Endoscopic partial sphincterotomy coupled with large balloon papilla dilation – Single stage approach for management of extra-hepatic bile ducts macro-lithiasis

Endoscopic papillary balloon dilation (EPBD) was introduced in the 80 s as an alternative for treatment of biliary lithiasis in order to minimize complications related to biliary endoscopic sphincterotomy (ES) and to preserve sphincter mechanism. However it could not gain wide acceptance because of high incidence of post procedural pancreatitis compared to ES alone. In 2003, endoscopic large balloon papillary dilation (ELPBD) coupled with ES, has been proposed as an alternative to lithotripsy for treatment of giant or difficult calculi of the common bile duct. Since then, several studies have evaluated the efficacy of such approach, however in the absence of clear instructions about indications, technique's standardization, morbidity rate and long-term results this procedure has not yet gained wide use. In this report we describe our technique of partial endoscopic sphincterotomy plus large papillary balloon dilation in the treatment of common bile duct and cystic duct macro-lithiasis. According to our clinical experience, we would like to focus on the technical points that have to be respected in order to reduce procedure's complications and to achieve successful clinical resultsWe conclude that endoscopic partial sphincterotomy plus large papillary balloon dilation seems a promising, effective and safe approach to treat giant extrahepatic biliary calculi, if performed after correct patient selection and under established guidelines. Keywords: Biliary stone, Endoscopic sphincterotomy, Papilla dilation, Giant stone, Sphincteroplasty, Choledocholithiasis, Vide

Outcome of Leaks After Sleeve Gastrectomy Based on a New Algorithm Addressing Leak Size and Gastric Stenosis

Text We welcomed with great interest the masterpiece of Nedelcu et al. Moreover, we believe in the importance of introducing a well-defined algorithm in order to standardize the endoscopic treatment modality for leak following bariatric surgery. However, according to our experience, we have some remarks to do. Here, we report a case of a 59-year-old woman, presenting an early fistula [3] following laparoscopic sleeve gastrectomy. At day 12 after surgery, she underwent reoperation for peritonitis with lavage and drainage of peritoneal cavity, and two peri-gastric surgical drainage were left in place. No primary repair was attempted due to severe local tissue inflammation. Endoscopy showed a 2-cm-long dehiscence, of the last staple fire line, allowing passing through with the scope. Swallow study through the scope showed the persistence of intra-abdominal collection in the left hypochondrium and the presence of a left bronchial tree fistula Electronic supplementary material The online version of this articl

Closure of gastrointestinal defects with Ovesco clip: long-term results and clinical implications

Background: The Over-The-Scope Clip (OTSC®, Ovesco Endoscopy GmbH, Tübingen, Germany) is an innovative clipping device that provides a strong tissue grasp and compression without provoking ischemia or laceration. In this retrospective study we evaluated immediate and long-term success rates of OTSC deployment in various pathologies of the gastrointestinal (GI) tract. Methods: A total of 45 patients (35 female, 10 male) with an average age of 56 years old (range, 24–90 years) were treated with an OTSC for GI defects resulting from a diagnostic or interventional endoscopic procedure (acute setting group) or for fistula following abdominal surgery (chronic setting group). All procedures were performed with CO 2 insufflation. Results: From January 2012 to December 2015 a total of 51 OTSCs were delivered in 45 patients for different kinds of GI defects. Technical success was always achieved in the acute setting group with an excellent clip adherence and a clinical long-term success rate of 100% (15/15). Meanwhile, considering the chronic setting group, technical success was achieved in 50% of patients with a long-term clinical success of 37% (11/30); two minor complications occurred. A total of three patients died due to causes not directly related to clip deployment. Overall clinical success rate was achieved in 58% cases (26/45 patients). A mean follow-up period of 17 months was accomplished (range, 1–36 months). Conclusion: OTSC deployment is an effective and minimally-invasive procedure for GI defects in acute settings. It avoids emergency surgical repair and it allows, in most cases, completion of the primary endoscopic procedure. OTSC should be incorporated as an essential technique of today’s modern endoscopic armamentarium in the management of GI defects in acute settings. OTSCs were less effective in cases of chronic defects

Post-biliary sphincterotomy bleeding despite covered metallic stent deployment

Several endoscopic techniques have been proposed for the management of post-sphincterotomy bleeding. Lately, self-expandable metal stents deployment has gained popularity especially as a rescue therapy when other endoscopic techniques fail

Endoscopic internal drainage as first-line treatment for fistula following gastrointestinal surgery: a case series

Leaks following gastrointestinal surgery are a dreadful complication burdened by high morbidity and not irrelevant mortality. Endoscopic internal drainage (EID) has showed optimal results in the treatment of leaks following bariatric surgery. We report our experience with EID as first-line treatment for fistulas following surgery along all gastrointestinal tract

Fully covered self-expandable metal stent in the treatment of postsurgical colorectal diseases: Outcome in 29 patients

Background: Self-expandable metal stent (SEMS) placement is a minimally invasive treatment for palliation of malignant colorectal strictures and as a bridge to surgery. However, the use of SEMS for benign colorectal diseases is controversial. The purpose of this retrospective study is to evaluate the efficacy and safety of fully covered SEMS (FCSEMS) placement in postsurgical colorectal diseases. Methods: From 2008 to 2014, 29 patients with 32 FCSEMS deployment procedures were evaluated. The indications for stent placement were: 17 anastomotic strictures (3/17 presented complete closure of the anastomosis); four anastomotic leaks; seven strictures associated with anastomotic leak; and one rectum-vagina fistula. Results: Clinical success was achieved in 18 out of 29 patients (62.1%) being symptom-free at an average of 19 months. In the remaining 11 patients (37.9%), a different treatment was needed: four patients required multiple endoscopic dilations, 4 patients colostomy confection, one patient definitive ileostomy and three patients revisional surgery. The FCSEMS were kept in place for a mean period of 34 (range: 6–65) days. Major complications occurred in 12 out of 29 patients (41.4%) and consisted of stent migration. Minor complications included two cases of transient fever, eight cases of abdominal or rectal pain, and one case of tenesmus. Conclusion: FCSEMS are considered a possible therapeutic option for treatment of postsurgical strictures and leaks. However, their efficacy in guaranteeing long-term anastomotic patency and leak closure is moderate. A major complication is migration. The use of FCSEMS for colonic postsurgical pathologies should be carefully evaluated for each patient

Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study

Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures