VideoGIE
A standardized imaging protocol for the endoscopic prediction of dysplasia within sessile serrated polyps (with video)
Dysplasia within sessile serrated polyps (SSPs) is difficult to detect and may be mistaken for an adenoma, risking incomplete resection of the background serrated tissue, and is strongly implicated in interval cancer after colonoscopy. The use of endoscopic imaging to detect dysplasia within SSPs has not been systematically studied.EUS-guided removal of a buried lumen-apposing metal stent caused by delayed inward migration after cyst-gastrostomy
A 63-year-old man with advanced chronic pancreatitis had a 6-cm pancreatic abscess drained through EUS-guided cyst-gastrostomy with a 15 × 10 mm lumen-apposing metal stent (LAMS). The puncture tract crossed the gastroesophageal junction, so that the intraluminal end of the LAMS lay in the esophagus. No adverse events ensued, and no residual pancreatic fluid collection (PFC) was seen at follow-up CT. The patient, however, was lost to follow-up and was readmitted 8 months later for upper GI bleeding related to nonsteroidal anti-inflammatory drug use.Endoscopic recovery of multiple migrated plastic stents during EUS-guided transmural drainage of pancreatic fluid collections
EUS-guided transmural drainage of pancreatic fluid collections is widely used, and multiple stents and nasocystic drainage are necessary for effective drainage in cases of pancreatic necrosis. Stent migration into the necrotic cyst is a possible adverse event of such procedures. Retrieval of migrated stents by the direct insertion of an endoscope into the cyst can be considered, but there is a high incidence of severe adverse events. We describe a case of multiple plastic stent migration into a pancreatic necrotic cyst, in which the stents were successfully recovered by use of a minimally invasive endoscopic technique.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.Endoscopic band ligation in diverticular bleeding: a stepwise approach for successful treatment
A 90-year-old man presented to the emergency department with acute painless hematochezia. A previous colonoscopy 2 years earlier confirmed severe diverticulosis in the sigmoid colon with active bleeding from a diverticulum, which was treated with thermal therapy and endoscopic clipping. Digital rectal examination demonstrated gross bright red blood with no evidence of hemorrhoids. Vital signs were negative for hypotension or orthostasis. Laboratory findings included normal hemoglobin and hematocrit: 15.6 g/dL and 44.7%, respectively.Successful closure of a cryotherapy-induced bleeding jejunal perforation with the over-the-scope clip system
A 63-year-old man with a history of resected esophageal adenocarcinoma was found to have residual dysplasia and was referred for cryotherapy. After the procedure, the patient experienced significant abdominal distention in the recovery room. He underwent immediate repeated endoscopy and was found to have a proximal jejunal perforation (Fig. 1A). An exposed pulsatile vessel was seen at the defect, with associated oozing from the wound site. With the aid of the twin grasper device, the defect was successfully closed with the deployment of a single 11-t over-the-scope clip (OTSC) (Fig.1B; Video 1, available online at www.giejournal.org ).Cholangitis many years after choledochoduodenostomy
An 83-year-old man with a history of diabetes mellitus and coronary artery disease underwent surgical bile duct diversion (choledochoduodenostomy) in 1993 because of “gallbladder and bile duct problems.” His old records were unavailable. The patient presented to our emergency department with typical symptoms of cholangitis. During ERCP, a 4-mm to 5-mm opening on the anterior part of the duodenal bulb was visualized and identified as the choledochoduodenostomy. After cannulation of this choledochoduodenostomy, several large filling defects were seen inside the common bile duct (CBD) extending down toward the papilla (Video 1 and Fig. 1).An unexpected cause of terminal ileitis
A 20-year-old woman with Crohn’s disease (CD) who had a positive family history of CD was referred to our hospital because of therapy-refractory CD, which had been diagnosed 2 years before referral. The initial diagnosis was made on the basis of clinical presentation and the results of ileocolonoscopy, which showed erosions in the terminal ileum. Pathologic examination of these lesions showed chronic inflammation without granulomas. At the time of referral, she had been treated with budesonide 9 mg once daily for more than a year.Trimming the fat: endoscopic suturing for tightening of prior endoscopic sleeve gastroplasty
A 60-year-old woman, weighing 214 pounds with body mass index (BMI) 33.5 kg/m2, underwent successful endoscopic sleeve gastroplasty (ESG). One year after ESG she weighed 169 pounds: 45 pounds weight loss, 21% total body weight loss (TBWL), with BMI 26.5. However, her weight reached a plateau, and she reported a diminishing change in satiety. The result of a gastric emptying study was normal. A preliminary study showed a ESG-induced decrease in caloric consumption and slowing of gastric emptying.Clinical utility of rapid on-site cytopathology
EUS-guided FNA (EUS-FNA) is an important technique for evaluating pancreatic lesions, lymphadenopathy adjacent to the intestinal tract, and GI subepithelial lesions. Rapid on-site evaluation (ROSE) involves the immediate application of the EUS-FNA sample from the EUS needle to a slide that is quickly stained and examined, typically in the endoscopy suite. The samples may be evaluated by a cytotechnician, a cytopathologist, or both. The simplicity and utility of the ROSE technique are not typically appreciated by those not performing EUS.Over-the-scope clip in postoperative pancreatic fistula
Pancreaticoduodenectomy is commonly performed for malignant diseases. To restore the communication between the pancreatic duct and intestinal tract, some surgeons prefer to perform pancreaticogastrostomy, which seems to be safer than pancreaticojejunostomy.Cystic pancreatic neuroendocrine tumors: correlation of in vivo needle-based confocal endomicroscopic findings by ex vivo analysis
A 30-year-old man was found to have an incidental pancreatic cystic lesion (PCL) during CT evaluation of a ureteral stone. EUS revealed a 3 cm × 2.6 cm cystic lesion with a thick wall in the pancreatic tail and 1.0 cm × 0.8 cm cystic lesions in both the uncinate and the genu of the pancreas. Needle-based confocal laser endomicroscopy (nCLE) of the tail lesion was performed with an AQ-Flex-19 miniprobe (Cellvizio; Mauna Kea Technologies Inc, Suwanee, Ga) and revealed well-demarcated clusters of cells (trabeculae) with surrounding fibrosis and vascularity (Fig. 1; Video 1, available online at www.giejournal.org ).EUS-guided right hepatic bile duct drainage in complicated hilar stricture
EUS-guided biliary drainage (EUS-BD) has been reported as a useful and safe salvage technique in cases of ERCP failure or inaccessible papilla. However, EUS-guided right hepatic bile duct drainage (EUS-RBD) remains challenging, although recent reports have described successful EUS-RBD with antegrade stenting or bypass stenting with conventional biliary metal stents. Recently we have developed a new single-pigtail plastic stent designed for EUS-BD. We describe 2 cases of EUS-RBD with use of the dedicated plastic stent.Percutaneous transhepatic cholangioscopy for the diagnosis of biliary obstruction in a patient with Roux-en-Y partial gastrectomy
A 71-year-old man who had undergone a Roux-en-Y partial gastrectomy and adjuvant chemoradiation for gastric adenocarcinoma 4 years earlier presented with obstructive jaundice. CT and MRI confirmed common bile duct (CBD) obstruction at the pancreatic “plateau” with no obvious expansive lesion (Fig. 1A). Transhepatic percutaneous drainage with a 10F pigtail was performed for relief of the jaundice. In consideration of a possible primary biliary neoplasia and the good clinical status of the patient, a differential diagnosis of metastatic gastric adenocarcinoma was important.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.Tubular adenoma arising in a choledochocele
A 64-year-old woman was admitted to our hospital because of high amylase levels. Contrast-enhanced CT revealed dilatation of the distal common bile duct in the wall of the duodenum at the oral side of the ampulla of Vater and a 10-mm nodule with contrast medium enhancement in the dilatated common bile duct. Duodenoscopy revealed an elevated lesion above the ampulla of Vater (Fig. 1A). Additionally, ERCP showed a cystic dilatation at the oral side of the ampulla of Vater and a 10-mm filling defect in the cystic dilatation (Fig. 1B).Successful management of ischemic cholangiopathy after failed endoscopic/percutaneous interventions, facilitated by digital cholangioscopy
A 63-year-old man who had undergone liver transplantation for hepatitis C experienced cholestasis 1.5 years later, which was initially assumed to be due to choledocholithiasis but was later established to be ischemic cholangiopathy secondary to hepatic artery thrombosis. This finding, which was not seen on any prior noninvasive imaging, was established by a hepatic angiogram, which was obtained after the failure of ERCP and percutaneous pranshepatic cholnagiography (PTC) attempts to gain access into the biliary system.Novel techniques for diagnosis of serous cystadenoma: fern pattern of vascularity confirmed by in vivo and ex vivo confocal laser endomicroscopy
An asymptomatic 59-year-old woman presented with an incidental pancreatic lesion on CT scan. EUS demonstrated a multiseptated cyst in the pancreatic tail that measured 6 cm × 3.5 cm. There was no associated mass or communication with the pancreatic duct. Needle-based confocal endomicroscopy (nCLE) with an AQ-Flex-19 miniprobe (Cellvizio; Mauna Kea Technologies Inc, Suwanee, Ga) was performed (Video 1, available online at www.giejournal.org ). A large superficial vascular network in a fern-leaf pattern was observed and supported the diagnosis of serous cystadenoma (SCA) (Fig. 1).Digital cholangioscopy-assisted endoscopic gallbladder drainage
Percutaneous cholecystostomy tube (PTC) placement has been the mainstay of therapy for patients with acute and chronic cholecystitis who are poor candidates for surgery. PTC is limited by catheter-related adverse events, postprocedure pain, and recurrence of cholecystitis. Alternatively, endoscopic gallbladder drainage (EGBD) by the placement of a plastic transcystic stent during ERCP has been shown to be effective. Comparative studies have shown EGBD to have fewer adverse events, lower pain scores, and less recurrence of cholecystitis compared with PTC.“Underwater” endoscopic submucosal dissection for superficial esophageal neoplasms
Endoscopic submucosal dissection (ESD) is an effective and minimally invasive treatment for superficial esophageal neoplasms (SENs) without metastasis. However, ESD for SENs has a substantial risk of adverse events. The most serious adverse event is perforation due to deep burn. We hypothesized that water immersion might improve or minimize the thermal damage to the muscle layer by its heat-sink effect and visualization during ESD. We performed underwater ESD in 9 patients with SENs (Fig. 1; Video 1, available online at www.giejournal.org ).Successful removal of deeply migrated pancreatic stent using biliary dilation balloon and the new single-operator digital cholangioscope
A 73-year-old woman who had previously undergone unsuccessful ERCP for choledocholithiasis underwent successful ERCP with extraction of a large stone and subsequent pancreatic duct (PD) stent placement for post-ERCP pancreatitis prophylaxis. The stent migrated spontaneously deep into the PD and could not be retrieved with standard ERCP tools, including grasping forceps, snares, and extraction balloon. An innovative technique was then devised whereby a 4 cm × 4 mm biliary dilation balloon was carefully placed alongside the stent, and the stent was dragged down from the deeper portions of the PD.Mating Ancylostoma duodenale under magnifying endoscopy
A 71-year-old man, a farmer, was referred for EGD because he had experienced dysphagia for 4 months. He appeared anemic on physical examination. His laboratory tests showed significantly low hemoglobin, 5.2 g/dL, and an increase in eosinophils to 26.7%. The result of an occult blood test was positive. EGD revealed a mass in the gastric cardia; furthermore, several short red worms were observed in the duodenal bulb (Fig. 1A). Narrow-band imaging (NBI) and magnification were used; the worms turned transparent on NBI, and their heads were attached to the intestinal wall (Video 1, available online at www.giejournal.org ).Liquid nitrogen cryospray ablation in palliation of Barrett’s esophagus–associated adenocarcinoma
A 56-year-old woman with multiple comorbidities presented with dysphagia and endoscopic examination revealed an esophageal mass with associated Barrett’s esophagus. The mass was 6 cm long (Fig. 1A), and histologic examination showed adenocarcinoma. Echoendoscopic staging showed a T2 lesion, but staging was incomplete because the radial echoendoscope could not traverse the malignant stricture. The patient was referred for oncology, surgical, and radiation oncology evaluation, but given her comorbidities she was determined not to be a candidate for those therapies.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.Endoscopic management of hepatic abscess after EUS-guided hepaticogastrostomy
A 55-year-old woman with metastatic pancreatic adenocarcinoma and biliary obstruction underwent unsuccessful ERCP. EUS-guided biliary drainage was performed, with placement of hepaticogastrostomy stents. After the procedure, the patient’s liver chemistry profile improved. Interval CT demonstrated a left hepatic lobe abscess extending along the lesser curvature of the stomach adjacent to the hepaticogastrostomy. The patient declined percutaneous drainage, and EUS-guided hepatic abscess drainage was performed (Video 1, available online at www.giejournal.org ).
