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The management of walled-off necrosis has evolved substantially over the past 23 years since its first description. In this article, we review its history and the evidence supporting modern treatment, which is still subject to heterogeneity across centers and among endoscopists. This allows for creativity and customization of what can be an endoscopic marathon. Our typical practice is discussed with image and video guides aimed at improving procedure success., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose of Review: Gastric outlet obstruction (GOO) can result from benign and malignant causes. Until recently, surgical gastrojejunostomy was the treatment of choice for patient with benign and malignant GOO with a good functional status. Endoscopic placement of luminal self-expandable metal stents is currently widely accepted as the first line of treatment for malignant GOO because of its effectiveness and minimally invasive nature. The main shortcoming of luminal stents is the high incidence of recurrent GOO most commonly because of tumor ingrowth/overgrowth. More recently, endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) has emerged as an alternative to both luminal stent placement and surgical gastrojejunostomy. Advantages of EUS-GE include its minimally invasive nature, efficacy and low incidence of recurrent GOO in cancer patient. We will describe five different techniques to perform this novel and rapidly evolving procedure using a biflanged, lumen-apposing metal stent and compare benefits and risks of each approach. These approaches include antegrade EUS-GE or 'traditional/downstream' and 'rendezvous' methods, retrograde EUS-GE or 'enterogastrostomy,'17 (EPASS), and antegrade EUS-GE 'direct' method., Recent Findings: A preprocedural computed tomography scan allows the proximity of the duodenum or jejunum to the stomach to be determined and to assess for the presence of significant ascites, which is a contraindication to EUS-GE. Technical success rates even in the early studies approximate 90%, regardless of the technique used. Clinical success rates have been exceptionally high as well, with only a minority of patients experiencing persistent symptoms despite technical success. One procedure-related death has been reported so far with an overall low morbidity. Pain, bleeding, pneumoperitoneum and peritonitis have been reported in one patient each. However, duration of follow-up in these studies has been short., Summary: We describe five different techniques to performing EUS-GE. Early studies show excellent efficacy. Stent misdeployment/displacement is the most frequent relevant adverse event. Prospective and preferably randomized trials with comparison to endoluminal enteral stents and surgical gastroenterostomy are needed.

Afferent limb syndrome is a postoperative complication of gastrointestinal surgery, resulting from obstruction of a biliary-enteric limb. Surgery has been the cornerstone of treatment for this condition, but advances in endoscopic and percutaneous techniques could offer less-invasive options. Creation of an internal endoscopic anastomosis between the obstructed afferent limb and an adjacent gastrointestinal lumen can relieve symptoms and might provide a long-term solution. We report the efficacy of endoscopic treatment of afferent limb syndrome using lumen-apposing self-expandable metal stents to create 3 types of enteric anastomoses: a jejunojejunostomy, 2 gastrojejunostomies, and a duodenuojejunostomy in patients who developed afferent limb obstruction following a resection for pancreaticobiliary cancer., (Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Patients with acute cholecystitis sometimes require placement of percutaneous cholecystostomy catheters, either as a bridge to surgery or as primary therapy. In patients who cannot undergo surgery, subsequent removal of the catheter can lead to recurrence of cholecystitis, whereas leaving the drain in place can cause adverse events. We investigated internalization of percutaneous cholecystostomy drainage catheters, using endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMS) as an alternative treatment strategy. Seven patients (median age, 57 years; 6 men) underwent EUS-guided cholecystoenterostomy for internalization of gallbladder drainage with EUS-guided placement of a 10- or 15-mm LAMS. All had initially been treated with placement of a percutaneous cholecystostomy catheter for cholecystitis and were later deemed unfit for cholecystectomy. Technical success was achieved in all patients in 1 endoscopic session, with subsequent removal of all percutaneous drains. Two patients required placement of self-expandable metal stents within the LAMS to successfully bridge the gallbladder and gastrointestinal lumen. No adverse events occurred after a median follow-up of 2.5 months. EUS-guided cholecystoenterostomy using a LAMS is therefore a viable option for internal gallbladder drainage in patients who have a percutaneous cholecystostomy catheter and are poor candidates for cholecystectomy., (Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Selected patients with unresectable perihilar cholangiocarcinoma can undergo neoadjuvant chemoradiotherapy followed by liver transplantation, which has been shown to improve survival. The aim of this study was to determine the feasibility and safety of endoscopic transpapillary insertion of nasobiliary tubes (NBTs) and brachytherapy catheters for high dose-rate (HDR) brachytherapy as part of this neoadjuvant chemoradiotherapy., Patients and Methods: Medical records of patients undergoing biliary brachytherapy for hilar cholangiocarcinoma at the Mayo Clinic, Rochester were reviewed. Patients were treated with curative intent using external beam radiotherapy (4500 cGy), chemotherapy (5-FU or capecitabine), and HDR brachytherapy (930 - 1600 cGy in one to four fractions delivered over 1 - 2 days) prior to planned liver transplantation., Results: Between 2009 and 2013, 40 patients underwent biliary HDR brachytherapy via endoscopically placed NBTs (8.5 - 10 Fr). Patients had a median age of 55 years (range 28 - 68); 25 patients (62.5 %) had primary sclerosing cholangitis. Prior to therapy, 29 patients (72.5 %) had plastic stents, two (5 %) had metal stents, and nine (22.5 %) had no stents. Bilateral NBTs were placed in five patients (12.5 %). NBT/brachytherapy catheter displacement was seen in eight patients (20 %) - five intraprocedure and three post-procedure. A radiotherapy error and NBT kinking each occurred once. Post-procedure adverse events included: cholangitis (n = 5; 12.5 %), severe abdominal pain (n = 3; 7.5 %), duodenopathy (n = 3; 7.5 %), gastropathy (n = 3; 7.5 %), and both duodenopathy and gastropathy (n = 2; 5 %)., Conclusion: HDR biliary brachytherapy administered via endoscopically placed NBTs and brachytherapy catheters is technically feasible and appears reasonably safe in selected patients with unresectable perihilar cholangiocarcinoma., (© Georg Thieme Verlag KG Stuttgart · New York.)

Over the last several years, there have been refinements in the understanding and nomenclature regarding the natural history of acute pancreatitis. Patients with acute pancreatitis frequently develop acute pancreatic collections that, over time, may evolve into pancreatic pseudocysts or walled-off necrosis. Endoscopic management of these local complications of acute pancreatitis continues to evolve. Treatment strategies range from simple drainage of liquefied contents to repeated direct endoscopic necrosectomy of a complex necrotic collection. In patients with chronic pancreatitis, pancreatic pseudocysts may arise as a consequence of pancreatic ductal obstruction that then leads to pancreatic ductal disruption. In this review, we focus on the indications, techniques and outcomes for endoscopic therapy of pancreatic pseudocysts and walled-off necrosis.

Zenker's diverticulum (ZD) is an outpouching of tissue through the Killian triangle that is believed to be caused by dysfunction of the cricopharyngeal muscle. ZD is a relatively uncommon disorder occurring in the elderly. The predominant symptom of ZD is dysphagia, and the most serious consequence is pulmonary aspiration. Videofluoroscopy confirms the diagnosis. Therapy of symptomatic ZD has evolved from an open surgical approach to less invasive transoral endoscopic techniques. Transoral endoscopic therapy using rigid instruments is performed primarily by otorhinolaryngologists, whereas transoral therapy using flexible endoscopes is performed by surgical endoscopists and gastroenterologists. The common goal of all modalities is severing of the septum between the esophageal lumen and the diverticulum containing the cricopharyngeal muscle. Although flexible endoscopic therapy was described nearly 20 years ago, it has experienced a recent resurgence paralleling the advancements of therapeutic endoscopy in other areas, such as endoscopic submucosal dissection. Direct head-to-head comparisons of rigid and flexible endoscopic therapy are lacking, and each approach has variations in techniques as well as advantages and disadvantages. In this article, we review the pathophysiology and management of patients with ZD with an emphasis on flexible endoscopic therapy., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

It has been nearly 20 years since the first peroral endoscopic necrosectomy was performed for patients with pancreatitis. We have since increased our understanding of pancreatitis, and the nomenclature has changed to define disease in which necrosis becomes organized (called "walled-off"). Endoscopic approaches to evaluate and treat pancreatitis have progressed from making small transmural tracts for irrigation to making large tracts, which allow the endoscope to move directly into necrotic cavities and perform endoscopic necrosectomy. The purpose of endoscopic debridement is to irrigate and/or remove areas of necrosis. Collaboration between therapeutic endoscopists and interventional radiologists has led to a combined approach to organized pancreatic necrosis. We discuss the history of peroral endoscopic treatment of organized (walled-off) pancreatic necrosis and current endoscopic approaches to therapy., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Cholecystitis is common and costly to the health care system. Cholecystectomy is curative and the treatment of choice. Alternatives to cholecystectomy, however, are needed for patients who cannot undergo this surgery. However, procedures such as percutaneous cholecystostomy, endoscopic transpapillary and transduodenal gallbladder drainage, and dissolution therapy have limitations such as continued gallstone burden. More effective and minimally invasive alternatives, therefore, are needed. We developed a hybrid percutaneous-endoscopic approach for complete gallstone clearance in an elderly patient who was not a candidate for surgery. If replicated and proven to be safe, this technique could be a minimally invasive alternative to cholecystectomy for patients with symptomatic gallstone disease who are not good candidates for surgery., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Hilar cholangiocarcinoma has a poor prognosis and surgery remains the only curative option. However, few patients are diagnosed at a curable stage and palliative therapies are, therefore, mandatory. Endoscopy could have a useful role in the work-up of patients with hilar cholangiocarcinoma who are unsuitable for surgery. Endoscopic retrograde cholangiopancreatography provides an opportunity to collect specimens for cytological or histological diagnosis, yet is often nondiagnostic. Other techniques, including fluorescence in situ hybridization, confocal laser endomicroscopy and endoscopic ultrasonography, are now improving the accuracy of tissue diagnosis. This Review presents an overview of the diagnostic and therapeutic role of endoscopic procedures in the management of hilar cholangiocarcinoma. The use of such procedures in guiding the therapeutic management of patients with hilar cholangiocarcinoma is discussed, and the relative success of endoscopic stenting as the main palliative therapy for obstructive jaundice (a common complication of hilar cholangiocarcinoma) is described. The potential role of photodynamic therapy as a palliative treatment for patients with hilar cholangiocarcinoma is also outlined.

Malignant biliary obstruction results in jaundice, often with symptoms that decrease the quality of life. Biliary stent placement has largely supplanted surgical bypass for palliation of malignant biliary obstruction. Traditional rigid plastic stents are commonly used, inexpensive and easily removed, although with limited duration of stent patency. Self-expandable metal stents (SEMS) attain larger luminal diameters and provide longer patency than traditional rigid plastic stents in patients with distal bile duct obstruction. SEMS are composed of a variety of metals and can be uncoated, partially covered, or fully covered. Data do not support a prolongation of patency with covered SEMS for distal obstruction, although they have the potential for removability. The data to support SEMS for palliation of hilar biliary obstruction are not as convincing and reintervention for stent occlusion can be difficult. In this article, the design and performance of expandable metal stents for treatment of malignant biliary obstruction will be reviewed.

Computed tomography (CT) findings that may differentiate walled-off pancreatic necrosis (WOPN) from pancreatic pseudocyst were investigated. CT examinations performed before endoscopic therapy of pancreatic fluid collection (PFC) in 73 patients (45 WOPN, 28 pseudocysts) were evaluated retrospectively by two radiologists. PFC was evaluated for size, extension to paracolic space, characteristics of wall and internal structure. The pancreas was evaluated for deformity or discontinuity, and pancreatic duct dilation. CT findings that were associated with WOPN or pseudocyst were identified. CT score (number of CT findings associated with WOPN minus number of findings associated with pseudocyst) was calculated for each PFC. PFC was categorized as WOPN or pseudocyst using a CT score threshold. Larger size, extension to paracolic space, irregular wall definition, presence of fat attenuation debris in PFC, pancreatic deformity or discontinuity (P < 0.05-0.0001) were findings associated with WOPN. Presence of pancreatic duct dilation was associated with pseudocyst. Using a CT score of 2 or higher as a threshold, CT differentiated WOPN from pseudocyst with an accuracy of 79.5-83.6%. Thus, CT can differentiate WOPN from pseudocysts.

Endoscopic retrograde cholangiography (ERC) is a well-established modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with postsurgical anatomy like Roux-en-Y anastomoses. Its effectiveness in post-orthotopic liver transplantation (OLT) patients with Roux-en-Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population. A total of 132 OLTs with Roux-en-Y biliary reconstruction were performed at our institution from June 1998 to August 2005. Data from consenting patients who underwent ERC were reviewed once they were identified through computerized medical index system. Of 132 OLT patients with Roux-en-Y biliary reconstruction, 31 patients (9 female and 22 male subjects ranging in age from 11 months to 70 years) underwent ERC. The indication for liver transplant was end-stage liver disease or occurrence of cholangiocarcinoma from primary sclerosing cholangitis in 28 patients and a case each of chronic hepatitis C, alcoholic liver disease, and metastatic islet cell carcinoma. A variable-stiffness pediatric colonoscope was used in most cases. ERC indications were both diagnostic and therapeutic and included the following: evaluation of increased liver biochemistries and fever in 12 patients, dilation of anastomotic biliary strictures in 10 patients, removal of fractured biliary tube or retained biliary stent in 6 patients, and in 1 patient each, biliary stone removal, management of bile leak, and jejunal tube extension placement for nutritional purpose. ERC was successful in 22 patients (71%). There were no postprocedural complications. Although ERC is technically more difficult and time-consuming in OLT patients with Roux-en-Y anastomoses, these data suggest that ERC is an effective and safe diagnostic and therapeutic modality with few or no complications when performed by experienced endoscopists. ERC was successful in most patients and allowed therapeutic interventions that obviated the need for percutaneous radiological intervention or surgery., (Copyright (c) 2007 AASLD.)

Background: Experience with minimal access, transoral/transmural endoscopic drainage/debridement of walled-off pancreatic necrosis (WOPN) after necrotizing pancreatitis is limited. We sought to determine outcome using this technique., Methods: Retrospective analysis., Results: From 1998 to 2006, 53 patients underwent transoral/transmural endoscopic drainage/debridement of sterile (27, 51%) and infected (26, 49%) WOPN. Intervention was performed a median of 49 days (range, 20-300 days) after onset of acute necrotizing pancreatitis. A median of 3 endoscopic procedures/patient (range, 1-12) were performed. Twenty-one patients (40%) required concurrent radiologic-guided catheter drainage of associated or subsequent areas of peripancreatic fluid and/or WOPN. Twelve patients (23%) required open operative intervention a median of 47 days (range, 5-540) after initial endoscopic drainage/debridement, due to persistence of WOPN (n = 3), recurrence of a fluid collection (n = 2), cutaneous fistula formation (n = 2), or technical failure, persistence of pancreatic pain, colonic obstruction, perforation, and flank abscess (n = 1 each). Final outcome after initial endoscopic intervention (median, 178 days) revealed successful endoscopic therapy in 43 (81%) and persistence of WOPN in 10 (19%). Preexistent diabetes mellitus, size of WOPN, and extension of WOPN into paracolic gutter were significant predictive factors for need of subsequent open operative therapy., Conclusions: Successful resolution of symptomatic, sterile, and infected WOPN can be achieved using a minimal access endoscopic approach. Adjuvant percutaneous drainage is necessary in up to 40% of patients, especially when WOPN extends to paracolic gutters or pelvis. Operative intervention for failed endoscopic treatment is required in about 20% of patients.

Background: Deep cannulation of the common bile duct (CBD) in patients with native papillary anatomy can be used as a marker of competence at ERCP., Objective: The primary aim of this study was to analyze a single-operator learning curve for supervised ERCPs in patients with native papillary anatomy and to assess the development of endoscopic competence, defined as the ability to deeply cannulate the CBD in the setting > or =80% of the time. Posttraining outcomes were evaluated as proof of training., Design: A retrospective review: 1097 ERCP procedures were analyzed, 697 were performed during ERCP training (July 2002-July 2003), 400 were performed after training as an independent operator, 499 and 303 procedures for training and posttraining periods, respectively, were performed with the intent of deep cannulation of CBD in patients with native papillary anatomy. Procedures were chronologically grouped into subsets. Success rates were plotted against time., Setting: Single center., Main Outcome Measurements: Rate of successful deep biliary cannulation., Results: The successful cannulation rate increased from 43% at the beginning of training to > or =80% after 350 to 400 supervised procedures. The success rate continued to improve posttraining with an aggregated success rate of >96% for the next 300 procedures performed as an independent operator., Limitations: Single operator., Conclusions: Achievement of a satisfactory success rate for deep biliary cannulation in patients with native papillary anatomy should be tracked by ERCP trainers and trainees. The consistent achievement of > or =80% success at deep biliary cannulation in such patients should become a standard for ERCP training programs to produce skilled and competent therapeutic biliary endoscopists.

Purpose of Review: The current endoscopic palliative modalities for unresectable cholangiocarcinoma are reviewed, focusing on the emergent methods of endoscopic palliation., Recent Findings: Cholangiocarcinoma is a rare malignant tumor arising from biliary epithelium. Endoscopic retrograde cholangiopancreaticography can provide histological diagnosis through brush cytology of the bile duct, and newer cytologic techniques such as digital image analysis and fluorescent in-situ hybridization may improve the cytologic accuracy for diagnosing cholangiocarcinoma. Endoscopic ultrasonography can play an adjunctive role in the diagnosis and staging by facilitating tissue acquisition through fine needle aspiration of the tumor and surrounding lymph nodes. Most patients present with unresectable disease and features of biliary obstruction. This has led to an emphasis on the role of palliative care. Biliary stent placement is an effective method of palliating obstructive jaundice. Newer modalities such as photodynamic therapy, intraluminal brachytherapy, and high-intensity ultrasound therapy may result in improved survival and play a future role as an adjunctive therapy to surgical resection., Summary: Several endoscopic palliative modalities have recently emerged. Among these, photodynamic therapy in addition to biliary stent placement appears to be a promising step towards the management of locally unresectable cholangiocarcinoma. Randomized, controlled trials are required, however, to further evaluate these therapies.

Cholangiocarcinoma (CCA) is an uncommon malignant tumor arising from the biliary epithelium. The incidence increases with age and usually affects individuals in their 6th or 7th decade of life. Those patients with underlying risk factors such as primary sclerosing cholangitis (PSC) and choledochal cysts generally present 2 decades earlier. Most patients clinically present with painless jaundice; however, other common symptoms include pruritus, weight loss, and abdominal pain. Although surgical resection offers the only hope for cure, most patients are found to have unresectable disease on initial presentation and have an extremely grim prognosis. This has led to an emphasis on the role of palliative care, with relief of biliary obstruction, in the management of these patients. Surgical bypass was once the primary means of palliation of jaundice in patients with unresectable cholangiocarcinoma but in the last 2 decades has been superseded by less invasive and less morbid nonsurgical procedures such as endoscopic and percutaneous biliary stent placement. Newer modalities of palliation such as endoscopic delivery of photodynamic therapy and high-intensity ultrasound therapy are emerging nonsurgical modalities that may result in improved survival and may play a future role as an adjunctive therapy to surgical resection.

Background: Comparative outcomes after endoscopic drainage of specific types of symptomatic pancreatic fluid collections, defined by using standardized nomenclature, have not been described. This study sought to determine outcome differences after attempted endoscopic drainage of pancreatic fluid collections classified as pancreatic necrosis, acute pseudocyst, and chronic pseudocyst., Methods: Outcomes were retrospectively analyzed for consecutive patients with symptoms caused by pancreatic fluid collections referred for endoscopic transmural and/or transpapillary drainage., Results: Complete endoscopic resolution was achieved in 113 of 138 patients (82%). Resolution was significantly more frequent in patients with chronic pseudocysts (59/64, 92%) than acute pseudocysts (23/31, 74%, p = 0.02) or necrosis (31/43, 72%, p = 0.006). Complications were more common in patients with necrosis (16/43, 37%) than chronic (11/64, 17%, p = 0.02) or acute pseudocysts (6/31, 19%, p = NS). At a median follow-up of 2.1 years after successful endoscopic treatment (resolution), pancreatic fluid collections had recurred in 18 of 113 patients (16%). Recurrences developed more commonly in patients with necrosis (9/31, 29%) than acute pseudocysts (2/23, 9%, p = 0.07) or chronic pseudocysts (7/59, 12%, p = 0.047)., Conclusions: Successful resolution of pancreatic fluid collections may be achieved endoscopically by an experienced therapeutic endoscopist. Outcomes differ depending on the type of pancreatic fluid collection drained. Further studies of endoscopic drainage of pancreatic fluid collections must use defined terminology to allow meaningful comparisons.

Gastrointestinal diseases account for considerable health care use and expenditures. We estimated the annual burden, costs, and research funding associated with gastrointestinal, liver, and pancreatic diseases in the United States. We generated estimates using data from the National Ambulatory Medical Care Survey; National Hospital Ambulatory Medical Care Survey; Nationwide Emergency Department Sample; National Inpatient Sample; Kids' Inpatient Database; Nationwide Readmissions Database; Surveillance, Epidemiology, and End Results program; National Vital Statistics System; Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research; MarketScan Commercial Claims and Encounters data; MarketScan Medicare Supplemental data; United Network for Organ Sharing registry; Medical Expenditure Panel Survey; and National Institutes of Health (NIH). Gastrointestinal health care expenditures totaled $119.6 billion in 2018. Annually, there were more than 36.8 million ambulatory visits for gastrointestinal symptoms and 43.4 million ambulatory visits with a primary gastrointestinal diagnosis. Hospitalizations for a principal gastrointestinal diagnosis accounted for more than 3.8 million admissions, with 403,699 readmissions. A total of 22.2 million gastrointestinal endoscopies were performed, and 284,844 new gastrointestinal cancers were diagnosed. Gastrointestinal diseases and cancers caused 255,407 deaths. The NIH supported $3.1 billion (7.5% of the NIH budget) for gastrointestinal research in 2020. Gastrointestinal diseases are responsible for millions of health care encounters and hundreds of thousands of deaths that annually costs billions of dollars in the United States. To reduce the high burden of gastrointestinal diseases, focused clinical and public health efforts, supported by additional research funding, are warranted. [ABSTRACT FROM AUTHOR]

Background There is no standard nor widely accepted way of reporting outcomes of treatment of biliary injuries. This hinders comparison of results among approaches and among centers. This paper presents a proposal to standardize terminology and reporting of results of treating biliary injuries. Methods The proposal was developed by an international group of surgeons, biliary endoscopists and interventional radiologists. The method is based on the concept of “patency” and is similar to the approach used to create reporting standards for arteriovenous hemodialysis access. Results The group considered definitions and gradings under the following headings: Definition of Patency, Definition of Index Treatment Periods, Grading of Severity of Biliary Injury, Grading of Patency, Metrics, Comparison of Surgical to Non Surgical Treatments and Presentation of Case Series. Conclusions A standard procedure for reporting outcomes of treating biliary injuries has been produced. It is applicable to presenting results of treatment by surgery, endoscopy, and interventional radiology. [ABSTRACT FROM AUTHOR]

Gastric outlet obstruction (GOO) is typically caused by intrinsic or extrinsic obstruction of the pyloric channel or duodenum. Surgical approaches to bypassing the obstruction have been the mainstay of therapy, though recent developments in endoscopy have allowed for a minimally invasive approach to managing GOO. The development of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) represents a major advancement in the management of GOO. EUS-GE involves placement of a covered self-expandable metal stent into either the third or fourth portion of the duodenum to create a gastroduodenostomy or into the jejunum to create a gastrojejunostomy. In this review, we will discuss the different approaches to EUS-GE and the indications for each approach including direct EUS-GE, EUS-guided balloon-occluded GE, assisted EUS-GE, and contrast-enhanced EUS-GE. [ABSTRACT FROM AUTHOR]

Background and study aims: Nonstricture benign biliary diseases (BBDs) such as leaks, perforations, and bleeding, have been traditionally managed by placement of one or more plastic stents. Emerging data support the use of covered, self-expandable, metal stents (CSEMSs). The aim of this study was to assess the outcomes of endoscopic temporary placement of CSEMS in patients with nonstricture BBD. Patients and methods: This was a retrospective study of CSEMS placement for BBD between May 2005 and August 2013 at two tertiary care centers. The main outcomemeasureswere resolution of perforation, bleeding, leak, and adverse events related to CSEMS treatment. Results: A total of 87 patients were included (median age 62 years [range 18-86]). Indications for stent placement were bile leaks (n=35, 40%), bleeding (n=27, 31%), perforation (n=18, 21%), and other conditions (n=7, 8%). Fully and partially covered 8-10-mm diameter CSEMS were placed and subsequently removed in all 87 patients (100 %). Resolution of the underlying problem was achieved for 33 bile leaks (94 %), 25 bleedings (93 %), 18 perforations (100%), and for 3 cases with other indications (43 %). The median duration of stenting was 9 weeks in patients with biliary leaks, 3 weeks for bleeding, and 9.5 weeks for perforations. Median follow-up was 82 weeks after stent removal. Seven adverse events occurred, including cholangitis in six patients (7 %), and tissue hyperplasia leading to difficulty in the removal of a partially covered SEMS in one patient. Conclusions: Nonstricture BBD can be effectively and safely treated with the short term placement of CSEMS. [ABSTRACT FROM AUTHOR]

A large number of patients worldwide receive anticoagulant and antiplatelet agents, collectively known as antithrombotic agents. Several new anticoagulants and antiplatelet agents recently were approved for use. Gastroenterologists may be unfamiliar with the mechanism of action, indications for use, and pharmacokinetics of these newer drugs. In patients undergoing elective and urgent endoscopic procedures, clinicians must be familiar with these medications to optimize outcomes. When the decision is made to continue the newer antithrombotic agents for elective procedures, the clinician must understand the risk that these agents may impart on procedural-induced bleeding. Finally, it is important to understand how to manage these agents in the presence of acute gastrointestinal bleeding. In this article the use of newer antithrombotic agents is reviewed. [Copyright &y& Elsevier]

Background and Aims: Traditional endoscopic management of benign biliary strictures (BBS) consists of placement of one or more plastic stents. Emerging data support the use of covered self-expandable metal stents (CSEMS). We sought to assess outcome of endoscopic temporary placement of CSEMS in patients with BBS. Methods: This was a retrospective study of CSEMS placement for BBS between May 2005 and July 2012 from two tertiary care centers. A total of 145 patients (81 males, median age 59 years) with BBS were identified; 73 of which were classified as extrinsic and were caused by chronic pancreatitis, and 70 were intrinsic. Main outcome measures were resolution of stricture and adverse events (AEs) due to self-expandable metal stents (SEMS)-related therapy. Results: Fully covered and partially covered 8-10 mm diameter SEMS were placed and subsequently removed in 121/125 (97 %) attempts in BBS (failure to remove four partially covered stents). Stricture resolution occurred in 83/125 (66 %) patients after a median stent duration of 26 weeks (median follow-up 90 weeks). Resolution of extrinsic strictures was significantly lower compared to intrinsic strictures (31/65, 48 % vs. 52/60, 87 %, p = 0.004) despite longer median stent duration (30 vs. 20 weeks). Thirty-seven AEs occurred in 25 patients (17 %), with 12 developing multiple AEs including cholangitis ( n = 17), pancreatitis ( n = 5), proximal stent migration ( n = 3), cholecystitis ( n = 2), pain requiring SEMS removal and/or hospitalization ( n = 3), inability to remove ( n = 4), and new stricture formation ( n = 3). Conclusions: Benign biliary strictures can be effectively treated with CSEMS. Successful resolution of biliary strictures due to extrinsic disease is seen significantly less often than those due to intrinsic disease. Removal is successful in all patients with fully covered SEMS. [ABSTRACT FROM AUTHOR]

Technological advances in ERCP have appeared to plateau. Nonetheless, specific areas within ERCP were well represented at this year's Digestive Disease Week (DDW). These areas are subdivided and discussed in detail. As expected, there remains concern about prevention of post-ERCP pancreatitis (PEP). Although pharmacologic therapy by using nonsteroidal anti-inflammatory drugs (NSAIDs) has clearly emerged as an alternative and/or adjunct to pancreatic duct (PD) stents, stents seem to remain the mainstay in the endoscopists' armamentarium for the prevention of PEP. Other topics covered included the use of cholangioscopy, diagnosis of biliary strictures, and treatment of strictures by using stents and radiofrequency ablation. [ABSTRACT FROM AUTHOR]

Background: Up to 15% to 30% of patients develop pancreatic fluid collections (PFCs) after pancreatic tail resection. Percutaneous and endoscopic methods have been used to drain these collections, though few data are available that compare outcomes of these modalities. Study Design: From December 1998 to April 2011, we identified all patients who underwent pancreatic tail resection and developed PFCs requiring intervention. The primary aim was to compare overall success rates in resolution of PFCs using endoscopic and percutaneous modalities. Success rates, hospital length of stay, number of CT scans, sinograms and endoscopies performed, and days with drain(s) in place were compared. Results: Forty-eight patients were identified. Percutaneous drainage was performed a median of 25 days postoperatively, compared with 85 days for endoscopic drainage (p < 0.001). Endoscopic and percutaneous methods had similar rates of technical success (100% vs 97%, p = 0.50) and treatment success (80% vs 81%, p = 0.92), respectively. Recurrence rates were 16.6% for the endoscopic group and 23% for the percutaneous group (p = 0.65), and adverse events occurred in 9.4% of those treated endoscopically vs 13.3% of those treated percutaneously (p = 0.68). Location and characteristics of PFCs did not influence success rates. Recurrences were often treated by “salvage” drainage via the other modality. Median hospital stay was longer after primary percutaneous drainage compared with primary endoscopic drainage (5.5 days vs 2 days, p = 0.046). Primary percutaneous drainage patients also had more CT scans (median 3 vs 2, p = 0.03). Conclusions: Endoscopic drainage and percutaneous drainage appear to be equally effective and complementary interventions for PFCs occurring after pancreatic tail resection. Primary endoscopic drainage may be associated with shorter hospital stay and fewer CT scans. [ABSTRACT FROM AUTHOR]

Abstract: After selective deep ductal cannulation, mastering different sphincterotomy techniques is a fundamental skill for the safe and effective practice of endoscopic retrograde cholangiopancreatography. In this review, we will discuss the indications, techniques, challenges, alternatives, and adverse events of endoscopic sphincterotomy, with a special focus on techniques. [Copyright &y& Elsevier]

Malignant biliary obstruction results in jaundice, often with symptoms that decrease the quality of life. Biliary stent placement has largely supplanted surgical bypass for palliation of malignant biliary obstruction. Traditional rigid plastic stents are commonly used, inexpensive and easily removed, although with limited duration of stent patency. Self-expandable metal stents (SEMS) attain larger luminal diameters and provide longer patency than traditional rigid plastic stents in patients with distal bile duct obstruction. SEMS are composed of a variety of metals and can be uncoated, partially covered, or fully covered. Data do not support a prolongation of patency with covered SEMS for distal obstruction, although they have the potential for removability. The data to support SEMS for palliation of hilar biliary obstruction are not as convincing and reintervention for stent occlusion can be difficult. In this article, the design and performance of expandable metal stents for treatment of malignant biliary obstruction will be reviewed. INSETS: Common causes of malignant obstructive jaundice.;Bismuth and Corlette classification.;Key issues. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe the outcome of patients undergoing flexible endoscopic therapy for symptomatic Zenker diverticulum. PATIENTS AND METHODS: We retrospectively evaluated the outcome of 22 consecutive patients who underwent flexible endoscopic cricopharyngeal myotomy using needle-knife electrocautery performed by a single endoscopist from March 2006 through January 2010. RESULTS: Of the 22 patients with symptomatic Zenker diverticulum, 13 were men and 9 were women (median age, 84.5 years). Moderate sedation was used in all but 3 (14%) of the patients. Postprocedural free air occurred in 6 patients (27%) and resolved uneventfully in all. Another patient developed a neck abscess 1 week after endoscopic treatment, which was surgically drained. All procedures were performed on an outpatient basis, although 8 patients (36%) required subsequent hospitalization. The mean (SD) length of stay in the hospital was 2.9 (1.64) days. All patients had initial symptomatic improvement, and 18 (82%) maintained improvement at a mean (SD) follow-up of 12.7 (9.2) months. CONCLUSION: Flexible endoscopic cricopharyngeal myotomy is an effective treatment of symptomatic Zenker diverticulum, with low recurrence rates and with the benefit of no general anesthesia and hospitalization In most cases. Esophageal perforation is the most common procedural complication. [ABSTRACT FROM AUTHOR]

OBJECTIVES:In patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for postcholecystectomy bile leak there is limited evidence to support the repeat ERCP at the time of stent removal. Esophagogastroduodenoscopy (EGD) with biliary stent removal may suffice. The aim of this study was to describe the clinical course of patients who underwent biliary stent placement for a postcholecystectomy bile leak and determine whether repeat ERCP is necessary.METHODS:We identified all adult patients who underwent biliary stent placement for postcholecystectomy bile leak from 1 January 1996 to 31 October 2008. Demographic data, cholecystectomy details, and procedural data were collected, specifically focusing on closure of the bile leak. Time to resolution of leak was calculated, up to either the date of the first repeat ERCP that demonstrated no persistent leak or the date of removal of any radiologically placed percutaneous drain, whichever came first.RESULTS:Sixty-four patients underwent repeat ERCP with biliary stent removal. The median time to repeat ERCP was 36 days (interquartile range (IQR) 26–48). Fifty-seven (89%) patients had resolved the leak by time of repeat ERCP. Of those in whom the leak had not resolved, 6 had a repeat exam within 14 days of stent placement; 4 of these resolved the leak by day 39. There were no procedure-related complications in the ERCP group. Thirteen patients underwent EGD with stent removal after a median of 29 days (IQR 23–38). None had adverse events, with a median follow-up of 38 months. Overall, the median time to resolution of biliary leak was 33 days (IQR 22–44). Importantly, repeat ERCP altered the management in only one patient in whom bile duct stones were found.CONCLUSIONS:Patients with uncomplicated postcholecystectomy bile leak who have clinically resolved their leak do not require cholangiography at the time of stent removal. In these patients, EGD with stent removal at 4–6 weeks seems to be sufficient and significantly less expensive. [ABSTRACT FROM AUTHOR]

Commentary: There now are a wide variety of self-expandable metal stents (SEMS) available to the endoscopist for treatment of biliary obstruction. Furthermore, there is increasing availability of stents with different designs and configurations; stents that are fully covered, uncovered, or partially covered; and several methods of stent deployment. Also, the clinical indications for use of SEMS are expanding to potentially include benign biliary tract disease as well as preoperative usage in potentially resectable malignant disease. In this Clinical Update, Dr Todd H. Baron reviews this topic, focusing on comparative clinical outcome studies of metal vs plastic stents for treatment of biliary obstruction. In addition, Dr Baron discusses possible complications of SEMS and how to manage them. – Richard C. K. Wong, MD, FASGE, Editor University Hospitals Case Medical Center, Cleveland, OH [Copyright &y& Elsevier]

An electrosurgery generator unit is a critical piece of equipment in any therapeutic endoscopy setting. Electrosurgery generators produce high-frequency alternating electric current and differ from electrocautery units in that both cutting and coagulation effects can be achieved. This ability to cut and coagulate at the same time makes electrosurgery an ideal therapeutic tool for gastrointestinal endoscopy. Although education and familiarity with these devices are accepted as the primary avenue to the safest and most effective clinical outcomes, concise information linking the basic properties of electrosurgery directly to clinical practice is not widespread. The following are the aims of this article: (i) to relate the fundamental electrosurgical principles to commonly performed procedures such as snare polypectomy, hot biopsy, sphincterotomy, bipolar hemostasis, and argon plasma coagulation, and (ii) to provide practical suggestions for the use of these devices on the basis of an understanding of electrosurgical principles and the available clinical data.Am J Gastroenterol 2009; 104:1563–1574; doi:10.1038/ajg.2009.105; published online 21 April 2009 [ABSTRACT FROM AUTHOR]

We report the successful closure of fistulae at the site of a benign colocolonic anastomotic stricture using self-expandable metal stents (SEMS). The stricture and fistulae developed after sigmoid colon resection for diverticulitis. After closure of the fistulae with a covered stent and resolution of inflammation, 10 months later the patient elected to undergo one-stage resection of the diseased colon and stent. Although there have been previously reported cases of SEMS for closure of malignant colonic fistula, there are limited reports of SEMS for closure of benign colonic fistulae and none demonstrate long-term success. We conclude that this patient exemplifies the potential applications of SEMS as definitive therapy for benign colorectal disease. [ABSTRACT FROM AUTHOR]

Endoscopic biliary sphincterotomy (ES) is the cornerstone of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Bleeding is one of the most frequent complications following ES. Rates of post-ES bleeding vary widely and its presentation may be immediate (intraprocedural) or several days later. Clinically, bleeding can range from insignificant to life threatening. Most bleeding episodes are managed successfully by conservative measures with or without endoscopic therapy. Endoscopic treatment options include injection, thermal, and mechanical methods—alone or in combination. For refractory cases, angiographic embolization, or surgery, is necessary. Both technical risk factors and patient risk factors contribute to the development of post-ES bleeding. When these risk factors are present, measures can be taken to reduce the risk of bleeding. In this manuscript the literature on post-ES bleeding is reviewed. [ABSTRACT FROM AUTHOR]

A 69-year-old man presented with obstructive jaundice. Endoscopic retrograde cholangiopancreatography was performed for biliary tree decompression and diagnostic tissue acquisition. Techniques, indications, methodologic considerations, and interpretation of tissue sampling at endoscopic retrograde cholangiopancreatography in patients with biliary/pancreatic strictures are discussed. This case-based educational presentation focuses on the importance of interdisciplinary communication between endoscopists and pathologists for optimal tissue sampling, interpretation, and diagnostic accuracy. [Copyright &y& Elsevier]

OBJECTIVE: The purpose is to provide initial validation of a novel simulation model's fidelity and ability to assess competence in colonoscopy skills. METHODS: In a prospective, cross-sectional design, each of 39 endoscopists (13 staff, 13 second year fellows, and 13 novices) performed a colonoscopy on a novel bovine simulation model. Staff endoscopists also completed a survey examining different aspects of the model's realism as compared to human colonoscopy. The groups' simulation performances were compared. Additionally, individual performances were correlated to patient-based performance data. RESULTS: Median model realism evaluation scores were favorable for nearly all parameters evaluated with mucosa appearance, endoscopic view, and paradoxical motion parameters receiving the highest scores. During simulation procedures, each group outperformed the less experienced groups in all parameters evaluated. Specifically, median cecal intubation times were: staff 226 s (IQR [interquartile range] 179–273), fellows 340 s (282–568), and novices 1,027 s (970–1,122) ( P < 0.05). Median total procedure times on the model were: staff 468 s (416–501), fellows 527 s (459–824), and novices 1,350 s (1,318–1,428) ( P < 0.05). Finally, individual cecal intubation times on the simulation model had a very high correlation to their respective patient-based times (r = 0.764). CONCLUSIONS: Overall, this model possesses a favorable degree of realism and is able to easily differentiate users based on their level of colonoscopy experience. More impressive, however, is the strong correlation between individual's simulated intubation times and actual patient-based colonoscopy data. In light of these findings, we speculate that this model has potential to be an effective tool for assessment of colonoscopic competence. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Traditionally, biliary brachytherapy sources are placed percutaneously via transhepatic drains or endoscopically via nasobiliary tubes (NBT). Another ERCP is needed for stent replacement after NBT removal. The aim of this study was to determine the feasibility and safety of endoscopic transpapillary insertion of irradiation sources through 10-Fr stents. METHODS: Medical records of Mayo Clinic Rochester patients undergoing biliary brachytherapy for hilar cholangiocarcinoma (CCA) were reviewed. Patients were part of a treatment protocol with curative intent including external beam radiation therapy (4,500 cGy), radiation sensitization (5-FU), and low dose rate (LDR) brachytherapy (<3,000 cGy) followed by liver transplantation. The 10-Fr biliary stent placed across the malignant biliary stricture was directly cannulated using a radiopaque 192Ir embedded ribbon within a 300-cm long, 5.1-Fr plastic sheath. After withdrawal of the endoscope, the external end of the brachytherapy catheter was rerouted transnasally and secured. Each patient was hospitalized in a shielded room up to 24 h after which the brachytherapy catheter was removed by hand. RESULTS: Between 1999 and 2004, 32 patients underwent biliary brachytherapy via endoscopically placed 10-Fr plastic stents (mean age 50.6 yr, 69% PSC, bilateral brachytherapy catheters 28.1%). The technical complication observed was immediate brachytherapy catheter displacement (7 of 32, 22%) managed by prompt brachytherapy catheter repositioning. CONCLUSION: LDR biliary brachytherapy administration via endoscopically placed biliary stents is technically feasible and appears reasonably safe in select patients with unresectable perihilar CCA. Unlike NBTs, stents can potentially be placed in bilateral ductal systems to accommodate dual brachytherapy catheters when indicated. [ABSTRACT FROM AUTHOR]

The article provides information about the quality indicators that are particular to endoscopic retrograde cholangiopancreatography (ERCP). Preprocedural quality indicators of ERCP include appropriate indication, assessment of procedural difficulty and informed consent. Intraprocedural quality indicators begins with the administration of sedation and ends with the removal of the endoscope. Postprocedural quality indicators of ERCP include the detachment of the endoscope to patient dismissal.

Polyp snares and needle knives are invaluable tools for the performance of therapeutic endoscopy. Endoscopic scissors, though uncommonly used, are useful in very selected circumstances. Colonic polypectomy is one of the most commonly performed therapeutic endoscopic procedures. Needle knives are used most commonly for biliary cannulation, but are adaptable to a range of therapeutic interventions. [Copyright &y& Elsevier]

BACKGROUND: Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ. OBJECTIVE: To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution. METHODS: Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed. RESULTS: Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics ( 23 ) or persistent site pain ( 14 ). CONCLUSIONS: DPEJ was associated with a moderate or severe complication in ∼10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved. [ABSTRACT FROM AUTHOR]