Fabio Cipolletta

Improved characterization of visible vessels in bleeding ulcers by using magnification endoscopy: results of a pilot study

BACKGROUND Not all exposed vessels carry the same risk of recurrent bleeding, and sometimes endoscopic therapy may not be warranted in the setting of profound acid inhibition therapy. OBJECTIVE To investigate the role of magnification endoscopy (ME) in improving the characterization of exposed vessels in ulcer hemorrhage. DESIGN Prospective study. SETTING Single-center teaching hospital. MAIN OUTCOME MEASUREMENTS Diagnostic accuracy and safety of ME in patients with bleeding peptic ulcers. RESULTS A total of 43 patients were studied. Exposed vessels were initially categorized as high risk (protuberant, translucent, or pale) in 25 and low risk (nonprotruding through the ulcer floor, pigmented, or dark red) in 18 cases. ME was subsequently performed, and the operator was asked to reclassify the vessel into 1 of these 2 categories. A magnified view provided a clear image of the vessel and allowed visualization of the artery, the site of rupture, and the presence of a clot plugging the hole. In 6 cases previously categorized as low risk, ME clearly showed the 2 ends of the vessel, the longitudinal tear in the vessel wall, and a protuberant aspect that was not seen with standard view. The lesion was then reclassified as high risk (diagnostic gain 33%). The mean procedure time for ME inspection was 7 +/- 4 minutes. No complications occurred. LIMITATIONS Absence of controls. CONCLUSIONS In patients with peptic ulcer bleeding and exposed vessels, ME allows clear visualization of the vessel wall and provides detailed clues to further characterize the lesion.

Successful endoscopic treatment of Bouveret's syndrome by mechanical lithotripsy

Gastric outlet obstruction secondary to the impaction of large biliary stones into the duodenum (Bouverets syndrome) is a well-known complication of biliary lithiasis, most often requiring surgical intervention. We report a case of successful endoscopic removal of a large stone impacted in the duodenal bulb by means of mechanical lithotripsy.

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

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

Improving the yield of EUS-guided histology

All published guidelines[1-5] suggest using EUS-FNA of cystic fluid, not as a routine test, but only in cysts in which the results are likely to alter management, and in cysts in which the diagnosis is unclear. For example, in the International Association of Pancreatology’s Fukuoka Guidelines,[1] the indication for EUS-FNA is the presence of these so-called “worrisome features” which are composed of several alerting clinical or morphological characteristics. Almost all the subsequent published guidelines have identified several similar characteristics of warning, which advise further investigation, particularly EUS‐FNA of cystic fluid. For these reasons, in recent years, there have been many attempts to improve TA in PCLs with many different devices in order to obtain an adequate specimen to be analyzed. CYTOLOGY

What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?

Opinion statementPurpose of reviewUpper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients.Recent findingsEarly endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common.SummaryA multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.

504 Endoscopic Piecemeal Resection of Large Colorectal Adenomas: a Systematic Two-Step Approach to Optimize Outcomes

Endoscopic Piecemeal Resection of Large Colorectal Adenomas: a Systematic Two-Step Approach to Optimize Outcomes Livio Cipolletta, Maria Antonia Bianco, Fabio Cipolletta, Claudia Cesaro, Gianluca Rotondano* Gastroenterology, Hospital Maresca, Torre del Greco, Italy Endoscopic piecemeal resection (EPMR) of colorectal lesions larger than 30 mm may occasionally require multiple steps and not infrequently end up with standard surgery. Two-step EPMR, i.e. the completion of the procedure within 4 to 6 weeks, would allow avoidance of excessive manipulation of the severed area thus reducing the risk of complications and, at the same time, facilitate early identification and treatment of adenoma remnants thus reducing the neoplastic recurrence rate. Aim of the study is to evaluate the impact of systematic two-step EPMR on early morbidity and 12-mo outcomes. Patients with sessile polyps or laterally spreading tumours (LST) larger than 30 mm were recruited in a prospective single-center study. EPMR was systematically performed in two scheduled sequential steps. At 1st step as much of the lesion as possible was removed, with obvious intent to complete resection; in the 2nd step, carried out 4 to 6 wks later, the procedure was completed. At this stage, magnified inspection of the resection area provided clues to simple biopsy (scar tissue devoid of any pattern) or further resection APC (adenoma remnants). Endoscopic follow-up was scheduled at 6 and 12 months after this second step (time zero). Over a period of 19 months, a total of 54 patients were included (35 males, mean age 66.8 years, age range 27-82). There were 23 sessile polyps mean size 42 (range 30-55) mm and 31 LSTs mean size 49 (range 30-75) mm. Sessile lesions were located in the rectosigmoid (17) and proximal colon (6), whereas LSTs were located in the proximal colon (13), left colon (5) and rectum (13). The standard ER technique by submucosal injection and snare resection was always employed. Intra-procedural bleeding was recorded in 7 instances, all successfully controlled by thermal therapy or clips. No delayed bleeding or perforation occurred. There was no procedure-related mortality. Final histology of the resected lesions was low-grade adenoma (4 sessile and 17 LST), high grade adenoma or mucosal cancer (19 sessile and 13 LST) and submucosal carcinoma (1 G-mixed LST). Retreatment was deemed necessary in 19/54 pts during the second step. See table for 12-months outcomes.Two-step EPMR of colorectal lesions 30 mm is safe and allows completion of the procedure at a later stage without jeopardizing positive long-term outcomes. This approach may potentially reduce the rate of “recurrent” adenoma by early inspection and retreatment of any residual tissue.

P.07.14 ENDOSCOPIC PIECEMEAL RESECTION OF LARGE COLORECTAL ADENOMAS: A SYSTEMATIC TWO-STEP APPROACH

of lidocain + adrenaline in order to have a local anesthesia and a safe use of APC. In case of extensive lesion (circumferential) we treat one quadrant at the time. Results: In one year we treated 33 male patients (18 HIV positive and 15 HIV negative): one with a circumferentially involment, 7 with half circumference and the others with a median of 3 lesions >5 mm. more than one condyloma >1 cm affecting one or more quadrant on the dentate line. We made a median of 1.5 treatments (range 1–5). In all patients we had a complete eradication of the lesions without sign of recurrence at six months endoscopic control. No complication occurred in our patients. Conclusions: Anorectal condyloma are lesions difficult to treat by endoscopy due to the difficulty to visualize the area and the high sensitivity of this area. Our experience demonstrates that the proposed endoscopic technique can improve the possibilities to treat the majority of these lesions (extensive or not) avoiding surgical approach.