Tips and Thought Processes to Overcome Difficult Situations in Third Space Endoscopy.

PURPOSE OF REVIEW: Third space endoscopy (TSE) offers diverse treatment options for a variety of conditions of the gastrointestinal tract and motility disorders. Accuracy and precise dissection have helped treat complex conventional surgeries with TSE. Despite over a decade of its presence, difficult situations are routinely encountered. RECENT FINDINGS: The first challenging situation is decision-making (before the procedure), the second is tackling procedure-induced pulmonary / insufflation-related adverse events and intra-operative complications (during the procedure), and the third is post-operative complications and morbidity (post-procedure). The performance of TSE procedures is not without risk. Patients should receive enough time to weigh their options, considering that attitudes toward risk impact decision-making. Continuous basic patient monitoring and the micro-movements of endoscopic and electrosurgical equipment is crucial to avoid accidental injury. Anaesthetists should be mindful of anticipated complications and closely monitor, diagnose, and treat them. Demanding situations need careful consideration, problem-solving, or persistence to overcome challenges. This brief review provides inputs on preventing and tackling difficult situations in TSE.

Stopgap Measures for Obesity Prior to Surgery.

PURPOSE OF REVIEW: The data on preventive measures for managing obesity prior to surgery is limited. This review highlights the role of stopgap measures for managing obesity before surgery. RECENT FINDINGS: Body weight regulation to achieve sustainable weight loss is a gradual process. Regular aerobic exercises, transformative yoga and restrained eating can contribute to a calorie deficit. Behavioural strategies aim to raise awareness, set goals, manage stress, and support adherence to healthier lifestyles. Pharmacotherapy can be adjunctive in inducing weight loss but could be better at maintaining weight. Intragastric balloon and endoscopic sleeve gastroplasty are restrictive procedures for patients before surgery. Obesity is a multifaceted chronic disease with adverse health consequences. There is a need to identify contributors to weight gain and treatment should target the cause of obesity. Utilize stop-gap measures and monitor progress for step-up or more intensive treatment. Structured weight loss needs lifelong commitment.

Oesophageal perforation by migrated Ryles tube.

A 72-year woman with a history of multiple cerebrovascular accidents presented with severe epigastric pain. An oesophageal perforation by the tip of a Ryles tube, which had migrated into the mediastinum, was diagnosed by radiography. An attempt at pushing the nasogastric tube into the stomach resulted in increasing the rupture to about 6 cm in size. Replacement by a triple-lumen nasojejunal feeding tube and subsequent feeding with c.1,400 calories per day enabled the perforation to close without further intervention.

Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy.

Background and study aims The utility of stone density at non-contrast computed tomography (NCCT) for predicting the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis (CCP) is relatively unexplored. Patients and methods This was a prospective observational study of patients with CCP. Hounsfield units (HU) were determined for the largest pancreatic ductal stone during pretreatment NCCT. All patients underwent ESWL until the largest stone was fragmented to <3mm, followed by endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The predictive factors following ESWL for successful stone extraction were studied and the receiver operating characteristic (ROC) curve determined the HU optimal cut-point. Results Eighty-two patients with a median (interquartile range) age of 36 years (range, 29-55); majority male 45 (54.9%), were included. Idiopathic CCP was noted in 78 patients (95.1%). The median stone density (SD) was 1095 HU (range, 860.7-1260.7) and the number of ESWL sessions was 2 (range, 2-3). Complete stone removal at index ERCP was achieved in 55 patients (67.1%). Those with partial clearance (n=27) needed a repeat ERCP, which was successful in 26 (96.3%); one patient (3.7%) underwent surgery. There was a significant, positive correlation between number of ESWL sessions and SD (r=0.797; P <0.001). On bivariate analysis, SD and the number of ESWL sessions revealed a significant association with complete ductal clearance. The optimal cut-point for complete stone removal by the ROC curve was 1106.5 HU (Youden index 0.726), with a sensitivity of 93% and a specificity of 80%. Conclusions The SD is a significant predictor of ESWL success followed by ductal clearance at ERCP, and <1106.5 HU is a predictor of good candidates for ESWL therapy.

Comparison of diagnostic outcomes, safety, and cost of Franseen-tip 19G versus 22G needles for endoscopic ultrasound-guided liver biopsies.

Background and study aims Favorable outcomes were noted with refinement in newer endoscopic ultrasound-guided liver biopsy (EUS-LB) needle tips. Still, the overall usefulness and benefit are yet to be well explored. Patients and methods This was a retrospective analysis of patients with EUS-LB (Franseen-tip 19G versus 22G FNB needle) over 2 years. EUS-LB was obtained in a one-pass, two-actuation, modified wet suction technique. Diagnostic yield, fragmentation rate, aggregate specimen length (AL), number of complete portal tracts (CPT), length of longest intact core (LIC), adverse events (AEs) (early), and cost of the procedure (1USD = 82 INR) were compared. Results Fifty-four patients (33 [61.1%], female) successfully underwent EUS-LB with a median age of 46 years (interquartile range [IQR] 34-54); the majority 32 (59.2%) underwent 19G biopsies. There was a significantly increased median (IQR) AL in the 19G compared with 22G (20 mm [19-21] vs. 15 [14-15], P < 0.001), respectively. Similarly, significantly lengthier median LIC and CPT were seen, respectively. A nonsignificant diagnostic yield was noted (100% vs. 90.9%, P = 0.082), respectively. The fragmentation rate was higher in 22G FNB needles (36.4% [95% CI 16-56] vs. 12.5% [95% CI 1-24], respectively; P = 0.038). Seven patients (12.9%) had mild AEs with no difference between groups. The average procedure cost with 19G was INR 63000 (768$), and with 22G needle was INR 54500 (664$). Conclusions The Franseen-tip 19G outperforms 22G with a significantly lower fragmentation rate, longer AL, LIC, and a higher number of CPT with a marginal increase in the procedure cost, without any difference in diagnostic yield and safety.

Advances in the Management of Pain in Chronic Pancreatitis.

PURPOSE OF REVIEW: The data on recent advances in managing chronic pancreatitis (CP) pain is limited. This review highlights the role of endotherapy and the advances in the overall management of pain in CP. RECENT FINDINGS: Of late, pancreatic biodegradable stents have been used in endotherapy with appreciable success. These include slow, medium, and fast degrading stents, which optimize the overall management of CP and could prevent the need for multiple procedures. Endoscopic ultrasound-guided celiac plexus block is reserved in selected patients to treat debilitating pain. Total pancreatectomy with islet autotransplantation in small duct disease has shown promising results. The indications for treating pain in CP with endoscopy and surgery need to be better defined. The complexity of pain control due to the incomplete understanding of pathomorphology makes the management of CP challenging. The current treatment methods are still evolving. Therapy aims to reduce pain, optimize recovery, maintain quality of life, and meet postoperative needs. Initial management includes lifestyle modification, nutrition optimization, risk factor reduction with abstinence from alcohol, cessation of tobacco and smoking. Supportive medical management involves the judicial use of analgesics, neuromodulators, antioxidants, pancreatic enzyme replacement for insufficiency, and diabetes management. Patients with intractable pain are ideal for therapeutic intervention. Being less invasive with an acceptable complication rate makes endotherapy the preferred first-line treatment. If found to be cost-effective, biodegradable stents can reduce the overall cost. Unfortunately, if patients remain symptomatic, surgery is preferred in case of failure or recurrence. For optimal results, appropriate patient selection is vital to maximizing outcomes.

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux after peroral endoscopic myotomy: a randomized sham-controlled study.

BACKGROUND : Endoscopic full-thickness plication (EFTP) has shown promising results in gastroesophageal reflux disease (GERD), but its efficacy in GERD after peroral endoscopic myotomy (POEM) is unclear. METHODS : In a prospective, randomized trial of post-POEM patients dependent on proton pump inhibitors (PPIs) for documented GERD, patients underwent EFTP (plication to remodel the gastroesophageal flap valve) or an endoscopic sham procedure (positioning of the EFTP device, but no stapling). The primary end point was improvement in acid exposure time (AET) < 6 % (3 months). Secondary end points included improvement in esophagitis (3 months), GERD Questionnaire (GERDQ) score (3 and 6 months), and PPI usage (6 months). RESULTS : 60 patients were randomized (30 in each group). At 3 months, a significantly higher proportion of patients achieved improvement in AET < 6 % in the EFTP group compared with the sham group (69.0 % [95 %CI 52.1-85.8] vs. 10.3 % [95 %CI 0-21.4], respectively). EFTP was statistically superior to sham (within-group analysis) in improving esophageal AET, DeMeester Score, and all reflux episodes (P < 0.001). A nonsignificant improvement in esophagitis was noted in the EFTP group (P = 0.14). Median GERDQ scores (3 months) were significantly better (P < 0.001) in the EFTP group, and the same trend continued at 6 months. A higher proportion of patients in the sham group continued to use PPIs (72.4 % [95 %CI 56.1-88.7] vs. 27.6 % [95 %CI 11.3-43.8]). There were no major adverse events in either group. CONCLUSION : EFTP improved post-POEM GERD symptoms, 24-hour pH impedance findings with normalization in one-third, and reduced PPI usage at 6 months.

Utility of the Novel SpyGlassTM DS II System and Laser Lithotripsy for Choledocholithiasis in Pregnancy.

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is considered a safe therapeutic modality even in pregnant women; however, adequate care needs to be taken. The utility of the SpyGlassTM DS II system in choledocholithiasis among pregnant women is unexplored. Methods: We retrospectively analyzed patients who underwent ERCP for choledocholithiasis in the absence of fluoroscopy using the SpyGlass DS II system from October 2019 to November 2020. Depending on the size and location of the stones, we used laser lithotripsy (LL) for large impacted stones, the balloon extraction technique for multiple stones, and the SpyGlass retrieval basket for single solitary stones. Results: A total of 10 (100% female) patients with a mean (±SD) age of 29.5 (±2.5) years underwent ERCP. Abdominal pain was the commonest presenting symptom in all patients. Four (40%) patients had cholangitis and 3 (30%) had pancreatitis. The majority of the patients (9; 90%) were in the second trimester. MRCP was the commonest radiological entity, used in 9 (90%) patients. ERCP was technically successful and the stones were removed from all of the patients in a mean (±SD) time of 30 (±3.5) min. LL was used successfully in 4 (40%) patients, balloon extraction in 3 (30%) patients, and the SpyGlass retrieval basket in 3 (30%) patients. There were no pre- or post-procedural complications. All of the patients had an uneventful childbirth, after which they underwent cholecystectomy and subsequent stent removal 2 weeks later. Conclusions: Use of the SpyGlass DS II system and LL during ERCP appears safe and effective for the treatment of choledocholithiasis among pregnant women.

Introdução e objectivo: A colangiopancreatografia retrógrada endoscópica (CPRE) é considerada uma modalidade terapêutica segura mesmo nas grávidas, contudo, alguns cuidados são necessários. A utilidade do novo sistema Spyglass DS II na coledocolitíase da gravidez continua por investigar. Métodos: Analisamos retrospectivamente doentes que fizeram CPRE por coledocolitíase sem fluoroscopia usando o sistema Spyglass DS II de Outubro de 2019 a Novembro de 2020. Dependendo do sítio e localização dos cálculos, usou-se as seguintes técnicas: litotripsia por lazer (LL) para cálculos grandes impactados; técnica de extração por balão para múltiplos cálculos; e extração com cesta guiada por spyglass para cálculo único. Resultados: Um total de 10 doentes (100% mulheres) realizou CPRE com uma média (dp) de idade de 29.5 anos (2.5). A dor abdominal foi o sintoma de apresentação principal em todos os doentes. Quatro (40%) doentes tinham colangite e 3 (30%) tinham pancreatite. A maioria das doentes estava no segundo trimestre da gravidez. A colangioRMN foi utilizada em 9 (90%) dos doentes. A CPRE e a extração dos cálculos foi possível em todos os doentes numa média (dp) de tempo de 30 (3.5) minutos. A LL foi usada com sucesso em 4 (40%) doentes, extração por balão em 3 (30%) doentes e extração com cesta guiada por spyglass em 3 (30%) doentes. Não se verificaram complicações pré ou pós procedimento. Todas as doentes tiveram um parto sem complicações, a seguir ao qual fizeram colecistectomia e subsequente remoção de prótese biliar em duas semanas. Conclusões: O sistema SpyGlass DS II e a LL durante a CPRE parecem seguros e eficazes no tratamento da coledocolitíase nas grávidas.

Usefulness of endoscopic ultrasound in children with pancreatobiliary and gastrointestinal symptoms.

Background and study aims Endoscopic ultrasound (EUS) is useful in diagnosing and treating childhood pancreatobiliary and gastrointestinal diseases. However, there are limited data on its effectiveness for various indications. Patients and methods This was a retrospective analysis of prospectively collected data of patients who underwent EUS for upper gastrointestinal tract disorders from January 2018 to December 2020 to assess its indications, findings, interventions, and complications. Results Ninety-two procedures were performed in 85 children, (70.5 % male; mean [SD] age 12.1 years [3.9] years) with a mean (SD) symptom duration of 1.1 (0.5) years. The procedures were technically successful in all patients. The primary indication for EUS was abdominal pain in 45(52.9%) and jaundice/cholangitis in 15 patients (17.6 %). General anesthesia was used in 12 (13 %) and TIVA in 80 patients (87 %). The most common diagnostic findings were choledocholithiasis in 21 (24.7 %) and cholelithiasis in 12 patients (14.1 %). Among interventions, EUS-guided cystogastrostomy for pancreatic pseudocyst was done in four patients (4.7 %), and EUS-guided rendezvous for failed ERCP in one patient (1.2 %) with cholangitis. There were no immediate post-procedural complications. Overall, EUS had a meaningful impact on the subsequent clinical management in 69 cases (81.2 %). Conclusions EUS in the pediatric population is safe, effective, and has a meaningful impact in appropriately selected cases. It can act as a rescue in major therapeutic procedures, but adequate care should be taken at the procedural level and during anesthesia.

Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography.

BACKGROUND: Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes. METHODS: Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied. RESULTS: As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage. CONCLUSION: Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

Endoscopic Retroperitoneal Necrosectomy for Infected Pancreatic Necrosis Using a Self-Expandable Metal Stent.

Infected walled-off pancreatic necrosis (WOPN) is a severe complication of acute pancreatitis. Surgery in these critically ill patients can be associated with increased morbidity and mortality. Hence, minimally invasive therapies have emerged as an alternative to surgery. Herein, we report a case of severe acute pancreatitis with WOPN which was treated percutaneously with a flexible endoscope through an esophageal self-expanding metal stent using a total retroperitoneal approach. Percutaneous direct endoscopic necrosectomy (p-DEN) using the retroperitoneal route improved the patient's parameters dramatically with resolution of sepsis without the need for surgery. p-DEN using a flexible endoscope passed through a large bore metal stent shows promise in selected patients with WOPN and can be used in patients who are not ideal candidates for transmural or surgical drainage.

A necrose pancreática infectada walled-off (WOPN) é uma complicação grave da pancreatite aguda (PA). A cirurgia nestes doentes críticos pode associar-se a um aumento da morbimortalidade. Assim, técnicas minimamente invasivas surgiram como alternativa à cirurgia. Reportamos um caso de PA grave com WOPN que foi tratada de forma percutânea com um endoscópio flexível através de uma prótese metálica auto-expansível usando uma abordagem totalmente retroperitoneal. A necrosectomia retroperitoneal endoscópica direta (p-DEN) usando a via retroperitoneal melhorou os parâmetros do doente significativamente com resolução da sépsis sem necessidade de cirurgia. p-DEN usando um endoscópico flexível que passa através uma prótese metálica de grande diâmetro parece ser uma técnica promissora em alguns doentes com WOPN, podendo ser utilizada em doentes que não são candidatos ideais para uma drenagem transmural ou cirúrgica.

Early outcomes of peroral endoscopic myotomy with fundoplication for achalasia cardia - Is it here to stay?

BACKGROUND: Peroral endoscopic myotomy with fundoplication (POEM-F) has garnered widespread attention since it tries to achieve an appropriate antireflux procedure during the same setting. The outcomes of POEM-F are currently unexplored. METHODS: Patients who underwent POEM-F at our center were retrospectively studied to assess its safety and early outcomes. RESULTS: Twenty patients [70% male; median age 32 years (range 25-41)], with a median symptom duration of 2.1 years (range 1.5-3.7) with achalasia were included. POEM-F procedure was completed in a median of 118 min (range 90-160), with 17/20 (85%) technical success. The median hospitalization was 4 days (range 2-7). Capnothorax (n = 3), resolved spontaneously (n = 2) in 4-6 h, while in one patient (n = 1) the endoscope inadvertently entered into the thoracic cavity for which prophylactic intercostal drain was required. Capnoperitoneum was seen in 17/17 (100%) patients who underwent fundoplication, subcutaneous emphysema in 8/17 (47%) patients. At 1-month follow-up endoscopy, 5/17 (29.4%) patients had loosening of the fundal wrap, 3/17 (17.6%) patients had ulceration in fundus and in gastroesophageal junction due to underlying hemoclips. At 3 months, loosening of the fundal wrap was seen in 7/17 (41.2%) patients. A 24-h pH-metry revealed abnormal esophageal acid exposure in 7/17 (41.2%) patients, while it was normal in those patients in whom the fundal wrap was maintained. 10/17 (58.8%) patients were off proton pump inhibitors. CONCLUSION: POEM-F is technically feasible with reasonable short term success. However, the durability, early success and safety of POEM-F need reassessment in long-term studies before being applied in clinical practice.

The Usefulness of an Endoscopic OverStitch Suturing System for Managing Anastomotic Dehiscence - A Case Report.

Anastomotic dehiscence (AD) after colorectal surgery contributes to poor outcomes resulting in multiple postoperative complications. Conventional management would be a repeat laparotomy and tension suturing. But owing to the unhealthy vicinities near the suture lines, there is a significant risk of technical failure which further increases postoperative morbidity and mortality. A 60-year-old male, with a history of hypertension, ischemic heart disease, and previous percutaneous transluminal coronary angioplasty, underwent sigmoid colectomy with colorectal anastomosis for complicated sigmoid diverticulitis. He then developed anastomotic site leak for which an ileostomy was done. Prior to the ileostomy revision, he was referred for colonoscopic evaluation which showed the persistence of a partial AD. We decided to close the defect endoscopically with the Apollo OverStitch device. Initial tissue preparation was done by creating a surgical surface using argon plasma coagulation at the perimeter of the leak site. A double channel therapeutic endoscope with the OverStitch assembly was passed to take full-thickness running sutures across the rent to facilitate full closure. The area examined showed good suture approximation and complete closure. The procedure was successful with no immediate or delayed postprocedural complications. Repeat endoscopic evaluation at about two weeks showed well-approximated edges with intact suture lines, and there was complete resolution of the leak. The patient subsequently underwent revision surgery after a month. The patient is under close follow-up and doing well. The Apollo OverStitch device has certainly opened new avenues in flexible endoscopic surgery which need further exploratory studies to add to existing promising results.

A deiscência anastomótica (DA) após a cirurgia colorretal contribui para piores resultados, resultando em múltiplas complicações pós-operatórias. A terapêutica convencional passa por repetir a laparotomia e uma sutura de tensão. Mas devido às condições locais perto das linhas de sutura há um risco significativo de falência técnica, o que aumenta ainda mais a morbimortalidade destes doentes. Neste caso um homem de 60 anos com história de hipertensão e cardiopatia isquémica com angioplastia coronária percutânea prévia foi submetido a colectomia do sigmóide com anastomose colorretal, devido a uma diverticulite do sigmóide complicada. Verificou-se deiscência da anastomose pelo que uma ileostomia foi realizada. Antes do encerramento da ileostomia o doente realizou colonoscopia que evidenciou persistência parcial da DA. Foi decidido encerramento endoscópico da DA utilizando o sistema de sutura Apollo OverStitch. O tecido foi inicialmente preparado através da criação de uma superfície cirúrgica utilizando coagulação com argon plasma dos bordos da DA. Foi utilizado um endoscópio terapêutico de duplo canal montado já com o sistema de OverStitch de forma a possibilitar suturas continuas transmurais, facilitando o encerramento da fístula. A área intervencionada mostrou uma boa aproximação dos bordos da sutura e um encerramento completo. O procedimento foi um sucesso, sem complicações imediatas ou tardias. A endoscopia de reavaliação duas semanas depois mostrou os bordos bem aproximados com linhas de sutura intactas com resolução completa de DA. A revisão cirúrgica foi efetuada um mês depois e o doente está clinicamente bem. O sistema de sutura Apollo OverStitch abre novas possibilidades na cirurgia endoscópica flexível, sendo necessários mais estudos exploratórios a acrescentar evidência aos promissores resultados já existentes.

An Indian Experience of Endoscopic Treatment of Obesity by Using a Novel Technique of Endoscopic Sleeve Gastroplasty (Accordion Procedure).

INTRODUCTION: Endoscopic Sleeve gastroplasty (ESG) is a novel minimally invasive endoscopic restrictive bariatric procedure. We studied the safety, effectiveness, 6-month weight loss outcomes of ESG. METHODS: We prospectively collected data for patients undergoing ESG at a tertiary care referral center. Laboratory investigations were performed preoperatively, and at 6 months post-operatively. Anthropometric measurements were noted pre and post-operatively at a frequency of 3 months for a 6-month follow-up. Patients with BMI ≥28 kg/m2 who were ready for multidisciplinary follow up for at least 6 months were part of the study. Weight was evaluated at 1, 3 and 6 months' post procedure, and percent of total weight loss (%TWL) and percent of extra weight loss (% EWL) was calculated. Adverse events and new-onset symptoms were recorded. RESULTS: This prospective study included 58 patients, [55(94.8%)females] who underwent ESG (Jun 2018 - July 2019) using the Over Stitch device (Apollo Endosurgery, Inc., Austin, Texas, US). Mean age was 42.1 years (range 23-53) and mean BMI (kg/m2) was 37.88 (range 28.4-42.9). A median of 5 plications (range 4-6) were used to provide a tubular restriction to the gastric cavity. Mean procedural time (min) was 55 (Range 45 - 86). The mean (±SD) weight reduced significantly from baseline of 98.3±20.4 to 81.8±19.1 at 6 months (p<0.001). The mean BMI reduced significantly from baseline of 37.88±5.76 to 31.37±5.23 at 6months (p<0.001). The mean % of TWL was 8.8 (5.6-16.1), 12.6(10.4-19.1) and 17.1 (11.2-24.1) at 1, 3 and 6 months respectively. The % of EWL was 21.3(12.3-34.3), 30.5(17.7-45.6) and 42.8 (24.5-61.9) at 1, 3 and 6 months respectively. No major complications developed, and patients were discharged on postoperative day 2 (+4 days). Nausea 29 (50%) and moderate to severe abdominal pain 14 (24.1%) were the most common adverse events, treated conservatively. Stitch loosening was noted in 1(1.7%) patient at third month who underwent resuturing. CONCLUSIONS: ESG appears safe and effective in treating obesity at our center. Mindfulness to reduction in %TWL, %EWL and BMI are critical in evaluating the initial success of ESG. Long term follow-up is required to assess for its sustained effect. Further research into dietary and behavioral modifications with ESG is warranted.

A rare case of intraductal tubulopapillary neoplasm of the pancreas - case report (with video).

Intraductal tubulopapillary neoplasm (ITPN) is a premalignant epithelial tumor of the pancreas. We report a case of ITPN detected incidentally during histopathology examination (HPE) from a specimen taken at the time of endosonography in a patient with pancreatitis. A 53-year-old man presented with severe recurrent epigastric pain, associated with episodic nonbilious vomiting, with a weight loss of about 7 Kg since 15 days. He underwent Magnetic resonance cholangiopancreatography which showed an ovoid soft tissue lesion in the Pancreatic duct (PD) reported as possible intraductal neoplasm. Patient underwent Endoscopic Ultrasound, whereby the PD was dilated and a large hypoechoic lesion was noted in the PD (head region) causing upstream dilatation. Lesion did not show any vascularity on Doppler. Fine needle biopsy was sent from the intraductal lesion for histopathology examination (HPE). Patient then underwent an ERCP. After performing a pancreatic sphincterotomy, pancreaticoscopy was done using SPYGLASS DS system which showed a nodular intraluminal lesion in the head region with irregular and abnormal vascularity and papillary fronds. Biopsies were taken from this lesion using SpyBite biopsy forceps. To our surprise this HPE report came out to be ITPN. Patient was then referred for surgery. There is often a difference of opinion in distinguishing and classifying such tumors when compared to the subtypes of mucinous neoplasm. Identification of this neoplasm is often challenging for pathologists as well as radiologists. We present this case since it is infrequent and atypical in routine medical practice.