Dario Ligresti

Definitive outcomes of self-expandable metal stents in patients with refractory post-transplant biliary anastomotic stenosis.

BACKGROUND Endoscopic retrograde cholangio-pancreatography is the gold standard of treatment in patients with biliary complications after liver transplantation. The benefits of fully covered self-expandable metal stents (FCSEMS) lie in their relative simplicity and the need for only two procedures, one for insertion, and the other for removal. Several case series have been published on such stents with generally good outcomes. Objective is to analyze definitive long-term outcomes of this treatment. METHODS Prospective, observational study in a single, tertiary-care referral centre. All consecutive patients with post-transplant biliary stenosis/leak were treated with FCSEMS after failure of conventional treatment. Recurrence was evaluated after four years. RESULTS From February 2008 to April 2012, 70 patients were included. In all patients, the metal stent was successfully placed. After a mean of 86.7 ± 38.4 days, the stent was removed. Forty-six patients (65.7%) showed resolution. After a mean of 4 ± 1.2 years, 61% of patients maintained the results, but 39% showed recurrence. On the tested variables the diagnosis of stenosis, the number of previous procedures and plastic stents placed correlate with better long-term results. CONCLUSIONS This series suggests a lack of long-term advantages of FCSEMS over plastic stents in the management of biliary stenosis after liver transplantation.

Hemospray rescue treatment of severe refractory bleeding associated with ischemic colitis: a case series.

Dear Editor: Ischemic colitis is a vascular condition of inadequate blood flow in the colon, which leads to colonic inflammation and mucosal damage with ulcerations; it is associated with significant morbidity and mortality. Multiple anecdotal case reports and case series have described associations of ischemic colitis with vascular surgery and vascular thromboembolism. Bleeding associated with nausea, vomiting, diarrhea, concomitant ischemic stroke, and ileus is quite common. Flexible sigmoidoscopy or complete colonoscopy is crucial for obtaining a histologic diagnosis, determining the severity of the IC, and treating the source of bleeding. Frequently used treatment modalities are injections, mechanical and thermal. However, these modalities may be not suitable in the case of tangentially located bleeding sites and diffusely bleeding lesions or when massive hemorrhage obscures the endoscopic view. Furthermore, thermo-coagulation, when suitable due to its in-depth application, can result in adverse events. Hemospray is an easily applicable hemostatic powder that has been shown to be effective in both focused and diffusely active bleeding lesions of the gastrointestinal tract. Evidence of its efficacy in the lower gastrointestinal bleeding (LGIB) is very limited, based on extrapolations of what happens in upper gastrointestinal bleeding, and on small series of patients. In Europe, Hemospray is not licensed for use in the lower gastrointestinal tract, so its use in this area is currently offlabel. To date, its use in the lower gastrointestinal tract is licensed only in Canada. We present our experience with Hemospray rescue treatment of four cases of life-threatening IC-related LGIB after failure of conventional endoscopic techniques. From April, 2013, to August, 2014, all patients who underwent Hemospray treatment for IC-related LGIB were retrospectively analyzed. Endoscopic hemostatic interventions were performed exclusively by interventional endoscopists experienced in therapeutic colonoscopy and specifically trained in Hemospray application. Training consisted of 1 day of hands-on training on an ex vivo model. Each procedure was performed using a high-definition colonoscope (CF-H190L—Olympus Europa SE & CO. KG, Hamburg, Germany). A diagnosis of IC was histologically obtained with biopsies in all patients. After failure of conventional hemostatic techniques, Hemospray was deployed onto the active bleeding site through dedicated catheters and propelled by short bursts of carbon dioxide until complete hemostasis was achieved. Success was defined as persistent hemostasis after 3–5 min of visual inspection following Hemospray application. Immediately after each Hemospray application, CO2 was carefully suctioned to reduce bowel wall thinning and its potentially associated risk of perforation, even if it should be noted that suctioning during Hemospray treatment can lead to scope channel obstruction. The use of both catheters included in the box was necessary to complete Hemospray treatment for each procedure, due to catheter kinking or obstruction during application. In one case, in order to proceed with the treatment, an additional standard biliary Luer-lock 10 Fr catheter (FS-OA-10 Cook Medical, Winston-Salem, NC) was used. A total of four intensive care unit patients (three men; median age 50, range 22–66), with severe hypotension, * Antonino Granata agranata@ismett.edu

Intraperitoneal rendezvous: a mini-invasive biliary reconstruction

re 1. A, Enhanced CT reconstruction image evaluating relationship between biliary catheter (arrow), common bile duct (arrowhead), and adjahepatic artery (asterisk). B, Cholangiogram showing complete proximal common bile duct interruption. C, Cholangiogram showing ssful biliary reconstruction after intraperitoneal rendezvous. D, Magnetic resonance image showing successful biliary reconstruction at 1-year w-up visit.

Bedside EUS-guided treatment in a critically ill patient with acute cholecystitis

re 1. Sequence of Hot AXIOS stent Boston Scientific, Marlborough, Mass placement: A, The catheter is energized (using pure-cut setting) and ced through the duodenal wall into the gallbladder. B, The distal flange of the covered metal stent is deployed. C, The stent is carefully retracted, he distal flange is positioned against the lumen wall; the black catheter shaft marker is visible on the endoscopic view. D, The proximal flange is yed.

Endoscopic Wedge Gastrectomy of a Gastric Subepithelial Tumor and Closure of the Gastric Wall Defect With the Overstitch Suturing System

Dear Editor, Gastrointestinal stromal tumors (GISTs) are the most common nonepithelial tumors of the gastrointestinal (GI) tract. In a histologically proven, small GIST, standard treatment is excision, unless major morbidity is expected, with no dissection of clinically negative lymph nodes. Recently, endoscopic full thickness resection of GISTs in the upper GI tract was considered a feasible therapeutic method in select patients, but, some authors considered macroperforation as an important technical issue that need an urgent surgical management. Lately, based on a novel endoscopic suturing system, resection of gastrointestinal tumors arising from the muscularis propria has become more feasible and safe. Furthermore, the use of carbon dioxide in GI endoscopy, as in laparoscopic surgery, reduces postprocedural abdominal pain and certain uncommon but severe adverse events during endoscopy, such as tension pneumothorax, air embolism, and abdominal compartment syndrome. A 51-year-old woman, with a clinical history of bowel infarction, portal thrombosis, and virus C–related cirrhosis, was affected by increase in size of the GIST with regard to a previous endoscopic ultrasound. We decided to perform an endoscopic full thickness resection in order to achieve a radical oncological resection. The resection was performed using an O-type HybridKnife (Erbe Elektromedizin, Tübingen, Germany). The tissue was injected a mixture prepared by diluting 0.8% indigo carmine dye in 0.9% saline solution to create a submucosal liquid pool. The excision resulted in a complete gastric wall defect (about 4 × 4 cm in length). OverStitch (Apollo Endosurgery, Austin, TX, USA) enables placement 779670 SRIXXX10.1177/1553350618779670Surgical InnovationGranata et al letter2018

Chronic tracheoesophageal fistula successfully treated using Amplatzer septal occluder

Tracheoesophageal fistula (TEF) is a serious life-threatening condition that appears in critically ill patients with a prolonged history of mechanical ventilation. Enteral feeding and dietary support combinedwith surgery is the gold standard. In selected patients, TEF healing can be ensured by a mini-invasive approach using an Amplatzer septal occluder (AGA Medical Corporation), intended for cardiac septal defect closure [1]. The Amplatzer septal occluder, which is composed of a nitinol mesh, has two self-expandable disks connected by a thin diameter waist (▶Fig. 1) and ensures mechanical closure of the two sides of the fistula, making a potential platform for subsequent tissue ingrowth [2]. This technique was used in a 44-year-old man with tracheostomy and a history of protracted invasive lung support. He had been diagnosed as having a TEF after numerous episodes of aspiration pneumonitis and had subsequently undergone anterior cervicotomy with surgical closure of the fistula. After 7 months, his dysphagia relapsed. Endoscopy confirmed recurrence of the TEF (▶Fig. 2), which was initially treated unsuccessfully by submucosal injection of acrylic glue. Given the poor clinical condition of the patient and the failure of both surgical and endoscopic therapy, it was decided to try positioning of an Amplatzer septal occluder (▶Video1). The procedure was performed using a gastroscope (GIF-1TH190; Olympus Europe) and a bronchoscope (BF-1T180; Olympus Europe). The TEF was cannulated using a papillotome (TRUETome; Boston Scientific) and a 0.025-inch guidewire (Jagwire; Boston Scientific) was inserted into the bronchial segment. The wire was then grasped with a biopsy forceps (Endo-Jaw; Olympus Europe) passed through the bronchoscope, providing countertraction by maintaining a straightened position. The septal occluder catheter was introduced and the two ends were released into the trachea and esophagus, respectively (▶Fig. 3). Successful closure of the TEF was confirmed by contrast medium injection (▶Fig. 4). The procedure was uneventful. E-Videos

Salvage procedure following lumen-apposing metal stent maldeployment during endoscopic ultrasound-guided biliary drainage

A jaundiced 82-year-old-woman was diagnosed with a cephalopancreatic, locally advanced adenocarcinoma. Endoscopic retrograde cholangiopancreatography was planned, but biliary cannulation was not achieved because of a large periampullary diverticulum (▶Fig. 1). We therefore decided to perform endoscopic ultrasound (EUS)-guided biliary drainage using an 8-mm electrocauterytipped lumen-apposing metal stent (LAMS; AXIOS-EC, Boston Scientific, Marlborough, Massachusetts, USA). The dilated common bile duct (CBD) (▶Fig. 2) was accessed from the bulb under EUS guidance with the electrocautery-tipped delivery system in a “freehand” fashion [1]. The distal flange did not fully expand because the tip of the catheter was too close to the facing wall of the CBD in an oblique direction, leaving insufficient room for the stent to fully open (▶Fig. 3). To secure the access to the CBD, a guidewire was inserted through the catheter into the biliary tree (▶Fig. 3). To allow the distal flange to fully open, the catheter was slightly withdrawn; however, the stent slid out of the CBD, with the fully released flange, into the abdominal cavity (▶Fig. 4). The catheter was then retrieved, and the open flange was re-sheathed by repositioning the stent deployment hub to the original position (▶Video1). The delivery system was reinserted over the wire, under endoscopic view, into the CBD without any further device energizing. The distal flange was then deployed under EUS view, and the proximal flange under endoscopic view (▶Fig. 5). Cholangiography confirmed that the stent was in place. The post-procedural course was uneventful. Stent maldeployment during EUS-guided biliary drainage is a severe adverse event. In cases where the CBD is not well dilated, with the potential for subsequent difficulty in stent deployment, the preventive placement of a through-the-stent guidewire is advisable. The described salvage procedure avoids the need for a second access to the CBD, maintaining the same route with a guidewire, and reintroducing the re-sheathed stent. This avoids the ▶ Fig. 1 Endoscopic view of the major papilla located on the inferior margin of the diverticulum (*). The common bile duct could not be cannulated with the guidewire because of marked tortuosity of the distal part. ▶ Fig. 2 Endoscopic ultrasound view of a 40-mm solid inhomogeneous hypoechoic lesion with irregular borders (*) in the head of the pancreas, infiltrating the portal vein (arrow) and the intrapancreatic common bile duct, and dilated up to 18mm at the upper/middle third (**). ▶ Fig. 3 Fluoroscopic view of the maldeployed distal flange of the stent inside the common bile duct (CBD). The tip of the releasing catheter (arrow) of the stent is closely facing the distal wall of the CBD (dashed white line), resulting in a slight kinking of the catheter axis (dashed red line). A 0.035-inch guidewire was inserted through the stent catheter to secure the access to the CBD.

Buried lumen-apposing metal stent (LAMS) following endoscopic ultrasound-guided gallbladder drainage: the LAMS-in-LAMS rescue treatment

A 70-year-old woman with jaundice who had been diagnosed with unresectable malignant distal biliary stricture underwent endoscopic ultrasound (EUS)-guided gallbladder drainage following failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided bile duct drainage was impractical because of the presence of an intervening vessel, and an EUS-guided cholecystogastrostomy was created with placement of an 8×8-mm lumen-apposing metal stent (LAMS) [1]. After 1 month, the patient complained of a recurrence of her jaundice and was scheduled for follow-up endoscopy. This revealed that the proximal flange of the stent was completely buried in the gastric wall (▶Fig. 1). A linear echoendoscope was then used, and a bending cannula (SwingTip; Olympus) was smoothly inserted through the fistula into the buried LAMS under combined fluoroscopic guidance. Injection of contrast medium revealed a distended gallbladder and slightly dilated intrahepatic biliary tree with no contrast leakage, confirming that the distal flange was still in the correct place (▶Fig. 2). A 0.035-inch guidewire was then passed through the cannula and coiled within the gallbladder. The delivery catheter of a 10×10-mm electrocautery-tipped LAMS (AXIOS-EC; Boston Scientific) was advanced over the wire into the gallbladder without energizing the device (▶Video1). The distal flange of the second LAMS was deployed in the gallbladder beyond the distal flange of the buried LAMS under fluoroscopic guidance. Slight traction was applied on the endoscope–stent coupled system, which allowed the proximal flange of the second LAMS to be deployed in the gastric cavity under endoscopic vision (▶Fig. 3). A through-the-LAMS-in-LAMS cholangiogram confirmed that the stent was correctly in place and that there was no contrast leakage. The post-procedure course was uneventful. A buried LAMS is a rare complication, previously reported for various indications and managed, when possible, by endoscopic stent removal [2–4]. In fact, stent removal is not only a technically demanding procedure but also, in the setting of biliary drainage, it increases the risk of bile leakage and subsequent peritonitis. The above-described LAMS-in-LAMS technique allows the endoscopist to recreate a safe drainage conduit without the need to remove the buried stent. ▶ Fig. 1 The buried stent is seen in the wall of the gastric antrum: a on endoscopic view, showing the proximal flange of the lumen-apposing metal stent completely buried in the gastric wall with a 2-mm fistulous orifice visible on the covering tissue overgrowth (arrow); b on endoscopic ultrasound view, showing the proximal flange (arrowheads) within the gastric wall; a clearly visible hypoechoic gastric muscular layer (*); and the distal flange in place in the gallbladder (arrow).

Endoscopic ultrasound-guided angiotherapy in refractory gastrointestinal bleeding from large isolated gastric varices: a same-session combined approach

A 36-year-old Asian man with severe portal hypertension due to hepatitis B virusrelated cirrhosis had been previously treated for acute gastrointestinal bleeding from a large isolated gastric varix (IGV-1) by injection of endoscopic cyanoacrylate glue at a local hospital (▶Fig. 1). Following an episode of massive recurrent hematemesis, the patient was hemodynamically stabilized and referred to our institute. Radiological evaluation revealed the presence of numerous collaterals in the gastric fundus with a large-caliber splenorenal shunt. With the patient under general anesthesia, it was found that the portal gradient did not decrease significantly with a transjugular intrahepatic portosystemic shunt (TIPS) positioned across the left hepatic and left intrahepatic veins [1], confirming that blood outflow was predominantly diverted towards the shunt (▶Fig. 2 a). We then decided to use a same-session combined technique involving balloon-occluded retrograde transvenous obliteration (B-RTO) of the left renal vein [2] and selective endoscopic ultrasound (EUS)-guided variceal embolization [3, 4] by coils and n-butyl2-cyanoacrylate (CYA) injection. A B-RTO was performed to obliterate the left renal vein before EUS-guided selective treatment in order to protect the pulmonary circulation from systemic embolization (▶Fig. 2b). Gastric varices (IGV-1) were then visualized from the stomach with a linear-array echoendoscope. Selective EUS-guided intravascular puncture was performed with a 22-gauge fine needle aspiration (FNA) needle (EZ Shot 3 Plus; Olympus Europe) and three 0.018-inch coils (MReye Embolization Coil; Cook Medical) were released through the needle under EUS and fluoroscopic control (▶Video1), the endovascular coils being advanced into the targeted vessel using the pushing acEndoscopy E-Videos E-Videos

Tissue acquisition in pancreatic cystic lesions

Despite the progress achieved by scientific research in recent years, pancreatic cystic lesions (PCLs) remain a challenging clinical problem. A significant percentage of benign PCLs are still wrongly sent to surgery, with all the related risks of a high number of surgery-related complications and mortality. Diagnosis of the type of PCL, and risk stratification for malignancy are essential for a correct management of these lesions. Several guidelines have identified some clinical and morphological aspects suggesting the need for more accurate exams. Endoscopic ultrasound fine needle aspiration (EUS-FNA) of cystic fluid for cytology is the advised method of tissue acquisition in several guidelines, and the most used technique around the world. However sensitivity and adequacy of this technique are limited by the low amount of cells dispersed in cystic fluid. Alternative techniques have been tested to target the cystic walls in an attempt to obtain microhistologic specimens in order to augment the probability of obtaining an adequate diagnostic sample. The aim of this review is to offer a critical overview of the existing literature on tissue acquisition in PCLs, and emphasize advantages and disadvantages of each technique, and unclear areas that need to be investigated with future research.