Sofiya Reicher

Carcinoma cuniculatum is a rare variant of well-differentiated squamous cell carcinoma. To date, there are less than 30 cases of esophageal carcinoma cuniculatum reported. It is frequently a diagnostic challenge: A definitive diagnosis typically cannot be made before esophagectomy. We present a uniquely aggressive case of esophageal carcinoma cuniculatum complicated by a bronchoesophageal fistula and successfully palliated with dual esophageal and endobronchial stenting.

Background and aims Transoral incisionless fundoplication (TIF) is an effective endoscopic treatment for refractory GERD with small or absent hiatal hernia (< 2 cm in length and width). The single-session laparoscopic hernia repair followed by transoral incisionless fundoplication (HH + TIF) aims to repair mechanical defects in the lower esophageal sphincter that leads to GERD in patients with hiatal hernias ≥ 2 cm. The procedure effectively treats GERD without causing added post-surgical dysphagia and gas bloating commonly associated with partial laparoscopic fundoplication. We aimed to assess patient satisfaction, symptom resolution, safety, and proton pump inhibitor use following the HH + TIF procedure. Methods Thirty-three patients underwent single-session laparoscopic hernia repair with intraoperative TIF using the EsophyX Z device (EndoGastric Solutions, Inc.) between June 2015 and June 2018. The presence of GERD and normal esophageal motility were confirmed with pH testing and manometry prior to the procedure. Data were collected on pre- and post-procedure symptoms, patient satisfaction, PPI use, and complications. Median post-procedure follow-up with symptom surveys was 9 months (11–29 months). Results Patients reported significant decreases in common GERD symptoms including heartburn, regurgitation, cough, and hoarse voice. Eighty-one percent (27/33) of patients were off daily PPIs. Ninety-four percent (31/33) of patients reported 75% or greater satisfaction with the procedure and outcomes. One patient had a superficial mucosal laceration after the procedure, likely due to vomiting, which was treated conservatively. Conclusions The majority of patients reported 75% or greater satisfaction with the procedure and had an improvement in GERD symptoms as well as decreased PPI use. There were no serious adverse events.

Background and aims: Post-ERCP complications increase with repeated attempts at cannulation. We evaluated several advanced biliary cannulation techniques applied when the standard approach fails. Methods: In total, 1873 consecutive patients underwent ERCP at our institution during the period 2010 – 2014. Guidewire-assisted (GA) cannulation with no contrast injection until deep biliary cannulation was considered the standard technique. Advanced techniques used were double wire-guided (DWG) cannulation, transpancreatic papillary septotomy (TPS), and needle-knife sphincterotomy (NKS). When GA cannulation failed, DWG cannulation was usually attempted first if the pancreatic duct (PD) wire was in place; if that failed, TPS or NKS was performed. Alternatively, TPS or NKS were performed alone. A prophylactic pancreatic stent was placed with repeated PD cannulation or PD contrast injection. During the last 2 years of review, indomethacin suppositories were given post-procedure to all patients who underwent advanced techniques. Results: The overall biliary cannulation success rate was 97 % (1823/1873). Advanced techniques were used in 12 % of ERCPs (230/1873), with 87 % (200/230) success rate. DWG was used alone or in combination with other techniques in 58 % (134/230) of advanced cases, with 68 % (91/134) success rate. Biliary cannulation was achieved in 96 % (91/95) of procedures when DWG was used alone, 76 % (26/34) with TPS alone, 80 % (37/46) for NKS alone, and 84 % (46/55) with multiple techniques. The overall rate of post-ERCP pancreatitis was 0.4 %, with all patients treated conservatively. Conclusion: In our experience at an urban tertiary care center, use of advanced techniques in difficult ERCP improved the overall success rate of biliary cannulation after standard technique failure without a significant increase in complication rate.