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.

Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor

A 57-year-old man underwent endoscopy for investigation of a duodenal polyp. Endoscopy revealed a hemispheric submucosal tumor, about 5 mm in diameter, in the anterior wall of the duodenal bulb. Endoscopic biopsy disclosed a neuroendocrine tumor histologically, therefore endoscopic mucosal resection was conducted. The tumor was effectively and evenly elevated after injection of a mixture of 0.2% hyaluronic acid and glycerol at a ratio of 1:1 into the submucosal layer. A small amount of indigo-carmine dye was also added for coloration of injection fluid. The lesion was completely resected en bloc with a snare after submucosal fluid injection. Immediately, muscle-fiber-like tissues were identified in the marginal area of the resected defect above the blue-colored layer, which suggested perforation. The defect was completely closed with a total of 9 endoclips, and no symptoms associated with peritonitis appeared thereafter. Histologically, the horizontal and vertical margins of the resected specimen were free of tumor and muscularis propria was also seen in the resected specimen. Generally, endoscopic mucosal resection is considered to be theoretically successful if the mucosal defect is colored blue. The blue layer in this case, however, had been created by unplanned injection into the subserosal rather than the submucosal layer.

Endotherapy of leaks and fistula

Perforations, leaks and fistula involving gastrointestinal(GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips(through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula.Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.

Evaluating long-term attachment of two different endoclips in the human gastrointestinal tract

AIM:To evaluate the long-term attachment of two types of endoclips in the human gastrointestinal tract. METHODS:In this prospective observational study,endoclips were placed and followed-up during endoscopies or using fluoroscopic images as part of a pro s pective feasibility study evaluating external beam radiotherapy (EBRT,wk 1-3) followed by high dose rate brachytherapy (HDRBT with an endoluminal app licator once a week for 3 wk,wk 9-11) in medically inoperablerectal cancer patients. Initially,the type and number of endoclips were chosenrandomly and later refined to 1 Resolution clip (Microvasive) proximal and 2 Quickclips (Olympus) distal to the tumor. Nine consecutive patients from between September 2007 and August 2008 were analyzed. Retention rates were evaluated over three different observational periods [period 1:pre-HDRBT (wk-2-8),period 2:during HD RBT (wk 9-11) and period 3:post-HDRBT (wk 1216)]. RESULTS:In this study,a total of 44 clips were placed during endoscopy,either at the beginning or at the end of period 1. The Resolution clip had a higher overall retention rate than the Quickclip (P = 0.01). After a median period of 81 d after placement (in period 1),longterm retention rates for the Resolution clip and Quickclip clip were 67% and 35% respectively. CONCLUSION:The Resolution clip has a high retention rate and is useful in situations where long-term attachment to the human gastrointestinal mucosa is warranted.

圈套器和止血夹肿瘤牵拉技术在胃黏膜下肿瘤内镜切除中的应用:倾向评分匹配分析

背景:包括内镜黏膜下剥离术(ESD)和内镜全层切除术(EFR)在内的内镜技术可用以切除较小的胃黏膜下肿瘤(SMT)。我们团队开发了一种圈套器和止血夹肿瘤牵拉方法,用以辅助SMT的内镜切除。本研究旨在评估这一技术的安全性和有效性。方法:本研究采用倾向评分匹配(PSM)分析,比较圈套器和止血夹辅助的ESD/EFR(圈套器牵拉组)与传统ESD/EFR(传统技术组)用于切除胃SMT的手术时间、整块切除率、围手术期并发症发生率及内镜治疗相关的费用。结果:2012年1月至2019年3月间收治的253例胃SMT患者纳入研究。PSM获得51对病例,两组围手术期并发症发生率和内镜耗材费用的差异均无统计学意义,但圈套器牵拉组中位手术时间缩短(39 vs 60 min,P=0.005),整块切除率提高(100%vs 88.2%,P=0.027)。结论:圈套器牵拉辅助的ESD/EFR用于胃SMT具有更高的手术效率和整块切除率,而且不会增加围手术期并发症发生风险和手术耗材费用。因此,该方法似乎是胃SMT内镜切除的良好选择。