Paul T. Kroner

Use of a Soehendra stent retriever in dilation of an anastomotic biliary stricture in a post-liver transplant patient

Occasionally, bile duct strictures in patients who have undergone liver transplantation are impossible to traverse, dilate, and stent. Herein we present a novel technique for the dilation of a recalcitrant stricture using the Soehendra stent retriever device. A 57-year-old woman with a history of orthotopic liver transplantation presented to the emergency department with pruritus and right-upper quadrant abdominal pain of 2 days’ duration. Results of laboratory tests were relevant for platelets (93000/mm3), alkaline phosphatase (181U/L), and alanine transaminase (80U/L). Endoscopic ultrasound revealed that the common bile duct (CBD) was dilated to 11mm, with a 5-mm stone in the distal duct. Another endoscopist attempted endoscopic retrograde cholangiopancreatography (ERCP) but cannulation was not achieved. Repeat ERCP displayed a fusiform distal CBD dilated to 20mm, with a tight 4-mm-long concentric stricture at the anastomosis (● Fig.1a,● Video 1). Although the guidewire was able to traverse the stricture, it was impossible to advance the tapered-tip biliary catheter (Conmed, Utica, New York, USA), the Titan balloon dilation catheter (Cook Medical, Winston-Salem, North Carolina, USA) or the Soehendra 7-Fr dilator. The wire was left in place and a 7-Fr Soehendra stent retriever was advanced over the guidewire using forward-clockwise rotation (● Fig.1b,● Fig.1c). The stent retriever passed through the stricture and enabled the passage of an 8-mm Titan balloon,

Endoscopic Mucosal Resection of Jejunal Polyps using Double-Balloon Enteroscopy

Background There are only two single case reports describing double-balloon enteroscopy (DBE)-assisted endoscopic mucosal resection (EMR) of the jejunum. The aim of this case series was to evaluate the feasibility and utility of DBE-assisted EMR in patients with familial and non-familial jejunal polyps. Patients and methods Observational, open-label, retrospective, single-arm case series in two hospitals. Results Eight patients underwent DBE assisted jejunal EMR. Median age of patients was 42 years (range 24–62 years), male: female ratio 1.5:1. DBE was done through the antegrade (i.e. oral) route in all patients. Four patients had FAP; two had Peutz-Jeghers syndrome, one had a sporadic adenoma and one had a bleeding jejunal polyp, which on histological examination turned out to be lipoma. 3/8 underwent piece-meal EMR. No immediate adverse events occurred. Conclusions This is the first case series presenting the technical details, feasibility and outcomes of EMR of the small bowel. EMR of the jejunum is feasible and safe during DBE.

Endoscopic reinforcement of the anastomosis followed by targeted endoscopic hemostasis for massive upper gastrointestinal bleeding after Whipple's surgery.

Although it occurs infrequently in patients undergoing the procedure, upper gastrointestinal (GI) bleeding after Whipple’s gastropancreaticoduodenectomy can be a devastating complication. Early GI bleeding that occurs within 24 to 48 hours postoperatively is an important cause of morbidity and mortality [1]. Emergency endoscopic procedures performed within a short time after major surgery have traditionally been discouraged on the grounds that insufflation may disrupt the anastomotic site and lead to perforation. Therefore, some experts use interventional radiology with embolization [2]. Herein, we present a novel endoscopic approach and solution to the management of a patient with renal failure and a contraindication to interventional radiology after Whipples surgery. On the first day after undergoing a Whipple’s gastropancreaticoduodenectomy to resect a tumor of the pancreatic head, a 53-year-old woman developed massive hematemesis and a sudden drop in her hemoglobin level from 9.6 to 5.6g/dL, with associated hypotension and tachycardia. Because her creatinine level was 1.9mg/dL, the administration of intravenous contrast and thus interventional radiology were contraindicated. An emergency esophagogastroduodenoscopy (EGD), performed with minimal carbon dioxide (instead of air) insufflation, showed the stomach to be filled with clots and fresh blood (● Fig.1a, ● Video 1). After the stomach had been partially clearedof bloodandclotswith anovertube (Guardus; US Endoscopy, Mentor, Ohio, USA) (● Video 1), active bleeding was

Dual esophageal and colon self-expanding metal stenting for colon cancer arising in esophageal interposition.

A 67-year-old man was referred for highgrade stenosis of the esophagus andmetastatic adenocarcinoma. His relevant medical history included esophagealmetastatic adenocarcinoma resected 10 years previously, for which he had undergone colonic interposition and chemotherapy. His risk factors included smoking one pack of cigarettes/day for over 20 years and consuming 2 ounces of alcohol/day for 30 years. He complained of progressive dysphagia to solids that had started 2 days before referral. An upper gastrointestinal series had been performed, which had been reported as a presumably malignant, high-grade stenosis of the distal esophagus adjacent to the esophagogastric junction, and he was therefore referred to our center. Esophagogastroduodenoscopy (EGD) showed anormal esophagocolonic anastomosis and an 8×5-cm mass at the colonic interposition, which was partially occluding the esophageal lumen (● Fig.1). A contrast esophagogram performed during the EGD showed a 4-cm area of stenosis in the mid and distal neoesophagus (● Fig.2). Two self-expanding metal stents were inserted. The first, a fully-covered esophageal stent (12cm in length), was placed at the cologastric anastomosis to prevent tumor ingrowth (● Fig.3a). The second, a non-covered colonic stent (10cm in length), was placed proximally in a “stentin-stent” fashion to anchor the covered stent (● Fig.3b,c). The stented area was endoscopically reassessed, and adequate expansion of the stents was confirmed (● Fig.4). No complications arose; the patient’s symptoms improved and he was discharged home the same day. Colonic interposition replacing the esophagus was described by Kelling and Vuillet in 1911 [1,2]. It is currently used in both benign (for example, stenosis or iatrogenic fistulae) andmalignant cases that warrant esophageal replacement. Acute complications include anastomotic dehiscence, fistula formation, interposed segment necrosis, and surgical site infection [3]. Longterm complications are less common, but include strictures, dumping syndrome, obstruction, gastrocolic reflux, diverticula formation, and rarely neoplasia [4,5]. Endoscopic palliation of neoplasia arising from colonic interposition is tricky, as esophageal stents do not have sufficient radial expansion to expand within a “colon” lumen. In our case, this difficulty was circumvented using a double-stenting technique that involved inserting first an esophageal stent and then a colonic stent to anchor the previous one, thereby ensuring adequate proximal expansion of the colon stent within the colonic-interposition neoesophagus.

Overtube and over-the-wire, through-the-scope balloon-assisted ERCP in a patient with complex hypopharyngeal stenosis after neck surgery

A 64-year-old man with T2N0 squamous cell carcinoma of the tongue base underwent treatment with radiation, followed by glossolaryngectomy, bilateral neck dissection, and placement of an anterolateral thigh flap graft. After 1 year, he presented with acute cholangitis (abdominal pain, jaundice, fever, chills, and hypotension), making emergency endoscopic retrograde cholangiopancreatography (ERCP) mandatory. A computed tomographic scan of the neck showed hypopharyngeal stenosis and neck swelling as a result of the previous surgery (● Fig.1a, ● Video1). At another institution, emergency ERCP had failed, and the patient was transferred to our institution for further treatment. On standard esophagogastroduodenoscopy, the changes due to the prior com-

Endoscopic introduction of an over-the-scope clip through an overtube to close a gastrocutaneous fistula in a patient with a complex upper esophageal stenosis.

A 51-year-oldmanwith a history of laryngeal cancer requiring total laryngectomy and placement of a forearm skin graft into the hypopharynx developed a nonhealing gastrocutaneous fistula after removal of a gastrostomy tube (● Fig.1a). The injection of indigo carmine through the skin made it possible to determine the precise location of the 3to 4-mm-diameter gastrocutaneous fistulawithin thickened gastric folds (● Fig.1b). A gastroscope could be passed into the stomach after an esophageal stenosis between the hypopharynx and upper esophageal sphincter, induced by radiation fibrosis and the presence of a forearm skin graft, had been dilated sequentially with 9-, 10-, and 12-mm Savary bougies; however, it was still not possible to pass the fistula-closing device, an overthe-scope clip (OTSC System; Ovesco Endoscopy, Tübingen, Germany), through the hypopharynx. Contrast esophagography after the dilation procedure did not show any endoluminal esophageal damage, so an overtube (Guardus overtube-esophageal; inner diameter 16.7mm, outer diameter 19.9mm; US Endoscopy, Mentor, Ohio, USA) was inserted into the esophagus. The large-diameter overtube served as a “giant working channel,” permitting passage of the endoscope loaded with the 11/6t OTSC device (● Fig.1c). Therefore, the overtube was used mainly to open the space to facilitate passage of the scope loaded with the device, especially during endotracheal intubation (this procedure was performed with the patient under general anesthesia). The fistula was closed successfully (● Fig.1d). Closure was documented by administering water-soluble contrast through the endoscope. The overtube and endoscope were removed, and the additional administration of contrast at the hypopharynx and upper esophagus did not reveal any damage, leak, or extravasation. This case is an example of “extreme endoscopy.” First, the complex fistula could be found by using interventional chromoendoscopy. The esophageal stricture was dilated, and an overtube was inserted into the stomach. The overtube served as a bridge of the upper esophageal stenosis, allowing smooth passage of the scope with a large fistula-closing device, such as the OTSC System. In summary, an impossible situation was converted into a therapeutic solution by combining the use of techniques and equipment widely available in the endoscopy suite, such as fluoroscopy, overtubes, dilation balloons, clipping devices, and chromoendoscopy.