Jm Gonzalez

Endoscopic ultrasound treatment of vascular complications in acute pancreatitis.

Bleeding due to vascular complications of acute pancreatitis is a rare dangerous condition that is diagnostically and therapeutically challenging, and represents the most life-threatening complication of acute pancreatitis. The overall goal of this report is to present a new potential indication for endoscopic ultrasound (EUS)-guided fine-needle injection in the management of vascular complications of pancreatitis, based on continuous real-time visualization of vessels, color flow, and Doppler. EUS has enabled successful scterotherapy and embolization of the perforating vein of esophagogastric varices and pancreatic pseudoaneurysm, respectively, in a 55-year-old patient with a history of recurrent/chronic alcoholic pancreatitis. This effective procedure represents a minimally invasive therapeutic option and provides an alternative to arterial embolization and surgery in the assessment and management of this category of complications.

Endoscopic ultrasound-guided vascular therapy: is it safe and effective?

Recent developments in therapeutic endoscopic ultrasound (EUS) have enabled new approaches to the management of refractory gastrointestinal bleeding, including EUS-guided sclerotherapy and vessel embolization. Few cases have been reported in the literature. Eight patients were admitted for severe, refractory gastrointestinal bleeding, seven of whom were actively bleeding. Causes of bleeding were gastric varices secondary to portal hypertension (n = 3); gastroduodenal artery aneurysm or fundal aneurysmal arterial malformation (n = 3); and Dieulafoys ulcer (n = 2); the latter five patients having arterial bleeding. During the procedures, the bleeding vessel was punctured with a 19-gauge needle then injected with a sclerosing agent (cyanoacrylate glue [n = 6] or polidocanol 2 % [n = 2]) under Doppler control. The median follow-up time was 9 months (3 - 18 months). In all 10 endoscopic procedures were performed. The procedure was successful at the first attempt in seven out of eight patients (87.5 %). No clinical complications were observed, although in one case there was diffusion of cyanoacrylate in the hepatic artery. The seven successful cases all showed immediate and complete disappearance of the Doppler flow signal at the end of the procedure. This retrospective study highlights the utility of EUS-guided vascular therapy. However, more large randomized studies should be conducted to confirm these results.

First European human gastric peroral endoscopic myotomy, for treatment of refractory gastroparesis.

We have therefore carried out G-POEM in a 51-year-old diabetic woman who suffered from disabling and refractory clinical gastroparesis; this was confirmed with by gastric emptying scintigraphy that showed an increased gastric emptying half-time.

G-POEM with antro-pyloromyotomy for the treatment of refractory gastroparesis: mid-term follow-up and factors predicting outcome

Gastric peroral endoscopic pyloromyotomy (G‐POEM) was introduced for treating refractory gastroparesis.

Gastrojejunal anastomosis using a tissue-apposing stent: a safety and feasibility study in live pigs

BACKGROUND AND STUDY AIMS Various techniques using surgical and natural orifice transluminal endoscopic surgery (NOTES) have been evaluated to create a gastrojejunal bypass. The aim of the current study was to determine the safety, feasibility, and efficacy of a new technique using a pure endoscopic approach and tissue-apposing stent placement for gastrojejunal anastomosis (GJA). MATERIALS AND METHODS This was a prospective, experimental study on six live pigs weighing 20 - 45  kg. Endoscopies were performed using a double-channel gastroscope, and included the creation of a GJA using a tissue-apposing, fully covered, self-expanding metallic stent. Antibiotic therapy was continued for 7 days after the procedure, and food was gradually reintroduced from Day 3. Changes in weight following the procedure were compared with a control group of age-matched animals. Anastomosis functionality was confirmed by endoscopy at 3 weeks (before the animals were euthanized), and during histopathological analysis. The primary outcomes were morbidity and mortality at 3 weeks. Secondary outcomes were technical feasibility, procedure time, and patency of the GJA. RESULTS The procedures were performed successfully in all animals. The mean procedure time was 26  ±  6.7 minutes (range 15 - 32 minutes). One case of stent migration occurred during the procedure; the stent was successfully replaced using the same procedure. All animals were alive after 3 weeks. The mean weight gain during follow-up was 0.85  ±  2.56  kg (range - 2 to + 2  kg) compared with 5.2  ±  1.6  kg (range 3 - 7  kg) in control animals (P = 0.007). At necropsy, the stents were still in place in all animals, without evidence of peritonitis. Histopathology confirmed permeable anastomoses with continuity of the mucosa and mucosa muscle layers. CONCLUSIONS GJA with a tissue-apposing stent is safe, feasible, and reproducible without anastomotic leakage in a porcine model using a pure endoscopic approach and standard endoscopic equipment.

Gastrojejunal Anastomosis Exclusively Using the 'NOTES' Technique in Live Pigs: A Feasibility and Reliability Study

Introduction. Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES. Methods. It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery. Results. The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers. Conclusion. Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.

Efficacy of the endoscopic rendez-vous technique for the reconstruction of complete esophageal disruptions.

BACKGROUND AND STUDY AIMS The rendezvous endoscopic approach, already described, might be an interesting technique in complete esophageal obstructions (CEO). PATIENTS AND METHODS This retrospective report on nine patients referred because of CEO classified patients into two groups based on length of their esophageal disruption: the long (> 5 cm) group were three patients (esophageal stripping at stent removal [n = 2] and caustic ingestion [n = 1]; two patients having superior esophageal sphincter [SES] destruction); the short (< 5 cm) group were six patients (anastomotic or post-radiotherapy). The procedures were performed under radiographic guidance. RESULTS All the reconstructions were successful. In four patients, a neo-SES was created, by transillumination (n = 2) or surgery (n = 2). The first dilation was performed by hydrostatic balloon, with additional metal stents (n = 4) and nasogastric tubes (n = 2) used. All the patients were able to eat after the procedure. Two delayed bleeds occurred, which were managed endoscopically. The patients underwent a median of seven dilations (range 3 - 55) over 8 months (2 - 32 months), with dilations ongoing in five patients, but all able to eat normally. CONCLUSION Endoscopic rendezvous for CEO is safe and effective, even in patients with long disruptions and complete loss of SES.

Treatment of Iatrogenic esophageal perforation: Do we need another tool?

In this issue, Gunnar Loske et al from Hambourg (Germany) reported their experience in 10 patients with esophageal perforations endoscopically managed by Endovacuum Therapy (EVT) 1. They achieved complete healing in all patients. Esophageal perforations are one of the worst iatrogenic perforations that can occur, 2 and really frightening to endoscopists (and cardiologists). Esophageal perforations occur mainly after endoscopic dilatation performed for peptic strictures, malignant strictures, achalasia, anastomotic strictures, and foreign body retrieval, roughly with a rate ranging from 0 % to 3 % 3. Other cases can occur after endoscopic submucosal dissection, with a mean rate of 2.4 %, or after passage of transesophageal blind echocardiography probes, a setting in which the complication is not so rare 2 3. However, mortality related to esophageal perforations is high, with a pool mortality of 11.9 % with either conservative or surgical management and with a long mean hospital stay of 32.9 days 3. It has been established that early recognition of the esophageal perforation is vital and management after 24 hours is clearly associated with an increased rate of mortality 2 3. What weapons are available to endoscopists for management of such perforations? First, we have to underscore that, to achieve the best outcomes, endoscopic treatment must be performed within the first 24 hours so as to avoid mediastinitis or pleural effusion that may require prior surgical drainage. Second, it is not acceptable to perform or to attempt any endoscopic closure without the use of CO² insufflation. Air insufflation is associated with pneumomediastinum, subcutaneous emphysema, diffusion of infection in surrounding tissue, and impaired respiration. The endoscopist can choose the best procedure for performing endoscopic closure based largely on the size of the perforation (25 mm being inaccessible to regular clips) or the location (under the crico-pharyngeal sphincter being the most difficult location for insertion of a stent or clipping). Recent recommendations from the European Society of Gastrointestinal Endoscopy (ESGE) suggest treating perforations < 10 mm with TTS clips, treating perforations ranging from 10 to 25 mm with OTSC clips, and larger perforations with temporary fully covered self-expanding metallic stents (SEMS) 3. However, adequate placement of TTS clips for full thickness repair is not so simple. Fully covered stents have a high migration rate and for perforation located in the esogastric junction, ESGE advises use of partially covered SEMS, which canbe retrieved by the stent-in-stent technique. In two small retrospective series, EVT has been advocated for managing esophageal perforations and found more effective than SEMS or surgery 4 5. In addition, it may be more effective for delayed management because the permanent suction can retrieve bacterial agents or saliva. Other series have shown also shown that EVT is efficient for management of colorectal fistula following surgery, with success rates ranging from 75 % to 88 % 6 7. However the real place for EVT in the management of esophageal perforation was not clearly elucidated in the ESGE guidelines 3. This series reported the results of EVT management in 10 patients. EVT was performed immediately after diagnosis and always within 24 hours. Interestingly, in six cases out of 10, the perforation was in a location difficult to manage endoscopically, four at the level of the cricopharyngeal sphincter and two at the esophagogastric junction. Drainage was removed within the first 2 to 5 days by simple oral withdrawal; 15 placement procedures were ultimately required. All the patients were cured within 3 to 7 days with no need for surgery, other endoscopic interventions or external thoracic drainage. The pattern of the tissue after removal of the foam showed typical granulation tissue then re-epithelialization at follow-up endoscopy. Although this was a small and retrospective study, the series yielded very attractive resuts. All the patients were cured within 1 week without requiring other management. Infection seemed to have been under control and at follow up, there was no evidence of stenosis. Although 15 endosopic procedures were required, that does not appear to be more than would be required with management using a stent. Therefore, EVT appears to be a cost-effective form of endoscopic management that should be compared to OTSC closure. EVT appears to be possible for perforations in all esophageal locations, which is a real advantage. The only problem may be the immediate availability of endoscopic vacuum devices in case of perforation. Perhaps one of these devices should always be available in every Endoscopy Unit. We could suggest to our institutions that EVT is also helpful in colorectal fistula after surgery, during the course of Crohn’s disease, or for treatment of walled-off pancreatic necrosis.

Prospective randomized comparison of endoscopic submucosal tunnel dissection and conventional submucosal dissection in the resection of superficial esophageal/gastric lesions in a living porcine model

Background and study aims: To assess experimentally endoscopic submucosal tunnel dissection (ESTD) as an alternative technique of endoscopic submucosal resection. Patients and methods: This was a prospective, randomized, comparative experimental animal study carried out over a period of 9 months at the surgical research and teaching center of Aix-Marseille University, France. Virtual esophageal and gastric lesions measuring 3 cm in diameter were resected in pigs weighing 25 to 30 kg. The primary aim was to evaluate ESTD’s efficacy compared with endoscopic submucosal dissection (ESD). The secondary aims were to determine complication rates as well as to assess procedure time and procedure speed, histologic quality of the resected specimen, and procedure cost. Results: Eighteen procedures (9 ESD and 9 ESTD) were performed in nine pigs. The technical success rate was 88.9 % for both techniques, with one single failure in each. The en bloc resection rate was 100 % for ESTD and 88.9 % for ESD (one failure). The complication rate (22 %) and median procedure time were similar but dissection speed was quicker with ESTD in the esophagus (P = 0.03). Median procedure cost (728 Euros for ESD and ESTD) did not differ. On histologic examination, the lateral margins were healthy in 100 % of ESTD and in 88.9 % of ESD (P = 0.49). Deep resection margins were of better quality in ESTD (median submucosal thickness: 1307.1 µm vs. 884.7 µm; P = 0.039). Conclusions: ESTD is feasible and safe but not superior in the treatment of superficial esophageal/gastric lesions in porcine models compared with ESD. Nevertheless it provides a better quality histologic specimen.

Endoscopic management of bariatric surgery complications

L’endoscopie digestive est devenue progressivement essentielle au diagnostic et au traitement des complications de la chirurgie bariatrique dont le nombre absolu ne cesse d’augmenter avec l’engouement légitime pour cette prise en charge de l’obésité. Différentes procédures endoluminales permettent de répondre aux problématiques postopératoires, notamment anastomotiques en cas de RYGB (Roux en Y Gastric bypass) et de la ligne d’agrafage pour la sleeve gastrectomy (SVG) (Tableau 1). Le point fort de l’endoscopie est son excellent profil de tolérance, y compris en situation aiguë et en période postopératoire précoce, notamment grâce à l’usage de l’insufflation au CO. De façon intéressante, les complications chirurgicales dans ce domaine ont poussé les endoscopistes à développer de nouvelles techniques, de nouveaux matériaux et concepts thérapeutiques innovants, contribuant probablement à l’avènement d’une nouvelle discipline médicochirurgicale : l’endoscopie chirurgicale.