Introduction
Achalasia after bariatric surgery is a rare pathological entity. Nonetheless, several cases have been described in literature. Per oral endoscopic myotomy has recently emerged as the ...preferred approach for the management of esophageal motility disorders.
Material and Methods
We report a video case of POEM performed in a female patient with prior multiple bariatric surgical procedures. In her past medical history, she underwent to laparoscopic lap band, sleeve gastrectomy, and Roux-Y-gastric bypass.
Results
POEM was carried out without complication. Myotomy was performed only for 1 cm below the cardias due to the presence of the gastro-jejunal anastomosis. Post-operative course was uneventful and oral diet was restarted after one day. At 2 months follow-up, the patient is asymptomatic with no weight regain.
Conclusion
We report the first case of POEM after three different bariatric surgical procedure. Fibrosis due to prior interventions did not hampered POEM procedure, and the shorter myotomy due to the presence of small gastric pouch did not reduced its efficacy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Introduction
Roux-en-Y gastric bypass (RYGB) is one of the most common surgical procedures for the management of morbid obesity. However, RYGB poses technical difficulties in exploring the gastric ...remnant and in performing endoscopic biliary interventions due to altered anatomy. Recently, EUS guided gastro-gastric anastomosis to access the excluded stomach has been introduced in order to allow direct trans-gastric interventions.
Method and Material
We report the case of a 38-year-old female referred to our unit to undergo EUS direct trans-gastric intervention (EDGI) for the management of a small stone in the biliary tract. Pre-procedural CT scan highlighted an abnormal distension of the gastric remnant. EUS guided jejuno-gastric anastomosis was carried out with the deployment of a 15 x 10 mm lumen apposing metal stent (LAMS).
Results
After 3 days, an upper GI endoscopy was performed, highlighting a mobile 25 mm polyp near the pylorus. Therefore endoscopic resection was planned before the performance of the ERCP. Piecemeal endoscopic mucosectomy was carried out with no evidence of any adverse event. However, endoscopic evaluation after specimen retrieval detected an almost complete dehiscence of the anastomosis. Emergency surgery was decided with restoration of the continuity of the gastric cavity to allow future endoscopic examinations/procedures.
Discussion
Here, we report the first case of dehiscence of the surgical gastro-jejunal anastomosis during EDGI procedure. Performing an ERCP during EDGI is probably safer than performing gastric interventions. When performing EDGI, it is paramount to carefully evaluate the type of planned gastric procedure and to adopt a tailored approach according the several variables involved.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Introduction
Treatment of pancreato-biliary disorders after gastric bypass is challenging due to altered anatomy. Several techniques have been proposed to overcome this condition; however, none has ...emerged as the gold standard treatment. Furthermore, a decision-making algorithm evaluating when and why apply one technique over another is still lacking.
Objectives
To describe a novel trans-gastric approach to allow endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass (RYGB) anatomy soon after prior laparoscopic cholecystectomy (LC) and to propose a decision-making algorithm for selection of the most suitable technique according a tailored approach.
Setting
Private hospital.
Methods
Between January and March 2020, patients with Roux-en-Y gastric bypass anatomy referred to our tertiary center to undergo ERCP after recent laparoscopic cholecystectomy were retrospectively evaluated. A 20 french (Fr) gastrostomy was performed during cholecystectomy. A single-stage ERCP was carried out by means of temporary trans-gastric stent deployment over a 20 Fr gastrostomy.
Results
A total of 5 patients (mean age 41; mean body mass index 48.3) were enrolled. ERCP was performed after an average of 2 days from surgery. Technical and clinical success was achieved in 100%. No adverse events occurred. Spontaneous closure of the gastrostomy after its bedside removal was observed in all cases.
Conclusions
Our approach allows to perform a single-stage ERCP in RYGB patients, early after LC, with no need of any other re-interventions. Any surgeon facing unexpected biliary disorders, during LC, can easily perform a 20 Fr gastrostomy thus allowing the patient to undergo early ERCP without any delay.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Fine needle aspiration (FNA) is currently the standard of care for sampling pancreatic solid masses by using endoscopic ultrasound (EUS). The accuracy of the technique is reported to be high, ...especially if coupled with the rapid on site evaluation (ROSE), and it has a high safety profile. However, FNA presents some limitations, such as the small amount of tissue that can be collected and the inability of obtaining a core tissue with intact histological architecture, which is relevant to perform immunohistochemical analysis, molecular profiling and, therefore, targeted therapies. Moreover, the presence of the ROSE by an expert cytopathologist is very important to maximize the diagnostic yield of FNA technique; however, it is not widely available, especially in small centers. Hence, the introduction of EUS fine needle biopsy (FNB) with a new generation of needles, which show a high safety profile too and a satisfying diagnostic accuracy even in the absence of ROSE, could be the key to overcome the limitations of FNA. However, FNB has not yet shown diagnostic superiority over FNA. Considering all the technical aspects of FNA and FNB, the different types of needle currently available, comparisons in term of diagnostic yield, and the different techniques of sampling, a tailored approach should be used in order to determine the needle that is most appropriate for the different specific scenarios.
Aim: Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 ...cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS).
Methods: All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence.
Results: Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9).
Conclusions: Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background
Gastro-bronchial and gastro-colic fistulas (GB-GC) represent a rare, but serious complication after laparoscopic sleeve gastrectomy (LSG). The aim of this study is to evaluate the efficacy ...of endoscopic first-line approach with endoscopic internal drainage (EID) by inserting double pigtail stents (DPS)
Methods
We retrospectively analyzed data from 40 consecutive patients referred at two tertiary centers for gastro-bronchial (
N
=30) and gastrocolic (
N
=10) fistulas following LSG. Nineteen patients previously experienced emergency surgical drainage. The mean interval between the index surgery and endoscopic fistula treatment was 265.6±521 days.
Results
Healing of the fistulous tract was achieved in 19 patients (47.5%), with complete resolution at an average follow-up of 16 months. Mean time of treatment duration was 157.8±141 days with 5.0±2.9 endoscopic sessions. No major adverse events were registered.
Conclusions
Despite complete fistula healing was achieved in less than 50% of our population, EID for GB/GC fistula after LSG still represents the most conservative approach with low complications rate. Previous surgical drainage seems to be a positive prognostic factor for endoscopic healing. While the longer the interval between the index surgery and endoscopic treatment, the lower was the rate of treatment success.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Post-operative collections are a recognized source of morbidity after abdominal surgery. Percutaneous drainage is currently considered the standard treatment but not all collections are ...accessible using this method. Since the adoption of EUS, endoscopic transmural drainage has become an attractive option in the management of such complications. The present study aimed to assess the efficacy, safety and modalities of endoscopic transmural drainage in the treatment of post-operative collections.
Methods
Data of all patients referred to our dedicated multidisciplinary facility from 2014 to 2017 for endoscopic drainage of symptomatic post-operative collections after failure of percutaneous drainage or when it was deemed impossible, were retrospectively analyzed.
Results
Thirty-two patients (17 males and 15 females) with a median age of 53 years old (range 31–74) were included. Collections resulted from pancreatic (
n
= 10), colorectal (
n
= 6), bariatric (
n
= 5), and other type of surgery (
n
= 11). Collection size was less than 5 cm in diameter in 10 (31%), between 5 and 10 cm in 17 (53%) ,and more than 10 cm in 5 (16%) patients. The median time from surgery to endoscopic drainage was 38 days (range 6–360). Eight (25%) patients underwent endoscopic guided drainage whereas 24 (75%) patients underwent EUS-guided drainage. Technical success was 100% and clinical success was achieved in 30 (93.4%) after a mean follow-up of 13.5 months (1.2–24.8). Overall complication was 12.5% including four patients who bled following trans-gastric drainage treated with conservative therapy.
Conclusions
The present series suggests that endoscopic transmural drainage represents an interesting alternative in the treatment of post-operative collection when percutaneous drainage is not possible or fails.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Physiological ageing and tumorigenesis are both associated with epigenomic alterations in human tissue cells, the most extensively investigated of which entails de novo cytosine methylation (i.e., ...hypermethylation) within the CpG dinucleotides of CpG islands. Genomic regions that become hypermethylated during tumorigenesis are generally believed to overlap regions that acquire methylation in normal tissues as an effect of ageing. To define the extension of this overlap, we analysed the DNA methylomes of 48 large-bowel tissue samples taken from women of different ages during screening colonoscopy: 18 paired samples of normal and lesional tissues from donors harbouring a precancerous lesion and 12 samples of normal mucosa from tumour-free donors. Each sample was subjected to targeted, genome-wide bisulphite sequencing of ~2.5% of the genome, including all CpG islands. In terms of both its magnitude and extension along the chromatin, tumour-associated DNA hypermethylation in these regions was much more conspicuous than that observed in the normal mucosal samples from older (vs. younger) tumour-free donors. 83% of the ageing-associated hypermethylated regions (n = 2501) coincided with hypermethylated regions observed in tumour samples. However, 86% of the regions displaying hypermethylation in precancerous lesions (n = 16,772) showed no methylation changes in the ageing normal mucosa. The tumour-specificity of this latter hypermethylation was validated using published sets of data on DNA methylation in normal and neoplastic colon tissues. This extensive set of genomic regions displaying tumour-specific hypermethylation represents a rich vein of putative biomarkers for the early, non-invasive detection of colorectal tumours in women of all ages.
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BFBNIB, GIS, IJS, KISLJ, NUK, PNG, UL, UM, UPUK
Background and Aims
Endoscopy is effective in management of bariatric surgery (BS) adverse events (AEs) but a comprehensive evaluation of long-term results is lacking. Our aim is to assess the ...effectiveness of a standardized algorithm for the treatment of BS-AE.
Patients and Methods
We retrospectively analyzed 1020 consecutive patients treated in our center from 2012 to 2020, collecting data on demographics, type of BS, complications, and endoscopic treatment. Clinical success (CS) was evaluated considering referral delay, healing time, surgery, and complications type. Logistic regression was performed to identify variables of CS.
Results
In the study period, we treated 339 fistulae (33.2%), 324 leaks (31.8%), 198 post-sleeve gastrectomy twist/stenosis (19.4%), 95 post-RYGB stenosis (9.3 %), 37 collections (3.6%), 15 LAGB migrations (1.5%), 7 weight regains (0.7%), and 2 hemorrhages (0.2%). Main endoscopic treatments were as follows: pigtail-stent positioning under endoscopic view for both leaks (CS 86.1%) and fistulas (CS 77.2%), or under EUS-guidance for collections (CS 88.2%); dilations and/or stent positioning for sleeve twist/stenosis (CS 80.6%) and bypass stenosis (CS 81.5%). After a median (IQR) follow-up of 18.5 months (4.29–38.68), complications rate was 1.9%. We found a 1% increased risk of redo-surgery every 10 days of delay to the first endoscopic treatment. Endoscopically treated patients had a more frequent regular diet compared to re-operated patients.
Conclusions
Endoscopic treatment of BS-AEs following a standardized algorithm is safe and effective. Early endoscopic treatment is associated with an increased CS rate.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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