The Role of Endoscopic Tattooing in Colorectal Surgery

The intraoperative finding of a lesion, which has already been located previously by endoscopy, can sometimes be a challenge, especially during laparoscopy. Failure to locate the exact place of the lesion can cause the resection of a wrong bowel segment. Endoscopic submucosal tattooing is a minimally invasive technique, allowing marking of a carcinoma or polyp that is not suitable for endoscopic mucosal resection (EMR) in the colon.During a colonoscopy for marking a certain spot, we use 0.5–1.0 mL of submucosal solution of indigo ink. Injecting the substance causes a dark mark, which is visible in the peritoneal cavity during surgery. The risks of this manipulation are coloring the peritoneum and other structures and organs outside the colon such as kidneys, omentum, stomach, or a part of the intestines. This can be avoided using the proper technique of injection. There are no strict rules of execution of the manipulation. The approach is individual and depends on the endoscopist and the location of the lesion. Frequently used methods are circular marking of the affected area and placement of the ink distally and/or proximally of the lesion.In conclusion, tattooing reduces time in the operating room, lowers the risk of healthy bowel resection and aids in faster finding of the exact location of the lesion. The procedure is easily executed by an experienced endoscopist and does not carry a significant risk of complications

Initial experience with peroral endoscopic myotomy in Bulgaria: case series

Achalasia is a rare motility disorder with unknown etiology that results in failure of relaxation of the lower esophageal sphincter (LES). As there is no etiological treatment, different pharmacological agents and invasive techniques have been used for relieving the symptoms. For the past decade, peroral endoscopic myotomy (POEM) has proven to have excellent results.We present a retrospective study of five patients that underwent POEM for primary achalasia. We used anterior approach for the submucosal tunneling. The procedure showed immediate results and no severe short- or long-term adverse events. We have been following the patients up for more than 3 years now.Since its invention more than ten years ago, the POEM procedure and its advantages and disadvantages compared to the pneumatic dilatation and the Heller myotomy have been extensively studied. There is still no universal opinion on which procedure should be the first line treatment

Prevention of Migration of Esophageal Self-Expandable Metallic Stents Using Endoscopic Clips

Background and Objectives: Esophageal stenting with self-expandable metallic stents (SEMS), for both benign and malignant reasons, has been widely practiced for decades, but migration still remains the most common complication of the procedure. In this report we aim to review our experience and results in stent fixation with clips. Materials and Methods: We present 18 patients who underwent esophageal stenting for both benign and malignant reasons. The SEMSs used were partially covered and were fixated with two to four through the scope hemostatic clips in the proximal end of the prothesis. The procedure was performed only on patients with a high risk of migration of the stent. Results: Migration occurred in only one of the above-mentioned patients and was treated with stent repositioning. The other adverse events that occurred were related to tumor growth in patients with malignant diseases. Conclusions: Clip fixation of an esophageal self-expandable metallic stent in cases considered high-risk for migration is a safe procedure. It reduces the migration rate significantly for both benign and malignant indications

Treatment approach in malignant left-bowel obstruction using self-expandable metallic stent: a case series

Endoscopic self-expandable metallic stent (SEMS) decompression in patients with bowel obstruction due to colon carcinoma has been practiced for over two decades now, both in potentially curable cases and metastatic cancer. Using this case series, we aim to review the literature on the subject and to present our initial experience with using this technique as a bridge to single stage surgery, thus minimizing colostomy creation. We retrospectively reviewed seven cases of bowel obstruction due to left-sided colonic cancer, between March 2020 and March 2021. All patients received SEMS prior to being treated, 7 to 13 days later, using either laparoscopic surgical techniques or open surgery methods. All seven patients underwent single stage surgery, eliminating the need for placing a temporary or permanent stoma, therefore minimizing the hospital stay and increasing the quality of life of the individual. We concluded that treatment with SEMSs for bowel obstruction in colorectal cancer was safe and well tolerated, resulting in primary anastomosis and restoration of the intestinal passage and low short-term morbidity

Treatment approach in malignant left-bowel obstruction using self-expandable metallic stent: a case series

Endoscopic self-expandable metallic stent (SEMS) decompression in patients with bowel obstruction due to colon carcinoma has been practiced for over two decades now, both in potentially curable cases and metastatic cancer. Using this case series, we aim to review the literature on the subject and to present our initial experience with using this technique as a bridge to single stage surgery, thus minimizing colostomy creation. We retrospectively reviewed seven cases of bowel obstruction due to left-sided colonic cancer, between March 2020 and March 2021. All patients received SEMS prior to being treated, 7 to 13 days later, using either laparoscopic surgical techniques or open surgery methods. All seven patients underwent single stage surgery, eliminating the need for placing a temporary or permanent stoma, therefore minimizing the hospital stay and increasing the quality of life of the individual. We concluded that treatment with SEMSs for bowel obstruction in colorectal cancer was safe and well tolerated, resulting in primary anastomosis and restoration of the intestinal passage and low short-term morbidity

Initial experience in target peroral endoscopic submucosal myotomy combined with septotomy for epiphrenic diverticulum

The epiphrenic esophageal diverticulum is a rare non-malignant condition that is commonly associated with motility disorders. It would normally be treated surgically, but with the advancement of endoscopy techniques, peroral endoscopic myotomy with septotomy (D-POEM) has shown its benefits in coping with the symptoms. We present a case of a 71-year-old woman with increasing symptoms of dysphagia, weight loss and imaging data showing a large epiphrenic diverticulum. We treated her using peroral endoscopic myotomy combined with septotomy of the diverticular septum. The procedure showed excellent results with reducing the amount of contrast materials retained in it, improving the quality of life of the patient, and increasing her weight. There were minimal adverse events and no perforations or severe adverse effects occurred. D-POEM is a new and rapidly evolving procedure that is proving to be a safe and effective method of treating epiphrenic esophageal diverticulum

Cost-Effectiveness in Alternative Treatment Options for Pancreatic Pseudocysts

Background and Objectives: Pancreatic pseudocysts often arise as complications of pancreatitis and present unique challenges in clinical management, encompassing considerations for both technical aspects and financial implications. Before the advancements of invasive gastroenterology, pancreatic pseudocysts have been drained surgically for many years. Nowadays, we have less invasive techniques with higher efficiency and lower mortality rates, however, they remain cost-challenging for most countries. Materials and Methods: We present four patients (two males and two females) with pancreatic pseudocysts who underwent endoscopic ultrasound-guided transgastric drainage using plastic stents accompanied by a standard lavage protocol using a nasocystic catheter. Results: All four patients had successful outcomes, and a follow-up at 6 months revealed no traces of the pseudocysts or any significant long-term complications. One acute complication (arterial bleeding) and one late complication (stent migration) were observed. As the study aimed to present a cheaper option for draining pancreatic pseudocysts, we investigated and compared costs for the materials we utilized and those associated with lumen-apposing metal stents. Upon compiling the data, a notable advantage was evident in favour of our method. Conclusions: While EUS-guided drainage of pancreatic pseudocysts using lumen-apposing metal stents (LAMSs) represents a high-end strategy for treating pancreatic pseudocysts, our method demonstrates better cost-effectiveness without compromising efficacy