- 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 ).
- 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).
- 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.
- In 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 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.
- Benign 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 (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 ).
- Obesity 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.
- Submucosal 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.