Efficacy of endoluminal gastroplication in Japanese patients with proton pump inhibitor-resistant,non-erosive esophagitis

AIM： To evaluate the efficacy, safety, and long-term outcomes of endoluminal gastroplication （ELGP） in pa- tients with proton pump inhibitor （PPI）-resistant, non- erosive reflux disease （NERD）. METHODS： The subjects were NERD patients, diag- nosed by upper endoscopy before PPI use, who had symptoms such as heartburn or reflux sensations two or more times a week even after 8 wk of full-dose PPI treatment. Prior to ELGP, while continuing full-dose PPImedication, patients＇ symptoms and quality of life （QOL） were assessed using the questionnaire for the diagno- sis of reflux disease, the frequency scale for symptoms of gastro-esophageal reflux disease （FSSG）, gastroin- testinal symptoms rating scale, a 36-item short-form. In addition, 24-h esophageal pH monitoring or 24-h in- traesophageal pH/impedance （MII-pH） monitoring was performed. The Bard EndoCinchTM was used for ELGP, and 2 or 3 plications were made. After ELGP, all acid reducers were temporarily discontinued, and medica- tion was resumed depending on the development and severity of symptoms. Three mo after ELGP, symptoms, QOL, pH or MII-pH monitoring, number of plications, and PPI medication were evaluated. Further, symptoms, number of plications, and PPI medication were evalu- ated 12 mo after ELGP to investigate long-term effects. RESULTS： The mean FSSG score decreased signifi- cantly from before ELGP to 3 and 12 mo after ELGP （19.1 ：k 10.5 to 10.3 ＋ 7.4 and 9.3 ＋ 9.9, P 〈 0.05, respectively）. The total number of plications decreased gradually at 3 and 12 mo after ELGP （2.4 ＋ 0.8 to 1.2 ：l： 0.8 and 0.8 ：l： 1.0, P 〈 0.05, respectively）. The FSSG scores in cases with no remaining plications and in cases with one or more remaining plications were 4.4 and 2.7, respectively, after 3 too, and 2.0 and 2.8, respectively, after 12 mo, showing no correlation to plication loss. On pH monitoring, there was no differ- ence in the percent time pH 〈 4 from before ELGP to 3 mo after. Impedance monitoring revealed no changes in the number of reflux episodes or the symptom index for reflux events from before ELGP to 3 mo after, but the symptom sensitivity index decreased significantly 3 mo after ELGP （16.1：1：12.9 to 3.9 ~ 8.3, P 〈 0.01）. At 3 mo after ELGP, 6 patients （31.6%） had reduced their PPI medication by 50% or more, and 11 patients （57.9%） were able to discontinue PPI medication alto- gether. After 12 mo, 3 patients （16.7%） were able toreduce the amount of PPI medication by 50% or more, and 22 patients （66.7%） were able to discontinue PPI medication altogether. A high percentage of cases with remaining plications had discontinued PPIs medication after 3 mo, but there was no difference after 12 mo. No serious complications were observed in this study. CONCLUSION： ELGP was safe, resulted in significant improvement in subjective symptoms, and allowed less medication to be used over the long term in patients with PPI-refractory NERD.

Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage:A critical analysis

Endoluminal vacuum-assisted therapy(EVT)has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients.Its application has been mainly reserved to low colorectal and colo-anal anastomoses.The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity,to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity.The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement,percutaneous drainage,endoscopic clipping of the anastomotic defect or stent placement.Nevertheless,despite this procedure is gaining acceptance among the surgical community,indications,inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous,making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure.Moreover,long-term and functional results are poorly reported.The present review is focused on critically analyzing the theoretical benefits and risks of the procedure,short-and long-term functional results and future direction in the application of EVT.

Angioscopic Observation of an Endoluminal Stent Graft: CT Imaging versus Angioscopic Imaging

We could observe the endoluminal stent graft (SG) following thoracic endovascular aneurysm repair (TEVAR) by a coronary artery angioscope and establish intravascular visualization of SG. The patient was a 70-year-old woman with the distal aortic arch aneurysm and the descending aortic aneurysm, and debranching TEVAR were performed. After 12 months follow up, urgent hospitalization was required for chest pain, and cardiac catheter examination with a coronary artery angioscope was performed. The endoluminal SG was observed. The observation in angioscope which is a video image is better than CT that is a still image, and observation in blood vessel or SG is possible. It may be possible to observe the endoluminal SG, allowing potential investigation of an endoleak, or the covering status of the SG with the native aortic vessel wall, or the state of intimal membrane formation in the endoluminal graft.

Endoluminal closure of an unrecognized penetrating stab wound of the duodenum with endoscopic band ligation: A case report

BACKGROUND A penetrating injury of a hollow viscus is an obvious indication for an exploratory laparotomy,but is not typically an indication for endoscopic treatment.CASE SUMMARY A 27-year-old man visited the emergency department with a self-inflicted abdominal stab wound.Injuries to the colon and ileum were detected,but an injury to the second portion of the duodenum was missed.On the day following admission to our institution,the patient became hemodynamically unstable with massive hematochezia,although there was no evidence of bleeding in the Levin tube or Jackson-Pratt drain.We thus performed an upper gastrointestinal endoscopy and discovered a missed duodenal injury that was actively bleeding.An endoscopic band ligation was performed for hemostasis and closure of the perforation.The patient was subsequently discharged without any complications.CONCLUSION A penetrating injury of the duodenum can be overlooked,so careful abdominal exploration is very important.If a missed duodenal injury is suspected,a cautious endoscopic approach may be helpful.

Preemptive endoluminal vacuum therapy after pancreaticoduodenectomy: A case report

BACKGROUND Pancreaticoduodenectomy is a technically demanding operation,with reported morbidity rates of approximately 40%-50%.A novel idea is to use endoscopic vacuum therapy(EVT)in a preemptive setting to prevent anastomotic leakage and pancreatic fistulas.In a recent case series,EVT was proven to be effective in preventing leaks in patients with anastomotic ischemia.There have been no previous reports on preemptive EVT after pancreaticoduodenectomy.CASE SUMMARY We describe the case of a 71-year-old woman with hypertension and diabetes who was admitted to the emergency room with jaundice,choluria,fecal acholia,abdominal pain,and fever.Admission examinations revealed leukocytosis and hyperbilirubinemia(total:13 mg/dL;conjugated:12.1 mg/dL).Abdominal ultrasound showed cholelithiasis and dilation of the common bile duct.Magnetic resonance imaging demonstrated a stenotic area,and a biopsy confirmed cholangiocarcinoma. Considering the high risk of leaks after pancreaticoduodenectomy,preemptive endoluminal vacuum therapy was performed.The system comprised a nasogastric tube,gauze,and an antimicrobial incise drape.The negative pressure was 125 mmHg,and no adverse events occurred.The patient was discharged on postoperative day 5 without any symptoms.CONCLUSION Preemptive endoluminal vacuum therapy may be a safe and feasible technique to reduce leaks after pancreaticoduodenectomy.

Efficacy and safety of percutaneous transhepatic biliary radiofrequency ablation in patients with malignant obstructive jaundice

BACKGROUND Percutaneous transhepatic cholangiodrainage(PTCD)and endoscopic retrograde cholangiopancreatography/endoscopic nasobiliary drainage are the most common clinical procedures for jaundice control in patients with unresectable malignant obstructive jaundice,yet the safety and effect of endobiliary radiofrequency ablation(EB-RFA)combined PTCD is rarely reported,in this article,we report our experience of EB-RFA combined PTCD in such patients.AIM To retrospectively study the efficacy and safety of EB-RFA combined PTCD in patients with unresectable malignant obstructive jaundice.METHODS Patients with unresectable malignant obstructive jaundice treated with EB-RFA under PTCD were selected,the bile ducts of the right posterior lobe was selected as the target bile ducts in all cases.The general conditions of all patients,preoperative tumour markers,total bilirubin(TBIL),direct bilirubin(DBIL),albumin(ALB),alkaline phosphatase(ALP),and glutamyl transferase(GGT)before and on the 7th day after the procedure,as well as perioperative complications,stent patency time and patient survival were recorded.RESULTS All patients successfully completed the operation,TBIL and DBIL decreased significantly in all patients at the 7th postoperative day(P=0.009 and 0.006,respectively);the values of ALB,ALP and GGT also decreased compared with the preoperative period,but the difference was not statistically significant.Perioperative biliary bleeding occurred in 2 patients,which was improved after transfusion of blood and other conservative treatments,pancreatitis appeared in 1 patient after the operation,no serious complication and death happened after operation.Except for 3 patients with loss of visits,the stent patency rate of the remaining 14 patients was 100%71%and 29%at the 1^(st),3^(rd),and 6^(th)postoperative months respectively,with a median survival of 4 months.CONCLUSION EB-RFA under PTCD in patients with unresectable malignant obstructive jaundice has a satisfactory therapeutic effect and high safety,which is worthy of further clinical practice.

Evolutions and Future Directions of Surgical Robotics: A Review

Although the robotics firstly appeared as an entertainment form, its capabilities have continuously advanced from the world’s first industrial robot to the surgical robotic systems which are today capable of performing many surgical maneuvers unaided. However, these surgical robots are not autonomous systems;they are designed to complete a surgeon’s abilities and converting surgeon’s movements into incredibly steady and accurate robotic movements that finally manipulate surgical instruments to assist delicate operations. This novel type of surgery is carried out in the form of minimally invasive surgical procedure and has offered valuable alternatives to enhance traditional open surgery approach. Although the surgical robotic systems began as external robots, technological progresses are directing the surgical robotic systems to endoluminal robots which consist of doing surgical maneuvers by navigating of robot through lumens of human body. Here, we will briefly review different applications of robotic systems in various fields of medicine. Then, we will discuss minimally invasive surgical systems and their role in progressing of minimally invasive surgery as a modern surgery method. By thoroughly investigating a considerable amount of published materials about the minimally invasive surgical technologies, we will study the recent research activities and commercially available samples of surgical robotic systems.

Endoscopic submucosal dissection for colorectal neoplasms

Although endoscopic submucosal dissection(ESD) gains acceptance as one of the standard treatments for esophageal and stomach neoplasms in Japan,it is still in the developing stage for colorectal neoplasms.In terms of indications,little likelihood of nodal metastasis and technical resectability are principally considered.Some of intramucosal neoplasms,carcinomas with minute submucosal invasion,and carcinoid tumors,which are technically unresectable by conventional endoscopic treatments,may become good candidates for ESD,considering substantial risks and obtained benefits.ESD as a staging measure to obtain histological information of the invasion depth and lymphovascular infiltration is acceptable because preoperative prediction is difficult in some cases.In terms of techniques,advantages of ESD in comparison with other endoscopic treatments are to be controllable in size and shape,and to be resectable even in large and fibrotic neoplasms.The disadvantages may be longer procedure time,heavier bleeding,and higher possibility of perforation.However,owing to refinement of the techniques,invention of devices,and the learning curve,acceptable technical safety has been achieved.Colorectal ESD is very promising and become one of the standard treatments for colorectal neoplasms in the near future.

Low grade dysplasia in Barrett's esophagus:Should we worry?

The optimal management for low-grade dysplasia(LGD)in Barrett’s esophagus is unclear.In this article the importance of LGD is discussed,including the significant risk of progression to esophageal adenocarcinoma.Endoscopic surveillance is a management option but is plagued by sampling error and issues of suboptimal endoscopy.Furthermore endoscopic surveillance has not been demonstrated to be cost-effective or to reduce cancer mortality.The emergence of endoluminal therapy over the past decade has resulted in a paradigm shift in the management of LGD.Ablative therapy,including radiofrequency ablation,has demonstrated promising results in the management of LGD with regards to safety,cost-effectiveness,durability and reduction in cancer risk.It is,however,vital that a shareddecision making process occurs between the physician and the patient as to the preferred management of LGD.As such the management of LGD should be"individualised."