Removal of press-through-packs impacted in the upper esophagus using an overtube

INTRODUCTIONForeign bodies in the esophagus should be removed toavoid serious complications, such as bleeding, mediastinitis, esophageal perforation and pulmonary aspiration[1-5]. Esophageal impaction of a foreign body with sharp edges is considered a med…     

Esophageal variceal ligation by reloading with inexpensive hemorrhoidal O-ring--is an overtube necessary?

The overtube is the major cause for severe complications during endoscopic variceal ligation with a single-shot ligator. This retrospective study was designed to examine the necessity of the placement of an overtube during elective endoscopic variceal ligation. Thirty-one sessions in 18 patients were analyzed. An overtube was inserted using an over-the-scope technique in 11 sessions (group 1) but was omitted in 20 sessions (group II). The complications, technical difficulties, and operating time were analyzed. Child's grading, the size of the esophageal varices, and the number of rubber bands deployed were comparable in both groups. There was a significantly longer operating time (p < 0.01) and more oropharyngeal injury (p = 0.03) in group I than in group II. Mid esophageal injury, which was associated with resistance in withdrawing the gastroscope from the overtube, occurred in 55% of sessions in group I but in 0% of session in group II. In conclusion, the use of an overtube is associated with more complications, and it can be omitted during elective endoscopic variceal ligation.     

A multipurpose overtube for diagnostic and therapeutic flexible fiberoptic endoscopy

A newly devised overtube for diagnostic and interventional endoscopy has been used in 140 cases. In 60 cases of acute gastrointestinal bleeding, adequate gastric lavage was completed in 14.1 +/- 1.3 min, using an average of 7.5 +/- 0.69 liters; the volume of fluid recovered was 103.9 +/- 0.58% of the volume infused. This tube also allows simultaneous gastric lavage and esophageal or gastric tamponade, enabling therapeutic intervention with sclerotherapy or bipolar coagulation in the patient with acute massive bleeding. This device can be employed for the removal of bezoars, foreign bodies, and multiple polyps.     

A new indication for transcutaneous cholangioscopy

The main indication for transcutaneous cholangioscopy through a channel of percutaneous transhepatic drainage are choledocholithiasis, hepatolithiasis and non-malignant or malignant stenosis of the bile ducts. In our department we were able to treat thus repeatedly also complete severing of the biliary pathways. GROUP: Twelve patients with complete severing of the right hepatic ducts (4x) or common bile duct (8x) after cholecystectomy could not be operated on account of great surgical risk or adhesions after operation. On account of cholangitis they had percutaneous transhepatic drainage. After three weeks transcutaneous cholangioscopy was performed and recanalization by means of a needle-shaped knife. The operation was terminated by introduction of a metal prosthesis Palmaz. RESULTS: The method was successful in all patients, there were no complications associated with the procedure. CONCLUSION: Transcutaneous cholangioscopy and recanalization of complete severing of the biliary pathways is a new safe method. It is indicated in patients with increased surgical risk. For restoration of the continuity of the bile ducts a metal prosthesis Palmaz is inserted. Short-term results of treatment are satisfactors, long-term results call for a longer follow up.     

Accurate hemostasis with a new endoscopic overtube for emergency endoscopy

Endoscopic hemostasis performed in the emergency room is difficult due to the presence of blood clots and food residue that makes obtaining a clear view of the bleeding vessel difficult. We experienced the efficacy of a newly developed inverted overtube to shorten the hemostatic time and obtain a clear endoscopic view with upper gastrointestinal bleeding patient who were transferred by ambulance car and required emergency endoscopy. The technique improved the endoscopic views and enabled us to perform the hemostatic procedures from the conventional standing position while freely and easily changing the patient’s position. The presence of blood clots and food residue in the gastric fornix or upper gastric body makes identifying a bleeding exposed vessel impossible. This set-up significantly shortened the procedure time. The inverted overtube helped us obtain a clear view in patients who were laid in the right lateral position. Rapid identification of ex-posed vessels resulted in success of hemostasis.     

Direct peroral cholangioscopy简

Peroral cholangioscopy is an important tool for diagnosis and treatment of various biliary disorders. Peroral cholangioscopy can be performed by using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope, or by direct insertion of a small-diameter endoscope into the bile duct. Direct peroral cholangioscopy refers to insertion of an ultraslim endoscope directly into the bile duct for visualization of the biliary mucosa and lumen. This approach provides a valuable and economic solution for diagnostic and therapeutic applications in the biliary tree. Compared to ductoscopy using a dedicated cholangioscope, the direct approach has several advantages and disadvantages. In this editorial, I discuss the advantages, disadvantages, and possible future developments pertaining to direct peroral cholangioscopy.     

Direct peroral cholangioscopy

Peroral cholangioscopy is an important tool for diagnosis and treatment of various biliary disorders. Peroral cholangioscopy can be performed by using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope, or by direct insertion of a small-diameter endoscope into the bile duct. Direct peroral cholangioscopy refers to insertion of an ultraslim endoscope directly into the bile duct for visualization of the biliary mucosa and lumen. This approach provides a valuable and economic solution for diagnostic and therapeutic applications in the biliary tree. Compared to ductoscopy using a dedicated cholangioscope, the direct approach has several advantages and disadvantages. In this editorial, I discuss the advantages, disadvantages, and possible future developments pertaining to direct peroral cholangioscopy.     

Diagnostic and therapeutic direct peroral cholangioscopy using an intraductal anchoring balloon

AIM: To report our experience using a recently introduced anchoring balloon for diagnostic and therapeutic direct peroral cholangioscopy (DPOC).METHODS: Consecutive patients referred for diagnostic or therapeutic peroral cholangioscopy were evaluated in a prospective cohort study. The patients underwent DPOC using an intraductal anchoring balloon, which was recently introduced to allow consistent access to the biliary tree with an ultraslim upper endoscope. The device was later voluntarily withdrawn from the market by the manufacturer.RESULTS: Fourteen patients underwent DPOC using the anchoring balloon. Biliary access with an ultraslim upper endoscope was accomplished in all 14 patients. In 12 (86%) patients, ductal access required sphincteroplasty with a 10-mm dilating balloon. Intraductal placement of the ultraslim upper endoscope allowed satisfactory visualization of the biliary mucosa to the level of the confluence of the right and left hepatic ducts in 13 of 14 patients (93%). Therapeutic interventions by DPOC were successfully completed in all five attempted cases (intraductal biopsy in one and DPOC guided laser lithotripsy in four). Adverse events occurred in a patient on immunosuppressive therapy who developed an intrahepatic biloma at the site of the anchoring balloon. This required hospitalization and antibiotics. Repeat endoscopic retrograde cholangiopancreatography 8 wk after the index procedure showed resolution of the biloma.CONCLUSION: Use of this anchoring balloon allowed consistent access to the biliary tree for performance of diagnostic and therapeutic DPOC distal to the biliary bifurcation.     

Therapeutic role of direct peroral cholangioscopy using an ultra-slim upper endoscope

Introduction

Peroral cholangioscopy provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother?Cbaby scope system is not widely used because of its disadvantages. Direct peroral cholangioscopy (POC) with a regular, ultra-slim, upper endoscope can provide a valuable and economic solution for evaluating bile duct lesions, although its therapeutic role in biliary tract disease is uncertain. We assessed the usefulness of direct POC with an ultra-slim endoscope for therapeutic application in patients with biliary diseases.

Methods

Several new techniques and accessories allow therapeutic intervention under direct POC using an ultra-slim upper endoscope with a larger, 2-mm working channel. Intracorporeal laser or electrohydraulic lithotripsy under direct POC is a main therapeutic intervention for patients with bile duct stones resistant to conventional endoscopic procedures. Tumor ablation therapy such as photodynamic therapy and argon plasma coagulation may be performed under direct POC. Direct POC can be applied to guide biliary interventions such as guidewire placement, stone removal, and migrated stent retrieval, using diverse accessories.

Conclusion

Direct POC with an ultra-slim upper endoscope allows therapeutic intervention for patients with biliary diseases. Enhancements of the endoscope and specialized accessories are expected to expand the therapeutic role of direct POC.     

Going for the loop: a unique overtube for the difficult colonoscopy

In up to 10% to 20% of colonoscopies, complete intubation of the colon may be considerably difficult. A principal cause of difficulty is looping of the endoscope shaft in a floppy, often tortuous segment of the colon that typically happens in the sigmoid colon. Also, if looping is not recognized and the scope is advanced with abandon, the risk of perforation will rise. Special "variable stiffness" colonoscopies are expensive and have not been unequivocally shown to be useful in preventing looping. The simplest approach to prevent looping is perhaps the use of an over-tube to prevent the shaft from bowing out. The ShapeLock could offer an ideal over-tube that is flexible enough to safely and easily negotiate bends in the colon but when needed be rigid enough to prevent looping with just a snap of its handle. It also has potential other applications including enteroscopy, transgastric endoscopy and access to difficult regions of the upper gastrointestinal tract.     

Staging cholangiocarcinoma by cholangioscopy

Peroral cholangioscopy (POCS) and percutaneous transhepatic cholangioscopy (PTCS) were first developed in the 1970s, and technical developments and clinical applications have taken place gradually ever since. POCS is used to diagnose small mucosal biliary lesions in non-icteric patients and early malignant changes in patients with persistent primary sclerosing cholangitis (PSC). Although PTCS is a more invasive diagnostic procedure than POCS, it has the advantage of precise diagnosis with mapping biopsy in defining the proximal and distal extension of superficially spreading cholangiocarcinoma (CCA) or mucin-producing CCA, which is predominantly found in papillary type CCA. POCS is significantly superior to ERCP in distinguishing between malignant and benign dominant bile duct stenoses in patients with PSC. The positive rate of PTCS biopsy for CCA is 96%, while morbidity and mortality of PTCS are 9% and 0%, respectively. Although magnetic resonance (MR) cholangiography may replace PTCS in determining the longitudinal spread of infiltrating type hilar CCA, the accuracy of MR cholangiography in papillary type hilar CCA is significantly lower than that of PTCS.