Double-channel Gastroscope Research Articles

Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife

Video 1Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife. A 61-year-old man with a 3-decade history of recurrent cholecystitis presented to the community emergency department with severe right upper quadrant pain. A CT scan was performed and revealed gangrenous cholecystitis with likely cholecystoduodenal fistulous communication.After discussion with the patient and the HPB team, the plan was made to attempt endoscopic extraction of the obstructing stone. This would be performed in the operating room, such that if endoscopic extraction was not possible, surgical management would proceed.During the endoscopy, 1 L of liquid material was suctioned and the retained solids were cleared as best as possible. The large obstructing stone was then seen in the duodenal cap. In the cap, we could appreciate the obstructing stone and the fistulous tract.We then passed a guidewire distal to the stone and advanced a 15- to 20-mm extraction balloon over the guidewire. The balloon was passed distal to the stone and inflated to 20mm. We then applied firm, steady traction in an attempt to extract the stone.With the double-channel gastroscope, we passed a second wire and extraction balloon distal to the stone to increase the amount of traction that could be applied. Both balloons were inflated distal to the stone, and steady, firm traction was again applied. Unfortunately, this was not successful either.We then decided to use a regular ERCP needle knife to incise the stone. Because the knife was delicate, it was easily deformable, so we decided to switch to a triangle-tip knife.Using the "PreciseSECT" mode on the electrosurgical unit, the stone was repeatedly incised. Particular care was taken to avoid flinging the knife and damaging the duodenal wall.Saline was used as the irrigation solution to ensure electrosurgical conductivity when the current was applied.At this point, we could appreciate fragmentation of the stones after repeated incision.After about 3 hours of stone incision and fragmentation, the guidewire was passed beyond the stone; the extraction balloon was advanced over the wire; and the balloon was again inflated with steady traction applied. This time, the stone was successfully extracted from the stomach.The duodenum was then examined. There were no remaining large pieces of stone or any significant mucosal damage or perforation.Using a mechanical lithotripter, the remaining larger fragments of stone were fragmented and extracted. However, because the stone had a large diameter, lithotripsy at the center was not initially possible, and the smaller lateral aspects had to be performed until the stone was completely fragmented.This case demonstrates the incision and fragmentation of a massive gallstone with the use of an endoscopic submucosal dissection knife and electrosurgical unit.With cautious application of this technique, successful endoscopic management of a large gallstone causing Bouveret syndrome was achieved. This technique avoided open surgical management and allowed for elective cholecystectomy at a later date with less morbidity.

1684 Paging Dr. MacGyver: A Novel Approach to Redeploying a Dislodged AXIOS Stent During a Pancreatic Necrosectomy

INTRODUCTION: Although multiple modalities exist for managing walled off and infected pancreatic necrosis, EUS-guided transmural drainage is often favored due to its minimally invasive and highly effective nature. The AXIOS stent has demonstrated clear superiority over double pigtail and fully covered self-expanding metal stents in this setting. Although the radial force from its wide luminal diameter and its dumbbell shape helps secure the stent in place, stent migration and dislodgement can still occur. Here, we present a case of stent dislodgement during a pancreatic necrosectomy, which was salvaged by stent extraction and endoscopic re-deployment using a stone extraction balloon catheter sheath. CASE DESCRIPTION/METHODS: A 68-year-old woman with a medical history notable for prior acute pancreatitis presented to the ED with abdominal pain, nausea, and vomiting. CT Abdomen revealed a large pancreatic fluid collection with surrounding necrosis. She was admitted to the SICU for management of necrotizing pancreatitis, and underwent cystgastrostomy with an AXIOS stent on day 14 of admission. During her necrosectomy one week later, the previously placed AXIOS stent was accidentally displaced into the stomach. The displaced stent was grasped with a rat tooth forceps and removed from the patient. One end of the extracted AXIOS stent was stretched so that it became thin enough to be inserted into an empty stone extraction balloon catheter sheath. The other end was then back-loaded into the larger channel of a double-channel gastroscope. The scope was then re-introduced and advanced into the pancreatic cyst cavity. A rat tooth forceps was inserted into the instrument channel and used to advance the back-loaded stent forward, re-deploying the stent under endoscopic guidance only, such that it again traversed the cystic cavity and stomach. The stent was then adjusted into its desired position using rat tooth forceps. DISCUSSION: As Interventional Endoscopy’s technologies continue to evolve, it will become increasingly important for the skilled endoscopist to understand the mechanics of the tools being used, and trouble shoot these technologies as unforeseen complications arise. The novel method for AXIOS stent re-deployment described here not only demonstrates this understanding, but also serves as an example of a cost saving recourse for dislodged AXIOS stent re-deployment. Indeed, in an era of cost-conscious care, one must trouble shoot in a manner that is both clinically effective and financially efficient. Watch the video: http://bit.ly/2O2RYbW.

Endoscopic augmentation of gastroesophageal junction using a full-thickness endoscopic suturing device.

Background and study aims This preliminary study was conducted to determine the feasibility and safety of endoscopic augmentation of the gastroesophageal junction (GEJ) using the Apollo OverStitch endoscopic suturing system in patients with gastroesophageal reflux disease (GERD) symptoms. Patients and methods Endoscopic augmentation of GEJ was performed on 10 consecutive patients and the data were analyzed retrospectively. Using a double-channel gastroscope affixed to the endoscopic suturing platform, interrupted sutures were placed on the gastric side of the GEJ in 2 layers in order to create a narrowed and elongated GEJ. Results Technical success was achieved in all patients, including those with a history of previous antireflux procedures (n = 7) and those with a hiatal hernia (n = 6). The median follow-up duration was 5 mo (range: 2 – 12). The median pre-procedure GERD-Health Related Quality of Life Questionnaire improved from 20 (range: 11 – 45) to a post-procedure score of 6 (range: 3 – 25) ( P = 0.001). The median duration of GERD symptom improvement after the procedure was 1 mo (range: 0.5 – 4). Adverse events were limited to 1 patient who developed nausea and vomiting, which was self-limited. Conclusions The use of a novel endoscopic suturing technique for the treatment of GERD is feasible and safe. The procedure resulted in short-term GERD symptom improvement. Further prospective studies using refined techniques are currently underway to improve durability and to prove efficacy.

Therapeutic application of purse-string sutures with nylon loops and metal clips under single-channel endoscopy for repair of gastrointestinal wall defects.

The present study was performed to evaluate the therapeutic safety and feasibility of purse-string sutures with nylon loops and metal clips under single-channel endoscopy to repair gastrointestinal wall defects that had previously developed during endoscopic full-thickness resection (EFR). A multicenter prospective cohort study of 42 patients who had developed defects of the gastrointestinal wall during EFR was conducted from April 2012 to October 2016. All lesions were endoscopically repaired with either a single-channel gastroscope (research group, n=18) or double-channel gastroscope (control group, n=24). The patients' clinical features, purse-string suturing times and complication rates were analyzed. There was no significant difference in the perforation rate between the research and control groups. There were also no significant differences in the purse-string suturing time (research vs. control group, 10.5 vs. 14.6 min, respectively; P=0.214), specimen size or complication rate (subcutaneous emphysema) between the two groups. No recurrences were observed during the follow-up period. The current data suggest that application of purse-string sutures with nylon loops and metal clips for repair of EFR-induced gastrointestinal wall defects may be safely and feasibly applied under single-channel gastroscopy as well as under double-channel gastroscopy.

Using a double-channel gastroscope reduces procedural time in performing gastric endoscopic submucosal dissection.

Objective:Complications are important determining factors for safety of endoscopic submucosal dissection (ESD). ESD of large lesions is associated with increased procedural time. This study investigated whether double-channel gastroscope could be used to reduce procedural time in gastric antrum ESD.Methods:A retrospective cohort study of 46 patients with one gastric antrum lesion resected by ESD was conducted between January 2013 and December 2015. The diameter of a lesion was from 2cm to 4cm in 46 patients. EUS before ESD was used to evaluate the submucosal vascular structure and the location of lesion in gastric wall. Forty six lesions had ESD with either the ordinary gastroscope (OS group) (n=24) or the double-channel gastroscope (DC group) (n=22).Results:The mean procedural time was significantly lower in the DC group than in the OS group (49.1 minutes vs. 20.5 minutes, p=0.04). There were no significant differences in submucosal injection frequency, specimen size, en bloc resection rate and perforation rate between the two endoscopic groups. There was no recurrence in any case during the follow-up period.Conclusions:Our data suggest that ESD utilizing double-channel gastroscope may provide a better platform for quicker ESD with equal safety.

Clinical evaluation of double-channel gastroscope for endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy.

AimTo evaluate the use of a double-channel gastroscope in patients with Billroth II gastrectomy to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions.Material and methodsFrom January 2008 to December 2013, 18 patients with Billroth II gastrectomy were enrolled in this study. Endoscopic retrograde cholangiopancreatography was performed using a straight forward gastroscope with double working channel (4.2-mm diameter, 2.8-mm diameter).ResultsThe success rate of selective cannulation and accomplishment of planned procedures was 15 out of 18 patients (83.3%), and no serious complications were encountered.ConclusionsThe double-channel gastroscope appears to be useful in performing endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy.

Trick for endoloop positioning before polypectomy by using a double-channel gastroscope

Trick for endoloop positioning before polypectomy by using a double-channel gastroscope

Is the Double Channel Gastroscope Useful in Endoscopic Mucosal Resection for Large Sessile Colon Polyps?

See Use of a Double-Channel Gastroscope Reduces Procedural Time in Large Left-Sided Colonic Endoscopic Mucosal Resections by Evangelos Voudoukis, Georgios Tribonias, Aikaterini Tavernaraki, et al., on page 136-141 Most colon polyps are less than 1 cm in size. However, endoscopists often encounter large sessile colon polyps greater than 2 cm in practice. Removal of a large sessile colon polyp is difficult due to a high rate of procedure-related complications, such as bleeding and perforation. Therefore, patients with large sessile colon polyps are referred to a tertiary hospital for appropriate treatment. There are two usual endoscopic treatments for large sessile colon polyps: conventional endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). ESD using various knives was initially introduced for the treatment of early gastric cancer, but has recently, been used for large sessile colon polyps. Theoretically, ESD is preferable to en bloc resection for better pathologic evaluation. However, because of high complication rates, ESD is not widely used for the treatment of large sessile colon polyps. Despite the advent of gastric ESD, piecemeal EMR is more widely used than ESD in such polyps. In Western countries, because of the technical difficulty and longer procedure time of ESD, piecemeal EMR is still the gold standard therapy for large sessile colon polyps >20 mm in diameter.1 Although many endoscopists are performing colonic EMR, little attention has been paid to reducing the procedure time, which can be a very important issue in high-volume centers. Longer procedure times may influence the work of physicians and other personnel in the endoscopy room. One study reported that the total procedure time for EMR in patients with large sessile colon polyps (2 cm or larger) averaged 51.4 minutes (standard deviation, 25.6).2 The mean size of the polyps was 34.2 mm, the perforation rate was 1.1%, and the post-EMR bleeding rate was 7.3%. Procedure time was measured from endoscope insertion to examination completion. In another large-scale study on ESD for large colon polyps, the mean procedure time was 116 minutes, with a mean tumor size of 35 mm; perforation occurred in 4.9%, and postoperative bleeding in 1.5%.3 In this issue of Clinical Endoscopy, Voudoukis et al.4 present their experience with large (>2 cm) sessile or flat left-sided colon polyp resection, focusing on the benefits of the double channel (DC) gastroscope for EMR. In their retrospective series, they compared the procedure time using a DC gastroscope to that for a standard colonoscope or gastroscope (OS). They measured the EMR procedure time from first submucosal injection to just following polyp resection. This measurement method was different from that used by other researchers. The mean procedure time differed significantly between the DC group (33±21 minutes) and the OS group (58.7±20.6 minutes, p=0.015); in the subgroup of patients with polyps larger than 40 mm, the statistical difference in the mean procedural time between the two groups was even more pronounced (p=0.004). They suggest that use of a DC gastroscope for large non-pedunculated rectosigmoid lesions significantly reduces the procedure time. A DC scope is sometimes used in a difficult colonic EMR, but is not widely used in a routine procedure. The primary technique using a DC scope is the simultaneous insertion of a forceps, which can grasp polyp tissue and pull it into position for snare polypectomy5 or EMR; endoscopists can use the injection needle and snare at the same time with the DC scope. This might reduce the total operative time, and enable endoscopists to perform procedures without interruption. Nishizawa et al.6 called it the two-sword fencing technique in ESD, which also saves the time of changing endoscopic devices. The two-sword fencing technique allows mucosal resection just after injection, before the collapse of the submucosal cushion. However, endoscopists must be careful when snare EMR using forceps, because the proper muscle is held inside the forceps. It is difficult to keep the dissection plane horizontal to the intestinal wall with ESD using a DC gastroscope. Information on use of a DC gastroscope would be useful in EMR or ESD for large sessile colon polyps. This study has several important features. It is the first study in which the authors have compared the DC scope with single channel scopes in EMR for large sessile colonic polyps. However, as the authors state in their discussion, the number of patients was too small to be able to generalize the results of the study. In addition, the authors compared the DC gastroscope with single channel scopes. Upper endoscopy and colonoscopy were included in the single channel OS scope group, and should have been compared individually with the DC gastroscope. Finally, this retrospective study was conducted by a single experienced endoscopist. The procedure time might be dependent on the features of the endoscopist. A prospective study with multiple endoscopists will be needed.

Use of a double-channel gastroscope reduces procedural time in large left-sided colonic endoscopic mucosal resections.

Background/AimsEndoscopic mucosal resection (EMR) of large colorectal lesions is associated with increased procedural time. The objective of this study was to evaluate the effect of double-channel gastroscope (DCG) use on the procedural time of EMRs in the rectosigmoid area.MethodsAll EMRs for sessile or flat rectosigmoid lesions ≥2 cm performed between July 2011 and September 2012 were retrospectively analyzed.ResultsThere were 55 lesions ≥2 cm in the rectosigmoid area in 55 patients, of which 26 were removed by EMR using a DCG (DC group) and 29 by using an ordinary colonoscope or gastroscope (OS group). The mean size of the removed polyps, morphology, adverse effects, and other parameters were similar between the two groups. The mean procedural time was significantly lower in the DC group than in the OS group (24.4±18.3 minutes vs. 36.3±24.4 minutes, p=0.015). Moreover, in a subgroup of patients with polyps >40 mm, the statistical difference in the mean procedural time between the DC and OS groups was even more pronounced (33±21 minutes vs. 58.7±20.6 minutes, p=0.004).ConclusionsOur data suggest that the use of a DCG in the resection of large nonpedunculated rectosigmoid lesions significantly reduces the procedural time.

Gastrojejunal anastomosis using a tissue-apposing stent: a safety and feasibility study in live pigs

Various techniques using surgical and natural orifice transluminal endoscopic surgery (NOTES) have been evaluated to create a gastrojejunal bypass. The aim of the current study was to determine the safety, feasibility, and efficacy of a new technique using a pure endoscopic approach and tissue-apposing stent placement for gastrojejunal anastomosis (GJA). This was a prospective, experimental study on six live pigs weighing 20 - 45 kg. Endoscopies were performed using a double-channel gastroscope, and included the creation of a GJA using a tissue-apposing, fully covered, self-expanding metallic stent. Antibiotic therapy was continued for 7 days after the procedure, and food was gradually reintroduced from Day 3. Changes in weight following the procedure were compared with a control group of age-matched animals. Anastomosis functionality was confirmed by endoscopy at 3 weeks (before the animals were euthanized), and during histopathological analysis. The primary outcomes were morbidity and mortality at 3 weeks. Secondary outcomes were technical feasibility, procedure time, and patency of the GJA. The procedures were performed successfully in all animals. The mean procedure time was 26 ± 6.7 minutes (range 15 - 32 minutes). One case of stent migration occurred during the procedure; the stent was successfully replaced using the same procedure. All animals were alive after 3 weeks. The mean weight gain during follow-up was 0.85 ± 2.56 kg (range - 2 to + 2 kg) compared with 5.2 ± 1.6 kg (range 3 - 7 kg) in control animals (P = 0.007). At necropsy, the stents were still in place in all animals, without evidence of peritonitis. Histopathology confirmed permeable anastomoses with continuity of the mucosa and mucosa muscle layers. GJA with a tissue-apposing stent is safe, feasible, and reproducible without anastomotic leakage in a porcine model using a pure endoscopic approach and standard endoscopic equipment.

Tu1452 The Use of Double Channel Gastroscope Reduced the Procedural Time in Recto-Sigmoid Endoscopic Mucosal Resections

Tu1452 The Use of Double Channel Gastroscope Reduced the Procedural Time in Recto-Sigmoid Endoscopic Mucosal Resections

Gastrojejunal Anastomosis Exclusively Using the “NOTES” Technique in Live Pigs

Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES. It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery. The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers. Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.

Fever of Undetermined Origin: Cervical Diskitis-Osteomyelitis Associated With Esophageal Self-Expanding Metal Stent

Conflicts of interest The authors disclose no conflicts. © 2013 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2013.05.039 Aof an esophageal self-expanding metal stent (SEMS). She was diagnosed with squamous cell carcinoma of the upper esophagus 6 months previously at another facility. She underwent placement of the partially covered SEMS at that time. She subsequently underwent chemotherapy and radiation therapy, with follow-up positron emission tomography–computed tomography (CT) showing no evidence of residual disease. About 2 weeks after completion of therapy, she started experiencing intolerance to liquids in the form of coughing episodes, followed by onset of fevers. Work-up for fever at the outside facility was unrevealing. Endoscopic removal of the SEMS was unsuccessful, and she was referred to our facility. Upon review of systems, she also reported upper back pain for the past few weeks. A barium esophagogram did not reveal any leak, fistula, obstruction, or perforation. A CT scan of the thorax suggested erosion of the posterior aspect of the SEMS into the C7 and T1 vertebral bodies (Figure A, sagittal CT view). Endoscopic views of the SEMS were unremarkable. The SEMS was removed under general anesthesia using a double-channel therapeutic gastroscope and 2 rat-tooth forceps, with no evidence of perforation noted after stent removal (Figure B). A barium esophagogram obtained after stent removal showed no evidence of a leak or fistula. Subsequent magnetic resonance imaging of the C-spine and T-spine showed enhancement of the C7, T1, T2, and T3 vertebral bodies, suggestive of diskitis-osteomyelitis (Figure C, sagittal T2-weighted magnetic resonance image). Blood cultures were negative. The patient’s fevers abated with appropriate antibiotic therapy. At the last follow-up evaluation 3 months later, she remained asymptomatic without any back pain or fevers. Esophageal SEMS have become an integral part of the management of malignant dysphagia. The patient’s initial symptoms of cough and intolerance to oral intake were suspicious for a tracheoesophageal fistula. However, barium esophagogram before and after stent removal failed to show the same. Her symptoms were likely caused by cervical spine involvement, esophageal dysmotility, and/or reflux. Cases of spondylodiscitis and osteomyelitis associated with esophageal stents, both plastic stents and SEMS, for benign indications as well as malignant indications have been reported previously. Although most cases have occurred in association with overt stent-induced perforation, there was no evidence of perforation in the current case. It is possible that a small perforation may have sealed by the time of fluoroscopic and endoscopic study at our institution. Given the widespread use of SEMS for palliation of dysphagia, clinicians need to be aware of the above described delayed complication associated with their use.

Feasibility of Transumbilical Flexible Endoscopic Preperitoneoscopy (FLEPP) and Its Utility for Inguinal Hernia Repair

Various NOTES (natural orifice translumenal endoscopic surgery) hernia repair techniques have been described. The aim of this study was to evaluate the feasibility of a transumibilically introduced conventional double-channel flexible endoscope for performing preperitoneoscopy (FLEPP, flexible endoscopic preperitoneoscopy technique) and to perform totally extraperitoneal (TEP) inguinal hernia meshplasty in an animal model. The study was done in 2 steps on 8 swines weighing 25 to 30 kg each: (1) establishing feasibility of preperitoneal dissection of the inguinal region using a conventional double-channel flexible gastroscope and making bed for mesh placement and (2) placement of a polypropylene mesh in the inguinal region to cover the myopectineal orifice. The flexible endoscope provided good vision and maneuverability to identify preperitoneal structures--namely, the arcuate line, insertion of rectus abdominis on pubis symphysis, inferior epigastric vessels, deep inguinal ring, spermatic cord, pubic symphysis, and psoas muscle--without causing any damage to any of the structures. The spermatic cord could be dissected to identify the vas deference. A 9 × 7 cm(2) oval mesh was successfully placed over the myopectineal orifice of Fruchaud with good overlap. Average time required for the complete FLEPP procedure (including mesh placement) was 55 minutes (range 45-90 minutes). This study demonstrates, for the first time, the feasibility of the transumbilical FLEPP technique and its utility for performing TEP inguinal hernia repair with prosthetic mesh placement in a swine model.

Su1264 Transgastric Peritoneoscopy Using a Forwarding-Viewing EUS: The Evaluation of Diagnostic and Therapeutic Potential for Notes

Su1264 Transgastric Peritoneoscopy Using a Forwarding-Viewing EUS: The Evaluation of Diagnostic and Therapeutic Potential for Notes

Transesophageal pulmonary lobectomy with single transthoracic port assistance: study with survival assessment in a porcine model

Thoracoscopic pulmonary lobectomy is being performed in an increasing number of patients. The aims of the current study were to assess natural orifice transluminal endoscopic surgery (NOTES) as an alternative to transthoracic endoscopic surgery, and to test the feasibility of peroral transesophageal right upper pulmonary lobectomy with the assistance of a single transthoracic trocar. In 10 acute and 4 survival pigs, right upper pulmonary lobectomy was performed using a forward-viewing double-channel gastroscope and an operative thoracoscope with a 5-mm working channel inserted through a single transthoracic 12-mm) port. Time, safety, and feasibility of the following steps were recorded in all animals: esophagotomy, hilar dissection, individual ligation of the hilum elements, pulmonary lobectomy, and specimen retrieval. In the survival experiments, esophagotomy was closed using a reticulated laparoscopy suture device and an esophageal stent was placed. These animals were kept alive and monitored for 2 weeks. Esophagotomy was performed safely in all animals (mean procedure duration 5.4 ± 1.7 minutes). Dissection of the right upper lobe hilum elements (bronchus, arteries, and veins) was carried out without adverse events. Individual ligation of the hilum elements was performed in all but two cases (time for dissection and ligation 44.2 ± 14.8 minutes). Lobectomy and specimen retrieval were completed in all animals (9.5 ± 3.1 minutes). Esophagotomy closure and stent placement were carried out in 20.0 ± 2.8 minutes in the survival animals. These animals fed normally and gained weight postoperatively without signs of disease. Endoscopic examination before necropsy revealed a pseudo-diverticulum in one animal, and wound dehiscence with confined collection/recess in the remaining animals. Transesophageal right upper pulmonary lobectomy using single transthoracic trocar assistance is feasible and may represent a step towards scar-free pulmonary lobectomy.

Sp852 Transpapillary and NOTES® Transgastric Drainage of a Postoperative Abscess with Clips Closure of the Leaking Duct Following a Pancreatic Tail Resection

Sp852 Transpapillary and NOTES® Transgastric Drainage of a Postoperative Abscess with Clips Closure of the Leaking Duct Following a Pancreatic Tail Resection

Endoscopic mucosal resection with the grasp-and-snare technique through a double-channel endoscope in humans

EMR is being used to manage premalignant lesions of the GI tract. Lifting of the lesion is required to perform EMR. Earlier biopsy or snare may cause scarring and preclude adequate lifting. We report our experience with a novel grasp-and-snare EMR technique that can be used when a good lifting is not achieved or the location of the lesion is challenging for standard EMR, such as in a fold. Single-center case series. Tertiary referral academic gastroenterology unit. Patients referred for endoscopic treatment of flat gastrointestinal polyps. Single-session EMR performed with a grasp-and-snare technique through a double-channel gastroscope or colonoscope. Technical success, complication rates, and recurrence rates. Seventeen patients with flat gastrointestinal polyps were referred: mean age 70 years, 11 (65%) male, polyp size 0.8 to 6 cm; 13 colonic, 2 duodenal, 1 gastric, and 1 esophageal EMR performed with grasp-and-snare technique in single sessions. Six polyps (35%) did not lift after injection of hydroxypropylmethylcellulose. Fourteen polyps (82%) were resected completely. Two complications occurred (12%): 1 bleeding treated medically and 1 perforation treated surgically. Residual disease at 1 year was 18%, but 8 patients (47%) had not yet had their 1-year follow-up. Single-center, uncontrolled, not randomized. Limited follow-up. The grasp-and-snare technique can be used to perform EMR with good outcomes and low complication rates in areas where poor lifting and accessibility are problems.

Stent placement provides safe esophageal closure in thoracic NOTESTM procedures

Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent. Nine Yorkshire swine underwent thoracic NOTES procedures. A double-channel gastroscope equipped with a mucosectomy device was used to create an esophageal mucosal defect. A 5-cm submucosal tunnel was created and the muscular esophageal wall was incised with a needle-knife. Mediastinoscopy and thoracoscopy were performed in all swine; lymphadenectomy was performed in seven swine. A prototype small intestinal submucosal (SurgiSIS(®)) covered stent was deployed over the mucosectomy site and tunnel. Three versions of the prototype stent were developed. Prenecropsy endoscopy confirmed stent location and permitted stent retrieval. Explanted esophagi were sent to pathology. Esophageal stenting was successful in all animals. Stent placement took 15.8 ± 4.8 minuted and no stent migration occurred. Prenecropsy endoscopy revealed proximal ingrowth of esophageal mucosa and erosion with Stent A. Mucosal inflammation and erosion was observed proximally with Stent B. No esophageal erosion or pressure damage from proximal radial forces was seen with Stent C. On necropsy, swine 5 had a 0.5-cm periesophageal abscess. Histology revealed a localized inflammatory lesion at the esophageal exit site in swine 1, 3, and 9. The mucosectomy site was partially healed in three swine and poorly healed in six. All swine thrived clinically, except for a brief period of mild lethargy in swine 9 who improved with short-term antibiotic therapy. The submucosal tunnels were completely healed and no esophageal bleeding or stricture formation was observed. All swine survived 13.8 ± 0.4 days and gained weight in the postoperative period. Esophageal stenting provides safe closure for NOTES thoracic procedures but may impede healing of the mucosectomy site.

Per-oral dual scope NOTES cholecystectomy in porcine model (with video)

Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument. Therefore, "pure NOTES" transgastric cholecystectomy has not yet been described. The authors successfully performed "pure NOTES" transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure) that allows completion of the procedure by pure NOTES without an external instrument. With the subject under general anesthesia, a double-channel gastroscope (Storz®, Tuttlingen, Germany) passed by mouth entered the peritoneum through the distal anterior gastric wall. The most ideal site for a second gastric exit was then selected for another single-channel scope. With the gallbladder retracted by the assistant operating the double-channel scope, retrograde cholecystectomy was performed by the primary surgeon using the single-channel scope. Four animals were killed immediately to study the quality of the operative dissection, whereas the other four pigs were kept alive. The gastrotomy was closed using a 27- to 30-mm cardiac septal occluder (Occlutech®, GmbH, Jena, Germany) according to a previously described method. The postoperative follow-up assessment of these animals included laparoscopy and necropsy 2 weeks later. All the cholecystectomies were immediately successful without any intraoperative complication. Scope withdrawal caused no injuries to the esophagus or pharynx. Although no overt postoperative complication was evident, two surviving pigs had signs of minor peritoneal infection. This study investigated "pure NOTES" transgastric cholecystectomy using tentative experimentation to overcome the "retraction" and "triangulation" issues and to realize a "pure NOTES" operation. The use of two endoscopes with selected differentiation of their gastric placements compensated for the lack of triangulation and retraction.