ULTRATHIN ENDOSCOPE‐ASSISTED ERCP FOR INACCESSIBLE PERIDIVERTICULAR PAPILLA BY A SINGLE‐BALLOON ENTEROSCOPE IN A PATIENT WITH ROUX‐EN‐Y ANASTOMOSIS

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux‐en Y (R‐Y). A 73‐year‐old man who had total gastrectomy with R‐Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre‐cutting, the ultraslim endoscope was replaced with a conventional forward‐viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure‐related complication.     

Approach to the endoscopic resection of duodenal lesions

Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations(such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.     

Current state of double balloon endoscopy: The latest approach to small intestinal diseases

Recent developments of capsule endoscopy and double balloon endoscopy (DBE) have made endoscopic examination of the entire small bowel practical, and changed the diagnostic algorithm for small bowel diseases. Double balloon endoscopy uses two balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops of intestine. Total inspection by DBE is usually achieved by combination of sequential oral and anal intubations; success rates are reported to be 40–80%. Indications for DBE include scrutiny for obscure gastrointestinal bleeding, small bowel tumor, small bowel stricture and following up evaluation of previously diagnosed small bowel diseases. Because DBE has an accessory channel and good maneuverability in the distal small intestine, it enables endoscopic treatment, including hemostasis, balloon dilation, polypectomy, mucosal resection, retrieval of foreign bodies and endoscopic retrograde cholangiopancreatography (in the case of post-operative anastomoses). Double balloon endoscopy is also useful for cases of difficult colonoscopy, providing success rates of total colonoscopy between 88–100%. Although it has been a few years since its development, the usefulness of DBE is now well recognized. This challenging procedure has become popular rapidly and is currently used in many countries.     

CURRENT STATUS OF DOUBLE BALLOON ENDOSCOPY

Yamamoto and colleagues have developed a novel insertion method of the endoscope, the ‘double balloon method’ for enteroscopy and, recently, a specialized system for the ‘double balloon method’ has been commercialized by Fujinon. The double balloon endoscopy enables visualization of the entire small bowel and also allows for interventional therapy in the small intestine. This method could be used either from the oral or anal approach. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, hemostasis, balloon dilatation, stent placement, polypectomy, and endoscopic mucosal resection. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.     

Clinical results of observation of the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope

Background and Aim: Esophagogastroduodenoscopy through the oral cavity of patients who have undergone percutaneous endoscopic gastrostomy (PEG) causes some distress and puts these patients at risk of aspiration pneumonia. The aim of this study was to evaluate results for the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope. Methods: The study subjects were 43 patients, who underwent exchange of a PEG button or tube, 20‐French or more in diameter. After PEG buttons or tubes were extracted from the gastrostomy tract, an ultrathin endoscope was inserted through the gastrostomy tract. The stomach and the duodenal bulb were observed and the esophagus was observed in retrograde passage. A new PEG button or tube was then inserted. The rate of successful insertion into the esophagus and duodenal bulb, the observation of the gastrostomy site in retroversion in the stomach, and the endoscopic findings were analyzed. Results: Ninety‐nine examinations were carried out. The esophagus could be observed in 95 (96.0%), the duodenum in 92 (92.9%) and the gastrostomy site in the stomach in all. Gastric polyps were detected in four patients, gastric erosions in two, reflux esophagitis in two, polypoid lesion at the gastrostomy tract in two, gastric ulcer scar in one, duodenal ulcer scar in one, early gastric cancer in one and recurrent esophageal cancer in one. Neither discomfort nor complications occurred during transgastrostomic endoscopy. Conclusions: Observation of the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope during a gastrostomy button or tube replacement may be useful and safe.     

Nonampullary duodenal adenoma:Current understanding of its diagnosis,pathogenesis,and clinical management

Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis(FAP), but nonampullary sporadic duodenal adenomas(SDAs)are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection(EMR), endoscopic submucosal dissection(ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polypfree duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAPrelated polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.     

Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent

A 78-year-old male was admitted to our hospital because of choledocholithiasis.ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation(EPLBD) with a size of 15 mm.Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla.Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis.Therefore, we placed a 10 mm fully covered selfexpandable metallic stent(SEMS) across the duodenal papilla, and the hemorrhage stopped immediately.After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct.A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct.We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.     

DOUBLE BALLOON ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN ROUX‐EN‐Y ANASTOMOSIS PATIENTS

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of patients with pancreaticobiliary disorders, but endoscopic therapy is very difficult to carry out in patients with a Roux‐en‐Y anastomosis. We herein present the results of ERCP for patients with a Roux‐en‐Y anastomosis using a double‐balloon endoscope. Six patients (six men with a mean age of 69 years) who had undergone prior gastric resection with Roux‐en‐Y reconstruction were enrolled in the present study and underwent ERCP and associated procedures. ERCP was carried out with a double balloon endoscope, which has one balloon attached to the tip of the endoscope and another attached to the distal end of the soft overtube. In all patients, entering the Y loop was successfully accomplished, and the papilla of Vater was also reached in all cases (100%). Cannulation was successful in four patients (66.7%). The final diagnosis was choledocholithiasis in two patients, biliary fistula in one patient and pancreatic cancer in one patient. A needle‐knife precut papillotomy was carried out after placement of a bile duct stent in two patients, and injection of N‐butyl‐2‐cyanoacrylate into a biliary fistula was carried out in one patient. None of the patients suffered from any complications. A double balloon endoscope is therefore considered to be useful for carrying out ERCP and associated procedures in patients with a Roux‐en‐Y anastomosis.     

Multiple giant duodenal ulcers associated with duodenal gastrinoma

A 59-year-old Japanese man with a history of chronic hepatitis C and cirrhosis was admitted to hospital because of severe abdominal pain and diarrhea. His discomfort had begun 2 months earlier and was localized to the upper abdomen. Upper gastrointestinal endoscopy showed multiple ulcerative lesions from the duodenal bulb to the descending part of the duodenum, one of which was a giant ulcer that filled half of the intestinal lumen. Despite continuous intravenous lansoprazole therapy, his abdominal symptoms did not improve. Upper gastrointestinal endoscopy was again performed to detect the tumor, but it was difficult to observe the tumor with a conventional endoscope. We then inverted a transnasal endoscope into the duodenum, and this enabled us to detect a 15-mm submucosal tumor in the upper wall of the duodenal bulb. Examination of specimens from endoscopic ultrasonography fine-needle aspiration biopsy of the tumor revealed gastrinoma in the duodenal bulb. We decided to perform an operative resection. The patient’s symptoms resolved after surgery, and he remained asymptomatic at follow-up 18 months later. Therefore, when it is difficult to detect the tumor directly by conventional endoscopy, we recommend that attempts be made to detect the tumor by inverting a transnasal endoscope into the duodenal bulb.     

Endoscopic mucosal resection and endoscopic submucosal dissection in the treatment of sporadic nonampullary duodenal adenomatous polyps

Although uncommon, sporadic nonampullary duodenal adenomas have a growing detection due to the widespread of endoscopy. Endoscopic therapy is being increasingly used for these lesions, since surgery, considered the standard treatment, carries significant morbidity and mortality. However, the knowledge about its risks and benefits is limited, which contributes to the current absence of standardized recommendations. This review aims to discuss the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in the treatment of these lesions. A literature review was performed, using the Pubmed database with the query: “(duodenum or duodenal) (endoscopy or endoscopic) adenoma resection”, in the human species and in English. Of the 189 retrieved articles, and after reading their abstracts, 19 were selected due to their scientific interest. The analysis of their references, led to the inclusion of 23 more articles for their relevance in this subject. The increased use of EMR in the duodenum has shown good results with complete resection rates exceeding 80% and low complication risk (delayed bleeding in less than 12% of the procedures). Although rarely used in the duodenum, ESD achieves close to 100% complete resection rates, but is associated with perforation and bleeding risk in up to one third of the cases. Even though literature is insufficient to draw definitive conclusions, studies suggest that EMR and ESD are valid options for the treatment of nonampullary adenomas. Thus, strategies to improve these techniques, and consequently increase the effectiveness and safety of the resection of these lesions, should be developed.     

Endoscopic resection of ampullary adenoma after a new insulated plastic pancreatic stent placement: A pilot study

Background and Aim: Although pancreatic stent insertion is recommended for the prevention of post‐procedure pancreatitis during endoscopic papillectomy, insertion of the stent after the procedure can be technically difficult. The aim of the present study was to determine the feasibility and safety of inserting a newly developed insulated pancreatic stent before endoscopic papillectomy. Methods: We conducted a prospective pilot study involving 11 consecutive patients with adenomas of the major duodenal papilla. After a 5F polytetrafluoroethylene‐insulated pancreatic stent was inserted through the tumor, the stent and tumor were simultaneously grasped with a snare. After resection of the tumor with the stent in place, the tumor was incised perpendicularly along the edge of the stent for retrieval of the specimen. Results: In all patients, the insulated pancreatic stents were successfully inserted before endoscopic papillectomy and were resistant to electrical current; retrieval of the specimen was technically feasible and successful without stent migration. There were no stent‐related complications, but five papillectomy‐related complications (including mild bleeding [n = 4] and late papillary stenosis [n = 1]) occurred without any episodes of acute pancreatitis or perforation. Conclusions: Pre‐resection stenting with a polytetrafluoroethylene‐insulated stent in patients with adenomas of the major duodenal papilla is a feasible and useful technique to prevent pancreatitis.     

Endoscopic management of mucosal lesions in the gastrointestinal tract

With the increasing role of endoscopy in patient evaluation, more mucosal lesions, including gastric, duodenal and colonic polyps, are encountered during routine examinations. It is imperative for gastroenterologists to become familiar with the endoscopic management of these various gastrointestinal lesions. In this article, various resection techniques will be discussed, including hot/cold forceps polypectomy, hot/cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The article will also discuss the evidence regarding the efficacy and safety of these techniques and the future direction of endoscopic management of mucosal lesions in the gastrointestinal tract.     

Endoscopic snare excision for a major papilla tumor

Tumors of the duodenal papilla include hyperplasia, adenoma, carcinoma in adenoma and carcinoma. As the duodenal papilla has special anatomical characteristics and treatment involves major intervention and correct preoperative diagnosis. In patients with adenoma, or early carcinoma of the papilla, various endoscopic snare excision techniques are indicated for complete removal the tumor. Pancreatitis and cholangitis are major complications caused by endoscopic techniques. In the present study, endoscopic snare excision of the tumor located at the major papilla was carried out in two cases with early carcinoma or adenoma patients using a therapeutic duodenoscope, a spiral snare for the colon, and pure cutting current. The patients who underwent insertion of a 5‐Fr pancreatic stent and a 7‐Fr biliary stent inserted immediately after endoscopic tumor resection did not develop either pancreatitis nor cholangitis. This seems to be a safe technical method to prevent complications of endoscopic snare excision of the major papilla tumor.     

ENDOSCOPIC FINDINGS OF ENTEROPATHY‐TYPE T‐CELL LYMPHOMA BY DOUBLE‐BALLOON ENTEROSCOPY AND CAPSULE ENDOSCOPY

Enteropathy‐type T‐cell lymphoma (ETL) is a rare primary intestinal disorder, particularly in Japan, and there have been few reports on the endoscopic findings of the disease. Here we report detailed endoscopic findings of ETL based on double‐balloon enteroscopy and capsule endoscopy. Double‐balloon enteroscopy and capsule endoscopy may be useful tools for diagnosing and monitoring the effects of therapy in patients with ETL.     

Endoscopic balloon dilation of postoperative duodenal stricture by using a new type of wire‐guided balloon catheter

When the stricture of gastrointestinal tract is complicated, the insertion of the balloon catheter is very difficult even with ‘through‐the‐scope’ balloon dilators. We present here a new type of multifunctional balloon dilator, controlled radial expansion (CRE) wire‐guided balloon dilatation catheter (Boston Scientific, MA, USA). This instrument enabled successful treatment of a complicated postoperative stricture of the duodenum. A 74‐year‐old man, who had undergone duodenum‐preserving resection of the head of the pancreas for mucin‐producing tumor, had severe stenosis at the duodenal second portion. After failed trials in negotiating the stricture by means of conventional balloon dilators, CRE wire‐guided balloon dilatation catheter was introduced through the working channel of the scope and advanced over a guide wire into the stricture under fluoroscopic control. The stenosis was successfully dilated up to the full size of the balloon (20 mm) by increasing the inflation pressure in a stepwise manner. After the procedure, the patient could consume soft food and gruel easily without complications. The dilation effect has been maintained up to the present for more than 12 months. This new instrument is recommended in endoscopic dilation as a safe and useful tool, even for a complicated stricture.     

Innovative therapeutic endoscopy in the upper gastrointestinal tract: Review of Japan Gastroenterological Endoscopic Society Core Sessions

Workshops on "Innovative Therapeutic Endoscopy" for upper gastrointestinal tract diseases were held four times as the Japan Gastroenterological Endoscopic Society (JGES) Core Sessions at the 93rd to 96th Biannual Meetings of the JGES. A total of 48 research presentations (including two invited lectures) were reported, and various discussions were held on these topics. When the research presentations were categorized according to the therapeutic procedure, endoscopic submucosal dissection (ESD) was the most frequent with 28 presentations (58.3%), followed by laparoscopy endoscopy cooperative surgery (LECS) with six presentations (12.5%). When the research presentations were classified by the target organ of the therapeutic procedures, the duodenum was the most frequent with 26 presentations (54.1%), followed by the stomach with 13 presentations (27.1%). The most important issue was the establishment of a safe and reliable endoscopic resection method for duodenal lesions. Issues related to gastric ESD were establishing an efficient traction method and a method to prevent post-ESD bleeding in high-risk patients. Other important issues were establishment of an efficient traction method and methods of preventing delayed bleeding in high-risk patients who undergo gastric ESD, expansion of indications for minimally invasive treatment using LECS for gastric cancer, the development of endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMTs), and improvement of per-oral endoscopic myotomy (POEM) for esophageal achalasia and per-oral endoscopic tumor resection (POET) for esophageal SMTs. Through the JGES Core Sessions, it is expected that the minimally invasive treatments using endoscopes developed in Japan will be further advanced.     

Study on minute surface structures of the depressed‐type early gastric cancer with magnifying endoscopy

Background: Gastric surface patterns and morphology of minute surface vessels in depressed lesions were analyzed using a magnifying endoscope with high resolving power to contribute to qualitative diagnosis of gastric cancer. Methods: Subjects were diagnosed with depressed‐type early gastric cancer (pT1), there were 63 lesions, 38 differentiated‐type lesions, and 25 undifferentiated‐type lesions. There were also 40 benign depressed lesions found. After routine observations with an endoscope, amplifying observations of lesions were made by EG‐410CR (Fuji Photo Optical; Saitama, Japan) (CR). The images were compared with macroscopic patterns and histopathological patterns of the surgical specimens and endoscopic mucosal resection specimens. Results: Surface patterns of gastric depressed lesions were classified as irregular protrusion, normal papilla, pseudopapilla and amorphia. Irregular protrusion was found only in cancerous lesions. Characteristic minute vessels were observed in amorphia. Their patterns were classified into the following six types: sand, fence, round net, flat net, branch and coil. Irregular protrusion and minute vessels in amorphia (round net, flat net, branch and coil) were specific to cancers. There was a tendency for round net and flat net patterns to be found often in differentiated cancers and for branch and coil patterns to be found often in undifferentiated cancers. Conclusion: This magnifying endoscopic classification is considered useful for the qualitative diagnosis of depressed‐type early gastric cancer.     

Randomized controlled trial comparing submucosal endoscopy with mucosal resection and endoscopic submucosal dissection in the esophagus and stomach: Animal study

Background and Aim

In Western countries, endoscopic submucosal dissection (ESD) has not prevailed as a result of training problems and a target patient population. We have previously reported a hybrid ESD technique, submucosal endoscopy with mucosal resection (SEMR), in which the submucosal dissection is carried out chiefly by blunt balloon dissection. We have also reported successful application in the porcine colon. In the present study, we compared the safety and efficacy of SEMR with ESD in the porcine esophagus and stomach.

Methods

SEMR and ESD were carried out in eight domestic pigs under general anesthesia. Resection sites were marked by circumferential coagulation. After circumferential ESD knife mucosal incision, submucosal fluid cushion (SFC) was created. In the SEMR group, the balloon catheter was inserted deep into the SFC. The balloon was then inflated and pulled back toward the endoscope tip repeatedly, altering the direction, to disrupt the submucosa. Residual strands were cut with an IT‐knife. En bloc resection rates, procedure times, complications and dissection difficulty scales (DDS) were recorded prospectively. DDS were rated using a visual analog scale.

Results

Thirty‐two resections (8 SEMR/8 ESD in the esophagus; 8 SEMR/8 ESD in the stomach) were done with no major adverse events. There was no statistical difference between the two techniques in either location in the above categories measured.

Conclusions

SEMR and traditional ESD are comparable techniques in safety and effectiveness when carried out in the esophagus and stomach. SEMR may serve as a more appealing technical option for endoscopists who are unable to sustain a traditional ESD practice volume.     

Postoperative Duodenal Stenosis as an Early Complication Following Laparoscopy‐Assisted REsection of Transverse Colon Cancer: Report of Successful Endoscopic Balloon Dilatation

A 69‐year‐old man underwent laparoscopy‐assisted resection for transverse colon cancer. He visited our department approxiately 1 month after operation suffering from nausea and epigastric discomfort. Endoscopy and X‐ray examina‐tion showed a severe stenosis in the second portion of the duodenum, which we believe was caused by the previous colectomy as indicated by no evidence of other causative event or factor found in his history or through thorough examination. He was then successfully treated by endoscopic balloon dilatation using of a controlled radial expansion wire‐guided balloon dilatation catheter. We report a case of postoperative duodenal stenosis as an early complication following laparoscopy‐assisted resection of transverse colon cancer. This case would be the first report documented in Japan that we are aware of. Furthermore, this experience suggested that endoscopic balloon dilatation for postoperative duodenal stenosis is effective.     

Endoscopic full-thickness resection of early mucosal neoplasms

Endoscopic full-thickness resection is a new resection technique that expands the possibilities of endoscopic resection. It is best evaluated for the resection of early mucosal neoplasms in the colorectum but can also be used in the upper gastrointestinal tract. In particular, it enables endoscopic resection in cases of so-called difficult adenomas in the colorectum. This includes resection of nonlifting adenomas and adenomas at difficult locations. Endoscopic full-thickness resection could help avoid surgery in these cases. The Full-Thickness Resection Device is the best-studied system thus far. It has high efficiency and low rate of complication for resection of difficult adenomas. Alternatively, snare resection above a previously-applied clip provides an additional method for endoscopic full-thickness resection. Both techniques have successfully been evaluated in the upper gastrointestinal tract, especially for resection of duodenal adenomas. For the resection of early gastric cancer, combined endoscopic and laparoscopic approaches might offer an alternative treatment for lesions that are not suitable for endoscopic resection alone.