Enad Dawod

Modern Management of Pancreatic Fluid Collections

The last decade has seen dramatic shift in paradigm in the management of pancreatic fluid collections with the rise of endoscopic therapy over radiologic or surgical management. Endosonographic drainage is now considered the gold standard therapy for pancreatic pseudocyst. Infected pancreatic necroses are being offered endoscopic necrosectomy that has been facilitated by the arrival on the market of large diameter lumen-apposing metal stent. Severe pancreatitis or failure to thrive should receive enteral nutrition while pancreatic ductal disruption or strictures are best treated by pancreatic stenting.

Endoscopic submucosal tunnel dissection for early squamous cell carcinoma of the esophagus

We report the case of an 83-year-old man with past medical history of hypertension who was initially referred for the evaluation of newly diagnosed squamous cell cancer (SCC) of the esophagus. An endoscopic ultrasound was performed and showed a medium-sized flat lesion in the mid-esophagus, which appeared to be invading the muscularis mucosa (T1a). During a multidisciplinary meeting, it was decided that the patient would benefit from an endoscopic submucosal dissection of the lesion. A medium-sized, flat lesion with no bleeding and no stigmata of recent bleeding was found in the upper third of the esophagus, 26–29cm from the incisors. The mass was nonobstructing and partially circumferential. Using optical coherence tomography (Ninepoint Medical, Bedford, Massachusetts, USA), the lesion was confirmed to be T1 without invasion into the submucosa. A GIF-H180 endoscope (Olympus, Tokyo, Japan) with a transparent cap was advanced to lesion. The borders of the lesion were marked circumferentially with a multipurpose knife (T knife; Erbe USA, Marietta, Georgia, USA). First, 10mL of saline with methylene blue was injected proximally to the lesion. A tunnel was created to the distal margin of the lesion and opened laterally. There was significant scaring in the submucosal space making dissection difficult (▶Fig. 1, ▶Video1). After careful dissection of the submucosal space, the lateral and distal borders were dissected with an IT2 knife (Olympus, Center Valley, Pennsylvania, USA). The lesion was completely removed en bloc and sent for histologic evaluation. The GIF-XP180 scope was inserted through the right nostril into the stomach. Enteral feeding was started in order to allow the site to heal by secondary intention. On 1-week follow-up, the patient had no complaints and was tolerating solid food. Based on the pathology, the resection margins were negative for carcinoma and dysplasia. SCC of the esophagus is the most common histologic type of esophageal cancer in Asia, with lower incidence in the United States [1]. Historically, surgery was thought to be the gold standard treatment for these patients; however, esophagectomy is associated with high rates of complications and mortality [2]. In recent years, many studies have shown that endoscopic therapy, particularly endoscopic submucosal dissection (ESD), is comparable to surgical resection but with lower morbidity [3]. However, esophageal ESD could be more difficult owing to the thinner wall and narrow lumen of the esophagus. Therefore, inspired by peroral endoscopic myotomy, endoscopic submucosal tunnel dissection (ESTD) has been developed for en bloc resection of these lesions, with promising results [4, 5]. This case demonstrates successful management of early SCC of the esophagus with ESTD.

Endoscopic removal of a proximally migrated pancreatic stent

A 64-year-old woman with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and biliary and pancreatic duct (PD) stent placement. She subsequently presented with postprandial abdominal distension of a few weeks’ duration. The patient had undergone a laparoscopic cholecystectomy following the ERCP; however, a repeat ERCP nearly 2 months after her initial endoscopy revealed a proximally migrated PD stent that could not be retrieved, prompting transfer to our center. Repeat ERCP revealed a normal-appearing PD with a retained PD stent, which had migrated towards the pancreas. The ventral PD was deeply cannulated with a short-nosed traction autotome, and a pancreatic sphincterotomy was performed. A pediatric biopsy forceps was then advanced into the duct over the wire, and closed over the pancreatic stent, but the stent appeared to be embedded. Further attempts to extract the PD stent with a rat tooth forceps and retrieval basket were also unsuccessful. The PD was then dilated with a 4-mm hurricane balloon and the pediatric biopsy forceps was again advanced over the wire, with successful extraction and complete removal of the retained PD stent (▶Fig. 1, ▶Video1). One 5 Fr ×12 cm, single-pigtail, plastic stent was placed into the ventral PD to prevent post-ERCP pancreatitis. The patient was discharged home the same day. At post-ERCP followup, the patient remained pain free and had normal liver chemistry. The removal of proximally migrated PD stents remains technically challenging owing to the small diameter, bending course, and often stricturing of the PD. Many devices have been successfully used for endoscopic removal of migrated stents, including a basket, snare, extraction balloon, and grasping forceps. Despite the lack of a standardized approach to migrated pancreatic stents, ERCP should be attempted at an experienced center for retrieval of a proximally migrated PD stent prior to considering surgical intervention [1].

A wormy surprise: ERCP for intrabiliary drainage of a hydatid cyst

A 41-year-old man with a known hepatic hydatid cyst presented with several months of abdominal pain and more recent onset of jaundice. Despite repeated courses of albendazole, he reported no clinical improvement. Upon presentation, he underwent magnetic resonance cholangiopancreatography (MRCP), which revealed a multiloculated cystic structure within hepatic segments 5 and 6, measuring approximately 7 ×4.5×6.5 cm with mildly enhancing septations, and diffuse intrahepatic biliary ductal dilatation (▶Fig. 1). The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) with the initial cholangiogram showing a hilar filling defect, a common bile duct (CBD) stricture, and dilated intrahepatic ducts in segments 5 and 8 (▶Fig. 2 a). A biliary sphincterotomy was performed and the cholangioscope was advanced over the wire into the CBD, where cyst membranes were visualized mid-duct (▶Fig. 2b, ▶Video1). The CBD was then dilated with a balloon catheter and copious amounts of cyst membranes were swept from the duct (▶Fig. 2 c). The cyst membranes were collected with a Roth Net and sent to microbiology. After multiple balloon sweeps, the cholangioscope was re-inserted into the bile duct and complete clearance of cyst membranes was confirmed. A 10-Fr ×7-cm straight plastic stent was deployed in the CBD at the end of the procedure. The patient was treated with albendazole and returned a few days later for an extended right hepatectomy. His postoperative course was complicated by a bile leak that required repeat ERCP and placement of a long plastic stent to cover the defect causing the observed leak. The patient was seen at follow-up and continues to remain free of both symptoms and cysts. While surgical resection has been the mainstay in the approach to the management of hepatic hydatid cysts, ERCP can be a useful modality both to aid in the diagnosis of hepatic cyst extension into the bile ducts and for therapeutic drainage of the tapeworm cyst and membranes.

Endoscopic ultrasound-guided transrectal pelvic abscess drainage using a lumen-apposing metal stent

A 31-year-old woman with asthma presented with 1 week of lower abdominal pain and fevers after a recent emergency room discharge for appendicitis that had been managed conservatively with antibiotics. Upon presentation, she underwent a computed tomography (CT) scan of the abdomen and pelvis, which revealed a multiloculated pelvic abscess measuring approximately 7.3 × 4.7 ×7.0 cm (▶Fig. 1). The collection was thought to be unamenable to drainage by interventional radiology. The patient underwent a lower gastrointestinal endoscopic ultrasound (EUS), which identified the pelvic abscess from the rectosigmoid colon. After color flow Doppler had been used to ensure there was no intervening vasculature, a cautery-enhanced delivery system was used to deploy a 10-mm lumen-apposing metal stent (LAMS; Axios; Boston Scientific, Marlborough, Massachusetts, USA) into the collection, with the distal flange in the collection and the proximal end in the sigmoid colon. This process was visualized under fluoroscopic, endosonographic, and endoscopic guidance. Copious amounts of purulent material were seen draining from the stent. The stent was then dilated and two doublepigtail plastic stents (10 Fr × 7 cm) were deployed into the metal stent to prevent migration (▶Video1). The patient was discharged on hospital day 4 after an uncomplicated post-operative course. A repeat CT scan of the abdomen and pelvis was performed nearly 3 weeks later and revealed resolution of the multiloculated pelvic abscess; the LAMS was endoscopically removed a few days later. The patient was subsequently seen in follow-up and has continued to remain asymptomatic. The use of LAMSs has revolutionized EUS as it creates a large conduit for drainage, as well as for passage of both the endoscope and a variety of endoscopic accessories [1]. While surgical resection has been the main approach to drainage of intra-abdominal and pelvic collections, EUS can be a useful modality to aid in the diagnosis and for therapeutic drainage of pelvic collections [2–5].

Peroral endoscopic myotomy (POEM) in jackhammer esophagus: a trick of the trade

A 69-year-old man presented for evaluation of progressive atypical chest pain. The patient noted 4 years of progressive daily chest pain, regurgitation of food, and intermittent dysphagia. After extensive evaluation, the patient underwent esophageal manometry which led to a diagnosis of jackhammer esophagus characterized by 100% hypercontractile waves. The patient had minimal symptomatic response to amitriptyline. He was referred for peroral endoscopic myotomy (POEM). During the procedure, a 1.5-cm mucosal incision was made using a multipurpose knife (Erbe) for an entry point into the submucosal space. The submucosal space was dissected using intermittent injection and dissection with forced coagulation setting. Dissection of the submucosal tunnel was performed down to the level of the gastroesophageal junction and distal to it by 3 cm (▶Video1). Dissection of the circular muscle bundle began from 2cm distal to themucosal entry down to the gastroesophageal junction. In addition, full-thickness myotomy was performed in the mid and distal tunnel. Division of the sphincter muscles was continued toward the stomach until the endoscope passed through the narrow segment of the lower esophageal sphincter (▶Fig. 1). The mucosal entry site was closed with hemostatic clips. At 1-month follow-up, the patient noted significant improvement in his pain and other symptoms. The revised Chicago classification recently defined jackhammer esophagus as a hypercontractile esophagus, with at least one contraction with a distal contractile integral (DCI) of at least 8000mmHg·s·cm [1]. Many treatments of jackhammer esophagus have been tried, including oral nitrates, balloon dilation, and surgical myotomy [2]. Recently POEM has been demonstrated as a safe and effective therapeutic modality for the treatment of spastic esophageal disorders [3], and particularly for jackhammer esophagus [4].

Two-step endoscopic radiofrequency ablation for metastatic cholangiocarcinoma

A 58-year-old woman with cholangiocarcinoma previously treated with partial hepatectomy with Roux-en-Y gastric bypass, presented with worsening jaundice. Despite chemotherapy, the patient was diagnosed with tumor obstructing the hepaticojejunostomy and associated intrahepatic biliary ductal dilation. She was referred for endoscopic retrograde cholangiopancreatography (ERCP) with intraductal radiofrequency ablation (RFA). However, conventional ERCP failed because of her altered anatomy. She was offered two-step RFA therapy (▶Video1). During the first step, the patient underwent a successful endoscopic ultrasound-guided hepaticogastrostomy with placement of a 10mm fully covered selfexpanding metal stent, bridged with a 7 Fr ×15 cm plastic double-pigtail stent. One month after biliary decompression and maturation of the hepaticogastrostomy, the patient underwent RFA of the malignant stricture and placement of a 7 Fr ×15 cm plastic double-pigtail stent in antegrade fashion, across the stricture (▶Fig. 1). Unresectable cholangiocarcinoma is a challenging disease, for which chemotherapy and radiotherapy are not typically able to provide significant survival benefits [1]. Local ablative therapies, particularly RFA, have been shown to improve symptoms in malignant biliary strictures [2, 3]. In addition, there is some suggestion that RFA may be associated with improved survival [4]. RFA requires biliary access to determine the location of the stricture. Then the radiofrequency energy can be directly applied at the stricture site. However, when access to the biliary stricture is not feasible during conventional ERCP, a successful two-step RFA via a hepaticogastrostomy can be offered successfully, as illustrated by this case.

Successful endoscopic removal of an eroded gastric ring with subsequent endoscopic suturing of the luminal defect

A 50-year-old woman with a history of Fobi Pouch Roux-en-Y gastric bypass (RYGB) presented to our hospital with abdominal pain, reflux, and significant weight loss. Initial endoscopic evaluation at an outside hospital revealed a Silastic ring that had eroded into the gastric pouch. The patient refused surgery and was referred to our institution for management. On upper endoscopy, there was evidence of a RYGB with an eroded Silastic ring protruding below the gastric pouch into the jejunum. A double-channel gastroscope was used. A rat tooth forceps (Rat Tooth Alligator Jaw Grasping Forceps; Olympus America Inc., Central Valley, Pennsylvania, USA) was deployed through one channel to grasp the ring from the mucosa. The ring was then dissected using endo-scissors (Olympus Endotherapy Loop Cutter; Olympus America Inc.,), which were inserted through the secondary channel. The endoscopic suturing system was used to repair the full-thickness defect created from ring removal. Three interrupted sutures were placed successfully across the gastrojejunal anastomosis, and a clinch was used to ensure closure of the ring defect. Closure was confirmed by lack of extravasation of contrast after injection (▶Fig. 1, ▶Video1). The procedure was well tolerated, and no adverse events occurred. At 1-month follow-up, the patient reported significant relief of her symptoms. The Silastic ring is a restrictive band, which is surgically placed around the gastrojejunal anastomosis in patients who have undergone RYGB. The intent is to further limit the size of the gastric pouch in order to achieve weight loss [1]. Possible causes of band erosion include: excessive constriction of the band, suturing the band to the stomach, and infection [2]. Symptomatic band migration or erosion necessitates removal [3]. E-Videos

Management of Benign and Malignant Pancreatic Duct Strictures

The diagnosis and management of pancreatic strictures, whether malignant or benign, remain challenging. The last 2 decades have seen dramatic progress in terms of both advanced imaging and endoscopic therapy. While plastic stents remain the cornerstone of the treatment of benign strictures, the advent of fully covered metal stents has initiated a new wave of interest in calibrating the pancreatic duct with fewer sessions. In malignant disease, palliation remains the priority and further data are necessary before offering systematic pancreatic stenting.