success was achieved for 98% of patients in the EUS‐GBD and 100% of the patients in the PT‐GBD group (P = .88). Clinical success was achieved by 96% of patients in the EUS‐GBD group and 91% in the PT‐GBD group (P = .20). There was a nonsignificant trend toward fewer AEs in the EUS‐GBD group (5 patients; 11%) than in the PT‐GBD group (14 patients; 32%) (P = .065). There were no significant differences in the severity of the AEs: mild, 2 in the EUS‐GBD group versus 5 in the PT‐GBD group (P = .27); moderate, 4 versus 3 (P = .98); severe, 1 versus 3 (P = .62); or deaths, 1 versus 3 (P = .61). The mean postprocedure pain score was lower in the EUS‐GBD group than in the PT‐GBD group (2.5 vs 6.5; P < .05). The EUS‐GBD group had a shorter average length of stay in the hospital (3 days) than the PT‐GBD group (9 days) (P < .05) and fewer repeat interventions (11 vs 112) (P < .05). The average number of repeat interventions per patients was 0.2 ± 0.4 EUS‐GBD group versus 2.5 ± 2.8 in the PT‐GBD group (P < .05). Median follow‐up after drainage was comparable in EUS‐GBD group (215 days; range, 1–621 days) versus the PT‐GBD group (265 days; range, 1–1638 days). Conclusions EUS‐GBD has similar technical and clinical success compared with PT‐GBD and should be considered an alternative for patients who are not candidates for surgery. Patients who undergo EUS‐GBD seem to have shorter hospital stays, lower pain scores, and fewer repeated interventions, with a trend toward fewer AEs. A prospective, comparative study is needed to confirm these results.

Deep enteroscopy with standard endoscopes using a novel through-the-scope balloon

BACKGROUND AND STUDY AIMS A new on-demand enteroscopy (ODE) device has been designed to allow deep enteroscopy using a standard adult colonoscope with the aid of a novel through-the-scope balloon. The aims of the current study were to establish the feasibility, efficacy, and safety of ODE in performing anterograde and retrograde enteroscopy. PATIENTS AND METHODS A retrospective, single-center study of 28 consecutive deep ODE procedures (11 anterograde and 17 retrograde) was performed. Diagnostic yield, therapeutic yield, technical success, procedure time, depth of maximal insertion (DMI), time to DMI, and adverse events were recorded. RESULTS The mean diagnostic and therapeutic yields were 45 % and 36 % for anterograde enteroscopy and 59 % and 47 % for retrograde enteroscopy, respectively. Technical success was achieved in 100 %. For anterograde enteroscopy, the mean total procedure time was 24 minutes, with a mean DMI of 1.2 m. For retrograde enteroscopy, the mean total procedure time was 31 minutes, with a mean DMI of 1.1 m. No adverse events were recorded. CONCLUSION Deep enteroscopy using a novel through-the-scope balloon and standard endoscope appeared to be feasible and safe, with rapid procedures times.

Efficient retrograde enteroscopy using a novel through-the-scope balloon

Deep enteroscopy can be achieved via double balloon, single balloon, and spiral enteroscopy [1]. Drawbacks of these systems include the need for a dedicated enteroscope, and consequently, specialized accessories [2]. In addition, a special skill set is required [3]. A new through-the-scope balloon catheter (NaviAid AB, SMART Medical Systems Ltd., Ra’anana, Israel) allows enteroscopy with a standard adult colonoscope. This device permits advancement deep into the small bowel in either an anterograde or retrograde approach. It consists of a single-use balloon catheter which is inserted through the working channel of the colonoscope (Fig. 1). The catheter is advanced ahead of the endoscope, including safely around corners, into the small bowel in a blind fashion. Once ahead of the endoscope, the balloon is inflated, anchors onto the small bowel and acts as a rail on which the endoscope is advanced. The device may be removed from the endoscope’s working channel during procedure to allow biopsy and therapy, and can be again re-inserted to facilitate further advancement. A 72-year-old female presented with a 6-month-history of abdominal pain, iron deficiency anemia, and imaging evidence of mural thickening of the mid to distal ileum. Through-the-scope balloon catheter-assisted retrograde enteroscopy was performed as the initial endoscopic investigation (Video 1 in supplementary material). The balloon catheter was deployed immediately after the endoscope intubated the terminal ileum. The endoscope was inserted 1 m beyond the ileocecal valve and the time taken to reach the inflamed area from the anus was only 18 min. Further advancement was limited by an

Closure of a chronic tracheoesophageal fistula by use of a cardiac septal occluder

In adults, an acquired tracheoesophageal fistula (TEF) is most commonly the result of cuff-induced tissue necrosis from prolonged mechanical ventilation. These patients are often poor surgical candidates, and hence a minimally invasive technique for closure may offer significant benefits. In this video, we demonstrate the use of a cardiac septal occluder (Amplatzer; St Jude Medical, Plymouth, Minn,) to close a TEF. This device is a self-expandable double umbrella-shaped polyester covered nitinol wire mesh. A 72-year-old woman was seen for management of a chronic, iatrogenic TEF as a result of tracheal stenting to manage a tracheal stricture as a consequence of prolonged intubation. A combined bronchoscopic, esophagoscopic, and fluoroscopic approach was used. The fistula was located 2 cm below the upper esophageal sphincter and measured 10 mm. The cardiac septal occluder was deployed across the fistula during a procedure time of 10 minutes (Fig. 1; Video 1, available online at www.giejournal.org). The patient was discharged home the same day, and a swallow test with contrast medium at 6 weeks revealed no active fistula. The patient recommenced a normal diet and remains well without episodes of aspiration pneumonia.

Safety of direct endoscopic necrosectomy in patients with gastric varices.

AIM To determine the feasibility and safety of transgastric direct endoscopic necrosectomy (DEN) in patients with walled-off necrosis (WON) and gastric varices. METHODS A single center retrospective study of consecutive DEN for WON was performed from 2012 to 2015. All DEN cases with gastric fundal varices noted on endoscopy, computed tomography (CT) or magnetic resonance imaging (MRI) during the admission for DEN were collected for analysis. In all cases, external urethral sphincter (EUS) with doppler was used to exclude the presence of intervening gastric varices or other vascular structures prior to 19 gauge fine-needle aspiration (FNA) needle access into the cavity. The tract was serially dilated to 20 mm and was entered with an endoscope for DEN. Pigtail stents were placed to facilitate drainage of the cavity. Procedure details were recorded. Comprehensive chart review was performed to evaluate for complications and WON recurrence. RESULTS Fifteen patients who underwent DEN for WON had gastric varices at the time of their procedure. All patients had an INR < 1.5 and platelets > 50. Of these patients, 11 had splenic vein thrombosis and 2 had portal vein thrombosis. Two patients had isolated gastric varices, type 1 and the remaining 13 had > 5 mm gastric submucosal varices on imaging by CT, MRI or EUS. No procedures were terminated without completing the DEN for any reason. One patient had self-limited intraprocedural bleeding related to balloon dilation of the tract. Two patients experienced delayed bleeding at 2 and 5 d post-op respectively. One required no therapy or intervention and the other received 1 unit transfusion and had an EGD which revealed no active bleeding. Resolution rate of WON was 100% (after up to 2 additional DEN in one patient) and no patients required interventional radiology or surgical interventions. CONCLUSION In patients with WON and gastric varices, DEN using EUS and doppler guidance may be performed safely. Successful resolution of WON does not appear to be compromised by the presence of gastric varices, with similar rates of resolution and only minor bleeding events. Experienced centers should not consider gastric varices a contraindication to DEN.

Novel intragastric trocar placed by PEG technique permits endolumenal use of rigid instruments to simplify complex endoscopic procedures.

BACKGROUND AND AIMS The lack of triangulation has restricted the growth of flexible endoscopic surgical techniques. In addition, endoscope channel size limits the type of tools that can be used. A novel percutaneous intragastric trocar (PIT) has been developed to address these issues. The aim of this study was to evaluate the procedural characteristics of PIT placement and removal, as well as its therapeutic applications. METHODS We placed 10 PIT devices in 8 Yorkshire pigs. We performed therapeutic procedures in 5 animals, including 3 endoscopic submucosal dissections (ESD), 2 gastroesophageal junction stapling procedures, and 2 full-thickness resections (FTR). Access site closure was standardized and performed in each animal, and leak testing was then completed. Immediately after this, necropsy was performed to determine whether acute adverse events had occurred. The primary endpoint was technical success, with secondary endpoints of successful access site closure and therapeutic procedure time. RESULTS Ten devices in 8 pigs were placed successfully (100%) into the stomach without adverse events. ESD was completed in 3 cases with a mean time of 13.5 minutes. Stapling at the gastroesophageal junction and FTR were each completed in 2 cases. Full-thickness suture closure was determined to be complete and successful on leak test in all 10 closure attempts. Necropsy revealed no acute adverse events in all cases. CONCLUSIONS The PIT device, deployed using the standard procedural steps of percutaneous endoscopic gastrostomy tube placement, is safe and effective for use in the porcine model. PIT allows use of rigid instruments not previously available to the flexible endoscopist, including laparoscopic staplers, and potentially shortens procedure times for complex endoscopic techniques by allowing adjustable tissue traction.

Quiz page January 2014: Cachexia, urinary tract infection, nephromegaly, and kidney failure.

Figure 1. Computed tomography of the abdomen shows bilaterally enlarged kidneys. CLINICAL PRESENTATION A 59-year-old homeless woman with chronic hepatitis C and active alcohol and substance abuse presented with symptoms of nausea and flank pain over the preceding 2 weeks. Physical examination was significant for tachycardia, hypotension, and normal temperature. The patient had cachexia (height, 158 cm; weight, 35 kg; body mass index, 14 kg/m) and bilateral costovertebral angle tenderness. At admission, laboratory test results were notable for serum urea nitrogen level of 264 mg/ dL, serum creatinine level of 13.9 mg/dL, and estimated glomerular filtration rate of 3 mL/min/ 1.73 m by the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula. The patient’s most recently known previous serum creatinine level, measured 10 years earlier, was 0.9 mg/dL, corresponding to estimated glomerular filtration rate of 75 mL/min/1.73 m. The patient showed the following values: total carbon dioxide, 12 mEq/L; anion gap, 35 mEq/L; white blood cell count, 54,130 cells/mL; hemoglobin, 10.0 g/dL, which decreased to 6.2 g/dL with hydration; and platelets, 37,000 cells/mL. Urinalysis showed 170 white blood cells per highpower field and urine culture grew pan-sensitive Escherichia coli. Serologic tests for hepatitis B, HIV (human immunodeficiency virus), antinuclear antibodies, antineutrophil cytoplasmic antibodies, complement C3 and C4, and serum and urine protein electrophoresis all produced normal or negative results. Computed tomography (CT) of the abdomen without intravenous contrast (Fig 1) showed bilateral kidney enlargement: the patient’s right kidney was 11 cm and the left kidney was 13.2 cm. There was no significant lymphadenopathy. The patient initiated hemodialysis therapy to manage uremia, and a diagnostic percutaneous kidney biopsy was performed (Figs 2-4).

Endoscopic Treatments Following Bariatric Surgery

Weight regain after bariatric surgery is common and can be managed with surgical interventions or less morbid endoscopic techniques. These endoscopic approaches target structural postoperative changes that are associated with weight regain, most notably dilation of the gastrojejunal anastomosis aperture. Purse string suture placement, as well as argon plasma coagulation application to the anastomosis, may result in significant and durable weight loss. Furthermore, various endoscopic approaches may be used to safely and effectively manage other complications of bariatric surgery that may result in poor weight loss or weight regain after surgery, including fistula formation.

A simply placed percutaneous intragastric trocar for use of laparoscopic tools in endoscopy.

The performance of transoral therapy is limited by the eed to achieve triangulation for tissue exposure, dissection, nd instrumentation and by the small channel size of an endocope. A novel transgastric trocar (EndoTAGSS, Kansas City, ansas, USA) is explained in this video (Video 1, available nline at www.giejournal.org) and is used in a porcine odel with a proven endoscopic technique analogous to ercutaneous endoscopic gastrostomy (PEG) tube lacement. The device allows for triangulation and novel ntralumenal techniques in a dual endoscopic/laparoscopic c t P e t T f a s f g t U l T i r f d Figure 1. The percutaneous intragastric troc

Reusing an electrocautery-enhanced stent deployment catheter to place additional pigtail stents for walled-off necrosis with disconnected duct

The development of an electrocautery-enhanced delivery system for lumen-apposing metal stents (Axios; Boston Scientific, Natick, Mass, USA) has simplified creation of a cystgastrostomy tract for the management of pancreatic walled-off necrosis. These larger-caliber transgastric metal stents are beneficial in terms of allowing for digestion and lavage of necrotic debris and to permit direct endoscopic necrosectomy. When disruption of the pancreatic duct is suspected, there remains a question of how to best manage the collection because there is a risk of recurrence of the collection, as well as highly morbid percutaneous fistulization if percutaneous drainage is attempted. Transpapillary pancreatic duct stent placement has been reported to result in resolution of a disrupted pancreatic duct in up to 58% of cases, which leaves something to be desired. As an alternative approach, creation of a second transduodenal drainage gateway may be helpful