Bhaumik Brahmbhatt

Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective.

Detection of early colorectal cancer is expected to rise in light of national colorectal cancer screening programs. This The present review article delineates current endoscopic risk assessments, differentiating invasive from non‐invasive neoplasia, for high likelihood of lymph node metastasis in early colorectal cancer, also termed high‐risk early colorectal cancer, and endoscopic and surgical resection methods from a Western hemisphere perspective.

Yield of double-balloon enteroscopy in the diagnosis and treatment of small bowel strictures.

BACKGROUND Small bowel strictures are common in gastroenterology practice. We report diagnostic and therapeutic yield of double-balloon enteroscopy for small bowel strictures. METHODS Retrospective study of 71 consecutive patients who were found to have small bowel stricture at the time of double-balloon enteroscopy. RESULTS During double-balloon enteroscopy, stricture identification and tissue sampling were possible in all 71 cases. Surgical pathology reported aetiology as non-steroidal anti-inflammatory drugs (32%), non-specific (21%), Crohns disease (21%), radiation-induced (9%), tumour (10%), anastomotic (4%), celiac disease (1%), and surgical adhesions (1%). Sixteen patients (23%) underwent balloon dilation. Sensitivity of abdominal computed-tomography and video-capsule endoscopy for strictures based on double balloon enteroscopy findings was 61% and 43%, respectively. CONCLUSION Double-balloon enteroscopy was safe and effective to access small bowel stricture with direct visualization and tissue sampling or for therapeutic balloon dilation. Given low sensitivity with conventional computed-tomography and/or video-capsule endoscopy for small bowel stricture, double-balloon enteroscopy can be considered if clinical suspicion is high.

Novel technique for flexible endoscopic repair of Zenker’s diverticulum

re 1. A, Gastrografin swallow study of ZD. B, Endoscopic repair of ZD. C, Hypothesis of our technique for endoscopic ZD repair. D, Endoscopic e stabilizing the CP bar and guidewire securing and orienting to esophageal lumen. E, Electrocautery device used to make incisions on CP bar, ted inferomedially, on both sides of the suture; the two incisions need not completely meet in the center because the snare will complete the inciF, Passing the snare over the suture, down to the base of the incisions, to resect part of the CP muscle. G, Final outcome, showing unifying the cavity e diverticulum with the esophageal lumen. ZD, Zenker’s diverticulum; CP, cricopharyngeal. Reused with permission from the Mayo Foundation for cal Education and Research. All rights reserved.

Massive bleeding after EUS-guided walled-off necrosis drainage

re 1. A, Preprocedural abdominal MRI demonstrating a large (12.3 7.4 6.4 cm) complex fluid collection with a thick outer wall surrounding ancreatic body (arrow) and suspected disruption of the pancreatic duct (arrowheads). B, EUS view demonstrating the LAMS catheter (arrow) inside the collection, and the distal end of the deployed stent (arrow). C, Upper endoscopic view showing dilation of the cystgastrostomy by f a wire-guided dilating balloon. D, Upper endoscopic view showing bleeding at the proximal end of the LAMS (gastric side). E, Arteriographic showing the deployed LAMS (arrow) and no evidence of extravasation of contrast material. F, Duodenoscopic view revealing the previously d cystgastrostomy stent on the gastric body. A hemostatic clip is seen at the site of active bleeding underneath the stent. G, EGD view demonng the gastric side of the cystgastrostomy without bleeding. H, MRI revealing nearly resolved walled-off necrosis (arrow). I, EGD views before and after (right) LAMS removal. MRI, magnetic resonance imaging; LAMS, lumen-apposing metal stent. The arrow represents the place where tent was.

Correction to: Endoscopic and surgical management of nonampullary duodenal neoplasms

This article was updated to correct the author listing for Carlos Roberto Simons-Linares.

Endoscopic and surgical management of nonampullary duodenal neoplasms

BackgroundSporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD).MethodsWe retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients.ResultsSurgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention.ConclusionsPost-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.

Treatment Modalities for Achalasia

Esophageal achalasia is an uncommon motility disorder of the esophagus characterized by failure of relaxation of the lower esophageal sphincter (LES) and absence of progressive peristalsis in the distal esophagus. Prior to treatment, it is imperative that other processes that may mimic achalasia are ruled out. Diagnosis is established by way of esophageal manometry in conjunction with an esophagram and esophagogastroduodenoscopy. A variety of treatment options are available to relieve outflow obstruction and improve symptoms with per-oral endoscopic myotomy (POEM) emerging as a novel and effective endoscopic approach in the management of the disease. This chapter will review treatment modalities for achalasia.

Selective application of fully covered biliary stents and narrow-diameter esophageal stents for proximal esophageal indications

BACKGROUND Proximal esophageal stents are poorly tolerated and have a high risk of complications. We report our experience using fully covered, biliary, self-expandable metal stents (B-SEMS) and narrow-diameter, esophageal, self-expandable metal stents (NDE-SEMS) for this group of patients. METHODS 24 patients underwent placement of B-SEMS or NDE-SEMS for proximal esophageal lesions between 1 January 2011 and 31 July 2016. The outcomes included improvement of dysphagia, healing of fistulas, and adverse events. RESULTS 10 patients received B-SEMS and 14 had NDE-SEMS. Median follow-up time was 11.5 months (range 0.5 - 62 months). In both cohorts, stents were left in place for a mean of 6 weeks. The dysphagia score decreased in 7 (70 %) and 10 (71.4 %) patients, and fistulas resolved in 3/5 (60.0 %) and 5/8 (62.5 %) patients with B-SEMS and NDE-SEMS, respectively. Stent migration occurred in three patients (30.0 %) with B-SEMS and five patients (35.7 %) with NDE-SEMS. CONCLUSIONS Both stents were well tolerated and resulted in overall improvement of dysphagia in 70.8 % of patients. B-SEMS appeared to be more favorable for cervical esophageal lesions with narrower diameters, while NDE-SEMS may be better for more distal lesions.

Outcome of long benign esophageal strictures undergoing endoscopictherapy: a tertiary center experience

Complex benign esophageal strictures are defined by length (≥2 cm), small diameter, and stricture angulation or tortuosity. The long-term course of complex esophageal strictures based on length is currently unclear. We suspect that the esophageal stricture length might impact the effectiveness of endoscopic dilation therapy. We performed a retrospective study of all benign esophageal strictures of 2 cm or longer treated at a single center between July 1, 2010, and May 31, 2014. Primary outcomes were changed in dysphagia score at the end of follow-up compared to first dilation at our facility and the need for gastrostomy placement or esophagectomy during follow-up. Data were stratified into four subgroups according to stricture length 20–29, 30–49, 50–99, and 100 mm or longer. Eighty-seven patients (mean age 66 years, 54% women) were followed over a median of 40 months. Patients underwent a median of 6 dilations, averaging 0.3 dilations per month. Median dysphagia score remained unchanged at 2; 37 (43%) patients reported resolution or improved dysphagia and 50 (57%) patients reported no improvement or worsened dysphagia. Gastrostomy placement or esophagectomy was needed for 23 (26%) and 3 (3%) patients, respectively. Median degree of dysphagia at the end of follow-up did not differ between the four stricture length subgroups, yet no patient had improvement in the 100 mm or longer subgroup. More than half of patients with long benign esophageal strictures had unchanged dysphagia or developed worse dysphagia during follow-up. Long-term outcomes did not differ between different stricture lengths .

A hybrid endoscopic technique to close tracheoesophageal fistula

Tracheoesophageal fistula (TEF) is a congenital or with literature reporting up to 20% recurrence. Here we acquired pathologic entity characterized by an abnormal communication between the posterior aspect of the trachea and the anterior wall of the esophagus. Acquired TEF is a not uncommon adverse event secondary to mechanical ventilation, trauma, esophageal tumor, prior laryngectomy, or esophagectomy. Given the potential serious consequence of possible fatal pulmonary aspiration, prompt closure of TEFs is critical. Although an endoscopic approach to TEFs has been optimized over the past years, including endoscopic stent placement and over-the-scope clip system, recurrent TEFs remain a therapeutic challenge,