Standard Gastroscope Research Articles

Choledocholithotripsy using peroral direct cholangioscopy through a standard gastroscope for a giant common bile duct stone: a case report.

Choledocholithotripsy using peroral direct cholangioscopy through a standard gastroscope for a giant common bile duct stone: a case report.

Evaluation of a single-use gastroscope in patients presenting with suspected upper gastrointestinal hemorrhage: a pilot feasibility study (One-Scope I).

BACKGROUND : Outbreaks of multidrug-resistant bacteria due to contaminated duodenoscopes and infection risks during the COVID-19 pandemic have driven the development of single-use endoscopes. The first single-use gastroscope is now available in Europe. Besides waste disposal and cost issues, the infection risk and performance remain unclear. We aimed to evaluate a single-use gastroscope in patients with signs of upper gastrointestinal bleeding. METHODS : 20 consecutive patients presenting with clinical signs of upper gastrointestinal bleeding between October and November 2022 were included in this case series. The primary aim was technical success, defined as access to the descending duodenum and adequate assessment of the upper gastrointestinal tract for the presence of a bleeding site. RESULTS : The primary aim was achieved in 19/20 patients (95 %). The bleeding site was identified in 18 patients. A therapeutic intervention was performed in six patients (two cap-mounted clips, one standard hemostatic clip, two variceal band ligations, one hemostatic powder, two adrenaline injections); technical and clinical success were achieved in all six patients. Two crossovers to a standard gastroscope occurred. CONCLUSIONS : Use of single-use gastroscopes may be feasible for patients presenting for urgent endoscopic evaluation and treatment of upper gastrointestinal bleeding.

Modified technique of peroral endoscopic myotomy using transnasal ultra-slim gastroscope in a child with achalasia cardia.

Video 1Demonstration of the modified technique of peroral endoscopic myotomy in a small child with achalasia cardia wherein a standard gastroscope could not be used because of anatomical constraints.

Design, fabrication, and preclinical testing of a miniaturized, multispectral, chip-on-tip, imaging probe for intraluminal fluorescence imaging of the gastrointestinal tract.

Gastrointestinal cancers continue to account for a disproportionately large percentage of annual cancer deaths in the US. Advancements in miniature imaging technology combined with a need for precise and thorough tumor detection in gastrointestinal cancer screenings fuel the demand for new, small-scale, and low-cost methods of localization and margin identification with improved accuracy. Here, we report the development of a miniaturized, chip-on-tip, multispectral, fluorescence imaging probe designed to port through a gastroscope working channel with the aim of detecting cancerous lesions in point-of-care endoscopy of the gastrointestinal lumen. Preclinical testing has confirmed fluorescence sensitivity and supports that this miniature probe can locate structures of interest via detection of fluorescence emission from exogenous contrast agents. This work demonstrates the design and preliminary performance evaluation of a miniaturized, single-use, chip-on-tip fluorescence imaging system, capable of detecting multiple fluorochromes, and devised for deployment via the accessory channel of a standard gastroscope.

OGBN P09 Sharing the experience of the use of Spyglass DS - guided electrohydraulic lithotripsy (SG-EHL) in the treatment of large gallstone causing Bouveret syndrome

Abstract Background Less than 1% of intestinal obstruction is accounted for by gallstone ileus. Gallstone ileus is a mechanical intestinal obstruction resulting from gallstone impaction within the gastrointestinal tract. Under 3% of gallstone ileus are caused by gallstone impaction in the duodenum or pylorus, which can give rise to a gastric outlet obstruction, described by Bouveret in 1896. Surgical intervention involves the removal of the stone by either a gastrotomy or duodenotomy, which is associated with significant morbidity. Advancement in endoscopic techniques, allows for more complex procedures, therefore, reducing the need for a surgical intervention and its accompanying morbidity. This abstract presents a rare case of a large gallstone (22mm×34mm) partially impacted in the duodenum of a 92-year-old female, which was treated with the Spyglass DS-guided electrohydraulic lithotripsy (DS-EHL). Methods A 92-year-old female with a previous history of gallstone ileus was treated by surgical intervention. The patient continued to complain of abdominal discomfort and occasional vomiting. A CT scan revealed a fistulous communication to the duodenal bulb, containing a large gall stone (22mm x34 mm). After consultation with the patient, an initial assessment with the use of standard endoscopy under general anaesthesia confirmed the visualisation of a portion of the gallstone in the duodenum, hanging through a well-established cholecysto-dudenal fistula. SPyglass DS - guided lithotripsy (SG-EHL) was used in the treatment of the large gallstone. Results Electrohydraulic lithotripsy (EHL) was attempted through the standard gastroscope, but we were unable to secure a safe position to target the stone. Therefore, a side view duodenoscope was used along with the SpyGlass DS to obtain good visualisation and stable access to target the stone with the EHL. The Spyglass guided electrohydraulic lithotripsy (SG-EHL) was used to fragment the stone. Despite consuming four EHL wires and using higher settings, we only managed to break the shell of the stone, reducing its size by approximately 3mm all around. The laser was not available at the time; therefore, the procedure was concluded. The patient had an uneventful recovery and was discharged home. No further symptoms were recorded by patient on follow up 5 months later. Conclusions Endoscopic management of an impacted gallstone causing gastric outlet obstruction is found to be safe and carries less morbidity than the traditional surgical approach. Therefore, it should be considered for being the procedure of choice to treat patients with Bouveret syndrome. Laser lithotripsy should be available on standby for cases that involve stones that are harder to break.

Metal stenting for caustic esophageal injury with bronchoesophageal fistula.

A 68-year-old woman presented after intentional ingestion of a pH 11 caustic solution (sodium hypochlorite and sodium hydroxide). Urgent gastroscopy showed severe distal esophageal stricturing with Zargar IIA injury [1] that could not be traversed with a standard gastroscope ([Fig. 1]). A computed tomography (CT) scan did not show evidence of esophageal perforation.

S2279 Bisphosphonate-Induced Esophageal Stricture: A Situation of Unusual Severity

Introduction: Pill-induced esophageal stricture is a rare but well-documented condition associated with various causative agents. Potassium chloride and quinine are the most common causes and are more likely to produce stricture than other agents (such as Bisphosphonates and Tetracyclines). Predisposing factors include older age, male gender, sustained release medication formulation and prior esophageal structural abnormality. Case Description/Methods: An 80-year-old female with history of osteoporosis taking Alendronate presented with 3 weeks history of progressive solid and liquid dysphagia and endorsed 20 lbs weight loss. The patient reported inability to keep any food down for 3 days prior to presentation and had begun requiring the use of oral suction at bedside due to inability to swallow her own saliva. She appeared clinically stable on exam. He laboratory study showed profound electrolytes abnormality. Esophagogastroduodenoscopy (EGD) showed circumferential mid esophageal ulceration that progressed to a narrow stricture that could not be traversed even with a stricture scope (5.9 mm diameter). Alendronate was discontinued and the patient was treated with liquid formulation omeprazole twice daily. Her diet was slowly advanced from clear liquid to mince. Her hospitalization was prolonged because she developed refeeding syndrome after reinitiating her diet. She was discharged after her electrolytes normalized. Two months after her initial presentation, her dysphagia had completely resolved. A repeat EGD revealed a tapered benign-appearing stricture in the distal esophagus, which was traversed without resistance with a standard gastroscope. Balloon dilation was performed to a diameter of 13 mm without creation of a mucosal rent (Figure). Discussion: This case highlights the severity and potential rapid progression of pill-induced esophageal damage caused by Bisphosphonate therapy. Esophagitis or esophageal mucosa ulceration are common. The mucosal damage is caused by direct contact of the drug with the esophageal mucosa. Reports of stricture formation from Alendronate use are rare. Stricture formation may be caused by chronic inflammation from long-term use. Clinicians should have a low index suspicion in a high-risk patient presenting with classic symptoms of dysphagia. In addition, patients should receive counseling on proper pill ingestion technique to prevent potential damage.Figure 1.: See attachment.

S2834 Gastro-Cutaneous Fistula Closure Using Novel Tack Suture System

Introduction: Gastro-cutaneous fistulas that develop at prior gastrostomy sites are usually successfully closed by the use of endoscopic suturing or the over-the-scope clips (OTSC). However, the endoscopic suturing device and the OTSC device measure approximately 16 mm and 14 mm, respectively, resulting in them not able to pass through narrow esophageal strictures. The endoscopic tack suture system is a novel technique that includes a through the scope suture-based device that was recently designed for the closure of large and irregular defects in the gastrointestinal tract. Even more advantageous is the ability for the tack suture system to be passed through the working channel of a standard gastroscope. Case Description/Methods: A 61-year-old male with past medical history of head and neck cancer presented with persistent gastro-cutaneous fistula drainage following gastrostomy tube removal. On endoscopic evaluation, a benign appearing esophageal stenosis in the upper esophagus required downgrading the scope from a therapeutic scope to a gastroscope. A gastric fistula was noted in the gastric body, but the exact site of the fistula was unclear as there were 2 defects side by side (Figure A). Both defects were treated with APC and the entire area was closed with a single tack suture system with 4 tacks drilled in healthy tissue surrounding the defect (Figure B). Following tack placement, a single suture was used to cinch down and close the defect (Figure C). On follow up the patient had no further fistula drainage. Discussion: Our case presents the use of a novel tack suturing system to close a persistent gastro-cutaneous fistula in the setting of an esophageal stricture. Commonly used defect closing devices such as the OTSC and endoscopic suturing device can be too large to navigate severe esophageal strictures. The endoscopic tack suture system has the ability to aid in the closure of fistulas, perforations, anastomotic leaks and submucosal dissections. While preclinical data reported no adverse events, possibilities include wound dehiscence, delayed perforation, and bleeding if the tacking system is improperly placed. Mahmoud et al. conducted the first and only multi-center study describing the feasibility and safety of the endoscopic tack suturing device in the clinical setting and found successful closure of defects in approximately 90% of cases. This novel tack suture system is a useful tool in cases that are confined to the parameters of a standard gastroscope.Figure 1.: A: Gastric fistula. B: Fistula following APC with 4 tacks drilled in healthy tissue surrounding the defect. C. Cinching of single suture with closure of gastric fistula.

S3584 Endoscopic Evaluation in a Patient with Post-Bulbar Duodenal Ulcer and Stricture

Introduction: Gastric outlet obstruction (GOO) is the least frequent complication of peptic ulcer disease (PUD) in the US after bleeding and perforation. Ulcers located in the pyloric region and duodenum are most causative of GOO. PUD has decreased since the advent of PPI and eradication of Helicobacter pylori. Although most patients have typical ulcer symptoms prior to the development of complications, asymptomatic ulcers necessitate the need for endoscopic evaluation. Early suspicion and endoscopic evaluation can assist with the prompt management of this complication. Case Description/Methods: 71 year-old white male evaluated for a 5 week history of abdominal pain, nausea, post-prandial vomiting, 35 pound weight loss. Denied the use of non-steroidal anti-inflammatory drugs. Medical history is significant for type 2 diabetes mellitus current tobacco use and hypertension. No prior history of PUD. Physical exam was notable for epigastric tenderness and muscle wasting. Contrasted Abdominopelvic CT showed questionable diverticulum in the second portion of the duodenum and no evidence of pancreatic mass. Endoscopic evaluation showed severe erosive esophagitis, a pinhole stricture in the duodenal bulb with the appearance of a benign peptic stricture. The duodenal stricture was unable to be traversed with a standard gastroscope. With fluoroscopic guidance, the stricture was dilated progressively with a balloon to 6mm, 8mm and 10mm. Biopsies were obtained and the stricture was then traversed with a pediatric scope. After endoscopic evaluation, it was determined that the duodenal stricture was not amenable to durable endoscopic intervention. Pathology, negative for Helicobacter pylori and malignancy. Patient subsequently underwent an exploratory laparotomy and gastrojejunostomy with gastro-jejunal tube placement. Patient continued to improve and was discharged to continue tube feeding at home, outpatient follow up with gastroenterology and surgery. Discussion: Endoscopy plays a critical role in the evaluation and management of patients with symptoms concerning for post bulbar duodenal ulcer, stricture and gastric outlet obstruction. Silent ulcers and complications are more prevalent in older patients. Early detection, evaluation and treatment of GOO could improve disease related morbidity and mortality. Risk modification which consists of tobacco cessation, treating post bulbar ulcers, duodenal ulcers and Helicobacter pylori infection could improve the GOO trends.Figure 1.: Severe Duodenal Stenosis.

Applying basic principles of surgery may pave the way for more effective endoscopic bariatric techniques.

Background and study aims In the last decade, gastroenterologists have been attempting to use endoscopy to reproduce the great success of traditional surgical suture techniques. Despite recent advances, we still lack a reliable method that results in a permanent suture with minimal incidence of suture failure. This was an experimental study in pigs with an innovative technique that applied basic surgical concepts to endoscopy to evaluate the effectiveness of a novel suture technique. Methods The procedures were performed on six live pigs under general anesthesia. Endoscopic mucosal resection (EMR) first was performed in the stomach, exposing the submucosal or muscularis propria layers. A novel device, a transparent chamber cap (DASE), was developed to aspirate the gastric wall, allowing the sutures to reach deep layers. The aspiration was performed with a standard gastroscope to which the novel cap was distally attached. Three sutures aligned were defined as a plication. Each pig received two or three plications and was placed on a liquid diet for 14 days after the procedure. The pigs were sacrificed at 4 and 8 weeks and the sutures were reviewed. Results The technique was feasible in all animals. Of 16 plications, only one failed. One perforation occurred after EMR. There were no other complications or adverse events. Permanent fusion of the gastric wall was confirmed by histology in all cases. Conclusions This study showed that basic principles of surgery can be applied endoscopically to ensure a permanent suture with reduced chances of failure. These findings can help to pave the way for more effective bariatric endoscopic techniques.

The over-the-scope grasper (OTSG).

BACKGROUND : Endoscopic removal of foreign bodies, coagulated blood, or necrotic debris is sometimes challenging and time-consuming, partly because of inadequate endoscopic instruments. Therefore, new devices are needed to overcome the current limitations. METHODS : The over-the-scope grasper (OTSG) is a new grasping tool that can be attached to any standard gastroscope. It has been developed for endoscopic removal of larger particles. We present retrospective data on five patients who were treated using the device for various indications, including necrosectomy, bolus impaction, and removal of blood clots. RESULTS : In two patients, the OTSG was used through a lumen-apposing metal stent for direct endoscopic necrosectomy after severe pancreatitis. The other patients had a massive blood clot in the esophagus after endoscopic submucosal dissection, or aphagia due to large meat chunks clogging the esophagus. The OTSG was used with technical success in all of the patients and without any procedure-associated complications. CONCLUSION : The OTSG appears to be a useful device for endoscopic removal of larger particles, blood clots, or necrotic debris. Preliminary experience shows that the device is effective and easy to use.

Retrievable puncture anchor traction method for endoscopic ultrasound-guided gastroenterostomy: A porcine study.

BACKGROUNDEndoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an alternative method for the surgical treatment of gastric outlet obstruction, but it is regarded as a challenging technique for endoscopists as the bowel is highly mobile and can tent away. Thus, the technique requires superb skill. In order to improve EUS-GE, we have developed a retrievable puncture anchor traction (RPAT) device for EUS-GE to address the issue of bowel tenting.AIMTo evaluate the feasibility of RPAT-assisted EUS-GE using an animal model.METHODSSix Bama mini pigs each weighing between 15 and 20 kg underwent the RPAT-assisted EUS-GE procedure. Care was taken to ensure that the animals experienced minimal pain and discomfort. Two days prior to the procedure the animals were limited to a liquid diet. No oral intake was allowed on the day before the procedure. A fully covered metal stent was placed between the stomach and the intestine using the RPAT-assisted EUS-GE method. Infection in the animals was determined. Four weeks after the procedure, a standard gastroscope was inserted into the pig’s intestine through a previously created fistula in order to check the status of the stents under anesthesia. The pig was euthanized after examination.RESULTSThe RPAT-assisted EUS-GE method allowed placement of the stents with no complications in all six animals. All the pigs tolerated a regular diet within hours of the procedure. The animals were monitored for four weeks after the RPAT-assisted EUS-GE, during which time all of the animals exhibited normal eating behavior and no signs of infection were observed. Endoscopic imaging performed four weeks after the RPAT-assisted EUS-GE showed that the stents remained patent and stable in all the animals. No tissue overgrowth or ingrowth was observed in any case. Each animal had a mature fistula, and the stents were removed without significant bleeding. Autopsies of all six pigs revealed complete adhesion between the intestine and the stomach wall.CONCLUSIONThe RPAT method helps reduce mobility of the bowel. Therefore, the RPAT-assisted EUS-GE method is a minimally invasive treatment modality.

1948 Dominant Claw Control: Role of OTSC Clip as Salvage Hemostasis Therapy

INTRODUCTION: Upper Gastrointestinal Hemorrhage (UGIH) remains a common problem in modern day endoscopy. Etiologies of UGIH include variceal, nonvariceal, neoplastic, vascular malformation, and iatrogenic among others. Endoscopic hemostasis is typically achieved by through the scope (TTS) clips, epinephrine injections, ablation techniques, coils and glues and self-expandable stents. Despite having multiple tools for bleeding control, rebleeding risk remains high among single vessel ulcers and larger lesions. Here we present a case where traditional hemostasis methods failed, and an over-the-scope clip (OTSC) was used as salvage/rescue hemostasis therapy. CASE DESCRIPTION/METHODS: 45-year-old asian Male with a history of cirrhosis secondary to alcohol presented with jaundice and melena with a hemoglobin of 5.9 gm/dl. EGD showed severe duodenitis. A side viewing duodenoscope showed a large, cratered duodenal bulb ulcer with a visible vessel. Epinephrine was injected and 5 hemoclips were placed. Despite this, there was still active oozing of blood. All the hemoclips were removed with snare. OTSC System was loaded onto a standard gastroscope and advanced to the lesion. Target tissue was sucked into the cap and OTSC® clip was released by turning the hand wheel. The clip closed itself and firmly anchored the tissue resulting in complete hemostasis. Proton pump inhibitors were continued and follow up endoscopy at 1 month showed healed ulcer site with clip in place. DISCUSSION: TTS clip can sometimes be not enough for UGI bleeding treatment especially during active bleeding, use in ulcers with a fibrotic base, or when the bleeding lesion is in a difficult-to-access anatomic location (e.g., gastric lesser curve or cardia, posterior duodenal wall). While OTSC have been well established in leaks, perforations, and fistulas, their role in UGIH is evolving. Several randomized trials comparing OTSC with conventional endoscopic hemostasis therapies are ongoing and results are awaiting, however our case reiterates that OTSC platform should be available and be part of endoscopic hemostasis armamentarium.

2123 The Vanishing Gastrojejunostomy: A Case Report

INTRODUCTION: Gastrojejunal anastomotic strictures or stenoses are well recognized complications from Roux-en-Y gastric bypass surgery. Endoscopy remains an effective and safe means to diagnose these complications, which can occur as early as one month after surgery. The two main treatment modalities include endoscopy, either with balloon or bouginage dilators, or open versus laparoscopic surgery. Despite direct visualization, endoscopy could easily miss a severely stenotic anastomosis, as illustrated in the case of our a patient with gastrojejunal stenosis status post gastric bypass surgery. CASE DESCRIPTION/METHODS: 43-year-old man with past medical history of morbid obesity s/p laparoscopic Roux-en-Y was admitted for acute nausea and vomiting. The Rouz-en-Y was performed one month ago and he initially was doing well with expected weight loss. Over the last 10 days, he had persistent nausea, vomiting, and anorexia. Labs were unremarkable at presentation. Initially, the surgical team was consulted and performed an EGD which revealed severe stenosis at the gastrojejunal anastomosis site; a balloon dilator was not able to be passed through the stenosis. The following day, gastroenterology team performed a repeat EGD, which revealed a large hematoma in the gastric body and epinephrine was injected. Initially, the gastrojejunal anastomosis was not clearly visualized despite partial dislodgement of the clot. However, under fluoroscopy, a closed, possible anastomotic site was identified and a wire was advanced through with contrast injection for verification that the wire was in fact in the bowel lumen. The anastomosis was then dilated and an AXIOS stent was placed across the anastomosis. The patient recovered well post-operatively, tolerating PO intake and was discharged. At follow up, the stent was successfully removed via rat-toothed forceps without complication. The anastomotic site was friable, but was wide open and a standard gastroscope was easily advanced through without complications. DISCUSSION: Gastrojejunal anastomotic stenosis is a known complication of Roux-en-Y gastric bypass surgeries. Its etiology is not completely understood and likely multifactorial but treatment options include endoscopic dilation and surgery. For our patient, fluoroscopic guidance with wire placement through the anastomotic site was required for successful deployment of the AXIOS stent. Therefore, endoscopic diagnosis should be considered as a safe modality for diagnosis and intervention for these complications.

Over-the-scope clip for acute esophageal variceal bleeding.

Over-the-scope clip (OTSC) has been reported to control non-variceal bleeding; however, the use of this device for acute variceal hemorrhage (AVH) is very limited. We report our experience regarding the use of OTSC in patients with AVH in terms of technical success and safety. A retrospective clinical experience case series study was conducted from October 2017 to June 2019 at two tertiary care centers. Adult patients with AVH as a result of small varices managed with OTSC after endoscopic band ligation (EBL) failure were enrolled. Standard gastroscope and OTSC 'type a' with a cap of 11mm in diameter were used in all procedures. Total of five patients with chronic liver disease (Child-Pugh score ≤8) and portal hypertension (hepatic venous pressure gradient, mean 14.4±1.3mmHg) were included. Four of them presented collapse of the bleeding varix, and one had wall disruption associated with fibrosis secondary to prior banding. We were able to stop AVH in all patients without clip-related adverse events during a 30-day follow-up period. Two patients developed solid food dysphagia after 3months of clip deployment that resolved after removal using a bipolar cutting device. Twin grasper or anchor were not used to aid or facilitate the approximation of opposite edges in any patient. No additional local therapies or new endoscopic session for variceal eradication were required. This case series shows preliminary success controlling AVH with OTSC after EBL failure in patients with small varices. Esophageal dysphagia may appear as a complication during follow up but it can be resolved by clip removal.

Direct peroral cholangioscopy in the management of difficult biliary stones: a new tool to confirm common bile duct clearance. Results of a preliminary study

Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence. We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed. Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 +/- 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence or suspicion of recurrent choledocholithiasis. Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.

Direct Peroral Cholangioscopy in the Management of Difficult Biliary Stones: a New Tool to Confirm Common Bile Duct Clearance. Results of a Preliminary Study

Background & Aims: Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence.Methods: We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed.Results: Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 ± 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence orsuspicion of recurrent choledocholithiasis.Conclusions: Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.

Improved endoscopic resection of large flat lesions and early cancers using an external additional working channel (AWC): a case series

Background En-bloc resection of large, flat lesions or early stages of cancer is challenging. No bimanual tasks are possible using standard endoscopes. Dual-channel endoscopes are not available everywhere and have a small distance between the channels. Patients and methods A new external additional working channel (AWC) (Ovesco, Tuebingen, Germany) was designed and developed potentially enabling bimanual tasks. Fixed to the tip of a standard gastroscope or pediatric colonoscope, a second endoscopic tool can be inserted through the AWC and used for tissue retraction during endoscopic resection. Results In the upper and lower gastrointestinal tract, endoscopic mucosal resection (EMR) with a modified grasp-and-snare technique and endoscopic submucosal dissection (ESD) were performed successfully using the AWC in eight patients. Complications were acute arterial bleeding post-EMR in two cases treated by endoscopic clipping. Conclusions We conclude that a newly developed external additional working channel (AWC) enables endoscopic resection of large lesions in the upper and lower gastrointestinal tract. Potential benefits are its suitability for EMR and ESD, no need for a dual-channel endoscope and an adjustable distance of working channels.

Hiding in Plain Sight: A Large Ampullary Adenoma Only Seen on Side-View Evaluation

Familial adenomatous polyposis (FAP) is an autosomal dominant genetic disorder characterized by the formation of innumerable adenomatous polyps. Patients with FAP have a high risk of malignancy due to progression of these adenomas to adenocarcinoma. In addition to the high risk for developing colorectal cancer in their lifetime, they are at increased risk for developing adenomatous lesions in extracolonic sites. The ampulla of Vater is one such location, and thus satisfactory visualization of the ampulla is important. However, the location and orientation of the ampulla makes visualization difficult using a standard gastroscope. Here we discuss a case of a patient with FAP found to have a seemingly normal ampulla on initial evaluation using a forward-viewing gastroscope, but on subsequent evaluation using a side-viewing duodenoscope, a 2x2cm ampullary adenoma with low grade dyplasia was visualized and resected. A 53-year-old Caucasian female with history of FAP status-post total proctocolectomy in the mid-1990s presented for surveillance esophagogastroduodenoscopy (EGD) and colonoscopy. She reported having undergone regular surveillance colonoscopies to evaluate for polyps, but her most last endoscopic evaluation was in 2001. During her EGD in 2018, she was first noted to have a seemingly normal duodenum on standard view (Figure 1). It was felt prudent to follow up with a side-viewing duodenoscope for ampullary evaluation. Upon insertion of the duodenoscope, a large 2x2cm ampullary polypoid mass was clearly seen (Figure 2). Biopsies demonstrated tubulovillous adenoma with low-grade dysplasia. Follow up endoscopic ultrasonography showed no evidence of invasion into the bile duct, pancreatic duct, or surrounding mucosa, and ampullectomy was performed. Pathology confirmed tubulovillous adenoma with low grade dysplasia. The patient had no complications and has continued with surveillance endoscopic follow-up (Figure 3). Case Highlights This case highlights the importance of using a side-viewing duodenoscope for complete examination of the duodenum, especially in patients with FAP or other conditions that predispose patients to ampullary/peri-ampullary disease. The prudent gastroenterologist must not only be properly trained to pass a side-viewing duodenoscope, but also have a heightened awareness of the limitations of the standard EGD examination. Even a rather large ampullary lesion may be missed in forward view that can be easily seen on side view.1872_A Figure 1. Normal appearing duodenum on standard forward view1872_B Figure 2. 2x2cm ampullary polypoid mass seen with side-view duodenoscope1872_C Figure 3. Ampulla on follow-up evaluation after ampullectomy

1036 COILS + CYANOACRYLATE VS. COILS ALONE IN THE ENDOSCOPIC ULTRASOUND-GUIDED MANAGEMENT OF GASTRIC VARICES [GOV II AND IGV I]: A RANDOMIZED, CONTROLLED THERAPEUTIC TRIAL.

Bleeding from gastric varices (GV) is associated with high mortality. Injection of cyanoacrylate (CYA) using standard gastroscopes (SG) presents higher hemostasis and lower re-bleeding rates compared to band ligation or sclerotherapy. Nevertheless, CYA-SG is associated with some adverse events. EUS-guided coils alone technique presents less adverse events, but it shows lower obliteration rate compared with EUS-guided CYA alone, with a significantly higher health care cost. To date, there is no data regarding comparison between EUS-guided coils+CYA vs. EUS-guided coils alone. to compare efficacy and safety of coils+CYA vs. coils alone in the EUS-guided management of GOV II and IGV I. Single-center, randomized, controlled trial (March-2016 - June-2017). Study protocol was approved by Institutional Review Board. Written informed consent was obtained. Selection criteria: 18-80 yo, hepatic cirrhosis with endoscopic evidence of GOV II or IGV I (Sarin classification), >50000 platelets/mL, INR≤2, not into Hepatorenal Syndrome. After randomization, two groups were formed. EUS procedure was performed by a 1° endoscopist, blind to patients’ history. EUS follow-up was performed 3 months later by a 2° endoscopist, blind to 1° EUS. Efficacy definition: EUS-Doppler evidenced GV obliteration, immediate GV disappearance, and later reappearance. Safety definition: complications and re-bleeding rate in a 30 days-follow up. Sample size considered 5% α-error, β-error 20%, and success rate for complete obliteration after 1° EUS-guided coils vs. EUS-CYA procedure (82% & 53%) described by Romero-Castro et. al. Differences between groups were established through respective hypothesis testing; p<0.01 was considered to be statistically significant. Endpoints were estimated through relative risk (RR). Analyses were performed using R v3.4.2. 59 patients were successfully included: 30 to EUS-guided coils+CYA, 29 to EUS-guided coils alone group. There were no statistical differences in baseline characteristics between groups (table 1), although a higher number of coils were necessary to manage bleeding in coils alone group (p<0.01). Compared to coils alone, coils+CYA technique exposes >6 times immediate GV disappearance (RR 6.3, 95% CI 2.5 – 15.8; p<0.01), with 10% more cases of complete obliteration, 10% less re-bleeding, preventing 14% GV reappearance and saving 14% re-interventions. There were no difference regarding adverse events in both groups (table 2). Due of a significant capability for disappearing GV, higher obliteration rate, lower re-bleeding, and GV reappearance prophylaxis; compared with EUS-guided coils alone, EUS-guided coils+CYA represent an effective technique in the management of GOV II and IGV I. Meanwhile, EUS-guided coils+CYA results to be as safe as EUS-guided coils alone.Tabled 1Table 1. Baseline characteristics.EUS-guidedCoils + CYA(n = 30)EUS-guidedCoils alone(n = 29)p-valueAge (years), mean ± SD61.77 ± 7.861.59 ± 12.50.947aGender (female), n (%)14 (46.7)10 (34.5)0.492bCirrhosis etiology, n (%)Alcohol7 (23.3)9 (31.0)0.710bNASH23 (76.6)20 (69.0)0.710bCirrhosis severityChild-Pugh Score, median (range min-max)6 (5 - 9)6 (5 - 11)0.362dChild-Pugh Score, n (%)A, n (%)28 (93.3)25 (86.2)0.508bB, n (%)2 (6.6)3 (10.3)C, n (%)01 (3.4)MELD Score, median (range)9 (6 - 13)9 (6 - 30)0.951dIndication1st Prophylaxis, n (%)3 (10.0)4 (13.8)0.707c2nd Prophylaxis, n (%)27 (90.0)25 (86.2)Active bleeding1/27 (3.7)4/25 (16.0)0.183ca. Student’s t-test; b. Chi-squared test; c. Fisher test; d. U-Mann Whitney test. Open table in a new tab Tabled 1Table 2. Varices characteristics, therapeutic approach, immediate and mediate outcomes.EUS-guidedCoils + CYA(n = 30)EUS-guidedCoils alone(n = 29)p-valueVarices initial evaluation and therapeutic approachType, n (%)GOV II19 (63.3)12 (41.4)0.153bIGV I11 (36.6)17 (58.6)Diameter (mm), n (%)21 (10 -32)25 (10 – 38)0.329dNo. of placed coils, median (range)2 (1 – 3)3 (1 – 7)0.009dPlaced coil size, n (%)10 mm15/30 (50.0)19/29 (65.5)0.412c12 mm12/30 (40.0)13/29 (44.8)0.062c14 mm11/30 (36.6)12/29 (41.4)0.153c16 mm12/30 (40.0)13/29 (44.8)0.742cCYA volume (ml), median (range)1.80 (1.20 – 2.40)n/an/aImmediate therapeutic evaluationTechnical success, n (%)30 (100.0)29 (100.0)n/aComplete obliteration, n (%)30 (100.0)26 (89.7)0.112cVarices disappearance, n (%)26 (86.6)4 (13.8)<0.001bAdverse events, n (%)00n/aFollow-up evaluationRe-bleeding, n (%)2/30 (6.6)5/29 (17.2)0.454cVarices Reappearance, n (%)3/26 (11.5)1/4 (25.0)0.173cRe-intervention, n (%)4/30 (13.3)8/29 (27.6)0.300bType of re-intervention, n (%)Ligation0/42/8 (25.0)Coils1/4 (25.0)1/8 (12.5)Coils + CYA3/4 (75.0)5/8 (62.5)Adverse events, n (%)2/30 (6.7)1/29 (3.4)1.000cType of adverse event, n (%)Pain1/2 (50.0)1/1 (100.0)Fever1/2 (50.0)0a. Student’s t-test; b. Chi-squared test; c. Fisher test; d. U-Mann Whitney test. Open table in a new tab