Lili Ma

Small bowel diverticulum (SBD) is an outpouching of the small intestinal wall and is often neglected in clinical practice due to its undiscerning location. Majority of SBD can be asymptomatic but can also be associated with life-threatening complications. We hereby performed a clinical analysis to investigate the characteristics associated with SBD. This retrospective case series analyzed clinical data from two tertiary referral centers. Clinical data including baseline characteristics, clinical presentation, diagnostic methods and treatment were systematically collected and reviewed. Subgroup analysis based on distinct location of the SBD, such as the duodenum, jejunum and ileum were also performed. A total of 149 cases of SBD were ultimately included in the present study analysis. Among 114 duodenal SBD cases, 42 (36.8%) were asymptomatic, while 58 (50.9%) presented with pain/discomfort. In contrast, jejunoileal SBD (n = 35) were predominantly symptomatic: 21 (60.0%) required surgical intervention due to complications such as obstruction (n = 8), bleeding (n = 12), or perforation (n = 5). Endoscopic modalities (DBE/VCE) achieved a diagnostic accuracy of 92.3% for jejunoileal SBD, surpassing radiological methods (CT/BaFT) at 38.5% (p < 0.001). Distinctive case highlights also provided examples of SBD found at different locations. Small bowel diverticular (SBD) disease is often overlooked in clinical practice, due to its discrete location and limited access. With continuous diagnostic advancements, including endoscopic techniques, the detection of SBD is expected to rise, gaining clinical awareness amongst gastroenterologists.

Natural orifice transluminal endoscopic surgery (NOTES) represents a revolutionary advancement in minimally invasive surgery, eliminating the need for external incisions and offering faster recovery and improved aesthetics. Endoscopic transgastric cholecystectomy (ETGC), a NOTES-based procedure, stands out for its potential to revolutionize gallbladder removal by offering a truly scarless alternative to traditional laparoscopic cholecystectomy (LC). This review explores the historical development of cholecystectomy, evolution of NOTES, and emergence of ETGC as a feasible alternative to LC. We highlight the technical refinements that have enabled ETGC, including innovations in full-thickness resection and suturing techniques, and discuss challenges such as visibility, orientation, and wound closure. Finally, we examine the role of robotic platforms in enhancing precision and expanding clinical applications by positioning ETGC as a transformative technique in the era of minimally invasive surgery.

Background and Aims: Duodenal perforation caused by foreign bodies (FBs) is very rare but is an urgent emergency that traditionally requires surgical intervention. Several case reports have reported the successful endoscopic removal of duodenal perforating FBs. Here we aimed to evaluate the safety and efficacy of endoscopic management of duodenal perforating FBs in adults.Methods: Between October 2004 and October 2022, 12,851 patients with endoscopically diagnosed gastrointestinal FBs from four tertiary hospitals in China were retrospectively reviewed. Patients were enrolled if they were endoscopically and/or radiographically diagnosed with duodenal perforating FBs.Results: The incidence of duodenal total FBs and perforating FBs was 1.9% and 0.3%, respectively. Thirty‐four patients were enrolled. Endoscopic removal was achieved in 25 patients (73.5%), and nine patients (26.5%) received surgery. For the endoscopic group, most perforating FBs were located in the duodenal bulb (36.0%) and descending part (28.0%). The adverse events included 3 mucosal injuries and 1 localized peritonitis. All patients were cured after conventional treatment. In the surgical group, most FBs were lodged in the descending part (55.6%). One patient developed localized peritonitis and one patient died of multiple organ failure. The significant features of FBs requiring surgery included FB over 10 cm, both sides perforation, multiple perforating FBs and massive pus overflow.Conclusion: Endoscopic removal of duodenal perforating FBs is safe and effective, and can be the first choice of treatment for experienced endoscopists. Surgical intervention may be required for patients with FBs over 10 cm, both sides perforation, multiple perforating FBs, or severe infections.

A patient was admitted with a 1-month history of intermittent abdominal pain, often associated with pre-prandial exacerbation. Then, 2 days prior to admission, the patient experienced hematochezia, with a rapid decline in hemoglobin level from 131 g/L to 80 g/L to 61 g/L. The patient underwent gastroscopy and colonoscopy, but no obvious cause of gastrointestinal bleeding was found. Considering the relative short course of disease, with no symptomatic evidence of obstruction, video capsule endoscopy (VCE) was ordered to determine the cause of obscure gastrointestinal bleeding. The VCE was completed in 11:14 hours but did not complete the entire small-bowel examination and failed to pass after 72 hours. A computed tomography scan revealed that the VCE device was retained in the small bowel, located in the left upper quadrant of the abdomen ([Fig. 1 a, b]). A double-balloon enteroscopy (DBE) was performed to retrieve the VCE device. An antegrade approach revealed multiple diverticula in the jejunum ([Fig. 1 c, d]). Initially, the location of the VCE device was difficult to identify, but it was later found within a large diverticulum located in the upper segment of the jejunum. Unlike extraction of video capsules in stricturing or obstructive diseases, extraction of a foreign object from a diverticulum is technically difficult due to sharp angulation of the scope and accurate snare positioning. After multiple attempts and repeated adjustment, the VCE device was finally retrieved ([Video 1]). Video 1 Retention of a video capsule endoscope in a jejunal diverticulum, retrieved with a polypectomy snare. As VCE is noninvasive and convenient, it has become a common diagnostic tool for the investigation of obscure gastrointestinal bleeding and other small-bowel disorders [1]. However, VCE device retention is a known adverse event, with a reported incidence of approximately 2 %–10 %. Although rare, device retention may cause severe life-threatening complications. The majority of cases of video capsule retention are due to stricturing diseases, such as Crohn’s disease, or obstructing disease, such as small-bowel tumors [2]. VCE device retention in diverticular disease is thus an even rarer complication. Device retention may not require immediate intervention, but prolonged retention may require surgical extraction. This report described a case of VCE device retention in a jejunal diverticulum, which was successfully retrieved with DBE. Endoscopy_UCTN_Code_TTT_1AP_2AB Article published online: 12 June 2023 © 2023. 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 Rüdigerstraße 14, 70469 Stuttgart, Germany

Background. Transjugular intrahepatic portosystemic shunt (TIPS) is suggested as the salvage therapy for gastroesophageal variceal bleeding in cirrhosis. However, rebleeding might occur in some patients after TIPS. Currently, there is a lack of evidence in the endoscopic management of recurrent bleeding in these patients. Aims. To evaluate the efficacy of endoscopic treatment in cirrhotic patients with recurrent bleeding after TIPS. Methods. Cirrhotic patients with gastroesophageal varices who received endoscopic treatment for recurrent bleeding after TIPS were included. Results. 6 patients were enrolled in this study. The median age of the patients was 47 years (range 27 to 65 years), and the duration of follow-up time was 346 (17-773) days. Stent stenosis or occlusion was found in 5 out of 6 patients after TIPS. Salvage endoscopic treatment, including esophageal variceal ligation (EVL), gastric variceal cyanoacrylate injection, esophageal variceal sclerotherapy, and balloon-occluded retrograde transvenous obliteration- (BRTO-) assisted endoscopic cyanoacrylate injection. Among included patients, 2 died shortly after EVL (14 and 19 days) due to variceal bleeding. Among other 4 patients, 2 had rebleeding episodes at 422 and 789 days, respectively. Conclusion. Endoscopic treatment may be an option for recurrent bleeding after TIPS in selected patients. Further studies are needed to carefully define the indication and efficacy of this option.

Treatment; Authors: S. Wu, X. Kong, Y. Wang, X. Fan, Q. Huang, R. Chen, W. Yu, L. Ma, Y. Sun, L. Jiang