Claudia F. Consiglieri

Aims Analysis of our experience with this type of esophageal stent. Evaluation of its feasibility, safety and efficacy. Methods Retrospective, single-center, and descriptive study. All those patients in whom a NITI-S Cervical Esophageal Stent (Taewoong Medical) was placed between 2012 and 2021 were identified from a specific stent-database. Demographics, technical and clinical data were collected from diagnostic tests and our health service provider. Results Seventeen patients were identified. Demographic and clinical characteristics are summarized in [Table 1]. The most used stent size was: ESP1610FV (58%). Technical success was 82%. Proximal end-flare deployment: 16cm from incisors (range: 12-19cm). Clinical success (oral diet tolerance) was 100%. Adverse events: 2 distal migrations, 1 ingrowth, with endoscopic resolution; 1 proximal migration and 2 intolerances due to pain that required removal. Mean follow-up: 3 months (SD±5.6). Up to 80% of the cases passed away and were related to the malignant disease’s progression. Conclusions This is one of the most extensive case series reporting the use of this dedicated cervical oesophageal stent. The main clinal indication is palliative for severe dysphagia. This stent seems to be effective and a safe option for cervical locations. Publication Date: 14 April 2022 (online) © 2022. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A 91yo man with history of Roux-en-Y reconstruction was admitted due to acute cholangitis. Cholangio-MRI: choledocholitiasis with intra and extrahepatic bile duct dilatation. A linear echoendoscope was used to perform an endoscopic biliary drainage. Firstly, EUS-guided biliary accesses by transgastric puncture of left intrahepatic biliary radical, confirmed by serum-instillation and bile-aspiration. Secondly, advancement of a guidewire anterogradely until reach enteral loop, through the papilla y by fluoroscopy-guidance. Finally, a transgastric-hepatic ostomy using a 6-Fr cystotome, and antegrade papilloplasty using a CRE balloon allowed a EUS-guided antegrade stenting (Biliary fully-covered metal stent, 60 x 10mm) without incidences. Publication Date: 14 April 2022 (online) © 2022. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

To facilitate the safe and simple introduction of an endoscopic ultrasound (EUS)-guided gastroenterostomy technique, we present a step-by-step teaching video of a variant technique for direct EUS-guided gastroenterostomy using a feeding tube ([Video 1]). The stages involved are as follows. Video 1 A teaching video demonstrating the technique of direct endoscopic ultrasound-guided gastroenterostomy using a feeding-tube waterjet system. Endoscopy_UCTN_Code_TTT_1AS_2AG Publication Date: 17 September 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

The main reasons for dislodgement of the distal flange of a lumen-apposing metal stent (LAMS) into the peritoneum during endoscopic ultrasound (EUS)-guided gastroenterostomy are that the delivery catheter pushes away the small bowel without entering it, or else that advancement of a preloaded guidewire tents away the jejunal loop (in both cases, the EUS window is lost). The main question is: Is the guidewire still in place? If yes, the action of choice is coaxial insertion of a second (coaxial) stent (LAMS, enteral self-expandable metal stent) through the misdeployed LAMS. If not, three options have been reported: LAMS-in-LAMS rescue with -intraperitoneal EUS guidance; natural orifice transluminal endoscopic surgery (NOTES); or surgery. We offer some helpful technical notes for intraperitoneal NOTES salvage ([Fig. 1], [Fig. 2], [Fig. 3]; [Video 1]): Video 1 Helpful technical notes for intraperitoneal natural orifice transluminal endoscopic surgery (NOTES) salvage in the scenario of a failed endoscopic ultrasound-guided gastroenteroanastomy with a misdeployed lumen-apposing metal stent. Relevant technical aspects during NOTEs are to: limit CO₂ insufflation; maneuver carefully; stabilize the guidewire; ensure meticulous fluoroscopic monitoring to help advancement of the second LAMS delivery catheter into the small bowel [1] [2] [3] [4]. Endoscopy_UCTN_Code_CPL_1AL_2AB Publication Date: 02 July 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A 61-year-old man was referred for an iron-deficiency anemia diagnostic process. Upper gastrointestinal endoscopy was performed and fortuitously revealed a small gastric subepithelial lesion. Endoscopic ultrasound (EUS) characterization revealed a solid lesion, with fusiform morphology, well-defined by smooth edges and an hypoechoic homogeneous internal pattern, measuring 12.3 × 5.8 mm, and originating in the muscularis propria layer, which confirmed a subepithelial tumor ([Fig. 1]). With the aim of avoiding EUS surveillance of the subepithelial tumor, a minimally invasive removal technique was planned [1] [2] [3]. Endoscopic band ligation of the subepithelial tumor was done using a Captivator endoscopic mucosal resection standard gastroscope device (Boston Scientific, Quincy, Massachusetts, USA) combined with a single-incision needle knife (SINK) biopsy (XL Triple-lumen needle knife; Boston Scientific; and pure-cut 90-W, Beamer CE600; ConMed, Utica, New York, USA). A standard videogastroscope was used, and four biopsy samples were obtained (Radial Jaw large capacity biopsy forceps; Boston Scientific) ([Fig. 2]). The patient remained in hospital for 24 hours and was called at 48 hours and 7 days after the procedure, with no incidents or adverse events being reported ([Video 1]). Video 1 Endoscopic band ligation without resection, plus single-incision needle knife biopsy, for a gastric subepithelial tumor. Pathological and immunohistochemistry examination revealed a fascicular proliferation of fusiform eosinophilic cells, negative for CD117 (c-kit) and DOG1, and positive for desmin and caldesmon, corresponding to the diagnosis of a leiomyoma ([Fig. 3]). The first EUS control, at 5 weeks after the procedure, revealed a complete disappearance of the subepithelial tumor features, showing a discreet eschar (simple biopsy with 4 samples, showing normal gastric mucosa). Long-term EUS control at 1 year showed that the subepithelial tumor had vanished, confirming the successful result and allowing discontinuation of endoscopic surveillance ([Fig. 4]). Endoscopic band ligation combined with SINK biopsy seems to be an effective minimally invasive technique that is safer than endoscopic resection for treating a gastric subepithelial tumor originating in the muscularis propria [4] [5]. Endoscopy_UCTN_Code_TTT_1AO_2AG

The appearance of the lumen-apposing metal stent (LAMS) has meant an authentic revolution. To date, the results are promising but it is necessary to note the technical incidents and LAMS-related complications. an EUS-transmural guided drainage using a HotAXIOS was planned for a 36-year-old man with oral intolerance due to a voluminous walled-off necrosis. The distal flange was left in the collection, but a total distal malposition occurred during the proximal flange delivery, despite correct apposition with visualization of the black mark. A rescue technique was performed inserting a second LAMS over-the-guidewire salvaging the initial failed transmural drainage. This case is a reminder that in similar scenarios, extreme tension of the echoendoscope can cause a malfunction of the AXIOS stent delivery system, and lead to a total distal malposition. This "LAMS-in-LAMS" technique is feasible, effective, and a very helpful rescue technique in cases of dislodged LAMS.

Complete gastrointestinal strictures are a technically demanding problem. In this setting, an anterograde technique is associated with a high risk of complications and a combined anterograde-retrograde technique requires a prior ostomy. Our aim was to assess the outcome of a first case series for the management of complete gastrointestinal strictures using endoscopic ultrasound (EUS)-guided puncture as a novel endoscopic approach. This retrospective case-series describes four cases that were referred for treatment of complete benign gastrointestinal strictures, three upper and one lower. Recanalization was attempted with EUS-guided puncture using a 22G or 19G needle and contrast filling was visualized by fluoroscopy. Afterwards, a cystotome and/or a dilator balloon were used under endoscopic and fluoroscopic guidance. A fully covered metal stent was placed in two cases, keeping the strictures open in order to prevent another stricture. Feasibility, adverse events, efficacy and the number of dilations required after recanalization were evaluated. Technical and clinical success was achieved in three of the four cases (75%). A first dilation was performed using a dilator balloon in all successful cases and fully covered metal stents were used in two cases. These patients underwent a consecutive number of balloon dilatations (range 1-4) and all three were able to eat a soft diet. No adverse events were related to the EUS-guided approach. In the failed case with a long stricture (> 3 cm), an endoscopic rendezvous technique was attempted which caused a pneumothorax requiring a chest tube placement. EUS-guided recanalization, as a first approach in the treatment of complete digestive stricture, is a feasible and promising procedure that can help to avoid major surgery.

EUS-guided fine-needle ethanol injection (FNI) therapy of some types of cystic and solid tumors has been documented. However, reported cases to date of gastrointestinal-stromal tumors (GIST) treated with this technique are scarce. Ethanol ablation is an alternative treatment with a low rate of adverse events in selected cases.