Viviana Parra

International collaborative study on EUS-guided gallbladder drainage: Are we ready for prime time?

BACKGROUND Cholecystectomy remains the gold standard treatment of cholecystitis. Endoscopic treatment of cholecystitis includes transpapillary gallbladder drainage. Recently, endoscopic ultrasound-guided transmural drainage of the gallbladder (EUS-GBD) has been reported. This study reports the cumulative experience of an international group performing EUS-GBD. METHODS Cases of EUS-GBD from January 2012 to November 2013 from 3 tertiary-care institutions were captured in a registry. Patient demographics, disease characteristics, procedural and clinical outcomes were recorded. RESULTS 35 patients (15 malignant, 20 benign) were included. Median age was 81 years (SD=13.76 years), sixteen (46%) were males. Median follow-up was 91.5 days (SD=157 days). Transmural access was obtained from the stomach (n=17) or duodenum (n=18). Stents placed included plastic (n=6), metal (n=20), or combination (n=7). Technical success was achieved in 91.4% (n=32). Immediate adverse events (14%) included: bleeding, stent migration, cholecystitis and hemoperitoneum. Delayed adverse events (11%) included abscess formation and recurrence of cholecystitis. Long-term clinical success rate was 89%. Stent type and puncture site were not associated with immediate (p=0.88, p=0.62), or long-term (p=0.47, p=0.27) success. CONCLUSIONS EUS-GBD appears to be feasible, safe, and effective. Prospective studies are needed to confirm these findings and identify the best technique to use. CLINICAL TRIAL REGISTRATION NCT01522573.

Pancreatic necrosectomy by using a lumen-apposing metal stent

the cyst. Next, we attempted to dilate the tract with a 10F dilation catheter; however, because of resistance, a needleknife was used to open the tract. On EUS imaging, slow bleeding was noted into the pseudocyst from the wall as the tract was being created. To address this, first the tract was dilated with a balloon catheter. Next, a fully covered self-expandable metal stent was placed with one end in the pseudocyst and the other end protruding into the stomach to form the cystgastrostomy tract as well as to tamponade the bleeding (Fig. 1). No active bleeding was seen after stent placement. After the procedure, the patient was admitted for monitoring, with hemoglobin remaining

Gastric peroral endoscopic myotomy for gastroparesis, after botulinum toxin injection

A 45-year-old woman had refractory Epstein–Barr virus-associated gastroparesis. Despite lifestyle modification and medication therapy, the patient had recurrent hospitalizations for gastroparesis. Management also included four previous sessions of endoscopic botulinum toxin injection. Despite transient symptomatic improvement, the patient’s symptoms had recurred. She was not a candidate for surgical implantation of a gastric pacemaker, so she was referred for gastric peroral endoscopic myotomy (G-POEM). During the procedure (▶Video1), a submucosal bleb was created with a methylene blue and saline solution, 6 cm proximal to the gastroesophageal junction. A mucosal entry point was incised with a multipurpose knife and an endoscope was advanced into the submucosa. The submucosal space was dissected using intermittent injection and dissection with spray coagulation current. In patients who have not undergone previous botulinum toxin injection, injection of the submucosa will facilitate separation between the mucosa and muscle layers (▶Fig. 1) However, this patient’s submucosal tunnel demonstrated significant scarring. The botulinum toxin caused areas of fusion of the mucosa and the muscularis with dense scarring and opaque submucosa leading to a more challenging dissection (▶Video1). Once the submucosal tunnel was dissected down to the pylorus level, pyloromyotomy was performed. The submucosal tunnel was washed with topical liquid gentamicin, and the mucosal entry site was closed using multiple endoscopic sutures. At 3 months’ follow-up, the patient has regained a normal quality of life with weight gain of 10 kg. G-POEM is a novel endoscopic therapy for refractory gastroparesis, that involves mucosal entry, submucosal tunneling, pyloromyotomy, and closure of the mucosal entry site. It is associated with an 86% symptomatic improvement in patients with refractory gastroparesis [1]. Previous endoscopic botulinum toxin injection is associated with a more challenging submucosal tunneling (▶Fig. 1). Recent studies recommend against endoscopic botulinum toxin injection for gastroparesis [2–4]. ▶Video1 highlights the submucosal fibrosis secondary to botulinum toxin injection that leads to a more challenging dissection during G-POEM.

Low-cost technique for resection of a large duodenal lipoma with the aid of a modified polypectomy snare

A 63-year-old man presented to our hospital with chronic abdominal pain associated with intermittent periods of postprandial vomiting. Esophagogastroduodenoscopy and endoscopic ultrasound confirmed the diagnosis of a lipoma in the second portion of the duodenum. Owing to the unavailability of a therapeutic gastroscope, a conventional polypectomy snare was modified (▶Fig. 1) in order to be used as a third hand that holds the lipoma, and works as an additional tool in parallel with the scope (▶Video1). The modification consisted of removing the handle of the manual control device, such that the endoscope could be extracted from the stomach cavity, leaving the snare body inside of it in the same way that a guidewire would be used. The modified polypectomy snare was placed around the pylorus to act as a “trap.” Then, the endoscope tip was advanced through the snare into the duodenum where the lesion was grasped and pulled into the antrum. The modified snare was closed around the pseudopedicle, holding the lipoma in the antrum. The lipoma was resected using a second polypectomy snare, and the mucosal defect was closed with a hemoclip. The patient was discharged home without complications. A modified polypectomy snare can be a useful accessory tool when a therapeutic endoscope is not available. Endoscopy_UCTN_Code_TTT_1AO_2AG

Novel management of a necrotic pancreatic fluid collection with staged cystgastrostomy followed by cystgastrojejunostomy: the Lizzie Grace maneuver

A 58-year-old man with severe alcoholrelated necrotizing pancreatitis was admitted and was treated initially with conservative management including aggressive intravenous fluid hydration and placement of a percutaneous gastrojejunostomy tube for enteral nutrition. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with no evidence of pancreatic duct disruption or contrast leakage, but sludge was swept from the bile duct and biliary sphincterotomy was performed. Endoscopic ultrasound (EUS) revealed acute inflammatory changes in the entire pancreas without any well-formed fluid collection that could be drained. The patient was treated conservatively with aggressive intravenous fluid hydration, bowel rest, and enteral nutrition for 4 weeks. He subsequently developed sepsis and a repeat computed tomography (CT) scan was performed, which demonstrated a large, complex 17×7-cm pancreatic fluid collection that was extending from the left anterior perirenal space to the left lower quadrant in the pelvis. EUS-guided cystgastrostomy was performed with a 15-mm lumen-apposing metal stent (LAMS; Axios, Boston Scientific, Natick, Massachusetts, USA). An ultrathin upper gastrointestinal (GI) endoscope was then used to enter the cyst cavity and a necrotic fistula tract was identified that extended into the jejunum with necrosis involving the jejunal lumen. Wire guidance was used to place a bridging esophageal fully covered self-expanding metal stent (FCSEMS; Wallstent, Boston Scientific) across the jejunal fistula tract with the distal end being in the jejunum and the proximal end in the stomach via the LAMS creating a cystgastrojejunostomy (▶Video1). A 12-mm over-thescope clip (OTSC; Ovesco, Cary, North Carolina, USA) was used to anchor the FCSEMS to the gastric mucosa to prevent migration. A repeat CT scan 2 weeks later showed interval improvement in the necrotic fluid collection but a 13×2.7-cm residual collection was seen extending deep into the left pelvis (▶Fig. 1). The decision was made to pursue repeat EUS-guided drainage through the existing cystgastrostomy fistula to access the deep pelvic collection. An upper GI endoscopy was performed with removal of the bridging cystgastrojejunostomy stents. The fistula tract appeared mature. An echoendoscope was then advanced through the fistula tract into the jejunum. The posterior pancreatic fluid collection was identified; a 15-mm LAMS (Axios, Boston Scientific) was deployed using an EUS-guided tech-