Endoscopic closure devices

Endobronchial closure of broncho-biliary fistula using Amplatzer device: Case report

Broncho-biliary fistula (BBF) is an extremely rare but serious medical condition resulting from pathological communication between the biliary system and the bronchial tree. Treatment options include both surgical and non-surgical approaches. Several endobronchial techniques, such as the spigot and glue, can be used for this purpose. This report discusses a patient who developed a broncho-biliary fistula following a liver biopsy. The BBF was diagnosed during bronchoscopy and successfully treated with an endobronchial Amplatzer device. To the best of our knowledge, this is the first report of the use of the Amplatzer device to manage BBF.

Endoscopic removal of a weight-loss device with stoma closure using a tack-and-suture device

Video 1.

Recent advances and current challenges in endoscopic resection with the full-thickness resection device

Endoscopic full-thickness resection (EFTR) has emerged as a viable technique in the management of mucosal and subepithelial lesions of the gastrointestinal tract (GIT) not amenable to conventional therapeutic approaches. While various devices and techniques have been described for EFTR, a single, combined full-thickness resection and closure device (full-thickness resection device, FTRD system, Ovesco Endoscopy AG, Tuebingen, Germany) has become commercially available in recent years. Initially, the FTRD system was limited to use in the colorectum only. Recently, a modified version of the FTRD has been released for EFTR in the upper GIT as well. This review provides a broad summary of the FTRD, highlighting recent advances and current challenges.

Analysis of Reported Adverse Events Associated with Over-the-Scope Endoscopic Suturing System: an FDA MAUDE Database Study

PURPOSE

The over-the-scope endoscopic suturing system (ESS) (OverStitch™) is one of the most widely utilized endoscopic suturing systems in current clinical practice; however, data on the adverse events associated with this device is scarce. Our study aims to evaluate the adverse events and complications associated with the over-the-scope ESS using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

MATERIALS AND METHODS

We analyzed the post-marketing surveillance data from the FDA MAUDE database for the over-the-scope ESS from January 2008 through June 2022.

RESULTS

Eighty-three reports were filed from January 2008 to June 2022. Adverse events were classified as device-related complications and patient-related adverse events. Seventy-seven device-related issues and 87 patient adverse events were identified. The most common device-related issue was difficulty to remove after deployment (n=12, 15.58%) followed by mechanical problem (n=10, 12.99%), mechanical jam (n=9, 11.69%), or entrapment of device (n=9, 11.69%). Of the 87 patient-related adverse events, the most common was perforation (n=19; 21.84%), followed by device embedded in tissue or plaque (n=10; 11.49%), and abdominal pain (n=8; 9.20%). Of the 19 patients who experienced perforation, two required open surgical repair and one required laparoscopic surgical repair.

CONCLUSION

The overall adverse events from the over-the-scope ESS remain acceptable as evidenced by the number of reported cases since 2008. However, it is important to note that adverse event rates might increase as the use of the device increases; therefore, it is essential for endoscopists to be aware of the potential common and rare adverse events associated with the use of the over-the-scope ESS device.

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome

BACKGROUND

Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT).

METHODS

In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies.

RESULTS

In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches.

CONCLUSIONS

Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

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.

Smart surgical sutures using soft artificial muscles

Wound closure with surgical sutures is a critical challenge for flexible endoscopic surgeries. Substantial efforts have been introduced to develop functional and smart surgical sutures to either monitor wound conditions or ease the complexity of knot tying. Although research interests in smart sutures by soft robotic technologies have emerged for years, it is challenging to develop a soft robotic structure that possesses a similar physical structure as conventional sutures while offering a self-tightening knot or anchor to close the wound. This paper introduces a new concept of smart sutures that can be programmed to achieve desired and uniform tension distribution while offering self-tightening knots or automatically deploying secured anchors. The core technology is a soft hydraulic artificial muscle that can be elongated and contracted under applied fluid pressure. Each suture is equipped with a pressure locking mechanism to hold its temporary elongated state and to induce self-shrinking ability. The puncturing and holding force for the smart sutures with anchors are examined. Ex-vivo experiments on fresh porcine stomach and colon demonstrate the usefulness of the new smart sutures. The new approaches are expected to pave the way for the further development of smart sutures that will benefit research, training, and commercialization in the surgical field.

Devices and techniques for flexible endoscopic management of Zenker's diverticulum (with videos)

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.

Closure of colonic deep mural injury and perforation with endoclips

INTRODUCTION

colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications.

OBJECTIVES

to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection.

METHODS

a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed.

RESULTS

after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm.

CONCLUSION

endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection.

MR Enterography of Complicated Crohn Disease: Stricturing and Penetrating Disease

ABSTRACT

Stricturing and penetrating disease are complications of Crohn disease (CD) that significantly affect patient outcomes. Careful evaluation for such complications is critical to the interpretation of magnetic resonance enterography. This manuscript outlines the key findings related to stricturing and penetrating CD and discusses current understanding of the pathophysiology and prognosis of complicated CD based on the literature.

Gastrointestinal fistula endoscopic closure techniques

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos)

BACKGROUND AND AIMS

As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type.

METHODS

The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized.

RESULTS

Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving.

CONCLUSIONS

Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.

Bowel Obstruction and Hydronephrosis Due to an Over-the-Scope Clip

An over-the-scope clip is a type of endoscopically placed clip used to treat gastrointestinal perforation, bleeding, or fistula. After the defect heals, the clip usually passes uneventfully through the gastrointestinal tract. An uncommon complication of over-the-scope clip placement is intestinal obstruction caused by luminal stenosis at the site of clip placement. Intestinal obstruction can rarely cause other downstream complications such as hydronephrosis from extrinsic compression of the urinary tract. We report a rare case of bilateral hydronephrosis caused by bowel obstruction from a migrated endoscopically placed clip.

[Endoscopic treatment of benign gastrointestinal fistulas]

OBJECTIVE

To evaluate the possibility and safety of modified endoscopic stent in the treatment of benign intestinal fistulas.

MATERIAL AND METHODS

Analysis of the experience of Sklifosovsky Research Institute for Emergency Care and recent numerous foreign reports confirms that staged treatment followed by delayed radical surgery is the most perspective approach. Modified endoscopic treatment of intestinal fistulas successfully used in 10 patients is reported in the article.

RESULTS

Endoscopic stenting of various parts of gastrointestinal tract is a minimally invasive treatment of this pathology and not followed by complications and mortality. An important advantage is early closure of fistula that reduces duration of treatment and improves further social and labor rehabilitation of patients.

The Use of the Overstitch to Close Perforations and Fistulas

Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.

Use of the Over the Scope Clip to Close Perforations and Fistulas

In gastrointestinal perforation or fistula, endoscopic closure techniques could be used as alternatives to surgery. Early endoscopic recognition and treatment of gastrointestinal perforation is the most important factor determining procedural success and clinical outcomes. The over-the-scope clip with full-thickness grasping capability provides greater technical and clinical success rates compared with the through-the-scope clips. Although the technical success rate of chronic fistula closure is comparable to perforation closure, it has a significantly lower clinical success owing to its less healthy tissue edge of the fistula. The over-the-scope clip system should be considered before surgery for the closure of perforation and fistula.

Endoscopic management of iatrogenic EUS-related duodenal perforations with over-the-scope clips

Background and study aims  Iatrogenic endoscopic ultrasound (EUS) perforations are life-threatening adverse event and to date, surgery has been the main treatment for them. The aim of this study was to assess feasibility and safety of conservative treatment with over-the-scope clips (OTSC). Patients and methods  We performed a retrospective study, including iatrogenic EUS duodenal perforation with conservative endoscopic management from 2011 to August 2018. Patients who initial had surgical management were excluded. Results  In 8504 EUS procedure occurred, 13 perforations occurred (0.15 %). Eleven patients were included in the study, all women. Mean patient age was 75 years (range 68 - 88). Eighth of 11 perforations (72.7 %) were due to a radial probe and three of 11 (27.3 %) were due to a curvilinear probe. Eleven procedures (100 %) were performed as diagnostic. Defect size ranged from 10 to 15 mm. All procedures were successful. Three of eleven patients (27 %) had a stay in intensive care unit for less than 72 hours and length of total hospital stay ranged from 3 to 22 days. Conclusion  Conservative endoscopic treatment of Iatrogenic EUS perforation, with OTSC is feasible, efficient and safe.

Complications of the Use of the OverStitch Endoscopic Suturing System

Endoscopic suturing with the OverStitch device is safe and effective for a wide range of applications from defect closure and stent fixation to hemostasis and bariatrics. OverStitch-related complications remain rare, although adverse events such as bleeding, mucosal injury, perigastric fluid collections, leaks, and perforations have been reported. Provider familiarity with the device and the specific pitfalls that may arise with OverStitch use in different situations is necessary to minimize the risk of adverse events. This article reviews potential complications and provides tips and troubleshooting techniques.

Optimized Training in the Use of Endoscopic Closure Devices

Successful closure of gastrointestinal defects is one of the most important goals for therapeutic endoscopy. Historically, surgical repair was the mainstay of treatment for any gastrointestinal defect; however, surgery is associated with high morbidity and mortality. Endoscopic management of gastrointestinal defects has developed rapidly in recent years and has become more effective, reducing the morbidity and mortality rates, and avoiding surgical interventions. Appropriate use of endoscopic techniques requires extensive knowledge of the devices and their advantages and limitations during practical applications.

ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection

With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.

Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos)

Background

Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data.

Methods

In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use.

Results

Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays).

Conclusions

Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.

Successful endoscopic closure of a refractory postoperative rectovaginal fistula

Background and study aims  A 71-year old female who received low anterior resection for rectal cancer visited Komatsu Municipal Hospital with complaints of passing feces from the vagina. Endoscopic examination revealed a postsurgical rectovaginal fistula. Medical approaches, including nonoperative management, initial endoscopic closure, transvaginal and endorectal surgery, and fecal diversion, were unsuccessful. Therefore, the patient underwent endoscopy with a pre-procedural endoscopic creation of mucosal pin holes around the fistula opening and clip insertion into the rectal wall in combination with electrocautery and clip closure. This novel approach was effective in achieving permanent closure of the fistula in a single procedure. Most rectovaginal fistulas are surgically managed, however, surgery may be more difficult, invasive, and unsatisfactory for refractory fistulas. Although endoscopic treatment with over-the-scope clips has been increasingly used as a less invasive approach for gastrointestinal fistulas with favorable results, it is not as effective for refractory rectovaginal fistulas. As a minimally invasive surgical procedure, this approach might be effective in small rectovaginal fistulas, particularly refractory ones.

Endoscopic closure of gastrointestinal perforations and fistulas using the Ovesco Over-The-Scope Clip system at a tertiary care hospital center

INTRODUCTION AND AIM

Enteric perforations and fistulas are difficult to manage due to comorbidities, poor nutritional status, and anatomic challenges related to multiple interventions in those patients. The use of endoscopic methods as a nonsurgical approach is increasing. The aim of the present study was to describe the clinical experience with the use of the Ovesco Over-The-Scope Clip system in the closure of perforations, fistulas, and other indications in the digestive tract at a tertiary care hospital center.

MATERIALS AND METHODS

A case series was carried out on patients that underwent lesion closure with the Ovesco clip, within the time frame of January 2015 to December 2017.

RESULTS

The Ovesco clip was used for closure in 14 patients ranging in age from 21-90 years, with different indications: iatrogenic perforations; anastomotic leaks and fistulas; tracheoesophageal fistulas; and esophagogastric perforation. Technical success was achieved in 100% of the patients and clinical success in 78.57%. No complications were reported.

CONCLUSIONS

The Ovesco Over-The-Scope Clip system is a safe and effective method for managing gastrointestinal acute perforations and fistulas.

Endoscopic Management of Gastrobronchial Fistula after Laparoscopic Sleeve Gastrectomy: A Case Report

Bariatric surgery has rapidly emerged as a modality for managing morbid obesity; however, despite being considered safe, some complications do exist. Formation of a gastrobronchial fistula is a rare complication of laparoscopic sleeve gastrectomy that is associated with high morbidity and mortality. Nowadays, novel endoscopic techniques have widely been adopted in the management of such cases, as they provide minimally invasive options that decrease the morbidity and mortality. Here, the author presents a report of a middle-aged, morbidly obese male who had previously undergone laparoscopic sleeve gastrectomy and returned with a 3-month history of productive cough. On upper gastrointestinal series, the patient was found to have a fistula communicating the stomach to the bronchial tree of his left lung (gastrobronchial fistula). He was treated with endoscopic fistula closure using an over-the-scope clip and a fully-covered Niti-S metallic stent. After this treatment, the patient's symptoms improved dramatically, and the stent was successfully removed 12 weeks later. This report highlights the management of a patient with gastrobronchial fistula formation following laparoscopic sleeve gastrectomy as well as provides a literature review of using combined endoscopic management to treat gastrobronchial fistulas.

Endoscopic closure of tracheoesophageal fistula for tuberculosis with an over-the-scope-clip

Surgical management has been the main approach for enteral fistulae. This approach is usually complex due to comorbidities, a wasted nutritional state and anatomical difficulties related to prior multiple interventions. Therefore, endoscopic methods such as clips, self-expanding metal stent (SEMS) and recently, the over scope clip (OTSC®) are increasing in popularity and use. Herein, we present the case of a patient with a HIV infection who was admitted due to respiratory symptoms. Radiological and microbiological studies documented a tracheoesophageal fistula due to tuberculosis (TB) and cytomegalovirus (CMV) infection. Therefore, an esophageal fully-covered stent was placed, which migrated into the stomach. The thoracic surgeons considered an esophagectomy with gastric ascent and muscle patch in the trachea. However, due to his poor nutritional status and comorbidity, an OTSC was placed to treat the fistulae. The patient also received medical treatment with anti-tuberculotics and anti-retrovirals.

Endoscopic management of perforations, leaks and fistulas

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

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.

What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?

OPINION STATEMENT

PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients.

RECENT FINDINGS

Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.

Endoscopic augmentation of gastroesophageal junction using a full-thickness endoscopic suturing device

Background and study aims  This preliminary study was conducted to determine the feasibility and safety of endoscopic augmentation of the gastroesophageal junction (GEJ) using the Apollo OverStitch endoscopic suturing system in patients with gastroesophageal reflux disease (GERD) symptoms. Patients and methods  Endoscopic augmentation of GEJ was performed on 10 consecutive patients and the data were analyzed retrospectively. Using a double-channel gastroscope affixed to the endoscopic suturing platform, interrupted sutures were placed on the gastric side of the GEJ in 2 layers in order to create a narrowed and elongated GEJ. Results  Technical success was achieved in all patients, including those with a history of previous antireflux procedures (n = 7) and those with a hiatal hernia (n = 6). The median follow-up duration was 5 mo (range: 2 - 12). The median pre-procedure GERD-Health Related Quality of Life Questionnaire improved from 20 (range: 11 - 45) to a post-procedure score of 6 (range: 3 - 25) ( P  = 0.001). The median duration of GERD symptom improvement after the procedure was 1 mo (range: 0.5 - 4). Adverse events were limited to 1 patient who developed nausea and vomiting, which was self-limited. Conclusions  The use of a novel endoscopic suturing technique for the treatment of GERD is feasible and safe. The procedure resulted in short-term GERD symptom improvement. Further prospective studies using refined techniques are currently underway to improve durability and to prove efficacy.

Emerging Endoscopic Treatments for Nonvariceal Upper Gastrointestinal Hemorrhage

Despite major improvements in endoscopic devices and therapeutic endoscopy, rebleeding rates and mortality have remained the same for several decades. Therefore, much interest has been paid to emerging therapeutic devices, such as the over-the-scope clip and hemostatic sprays. Other emerging technologies, such as radiofrequency ablation, endoscopic suturing devices, and ultrasound-guided angiotherapy, are also being investigated to improve therapeutic outcomes in specific situations. This narrative review details the technical aspects, clinical applications, outcomes, and potential limitations of these devices in the context of nonvariceal upper gastrointestinal hemorrhage.

Basic training in digestive endoscopy for resident physicians in gastroenterology. Recommendations by the Sociedad Española de Endoscopia Digestiva (SEED)

Digestive endoscopy is the most effective tool available for the diagnosis of multiple gastrointestinal (GI) tract conditions, and it represents a key aspect in the training of gastroenterology residents according to the Spanish MIR (médico interno residente) program. The Sociedad Española de Endoscopia Digestiva (SEED), aware of all the technical advances that have emerged during the past few years, deems it necessary to define a program of the skills specialists-in-training in gastroenterology should acquire during their residency. This paper describes the goals of endoscopy training, the techniques that should be mastered, and the diagnostic and therapeutic skills this specialty requires. Finally, a model is suggested for the assessment of competence.

Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae

Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.

The Management of Intestinal Penetrating Crohn's Disease

Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.

Recent Trends in Endoscopic Bariatric Therapies

Obesity and its associated metabolic diseases including diabetes mellitus are severe medical problems that are increasing in prevalence worldwide and result in significant healthcare expenses. While behavioral and pharmacological treatment approaches are partly effective in the short term, their effects are not long-lasting. Although previous studies have described bariatric surgery as the most effective treatment for obesity, it is associated with morbidity, mortality, and economic burden. Endoluminal interventions performed entirely using gastrointestinal flexible endoscopy offer alternative approaches to the treatment of obesity that are safer and more cost-effective than current surgical approaches. The use of endoluminal techniques in the field of metabolic obesity disease has diverse promising applications including endoscopic gastroplasty, intragastric balloon, endoluminal malabsorptive bariatric procedures, and gastric electrical stimulation (GES) for the modulation of gastric emptying. This review discusses recent trends and roles in endoscopic bariatric therapies using the currently available endoluminal and transgastric technologies.

Treatment of leakage via metallic stents placements after endoscopic full-thickness resection for esophageal and gastroesophageal junction submucosal tumors

OBJECTIVE

The objective of this study is to evaluate the feasibility and efficacy of endoscopic full-thickness resection (EFTR) and fully covered retrievable self-expandable metal stents (SEMSs) placement for this kind of tumors.

METHODS

A total of six consecutive patients, presenting with esophageal and GE junction SMTs, received EFTR and SEMSs placement at the our endoscopic center between January 2015 and June 2015. Their medical records were thoroughly investigated.

RESULTS

EFTR was performed successfully in all cases. The en bloc resection rate was 100%. The final pathological diagnoses were leiomyomas in all six cases. No patients developed delayed bleeding. SEMSs were placed immediately after EFTR during the same endoscopic session except patient #1. Complete healing of esophageal leakage after stent placement was achieved for 6/6 patients (100%) without the need for surgical interventions. Stent migration occurred in one patient. No residual tumor or tumor recurrence was observed during the follow-up period.

CONCLUSIONS

EFTR combined with fully covered retrievable self-expandable metallic stents placement is a feasible and effective new method for providing radical treatments for SMTs from the deep MP layer of esophagus and GE junction. Standardization of the procedure should be studied further.

Outcome, comorbidity, hospitalization and 30-day mortality after closure of acute perforations and postoperative anastomotic leaks by the over-the-scope clip (OTSC) in an unselected cohort of patients

BACKGROUND

Acute gastrointestinal (GI) wall defects contain a high risk of morbidity and mortality and may be closed endoscopically by a full-thickness over-the-scope clip (OTSC).

METHODS

Unselected consecutive patients presenting with acute non-surgical perforations or postoperative anastomotic leaks or perforations underwent attempted OTSC placement as primary closure method after interdisciplinary consensus in three tertiary referral centres. Their clinical data and intervention characteristics were evaluated in an intention to treat analysis during a 24-month period to assess closure rates, 30-day mortality, hospitalization and comorbidity.

RESULTS

In total, 34 patients (16 females, 18 males, 69.5 years) were included with 22 non-surgical perforations and 12 postoperative anastomotic leaks or perforations. Definitive closure of the perforations and leaks was achieved in 26/34 patients (76.5 %). Successful closure of the GI wall defect resulted in a significantly shorter hospital stay (8 days, p = 0.03) and was significantly correlated with comorbidity (r = 0.56, p = 0.005). In the group with OTSC failure, hospitalization was 18 days and 6 of 8 patients (75 %) required immediate surgery. Three deaths occurred in the group with successful OTSC closure due to comorbidity, while one death in the OTSC failure group was related to a refractory perforation. Favourable indications and locations for a successful OTSC procedure were identified as PEG complications, endoscopic or postoperative leaks of stomach, colon or rectum, respectively.

CONCLUSIONS

In unselected patients, OTSC was effective for closure of acute GI wall defects in more than 75 % of all patients. Clinical success and short hospitalization were best achieved in patients without comorbidity, but closure of the perforation or the anastomotic leak was found to be not the only parameter relevant for patient outcome and mortality.

Over-the-scope clip for endoscopic closure of gastrogastric fistulae

BACKGROUND

Gastrogastric fistulae (GGF) are a well-known complication of Roux-en-Y gastric bypass (RYGB). Endoscopic approaches for closure of GGF have gained popularity, but with limited data and efficacy.

OBJECTIVES

The primary arm of the study was to evaluate the safety and efficacy of the endoscopic closure of GGF using the over-the-scope clip (OTSC) device.

SETTING

University hospital, United States METHODS: This is a retrospective review of consecutive patients at a single academic center from September 2013 to December 2014 who underwent upper endoscopy with attempted OTSC placement for closure of GGF related to RYGB. Preprocedural, procedural, and postprocedural data were collected. Outcome measures included technical success, primary success, and long-term success.

RESULTS

A total of 14 patients underwent attempted GGF closure using OTSC. Twelve of the 14 patients (85.7%) had technical success. Four patients were lost to follow-up. Primary success was achieved in 5 of the 10 patients (50%) in which it was assessed, either by upper gastrointestinal series or endoscopy. One of the 5 patients who had primary success was then lost to follow-up. Of the 4 patients in whom primary success was achieved and had long-term follow up, 75% (n = 3) achieved long-term success at a mean follow-up of 6.6 months from initial OTSC placement (range, 3-9), making for a long-term success rate of 33% (3/9). There were no reported complications.

CONCLUSION

OTSC closure of small GGF is feasible, safe, and offers a reasonable alternative to surgical revision. Large GGF may undergo attempted endoscopic closure, acknowledging a high failure rate.

Iatrogenic Perforations During Colonoscopy In a Portuguese Population: A Study Including In and Out-Of-Hospital Procedures

INTRODUCTION

The risk of iatrogenic perforations in colonoscopy is not negligible. Experience with endoscopic closure of perforations is increasing and new devices for this purpose are being released, making endoscopy a therapeutic option. National data regarding iatrogenic perforations is scarce and the burden of iatrogenic perforations in out-hospital procedures is poorly characterized in the literature.

OBJECTIVE

Evaluation of iatrogenic perforations rate during colonoscopy, their characteristics, management and prognosis.

METHODS

Retrospective study of all patients with perforations secondary to in-hospital and non-hospital colonoscopies treated in a tertiary hospital between 01-01-2006 and 01-10-2014. Demographic, endoscopic, radiological and therapeutic data were analyzed.

RESULTS

Fifty-three perforations were identified, 20 occurring in colonoscopies performed in non-hospital environment (45% with therapeutic procedures) and 33 occurring in-hospital procedures (73% in therapeutic colonoscopies; representing 0.12% of all colonoscopies carried out in-hospital). Patients: male in 56%, average age of 71 years, history of previous abdominopelvic surgery in 31% and diverticulosis in 10%. Colonoscopy: elective in 93%, under deep sedation in 21%, with less than excellent/good bowel preparation in 56%. A resident was the first performer in 10 cases. Perforations: average size of 21 mm (4-130 mm), diagnosed during the procedure in 51% of cases and occurred in rectum-sigmoid transition in 58.5%. Regarding therapeutics, all patients with perforation occurring in non-hospital colonoscopies were managed by surgery. Concerning treatment of those in our unit: 2-conservative, 12-endoscopic (10 successfully), 21-surgical (including the 2 cases with failure of the endoscopic approach). Comparing endoscopic treatment (n = 10, G1) versus surgery (n = 21; G2): perforation size - 9 mm (G1) versus 28 mm (G2); perforation location - 7/10 in rectum-sigmoid (G1) versus 8/21 in rectum-sigmoid and 10/21 transverse/ascending colon/hepatic angle (G2). Morbidity: 1 infection in G1 and 13 complications in G2 (infection, hemorrhage, fistula). Mortality: no deaths in G1 and 2 deaths at 30 days due to septic shock in G2.

CONCLUSION

Perforations in colonoscopy are rare in our clinical practice. Endoscopic closure was effective, though limited to perforations found during the procedure. The mortality was relatively low and endoscopic management did not seem to worsen it. An additional effort is necessary in order to detect perforations during colonoscopy.

Efficacy of the Ovesco Clip for Closure of Endoscope Related Perforations

Aim. To study the efficacy and other treatment outcomes of Ovesco clip closure of iatrogenic perforation. Methods. Retrospective study from 3 tertiary-care hospitals in Thailand. Patients with iatrogenic perforation who underwent immediate endoscopic closure by Ovesco clip were included. Patients' demographic data, perforation size, number of Ovesco clips used, fasting day, length of hospital stay, success rates, and complication rate were recorded. Technical success was defined as closure achievement during endoscopic procedure and clinical success was defined as the patient can be discharged without the need of additional surgical or radiological intervention. Results. There were 6 iatrogenic perforations in 2 male and 4 female patients. The median age was 59 years (range 39-78 years). The locations of perforation were 5 duodenal walls and 1 rectosigmoid junction. The median perforation size was 13 mm (range 10-40 mm). The technical success was 100% and the clinical success was 83.3%. The success rates per locations were 100% in colon and 80% in duodenum, respectively. The median fasting time was 5 days (range 1-10 days) and the median length of hospital stay was 10 days (range 2-22 days). There was no mortality in any. Conclusion. Ovesco clip seems to be an effective and safe tool for a closure of iatrogenic perforation.