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

Impact of Slim Linear Echoendoscope on the Practice of EUS

BACKGROUND

Standard linear echoendoscopes have a large distal tip and bending radius, which can preclude adequate examination in some patients.

OBJECTIVE

We examined the impact of having available slim linear echoendoscopes (SLE) on our endoscopic ultrasound (EUS) practice.

MATERIALS AND METHODS

As a quality improvement measure, data on the need for the use of SLE were documented in 2000 consecutive procedures performed over a 10-month period from February to November 2022. When examination using a standard size echoendoscope failed due to technical limitations, the procedure was reattempted in the same session using a SLE. The main outcome was the impact of SLE, which was defined as the establishment of a new diagnosis or if findings altered treatment plan.

RESULTS

A complete EUS examination failed in 23 of 2000 procedures (1.15%, 95% CI, 0.73-1.72%) performed using standard size echoendoscope (14 male, median age 73 y [IQR 66 to 79]). The examination was technically successful when using SLE in 22 of 23 (95.6%) patients. SLE impacted clinical management in all 22 patients (100%) by establishing tissue diagnosis in 19 and/or altering subsequent treatment plan in 5. Adverse event of transient hypoxia was observed in one patient (4.3%).

CONCLUSIONS

A very experienced EUS team required SLE in 1.1% of consecutive examinations. Our findings suggest that when used, 95% of patients benefitted as it had a significant impact on their clinical management.

Over-the-Scope Clip-Associated Endoscopic Muscular Dissection for Seven Cases of Small Gastric Submucosal Tumor: A Video-Based Case Series

Objectives

To evaluate the methodology, feasibility, safety, and efficacy of a novel method called over-the-scope clip- (OTSC-) associated endoscopic muscular dissection for small GSMT.

Methods

A pilot study on small GSMT diameter ≤ 1 cm was performed. OTSC-associated endoscopic muscular dissection was based on the requirement of OTSC apparatus and ESD technique; after ligaturing the bottom of small GSMT by OTSC, ESD was performed to resect the tumors, and the wounds of ESD were closed by clips finally. All the patients were followed up for more than 3 months, and the complications during and after OTSC-associated endoscopic muscular dissection were recorded.

Results

A total of 7 consecutive patients with small GSMT were included. All tumors were completely dissected without any perforation or infection during and after the procedure in all cases, while three patients had mild abdominal pain, and one experienced postoperative bleeding after the procedure which was treated by the endoscopy with titanium clips. All the patients were followed by endoscopy three months later, all the wounds healed well, and all the OTSCs were still in the gastric wall.

Conclusions

OTSC-associated endoscopic muscular dissection as a novel endoscopic interventional therapy should be a convenient, safe, and effective therapy for small GSMT. The short-time outcome is excellent, whereas long-term effect is unclear, and the further follow-up is needed to schedule.

Endoscopic Closure of an Acute Duodenal Perforation Occurring during Endoscopic Ultrasound Using Endoclips and Polyglycolic Acid Sheets with Fibrin Glue

Acute duodenal perforation during endoscopic ultrasound (EUS) is a serious complication. The conventional endoscopic treatment for duodenal perforations such as endoscopic clipping is unsatisfactory; recently, the effectiveness of over-the-scope clipping (OTSC) has been reported. A 91-year-old woman was referred to our hospital with the chief complaint of jaundice. Contrast-enhanced computed tomography showed a 2-cm mass in the pancreatic head; we planned EUS-guided fine-needle aspiration. During exploration for a puncture route from the duodenal bulb using a linear echoendoscope under carbon dioxide insufflation, the duodenal lumen was suddenly filled with blood. A perforation <15 mm was identified in the superior duodenal horn. We attempted an endoscopic closure with multiple endoclips but could not completely close the perforation site. Strips of bioabsorbable polyglycolic acid (PGA) sheets were placed over the gaps between the endoclips with biopsy forceps and fixed in place with fibrin glue, completely covering the perforation site. Two days after the procedure, the perforation site had closed. Nine days later, endoscopic biliary stenting was performed. The patient was diagnosed with pancreatic cancer through bile cytology, and the optimal supportive care for her age was selected. Endoscopic tissue shielding with PGA sheets and fibrin glue is increasingly being reported for use during gastrointestinal endoscopic procedures. In this case, surgery was avoided due to successful endoscopic treatment using endoclips and PGA sheets with fibrin glue without OTSC. This method may be useful for repairing acute duodenal perforations during EUS and should therefore be known to pancreatobiliary endoscopists.