Marco A. D’Assuncao

Insertion of fully covered self-expandable metal stent during balloon-assisted ERCP in patient with surgically altered upper gastrointestinal anatomy

The presence of complex, surgically altered gastrointestinal (GI) anatomy poses a diagnostic and therapeutic challenge to the endoscopist treating patients with pancreaticobiliary disorders. Placing fully covered metal stents into the bile duct during endoscopic retrograde cholangiopancreatography (ERCP) through standard forward-viewing scopes, such as doubleand single-balloon enteroscopes and colonoscopes, is impossible as the working channel is too small, even with the new-generation short double-balloon enteroscopes [1, 2]. Herein, we present a novel technique to insert fully covered metal stents into the bile duct using balloon-assisted ERCP, whereby the overtube is used as a giant working channel. A 43-year male patient who had undergone Whipple operation with Roux-en-Y hepaticojejunostomy for a “pancreatic cyst” (or choledochal cyst) at age 3 years presented with choledocholithiasis and cholangitis. The magnetic resonance cholangiopancreatography showed a tight hepaticojejunostomy stricture and dilated bile ducts full of stones. ERCP failed at two different medical centers using traditional methods. We performed a double-balloon enteroscopy-assisted ERCP (▶Video1). The hepaticojejunostomy was very narrow. A long (650 cm) guidewire (Metro; Cook Medical, Bloomington, Indiana, USA) was advanced through the narrow opening of the hepatico-jejunal anastomosis. A catheter was advanced over the long wire. Cholangiography revealed a tight and short anastomotic stricture (▶Fig. 1, ▶Video1). The hepaticojejunostomy was dilated with a 6mm through-thescope balloon (Hercules; Cook Medical) (▶Fig. 1, ▶Video1). The guidewire was inserted deep into into the bile duct system and the enteroscope was withdrawn, leaving the overtube in place as a working channel. As the fully covered self-expandable metal stent (fcSEMS) delivery system is shorter than the length of the overtube, the overtube was incised on the side just before the mouthpiece, and the delivery system was inserted under fluoroscopic guidance (▶Video1). The wire was tightly grasped with a hemostat forceps. An fcSEMS 10×40mm (Evolution biliary SEMS; Cook Medical) was deployed, resulting in excellent bile duct drainage. A gastroscope was then inserted through the overtube to inspect the fully deployed stent and to remove stones during direct cholangioscopy. Multiple stones were extracted. Because there were several large stones inside the massively dilated bile duct, small plastic stents were inserted through the fcSEMS to guarantee bile flow. Cholangitis and cholestasis resolved, and the patient was discharged home 2 days later. To the best of our knowledge, this is the first video report on successful insertion of fully covered metal stents during balloon-assisted ERCP. Our case also highlights a case of “extreme endoscopy,” where multiple endoscopes, accessories, and instruments are used to solve a complex pancreaticobiliary problem. Not only did balloon-assisted ERCP reach the bile ducts, but the balloon-assisted enteroscopy overtube worked as a giant working channel, allowing the operator to adE-Videos

Successful endoscopic treatment of a “windsock” diverticulum: a rare case of duodenal subocclusion

Intraluminal “windsock” diverticulum is a rare congenital anomaly, caused by an incomplete recanalization of the duodenum during embryological development [1]. Although most cases are asymptomatic, patients may present with abdominal pain, postprandial fullness, and vomiting. The mean time of presentation is during the fourth decade of life. The most common complications are bleeding, partial bowel obstruction, and, rarely, pancreatitis [2]. Different treatment options have been described [3, 4] and, to our knowledge, fewer than 40 cases of endoscopic treatment have been reported to date. A 29-year-old woman presented with a long history of postprandial nausea and vomiting that worsened during the last month. There was no significant weight loss, but her body mass index was 17.85 kg/m2. Barium contrast study of the small bowel suggested a “windsock sign” (▶Fig. 1). Upper gastrointestinal endoscopy revealed a markedly dilated duodenal bulb, a 4-cm intraluminal diverticulum near the major papilla, and a small opening near the base of the diverticulum through which the gastroscope could not pass (▶Fig. 2 a, b). Using an endoscopic retrograde cholangiopancreatography catheter under fluoroscopic guidance, we confirmed the suspicion of an intraluminal duodenal diverticulum (▶Fig. 2 c). Wire-guided hydrostatic balloon dilation of the aperture up to 15mm was performed, allowing the scope to pass. The diverticulum was incised from base to bottom using a needle-knife (▶Fig. 3, ▶Video1) leading to significant bleeding. Hemostasis was achieved after epinephrine solution injection and hemoclip deployment. The patient had an uneventful postprocedural course. Follow-up re-examination at 30 days revealed absence of gastric stasis, although passage of the gastroscope through the previously incised area (▶Fig. 4) required specific maneuvers. Extension of the incision was performed using an insulatedtip knife, resulting in a wide opening of the duodenal lumen. The patient had a satisfactory postprocedural course, with total acceptance of oral feeding. This case illustrates a safe approach to symptomatic patients diagnosed with internal duodenal diverticulum.

Safe technique for direct percutaneous endoscopic jejunostomy tube placement using single-balloon enteroscopy with fluoroscopy

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method for the delivery of nutrition in patients with a variety of gastrointestinal (GI) problems [1–3]. However, DPEJ using standard colonoscopes or the push technique remains a technically challenging procedure, with success rates of about 68% in expert hands [2]. Herein, we present the key steps to conducting a successful DPEJ using a single-balloon enteroscopy technique. A 62-year-old woman presented with severe necrotizing pancreatitis mandating intensive care therapy. The pancreas necrosis progressed into a huge collection, resulting in partial gastric outlet obstruction (▶Fig. 1 a). Despite endoscopic drainage, the patient remained nauseated and was unable to tolerate oral feeding. We were consulted to place a direct percutaneous jejunostomy (PEG) tube. The patient was placed in the supine position, and the therapeutic double-balloon enteroscope was used in single-balloon mode (i. e. no balloon was attached to the tip of the scope) (▶Video1). The scope and overtube were then advanced to about 80 cm distal to the pylorus. A jejunal loop was then carefully located using both endoscopic and fluoroscopic guidance (▶Video1). PEG tube placement was performed using the Ponsky method (pull-type technique using a 20 Fr PEG-kit; Cook Medical, Bloomington, Indiana, USA) (▶Video1). Once the string had been endoscopically grasped by the snare, the scope and string were pulled back out through the overtube (▶Fig. 1b, c, ▶Video1). A key element of the technique is the overtube, which is left in situ. The string was attached to the PEG tube and, as the string was pulled back out through the skin incision, the PEG tube was pulled through (i. e. inside) the overtube (▶Video1). The scope was advanced into the overtube and was used to help push the PEG button, and subsequently to inspect the jejunum for correctness of PEG tube placement (▶Fig. 1d, ▶Video1). An enteral diet was started 12 hours later. This new method of PEG tube placement focuses on three key components: 1) use of a balloon-assisted overtube, which provides endoscopic stabilization during the procedure; 2) use of fluoroscopy, leading to increased success of finding an adequate jejunal loop for puncture; 3) leaving the overtube in place during the entire procedure (and also for PEG tube removal), which decreases the risk of GI luminal damage during pulling of the PEG tube and during scope manipulation, as the overtube “shields” the inside of the GI tract. The combination of all these aspects may increase the safety and success of this technique.

A novel mechanical simulator for hands-on bariatric endoscopy training in intragastric balloon placement

Bariatric endoscopy is a novel and expanding field in gastrointestinal (GI) endoscopy [1]. The most common bariatric endoscopy procedure is intragastric balloon (IGB) placement [2]. Currently most training occurs with a proctor and a patient. Of course, this approach has potential ethical disadvantages [3], and obtaining the skills for IGB placement using an ex vivo hands-on model would be an ideal solution [4]. We developed a novel mechanical simulator for endoscopic hands-on training with the IGB procedure (LELLA model; EndoWorks LLC, Florida, USA). The model consists of a transparent polycarbonate resin phantom with a fully accessible upper GI tract (▶Fig. 1; ▶Video1). The IGB placement is carried out step by step with endoscopic, as well as external, visual control, which allows an extended comprehensive view of the physics applied in IGB placement and retrieval (▶Video1). The esophagus was developed from a plastic conduit of 3 cm in diameter. It connects proximally to a standard mouthpiece and distally to a red rubber ring, which simulates the gastroesophageal junction and cardia region, an important anatomical landmark for the IGB procedure. The stomachmodel is a round acrylic based chamber of 20 cm in diameter and supports all Food and Drug Administration (FDA)-approved single IGBs. For the purpose of this video, we used the Spatz 3 Adjustable Balloon System (Spatz FGIA, Inc., New York, USA) (▶Fig. 2). The IGB was filled with 600mL of purple isotonic drink (Gatorade) allowing several reuses of the device and thereby reducing the costs associated with training (▶Fig. 2). IGB systems that require drilling are an exception as they are ruptured after one use. In addition, the use of isotonic drinks avoids staining the prototype, which can be an issue when using a saline and methylene blue solution. Balloon emptying is carried out after retrieving the retractile drainage catheter with a rat-tooth forceps and aspirating the fluid using a negative pressure aspiration system (▶Fig. 2; ▶Video1). After endoscopically confirming complete shrinkage of the IGB, the decompressed balloon is withdrawn through the esophagus and mouthpiece. E-Videos