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An 80-year-old female with a mechanic mitral valve treated with acenocumarol was admitted to the hospital due to tarry stools over the last two days and hemoglobin levels of 5.6 g/dl. She had not biliary pathology. An emergency esophagogastroduodenoscopy showed lots of fresh clots over the second part of the duodenum that seemed to come from the major papilla. A duodenoscopy was performed in order to obtain a direct view, showing a huge clot near the papilla. Its removal with a polypectomy snare revealed a large duodenum diverticulum with little saculations inside, one of which showed a visible, actively bleeding vessel. Sclerosis with epinephrine was performed and subsequently, two through-the-scope Cook® 11 mm clips were placed, achieving the cessation of the hemorrhage. Several attempts with different clips were needed since they were separated by the elevator nail of the duodenoscope. No complications developed during the procedure or once anticoagulation was restarted.

Abstract: Endoscopic resection (ER) for non-ampullary duodenal lesions (NADLs) is technically more difficult than lesions of the stomach. However, endoscopic treatment of duodenal lesions has been increasingly performed in recent years. This study aimed to evaluate the efficacy and safety of ER for NADLs.Patients who underwent ER for NADLs between 2004 and 2019 were retrospectively reviewed. Clinical and pathologic features of the lesions including the clinical outcomes and adverse events were analyzed.The study included 80 patients with NADLs. The mean age of patients was 59.3 years (22-80 years), the mean size of the lesion was 8.8 ± 7.0 mm, and the mean procedure time was 13.2 ± 11.2 min. Half (40/80) of the lesions were in the duodenal bulb including the superior duodenal angle. Final histological data showed 56 adenomas (70.5%), 13 Brunner gland tumors (16.2%), and 4 pyloric gland tumors (5.0%). The final diagnoses of 5 lesions after ER showed higher-grade dysplasia compared to pre-ER biopsy findings. The en bloc resection rate was 93.8% (75/80), and the complete resection rate with clear margins was 90.0% (72/80). Micro-perforation occurred in 2 of 80 patients and was successfully treated with conservative treatment. There were no cases of delayed bleeding. The mean follow-up period was 27.0 months (2-119 months) with no cases of recurrence.ER may be an effective treatment for NADLs with favorable long-term outcomes. However, the possibility of perforation complications should always be considered during ER., Competing Interests: The authors have no conflicts of interest or funding to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Endoscopically placed duodenal stents are commonly performed procedures for palliation of obstruction due to malignancy. A relatively small number of studies highlight the potential complications of this procedure, and to date no data have been published in New Zealand specifically addressing this issue. We aimed to retrospectively review complications from duodenal stents at our center and factors associated with the complications., Method: We retrospectively reviewed our endoscopy reporting system, Provation MD, for patients who underwent endoscopic duodenal stenting between 1 April 2010 and 31 March 2020. We searched the system for the keywords 'prosthesis or stent', 'duodenal mass or tumour' and 'duodenal stenosis or stricture'. Their clinical records were reviewed. Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction. Patients were excluded if the obstruction was due to a benign pathology or if the obstruction was proximal to duodenum. Patient demographics, the type of stent used and any stent-related complications were recorded. Previous radiotherapy to chest or abdomen was also recorded., Results: We identified 61 patients who underwent palliative endoscopic duodenal stenting. The overall complication rate was 15% (9/61), with five cases of stent migration, two cases of perforation and two cases of late tumour ingrowth requiring re-stenting. Three out of five stent-migration cases had non-obstructive lesions. Both the cases of perforation had previous radiotherapy., Conclusion: Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. The complication rate was found to be higher among the 60-69 age group, the New Zealand Māori/Pacific Islander ethnic group, patients with Niti-S stent and those with duodenal adenocarcinoma as the primary diagnosis, but these higher rates were not found to be statistically significant. Larger studies are required to assess factors associated with complication rates., Competing Interests: Nil.

Background: Upper gastrointestinal endoscopic examination is a relatively safe procedure; however, all endoscopic procedures are invasive and are associated with a risk of iatrogenic perforation. To evaluate clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation. Factors associated with surgical management or mortality were analyzed., Methods: Between November 2008 and November 2018, the medical records of 149,792 upper gastrointestinal endoscopic procedures were evaluated. The mechanisms of perforations were categorized as electrocoagulation-induced or blunt trauma-induced injuries. The incidence and clinical outcomes of iatrogenic perforations based on the types of procedures performed were evaluated., Results: Iatrogenic endoscopic perforations occurred in 28 cases (0.019%). Iatrogenic perforation-related mortality occurred in 3 patients. The iatrogenic perforation rate based on the types of procedures performed was as follows: diagnostic endoscopy = 0.002%, duodenal endoscopic mucosal resection = 0.9%, esophageal endoscopic submucosal dissection = 10.7%, gastric endoscopic submucosal dissection = 0.2%, endoscopic self-expandable metal stent insertion for malignant esophageal obstruction = 0.1%, duodenoscope-induced injury = 0.02%, endoscopic sphincterotomy = 0.08%, and ampullectomy = 6.8%. All electrocoagulation-induced perforations (n = 21) were managed successfully (15 cases of endoscopic closure, 5 cases treated conservatively, and 1 case treated surgically). Three patients died among those with blunt trauma-induced perforations (n = 7). The factors associated with surgical management or mortality were old age, poor performance status (Eastern Cooperative Oncology Group score ≥ 1), advanced malignancy, and blunt trauma., Conclusions: Most cases of electrocoagulation-induced iatrogenic perforations can be treated using endoscopic clips. If endoscopic closure fails for blunt trauma-induced perforations, prompt surgical management is mandatory.

Background: treatment of intraduodenal levodopa using percutaneous endoscopic gastrostomy is an alternative therapy in patients with advanced Parkinson's disease. There are few studies that have evaluated the endoscopic aspects of this technique., Objectives: to describe our experience and adverse events regarding this technique in advanced Parkinson's disease., Method: a retrospective study was performed from January 2007 to January 2019 in a tertiary healthcare center., Results: thirty-seven patients aged 65.1 ± 10.3 years were included in the study, 21 were male and the disease duration was ten years (1-26). The median follow-up was 16 months (1-144). The device was successfully placed in all cases. The persistence rate with the PEG-D at the end of follow-up was 62.2%. The system was removed in 14 patients, seven due to neurological impairment, four because of the decision of the patient and three due to related events. Fifty-nine adverse events occurred in 23 patients (62.2%, 0.63 per patient-year), four of which were severe (8.1%, 0.05 per patient-year). Minor adverse events included 14 (37.8%) related to the stoma, six (16.2%) to the gastric tube and 15 (40.5%) to the duodenal tube. Forty-four system replacements were performed in 20 patients (54.1%, 0.52 per patient-year). Male sex, age over 70 and a higher comorbidity index were associated with a greater likelihood of persistence of the system (OR: 0.14, 95% CI: 0.03-0.62; OR: 0.52, 95% CI: 0.32-0.86; OR: 0.16, 95% CI: 0.03-0.99, respectively). No predictors of adverse events associated with PEG-D were identified., Conclusions: percutaneous endoscopic gastrostomy for the continuous delivery of duodenal levodopa is a highly effective technique. Adverse events are common, although most are resolved by endoscopy.

Background: It is widely recognized that endoscopic resection (ER) of superficial non-ampullary duodenal epithelial tumors (SNADETs) is technically challenging and may carry high risks of intraoperative and delayed bleeding and perforation. These adverse events could be more critical than those occurring in other levels of the gastrointestinal tract. Because of the low prevalence of the disease and the high risks of severe adverse events, the curability including short- and long-term outcomes have not been standardized yet., Aim: To investigate the curability including short- and long-term outcomes of ER for SNADETs in a large case series., Methods: This retrospective study included cases that underwent ER for SNADETs at our university hospital between March 2004 and July 2017. Short-term outcomes of ER were measured based on en bloc and R0 resection rates as well as adverse events. Long-term outcomes included local recurrence detected on endoscopic surveillance and disease-specific mortality in patients followed up for ≥ 12 mo after ER., Results: In the study, 131 patients with 147 SNADETs were analyzed. The 147 ERs consisted of 136 endoscopic mucosal resections (EMRs) (93%) and 11 endoscopic submucosal dissections (ESDs) (7%). The median tumor diameter was 10 mm. The pathology diagnosis was adenocarcinoma (56/147, 38%), high-grade intraepithelial neoplasia (44/147, 30%), or low-grade intraepithelial neoplasia (47/147, 32%). The R0 resection rate was 68% (93/136) in the EMR group and 73% (8/11) in the ESD group, respectively. Cap-assisted EMR (known as EMR-C) showed a higher rate of R0 resection compared to the conventional method of EMR using a snare (78% vs 62%, P = 0.06). No adverse event was observed in the EMR group, whereas delayed bleeding, intraoperative perforation, and delayed perforation in 3, 3, and 5 patients occurred in the ESD group, respectively. One patient with perforation required emergency surgery. In the 43 mo median follow-up period, local recurrence was found in four EMR cases and all cases were treated endoscopically. No patient died due to tumor recurrence., Conclusion: Our findings suggest that ER provides good long-term outcomes in the patients with SNADETs. EMR is likely to become the safe and reliable treatment for small SNADETs., Competing Interests: Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.

Background and Aims: Duodenoscopes have been implicated in the transmission of multidrug-resistant organisms (MDRO). We compared the frequency of duodenoscope contamination with MDRO or any other bacteria after disinfection or sterilization by 3 different methods., Methods: We performed a single-center prospective randomized study in which duodenoscopes were randomly reprocessed by standard high-level disinfection (sHLD), double high-level disinfection (dHLD), or standard high-level disinfection followed by ethylene oxide gas sterilization (HLD/ETO). Samples were collected from the elevator mechanism and working channel of each duodenoscope and cultured before use. The primary outcome was the proportion of duodenoscopes with an elevator mechanism or working channel culture showing 1 or more MDRO; secondary outcomes included the frequency of duodenoscope contamination with more than 0 and 10 or more colony-forming units (CFU) of aerobic bacterial growth on either sampling location., Results: After 3 months of enrollment, the study was closed because of the futility; we did not observe sufficient events to evaluate the primary outcome. Among 541 duodenoscope culture events, 516 were included in the final analysis. No duodenoscope culture in any group was positive for MDRO. Bacterial growth of more than 0 CFU was noted in 16.1% duodenoscopes in the sHLD group, 16.0% in the dHLD group, and 22.5% in the HLD/ETO group (P = .21). Bacterial growth or 10 or more CFU was noted in 2.3% of duodenoscopes in the sHLD group, 4.1% in the dHLD group, and 4.2% in the HLD/ETO group (P = .36). MRDOs were cultured from 3.2% of pre-procedure rectal swabs and 2.5% of duodenal aspirates., Conclusions: In a comparison of duodenoscopes reprocessed by sHLD, dHLD, or HLD/ETO, we found no significant differences between groups for MDRO or bacteria contamination. Enhanced disinfection methods (dHLD or HLD/ETO) did not provide additional protection against contamination. However, insufficient events occurred to assess our primary study end-point. ClinicalTrials.gov no: NCT02611648., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Aim: To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery (LECS) for early non-ampullary duodenal tumors., Methods: Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small (less than 10 mm) submucosal tumors (SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection (ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique., Results: Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc . The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications (Clavien-Dindo classification grade III or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient., Conclusion: LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to disclose.

Aim: To determine the safety and efficacy of endoscopic duodenal stent placement in patients with malignant gastric outlet obstruction., Methods: This prospective, observational, multicenter study included 39 consecutive patients with malignant gastric outlet obstruction. All patients underwent endoscopic placement of a nitinol, uncovered, self-expandable metal stent. The primary outcome was clinical success at 2 wk after stent placement that was defined as improvement in the Gastric Outlet Obstruction Scoring System score relative to the baseline., Results: Technical success was achieved in all duodenal stent procedures. Procedure-related complications occurred in 4 patients (10.3%) in the form of mild pneumonitis. No other morbidities or mortalities were observed. The clinical success rate was 92.3%. The mean survival period after stent placement was 103 d. The mean period of stent patency was 149 d and the patency remained acceptable for the survival period. Stent dysfunction occurred in 3 patients (7.7%) on account of tumor growth., Conclusion: Endoscopic management using duodenal stents for patients with incurable malignant gastric outlet obstruction is safe and improved patients' quality of life.

Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis (FAP), but nonampullary sporadic duodenal adenomas (SDAs) are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polyp-free duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAP-related polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.

Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.

Aim: To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors., Methods: A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach., Results: The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described., Conclusion: Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.

We are presenting the management of an infected pancreatic fluid collection that occurred six months after distal pancreatectomy in the setting of a radical resection for adrenal carcinoma. Progressive increase in size of the cyst and failure of endoscopic drainage represented the surgical indications for cystogastrostomy. The procedure was facilitated by robotic approach with da Vinci Surgical System. Though as per current literature the endoscopic drainage has largely been accepted for this pathology due to its high rate of success and a low rate of complications, in this particular case, surgical drainage by the minimally invasive robotic approach was successful after endoscopic approach has failed., (Celsius.)

Aim: To compare closure methods, closure times and medical costs between two groups of patients who had post-endoscopic resection (ER) artificial ulcer floor closures., Methods: Nineteen patients with duodenal adenoma, early duodenal cancer, and subepithelial tumors that received ER between September 2009 and September 2014 at Kagawa University Hospital and Ehime Rosai Hospital, an affiliated hospital of Kagawa University, were included in the study. We retrospectively compared two groups of patients who received post-ER artificial ulcer floor closure: the conventional clip group vs the over-the-scope clip (OTSC) group. Delayed bleeding, procedure time of closure, delayed perforation, total number of conventional clips and OTSCs and medical costs were analyzed., Results: Although we observed delayed bleeding in three patients in the conventional clip group, we observed no delayed bleeding in the OTSC group (P = 0.049). We did not observe perforation in either group. The mean procedure times for ulcer closure were 33.26 ± 12.57 min and 9.71 ± 2.92 min, respectively (P = 0.0001). The resection diameters were 18.8 ± 1.30 mm and 22.9 ± 1.21 mm for the conventional clip group and the OTSC group, respectively, with significant difference (P = 0.039). As for medical costs, the costs of all conventional clips were USD $1257 and the costs of OTSCs were $7850 (P = 0.005). If the post-ER ulcer is under 20 mm in diameter, a conventional clip closure may be more suitable with regard to the prevention of delayed perforation and to medical costs., Conclusion: If the post-ER ulcer is over 20 mm, the OTSC closure should be selected with regard to safety and reliable closure even if there are high medical costs.

Aim: To compare the clinical outcomes of uncovered and covered self-expandable metal stent placements in patients with malignant duodenal obstruction., Methods: A total of 67 patients were retrospectively enrolled from January 2003 to June 2013. All patients had symptomatic obstruction characterized by nausea, vomiting, reduced oral intake, and weight loss. The exclusion criteria included asymptomatic duodenal obstruction, perforation or peritonitis, concomitant small bowel obstruction, or duodenal obstruction caused by benign strictures. The technical and clinical success rate, complication rate, and stent patency were compared according to the placement of uncovered (n = 38) or covered (n = 29) stents., Results: The technical and clinical success rates did not differ between the uncovered and covered stent groups (100% vs 96.6% and 89.5% vs 82.8%). There were no differences in the overall complication rates between the uncovered and covered stent groups (31.6% vs 41.4%). However, stent migration occurred more frequently with covered than uncovered stents [20.7% (6/29) vs 0% (0/38), P < 0.05]. Moreover, the overall cumulative median duration of stent patency was longer in uncovered than in covered stents [251 d (95%CI: 149.8 d-352.2 d) vs 139 d (95%CI: 45.5 d-232.5 d), P < 0.05 by log-rank test] The overall cumulative median survival period was not different between the uncovered stent (70 d) and covered stent groups (60 d)., Conclusion: Uncovered stents may be preferable in malignant duodenal obstruction because of their greater resistance to stent migration and longer stent patency than covered stents.

Aim: To determine an appropriate compartmentalization of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for duodenal tumors., Methods: Forty-six duodenal lesions (excluding papillary lesions) from 44 patients with duodenal tumors treated endoscopically between 2005 and 2013 were divided into the ESD and EMR groups for retrospective comparison and analysis., Results: The mean age was 65 ± 9 years (35-79 years). There were 24 lesions from men and 22 from women. The lesions consisted of 6 early cancers, 31 adenomas and 9 neuroendocrine tumors. Lesion location was the duodenal bulb in 15 cases and the descending part of the duodenum in 31 cases. The most common macroscopic morphology was elevated type in 21 cases (45.6%). Mean tumor diameter was 11.9 ± 9.7 mm (3-60 mm). Treatment procedure was ESD (15 cases) vs EMR (31 cases). The examined parameters in the ESD vs EMR groups were as follows: mean tumor diameter, 12.9 ± 14.3 mm (3-60 mm) vs 11.4 ± 6.7 mm (4-25 mm); en bloc resection rate, 86.7% vs 83.9%; complete resection rate, 86.7% vs 74.2%; procedure time, 86.5 ± 63.1 min (15-217 min) vs 13.2 ± 17.0 min (2-89 min) (P < 0.0001); intraprocedural perforation, 3 cases vs none (P = 0.0300); delayed perforation, none in either group; postprocedural bleeding, 1 case vs none; mean postoperative length of hospitalization, 8.2 ± 2.9 d (5-16 d) vs 6.1 ± 2.0 d (2-12 d) (P = 0.0067); recurrence, none vs 1 case (occurring at 7 mo postoperatively)., Conclusion: ESD was associated with a longer procedure time and a higher incidence of intraprocedural perforation; EMR was associated with a lower rate of complete resection.

Background: There are no prospective data regarding the risk of prosthetic joint infection following routine gastrointestinal endoscopic procedures. We wanted to determine the risk of prosthetic hip or knee infection following gastrointestinal endoscopic procedures in patients with joint arthroplasty., Methods: We conducted a prospective, single-center, case-control study at a single, tertiary-care referral center. Cases were defined as adult patients hospitalized for prosthetic joint infection of the hip or knee between December 1, 2001 and May 31, 2006. Controls were adult patients with hip or knee arthroplasties but without a diagnosis of joint infection, hospitalized during the same time period at the same orthopedic hospital. The main outcome measure was the odds ratio (OR) of prosthetic joint infection after gastrointestinal endoscopic procedures performed within 2 years before admission., Results: 339 cases and 339 controls were included in the study. Of these, 70 cases (21%) cases and 82 controls (24%) had undergone a gastrointestinal endoscopic procedure in the preceding 2 years. Among gastrointestinal procedures that were assessed, esophago-gastro-duodenoscopy (EGD) with biopsy was associated with an increased risk of prosthetic joint infection (OR = 3, 95% CI: 1.1-7). In a multivariable analysis adjusting for sex, age, joint age, immunosuppression, BMI, presence of wound drain, prior arthroplasty, malignancy, ASA score, and prothrombin time, the OR for infection after EGD with biopsy was 4 (95% CI: 1.5-10)., Interpretation: EGD with biopsy was associated with an increased risk of prosthetic joint infection in patients with hip or knee arthroplasties. This association will need to be confirmed in other epidemiological studies and adequately powered prospective clinical trials prior to recommending antibiotic prophylaxis in these patients.

Objective: To determine the incidence of bacteremia, as detected by routine methods for bacterial culture of blood samples, following routine endoscopic biopsy of the stomach and duodenum in healthy research dogs and to determine whether treatment with omeprazole administration affected the incidence of bacteremia., Animals: 8 healthy purpose-bred research dogs., Procedures: All dogs underwent gastroduodenoscopy with biopsy at 4 points: twice prior to treatment with omeprazole, once following 15 days of omeprazole treatment (20 mg, PO, q 12 h), and once 14 days after treatment ceased. Dogs had a mean ± SD body weight of 18.6 ± 2.0 kg. Blood samples were aseptically obtained at 3 points during each procedure (before, immediately following, and 24 hours after endoscopy), and routine aerobic and anaerobic bacterial culture of blood was performed., Results: 96 cultures were attempted for each culture method, yielding positive results of aerobic culture for 2 dogs at separate time points and no positive results of anaerobic culture., Conclusions and Clinical Relevance: Routine gastrointestinal endoscopy with biopsy in healthy dogs did not result in a detectable bacteremia in most dogs. Treatment with the gastric acid-suppressing medication omeprazole did not affect the incidence of bacteremia as detected via standard techniques.

We report a case of intestinal obstruction and duodenal dissection resulting from an intramural haematoma after therapeutic upper digestive endoscopy with injection therapy for a bleeding duodenal ulcer in a patient on long-term haemodialysis with liver cirrhosis.

Introduction: endoscopic mucosal resection is an accepted technique for the treatment of proximal gastrointestinal tract superficial lesions., Objectives: to evaluate the efficacy and safety of this procedure in the proximal gastrointestinal tract., Material and Methods: forty one consecutive patients (23 males and 18 females, mean age of 61 ± 11.5 years) were included in our study. Fifty nine resections were performed in these patients in 69 sessions. Lesions treated consisted of elevated lesions with high grade dysplasia in the context of Barrett's esophagus (group A), high grade dysplasia appearing in random biopsies taken during the follow-up of Barrett's esophagus (group B) and superficial gastroduodenal lesions (group C). Snare resection after submucosal injection, band ligator-assisted or cap-assisted mucosal resection were the chosen techniques., Results: we resected 7 elevated lesions with high grade dysplasia in the context of Barrett's esophagus, 6 complete Barrett's esophagus with high grade dysplasia in 16 sequential sessions and 46 gastroduodenal superficial lesions (10 adenomas, 9 gastric superficial carcinomas, 18 carcinoid tumours and 9 lesions of different histological nature). Resections in the two first groups were complete in 100% of the cases, and in 97.9% of the cases in group C. Complications included 2 cases of limited deferred bleeding (groups A and B) and another two cases of stenosis with little clinical relevance in Group B., Conclusions: a) endoscopic mucosal resection is an efficient technique for the treatment of proximal gastrointestinal tract superficial lesions; b) it is a safe procedure with a low percentage of complications, which can generally be managed endoscopically; and c) in contrast with other ablative techniques, endoscopic mucosal resection offers the possibility of a pathologic analysis of the samples.

The results of endoscopic transpapillary surgical interventions in 115 patients, suffering choledocholithiasis, caused by the multiple calculi presence, were analyzed. The patients were divided on four groups, depending on the treatment provided. In 78 patients (first group) endoscopic papillosphincterotomy with mechanical lithoextraction in conjunction with spasmolytic and infusion therapy were performed. In 16 patients (second group) endoscopic papillosphincterotomy with mechanical lithotripsy and partial lithoextraction, endobiliary stenting with further spasmolytic and infusion therapy were performed. In 11 patients (the third group) endoscopic papillosphincterotomy, mechanical lithotripsy with a partial lithoextraction and nasobiliary drainage were used. In 10 patients (the fourth group) endoscopic papillosphincterotomy, mechanical lithotripsy, nasobiliary drainage and endobiliary stenting were applied. The best results were achieved in the first group: the smallest duration of the operation--(32.2 +/- 12.6) min, the smallest stationary state duration--(3.3 +/- 1.2) days, the lowest rate of intraoperative complications--2.6%.

Endoscopic duodenal polypectomy is a routine procedure particularly useful for obtaining histological diagnosis but it is not without serious complications. This is a case report of severe necrotising pancreatitis after duodenal polypectomy. We suggest that experienced endoscopists should carry out polypectomies and that clear guidelines for the management of duodenal polyps are required. Patients undergoing endoscopic duodenal polypectomies should be placed at the beginning of the endoscopy list and observed for at least 4 h.

We report a case of intestinal obstruction due to intramural hematoma of the duodenum following therapeutic endoscopy for a bleeding duodenal ulcer in a patient with liver cirrhosis. A 44-year-old man was admitted to our hospital with severe epigastralgia, nausea and tarry stool. Two years previously he had undergone endoscopic sclerotherapy for esophageal varices caused by alcoholic liver cirrhosis. Endoscopy revealed an open ulcer with a bleeding vessel in the duodenal bulb, and sclerotherapy was performed by clipping the vessel and injecting 20 ml of 0.2% epinephrine. His platelet count was 3.5x10(4)/mul. Twelve hours later, he again developed epigastralgia and hypotension. Emergency computed tomography and ultrasonography revealed an intramural hematoma, 15x18 cm in diameter, at the dorsal and lateral duodenum. Endoscopy and upper gastrointestinal series revealed severe stenosis of the duodenal lumen caused by intramural hematoma. He received parenteral feeding for 22 days and within 8 weeks the hematoma was gradually absorbed using conservative management. Intramural duodenal hematoma may be diagnosed as a complication of the endoscopic procedure in a patient with a bleeding tendency, such as liver cirrhosis.

Objective: To probe the potential use of duodenoscopy in the diagnosis and treatment of acute gallstone pancreatitis (GP)., Methods: Fourty-five patients with acute GP were randomly divided into endoscopic retrograde cholangiopancreatography (ERCP) group (n=20) and non-ERCP group (n=25). Each group was subdivided into mild and severe groups according to APACHE II scores. They were given supportive treatment combined with traditional Chinese medicine. The patients in the ERCP group received ERCP within 24 hours after admission. If there were stones in the common bile duct with stenosis of the inferior extremity or ampulla, endoscopic sphincterotomy (ES) was performed to extract the stones by basket. If no calculi were identified or multiple stones were large, endoscopic naso-biliary drainage (ENBD) was carried out., Results: The incidence of complication, length of hospitalization and cost were markedly lower in patients with severe acute GP in the ERCP group than those in the non-ERCP group (P<0.05), in contrast to the 2 mild subgroups of the ERCP and non-ERCP groups (P>0.05)., Conclusion: It is feasible, effective and safe to apply duodenoscopy in the treatment of severe acute GP.

Chyloperitoneum is a rare and challenging complication of abdominal surgery. We report a case of iatrogenic chyloperitoneum. Infusion of octreotide, a somatostatin analogue, together with total parenteral nutrition followed by medium chain triglyceride diet resulted in rapid resolution of chyloperitoneum. We believe this to be the first report of successful use of octreotide in iatrogenic chyloperitoneum in a child.

Objective: To summarize the results of endoscopic therapy for acute hemorrhage from gastroduodenal malignant lesions., Design: The 3-year experience (1989 through 1991) of a specialized gastrointestinal (GI) bleeding team in the endoscopic treatment of acute upper GI bleeding from gastroduodenal malignant tumors was retrospectively reviewed., Material and Methods: Of 1,083 consecutive patients with acute major upper GI hemorrhage, 21 (1.9%) were found to have advanced tumors of the stomach and duodenum, 15 of whom received endoscopic therapy. In this study group of 15 patients, the tumors were gastric in 11 and duodenal in 4. Endoscopic treatment consisted of injection of epinephrine, heater probe coagulation, neodymium:yttrium-aluminum-garnet laser coagulation, or injection of sodium tetradecyl sulfate., Results: Initial endoscopic hemostasis was achieved in 10 of the 15 patients (67%); however, bleeding recurred in 8 of 10 (80%), and all 5 in whom endoscopic hemostasis was not achieved continued to bleed. Mean transfusion requirements for the 30 days before and the 30 days after the first endoscopic treatment were 7.6 and 6.4 units of packed erythrocytes, respectively (P > 0.10). Five major procedure-related complications occurred, two of which were fatal. The median duration of survival after the first endoscopic treatment was 39 days (range, 1 to 1,414)., Conclusion: In patients with major bleeding from advanced gastroduodenal malignant lesions, endoscopic therapy seems to provide limited benefit.

A 36-year-old man with overgrowth of Staphylococcus aureus in the small bowel underwent a biopsy of the small bowel and presented 5 weeks later with multiple liver abscesses. To our knowledge, small bowel biopsy has never been associated with liver abscesses. We discuss the literature on liver abscesses in patients with AIDS and the risks of bacteremia following upper endoscopy and small bowel biopsy and propose that the etiology of the liver abscesses in our patient was seeding of the portal vein following biopsy of a small bowel that had significant bacterial overgrowth.

Three instances of subclinical reinfection with Campylobacter pylori were observed in two successfully treated patients during follow-up of C. pylori gastritis. The reinfections occurred 1 month and 21 months (patient 1) and 32 months (patient 2) after the completion of antibacterial treatment. Sequential measurement by ELISA of serum IgG antibody levels to the microorganism showed a significant increase in two of the three instances of reinfection. Patient-to-patient transmission was proved by restriction enzyme analysis of bacterial DNA. Between patients the endoscope had been mechanically cleaned using a detergent and treated with 70% ethanol. The risk of gastroscopic cross-infection with C. pylori was estimated by retrospective analysis of the data of 281 negative examinations (107 in 47 initially negative patients and 174 in 37 cured patients). The frequency in uninfected patients of documented endoscopic transmission of C. pylori infection was 1.1% in this study, corresponding with three iatrogenic acquisitions of manifest infection for every 1000 gastroduodenoscopies in our clinic.

A 30 year old man developed severe respiratory distress during upper gastrointestinal endoscopy. He had a short oesophagus and part of the stomach was intrathoracic. Air-insufflation during endoscopy caused distension of the stomach inside the chest leading to respiratory distress. When part of the stomach is intrathoracic, the endoscopist should be cautious and the possibility of respiratory embarrassment kept in mind during air-insufflation.

The impact of endoscope diameter and the presence of systemic sedation on the cardiopulmonary risk of esophagogastroduodenoscopy was investigated. One hundred and forty-six patients undergoing elective esophagogastroduodenoscopy were randomly assigned to one of three groups which differed in either endoscope diameter or use of sedation: group 1 (8.5-mm endoscope with no sedation), group 2 (8.5-mm endoscope with diazepam), and group 3 (11.5-mm endoscope with diazepam). Esophagogastroduodenoscopy was tolerated best by group 2, and this group had the fewest electrocardiographic changes observed on a Holter recording during esophagogastroduodenoscopy. The incidence of electrocardiographic changes during esophagogastroduodenoscopy correlated with patient tolerance (p less than 0.001) and the use of the smaller endoscope (p less than 0.05). The most common arrhythmia was sinus tachycardia (49 patients), but more serious electrocardiographic changes were observed in 21 patients. Serious arrhythmias were more common in patients with a prior history of cardiovascular disease compared with patients with no such history (30% vs. 6%, p less than 0.001). Arterial oxygen desaturation (measured by ear oximetry) during intubation and esophagogastroduodenoscopy was usually modest (2%-5%). However, 16 patients receiving diazepam experienced high levels of desaturation exceeding 7%; this small group of patients also experienced more electrocardiographic changes than other patients. The use of diazepam sedation and an 8.5-mm endoscope may offer the safest and most comfortable combination for most patients undergoing esophagogastroduodenoscopy. Diazepam sedation, however, may represent a potential danger to a small number of patients with marginal baseline arterial saturation.

The charts of all patients with common bile duct (CBD) stones admitted to Virginia Mason Medical Center between January 1, 1981 and July 31, 1986 were reviewed to define current methods of management and results of operative versus endoscopic therapy. Two hundred thirty-seven patients with CBD stones were treated. One hundred thirty patients had intact gallbladders. Of these patients, 76 (59%) underwent cholecystectomy and common bile duct exploration (CBDE) while 54 (41%) underwent endoscopic papillotomy (EP) only. Of the 107 patients admitted with recurrent stones after cholecystectomy, all but five were treated with EP. The overall mortality rate was 3.0%. Complications, success, and death rates were all similar for CBDE and EP, but the complications of EP were often serious and directly related to the procedure (GI hemorrhage, 6; duodenal perforation, 5; biliary sepsis, 4; pancreatitis, 1). Patients undergoing EP required significantly shorter hospitalization than those undergoing CBDE. Multivariate analysis showed that age greater than 70 years, technical failure, and complications increased the risk of death, regardless of procedure performed. Twenty-one per cent of those undergoing EP with gallbladders intact eventually required cholecystectomy. The conclusion is that the results of EP and CBDE are similar, and the use of EP has not reduced the mortality rates of this disease.

One hundred twenty-one patients with extrahepatic biliary obstruction underwent endoscopic sphincterotomy (EST). This was followed by balloon occlusion catheter or dormia basket stone extraction in 106 patients with choledocholithiasis, and by transpapillary biliary endoprosthesis placement in 15 patients with malignant distal common bile duct obstruction. All patients had excellent biliary decompression. Complications not requiring surgical intervention were seen in six patients. This article shows that EST is a low-risk, effective therapy for benign and malignant extrahepatic biliary obstruction.