"Down-to-Up" transanal NOTES Total mesorectal excision for rectal cancer: Preliminary series of 9 patients

Background: Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde ("Down-to-Up") total mesorectal excision for rectal cancer. Materials And Methods: Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis. Results: Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients. Conclusion: This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results

Extreme bariatric endoscopy: stenting to reconnect the pouch to the gastrojejunostomy after a Roux-en-Y gastric bypass

Among the possible complications of bariatric surgery, fistula and partial dehiscence of the gastric suture are well known. Reoperation often is required but results in significant morbidity. Endoscopic treatment of some bariatric complications is feasible and efficient. A modified metallic stent was placed between the gastroaesophageal junction and the alimentary jejunal limb, allowing the passage of a nasoenteric feeding tube into the jejunal limb. Endoscopy showed disruption of nearly the entire staple line at the gastric pouch. The modified stent was placed and allowed wound healing. After 31 days, the stent had migrated and was removed endoscopically. Total clousure of the fistula was reported 30 days afterward. Endoscopic treatment of some bariatric surgery complications is feasible and has been reported previously. This report presents a case of a serious leakage treated by placement of a self-expandable metal stent to bridge the fistula

Treatment of ring slippage after gastric bypass: long-term results after endoscopic dilation with an achalasia balloon (with videos)

Background: Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery. Objective: To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass. Design: Case series. Setting: Federal University of Pernambuco and sao Paulo University. Patients: This study involved 39 consecutive patients who-were screened for inclusion. Intervention: Endoscopic dilation with an achalasia balloon. Main Outcome Measurements: Technical success and safety of the procedure. Results: Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months). Limitations: This was not a randomized, comparison study, and the number of patients was relatively small. Conclusion: The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal. (Gastrointest Endosc 2010;72:44-9.

International multicenter study of safety and effectiveness of Swedish Adjustable Gastric Band in 1-, 3-, and 5-year follow-up cohorts

New Yor

Duodenal mucosal resurfacing: Multicenter experience implementing a minimally invasive endoscopic procedure for treatment of type 2 diabetes mellitus.

Background and study aims  Duodenal mucosal resurfacing (DMR) is an endoscopic procedure which improves insulin resistant metabolic disease, including type 2 diabetes mellitus (T2DM). The aim of this report was to evaluate the feasibility and procedural aspects of DMR and to provide more specific DMR procedural guidance for endoscopists. Patients and methods  In this international multicenter, prospective, open-label study, patients on oral anti-diabetic agents for treating T2DM underwent single DMR. DMR entails circumferential submucosal lifting followed by circumferential mucosal hydrothermal ablation using an over-the-guidewire balloon catheter for lifting and ablation. For the first 28 patients a dual catheter system was used. During the study, a new integrated catheter was developed which was used for the latter 18 patients. During DMR, procedure success (complete DMR: duodenal ablation length ≥ 9 cm) and procedure duration were captured. Results  Forty-six patients underwent DMR. Using the dual catheter system, a complete DMR was performed in 22 of 28 patients (79 %). In the next eighteen patients who underwent DMR with the integrated catheter, a complete DMR was performed in 15 of 18 patients (83 %). The integrated catheter facilitated the DMR procedure and resulted in a reduction in procedure time. A detailed table and video are provided for future endoscopists. Conclusions  In our multicenter study, DMR was found to be feasible in the hands of experienced endoscopists. The integrated DMR catheter was a welcome modification during the study, allowing for easier ablation administration. Further optimization of the technique would be valuable prior to widespread dissemination.status: publishe

Duodenal mucosal resurfacing: proof-of-concept, procedural development, and initial implementation in the clinical setting

Background and Aims: We aimed to develop duodenal mucosal resurfacing (DMR), a minimally invasive upper endoscopic hydrothermal ablation procedure, to treat insulin-resistant metabolic diseases. Methods: We completed a sham-controlled, rodent proof-of-concept study and longitudinal safety study in pigs to demonstrate feasibility to test DMR in humans. Subsequently, the DMR procedure was implemented in an open-label first-in-human (FIH) study of safety and efficacy in patients with type 2 diabetes (T2D). Results: In rats, duodenal abrasion reduced hyperglycemia by 59 mg/dL on average, compared with no change from baseline in the sham treatment arm (P < .05). In pigs, the balloon catheter successfully and safely delivered hydrothermal ablation to the duodenal mucosa and superficial submucosa. Complete mucosal healing was demonstrated by week 6. In the FIH study, hydrothermal ablation was successfully administered with no evidence of perforation, pancreatitis, or hemorrhage. Duodenal biopsy specimens obtained 3 months postprocedure demonstrated full mucosal regrowth. No inflammation was observed, and there was minimal-to-mild collagen banding deposition observed in a proportion of ablation site biopsy specimens with no evidence of fibrotic scarring. Glycemic and hepatic measures improved through 6 months of follow-up. Conclusions: DMR shows potential as an endoscopic intervention that improves glycemic and hepatic parameters in patients with T2D. Further mechanistic and clinical studies are underway to further explore DMR as a treatment for metabolic disease

Endoscopic duodenal mucosal resurfacing for the treatment of type 2 diabetes:6-month interim analysis from the first-in-human proof-of-concept study

OBJECTIVE To assess procedural safety and glycemic indices at 6 months in a first-in-human study of duodenal mucosal resurfacing (DMR), a novel, minimally invasive, upper endoscopic procedure involving hydrothermal ablation of the duodenal mucosa, in patients with type 2 diabetes and HbA1c 657.5% (58 mmol/mol) on one or more oral antidiabetic agents. RESEARCH DESIGN AND METHODS Using novel balloon catheters, DMR was conducted on varying lengths of duodenum in anesthetized patients at a single medical center. RESULTS A total of 39 patients with type 2 diabetes (screening HbA1c 9.5% [80 mmol/mol]; BMI 31 kg/m2) were treated and included in the interimefficacy analysis: 28 had a long duodenal segment ablated (LS; 3c9.3 cm treated) and 11 had a short segment ablated (SS; 3c3.4 cm treated). Overall, DMR was well tolerated with minimal gastrointestinal symptoms postprocedure. Three patients experienced duodenal stenosis treated successfully by balloon dilation. HbA1c was reduced by 1.2% at 6 months in the full cohort (P < 0.001). More potent glycemic effects were observed among the LS cohort, who experienced a 2.5% reduction in mean HbA1c at 3months postprocedure vs. 1.2%in the SS group (P < 0.05) and a 1.4% reduction at 6 months vs. 0.7% in the SS group (P = 0.3). This occurred despite net medication reductions in the LS cohort between 0 and 6 months. Among LS patients with a screening HbA1c of 7.5-10% (58-86 mmol/mol) and on stable antidiabetic medications postprocedure, HbA1c was reduced by 1.8% at 6 months (P < 0.01). CONCLUSIONS Single-procedure DMR elicits a clinically significant improvement in hyperglycemia in patients with type 2 diabetes in the short-term, with acceptable safety and tolerability. Long-termsafety, efficacy, and durability and possiblemechanisms of action require further investigation