Introduction: Management of esophageal anastomotic leaks (AL) and esophageal perforations (EP) remains difficult and often requires an interdisciplinary treatment modality. For primary endoscopic ...management, self-expanding metallic stent (SEMS) placement is often considered first-line therapy. Recently, endoscopic vacuum therapy (EVT) has emerged as an alternative or adjunct for management of these conditions. So far, data for EVT in the upper gastrointestinal-tract is restricted to single centre, non-randomized trials. No studies on optimal negative pressure application during EVT exist. The aim of our study is to describe our centre’s experience with low negative pressure (LNP) EVT for these indications over the past 5-years. Patients and Methods: Between January 2014 and December 2018, 30 patients were endoscopically treated for AL (n = 23) or EP (n = 7). All patients were primarily treated with EVT and LNP between –20 and –50 mm Hg. Additional endoscopic treatment was added when EVT failed. Procedural and peri-procedural data, as well as clinical outcomes including morbidity and mortality, were analysed. Results: Clinical successful endoscopic treatment of EP and AL was achieved in 83.3% (n = 25/30), with 73.3% success using EVT alone (n = 22/30). Mean treatment duration until leak closure was 16.1 days (range 2–58 days). Additional treatment modalities for complete leak resolution was necessary in 10% (n = 3/30), including SEMS placement and fibrin glue injection. Mean hospital stay for patients with EP was shorter with 33.7 days compared to AL with 54.4 days (p = 0.08). Estimated preoperative 10-year overall survival (Charlson comorbidity score) was 39.4% in patients with AL and 59.9% in patients with EP (p = 0.26). A mean of 5.1 EVT changes (range 1–12) was needed in EP and 3.6 changes (range 1–13) in AL to achieve complete closure, switch to other treatment modality, or reach endoscopic failure (p = 0.38). Conclusion: LNP EVT enables effective minimally – invasive endoluminal leak closure from anastomotic esophageal leaks and EP in high-morbid patients. In this study, EVT was combined with other endoscopic treatment options such as SEMS placement or fibrin glue injection in order to achieve leak or perforation closure in the vast majority of patients (83.3%). Low aspiration pressures led to slower but still sufficient clinical results.
Purpose
A perforated peptic ulcer can be managed laparoscopically in selected patients. The purpose of this study was to evaluate whether conversion of emergency laparoscopy is inferior to primary ...median laparotomy in terms of postoperative morbidity and mortality.
Methods
We analyzed patients who underwent laparoscopic or open surgery for a perforated peptic ulcer at the Department of Surgery, University of Schleswig–Holstein, Campus Luebeck between January, 1996 and December, 2010. Perforations were graded according to the Boey classification, a preoperative risk-scoring system.
Results
Conversion to laparotomy was necessary in 20 of the 45 patients who underwent laparoscopic surgery (CG); therefore, laparoscopic operations were completed in 25 patients (LG). The third patient cohort comprised 139 patients who underwent primary laparotomy (OG). Overall minor morbidity was significantly lower (
p
= 0.048) in the LG patients than in the OG patients, whereas no significant differences were found in major morbidity and mortality, particularly between the OG and CG.
Conclusion
Patients’ suitability for laparoscopic management should be decided on according to Boey’s clinical scoring system. Our findings demonstrated that conversion from laparoscopy to laparotomy was not associated with elevated postoperative morbidity or mortality versus initial laparotomy. Therefore, emergency operations may be commenced laparoscopically in selected patients, especially considering the postoperative advantages of this approach.
Gastrointestinal (GI) bleeding is a common complication after heart assist device placement. Reasons for bleeding are multifactorial. Endoscopic therapy is the treatment of choice, whereas invasive ...procedures are avoided in these critically ill patients. We present the case of a 65-year-old male patient experiencing severe GI bleeding after left ventricular assist device (LVAD) and right ventricular assist device (RVAD) placement with therapeutic anticoagulation. Endoscopically, multiple gastric bleeding sources were found but could not be treated effectively due to a large blood clot. A combined endoscopic and surgical treatment was initiated, including gastrotomy for blood clot removal, surgical transgastric suturing, endoscopic over-the-scope clip (OTSC) placement and hemospray application. Postoperative endoscopic visualization showed effective bleeding control. The patient unfortunately died due to causes unrelated to the treatment. This case shows that a minimal invasive combination of endoscopic and surgical techniques can be an alternative treatment for severe upper GI bleeding in critically ill and anticoagulated patients.
Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, ...endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.
Abstract
Introduction
The over-the-scope-clip (OTSC) can potentially overcome
limitations of standard clips and achieve more efficient and reliable
hemostasis. Data on OTSC use for non-variceal ...upper gastrointestinal bleeding
(NVUGIB) in patients with cardiovascular comorbidities are currently limited.
Patients and methods
We prospectively collected and retrospectively
analyzed our database from February 2009 to September 2015 from all patients who
underwent emergency endoscopy for high-risk NVUGIB in 2 academic centers and
were treated with OTSC as first-line (n = 81) or second-line therapy (n = 19).
Results
One hundred patients mean age 72 (range 27 – 97 years) were
included in this study. Fifty-one percent (n = 51) had severe cardiovascular
co-morbidity (ischemic heart disease, congestive heart failure, hypertension,
valvular heart disease, peripheral arterial occlusive disease and atrial
fibrillation) and 73 % (n = 73) were on antiplatelet or/and anticoagulation
therapy. The median size of the treated ulcers was 3 cm (range 1 – 5 cm). In
94 % (n = 94) primary hemostasis with OTSC was achieved. Clinical long-term
success during a mean 6-month follow-up without rebleeding was 86 % (n = 86).
Conclusions
In this cohort OTSC was demonstrated to be a safe and
effective first- or second-line treatment for NVUGIB in high-risk patients with
cardiovascular disease and complex, large ulcers.
Meeting presentations:
Annual Meeting of the German Society of Endoscopy (DEGBV) in Mannheim, Germany,
March 17
th
–19
th
, 2016 and DDW 2016 in San Diego, United
States
Post-sleeve gastrectomy fistulas are a rare but possibly severe life-threatening complication. Besides early reoperation and drainage, endoscopy is the main treatment option. According to the ...clinical setting, endoscopic treatment options comprise stent or clip placement. New endoscopic therapies have recently gained attention, including endoscopic vacuum therapy, VacStent therapy, endoscopic internal drainage with pigtail stents, endoscopic suturing and stem cell injection. In this narrative review, we shed light on recent literature, developments, indications and contraindications of these treatments. Intragastric gastric band migration is a rare complication after gastric band positioning. Reoperation can sometimes be difficult, especially when a gastric band has already migrated far into the stomach. Endoscopic retrieval can be a valid, non-invasive therapeutic solution. We reviewed the current literature on this matter.
Postoperative non variceal upper gastrointestinal haemorrhage may occur early or late and affect a variable percentage of patients—up to about 2%. Most cases of intraluminal bleeding are an ...indication for urgent Esophagogastroduodenoscopy (EGD) and require endoscopic haemostatic treatment. In addition to the approach usually adopted in non-variceal upper haemorrhages, these cases may be burdened with difficulties in terms of anastomotic tissue, angled positions, and the risk of further complications. There is also extreme variability related to the type of surgery performed, in the context of oncological disease or bariatric surgery. At the same time, the world of haemostatic devices available in digestive endoscopy is increasing, meeting high efficacy rates and attempting to treat even the most complex cases. Our narrative review summarises the current evidence in terms of different approaches to endoscopic haemostasis in upper bleeding in altered anatomy after surgery, proposing an up-to-date guidance for endoscopic clinicians and at the same time, highlighting areas of future scientific research.
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