Society: ASGE

LIVE STREAM SESSION

Background: Malnutrition is a complication of Roux-en-Y gastric bypass (RYGB) and can range from micronutrient deficiencies to protein-calorie malnutrition. Malignant neoplasms and certain surgical complications can increase this risk. Surgical reversion of RYGB can be associated with increased morbidity and mortality.

Case Presentation: A 59-year-old female with a history of a RYGB for obesity and protein-calorie malnutrition (49 kgs, BMI of 16 kg/m2) was admitted with septic shock secondary to intra-abdominal abscesses due to a dislodged percutaneous endoscopic gastrostomy (PEG) placed for management of failure to thrive. She underwent exploratory laparotomy with G-tube removal, gastric wedge resection, J-tube insertion, and vacuum-assisted closure (VAC). Her course was complicated by the inadvertent removal of her J-tube. Given non-surgical candidacy for surgical reversion and previous complications, the patient opted to undergo an endoscopic reversal of her RYGB.

Endoscopic Methods: During stage 1 of her procedure, an endoscopic ultrasound (EUS)-guided gastrogastrostomy using a 20x10 mm cautery-enhanced LAMS was performed thus creating a gastric-gastric (G-G) access. The LAMS was dilated up to 18 mm. Visual confirmation of the remnant stomach was obtained. Two weeks after the index procedure, no gross lesions were noted in the remnant stomach and excellent apposition of the LAMS was noted. Thus, we decided to complete the endoscopic reversion of her RGYB by using a transoral outlet occlusion (TORO) technique. First, a 1.5-2 cm circumferential area of mucosal tissue at the gastrojejunal anastomosis (GJA) rim was ablated using straight fire argon plasma coagulation (APC; forced APC, flow of 0.8 L/min, power of 70 W). Afterward, we loaded an endoscopic suturing system in a dual-channel scope and a single 2.0 nonabsorbable polypropylene suture was then used to place multiple full-thickness stitches around the GJA in a running fashion. The suture was then cinched and complete closure of the GJA was achieved. She had no post-procedural complications and was discharged on BID open-capsule PPI, QID liquid sucralfate, and an antiemetic regimen. At a 2-week post-procedure follow-up, the patient continues to do well with an excellent appetite and weight regain of 3.5 kgs.

Clinical Implications: There is a paucity of data on endoscopic reversion of RYGB aiming at a partial reversion of the RYGB with no targeted therapy for the GJA which can help prevent the bypass of the oral intake of these patients and thus potentially improve nutritional parameters.

Conclusion: Combined EUS-guided gastrogastrostomy and the TORO technique for the endoscopic reversion of a Roux-en-Y gastric bypass (RYGB) appears to be technically feasible in patients with failure to thrive after RYGB. Larger studies are necessary to examine long-term efficacy and safety in this population.

Background
Endoscopic sleeve gastroplasty (ESG) is an effective weight loss procedure that uses endoscopic suturing to reduce gastric volume. For a proportion of patients, weight regain occurs and is associated with suture loss. Suture loss is a complex process affected by the forces experienced at the interface of the mucosa and suture. Based on follow up endoscopy studies, suture failure appears to involve both breakdown of the gastric mucosa, suture material deformation, and erosion of the tissue anchors through the gastric wall. Pledgets are flexible pads used during approximation of delicate tissues to spread forces along a suture line without needing to reduce suture tension. To reduce the likelihood of suture failure, we developed a technique to place surgical pledgets endoscopically to distribute forces at the tissue anchor/gastric mucosal interface.

Case Presentation
A 31 year old female with a history of obesity (BMI 37.8) refractory to lifestyle modification and GLP-1 agonist therapy as well as diabetes and fatty liver disease elected to undergo ESG after consideration of bariatric surgery and further medication trials. The procedure was uncomplicated, and she was discharged the same day with minimal pain and nausea. She underwent standard follow up and diet progression. At one month follow up she had lost 8% of her total body weight.

Endoscopic Methods
We performed ESG using a standardized U-stitch pattern with reinforcing interrupted sutures after each U. To optimize durability, we reinforced selected interrupted sutures with 1cm x 2cm teflon pledgets. The procedure was completed in 75 minutes with a total of 60 stitches. Pledget reinforcement was achieved by replacing the suture needle onto the needle driver and withdrawing the endoscope after both bites of the interrupted suture were taken. With both ends of the suture outside the patient, the needle end of the suture was advanced through the pledget and then pulled into the stomach through an overtube by placing gentle traction on the trailing suture end. The trailing suture end was then advanced through a separate pledget and the trailing suture pulled through the endoscope channel using biopsy forceps. The trailing pledget was then pushed in the gastric lumen by advancing the endoscope while placing gentle traction on the trailing end of the suture at the instrument channel opening. The suture was then secured using a standard suture cinch.

Conclusions
Pledget reinforcement for endoscopic suturing is feasible and does not add significantly to procedure time. Pledgets have been shown effective at distributing suture tension and may improve the durability of endoscopic sleeve gastroplasty. Further studies looking at comparative long-term outcomes are indicated and ongoing.

Background: Since the first transgastric natural orifice transluminal endoscopic surgery (NOTES) was described, various applications and modified procedures have been investigated including peritoneoscopy. The submucosal tunneling method enhances the safety of peritoneal access and gastric closure and minimizes the risk of intraperitoneal leakage of gastric air and juice. In this case report we describe a transgastric NOTES as a rescue measure to retrieve an extraluminally migrated LAMS.
Presentation: A 52-year-old male was referred to our unit for EUS guided drainage of a liver abscess. During the procedure there was a complication due to misplacement of the proximal phalange of the stent into the peritoneum secondary to miscalculation between the length of the stent and the distance between the abscess and the lumen wall. A decision to drain the abscess using a longer and thicker LAMS was taken to reduce the risk of spillage of pus into the peritoneal cavity. A second endoscopic procedure was scheduled for an attempt to remove the migrated stent. After several failed attempts to remove the migrated stent through the second LAMS due to extreme angulation, another approach was taken. A submucosal tunnel was created in the antrum. An iatrogenic perforation to enter the peritoneal cavity was performed. Careful dissection guided by fluoroscopy was carried out to locate the stent. The stent was grasped with a forceps and retrieved successfully through the submucosal tunnel. Finally, the mucosal incision was closed using an over the scope clip. The patient evolution was satisfactory and he was discharged 2 days after the procedure.
Conclusion: This case demonstrates the feasibility of transgastric NOTES for the retrieval of extraluminally migrated stents.

Background: Endoscopic submucosal dissection (ESD) is an effective treatment for superficial neoplasia in the esophagus. However, circumferential esophageal ESD has a high risk of stenosis, especially in cases with a significant longitudinal extent of the resection. Unfortunately, no effective treatment is available to prevent stenosis after extensive, circumferential ESD. Stricture prevention by injection of corticosteroids, oral corticosteroids or stent placement have been explored, but are often not enough to prevent severe strictures. Even after such preventive measures, patients often still require multiple endoscopic dilations. In our practice, we have extensive experience in teaching patients self dilation with bougies, for treatment of refractory esophageal stenoses, also for post-ESD stenoses.
Aim of this video was to demonstrate a novel approach to prevent stenosis after extensive circumferential ESD in the esophagus.
Methods: We present a case of a 75-year old woman, who was referred with squamous cell neoplasia in her esophagus, over a length of 10cm. The neoplastic lesion was removed by ESD, resulting in a circumferential wound of 13 cm. Histology showed a well to moderately differentiated T1m3 squamous cell cancer, without lymphovascular invasion, and R0 resection margins. To prevent stricture, corticosteroids were injected into the submucosa immediately after the resection and the patient received a course of oral prednisolone. Furthermore, because we anticipated an almost certain risk of esophageal stenosis after the procedure, we tought the patient self dilation with a 14mm bougie, before we performed the ESD. Two days after the procedure, the patient started with self dilation by advancing a 14mm bougie once daily.
Result: The patient could tolerate a normal diet after ESD, without experiencing any dysphagia. No endoscopic dilations were necessary. No complications of the self dilation occurred. Eight weeks after the ESD we performed the first follow-up endoscopy to inspect the esophagus. The wound had started healing at the proximal and distal side, but had not yet healed completely. A diagnostic endoscope could easily pass, without any signs of esophageal stenosis.
Conclusion: Teaching self dilations prior to ESD may allow selected patients undergoing extensive circumferential ESD, to maintain an adequate diameter of the esophagus and thus preventing the need for multiple endoscopic dilations, when self dilatations are initiated shortly after the procedure and maintained throughout the healing phase.

Colorectal Endoscopic Submucosal Dissection (ESD) using monopolar knives was slowly adopted by Western endoscopists due to procedure time constraints and a relatively higher risk of short and/or long-term adverse events. Compared to monopolar knives, bipolar devices have fundamental potential benefits such as precise tissue cutting by direct contact and the use of low-voltage current directed between 2 electrodes with no requirement for a return plate. The novel ESD device incorporates both a bipolar radiofrequency energy for tissue cutting (400KHz/30W) and a microwave energy (5.8GHz/9W) used for the pre-coagulation of vessels or active control of bleeding. With this novel ESD device, a ‘clean’ cut of the mucosa and submucosal layer is achieved, averting any tissue charring. Another innovation is combining this endoscopic technology with an additional carbon dioxide/CO² insufflation exchange apparatus passed via the trans-anal platform to maintain constant and safe CO₂ insufflation and bowel wall distension during resection beyond the rectum, filling up the left colon.
A 9cm x 8cm cm flat (Laterally Spreading Tumour, Granular-type, Nodular Mixed type) lesion in the sigmoid-descending junction was examined by chromo-endoscopy and narrow-band-imaging to confirm the absence of signs of deeper invasion. During mucosal incisions (yellow pedal), the bowel pressure was set at 7-8mmHg to allow minimal submucosal ‘stretch’ and thinning. Similar pressure conditions were selected for submucosal entry and tunnelling. Lateral sweeping cuts of the submucosa (yellow pedal) were directed in a ‘in(tunnel)-to-out(edges)’ orientation. The curved tip of the novel ESD device maintained a deep resection plane even when tattoo-induced fibrotic patches were encountered. At the end of the procedure, optimisation of submucosal tension was achieved by increasing the luminal pressure to 11-12mm Hg. Microwave energy (blue pedal) was targeted by close contact to obtain a high-power density with vessels for a focused haemostasis and to deliver effective coagulation up to 10 secs and repeated where necessary for larger vessels. The inspection of the post-resection base revealed an intact muscle layer, with no signs of thermal injury. The real cutting time was 122mins (total procedure time was 210mins from first-to-last cut/speed of 20cm²/h). The patient had a full and painless recovery, and was discharged the next day. Histology of the pinned-out specimen showed an R0 resection of a high-grade dyplastic tubulo-villous adenoma with a well-preserved non-cauterised submucosa. No immediate or delayed complications were observed. At one-year follow-up, the healed scar was free of recurrence, and was covered by ‘smooth’ normalised epithelium without stenosis. An international registry with various operators to define the efficacy of this novel trans-anal technique appears warranted.

Background: Peroral endoscopic myotomy (POEM) has emerged as a first-line therapy for achalasia. Injection is used to facilitate entry and dissection of a tunnel in the submucosal space. Subsequently, a selective myotomy of the circular and variably longitudinal muscle fibers is performed, without the use of an injectate, with limited visualization of structures deep to the muscularis layer. Risks of the myotomy portion of POEM include injury to extraluminal structures and blood vessels, which have been reported to result in pneumothorax, capnoperitoneum, and hemorrhage. Here we present a novel technique that employs injection through the muscularis propria layer during the myotomy phase to facilitate safer and more controlled myotomy via expansion of the intermuscular and subadventitial planes.

Case Presentation: A 26-year-old man presented with a 20-lb weight loss and intermittent episodes of dysphagia to solid foods. Manometry studies were consistent with type II achalasia and he was referred for POEM.

Endoscopic Methods: The procedure was initiated in the standard fashion using an injection-capable knife. Submucosal tunnelling was carried 3cm distal to the gastroesophageal junction. Novel injection-lift myotomy was then initiated by injecting directly into the muscular propria layer, expanding the intermuscular and subadventitial spaces with the mixture of saline and methylene blue, in order to allow for better visualization of the muscle fibers, vessels, and extraluminal structures. Selective myotomy of the circular muscle bundle was then performed, using intermittent fluid injection to maintain expansion of the subadventitial and intermuscular spaces. Following the circular myotomy, the distal portion of the longitudinal muscle was divided, resulting in a full thickness myotomy. The myotomy was completed without any significant bleeding or adverse events and maintained excellent visualization throughout.

Conclusions: POEM is rarely associated with serious adverse events including pneumothorax, hemorrhage, and even death. These complications typically arise during the myotomy stage of the procedure due to injury to extraluminal structures. In this case, injection of the intermuscular and adventitial spaces with methylene blue and saline created a cushion that lifted the muscle fibers into the lumen, allowing for better visualization and a more precise dissection. Large extraluminal vessels were also better visualized, and therefore avoided. This case shows how injection-lift myotomy is a safe technique that could potentially reduce the risk of esophageal perforation, bleeding, and damage to adjacent organs during POEM.

Bianca Di Cocco

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