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Background: The field of bariatric endoscopy continues to evolve with the introduction of new technology and refinement of endoscopic techniques. Recently, the gastric antrum has gained interest as a potential novel therapeutic target. The gastric antrum represents the motor function of the stomach, and as such alteration to the antrum could result in changes that impact motor function and result in enhanced satiety and satiation. However, current endoscopic techniques for antrum reduction through per oral suturing have limitations with long-term durability. Therefore, we investigated the use of a modified gastrostomy tube (EndoTAGGS, Shawnee, KS) and non-cutting stapling device to reduce the gastric antrum.

Case Presentation: We demonstrated a novel approach to endoluminal gastroplasty using a modified gastrostomy tube and laparoscopic stapler. The procedure was successfully carried out in two porcine models. First, a modified gastrostomy tube (also called a percutaneous intragastric trocar (PIT)) was placed using a technique analogous to pull-through placement of a standard percutaneous gastrostomy tube. The distal tip of the tube is cut and a single 12-mm gastric port is attached. A 12-mm laparoscopic non-cutting stapler (Ethicon Inc., Raritan, NJ) is inserted through the port and into the stomach. A helical endoscopic tissue grasper (Apollo Endosurgery, Austin, TX) is used to secure and retract tissue into the jaws of the stapler, which is fired to create full-thickness imbrications of the stomach. The procedure is repeated multiple times along the anterior wall, greater curvature, and posterior wall until the stomach is reduced and tubularization is achieved.

Endoscopic Methods: The novel endoluminal gastroplasty procedure was successfully performed in two porcine models without immediate complications. Endoscopic images demonstrated sequential staple lines leading to effective reduction and tubularization of the antrum. During necropsy, full-thickness imbrications were found at the staple sites. There was no evidence of perforation at the staple site or trocar placement.

Conclusions: In conclusion, we were able to demonstrate a novel approach to endoluminal gastroplasty using a novel modified gastrostomy tube and laparoscopic stapler. The use of a PIT can overcome limitations of current endoscopic techniques by allowing for the use of larger diameter devices in a combined endoscopic/laparoscopic approach. Further studies are needed to refine the technique and explore therapy targeting antrum reduction in the treatment of obesity.

Background: One of the newest potential developments in endoscopy is the use of the duodenum as a therapeutic target for type 2 diabetes mellitus (T2DM). Endoscopic Re-Cellularization via Electroporation Therapy (ReCET) is a novel technology that utilizes a pulsed electrical field to create voltage gradient across living cells, triggering apoptosis. It is delivered through a generator, controller, and a flexible catheter with electrodes on an expandable flex circuit to deliver a 750v current on the duodenal mucosa. Compared to thermal-based technologies, ReCET is potentially safer as the energy delivery to the tissue is at a cellular level, thus it only penetrates superficial layer of the mucosa. We report herein the first case of a patient treated with ReCET therapy.

Methods: We present a case of a 68-year-old male with class I obesity (BMI 34.0 kg/m2) and type 2 diabetes mellitus in the past 5 years. His baseline HbA1c and fasting plasma glucose were 8.4% and 170 mg/dL, despite being on optimized doses of two oral antidiabetic medications. He was treated with ReCET therapy receiving a total of 7 doses of pulsed electrical field.

Results: ReCET therapy resulted in significant improvement in the patient’s diabetes-related parameters. His HBA1c reduced from 8.4% to 7.5%, 6.5%, and 6.8% at weeks 4, 12, and 24. His plasma glucose levels were monitored by a continuos glucose monitor (CGM), whose reports showed an improvement in the percentage of readings within normal range (baseline: 56%; week 4: 96%; week 12:100%; week 24: 96%).

Conclusions: ReCET is a novel and safe non-thermal modality that overcomes many limitations of thermal-based ablative energies and may help with altering disease progression in T2DM.

In this video, we present an algorithmic approach to the endoscopic management of bile duct stones, with validation of a predetermined protocol. By following this algorithmic approach, ductal clearance was achieved in in a single session in 99.6% of patients.

Prior interventions can cause submucosal fibrosis and scarring, making subsequent resection challenging. There is limited data to guide management of residual and scarred lesions. In this video we share tools and techniques for endoscopic management of residual and scarred lesions.

Tools and Techniques

Hot Avulsion
Hot biopsy forceps are used to grasp tissue and pull away from the wall using a combination of mechanical traction and application of cautery to remove tissue. Studies have demonstrated non-inferiority and safety of this technique in comparison to argon plasma coagulation (APC). The recurrent rate of hot avulsion with endoscopic mucosal resection (EMR) was 10.3% vs 59% for APC with EMR.

Band endoscopic mucosal resection
The band EMR technique uses the existing technology of variceal band ligation to place a band on flat mucosal lesions prior to resection with a snare using electrocautery. In a study on follow-up of EMR of neuroendocrine tumor (NET) scars (N=37), majority were resected using band EMR and found to have 38% residual NET in the specimen, highlighting the need to get submucosal sampling to ensure complete resection. This technique is an off-label use since these band resection kits are only FDA approved for use in the upper gastrointestinal tract.

Powered Endoscopic Tissue Resection Device (PED)
The PED includes a console and a single-use catheter with small rotating cutting blade passed through the instrument channel of scope. Endoscopic resection typically begins at one edge of the lesion and proceeds in a stepwise fashion. A multicenter review of 41 lesions that underwent PED found the initial technical success rate to be 98%. The reported intra-procedural bleeding rates were 29%, with delayed bleeding up to 6%, and no reported perforations.

Endoscopic full-thickness resection (EFTR)
The non-exposed (bowel wall segment containing the lesion is invaginated toward the lumen to allow a secure serosa-to-serosa apposition) EFTR technique can be effectively used for resection of small (<2cm) lesions. In a multi-center analysis of 104 patients with non-lifting adenoma, EFTR was performed with a R0 resection rate of 77%. On 3-month follow-up, residual neoplasia was noted in 18 (15.3%) patients.

Dissection Enabled Scaffold Assisted Resection (DESCAR)
Our group has previously developed and published experience using the DESCAR method. This uses ESD skills and knives to dissect the outer margin of tissue surrounding the scarred polyp to provide scaffold, in which a snare can be placed and more easily capture the scarred tissue for resection. A study including 29 lesions underwent DESCAR with 100% technical success.

Conclusion
The above discussed tools and techniques to manage scarred benign lesions along with adequate training and proper preparation, can result in successful resection of these challenging lesions.

Dennis Chen

Appearances