Sindhu Barola

Endoscopic sleeve gastroplasty: the learning curve

Background and study aims  Endoscopic sleeve gastroplasty (ESG) is gaining traction as a minimally invasive bariatric treatment. Concern that the learning curve may be slow, even among those proficient in endoscopic suturing, is a barrier to widespread implementation of the procedure. Therefore, we aimed to define the learning curve for ESG in a single endoscopist experienced in endoscopic suturing who participated in a 1-day ESG training program. Patients and methods  Consecutive patients who underwent ESG between February 2016 and November 2016 were included. The performing endoscopist, who is proficient in endoscopic suturing for non-ESG procedures, participated in a 1-day ESG training session before offering ESG to patients. The outcome measurements were length of procedure (LOP) and number of plications per procedure. Nonlinear regression was used to determine the learning plateau and calculate the learning rate. Results  Twenty-one consecutive patients (8 males), with mean age 47.7 ± 11.2 years and mean body mass index 41.8 ± 8.5 kg/m 2 underwent ESG. LOP decreased significantly across consecutive procedures, with a learning plateau at 101.5 minutes and a learning rate of 7 cases ( P  = 0.04). The number of plications per procedure also decreased significantly across consecutive procedures, with a plateau at 8 sutures and a learning rate of 9 cases ( P  < 0.001). Further, the average time per plication decreased significantly with consecutive procedures, reaching a plateau at 9 procedures ( P  < 0.001). Conclusions  Endoscopists experienced in endoscopic suturing are expected to achieve a reduction in LOP and number of plications per procedure in successive cases, with progress plateauing at 7 and 9 cases, respectively.

A Randomized Controlled Trial Comparing the Depth of Maximal Insertion Between Anterograde Single-Balloon Versus Spiral Enteroscopy:

Background: Three device-assisted deep endoscopic platforms presently exist and are available for clinical use: double-balloon enteroscopy, single-balloon enteroscopy (SBE), and spiral enteroscopy (SE). In a retrospective study, SE was associated with a greater depth of maximal insertion (DMI) with similar diagnostic yields and procedure time as compared with SBE. Aims: This was a prospective, randomized comparison of SE and SBE with respect to DMI, diagnostic yield, procedure time, and rate of adverse events. Methods: Patients were prospectively randomized to undergo either anterograde SE or SBE. Patient demographics, indication for procedure, DMI, procedure time, therapeutic procedure time, adverse event, diagnostic findings, and therapeutic interventions were prospectively recorded. The primary outcome was DMI. Secondary outcomes included: procedure time; diagnostic yield; therapeutic yield and adverse event rates. Results: During the study period, 30 patients underwent deep enteroscopy (SE 13, SBE 17). The most common indication was gastrointestinal bleeding in both groups. There was no significant difference in the DMI between SE and SBE (330.0 ± 88.2 cm vs 285.3 ± 80.8 cm, P = .16). There was no difference between SE and SBE in procedure time (37.0 ± 10.5 vs 38.3 ± 12.4, P = .76), diagnostic yield (SE = 9 [69%] vs SBE = 7 [41%], P = .16), or therapeutic yield (SE = 6 [46%] vs SBE = 4 [24%], P = .26). There were no major adverse events in either group. Conclusions: Spiral enteroscopy and SBE are similar with respect to DMI, diagnostic yield, therapeutic yield, procedure time, and rate of adverse events. Small numbers prevent giving a definitive judgment and future adequately powered prospective study is required to confirm these findings.

Demonstration of transoral gastric outlet reduction: 2-fold running suture technique

Weight regain after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of the RYGB. Endoscopic revision of a dilatated GJ, called transoral outlet reduction (TORe), has been proved effective and allows patients to avoid reoperation. A 43-year-old woman who had undergone gastric bypass 3 years previously regained 40% of her lost weight, lost postprandial satiety, and had symptoms of dumping syndrome. Endoscopy revealed a dilatated (30 mm) GJ anastomosis (Fig. 1A). Video 1 (available online at www. VideoGIE.org) demonstrates a 2-fold running suture method, a novel method to perform TORe. Before endoscopic suturing, we performed aggressive argon plasma coagulation therapy to the gastric side of the gastric outlet

Technique of endoscopic suturing of an enteral feeding tube to manage recurrent dislodgement

Figure 2. Bite performed through the PEG-jejunal tube adjacent to the balloon toward the jejunal end. The rate of early PEG tube dislodgement (<10 days) varies between 0.6% and 4.0%; however, late dislodgement is seen in up to 12.8% cases, with the majority requiring an emergency department visit. Recurrent dislodgement of the PEG-jejunal (PEG-J) tube is common in neurologically impaired patients. We used a novel approach of endoscopic suturing to successfully prevent recurrent dislodgement of the PEG-J tube. We present a video (Video 1, available online at www.VideoGIE.org) that demonstrates endoscopic suturing of a PEG-J tube. A 31-year-old woman with seizure disorder had a PEG tube placed because of gastroparesis. She presented with recurrent dislodgement (2 episodes per month) of the PEG portion of the PEG-J tube secondary to episodes of seizures. Each time, the single-system PEG-J was replaced endoscopically. She was referred for an opinion regarding endoscopic fixation. The decision was made to secure the PEG portion of the PEG-J to the gastric wall by means of full-thickness endoscopic suturing (OverStitch, Apollo Endosurgery, Austin, Tex). The endoscope was passed into the stomach and was advanced to the second portion of the duodenum. The PEGJ tube was reinserted, and the balloon was filled with normal saline solution to 10 mL. The endoscopic suturing system was then mounted on a therapeutic double-channel gastroscope. A full-thickness bite was taken on the gastric wall by use of a helix (Fig. 1), and then a bite was performed through the PEG-J tube (Fig. 2) adjacent to the balloon toward the jejunal end. The J tube lumen was sealed with surrounding tissue at the time of cinching (Fig. 3). Another full-thickness bite was taken through the gastric wall. The suture was then cinched tightly but not too much because we wished to avoid pressure injury to the mucosa. The process was repeated on the opposite side (Fig. 4). Clinical follow-up at 3 months revealed that the patient had experienced no further episodes of tube dislodgement.

Novel Technique to Manage Recurrent PEG-J Tube Dislodgement With Full-Thickness Endoscopic Suturing

Novel Technique to Manage Recurrent PEG-J Tube Dislodgement With Full-Thickness Endoscopic Suturing

Pancreatic Carcinoma Diagnosed by Peroral Pancreatoscopy Using the SpyGlass System

A 74-year-old woman presented to our clinic with right upper quadrant pain. Abdominal ultrasound revealed a moderately dilated common bile duct (CBD), main pancreatic duct (PD), and intrahepatic ducts. Computed tomography of the abdomen with contrast showed a dilated CBD, stricture of the proximal main PD with upstream dilatation, and evidence of mild acute interstitial edematous pancreatitis (a). There was no evidence of a definite pancreatic mass. Magnetic resonance imaging of the abdomen showed dilatation of the PD, with apparent high-grade, short-segment stricture in the region of the pancreatic head without evidence of a pancreatic mass. Positron emission tomography showed atrophy of the pancreas without a definite pancreatic head mass. Endoscopic ultrasound showed a dilated main PD with no echogenic duct wall, thickening, stricture, or pancreatic mass. Endoscopic retrograde cholangiopancreatography revealed a moderately dilated biliary tree and a main PD that was irregular in contour (b,c). SpyGlass pancreatoscopy of the main PD revealed frondlike villous projections (d). Intraductal SpyGlass-directed biopsy specimens were taken, and a pancreatic stent was placed. Histology demonstrated severely atypical cells consistent with invasive, moderately to poorly differentiated adenocarcinoma. Despite her age, the patient underwent a Whipple pancreatoduodenectomy owing to the early diagnosis. SpyGlass pancreatoscopy, which in this case was critical to early diagnosis of the PD stricture, can be used for the evaluation of indeterminate strictures of the pancreatic duct. (Informed consent was obtained from the patient to publish these images.)

Spontaneous Hyperinflation of an Intragastric Balloon 5 Months After Insertion

A 27-year-old Indian man presented with a 2-month history of recurrent vomiting. He had experienced postprandial fullness/bloating for the past month. He did not respond to proton pump inhibitors or an antiemetic. He had no history of food allergies or allergic disorders. Stool was negative for ova and cyst. Esophagogastroduodenoscopy revealed approximately six strictures with poststenotic dilation starting at the duodenal bulb and extending into the third part of the duodenum (a; arrows). These strictures were associated with mild circumferential erythema, ulceration, and diverticula (a; arrowhead). Biopsies from the duodenum revealed expansion of the lamina propria by intense inflammation. The submucosa showed Brunner’s glands, characteristic of duodenal biopsy (b; arrow). Biopsy showed prominent eosinophils (b; arrowhead) with focal clustering in the lamina propria. There were approximately 60 eosinophils/high-power field, confirming the diagnosis of eosinophilic duodenitis (ED). Computed tomography of the abdomen showed duodenal strictures with poststenotic dilation (c; arrows). The patient responded well to a course of oral steroids, and his symptoms continued to improve with maintenance steroids. There are few case reports of a single duodenal stricture due to ED. An extensive literature review indicates that this case, with approximately six duodenal strictures, is particularly rare. (Informed consent was obtained from the patient to publish these images.)