Double-balloon Research Articles

Peri-Urethral and Anterior Vaginal Wall Masses: Does Radiological Imaging Change the Predicted Diagnosis?

This study aims to determine the accuracy of radiological imaging compared with surgical pathology in patients with periurethral (PU) and anterior vaginal wall (AVW) lesions. This study is a retrospective analysis of 126 women who underwent surgical treatment for PU and AVW masses between 2011 and 2020. Clinicopathological data were extracted along with radiological findings from medical records. The primary outcome was the diagnostic accuracy of preoperative imaging compared to the gold standard, pathological diagnosis. The secondary outcome was the rate of imaging correcting the clinical diagnosis. A total of 126 women with a median age of 42 underwent surgical treatment for PU and AVW masses. The most diagnoses were periurethral cysts (PUC) (52%) and urethral diverticulum (UD) (39%). Clinical diagnosis was accurate in 102 cases (81%) for the group of pathological diagnoses. Magnetic resonance imaging (MRI) and transvaginal ultrasound (TV US) were performed in 82 (65%) and 22 (17%) cases. The accuracy of MRI and TV US for the diagnosis of PU and AVW lesions was 76% and 82%, respectively. MRI and TV US corrected the clinical diagnosis in five (6%) and two (9%) cases, respectively. Voiding cystourethrography (VCUG) and double balloon urethrography (DBU), each performed in six (5%) cases, were accurate in four (67%) and three (50%) cases. No statistical difference was found for any imaging modality compared to clinical diagnosis. Clinical diagnosis based on pelvic and cystoscopy examinations was sufficient for diagnosing PU and AVW masses and was not significantly different from imaging diagnosis. Imaging may be helpful with preoperative surgical planning in selected cases.

The double-balloon technique: a safe and effective adjunctive technique in patients undergoing arterial therapy for hepatic malignancies with vascular supply not amenable to selective administration

PurposeDuring catheter directed intraarterial therapy for liver lesions, challenging hepatic vascular anatomy can sometimes prevent selective administration of treatment delivery to liver tumors leading to increased toxicity to normal liver parenchyma. The objective of this study is to describe a variation of the double balloon technique that isolates the feeding artery to liver tumors proximally and distally to provide treatment delivery in lesions that cannot be otherwise selected.Materials and methodsAn IRB-approved retrospective review of 7 patients who had undergone either radioembolization, chemoembolization, or bland embolization and the double balloon technique was employed. The devices used for flow augmentation were two 2.1 French balloon microcatheters (Sniper™, Embolx). One balloon was inflated distal to target vessel and the second was inflated proximal to protect from reflux.ResultsDEB-TACE was performed in 3 cases, 90Y was performed in 4, and bland embolization was performed in the last patient. There were no adverse effects from the procedure or clinically evident effects from non-target embolization. Mean follow up time was 286.4 +/− 200.1 days. Six of the 7 patients are alive. One patient passed away on post-procedure day 121 from septic shock unrelated to the procedure. One patient was bridged to transplant with an additional TACE of a separate lesion.ConclusionDouble-balloon technique for patients undergoing 90Y or chemoembolization is a safe adjunctive technique for super selective treatment of hepatic lesions where direct selection via catheter is not feasible. This may increase the range of lesions that can be both safely and effectively treated by catheter directed therapies.

Obscure Gastrointestinal Bleeding Caused by a Small Intestinal Lymphatic-venous Malformation: A Case Report with a Literature Review

A 44-year-old woman presented with severe anemia. We strongly suspected gastrointestinal bleeding; however, esophagogastroduodenoscopy, colonoscopy, and computed tomography showed no bleeding sources. Video capsule endoscopy revealed an actively bleeding submucosal lesion within the jejunum. Double-balloon enteroscopy revealed a 20-mm continuously bleeding submucosal lesion in the distal jejunum. We suspected small intestinal vascular malformation and performed surgical resection. The resected specimen pathologically comprised dilated, thin-walled lymphatic channels and blood vessels involving the small intestinal submucosa. Therefore, the patient was diagnosed with small intestinal lymphatic-venous malformation. Postoperatively, the patient recovered well, and recurrence was not observed.

Double Balloon Catheter Tamponade in the Management of Primary Atonic Postpartum Hemorrhage: A Novel Technique in Low Resource Settings

Double Balloon Catheter Tamponade in the Management of Primary Atonic Postpartum Hemorrhage: A Novel Technique in Low Resource Settings

Targeted intra-arterial gemcitabine vs. continuation of IV gemcitabine plus nab-paclitaxel following induction with sequential IV gemcitabine plus nab-paclitaxel and radiotherapy for unresectable locally advanced pancreatic cancer (TIGeR-PaC): A randomized phase 3 multicenter study.

TPS773 Background: Prognosis for locally advanced pancreatic cancer (LAPC) remains dismal even with advances in cancer therapy. Beyond systemic therapies, local disease control is important in these patients. Local double balloon mediated delivery of intra-arterial gemcitabine (IAG) was demonstrated to be safe in this patient population in a prior study1. TIGeR-PaC is an ongoing Phase-3 clinical trial comparing the efficacy of this approach compared to standard of care IV gemcitabine/nab-paclitaxel (GN) for patients with LAPC. Methods: The trial is designed with an induction phase of upfront systemic therapy prior to IAG. Patients with LAPC diagnosed within 6 weeks and ECOG 0-1, receive 3 cycles of GN and 1 cycle of radiation. The form of radiation was either IMRT, 50 Gy in 25 fractions, with concomitant capecitabine or SBRT, 33 Gy in 5 fractions (per site preference). Following induction, patients with non-progressive disease were randomized to receive IAG (8 treatments every two weeks for 16 weeks) or continuing therapy with 4 cycles of GN. After the 16 weeks of randomized therapy, the patients with non-progressive disease went on to continue systemic therapy (GN or capecitabine, per investigator’s preference) until disease progression and then followed for survival only. The primary endpoint is overall survival, and the study has an 80% power to detect a hazard ratio of 0.6 between the two arms. As of September 1st, 2022, 189 patients have been enrolled in the trial. In its initial design the trial expected a 35% drop out rate during the induction phase; however, two years into the trial the actual observed dropout rate was 53%. Beyond progression (22%), the key element of dropout rate was AE/SAE during radiation with IMRT/capecitabine (17%) vs. only 6% with SBRT. To increase accrual of randomized patients, the protocol and the statistical plan were modified to restrict the mode of radiation during induction to SBRT only starting December 2021. Since the modification of the protocol, the dropout rate during induction has decreased to 38%. As of this abstract, 43 patients have been randomized following induction with GN and SBRT. The rate of SAE during active treatment is not different between the 2 arms (20% in each arm), and the most common SAE is GI side effects in both arms. The protocol has a pre-planned interim analysis after 26 events, with 23 events at this writing we expect our first interim analysis later this year. 1. Rosemurgy AS, e al: J Pancreat Cancer. 2017;3(1):58-65. doi:10.1089/pancan.2017.0011. Clinical trial information: NCT03257033 .

Endoscopic and histological characteristics of small bowel tumors diagnosed by double-balloon enteroscopy.

Double-balloon enteroscopy (DBE) allows for the diagnoses and treatment of small bowel tumors (SBTs). This study aimed to evaluate the utility of DBE for the diagnosis and treatment of SBTs. Patients diagnosed with SBTs who underwent DBE were included in this study. According to their endoscopic appearances, they were categorized as polyps or masses, and according to their histological characteristics, they were categorized as benign or malignant SBTs. A total of 704 patients were retrospectively analyzed, and 90 (12.8%) were diagnosed with SBTs. According to their endoscopic appearance, 48 (53.3%) had polyps and 42 (46.7%) had masses. Additionally, 53 (58.9%) and 37 (41.1%) patients had malignant and benign SBTs, respectively, depending on their histological characteristics. Patients diagnosed with polyps were younger than those diagnosed with masses (p<0.001). Patients diagnosed with benign SBTs were younger than those diagnosed with malignant SBT (p<0.001). Overall, histological diagnosis was determined using DBE in 73 (81.1%) patients. DBE is a useful method for diagnosing SBTs. Additionally, the histological type of the lesion can be determined using DBE.

An Isolated Intestinal Juvenile Polyp Diagnosed by Abdominal Ultrasonography and Resected by Double-Balloon Endoscopy: A Case Report and Literature Review.

Juvenile polyps, typically localized in the rectum and sigmoid colon, are a common cause of pediatric bloody stool. An isolated small intestinal juvenile polyp is uncommon and generally difficult to diagnose. The first case of an isolated juvenile polyp diagnosed by abdominal ultrasonography before acute abdomen had developed and resected by double-balloon endoscopy is presented along with a review of previous reports including this case. A two-year-old Japanese boy was referred to our institute for further evaluation of anemia persisting from one year of age. Laboratory findings showed mild iron deficiency anemia and elevated fecal human hemoglobin (Hb) and fecal calprotectin values. Upper and lower endoscopic findings showed no abnormalities. Because the abdominal ultrasonography performed one year later demonstrated a 15 mm jejunal polyp, combined with a similar finding on small intestinal capsule endoscopy, this was diagnosed as an isolated lesion. The lesion was resected by cautery with double-balloon endoscopy and diagnosed as a juvenile polyp pathologically. All clinical symptoms disappeared, and all laboratory data improved after treatment, without recurrence for more than one year after the procedure. Abdominal ultrasonographic screening and the fecal calprotectin value led to the diagnosis and non-surgical invasive treatment of an isolated small intestinal juvenile polyp.

Isolated small bowel disease and multiple lung nodules: an unusual initial presentation of pediatric Crohn’s disease

Crohn’s disease (CD) is a chronic idiopathic inflammatory disorder of the gastrointestinal tract characterized by transmural inflammation, skip lesions, and architectural changes. Isolated small bowel involvement is seen in approximately 1% of patients with CD at diagnosis. Extraintestinal manifestations can occur, with pulmonary involvement seen in &lt;1% of all CD. We report an unusual case of a previously healthy 12-year old male who presented to hospital with acute abdominal pain, emesis, and fever. He had microcytic anemia, thrombocytosis, elevated C-reactive protein, hypoalbuminemia, digital clubbing, and poor growth. Interestingly, initial upper endoscopy and ileocolonoscopy were unremarkable. Pathology revealed colonic nonnecrotizing granulomas without inflammation. He incidentally was found to have multiple lung nodules despite the absence of respiratory symptoms, and MRE revealed five small bowel strictures. This prompted work-up for alternative etiologies including infectious and rheumatologic, which were negative. Ultimately, five months later, double balloon enteroscopy revealed ileal ulcerations at the strictures and several small aphthous ulcers in the transverse and sigmoid colon. Biopsies showed active ileitis and chronic active colitis with nonnecrotizing granulomas. He developed perianal disease, confirmed on MR pelvis, and a diagnosis of CD was made. The patient started infliximab therapy and is clinically in remission. This is a rare and unique phenotype of CD with initial presentation of multiple lung nodules and isolated small bowel disease. This case highlights the importance of recognizing that pulmonary manifestations should be considered in the absence of respiratory symptoms and that a normal first endoscopy does not preclude a diagnosis of CD.

Effects of labor induction in obesity with delayed pregnancy: A retrospective study based on Chinese obese primipara.

To test the hypothesis that obese primiparous women with an unfavorable cervix in delayed pregnancy may experience a worse induction of labor. In total, 467 primiparas with poor cervical condition and delayed pregnancy (gestational age [GA]: >40weeks) were divided into an obese primiparas group (body mass index [BMI] >30kg/m2; n=166) and a non-obese primiparas group (BMI < 30kg/m2; (n=301). Labor was induced by various methods, double balloon, dinoprostone inserts, and amniotomy combined with oxytocin depending on the Bishop score. Experimental data were analyzed by Statistical Product Service Solutions (SPSS). BMI in the obese primiparas group was higher than in the non-obese group (33.91 ± 2.67 versus 24.09 ± 5.78, p<0.001), and there were significant differences in uterine tone and duration of contractions between the two groups in the second stage of labour (p=0.041, p=0.026, respectively).The rate of cesarean section (CS) was significantly higher in the primiparas group (23.49% versus 12.29%; P=0.002). There was a significant difference between the two groups in terms of the duration of time to vaginal delivery (VD) (18h versus 8h; P <0.001) while the duration until VD in the obese primiparas group within 12 hours and 24 hours was significantly longer (P <0.001). After adjusting for possible confounders, caesarean section rates remained high in the obese primiparas women (OR: 2.564;95%CI1.919,3.864;P<0.001). Similarly, after adjusting for the same confounding factors, obese primiparas women increased the duration until VD within 24h by 3.598 hours. Obese primiparas with an unfavorable cervix in delayed pregnancy have a significantly higher risk of CS and a longer duration until VD than non-obese primiparas during labor induction.

Jejunal intussusception and perforation due to enteric muco-submucosal elongated polyp: a case report and literature review

BackgroundA muco-submucosal elongated polyp is a non-neoplastic growth composed of mucosa and submucosa. Although muco-submucosal elongated polyps are commonly reported in the large intestine, they are rare in the small intestine, in which they are called enteric muco-submucosal elongated polyps. We herein present a case of jejunal intussusception and perforation due to an enteric muco-submucosal elongated polyp.Case presentationA 46-year-old woman presented with abdominal pain and vomiting. Computed tomography revealed jejunal intussusception, which was reduced via a nasointestinal ileus tube. Oral double-balloon endoscopy showed an elongated polyp in the proximal jejunum. The patient refused surgical resection and thus, the polyp was monitored. Six months later, the patient was readmitted with the recurrence of jejunal intussusception and underwent emergency surgery. Intraoperative findings revealed an intussuscepted bowel with an elongated polyp and multiple perforations in the proximal jejunum. We resected approximately 90 cm of the bowel, including the intussuscepted segment and perforated sites. The pedunculated polyp, which was 60 mm in length, was located on the oral side of the resected specimen. Histopathologically, the polyp was covered by normal mucosa and the submucosa consisted of edematous loose connective tissue. The histopathological diagnosis confirmed an enteric muco-submucosal elongated polyp.ConclusionsSymptomatic patients with enteric muco-submucosal elongated polyps may be at risk of complications, as observed in the present case, and need to undergo timely resection.

A Nationwide Survey on Gastrointestinal Endoscopy Practice Patterns among Pediatric Endoscopists in South Korea.

Gastrointestinal (GI) endoscopy is an important tool for diagnosing and treating GI diseases in children. This study aimed to analyze the current GI endoscopy practice patterns among South Korean pediatric endoscopists. Twelve members of the Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition developed a questionnaire. The questionnaire was emailed to pediatric gastroenterologists attending general and tertiary hospitals in South Korea. The response rate was 86.7% (52/60), and 49 of the respondents (94.2%) were currently performing endoscopy. All respondents were performing esophagogastroduodenoscopy, and 43 (87.8%) were performing colonoscopy. Relatively rare procedures for children, such as double-balloon enteroscopy (DBE) (4.1%), endoscopic retrograde cholangiopancreatography (ERCP) (2.0%), and endoscopic ultrasound (EUS) (2.0%), were only performed by pediatric gastroenterologists at very few centers, but were performed by adult endoscopists in most of the centers; of all the respondents, 83.7% (41/49) performed emergency endoscopy. In most centers, the majority of the endoscopies were performed under sedation, with midazolam (100.0%) and ketamine (67.3%) as the most frequently used sedatives. While most pediatric GI endoscopists perform common GI endoscopic procedures, rare procedures, such as DBE, ERCP, and EUS, are only performed by pediatric gastroenterologists at very few centers, and by adult GI endoscopists at most of the centers. For such rare procedures, close communication and cooperation with adult GI endoscopists are required.

Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatment

Background and study aims The increase in hepaticojejunostomies has led to an increase in benign strictures of the anastomosis. Double balloon enteroscopy-assisted ERCP (DBE-ERCP) and percutaneous transhepatic biliary drainage (PTBD) are treatment options; however, there is lack of long-term outcomes, with no consensus on management. We performed a retrospective study assessing the outcomes of patients referred for endoscopic management of hepaticojejunostomy anastomotic strictures (HJAS). Patients and methods All consecutive patients at a tertiary institution underwent endoscopic intervention for suspected HJAS between 2009 and 2021 were enrolled. Results Eighty-two subjects underwent DBE-ERCP for suspected HJAS. The technical success rate was 77 % (63/82). HJAS was confirmed in 41 patients. The clinical success rate for DBE-ERCP ± PTBD was 71 % (29/41). DBE-ERCP alone achieved clinical success in 49 % of patients (20/41). PTBD was required in 49 % (20/41). Dual therapy was required in 22 % (9/41). Those with liver transplant had less technical success compared to other surgeries (72.1 % vs 82.1 % P = 0.29), less clinical success with DBE-ERCP alone (40 % vs 62.5 % P = 0.16) and required more PTBD (56 % vs 37.5 % P = 0.25). All those with ischemic biliopathy (n = 9) required PTBD for clinical success, required more DBE-ERCP (4.4 vs 2.0, P = 0.004), more PTBD (4.7 vs 0.3, P < 0.0001), longer treatment duration (181.6 vs 99.5 days P = 0.12), and had higher rates of recurrence (55.6 % vs 30.3 % P = 0.18) compared to those with HJAS alone. Liver transplant was the leading cause of ischemic biliopathy (89 %). The overall adverse event rate was 7 %. Conclusions DBE-ERCP is an effective diagnostic and therapeutic tool in those with altered gastrointestinal anatomy and is associated with low complication rates.

TUMEURS GRELIQUES QUELLES DIVERSITES HISTOLOGIQUE ?

Primary malignant tumors of the small intestine are rare tumors. They represent 1 to 5% of all tumors of the digestive tract. The multiplicity of histological types associated with the rarity of these tumors. The small intestine is considered as a clinically silent area and this results in a delay in diagnosis and therefore a non-optimal treatment and a severe prognosis. The objective of our work is to report the epidemiological, diagnostic characteristics of patients with small bowel tumors as well as their endoscopic and histological aspects collected in the hepato-gastroenterology department of the Hassan II University Hospital of Fez. Patient and method:We retrospectively analyzed the clinical records of 8 patients with the diagnosis of small bowel malignancies admitted to our training over a period of 11 years. Results: The average age of our patients was 42 years,The sex ratio M/F was 3, the tumor was revealed by an upper GI hemorrhage in 50%(N: 4) followed by abdominal pain in 37%(N: 3) and koening syndrome in 12%(N: 1). The CT scan showed a parietal thickening in all the cases, of which 1 case showed a mass. Double balloon enteroscopy was performed in 8 patients (100%), the endoscopic aspect revealed an ulcerating process in 75% (N: 6), a tumor of sub-mucosal appearance in 12% (N: 1). An ulcerated jejunal stenosis that could not be crossed in 12% (N:1).the biopsy by enteroscopy had allowed to make the diagnosis in 100% of the cases (N: 8).the histological examination had objectified: lymphomas in 37%( N: 3), GIST in 25% cases (N: 2), adenocarcinomas in 25% cases (N: 2) and neuroendocrine tumor in 12% (N: 1). The evolution was unfavorable in all our cases with a median survival rate of 10 months. Conclusion: Small bowel tumors are rare but interesting because of their great histological diversity. The diagnosis is difficult because of the non-specific symptomatology, In our study the couple imaging -enteroscopy had allowed to establish the diagnosis in all our cases, with predominance of the anatomopathological aspect of lymphoma in 37% of the cases.

Gastrointestinal Bleeding in a Child: Is It a Meckel Diverticulum?

A 2-year-9-month-old boy with multiple episodes of melena and hematochezia with unclear cause was admitted to our hospital. Laboratory tests showed iron deficiency anemia (hemoglobin of 5 g/dL) and positive fecal occult blood test. Single-operator double-balloon enteroscopy (DBE) through the anal route was performed and revealed multiple patchy mucosal eminence consisted of ectopic gastric pit and loss of villi observed by electronic stain in the distal jejunum, approximately 2 m from the ileocecal valve. The bowel cavity was deformed like a maze in the distal jejunum. There are several mucosal bridging structures and focal stricture, making it difficult to determine the direction of the lumen. Two irregular deep ulcers were found near the stricture (A [a–f] and Video 1). Emission computer tomography Tc99m pertechnetate scan showed multiple areas of radioisotope uptake in the middle and lower abdomen. At laparotomy, a 46-cm-long cyst was noted on the mesentery aspect that protruded alongside from the distal jejunum (B [a–c]). Resection of 58 cm of the jejunum was performed including the cyst. Pathology showed a duplication cyst located on the mesenteric aspect with ectopic gastric mucosa (C). The postoperative diagnosis was a duplication cyst of the jejunum. The patient was discharged 14 days after surgery and remained symptom-free thereafter. Intestinal duplication cysts are rare congenital malformations that can appear anywhere in the gastrointestinal tract. The preoperative diagnosis of a duplication cyst is difficult and can be easily misdiagnosed as Meckel diverticulum. Duplication cysts usually locate on the mesenteric aspect as in our case, in contrast to Meckel diverticulum that localizes on the antimesenteric aspect. In our case, the deformed intestine was found approximately 2 m from the ileocecal valve, which was not common in Meckel diverticulum. To the best of our knowledge, this is the first reported tubular type of jejunal duplication cyst case with an DBE video. DBE can be a useful tool for the diagnosis of intestinal duplication in young children. Watch the Video, Supplementary Digital Content 1, https://links.lww.com/AJG/C853. (Informed consent was obtained from the patient to publish these images.)

Application of COOK® cervical ripening balloon combined with artificial rupture of membranes and oxytocin in labor induction for full-term pregnancy

Objective: The use of COOK[Formula: see text] balloon in the process of induction of labor is gradually promoted. This study was conducted to investigate the safety and efficacy of COOK[Formula: see text] double balloon in promoting the maturity of uterine neck, and whether COOK[Formula: see text] double balloon can improve the success rate of induced labor. Methods: A total of 343 pregnant women with full-term pregnancy in Shanghai Putuo Maternity &amp; Infant Health Hospital from January 1st to September 30th of 2016 were enrolled. Of all the pregnant women, 166 had labor induction, which included the use of a COOK[Formula: see text] balloon, the implementation of artificial rupture of membranes (AROM) and oxytocin intravenous (IV) drip (COOK[Formula: see text] group). The other 177 pregnant women with spontaneous rupture of membranes (SROM) and mature cervix only were administrated with oxytocin IV drip to promote regular uterus contraction (oxytocin group). Maternal adverse reactions, mode of delivery and delivery outcomes of two groups were subsequently compared between the two groups. Results: There were significant differences of maternal age ([Formula: see text] versus [Formula: see text] years, [Formula: see text]), gestational age ([Formula: see text] versus [Formula: see text] years, [Formula: see text]) and birth weight ([Formula: see text] versus [Formula: see text][Formula: see text]g, [Formula: see text]) between the COOK[Formula: see text] group and the oxytocin group. There were no significant differences in terms of gravidity, parity, mode of delivery, analgesia, 1 min and 5 min Apgar score, labor time, postpartum hemorrhage, and adverse events. Conclusion: Use of a COOK[Formula: see text] balloon may help in full-term pregnancy for women with immature cervix and to obtain the same pregnancy results as those with mature cervix, without extra occurrence of adverse events.

Endoscopic treatment of intussusception due to small intestine polyps in patients with Peutz-Jeghers Syndrome.

Background and study aims Intussusception caused by intestinal polyps in patients with Peutz-Jeghers syndrome usually requires laparotomy. Patients following successful endoscopic reduction using double-balloon endoscopy (DBE) have been reported. The aim of this study was to evaluate the feasibility of endoscopic treatment of intussusception. Patients and methods We retrospectively reviewed patients who underwent DBE for intussusception due to small intestine polyps in patients with Peutz-Jeghers syndrome from January 2004 to June 2020. Results Twenty-seven (antegrade 22, retrograde 5) DBEs were performed in 19 patients with 25 sites of intussusception identified during the study period. If the intussusception remained once the endoscope reached the site, endoscopic reduction of the intussusception was performed as needed (15 sites). Ultimately, endoscopic resections (8 sites) or ischemic polypectomies (16 sites) of the polyp causing the intussusception were completed at 24 sites. Only one site could not be treated endoscopically and was treated surgically. The final per-site and per-patient success rates of endoscopic treatment were 96 % (24/25) and 95 % (18/19) respectively. Two patients developed mild acute pancreatitis and one patient developed intussusception after the procedures, both of which were treated non-operatively. Conclusions Endoscopic treatment of intussusception is feasible to avoid laparotomy in patients with Peutz-Jeghers syndrome.

Clinical Features and Management of Small Bowel Masses Detected During Device-Assisted Enteroscopy: A Multi-Center Experience.

Small bowel mass lesions (SBMLs) are rare, span a range of different histologies and phenotypes, and our understanding of them is limited. Some lesions occur in patients with recognized polyposis syndromes and others arise sporadically. The current literature regarding SBMLs is limited to small retrospective studies, case reports, and small case series. This large multi-center study aims to understand the various clinical presentations, histologies and management options for SBMLs. After obtaining Institutional Review Board (IRB) approval, electronic records were used to identify all device-assisted enteroscopy (DAE) performed for luminal small bowel evaluation in adult patients at three US referral centers (Duke, LSU and UMass) from January 1, 2014, to October 1, 2020. We identified all patients within this cohort in whom a SBML was detected. Using a focused electronic medical record chart review, we collected patient, procedure, and lesion-related data and used descriptive statistics to explore relationships between these data and outcomes. A total of 218 patients (49 at Duke, 148 at LSU, and 21 at UMass) in this cohort had at least one SBML found on DAE. The most common presenting symptoms were iron-deficiency anemia/bleeding (73.3%) and abnormal imaging (33.6%). Thirty-five percent of patients had symptoms for more than a year prior to their diagnosis. Most patients (71.6%) underwent video capsule endoscopy (VCE) prior to DAE and 84% of these exams showed the lesion. The lesion was seen less frequently (48.9%) on computed tomography (CT) scan performed prior to DAE. The majority of lesions were found on antegrade (56%) or retrograde (29.8%) double-balloon enteroscopy (DBE). The most common lesion phenotypes were submucosal (41.3%) and pedunculated (33%) with a much smaller number being sessile (14.7%) or obstructing/invasive (11%). They were found equally as commonly in the jejunum (46.3%) and ileum (49.5%). Most lesions were 10 - 20 mm in size (47%) but 22.1% were larger than 20 mm. The most common histologies were neuroendocrine tumors (NETs, 20.6%) and hamartomas (20.6%). Primary adenocarcinoma of the small bowel was rare, constituting only 5% of lesions. The majority of polyps (78.4%) were sporadic, compared to 21.7% associated with a polyposis or hereditary cancer syndrome, most commonly Peutz-Jeghers syndrome (18.3%). After DAE, 37.6% were advised to undergo surgical resection and 48% were advised to undergo endoscopic surveillance or no further management because of benign histology or successful endoscopic resection. In this multi-center retrospective study we found that SBMLs are more likely to be sporadic than syndromic, medium in size and either pedunculated or submucosal. NETs and hamartomas predominated and symptoms, most commonly anemia, can be present for more than a year prior to diagnosis. Close to one half of lesions required either no further intervention or only endoscopic surveillance.

Comparison of Outcomes of Different Balloon Sets in Patients undergoing Percutaneous Transvenous Mitral Commissurotomy – Bigger and Differ is Better!

Background: Although the Inoue balloon technique is said to be more popular worldwide for PTMC in those who have severe MS, the Bonhoeffer multi-track (double balloon technique) system is used in our center. On the other hand, it is unknown which balloon set size will produce the best results. The current study's objective is to assess the efficacy of different balloon sets utilized in symptomatic patients with moderate to severe mitral stenosis (MS) following percutaneous transvenous mitral commissurotomy (PTMC).&#x0D; Methodology: There were 203 consecutive patients. In 154 patients, a 14x14mm balloon set was used, and in the other 49 patients, a 14x16mm balloon set. PTMC was deemed successful when MVA 1.5 cm2 was attained with just minimal MR. Patients with valve areas less than 1.5 cm2 and more severe MR are regarded as failed.&#x0D; Results: With a 14x16mm balloon set, post-procedure examination revealed noticeably better accomplishment in the valve area (2.960.84 cm2 versus 3.260.95 cm2; P=0.024). With a 14x16mm balloon set, a tendency towards a lower post-procedure mean pressure gradient across the mitral valve was seen (6.052.19 mmHg versus 5.472.24 mmHg; P=0.107). There was no discernible change in post-procedure MR, tamponade, or procedural failure. However, there was no significant statistical difference in the treatment efficacy between the groups (87.7% with a 14x16mm balloon set versus 77.9% with a 14x14mm balloon set; P=0.153).&#x0D; Conclusion: A 14x16 mm balloon set might be a better and safer option, particularly for taller and older patients with larger annuli.

Treatment and follow-up of late onset intra hepatic bile duct stones in congenital biliary dilatation.

The postoperative course after surgery for congenital biliary dilatation (CBD) has some complications. Intrahepatic bile duct (IHBD) stones were known as a late complication. We report on the treatment and long-term follow-up of postoperative IHBD stones in our department. Patients who underwent CBD surgery at age 15years or younger in our department were identified. Those followed up for 5years or more were enrolled. Annual blood chemistry tests and abdominal ultrasonography were performed. Each patient's surgical procedure, IHBD stone diagnosis, treatments, and outcomes were retrospectively assessed. Fifty-one patients were analyzed. The median age at the last visit was 24years (range 7-45years), and the median age at CBD surgery was 3years. Eight patients (16%) developed late-onset IHBD stones. The median age at onset was 25years, and the median duration after surgery was 20years. The initial treatment was double-balloon enteroscopy (DBE) in 4 cases, which resulted in stone removal in 3 of the 4 patients (75%). Since CBD may cause late-onset IHBD stones, continuous follow-up is required even in adulthood. In this study, DBE was effective and minimally invasive, and it is recommended as the initial treatment.

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography for patients with Roux-en-Y gastric bypass anatomy: technical overview.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass anatomy is a well-documented challenge. Traditionally, this problem has been overcome with adjunctive techniques, such as device-assisted ERCP, including double-balloon or single-balloon enteroscopy and laparoscopy-assisted transgastric ERCP. Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a novel technique that enables access to the ampulla using a duodenoscope without surgical intervention and has shown high clinical and technical success rates in recent studies. However, this approach is technically demanding, necessitating a thorough understanding of the gastrointestinal anatomy as well as high operator experience. In this review, we provide a technical overview of EDGE in parallel with our personal experience at our center and propose a simple algorithm to select patients for its appropriate application. In conjunction, the outcomes of EDGE compared with those of device-assisted and laparoscopy-assisted transgastric ERCP will be discussed.