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Gastric fistula formation is a known complication of bariatric surgery. Many gastric fistulae can be managed endoscopically, however, it can be difficult to successfully treat chronic fistulae. New techniques such as cardiac septal occluders continue to add to the endoscopic arsenal for fistula closure. A drawback of cardiac septal occluders is their large diameter. Vascular plugs come in smaller diameters and can therefore be deployed into smaller fistulae. We present a video demonstration of vascular plug deployment for gastrointestinal fistulae closure.

Endoscopic Methods:
Our case series focuses on vascular plug deployment for management of gastro-bronchial and gastro-gastric fistulae that were refractory to traditional management (including over-the-scope suturing, through-the-scope helical tack placement, endoscopic internal drainage, and endoscopic diversion therapy). In our cases fistulae were small, measuring 3 mm to 4mm in diameter, respectively.

Vascular plug manufacturers recommend that the plug diameter should measure 50% larger than the target lumen. Thus, for both cases we chose to deploy a 6 mm by 6 mm vascular plug. The vascular plug is made of a nitinol mesh and is attached to a delivery wire via a screw attachment. Advancing or retracting the delivery wire advances or recaptures the vascular plug. Once in position, counterclockwise torque of the delivery wire unscrews the vascular plug and releases it. The vascular plug comes loaded on a 100 cm delivery wire, which prevents deployment through the endoscopic working channel. Therefore, we use a modified 10-7-5 biliary dilation catheter to deliver the vascular plug. The catheter is altered by modifying the distal tapered end to allow for plug deployment and then modifying the proximal end to accommodate the 100 cm delivery wire. These modifications also allow for the plug to be inserted into the catheter.

In our cases, pre-procedurally patients with gastro-bronchial and gastro-gastric fistulae reported significant coughing and reflux respectively. Vascular plug deployment in both cases was technically successful and clinically successful as both patients immediately had improvement in symptoms and a subsequent durable response.

Conclusion:
This case series highlights the use of vascular plug devices as feasible alternate endoscopic therapies for gastric fistulae closure where other established techniques have failed. In two cases of difficult-to-manage gastric fistulae, closure was achieved using vascular plugs and modified versions of available endoscopic tools. Both patients achieved symptomatic resolution and avoided the need for surgical intervention. Further study is needed to better analyze the potential benefits and limitations of these interventions as well as long-term clinical outcomes.

Background: Local excision is a potentially curative and organ-preserving option in rectal cancer with submucosal invasion. However, there are concerns regarding positive deep resection margins in submucosal approaches and disruption of the total mesorectal excision plane in full-thickness strategies. Here we present a step-by-step demonstration of endoscopic intermuscular dissection (EID) within the plane between the longitudinal and circular rectal muscle wall, which offers a high likelihood of achieving a negative vertical margin and accurate evaluation of invasion depth in situations where deep submucosal invasion is suspected or possible.

Case Presentation: A 31-year-old woman underwent a colonoscopy for evaluation of rectal bleeding and diarrhea. Colonoscopy demonstrated a 2 cm mass in the distal rectum with biopsies consistent with adenocarcinoma. Magnetic resonance imaging suggested a T1N0 lesion located 4 cm from the anal verge. After multidisciplinary discussion, en bloc endoscopic resection via EID was recommended for local control, pathological staging, and evaluation for risk of lymph node metastasis.

Endoscopic Methods: A solution of epinephrine, methylene blue, and saline was prepared for submucosal lifting. A transverse mucosal incision was made at the anal margin just above the dentate line to create a stable submucosal tunnel. Solution was then injected into the intermuscular plane, and the inner circular muscle layer was incised to enter the intermuscular space. Dissection of the intermuscular connective tissue was conducted in the oral direction until the endoscope was well beyond the oral margin of the lesion. The endoscope was then retroflexed, and the oral margin of the lesion was incised into the submucosa and intermuscular space until the tunnel was re-encountered. Finally, the lateral borders were undermined to release the specimen. No bleeding, full-thickness defects, or longitudinal muscle injury was observed. Pathology confirmed a pT1b, SM3, moderately-to-poorly differentiated, high-grade adenocarcinoma with negative margins. The patient was discharged same day and prescribed antibiotics for 7 days. Following multidisciplinary discussion at tumour board, the patient elected to undergo adjuvant chemoradiation to reduce her risk of recurrence in the regional lymph nodes.

Conclusions: By providing en bloc specimens while avoiding distortion of the total mesorectal excision plane, EID offers several benefits over conventional approaches for the local resection of T1 rectal cancers. A prospective study of 67 patients demonstrated high technical success and R0 resection rates of 96% and 81%, respectively, with no major adverse events. Future research is needed to delineate optimal procedural indications and the role of combinatorial adjuvant therapy to maximize EID’s curative potential.

Introduction: Along with the obesity pandemic, the incidence of associated metabolic diseases has also risen globally. Few patients in need of treatment receive medical care; thus, novel alternatives to address these conditions are crucial as they may increase the reach of medical assistance. Endoscopic bariatric therapies have emerged as one such modality, but no currently available technique targets both the stomach and the small bowel. This characteristic is prominent in Gastric Bypass surgery and is considered a cornerstone of its bariatric and metabolic effects. We developed a novel minimally invasive endoscopic device that mimics its positive effects minimizing its main downsides (irreversibility and malabsorption). Methods: The procedure begins with a side-to-side gastrojejunal anastomosis (GJA) - either surgical or endoscopic using a lumen-apposing metal stent. Then, we developed a C-shaped device that anchors proximally on the gastric outlet, and distally on the gastric side of the GJA. The proximal anchoring system is a fully-covered stent-like bottle neck-shaped nitinol frame that diverts food from the antrum. The distal anchoring system is a large ring-shaped metal device that gently overrides the GJA. A tether with an external ePTFE protective sleeve connects those two systems. Internally, it has a spring on its distal edge (anastomotic ring) and a sliding joint on its proximal edge (bottle-neck nitinol frame). This mechanism creates a gentle coiling property that accommodates peristaltic movements and preserves intestinal motility. This works as a passive non-ulcerogenic anti-migration system. After retrogradely placing a guidewire in the stomach through the GJA, the device is inserted over the wire. Then, a standard endoscopic sleeve gastroplasty (ESG) is performed. The final aspect is a reduced gastric volume with impaired gastric emptying and bypass of the antrum and proximal small bowel. Results: 4 pigs were included in this proof-of-concept study, 2 healthy controls and 2 survival models. The procedures were technically successful in both pigs, and the animals had an uneventful post-procedural course. Weight trends were significantly different between intervention and control pigs. While control ones steadily and progressively gained weight throughout an 8-week follow-up (+4.2kg/week), the first intervention pig gained less weight (+1.25kg/week), and the second lost at a -0.3kg/week rate (Figure 2). At follow-up, no ulcers or erosions were found at the anchoring sites. No migration, bleeding, or other adverse events occurred. Conclusion: The endoscopic DDAB procedure is feasible and supports the rationale of dynamic equilibrium and passive anchoring. Physiology studies are still needed, but the anatomical changes and weight loss trends suggest it promotes an effect like a surgical Gastric Bypass.

An 81-year-old male successfully underwent central access Z-POEM for a treatment of a symptomatic Zenker’s diverticulum. One day post-procedure, he developed subcutaneous emphysema secondary to leak from premature opening of the entry closure. The leak was closed with X-Tack system and fully covered esophageal metal stent (FCEMS). Subsequent esophagram confirmed no leak following stent removal and he was discharged home.

One week later, he presented with cough without dysphagia. Repeat endoscopy showed reopening of the fistula with an 8 cm cavity extending into the posterior mediastinum. After thorough lavage, the fistula was closed with X-Tack system and covered with a FCEMS. Postprocedural esophagram demonstrated no leak, but stent migrated subsequently. Five endoscopies were performed afterwards for stent revisions but sealing of leak was not successful. With his age and comorbidities, surgical intervention was avoided. Endoscopic ultrasound-guided drainage was not feasible due to the UES stenosis and the cavity being wide but thin. Therefore, a decision was made for endoscopic guided direct transesophageal puncture and retrograde placement of the drain to facilitate drainage and healing of the cavity.

The cavity was irrigated with a slim upper endoscope and suctioned until clear. The cavity measured 7 cm. Argon plasma coagulation was performed ablating the internal lining of the cavity. Using a bronchoscope with larger accessory channel within the cavity, the distal end of the cavity was identified by the transillumination seen from the esophageal lumen on a side-by-side slim upper endoscope. A 19 gauge fine-needle aspiration needle was advanced to the esophageal lumen from the cavity. A 0.025-inch guidewire was passed through the needle towards esophageal lumen. To close the fistula, suture was placed using endoscopic suturing device. To reinforce the sealing, a 14 x 62 mm FCEMS was placed covering the fistula. The guidewire was then retrieved through the stent and a 7 Fr nasocystic tube was advanced over the wire through the stent under fluoroscopic guidance into the cavity in retrograde fashion resulting its tip to coil within the cavity. The nasocystic tube was attached to bulb suction to initiate vacuum therapy. Ten days later, a CT chest confirmed resolution of the cavity and the leak. Tube was removed and the patient was discharged home with gradual advancement of the diet. Two weeks later, an endoscopy was performed, and the stent was removed. The leak site was well-healed.

In conclusion, novel endoscopic direct transesophageal puncture for retrograde drain placement tandem with endoscopic closure was safe and effective in a patient with esophageal leak following Z-POEM. The technique is minimally invasive and can be a promising alternative to surgery for managing large mediastinal esophageal leaks in the cervical esophagus.

BACKGROUND:
Anorectal GISTs - rare aggressive tumors arising from circular muscle of rectum and/or internal anal sphincter (IAS). Standard treatment – surgical. Sphincter saving surgery is difficult when IAS is involved; necessitates abdominoperineal resection (APR) with permanent colostomy. Submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) can be implemented in rectum to perform sphincter saving resection of suitable SELs.
METHODS:
Case 1: 57-year-male, biopsy proven GIST–Anal canal. Advised APR + end-colostomy – refused. Neo-adjuvant Imatinib 400mg x 6m → size regression (45x42 to 30x20mm). Sigmoidoscopy – normal overlying mucosa. Radial EUS – SEL from IAS, external anal sphincter (EAS) free. Anorectal Manometry (ARM) – normal. Plan – STER. Jack-knife position. Orientation of lesion confirmed with simultaneous digital palpation. Distal border of SEL marked just proximal to dentate line - coagulation current. Submucosal (SM) elevation, transverse incision proximal to dentate line, SM tunneling to expose SEL. SEL enucleated from surrounding muscle maintaining intact capsule. Injury to EAS avoided. Specimen retrieved enbloc, hemostasis achieved and mucosal incision closed. Case 2 : 62-year-male, Sigmoidoscopy – Ulcerated lesion in anorectal region. Biopsy – GIST. Advised APR + end-colostomy–refused. Initiated on Imatinib 400mg x 3m → size regression (47x45 to 25x23mm). Radial EUS - SEL from IAS, thinned out EAS. ARM - normal. Plan - EFTR. Marking of distal border of SEL, submucosal injection, transverse incision, dissection – SEL exposed. Lesion dissected from surrounding muscle. Blunt dissection – tumor separated from levator ani. Specimen retrieved, hemostasis achieved & closure done.
RESULTS:
Case 1 & 2: Post-procedure period uneventful. First bowel movement after 24 hours. Discharged after three days on laxatives. Histopathological examination and immunohistochemistry confirmed GIST (margins free). 8 week follow up - no incontinence (ARM - Normal). Follow up sigmoidoscopy and PET at 6 months showed no recurrence of lesion.
CONCLUSION:
This video demonstrates the safety and efficacy of endoscopic resection techniques for anorectal GIST and highlights the selection criteria & technical aspects of STER and EFTR for managing such patients.

Background
Gastric volvulus is treated with anterior abdominal wall gastropexy with endoscopic gastrostomy tube(s) placement and/or laparoscopic suturing gastropexy when patients have significant comorbidities. Here we describe a case of gastric volvulus managed with two-point gastropexy with endoscopic gastrostomy tube placement combined with endoscopic transabdominal suturing.

Case Presentation
A 50-year-old male with facioscapulohumeral muscular dystrophy with levoscolosis, restrictive lung disease, and pulmonary fibrosis presented with intermittent nausea, abdominal pain, and torsion of his stomach consistent with recurrent gastric volvulus ongoing for 1.5 months, requiring multiple hospitalizations. He was deemed a poor surgical candidate given his comorbidities and was offered endoscopic placement of two gastrostomy tubes but this was declined by the patient. Thus, two-point gastropexy with one gastrostomy tube and endoscopic transabdominal suturing was considered.

Endoscopic Methods
A 20F gastrostomy tube was placed at the greater curvature of the stomach. A second site 5 cm lateral to the gastrostomy site in the body of the stomach with good transillumination and manual external pressure was identified for transabdominal suturing. A 14G angiocatheter was introduced through the abdominal wall and into the stomach under direct endoscopic view. SpyBite Max forceps pre-loaded with an 2-0 Vicryl suture were introduced through the angiocatheter into the gastric lumen. Endoscopically, biopsy forceps were closed around the suture to hold it within the gastric lumen. Another site one centimeter from the initial angiocatheter site was identified and a second 14G angiocatheter was introduced through the abdominal wall and into the stomach under direct endoscopic view. The SpyBite Max forceps was advanced through the second angiocatheter to grasp the intraluminal suture. The SpyBite Max forceps were then pulled back, bringing the end of the suture outside the body. This process was repeated with a second, 2-0 Silk suture. All four angiocatheters were removed and the sutures were tied together gently apposing the skin. The patient did well post procedurally and was discharged by post operative day 2. He has not had recurrence of the gastric volvulus to date. However, due to ongoing PEG site discomfort for two years, endoscopy was repeated to remove the gastrostomy tube and perform endoscopic transabdominal suturing at the PEG fistula site for gastropexy reinforcement and fistula closure.

Conclusions
Endoscopic transabdominal suturing has been described for fistula closure, but to our knowledge, this is the first case of this technique used for gastric volvulus.

Satish Nagula

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