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Laparoscopy-assisted endoscopic full-thickness resection (LAEFTR) has been suggested as an alternative to laparoscopic wedge resection in the treatment of gastric subepithelial tumors (SETs). It is expected to minimize the resection of the tissue surrounding the tumors and maintain the function of the remnant stomach. Here, we performed a prospective pilot study to evaluate the efficacy of laparoscopy-assisted endoscopic full-thickness resection (LAEFTR) for patients with gastric SETs.We enrolled twelve patients who were diagnosed with gastric SETs with an intraluminal growth pattern or which is located in the gastric antrum between October 2011 and September 2013. LAEFTR was performed endoscopically using an endoscopic knife to make an incision half way around the tumor circumference and a laparoscopic resection around the remaining tumor circumference, followed by its laparoscopic removal. The feasibility, safety, and effectiveness of LAEFTR for gastric SETs were evaluated.The median size of the tumors in twelve patients was 22 mm (21-33). Of the 12 patients, 8 received LAEFTR, while the others underwent conventional laparoscopic wedge resection, since their tumor outlines were clearly visible in laparoscopic view. In 8 patients who underwent LAEFTR, the mean total operation time (endoscopic procedure time/laparoscopic procedure time) were 117 (37/41) min. The tumors were completely resected with clear margin, and there was no perioperative and postoperative complications.LAEFTR currently seems to be the ideal treatment modality of intraluminal gastric SETs where their resection margins are difficult to define under laparoscopic guidance alone.

Benign esophageal strictures are regularly encountered problems in clinical practice. The management of refractory benign esophageal stricture, which fails to establish adequate food passage despite multiple dilatation sessions, has been considered challenging. Experimental animal models are essential for the development of effective treatment methods. The aim of this study was to establish a new animal model of benign esophageal stricture using rabbits.Corrosive injury of the esophagus was induced by administration of 1 ml of 1.5% sodium hydroxide in eight rabbits using an ultraslim upper endoscope equipped with a 5-Fr polytetrafluoroethylene tube and 5-Fr balloon catheter. Two weeks after corrosive injury, endoscopic examination was performed to confirm the state of the injury site. Four weeks after corrosive injury, the esophageal stricture was assessed by endoscopy and esophagography. All animals were then euthanized.Two weeks after corrosive injury, endoscopic examination showed that ulceration had been induced. Four weeks after corrosive injury, endoscopic, radiologic and gross examinations showed that esophageal stricture had been induced without complications in all animals. The esophageal lumen diameter was reduced by an average of 51.8% (range, 48.3%-57.2%), and the mean stricture length was 25.7 mm (range, 20.1-29.3 mm). Microscopic examination revealed focal ulceration and submucosal thickening secondary to fibrosis.Rabbit esophageal stricture induced by endoscopic delivery of a small amount of low-concentration sodium hydroxide is a relatively simple, safe, and reproducible animal model. This model may be useful in the development of new treatment methods for esophageal stricture.

Endoscopic transpapillary gallbladder drainage using a nasocystic tube or plastic stent has been attempted as an alternative to percutaneous drainage for patients with acute cholecystitis who are not candidates for urgent cholecystectomy. We aimed to assess the efficacy of single-step endoscopic drainage of the common bile duct and gallbladder, and to evaluate which endoscopic transpapillary gallbladder drainage method is ideal as a bridge before elective cholecystectomy.From July 2011 to December 2014, 35 patients with acute moderate-to-severe cholecystitis and a suspicion of choledocholithiasis were randomly assigned to the endoscopic naso-gallbladder drainage (ENGBD) (n = 17) or endoscopic gallbladder stenting (EGBS) (n = 18) group.Bile duct clearance was performed successfully in all cases. No significant differences were found between the ENGBD and EGBS groups in the technical success rates [82.4% (14/17) vs. 88.9% (16/18), p = 0.658] and clinical success rates [by intention-to-treat analysis: 70.6% (12/17) vs. 83.3% (15/18), p = 0.443; by per protocol analysis of technically feasible cases: 85.7% (12/14) vs. 93.8% (15/16), p = 0.586]. Three ENGBD patients and two EGBS patients experienced adverse events (p = 0.658). No significant differences were found in operation time or rate of conversion to open cholecystectomy.Single-step endoscopic transpapillary drainage of the common bile duct and gallbladder seems to be an acceptable therapeutic modality in patients with acute cholecystitis and a suspicion of choledocholithiasis. There were no significant differences in the technical and clinical outcomes between ENGBD and EGBS as a bridge before cholecystectomy.

The placement of self-expandable metallic stents (SEMS) is known to be effective palliative treatment of malignant gastroduodenal obstruction. There are two types of SEMS--covered and uncovered--each with its own advantages and disadvantages. This study was conducted to compare between the clinical outcomes of covered and uncovered stents in patients with malignant gastroduodenal obstruction.The study was conducted prospectively from January 1998 to June 2007 and 154 patients were included. All had symptomatic gastroduodenal obstruction and were not candidates for curative operation. Seventy patients received covered SEMS, while the other 84 received uncovered SEMS. We compared technical and clinical success rates, tumour ingrowth rate, stent migration rate, stent patency time and patient survival in both SEMS groups.The technical and clinical success rates of the covered and uncovered stent groups did not differ. Stent migration was more frequent in the covered stent group than in the uncovered group (17.1% versus 0%; p=0.0001). Tumour ingrowth was more frequent in the uncovered stent group than in the covered group (16.6% versus 2.9%; p=0.0066). Stent re-intervention rate, stent patency time and patient survival did not differ between groups.Covered and uncovered stent insertions are technically feasible and effective palliative treatment of malignant gastroduodenal obstruction. Covered stents can reduce the risk of tumour ingrowth, whereas uncovered stents are effective in preventing stent migration. However, covered stents did not differ from uncovered stents in regard to other clinical outcomes.

Covered self-expandable metal stents (SEMSs) are increasingly used as alternatives to uncovered SEMSs for the palliation of inoperable malignant distal biliary obstruction to counteract tumor ingrowth. We aimed to compare the outcomes of partially covered and uncovered SEMSs with identical mesh structures and anti-migration properties, such as low axial force and flared ends.One hundred and three patients who were diagnosed with inoperable malignant distal biliary obstruction between January 2006 and August 2013 were randomly assigned to either the partially covered (n = 51) or uncovered (n = 52) SEMS group.There were no significant differences in the cumulative stent patency, overall patient survival, stent dysfunction-free survival and overall adverse events, including pancreatitis and cholecystitis, between the two groups. Compared to the uncovered group, stent migration (5.9% vs. 0%, p = 0.118) and tumor overgrowth (7.8% vs. 1.9%, p = 0.205) were non-significantly more frequent in the partially covered group, whereas tumor ingrowth showed a significantly higher incidence in the uncovered group (5.9% vs. 19.2%, p = 0.041). Stent migration in the partially covered group occurred only in patients with short stenosis of the utmost distal bile duct (two in ampullary cancer, one in bile duct cancer), and did not occur in any patients with pancreatic cancer.For the palliation of malignant distal biliary obstruction, endoscopic placement of partially covered SEMSs with anti-migration designs and identical mesh structures to uncovered SEMSs failed to prolong cumulative stent patency or reduce stent migration.

In the palliative treatment of malignant dysphagia, fully covered, retrievable metal stents are not commonly used, mainly due to the high risk of migration. Therefore, we performed a prospective study to evaluate the clinical efficacy of a fully covered, retrievable self-expanding metal stent (Niti-S).Between October 1998 and February 2009, 100 consecutive patients with malignant esophageal obstruction treated with the fully covered Niti-S stent (Niti-S, Taewoong Medical, Seoul, South Korea) were included. Data collected contained functional outcome, feasibility of endoscopic stent retrieval, recurrent dysphagia, complications, and survival.At 4 weeks after stent placement, dysphagia significantly improved in all patients (p = 0.000). Recurrent dysphagia occurred in 19 of 100 patients treated with Niti-S stents (19%) mainly due to tumor overgrowth (7/100, 7%), stent migration (6/100, 6%), and food impaction (6/100, 6%). Endoscopic stent retrieval was successful in all the attempted 17 patients (17/100, 17%)--7 overgrowth, 6 stent migration, 2 stent degradation, and 2 severe pain. Major complications were 2 hemorrhage, 2 severe pain, and 1 tracheal compression (5/100, 5%), and minor complications were 10 retrosternal pain and 7 symptomatic gastroesophageal reflux (17/100, 17%). After a median follow-up of 142 days, 97 patients had expired. There was no stent-related mortality or 30-day mortality.The fully covered, retrievable Niti-S stent has proved its effectiveness for palliation of malignant dysphagia and feasibility of endoscopic retrieval. We estimate its dog-bone shaped flanges at both ends and it being completely covered provide good resistance to migration and overgrowth.

Although still controversial, bilateral stenting may be the best option for palliative drainage of malignant hilar biliary obstruction. The aim of our study was to evaluate the technical and clinical efficacies of endoscopic bilateral metal stenting using a biliary Y-stent for the management of malignant hilar obstruction.This prospective, uncontrolled study included 30 consecutive patients with unresectable malignant hilar strictures in whom we intended to perform endoscopic bilateral stent-in-stent deployment using a biliary Y-stent. After deployment of the Y-stent across the hilar stricture, a conventional biliary metal stent was inserted in a Y-configuration in which it traversed the wider-mesh central portion of the Y-stent to enter the opposite hepatic lobe.Bilateral metal stenting using a Y-stent was successful in 26 of 30 patients (86.7%), and successful drainage was achieved in all 26 patients (100%). Early complications occurred in 3 patients (cholangitis, 1; cholecystitis, 2) without procedure-related mortality. As late complications during the follow-up period (median, 176 days; range, 70-473 days), stent occlusion occurred in 10 of 26 patients (38.5%). Four patients were managed with the insertion of a plastic stent through the occluded metal stent, and the remaining patients were treated with percutaneous biliary drainage. The median survival and stent patency were 176 days and 140 days, respectively.Y-shaped endoscopic bilateral stenting using a Y-stent appears to be a feasible and effective method with high technical success and low stent-related complications for palliation of unresectable malignant hilar biliary obstruction.