Advances and challenges in peroral endoscopic myotomy:Safety,precision,and post-procedure management

Peroral endoscopic myotomy(POEM)has revolutionized the treatment of upper gastrointestinal tract motility disorders,particularly achalasia.This editorial explores the efficacy,safety,and challenges of POEM,emphasizing its role as a primary treatment with excellent long-term outcomes and minimal adverse events.The evolution of POEM underscores the need for precision in myotomy techniques and the importance of interdisciplinary collaboration,especially regar-ding anesthetic considerations.Despite significant advances,challenges remain in standardizing safety protocols and managing complications.As POEM appli-cations expand,precision endoscopy continues to enhance therapeutic outcomes,promising a transformative impact on gastrointestinal motility disorder manage-ment.

Endoscopic ultrasound-guided biliary drainage after failed endoscopic retrograde cholangiopancreatography: The road is open for almighty biliopancreatic endoscopists!

Commentary on the article written and published by Peng et al,investigating the role of endoscopic ultrasound(EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiopan-creatography(ERCP).For 40 years endoscopic biliary drainage was synonymous with ERCP,and EUS was used mainly for diagnostic purposes.The advent of therapeutic EUS has revolutionized the field,especially with the development of a novel device such as electrocautery-enhanced lumen-apposing metal stents.Complete biliopancreatic endoscopists with both skills in ERCP and in interven-tional EUS,would be ideally suited to ensure patients the best drainage technique according to each individual situation.

Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography(ERCP) is one of the most frequently used image-guided procedures in gastrointestinal endoscopy. Post-ERCP pancreatitis is an important concern, and prophylaxis, cannulation and other related technical procedures have been well documented by endoscopists. In addition, medical radiation exposure is of great concern in the general population because of its rapidly increasing frequency and its potential carcinogenic effects. International organizations and radiological societies have established diagnostic reference levels, which guide proper radiation use and serve as global standards for all procedures that use ionizing radiation. However, data on gastrointestinal fluoroscopic procedures are still lacking because the demand for these procedures has recently increased. In this review, we present the current status of quality indicators for ERCP and the methods for measuring radiation exposure in the clinical setting as the next quality indicator for ERCP. To reduce radiation exposure, knowledge of its adverse effects and the procedures for proper measurement and protection are essential. Additionally, further studies on the factors that affect radiation exposure, exposure management and diagnostic reference levels are necessary. Then, we can discuss how to manage medical radiation use inthese complex fluoroscopic procedures. This knowledge will help us to protect not only patients but also endoscopists and medical staff in the fluoroscopy unit.

Highlight of Endoscopic procedures developed in Japan

Endoscopic submucosal dissection （ESD） invented in Japan, plays an important role in the treatment of early gastrointestinal cancer （EGC） and dysplasia. Endoscopic procedures are now widely spreading around the world. ESD has the advantage that en bloc resection as well as pathological view can be achieved when compared with conventional endoscopic mucosal resection （1）.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography(SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76(90%) procedures and clinical success rate of 30/34(88%) patients. Mild adverse event rate was 8/76(11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30(80%) procedures( P = 0.194 vs. biliary SBEERCP) and clinical success rate of 11/17(65%) patients( P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30(20%)( P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study

BACKGROUND Glucagon-like peptide-1 receptor agonists(GLP-1 RA)are effective in diabetes and obesity,reducing hyperglycemia by increasing insulin release and delaying gastric emptying.However,they can cause gastroparesis,raising concerns about aspiration during procedures.Recent guidelines advise discontinuing GLP-1 RA before surgery to reduce the risk of pulmonary aspiration.AIM To evaluate the effect of GLP-1 RAs on gastric residual contents during endosco-pic procedures.METHODS A retrospective chart review at BronxCare Health System,New York,from January 2019 to October 2023,assessed gastric residue and aspiration in GLP-1 RA patients undergoing endoscopic procedures.Two groups were compared based on dietary status before the procedure.Data included demographics,symptoms of gastroparesis,opiate use,hemoglobin A1c,GLP-1 agonist indication,endo-scopic details,and aspiration occurrence.IBM SPSS was used for analysis,cal-culating means,standard deviations,and applying Pearson’s chi-square and t-tests for associations,with P<0.05 as being significant.RESULTS During the study,306 patients were included,with 41.2%on a clear liquid/low residue diet and 58.8%on a regular diet before endoscopy.Most patients(63.1%)were male,with a mean age of 60±12 years.The majority(85.6%)were on GLP-1 RAs for diabetes,and 10.1%reported digestive symptoms before endoscopy.Among those on a clear liquid diet,1.5%had residual food at endoscopy compared to 10%on a regular diet,which was statistically significant(P=0.03).Out of 31 patients with digestive symptoms,13%had residual food,all from the regular diet group(P=0.130).No complications were reported during or after the procedures.CONCLUSION The study reflects a significant rise in GLP-1 RA use for diabetes and obesity.A 24-hour liquid diet seems safe for endoscopic procedures without aspiration.Patients with upper gastrointestinal symptoms might have a higher residual food risk,though not statistically significant.Further research is needed to assess risks based on diabetes duration,gastroparesis,and GLP-1 RA dosing,aiming to minimize interruptions in therapy during procedures.

Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030,a high mortality rate considering the number of cases.Surgery and chemotherapy are the main treatment options,but they are burdensome for patients.A clear histological diagnosis is needed to determine a treatment plan,and endoscopic ultrasound(EUS)-guided tissue acquisition(TA)is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding.With the development of personalized medicine and precision treatment,there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure,leading to the development of the fine-needle biopsy(FNB)needle.EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration(FNA)as the procedure of choice for EUS-TA of pancreatic cancer.However,EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions,so it is important clinicians are familiar with both.Given these recent developments,we present an up-to-date review of the role of EUS-TA in pancreatic cancer.Particularly,technical aspects,such as needle caliber,negative pressure,and puncture methods,for obtaining an adequate specimen in EUS-TA are discussed.

Endoscopic treatment for acute appendicitis with coexistent acute pancreatitis: Two case reports

BACKGROUND Appendectomy is the procedure of choice for the treatment of acute appendicitis.However,surgery may not be appropriate for patients with coexisting severe illness or comorbidities such as acute pancreatitis(AP).Endoscopic retrograde appendicitis treatment(ERAT)may be a novel alternative to surgery for treating such patients where existing medical therapies have failed.CASE SUMMARY We report 2 cases of moderately severe AP who developed acute uncomplicated appendicitis during their hospital stay and did not respond to traditional medical therapy.One patient had moderately severe AP due to hyperlipidemia,while the other patient had a gallstone induced by moderately severe AP.Neither patient was fit to undergo an appendectomy procedure because of the concurrent AP.Therefore,the alternative and minimally invasive ERAT was considered.After written informed consent was collected from the patients,the ERAT procedure was performed.Both patients exhibited fast postoperative recovery after ERAT with minimal surgical trauma.CONCLUSION ERAT is a safe and effective minimally invasive endoscopic procedure for acute appendicitis in patients with coexistent AP.

Safe procedure in endoscopic submucosal dissection for colorectal tumors focused on preventing complications

Endoscopic submucosal dissection (ESD) is efficient for en bloc resection of large colorectal tumors. However, it has several technical difficulties, because the wall of the colon is thin and due to the winding nature of the colon. The main complications of ESD comprise postoperative perforation and hemorrhage, similar to endoscopic mucosal resection (EMR). In particular, the rate of perforation in ESD is higher than that in EMR. Perforation of the colon can cause fatal peritonitis. Endoscopic clipping is reported to be an efficient therapy for perforation. Most cases with perforation are treated conservatively without urgent surgical intervention. However, the rate of postoperative hemorrhage in ESD is similar to that in EMR. Endoscopic therapy including endoscopic clipping is performed and most of the cases are treated conservatively without blood transfusion. In blood examination, some degree of inflammation is detected after ESD. For the standardization of ESD, it is most important to decrease the rate of perforation. Adopting a safe strategy for ESD and a suitable choice of knife are both important waysof preventing perforation. Moreover, appropriate training and increasing experience can improve the endoscopic technique and can decrease the rate of perforation. In this review, we describe safe procedures in ESD to prevent complications, the complications of ESD and their management.

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients were submitted to surgery (log-odds, ADC: -2.1206 ± 0.6249 vs SCC: 4.1356 ± 0.4038, P < 0.05). The odds for re-classification of tumor stage after endoscopic resection were 53% and 39% for ADC and SCC, respectively. Local tumor recurrence was best predicted by grade 3 differentiation and piecemeal resection, metachronous cancer development by the carcinoma in situ component, and lymph node positivity by lymphovascular invasion. With regard to surgically resected patients: Significant differences in patients with positive lymph nodes were observed between ADC and SCC [coefficient: 1.889569, 95%CI: (0.3945146, 3.384624), P<0.01). In contrast, lymphovascular and microvascular invasion and grade 3 patients between histologic types were comparable, the respective rank order of the predictors of lymph node positivity was: Grade 3, lymphovascular invasion (L+), microvascular invasion (V+), submucosal (Sm) 3 invasion, Sm2 invasion and Sm1 invasion. Histologic type (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were Sm3 invasion and (V+). For ADC, the most important predictor was (L+). CONCLUSION: Local tumor recurrence is predicted by grade 3, metachronous cancer by the carcinoma insitu component, and lymph node positivity by L+. T1b cancer should be treated with surgical resection.

Usefulness of the clip-flap method of endoscopic submucosal dissection: A randomized controlled trial

AIM To prospectively investigate the efficacy and safety of clipflap assisted endoscopic submucosal dissection(ESD) for gastric tumors.METHODS From May 2015 to October 2016, we enrolled 104 patients with gastric cancer or adenoma scheduled for ESD at Shiga University of Medical Science Hospital. We randomized patients into two subgroups using the minimization method based on location of the tumor(upper, middle or lower third of the stomach), tumor size(< 20 mm or > 20 mm) and ulcer status: ESD using an endoclip(the clip-flap group) and ESD without an endoclip(the conventional group). Therapeutic efficacy(procedure time) and safety(complication: Gastrointestinal bleeding and perforation) were assessed. RESULTS En bloc resection was performed in all patients. Four patients had delayed bleeding(3.8%) and two had perforation(1.9%). No significant differences in en bloc resection rate(conventional group: 100%, clip flap group: 100%), curative endoscopic resection rate(conventional group: 90.9%, clip flap group: 89.8%, P = 0.85), procedure time(conventional group: 70.8 ± 46.2 min, clip flap group: 74.7 ± 53.3 min, P = 0.69), area of resected specimen(conventional group: 884.6 ± 792.1 mm^2, clip flap group: 1006.4 ± 1004.8 mm^2, P = 0.49), delayed bleeding rate(conventional group: 5.5%, clip flap group: 2.0%, P = 0.49), or perforation rate(conventional group: 1.8%, clip flap group: 2.0%, P = 0.93) were found between the two groups. Lessexperienced endoscopists did not show any differences in procedure time between the two groups.CONCLUSION For patients with early-stage gastric tumors, the clipflap method has no advantage in efficacy or safety compared with the conventional method.

Response to endoscopic therapy for biliary anastomotic strictures in deceased versus living donor liver transplantation

BACKGROUND:Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation(DDLT) and living donor liver transplantation(LDLT).LDLT is thought to be associated with higher rates of biliary complications,but there are few studies comparing the success of endoscopic management of anastomotic strictures between the two groups.This study aims to compare our experience in the endoscopic management of anastomotic strictures in DDLT versus LDLT.METHODS:This is a retrospective database review of all liver transplant patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) after liver transplantation.The frequency of anastomotic stricture and the time to develop and to resolve anastomotic stricture were compared between DDLT and LDLT.The response of anastomotic stricture to endoscopic therapy was also analyzed.RESULTS:A total of 362 patients underwent liver transplantation between 2003 and 2011,with 125 requiring ERCP to manage biliary complications.Thirty-three(9.9%) cases of DDLT and 8(27.6%) of LDLT(P=0.01) were found to have anastomotic stricture.When comparing DDLT and LDLT,there was no difference in the mean time to the development of anastomotic strictures(98±17 vs 172±65 days,P=0.11),likelihood of response to ERCP [22(66.7%) vs 6(75.0%),P=0.69],mean time to the resolution of anastomotic strictures(268±77 vs 125±37 days,P=0.34),and the number of ERCPs required to achieve resolution(3.9±0.4 vs 4.7±0.9,P=0.38).CONCLUSIONS:Endoscopic therapy is effective in the majority of biliary complications relating to liver transplantation.Anastomotic strictures occur more frequently in LDLT compared with DDLT,with equivalent endoscopic treatment response and outcomes for both groups.

Endoscopic treatment for pancreatic diseases:Needle-knife-guided cannulation via the minor papilla

AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulationsvia the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.RESULTS: Standard methods were successful in79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17(89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%,(79 +17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further(80.6%, 79/98 vs98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods(4.7% vs 10.5%, P = 0.301).CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.

Predictive factors of endoscopic submucosal dissection procedure time for gastric superficial neoplasia

AIM:To identify the determinants of endoscopic submucosal dissection(ESD) operation time.METHODS:This investigation was conducted as a single-center,prospective study in which ESD was performed by the same endoscopist at the Chinese PLA General Hospital.A total of 173 patients underwent ESD operations performed by Dr.Lu from July 2007 to December 2011,and 183 lesions were enrolled.Patient gender,age,tumor location,gross type,tumor size,pathological type and adhesions were recorded prospectively.The order of treatment represented the experience of the operator.Univariate analysis and multivariate analysis were performed to evaluate the relationships between these factors and ESD procedure time.RESULTS:Univariate analysis showed the ESD time was closely related to the gender(P = 0.0210),tumor size(P < 0.0001),location(P < 0.0001),gross type(P < 0.0001) and adhesion(P = 0.0010).The surgical proficiency level was associated with ESD time in unit area(P < 0.0001).Multivariate analysis revealed that the ESD time was positively correlated with tumor size(P < 0.0001),adhesion(P < 0.0001) and location(P < 0.0001),but negatively correlated with surgical proficiency level(P = 0.0046).CONCLUSION:Large tumor size,adjacency to the cardia,and adhesion are predictors of a long ESD time,whereas high surgical proficiency level predicts a short ESD time.

A novel device for endoscopic submucosal dissection,the Fork knife

AIM： To introduce and evaluate the efficacy and technical aspects of endoscopic submucosal dissection （ESD） using a novel device, the Fork knife. METHODS： From March 2004 to April 2008, ESD was performed on 265 gastric lesions using a Fork knife （Endo FS） （group A） and on 72 gastric lesions using a Flexknife （group B） at a single tertiary referral center. We retrospectively compared the endoscopic characteristics of the tumors, pathological findings, and sizes of the resected specimens. We also compared the en b/oc resection rate, complete resection rate, complications, and procedure time between the two groups. RESULTS： The mean size of the resected specimens was 4.27 ± 1.26 cm in group A and 4.29 ± 1.48 cm in group B. The en b/oc resection rate was 95.8% （254/265 lesions） in group A and 93.1% （67/72） in group B. Complete ESD without tumor cell invasion of the resected margin was obtained in 81.1% （215/265） of group A and in 73.6% （53/72） of group B. The perforation rate was 0.8% （2/265） in group A and 1.4% （1/72） in group B. The mean procedure time was 59.63 ± 56.12 min in group A and 76.65 ± 70.75 min in group B （P 〈 0.05）. CONCLUSION： The Fork knife （Endo FS） is useful for clinical practice and has the advantage of reducing the procedure time.

Successful endoscopic closure of a colonic perforation one day after endoscopic mucosal resection of a lesion in the transverse colon

A 73-year-old man underwent endoscopic mucosal resection(EMR) of a 20-mm flat elevated lesion on the transverse colon. The morning after the procedure, he started to have severe right upper quadrant pain after his first meal. A computed tomography scan revealed free air and a stomach filled with food. He was diagnosed to have delayed post-EMR intestinal perforation. He underwent emergent colonoscopy and clipping of the perforated site. He was discharged 8 d after the endoscopic closure without the need for surgical intervention. The meal was not the cause of the colon transversum perforation.

Electrocautery vs non-electrocautery dilation catheters in endoscopic ultrasonography-guided pancreatic fluid collection drainage

AIM: To investigate the safety and utility of an electrocautery dilation catheter for endoscopic ultrasonography(EUS)-guided pancreatic fluid collection drainage.METHODS: A single-center, exploratory, retrospective study was conducted between August 2010 and August 2014. This study was approved by the Medical Ethics Committee of our institution. Informed, written consent was obtained from each patient prior to the procedure. The subjects included 28 consecutive patients who underwent EUS-guided transmural drainage(EUS-TD) for symptomatic pancreatic and peripancreatic fluid collections(PFCs) by fine needle aspiration using a 19-gauge needle. These patients were retrospectively divided into two groups based on the use of an electrocautery dilation catheter as a fistula dilation device; 15 patients were treated with an electrocautery dilation catheter(electrocautery group), and 13 patients were treated with a non-electrocautery dilation catheter(non-electrocautery group). We evaluated the technical and clinical successes and the adverse events associated with EUS-TD for the treatment of PFCs between the two groups.RESULTS: There were no significant differences in age, sex, type, location and diameter of PFCs between the groups. Thirteen patients(87%) in the electrocauterygroup and 10 patients(77%) in the non-electrocautery group presented with infected PFCs. The technical success rates of EUS-TD for the treatment of PFCs were 100%(15/15) and 100%(13/13) for the electrocautery and the non-electrocautery groups, respectively. The clinical success rates of EUS-TD for the treatment of PFCs were 67%(10/15) and 69%(9/13) for the electrocautery and the non-electrocautery groups, respectively(P = 0.794). The procedure time of EUS-TD for the treatment of PFCs in the electrocautery group was significantly shorter than that of the non-electrocautery group(mean ± SD: 30 ± 12 min vs 52 ± 20 min, P < 0.001). Adverse events associated with EUS-TD for the treatment of PFCs occurred in 0 patients and 1 patient for the electrocautery and the non-electrocautery groups, respectively(P = 0.942).CONCLUSION: EUS-TD using an electrocautery dilation catheter as a fistula dilation device for the treatment of symptomatic PFCs appears safe and contributes to a shorter procedure time.

Influence of night duty on endoscopic therapy for bile duct stones

AIM To examine the influence of night duty(ND) on endoscopic therapy for biliary duct stones.METHODS The subjects consisted of 133 patients who received initial endoscopic therapy for biliary duct stones performed by eight endoscopists after they had been on(ND group, n = 34 patients) or not [day duty(DD) group, n = 99 patients]. Patient characteristics(age, gender, history of abdominal surgery, transverse diameter of the largest stone, number of stones), years of experience of the endoscopists, endoscopic procedures [sphincterotomy, papillary balloon dilation(EPBD), papillary large balloon dilation(EPLBD)], and outcomes of initial endoscopy(procedure time; rate of stone removal by the first endoscopist; proceduresuccess rate by the first endoscopist: removal of stones or endoscopic retrograde biliary drainage; rate of final stone removal; final procedure success rate; complications; hospitalization after the procedure) were compared retrospectively between the two groups. History of abdominal surgery and treatment outcomes were also compared between the groups for each of the four endoscopists who performed most of the procedures in the ND group.RESULTS There were no significant differences regarding the number of treatments performed by each endoscopist or the years of experience between the ND and DD groups. The frequency of endoscopic retrograde cholangiopancreatography procedures did not differ significantly between the groups. There were also no significant differences regarding patient characteristics: age, gender, history of abdominal surgery(ND 7: Billroth II 4, R-Y 3; DD 18: double tract reconstruction 1, Billroth I 3, Billroth II 6, R-Y 7, duodenoduodenostomy for annular pancreas 1), transverse diameter of largest stone, and number of stones between the two groups. Among the treatment procedures, the endoscopic s p h i n c t e r o t o m y a n d E P B D r a t e s d i d n o t d i f f e r significantly between the groups. However, EPLBD was performed more frequently in the ND group [47.1%(16/34) v s 19.2%(19/99)]. Regarding outcomes, there were no significant differences in the rate of stone removal, procedure success rate, complications(ND: pancreatitis 1; DD: pancreatitis 6, duodenal bleeding 1, decreased blood pressure 1, hypoxia 2), or hospitalization after the procedure. However, the procedure time was significantly longer in the ND group(71.5 ± 44.7 vs 54.2 ± 28.8). Among the four endoscopists, there were no significant differences in patient history of abdominal surgery, removal of stones, or procedure success rate. However, the procedure time for one endoscopist was significantly longer in the ND group.CONCLUSION The time required for endoscopic therapy for bile duct stones might be influenced by ND.

Surgical treatment of a rare complication after endoscopic stent placement for anastomotic leakage after esophageal resection

The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Complete obstruction of the esophagus, induced by preoperative chemo-radiation therapy. Normally, strictures are treated by repeated dilatations, however, in case of complete obstruction, the perforation rate of standard blind anterograde wire access and dilation is severely increased. In order to minimize the risk of perforations, the rendezvous technique was introduced. This technique involves an anterograde approach in combination with a retrograde approach in order to open and dilatate the esophagus. While technical success rates between 83% and 100% have been reported in literature, data on clinical outcomes are scarcer. The limited amount of studies available claim that success was achieved in almost half of patients. The patient in our case currently has an oral diet without restrictions and rates his quality of life with a VAS-score ten out of ten.

Same site submucosal tunneling for a repeat per oral endoscopic myotomy: a safe and feasible option

Per oral endoscopic myotomy(POEM) is a novel endoscopic procedure for achalasia treatment. Due to its novelty and high success rates, a repeat procedure is usually not warranted, making the feasibility and safety of such approach unknown. We report the first case of a successful repeat POEM done at the same site of a previously uncompleted POEM. An 84-year-old female with type 2 achalasia presented for a POEM procedure. The procedure was aborted at the end of tunneling and before myotomy due to hypotension, which later resolved spontaneously. POEM was re-attempted at the same site of the original tunnel 1 year afterward, and surprisingly we didn't encounter any submucosal fibrosis. The procedure felt similar to a native POEM and a myotomy was performed uneventfully. Our case is the first to suggest that submucosal tunneling during a repeat POEM can be done at the same site. Hypotension during POEM is a rare complication that should be recognized as a potential result of tension capnothorax, it can however, be managed with close supportive care.