Juliana Yang

Sa1934 ENDOSCOPIC FULL THICKNESS RESECTION USING A CLIP NON-EXPOSED METHOD FOR GASTROINTESTINAL TRACT LESIONS: A META-ANALYSIS

Background and study aims Endoscopic full-thickness resection (EFTR) allows for treatment of epithelial and subepithelial lesions (SELs) unsuitable to conventional resection techniques. This meta-analysis aimed to assess the efficacy and safety of clip-assisted method for non-exposed EFTR using FTRD or over-the-scope clip of gastrointestinal tumors. Methods A comprehensive literature search was performed. The primary outcome of interest was the rate of histologic complete resection (R0). Secondary outcomes of interest were the rate of enbloc resection, FTR, adverse events, and post-EFTR surgery. Random-effects model was used to calculate pooled estimates and generate forest plots. Results Eighteen studies with 730 patients and 733 lesions were included in the analyses. Indications for EFTR were difficult/residual colorectal adenoma, adenoma at a diverticulum or appendiceal orifice and early cancer (n=634), colorectal SELs (n =42), and upper gastrointestinal lesions (n = 51), other colonic lesions (n =6). Median size of lesions was 13.5mm. There were 22 failed EFTR attempts. Pooled overall R0 resection rate was 82% (95% CI: 75, 89). The pooled overall FTR rate was 83% (95% CI: 77, 89). The pooled overall enbloc resection rate was 95 (95% CI: 92, 96). The pooled estimates for perforation and bleeding were <0.1% and 2%, respectively. Following EFTR, a total of 110 patients underwent surgery for any reason [pooled rate 7% (95% 2, 14). The pooled rates for post-EFTR surgery due to invasive cancer, for non-curative endoscopic resection and for adverse events were 4%, <0.1% and <0.1%, respectively. No mortality related to EFTR was noted. Conclusions EFTR appears to be safe and effective for gastrointestinal lesions that are not amenable to conventional endoscopic resection. This technique should be considered as an alternative to surgery in selected cases. Original article Supplementary material Online content viewable at: https://doi.org/10.1055/a-1073-7593 Brewer Gutierrez Olaya I et al. Endoscopic full-thickness resection... Endoscopy International Open 2020; 08: E313–E325 E313 Published online: 2020-02-21

Successful single-session cricopharyngeal and Zenker’s diverticulum peroral endoscopic myotomy

Therapy of symptomatic Zenker’s diverticulum can be accomplished with open surgery, rigid endoscopy, or flexible endoscopy [1]. Peroral endoscopic myotomy (POEM) can be used to treat Zenker’s diverticulum using the principles of submucosal tunneling. Zenker’s POEM has potential advantages over traditional endoscopic septotomy, including complete septum division and mucosal integrity during septotomy. Importantly, Zenker’s POEM may be associated with a decreased risk of symptom recurrence, because of the complete exposure and dissection of the septum (▶Table 1). We describe a patient with a hypertensive cricopharyngeus muscle and Zenker’s diverticulum successfully treated with POEM in the same session. A 94-year-old woman with a past medical history of hypertension and atrial fibrillation was referred with daily symptoms of solid and liquid food dysphagia and regurgitation, which occurred with every meal. She denied weight loss and dyspnea. A barium esophagogram revealed a 4-cm Zenker’s diverticulum and the decision was made to perform Zenker’s POEM. A diagnostic gastroscope fitted with a clear cap was advanced. A very tight cricopharyngeus muscle was noted at 17 cm from the incisors and a large Zenker’s diverticulum was identified. A mucosal bleb was created 2 cm above the cricopharyngeus muscle at 15 cm from the incisors. A 1.5-cm incision was made with a triangle-tip knife using a predetermined electrocautery setting. The submucosal fibers were dissected with spray coagulation and the endoscope was advanced to the submucosal space. A submucosal tunnel was created using spray coagulation and injection of saline with indigo carmine solution via the pump (▶Fig. 1 a). When vessels were identified they were treated using a coagulation grasper with soft coagulation. The septum of the Zenker’s diverticulum was identified. After the tunnel on the esophageal side of the septum had been completed, the tunnel on the diverticular side was commenced and completed with complete exposure of the septum (▶Fig. 1b). Septotomy was then performed using a combination of the insulated-tip knife and the triangle-tip knife with spray coagulation current. After the septotomy had been completed, the tight cricopharyngeus muscle was identified and cricopharyngeal myotomy was performed using the insulated-tip knife in retrograde fashion (▶Fig. 1 c). This resulted in easy passage of the endoscope ▶Table 1 Comparison between standard endoscopic septotomy and the POEM technique in the treatment of Zenker’s diverticulum.

Endoscopically guided percutaneous suturing to facilitate closure of a large gastrocutaneous fistula with an over-the-scope clip

Persistent gastrocutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal is an uncommon complication [1]. Advances in endoscopy have enabled endoscopic closure of these defects with a multitude of modalities, including argon plasma coagulation (APC), endoscopic suturing, and over-the-scope clips (OTSCs) [2–4]. Percutaneous endoscopic suturing has recently been described for closure of GCF (▶Fig. 1, ▶Video1) [5]. We describe the case of a 24-year-old man with a history of acquired immunodeficiency syndrome and disseminated Mycobacterium avium complex, who was not compliant with medical treatment. For 6 months he had experienced increasing discharge from a former PEG site (the PEG tube had been removed 10 years previously). On upper endoscopy he had a large GCF (▶Fig. 2). APC was applied to the fistula tract and surrounding tissue (▶Fig. 3). Two interrupted sutures were used to close the defect using the overstitch device (Apollo Endosurgery, Austin, Texas, USA). The was no evidence of a leak from the cutaneous side of the fistula after closure. The patient resumed a full diet and was placed on acid suppression therapy. He re-presented 2 weeks later with recurrent leakage from the GCF. On upper endoscopy, the GCF had reopened and the sutures had loosened (▶Fig. 4). APC was again applied to the GCF. Then, two E-Videos

Rendezvous recanalization of a postoperative coloanal anastomotic dehiscence with a lumen-apposing metal stent

LAMSs have been successfully used for the recanalization of complete colorectal anastomotic obstructions [1, 2]. However, there are no reports of using LAMSs in the treatment of coloanal anastomotic dehiscence. A 51-year-old man with a rectosigmoid tumor underwent low anterior resection. His surgery was then complicated by leakage, which was treated by proctectomy, coloanal anastomosis, and creation of a diverting ileostomy. On followup sigmoidoscopy, the anastomosis appeared to have dehisced and no lumen to the proximal colon was identified. Therefore, a rendezvous approach was planned for the treatment of coloanal anastomotic dehiscence. An upper gastrointestinal (GI) endoscope was advanced transanally to the coloanal anastomosis, while a pediatric colonoscope was advanced towards the anastomosis through the loop ileostomy (▶Fig. 1). With the use of fluoroscopic guidance and transillumination, the dehiscent coloanal anastomosis was identified. A guidewire was advanced in an antegrade direction and was captured from the anus. A 15×10-mm LAMS was then inserted over the wire from the anal side and successfully deployed across the anastomosis (▶Fig. 2 and ▶Fig. 3; ▶Video1). The patient was discharged home in good condition 1 day after the procedure. After 2 months, a flexible sigmoidoscopy was carried out, in which the stent was removed with a forceps. The upper GI endoscope was advanced to a point proximal to the anastomosis, which was noted to be widely patent (▶Fig. 4). The stent was then reloaded into the therapeutic upper ▶ Fig. 1 Fluoroscopic image showing the rendezvous approach. ▶ Fig. 2 Endoscopic view showing proper deployment of the stent across the dehiscence. ▶ Fig. 3 Fluoroscopic image showing the lumen-apposing metal stent in situ.