Flexible endosopic management of Zenker's diverticulum: characteristics and outcomes of 52 cases at a tertiary referral center.

Zenker's diverticulum causes substantial morbidity among affected elderly patients. In the United States, rigid endoscopic cricopharyngeal myotomy is the mainstay of management and the flexible endoscopic technique is reserved for those not deemed candidates for rigid endoscopy due to an inability to extend the neck and/or medical comorbidities. Short- and long-term outcomes following flexible endoscopic cricopharyngeal myotomy in the United States are limited. We reviewed the patient characteristics and outcomes of 58 consecutive flexible endoscopic cricopharyngeal myotomies performed at Mayo Clinic, Rochester, between March 2006 and November 2013. There were 58 procedures performed on 52 unique patients. The median age was 77 years, and 48% of patients were female. More than one third of patients had either failed previous rigid therapy or were deemed inoperable by the referring surgeon. Size of the diverticulum ranged from 1 cm to 5 cm with a mean of 2.8 cm. Most procedures (67%) were performed under general anesthesia. Initial procedural success was achieved in all patients. Of the patients, 77% reported complete symptom resolution at mean follow-up time of 26 months. Of the procedures, 71% were not associated with any adverse event, but esophageal microperforation occurred during 11 procedures (19%). Of these, nine resolved with conservative management, one required an endoscopic stent, and one developed a neck abscess that required drainage. Our data show in a group of elderly patients with preexisting comorbidities flexible endoscopy therapy for Zenker's diverticulum is feasible. Initial symptomatic improvement was universal, and long-term response appears durable. The most common adverse event was esophageal microperforation, and the majority (82%) of these resolved with conservative management. Direct comparison with outcomes of rigid endoscopic or open surgical techniques has not been performed, but these data suggest that a randomized trial is warranted to assess the efficacy and safety of a flexible endoscopic technique.

The use of double lasso, fully covered self-expandable metal stents with new "anchoring flap" system in the treatment of benign biliary diseases.

BACKGROUND: Many benign biliary diseases (BBD) can be treated with fully covered, self-expandable metal stents (FCSEMS) but stent migration occurs in up to 35.7 %. The aim of this study was to prospectively assess the rate of, safety and effectiveness and stent migration of a new biliary FCSEMS with an anti-migration flap (FCSEMS-AF) in patients with BBD. PATIENTS AND METHODS: This was a prospective study from four Italian referral endoscopy centers of 32 consecutive patients (10 females and 22 males; mean age: 60.1 ± 14.8 years; range: 32-84 years) with BBD who were offered endoscopic placement of a FCSEMS-AF as first-line therapy. RESULTS: Were 24 strictures and 8 leaks. Stent placement was technically successful in 32/32 patients (100 %). Immediate clinical improvement was seen in all 32 patients (100 %). One late stent migration occurred (3.3 %). FCSEMS-AF were removed from 30 of the 32 patients (93.7 %) at a mean (± SD) of 124.4 ± 84.2 days (range: 10-386 days) after placement. All patients remained clinically and biochemically well at 1- and 3-month follow-up. One patient (3.3 %) with a post-laparoscopic cholecystectomy stricture developed distal stent migration at 125 days. CONCLUSION: This new FCSEMS with anti-migration flap seems to be a safe and effective first-line treatment option for patients with BBD.

Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series.

Endoscopic retrograde cholangiopancreatography (ERCP) remains technically challenging following Roux-en-Y gastric bypass (RYGB). Various techniques have been described to access the excluded stomach. We describe our experience using percutaneous-assisted transprosthetic endoscopic therapy (PATENT) to perform antegrade ERCP. Balloon enteroscopy was used to access the excluded stomach. Direct retrograde percutaneous endoscopic gastrostomy (RPEG) was performed and an esophageal self-expandable metal stent (SEMS) was deployed within the gastrostomy tract. A duodenoscope was advanced through the SEMS and antegrade ERCP was performed. Following ERCP, a gastrostomy tube was placed through the SEMS to maintain patency. Five patients underwent successful antegrade ERCP using PATENT. All patients had a diagnosis of sphincter of Oddi dysfunction. Biliary sphincterotomy was performed in all patients and liver enzymes normalized in four patients with preprocedural elevations. In conclusion, antegrade ERCP employing PATENT is feasible and can be performed during a single endoscopic session in patients with previous RYGB.

Esophageal self-expandable stent material and mesh grid density are the major determining factors of external beam radiation dose perturbation: results from a phantom model.

BACKGROUND: Self-expandable esophageal stents are increasingly used for palliation or as an adjunct to chemoradiation for esophageal neoplasia. The optimal esophageal stent design and material to minimize dose perturbation with external beam radiation are unknown. We sought to quantify the deviation from intended radiation dose as a function of stent material and mesh density design. METHODS: A laboratory dosimetric film model was used to quantify perturbation of intended radiation dose among 16 different esophageal stents with varying material and stent mesh density design. RESULTS: Radiation dose enhancement due to stent backscatter ranged from 0 % to 7.3 %, collectively representing a standard difference from the intended mean radiation dose of 1.9 (95 % confidence interval [CI] 1.5 - 2.2). This enhancement was negligible for polymer-based stents and approached 0 % for the biodegradable stents. In contrast, all metal alloy stents had significant radiation backscatter; this was largely determined by the density of mesh design and not by the type of alloy used. CONCLUSIONS: Stent characteristics should be considered when selecting the optimal stent for treatment and palliation of malignant esophageal strictures, especially when adjuvant or neo-adjuvant radiotherapy is planned.

Covered self-expanding metal stent use in the pancreatic duct: a case series.

Plastic stents have been used in the pancreatic duct for a variety of indications. However, unlike in the bile duct, the use of covered self-expanding metal stents (CSEMSs) has been discouraged because multiple side branches drain into main pancreatic duct (MPD) and the ductal diameter is relatively small. This report aims to describe our experience using CSEMSs in the pancreatic duct in a series of nine patients, with special focus on adverse events. Indications were strictures (n = 5), intraductal mucinous neoplasm (IMPN; n = 1), pancreatic duct leak (n = 1), disconnected duct syndrome (n = 1), and severe acute pancreatitis/necrosis with disrupted duct (n = 1). Eight patients had symptomatic improvement, or radiological resolution of or improvement in their strictures, leaks, perforation, and necrosis. Two of these have indwelling CSEMSs for ongoing treatment. One patient (disconnected duct syndrome) was considered a treatment failure as the stent migrated and the patient underwent distal pancreatectomy for refractory pain. Two patients underwent pancreaticoduodenectomy for their malignancies after their CSEMSs had been in place for 43 and 49 days, respectively. Importantly no patients, including those with indwelling CSEMSs, developed stent-related acute pancreatitis with a median follow-up of 4 months. One patient developed post-procedure pain requiring hospitalization for 1 day. Median stent duration was 77 days. These observations suggest there is a potential role for the use of CSEMSs in the MPD in selected patients with pancreatic pathology.

Outcome of access sphincterotomy using a needle knife converted from a standard biliary sphincterotome.

Cannulation fails in up to 10 % of all endoscopic retrograde cholangiopancreatographies (ERCPs). A standard sphincterotome can be converted to a needle knife to perform precut sphincterotomy (PCS). In this retrospective study, we analyzed cannulation rates, adverse events, and the percentage of patients requiring a second sphincterotome using a converted needle knife. Over a 7-year period, 3322 ERCPs were performed by one experienced therapeutic endoscopist; 1487 sphincterotomies were performed, 78 precut sphincterotomies using a converted needle knife. Successful cannulation using the converted needle knife was achieved in 96 % of cases at the initial procedure. Adverse events occurred in 17 % and post-ERCP pancreatitis was reported in 10 % of patients. A second sphincterotome was needed in 13 % of cases. This study shows a converted needle knife can be used for successful cannulation of either the biliary or the pancreatic duct after a failed cannulation with a standard sphincterotome, with a low percentage of adverse events anda reduction in the need for accessories.

Endoscopic treatment of intraluminal duodenal ("windsock") diverticulum: varying techniques from five cases.

The optimal endoscopic approach to intraluminal duodenal diverticulum (IDD) has not been established. We report on our experience of endoscopic resection of symptomatic IDD in five patients (three men, two women; mean age 37 years) who were treated between August 2004 and April 2012. Four patients underwent endoscopic diverticulectomy using a standard polypectomy snare. Following diverticulectomy, the remaining duodenal septum was incised using a needle-knife in two patients. The fifth patient underwent endoscopic diverticulotomy using a needle-knife. In four cases the IDD was resected and reviewed histologically and demonstrated substantial vascularity. All patients developed clinically significant, post-procedural bleeding, which was managed endoscopically. Endoscopic management of symptomatic IDD can be achieved using various approaches. Post-procedural bleeding appears to be a common adverse event, but this complication can be managed endoscopically.

Photodynamic therapy of intraductal papillary mucinous neoplasm.

Intraductal papillary mucinous neoplasm (IPMN) of the main pancreatic duct is usually treated by surgical excision of the affected pancreas. Nonoperative ablative therapies have not been described. We treated IPMN of the pancreatic duct with photodynamic therapy (PDT) in a patient who was a poor operative candidate. Porfimer sodium was administered intravenously, and laser light was delivered by a diffusing catheter placed in the pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP). Imaging and biopsy findings of IPMN resolved after PDT, and symptoms also resolved. Metastatic cancer was diagnosed 2 years after PDT had been initiated. Pancreatic PDT was well tolerated in this case, and may be a therapeutic option for selected patients with IPMN of the main pancreatic duct.

Endoscopic and surgical management of serrated colonic polyps.

BACKGROUND: Serrated polyps are an inhomogeneous group of lesions that harbour precursors of colorectal cancer. Current research has been directed at further defining the histopathological characteristics of these lesions, but definitive treatment recommendations are unclear. The aim was to review the current literature regarding classification, molecular genetics and natural history of these lesions in order to propose a treatment algorithm for surgeons to consider. METHODS: The PubMed database was searched using the following search terms: serrated polyp, serrated adenoma, hyperplastic polyp, hyperplastic polyposis, adenoma, endoscopy, surgery, guidelines. Papers published between 1980 and 2010 were selected. RESULTS: Sixty papers met the selection criteria. Most authors agree that recommendations regarding endoscopic or surgical management should be based on the polyp's neoplastic potential. Polyps greater than 5 mm should be biopsied to determine their histology so that intervention can be directed accurately. Narrow-band imaging or chromoendoscopy may facilitate the detection and assessment of extent of lesions. Complete endoscopic removal of sessile serrated adenomas in the left or right colon is recommended. Follow-up colonoscopy is recommended in 2-6 months if endoscopic removal is incomplete. If the lesion cannot be entirely removed endoscopically, segmental colectomy is strongly recommended owing to the malignant potential of these polyps. Left-sided lesions are more likely to be pedunculated, making them more amenable to successful endoscopic removal. CONCLUSION: Even though the neoplastic potential of certain subtypes of serrated polyp is heavily supported, further studies are needed to make definitive endoscopic and surgical recommendations.

Outcome of emergency ERCP in the intensive care unit.

There are limited data on the outcome of emergency endoscopic retrograde cholangiopancreatography (ERCP) performed in the intensive care unit (ICU). We sought to assess the frequency, indications, and clinical outcomes of ERCPs performed in ICU patients who were too unstable to be transported to the endoscopy unit. An electronic endoscopy database was used to identify the patients (n = 22) and to assess procedural success, complications, and mortality. The indications for ERCP included suspected biliary sepsis, suspected gallstone pancreatitis, and known choledocholithiasis with cholangitis. Biliary cannulation, which was attempted in all patients, was successful in 19 patients (86 %), and of these 18 (95 %) underwent a technically successful endoscopic therapy. There were no apparent endoscopic complications. Therefore, emergency bedside ERCP in ICU patients, which is primarily performed for the management of suspected biliary sepsis and gallstone pancreatitis, can achieve high technical success rates when performed by experienced endoscopists, although the 30-day mortality rate remains high due to multiorgan dysfunction.

Colonic stenting: a palliative measure only or a bridge to surgery?

Self-expandable metal stents (SEMS) are used to relieve malignant luminal obstruction throughout the gastrointestinal tract. Colonic SEMS are used most often for palliation of obstruction in nonoperative candidates or in patients with advanced disease. The other indication for colonic stent placement is as a preoperative modality for the relief of acute obstruction so that resection can be done on an elective basis after stabilization of the acute illness and bowel preparation. For both of these indications, the goal is avoidance of a temporary or permanent ostomy. In this manuscript the supporting data for each of these indications will be reviewed.

European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis.

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Risk factors for post-ERCP pancreatitis (PEP) are both patient-related and procedure-related. Identification of patients at high risk for PEP is important in order to target prophylactic measures. Prevention of PEP includes administration of nonsteroidal inflammatory drugs (NSAIDs), use of specific cannulation techniques, and placement of temporary pancreatic stents. The aim of this guideline commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to provide practical, graded, recommendations for the prevention of PEP.

Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is challenging to perform in patients with postsurgical gastrointestinal anatomy. We assessed the diagnostic and therapeutic success rates using single-balloon enteroscopy in patients with Roux-en-Y anastomosis. PATIENTS AND METHODS: Patients who underwent single-balloon ERCP between April 2008 and February 2010 were retrospectively identified using a computerized endoscopy database. Diagnostic success was defined as successful duct cannulation or securing the diagnosis, and therapeutic success was defined as the ability to successfully carry out endoscopic therapy. Complications of ERCP were defined according to standard criteria. RESULTS: A total of 50 patients (34-male, mean age 57 years, range 19 - 85 years) with Roux-en-Y anastomosis underwent ERCP using a single-balloon enteroscope on 56 occasions. Indications for ERCP were cholestasis, acute cholangitis, recurrent primary sclerosing cholangitis with strictures, and choledocholithiasis. Overall diagnostic success was achieved in 39 / 56 cases (70 %). Therapeutic success was achieved in 21/23 cases (91 %). In 16 cases therapeutic intervention was not required. Therapeutic interventions included balloon dilation of strictures (n = 14), retrieval of retained biliopancreatic stents (n = 5), biliary stone extraction (n = 2), insertion of biliopancreatic stents (n = 4), and biliary and pancreatic sphincterotomy (n = 5). No major complications occurred. Importantly, in 22 / 56 procedures (39 %) a prior attempt at ERCP failed using conventional colonoscopes; single-balloon ERCP was successful in 15 / 22 (68 %) of these cases. CONCLUSIONS: Single-balloon ERCP is feasible in patients with complex postsurgical Roux-en-Y anastomosis, allows diagnostic evaluation and therapeutic intervention in patients with pancreaticobiliary disease, and is a useful salvage technique in the majority of patients in whom ERCP using colonoscopies has failed.

Endoscopic recanalization following accidental ligation of the common hepatic duct. A new technique.

Bile duct injury is a known complication of cholecystectomy. While minor injuries can be treated endoscopically, successful endoscopic management of complete ligation of the common hepatic duct (CHD) has not been described. Our aim was to report a novel technique for endoscopic recanalization of accidently ligated CHD. We demonstrated a 75 year old woman presented with a small bile leak and complete ligation of the CHD after open cholecystectomy subjected to successful biliary endoscopic recanalization. Cholangiogram demonstrated resolution of the bile leak and minimal residual narrowing of the CHD. Endoscopic intervention following biliary needle puncture access may avoid surgery in patients with CHD ligation or complex stenosis.

Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases.

BACKGROUND: Self-expanding metal stents (SEMS) are an established treatment for palliation of malignant colorectal strictures and as a bridge to surgery for acute malignant colonic obstruction. Patients with benign colonic strictures may benefit from stent placement, but little data exist for this indication. METHODS: All cases of colonic stent placement identified from a prospectively collected gastrointestinal database from April 1999 to August 2006 were reviewed. During the study period, 23 patients with benign obstructive disease underwent endoscopic SEMS placement. The etiologies of the stricture were diverticular/inflammatory (n = 16), postsurgical anastomotic (n = 3), radiation-induced (n = 3), and Crohn's (n = 1) disease. All strictures were located in the left colon. Five patients had an associated colonic fistula. Uncovered Enteral Wallstents or Ultraflex Precision Colonic stents (Boston Scientific) were endoscopically placed in all but one patient. RESULTS: Stent placement was technically successful for all 23 patients, and obstruction was relieved for 22 patients (95%). Major complications occurred in 38% of the patients including migration (n = 2), reobstruction (n = 4), and perforation (n = 2). Of these major complications, 87% occurred after 7 days. Four patients did not undergo an operation. Of the 19 patients who underwent planned surgical resection, 16 were successfully decompressed and converted from an emergent operation to an elective one with a median time to surgical resection of 12 days (range, 2 days to 18 months). Surgery was delayed more than 30 days after stent placement for six of these patients. Of the 19 patients who underwent a colectomy, 8 (42%) did not need a stoma after stent insertion. CONCLUSIONS: SEMS can effectively decompress high-grade, benign colonic obstruction, thereby allowing elective surgery. The use of SEMS can offer medium-term symptom relief for benign colorectal strictures, but this approach is associated with a high rate of delayed complications. Thus, if elective surgery is planned, data from this small study suggest that it should be performed within 7 days of stent placement.

Risk of pancreatitis following endoscopically placed large-bore plastic biliary stents with and without biliary sphincterotomy for management of postoperative bile leaks.

BACKGROUND: Endoscopic transpapillary biliary stent placement is effective for closure of postoperative bile leaks. Large-bore stents (10 French) may transiently obstruct the adjacent pancreatic duct orifice causing acute pancreatitis. Endoscopic biliary sphincterotomy may reduce this risk, but it introduces separate risks of bleeding and perforation. The objective of this study was to compare complications after large-bore biliary stent placement (10 Fr) with and without sphincterotomy in patients with bile leaks. METHODS: The institutional endoscopy database was queried to identify patients who had undergone endoscopic retrograde cholangiopancreatogrpahy (ERCP) for bile leak between March 1996 and August 2006. Procedural reports were reviewed for evidence of biliary sphincterotomy, cholangiographic and pancreatographic findings, transpapillary stent placement, and procedural complications. Patients with prior biliary sphincterotomy, choledochoenteric anastomosis, placement of multiple biliary stents and expandable metal biliary stents, biliary stents smaller than 10 Fr, and patients in whom a stent was not placed were excluded. The chi-square test was used for categorical variables. Probability

Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management.

Zenker's diverticulum (ZD) is the most common type of diverticulum in the upper gastrointestinal tract. Most patients are elderly and present with symptoms of dysphagia. Serious complications include aspiration and malnutrition. The most common treatments are open surgical diverticulectomy with or without cricopharyngeal myotomy and rigid endoscopic myotomy. Recently, cricopharyngeal myotomy using flexible endoscopes has been described as a treatment option for symptomatic ZD. In this article we describe the pathophysiology, clinical presentation and review the techniques and outcome following flexible endoscopic management of Zenker's diverticulum.

Role of endoscopy in the management of esophageal diseases.

Endoscopy plays a major role in diseases of the esophagus. Endoscopic findings alone can suggest or confirm a variety of diagnoses, especially with newer imaging modalities, which can be confirmed by endoscopic biopsy. Endoscopic ultrasound allows accurate staging for the management of esophageal malignancies. In the area of therapeutics, endoscopy allows for dilation of strictures, resection and ablation of premalignant lesions and placement of stents for benign and malignant diseases. This article will summarize the latest advances in diagnostic and therapeutic endoscopy.

Endoscopic transpapillary gallbladder drainage: 10-year single center experience.

AIM: A subset of patients with acute cholecystitis is severely ill and extremely high-risk to undergo cholecystectomy. Data on the use of endoscopic transpapillary gallbladder drainage (ETGBD) in the treatment of acute cholecystitis are limited. This article reviews the 10-year experience of ETGBD at Mayo Clinic and evaluated patient and procedure characteristics. METHODS: A retrospective review of the endoscopy database from 1998-2007 was performed to identify patients who had undergone ETGBD. Clinical information and procedure details were abstracted from the electronic medical record. RESULTS: Fifty one patients underwent ETGBD for acute cholecystitis between 1998 to July 2007. The mean age was 62+/-19 years and 67% of patients were males. The median number of comorbid medical conditions was two (range 0-5) and 27% had underlying diabetes mellitus. Acute calculous cholecystitis was the predominant indication for ETGBD (78%). A gallbladder stent was used in 33 (65%) patients, nasocholecystic drain in 14 (27%) patients, and both in four patients (8%). Bleeding (4%) and sedation-related complications (4%) were the most common complications noted. Among patients who underwent cholecystectomy, the majority (76%) needed an open procedure. The median time to cholecystectomy was 15 days (range 1-352 days). Four patients (8%) succumbed to septic shock during their hospitalization. CONCLUSIONS: ETGBD is a valuable alternative therapeutic modality for the treatment of patients with acute cholecystitis who are at high-risk for early cholecystectomy, and/or those who have contraindications to percutaneous gallbladder drainage.