Juan P. Gutierrez

Over-the-scope clip-assisted method for resection of full-thickness submucosal lesions of the gastrointestinal tract.

BACKGROUND AND STUDY AIMS The over-the-scope clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) is deployed after suctioning tissue into the cap. The tissue may then be resected endoscopically. The aim of this study was to evaluate the efficacy and safety of the OTSC for the endoscopic resection of gastrointestinal tumors. PATIENTS AND METHODS This was a retrospective, observational cohort study of patients undergoing endoscopic resection of submucosal lesions. RESULTS Eight patients underwent endoscopic resection of neuroendocrine tumors (NETs) of the duodenum (n = 4), rectum (n = 1), or stomach (n = 2), or granular cell tumor (GCT) of the esophagus (n = 1). The mean size of the lesions was 13.4 mm (range 9 - 20 mm). Application of the clip was successful in all patients. A successful endoscopic resection was accomplished in all. A complete resection (R0) was accomplished in 7/8 patients (87.5 %). A full-thickness resection was achieved in 2/8 (25.0 %), one in a patient with a gastric NET and the other in a patient with GCT of the esophagus. There were no complications. CONCLUSIONS This case series suggests that the OTSC system may be a valuable tool for the resection of submucosal lesions, but further prospective and randomized studies are necessary to assess the indications and outcome.

Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding

Background and study aim: The novel over-the-scope clip (OTSC) allows for excellent apposition of tissue, potentially permitting hemostasis to be achieved in various types of gastrointestinal lesions. This study aimed to evaluate the usefulness and safety of OTSCs for endoscopic hemostasis in patients with upper gastrointestinal bleeding in whom traditional endoscopic methods had failed. Patients and methods: A retrospective case series of all patients who underwent placement of an OTSC for severe recurrent upper gastrointestinal bleeding over a 14-month period was studied. Outcome data for the procedure included achievement of primary hemostasis, episodes of recurrent bleeding, and complications. Results: Twelve consecutive patients (67 % men; mean age 59, range 29 – 86) with ongoing upper gastrointestinal bleeding despite previous endoscopic management were included. They had a mean ASA score of 3 (range 2 – 4), a mean hemoglobin of 7.2 g/dL (range 5.2 – 9.1), and shock was present in 75 % of patients. They had all received packed red blood cells (mean 5.1 units, range 2 – 12). The etiology of bleeding was: duodenal ulcer (n = 6), gastric ulcer (n = 2) Dieulafoy lesion (n = 2), anastomotic ulceration (n = 1), Mallory – Weiss tear (n = 1). Hemostasis was achieved in all patients. Rebleeding occurred in two patients 1 day and 7 days after OTSC placement. There were no complications associated with OTSC application. Conclusions: OTSC use represents an effective, easily performed, and safe endoscopic therapy for various causes of severe acute gastrointestinal bleeding when conventional endoscopic techniques have failed. This therapy should be added to the armamentarium of therapeutic endoscopists.

Endoscopic extra-cavitary drainage of pancreatic necrosis with fully covered self-expanding metal stents (fcSEMS) and staged lavage with a high-flow water jet system

Aim: To present a novel, less-invasive method of endoscopic drainage (ED) for walled-off pancreatic necrosis (WON).We describe the feasibility, success rate, and complications of combined ED extra-cavitary lavage and debridement of WON using a biliary catheter and high-flow water jet system (water pump). Patients and methods: Endoscopic ultrasound (EUS)-guided drainage was performed with insertion of two 7-Fr, 4-cm double pigtail stents. Subsequently a fully covered self-expanding metal stent (fcSEMS) was placed. The key aspect of the debridement was the insertion of a 5-Fr biliary catheter through or along the fcSEMS into the cavity, with ensuing saline lavage using a high-flow water jet system. The patients were then brought back for repeated, planned endoscopic lavages of the WON. No endoscopic intra-cavitary exploration was performed. Results: A total of 17 patients (15 men, 2 women; mean age 52.6, range 24 – 69; mean American Society of Anesthesiologists [ASA] score of 3) underwent ED of WON with this new method. The mean initial WON diameter was 9.5 cm, range 8 to 26 cm. The total number of ED was 84, range 2 to 13. The mean stenting period was 42.5 days. The mean follow-up was 51 days, range 3 to 370. A resolution of the WON was achieved in 14 patients (82.3 %). There were no major complications associated with this method. Conclusion: ED of complex WON with fcSEMS followed by repeated endoscopic extra-cavitary lavage and debridement using a biliary catheter and high-flow water jet system is a minimally invasive, feasible method with high technical and clinical success and minimal complications.

New technique to carry out endoscopic necrosectomy lavage using a pump

Aggressive intra-cavitary endoscopic drainage of complex pancreatic fluid collections (PFC) including pancreatic necrosis is well established. However, current data show that utilization of multiple plastic and/or self-expanding metal stents also leads to resolution of complex necrotizing PFC. Nevertheless, the presence of stents does not guarantee complete resolution of the collection and repeated endoscopies with lavage are thus necessary. Herein, we present a simple and novel method of endoscopic drainage for pancreatic necrosis using a water pump. A 63-year-old man with an extensive walled-off necrosis (WON) that measured 18.6 × 6.1 cm (Fig. 1a) was referred to Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama, Birmingham, USA. Endoscopic ultrasound (EUS)-guided drainage was done with insertion of two 7-Fr, 4-cm double pigtail stents resulting in minimal drainage of thick purulent material. During a second session, a 10 × 80-mm fully covered self-expanding metal stent (fcSEMS) was placed (Fig. 1b,c). Subsequently, the pancreatic necrosis cavity was lavaged with normal saline using an ultra-slim endoscope and a 5-Fr biliary cannula attached to a water-irrigation pump (Olympus endoscopic flushing pump; Olympus America, Center Valley, PA, USA) (Fig. 2). During lavage, a large number of thick necrotic particles were removed. This material emerged through the fcSEMS and exited into the stomach. In addition, repetitive suction was used to remove the thick liquid through the scope. During the entire procedure, careful attention was paid to recover all the injected fluid. A total of 0.7 L was introduced and retrieved. This procedure was repeated on five occasions for 3 days. The patient had an outstanding outcome and was promptly discharged home. In summary, placement of fcSEMS and saline lavage using our proposed water-irrigation-pump method was essential for success in the present case. We believe that carrying out endoscopic necrosectomy lavage using this novel waterirrigation-pump technique using CO2 insufflation may be an efficient method for the therapy of complex PFC.

To anchor or not to anchor self-expanding metal stents in malignant esophageal disease: Is this still a question?

are one of the main pillars for the palliative therapy of esophageal cancer [1]. Furthermore, SEMSs are also useful to treat a myriad of esophageal conditions, including benign stenosis, anastomotic insufficiency after gastroesophageal operations, and various types of leaks, perforations, and fistulae [2–4]. When Symonds inserted the first stent for the palliation of esophageal cancer, it was a rudimentary tube made of rubber originating from the tropical tree gutta percha [5]. Although these rubber stents improved the patient’s ability to ingest some nutrients, mainly liquids and semi-liquids, they soon became dislodged and migrated distally. Thus, the advent of the fully or partially covered SEMS was a major breakthrough in the therapy and palliation of esophageal diseases [1, 6, 7]. Nonetheless, despite improvements in design, with proximal or mid-stent tulips, various shapes and diameters, and the presence of outward, expansive radial forces, these SEMSs still have high migration rates [2, 6–9]. Therefore, experts all over the world have proposed additional methods to prevent stent migration, including strings, throughand over-the-scope clips (OTSCs), and suturing devices [3, 4, 6,10–12]. A common misconception is that in the presence of stenotic esophageal disease due to intrinsic or extrinsic neoplasms, SEMS migration occurs only rarely. However, this is not the case, especially in patients with malignant dysphagia and strictures that allow passage of the endoscope, and in those who have undergone chemoand/or radiation therapy [6, 7]. For this reason, the study by Watanabe et al., presented in this issue of Endoscopy International Open, is interesting [13]. The investigators from Fukushima, Japan, present the first study evaluating the feasibility of esophageal SEMS fixation with an OTSC for patients with malignant esophageal stricture. The investigators set out not only to determine the technical success of this technique, but also to investigate the clinical success, which was defined as an improvement of at least 1 grade in the dysphagia score 1 week after stent placement. A total of 12 patients with malignant esophageal strictures and a dysphagia score of at least 2 who were not candidates for curative surgery were included. The technical success rate was 100 % and successful application of the OTSC was accomplished in all SEMS placements, with a median procedure time required for OTSC placement of 11 minutes, and no adverse events. The clinical success rate was 92.3%, with only one patient not showing improvement in dysphagia. The median follow-up period after SEMS placement was 2 months and no delayed adverse events, including migration of the SEMS, were observed during this follow-up period. In summary, this study showed that SEMS placement and fixation with an OTSC for malignant esophageal strictures was successfully, safely, rapidly, and easily accomplished in all cases, and resulted in dysphagia resolution in the majority of patients. Does this mean that all patients with malignant dysphagia require stent fixation after stent placement? The answer is definitely not. However, the practicing endoscopist should be aware that stent fixation should be considered in a significant percentage of patients with malignant dysphagia (i. e. those in whom the scope can still pass through the stenosis, patients receiving or who have received chemoand/or radiation therapy), and in most patients with benign disease [6, 10–12]. Is the additional cost associated with stent fixation worth it? We believe that the costs are justified because stent migration To anchor or not to anchor self-expanding metal stents in malignant esophageal disease: Is this still a question?