Endoscopy plays an important role in the diagnosis and treatment of postoperative complications of gastric cancer. Endoscopic intervention can avoid the second operation and has attracted wide attention. Early gastric anastomotic bleeding after gastrectomy is the most common. With the development of technology, emergency endoscopy and endoscopic hemostasis provide a new treatment approach. According to the specific circumstances, endoscopists can choose metal clamp to stop bleeding, electrocoagulation hemostasis, local injection of epinephrine or sclerotherapy agents, and spraying specific hemostatic agents. Anastomotic fistula is a serious postoperative complication. In addition to endoscopically placing the small intestine nutrition tube for early enteral nutrition support treatment, endoscopic treatment, including stent, metal clip, OTSC, and Over-stitch suture system, can be chosen to close fistula. For anastomotic obstruction or stricture, endoscopic balloon or probe expansion and stent placement can be chosen. For esophageal anastomotic intractable obstruction after gastroesophageal surgery, radial incision of obstruction by the hook knife or IT knife, a new method named ERI, is a good choice. Bile leakage caused by bile duct injury can be treated by placing the stent or nasal bile duct. In addition, endoscopic methods are widely used as follows: abdominal abscess can be treated by the direct intervention under endoscopy; adhesive ileus can be treated by placing the catheter under the guidance of endoscopy to attract pressure; alkaline reflux gastritis can be rapidly diagnosed by endoscopy; gastric outlet obstruction mainly caused by cancer recurrence can be relieved by metal stent placement and the combination of endoscopy and X-ray can increase success rate; pyloric dysfunction and spasm caused by the vagus nerve injury during proximal gastrectomy can be treated by endoscopic pyloromyotomy, a new method named G-POEM, and the short-term outcomes are significant. Endoscopic submucosal dissection (ESD) allows complete resection of residual gastric precancerous lesions, however it should be performed by the experienced endoscopists.
Anastomosis, Surgical ; adverse effects ; Bile Ducts ; injuries ; Constriction, Pathologic ; etiology ; therapy ; Digestive System Fistula ; etiology ; therapy ; Duodenogastric Reflux ; diagnostic imaging ; etiology ; Endoscopy, Gastrointestinal ; methods ; Enteral Nutrition ; instrumentation ; methods ; Female ; Gastrectomy ; adverse effects ; Gastric Outlet Obstruction ; surgery ; Gastritis ; diagnosis ; Gastrointestinal Hemorrhage ; etiology ; therapy ; Hemostasis, Endoscopic ; methods ; Hemostatics ; administration & dosage ; therapeutic use ; Humans ; Male ; Neoplasm Recurrence, Local ; surgery ; Postoperative Complications ; diagnosis ; therapy ; Precancerous Conditions ; surgery ; Pylorus ; innervation ; physiopathology ; surgery ; Stents ; Stomach Neoplasms ; complications ; surgery ; Treatment Outcome ; Vagus Nerve Injuries ; etiology ; surgery

Surgical operation in treating obesity and type 2 diabetes is popularizing rapidly in China. Correct prevention and recognition of perioperation-related operative complications is the premise of ensuring surgical safety. Familiar complications of the operation include deep venous thrombosis, pulmonary artery embolism, anastomotic bleeding, anastomotic fistula and marginal ulcer. The prevention of deep venous thrombosis is better than treatment. The concrete measures contain physical prophylaxis (graduated compression stocking and intermittent pneumatic compression leg sleeves) and drug prophylaxis (unfractionated heparin and low molecular heparin), and the treatment is mainly thrombolysis or operative thrombectomy. The treatment of pulmonary artery embolism includes remittance of pulmonary arterial hypertension, anticoagulation, thrombolysis, operative thrombectomy, interventional therapy and extracorporeal membrane oxygenation (ECMO). Hemorrhage is a rarely occurred but relatively serious complication after bariatric surgery. The primary cause of anastomotic bleeding after laparoscopic gastric bypass is incomplete hemostasis or weak laparoscopic repair. The common bleeding site in laparoscopic sleeve gastrectomy is gastric stump and close to partes pylorica, and the bleeding may be induced by malformation and weak repair technique. Patients with hemodynamic instability caused by active bleeding or excessive bleeding should timely received surgical treatment. Anastomotic fistula in gastric bypass can be divided into gastrointestinal anastomotic fistula and jejunum-jejunum anastomotic fistula. The treatment of postoperative anastomotic fistula should vary with each individual, and conservative treatment or operative treatment should be adopted. Anastomotic stenosis is mainly related to the operative techniques. Stenosis after sleeve gastrectomy often occurs in gastric angle, and the treatment methods include balloon dilatation and stent implantation, and surgical treatment should be performed when necessary. Marginal ulcer after gastric bypass is a kind of peptic ulcer occurring close to small intestine mucosa in the junction point of stomach and jejunum. Ulcer will also occur in the vestige stomach after laparoscopic sleeve gastrectomy, and the occurrence site locates mostly in the gastric antrum incisal margin. Preoperative anti-HP (helicobacter pylorus) therapy and postoperative continuous administration of proton pump inhibitor (PPI) for six months is the main means to prevent and treat marginal ulcer. For patients on whom conservative treatment is invalid, endoscopic repair or surgical repair should be considered. Different surgical procedures will generate different related operative complications. Fully understanding and effectively dealing with the complications of various surgical procedures through multidisciplinary cooperation is a guarantee for successful operation.
Anastomosis, Surgical ; adverse effects ; Anticoagulants ; therapeutic use ; Bariatric Surgery ; adverse effects ; Catheterization ; China ; Conservative Treatment ; Constriction, Pathologic ; etiology ; therapy ; Digestive System Fistula ; etiology ; therapy ; Endoscopy, Gastrointestinal ; methods ; Extracorporeal Membrane Oxygenation ; Gastrectomy ; adverse effects ; Gastric Bypass ; adverse effects ; Gastric Mucosa ; pathology ; Gastric Stump ; physiopathology ; surgery ; Gastrointestinal Hemorrhage ; etiology ; prevention & control ; surgery ; Hemostasis, Surgical ; adverse effects ; methods ; Hemostatic Techniques ; Heparin ; therapeutic use ; Humans ; Intermittent Pneumatic Compression Devices ; Intestine, Small ; pathology ; Laparoscopy ; adverse effects ; Margins of Excision ; Peptic Ulcer ; etiology ; therapy ; Postoperative Complications ; diagnosis ; prevention & control ; therapy ; Pulmonary Embolism ; etiology ; therapy ; Stents ; Stockings, Compression ; Thrombectomy ; Thrombolytic Therapy ; Venous Thrombosis ; etiology ; prevention & control ; therapy

The emerging endoscopic technologies are proved to be effective treatments for obesity in selected patients and to offer the potential advantages of reduced invasiveness, reversibility and repeatability. From the view of operation principle, endoscopic technologies can be classified as restrictive procedure, malabsorption procedure and endoscopic revision of gastric bypass. Restrictive procedures include intragastric balloon, aspiration therapy, endoscopic sleeve gastroplasty (ESG) and transoral gastroplasty. Intragastric balloon employs space occupying, volume restriction and satiety mechanisms, which is superior to drugs and lifestyle change, but shorter than sleeve and bypass surgery. Aspiration therapy is similar to standard percutaneous endoscopic gastrostomy, while there are no available data regarding the obesity and metabolic improvement. Compared with traditional bariatric surgery, ESG does not excise gastric tissue with less complications and without weight regain, but it can not be used as an independent operation still now. Transoral gastroplasty is rarely applied clinically whose efficacy and long-term complications need further studies. Malabsorption surgery includes endoscopic duodenojejunal bypass sleeve (EDJBS) and endoscopic gastroduodenojejunal bypass sleeve(EGDJBS). EDJBS may have the similar mechanism like bypass reducing the blood glucose. Even with obvious effect of weight loss, EDJBS has high morbidity of complications and requirements of the skilled operators. EGDJBS, which imitates bypass anatomy changes and belongs to the mixed operation, should be superior to the above procedures in reducing weight theoretically, but due to the lack of clinical data, its short-term and long-term efficacy still need further clinical observation. As compared to the complexity and risks associated with telescopic surgical revision, endoscopic suturing has been confirmed as less invasive and safer for stomal revisions, while its long-term efficacy of reducing weight and improvement of diabetes are not yet clear. Even if long-term efficacy of reducing weight and morbidity of complication in endoscopic bariatric surgery are still indefinite, and clinical trial researches of large sample and long-term follow-up are absent, with the development of endoscopic skill and the gradual clinical application, endoscopic bariatric surgery will provide a new option for the patients of obesity and metabolic diseases.
Bariatric Surgery ; adverse effects ; methods ; statistics & numerical data ; trends ; Disease Management ; Endoscopy ; adverse effects ; methods ; statistics & numerical data ; Gastric Balloon ; statistics & numerical data ; Gastric Bypass ; adverse effects ; methods ; statistics & numerical data ; Gastroplasty ; adverse effects ; methods ; statistics & numerical data ; Humans ; Metabolic Diseases ; surgery ; Obesity ; surgery ; Reoperation ; adverse effects ; methods ; statistics & numerical data ; Surgical Stomas ; pathology ; statistics & numerical data ; Treatment Outcome ; Weight Loss

OBJECTIVE: To evaluate the efficacy and safety of peroral endoscopic myotomy (POEM) for achalasia cardia (AC).
 METHODS: A total of 62 patients with AC were enrolled and treated with POEM in the Third Xiangya Hospital, Central South University from April 2012 to October 2014. The symptoms and complications were retrospectively analyzed.
 RESULTS: The ages of patients, including 32 males and 30 females, were 14-68 (43.2±5.6) years old. Eckardt scores were 4-6 or ≥7 for 25 patients or 37 patients (including 20 patients were at a score of 12). Thirteen patients suffered balloon expansion for 2-3 times. Sixty-one patients had completed POEM treatment, 1 patient were given Heller surgery instead of POEM because of extensive submucosal adhesion during POEM. The operative time for POEM was (60.8±15.1) min. Fourteen patients had mild subcutaneous emphysema. Among them, 5 suffered pneumoperitoneum and felt better after abdominal puncture exhaust; 2 patients suffered bronchospasm hypoxemia and were relieved after treatment by positive pressure oxygen for 1 h. The hospital stay was (4.3±1.2) d. The postoperative follow-up period was (11.4±5.4) months. Swallowing obstruction, vomiting and chest pain in patients was relieved at different degrees. The treatment effective rate was 100%. 
 CONCLUSION POEM is a safe, effective and minimally invasive approach for AC.
Adolescent ; Adult ; Aged ; Cardia ; physiopathology ; Endoscopy ; adverse effects ; methods ; Esophageal Achalasia ; surgery ; Esophageal Sphincter, Lower ; physiopathology ; Female ; Humans ; Length of Stay ; Male ; Middle Aged ; Operative Time ; Postoperative Period ; Retrospective Studies ; Treatment Outcome ; Young Adult

BACKGROUND/AIMS: Controversy remains over the optimal approach to preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma. We compared the clinical outcomes of endoscopic biliary drainage (EBD) with those of percutaneous transhepatic biliary drainage (PTBD) in patients undergoing preoperative biliary drainage for perihilar cholangiocarcinoma. METHODS: A total of 106 consecutive patients who underwent biliary drainage before surgical treatment were divided into two groups: the PTBD group (n=62) and the EBD group (n=44). RESULTS: Successful drainage on the first attempt was achieved in 36 of 62 patients (58.1%) with PTBD, and in 25 of 44 patients (56.8%) with EBD. There were no significant differences in predrainage patient demographics and decompression periods between the two groups. Procedure-related complications, especially cholangitis and pancreatitis, were significantly more frequent in the EBD group than the PTBD group (PTBD vs EBD: 22.6% vs 54.5%, p<0.001). Two patients (3.8%) in the PTBD group experienced catheter tract implantation metastasis after curative resection during the follow-up period. CONCLUSIONS: EBD was associated with a higher risk of procedure-related complications than PTBD. These complications were managed properly without severe morbidity; however, in the PTBD group, there were two cases of cancer dissemination along the catheter tract.
Aged ; Aged, 80 and over ; Bile Duct Neoplasms/*surgery ; Bile Ducts/surgery ; Cholangitis/etiology ; Drainage/adverse effects/*methods ; Endoscopy, Gastrointestinal/adverse effects/*methods ; Female ; Humans ; Klatskin Tumor/*surgery ; Liver/surgery ; Male ; Middle Aged ; Pancreatitis/etiology ; Postoperative Complications/etiology ; Preoperative Care/adverse effects/*methods ; Treatment Outcome

BACKGROUND/AIMS: To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC). METHODS: This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed. RESULTS: The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death. CONCLUSIONS: The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.
Adult ; Aged ; Aged, 80 and over ; Chi-Square Distribution ; Enbucrilate/*administration & dosage/adverse effects ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/complications/diagnosis/mortality/*therapy ; Female ; Gastrointestinal Hemorrhage/diagnosis/etiology/mortality/*therapy ; Hemostasis, Endoscopic/adverse effects/*methods/mortality ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Proton Pump Inhibitors/adverse effects/*therapeutic use ; Recurrence ; Retrospective Studies ; Risk Factors ; Sclerosing Solutions/*administration & dosage/adverse effects ; Sclerotherapy/adverse effects/*methods/mortality ; Time Factors ; Treatment Outcome ; Young Adult

BACKGROUND/AIMS: Various anatomical features of the biliary tree affect ability to remove difficult common bile duct (CBD) stones. In this study, we evaluated the clinical characteristics and outcomes of the endoscopic treatment of stones in stemware-shaped CBDs. METHODS: Thirty-four patients with a stone and a stemware-shaped CBD who were treated at different tertiary referral centers from January 2008 to December 2012 were studied retrospectively. When stone removal failed, percutaneous or direct peroral cholangioscopic lithotripsy, endoscopic retrograde biliary drainage, or surgery was performed as a second-line procedure. RESULTS: The overall success rate of the first-line procedure was 41.2%. Five of the 34 patients (14.7%) experienced procedure-related complications. No procedure-related mortality occurred. Mechanical lithotripsy was required to completely remove stones in 13 patients (38.2%). Conversion to a second-line procedure was required in 20 patients (58.8%). Mechanical lithotripsy was needed in 75% and 66.7% of those with a stone size of <1 cm or > or =1 cm, respectively. Stone recurrence occurred in two patients (9.1%) after 6 months and 27 months, respectively. CONCLUSIONS: The endoscopic treatment of stones in a stemware-shaped CBD is challenging. The careful assessment of difficult CBD stones is required before endoscopic procedures.
Adult ; Aged ; Aged, 80 and over ; Cholangiopancreatography, Endoscopic Retrograde/adverse effects/methods ; Choledocholithiasis/complications/*surgery ; Common Bile Duct/*anatomy & histology/surgery ; Endoscopy, Gastrointestinal/adverse effects/*methods ; Female ; Humans ; Lithotripsy/adverse effects/*methods ; Male ; Middle Aged ; Treatment Outcome

BACKGROUND/AIMS: Propofol sedation for elderly patients during time-consuming endoscopic procedures is controversial. Therefore, we investigated the safety of using propofol in elderly patients during upper gastrointestinal therapeutic endoscopy. METHODS: The medical records of 160 patients who underwent therapeutic endoscopic procedures under gastroenterologist-guided propofol sedation at a single institution were retrospectively reviewed. The subjects were divided into two groups: a younger group, patients <75 years old; and an elderly group, patients > or =75 years old. The two groups were compared with respect to the therapeutic regimen, circulatory dynamics, and presence/absence of discontinuation of propofol treatment. RESULTS: Although the number of patients with liver dysfunction was higher in the elderly group, there were no other significant differences in the baseline characteristics, including the American Society of Anesthesiologists classification, between the elderly and younger groups. The average maintenance rate of continuous propofol infusion was lower in the elderly patients. No statistically significant differences were found in the occurrence of adverse events between the elderly and younger groups. None of the patients returned to a resedated state after the initial recovery from sedation. CONCLUSIONS: Gastroenterologist-guided propofol sedation in elderly patients can be safely achieved in the same manner as that in younger patients, even for time-consuming upper gastrointestinal therapeutic endoscopic procedures.
Age Factors ; Aged ; Aged, 80 and over ; Conscious Sedation/adverse effects/*methods ; *Endoscopy, Gastrointestinal/methods ; Female ; Humans ; *Hypnotics and Sedatives/adverse effects ; Male ; *Propofol/adverse effects ; Retrospective Studies

Esophageal perforation after endoscopic forceful pneumatic dilatation for achalasia is a devastating complication and surgical treatment is necessary. A 65-yr-old man and a 54-yr-old woman referred for esophageal perforation two hours after pneumatic dilatation and during the procedure, respectively. Gastroplasties through thoracotomy were performed in both cases and their recoveries were uneventful. The esophagogram with gastrografin on the post-operative 8th day did not show any passage disturbance or leakage at the anastomosis site. On the follow-up endoscopy 4 to 6 months after operation revealed that reflux esophagitis of LA classification A were noted in the both patients. They did not complain any reflux symptom or dysphagia for 9 to 13 months after operation. Instead of the most widely used procedure; primary repair of perforation site, wrapping with intercostal muscle flap and esophagomyotomy, gastroplasty was performed in two cases of iatrogenic esophageal perforation in achalasia and experienced good results.
Aged ; Deglutition Disorders/complications ; Endoscopy, Gastrointestinal/*adverse effects ; Esophageal Achalasia/*surgery ; Esophageal Perforation/*surgery ; Esophagus/*surgery ; Female ; Gastroesophageal Reflux/complications ; Gastroplasty/*methods ; Humans ; Male ; Middle Aged ; Thoracotomy

PURPOSE: Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications. MATERIALS AND METHODS: A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded. RESULTS: The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications. CONCLUSION: BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.
Aged ; Anesthetics, Intravenous/*administration & dosage/therapeutic use ; *Consciousness Monitors ; Endoscopy/methods ; Female ; Humans ; Intraoperative Complications/*prevention & control ; Male ; Middle Aged ; Monitoring, Physiologic/methods ; Piperidines/*administration & dosage/adverse effects/therapeutic use ; Propofol/*administration & dosage/adverse effects/therapeutic use