New Technique for Magnetic Compression Anastomosis Without Incision for Gastrointestinal Obstruction

BACKGROUND

Magnetic compression anastomosis (MCA) is a novel technique of anastomosis similar to that with surgery, but in a minimally invasive manner. Few reports are available on the utility and feasibility of MCA for gastrointestinal anastomosis without requiring general anesthesia in humans, owing to the difficulty of delivering magnets. We evaluated the safety, efficacy, and feasibility of MCA in gastrointestinal obstruction without requiring general anesthesia.

STUDY DESIGN

In this retrospective single-center study, patients who underwent MCA from January 2013 to October 2019 were included. Adult patients with gastrointestinal obstruction or stenosis, irrespective of the underlying disease, with severe comorbidities, complicated abdominal surgical history, or postoperative complications, and who were unable to tolerate surgery, were eligible for inclusion. Two magnets were delivered by a combination of endoscopic and fluoroscopic procedures and placed in the lumen of the organ to be anastomosed. The main outcome was the technical success of MCA.

RESULTS

Fourteen patients underwent MCA, and the technical success of MCA was achieved in 100% of the cases. The mean procedural time, duration for anastomosis formation, and postoperative hospital stay were 44 minutes, 13 days, and 36 days, respectively. Two patients underwent anastomotic restenosis, and 1 patient had an anastomotic perforation due to balloon dilatation to prevent restenosis. The mean follow-up period was 34 months.

CONCLUSIONS

MCA without general anesthesia for gastrointestinal anastomosis is safe, useful, and feasible. MCA can be a valuable alternative to surgery in gastrointestinal obstruction.

Acute Gastric Hemorrhage due to Gastric Cancer Eroding Into a Splenic Artery Pseudoaneurysm: Two Dangerously Rare Etiologies of Upper Gastrointestinal Bleeding

Splenic artery pseudoaneurysms (SAPs) are rare causes of upper gastrointestinal bleeding (UGIB), with less than 250 reported cases in the literature. The highest incidence of SAPs is in patients with a history of acute or chronic pancreatitis or splenic artery trauma. SAP in the setting of gastric malignancy is an exceedingly rare finding. We present the unusual hospital course of an 82-year-old male with advanced gastric cancer presenting with UGIB secondary to a visceral communication between his known gastric malignancy and a SAP.

Gastric cancer

Gastric cancer is the fifth most common cancer and the third most common cause of cancer death globally. Risk factors for the condition include Helicobacter pylori infection, age, high salt intake, and diets low in fruit and vegetables. Gastric cancer is diagnosed histologically after endoscopic biopsy and staged using CT, endoscopic ultrasound, PET, and laparoscopy. It is a molecularly and phenotypically highly heterogeneous disease. The main treatment for early gastric cancer is endoscopic resection. Non-early operable gastric cancer is treated with surgery, which should include D2 lymphadenectomy (including lymph node stations in the perigastric mesentery and along the celiac arterial branches). Perioperative or adjuvant chemotherapy improves survival in patients with stage 1B or higher cancers. Advanced gastric cancer is treated with sequential lines of chemotherapy, starting with a platinum and fluoropyrimidine doublet in the first line; median survival is less than 1 year. Targeted therapies licensed to treat gastric cancer include trastuzumab (HER2-positive patients first line), ramucirumab (anti-angiogenic second line), and nivolumab or pembrolizumab (anti-PD-1 third line).

Magnetic compression anastomosis is effective in treating stenosis after esophageal cancer surgery: a case report

BACKGROUND

Esophagostomy is important in the treatment of esophageal cancer. However, esophagectomy has a higher risk of postoperative complications. Treatment for complications is often difficult, and in some cases, oral intake is no longer possible. Recently, magnetic compression anastomosis (MCA) was developed; it is a relatively safe method of anastomosis that does not require surgery in patients with stricture, obstruction, or dehiscence of the anastomosis after surgery.

CASE PRESENTATION

The patient was a 76-year-old Japanese man. He underwent esophagectomy with a three-field dissection for esophageal cancer. A cervical esophagostomy and chest drainage were performed for necrosis of the gastric tube. Following infection control, colon interposition was performed. However, after the operation, the colon necrotized and formed an abscess. Drainage controlled the infection, but the colon was completely obstructed. The patient was referred to our hospital to restore oral ingestion. Contrast studies showed that the length of the occlusion was 10 mm. The reconstruction was examined; reanastomosis by surgery was judged to be a high risk, so the strategy of anastomosis by MCA was adopted. In the operation, the anterior chest was opened to expose the colon, and a magnet was inserted directly into the blind end of the colon. The magnet was guided to the blind end of the esophagus using an oral endoscope. Two weeks after MCA, a contrast study confirmed the passage of the contrast agent from the esophagus to the colon. The patient eventually took 18 bougies after the MCA. However, since then, he has not needed a bougie. As of 1 year and 8 months after the MCA, the patient is living at home with oral intake restored.

CONCLUSIONS

MCA is an effective and safe treatment for complete stenosis after esophageal cancer surgery.

Magnetic compression anastomosis for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction: a case report

BACKGROUND

Postoperative non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction is a rare complication. If endoscopic balloon dilation proves ineffective, patients need re-operation under general anesthesia and experience a high rate of postoperative complications. Magnetic compression anastomosis is a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. We report a case in which magnetic compression anastomosis was successfully performed to avoid re-operation for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction.

CASE PRESENTATION

A 70-year-old woman was admitted to our hospital for treatment of non-anastomotic stenosis of the proximal jejunum. Open total gastrectomy and Roux-en-Y reconstruction were performed 2 years previously for advanced gastric cancer at another hospital. She complained of anorexia and obstructed passage of food. No recurrence of gastric cancer was identified. Esophagogastroduodenoscopy showed circumferential membranous stenosis of the jejunum 3 cm distal to the esophago-jejunal anastomosis. Endoscopic balloon dilation was performed three times, but proved ineffective. Magnetic compression anastomosis was planned because the stenosis existed near the esophago-jejunal anastomosis and re-operation was a highly invasive procedure requiring intrathoracic anastomosis. Endoscopic balloon dilation preceded placement of the parent magnet on the anal side of the stenosis. Confirming the improvement of stenosis, the parent magnet was placed on the anal side of the stenosis during esophagogastroduodenoscopy. The parent magnet attached to nylon thread was fixed to the cheek to prevent magnet migration. A week after placing the parent magnet, restenosis was confirmed and the daughter magnet was placed via nylon thread on the oral side of the stenosis. The two magnets were adsorbed in the end-to-end direction across the stenosis. Magnets adsorbed in the end-to-end direction moved to the anal side 11 days after placement. Wide anastomosis was confirmed by esophagogastroduodenoscopy. Endoscopic balloon dilation was regularly performed to prevent restenosis after magnetic compression anastomosis. No complications were observed postoperatively. The patient was able to eat normally and successfully reintegrated into society.

CONCLUSIONS

Magnetic compression anastomosis could be a feasible procedure to avoid surgery for non-anastomotic stenosis of the proximal jejunum after gastrectomy with Roux-en-Y reconstruction.

Filling of Polyglycolic Acid Sheets for Closure of Gastrointestinal Fistulas With an Easily Deliverable Technique Using a Guidewire

BACKGROUND

This retrospective study aimed to investigate the suitable indications, methodology and long-term effect of the closure of gastrointestinal (GI) fistulas using polyglycolic acid (PGA) sheets and fibrin glue (FG) and to evaluate the usefulness of a delivery technique using a guidewire.

METHODS

It involved 10 applications in six patients (median age 73 (range 53 - 78) years old, three men) with GI fistulas. A guidewire was introduced endoscopically or percutaneously into the fistula beyond the opposite orifice of the fistula with radiologic control. A tapered catheter was inserted over the guidewire, and the fistula was cleaned with an adequate quantity of saline. Subsequently, a small piece of PGA sheet was skewered onto the guidewire at the center and then pushed using the tapered catheter over the guidewire and delivered into the fistula. In cases of endoscopic procedure, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG.

RESULTS

Technical success of fistula closure was achieved in all applications, and no complications were observed after the procedure. The long-term occlusion of the fistula was ultimately achieved in four of six patients at 202 - 654 days (median duration, 244 days) after the last procedure with one or two applications.

CONCLUSIONS

The closure of GI fistulas using PGA sheets and FG demonstrated long-term efficacy for upper GI fistula of a certain length, and the filling technique using a guidewire ensured a safe smooth procedure.

Endoscopic Gastrojejunostomy for Superior Mesenteric Artery Syndrome Using Magnetic Compression Anastomosis

An 89-year-old woman who was bedridden suffered repeated vomiting due to superior mesenteric artery syndrome (SMAS). We performed gastrojejunostomy via the magnetic compression anastomosis (MCA) technique because her situation was not improved by conservative therapy and because the operative risk was high. We prepared two neodymium magnets: a flat plate-shaped magnet (15 × 3 mm) and a ring-shaped magnet of the same size. The ring-shaped magnet which passed through a guidewire was pushed to the duodenum by an endoscope over the guidewire. The duodenal stricture was balloon-dilated in front of the magnet, and the magnet was pushed all together beyond the stricture and placed at the duodenojejunal junction. Subsequently, the flat plate-shaped magnet was delivered endoscopically to the stomach using a biopsy forceps. The magnets were attracted towards each other transmurally after one more flat plate-shaped magnet was added to the gastric-side magnet. Completion of gastrojejunostomy was confirmed while retrieving the magnets 10 days after starting compression. She has been asymptomatic for 1 month since anastomosis. Endoscopic gastrojejunostomy using MCA was an effective, low-invasive treatment for SMAS.

Experience of Endoscopic Jejunojejunostomy for Anastomotic Obstruction After Subtotal Gastrectomy Using Magnetic Compression Anastomosis

Magnetic compression anastomosis (MCA) was developed as a low-invasive treatment for gastro-enteric or entero-enteric obstruction. A 72-year-old man underwent subtotal gastrectomy with Billroth II reconstruction for early gastric cancer. After the operation, he suffered from repeated aspiration pneumonia due to anastomotic obstruction caused by jejunal kinking at the efferent loop of anastomosis. We therefore performed jejunojejunostomy via the MCA technique, as his situation was not improved despite conservative therapy and he had a high reoperative risk. We prepared two flat plate-shaped neodymium magnets (15 × 3 mm) each with a small hole, and a nylon thread was passed through each hole. Each magnet was then delivered endoscopically to the anal side of the jejunal kinking, subsequently to the anastomosis, using biopsy forceps. The two magnets immediately became attracted towards each other transmurally. Oozing hemorrhage with clot at the mated magnets was observed 10 days after starting the compression. After retrieving the magnets, we confirmed the completion of jejunojejunostomy and then successfully achieved hemostasis of the anastomotic hemorrhage using argon plasma coagulation. The widely patent anastomosis was confirmed endoscopically 1 month after canalization; and he has been asymptomatic and able to eat a normal diet ever since. Endoscopic MCA is an effective, low-invasive treatment for anastomotic obstruction after subtotal gastrectomy. A standardized, safer procedure should be established for general use in the clinical setting.

Defect repair with fibrin glue/polyglycolic acid after endoscopic laryngopharyngeal cancer resection

OBJECTIVES/HYPOTHESIS

In 2013, we introduced a modified technique for mucosal/muscle layer defect coverage with fibrin glue and polyglycolic acid (PGA) sheets (mMCFP technique) in patients undergoing endoscopic transoral surgeries for laryngopharyngeal cancers. This technique allows easy and convenient coverage of the wound surface, even when it involves the laryngopharyngeal lumen. To our knowledge, use of the MCFP technique for coverage of postoperative mucosal and/or muscle layer defects involving the laryngopharyngeal lumen has not been reported. The aim of the present study was to retrospectively evaluate the safety of our mMCFP technique used simultaneously with endoscopic transoral resection of Tis, T1, T2, and select T3 pharyngeal and supraglottic cancers.

STUDY DESIGN

A single centre retrospective study.

METHODS

Between June 2013 and February 2019, 102 patients underwent simultaneous end-flexible-rigidscopic transoral surgery and wound coverage using our mMCFP technique. All patients required mucosal and/or muscle layer resection. For all patients, we recorded the incidence of postoperative complications and the time period for which the PGA sheets could be observed after surgery.

RESULTS

In 41%, 35%, and 8% patients, the PGA sheets could be observed on the wound surface for 2, 3, and 4 weeks, respectively. Other than postoperative bleeding in two patients (2%), no postoperative complications were recorded.

CONCLUSIONS

The findings of this study suggest that our mMCFP technique is a safe and simple method for the repair of mucosal and/or muscle layer defects after endoscopic transoral surgery for laryngopharyngeal cancers.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1740-1745, 2020.

Endoscopic shielding using oxidized regenerated cellulose after argon plasma coagulation under mandatory dual antiplatelet therapy

Endoscopic shielding is an innovative concept in therapeutic endoscopy. Its usage has been mostly restricted to wide‐field endoscopic mucosal resection and/or endoscopic submucosal dissection. A novel potential clinical use may be in bleeding pophylaxis for argon plasma coagulation‐related ulcers under concomitant mandatory dual antiplatelet therapy.

Endoscopic management of tracheoesophageal fistulas

Tracheoesophageal fistulas (TEF) are pathologic communications between the trachea and esophagus. TEF can lead to significant respiratory distress that may result in lethal respiratory compromise, often due to recurrent and intractable infections. Through the use of endoscopy, some TEF can be successfully repaired using different approaches depending on the size, location, availability, and experience of the treating endoscopist. The aim of this manuscript is to provide an up-to-date review of the endoscopic management of TEF for gastroenterologists.