Endoscopic Management of Dysfunctioning Gastric Band after Sleeve Gastrectomy with the Luso-Cor® Esophageal Stent.

Sleeve gastrectomy (SG) can be aided by the addition of a calibration silicone ring, banded SG (BSG). It provides better weight loss than non-banded SG but with higher rate of adverse events. The aim of this case report is to further contribute to the knowledge of how to endoscopically manage these patients by placing a new esophageal stent (Luso-Cor®). A 58-year-old female with grade III obesity (weight 110 kg, BMI: 45.2 kg/m2) underwent SG in 2013. Due to the limited weight loss, a surgical calibration silicon ring was placed in 2017. In the following months, she developed recurrent and abundant postprandial regurgitation, achieving a minimum weight of 66 kg (BMI: 27.1 kg/m2). Gastroesophageal transit showed a stricture at the junction of the gastric corpus and antrum, causing gastric outlet obstruction. Endoscopy identified a regular luminal stenosis with normal mucosa, which allowed easy passage of the endoscope with slight pressure. Two sessions of endoscopic dilatation were performed, first with an 18-mm through-the-scope balloon and later with a 30-mm pneumatic balloon without symptomatic relief. A two-step endoscopic therapeutic approach was proposed to first promote intragastric ring erosion by placing a new partially covered metallic stent, Luso-Cor® esophageal stent 30/20/30 × 240 mm, and subsequently retrieve the stent, followed by cutting and retrieval of the ring. The proximal flare with a 30 mm diameter was placed in the distal esophagus and the distal edge in the prepyloric antrum. However, 2 weeks later, she complained of vomiting and abdominal fullness. Complete migration of the proximal flare of the stent into the remnant gastric fundus was seen on the contrast study. Endoscopy was performed, and the stent was easily removed. A blue calibration ring, partially eroded into the gastric lumen, was observed at the site of gastric tube stenosis. After stent removal, the patient was asymptomatic, and so conservative follow-up was decided. A follow-up endoscopy, performed 5 months later, showed complete reepithelization of the eroded ring. The patient remains asymptomatic after 3 years of follow-up and has regained weight up to 76 kg (BMI: 31.2 kg/m2). The efficacy of endoscopy on the management of ring-related adverse events has been previously reported. Small-case series describe the use of multiple pneumatic dilations or the deployment of plastic or covered metallic stents to cause erosion of the overlying mucosa, followed by cutting and retrieval of the ring. In conclusion, we believe that the mural pressure exerted by the Luso-Cor® esophageal stent, in the limited period it remained in situ, was sufficient to relieve the luminal pressure of the silicon ring, realigning the ring with the remnant gastric tube. This rare clinical entity highlights the potential role of specific metallic stents in the management of these patients.

A cirurgia bariátrica de gastrectomia vertical (sleeve gástrico) pode ser complementada pela adição de um anel restritivo de silicone ­ sleeve gástrico com anel de silastic. O acréscimo deste anel promove uma maior perda de peso, no entanto está associado a maior risco de eventos adversos. O objetivo da apresentação deste caso é contribuir para as diferentes técnicas úteis no tratamento das complicações relacionadas com o anel, através da utilização de uma prótese esofágica (Luso-Cor®).Uma doente de 58 anos, com obesidade grau III (peso 110 kg, IMC 45,2 kg/m2), foi submetida a um sleeve gástrico em 2013. Não apresentou perda de peso favorável e, em 2017, foi colocado um anel de silicone rodeando o tubo gástrico. Nos meses seguintes desenvolveu regurgitação pós-prandial recorrente e abundante, alcançando um peso mínimo de 66 kg (IMC 27,1 kg/m2). Realizou um trânsito gastroesofágico que revelou uma estenose na junção do corpo com o antro gástrico, com evidência de obstrução do esvaziamento gástrico. A endoscopia digestiva alta identificou uma estenose regular recoberta por mucosa sem lesões, com passagem do aparelho após pressão ligeira. Foram realizadas duas sessões de dilatação, inicialmente com balão trough-the-scope de 18 mm e posteriormente com balão pneumático de 30 mm. Os sintomas persistiram e, por esse motivo, foi decidido uma abordagem em dois tempos: primeiro promover a erosão intragástrica da banda para depois a seccionar e remover intraluminalmente. Nesse sentido, foi colocada uma prótese metálica esofágica parcialmente coberta, Luso-Cor® 30/20/30 × 240 mm. O segmento proximal da prótese com 30 mm de diâmetro foi colocado no esófago e o bordo distal da prótese ficou no antro pré-pilórico. No entanto, duas semanas depois, a doente queixou-se de vómitos e enfartamento precoce. O estudo radiográfico com contraste revelou migração distal da prótese, com deslocamento do segmento proximal para o corpo gástrico remanescente. A prótese foi removida endoscopicamente sem dificuldade e, na região da estenose, foi observado o anel de silicone parcialmente erosionado para o lúmen gástrico. Após remoção da prótese a doente evoluiu favoravelmente, sem novos sintomas, e, por esse motivo, foi decido seguimento sem novas intervenções. A endoscopia de seguimento, realizada cinco meses após, demonstrou reepitelização completa do anel parcialmente erosionado. A doente permanece assintomática após três anos de seguimento e voltou a ganhar peso (peso atual 76 kg, IMC 31,2 kg/m2). A eficácia da resolução endoscópica de estenoses relacionadas com anel de silicone no sleeve gástrico já foi relatada. Pequenas séries de casos utilizaram múltiplas sessões de dilatação com balão pneumático ou colocação de próteses plásticas ou metálicas cobertas para promover erosão intragástrica do anel e sua remoção. Acreditamos que a pressão mural exercida pela prótese Luso-Cor®, no curto tempo em que permaneceu in situ, foi suficiente para aliviar a obstrução, realinhando o seu diâmetro com o restante tubo gástrico. Através do relato desta entidade clínica rara, esperamos contribuir para o conhecimento das próteses metálicas específicas para o manejo destes doentes.

Is endoscopic ultrasound-guided gastroenterostomy better than surgical gastrojejunostomy or duodenal stenting?

OBJECTIVES: Gastrojejunostomy is a critical procedure for managing gastric outlet obstruction. While surgical gastrojejunostomy has traditionally been the standard approach, endoscopic ultrasound (EUS)-guided gastroenterostomy has emerged as a promising endoscopic alternative. This comprehensive review aims to explore the development, techniques, outcomes, and comparative effectiveness of EUS-guided gastroenterostomy in comparison to duodenal stenting and surgical gastrojejunostomy. METHODS: A comprehensive literature search was conducted using electronic databases to identify relevant studies published up to April 2024. The search included keywords related to EUS-guided gastrojejunostomy, surgical gastrojejunostomy, and duodenal stenting. Studies reporting on technical success, clinical success, complications, recurrence rates, quality of life, and long-term outcomes were included for analysis. RESULTS: The development of EUS-guided gastroenterostomy has evolved significantly over the years, driven by device advancements and improved endoscopic techniques. Comparative studies have shown that the technique offers several advantages, including the ability to create an anastomosis without the need for surgery, reduced invasiveness, shorter hospital stays, and potentially improved patient outcomes as compared to duodenal stenting and surgical gastrojejunostomy. CONCLUSION: Endoscopic ultrasound-guided gastroenterostomy represents a promising alternative to surgical gastrojejunostomy and duodenal stenting for the management of gastric outlet obstruction. The technique has evolved significantly, offering a less invasive and more effective treatment option.

Bilio-Cecal Stent Migration Presenting as Massive Rectal Bleeding.

Endoscopic biliary stenting is a well-established intervention for the treatment of biliary, hepatic, and pancreatic disorders. The common indications include strictures, neoplasms, stones, infections, and bile leaks. Stents can be occluded, predisposing patients to ascending cholangitis and biliary sepsis. Distal stent migration is another known complication of endoscopic stenting and is usually spontaneous. Bowel perforation, abscesses, bleeding, and pancreatitis are rare complications of distal stent migration and are usually limited to the duodenum. Herein, we describe an extremely rare case of bilio-cecal stent migration presenting as rectal bleeding.

Gastric Tube Volvulus Occurring Years After Esophagectomy and Its Successful Treatment Via Endoscopic Stenting.

Esophageal cancer is frequently treated with esophagectomy, which is associated with distinct complications. Delayed gastric conduit emptying is a well-recognized complication that usually occurs within the postoperative period. By contrast, gastric tube volvulus is a rarer complication with a more variable time course of onset after esophagectomy and can be mistaken for delayed gastric conduit emptying. We describe the fifth reported case of gastric tube volvulus occurring years after esophagectomy and its successful treatment via endoscopic stenting.

[Complicated gastric cancer and modern treatment approaches]. / Oslozhnennye formy raka zheludka ­ sovremennye podkhody k lecheniyu.

Among all patients with gastric cancer, 40% admit to the hospitals due to cancer-related complications. The most common complications of gastric cancer are bleeding (22-80%), malignant gastric outlet obstruction (26-60%), and perforation (less than 5%). The main treatment methods for gastric cancer complicated by bleeding are various forms of endoscopic hemostasis, transarterial embolization and external beam radiotherapy. Surgical treatment is possible in case of ineffective management. However, surgical algorithm is not standardized. Malignant gastric outlet stenosis requires decompression: endoscopic stenting, palliative gastroenterostomy. Surgical treatment is also possible (gastrectomy, proximal or distal resection of the stomach). The main problem for patients with complicated gastric cancer is the lack of standardized algorithms and abundance of potential surgical techniques. The aim of our review is to systematize available data on the treatment of complicated gastric cancer and to standardize existing methods.

Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes.

BACKGROUND: Oncological outcomes of stenting as a bridge to surgery (SBTS) remain a major concern, despite perioperative benefits it offers. This study aims to evaluate the differences in recurrence patterns and survival in patients with non-metastatic, obstructing left sided colon cancers treated by SBTS versus upfront emergency surgery (ES). METHODS: This is a retrospective, single-centre cohort study of 227 consecutive patients with non-metastatic, obstructing left sided colon cancer between 2007 and 2016. Primary outcomes were pattern of recurrence, and survival. Univariate, bivariate and multivariate logistic regression were done to determine relationships between factors and recurrence. Kaplan Meier curves and log rank tests were used to analyse survival outcomes. RESULTS: Of the 227 patients included, 62 underwent SBTS and 165 underwent upfront ES. There was a higher rate of peritoneal recurrence in SBTS group (27.4 vs 15.2% p = 0.034), with no difference observed in overall, liver or lung recurrences. No significant difference in overall survival (p = 0.11), cancer specific survival (p = 0.35), or recurrence free survival (p = 0.107) was observed. Univariate analysis showed that SBTS (OR 2.12, p = 0.036), diabetes mellitus (DM) (OR 2.58, p = 0.013), T4 (OR 2.81, p = 0.001), N + (OR 4.02, p = 0.001), lymphovascular invasion (OR 2.43, p = 0.011) contributed to a higher rate of peritoneal recurrence. Bivariate analysis showed synergistic relationship between T4 tumors and SBTS: in T4 tumors that underwent SBTS, the odds of having peritoneal recurrence was 6.8 times higher when compared to ES (p = 0.004); whilst in T2/3 tumors there was no significant difference observed (OR 1.33, p = 0.55). Multivariable analysis showed SBTS (OR 2.60, p = 0.04), DM (OR 2.88, p = 0.012), N + (OR 2.97, p = 0.026) were significant predictors for peritoneal recurrence. CONCLUSIONS: There are concerns over oncological safety of SBTS even with low rates of stent-related perforation. Higher rates of peritoneal recurrence are seen especially with T4 colon cancers treated with SBTS. SBTS, DM and nodal stage were significant predictors for peritoneal recurrence.

Comparative outcome of single versus two double-pigtail stents for endoscopic drainage of pancreatic fluid collections with minimal necrosis: a retrospective analysis.

Background: Endoscopic ultrasound (EUS)-guided cystogastrostomy is the treatment of choice for managing symptomatic pancreatic fluid collections (PFC). However, studies on the number of stents for optimal drainage of PFCs are limited. Hence, the present study was conducted to compare the outcome of single versus two double-pigtail stents for endoscopic drainage of PFCs. Methods: This is a single-center, retrospective analysis of patients undergoing endoscopic drainage of PFCs with minimal necrosis (pseudocyst or walled-off necrosis with <30% solid content) at a tertiary center in South India from October 2020 to October 2022. Post-procedure, patients were followed up for clinical improvement, and stents were removed after documentation of cyst size reduction on imaging. Results: Sixty-three patients (82.5% males, median age: 34 years) fulfilling the selection criteria were included. For single stent placement (n = 47), stents of size 8.5 Fr or 10 Fr were used, while for placement of two stents (n = 16), 7 Fr stents were used. The technical success rate was 100%. Intraprocedural and early postprocedural adverse events (all mild to moderate) were comparable between the groups (17.0% with single stent vs. 25.0% with two stents, p = NS). Clinical success was achieved in 93.6% of patients, with no difference between both groups. Three patients in the single stent group required additional procedures. All patients underwent successful stent removal after a median follow-up of 14 weeks. Conclusion: A single pigtail stent of 8.5 Fr or 10 Fr size for EUSguided cystogastrostomy provides efficacy and safety similar to that of two stents.

Delayed bowel stenosis following subtotal resection of the small intestine for non-occlusive mesenteric ischemia.

We report herein a case of delayed bowel stenosis after surgery for non-occlusive mesenteric ischemia (NOMI), which was successfully treated with endoscopic stenting. The patient was a 78-year-old woman who underwent an emergency laparotomy for NOMI and duodeno-ileal anastomosis. Necrosis was observed in almost all areas of the small intestine except for the beginning of the jejunum and the end of the ileum. Postoperatively, the patient was discharged with central venous nutrition, but was readmitted on postoperative day 54 with a diagnosis of postoperative ileus. The patient failed to respond to conservative treatment. Fluoroscopic endoscopy revealed wall stiffness and circumferential stenosis in the ascending colon at a different site from that of the anastomosis. Based on this finding, delayed stenosis of the ascending colon after NOMI treatment was diagnosed. Bougie dilatation was performed for the stenosis, leading to temporary improvement. However, stenosis along with ileus soon recurred. To prevent restenosis, a metallic stent was endoscopically implanted at the stenotic site. Thereafter, the patient was discharged without any further episodes of restenosis. Delayed bowel stenosis may occur after a subtotal resection of the small intestine for NOMI. Endoscopic stenting is an effective treatment option if resection is difficult.

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting.

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.

A colocação de próteses endoscópicas é uma técnica que tem testemunhado avanços notáveis na última década, resultando na evolução da prática clínica diária dos gastroenterologistas em todo o mundo. As indicações para a colocação de próteses endoscópicas têm expandido progressivamente, tornando-se uma opção cada vez mais frequente no algoritmo de abordagem das mais variadas condições benignas e malignas do trato gastrointestinal (desde o esófago ao reto). Além da expansão nas indicações, o aprimoramento tecnológico contínuo e o desenvolvimento de novas próteses endoscópicos resultaram num maior sucesso dessas abordagens e, em alguns casos, permitiram novas aplicações. Esta revisão tem como objetivo resumir as melhores práticas em colocação de próteses endoscópicas esofágicas, gastroduodenais e colorretais.

Efficacy of lumen-apposing metal stents for the management of benign gastrointestinal stricture: a systematic review and meta-analysis.

Background: Lumen-apposing metal stents (LAMS) are an evolving option for the management of benign gastrointestinal (GI) strictures. Multiple studies have reported on the efficacy and safety of LAMS for benign GI strictures, but were limited by their small sample size. Hence, we conducted this meta-analysis to assess the critical role of LAMS for the management of benign GI strictures. Methods: A literature search of various databases from inception until October 2022 was conducted for studies evaluating the outcome of LAMS in patients with benign GI strictures. The outcomes assessed included technical and clinical success, adverse events including stent migration, and reintervention. Pooled event rates across studies were expressed with summative statistics. Results: A total of 18 studies (527 patients) were included in the present analysis. The pooled event rates for technical, short-term and long-term clinical success were 99.9% (95% confidence interval [CI] 99.1-100.0), 93.9% (95%CI 90.7-100.0), and 72.8% (95%CI 55.7-90.0), respectively. The pooled incidence of adverse events and stent migration with LAMS for benign GI strictures was 13.5% (95%CI 8.6-18.5) and 10.6% (95%CI 6.0-15.2), respectively. The pooled event rate for reintervention with LAMS for GI strictures was 23.0% (95%CI 15.7-30.3). In a subgroup analysis focusing only on anastomotic strictures there was no significant difference in the pooled event rates for various outcomes. Conclusions: LAMS have a high technical and short-term clinical success rate, with an acceptable safety profile for the management of benign GI strictures. Further studies are needed to determine the appropriate duration of stent therapy and long-term outcomes.

Advanced Endoscopy for Thoracic Surgeons.

The thoracic surgeon, well versed in advanced endoscopy, has an array of therapeutic options for foregut pathologic conditions. Peroral endoscopic myotomy (POEM) offers a less-invasive means to treat achalasia, and the authors' preferred approach is described in this article. They also describe variations of POEM, such as G-POEM, Z-POEM, and D-POEM. In addition, endoscopic stenting, endoluminal vacuum therapy, endoscopic internal drainage, and endoscopic suturing/clipping are discussed and can be valuable tools for esophageal leaks and perforations. Endoscopic procedures are advancing rapidly, and thoracic surgeons must maintain at the forefront of these technologies.

Stenting as a bridge to surgery in obstructing colon cancer: Long-term recurrence pattern and competing risk of mortality.

BACKGROUND: Stenting as a bridge to curative surgery (SBTS) for obstructing colon cancer (OCC) has been associated with possibly worse oncological outcomes. AIM: To evaluate the recurrence patterns, survival outcomes, and colorectal cancer (CRC)-specific death in patients undergoing SBTS for OCC. METHODS: Data from 62 patients undergoing SBTS at a single tertiary centre over ten years between 2007 and 2016 were retrospectively examined. Primary outcomes were recurrence patterns, overall survival (OS), cancer-specific survival (CSS), and CRC-specific death. OS and CSS were estimated using the Kaplan-Meier curves. Competing risk analysis with cumulative incidence function (CIF) was used to estimate CRC-specific mortality with other cause-specific death as a competing event. Fine-Gray regressions were performed to determine prognostic factors of CRC-specific death. Univariate and multivariate subdistribution hazard ratios and their corresponding Wald test P values were calculated. RESULTS: 28 patients (45.2%) developed metastases after a median period of 16 mo. Among the 18 patients with single-site metastases: Four had lung-only metastases (14.3%), four had liver-only metastases (14.3%), and 10 had peritoneum-only metastases (35.7%), while 10 patients had two or more sites of metastatic disease (35.7%). The peritoneum was the most prevalent (60.7%) site of metastatic involvement (17/28). The median follow-up duration was 46 mo. 26 (41.9%) of the 62 patients died, of which 16 (61.5%) were CRC-specific deaths and 10 (38.5%) were deaths owing to other causes. The 1-, 3-, and 5-year OS probabilities were 88%, 74%, and 59%; 1-, 3-, and 5-year CSS probabilities were 97%, 83%, and 67%. The highest CIF for CRC-specific death at 60 mo was liver-only recurrence (0.69). Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictive of CRC-specific death. CONCLUSION: The peritoneum was the most common metastatic site among patients undergoing SBTS. Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictors of CRC-specific death.

Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis.

BACKGROUND: Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO. METHODS: MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed. RESULTS: After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0 years) and 2116 GJ patients (40.4% female, age: 66.8 years) were included. ES patients experienced a shorter survival time (mean difference -24.77 days, 95% Cl - 45.11 to - 4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001). CONCLUSION: ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.

Assessing the Impact of Medication and Stenting on the Quality of Life of Patients With Chronic Pancreatitis: A Prospective Study.

This research aimed to assess the effect of pharmacotherapy alone versus the combination of pharmacotherapy and endoscopic stenting on the quality of life (QoL) outcomes of chronic pancreatitis patients. Chronic pancreatitis, an inflammatory disease, often presents with persistent pain, affecting patients' quality of life. Thirty patients treated either with pharmacotherapy alone or with the addition of endoscopic stenting were analyzed. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) was used to gather data on the patients' QoL. Results showed that both treatment groups experienced improvements in global health, role functioning, fatigue, and abdominal pain scores over follow-ups. Specifically, the stenting group saw notable enhancements in global health and role functioning. The study's conclusions provide valuable insights into the potential benefits of both treatments, with stenting offering significant improvements in certain QoL parameters. However, the sample size and source limit generalizability, suggesting the need for more extensive research across diverse settings.

Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting.

Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference - 11.57 days; 95% CI [- 17.45 to - 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.

[Endoscopic intraluminal treatment of pancreatic fluid collections after pancreas transplantation]. / Endoskopicheskoe vnutriprosvetnoe lechenie pankreaticheskikh zatekov posle transplantatsii podzheludochnoi zhelezy.

OBJECTIVE: To improve the outcomes after pancreas transplantation complicated by pancreatitis using percutaneous drainage and endoscopic stenting of the main pancreatic duct. MATERIAL AND METHODS: There were 64 transplantations of the pancreatoduodenal complex between January 1, 2012 and December 31, 2021 at the Sklifosovsky Research Institute for Emergency Care. In 11 (17.2%) cases, early postoperative period was complicated by acute pancreatitis and parapancreatic fluid accumulations. Of these, 7 patients underwent ultrasound-guided percutaneous drainage of focal destructions. This procedure was effective and did not require additional treatment. In 4 patients, debridement and drainage were ineffective and required additional endoscopic stenting of the main pancreatic duct. RESULTS: All patients underwent percutaneous drainage of peripancreatic fluid collections and subsequent fistulography. All patients had inhomogeneous cavities with irregular shape and volume of 19.6±1.8 cm3. In 3 (75%) out of 4 patients, there was a passage of contrast agent into the main pancreatic duct of the graft and donor duodenal stump. We did not find contrast enhancement of ductal system in 1 (25%) patient since filling of the cavity with a contrast agent was not tight. Sensitivity of this method for detecting pancreatic ductal defects was 75%. Indications for stenting of the main pancreatic duct were established in 22.5±9.6 days after transplantation. Drainage and debridement were ineffective in 2 (50%) patients. In other 2 (50%) patients, peripancreatic fluid collections enlarged. All patients underwent endoscopic stenting of the main pancreatic duct. CONCLUSION: Endoscopic stenting of the main pancreatic duct of the donor pancreas combined with percutaneous drainage of peripancreatic fluid accumulations is a highly effective and minimally invasive approach for fluid collections after transplantation of the pancreatoduodenal complex. This method also minimizes the incidence of postoperative complications. Thanks to this method, we avoided redo open surgeries in all cases.

Intraoperative endoscopic retrograde cholangiopancreatography for traumatic pancreatic ductal injuries: Two case reports.

BACKGROUND: In order to successfully manage traumatic pancreatic duct (PD) leaks, early diagnosis and operative management is paramount in reducing morbidity and mortality. In the acute setting, endoscopic retrograde cholangiopancreatography (ERCP) can be a useful, adjunctive modality during exploratory laparotomy. ERCP with sphincterotomy and stent placement improves preferential drainage in the setting of injury, allowing the pancreatic leak to properly heal. However, data in this acute setting is limited. CASE SUMMARY: In this case series, a 27-year-old male and 16-year-old female presented with PD leaks secondary to a gunshot wound and blunt abdominal trauma, respectively. Both underwent intraoperative ERCP within an average of 5.9 h from time of presentation. A sphincterotomy and plastic pancreatic stent placement was performed with a 100% technical and clinical success. There were no associated immediate or long-term complications. Following discharge, both patients underwent repeat ERCP for stent removal with resolution of ductal injury. CONCLUSION: These experiences further demonstrated that widespread adaption and optimal timing of ERCP may improve outcomes in trauma centers.

Endoscopic Stenting and Palliative Chemotherapy in Advanced Colorectal Cancer: Friends or Foes? An Analysis of the Current Literature.

BACKGROUND/AIM: Chemotherapy offers a clear benefit in terms of survival rates of stage IV metastatic colorectal cancer (CRC) patients, but this advantage might be mitigated by the theoretical risks of short- and mid-term complications in the cases of contextual self-expandable metal stent (SEMS) positioning, which might also affect survival rates. MATERIALS AND METHODS: We reviewed all available literature from Medline and Scopus databases to study the role of chemotherapy with or without the simultaneous administration of targeted therapy in increasing the risk of the complications after SEMS positioning and, eventually, in affecting the survival rates. RESULTS: Thirteen retrospective studies and 1 randomized controlled trial (RCT) were eligible for the present analysis. The study group consisted of a total of 682 patients. A total of 305 patients were treated with conventional chemotherapy, 212 with conventional chemotherapy also containing targeted therapy, and 165 with no chemotherapy administration. Chemotherapy administration did not increase the rate of SEMS-related complications and these complications did not affect the overall survival rates. CONCLUSION: Chemotherapy administration is not associated with a higher risk of SEMS-related complications and a reduction in the survival rates.

A modular simulation curriculum to teach endoscopic stenting to practicing surgeons: an "Into the fire" approach.

BACKGROUND: Flexible endoscopy is a valuable tool for the gastrointestinal (GI) surgeon, creating a need for effective and efficient training curricula in therapeutic endoscopic techniques for trainees and practicing providers. Here, we present a simulation-based modular curriculum using an "into the fire" approach with hands-on pre- and post-testing to teach endoscopic stenting to practicing surgeons. METHODS: Three advanced flexible endoscopy courses were taught by expert surgical endoscopists from 2018 to 2019. The stenting module involved using self-expandable metal stents to manage simulated esophageal and gastroduodenal strictures on a non-tissue GI model. Based on the educational theories of inquiry-based learning, the simulation curriculum was designed with a series of pre-tests, didactics, mentored hands-on instructions, and post-tests. Assessments included a confidence survey, knowledge-based written test, and evaluation form specific to the hands-on performance of endoscopic stenting. RESULTS: Twenty-eight practicing surgeons with varying endoscopic experiences participated in the course. Most of the participants (67.9%) had completed over 100 upper endoscopic procedures and 57.1% were certified in Fundamentals of Endoscopic Surgery. After completing the modular curriculum, participant confidence survey scores improved from 11.4 ± 4.2 to 20.7 ± 4.0 (p < 0.001). Knowledge-based written test scores also improved from 7.1 ± 1.2 to 8.4 ± 0.9 (p < 0.001). In terms of technical performance, overall hands-on performance scores improved from 21.3 ± 2.7 to 28.9 ± 1.2 (p < 0.001) with significant improvement in each individual component of the assessment (all p values < 0.01) and the greatest improvement seen in equipment handling (88%) and flow of procedure (54%). CONCLUSION: Our modular simulation curriculum using an "into the fire" approach to teach endoscopic stenting is effective in improving learner knowledge, confidence, and hands-on performance of endoscopic stenting. This approach to simulation is effective, efficient, and adaptable to teaching practicing surgeons with varying levels of experience.