Omid Sanaei

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.

Double endoscopic bypass for gastric outlet obstruction and biliary 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.

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

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.

Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: an international multicenter study

Background and study aims  The efficacy of per oral endoscopic myotomy (POEM) in non-achalasia esophageal motility disorders such as esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), and jackhammer esophagus (JE) has not been well demonstrated. The aim of this international multicenter study was to assess clinical outcomes of POEM in patients with non-achalasia disorders, namely DES, JE, and EGJOO, in a large cohort of patients. Patients and methods  This was a retrospective study at 11 centers. Consecutive patients who underwent POEM for EGJOO, DES, or JE between 1/2014 and 9/2016 were included. Rates of technical success (completion of myotomy), clinical response (symptom improvement/Eckardt score ≤ 3), and adverse events (AEs, severity per ASGE lexicon) were ascertained . Results  Fifty patients (56 % female; mean age 61.7 years) underwent POEM for EGJOO (n = 15), DES (n = 17), and JE (n = 18). The majority of patients (68 %) were treatment-naïve. Technical success was achieved in all patients with a mean procedural time of 88.4 ± 44.7 min. Mean total myotomy length was 15.1 ± 4.7 cm. Chest pain improved in 88.9 % of EGJOO and 87.0 % of DES/JE ( P  = 0.88). Clinical success was achieved in 93.3 % of EGJOO and in 84.9 % of DES/JE ( P  = 0.41) with a median follow-up of 195 and 272 days, respectively. Mean Eckardt score decreased from 6.2 to 1.0 in EGJOO ( P  < 0.001) and from 6.9 to 1.9 in DES/JE ( P  < 0.001). A total of 9 (18 %) AEs occurred and were rated as mild in 55.6 % and moderate in 44.4 %. Conclusion  POEM is effective and safe in management of non-achalasia esophageal motility disorders, which include DES, JE, and EGJOO.

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

Background and study aims  Self-expandable metallic stents (SEMS) have been increasingly used in benign conditions (e. g. strictures, fistulas, leaks, and perforations). Fully covered SEMS (FSEMS) were introduced to avoid undesirable consequences of partially covered SEMS (PSEMS), but come with higher risk of stent migration. Endoscopic suturing (ES) for stent fixation has been shown to reduce migration of FSEMS. Our aim was to compare the outcomes of FSEMS with ES (FS/ES) versus PSEMS in patients with benign upper gastrointestinal conditions. Patients and methods  We retrospectively identified all patients who underwent stent placement for benign gastrointestinal conditions at seven US tertiary-care centers. Patients were divided into two groups: FSEMS with ES (FS/ES group) and PSEMS (PSEMS group). Clinical outcomes between the two groups were compared. Results  A total of 74 (FS/ES 46, PSEMS 28) patients were included. On multivariable analysis, there was no significant difference in rate of stent migration between FS/ES (43 %) and PSEMS (15 %) (adjusted odds ratio 0.56; 95 % CI 0.15 – 2.00). Clinical success was similar [68 % vs. 64 %; P  = 0.81]. Rate of adverse events (AEs) was higher in PSEMS group [13 (46 %) vs. 10 (21 %); P  = 0.03). Difficult stent removal was higher in the PSEMS group (n = 5;17 %) vs. 0 % in the FS/ES group; P  = 0.005. Conclusions  The proportion of stent migration of FS/ES and PSEMS are similar. Rates of other stent-related AEs were higher in the PSEMS group. PSEMS was associated with tissue ingrowth or overgrowth leading to difficult stent removal, and secondary stricture formation. Thus, FSEMS with ES for stent fixation may be the preferred modality over PSEMS for the treatment of benign upper gastrointestinal conditions.

EUS-guided gastroenterostomy in management of benign gastric outlet obstruction

Background and study aims  Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in malignant gastric outlet obstruction (GOO) appears to be promising; however, its role in benign GOO is unclear. The aim of this study was to ascertain the clinical efficacy and safety of EUS-GE in benign GOO. Patients and methods  This was an international retrospective series involving 5 tertiary centers. Consecutive patients who underwent EUS-GE between 1/2013 – 10/2016 for benign GOO were included. The primary endpoint was the rate of clinical success defined as ability to tolerate oral intake without vomiting. Secondary endpoints included technical success and rate of adverse events (AE). Results  Overall, 26 patients (46.2 % female; mean age 57.7 ± 13.9 years) underwent EUS-GE for benign GOO due to strictures from chronic pancreatitis (n = 11), surgical anastomosis (n = 6), peptic ulcer disease (n = 5), acute pancreatitis (n = 1), superior mesentery artery syndrome (n = 1), caustic injury (n = 1), and hematoma (n = 1). Technical success was achieved in 96.2 %. Dilation of the lumen apposing metal stent was performed in 13/25 (52 %) with a mean maximum diameter of 14.6 ± 1.0 mm. Mean procedure time was 44.6 ± 26.1 min. Clinical success was observed in 84.0 % with a mean time to oral intake of 1.4 ± 1.9 days and a median follow-up of 176.5 (IQR: 47 – 445.75) days. Rate of unplanned re-intervention was 4.8 %. 3 AE were noted including 2 misdeployed stents and 1 gastric leak needing surgical intervention following elective GE stent removal. Conclusions  EUS-GE is a promising treatment for benign GOO. Larger and prospective data are needed to further validate this novel endoscopic technique in treating benign GOO of various etiologies.

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.

Peroral endoscopic myotomy for the treatment of achalasia patients with Roux-en-Y gastric bypass anatomy

BACKGROUND  The outcome of peroral endoscopic myotomy (POEM) in patients with prior Roux-en-Y gastric bypass (RYGB) is not known and some experts have recommended against its performance in this patient population because of the risk of postoperative regurgitation. The aim of this study was to report on the outcomes of POEM in patients with RYGB anatomy. METHODS  Patients with RYGB anatomy who underwent POEM for the treatment of achalasia at three tertiary centers were included. POEM was performed in standard fashion using the anterior or posterior approach. Clinical response was defined by a decrease in Eckardt score to ≤ 3. Results of esophageal acid exposure testing/pH-impedance and manometric testing after POEM were reported when available. RESULTS  A total of 10 achalasia patients with prior RYGB surgery underwent POEM. All procedures were technically successful with anterior myotomy performed in seven patients. The mean submucosal tunnel length and myotomy length were 12.9 cm and 11.1 cm, respectively. The mean procedure time was 72 minutes and mean length of hospital stay was 1.5 days. Clinical success was achieved in all 10 patients with a significant decrease in Eckardt score from 6.5 to 1 (P < 0.001). None of the patients experienced post-procedural regurgitation. Post-procedural pH testing was obtained in six patients and was normal in all of them. CONCLUSIONS  This study suggests the feasibility, safety, and efficacy of POEM in patients with prior RYGB surgery. The risk of gastroesophageal reflux disease in these patients seems to be minimal after POEM.