Double-endoscope assisted endoscopic submucosal dissection for treating tumors in rectum and distal colon by expert endoscopists: a feasibility study

Background!#!Colorectal endoscopic submucosal dissection (ESD) is an effective but challenging procedure. To facilitate ESD, several methods that apply traction are available; however, the optimal one remains to be established. The aim of this study was to evaluate the feasibility and safety of the double-endoscope assisted ESD (DEA-ESD) by improving traction to treat complex colorectal lesions.!##!Methods!#!Naïve or previously treated lesions in the rectum and sigmoid colon were included. A grasping forceps advanced through a small-caliber endoscope (GIF-XP190N, Olympus Medical Systems, Tokyo, Japan, 5.4 mm outer diameter) was used to apply traction to the mucosal flap. Lesions were deemed complex when they exceeded a total of nine points on the SMSA scoring system (size, morphology, site, and access) and recurrent when they were previously treated with endoscopic mucosal resection (EMR). Outcome measures included procedural success, total procedure time, complications, and recurrence rate at 3-month follow-up.!##!Results!#!Nine patients (mean age 62.3 ± 14.5 years) were included; five had rectal and four had tumors in the sigmoid colon. The median SMSA score was 14 (SMSA Level IV-complex polyp), while three patients were pre-treated with EMR. DEA-ESD was technically feasible in all cases. En bloc resection and R0 resection rates were 100%, respectively, with a mean procedure time of 128.4 ± 54.1 min. No immediate or delayed complications occurred.!##!Conclusions!#!DEA-ESD is a feasible and safe method for treating complex or recurrent tumors in the rectum and distal colon

Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique

Abstract Background and study aim Relief from dysphagia and regurgitation are the main goals of therapy in symptomatic Zenker’s diverticulum. Flexible endoscopic treatment has proved to be an effective and safe method in control of these symptoms. The aim of our study was to further improve the resection of the cricopharyngeal muscle using a new technique, the double incision and snare resection (DISR) procedure, to reduce the recurrence rate. Patients and methods From February 2016 to April 2017, 16 patients were treated with 18 DISR procedures at our institution. The symptoms of the patients were recorded by a seven-item questionnaire prior to treatment, and re-evaluation was scheduled at 1 and 6 months after treatment. Results The median age was 70 years (range 55 – 85), and 10 patients were men (62 %). The median size of the diverticulum was 20 mm (range 5 – 40 mm), and the DISR procedure was performed in 28 minutes (range 20 – 47 minutes), with no major postinterventional complications. All patients re-started oral nutrition on the day after the intervention; a gastric tube was not required. The median follow-up was 3 months (range 1 – 15 months). Two patients received a planned second-step procedure, one because of a very large cricopharyngeal muscle and one because of a cyst inside the Zenker’s bridge. Although one patient suffered from mild recurrence of symptoms, she refused a second treatment. All other patients were free of symptoms after treatment. Conclusions The DISR procedure is a new endoscopic treatment technique that safely and reproducibly offers relief from symptomatic Zenker’s diverticulum.</jats:p

Chromoendoscopy in magnetically guided capsule endoscopy

Background Diagnosis of intestinal metaplasia and dysplasia via conventional endoscopy is characterized by low interobserver agreement and poor correlation with histopathologic findings. Chromoendoscopy significantly enhances the visibility of mucosa irregularities, like metaplasia and dysplasia mucosa. Magnetically guided capsule endoscopy (MGCE) offers an alternative technology for upper GI examination. We expect the difficulties of diagnosis of neoplasm in conventional endoscopy to transfer to MGCE. Thus, we aim to chart a path for the application of chromoendoscopy on MGCE via an ex-vivo animal study. Methods We propose a modified preparation protocol which adds a staining step to the existing MGCE preparation protocol. An optimal staining concentration is quantitatively determined for different stain types and pathologies. To that end 190 pig stomach tissue samples with and without lesion imitations were stained with different dye concentrations. Quantitative visual criteria are introduced to measure the quality of the staining with respect to mucosa and lesion visibility. Thusly determined optimal concentrations are tested in an ex-vivo pig stomach experiment under magnetic guidance of an endoscopic capsule with the modified protocol. Results We found that the proposed protocol modification does not impact the visibility in the stomach or steerability of the endoscopy capsule. An average optimal staining concentration for the proposed protocol was found at 0.4% for Methylene blue and Indigo carmine. The lesion visibility is improved using the previously obtained optimal dye concentration. Conclusions We conclude that chromoendoscopy may be applied in MGCE and improves mucosa and lesion visibility. Systematic evaluation provides important information on appropriate staining concentration. However, further animal and human in-vivo studies are necessary