Needle Knife Research Articles

A case control study:the treatment of cervical vertigo with micro needle knife

To observe the clinical efficacy of micro needle knife therapy on cervical vertigo. A total of 300 patients with cervical vertigo treated from January 1, 2017 to December 31, 2019 were randomly divided into micro needle knife group (96 cases, 4 cases falling off), traditional acupuncture group (96 cases, 4 cases falling off) and oral drug group(95 cases, 5 cases falling off). The micro needle knife group was treated with micro needle knife in the local upper cervical segment once every other day for 7 times; the traditional acupuncture group was treated with traditional acupuncture once a day for 2 weeks;the oral drug group was given Merislon (betahistine mesilate tablets) orally, 6 mg each time, 3 times a day for 2 weeks. The patients were followed up before treatment, at the end of treatment and 3 months after treatment. The dizziness handicap inventory(DHI) was observed and the curative effect was evaluated according to the DHI score. At the end of the course of treatment and 3 months after the treatment, DHI scores of the three groups were significantly lower than those before treatment(P<0.01), and the DHI scores of micro needle knife group were lower than those of traditional acupuncture group and oral drug group at the same time point after treatment (P<0.01). There was no statistically significant difference in DHI scores between traditional acupuncture group and oral drug group at the same time after treatment(P< 0.05). The curative effect was evaluated according to DHI score:in micro needle knife group, 50 cases were cured, 28 cases were markedly effective, 14 cases were improved, the total effective rate was 95.83%; in traditional acupuncture group, 28 cases were cured, 26 cases were markedly effective, and 24 cases were improved, with the total effective rate of 81.25%;in oral drug group, 18 cases were cured, 20 cases were markedly effective, and 28 cases were improved, with the total effective rate of 69.47%. The total effective rate of micro needle knife group was significantly higher than that of other two groups (χ2=45.956, P=0.000). Among the cured patients in the three groups, the time required in the micro needle knife group was significantly less than that in the traditional acupuncture group and oral drug group(F=18.796, P=0.000). Micro needle knife loosening atlantoaxial soft tissue has obvious curative effect on cervical vertigo which clinical cure rate, effective rate and treatment time required for cured patients are better than traditional acupuncture and oral drug.

Fistulotomy versus standard cannulation as the primary technique for all patients undergoing ERCP with a native papilla: a protocol for a single center randomized controlled trial

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is an indispensable procedure for the management of pancreaticobiliary diseases. Post-ERCP pancreatitis (PEP) is the most common serious adverse event. One risk factor of PEP is difficulty achieving biliary access. The conventional ERCP technique involves the cannulation of the bile duct via the ampulla of Vater, followed by sphincter incision using electrocautery. Conventionally, if the standard method fails then, precut techniques have been utilized as an alternative means of gaining biliary access. The needle-knife fistulotomy (NKF) technique involves identifying the intra-duodenal segment of the bile duct and uses a needle knife to incise directly into the bile duct. This is done above and away from the natural office, thus minimizing thermal damage which may result in PEP. Our recent prospective study of 50 patients demonstrated the safety and feasibility of the NKF precut technique as a primary means of gaining biliary access. The next step is to conduct a randomized controlled trial to compare the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP.MethodsA randomized control trial of 538 consecutive, non-selective patients with pancreaticobiliary disease undergoing ERCP at a tertiary care center in Kingston, Ontario, Canada, will be conducted. Patients will be randomized to one of two treatment groups, standard cannulation or NKF. The primary outcome of the study will be the incidence of PEP. Secondary outcomes will include rate of successful cannulation of the common bile duct (CBD), time to successful cannulation, total procedure time, difficulty of cannulation, and incidence of complications.DiscussionThis RCT will yield important answers regarding the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP. The results of our study could alter ERCP practices and outcomes if NKF is shown to reduce PEP risk.Trial registrationClinicalTrials.govNCT04559867. Registered on September 23, 2020

Effect of needle knife on mTOR/Atg/ULK1/Beclin-1 axis and chondrocyte autophagy in rats with knee osteoarthritis

To observe the effect of needle knife on chondrocyte autophagy and expressions of autophagy-related protein and mammalian target of rapamycin (mTOR) in rats with knee osteoarthritis (KOA), and to explore the possible mechanism of needle knife for KOA. A total of 42 SD rats were randomly divided into a normal group, a model group and a needle knife group, 14 rats in each group. Except for the normal group, the other two groups were injected with the mixture of papain and L-cysteine into the left hind knee joint to establish the KOA model. After modeling, the rats in the needle knife group were treated with needle knife at strip or nodule around the quadriceps femoris and medial and lateral collateral ligament on the affected side, once a week for 3 times (3 weeks). The changes of left knee circumference in each group were observed; the chondrocytes and ultrastructure of left knee joint were observed by HE staining and electron microscope; the mRNA and protein expressions of autophagy-related genes (Atg5, Atg12, Atg4a), Unc-51 like autophagy activated kinase 1 (ULK1), autophagy gene Beclin-1 and mTOR in left knee cartilage were detected by real-time fluorescence quantitative PCR and Western blot. After modeling, the left knee circumferences in the model group and the needle knife group were increased compared with those before modeling and in the normal group (P<0.05); after intervention, the left knee circumference in the needle knife group was smaller than that in the model group and after modeling (P<0.05). Compared with the normal group, the number of chondrocytes was decreased, and a few cells swelled, nuclei shrank, mitochondria swelled and autophagosomes decreased in the model group; compared with the model group, the number of chondrocytes was increased , and most cell structures returned to normal, and autophagosomes was increased. Compared with the normal group, the mRNA and protein expressions of Atg5, Atg12, Atg4a, Beclin-1 and ULK1 in the knee cartilage in the model group were decreased (P<0.05); compared with the model group, the expressions of the above indexes in the needle knife group were increased (P<0.05). Compared with the normal group, the mRNA and protein expressions of mTOR in the knee cartilage in the model group were increased (P<0.05); compared with the model group, the expressions of the above indexes in the needle knife group were decreased (P<0.05). The needle knife intervention could improve knee cartilage injury in rats with KOA, and its mechanism may be related to reducing the expression of mTOR and up-regulating the expressions of Atg5, Atg12, Atg4a, ULK1 and Beclin-1, so as to promote chondrocyte autophagy and delay the aging and degeneration of chondrocytes.

Different entry points of needle knife for lumbar disc herniation: a randomized controlled trial

To compare the clinical efficacy and safety among three different entry points of needle knife, including tenderness point, intervertebral foramen point and articular process node, for lumbar disc herniation (LDH). A total of 105 patients with LDH were randomly divided into a tenderness point group (35 cases, 1 case dropped off ), an intervertebral foramen point group (35 cases) and an articular process node group (35 cases, 1 case dropped off ). In the three groups, the needle knife was given at positive tenderness points of lumbosacral and hip, the external point of intervertebral foramen and the node of vertebral joint process respectively, once a week for a total of 4 times. The scores of Japanese Orthopaedic Association (JOA), Oswestry disability index (ODI), visual analogue scale (VAS) were recorded before treatment, 2 weeks and 4 weeks into treatment, and 3 months follow-up after treatment, and the clinical efficacy and safety was observed. Compared before treatment, the JOA scores in each group were increased 2, 4 weeks into treatment and in the follow-up (P<0.05); 4 weeks into treatment and in the follow-up, the JOA scores in the tenderness point group and the articular process node group were higher than those in the intervertebral foramen point group (P<0.05). Compared before treatment, except for ODI score 2 weeks into treatment in the intervertebral foramen point group, the ODI and VAS scores in each group were decreased 2, 4 weeks into treatment and in the follow-up (P<0.05), and the ODI scores in the tenderness point group and the articular process node group were lower than those in the intervertebral foramen point group (P<0.05). In 2 weeks into treatment, the VAS scores in the tenderness point group and the articular process node group were lower than those in the intervertebral foramen point group (P<0.05); in 4 weeks into treatment and follow-up, the VAS scores in the tenderness point group were lower than the other two groups (P<0.05). After treatment, the clinical efficacy of each group was similar (P>0.05); during the follow-up, the total effective rate in the tenderness point group was higher than that in the intervertebral foramen point group (P<0.05). There were no serious adverse events in each group. The three different entry points of needle knife all could improve the symptoms of patients with LDH. The comprehensive effect of improving the subjective symptoms, lumbar function, pain degree and long-term curative effect is better in the tenderness point group.

Different acupotomy for stenosing tenosynovitis: A protocol for systematic review and network meta-analysis.

Background:Stenosing tenosynovitis (STS) is a chronic aseptic inflammation caused by mechanical friction. The main clinical manifestations are local pain and limited activity of the affected parts, which reduce people's quality of life. The clinical effect of acupotomy in the treatment of STS is significant, and the operation is simple and the side effect is small. But there are many kinds of acupotomology, and there is a lack of comparative study between different Acupotomology. In this study, the effectiveness of 4 commonly used needle knife therapies (v-knife, oblique knife, crochet knife, flat knife) was ranked by the method of network meta.Methods:CNKI, Wanfang, VIP, Sinomed, PubMed, and Cochrane Library were searched to collect randomized controlled trials of v-knife, oblique knife, crochet knife, and flat knife in the treatment of STS. The search time limit is from the date of establishment to October 15, 2021. Revman5.3, gemtc 0.14.3, and stata14.2 were used for data analysis, and Cochrane bias risk assessment tool was used to screen and evaluate the quality of included literatures.Conclusion:Objective to provide evidence-based medicine evidence for clinical selection of the best needle knife treatment scheme for STS.

Observation on the Therapeutic Effect of Ultrasound-guided Needle Knife in the Treatment of Lumbar Three Transverse Processes Syndrome

Observation on the Therapeutic Effect of Ultrasound-guided Needle Knife in the Treatment of Lumbar Three Transverse Processes Syndrome

Treatment of Scapulohumeral Periarthritis with C-Shaped Needle Knife Release

To introduce one case of Scapulohumeral Periarthritis Treated by "C" needle knife loosening. [Methods] under local anesthesia, the patients were given the "C" needle knife release operation, and the patients were instructed to perform functional exercises such as shoulder joint activity. [results] after the "C" needle knife release treatment, the pain symptoms of shoulder joint disappeared, the activity disorder of shoulder joint improved obviously, and the follow-up was not recurred for 5 months. [Conclusion] the "C" needle knife has a significant effect on periarthritis of shoulder, simple operation, less complications, high safety and wide application range, which can effectively improve the symptoms and functional activities of shoulder joint of patients, and solve the problem of high effective rate and low cure rate of traditional needle knife treatment.

Needle knife in the treatment of primary dysmenorrhea: a systematic review and meta-analysis

Needle knife in the treatment of primary dysmenorrhea: a systematic review and meta-analysis

Research Progress of Acupuncture and Moxibustion on Knee Osteoarthritis

Knee osteoarthritis (KOA) is a chronic inflammatory disease characterized by cartilage degeneration, osteophyte formation and joint inflammation, which is mainly good in middle-aged and elderly people. The main manifestations are knee pain or dull pain, swelling, joint clicking, and even knee stiffness, limited mobility, muscle spasm around and muscle atrophy, which seriously affect the quality of life. Acupuncture and moxibustion, as a characteristic treatment for KOA in Traditional Chinese medicine (TCM), has accumulated rich clinical experience in the treatment of KOA, and there are numerous therapies, including conventional acupuncture, fire needle, warm needle, silver needle, electroacupuncture, small needle knife, internal heat needle, moxibustion and combined therapy. All of them have the characteristics of easy operation, low cost, significant effect, safety and reliability.

Evaluation on the Curative Effect of Brachial Plexus Anesthesia after Joint Loosening and Small Needle Knife Release in Treatment of Periarthritis of Shoulder

Evaluation on the Curative Effect of Brachial Plexus Anesthesia after Joint Loosening and Small Needle Knife Release in Treatment of Periarthritis of Shoulder

Clinical Observation of Micro Needle Knife Combined with Moxibustion in Treatment of Anserus Bursitis

Clinical Observation of Micro Needle Knife Combined with Moxibustion in Treatment of Anserus Bursitis

Needle knife fistulotomy in flat and diverticular papillae: Is it time for redemption?

BackgroundEuropean Society of Gastrointestinal Endoscopy (ESGE) recommends needle-knife fistulotomy (NKF) as the preferred precut technique in cases when standard cannulation techniques fail. Despite scarce scientific evidence, flat and diverticular papillae are thought not to be ideal for NKF, as they are associated with poor outcomes. The present study aimed to determine the outcomes of the use of NKF in relation to flat and intradiverticular papillae. MethodsThis prospective multicenter study enrolled consecutive patients, evidencing naïve flat (group A, n = 49) or diverticular papilla (group B, n = 28), who underwent NKF after failure of standard cannulation techniques. Diverticular morphology was subdivided into intradiverticular (group B1, n = 14) and diverticular border papillae (group B2, n = 14), using a previously validated endoscopic classification of the major papilla. The success of biliary cannulation at initial endoscopic retrograde cholangiopancreatography (ERCP), overall biliary cannulation, overall cannulation time, and the rate of adverse events were assessed in the study. ResultsThe initial cannulation rates were 93.9%, 64.3% and 71.4% for group A, B1, and B2, respectively (P = 0.005); overall cannulation rates after a second ERCP were 98.0%, 92.9% and 85.7%, respectively (P = 0.134). Adverse events occurred in 11.7% of patients, with post-ERCP pancreatitis (PEP) being the most common adverse event (10.4%). Although there was a trend towards a higher incidence of PEP in flat papillae, univariate and multivariate analyses did not show any significant relationship between pancreatitis and trainee involvement, papillary morphology, nor overall cannulation time. ConclusionsAlthough flat papillae are associated with high success rates of biliary cannulation using NKF, the rate of PEP is not negligible. NKF is feasible in diverticular papillae, but it is associated with a modest success rate in the initial ERCP.

Effect of Acupotomy Intervention on Fibrosis of Rectus Femoris in Rabbits with Knee Osteoarthritis

<bold>Objective:</bold> To observe the effects of acupotomy intervention on the fibrosis of the rectus femoris in rabbits with knee osteoarthritis from the histological and molecular level, and to reveal the possible mechanism of the needle knife in the treatment of knee osteoarthritis. <sec><title>Methods</title> Twenty-four healthy male New Zealand rabbits were randomly divided into blank group, model group and acupotomy group used by random number table method, with 8 rabbits in each group. Modified Videman method was used to replicate the osteoarthritis model of the knee with left hind limb extended plaster immobility for 6 weeks. Lequesne MG knee joint grade score, X-ray and MRI imaging examination of knee joint and pathological morphology of rectus femoris were confirmed after successful modeling. In acupotomy group, the transfascial focal points of quadriceps femoris muscle were released by acupotomy under the guidance of Jingjin theory, treatment points included Hedingci (the focal lesion point of the foot yangming meridian, located at the attachment of the positive upper margin of the quadriceps tendon and the patella), Binwaishang (the focal lesion point of the foot yangming meridian, located at the attachment of the lateral upper edge of the patella to the lateral femoral muscle tendon), Binneishang (the focal lesion point of the foot yangming meridian, located at the attachment of the medial femoral muscle tendon to the inner upper edge of the patella), once a week, for a total of 4 times of treatment. The blank group and model group were routinely fed and grabbed without intervention. One week after the end of intervention, masson staining was used to detect the changes in the tissue morphology and collagen volume fraction of the rectus femoris to observe the effect of acupotomy on the fibrosis of the rectus femoris in rabbits with knee osteoarthritis. RT-PCR and Western blot were used to detect the mRNA and protein expression levels of type Ⅰ collagen fibers (ColⅠ), vimentin (VIM), and Alpha-smooth muscle actin (α-SMA) in the rectus femoris muscle to observe the effect of acupotomy on the knee osteoarthritis. </sec><sec><title>Results</title> 1) Masson staining results showed that neat red-stained skeletal muscle fibers can be seen in the blank group; skeletal muscle fibers can be seen in the model group damaged and surrounded by a large amount of blue-stained collagen fibers; in the acupotomy group, skeletal muscle fibers can be seen neatly and a small amount of blue-stained collagen fibers wrap around. Compared with the blank group, the collagen volume fraction of rectus femoris muscle in the model group increased, and the difference was statistically significant (<italic>P</italic><0.01). Compared with the model group, the acupotomy group had decreased collagen volume fraction of rectus femoris muscle, and the difference was statistically significant (<italic>P</italic><0.01). 2) RT-PCR results showed that the mRNA expressions of ColⅠ, VIM and α-SMA in the model group were significantly higher than those in the blank group (<italic>P</italic><0.01), while those in the acupotomy group were significantly lower than those in the model group, and the difference was statistically significant (<italic>P</italic><0.01). 3) Western blot results showed that the proteins expressions of ColⅠ, VIM and α-SMA in the model group were significantly higher than those in the blank group (<italic>P</italic><0.01), while those in the acupotomy group were significantly lower than those in the model group, and the difference was statistically significant (<italic>P</italic><0.01). </sec><sec><title>Conclusion</title> Based on the Jingjin theory, the release of quadriceps femoris transfascial focal point by acupotomy can down-regulate the expression levels of mRNA and protein of ColⅠ, VIM, α-SMA, and reduce the degree on fibrosis of rectus femoris muscle, which may be one of the mechanisms of acupotomy for KOA. </sec>

S1024 The Effect of Unintended Pancreatic Duct Cannulation on Post-ERCP Pancreatitis

Introduction: Post-ERCP pancreatitis (PEP) is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Numerous studies have identified multiple synergistic patient-based risk factors for PEP including suspected sphincter of Oddi dysfunction, prior PEP, female gender, younger age, normal serum bilirubin, and history of acute recurrent pancreatitis. However, unintended pancreatic duct (PD) cannulation is less well studied as a risk factor for PEP. Our study investigates the risk of PEP in unintended PD cannulation. Methods: We conducted a retrospective cohort study of all ERCPs by a single advanced endoscopist between December 2013 and January 2020 at a tertiary medical center. Patients with prior sphincterotomy were considered to have a non-native papilla and were excluded. Details of the ERCP, laboratory results, hospitalizations, clinic visits, and follow-up phone calls were identified via chart review. PEP was defined by the revised Atlanta classification. Multiple logistic regression analysis was used to model demographic and clinical features of those who did and did not develop PEP. Group differences for various factors were compared using odds ratios calculated via Fisher’s exact test. Results: 823 ERCPs were included in this analysis of which 3.77% were complicated by PEP. The incidence of PEP was 8.4% among unintended PD cannulation, 3.2% among intentional PD cannulation, and 1.5% among no PD cannulation (Fisher's exact p-value < 0.00005). Using multiple logistic regression, PEP positively correlated with unintended PD cannulation (p-value < 0.005) but not intended PD cannulation. When controlled for age and gender, needle knife sphincterotomy was also identified as a risk factor for PEP (p-value = 0.017). Additionally, age was negatively correlated with PEP in unintended PD cannulation (p-value = 0.027). In both unintended and intended PD cannulation, PEP rates were not affected by contrast injection into the PD compared with just guidewire cannulation without contrast injection. Conclusion: While unintended PD cannulation appears to increase the likelihood of PEP, intentional cannulation does not seem to have the same effect, suggesting that underlying pancreatic disease such as chronic pancreatitis or pancreatic trauma confers a lower risk of PEP. Further studies are needed to determine whether patients with unintended PD cannulation could benefit from more aggressive PEP prophylaxis or monitoring after ERCP.

Evaluation of efficiency and safety of muscular region's acupuncture treatments for knee osteoarthritis: A protocol for systematic review and network meta-analysis.

Background:As a chronic degenerative disease, knee osteoarthritis (KOA) is mainly characterized by loose ligaments around the knee joint, degeneration of cartilage in the knee joint, and atrophy of surrounding muscles. According to related investigations, the incidence of knee osteoarthritis in China is 8.1%, of which 10.3% are women and 5.7% are men. Therefore, in order to improve the therapeutic effect of KOA, we must constantly explore new ways to treat the disease. The purpose of this study is to evaluate the effectiveness and safety of acupuncture with needle knife, blade needle, long-round needle, fire needle, micro-needle knife with conventional acupuncture intervention in KOA.Methods:Computer search of PubMed, Cochrane Library, Web of Science, CNKI, Wangfang, and VIP database, search for randomized controlled trials of muscular region's acupuncture therapy on KOA, the search time limit is to build the database until July 9, 2021. To ensure the comprehensiveness of the search, relevant references and conference literature are also included. After 2 researchers independently screened the literature, extracted data, and evaluated the risk of bias in the included studies, the Stata 14.0 software was used for data analysis.Results:The effectiveness and safety of muscular region's acupuncture in the treatment of patients with KOA will be systematically evaluated.Conclusion:The results of this study will provide strong evidence to determine whether muscular region's acupuncture is effective in the treatment of KOA.Registration number:INPLASY202170031 (https://inplasy.com/inplasy-2021-7-0031/)

Endoscopic neo-anastomosis by Rendez-vous technique for the treatment of complete occlusion of bilioenteric anastomoses and distal bile ducts (case series).

The complete occlusion of bilioenteric anastomoses is a rare and challenging clinical condition. Repeated surgery is burdened with technical difficulties and significant morbidity. We report the first series of completely occluded bilioenteric anastomoses resp. distal bile duct successfully treated by simultaneous percutaneous and retrograde endoscopic interventions. This case series includes 4 patients with obstructive jaundice and/or recurring cholangitis and pain due to complete fibrotic occlusion of a hepaticojejunostomy (3 patients) and the distal bile duct (1 patient). After performing PTCD and stepwise dilation of the biliocutaneous tract, we tried to approach the occluded anastomosis from 2 sides by simultaneous percutaneous cholangioscopy and peroral device-assisted enteroscopy/duodenoscopy. By cutting through the separating tissue layer with a needle knife under endoscopic and fluoroscopic control using diaphanoscopy, a new anastomosis should be established followed by dilation of the neoanastomosis with subsequent percutaneous transhepatic drainage for a minimum of 1 year to prevent re-occlusion. The Rendez-vous maneuver was successful in 3/4 cases. In one case, the retrograde access to the anastomosis failed, so the neoanastomosis was cut under cholangioscopic and fluoroscopic guidance only. The neoanastomosis could be established successfully in all 4 cases. Jaundice, cholangitis, and pain disappeared. Minor periinterventional adverse events were cholangitis (n = 1) and pneumonia (n = 1) due to aspiration, which could be managed conservatively. No serious adverse events were observed, and no re-occlusion of any neoanastomosis occurred during the follow-up before and after removal of the percutaneous drainage. Simultaneous percutaneous cholangioscopy and device-assisted enteroscopy/duodenoscopy with endoscopic creation of a neoanastomosis is a possible concept for the treatment of completely occluded bilioenteric anastomoses and distal bile ducts. This case series confirms the feasibility, safety, and long-term effectiveness of this treatment.

Management of biliary diseases after the failure of initial needle knife precut sphincterotomy for biliary cannulation

Endoscopic retrograde cholangiopancreatography is not always successful even with needle knife precut sphincterotomy (NKPS). How to manage these patients with initial NKPS failure has not been well studied. We report the outcomes of patients who received endoscopic and non-endoscopic rescue treatment after the initial NKPS failure. During the 15 years from 2004 to 2018, 87 patients with initial NKPS failure received interval endoscopic treatment (IET group, n = 43), percutaneous transhepatic biliary drainage (PTBD group, n = 25), or bile duct surgery (BDS group, n = 19) were retrospectively studied. Compared with the PTBD group, the prevalence of choledocholithiasis was higher (69.8% vs. 16.0%, p < 0.001), and malignant bile duct stricture were lower (20.9% vs. 76.0%, p < 0.001) in the IET group. Furthermore, the IET group had a significantly longer time interval between the first and second treatment procedures (4 days vs. 2 days, p = 0.001), a lower technique success rate (79.1% vs. 100%, p = 0.021), and a shorter length of hospital stay (7 days vs. 18 days, p < 0.001). Compared to the BDS group, the only significant finding was that the patients in the IET group were older. Although not statistically significant, the complication rate was lowest in the IET group (7.0%) while highest in the BDS group (15.8%). Complications in the IET group were also mild, as compared with the other two groups. In conclusion, IET should be considered after initial failed NKPS for deep biliary cannulation before contemplating more invasive treatment such as BDS. PTBD may be the alternative therapy for patients with malignant biliary obstruction.

A Rare Case of Ileocecal Intussusception in an Adult

Question: A 91-year-old woman with ulcerative colitis in clinical and endoscopic remission on mesalazine presented with a 2-day history of severe right lower abdominal pain, nausea, and vomiting. Physical examination showed abdominal distention and tenderness in the right side of the abdomen. A computed tomography scan of the abdomen showed dilated small bowel loops and a typical target sign (Figure A, arrow), suggesting colonic intussusception and a lead point intussusception with invaginated mesenteric fat and vessels (Figure B, arrow). Colonoscopy revealed the invagination of the terminal ileum (intussusceptum) into the ascending colon (Figure C) and localized marked edematous swelling of the ileocecal valve as the lead point. The ileocecal region showed no mucosal changes suggestive of ischemia. What is the most likely diagnosis? How should the patient be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. The swollen ileocecal valve was punctured with an endoscopic needle knife, causing clear fluid to leak out (Figure D, E). The submucosa was confirmed to be highly edematous and filled with fluid. The swollen mucosa then became completely deflated, and the intussusception was immediately resolved (Figure F, Video). Histologic findings of the biopsy specimens revealed no pathological findings other than edema in the submucosa and the lamina propria. No malignant cells were found in the examined fluid. There was no evidence of a causal factor of intussusception, such as bowel ischemia, inflammation, diverticulum, lesions that were either benign or malignant, or any other pathological trigger. The cause of the localized edema of the ileocecal valve was unknown. Based on these findings, the diagnosis of adult idiopathic ileocecal intussusception was made. The patient completely recovered and was discharged without procedure-related complications. No recurrence of intussusception occurred over a 3-year follow-up period. Adult intussusception represents 5% of all cases of intussusception and accounts for only 1%–5% of bowel obstructions in adults, and most cases involve identifiable etiologies such as benign or malignant tumors.1Azar T. Berger D.L. Adult intussusception.Ann Surg. 1997; 226: 134-138Crossref PubMed Scopus (677) Google Scholar In contrast, idiopathic intussusception is frequent in children, but rare in adults. Owing to the high rate of malignancy or other structural change causing adult intussusception, a surgical approach has been served as the treatment of choice.1Azar T. Berger D.L. Adult intussusception.Ann Surg. 1997; 226: 134-138Crossref PubMed Scopus (677) Google Scholar,2Lindor R.A. Bellolio M.F. Sadosty A.T. et al.Adult intussusception: presentation, management, and outcomes of 148 patients.J Emerg Med. 2012; 43: 1-6Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar However, intestinal resection surgery may be overly invasive when the intussusception does not involve neoplastic lesions.3Imasato M. Kim H.M. Higashi S. et al.Laparoscopic surgery for idiopathic adult intussusception successfully reduced by colonoscopy.J Anus Rectum Colon. 2019; 3: 49-52Crossref PubMed Google Scholar If endoscopic reduction is possible, as in our case, emergency surgery can be avoided and appropriate treatment can be performed. Therefore, a nonoperative approach with endoscopic reduction should be attempted when the lead point is thought to be benign or idiopathic. https://www.gastrojournal.org/cms/asset/f81955b8-fb7a-47f7-b5b2-a48da942c0eb/mmc1.mp4Loading ... Download .mp4 (45.01 MB) Help with .mp4 files Supplementary Video

Acute papillary stone impaction: An ideal indication for upfront needle knife papillotomy ("needle knife excision").

Needle knife papillotomy (NKP) is still considered a rescue technique after conventional access failure due to traditional high complication rates, albeit data are maturing for early use of NKP in standard endoscopic retrograde cholangiopancreatography indications. By contrast, in certain settings NKP should be prioritized to a first‐class indication, such as in choledochocele management and/or, more often encountered in clinical practice, true papillary stone impaction with or without gallstone pancreatitis. The latter results in prompt stone release; thus, the procedure might become alternatively designated as “needle knife excision.”

Endoscopic pancreatic stenting using the combination technique of injection needle and needle knife for complete pancreaticojejunal anastomotic obstruction.

Watch a video of this article. A 69-year-old woman who underwent pancreaticoduodenectomy presented with chronic diarrhea and exacerbation of diabetes mellitus. Magnetic resonance cholangiopancreatography revealed dilatation of the main pancreatic duct (MPD) (Fig. 1a). Exocrine and endocrine pancreatic insufficiency due to pancreaticojejunal anastomotic stenosis (PJS) were considered as possible causes of the symptoms. Therefore, endoscopic retrograde pancreatography (ERP) was planned. On endoscope (PCF-H290ZI; Olympus Medical Systems, Tokyo, Japan) insertion, the anastomotic site (AS), which was characterized by membranous obstruction, was identified (Fig. 2a). ERP using a conventional cannulation method was considered difficult because of complete anastomotic obstruction (CAO). As we confirmed that there were no major blood vessels around the AS on computed tomography (Fig. 1b), ERP using an injection needle (23-G TOP endoscopic injection needle; TOP, Tokyo, Japan) was performed. Four punctures were required for ERP and dilatation of the MPD was observed (Fig. 2b). The AS was incised using a needle knife (KD-1L-1; Olympus Medical Systems) (Fig. 2c). After incision of the AS and guidewire placement, it was dilated using a dilator (ES dilator; Zeon Medical, Tokyo, Japan) and a 5-Fr × 5-cm pancreatic stent (Advanix Pancreatic Stent; Boston Scientific Japan, Tokyo, Japan) was placed without adverse events (Fig. 2d) (Video S1). For CAO in PJS, endoscopic ultrasound-guided pancreatic duct drainage is preferred because endoscopic pancreatic stenting under ERP (EPS) is technically challenging.1-3 However, EPS has the advantage that it can be safely performed using a physiological route.4 Similar to our technique, for CAO in hepaticojejunostomy, cholangiography and guidewire placement were simultaneously performed through a 20-G injection needle, and the access route to the bile duct was secured using a diathermic dilator via a guidewire.5 This technique should also be considered because it does not involve a blind incision with the risk of perforation. EPS using these techniques may be a treatment option for CAO. This study was conducted in accordance with the ethical standards described in the latest revision of the Declaration of Helsinki. Informed consent for patient participation and publication was received. All data relevant to the study are included in the article. Authors declare no conflict of interest for this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.