Antonia Gantschnigg

Summary: Background: Boerhaave’s syndrome (BS) is a rare but often fatal condition with high mortality rates despite intensive treatment. Data are scarce. We herein report a single-center experience with BS. The aim of this study was to investigate and point out the role of endoluminal vacuum therapy (EVT) in BS. Methods: Between June 2011 and April 2024, all patients with BS in our tertiary referral center with a unit specialized in surgical endoscopy were analyzed regarding age, gender, delay of diagnosis, treatment technique, and outcome. Results: During the study period, 12 consecutive patients (9 male) were treated for BS. The median age was 64.8 years. Five patients were treated with EVT only, four with surgery and simultaneous EVT, and three by surgery only. After implementation of EVT, all patients were treated with either EVT only or surgery with simultaneous EVT. Intensive care unit stay was significantly shorter in patients treated with EVT only. The 30-day mortality was 25% (3 patients). No long-term complications occurred. Conclusion: This investigation led to our current strategy of applying only EVT in patients in a stable condition and no CT signs of vast pleural content. Otherwise, surgery plus EVT is performed.

Gastrointestinal cutaneous fistulas are complex and challenging surgical conditions that occur predominantly postoperatively [1]. Effective treatment requires a multidisciplinary approach, with surgical revision carefully planned and typically considered after the failure of conservative treatments [2]. Endoscopic therapies, including clipping and vacuum therapy, along with newly developed endoscopic suture-based techniques, have shown promising results in closing fistulas without the high morbidity and mortality of surgical interventions [3] [4] [5]. We present the case of a 64-year-old man who developed an enterocutaneous fistula following a laparoscopic one-anastomosis gastric bypass for morbid obesity. His postoperative course was complicated by perforation at the biliopancreatic limb. After two unsuccessful attempts at permanent closure surgically and a subsequent subcutaneous infection, an enterocutaneous fistula developed. A temporary fistula closure was achieved using an over-the-scope (OTS) clip but, after displacement of the clip ([Fig. 1] a), the fistula persisted. Endoscopic fistula closure was performed 10 months postoperatively. This was carried out using an endoscopic helix tacking system (X-Tack; Boston Scientific Corporation, Marlborough, Massachusetts, USA) after argon plasma coagulation of the fistula tract had been performed ([Fig. 1] b,c; [Video 1]), and was followed by placement of an external suture to close the cutaneous opening of the fistula. The patient’s postinterventional course was uneventful. At follow-up after 2 months, no recurrence of the fistula was detected. Endoscopic enterocutaneous fistula closure is safe and feasible after failed surgery. Novel endoscopic suturing devices extend the possibilities for a tailored approach regarding different locations and types of fistula. Endoscopy_UCTN_Code_TTT_1AO_2AZ Article published online: 14 January 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Purpose: Robotic-assisted surgery is an alternative technique for patients undergoing minimal invasive cholecystectomy (CHE). The aim of this study is to compare the outcomes and costs of laparoscopic versus robotic CHE, previously described as the major disadvantage of the robotic system, in a single Austrian tertiary center. Methods: A retrospective single-center analysis was carried out of all patients who underwent an elective minimally invasive cholecystectomy between January 2010 and August 2020 at our tertiary referral institution. Patients were divided into two groups: robotic-assisted CHE (RC) and laparoscopic CHE (LC) and compared according to demographic data, short-term postoperative outcomes and costs. Results: In the study period, 2088 elective minimal invasive cholecystectomies were performed. Of these, 220 patients met the inclusion criteria and were analyzed. One hundred ten (50%) patients underwent LC, and 110 patients RC. There was no significant difference in the mean operation time between both groups (RC: 60.2 min vs LC: 62.0 min; p = 0.58). Postoperative length of stay was the same in both groups (RC: 2.65 days vs LC: 2.65 days, p = 1). Overall hospital costs were slightly higher in the robotic group with a total of €2088 for RC versus €1726 for LC. Conclusions: Robotic-assisted cholecystectomy is a safe and feasible alternative to laparoscopic cholecystectomy. Since there are no significant clinical and cost differences between the two procedures, RC is a justified operation for training the whole operation team in handling the system as a first step procedure. Prospective randomized trials are necessary to confirm these conclusions.

Purpose: Electrocautery-enhanced lumen-apposing stents (EC-LAMS) were originally designed for the drainage of the gallbladder, bile duct, and pancreas pseudocysts. Throughout the years, several off-label indications were established. This study aims to evaluate the indication, safety, efficacy, and outcome of all LAMS implanted in a single tertiary referral center. Methods: From April 2016 to April 2022, all patients undergoing LAMS placement in a single tertiary center were included. We present a detailed analysis of indications, success rates, and complications based on a retrospective analysis of our prospectively maintained database. Results: A total of 86 stents were placed in 77 patients between April 2016 and April 2022. Indications were walled-off pancreatic necrosis (25.6%), bile duct obstructions (16.3%), acute cholecystitis (15.1%), pancreas pseudocysts (15.1%), postoperative collections (10.5%), postoperative pancreatic fistulas (9.3%), and gastro-gastrostomy/jejunostomy (8.1%) to enable to perform an endoscopic retrograde cholangiopancreatography in patients with gastric bypass. Technical success was 97.7% (84 out of 86). A total of 10 (11.7%) adverse events were observed. In 3 patients (3.5%), severe complications occurred, which required acute surgery; one displacement was closed through clips. In 7 patients (8.2%), bleedings occurred during necrosectomy or from mucosal erosions at the stent side, respectively, that were treated with endoclips. Conclusions: EC-LAMS are safe and show a high technical success rate in all indications. In everyday clinical practice, the main indications are hepato-pancreato-biliary, and therefore an hepato-pancreato-biliary-surgical department should have EC-LAMS in their armamentarium.

Background: We integrated a standardized questionnaire focusing on adverse events and performance measures in gastrointestinal endoscopy as a mandatory component of the electronical medical record. Methods: This retrospective study was conducted using prospectively collected data on quality parameters and adverse events (AEPM) for all diagnostic and therapeutic endoscopic procedures at our center between 2018 and 2020. Results: A total of 7532 consecutive endoscopic procedures were performed in 5035 patients. The proportion of high-risk examinations and high-risk patients was 20% and 23%, respectively. Severe adverse events (AEs, n = 21) occurred in 0.3% of procedures and significantly more often in patients with an ASA score > II (0.6%, p < 0.01). We observed no long-term morbidity after severe AEs. Mortality was 0.03% (n = 2). Following screening colonoscopy (n = 242), four endoscopists documented AEPM in more than 98% of the examinations. The cecal intubation rate was 97%, and the mean adenoma detection rate 60%. The quality of lavage was documented in 97% (rated as good in 70% and moderate in 24%). Conclusions: The risk of adverse events is significantly increased in patients with an ASA score > II, which should be considered when choosing treatment methods and precautionary measures. Continuous recording of AEPM can be effectively integrated into the clinical reporting process, enabling analysis of the data and feedback to be provided to endoscopists.

A 53-year-old patient with a history of alcohol abuse presented with acute severe epigastric pain. Computed tomography (CT) showed signs of acute pancreatitis with a 9-cm measuring walled-off pancreatic necrosis (WOPN) in the pancreatic tail, with broad-based contact to the greater curvature of the stomach. Initial gastroscopy revealed severe ischemic gastric wall necrosis without signs of perforation ([Fig. 1]). An electrocautery-enhanced lumen-apposing metal stent (LAMS; 15 × 10 mm) was implanted transgastrically under endoscopic ultrasound guidance, to enable direct necrosectomy ([Fig. 2]). Because of a suspicion of splenic infarction, another CT scan was performed; this showed free air collections in the upper abdomen, with urgent suspicion of gastric wall perforation in the area of the ischemic gastric wall. A gastrectomy was done, with reconstruction by esophagojejunostomy and Roux-en-Y anastomosis. Gastroscopy 6 days postoperatively revealed an anastomotic leak at the esophagojejunostomy. Endoscopic vacuum therapy was started with changes every 3–4 days. At 16 days postoperatively, a second endoscopic vacuum sponge was inserted into a newly occurring insufficiency in the jejunal blind stump that accessed the 5-cm necrotic pancreatic cavity. At 3 weeks later, after complete healing of the esophagojejunostomy anastomosis, vacuum therapy was ended, and a LAMS (20 × 16 mm) was implanted in the jejunal blind stump providing access for necrosectomy of the WOPN ([Video 1]). After five extensive endoscopic necrosectomies, the stent was removed. The patient was free of infection up to that time and was discharged from the hospital. At follow-up gastroscopy 1 week later, the jejunal blind stump had healed except for a 6-mm blind-ending fistula without secretion. Video 1 Direct retroperitoneal necrosectomy through an insufficient jejunal blind stump, after gastrectomy for necrotizing pancreatitis. Acute pancreatitis is a common disease with an unpredictable course and a wide range of severity [1] [2]. This case highlights the difficulty in managing the potential complications and describes how a secondary post-surgical complication enabled an unusual approach for endoscopic treatment. Endoscopy_UCTN_Code_TTT_1AR_2AI Article published online: 14 July 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Purpose A few studies suggest that hormones play a role in the motility of the lower esophagus, but data is rare. In this prospective study we evaluated the correlation between hormones (TSH, fT3, fT4, calcitonin, gastrin, and VIP) and gastroesophageal reflux disease (GERD), esophageal motility disorders, and gastrointestinal symptoms. Methods 100 consecutive patients with reflux symptoms and dysphagia were hospitalized for diagnostic evaluation. Self-reporting questionnaires were handed out and patients routinely underwent serum analysis (TSH, fT3, fT4, calcitonin, gastrin, and VIP), 24-hour-pH-impendance monitoring, and high-resolution manometry. Results Motility disorders were found in 38 out of 86 patients. There were no correlations between hormones, the DeMeester Score, and the lower esophageal sphincter pressure. A strong inverse relation between calcitonin and the Integrated Relaxation Pressure of the esophagogastric junction was found (r=–0.492; p<0.001). No correlations were found between hormone levels and the responses given in the questionnaires. Positive correlations, however, were found between VIP and gastrointestinal symptoms, as well as correlations between fT3 and dysphagia. Within the group with minor motility disorders, TSH and fT4 correlated with outcomes of the SCL-questionnaire. fT4 correlated with the typical symptoms, as well as the gastrointestinal symptoms (diarrhea, constipation, flatulence). TSH correlated with the typical symptoms. Moreover, a correlation between VIP and gas-bloat-symptoms was found within group II Conclusions No correlation between TSH, fT3, fT4, gastrin, VIP, calcitonin, and GERD in the sense of acid reflux was found, although calcitonin seems to have an effect on the lower esophageal sphincter.

A 76-year-old patient presented with pancreatic duct dilatation on magnetic resonance imaging (MRI). The patient had no symptoms and no previous history of hepatobiliary or pancreatic disease. Endosonography showed pancreatic duct dilatation (12 mm) in the pancreatic body and tail. The pancreatic duct in the pancreatic head was only moderately dilated (5 mm). Endoscopic retrograde cholangiopancreatography (ERCP) showed a normal major papilla and normal biliary system. Pancreatography revealed a blind-ending main pancreatic duct of only 35 mm in length. The minor papilla was found in the typical position, 2 cm above the major papilla. Pancreatography confirmed the dilated main pancreatic duct in the pancreatic body and tail, with a narrow Santorini duct ([Fig. 1 a]), so a plastic drain was inserted. Chronic pancreatitis because of pancreas divisum was assumed to be the reason for the duct dilatation. During follow-up ERCP 10 weeks later, pancreatography showed the typical sign of mucus in the Santorini duct, with shallow contrast passage ([Fig. 1 b]). After the extraction of a large amount of mucus, a mucinous tumor measuring 14 mm was detected in the Santorini duct ([Fig. 1 c]). Transpapillary biopsy was performed using a one-sided opening-cup biopsy forceps (Olympus Corporation, Tokyo, Japan) and pathological results showed an intrapapillary mucinous neoplasm (IPMN). Because of the location of the neoplasm within the Santorini duct in a pancreas divisum, this was classified as a main duct IPMN ([Video 1]). Video 1 Intraductal papillary mucinous neoplasm of the Santorini duct in a patient with pancreas divisum diagnosed by transpapillary biopsy. In line with the revised Fukuoka guidelines [1], surgery was considered; however, after discussion with the patient, surgery was not pursued owing to the patient’s cardiological co-morbidities. Further surveillance was performed by direct pancreatoscopy (SpyGlass DS System, Boston Scientific Corporation, Marlborough, Massachusetts, USA) and the typical papillary structure of an IPMN was seen, with re-biopsy performed ([Fig. 2]). IPMN of the Santorini duct is a rare finding [2]. This case outlines the difficulty of differentiating between chronic pancreatitis and carcinoma of the pancreas and its precursor lesions. Endoscopy_UCTN_Code_CCL_1AZ_2AB Publication Date: 26 January 2022 (online) © 2022. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany