Endoscopic Vacuum Therapy (EVT) for Persistent Duodenal Stump Dehiscence After Upper Gastrointestinal Surgery in Selected Patients: A Tertiary Referral Center Case Series.

INTRODUCTION: The usefulness of endoscopic vacuum therapy (EVT) in the setting of postoperative gastrointestinal leaks is widely described. On this basis, we would like to focus a specific application of EVT: the dehiscence of the duodenal stump after upper gastrointestinal surgery. Standard EVT is not applicable in these cases because of technical limitations (length of overtube and devices). However, vacuum stimulates the healing of leaks and fistulas through granulation tissue's formation and would be effective also in this setting. MATERIALS AND METHODS: Between October 2019 and January 2020, 7 consecutive patients (4 M, 3 F, 62±9 y old) affected by duodenal stump's dehiscence were endoscopically treated by the placement of a large-bore (14 to 18 Ch) suction tube across the wall's defect into the peritoneal cavity. Continuous aspiration at -80/-100 mm Hg was applied. Clinical success was established both by fluoroscopic check injecting contrast medium from the tube to verify the fistula's closure and by abdominal computed tomography scan to exclude residual fluid collections. RESULTS: Technical and clinical success were achieved in all the patients. The suction tube was maintained in site for 12±5 days in continuous aspiration. The drainage's output became null in 2±1 days without any intra-abdominal residual fluid collection. The principle of this technique is to let the duodenal walls' stump to collapse on the intraluminal part of the tube (with subsequent mucosal intussusception into the holes of the tube itself) creating a sort of vacuum-packed barrier to interrupt the outflow of enteric materials into the fistula's path. It guarantees the fistula's closure by the gradual formation of granulation tissue. CONCLUSIONS: The present technique offers a safe and viable endoscopic alternative to treat duodenal stump's leaks after upper gastrointestinal surgery.

Peroral Endoscopic Diverticulotomy (POED) for Zenker Diverticulum Using Submucosal Injection to Perform a Complete Myotomy.

Endoscopic diverticulotomy associated with cricopharyngeal myotomy is a well-known and safe treatment for Zenker diverticulum. We describe our first 5 consecutive cases treated by a new variant of the technique that allows a deeper and longer myotomy than the standard one. Technical success was achieved in all the cases. All patients showed a significant improvement and relevant disappearance of preoperative dysphagia. Tips for the technique are described in the paper. This variant of peroral endoscopic diverticulotomy for Zenker diverticulum is feasible, effective, and guarantees a complete myotomy in selected patients.

Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy.

BACKGROUND: Management of biliary adverse events (BAEs) after biliodigestive anastomosis is challenging. We propose a new endoscopic approach to improve BAEs in this clinical setting. METHODS: Patients who had BAEs after a hepaticojejunostomy with Roux-en-Y loop or a Whipple procedure underwent creation of an entero-enteral endoscopic bypass (EEEB) between the duodenal/gastric wall and the biliary jejunal loop under endoscopic ultrasound (EUS) and fluoroscopic guidance using specifically designed fully covered self-expandable metal stents. RESULTS: 32 consecutive patients underwent EEEB, which was successful in all but one patient. One procedural and five long-term mild adverse events occurred. Endoscopic retrograde cholangiography (ERC) through the EEEB successfully treated all types of BAEs in these patients. Disease recurred in two patients who were successfully re-treated through the EEEB. CONCLUSIONS: Our retrospective study showed that in patients with BAEs after biliodigestive anastomosis, EEEB is safe, feasible, and allows a successful long-term treatment of different BAEs in a tertiary referral center with high-level experience in both endoscopic retrograde cholangiopancreatography and EUS.

Primary endotherapy for Strasberg type C bile leaks.

BACKGROUND: Endotherapy is considered by some as the treatment of choice for most external biliary fistulas after laparoscopic cholecystectomy except for those originating from isolated/disconnected ducts, as in Strasberg type C lesions. Endoscopic intervention is not generally considered among treatment options because the isolated duct cannot be opacified during cholangiography and is inaccessible with the usual endoscopic methods. METHODS: Our interventional endotherapy for this type of complication consists of cannulating the isolated duct by passing a guidewire out of the cystic duct or the disruption of the common bile duct into the pathway of the biliary fistula. The key element of this endoscopic treatment is to restore the continuity of the biliary tree. Our case series (from March 2012 to September 2017) consists of 19 patients (9 males, 10 females) with Strasberg type C bile leaks. The access to the transected biliary duct was obtained by purposeful puncture of the cystic duct stump into the peritoneal cavity and then intubation of the biliary duct by a 0.035 hydrophilic guidewire. In 17 cases, we performed direct cannulation of the isolated transected duct. In 2 cases, we performed an endoscopic "step-up approach" (a 2-session variant of the technique). RESULTS: Technical and clinical success rates were both 100%. Drainage form the abdominal drain stopped in a mean of 1.2 days. There was 1 recurrence after 4 weeks (attributable to displacement of the metal stent), but we were able to retreat the patient endoscopically. Our technique is minimally invasive but very effective in healing the fistulas. Operative repair, in contrast, is a major operation with increased morbidity, prolonged hospital stay, and is more costly. Moreover, on the basis of the available literature, endotherapy passing through the abdominal cavity became safe in expert centers. CONCLUSION: The described endoscopic treatment is innovative, safe, and effective and is applicable in tertiary-level centers but requires considerable interventional endoscopic expertise. This minimally invasive procedure can increase the rate of fistula healing and decreases the need for more aggressive and risky operative procedures.

Consanguinity and the Risk of Hashimoto's Thyroiditis.

BACKGROUND: Hashimoto's thyroiditis (HT) is the most common autoimmune thyroid disease that may lead to hypothyroidism due to progressive destruction of the thyroid. The etiology of HT is unclear. However, it is associated with multiple genetic predispositions. Consanguinity has been associated with an increased susceptibility to different inherited conditions. This study investigated the association between consanguinity and risk of HT for the first time. METHODS: Using a case-control study design, 298 HT patients were compared with two subject groups: (i) 299 participants with non-HT hypothyroidism, and (ii) 298 healthy control participants. The three groups were age and sex matched. Presence of consanguinity among the parents was compared in these groups, and odds ratios (OR) were calculated to establish a correlation. RESULTS: Consanguinity significantly increased the risk of HT (compared with healthy subjects; OR = 3.3; p < 0.0001). In addition, consanguinity was a significant risk factor for HT compared with non-HT hypothyroidism patients (OR = 2.8; p < 0.0001). However, the prevalence of consanguinity was not significantly different in non-HT hypothyroidism patients and healthy subjects. CONCLUSIONS: The results suggest that the risk for HT is increased in consanguineous unions, but no significant increase in the risk of non-HT hypothyroidism was observed. However, for more precise risk estimates, larger studies that include different populations may be helpful. These findings highlight the health impact of consanguinity and have applications in empiric risk estimations in genetic counseling, particularly in countries with high rates of consanguineous marriages.