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Endoscopic management of postsurgical leaks.

Gastrointestinal Intervention.2016;5(1):6-14. doi:10.18528/gii150023

Postsurgical leaks are a major complication with significant mobidity and mortality. Conventional conservative and surgical approaches are highly morbid with limited success. Over the last decade several endoscopic techniques have proved effective with a favorable safety profile. Nevertheless, most data still come from retrospective series, and many studies included heterogenous patient groups pooling complex surgical leaks with minor endoscopic perforations. This review focuses on the endoscopic management of the more difficult postsurgical leaks. Stents and over-the-scope clips are currently the key endoscopic techniques for leak closure, but emerging techniques such as vacuum sponge therapy and endoscopic internal drainage have proved to be at least as effective. The current trend is to use these different techniques interchangeably or simultaneously rather than assuming a single standardized approach.
Anastomotic Leak ; Drainage ; Esophageal Fistula ; Gastric Fistula ; Humans ; Mortality ; Porifera ; Retrospective Studies ; Self Expandable Metallic Stents ; Stents ; Vacuum

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Endoscopic resection for early gastric cancer: The current controversies.

Xian Feng XIA ; Philip Wai Yan CHIU

Gastrointestinal Intervention.2016;5(1):1-5. doi:10.18528/gii150024

Gastric cancer remained second commonest cancer worldwide. The diagnosis of early gastric cancer (EGC) is increasing in Japan and South Korea resulting in better oncological outcomes. Endoscopic resection (ER) is safe and effective treatment for EGC with minimal risk of lymph node metastasis. The oncological clearance of ER for EGC in expanded criteria remains controversial. Several retrospective studies showed that endoscopic submucosal dissection (ESD) achieved minimal local recurrence and excellent survival for EGC in expanded indications. With an increasing trend of cancer occuring in the aging population, ER will play a major role in treatment of EGC among elderly who usually have multiple comorbidities. Salvage gastrectomy is generally recommended for those with non-curative ESD, while further researches should be conducted to refine the risks of nodal metastasis for various submucosal EGCs. Endoscopic surveillance is recommended for long term follow-up of patients after curative ESD as the risk of metachronous cancer is significant. Eradication of Helicobacter pylori is generally recommended for EGC treated by ER with a view to reduce the risk of metachronous tumor.
Aged ; Aging ; Comorbidity ; Diagnosis ; Follow-Up Studies ; Gastrectomy ; Helicobacter pylori ; Humans ; Japan ; Korea ; Lymph Nodes ; Neoplasm Metastasis ; Recurrence ; Retrospective Studies ; Stomach Neoplasms*

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The use of OverStitch™ for the treatment of intestinal perforation, fistulas and leaks.

Thiruvengadam MUNIRAJ ; Harry R ASLANIAN

Gastrointestinal Intervention.2017;6(3):151-156. doi:10.18528/gii170002

Gastrointestinal perforations, leaks and fistulas may complicate endoscopic and surgical procedures. Surgical repair is associated with significant morbidity. Therapeutic endoscopic tools and techniques have included the application of tissue sealants, clip closure, and stent placement. Endoscopic suturing is a rapidly evolving minimally invasive technique. The OverStitchTM (Apollo Endosurgery, USA) is currently the only available endoscopic suturing system. Although technically more difficult than clip closure, endoscopic suturing allows closure of larger defects. In some settings, outcomes similar to surgical management with less morbidity may be achieved. This review describes the OverStitchTM endoscopic suturing system and the published literature regarding its use for perforations, leaks and fistulas.
Fistula* ; Intestinal Perforation* ; Stents

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Risks of transesophageal endoscopic ultrasonography-guided biliary drainage.

Nozomi OKUNO ; Kazuo HARA ; Nobumasa MIZUNO ; Susumu HIJIOKA ; Takamichi KUWAHARA ; Masahiro TAJIKA ; Tsutomu TANAKA ; Makoto ISHIHARA ; Yutaka HIRAYAMA ; Sachiyo ONISHI ; Yasumasa NIWA

Gastrointestinal Intervention.2017;6(1):82-84. doi:10.18528/gii.170008

SUMMARY OF EVENT: Pneumoderma, mediastinal emphysema, and bilateral pneumothorax were developed in the patient who had undergone transesophageal endoscopic ultrasonography-guided rendezvous technique. Chest drainage was performed immediately. TEACHING POINT: Transesophageal approach carries the potential risks of severe complications such as mediastinal emphysema, mediastinitis, and pneumothorax. To prevent puncturing through the esophagus, clipping the esophagogastric junction using a forward-viewing scope before procedure is very useful. In cases of inadvertent transesophageal puncture, devices other than the needle should not be passed through the site.
Drainage* ; Endosonography ; Esophagogastric Junction ; Esophagus ; Humans ; Mediastinal Emphysema ; Mediastinitis ; Needles ; Pneumothorax ; Punctures ; Thorax

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Endoscopic retrograde cholangiopancreatography in surgically altered anatomy.

Deepinder GOYAL ; Benan KASAPOGLU ; Nirav THOSANI

Gastrointestinal Intervention.2017;6(1):78-81. doi:10.18528/gii.170009

Endoscopic retrograde cholangiopancreatography (ERCP) in a surgically altered anatomy is a technically challenging undertaking with variable success and adverse event rates. There are several potential challenges to successfully perform an ERCP in patients with surgically altered anatomy such as identification of afferent limb, accessing and visualization of the papilla, and selective cannulation of the biliary and pancreatic ducts from altered orientation of the papilla. Several strategies to improve the success rate have been recommended by various endoscopy experts. In this review, we discussed the published literature involving various ERCP techniques described for surgically altered anatomies.
Catheterization ; Cholangiopancreatography, Endoscopic Retrograde* ; Endoscopy ; Extremities ; Gastric Bypass ; Humans ; Mortuary Practice ; Pancreatic Ducts ; Pancreaticoduodenectomy

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Percutaneous intervention for bilioenteric anastomotic strictures: Current strategies and future directions.

Rayhan HAI ; Joshua KUBAN

Gastrointestinal Intervention.2017;6(1):70-77. doi:10.18528/gii.160034

Postoperative bilioenteric anastomotic strictures are encountered in a significant number of patients after primary biliary repair, hepatopancreaticobiliary tumor resection, and liver transplantation. Due to difficulties with repeat surgery and endoscopic access, percutaneous dilation has become the accepted treatment in these cases. While the overall paradigm of percutaneous access, balloon dilation, and catheter stenting remains consistent, institutional protocols differ in several technical variables including balloon sizes, inflation techniques, catheter sizing, and overall time course of treatment, amongst others. The current review aims to discuss various treatment protocols and their relative efficacy, as well as touch on emerging techniques.
Biliary Tract ; Catheters ; Clinical Protocols ; Constriction, Pathologic* ; Humans ; Inflation, Economic ; Liver Transplantation ; Radiology, Interventional ; Reoperation ; Stents

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Recent developments in endoscopic ultrasound-guided diagnosis and therapy of pancreatic cystic neoplasms.

Tejas KIRTANE ; Manoop S BHUTANI

Gastrointestinal Intervention.2017;6(1):63-69. doi:10.18528/gii.170006

This review highlights new developments in the field of endoscopic ultrasound (EUS)-guided diagnosis and therapy of pancreatic cystic neoplasms. Studies pertinent to pancreatic cyst diagnosis by morphology, namely diagnostic accuracies of various criteria such as pancreatic cyst size, pancreatic duct size, mural nodules and use of EUS contrast agent are discussed. Tissue acquisition during EUS using a novel brush for cytology as well as microforceps is explored further. The role of multiple emerging molecular markers such as CEA, BRAF, KRAS, and GNAS, to name a few, is covered in detail. Recent developments relating to the utility of micro-RNAs in the analysis of cyst fluid is explored. Needle based confocal laser endomicroscopy for pancreatic cyst imaging is a recent development, and findings from recent trials are discussed. Furthermore, recent data regarding the role of ablative therapies using alcohol, paclitaxel and radiofrequency ablation of cyst is covered. Also, given the multiplicity of guidelines regarding management of pancreatic cystic neoplasms, we discuss the merits and shortcoming of these guidelines.
Biomarkers ; Catheter Ablation ; Cyst Fluid ; Diagnosis* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Needles ; Paclitaxel ; Pancreatic Cyst* ; Pancreatic Ducts ; Pancreatic Neoplasms ; Ultrasonography

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Endoscopic management of postoperative fistulas and leaks.

Prathab DEVARAJ ; Hemanth GAVINI

Gastrointestinal Intervention.2017;6(1):54-62. doi:10.18528/gii.160032

Postoperative complications from gastrointestinal surgery can be associated with significant morbidity, and mortality especially if repeat surgery is needed to address these complications. There are wide array of endoscopic interventions and tools available for management of these complications using minimally invasive methods thus decreasing length of hospitalization, morbidity and leading to better patient outcomes. With the advent new tools like Overstitch device, Over the Scope Clip, fibrin glue, etc., these complications can be managed successfully with minimal morbidity. We provide an indepth discussion about available endoscopic options and their application in various scenarios in our article. Endoscopist should be familiar with these complications and endoscopic tools to promote use of these tools and techniques to achieve successful management of these complex conditions.
Adhesives ; Anastomotic Leak ; Fibrin Tissue Adhesive ; Fistula* ; Hospitalization ; Humans ; Mortality ; Postoperative Complications ; Reoperation

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Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies.

Paul R TARNASKY ; Prashant KEDIA

Gastrointestinal Intervention.2017;6(1):37-53. doi:10.18528/gii.170004

Adverse events after endoscopic retrograde cholangiopancreatography (ERCP) are not uncommon and can be associated with tragic outcomes. Bleeding, perforation, and post-ERCP pancreatitis are the most common complications. Some events are unavoidable; others are associated with well described risk factors so that they can be either anticipated and/or measures can be taken for prevention or at least risk reduction. This review will focus on the more common complications after ERCP, their risk factors, and potential strategies for risk reduction. Additionally, recommendations for management of ERCP complications will be presented.
Cholangiopancreatography, Endoscopic Retrograde* ; Hemorrhage ; Intestinal Perforation ; Pancreatitis ; Risk Factors ; Risk Reduction Behavior

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An appraisal of pancreatic cyst fluid molecular markers.

Rohan M MODI ; Ravi B PAVURALA ; Somashekar G KRISHNA

Gastrointestinal Intervention.2017;6(1):32-36. doi:10.18528/gii.170005

Pancreatic malignancy is the third leading cause of cancer related death in the United States with limited viable screening options. By the end of this decade, cancers are poised to become the leading cause of death with pancreatic cancer projected to be the second leading cause of cancer related mortality. Pancreatic cystic lesions (PCLs) are found in approximately 5%–14% of patients due to the increased utilization of cross-sectional imaging, with approximately 8%–10% of pancreatic cancers originating as PCLs. Current screening guidelines have shown discrepancies between morphologic characteristics of PCLs and identifying advanced pancreatic disease. Molecular analysis has emerged as a novel technology to aid in adequate diagnosis and management decisions of PCLs. Mucinous cysts including intraductal papillary mucinous neoplasms (IPMNs) or mucinous cystic neoplasms have similar oncogenic mutations including KRAS, TP53, SMAD4, PIK3CA, PTEN, or CKDN2A, while GNAS and RNF43 mutations are specific only to IPMNs. Serous cystadenomas have been associated with a loss of tumor suppressor gene VHL, while solid-psuedopapillary neoplasms have an oncogenic mutation CTNNB1. A specific molecular marker to diagnose existing high-grade dysplasia or impending malignant transformation is yet to be identified. Moving forward it is important to advance technology in isolating and identifying high-risk molecular markers from cyst fluid while considering their increased utilization in the evaluation of PCLs.
Biomarkers, Tumor ; Cause of Death ; Cyst Fluid ; Cystadenoma, Serous ; Diagnosis ; Genes, Tumor Suppressor ; Humans ; Loss of Heterozygosity ; Mass Screening ; Mortality ; Mucins ; Neoplasms, Cystic, Mucinous, and Serous ; Pancreatic Cyst* ; Pancreatic Diseases ; Pancreatic Neoplasms ; United States

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