C. Barbera

Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip (OTSC) device: Case series from a tertiary referral center

Gastrointestinal perforations and post-surgical fistulas are dreaded complications that dramatically increase morbidity and mortality. A new endoscopic over-the-scope clip (OTSC) system may be potentially useful for sealing visceral perforations in several clinical settings. We evaluated the advantages and clinical impact of the placement of OTSCs on the management of non-malignant gut leaks in 12 consecutive patients. OTSCs of 9.5 or 10.5 mm were used, according to the diameter of the defect within the wall. The indications for treatment were mainly related to post-surgical fistulas. Healing of the fistula was assessed by endoscopic or radiological means, and failed only once. No OTSC-related complications occurred. Endoscopic closure of perforations and post-surgical fistulas with the OTSC system is a simple and minimally invasive technique. This approach, when feasible, may be less expensive and more advantageous than a surgical approach.

Single balloon enteroscopy: Technical aspects and clinical applications

The small bowel has long been considered a black box for endoscopists because of its long length and the presence of multiple complex loop. Most of the small bowel is inaccessible by traditional endoscopic means. In addition, radiographic studies have significant limitations with regard to diagnostic yield, and surgery is an invasive alternative. This limitation was overcome through the development of balloon enteroscopy that becomes established throughout the world for diagnostic and therapeutic examinations of the small bowel. The single-balloon enteroscope (SBE) system (Olympus, Tokyo, Japan) was introduced into the commercial market in 2007. Several study demonstrated its efficacy and safety. Early reports on the use of single-balloon enteroscopy have suggested a high diagnostic yield and similar therapeutic potential to that of the double-balloon endoscope. SBE is viable technique for in the management of small bowel disease. Technically, it is easy to perform, may be efficient, and in the literature data available, seems to provide high diagnostic and therapeutic yield.

Bowel preparation with polyethylene glycol electrolyte solution: optimizing the splitting regimen

AIM Quality of bowel cleansing significantly increases the shorter the time between bowel solution intake and endoscopic examination. We tested the efficacy and patient tolerability following a modified polyethylene glycol electrolyte (PEG) splitting regimen. METHODS This was a prospective, single-blind, randomized, study. Patients were assigned to receive either PEG 4 L the afternoon before colonoscopy or PEG 3 L the day before and 1 L 3h before the procedure the day of colonoscopy. RESULTS The study population consisted of 336 patients, including 168 participants in each study arm. Although the bowel preparation quality was similarly quoted as excellent/good following the split and full regimen (95.2% vs 92.8%; p=0.3), a significant (p<0.0001) shift from good towards an excellent preparation (26.8% vs 68.4%) was observed following the split regimen as compared to the full regimen (55.4% vs 37.5%). The incidence of side-effects did not differ. When patients were asked about a future preparation if needed, 69% and 31% following the split and full regimen, respectively, declared to accept again the same preparation, the difference being statistically significant (p<0.001). CONCLUSIONS Our data found that an excellent bowel cleansing could be frequently achieved by simply modifying the split regimen from the standard PEG 2 plus 2 L to 3 plus 1 L.

Cholangiocarcinoma and malignant bile duct obstruction: A review of last decades advances in therapeutic endoscopy

In the last decades many advances have been achieved in endoscopy, in the diagnosis and therapy of cholangiocarcinoma, however blood test, magnetic resonance imaging, computed tomography scan may fail to detect neoplastic disease at early stage, thus the diagnosis of cholangiocarcinoma is achieved usually at unresectable stage. In the last decades the role of endoscopy has moved from a diagnostic role to an invaluable therapeutic tool for patients affected by malignant bile duct obstruction. One of the major issues for cholangiocarcinoma is bile ducts occlusion, leading to jaundice, cholangitis and hepatic failure. Currently, endoscopy has a key role in the work up of cholangiocarcinoma, both in patients amenable to surgical intervention as well as in those unfit for surgery or not amenable to immediate surgical curative resection owing to locally advanced or advanced disease, with palliative intention. Endoscopy allows successful biliary drainage and stenting in more than 90% of patients with malignant bile duct obstruction, and allows rapid reduction of jaundice decreasing the risk of biliary sepsis. When biliary drainage and stenting cannot be achieved with endoscopy alone, endoscopic ultrasound-guided biliary drainage represents an effective alternative method affording successful biliary drainage in more than 80% of cases. The purpose of this review is to focus on the currently available endoscopic management options in patients with cholangiocarcinoma.

Single-step endoscopic ultrasound-guided fluoroless gallbladder drainage using the Axios lumen-apposing metal stent

Severe acute cholecystitis is a condition that requires urgent surgical intervention to prevent sepsis and death. Elderly patients can be unfit for surgery because of comorbidities so alternative techniques are required for gallbladder drainage [1]. Here we report the case of a 93-year-old woman with abdominal pain, fever, and vomiting who was referred to our unit to undergo gallbladder drainage. An abdominal computed tomography (CT) scan showed cholelithiasis, gallbladder distension with wall thickening, and peri-cholecystic fluid. However, because of renal and cardiorespiratory comorbidities, the patient was judged unfit for surgery. Fluoroless endoscopic ultrasound (EUS)guided transluminal gallbladder drainage was therefore performed using a fully covered metal stent (10mm in diameter; Hot Axios, Boston Scientific Inc., Natick, Massachusetts, USA). The gallbladder was directly punctured using the cautery tip of the device. This was possible owing to a favorable position of the gallbladder, which was closely abutting the duodenum. The lumen-apposing metal stent (LAMS) was then deployed, with subsequent rapid drainage of the gallbladder. The patient became asymptomatic in the days following the procedure andwas discharged 5 days later. EUS-guided transmural gallbladder drainage, which has been practiced since 2007, requires multiple steps and devices to achieve gallbladder access, dilation of the duodenal wall, and stent deployment [1]. The need for device exchange over a wire can result in an increased risk of adverse events, such as perforation, bleeding, and infection. Furthermore, until now, the stents used for these indications have had to be borrowed from those intended for use during endoscopic retrograde cholangiopancreatography (ERCP). The Axios system is a new specifically designed fluoroless EUS-guided fully covered lumen-apposing metal stent, which is used for drainage of pancreatic fluid collections, the gallbladder, and the bile duct [2,4,5]. The Axios delivery system provides good maneuverability and visibility, making the sheath suitable for direct puncture. Our experience suggests that EUS-guided gallbladder drainage should be considered as a first option in patients unfit for surgery [3]. This new device may be easier to deploy than other stents and maintains good apposition of the two walls to create an iatrogenic anastomosis.

PDX-1 mRNA expression in endoscopic ultrasound-guided fine needle cytoaspirate: Perspectives in the diagnosis of pancreatic cancer

BACKGROUND AND AIMS Endoscopic ultrasound-guided fine needle aspiration is routinely used in the diagnostic work up of pancreatic cancer but has a low sensitivity. Studies showed that Pancreatic Duodenal Homeobox-1 (PDX-1) is expressed in pancreatic cancer, which is associated with a worse prognosis. We aimed to verify whether the assessment of PDX-1 in endoscopic ultrasound-guided fine needle aspiration samples may be helpful for the diagnosis of pancreatic cancer. METHODS mRNA of 54 pancreatic cancer and 25 cystic lesions was extracted. PDX-1 expression was assessed by Real-Time PCR. RESULTS In all but two patients with pancreatic cancer, PDX-1 was expressed and was found positive in 7 patients with pancreatic cancer in which cytology was negative. The positivity was associated with a probability of 0.98 (95% CI 0.90-1.00) of having cancer and the negativity with one of 0.08 (95% CI 0.01-0.27). The probability of cancer rose to 1.00 (95% CI 0.97-1.00) for patients positive to both PDX-1 and cytology and fell to 0.0 (95% CI 0.00-0.15) in patients negative for both. CONCLUSIONS PDX-1mRNA is detectable in samples of pancreatic cancer. Its quantification may be helpful to improve the diagnosis of pancreatic cancer.

Retroperitoneal Schwannoma: When EUS-Guided FNA can Avoid Surgery

Schwannomas are rare benign tumor that arises from peripheral or cranial nerve. Commonly, they occur into the head or neck and rarely into the retroperitoneum or pancreas. Usually they are asymptomatic tumor, discovered incidentally. Final diagnosis is generally confirmed after surgical intervention. The possibility to reach the lesion by EUS and to perform FNA can avoid invasive procedures. Here we discuss a rare case of retroperitoneal schwannoma diagnosed by Endoscopic ultrasound (EUS) guided Fine needle aspiration (FNA).

Double- vs. single-balloon enteroscopy: and the winner is…

We read with interest the review by May on balloon-assisted enteroscopy [1]. The author concluded that double-balloon enteroscopy (DBE) is superior to single-balloon enteroscopy (SBE). However, we would like to make some comments. SBE represents one emerging technique for deep enteroscopy, in parallel with DBE and spiral enteroscopy. May focused her attention on the study by Takano et al. [2], inwhich a significant differencewas found between DBE and SBEwith respect to total enteroscopy rate (57% and 0%, respectively; P=0.002). However, this study has two significant limitations. First, the authors hadmuchmore experiencewith DBE than with SBE: when they started the study, they had performed 248 DBE procedures but only 10 SBE procedures. Second, only 14 SBEprocedureswere carried outduring the 24-month study period. This low case volume would have delayed the learning curve and made it difficult to achieve an adequate skill level. An indirect test that confirms this is the longer examination time and radiographic fluoroscopy time recorded for SBE procedures (185.9 ± 34.9 minutes vs. 160.7 ± 29.0minutes for examination time [P =0.03] and 14.5 ± 7.0 minutes vs. 9.3 ± 5.0 minutes for fluoroscopy time [P=0.03]). In a multicenter US study, Mehdizadeh et al. showed a significant learning curve in acquiring the skills necessary to performballoon-assisted enteroscopy, with a significant decline in overall procedure time and fluoroscopy time after the first 10 DBE cases [3]. Moreover, in contrast to the total enteroscopy rate, Takanoetal. showed that thediagnostic yield and therapeutic yieldwere not significantly different between SBE and DBE procedures, and concluded that both techniques seem tobe interchangeable indaily clinical gastroenterology practice. Recently, Domagk et al. published the first randomized multicenter, head-to-head comparison trial of DBE (by Fujinon) vs. SBE (by Olympus). The study demonstrated the noninferiority of SBE with respect to the insertion depth and complete visualization in a considerable number of patients (130 procedures) over a short study period (12months) [4]. Previous experience with SBE demonstrated that the total enteroscopy rate with SBE was between 5% and 25% [5–8]. These findings might be explained in part by inexperience in using the SBE technique. In an Italian multicenter prospective study, presented during the 2011 United European Gastroenterology Week (22–26 October; Stockholm, Sweden), the authors found a total enteroscopy rate for SBE of 47%, higher than that previously reported in the literature [9]. The endoscopists participating in this study were experienced in the SBE technique and had performed at least 30 SBE procedures before starting the study. These results are comparable with those reported in a recent review on DBE published by Xin et al. [10]. They reported data on total enteroscopy from 23 studies involving 1143 patients. Successful total enteroscopy was achieved in 569 patients and the consequent pooled total enteroscopy rate was 44.0%; the rate was similar between the two procedures. Incidentally, the question remains whether the technically appreciated end point of “total enteroscopy rate” is preferable over the end point of “clinical impact.” Although depth of insertion remains the most common question posed to endoscopists performing deep enteroscopy, the answer to this question is often irrelevant: it is neither the depth of insertion nor the total enteroscopy rate (which appear to be similar between the two procedures), that are important but rather the clinical impact of the enteroscopy. In other words, what is important is the ability of the procedure to detect lesions and to allow for a therapeutic intervention. In conclusion, data published to date are conflicting. More comparative studies between DBE and SBE are necessary in order to nominate the winner.

Feasibility and efficacy of double over-the-scope clipping for colonic iatrogenic perforation

Colorectal iatrogenic perforation is a rare adverse event in diagnostic colonoscopy, occurring in a range of 0.03% to 0.8% of cases. Risk factors include endoscopist’s inexperience, female gender, pericolic adhesions, inflammatory colonic diseases, severe diverticular disease, and weakened colonic-wall tissues because of older age. The over-the-scope clip (OTSC, Ovesco Endoscopy GmbH, Tübingen, Germany) is a useful tool, recommended as first-line endoscopic treatment for endoscopic acute iatrogenic perforation, which can help to avoid emergency surgical repair. However, the deployment of an OTSC to completely close the defect may be challenging in some cases because of the size, the position of the hole (ie, sigmoid-rectal junction), and the presence of other endoscopic devices (ie, through-thescope clip or OTSC). To the best of our knowledge, the deployment of 2 adjacent OTSCs has not been described in the medical literature. Here we report the case of an 89-year-old woman referred to our unit for colonoscopy (CFHQ190L; Olympus Co, Tokyo, Japan) because of a positive hemoccult test result and anemia. Because of pericolic adhesions in a

Endoscopic retrograde cholangiography after endoscopic ultrasound-related duodenal perforation: keep calm, use over-the-scope clip, and carry on!

The over-the-scope clip (OTSC) is a useful tool recommended as first-line endoscopic treatment for endoscopic acute iatrogenic perforation [1]. A retrospective study documented that OTSCs can avoid emergency surgical repair, allowing, in some cases, completion of the primary endoscopic procedure. As documented only once in the literature, its use could allow subsequent endoscopic procedures to be performed in the same session, owing to the endurance of the device during pneumatic and mechanical stress [2]. Here we report the video case of a 93-year-old woman who was referred to our unit to undergo biliopancreatic endoscopic ultrasound (GF-UCT 180; Olympus Co., Tokyo, Japan) for suspected choledocholithiasis, in the context of acute cholangitis; the patient was not a suitable candidate for surgery (cholecystectomy). After multiple biliary stones were detected in the common bile duct, a perforation was apparent in the wall of the superoanterior duodenal bulb. Because of the size of the perforation (about 15mm), an OTSC (11/6mm traumatic type; Ovesco Endoscopy GmbH, Tübingen, Germany) was applied using the suction technique to completely seal the defect [3]. As no further leakage was apparent following injection of contrast medium and the patient’s clinical conditionwas stable, endoscopic retrograde cholangiography (ERC; TJF-160 VR; Olympus Co.) with extraction of multiple biliary stones was performed in the same session (▶Video1). All procedures were performed with anesthesiological assistance, using carbon dioxide insufflation. ERC took about 45 minutes for complete biliary drainage (▶Fig. 1). The subsequent contrast medium (▶Fig. 2) and computed tomography scan with oral gastrographin confirmed the complete closure, despite the longlasting pneumatic and mechanical stress. No further complication occurred and the asymptomatic patient was discharged 1 week later. In conclusion, prompt endoscopic treatment using OTSCs represents an effective approach that can avoid later complications or surgical repair. Furthermore, the use of OTSCs can allow the completion of endoscopic procedure(s) in the same session, as the clips can endure prolonged pneumatic and mechanical stress.