Gabriele Curcio

An 81-year-old woman with malignant gastric outlet obstruction due to pancreatic adenocarcinoma ([Fig. 1 a]) was referred to our institute for endoscopic ultrasound (EUS)-guided gastroenterostomy. Under general anesthesia, a 0035-inch guidewire (Navigator; Olympus Medical Systems, Center Valley, Pennsylvania, USA) was inserted through the duodenal stenosis ([Fig. 2 a]) deep into the small bowel using a standard gastroscope under fluoroscopic assistance ([Fig. 2 b]). A 20-mm balloon dilator (CRE balloon; Boston Scientific, Marlborough, Massachusetts, USA) was then inserted over the wire across the obstruction and filled with contrast fluid ([Fig. 2 c]). A therapeutic linear echoendoscope (GF-UC140P; Olympus Medical Systems) was used to locate the balloon in a small-bowel loop adjacent to the gastric wall ([Fig. 3 a, b]). The jejunal loop was accessed directly from the stomach with a 15-mm diameter lumen-apposing metal stent (LAMS) contained within an electrocautery-enhanced delivery system (Hot AXIOS; Boston Scientific) ([Fig. 3 c]), avoiding the multiple accessory exchanges previously described with other techniques [1] [2] [3]. In fact, there was no need for a fine-needle aspiration needle, guidewire, or tract dilation, and the stent was released in a single-step, exchange-free fashion ([Video 1]). During the procedure, the small-bowel loop was kept in close apposition to the gastric wall by pulling on the inflated balloon, which was firmly anchored within the bowel loop. The Trendelenburg position of the patient further helped to obtain “gravity countertraction” to puncture. Direct access into the jejunal loop was performed by aiming the electrocautery tip of the delivery system slightly distally to the balloon in order to avoid any eventual entrapment of the distal flange of the stent inside a popped balloon. As a result, the balloon remained intact and the LAMS was successfully released ([Fig. 4 a, b]). After deployment of the AXIOS stent, the lumen of the stent was balloon-(over)dilated up to 18 mm ([Fig. 5 a]). A through-the-stent contrastography revealed no leak of contrast fluid at the end of the procedure ([Fig. 5 b]). The patient resumed an oral diet the day after the procedure, after a follow-up computed tomography scan confirmed the correct position of the stent ([Fig. 1 b]). Endoscopy_UCTN_Code_TTT_1AS_2AG

A 64-year-old man with multiple comorbidities (obesity and metabolic syndrome, dilated cardiomyopathy, type 2 diabetes mellitus, chronic renal insufficiency, obstructive sleep apnea syndrome, and colonic diverticula) underwent anterior resection for distal rectal cancer with protective ileostomy. A few days later, enteral juice was flowing from surgical drains; an urgent endoscopy with fluoroscopy showed the presence of a small (8-mm) anastomotic leak, which was managed conservatively. At 1-month follow-up, endoscopy showed a 75 % anastomotic dehiscence with intraluminal migration of a drain ([Fig. 1]). The patient’s clinical condition worsened and, after multidisciplinary discussion, an endoscopic transanastomotic fully covered metal stent placement was planned. The ideal stent had to have a large bore, be sufficiently long, and to have an antimigration system. A large-bore over-the-wire stent with a double antimigration system appeared to have these features (head diameter 32 mm, body diameter 24 mm, length 18 cm, BETA stent; Taewoong Medical, Gyeonggi-do, South Korea) ([Fig. 2]). As the stent was developed for the treatment of postbariatric surgery leak, specific measures were taken to ensure its antimigration activity and to place the larger stent flare proximally in the colon. On the back table, the stent was released inside a 32-Fr tube; the tube and enclosed stent were then turned round, and the stent was reassembled by inserting the original release system but through the opposite end of the stent ([Fig. 3]). With the patient under deep sedation, and using endoscopic and radiologic control, the stent was easily released across the anastomotic dehiscence ([Fig. 4]). Enteric flow through the abdominal drain immediately stopped, allowing removal of the drain 1 week later. The stent was removed 3 months later, and endoscopy showed complete anastomotic dehiscence resolution ([Fig. 5]). The patient remained asymptomatic during the 8-month follow-up. Anastomotic dehiscence is the “Achilles’ heel” of resectional colorectal pathology, and is the most common cause of postoperative morbidity and mortality [1] [2] [3]. This case report describes a new, alternative nonsurgical method for treating a severe complication, such as colorectal anastomotic dehiscence, using a modified large-bore fully covered stent ([Video 1]). Endoscopy_UCTN_Code_TTT_1AQ_2AG

A 51-year-old woman affected with Crohn’s disease developed a distal ileum abscess requiring right hemicolectomy. A few days later, bile was flowing from surgical drains, and a computed tomography (CT) scan showed a duodenal leak. Surgical suture of the duodenal wall was attempted, but failed. The patient was then referred to our institute and, to promote duodenal healing, the predetermined goal was to stop both the enteric and the biliary flows through the leak ([Fig. 1]). A percutaneous transhepatic cholangiography (PTC) was done to divert bile flow. To divert the enteric flow, a treatment with a fully covered metal stent (26 mm body diameter, 34 mm flare diameter, and 10 cm length; Beta stent; Taewoong Medical, Gyeonggi-do, South Korea) ([Fig. 2]) was planned. The Beta stent is an over-the-wire stent, with a specific antimigration system, developed for the treatment of post-bariatric surgery leak. To enhance the depth of the stent insertion into the duodenum, a single-balloon enteroscopy overtube (ST-SB1; Olympus Europe, Hamburg, Germany) was used to prevent gastric looping thus straightening the release system from the esophagus through the stomach to the distal duodenum [1]. The procedure was carried out under endoscopic and radiologic control and with the patient under general anesthesia. The enteroscopy overtube was advanced through the duodenum and stabilized beyond the ligament of Treitz. A small orifice was created by puncturing the overtube about 70 cm from its distal end ([Fig. 3 a]) and the Beta stent was inserted through the orifice over the wire ([Fig. 3 b]). When the stent was in the correct position, the overtube was twisted and slightly retracted allowing stent placement from the duodenal bulb beyond the ligament of Treitz ([Video 1]). The abdominal drainage flow stopped immediately, and the patient was restarted on oral feeding 1 week later. The stent was removed 3 months later, and the leak appeared to have resolved ([Video 1], [Fig. 4]). The patient remained asymptomatic during the 8-month follow-up. Duodenal leak is a life-threatening condition, with a high rate of complications, and entailing a long period of hospitalization. Diversion of the enteric and the biliary flows away from the fistula seems to be effective in promoting rapid healing [2]. This report describes a new, overtube-assisted method for safely releasing a large-bore over-the-wire enteral stent directly into the duodenum to resolve a case of leakage. Endoscopy_UCTN_Code_TTT_1AP_2AD

We read with interest the study by Al-Haddad et al. [1] on the accuracy of integrated molecular pathology (IMP) testing in assessing the malignant potential of pancreatic cysts, and the comparison with the 2012 Sendai guideline management criteria model. The authors found that IMP testing can differentiate between the need for surveillance and the need for surgery more accurately than the Sendai criteria. We were surprised at the positive predictive value (PPV) calculated for the 2012 Sendai criteria for malignancy in this article. The authors found a PPV of 20.8 % for the Sendai criteria versus 57.9 % for IMP testing. This value is significantly lower than the PPV (88 %) for the 2012 Sendai criteria reported by Goh et al. [2]. This remarkable difference is likely due to the surgical criteria chosen by Al-Haddad et al. In their study, the surgical category required the presence of at least one of the following features: obstructive jaundice in a patient with a cystic lesion of the pancreatic head, cyst size larger than 3 cm, enhancing solid component or definite mural nodule, severe cytological findings, main duct involvement, main duct dilatation (≥ 1 cm), abrupt changes in duct caliber, or a presumptive diagnosis of mucinous cystic neoplasm based on cytologic indications of mucin. In the 2012 Sendai guidelines [3], a size larger than 3 cm is not considered to be a definitive surgical criterion, but rather an indication for endoscopic ultrasonography, as are non-enhancing mural nodule and main duct involvement. The identification of mucin on cytologic examination or carcinoembryonic antigen (CEA) in cystic fluid (≥ 192 ng/mL) is not a surgical indication, but only indirect evidence of the mucinous nature of a lesion. In our opinion, the interpretation of the 2012 Sendai guidelines on surgical indications reported by Al-Haddad et al. may explain why their PPV was less statistically significant than that reported by Goh et al. The authors repeated the calculation, completely excluding cyst size and omitting all presumptive cytologic and CEA criteria for mucinous cysts, with minimal impact on the performance of the 2012 Sendai model (only [sic] 8 times and 11.6 times higher risks for malignant outcome, respectively, in patients meeting surgical criteria). However, there is no discussion of other surgical criteria, such as non-enhancing mural nodule, main duct involvement, and cytologic indications of mucin, which at best are considered “worrisome features” by the 2012 Sendai guidelines, not definitive surgical indications [3]. Furthermore it is not clear why the authors recalculated the relative risk, omitting the doubtful surgical criteria (cyst size and the presence of mucus or cystic CEA > 192 ng/mL), but not the PPV, which can offer a more useful comparative value. The authors chose four molecular criteria for malignancy (listed in Table 1 of their article), referring to a multicenter study by Khalid et al. [4], but the chosen criteria correspond only partially to the criteria cited in the study of Khalid et al. Furthermore, one of the molecular criteria for malignancy chosen by Al-Haddad et al. (a single low clonality oncogene mutation) seems to correlate more with the mucinous nature of a cyst than with malignancy [4]. We believe that further prospective studies are needed before conclusions can be drawn about the clinical application of IMP testing, and molecular analysis in general, to risk stratification for malignancy in pancreatic cystic lesions.