VideoGIE
Technical aspects of endoscopic sleeve gastroplasty
Of the currently available endoscopic bariatric options in the United States, endoscopic sleeve gastroplasty (ESG) appears to be the most effective and durable. However, it is highly operator dependent. In ESG, the volume of the stomach is reduced by approximately 70% through the creation of a small-diameter sleeve along the lesser curvature of the stomach by use of an endoscopic suturing device (OverStitch, Apollo Endosurgery, Austin, Tex). We present a case that demonstrates important technical aspects of the ESG procedure.Transoral incisionless endoscopic fundoplication guided by impedance planimetry to treat severe GERD symptoms after per-oral endoscopic myotomy
A 61-year-old man with a history of type II achalasia and an Eckardt score of 6 underwent per-oral endoscopic myotomy (POEM). He presented 4 months after the procedure with GERD (score of 36 on GERD questionnaire) and an Eckardt score of 0. Upper endoscopy revealed LA grade C esophagitis, and a ph-Impedance study demonstrated a DeMeester score of 123.8. Transoral incisionless endoscopic fundoplication was then performed (Video 1). Preprocedure impedance planimetry was performed to obtain baseline measurements.Novel hybrid technique for closure of refractory gastrocutaneous fistula: endoscopically guided percutaneous suturing
A 40-year-old woman had a history of epilepsy and global developmental delay after placement of a percutaneous endoscopic gastrostomy (PEG) tube 25 years earlier. She had an 18F gastrostomy tube exchanged every 2 months. During the past year, the stoma had increased in size progressively, and the patient presented with PEG site leakage. An initial attempt at gastrocutaneous fistula (GCF) closure with both an over-the-scope clip and endoscopic suturing was not possible because of a narrow mouth aperture.Two-stage endoscopic approach for the management of a large symptomatic epiphrenic diverticulum in the setting of achalasia
A 60-year-old woman presented with achalasia (subtype I) with a large epiphrenic diverticulum as shown by EGD. The patient was not agreeable to surgical therapy; hence, a 2-stage endoscopic approach was developed (Fig. 1; Video 1, available online at www.giejournal.org ). First, a per-oral endoscopic myotomy (POEM) was performed. Next, the patient underwent endoscopic creation of a fistula from the esophageal diverticulum to the gastric fundus. The fistula was then dilated with a biliary dilation balloon.A novel “balloon/snare apparatus” technique to facilitate easy creation of fistula tract during EUS-guided gastroenterostomy
EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for the management of gastric outlet obstruction (GOO). During EUS-GE, creation of a fistula tract can be challenging because the small bowel tends to move away from the stomach. We describe a novel method to secure the guidewire, permitting safe creation of a gastroenterostomy fistula. The first patient was a 48-year-old man with a history of chronic calcific pancreatitis complicated by duodenal stricture and GOO. Multiple endoscopic balloon dilations were performed, without durable benefit.Septotomy: an adjunct endoscopic treatment for post–sleeve gastrectomy fistulas
A 48-year-old woman presented with progressive abdominal pain 2 weeks after she had undergone laparoscopic sleeve gastrectomy (SG). A CT scan of the abdomen demonstrated postsurgical changes related to SG and a large extraluminal collection containing fluid, debris, and air adjacent to the surgical staple line. A percutaneous drain was placed, and endoscopic closure of the defect was attempted. Endoscopy revealed a fistulous opening adjacent to normal gastric lumen. The internal orifice of the gastrocutaneous (GC) fistula conditioned a pouch-like lumen, which was divided from the gastric lumen by a 15-mm-long septum (Fig. 1A).Endoscopic transmural necrosectomy through spontaneous pancreaticoduodenal fistula
A 32-year-old man with no relevant medical history initially presented to the emergency department with 24 hours of severe abdominal pain and received a diagnosis of acute interstitial pancreatitis. He was given supportive treatment and discharged home; however, 6 weeks after discharge he returned with abdominal pain, fever, and gram-negative rod bacteremia. Repeated imaging at that time demonstrated walled-off necrosis (WON) involving the pancreas and extrapancreatic tissues and a possible cystduodenal fistula.EUS-guided rescue of early dislodgement of a lumen-apposing stent
The lumen-apposing stent (Axios, Xlumena Inc, Mountain View, Calif) has been used for endoscopic management of pseudocyst and gallbladder drainage with very high technical and clinical success. Even though it has bilateral large flanges to prevent migration, stent migration and dislodgement have been reported in 5% of patients.Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass
Gastrojejunal stomal strictures occur in 3% to 28% of patients as a late adverse event after Roux-en-Y gastric bypass. They are commonly treated by through-the-scope balloon dilation, although this is associated with a perforation rate of 2% to 5%. Fully covered self-expandable metal stents carry a risk of stent migration, and surgical intervention has a significant morbidity.Double peroral endoscopic myotomy for achalasia
As experience grows with peroral endoscopic myotomy (POEM), operators are taking on more anatomically challenging cases. Additionally, we are now seeing patients who relapse after a prior POEM. Therefore, the operator must be aware of the steps necessary to adequately investigate and treat such patients. For example, it is of no benefit to continue to target the lower esophageal sphincter if this already has been treated effectively. We herein present 2 different teaching cases in which 2 POEM procedures (double POEM) were performed in each of the patients (Video 1, available online at www.giejournal.org ).Novel endoscopic approach for a large intraluminal duodenal (“windsock”) diverticulum
A 59-year-old woman presented for evaluation of recurrent acute pancreatitis over 8 years and had previously undergone a cholecystectomy. Additionally, she had a longstanding history of foregut symptoms with multiple prior upper endoscopies not identifying an abnormality. Cross-sectional imaging revealed a dilated common bile duct with no mass seen on EUS. At attempted ERCP, a structure was identified that was in the correct location for the major papilla but was odd in appearance. This was subsequently found to be a large intraluminal duodenal “windsock” diverticulum (Fig. 1).EUS-guided gastrojejunostomy for management of complete gastric outlet obstruction
An 86-year-old woman presented for management of gastric outlet obstruction secondary to locally advanced pancreatic adenocarcinoma. An enteral stent was not possible because a guidewire was unable to pass through the stricture. After a multidisciplinary meeting, the decision was made to proceed with EUS-guided gastrojejunostomy and lumen-opposing stent insertion.Endoscopic reversal of gastric bypass for severe malnutrition after Roux-en-Y gastric bypass surgery
Severe malnutrition has been reported in 4% of patients after Roux-en-Y gastric bypass surgery. This condition leads to hospitalization in 54% of patients, with a mortality rate of 18%. The common causes of severe malnutrition after bariatric surgery include surgical mechanical adverse events and noncompliance with nutritional supplements. The treatment involves nutritional support and correction of the underlying causes; surgical reversal is required in some cases. In this video, we demonstrate endoscopic fistulization and stent bridge of the functional and defunctionalized stomach as a therapeutic option for severe malnutrition after Roux-en-Y gastric bypass surgery.
