Simon K. Lo

Double balloon enteroscopy can be safely done in elderly patients with significant co‐morbidities

Performance of double balloon enteroscopy (DBE) on older patients with comorbidities is a matter of safety. We aimed to investigate the utility and safety of DBE in older patients.

Endoscopic approach to the patient with benign or malignant ampullary lesions.

Adenoma and adenocarcinoma are the most common ampullary lesions. Advances in diagnostic modalities including endoscopic ultrasonography and intraductal ultrasonography have provided useful information that aids in diagnosing and managing ampullary lesions. Endoscopic papillectomy can be a curative therapy for localized ampullary adenoma and have a role in the diagnosis of indeterminate ampullary lesions that may contain a hidden malignancy. However, the consensus on how and when to use endoscopic papillectomy has not been fully established. This article reviews the approach to the patient with benign or malignant ampullary lesion.

A new method for endoscopic closure of gastrocolonic fistula: novel application of a cardiac septal defect closure device (with video)

BACKGROUNDnGastrocolonic fistula after percutaneous endoscopic gastrostomy PEG tube placement is an uncommon but serious complication. These fistulous tracts are often fibrotic and frequently require surgical intervention.nnnOBJECTIVEnTo describe a novel endoscopic treatment for gastrocolonic fistula.nnnDESIGNnCase report.nnnSETTINGnInpatient hospital setting.nnnPATIENTnAn 82-year-old woman was seen 1 year after PEG placement with feculent vomiting; imaging studies showed a gastrocolonic fistula. Cardiopulmonary comorbidities posed an unacceptable surgical risk. Endoscopic attempts at fistula closure with hemoclip placement and biodegradable plug were unsuccessful. Total parenteral nutrition resulted in multiple metabolic and infectious complications.nnnINTERVENTIONnGastrocolonic fistula closure was performed twice by using cardiac septal defect closure devices. The first closure was achieved by using the Amplatzer double-disk nitinol wire mesh atrial septal defect closure device, which was deployed under endoscopic and fluoroscopic guidance across the fistula tract. The proximal disk was then injected with cyanoacrylate glue to create a watertight seal. The second closure, performed 4 months later after collapse of the initial device, was performed by using the CardioSEAL septal repair implant. This was secured in place with hemoclips and similarly injected with cyanoacrylate glue to create a watertight seal.nnnMAIN OUTCOME MEASUREMENTSnFistula closure, as determined by contrast gastrogram through a PEG tube and gastrograffin enema.nnnRESULTSnSuccessful fistula closure was achieved for 4 months after initial device placement. After the second device was placed, the patient remained clinically well until her demise 18 months later from unrelated causes.nnnLIMITATIONSnThese procedures were performed on only one subject.nnnCONCLUSIONSnSuccessful endoscopic closure of gastrocolonic fistula can be achieved, even with long-standing, fibrotic fistulous tracts by using a novel endoscopic approach.

Techniques, tricks, and complications of enteroscopy.

Small bowel endoscopy has made tremendous advances over the last 8 years. The introduction of capsule endoscopy, double-balloon enteroscopy, single-balloon enteroscopy and spiral overtube-assisted enteroscopy have completely removed the mystery in investigating the small intestine. These new procedures are challenging and timeconsuming to perform. A brief overview on the technical issues and complications related to these small bowel endoscopy procedures is presented.

Changes in the small bowel of symptomatic kidney transplant recipients converted from mycophenolate mofetil to enteric-coated mycophenolate sodium.

Background/Aims: Gastrointestinal (GI) symptoms in renal transplant recipients may be caused due to mycophenolic acid (MPA) toxicity. Using small bowel capsule endoscopy (SBCE) we examined the impact of conversion from Mycophenolate Mofetil (MMF) to enteric-coated formulation of Mycophenolate Sodium (EC-MPS) given to treat GI mucosal lesions. Methods: Adult kidney-only recipients at least 30 days after transplant, presenting with GI symptoms while receiving MMF completed a Gastrointestinal Symptom Rating Scale (GSRS) questionnaire, underwent SBCE, and had MMF substituted by EC-MPS. After 30 days, GSRS and SBCE were repeated and findings were compared to baseline values. Patients who were still on EC-MPS 6-24 months post-conversion were contacted for completing a follow-up GSRS questionnaire and SBCE. Results: Eighteen out of 23 subjects completed the first part of the study. Subjects median ages and post-transplant time were 47.5 years old and 4.5 months, respectively. Tacrolimus, MMF and prednisone was the main regimen (94%), with a median MMF dose of 750 mg BID. The average baseline GSRS was 2.99 ± 0.81; it significantly decreased to 2.19 ± 0.8 at 30 days post-conversion. At baseline, 50 had gastric and 89% had small bowel lesions. At 30 days, 29 and 62% of the SBCE were still showing gastric and small bowel lesions, respectively. Of 5 patients in the study extension, 4 had abnormal SBCE findings but have been reporting improvement in their symptoms. Conclusion: Stomach and small bowel mucosal lesions are common in kidney recipients with GI symptoms when treated with MMF. Conversion to EC-MPS for 30 days significantly alleviated the GI symptoms; however, no evident correlation with SBCE findings was found.

Endoscopic Palliation of Pancreatic Cancer

There is no doubt that our long-range goal is to cure pancreatic cancer. Realistically, most of what we can do currently is treat the disabling symptoms of this dreadful disease. Biliary decompression, intestinal stenting, celiac plexus neurolysis, and fiducial placement are some of the endoscopic procedures that aim to provide better quality of life to patients suffering from this disease. A thorough understanding of these options will help patients make good decisions in choosing the proper treatment. Endoscopists who perform these procedures must possess great skills, but importantly, they must also be compassionate and act with good judgment.