Multidisciplinary, minimally invasive approach for oesophageal perforations with delayed presentation.

Background: The present study aims to report the outcomes of a multidisciplinary, minimally invasive approach to treating patients with delayed presentation of oesophageal perforation. Patients and Methods: The present study is a retrospective analysis of prospectively maintained data at a tertiary care centre. All patients with oesophageal perforation presenting over 48 h after the onset of symptoms and without oesophageal obstruction were included in the study. Self-expanding Metallic Stent (SEMS) or endoscopic clip placement was performed in all the patients, followed by video-assisted thoracoscopic surgery (VATS) debridement and decortication of pleural cavity collection. 'Success' was defined as, discharge without the need of oesophageal diversion and complete healing of leak site at 8 weeks with successful removal of the stent. Results: Between March 2012 and December 2019, 12 patients (10 males, median age of 55 years- range of 39-71 years) with oesophageal perforation and delayed presentation underwent treatment with this approach. Ten patients had spontaneous perforation (83.3%) and one patient each had upper gastrointestinal endoscopy-induced and post-traumatic perforation. The median duration of symptoms was 8 days (range 3-31 days). SEMS was placed in ten patients and, in two patients, an over-the-scope clip was used. VATS decortication was done in ten patients (83.3%) and the remaining two (16.7%) underwent VATS debridement. One patient required oesophageal diversion and another patient expired due to sepsis. The overall success with this approach was 83.3%. Conclusion: This multidisciplinary, minimally invasive approach is feasible in patients with thoracic oesophageal perforation and delayed presentation, with a high success rate.

Near-infrared fluorescent solid material for visualizing indwelling devices implanted for medical use.

BACKGROUND: In clinical practice, various devices are implanted into the body for medical reasons. As X-ray fluoroscopy is necessary to visualize medical devices implanted into the body, the development of a less-invasive visualization method is highly desired. This study aimed to investigate the clinical applicability of our novel solid material that emits near-infrared fluorescence. METHODS: We developed a solid resin material that emits near-infrared fluorescence. This material incorporates a near-infrared fluorescent pigment, with quantum yield ≥ 20 times than that of indocyanine green. It can be sterilized for medical treatment. This resin material is designed to be molded into a catheter and inserted into the body with an endoscope clip. In this preclinical experiment using a swine model, the resin material was embedded into the body of the swine and visualized with a near-infrared fluorescence camera system. RESULTS: Endoscopic clips were placed in the mucosa of the stomach, esophagus, and large intestine, and the indwelling ureteral catheters were successfully visualized by near-infrared fluorescence laparoscopy. CONCLUSIONS: We confirmed the tissue permeability of the fluorescence emitted by our novel near-infrared fluorescent material and the possibility of its clinical application. This material may allow visualization of devices embedded in the body.

Endoscopic closure of large colonic perforations with a novel endoscopic clip device: An animal study (with videos).

BACKGROUND AND AIM: An endoscopic clip device was newly designed to accomplish the closure of large gastrointestinal defects. The aim of this study was to determine the feasibility and efficacy of this device in an ex vivo experimental setting. METHODS: This prospective study was conducted in porcine colons (n = 5). A large (3-4 cm) linear full-thickness incision was created using a scalpel externally. The device was used for endoscopic closure. The procedure time, number of clips, and success rate of closure were determined. RESULTS: Ten defects were created in five porcine colons (two incisions in each specimen). Successful closure was achieved in all defects. The mean procedure time was 24.30 ± 4.42 min, the mean leak pressure is 28.30 ± 9.49 mmHg, and the mean number of additional conventional hemostatic clips used was 5.10 ± 0.99. CONCLUSIONS: The results indicated that this clip achieved the convenient and reliable closure of large defects in the colon wall in an ex vivo porcine model and seems to be a promising option for closing large gastrointestinal perforations.

Tumor localization using radio-frequency identification clip marker: experimental results of an ex vivo porcine model.

PURPOSE: With the widespread use of minimally invasive surgery, tumor detection is becoming more difficult. We present the experimental results of a radio-frequency identification (RFID) lesion detection system in an ex vivo porcine model. METHODS: The efficacy and feasibility of a newly developed RFID lesion detection system were examined. It was applied to the stomach and colon of pigs weighing 40 kg. The RFID clip was attached to the upper and lower mucosal sides of the stomach. Colon specimens with thin and thick walls were used. The clipped sites were marked on the serosa by a pin. The longest distance from the pin the RFID tag could be detected was measured 25 times in each direction. RESULTS: In the upper gastric wall, the RFID tag detection distance was 4.5 ± 0.9 mm, 5.6 ± 0.7 mm, 12.5 ± 0.7 mm, and 5.3 ± 0.5 mm in the four directions, respectively (right, left, upper, and lower). In the antrum, the RFID tag detection distance was 5.8 ± 0.7 mm, 6.9 ± 0.5 mm, 5.6 ± 0.5 mm, and 3.7 ± 0.5 mm in the four directions. In the thin colon, the RFID tag detection distance was 6.3 ± 0.5 mm, 5.0 ± 0.5 mm, 9.7 ± 0.7 mm, and 6.4 ± 0.4 mm in the four directions. In the thick colon, the RFID tag detection distance was 3.5 ± 0.8 mm, 6.6 ± 0.5 mm, 8.4 ± 0.6 mm, and 9.8 ± 0.5 mm in the four directions. The area of detection was smallest for the antrum (83.7 mm2) and similar for the other sites (150.6, 154.7 and 157.7 mm2 for the upper body, thin colon, and thick colon, respectively). CONCLUSIONS: The distance at which the RFID tag was detected was usually within 10 mm. These results indicate the feasibility of the clinical application of the add-on clip and RFID tag as a marker for identifying the location of various gastrointestinal tumors.

Efficacy and safety of the remOVE System for OTSC® and FTRD® clip removal: data from a PMCF analysis.

INTRODUCTION: The remOVE System (Ovesco Endoscopy AG, Tuebingen, Germany) is a medical device for the endoscopic removal of OTSC or FTRD clips (Ovesco Endoscopy AG, Tuebingen, Germany). The aim of this paper is to assess the efficacy and safety of this system. MATERIAL AND METHODS: A total of 74 patients underwent clip extraction. The standard removal procedure comprises fragmenting the clip by applying an electrical direct current pulse at two opposing sides of the clip. RESULTS: Clip fragmentation was successful in 72 of 74 patients (97.3%). In two cases (2.7%) clip fragmentation was not possible. In nine cases (12.2%) a clip fragment could not be removed and was left in place. Complications occurred in three cases (4.1%): two minor bleedings near the clip removal site (2.7%), and one superficial mucosal tear resulting from clip fragment extraction (1.4%). DISCUSSION: Based on this study, the use of the remOVE System for OTSC or FTRD clip removal can be considered safe and effective.

Endoscopic Management of Boerhaave Syndrome: Are Outcomes Better Than Surgery? A Case Report and Review of Literature.

Boerhaave syndrome (BS) is a rare clinical diagnosis associated with a high morbidity and mortality rate. Diagnosis of this condition is usually delayed which can lead to a very poor outcome. The timing of presentation and time to management plays a very important role in the prognosis and selection of the management method. With the advances seen in therapeutic endoscopy, many authors have been exploring the possibility of shifting the focus of management from surgery to interventional endoscopy. We present a case report of a patient presenting with BS that was successfully managed endoscopically. We also reviewed the literature on how surgical management compares to endoscopic management and attempted to establish general recommendations from available literature on management of BS.

Usefulness of the hybrid technique of interventional radiology and endoscopic treatment for intestinal bleeding after pancreaticoduodenectomy: a case report.

Introduction and importance: In endovascular treatment of ruptured pseudoaneurysm after pancreaticoduodenectomy (PD) with gastrointestinal bleeding, treatment for vasospasm of the culprit vessel from haemorrhagic shock and subsequent reperfusion has not been determined before. Case presentation: The authors hereby present you with a case of a 59-year-old man with unknown operative method upon arrival at the Emergecy room and who had hematemesis and collapse 6 months post-PD surgery. Clinical discussion: An initial contrast-enhanced computed tomography (CT) revealed no obvious source of bleeding, so an upper gastrointestinal endoscope was performed. Rebleeding occurred during the examination, and interventional radiology was performed because haemostasis was difficult. Coil embolization was performed for leakage of contrast material from the gastroduodenal artery stump into the gastrointestinal tract. However, because the embolization was uncertain due to vasospasm of the common hepatic artery, endoscopic clipping of the perforation site was also performed to prevent rebleeding due to reperfusion after improvement of vasospasm. A CT scan 5 days later showed reperfusion of the coil-implanted vessel. No rebleeding or hepatic infarction occurred postoperatively. Conclusion: In this case, the haemostasis by coil embolization was uncertain due to the presence of vasospasm, and clipping was used in combination with the procedure to prevent rebleeding.

Post-cholecystectomy Clip Migration: A Case Report.

Surgical clip migration into the common bile duct (CBD) with subsequent stone formation is an exceedingly rare complication following both laparoscopic and open cholecystectomy, with fewer than 100 cases reported in the literature. Herein, we present the case of a 78-year-old female who presented with abdominal pain and dark urine six years after an open cholecystectomy. Her abdominal ultrasonography revealed no abnormalities, with only mild derangements noted in liver function tests. However, computed tomography of the abdomen unveiled a single metallic surgical clip lodged within the CBD, surrounded by a bile stone, alongside another clip at the gallbladder fossa. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), during which the clip was successfully removed. The procedure has utilized SpyGlass cholangioscopy. While clip migration into the CBD remains a rare phenomenon, it should be considered in the differential diagnosis of patients presenting with obstructive jaundice or biliary colic post-cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips-related complications but surgical common bile duct exploration may be necessary. This case highlights the importance of vigilance and prompt intervention in managing post-cholecystectomy clip migration (PCCM) but potentially serious postoperative complications.

A Rare Case of Conservative Management of Multiple Aerodigestive Fistulas in a Patient.

Acquired aerodigestive fistulas include tracheoesophageal fistulas (TEF) and bronchoesophageal fistulas (BEF). Common causes of acquired fistulas are usually malignant in origin. Tubercular tracheoesophageal fistula and bronchoesophageal fistula are rare. The limited availability of literature often presents a challenge in the treatment of tubercular TEF. We present the case of a 47-year-old woman who presented with complaints of progressive dysphagia and epigastric pain. Preliminary investigation showed raised erythrocyte sedimentation rate (ESR) of 65 mm/h and further evaluation by esophagogastroduodenoscopy for dysphagia revealed multiple ulcerated lesions in the esophagus, computed tomography (CT) revealed the presence of tracheoesophageal and bronchoesophageal fistulas with lung consolidation, and histological examination revealed granulomatous inflammation. The symptoms were managed conservatively with anti-tubercular medicine alone and showed good response.

Advanced Endoscopy for Thoracic Surgeons.

The thoracic surgeon, well versed in advanced endoscopy, has an array of therapeutic options for foregut pathologic conditions. Peroral endoscopic myotomy (POEM) offers a less-invasive means to treat achalasia, and the authors' preferred approach is described in this article. They also describe variations of POEM, such as G-POEM, Z-POEM, and D-POEM. In addition, endoscopic stenting, endoluminal vacuum therapy, endoscopic internal drainage, and endoscopic suturing/clipping are discussed and can be valuable tools for esophageal leaks and perforations. Endoscopic procedures are advancing rapidly, and thoracic surgeons must maintain at the forefront of these technologies.

The Use of the Overstitch to Close Endoscopic Resection Defects.

Endoscopic resection of luminal gastrointestinal neoplasia offers a minimally invasive, lower risk alternative that can be successful in the appropriate setting. Bleeding and perforation can occur with endoscopic mucosal resection and endoscopic submucosal dissection. Defect closure with conventional endoclips or modified technique using endoloops can decrease the risk of adverse events. The Overstitch (Apollo Endosurgery, Austin, TX) endoscopic suturing device is designed for tissue apposition and thus can effectively close a large resection defect. Herein we describe our technique. Our and other groups' initial experience with suturing for closure of the resection defect demonstrates high procedural success rates and safety.

Endoscopic Biliary Intervention Using Traction Devices for Periampullary Diverticulum.

We describe the case a 92-year-old woman who was admitted to our hospital with choledocholithiasis and periampullary diverticulum (PAD). Due to PAD, clear visualization of the ampulla of Vater could not be obtained. Although selective bile duct cannulation was difficult, a 7-Fr plastic stent was placed during the first session. Fifteen days later, endoscopic retrograde cholangiopancreatography was retried using traction devices, and the papilla became visible. Endoscopic sphincterotomy and stone extraction were performed without any complications. The application of traction devices in endoscopic submucosal dissection may be a promising technique in cases in which endoscopic biliary intervention is difficult due to PAD.

Preventing Rescue Surgeries by Endoscopic Clipping: A Valuable Resource in the Surgeon's Toolbox.

AIM: Over-the-scope-clip (OTSC) System is a relatively new endoluminal intervention for gastrointestinal (GI) leaks, fistulas, and bleeding. Here, we present a single center experience with the device over the course of 4 years. METHODS: Retrospective chart review was conducted for patients who received endoscopic OTSC treatment. Primary outcome is the resolution of the original indication for clip placement. Secondary outcomes are complications and time to resolution. RESULTS: Forty-one patients underwent treatment with the OTSC system from 2011 to 2015 with average follow-up of 152 days. The average age is 53.7. The most common site of clip placement was in the stomach (44%). Clips were placed after surgical complication for 28 patients (68%), endoscopic complications for 8 patients (19%), and spontaneous presentation in 5 patients (12%). Technical success was achieved in all patients. Overall, 34 patients (83%) were successfully treated. Nine patients required multiple clips and three patients required additional treatment modalities after OTSC. Four patients used the OTSC as a bridging therapy to surgery. Using OTSC for palliation versus nonpalliative indications was associated with lower rates of treatment success (50% versus 86%, P = .028). Using OTSC for symptoms <6 months had higher rates of treatment success than those experiencing longer symptoms (88% versus 65%, P = .045). There were no major morbidities or mortalities directly associated with the OTSC system. Complications from clip use were pain in two patients (5%) and hematemesis in one patient (3%). CONCLUSIONS: The OTSC System can be a very successful treatment for iatrogenic or spontaneous GI leaks and bleeds. Treatment success is more likely in patients treated within 6 months of diagnosis and less likely to when used for palliation. It was also successfully used as bridging therapy in several patients.

Endoscopic Management of Benign Esophageal Ruptures and Leaks.

OPINION STATEMENT: Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.

Esophageal ESD: technique and prevention of complications.

The advantage of endoscopic submucosal dissection (ESD) is the ability to achieve high R0 resection, providing low local recurrence rate. Esophageal ESD is technically more difficult than gastric ESD due to the narrower space of the esophagus for endoscopic maneuvers. Also, the risk of perforation is higher because of the thin muscle layer of the esophageal wall. Blind dissection should be avoided to prevent perforation. A clip with line method is useful to keep a good endoscopic view with countertraction. Only an operator who has adequate skill should perform esophageal ESD.

Optimal Timing of Endoscopic Clipping for Determining the Resection Line for Laparoscopy-assisted Distal Gastrectomy / 대한소화기학회지

BACKGROUND/AIMS: Pre-operative endoscopic clipping for determining the resection line in patients with early gastric cancer has been used safely, and its efficacy has been demonstrated. However, the optimal timing of endoscopic clipping for determining the resection line in early gastric cancer patients undergoing laparoscopy-assisted distal gastrectomy has not been investigated. METHODS: A retrospective analysis of 92 patients with early gastric cancer who underwent gastric resection after endoscopic clipping at Inje University Sanggye Paik Hospital (Seoul, Korea) was performed. We analyzed the clinical and endoscopic features of patients, number of clips, time from clipping to surgery, and number of patients showing detachment of clips from the gastric wall before surgery. Patients were categorized according to the following two groups: group A included patients whose clips were applied within one day before surgery and group B included patients whose clips were applied more than one day before surgery. RESULTS: Of the 92 patients, 56 were included in group A and 36 were included in group B. In 11 patients (12.0%, five in group A and six in group B, p=0.329), the clips were detached from the gastric wall before surgery. The mean time from clipping to surgery did not differ significantly between the detached and non-detached groups (11 patients, mean 4.6+/-4.6 days vs. 81 patients, mean 3.0+/-4.0 days, p=0.227). CONCLUSIONS: The timing of endoscopic clipping for localization of tumors in early gastric cancer patients undergoing gastrectomy is not important for determining the resection line.