Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.

Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy:A prospective randomized,multicenter study

AIM:To evaluate and compare the clinical outcomes of prophylactic submucosal saline-epinephrine injection and saline injection alone for large colon polyps by conventional polypectomy. METHODS:A prospective study was conducted from July 2003 to July 2004 at 11 tertiary endoscopic centers. Large colon polyps (> 10 mm in diameter) wererandomized to undergo endoscopic polypectomy with submucosal saline-epinephrine injection (epinephrine group) or normal saline injection (saline group). Endoscopic polypectomy was performed by the conventional snare method,and early (< 12 h) and late bleeding complications (12 h-30 d) were observed. RESULTS:A total of 561 polyps in 486 patients were resected by endoscopic polypectomy. Overall,bleeding complications occurred in 7.6% (37/486) of the patients,including 4.9% (12/244) in the epinephrine group,and 10.3% (25/242) in the saline group. Early and late postpolypectomy bleeding (PPB) occurred in 6.6% (32/486) and 1% (5/486) of the patients,respectively,including 4.5% (11/244),0.4% (1/244) in the epinephrine group,and 8.7% (21/242),1.7% (4/242) in the saline group. No significant differences in the rates of overall,early and late PPB were observed between the 2 groups. Multivariate stepwise logistic regression analysis revealed that large size (> 2 cm) and neoplastic polyps were independently and significantly associated with the presence of PPB. CONCLUSION:The prophylactic submucosal injection of diluted epinephrine does not appear to provide an additional advantage over the saline injection alone for the prevention of PPB.

Ampullary adenomyoma presenting as acute recurrent pancreatitis

Adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. Despite its benign nature,ampullary adenomyoma is usually presented as biliary obstruction. Most cases are misdiagnosed as carcinoma or adenoma by preoperative endoscopic or radiologic procedure. Therefore,it is frequently treated with extensive surgery. To our knowledge,this is the first reported case in English literature of adenomyoma located in the peripancreatic orifice resulting in intermittent pancreatic duct obstruction and recurrent pancreatitis diagnosed by the endoscopic piecemeal resection.

Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP

The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage(PTBD).When a selective common bile duct cannulation fails,PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques.Traditionally,rendezvous procedures such as the PTBDassisted over-the-wire cannulation method,or the parallel cannulation technique,may be available when a bile duct cannot be selectively cannulated.When selective intrahepatic bile duct(IHD) cannulation fails,this modified rendezvous technique may be a feasible alternative.We report the case of a modified rendezvous technique,in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla's orifice,in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction.Clinically this procedure may be a feasible and timesaving technique.

Chemical ablation of the gallbladder using alcohol in cholecystitis after palliative biliary stenting

Chemical ablation of the gallbladder is effective in patients at high risk of complications after surgery. Percutaneous gallbladder drainage is an effective treatment for cholecystitis; however, when the drain tube cannot be removed because of recurrent symptoms, retaining it can cause problems. An 82-year-old woman presented with cholecystitis and cholangitis caused by biliary stent occlusion and suspected tumor invasion of the cystic duct. We present successful chemical ablation of the gallbladder using pure alcohol, through a percutaneous gallbladder drainage tube, in a patient who developed intractable cholecystitis with obstruction of the cystic duct after receiving a biliary stent. Our results suggest that chemical ablation therapy is an effective alternative to surgical therapy for intractable cholecystitis.

Usefulness of magnifying endoscopy in post-endoscopic resection scar for early gastric neoplasm:A prospective short-term follow-up endoscopy study

AIM:To investigate the relationship between post-endoscopic resection(ER) scars on magnifying endoscopy(ME) and the pathological diagnosis in order to validate the clinical significance of ME.METHODS:From January,2007 to June,2008,124 patients with 129 post-ER scar lesions were enrolled.Mucosal pit patterns on ME were compared with conventional endoscopy(CE) findings and histological results obtained from targeted biopsies.RESULTS:CE fi ndings showed nodular scars(53/129),erythematous scars(85/129),and ulcerative scars(4/129).The post-ER scars were classified into four pit patterns of sulci and ridges on ME:47 round;54 short rod or tubular;19 branched or gyrus-like;and9 destroyed pits.Sensitivity and specificity were 88.9% and 62.5%,respectively,by the presence of nodularity on CE.Erythematous lesions were high sensitivity(100%),but specificity was as low as 36.7%.The range of the positive predictive value (PPV) on CE was as low as 10.6%-25%.Nine type  pit patterns were diagnosed as tumor lesions,and 120 cases of type pit patterns revealed non-neoplastic lesions.Thus,the sensitivity,specificity,and the PPV of ME were 100%.CONCLUSION:ME findings can detect the presence of tumor in post-ER scar lesions,and make evident the biopsy target site in short-term follow-up.Further large-scale and long-term studies are needed to determine whether ME can replace endoscopic biopsy.

Endoscopic diverticulotomy with an isolated-tip needle-knife papillotome (Iso-Tome) and a fitted overtube for the treatment of a Killian-Jamieson diverticulum

A Killian-Jamieson diverticulum (KJD) is an unfamiliar and rare cervical esophageal diverticulum. This diverticulum originates on the anterolateral wall of the proximal cervical esophagus through a muscular gap (the Killian-Jamieson space) below the cricopharyngeal muscle and lateral to the longitudinal muscle of the esophagus. To date, only surgical treatment has been recommended for a symptomatic KJD due to its close proximity to the recurrent laryngeal nerve and the concern of possible nerve injury. Recently, traditional open surgery for a symptomatic KJD is being challenged by the development of new endoscopic techniques and devices. We present here a case of a symptomatic KJD that was successfully treated with the flexible endoscopic diverticulotomy using two new devices. An isolated-tip needle-knife papillotome (Iso-Tome) was used for the dissection of the tissue bridge of the diverticulum. And a flexible overtube with a modifi ed distal end (a fi tted overtube) was used for adequate visualization of the tissue bridge of the diverticulum and protection of the surrounding tissue during dissection of the tissue bridge. Our successful experience suggests that the flexible endoscopic diverticulotomy with the use of appropriate endoscopicdevices can be a safe and effective method for the treatment of a symptomatic KJD.

Aortoduodenal fistula and aortic aneurysm secondary to biliary stent-induced retroperitoneal perforation

Duodenal perforations caused by biliary prostheses are not uncommon, and they are potentially life threatening and require immediate treatment. We describe an unusual case of aortic aneurysm and rupture which occurred after retroperitoneal aortoduodenal fistula formation as a rare complication caused by biliary metallic stent-related duodenal perforation. To our knowledge, this is the first report describing a lethal complication of a bleeding, aortoduodenal fistula and caused by biliary metallic stent-induced perforation.

Endoscopic transcystic stent placement for an intrahepatic abscess due to gallbladder perforation

Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.