Clinical Endoscopy

Case Report

Stepwise Algorithmic Approach to Endoscopic Removal of Biliary Partially Covered and Uncovered Self-Expanding Metal Stents: Deepanshu Jain, Assaf Stein, Muhammad K. Hasan; Clin Endosc 2021;54(4):608-612. Published online September 8, 2020; DOI: https://doi.org/10.5946/ce.2020.189

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Self-expanding metal stents play a crucial role in the management of patients with biliary obstruction. Endoscopic extraction of uncovered metal stents (UCMSs) and partially covered metal stents (PCMSs) could be challenging because of tissue ingrowth. No standardized technique can guarantee universal success. We present our technique and experience of endoscopic extraction of biliary stents in two patients with a UCMS and three patients with a PCMS. Three of the five patients had a previous failed attempt of stent extraction at an outside hospital. Overall, our composite success rate was 80% (4/5). The individual success rate was 100% (3/3) for PCMSs and 50% (1/2) for UCMSs. The stent-in-stent technique, in which a fully covered metal stent is placed through an existing UCMS/PCMS, was used in 60% (3/5) of the cases, with a success rate of 66.7% (2/3). We share our algorithmic approach to each case, with detailed emphasis on the technical aspects of the procedure.

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Palliation in Gallbladder Cancer: The Role of Gastrointestinal Endoscopy
Tommaso Schepis, Ivo Boškoski, Andrea Tringali, Vincenzo Bove, Guido Costamagna
Cancers.2022; 14(7): 1686. CrossRef
Successful removal of an uncovered metallic stent using peroral direct cholangioscopy and the stent-in-stent technique
Akihiro Matsumi, Kazuyuki Matsumoto, Tatsuhiro Yamazaki, Shigeru Horiguchi, Koichiro Tsutsumi, Hironari Kato, Hiroyuki Okada
Endoscopy.2022; 54(S 02): E860. CrossRef
Role of ERCP in Benign Biliary Strictures
Tommaso Schepis, Ivo Boškoski, Andrea Tringali, Guido Costamagna
Gastrointestinal Endoscopy Clinics of North America.2022; 32(3): 455. CrossRef

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Brief Report

A Survey of Peri-Colonoscopy Management of Anti-Diabetic Medications: Byeori Lee, Deepanshu Jain, Michael Rajala; Clin Endosc 2020;53(5):623-626. Published online April 28, 2020; DOI: https://doi.org/10.5946/ce.2020.021

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Koloskopie geplant? Worauf es jetzt bei Menschen mit Diabetes mellitus ankommt
Henning Adamek, Karsten Müssig
Info Diabetologie.2024; 18(5): 32. CrossRef
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Venkatesan Thiruvenkatarajan, Joshua M. Inglis, Emily Meyer, Mahesh M. Umapathysivam, Nagesh Nanjappa, Roelof Van Wijk, David Jesudason
Canadian Journal of Diabetes.2023; 47(3): 287. CrossRef
Adjustment of Anti-Hyperglycaemic Agents During Bowel Preparation for Colonoscopy in Patients with Diabetes
Karsten Müssig, Henning E. Adamek
Experimental and Clinical Endocrinology & Diabetes.2022; 130(09): 627. CrossRef

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Reviews

Atraumatic Splenic Hemorrhage as a Rare Complication of Pancreatitis: Case Report and Literature Review: Deepanshu Jain, Byeori Lee, Michael Rajala; Clin Endosc 2020;53(3):311-320. Published online July 24, 2019; DOI: https://doi.org/10.5946/ce.2019.087

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Splenic hemorrhage (hematoma and rupture) is a rare complication of pancreatitis. In this article, we present a rare case of spontaneous splenic rupture as a complication of acute pancreatitis. A literature review was also completed to describe the patient characteristics, associated pancreatitis etiology, clinical presentations, risk factors, diagnostic and treatment modalities, and outcomes.

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Akute nekrotisierende Pankreatitis mit hämorrhagischem Schock bei sekundärer Milzruptur: Ein Fallbericht und Literaturübersicht
Leon Kaiser, Golo Petzold, Ali Seif Amir Hosseini, Volker Ellenrieder, Albrecht Neesse, Christoph Ammer-Herrmenau
Zeitschrift für Gastroenterologie.2023; 61(11): 1494. CrossRef
Association of Atraumatic Splenic Rupture and Acute Pancreatitis: Case Report with Literature Review
Lidija Ljubicic, Vibor Sesa, Silvija Cukovic-Cavka, Ivan Romic, Igor Petrovic, Neil Donald Merrett
Case Reports in Surgery.2022; 2022: 1. CrossRef
Acute pancreatitis with necrosis of the transverse colon and the great gastric curvature
Pietro CUMBO, Gabriella CAVALOT, Annalisa ROMANO, Marco ALLASIA, Carlo PALENZONA, Francesco POTENTE, Mariangela AZZELLINO, Luca B. LO PICCOLO
Chirurgia.2022;[Epub] CrossRef
Chronic lymphocytic leukemia, a rare cause of spontaneous rupture of the spleen
Madani Ayoub, Mohamed Yassine Mabrouk, Hajar Abdelouahab, Imane Kamaoui, Miry Achraf, Siham Hamaz, Khalid Serraj, Jabi Rachid, Bouziane Mohamed
International Journal of Surgery Case Reports.2022; 96: 107315. CrossRef
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Marko Murruste, Ülle Kirsimägi, Karri Kase, Tatjana Veršinina, Peep Talving, Urmas Lepner
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Case report of a spontaneous splenic rupture in a patient with chronic lymphocytic leukaemia treated by arterial splenic embolization
Héloïse Tessely, Stéphane Journe, Raphaël Katz, Jean Lemaitre
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Roshini Nadaraja, Zarif Yahya, Krinal Mori, Ahmad Aly
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Krittin J. Supapannachart, Christopher R. Funk, Lauren M. Gensler, Matthew P. Butters
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Rita Martelo, João C Morais, Angeles Rábago, Inês C Borges, Francisco Rodrigues
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Splenic rupture caused by pancreatic pseudocyst successfully treated by endoscopic ultrasound-guided drainage
Naoyuki Hasegawa, Yoshimi Ito, Masamichi Yamaura, Masato Endo, Kazunori Ishige, Kuniaki Fukuda, Ichinosuke Hyodo, Yuji Mizokami
Clinical Journal of Gastroenterology.2020; 13(5): 981. CrossRef
Splenic Subcapsular Hematoma Complicating a Case of Pancreatitis
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Cureus.2020;[Epub] CrossRef

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De-novo Gastrointestinal Anastomosis with Lumen Apposing Metal Stent: Deepanshu Jain, Ankit Chhoda, Abhinav Sharma, Shashideep Singhal; Clin Endosc 2018;51(5):439-449. Published online September 27, 2018; DOI: https://doi.org/10.5946/ce.2018.077

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Gastric outlet obstruction, afferent or efferent limb obstruction, and biliary obstruction among patients with altered anatomy often require surgical intervention which is associated with significant morbidity and mortality. Endoscopic dilation for benign etiologies requires multiple sessions, whereas self-expandable metal stents used for malignant etiologies often fail due to tumor in-growth. Lumen apposing metal stents, placed endoscopically with the intent of creating a de-novo gastrointestinal anastomosis bypassing the site of obstruction, can potentially achieve similar efficacy, with a much lower complication rate. In our study cohort (n=79), the composite technical success rate and clinical success rate was 91.1% (72/79) and 97.2% (70/72), respectively. Five different techniques were used: 43% (34/79) underwent the balloon-assisted method, 27.9% (22/79) underwent endoscopic ultrasound-guided balloon occluded gastro-jejunostomy bypass, 20.3% (16/79) underwent the direct technique, 6.3% (5/79) underwent the hybrid rendezvous technique, and 2.5% (2/79) underwent natural orifice transluminal endoscopic surgery (NOTES)-assisted procedure. All techniques required an echoendoscope except NOTES. In all, 53.2% (42/79) had non-cautery enhanced Axios stent, 44.3% (35/79) had hot Axios stent, and 2.5% (2/79) had Niti-S spaxus stent. Symptom-recurrence was seen in 2.8%, and 6.3% had a complication (bleeding, abdominal pain or peritonitis). All procedures were performed by experts at centers of excellence with adequate surgical back up.

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Salvage endoscopic ultrasound-guided gastrojejunostomy as a bridge to definitive surgical therapy for duodenal adenocarcinoma presenting with duodenal stent obstruction
Tiffany Z. Yu, Abishek Agnihotri, Richard Zheng, Babar Bashir, Nayeem Nasher, Charles J. Yeo, Avinoam Nevler, Harish Lavu, Wilbur B. Bowne, Anand Kumar
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Ji Hong Oh, Seung Goun Hong
The Korean Journal of Medicine.2022; 97(3): 191. CrossRef
Short benign ileocolonic anastomotic strictures - management with bi-flanged metal stents: Six case reports and review of literature
Panagiotis Kasapidis, Georgios Mavrogenis, Dimitrios Mandrekas, Fateh Bazerbachi
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Long-term placement of lumen-apposing metal stent after endoscopic ultrasound-guided duodeno- and jejunojejunal anastomosis for direct access to excluded jejunal limb
Gianfranco Donatelli, Fabrizio Cereatti, Andrea Spota, David Danan, Thierry Tuszynski, Jean-Loup Dumont, Serge Derhy
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Kornpong Vantanasiri, Guru Trikudanathan
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Sławomir Kozieł, Katarzyna Kozłowska-Petriczko, Katarzyna M. Pawlak, Jan Petriczko, Anna Wiechowska-Kozłowska
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Ryan B. Mirchin, Syed Kashif Mahmood
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Abdulla Nasser, Marc Cullen, Mohammed Barawi
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Endoscopic Ultrasound-Guided Gallbladder Drainage Using a Lumen-Apposing Metal Stent for Acute Cholecystitis: A Systematic Review: Deepanshu Jain, Bharat Singh Bhandari, Nikhil Agrawal, Shashideep Singhal; Clin Endosc 2018;51(5):450-462. Published online June 1, 2018; DOI: https://doi.org/10.5946/ce.2018.024

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Surgery remains the standard treatment for acute cholecystitis except in high-risk candidates where percutaneous transhepatic gallbladder drainage (PT-GBD), endoscopic transpapillary cystic duct stenting (ET-CDS), and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) are potential choices. PT-GBD is contraindicated in patients with coagulopathy or ascites and is not preferred by patients owing to aesthetic reasons. ET-CDS is successful only if the cystic duct can be visualized and cannulated. For 189 patients who underwent EUS-GBD via insertion of a lumen-apposing metal stent (LAMS), the composite technical success rate was 95.2%, which increased to 96.8% when LAMS was combined with co-axial self-expandable metal stent (SEMS). The composite clinical success rate was 96.7%. We observed a small risk of recurrent cholecystitis (5.1%), gastrointestinal bleeding (2.6%) and stent migration (1.1%). Cautery enhanced LAMS significantly decreases the stent deployment time compared to non-cautery enhanced LAMS. Prophylactic placement of a pigtail stent or SEMS through the LAMS avoids re-interventions, particularly in patients, where it is intended to remain in situ indefinitely. Limited evidence suggests that the efficacy of EUS-GBD via LAMS is comparable to that of PT-GBD with the former showing better results in postoperative pain, length of hospitalization, and need for antibiotics. EUS-GBD via LAMS is a safe and efficacious option when performed by experts.

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Focused Review Series: Expanding the Indication with Safety Issue of Endoscopic Ultrasound

Contrast Enhanced Harmonic Endoscopic Ultrasound: A Novel Approach for Diagnosis and Management of Gastrointestinal Stromal Tumors: Ankit Chhoda, Deepanshu Jain, Venkateswar R Surabhi, Shashideep Singhal; Clin Endosc 2018;51(3):215-221. Published online May 31, 2018; DOI: https://doi.org/10.5946/ce.2017.170

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The histologic analysis of gastrointestinal stromal tumors (GISTs) is a common method to detect the mitotic activity and to subsequently determine the risk of GISTs for malignancy. The potential false negative error due to inadequate yield of specimens and actual determination of malignancy risk requires analysis of the whole tumor. We aimed to assess the role of contrast enhanced endoscopic ultrasound (CE-EUS) in the management of GISTs. Two authors individually did review of English literatures to identify nine peer-reviewed original articles using keywords- contrast endoscopic ultrasound, GIST and submucosal tumor. Studies were heterogeneous in their aims looking either at differentiating submucosal lesions from GISTs, estimating malignant potential of GISTs with histologic correlation or studying the role of angiogenesis in malignant risk stratification. CE-EUS had moderate to high efficacy in differentiating GISTs from alternative submucosal tumors. CE-EUS had a higher sensitivity than EUS-guided fine needle aspiration, contrast computed tomography and Doppler EUS for detection of neo-vascularity within the GISTs. However, the evidence of abnormal angiogenesis within GIST as a prognostic factor needs further validation. CE-EUS is a non-invasive modality, which can help differentiate GISTs and provide valuable assessment of their perfusion patterns to allow better prediction of their malignant potential but more experience is needed.

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Reviews

Endoscopic Sleeve Gastroplasty - A New Tool to Manage Obesity: Deepanshu Jain, Bharat Singh Bhandari, Ankit Arora, Shashideep Singhal; Clin Endosc 2017;50(6):552-561. Published online June 13, 2017; DOI: https://doi.org/10.5946/ce.2017.032

Abstract PDF PubReader ePub

Obesity is a growing pandemic across the world. Dietary restrictions and behavior modifications alone have a limited benefit. Bariatric surgery, despite being the current gold standard, has limited acceptance by patients due to cost and associated morbidity. In our review, we have discussed nine original studies describing endoscopic sleeve gastroplasty (ESG). A total of 172 subjects successfully underwent ESG. Of 65 subjects with follow up data, 95.4% (62/65) had intact gastric sleeve confirmed via esophagogastroduodenoscopy or oral contrast study at the end of study specific follow up interval (the longest being 6 months). Individual studies reported a technical success rate for intact gastric sleeve from as low as 50% to as high as 100%. A statistically significant (p<0.05) weight loss was reported in seven of the eight studies with available data. None of the patients experienced any intra-procedure complications, and approximately 2.3% (4/172) of patients experienced major post-procedure complications; however, no mortality was reported. Majority of the studies reported relatively high incidence of minor post-procedure complications, which improved with symptomatic treatment alone. Good patient tolerance with comparable clinical efficacy in achieving and sustaining desired weight loss makes ESG an attractive option to consider among other bariatric therapies.

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Esophageal Stricture Prevention after Endoscopic Submucosal Dissection: Deepanshu Jain, Shashideep Singhal; Clin Endosc 2016;49(3):241-256. Published online March 7, 2016; DOI: https://doi.org/10.5946/ce.2015.099

Abstract PDF PubReader ePub

Advances in diagnostic modalities and improvement in surveillance programs for Barrett esophagus has resulted in an increase in the incidence of superficial esophageal cancers (SECs). SEC, due to their limited metastatic potential, are amenable to non-invasive treatment modalities. Endoscopic ultrasound, endoscopic mucosal resection, and endoscopic submucosal dissection (ESD) are some of the new modalities that gastroenterologists have used over the last decade to diagnose and treat SEC. However, esophageal stricture (ES) is a very common complication and a major cause of morbidity post-ESD. In the past few years, there has been a tremendous effort to reduce the incidence of ES among patients undergoing ESD. Steroids have shown the most consistent results over time with minimal complications although the preferred mode of delivery is debatable, with both systemic and local therapy having pros and cons for specific subgroups of patients. Newer modalities such as esophageal stents, autologous cell sheet transplantation, polyglycolic acid, and tranilast have shown promising results but the depth of experience with these methods is still limited. We have summarized case reports, prospective single center studies, and randomized controlled trials describing the various methods intended to reduce the incidence of ES after ESD. Indications, techniques, outcomes, limitations, and reported complications are discussed.

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Original Article

Predicting Colonoscopy Time: A Quality Improvement Initiative: Deepanshu Jain, Abhinav Goyal, Stacey Zavala; Clin Endosc 2016;49(6):555-559. Published online March 2, 2016; DOI: https://doi.org/10.5946/ce.2015.110

Abstract PDF PubReader ePub

Background
/Aims: There is lack of consensus on the optimal time allotted for colonoscopy, which increases patient wait times. Our aim was to identify and quantify the individual pre-procedural factors that determine the total procedure time (TPT) of colonoscopy.
Methods
This retrospective study involved 4,494 subjects, undergoing outpatient colonoscopy. Effects of age, sex, body mass index, abdominal surgery history, procedure indication (screening, surveillance, or diagnostic), procedure session (morning or afternoon), and endoscopist’s experience (fellow or attending) on TPT were evaluated using multiple regression analysis. A p<0.05 was considered significant.
Results
A total of 1,239 subjects satisfied the inclusion/exclusion criteria. Women, older individuals, and those with a history of abdominal surgery were found to have a shorter TPT (p>0.05) as did afternoon session colonoscopies (p=0.004). Less experienced endoscopists had longer TPTs (p>0.05). Screening (p=0.01) and surveillance (p=0.008) colonoscopies had a longer TPT than diagnostic procedures. Overall, the F-value of the regression model was 0.0009.
Conclusions
The indication for colonoscopy and the time of day have statistically significant associations with TPT. These results will help in streamlining workflow, reduce wait time, and improve patient satisfaction.

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Michal F Kaminski, Siwan Thomas‐Gibson, Marek Bugajski, Michael Bretthauer, Colin J Rees, Evelien Dekker, Geir Hoff, Rodrigo Jover, Stepan Suchanek, Monika Ferlitsch, John Anderson, Thomas Roesch, Rolf Hultcranz, Istvan Racz, Ernst J Kuipers, Kjetil Garbo
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Review

Transoral Incisionless Fundoplication for Refractory Gastroesophageal Reflux Disease: Where Do We Stand?: Deepanshu Jain, Shashideep Singhal; Clin Endosc 2016;49(2):147-156. Published online February 15, 2016; DOI: https://doi.org/10.5946/ce.2015.044

Abstract PDF PubReader ePub

Gastroesophageal reflux disease (GERD) is a chronic, progressive, and costly medical condition affecting a substantial proportion of the world population, predominantly the Western population. The available treatment options for patients with refractory GERD symptoms are limited to either laparoscopic surgery with significant sequelae or potentially lifelong, high-dose proton pump inhibitor therapy. The restoration of the antireflux competence of the gastroesophageal junction at the anatomic and physiologic levels is critical for the effective long-term treatment of GERD. Transoral incisionless fundoplication (TIF) surgery is a safe, well-tolerated, and effective treatment that has yielded significant symptomatic improvement in patients with medically refractory GERD symptoms. In this review article, we have summarized case series and reports describing the role of TIF for patients with gastroesophageal reflux symptoms. The reported indications, techniques, complications, and success rates are also discussed.

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Andreas Tschoner
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Glenn M. Ihde
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Lauren Rabach, Adham R. Saad, Vic Velanovich
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Jimin Han, Matthew Chin, Kyle J. Fortinsky, Reem Sharaiha, Christopher J. Gostout, Kenneth J. Chang
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Endoscopic Management of Gastroesophageal Reflux Disease: Revisited
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Original Article

Obesity and Cecal Intubation Time: Deepanshu Jain, Abhinav Goyal, Jorge Uribe; Clin Endosc 2016;49(2):187-190. Published online February 12, 2016; DOI: https://doi.org/10.5946/ce.2015.079

Abstract PDF PubReader ePub

Background
/Aims: Obesity is a much-debated factor with conflicting evidence regarding its association with cecum intubation rates during colonoscopy. We aimed to identify the association between cecal intubation (CI) time and obesity by eliminating confounding factors.
Methods
A retrospective chart review of subjects undergoing outpatient colonoscopy was conducted. The population was categorized by sex and obesity (body mass index [BMI, kg/m² ]: I, <24.9; II, 25 to 29.9; III, ≥30). CI time was used as a marker for a difficult colonoscopy. Mean CI times (MCT) were compared for statistical significance using analysis of variance tests.
Results
A total of 926 subjects were included. Overall MCT was 15.7±7.9 minutes, and it was 15.9±7.9 and 15.5±7.9 minutes for men and women, respectively. MCT among women for BMI category I, II, and III was 14.4±6.5, 15.5±8.3, and 16.2±8.1 minutes (p=0.55), whereas for men, it was 16.3±8.9, 15.9±8.0, and 15.6±7.2 minutes (p=0.95), respectively.
Conclusions
BMI had a positive association with CI time for women, but had a negative association with CI for men.

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