Needle-knife Papillotome Research Articles

Initial experience with a homemade "hybrid-tome" for needle-knife precut in patients with difficult biliary cannulation.

Background and study aims Current clinical guidelines recommend needle-knife precut (NKP) as the primary and best method for performing a biliary cannulation (BC) when simple techniques fail and the criteria are met for difficult BC (DBC). However, many endoscopists avoid or defer early NKP in favor of alternative, simpler techniques that have not been shown to be either safer or more effective. Our goal is to test a device that provides the needle-knife papillotome (NKPT) with traction capability and which can facilitate the learning and execution of NKP. Patients and methods This was a descriptive bicentric observational study of a personal cohort of patients undergoing early NKP to analyse the efficacy and safety of the technique with a “hybrid-tome” (HT) built using the isolated core of a NKPT and a conventional canulotome. Results Over a 4-year period, we performed 43 NKPs with the HT, achieving BC in one or two steps in all cases. The 100 % technical success was matched by a 95 % clinical success rate. We recorded 11 adverse events (23 %): five hemorrhages, four pancreatitis, and two cholangitis. In addition to the objective data, we confirmed that HT facilitates alignment with the duodenal papilla and the execution of pre-cutting, especially if the papilla is intradiverticular or hidden by folds. Conclusions The HT tested seems to help trained endoscopists to perform NKP, especially in some anatomic situations, which can improve compliance with the guidelines recommended for early NKP in patients with DBC.

Endoscopic Myotomy and Pyloroplasty of Benign NSAID-Induced Pyloric Stricture With Combination Needle Knife Papillotome and Balloon Dilation

Endoscopic Myotomy and Pyloroplasty of Benign NSAID-Induced Pyloric Stricture With Combination Needle Knife Papillotome and Balloon Dilation

Comparison of removal techniques in the management of buried bumper syndrome: a retrospective cohort study of 82 patients.

Background and study aims Buried bumper syndrome is an infrequent complication of percutaneous endoscopic gastrostomy (PEG) that can result in tube dysfunction, gastric perforation, bleeding, peritonitis or death. The aim of this study was to compare the efficacy of different PEG tube removal methods in the management of buried bumper syndrome in a large retrospective cohort. Patients and methods From 2002 to 2013, 82 cases of buried bumper syndrome were identified from the databases of two endoscopy referral centers. We evaluated the interval between gastrostomy tube placement and diagnosis of buried bumper syndrome, type of treatment, success rate and complications. Four methods were analyzed: bougie, grasp, needle-knife and minimally invasive push method using a papillotome, which were selected based on the depth of the buried bumper. Results The buried bumper was cut free with a wire-guided papillotome in 35 patients (42.7 %) and with a needle-knife in 22 patients (26.8 %). It could be pushed into the stomach with a dilator without cutting in 10 patients (12.2 %), and was pulled into the stomach with a grasper in 12 patients (14.6 %). No adverse events (AEs) were registered in 70 cases (85.4 %). Bleeding occurred in 7 patients (31.8 %) after cutting with a needle-knife papillotome and in 1 patient (8.3 %) after grasping. No bleeding was recorded after using a standard papillotome or a bougie ( P < 0.05). Ten of 22 patients (45.5 %) treated with the needle-knife had a serious AE and 1 patient died (4.5 %). Conclusions We recommend that incomplete buried bumpers be removed with a bougie. In cases of complete buried bumper syndrome, the bumper should be cut with a wire-guided papillotome and pushed into the stomach.

Complications of Endoscopic Retrograde Cholangiopancreatography in children with Chronic Pancreatitis

A new papillotome has been developed, an isolated-tip needle-knife papillotome (Iso-Tome) that has a semi-oval-shaped tip of epoxide adhesive to prevent electric leakage from the tip of the incising needle. The coated tip aids in keeping the papillotome tightly in the orifice of the ampulla of Vater and is believed to prevent unintentional deep cuts or perforations. This study was done to evaluate the clinical usefulness of the new papillotome for pre-cut papillotomy.From June 2003 to November 2003, 115 patients underwent attempted ERCP. If biliary cannulation failed by the conventional method, pre-cut papillotomy was performed by using the Iso-Tome in the direction of the bile duct. After successful bile-duct cannulation, papillotomy was extended for therapeutic procedures, such as stone removal or stent insertion, in the majority of the cases. Post-ERCP complications were classified according to consensus guidelines.Pre-cut papillotomy with the Iso-Tome was done in 25 patients (21.7% of cases). Protective pancreatic stents were not used. Of these patients, 11 had common bile duct stones, 7 had pancreatitis, 5 had malignancies, one had sphincter of Oddi dysfunction, and one had bile-duct leak. After pre-cut papillotomy with the Iso-Tome, bile-duct cannulation was successfully achieved in 23 of 25 (92%) patients. Complications occurred in 7 of 25 patients (28%) and consisted of mild pancreatitis in 5 (20%), moderate bleeding in one (4%), and biliary pain in one (4%). All 7 patients with complications were managed medically, and there was no death.In this pilot study, the isolated-tip needle knife was found to be a clinically useful papillotome for pre-cut papillotomy. Further large comparative studies (with and without pancreatic protective stents) are needed to determine improved efficacy and safety compared with standard techniques.

An Unusual Cause of Recurrent Vomiting

Question: A 28-year-old man was admitted for postprandial epigastric pain, and chronic vomiting for 6 months, associated with a 6-kg weight loss. He had no relevant medical or family history. Physical examination and laboratory workup were normal. An anechoic lesion located in the second part of the duodenum wall was revealed on abdominal ultrasound imaging, and a submucosal mass was diagnosed in the same region, using an upper endoscopy technique (Figure A). Furthermore, endoscopic ultrasound imaging (Figure B) and magnetic resonance imaging with dynamic sequences (Figure C) showed a 25 × 26-mm cystic duodenal lesion. There was no connection between the lesion and the biliary and pancreatic ducts, which seemed to be normal. What is your diagnosis? How should the patient be treated? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Endoscopic ultrasound imaging showed an anechoic duodenal lesion with an inner echogenic ring and an outer hypoechoic ring. Abdominal magnetic resonance imaging found a consistent appearance of a duodenal cyst protruding into the duodenal lumen, in the second part of the duodenum. These findings are specific to an enteric duplication cyst. We performed an endoscopic treatment of the cyst. The cyst's roof was first punctured using a needle-knife papillotome. The wall of the cyst was then incised using a polypectomy snare. Pathologic examination showed a double muscle layer with both mucosal and submucosal layers (Figure D), confirming the diagnosis of duodenal duplication cyst. The patient was discharged of hospital 24 hours later. Follow-up was uneventful. Duodenal duplication cyst is a rare congenital malformation.1Chen J.-J. Lee H.-C. Yeung C.-Y. et al.Meta-analysis: the clinical features of the duodenal duplication cyst.J Pediatr Surg. 2010; 45: 1598-1606Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 2Antaki F. Tringali A. Deprez P. et al.A case series of symptomatic intraluminal duodenal duplication cysts: presentation, endoscopic therapy, and long-term outcome (with video).Gastrointest Endosc. 2008; 67: 163-168Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Although exceptional malignant tumor developments have been described, duodenal duplication is usually associated with a good prognosis. Before the era of therapeutic endoscopy, surgical resection was performed in symptomatic patients, with significant morbidity. Various straightforward, safe, and effective endoscopic techniques have since been described, including cyst puncture, snare resection, and cyst needle aspiration/ligation, as suggested by Gjeorgjievski et al.3Gjeorgjievski M. Manickam P. Ghaith G. et al.Safety and efficacy of endoscopic therapy for nonmalignant duodenal duplication cysts.Medicine (Baltimore). 2016; 95: e3799Crossref PubMed Scopus (12) Google Scholar Long-term clinical outcomes are excellent, making therapeutic endoscopy a valid, minimally invasive alternative to surgical resection.

Flexible endoscopic treatment of Zenker's diverticulum: thirteen years' experience in Spain.

Flexible endoscopic treatment is one of the alternative approaches for the management of Zenker's diverticum. The present paper shows our short-term and long-term results with flexible endoscopic cricopharyngeal myotomy/septotomy. A retrospective analysis of our experience in patients with Zenker's diverticulum treated using a flexible endoscope, assisted by a flexible diverticuloscope, between 2002 and 2015. Myotomy/septotomy was performed with a needle-knife papillotome under deep sedation or general anesthesia. Among the 64 patients treated, two died within 10 days of surgery from causes not directly related to the procedure, and one presented with pharyngo-esophageal perforation, which recovered with conservative management at 47 days after admission. Four additional patients were lost to short-term follow-up. Among the 57 remaining patients, 52 had complete relief of dysphagia after 6 weeks. Eleven of these had recurrent symptoms on the mid and the long term. Eight were retreated with the same flexible endoscopic technique, one with a hybrid endoscopic approach, one with classical open surgery and one refused retreatment. After a mean follow-up of 2 years and a half, 33 of 37 patients reported absent or minimal dysphagia, controllable with punctual dietary restrictions. Flexible endoscopic treatment for Zenker's diverticulum is effective and safe. It represents an option on an equal footing to rigid endoscopy and classical open surgery and may also be used when the latter two are technically impracticable or contraindicated.

소아 연하장애의 임상적 평가와 선별검사

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are the mainstays of the diagnosis and treatment of variable hepatobiliary and pancreatic diseases. The success rate of ERCP and EST in patients who have undergone a Billroth II gastrectomy is lower than in patients with a normal anatomy. Because the view of the ampulla is rotated 180o in patients with Billroth II, several methods (ex, precut biliary needle-knife papillotome or wire-guided billroth II papillotome) have been used for endoscopic sphincterotomy instead of a pull-type papillotome. Using the recently devised pull-type and rotatable papillotome (Autotome), we performed successful ERCP and EST in 2 patients with a Billroth II gastrectomy without complications. (Korean J Gastrointest Endosc 2007;35:445-450)

Needle-Knife Fistulotomy With Percutaneous Transhepatic Cholangioscopy for Managing Complete Bilioenteric Anastomosis Occlusion

Untreated benign biliary stricture can lead to serious complications including recurrent cholangitis, biliary cirrhosis, hepatic failure, and death. Benign stricture of a postoperative anastomosis site is also a problematic issue after biliary surgery. Percutaneous transhepatic cholangioscopy (PTCS) with balloon dilatation is a recently introduced noninvasive therapeutic option for biliary stricture. Guidewire insertion through the stricture site is essential for the success of PTCS treatment. Recently, we treated a difficult case with complete bilioenteric anastomosis stricture that failed to allow passage of the guidewire for balloon dilation. The stricture was treated with artificial bilioenteric fistula using a needle-knife papillotome during the PTCS.

The role of endoscopy in the evaluation and management of dysphagia

The role of endoscopy in the evaluation and management of dysphagia

Sa1307 New Technique of Endoscopic Sphincterotomy With Iso-Tome® to Incise Completely Distal Papillary Roof in Patients With Choledocholithiasis and With Spontaneous or Artificial(Fistulotomy) Choledochoduodenal Fistula on the Ampulla of Vater

Background/Aims: It is sometimes problematic to incise completely distal papillary roof(PR) in patients with choledocholithiasis and with spontaneous or artificial(fistulotomy) choledochoduodenal fistula(CDF) on the ampulla of Vater(AV). An isolated-tip needleknife papillotome(Iso-Tome®) which is helpful in preventing electric leakage from the tip A G A A b st ra ct s

The Manometric Finding of Inclusion Body Myositis

Background: Zenker diverticulum (ZD) is a lesion most often seen in elderly patients. The traditional treatment is surgical but recently endoscopic septoplasty has been described as an alternative approach, especially in high surgical risk patients. We aimed to determine the efficacy and safety of flexible endoscopic septoplasty (FES) for symptomatic ZD. Methods: Retrospective review of all patients who underwent FES for ZD over the previous 5 years at St Michael's Hospital, Toronto were identified. Patient charts were reviewed to record patient demographics, procedure technique, operative times, sedation requirements, and complications. Patients were contacted via telephone to establish postoperative symptoms within 12 months of treatment and to evaluate current symptoms using a validated dysphagia score from 0 (no dysphagia) to 4 (complete dysphagia) and overall symptoms in terms of complete/near complete response, moderate response and complete recurrence. Results: Forty-three patients underwent FES between 2005 and 2010. The median age was 75 years (IQR 68-83). Twenty-nine (67.4%) were male. The mean (range) ZD size was 3.0cm (1 5cm). All patients were treated on an outpatient basis. A total of 90 procedures were performed, with a median of 2 procedures (IQR 1-3) per patient. Procedures were performed with conscious sedation in 88 (97.8%) cases, with median sedation requirements of 3mg (IQR 3-6) of midazolam and 100mcg (IQR 87.5-100) of fentanyl. The mean procedure time was 34 minutes (range 10 65). Thirty patients were contactable to assess response to therapy. Within 12 months of the initial therapy, 15 (50%) had complete/near complete symptom resolution, 10 (33.3%) moderate symptom improvement and 5 (16.7%) complete symptom recurrence. Following retreatment in the latter two groups, at a mean follow-up of 13.5 months, 2 (13.3%) had complete/near complete symptom resolution, 9 (60%) moderate symptom improvement and 3 (20%) complete symptom recurrence. Complications included 2 perforations (one requiring surgical drainage of a neck abscess); 2 cases of minor bleeding and 1 patient admitted with fever post procedure (perforation excluded on imaging). Mean admission duration was 7.8 days (range 1-13). Conclusion: (i) FES using needle-knife papillotome is a safe and effective therapy for ZD. (ii) FES should be considered in patients in whom surgery is considered high-risk or technically difficult. (iii) Repeat FES in poor responders is effective and safe (iv) Further studies to refine this technique are required to improve symptoms. Acknowledgment S.R. has been supported by a UWA Medical Research fellowship and the Faculty of Medicine, Dentistry and Health Sciences in Perth, Western Australia.

Outcomes of Flexible Endoscopic Septoplasty With Needle Knife for the Treatment of Zenker Diverticulum

Background: Zenker diverticulum (ZD) is a lesion most often seen in elderly patients. The traditional treatment is surgical but recently endoscopic septoplasty has been described as an alternative approach, especially in high surgical risk patients. We aimed to determine the efficacy and safety of flexible endoscopic septoplasty (FES) for symptomatic ZD. Methods: Retrospective review of all patients who underwent FES for ZD over the previous 5 years at St Michael's Hospital, Toronto were identified. Patient charts were reviewed to record patient demographics, procedure technique, operative times, sedation requirements, and complications. Patients were contacted via telephone to establish postoperative symptoms within 12 months of treatment and to evaluate current symptoms using a validated dysphagia score from 0 (no dysphagia) to 4 (complete dysphagia) and overall symptoms in terms of complete/near complete response, moderate response and complete recurrence. Results: Forty-three patients underwent FES between 2005 and 2010. The median age was 75 years (IQR 68-83). Twenty-nine (67.4%) were male. The mean (range) ZD size was 3.0cm (1 5cm). All patients were treated on an outpatient basis. A total of 90 procedures were performed, with a median of 2 procedures (IQR 1-3) per patient. Procedures were performed with conscious sedation in 88 (97.8%) cases, with median sedation requirements of 3mg (IQR 3-6) of midazolam and 100mcg (IQR 87.5-100) of fentanyl. The mean procedure time was 34 minutes (range 10 65). Thirty patients were contactable to assess response to therapy. Within 12 months of the initial therapy, 15 (50%) had complete/near complete symptom resolution, 10 (33.3%) moderate symptom improvement and 5 (16.7%) complete symptom recurrence. Following retreatment in the latter two groups, at a mean follow-up of 13.5 months, 2 (13.3%) had complete/near complete symptom resolution, 9 (60%) moderate symptom improvement and 3 (20%) complete symptom recurrence. Complications included 2 perforations (one requiring surgical drainage of a neck abscess); 2 cases of minor bleeding and 1 patient admitted with fever post procedure (perforation excluded on imaging). Mean admission duration was 7.8 days (range 1-13). Conclusion: (i) FES using needle-knife papillotome is a safe and effective therapy for ZD. (ii) FES should be considered in patients in whom surgery is considered high-risk or technically difficult. (iii) Repeat FES in poor responders is effective and safe (iv) Further studies to refine this technique are required to improve symptoms. Acknowledgment S.R. has been supported by a UWA Medical Research fellowship and the Faculty of Medicine, Dentistry and Health Sciences in Perth, Western Australia.

Manometric Characteristics of Opioid Esophageal Dysmotility Disorder by High-Resolution Manometry

Background: Zenker diverticulum (ZD) is a lesion most often seen in elderly patients. The traditional treatment is surgical but recently endoscopic septoplasty has been described as an alternative approach, especially in high surgical risk patients. We aimed to determine the efficacy and safety of flexible endoscopic septoplasty (FES) for symptomatic ZD. Methods: Retrospective review of all patients who underwent FES for ZD over the previous 5 years at St Michael's Hospital, Toronto were identified. Patient charts were reviewed to record patient demographics, procedure technique, operative times, sedation requirements, and complications. Patients were contacted via telephone to establish postoperative symptoms within 12 months of treatment and to evaluate current symptoms using a validated dysphagia score from 0 (no dysphagia) to 4 (complete dysphagia) and overall symptoms in terms of complete/near complete response, moderate response and complete recurrence. Results: Forty-three patients underwent FES between 2005 and 2010. The median age was 75 years (IQR 68-83). Twenty-nine (67.4%) were male. The mean (range) ZD size was 3.0cm (1 5cm). All patients were treated on an outpatient basis. A total of 90 procedures were performed, with a median of 2 procedures (IQR 1-3) per patient. Procedures were performed with conscious sedation in 88 (97.8%) cases, with median sedation requirements of 3mg (IQR 3-6) of midazolam and 100mcg (IQR 87.5-100) of fentanyl. The mean procedure time was 34 minutes (range 10 65). Thirty patients were contactable to assess response to therapy. Within 12 months of the initial therapy, 15 (50%) had complete/near complete symptom resolution, 10 (33.3%) moderate symptom improvement and 5 (16.7%) complete symptom recurrence. Following retreatment in the latter two groups, at a mean follow-up of 13.5 months, 2 (13.3%) had complete/near complete symptom resolution, 9 (60%) moderate symptom improvement and 3 (20%) complete symptom recurrence. Complications included 2 perforations (one requiring surgical drainage of a neck abscess); 2 cases of minor bleeding and 1 patient admitted with fever post procedure (perforation excluded on imaging). Mean admission duration was 7.8 days (range 1-13). Conclusion: (i) FES using needle-knife papillotome is a safe and effective therapy for ZD. (ii) FES should be considered in patients in whom surgery is considered high-risk or technically difficult. (iii) Repeat FES in poor responders is effective and safe (iv) Further studies to refine this technique are required to improve symptoms. Acknowledgment S.R. has been supported by a UWA Medical Research fellowship and the Faculty of Medicine, Dentistry and Health Sciences in Perth, Western Australia.

Endoscopic Treatment of Zenker Diverticulum: Results of a 7-Year Experience

Zenker diverticulum (ZD) is a rare disease usually seen in elderly patients who present with symptoms of worsening dysphagia and regurgitation. Although open surgical approach is still the standard management for symptomatic patients, the endoscopic technique has evolved as an alternative approach, especially for highly morbid patients. We are reporting our experience for treating ZD using endoscopic needle-knife papillotome. A total of 18 patients with a mean age of 80 years (range 68 to 91 years) were included in our prospective cohort study. All patients underwent endoscopic cricopharyngeal myotomy for symptomatic ZD using needle-knife papillotome at Brandon Regional Health Centre during a 7-year period. Mean follow-up was 27.5 months. A dysphagia score system from 0 (no dysphagia) to 4 (severe dysphagia) was used. All patients' baseline characteristics, pre- and postoperative symptoms, operative time, time to oral intake, length of hospital stay, recurrence of symptoms, and complications were analyzed. Dysphagia score and regurgitation symptoms improved substantially after treatment. Mean operative time was 28.4 minutes. Oral intake was resumed within 24 hours in all but 1 patient. Hospital stay for the majority was 24 to 48 hours. Only 1 patient had a microperforation treated conservatively and 2 patients had re-do procedures for persistence of dysphagia. Endoscopic cricopharyngeal myotomy using needle-knife papillotome is an effective approach to manage ZD for highly morbid patients. It is minimally invasive, decreases anesthetic time, shortens hospital stay, and has a low complication rate.

ERCP cannulation and sphincterotomy devices

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic, and a MAUDE (Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the governing board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review the MEDLINE database was searched through February 2009 for articles related to cannulation and sphincterotomy devices by using the keywords ERCP, standard catheter, sphincterotome, cannulation, sphincterotomy, precut, major papilla, minor papilla, needle-knife, complication, pancreatitis, biliary, and pancreatic in different search term combinations. Technology Status Evaluation Reports are scientific reviews provided solely, for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, ordiscouraginganyparticulartreatmentorpayment for such treatment.

ENDOSONOGRAPHY‐GUIDED GALLBLADDER DRAINAGE FOR ACUTE CHOLECYSTITIS FOLLOWING COVERED METAL STENT DEPLOYMENT

Endosonography-guided biliary drainage (ESBD) is gaining acceptance as an effective treatment for obstructive jaundice. Only a few reports on the application of this technique to the gallbladder (endosonography-guided gallbladder drainage [ESGBD]) have been published in the literature. In order to relieve acute cholecystitis which developed in a patient with unresectable malignant biliary obstruction after deployment of a covered metal stent (CMS), we applied this technique. ESGBD was carried out by using an electronic curved linear array echoendoscope. After visualization of the gallbladder and determination of the puncture route, a needle knife papillotome was advanced with electrocautery to pierce the gastric and gallbladder walls. Under the guidance of a guidewire inserted through the needle sheath into the gallbladder, a 7.2 Fr, 30 cm-long, single pigtail plastic tube was placed to bridge the gallbladder and the stomach. No complications relevant to the procedure were encountered. ESGBD was quite effective in ameliorating the patient's acute cholecystitis and the drainage tube was removed after 10 days without sequelae. Acute cholecystitis following CMS deployment is considered to be a good indication for ESGBD.

Endoscopic diverticulotomy with an isolated-tip needle-knife papillotome (Iso-Tome) and a fitted overtube for the treatment of a Killian-Jamieson diverticulum

A Killian-Jamieson diverticulum (KJD) is an unfamiliar and rare cervical esophageal diverticulum. This diverticulum originates on the anterolateral wall of the proximal cervical esophagus through a muscular gap (the Killian-Jamieson space) below the cricopharyngeal muscle and lateral to the longitudinal muscle of the esophagus. To date, only surgical treatment has been recommended for a symptomatic KJD due to its close proximity to the recurrent laryngeal nerve and the concern of possible nerve injury. Recently, traditional open surgery for a symptomatic KJD is being challenged by the development of new endoscopic techniques and devices. We present here a case of a symptomatic KJD that was successfully treated with the flexible endoscopic diverticulotomy using two new devices. An isolated-tip needle-knife papillotome (Iso-Tome) was used for the dissection of the tissue bridge of the diverticulum. And a flexible overtube with a modified distal end (a fitted overtube) was used for adequate visualization of the tissue bridge of the diverticulum and protection of the surrounding tissue during dissection of the tissue bridge. Our successful experience suggests that the flexible endoscopic diverticulotomy with the use of appropriate endoscopic devices can be a safe and effective method for the treatment of a symptomatic KJD.

Closure of Gastrotomy After Transgastric Tubal Ligation Using the Eagle Claw VII-A Survival Experiment in a Porcine Model

Background: The main barrier to the safe introduction of Natural Orifice Translumenal Endsocopic Surgery (NOTES) through stomach is secure closure of the gastrostomy. We tested the security of closure of gastrotomy using a prototype endoscopic suturing device-Eagle Claw VII. Method: We performed the procedures under GA in pigs weighted 50 kg. We employed double channel endoscope and inserting a long overtube to esophagus. The stomach was flushed with 1000 mls neomycin solution, and gastric puncture was performed using needle knife papillotome. This was extended with sphincterotome. The endoscope then passed via gastrotomy into the peritoneal cavity. The Fallopian tube was identified adjacent to the ovary. Bilateral tubal ligation was performed using double endoloops. The tubes were transected using needle knife. Closure of the gastrotomy was performed using the Eagle Claw VII by full thickness suturing. The sutures were tightened intracorporeally using a detachable needle tip engaged in plastic casing. The suture used is 3-O nylon. The pigs were allowed to survived for 2 weeks before euthanasia. Results: We performed transgastric bilateral tubal ligation and closure of gastrotomy in 3 pigs. The average operative time was 180 minutes. All the closures of gastrotomy were performed with 3 interrupted sutures through Eagle Claw. All the pigs tolerated diet well. Follow-up endoscopy was performed 2 weeks later and all closures were completely healed. Laparotomy was then performed and all the gastrotomy closures were confirmed to be intact without evidence of leakage. Conclusions: The gastrotomy after transgastric surgery can be safely and securely closed with Eagle Claw VII.

Clinical Usefulness of the Mucosa-Tracking-Technique (MTT) with the Iso-Tome in Precut Papillotomy

Background/Aims: This study was done to evaluate the clinical usefulness of MTT in precut papillotomy using the Iso-Tome, an isolated-tip needle-knife papillotome (which was firstly introduced in Gastrointest Endosc 2005;62:588-591). Methods: From September 2004 to June 2006, there were 59 patients (35 choledocholithiasis, 10 malignancies, 7 pancreatitis, 7 others) who underwent precut papillotomy with the Iso-Tome consecutively when biliary cannulation failed by the conventional method. The intrapapillary (common channel, bile and pancreatic duct) mucosa of the ampulla of Vater (AV) contacted with the isolated-tip of the Iso-Tome was scathelessly preserved on precut papillotomy starting from the orifice of the AV. The intactly exposed intrapapillary mucosa was carefully tracked and classified into four groups; fully exposed and oriented toward the direction of the bile duct (group A) or the pancreatic duct (group B), partially exposed (group C), and submucosa only exposed (group D). Initial success rates of bile duct cannulation (ISRBC), time (minutes) required for bile duct cannulation from placing the Iso-Tome into the orifice of the AV (TBC), and complications were compared between four groups. Results: see table. Summary; (1) ISRBC was 86.4% (51/59) in total and higher in the mucosa-exposed groups (group A, B, C) than in group D, (2) ISRBC was 100% in group B even though primary incision was incorrectly oriented toward the direction of the pancreatic duct, (3) TBC was the shortest in the group A, (4) Complications occurred totally in 6.8% (4/59) and consisted of 4 pancreatitis (3 mild; 1 moderate). There was no difference of complication rates between four groups and all 4 patients with complications were managed medically. Conclusion: It is critical for successful precut papillotomy to expose the intrapapillary mucosa of the AV intactly and sufficiently as possible and then to track the orientation of the exposed intrapapillary mucosa carefully. MTT with the Iso-Tome is a useful method to improve the efficiency of precut papillotomy. Tabled 1 Group A (n = 29) Group B (n = 4) Group C (n = 19) Group D (n = 7) p value Gender (female/male) 8/21 3/1 9/10 5/2 0.07 Age (yrs; mean ± SD) 63.5 ± 16.2 69.8 ± 11.9 67.8 ± 12.1 62.4 ± 14.8 0.65 ISRBC (%) 96.6%(28/29) 100% (4/4) 84.2% (16/19) 42.9% (3/7) 0.002 TBC (minutes;mean ± SD) 4.3 ± 2.8 23.9 ± 10.6 12.4 ± 13.6 16.3 ± 14.4 0.0003 Complications (%) 0% 25% (1/4;1 moderate pancreatitis) 10.5% (2/19; 2 mild pancreatitis) 14.3% (1/7; 1 mild pancreatitis) 0.15 Open table in a new tab

Pre-cut papillotomy with a new papillotome

A new papillotome has been developed, an isolated-tip needle-knife papillotome (Iso-Tome) that has a semi-oval-shaped tip of epoxide adhesive to prevent electric leakage from the tip of the incising needle. The coated tip aids in keeping the papillotome tightly in the orifice of the ampulla of Vater and is believed to prevent unintentional deep cuts or perforations. This study was done to evaluate the clinical usefulness of the new papillotome for pre-cut papillotomy. From June 2003 to November 2003, 115 patients underwent attempted ERCP. If biliary cannulation failed by the conventional method, pre-cut papillotomy was performed by using the Iso-Tome in the direction of the bile duct. After successful bile-duct cannulation, papillotomy was extended for therapeutic procedures, such as stone removal or stent insertion, in the majority of the cases. Post-ERCP complications were classified according to consensus guidelines. Pre-cut papillotomy with the Iso-Tome was done in 25 patients (21.7% of cases). Protective pancreatic stents were not used. Of these patients, 11 had common bile duct stones, 7 had pancreatitis, 5 had malignancies, one had sphincter of Oddi dysfunction, and one had bile-duct leak. After pre-cut papillotomy with the Iso-Tome, bile-duct cannulation was successfully achieved in 23 of 25 (92%) patients. Complications occurred in 7 of 25 patients (28%) and consisted of mild pancreatitis in 5 (20%), moderate bleeding in one (4%), and biliary pain in one (4%). All 7 patients with complications were managed medically, and there was no death. In this pilot study, the isolated-tip needle knife was found to be a clinically useful papillotome for pre-cut papillotomy. Further large comparative studies (with and without pancreatic protective stents) are needed to determine improved efficacy and safety compared with standard techniques.