Duodenoscope as a Vector for Transmission

Elevator-based endoscope-related infections from patient cross-contamination is a multifactorial problem related to device design, maintenance, and function, with additional risk incurred from a high-level disinfection process that lacks quality controls. This article reviews the historical context for these outbreaks, technical aspects of scope design contributing to this risk, and innovations in endoscope technology that have the potential to overcome these shortcomings. Also reviewed are interim solutions and the data that support use of some of these interventions. Still needed are a validated manufacturer-recommended schedule for routine duodenoscope and echoendoscope maintenance with reprocessing protocols that can be implemented in endoscopy units.

Endoscopic management of unresectable malignant gastroduodenal obstruction with a nitinol uncovered metal stent: A prospective Japanese multicenter study

AIM: To determine the safety and efficacy of endoscopic duodenal stent placement in patients with malignant gastric outlet obstruction.

METHODS: This prospective, observational, multicenter study included 39 consecutive patients with malignant gastric outlet obstruction. All patients underwent endoscopic placement of a nitinol, uncovered, self-expandable metal stent. The primary outcome was clinical success at 2 wk after stent placement that was defined as improvement in the Gastric Outlet Obstruction Scoring System score relative to the baseline.

RESULTS: Technical success was achieved in all duodenal stent procedures. Procedure-related complications occurred in 4 patients (10.3%) in the form of mild pneumonitis. No other morbidities or mortalities were observed. The clinical success rate was 92.3%. The mean survival period after stent placement was 103 d. The mean period of stent patency was 149 d and the patency remained acceptable for the survival period. Stent dysfunction occurred in 3 patients (7.7%) on account of tumor growth.

CONCLUSION: Endoscopic management using duodenal stents for patients with incurable malignant gastric outlet obstruction is safe and improved patients’ quality of life.

Approach to the endoscopic resection of duodenal lesions

Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.

Surgical or endoscopic management for post-ERCP large transmural duodenal perforations: a randomized prospective trial

INTRODUCTION

Duodenal perforations are an uncommon adverse event during ERCP. Patients can develop significant morbidity and mortality. Even though surgery has been used to manage duodenal complications, therapeutic endoscopy has seen significant advances.

OBJECTIVE

To compare endoscopic approach with surgical intervention in patients with duodenal perforations post-ERCP.

MATERIAL AND METHODS

prospective randomized study in a tertiary center with 23 patients divided in 2 groups. Within 12 hours after the event, the patients underwent endoscopic or surgical approach. Endoscopic approach included closure of the perforation with endoclips and SEMS. Surgical repair included hepaticojejunostomy, suture of the perforation or duodenal suture. The success was defined as closure of the defect. Secondary outcomes included mortality, adverse events, days of hospitalization and costs.

RESULTS

The success was 100% in both groups. There was one death in the endoscopic group secondary to sepsis. There was no statistical difference in mortality or adverse events. We noticed statistical difference in favor of the endoscopic group considering shorter hospitalization (4.1 days versus 15.2 days, with p=0.0123) and lower cost per patient (U$14,700 versus U$19,872, with p=0.0103).

CONCLUSIONS

Endoscopic approach with SEMS and endoclips is an alternative to surgery in large transmural duodenal perforations post-ERCP.

Endoscopic Removal of Duodenal Perforating Fishbone - A Case Report

BACKGROUND

Accidental ingestion of foreign bodies is common in clinical practice. While perforation of the ileum and jejunum due to the ingested foreign body is common, duodenal perforation is rare. In this report, our experience with this rare entity is shared.

CASE REPORT

Here we present a 31-year-old patient with gastrointestinal tract perforation at the second part of the duodenum due to an ingested fishbone. The patient was admitted to the emergency room with abdominal pain. Right upper quadrant tenderness was detected at physical examination, and leukocytosis on the laboratory test results. Ultra-sonography was not diagnostic, however, computerized tomo-graphy showed an ingested foreign body in the second part of the duodenum. A fishbone perforating the duodenum was retrieved by endoscopy. The patient was managed non-operatively, and discharged without any problems on the third day after endoscopy.

CONCLUSION

Endoscopic removal and non-operative management may be feasible in carefully selected patients with duodenal perforated fishbone ingestion.

Comparison between uncovered and covered self-expandable metal stent placement in malignant duodenal obstruction

AIM: To compare the clinical outcomes of uncovered and covered self-expandable metal stent placements in patients with malignant duodenal obstruction.

METHODS: A total of 67 patients were retrospectively enrolled from January 2003 to June 2013. All patients had symptomatic obstruction characterized by nausea, vomiting, reduced oral intake, and weight loss. The exclusion criteria included asymptomatic duodenal obstruction, perforation or peritonitis, concomitant small bowel obstruction, or duodenal obstruction caused by benign strictures. The technical and clinical success rate, complication rate, and stent patency were compared according to the placement of uncovered (n = 38) or covered (n = 29) stents.

RESULTS: The technical and clinical success rates did not differ between the uncovered and covered stent groups (100% vs 96.6% and 89.5% vs 82.8%). There were no differences in the overall complication rates between the uncovered and covered stent groups (31.6% vs 41.4%). However, stent migration occurred more frequently with covered than uncovered stents [20.7% (6/29) vs 0% (0/38), P < 0.05]. Moreover, the overall cumulative median duration of stent patency was longer in uncovered than in covered stents [251 d (95%CI: 149.8 d-352.2 d) vs 139 d (95%CI: 45.5 d-232.5 d), P < 0.05 by log-rank test] The overall cumulative median survival period was not different between the uncovered stent (70 d) and covered stent groups (60 d).

CONCLUSION: Uncovered stents may be preferable in malignant duodenal obstruction because of their greater resistance to stent migration and longer stent patency than covered stents.