Olaya I. Brewer Gutierrez

Efficacy and Safety of Digital Single-Operator Cholangioscopy for Difficult Biliary Stones

BACKGROUND & AIMS: It is not clear whether digital single‐operator cholangioscopy (D‐SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D‐SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D‐SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D‐SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26–21.2; P = .02). Procedure time increased odds of more than 1 session of D‐SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01–1.03; P < .001). CONCLUSIONS: In a multicenter, international, retrospective analysis, we found D‐SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.

Cost-effectiveness analysis comparing lumen-apposing metal stents with plastic stents in the management of pancreatic walled-off necrosis

BACKGROUND AND AIMS EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON. METHODS A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.

Double endoscopic bypass for gastric outlet obstruction and biliary obstruction

were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.

Submucosal tunneling endoscopic resection of a gigantic esophageal leiomyoma

50,000 was established. RESULTS LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.

Endoscopic ultrasonography-guided freestyle rendezvous recanalization of a complete postoperative rectosigmoid anastomotic obstruction with a lumen-apposing metal stent

20,029 compared with U.S.

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

15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.

Fully-covered metal stents with endoscopic suturing vs. partially-covered metal stents for benign upper gastrointestinal diseases: a comparative study

49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results. CONCLUSION LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.

EUS-guided gastroenterostomy in management of benign gastric outlet obstruction

Background and study aims  Double endoscopic bypass entails EUS-guided gastroenterostomy (EUS-GE) and EUS-guided biliary drainage (EUS-BD) in patients who present with gastric outlet and biliary obstruction. We report a multicenter experience with double endoscopic bypass. Patients and methods  Retrospective, multicenter series involving 3 US centers. Patients who underwent double endoscopic bypass for malignant gastric and biliary obstruction from 1/2015 to 12/2016 were included. Primary outcome was clinical success defined as tolerance of oral intake and resolution of cholestasis. Secondary outcomes included technical success, re-interventions and adverse events (AE). Results  Seven patients with pancreatic head cancer (57.1 % females; mean age 64.6 ± 12.5 years) underwent double endoscopic bypass. Four patients had EUS-GE and EUS-BD performed during the same session with a mean procedure time of 70 ± 20.4 minutes. EUS-GE and EUS-BD were technically successful in all patients, all of whom were able to tolerate oral intake with resolution of cholestasis in 6 (87.5 %). One patient had a repeat EUS-BD with normalization of bilirubin. There were no adverse events. Conclusions  Double endoscopic bypass is feasible and effective when performed by experienced operators. Studies comparing this novel concept to existing techniques are warranted.

Plastic stents are more cost-effective than lumen-apposing metal stents in management of pancreatic pseudocysts

Submucosal tunneling endoscopic resection (STER) for removal of small upper gastrointestinal tumors arising from the muscularis propria has been demonstrated to be effective and safe [1, 2]. We demonstrated the submucosal tunneling technique for removal of a 10-cm esophageal leiomyoma, and subsequent management of a large mucosotomy. A 66-year-old woman presented with slowly progressive solid-food dysphagia. Computed tomography (CT) scan revealed a 10×4×3-cm esophageal mass. Esophagogastroduodenoscopy showed a large esophageal subepithelial lesion at 20–30 cm from the incisors. Endoscopic ultrasound (EUS) revealed a homogeneous hypoechoic lesion with central calcification arising from the muscularis propria. The results of EUS-guided fineneedle aspiration were consistent with leiomyoma. The patients refused surgical resection, and the submucosal tunneling endoscopic resection procedure was offered. Mucosal incision was done 3 cm proximal to the lesion using a triangular-tip knife (Olympus, Tokyo, Japan) (▶Fig. 1 a, b) (▶Video1). Submucosal fiber was dissected to create the submucosal tunnel and this was continued to the level of the lesion (▶Fig. 1 c). The lesion was dissected away from submucosal fiber, mucosa, and muscularis propria using an insulation-tipped diathermic knife (IT2 knife; Olympus) (▶Fig. 1d). Because of the size mismatch between the submucosal tunnel and the lesion, the lesion could not be removed from the tunnel. The decision was made to fragment the tumor into smaller pieces which were then removed from the tunnel (▶Fig. 1 e). A large defect was seen in the muscle layer after resection of the tumor (▶Fig. 1 f). We successfully placed 8 endoscopic clips (Resolution Clip; Boston Scientific, Boston, Massachusetts, USA) for closure of the mucosal incision. The patient was given Unasyn (ampicillin/sulbactam) intravenously. On postoperative day 1, esophagography revealed an esophageal leak. Urgent EGD showed that endoclips had fallen off (▶Fig. 1g). The clips were removed and a fully covered metal stent, 23mm in diameter (Wallflex; Boston Scientific), was deployed across the mucosal defect (▶Fig. 1h). The patient tolerated a soft diet and was discharged home on postoperative day 6. Repeat EGD was done at 4 weeks, with removal of the stent; the mucosal defect was well healed (▶Fig. 1 i). The patient had resolution of dysphagia.

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

A 44-year-old woman with a large symptomatic uterine leiomyoma underwent radical pelvic mass resection, bilateral salpingo-oophorectomy, and modified pelvic exenteration with rectosigmoid resection and creation of a diverting ileostomy. A sigmoidoscopy performed 2 months later followed by a water-soluble contrast enema showed complete obstruction of the rectosigmoid anastomosis. An endoscopic ultrasonography (EUS)-guided recanalization of the obstruction was planned. A pediatric colonoscope was advanced through the ileostomy towards the sigmoid colon. Water was injected into the proximal side of obstruction to provide acoustic interface. A linear echoendoscope was then advanced through the rectum (▶Fig. 1). The area of proximal colon was identified endoscopically by transillumination (▶Fig. 2) and endosonographically by detecting the fluid-filled lumen and the pediatric colonoscope. Under EUS guidance, the proximal colon was punctured with a cautery-enhanced lumen-apposing metal stent (LAMS; Axios, 15-mm diameter; Boston Scientific, Galway, Ireland). The proximal flange of the stent was deployed in the proximal colon and the distal flange was deployed in the rectal stump. The stent was then dilated with a controlled radial expansion balloon up to 15mm (▶Fig. 3 a, b); ▶Video1). The procedure was completed with no complications, and the patient was discharged home on the same day. At the 1 month follow-up, sigmoidoscopy was performed and the stent was found to have migrated distally. The anastomosis was patent, the stent was removed (▶Fig. 3 c), and, 1 day later, ileostomy reversal was successfully performed. At her 10-month follow-up, the patient continued to report normal bowel movements with no residual symptoms. In conclusion, EUS-guided recanalization of complete colorectal obstruction using a LAMS placed via the rendezvous technique was feasible and effective. In addition, freestyle deployment of a LAMS with a cautery tip facilitated an efficient procedure.