Faculty Bibliography

BACKGROUND:ERCP is challenging in patients with Roux-en-Y gastric bypass. Using EUS to gain access to the excluded stomach and subsequently performing transcutaneous ERCP was described recently. OBJECTIVE:We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). DESIGN/METHODS:Single-center case series. SETTING/METHODS:Tertiary center with expertise in EUS-guided procedures. PATIENTS/METHODS:Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. INTERVENTIONS/METHODS:A linear echoendoscope was used to access the excluded stomach. A LAMS was deployed over a wire to create a gastrogastric or jejunogastric fistula. A duodenoscope was then passed through the LAMS and conventional ERCP was performed. MAIN OUTCOME MEASUREMENTS/METHODS:Technical and clinical success rates as well as adverse events. RESULTS:EUS-guided creation of a gastrogastric or jejunogastric fistula via placement of a LAMS was successful in all cases (100%). The ability to perform ERCP through the fashioned fistula during the index procedure was successful in 3 of 5 cases (60%). Two LAMS dislodgments requiring restenting were observed. No major adverse events were observed. No weight regain occurred. The median procedure time was 68.0 minutes. LIMITATIONS/CONCLUSIONS:Small sample, single-institution experience. CONCLUSION/CONCLUSIONS:The internal EDGE procedure may offer a cost-effective, minimally invasive option for a common problem in a growing patient demographic. Further refinement of the technique is required to minimize adverse events. ( CLINICAL TRIAL REGISTRATION NUMBER/BACKGROUND:NCT01522573.).

BACKGROUND:Radiofrequency ablation of malignant biliary strictures has been offered for the last 3 years, but only limited data have been published. AIM/OBJECTIVE:To assess the safety, efficacy, and survival outcomes of patients receiving endoscopic radiofrequency ablation. METHODS:Between April 2010 and December 2013, 69 patients with unresectable neoplastic lesions and malignant biliary obstruction underwent 98 radiofrequency ablation sessions with stenting. RESULTS:A total of 69 patients (22 male, aged 66.1 ± 13.3) were included in the registry. The etiology of malignant biliary stricture included unresectable cholangiocarcinoma (n = 45), pancreatic cancer (n = 19), gallbladder cancer (n = 2), gastric cancer (n = 1), and liver metastasis from colon cancer (n = 3). Seventy-eight percentage of patients had prior chemotherapy. All strictures were stented post-radiofrequency ablation with either plastic stents or metal stents. The mean stricture length treated was 14.3 mm. There was a statistically significant improvement in stricture diameter post-ablation (p < 0.0001). The likelihood of stricture improvement was significantly greater in pancreatic cancer-associated strictures [RR 1.8 (95 % 1.03-5.38)]. Seven patients (10 %) had adverse events, not linked directly to radiofrequency ablation. Median survival was 11.46 months (6.2-25 months). CONCLUSION/CONCLUSIONS:Radiofrequency ablation is effective and safe in malignant biliary obstruction and seems to be associated with improved survival.

BACKGROUND AND STUDY AIMS/OBJECTIVE:Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (FCSEMS). Recent studies have demonstrated migration rates between 30% and 60%. The aim of this study was to determine the effect of fixation of the FCSEMS by endoscopic suturing on migration rate. PATIENT AND METHODS/METHODS:Patients who underwent stent placement for esophageal strictures and leaks over the last year were captured and reviewed retrospectively. Group A, cases, were patients who underwent suture placement and group B, controls, were patients who had stents without sutures. Basic demographics, indications, and adverse events (AEs) were collected. Kaplan-Meier analysis and Cox regression modeling were conducted to determine estimates and predictors of stent migration in patients with and without suture placement. RESULTS:Thirty-seven patients (18 males, 48.65%), mean age 57.2 years (±16.3 y), were treated with esophageal FCSEMS. A total of 17 patients received sutures (group A) and 20 patients received stents without sutures (group B). Stent migration was noted in a total of 13 of the 37 patients (35%) [2 (11%) in group A and 11 (55%) in group B]. Using Kaplan-Meier analysis and log-rank analysis, fixation of the stent with suturing reduced the risk of migration (P=0.04). There were no AEs directly related to suture placement. CONCLUSIONS:Anchoring of the upper flare of the FCSEMS with endoscopic sutures is technically feasible and significantly reduces stent migration rate when compared with no suturing, and is a safe procedure with very low AEs rates.

BACKGROUND:Patients with Roux-en-Y gastric bypass (RYGB) anatomy pose challenges when endoscopic retrograde cholangiopancreatography (ERCP) is required. Deep enteroscopy-assisted ERCP can allow pancreaticobiliary intervention in these patients, but with limited success. This case series describes endoscopic ultrasound-directed transgastric ERCP (EDGE) for patients following RYGB. METHODS:Patients with RYGB anatomy undergoing EDGE at a tertiary care center were included in this prospective single-arm feasibility study. All procedures were performed in two stages. First a 16-Fr percutaneous endoscopic gastrostomy (PEG) was placed in the excluded stomach using endoscopic ultrasound (EUS) guidance. Second, ERCP was performed through the newly fashioned gastrostomy and a transcutaneous fully covered metal esophageal stent. RESULTS:Six patients (5 women, 1 man) with RYGB anatomy underwent EDGE. EUS-guided PEG placement was successful in all six patients (100 %). Antegrade ERCP was successful in all six patients (100 %) with the stages being separated by a mean of 5.8 days. The mean procedure times for the two stages were 81 minutes and 98 minutes. Two patients (33 %) had localized PEG site infections that were managed with oral antibiotics. There were no adverse events related to ERCP. CONCLUSIONS:EDGE is both feasible and safe to perform in RYGB patients. Given the high success rates of our recent experience, we suspect that this technique can be performed as a one-stage procedure to provide a cost-effective, minimally invasive option for a common problem in a growing patient population.

BACKGROUND AND AIMS/OBJECTIVE:Novel endoscopic techniques have been developed as effective treatments for obesity. Recently, reduction of gastric volume via endoscopic placement of full-thickness sutures, termed endoscopic sleeve gastroplasty (ESG), has been described. Our aim was to evaluate the safety, technical feasibility, and clinical outcomes for ESG. PATIENT AND METHODS/METHODS:Between August 2013 and May 2014, ESG was performed on 10 patients using an endoscopic suturing device. Their weight loss, waist circumference, and clinical outcomes were assessed. RESULTS:Mean patient age was 43.7 years and mean body mass index (BMI) was 45.2 kg/m(2). There were no significant adverse events noted. After 1 month, 3 months, and 6 months, excess weight loss of 18 %, 26 %, and 30 %, and mean weight loss of 11.5 kg, 19.4 kg, and 33.0 kg, respectively, were observed. The differences observed in mean BMI and waist circumference were 4.9 kg/m(2) (P = 0.0004) and 21.7 cm (P = 0.003), respectively. CONCLUSIONS:ESG is effective in achieving weight loss with minimal adverse events. This approach may provide a cost-effective outpatient procedure to add to the steadily growing armamentarium available for treatment of this significant epidemic.