Gerard Aguila

EUS-guided gastroenterostomy: the first U.S. clinical experience (with video)

BACKGROUND AND AIMS There are limitations to enteral self-expandable metal stents and surgical gastrojejunostomy in the treatment of patients with gastric outlet obstruction (GOO). EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers long-lasting luminal patency without the risk of tumor ingrowth and/or overgrowth, while avoiding the morbidity of a surgical procedure. The aims of this study were to report the first U.S. clinical experience with EUS-GE in terms of technical success, clinical success, and adverse events and to detail the technical aspects of performing EUS-GE. METHODS This was a retrospective study from two tertiary-care centers. EUS-GE was performed by using either the direct EUS-GE or balloon-assisted EUS-GE technique. Technical success was defined as adequate positioning and deployment of the stent as determined endoscopically and radiologically. Clinical success was defined as the patients ability to tolerate oral intake without vomiting. RESULTS A total of 10 patients underwent attempted EUS-GE. Malignant GOO was present in 3 patients, whereas benign obstruction was found in the remaining 7. One patient had complete GOO and underwent successful direct EUS-GE. In the remaining 9 patients, balloon-assisted EUS-GE was attempted and was successful in 8. Thus, technical success occurred in 9 patients (90%). There were no procedure-related adverse events. Mean procedure time was 96 minutes (range 45-152 minutes), and mean length of hospital stay was 2.2 days. Clinical success with resumption of solid oral intake was achieved in all 9 patients (100%) who underwent successful EUS-GE. A total of 8 patients were able to tolerate almost a normal diet and/or full diet, and 1 patient tolerated a soft diet. There was no symptom recurrence during a mean follow-up period of 150 days. CONCLUSIONS EUS-GE is a promising new technique for the treatment of symptoms of benign and malignant GOO. Prospective, multicenter trials are needed to confirm these results.

Novel technique for submucosal tunneling and endoscopic resection of submucosal tumors (with video)

p t a E a t e e s s ( b t m GI submucosal tumors (SMTs) are a diagnostic dilemma for endoscopists because of the difficulty in defining the origin of the lesion (intramural vs extramural and layer of origin), in addition to challenges in obtaining tissue for diagnosis.1 EUS-guided FNA (EUS-FNA) is frequently performed or tissue diagnosis of SMTs. Although EUS-FNA is currently onsidered the standard method for sampling SMTs, its diagostic yield is suboptimal and ranges between 38% and 4%.2-4 Submucosal tunneling and endoscopic resection (STER) of SMTs of the esophagus and stomach was recently described5-7 based on concepts of submucosal tunneling and ap closure and represents a novel submucosal operation SuMO) technique.8 STER provides definitive histologic diagosis of SMTs and allows for a minimally invasive therapeutic pproach to SMTs. We present our experience with using a ovel gel for facilitating STER of esophageal submucosal esions in 4 nonsurvival pig experiments.

A Novel Submucosal Gel Permits Simple and Efficient Gastric Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) has developed into an accepted therapy for early gastroinestinal neoplasia, especially in Asian countries.1– 4 A ajor benefit of ESD is that it allows en bloc resection nd, thus, decreases risk of neoplastic recurrence.5 Western endoscopists have not embraced ESD techniques nearly as readily as their Eastern counterparts. This is likely due to a multitude of factors including low incidence of gastric malignancies, less exposure to ESD training, reimbursement issues, lengthy procedural times, and higher complication rates as compared to endoscopic mucosal resection (EMR).6 Methods that simplify the steps associated with ESD may help to proliferate its use. A new endoscopic gel (Cook Medical Inc, Winston-Salem, NC) was recently developed. This viscous gel was introduced for submucosal injection prior to excision of lesions of the gastrointestinal tract as the lesions are lifted by a visible bleb. Our exploratory laboratory experiments suggested that the gel also has tissue dissecting properties. Here, we present our initial experience with the use of this novel gel for facilitating submucosal dissection during gastric ESD.

Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video).

BACKGROUND An adequate myotomy on the gastric side is considered essential to optimize outcomes in patients undergoing per-oral endoscopic myotomy (POEM). An objective method to measure the length of gastric myotomy has not yet been reported. OBJECTIVE To evaluate a new method of precisely determining the length of the submucosal tunnel below the esophagogastric junction (EGJ) using intraprocedural fluoroscopy. DESIGN Single-center cohort study. SETTING Academic tertiary care center. PATIENTS Twenty-four consecutive patients who underwent POEM for management of achalasia. INTERVENTIONS A radiopaque marker (endoscopic clip placed at the EGJ or fluoroscopically guided placement of a 19-gauge needle on the skin) was used to mark the EGJ. The endoscope was inserted to the most distal aspect of the submucosal tunnel and, using fluoroscopy, the distance between the radiopaque marker and the tip of the endoscope was measured. MAIN OUTCOME MEASUREMENTS Technical success, procedural impact, duration of technique, and adverse events. RESULTS Technical success was achieved in 100% of patients. The submucosal tunnel was extended in 5 patients (20.8%) with a mean extension of 1.4±.5 cm. The mean increase in procedure time was 4 minutes with the endoscopic clip and 2 minutes with the 19-gauge needle. There were no adverse events associated with this technique. LIMITATIONS Need for fluoroscopy. Absence of available criterion standard. CONCLUSIONS Intraprocedural fluoroscopy was an efficient and safe method of objectively documenting the extent of gastric myotomy during POEM. This may benefit those investigating the anatomic and physiologic changes that occur during the myotomy and those early in their experience performing POEM.

Septotomy: an adjunct endoscopic treatment for post–sleeve gastrectomy fistulas

A 48-year-old woman presented with progressive abdominal pain 2 weeks after she had undergone laparoscopic sleeve gastrectomy (SG). A CT scan of the abdomen demonstrated postsurgical changes related to SG and a large extraluminal collection containing fluid, debris, and air adjacent to the surgical staple line. A percutaneous drain was placed, and endoscopic closure of the defect was attempted. Endoscopy revealed a fistulous opening adjacent to normal gastric lumen. The internal orifice of the gastrocutaneous (GC) fistula conditioned a pouchlike lumen, which was divided from the gastric lumen by a 15-mm-long septum (Fig. 1A). Septotomy was performed with argon plasma coagulation (40W) (ERBE, Tubingen, Germany) and resulted in communication of the 2 lumens (Fig. 1B). The edges of the fistula were ablated with argon plasma coagulation and the defect was closed with an overthe-scope clip (Video 1, available online at www.giejournal. org). Immediate injection of contrast medium into the gastric lumen demonstrated complete closure of the fistula (Fig. 1). The percutaneous drainage was removed 12 days later after progressive output decrement. A CT scan 6 weeks later demonstrated a smaller collection without

Transoral incisionless endoscopic fundoplication guided by impedance planimetry to treat severe GERD symptoms after per-oral endoscopic myotomy

A 61-year-old man with a history of type II achalasia and an Eckardt score of 6 underwent per-oral endoscopic myotomy (POEM). He presented 4 months after the procedure with GERD (score of 36 on GERD questionnaire) and an Eckardt score of 0. Upper endoscopy revealed LA grade C esophagitis, and a ph-Impedance study demonstrated a DeMeester score of 123.8. Transoral incisionless endoscopic fundoplication was then performed (Video 1). Preprocedure impedance planimetry was performed to obtain baseline measurements. A transoral staples device was advanced into the stomach through an overtube. Retroflexion facilitated the identification of the stapling location, and the

Which clip? A prospective comparative study of retention rates of endoscopic clips on normal mucosa and ulcers in a porcine model

Background/Aim: There are currently no data on the relative retention rates of the Instinct clip, Resolution clip, and QuickClip2Long. Also, it is unknown whether retention rate differs when clips are applied to ulcerated rather than normal mucosa. The aim of this study is to compare the retention rates of three commonly used endoscopic clips. Materials and Methods: Six pigs underwent upper endoscopy with placement of one of each of the three types of clips on normal mucosa in the gastric body. Three mucosal resections were also performed to create “ulcers”. Each ulcer was closed with placement of one of the three different clips. Repeat endoscopy was performed weekly for up to 4 weeks. Results: Only the Instinct and Resolution clips remained attached for the duration of the study (4 weeks). At each time point, a greater proportion of Instinct clips were retained on normal mucosa, followed by Resolution clips. QuickClip2Long had the lowest retention rate on normal mucosa. Similar retention rates of Instinct clips and Resolution clips were seen on simulated ulcers, although both were superior to QuickClip2Long. However, the difference did not reach statistical significance. All QuickClip2Long clips were dislodged at 4 weeks in both the groups. Conclusions: The Resolution and Instinct clips have comparable retention rates and both appeared to be better than the QuickClip2Long on normal mucosa-simulated ulcers; however this did not reach statistical significance. Both the Resolution clip and the Instinct clip may be preferred in clinical situations when long-term clip attachment is required, including marking of tumors for radiotherapy and anchoring feeding tubes or stents. Either of the currently available clips may be suitable for closure of iatrogenic mucosal defects without features of chronicity.

Percutaneously assisted EUS-guided gastrojejunostomy for the treatment of afferent limb syndrome

re 1. Afferent limb syndrome. A, CT view showing dilatation of the intrahepatic and extrahepatic ducts (white arrow), dilatation of the afferent loop arrow), and ascites suggestive of afferent limb syndrome. B, Fluoroscopic view demonstrating a nontraversable stricture 10-cm long at the afferent (red line). C, EUS view also revealing a dilatated loop of small bowel (red arrow), consistent with afferent limb syndrome. D, Instillation of a mixed ion of saline solution, contrast medium, and methylene blue through a previously placed percutaneous transhepatic cholangiography tube to dilate fferent limb; EUS view revealing a dilatated loop of small bowel. The dilated jejunal loop was targeted with a 19-gauge FNA needle and a blue solution uctioned from the jejunal lumen (red arrow), confirming a good position of the FNA needle into the afferent limb lumen. E, Advancement of a LAMS e afferent limb lumen over the guidewire and deployment of the distal flange (red arrow). F, Dilation of the gastrojejunostomy (red arrow). G, Final scopic view of the proximal end of the LAMS (gastric side). LAMS, lumen-apposing metallic stent.