Colonoscopic perforation:A report from World Gastroenterology Organization endoscopy training center in Thailand

瞄准：决定 colonoscopic 穿孔(CP ) 的发生，并且从在泰国训练中心的世界肠胃病学组织(WGO ) 内视镜检查法与 CP 评估病人的临床的调查结果，管理和结果。方法：所有 colonoscopies 和 sigmoidoscopies 在内视镜的单位表现在 1999 和 2007 之间，药 Siriraj 医院的教师， Mahidol 大学，曼谷被考察。CP，病人的特征，内视镜的信息， intra 起作用的调查结果，管理和结果的发生被分析。结果：结肠(13699 colonoscopies 和 3658 灵活 sigmoidoscopies ) 的 17357 内视镜的过程的一个总数在 9 年的经期上在 Siriraj 医院里被执行。十五个病人(0.09%) 有 CP：14 从结肠镜检查并且 1 从乙状结肠镜检查。穿孔的最普通的地点在 S 字形的冒号(80%) ，由横向的冒号(13%) 列在后面。穿孔被直接损伤从柄或内诊镜的尖端引起(n = 12， 80%) 并且内视镜的 polypectomy (n = 3， 20%) 。有 CP 的所有病人经历了外科的管理：主要修理(27%) 和肠切除术(73%) 。死亡率是 13% ，手术后的复杂并发症率是 53% 。结论：CP 是稀罕却严肃的复杂并发症追随者结肠镜检查和乙状结肠镜检查，与病态和死亡的高率。CP 的发生是 0.09% 。外科仍然是 CP 管理的支柱。

Sedation-related complications in gastrointestinal endoscopy

Sedation practices for gastrointestinal endoscopic(GIE) procedures vary widely in different countries depending on health system regulations and local circumstances. The goal of procedural sedation is the safe and effective control of pain and anxiety, as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation-related complications in gastrointestinal endoscopy, once occurred, can lead to significant morbidity and occasional mortality in patients. The risk factors of these complications include the type, dose and mode of administration of sedative agents, as well as the patient's age and underlying medical diseases. Complications attributed to moderate and deep sedation levels are more often associated with cardiovascular and respiratory systems. However, sedation-related complications during GIE procedures are commonly transient and of a mild degree. The risk for these complications while providing any level of sedation is greatest when caring for patients already medically compromised. Significant unwanted complications can generally be prevented by careful pre-procedure assessment and preparation, appropriate monitoring and support, as well as post-procedure management. Additionally, physicians must be prepared to manage these complications. This article will review sedation-related complications duringmoderate and deep sedation for GIE procedures and also address their appropriate management.

Sedation and monitoring for gastrointestinal endoscopy

The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities.Additionally,appropriate selection and preparation of patients,suitable sedative technique,application of drugs,adequate monitoring,and proper recovery of patients is essential.The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness.Sedation practices for gastrointestinal endoscopy(GIE) vary widely.The majority of GIE patients are ambulatory cases.Most of this procedure requires a short time.So,short acting,rapid onset drugs with little adverse effects and improved safety profiles are commonly used.The present review focuses on commonly used regimens and monitoring practices in GIE sedation.This article is to discuss the decision making process used to determine appropriate pre-sedation assessment,monitoring,drug selection,dose of sedative agents,sedation endpoint and post-sedation care.It also reviews the current status of sedation and monitoring for GIE procedures in Thailand.

Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention

Endoscopic retrograde cholangiopancreatography(ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation re-sults in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.

Rare adult gastric duplication cyst mimicking a gastrointestinal stromal tumor

Gastric duplication cyst is a very rare gastrointestinal tract malformation that accounts for 2%-4%of alimentary tract duplications.Most cases are diagnosed within the first year of life,following presentation of abdominal pain,vomiting,and weight loss and clinical discovery of an abdominal palpable mass.This case report describes a very uncommon symptomatic gastric duplication cyst diagnosed for the first time in adulthood.Only a few other case reports of similar condition exist,and all were identified by endosonography.The current case involves a 52-year-old male who presented with a onemonth history of progressive iron deficiency anemia without overt gastrointestinal bleeding.The patient underwent esophagogastroduodenoscopy,which revealed a 2.0 cm pinkish subepithelial lesion,suspected to be a gastrointestinal stromal tumor(GIST)and source of gastrointestinal bleeding.The endosonography showed inhomogeneous hypoechoic lesions with focal anechoic areas arising from a second and third layer of the gastric wall.Differential diagnoses of GIST,neuroendocrine tumor,or pancreatic heterotopia were made.The lesion was removed using an endoscopic submucosal resection technique.Histopathology revealed an erosive gastric mass composed of a complex structure of dilated gastric glands surrounded by fibro-muscular tissue,fibroblasts,and smooth muscle bundles,which led to the diagnosis of gastric duplication.

Dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography

BACKGROUND:In general,the dose requirement and complications of propofol are lower when used in the diluted form than in the undiluted form.The aim of this study was to determine the dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography.METHODS:Eighty-six patients were randomly assigned to either group D (diluted propofol) or U (undiluted propofol).All patients were sedated with 0.02-0.03 mg/kg midazolam (total dose ≤2 mg for age <70 years and 1 mg for age ≥70) and 0.5-1 μg/kg fentanyl (total dose ≤75 μg for age <70 and ≤50 μg for age ≥70).Patients in group U (42) were sedated with standard undiluted propofol (10 mg/mL).Patients in group D (44) were sedated with diluted propofol (5 mg/mL).All patients in both groups were monitored for the depth of sedation using the Narcotrend system.The primary outcome variable was the total dose of propofol used during the procedure.The secondary outcome variables were complications during and immediately after the procedure,and recovery time.RESULTS:All endoscopies were completed successfully.Mean propofol doses per body weight and per body weight per hour in groups D and U were 3.0 mg/kg,6.2 mg/kg per hour and 4.7 mg/kg,8.0 mg/kg per hour,respectively.The mean dose of propofol,expressed as total dose,dose/kg or dose/kg per hour and the recovery time were not significantly different between the two groups.Sedation-related adverse events during and immediately after the procedure were higher in group U (42.9%) than in group D (18.2%) (P=0.013).CONCLUSIONS:Propofol requirement and recovery time in the diluted and undiluted propofol groups were comparable.However,the sedation-related hypotension was significantly lower in the diluted group than the undiluted group.

Comparison of early pre-cutting vs standard technique for biliary cannulation in endoscopic retrograde cholangiopancreatography: A personal experience

AIM: To compare the results and complications of early pre-cutting technique with standard technique. METHODS: From January 2003 to December 2004, a total of 416 consecutive therapeutic biliary ERCP procedures were performed by one endoscopist (T.A.). Data were retrospectively collected according to procedure indication and results. Of these, 293 procedures (70.4%) were done with standard technique (group A) and 123 procedures (29.6%) with early pre-cutting technique in case of difficult cannulation (group B). The results and complications of ERCP were compared. RESULTS: Success rate of first attempt cannulation was 98.0% in group A and 87.8% in group B. The overall incidence of post-ERCP pancreatitis, hemorrhage, perforation and cholangitis was 0%, 0.2%, 0.5% and 0.5%, respectively. Morbidity rate was not significantly different. No procedure-related mortality was occurred. CONCLUSION: For an experienced hand, the early pre-cutting technique for biliary cannulation is safe and effective as standard technique.

Endoscopic ultrasound-guided biliary drainage:Bilateral systems drainage via left duct approach

Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed,thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage,both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently,only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma,and thus can be used as an alternative to percutaneous biliary drainage.

Endoscopic ultrasound-guided biliary drainage as an alternative to percutaneous drainage and surgical bypass

Endoscopic retrograde cholangiopancreatography had been a treatment modality of choice for both benign and malignant biliary tract obstruction for more than half century, with a very high clinical success rate and low complications. But in certain circumstances, such as advanced and locally advanced pancreatobiliary malignancies(pancreatic cancer, cholangiocarcinoma, ampullary tumor) and tight benign strictures, endoscopic retrograde cholangiopancreatography(ERCP) fails. Up to this point, the only alternative interventions for these conditions were percutaneous transhepatic biliary drainage or surgery. Endoscopic ultrasound guided interventions was introduced for a couple decades with the better visualization and achievement of the pancreatobiliary tract. And it's still in the process of ongoing development. The inventions of new techniques and accessories lead to more feasibility of high-ended procedures. Endoscopic ultrasound guided biliary drainage was a novel treatment modality for the patient who failed ERCP with the less invasive technique comparing to surgical bypass. The technical and clinical success was high with acceptable complications. Regarded the ability to drain the biliary tract internally without an exploratory laparotomy, this treatment modality became a very interesting procedures for many endosonographers, worldwide, in a short period. We have reviewed the literature and suggest that endoscopic ultrasoundguided biliary drainage is also an option, and one with a high probability of success, for biliary drainage in the patients who failed conventional endoscopic drainage.

Massive gastric antral vascular ectasia successfully treated by endoscopic band ligation as the initial therapy

Gastric antral vascular ectasia(GAVE) accounted for 4% of non-variceal gastrointestinal hemorrhage.Even though unclear pathogenesis,GAVE often associated with chronic renal failure,autoimmune diseases and cirrhosis.Asymptomatic lesions were reasonably not to treated.The treatment options for GAVE are nonendoscopic and endoscopic treatments.For the pharmacological treatment,some success were reported for the use of octreotide,thalidomide and tranexamic acid.While the endoscopic treatment is the mainstay for treatment of symptomatic lesions.The endoscopic ablative therapies such as argon plasma coagulation was reported with good clinical outcomes.However,these treatment options had some limitation due to the need of special equipment and multiple sessions needed to control the bleeding.We reported another treatment option using the routine-achievable instrument such as endoscopic band ligation as an initial treatment which also provided a good treatment outcome and less sessions.

Endoscopic ultrasound-guided interventions in specialsituations

Endoscopic ultrasound(EUS) was introduced in 1982 and has since become a popular advanced procedure for diagnosis and therapeutic intervention. Initially, EUS was most commonly used for the diagnosis of pancreatobiliary diseases and tissue acquisition. EUS was first used for guided cholangiography in 1996, followed by EUS-guided biliary drainage in 2001. Advancements in equipment and endoscopic accessories have led to an expansion of EUS-guided procedures, which now include EUS-guided drainage of intra-abdominal abscesses or collections, intravascular treatment of refractory variceal and nonvariceal bleeding, transmural pancreatic drainage, common bile duct stone clearance, enteral feeding tube placement and entero-enteric anastomosis. Patients with surgically altered upper gastrointestinal anatomies have greatly benefited from EUS also. This systematic review describes and discusses EUS procedures performed in uncommon diseases and conditions, as well as applications on more vulnerable patients such as young children and pregnant women. In these cases, routine approaches do not always apply, and thus may require the use of innovative and unconventional techniques. Increased knowledge of such special applications will help increase the success rates of these procedures and provide a foundation for additional advances and utilizations of the technique.

Registered nurse-administered sedation for gastrointestinal endoscopic procedure

The rising use of nonanesthesiologist-administered sedation for gastrointestinal endoscopy has clinical significances. Most endoscopic patients require some forms of sedation and/or anesthesia. The goals of this sedation are to guard the patient's safety, minimize physical discomfort, to control behavior and to diminish psychological responses. Generally, moderate sedation for these procedures has been offered by the non-anesthesiologist by using benzodiazepines and/or opioids. Anesthesiologists and non-anesthesiologist personnel will need to work together for these challenges and for safety of the patients. The sedation training courses including clinical skills and knowledge are necessary for the registered nurses to facilitate the patient safety and the successful procedure. However, appropriate patient selection and preparation, adequate monitoring and regular training will ensure that the use of nurse-administered sedation is a feasible and safe technique for gastrointestinal endoscopic procedures.

Feasibility and safety of using Soehendra stent retriever as a new technique for biliary access in endoscopic ultrasoundguided biliary drainage

AIM:To assess the feasibility and safety of the use of soehendra stent retriever as a new technique for biliary access in endoscopic ultrasound-guided biliary drainage.METHODS:The medical records and endoscopic reports of the patients who underwent endoscopic ultrasound-guided biliary drainage(EUS-BD) owing to failed endoscopic retrograde cholangiopancreatography in our institute between June 2011 and January 2014 were collected and reviewed.All the procedures were performed in the endoscopic suite under intravenous sedation with propofol and full anaesthetic monitoring.Then we used the Soehendra stent retriever as new equipment for neo-tract creation and dilation when performing EUS-BD procedures.The patients were observed in the recovery room for 1-2 h and transferred to the regular ward,patients' clinical data were reviewed and analysed,clinical outcomes were defined by using several different criteria.Data were analysed by using SPSS 13 and presented as percentages,means,and medians.RESULTS:A total of 12 patients were enrolled.The most common indications for EUS-BD in this series were failed common bile duct cannulation,duodenal obstruction,failed selective intrahepatic duct cannulation,and surgical altered anatomy for 50%,25%,16.7%,and 8.3%,respectively.Seven patients underwent EUS-guided hepaticogastrostomy(58.3%),and 5 underwent EUS-guided choledochoduodenostomy(41.7%).The technical success rate was 100%,while the clinical success rate was 91.7%.Major and minor complications occurred in 16.6% and 33.3% of patients,respectively,but there were no procedurerelated death.CONCLUSION:Soehendra stent retriever could be used as an alternative instrument for biliary access in endoscopic ultrasound guided biliary drainage.

Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type pain.Obstruction of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches,ranging from pharmacologic,endoscopic and radiologic treatments to surgical interventions.When the conservative treatment approaches fail to resolve symptomatic cases,however,endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach,despite its well-recognized drawbacks.When the conventional transpapillary approach fails to achieve the necessary drainage,the patients may benefit from application of the less invasive endoscopic ultrasound(EUS)-guided pancreatic duct interventions.Here,we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 mo.Computed tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at genu.After conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms,EUS-guided pancreaticogastrostomy(PGS)was applied using a fully covered,self-expandable,10-mm diameter metallic stent.The treatment resolved the case and the patient experienced no adverse events.EUS-guided PGS with a regular biliary fully covered,self-expandable metallic stent effectively and safely treated pancreatictype pain in chronic pancreatitis.

Mediastinal small cell carcinoma with liver and bone marrow metastasis, mimicking lymphoma

Primary mediastinal neuroendocrine tumors are a rare malignancy that accounts for < 10% of all mediastinal tumors. The case presented here involves a 52-yearold man who had been suffering for 3 mo from chronic cough, anorexia and substantial weight loss, as well as 2 wk of jaundice prior to his admission. A computed tomography scan showed a 4.3 cm × 6.6 cm mediastinal mass with multiple liver nodules scattered along both hepatic lobes. Endoscopic ultrasound showed a large heterogeneous hypoechoic mass at the mediastinum with multiple target-like nodules in the liver. Fine-needle aspiration specimens revealed numerous, small, round cells with hyperchromatic nuclei, scarce cytoplasm, and frequent mitotic features. Immunohistochemical study revealed positive results for AE1/AE3, CD56 and chromogranin A, with negative findings for synaptophysin, CK20, vimentin, CK8/18 and CD45. The patient was subsequently diagnosed with a poorly differentiated neuroendocrine carcinoma, small cell type. A bone marrow biopsy also revealed extensive involvement by the carcinoma.

Uncommon complications of therapeutic endoscopic ultrasonography: What, why, and how to prevent

There is an increasing role for endoscopic ultrasound(EUS)-guided interventions in the treatment of many conditions. Although it has been shown that these types of interventions are effective and safe, they continue to be considered only as alternative treatments in some situations. This is in part due to the occurrence of complications with these techniques, which can occur even when performed by experienced endosonographers. Although common complications have been described for many procedures, it is also crucial to be aware of uncommon complications. This review describes rare complications that have been reported with several EUS-guided interventions. EUS-guided biliary drainage is accepted as an alternative treatment for malignant biliary obstruction. Most of the uncommon complications related to this procedure involve stent malfunction, such as the migration or malposition of stents. Rare complications of EUS-guided pancreatic pseudocyst drainage can result from air embolism and infection. Finally, a range of uncommon complications has been reported for EUS-guided celiac plexus neurolysis, involving neural and vascular injuries that can be fatal. The goal of this review is to identify possible complications and promote an understanding of how they occur in order to increase general awareness of these adverse events with the hope that they can be avoided in the future.

Dexmedetomidine in gastrointestinal endoscopic procedures

Gastrointestinal endoscopy is the gold standard in the examination and the treatment of the diseases of gastrointestinal system, but the disadvantage of being painful process. At this point the sedative and analgesic agents may be important. Dexmedetomidine is a new sedoanalgesic agent which is alternative to benzodiazepines and opioids. It has analgesia, amnesia, sedative and anxiolytic properties. The use of dexmedetomidine as the sole anesthetic agent and as the adjuvant analgesic agent has been published but has not been approved because of the inconsistency of efficacy and safety. The author has been collected the published papers in the literature. This article is aimed to describe the use of dexmedetomidine in various gastrointestinal endoscopic procedures.

Failure of sequential biliary stenting for unsuccessful common bile duct stone removal

AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy. METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared. RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed beforecomplete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions). CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.

在大 ampullary 癌的塑料胆汁的 stent 的不平常的穿入: 一份案例报告

Endoscopic biliary stenting is a well-established treatment of choice for many obstructive biliary disorders.Commonly used plastic endoprostheses have a higher risk of clogging and dislocation.Distal stent migration is an infrequent complication.Duodenum is the most common site of a migrated biliary stent.Intestinal perforation can occur during the initial insertion or endoscopic or percutaneous manipulation,or as a late consequence of stent placement.A 52-year-old male who presented with obstructive jaundice underwent endoscopic retrograde cholangiopancreatography(ERCP) with plastic stent placement.However,jaundice did not improve and he then underwent ERCP which revealed the plastic stent penetrating the ampullary tumor into the duodenal wall causing malfunction of the stent.A new plastic stent was inserted and the patient underwent Whipple’s operation.He is currently doing well after the operation.

Impact of alcohol consumption on treatment outcome of hepatocellular carcinoma patients with viral hepatitis who underwent transarterial chemoembolization

BACKGROUND Alcohol consumption increases the risk of hepatocellular carcinoma(HCC)in patients with pre-existing liver disease,including viral hepatitis.However,studies on the impact of alcohol consumption on the outcomes of HCC are limited.We hypothesized that alcohol had an additional effect with chronic viral hepatitis infection on treatment outcomes after transarterial chemoembolization(TACE)in patients with intermediate-stage HCC(Barcelona Clinical Liver Cancer[BCLC]-B).AIM To evaluate the additional effect of alcohol on treatment outcomes of TACE among HCC patients with viral hepatitis.METHODS This study,conducted at Hatyai Hospital in Thailand,included HCC patients over 18 years of age with chronic viral hepatitis.Records of HCC patients with viral hepatitis classified as BCLC-B who underwent TACE as the first treatment modality between 2014 and 2019 were retrospectively reviewed.Patients with chronic viral hepatitis only were categorized under group A,and those with chronic viral hepatitis and concurrent alcohol consumption were categorized under group B.Both groups were compared,and the Cox proportional-hazards model was used to identify the survival-influencing variables.RESULTS Of the 69 patients,53 were categorized in group A and 16 in group B.There were no statistically significant differences in tumor characteristics between the two patient groups.However,Group A had a statistically significantly higher proportion of complete response(24.5%vs 0%,P=0.030)and a higher median survival rate(26.2 mo vs 8.4 mo;log-rank P=0.012)compared to group B.Factors associated with decreased survival in the proportional-hazards model included alcohol consumption(hazards ratio[HR],2.377;95%confidence interval[CI],1.109-5.095;P=0.026),presence of portal hypertension(HR,2.578;95%CI,1.320–5.037;P=0.006),largest tumor size>5 cm(HR,3.558;95%CI,1.824-6.939;P<0.001),and serum alpha-fetoprotein level>100 ng/mL(HR,2.536;95%CI,1.377-4.670;P=0.003).CONCLUSION In HCC BCLC B patients with chronic viral hepatitis,alcohol consumption is an independent risk factor for increased mortality and decreases the rate of complete response and survival after TACE.