Paola Soriani

Thulium laser in interventional endoscopy: animal and human studies

Background and study aims The thulium laser system (TLS) is an emerging surgical tool. The 2-μm wavelength provides a confined coagulation depth (0.2 - 0.4 mm) to reduce the potential for inadvertent injuries. For the first time ever, we assessed TLS feasibility for endoscopic hemostasis ex vivo in pigs. In addition, we performed the first in vivo hemostatic treatments in humans. Patients and methods Tissue damage induced by TLS using different settings and optical fibers was compared to that from argon plasma coagulation (APC) in established ex vivo animal models. Three consecutive patients with complex nonvariceal upper gastrointestinal bleedings were treated and followed up. Results No deep submucosal injury was observed in animal models. The TLS showed a progressive penetration depth with increased power outputs and tissue exposures but very limited vertical tissue injury (0.1 - 2.0 mm) and lateral spreading damage (0.1 - 0.3 mm and 0.2 - 0.7 mm using the 365-µm and 550-µm fibers, respectively). In vivo, endoscopic hemostasis with TLS was always successful without complications. Conclusions The TLS has proven to be very precise and easy to use. This novel technique appears to be a promising tool for advanced interventional endoscopy.

Colo-rectal endoscopic full-thickness resection (EFTR) with the over-the-scope device (FTRD®): A multicenter Italian experience

BACKGROUND AND AIM Endoscopic full-thickness resection(EFTR) with FTRD® in colo-rectum may be useful for several indications.The aim was to assess its efficacy and safety. MATERIAL AND METHODS In this retrospective multicenter study 114 patients were screened; 110 (61M/49F, mean age 68 ± 11 years, range 20-90) underwent EFTR using FTRD®. Indications were:residual/recurrent adenoma (39), incomplete resection at histology (R1 resection) (26), non-lifting lesion (12), adenoma involving the appendix (2) or diverticulum (2), subepithelial lesions(10), suspected T1 carcinoma (16), diagnostic resection (3). Technical success (TS: lesion reached and resected), R0 resection (negative lateral and deep margins),EFTR rate(all layers documented in the specimen) and safety have been evaluated. RESULTS TS was achieved in 94.4% of cases. EFTR was achieved in 91% with lateral and deep R0 resection in 90% and 92%. Mean size of specimens was 20 mm (range 6-42). In residual/recurrent adenomas, final analysis revealed: low-risk T1 (11), adenoma with low-grade dysplasia (LGD) (24) and high-grade dysplasia (HGD) (3), scar tissue (1). Histology reports of R1 resections were: adenoma with LGD (6), with HGD (1), low-risk (6) and high-risk (1) T1, scar tissue (12). Non-lifting lesions were diagnosed as: adenoma with HGD (3), low-risk (7) and high risk (2) T1. Adverse clinical events occurred in 12 patients (11%),while adverse technical events in11%. Three-months follow-up was available in 100 cases and residual disease was evident in only seven patients. CONCLUSIONS EFTR using FTRD® seems to be a feasible, effective and safe technique for treating selected colo-rectal lesions. Comparative prospective studies are needed to confirm these promising results.

Feasibility and efficacy of double over-the-scope clipping for colonic iatrogenic perforation

Colorectal iatrogenic perforation is a rare adverse event in diagnostic colonoscopy, occurring in a range of 0.03% to 0.8% of cases. Risk factors include endoscopist’s inexperience, female gender, pericolic adhesions, inflammatory colonic diseases, severe diverticular disease, and weakened colonic-wall tissues because of older age. The over-the-scope clip (OTSC, Ovesco Endoscopy GmbH, Tübingen, Germany) is a useful tool, recommended as first-line endoscopic treatment for endoscopic acute iatrogenic perforation, which can help to avoid emergency surgical repair. However, the deployment of an OTSC to completely close the defect may be challenging in some cases because of the size, the position of the hole (ie, sigmoid-rectal junction), and the presence of other endoscopic devices (ie, through-thescope clip or OTSC). To the best of our knowledge, the deployment of 2 adjacent OTSCs has not been described in the medical literature. Here we report the case of an 89-year-old woman referred to our unit for colonoscopy (CFHQ190L; Olympus Co, Tokyo, Japan) because of a positive hemoccult test result and anemia. Because of pericolic adhesions in a

Endoscopic full-thickness resection for T1 early rectal cancer: a case series and video report

Background and study aims  Endoscopic treatment of malignant colorectal polyps is often challenging, especially for early rectal cancer (ERC) localized close to the dentate line. Conversely, the surgical approach may result in temporary or definitive stoma and in frequent post-surgical complications. The Full-Thickness Resection Device (FTRD ® ) System (Ovesco Endoscopy, Tübingen, Germany) is a novel system that, besides having other indications, appears to be promising for wall-thickness excision of intestinal T1 carcinoma following incomplete endoscopic resection. However, follow-up data on patients treated with this device are scarce, particularly for ERC. Patients and methods  Six consecutive patients with incomplete endoscopic resection of T1-ERC were treated with the FTRD and their long-term outcomes were evaluated based on a detailed clinical and instrumental assessment. Results  The endoscopic en bloc full-thickness resection was technically feasible in all patients. The histopathologic analysis showed a complete endoscopic resection in all cases, and a full-thickness excision in four. Neither complications, nor disease recurrence were observed during the 1-year follow-up period. Conclusions  The FTRD System is a promising tool for treating ERC featuring a residual risk of disease recurrence after incomplete endoscopic mucosal resection in patients unfit for surgery or refusing a surgical approach.

Endoscopic retrograde cholangiography after endoscopic ultrasound-related duodenal perforation: keep calm, use over-the-scope clip, and carry on!

The over-the-scope clip (OTSC) is a useful tool recommended as first-line endoscopic treatment for endoscopic acute iatrogenic perforation [1]. A retrospective study documented that OTSCs can avoid emergency surgical repair, allowing, in some cases, completion of the primary endoscopic procedure. As documented only once in the literature, its use could allow subsequent endoscopic procedures to be performed in the same session, owing to the endurance of the device during pneumatic and mechanical stress [2]. Here we report the video case of a 93-year-old woman who was referred to our unit to undergo biliopancreatic endoscopic ultrasound (GF-UCT 180; Olympus Co., Tokyo, Japan) for suspected choledocholithiasis, in the context of acute cholangitis; the patient was not a suitable candidate for surgery (cholecystectomy). After multiple biliary stones were detected in the common bile duct, a perforation was apparent in the wall of the superoanterior duodenal bulb. Because of the size of the perforation (about 15mm), an OTSC (11/6mm traumatic type; Ovesco Endoscopy GmbH, Tübingen, Germany) was applied using the suction technique to completely seal the defect [3]. As no further leakage was apparent following injection of contrast medium and the patient’s clinical conditionwas stable, endoscopic retrograde cholangiography (ERC; TJF-160 VR; Olympus Co.) with extraction of multiple biliary stones was performed in the same session (▶Video1). All procedures were performed with anesthesiological assistance, using carbon dioxide insufflation. ERC took about 45 minutes for complete biliary drainage (▶Fig. 1). The subsequent contrast medium (▶Fig. 2) and computed tomography scan with oral gastrographin confirmed the complete closure, despite the longlasting pneumatic and mechanical stress. No further complication occurred and the asymptomatic patient was discharged 1 week later. In conclusion, prompt endoscopic treatment using OTSCs represents an effective approach that can avoid later complications or surgical repair. Furthermore, the use of OTSCs can allow the completion of endoscopic procedure(s) in the same session, as the clips can endure prolonged pneumatic and mechanical stress.

Endoscopic dissection of a symptomatic giant gastric leiomyoma arising from the muscularis propria

Gastrointestinal (GI) subepithelial masses represent a heterogeneous group of lesions, ranging from benign to malignant, for which management is sometimes challenging [1, 2]. We report the case of an 85-year-old woman, with a history of coronary artery disease and chronic atrial fibrillation being treated with anticoagulant therapy, who underwent urgent upper GI endoscopy for hemorrhagic shock andmelena. During this procedure, a giant, 15-cm, non-pedunculated mass that was ulcerated on top was found at the greater curvature of the anterior wall of the stomach (▶Fig. 1). The patient then underwent radial endoscopic ultrasonography (EUS; GF-UE160AL5; Olympus), which showed a hypoechoic homogeneous intramural mass that was arising from the muscularis propria andwas suspected to be a leiomyoma (▶Fig. 2). In order to achieve a definitive diagnosis, EUS with fine needle aspiration (FNA) was performed (GF-UCT180; Olympus) using a 22-gauge needle (ExpectSlimLine; Boston Scientific). Histology and immunohistochemical staining revealed that the specimen was compatible with a leiomyoma (SMA positive, CD117 and CD34 negative). Total body computed tomography (CT) excluded metastatic disease. Because this was a symptomatic hemorrhagic lesion and there was a need to continue anticoagulant therapy, an endoscopic dissection was performed. We used the HybridKnife T-type (ERBE Elektromedizin GmbH) and a solution composed of 250mL normal saline, 2mL indigo carmine, and 1mL epinephrine. The procedure took 115 minutes and resulted in an en bloc specimen, with no complications occurring (▶Fig. 3; ▶Video1). However, because of its size, it was not possible to retrieve the whole lesion, which resulted in it being completely digested by gastric secretions by the following day (▶Fig. 4). Low molecular weight heparin was re-introduced 24 hours after the procedure and the patient was discharged 2 days later. Upper GI endoscopy and EUS performed 3 months later revealed a regular scar, without any remnant pathological tissue. This case illustrates the feasibility and safety of endoscopic dissection of a symptomatic giant gastric leiomyoma, even in a high risk patient who was receiving ongoing anticoagulant therapy, in whom surgery would have carried considerable risk. Moreover, EUS-FNA achieved an accurate evaluation of the lesion’s layer of origin and its histopathologic characteristics, thereby allowing a definitive diagnosis to be made and the appropriate therapeutic option to be chosen.