Submucosal tunneling and en bloc endoscopic resection facilitates laparoscopic transgastric removal of a large GI stromal tumor at the esophagogastric junctionEndoscopic resection of gastrointestinal stromal tumor (GIST) of the esophagogastric junction (EGJ) can be performed by submucosal tunneling and endoscopic resection (STER). However, the maximal reported lesion size is 3.3 cm. En bloc resection is mandatory because of the malignant potential of a GIST. Laparoscopic wedge resection (LWR) at the EGJ is technically challenging, with a risk of lumenal narrowing leading to dysphagia and injury of the lower esophageal sphincter. STER of large EGJ lesions can release the tumor from the EGJ and facilitate easy access for transgastric LWR while avoiding the risks of LWR techniques.
Double peroral endoscopic myotomy for achalasiaAs 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 ).
Flexible endoscopic Zenker’s diverticulotomyZenker’s diverticulum (ZD) is an outpouching of tissue through the Killian triangle caused by hypertension of the cricopharyngeus. The predominant symptom of ZD is dysphagia, and the most serious consequence is pulmonary aspiration. Therapy of symptomatic ZD has evolved from an open surgical approach to a less invasive transoral endoscopic technique. The transoral approach, which includes both rigid and flexible endoscopic techniques, is currently the preferred method.
EUS-guided biliary drainage with antegrade transpapillary placement of a metal biliary stentEUS-guided biliary drainage (EUS-BD) is a minimally invasive technique that provides biliary drainage in patients with malignant biliary obstruction in whom endoscopic retrograde cholangiography (ERC) is not feasible. Intrahepatic or extrahepatic biliary access is obtained, after which transluminal or transpapillary drainage is performed with stent placement. Transpapillary stents can be placed in a retrograde fashion by using the rendezvous technique in which endoscope exchange is required. A transpapillary stent also can be placed in an antegrade fashion.
Closure of a large, persistent enterocutaneous fistula by use of a ventricular septal occluderEnterocutaneous fistulas are associated with a significant morbidity and a mortality of between 5% and 20%. The most common causes are iatrogenic (jejunal feeding), Crohn’s disease, radiotherapy-induced, and secondary to malignancy. These patients are often poor surgical candidates, and hence a minimally invasive technique for closure may offer significant benefits.
Closure of a chronic tracheoesophageal fistula by use of a cardiac septal occluderIn adults, an acquired tracheoesophageal fistula (TEF) is most commonly the result of cuff-induced tissue necrosis from prolonged mechanical ventilation. These patients are often poor surgical candidates, and hence a minimally invasive technique for closure may offer significant benefits.
EUS-guided angiotherapyEUS-guided angiotherapy is a growing concept that allows for precise delivery of intravascular therapies to afferent vessels and real-time confirmation of thrombosis. The medical literature supports EUS-guided therapy for gastric varices by using coil deployment and cyanoacrylate. In theory, the coil minimizes the cyanoacrylate volume necessary because the coil acts as a scaffold, and this may decrease the risk of systemic embolization. This video (Video 1, available online at www.giejournal.org ) demonstrates 3 cases of GI bleeding that were successfully managed by using EUS-guided angiotherapy.
EUS-guided rendezvous and reversal of complete rectal anastomotic stenosis after Hartmann's reversalBenign postoperative colorectal anastomotic strictures occur in up to 30% of cases. Strictures can be managed with repeated surgery or endoscopic dilatation and metallic stent placement. A 54-year-old man underwent left colectomy, Hartmann's pouch, and colostomy for treatment of ischemic colitis. Reversal of Hartmann's with diverting loop ileostomy was performed 9 months after surgery. During preoperative endoscopic evaluation for loop ileostomy reversal, complete stenosis of the anastomosis was noted.
Submucosal tunneling endoscopic resection of a giant esophageal leiomyomaSubmucosal tunneling endoscopic resection (STER) for removal of upper GI tumors arising from the muscularis propria (MP) has been demonstrated to be effective and safe. In this video, we demonstrate the feasibility of STER for a giant, symptomatic esophageal leiomyoma and the closure of a large mucosal entry. A 53-year-old woman was seen with a 2-month history of progressive dysphagia and chest pain. A chest CT scan revealed a 6 × 2.8 × 2.2-cm esophageal mass adjacent to the descending aorta and azygos vein (Fig. 1; Video 1, available online at www.giejournal.org ).
Percutaneous through-the-stent assisted ERCP in patients with Roux-en-Y gastric bypassObesity affects 35% of men and women in the United States. Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric surgery, accounting for 60% of all procedures. ERCP in patients after RYGB is challenging because of lengthy Roux limbs, use of forward-viewing endoscopes without an elevator, and limitation of available accessories. A 69-year-old woman with RYGB presented with a symptomatic stone in the distal common bile duct. Single-balloon–assisted enteroscopy was performed to the excluded stomach.
Closure methods in submucosal endoscopySubmucosal endoscopy requires transforming the submucosal layer into an endoscopic working space to allow safe access to the muscularis propria and beyond. The submucosal tunnel places the mucosal incision proximal to the area of interest, thereby simplifying closure to merely mucosal apposition. The earliest clinical adaptation of submucosal endoscopy was peroral endoscopic myotomy for the management of achalasia. More recently, submucosal tunneling endoscopic resection has been demonstrated to be a suitable alternative to surgical removal of tumors originating from the muscularis propria.
EUS-guided drainage of a mediastinal abscessA 61-year-old man with esophageal adenocarcinoma underwent minimally invasive esophagectomy and gastric pull-through. The initial postoperative course was without adverse events, and he was discharged home. However, on day 7 the patient was readmitted with fever, rapid atrial fibrillation, and leukocytosis. Chest CT scan revealed a 6.3 cm × 4.6 cm mediastinal abscess adjacent to the gastric pull-through (Fig. 1; Video 1, available online at www.giejournal.org ). EUS-guided drainage was performed.
Peroral endoscopic myotomy: a 4-step approach to a challenging procedurePeroral endoscopic myotomy (POEM) was first described in a swine model in 2007. Six years later, more than 2000 clinical procedures have been performed in several centers across the world as another treatment modality for achalasia. Initial clinical data from Asia, Europe, and the United States has demonstrated the effectiveness and safety of this procedure when performed by experienced endoscopists.
EUS-guided drainage of a giant hemorrhagic pseudocyst by a through-the-scope esophageal metal stentA 78-year-old man with acute chronic pancreatitis was admitted with abdominal pain. Hemorrhagic transformation of a pseudocyst had developed, and he was hemodynamically unstable, requiring splenic artery embolization. He had symptoms of gastric outlet obstruction. The pseudocyst measured 17 × 14 cm on a CT scan and caused extrinsic mass effect on the stomach. EUS-guided drainage was performed. A cystogastrostomy was created and sequentially dilated by using pneumatic balloon dilators over a guidewire to a diameter of 18 mm.
EUS-guided biliary drainage by using a hepatogastrostomy approachPancreatic cancer frequently recurs after Whipple surgery and may result in recurrent obstructive jaundice. ERCP is more challenging in this setting because of surgical anatomy. These patients are commonly managed by percutaneous transhepatic biliary drainage. EUS-guided biliary drainage (EGBD) has been increasingly used as a minimally invasive alternative to surgery or radiotherapy.