Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model. METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope. RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to sixstitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.

Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents

AIM:To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) with a fully covered self-expandable metallic stent(FCSEMS).METHODS:From April 2009 to August 2010,15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography(ERCP) were included.These 15 patients consisted of 8 men and 7 women and had a median age of 61 years(range:30-91 years).The underlying causes of the distal malignant biliary obstruction were pancreatic cancer(n = 9),ampulla of Vater cancer(n = 2),renal cell carcinoma(n = 1),advanced gastric cancer(n = 1),lymphoma(n = 1),and duodenal cancer(n = 1).RESULTS:The technical success rate of EUS-CDS with an FCSEMS was 86.7%(13/15),and functional success was achieved in 100%(13/13) of those cases.In two patients,the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct.The mean duration of stent patency was 264 d.Early adverse events developed in three patients(3/13,23.1%),including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient.During the follow-up period(median:186 d,range:52-388 d),distal stent migration occurred in four patients(4/13,30.8%).In 3 patients,the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.CONCLUSION:EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.

Recent advances in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: A systematic review

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)in patients with Billroth Ⅱ gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy.However,there has been a paucity of comparative studies regarding ERCP in Billroth Ⅱ gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations.This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth Ⅱ gastrectomy patients.AIM To systematically review the literature regarding ERCP in Billroth Ⅱ gastrectomy patients.METHODS A systematic review was performed on the literature published between May 1975 and January 2019.The following electronic databases were searched:PubMed,EMBASE,and Cochrane Library.The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed.RESULTS A total of 43 studies involving 2669 patients were included.The study designs were 36(83.7%)retrospective cohort studies,4(9.3%)retrospective comparative studies,2(4.7%)prospective comparative studies,and 1(2.3%)prospective cohort study.Of a total of 2669 patients,there were 1432 cases(55.6%)of sideviewing endoscopy,664(25.8%)cases of forward-viewing endoscopy,171(6.6%)cases of balloon-assisted enteroscopy,169(6.6%)cases of anterior obliqueviewing endoscopy,64(2.5%)cases of dual-lumen endoscopy,31(1.2%)cases of colonoscopy,and 14(0.5%)cases of multiple bending endoscopy.The overall success rate of afferent loop intubation was 91.3%(2437/2669),and the overall success rate of selective cannulation was 87.9%(2346/2437).A total of 195 cases(7.3%)of adverse events occurred.The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows:side-viewing endoscopy 98.2%and 95.3%;forward-viewing endoscopy 97.4%and 95.2%;balloon-assisted enteroscopy 95.4%and 97.5%;oblique-viewing endoscopy 94.1%and 97.5%;and dual-lumen endoscopy 82.8%and 100%,respectively.The rate of bowel perforation was slightly higher in side-viewing endoscopy(3.6%)and balloon-assisted enteroscopy(4.1%)compared with forward-viewing endoscopy(1.7%)and anterior oblique-viewing endoscopy(1.2%).Mortality only occurred in side-viewing endoscopy(n=9,0.6%).CONCLUSION The performance of ERCP in the Billroth Ⅱ gastrectomy population has been improving with choice of various type of endoscope and sphincter management.More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth Ⅱ gastrectomy patients.

Diagnostic performance of the current risk-stratified approach with computed tomography for suspected choledocholithiasis and its options when negative finding

Background:Several studies evaluated the current guideline of the American Society for Gastrointestinal Endoscopy(ASGE)and reported only suboptimal accuracy.This study evaluated the diagnostic performance of the ASGE guideline based on computed tomography(CT)and role of endoscopic ultrasonography(EUS)and magnetic resonance cholangiopancreatography(MRCP)in patients with suspected choledocholithiasis but negative CT finding.Methods:Patients with suspected choledocholithiasis undergoing ERCP between January 2016 and January 2017 were retrospectively analyzed.All patients underwent CT to detect choledocholithiasis.EUS or MRCP was performed when the CT scan showed negative findings.Patients were classified into the high and intermediate-risk groups,based on predictors from the ASGE criteria.Results:Of 583 patients with suspected choledocholithiasis,340(58.3%)had stones on ERCP(65.9%in the high-risk group and 40.6%in the intermediate-risk group).The accuracy of ASGE guideline for CT was 63.98%(79.12%sensitivity,42.80%specificity)and 36.02%(20.88%sensitivity,57.20%specificity)in the high-risk and intermediate-risk groups,respectively.In 103 patients in the high-risk group underwent both CT and US,the accuracy of CT was higher than that of US for detecting choledocholithiasis(78.64%vs.53.40%),with a significant difference in area under the curve(AUC)(0.78 vs.0.59,P<0.001).Of 339 with negative CT finding,the accuracy of EUS was higher than that of MRCP(90.91%vs.82.76%),but with no significant difference in AUC(0.91 vs.0.83,P=0.347).Conclusions:CT-based ASGE guideline showed superior diagnostic performance than US for predicting choledocholithiasis.The diagnostic options,EUS or MRCP,with negative CT finding showed comparable performance.Therefore,the diagnostic modality should be selected based on availability,experience,cost,and contraindications.

Clinical course of ulcerative colitis patients who develop acute pancreatitis

AIM To investigate the clinical course of ulcerative colitis(UC)patients who develop acute pancreatitis.METHODS We analyzed 3307 UC patients from the inflammatory bowel disease registry at Asan Medical Center from June 1989 to May 2015.The clinical course of UC patients who developed acute pancreatitis was compared with that of non-pancreatitis UC patients.RESULTS Among 51 patients who developed acute pancreatitis,13(0.40%)had autoimmune,10(0.30%)had aminosalicylate-induced,and 13(1.73%)had thiopurineinduced pancreatitis.All 13 patients with autoimmune pancreatitis(AIP)had type 2 AIP.Two(15.4%)patients had pre-existing AIP,and three(23.1%)patients developed AIP and UC simultaneously.Compared to non-pancreatitis patients,AIP patients had UC diagnosed at a significantly younger age(median,22.9 years vs 36.4 years;P=0.001).AIP and aminosalicylate-induced pancreatitis patients had more extensive UC compared to non-pancreatitis patients.All patients with pancreatitis recovered uneventfully,and there were no recurrences.Biologics were used more frequently in aminosalicylate-and thiopurine-induced pancreatitis patients compared to non-pancreatitis patients[adjusted OR(95%CI),5.16(1.42-18.67)and6.90(1.83-25.98),respectively].Biologic utilization rate was similar among AIP and non-pancreatitis patients[OR(95%CI),0.84(0.11-6.66)].Colectomy rates for autoimmune,aminosalicylate-induced,and thiopurineinduced pancreatitis,and for non-pancreatitis patients were 15.4%(2/13),20%(2/10),15.4%(2/13),and7.3%(239/3256),respectively;the rates were not significantly different after adjusting for baseline disease extent.CONCLUSION Pancreatitis patients show a non-significant increase in colectomy,after adjusting for baseline disease extent.

Forward-viewing endoscopic ultrasound-guided NOTES interventions: A study on peritoneoscopic potential

AIM:To evaluate the feasibility of diagnostic and therapeutic transgastric(TG)peritoneoscopic interventions with a forward-viewing endoscopic ultrasound(FV-EUS).METHODS:This prospective endoscopic experimental study used an animal model.Combined TG peritoneoscopic interventions and EUS examination of the intraabdominal organs were performed using an FV-EUS on 10 animal models(1 porcine and 9 canine).The procedures carried out include EUS evaluation and endoscopic biopsy of intraperitoneal organs,EUS-guided fine needle aspiration(EUS-FNA),EUS-guided radiofrequency ablation(EUS-RFA),and argon plasma coagulation(APC)for hemostatic control.The animals were kept alive for 7 d,and then necropsy was performed to evaluate results and complications.RESULTS:In all 10 animals,TG peritoneoscopy,followed by endoscopic biopsy for the liver,spleen,abdominal wall,and omentum,was performed successfully.APC helped control minor bleeding.Visualization of intra-abdominal solid organs with real-time EUS was accomplished with ease.Intraperitoneal EUS-FNA was successfully performed on the liver,spleen,and kidney.Similarly,a successful outcome was achieved with EUSRFA of the hepatic parenchyma.No adverse events were recorded during the study.CONCLUSION:Peritoneoscopic natural orifice transluminal endoscopic surgery(NOTES)interventions through FV-EUS were feasible in providing evaluation and performing endoscopic procedures.It promises potential as a platform for future EUS-based NOTES.