Shannon M. Chan

Use of the Over-The-Scope Clip for treatment of refractory upper gastrointestinal bleeding: a case series.

The Over-The-Scope Clip (OTSC; Ovesco, Tübingen, Germany) is a novel endoscopic clipping device designed for tissue approximation. The device has been used in the closure of fistulas and perforations. We hereby report on a series of patients in whom OTSCs were used for endoscopic control of refractory or major upper gastrointestinal bleeding from lesions in the gastroduodenal tract between 1 July and 31 December 2012. Nine patients were included (median age 72.5 years, range 39 - 91) with bleeding gastric ulcers (n = 2), bleeding duodenal ulcers (n = 5), bleeding gastrointestinal stromal tumor in the stomach (n = 1), and bleeding from ulcerative carcinoma of the pancreas (n = 1). The median size of the ulcers was 2.5 cm (range 1 - 4). Six of the nine patients had undergone previous endoscopic hemostasis. Technical success was achieved in all patients and the clinical effectiveness was 77.8 %. The OTSC is a safe and effective method of endoscopic hemostasis for major bleeding from miscellaneous upper gastrointestinal causes and should be considered in patients with refractory bleeding after failure of conventional methods of endoscopic hemostasis.

Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia

This retrospective cohort study compared clinical outcomes and quality of life after peroral endoscopic myotomy (POEM) against laparoscopic Heller myotomy (LHM) for treatment of achalasia.

Direct incision versus submucosal tunneling as a method of creating transgastric accesses for natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy: Randomized controlled trial

The optimal approach for creating accesses for transgastric peritoneoscopy is still uncertain. The present study aims to assess the feasibility of carrying out transgastric submucosal tunnel (SMT) peritoneoscopy and to determine whether this approach improves or restricts access to various sectors within the peritoneal cavity.

Controversies on the treatment strategy for rectal submucosal cancer: case series and review of the literature.

Endoscopic submucosal dissection (SD) has emerged as one of the treatment strategies for submucosal rectal cancers. The present study reviewed the clinical outcomes of patients with rectal submucosal cancer treated by ESD. This was a retrospective review of four patients who had rectal tumor treated by ESD from 2010 to 2012 with histopathology showing T1 submucosal adenocarcinoma. The mean age (SD) was 69.5 (7.33) and the male to female ratio was 3:1. There were no post‐ESD complications. The mean (SD) size of the tumors was 2.93 (0.87) cm. One patient with deep resection margin involvement received laparoscopic low anterior resection. Another with deep margin involvement of <1 mm refused surgery and was treated by chemoradiotherapy.There was no recurrence in all the cases with a mean follow‐up duration of 461.3 (209.0) days. ESD was one of the important treatment strategies for T1sm‐s rectal cancer especially when the risk of nodal metastasis was low. ESD spared the patient from colostomy when the T1 cancer was located in the lower third of the rectum. The role of adjuvant and neoadjuvant chemoradiotherapy remains controversial.

Can we now recommend OTSC as first-line therapy in case of non-variceal upper gastrointestinal bleeding?

gastrointestinal bleeding, endoscopic hemostasis and acid suppression have significantly improved outcomes [1–3]. However, 8% to 15% of patients continue to bleed or develop further bleeding [3, 4]. Further bleeding remains one of the most important predictors of mortality [3, 5, 6]. Research, therefore, has been focused on methods to improve endoscopic hemostasis, and thus mortality. The standard of care in endoscopic hemostasis is either application of contact thermocoagulation or mechanical therapy such as haemostatic clips [7–9] with or without pre-injection with diluted adrenaline. However, there are limitations to conventional hemostatic methods. In an ex vivo bleeding model using canine mesenteric arteries, endoscopic thermocoagulation could only consistently seal arteries up to 2mm [10]. Hemostatic clips achieve hemostasis through mechanical tamponade over the bleeding vessel. However, tangential application of hemostatic clips can be difficult in lesions located in the bulbar duodenum and the lesser curvature of the stomach. Furthermore, the clips often dislodge, leading to recurrent bleeding. Application of clips can also sometimes be difficult in chronic ulcers with a fibrotic base. The Over-The-Scope-Clip (OTSC; Oversco Endoscopy AG, Tübingen, Germany) has been successfully used to close perforations of the gastrointestinal tract and to control gastrointestinal bleeding [11]. With a wider jaw and greater strength, the OTSC has the advantages of a firm grip over a larger amount of tissue. Clip retention is almost universal. To date, only small-scale retrospective series with the device have been perfomed. Kirschniak et al reported the first clinical experience with OTSC for gastrointestinal bleeding and achieved 100% primary hemostasis with no rebleeding [12]. In another series including 30 cases in which conventional endoscopic hemostasis had failed, the authors reported a 97% success rate for primary hemostasis and 6% rebleeding rate [13]. In our series where we also included cases refractory to conventional endoscopic treatment, we achieved a 10 /10 (100%) success rate for primary hemostasis. However, rebleeding occurred in to 22% [14]. From the limited data available, a 97% to 100% primary success rate was achieved [11–17]. However, the rebleeding rate ranges from 0% to 22% [11–17]. In this latest issue of Endoscopy International Open, one of the largest experiences with OTSC in management of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) has been published. Wedi et al reported their 6-year experience with 100 patients from two academic centers in Germany. In this study, a 94% success rate for primary hemostasis was reported. However, 3 of the 6 patients in whom initial OTSC placement failed died. Of the 94 patients in whom the procedure succeeded, 5 developed an early rebleed (within 24 hours) and 3 developed a late rebleed (≤30 days). Four of these 8 patients died consequently. The mortality following failed OTSC application was high. In another recently published cohort of 100 patients including treatment of both NVUGIB and lower gastrointestinal bleeding, similar results were found [18]. Sixty-nine patients had NVUGIB treated with OTSC, either as first-line or salvage Can we now recommend OTSC as first-line therapy in case of non-variceal upper gastrointestinal bleeding?

Removal of submucosal embedded fish bone in the esophagus with endoscopic submucosal dissection

If a foreign body is deeply embedded into the wall of the esophagus after accidental ingestion, surgical exploration for removal and repair is usually required. We report a rare case of foreign body embedment in the esophageal wall and its successful removal by endoscopic submucosal dissection (ESD). A 77-year-oldwomanpresentedwith odynophagia after fish bone ingestion. Initial endoscopy showed a hematoma 1 cm below the cricopharyngeus, but the foreign body was not identified. A CT scan revealed a 2-cm linear foreign body at the cervical esophagus. Repeated endoscopy showed a 2-cm submucosal bulge at the cervical esophagus. After submucosal injection of amixture of normal saline solution and indigo carmine, a mucosal incision was created with an ESD knife. The fish bone was then identified at the submucosal plane of the esophagus and was removed with forceps (Fig. 1; Video 1, available online at www.VideoGIE.org). The mucosal defect was closed with endoscopic clips. The patient recovered uneventfully after the endoscopic procedure. ESD was used in this case for removal of an esophageal foreign body, avoiding the need for surgical exploration of the esophagus. With increasing experience

DDW 2016 review: Advances in therapeutic upper gastrointestinal endoscopy

This is a review of the abstracts presented at Digestive Disease Week 2016, 21–24 May 2016 in San Diego, CA, USA, focusing on novel advances in therapeutic endoscopy of the upper gastrointestinal tract.

An innovative ex-vivo porcine upper gastrointestinal model for submucosal tunnelling endoscopic resection (STER)

Background and study aims: Submucosal tunnelling endoscopic resection (STER) is a novel endoscopic technique to remove submucosal tumour (SMT). We propose a novel, low cost simulator for training of techniques for STER. Patients and methods: The model consisted of an ex-planted porcine oesophagus, stomach and duodenum with marbles embedded surgically in the submucosal plane. Two expert endoscopists with experience in submucosal tunnelling and 5 board-certified endoscopists with no experience in submucosal tunnelling were recruited. Participants were asked to perform a diagnostic endoscopy and 2 STER procedures, 1 in the oesophagus and 1 in the stomach. They also answered a structured questionnaire. Factors including operative time, mucosal and muscular injury rate, injection volume and accuracy of endoscopic closure were assessed. Results: The median time for localization of all SMTs was 40.1 seconds for experts and 38.5 seconds for novices (P = 1.000). For esophageal STER, the length of mucosal incisions and tunnelling distances were comparable between the 2 groups. The median volume injected by the novice group was significantly lower than the experts (15 mL vs 42.5 mL (P = 0.05). The median tunnelling time per length was 25.9 seconds/mm for the experts and 40.8 seconds/mm for the novice group (P = 0.38). There was a higher rate of mucosal injury and muscular perforation in the novice group (8 vs 0; P = 0.05). For gastric STER, the length of mucosal incisions and tunnel distances were comparable between the 2 groups. The median tunnelling time per length for the experts was 23.3 seconds/mm and 34.6 seconds/mm for the novice group (P = 0.38). One mucosal injury was incurred by a novice. The rate of dissection in the stomach and the oesophagus was not statistically different (P = 0.620). All participants voted that the model provides a realistic simulation and recommended it for training. Conclusions: STER is an advanced endoscopic technique where its indication is currently explored. Experienced and novice STER endoscopists have expressed the usefulness of this model as a training tool. This low-cost model can be used for future research in STER.

Current advances in liver surgery

Hepatobiliary surgery has taken a big step forward in recent decades especially in the minimally invasive approach for hepatectomy. From being sceptical at the beginning of the 1990s when laparoscopic surgery had become prevalent, to now, where laparoscopic hepatectomy has been well-established, especially in minor hepatectomies; this new technique has evolved rapidly over the past 20-years demonstrating better short-term outcomes and equivalent oncological outcomes in selected patients and in expert hands. Laparoscopic hepatectomy is indeed, more difficult to master than the open procedure with restrictions in working space, difficulty in haemostasis and the potential risk of gas embolism. However, with better visibility of the operative field around the liver, especially beneath the costal margin, the magnified view and theoretical advantage of pneumoperitoneum acting as haemostatic pressure have made laparoscopic hepatectomy increasingly popular. Another important advancement is the new surgical technique of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This procedure induces more rapid liver hypertrophy within a median period of 9-days, allowing resection to be performed in candidates with borderline functional liver remnant and at an earlier date. However, studies have shown that ALPPS is associated with a relatively higher rate of morbidity and mortality. Therefore, it remains a highly controversial treatment option and more studies have to be performed to establish its usefulness and define its role in liver surgery.

Case report and a review of the literature of two patients with gastric MALToma and pulmonary metastasis

Gastric mucosa‐associated lymphoid tissue lymphoma (or MALToma) is a relatively rare form of low‐grade B‐cell malignancy arising from the mucosal associated lymphoid tissue of the stomach. The majority of cases can be treated with Helicobacter pylori eradication with good prognosis. However, few reports have been published on the treatment of gastric MALToma with pulmonary metastasis. We report two such cases managed with systemic chemotherapy. At the time of writing, one of the cases was in static disease while the other had complete remission. In both patients, pulmonary metastases were detected upon staging thoracic computed tomography.