Endoscopic sleeve gastroplasty: live uncut procedure

Mirizzi syndrome (MS) is characterized by common hepatic duct obstruction due to mechanical compression and surrounding inflammation by a gallstone impacted in the cystic duct (type I) or at the gallbladder neck (type II). Preoperative diagnosis of the syndrome is mandatory and associated with a decrease of complication rate of surgical management. Endoscopic therapies like ERCP with lithotripsy or endoscopic extraction of cystic duct calculi followed by laparoscopic cholecystectomy have been described. Here we report successful endoscopic stone-clearance using double-cannulation and large balloon dilatation of the papilla for giant biliary stone impacted in the cystic duct inserted low in the common hepatic duct causing type I MS.
Bibliographic reference:
Double-cannulation and large papillary balloon dilation: key to successful endoscopic treatment of mirizzi syndrome in low insertion of cystic duct. Donatelli G, Dhumane P, Dallemagne B, Marx L, Delvaux M, Gay G, Marescaux J. Dig Endosc 2012;24:466-9.

Bariatric surgery is widely performed and some specific complications are related to bariatric procedures. In this lecture, Dr. Galvao Neto looks into the endoscopic approach for different complications.

Bariatric surgery has emerged as a highly effective treatment for obesity and is increasingly recognized to have benefits for glycemic management in patients with pre-existing type 2 diabetes mellitus (T2DM). Understanding the efficacy and physiological effects of bariatric surgery on metabolism will push forward a novel approach to interventional procedures for diabetes treatment. In this key lecture, Dr. Galvao Neto presents the first result of a novel endoscopic approach to type 2 diabetes, namely duodenal mucosal resurfacing.

The Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has become the gold standard for the treatment of cholelithiasis with a success rate of 95%.
The dimensions of a giant biliary calculus are equal to or bigger than 2cm.
Various endoscopic tools such as the mechanical lithotripsy or extracorporeal shock wave lithotripsy (ESWL) have been described to treat this pathology. Surgery is offered to cases unresolved by endoscopic therapy.
Recently, the sphincteroplasty with a large-size balloon dilatation of the papilla has been described as an option for the endoscopic management of the giant biliary stone.
This is a case of extraction of giant common bile duct calculus using the combination of sphincterotomy and large-size balloon sphincteroplasty.

Patients with liver cirrhosis present with portal hypertension (PHT), which causes various pathological changes in the entire gastrointestinal tract (from esophagus to anus). In this video, the Mallory Weiss tear (MWT) occurred accidentally during ESD of a gastric antral adenoma in a cirrhotic patient. It was successfully managed by means of endoscopic clipping. The patient had two episodes of retching during endoscopy, which might have contributed to gastric over-distension. With esophagogastroduodenoscopy (EGD) being so commonly performed in cirrhotic patients and ESD being more and more commonly used for treatment of gastric mucosal lesions, this case report should serve as a precautionary reminder in such case scenarios.

POEM (peroral endoscopic myotomy) is an emerging procedure, which has evolved from the era of NOTES. The most cardinal indication for POEM is achalasia of the cardia. Other indications include diffuse esophageal spasm, jackhammer esophagus, and surgically failed cases.
The steps of POEM include the following: mucosotomy, submucous tunnelling, myotomy, closure of mucosotomy.
The myotomy is started 2 to 3cm distal to the mucosotomy and is continued to the end of the tunnel at 2 to 3cm distally to the gastroesophageal junction (GEJ). A partial myotomy is most commonly performed by means of careful dissection of circular fibers, hence avoiding longitudinal fibers to prevent entry into the mediastinum. The mucosotomy is then closed to prevent any leakage with the use of endoscopic clips or of an endoscopic suturing device. About the EndoFLIP™ (Endolumenal Functional Lumen Imaging Probe) Imaging System: this is a functional endoluminal imaging probe, which helps in the assessment of gastroesophageal junction distensibility and compliance after the procedure.
Complications of POEM:
Inadvertent mucosotomy is the most common complication.
Complications due to insufflation (pneumomediastinum, pneumoperitoneum) can be controlled by using carbon dioxide for insufflation. Esophageal leak is the most dreaded complication with rates ranging from 0 to 5.6%.

This video demonstrates the case of a 27-year-old woman, admitted to the emergency department for acute right hypochondrium pain.
Clinical examination found a positive Murphy’s sign. Biological findings showed a cholestasis (Gamma Glutamyl Transferase at 576 l/U, Alkaline Phosphatase at 346 l/U), and cytolysis (AST at 460 I/U, ALT at 635 I/U) without jaundice.
Abdominal ultrasonography confirmed the presence of acute cholecystitis with thickening of the gallbladder wall associated with a moderate 8mm dilatation of the common bile duct without any lithiasis.
Antibiotic therapy was started and cholecystectomy with intraoperative cholangiography was decided upon because of the clinical presentation and biological disturbance.

Peroral endoscopic myotomy (POEM) is the application of esophageal myotomy by utilizing a submucosal tunnelling method. In this video, the POEM procedure was performed for a child with congenital distal esophageal stenosis and with a previous history of cleft palate, cleft lip, and multiple previous dilations with solid food dysphagia. In this video, Dr. Swanström demonstrates the technique and details the principles of POEM.

A 48-year-old man was addressed for endoscopic evaluation of chronic pain of the left lower quadrant. Gastroscopy was unrevealing. However, colonoscopy disclosed a villous-like pedunculated polyp of the sigmoid colon, 2.5cm in diameter, with fresh blood distally to it. Due to its size and to the high risk of bleeding, we decided to remove it by means of the endoloop technique.

This video describes the technique for repair of central ventral defects by endoscopic subcutaneous component separation, suture closure of the central ventral defects using V-Loc™ suture and reinforcement of the reconstruction with an underlay composite mesh. Advantages of this approach are the preservation of abdominal wall dynamics with a low recurrence rate and fewer complications usually observed in other complex abdominal reconstructions such as seromas, hematomas, infection, pain, delayed recovery, and undesirable cosmetic results. The video shows the endoscopic subcutaneous component separation technique in detail as well as the identification and closure of the central ventral defect and the underlay placement of a composite mesh. CT-scan images of abdominal wall reconstruction at three months postoperatively are presented. In our first 6 cases, early clinical and CT-scan results were encouraging.