The role of endoscopy in the management of pancreatic necrosis.

The management of acute pancreatitis has seen many advances over the past three decades. Attempts to improve care have led to new definitions, classification systems, and treatment strategies. Despite those efforts, considerable morbidity and mortality result from complications of severe acute pancreatitis. Much attention has been given to new ways to treat these complications, including inflammatory pancreatic fluid collections and associated infections. Endoscopy has become one of the established modalities for the treatment of these complications in many expert centers. This chapter will specifically address the role of endoscopy in the management of pancreatic necrosis.

Small bowel cancers diagnosed by device-assisted enteroscopy at a U.S. referral center: a five-year experience.

BACKGROUND: Primary malignant neoplasms of the small bowel comprise only 1-3% of all gastrointestinal malignancies. Small bowel cancers pose a significant diagnostic challenge. The recent development of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE) have greatly facilitated evaluation of the small bowel. METHODS: We retrospectively reviewed all cases referred to a single U.S. center from September 2004 to July 2009 to determine the frequency and type of primary small bowel cancers found on DAE. RESULTS: The charts of 555 patients who underwent a total of 805 procedures (768 double-balloon and 37 rotational enteroscopies) were reviewed. A total of 20 patients with small bowel cancers were diagnosed. There was no gender predominance (ten men and ten women). The average age at presentation was 66 ± 11 years, essentially identical to our overall population. We identified eight neuroendocrine tumors, five adenocarcinomas, four GIST, two lymphomas, and one poorly differentiated carcinoma. CONCLUSIONS: Small bowel cancer is a rare but important finding on DAE. The per-patient incidence in our series was 3.6%. A recent multicenter Japanese series showing a higher incidence of small bowel tumors (14%) included polyposis syndrome patients and benign lesions, which were excluded from our study. The high frequency of neuroendocrine tumors in our series was also in contrast to the Japanese series, where lymphoma and GIST were more common. This may reflect a difference between our referral populations. Most of our patients underwent surgery as a consequence of these findings, underscoring the importance of identifying these tumors. DAE provides direct endoscopic access to the small bowel and is a valuable tool in the diagnosis of small bowel cancers.

A Novel Approach to Management of Esophageal Pill Impaction.

A 26-year-old male presented with symptoms of acute esophageal obstruction immediately after swallowing an 800-mg ibuprofen tablet. Multiple attempts to extract the pill with a variety of traditional endoscopic retrieval devices were unsuccessful. We successfully destroyed the pill using a threaded-tip biliary stent retrieval device to drill a hole in the center of the pill, which allowed us to use a rat-tooth forceps to crush the pill. This case report demonstrates a novel use of this device in a challenging esophageal pill extraction.

Thorascopic resection of esophageal heterotopic pancreas.

Heterotopic pancreas is normal pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Heterotopic pancreatic tissue is a rare congenital anomaly found usually in the stomach, duodenum, or jejunum and is rarely seen in the esophagus. This is a case of heterotopic pancreas found in the esophagus that was removed thorascopically.