Invasive Endoscopic Treatment Research Articles

Endoscopic full-thickness resection of gastric ectopic splenic nodules

BackgroundEctopic spleen is extremely rare. Most cases are congenital, acquired ectopic spleen may be a consequence of surgery or trauma to the spleen. The ectopic spleen in the gastric wall we reported is even rarer.Case presentationWe report a 41-year-old female patient, with a past history of splenectomy, who presented with heartburn. Gastroscopy revealed a swelling in the fundus in the stomach. Ultrasonography and computed tomographic examination suggested the possibility of gastrointestinal stromal tumor. We performed endoscopic resection of the mass. Pathological examination of the resected mass showed ectopic spleen.ConclusionWhen a patient with a history of splenectomy presents with a gastric submucosal tumor, ectopic spleen should also be considered in the differential diagnoses. And minimally invasive endoscopic treatment can achieve the purpose of diagnosis and treatment for unobvious submucosal tumors.

Outcomes of balloon dilation for paediatric laryngeal stenosis.

SUMMARYObjectiveBalloon dilation (BD) is a minimally invasive endoscopic treatment for paediatric laryngeal stenosis (LS) with reduced morbidity compared to open surgery. We retrospectively describe our experience in a cohort of children with chronic LS.MethodsFourteen children (median age: 28.5; range: 2-81 months) with chronic LS (multilevel in 8) were treated with tubeless total intravenous anaesthesia under spontaneous ventilation.ResultsGrade III LS was preoperatively detected in 12 children; the remaining 2 had grade IV stenosis. Six had prior tracheotomy, and one received it during the first intervention. Dilation laryngoplasty was the primary treatment in 11 children and was used as an adjuvant treatment in 3 after open reconstructive surgery. The median number of dilations was 2 (range: 1-6). There were no postoperative complications. At the end of the follow-up (median: 20.5; range: 2-46 months), detectable laryngeal lumen widening and/or respiratory improvement occurred in 12 children. Two of 7 patients with tracheostomy were decannulated.ConclusionsBalloon laryngoplasty is a valuable therapeutic option to improve laryngeal patency in children with chronic multilevel LS, both as a primary and secondary adjuvant treatment after reconstructive surgery.

Endoscopic Ultrasonography-Guided Gastroenterostomy Techniques for Treatment of Malignant Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.

Stage approach in surgical treatment of acute pancreatitis.

The article deals with the problem of diagnosis and treatment of acute pancreatitis, which remains one of the most common surgical diseases of the abdominal cavity with a high risk of complications, the mortality rate of which reaches 5.5%, and in acute pancreatitis it varies within 40-70%. The purpose of this work is to improve the results of surgical treatment of patients with acute pancreatitis. The results of treatment of 112 patients with acute pancreatitis, who were hospitalized in the procedure of ambulance in the Department of Surgery No. 2 of the Bogomolets National Medical University in 2009-2019 period are analyzed. Severe disease course was observed in 83 (74.1%) patients, moderate – in 29 (25.9%) patients. In the early phase of the disease, endoscopic operations were performed in 44 (39.3%) patients, and laparotomy was performed in 12 (10.7%) patients with advanced purulent peritonitis. In the late phase 15 (13.4%) patients underwent laparotomy, necrsequestrectomy, abdominization of the pancreas, drainage of the abdominal cavity and retroperitoneal space, 36 (32.1%) patients were treated with ultrasound-guided puncture treatments. In the case of progression of the disease and ineffective drainage under ultrasound control, 5 (4.5%) patients were treated with retroperitoneoscopically assisted necrsequestrectomy, combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy was performed in 3 (2.7%) patients, and in 2 (1.8%) patients – open laparotomy, abdominization, necrsequestrectomy, drainage of the abdominal cavity and retroperitoneal space. The surgical intervention in the late phase of the disease was 21±4.2 days from the onset of the disease. A stage approach in the treatment of acute pancreatitis was applied to 80 (71.4%) patients in the main group. The comparison group consisted of 32 (28.6%) patients who underwent laparotomy and laparoscopic interventions in the early and late periods of the disease without prior use of endoscopic interventions or drainage operations under ultrasound control. In the main group the length of stay in the hospital was 21,3±4,2 days, in the comparison group – 48.2±5.3 days respectively. In 42 (95.5%) patients who underwent endoscopic surgery, a positive clinical effect, rapid regression of symptoms of acute pancreatitis was achieved. In two (4.5%) patients who underwent endoscopic interventions, the disease progressed with the development of an abscess of the omental pouch, they underwent puncture drainage under ultrasound control. When using puncture drainage operations under ultrasound control in 26 (72.2%) patients, a positive result was achieved, the abscess cavity decreased by 63±6.2% within 7 days. In 10 (27.8%) patients due to the progression of the disease, the following stage of treatment was performed: retroperitoneoscopically assisted necrsequestrectomy (5 (13.9%) patients), combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy (3 (8.3%) patients), and open laparotomy, abdominization, necrosequestrectomy, drainage of the abdominal cavity and retroperitoneal space (2 (5.6%) patients). Complications in the main group developed in two (2.5%) patients, the mortality rate was 2.5% (two patients). In the comparison group, complications developed in 8 (25%) patients, the mortality rate was 18.8% (6 patients). The use of minimally invasive endoscopic interventions, draining surgeries under ultrasound control followed by combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy or open laparotomy reduces the length of hospital stay of patients from 48.2±5.3 days (comparison group) to 21.3±4.2 days (main group) (p<0.0001, t=28.346) and the number of complications by 22.5% (p=0.0002, χ2=14.104, CI 9.2333-39.7022). The use of a stage approach in the surgical treatment of acute pancreatitis reduces mortality by 16.3% (p=0.0026, χ2 =9.058, CI 4.6571-32.9639).

Sa1933 ENDOSCOPIC SLEEVE GASTROPLASTY IN THE MANAGEMENT OF WEIGHT REGAIN AFTER SLEEVE GASTRECTOMY

Sleeve gastrectomy (SG) has become a well-standardized surgical treatment option for obesity. However, the rate of weight regain (WR) after SG in long-term follow-up is relatively high. This multicenter study is the first to evaluate the use of an Endoscopic Sleeve Gastroplasty (ESG) technique for the management of WR after SG including patients with overweight-obesity across the full BMI spectrum. This is a multicenter retrospective study, including patients with WR following SG who underwent ESG for weight loss. The primary outcomes included AWL, %TWL, change in BMI, %EWL at 6 and 12 months in patients with overweight or obesity, and safety profile. Clinical success was defined as achieving ≥25% EWL at 1-year with ≤5% serious adverse event (SAE) rate following the ASGE/ASMBS threshold, and %TWL>10%. Thirty-four patients underwent ESG after SG. Technical success was 100%. At 1 year, 82.35% and 100% of patients achieved >10%TWL and >25% EWL, respectively. On avarage, %TWL was 13.2±3.9 and 18.3±5.5 and %EWL was 51.9±19.1and 69.9±29.9 at 6 months and 1-year, respectively (Table 1). %TWL was 14.2 ± 12.5, 19.3 ± 5.3, 17.5 ± 5.2, and 20.4 ± 3.3, and %EWL was 88.5±52.8, 84.4±22.4, 55.4±14.8, and 47.8±11.2 for overweight, obesity class I, II, and III, respectively at 1-year follow-up (Figures 1). No predictors of success were identified in the multivariable regression analysis. No SAE were reported. Given a rise in the number of sleeve gastrectomy being performed worldwide, there is an increasing demand for a minimally invasive endoscopic treatment option for weight regain following SG. Considering the minimally invasive outpatient nature of ESG, the reproducibility among centers, the low prevalence of SAE, and the favorable clinical outcomes, ESG following SG appears to be safe and effective and may offer a solution for the treatment of this challenging patient population.Figure 1Comparison between %TWL at 3, 6, 9 and 12 months follow-up in all BMI subgroupsView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Sa1251 PREDICTOR OF CLINICAL FAILURE OF PER-ORAL ENDOSCOPIC MYOTOMY: A LARGE SINGLE-CENTER EXPERIENCE

Per-oral endoscopic myotomy (POEM) is considered as an effective and safe minimally invasive endoscopic treatment for esophageal achalasia and achalasia related motility disorders, and more than 2000 cases have been performed at our institution. Although POEM is a highly efficacious treatment, there have been reports of clinical failure and the cause of these failure is unknown. This study aimed to identify the predictor of clinical failure of POEM. We conducted a retrospective analysis of a prospectively maintained database comprised of consecutive patients who underwent POEM for esophageal achalasia or achalasia related motility disorders at a tertiary-referral center between 2008 and 2019. Clinical failure of POEM was defined as primary failure with Eckardt score not decreasing to 3 or under during one-year follow-up. Patients were divided into two groups according to whether they had clinically successful POEM or failed POEM. Baseline characteristics (Age, sex, BMI, duration of symptoms, esophageal diameter, manometric diagnosis), anti-thrombotic agents, prior treatments, myotomy orientation, myotomy length were retrieved. Univariate and multivariate logistic regression analyses were performed to assess the predictive factors of clinical failure (Table 1, 2). A total of 2091 POEM were performed, 1770 of whom had available 3-12 months follow-up data. Of those, 75 cases (4.2%) were considered failed POEM in short term follow-up. Multivariate analysis revealed that younger age (odd ratio [OR] 0.98, 95% confidence interval [95% CI] 0.97-0.99, P=0.009) , prior Heller myotomy ([OR] 4.13, [95%CI] 1.88-9.09, P<0.001), prior endoscopic balloon dilatation ([OR] 1.90, [95%CI] 1.15-3.15, P=0.012) were independent factors associated with clinical failure of POEM. Younger age, prior Heller myotomy, and prior endoscopic balloon dilatation were identified as the independent predictors of clinical failure of POEM in this single center large cohort study.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Frontiers of Robotic Colonoscopy: A Comprehensive Review of Robotic Colonoscopes and Technologies.

Flexible colonoscopy remains the prime mean of screening for colorectal cancer (CRC) and the gold standard of all population-based screening pathways around the world. Almost 60% of CRC deaths could be prevented with screening. However, colonoscopy attendance rates are affected by discomfort, fear of pain and embarrassment or loss of control during the procedure. Moreover, the emergence and global thread of new communicable diseases might seriously affect the functioning of contemporary centres performing gastrointestinal endoscopy. Innovative solutions are needed: artificial intelligence (AI) and physical robotics will drastically contribute for the future of the healthcare services. The translation of robotic technologies from traditional surgery to minimally invasive endoscopic interventions is an emerging field, mainly challenged by the tough requirements for miniaturization. Pioneering approaches for robotic colonoscopy have been reported in the nineties, with the appearance of inchworm-like devices. Since then, robotic colonoscopes with assistive functionalities have become commercially available. Research prototypes promise enhanced accessibility and flexibility for future therapeutic interventions, even via autonomous or robotic-assisted agents, such as robotic capsules. Furthermore, the pairing of such endoscopic systems with AI-enabled image analysis and recognition methods promises enhanced diagnostic yield. By assembling a multidisciplinary team of engineers and endoscopists, the paper aims to provide a contemporary and highly-pictorial critical review for robotic colonoscopes, hence providing clinicians and researchers with a glimpse of the major changes and challenges that lie ahead.

Short- and long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell cancer in patients with prior gastrectomy.

The surgery for esophageal cancer arising after prior gastrectomy is technically difficult with high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic treatment for superficial SCC with high curative resection rate. But few studies are concerned about ESD under these circumstances. The aim of this study was to elucidate the short- and long-term outcomes of ESD for superficial esophageal squamous cell cancer (SCC) in patients with prior gastrectomy. From January 2009 to January 2019, 37 patients with prior gastrectomy who underwent ESD for superficial esophageal SCC were retrospectively enrolled at the Zhongshan Hospital, Fudan University in Shanghai, China. Rates of en bloc resection, complete resection, curative resection, incidence of postoperative bleeding, perforation and postoperative stricture were evaluated as short-term outcomes. Overall survival, and local recurrence-free survival were evaluated as long-term outcomes. The rate of en bloc resection, complete resection and curative resection were 94.6%, 86.5% and 78.4%, respectively. No perforation was observed. 1 (2.7%) patient experienced postoperative bleeding. During the median observation of 43months, 3 (8.6%) patients experienced esophageal stricture, successfully managed by balloon dilation. 3(8.6%) patients had local recurrence after ESD with 5-year local recurrence-free survival rate of 91.4%. During the observation period, 4 patients died of other reasons. The 1, 3, 5-year overall survival rates were 97.1%, 97.1% and 91.4%. The short-term outcomes indicate ESD is technically difficult with lower resection completeness in patients after gastrectomy, while the long-term outcomes are rather favorable.

Peroral endoscopic fundoplication: a brand-new intervention forGERD.

Peroral endoscopic fundoplication: a brand-new intervention forGERD.

Non-endoscopic management of a giant ureterocele: a case report in resource poor African hospital

Ureterocele is a cystic dilatation of the distal sub mucosal part of the ureter. It is a congenital anomaly that may co-exist with other anomalies. It has an incidence 1 in 4000 live births. Patients present with symptoms at paediatric age or may remain asymptomatic till adulthood. Our 30 year old female patient was assessed for a giant orthotropic right ureterocele with obstructive uropathy, in a hospital that has no modern facilities for endoscopic treatment. She then had successful open surgical repair of the ureterocele with satisfactory outcome. Minimally invasive endoscopic treatment options remains the gold standard. Patients from poor resource regions can as well be treated successfully by open surgical repair like our index case presented.

Initial experience with minimally invasive treatment of pilonidal sinus in children.

IntroductionSinus pilonidalis (SP) is an acquired inflammatory disease, which is relatively common in the paediatric population. Surgery is indicated in symptomatic patients. In 2017, minimally invasive pilonidal sinus treatment (EPSiT) was adapted to the paediatric population.AimTo evaluate the first experience with minimally invasive endoscopic treatment of SP (PEPSiT) in children and adolescents in the Czech Republic.Material and methodsA retrospective review of all consecutive paediatric patients who underwent PEPSiT from November 2018 to February 2020. The monitored parameters were demographics, perioperative course of the disease, surgery, length of hospitalisation, postoperative complications, healing, disease recurrence, and follow-up.ResultsSeventeen patients were enrolled in the study. The median age at surgery was 17.1 years (range: 12.5–18). The subjects comprised 76% males, and the median body mass index was 25.6 kg/m2 (range: 17–30.3 kg/m2). Thirteen patients underwent previous surgical treatment (76%) under local anaesthesia. The median duration of PEPSiT was 50 min (range: 30–85 min). The subjective evaluation of pain by patients on the VAS scale was 0 on the day of discharge. There were no postoperative complications up to the 30th postoperative day. Two disease recurrences were successfully managed by re-PEPSiT. By the end of follow-up, 14/15 patients had healed. Two patients are still within 3 months of surgery, which is too soon to definitively evaluate possible recurrence of the disease.ConclusionsThese preliminary results show that PEPSiT is a highly promising method. It is safe and well-tolerated by patients (short hospital stay, quick return to normal life, low pain and analgesic consumption). Two recurrences of disease were treated by re-PEPSiT.

Minimally invasive treatment of post-burn esophageal perforation

Perforation of the esophagus is a serious and dangerous condition due to progressive development of mediastinitis and sepsis. This disease is often fatal. In the last decade, endoscopic stenting of the esophagus became more common in these patients as an alternative to traditional surgery. We report successful minimally invasive endoscopic treatment of esophageal perforation with post-burn necrosis of its wall.

Minimally Invasive Migraine Surgery: Our 9-year Experience

INTRODUCTION: Migraine headache is a very common disorder affecting 1.7%–4% of the world’s adult population. The first line therapy for these patients is usually a combination of conservative treatments. Despite this large variety of options available, some patients remain refractory. For such group, migraine surgery might offer a definitive solution for their medical condition. In these patients, migraine is usually caused by extracranial nerve compression due to vascular, fascial, or muscular structures nearby. The aim of migraine surgery is to relieve such compression at specific trigger points located in the occipital, temporal, and frontal regions. MATERIALS AND METHODS: From June 2011 to December 2018, in our Plastic Surgery Unit at the University of Parma, Italy, we performed 235 surgical procedures for migraine in patients suffering from either frontal, occipital, or temporal headache.1–5 In patients with occipital and temporal migraine, nerve decompression was achieved by occipital and superficial temporal artery ligation, respectively. Vessels were previously localized by mean of portable Doppler device. In patients suffering from frontal headache, we performed nerve decompression with single-entry endoscopic myotomies of procerus, corrugator, and depressor supercilii muscles. RESULTS: Among patient suffering from occipital migraine, 95% of them observed significant improvement of their condition, with 86% reporting complete relief. In temporal migraine, positive outcome was achieved in 83% of the patients (50% complete elimination and 33% partial improvement). In patient treated with endoscopic frontal myotomies, positive results were observed in 94% of the patients (32% complete elimination, 62% partial improvement). CONCLUSIONS: Migraine is a common and debilitating condition that can be treated successfully with minimally invasive surgical procedures. We believe that vascular compression is the main causative agent in occipital and temporal migraine headache since the outstanding outcome that can be achieved by ligation only of occipital and superficial temporal artery, respectively. Frontal triggered migraine deactivation surgery still has fairly good outcomes but we feel that something is still missing and more researches should be performed. REFERENCES: 1. Raposio E, Bertozzi N, Bordin C, et al. Surgical therapy of migraine and tension – type headaches. In: Turker H, ed. Current Perspectives on Less-known Aspects of Headache. InTech; 2017. doi:10.5772/64652. 2. Caruana G, Bertozzi N, Boschi E, et al. Endoscopic forehead surgery for migraine therapy: personal technique. Ann Ital Chir. 2014;85:583–586. 3. Raposio E, Caruana G. Tips for the surgical treatment of occipital nerve-triggered headaches. Eur J Plast Surg. 2016:1–6. doi: 10.1007/s00238-016-1249-8. 4. Raposio E, Caruana G. Minimally invasive endoscopic surgical treatment of headache. In: Raposio E, ed. Atlas of Endoscopic Plastic Surgery. 1st ed. New York, N.Y.: Springer; 2015:17–23. 5. Polotto S, Simonacci F, Grignaffini E, et al. Surgical treatment of frontal and occipital migraines: a comparison of results. Plast Reconstr Surg Glob Open. 2016;14:e653.

Submucosal cavernous hemangioma of the esophagus. the rare clinical case of endoscopic diagnosis and treatment by the endoscopic submucosal dissection method (esd)

The cavernous esophagus hemangiomais a rare, benign vascular neoplasm of the esophagus, which is asymptomatic and can be detected by chance during diagnostic video gastroscopy.The aim ofthe study is to describe in the rare clinical case of diagnosis and an integrated approach in choosing an endoscopic method of treating a submucosal benign vascular neoplasm of the esophagus (cavernous hemangioma).Material and method. A 46-year-old patient was sent to the University Hospital of ZSMU to conduct video esophagogastroduodenoscopy in order to examine and select the treatment method for the submucosaltumor of the upper third of the esophagus found in one of the city’s clinics.Results. A comprehensive examination of the patient with a submucosal neoplasm of the upper third of the esophagus, including video esophagogastroscopy with high-resolution endoscopes (EGD), endoscopic ultrasonography (EUS), and computer-aided tomography (CT) were performed. At the EGD a submucosal tumor was reviled in the upper third of the esophagus. It was bluish in color, had a wide base, 3cm in length and 2cm in height, movable, with soft-elastic consistency. EUS revealed that the tumor is not associated with the muscular layer, has many small vessels. The structure of the neoplasm was hypoechoic, inhomogeneous due to the inclusion of calcinates. On CT scan a rounded tumor was found in the lumen of the upper third of the esophagus, 20x15x30mm in size, with clear and even margins, homogeneous structure with a single calcinate in the structure was found. The patient was underwent of endoscopic surgery. The tumor was removed by the endoscopic submucosal dissection (ESD).Conclusion. Cavernous esophagus hemangioma is a rare vascular submucosal neoplasm of the esophagus, which is usually asymptomatic, but has a great potential for complications such as bleeding, which is sometimes fatal. Timely diagnosis and minimally invasive endoscopic treatment methods are the prevention of complications and the treatment of choice for the treatment of esophageal submucoustumors.

Experience in Simultaneous Endoscopic Submucosal Dissection Treating Synchronous Multiple Primary Early Esophageal Cancers.

Objective: Synchronous multiple primary early esophageal cancers (SMPEEC) are rare and aggressive. Early detection of esophageal cancer can improve survival rate. Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic treatment of early esophageal cancers. However, ESD for SMPEEC is little known. We aimed to clarify the clinical outcomes of simultaneous ESD treating SMPEEC. Methods: We retrospectively reviewed the medical data of 34 patients, who underwent ESD for SMPEEC at Endoscopy Center of Zhongshan Hospital, Fudan University, between May 2013 and December 2014. The data of lesion size, histopathology, en bloc resection, curative resection, complication, and tumor local recurrence were analyzed. Results: Among 34 patients, 67 lesions were removed simultaneously in 33 cases; 2 lesions were removed in 2 operations for 1 case. For the simultaneous resection, the en bloc rate was 97.01% (65/67) and the curative resection rate was 92.54% (62/67). Postoperative stricture occurred in two cases and delayed bleeding occurred in one case. There was one local recurrence, no metastasis or procedure-related death. Conclusions: Simultaneous ESD as a treatment for SMPEEC is technically feasible, benefited from reducing hospitalization time and medical expenses. For the cases with risk factors of complications, simultaneous ESD needs to be avoided.

Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment.

Esophageal diverticula are rare conditions that cause esophageal symptoms, such as dysphagia, regurgitation, and chest pain. They are classified according to their location and characteristic pathophysiology into three types: epiphrenic diverticulum, Zenker’s diverticulum, and Rokitansky diverticulum. The former two disorders take the form of protrusions, and symptomatic cases require interventional treatment. However, the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum, particularly when it is located closer to the oral orifice. Since the condition itself is not malignant, minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms. Several types of endoscopic devices and techniques are currently employed, including peroral endoscopic myotomy (POEM). However, the use of minimally invasive endoscopic approaches, like POEM, has allowed the development of new disorder called iatrogenic esophageal diverticula. In this paper, we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.

Parameters Suggesting Spontaneous Passage of Stones from Common Bile Duct: A Retrospective Study.

Background Common bile duct (CBD) stones are common. However, they are known to pass spontaneously, which obviates the need for ERCP. Aim The aim of this study is to identify specific predictors for spontaneous passage of CBD stones. Methods Data was retrospectively collected for all patients who were hospitalized with clinical, laboratory, or ultrasonographic evidence of choledocholithiasis and who underwent magnetic resonance cholangiopancreatography (MRCP) in Hadassah Medical Center between 2005 and 2011. The patients were classified into 4 groups: group A (positive MRCP and positive ERCP), group B (positive MRCP but negative ERCP), group C (positive MRCP but did not undergo ERCP), and group D (negative MRCP that did not undergo ERCP) for choledocholithiasis. All positive MRCP-groups (A+B+C) were further grouped together into group E. We compared groups A versus B and groups E versus D. Results Comparing groups A versus B, only gamma-glutamyl transferase predicted spontaneous passage of stones from CBD, as the level was significantly higher in group A (677±12.1) versus group B (362.4±216.2) (P=0.023). Patients with small stone diameter (P=0.001), distal stones (P=0.05), and absence of intrahepatic dilatation (P=0.047) tend to pass their stones spontaneously. Comparing groups D versus E, it was found that male gender (P=0.03), older age (P<0.001), high levels of GGT (P=0.022), high levels of alkaline phosphatase (P=0.011), high levels of total bilirubin (P=0.007), and lower levels of amylase (P<0.001) are predictors for positive MRCP studies for CBD stones. Conclusion Identification of specific predictors is important to avoid unnecessary invasive endoscopic intervention.

Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure.

Peroral endoscopic myotomy (POEM) has become the minimally invasive endoscopic treatment for achalasia; however, gastroesophageal reflux (GER) post-POEM has been reported. A pilot study was conducted in which an endoscopic fundoplication was added to the standard POEM (POEM + F) procedure to overcome this issue. We report the technical details of POEM + F and short-term safety results. POEM + F was performed in 21 patients. After completing myotomy, the endoscope was advanced from the submucosal tunnel into the peritoneal cavity. A partial mechanical barrier was created by retracting the anterior gastric wall at the esophagogastric junction with the use of endoclips and an endoloop. POEM + F was technically feasible in all cases and created a visually recognizable fundoplication. The clinical course after POEM + F was uneventful. No immediate or delayed complications occurred. POEM + F may help mitigate the post-POEM incidence of GER and serve as a minimally invasive endoscopic alternative to a laparoscopic Heller-Dor procedure. This is the largest case series of peroral natural orifice transluminal endoscopic surgery without laparoscopic assistance in the human foregut.

Crohn’s disease: modern diagnosic and treatment

A review of modern laboratory and instrumental methods of diagnosis in patients with Crohn’s disease, their rational combined use is given. Conservative and surgical treatment are considered. Particular attention is paid to minimally invasive endoscopic treatment of Crohn’s disease complications.

CURRENT ASPECTS OF DIAGNOSTICS AND TREATMENT OF ACUTE BILLARIAN PANCREATITIS

Relevance. The article is devoted to the problem of diagnosis and treatment of acute biliary pancreatitis, which remains one of the most common surgical diseases of the abdominal cavity and accounts for 33.2% of the total number of patients with acute pancreatitis.&#x0D; Objective of the work is to improve the diagnosis and results of surgical treatment of patients with acute pancreatitis of biliary etiology.&#x0D; Materials and methods. The results of treatment of 264 patients with acute pancreatitis of biliary etiology are analyzed. Operative treatment was applied in 92 (34,8 %) patients: endoscopic operations were performed in 44 patients (16,7 %). Thus, in 10 (3,8 %) patients, endoscopic papilloprotectomy was performed with the auditory of the duct system and the extraction of concrements. In other cases, organo-preserving intervention was performed without disturbing the morphofunctional integrity of the sphincter apparatus of the duct system: the cannulation in 6 (2,3%) patients, mechanical (balloon) in 5 (1,9 %) cases, pharmacological (myogenic antispasmodic) dilatation of distal duct and a large duodenal papilla in 11 (4,2 %) patients. In residual choledocholithiasis, a technique of papillotomy under the control of choledochoscopy was proposed – 12 (4,54 %) patients. A comparative analysis of the effectiveness of the treatment of patients who used the "open" (comparative group) and noninvasive endoscopic interventions in the early disease (the main group) was performed.&#x0D; Results. So in the main group the length of stay in the hospital was 12±3,2 days, respectively, in the comparison group – 26±4,3 days. In 42 (95,4 %) patients who had undergone endoscopic surgery, a positive clinical effect, a rapid regress of the symptoms of acute pancreatitis was achieved. In two (4,5 %) patients in the main group, the course was complicated by the development of the abscess of the stuffing box, and puncture under ultrasound control was performed. In patients of the comparison group complications arose in 5 (41,6 %) patients, it is noteworthy that all of them had undergone operative interventions, which were limited only to the rehabilitation and drainage of the abdominal cavity, a stuffing box bag. The mortality rate among unopposed was 1,2 % (2 patients), and among the operated – 11,9 % (11 patients). Among prooperated patients who died, 81,8 % (9 people) were elderly patients.&#x0D; Conclusions. The use of minimally invasive endoscopic interventions in the early phase of the disease reduces the length of stay of patients in the hospital from 26±4,3 days (comparison group) to 12 3,2 days (main group) and the number of complications occurring by 37,1 % (P &lt;0, 05). Application of the proposed method of papillotomy under the control of choledochoscopy makes it possible to reduce the risk of perforation of the wall of the duodenum with the development of peritonitis or retroperitoneal phlegmon by 1,2 % (P &lt;0,05).