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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.

Introduction
Therapeutic approaches such as endoscopic closure, diversion and drainage for managing post-operative gastric leaks are done sequentially or in a combined manner. When these techniques fail, the patient is subjected to high risk surgery in hostile anatomic environments. We describe a case of refractory gastric leak and fistula formation status-post sleeve gastrectomy managed with a novel 2-stage approach, including an obtruded PEG bumper and a self-expanding vascular plug.

Case Presentation
A 61-year-old female with a 3-month history of laparoscopic sleeve gastrectomy presented with a subdiaphragmatic leak and fistula. Her symptoms were unresponsive to stenting, septotomy, drainage and a septal occluding device. She had resistant and worsening peri-splenic collection despite abdominal percutaneous drains in place. A 2-step approach was devised based on the driving pathophysiology.
Firstly, the stents and drains were removed and we placed a modified obtruded PEG tube to isolate the abscess cavity from the gastric sleeve leak and to create adequate negative pressure in the abscess cavity. Next, after elimination of the cavity, the modified PEG tube was removed and replaced with an 8 Fr double pigtail catheter to reduce the size of PEG tract. Secondly, after reducing the size of the linearized tract, under fluoroscopic guidance, we placed a a self-expanding vascular plug made water-resistant by combining cyanoacrylate and a silicone one-way valve. This plug was sutured to a truncated ureteral stent to drain any serous fluid produced in the tract due to a foreign body. At this point, the patient resumed the diet and after 7 weeks a repeat CT scan showed no residual fluid or gas collection. The planned surgery was cancelled with plans to remove the 7 Fr stent in 5 weeks.

Conclusion
Leaks and fistulas following sleeve gastrectomy are rare complications that require a multi-modality approach for management. We successfully managed a refractory leak with a novel 2 staged approach using an obtruded PEG bumper with negative intracavitary pressure to resolve the abscess cavity followed by a modified vascular plug to stop the leak.

Introduction
Endoscopic methods of hiatal hernia reduction utilizing percutaneous endoscopic gastrostomy (PEG) gastropexy have been described in surgically challenging patients. However, PEG insertion may be complicated by buried bumper syndrome, which can be life threatening. We describe the use of endoscopic suturing and the novel use of a repurposed JP drain bulb to manage buried bumper syndrome.

Case Presentation
A 62-year-old female with past medical history notable for a complex type-II paraesophageal hiatal and severe obesity who presented with complaints of episodic upper abdominal pain and distension.
Initial CT scan of the abdomen revealed a large hiatal hernia, with nearly 50% of the stomach within the thoracic cavity including a para-esophageal component (Figure 1). Due to complex anatomy and risk of surgery, she underwent endoscopic reduction of the large paraesophageal and hiatal hernia with the placement of an externally removable 20 Fr gastrostomy tube to fix the stomach in abdominal cavity.
She was readmitted one week later due to fever, erythema and leakage around her PEG site. Endoscopy revealed a 10mm non-bleeding cratered gastric ulcer in the gastric body beneath the gastrotomy tube bumper (buried bumper syndrome).
In order to provide ongoing traction and to allow for tract maturation, a larger bumper, cut from a JP drain bulb was utilized. The large bumper was placed over the original bumper of the new gastrostomy tube. The previous PEG tube was removed and replaced with a new 20 Fr PEG tube, placed with a large, modified bumper (Figure 2). Additionally, the PEG site ulcer was repaired with endoscopic suturing using a single running 2.0 polypropylene suture. Repeat imaging confirmed appropriate placement of the gastrostomy tube and bumper.
The patient's condition continued to improve including reduction in PEG site pain post-procedurally. The tube is projected to remain in situ for 6 months, to allow for adhesions to form between the stomach and abdominal wall to create durable endoscopic gastropexy.

Conclusions
Treatment of buried bumper is challenging in the acute setting after PEG tube placement, as gastric to abdominal wall apposition is needed to prevent leak. We described a novel treatment approach for buried bumper syndrome utilizing endoscopic suturing and a repurposed JP drain bulb to ensure ongoing apposition of the stomach to the abdominal wall and redistribution of PEG traction forces to allow for ulcer healing.

Trenton Hinkley

Appearances