Novel modified endoscopic mucosal resection of large GI lesions (> 20 mm) using an external additional working channel (AWC) may improve R0 resection rate: initial clinical experience.

BACKGROUND: En-bloc resection of large, flat dysplastic mucosal lesions of the luminal GI tract can be challenging. In order to improve the efficacy of resection for lesions ≥2 cm and to optimize R0 resection rates of lesions suspected of harboring high-grade dysplasia or early adenocarcinoma, a novel grasp and snare EMR technique utilizing a novel over the scope additional accessory channel, termed EMR Plus (EMR+), was developed. The aim of this pilot study is to describe the early safety and efficacy data from the first in human clinical cases. METHODS: A novel external over-the-scope additional working channel (AWC) (Ovesco, Tuebingen, Germany) was utilized for the EMR+ procedure, allowing a second endoscopic device to be used through the AWC while using otherwise standard endoscopic equipment. The EMR+ technique allows tissue retraction and a degree of triangulation during endoscopic resection. We performed EMR+ procedure in 6 patients between 02/2018-12/2018 for lesions in the upper and lower GI tract. RESULTS: The EMR+ technique utilizing the AWC was performed successfully in 6 resection procedures of the upper and/or lower GI tract in 6 patients in 2 endoscopy centers. All resections were performed successfully with the EMR+ technique, all achieving an R0 resection. No severe adverse events occurred in any of the procedures. CONCLUSIONS: The EMR+ technique, utilizing an additional working channel, had an acceptable safety and efficacy profile in this preliminary study demonstrating it's first use in humans. This technique may allow an additional option to providers to remove complex, large mucosal-based lesions in the GI tract using standard endoscopic equipment and a novel AWC device.

Efficacy of Endoscopic Treatment of Post-Sleeve Gastrectomy Fistulas According to the Radiological Type.

BACKGROUND AND AIMS: The originality of this retrospective study relies on the evaluation of the effectiveness of the endoscopic internal drainage (EID) according to the type of fistula. METHODS: The type of fistula was classified initially according to a CT scan with oral opacification: fistula without a communicating abscess (type I), fistula with a communicating abscess (type II), and fistula with an abscessed sub- and sus-diaphragmatic communicating collection (type III). Treatment algorithm consisted of the insertion of a nasojejunal feeding tube (NJFT) for type I fistulas and the placement of a NJFT with EID with or without surgical drainage for types II and III. RESULTS: Forty-nine patients were included. The clinical success rate with fistula healing was 100% in group I, 96% in group II, and 12% for group III (p = 0.001). Mean time for diagnosis of the fistula was significantly higher in type III (p = 0.04). The mean estimated size of the defect was higher in type II, 11.2 mm and III, 10 mm versus type I, 2.8 mm (p = 0.001). The average number of scheduled endoscopic sessions were 2, 2.7, and 5.2 for types I, II, and III, respectively (p = 0.001). The number of unscheduled reinterventions was also significantly higher in type III (p = 0.03). The NJFT was left in place for a significantly longer duration in type III (136 days) compared to types I (3, 13) and II (49) p = 0.001. CONCLUSION: This study shows that proper characterization of the type of fistula before the endoscopic treatment of post-sleeve fistulas improves the efficacy of the endoscopic treatment.

Outcomes of endoscopic ultrasound-guided biliary drainage: A systematic review and meta-analysis.

Background: Success and event rates of endoscopic ultrasound (EUS)-guided biliary drainage vary with techniques, and results from different studies remain inconsistent. Objective: We conducted a proportion meta-analysis to evaluate the efficacy and safety of EUS-guided biliary drainage and compare the outcomes of current procedures. Methods: We searched MEDLINE, Embase, Cochrane and Web of knowledge to identify studies reporting technical success, clinical success and complication rates of EUS-guided biliary drainage techniques to estimate their clinical and technical efficacy and safety. Results: We identified 17 studies including a total of 686 patients. The overall clinical success and technical success rates were respectively 84% confidence interval (CI) 95% (80-88) and 96% CI 95% (93-98) for hepaticogastrostomy, and respectively 87% CI 95% (82-91) and 95% CI 95 (91-97) for choledochoduodenostomy. Reported adverse event rates were significantly higher (p = 0.01) for hepaticogastrostomy (29% CI 95% (24-34)) compared to choledochoduodenostomy (20% CI 95% (16-25)). Compared with hepaticogastrostomy, the pooled odds ratio for the complication rate of choledochoduodenostomy was 2.01 (1.25; 3.24) (p = 0.0042), suggesting that choledochoduodenostomy might be safer than hepaticogastrostomy. Conclusion: The available literature suggests choledochoduodenostomy may be a safer approach compared to hepaticogastrostomy. Randomized controlled trials with sufficiently large cohorts are needed to compare techniques and confirm these findings.