Use of a novel endoscopic overtube with bilateral tool channels for endoscopic resection of experimental lesions and repair of intestinal defects in the right colon: preclinical trial.

BACKGROUND: Endoscopic tumor resection and intestinal defect repair are technically challenging leading to invasive surgery and colectomy performed for resection of benign polyps. In this study, we evaluated the use of an endoscopic overtube with bilateral tool channels for these procedures. METHODS: Using a fresh porcine colorectum in a 3D ex vivo model, 3 cm lesions at the posterior wall of the transverse colon were removed by two different techniques: standard endoscopic submucosal dissection (ESD) technique (STD, n = 12) and ESD using the overtube with an endoscopic snare and grasper through the bilateral channels (OT, n = 12). Procedure times and the number of muscular injuries were evaluated. Using the same model, 5-10 mm full-thickness perforations within a 3 cm mucosal defect at the posterior wall of the transverse colon were closed by two different techniques: standard endoscopic closure technique (STD, n = 12) and endoscopic closure using the overtube with two graspers (OT, n = 12). The outcomes measured included bursting pressure and the number of endoscopic clips used for closure. RESULTS: Endoscopic resection of lesions was performed by the OT group in a significantly shorter total procedure time (STD vs. OT = median 38.9 min vs. 17.3, p < 0.001) and with fewer muscular injuries (median 0 vs. 2, p = 0.002), compared with the STD group. After repair of intestinal defects, the OT group showed higher median bursting pressures (STD vs. OT = 11.2 mmHg vs. 57.1, p = 0.008) despite using fewer clips (median 13 vs. 10, p < 0.001). CONCLUSION: This study demonstrates a novel traction technique with an endoscopic overtube using multiple instruments to remove lesions and repair intestinal defects in the colon more effectively. This endoscopic platform could provide a safe alternative to invasive surgical treatment.

Use of enteroscope without the overtube in incomplete colonoscopies.

Objectives: Colonoscopy is the gold standard diagnostic method for colorectal cancer (CRC) screening. Despite the progress in the endoscopy technology field, a small percentage of colonoscopies is still incomplete. The reasons for that are mostly associated with anatomic features, such as fixed, angulated, long and loopy colon, intra-abdominal adherences and female gender. To overcome such difficulties, the usefulness of scopes different from conventional adult colonoscope (CF), such as paediatric colonoscope (PCF), gastroscope (GIF), single and double balloon enteroscope (SBE and DBE, respectively), has been shown in literature. Our retrospective study aims to evaluate the caecal intubation rate using a SBE without the overtube in patients who previously underwent an incomplete procedure with a different scope.Methods: Patients with a previous incomplete colonoscopy with CF, PCF or GIF were retrospectively enrolled through the analysis of a dedicated database. The enteroscope used was the Olympus Enteropro Single Balloon SiF-Q180 with no overtube. Complete colonoscopy was defined as successful caecal intubation.Results: SBE was used to scope 47 adult patients, mostly female, and it led to a complete procedure in 91% of them. The most frequent reason for an incomplete procedure even with the use of SBE was a fixed and angulated colon.Conclusions: Colonoscopy performed with SBE was safe and no adverse events during and/or after the procedure occurred. Our results suggest that SBE with no overtube is a useful and valid alternative to other type of scopes in difficult cases, especially those related to fixed/angulated colon and in female gender.

MIEO: a micro-invasive endoscopic operation port system for transluminal interventions-an acute and survival porcine study.

BACKGROUND: A reliable and sterile access through the intestinal wall to ease flexible endoscopic transluminal interventions is still appealing but lacks a suitable port system. METHODS: In a granted industry cooperation, we developed the MIEO-Port, a flexible three components overtube system that provides a temporary hermetic sealing of the intestinal wall to allow endoscopic disinfection and manipulation to gain access to the abdominal cavity. The port features an innovative head part which allows for coupling the port to the intestinal wall by vacuum suction and for controlled jetting the isolated intestinal surface with a disinfectant. The device was tested in vivo in 6 pigs for acute and long-term usability. All animal tests were approved by the local ethics committee. RESULTS: In the acute experiment, the port system supported sealed endoscopic mucosa resection and transluminal cholecystectomy. In the survival study on 5 animals, the MIEO-Port proved its reliability after transcolonic peritoneoscopy. In one animal, a port dislocation occurred after extensive retroperitoneal preparation, one animal revealed bacterial contamination at necropsy; however, all animals showed a favourable course over ten days and offered no signs of peritonitis or abscedation during post-mortem examination. DISCUSSION: To the best of our knowledge, the MIEO-Port system is the first device to provide a reliable and sterile flexible access to the peritoneal cavity that can be used throughout the entire gastrointestinal tract regardless of the access route and which combines hermetic sealing with local sterilization. Further studies are warranted.

Improving suboptimal bowel prep using a novel on-demand overtube device: an in vivo animal study.

Video 1Use of a novel, on-demand overtube to perform a targeted right colonic enema and improve suboptimal bowel preparation.

Strategies to manage the difficult colonoscopy.

During endoscopy, an endoscopist is inevitably faced with the occasional "difficult colonoscopy," in which the endoscopist finds it challenging to advance the endoscope to the cecum. Beyond optimization of technique, with minimized looping, minimal insufflation, sufficient sedation, and abdominal splinting when needed, sometimes additional tools may be needed. In this review, we cover available techniques and technologies to help navigate the difficult colonoscopy, including the ultrathin colonoscope, rigidizing overtube, balloon-assisted colonoscopy and the abdominal compression device.

Promising way to address massive intragastric clotting in patients with acute upper gastrointestinal bleeding: A case report.

BACKGROUND: Massive intragastric clotting (MIC) makes endoscopic therapy difficult in patients with acute upper gastrointestinal bleeding. Literature data on how to address this problem are limited. Here, we report on a case of massive stomach bleeding with MIC that was successfully treated endoscopically using an overtube of single-balloon enteroscopy. CASE SUMMARY: A 62-year-old gentleman with metastatic lung cancer was admitted to the intensive care unit due to tarry stools and hematemesis of 1500 mL of blood during hospitalization. Emergent esophagogastroduodenoscopy revealed massive blood clots and fresh blood in the stomach with evidence of active bleeding. Bleeding sites could not be observed even by changing the patient's position and aggressive endoscope suction. The MIC was successfully removed using an overtube connected with a suction pipe, which was inserted into the stomach with an overtube of a single-balloon enteroscope. An ultrathin gastroscope was also introduced through the nose into the stomach to guide the suction. A massive blood clot was successfully removed, and an ulcer with oozing bleeding at the inferior lesser curvature of the upper gastric body was revealed, facilitating endoscopic hemostatic therapy. CONCLUSION: This technique appears to be a previously unreported method to suction MIC out of the stomach in patients with acute upper gastrointestinal bleeding. This technique could be considered when other methods are not available or if they fail to remove massive blood clots in the stomach.

Efficacy of single-balloon overtube for endoscopic submucosal dissection in the proximal colon: A propensity score-matched analysis.

Objectives: A single-balloon overtube (SBO) can improve poor scope operability during colonic endoscopic submucosal dissection (ESD). We aimed to evaluate the clinical usefulness of SBO for ESD in the proximal colon and the predictive factors for cases in which SBO is useful. Methods: A total of 88 tumors located in the proximal colon resected by balloon-assisted ESD (BA-ESD) using SBO and 461 tumors resected by conventional ESD (C-ESD) between June 2015 and November 2020 were considered. Seventy-eight tumors each in the BA-ESD and C-ESD groups were matched by propensity score matching. ESD outcomes were compared between the groups, and a decision tree analysis was performed to explore the predictive factors for cases in which SBO is useful. Results: There were no significant differences between the groups in the major outcomes such as en bloc resection rate (95% vs. 99%, p = 0.17), R0 resection rate (92% vs. 96%, p = 0.30), mean dissection speed (16 mm2/min vs. 16 mm2/min, p = 0.53), and intraoperative perforation rate (5% vs. 6%, p = 0.73). Even when considering cases with poor preoperative scope operability, there were no significant differences between the groups. Comparison of tumors ≥40 mm in diameter between the groups confirmed that the intraoperative perforation rate was significantly lower in the BA-ESD group than in the C-ESD group (0% vs. 24%, p = 0.0188). Conclusion: SBO is useful for ESD of tumors ≥40 mm in diameter in the proximal colon to prevent intraoperative perforation, which usually has a long procedure time.

A case of successful removal of a migrated fish bone in the bile duct after pancreaticoduodenectomy using overtube-assisted cholangioscopy.

Fish bone migration into the bile duct in patients with surgically altered anatomy is a very rare cause of bile duct stones. Recently, balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) is performed for biliary lesions in patients with surgically altered anatomy. We report on a 73-year-old Japanese man with a history of pancreaticoduodenectomy for intraductal papillary mucinous adenoma. A 20 mm long linear hyperattenuating structure in the left intrahepatic bile duct was noted on routine follow-up computed tomography 14 years postoperatively. The linear structure persisted until follow-up computed tomography performed 15 years postoperatively, and the left intrahepatic bile duct was shown to be dilated. We performed BAERCP for the diagnosis and treatment of the linear structure but could not visualize the linear structure in the left intrahepatic bile duct via enteroscopy and fluoroscopy. We removed the enteroscope, leaving the overtube, and inserted the cholangioscope through the overtube over the guide wire. We observed a brown rod-shaped linear structure in the left intrahepatic bile duct and removed it under direct visualization via overtube-assisted cholangioscopy. We conclude that overtube-assisted cholangioscopy was useful for assessing undiagnosed biliary lesions using conventional BAERCP and removing fish bones in the bile duct of the patient with altered gastrointestinal anatomy.

Gastrointestinal Residue Removal Using a Balloon Overtube under Ultrathin Endoscopic Navigation: Ex Vivo and In Vivo Experimental Studies.

Pooled gastric residues involving blood clots and food interrupt appropriate endoscopic intervention, leading to poor outcomes in endoscopic hemostasis and lifesaving. However, procedures and devices that enable the effective removal of gastrointestinal residues remain unsatisfactory. This study aimed to evaluate the efficacy and safety of our developed suction method in ex vivo and in vivo studies. We created a hand-made device with a large suction diameter, consisting of a balloon overtube and an ultrathin endoscope for navigation. In the ex vivo study, we compared the success rate and the suctioning time for four types of simulated residue between a standard endoscope and our device. Our device had s significantly higher suction ability and a shorter procedure time than the standard endoscope. The subsequent in vivo animal study involved five beagle dogs that were administered with food jelly to mimic gastric residue. Suction was performed twice for five dogs (ten attempts). The outcome measure was the successful procedure rate; secondary outcomes were procedure-associated complications and procedure time. The procedure was successful in all attempts, without any complications. The mean procedure time was 5 min. This novel method enabled the efficient and safe removal of gastric residue, and our findings will likely lead to the development of the instrument.

Successful Management of Pharyngeal Perforation Caused by Overtube Insertion During Endoscopic Submucosal Dissection.

A woman in her 70s underwent endoscopic submucosal dissection (ESD) for gastric-type adenoma in the anterior wall of the upper gastric body with intravenous anesthesia. We decided to use an overtube to control the air volume in the stomach. The overtube was inserted under endoscopic guidance using a sufficient amount of lubricating jelly. We encountered resistance when the top of the overtube was advanced to the pharynx; therefore, we stopped the overtube insertion and pulled the tube out immediately. We observed a linear injury in the posterior wall of the hypopharynx. The injury was deep and diagnosed as a pharyngeal perforation. Computed tomography (CT) revealed free air in the neck, with mediastinal emphysema. Conservative treatment was initiated after consultation with the otorhinolaryngologist; the patient received nothing per mouth and was administered intravenous antibiotics. The patient did not develop a fever and no signs of inflammation were observed. CT performed on postoperative day (POD) 5 revealed the disappearance of the mediastinal emphysema and a soft diet was introduced. The patient was discharged on POD 7. The ESD was postponed to two months later and was performed successfully. The scar of the perforation site was confirmed. In this report, we describe an extremely rare adverse event associated with overtube insertion. Although the incidence of pharyngeal perforation is low and its management is controversial, it was done without surgical intervention in the present case.

Tips and tricks for endoscopic negative pressure therapy.

Endoscopic negative-pressure therapy (ENPT) is becoming a valuable tool in surgical complication management of transmural intestinal defects and wounds in the upper and lower gastrointestinal tract. Innovative materials for drains have been developed, endoscopic techniques adapted, and new indications for ENPT have been found. Based on our broad clinical experience, numerous tips and tricks are described, which contribute to the safety of dealing with the new therapy. The aim of this work is to present these methods. The focus is on describing the treatment in the esophagus.

Real steak knives of cincinnati: Repeated foreign body ingestion with novel endoscopic removal.

Repeated ingestion of foreign objects presents a multidisciplinary endoscopic dilemma. We report a 32-year-old female patient with history of multiple previous foreign body ingestions requiring several past exploratory laparotomies, who presents with a knife blade in the esophagus. We present a novel method of using a rigid cervical esophagoscope with a salivary bypass tube. The tip of the knife was isolated into the cervical esophagoscope, and the salivary bypass tube advanced off the cervical esophagoscope over the knife, shielding the serrated edge during removal preventing laceration to the esophagus. Laryngoscope, 129:567-568, 2019.

[Tips and tricks for endoscopic negative pressure therapy. German version]. / Tipps und Tricks in der endoskopischen Unterdrucktherapie.

Endoscopic negative-pressure therapy (ENPT) is becoming a valuable tool in surgical complication management of transmural intestinal defects and wounds in the upper and lower gastrointestinal tract. Innovative materials for drains have been developed, endoscopic techniques adapted, and new indications for ENPT have been found. Based on our broad clinical experience, numerous tips and tricks are described, which contribute to the safety of dealing with the new therapy. The aim of this work is to present these methods. The focus is on describing the treatment in the esophagus.

Endoscopic Removal of Large Sharp-edged Foreign Bodies in the Gastrointestinal Tract Using an Innovative Modification of the Overtube.

Foreign body ingestion is commonly encountered in clinical practice. According to standard guidelines, urgent therapeutic endoscopy should be performed in cases involving sharp objects to prevent complications. Although several extraction methods are available, few cases may still pose a therapeutic challenge. This report describes a novel endoscopic technique utilizing modification of the standard overtube to facilitate the removal of a large razor blade. This technique offers a minimally invasive approach for rapid retrieval of large sharp-edged foreign bodies, obviating the need for a surgical exploration. Additionally, this article compares various imaging modalities for prompt detection of gastrointestinal foreign bodies to avoid unnecessary delays in endoscopic intervention.

Overtube-Assisted Foreign Body Removal: A Review of Endoscopic Management and Case Illustration.

The ingestion of foreign bodies is a common medical emergency seen in both adults and children. In children, the most commonly ingested foreign bodies include coins, toys, magnets, and batteries. In adults, food bolus impaction represents the most common cause of foreign body ingestion. The majority of foreign bodies pass spontaneously. Sharp or pointed objects increase the risk of perforation. Emergent endoscopic intervention is indicated in cases of esophageal obstruction, ingestion of disk batteries, and sharp pointed objects in the esophagus. Flexible endoscopy is the therapeutic method of choice for removing foreign bodies. It is preferred due to its high success rate and low risk for complications. Additionally, the use of an overtube provides gastric and esophageal protection from mucosal laceration. We present a 27-year-old male who ingested six razor blades and a curtain hook and review endoscopic management.

New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum: A case series.

AIM: To report about the combination and advantages of a stapler-assisted diverticulotomy performed by flexible endoscopy. METHODS: From November 2014 till December 2015 17 patients (8 female, 9 male, average age 69.8 years) with a symptomatic Zenker diverticulum (mean size 3.5 cm) were treated by inserting a new 5 mm fully rotatable surgical stapler (MicroCutter30 Xchange, Cardica Inc.) next to an ultrathin flexible endoscope through an overtube. The Patients were under conscious sedation with the head reclined in left position, the stapler placed centrally and pushed forward to the bottom of the diverticulum. The septum was divided by the staple rows under flexible endoscopic control. RESULTS: In eleven patients (64.7%) the stapler successfully divided the septum completely. Mean procedure time was 21 min, medium size of the septum was 2.8 cm (range 1.5 cm to 4 cm). In four patients the septum was shorter than 3 cm, in seven longer than 3 cm. To divide the septum, averagely 1.3 stapler cartridges were used. Two minor bleedings occurred. Major adverse events like perforation or secondary haemorrhage did not occur. After an average time of two days patients were discharged from the hospital. In 6 patients (35.3%) the stapler failed due to a thick septum or insufficient reclination of the head. Follow up endoscopy was performed after an average of two months in 9 patients; 4 patients (44.4%) were free of symptoms, 5 patients (55.6%) stated an improvement. A relapse of symptoms did not occur. CONCLUSION: Flexible endoscopic Zenker diverticulotomy by using a surgical stapler is a new, safe and efficient treatment modality. A simultaneously tissue opening and occlusion prevents major complications.

Utility of the balloon-overtube-assisted modified over-the-wire stenting technique to treat post-sleeve gastrectomy complications.

AIM: To describe a modified technique of deployment of stents using the overtube developed for balloon-assisted enteroscopy in post-sleeve gastrectomy (SG) complications. METHODS: Between January 2010 and December 2015, all patients submitted to an endoscopic stenting procedure to treat a post-SG stenosis or leakage were retrospectively collected. Procedures from patients in which the stent was deployed using the balloon-overtube-assisted modified over-the-wire (OTW) stenting technique were described. The technical success, corresponding to proper placement of the stent in the stomach resulting in exclusion of the SG leak or the stenosis, was evaluated. Complications related to stenting were also reported. RESULTS: Five procedures were included to treat 2 staple line leaks and 3 stenoses. Two types of stents were used, including a fully covered self-expandable metal stent designed for the SG anatomy (Hanarostent, ECBB-30-240-090; M.I. Tech, Co., Ltd, Seoul, South Korea) in 4 procedures and a biodegradable stent (BD stent 019-10A-25/20/25-080, SX-ELLA, Hradec Kralove, Czech Republic) in the remaining procedure. In all cases, an overtube was advanced with the endoscope through the SG to the duodenum. After placement of the guidewire and removal of the endoscope, the stent was easily advanced through the overtube. The overtube was pulled back and the stent was successfully deployed under fluoroscopic guidance. Technical success was achieved in all patients. CONCLUSION: The adoption of a modified technique of deployment of OTW stents using an overtube may represent an effective option in the approach of SG complications.

Approach to Incomplete Colonoscopy: New Techniques and Technologies.

Colonoscopy is the most widely used screening modality for the detection and removal of colon polyps and for the prevention of colorectal cancer. To identify all colon lesions and reduce the risk of colorectal cancer, it is important to perform a complete colonoscopy. The success of screening colonoscopy depends upon several parameters, including bowel preparation and adenoma detection rate. Incomplete colonoscopy rates vary from 4% to 25% and are associated with higher rates of interval proximal colon cancer. This article reviews the potential causes of and preventive measures for incomplete colonoscopy, as well as techniques and technologies that may improve the rate of complete colonoscopy.

Recent Development of Techniques and Devices in Colorectal Endoscopic Submucosal Dissection.

Colorectal endoscopic submucosal dissection (ESD) is now a well-established endoscopic treatment for early-stage colorectal neoplasms, especially in Asian countries, including Japan. Despite the spread of colorectal ESD, there are still situations in which achieving successful submucosal dissection is difficult. Various novel techniques and devices have been developed to overcome these difficulties, and past reports have shown that some of these strategies can be applied to colorectal ESD. We review several recent developments in the field. The techniques reviewed include the pocket creation method and traction methods and the devices reviewed include the overtube with balloon and electrosurgical knives with water-jet function. These improved techniques and devices can facilitate safer, more reliable ESDs and expand its applicability and acceptability all over the world.

Intragastric Balloon for Overweight Patients.

BACKGROUND AND OBJECTIVES: Current treatments for overweight adults include reduced-calorie diet, exercise, behavior modification, and selective use of medications. Many achieve suboptimal results with these measures and progress to obesity. Whether the intragastric balloon (IGB), a reversible device approved for treatment of obesity, is a safe and effective option in overweight adults is less well studied. We conducted a study to prospectively analyze the safety and effectiveness of IGB in overweight adults, to compare the results to a simultaneously studied cohort of obese patients, and to share procedural tips for safe IGB placement and removal. METHODS: One hundred thirty-nine patients were evaluated in this prospective, nonrandomized study. Twenty-six overweight [body mass index (BMI), 26-30)] and 113 obese (BMI > 30) patients underwent outpatient, endoscopic IGB placement under intravenous sedation. The IGB was filled with a 550-900 mL (average, 640 mL) solution of saline, radiological contrast, and methylene blue, with an approximate final proportion of 65:2:1. The patients were followed up at 1-2 weeks and then monthly for 6 months. At 6 months, they underwent IGB removal via an esophageal overtube to optimize safety, and then they were observed for 6 more months. RESULTS: IGB time was 190 ± 36 d in the overweight patients and 192 ± 43 d in the obese patients. Symptoms of IGB intolerance included nausea and pain, which were transiently present in 50-95% of patients for several days, and necessitated early IGB removal in 6% of patients. There were no procedure-related complications and no IGB-related esophagitis, erosion, perforation, or obstruction. The percentage of excess weight loss (EWL%) was 96 ± 54% in the overweight group and 41 ± 26% in the obese group (P < 0.001). CONCLUSION: In overweight adults failing standard treatments, IGB placement for 6 months had an acceptable safety profile and excellent weight loss.