Background and Aims: Malignant gastric outlet obstruction (GOO) is an exceptionally rare and devastating condition in children, for which evidence-based management strategies are lacking. Although recent European guidelines endorse EUS-guided gastroenterostomy (EUS-GE) as an alternative to endoscopic stent placement and surgical gastroenterostomy in adults, its use in pediatrics is virtually unreported, to our knowledge. This absence of data leaves clinicians facing complex decision-making in profoundly challenging circumstances. We report on a pediatric case to illustrate the technical feasibility and potential clinical role of EUS-GE in malignant GOO. Methods: We describe stent placement during EUS-GE using the wireless EUS-GE simplified technique (WEST) in a 3-year-old boy with malignant GOO caused by recurrent abdominal neuroblastoma. Results: The procedure was technically and clinically successful, permitting resumption of oral intake and durable symptom control. The patient died 2 months later during palliative chemotherapy, without recurrence of GOO. Conclusions: This case highlights EUS-GE as a feasible palliative option for malignant GOO in highly selected pediatric patients. Given the rarity and severity of this condition, EUS-GE may be considered in expert centers with substantial experience in therapeutic EUS, underscoring the need for further reporting to inform future pediatric practice.
Background and Aims:Endoscopic submucosal dissection (ESD) of lesions involving the ileocecal valve and terminal ileum is technically challenging. The saline-immersion technique for ESD combined with countertraction may improve visualization, safety, and dissection efficiency in these complex locations. Methods:A 71-year-old patient underwent ESD for a 4-cm nongranular flat adenoma involving the entire ileocecal valve and extending into the distal terminal ileum. The procedure was performed with the patient under general anesthesia using a pediatric colonoscope (PCF-H190TL; Olympus, Tokyo, Japan) with a tapered hood (ST Hood; Fujifilm, Tokyo, Japan). After chromoendoscopic margin delineation, the lumen was filled with saline solution, and submucosal dissection was completed under saline immersion using ENDO CUT current (Erbe VIO 3, Tübingen, Germany). Two clip-and-band complexes provided internal countertraction to improve exposure and facilitate controlled dissection. Results:En bloc resection, including the ileocecal valve and ileal extension, was achieved. Hemostasis was secured with hot biopsy forceps, and partial defect closure was performed with clips. The postoperative course was uneventful, and the patient was discharged after 48 hours. Oral budesonide was administered for 2 months to reduce the risk of stricture. At 3-month follow-up, the patient was asymptomatic without endoscopic recurrence. Conclusions:Under-saline solution ESD with clip-and-band traction appears safe and effective for extensive ileocecal lesions, providing stable visualization, reliable countertraction, and easy access to the submucosal space.
Background and Aims: Sigmoid volvulus is a major cause of large-bowel obstruction in “volvulus belt” countries, where it accounts for up to 50% of cases. Flexible endoscopic detorsion is the first-line therapy for stable patients; however, recurrence rates may reach 75%. Placement of a rectal decompression tube reduces early recurrence and facilitates elective surgery. In many low-resource settings, commercial tubes are unavailable. This video demonstrates the safe, low-cost use of rectal anesthesia corrugated tubes as a practical alternative. Methods: We present the case of a 74-year-old woman exhibiting clinical and radiographic signs of sigmoid volvulus. After flexible endoscopic detorsion, a rectal anesthesia corrugated tube was placed. This video illustrates the step-by-step technique, focusing on technical details, potential pitfalls, and troubleshooting tips. Results: The patient underwent successful decompression. Radiographic control showed the resolution of the volvulus and correct placement of the tube. The tube stayed in place until the elective laparoscopic sigmoidectomy on day 6. The patient had an uneventful recovery, leading to her discharge on postoperative day 10. Conclusions: Endoscopic decompression combined with the placement of a rectal anesthesia corrugated tube represents a feasible and practical bridge to surgery. This educational video serves as a valuable resource for training endoscopists, particularly in settings with limited resources.
Background and Aims: High-risk endoscopic interventions (bleeding control and perforation closure) require deliberate, repeated practice, yet structured hands-on training is scarce. We developed a Muscat Endoscopy Academy Gastric Simulator (MEA-GASTROSIM), a compact, reusable ex vivo upper-GI simulator built from low-cost, locally sourced materials, aligned with international recommendations supporting simulation in competency-based endoscopy training. Methods: The system uses a custom-made stomach-shaped wooden mold on a stable pedestal, lined with a 2-component silicone layer and an aluminum conductive layer, and covered with ex vivo animal stomach tissue. A transparent acrylic cover recreates the confined working field and permits instructor visualization; a lateral access port approximates esophageal entry. Bleeding is simulated by colored-fluid injection and subtissue tubing connected to syringes for pressure-controlled, pulsatile flow. Perforations and resection-type defects are created as tailored tissue defects to practice endoscopic closure. Results: MEA-GASTROSIM supports repeatable, escalating scenarios of oozing and spurting hemorrhage and clinically relevant defects, enabling practice of lesion identification, device selection, injection, clipping, coagulation, and closure, including suturing with immediate feedback. Conclusions: MEA-GASTROSIM offers a realistic, affordable platform for progressive skill refinement in hemostasis and perforation management without exposing patients to risk.
Background and Aims: Endoscopic submucosal dissection (ESD) for a gastric lesion in a patient with familial adenomatous polyposis (FAP) with fundic gland polyps is challenging due to dense polyposis, limiting visualization and access during resection. Methods: A 49-year-old woman with FAP and a high-grade dysplastic gastric lesion underwent ESD. Because of dense polyposis obscuring the instrument tip, proximal EMR was performed under saline solution immersion to create a submucosal entry point for the ESD. Results: The proximal EMR enabled clear visualization of the submucosal layer and facilitated safe initiation of ESD. After traction-assisted ESD, en bloc resection was achieved without adverse events. The post-ESD defect was successfully closed with endoscopic suturing. Follow-up upper endoscopy at 3 months showed no local recurrence. Conclusions: This case highlights the technical challenges of performing gastric ESD in patients with FAP and dense fundic gland polyps, in which visualization and access to the submucosal layer are limited. Creating a submucosal entry point with EMR can improve exposure and facilitate safe initiation of ESD. This hybrid approach may serve as a useful strategy for endoscopists facing similar difficult anatomy.
Background and Aims:EUS-guided therapy for fundal varices targets the gastric shunt or afferent feeders. In cases with multiple feeders, this may not achieve complete obliteration. We aimed to target the single efferent channel in a patient with multiple feeder vessels. Methods:We describe EUS-guided occlusion of the shunt efferent in a patient with gastric variceal bleed and multiple inflow tracts. The efferent was traced from the left renal vein and targeted with coils and cyanoacrylate glue. Results:Coil plus glue embolization of the shunt efferent achieved complete variceal obliteration. The patient had no further variceal bleeding or decompensation at 6 months. At 1-year follow-up, the patient was asymptomatic; small esophageal varices were noted. Conclusions:EUS-guided coil-assisted retrograde transgastric occlusion is a safe and effective alternative to interventional radiology-guided therapy of gastric varices in cases with multiple afferents or feeder vessels. Development of new esophageal varices is a recognized limitation and should be monitored.
Background and Aims: Endoscopic resection of polyps at the ileocecal valve (ICV) remains challenging. Herein, we present a review of the current literature and a case series with video of hybrid endoscopic submucosal dissection—endoscopic mucosal resection (ESD-EMR) for the management of polyps at the ICV. Methods: This article and accompanying video outline the technique of hybrid ESD-EMR. This technique was ultimately used for the management of ICV polyps in 10 patients at a single-center institution. Results: As outlined in the video, endoscopic submucosal dissection was first performed to create a “trench” for the snare to anchor into the lesion and ensure negative margins at the ileal aspect of the lesion. Endoscopic mucosal resection was then performed in a piecemeal or en bloc fashion to complete resection of the polyp. Technical success of the procedure was 100%. Adverse events were noted in 20% of cases, consisting of 1 case of postpolypectomy syndrome (American Society for Gastrointestinal Endoscopy [ASGE] grade I) and 1 case of early bleeding (ASGE grade IIIa). One patient had residual disease on follow-up that was easily managed endoscopically. No patients required surgical referral after endoscopic resection. Conclusion: We conclude that hybrid ESD-EMR may be an effective resection strategy for the management of large polyps at the ICV.
Background and Aims: Sigmoid fistulas pose significant management challenges, often requiring prolonged antibiotics, percutaneous drainage, and surgical intervention. Endoscopic vacuum therapy (EVT), used for gastrointestinal tract leaks and fistulas, promotes granulation and controlled closure using continuous negative pressure. Its application in sigmoid fistulas is less commonly reported. Thus, we present a case demonstrating successful EVT for a persistent sigmoid fistula, highlighting technical considerations and treatment course. The aims of this article are to share clinical rationale, illustrate procedural steps, and summarize EVT applications and benefits to describe EVT as a potential option for managing complex gastrointestinal tract defects. Methods: An initial closure attempt using a helical tack—based suturing system (Boston Scientific, Marlborough, Mass, USA) was unsuccessful. A later attempt using a full-thickness endoscopic suturing system also failed. Granulation and defect closure were subsequently achieved using EVT via intracavitary sponge placement and serial exchanges. Imaging and endoscopic findings were documented to illustrate technique, healing progression, and treatment outcomes. Results: The patient's sigmoid fistula was successfully closed using EVT over the course of approximately 2 months. Conclusions: EVT is an effective minimally invasive closure technique in the management of sigmoid fistulas. This case highlights EVT as a valuable therapeutic option for lower gastrointestinal fistulas, offering safe, reproducible, and organ-preserving management.
Background and Aims: Leiomyomas are the most common benign neoplasm of the esophagus. Although typically asymptomatic, they can cause retrosternal discomfort and dysphagia. Submucosal tunneling endoscopic resection (STER) has been increasingly used for resecting esophageal subepithelial lesions. We present this case of STER for resection of a 4-cm esophageal leiomyoma. Methods: A 44-year-old man presenting with retrosternal discomfort, dysphagia, and heartburn was found on EGD to have a 4-cm subepithelial lesion in the mid esophagus. Subsequent endoscopic ultrasound and fine-needle biopsy confirmed this as a leiomyoma on pathology. STER was performed, which involved making a mucosotomy 4 cm proximal to the lesion, creating a submucosal tunnel, and removing the lesion in a piecemeal fashion. The patient developed transient hypoxia lasting 1 to 2 minutes, with chest x-ray showing intraprocedural pneumothorax, which spontaneously resolved at the end of the case. He was admitted for observation and discharged in stable condition after 2 days. He was doing well at follow-up. Results: The patient had a successful piecemeal removal of a 4-cm esophageal leiomyoma using the STER technique. Conclusions: STER is a viable, minimally invasive method for removing leiomyomas and other subepithelial lesions from the esophagus.
Background and Aims: Indeterminate gastric outlet obstruction can be managed with placement of temporary stents; however, currently available stents are not designed for duodenal placement, and downstream migration is a significant concern. Methods: This Original Article and accompanying video demonstrate placement of a through-the-scope fully covered self-expandable metal stent (FCSEMS) with biflanged ends across the duodenal stenosis. Results: In the case example of a patient with severe duodenal stenosis, despite utilization of a lumen-apposing metal stent, various duodenoscopes, and patient repositioning, the ampulla could not be reached. Subsequently, the FCSEMS with biflanged ends (midbody diameter: 20 mm; flare diameter: 28 mm) was placed across the duodenal stenosis, and ERCP could be successfully performed through the stent. Conclusions: This case highlights the successful placement of an FCSEMS with biflanged ends in a patient with indeterminate gastric outlet obstruction for eventual ampullary access. The wide caliber of the stent allowed duodenoscope maneuverability and sphincterotome bowing to facilitate ERCP. The biflanged ends on the FCSEMS may potentially provide antimigratory properties, which is a concern for currently available stents for the management of duodenal obstruction.
Background and Aims: Rectal gastrointestinal stromal tumors (GISTs) are rare, and optimal management of localized disease remains uncertain. Endoscopic intermuscular dissection (EID) is an emerging minimally invasive technique that allows en bloc removal of selected subepithelial lesions that do not extend beyond the circular layer of the muscularis propria while preserving anorectal anatomy. We present a case of a rectal GIST successfully treated with EID. A 53-year-old man undergoing high-risk colorectal cancer surveillance was found to have a subepithelial rectal lesion 1.5 cm proximal to the dentate line. Endoscopic ultrasound and biopsy confirmed a low-grade GIST. The patient was referred for endoscopic submucosal dissection. Methods: The procedure began with thermal marking followed by repeated methylene blue injections to maintain a well-defined submucosal plane. Once the lesion was identified as originating from the muscularis propria, the approach was converted to EID, allowing capsule-preserving en bloc resection within the intermuscular space. The defect was subsequently closed with a running endoscopic suturing device. Results: Pathology confirmed a spindle-cell, low-grade GIST with negative margins and no lymphovascular invasion. At 14-month follow-up, there were no delayed adverse events or evidence of recurrence. Conclusions: This case demonstrates the feasibility and safety of EID for small rectal GISTs originating from the muscularis propria.
Background and Aims: Endoscopic esophageal foreign body removal is a common procedure performed by pediatric gastroenterologists and surgeons. However, when foreign bodies are embedded in the esophageal wall, traditional treatment has instead involved surgical resection. As recently described, advanced endoscopic techniques enable endoscopic retrieval of embedded esophageal foreign bodies. Methods: We present a case of endoscopic retrieval of a coin embedded in the esophagus of a 2-year-old male. The patient presented with wheezing and radiograph findings consistent with an esophageal foreign body. Endoscopy was performed, but the procedure was aborted after the coin was identified to be completely embedded within the mucosa of the esophageal wall. A CT scan then confirmed the embedded coin. Results: A decision was made to perform a repeat endoscopy, with conversion to thoracotomy if the coin could not be successfully removed endoscopically. On repeat endoscopy, the coin was visualized, although its superior edge was surrounded by heaped-up mucosa. Mucosotomy and myotomy were necessary to fully expose the coin, which was then removed. The patient's diet was advanced postoperatively, and he was discharged after an esophagram showed no evidence of a leak. Conclusions: Providers should consider endoscopic removal of embedded esophageal foreign bodies for pediatric patients.
Background and Aims: Endoscopy has emerged as a safe and effective treatment for esophageal perforation, but varices have traditionally been considered a contraindication. We aimed to treat an esophageal perforation with endoluminal suturing during an active variceal bleed. Methods: A 55-year-old woman with (previously) compensated alcohol-associated cirrhosis presented with hematemesis, hypotension, and tachycardia. Although endoscopy was being arranged, the care team attempted to place a Sengstaken-Blakemore tube. The gastric balloon was inadvertently inflated in the esophagus; malposition was confirmed on chest radiograph. Bedside EGD revealed esophageal varices and a briskly bleeding, large, linear perforation extending from 24 to 36 cm from the incisors. Repeat CT was consistent with hemopneumomediastinum. She was brought to the interventional endoscopy suite, where an over-the-scope endoscopic suturing device was used both to close the perforation and to achieve hemostasis. No esophageal stent was placed. The esophagus was filled with water-soluble contrast, and a CT scan revealed no extraluminal contrast. Results: The patient was weaned off vasopressors and extubated. Her diet was advanced, and she had no residual dysphagia. Conclusions: Endoscopic suturing may be considered as salvage therapy for esophageal perforation in selected patients who are not candidates for surgery.
Background and Aims: EUS-guided gastroenterostomy (EUS-GE) is effective for palliating malignant gastric outlet obstruction (GOO). Inadvertent gastrocolostomy, although rare, can be a serious adverse event. We present an endoscopic rescue strategy in a case of gastrocolonic and colojejunal fistula after EUS-GE. Methods: A 59-year-old woman with duodenal adenocarcinoma underwent EUS-GE with a 20- × 10-mm lumen-apposing metal stent (LAMS) because of GOO. One week later, the patient presented with postprandial diarrhea, nausea, and halitosis. Imaging and endoscopy revealed a gastrocolonic fistula and a mature colojejunal fistula. Results: Under endoscopic and fluoroscopic guidance, a partially covered self-expandable metal stent was deployed transcolonically through the LAMS into the jejunum. The procedure was uneventful. The patient resumed oral intake within 24 hours, and follow-up confirmed correct stent positioning and clinical improvement. Conclusions: Transcolonic stent placement through the LAMS appears to be a feasible rescue solution for managing inadvertent gastrocolostomy after EUS-GE in the presence of a concurrent colojejunal fistula.
Background and Aims: Endoscopic submucosal dissection (ESD) is an established technique for the management of large colorectal lesions, offering high en bloc and R0 resection rates. Although traction-assisted and tunneling ESD techniques are individually established, each may have limitations in achieving dissection efficiency. We describe important technical considerations in managing large rectal lesions using a combination of both techniques. Methods: A 42-year-old man with mucous stools was found to have a 12-cm rectal laterally spreading tumor, granular type with a dominant nodule. Careful lesion assessment excluded deep submucosal invasion. ESD was performed using both techniques. Results: Initial oral and anal incisions were performed, followed by tunneling dissection. Because of the limited submucosal plane, 2 sequential tractions were applied to enhance exposure. The procedure was completed with en bloc resection, without deep mural injury, and the specimen was successfully retrieved manually to avoid fragmentation. The specimen measured 12 cm, and final pathology showed tubulovillous adenoma, with high-grade dysplasia and R0 resection. Conclusions: The use of tunneling and traction-assisted ESD aids in maintaining an optimal dissection plane and minimizing deep mural injury. Strategic traction placement and gravity-assisted patient positioning are critical for procedural efficiency. Finally, manual specimen extraction can be considered to preserve specimen integrity.
Background and Aims: Patients may require biliary stent placement for cholecystitis, but stent dislocation rarely results in colonic perforation. We describe a patient whose biliary stent dislodged between the transverse colon and gallbladder, creating a fistula. We aim to highlight the importance of early recognition and describe a minimally invasive approach to fistula closure. Methods: We used a novel technique using simultaneous bidirectional endoscopy, performing colonoscopy and ERCP concurrently to repair a cholecystocolonic fistula caused by biliary stent migration. Results: This combined approach enabled direct visualization of the fistula via the colonoscope, allowing precise grasping and closure of the fistulous tract during the withdrawal of the biliary stent through the ERCP scope. During the same session, the eroding biliary plastic stent was replaced, minimizing procedure time and anesthesia exposure to the patient. Conclusions: Simultaneous bidirectional endoscopy can be considered an effective approach to the management of biliary-enteric fistulas. This technique allows closure under direct visualization while addressing the underlying stent in a single session. This approach has the potential to reduce adverse events by avoiding surgical interventions. Wider adoption of this technique may benefit select patients with similar presentations.
Background and Aims:Large colorectal lipomas can cause symptoms such as abdominal pain, bleeding, and intussusception. Despite increasing reports of endoscopic treatments, endoscopic resection of large lipomas remains technically challenging. Here, we report a case of successful endoscopic submucosal dissection (ESD) using multiple traction bands for a large lipoma after failed unroofing. Methods:A 55-year-old woman with chronic abdominal pain had a 70-mm submucosal tumor in the ascending colon, confirmed to be a lipoma. Initial unroofing failed because of poor electrical conductivity of the lipoma. Two months later, with the patient having persistent symptoms and a remaining 50-mm lipoma, ESD was performed. Multiple traction bands were clipped between the lipoma and the contralateral wall to lift the tumor and improve visualization. Results:ESD was successfully performed using multiple traction devices applied sequentially to maintain tension and visibility during dissection. The lesion was completely removed en bloc, and the defect was closed using the clip-with-line pulley-securing technique. Histology confirmed a benign lipoma. The patient remained symptom free with no recurrence at 1-year follow-up. Conclusions:Multiple traction-assisted ESD is a safe and effective approach for large colorectal lipomas, enabling minimally invasive resection while reducing the risk of perforation and recurrence.
Background and Aims: EUS-guided choledochoduodenostomy (EUS-CDS) has become an established alternative to percutaneous or surgical approaches in cases of failed or predicted difficult ERCP. Methods: We report a case of complex endoscopic management of biliary obstruction in a 46-year-old woman with inoperable pancreatic adenocarcinoma. Because of tumor-related deformation of the papillary region, primary transpapillary drainage was not feasible. Results: EUS-CDS using a 6- × 8-mm electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot AXIOS stent; Boston Scientific, Marlborough, Mass, USA) was performed. Misdeployment of the distal flange led to bile leakage and stent dysfunction. Subsequent placement of a fully covered self-expandable metal stent (8 mm × 6 cm) (BONASTENT; MTW, Wesel, Germany) resulted in secondary stent dislocation into the paraduodenal space. The dislocated stent was successfully retrieved endoscopically through the original access using a 3-mm cholangioscope (Scivita, Boston Scientific). The duodenal defect was closed with 2 closure clips (MANTIS Clip, Boston Scientific). The patient recovered uneventfully and remained asymptomatic at 2-month follow-up. Conclusions: This case illustrates the feasibility of endoscopic rescue in a challenging scenario after LAMS misdeployment using advanced ERCP and closure techniques.
Background and Aims: Autoimmune cholangiopathy can mimic cholangiocarcinoma. This video highlights the presentation and management of a patient with obstructive jaundice in the setting of a biliary stricture concerning for hilar cholangiocarcinoma who had resolution of her symptoms with steroids. Methods: A 49-year-old woman without autoimmune history presented with abdominal pain and jaundice and was found to have elevated liver enzymes (total bilirubin, 4.7 mg/dL; alkaline phosphatase, 405 U/L; aspartate aminotransferase, 174 U/L; and alanine aminotransferase, 530 U/L), a mass at the hepatic duct confluence, and a filling defect in the common bile duct on cross-sectional imaging. Serum carbohydrate antigen 19-9 (9 U/mL) and immunoglobulin G4 (IgG4)/IgG (7.2%) were normal. After multiple negative samples obtained by EUS/ERCP, including brushing, biopsy, and fluorescence in situ hybridization, she opted to trial systemic steroids for suspected autoimmune cholangiopathy. Results: After 4 weeks of prednisone, an EUS/ERCP was performed and noted improvement in biliary duct dilatation, duct wall thickness, and stricture size. The periductal mass was not appreciated. Repeat cholangioscopy noted gross improvement in duct stenosis and neovascular changes. At 4-month follow-up, she remained clinically asymptomatic, with normal laboratory values and no radiographic evidence of a hilar mass or bile duct stricture. Conclusions: Autoimmune cholangiopathy can mimic cholangiocarcinoma and should be considered when the cytopathology result of hilar strictures is repeatedly negative.
Background and Aims: Papillary stricture is a clinically relevant late adverse event of endoscopic papillectomy (EP) and may result in concurrent cholangitis and pancreatitis. Although endoscopic drainage is the first-line modality, biliary and pancreatic duct access can be challenging because of fibrotic strictures after EP. This article aims to demonstrate the feasibility of EUS-assisted rendezvous (EUS-RV) combined with a double-lumen papillotome (MagicTome; PIOLAX Inc, Yokohama, Japan) to achieve dual-duct access. Methods: We present a case of a 70-year-old woman with cholangitis and pancreatitis caused by post-EP stricture. After a failed ERCP, a salvage EUS-RV was performed to access the biliary duct, followed by pancreatic duct cannulation using a double-lumen papillotome. Results: The distal bile duct was punctured from the duodenum with a 19-gauge needle (EZ Shot 3 Plus; Olympus, Tokyo, Japan), and a 0.025-inch guidewire (VisiGlide 2; Olympus) was advanced through the stricture into the duodenum. The guidewire was retrieved with biopsy forceps, and biliary access was established. Subsequently, using a double-lumen papillotome, we cannulated the pancreatic duct. Balloon dilation and plastic stent placement were performed in both ducts without adverse events. The stents were removed after 12 months. No recurrence was observed during 12 months of follow-up. Conclusions: EUS-RV combined with a double-lumen papillotome is a useful salvage strategy for complete post-EP strictures. This method can be applied to difficult cannulation, particularly when dual-duct access is required.
