[Treatment of nonvariceal upper gastrointestinal bleeding: endoluminal-endovascular-surgical]

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (UGIB) has a high mortality. Hematemesis sometimes with melena are the leading clinical symptoms. Peptic ulcers and (erosive) inflammation are common, whereas Mallory-Weiss syndrome, neoplasms, angiodysplasia and diffuse UGIB are less common.

PROBLEM

A risk stratification is based on the medical history, clinical presentation and laboratory tests, which are considered in the Glasgow-Blatchford score; however, which treatment approach is optimal?

RESULTS

After stabilisation under restricted transfusion indications, temporary stoppage of anticoagulants and optimized coagulation is beneficial and proton pump inhibitors (PPI) should be started. Prokinetics improve the endoscopic conditions in UGIB. The use of an endoscopic Doppler probe optimizes localization of the bleeding site. The use of the Forrest classification and Helicobacter pylori diagnostics are recommended. Mechanical (clips, injection), thermal (argon plasma coagulation, APC) and topical (hemostatic powder) endoscopic treatment procedures are available. Endoluminal hemostasis is very effective. Only clip application is suitable as monotherapy whereas all other endoscopic options should be combined. Angiography followed by transarterial embolization (TAE) can be used for therapy. Despite the high primary success rate, the risk of rebleeding is high. Surgery as the primary treatment is rarely necessary, although effective. Compared to TAE complications are higher, but there is no difference regarding mortality.

CONCLUSION

Endoscopy remains the gold standard for the initial diagnostics and treatment of UGIB. In cases of rebleeding repeated endoscopy is recommended. With persistent UGIB an endovascular procedure should be evaluated. Surgery remains an important salvage option.

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.

CASE SUMMARY

A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.

CONCLUSION

APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.

Endoscopic Tunneled Stricturotomy with Full-Thickness Dissection in the Management of a Sleeve Gastrectomy Stenosis

INTRODUCTION

Laparoscopic sleeve gastrectomy is becoming the most commonly performed bariatric surgery. Despite clinical efficacy, adverse events have gradually increase due to its rapid adoption. Sleeve stenosis is the second most common adverse event, occurring in 0.7 to 4% of patients undergoing laparoscopic sleeve gastrectomy (LSG). Endoscopic management with pneumatic balloon dilation (PBD) or stent placement is commonly performed, with a success rate of up to 88%. Recently, Moura et al. (VideoGIE 4(2):68-71, 2018) described a new technique, named as endoscopic tunneled stricturotomy. In this video, we demonstrated the evolution of this technique including full-thickness dissection with staple line disruption.

METHODS

A 28-year-old woman with a BMI of 35.3 kg/m2 who underwent LSG, presented with dysphagia to solid food. An upper GI series showed a stenosis at the level of the incisura angularis. The patient was then referred for endoscopic evaluation.

RESULTS

She underwent three endoscopic PBD in an attempt to treat the stenosis. Unfortunately, her symptoms did not improve. After failed PBD treatment, an endoscopic tunneled stricturotomy with full-thickness dissection was performed. The procedure is performed in 6 steps: (1) identification of the stenosis, (2) submucosal injection 3-5 cm before the stenosis, (3) incision, (4) submucosal tunneling, (5) stricturotomy with full-thickness dissection, and (6) mucosal closure. During follow-up, the patient maintained a 1200-cal diet, without recurrence of symptoms.

CONCLUSION

Endoscopic tunneled stricturotomy with full-thickness dissection is feasible and appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure may be an option after conventional treatment failure or may be considered as a primary alternative.

Outcomes of a novel bariatric stent in the management of sleeve gastrectomy leaks: a multicenter study

BACKGROUND

The management of laparoscopic sleeve gastrectomy leaks remains a challenge. This can be treated with placement of self-expandable metal stents, which are most effective in the acute and early settings. However, migration is a frequent adverse event (AE). Novel, fully covered stents with a larger proximal flare to limit migration designed specifically to treat postsleeve leaks were recently introduced.

OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of a novel stent specifically designed for postsleeve leaks treatment.

SETTING

Multicenter retrospective study.

METHODS

This is a multicenter study, including patients with acute and early post laparoscopic sleeve gastrectomy leaks, treated with a large bariatric stent. The outcomes include technical success, clinical success, and safety profile. A multivariable regression was performed to assess predictors of success.

RESULTS

Thirty-seven patients were included (10 acute and 27 early leaks), with 30 stents in the postpyloric (POST) and 7 in the prepyloric position. Technical success was 100%. Mean stent dwell time was 29.08 days. Clinical success was achieved in 78.37%. Leak duration, leak size, and stent dwell time did not correlate with clinical success. During follow-up, 8 patients had stent migration (21.62%) and all were in a POST position. AE poststent removal were also evaluated (prepyloric: 57.14% vs POST: 33.3%, P = .45). There was no difference between prepyloric and POST position in the severe AE analysis.

CONCLUSIONS

This novel, large-caliber, fully covered stent specifically designed for sleeve leaks appears to be effective at treating acute and early leaks. However, the large flanges and long stent length do not appear to reduce migration rate and may be associated with higher overall severe AE rates. Avoiding placement in the POST position may help mitigate migration risk; however, owing to the risk profile this stent should be used with caution.

Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities.

METHODS

This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assisted ESD (RESD) in an ex vivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload.

RESULTS

Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P < .0001). The perforation rate was higher in the ESD group (60% vs 30%, P = .18). Total procedure time (34.1 vs 88.6 min, P = .001) and dissection time (27.8 vs 79.4 minutes, P = .002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P = .01).

CONCLUSIONS

RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads.

Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects

BACKGROUND

Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period.

METHODS

A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure.

RESULTS

We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5 months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention.

CONCLUSIONS

Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.

Fistula Recurrence: A Clinical Reality after Successful Endoscopic Closure of Laparoscopic Sleeve Gastrectomy Fistulas

Background and Aims

Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas.

Methods

This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence.

Results

The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4-145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1-10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15-72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50-205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence.

Conclusions

A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically.

Key Messages

Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically.

An Ancient Chinese Herbal Decoction Containing Angelicae Sinensis Radix, Astragali Radix, Jujuba Fructus, and Zingiberis Rhizoma Recens Stimulates the Browning Conversion of White Adipocyte in Cultured 3T3-L1 Cells

Background

Abnormal storage of white adipocyte tissue (WAT) is the major factor causing obesity. The promising strategies for obesity treatment are building up the brown adipocyte tissue (BAT) and/or expedite fatty acid catabolism. Traditional Chinese Medicine (TCM) sheds light on preventing obesity. Ginger is one of the most effective herbs for antiobesity by accelerating browning WAT. To fortify the antiobesity effect of ginger, an ancient Chinese herbal decoction composed of four herbs, Angelicae Sinensis Radix (ASR), Astragali Radix (AR), Jujuba Fructus (JF), and Zingiberis Rhizoma Recens (ZRR; ginger), was tested here: this herbal formula was written in AD 1155, named as Danggui Buxue Tang (DBT₁₁₅₅). Therefore, the antiobesity function of this ancient herbal decoction was revealed in vitro by cultured 3T3-L1 cells.

Materials and Method

The lipid accumulation was detected by Oil Red O staining. Furthermore, the underlying working mechanisms of antiobesity functions of DBT₁₁₅₅ were confirmed in 3T3-L1 cells by confocal microscopy, western blot, and RT-PCR.

Results

DBT₁₁₅₅ was able to actuate brown fat-specific gene activations, which included (i) expression of PPARγ, UCP1, and PCG1α and (ii) fatty acid oxidation genes, i.e., CPT1A and HSL. The increase of browning WAT, triggered by DBT₁₁₅₅, was possibly mediated by a Ca²⁺-AMPK signaling pathway, because the application of Ca²⁺ chelator, BAMPTA-AM, reversed the effect.

Conclusion

These findings suggested that the herbal mixture DBT₁₁₅₅ could potentiate the antiobesity functions of ginger, which might have potential therapeutic implications.

Bariatric surgery as a treatment for metabolic syndrome

Obesity is the pandemic of the 21st century. Obesity comorbidities, including hypertension, dyslipidaemia and glucose intolerance define metabolic syndrome, which increases mortality risk and decreases the quality of life. Compared with lifestyles (diet and physical activity) and pharmacological interventions, bariatric surgery is by far the most effective treatment for obesity and its comorbidities. This minimally invasive surgical treatment is based on an increase of satiety (by hormonal regulation and decreasing stomach volume) or a decrease in nutrient retention (gastric and/or intestinal resection). Bariatric surgery has widely demonstrated a beneficial effect on excess body weight loss, cardiovascular risk, dyslipidaemia, non-alcoholic fatty liver disease or glucose homeostasis, among other obesity-related metabolic diseases. This review describes current efforts for the implementation of bariatric surgery in metabolic syndrome, which are mainly focused on the formulation of key definition criteria for targeting the most suitable population for this therapeutic approach. Patients should undergo appropriate nutritional and psychological follow up in order to achieve and maintain weight loss milestones and a healthy metabolic status.

Spontaneous Gastrojejunal Fistulization after Roux-en-Y Bypass Surgery: A Case Report and Review of Literature

Fistula development is an uncommon but well-recognized complication following Roux-en-Y gastric bypass (RYGB). The broad spectrum of clinical presentation represents a challenge at the time of diagnosis. We present the case of a patient who developed gastrojejunal fistulization after gastric bypass surgery.

Efficacy and safety of endoscopic sleeve gastroplasty for obesity patients: a meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, effective, and safe technique for weight loss intervention. Since a relatively small number of cases were present in previous studies, this study aimed to elucidate the efficacy and safety of ESG.

METHODS

Relevant publications were identified through searching PubMed, EMBASE, Cochrane, and Web of Science before March 1, 2019. The percentage of total body weight loss (%TBWL), percentage of excess weight loss (%EWL), and the adverse event rate in each follow-up session were extracted, pooled, and analyzed. Forest plots were graphed based on random effects models.

RESULTS

A total of 1542 patients from nine studies were eligible for analysis. The pooled results of %TBWL at 1, 3, 6, and 12 months were 8.78% (p = 0.000), 11.85% (p = 0.000), 14.47% (p = 0.024), and 16.09% (p = 0.063), respectively. The pooled results of %EWL at 1, 3, 6, and 12 months were 31.16% (p = 0.000), 43.61% (p = 0.000), 53.14% (p = 0.000), and 59.08% (p = 0.015), respectively. Finally, the pooled rate of mild adverse events was 72% (p < 0.01), and the pooled estimate of severe adverse events was only 1% (p = 0.08).

CONCLUSION

Although the conventional surgical sleeve gastrectomy is the gold standard for bariatric surgery, ESG could be a promising minimally invasive alternative for treating obesity with satisfactory efficacy and low risk.

Disseminated metastatic cutaneous melanoma to pancreas and upper gastrointestinal tract diagnosed by endoscopic ultrasound: an unusual case

There is a wide variety of pancreatic neoplasms identified, but the great majority of them are of primary origin. Metastatic disease in the pancreatic parenchyma is quite rare (2-5% of pancreatic malignancies) and most often is quite difficult to differentiate from other primary lesions. Most of the imaging studies fail to give certain discriminating features for metastatic pancreatic neoplasms, contrary to endoscopic ultrasound and tissue sampling, which can provide an accurate diagnosis. In this report, we present a case of a male middle aged man who was admitted to our hospital with painless jaundice and finally was diagnosed with a cutaneous scalp melanoma dispersedly metastasized to the pancreas and upper gastrointestinal tract (stomach and duodenum).

Endoscopic resection of the pancreatic tail and subsequent wound healing mechanisms in a porcine model

BACKGROUND

Laparoscopic resection of the pancreatic body and tail is the predominant methodology to remove lesions in these locations; its safety and surgical planning are relatively mature, but it remains a complex and high-precision surgical operation, requiring abundant experience and skills in laparoscopic surgery, with a 10% rate of complications.

AIM

To verify the feasibility and safety, as well as to examine the complications of endoscopic pancreatectomy and healing mechanisms of pancreatic wounds after endoscopic resection.

METHODS

Transgastric endoscopic resections of varying sizes of pancreases were performed in 15 healthy Bama miniature pigs. The technical success rate, the incidence of serious complications, and the survival of the animals were studied. The healing of the wounds was evaluated by sacrificing the animals at various time points. Finally, the expression of transforming growth factor-β1 and Smad3/Smad7 in the surgical site was examined by immunohistochemistry to explore the role of these factors in wound healing of the pancreas.

RESULTS

Partial and total resections were successfully performed in two groups of animals, respectively. The technical success rate and the survival rate of the pigs were both 100%. We obtained 12 pancreatic tissue samples by endoscopic resection. The pancreatic wounds were closed with metal clips in one group and the wounds healed well by forming scars. There was a small amount of pancreatic leakage in the other group, but it can be fully encapsulated. The level of transforming growth factor-β1 (TGF-β1) in the wounds increased during the inflammatory and fibrous hyperplasia phases, and decreased in the scar phase. The expression of Smad3 paralleled that of TGF-β1, while the expression of Smad7 had an inverse relationship with the expression of TGF-β1.

CONCLUSION

Purely transgastric endoscopic resection of the pancreas is a safe, effective, and feasible procedure, but the incidence of pancreatic leakage in total pancreatic tail resection is high. The expression of TGF-β1 and Smad3/Samd7 is related to the progression of pancreatic wound healing.

Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient's quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

Modified-ESD Plus APC and Suturing for Treatment of Weight Regain After Gastric Bypass

BACKGROUND

Mechanisms for weight regain after gastric bypass are not fully understood and the process is likely multifactorial. The initial step in the management of weight regain is a comprehensive evaluation of contributing factors. While lifestyle modification is fundamental, it has limited efficacy which can be enhanced by medications and/or endoscopic revision. Anatomic changes such as larger pouch size and dilation of the gastrojejunal anastomosis (GJA) may contribute to increased postoperative weight gain. Endoluminal revisions offer an effective and less invasive management strategy for this population.

METHODS

A 55-year-old female with history of RYGB in 2006 presented with weight regain. She was referred to our unit for endoscopic evaluation.

RESULTS

During endoscopy, a large GJA (25 mm in diameter) was diagnosed. A novel trans-oral outlet reduction (TORe) was then performed. A modified ESD was first performed on the GJA, followed by argon plasma coagulation of the margins of the ESD. Then a purse-string TORe with suturing was performed, using a 10 mm balloon to size the GJA. On 6-month follow-up, patient lost 20 lb. and 12.26 %TBWL and EGD showed a 10 mm diameter GJA. On 1-year follow-up, patient weight loss was 14 lb. and 8.58 %TBWL. The follow-up endoscopy showed a 12 mm diameter GJA.

CONCLUSION

Endoluminal therapies are safe, reproducible, and effective in the treatment of weight regain and should be utilized as a first-line approach to manage this condition. This novel-combined approach is feasible and may be more effective in the treatment of weight regain.

Novel technique for anastomotic salvage using transanal minimally invasive surgery: A case report

BACKGROUND

Anastomotic leak (AL) after low anterior resection (LAR) can be a highly morbid complication. The incidence of AL ranges from 5% to 20% depending on patient characteristics and the distance of the anastomosis from the anal verge. Low anastomoses and leaks pose technical challenges for endoscopic treatment. The aim of this report was to describe the use of a commercially available laparoscopic energy device through a transanal minimally invasive surgery (TAMIS) port for the management of a symptomatic leak not requiring relaparotomy (grade B) after a LAR with diverting loop ileostomy.

CASE SUMMARY

A TAMIS GelPOINT Path port was inserted into the anus to access the distal rectum. Pneumorectum was achieved with AirSeal insufflation and a 30 degree laparoscope was introduced through a trocar. A LigaSure^TM Retractable L-Hook device was then used to perform a septotomy of the chronic sinus tract identified posterior to the coloproctostomy. The procedure was then repeated twice in three weeks intervals with ultimate resolution of the chronic leak cavity. Several months after serial TAMIS septotomies, barium enema demonstrated a patent anastomosis with no evidence of persistent leak or stricture. The patient subsequently underwent ileostomy reversal and has had no significant post-operative issues.

CONCLUSION

TAMIS septotomy with the LigaSure^TM Retractable L-Hook is a feasible and effective, minimally invasive salvage technique for the treatment of grade B ALs. Larger studies are needed to assess the generalizability and long-term results of this technique.

TREATING SIMPLE BENIGN ESOPHAGEAL STRICTURES WITH SAVARY-GILLIARD DILATORS: IS THE RULE OF THREE STILL NECESSARY?

BACKGROUND

Bougies dilation is considered an effective technique for the treatment of simple benign esophageal strictures. The "rule of three" has been advocated to prevent reported adverse events such as bleeding and perforation. However, adherence to this rule has increased the cost and duration of treatment.

OBJECTIVE

To demonstrate the safety and long-term benefits of progressive bougie dilations until reaching 15 mm (45Fr) in one single session endoscopy with non-adherence to the rule of three.

METHODS

A retrospective analysis of a prospectively collected data of patients with simple benign esophageal strictures treated with multiple progressive bougie dilators until reaching 15 mm (45Fr) in one single session.

RESULTS

The median age was 58 years (range 28-89), and 83.3% of patients were female. The main presenting symptom was dysphagia for solids in 11/12 cases (91.6%). The cause of their simple benign esophageal stricture was distributed as follows: 7/12 esophageal webs, 2/12 peptic stenosis, 2/12 Schatzki rings and one caustic injury. 75% required only one session for clinical success. No serious adverse events were described. No recurrence of symptoms was noted in a median follow-up of 20 months.

CONCLUSION

The rule of three in patients with simple benign esophageal strictures secondary to esophageal webs, Schatzki rings and peptic strictures treated with Savary-Gilliard dilators is not necessary, showing good clinical results. Prospective studies with more patients are necessary.

Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects

A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.

Endoscopic sleeve gastroplasty: From whence we came and where we are going

The most effective and durable treatment for obesity is bariatric surgery. However, less than 2% of eligible patients who fulfill the criteria for bariatric surgery undergo the procedure. As a result, there is a drive to develop less invasive therapies to combat obesity. Endoscopic bariatric therapies (EBT) for weight loss are important since they are more effective than pharmacological treatments and lifestyle changes and present lower adverse event rates compared to bariatric surgery. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive EBT that involves remodeling of the greater curvature. ESG demonstrated favorable outcomes in several centers, with up to 20.9% total body weight loss and 60.4% excess weight loss (EWL) on 2-year follow-up, with a low rate of severe adverse events (SAE). As such, it could be considered safe and effective in light of ASGE/ASMBS thresholds of > 25% EWL and ≤ 5% SAE, although there are no comparative trials to support this. Additionally, ESG showed improvement in diabetes mellitus type 2, hypertension, and other obesity-related comorbidities. As this procedure continues to develop there are several areas that can be addressed to improve outcomes, including device improvements, technique standardization, patient selection, personalized medicine, combination therapies, and training standardization. In this editorial we discuss the origins of the ESG, current data, and future developments.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Development of Bariatric and Metabolic Endoscopy

Objective:

With the evolution of society and changes in human lifestyle, obesity is becoming increasingly prevalent worldwide, and obesity-related comorbidities such as diabetes, hyperlipidemia, hypertension, and coronary heart disease are more common. As a result, new devices and methods for bariatric and metabolic endoscopy are being developed for clinical use, offering new options for patients. This review discussed the progress in bariatric and metabolic endoscopy.

Data Sources:

This review was based on data in articles published in the PubMed database up to September 2017, with the following keywords: “obesity”, “endoscopy”, “weight loss”, and “metabolism”.

Study Selection:

Original articles about various endoscopic methods of weight loss and other reviews of bariatric and metabolic endoscopy were included and analyzed.

Results:

The technology of bariatric and metabolic endoscopy has advanced rapidly in recent years. The intragastric balloon (IGB), with its comparatively long period of development, is the most mature and widely used instrument. Multiple new endoscopic devices have been created in recent years, with different targets to achieve weight loss. Despite the proliferation of new devices, the lack of clinical data results in a shortage of clinical experience and instruction in the use of this new equipment.

Conclusions:

Bariatric and metabolic endoscopy would help obese people lose weight or prepare for bariatric surgery and hopefully alleviate some of the complications of bariatric procedures. Adequate studies and data are still needed for the new endoscopic devices.

Endoscopic management of nonvariceal upper gastrointestinal bleeding

Endoscopic therapy is the mainstay of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB). Injection plus mechanical or thermal therapy continues to be the most widely used option. New endoscopic devices such as the use of an inert powder or a new class of over-the-scope clip system have demonstrated encouraging results as a rescue therapy for difficult hemostasis. Emerging data suggest that Doppler ultrasound-guided endoscopic therapy may improve the outcome of peptic ulcer bleeding. This review sumarizes the recent advances in the management of NVUGIB. With increasing use of anti-platelet agents and anti-coagulants, the management of NVUGIB in patients on anti-thrombotic therapy is also discussed.

Endoscopic ultrasound-guided vs endoscopic retrograde cholangiopancreatography biliary drainage for obstructed distal malignant biliary strictures: A systematic review and meta-analysis

BACKGROUND

For palliation of malignant biliary obstruction (MBO), the gold-standard method of biliary drainage is endoscopic retrograde cholangiopancreatography (ERCP) with the placement of metallic stents. Endoscopic ultrasound (EUS)-guided drainage is an alternative that is typically reserved for cases of ERCP failure. Recently, however, there have been robust randomized clinical trials (RCTs) comparing EUS-guided drainage and ERCP as primary approaches to MBO.

AIM

To compare EUS guidance and ERCP in terms of their effectiveness and safety in palliative biliary drainage for MBO.

METHODS

This was a systematic review and meta-analysis, in which we searched the MEDLINE, Excerpta Medica, and Cochrane Central Register of Controlled Trials databases. Only RCTs comparing EUS and ERCP for primary drainage of MBO were eligible. All of the studies selected provided data regarding the rates of technical and clinical success, as well as the duration of the procedure, adverse events, and stent patency. We assessed the risk of biases using the Jadad score and the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation criteria.

RESULTS

The database searches yielded 5920 records, from which we selected 3 RCTs involving a total of 222 patients (112 submitted to EUS and 110 submitted to ERCP). In the EUS and ERCP groups, the rate of technical success was 91.96% and 91.81%, respectively, with a risk difference (RD) of 0.00% (95%CI: -0.07, 0.07; P = 0.97; I 2 = 0%). The clinical success was 84.81% and 85.53% in the EUS and ERCP groups, respectively, with an RD of -0.01% (95%CI: -0.12, 0.10; P = 0.90; I 2 = 0%). The mean difference (MD) for the duration of the procedure was -0.12% (95%CI: -8.20, 7.97; P = 0.98; I 2 = 84%). In the EUS and ERCP groups, there were 14 and 25 adverse events, respectively, with an RD of -0.06% (95%CI: -0.23, 0.12; P = 0.54; I 2 = 77%). The MD for stent patency was 9.32% (95%CI: -4.53, 23.18; P = 0.19; I 2 = 44%). The stent dysfunction rate was significantly lower in the EUS group (MD = -0.22%; 95CI:-0.35, -0.08; P = 0.001; I 2 = 0%).

CONCLUSION

EUS represents an interesting alternative to ERCP for MBO drainage, demonstrating lower stent dysfunction rates compared with ERCP. Technical and clinical success, duration, adverse events and patency rates were similar.

Yield of biliary stent cytology: Is it time to think lean?

Background and study aims  During evaluation of pancreaticobiliary strictures, it is common practice to send biliary stents for cytologic analysis. However, in recent years, complementary tissue acquisition techniques ranging from cholangioscopy to fine-needle biopsy have improved the ability to acquire tissue and diagnose malignancy. Data are limited on the current diagnostic yield and cost effectiveness of biliary stent analysis. Patients and methods  We performed a retrospective study of all pancreaticobiliary stents sent for analysis in a tertiary care academic medical center from June 2013 to September 2016. Patient demographics, stent information, and final diagnosis history were collected through chart review. Costs were determined using published reimbursement rates for Medicare. Results  Two hundred thirty-one stents from 175 patients were sent for cytologic analysis during the study period. Of the 62 stents obtained from patients ultimately diagnosed with malignancy, only one (1.6 %) had positive cytology for malignant cells, while the others were acellular/non-diagnostic (2/62, 3.2 %), negative (48/62, 77.4 %), or atypical (11/62, 17.7 %). The sensitivity of stent cytology for diagnosis of malignancy was 1.6 % (1/62). No cases were identified in which stent cytology changed clinical management. From a payer perspective, the mean estimated cost for each stent cytologic analysis is greater than $ 70.00. Conclusions  While stent cytologic analysis is a common clinical practice, the diagnostic yield and cost effectiveness of the practice must be reevaluated. With the rise of newer diagnostic technologies such as digital cholangioscopy and endoscopic ultrasound-guided fine-needle biopsy, it may be time to "think lean" and acknowledge a sunset for biliary stent cytology.

Long-term outcomes of endoscopic submucosal dissection versus surgery in early gastric cancer: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) and gastrectomy with lymph node dissection are considered acceptable treatment modalities for early gastric cancer (EGC). In the last decade, ESD has become more favorable than surgery as it offers faster recovery, lower costs, and a superior quality of life when compared to gastrectomy. The aim of this study is to compare the long-term outcome of ESD versus surgery in EGC. We performed a systematic and comprehensive search of major reference databases (Medline, Embase, CINHAL) for all studies that compared the outcome of EGC for patients underwent ESD or surgery in the same cohort. A systematic review was conducted through November 2017, using pooled analysis to calculate 5-year overall survival (OS) rate, disease-specific survival (DSS) rate, disease-free survival (DFS) rate, and recurrence-free survival (RFS) rate of ESD versus gastrectomy. Five-year OS and DSS were similar between ESD and gastrectomy groups 96 versus 96% and 99.4 versus 99.2%, respectively. Likewise, DFS was similar in both groups 95.9 versus 98.5% odds ratio 1.86 (0.57-6.0) P=0.3. However, ESD had a lower RFS compared to surgery 92.4 versus 98.3% odds ratio 0.17 (0.1-4.9) P=0.001. Overall, there was a higher recurrence rate in patients who underwent ESD compared to surgery [40/2943 (1.4%) vs. 12/3116 (0.4) risk ratio (RR) 2.5 (1.3-4.8) P=0.005]. Moreover, synchronous and metachronous cancers were more prevalent in the ESD group compared to the surgery group [1.5 vs. 0.1% RR 5.7 (1.5-21.9) P=0.01] [16/1082 (1.5%) vs. 1/1485 (0.1%) RR 10.1 (5.9-17.1) P=0.0001]. Five-year OS, DSS and DFS were similar between ESD and surgery groups. However, recurrent, synchronous and metachronous cancers were more prevalent in patients treated by ESD compared to patients treated by surgery, resulting in a lower RFS. Adequate surveillance with upper endoscopy is crucial after ESD to detect early recurrence and metachronous lesions.

Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas

BACKGROUND

Endoscopy has evolved to become first-line therapy for the treatment of post-bariatric leaks; however, many sessions are often required with variable success rates. Due to these limitations, the use of the cardiac septal defect occluder (CSDO) has recently been reported in this population.

METHODS

The study population was a multicenter retrospective series of patients with post-bariatric surgical leaks who underwent treatment with CSDO placement. Data on the type of surgery, previous treatment details, fistula dimensions, success rate, and adverse events were collected. Leaks were grouped according to the International Sleeve Gastrectomy Expert Panel Consensus. Outcomes included technical and clinical success and safety of the CSDO. Regression analysis was performed to determine the predictors of response.

RESULTS

Forty-three patients with leaks were included (31 sleeve gastrectomy and 12 Roux-en-Y gastric bypass). They were divided into acute (n = 3), early (n = 5), late (n = 23), and chronic (n = 12). Forty patients had failed previous endoscopic treatment and 3 patients had CSDO as the primary treatment. Median follow-up was 34 weeks. Technical success was achieved in all patients and clinical success in 39 patients (90.7%). All chronic, late, and early leaks were successfully closed, except one undrained late leak. The 5 patients with early leaks had an initial satisfactory response, but within 30 days, drainage recurred. The CSDOs were removed and replaced with larger-diameter devices leading to permanent defect closure. Acute leaks were not successfully closed in all 3 patients. Regression analysis showed that chronicity and previous treatment were associated with fistula closure; success rates for late/chronic leaks versus acute/early leaks were 97.1% and 62.5%, respectively (P = .0023).

CONCLUSION

This observational study found that the CSDO had a high efficacy rate in patients with non-acute leaks, with no adverse events. All early, late, and chronic leaks were successfully closed, except for one undrained late leak. However, early leaks required a second placement of a larger CSDO in all cases. These results suggest that the CSDO should be considered for non-acute fistula and that traditional closure methods are likely preferred in the acute and early settings.

Same-session endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography-based tissue sampling in suspected malignant biliary obstruction: A multicenter experience

BACKGROUND AND AIM

Few studies compared endoscopic ultrasound (EUS)-guided fine needle aspiration (EUS-FNA) with endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling in terms of diagnostic accuracy in suspected malignant biliary obstruction. We evaluated and compared the diagnostic performance of EUS-FNA and ERCP-based tissue sampling.

METHODS

This multicenter study included 263 patients with suspected malignant biliary obstruction who underwent same-session EUS and ERCP between 2012 and 2016.

RESULTS

Malignancies were confirmed in 239 patients (90.9%) and benign in 24 patients (9.1%). Overall diagnostic sensitivity and accuracy were 73.6% and 76.1% for EUS-FNA, 56.5% and 60.5% for ERCP, and 85.8% and 87.1% for EUS/ERCP combination. EUS-FNA showed higher overall performances compared with ERCP (P < 0.001), whereas EUS/ERCP combination was superior to EUS-FNA alone (P-value < 0.001). EUS-FNA showed higher sensitivity and accuracy compared with ERCP for pancreatic masses (n = 187, both P-values < 0.001) but not for biliary lesions (n = 76, both P-values = 0.847). Sensitivity and accuracy of EUS/ERCP combination were superior to those of EUS-FNA for both pancreatic and biliary lesions (both P-values < 0.001). For patients with large mass (≥ 4 cm), there was no significant differences between ERCP/EUS combination and EUS-FNA (P-value = 0.31).

CONCLUSIONS

Same-session EUS-FNA and ERCP combination was superior to EUS-FNA for both pancreatic masses and biliary lesions. Same-session EUS/ERCP combination can be considered a proper diagnostic method for suspected malignant biliary obstruction regardless of the origin of lesions. On the other hand, EUS-FNA alone was sufficient for diagnosis compared with EUS/ERCP combination in cases with large mass. Strategic diagnostic approach, according to clinical features of individual patient, is required.

Modifying an Intragastric Balloon for the Treatment of Obesity: a Unique Approach

INTRODUCTION

The use of intragastric balloons (IGB) for the treatment of obesity has been increasing significantly, with data confirming its effectiveness with low complication rates. Adjustable balloons are not widely available for use in all countries, including the USA. In this video, we demonstrate a unique technique in which a conventional nonadjustable balloon is modified to an adjustable balloon to improve weight loss.

METHODS

A 35-year-old woman with a BMI of 36.1 kg/m2 (84.4 kg) who had failed prior medical therapy for obesity presented for IGB placement. After discussion with the patient, including risks and benefits, a conventional IGB modified to a novel adjustable IGB was placed.

RESULTS

In this primary experience, we describe the use of a conventional IGB modified to an adjustable balloon. First, during balloon placement, an initial 500 ml of saline was instilled. At one-month follow-up, the patient only experienced 3.67%TBWL; thus, the balloon was adjusted with the addition of 160 ml of saline through the newly created modification catheter. At a 2-month follow-up, a second adjustment was performed with the addition of 180 ml, for a total of 840 ml. At 4 months, patient experienced 10% TBWL and decreased in BMI by 3.6 kg/m2. No adverse events were reported.

CONCLUSION

The transformation of a nonadjustable balloon into an adjustable balloon is feasible and effective in weight loss. This technique may be an alternative in cases where adjustable balloon is not available. Further studies are warranted to confirm the safety and efficacy of this novel device.

Comparison of monopolar hemostatic forceps with soft coagulation versus hemoclip for peptic ulcer bleeding: a randomized trial (with video)

BACKGROUND AND AIMS

Although various methods are used in the treatment of peptic ulcer bleeding, there is not a standard recommended approach. The choice depends on multiple factors such as location of the ulcer, clinical experience of the endoscopist, and local facilities of the clinic. We aimed to compare the efficacy of monopolar hemostatic forceps soft coagulation (MHFSC) and hemoclips (HCs) in the treatment of peptic ulcer-related upper GI bleeding.

METHODS

The study group included patients who had GI bleeding due to Forrest 1a, 1b, and 2a gastric or duodenal ulcers within 1 year. Patients with bleeding diathesis, history of gastrectomy, pregnancy, or younger than age 18 years were excluded. The remaining were randomized to MHFSC and HC treatment groups and compared in terms of clinical and endoscopic features, initial hemostasis success rates, recurrent bleeding rates within the first 7 days, time to achieve hemostasis, length of hospitalization stay, and adverse events.

RESULTS

One hundred twelve patients were randomized to MHFSC (n = 56) and HC (n = 56) groups. There was no statistically significant difference between the groups with respect to demographic features, medications, underlying chronic diseases, location, and Forrest classification of the ulcers. The initial hemostasis success rate was 98.2% (55/56) in the MHFSC group and 80.4% (45/56) in the HC group (P = .004). Recurrent bleeding was detected in 2 patients in the MHFSC group (3.6%) and 8 patients in the HC group (17.7%; P = .04). The duration of endoscopic procedures (302 ± 87.8 vs 568 ± 140.4 seconds) and the length of hospital stay (3.50 ± 1.03 vs 4.37 ± 1.86 days) were significantly shorter in the MHFSC group. There were no adverse events in either group.

CONCLUSIONS

MHFSC is more effective in achieving initial hemostasis compared with HCs in the treatment of peptic ulcer bleeding and provides a shorter procedure time and a lower recurrent bleeding rate.

Efficacy of Endoscopic Treatment of Post-Sleeve Gastrectomy Fistulas According to the Radiological Type

BACKGROUND AND AIMS

The originality of this retrospective study relies on the evaluation of the effectiveness of the endoscopic internal drainage (EID) according to the type of fistula.

METHODS

The type of fistula was classified initially according to a CT scan with oral opacification: fistula without a communicating abscess (type I), fistula with a communicating abscess (type II), and fistula with an abscessed sub- and sus-diaphragmatic communicating collection (type III). Treatment algorithm consisted of the insertion of a nasojejunal feeding tube (NJFT) for type I fistulas and the placement of a NJFT with EID with or without surgical drainage for types II and III.

RESULTS

Forty-nine patients were included. The clinical success rate with fistula healing was 100% in group I, 96% in group II, and 12% for group III (p = 0.001). Mean time for diagnosis of the fistula was significantly higher in type III (p = 0.04). The mean estimated size of the defect was higher in type II, 11.2 mm and III, 10 mm versus type I, 2.8 mm (p = 0.001). The average number of scheduled endoscopic sessions were 2, 2.7, and 5.2 for types I, II, and III, respectively (p = 0.001). The number of unscheduled reinterventions was also significantly higher in type III (p = 0.03). The NJFT was left in place for a significantly longer duration in type III (136 days) compared to types I (3, 13) and II (49) p = 0.001.

CONCLUSION

This study shows that proper characterization of the type of fistula before the endoscopic treatment of post-sleeve fistulas improves the efficacy of the endoscopic treatment.

Management of benign oesophageal strictures

Benign oesophageal strictures are an important gastrointestinal condition that can cause substantial morbidity. There are many different aetiologies and each case needs careful evaluation and individualised treatment. Management usually involves targeting therapy to the underlying cause, but oesophageal dilatation is an important part of the algorithm. The recent British Society of Gastroenterology guidelines provide advice on the use of dilatation for benign strictures and cover patient preparation, the dilatation procedure and disease-specific considerations. This article provides a summary of the key messages from the guidelines and applies them to routine clinical practice. It also includes practical advice on the clinical assessment, investigation and management of benign oesophageal strictures and gives an approach to the management of refractory strictures. Areas where evidence is sparse and further research is needed are highlighted.

Endoscopic bariatric therapies for treating obesity: a learning curve for gastroenterologists

Obesity represents a growing public health threat. Until recently, surgery was the primary means for treating pharmacotherapy resistant obese patients. However, therapeutic endoscopy has evolved as an effective and safe alternative strategy. Particularly, endoscopic bariatric therapy (EBT) can bridge the gap in patients who do not fit the BMI criteria for surgery and fail conservative or medical therapy. Today there are many tools within the realm of EBT available to endoscopists. While there are no formal guidelines for their use, training and use of these tools are limited by the type of institution, preferences of senior endoscopists, cost, and availability. We review different EBT tools available to trainees and gastroenterologist, and the learning curves associated with them.

Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care

The role of endoscopic retrograde cholangiopancreatography (ERCP) has dramatically changed in the last years, mainly into that of a therapeutic procedure. The treatment of benign biliary disease, like “difficult” choledocolithiasis, with endoscopic papillary large balloon dilation combined with endoscopic sphinterotomy has proven an effective and safe technique. Moreover, safety in ERCP has improved as well, with the prevention of post-ERCP pancreatitis and patient-to-patient transmission of infections. The advent of self-expandable metal stenting has radically changed the management of biliopancreatic malignant strictures, while the role for therapy of benign strictures is still controversial. In addition, cholangioscopy (though the direct visualization of the biliopancreatic ductal system) has allowed for characterization of indeterminate biliary strictures and facilitated rescue therapy of large biliary stones deemed removable. Encouraging data from tissue ablation techniques, such as photodynamic therapy and radiofrequency ablation, need to be confirmed by large sample size clinical controlled trials. On the other hand, we have no drug-coated stents yet available to implant and evidence for the use of biodegradable stents is still weak. The competency and privileging of ERCP and endoscopic ultrasonography have been analyzed longer but the switch between the two procedures, at the same time, is becoming ordinary; as such, the endoscopist interested in this field should undergo parallel edification through training plans. Finally, the American Society for Gastrointestinal Endoscopy’s statement on non-anesthesiologist administration of propofol for gastrointestinal endoscopy is not actually endorsed by the European Society of Anaesthesiology, having many medical-legal implications in some European countries.

Endoscopic management of weight regain following Roux-en-Y gastric bypass

INTRODUCTION

With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population.

AREAS COVERED

We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care.

EXPERT COMMENTARY

Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.

Surgical management of obesity

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.

Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review

Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.

A rare non-oncological pancreatic mass: eosinophilic pancreatitis diagnosis through EUS-FNA

Background and study aims  Eosinophilic pancreatitis (EP) is a rare etiology of chronic pancreatitis, and few cases have been reported. It is characterized by eosinophilic infiltration of the pancreas and elevated IgE levels. EP is difficult to distinguish from pancreatic cancer based on clinical symptoms and auxiliary exams. We present a case of EP and debate the routine performance of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for resectable pancreatic mass.

Surgically resected pancreatic metastasis from nasal malignant melanoma: case report and literature review

A 13-mm mass was observed in the pancreatic head of a 70-year-old woman who had undergone melanoma resection in the nasal cavity 10 years earlier. Endoscopic ultrasonography (EUS) showed that the mass consisted of multiple hypoechoic nodules. EUS-guided fine needle aspiration and pancreatic juice cytologies revealed neoplastic cells positive for HMB45 and melan-A staining with a few melanin granules, indicating the presence of a metastatic malignant melanoma. These additional stainings were evaluated after surgery. In the surgically resected specimen, the mass had multiple nodule-like structures, some of which were brown colored. Immunocytochemistry and electronic microscopy findings confirmed the diagnosis of malignant melanoma. Microscopic findings were similar to the nasal specimen; therefore, the pancreatic lesion was considered to be a metastasis from the nasal cavity.

Spanish consensus document on bariatric endoscopy. Part 2: specific endoscopic treatments

During the last years we have been witnessing a significant increase in the number and type of bariatric endoscopic techniques: we have different types of balloons, suture systems, injection of substances and malabsorptive prosthesis, etc. Also, some endoscopic revisional procedures for patients with weight regain after bariatric surgery have been incorporated. This makes it necessary to protocolize, position and regularize all these techniques, through a consensus that allows their clinical application with the maximum medical rigor and scientific evidence available.