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Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.
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Endoscopia Gastrointestinal , Fístula Gástrica , Humanos , Endoscopia Gastrointestinal/métodos , Fístula Gástrica/terapia , Fístula Gástrica/cirurgia , Stents , Resultado do Tratamento , Fístula Esofágica/terapia , Fístula Esofágica/cirurgia , Fístula Esofágica/diagnóstico por imagem , Drenagem/instrumentação , Drenagem/métodos , Trato Gastrointestinal Superior/diagnóstico por imagemAssuntos
Ressecção Endoscópica de Mucosa , Técnicas de Sutura , Humanos , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Ressecção Endoscópica de Mucosa/instrumentação , Técnicas de Sutura/instrumentação , Técnicas de Sutura/efeitos adversos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Reto/cirurgia , Neoplasias Retais/cirurgia , Masculino , Feminino , IdosoRESUMO
With the alarmingly increasing prevalence of obesity in the Western world, it has become necessary to provide more acceptable treatment options for patients with obesity. Minimally invasive endoscopic techniques are continuously evolving. Currently, metabolic and bariatric endoscopies encompass several different techniques that can offer significant weight loss and improvement in comorbidities with a favorable safety profile. Restrictive bariatric procedures include the use of intragastric balloons and gastric remodeling techniques with different suturing devices. Several studies have demonstrated the efficacy and safety of these techniques that are widely used in clinical practice. Small intestine-targeted metabolic endoscopy is an intriguing and rapidly evolving field of research, although it is not widespread in routine practice. These techniques include duodenal-jejunal bypass liners, duodenal mucosal resurfacing, and incisionless anastomoses. The aim of this review article is to provide a detailed update on the currently available bariatric endoscopy techniques in Western countries.
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OBJECTIVE: Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that proved to be safe and effective in obesity treatment. However, not all subjects respond to treatment in the same way, and, with a view to personalized care, it is essential to identify predictors of success or failure. METHODS: A retrospective 2-year followed-up cohort of ESG subjects was analyzed to investigate the presence of any baseline or early indicators of long-term optimal or suboptimal ESG outcomes. RESULTS: A total of 315 subjects (73% women) were included, with 73% of patients exhibiting an Excess weight loss percentage (%EWL) >25% at the 24 months. Neither demographic parameters (age and sex), smoking habits, and menopause in women nor the presence of comorbidities proved potential predictive value. Interestingly, the %EWL at 1 month after ESG was the strongest predictor of 24-month therapeutic success. Subsequently, we estimated an "early threshold for success" for 1 month-%EWL by employing Youden's index method. CONCLUSIONS: ESG is a safe and effective bariatric treatment that can be offered to a wide range of subjects. Early weight loss seems to impact long-term ESG results significantly and may allow proper early post-operative care optimization.
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Gastroplastia , Obesidade Mórbida , Humanos , Feminino , Masculino , Gastroplastia/métodos , Obesidade/cirurgia , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
PURPOSE: Obesity and pregnancy are strictly related: on the one hand, obesity-one of the most common comorbidities in women of reproductive age-contributes to infertility and obesity-related pregnancy complications, whereas pregnancy is a condition in which, physiologically, the pregnant woman undergoes weight gain. Endoscopic sleeve gastroplasty (ESG) may be used for the treatment of obesity in women of childbearing age. MATERIALS AND METHODS: A retrospective analysis was conducted to evaluate weight trajectories, the evolution of obesity-related comorbidities, and lifestyle modification in women who became pregnant after ESG. A comparison was made between childbearing-age women who became pregnant after ESG and non-pregnant women. RESULTS: A total of 150 childbearing-age women underwent ESG at a large tertiary medical center. Of these, 11 patients (33.4 ± 6.2 years) became pregnant after the procedure, following a mean time interval of 5.5 ± 3.9 months. Three women (two affected by polycystic ovary syndrome) reported difficulty getting pregnant before undergoing ESG. The mean preconception BMI was 31.9±4.0 kg/m2 (-7.24 ± 4.0 kg/m2 after ESG). Total body weight loss (TBWL, %) was 18.08 ± 8.00, 11.00 ± 11.08, and 12.08 ± 8.49, at the beginning of pregnancy, at the delivery, and at the first follow-up (19.6 ± 7.8 months after ESG). TBWL of at least 5% was achieved before pregnancy in all patients (73% reached a TBWL ≥ 10%). No significant differences in weight loss and QoL were found between the pregnancy and non-pregnancy groups up to 24 months after ESG. CONCLUSIONS: Endoscopic sleeve gastroplasty allows for adequate weight loss before and after pregnancy in patients with obesity.
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Gastroplastia , Obesidade Mórbida , Humanos , Feminino , Estudos Retrospectivos , Qualidade de Vida , Obesidade Mórbida/cirurgia , Resultado do Tratamento , Obesidade/cirurgia , Redução de PesoRESUMO
BACKGROUND: Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight regain after RYBG. MATERIALS AND METHODS: A retrospective analysis was performed on a prospective database. Sigstad's score, early and late Arts Dumping Score (ADS) questionnaires, absolute weight loss (AWL), percentage of total body weight loss (%TBWL), and percentage of excess weight loss (%EWL) were assessed at baseline and at 6, 12, and 24 months after TORe. RESULTS: Eighty-seven patients (median age 46 years, 79% female) underwent TORe. The median baseline BMI was 36.2 kg/m2. Out of 87 patients, 58 were classified as "dumpers" due to Sigstad's score ≥ 7. The resolution rate of DS (Sigstad's score < 7) was 68.9%, 66.7%, and 57.2% at 6, 12, and 24 months after TORe, respectively. A significant decrease in Sigstad's score as well as in early and late ADS questionnaires was observed (p < 0.001). The median Sigstad's score dropped from 15 (11-8.5) pre-operatively to 2 (0-12) at 24 months. The %TBWL was 10.5%, 9.9%, and 8.1% at 6, 12, and 24 months, respectively. Further, "dumpers" with resolution of DS showed better weight loss results compared with those with persistent DS (p < 0.001). The only adverse event observed was a perigastric fluid collection successfully managed conservatively. CONCLUSION: TORe is a minimally invasive treatment for DS and/or weight regain after RYGB, with evidence of long-term efficacy.
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Derivação Gástrica , Obesidade Mórbida , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Síndrome de Esvaziamento Rápido/etiologia , Síndrome de Esvaziamento Rápido/cirurgia , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Aumento de Peso , Técnicas de Sutura , Reoperação/métodos , Redução de Peso , Resultado do TratamentoAssuntos
Gastroplastia , Obesidade Mórbida , Humanos , Redução de Peso , Gastrectomia , Endoscopia , Resultado do TratamentoRESUMO
Obesity is a chronic, relapsing disease representing a global epidemic. To date, bariatric surgery is the most effective treatment for morbid obesity in the long-term. Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric interventions, with excellent long-term outcomes. However, about one-third of patients may experience weight regain over time, as well as dumping syndrome. Both these conditions are challenging to manage and require a multidisciplinary and personalized approach. The dilation of the gastro-jejunal anastomosis is a recognized etiological factor for both weight regain and dumping syndrome. Dietary modifications, behavioral interventions, and medications represent the first therapeutic step. Revisional surgery is the traditional approach when non-invasive treatments fail. However, re-interventions may be technically difficult and are associated with increased morbidity and mortality. Transoral outlet reduction (TORe) is an endoscopic procedure aimed at reducing the size of the anastomosis and is proposed as a minimally invasive treatment of weight regain and/or dumping syndrome refractory to conservative therapies. This review is aimed at providing a narrative overview of the role of TORe as part of the multidisciplinary therapeutic toolkit nowadays available to approach weight regain and dumping syndrome after RYGB.
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Background and study aims Endoscopic drainage of benign biliary and pancreatic strictures can be challenging, especially when tightness of the stenosis does not allow passage of mechanical and pneumatic dilation catheters. Electroincision of benign biliopancreatic can be considered in selected cases. Patients and methods Three male patients (mean age 33 years, range 9-60) underwent endoscopic retrograde cholangiopancreatography to drain anastomotic biliary stricture (ABS) following orthotopic liver transplantation (nâ=â2) and pancreatic duct stenosis due to abdominal trauma (nâ=â1). The biliopancreatic strictures could be passed only with a thin 0.020-inch hydrophilic guidewire. Conventional mechanical and pneumatic dilators failed to pass the strictures due to weakness of the guidewire. Therefore, electrosurgical incision by over-the-wire 6Fr cystotome or needle-knife was attempted using pure cut current. Results The two cases of ABS were approached also by cholangioscopy and the 6Fr cystotome easily passed the strictures, allowing subsequent pneumatic dilatation and insertion of multiple plastic stents. The patient with a pancreatic duct stricture underwent electrosurgical incision using a thin needle knife over-the-wire, resulting in insertion of a 7Fr pancreatic stent. No adverse events occurred; all the patients were discharged within 24 to 48 hours. Conclusions Electrosurgical incision of benign biliopancreatic strictures could be considered in selected patients whom conventional dilation techniques fail.
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PURPOSE: With the aging of the population and the epidemic spread of obesity, the frequency of older individuals with obesity is steadily growing. To date, no data evaluating the use of endoscopic sleeve gastroplasty (ESG) in the elderly have been published. In this case series, we evaluate the short- and medium-term outcomes of ESG in patients with obesity aged 65 years and older. MATERIALS AND METHODS: A retrospective analysis was done on a prospective database; patients aged 65 years and older were included in our analysis. EWL%, TBWL%, the Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire, and the presence of comorbidities were assessed. RESULTS: Eighteen patients aged 65 years and older underwent ESG between November 2017 and July 2021. The median age was 67 years and the mean baseline BMI was 41.2 kg/m2. After ESG, the median TBWL% was 15.1%, 15.5%, and 15.5% at 6, 12, and 24 months, while the median %EWL was 39%, 37%, and 41% at 6, 12, and 24 months, respectively. The median BAROS score was 3.0, 3.4, and 2.5 at 6, 12, and 24 months, respectively. Six out of twelve patients with hypertension and 3/4 diabetic patients reduced or removed their medications within 12 months following ESG. Two out of six patients with OSA stopped therapy with CPAP. No adverse events were recorded. CONCLUSION: According to our experience, ESG is a promising therapeutic option for elder individuals with obesity who fail non-invasive methods, and who refuse or are deemed not suitable for bariatric surgery because of age and comorbidities.
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Gastroplastia , Obesidade Mórbida , Idoso , Gastroplastia/métodos , Humanos , Obesidade/etiologia , Obesidade/cirurgia , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
Background: Endoscopic sleeve gastroplasty (ESG) is an incisionless procedure that reduces the size of the gastric cavity. In prior studies, it has been proven to be a safe and effective treatment for obesity. In this study, we performed a collaborative study to evaluate the effectiveness of ESG among new endobariatric programs. Methods: This was an international, multicenter study reviewing the outcomes of ESG in centers starting ESG programs. Total body weight loss, change of body mass index (BMI), excess body weight loss (EBWL), technical success, duration of hospitalization, and immediate and delayed adverse events and complications at 24 h, 1 week, and 1, 3, and 6 months post-procedure were evaluated. Results: A total of 91 patients (35 males) from six centers were included. The patients' mean BMI before the procedure was 38.7 kg/m2. BMI reduction at 3 months was 7.3 (p < 0.000), at 6 months 9.3 (p < 0.000), and at 12 months 8.6 (p < 0.000) from baseline. EBWL was 17.3% at 1 month (p < 0.000), 29.2% at 3 months (p < 0.000), and 35.6% at 6 months (p < 0.000). The mean procedure duration was 85.1 min. The mean length of hospital stay post-procedure was 27 h. Conclusion: ESG provides EBWL percentage sustained up to 12 months. These results are equivalent among the new ESG centers compared to previous studies by expert centers. Lay title: Endoscopic sleeve gastroplasty in new bariatric endoscopy programs. Plain Language Summary: This article is the result of a collaborative international study on new endoscopic programs offering endoscopic sleeve gastroplasty.The minimally invasiveness and increasing accessibility of this technique makes it very attractive for patients with obesity while being poor candidate for surgery or refusing surgery.This study will also provide valuable information regarding this rising technique of endobariatric treatment.
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Gallbladder cancer is a rare malignancy burdened by poor prognosis with an estimated 5-year survival of 5% to 13% due to late presentation, early infiltration of surrounding tissues, and lack of successful treatments. The only curative approach is surgery; however, more than 50% of cases are unresectable at the time of diagnosis. Endoscopy represents, together with surgery and chemotherapy, an available palliative option in advanced gallbladder cancers not eligible for curative treatments. Cholangitis, jaundice, gastric outlet obstruction, and pain are common complications of advanced gallbladder cancer that may need endoscopic management in order to improve the overall survival and the patients' quality of life. Endoscopic biliary drainage is frequently performed to manage cholangitis and jaundice. ERCP is generally the preferred technique allowing the placement of a plastic stent or a self-expandable metal stent depending on the singular clinical case. EUS-guided biliary drainage is an available alternative for patients not amenable to ERCP drainage (e.g., altered anatomy). Gastric outlet obstruction is another rare complication of gallbladder malignancy growing in contact with the duodenal wall and causing its compression. Endoscopy is a less invasive alternative to surgery, offering different options such as an intraluminal self-expandable metal stent or EUS-guided gastroenteroanastomosis. Abdominal pain associated with cancer progression is generally managed with medical treatments; however, for incoercible pain, EUS-guided celiac plexus neurolysis has been described as an effective and safe treatment. Locoregional treatments, such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and intraluminal brachytherapy (IBT), have been described in the control of disease progression; however, their role in daily clinical practice has not been established yet. The aim of this study is to perform a review of the literature in order to assess the role of endoscopy and the available techniques in the palliative therapy of advanced gallbladder malignancy.