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Main recommendations: Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3 A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4 Trained EMR practitioners should be familiar with the patient consent process for EMR. 5 The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6 Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7 A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8 A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9 A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10 Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11 Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document. [ABSTRACT FROM AUTHOR]

[35] When comparing conventional endoscopic "blind" cyanoacrylate injection to EUS-guided cyanoacrylate injection for gastric varices, Bick et al found that EUS-guided injection decreased (mainly early) rebleeding rate, despite injecting more varices with less glue in the EUS group. Keywords: endoscopy; hepatology; endoscopic ultrasound; portal hypertension; varices EN endoscopy hepatology endoscopic ultrasound portal hypertension varices 176 188 13 07/18/23 20230501 NES 230501 Lay Summary Upper gastrointestinal endoscopy and ultrasound endoscopy are important tools in the diagnosis and treatment of liver disease. [5][6] Esophageal VNT, as defined by the Baveno working group, are medium-to-large varices, I or i varices with the presence of red spots or red wale signs, I or i varices in patients with Child C cirrhosis. Sarin's classification for gastric varices Gastroesophageal varices type 1 (GOV 1)Continuation of esophageal varices into the lesser curvature Gastroesophageal varices type 2 (GOV 2)Esophageal varices extending to the fundus Isolated gastric varices type 1 (IGV 1)Fundal varices in absence of esophageal varices Isolated gastric varices type 2 (IGV 2)Varices in the stomach outside the cardiofundal region or in the first part of the duodenum ht 1 Source: Adapted from Philips CA, Sahney A. Oesophageal and gastric varices: historical aspects, classification and grading: everything in one place. [Extracted from the article]

The benefits of TIPS insertion for patients with ACLF outweigh the disadvantages, and TIPS should be considered as an option for variceal bleeding, potentially reducing the mortality rate of patients with ACLF and bleeding. [10] Gastrointestinal hemorrhage contributes mainly to the clinical course of UDC and despite the standard of care, timely control of bleeding, prevention of ACLF, and rebleeding and mortality are vital. Prevention and Treatment of Bleeding as Precipitant The management of bleeding as a precipitating event for AD or ACLF consists not only of bleeding control but also of prevention of ACLF (see above) and secondary prophylaxis. Keywords: TIPS; acute-on-chronic liver failure; variceal bleeding; systemic inflammation EN TIPS acute-on-chronic liver failure variceal bleeding systemic inflammation 189 205 17 07/18/23 20230501 NES 230501 Cirrhosis is the end stage of liver fibrosis following chronic and sustained injury to the liver leading to parenchymal extinction, regenerative nodules, and the arise of completely vascularized fibrotic septa responsible for portosystemic shunting. [Extracted from the article]

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection. [ABSTRACT FROM AUTHOR]

This article discusses the use of HaemoCer PLUS, a hemostatic powder, in the treatment and prevention of lower gastrointestinal (GI) bleeding after endoscopic resectional procedures. GI bleeding is a common complication of these procedures, and current treatments include injection therapy, mechanical therapy, and thermal therapy. The study aims to establish a multicenter registry to collect data on the use of HaemoCer PLUS for the prevention of delayed bleeding after colonic endoscopic resectional procedures. Preliminary results suggest that HaemoCer PLUS may be an effective additional therapy for preventing bleeding in patients with large colonic endoscopic resections who are on ongoing antiplatelet therapy. However, managing combined antiplatelet and anticoagulant therapy in patients with comorbidities remains challenging. [Extracted from the article]

This article discusses a prospective observational study that evaluated the feasibility and effectiveness of a novel self-assembling peptide hemostatic gel for initial hemostasis in endoscopic sphincterotomy-related hemorrhage. The study included 202 patients who underwent endoscopic sphincterotomy, with 20 patients experiencing bleeding and receiving the hemostatic gel. The results showed that the application of the hemostatic gel was a safe and effective method for achieving hemostasis in these cases. The study suggests that the hemostatic gel may be a viable option for initial hemostasis in endoscopic sphincterotomy-related bleeding. [Extracted from the article]

This article, published in the journal Endoscopy, explores the risk factors associated with delayed post polypectomy bleeding, which is a common complication of endoscopic polypectomy. The study suggests that endoscopic hemostasis is usually not necessary for low-risk stigmata, such as flat pigmented stigma or a clean base. However, for high-risk stigmata, such as active bleeding or visible vessels, endoscopic hemostasis may be warranted. The study also highlights potential risk factors for high-risk stigmata, including hemodynamic instability, the need for transfusion, shock index, polyp size, and the use of prophylactic hemostatic clips. The authors conclude that further research is needed to determine which patients with delayed post polypectomy bleeding can be treated conservatively. [Extracted from the article]

This article, published in the journal Endoscopy, compares the clinical and endoscopic features of upper gastrointestinal bleeding (UGI) in young and elderly patients. The study, conducted over a one-year period, included 332 patients admitted to the emergency endoscopy unit for UGI bleeding. The results showed that while older patients had more comorbidities and were more likely to be on antithrombotic therapy, there was no significant difference in the severity of bleeding between the two age groups. The presence of active bleeding was the only factor that predicted the need for endoscopic hemostasis. Overall, the study suggests that UGI bleeding in older patients may not be more severe than in younger patients. [Extracted from the article]

This article discusses the advancements in endoscopic submucosal dissection (ESD) for the treatment of colonic tumors. The authors present a case study using the latest technological developments to simplify the procedure. These innovations include a flexible knife for high-pressure injection, a multipolar adaptive traction device for better exposure, an ergonomic pedal fixator to reduce errors, and red dichromic imaging for early detection of bleeding points. The authors suggest that these new advancements could improve the accessibility and dissemination of ESD, but emphasize the importance of organized and effective training. [Extracted from the article]

BACKGROUND : Prior studies have shown the effectiveness of both endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Therefore, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. METHODS : We reviewed data for 1679 patients with CDH who were treated with EBL (n = 638) or clipping (n = 1041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J study). Logistic regression analysis was used to compare outcomes between the two treatments. RESULTS : In multivariate analysis, EBL was independently associated with reduced risk of early rebleeding (adjusted odds ratio [OR] 0.46; P < 0.001) and late rebleeding (adjusted OR 0.62; P < 0.001) compared with clipping. These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant differences were found between the treatments in the rates of initial hemostasis or mortality. Compared with clipping, EBL independently reduced the risk of needing interventional radiology (adjusted OR 0.37; P = 0.006) and prolonged length of hospital stay (adjusted OR 0.35; P < 0.001), but not need for surgery. Diverticulitis developed in one patient (0.16 %) following EBL and two patients (0.19 %) following clipping. Perforation occurred in two patients (0.31 %) following EBL and none following clipping. CONCLUSIONS : Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH, offering the advantages of lower early and late rebleeding rates, reduced need for interventional radiology, and shorter length of hospital stay. [ABSTRACT FROM AUTHOR]

This article discusses a case study of a 54-year-old woman who underwent endoscopic submucosal dissection (ESD) for a tumor in the rectum. The ESD procedure resulted in post-operative bleeding, and various techniques were attempted to control the bleeding without success. The Apollo Overstitch suturing system was then used, which effectively achieved immediate and long-lasting bleeding control. The article concludes that this suturing system is a safe and effective option when other methods of endoscopic hemostasis have failed. [Extracted from the article]

This article, titled "A rare case of melena: Ampullary Hemangioma," discusses the case of a 64-year-old female patient who presented to the emergency department with melena (black, tarry stools) and a drop in hemoglobin levels. After resuscitation, a gastroscopy was performed, revealing a smooth atypical hemorrhagic mass protruding from the ampulla. Biopsies were inconclusive, so the option of surgical biopsy and ampullectomy (removal of the ampulla) was offered and chosen by the patient's family. Computed tomography confirmed a 3.5 cm non-metastatic ampullary mass, and the patient underwent successful surgical ampullectomy. The final pathology confirmed the diagnosis of ampullary hemangioma, a rare benign vascular tumor that can cause melena. The article highlights the challenges of endoscopic hemostasis (stopping bleeding) in such rare conditions, which often require surgical resection. [Extracted from the article]

This article presents the preliminary results of a study on colorectal endoscopic submucosal dissection (ESD) procedures. The study included 29 patients with 30 lesions, with the majority of patients being women. The ESD technique was successful in 86.67% of cases, with only one patient experiencing delayed bleeding. The study found that starting colorectal ESD in a single center with a single operator team is feasible and yields good initial results. [Extracted from the article]

This article, published in the journal Endoscopy, examines the clinical efficacy and cost-effectiveness of local hemostatic agents in upper gastrointestinal bleeding (UGIB). The study focuses on the use of bentonite and synthetic peptides as local hemostatic agents and evaluates their effectiveness in achieving immediate endoscopic hemostasis and preventing UGIB recurrence. The retrospective monocenter study includes 274 patients who received these agents at a tertiary center between 2013 and 2023. The results show that both bentonite and synthetic peptides are safe and effective in treating UGIB, with synthetic peptides showing a trend towards lower rates of recurrent UGIB episodes. [Extracted from the article]

This article, published in the journal Endoscopy, compares the clinical and endoscopic features of upper gastrointestinal bleeding (UGI) in young and elderly patients. The study, conducted over a one-year period, included 332 patients admitted to the emergency endoscopy unit for UGI bleeding. The results showed that while older patients had more comorbidities and were more likely to be on antithrombotic therapy, there was no significant difference in the severity of bleeding between the two age groups. The presence of active bleeding was the only factor that predicted the need for endoscopic hemostasis. Overall, the study suggests that UGI bleeding in older patients may not be more severe than in younger patients. [Extracted from the article]

This article compares the clinical, endoscopic, and evolutionary features of patients with upper gastrointestinal hemorrhage (UGI) who are newly admitted to the emergency department (group A) versus those who are already hospitalized (group B). The study included 332 patients and found that 81% of cases presented with community hemorrhage, while 19% had in-hospital hemorrhage. The study found that there were no statistically significant differences in age, sex, or origin of bleeding between the two groups. However, there were significant differences in the presence of comorbidities, use of antithrombotic drugs, presence of active bleeding, use of endoscopic hemostatic procedures, and need for transfusion. The study also found higher transfusion requirements, active bleeding rates, use of endoscopic hemostasis, and mortality for in-hospital bleeding. [Extracted from the article]

This article, published in the journal Endoscopy, compares the efficacy of hemostatic powder (HP) with conventional treatments for malignancy-related upper gastrointestinal bleeding (UGIB). The study analyzed data from 213 patients with UGIB, with 86 patients treated with HP and 127 patients treated with conventional hemostatic treatments. The results showed that HP had a higher initial hemostasis success rate compared to conventional treatments. However, there were no significant differences in terms of blood transfusion, rebleeding rates, length of hospitalization, and 30-day all-cause mortality. The study suggests that HP may be an effective and safe method for managing acute malignancy-related UGIB, but further research is needed. [Extracted from the article]

This article compares the outcomes of endoscopic treatment for nonvariceal upper gastrointestinal hemorrhage (NVUGIH) caused by peptic ulcers (PU) and Dieulafoy's lesions (DL). The study reviewed the endoscopy database of a hospital over a 10-year period and included patients who underwent upper gastrointestinal endoscopies for hematemesis, hematochezia, and melena. The results showed that DL patients had a significantly higher need for endoscopic hemostasis compared to PU patients. Combination therapy was the preferred technique in both groups, and there was no statistically significant difference in terms of persistent or recurrent bleeding between the two groups. [Extracted from the article]

This article discusses the use of endoscopic papillectomy (EP) as a treatment for ampullary lesions (AL) of the minor duodenal papilla. The study identified 20 patients with AL of the minor papilla and compared them to a cohort of 40 patients with AL of the major papilla. The results showed that EP was safe and effective for treating AL of the minor papilla, with comparable rates of complete resection, en bloc resection, and recurrences between the two groups. There were no severe complications reported, although one patient experienced delayed bleeding that was successfully treated. The authors conclude that AL of the minor papilla can be managed according to guidelines for EP of the major papilla. [Extracted from the article]

This article discusses the role of the expert Endoscopy Nurse in performing endoscopic full-thickness resection (EFTR) procedures. The nurse assembles the device and acts as a second operator alongside the endoscopist. The success of the procedure depends on the collaboration between the nurse and the endoscopist. The article presents the results of 46 procedures performed in their Endoscopy Unit, with all cases achieving complete resection. The histological examination revealed various findings, including low grade dysplasia, high grade dysplasia, and adenocarcinoma foci. There were no major complications, and any bleeding was successfully treated. The article concludes that EFTR is a promising technique that can be an alternative to surgery, reducing hospitalization costs. The collaboration between the physician and the experienced Endoscopy Nurse is crucial for the success of the procedure. [Extracted from the article]

This article provides a retrospective evaluation of 224 patients admitted to a tertiary hospital with upper gastrointestinal bleeding (UGIB). The study aimed to characterize the clinical and endoscopic findings, efficacy of hemostasis, duration of hospitalization, and hospital mortality in these patients. The results showed that UGIB was more common in males and that peptic ulcer was the primary cause. Endoscopic hemostasis was effective in most cases, but oncological and chronic respiratory diseases were risk factors for rebleeding. Chronic liver disease, oncological disease, NSAIDs, ICU admission, and alcohol abuse were associated with higher in-patient mortality. [Extracted from the article]

Background:  Endoscopic submucosal dissection (ESD) is associated with a risk of bleeding. Bleeding is usually treated with diathermy, although this does carry a risk of mucosal thermal injury. Purastat is a topical hemostat that may be effective in controlling bleeding during ESD, thereby reducing the use of heat therapy. The aim of this study was to assess the reduction in heat therapy used in the interventional group (Purastat) compared with the control group. The secondary aims were to compare the procedure length, time for hemostasis, delayed bleeding rate, adverse events, and wound healing between the groups.Methods:  This was a single-center randomized controlled trial of 101 patients undergoing ESD. Participants were randomized to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used. Follow-up endoscopy was performed at 4 weeks to assess wound healing.Results:  There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P < 0.001). There were no significant differences in the procedure length, time for hemostasis, and delayed bleeding rate between the groups. Complete wound healing at 4 weeks was noted in 48.8 % of patients in the interventional group compared with 25.0 % of controls (P = 0.02).Conclusions:  This study has demonstrated that Purastat is an effective hemostat that can reduce the need for heat therapy for bleeding during ESD. It may also have a role in improving post-resection wound healing. [ABSTRACT FROM AUTHOR]

Background: Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % - 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy.Methods: Data were collected prospectively (January 2016 - March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist's discretion.Results: 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P < 0.05) compared with monotherapy or rescue therapy. There were high immediate hemostasis rates across all peptic ulcer disease Forrest classifications.Conclusions: This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers. [ABSTRACT FROM AUTHOR]

Most modalities involve clipping or endoscopic band ligation (EBL), which is preferred for preventing early rebleeding [3][4][5]; however, rebleeding often occurs even after EBL. Several endoscopic modalities are used to treat colonic diverticular bleeding (CDB), a predominant lower gastrointestinal bleeding type [1][2]. [Extracted from the article]

We then identified the bleeding diverticulum, but were unable to identify the bleeding vessels within the diverticulum because of the severe active bleeding (Fig. Although various endoscopic hemostasis techniques for colonic diverticular bleeding have recently been reported [1], identifying the bleeding diverticulum among other diverticula is difficult [2], and identifying the bleeding vessels within the diverticulum is even more difficult. [Extracted from the article]

Background: Acute gastric variceal hemorrhage (AGVH) is a serious complication of portal hypertension. Endoscopic cyanoacrylate glue injection is standard therapy for acute hemostasis; however, it may be associated with serious complications. The role of thrombin injection has not been confirmed. This study compared endoscopic thrombin and glue injections in the hemostasis of AGVH.Methods: 68 eligible patients with AGVH were randomized to receive thrombin injection (33 patients) or glue injection (35 patients). The primary end point was injection-induced gastric ulcers. Secondary end points were acute hemostasis, rebleeding, and mortality within 42 days.Results: Both groups had comparable baseline data. Hemostasis of active bleeding at endoscopy was 90.0 % (9/10) in the thrombin group and 90.9 % (10/11) in the glue group (P = 0.58), and 48-hour hemostasis was achieved in 93.9 % (31/33) and 97.1 % (34/35), respectively (P = 0.60). Treatment failure at 5 days occurred in two patients (6.1 %) in the thrombin group and two patients (5.7 %) in the glue group (P > 0.99). Gastric ulcers occurred in none of the thrombin group and 11/30 (36.7 %) of the glue group (P < 0.001, 95 % confidence interval [CI] 8 % - 27 %). Complications occurred in 4 (12.1 %) and 18 (51.4 %) patients in the thrombin and glue groups, respectively (P < 0.001, 95 %CI 22 % - 45 %). Two patients who received glue had post-treatment gastric ulcer bleeding. One patient in each group died.Conclusions: Endoscopic thrombin injection was similar to glue injection in achieving successful hemostasis of AGVH. However, a higher incidence of complications may be associated with glue injection. [ABSTRACT FROM AUTHOR]

Background: Gastric variceal bleeding is a life-threating condition with challenging management. We aimed to compare the efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization and cyanoacrylate injection versus EUS-guided coil embolization alone in the management of gastric varices.Methods: A single-center, parallel-randomized controlled trial involving 60 participants with gastric varices (GOV II and IGV I) who were randomly allocated to EUS-guided coil embolization and cyanoacrylate injection (n = 30) or EUS-guided coil embolization alone (n = 30). The primary end points were the technical and clinical success rates of both procedures. The secondary end points were the reappearance of gastric varices during follow-up, along with rebleeding, the need for reintervention, and complication and survival rates.Results: The technical success rate was 100 % in both groups. Immediate disappearance of varices was observed in 86.7 % of patients treated with coils and cyanoacrylate, versus 13.3 % of patients treated with coils alone (P < 0.001). Median survival time was 16.4 months with coils and cyanoacrylate versus 14.2 months with coils alone (P = 0.90). Rebleeding occurred in 3.3 % of patients treated with combined treatment and 20 % of those treated with coils alone (P = 0.04). With combined treatment, 83.3 % of patients were free from reintervention versus 60 % with coils alone (hazard ratio 0.27; 95 % confidence interval 0.095 - 0.797; P = 0.01).Conclusions: EUS-guided coil embolization with cyanoacrylate injection achieved excellent clinical success, with lower rates of rebleeding and reintervention than coil treatment alone. Multicenter studies are required to define the most appropriate technique for gastric variceal obliteration. [ABSTRACT FROM AUTHOR]

The net effect is precise and clean tissue excision, limited thermal injury to the submucosal bed beneath the lesion, and sharp crisp mucosal incision margins where the lesion has been removed, which facilitates subsequent evaluation for potential residual adenoma. I inspect the mucosal defect after every resection for adequacy of resection and DMI (Fig. 2 Endoscopic views showing: a - c a 40-mm 0-IIa granular lesion treated with wide-field endoscopic mucosal resection; d - f endoscopic mucosal resection (EMR) of a 90 % circumferential 0-IIa + Is granular lesion, with snare-tip soft coagulation applied to the margin of the post-EMR defect at completion of the procedure for the prevention of adenoma recurrence. [Extracted from the article]

2 Endoscopic images showing: a the difficulty of locating the bleeding artery because of the tumor and surrounding mucosa; b successful control of the bleeding after the wound had been expanded, which allowed the transected artery to be seen. This allowed the bleeding artery to be seen and the bleeding was then controlled by precisely applying electrocoagulation (Fig. [Extracted from the article]

Endoscopic therapy in the management of patients with severe rectal bleeding following transrectal ultrasound-guided prostate biopsy: a case-based systematic review. Severe bleeding, affecting up to 1 % of patients undergoing transrectal prostate biopsy, is uncommon but can be life-threatening [2]. [Extracted from the article]

2 It was possible to make an incision with a good field of view under gel immersion endoscopy even in a situation with heavy bleeding. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). [Extracted from the article]

Traction, using the M-loop method, provides adequate exposure of the papilla, facilitating hemostasis in patients with post-ES bleeding. B Video 1 b Endoscopic hemostasis, achieved using the multiloop traction method for post-sphincterotomy bleeding of the peridiverticular papilla. Hemostasis for post-ES bleeding may be challenging in patients with PAD due to the deviation of the papilla's position. [Extracted from the article]

Introduction Although the indications for endoscopic procedures have increased in recent times, there are also some limitations. This review discusses the practical points to prevent and treat complications in microendoscopic spine surgery. Material and Methods A literature search was conducted for the relevant articles after a topic search on PubMed, Google Scholar, and Medline. The review is based on the experience of 1,574 spinal endoscopic procedures performed by the senior author. Results Advantages of endoscopic surgery include better visualization, panoramic vision, and the ability to work around corners. Limitations with endoscopic procedures include proximal blind areas, obstruction in instrument handling due to a narrow corridor, disorientation, frequent lens fogging, loss of depth perception, and difficulty in achieving hemostasis, leading to complications and longer operative time during the learning curve. Conclusion Surgeons need to learn endoscopic skills in addition to microsurgical ones to perform microendoscopic procedures properly. Attending live workshops, watching operative videos, visiting various departments, watching an experienced and accomplished endoscopic surgeon, proper case selection, a multidisciplinary team approach, practicing on models, hands-on cadaveric workshops, laboratory training, and simulators can improve results and shorten the learning curve. [ABSTRACT FROM AUTHOR]

The article presents a video endoscopy as a patient undergoes massive upper gastrointestinal bleeding post-Whipple's surgery from anastomotic varices due to mesenteric hypertension.

B Video 1 b Successful gel immersion duodenal endoscopic submucosal dissection using a novel gel product for a duodenal epithelial tumor. Gel immersion endoscopy simplifies hemostasis during endoscopic submucosal dissection using the pocket-creation method. [Extracted from the article]

Background and study aims Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage. Patients and methods We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies. Results Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 - 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded. Conclusions Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods. [ABSTRACT FROM AUTHOR]

Objectives The nasoseptal flap (NSF) has become the workhorse for reconstruction in endoscopic endonasal skull-base surgery. The NSF, though useful in reconstruction, may lead to significant donor site morbidity. Published techniques to reduce the donor site morbidity, free mucosal grafts, and septal rotational flaps have shown to reduce crusting and remucosalization times. We present a novel technique utilizing posterior septal mucosa as a free mucosal graft for reconstruction of the anterior septal donor site. The septal mucosal graft is taken from the mucosa overlying the posterior septectomy site of the endonasal approach to skull base tumors. Design Retrospective chart review. Setting Single tertiary academic medical center. Participants All patients who underwent endoscopic endonasal skull-base surgery between November 1, 2014 and August 30, 2015 with free mucosal graft reconstruction of the NSF donor site. Main Outcome Measures Postoperative graft success. Results Fifteen patients underwent septal reconstruction using a septal free mucosal graft. There was a 100% graft success rate with near complete remucosalization by 6 weeks postoperatively. Conclusions The posterior septal free mucosal graft is a simple, reliable method for reconstructing the NSF donor site. The advantages of this technique include utilization of native septal mucosal tissue and middle turbinate preservation. [ABSTRACT FROM AUTHOR]

Background and study aims The thulium laser system (TLS) is an emerging surgical tool. The 2-μm wavelength provides a confined coagulation depth (0.2 - 0.4 mm) to reduce the potential for inadvertent injuries. For the first time ever, we assessed TLS feasibility for endoscopic hemostasis ex vivo in pigs. In addition, we performed the first in vivo hemostatic treatments in humans. Patients and methods Tissue damage induced by TLS using different settings and optical fibers was compared to that from argon plasma coagulation (APC) in established ex vivo animal models. Three consecutive patients with complex nonvariceal upper gastrointestinal bleedings were treated and followed up. Results No deep submucosal injury was observed in animal models. The TLS showed a progressive penetration depth with increased power outputs and tissue exposures but very limited vertical tissue injury (0.1 - 2.0 mm) and lateral spreading damage (0.1 - 0.3 mm and 0.2 - 0.7 mm using the 365-µm and 550-µm fibers, respectively). In vivo, endoscopic hemostasis with TLS was always successful without complications. Conclusions The TLS has proven to be very precise and easy to use. This novel technique appears to be a promising tool for advanced interventional endoscopy. [ABSTRACT FROM AUTHOR]

Background and Study Aims: Endoscopic submucosal dissection (ESD) is performed for treatment of various gastrointestinal lesions; however, the cecum in proximity to the appendiceal orifice remains a challenging area. We reviewed our experience with cecal ESD near the appendiceal orifice in order to clarify whether this procedure is a safe and effective therapeutic option.Patients and Methods: We retrospectively reviewed ESD for lesions within approximately 12 mm of the appendiceal orifice at Kobe University Hospital and an affiliated hospital between January 2003 and December 2014. Lesions were classified as: Type 0, proximity to the appendiceal orifice but does not reach it; Type 1, reaches border of the appendix, but does not enter orifice; Type 2, enters orifice, and transition to normal appendiceal mucosa is discernible on inspection of the appendiceal lumen; and Type 3, enters orifice deeply and tumor edge cannot be observed. ESD was not performed for Type 3 lesions unless appendectomy was performed prior to ESD.Results: A total of 76 lesions satisfied the inclusion criteria (47 Type 0 lesions, 20 Type 1, 6 Type 2, and 3 Type 3). En bloc resection was achieved in 72 lesions (94.7 %). Median specimen size was 49 mm (range 15 - 114 mm), and median tumor size was 35.5 mm (10 - 110 mm). One patient experienced postoperative bleeding, which was treated by endoscopic hemostasis. Another patient who experienced intraoperative perforation and was treated by clip closure later developed appendicitis; he underwent emergency ileocecal surgical resection. Another patient experienced postoperative appendicitis and recovered with antibiotic treatment.Conclusions: ESD in close proximity to the appendiceal orifice seems safe and effective. [ABSTRACT FROM AUTHOR]

Background and Study Aim: Previous studies have shown that both scheduled second-look endoscopy and high-dose continuous omeprazole infusion are effective in preventing peptic ulcer rebleeding. The aim of this noninferiority trial was to compare the efficacy of these two strategies for the prevention of rebleeding following primary endoscopic hemostasis.Patients and Methods: Consecutive patients who received endoscopic treatment for bleeding peptic ulcers (actively bleeding, with nonbleeding visible vessels) were randomized to two treatment groups following hemostasis. One group (second-look endoscopy group) received the proton pump inhibitor (PPI) omeprazole as an intravenous bolus every 12 hours for 72 hours and a second endoscopy within 16 - 24 hours with retreatment for persistent stigmata of bleeding. The other group (PPI infusion group) received continuous high-dose omeprazole infusion for 72 hours. Patients who developed rebleeding underwent surgery if repeat endoscopic therapy failed. The primary outcome was the rebleeding rate within 30 days after initial hemostasis. The margin for noninferiority was set at 5 %.Results: A total of 153 patients were randomized to the PPI infusion group and 152 to the second-look endoscopy group. Rebleeding occurred within 30 days in 10 patients (6.5 %) in the PPI infusion group and in 12 patients (7.9 %) in the second-look endoscopy group (P = 0.646). Surgery was required for rebleeding in six patients from the PPI infusion group and three patients in the second-look endoscopy group (P = 0.32). Intensive care unit stay, transfusion requirements, and mortality were not different between the groups. Patients in the second-look endoscopy group were discharged 1 day earlier than those in the PPI infusion group (P < 0.001).Conclusions: After endoscopic hemostasis, high-dose PPI infusion was not inferior to second-look endoscopy with bolus PPI in preventing peptic ulcer rebleeding.Trial Registration: ClinicalTrials.gov (NCT: 00164931). [ABSTRACT FROM AUTHOR]

Thus, the submucosal fibrous tissue could be identified through the hematoma, and was dissected despite the presence of the hematoma. 2 a Endoscopic image of the submucosal layer with severe hematoma observed using white light. b Endoscopic image of the submucosal layer with severe hematoma observed using red dichromatic imaging (RDI). [Extracted from the article]

3 Causative diverticulum with active bleeding. a The blood stream was difficult to identify using white-light endoscopy. b The blood stream was clearly depicted amidst blood pooling on the red dichromatic imaging mode. 2 Endoscopic view of the ascending colon. a On white-light endoscopy, evidence of recent bleeding was difficult to obtain owing to the surrounding environment consisting of pooled residual blood. b Red dichromatic imaging enhanced the evidence of recent bleeding and easily distinguished it from the surrounding environment. [Extracted from the article]

Background and Study Aims: Endoscopic treatment of active gastrointestinal bleeding often remains difficult, and considerable technical expertise is required. Our aim was to assess the efficacy and safety of endoscopic hemostasis with a liquid combination of bovine activated factors IIa/VIIa/IXa/Xa (SeraSeal).Methods: Patients with active gastrointestinal bleeding were prospectively included. In group A, 5 mL of bovine activated factors IIa/VIIa/IXa/Xa was topically applied via catheters to the bleeding site as initial hemostasis; group B received a similar application but as rescue therapy after failure of conventional endoscopic hemostasis.Results: In group A, bleeding was stopped by the agent in 15 /22 patients (68 %) and by conventional endoscopic hemostasis in 5 of the other 7, with coiling and surgery required for definitive hemostasis in 2. In group B, the addition of the agent definitively stopped bleeding in 13 /15 patients (87 %), with hemostasis in the remaining 2 achieved with fibrin glue. Rebleeding was observed in 1 patient.Conclusions: Our proof of concept study suggests that the use of bovine activated factors IIa/VIIa/IXa/Xa might be a safe and effective addition to current endoscopic hemostatic strategies, but further studies are necessary.ClinicalTrials.gov identifier: NCT02349490. [ABSTRACT FROM AUTHOR]

Background and Study Aims: Colonic diverticular hemorrhage is the most common cause of lower intestinal bleeding. We tried to develop a convenient and reliable hemostatic method, endoscopic detachable snare ligation (EDSL), to treat diverticular hemorrhage and retrospectively explored its safety and efficacy.Patients and Methods: The definitive bleeding diverticulum was ligated with a detachable snare, instead of a rubber band, in a procedure similar to endoscopic band ligation. Removal of the scope to attach a ligation device and reinsertion for treatment are not needed in this method.Results: From November 2013 to September 2014, EDSL was used to treat 8 patients with colonic diverticular hemorrhage. The mean procedure time required for hemostasis after identification of the bleeding diverticulum was 5 ± 2 minutes. Sustained hemostasis was achieved in 7 patients (88 %), and early rebleeding occurred in 1 patient, in whom the applied suction seemed inadequate. No complications occurred in any patient.Conclusions: EDSL may be a safe and effective treatment for colonic diverticular hemorrhage. However, additional studies are warranted to confirm these initial exploratory data. [ABSTRACT FROM AUTHOR]

Although right hemicolectomy would have been the standard therapy, because of the small size of the lesion and the advanced age of our patient, we decided to perform a diagnostic en bloc resection using ESD with countertraction (Fig. B Video 1 b Endoscopic submucosal dissection using countertraction is performed for a colonic laterally spreading tumor; bleeding is later identified from the opposite colonic wall and endoscopic hemostasis is achieved. [Extracted from the article]

Background and study aim: The endoscopic hemostatic therapies currently available do not always result in hemostasis of gastrointestinal bleeding. Oxidized regenerated cellulose (ORC) mesh is a widely available surgical hemostatic material. The aim of this study was to evaluate the hemostatic efficacy of ORC in experimental gastric hemorrhage after endoscopic resection. Methods: This was a prospective, two-stage experimental, Phase I, proof-of-concept study. In Stage 1, eight gastric mucosal lesions were created in anticoagulated rabbits and treated with ORC (closed or open pores). In Stage 2, the endoscopic introduction and application of ORC mesh pieceswere evaluated in a porcine model of endoscopic submucosal dissection (ESD). Results: In Stage 1, hemostasis was achieved in all lesions. Hemostasis was achieved more rapidly with closed-pore than open-pore ORC (24.5 vs. 66.5 seconds) (P<0.01). At 24 hours, all lesions showed persistent hemostasis. There were no episodes of rebleeding, complications, or mortality. In Stage 2, the endoscopic introduction of ORC pieces and application with a biopsy forceps were feasible in all ESD lesions. Conclusions: ORC was an effective hemostatic agent for bleeding lesions following mucosal resection in anticoagulated rabbits. Closed-pore ORC achieved hemostasis faster than open-pore ORC. Endoscopic introduction and release of ORC were feasible. [ABSTRACT FROM AUTHOR]

Nonvariceal upper gastrointestinal (UGI) bleeding recurs after appropriate endoscopic therapy in 10%-15% of cases. The mortality rate can be as high as 25% when bleeding recurs, but there is no consensus about the best modality for endoscopic re-treatment. The aim of this study was to evaluate clipping and detachable snaring (CDS) for rescue endoscopic control of nonvariceal UGI hemorrhage. We report a case series of seven patients from a Korean tertiary center who underwent endoscopic hemostasis using the combined method of detachable snares with hemoclips. The success rate of endoscopic hemostasis with CDS was 86%: six of the seven patients who had experienced primary endoscopic treatment failure or recurrent bleeding after endoscopic hemostasis were treated successfully. In conclusion, rescue endoscopic bleeding control by means of CDS is an option for controlling nonvariceal UGI bleeding when no other method of endoscopic treatment for recurrent bleeding and primary hemostatic failure is possible. [ABSTRACT FROM AUTHOR]

Gastrointestinal endoscopy currently includes many therapeutic methods that are technically challenging and frequently associated with a significant risk of complications. Several issues such as the limited number of clinical cases and practice in emergency situations, and technical difficulty may limit the opportunity for training, and increased exposure in more relaxed situations would be desirable. Moreover, providing the patient with the best possible standard of care is a must. Animal models are the most easily available simulators. Training in these models has been recommended for several complex techniques, among which hemostasis, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and endoscopic submucosal dissection are reviewed here. Ex vivo models are much easier to set up and, from an ethical standpoint, they should be used for the initial step in training whenever possible before moving on to in vivo models. Although simulation with animal models has been the subject of a good number of studies, very few of them have evaluated the impact on clinical outcomes, and clearly more studies are needed. Nevertheless, available evidence does suggest that practicing on animal models has an influence on the learning curve and facilitates the acquisition of skills in the complex endoscopic techniques reviewed [ABSTRACT FROM AUTHOR]