Conventional Endoscopic Treatment Research Articles

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Common Bile Duct Stones: Endoscopic Management of Difficult Common Bile Duct Stones

Difficult common bile duct (CBD) stones are difficult to remove using conventional stone clearance methods such as endoscopic papillary sphincterotomy. In this guideline, we present several recommendations and relevant information on the endoscopic treatment of difficult CBD stones. For the primary treatment of large CBD stones in patients without distal bile duct stricture, we recommend limited endoscopic sphincterotomy followed by endoscopic papillary large balloon dilation. For large CBD stones that are difficult to remove with conventional endoscopic treatment methods, we recommend electrohydraulic or laser lithotripsy under cholangioscopy. Short-term biliary stenting is recommended in patients with CBD stones that are difficult to remove by these methods. Finally, endoscopic treatment via small bowel enteroscopy or percutaneous transhepatic cholangioscopy may be an option in patients with surgically altered anatomy.

Evaluating the Efficacy of a Novel Hemostatic Powder Compared to Traditional Treatments in Non-Variceal Upper Gastrointestinal Bleeding: A Multicenter, Randomized Non-inferiority Study

Hemostatic powders have been rapidly developed and used to treat gastrointestinal bleeding. We aimed to investigate the non-inferiority of the newly developed hemostatic powder (CEGP-003) compared to conventional endoscopic treatments for non-variceal upper gastrointestinal bleeding (NVUGIB). This prospective, multicenter, randomized, open-label, controlled trial was conducted at four referral institutions. We enrolled consecutive patients who underwent emergency endoscopy for NVUGIB. The patients were randomly assigned to either the CEGP-003 or the conventional treatment group. In the CEGP-003 group, the hemostatic powder was applied as a spray. Conventional endoscopic treatments included electrical coagulation and hemoclipping. Between November 2019 and June 2022, 218 patients were enrolled (CEGP-003, 108; conventional, 110). Initial hemostasis was achieved in 104 of 108 patients (96.3%) in the CEGP-003 group and 101 of 110 patients (91.8%) in the conventional treatment group. The CEGP-003 group exhibited a significantly higher re-bleeding rate than the conventional treatment group. Multivariate analysis that age, duodenum and middle 1/3 of stomach, and CEGP-003 use as the initial hemostatic treatment were independent risk factors for re-bleeding. No adverse events were associated with CEGP-003. CEGP-003 demonstrates promise as an initial endoscopic therapy for NVUGIB, however close monitoring is warranted due to the risk of re-bleeding (Cris.nih.go.kr, number: KCT0004655).

Eficacia y seguridad del balón de dilatación uretral Optilume® en la práctica clínica real: análisis multicéntrico en España

IntroductionThe Optilume® paclitaxel-coated urethral dilatation balloon is an alternative to conventional endoscopic treatments that combines mechanical dilatation with local delivery of paclitaxel. ObjectiveTo describe the success rate and analyze the safety of the device in real clinical practice. To evaluate possible predictors of treatment failure. Material and methodsRetrospective multicenter study in patients diagnosed with urethral stricture and treated with an Optilume® balloon in routine clinical practice. Data were collected from flowmetry, questionnaires (PROM and IPSS) and cystoscopy before surgery, and 3, 6 and 12 months after the procedure, according to standard practice. Surgical success was defined as the absence of subsequent urethral manipulation and a Qmax>10ml/s. Results238 patients treated with Optilume® in 12 Spanish hospitals between May 2021 and April 2024 were included in the study. Of these, 156 who had a minimum follow-up of 3 months, were analyzed. Median stricture length: 1.5cm (0.5 - 5.3), mainly in bulbar urethra (87.7%). Of the total, 12.8% of patients had a history of pelvic radiotherapy, and 81.4% had undergone prior urethral manipulation. Postoperative complications were reported in 14.2% of the total. The treatment success rate was 73.8%, with a median follow-up of 8 months (5-12). No predictors of stricture recurrence were identified. Recurrence rates were higher in strictures located in the posterior versus anterior urethra (42.9% vs. 24.6%, p=0.126). No significant differences were observed between patients with and without prior urethral manipulation. ConclusionTreatment with Optilume® has been shown to be safe and effective in short-term routine clinical practice.

Efficacy and safety of Optilume® paclitaxel-coated urethral dilatation balloon in real-life: experience in a Spanish multicenter study

IntroductionThe Optilume® Paclitaxel-coated urethral dilatation balloon is an alternative to conventional endoscopic treatments that combines mechanical dilatation with local delivery of paclitaxel. ObjectiveTo describe the success rate and analyze the safety of the device in real clinical practice. To evaluate possible predictors of treatment failure. Materials and methodsRetrospective multicenter study in patients diagnosed with urethral stricture and treated with an Optilume® balloon in routine clinical practice. Data were collected from flowmetry, questionnaires (PROM and IPSS) and cystoscopy before surgery, and 3, 6 and 12 months after the procedure, according to standard practice. Surgical success was defined as the absence of subsequent urethral manipulation and a Qmax >10 ml/s. Results238 patients treated with Optilume® in 12 Spanish hospitals between May 2021 and April 2024 were included in the study. Of these, 156 who had a minimum follow-up of 3 months, were analyzed. Median stricture length: 1.5 cm (0.5–5.3), mainly in bulbar urethra (87.7%). Of the total, 12.8% of patients had a history of pelvic radiotherapy, and 81.4% had undergone prior urethral manipulation. Postoperative complications were reported in 14.2% of the total. The treatment success rate was 73.8%, with a median follow-up of 8 months (5–12). No predictors of stricture recurrence were identified. Recurrence rates were higher in strictures located in the posterior versus anterior urethra (42.9% vs. 24.6%, p = 0.126). No significant differences were observed between patients with and without prior urethral manipulation. ConclusionTreatment with Optilume® has been shown to be safe and effective in short-term routine clinical practice.

Percutaneous transhepatic papillary ballooning and extraction for common bile duct stones: a single-center experience.

At present, some common bile duct stones (CBDSs) cannot be removed by conventional endoscopic treatment. Percutaneous transhepatic papillary ballooning and extraction (PTPBE) is a promising treatment for CBDSs. This study aimed to evaluate the feasibility and efficacy of PTPBE for removing CBDSs. From April 2013 to April 2021, 29 patients with CBDSs underwent PTPBE at The First Affiliated Hospital of Zhengzhou University; their clinical data were retrospectively analyzed. The technical success, clinical success, procedure time, radiation dose, 1-year CBDSs recurrence rate, and incidence of early/late complications were recorded, and white blood cell (WBC) counts and alanine aminotransferase (ALT), C-reactive protein (CRP), total bilirubin (TBIL), and carbohydrate antigen-199 (CA-199) levels were compared before the interventional procedure and 1 month later. The CBDSs were successfully removed in 29 patients (the CBDSs in 20 patients were resolved once, and in 9 patients, they were resolved twice). The mean procedure time and radiation dose were 56.38±13.56 minutes and 732.07±262.23 miligray (mGy), respectively. The technical and clinical success rates were both 100%. The incidence of early complications (including pancreatitis and bile duct bleeding) and late complications (reflux cholangitis) was 10.34% and 3.45%, respectively. The WBC (both P<0.01), ALT (both P<0.01), CRP (both P<0.01), CA-199 (both P<0.01), and TBIL (both P<0.01) significantly decreased before PTPBE and 1 month later. PTPBE is a safe and effective alternative solution for elderly patients who cannot undergo or refuse traditional surgical and endoscopic treatments.

Treatment of Leakage Following Sleeve Gastrectomy by Laparo-Endoscopic Gastrostomy (LEG).

Sleeve gastrectomy (SG) is widely recognized as the leading bariatric procedure worldwide. However, leakage, its major complication, remains a significant concern. This study focuses on the challenges of managing leakage, especially when conventional endoscopic treatments are ineffective. Although a novel one-step approach as reported by Pulimuttil James Zachariah from Wei-Jei Lee's team has demonstrated promise, further investigations and reports on its efficacy are currently insufficient. Between January 2021 and November 2023, we analyzed five patients treated at our center for SG leakage. Patient data include demographics, comorbidities, surgical details, and outcomes. The study details Laparo-Endoscopic Gastrostomy procedures performed post-SG leakage diagnosis, highlighting differences between acute and chronic instances. The study effectively implemented Zachariah's one-step approach, achieving favorable results in all five cases. Patient characteristics, presentation, postoperative progression, and additional treatments were documented. The outcome supports Zachariah's assertion that the one-step approach is a simple, safe, and cost-effective approach for SG leakage, avoiding digestive tract reconstruction. Despite potential limitations, including challenges in closing large defects and extended healing times, the procedure's effectiveness in decompression, drainage, and nutritional support significantly contributes to its elevated healing rate. The study emphasizes the importance of timely abdominal drain removal based on clinical conditions, challenging traditional practices for better clinical outcomes.

Magnetic compression anastomosis for the treatment of complete biliary obstruction after cholecystectomy

Background & AimsPost-cholecystectomy biliary strictures can be treated surgically or non-surgically. Although endoscopic or percutaneous treatments are the preferred approaches, these methods are not feasible in cases where complete stricture occlusion prevents the successful passage of a guidewire. The utility of magnetic compression anastomosis (MCA) in patients with post-cholecystectomy complete biliary obstruction that cannot be treated conventionally was evaluated. MethodsMCA was performed in 10 patients with post-cholecystectomy biliary strictures that did not resolve with conventional endoscopic or percutaneous treatment. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and another was advanced via endoscopic retrograde cholangiopancreatography(ERCP) of the common bile duct. After magnet approximation and recanalization, a fully covered self-expandable metal stent (FCSEMS) was placed for 3 months and then replaced for a further 3 months. Stricture resolution was evaluated after FCSEMS removal. ResultsAmong the 10 patients who underwent MCA for post-cholecystectomy biliary stricture, the biliary injury was Strasberg type B in 2, type C in 3, and type E in 5. Recanalization was successful in all patients (technical success rate 100%). The mean follow-up period after recanalization was 50.2 months (range 13.2–116.8 months). Partial restenosis after MCA occurred in two patients at 24.1 and 1.6 months after stent removal. ERCP with FCSEMS placement resolved the recurrent stenosis in both patients. ConclusionsMCA is a useful alternative nonsurgical treatment for complete biliary obstruction after cholecystectomy that cannot be resolved by conventional methods.

Endoscopic application of magnetic compression anastomosis: a review.

Magnetic compression anastomosis (MCA) is a new method that provides sutureless passage construction for tubular organs. Due to the high recurrence rate of conventional endoscopic treatment and the high morbidity and mortality of surgical procedures, the MCA technique shows promise. The aim of this review is to comprehensively examine the literature related to the use of MCA in different gastrointestinal diseases over the past few years, categorizing them according to the anastomotic site and describing in detail the various methods of magnet delivery and the clinical outcomes of MCA. MCA is an innovative technique, and its use represents an advancement in the field of minimally invasive interventions. Comparison studies have shown that the anastomosis formed by MCA is comparable to or better than surgical sutures in terms of general appearance and histology. Although most of the current research has involved animal studies or studies with small populations, the safety and feasibility of MCA have been preliminarily demonstrated. Large prospective studies involving populations are still needed to guarantee the security of MCA. For technologies that have been initially used in clinical settings, effective measures should also be implemented to identify, even prevent, complications. Furthermore, specific commercial magnets must be created and optimized in this emerging area.

Comparative study between biliary covered self-expandable metal stent and conventional endoscopic bile drainage treatment in endoscopic retrograde cholangiopancreatography-related Stapfer type II retroperitoneal perforations.

Perforation is one of the most serious complications of endoscopic retrograde cholangiopancreatography (ERCP). Conventional nonsurgical endoscopic treatments including intravenous antibiotic administration and plastic endoscopic biliary drainage are generally approved for the treatment of ERCP-related Stapfer type II perforation (perivaterian type). Biliary covered metal stent placement has recently been reported to have favorable outcomes in ERCP-related Stapfer type II perforations. We aimed to compare the outcomes of conventional endoscopic bile drainage and biliary covered self-expandable metal stent (SEMS) insertion in patients with Stapfer type II perforation. Medical records of patients who underwent ERCP at Kyungpook National University Hospital in Daegu from 2011 to 2022 were retrospectively reviewed. A total of 8,402 ERCP procedures were performed in our hospital. Sixty-six ERCP-related perforations (0.78%) were identified. Among them, 37 patients (56.1%) who had Stapfer type II perforations were enrolled. Thirteen and twenty-four patients received biliary covered SEMS insertion and conventional endoscopic bile drainage treatments, respectively. No significant differences were observed in the clinical success rate (92.3% vs. 91.7%, p = 1.000), hospital stay (9.46 ± 5.97 vs. 13.9 ± 13.2 days, p = 0.258), and post-ERCP-related fasting time (5.4 ± 3.4 vs 4.3 ± 3.0 days, p = 0.305). Complications including bleeding, post-ERCP pancreatitis, fever, and death were not significantly different between the two groups. The conventional endoscopic bile drainage group took less time for ERCP than the SEMS group (11.5 ± 5.2 vs. 18.5 ± 11.2 min, p = 0.013). Compared with the conventional endoscopic bile drainage treatment method, biliary covered SEMS did not improve patient outcomes in ERCP-related Stapfer type II perforations.

Endoscopic resection and laparoscopic lymph node dissection for early gastric cancer beyond conventional endoscopic treatment indications: a 10-year outcome study.

Endoscopic full-thickness gastric resection (EFTGR) with laparoscopic regional lymph node dissection (LLND) and endoscopic submucosal dissection (ESD) with LLND have been investigated as treatment options for early gastric cancer beyond the absolute indications for ESD. However, comparative studies on the long-term outcomes of these procedures are lacking. This study aimed to analyze and compare the 10-year outcomes of both procedures in a real clinical setting. Between January 2009 and December 2013, 28 and 37 patients diagnosed with EGC beyond the absolute indications for ESD were treated with EFTGR with LLND and ESD with LLND, respectively. In both procedures, the dye was injected into the tumor. However, after injection and LLND, EFTGR was performed immediately in the EFTGR with LLND group, whereas LLND was followed by ESD in the ESD with LLND group. The primary endpoint was the 10-year survival rate. The EFTGR with LLND group had one case of local recurrence (3.6%) and mortality (3.6%) each, while the ESD with LLND group had none (0.0% for both); however, the differences were not statistically significant (P = 0.247 for each). Furthermore, there was no significant difference in complications such as ischemia and anastomosis leakage between the groups (P = 0.247). When the procedures were properly applied, EFTGR with LLND and ESD with LLND did not increase the 10-year mortality in patients with EGC beyond the absolute ESD indications compared with conventional radical gastrectomy.

Efficacy of new hemostatic techniques in nonvariceal gastrointestinal bleeding: A systematic review and network meta-analysis.

Nonvariceal gastrointestinal bleeding (NVGIB) is a common medical condition with significant mortality and morbidity. Several types of hemostatic modalities are currently available in clinical setting. This systematic review and network meta-analysis aimed to assess the efficacy of these modalities in treating NVGIB. PubMed, EMBASE, and the Cochrane Library databases were searched for studies that compared the efficacy of different hemostatic techniques (over-the-scope clip [OTSC], hemostatic powder [HP] and conventional endoscopic treatment [CET]) for NVGIB published up to June 2022. The 30-day rebleeding rate was regarded as the primary outcome. We performed pairwise and network meta-analyses for all treatments. The heterogeneity and transitivity were evaluated. Twenty-two studies were included. Regarding the 30-day rebleeding rate, OTSC and HP plus CET showed superior efficacy in treating NVGIB compared with CET (OTSC vs CET: relative risk [RR] 0.42, 95% confidence interval [CI] 0.28-0.60; HP plus CET vs CET: RR 0.40, 95% CI 0.17-0.87), while OTSC and HP plus CET had comparable efficacy (RR 0.95, 95% CI 0.38-2.31). HP plus CET ranked the highest in the network ranking estimate. The sensitivity analysis showed that it was not robust that OTSC was superior to CET regarding the short-term rebleeding rate and the initial hemostasis rate. While all-cause mortality, bleeding-related mortality and necessity of surgical or angiographic salvage therapy showed no statistically significant difference. OTSC and HP plus CET significantly reduced 30-day rebleeding rate compared to CET and had comparable efficacy in the treatment of NVGIB.

Comparison of a Polysaccharide Hemostatic Powder and Conventional Therapy for Peptic Ulcer Bleeding

Hemostatic powders have been clinically used in the treatment of gastrointestinal bleeding. We investigated the non-inferiority of a polysaccharide hemostatic powder (PHP), compared with conventional endoscopic treatments, for peptic ulcer bleeding (PUB). This study was a prospective multicenter randomized open-label controlled trial at four referral institutions. We consecutively enrolled patients who had undergone emergency endoscopy for PUB. The patients were randomly assigned to either a PHP or conventional treatment group. In the PHP group, diluted epinephrine was injected, and the powder was applied as a spray. Conventional endoscopic treatment included the use of electrical coagulation or hemoclipping after injection of diluted epinephrine. Between July 2017 and May 2021, 216 patients were enrolled in this study (PHP group, 105; control group, 111). Initial hemostasis was achieved in 92 of 105 patients (87.6%) in the PHP group and 96 of 111 patients (86.5%) in the conventional treatment group. Re-bleeding did not differ between the two groups. In subgroup analysis, the initial hemostasis failure rate in the conventional treatment group was 13.6% for Forrest IIa cases; however, there was no initial hemostasis failure in the PHP group (P=0.023). Large ulcer size (≥15mm) and chronic kidney disease with dialysis were independent risk factors for re-bleeding at 30 days. No adverse events were associated with PHP use. PHP is not inferior to conventional treatments and could be of use in initial endoscopic treatment for PUB. Further studies are needed to confirm the re-bleeding rate of PHP (ClinicalTrials.gov 02717416).

Submucosal endoscopy: the present and future.

Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.

EUS-directed transgastric endoscopy for upper gastrointestinal bleeding.

A 64-year-old man who had undergone a Roux-en-Y gastric bypass presented because of massive upper gastrointestinal bleeding. The diagnostic and initial therapeutic approach included an upper-endoscopy and colonoscopy without finding the bleeding source. After blood transfusions and hemodynamic stability was reached, a computed tomography angiography was performed. Finding an active extravasation of contrast in the duodenal bulb. After discussion of options, a EUS-directed transgastric endoscopy was proposed. A linear echoendoscope (GF-UCT180; Olympus America, Center Valley, Pa, USA) was advanced into the gastric pouch. Under US guidance, the excluded stomach was located. Under fluoroscopic and US guidance, the remnant stomach was punctured with a 19-gauge EUS needle. As a safety measure; sterile water, methylene blue, and contrast material were injected. Through endosonographic vision a 15-mm × 10-mm cautery-enhanced, lumen-apposing metal stent (LAMS, Axios; Boston Scientific, Natick, Mass, USA) was inserted [Figure 1] creating a gastrogastric fistula between the pouch and the remnant stomach. A gastroscope (GIF-HQ190, Olympus America) was then inserted, followed by a 12 mm CRE balloon (CRE™ Single-Use WIREGUIDED Balloon Dilator) used for dilatation [Figure 2]. The scope was advanced to the duodenal bulb, finding a Forrest IIa ulcer. Conventional endoscopic treatment was performed with submucosal epinephrine injection and mechanical hemostasis with clips Figure 3. The LAMS was left until it was verified that there was no rebleeding risk. Bariatric surgery modifies patient’s anatomy and physiology, bleeding duodenal ulcer are usually treated with urgent laparotomy or interventional radiology.[1] EUS-directed transgastric procedures may offer a minimally invasive, effective option, with less resource utilization in modified anatomy patients that require endoscopic access to gastric remnant for therapeutic procedures.[2,3] To the best of our knowledge, this was the first edge procedure used as a therapeutic measure for bleeding in patients with modified anatomy.Figure 1: EUS gastro-gastric fistulaFigure 2: LAMS ballon dilatationFigure 3: Conventional endoscopic treatmentDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Endourological treatment of non-muscular-invasive bladder tumors

Background: Transurethral resection of the bladder is one of the essential methods in the diagnosis, treatment and management of non-muscularinvasive bladder cancer. The purpose of the procedure is to remove completely all visually detected tumors with a following establishment of a very precise histological diagnosis. The aim of the study is to compare the results of conventional transurethral endoscopic treatment and the En-bloc resection method using different types of energy sources in the treatment of bladder tumors. Material and methods: A total number of 88 patients underwent endourological interventions. Regarding the distribution, 23 patients had conventional transurethral resection, 22 – En-bloc monopolar resection, 21 – En-bloc bipolar resection and 22 – En-bloc with Thu:YAG laser. Clinical data, intraoperative and postoperative data and also the histopathological examination results were compared. Results: The compared groups were heterogeneous by age, sex, tumor characteristic (size, number, location). No significant differences were observed during the operations, comparing the intraoperative and postoperative complications of the studied groups. The detrusor musculature was detected in 74% of cases after conventional transurethral resection, in 91% of cases of En-bloc monopolar resection, in 95% of cases of En-bloc bipolar resection and in 96% of cases of En-bloc Thu:YAG laser. Conclusions: The En-bloc resection technique of non-muscular-invasive bladder tumors is a safe and effective method comparing with the conventional transurethral resection; it allows more favorable postoperative results and obtaining better quality tumor samples which allow establishing correct diagnosis of the disease.

The “Parachute” Technique for the Endoscopic Repair of High-Flow Anterior Skull-Base CSF Leaks

This study aims to assess the feasibility and reliability of our endoscopic trans-nasal technique for the repair of cribriform and sellar high-flow cerebrospinal fluid (CSF) leaks. A comparison between patients suffering from high-flow rhinorrhea and treated through a free grafting endoscopic technique or the "parachute" technique, our nasal packing proposal, was performed. Thirty-three patients were included. The mean age was 52 years (range: 36-68 years). The etiology of the CSF leaks was iatrogenic in 16 cases (48.5%), traumatic in 5 cases (15.2%), spontaneous in 11 cases (33.3%), and related to anterior skull base tumors in 1 case (3%). The bone defect affected the sphenoidal sinus in 20 cases (60.6%), the cribriform plate of the ethmoid in 10 cases (30.3%), and both the sphenoid and ethmoid in 3 cases (9.1%). The mean size of bone defects was 8.5 ± 3.9 mm. The median follow-up was 28 (64) months. A CSF leak recurrence occurred in no cases treated with the parachute technique and in 3 cases that underwent conventional endoscopic treatments. The CSF leak recurrences were associated with 2 iatrogenic and 1 post-traumatic fistula. All the CSF leak recurrences underwent the parachute technique, not showing second recurrences. Our results suggest that the parachute technique is simple, safe, and effective. We recommend it as an alternative treatment to vascular flaps for the treatment of high-flow and recurrent fistulas.

Per Oral Endoscopic Myotomy for the Management of Large Esophageal Diverticula (D-POEM): Safe and Effective Modality for Complete Septotomy.

With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker's while two had epiphrenic diverticulum. The median symptom duration was 12months with a mean diverticulum size of 68.8 ± 1.9mm. The mean procedure time was 64.80 ± 12.6min. with a mean septotomy/myotomy length of 79.44 ± 12.2mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280days (range 98-330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.

EUS in the diagnosis of pathologically undiagnosed esophageal tuberculosis

BackgroundEsophageal tuberculosis (ET) is relatively rare, and the diagnosis is challenging. The aim of this study was to evaluate the clinical features of ET and highlight the role of endoscopic ultrasonography (EUS) in the diagnosis of pathologically undiagnosed ET.MethodsWe retrospectively analysed the clinical features, radiological performances, conventional endoscopic appearances, EUS features, treatment and outcomes of pathologically undiagnosed ET between January 2011 and December 2018. All 9 patients failed to be diagnosed by at least two repeated biopsies (such as routine biopsy, multipoint or deep biopsy, and even or EUS-guided fine-needle aspiration (EUS-FNA)).ResultsNine patients (66.7% female) with a mean age of 45 years (range 29–59) complained of retrosternal pain or discomfort, or (and) dysphagia. Esophagoscopy demonstrated protruding lesions in the mucosa with central ulcers or erosion in five patients, submucosal bulges with smooth surfaces in one patient, submucosal bulges with diverticula in one patient, ulcers with suspicious fistula formation in one patient, and multiple ulcers in one patient. None of the patients received confirmed histopathological or bacteriological diagnoses by repeated biopsies. However, they were first suspected to have ET based on EUS examination. Because EUS found some characteristic ultrasonographic changes, which were very helpful for the diagnosis of ET when combined with clinical manifestations, the patients subsequently received diagnostic antituberculosis therapy. Finally, the patients recovered or improved with follow-up times ranging from 3 to 10 months.ConclusionsEUS could help in the diagnosis of ET on basis of EUS features like poorly defined esophageal wall structure, enlarged paraesophageal or mediastinal lymph nodes, hypoechoic lesions of esophageal wall that are linked to the enlarged paraesophageal lymph nodes. However all attempts should be made to obtain histological or microbiological diagnosis.

3129 Management of a Massive Peptic Ulcer Bleed With Over-the-Scope Clip

INTRODUCTION: Actively bleeding ulcers located in the posterior duodenal bulb are often difficult to manage with conventional endoscopic treatment. We present a case of a successful use of over-the-scope-clip (OTSC) of a spurting artery after failing multiple standard endoscopic therapies. CASE DESCRIPTION/METHODS: A 60 year-old man with a history of myocardial infarction in 2014 on aspirin and plavix presented with pre-syncopal symptoms and five episodes of melena that started one day prior to admission. The patient denied prior use of anticoagulants and history of gastrointestinal bleeding. Upon presentation, his vitals were stable and initial lab values were as follows: hemoglobin 9.8 g/dL (baseline 15 g/dL), platelet count 342 K/uL, INR 1.2, and BUN 29 mg/dL. He was started on an intravenous proton pump inhibitor. An esophagogastroduodenoscopy showed multiple large cratered ulcers measuring 1-2.5 cm involving most of the duodenal bulb. There was evidence of active bleedingfrom a spurting pulsatile vessel along the posteroinferior wall at the apex of the duodenal bulbnear the sweep (Figure 1). Initial attemptsat hemostasis wereunsuccessful despite injection of 1:10,000 solution of epinephrine andthe use of thehemostatic spray. The use of a coagulation forceps was unsuccessful as well. Given the location of the vessel and mucosal friability, the lesion was not amenable to through the scope clipping. Hemostasis was finally achieved after successful placement of a 12 mm OTSC (Figure 2). In addition, the area was retreated with the remainder of the hemostatic spray (Figure 3). The patient was transferred to the medical intensive care unit where overnight, the hemoglobin decreased from 8.2 g/dL to 7.2 g/dL without overt evidence of bleeding. The patient underwent angiography which did not reveal any active extravasation and empiric coil embolization of the gastroduodenal artery was performed. DISCUSSION: We present a case of a massive peptic ulcer bleed that was difficult to manage with standard treatment based on the large size and posterior bulb location. OTSC is commonly used for severe recurrent bleeding but its role during the index endoscopy is still unclear. OTSC should be considered as a potential first line therapy in bleeding lesions at high risk of standard endoscopic treatment failure.

Refractory Bergmann type A bile leak: the need to strike a balance.

Background and study aims Endoscopic therapy for postoperative Bergmann type A bile leaks is based on biliary sphincterotomy ± stent insertion. However, recurrent or refractory bile leaks can occur. Patients and methods This was retrospective study including all consecutive patients who were referred to our center with a Bergmann type A bile leak refractory to previous conventional endoscopic treatments. Results Seventeen patients with post-cholecystectomy-refractory Bergmann type A bile leak were included. All had received prior endoscopic biliary sphincterotomy with biliary stent or nasobiliary catheter placement and all had a percutaneous or surgical abdominal drainage. Repeat endoscopic retrograde cholangiopancreatography (ERCP) confirmed a Bergmann type A bile leak and in all patients we observed that the abdominal drainage was placed adjacent to the origin of the fistula. Our treatment consisted of pulling the drain away from the fistulous site, with extension of the previous sphincterotomy when needed. The treatment was successful in all cases. Mild complications occurred in three patients. Conclusions Our retrospective study shows that refractory Bergmann type A bile leak may be a consequence of an unfavorable position of the abdominal drainage tube, which can be corrected by pulling the drain away from the origin of the fistula. This establishes a favorable pressure gradient that leads the bile flowing from the bile duct into the duodenum.