Endoscopic submucosal tunnel dissection for largesuperficial esophageal squamous cell neoplasms

Endoscopic submucosal dissection(ESD)is a wellestablished treatment for superficial esophageal squamous cell neoplasms(SESCNs)with no risk of lymphatic metastasis.However,for large SESCNs,especially when exceeding two-thirds of the esophageal circumference,conventional ESD is time-consuming and has an increased risk of adverse events.Based on the submucosal tunnel conception,endoscopic submucosal tunnel dissection(ESTD)was first introduced by us to remove large SESCNs,with excellent results.Studies from different centers also reported favorable results.Compared with conventional ESD,ESTD has a more rapid dissection speed and R0 resection rate.Currently in China,ESTD for large SESCNs is an important part of the digestive endoscopic tunnel technique,as is peroral endoscopic myotomy for achalasia and submucosal tunnel endoscopic resection for submucosal tumors of the muscularis propria.However,not all patients with SESCNs are candidates for ESTD,and postoperative esophageal strictures should also be taken into consideration,especially for lesions with a circumference greater than three-quarters.In this article,we describe our experience,review the literature of ESTD,and provide detailed information on indications,standard procedures,outcomes,and complications of ESTD.

Consensus on the digestive endoscopic tunnel technique

With the digestive endoscopic tunnel technique(DETT), many diseases that previously would have been treated by surgery are now endoscopically curable by establishing a submucosal tunnel between the mucosa and muscularis propria(MP). Through the tunnel, endoscopic diagnosis or treatment is performed for lesions in the mucosa, in the MP, and even outside the gastrointestinal(GI) tract.At present, the tunnel technique application range covers the following:(1)Treatment of lesions originating from the mucosal layer, e.g., endoscopic submucosal tunnel dissection for oesophageal large or circular early-stage cancer or precancerosis;(2) treatment of lesions from the MP layer, per-oral endoscopic myotomy, submucosal tunnelling endoscopic resection, etc.; and(3) diagnosis and treatment of lesions outside the GI tract, such as resection of lymph nodes and benign tumour excision in the mediastinum or abdominal cavity. With the increasing number of DETTs performed worldwide, endoscopic tunnel therapeutics, which is based on DETT, has been gradually developed and optimized. However, there is not yet an expert consensus on DETT to regulate its indications, contraindications, surgical procedure, and postoperative treatment.The International DETT Alliance signed up this consensus to standardize the procedures of DETT. In this consensus, we describe the definition, mechanism,and significance of DETT, prevention of infection and concepts of DETTassociated complications, methods to establish a submucosal tunnel, and application of DETT for lesions in the mucosa, in the MP and outside the GI tract(indications and contraindications, procedures, pre-and postoperative treatments, effectiveness, complications and treatments, and a comparison between DETT and other operations).

Prospective single-center feasible study of innovative autorelease bile duct supporter to delay adverse events after endoscopic papillectomy

BACKGROUND Conventional endoscopic papillectomy(EP)is safe and effective for the treatment of small papilla adenoma to even large laterally spreading tumors of duodenum lesions.As reported by some existing studies,temporarily placing a prophylactic stent in the pancreatic and bile duct can lower the risk of this perioperative complication.AIM To evaluate the usefulness,convenience,safety,and short-term results of a novel autorelease bile duct supporter after EP procedure,especially the effectiveness in preventing EP.METHODS A single-center comparison study was conducted to verify the feasibility of the novel method.After EP,a metallic endoclip and human fibrin sealant kit were applied for protection.The autorelease bile duct supporter fell into the duct segment and the intestinal segment.Specifically,the intestinal segment was extended by nearly 5 cm as a bent coil.The bile was isolated from the pancreatic juice using an autorelease bile duct supporter,which protected the wound surface.The autorelease bile duct supporter fell off naturally and arrived in colon nearly 10 d after the operation.RESULTS En bloc endoscopic resection was performed in 6/8 patients(75%),and piecemeal resection was performed in 2/8 of patients(25%).None of the above patients were positive for neoplastic lymph nodes or distant metastasis.No cases of mortality,hemorrhage,delayed perforation,pancreatitis,cholangitis or duct stenosis with the conventional medical treatment were reported.The autorelease bile duct supporter in 7 of 8 patients fell off naturally and arrived in colon 10 d after the operation.One autorelease bile duct supporter was successfully removed using forceps or snare under endoscopy.No recurrence was identified during the 8-mo(ranging from 6-9 mo)follow-up period.CONCLUSION In brief,it was found that the autorelease bile duct supporter could decrease the frequency of procedure-associated complications without second endoscopic retraction.Secure closure of the resection wound with clips and fibrin glue were indicated to be promising and important for the use of autorelease bile duct supporters.Well-designed larger-scale comparative studies are required to confirm the findings of this study.

Multiple hidden vessels in walled-off necrosis with high-risk bleeding: Report of two cases

BACKGROUND Walled-off necrosis(WON),as a local complication of acute necrotizing pancreatitis,is difficult to differentiate from pancreatic pseudocysts(PPC).Imaging modalities such as computed tomography show a lower accuracy than endoscopic ultrasound(EUS)in confirming the diagnosis.EUS-guided cystogastrostomy following direct endoscopic necrosectomy has achieved excellent results and has been regarded as a preferred alternative to traditional surgery.However,highrisk bleeding is one of the greatest concerns.CASE SUMMARY Two patients with symptomatic pancreatic fluid collections(PFCs)were admitted to our hospital for EUS-guided lumen-apposing metal stent therapy.The female patient suffered from intermittent abdominal pain and underwent two perioperative CT examinations.The male patient had recurrent pancreatitis and showed a growing PFC.The initial diagnosis was a PPC according to contrast-enhanced CT.However,the evidence of solid contents on EUS prompted revision of the diagnosis to WON.An endoscope was inserted into the cavity,and some necrotic debris and multiple hidden vascular structures were observed.Owing to conservative treatment by irrigation with sterile water instead of direct necrosectomy,we successfully avoided damaging hidden vessels and reduced the risk of intraoperative bleeding.CONCLUSION The application of EUS is helpful for the identification of PFCs.Careful intervention should be conducted for WON with multiple vessels to prevent bleeding.

Long-term outcomes of peroral endoscopic myotomy in achalasia patients with a minimum follow-up of 7 years

There was an enormous increase in reports confirming the safety and efficacy of using peroral endoscopic myotomy(POEM)to treat achalasia since the pioneering of the technique in 2010.[1]However,the reports focused on short to medium-term follow-ups,and data on long-term outcomes of POEM for achalasia were very limited.It still remains unknown whether the satisfactory short-term outcomes are long lasting.Additionally,some achalasia patients receiving POEM noted that they could benefit from post-operative dietary recommendations that would be helpful for symptom remission.Therefore,this study aimed to determine the long-term treatment outcomes of using POEM to treat achalasia,and to assess postoperative Eckardt scores over this period.We also crafted a set of post-POEM dietary recommendations according to the feedback from achalasia patients who underwent this treatment to achieve better symptom remission for post-POEM patients.