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Introduction Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition. Objective To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach. Methods A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined. Results Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 − 41 months). Conclusion Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

OBJECTIVE To compare procedure burden, oncologic, surgical and renal-function outcomes between patients with low-grade upper urothelial cancer (UTUC) who were referred for either radical management (RM) or kidney-sparing endoscopic management (EM). PATIENTS AND METHODS We retrospectively reviewed data of all patients treated for UTUC at our tertiary medical center between 2000 and 2018 and selected patients diagnosed with unilateral low-grade UTUC. RESULTS Twenty-four patients were treated with EM and 37 with RM. Surgical and oncologic risk factors were similar between the arms except for tumor size. Mean follow-up was 4.9 ± 3.4 years. The 5-year overall-survival rate was 85% with EM and 84% with RM (P = .707). Metastasis-free and cancer-specific survival were also similar (P = .994, P = .960). End-of-follow-up average glomerular filtration rates were 58.7 ± 21.5 and 49.2 ± 22.1 mL/min/1.73 m2, respectively (P = .12). Ninety-two percent of patients managed endoscopically had local recurrences, with an average of 3.2 recurrences per patient. Four (17%) patients underwent salvage radical nephroureterectomy. Procedure burden was higher with EM, having 6.5 ± 4.4 operations and 344 ± 272 minutes under anesthesia compared with 1.9 ± 0.4 operations (P

Laparoscopic sleeve gastrectomy (LSG) has become a standalone primary procedure as a bariatric metabolic surgery since the early 2000s. The overall complication rate of LSG is reported to range from 2% to 15%. Staple line leakage (SLL) remains a major adverse event and occurs in approximately 1–6% of patients. Choosing the optimal treatment modality is a complex process. Clinicians must understand that nutritional support and drainage of fluid collection are essential for initial management. Conservative endoscopic management and sufficient drainage can resolve approximately 70% of SLLs. Endoscopic management of bariatric complications has been rapidly evolving in recent years and can be considered in all patients who are hemodynamically stable. We will review the available endoscopic management techniques, including stent placement (self-expanding stents and bariatric-specific stents), clipping, tissue sealant application, and internal drainage (double-pigtail stents [DPS] placement, endoscopic vacuum therapy, and septotomy). Stent placement remains the mainstream treatment for SLLs. However, healing with stents requires multiple sessions/stents and a long course of recovery. Endoscopic internal drainage is gaining popularity and has the potential to be a superior method. The importance of early intervention and combined endoscopic methods should be recognized.

AIM Conventional surgical management of colovesical and colovaginal fistulas can be morbid and is contraindicated in many patients. Our aim in this work is to evaluate our experience in the management of colovesical and colovaginal fistulas with endoscopic over-the-scope (OTS) clips. METHOD A retrospective review of all patients who underwent attempted endoscopic OTS clip management of colovesical and colovaginal fistulas between 2013 and 2020 was performed. Preoperative risk factors, operative details and postoperative outcomes are reported. RESULTS Ten patients were identified. Fistula types were: colovesical (five), rectovesical (two), colovaginal (two) and rectovaginal (one). The aetiology of the fistula was diverticular disease in seven (70%) cases and surgical complication of pelvic surgery in three (30%). The mean defect age was 157 ± 98 days, the mean defect diameter was 4.5 mm (range 2-10 mm) and the mean fistula length was 15 mm (range 2-25 mm). In nine (90%) cases, fistula identification and cannulation were performed through the nonenteric lumen of the fistula. Initial management with an OTS clip was technically successful in eight (80%) patients. Of the eight patients who underwent OTS clip placement, long-term success (mean follow-up 218 days, range 25-673 days) was achieved after initial intervention in four (50%) patients. One patient underwent serial OTS clip procedures and achieved long-term success after four interventions; three patients have not undergone a repeat procedure after initial failure. CONCLUSION Endoscopic management of colovesical and colovaginal fistulas with OTS clips offers a promising therapeutic option for patients with contraindications to conventional surgical management. Immediate technical success and long-term success rates are similar to other gastrointestinal tract applications of OTS clips.

BACKGROUND There is no consensus on the optimal drainage technique in the management of biliary anastomotic strictures occurring after right-lobe living-donor liver transplantation (RL LDLT). AIMS To investigate whether there is a superiority between unilateral and bilateral drainage groups in terms of efficacy and safety of biliary drainage in RL LDLT patients undergoing double-biliary reconstruction. STUDY DESIGN Retrospective Cohort Methods: Between January 2009 and August 2019, 1693 patients underwent RL LDLT. Of these, 182 patients who developed biliary anastomotic strictures out of the 306 patients who had double-biliary reconstruction, were included in the study. One hundred fifty-five patients with technical success were divided into 2 groups as unilateral (n=116) and bilateral (n=39) drainage groups. The groups were compared in terms of variable parameters such as clinical success, additional procedure, post-ERCP complication, procedures after clinical failure, hospital stay, mortality, and survival. RESULTS The clinical success was higher in the bilateral group (70% vs. 82%, P = .201). In the initial and the follow-up periods, a total of 44 (38%) patients in the unilateral group were switched to the bilateral drainage group due to the increased need for stenting. The placement of a stent successfully solved the problem only in 28% (32/117) of the patients in the unilateral group, while this rate was 44% (17/39) in the bilateral group. The median follow-up time of both groups was 42 months, and was equal. The number of stent-free follow-up patients in the unilateral drainage group was less than that in the bilateral drainage group (4 and 7, respectively). CONCLUSION An active attempt should be made for bilateral drainage in patients with biliary anastomotic stricture following RL LDLT. However, for patients in whom bilateral drainage is not possible, unilateral drainage may be recommended, with the placement of a maximum number of stents following primary biliary balloon dilatation, depending on the degree of stricture.

To demonstrate our experience in treating pyriform fossa sinus tracts (PFST) using a novel technique of endoscopic cauterisation of the pyriform fossa sinus opening combined with injection of sodium carboxymethylcellulose gel (VoiceGel) lateral to the tract to encourage tight closure.Over a 48-month period, we used this technique on 11 patients who were diagnosed with PFST at BC Children's Hospital, a tertiary paediatric centre in Vancouver, BC, Canada.The 11 patients included 8 males and 3 females, and mean age at presentation was 69 months (range 22-108 months). Mean time from beginning of symptoms till diagnosis was 15 months (range 12-22 months). Ten PFST were on the left side of the neck and one on the right. Nine patients presented with recurrent neck infections and two had suppurative thyroiditis. All patients had endoscopic cauterisation of their PFST opening combined with injection of carboxymethylcellulose lateral to the sinus tract to cause tract collapse. Mean follow up was 15.8 months (range 8-24). All patients are asymptomatic without recurrence at the last follow-up visit. No post-operative complications were reported.Endoscopic management of paediatric PFST combined with the injection of sodium carboxymethylcellulose gel lateral to the sinus tract appears to be a safe and effective treatment option for PFST.Trattamento delle fistole congenite del seno piriforme mediante cauterizzazione endoscopica e iniezione di Voicegel.Descrivere la nostra esperienza nel trattamento delle fistole congenite del seno piriforme (PFST) utilizzando una nuova tecnica di cauterizzazione endoscopica del seno piriforme ed iniezione di gel di sodio carbossimetilcellulosa (VoiceGel) per favorire la chiusura del tramite.Per un periodo di 48 mesi, abbiamo utilizzato questa tecnica su undici bambini a cui è stata diagnosticata la PFST al BC Children’s Hospital, un centro pediatrico terziario di Vancouver, BC, Canada.Il gruppo di bambini includeva 8 maschi e 3 femmine, l’età media era di 69 mesi (range 22-108 mesi). Il tempo medio dall’inizio dei sintomi fino alla diagnosi è stato di 15 mesi (range 12-22 mesi). Dieci PFST erano sul lato sinistro del collo e uno a destra. 9 pazienti soffrivano di infezioni ricorrenti del collo e due avevano tiroidite suppurativa. Tutti i pazienti sono stati trattati mediante cauterizzazione endoscopica ed iniezione di carbossimetilcellulosa per cicatrizzare il tratto fistoloso. Il follow-up medio è stato di 15,8 mesi (range 8-24). Tutti i pazienti sono asintomatici, senza recidive al follow-up. Non sono state riportate complicanze postoperatorie.Il trattamento endoscopico della PFST pediatrica combinata con l’iniezione di gel di carbossimetilcellulosa di sodio sembra essere un’opzione terapeutica sicura ed efficace per le PFST.

Summary. Purpose. To optimize the tactics of endoscopic interventions for cholelithiasis complicated by obstruction of the terminal portion of the common bile duct to reduce the incidence of postoperative complications and mortality in elderly and senile people. Materials and methods. The results of examination and treatment of 221 elderly and senile patients with cholelithiasis complicated by obstruction of the terminal section of the common bile duct were analyzed. Results. Using of existing methods and proposed new methods of endoscopic management of cholelithiasis complicated by obstruction of the terminal section of the common bile duct allow to reliably reduce the incidence of postoperative complications in elderly and senile patients from 19.8 to 9.5%, postoperative mortality from 10.3 to 2.9% Conclusions. In elderly and senile patients with obstruction of the terminal section of the common bile duct and common bile duct stones who bear high operational risk, endoscopic papillosphincterotomy with stone removal is a sufficient method of treatment. In case of unremovable common bile duct stones, endoscopic papillosphincterotomy and stenting allow to avoid revision of the common bile duct, and in high-risk patients those methods allow to refrain from open surgery.

Objetivos: mostrar la eficacia y seguridad de los stents metálicos autoexpandibles para el manejo endoscópico de las fístulas esofágicas. Materiales y métodos: se evalúo una serie de casos de manera retrospectiva entre el 2007 y el 2017, en los que se manejaron a 11 pacientes con un stent metálico autoexpandible para el manejo de fístula esofágica, en quienes se realizó el diagnóstico por clínica, endoscopia digestiva alta o estudios radiológicos en la unidad de gastroenterología del Hospital Universitario San Ignacio (HUSI) de Bogotá D. C., Colombia. Resultados: el principal síntoma inicial fue la disnea en 27,3 % de los casos, seguido por tos en un 18,2 %. El hallazgo más frecuentemente encontrado durante el seguimiento fue el derrame pleural en el 36,4 %, se realizó el diagnóstico de fístula en el 45,5 % con esofagograma y el tipo de lesión más reportada fue la fuga en la anastomosis esofagoentérica, con un 45,5 %, seguida de la esofagopleural, con un 36,4 %; y estos pacientes fueron manejados con un stent metálico autoexpandible. En el 100 % hubo éxito técnico y la resolución del defecto se evidenció en el 72,7 % de los casos. La única complicación reportada fue el desplazamiento del stent en el 27,3 %, y en un paciente se requirió el cambio del stent en 3 oportunidades. El promedio de estancia hospitalaria fue de 41,5 días. Conclusiones: el manejo endoscópico de las fístulas esofagogástricas con stents metálicos autoexpandibles es efectivo y seguro, con una baja tasa de complicaciones.

Introduction An isolated calyx is a rare complication in which the renal calyx and pelvis are disconnected. The treatment is often complicated. Case presentation An 81‐year‐old man underwent robot‐assisted partial nephrectomy for the treatment of renal cell carcinoma (cT1bN0M0). Postoperatively, urine leakage was observed and did not improve with conservative measures. Retrograde pyelography and computed tomography revealed that urine leakage originated from the isolated calyx caused by infundibular stenosis. Endoscopic treatment via the transurethral approach was selected to preserve renal function. Ureteroscopy showed that the upper calyx was completely obstructed by the sutures. Therefore, we cut the suture thread using laser, and a ureteral stent was placed in the upper renal calyx. Fluid drainage immediately disappeared after the procedure, and the patient did not lose renal function. Conclusion Endoscopic management might be an option for isolated calyx after robot‐assisted partial nephrectomy.

OBJECTIVES Although lumen-apposing metal stents (LAMS) are being increasingly used in lieu of plastic stents, the clinical approach to endoscopic management of pancreatic fluid collections (PFCs) is poorly standardized. We compared outcomes of approaches over two time intervals, initially using plastic stents and later integrating LAMS. METHODS This was a retrospective, observational, before-after study of prospectively collected data on consecutive patients with symptomatic PFCs managed over two time periods. In the initial period (January 2010-January 2015) endoscopic treatment was undertaken with plastic stents and in the later period (February 2015-August 2020) by integration of LAMS with selective use of plastic stents. The treatment strategy in both periods were tailored to size, extent, type of PFC and stepwise response to intervention. The main outcome was treatment success, defined as resolution of PFC and presenting symptoms at 6-month follow-up. RESULTS A total of 160 patients were treated with plastic stents and 227 patients were treated using an integrated LAMS approach. Treatment success was significantly higher for the integrated approach compared to using only plastic stents (95.6 vs. 89.4%; P = 0.018), which was confirmed to be predictive of treatment success on multivariable logistic regression analysis (odds ratio 2.7, 95% confidence interval 1.1-6.4; P = 0.028). CONCLUSIONS A structured approach integrating LAMS with selective use of plastic stents improved treatment success in patients with PFCs compared to an approach using only plastic stents.

Laryngotracheal malformations are rare and potentially life-threatening conditions caused by the abnormal development of the airway during embryogenesis. They can occur isolated or can be associated with other congenital anomalies. The aim of this report is to evaluate the possibilities offered by endoscopic surgery in the management of these complex pathologies. We describe two cases of severe laryngotracheal malformations that were endoscopically treated along with the use of laryngotracheal stents at the tertiary referral center of Vicenza. Clinical presentation, associated malformations, therapeutic strategy, surgical techniques, complications, and results are reported, along with a review of the literature. The children that were managed are now 10.5 and 9.5 years old and have been permanently decannulated. They have normal psychophysical development and are able to breathe and swallow without any issues. Furthermore, no changes to vocal development have been observed. The management of congenital laryngeal stenosis, particularly if associated with other complex malformations, remains a challenging issue. The goal of treatment should be early restoration of the airways by adopting devices and solutions that have minimal restrictions on functional and psychophysical development of the child. In order to achieve these objectives, endoscopic airway surgery and the use of laryngotracheal stents have proven to be safe and effective.

Background/Aims: STRETTA improves the quality of life and reduces the need for anti-reflux medication in select patients, especially those with uncomplicated gastroesophageal reflux disease (GERD). We aimed to review the outcomes of STRETTA in patients with medically refractory GERD, who had undergone previous gastric surgery.Methods: This was a review of a prospective database in a British center. Since 2016, all GERD patients who underwent STRETTA and had a history of previous gastric surgery were studied (n=11). Anti-reflux medication pre- and post-STRETTA was evaluated. The outcomes were assessed objectively by the change in anti-reflux medication and subjectively through a pre- and post-procedure GERD-health-related quality of life (HRQL) questionnaire.Results: The median length of follow-up was 23 months. Nine patients demonstrated improved GERD-HRQL scores following STRETTA (82%). Of the 7 patients who underwent fundoplication, all reported improved symptoms, with 3 patients discontinuing the medication and 3 patients on a reduced dose of proton pump inhibitor. Four patients underwent surgery other than fundoplication, of which 2 reported improvement and discontinued the proton pump inhibitor. Two patients reported no improvement.Conclusions: This study demonstrates that STRETTA is successful in reducing refractory GERD in patients with previous gastric surgery. The outcomes were comparable to published outcomes in patients with uncomplicated GERD with no previous history of gastric surgery.

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.

BACKGROUND AND AIMS: Endoscopic management of large main pancreatic ductal (MPD) stones often require treatment with lithotripsy. Extracorporeal shock wave lithotripsy (ESWL) has been the mainstay therapy, and single-operator pancreatoscopy with intraductal (intracorporeal) lithotripsy (SOPIL) is an emerging technique. However, no comparative studies between these techniques exist. We therefore aimed to compare ESWL to SOPIL for the treatment of large MPD stones. METHODS: This is a retrospective cohort study comparing patients who were treated with ESWL or SOPIL from September 2013 to September 2019 at a single tertiary center. Logistic regression was performed to identify factors associated with technical success and efficient stone clearance (≤ 2 procedures to clear stones). RESULTS: There were 240 patients who were treated with ESWL and 18 treated with SOPIL. The overall technical success rate of stone clearance was 224/258 (86.8%), which was similar between the ESWL and SOPIL groups (86.7% vs 88.9%, p = 1.000). A SOPIL approach required fewer total procedures (1.6 ± 0.6 vs 3.1 ± 1.5, p < 0.001) and less aggregate procedure time (101.6 ± 68.2 vs 191.8 ± 111.6 min, p = 0.001). Adverse event rates were similar between the groups (6.3% vs 5.6%, p = 1.000). The use of SOPIL was independently associated with greater efficiency compared to ESWL (OR 5.241 [1.348–20.369], p = 0.017). Stone size > 10 mm was associated with less efficient stone clearance (OR 0.484 [0.256–0.912], p = 0.025). CONCLUSION: Both ESWL and SOPIL are safe and effective endoscopic adjunct modalities for treating large pancreatic duct stones. SOPIL is an emerging alternative to ESWL that is potentially more efficient for lithotripsy and MPD stone clearance.

To explore the novel treatment of small gastric submucosal tumors (SMTs) originating from the muscularis propria layer (SMT-MPs), we utilized endoscopic band ligation (EBL) with a precut of the covering mucosa.From Jan. 2012 to Dec. 2019, 111 patients with 124 gastric SMT-MPs were treated by precutting EBL. The clinical characteristics, operation duration, postoperative adverse events, and follow-up profiles were retrospectively collected.A total of 124 tumors from 111 patients were successfully treated by precutting EBL. No adverse events, including perforation and major bleeding, were observed. Furthermore, 93 patients (83.8%) underwent endoscopic surveillance postoperatively, and during the follow-up period, no local recurrence was detected.Precutting EBL appears to be a safe and simple method for removing gastric SMT-MPs16 mm (mainly indicated for potentially malignant GISTs), but further studies with longer follow-up are needed to assess the radicality of this intervention.

Background and Aims Zenker’s diverticulum (ZD) has traditionally been treated with open surgery or rigid endoscopy. With the advances in endoscopy, alternative flexible endoscopic treatments have been developed. Methods This document reviews current endoscopic techniques and devices used to treat ZD. Results The endoscopic techniques may be categorized as the traditional flexible endoscopic septal division and the more recent submucosal tunneling endoscopic septum division, also known as peroral endoscopic myotomy for ZD. This document also addresses clinical outcomes, safety, and financial considerations. Conclusions Flexible endoscopic approaches treat symptomatic ZD with results that are favorable compared with traditional open surgical or rigid endoscopic alternatives.

Background: Endoscopic management of lumbar disc herniation as a minimally invasive procedure become more popular around the world. Although accepted surgical outcomes of the endoscopic approach to manage lumbar disc herniation [LDH], this procedure still to be relatively challenging and needs a high learning curve, so operative failures and complications may occur. The Aim of The Work: To assess using the endoscope in the management of lumbar disc prolapse by interlaminar approach using Easy Go and Destandau systems. Patients and Methods: This is study included twenty patients, who had lumbar disc herniation, and operated by using Easy Go and Destandau's endoscopic systems after the failure of conservative treatment. They were included between March 2016 and April 2020. They followed up for at least three months postoperatively. All were selected from the Neurosurgery Department, Al-Azhar University Hospitals, Egypt. Results: Low back pain was the main complaint reported by all patients. The radicular side was mainly the left side [70.0%] and L4/L5 was the most common affected level [65.0%]; the disc protrusion was mainly paracentral [80.0%]. There was a significant pain reduction after surgery when compared to before surgery. The outcome was excellent for 55.0%, good for 25%, fair for 15% and poor for 5%. Complications were in the form of unintended durotomy among 10.0%, nerve injury among 10.0% and infection among 5.0%. Conclusion: Endoscopic lumbar discectomy through interlaminar approach by Destandau's and Easy Go systems become a golden procedure to manage lumbar disc prolapse at any level especially L5-S1 as a minimally invasive technique with some accepted complications that can easily be managed compared to classic traditional open techniques.

Introduction Endoscopic management of Zenker diverticuli (ZD) has traditionally been via septotomy technique. The recent development of tunneling technique has shown to be both efficacious and safe. The aim of this study is to evaluate the tunneling technique using per oral endoscopic myotomy (Z-POEM) versus septotomy. Methods Patients who underwent endoscopic management of ZD either by Z-POEM or septotomy from March 2017 until November 2020 from 9 international academic centers were included. Demographics, clinical data preprocedure and postprocedure, procedure time, adverse events, and hospital length of stay were analyzed. Results A total of 101 patients (mean age 74.9 y old, 55.4% male) were included: septotomy (n=49), Z-POEM (n=52). Preprocedure Functional Oral Intake Scale score and Eckardt score was 5.3 and 5.4 for the septotomy group and 5.9 and 5.15 for the Z-POEM group. Technical success was achieved in 98% of the Z-POEM group and 100% of the septotomy group. Clinical success was achieved in 84% and 92% in the septotomy versus Z-POEM groups. Adverse events occurred in 30.6% (n=15) in septotomy group versus 9.6% (n=5) in the Z-POEM group (P=0.017). Reintervention for ongoing symptoms occurred in 7 patients in the septotomy group and 3 patients in the Z-POEM group. Mean hospital length of stay was shorter for the Z-POEM group, at 1.5 versus 1.9 days. Conclusions A tunneling technique via the Z-POEM procedure is an efficacious and safe endoscopic treatment for ZD. Z-POEM is a safer procedure with a statistically significant reduction in adverse events compared with traditional septotomy technique.

PURPOSE OF REVIEW Posterior urethral obstruction (PUO) from prostate surgery for benign and malignant conditions poses a significant reconstructive challenge. Endoscopic management demonstrates only modest success and often definitive reconstructive solutions are necessary to limit morbidity and firmly establish posterior urethral continuity. This often demands a combined abdominoperineal approach, pubic bone resection, and even sacrifice of the external urinary sphincter and anterior urethral blood supply. Recently, a robotic-assisted approach has been described. Enhanced instrument dexterity, magnified visualization, and adjunctive measures to assess tissue quality may enable the reconstructive surgeon to engage posterior strictures deep within the confines of the narrow male pelvis and optimize functional outcomes. The purpose of this review is to review the literature regarding endoscopic, open, and robotic management outcomes for the treatment of PUO, and provide an updated treatment algorithm based upon location and complexity of the stricture. RECENT FINDINGS Contingent upon etiology, small case series suggest that robotic bladder neck reconstruction has durable reconstructive outcomes with acceptable rates of incontinence in carefully selected patients. SUMMARY Initial reports suggest that robotic bladder neck reconstruction for recalcitrant PUO may offer novel reconstructive solutions and durable function outcomes in select patients.

Objective To analyze the outcomes of the endoscopic transcanal approach for removal of early stage middle ear paraganglioma tumors (MEPT). Study design Cases series with chart review. Setting Two tertiary Australian Otology centers. Patients Adult patients with middle ear paraganglioma tumors treated with transcanal endoscopic approach from 2/2016 to 12/2019. Tumor staging was described using the Modified Fisch-Mattox (MFM). Inclusion criteria included patients with an MFM Class A or B. Exclusion criteria included higher staged or syndromic disease. Intervention All tumors were managed with transcanal endoscopic approach. Main outcome measures Primary outcome measures included disease clearance and hearing measured according to the AAO-HNS guidelines. Secondary outcomes included complications, duration of surgery, and length of stay. Results Ten patients underwent totally endoscopic transcanal resection of MEPT (9 female, mean age of 45.5 years, 70% were left sided). Mean tumor size was 6.1 mm (SD 3.4 mm). Five cases (50%) were classified using the MFM system as class A1, two cases were class A2, and three cases were class B1. Three cases required canalplasty for access but were completed entirely endoscopically. Nine of the 10 cases had complete audiometric data. Pre- and postoperative mean air conduction remained stable with a decrease in mean air-bone gap of 2.84 dB. Postoperative complications include one pinhole perforation. There were no facial nerve complications. Mean follow-up period was 10 months (range 4-25 mo) with all cases having resolution of pulsatile tinnitus and no tumor recurrence. Conclusion The transcanal endoscopic approach for early stage MEPT offers excellent visualization and permits safe and effective removal of disease with the advantages of a minimally invasive technique for patient recovery.

Background and Aims Buried bumper syndrome (BBS) is a rare adverse event of percutaneous endoscopic gastrostomy (PEG) placement in which the internal bumper migrates through the stomal tract to become embedded within the gastric wall. Excessive tension between the internal and external bumpers, causing ischemic necrosis of the gastric wall, is believed to be the main etiologic factor. Several techniques for endoscopic management of BBS have been described using off-label devices. The Flamingo set is a novel, sphincterotome-like device specifically designed for BBS management. We aimed to evaluate the effectiveness of the Flamingo device in a large, homogeneous cohort of patients with BBS. Methods A guidewire was inserted through the external access of the PEG tube into the gastric lumen. The Flamingo device was then introduced into the stomach over the guidewire. This dedicated tool can be flexed by 180 degrees, exposing a sphincterotome-like cutting wire, which is used to incise the overgrown tissue until the PEG bumper is exposed. A retrospective, international, multicenter cohort study was conducted on 54 patients between December 2016 and February 2019. Results The buried bumper was successfully removed in 53 of 55 procedures (96.4%). The median time for the endoscopic removal of the buried bumper was 22 minutes (range, 5-60). Periprocedural endoscopic adverse events occurred in 7 procedures (12.7%) and were successfully managed endoscopically. A median follow-up of 150 days (range, 33-593) was performed in 29 patients (52.7%), during which no significant adverse events occurred. Conclusions Through our experience, we found this dedicated novel device to be safe, quick, and effective for minimally invasive, endoscopic management of BBS.

Gastroesophageal reflux disease (GERD) occurs in up to 20% of the population. Effective management of the condition is essential to reduce both symptoms and the risk for dysplastic changes of esophageal mucosa. Although lifestyle and diet modification and proton-pump inhibitors (PPIs) remain the standard of therapy, approximately 30% of patients experience persistent or recurrent symptoms with this therapy, which has been labeled PPI-refractory GERD. Surgical antireflux procedures have long been the standard therapy for PPI-refractory GERD, but drawbacks include cost and surgical morbidity. Endoscopic techniques for GERD management have been developed over the past 20 years including transoral incisionless fundoplication, the Stretta procedure, and antireflux mucosectomy. This article will review the current literature on each of these endoscopic procedures as well as highlight areas where further research is needed to fully understand the best practices for use of these endoscopic techniques for the management of PPI-refractory GERD.

Gastroparesis is a complex pathology that continues to evolve in its diagnosis and treatment. Throughout the years, we have gained a more thorough understanding of normal and pathologic physiology of the stomach, which has allowed us to garner different approaches to the treatment of gastroparesis. We aim to evaluate the current literature regarding diagnosis and treatment of gastroparesis with a specific focus on the endoscopic management of this pathology.

Despite initial weight loss following bariatric surgery, weight recidivism is common. While weight regain is multifactorial and includes behavioral, psychosocial, and medical causes, changes in anatomy also play a role. Dilation of the gastrojejunal anastomosis following Roux-en-Y gastric bypass and enlargement of the gastric sleeve following sleeve gastrectomy are both important considerations. Historically, surgical revision has been performed to address weight regain; however, morbidity and mortality are not insignificant. Over the past decade, a variety of endoscopic approaches have been described for weight recidivism, several of which have proven to be safe, effective, and durable. This article will review each of these techniques in detail.

Enterocutaneous fistulae (ECFs), abnormal epithelialized connections between the small bowel and skin, are associated with significant morbidity, and pose a unique challenge to patients and clinicians. Management of ECF requires sepsis control, effluent management, nutritional support, and local wound care. Traditionally, surgical intervention was required for ECF that failed to close with conservative management. With the rise of therapeutic endoscopy, new management strategies have emerged. Fluoroscopy-guided endoscopy is now used to delineate anatomy and determine potential therapy options. Definitive endoscopic management may involve through-the-scope and over-the-scope clips, or endoscopic suturing devices. Adjuncts to definitive management include removing foreign bodies, alleviating distal obstructions, and de-epithelializing fistula tracts. Even if an ECF is not amenable to definitive endoscopic therapy, endoscopy may help temporize and optimize a patient preoperatively. Endoscopy allows for the placement and repositioning of drains, stent placement to allow for diversion or improved wound care, and the placement of enteric feeding access. As endoscopic techniques expand and more tools become available, the ability to manage complex problems, such as ECF, endoscopically will grow.

BACKGROUND: Endoscopic management of duodenal subepithelial lesions is challenging, and there are only a few studies on this topic. This study aimed to evaluate the safety and efficacy of endoscopic resection for the treatment of duodenal subepithelial lesions. METHODS: We retrospectively analyzed the clinical data, including epidemiologic characteristics, therapeutic outcomes, complications, and follow-up results, of 49 patients with duodenal subepithelial lesions who underwent endoscopic resection at our hospital between August 2010 and September 2019. RESULTS: We performed 35 endoscopic submucosal dissection, 9 endoscopic mucosal resection, 3 endoscopic submucosal excavation, and 2 endoscopic full-thickness resection. The en bloc resection rate and R0 resection rate were 95.9% and 89.8%, respectively. Delayed perforations developed in 2 (4.1%) patients; surgical intervention was required for both. Coagulation syndrome developed in 1 (2.0%) patient; however, it was treated conservatively. Delayed bleeding or other serious complications did not occur. One patient underwent complementary surgery after endoscopic resection. One (2.3%) recurrence occurred in patients who underwent endoscopic resection at a median follow-up duration of 24 months (range, 1–88 months). CONCLUSIONS: Endoscopic resection is an effective, safe, and minimally invasive method for the histopathologic assessment and curative treatment of duodenal subepithelial lesions originating from the submucosal or muscularis propria.

Kidney transplantation represents the gold standard treatment option for patients with end-stage renal disease. Improvements in surgical technique and pharmacologic treatment have continuously prolonged allograft survival in recent years. However, urological complications are frequently observed, leading to both postoperative morbidity and putative deterioration of allograft function. While open redo surgery in these patients is often accompanied by elevated surgical risk, endoscopic management of urological complications is an alternative, minimal-invasive option. In the present article, we reviewed the literature on relevant urological postoperative complications after kidney transplantation and describe preventive approaches during the pre-transplantation assessment and their management using minimal-invasive approaches.

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed endoscopic procedures and a first-line treatment for the establishment of enteral access in those with intolerance or contraindication to oral feedings. A small amount of pneumoperitoneum in the immediate postprocedure period is well reported after PEG tube placement. However, pneumoperitoneum resulting from displaced gastric bumper within 24 hours postprocedure is uncommon and rarely reported in the literature. Timely diagnosis and early endoscopic management can help tackle such an unusual complication.

Background Dieulafoy arteriole is a lamina propria vessel that unlike the other arterioles is getting bigger and bending into the mucosa of the gastrointestinal tract. Such anatomic aberration is unusual cause for life threatening gastrointestinal bleeds. Case presentation Herein, we report a case of an elderly gentleman, who had massively bleeding Dieulafoy lesion and endoscopic hemostasis of the spurting Dieulafoy by the use of the over-the-scope clip (OVESCO, Tübingen, Germany) has been successfully undertaken. Conclusion The endoscopic management of Dieulafoy related bleeds can be enriched by the use of over-the-scope clip, OVESCO, technique.

Aims To describe the use of laser, endoscopic balloon dilatation with jet ventilation anaesthesia in the treatment of pregnant women with idiopathic subglottic stenosis. Materials and methods This is a case review of pregnant women with idiopathic subglottic stenosis, presenting to a tertiary referral centre with worsening breathlessness. Data were extracted from patient case notes. Results Four women underwent surgical management of subglottic stenosis in pregnancy. One patient required two procedures during the course of their pregnancy due to restenosis. All women had improvement in symptoms post-operatively and went on to deliver healthy babies at term. Conclusion Endoscopic balloon dilatation of idiopathic subglottic stenosis is a safe and viable treatment option in pregnancy and should be offered as first-line treatment in symptomatic women.

Congenital cholesteatoma is a rare, primarily pediatric disease that presents in otherwise healthy ears. Typically, this disease is found in a well-defined sac in the middle ear, making it particularly suited for removal through transcanal endoscopic ear surgery. This article reviews the ways in which endoscopy can be applied to the surgical management of congenital cholesteatoma and provides a guide based on congenital cholesteatoma stage and extent. Outcomes have shown similar rates of residual disease in total endoscopic ear surgery compared with operative microscopy.

Pediatric airway evaluation and surgery have evolved over time to involve less invasive techniques in order to facilitate quicker recovery and potentially less discomfort. Over the past decade, new indications, techniques, and data have emerged to support the use of these techniques routinely. In this article, we present techniques for evaluation and outcomes for endoscopic management of the pediatric larynx and review relevant recent publications relevant to pediatric endoscopic airway surgery. Laryngeal ultrasound has been shown to be an effective modality for evaluating vocal fold motion and potentially for evaluating laryngeal lesions. Innovations in surgical techniques include epiglottopexy for supraglottic obstruction, new airway balloons for dilating subglottic stenosis, and endoscopic cricoid split with or without a cartilage graft and vocal fold suture lateralization for bilateral vocal fold immobility. Less invasive techniques of diagnosis and management are viable options for pediatric airway patients and may replace or serve as adjuncts to traditional modalities.

The purpose of this study is to determine the effectiveness and safety of endoscopic management compared to ureterovesical reimplantation in pediatric patients with high-grade vesicoureteral reflux in terms of urinary tract infection. We performed a network meta-analysis. We searched in MEDLINE, EMBASE, LILACS, and CENTRAL. We included clinical experiments, quasi-experiments, and cohorts studies. The population was men and women between 1 month and 15 years old. Patients had primary high-grade VUR diagnosed by voiding cystourethrography. The interventions were subureteric bulking agent endoscopic injection (polytetrafluoroethylene, hyaluronic acid, collagen, Dx/Ha, and PPC) vs vesicoureteral reimplantation (Cohen, Politano-Leadbetter, Glenn-Anderson, and Lich-Gregoir), and the primary outcome was urinary infections. Nine studies accomplished the inclusion criteria (seven observational and two clinical experiments). A total of 1448 renal units underwent surgical treatments for the correction of high-grade VUR. Regarding the primary outcome, we compared Dx/Ha with Cohen, Lich-Gregoir, and PPC, finding an RD of −0.02 (95%CI −0.09 to 0.06), RD of −0.02 (95%CI −0.10 to 0.07), and an RD of −0.03 (− 0.13 to 0.07), respectively. Conclusion: Our study showed that there were no differences in UTI episodes after VUR correction in patients undergoing endoscopic management compared with vesicoureteral reimplantation.

Introduction: Paranasal sinuses mucoceles are benign, epithelial lined, mucus filled lesions, causing destruction of the adjacent sinus walls, and with further gradual extension to adjacent structures, serious morbidities and mortalities may occur. Objective: To emphasize on the efficacy of endonasal endoscopic marsupialization in the treatment of paranasal sinus mucoceles. Method: Retrospective descriptive study on paranasal sinus mucocele cases operated on endoscopically by the author (AAM), in the 10-year-period from to 2009-2019. Result: Total of 23 cases were included, 16 were males and 7 females, age ranging between 14 - 76 years, with a mean age of 45 years Location of mucoceles varied between: Frontal 7 cases (30%), Fronto-ethmoidal 6 cases (26%), Isolated Ethmoidal accounted for 3 cases (13%), sphenoidal 4 cases (17%), maxillary were 3 cases (13%) all of the 23 cases underwent endonasal endoscopic complete marsupialization, none of them required combination with external approach in-spite of different locations and complications, with no recurrence in a mean follow up period of 2.4 years. Conclusion: Endonasal endoscopic approach is a safe, efficient approach in the treatment of most paranasal sinus mucocele case in their different presentations and locations.

Introduction: Gastric varices are frequently seen in patients with portal hypertension. The mainstay of treatment is variceal injection with a mixture of N-butyl-2-Cyanoacrylate and lipiodol. The use of N-butyl-2-Cyanoacrylate without lipiodol is not extensively studied and it can be a cost-effective approach. The objective of our study was to evaluate whether the use of N-butyl-2-Cyanoacrylate without lipiodol is a safe and effective endoscopic treatment for gastric varices. Material and Methods: This prospective observational study was conducted between June 2016 and May 2017 at the Department of Gastroenterology, Gujranwala Medical College/ DHQ Teaching Hospital, Gujranwala. A total of 100 patients with gastric varices diagnosed on upper GI endoscopy were enrolled in the study. N-butyl-2-Cyanoacrylate without lipiodol was injected into the gastric varices of all the patients. All procedures were performed by experienced gastroenterologists. The patients underwent monthly follow-up endoscopies to determine the outcome and adverse events. Results: Out of 100 patients, 40 patients (40 %) were men and 60 (60%) were women. The mean age was 53 years. The mean volume of N-butyl-2-Cyanoacrylate used per session was 1.5ml ± 0.5 ml (range 1-2ml). Obliteration of Gastric varices was achieved in 92 patients (92%) while in 04 patients (4%) varices did not obliterate over a mean follow-up of 12 months. No treatment-related immediate or late complications were observed in all patients. Four patients (4%) died of delayed rebleeding (after two weeks of intervention). Conclusion: Injection therapy of gastric varices with N-butyl-2-Cyanoacrylate alone without lipiodol is a safe and cost-effective method for gastric varices.

Background Gastric variceal (GV) bleeding is among the most morbid sequelae of portal hypertension, with mortality ranging from 30% to 50%. Pediatric data focused on endoscopic approaches to management are needed. The present study represents the first pediatric case series of endoscopic ultrasound (EUS)-guided coil placement within feeding vessels as monotherapy for management of GV bleeding. Methods Using our prospectively maintained endoscopy database, we identified patients 18 years and younger who underwent EUS-guided coil placement for management of GV bleeding from 2008 to 2018. Demographics, indication, procedural interventions/findings, and available clinical outcomes data were analyzed. Results Twelve patients (median age 15, range 11-18 years) underwent EUS-guided coil placement for GV bleeding. All had portal hypertension, with EV in 58.3% and prior GV bleeding with attempted endoscopic management in 75%. Coil placement was accomplished using a linear echoendoscope and a 19-gauge needle. A mean of 2.75 (± 0.43) coils were placed in each patient (4, 6, 8, and 10 mm Nester Embolization Coils, Cook Medical, Bloomington, Indiana, USA). Immediate hemostasis was achieved in all patients, and 25% of patients developed recurrent gastric varices at a median of 5.5 months following the initial EUS-guided coil placement (range 4-6 months) over the median 12 month follow-up period. Conclusions The present study establishes the feasibility and efficacy of EUS-guided coil placement as monotherapy for GV bleeding in children and adolescents. The technique was technically successful, with primary hemostasis achieved in all patients. EUS-guided embolization with coils may represent an alternative to current approaches for management of highly morbid GV bleeding.

Pharyngoesophageal injury has high morbidity and mortality despite advances in diagnostics and surgical therapy. It is essential to rapidly identify patients injury to avoid severe sequelae. In this review, the common etiologies of penetrating esophageal injury will be reviewed as well as the initial evaluation and diagnostic techniques. Management of pharyngoesophageal injuries will be discussed including indications for observation, endoscopic management, or open surgical repair.

Laryngotracheal and pharyngoesophageal injuries are a relatively rare component of head and neck trauma; however, if not managed correctly, the consequences of these injuries can be life threatening. The early management of these injuries involves bedside endoscopic evaluation, often followed by formal endoscopy in the operating room. While many of these patients may require open surgical procedures, some of these injuries, and especially the long-term complications they cause, can be managed endoscopically. In this article, we will review various forms of endoscopic management of laryngotracheal and pharyngoesophageal injuries.

The aim of this study was to evaluate the endourologic management of post-cesarean section ureterovaginal fistula. Between February 2016 and March 2019, eight patients presented because of vaginal leakage after cesarean section. All presented within 15 days from their original operations. Three of the patients had a vague lower abdominal pain, and five had ipsilateral flank pain; all had vaginal leakage. Physical examination, ultrasonography, and IVP were done to confirm the diagnosis. Ureteroscopy was the first treatment attempt, using two or three guide wires to find the proximal part of the ureter and insert a JJ stent. In six patients, we could insert guide wires, find the proximal part of the ureter, and finally insert a JJ stent. In two patients, we could not even pass a guide wire, so we changed the position, and ureteral reimplantation was done. The stents were removed after 6 weeks, and after 3 months an IVP was planned again that showed all fistulae had resolved with no evidence of ureteral stricture. In cases of ureterovaginal fistula after cesarean section, ultrasonography and IVP with lateral view x-ray films may confirm the diagnosis. The traditional treatment for ureterovaginal fistula is ureteral reimplantation, but endoscopic management may be a viable technique with less invasiveness and faster results and recovery. Thus, retrograde stenting can be accomplished in selected patients with ureterovaginal fistula after cesarean section and may eliminate the need for reimplantation of the ureter.

ObjectiveLarge (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known.DesignConsecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods.ResultsA total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively.ConclusionsIn a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.