Giuseppe Grande

Single-step endoscopic ultrasound-guided fluoroless gallbladder drainage using the Axios lumen-apposing metal stent

Severe acute cholecystitis is a condition that requires urgent surgical intervention to prevent sepsis and death. Elderly patients can be unfit for surgery because of comorbidities so alternative techniques are required for gallbladder drainage [1]. Here we report the case of a 93-year-old woman with abdominal pain, fever, and vomiting who was referred to our unit to undergo gallbladder drainage. An abdominal computed tomography (CT) scan showed cholelithiasis, gallbladder distension with wall thickening, and peri-cholecystic fluid. However, because of renal and cardiorespiratory comorbidities, the patient was judged unfit for surgery. Fluoroless endoscopic ultrasound (EUS)guided transluminal gallbladder drainage was therefore performed using a fully covered metal stent (10mm in diameter; Hot Axios, Boston Scientific Inc., Natick, Massachusetts, USA). The gallbladder was directly punctured using the cautery tip of the device. This was possible owing to a favorable position of the gallbladder, which was closely abutting the duodenum. The lumen-apposing metal stent (LAMS) was then deployed, with subsequent rapid drainage of the gallbladder. The patient became asymptomatic in the days following the procedure andwas discharged 5 days later. EUS-guided transmural gallbladder drainage, which has been practiced since 2007, requires multiple steps and devices to achieve gallbladder access, dilation of the duodenal wall, and stent deployment [1]. The need for device exchange over a wire can result in an increased risk of adverse events, such as perforation, bleeding, and infection. Furthermore, until now, the stents used for these indications have had to be borrowed from those intended for use during endoscopic retrograde cholangiopancreatography (ERCP). The Axios system is a new specifically designed fluoroless EUS-guided fully covered lumen-apposing metal stent, which is used for drainage of pancreatic fluid collections, the gallbladder, and the bile duct [2,4,5]. The Axios delivery system provides good maneuverability and visibility, making the sheath suitable for direct puncture. Our experience suggests that EUS-guided gallbladder drainage should be considered as a first option in patients unfit for surgery [3]. This new device may be easier to deploy than other stents and maintains good apposition of the two walls to create an iatrogenic anastomosis.

Over-the-scope clip closure for treatment of post-pancreaticogastrostomy pancreatic fistula: A case series.

The over‐the‐scope clip (OTSC) system is a recently developed endoscopic device. In the last few years, it has been successfully used for severe bleeding or deep wall lesions, or perforations of the gastrointestinal (GI) tract. We hereby report a series of patients with post‐pancreaticogastrostomy pancreatic fistula in whom OTSC were used as endoscopic treatment.

The Role of Colonoscopy in the Diverticular Disease.

Colonic diverticula are one of the most frequent conditions found during the endoscopic examination of the lower digestive tract, interestingly in >70% of people after 80 years old. Of them, only a few percentage develop complications such as acute diverticulitis or diverticular bleeding. Up to now, colonoscopy represents the most important diagnostic and therapeutic tool on the hands of the clinicians. On the basis of this the need for a standardized and reproducible approach is now emerging. This short review article is tasked to point out some open issues concerning the role of colonoscopy in diverticular disease.

The “three-in-one” formulation of bismuth quadruple therapy for Helicobacter pylori eradication with or without probiotics supplementation: Efficacy and safety in daily clinical practice

Clinical trials have shown a good efficacy of the “three‐in‐one” formulation of bismuth quadruple therapy (BQT) for Helicobacter (H.) pylori eradication. We aimed to assess the efficacy and safety of the three‐in‐one BQT in clinical practice, and investigate the effect of probiotic supplementation, in Italy.

Endoscopic papillary large balloon dilation in patients with large biliary stones and periampullary diverticula: Results of a multicentric series

INTRODUCTION Stone extraction represents the most frequent indication for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic papillary large balloon dilation (EPLBD) is a recent introduced approach consisting of an endoscopic papillary large balloon dilation following limited endoscopic sphyncterotomy (ES), which has been proven to be safe and effective for extraction of large common bile duct (CBD) stones. Peri-ampullary diverticula (PAD) are described in 10-20% of patients undergoing ERCP. Aim of our study is to evaluate efficacy and safety of EPLBD for the extraction of large biliary stones in patients with PAD. METHODS The prospectively collected endoscopy databases of 4 Italian ERCP high-volume centers were reviewed retrospectively, and all consecutive patients with an instrumental diagnosis of large biliary stones and PAD, between September 2014 and October 2016, were included in this study. RESULTS Eighty-one patients (36 males, median age 75 years) were treated between September 2014 and October 2016. Deep biliary cannulation was reached in 78/80 patients. Successful extraction was achieved in 74/78 patients at the first attempt. AEs occurred in 8 patients (1 severe). Younger age, stone size and incomplete stone extraction were significantly associated with AEs. CONCLUSIONS EPLBD is an effective and safe technique in patients with PAD and large biliary stones, which avoids the need of other techniques, thereby reducing the risks of adverse events.

Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: Systematic review and meta-analysis

BACKGROUND AND AIM The aim of this systematic review and meta-analysis was to assess the risk of post-polypectomy bleeding (PPB) in patients that underwent colorectal polypectomy and exposed to ASA/NSAIDs. METHODS Relevant publications were identified in MEDLINE/EMBASE for the period 1950-2016. Studies with specified ASA/NSAIDs exposure and bleeding rate were included. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was based on fixed or random effect models in relation to the heterogeneity. RESULTS 11 studies (4 prospective and 7 retrospective) including 9307 patients were included in the analyses. Overall, 344 patients (OR 1.8; 95% CI 1.2-2.7; p-value 0.001, I2 52%) experienced rectal bleeding after procedure. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR 1.1; CI 95% 0.6-2.1; d.f.=1, p=0.64, I2 0%), the risk of delayed PPB was augmented (OR 1.7; 95% CI 1.2-2.2; d.f.=8, p=0.127, I2 36%). CONCLUSIONS ASA/NSAIDs are not a risk factor for immediate PPB but the chance of delayed is increased.

Endoscopic retrograde cholangiography after endoscopic ultrasound-related duodenal perforation: keep calm, use over-the-scope clip, and carry on!

The over-the-scope clip (OTSC) is a useful tool recommended as first-line endoscopic treatment for endoscopic acute iatrogenic perforation [1]. A retrospective study documented that OTSCs can avoid emergency surgical repair, allowing, in some cases, completion of the primary endoscopic procedure. As documented only once in the literature, its use could allow subsequent endoscopic procedures to be performed in the same session, owing to the endurance of the device during pneumatic and mechanical stress [2]. Here we report the video case of a 93-year-old woman who was referred to our unit to undergo biliopancreatic endoscopic ultrasound (GF-UCT 180; Olympus Co., Tokyo, Japan) for suspected choledocholithiasis, in the context of acute cholangitis; the patient was not a suitable candidate for surgery (cholecystectomy). After multiple biliary stones were detected in the common bile duct, a perforation was apparent in the wall of the superoanterior duodenal bulb. Because of the size of the perforation (about 15mm), an OTSC (11/6mm traumatic type; Ovesco Endoscopy GmbH, Tübingen, Germany) was applied using the suction technique to completely seal the defect [3]. As no further leakage was apparent following injection of contrast medium and the patient’s clinical conditionwas stable, endoscopic retrograde cholangiography (ERC; TJF-160 VR; Olympus Co.) with extraction of multiple biliary stones was performed in the same session (▶Video1). All procedures were performed with anesthesiological assistance, using carbon dioxide insufflation. ERC took about 45 minutes for complete biliary drainage (▶Fig. 1). The subsequent contrast medium (▶Fig. 2) and computed tomography scan with oral gastrographin confirmed the complete closure, despite the longlasting pneumatic and mechanical stress. No further complication occurred and the asymptomatic patient was discharged 1 week later. In conclusion, prompt endoscopic treatment using OTSCs represents an effective approach that can avoid later complications or surgical repair. Furthermore, the use of OTSCs can allow the completion of endoscopic procedure(s) in the same session, as the clips can endure prolonged pneumatic and mechanical stress.

Endoscopic dissection of a symptomatic giant gastric leiomyoma arising from the muscularis propria

Gastrointestinal (GI) subepithelial masses represent a heterogeneous group of lesions, ranging from benign to malignant, for which management is sometimes challenging [1, 2]. We report the case of an 85-year-old woman, with a history of coronary artery disease and chronic atrial fibrillation being treated with anticoagulant therapy, who underwent urgent upper GI endoscopy for hemorrhagic shock andmelena. During this procedure, a giant, 15-cm, non-pedunculated mass that was ulcerated on top was found at the greater curvature of the anterior wall of the stomach (▶Fig. 1). The patient then underwent radial endoscopic ultrasonography (EUS; GF-UE160AL5; Olympus), which showed a hypoechoic homogeneous intramural mass that was arising from the muscularis propria andwas suspected to be a leiomyoma (▶Fig. 2). In order to achieve a definitive diagnosis, EUS with fine needle aspiration (FNA) was performed (GF-UCT180; Olympus) using a 22-gauge needle (ExpectSlimLine; Boston Scientific). Histology and immunohistochemical staining revealed that the specimen was compatible with a leiomyoma (SMA positive, CD117 and CD34 negative). Total body computed tomography (CT) excluded metastatic disease. Because this was a symptomatic hemorrhagic lesion and there was a need to continue anticoagulant therapy, an endoscopic dissection was performed. We used the HybridKnife T-type (ERBE Elektromedizin GmbH) and a solution composed of 250mL normal saline, 2mL indigo carmine, and 1mL epinephrine. The procedure took 115 minutes and resulted in an en bloc specimen, with no complications occurring (▶Fig. 3; ▶Video1). However, because of its size, it was not possible to retrieve the whole lesion, which resulted in it being completely digested by gastric secretions by the following day (▶Fig. 4). Low molecular weight heparin was re-introduced 24 hours after the procedure and the patient was discharged 2 days later. Upper GI endoscopy and EUS performed 3 months later revealed a regular scar, without any remnant pathological tissue. This case illustrates the feasibility and safety of endoscopic dissection of a symptomatic giant gastric leiomyoma, even in a high risk patient who was receiving ongoing anticoagulant therapy, in whom surgery would have carried considerable risk. Moreover, EUS-FNA achieved an accurate evaluation of the lesion’s layer of origin and its histopathologic characteristics, thereby allowing a definitive diagnosis to be made and the appropriate therapeutic option to be chosen.

Quick, safe and effective repair of EUS-related duodenal perforation using over-the-scope clip system (with video).

Duodenal perforation is a rare but potentially life-threating complication of bilio-pancreatic endoscopic-ultrasound (EUS) examination. Here we report a case of 90 yeas-old patient underwent to EUS with curvilinear ecoendoscope and complicated by duodenal wall perforation. As reported in our case, Over-the-scope clipping system represents a quick, safe and effective approach in order close the leak and prevent further complication.

Endoscopic Treatment of Stent-Related Esophagobronchial Fistula

A 64-year-old man suffering from progressive dysphagia due to malignant esophageal stenosis was admitted for the onset of cough that worsened after meals and shortness of breath. The patient had been treated 2 weeks before with the placement of a partially covered self-expandable metal stent in the upper-mid esophagus (Niti-S Doubletype, 22x80 mm, Taewoong Medical, Seoul, South Korea). A chest x-ray showed no abnormalities, but a subsequent upper gastrointestinal tract x-ray with contrast showed the passage of gastrografin (Bayer, Germany) within the mainstream left bronchus, starting from the lower end of the esophageal stent (Figure 1). An upper endoscopy confirmed the suspicion, showing a small orifice in the esophageal wall, closer to the lower end of metallic stent (Figure 2).