To investigate technical feasibility, outcomes and adverse events of the lumen-apposing metal stent (LAMS) for benign gastrointestinal (GI) tract strictures.Between July 2015 and January 2017, patients undergoing treatment by LAMS for benign GI strictures at three tertiary referral centers were included in this study. Primary outcomes included technical success, short-term clinical success, long-term clinical success, and adverse events. Short-term clinical success was defined as symptom resolution at 30 d after stent placement. Long-term clinical success was defined by symptom resolution at 60 d in patients who continued to have indwelling stent, or continued symptom resolution at 30 d after elective stent removal.A total of 21 patients (mean age 62.6 years, 47.6% males) underwent placement of LAMS for benign GI strictures. A 15 mm × 10 mm LAMS was placed in 16 patients, a 10 mm × 10 mm LAMS was placed in 2 patients, and a 16 mm × 30 mm LAMS was placed in 3 patients. Technical success was obtained in all cases. Short-term clinical success was achieved in 19 out of 21 cases (90.5%), and long-term clinical success was achieved in 12 out of 18 (66.7%). Mean (range) stent indwell time was 107.2 (28-370) d. After a mean (range) dwell time of 104.3 (28-306) d, 9 LAMSs were removed due to the following complications: ulceration at stent site (n = 1), angulation (n = 2), migration (n = 4) and stricture overgrowth (n = 2). Migration occurred in 4 cases (19.0%), and it was associated with stricture resolution in one case. Median (range) follow-up period was 119 (31-422) d.Utilization of LAMS for benign strictures has shown to be technically feasible and safe, but adverse events highlight the need for further study of its indications.
Introduction: Colonoscopy has served as a highly sensitive method of identifying tumors, polyps, ulcers, active bleeding and inflammation. It is also associated with a significant reduction in mortality from colorectal cancer (CRC). However, achieving widespread adherence to colonoscopy has been a challenge. Patient fears of colonoscopy may contribute to nonadherence, and the most commonly reported fears have included pain, complications and bowel preparation. No previous study has described the perception toward colonoscopy among veterans. Methods: Between November 2014 and May 2016, patients scheduled for colonoscopy in a Veterans Affairs hospital and an academic medical center were enrolled in this study. Patients had to be undergoing colonoscopy for CRC screening, surveillance or diagnostic purpose. As part of a study questionnaire, prior to the procedure, each patient was asked to select or describe his or her single greatest fear pertaining to colonoscopy, or state he or she had no fears at all. Patient responses were analyzed with chi-square goodness-of-fit tests to find any significant differences between the two groups. Results: 64 veteran (age 60.4 years, 93.3% males) and 51 non-veteran patients (mean age 55.8 years, 45.1% males) participated in this study. Differences in age and gender between the groups were signifi cant (P< 0.05). There was a significant difference between groups in patients reporting one fear, 28 veterans (43.7%) and 39 non-veterans (76.5%,P< 0.05). Among veterans who had one fear, the most commonly reported greatest fear included procedure complications (28.6%), pain (21.4%) and bowel preparation (21.4%). Among non-veterans who had at least one fear, the most commonly reported single greatest fears included bowel preparation (25.6%), pain (23.1%) and procedure findings (23.1%). Fear of a post-procedure complication in the non-veteran group was lower at 10.2%. There were no significant differences between the two groups pertaining to reported single greatest fear of colonoscopy. Conclusion: The findings of this study highlight potential differences in perspectives toward colonoscopy between the veteran and non-veteran population. Although the significant differences in gender composition between groups may have been a factor as described in prior studies, this study supports the importance of future investigation of perspectives and education among patients eligible for colonoscopy. Improved educational efforts may ultimately lead to improvement in adherence.
Introduction: Differentiating pancreatic cystic neoplasms remains a challenge using the current technique of Endoscopic Ultrasound-guided fine needle aspiration (EUS-FNA). Recently, a miniaturized biopsy forceps with an outer diameter of acquire tissue. This through-the-needle forceps biopsy technique (TTNFB) has the potential to increase the diagnostic yield of EUS-FNA for pancreatic cystic neoplasms. The primary aim of this study was to evaluate the technical success and safety of EUS-guided TTNFB for pancreatic cystic lesions. The secondary aim was to evaluate the additive value in diagnostic yield this technique may afford over standard EUS-FNA for pancreatic cystic lesions. Methods: This was a retrospective review of all cases of EUS-guided TTNFB performed for pancreatic cystic lesions at a single academic institution over a 12-month period. Technical success was defined as acquisition of adequate tissue for formal histologic analysis. Safety was assessed through recording peri/post procedural adverse events. EUS-TTN forceps biopsy was performed using the Moray® forceps (US Endoscopy, Mentor, OH) through a standard 19G FNA needle. Biopsy of the cyst wall or septum was performed in each case using the same technique. EUS-FNA of cyst fluid for analysis was performed on each patient when possible. When intraductal papillary mucinous neoplasms (IPMN) was suspected, mucin (MUC) staining was performed to verify the results of the histology and to subtype IPMN. Results: The study included 15 cystic lesions (mean size 26.6mm) in 15 patients. Technical success was 87% (13/15). There was 1 adverse event of intracystic bleeding with no clinical sequelae (6.7%). There were no episodes of pancreatitis. EUS-guided TTNFB with histologic analysis yielded a diagnosis in 11/15 patients (73%) as compared to 0/15 (0%) patients using EUS-FNA and cytologic analysis (p < 0.01). 7 of 8 IPMNs were able to be subtyped based on histologic analysis and MUC staining. Conclusion: This study demonstrates that EUS-TTN forceps biopsy of pancreatic cystic lesions appears safe and can be performed with high technical success. TTN forceps biopsy with histologic analysis demonstrated a significantly higher diagnostic yield for pancreatic cystic lesions compared to EUS-FNA and cytologic analysis. Furthermore, subtyping of IPMN was feasible in this study. EUS-guided through the needle forceps biopsy is a novel technique that should be considered in the diagnostic algorithm for patients with pancreatic cystic lesions.
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
The management of gallstone ileus has primarily involved surgical intervention by enterolithotomy with or without bowel resection. Given that gallstone ileus is most common in elderly patients with comorbidities, the mortality and morbidity associated with surgical intervention are significant. We report a case of using electrohydraulic lithotripsy (EHL) to treat gallstone ileus in a patient with ileocolonic anastomotic stenosis. A 73-year-old male with a history of cirrhosis, Crohn's disease, prior small bowel resection and ileocolonic anastomosis presented with lower abdominal pain, nausea and vomiting. He underwent colonoscopy, which demonstrated an impacted 3 cm by 2 cm mixed pigment gallstone at the site of his prior ileocolonic anastomosis. This anastomosis appeared to have strictured. Previous attempts using a Roth net were unsuccessful in retrieving the stone. The patient was referred to an academic tertiary care center for further management of his gallstone ileus. He underwent a colonoscopy, where the gallstone was identified at the stenotic ileocolonic anastomosis. The anastomosis was dilated under endoscopic and fluoroscopic guidance to 20mm. Initial attempts to retrieve the stone with a Roth net were unsuccessful in pulling the stone through the anastomosis. The decision was made to perform electrohydraulic lithotripsy. The EHL generator and at a power level of 100 and shock frequency of 15 shocks/second was utilized. The lumen was perfused with saline to provide the fluid medium at the stone-probe interface for EHL. Shock waves were delivered which led to effective fragmentation of the stone. The fragmented stones were cleared from the small bowel entirely through using a Roth net basket. On 8 weeks follow-up, patient continues to remain asymptomatic. Technique Highlights: EHL in this instance was effective in fragmenting a large gallstone. In using this technique, complete immersion with saline should be used as the medium in the lumen of the bowel. Also care must be made to ensure constant visualization of contact of the EHL probe and the stone or fragment being targeted. Our case highlights the potential role of EHL to treat complicated cases of gallstone ileus in patients who are poor surgical candidates for enterolithotomy. Watch the video: https://goo.gl/ZkJcWb
Background and study aims Lumen-apposing metal stents (LAMS) have been designed as proprietary stents for the management of pseudocysts (PC)/walled off necrosis (WON). There has been concern about adverse events (AEs) with LAMS including bleeding, buried stent syndrome and migration. Prior to LAMS becoming available, fully-covered self-expandable metal esophageal and biliary stents (FCSEMSs) were used off-label for management of PC/WON with many centers demonstrating low rates of AEs. The primary aim of this study was to study the safety and efficacy of FCSEMS for the management of pseudocysts/WON. Patients and methods This was a retrospective review of all endoscopic ultrasound (EUS)-guided placement of FCSEMSs for drainage of PC/WON cases performed at our institution over 4-year period. The primary outcomes studied were technical success, AEs, PC/WON resolution, and salvage surgical/radiologic intervention. Results Technical success achieved in 65 of 65 (100 %) study patients. An AE occurred 0 of 25 patients (0 %) with PC, and in 10 of 40 patients (25 %) with WON: bleeding (3 %), migration (5 %) and stent dysfunction/infection (18 %). There was resolution in 25 of 25 patients (100 %) with a PC and 31 of 40 patients (78 %) with a WON. Salvage therapy by interventional radiology or surgery was performed in nine of 40 patients (22 %). Conclusions This single-center 4-year experience in the pre-LAMS era showed that FCSEMS was safe and effective in all patients with PC and over 75 % of patients with WON. Given the large cost differential between LAMS and FCSEMS and the efficacy and safety shown with FCSEMS, we believe that FCSEMS should still be considered a first-line option for patients with pancreatic fluid collections, particularly in patients with PCs.
The management of gallstone ileus has primarily involved surgical intervention by enterolithotomy with or without bowel resection. Given that gallstone ileus is most common in elderly patients with comorbidities, the mortality and morbidity associated with surgical intervention are significant. We report a case of using electrohydraulic lithotripsy (EHL) to treat gallstone ileus in a patient with ileocolonic anastomotic stenosis. A 73-year-old male with a history of cirrhosis, Crohn's disease, prior small bowel resection and ileocolonic anastomosis presented with lower abdominal pain, nausea and vomiting. He underwent colonoscopy, which demonstrated an impacted 3 cm by 2 cm mixed pigment gallstone at the site of his prior ileocolonic anastomosis. This anastomosis appeared to have strictured. Previous attempts using a Roth net were unsuccessful in retrieving the stone. The patient was referred to an academic tertiary care center for further management of his gallstone ileus. He underwent a colonoscopy, where the gallstone was identified at the stenotic ileocolonic anastomosis. The anastomosis was dilated under endoscopic and fluoroscopic guidance to 20mm. Initial attempts to retrieve the stone with a Roth net were unsuccessful in pulling the stone through the anastomosis. The decision was made to perform electrohydraulic lithotripsy. The EHL generator and at a power level of 100 and shock frequency of 15 shocks/second was utilized. The lumen was perfused with saline to provide the fluid medium at the stone-probe interface for EHL. Shock waves were delivered which led to effective fragmentation of the stone. The fragmented stones were cleared from the small bowel entirely through using a Roth net basket. On 8 weeks follow-up, patient continues to remain asymptomatic. Technique Highlights: EHL in this instance was effective in fragmenting a large gallstone. In using this technique, complete immersion with saline should be used as the medium in the lumen of the bowel. Also care must be made to ensure constant visualization of contact of the EHL probe and the stone or fragment being targeted. Our case highlights the potential role of EHL to treat complicated cases of gallstone ileus in patients who are poor surgical candidates for enterolithotomy.Figure: Gallstone in Small bowel.Figure: Fragmented stone after EHL.
