Videos
Top tips for maximum detection during colonoscope withdrawal (with video)
Optimizing detection of polyps during colonoscopy is key, whether they are flat lesions in the right side of the colon or small polyps behind folds. Good withdrawal technique will help in improved detection, characterization, and resection of all polyps during colonoscopy. Continuing with our series of tips to improve endoscopic techniques, Dr Doug Rex, in this issue, presents top tips to maximize lesion detection during colonoscopy.Top tips for endoscopic diverticulotomy for Zenker’s diverticula (with video)
For many years gastroenterologists had little role to play in patients with Zenker's diverticula beyond ordering a contrast study or performing an EGD. These patients were routinely handed off to ear, nose, and throat surgeons for definitive therapy. In recent years, endoscopic therapy, which can come in a variety of forms, for Zenker's diverticula has increased in popularity. The most common, and perhaps most successful, of these is the so-called endoscopic diverticulotomy. These procedures, which I can attest are very satisfying to perform, can often produce profound and lasting symptomatic improvement in these patients.Suturing a 20-mm lumen-apposing metal stent allows for safe same-session EUS-directed transgastric intervention in patients with Roux-en-Y gastric bypass anatomy: a multicenter study (with video)
EUS-directed transgastric intervention (EDGI) is an established technique for the management of pancreaticobiliary pathology in Roux-en-Y gastric bypass (RYGB) patients. There is an inherent risk of intraprocedural stent dislodgement, leading to perforation. The procedure is therefore often performed in 2 stages, 2 to 4 weeks apart, to allow for fistula maturation to mitigate the risk of lumen-apposing metal stent (LAMS) dislodgment. However, some clinical indications such as cholangitis require more urgent intervention, rendering this approach impractical.EUS-guided ileorectal anastomosis for relief of complete benign small-bowel obstruction (with video)
A 52-year-old man underwent an ileorectal anastomosis after a subtotal colectomy because of acute complicated diverticulitis. Seven days later, a CT scan revealed a pneumoperitoneum (A), but no clear perforation was discovered during surgery. Endoscopy disclosed a complete stenosis of the anastomosis, 15 cm from the dentate line, which prevented us from advancing a guidewire (B). A linear-array echoendoscopy (performed with EUS) was performed through the rectum, and the ileal loop with liquid inside was identified.Everted diverticula with endoscopic mucosal changes mimicking serrated lesions (with video)
Everted colonic diverticula sometimes demonstrate overlying mucosa with a finely nodular or “cloudlike” surface (A-C). This may cause the overlying mucosa to be mistaken for a sessile serrated lesion, leading to endoscopic resection. However, the mucosa is essentially normal histologically, and resection is not warranted (D, H&E, orig. mag. ×40).Endocytoscopy for assessing histologic inflammation in ulcerative colitis: development and prospective validation of the ELECT (ErLangen Endocytoscopy in ColiTis) score (with videos)
Apart from endoscopic healing as an established treatment goal in patients with inflammatory bowel disease (IBD), histologic remission is an emerging endpoint that might even better predict disease outcome, especially in ulcerative colitis (UC). Within this study, we aimed to evaluate whether endocytoscopy (EC) as an in vivo contact microscopy technology can accurately assess histologic inflammation and predict the further course of disease in UC patients.Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video)
Accurately diagnosing malignant biliary strictures (MBSs) as benign or malignant remains challenging. It has been suggested that direct visualization and interpretation of cholangioscopy images provide greater accuracy for stricture classification than current sampling techniques (ie, brush cytology and forceps biopsy sampling) using ERCP. We aimed to develop a convolutional neural network (CNN) model capable of accurate stricture classification and real-time evaluation based solely on cholangioscopy image analysis.Top tips for endoscopic drainage and debridement of walled-off pancreatic necrosis (with videos)
It seems like only yesterday that pancreatic necrosis was primarily treated with surgical approaches. Endoscopic therapy for pancreatic necrosis was initially developed by a small number of pioneers, but the last decade has seen a plethora of prospective, randomized studies comparing surgery with endoscopy and the winner is clear: Endoscopic therapy produces equal or superior outcomes to surgery.1,2 The introduction of lumen-apposing metal stents (LAMSs) has also greatly facilitated the dissemination of these procedures into the hands of interventional endosonographers.Cholangioscopic diagnosis of biliary amyloidosis presenting as bile duct obstruction with cholangitis (with video)
A 73-year-old woman with a history of cardiac amyloidosis presented with obstructive jaundice and upper right postprandial abdominal pain. Computed tomography yielded findings suggestive of common bile duct stones with acute cholangitis. A cholangiogram demonstrated 2 oval filling defects in the common bile duct (A). Intraductal US revealed hypoechoic, homogenous submucosal mass lesions (B). Single-operator cholangioscopy (SpyGlass DS II, Boston Scientific, Marlborough, Mass, USA) showed a protruding mass lesion with tortuous and dilated vessels and central ulceration (C) (Video 1, available online at www.giejournal.org ).EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video)
Traditionally, palliative treatment of malignant gastric outlet obstruction (GOO) has been surgical, but surgical treatment carries significant morbidity and mortality rates. Endoscopic placement of a duodenal self-expandable metal stent (D-SEMS) has been proven to be successful for this indication in the short term. However, D-SEMSs are likely to malfunction over time. EUS-guided gastroenterostomy (EUS-GE) may help overcome these limitations. We aimed to evaluate stent failure–free survival at 3 months.Top tips for EUS-guided biliary rendezvous (with video)
EUS-guided biliary drainage techniques come in several varieties, but EUS rendezvous may be the most commonly performed. In this technique, a guidewire is passed through a needle that has been used to puncture the biliary tree, either through the stomach or the duodenum. The wire is advanced to the duodenum through the ampulla, and cannulation can then be performed over, or next to, the wire, allowing transampullary access to the bile duct for sphincterotomy, stent placement, or other maneuvers.Comparison of focal cryoballoon ablation with 10- and 8-second doses for treatment of Barrett’s esophagus–related neoplasia: results from a prospective European multicenter study (with video)
Focal cryoballoon ablation (FCBA) is currently being investigated for the treatment of Barrett’s esophagus (BE)-related neoplasia in a European multicenter study (Euro-Coldplay study). After inclusion of 28 of 107 patients, the initial dose of 10 seconds was lowered to 8 seconds. The current study aimed to compare the efficacy and safety of a single FCBA treatment session with 10 seconds versus 8 seconds.EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos)
EMR is the mainstay of therapy for large colorectal polyps. Local recurrence after EMR is common and can be reduced using margin ablation. Our aim was to evaluate recurrence rates when using hybrid argon plasma coagulation (h-APC) ablation after EMR.Endoscopic resection of upper GI extraluminal tumors (with videos)
Endoscopic resection is a feasible treatment for GI extraluminal tumors but remains a challenging procedure with limited data. In this study, we assessed the safety and efficacy of endoscopic resection for extraluminal tumors in the upper GI tract.Comparison of no stent fixation, endoscopic suturing, and a novel over-the-scope clip for stent fixation in preventing migration of fully covered self-expanding metal stents: a retrospective comparative study (with video)
Endoscopic suturing and over-the-scope clips (OTSCs) are used to prevent migration of fully covered self-expandable metal stents (FCSEMSs). Recently, a dedicated OTSC was developed for securing FCSEMSs. Our primary aim was to compare the frequency of stent migration without stent fixation versus fixation with suturing or OTSCs, and out secondary aims were to compare clinical success, procedure duration, and adverse events.Cap-assisted EMR versus standard inject and cut EMR for treatment of large colonic laterally spreading tumors: a randomized multicenter study (with videos)
Piecemeal EMR of colorectal laterally spreading tumors (LSTs) >20 mm is effective. Experience is limited in the use of cap-assisted EMR (EMR-C) for resection of colonic lesions. We compared the efficacy and the safety of EMR-C for the removal of colonic LSTs ≥30 mm with “inject-and-cut” standard EMR (EMR-S).Robotics in therapeutic endoscopy (with video)
Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing.Comparison of distal primary obesity surgery endolumenal techniques for the treatment of obesity (with videos)
Distal primary obesity surgery endolumenal (POSE) procedures involve plication of the gastric body, sparing the fundus. We aim to assess the efficacy of distal POSE procedures and to compare plication techniques (single-helix vs double-helix approaches).Assessment of submucosal distortion and mass effect seen at follow-up after colorectal EMR with ORISE (with video)
ORISE (Boston Scientific, Marlborough, Mass, USA) is a viscous gel used for submucosal injection. We noted anecdotally that ORISE is associated with submucosal distortion of EMR scars at follow-up.Flower in the duodenum (with video)
A 62-year-old man who was experiencing hematemesis and black stool was referred to our hospital because of repeated GI bleeding from the duodenum. Physical examination revealed pallor, a heart rate of 78 beats/min and blood pressure of 132/79 mm Hg. No abnormal findings were observed in the abdomen. The admission laboratory results revealed hemoglobin 7.4 g/dL.Efficacy of narrow-band imaging during peroral cholangioscopy for predicting malignancy of indeterminate biliary strictures (with videos)
Direct peroral cholangioscopy (POC) can be useful when combined with narrow-band imaging (NBI) to explore the etiologies of indeterminate biliary strictures. We evaluated the efficacy of NBI compared with that of conventional white-light imaging (WLI) during POC diagnosis of indeterminate biliary strictures.Gastric peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video)
Gastric peroral endoscopic myotomy (G-POEM) is used for refractory gastroparesis (RG) with good early-term but variable mid- and long-term outcomes. Limited data exist about candidates and long-term clinical and predictive factors. Our aim was to evaluate the 4-year follow-up efficacy and predictive factors in patients with RG.A computed tomography—negative pancreatic lesion diagnosed by endoscopic ultrasound imaging enhancement (with video)
A 50-year-old woman was admitted for slightly elevated serum carbohydrate antigen 19-9 (39 U/mL) and negative findings from 2 rounds of computed tomography (CT) scanning at a 6-month interval (A). The patient underwent EUS examination. In the initial scanning, the pancreatic parenchyma was normal, without ductal dilatation. To avoid missing a potential isoechoic lesion, we next performed imaging enhancement by adjusting the acoustic parameters in the US (HI VISION Preirus, Hitachi, Tokyo, Japan).Hookworm-induced refractory gastric ulcer (with video)
A 63-year-old man presented to the gastroenterology clinic with a 1-month history of upper middle abdominal pain. Laboratory studies revealed an eosinophil count of 660/mm3 (reference range, 20-520/mm3) and elevated immunoglobulin E (IgE). EGD showed a gastric ulcer (A) with Helicobacter pylori infection. Histopathologic examination revealed chronic nonatrophic gastritis with eosinophil infiltration in the lamina propria (B; 30-40/high power field [HPF]; partially marked by black arrows; H&E, orig.Prospective comparison study between 19-gauge needle with .025-inch guidewire and 22-gauge needle with novel .018-inch guidewire during EUS-guided transhepatic biliary drainage (with video)
If the diameter of the intrahepatic bile duct is much less dilated, bile duct puncture with a 19-gauge needle can be challenging during EUS-guided biliary drainage (EUS-BD). These characteristics can decrease the difficulty of bile duct puncture, but use of a 22-gauge needle is less feasible because of poor visibility, maneuverability, and stiffness of the conventional .018-inch guidewire. A novel, improved .018-inch guidewire has recently become available. We conducted a prospective study to evaluate the technical feasibility and safety of EUS-BD in patients with insufficient bile duct dilatation using a 22-gauge needle and the new .018-inch guidewire.
