Esophageal Stenting With Sutures: Time to Redefine Our Standards?

BACKGROUND AND STUDY AIMS: Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (FCSEMS). Recent studies have demonstrated migration rates between 30% and 60%. The aim of this study was to determine the effect of fixation of the FCSEMS by endoscopic suturing on migration rate. PATIENT AND METHODS: Patients who underwent stent placement for esophageal strictures and leaks over the last year were captured and reviewed retrospectively. Group A, cases, were patients who underwent suture placement and group B, controls, were patients who had stents without sutures. Basic demographics, indications, and adverse events (AEs) were collected. Kaplan-Meier analysis and Cox regression modeling were conducted to determine estimates and predictors of stent migration in patients with and without suture placement. RESULTS: Thirty-seven patients (18 males, 48.65%), mean age 57.2 years (±16.3 y), were treated with esophageal FCSEMS. A total of 17 patients received sutures (group A) and 20 patients received stents without sutures (group B). Stent migration was noted in a total of 13 of the 37 patients (35%) [2 (11%) in group A and 11 (55%) in group B]. Using Kaplan-Meier analysis and log-rank analysis, fixation of the stent with suturing reduced the risk of migration (P=0.04). There were no AEs directly related to suture placement. CONCLUSIONS: Anchoring of the upper flare of the FCSEMS with endoscopic sutures is technically feasible and significantly reduces stent migration rate when compared with no suturing, and is a safe procedure with very low AEs rates.

Pancreatic necrosectomy using covered esophageal stents: a novel approach.

BACKGROUND: Endoscopic necrosectomy for necrotizing pancreatitis has been increasingly used as an alternative to surgical or percutaneous interventions. The use of fully covered esophageal self-expandable metallic stents may provide a safer and more efficient route for internal drainage. The aim of this study was to evaluate the safety and efficacy of endoscopic treatment of pancreatic necrosis with these stents. METHODS: A retrospective study at 2 US academic hospitals included patients with infected pancreatic necrosis from July 2009 to November 2012. These patients underwent transgastric placement of fully covered esophageal metallic stents draining the necrosis. After necrosectomy, patients underwent regular sessions of endoscopic irrigation and debridement of cystic contents. The efficacy endpoint was successful resolution of infected pancreatic necrosis without the need for surgical or percutaneous interventions. RESULTS: Seventeen patients were included with the mean age of 41±12 years. A mean of 5.3±3.4 sessions were required for complete drainage and the follow-up period was 237.6±165 days. Etiology included gallstone pancreatitis (6), alcohol abuse (6), s/p distal pancreatectomy (2), postendoscopic retrograde cholangiopancreatography pancreatitis (1), medication-induced pancreatitis (1), and hyperlipidemia (1). Mean size of the necrosis was 14.8 cm (SD 5.6 cm), ranging from 8 to 19 cm. Two patients failed endoscopic intervention and required surgery. The only complication was a perforation during tract dilation, which was managed conservatively. Fifteen patients (88%) achieved complete resolution. CONCLUSIONS: Endoscopic necrosectomy with covered esophageal metal stents is a safe and successful treatment option for infected pancreatic necrosis.

Pre- and post-training session evaluation for interobserver agreement and diagnostic accuracy of probe-based confocal laser endomicroscopy for biliary strictures.

BACKGROUND AND AIM: Current diagnostic modalities for indeterminate biliary strictures offer low accuracy. Probe-based confocal laser endomicroscopy (pCLE) permits microscopic assessment of mucosal structures by obtaining real-time high-resolution images of the mucosal layers of the gastrointestinal tract. Previously, an interobserver study demonstrated poor to fair agreement even among experienced confocal endomicroscopy operators. Our objective was to assess interobserver agreement and diagnostic accuracy upon completion of a pCLE training session. METHODS: Forty de-identified pCLE video clips of indeterminate biliary strictures were sent to five endoscopists at four tertiary care centers for scoring. Observers subsequently attended a teaching session by an expert pCLE user that included 20 training clips and rescored the same pCLE video clips, which were randomized and renumbered. RESULTS: Pre-training interobserver agreement for all observers was 'fair' (Κ: 0.31, P-value: <0.0001) and diagnostic accuracy was 72% (55-80%). Post-training interobserver agreement for all observers was 'substantial' (Κ: 0.74, P-value: <0.0001) and diagnostic accuracy was 89% (80-95%). Using a paired t-test, we observed an increase of 17% (95% CI 7.6-26.4) in post-training diagnostic accuracy (t = 5.01, df = 4, P-value 0.007). CONCLUSIONS: Interobserver agreement and diagnostic accuracy improved after observers underwent training by an expert pCLE user with a specific sequence set. Users should participate in such training programs to maximize diagnostic accuracy of pCLE evaluation.

Location of bile leak predicts the success of ERCP performed for postoperative bile leaks.

BACKGROUND: ERCP is effective for treating a bile leak (BL) after cholecystectomy (CCY), but few data exist on its effectiveness after hepatobiliary surgery (HBS). OBJECTIVE: To determine the effectiveness of ERCP for treating BLs after HBS compared with BLs after cholecystectomy and to identify factors associated with treatment success. DESIGN: Retrospective cohort. SETTING: Academic tertiary-care referral center. PATIENTS: Patients referred from 2001 to 2009 for ERCP treatment of BL after cholecystectomy or HBS. INTERVENTIONS: ERCP. MAIN OUTCOME MEASUREMENTS: Resolution of BL after a single ERCP. RESULTS: A total of 223 patients were identified and 46 were excluded. Fifty underwent ERCP for treatment of BL after HBS and 127 after CCY. A single ERCP was successful at resolving BL in 89% of patients. Failure occurred in 7 HBS patients (14%) and 12 CCY patients (9%) (P = .379). After multiple ERCPs, success improved to 95% of the CCY group and 86% of the HBS group (P = .033). HBS patients underwent 30% more ERCPs (P = .049). ERCP was 3.3 times more likely to be successful in patients with cystic duct or duct of Luschka BLs (P = .028). Patients undergoing biliary stent placement were significantly more likely to have successful outcomes (odds ratio 71.0, P < .001). Surgical history or biliary sphincterotomy did not affect outcome. Odds of treatment failure were 3.5 times higher for each additional ERCP performed (P < .001). LIMITATIONS: Single-center, retrospective study. CONCLUSIONS: ERCP is effective for treating postoperative BLs. Location of a BL and placement of a biliary stent are the best predictors of endoscopic treatment success.

Prognosis of invasive intraductal papillary mucinous neoplasm depends on histological and precursor epithelial subtypes.

OBJECTIVE: Invasive cancers arising from intraductal papillary mucinous neoplasm (IPMN) are recognised as a morphologically and biologically heterogeneous group of neoplasms. Less is known about the epithelial subtypes of the precursor IPMN from which these lesions arise. The authors investigate the clinicopathological characteristics and the impact on survival of both the invasive component and its background IPMN. DESIGN AND PATIENTS: The study cohort comprised 61 patients with invasive IPMN (study group) and 570 patients with pancreatic ductal adenocarcinoma (PDAC, control group) resected at a single institution. Multivariate analyses were performed using a stage-matched Cox proportional hazard model. RESULTS: The histology of invasive components of the IPMN cohort was tubular in 38 (62%), colloid in 16 (26%), and oncocytic in seven (12%). Compared with PDAC, invasive IPMNs were associated with a lower incidence of adverse pathological features and improved mortality by multivariate analysis (HR 0.58; 95% CI 0.39 to 0.86). In subtype analysis, this favourable outcome remained only for colloid and oncocytic carcinomas, while tubular adenocarcinoma was associated with worse overall survival, not significantly different from that of PDAC (HR 0.85; 95% CI 0.53 to 1.36). Colloid and oncocytic carcinomas arose only from intestinal- and oncocytic-type IPMNs, respectively, and were mostly of the main-duct type, whereas tubular adenocarcinomas primarily originated in the gastric background, which was often associated with branch-duct IPMN. Overall survival of patients with invasive adenocarcinomas arising from gastric-type IPMN was significantly worse than that of patients with non-gastric-type IPMN (p=0.016). CONCLUSIONS: Tubular, colloid and oncocytic invasive IPMNs have varying prognosis, and arise from different epithelial subtypes. Colloid and oncocytic types have markedly improved biology, whereas the tubular type has a course that resembles PDAC. Analysis of these subtypes indicates that the background epithelium plays an equally, if not more, important role in defining the biology and prognosis of invasive IPMNs.

Feasibility of EUS-guided injection of irinotecan-loaded microspheres into the swine pancreas.

BACKGROUND: LC beads (Biocompatibles International plc) are designed for the time-released delivery of the chemotherapeutic agent irinotecan into focal, hypervascularized, hepatic tumors. OBJECTIVE: To determine the feasibility of EUS-guided injection of LC beads (with/without irinotecan) into the swine pancreas. DESIGN: Survival animal study. SETTING: Academic center. SUBJECTS: This study involved 12 Yorkshire swine. INTERVENTION: LC beads without irinotecan and loaded with up to 300 mg of irinotecan were injected under EUS guidance with a 19-gauge needle into the tail of the pancreas. CT scanning and necropsy with histology were performed at day 7. MAIN OUTCOME MEASUREMENTS: Feasibility of the injections, gross and microscopic evidence of pancreatic inflammation, and clinical tolerance by the animals. RESULTS: After injection of LC beads with/without irinotecan, in 10 of 12 animals an intrapancreatic, hyperechoic focus with an average diameter of 2.2 cm was visible by EUS, and a hypodense area in the tail of the pancreas was visible by contrast CT. In 2 animals (1 with irinotecan and 1 without) no beads were seen on CT. In 10 of 12 animals, a depot of beads was located in the tail of the pancreas on gross inspection and histology. Drug depot with only localized pancreatic tissue reactions was seen on histopathologic review. LIMITATIONS: Animal study. CONCLUSION: The EUS-guided injection of LC beads (with/without irinotecan) into the pancreas of the pig is feasible and safe. This technique is a potential minimally invasive local treatment option for locally advanced pancreatic cancer.

A prospective, randomized trial of esophageal submucosal tunnel closure with a stent versus no closure to secure a transesophageal natural orifice transluminal endoscopic surgery access site.

BACKGROUND: Secure esophagotomy closure methods are a critical element in the advancement of transesophageal natural orifice transluminal endoscopic surgery (NOTES) procedures. OBJECTIVE: To compare the clinical outcomes in swine receiving an esophageal stent or no stent after a submucosal tunnel NOTES access procedure. DESIGN: Prospective, randomized, controlled trial in 10 Yorkshire swine. SETTING: Academic center. INTERVENTION: An endoscopic mucosectomy device was used to create an esophageal mucosal defect. An endoscope was advanced through a submucosal tunnel into the mediastinum and thorax, and diagnostic mediastinoscopy and thoracoscopy were performed. Ten animals were randomized to no stenting (n = 5) or stenting (n = 5) with a prototype small-intestine submucosa-covered stent. MAIN OUTCOME MEASUREMENTS: Gross and histologic appearance of the mucosectomy and esophagotomy sites as well as clinical outcomes. RESULTS: There was a significant difference in the overall procedure time between the animals that received a stent (35.0 min, range 27-46.0 min) and those with no closure (19.0 min, range 17-32 min) (P value = .018). The unstented group achieved endoscopic and histologic evidence of complete re-epithelialization and healing (100%) at the mucosectomy site compared with the stented group (20%, P = .048). Stent migration into the stomach occurred in two swine. Both groups had complete closure of the submucosal tunnel and well-healed esophagotomy sites. LIMITATIONS: Animal study, small number of subjects. CONCLUSION: The placement of a covered esophageal stent significantly interferes with mucosectomy site healing.

Stent placement provides safe esophageal closure in thoracic NOTES(TM) procedures.

BACKGROUND: Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent. METHODS: Nine Yorkshire swine underwent thoracic NOTES procedures. A double-channel gastroscope equipped with a mucosectomy device was used to create an esophageal mucosal defect. A 5-cm submucosal tunnel was created and the muscular esophageal wall was incised with a needle-knife. Mediastinoscopy and thoracoscopy were performed in all swine; lymphadenectomy was performed in seven swine. A prototype small intestinal submucosal (SurgiSIS(®)) covered stent was deployed over the mucosectomy site and tunnel. Three versions of the prototype stent were developed. Prenecropsy endoscopy confirmed stent location and permitted stent retrieval. Explanted esophagi were sent to pathology. RESULTS: Esophageal stenting was successful in all animals. Stent placement took 15.8 ± 4.8 minuted and no stent migration occurred. Prenecropsy endoscopy revealed proximal ingrowth of esophageal mucosa and erosion with Stent A. Mucosal inflammation and erosion was observed proximally with Stent B. No esophageal erosion or pressure damage from proximal radial forces was seen with Stent C. On necropsy, swine 5 had a 0.5-cm periesophageal abscess. Histology revealed a localized inflammatory lesion at the esophageal exit site in swine 1, 3, and 9. The mucosectomy site was partially healed in three swine and poorly healed in six. All swine thrived clinically, except for a brief period of mild lethargy in swine 9 who improved with short-term antibiotic therapy. The submucosal tunnels were completely healed and no esophageal bleeding or stricture formation was observed. All swine survived 13.8 ± 0.4 days and gained weight in the postoperative period. CONCLUSIONS: Esophageal stenting provides safe closure for NOTES thoracic procedures but may impede healing of the mucosectomy site.

Accuracy of EUS in the evaluation of small gastric subepithelial lesions.

BACKGROUND: EUS combined with endoluminal resection techniques is increasingly used to provide a definitive diagnosis of small gastric subepithelial lesions seen on standard upper endoscopy. OBJECTIVE: To evaluate the accuracy of EUS in diagnosing small gastric subepithelial lesions by using histology as the criterion standard. DESIGN: A retrospective study. SETTING: Academic tertiary care center. PATIENTS: A total of 22 patients (15 women, mean age 62.2 years) with an endoscopically resected gastric subepithelial lesion were included in this 3-year retrospective study. MAIN OUTCOME MEASUREMENTS: The size, echogenicity, the layer of origin, and presumptive diagnosis were determined by EUS. The diagnostic accuracy of EUS was determined by using histology as the criterion standard. RESULTS: The mean size of the 22 lesions was 13.6 mm (range 8-20 mm). An endoscopic cap band mucosectomy device was used to resect 16 (72.7%) lesions, whereas 6 (27.3%) were resected with a saline solution-assisted and snare technique. Using histology as a criterion standard, we found that the accuracy of the EUS diagnosis was 10 of 22 (45.5%). EUS alone had an accuracy rate of 30.8% and 66.7%, respectively, in the diagnosis of neoplastic and non-neoplastic lesions. LIMITATIONS: A single-center, retrospective analysis. CONCLUSION: EUS imaging had a low accuracy rate in the diagnosis of gastric subepithelial lesions, and endoscopic submucosal resection should be performed to provide a histologic diagnosis. Resection of small subepithelial lesions of 20 mm or less can be accomplished en bloc with an endoscopic cap band mucosectomy device.

Diagnosis of pancreatic neoplasia with EUS and FNA: a report of accuracy.

BACKGROUND: EUS-guided FNA has the potential to provide diagnostic cytologic material from pancreatic lesions that are suspicious for malignancy. OBJECTIVE: To determine the operating characteristics of EUS-FNA in the diagnosis of pancreatic adenocarcinoma and pancreatic neuroendocrine neoplasms (PENs). DESIGN: Retrospective analysis of a prospectively maintained database. SETTING: Academic tertiary-care center. PATIENTS: This study involved 559 patients undergoing evaluation of pancreatic masses or diffuse pancreatic parenchymal abnormalities. MAIN OUTCOME MEASUREMENTS: Performance characteristics of EUS-FNA of pancreatic adenocarcinoma and PEN. RESULTS: From January 1997 to December 2005, 737 patients undergoing initial EUS-FNA evaluation for a pancreatic mass were identified. In the final analysis, 559 patients with 560 FNA-sampled lesions were included. Overall, 442 lesions were pancreatic adenocarcinoma, and 40 were PEN. The sensitivity of EUS-FNA in the diagnosis of pancreatic adenocarcinomas and PENs was 77% (95% CI, 72.8%-80.8%) and 68% (95% CI, 50.8%-80.9%), respectively, using strict cytologic criteria. Reclassification of atypical and suspicious cytologies as diagnostic of malignancy resulted in a sensitivity of 93%, (95% CI, 90.9%-99.7%) in adenocarcinoma and 80% (95% CI, 63.9%-90.4%) in PEN. Tumor size, tumor location, and number of needle passes did not significantly influence diagnosis, but immediate cytologic evaluation was influential. LIMITATIONS: Retrospective analysis at a single center. CONCLUSIONS: In a large, well-controlled study, EUS-FNA was found to be an accurate test (80%) for the detection of pancreatic adenocarcinoma by using aspiration cytology. The accuracy of the examination is significantly improved (94%) when atypical and suspicious samples are considered positive. Finally, only 2 to 3 FNA passes may be needed to achieve a good diagnostic yield.

Feasibility of endoscopic transesophageal thoracic sympathectomy (with video).

BACKGROUND: Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain. OBJECTIVE: To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model. DESIGN: Nonsurvival animal study. SETTING: Animal trial at a tertiary care academic center. SUBJECTS: This study involved 8 healthy Yorkshire swine. INTERVENTIONS: After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure. MAIN OUTCOME MEASUREMENTS: Feasibility of endoscopic transesophageal thoracic sympathectomy. RESULTS: The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4+/-24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability. LIMITATIONS: Nonsurvival series, animal study. CONCLUSIONS: Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.

Endoscopic transesophageal mediastinal lymph node dissection and en bloc resection by using mediastinal and thoracic approaches (with video).

BACKGROUND: The criterion standard for sampling mediastinal lymph nodes is cervical mediastinoscopy. Current methods that require transthoracic or cervical incisions can result in significant postoperative pain. OBJECTIVE: To determine the feasibility of a novel, transesophageal endoscopic technique for mediastinal lymph node dissection and en bloc resection. DESIGN: Nonsurvival and survival animal study. SETTING: Animal trial at a tertiary-care academic center. SUBJECTS: This study involved 12 Yorkshire swine. INTERVENTION: An endoscopic cap band mucosectomy device was used to create an esophageal mucosal defect. By using the tip of the endoscope and biopsy forceps, a submucosal tunnel was fashioned, and, within the submucosal space, a hook-knife incised the muscular esophageal wall. The endoscope was then advanced into the mediastinum and chest. Mediastinoscopy and thoracoscopy were performed to identify lymph node stations. Prototype endoscopic devices permitted lymph node dissection prior to removal with an electrocautery snare. A covered prototype stent was placed over the mucosectomy site. MAIN OUTCOME MEASUREMENTS: Feasibility of endoscopic transesophageal lymphadenectomy. RESULTS: Three lymph nodes (1 para-aortic and 2 right paratracheal) were removed in the 3 nonsurvival swine. Nine swine were survived for 14 days (range 13-14 days) and had a total of 7 lymph nodes (2 para-aortic and 5 paratracheal) removed. Two swine had no endoscopically visible lymph nodes in the mediastinum or chest. Lymph node dissection and resection was successful in all cases where lymph nodes were identified. Lymphadenectomy was completed in a median time of 20.0 minutes (range 8-60 minutes); median total procedure time was 70.0 minutes (range 28-105 minutes). Median lymph node size was 1.1 cm (range 0.6-1.4 cm). LIMITATIONS: Animal study. CONCLUSION: An endoscopic transesophageal approach can accomplish mediastinal lymph node dissection and en bloc resection and provides architecturally intact lymph node specimens for histologic examination.

Leaks and endoscopic assessment of break of integrity after NOTES gastrotomy: the LEAKING study, a prospective, randomized, controlled trial.

BACKGROUND: Gastric leak testing after natural orifice transluminal endoscopic surgery (NOTES) gastrotomy closure may help reduce the risk of leaks after transgastric procedures. OBJECTIVE: To develop a novel endoscopy-based system to determine the presence of a leak after NOTES gastrotomy and to compare this system prospectively with radiographic leak testing. DESIGN: Prospective, randomized, controlled trial. SETTING: Academic Medical Center laboratory. SUBJECTS: Fifty swine. INTERVENTION: During the pretrial phase, an endoscopic system for the measurement of intragastric pressure was developed. In the trial phase, swine with a NOTES gastrotomy were randomized to endoscopic versus radiographic leak testing. If a leak was demonstrated, the gastrotomy was reclosed by using a second-generation prototype T-anchor system. The primary outcome was leak detection after gastrotomy closure. The secondary outcome variables included necropsy findings, peritoneal fluid analysis, histologic examination, and clinical outcome. RESULTS: Fourteen swine were included in the pretrial phase and 36 in the randomized trial. Swine were survived for a mean of 9 days postoperatively. Endoscopic pressure monitoring demonstrated a reproducible change in intragastric pressure with insufflation; r = 0.735, P = .001 and r = 0.769, P < or = .000 for the total and maximum pressures, respectively. Post-peritoneoscopy, there was a detectable and significant decrease in the mean total and mean maximum pressures versus baseline (P = .006 and P = .009). There was no significant difference between the radiologic and endoscopic arms in leak detection rate (4/18 vs 3/18, respectively, P = .500). Clinical outcomes and mean weight gain were equivalent. There was 1 operative abdominal wall injury and no deaths. LIMITATIONS: Animal study. CONCLUSION: Endoscopic pressure monitoring was reproducible, demonstrated the presence of gastric leak, and was as reliable as contrast-based radiographic leak testing.

Pancreatic cystic lesions: when to watch, when to operate, and when to ignore.

Pancreatic cystic lesions are being increasingly identified with the widespread use of state-of-the-art imaging. These lesions are categorized into a broad range of neoplastic cysts and inflammatory pseudocysts. Identification of a pancreatic cyst requires the clinician to focus on the main clinical challenge of the benign or malignant nature of the cyst. Neoplastic cysts range the spectrum from benign, to premalignant, to frank malignancy. The management of these lesions is difficult, and the decision to resect or observe a lesion is hampered by limitations in current imaging and tissue sampling techniques that prevent the accurate characterization of all lesions. This article reviews current guidelines for the evaluation of pancreatic cystic lesions, underscores the challenges posed by these lesions, and discusses current and future studies that will aid in patient management.

Reducing the unexpectedly high rate of injuries caused by NOTES gastrotomy creation.

BACKGROUND: Despite the wide range of natural orifice transluminal endoscopic surgery (NOTES) procedures reported to date using a transgastric endoscopic approach, complications associated with gastrotomy creation have not been described. This study was conducted to identify the incidence and types of complications related to gastrotomy creation with the needle knife puncture and balloon dilatation technique for NOTES access to the peritoneal cavity. METHODS: Between May 2007 and August 2008, transgastric procedures were performed in 76 swine at a single institution. A total of 58 gastrotomies were created using the needle knife puncture and balloon dilatation technique without laparoscopic observation and 18 gastrotomies were created under laparoscopic visualization after CO(2) insufflation through a laparoscopic port. In all cases, a needle knife with an electrosurgical current of 25-W coagulation and/or 25-W cut and a wire-guided endoscopic balloon dilated to 20 mm were used to create the gastrotomy. All complications were collected prospectively and reviewed from laboratory medical records, operative reports, and necropsy findings. RESULTS: NOTES gastrotomy-related complications occurred in 10/76 (13.2%) animals. Major complications occurred in six animals (7.9%), including four splenic lacerations, a mesenteric tear, and a fatal diaphragmatic injury. Minor complications occurred in four animals (5.3%), including three abdominal wall injuries and minor gastrotomy site bleeding. When pregastrotomy laparoscopic guidance was used, only one injury occurred in 18 animals (5.5%), but 9/58 (15.5%) gastrotomies performed without laparoscopic visualization caused some type of injury. The difference in rate of injury did not achieve statistical significance. No learning curve effect could be identified. CONCLUSIONS: Injuries to adjacent viscera occur more often than is reported with the traditional transgastric needle knife NOTES access technique. Gastric punctures should be made either with laparoscopic visualization or by other techniques such as the PEG approach or with noncutting devices to reduce the incidence of visceral injury associated with transgastric peritoneal entry.

Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model.

BACKGROUND: The feasibility of transanal rectosigmoid resection with transanal endoscopic microsurgery (TEM) was previously demonstrated in a swine nonsurvival model in which transgastric endoscopic assistance also was shown to extend the length of colon mobilized transanally. METHODS: A 2-week survival study evaluating transanal endoscopic rectosigmoid resection with stapled colorectal anastomosis was conducted with swine using the transanal approach alone (TEM group, n = 10) or a transanal approach combined with transgastric endoscopic assistance (TEM + TG group, n = 10). Gastrotomies were created using a needleknife and balloon dilation, then closed using prototype T-tags. Outcomes were evaluated and compared between the groups using Student's t-test and Fisher's exact test. RESULTS: Relative to the TEM group, the average length of rectosigmoid mobilized in the TEM + TG group was 15.6 versus 10.5 cm (p < 0.0005), the length of the resected specimen was 9 versus 6.2 cm (p < 0.0005), and the mean operative time was 254.5 versus 97.5 min (p < 0.0005). Intraoperatively, no organ injury or major bleeding was noted. Two T-tag misfires occurred during gastrotomy closure and four small staple line defects requiring transanal repair including one in the TEM group and three in the TEM + TG group (p = 0.2). Postoperatively, there was no mortality, and the animals gained an average of 3.4 lb. Two major complications (10%) were identified at necropsy in the TEM + TG group including an intraabdominal abscess and an abdominal wall hematoma related to T-tag misfire. Gastrotomy closure sites and colorectal anastomoses were all grossly healed, with adhesions noted in 60 and 70% and microabscesses in 50 and 20% of the gastrotomy sites and colorectal anastomoses, respectively. CONCLUSIONS: Natural orifice translumenal endoscopic surgery (NOTES) for rectosigmoid resection using TEM with or without transgastric endoscopic assistance is feasible and associated with low morbidity in a porcine survival model. Transgastric assistance significantly prolongs the operative time but extends the length of the rectosigmoid mobilized transanally, with a nonsignificant increase in complication rates related to gastrotomy creation.

Heads or tails: confusion about "proximal" and "distal" terminology for pancreaticobiliary anatomy.

BACKGROUND AND STUDY AIMS: The anatomical meaning of the terms "proximal" and "distal" in relation to the pancreaticobiliary anatomy can be confusing. We aimed to investigate practice patterns of use of the terms "proximal" and "distal" for pancreaticobiliary anatomy amongst various medical specialties. MATERIALS AND METHODS: An online survey link to a normal pancreaticobiliary diagram was emailed to a multispecialty physician pool. Respondents were asked to label various parts of the common bile duct (CBD) and pancreatic duct (PD) using the terms "proximal," "distal," "not sure," or "other." Variability in use of these terms between specialties was assessed. RESULTS: We received 370 completed surveys from 182 gastroenterologists (49.2 %), 97 surgeons (26.2 %), 68 radiologists (18.4 %), and 23 other physicians (6.2 %). There was overall consensus in describing the upper/sub-hepatic CBD as "proximal CBD" (73.8 %, P  = 0.1499) and the lower/pre-ampullary portion as "distal CBD" (84.6 %, P  = 0.1821). CONCLUSIONS: Although use of the terms "proximal" and "distal" is still very common to describe pancreaticobiliary anatomy, there is a discordance about its meaning, particularly for the PD. Use of descriptive terminology may be a more accurate alternative to prior ambiguous terminologies such as "proximal" or "distal" and can serve to improve communication and decrease the possibility of medical errors.

Advanced endoscopic ultrasound management techniques for preneoplastic pancreatic cystic lesions.

Pancreatic cystic lesions can be benign, premalignant or malignant. The recent increase in detection and tremendous clinical variability of pancreatic cysts has presented a significant therapeutic challenge to physicians. Mucinous cystic neoplasms are of particular interest given their known malignant potential. This review article provides a brief but comprehensive review of premalignant pancreatic cystic lesions with advanced endoscopic ultrasound (EUS) management approaches. A comprehensive literature search was performed using PubMed, Cochrane, OVID and EMBASE databases. Preneoplastic pancreatic cystic lesions include mucinous cystadenoma and intraductal papillary mucinous neoplasm. The 2012 International Sendai Guidelines guide physicians in their management of pancreatic cystic lesions. Some of the advanced EUS management techniques include ethanol ablation, chemotherapeutic (paclitaxel) ablation, radiofrequency ablation and cryotherapy. In future, EUS-guided injections of drug-eluting beads and neodymium:yttrium aluminum agent laser ablation is predicted to be an integral part of EUS-guided management techniques. In summary, International Sendai Consensus Guidelines should be used to make a decision regarding management of pancreatic cystic lesions. Advanced EUS techniques are proving extremely beneficial in management, especially in those patients who are at high surgical risk.

Endoscopic Gallbladder Drainage for Acute Cholecystitis.

BACKGROUND/AIMS: Surgery is the mainstay of treatment for cholecystitis. However, gallbladder stenting (GBS) has shown promise in debilitated or high-risk patients. Endoscopic transpapillary GBS and endoscopic ultrasound-guided GBS (EUS-GBS) have been proposed as safe and effective modalities for gallbladder drainage. METHODS: Data from patients with cholecystitis were prospectively collected from August 2004 to May 2013 from two United States academic university hospitals and analyzed retrospectively. The following treatment algorithm was adopted. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and cystic duct stenting was initially attempted. If deemed feasible by the endoscopist, EUS-GBS was then pursued. RESULTS: During the study period, 139 patients underwent endoscopic gallbladder drainage. Among these, drainage was performed in 94 and 45 cases for benign and malignant indications, respectively. Successful endoscopic gallbladder drainage was defined as decompression of the gallbladder without incidence of cholecystitis, and was achieved with ERCP and cystic duct stenting in 117 of 128 cases (91%). Successful endoscopic gallbladder drainage was also achieved with EUS-guided gallbladder drainage using transmural stent placement in 11 of 11 cases (100%). Complications occurred in 11 cases (8%). CONCLUSIONS: Endoscopic gallbladder drainage techniques are safe and efficacious methods for gallbladder decompression in non-surgical patients with comorbidities.