Carlo Jung

Use of the over-the-scope-clip (OTSC) in non-variceal upper gastrointestinal bleeding in patients with severe cardiovascular comorbidities: a retrospective study

Introduction  The over-the-scope-clip (OTSC) can potentially overcome limitations of standard clips and achieve more efficient and reliable hemostasis. Data on OTSC use for non-variceal upper gastrointestinal bleeding (NVUGIB) in patients with cardiovascular comorbidities are currently limited. Patients and methods  We prospectively collected and retrospectively analyzed our database from February 2009 to September 2015 from all patients who underwent emergency endoscopy for high-risk NVUGIB in 2 academic centers and were treated with OTSC as first-line (n = 81) or second-line therapy (n = 19). Results  One hundred patients mean age 72 (range 27 – 97 years) were included in this study. Fifty-one percent (n = 51) had severe cardiovascular co-morbidity (ischemic heart disease, congestive heart failure, hypertension, valvular heart disease, peripheral arterial occlusive disease and atrial fibrillation) and 73 % (n = 73) were on antiplatelet or/and anticoagulation therapy. The median size of the treated ulcers was 3 cm (range 1 – 5 cm). In 94 % (n = 94) primary hemostasis with OTSC was achieved. Clinical long-term success during a mean 6-month follow-up without rebleeding was 86 % (n = 86). Conclusions  In this cohort OTSC was demonstrated to be a safe and effective first- or second-line treatment for NVUGIB in high-risk patients with cardiovascular disease and complex, large ulcers.

Full-Thickness Resection Device for Complex Colorectal Lesions in High-Risk Patients as a Last-Resort Endoscopic Treatment: Initial Clinical Experience and Review of the Current Literature.

The full-thickness resection device (FTRD) is a novel endoscopic device approved for the resection of colorectal lesions. This case-series describes the device and its use in high-risk patients with colorectal lesions and provides an overview of the potential indications in recently published data. Between December 2014 and September 2015, 3 patients underwent endoscopic full thickness resection using the FTRD for colorectal lesions: 1 case for a T1 adenocarcinoma in the region of a surgical anastomosis after recto-sigmoidectomy, 1 case for a non-lifting colonic adenoma with low-grade dysplasia in an 89-year old patient and 1 for a recurrent adenoma with high-grade dysplasia in a young patient with ulcerative rectocolitis who was under immunosuppression after renal transplantation. Both technical and clinical success rates were achieved in all cases. The size of removed lesions ranged from 9 to 30 mm. Overall, the most frequent indication in the literature has been for lifting or non-lifting adenoma, submucosal tumors, neuroendocrin tumors, incomplete endoscopic resection (R1) or T1 carcinoma. Colorectal FTRD is a feasible technique for the treatment of colorectal lesions and represents a minimally invasive alternative for either surgical or conventional endoscopic resection strategies.

Individual endoscopic management of anastomotic insufficiency after esophagectomy for esophageal squamous cell carcinoma and creation of a neostomach

A 57-year-old patient with a T3, cN0, G2, M0 esophageal squamous cell cancer received neoadjuvant radiochemotherapy according to the CROSS trial. After successful esophagectomy and consecutive gastroesophageal anastomosis, the patient recovered appropriately. Unfortunately, the patient developed circular anastomotic insufficiency with two cavities at Day 7 (▶Fig. 1). One of the cavities arose from the circular insufficiency (2×2 cm), and the other was formed by a stapler insufficiency of the stomach (3×2 cm). The final tumor stage was histologically proven to be ypT0, N0, cM0, L0, V0, R0. We started repetitive endoluminal vacuum therapy (Endo-Sponge; B. Braun, Melsungen, Germany) for a treatment period of 2 months (▶Video1). Owing to the remarkable dimension of the cavities, we decided initially to place two devices per insufficiency (▶Fig. 2), and in total, 11 device replacements were performed. After 2 weeks of treatment, the use of one Endo-Sponge appeared to be sufficient to cover all areas of insufficiency. A negative intracavital pressure was applied (15–20mmHg) in order to avoid the development of pulmonary fistula. Antibiotic and antifungal treatment was also administered during the first 2 weeks of the vacuum therapy. The patient received parenteral nutrition but was allowed to drink liquids during the treatment period (▶Fig. 3). Unfortunately, despite appropriate endoscopic procedures and frequent Endo-Sponge exchange, the insufficiencies failed to heal and the cavities persisted. Therefore, a more aggressive endoscopic therapeutic approach was initiated (▶Video1). We utilized cytological brushes and argon plasma coagulation at the edges of cavital insufficiencies in order to induce vascular spreading and wound granulation (▶Fig. 4). Fibrotic tissue and surgical staple sutures were endoscopically removed using cutting devices and graspers. Mucosal bridges were cut by needle-knife incision, leading to development of a neostomach and esophagogastric continuity. In addition, epithelial mucosa spreading occurred, evolving from the upper esophageal tissue. After 2 months of endoscopic treatment, neither fistula nor anastomotic insufficiencies were detectable. In addition, a neostomach had been created, consisting of mediastinal parietal pleura, the distal esophagus, and the remnant stomE-Videos

Combined Endoscopic and Surgical Treatment of Severe Gastrointestinal Bleeding in a Patient with Heart Assist Device under Therapeutic Anticoagulation

Gastrointestinal (GI) bleeding is a common complication after heart assist device placement. Reasons for bleeding are multifactorial. Endoscopic therapy is the treatment of choice, whereas invasive procedures are avoided in these critically ill patients. We present the case of a 65-year-old male patient experiencing severe GI bleeding after left ventricular assist device (LVAD) and right ventricular assist device (RVAD) placement with therapeutic anticoagulation. Endoscopically, multiple gastric bleeding sources were found but could not be treated effectively due to a large blood clot. A combined endoscopic and surgical treatment was initiated, including gastrotomy for blood clot removal, surgical transgastric suturing, endoscopic over-the-scope clip (OTSC) placement and hemospray application. Postoperative endoscopic visualization showed effective bleeding control. The patient unfortunately died due to causes unrelated to the treatment. This case shows that a minimal invasive combination of endoscopic and surgical techniques can be an alternative treatment for severe upper GI bleeding in critically ill and anticoagulated patients.