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OBJECTIVE Preemptive endoluminal vacuum therapy (pEVT) is a novel concept to reduce postoperative morbidity and has the potential to disrupt current treatment paradigms for patients undergoing esophagectomy. SUMMARY OF BACKGROUND DATA Endoluminal vacuum therapy is an accepted treatment for AL after esophagectomy. METHODS Retrospective analysis of patients undergoing minimally invasive Ivor Lewis esophagectomy with pEVT between 11/2017 and 10/2020. The sponge was removed endoscopically after 4-6 days, and anastomosis and gastric conduit were assessed according to a novel endoscopic grading system. Further management was customized according to endoscopic appearance and clinical course. Endpoints were postoperative morbidity and AL rate, defined according to the Clavien-Dindo (CD) and International Esodata Study Group classifications. RESULTS PEVT was performed in 67 consecutive patients, 57 (85%) were high-risk patients with an ASA score >2, WHO/ECOG score >1, age >65 years, or BMI >29 kg/m2. Thirty patients experienced textbook outcome, and overall minor (≤CD IIIa) and major (≥CD IIIb) morbidity was 40.3% and 14.9% respectively. 30-day-mortality was 0%. Forty-nine patients (73%) had uneventful anastomotic healing after pEVT without further endoscopic treatment. The remaining 18 patients (27%) underwent prolonged EVT with uneventful anastomotic healing in 13 patients (19%), contained AL in 4 patients (6%), and 1 uncontained leakage (1.5%) in a case with proximal gastric conduit necrosis, resulting in an overall AL rate of 7.5%. CONCLUSIONS PEVT is an innovative and safe procedure with a promising potential to reduce postoperative morbidity after minimally invasive Ivor Lewis esophagectomy and may be particularly valuable in highly comorbid cases.

Introduction: Anastomotic leakage (AL) accounts for a significant proportion of morbidity following oesophagectomy. Endoluminal negative pressure (ENP) therapy via a specifically designed polyurethane foam (EsoSponge®, B.Braun Medical, Melsungen, Germany) has become the standard of care for AL in many specialized centres. The prophylactic (pENP) application of this technique aims to reduce postoperative morbidity and is a novel approach which has not yet been investigated in a prospective study. The aim of this study is therefore to assess the effect of pENP at the anastomotic site in high-risk patients undergoing minimally invasive transthoracic Ivor Lewis oesophagectomy. Methods and analysis: The study design is a prospective, multi-centre, two-arm, parallel-group, randomised controlled trial and will be conducted in two phases. Phase one is a randomised feasibility and safety pilot trial involving 40 consecutive patients. After definitive sample size calculation, additional patients will be included accordingly during phase two. The primary outcome of the study will be the postoperative length of hospitalization until reaching previously defined “fit for discharge criteria”. Secondary outcomes will include postoperative morbidity, mortality and postoperative AL-rates based on 90-day follow-up. A confirmatory analysis based on intention-to-treat will be performed. Ethics and dissemination: The ethics committee of the University of Zurich approved this study (2019-00562), which has been registered with ClinicalTrials.gov on 14.11.2019 (NCT04162860) and the Swiss National Clinical Trials Portal (SNCTP000003524). The results of the study will be published and presented at appropriate conferences.

Background The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment. Methods A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008–2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included. Results Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required. Conclusion Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple’s procedure may be required depending on tissue friability and diverticular collar size.

Alongside the evolution of interventional endoscopy, the need for a more sophisticated closure tool tailored to the treatment of new challenging indications has been increasing rapidly.We here present our collected data on 262 Over-The-Scope-Clip (OTSC®) placements in a total of 233 interventions at our institution. Follow-up was focused on clinically lasting success with regards to different indications.Immediate success of OTSC® treatment was observed in 87.1% of all sessions (203/233). The success ratesOur cohort confirms previous data on the clinical usefulness of the OTSC® in daily routine practice.

The worldwide number of performed bariatric surgeries is increasing continuously, whereas laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are conducted most frequently. Alongside with the usual post-operative and metabolic complications, luminal complications such as anastomotic bleeding, ulceration, leakage, fistula formation, enlargement and stenosis of the anastomosis may occur. Evolution of interventional endoscopy frequently allows endoscopic management of complications, avoiding surgical interventions in most cases. Here, we review the various luminal complications after bariatric surgery with a focus on their endoscopic management.

INTRODUCTION The accuracy of preoperative lymph-node staging in patients with adenocarcinoma of the esophagogastric junction (AEG) or gastric cancer (GC) is low. The aim of this study was to assess the accuracy of [18F]fluorodeoxyglucose positron emission tomography/computed tomography (PET-CT) for lymph-node staging in patients with AEG or GC, with or without neoadjuvant treatment. PATIENTS AND METHODS 221 consecutive patients with GC (n = 88) or AEG (n = 133) were evaluated. Initial staging included endoscopic ultrasound (EUS), multidetector spiral CT (MDCT) and PET-CT. PET-CT was performed for restaging in patients after neoadjuvant treatment (n = 94). Systematic lymphadenectomy was routinely performed with histopathological assessment of individual mediastinal and abdominal lymph-node stations. Preoperative staging from EUS, MDCT, and PET-CT was correlated with histopathological results. RESULTS PET-CT showed a high specificity (91%) and positive predictive value (89%) for the preoperative detection of lymph-node metastases. In comparison, EUS was more sensitive (73% versus 50%, P

Summary Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien–Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0–26.2). PEVT appears to be a safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.

Anastomotic leakages or staple line defects after Roux-en-Y gastric bypass (RYGB) and primary laparoscopic sleeve gastrectomy (LSG), respectively, with consecutive bariatric revisional surgery are associated with relevant morbidity and mortality rates. Endoscopic vacuum therapy (EVT) with or without stent-over-sponge (SOS) has been shown to be a promising therapy in foregut wall defects of various etiologies and may therefore be applied in the treatment of postbariatric leaks. We report the results of six consecutive patients treated with EVT (83% in combination with SOS) for early postoperative leakages in close proximity to the esophagogastric junction (EGJ) after LSG (n = 2) and RYGB (n = 4) from May 2016 to May2018. All patients (2/6 male, median age 51 years, median BMI 44.2 kg/m2) were treated successfully without further signs of persisting leakage at the last gastroscopy. The lesions’ size ranged from 0.5 cm2 to 9 cm2, and the leaks were connected to large (max. 225 cm2) abscess cavities in 80% of the cases. Median duration of treatment (= EVT in situ) was 23.5 days (range, 7–89). The number of endoscopic interventions ranged from 1 to 24 (median, n = 7), with a median duration between vacuum sponge replacements of 4 days. EVT is an effective and safe treatment for staple line defects or anastomotic leakage after bariatric surgeries and can therefore be adopted for the treatment of midgut wall defects. Further studies with a greater number of patients comparing surgical drainage alone or in combination with EVT versus EVT alone are needed.

A 74-year-old woman with extensive lichen planus mucosae (LPM) developed stenotic esophagitis that was refractory to intravenous glucocorticosteroids. Esophageal dilatations to 14 mm width were repeatedly performed without any lasting effect. After introducing oral apremilast, she experienced complete clinical remission within the first 4 weeks of treatment. Control esophagoscopy confirmed a marked recovery of the esophageal mucosa with no recurrence of the former stenosis. Our observation is in line with the case series of Paul et al. [J Am Acad Dermatol 2013;68: 255–261] who first reported on the benefit of apremilast in patients with extensive LPM. Ideally, the effectiveness of apremilast in LPM should be studied in a randomized controlled trial.

Background and study aims Endoluminal vacuum therapy (EVT) has evolved as a promising option for endoscopic treatment of foregut wall injuries in addition to the classic closure techniques using clips or stents. To improve vacuum force and maintain esophageal passage, we combined endosponge treatment with a partially covered self-expandable metal stent (stent-over-sponge; SOS). Patients and methods Twelve patients with infected upper gastrointestinal wall defects were treated with the SOS technique. Results Indications for SOS were anastomotic leakage after surgery (n = 11) and chronic foregut fistula (n = 1). SOS treatment was used as a first-line treatment in seven patients with a success rate of 71.4 % (5/7) and as a second-line treatment after failed previous EVT treatment in five patients (success rate 80 %; 4/5). Overall, SOS treatment was successful in 75 % of patients (9/12). No severe adverse events occurred. Conclusion SOS is an effective method to treat severely infected foregut wall defects in patients where EVT has failed, and also as a first-line treatment. Comparative prospective studies are needed to confirm our preliminary results.

A 57-year old woman underwent lung transplantation for non-specific interstitial pneumonia. Primary graft dysfunction was diagnosed requiring continued use of extracorporeal membrane oxygenation (ECMO). Within three days she developed recurring hemothoraces requiring two surgical evacuations. After ECMO removal a series of complications occurred within four months: femoral thrombosis, persisting tachycardic atrial fibrillation, pneumopericardium with an esophagopericardial fistula and purulent pericarditis, septic shock, multiorgan failure and intracerebral hemorrhage with ventricular involvement requiring external ventricular drainage. Interdisciplinary management coordinated by the intensive care specialist, transplant surgeon and pulmonologist with various interventions by the respective specialists followed by intensive physical rehabilitation allowed for discharge home on day 235 post transplant. Subsequently quality of life was considered good by the patient and family. Keywords: Lung transplantation, Esophagopericardial fistula, Intracranial hemorrhage, Complications, Treatment

Over-the-scope-clips (OTSC®) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC® treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC® closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC® closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC® closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC® was achieved in all patients with no immediate or long-term complications. OTSC® is a promising endoscopic treatment option for this condition with a potentially high immediate and long term success rate in patients with multiple comorbidities.

Biliary complications following liver transplantations, with leaks and bile duct strictures being the most common ones, are greatly feared. Portobiliary fistulas are rare, but may cause potentially life-threatening complications. The presented case shows the first successful treatment of a portobiliary fistula by an endoscopically deployed fully covered self-expandable metal stent after liver transplantation. In accordance to the already established use in refractory bile leaks, we believe that fully covered self-expandable metal stent is a safe and efficient treatment option for portobiliary fistula.

Background: Management of leakages of the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) can be complex. New endoscopic techniques such as covered stents and over-the-scope clips (OTCs) have been developed and are valuable alternative therapeutic options to reoperation and drainage. The aim of this study was to compare the value of stents and OTCs with surgical treatment options for the therapy of anastomotic leakages after LRYGB. Methods: Results of patients who were treated surgically with reoperation, local irrigation and drain placement (n = 9) were compared with results of patients who were treated endoscopically with stent and/or OTC placement (n = 5). Success rate, length of hospital stay, mortality, number of OTC applications/stent placement and percutaneous drainage placements were analyzed. Results: Overall, 14 of 1,046 patients (1.34%) developed a leakage of their gastrojejunal anastomosis after LRYGB between 2000 and 2012. While the success rate in surgically treated patients was 88%, the endoscopic treatment using a sequential approach with stenting, OTC application and percutaneous placement of drainages resulted in a 100% closure rate. The mortality rate and length of stay were not substantially different after both treatment regimens. Conclusion: Endoscopic management of anastomotic leakages after LRYGB may constitute a valuable alternative therapeutic option to surgical reoperation and drainage placement.

Acute esophageal variceal bleeding in patients with portal hypertension remains a complication with a high mortality today. In cases refractory to standard therapy including endoscopic band ligation and pharmacological therapy, traditionally balloon tamponade has been used as salvage therapy. However, these techniques show several important limitations. Self-expanding metal stents (SEMS) have been proposed as an alternative rescue treatment. The use of variceal stenting in 7 patients with a total of 9 bleeding episodes in three different Swiss hospitals is demonstrated. While immediate bleeding control is achieved in a high percentage of cases, the 5-day and 6-week mortality rate remain high. Mortality is strongly influenced by the severity of the underlying liver disease. Accordingly, our data represent a high-risk patient collective. Thanks to their safety and easy handling, SEMS are an interesting alternative to balloon tamponade as a bridging intervention to definitive therapy including the pre-hospital setting.

To date, there is no standardized treatment for esophageal perforations and leakages caused by underlying benign diseases, and it is still debated whether a conservative, endoscopic treatment or a surgical approach is preferable. However, some cases series have successfully demonstrated the feasibility of a temporary placement of self-expanding stents.All patients with benign leakages of the esophagus or gastroesophageal junction or fistulas at gastroesophageal anastomosis were collected during the past 12 years and analyzed retrospectively. The patients treated with endoscopic stenting were analyzed for sustained success, complications, time to stenting, lesion size, number of stents used, need for percutaneous drainage.Eighty-five of eight-eight patients were included in this analysis. Three patients were conservatively managed only. The success rate of stent treatment with an average of 1.3 stents was 79%. Success was highest (94%, n = 30 of 32, no complications or mortality) in iatrogenic lesions that were immediately diagnosed and treated. Spontaneous lesions, including lesions due to Boerhaave's syndrome, were healed in 73% and anastomotic leakages were closed in 71%. Fistula had a lower success rate of 43%. Use of multiple stents sequentially placed was necessary in 23% of the cases. Percutaneous drainage was necessary in 25% of all cases.Temporary stent placement for benign leakages of the esophagus is safe and seems to improve treatment success. Adjacent fluid collections should be drained percutaneously.

Background and Study Aims: The role of cyst cytology to diagnose mediastinal duplication cysts remains controversial. Since endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of duplication cysts has been considered as safe so far, there are only a few case reports of infections following FNA. Case Summary: We report a case series of all patients at our institution undergoing EUS evaluation for suspected mediastinal duplication cysts (n = 5) in the last 15 years. The mediastinal lesion in 4 patients did not feature typical EUS features for duplication cysts, wherefore we did perform EUS-guided FNA in order to rule out malignancy. In 3 out of 4 patients, a duplication cyst was confirmed. The fourth lesion turned out to be a sarcoma. All 4 patients developed severe FNA-induced cyst infection causing mediastinitis and the need for surgical debridement. Despite an immediate review of the FNA by the on-site cytopathologist with establishing the diagnosis of a duplication cyst, peri-interventional broad-spectrum antibiotics could not prevent severe infections of the lesions. Conclusions: Given the potentially high rate of infectious complications, we advocate a very restrictive indication for diagnostic FNA in mediastinal masses. Yet, in unclear cases, FNA might be indispensable despite the potential adverse events in order to rule out hypoechogenic, mediastinal malignancy.

A new approach for the treatment of complicated anastomotic leaks following esophageal resections by combining vacuum-assisted therapy with covered self-expanding stents is reported. This is not an approach for a simple leak but a rescue maneuver for complex uncontained leaks. It is known that anastomotic leakages particularly situated in the chest can be successfully treated with endoscopically placed self-expanding stents with/without additional drainage. If this approach fails, reoperation with substantial morbidity is frequently necessary. Two complicated anastomotic leakages refractory to stenting alone were successfully treated with the combination of an endo-sponge-assisted device covered by a self-expanding metallic stent. If stent therapy fails or the perianastomotic abscess cavity is large and complex to drain from outside, the endoscopic two-modality approach can be considered.

Despite the increasing use of carbon dioxide for endoscopies during the last years, ambient air is still used. The amount of air depends on several factors such as examination time, presumable diameter of the endoscope channel and of course active use of air by the operator. Although endoscopic complications due to ambient air in the gastrointestinal (GI) tract are a rare observation and mostly described in the colon, we report five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer. Due to insufflation of inadequate amounts of air through the endoscope channel, all patients deteriorated in circulation and ventilation. Two rumenocenteses and consecutively three laparotomies had to be performed in three patients. In the other two, gastroscopies had to be stopped for an emergency computed tomography. All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air. Therefore in emergency situations, endoscopies should be performed with either submersion, low air flow pumps or even better by the use of carbon dioxide.

Background Anastomotic leak (AL) remains a major cause of morbidity in upper-GI surgery. In many centers, endoluminal vacuum drainage (EVD) has become the mainstay of therapy for AL after esophageal and gastric resections. A new idea is to use the EVD technology in a preemptive setting. In this context, we present a case series of patients that received PEVD upon completion of the anastomosis during esophago-gastric surgery. Methods Intraoperative PEVD was performed in 10 consecutive patients undergoing minimally invasive esophagectomy with cervical (n = 1) or high intrathoracic (n = 6) anastomosis, and open transhiatally extended (n = 1) or minimally invasive (n = 2) total gastrectomy. The EVD device was removed after three to six (mean 4) days, and the anastomosis was endoscopically inspected for ischemia and AL. Additional contrast radiography, computed tomography, or gastroscopy to exclude AL was performed in seven patients. Primary endpoints in this retrospective series was AL; secondary endpoints were the postoperative morbidity measured by the Clavien-Dindo (CD) classification and the comprehensive complication index (CCI), all at 30 days after surgery. Results Perioperative mortality was 0% with uneventful anastomotic healing in all patients of this series (AL rate 0%, anastomotic stenosis 0%). There were no adverse events attributable to PEVD. None of the patients experienced major morbidity (> CD grade IIIa) during the postoperative course. The median postoperative ICU and hospital stay was 1 (IQR 1-1.75) and 14 (IQR 12-16) days, respectively. Five patients (50%) developed at least one complication, mostly related to infection (2 patients) and pulmonary events (2 patients). The mean CCI at 30 days after surgery was 13.7 (range 0-39.5). Conclusion PEVD appears to be a safe procedure that may emerge as a groundbreaking technology in patients undergoing esophageal or gastric resection. Further research is needed to elucidate the true potential of this technique. Disclosure All authors have declared no conflicts of interest.

Background Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes. Objective To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes. Design Randomized controlled study. Setting University Hospital of Zurich, Switzerland. Patients Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. Main Outcome Measurements Success rates of endoscopic placement of enteral feeding tubes. Results A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument ( P Limitations In rare cases, the randomization list could not be followed correctly. Conclusions This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.

Background/Aims: To identify the number and potential causes of unnecessary diagnostic procedures in a cohort of patients with autoimmune pancreatitis (AIP). Methods: All AIP cases at our centre between April 2006 and April 2013 were collected and followed up. Diagnosis was established by the International Consensus Diagnostic Criteria (ICDC). Demographic, clinical, radiological, serological data, the number of diagnostic procedures and the reason for referral were recorded. Possible risk factors for a delayed diagnosis of AIP were analysed. Results: A total of 29 patients (median age 60 years; 22 males and 7 females) were diagnosed with AIP using ICDC. Twenty-five patients were diagnosed with definite, 2 with possible type 1 AIP and 2 with type 2 AIP. In 29 patients, 50 ERCPs and 18 EUS were carried out; based on ICDC recommendations, a total of 20 ERCPs and 4 EUS were unnecessary diagnostic procedures. Eight patients (23.0%) were referred for unnecessary surgery. Jaundice was shown to be a significant risk factor for unnecessary endoscopic investigations (OR 11.00, 95% CI 1.14-106.43, p = 0.04). Conclusion: Diagnosis of AIP still remains a challenge. Patients with jaundice are at particular risk of being subjected to unnecessary endoscopic procedures. Use of ICDC would help avoid unnecessary examinations or even major surgeries at times.

BACKGROUND AND STUDY AIM The correct placement of an enteral feeding tube in the duodenum in critically ill patients is usually controlled radiographically. However, a direct bedside method that obviates the need for exposure to radiation would be preferable. The aim of this study was to demonstrate the usefulness of bedside sonographic position control for placing enteral feeding tubes in critically ill patients. PATIENTS AND METHODS After placement of the enteral feeding tube, the position of the tip was determined using bedside transabdominal ultrasound. Native ultrasound was enhanced by injection of air bubbles into the feeding tube. The tube was regarded as being correctly positioned when the tube was visualized within the second or third parts of the duodenum. Plain abdominal radiographs with contrast served as the gold standard test. RESULTS A total of 76 consecutive examinations were analyzed. In 12 patients, access to the upper abdominal wall was not possible because of open wounds; in another 13 patients who had undergone extensive abdominal surgery, the duodenum could not be identified and so no conclusion could be reached regarding the position of the tube. In 51/76 patients (67 %) ultrasound identified the duodenum and it was possible to determine the position of the tube (46 true positives and 2 true negatives); the position was incorrectly diagnosed in three patients. The sensitivity was 96 % (95 %CI 87 % - 98 %) and the specificity was 50 % (95 %CI 36 % - 65 %), with a positive predictive value of 94 %. CONCLUSIONS Bedside sonographic control of the positioning of enteral feeding tubes is very sensitive and can be a valuable alternative to radiological control, especially in patients without open abdominal wounds, external installations, or extensive abdominal surgery.

Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a hemostatic agent recently introduced for the management of upper gastrointestinal bleeding (GIB). To date, there is little experience with this fairly new hemostatic tool. The aim of this case series was to reflect the use and effectiveness of Hemospray as a treatment option in GIB in everyday clinical practice at two tertiary referral centers. Consecutive patients (n = 16) with active GIB of various origins were treated with Hemospray. The rate of successful initial hemostasis was 93.75 % (15 /16; salvage therapy 92.85 % [13/14]; monotherapy 100 % [2 /2]). The rebleeding rate within 7 days was 12.5 % (2/16). One patient, in whom interventional radiology also failed, had to undergo surgery as salvage therapy. The effectiveness of Hemospray in the management of GIB in various clinical situations is promising. Future multicenter randomized prospective trials for clearly defined bleeding situations are needed for greater generalizability of case series findings.

Since its introduction by Gauderer et al. in 1980, PEG has become the most widespread method of establishing enteral access. Although this technique is safe, there are well-known early and late complications. Immediate complications are a consequence of the endoscopic procedure itself and include respiratory distress, cardiac events, and esophageal injuries, e.g., perforation. During the procedure, insertion of the needle or the PEG tube may injure tissue interposed between the stomach wall and the skin. For example, damage to the colon after PEG placement has been described. The present report describes two cases of liver injury as an early complication of the PEG procedure.

Neutropenic enteritis (NE) or enterocolitis (NEC) is a rare, but potentially life-threatening side effect of neutropenia-inducing chemotherapy agents. Generally, its occurrence is attributed to leukemia-associated chemotherapies. Two cases of NE have been reported after the appliance of pemetrexed for treatment of non-small cell lung cancers. To our knowledge, NE has never been reported due to treatment with pemetrexed for malignant pleural mesothelioma (MPM). We present a case of MPM in a 77-year-old male suffering from severe NE one week after the seventeenth cycle of pemetrexed in the course of maintenance therapy for MPM, which could be treated successfully with antibiotic coverage and supportive measures. Concomitantly the patient showed a severe hyperpigmentation of his entire integument sparing the palms of both hands and the soles of his feet. After exclusion of alternative causes of skin hyperpigmentation, a pemetrexed-induced cutaneous hyperpigmentation was assumed according to two previous case reports. A combination of both pemetrexed-induced side effects in one patient has not been reported to date.

Obscure gastrointestinal bleeding can lead to extensive diagnostic work-up, as well as repeated episodes of hospitalizations with significant morbidity. Patients with a previous small-bowel anastomosis seem to be prone to varices at this site, even in the absence of portal hypertension. We report here five cases with varices of this type. All the anastomoses in these patients were reached using overtube-assisted single- or double-balloon enteroscopy. The bleeding varices were treated by injecting N-butyl-2-cyanoacrylate (Histoacryl). Bleeding was stopped in all five patients without any adverse events, requiring one session in four patients and a second session in one patient.

Background: Newer techniques such as mucosal resection, submucosal dissection and risky polypectomy will probably lead to increasing numbers of iatrogenic perforations. Reliable immediate closure of these lesions would increase safety and acceptance of the interventions. Methods: All acute directly observed perforations during diagnostic or therapeutic endoscopy were treated by the application of an over-the-scope clip. All consecutive patients from 2009 to August 2011 were followed in our tertiary referral center. The main outcome was technically successful closure of the perforation during endoscopy with a subsequent clinical observation for 24 h. Results: During the observation period, acute perforation occurred in 14 patients. All but 1 patient had technically successful treatment. Due to persistent abdominal pain, 3 patients had to be sent to the theater for laparoscopic evaluation after colon perforation. These 3 lesions were proven to be sealed and no resection of the colon was indicated. One patient with gastric adenocarcinoma had to be resected subtotally following endoscopic mucosal resection. Hospital stay ranged from 2 to 21 days. Conclusion: Directly observed perforations up to 30 mm diameter during endoscopy should be treated by deploying an over-the-scope clip. Endoscopists should be encouraged to be trained and to use over-the-scope clips in the stomach, duodenum and colon.

With increasingly advanced therapeutic endoscopic procedures and more complex gastrointestinal surgery, endoscopists are more often confronted with perforations, fistulas, and anastomotic leakages for which nonsurgical closure is desired. The over-the-scope clip (OTSC) is a novel endoscopic tool for consideration in such situations. We treated seven patients (age range 35 – 83 years; five men, two women), three with colonic perforation, one with perforation of the stomach, and three with anastomotic leakage after gastrointestinal surgery. Follow-up was at least 74 days. Eight OTSCs were deployed. In all but one patient closure of the perforation was demonstrated. Further surgery was avoided in four of the seven patients. The OTSC is a system that is easy to handle and safe. It seems to be ideally suited to use for a relatively small (iatrogenic) perforation, where a single clip can be released with carbon dioxide insufflation. Anastomosis leakage and larger dehiscence can also be treated to avoid further surgery, but the utility in this situation needs to be defined in the future.

BACKGROUND AND STUDY AIMS: Bacterial contamination of endoscopy suites is of concern; however studies evaluating bacterial aerosols are lacking. We aimed to determine the effectiveness of air suctioning during removal of biopsy forceps in reducing bacterial air contamination. PATIENTS AND METHODS: This was a prospective single-blinded trial involving 50 patients who were undergoing elective nontherapeutic colonoscopy. During colonoscopy, endoscopists removed the biopsy forceps first without and then with suctioning following contact with the sigmoid mucosa. A total of 50 L of air was collected continuously for 30 seconds at 30-cm distance from the biopsy channel valve of the colonoscope, with time starting at forceps removal. Airborne bacteria were collected by an impactor air sampler (MAS-100). Standard Petri dishes with CNA blood agar were used to culture Gram-positive bacteria. Main outcome measure was the bacterial load in endoscopy room air. RESULTS: At the beginning and end of the daily colonoscopy program, the median (and interquartile [IQR] range) bioaerosol burden was 4 colony forming units (CFU)/m (3) (IQR 3 - 6) and 16 CFU/m (3) (IQR 13 - 18), respectively. Air suctioning during removal of the biopsy forceps reduced the bioaerosol burden from a median of 14 CFU/m (3) (IQR 11 - 29) to a median of 7 CFU/m (3) (IQR 4 - 16) ( P = 0.0001). Predominantly enterococci were identified on the agar plates. CONCLUSION: The bacterial aerosol burden during handling of biopsy forceps can be reduced by applying air suction while removing the forceps. This simple method may reduce transmission of infectious agents during gastrointestinal endoscopies.

BACKGROUND AND STUDY AIM: Capsule endoscopy is widely used for diagnosis of small-bowel disease; however, the impact of capsule endoscopy on clinical management remains uncertain. We conducted a prospective study of the impact capsule endoscopy on clinical management decisions in 128 patients with suspected small-bowel pathology. METHODS: Prior to performing each procedure the gastroenterologist predicted the findings of capsule endoscopy and further management based on the clinical history and previous investigations. This prediction was compared with the actual results of capsule endoscopy and the following investigative and therapeutic management. RESULTS: The actual findings of capsule endoscopy and the further management were consistent with clinical prediction in 93/128 patients (73 %) and, irrespective of capsule endoscopy findings, no further procedures were required in 80 % of these patients. In 13 patients (10 %), gastric or colonic pathology was discovered that had not been detected on prior gastroscopy or colonoscopy. Thus, capsule endoscopy findings in the small bowel changed clinical management in 22 patients (17 %). In 4 patients, positive findings on capsule endoscopy that had not been predicted by the examiner prompted referral for abdominal surgery. Conversely, planned surgery was canceled in four other patients. CONCLUSION: In this series of patients referred for capsule endoscopy, small-bowel findings and appropriate clinical management were predicted on clinical grounds alone in approximately three-quarters of patients. Repetition of standard upper and lower endoscopy may be useful in many patients prior to small-bowel imaging. Referral for capsule endoscopy should take into account whether the findings will impact on clinical management; however, capsule endoscopy is mandatory in patients in whom surgery for small-bowel bleeding is intended.

We describe a case of cerebral aspergillosis which was successfully treated with a combination of caspofungin and voriconazole. The patient remains in remission 18 months after stopping antifungal treatment. We discuss primary and salvage therapy of invasive aspergillosis with focus on cerebral involvement. Since historical data showed a fatal outcome in most cases, amphotericin B does not cross the blood brain barrier while voriconazole does, we chose a combination of voriconazole plus caspofungin as primary therapy.

BACKGROUND Perihepatic lymph node enlargement (LNE) is often present in patients with chronic hepatitis C (CHC) and correlates with the degree of inflammation, as well as the stage of fibrosis of the liver. LNE at sites distant from the liver hilum, however, is not a common feature of chronic hepatitis but may occur during antiviral therapy as we report here. OBJECTIVES The aim of this study was to examine the frequency and aetiology of LNE at sites distant from the liver hilum in patients with chronic hepatitis C during combination therapy with pegylated interferon alpha and ribavirin. METHODS The charts of all patients undergoing therapy with PEG and RIBA for CHC at our institution from January 2002 to April 2003 were reviewed for those who developed de novo LNE at sites distant from the liver hilum. RESULTS In total, 8/217 patients (3.7%) or 5/125 patients treated within clinical trials (4.0%) were recorded to have developed de novo LNE during antiviral therapy. CONCLUSION LNE at various sites distant from the liver hilum was observed in up to 4% of our patients during treatment of CHC with PEG and RIBA. While being reactive in nature and resolving upon cessation of therapy in the majority of patients de novo LNE may be due to serious disease and warrants further investigations.

The diagnostic yield of capsule endoscopy depends on the quality of visualization of the small-bowel wall and complete passage through the small bowel. This study examined the effect of bowel preparation on the volume of intestinal content and on small-bowel transit.Sixty-one consecutive patients (34 men, 27 women; mean age 56 years, range 17-88 years) were enrolled in the study. Although not randomized, 33 patients received a bowel preparation, and 28 had no preparation. Gastric emptying, small-bowel transit time, overall preparation assessment, and bowel-wall visualization were evaluated by 3 investigators who were unaware of whether the patient had undergone bowel preparation.Small-bowel transit time was significantly shorter in patients with bowel preparation (median 213 minutes: 95% CI[190, 267]) than in those without preparation (median 253 minutes: 95% CI[228, 307]) (p0.01). The capsule reached the cecum in 97% of patients in the bowel-preparation group, compared with 76% in the nonpreparation group (p=0.02). Bowel preparation improved the quality of visualization significantly; this effect was more pronounced in the distal small bowel.This study demonstrated that bowel preparation accelerates small-bowel capsule transit and leads to a higher rate of complete capsule endoscopy. Visualization of the small bowel was improved by bowel preparation. Bowel preparation before capsule endoscopy is recommended.

Transnasal, Ultrathin Endoscopy for the Placement of Nasoenteral Feeding Tubes in Critically Ill Patients: Does the Working Length of the Endoscope Matter? First Results Stephan Wildi, Christoph Gubler, Stephan Vavricka, Dieter Menne, Michael Fried, Peter Bauerfeind Background: Early enteral feeding may improve outcomes in critically ill patients. Transnasal endoscopy with an ultrathin endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in these patients. Success rates were limited by the short working length of the ultrathin endoscopes. Aim: To compare the success rate of a 133 cm-long, ultrathin video-endoscope with a standard 92.5 cm-long, ultrathin, fiberoptic endoscope for the transnasal placement of nasoenteral feeding tubes. Methods: Critically ill patients were randomly assigned to transnasal feeding tube placement with the standard 92.5 cm-long, ultrathin, fiberoptic endoscope (Olympus GIF-N30) or a new 133 cmlong, ultrathin, prototype video-endoscope (Olympus XGIF-N140Y). Patients characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. Results: To date, 89 patients (29 women; mean age 51.8, range 20-81) were analyzed. The two groups were similar with regard to patients characteristics, body length, technical difficulty and patient tolerance. So far, the 133 cm-long instrument tended to be superior with respect to successful placement of the nasoenteral feeding tube (90% vs. 76%). Procedure time tended to be longer with the 133 cm-long instrument (557sec vs. 462sec). Conclusions: This ongoing study demonstrates that placement of a nasoenteral feeding tube with a 133 cm-long, ultrathin video-endoscope is safe and tends to be more successful than with 92.5 cm-long, ultrathin, standard instrument. Abstracts