Comparison of flexible endoscopic needle knife septotomy and peroral endoscopic myotomy for treatment of Zenker's diverticulum.

BACKGROUND AND AIMS: Treatment of Zenker's diverticulum (ZD) has evolved from flexible endoscopic septotomy (FES) to peroral endoscopic myotomy (Z-POEM). In this study, we compare efficacy and safety of FES with a needle knife septotomy (FENKS) and Z-POEM for symptomatic ZD. METHODS: Consecutive patients at a single institution who underwent endoscopic ZD treatment by FENKS or Z-POEM were identified. Demographics, clinical characteristics, procedure technique, technical and clinical success, and adverse events (AEs) within 30 days were reviewed and compared between the two groups. AEs were classified by the AGREE classification. Baseline and post-procedure Dakkak and Bennett's (DB) scores were reported at 6, 12 and 24 months. Clinical success (DB score ≤1) was assessed by per-protocol (PP) and intention-to-treat analyses (ITT). RESULTS: 60 patients (55% M, mean 72±12 yrs.) underwent FENKS (n=21) or Z-POEM (n=39) between 2016 and 2023. Baseline clinical characteristics were similar and overall technical success was 98.3%. Clinical success by PP and ITT analyses at 6, 12 and 24 months after intervention were similar between both groups. The FENKS group had a higher prevalence (29% vs. 5%, p=0.018) and severity (p=0.032) of AEs and were more likely to be hospitalized after treatment (71% vs. 33%, p=0.007). During a median follow up of 18 months, reintervention was required for 5 (10%) in the FENKS (n=2, 9%) and Z-POEM (n=3, 7.6%) groups (p=1.0) a mean 7.6 ± 4.4 months after initial therapy. CONCLUSION: Treatment of ZD with Z-POEM appears to be safer than FENKS with similar short- and mid-term clinical success.

Tunnel-free peroral endoscopic myotomy reduces procedural time and maintains efficacy in Zenker's diverticulum.

Background: Peroral endoscopic myotomy (Z-POEM) is an effective treatment for Zenker's diverticulum (ZD), but procedural time and safety vary based on technique. Modified Z-POEM approaches incorporating fewer submucosal tunnels may offer advantages. Methods: In this retrospective, single-center study, we compared outcomes among 20 patients with ZD undergoing standard Z-POEM (2 tunnels), single-tunnel Z-POEM (ST Z-POEM), or tunnel-free Z-POEM (TF Z-POEM). All procedures included mucosotomy over the septum and deep extension of myotomy into the esophagus (2 cm). Primary endpoints were procedural time, clinical success, and adverse events. Results: Patients had a mean age of 67.3±12.2 years, and 70% presented with respiratory symptoms. Mean procedure times were 45 min (standard Z-POEM), 33 min (ST Z-POEM), and 30 min (TF Z-POEM), with a statistically significant difference between the standard and TF Z-POEM groups (P=0.014). Technical success was 100%, and the mean hospital stay was 1.3±1.3 days. One adverse event (5%) occurred. Clinical success, defined as improvement in dysphagia score (3 to 0.05, P<0.001) and resolution of respiratory symptoms, was achieved in all patients. Conclusions: In this study, modified Z-POEM techniques utilizing single-tunnel or tunnel-free approaches, combined with over-the-septum mucosotomy and deep esophageal myotomy (2 cm), demonstrated feasibility, safety and a significantly shorter procedural time compared to standard Z-POEM. These findings suggest potential benefits for ZD treatment, warranting further investigation in larger prospective studies.

Traditional septotomy or Z-POEM for Zenker's diverticulum.

Zenker's diverticulum (ZD), also known as a cricopharyngeal pouch, is a pulsion pseudodiverticulum located dorsally at the pharyngoesophageal junction. The pathophysiology of ZD involves cricopharyngeal spasm, incoordination, impaired upper esophageal sphincter opening, and structural changes in the cricopharyngeal muscle, leading to symptoms such as dysphagia, regurgitation of undigested food, foreign body sensation, halitosis, unintentional weight loss, and respiratory issues. Treatment for symptomatic ZD typically involves myotomy of the cricopharyngeal muscle. Endoscopic techniques, particularly flexible endoscopy septotomy (FES) and Zenker peroral endoscopic myotomy (Z-POEM), have become preferred options due to their minimally invasive nature. This review discusses the techniques and clinical outcomes of FES and Z-POEM, focusing on specific clinical scenarios to guide the choice between these methods. Additionally, the variability in FES techniques, the effectiveness of Z-POEM, and the impact of different diverticulum sizes on treatment outcomes are analyzed, providing a comprehensive overview of current therapeutic approaches for ZD.

Combination of Precut Techniques in Difficult Biliary Cannulation.

Background: Selective biliary cannulation (SBC) is a prerequisite for successful endoscopic retrograde cholangiopancreatography (ERCP). SBC has the potential to fail in as many as 20% of cases, even with skilled endoscopists. Precut incision techniques like needle-knife sphincterotomy (NKS) and transpancreatic septotomy (TPS) can be used in cases where standard cannulation techniques fail. However, these precut techniques may also fail in some cases. We aimed to evaluate the procedural success of the combined TPS + NKS technique in difficult biliary cannulation. Patients and methods: The study included 289 patients who underwent ERCP with precut techniques from 2017 to 2022. Patients were classified into the following three groups and evaluated retrospectively in terms of cannulation success, and ERCP-related adverse effects: Transpancreatic septotomy, NKS, and TPS + NKS; statistical package for the social sciences (SPSS), version 29.0, software was used to analyze the data. Results: The success rate of SBC was 69% in the TPS group, 75.3% in the NCS group, and 87% in the TPS + NCS group. There was no significant difference between the NKS and TPS + NKS groups. Cannulation success in both NKS group and NKS + TPS groups was significantly higher than in the TPS group (p < 0.001). Complication rates were similar. Conclusion: In cases where standard sphincterotomy and precut techniques fail, a second precut technique can be used. A previous TPS does not prevent NKS. How to cite this article: Abiyev A, Tuzcu B, Bilican G, et al. Combination of Precut Techniques in Difficult Biliary Cannulation. Euroasian J Hepato-Gastroenterol 2024;14(1):56-59.

Indications, safety, and effectiveness of transcatheter electrosurgical septotomy during endovascular repair of aortic dissections.

OBJECTIVE: Endovascular repair of aortic dissections may be complicated by inadequate sealing zones, persistent false lumen perfusion, and limited space for catheter manipulation and target artery incorporation. The aim of this study was to describe the indications, technical success, and early outcomes of transcatheter electrosurgical septotomy (TES) during endovascular repair of aortic dissections. METHODS: We reviewed the clinical data of consecutive patients treated by endovascular repair of aortic dissections with adjunctive TES in two centers between 2021 and 2023. End points were technical success, defined by successful septotomy without dislodgment of the lamella or target artery occlusion, and 30-day rates of major adverse events (MAEs). RESULTS: Among 197 patients treated by endovascular repair for aortic dissections, 36 patients (18%) (median age, 61.5 years (interquartile range, 55.0-72.5 years; 83% male) underwent adjunctive TES for acute (n = 3 [8%]), subacute (n = 1 [3%]), or chronic postdissection aneurysms (n = 32 [89%]). Indications for TES were severe true lumen (TL) compression (≤16 mm) in 28 patients (78%), target vessel origin from false lumen in 19 (53%), creation of suitable landing zone in 12 (33%), and organ/limb malperfusion in four (11%). Endovascular repair included fenestrated-branched endovascular aortic repair (EVAR) in 18 patients (50%), thoracic EVAR/EVAR/PETTICOAT in 11 (31%), and arch branch repair in 7 (19%). All patients had dissections extending through zones 5 to 7, and 28 patients (78%) underwent TES across the renal-mesenteric segment. Technical success of TES was 92% (33/36) for all patients and 97% (32/33) among those with subacute or chronic postdissection aneurysms. There were three technical failures, including two patients with acute dissections with inadvertent superior mesenteric artery dissection in one patient and distal dislodgement of the dissection lamella in two patients. There were no arterial disruptions. The mean postseptotomy aortic lumen increased from 13.2 ± 4.8 mm to 28.4 ± 6.8 mm (P < .001). All 18 patients treated by fenestrated-branched EVAR had successful incorporation of 78 target arteries. There was one early death (3%) from stroke, and three patients (8%) had major adverse events. After a median follow-up of 8 months (interquartile range, 4.5-13.5 months), 13 patients (36%) had secondary interventions, and two (6%) died from non-aortic-related events. There were no other complications associated with TES. CONCLUSIONS: TES is an adjunctive technique that may optimize sealing zones and luminal aortic diameter during endovascular repair of subacute and chronic postdissection. Although no arterial disruptions or target vessel loss occurred, patients with acute dissections are prone to technical failures related to dislodgement of the lamella.

Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms.

Objective: Endovascular repair of chronic dissecting aortoiliac aneurysms is challenging given the rigid septum, compressed true lumen (TL), and target vessels frequently originating in the false lumen. We have used transcatheter electrosurgical aortic septotomy (TEAS) before stent graft implantation under intravascular ultrasound (IVUS) and fusion guidance. The purpose of this study is to assess the outcomes of TEAS during complex endovascular repair of dissecting aneurysms. Methods: From 2021 to 2023, 17 patients underwent TEAS. The primary end point was technical success, with secondary end points of proximal and distal seals, target vessel instability, aortic and iliac TL and cross-sectional area (CSA) expansion, and aortic-related death. During the procedure, the aortic septum is crossed through a pre-existing entry or via electrocautery-activated 0.018-in. Astato XS20 wire (Asahi-Intecc) under IVUS and fusion guidance. The penetrated wire is then snared in the false lumen and pulled through the ipsilateral femoral access. A 1-cm length of the middle of the Astato wire coating is kinked in a three-sided polygonal configuration, denuded the inner surface of the wire using a no. 15 blade, and positioned at the apex of the septum. Both ends of the Astato wire are insulated with 0.018-in. microcatheters, and the back end of the wire is denuded and connected to cautery. Gentle traction is applied to the wire, and short bursts of electrocautery cutting are applied at 60 to 80 W. Results: The technical success of the septotomy was 100%. No incidence of visceral or lower extremity malperfusion, vascular injury, or distal embolization occurred. Of the 17 patients, 4 underwent thoracic endovascular aneurysm repair, 2 underwent endovascular aortic repair, and 11 underwent fenestrated/branched endovascular aneurysm repair after septotomy. All target vessels were successfully stented. A distal landing zone seal with exclusion of the false lumen was achieved in 16 of the 17 patients (94.1%). One patient required embolization of the false lumen of the celiac artery after septotomy. The TL mean diameter and CSA of the descending thoracic aorta after septotomy was expanded by 7.01 ± 1.9 mm (relative mean diameter expansion, 42.3%; P < .0001) and 2.71 ± 0.4 cm2 (relative mean CSA expansion, 57.3%, P<.0001). For patients who required septotomy through the common iliac arteries, the mean TL was expanded by 8.1 ± 3.7 mm (relative mean diameter expansion, 76%; P < .0001) and 1.76 ± 0.91 cm2 (relative mean CSA expansion, 209%; P < .0001). The 1-year freedom from target vessel instability was 91%. Conclusions: The use of IVUS and fusion-guided TEAS offers a promising technique to facilitate TL expansion and false lumen exclusion in chronic dissecting aortic aneurysms before repair. The durability and long-term outcomes of this technique in a larger cohort remain to be elucidated.

Visceral Aorta Electrocautery Septotomy to Allow Branched Endovascular Aortic Repair in Ruptured Chronic Post-Dissection Thoraco-Abdominal Aneurysm.

PURPOSE: Endovascular repair of chronic post-dissection thoraco-abdominal aortic aneurysms (PD-TAAA) presents specific technical challenges due to the presence of chronic septum. Small true lumen diameter and false lumen visceral vessel origin can make branched endograft prohibitive. Septotomy may allow to overcome these challenges in cases of high complex anatomy. TECHNIQUE: We describe the application of electrocautery septotomy to the visceral aorta segment to deploy an off-the-shelf branched endograft in a chronic PD-TAAA rupture with true lumen collapse. CONCLUSIONS: Electrocautery septotomy can be an effective adjunctive technique to facilitate branched endograft, overcoming technical challenges associated with the endovascular treatment of chronic PD-TAAA. CLINICAL IMPACT: Electrocautery septotomy is an adjunctive technique that can facilitate endovascular treatment of post-dissection thoraco-abdominal aneurysm. By creating a common lumen, this technique might reduce the number of re-interventions associated with PD-TAAA endovascular exclusion.

Cutting balloon septotomy for repair of right common iliac artery aneurysm in the setting of type B aortic dissection.

We report a case of using cutting balloon septotomy for a 5-cm right common iliac artery aneurysm repair in a patient with a chronic type B aortic dissection after open repair 10 years before. This technique uses intravenous ultrasound to facilitate deployment of a cutting balloon to shear through the dissection flap, allowing for optimization of the landing zone for endovascular repair of a right common iliac artery aneurysm. Various methods are available for performing septotomy, and the use of a cutting balloon is one that helps with stent placement and position.

Transcatheter electrosurgical septotomy technique for chronic postdissection aortic aneurysms.

Aortic dissection often results in chronic aneurysmal degeneration due to progressive false lumen expansion. Thoracic endovascular aortic repair and other techniques of vessel incorporation such as fenestrated-branched or parallel grafts have been increasingly used to treat chronic postdissection aneurysms. True lumen compression or a vessel origin from the false lumen can present considerable technical challenges. In these cases, the limited true lumen space can result in inadequate stent graft expansion or restrict the ability to reposition the device or manipulate catheters. Reentrance techniques can be used selectively to assist with target vessel catheterization. Transcatheter electrosurgical septotomy is a novel technique that has evolved from the cardiology experience with transseptal or transcatheter aortic valve procedures. This technique has been applied in select patients with chronic dissection to create a proximal or distal landing zone, disrupt the septum in patients with an excessively compressed true lumen, or connect the true and false lumen in patients with vessels that have separate origins. In the present report, we summarize the indications and technical pitfalls of transcatheter electrosurgical septotomy in patients treated by endovascular repair for chronic postdissection aortic aneurysms.

Feasibility and safety of per-oral endoscopic septotomy for Killian-Jamieson diverticulum: Case series with video.

BACKGROUND AND AIMS: Killian-Jamieson diverticulum (KJD) is a relatively uncommon variant of pharyngoesophageal diverticula, distinct from the more prevalent Zenker diverticulum. However, literature on endoscopic management of KJD remains limited. This study aimed to elucidate the efficacy and safety of peroral endoscopic septotomy (POES) as a treatment approach for symptomatic KJD. METHODS: In this retrospective observational study, we investigated the outcomes of nine consecutive patients who underwent POES for KJD between January 2019 and May 2023. Follow-up data of at least 2 months post-treatment were analyzed. The primary outcome measure was the technical success rate of POES. Secondary outcomes encompassed the clinical success rate, defined as symptomatic improvement 2 months after POES, and the incidence of adverse events. RESULTS: All patients presented with dysphagia, with a median symptom duration of 6 months (interquartile range [IQR]: 3-12 months). The median diverticulum size was 32 mm (IQR: 24-42 mm). The median duration of the operation time was 66 min (IQR: 60-109). A 100% technical success rate was achieved, with complete closure of the defect in all cases. There were no adverse events related to this treatment. The median hospitalization duration was 5 days (IQR: 4-6), and the clinical success rate was 88.9%. Follow-up barium esophagograms exhibited significant improvement in the flow of the barium for all patients. CONCLUSIONS: Despite the relatively limited case volume, our findings underscore that POES is a safe and efficacious approach for managing symptomatic KJD.

[Application experience of prelacrimal recess combined with septotomy in resection of recurrent inverted papilloma].

Objective:To investigate the effectiveness of nasal endoscopic anterior lacrimal recess approach combined with temporary fenestration of the nasal septum in resecting recurrent nasal inverted papilloma. Methods:Patients with recurrent nasal inverted papilloma who underwent reoperation in our hospital during the past 2 years were included . The nasal septum may hinder full access to and effective treatment of the lesions at the anterior and medial wall of the maxillary sinus by endoscope, aspirator and surgical instrument in the narrow aperture of the prelacrimal recess, although these lesions could be observed by 70° nasal endoscope. Results:The nasal septum is temporarily opened on the basis of the prelacrimal recess approach, and the nasal endoscope and instrument was introduced through trans-septal window, so as to provide a better view of the operative field and the angular range of the instrument's movement. Conclusion:The recurrent nasal inverted papilloma could be successfully managed by re-endoscopic anterior lacrimal recess approach combined with temporary fenestration of the nasal septum, and no recurrence was observed during the 2-year follow-up. This surgical approach is recommended for the inverted papilla which originates from the anterior medial wall of the maxillary sinus, as the tumor can be removed completely using this surgical approach.

Is the Surgical Drainage Mandatory for Leak after Sleeve Gastrectomy?

INTRODUCTION: Despite the unanimous acknowledgement of the laparoscopic sleeve gastrectomy (LSG) worldwide, the leak remains its deficiency. For the last decade, the surgical treatment was practically considered mandatory for almost any collection following LSG. The aim of this study is to evaluate the need for surgical drainage for leak following LSG. METHODS: All consecutive patients having gone through LSG from January 2017 to December 2020 were enrolled in our study. Once the demographic data and the leak history were registered, we analyzed the outcome of the surgical or endoscopic drainage, the characteristics of the endoscopic treatment, and the evolution to complete healing. RESULTS: A total of 1249 patients underwent LSG and the leak occurred in 11 cases (0.9%). There were 10 women with a mean age of 47.8 years (27-63). The surgical drainage was performed for three patients and the rest of the eight patients underwent primary endoscopic treatment. The endoscopic treatment was represented with pigtails for seven cases and septotomy with balloon dilation for four cases. In two out of these four cases, the septotomy was anticipated by the use of a nasocavitary drain for 2 weeks. The average number of endoscopic procedures was 3.2 (range 2-6). The leaks achieved complete healing after an average duration of 4.8 months (range 1-9 months). No mortality was recorded for a leak. CONCLUSIONS: The treatment of the gastric leak must be tailored to each patient. Although there is still no consensus for the endoscopic drainage of leaks after LSG, the surgical approach can be avoided in up to 72%. The benefits of pigtails and nasocavitary drains followed by endoscopic septotomy are undeniable, and they should be included in the armamentarium of any bariatric center.

Aortic septotomy to optimize landing zones during thoracic endovascular aortic repair for chronic type B aortic dissection.

OBJECTIVE: The role of thoracic endovascular aortic repair for chronic type B aortic dissection remains controversial. Clinical outcomes of thoracic endovascular aortic repair with recently implemented aortic septotomy strategy were compared with stand-alone thoracic endovascular aortic repair. METHODS: Between 2008 and 2020, 88 patients with chronic type B aortic dissection and degenerative aortic aneurysm underwent a thoracic endovascular aortic repair with or without adjunctive aortic septotomy, consisting of 36 (41%) with de novo chronic type B aortic dissection and 52 (59%) with residual chronic type B aortic dissection after type A aortic dissection repair. RESULTS: Aortic septotomy was performed in 31 patients (35%) to optimize the proximal (3/31;10%) and distal (31/31;100%) landing zones. The aortic septotomy techniques comprised laser aortic septotomy in 16 patients (52%) and cheese wire septotomy in 15 patients (48%) with a 97% overall technical success rate. The median time interval between aortic dissection occurrence and thoracic endovascular aortic repair was 1.2 years. During follow-up, there were 12 (21%) sudden deaths and 17 (30%) combined aorta-related and sudden deaths in the nonaortic septotomy group, whereas there were no deaths in the septotomy group (P < .001). Patients without aortic septotomy required aortic reinterventions more frequently than those with aortic septotomy (30% vs 7%; P = .014), and 77% of these procedures were related to residual retrograde false lumen flow. Positive aortic remodeling was confirmed in 90% and 37% in the aortic septotomy and nonseptotomy groups, respectively (P < .001). CONCLUSIONS: Stand-alone thoracic endovascular aortic repair outcomes without adjunctive procedures for chronic type B aortic dissection remain unfavorable. In contrast, landing zone optimization using aortic septotomy resulted in a remarkably higher positive aortic remodeling rate. Routine aortic septotomy strategy may positively affect long-term chronic type B aortic dissection survival and expand thoracic endovascular aortic repair candidacy.

Characterizing a CT esophagram protocol after flexible endoscopic diverticulotomy for Zenker's diverticulum: a retrospective series.

Background: Flexible endoscopic cricopharyngeal myotomy and septotomy offer a minimally invasive transluminal option for the treatment of symptomatic Zenker's diverticulum (ZD). There is currently no consensus regarding postoperative follow-up imaging. We suggest a standardized computed tomography (CT) esophagram protocol for radiographic evaluation of postoperative findings. Methods: Single center retrospective analysis of patients with symptomatic ZD who underwent flexible endoscopic diverticulotomy and postoperative imaging with CT esophagram from January 2015 to March 2020. An experienced radiologist blinded to the initial imaging reports prospectively interpreted all CT esophagram findings, in order to minimize bias. Results: Twenty-one patients underwent CT esophagram following flexible endoscopic diverticulotomy for ZD. Diverticulotomy was technically successful in all patients. Most common findings on imaging included: atelectasis (13/21; 62%), persistent esophageal diverticulum (7/21; 33%), pneumomediastinum (3/21; 14%), aspiration (2/21; 10%), and extraluminal air and contrast extravasation consistent with focal esophageal perforation (1/21; 5%). Conclusions: We describe a standardized, simple, and accessible CT esophagram protocol for postoperative imaging of patients with post-flexible endoscopic cricopharyngeal myotomy and septotomy for ZD. CT esophagram facilitates a definitive exclusion of focal esophageal perforation as a postoperative complication of flexible endoscopic diverticulotomy by ruling out extraluminal air and contrast extravasation.

The role of peroral endoscopic myotomy for Zenker's diverticulum: a systematic review and meta-analysis.

BACKGROUND: Zenker's peroral endoscopic myotomy (Z-POEM) has revolutionized the therapeutic strategy for Zenker's diverticulum (ZD) with promising results. We conducted this meta-analysis to estimate the safety and efficacy of Z-POEM for ZD and compare the feasibility and effectiveness of Z-POEM with that of flexible endoscopic septotomy (FES). METHODS: A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science, and Cochrane Library databases to query for studies that assessed the safety and efficacy of Z-POEM for ZD. All articles published from inception to July 31, 2021 were included. The primary outcomes were the overall technical success rate, clinical success rate, incidence of adverse events, and clinical recurrence rate. RESULTS: Eleven studies involving 357 patients undergone Z-POEM were included. Overall, the quality of included studies was above average, with five studies rated as high quality and six ranked as moderate quality. The overall pooled technical success rate for Z-POEM was 96.3% (95% confidence interval [CI] 93.6-97.9%; I2 = 0%). The total pooled clinical success rate for Z-POEM was 93.0% (95% CI 89.4-95.4%; I2 = 0%). The pooled incidence of adverse events for Z-POEM was 12.4% (95% CI 9.1-16.7%; I2 = 0%). The pooled clinical recurrence rate for Z-POEM was 11.2% (95% CI 7.6-16.2%; I2 = 0%). The clinical success for Z-POEM was significantly better than that of FES (relative risk [RR]: 1.11; CI 95% 1.03-1.18; p = 0.004, I2 = 0%), while there were no significant differences in technical success, adverse events, and clinical recurrence between Z-POEM and FES. CONCLUSION: Z-POEM could be an effective and safe therapeutic modality for ZD, and even has a slightly higher clinical success rate than FES. However, comparative studies with long-term follow-up will be needed to further confirm our finding.

Laser aortic septotomy during thoracic endovascular aortic repair for chronic type B aortic dissection.

OBJECTIVE: Persistent false lumen perfusion due to the presence of a thick aortic septum is a significant obstacle to successful thoracic endovascular aortic repair for chronic type B aortic dissection (cTBAD). We describe our new approach of laser aortic septotomy to optimize the landing zone. METHODS: Between 2019 and 2020, 11 patients with cTBAD with degenerative aneurysm underwent laser aortic septotomy during thoracic endovascular aortic repair. A prospectively maintained database was retrospectively reviewed. RESULTS: The median age was 70.0 years, and 10 (91%) were men. Six (55%) were de novo type B aortic dissection and 5 (45%) were residual type B aortic dissection. The age of aortic dissection was 2.9 years (interquartile range, 1.1-12.1). Technical success was achieved in 91% (10/11). In 1 case (9%), laser aortic septotomy was not feasible due to extremely tortuous aorta. Among successful cases, the median extents of proximal and distal laser fenestrations were Th7.5 and Th11.0, respectively and distal landing zones included zone 4 (40%) and zone 5 (60%). Two (18%) underwent a continuous longitudinal laser fenestration, and 8 (73%) had longitudinal spot laser fenestrations with immediate balloon dilatations. Apposition of the stent-graft to the outer aortic wall of the newly created common aortic lumen with elimination of retrograde false lumen flow was achieved in all cases. CONCLUSIONS: This is the first description using the laser technology to optimize the distal landing zone for cTBAD. This new technique is safe and reproducible, with excellent controllability to achieve aortic septotomy at the desired target aorta segment.

Leak After Sleeve Gastrectomy: Updated Algorithm of Treatment.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is currently the most common procedure performed worldwide, and still the leak is considered the main limitation. After an initial enthusiasm for stents, the endoscopic treatment evolved including in the current management the septotomy with balloon dilatation and pigtails insertions. The aim of this study was to evaluate the updated algorithm of endoscopic treatment of leak following LSG including septotomy and balloon dilatation. METHODS: All consecutive patients treated by endoscopy between January 2018 and March 2020 for leak following LSG were included in the current study. After recording the demographic and the leak history, we have analyzed the number of endoscopic sessions, the duration of treatment, and the healing rate of endoscopic treatment for 3 groups: A, small orifice (< 10 mm); B, large orifice (> 10 mm) and acute leak; and group C with large orifice and late leak. RESULTS: A total of 53 patients received endoscopic treatment for leak following LSG. The leaks achieved complete healing after average duration of 3.2 months (range 1-7 months), 2.3 months for group A, 4.2 months for group B, and 3.7 months for group C. The average number of endoscopic procedures was 2.8 (range 2-6) and was required for general population: for group A, 2.3 sessions; in group B, 3.4 sessions; and in group C, 2.7 sessions. Two out of 53 patients (3.8%) required additional treatment outside of the current algorithm, one in group A and another in group B. One patient was transferred for pulmonary abscess, and for another patient, the leak was considered chronic after a total of 14 months, and a laparoscopic fistula-jejunostomy was performed with favorable outcomes. CONCLUSIONS: Although there is still no consensus for endoscopic management of leaks after LSG, the benefits of pigtails and the septotomy are undeniable, and it should be included in the armamentarium of any bariatric endoscopic service.

Endoscopic Septotomy as a Treatment for Chronic Leak after Laparoscopic Sleeve Gastrectomy.

Acute leakage after sleeve gastrectomy progresses into chronic leakage by 10-28.1%, which causes the surgeon to be disturbed. The main treatment for chronic leakage is surgery, but the authors report successful care with endoscopic septotomy. Forty-one year old female patient with a BMI of 42.8 (161.6 cm/111.8 kg) underwent a laparoscopic sleeve gastrectomy. The leakage of the proximal part of the staple resection line was verified in the abdominal CT on the fourth day after the procedure due to pain in the left shoulder that could not be clarified. After appropriate treatment including stent, the patient ended the acute leakage treatment 150 days after surgery. However, the patient was visited for 10 months after removed percutaneous catheter drainage due to fever and pain in the left shoulder. Afterwards, chronic leakage was confirmed from the CT and endoscopy at POD 15 months. We performed endoscopic treatment in the operating room under general anesthesia. At the gastroesophageal junction, we could find chronic leak orifice and bridging fold between stomach lumen and abscess pocket. Endoscopic septotomy was performed with the endoscopic knife and electrosurgical surgical unit, until the stomach lumen and abscess pockets were fully in communication. After the patient was discharged without any complications and is currently under close observation. Endoscopic septotomy as a treatment for chronic leak is feasible and safe. Herein, we report this case with video clip.