Search

Endoscopic diverticulotomy associated with cricopharyngeal myotomy is a well-known and safe treatment for Zenker diverticulum. We describe our first 5 consecutive cases treated by a new variant of the technique that allows a deeper and longer myotomy than the standard one. Technical success was achieved in all the cases. All patients showed a significant improvement and relevant disappearance of preoperative dysphagia. Tips for the technique are described in the paper. This variant of peroral endoscopic diverticulotomy for Zenker diverticulum is feasible, effective, and guarantees a complete myotomy in selected patients.

Background Management of biliary adverse events (BAEs) after biliodigestive anastomosis is challenging. We propose a new endoscopic approach to improve BAEs in this clinical setting. Methods Patients who had BAEs after a hepaticojejunostomy with Roux-en-Y loop or a Whipple procedure underwent creation of an entero-enteral endoscopic bypass (EEEB) between the duodenal/gastric wall and the biliary jejunal loop under endoscopic ultrasound (EUS) and fluoroscopic guidance using specifically designed fully covered self-expandable metal stents. Results 32 consecutive patients underwent EEEB, which was successful in all but one patient. One procedural and five long-term mild adverse events occurred. Endoscopic retrograde cholangiography (ERC) through the EEEB successfully treated all types of BAEs in these patients. Disease recurred in two patients who were successfully re-treated through the EEEB. Conclusions Our retrospective study showed that in patients with BAEs after biliodigestive anastomosis, EEEB is safe, feasible, and allows a successful long-term treatment of different BAEs in a tertiary referral center with high-level experience in both endoscopic retrograde cholangiopancreatography and EUS.

Background Endotherapy is considered by some as the treatment of choice for most external biliary fistulas after laparoscopic cholecystectomy except for those originating from isolated/disconnected ducts, as in Strasberg type C lesions. Endoscopic intervention is not generally considered among treatment options because the isolated duct cannot be opacified during cholangiography and is inaccessible with the usual endoscopic methods. Methods Our interventional endotherapy for this type of complication consists of cannulating the isolated duct by passing a guidewire out of the cystic duct or the disruption of the common bile duct into the pathway of the biliary fistula. The key element of this endoscopic treatment is to restore the continuity of the biliary tree. Our case series (from March 2012 to September 2017) consists of 19 patients (9 males, 10 females) with Strasberg type C bile leaks. The access to the transected biliary duct was obtained by purposeful puncture of the cystic duct stump into the peritoneal cavity and then intubation of the biliary duct by a 0.035 hydrophilic guidewire. In 17 cases, we performed direct cannulation of the isolated transected duct. In 2 cases, we performed an endoscopic “step-up approach” (a 2-session variant of the technique). Results Technical and clinical success rates were both 100%. Drainage form the abdominal drain stopped in a mean of 1.2 days. There was 1 recurrence after 4 weeks (attributable to displacement of the metal stent), but we were able to retreat the patient endoscopically. Our technique is minimally invasive but very effective in healing the fistulas. Operative repair, in contrast, is a major operation with increased morbidity, prolonged hospital stay, and is more costly. Moreover, on the basis of the available literature, endotherapy passing through the abdominal cavity became safe in expert centers. Conclusion The described endoscopic treatment is innovative, safe, and effective and is applicable in tertiary-level centers but requires considerable interventional endoscopic expertise. This minimally invasive procedure can increase the rate of fistula healing and decreases the need for more aggressive and risky operative procedures.

This image ([figure 1][1]) is a photogram of a small-bowel capsule endoscopy and shows an intestinal Taenia spp causing persistent anaemia (requiring several blood transfusions) due to many jejunal and ileal mucosal erosions ([figure 2][2]) in a 52-year-old patient under oral anticoagulant therapy.