Bertrand Marie Vergeau

Closure of gastrointestinal defects with Ovesco clip: long-term results and clinical implications.

Background: The Over-The-Scope Clip (OTSC®, Ovesco Endoscopy GmbH, Tübingen, Germany) is an innovative clipping device that provides a strong tissue grasp and compression without provoking ischemia or laceration. In this retrospective study we evaluated immediate and long-term success rates of OTSC deployment in various pathologies of the gastrointestinal (GI) tract. Methods: A total of 45 patients (35 female, 10 male) with an average age of 56 years old (range, 24–90 years) were treated with an OTSC for GI defects resulting from a diagnostic or interventional endoscopic procedure (acute setting group) or for fistula following abdominal surgery (chronic setting group). All procedures were performed with CO2 insufflation. Results: From January 2012 to December 2015 a total of 51 OTSCs were delivered in 45 patients for different kinds of GI defects. Technical success was always achieved in the acute setting group with an excellent clip adherence and a clinical long-term success rate of 100% (15/15). Meanwhile, considering the chronic setting group, technical success was achieved in 50% of patients with a long-term clinical success of 37% (11/30); two minor complications occurred. A total of three patients died due to causes not directly related to clip deployment. Overall clinical success rate was achieved in 58% cases (26/45 patients). A mean follow-up period of 17 months was accomplished (range, 1–36 months). Conclusion: OTSC deployment is an effective and minimally-invasive procedure for GI defects in acute settings. It avoids emergency surgical repair and it allows, in most cases, completion of the primary endoscopic procedure. OTSC should be incorporated as an essential technique of today’s modern endoscopic armamentarium in the management of GI defects in acute settings. OTSCs were less effective in cases of chronic defects.

Endoscopic internal drainage as first-line treatment for fistula following gastrointestinal surgery: a case series

Background and study aims: Leaks following gastrointestinal surgery are a dreadful complication burdened by high morbidity and not irrelevant mortality. Endoscopic internal drainage (EID) has showed optimal results in the treatment of leaks following bariatric surgery. We report our experience with EID as first-line treatment for fistulas following surgery along all gastrointestinal tract.

Combined endoscopic and radiologic approach for complex bile duct injuries (with video)

4. Van Tienhoven G, Gouma DJ, Richel DJ. Neoadjuvant chemoradiotherapy has a potential role in pancreatic carcinoma. Ther Adv Med Oncol 2011;3:27-33. 5. Goldstein SD, Ford EC, Duhon M, et al. Use of respiratory-correlated four-dimensional computed tomography to determine acceptable treatment margins for locally advanced pancreatic adenocarcinoma. Int J Radiat Oncol Biol Phys 2010;76:597-602. 6. Van der Horst A, Wognum S, Davila Fajardo R, et al. Interfractional position variation of pancreatic tumors quantified using intratumoral fiducial markers and daily cone beam computed tomography. Int J Radiat Oncol Biol Phys 2013;87:202-8. 7. Park W, Yan B, Schellenberg D. EUS-guided gold fiducial insertion for image-guided radiation therapy of pancreatic cancer: 50 successful cases without fluoroscopy. Gastrointest Endosc 2010;71:513-8. 8. Sanders M, Moser A, Khalid A. EUS-guided fiducial placement for stereotactic body radiotherapy in locally advanced and recurrent pancreatic cancer. Gastrointest Endosc 2010;71:1178-84. 9. Varadarajulu S, Trevino JM, Shen S, et al. The use of endoscopic ultrasound-guided gold markers in image-guided radiation therapy of pancreatic cancers: a case series. Endoscopy 2010;42: 423-5.

Outcome of Leaks After Sleeve Gastrectomy Based on a New Algorithm Addressing Leak Size and Gastric Stenosis

We welcomed with great interest the masterpiece of Nedelcu et al. [1] concerning the outcome of leaks after laparoscopic sleeve gastrectomy (LSG) based on a new algorithm addressing leak size and gastric stenosis. The article stressed the importance of adopting this new algorithm in order to standardize leak management, thus reducing the number of endoscopic procedures. We agree with the authors about the use of endoscopic internal drainage (EID) by means of double pigtail to achieve complete healing. As already reported by our team [2], since March 2013, we adopted EID as the only endoscopic treatment in case of fistulas after LSG or gastric bypass, irrespective to leak size. Moreover, we believe in the importance of introducing a well-defined algorithm in order to standardize the endoscopic treatment modality for leak following bariatric surgery. However, according to our experience, we have some remarks to do. Here, we report a case of a 59-year-old woman, presenting an early fistula [3] following laparoscopic sleeve gastrectomy. At day 12 after surgery, she underwent reoperation for peritonitis with lavage and drainage of peritoneal cavity, and two peri-gastric surgical drainage were left in place. No primary repair was attempted due to severe local tissue inflammation. Endoscopy showed a 2-cm-long dehiscence, of the last staple fire line, allowing passing through with the scope. Swallow study through the scope showed the persistence of intra-abdominal collection in the left hypochondrium and the presence of a left bronchial tree fistula (Fig. 1). EID was performed and two 10 Fr double pigtail drains (DPD) were positioned with the aim to drain and promote re-epithelialization of the cavity. After four endoscopic sessions, an Ovesco® clip (OTSC®; Ovesco Endoscopy GmbH, Tubingen, Germany) was delivered to close the remaining blind cross-fistula.

Colic and gastric over-the-scope clip (Ovesco) for the treatment of a large duodenal perforation during endoscopic retrograde cholangiopancreatography.

Successful management of endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforations, up to 20 mm, has been reported using several endoscopic devices [Von Renteln et al. 2010; Buffoli et al. 2012; Dogan et al. 2013; Donatelli et al. 2013; Meduri et al. 2014], however, surgery remains the standard of care management of larger defects [Wu et al. 2006; Lee et al. 2013]. Here we report, to the best of the authors’ knowledge, the first case of successful treatment of a large duodenal perforation (>20 mm) during ERCP, using several Ovesco clips. A 66-year-old white man was addressed for biliary drainage due to important cholestasis secondary to a liver metastatic lesion of an urothelial cancer treated by surgery and chemotherapy. During ERCP and while delivering the third plastic 10F stent (Figure 1) a movement of the endoscope provoked a large retroperitoneal duodenal perforation occupying 1/3 of the duodenal wall (Figure 2), opposite to the papilla at the early beginning of second duodenum. The size of perforation was important, mostly because the duodenal wall is thin and injury provoked a mucosal laceration with tearing of the wall. The decision to deliver a plastic stent instead of a metal one was taken given the poor prognosis of the patient, and namely because the stenosis was evaluated as ‘Bismuth IV’, and in the case of no improvement of liver function tests, a radiological percutaneous transhepatic approach would be compromised. Then the duodenoscope together with the partially delivered stent were immediately retrieved. A standard gastroscope loaded with an 11t Ovesco (OTSC®; Ovesco Endoscopy GmbH, Tubingen, Germany), under CO2 insufflation, was introduced but unfortunately the duodenal tear was too large, both in length and width, making it impossible to aspirate both edges of the tear in the cap or approach using a Twin Grasper®. A coloscope loaded with a 14t Ovesco was subsequently introduced and endoscopic suturing was started between the greater omentum and one edge of the duodenal tear (Figure 3). Since a closure defect persisted at the other end as shown after contrast-medium injection (Figure 4), the gastric Ovesco was delivered while aspirating the omentum incarcerated between the first colic clip and the free edge of the perforation, achieving full closure without contrast-medium extravasation (Figure 5). A nasogastric tube was left in place in soft aspiration. The patient was then transferred to the intensive care unit (ICU), for surveillance, where he remained for 7 days before being discharged. During his stay in the ICU, no fever was detected, the liver function tests were improved, and no further ERCP was needed to add the third stent. We only noticed a transient rise of the C-reactive protein, before its complete normalization, and CT scan as well as water-soluble contrast upper-studies performed on days 2 and 5 postoperatively were normal (Figure 6). Oral nutrition was started on day 6. At 1 month after endoscopy, the patient is fully asymptomatic. Figure 1. Hilar stenosis with 2 plastic stents in place. The guidewire in the left duct is about be placed, in order to deliver the third stent. Figure 2. Large duodenal defect. Figure 3. Colic clip Ovesco in place incarcerating greater omentum. Figure 4. Contrast-medium extravasation at the one end of the duodenal perforation despite colic Ovesco placement, given the large size of the defect. Figure 5. Watertight closure achieved using a ‘bridge technique’ using Ovesco on Ovesco. Figure 6. CT scan showing clips in place with no extravasation of contrast medium. In conclusion OTSC is a surgery-sparing device, and colic and gastric clips together can be a useful tool for the closure of large duodenal defects. However, the use of a colic Ovesco should be considered too, mainly because of its size, for upper gastrointestinal interventions in an expert’s hands.

Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video)

Background and study aims Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP. Patients and methods From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 – 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features. Results Technical success was achieved in all cases (100 %). Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months. 12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation. Conclusions Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.

Post-biliary sphincterotomy bleeding despite covered metallic stent deployment

Objectives: Several endoscopic techniques have been proposed for the management of post-sphincterotomy bleeding. Lately, self-expandable metal stents deployment has gained popularity especially as a rescue therapy when other endoscopic techniques fail. Methods-results: We report the case report of a massive post-sphincterotomy bleeding in a patient with a self-expandable metal stent in the biliary tree. Despite the presence of a correctly positioned self-expandable metal stent, a new endoscopic session was required to control the bleeding. Conclusions: Self-expandable metal stent may be useful to manage post-endoscopic sphincterotomy bleeding. However, up to now there is no specifically designed self-expandable metal stent for such complication. Large new designed self-expandable metal stent may be a useful tool for biliary endoscopist.

Emergency endoscopic exploration of a pancreatic pseudocyst to retrieve a migrated pigtail stent

Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocyst using double-pigtail plastic stents is a well-established technique with a high success rate (95%–100%). Early adverse events, namely bleeding and perforation, occur in up to 5% of the procedure [1–3]. A 38-year-old woman with a history of alcohol abuse was admitted to hospital because of dysphagia, abdominal pain, and vomiting. Computed tomography (CT) scan showed an encapsulated pancreatic fluid collection, and therefore EUS-guided drainage was performed. EUS-guided access to the collection was achieved with a 19-gauge needle (▶Fig. 1) and a first guidewire was inserted. A cystotome was used, followed by hydrostatic dilation up to 8mm. After insertion of a second guidewire, a double-pigtail 7-Fr, 5-cm plastic stent was delivered, but immediately after deployment the stent spontaneously migrated inside the collection (▶Fig. 2). Blind retrieval was attempted without success with both foreign-body forceps and Dormia basket (▶Fig. 3). Therefore a lumen-apposing metal stent (LAMS) was thendeployed (▶Fig. 4), and a slim gastroscope was advanced inside the pseudocyst (▶Fig. 5). Exploration of the cavity allowed location of the migrated pigtail stent and retrieval using a pediatric biopsy forceps (▶Video1). Finally, a duodenoscope was used to remove the LAMS and to insert two 10-Fr double-pigtail plastic stents (▶Fig. 6). Inadvertent plastic stent migration inside a cavity is an adverse event that may be difficult to manage. Massive dilation of the tract is not recommended as first-line treatment because of the risk of perforation. Deployment of a LAMS seems a safe and effective option for guaranteeing sustained access to the cavity and allowing the use of a slim endoscope to explore the cavity. In our patient the pseudocyst was not infected; therefore we decided to remove the metal stent in order to allow an early oral diet and reduce the risk of superinfection caused by food stasis. Nonetheless, use of a LAMS might prove very useful in the management of adverse events related to drainage of pseudocysts.

Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study

Background and study aims: Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures. Patients and methods: This retrospective study included 66 consecutive patients presenting with a duodenal stricture impeding the ability to perform an ERCP. Provisional duodenal stenting was performed as a bridge to ERCP. A second endoscopic session was performed to remove the provisional stent and to perform an ERCP. Afterward, a permanent duodenal stent was delivered if necessary. Results: Sixty-six duodenal stents (17 pcSEMS and 49 fcSEMS) were delivered with a median indwelling time of 3.15 (1 – 7) days. Two migrations occurred in the pcSEMS group, 1 of which required lower endoscopy for retrieval. No other procedure-related complications were observed. At second endoscopy a successful ERCP was performed in 56 patients (85 %); 10 patients (15 %) with endoscopic failure underwent PTBD or EUS-BD. Forty patients needed permanent duodenal stenting. Conclusions: Provisional removable covered duodenal stenting as a bridge to ERCP for duodenal obstruction is safe procedure and in most cases allows successful performance of therapeutic ERCP. This technique could be a sound option as a step up approach before referring such cases for more complex techniques such as EUS-BD or PTBD.

Portography: a potentially fatal complication during endoscopic ultrasound-guided choledochoduodenostomy

Endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CDS) is a safe alternative to transhepatic cholangiography when endoscopic retrograde cholangiopancreatography (ERCP) has failed or in patients with altered anatomy [1]. There are however several adverse events that can be life-threatening in some circumstances [1, 2]. A 66-year-old woman presented with obstructive jaundice secondary to advanced pancreatic cancer. A gastrojejunal anastomosis had been previously performed to bypass a long duodenal stenosis. EUS-CDS was attempted because of difficulties in reaching the papilla. Temporary duodenal stenting as a bridge to ERCP was not considered given its high failure rate in the presence of tumor infiltration [3]. Under carbon dioxide insufflation, the dilated common bile duct (CBD) was punctured and bile was subsequently aspirated. The biliary tree was opacified and a 0.0025-inch angled guidewire was inserted quite easily. A fistulotomy was performed with some temporary bleeding, which was controlled, at the puncture site. Shockingly, at the re-opacification check, the vascular portal system was recognized (▶Fig. 1), indicating that it had been catheterized, probably secondarily to erroneous guidewire manipulation. Given the absence of bleeding and the patient’s stable vital parameters, the procedure was started again, and this time was successfully performed (▶Video1). The patient’s recovery was uneventful and she left hospital 48 hours later. Opacification and/or deep cannulation of the portal vein is a rare complication of ERCP [4], which occurs mainly in patients with biliopancreatic cancer during difficult cannulation or pre-cut, and may lead to potentially fatal air embolism. Balloon tamponade, covered stenting, or surgical repair is necessary in case of large defects. Being able to recognize an erroneous catheterization during secondary opacification is mandatory and should result in the procedure being stopped immediately, not wrongly considering that it is the CBD. This is the first report of portography as a complication during EUS-CDS. Certain technical steps are important to minimize the effects of this complication: gentle manipulation during deep insertion of the guidewire, followed by a ▶ Fig. 1 Images of the re-opacification check during endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) showing opacification of the vascular portal system with medium contrast wash-out, following accidental catheterization of the portal vein due, probably, to erroneous guidewire manipulation.