John A. Evans

Using external magnet guidance and endoscopically placed magnets to create suture-free gastro-enteral anastomoses

BackgroundTo facilitate endolumenal and natural orifice procedures, this study evaluated a novel technique using external and endoscopically placed magnets to create suture-free gastroenteral anastomoses.MethodsSeven anesthetized adult swine underwent endoscopic placement of magnets into the small bowel and stomach. Using external magnets, the endoscopically placed internal magnets were brought into opposition under endoscopic view. After 1–2xa0weeks, the pigs were killed and analyzed. At laparotomy and under sterile conditions, peritoneal cultures were obtained. The anastomoses were evaluated endoscopically and tested using an air insufflation test. Finally, the anastomoses were resected and evaluated microscopically.ResultsThe average operative time for endoscopic placement of the magnets was 34.3xa0±xa014.8xa0min. Successful placement and creation of anastomoses occurred in six of the pigs. One pig did not form an anastomosis because the magnets were too large to pass through the pylorus at the time of attempted magnet placement. Six swine experienced uncomplicated postoperative courses. One pig’s postoperative course involved constipation for several days, requiring additional fluids and fiber supplementation. The findings at endoscopy showed that the magnets were adhered to the anastomosis, which were easily freed, or within the stomach. The air insufflation test results were negative for all the pigs. At laparotomy, there was no evidence of infection, abscess, or leak, but two peritoneal culture results were positive with scant growth of Staphylococcus aureus and coagulase-negative staphylococcus, presumably contaminants. Microscopically, the anastomoses illustrated granulation and fibrous connective tissue without evidence of infection or leak.ConclusionEndoscopically placed magnets with external magnet guidance is a feasible and novel approach to creating patent gastroenteral anastomoses without abdominal incisions or sutures.

Pancreas Cystic Lymphangioma Diagnosed with EUS-FNA

CONTEXTnEndoscopic ultrasound has proved to be an invaluable tool when obtaining high quality images of the pancreas. Furthermore, fine-needle aspiration of suspected lesions can be carried out simultaneously thus providing tissue samples for cytologic diagnosis. We present two cases of a rare pancreatic lesion that were diagnosed by endoscopic ultrasound with fine-needle aspiration. CASE #1: A 60-year-old asymptomatic gentleman was found to have an incidental pancreatic lesion on abdominal computed tomography scan during a cardiac workup. Patient had no personal or family medical history that would predispose him to pancreatic lesions. Endoscopic ultrasound was performed and patient was diagnosed with pancreatic cystic lymphangioma. CASE #2: A 40-year-old asymptomatic gentleman with history of heavy alcohol use was found to have an incidental pancreatic lesion on computed tomography scan during a work up of chest pain. Computed tomography guided fine-needle aspiration was negative for malignancy but no other studies were performed on the fluid sample at that time. Patient was then referred to our institution after repeat computed tomography scan showed a stable lesion. Endoscopic ultrasound did not show evidence of pancreatitis and fine-needle aspiration was consistent with pancreatic cystic lymphangioma.nnnDISCUSSIONnThe universally available and escalating use of computed tomography scans has led to an increased detection of incidental cystic pancreatic lesions. Pancreatic cystic lymphangiomas are a rare lesion and account for less than one percent of all pancreatic cystic lesions. These lesions are easily and accurately diagnosed by the use of endoscopic ultrasound guided fine-needle aspiration.

A novel method for performing multiple wire insertions during endoscopic cyst gastrostomy

BACKGROUNDnEndoscopic cyst gastrostomy is effective in the management of uncomplicated pancreatic pseudocysts. A challenging aspect of the procedure is the insertion and confirmation of at least 2 guidewires into the cyst. Many technical procedures to accomplish the wire insertion have been described but are complicated.nnnOBJECTIVEnWe describe the use of a simple commercially available catheter that allows multiple wires to be inserted into a pancreatic pseudocyst as an efficient and simple means of performing a cyst gastrostomy.nnnDESIGNnCase series.nnnSETTINGnAcademic referral center.nnnPATIENTSnFour consecutive patients undergoing EUS-guided cyst gastrostomy.nnnINTERVENTIONSnA Haber ramp was used as the means for the introduction of multiple wires into a pancreatic pseudocyst.nnnMAIN OUTCOME MEASUREMENTSnTechnical success without loss of wire access during the cyst gastrostomy.nnnRESULTSnFour patients underwent successful pancreatic cyst gastrostomy. There was no loss of wire access during the procedure. There were no intraprocedure or postprocedure complications.nnnLIMITATIONSnSmall patient population.nnnCONCLUSIONSnThe use of the Haber ramp provides a simple and efficient means for introducing, ensuring, and maintaining wire access during the creation of an endoscopic cyst gastrostomy.

Difficult Biliary Cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure routinely performed by endoscopists. ERCP cannulation requires the insertion of a subcentimeter catheter through a tiny orifice at a distance of almost a meter from the operator. Only after successful cannulation of the bile duct can the real “business” of ERCP be performed (eg, sphincterotomy, stone extraction, stent placement). Selective bile duct cannulation is all the more exacting due to the occasional anatomic challenge (eg, postsurgical anatomy, duodenal stricture) or wayward catheter. Serious morbid complications can and do occur, even in the hands of the most gifted and facile endoscopists. Although there are some “tricks” to facilitate successful cannulation of the bile duct, experience “trumps” all tricks. Of greatest importance when faced with a difficult cannulation is the recognition of one’s personal limitations.

Characteristic endoscopic ultrasound findings of ampullary lesions that predict the need for surgical excision or endoscopic ampullectomy

Background and Objectives: The management of ampullary lesions has evolved to include endoscopic ampullectomy (EA) as a curative approach to cancers of the ampulla of Vater. With this change comes a need to risk-stratify patients at initial diagnosis. Materials and Methods: Patients with verified ampullary lesions (N = 50) were analyzed in a case-control design. We evaluated endoscopic ultrasound (EUS) data to define characteristics that yield a high sensitivity in selecting candidates for EA. Results: Using data from previously published studies yielded a sensitivity of 0.765 in appropriately identifying the 34 surgical cases. Expanding these characteristics increased the sensitivity of EUS to 0.971 in identifying surgical candidates. Additionally, of advanced disease cases, the expanded characteristics correctly identified these cases with a sensitivity of 1.0-improved over 0.708 using prior published data. Conclusion: EA should be strongly considered if ampullary lesions are found to fit the following characteristics after EUS evaluation: lesion size <2.5 cm, invasion ≤4 mm, pancreatic duct dilatation ≤3 mm, ≤T1 lesion, no lymph nodes present, and no ductal stent in place. Furthermore, EUS data can be used to identify all high-risk lesions. With these characteristics identified, clinicians are better able to risk-stratify patients using EUS as either appropriate for or too high-risk for endoscopic resection.

Endoscopic closure of persistent gastric leak and fistula following laparoscopic sleeve gastrectomy

Highlights • LSG leaks often complicate post-operative recovery and require additional surgery.• Current non-invasive measures for LSG leaks can increase morbidity.• Endoscopy may serve as advancement in non-invasive management using materials in an innovative method.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMSnThe obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP.nnnMETHODSnThis is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated.nnnRESULTSnA total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred.nnnCONCLUSIONSnOur large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.