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Pancreatic cancer has known precursor lesions with potential to develop into malignancy over time. At least 20% of pancreatic cancer evolves from mucinous cystic neoplasms and intraductal papillary mucinous neoplasms, which are often discovered incidentally.1,2 Current guidelines for the management of mucinous cystic neoplasms and intraductal papillary mucinous neoplasms include long-term surveillance, which is expensive and nontherapeutic, or surgical resection, which is associated with major risk and may not be an option for patients with significant concomitant illness.3.

Background and Aims There is a significant bleeding risk after gastric endoscopic submucosal dissection (ESD) and EMR cases. This case series describes the use of an endoscopic hemostasis spray, which is not typically used to treat this type of bleeding, after multiple attempts with other modalities failed. Methods We present 2 patient cases of ESD and EMR used to treat a gastric adenoma (case 1) and 2 gastric hyperplastic masses (case 2) with refractory bleeding after use of multiple other treatment modalities. Both patients were not surgical candidates because of their medical comorbidities. Results Bleeding was eventually controlled with the use of endoscopic hemostasis spray after attempts were made using SB Knife Jr tip, Coagrasper Hemostatic Forceps, Argon Photocoagulation, and scope tamponade. Conclusions In very specific cases, endoscopic hemostasis spray may have some utility for refractory bleeding after dissection of gastric lesions. After using this spray, it became technically challenging to suture endoscopically because of the mud-like quality of the hemostasis material., Video Video 1 • The known fungating, partially circumferential adenoma measuring approximately 5 × 4 cm was found in the posterior wall of the gastric antrum and prepyloric region of the stomach. • The lesion was marked at its periphery with an SB Knife Jr (Olympus America) and then lifted away from the muscularis propria with targeted submucosal injections. • The standard dissection technique was used to separate the tumor from the underlying muscle layers en bloc. The remaining stalk was resected using a snare owing to angulation of the stomach. • Persistent bleeding occurred throughout the procedure and appeared to be from tumor-driven angiogenesis pathology. • Multiple attempts were made to control bleeding, including mechanical tamponade with the SB short knife with the addition of soft coaguation current, argon photo coagulation, and scope tamponade using the endoscope cap. • However, despite use of these hemostatic agents, bleeding persisted, and a decision was made to use a single application of hemostasis spray, which was immediately effective. • Note that clips were not used because there were multiple sites of bleeding and suturing of the lesion was planned. • Subsequently, a dual channel flexible endoscope fitted with the Overstitch suturing device (Apollo Endosurgery) was advanced into position, and the resection site was progressively closed with sutures, which were cinched into place under direct visualization. However, the resection site was only 80% closed because of the adherent and mud-like quality of the hemostasis spray, which made effective suturing problematic, and the case was concluded. Video 2 . • This mass lesion was located in the antrum and prepyloric region of the stomach, causing intermittent gastric outlet obstruction with ulcerations (red arrow) and thought to be causing ongoing blood loss. The hyperplastic mass involved the duodenum as well. • The decision was made to resect it using cap-band EMR. • There was continuous venous bleeding after resection. Initially, a snare tip and soft coagulation were used to treat bleeding. • The bleeding persisted, so a thermal hemostasis coagulation grasper was used next. This was initially successful, but then there was recurrent bleeding. • An attempt was made to clip the lesion, but the lesion continued to bleed through the clip. • Hemostasis spray was then used as a salvage method with successful control of the bleeding. Video link

The incidence of acute pancreatitis (AP) has increased in the pediatric population over the past few decades and it stands to follow that the complications of severe AP, including symptomatic pancreatic fluid collections (PFCs) will increase as well. In adults, the therapeutic options for this situation have undergone a dramatic evolution from mainly surgical approaches to less invasive endoscopic approaches, mainly endoscopic ultrasound-guided transmural drainage (EUS-TD) followed be direct endoscopic necrosectomy if needed. This has proven safe and effective in adults; however, this approach has not been well studied or reported in pediatric populations. Here we demonstrate that EUS-TD seems to offer a safe, efficacious and minimally invasive approach to the management of large PFCs in pediatric patients by reviewing two representative cases at our institution.

Background and Aims Walled-off pancreatic necrosis is a well-known serious adverse event of severe acute pancreatitis. EUS-guided transluminal access followed by direct endoscopic necrosectomy is increasingly used to remove necrosis, with good efficacy and a superior safety profile when compared with surgery. However, a percentage of patients is too critically ill to undergo this procedure or lack an appropriate transluminal window for access. Here we describe the use of percutaneous flexible endoscopic necrosectomy (PEN) with use of standard-sized upper endoscopes and accessories in a retrospective single-institution experience with a video demonstration of 1 patient in the series. Methods The authors present a 23-patient retrospective case series of PEN with standard-sized endoscopes. The series includes 12 patients from a previously published analysis in 2016 and 11 additional patients from 2013 to 2018. A representative case illustrates the described technique in a patient with severe acute pancreatitis complicated by multisystem organ failure who required immediate drainage of a pancreatic fluid collection and placement of a percutaneous drain into the collection for decompression. The drain was serially upsized to 28F, and its tract was used for PEN. Results A total of 23 patients have undergone PEN at our institution. On average, the size of the pancreatic fluid collection was 11.6 cm in cross-sectional diameter. Of those 23 patients, 11 presented with symptoms of severe disease. The median time from onset of symptoms to PEN was 84 days. The median number of procedures per patient was 2.1. The median time to complete resolution of symptoms and fluid collections was 67 days. In total, resolution was reached in 22 of 23 patients. Two patients died of unrelated causes. Conclusion PEN is a minimally invasive and effective treatment approach to walled-off pancreatic necrosis in patients who are not amenable to transluminal drainage and in whom percutaneous drains have been successfully placed. This case series demonstrates the efficacy and safety of this approach. A randomized prospective trial would be warranted to validate these results.

Background and study aims Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic cystic lesions (PCLs) is an important diagnostic tool; however, it is often unsuccessful due to high viscosity of cystic fluid. In an effort to improve FNA, we objectively compared eight vacuum device configurations to determine the most effective method for aspirating viscous fluid collections. We also tested a high-frequency oscillation (HFO) technique that could be employed in FNA. Materials and methods Maximum gauge pressures of four vacuum devices were measured: two standard EUS-FNA syringes, a 50-cc Alliance II device, and a nonmedical hand vacuum pump. To aspirate a viscous stock solution, 19-gauge and 22-gauge needles were used and flow rates were calculated. HFO was also applied to the needle during aspiration to determine effect on aspiration rate. Results Aspiration devices generated maximum gauge pressures ranging from –21.5 to –27.5 inHg. The 19-gauge FNA needle aspirated viscous fluid 11.3 × faster on average than a 22-gauge needle. HFO increased average flow rates by 29.7 % in 19G and 124.6 % in 22G configurations. Conclusion EUS-FNA of viscous fluid can be optimized by using the lowest possible gauge needle and connecting a vacuum device capable of generating and sustaining near perfect vacuum. This can be accomplished by maximizing syringe volume. In addition, connector-tubing length between the syringe and needle should be minimized, and tubing wall should be sufficiently strong to resist collapse under vacuum. Other novel techniques to increase fluid yield include a hand vacuum pump and application of HFO to FNA.

Background and study aims Pancreatic cystic lesions are being increasingly recognized on cross-sectional imaging and mucinous premalignant cysts represent one of the most prevalent types. Endoscopic ultrasound (EUS)-guided chemoablation offers a safe and minimally invasive ablation approach yet with limited efficacy. Patients who develop acute pancreatitis as a complication of chemoablation with alcohol however experience ablation rates up to 100 %. This evidence suggests that recruitment of the body’s immune system may represent an avenue to significantly increase the efficacy of EUS-guided chemoablation. Here we illustrate this immune-mediated tumor killing phenomenon through a case presentation at our institution.

Background and Aims GI tract perforations and anastomotic dehiscence are increasingly effectively being repaired endoscopically; however, well-known and long-held surgical principles must still be honored. One important principle is that significant extraluminal contamination must be washed out, debrided, and drained in conjunction with repair of the defect if the wound is to effectively heal and resolve. Here we describe the use of endoscopic washout and debridement of extraluminal contamination at the time of luminal defect closure in a 7-patient series at our institution, with video demonstration of 2 patients in the series. Methods We reviewed a series of 7 patients at our institution and provide a video demonstration of the described technique in 2 patients. A 50-year-old man with decompensated liver cirrhosis presented with a large distal esophageal disruption secondary to a severe Minnesota tube injury. Extensive thoracic and mediastinal contamination of solid and liquid debris was removed and washed out endoscopically, followed by esophageal defect repair. Closure of the defect with overlapping, fully covered, esophageal stents sutured in place was successful after attempts at repairing the primary disruption with suturing alone failed. A 49-year-old man with multiple endocrine neoplasia type 1 and multiple prior surgeries presented with an acute abdomen and sepsis secondary to a fully perforated duodenal ulcer. Extensive endoscopic washout and lavage of the purulent liquid and semiliquid debris covering the liver, stomach, and adjacent structures was performed, followed by closure of the perforation by endoscopic suturing. A percutaneous pigtailed drainage catheter was placed in the extraluminal cavity to facilitate postoperative drainage, followed by placement of a PEG with jejunal extension for enteric exclusion and nutrition. Results The results for all 7 patients were reviewed. The overall rate of technical success, defined as effective repair of the luminal defect and drainage of extraluminal contamination, was 100%. The overall rate of clinical success, defined as clinical recovery and return to the patient's previous state of health, was 86% because 1 patient died because of severe concomitant disease. The length of time from the described procedure to hospital discharge ranged from 8 to 52 days (mean, 27 days). Conclusion Endoscopic washout and debridement can effectively and immediately address extraluminal contamination at the time of endoscopic luminal defect repair in appropriately selected patients. Therefore, it may represent a valuable option to address this clinical situation when a more conventional surgical approach is problematic. A more structured study should be considered for the development and validation of this approach.

Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy has proven to be a feasible, safe therapy for management of esophageal wall defects, but with limited success. We describe a retrospective single-center analysis of two patients who underwent endoscopic vacuum therapy for significant esophageal disruptions with a median cross-sectional diameter of 10.7 cm. The technique involved the use of a standard upper video endoscope, nasogastric tube, and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal or thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events. Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross-sectional diameter was 10.7 cm. The average number of endoscopic vacuum therapy performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. One patient died 6 weeks later due to severe sepsis from aspiration pneumonia. Endoscopic washout and debridement followed by endoscopic vacuum therapy can be effective for large, even multiple, thoracic and mediastinal contaminations following esophageal perforation and gastroesopagheal anastomotic dehiscence and leaks in appropriately selected patients.

Compartment syndrome is an orthopedic emergency in which the neurovasculature of the extremity is compromised. Typically, it presents unilaterally and is the consequence of major trauma to the extremity in the form of fracture. However, more uncommon etiologies of compartment syndrome have been reported, which includes reperfusion injury, burns, and congenital or acquired bleeding disorders. We present an extremely rare case of bilateral posterior thigh compartment syndrome thought to be due to intravenous drug abuse (IVDA) causing prolonged ischemia with subsequent reperfusion. This case is particularly relevant in today's clinical setting given the current opioid epidemic and subsequent rise in intravenous drug use.

Adalimumab is a recombinant monoclonal antibody to tumor necrosis factor alpha (TNFα) used in the treatment of inflammatory and autoimmune conditions, including ulcerative colitis (UC). Adverse side effects include infection and injection-site cutaneous reactions; however, rare adverse events such as pancytopenia have been recorded. Here we describe a case of pancytopenia and reversible lymphadenopathy related to adalimumab administration in a patient with UC.