The SAGES Manual of Flexible Endoscopy [1st ed. 2020] 978-3-030-23589-5, 978-3-030-23590-1

Table of contents :
Front Matter ....Pages i-xix
Front Matter ....Pages 1-1
SAGES University Masters Program: Flexible Endoscopy Pathway (Daniel B. Jones, Linda Schultz, Brian P. Jacob)....Pages 3-14
Masters Program Flexible Endoscopy Pathway: Diagnostic Esophagogastroduodenoscopy (Consandre P. Romain, Robert Joshua Bowles, Jose M. Martinez)....Pages 15-27
Masters Program Flexible Endoscopy Pathway: Diagnostic Colonoscopy (Emily Huang, Syed G. Husain)....Pages 29-49
Masters Program Flexible Endoscopy Pathway: Percutaneous Endoscopic Gastrotomy (PEG) (Daniel Davila, Ramona Ilie, Edward Lin)....Pages 51-67
Masters Program Flexible Endoscopy Pathway: Stenting (Wanda Lam, Ian Greenwalt, Jeffrey Marks)....Pages 69-80
Masters Program Flexible Endoscopy Pathway: Balloon Dilation (Jordan D. Bohnen, Ozanan R. Meireles)....Pages 81-98
Front Matter ....Pages 99-99
Endoscopy Tower Setup and Troubleshooting (Andrew J. Lambour, Sarah E. Billmeier)....Pages 101-111
Patient Preparation, Sedation, and Monitoring for Flexible Endoscopy (Diya Alaedeen, Jessica Ardila Gatas)....Pages 113-129
Front Matter ....Pages 131-131
Endoscopic Evaluation of Surgical Patients (Ezra N. Teitelbaum)....Pages 133-158
Basic Endoscopic Tissue Sampling Techniques and Specimen Retrieval Methods (Kelli Ann K. Ifuku, Simon Che, Dean J. Mikami)....Pages 159-173
Advanced Endoscopic Tissue Resection Methods: Radiofrequency Ablation (RFA), Endoscopic Mucosal Resection (EMR), Endoscopic Submucosal Dissection (ESD), and Endoscopic Full Thickness Resection (EFTR) (Bailey Su, Rhys Kavanagh, Peter Nau, Michael B. Ujiki)....Pages 175-191
Endoscopic Retrieval of Foreign Bodies (Jessica Koller Gorham, Thadeus L. Trus)....Pages 193-205
Achalasia Management: Botox, Dilation, Peroral Esophageal Myotomy (POEM), Peroral Pyloromyotomy (POP) (Ryan A. J. Campagna, Eric S. Hungness)....Pages 207-221
Thermal Methods to Control Gastrointestinal Bleeding (Brian J. Dunkin, Shawn M. Purnell, John Joseph Nguyen-Lee)....Pages 223-239
Nonthermal Methods for Control of Gastrointestinal Bleeding: Inject, Clip, Sprays (Shannon J. Morales, B. Fernando Santos)....Pages 241-267
Endoscopic Closure of Full-Thickness Gastrointestinal Defects (Joshua S. Winder, Eric M. Pauli)....Pages 269-301
Endolumenal Anastomotic Devices: Magnets and Lumen-Apposing Stents (Rami El Abiad, Henning Gerke)....Pages 303-320
Management of Pancreaticobiliary Disease: Endoscopic Retrograde Cholangiopancreatography (ERCP) (Colleen M. Alexander, Vimal Kumar Narula)....Pages 321-378
Management of Pancreatico-Biliary Disease: Endoscopic Ultrasound (EUS) (Robert D. Fanelli, Stephanie M. Fanelli, Josephine A. Fanelli)....Pages 379-399
Management of Pancreaticobiliary Disease: Pseudocyst (Garrett Filas Mortensen, Vladimir Davidyuk, Gary C. Vitale)....Pages 401-420
Pancreaticobiliary Options in Patients with Altered Surgical Anatomy (Konstantinos Spaniolas, Anthony J. Hesketh)....Pages 421-442
Enteral Feeding Access: Direct Percutaneous Endoscopic Jejunostomy (DPEJ) (Bipan Chand, Vineeth Sudhindran)....Pages 443-459
Percutaneous Endoscopic Gastrostomy (PEG) Rescue (Vamsi V. Alli)....Pages 461-473
Evaluation and Management of Patients with Gastroesophageal Reflux Disease (GERD): Radiofrequency Ablation (RFA) (Jin Sol Oh, Andrew S. Wright)....Pages 475-486
Evaluation and Management of Patients with Gastroesophageal Reflux Disease (GERD): TIF/Plication Methods (Emily C. Benham, Kyle A. Perry)....Pages 487-499
Front Matter ....Pages 501-501
Bariatric Endoscopic Procedures: Space-Occupying Devices (Laurel L. Tangalakis, Philip Omotosho)....Pages 503-514
Bariatric Endoscopic Procedures: Evacuation Therapy (Caitlin A. Halbert, Elizabeth G. McCarthy)....Pages 515-523
Bariatric Endoscopic Procedures: Malabsorptive Devices and Methods (Ryan C. Broderick, Bryan J. Sandler)....Pages 525-535
Bariatric Endoscopic Procedures: Reduction in Gastric Volume Methods (Vitor Ottoboni Brunaldi, Rafael Pasqualini de Carvalho, Natan Zundel, Manoel Galvao Neto)....Pages 537-552
Back Matter ....Pages 553-570

Citation preview

The SAGES University Masters Program Series Editor-in-Chief: Brian Jacob

The SAGES Manual of Flexible Endoscopy Peter Nau Eric M. Pauli Bryan J. Sandler Thadeus L. Trus Editors

123

The SAGES Manual of Flexible Endoscopy

The SAGES University Masters Program Series Editor-in-Chief: Brian Jacob

Peter Nau  •  Eric M. Pauli Bryan J. Sandler  •  Thadeus L. Trus Editors

The SAGES Manual of Flexible Endoscopy

Editors

Peter Nau University of Iowa Iowa City, IA USA

Eric M. Pauli Penn State Milton S. Hershey Medical Cen Hershey, PA USA

Bryan J. Sandler University of California San Diego La Jolla, CA USA

Thadeus L. Trus Dartmouth–Hitchcock Medical Center Lebanon, NH USA

ISBN 978-3-030-23589-5    ISBN 978-3-030-23590-1 (eBook) https://doi.org/10.1007/978-3-030-23590-1 © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To Kayla and our children for keeping me grounded. To my many mentors who have taught me the importance of clinical excellence as well as the value of balance. Peter Nau I owe my career as a surgical endoscopist to a number of individuals. I fell in love with flexible endoscopy during my residency research years at Penn State working with Drs. Abraham Mathew and Matthew Moyer, two gastroenterologists with whom I collaborated on natural orifice surgery projects. Leaving the lab, Drs. George Maish and Kenneth Graf let me essentially run the endoscopy lab at our local VA. They never once made me go to the OR to operate when I wanted to be scoping and performing endoscopic interventions. I finished residency with almost 600 endoscopies on the books, largely due to their willingness to let me follow my passion. I took my basic endoscopy skillset to Cleveland, where Drs. Jeffrey Marks and Jeffrey Ponsky elevated it to a new level. They helped me understand the full potential

of the flexible endoscopic surgeon, they taught me to think outside the standard boxes most surgeons are comfortable in, and they promoted me on a national level. When I returned to Penn State, my chairman, Dr. Peter Dillon, instructed the OR to equip me with what I needed to be successful. I opened an Olympus endoscope catalogue and circled everything, and they purchased it all. My senior partners Drs. Randy Haluck, Ann Rogers, and Jerome Lyn-Sue sent me every patient they had who needed endoscopy, trusting my capabilities from day one. What more could I ask for? There are other individuals as well: GI colleagues, surgical partners, fellows, and residents who have made it possible. Special recognition goes to my friend Mr. Christopher Ramsay, whose dedication in promoting the surgeonendoscopist deserves much more recognition than it will likely ever receive. Finally, immense amounts of love and thanks go to my wife, Dr. Jaimey Pauli, and our daughter, Rory, for letting me make an academic career out of my passion. Eric M. Pauli I’d like to dedicate this manual to the surgical trainees at UC San Diego and elsewhere in their pursuit of surgical endoscopy excellence as well as to the mentors I’ve had during my training to whom I owe much: thank you all. Bryan J. Sandler Thanks to family, friends, students, residents, and fellows. Thadeus L. Trus

Preface

Flexible endoscopy is a critical component in the delivery of high-quality, comprehensive surgical care. While gastroenterologists serve a vital role in this regard, for many patients, flexible endoscopy is only available in the hands of a surgeon. Perhaps more importantly, surgeons are uniquely able to utilize endoscopy in the preoperative, intraoperative, and postoperative setting and are able to approach endoscopy with a robust understanding of surgical anatomy. Surgeons facile in flexible endoscopy can assure an accurate diagnosis warranting intervention, can assess of the quality of their operation in real time, and can manage their own postoperative complications. The history of modern surgery is that of operative interventions being replaced by therapy delivered via a flexible endoscope. The ability of surgeons to identify the faults of current therapy and to witness first-hand the morbidity of their own operations has driven them to innovate endoscopically. Endoscopic illumination, colonoscopic polypectomy, endoscopic retrograde cholangiopancreatography, percutaneous endoscopic gastrostomy, esophageal variceal banding, per-oral endoscopic myotomy, and endoscopic therapies for obesity, bleeding, gastroesophageal reflux, and dysplastic tissues all have been developed by or with surgeons. There is little doubt that these trends will continue in the future, as increasingly more procedures are being offered via an endoscopic platform. vii

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Preface

The SAGES Manual of Flexible Endoscopy is written for surgeons of all training and skill levels. For residents, we hope this text inspires you to see the value-added proposition that endoscopy can bring to your practice as a gastrointestinal surgeon. For fellows, the manual was designed to serve as the backbone of your flexible endoscopy curriculum and was built around the Entrustable Professional Activity model of education. For practicing surgeons, the text will provide you with an overview of modern endoscopy practice and (we hope) motivate you to seek education and training opportunities to expand the offerings of endoscopy in your practice. Iowa City, IA, USA Hershey, PA, USA La Jolla, CA, USA Lebanon, NH, USA

Peter Nau, MD, MS, FACS Eric M. Pauli, MD, FACS, FASGE Bryan J. Sandler, MD, FACS Thadeus L. Trus, MD

Contents

Part I SAGES Masters Program 1 SAGES University Masters Program: Flexible Endoscopy Pathway�������������������������������������������������������   3 Daniel B. Jones, Linda Schultz, and Brian P. Jacob 2 Masters Program Flexible Endoscopy Pathway: Diagnostic Esophagogastroduodenoscopy�����������������  15 Consandre P. Romain, Robert Joshua Bowles, and Jose M. Martinez 3 Masters Program Flexible Endoscopy Pathway: Diagnostic Colonoscopy �����������������������������������������������  29 Emily Huang and Syed G. Husain 4 Masters Program Flexible Endoscopy Pathway: Percutaneous Endoscopic Gastrotomy (PEG)�����������  51 Daniel Davila, Ramona Ilie, and Edward Lin 5 Masters Program Flexible Endoscopy Pathway: Stenting ���������������������������������������������������������������������������  69 Wanda Lam, Ian Greenwalt, and Jeffrey Marks 6 Masters Program Flexible Endoscopy Pathway: Balloon Dilation�������������������������������������������������������������  81 Jordan D. Bohnen and Ozanan R. Meireles ix

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Contents

Part II Flexible Endoscopy Basics 7 Endoscopy Tower Setup and Troubleshooting�����������101 Andrew J. Lambour and Sarah E. Billmeier 8 Patient Preparation, Sedation, and Monitoring for Flexible Endoscopy ������������������������������������������������� 113 Diya Alaedeen and Jessica Ardila Gatas

Part III Flexible Endoscopy Procedures 9 Endoscopic Evaluation of Surgical Patients��������������� 133 Ezra N. Teitelbaum 10 Basic Endoscopic Tissue Sampling Techniques and Specimen Retrieval Methods��������������������������������� 159 Kelli Ann K. Ifuku, Simon Che, and Dean J. Mikami 11 Advanced Endoscopic Tissue Resection Methods: Radiofrequency Ablation (RFA), Endoscopic Mucosal Resection (EMR), Endoscopic Submucosal Dissection (ESD), and Endoscopic Full Thickness Resection (EFTR) ��������������������������������������������������������������������������� 175 Bailey Su, Rhys Kavanagh, Peter Nau, and Michael B. Ujiki 12 Endoscopic Retrieval of Foreign Bodies��������������������� 193 Jessica Koller Gorham and Thadeus L. Trus 13 Achalasia Management: Botox, Dilation, Peroral Esophageal Myotomy (POEM), Peroral Pyloromyotomy (POP)����������������������������������� 207 Ryan A. J. Campagna and Eric S. Hungness 14 Thermal Methods to Control Gastrointestinal Bleeding��������������������������������������������������������������������������� 223 Brian J. Dunkin, Shawn M. Purnell, and John Joseph Nguyen-Lee

Contents

xi

15 Nonthermal Methods for Control of Gastrointestinal Bleeding: Inject, Clip, Sprays ��������������������������������������� 241 Shannon J. Morales and B. Fernando Santos 16 Endoscopic Closure of Full-Thickness Gastrointestinal Defects ����������������������������������������������� 269 Joshua S. Winder and Eric M. Pauli 17 Endolumenal Anastomotic Devices: Magnets and Lumen-­Apposing Stents����������������������������������������� 303 Rami El Abiad and Henning Gerke 18 Management of Pancreaticobiliary Disease: Endoscopic Retrograde Cholangiopancreatography (ERCP) ��������������������������������������������������������������������������� 321 Colleen M. Alexander and Vimal Kumar Narula 19 Management of Pancreatico-Biliary Disease: Endoscopic Ultrasound (EUS)������������������������������������� 379 Robert D. Fanelli, Stephanie M. Fanelli, and Josephine A. Fanelli 20 Management of Pancreaticobiliary Disease: Pseudocyst�����������������������������������������������������������������������401 Garrett Filas Mortensen, Vladimir Davidyuk, and Gary C. Vitale 21 Pancreaticobiliary Options in Patients with Altered Surgical Anatomy��������������������������������������������� 421 Konstantinos Spaniolas and Anthony J. Hesketh 22 Enteral Feeding Access: Direct Percutaneous Endoscopic Jejunostomy (DPEJ) ������������������������������� 443 Bipan Chand and Vineeth Sudhindran 23 Percutaneous Endoscopic Gastrostomy (PEG) Rescue ����������������������������������������������������������������������������� 461 Vamsi V. Alli

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Contents

24 Evaluation and Management of Patients with Gastroesophageal Reflux Disease (GERD): Radiofrequency Ablation (RFA)��������������������������������� 475 Jin Sol Oh and Andrew S. Wright 25 Evaluation and Management of Patients with Gastroesophageal Reflux Disease (GERD): TIF/Plication Methods��������������������������������������������������� 487 Emily C. Benham and Kyle A. Perry

Part IV Bariatric Flexible Endoscopy 26 Bariatric Endoscopic Procedures: Space-­Occupying Devices����������������������������������������������������������������������������� 503 Laurel L. Tangalakis and Philip Omotosho 27 Bariatric Endoscopic Procedures: Evacuation Therapy��������������������������������������������������������������������������� 515 Caitlin A. Halbert and Elizabeth G. McCarthy 28 Bariatric Endoscopic Procedures: Malabsorptive Devices and Methods����������������������������������������������������� 525 Ryan C. Broderick and Bryan J. Sandler 29 Bariatric Endoscopic Procedures: Reduction in Gastric Volume Methods����������������������������������������������� 537 Vitor Ottoboni Brunaldi, Rafael Pasqualini de Carvalho, Natan Zundel, and Manoel Galvao Neto Index����������������������������������������������������������������������������������������� 553

Contributors

Diya  Alaedeen, MD Cleveland Clinic, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA Colleen  M.  Alexander, MD Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA Vamsi  V.  Alli, MD Penn State Hershey Medical Center, Department of Surgery, Division of Minimally Invasive Surgery, Hershey, PA, USA Penn State College of Medicine, Department of Surgery, Division of Minimally Invasive Surgery, Hershey, PA, USA Jessica  Ardila  Gatas, MD  Cleveland Clinic, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA Emily C. Benham, MD  The Ohio State University, Division of General and Gastrointestinal Surgery, Columbus, OH, USA Sarah  E.  Billmeier, MD, MPH Dartmouth Hitchcock Medical Center, Division of Minimally Invasive Surgery, Lebanon, NH, USA Dartmouth College Geisel School of Medicine, Hanover, NH, USA Jordan D. Bohnen, MD, MBA  Harvard University Medical School, Massachusetts General Hospital, Department of Surgery, Boston, MA, USA xiii

xiv

Contributors

Robert  Joshua  Bowles, MD, FACS Division of Laparoendoscopic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL, USA Ryan C. Broderick, MD  University of California San Diego, Department of Surgery, Division of Minimally Invasive Surgery, La Jolla, CA, USA Ryan A. J. Campagna, MD  Northwestern Memorial Hospital, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Bipan  Chand, MD, FACS, FASMBS, FASGE Loyola University Medical Center, Department of Surgery, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA Simon  Che, MD University of Hawaii, Department of Surgery, Honolulu, HI, USA Vladimir  Davidyuk, MD ERCP and Pancreaticobiliary Surgery, University of Louisville, Louisville, KY, USA Albany Medical Center, Department of Surgery, Albany, NY, USA Daniel  Davila, MD, BA, BFA Emory University Hospital, Department of General Surgery, Atlanta, GA, USA Emory University School of Medicine, Department of Surgery, Atlanta, GA, USA Brian  J.  Dunkin, MD Houston Methodist Hospital, Department of Surgery, Houston, TX, USA Rami  El Abiad, MD University of Iowa Hospitals and Clinics, Department of Gastroenterology and Hepatology, Iowa City, IA, USA Josephine A. Fanelli, MS, CRNP, AGPCNP-BC  The Guthrie Clinic, Division of Endocrinology and Metabolism, Department of Medicine, Sayre, PA, USA

Contributors

xv

Robert  D.  Fanelli, MD, MHA, FACS, FASGE The Guthrie Clinic, Department of Surgery, Geisinger Commonwealth School of Medicine, Sayre, PA, USA Stephanie  M.  Fanelli The Ohio State University College of Medicine, School of Health and Rehabilitation Sciences, Columbus, OH, USA Garrett  Filas  Mortensen, MD Medical Associates Department of Surgery, Dubuque, IA, USA ERCP and Pancreaticobiliary Surgery, University of Louisville, Louisville, KY, USA Manoel  Galvao  Neto, MD, MSc Florida International University, Department of Surgery, Miami, FL, USA Henning  Gerke, MD University of Iowa Hospitals and Clinics, Department of Medicine, Division of Gastroenterology and Hepatology, Iowa City, IA, USA Ian  Greenwalt, MD, BA  University Hospitals of Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA Caitlin A. Halbert, DO, MS  Christiana Care Health System, Department of Surgery, Wilmington, DE, USA Anthony J. Hesketh, MD, PhD, MS  Stony Brook University, Department of Surgery, Stony Brook, NY, USA Emily Huang, MD, MEd  The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA The Ohio State University College of Medicine, Department of Surgery, Columbus, OH, USA Eric  S.  Hungness, MD Northwestern Memorial Hospital, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

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Contributors

Syed  G.  Husain, MD, FACS, FASCRS The Ohio State University Wexner Medical Center, Department of Surgery, Division of Colon and Rectal Surgery, Columbus, OH, USA The Ohio State University College of Medicine, Department of Surgery, Columbus, OH, USA Kelli Ann K. Ifuku, BA  University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA Ramona  Ilie, MD  Emory University Hospital, Department of General Surgery, Atlanta, GA, USA Emory University School of Medicine, Department of Surgery, Atlanta, GA, USA Brian  P.  Jacob, MD The Mount Sinai Hospital, New York, NY, USA Daniel  B.  Jones, MD, MS Minimally Invasive Surgery and Bariatric Surgery, Beth Israel Deaconess Medical Center, Harvard University Medical School, Boston, MA, USA Rhys  Kavanagh, MD, FRCS University of Iowa Hospitals and Clinics, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA Jessica  Koller  Gorham, MD Ochsner Medical Center, Department of General Surgery, New Orleans, LA, USA Wanda Lam, MD  University Hospitals of Cleveland Medical Center, Department of Surgery, Cleveland, OH, USA Andrew J. Lambour, MD  Department of Surgery, Dartmouth-­ Hitchcock Medical Center, Lebanon, NH, USA Edward  Lin, DO, MBA Emory University Hospital, Department of General Surgery, Atlanta, GA, USA Emory University School of Medicine, Department of Surgery, Atlanta, GA, USA Jeffrey  Marks, MD University Hospitals of Cleveland Medical Center, Department of Surgery, Case Western Reserve University, Cleveland, OH, USA

Contributors

xvii

Jose M. Martinez, MD, FACS  Division of Laparoendoscopic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL, USA Elizabeth G. McCarthy, MD  Christiana Care Health System, Department of Surgery, Newark, DE, USA Ozanan R. Meireles, MD  Surgical Artificial Intelligence and Innovation Laboratory, Harvard University Medical School, Massachusetts General Hospital, Department of Surgery, Boston, MA, USA Dean  J.  Mikami, MD, FACS University of Hawaii, Department of Surgery, Honolulu, HI, USA Shannon  J.  Morales, MD, MBA Dartmouth-Hitchcock Medical Center, Department of Medicine, Section of Gastroenterology Hepatology, Lebanon, NH, USA Darmouth College Geisel School of Medicine, Hanover, NH, USA Vimal Kumar Narula, MD  The Ohio State Wexner Medical Center, Department of Surgery, Columbus, OH, USA The Ohio State University College of Medicine, Department of Surgery, Division of General and Gastrointestinal Surgery, Columbus, OH, USA Peter  Nau, MD, MS, FACS Carver College of Medicine, University of Iowa, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA John Joseph Nguyen-Lee, MD  Houston Methodist Hospital, Department of Surgery, Houston, TX, USA Philip  Omotosho, MD Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Rush University, Chicago, IL, USA Vitor Ottoboni Brunaldi, MD, MSC  University of São Paulo Medical School, Gastrointestinal Endoscopy Unit, Gastroenterology Department, São Paolo, Brazil

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Contributors

Rafael Pasqualini de Carvalho, MD, MSc  Faculty of Medicine of Ribeirão Preto, Department of Anatomy and Surgery, Ribeirão Preto, Brazil Eric  M.  Pauli, MD, FACS, FASGE Penn State Hershey Medical Center, Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Hershey, PA, USA Kyle A. Perry, MD, FACS  The Ohio State University, Division of General and Gastrointestinal Surgery, Columbus, OH, USA Shawn  M.  Purnell, MD Houston Methodist Hospital, Department of Surgery, Houston, TX, USA Consandre  P.  Romain, MD Division of Laparoendoscopic Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA Bryan  J.  Sandler, MD, FACS University of California San Diego, Department of Surgery, Division of Minimally Invasive Surgery, La Jolla, CA, USA B. Fernando Santos, MD  Dartmouth College Geisel School of Medicine, Department of Surgery, Hanover, NH, USA Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, NH, USA Linda  Schultz, BS  SAGES: Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA, USA Jin  Sol  Oh, MD  University of Washington, Department of Surgery, Seattle, WA, USA Konstantinos  Spaniolas, MD Stony Brook University, Department of Surgery, Stony Brook, NY, USA Bailey Su, MD, MBS  University of Chicago, Department of Surgery, Chicago, IL, USA Vineeth Sudhindran, MBBS, MS General Surgery Department of General Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Contributors

xix

Laurel  L.  Tangalakis, MD Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Rush University, Chicago, IL, USA Ezra  N.  Teitelbaum, MD, Med Northwestern University, Department of Surgery, Chicago, IL, USA Thadeus L. Trus, MD  Geisel School of Medicine, Dartmouth College, Hanover, NH, USA Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Michael  B.  Ujiki, MD, FACS Division of Gastrointestinal and General Surgery, NorthShore University HealthSystem, Department of Surgery, Evanston, IL, USA University of Chicago Pritzker School of Medicine, Department of Surgery, Chicago, IL, USA Gary  C.  Vitale, MD University of Louisville School of Medicine, Department of Surgery, Louisville, KY, USA Joshua S. Winder, MD  Penn State Hershey Medical Center, Department of Surgery, Hershey, PA, USA Andrew  S.  Wright, MD University of Washington, Department of Surgery, Seattle, WA, USA Natan  Zundel, MD Florida International University, Department of Surgery, Miami, FL, USA

Part I

SAGES Masters Program

Chapter 1 SAGES University Masters Program: Flexible Endoscopy Pathway Daniel B. Jones, Linda Schultz, and Brian P. Jacob

Adapted with permission of Springer International Publishers from Jones DB, Stefanidis D, Korndorffer JR Jr, Dimick JB, Jacob BP, Schultz L, et al. SAGES University MASTERS Program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017 Aug;31(8):3061-3071.

D. B. Jones (*) Minimally Invasive Surgery and Bariatric Surgery, Beth Israel Deaconess Medical Center, Harvard University Medical School, Boston, MA, USA e-mail: [email protected] L. Schultz SAGES: Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA, USA B. P. Jacob The Mount Sinai Hospital, New York, NY, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_1

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D. B. Jones et al.

Overview The Society of American Gastrointestinal and Endoscopic Surgery (SAGES) Masters Program organizes educational materials along clinical pathways into discrete blocks of content which could be accessed by a surgeon attending the SAGES annual meeting or by logging into the online SAGES University (Fig. 1.1) [1]. The SAGES Masters Program currently has eight pathways including acute care, biliary, bariatrics, colon, foregut, hernia, flexible endoscopy, and robotic surgery (Fig. 1.2). Figure 1.1  SAGES Masters Program logo

Figure 1.2  SAGES Masters Program clinical pathways

Acute care

Bariatric

Biliary

Colorectal

Flex endo

Foregut

Hernia

Robotics

Chapter 1.  SAGES University Masters Program…

Competency Curriculum

Proficiency Curriculum

Mastery Curriculum

5

Coaching

Figure 1.3  SAGES Masters Program progression

Each pathway is divided into three levels of targeted performance: competency, proficiency, and mastery (Fig.  1.3). The levels originate from the Dreyfus model of skill acquisition [2], which has five stages: novice, advanced beginner, competency, proficiency, and expertise. The SAGES Masters Program is based on the three more advanced stages of skill acquisition: competency, proficiency, and expertise. Competency is defined as what a graduating general surgery chief resident or minimally invasive surgery (MIS) fellow should be able to achieve. Proficiency is what a surgeon approximately 3 years out from training should be able to accomplish. Mastery is what more experienced surgeons should be able to accomplish after several years in practice. Mastery is applicable to SAGES surgeons seeking in-depth knowledge in a pathway, including the following: areas of controversy, outcomes, best practice, and ability to mentor colleagues. Over time, with the utilization of coaching and participation in SAGES courses, this level should be obtainable by the majority of SAGES members. This edition of The SAGES Manual of Flexible Endoscopy aligns with the current version of the new SAGES University Masters Program Flexible Endoscopy pathway (Table 1.1). This chapter provides an overview of the key elements of the SAGES Masters Flexible Endoscopy Program.

Flexible Endoscopy Curriculum The key elements of the flexible endoscopy curriculum include core lectures for the pathway, which provides a 45-minute general overview including basic anatomy, physiology, diagnostic workup, and surgical management. As of 2018, all lecture content of the SAGES annual meetings are labeled

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D. B. Jones et al.

Table 1.1  Flexible endoscopy curriculum Curriculum Elements

Competency

Anchoring procedure – competency

2

Core lecture

1

Core MCE 70%

1

Annual meeting content

6

Guidelines

1

SA CME hours

6

Sentinel articles

2

Social media

2

SAGES Top 21 video

1

FES

9

SAGES video atlas review

2

SAGES video atlas exam

1

GAGES

1

Credits

35

Curriculum elements

Proficiency

Anchoring procedure – proficiency

2

Core lecture

1

Core MCE 70%

1

Annual meeting content

7

FUSE

12

Outcomes database enrollment

2

SA CME hours (ASMBS electives, SAGES or SAGES-endorsed)

6

Sentinel articles

2

Social media

2

Credits

35

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Table 1.1 (continued) Curriculum elements

Mastery

Anchoring procedure – mastery

2

Core lecture

1

Core MCE 70%

1

Annual meeting content

7

Fundamentals of surgical coaching

4

Outcomes database reporting

2

SA CME credits (ASMBS electives, SAGES or SAGES-endorsed)

6

Sentinel articles

2

Serving as video assessment reviewer and providing feedback (FSC)

4

Social media

6

Credits

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as follows: basic (100), intermediate (200), and advanced (300). This allows attendees to choose lectures that best fit their educational needs. Coding the content additionally facilitates online retrieval of specific educational material, with varying degrees of endoscopic complexity, ranging from introductory to complex endoscopic interventions. SAGES identified the need to develop targeted, complex content for its mastery level curriculum and created 25-­minute lectures focused on specific topics. Mastery level content assumes that the attendee already has a good understanding of diseases and management from attending/watching competency- and proficiency-level lectures. Ideally, in order to supplement a chosen topic, the mastery lectures would also identify key prerequisite articles from Surgical Endoscopy and other journals, in addition to SAGES University videos. Many of these lectures will be forthcoming at future SAGES annual meetings.

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The Masters Program has a self-assessment, multiple choice exam for each module to guide learner progression throughout the curriculum. Questions are submitted by core lecture speakers and SAGES annual meeting faculty. The goal of the questions is to use assessment for learning, with the assessment being criterion-referenced with the percent correct set at 80%. Learners will be able to review incorrect answers, review educational content, and retake the examination until a passing score is obtained. The Masters Program flexible endoscopy curriculum utilizes SAGES existing educational products including the Fundamentals of Endoscopic Surgery (FES™), the Fundamental Use of Surgical Energy (FUSE™), and SAGES Top 21 Videos and Pearls (Fig. 1.4a, b). The Curriculum Task Force has placed the aforementioned modules along a continuum of the curriculum pathway. For example, FES occurs during the competency level curriculum, whereas the Fundamental Use of Surgical Energy (FUSE) is required during the proficiency curriculum. The Fundamentals of Figure 1.4  SAGES Educational Content: (a) FLS™; (b) FUSE™. (Trademarks by SAGES)

a

b

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Endoscopic Surgery (FES) (available at www.fesprogram. org) includes a multiple choice exam and a skills assessment conducted on an endoscopic simulator. Tasks include endoscopic target acquisition, loop reduction, and retroflex endoscope navigation. Since 2018, FES has been required of all US general surgery residents seeking to sit for the American Board of Surgery qualifying examinations. The Fundamental Use of Surgical Energy (available at www.fuseprogram.org) teaches about the safe use of electrosurgery in the endoscopy suite or operating room. After learners complete the self-­ paced modules, they may take the certifying examination. Top 21 Videos are edited videos of the most commonly performed diagnostic and therapeutic endoscopy procedures. Cases are straightforward with quality video and clear anatomy. Pearls are step-by-step video clips of endoscopic operations. The authors show different variations for each step. The learner should have a fundamental understanding of the operation. SAGES Guidelines provide evidence-based recommendations for surgeons and are developed by the SAGES Guidelines Committee following the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine standards (formerly the Institute of Medicine) for guideline development [3]. Each clinical practice guideline has been systematically researched, reviewed, and revised by the SAGES Guidelines Committee and an appropriate multidisciplinary team. The strength of the provided ­recommendations is determined based on the quality of the available literature using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology [4]. SAGES Guidelines cover a wide range of topics relevant to the practice of SAGES surgeon members and are updated on a regular basis. Since the developed guidelines provide an appraisal of the available literature, they are included in the Masters Program. The Curriculum Task Force identified the need to select required readings for the Masters Program based on key articles for the curriculum core procedures. Summaries of each of these articles follow the American College of Surgeons (ACS) Selected Readings format.

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Facebook™ Groups While there are many great platforms available to permit online collaboration by user-generated content, Facebook™ offers a unique, highly developed mobile platform that is ideal for global professional collaboration and daily continuing surgical education (Fig.  1.5). Eight unique vetted membership-­only closed Facebook™ groups were created for the Masters Program, including a group for bariatrics, hernia, colorectal, biliary, acute care, flexible endoscopy, robotics, and foregut. The SAGES Flex Endo Masters Program Collaboration Facebook™ group (available at www.facebook.com/groups/SAGESFlexEndo) is independent of the other groups and is populated only by physicians, mostly surgeons, with training and/or interest in gastrointestinal endoscopy. The group allows for video assessment, feedback, and coaching as a tool to improve practice. Based on the anchoring procedures determined via group consensus (Table 1.2), participants in the Masters Program will submit video clips on closed Facebook™ groups, with other participants and/or SAGES members providing qualitative feedback. For the flexible endoscopy curriculum, surgeons would submit videos during diagnostic upper endoscopy or colonoscopy and complete videos of therapeutic procedures like percutaneous endoscopic gastrostomy. Using crowdsourcing, other surgeons would comment and provide feedback. However, for the mastery level, participants will submit a video of stricture dilation and stent placement to be evaluated by an expert panel. A standardized video assessment tool, depending on the specific procedure, will be used. A benchmark will also be utilized to determine when the participant has achieved the mastery level for that procedure. The group provides an international platform for physicians interested in optimizing outcomes in flexible endoscopy to collaborate, share, discuss, and post photos, videos, and anything related to their specialty. By embracing social media as a collaborative forum, surgeons can more effectively and transparently obtain immediate global feedback that can

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Figure 1.5  SAGES Flex Endo Facebook™ Group (Trademark by Facebook)

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Table 1.2  Anchoring procedures for flexible endoscopy pathway Anchoring procedure by pathway Level Diagnostic EGD/colonoscopy Competency Percutaneous endoscopic gastrostomy (PEG)

Proficiency

Stent placement or dilation

Mastery

potentially improve patient outcomes, as well as the quality of care provided, all while transforming the way SAGES members interact. For the first two levels of the Masters Program, competency and proficiency, participants will be required to post videos of the anchoring procedures and will receive qualitative feedback from other participants. Once the participant has achieved mastery level, they will participate as a coach by providing feedback to participants in the first two levels. Masters Program participants will therefore need to learn the fundamental principles of surgical coaching. Key activities of coaching include goal setting, active listening, powerful inquiry, and constructive feedback [5, 6]. Importantly, peer coaching is much different than traditional education, where there is an expert and a learner. Peer coaching is a “co-­ learning” model where the coach is facilitating the development of the coachee by using inquiry/advocacy (i.e., open-ended questions) in a noncompetitive manner. Surgical coaching skills are therefore a crucial part of the Masters curriculum. At the 2017 SAGES Annual Meeting, a postgraduate course on coaching skills was developed and video recorded. The goal is to develop a “coaching culture” within the SAGES Masters Program, wherein both participants and coaches are committed to lifelong learning and development. The need for a more structured approach to the education of practicing surgeons as outlined by the SAGES Masters Program is well recognized [7]. Since performance feedback usually stops after training completion and current approaches to Maintenance of Certification are suboptimal, the need for peer coaching has recently received increased attention in surgery [5, 6]. SAGES has recognized this need, and its

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Masters Program embraces social media for surgical education to help provide a free, mobile, and easy-to-use platform to surgeons globally. Access to the Masters Program groups enables surgeons at all levels to partake in program curriculum and obtain feedback from peers, mentors, and experts. By creating physician-only private groups dedicated to this project, SAGES can now offer surgeons posting in these groups the ability to discuss preoperative, intraoperative, and postoperative issues with other SAGES colleagues and mentors. In addition, the platform permits transparent and responsive dialogue about technique, continuing the theme of deliberate, lifelong learning. To accommodate the needs of this program, SAGES University is upgrading its web-based features. A new learning management system (LMS) will track participant progress and simplify access to SAGES University. The new LMS infrastructure will enable access to videos and lectures on demand and allow search functions in relation to content, level of difficulty, and author. Once enrolled in the Masters Program, the LMS will track lectures, educational products, continued medical education credits, and other completed requirements. Participants will be able to see where they stand in relation to module completion, and SAGES will alert learners to relevant content they may be interested in pursuing. Until the new LMS is operational, the SAGES Manual of Flexible Endoscopy will help guide learners through the Masters Program Curriculum for Flexible Endoscopy.

Conclusions The Masters Program is an innovative, voluntary curriculum that embraces the concept of lifelong learning, and its curriculum is organized from basic principles to more complex content. The SAGES Masters Program Flexible Endoscopy pathway facilitates deliberate, focused postgraduate teaching and learning. Verified completion of the Masters Program indicates completion of the curriculum but is not meant to certify competency, proficiency, or mastery of surgeons.

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References 1. Jones DB, Stefanidis D, Korndorffer JR, Dimick JB, Jacob BP, Schultz L, et  al. SAGES University Masters Program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017 Aug;31(8):3061–71. 2. Dreyfus SE. The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177–81. 3. Graham R, Mancher M, Miller Woman D, Greenfield S, Steinberg E, Institute of Medicine (US) Committee on standards for developing trustworthy clinical practice guidelines. Clinical practice guidelines we can trust. Washington, DC: National Academies Press (US); 2011. 4. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6. 5. Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA.  Surgical coaching for individual performance improvement. Ann Surg. 2015;261:32–4. 6. Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282–3. 7. Sachdeva AK. Acquiring skills in new procedures and technology: the challenge and the opportunity. Arch Surg. 2005;140:387–9.

Chapter 2 Masters Program Flexible Endoscopy Pathway: Diagnostic Esophagogastroduodenoscopy Consandre P. Romain, Robert Joshua Bowles, and Jose M. Martinez

Learning Objectives

1. Applications of upper endoscopy . Indications for diagnostic EGD 2 3. Pre-procedure preparation 4. Technical steps of EGD 5. Documentation of EGD

C. P. Romain (*) Division of Laparoendoscopic Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA R. J. Bowles · J. M. Martinez Division of Laparoendoscopic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_2

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Introduction Since it was first performed in the 1950s, esophagogastroduodenoscopy (EGD) has been established as the primary modality for the diagnosis and treatment of a gamut of upper gastrointestinal conditions. An estimated 6.9 million EGDs were performed in 2009 [1]. The practical use of the endoscope has expanded exponentially over the past two decades. Due to standardization in patient preparation, procedural sedation, and advances in endoscopic equipment, EGD is increasingly valuable to the general surgeon. The indications for EGD are numerous, and the list continues to grow as more clinical applications are established through the development of new accessories and equipment. The surgical endoscopist can not only perform a thorough mucosal evaluation but can also perform adequate tissue sampling, sclerotherapy, clipping for bleeding control or for the closure of mucosal or full-thickness defects, balloon dilation of strictures and stenting of partial obstructions, and enteral access procedures. Surgical endoscopists also perform a variety of other advanced procedures including minimally invasive tumor resection via endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) [2]. The flexible endoscope also allows us to treat surgical conditions that in the past were only achieved by a transabdominal approach. These include per-oral esophageal myotomy (POEM) for the treatment of achalasia and per-oral pyloromyotomy (POP) for the treatment of adult-onset pyloric stenosis and idiopathic refractory gastroparesis. Endoscopic bariatric procedures (e.g., balloon, sutured gastric plication) have also been adopted by bariatric surgeons as less-invasive options for weight loss in select patients [3]. Mucosal ablation for Barrett’s esophagus and endoscopic antireflux procedures are also well established [4]. This discussion will, however, focus on the indications, preoperative preparation, technical aspects, and surgical pearls and pitfalls of performing a diagnostic EGD.

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Diagnostic EGD is routinely used as a primary tool to evaluate patients with suspected or established foregut pathology. EGD is the only modality to allow direct visualization of the upper gastrointestinal tract and obtain a tissue biopsy. The indications for diagnostic EGD include but are not limited to the evaluation of chronic abdominal pain, dysphagia, gastroesophageal reflux disease, anemia, gastrointestinal bleeding, neoplasms, ulcers, and a host of other foregut pathologies. Patient evaluation and preparation prior to any endoscopy is of utmost importance. See Chap. 8 on patient preparation, sedation, and monitoring for a more detailed review of these aspects. Every patient should have a thorough history and physical exam to determine basic fitness and ability to undergo endoscopy in a way that will minimize adverse outcomes and complications. Several elements of the patient’s comprehensive history and physical exam will allow the endoscopist and anesthesiologist to make adequate preparations before the procedure. A review of the patient’s past medical history will reveal any potentially prohibitive cardiovascular or pulmonary disease, obesity, and obstructive sleep apnea. The past surgical history will reveal any prior neck, cervical spine, or oral surgery and any possible altered alimentary tract anatomy. A review of medications is crucial as it is important to be aware of any medications that may interact with sedatives and analgesics used during the procedure. The same goes for the patient’s social history and any ongoing substance abuse. Anticoagulants should be held for the appropriate recommended duration [5]. The patient should be made NPO prior to the procedure according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines [6]. Appropriate prophylactic antibiotics should be administered depending on the procedure to be performed and the patient’s medical history [7–9]. Finally, an informed consent should be obtained after a thorough discussion with the patient or their proxy regarding the risks and benefits of the procedure.

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The risk of adverse events during diagnostic EGD is low and complications are rare; however, the risk is not zero. Complications include aspiration pneumonia, bleeding, infection, perforation, and implant migration or impaction leading to injury [10]. The endoscopist can take several steps to minimize those complications. The patient is kept NPO prior to EGD to decrease the amount of stomach content during anesthesia and instrumentation and decrease the risk of aspiration. The patient is kept off anticoagulants, when appropriate, to decrease the risk of bleeding. Antibiotics are administered when necessary to decrease the risk of bacterial translocation. Specific maneuvers or patient positioning are employed throughout the procedure to minimize the risk of perforation and implant malposition or migration. Preparation of the staff and the endoscopy suite is equally important to ensure the expected outcome of the procedure [11]. In the case of endoscopist-administered sedation, the provider should have a discussion with the staff prior to the procedure and verify that a suitable dose of medication, IV fluids, and resuscitative equipment are available in the room prior to the start of the procedure. Verification of a working pulse oximeter, sphygmomanometer, and heart rhythm monitors is essential. In the case of sedation by an anesthesia provider, the endoscopist should have a discussion with the anesthesia staff regarding the anticipated procedure including depth and duration of sedation and the need for endotracheal intubation for patients at increased risk of aspiration such as complete esophageal impaction or achalasia with megaesophagus. The endoscopist would also verify at this time that any equipment specific to the procedure, i.e., biopsy forceps, snares, baskets, clips, sclerotherapy needles, etc., is available. For a diagnostic EGD, the patient is typically placed in the left lateral decubitus position with the head slightly elevated or on a pillow [12]. A mouthpiece or bite block is placed in the patient’s mouth prior to the induction of anesthesia in the case of conscious sedation or monitored anesthesia care (MAC). The bite block is placed after induction and intubation in the

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scenario where general anesthesia is preferred or required. The endoscopist will ensure that all of the scope’s functions are working properly. Adequate connection of suction and insufflation tubing is checked. The functions can be checked by placing the tip of the endoscope in a cup of sterile water, and the suction button on the endoscope is depressed to verify function. The insufflation button is covered but not depressed to check for insufflation (bubbles are formed in the cup of water). The endoscope is then removed from the water as the insufflation button is depressed to demonstrate scope irrigation. White balancing of the scope is achieved as needed per scope manufacturer’s recommendations. The large (up/down) wheel and the small (left/right) wheel are turned to verify proper function. The small wheel is then placed in the neutral position and locked or unlocked per endoscopist’s preference. The examiner is now ready to start the endoscopy.

Scope Insertion The endoscopist stands facing the patient with the endoscope connected to the scope tower behind and to the right of the endoscopist’s hip (Fig.  2.1). The flexible endoscope tip is lubricated with a water-soluble surgical lube from the tip to the 20  cm mark with care taken not to obscure the front-­ viewing lens with the lube. The scope is then held distal to the 20 cm mark and inserted through the patient’s bite block into the patient’s mouth. This can be done blindly until the scope passes through the upper esophageal sphincter; however, this maneuver tends to increase patient discomfort, the rate of inadvertent passage into the airway, and the potential risk for injury. A controlled passage of the endoscope under direct visualization through the mouth and oropharynx is preferred and recommended. Careful inspection of the oropharynx and hypopharynx during esophageal intubation will not only decrease patient discomfort and the rate of tracheal intubation but also aid in the identification of upper esophageal pathology. Common landmarks identified include the base of

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Figure 2.1 With the patient in the left lateral decubitus position with a bite block in place, the scope is held with the tip in the neutral position and passed into the patient’s mouth. Note the scope tower behind and to the right of the endoscopist

tongue, palate, uvula, epiglottis, arytenoid cartilages, and upper esophageal sphincter. With the tip of the scope in the neutral position, the scope is passed into the patient’s mouth over the tongue. This will produce an upside-down image on the screen with the tongue on top and the hard palate on the bottom (Fig. 2.2). The horizontal black line representing the horizon separating those two structures is targeted as the scope is advanced 5–7 cm in this fashion. Next, the endoscopist will perform a gentle upward tip deflection (big wheel down) to follow the curve of the base of the tongue to the uvula. The scope is advanced to 12–15 cm from the incisors with this maneuver and fall into the distal-most portion of the pharynx, the hypopharynx where the epiglottis and vocal cords are seen in the center top of the screen, the arytenoid cartilages in the midline, and the right and left piriformis sinuses on the bottom right and left corners (Fig.  2.3a, b). The scope is then gently straightened by releasing the big wheel in the neutral position while applying constant insufflation and gentle for-

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Tongue

Hard Palate

Figure 2.2  Adequate orientation of the scope once in the patient’s mouth reveals an image where the patient’s tongue is seen at the top of the screen and the hard palate at the bottom. The black line or horizon is followed as the scope is advanced to the oropharynx

ward pressure. The patient under conscious sedation can be asked to swallow at this time. This will cause relaxation of the cricopharyngeus with passage of the scope into the upper esophagus (Fig. 2.4a, b). Once beyond the upper esophageal sphincter, the lumen is distended with insufflation, and a global survey of the esophagus is performed to rule out any mucosal abnormalities including fungal or reflux esophagitis, mucosal tears, ulcerations, webs, Schatzki’s rings or strictures, and mucosal/submucosal lesions. Other pertinent findings include diverticula, varices, hiatal hernia, and Barrett’s esophagus. Photo documentation of a bird’s-eye view of the esophagus and then of the Z line is obtained. The location of the Z line from the incisors is measured and noted.

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a

b

Vocal Cords

Piriformis Sinuses

Figure 2.3  (a, b) A gentle upward tip deflection (big wheel down) to follow the curve of the base of the tongue to the uvula. The scope is advanced to 12–15 cm from the incisors with this maneuver and falls into the distal-most portion of the pharynx, the hypopharynx where the epiglottis (a) and vocal cords (b) are seen in the center top of the screen, the arytenoid cartilages in the midline, and the right and left piriformis sinuses (b) on the bottom right and left corners

Red-out: Cricopharyngeus

a

Relaxed Upper Esophageal sphincter

b

Figure 2.4  (a, b) The scope is then gently straightened by releasing the big wheel in the neutral position while applying constant insufflation and gentle forward pressure. The patient under conscious sedation can be asked to swallow at this time. This will cause relaxation of the cricopharyngeus (red-out) (a), with passage of the scope into the upper esophagus (b)

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Stomach The scope is then advanced into the stomach. With continued insufflation, a global survey of the stomach body is performed. Masses, mucosal lesions or ulcerations, varices, retained gastric contents, or bile reflux into the stomach would be noted at this time. The scope is methodically advanced through the body of the stomach towards the antrum and pylorus using the lesser curve on the right of the video screen as a landmark. Any identified pathology should be clearly documented with respect to size and location. Anterior/posterior gastric wall, lesser or greater curvature, and proximity to pylorus or gastroesophageal junction are common landmarks used to document location of a lesion. The antrum, a common location for gastritis and ulcerations, should be meticulously examined. Photo documentation of a bird’s-eye view of the stomach, the antrum, and the pylorus and any other positive findings should be obtained at this time.

Duodenum The scope is passed through the pylorus into the duodenal bulb. A global survey of the bulb will reveal any mucosal or submucosal lesions, ulceration, or diverticula. The duodenal bulb must be carefully evaluated upon initial scope insertion as visualization is usually limited on scope withdrawal. Duodenal ulcers are most commonly found in the duodenal bulb; however, one must also inspect for duodenitis, polyps, as well as diverticula. A specific maneuver will then assist scope passage into the second portion of the duodenum while minimizing scope trauma to the duodenal mucosa and retraction of the scope back into the stomach. The scope is advanced to the end of the duodenal bulb where the turn into the second portion of the duodenum is encountered. Rightward deflection of the tip (small wheel), clockwise rotation of the scope handle with simultaneous upward tip deflection, and

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advancement of endoscope will reveal the second portion of the duodenum. After the scope is advanced to the second portion of the duodenum, the area of the ampulla of Vater will be identified. The ampulla may not be completely visible using a forward viewing gastroscope, but one should be able to identify periampullary diverticula as well as large ampullary lesions. The third portion of the duodenum is inspected for similar mucosal and submucosal abnormalities. It is usually reached by scope withdrawal causing a paradoxical effect of the scope tip advancing into the third portion of the duodenum. The fourth portion of the duodenum and proximal jejunum are not part of a diagnostic upper endoscopy. Further scope insertion is required to reach this area; thus, a longer endoscope is usually required. With both hands on the handle to maneuver the knobs, the endoscopist takes a few steps back, withdrawing the scope from the duodenum, using the knobs and scope rotation to examine the entire lumen of the second and third portion of the duodenum. Photo documentation of the duodenal bulb, periampullary region, and second and third portion of the duodenum is obtained. Biopsy of any lesions or random biopsy to rule out celiac disease and any other indicated therapeutic intervention can be performed at this time.

Antrum to GE Junction Usually performed after the duodenal inspection, the scope is retroflexed by upward deflection of the tip of the scope (large wheel up) and by turning the small wheel to the left to examine the lesser curve of the stomach, the incisura, the gastric cardia, and gastroesophageal junction. The scope is pulled back to advance its tip closer to the cardia and GE junction for better visualization of those structures. Pertinent pathology to be noted includes hiatal or paraesophageal hernia, ulcers at incisura and other mucosal or submucosal lesions. Photo documentation of the incisura and gastroesophageal junction is obtained. The scope straightened and biopsies of

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the antrum, random gastric biopsies, or any other diagnostic or therapeutic procedures can be performed at this time. The endoscopist should avoid overdistention of the stomach as this precludes adequate biopsy specimen from the stretched-­ out mucosa.

Scope Withdrawal Once all indicated procedures are performed, the stomach is decompressed, and the scope is withdrawn. The esophagus is again examined on the way out and suctioned only above the level of the upper esophageal sphincter to remove any excess saliva from the oropharynx prior to terminating the procedure. Limited evaluation of the external vocal cords may be performed quickly at this time without inciting the patient’s gag reflex. The bite block is removed and the patient monitored until awake from anesthesia. The quality of endoscopic exam is inherently related to the quality of the post-procedure documentation. Pertinent positive and negative findings should be noted, and photographs should be referenced when applicable. The endoscopist should provide a detailed description of positive findings. This will help other providers in the healthcare team better care for the patient by taking the appropriate next steps. It will also serve as a reference for future exams to monitor the progression or stability of findings. For example, when a hiatal hernia is encountered, it is important to note the location of the Z line and the diaphragmatic pinch from the incisors. Adequate description of Barrett’s changes, esophagitis, ulcers, varices, etc., are equally important in dictating further management. The indications for flexible endoscope are broad, and endoscopists continue to find more applications for it. A diagnostic EGD allows us to directly visualize and promptly treat many conditions of the upper gastrointestinal tract. Though complications can arise from an upper endoscopy, a thorough understanding of how to prepare the ancillary staff and the

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patient and a comprehensive handle on the maneuverability of the endoscope will limit adverse events. It is, however, essential that the endoscopist has direct communication with the surgeon when a complication does occur. It is also paramount that the general surgeon familiarizes themselves with the flexible endoscope as this will open many avenues for ways to care for patients in a minimally invasive fashion. Pearls/Pitfalls

1. Know the many indications for EGD and the wealth of information that can be obtained during a short examination. 2. Patient, staff, and equipment preparation prior to the procedure are essential. 3. Major complications are rare; however, the endoscopist should follow several guidelines to ensure the expected outcome every time. 4. A controlled passage under direct visualization is key on scope entry. 5. Controlled movement of scope, suction, and insufflation allow for a complete and expeditious examination. 6. Adequate documentation allows for appropriate patient management and follow-up endoscopy.

References 1. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et  al. Burden of gastrointestinal disease in the United States: 2012 update. (e1-3). Gastroenterology. 2012;143:1179–87. 2. ASGE Standards of Practice Committee, Sharaf RN, Shergill AK, Odze RD, Krinsky ML, Fukami N, et al. Endoscopic mucosal tissue sampling. Gastrointest Endosc. 2013;78(2):216–24. 3. American Society for Gastrointestinal Endoscopy Standards of Practice Committee, Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, et al. The role of endos-

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copy in the bariatric surgery patient. Gastrointest Endosc. 2015;81(5):1063–72. 4. Standards of Practice Committee, Wani S, Qumseya B, Sultan S, Agrawal D, Chandrasekhara V, et  al. Endoscopic eradication therapy for patients with Barrett’s esophagus–associated dysplasia and intramucosal cancer. Gastrointest Endosc. 2018;87(4):907–931.e9. 5. ASGE Standards of Practice Committee, Acosta RD, Abraham NS, Chandrasekhara V, Chathadi KV, Early DS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3–16. 6. ASGE Standards of Practice Committee, Early DS, Lightdale JR, Vargo JJ 2nd, Acosta RD, Chandrasekhara V, et  al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018;87(2):327–37. 7. ASGE Quality Assurance in Endoscopy Committee, Calderwood AH, Day LW, Muthusamy VR, Collins J, Hambrick RD 3rd, et al. ASGE guideline for infection control during GI endoscopy. Gastrointest Endosc. 2018;87(5):1167–79. 8. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-­ Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;9:CD002907. 9. Lipp A, Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. Cochrane Database Syst Rev. 2006;11:CD005571. 10. ASGE Standards of Practice Committee, Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, et al. Adverse events of upper GI endoscopy. Gastrointest Endosc. 2012;76:707–18. 11. ASGE Endoscopy Unit Quality Indicator Taskforce, Day LW, Cohen J, Greenwald D, Petersen BR, Schlossberg NS, et  al. Quality indicators for gastrointestinal endoscopy units. VideoGIE. 2017;2(6):119–40. 12. Lee S-H, Park Y-K, Cho S-M, Kang J-K, Lee D-J. Technical skills and training of upper gastrointestinal endoscopy for new beginners. World J Gastroenterol: WJG. 2015;21(3):759–85.

Chapter 3 Masters Program Flexible Endoscopy Pathway: Diagnostic Colonoscopy Emily Huang and Syed G. Husain

Learning Objectives

1. Describe the indications for diagnostic colonoscopy . Describe the appropriate setup for diagnostic 2 colonoscopy 3. Describe principles for appropriate documentation of visual findings in diagnostic colonoscopy

E. Huang The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA The Ohio State University College of Medicine, Department of Surgery, Columbus, OH, USA S. G. Husain (*) The Ohio State University College of Medicine, Department of Surgery, Columbus, OH, USA The Ohio State University Wexner Medical Center, Department of Surgery, Division of Colon and Rectal Surgery, Columbus, OH, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_3

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4. Apply principles of safe endoscopy to specific diagnostic situations, including choice of insufflation, extent of endoscope insertion, and choice of sedation technique 5. Apply specific techniques for making progress in the course of diagnostic colonoscopy, such as insertion-­ withdrawal, torqueing, and suctioning 6. Utilize appropriate diagnostic tools in special circumstances, such as biopsy in inflammatory bowel disease surveillance or in patients suspected to have microscopic colitis

Introduction Diagnostic colonoscopy is an endoscopic examination performed for evaluating a specific symptom, as opposed to screening colonoscopy, which is performed to search for polyps or cancer in an asymptomatic individual. Out of the estimated 15 million colonoscopies performed in the United States in 2012, approximately 6.3 million were for screening purposes while the remainder were diagnostic exams [1]. Diagnostic colonoscopy may be performed under emergent or non-emergent conditions, and because of this, the patient’s functional status or medical comorbidities can have a significant impact on decision-making and procedural considerations. Diagnostic colonoscopy not only attempts to provide valuable insight into the underlying etiology but also provides a vehicle for treatment of the problem via endoscopic intervention. This chapter discusses indications for and performance of diagnostic colonoscopy under a number of different circumstances. Screening and surveillance of colorectal neoplasia and endoscopic therapeutic interventions are beyond the scope of this chapter and will not be addressed here.

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Indications and Contraindications By far the most common indication for diagnostic colonoscopy is rectal bleeding. As many as 35% of all colonoscopic exams performed in patients 50 years or younger are for evaluation of hematochezia [2]. In addition to hematochezia, colonoscopy is often indicated for evaluation of occult gastrointestinal bleeding (hemoccult-positive stool), melena, or unexplained iron deficiency anemia. Other indications include evaluation for a change in bowel habits, abdominal pain, and large bowel obstruction or diagnosis of ischemic colitis. Patients with inflammatory bowel disease often require repeated endoscopic evaluation for disease staging, treatment planning, or assessment of response to a particular therapy. Likewise, many postoperative patients require an endoscopic evaluation of the anastomosis prior to proceeding reversal of a protective stoma. Contraindications to diagnostic colonoscopy include symptoms suggestive of perforation (e.g., peritonitis) or situations that expose patients to an unacceptable risk of iatrogenic perforation such as acute diverticulitis, fulminant colitis, or toxic megacolon and complete or near complete obstruction. The patient’s overall medical condition and hemodynamic stability should also be taken into account; the patient must be able to tolerate transient increments in intra-­ abdominal pressure, positioning and/or abdominal manipulation, and enteric insufflation.

Materials and Setup The operational details of the endoscopy tower and scope controls, patient preparation, sedation, and monitoring for diagnostic colonoscopy are generally similar to those during screening colonoscopy. That being said, diagnostic colonoscopy differs from screening procedures in several key aspects, often mandating significant modifications to pre-procedure preparations. A thorough understanding of the patient’s

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­istory and medical condition will inform appropriate h decision-­making, allowing the operator to modify the setup appropriately for a specific diagnostic indication. By considering all of the potential contingencies and preparing for them, one can optimize the chances of a good outcome. While the endoscopy suite offers the greatest ergonomic ease for the endoscopist coupled with prompt access to a variety of endoscopic tools, a bedside exam using a portable tower may be ideal for a critically ill or unstable patient. However, the very virtue that makes a tower portable also limits the armamentarium at the endoscopist’s disposal. Therefore, a detailed knowledge of the limitations of the portable endoscopy tower is essential for a seamless bedside exam. The endoscopist should be able to anticipate and request the required equipment to minimize interruptions during the course of an exam. Examples of indication-based endoscopic setup are discussed in the ensuing section titled, “Specific Considerations.” The optimal room setup for diagnostic colonoscopy has the patient positioned in left lateral decubitus position in the center of the room, with the endoscopist and tower behind the patient facing the monitor. Make sure that the bed height is adjusted so that the endoscopist can naturally carry the elbows ergonomically at about a 90-degree angle, to minimize fatigue. A nurse or anesthetist monitors vital signs during the procedure, depending on the level of sedation. A second assistant can stand across the bed from the endoscopist to help with patient repositioning or splinting the abdomen to help brace the colonoscope over tortuous areas to prevent looping. This assistant can also help to monitor abdominal distension and warn the endoscopist if physical exam suggests colonic overdistension (Fig. 3.1). A note on insufflation: room air and carbon dioxide insufflation are both typically available for colonoscopy. Carbon dioxide is absorbed into the bloodstream where it is transported to the lungs and exhaled fairly rapidly to maintain equilibrium. Data suggest that carbon dioxide is safe and

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Figure 3.1  Room setup for diagnostic colonoscopy. (Used with permission of SAGES and Springer Nature from Safadi and Marks [11])

decreases bowel distension and discomfort after colonoscopy [3]. We recommend using carbon dioxide whenever available and strongly encourage its use in situations where distension may be particularly risky, such as in the case of obstruction where perforation is a real risk.

Specific Conduct Colonoscopy begins with an external inspection of the anus and digital rectal exam. This allows for additional data on distal masses or lesions that might be the source of symptoms and simultaneously relaxes the anal sphincter to allow for easier colonoscope insertion.

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The scope should be placed in a relaxed straight position, fully supported upon the bed. This positioning facilitates the mechanics of advancing the tip of the scope through the turns of the colon. It also diminishes operator exhaustion from holding the weight of the scope against gravity in a tense and overly twisted position. Furthermore, resting the entire length of the scope on the bed minimizes the risk of inadvertent gravity-induced withdrawal of the scope. Most endoscopists prefer to hold the shaft of the scope with the right hand, using torque to turn the tip of the scope within the lumen, while the left hand operates the buttons and wheels to control insufflation, irrigation, suction, and tip deflection. Various other manipulation techniques may help at specific turns during the procedure, such as holding the shaft in place with the last digits of the left hand to free the right hand for additional wheel deflection or asking an assistant to hold the shaft as the endoscopist operates the wheels with two hands. Again, maintaining the external portion of the scope in as relaxed and straight a position as possible will decrease operator fatigue throughout the procedure. The procedure starts with gently guiding a well-lubricated scope “side first” through the anus until the mucosa is in view; this insertion technique will prevent anal trauma and pain. At this point, insufflation can begin to open the lumen. The safest mode for advancing the tip of the scope is with the lumen in view at all times. The risk of perforating the colon with the tip of the scope is minimal as long as it is kept centered in the colonic lumen. While maintaining the colonic lumen is the safest approach, it is often not possible in difficult, overly tortuous colons. In fact, it is usually easier to navigate tortuosity with an off-centered lumen, as the scope follows a most efficient path through a segment that is bent back upon itself. If a fold of mucosa obscures the view, the examiner should retract the scope, re-center the lumen, and proceed forward. Although sliding the scope around a tight turn is usually discouraged due to the associated risk of perforation, it is often necessary to do so in order to successfully negotiate a tight curve. Extreme caution should be exercised in this situation, and signs that predict imminent perforation—like blanching

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of mucosal blood vessels or halting of the “sliding mucosa”— should prompt immediate withdrawal of the scope to a safer location. In a similar vein, while insufflation is essential in keeping the lumen open, over-insufflation can be detrimental and should be avoided. Over-insufflation not only leads to patient discomfort but also increases the risk of perforation from tearing along the shaft of the scope, elongates the colon, and makes tortuous segments more rigid for navigation. It is good practice to insufflate, advance, suction, and repeat. In the rectum, simple manipulations often result in successful advancement of the scope past the valves of Houston, as the total length of inserted scope is still short. The sigmoid colon presents unique challenges due to its muscular wall that is inclined to spasm, non-fixed anatomy, and diverticular disease which may be treacherous due to risk of tearing. As the inserted length increases into the sigmoid colon, the scope tends to bow instead of advancing, causing “looping,” in which more and more length is inserted without an attendant a

b

c

Figure 3.2  Diagram of looping in the sigmoid colon. (a) Loop formation in sigmoid colon. (b) Alpha loop in the sigmoid colon,clockwise torque can help to derotate the loop. (c) Passage through the splenic flexure can be facilitated by a combination of push, pull, jiggle, and torque to remove the loops. (Used with permission of SAGES and Springer Nature from Safadi and Marks [11])

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advancement of the tip. Eventually paradoxical motion occurs, where the tip appears to retract with scope advancement (Fig.  3.2). In order to avoid this, periodic suction should be used to decrease the insufflation followed by scope withdrawal while manipulating the wheels to keep the tip stationary in the lumen. This can be done in a jiggling motion to encourage the distal colon to more tightly accordion over the shaft of the colonoscope. In practice, performing colonoscopy is much less an inexorable march forward than it is a serious of parries and counter-parries. In addition to suction-assisted telescoping of colon over the colonoscope, torqueing the scope is also instrumental in reducing the sigmoid colonic loop. As a corollary, patient body habitus is highly predictive of procedural difficulty in an inverse manner to difficulty of abdominal surgery: thin patients tend to have long, floppy colons that are more difficult to thread, while obese patients have short colons well tethered in place by mesentery, decreasing the chances of looping. Another way to manage looping is to have an assistant splint the sigmoid, bracing the scope to keep it straight. The examiner should be aware of the fact that abdominal splinting can be uncomfortable for the patient in certain situations. The splenic and hepatic flexures are areas where specific maneuvers might be necessary to advance. At the splenic flexure, with the patient in left lateral decubitus position, the scope must advance against gravity to enter the transverse colon while bowing against the sigmoid loop. Some endoscopists make it standard practice to reposition the patient supine at this junction; at minimum, repositioning should be in the toolbox of maneuvers to assist traversing this area. The hepatic flexure is another common location to experience paradoxical motion. Instead of pushing forward, the examiner should use suction while keeping the lumen of the ascending colon in view. This maneuver in conjunction with torqueing is often enough to accordion the distal colon onto the scope shaft, successfully advancing the tip into the ascending colon. Repositioning the patient or applying right upper quadrant pressure may also help at this juncture.

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Finally, terminal ileal intubation may be needed in the course of a diagnostic colonoscopy. In order to be able to ­fluently conduct this skill when it is needed, it is a good idea to practice it regularly. To intubate the ileum, the ileocecal valve is located by its appearance as a slightly thicker semilunar fold in the cecum, the scope is advanced past the valve, the tip of the scope deflected, and the scope pulled back against the wall of the cecum until the tip hooks into the valve. The scope can then be advanced in the typical fashion with insufflation. Retroflexion is the last step of colonoscopy and allows visualization of the distal-most rectum and internal hemorrhoidal cushions. With the scope tip positioned just proximal to the anal sphincter, the tip is completely deflected and the scope advanced against a rectal valve; this maneuver results in a retroflexed position. The tip is then maintained in a fully flexed position while the scope is torqued in a clockwise/ counterclockwise direction, allowing visualization of the distal rectum and hemorrhoids. Retroflexion should be avoided in instances where the integrity of rectal wall may be compromised, such as the presence of a large rectal tumor or severe proctitis. For screening colonoscopy, intraprocedural quality metrics have been developed by the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG) [4]. These include cecal intubation with photo documentation of a cecal landmark, adenoma detection rate, and withdrawal time at least 6 minutes on average among others. It is important to note that these metrics are not applicable to diagnostic colonoscopy.

Specific Considerations By considering the differential diagnosis and specific disease-­related aspects relevant to the situation at hand, both equipment and personnel resources can be optimally aligned to better prepare for a given exam. Mental preparation for diagnostic colonoscopy should include considering

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all of the potential pitfalls and the measures required to address them.

Gastrointestinal Bleeding Colonoscopy has both diagnostic and therapeutic roles in gastrointestinal bleeding. The differential diagnoses are listed in Table 3.1. To prepare for the procedure, the following aspects should be taken into consideration: 1. Briskness of bleed (is this colonoscopy for unexplained anemia or bowel movements of bright red blood with hemodynamic instability?) 2. Location of bleed (is the source likely to be proximal or rectal?) 3. What interventions may be planned for treatment (is the bleeding amenable to treatment with an endoscopic procedure such as clipping, cautery, or injection, or surgical resection might be indicated for treatment? If the source is a tumor, what are the treatment plans and what might be needed to formulate those plans, such as tissue sampling or tattooing?) Examples of required instruments include hemostatic equipment (cautery, injection, argon, endoscopic clips, etc.) for exams being performed for evaluation of significant lower GI hemorrhage and power irrigator/suction for situations where a patient’s clinical condition or the urgency of the exam preclude a full bowel prep. Patients with chronic, minor rectal bleeding or those with occult blood loss can be evaluated with an elective colonoscopic exam. On the other hand, patients with acute lower GI bleed significant enough to cause hemodynamic instability should undergo radiologic localization (bleeding scan or angiogram) of the bleeding source rather than an endoscopic evaluation. Patients may present with a GI bleed that falls between the two extremes of the spectrum described above; hemodynamically stable patients with a major lower GI bleed

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Table 3.1 Causes of lower gastrointestinal bleeding and specific considerations in diagnostic colonoscopy Specific considerations in diagnostic Diagnosis colonoscopy Diverticular bleeding Endoscopic treatment (clipping, injection) may be possible, but oozing from within a diverticulum may be technically difficult to control and at high risk for perforation Tattoo for localization if surgical resection will be necessary Neoplasia—colon

Tissue sampling by biopsy Tattoo for surgical localization Bleeding may be a general ooze and not controllable endoscopically

Neoplasia—rectum

Tissue sampling by biopsy Tattoo for surgical localization Specific measurement of distance from sphincter complex for neoadjuvant radiation and operative planning Bleeding may be a general ooze and not controllable endoscopically

Inflammatory bowel disease

Intubation of terminal ileum with careful photo and written documentation and biopsies. Careful photo and written documentation of extent and severity of disease, including patchy mesentery-sided inflammation suggesting Crohn’s disease Biopsy sampling from each colonic segment for UC Biopsy of any abnormal areas

Arteriovenous malformation

Endoscopic treatment (clipping, cauterization, injection) Tattoo for localization if surgical resection will be necessary

(continued)

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Table 3.1 (continued) Diagnosis

Specific considerations in diagnostic colonoscopy

Ischemic colitis

Goal is to diagnose ischemia and distribution Biopsy if etiology unclear Beware of overdistension which may perforate weakened bowel wall See also separate section on ischemia, below

Infectious colitis

Careful photo and written documentation of findings Tissue sampling by biopsy Stool sampling

Proctitis (radiation, sexually transmitted infections, etc.)

Tissue sampling by biopsy Stool sampling Defer retroflexion

Hemorrhoids

Usually seen on retroflexion

Anastomotic Bleeding

Perform colonoscopy with caution Clipping preferred over cauterization or injection

often require an urgent colonoscopic evaluation. The urgent nature of these exams often does not allow the luxury of a full bowel prep. More recently, there has been a trend towards rapid purge prep [5]. While the prep does appear to improve diagnostic yield of the colonoscopic exam [6], the presence of blood in the lumen acts as a light sink and often obscures visualization despite a bowel prep. Thus, it is critical to have power irrigation and suction set up as mentioned in the previous section. It is often useful to suction in short bursts while maintaining continuous insufflation to prevent collapse of the luminal workspace. Given the difficulties described, colonoscopy in the face of acute lower GI bleed presents a daunting challenge and requires superlative technical skills for successful completion. Understandably, diagnostic colonoscopy

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exams performed for urgent indications also tend to carry a higher perforation risk than screening exams [7]. It is important to bear in mind that unequivocal localization of the bleeding source can be made only if active bleeding is observed during the course of an exam. A visible vessel or a densely adherent clot also provides corroborative evidence. In authors’ experience, the proximal extent of blood in the colon is a poor indicator of bleeding site, as blood from anorectal source can often smear proximal colon in a retrograde fashion. Likewise, finding bile in the proximal colon and/or terminal ileum with blood in the distal colon is not enough evidence to rule out a proximal source of bleeding. Finally, mere presence of multiple diverticula or a blood-­filled diverticulum can often be misleading and result in inaccurate localization of bleeding site.

Ischemic Colitis Pre-procedure patient evaluations, including a review of comorbidities, physical exam, and labs, offer invaluable clues that often suggest bowel ischemia with a high degree of confidence. A history of cardiovascular disease, aortic aneurysm repair, extracorporeal circulation, and use of ventricular assist devices should alert the examiner of potential ischemic colitis as the underlying etiology of lower GI bleed. Other findings include pain out of proportion to exam and laboratory markers for ischemia such as elevated serum lactate or leukocytosis. Radiographic findings of mucosal hypoenhancement, mural thickening, and pneumatosis may be evident on CT, or thumbprinting on barium enema, but these are present in a minority of patients with more advanced colonic ischemia. Because of its higher sensitivity, colonoscopy has emerged as the primary modality for the diagnosis of ischemic colitis. Mucosal findings associated with the different stages of ischemia are noted in Table 3.2 [8]. An important procedural consideration for ischemic colitis is avoiding scope insertion

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Table 3.2  Diagnostic colonoscopy findings in colonic ischemia Stage Early Petechial hemorrhages Submucosal hematoma Pale edematous mucosa Late

Segmental erythema Ulcerations, sometimes a single long ulcer (“single stripe”) Active bleeding and friability

Severe

Cyanotic, dusky, grey mucosa Pseudopolyps Pseudomembranes

Chronic (weeks to months)

Stricturing Decreased haustrations Mucosal granulation

Used with permission of Wolters Kluwer from Green and Tendler [8]

beyond the area of ischemia. The exam should conclude as soon as the diagnosis is confirmed; advancing the scope beyond the area of ischemia carries a significant risk of ­perforation. Besides the obvious risk of perforation, pressurization of the colonic lumen further decreases the blood flow, in turn potentiating the effects of colonic ischemia. Thus, avoiding overinsufflation is critical in these cases. In addition to judicious use of insufflation, carbon dioxide insufflation is recommended instead of air due to the favorable impact on mucosal blood flow caused by the vasodilatory effects of carbon dioxide [9]. Colonic ischemia can present as mild mucosal involvement, which can be managed nonoperatively, to frank necrosis of the colonic wall necessitating an emergent surgical intervention. It is important to note that the endoscopic appearance of the colonic mucosa should not be used as the sole indication for surgical intervention. Despite offering excellent insight into the state of mucosal perfusion, endoscopic evaluation lacks the ability to predict whether the

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ischemia is limited to the mucosa or has progressed to transmural necrosis. Therefore, the authors feel that the patient’s overall clinical condition should be the primary driving factor in surgical decision-making.

Abnormal Radiologic Findings Diagnostic colonoscopy is often requested when a radiologic exam (CT, PET, etc.) unveils an incidental abnormal finding involving the colon or rectum. In this scenario, endoscopic exam not only allows the opportunity to establish the diagnosis and perform a histopathologic analysis but also carries the potential for therapeutic intervention. While colonoscopy is much superior to radiologic imaging for the detection of mucosa-based lesions, it lacks the ability to identify extraluminal (submucosal and extramural) processes like lymphoma or metastatic involvement of the colon by an extracolonic malignancy. It is important to bear this limitation in mind, as endoscopic exams may be falsely negative in these situations.

Obstruction While complete colonic obstruction is generally considered a contraindication, colonoscopy is frequently performed for evaluation of partial colonic obstruction. Great caution should be exercised to minimize insufflation of an already distended colon, and bowel prep should be used with caution in patients with significant colonic distension. The examiner should remain continually vigilant of insufflation pressures and utilize carbon dioxide insufflation instead of room air. In some cases, diagnostic colonoscopy can be combined with a therapeutic procedure, such as stenting as a bridge to surgical resection or colonic decompression in cases of pseudo-obstruction.

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Inflammatory Bowel Disease Inflammatory bowel disease (IBD) typically presents with a combination of crampy abdominal pain, diarrhea, and gastrointestinal bleeding. The initial diagnosis is made by a colonoscopic exam demonstrating mucosal inflammation ­ and/or ulcers. Histopathologic evaluation of biopsies demonstrating features typical of inflammatory bowel disease can help to reinforce the diagnosis, although these biopsies often show nonspecific inflammation, and the granulomas pathognomonic of Crohn’s disease are seen only in a minority of cases. Therefore, the diagnosis is a combination of clinical findings, typical endoscopic exam, and histopathologic features. Prior to performing diagnostic colonoscopy for inflammatory bowel disease, the examiners should familiarize themselves with validated endoscopic scoring systems for IBD such as the Crohn’s Disease Endoscopic Index of Severity/Ulcerative Colitis Endoscopic Index of Severity (CDEIS/UCEIS), the Simple Endoscopic Score for Crohn’s Disease (SES-CD), Harvey Bradshaw Index, and Rutgeerts score. These scoring systems standardize the disease severity in IBD, leading to accurate staging, and are instrumental in determining optimal medical management. For example, a patient with disease confined to the rectum may benefit from anti-inflammatory enemas compared to a patient with ileocecal disease where enemas do not have any therapeutic role. The extent and severity of disease should not only be documented but a pictorial record should also be generated. Finally, it is also important to document normal appearing segments as this can carry important treatment implications. For example, in cases with severe Crohn’s colitis where colectomy is deemed necessary, rectal sparing makes the patient a candidate for ileorectal anastomosis rather than an end ileostomy, which would be the treatment of choice in a patient without rectal sparing. It goes without saying that every attempt should be made to intubate and document the appearance of the terminal ileum in patients with suspected IBD.

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Colorectal cancer surveillance in patients with IBD, or exams to document response to medical treatment, is beyond the scope of this chapter and will not be discussed here.

Diarrhea and Abdominal Pain While colonoscopy is not the primary investigative modality for patients with chronic diarrhea and abdominal pain, it is often performed after initial studies fail to reveal an underlying etiology. Colonoscopy is very effective in identifying colitis secondary to IBD or infections, conditions which are readily apparent due to the presence of inflamed and sometimes ulcerated colonic mucosa. However, many cases of chronic diarrhea are caused by microscopic colitis, a condition typically presenting without any obvious endoscopic finding, in which diagnosis can only be made with histologic evaluation of apparently normal mucosa. Multiple left- and right-sided colonic biopsies are recommended to help establish the diagnosis when microscopic colitis is suspected. Finally, an attempt should be made to perform limited retrograde enteroscopy by intubating the terminal ileum and documenting the presence of normal ileal mucosa. Colonoscopic exams performed for investigation of chronic abdominal pain typically carry a very low diagnostic yield. This is especially true if the abdominal pain is part of an irritable bowel syndrome (IBS) symptom complex. The conduct of this exam is similar to a routine colonoscopy with one notable exception: patients with IBS are often hypersensitive to colonic distension and may not be able to tolerate the exam under moderate sedation. Therefore, consideration should be given to performing these exams under deep sedation, entailing the services of an anesthesiologist.

Diagnostic Colonoscopy in Surgical Patients The surgical population represents a distinct subset of patients that require specific procedural and technical adjustments.

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Figure 3.3  Endoscopic view of ileocolic anastomosis. Black arrow: colonic blind end; white arrow: ileal blind end

These considerations can be quite different from nonsurgical patients, and an in-depth knowledge of postsurgical endoscopic anatomy is crucial to a successful exam. It is important to bear in mind that retroflexion is often required to intubate the true lumen of the proximal limb in a side-to-­side anastomosis. This is especially true in the case of ileocolic anastomoses, where blind ends can lead a novice examiner to misinterpret it as an anastomotic stricture (Fig. 3.3). Similarly, a long blind rectal stump in an end-to-side colorectal anastomosis can mimic a true lumen and lead to confusion during the exam. Diagnostic colonoscopy may be indicated in preoperative, intraoperative, or postoperative settings. In the preoperative setting, colonoscopy is often used for accurate lesion localization to guide surgical resection. Typically, localization entails placement of a tattoo in the submucosal plane. A variety of substances are available for endoscopic tattooing, among which the most popular choice is commercially available sterile carbon particles. The examiner should be aware that the tattoo is ideally placed just distal to the lesion with documentation. At

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least three areas of the colonic circumference should be marked to avoid tattoo placement in the m ­ esentery, which would not be visible intraoperatively. We recommend injecting at least 0.5 ml at each site to prevent creation of a low-volume, faint tattoo which may not be readily noticeable intraoperatively. On the other hand, large-volume injections are also discouraged as resultant local inflammation leads to adhesions which in turn can complicate subsequent dissection. Diagnostic colonoscopy is occasionally performed intraoperatively to localize a lesion that is not otherwise apparent during surgery. Important considerations for this particular scenario include utilization of carbon dioxide and avoiding over-insufflation that might interfere with the conduct of the operation, specially in laparoscopic cases. In the postoperative setting, diagnostic colonoscopy may be necessary for control of anastomotic bleeding or to document anastomotic integrity prior to protective stoma reversal. Anastomotic bleeding is seen in about 5% of cases in the immediate postoperative period [10]. In most of these cases, the bleeding subsides spontaneously and nothing more than supportive care is needed. However, on occasion the briskness or persistent nature of hemorrhage may necessitate an endoscopic intervention. We prefer to use hemostatic clips in this situation; in our opinion, electrocautery or epinephrine injection can compromise anastomotic blood supply and carries a higher risk of anastomotic dehiscence. Colonoscopic evaluation in the immediate postoperative period should be carried out with utmost caution to avoid traction and possible disruption of the fresh anastomosis.

Pearls and Pitfalls

1. Diagnostic colonoscopy may be performed in patients ranging from well to critically ill, and all aspects of the procedure, from prep to sedation to extent, may need to be adjusted accordingly. 2. In most cases, carbon dioxide is safer than room air insufflation for the purposes of diagnostic colonoscopy.

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3. In practice, performing colonoscopy is much less an inexorable march forward than it is a serious of parries and counter-parries (advancement and withdrawal). 4. The endoscopist must always thoughtfully prepare for diagnostic colonoscopy and anticipate material and personnel needs ahead of time. 5. Understanding and anticipating potentially encountered pathophysiology will allow the endoscopist to utilize appropriate diagnostic tools, for example, random biopsy of normal appearing mucosa in microscopic colitis; this depends on patient history and exam. 6. Postsurgical anatomy can be confounding (e.g., a blind-­appearing end at a side-to-side anastomosis), and review of the operative report prior to beginning the colonoscopy may help frame expectations.

References 1. Joseph DA, Meester RG, Zauber AG, Manninen DL, Winges L, Dong FB, et  al. Colorectal cancer screening: estimated future colonoscopy need and current volume and capacity. Cancer. 2016;122(16):2479–86. Erratum in: Cancer. 2017;123(19):3857. 2. Lieberman DA, Williams JL, Holub JL, Morris CD, Logan JR, Eisen GM, et al. Colonoscopy utilization and outcomes 2000 to 2011. Gastrointest Endosc. 2014;80(1):133–43. 3. Wu J, Hu B.  The role of carbon dioxide insufflation in colonoscopy: a systematic review and meta-analysis. Endoscopy. 2012;44(2):128–36. 4. Rex DK, Petrini JL, Baron TH, Chak A, Cohen J, Deal SE, et  al. Quality indicators for colonoscopy. Gastrointest Endosc. 2006;63(4):S16–28. 5. Wong RC.  Immediate unprepared hydroflush colonoscopy for management of severe lower gastrointestinal bleeding. Gastroenterol Hepatol (N Y). 2013;9(1):31–4. 6. Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, et al. Urgent colonoscopy for evaluation and man-

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agement of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100(11):2395–402. 7. Warren JL, Klabunde CN, Mariotto AB, Meekins A, Topor M, Brown ML, et al. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med. 2009;150(12):849–57, W152. 8. Green BT, Tendler DA. Ischemic colitis: a clinical review. South Med J. 2005;98(2):217–22. 9. Gandhi SK, Hanson MM, Vernava AM, Kaminski DL, Longo WE. Ischemic colitis. Dis Colon Rectum. 1996;39(1):88–100. 10. Golda T, Zerpa C, Kreisler E, Trenti L, Biondo S. Incidence and management of anastomotic bleeding after ileocolic anastomosis. Color Dis. 2013;15(10):1301–8. 11. Safadi BY, Marks JM. Diagnostic colonoscopy. In: Scott-Conner CEH, editor. The SAGES manual: fundaments of laparoscopy, thoracoscopy, and GI endoscopy. 2nd ed. New  York: Springer Science + Business Media; 2006.

Chapter 4 Masters Program Flexible Endoscopy Pathway: Percutaneous Endoscopic Gastrotomy (PEG) Daniel Davila, Ramona Ilie, and Edward Lin

Abbreviations NG Nasogastric PEG Percutaneous endoscopic gastrotomy Learning Objectives

1. Understand the indications for potential placement and the relative and absolute contraindications to make appropriate patient selection 2. Be able to describe the steps of the procedure including modifications for special circumstances 3. Be able to diagnose and treat early and late complications of tube placement

D. Davila · R. Ilie (*) · E. Lin Emory University Hospital, Department of General Surgery, Atlanta, GA, USA Emory University School of Medicine, Department of Surgery, Atlanta, GA, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_4

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Background In 1980, Ponsky and Gauderer [1] introduced the percutaneous endoscopic gastrotomy (PEG) technique, a novel, nonoperative approach to obtaining enteral access. Access prior to that required an open approach for a patient population often already suffering from significant comorbidities. In addition to decreased invasiveness, PEG tube placement reduces the level of anesthesia required and enables its use within 24  hours of placement. It has become the preferred route of feeding and nutritional support in patients requiring long-term assistance who are unable to eat by mouth. A number of modifications to the original technique have been proposed, yet the classic description remains popular and reliable.

Preoperative Evaluation Indications PEG placement is indicated primarily for one of two purposes: enteral access or gastric decompression. Enteral access for nutrition is the most common reason for consultation. Enteral feed formulations are less expensive than parenteral nutrition and more easily administered by patients or family. In some patients, the procedure can be performed on an outpatient basis [2]. Conditions requiring enteral access generally render the patients unable to obtain adequate oral nutrition. Some of the neurologic diseases that commonly benefit from PEG placement include stroke, traumatic brain injury, cerebral palsy, motor neuron disease (i.e., amyotrophic lateral sclerosis), and multiple sclerosis. Head or neck surgery or trauma can also be a barrier to oral intake. Palliative PEG tubes may also be indicated in patients with inoperable intestinal obstruction seeking relief.

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Relative and Absolute Contraindications Absolute contraindications to PEG placement include hemodynamic instability, severe ascites, and history of total gastrectomy. Pregnancy, mild to moderate ascites, sepsis, partial gastrectomy, advanced peritoneal cancer, and interposed organs are relative contraindications. The gravid uterus that displaces the stomach and adjacent organs may increase the difficulty of tube insertion but has been safely placed in women up to 29 weeks’ gestation [3]. PEG placement in the presence of active abdominal ascites risks persistent fluid leaks at the insertion site and intra-abdominal contamination. Prior gastric resection provides less available stomach for access, creates potentially limiting adhesions, and makes it more difficult to distend the stomach against the abdominal wall. Although not mandatory, preprocedural cross-sectional imaging, if available, may improve the chances of successful PEG insertion in these more complicated presentations. In patients with gastroparesis or gastric outlet obstruction, PEG placement is obviously useless for nutrition delivery unless a gastrojejunostomy extension is planned. The same may hold true for those with moderate to severe gastroesophageal reflux that may be exacerbated by tube feeds; these patients may be better served by a jejunostomy tube. PEG placement is an elective procedure and timing bears some consideration. The ideal PEG candidate has had sufficient preprocedural nutrition, most commonly via nasogastric tube feeds to promote timely healing and verify adequate gastric emptying. For those presenting for decompression, preprocedural nasogastric (NG) placement should occur and stomach contents sufficiently emptied as these patients are at higher risk for aspiration during the procedure.

Informed Consent A significant proportion of PEG tube candidates cannot consent for themselves due to neurological dysfunction or critical illness. A legally permitted decision maker or power of attorney

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is then required for any procedure, and in some jurisdictions, physicians can make these determinations. In addition to the general discussions about indications and risks of any surgical intervention, risks specifically related to PEG tube placement include bleeding, bowel perforation, tube dislodgement, infections, enteric leaks, and peritonitis. Alternative approaches to endoscopic placement may include open gastrotomy and laparoscopic or image-guided percutaneous approaches. In patients with impending demise or without clear survival advantage to enteral access, a PEG tube may not be of any benefit [4]. Any PEG tube placed should be meant for longer-term benefit (i.e., weeks to months) rather than short term (i.e., few weeks).

Technique Equipment A standard operating room, endoscopy suite, or even an intensive care unit can accommodate PEG placement so long as adequate cardiopulmonary status can be monitored. Required equipment includes a gastroscope with working port, functional insufflation, suction, and visual monitor. PEG tube kits generally include: • Antiseptic solution for skin preparation • A silicone gastrotomy tube with bumper (usually 20 French but smaller and larger tubes are available) • Needle with cannula, 14 gauge usually supplied • Local anesthetic with needles and syringe • #11 scalpel • ≥150 cm looped insertion wire∗ • Endoscopic grasping snare • Scissors • Hemostat • Skin bolster • Pinch clamp • Dual port adapter ∗ Importantly, kits come in “Push” or “Pull” varieties of which “Push” versions carry a longer wire

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In addition to the above, an optional topical antibacterial can also be applied to the site after tube placement. As an invasive procedure, universal precautions should be adhered to which includes appropriate personal protective equipment, eye protection, a standard face mask, gown, and sterile gloves for the person performing the skin incision and wire passing or pulling. This procedure is considered a clean-­ contaminated procedure because the alimentary tract is entered.

Preparation Patients should usually fast prior to the procedure. About 4–8  hours fasting is usually adequate, but in select patients, shorter fasting periods can be considered. Patients with gastroparesis or distal obstruction should have longer periods of fasting or even preprocedural nasogastric tube placement. Pre-procedural antibiotics should be administered within 1  hour of tube placement. A number of randomized controlled trials and one systematic review have shown a clear benefit in decreasing peristomal infections from 26% to 8.7% with the administration of pre-procedure antibiotics [3, 5]. Typically, a single intravenous dose of a cephalosporin is sufficient. The literature on anti-platelet medications and anticoagulation periprocedurally is less clear. These studies are uniformly retrospective and observational in nature but suggest aspirin and even clopidogrel and dipyridamole, individually or in combination, may not increase bleeding complications though it was not powered to detect a difference [6]. Instead, low platelet counts may increase bleeding risk. A separate study by Singh and colleagues [7] found no increased bleeding following PEG placement while on antiplatelet medications or heparin prophylaxis, though ongoing therapeutic heparin drip predicted procedure-related bleeding. Between the two studies, bleeding events remained low between 0.5% and 2.8%. Until higher level evidence is available, aspirin and prophylactic heparin are likely safe to continue periprocedurally.

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Clopidogrel or dipyridamole cessation should be discussed on a risk-to-benefit basis. Therapeutic anticoagulation at PEG placement should be avoided. No preoperative imaging is indicated. Any already available imaging can be reviewed to help locate the stomach in relation to the costal margins and visceral organs. Appropriate sedation requires an analgesic, amnestic, and anxiolytic. A common combination can be fentanyl and midazolam which have quick elimination half-lives and limited autonomic effects. When necessary, general anesthesia can be employed. For patients with neuromuscular dysfunction, general anesthesia may further impair spontaneous ventilation and an efficient procedure with moderate intravenous sedation may be a better approach; generous local anesthesia can further accomplish this aim.

Positioning/Environment The patient is positioned supine, but it is possible to perform the procedure with the head of bed elevated to 45°. The bed height should be adjusted to the endoscopist’s comfort. The endoscopy tower and endoscopist should be to the patient’s left and a video monitor on the opposite side, to the patient’s right. Working room should be made on either side for the surgeon managing the abdominal portion of the case. A table or working space should be prepared near the abdominal surgeon for equipment access. Once the endoscope is introduced, room lights should be dimmed to better appreciate transillumination of the abdominal wall. In certain circumstances, it may be difficult to reposition the patient, and the endoscopist will need to proceed from unconventional positions such as from the patient’s right side or with the viewing monitor at the foot of the bed while the scope is inserted up at the head.

Steps The “pull” technique originally described by Ponsky and Gauderer remains the most popular approach. Once supplemental oxygen is established, and sedation commenced, a

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mouth guard is placed to protect the lips and the teeth. An endoscope is introduced through the patient’s mouth into the stomach in the standard fashion. Gastric insufflation is performed to cause apposition of the anterior stomach to the abdominal wall. The abdomen is prepped and draped in standard fashion. Starting near the xyphoid and proceeding caudad, direct palpation is performed with one finger while visualizing for indentation on the viewing monitor. The ideal location can be anywhere to the left of midline and at least two fingerbreadths below the costal margin. To determine the safest location for access, 1-to-1 finger palpation and transillumination should be obtained. While intermittently pressing various locations on the abdominal wall, the best corresponding gastric indentation should be noted. With room lights dimmed and the gastroscope moved closer to the best indentation, successful transillumination suggests no intervening structures. With the ideal location identified, local anesthetic is infiltrated in the skin and an incision of 1–1.5 cm is made. A needle within a cannula on a syringe is placed through the incision while on suction; air or enteral content not directly associated with gastric placement on endoscopic view suggests intestinal puncture, and a different trajectory or location should be used. In women, it is best to avoid placement immediately under the breast and to stay below the bra line. Once visible within the stomach, the rigid needle is removed (Fig.  4.1), and the looped wire is inserted through the angiocatheter and grasped with the endoscopic snare (Fig. 4.2). The endoscope with wire is withdrawn retrograde out of the mouth. The intended gastrotomy tube is secured to the wire and pulled by the abdominal surgeon down the oropharynx, esophagus, into the stomach, and out through the abdominal wall (Fig. 4.3). Care must be taken to stop pulling once the tube markers are seen and the internal bumper is felt against the stomach wall. Pulling any more will cause dislodgement of the tube and the procedure will have to start from the beginning. Once the tube is in position, the PEG tube is cut to length and a bumper loosely applied near the skin edge such that the bumper is along the abdominal wall and can rotate 360° without difficulty. The tube clamp and

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Figure 4.1  Endoscopic visualization of the percutaneous insertion of the 14-gauge needle with catheter

Figure 4.2  Endoscopic visualization of the snaring of insertion wire during percutaneous endoscopic gastrotomy

universal adapter are affixed to the tube. A dressing and antibiotic ointment can be applied at this time. The endoscope can be reintroduced to verify correct position and hemostasis. Whenever withdrawn, the endoscopist should evacuate the air from the stomach. The PEG tube can also be placed to

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Figure 4.3  External pulling of the looped wire and attached tubing

gravity drainage bag if there is desire to keep the stomach collapsed. The tube marking at the skin should be documented and communicated among care providers. A tube that is pressed too tightly against the skin and the stomach can cause necrosis of one or both areas, leading to infections and leaks.

Alternative Methods Similar endoscopic-assisted gastrotomy tube methods have been described, namely, the “Push” technique and Russell introducer method. The “Push” technique is the same as the “Pull” technique outlined above, but instead of the wire and PEG tube being pulled from the abdominal aspect, a longer wire held firmly from both ends facilitates pushing the PEG tube down the wire through the mouth until it is able to be grasped at the abdomen and pulled to length.

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The Russell technique uses the endoscope solely to facilitate insufflation, best site localization, and direct visualization but does not interact with the PEG tube. Instead, a Seldinger-­ style technique is used at the angiocatheter site as obtained above to progressively dilate the tube site until a peel-away sheath is placed into the stomach and an inflatable gastrotomy tube is placed through the sheath (Fig. 4.2). This approach most notably differs from the prior two in that the gastrotomy tube never passes through the oropharynx or esophagus.

Postoperative Early Aftercare Since the tube is placed under visualization, medications can be administered immediately. Traditionally, tube feed initiation has been delayed until 12–24 hours post placement, but there are reports that the tube can be used for feedings as soon as 4  hours after placement. One study has examined immediate feeding, but a meta-analysis by Bechtold and colleagues [8] found that initiating enteral feeding at 4  hours post placement did not increase mortality or complications including infection, emesis, pneumonia, or bleeding. Although gastric residuals were higher in the early feeding group, this did not correspond to any clinical difference, suggesting tube feeds can be started safely as early as 4  hours post placement. There is no literature regarding the appropriate timing to restart anticoagulation, but 6–12 hours would appear safe for prophylactic anticoagulation and 12–24 hours for therapeutic anticoagulation assuming no signs of ongoing blood loss. Daily care post placement includes rotating the tube to confirm adequate laxity, verifying hemostasis, and routine tube site cleaning. Submersion bathing and swimming should be avoided for at least 2–3 weeks and until there is no significant drainage around the tube.

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The tube should be flushed with water (tap or sterile) before and after each use and especially with medication administration. Should the tube become blocked, warm water should be used to both aspirate and irrigate the tube. Additional solutions that may be of benefit include pancreatic enzymes with bicarbonate solution or soda, which are left in the tube for at least 10 minutes to be effective.

Late Aftercare PEG tube tracts will mature by 3–4  weeks. Therefore, the common practice is to wait at least 2  weeks to 6  months before exchanging tubes. The longer the tube is in place, the more mature the tract will be. For many patients, the need and indication for original placement may resolve in this time span. Follow-up at that time may include PEG tube removal. Removal of a PEG tube is performed in the clinic and entails significant traction to the tube to compress and remove the internal bumper. Patients should be cautioned beforehand, and every effort should be made to perform the removal with adequate grip, splash protection, and a dressing ready. Always verify the tube has not been exchanged to or placed as an inflatable tip catheter that can be removed easily on deflating the balloon. The tube site closes within a few days. A persistent gastrocutaneous fistula is rare but may require operative closure. Post-removal pain control can be achieved with simple over-the-counter analgesics. If the bumper breaks off, one should consider endoscopic removal particularly in smaller patients or children as there are case reports of distal obstruction requiring operative intervention. In patients on active anticoagulation, the anticoagulation should be stopped before the procedure, or removed endoscopically by cutting the tubing to avoid the trauma of pulling the bumper through the stomach and abdominal wall.

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Complications Minor Skin bleeding is usually treatable by direct pressure or topical hemostatic agents and is self-limited. On occasion, a skin suture may be placed to stop bleeding. Granulation tissue, which can be more prone to infection or bleeding, may appear due to ongoing tube irritation. This may be relieved with basic wound care and better stabilization of the tube. Persistent granulation requires debridement or cauterization with silver nitrate. Peristomal infections or skin cellulitis occurs in as many as 26% of PEG tube procedures. This is notably reduced to 3.4–8% with adherence to timely and appropriate preoperative antibiotics [9]. Some literature would suggest decreased infections when the Russell introducer technique is utilized as the PEG tube never contacts the oropharyngeal flora; one study found the standard “Pull” technique associated with an odds ratio of 13 relative to the Russell technique [10]. Minor infections may resolve with topical antimicrobials and daily care. More involved infections may require a course of antibiotics or even incision and drainage. Making too small a skin incision may trap in and promote an otherwise minor inoculation of bacteria, so the length of the incision bears additional consideration. Peristomal leakage or gastric outlet obstruction can occur from a tube that is too loose. Referring back to the original length of tube at the skin and pulling the tube while rotating may remove excessive laxity.

Major Dislodgement is a risk with any tube placement. Dislodgement within hours or days of placement will require replacement of the tube. While waiting for tube replacement, a nasogastric tube to suction can be placed and antibiotics administered. It is possible to endoscopically replace this tube through the

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same site without going to the operating room. All this depends on the patient’s condition and if peritonitis is present. Early dislodgement between weeks 1–6 may be treated with early tube replacement using a similar-sized tube through the same site as the tract will close within hours. Confirmation of proper placement by flushing and withdrawal of gastric content or by contrast radiography should be performed before using the tube. Similarly, fluoroscopy imaging can also be very helpful in tube replacement after accidental dislodgement. Clinically significant bleeding from the liver, superior epigastric artery, or arteries/veins neighboring the stomach can occur and is at highest risk in those on full anticoagulation. Prompt volume resuscitation and obtaining a blood count are essential. Endoscopic and/or laparoscopic exploration may be indicated to control major bleeding not controlled with noninvasive measures. Visceral injury, especially the transverse colon as it drapes across the lower stomach, is a rare but real risk after PEG placement. Small bowel, liver, spleen, and gastric injury can also occur. A needle injury will usually heal well without intervention. Major colonic injuries presenting with peritonitis will require operative exploration. When there is concern for fistula formation to neighboring bowel, a CT scan with intravenous and water-soluble contrast can help identify it. Occasionally, a gastrocolocutaneous fistula may not be clinically apparent until PEG tube removal. Most of these will close spontaneously [11]. In the event that the colon is traversed without peritonitis, the PEG tube should be left to passive drainage, and the site can be pouched like a controlled fistula. Immediately pulling the tube, especially a fresh one, will most certainly require surgical intervention to close the colotomy and gastrotomy. The tube may often be pulled safely after allowing the tract to mature with time. If the liver is traversed at its edge, it is acceptable to continue using the tube as long as there is no bleeding or infection. The tube can be removed in the usual fashion several

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weeks later. If the tube traverses a significant portion of the liver parenchyma, it is advisable to tighten the bumper of the tube for hemostasis and decide on a plan to remove the tube and place it at a different site. In this case, the tube should not be pulled out of the abdominal wall but rather pulled back endoscopically to avoid bumper trauma to the liver parenchyma. Buried bumper syndrome presents with intense pain and occasionally infection at the tube site as the internal bumper is lodged within the tube tract, no longer within the gastric lumen. It can occur early or late as excessive tension on the internal bumper can occur at any time after placement. Immediate removal and resiting is indicated, whether by mere manual traction or endoscopically. Rare occurrences of pharyngeal or esophageal tumor seeding to the PEG site have been documented. In patients with particularly friable or concerning tissue in the path of the gastrotomy tube, the Russell technique may decrease this risk [3].

Special Considerations The morbidly obese and super obese represent a growing portion of the population and can present a unique challenge for PEG placement. 1-to-1 palpation, transillumination, and directing the needle and angiocatheter into the gastric lumen may be difficult. The epigastrium is the thinnest region of the abdominal wall and increases successful placement. Reverse Trendelenburg allows gravity to bring the stomach inferior to the costal margins. Darkened room lighting and full fisted ballottement can further assist in transillumination. When especially difficult to improve subtle 1-to-1 palpation, a small cutdown technique may make both gastric indentation and transillumination more successful. The use of a spinal needle or other long angiocatheter may be necessary, and access to these can be anticipated pre-op. Taking advantage of these additional techniques will allow successful PEG placement in

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almost all morbidly obese [12] or even super morbidly obese patients [13]. In some cases, laparoscopic visualization or combined endoscopy-CAT scan localization can help access the stomach. The super thin habitus with fragile abdominal wall is especially at risk for concomitant visceral or mesenteric injury. Furthermore, there is little tissue between the stomach and the skin, which increases the risks of skin ulceration, buried bumper syndrome, leaks, poor stoma sealing, and infection. Contorted or atypical anatomy such as those with severe cerebral palsy with contractures, elderly, or upper abdominal ostomies may require preoperative imaging to verify PEG candidacy. A CT abdomen and pelvis is most commonly ordered to determine this. Occasionally, laparoscopic assistance may be needed or laparoscopic versus open gastrotomy tube placement may be preferable.

Pearls and Pitfalls

1. PEG tube placement is never urgent or emergent. Perform them safely and with a plan. If distally obstructed, always place a nasogastric tube prior to sedation to decrease aspiration risk. 2. In the super obese, reverse Trendelenburg position and gravity help bring the stomach below the rib cage. 3. The epigastrium is the thinnest part of the abdominal wall in the super obese. You may need a longer angiocatheter to access the stomach. 4. If the skin incision of the insertion site is too small, you will more likely get skin breakdown. Make the incision to allow gap between the tube and skin. 5. Stop anticoagulation before removing PEG tube or remove endoscopically by pulling the bumper with a snare to minimize bleeding to the stomach and abdominal wall.

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References 1. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrotomy: a nonoperative technique for feeding gastrotomy. Gastrointest Endosc. 1981;27(1):9–11. 2. Wilhelm SM, Ortega KA, Stellato TA. Guidelines for identification and management of outpatient percutaneous endoscopic gastrotomy tube placement. Am J Surg. 2010;199(3):396–9; discussion 9–400. 3. Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT.  Percutaneous endoscopic gastrotomy: indications, technique, complications and management. World J Gastroenterol. 2014;20(24):7739–51. 4. Sanders DS, Carter MJ, D’Silva J, James G, Bolton RP, Bardhan KD.  Survival analysis in percutaneous endoscopic gastrotomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol. 2000;95(6):1472–5. 5. Lipp A, Lusardi G. A systematic review of prophylactic antimicrobials in PEG placement. J Clin Nurs. 2009;18(7):938–48. 6. Barton CA, McMillian WD, Osler T, Charash WE, Igneri PA, Brenny NC, et  al. Anticoagulation management around percutaneous bedside procedures: is adjustment required? J Trauma Acute Care Surg. 2012;72(4):815–20; quiz 1124–5. 7. Singh D, Laya AS, Vaidya OU, Ahmed SA, Bonham AJ, Clarkston WK. Risk of bleeding after percutaneous endoscopic gastrotomy (PEG). Dig Dis Sci. 2012;57(4):973–80. 8. Bechtold ML, Matteson ML, Choudhary A, Puli SR, Jiang PP, Roy PK.  Early versus delayed feeding after placement of a percutaneous endoscopic gastrotomy: a meta-analysis. Am J Gastroenterol. 2008;103(11):2919–24. 9. Lee C, Im JP, Kim JW, Kim SE, Ryu DY, Cha JM, et al. Risk factors for complications and mortality of percutaneous endoscopic gastrotomy: a multicenter, retrospective study. Surg Endosc. 2013;27(10):3806–15. 10. Campoli PM, de Paula AA, Alves LG, Turchi MD. Effect of the introducer technique compared with the pull technique on the peristomal infection rate in PEG: a meta-analysis. Gastrointest Endosc. 2012;75(5):988–96. 11. Schrag SP, Sharma R, Jaik NP, Seamon MJ, Lukaszczyk JJ, Martin ND, et  al. Complications related to percutaneous endoscopic

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gastrotomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16(4):407–18. 12. Bender JS.  Percutaneous endoscopic gastrotomy placement in the morbidly obese. Gastrointest Endosc. 1992;38(1):97–8. 13. Bochicchio GV, Guzzo JL, Scalea TM.  Percutaneous endo scopic gastrotomy in the super morbidly obese patient. JSLS. 2006;10(4):409–13.

Chapter 5 Masters Program Flexible Endoscopy Pathway: Stenting Wanda Lam, Ian Greenwalt, and Jeffrey Marks

Learning Objectives

1. Understanding the characteristics and techniques of endoscopic stenting of the foregut and hindgut 2. Understanding the indications, contraindications, and complications of esophageal and gastric stenting 3. Understanding the indications, contraindications, and complications of colorectal stenting

W. Lam · I. Greenwalt · J. Marks (*) University Hospitals of Cleveland Medical Center, Department of Surgery, Cleveland, OH, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_5

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Introduction The introduction of enteric stenting has allowed for minimally invasive approach to pathologies of the digestive tract; these are often challenging clinical scenarios. Though originally developed for the use of malignant biliary strictures and obstructions, the application and efficacy of self-expanding metal stents (SEMS) and self-expanding plastic stents (SEPS) have significantly grown since their inception. SEMS and SEPS have roles in the management of strictures and obstructions of the esophagus, gastric outlet, and large bowel, as well as an increasing role in the management of foregut and hindgut leaks and fistulae.

Stent Characteristics and Stenting Techniques When compared to their predecessors of pulsion tubes and rigid endoprostheses, expandable stents have lower rates of morbidity and mortality as well as a greater therapeutic range. Expandable stents can be placed across more narrow strictures and achieve a larger inner diameter compared to previously used prostheses [1]. Uncovered metal stents, composed of metal alloys such as Nitinol or Elgiloy, integrate themselves into the surrounding tumor or tissue via pressure necrosis followed by tumor ingrowth and granulation [2]. While this is advantageous in decreasing stent migration, it can be problematic, resulting in luminal narrowing and obstruction. Because of this, uncovered stents are best reserved for patients with shorter life expectancy (5 mm that does not extend between two mucosal folds

C

One (or more) mucosal break that is continuous between two mucosal folds but which involves less than 75% of the esophageal circumference

D

One (or more) mucosal break that involves more than 75% of the esophageal circumference

Used with permission of BMJ Publishing Group from Lundell et al. [11]

essential to diagnose Barrett’s esophagus prior to surgery and, once confirmed, perform a sufficient pathologic evaluation with four-quadrant biopsies every 1–2 cm (i.e., Seattle protocol) in order to evaluate for dysplasia or malignancy. Either diagnosis would radically alter the patient’s treatment plan. The esophagus should also be carefully evaluated for signs of eosinophilic esophagitis, such as rings or longitudinal furrows (Fig.  9.4a–f) [3]. If any of these are present, multiple biopsies of both the proximal and distal esophagus should be taken to evaluate for the histologic presence of eosinophils. The presence of retained food material in the stomach can be an indication of gastroparesis and should be investigated with a gastric-emptying study prior to proceeding with surgery. Areas of gastritis and gastric or duodenal ulcer disease should be biopsied to evaluate for H. pylori infection, malignancy, and other pathologies. Achalasia Patients with achalasia and other esophageal motility disorders require thorough diagnostic endoscopy prior to ­proceeding with any endoscopic or surgical intervention. The initial goal of EGD in patients with dysphagia is to evaluate for a source of mechanical obstruction due to intrinsic luminal

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pathology or extrinsic compression. Esophageal retention of food matter can limit visualization and put patients at risk for aspiration, so patients with suspected or known achalasia should be kept on a clear liquid diet for 48  hours prior to a

d

b

e

c

Figure 9.4  (a–f) Endoscopic, radiographic, and histologic images of patients with eosinophilic esophagitis. (a) White specks of esophageal mucosa consistent with eosinophilic microabscesses. (b) Ringed appearance of the esophagus. (c) Linear furrowing of esophageal mucosa. (d) Esophageal food impaction in setting of eosinophilic esophagitis. (e) Ringed appearance of esophagus as visualized on esophogram. (f) Histology of eosinophilic esophagitis. (All: Used with permission of Elsevier from Kavitt et al. [3])

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f

Figure 9.4  (continued)

endoscopy. The mucosal surfaces of the esophageal and stomach must be carefully examined and biopsies taken of any irregularity. Subepithelial masses or areas concerning for extrinsic compression can be investigated further with cross-­ sectional imaging (CT scan, MRI) and/or endoscopic ultrasound (EUS). Patients without mechanical obstruction should undergo high-resolution manometry to evaluate for a “functional” obstruction (i.e., achalasia or other esophageal motility disorders). In patients with a history highly suspicious for achalasia, the endoscopist can plan for direct placement of the manometry catheter at the time of diagnostic EGD, as long as no mechanical obstruction is found. This strategy speeds the time to diagnosis and avoids awake placement of the manometry catheter, which can be extremely uncomfortable. An endoscopic evaluation of esophageal anatomy is important for determining the optimal treatment modality for patients with achalasia. An extremely tortuous or “sigmoid”shaped esophagus can increase the risk of perforation during pneumatic dilation and can make creation of a submucosal tunnel across the EGJ impossible during peroral endoscopic myotomy (POEM). Achalasics can also occasionally have a concurrent hiatal hernia which can be diagnosed during EGD.

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Hiatal hernia would increase the risk of iatrogenic GERD after either pneumatic dilation or POEM. As a result, patients with achalasia and either sigmoid esophagus or hiatal hernia are usually best suited for a laparoscopic Heller myotomy with partial fundoplication, with concurrent hiatal hernia repair if present. Bariatric Surgery The role of routine preoperative EGD in patients being evaluated for bariatric surgery is somewhat controversial. Some centers elect to perform selective endoscopy only in patients with symptoms such heartburn, dysphagia, regurgitation, or postprandial complaints. Consideration should be given to utilization of MAC anesthesia with a dedicated provider due to the difficulties inherent in airway management for this patient population. The esophagus should be carefully evaluated for esophagitis and Barrett’s esophagus. Patients should be evaluated for H. pylori infection with either noninvasive testing (serum antibodies, urea breath testing, or stool antigen) or with gastric biopsies. The stomach and duodenum should be examined for polyps and other masses, including subepithelial tumors. The anatomic position of any lesions in the stomach must be carefully evaluated, so that their location in relationship to the staple lines of the planned bariatric procedure can be assessed. Additionally, retroflexed assessment for hiatal hernia is essential, as small hernias may not be appreciated at the time of surgery. Missed hernias can lead to GERD postoperatively, especially following sleeve gastrectomy. Esophageal and Gastric Cancer Endoscopy is the primary means of diagnosis of esophageal and gastric cancers. It also serves an important role in preoperative planning. During initial EGD, obtaining an accurate tissue diagnosis is of utmost importance. Esophageal and gastric mucosal-based tumors should be sampled with multiple

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biopsies, and obtaining at least seven biopsies has been shown to increase diagnostic yield for suspicious gastric ulcers [4]. Mucosal nodules in patients with Barrett’s esophagus should be evaluated using endoscopic mucosal resection (EMR) so that depth of invasion can be assessed. The proximal and distal extent of tumors from the incisors should be measured, and their relationship with important anatomic structures, such as the upper and lower esophageal sphincters and pylorus, should be assessed. The anatomy of adenocarcinomas near the EGJ should be evaluated according to the Siewert classification (Table  9.2). This will determine whether they are treated as esophageal or gastric cancers, which will affect neoadjuvant therapy and the anatomic resection that is ultimately performed (i.e., esophagectomy vs. total gastrectomy). Tumors causing luminal narrowing can be traversed using a small-caliber pediatric gastroscope. However, it is important not to perform interventions such as dilation or stent placement at the time of diagnostic EGD in patients with possible malignant conditions of the esophagus and stomach. A pathologic diagnosis must first be confirmed and then a staging workup completed, which will include cross-sectional imaging and EUS.  Only after patients are staged can a treatment plan be formulated which may include a combination of medical, radiation, endoscopic, and surgical therapies. Table 9.2 Siewert classification for adenocarcinomas arising in proximity to the esophagogastric junction (EGJ) Siewert Treatment classification Description approach I Tumor center located between Esophageal 5 and 1 cm proximal to the EGJ cancer II

Tumor center located between 1 cm proximal and 2 cm distal to the EGJ

Esophageal cancer

III

Tumor center located between 2 and 5 cm distal to the EGJ

Gastric cancer

Used with permission of SAGE Publishing from Siewert et al. [12]

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Endoscopy Prior to Colorectal Surgery Similar to EGD and foregut surgery, colonoscopy plays an essential role in the workup prior to colorectal operations. Important components include defining important anatomy, accurately describing and diagnosing disease pathology, and performing a thorough assessment of the colon to exclude secondary processes. Key to performing a thorough colonoscopic examination is the adequacy of the patient’s bowel preparation. A number of standard bowel preps are available, and many institutions standardize these across providers. Utilization of a 2-day split prep should be considered in patients with a history of inadequate prep during prior colonoscopies. In general, a complete examination of the entire colonic mucosal surfaces with intubation of the terminal ileum and retroflexed examination of the rectum should be performed. Photo documentation of lesions and areas of disease process is important when evaluating a patient in a preoperative context. Tissue diagnosis of all lesions should be obtained via biopsy or polypectomy. Techniques for polypectomy, including indications for use of adjunctive techniques such as submucosal lift and endoscopic submucosal dissection (ESD), are discussed in the chapters on basic endoscopic tissue sampling techniques and specimen retrieval methods (Chap. 10) and advanced endoscopic tissue resection methods (Chap. 11).

Disease-Specific Considerations Colorectal Cancer Colonoscopy with biopsy is the primary means of diagnosis for colorectal cancers. If a mucosal tumor suspicious for malignancy is discovered, multiple biopsies should be performed to reduce the risk of sampling error. Suspicious lesions should be tattooed at the time of initial endoscopy in order to localize them during subsequent surgical resection. There is no consensus as to the optimal tattooing strategy, but

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the majority of endoscopists tattoo just distal to the lesion [5]. Indian ink should be injected in multiple quadrants and the location of injection in relation to the lesion should be clearly documented in the endoscopy report. In addition to tattooing, the anatomic location of the lesion should be estimated based on scope distance from the anal verge and luminal anatomic markers (e.g., splenic and hepatic flexures). The distance of rectal cancers from the anal verge should be evaluated with a rigid proctoscope to eliminate measurement error due to colonoscopic flexion. Ideally, the entirety of the colon proximal to the lesion should be evaluated in order to detect synchronous cancers or polyps. Lesions that narrow the lumen can often be traversed using a pediatric colonoscope. Dilation should not be attempted at the time of diagnostic endoscopy due to a high risk of perforation. In patients with lesions that cannot be traversed at the time of initial endoscopy, repeat “second-­look” colonoscopy, CT colonography, capsule colonoscopy, and intra- or postoperative colonoscopy following resection are all acceptable strategies for evaluating the proximal colon [6]. Inflammatory Bowel Disease Colonoscopy serves a central role in the diagnosis, management, and preoperative evaluation of patients with inflammatory bowel disease (IBD). Initial diagnostic colonoscopy with ileoscopy and biopsy is essential in differentiating Crohn’s disease from ulcerative colitis and in evaluating the pattern and extent of disease. Biopsies should be taken of all diseased portions and of normal segments of bowel. Disease phenotypes should be classified according to a validated system, such as the Montreal classification (Table 9.3) [7]. Endoscopic findings such as Crohn’s strictures or dysplasia in ulcerative colitis are often the indication for surgical resection in patients with IBD. Therefore, a thorough and evidence-­ based approach to performing colonoscopy and endoscopic interventions, such as dilation for strictures, is essential. Performance of such interventions is discussed in the chapter

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Table 9.3  Revised Montreal classification for inflammatory bowel disease Ulcerative colitis Classification

Definition

Maximal endoscopic involvement

E1

Proctitis

Limited to rectum

E2

Left-sided

Limited to colonic mucosa distal to splenic flexure

E3

Extensive

Extends proximal to splenic flexure

A: Age of onset

L: Location

B: Behavior

A1 = ≤16 y

L1 = ileal

B1 = non-stricturing, non-­ penetrating

A2 = 17–40 y

L2 = colonic

B2 = stricturing

A3 = >40 y

L3 = ileocolonic

B3 = penetrating

L4  = isolated upper GI

+ p = perianal disease is present

Crohn’s disease

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Masters Program Flexible Endoscopy Pathway: Balloon Dilation (Chap. 6). As with disease processes of the foregut, if surgeons treating patients with IBD perform the preoperative colonoscopy themselves, it can streamline patients’ treatment and avoid lapses in communication of essential endoscopic findings. However, this is not always possible, which makes photo and written documentation, as well as communication between endoscopist and surgeon, of vital importance.

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Diverticulitis Patients who have an episode of acute diverticulitis should be evaluated with a colonoscopy 6–8  weeks after resolution of symptoms in order to rule out malignancy and IBD. Endoscopy should also describe the extent and pattern of diverticular disease and evaluate for complications of diverticulitis, such as stricture and fistula formation. However, the need for elective surgery is based on clinical factors such as patient age, comorbidities, and the number and severity of acute diverticulitis episodes, rather than findings on colonoscopy.

Intraoperative Endoscopy Evaluation of Anatomy and Anastomoses Intraoperative endoscopy plays an essential role in the evaluation of anatomy during operations throughout the GI tract. It is helpful to perform these endoscopies using CO2 insufflation, rather than room air, in order to speed absorption and limit postoperative bloating and nausea. Surgeons who can perform high-quality endoscopic evaluations will find an increasing number of uses of the scope in the operating room. The following are just a few of the many uses of intraoperative endoscopy. During laparoscopic anti-reflux surgery and hiatal/paraesophageal hernia repair, endoscopy allows the surgeon to accurately assess anatomy and judge the adequacy of surgical reconstruction of the hiatus and EGJ flap valve. During these operations, it is essential to achieve at least 2–3 cm of intra-­ abdominal esophageal length, so that the fundoplication can be formed in an intra-abdominal position around the esophagus (rather than in an incorrect position around the stomach). However, in patients with hiatal hernia and loss of their native EGJ valve and angle of His, it can be difficult to determine the exact location of the EGJ laparoscopically. Intraoperative EGD can be performed to identify the proximal

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extent of the gastric folds as a marker of the true EGJ.  This position can be correlated laparoscopically by observing the location of the gastroscope light or by pressing with a laparoscopic instrument and noting its location intraluminally. After construction of the fundoplication, many surgeons perform a routine endoscopy to evaluate its appearance. The fundoplication should be confirmed to be around the esophagus (rather than the stomach), and the adequacy of the wrap can be assessed visually. It is important to be familiar with the normal appearance of Nissen, Toupet, and Dor fundoplications so that abnormalities such as twisting, laxity, and low construction around the stomach can all be identified and corrected in the operating room (Fig. 9.5a–c) [8]. Evaluation of anastomoses is another important role of intraoperative endoscopy during both foregut and colorectal operations. Anastomoses should be assessed for bleeding, patency, and leak. In order to perform an adequate leak test, the bowel beyond the anastomosis should be occluded to allow for adequate distention of the anastomosis and limit unnecessary bowel distention distally. This is typically done using a used stapler cartridge or a non-crushing bowel clamp. The anastomosis is submerged in saline and observed for bubbling as endoscopic insufflation is performed. Anastomoses that demonstrate a leak should be either repaired or reconstructed, and creation of a diverting stoma or distal feeding access should be considered in the setting of colorectal and foregut operations, respectively. Routine insufflation testing of colorectal anastomoses has been shown to decrease the incidence of postoperative anastomotic leak and is currently considered standard of care [9].

Combined Laparoscopic-Endoscopic Procedures Operations that combine laparoscopy with endoscopy are becoming increasingly common and make up an important component of the armamentarium of the modern general surgeon. As one gains familiarity with these techniques,

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endoscopy and laparoscopy can be combined in creative ways to enhance the efficacy and safety of procedures that were traditionally the domain of one modality or the other. One such common combined procedure is laparoscopic-­ assisted ERCP for management of choledocholithisis and other biliary pathology. The most common indication for laparoscopic-assisted ERCP is in patients who have previously undergone a Roux-en-Y gastric bypass (RYGB). This anatomy makes traditional ERCP difficult, with cannulation success rates often less than 50%. In patients who have undergone RYGB for weight loss (i.e., without gastrectomy), the gastric remnant makes the perfect conduit for introduction of the ERCP duodenoscope. To perform the procedure, laparoscopic ports are placed and a site on the gastric antrum or distal body is selected, paying care to identify and avoid the Roux limb if it is in an antegastric position. Stay stitches are then placed in at least two positions around the site and brought through the skin using a Carter-Thomason suture passer. A gastrotomy is then created between the stay sutures.

Figure 9.5  (a–c) Surgical fundoplication techniques. (a) A complete 360-degree Nissen fundoplication creates a nipple valve. On retroflexed endoscopic view, the lip of the valve should be thin, the body of the valve should have a “stacked coils” appearance in alignment with the long axis of the endoscope, and the valve should adhere tightly to the scope. The posterior groove will be deep and anterior groove will be shallow. White lines depict the appropriate orientation of the gastric folds as just below the diaphragm and directed perpendicular to the endoscope and parallel to the diaphragm. (b) The Toupet fundoplication is a partial 270-degree posterior wrap which creates a flap valve. The lip of the valve should be thick and “omega” shaped and the valve should be moderately adherent to the scope. Both the anterior and posterior groove should be shallow. (c) The Dor fundoplication is a partial 180-degree anterior wrap which creates a flap valve. The lip of the valve should be wide and “S” shaped, and the valve should be moderately adherent to the scope. The anterior groove should be shallow, and there is no posterior groove. (All: Used with permission of Wolters Kluwer from Yadlapati et al. [8])

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The ERCP scope can be inserted directed into the gastrotomy, but we prefer to introduce a 15  mm laparoscopic port through the gastrotomy. The scope is then introduced through the port while the stomach is pulled up to the anterior abdominal wall using the stay sutures. This helps to avoid peritoneal contamination and maintain endoscopic insufflation. After completion of the ERCP, the gastrotomy can be closed using either sutures or a laparoscopic stapler. If there is a need for further enteral access, a gastrostomy tube can be inserted through the gastrotomy and left in place. Other uses of a combined laparoscopic-endoscopic approach are for diagnostic and therapeutic enteroscopy, as well as gastrostomy tube placement. As both capsule and double-balloon endoscopy become increasingly sophisticated, it is easier to perform a diagnostic evaluation of the entire small bowel lumen. However, in some cases, adequate assessment cannot be performed or an endoscopic intervention is required in a location in the small bowel that cannot be accessed endoscopically. In such circumstances, a dual endoscopic-laparoscopic approach can be used. Using endoscopic bowel graspers or, in some cases, hand-port assistance, the bowel to fed over the endoscope. Once the lesion is identified, an endoscopic or laparoscopic intervention can be performed as needed. Percutaneous endoscopic gastrostomy (PEG) tube placement is another common endoscopic intervention for which laparoscopy can serve as a useful adjunct. Safe PEG placement relies on the direct apposition of the stomach with the anterior abdominal wall. This is evaluated endoscopically by confirmation of one-to-one palpation, transillumination, and a “safe track” needle aspiration technique. Often one or more of these methods cannot confirm gastric-abdominal wall apposition, commonly in patients with obesity, prior abdominal surgery, or small bowel or colonic distension. In such instances, laparoscopic assistance can ensure safe passage of the PEG needle and sheath into the anterior stomach. Often this requires placement of only a single 5 mm trocar so that the needle can be advanced through the peritoneal cavity

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under laparoscopic visualization. In more complex cases, further ports can be placed to hold bowel out of the way or perform adhesiolysis as necessary to bring the anterior stomach to the abdominal wall.

Postoperative Endoscopy Endoscopy plays a crucial role in the evaluation of patients after GI surgery. Its utility can generally be divided into (1) procedures performed in the short-term postoperative period in order to detect and treat surgical complications and (2) endoscopy for longer-term follow-up to investigate new symptoms or survey disease processes longitudinally.

Diagnosis and Management of Complications Endoscopy in the days to weeks after GI surgery is an essential tool for the diagnosis and management of intraluminal bleeding, obstruction, and anastomotic leak. Hematemesis and hematochezia after GI surgery should be assumed to be originating from the surgical site until proven otherwise. Given that these are focal bleeds, they are usually best managed with prompt endoscopic intervention. Anastomoses can be approached endoscopically even in the immediate postoperative period, as the risk of iatrogenic perforation is extremely low. Consideration should be made to performing such endoscopy under general anesthesia with endotracheal intubation. This ensures maintenance of a secure airway and allows for conversion to a combined surgical intervention (either laparoscopic or open) if the bleeding cannot be controlled with endoscopy alone. When approaching a surgical bleed endoscopically, visualization is paramount. For foregut bleeding, placing a nasogastric tube and performing lavage can help clear old blood. The use of an irrigation pump system, or even a double-lumen therapeutic endoscope, can assist in evacuating blood from the endoscopic field. Once the

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site of bleeding is identified, the use of “cold” methods of hemorrhage control should be used, primarily endoscopic clip placement. The use of cautery, argon plasma coagulation, and other thermal methods should be avoided if possible, as they can cause tissue ischemia and perforation when used on fresh anastomoses or other surgical sites. Initial evaluation of anastomotic leak is typically done radiographically with either contrast fluoroscopy or CT scan. However, both modalities can produce false negative results and neither provides the opportunity for therapeutic intervention. Especially in the case of foregut anastomoses, upper endoscopy provides a sensitive and specific means of diagnosis and allows for a range of therapies to be applied once a leak is confirmed. Endoscopic findings in patients with anastomotic leak can vary. Although occasionally a large dehiscence of the anastomosis can be visualized, this is more the exception than the rule. Mucosal ischemia can often be seen on one or both sides of the anastomosis, as well as ulceration or inflammation of the mucosa immediately around the area of the leak. If the patient has surgical or percutaneously placed intra-abdominal drains, these can be injected with blue dye to reveal the site of the leak endoscopically. Conversely, fluoroscopy can be used while injecting contrast endoscopically in order to identify an area of extravasation. Several methods exist for treating leaks endoscopically including therapies that attempt to seal the leak, such as clips, fully or partially covered self-expanding metal stents (SEMS), and endoscopic suturing. An alternative strategy, which we typically prefer, is internal drainage of the leak into the GI track, using either double-pigtail drains (typically ERCP-­type, biliary stents) or endolumenal VAC therapy (Fig. 9.6a–f). This allows for both immediate source control and long-term destination therapy, enabling the leak to gradually seal from the “outside in.” Choosing amongst the wide array of endoscopic interventions is a complex decision-making process that must take into consideration the patient’s clinical status and characteristics of the leak itself.

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Figure 9.6  (a–f) Placement of double-pigtail biliary stents for internal drainage of a staple-line leak in a patient after laparoscopic sleeve gastrectomy. (a) The leak is identified by injecting blue dye through an intraperitoneal drain and observing intraluminal extravasation. (b) An endoscopic cautery knife is used to cut down through the leak track until the intraperitoneal drain (c) is reached. (d) An endoscopic guidewire is passed into the leak cavity and the intraperitoneal drain is removed. (e) A double-pigtail biliary stent is passed over the guidewire and into the leak cavity. (f) The final view of three deployed double-pigtail stents

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Long-Term Evaluation and Surveillance Endoscopy is used in the long term after GI surgeries to both evaluate changes in a patient’s clinical condition (e.g., recurrent dysphagia after laparoscopic Heller myotomy) and to perform routine surveillance for disease recurrence (e.g., colonoscopy after partial colectomy for cancer). Both applications require the surgeon to have an up-to-date understanding of evidence-based diagnostic and surveillance protocols. Additionally, they require a system for longitudinally tracking patients to ensure they are not “lost to follow­up” after their index operation. The new onset of GI symptoms should always be assumed to be due to either a complication of the original operation or change in the disease process, even in a patient who was operated on years prior. Especially when it comes to functional operations (such as those for GERD and achalasia) or oncologic resections, new symptoms require prompt investigation. This often requires some combination of radiology studies and endoscopy. The endoscopist should anticipate what pathologies may be encountered and be prepared to intervene: for example, with endoscopic dilation of anastomotic stricture in a patient with dysphagia after RYGB. Endoscopy forms a core component of long-term routine disease surveillance after cancer resections throughout the GI track. It is important for GI surgeons to stay abreast of the latest evidence-based guidelines for cancer surveillance. Ideally surgeons can perform such surveillance endoscopy for patients on whom they have operated. At the very least, the surgeon must be actively involved in tracking patients long term, so that surveillance occurs at appropriate intervals. For example, current guidelines recommend colonoscopy at 1 year after resection for colon adenocarcinoma, with repeat colonoscopy after 3 and then 5  years if no adenomas are detected.

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Pearls and Pitfalls

1. Performing preoperative endoscopy allows for easier recognition of anatomy and disease processes that may affect the operative plan. 2. During pre- and intraoperative upper endoscopy, it is essential to be able to accurately identify anatomic ­landmarks such as the upper esophageal sphincter, esophagogastric junction, and position of lesions within the stomach. 3. During intraoperative endoscopy, the use of CO2 (rather than room air) insufflation and occlusion of the bowel beyond the segment being evaluated can decrease postoperative bowel distention and resulting symptoms. 4. Endoscopy should be used liberally in the evaluation of patients with suspected complications after GI surgery, including anastomotic leak. A recent anastomosis is not a contraindication to endoscopy and, if performed in a careful manner, iatrogenic perforation is extremely uncommon. 5. Surgeons must be familiar with current recommendations for postoperative endoscopic surveillance and take the lead in tracking patients longitudinally so that appropriate surveillance actually occurs.

References 1. Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol. 2016;111(1):30–50; quiz 1. 2. Hill LD, Kozarek RA, Kraemer SJ, Aye RW, Mercer CD, Low DE, et al. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointest Endosc. 1996;44(5):541–7. 3. Kavitt RT, Hirano I, Vaezi MF. Diagnosis and treatment of eosinophilic esophagitis in adults. Am J Med. 2016;129(9):924–34.

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4. Graham DY, Schwartz JT, Cain GD, Gyorkey F.  Prospective evaluation of biopsy number in the diagnosis of esophageal and gastric carcinoma. Gastroenterology. 1982;82(2):228–31. 5. Letarte F, Webb M, Raval M, Karimuddin A, Brown CJ, Phang PT. Tattooing or not? A review of current practice and outcomes for laparoscopic colonic resection following endoscopy at a tertiary care centre. Can J Surg (Journal canadien de chirurgie). 2017;60(6):394–8. 6. Vogel JD, Eskicioglu C, Weiser MR, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of colon cancer. Dis Colon Rectum. 2017;60(10):999–1017. 7. Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR, et  al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol (Journal canadien de gastroenterologie). 2005;19(Suppl A):5A–36A. 8. Yadlapati R, Hungness ES, Pandolfino JE.  Complications of antireflux surgery. Am J Gastroenterol. 2018;113(8):1137–47. 9. Beard JD, Nicholson ML, Sayers RD, Lloyd D, Everson NW. Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg. 1990;77(10):1095–7. 10. Kahrilas PJ, Kim HC, Pandolfino JE.  Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601–16. 11. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999 Aug;45(2):172–80. 12. Siewert JR, Feith M, Werner M, Stein HJ.  Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients. Ann Surg. 2000;232(3):353–61.

Chapter 10 Basic Endoscopic Tissue Sampling Techniques and Specimen Retrieval Methods Kelli Ann K. Ifuku, Simon Che, and Dean J. Mikami

Learning Objectives

1. Understand the key principles of basic tissue sampling in different organ systems. 2. Be familiar with the different types of biopsy tools. 3. Be familiar with the different specimen retrieval methods.

Introduction Flexible endoscopy is an essential skill set for the general surgeon. Understanding the key principles to safe and effective biopsy techniques and retrieval methods is a valuable diagnostic K. A. K. Ifuku University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA S. Che · D. J. Mikami (*) University of Hawaii, Department of Surgery, Honolulu, HI, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_10

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tool and allows for tissue diagnosis in a minimally invasive fashion. This chapter will cover the tools and techniques necessary for safe and effective endoscopic tissue sampling.

Endoscopic Instruments Biopsy Forceps Biopsy forceps are the most commonly used devices for tissue sampling. They are used for various indications and endoscopic procedures and are available in a variety of sizes, lengths, and diameters. Single-bite cold-biopsy forceps that take a single sample at a time are the standard. The forceps’ jaws can be round, oval, elongated, fenestrated, smoother, and serrated. The addition of a needle-spike in the center of the biopsy forceps enables two biopsies to be taken without removing and reinserting forceps that effectively enhance direct lesion sampling, stabilize of the forceps cups, and provide deeper tissue penetration. “Jumbo” or large-capacity forceps open up two to three times the span for standard forceps to sample a larger surface area but do not always achieve a greater depth [1]. Large-capacity forceps require the use of a biopsy channel that is 3.6 mm or greater, whereas standard forceps can pass through a 2.8 mm channel. Multiple bite forceps can take four specimens at a time. Biopsy forceps with monopolar electrocautery is named hot biopsy forceps. They were originally developed for simultaneous tissue biopsy and hemostasis in the setting of hemostasis during biopsy or treatment of gastrointestinal (GI) bleeding [2]. See Fig. 10.1 [3].

Snares Endoscopic snares are most often used to resect GI polyps. However, they can be employed to snare larger biopsy

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Figure 10.1  Endoscopic biopsy forceps. (Used with permission of SAGES and Springer Nature from Maera and Narula [3])

samples compared to forceps using lift and cut, suction and cut, and EMR techniques. Snares employ metal wires in loop shapes to be used with or without electrosurgical energy to resect flat or pedunculated polyps The snare is loaded into the plastic catheter and pushed through the endoscopic working channel. Once open, it will expand to a round or oval shape. Once the snare circumferences the tissue sample, an assistant can close the handles and retrieve the specimen. Retrieval can be facilitated with the use of a Roth net attached to the rim of the snare for atraumatic removal. The material used can be monofilament or braided wires and come in different sizes and shapes. The snare itself can be single or multiuse. See Fig. 10.2 [3].

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Figure 10.2 Endoscopic snare. (Used with permission of SAGES and Springer Nature from Maera and Narula [3])

Brushes Endoscopic cytology brushes can sample tissue in the lumen of the GI tract and pancreatic and biliary ducts. The cytological samples are placed in cytological solutions or glass slides. The brush tip with a sheath is inserted through a catheter with or without a guide wire. The variations of cytology brushes involve size, stiffness, wire or non-wire guided, single or multi-lumen, and with or without flexible guide tip. See Fig. 10.3 [3].

Needle-Based Aspiration Hollow-bore needles with suction are another mechanism for obtaining cytological tissues, getting tissue samples from pancreaticobiliary lesions and lymph nodes or neoplasms around

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Figure 10.3  Endoscopic cytology brush. (Used with permission of SAGES and Springer Nature from Maera and Narula [3])

the upper GI tract, or to puncture and drain an abscess or infected pancreatic cyst. The most common use of this method is with EUS for visualization. FNA with a guide wire during ERCP is not used commonly. Aspiration can disrupt the quality or the quantity of the specimen that is able to be procured. Constant vacuum suction can disrupt the specimen. Without the suction, samples are often inadequate for more than cytology despite multiple passes.

Organ-Specific Techniques Flexible endoscopic tissue sampling is an essential procedure in the diagnosis of a variety of pathology along the GI tract. Upper GI endoscopy (Esophagogastroduodenoscopy or EGD) can be used to obtain mucosal biopsies along the esophagus, stomach, and duodenum as well as cellular aspirates from

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the pancreaticobiliary system. Lower GI endoscopy is used in the screening and diagnosis of diseases of the colon and rectum.

Esophagus  astroesophageal Reflux Disease (GERD) G and Its Complications In GERD, upper endoscopy is not routinely performed. EGD is indicated in patients who present with alarming features of bleeding, weight loss, anorexia, dysphagia, and those with GI cancer in first-degree relatives. However, there exists no protocol for the random biopsy of normal-appearing mucosa in GERD. Endoscopy is important in detecting complications of chronic disease that can lead to ulceration of the distal esophagus and metaplasia, predisposing individuals toward the development of esophageal cancer. Targeted biopsy of irregular mucosa is important in the identification of complications of GERD.  Barrett’s esophagus is the squamocolumnar metaplasia of the esophageal mucosa and predisposes individuals to a 20-fold increased risk of developing esophageal adenocarcinoma. Patients with Barrett’s are at increased risk for developing esophageal adenocarcinoma. Lesions suspicious for Barrett’s esophagus described as tongues of salmon-colored mucosa are encountered. Current guidelines, including those of the Seattle protocol, recommend that tissue samples should be obtained only when disease extends more than 1  cm proximal to the gastroesophageal junction and not in short segment Barrett’s (50, Caucasian race, central obesity, current or past smoking habit, and a first-degree relative with Barrett’s esophagus or esophageal

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adenocarcinoma. When Barrett’s is diagnosed, it should be surveyed due to its malignant potential. Surveillance includes four quadrant biopsies at every 2  cm every 3–5  years in patients without dysplasia. In those with known low-grade dysplasia, screening should include four quadrant biopsies at 1  cm interval every 6–12  months. The American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) guidelines differ in the screening of Barrett’s with high-grade dysplasia. ACG recommends therapeutic interventions in those with high-grade dysplasia, while AGA recommends screening every 3 months in those who do not receive ablation [5, 6]. The sensitivity of detecting early-­ stage cancer can be improved with the use of advanced endoscopy such as chromoendoscopy or magnification endoscopy [7]. In the setting of lesions suspicious for malignancy, endoscopic biopsy of six or more sites reaches a diagnostic yield of 100%. Biopsy of necrotic or fibrotic tissues should not be done. Furthermore, brushings and cytology can be helpful in near obstructing lesions. When these sampling techniques fail, endoscopic ultrasound and fine-needle aspiration can be performed [8].

Eosinophilic Esophagitis Tissue biopsy is also used to diagnose eosinophilic esophagitis and infectious esophagitis. Eosinophilic esophagitis can cause dysphagia and food impaction and can be seen in more than 1:1000 people. Its diagnosis is based on histologic count of more than 15 eosinophils per high powered field. Current recommended biopsy pattern includes two to four samples from both the proximal and distal esophagus [9]. Samples from the stomach antrum and duodenum may help to identify eosinophilic esophagitis from the eosinophilia sometimes caused by GERD [10]. Infectious esophagitis is caused by opportunistic infections in the immunosuppressed and those infected with various pathogens. Viral infections from human immunodeficiency virus (HIV), cytomegalovirus (CMV), and human herpes

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virus (HHV) cause ulcerated lesions. Diagnosis is dependent on polymerase chain reaction (PCR) analysis of endoscopic biopsies. At least three samples should be obtained from the base of the ulcers in suspected CMV infections and from the edge of the ulcers in suspected HSV infections. These are best diagnosed with PCR. Diagnosis of suspected HSV lesions is obtained from biopsies at the ulcer edge. Multiple biopsies of random sites and at least three samples should be obtained from the base of the ulcers. Candida infections should be diagnosed with multiple biopsies of the grossly abnormal yellow plaques [11, 12].

Stomach Helicobacter pylori Infection Endoscopic biopsies of the stomach are important in the diagnosis of Helicobacter pylori (H. pylori) infections. H. pylori is found in half to two-thirds of the world’s population. Patients with H. pylori infections often present with symptoms of dyspepsia and often go through either empiric acid suppression therapy, noninvasive testing such as urease breath test, stool antigen testing, and antibody-based testing or undergo early endoscopy [13]. Endoscopy for dyspepsia is indicated in those who present with alarming features which include age >50, first-degree relative with an upper GI malignancy, hematemesis, anemia, dysphagia, or persistent vomiting. In comparison to noninvasive methods, endoscopy can not only diagnose H. pylori in the setting of normal-appearing mucosa but can also identify complications of chronic infection. Rapid urease testing of tissue samples is a highly economic, sensitive, and specific method for diagnosing the presence of H. pylori. Typically, one to two biopsies, 5  cm proximal to the pylorus on the lesser curve near the angularis or on the greater curvature opposite the angularis, should be obtained. However, PPI use may decrease the sensitivity of urease testing, and, ideally, any

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acid suppression therapy should be discontinued for 2 weeks before endoscopy. When urease testing is negative, tissue biopsies should be sent for histologic diagnosis of H. pylori infection. Adequate histologic sampling can be obtained either from a three-biopsy protocol or a five-biopsy protocol. The three-biopsy protocol includes one sample from the angulus corpus–antrum junction, one from the greater curvature of the corpus, and one from the greater curvature of the antrum. The five-biopsy protocol includes two samples from the antrum (one 2–3 cm from the pylorus lesser curvature and one 2–3 cm from the pylorus greater curvature), two samples from the corpus (one 8 cm from the cardia lesser curvature and one 8  cm from the cardia greater curvature), and one from the angularis [12]. More recently, PCR testing of biopsy samples has become a popular and effective method for diagnosis of H. pylori infection [14]. Early diagnosis and eradication of H. pylori infection can help to prevent complications of chronic infection. H. pylori is responsible for the pathogenesis peptic ulcer disease (PUD), gastritis, mucosal-associated lymphoid tissue (MALT) lymphoma, gastric polyps, and gastric adenocarcinoma. It is responsible for more than 80% of PUD and is indicated in 75% of all non-cardia gastric cancers. On endoscopy, those with peptic ulcer disease can present with either benign-appearing ulcers (smooth rounded edges with a flat base) or malignant-appearing ulcers (nodular irregular edges). However, macroscopic appearance, as well as histology from single biopsies, can often miss underlying malignancies. As a result, it is recommended that more than eight biopsies from the base and edges of gastric ulcers be taken to rule out gastric carcinoma with adequate sensitivity [11]. MALT lymphoma is a rare B-cell lymphoma associated with H. pylori infection. On endoscopy, there are nonspecific changes. Diagnostic sampling should include two biopsies from each of the stomach antrum, greater curvature, lesser curvature, and fundus. This tissue samples can be analyzed histologically and with PCR.  More recently, narrow band

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imaging has been used to identify the tree-like appearance of blood vessels associated with MALT lymphoma to allow for more targeted biopsies [15]. Chronic infection from H. pylori can also lead to environmental metaplastic atrophic gastritis (EMAG). Those with risk factors including a family history should undergo a 12-biopsy protocol, including one biopsy in each quadrant of the antrum, two in the angularis, four in the body, and two in the cardia [11]. H. pylori and chronic PPI use can also be associated with the development of hyperplastic polyps and adenomas that have low malignant potential. However, biopsies should be completed to rule out possible dysplasia or malignancy. All adenomatous polyps, fundic gland polyps greater than 10  mm, and hyperplastic polyps greater than 5 mm should be removed [11, 12].

Duodenum Celiac disease is an immune-mediated reaction to dietary gluten that is the most common cause of malabsorption. Exposure to gluten leads to injury of the small intestine and can not only cause vague GI symptoms such as diarrhea, abdominal pain, and bloating but also may present with sequelae of malabsorption. While anti-celiac antibodies, immunoglobulin A, and anti-tissue transglutaminase antibodies are detectable, biopsies of the duodenal mucosa are important in confirming the diagnosis. Diagnostic endoscopy is indicated when celiac disease is suspected based on clinical signs, symptoms, laboratory findings, or family history of celiac disease. Biopsies should be conducted with the patient on a gluten-containing diet. Usually, one to two biopsies of the duodenal bulb and at least four biopsies of the distal duodenum are recommended to confirm the diagnosis of celiac disease. Once diagnosed, endoscopic sampling is also helpful in monitoring cases of celiac disease refractory to a gluten-­ free diet [16].

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Pancreas and Bile Ducts Endoscopic retrograde cholangiopancreatography (ERCP) is the primary modality for access to the pancreaticobiliary system. ERCP allows for visualization, diagnostic tissue sampling, and therapeutic interventions that address the concerns of benign or malignant biliary strictures and pancreatic masses. The type of tumor, primarily in the cut or outside compression, and the location of the tumor (distal or proximal) affect the efficacy of the diagnostic method. Brush cytology, EUS FNA, forceps biopsy, bile aspiration, and pancreatic duct scraping can each be used to obtain cytological samples of varying degrees of sensitivity and usually high specificity. Brush cytology is the most commonly used for ERCP tissue sampling. Studies suggest sensitivity around 45% and specificity of 99% [17]. Endoscopic FNA has reported specificity between 76% and 83% with 97% and 100% sensitivity [18]. Similarly, forceps biopsy has a sensitivity of 48% [17]. Scraping of the pancreatic duct for cytological samples is very effective, with sensitivities in the 90–97% [19]. At this time, the question of how to increase the sensitivity of these processes can be addressed with better proficiency of different sampling techniques, doing more than one method at a time, the style of the instrument that is used, and the methods by which cells are collected for cytopathologists.

Colon and Rectum Screening for colorectal cancer and identification of premalignant polyps is the most common indication for colonoscopy. There exist well-known protocols for the initiation of screening colonoscopy in normal risk individuals as well as those with a family history of colorectal cancer, familial adenomatous polyposis, and hereditary nonpolyposis colorectal cancer [20]. These guidelines also document the interval between screening colonoscopies when polyps of varying clinical significance are found [21]. Typically,

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screening starts at age 50 with interval colonoscopies completed every 10 years when no suspicious lesions were found and repeat colonoscopy every 3–5  years when multiple polyps or high-­risk polyps are found. Most commonly, polyps can be sessile or pedunculated and sampled using either cold biopsy forceps or snare biopsy. Newer techniques for detecting polyps include the use of narrow band imaging and magnification endoscopy. Advances for complete removal of larger lesions include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) which include lifting the lesion off the submucosal space to aid in resection [22]. Colonoscopy also plays an integral role in the diagnosis of inflammatory bowel disease (IBD). Those with suspected polyps should undergo ileo-colonoscopy with two or more biopsies in five locations which include the terminal ileum, ascending colon, transverse colon, sigmoid colon, and rectum. Samples from both grossly normal-appearing and abnormal-­ appearing mucosa should be completed. In those with confirmed IBD, surveillance should be conducted to assess for development of malignant lesions. Surveillance should begin 8–10  years after the diagnosis of pancolitis and 12–15  years after the diagnosis of left-sided colitis. Protocols suggest four quadrant biopsies every 10 cm from the cecum to the rectum with a minimum of 33 biopsy sites. Sampling every 5  cm should be considered for the rectum and sigmoid due to the increased risk of cancer [11, 12].

Summary Endoscopy is integral in the diagnosis of a variety of diseases along the GI tract. Tissue sampling is completed using a variety of techniques and instruments that make endoscopy and biopsy safe and reliable. There exist many protocols to ensure adequate sensitivity and diagnostic yield. Newer technologies help with both visualization of lesions as well as appropriate resection for sampling.

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Pearls and Pitfalls

1. Each endoscopic instrument has a specific retrieval method in order to successfully obtain tissue samples. 2. The indication for endoscopic tissue sampling should guide the selection of appropriate instrument. 3. Monopolar electrocautery should be avoided in obtaining tissue samples. 4. Endoscopic snares are useful in extracting pedunculated lesions. 5. Endoscopic brushes and needle aspiration are integral parts in obtaining cytology for pancreaticobiliary lesions. 6. Each organ system and disease requires a certain yield from tissue biopsy for adequate screening and diagnosis of disease.

References 1. Faigel DO, Eisen GM, Baron TH, Dominitz JA, Goldstein JL, Hirota WK, et  al. Tissue sampling and analysis. Gastrointest Endosc. 2003;57(7):811–6. 2. Gilbert DA, DiMarino AJ, Jensen DM, Katon R, Kimmey MB, Laine LA, et al. Status evaluation: hot biopsy forceps. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee. Gastrointest Endosc. 1992;38(6):753–6. 3. Maera MP, Narula VK. Endoscopic tools: instruments. In: Kroh M, Reavis KM, editors. The SAGES manual: operating through the endoscope. Cham: Springer; 2016. 4. Loughrey MB, Johnston BT.  Guidance on the effective use of upper gastrointestinal histopathology. Frontline Gastroenterol. 2014;5(2):88–95. 5. American Gastroenterological Association, Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ.  American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140(3):1084–91.

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6. Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol. 2016;111(1):30–50; quiz 51. 7. Meves V, Behrens A, Pohl J. Diagnostics and early diagnosis of esophageal cancer. Viszeralmedizin. 2015;31(5):315–8. 8. Wang KK, Wongkeesong M, Buttar NS.  American Gastroenterological Association technical review on the role of the gastroenterologist in the management of esophageal carcinoma. Gastroenterology. 2005;128(5):1471–505. 9. Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA, et  al. ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol. 2013;108(5):679–92; quiz 693. 10. Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128(1):3–20.e6; quiz 21–2. 11. Peixoto A, Silva M, Pereira P, Macedo G.  Biopsies in gastrointestinal endoscopy: when and how. GE Port J Gastroenterol. 2016;23(1):19–27. 12. ASGE Standards of Practice Committee, Sharaf RN, Shergill AK, Odze RD, Krinsky ML, Fukami N, et al. Endoscopic mucosal tissue sampling. Gastrointest Endosc. 2013;78(2):216–24. 13. ASGE Standards of Practice Committee, Shaukat A, Wang A, Acosta RD, Bruining DH, Chandrasekhara V, et al. The role of endoscopy in dyspepsia. Gastrointest Endosc. 2015;82(2):227–32. 14. Wang YK, Kuo FC, Liu CJ, Wu MC, Shih HY, Wang SS, et  al. Diagnosis of Helicobacter pylori infection: current options and developments. World J Gastroenterol. 2015;21(40):11221–35. 15. Nonaka K, Ohata K, Matsuhashi N, Shimizu M, Arai S, Hiejima Y, et al. Is narrow-band imaging useful for histological e­ valuation of gastric mucosa-associated lymphoid tissue lymphoma after treatment? Dig Endosc. 2014;26(3):358–64. 16. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA, American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013;108(5):656–76; quiz 677. 17. Navaneethan U, Njei B, Lourdusamy V, Konjeti R, Vargo JJ, Parsi MA.  Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures:

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a systematic review and meta-analysis. Gastrointest Endosc. 2015;81(1):168–76. 18. Sadeghi A, Mohamadnejad M, Islami F, Keshtkar A, Biglari M, Malekzadeh R, et  al. Diagnostic yield of EUS-guided FNA for malignant biliary stricture: a systematic review and meta-­ analysis. Gastrointest Endosc. 2016;83(2):290–8.e1. 19. Uehara H, Tatsumi K, Masuda E, Kato M, Kizu T, Ishida T, et al. Scraping cytology with a guidewire for pancreatic-ductal strictures. Gastrointest Endosc. 2009;70(1):52–9. 20. Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, et  al. Colorectal cancer screening: recommendations for physicians and patients from the U.S.  Multi-­ Society Task Force on Colorectal Cancer. Gastroenterology. 2017;153(1):307–23. 21. Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR.  Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-­ Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143(3):844–57. 22. Yoshida N, Yagi N, Inada Y, Kugai M, Yanagisawa A, Naito Y.  Therapeutic and diagnostic approaches in colonoscopy, endoscopy of GI tract, in endoscopy of GI tract. In: Amornyotin S, editor. Endoscopy of GI tract. London: IntechOpen; 2013.

Chapter 11 Advanced Endoscopic Tissue Resection Methods: Radiofrequency Ablation (RFA), Endoscopic Mucosal Resection (EMR), Endoscopic Submucosal Dissection (ESD), and Endoscopic Full Thickness Resection (EFTR) Bailey Su, Rhys Kavanagh, Peter Nau, and Michael B. Ujiki

B. Su (*) University of Chicago, Department of Surgery, Chicago, IL, USA e-mail: [email protected] R. Kavanagh University of Iowa Hospitals and Clinics, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA P. Nau Carver College of Medicine, University of Iowa, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_11

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Learning Objectives

1. Describe the different pathology amenable to advanced endoscopic techniques. 2. Discuss the indications and essential steps of radiofrequency ablation of Barrett’s esophagus. 3. Discuss the critical steps and characteristics of endoscopic mucosal resection and endoscopic submucosal dissection. 4. Introduce the endoscopic full thickness resection technique.

Background Management of gastrointestinal lesions has changed dramatically with the development of advanced endoscopic techniques. Patients who previously would have undergone esophagectomy for superficial lesions are now undergoing an outpatient procedure with the same disease-free survival and mortality, but with significantly lower complication rates. These advanced endoscopic techniques include radiofrequency ablation (RFA), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and ­endoscopic full thickness resection (EFTR). Herein is a discussion of the different techniques and diverse pathology which can be addressed using these advanced endoscopic therapies.

M. B. Ujiki Division of Gastrointestinal and General Surgery, NorthShore University HealthSystem, Department of Surgery, Evanston, IL, USA University of Chicago Pritzker School of Medicine, Department of Surgery, Chicago, IL, USA

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Pathology Suitable to Endoscopic Approaches Esophagus Barrett’s Esophagus Barrett’s esophagus (BE) describes the process by which the normal squamous epithelial lining of the esophagus changes to columnar lined epithelium. Risk factors for BE include GERD, obesity, male sex, Caucasian ethnicity, age, and smoking. A diagnosis of GERD confers a 10–15% risk of BE [1]. The rate that BE progresses to adenocarcinoma (AC) has been quantified in large population-based studies as being 3.86 cases per 1000 per year (~0.2–0.5% per year) in BE without dysplasia, 7.66 cases per 1000 per year (~0.7% per year) in low-grade dysplasia (LGD), and 146 cases per 1000 per year (~7% per year) in high-grade dysplasia (HGD) [1, 2]. Significant effort has been invested into finding treatment options for Barrett’s-associated dysplasia to prevent the progression to AC. To date, endeavors have focused on less invasive options to stave off cancer presentation and avoid the morbidity of an esophageal resection. Endoscopic interventions that have come to the forefront are resection strategies such as EMR and ESD and ablation strategies such as RFA.  Currently, RFA is not recommended in patients with nondysplastic BE due to low rates of progression [3]. In cases of non-nodular BE and LGD or HGD, ablative therapy is recommended because it is effective in eradicating dysplasia and decreasing risk of progression [3–8]. Any patient with nodular BE should undergo EMR to obtain optimal histopathological staging, and subsequent ablative therapy should also be performed to eradicate all intestinal metaplasia [1]. Similarly, individuals who have had T1a lesions resected to negative margins by EMR or ESD should also have endoscopic ablation of their remaining BE [9].

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Esophageal Cancer In 2012, there were 456,000 new cases and 400,000 deaths related to esophageal cancer worldwide. Squamous cell carcinoma (SCC) is more commonly seen in Asia, whereas AC incidence is on the rise in America and Northern Europe. The presence of nodal metastasis is a contraindication to endoscopic intervention; therefore, assessing the risk of nodal metastasis is paramount to determine a patient’s candidacy for endoscopic resection. The risk of nodal metastases for mucosal AC (T1a) is around 1–2% [10]. For squamous cell cancer, the risk of lymph node involvement is almost zero for T1am1 or m2, but increases to 8–18% for T1am3 lesions [11]. Therefore, endoscopic resection has become the gold standard in management of most T1a lesions. Tumors extending to the muscularis propria and beyond are not amenable to endoscopic resection. Once a lesion is deemed amenable to endoscopic resection, decision to perform EMR or ESD is usually based on size. Lesions >15–20 mm should be treated with ESD.  In general, ESD has been shown to achieve a higher R0 resection rate for early esophageal tumors; however, it is technically more challenging and comes with higher risk of stricture [12, 13].

Stomach Endoscopic resection is accepted as a treatment option for early gastric cancer, particularly those with negligible risk of lymph node metastasis. According to the European Society of Gastrointestinal Endoscopy (ESGE), lesions that should be considered for endoscopic resection because of very low or no risk of lymph node metastasis are summarized in Fig.  11.1 [11, 14]. ESD has been shown to result in higher rates of R0 resection and decreased risk of recurrence albeit at the expense of longer procedure times and higher risk of perforation [14].

Chapter 11.  Advanced Endoscopic Tissue Resection… Dysplasia Intramucosal cancer

Histology

Any size

179

Submucosal cancer

Ulcer

Ulcer

SM1

(−)

(+)

( 500 µm) Any depth

2 cm > 2 cm

3 cm > 3 cm

3 cm

SM 2

> 3 cm

Differentiated Undifferentiated

Absolute indication for endoscopic resection Expanded indication for endoscopic resection Surgery

Figure 11.1 Summary of indications for endoscopic resection of gastric pathology. (Modified with permission of Springer Nature from Gotoda [14])

Colon The use of advanced endoscopic resection in the colon is not as well studied as those in the esophagus and stomach. These procedures, especially ESD, are technically more challenging in the colorectum. Furthermore, issues with practice environment, lack of experience, poor reimbursement, and fear of complications have prevented widespread adoption in Western countries. The majority of superficial pedunculated lesions or sessile lesions 10 mm but 20 mm or with features concerning for submucosal invasion, ESD or surgery should be considered. For patients with superficial submucosal invasion (  50  years old, symptom relief following a single treatment, and diminished LES pressure immediately following injection [5]. Given the modest efficacy and frequent LES architectural distortion, many providers reserve botulinum toxin for patients not suitable for myotomy or for whom the treatment response aids in diagnosis.

Pneumatic Dilation Mechanical disruption of the lower esophageal sphincter is the most effective treatment for achalasia. Pneumatic dilation

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(PD) entails the placement of a rigid balloon across the esophagogastric junction (EGJ) under fluoroscopic guidance [1]. Typical achalasia balloon diameters include 30, 35, and 40 mm. Once in place, the balloon is connected to a handheld manometer and filled per device specifications, with typical intra-bag pressures ranging from 5 to 8 PSI. Clinical indicators of a successful dilation include fluoroscopic obliteration of the balloon waist and mucosal disruption visible on EGD. Many studies have examined the efficacy of PD as a primary treatment for achalasia (Table  13.1). The European Achalasia Trial [7, 11] is a robust prospective comparison of two commonly employed achalasia treatments  – PD and laparoscopic Heller myotomy with Dor fundoplication. Patients with newly diagnosed achalasia were randomized to a treatment and followed with serial clinical and physiologic testing for 5 years. For the majority of patients randomized to PD, treatment entailed an initial dilation to 30  mm followed by a second dilation to 35  mm 1–3  weeks later. Patients who had persistent or recurrent symptoms were Table 13.1  Select randomized clinical trials with treatment for achalasia Report Treatment Follow-up (year) Patients arms (months) Moonen 201 PD vs. 76 (2016) [7] LHM

PD as a primary

Persson (2015) [8]

53

PD vs. LHM

82

Failure rate: 36% PD, 8% LHM (p = 0.02)

Novais (2010) [9]

94

PD vs. LHM

3

Clinical success: 74% PD, 88% LHM (p = NS)

Kostic (2007) [10]

51

PD vs. LHM

12

Failure rate: 24% PD, 4% LHM (p = 0.05)

Results Clinical success: 82% PD, 84% LHM (p = NS)

Abbreviations: LHM laparoscopic Heller myotomy and partial fundoplication, PD pneumatic dilation, NS not significant

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allotted two additional dilation sets (35 and 40 mm dilations spaced 2 weeks apart) before qualifying as a treatment failure. Clinical success was gauged with the most commonly used achalasia symptom scale, the Eckhart score. A score ≤ 3 was defined as a success. At the conclusion of the European Achalasia Trial, there was no significant difference between the clinical success rates of laparoscopic Heller myotomy with Dor fundoplication and PD (84% and 82%, respectively). Secondary outcomes, including the rate of treatment failures, basal LES pressure, and esophageal emptying via barium e­ sophagography, were also similar [7]. However, 25% of patients in the PD arm required additional dilation sets for persistent or recurrent symptoms. Moreover, patients in the laparoscopic Heller myotomy arm were not treated for recurrent symptoms, which likely altered the long-term clinical success rate. Regardless of its limitations, this well-designed study firmly supports the use of PD as a primary treatment for achalasia. A key feature of PD therapy is patient selection. Recurrent symptoms after initial PD are more likely to occur in patients who are male, less than 40 years old, have pretreatment daily chest pain, or have pretreatment barium retention >5 cm [11, 12]. Achalasia subtype is also of interest, with Type III patients faring considerably better with surgical myotomy than PD. In one representative study, clinical success rates at a minimum of 2-year follow-up were 86% and 46% in the laparoscopic Heller myotomy and PD groups, respectively [13]. Thus, patient selection remains vitally important to provide achalasia treatment that is effective, safe, and durable.

Peroral Esophageal Myotomy Surgical division of the lower esophageal sphincter is an important aspect of achalasia treatment. Traditional techniques include the Heller myotomy, wherein the outer longitudinal and inner circular muscle fibers of EGJ are completely divided. The myotomy is coupled with a partial fundoplication

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to impart a modest anti-reflux barrier. The procedure is most often accomplished via an open or minimally invasive abdominal approach. Patients with prior foregut surgery and/or a shortened esophagus may require a thoracic approach. Heller myotomy provides long-term symptom relief to over 80% of patients with a 10–30% rate of postoperative GERD [7]. In 2010, Inoue and colleagues [14] described a novel myotomy technique based on the principles of endoscopic submucosal dissection. POEM has gained considerable traction since that time and stands as an important tool in the modern achalasia treatment armamentarium. Robust short-­ term data support the efficacy and safety of POEM, and encouraging long-term data are now emerging in the literature (Table  13.2). Unfortunately, existing comparisons of POEM to Heller myotomy are mostly single-institution studies powered with historical controls, with the results of multi-­ institutional prospective trials forthcoming. POEM is utilized by surgeons and gastroenterologists with advanced endoscopic skills. Although the technical aspects of POEM are similar to an endoscopic mucosal discussion, most practitioners obtain additional training in the form of handson courses and animal labs. A proctor with considerable ­ POEM experience should observe a novice practitioner’s first independent case. Several studies have identified a learning curve of 15–60 cases, after which procedural times and complication rates are comparable to experienced physicians [20]. The procedure typically takes place in an operating room or an advanced endoscopy suite. Following the induction of general endotracheal anesthesia, the esophagus is examined under carbon dioxide insufflation and cleared of any residual debris. The point of entry is based on the approach (anterior or posterior) and expected myotomy length, the latter of which usually ranges from 8 to 12  cm. Specifically, most myotomies incorporate 4–6 cm of distal esophagus, the entire lower esophageal sphincter, and 2–3 cm of the gastric cardia. Patients with Type III or spastic achalasia require an extended proximal myotomy to divide affected segments. Pre-­ procedural high-resolution manometry is especially useful for this purpose.

45

500

Chen (2015) [18]

Inoue (2015) [19]

>36

24

29 91% (386/423)

100% (45/45)

79% (62/79)

92% (103/112)

24% (45/191)

–

–

40% (27/68)

a

Abbreviations: EGJ esophagogastric junction, GERD gastroesophageal reflux disease Eckardt score ≤ 3 b Endoscopic evidence of esophagitis or positive pH study

80

Werner (2016) [17]

28

25 vs. 12

25 vs. 11

32 vs. 10

31 vs. 12

112

Hungness (2016) [14]

13% (2/16)

23 vs. 9

83% (19/23)

36

Teitelbaum (2018) [16]

65

EGJ relaxation pressure (mmHg) (pre vs. post) 28 vs. 12

Table 13.2  Reports with moderate- and long-term POEM outcomes Follow-up Clinical Report (year) Patients (months) successa Objective GERDb Li (2018) [15] 564 49 87% (366/420) 17% (58/341)

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a

d

b

215

c

e

Figure 13.2  Endoscopic images illustrating the fundamental steps of POEM. (a) Creation of a submucosal wheal. (b) Mucosotomy. (c) Creation of submucosal tunnel. (d) Myotomy. (e) Clip closure of mucosotomy

After the point of entry is determined, a submucosal wheal is raised with a saline-based dye solution. A 1–2 cm mucosotomy is made with an electrocautery knife, and the endoscope is introduced into the submucosal space (Fig. 13.2a–e). A beveled, translucent endoscopic cap is employed for maneuvering and blunt dissection. Once inside the submucosal space, the connective tissue is divided under direct vision. Periodic instillations of dye and blunt endoscopic dissection augment electrocautery to this end. Other methods of submucosal tunneling include the passage of a through-the-scope dilating balloon into the submucosal space [15]. EGJ is identified by palisading vessels and a sudden narrowing in the mucosa– muscle interface. Completion of the tunnel is confirmed via endoscopic measurements and visualization of submucosal blue dye in the proximal stomach during retroflexion.

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A myotomy is subsequently fashioned within the submucosal tunnel. Most endoscopists proceed in a proximal to distal fashion, while others divide the muscle in a retrograde manner originating in the stomach [15]. Adequacy of the myotomy is confirmed by the gross intraluminal appearance of the EGJ and endoscopic measurements. Common ­intra-­procedural challenges include submucosal tunnel bleeding and capnoperitoneum. The former is best addressed with prophylactic maintenance of systolic blood pressures less than 120 mmHg. Pressure and coagulation forceps are useful reactionary measures. Capnoperitoneum is addressed with insertion of a Veress needle into the abdominal cavity. POEM has demonstrated excellent short-term results, with 90–95% of patients reporting continued symptom relief at 2-year follow-up [20]. Success rates remain well over 85% at 5-year follow-up and are comparable to laparoscopic Heller myotomy [21]. Indeed, there is evidence that patients with Type III achalasia may fare better with POEM as compared to laparoscopic Heller myotomy, likely due to the former’s capacitance for a proximal extended myotomy [13]. The most feared side effect of POEM is GERD, which occurs in 30–50% of patients [22]. Fortunately, the vast majority of cases are controlled with a daily proton pump inhibitor. Treatment options for symptom persistence or recurrence after POEM include PD, repeat endoscopic myotomy via an alternative orientation, and Heller myotomy.

Peroral Pyloromyotomy Gastroparesis is a heterogeneous disease characterized by abnormal gastric motility and diminished emptying. Patients present with a variety of symptoms including nausea, early satiety, bloating, abdominal pain, vomiting, and weight loss. The majority of cases are due to diabetes and deliberate/iatrogenic injury of the vagus nerve. A significant portion of cases are idiopathic. Medical treatments are limited and include the restoration of normoglycemia and metoclopramide [23]. Surgical treatments, such as gastric electrical

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stimulation and laparoscopic pyloromyotomy, offer moderate relief at the expense of typical operative risks [24, 25]. Not long after the introduction of POEM, a pyloromyotomy technique using similar endoscopic submucosal dissection principles was described for the treatment of gastroparesis [26]. The approach was coined gastric peroral endoscopic myotomy (G-POEM) and is alternatively known as peroral pyloromyotomy (POP). The procedure adopts fundamental steps analogous to POEM including submucosal bleb creation, mucosotomy, submucosal tunneling, and myotomy (Table  13.3). Early results in small patient samples are encouraging, with one multicenter study noting improved symptoms and objective gastric emptying in >80% of patients at 6 months follow-up [27]. The reported use of POP in patients with achalasia is limited. Iatrogenic vagal nerve injury and subsequent gastroparesis is a rare but often feared complication of surgical Table 13.3  Procedural comparison of POEM and POP POEM POP Special Transparent cap, CO2 Transparent cap, CO2 equipment insufflation insufflation Approach

Anterior or posterior wall of the esophagus

Greater or lesser curvature of the stomach

Mucosotomy length

1–2 cm

1–2 cm

Submucosal tunnel length

12–15 cm

6–8 cm

Myotomy direction

Antegrade or retrograde

Antegrade or retrograde

Myotomy length

8–12 cm

3–5 cm

Myotomy thicknessa

Selective or full thickness

Selective or full thickness

Selective circular myotomy or full thickness circular and longitudinal myotomy

a

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myotomy, especially when performed in the context of previous esophageal surgery. Patients may present with bloating, abdominal pain, and/or recurrent dysphagia following Heller myotomy and partial fundoplication. In the absence of esophagitis, obvious wrap disruption, or significant esophageal retention, a gastric emptying study should be employed to rule out gastroparesis. Patients with delayed emptying may benefit from a pyloromyotomy, and an endoscopic approach might confer improved morbidity compared to a repeat foregut operation. POP is also useful for patients with an unclear diagnosis or for whom there are multiple contributing factors. In this context, treatments can be approached either in a stepwise fashion with interval symptom monitoring or in close succession [28]. Pearls and Pitfalls

1. The evaluation, diagnosis, and treatment of patients with achalasia are complex and necessitate a multidisciplinary approach. 2. Primary treatment with Botulinum toxin injection should be reserved for patients who are unable to undergo mechanical disruption of the LES or for whom a single treatment clarifies an otherwise ambiguous diagnosis. 3. The key to successful treatment with PD is patient selection. 4. POEM provides durable symptom relief that is comparable to laparoscopic Heller myotomy. 5. In lieu of repeat foregut surgery, some providers may utilize POP in patients with postoperative iatrogenic gastroparesis.

References 1. Pandolfino JE, Gawron AJ.  Achalasia: a systematic review. JAMA. 2015;313(18):1841–52.

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2. Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJPM, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27(2):160–74. 3. Hoogerwerf WA, Pasricha PJ. Pharmacologic therapy in treating achalasia. Gastrointest Endosc Clin N Am. 2001;11(2):311–24, vii. 4. Annese V, Bassotti G, Coccia G, Dinelli M, D’Onofrio V, Gatto G, et  al. A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. Gut. 2000;46(5):597–600. 5. Lake JM, Wong RKH. Review article: the management of achalasia – a comparison of different treatment modalities. Aliment Pharmacol Ther. 2006;24(6):909–18. 6. Vaezi MF, Felix VN, Penagini R, Mauro A, de Moura EGH, Pu LZCT, et al. Achalasia: from diagnosis to management. Ann N Y Acad Sci. 2016;1381(1):34–44. 7. Moonen A, Annese V, Belmans A, Bredenoord AJ, Bruley des Varannes S, Costantini M, et  al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut. 2016;65(5):732–9. 8. Persson J, Johnsson E, Kostic S, Lundell L, Smedh U. Treatment of achalasia with laparoscopic myotomy or pneumatic dilatation: long-term results of a prospective, randomized study. World J Surg. 2015;39(3):713–20. 9. Novais PA, Lemme EM. 24-h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy. Aliment Pharmacol Ther. 2010;32(10):1257–65. 10. Kostic S, Kjellin A, Ruth M, Lönroth H, Johnsson E, Andersson M, et  al. Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia. Results of a randomized controlled trial. World J Surg. 2007;31(3):470–8. 11. Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med. 2011;364(19):1807–16. 12. Rohof WO, Lei A, Boeckxstaens GE.  Esophageal stasis on a timed barium esophagogram predicts recurrent symptoms in patients with long-standing achalasia. Am J Gastroenterol. 2012;108:49.

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13. Rohof WO, Salvador R, Annese V, Bruley des Varannes S, Chaussade S, Costantini M, et  al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology. 2013;144(4):718–25. 14. Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, et  al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265–71. 15. Stavropoulos SN, Modayil RJ, Friedel D, Savides T.  The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc. 2013;27(9):3322–38. 16. Teitelbaum EN, Dunst CM, Reavis KM, Sharata AM, Ward MA, DeMeester SR, et  al. Clinical outcomes 5 years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2018;32(1):421–7. 17. Werner YB, Costamagna G, Swanström LL, von Renteln D, Familiari P, Sharata AM, et  al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut. 2016;65(6):899–906. 18. Chen X, Li Q-P, Ji G-Z, Ge X-X, Xhang X-H, Zhao X-Y, et al. A 2-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy. Eur J Cardiothorac Surg. 2015;47(5):890–6. 19. Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, Minami H, et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015;221(2):256–64. 20. Hungness ES, Sternbach JM, Teitelbaum EN, Kahrilas PJ, Pandolfino JE, Soper NJ. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg. 2016;264(3):508–17. 21. Li Q-L, Wu Q-N, Zhang X-C, Xu M-D, Zhang W, Chen S-Y, et al. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc. 2018;87(6):1405–12.e3. 22. Crespin OM, Liu LWC, Parmar A, Jackson TD, Hamid J, Shlomovitz E, et al. Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc. 2017;31(5):2187–201. 23. Navas CM, Patel NK, Lacy BE.  Gastroparesis: medical and therapeutic advances. Dig Dis Sci. 2017;62(9):2231–40.

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24. Abell TL, Van Cutsem E, Abrahamsson H, Huizinga JD, Konturek JW, Galmiche JP, et  al. Gastric electrical stimulation in intractable symptomatic gastroparesis. Digestion. 2002;66(4):204–12. 25. Shada AL, Dunst CM, Pescarus R, Speer EA, Cassera M, Reavis KM, et  al. Laparoscopic pyloroplasty is a safe and effective first-­ ­ line surgical therapy for refractory gastroparesis. Surg Endosc. 2016;30(4):1326–32. 26. Khashab MA, Stein E, Clarke JO, Saxena P, Kumbhari V, Chander Roland B, et  al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2013;78(5):764–8. 27. Khashab MA, Ngamruengphong S, Carr-Locke D, Bapaye A, Benias PC, Serouya S, et  al. Gastric per-oral endoscopic myotomy for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2017;85(1):123–8. 28. Bapaye A, Mahadik M, Pujari R, Vyas V, Dubale N.  Per-oral endoscopic pyloromyotomy and per-oral endoscopic myotomy for coexisting refractory gastroparesis and recurrent achalasia cardia in a single patient. Gastrointest Endosc. 2016;84(4):734–5.

Chapter 14 Thermal Methods to Control Gastrointestinal Bleeding Brian J. Dunkin, Shawn M. Purnell, and John Joseph Nguyen-Lee

Learning Objectives

After reviewing this chapter, the reader will be able to 1. Describe basic principles of electrosurgery 2 . Describe the principle of coaptive coagulation 3. Compare the three classes of thermal tools available for GI bleeding 4. Describe the principles of combination therapy for GI bleeding 5. Recognize complications specific to using thermal energy in the GI tract

Introduction Bleeding in the gastrointestinal (GI) tract is a common malady that can usually be controlled with the use of therapeutic endoscopy. Once a bleeding site has been endoscopically B. J. Dunkin (*) · S. M. Purnell · J. J. Nguyen-Lee Houston Methodist Hospital, Department of Surgery, Houston, TX, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_14

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identified, there are essentially three methods used to achieve hemostasis: application of energy, mechanical control with clip or loop ligation, or injection therapy. This chapter focuses on the principles of using energy to control GI bleeding and common tools available to deliver it.

Principles of Electrosurgery Electrosurgery is the use of alternating current (AC) electricity to raise intracellular temperature in order to vaporize or coagulate tissue. Coursing AC current through tissue causes the ions within the cells of the tissue to move back and forth at the same frequency as the change in polarity of the alternating current (Fig. 14.1). This conversion of electrical energy into kinetic energy results in the buildup of heat within the cell, rapidly boiling the intracellular water, and causing the cell to explode apart. Thus, electrosurgery is the intracellular conversion of electrical energy to kinetic energy and then into thermal energy. This differentiates it from “cautery” which is the direct transfer of heat from one object to another. In order to avoid electrocuting a patient (i.e., depolarizing muscle and neural cells) when passing AC current through tissue, the electrosurgical unit (ESU) converts low-frequency AC current coming from the outlet (60  Hz in the US) into high-frequency AC current (>350 kHz) to be applied via an electrosurgical device (Fig. 14.2). Because the high-frequency current is in the same range as AM radio waves (550– 1550 kHz), the energy coming from a typical ESU is classified as radiofrequency (RF) energy. RF electrosurgical energy courses through a patient’s body at such a high-frequency that it does not cause electrocution. There are two modalities in which electrosurgical energy can be delivered to a patient – monopolar and bipolar. When using a monopolar device, energy courses from the ESU, through the device, through the patient’s body, and then back to the ESU via a dispersive electrode or “grounding pad” (Fig. 14.3a). For bipolar devices, the energy coming from the

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Figure 14.1  Alternating current causing ions in cell to rapidly move back and forth

ESU is only conducted through the tissue that is in contact with two metallic parts of the device and then back to the ESU. No grounding pad is required (Fig. 14.3b). Understanding these principles illustrates why monopolar energy may ­interfere with implanted electrical devices in the patient’s body (e.g., pacemaker, defibrillator, etc.) whereas bipolar energy is less likely to do so. The tissue effect achieved by applying electrosurgical energy to the body varies depending on a number of factors. The first is the type of electrical waveform. “Cutting” current

300,000+ Cycles

Figure 14.2  Electrosurgical Unit (ESU) converting low-frequency alternating current from outlet to high-frequency current for use in the patient

60 Cycles

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a

b

Figure 14.3 (a) Monopolar electrosurgery current pathway. (b) Bipolar electrosurgery current pathway

is a relatively low-voltage continuous waveform that results in such rapid heating of water within cells that it vaporizes, causing the cell to explode and the tissue to separate (Fig. 14.4a). “Coagulation” current is a higher voltage waveform that is not continuous (Fig.  14.4b). In fact, the typical coagulation current coming from an ESU is only “on” 6% of the time which results in lower tissue temperatures that do not destroy cellular proteins but only alter them. Depending on how coagulation current is applied, tissue can be “coagulated” (i.e., heated to a point that proteins are denatured and crosslinked while the tissues is dehydrated), or fulgurated (i.e., superficially carbonized). Current density, the amount of current per unit area coursing through tissue, is another factor that effects tissue response to electrosurgical energy. In general, the higher the current density the more significant the tissue effect. For instance, if a set amount of current from an ESU is passed

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a

Low Voltage

b High Voltage

Pure CUT

COAG

100% on

6% on 94% off

Figure 14.4  (a) Cutting current. (b) Coagulation current

through a needle where only the tip is in contact with tissue, the effect of that energy will be exuberant (e.g., rapid coagulation or cutting). However, that same amount of current is “collected” by the grounding pad which has a large amount of surface in contact with skin (i.e., low current density) and, as a result, does not cause any damage to the tissue it touches. Finally, an important concept used to achieve hemostasis in a bleeding blood vessel is called “coaptive hemostasis” or “coaptive coagulation.” Coaptive coagulation combines energy with pressure to seal blood vessels. When two walls of a blood vessel are compressed against each other and coagulation current applied, the proteins in the walls of the blood vessel cross-link resulting in adherence to each other and a cessation of blood flow (Fig. 14.5). This important principle is frequently used to achieve hemostasis when managing GI bleeding.

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Figure 14.5 Coaptive coagulation. (Used with permission of Springer Nature from Dunkin and Lyons [6])

Thermal Tools for GI Bleeding There are three classes of tools that use energy to control GI bleeding: (1) Monopolar, (2) Bipolar, and (3) Cautery. Among the most common monopolar tools are forceps. Many medical device manufacturers make monopolar forceps to be used in the GI tract and all work using the same principles (Fig. 14.6a, b). The metal tip of the forceps is connected to a wire within the shaft that is connected to the ESU. Monopolar energy is applied to the tissue grasped within the forceps. Monopolar forceps fashioned with precise tip configurations are commonly used to manage or prevent bleeding from exposed submucosal vessels after complex procedures. One such procedure is endoscopic submucosal dissection (ESD), where large portions of GI mucosa are removed down to the level of the muscularis propria, leaving behind exposed submucosal blood vessels. These vessels are coagulated pre-­ emptively to prevent post-procedure bleeding. Monopolar forceps are less commonly used to manage pathologically induced GI bleeding such as that from ulcers, diverticula, or

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b

Figure 14.6  Monopolar forceps. (a) Coagrasper hemostatic forceps (Used with permission of Olympus America, Center Valley, PA, USA); (b) Radial jaw 4 hot biopsy forceps (Used with permission of Boston Scientific, Marlborough, MA, USA)

arteriovenous malformations, because application may be mechanically difficult (e.g., bleeding from a fibrotic peptic ulcer where the tissue cannot be grasped) or risk full thickness thermal injury in thin-walled structures such as the duodenum and colon. Technically, the forceps is closed on the target vessel and electrical current applied for 1–2  seconds using an ESU setting of 60  W for thinner-walled structures (e.g., duodenum or right colon) or 80  W for thicker-walled structures (e.g., stomach or rectum) [1]. Another common monopolar device used for energy delivery in the GI tract is the argon plasma coagulator (APC). This interesting device delivers monopolar electrosurgical energy to the mucosa via an argon gas. This noncontact method of fulguration is particularly effective in managing superficial mucosal lesions such as arteriovenous ­malformations and radiation proctitis. Argon gas is electrically conductive when ionized (excited) with energy. Argon gas flows through a specialized catheter with a tungsten wire at its tip. The wire is connected to the ESU and delivers a monopolar electrical current to the cloud of argon gas, thus converting inert argon to ionized argon gas  – argon plasma (Fig. 14.7). Using APC, the mucosa can be “painted” to fulgurate larger areas without deep penetration of the tissue or

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Figure 14.7  Forward-firing argon plasma coagulation (APC) probe. (Used with permission of Springer Nature from Dunkin and Lyons [6])

disruption of the resultant coagulum. The optimal distance between the APC probe and target tissue ranges from 2 to 8 mm, and both rate of gas flow and wattage are adjusted to achieve the desired tissue effect [2]. Flexible endoscopic APC probes come in three configurations – forward, side, and radially firing. Because the APC “pumps” inert argon gas into the closed space of the GI tract, care must be taken to periodically aspirate the gas so as not to over distend the stomach or bowel. The most common bipolar device used to manage GI bleeding is called the multipolar electrocoagulation (MPEC) probe (Fig. 14.8). This device delivers electrical energy to the target tissue via adjacent electrodes (i.e., wire wraps) on its tip. Current flows from one electrode (wire wrap), through the contact tissue, and then back to the ESU via an adjacent electrode (wrap). Thus, in contrast to monopolar electrosurgery, bipolar does not require a grounding pad. The bipolar probe is used most effectively when the principle of coaptive coagulation is applied, particularly in thick-walled structures

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Figure 14.8 Multipolar electrocoagulation (MPEC) probe. (Used with permission of Springer Nature from Dunkin and Lyons [6])

like the stomach where pressure and energy application to a bleeding vessel at the base of an ulcer is unlikely to result in perforation. Low voltage is desirable to avoid desiccating tissue too quickly with resultant limited coagulation depth, and charring that may cause adherence of the probe to the tissue [3]. A standard ESU setting for the MPEC probe starts at 20  W and usually does not exceed 50  W [4]. Most MPEC probes contain an irrigation channel that can be connected to a foot-pedal controlled pump or syringe to wash away blood in the field or separate the probe from the target tissue without disrupting the coagulum. A newer technology less commonly used for GI bleeding is the Barrx™ radiofrequency (RFA) ablation system (Medtronic, Minneapolis, MN, USA). The Barrx™ focal ­catheters consist of a bipolar electrode array mounted on a paddle (Barrx™ 60 or 90 RFA focal catheters or Channel RFA catheters) or a self-adjusting balloon (Barrx™ 360 express RFA balloon catheter) (Fig.  14.9a–c). The array is applied to the target tissue and a preset amount of energy delivered (10–12 J/cm2). Similar to APC, this type of energy array is best used to treat superficial mucosal lesions such as arteriovenous malformations and radiation proctitis. Cautery can also be used to control bleeding in the GI tract using a heater probe (HP) (Fig.  14.10). The HP is a

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a

233

b

c

Figure 14.9  Bipolar electrode array catheters. (a) Barrx™ 90 Focal RFA Catheter; (b) Barrx™ Channel RFA Endoscopic Catheter; (c) Barrx™ 360 Express RFA Balloon Catheter. (All: Used with permission of Medtronic. Copyright © 2019 Medtronic. All Rights Reserved)

Figure 14.10 Heater probe. (Used with permission of Olympus America, Center Valley, PA, USA)

Teflon-coated hollow aluminum cylinder with an inner heating coil. A thermocoupling device at the tip maintains a constant temperature, and an irrigation channel is integrated into the device. In contrast to MPEC, the HP coagulates tissue

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using direct heat transfer (aka cautery). Like the MPEC probe, it is applied using the principle of coaptive coagulation, but with a set amount of energy delivery (5–30  J) per activation.

Approach to Bleeding in the GI Tract Thermal therapies for controlling GI bleeding are most effective when combined with injection therapy [5]. The typical workflow starts with identifying the site of bleeding and clearing away adherent clot. Epinephrine diluted to 1:10,000– 1:200,000 concentration is then injected into the area using a sclerotherapy needle to reduce or stop the acute bleeding (Fig. 14.11). Thermal or mechanical therapy (Chap. 15) is then applied. In peptic ulcer disease, this combination of therapy has been shown to increase the success of initial hemorrhage control and reduce the risk of re-bleeding post procedure. All monopolar and most bipolar devices rely on the operator to control energy delivery. Thus, experience and visual

Figure 14.11  Interject™ sclerotherapy needle. (Used with permission of Boston Scientific, Marlborough, MA, USA)

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Table 14.1  Recommended settings for energy devices used to stop GI bleeding Ulcer

Mallory– Weiss tear Dieulafoy

GAVE Angiodysplasia

 Power settings (W)

15–25

15–20

15–20

10–15

10–15

 Pulse duration (s)

6–14

4

8–10

1–2

1–2

 Power settings (W)

15–30

20

30

30

10–20

 Pulse duration (s)

4–5

3

4

 Power settings (W)

60–80

N/A

60–80

60–80

60–80

 Argon flow (l/min)

1–2

N/A

1–2

1–2

1–2

MPECa

Heater probe

APCb

a

MPEC multipolar electrocoagulation APC argon plasma coagulation

b

monitoring of tissue effect is important during the procedure. Table  14.1 provides guidance on application of the MPEC, heater, and APC probes for treating non-variceal upper gastrointestinal bleeding sites.

Avoiding Complications Emergently delivering energy to the site of bleeding within the closed lumen of the GI tract and while working through the instrument channel of an endoscope presents unique opportunities for complications. Such complications can generally be divided into three categories: (1) Patient factors, (2) Operator error, and (3) Tissue response.

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Proper preparation of a patient for emergency endoscopy to treat GI bleeding is multifactorial (Chap. 8). Important patient factors specifically related to energy use include the proper application of the grounding pad and management of implanted electrical devices (e.g., rhythm management devices or pain pumps). As discussed in the Principles of Electrosurgery section of this chapter, the reason why energy from the ESU does not cause tissue heating at the site of the grounding pad is due to the large surface area of the pad which greatly reduces the current density running through the tissue to which it is applied. If the pad is not in good contact with the skin (e.g., dense hair at the site of application or poor adherence due to skin character, lotions, or moisture) this can reduce the effective surface area, increase current density, and cause thermal injury at the site. Proper application of the pad prior to applying energy and monitoring the integrity of its contact with the patient’s skin throughout the procedure is critical. Monopolar electrosurgery passes alternating electrical current through the patient between an active electrode (the device) and the reference electrode (the grounding pad). Such current can interfere with implanted electrical devices. If these devices are critical to the health of the patient (e.g., a heart pacemaker or defibrillator), inadvertent activation or interference with activation can be life threatening. In general, it is best to place the grounding pad as close to the anticipated site of energy application as possible and in a manner that the path of energy does not cross the electrodes of the implanted device. Short applications of energy using the lowest power settings possible are also advised. Choosing a bipolar device or HP essentially eliminates the risk of this type of interference. Expert consultation as to the proper protection of the patient and the implanted device is recommended. Proper use of energy devices minimizes patient risk and maximizes effectiveness. One important operator error is unintentional coupling. When managing GI bleeding, this

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may happen in two ways. The first results from failure to deliver the entire conductive surface of the endoscopic instrument outside of the working channel of the endoscope and into the direct view of the endoscopist. When this occurs and energy is applied, the portion of the tool that is still within the working channel can directly couple to the tip of the scope – possibly through an insulation failure – and burn the wall of the GI tract outside of the view of the endoscopist. Thus, it is important to have the entire working area of the endoscopic device within view before applying energy. The second results from electrosurgical energy application in the area of another object capable of conducting electrical current such as a metallic clip or an opposing luminal surface of the GI tract. If the energy device is intentionally or ­unintentionally in contact with an endoscopic clip, current passing through the clip will have the highest density at the tissue gathered in the clip tip. This may result in a full thickness thermal injury with resultant perforation. Electrosurgical energy should never be applied directly to endoscopic clips, and care must be taken to avoid inadvertent direct coupling when working around them. Separate from carefully using these electrosurgical devices, managing other factors in the variable thickness, closed lumen of the GI tract is important. When possible, proper bowel preparation should be administered to minimize the presence of combustible methane gas, and argon gas frequently aspirated during the use of APC to avoid over distention or even perforation. Tissue thickness and integrity also vary in different parts of the GI tract based on anatomic location and the patient’s personal characteristics and comorbidities. In order to avoid full thickness thermal injury, energy application must be modified depending on what part of the intestinal tract is being treated and the underlying pathology. In thin-walled parts of the GI tract (e.g., duodenum or cecum), careful consideration should be given to use of alternative non-thermal strategies for managing GI bleeding that reduce the risk of full thickness perforation.

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Summary The endoscopic use of thermal methods to control GI bleeding has revolutionized the management of these challenging patients. The majority of bleeding lesions can be stopped without the need for surgery and with greatly decreased morbidity and mortality. A thorough understanding of the principles of electrosurgery and the devices used to deliver energy to the GI mucosa is critical to maximizing the likelihood of therapeutic success while minimizing complications. Pearls and Pitfalls

1. Understanding the principles of electrosurgery and cautery is critical to using thermal methods to control GI bleeding. 2. Endoscopic tools and electrosurgical units of similar class and type vary from manufacturer to manufacturer. A responsible endoscopist takes the time to thoroughly understand their tools prior to use. 3. Consider important patient factors such as the presence of implanted electrical devices and the integrity of the grounding pad site prior to using electrosurgical energy. 4. Avoid the use of electrosurgery around metallic clips. 5. Frequently aspirate the argon gas when using an APC.

References 1. Arima S, Sakata Y, Ogata S, Tominaga N, Tsuruoka N, Mannen K, et al. Evaluation of hemostasis with soft coagulation using endoscopic hemostatic forceps in comparison with metallic hemoclips for bleeding gastric ulcers: a prospective, randomized trial. J Gastroenterol. 2010;45:501–5. 2. Cipolletta L, Bianco MA, Rotondano G, Piscopo R, Prisco A, Garofano ML. Prospective comparison of argon plasma coagulator and heater probe in the endoscopic treatment of major peptic ulcer bleeding. Gastrointest Endosc. 1998;48:191–5.

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3. Morris ML, Tucker RD, Baron TH, Song LM.  Electrosurgery in gastrointestinal endoscopy: principles to practice. Am J Gastroenterol. 2009;104(6):1563. 4. Asge Technology Committee, Conway JD, Adler DG, Diehl DL, Farraye FA, Kantsevoy SV, et al. Endoscopic hemostatic devices. Gastrointest Endosc. 2009;69(6):987–96. 5. Jung K, Moon W.  Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: an evidence-based review. World J Gastrointest Endosc. 2019;11(2):68–83. 6. Dunkin BJ, Lyons CD.  Electrosurgical energy in gastrointestinal endoscopy. In: Feldman LS, Fuchshuber PR, Jones DB, editors. The SAGES manual of fundamental use of surgical energy. New York: Springer Science + Business Media; 2012.

Chapter 15 Nonthermal Methods for Control of Gastrointestinal Bleeding: Inject, Clip, Sprays Shannon J. Morales and B. Fernando Santos Learning Objectives

1. Describe the indications for use of various nonthermal methods for control of GI bleeding. 2. Describe techniques for employing these methods, including specific pointers and pitfalls. 3. Gain familiarity with the medical management of GI bleeding prior to and following endoscopic control of GI bleeding.

S. J. Morales Dartmouth-Hitchcock Medical Center, Department of Medicine, Section of Gastroenterology Hepatology, Lebanon, NH, USA Darmouth College Geisel School of Medicine, Hanover, NH, USA B. F. Santos (*) Dartmouth College Geisel School of Medicine, Department of Surgery, Hanover, NH, USA Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, NH, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_15

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Introduction Control of gastrointestinal (GI) bleeding can be achieved with both thermal techniques, such as bipolar and monopolar coagulation (Chap. 14), or nonthermal techniques, such as needle injection, hemostatic clip placement, and rubber band placement, among others. With this chapter, we will focus specifically on the nonthermal techniques. We will discuss appropriate indications for use, guide the reader through a technical approach to achieve hemostasis, and describe commonly encountered pitfalls and complications when employing these methods. Upper GI bleeding (UGIB), defined as bleeding proximal to the ligament of Treitz, accounts for roughly 300,000 hospitalizations each year in the United States (US). The mortality associated with a hospitalization for an upper GI bleed ranges widely among various reports, from 2% to 15% [1]. The vast majority of these bleeding episodes are due to peptic ulcer disease and gastroduodenal erosions, with a smaller number due to esophagitis, esophageal or gastric variceal hemorrhage, arteriovenous malformations, portal hypertensive gastropathy, Mallory–Weiss tears, malignancy, arteriovenous malformation (AVM), and other vascular lesions, such as Dieulafoy lesions (Table  15.1). Nonsteroidal anti-­ inflammatory drug (NSAID) use, alcohol consumption, and Helicobacter pylori infection are the primary drivers of upper GI bleeding. Esophagogastroduodenoscopy (EGD) plays a primary role in the evaluation and management of UGIB [2]. Lower GI bleeding (LGIB), defined as bleeding from a colonic source, accounts for approximately 225,000 hospitalizations per year in the US, and carries an overall mortality of 3.9% [1]. Etiologies of lower GI bleeding include diverticulosis, cancers/polyps, colitis, angiodysplasia, post-polypectomy, and rectal outlet bleeding (Table  15.1). Colonoscopy is the initial diagnostic modality of choice to manage lower GI bleeding [3, 4]. Small bowel bleeding is less common than either UGIB or LGIB, with etiologies including ulcers, malignancies, and angiodyplasia. Such bleeding sites are often only diagnosed

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Table 15.1  List of common etiologies of gastrointestinal bleeding and their frequencies Etiology Frequency Upper GI bleeding Peptic ulcer disease

36%

Esophagitis

24%

Gastritis

22%

Duodenitis

13%

Esophageal or gastric varices

11%

Portal hypertensive gastropathy

6%

Mallory–Weiss tear

4%

Upper GI malignancy

4%

Angiodysplasia

3%

Lower GI bleeding Diverticulosis

33%

Cancer/polyps

19%

Colitis

18%

Unknown

16%

Angiodysplasia

8%

Post-polypectomy

6%

Anorectal

4%

on imaging studies or via capsule endoscopy. Endoscopic evaluation and treatment of this entity is often more difficult, typically requiring push enteroscopy or balloon-assisted enteroscopy [5].

Initial Approach to a Bleeding Patient When patients present with signs of gastrointestinal hemorrhage, including hematemesis, melena, and hematochezia,

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early identification of the severity of the bleeding, early and aggressive resuscitation, and assessment for the likely source of blood loss are all vitally important. Risk stratification schema have been proposed but are rarely used in clinical settings. Such schema include the Glasgow–Blatchford score, the Rockall score, and AIMS65, which utilize various patient characteristics, laboratory values, and clinical factors to attempt to predict mortality in patients presenting with GI bleeding (Table  15.2) [1, 2]. Urgent evaluation with upper endoscopy (i.e., within 24  hours of presentation) is recommended in patients presenting with hematemesis; signs of hypovolemia including hypotension, tachycardia, and shock, and a hemoglobin 80

1

4

 10–25

 60–79

 12–12.9

3

 8–10

  65

1

Score 1

INR > 1.5

AIMS65 Risk factor Albumin 8 mm, or biliary dilation [11]. Patients without evidence of jaundice and a normal bile duct on ultrasound have a low (50% probability)

Strong

Intermediate (10–50% probability)

Visualized stone on ultrasound Clinical diagnosis of ascending cholangitis Total bilirubin >4 mg/dL

Dilated CBD >8 mm in a patient with an intact gallbladder Total bilirubin 1.8–4 mg/dL

Age >55 years Clinical diagnosis of gallstone pancreatitis on presentation Abnormal LFTs other than bilirubin (AST, ALT, GGT, or ALP)

Risk of choledocholithiasis based on predictors High

Intermediate

Low

1 or more very strong predictors Both strong predictors

1 strong predictor, with or without intermediate predictors 1–3 intermediate predictors

No predictors present

Adapted with permission of Elsevier from ASGE Standards of Practice Committee, Maple et al. [47] mm Millimeters, LFTs liver function tests, ALT alanine transaminase, AST aspartate transaminase, GGT gamma-glutamyl transpeptidase, ALP alkaline phosphatase

e­ ndoscopic ultrasound can be used to determine if ERCP is indicated, often in the same setting if the endoscopist is trained to perform both EUS and ERCP [7]. In addition to the clinical predictors listed in Table 18.1, anatomic variants also contribute to choledocholithiasis. A low insertion of the cystic duct into the distal third of the common bile duct or an oblique course of the CBD where it is positioned less than 45 degrees from horizontal increases the risk of choledocholithiasis. Periampullary diverticula are associated with increased diameter of the CBD and recurrent CBD stones [12].

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The approach to clearance of the common bile duct after choledocholithiasis is suspected will depend on the clinical situation. ERCP can be performed pre-, intra-, or postoperatively, or other methods of ductal clearance can be employed such as intraoperative common bile duct exploration. ERCP is successful for ductal clearance of stones in 80–90% of cases and has similar outcomes to intraoperative common bile duct exploration, so selection of the ideal approach often depends on the resources available [11]. When feasible, laparoscopic cholecystectomy with simultaneous laparoscopic CBD exploration offers a single-step approach with equivalent clearance of choledocholithiasis, morbidity, mortality, and a trend toward shorter hospital stays [13, 14]. A two-step approach with ERCP before or after laparoscopic cholecystectomy is safe but has the disadvantage of coordinating two separate procedures. Reasons for failure of ERCP to clear stones include large or impacted stones, intrahepatic stones, altered gastric or duodenal anatomy, and duodenal diverticula [11]. If ERCP is successful at clearing the CBD of stones, it is recommended for the patient to undergo cholecystectomy within a few weeks to help reduce the chances of recurrent CBD stones prior to cholecystectomy. If ERCP is unsuccessful at initial clearance of biliary stones, a stent can be placed to facilitate future clearance of the stones. If repeated attempts at endoscopic clearance of CBD stones are unsuccessful, surgical or percutaneous drainage options will need to be considered. For patients found to have a retained CBD stone postoperatively, ERCP is the treatment of choice for biliary clearance [11]. Gallstone Pancreatitis Approximately 40–70% of cases of acute pancreatitis can be attributed to gallstones [9]. Pancreatitis develops in the setting of choledocholithiasis when there is obstruction of the pancreatic duct due to external compression, inflammation, or obstruction of the common pancreaticobiliary channel. The diagnosis is supported by elevation of the serum alanine aminotransferase (ALT) >150 IU/L which has a 95% positive

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predictive value in patients with acute pancreatitis [15]. ERCP for gallstone pancreatitis is generally not necessary unless a CBD stone, increased LFTs, or cholangitis is also present [15]. Hepatolithiasis Although most biliary stones are within the gallbladder or common bile duct, stones can form primarily or migrate into the intrahepatic ducts. Hepatolithiasis may be diagnosed on ERCP, but ERCP is not the preferred modality for treatment due to the difficulty of clearing the intrahepatic ducts. Percutaneous transhepatic cholangiography is the modality of choice for clearance of intrahepatic stones, or advanced multimodal techniques such as percutaneous transcatheter lithotripsy may be required [16]. Pancreatic Stones and Strictures Pancreatic stones and strictures are usually seen in the context of chronic pancreatitis. ERCP is indicated for removal of pancreatic ductal stones or dilation of strictures and may help with pain relief [5]. ERCP can also be used for preoperative evaluation in patients with chronic pancreatitis [7]. Except as detailed above in section “Gallstone Pancreatitis,” ERCP is not indicated in the setting of acute pancreatitis but may be useful for treatment of anatomic variants contributing to chronic pancreatitis. Cholangitis In the United States, approximately 60% of cases of biliary obstruction are caused by gallstones, with the remaining 40% caused by other etiologies including strictures or parasitic infection [9]. Biliary obstruction or stasis increases the risk of cholangitis. The mortality of acute cholangitis was >50% in 1980 but has decreased dramatically in parallel with the development of endoscopic techniques for biliary decompression, highlighting the utility of ERCP in the treatment of this condition [9]. Acute cholangitis must be

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diagnosed and treated promptly, as it still carries a 11–30% risk of mortality [9]. Clinical suspicion must be high as not all patients will have the classical findings of Charcot’s triad (right upper quadrant pain, fevers, and jaundice) and Reynold’s pentad (Charcot’s triad, plus hypotension and altered mental status). Laboratory findings consistent with cholangitis may show elevation in alkaline phosphatase (ALP) and gamma-­ glutamyl transpeptidase (GGT) in approximately 90% of patients [15]. Patients may also have elevations in total or direct bilirubin, transaminases, white blood cell count, C-reactive protein, and erythrocyte sedimentation rate (ESR) [15]. Management of acute cholangitis after initial stabilization and antibiotic administration depends on the clinical situation but should involve prompt decompression of the biliary system via ERCP, PTC, or surgery. Antibiotic selection will depend on the clinical situation and risk factors, with coverage of the most likely enteric pathogens such as E. coli, Klebsiella, and Enterococcus, although polymicrobial infections have become more common [17]. ERCP is successful at treating >90% of cases of cholangitis and has a complication rate of approximately 5% and mortality of 1%, making it a good option if possible [17]. Suspected cholangitis unresponsive to fluid resuscitation and antibiotics is one of the few conditions for which ERCP is indicated as the initial diagnostic and treatment choice. PTC can be used when ERCP is unsuccessful or impractical, such as in cases of altered surgical anatomy, proximal biliary obstruction, or hemodynamic instability making ERCP impossible. Surgery is considered a last resort for the treatment of cholangitis. Parasitic Infection Multiple parasitic organisms are known to cause infectious complications of the pancreaticobiliary system including Clonorchis sinensis, Ascaris lumbricoides (roundworm), Echinococcus granulosus, and Fasciola hepatica [10]. Presentation can vary from biliary colic or obstruction to cholangitis and rarely pancreatitis. Approximately one-fourth

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of echinococcal hydatid cysts rupture into the biliary tree, causing obstructive symptoms [18]. Some parasitic infections such as clonorchiasis also increase the risk of cholangiocarcinoma [18]. Although medical therapy is the first-line treatment, ERCP is indicated if needed for confirmation of the diagnosis, removal of the parasites in persistent or obstructive cases, and management of complications such as biliary strictures [18]. Benign Fibrotic Stricture The most common form of benign stricture is iatrogenic, typically after cholecystectomy or surgical anastomosis such as hepatic resection or transplantation. Other etiologies of benign stricture include chronic inflammatory processes, such as primary sclerosing cholangitis (PSC), chronic pancreatitis, and immunoglobulin G-4 (IgG4 or autoimmune) cholangiopathy, or ischemic processes such as polyarteritis nodosa [19]. MRCP is useful in diagnosing a stricture but may not be able to determine the cause. ERCP is indicated to rule out malignant stricture and for therapeutic dilation with placement of parallel stents which can be progressively increased in diameter every 3–4 months until the stricture is resolved [19]. Benign Extrinsic Compression Extrinsic compression of the pancreaticobiliary ducts can result in obstruction, typically due to Mirizzi’s syndrome or dilated periductal veins such as the portal vein or inferior vena cava (IVC). Mirizzi’s syndrome is defined as compression of the hepatic duct due to an impacted stone in the cystic duct or gallbladder. Whenever extrinsic compression is observed, malignancy should also be considered in the differential diagnosis [10]. Mirizzi’s syndrome can be diagnosed with imaging (CT sensitivity 42%, MRCP sensitivity 95%) or ERCP (sensitivity approaching 100%) [17]. Treatment may include ERCP for stenting and biliary decompression, but the definitive treatment is surgical intervention [17].

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Malignant Causes of Biliary Obstruction and Stricture As the therapeutic capabilities of ERCP have improved, it has become more influential in the treatment of malignant pancreaticobiliary strictures and obstructions. Malignant lesions can be primary such as cholangiocarcinoma and ampullary carcinoma, or of metastatic origin. Cholangiocarcinoma is a primary cancer of the bile ducts and can develop at any level. If the cholangiocarcinoma is found at the confluence of the right and left hepatic ducts, it is called a Klatskin tumor [10]. Ampullary adenocarcinoma is a rare diagnosis. Its presence can be suggested by a “double duct sign”—concurrent dilation of the CBD and pancreatic duct—often with the tumor itself not visible on imaging [10]. Patients with suspected biliary malignancy may require ERCP for biopsy or brushings to confirm the diagnosis. Sphincterotomy is indicated in patients with ampullary carcinoma who are not candidates for surgical resection, but some endoscopists prefer stenting due to a lower risk of bleeding [7]. Temporary plastic or more permanent metallic stents can be placed during ERCP to help alleviate obstruction caused by malignant strictures. Increased risk of postoperative infection has been reported in some patients who underwent preoperative ERCP for decompression of the pancreaticobiliary system followed by surgical resection of pancreatic adenocarcinoma, which likely is related to the introduction of enteric flora into the pancreaticobiliary system with instrumentation; therefore, coordination with the patient’s care team should determine if ERCP decompression is required preoperatively [7].

Sphincter of Oddi Dysfunction: Papillary Stenosis The sphincter of Oddi surrounds the distal common bile duct, main pancreatic duct, and, if present, the common channel where the ducts come together (Fig. 18.3a, b). It helps regulate the excretion of bile and pancreatic fluid and helps to maintain sterility of the ducts by preventing reflux of duodenal

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contents. Abnormal contractility is described as sphincter of Oddi dysfunction (SOD) [20]. ERCP-guided manometry can be utilized to diagnose SOD, but rates of post-manometry pancreatitis approach 20%; therefore, it should be reserved for patients with clinically significant symptoms [20]. Multiple classification systems exist (Table 18.2), but some studies have called into question whether pancreaticobiliary pain in the absence of laboratory or imaging abnormalities (type III SOD) is a true entity [21]. Currently ERCP is considered indicated for the confirmation and treatment of type I and II SOD, but not for type III as the risk of post-ERCP pancreatitis outweighs the benefit in these patients [21]. If indicated, SOD can be treated with biliary, pancreatic, or combination Table 18.2  Classification of sphincter of Oddi dysfunction Modified Milwaukee Modified Milwaukee classification, classification, biliary-type SOD pancreatic-­type SOD Criteria (a) Biliary-type pain (Rome criteria)

(a) Pancreatic-type pain

(b) AST or ALP >2 times (b) Amylase or lipase >1.5–2 times normal on 2 or more occasions normal (c) Delayed drainage of contrast from the CBD on ERCP >45 minutes and a CBD dilated >12 mm

(c) Pancreatic duct diameter >6 mm (head), or >5 mm (body)

Classification Type I: all three criteria (a), (b), and (c)

Type I: all three criteria (a), (b), and (c)

Type II: (a) plus (b) or (c)

Type II: (a) plus (b) or (c)

Type III: (a) only

Type III: (a) only

Adapted with permission of Elsevier from Novak and Al-Kawas [48] SOD Sphincter of Oddi dysfunction, AST aspartate transaminase, ALP alkaline phosphatase, CBD common bile duct, ERCP endoscopic retrograde cholangiopancreatography

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sphincterotomy depending upon the manometric diagnosis; however, treatment recommendations continue to evolve. Sphincterotomy is also indicated for papillary stenosis—a separate entity from SOD due to the presence of an anatomic narrowing at the sphincter of Oddi caused by inflammation or fibrosis—but can be difficult to differentiate from SOD and is similarly treated with dilation or sphincterotomy.

Biliary or Pancreatic Duct Leak Postoperative ERCP can be a useful tool in the diagnosis and treatment of postoperative pancreaticobiliary duct leakage. Treatment of post-cholecystectomy bile leak is the most common postoperative leak treated with ERCP, followed by leaks after liver resection and transplantation [22]. Clinically significant bile leaks occur in 1.1% or less of patients undergoing cholecystectomy and can usually be treated with ERCP if the bile duct is still in continuity [22]. Placement of a stent across the ampulla facilitates drainage of bile into the duodenum. This reduces the pressure gradient across the bile duct wall and decreases the drainage through the injury site thus allowing it to heal. The role of ERCP in postsurgical pancreatic leaks is less clear. Postsurgical anatomy may limit access to the pancreatic duct, and often other methods such as medical therapy with octreotide or percutaneous drainage are effective at treating the pancreatic leak [23].

Post-trauma ERCP can also be used to treat post-traumatic ductal disruption in stable patients. Its role in the acute setting is still evolving but has been supported in the treatment of stable patients with pancreatic ductal disruption and fluid collection, preferably with pancreatic sphincterotomy and stent placement [23].

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 issue Sampling or Resection of Pancreaticobiliary T Lesions ERCP can be used to biopsy suspicious lesions which are accessible endoscopically such as lesions of the ampulla, CBD, or proximal pancreatic duct. Assessment for malignancy is often combined with EUS for further characterization of the lesion and ultrasound-guided biopsy (Chap. 19). ERCP is indicated for diagnosis of clinically suspected malignancy in the pancreatic head when other diagnostic modalities including EUS have been equivocal or normal. Tissue can be obtained using multiple techniques including biopsy forceps, brushings, or needle aspiration. Ampullectomy can be performed for an adenoma of the papilla, but surgical intervention may be required if there is an underlying malignancy [7].

Pancreatic Divisum and Ductal Abnormalities Acute and Chronic Pancreatitis Pancreatitis can have differing causes; therefore, ERCP is not always indicated. There are several circumstances in which ERCP can be useful for diagnostic or treatment purposes in pancreatitis. Acute pancreatitis is rarely an indication for ERCP but can be in the setting of concomitant worsening jaundice or cholangitis despite medical management [5]. ERCP is also indicated if the patient has recurrent episodes of acute pancreatitis for which the etiology is uncertain, termed idiopathic acute recurrent pancreatitis (IARP). These patients should be evaluated with imaging and EUS to evaluate for potential etiologies such as microlithiasis and anatomic defects such as choledochocele, ampullary tumor, or pancreatic divisum [7]. Patients with chronic pancreatitis may benefit from ERCP with pancreatic sphincterotomy to remove ductal stones and dilate strictures or for preoperative planning [5, 7].

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Pancreatic Divisum ERCP is generally reserved for treatment of pancreatic divisum with pancreatic sphincterotomy of the minor papilla since other diagnostic methods (MRCP, EUS) are preferable to pancreatoscopy due to the risk of post-ERCP pancreatitis [5, 7].

Pancreatic Pseudocyst As EUS has become more commonly available, ERCP alone for the treatment of pancreatic pseudocysts is less common but may still be performed for stenting if the cyst communicates with the main pancreatic duct or can be performed for preoperative evaluation [5, 7].

Rare Diagnoses Choledochocele If the choledochocele involves the major papilla, ERCP is indicated for sphincterotomy since this configuration is associated with impaired biliary drainage [7].

Fistulas Abnormal or fistulous connections to the pancreaticobiliary tree are uncommon and can be difficult to diagnose. The most common biliary-enteric fistula is a choledochoduodenal fistula due to chronic gallstone disease, with the second most common being a cholecystocolonic fistula [17]. ERCP may be useful if other diagnostic modalities are equivocal, although the treatment is more likely to be surgical. Biliary-vascular fistulas account for approximately 10% of cases of hemobilia, with blood exiting the ampulla of Vater on upper endoscopy suggesting a biliary source [17]. Selective hepatic angiography is the intervention of choice for localization of the source and potential embolization [17]. Bilhemia (direct flow of bile into the vascular system from a biliary

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vascular fistula) can be seen when the fistula is between an obstructed biliary system and a vein such as the IVC, portal vein, or a hepatic vein. It can present with sepsis or pulmonary embolism, jaundice, or marked direct hyperbilirubinemia without transaminase elevation and is best visualized with ERCP or PTC. Treatment of the biliary obstruction may result in spontaneous closure of the fistula, or treatments to exclude the fistula with stents, angiographic coils, or balloon tamponade have been reported [17]. Biliary thoracic fistulas can communicate with the pleural space or bronchial tree. Trauma, iatrogenic causes, malignancy, and biliary obstruction are the most common causes in developed countries, but amoebic liver abscesses are the most common cause elsewhere [17]. Patients may present with a productive cough with bile staining, pleural effusion, or ­infection. Treatment typically consists of chest tube drainage of any abscess or pleural effusion and subsequent endoscopic sphincterotomy if the fistula fails to close. Surgical intervention is considered a last resort [17].

Sump Syndrome Although rare, sump syndrome can occur postoperatively after biliary-enteric anastomosis and results from biliary stasis or reflux of debris into the anastomosis which creates a propensity for stone formation and cholangitis. Sphincterotomy provides an endoscopic treatment which is often effective. Sump syndrome is less common with hepaticojejunostomy than with choledochoduodenostomy and has become less frequent as surgical practices have changed [7].

Contraindications to ERCP Absolute Contraindications Known or suspected perforated viscus is perhaps the only absolute contraindication to ERCP, although as techniques for the closure of full-thickness enterotomies improve, this is also becoming a relative contraindication [7].

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Relative Contraindications • Cardiopulmonary Instability: A patient who is unable to tolerate the anesthesia or positioning required for ERCP may be unable to undergo the procedure. • Coagulopathy: In patients who have not had their coagulopathy corrected, ERCP can be performed, but sphincterotomy is not recommended [4]. Stent placement is a safer option in these patients as the risk of bleeding is lower, but coagulopathy should be corrected before ERCP whenever possible. • Pregnancy: ERCP can be safely performed during pregnancy, but efforts should be made to shield the fetus from radiation as much as possible. In cases where surgical intervention would be high risk, ERCP can be used as a temporizing measure until pregnancy is completed [4]. • Severe Allergy to Contrast: In cases of documented severe allergic reaction to ERCP contrast medium, careful consideration is needed to determine if the risks of ERCP are less than the potential benefits [7]. Because systemic absorption of endoscopically administered contrast is much lower than intravenous administration (approximately 1%), many patients with an iodine allergy can undergo ERCP without complication, with or without a pretreatment regimen [24]. • Type III Sphincter of Oddi Dysfunction: see section “Sphincter Of Oddi Dysfunction: Papillary Stenosis” above. These patients have an increased risk of post-ERCP pancreatitis; therefore, ERCP and manometry are not recommended [21]. • Anatomic Considerations: Access to the ampulla for the purposes of ERCP can be much more challenging in patients with altered surgical anatomy such as Billroth II reconstruction or gastric bypass. In expert hands, ERCP is not contraindicated, but specialized techniques for access may be required (Chap. 21).

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Pre-ERCP Patient Preparation General considerations for the pre-endoscopy patient are detailed in Chap. 8. For patients requiring ERCP, it is important to consider their ability to tolerate the anesthesia modality of choice—typically general anesthesia—as well as the patient’s ability to be positioned prone. The risk of requiring airway maneuvers during the procedure or having a sedation-­related complication increases with ASA class, body mass index (BMI) >30, and risk of obstructive sleep apnea (OSA) [25]. Patients with severe cardiopulmonary disease, morbid obesity, or cervical spinal disease may require supine or left-­lateral positioning instead, which can increase the difficulty of cannulation [4]. Routine laboratory tests are not required before ERCP, but female patients of childbearing age should have a pregnancy test since additional radiation shielding may be required. Patients taking anticoagulants will need their medications addressed. Attention should be paid to the patient’s medical and surgical history as cirrhosis, varices, strictures, and altered esophageal, gastric, or duodenal anatomy may necessitate a different procedural approach. Patients with history of esophageal stricture may require endoscopic evaluation or dilation with a standard forward-viewing gastroscope prior to passage of the duodenoscope. Cirrhosis is a known risk factor for complications after ERCP such as post-­ sphincterotomy hemorrhage but still may be the least invasive option in select patients [26]. Pre-procedural optimization of cirrhosis, including correction of coagulopathy, antibiotics, diuretics, or hyperalimentation, is recommended [26]. Consideration should also be given to whether additional procedures such as EUS or PTC are necessary, as these may require coordination with other specialists for a combination approach.

Antibiotic Prophylaxis Pre-procedural antibiotics are not required for all ERCP interventions but are recommended for certain diagnoses or

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procedures. Antibiotic prophylaxis is recommended for ERCP in all patients with biliary obstruction, with pancreatic cystic lesions, or with a history of liver transplantation [5]. Pre-ERCP antibiotics are also recommended for cirrhosis and certain high-risk cardiac conditions (prosthetic heart valve, history of endocarditis, systemic-pulmonary shunt, systemic vascular graft less than 1-year old, or cyanotic congenital heart disease) [4]. Antibiotic prophylaxis is not necessary for patients with prosthetic joints or mitral valve prolapse without valvular regurgitation [4].

Anticoagulation Management of anticoagulation regimens and thromboembolism prevention will depend upon patient risk factors such as atrial fibrillation or a mechanical heart valve and the procedure to be performed. ERCP without sphincterotomy is a low-risk procedure for thromboembolism or bleeding, whereas ERCP with biliary sphincterotomy is considered high risk. Routine laboratory testing before ERCP is only indicated in patients with known anticoagulant use, bleeding disorder, or another coagulopathy. It is generally recommended to maintain an INR 50  K/UL before proceeding with ERCP [15]. Warfarin should be stopped 5 days prior to elective ERCP and bridged if necessary, with cessation of the bridge medication (usually enoxaparin) the day before the procedure. Antiplatelet medications should be stopped 7–10 days prior to an elective ERCP procedure and should not be restarted for 5–7  days if a sphincterotomy was performed [4]. For urgent or emergent ERCP, it may not be possible to hold the patient’s anticoagulation medications, but their anticoagulated state can be verified with appropriate laboratory testing and corrected according to standard preoperative protocols.

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Intra-procedural Considerations for ERCP Medications • Sedation and Anesthetics: Conscious sedation, deep sedation, or general anesthesia can be used for ERCP and is summarized elsewhere (Chap. 8). It is important to have a nurse or anesthesia staff member dedicated to patient monitoring during the procedure. • Contrast Agent: An iodine-based contrast agent such as iohexol is used with cholangiopancreatography to visualize the pancreaticobiliary system. The concentration of contrast injected may vary depending on endoscopist preference. High- and low-osmolality formulations are ­ commercially available or can be diluted at the bedside with saline. Although the reported absorption of iodine from ERCP is approximately 1% that of IV administration, it is prudent to give periprocedural prophylaxis or use low-­osmolality contrast in patients with a reported iodine allergy [24]. • Carbon Dioxide (CO2) Insufflation: Use of CO2 gas for insufflation is recommended for ERCP because it causes less abdominal pain and distention post-procedure, is better tolerated than air should an embolism occur, and is more rapidly absorbed when pneumoperitoneum or pneumatosis occurs [24]. • Anti-motility Agents: Medications such as glucagon, hyoscyamine, or atropine can be used to slow gastrointestinal motility during ERCP cannulation. Dosing recommendations differ, generally with a starting dose of 0.5–1 mg for glucagon and 0.5  mg for hyoscyamine [27]. Glucagon should be used with caution in diabetic patients as it may also affect post-ERCP glucose control [28]. • Pro-secretory Agents: Medications such as secretin or sincalide (a synthetic cholecystokinin agonist) can be useful for difficult cannulations [25]. Secretin administration in conjunction with methylene blue sprayed on the minor

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papilla can help identify the os in patients with pancreatic divisum [25]. • Prophylaxis for Post-ERCP Pancreatitis: Multiple medications have been studied for the prevention of post-ERCP pancreatitis (PEP) including interleukin-10, allopurinol, somatostatin, octreotide, gabexate, heparin, and nitroglycerin, but none of these have been clearly proven beneficial [4]. Currently, rectal administration of 100 mg indomethacin has the strongest evidence to support its use for prevention of PEP [29]. Some have called into question the quality of the studies supporting the use of indomethacin, but it appears to have at least a trend toward significance and is an easy, inexpensive method when compared to pancreatic stenting and has gained widespread support [21].

Radiation Exposure It is the responsibility of the endoscopist to be familiar with the proper use of fluoroscopy and to minimize radiation exposure to the patient and staff as much as possible. This can be facilitated in many ways such as appropriate positioning of the x-ray tube, minimization of exposure time, and use of shielding. The main way to reduce radiation exposure time is to limit continuous fluoroscopy time. Additional techniques such as pulse fluoroscopy, last-image-held-on-screen mode, and limiting time in magnification mode are also helpful. All staff should wear proper protective shielding which may include a lead apron, thyroid shield, and protective glasses or should be positioned behind a protective shield. Since many patients will have had other imaging modalities or radiation exposure, it is important to consider the cumulative radiation dose to the patient, and the total radiation dose for the ERCP should be documented for later reference. Female patients of reproductive age should have a pregnancy test as additional shielding of the fetus is necessary in pregnant patients (see section “Relative Contraindications”).

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ERCP Diagnostic and Therapeutic Techniques Duodenoscope Introduction Prior to starting the procedure, the proper duodenoscope should be selected. A standard side-viewing duodenoscope has an approximate diameter of 11 mm and a working channel of 3.2–4.2 mm, whereas a therapeutic duodenoscope has a working channel of up to 4.8 mm which allows for passage of larger instruments [5, 24]. A pediatric duodenoscope should be used in young children and has a 7.4 mm diameter and 2.2 mm working channel, although a standard duodenoscope can usually be used for children 2 years and older [5, 24]. Due to the side-viewing configuration of the duodenoscope, esophageal cannulation is blind, and the duodenoscope should not be flexed for visualization in the esophagus as this risks injury. The endoscopist should be mindful of potential abnormalities such as esophageal diverticulum, strictures, varices, hiatal hernia, or pyloric stenosis which could complicate passage of the duodenoscope [4]. Strictures may be able to be dilated with a forward-viewing gastroscope to allow subsequent passage of the duodenoscope [4, 5]. If there is difficulty in gaining access to the duodenum, the patient can be placed in left lateral decubitus position and then transitioned to prone positioning after the duodenoscope passes the pylorus [4]. Once the duodenoscope is in the stomach, it can be partially distended with gentle insufflation and advanced along the greater curvature of the stomach [5]. The pylorus should be positioned almost out of view at 6 o’clock and then intubated. The need for the procedure should be re-evaluated if severe gastritis is present, as continuing with the procedure may cause bleeding [4, 5]. The duodenoscope is then advanced through the duodenal bulb and into the 2nd portion of the duodenum. The ampulla of Vater should be visualized, usually near the medial 2nd portion of the duodenum at 1–2 o’clock. Positioning is then transitioned from “long scope” (with the duodenoscope coursing along the greater curve of the stomach) to “short scope” (with

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b

Figure 18.4  (a, b) Duodenoscope fluoroscopic positioning and normal cholangiogram. The duodenoscope initially courses in “long scope” position (a) along the greater curve of the stomach (in this image a biliary stent is also visible on fluoroscopy). The duodenoscope is then typically transitioned to “short scope” position (b) for cannulation. A normal cholangiogram (b) visualizes the intrahepatic and extrahepatic biliary system, in this case also visualizing a patent cystic duct and a gallbladder containing gallstones

the duodenoscope taking a straighter course along the lesser curve of the stomach) position (Fig. 18.4a, b). This is accomplished by deflecting the duodenoscope tip to the right (small wheel forward) and up (large wheel down) to create a hook shape that helps hold the tip in place as the duodenoscope is straightened. To facilitate cannulation, the ampulla is placed in the upper middle of the visualized field for an en face view. Visualization of the ampulla may be difficult if a periampullary diverticulum is present or it is located behind a duodenal fold. Looking for bile staining near the expected location, the confluence of horizontal and vertical mucosal folds can be helpful [5]. The ampulla should be inspected; a friable or edematous ampulla may indicate the recent passage of a stone or instrumentation, or a mass. A bulging or firm ampulla may be due to a stone or neoplasm. Bubbles obstructing visualization can be minimized by flushing with a surfactant such as simethicone [5].

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Cannulation and Cholangiopancreatography Cholangiography Once the duodenoscope is in position, a scout x-ray should be obtained to evaluate for calcifications, foreign bodies (such as stents, drains, or surgical clips), free air, or retained contrast [4]. Periodic still images should be saved to document the patient’s anatomy and any pertinent findings during cholangiopancreatography, as well as to assess for biliary drainage or complications such as free air at the conclusion of the case [30]. The diameter of the duodenoscope (usually 11.5  mm) can be used to estimate fluoroscopic dimensions such as the diameter of the common bile duct. Ideally, contrast is injected after the desired duct is deeply cannulated and prior to sphincterotomy because sphincterotomy introduces air which can make later assessment for filling defects more difficult. Any filling defects need to be evaluated as they may represent air bubbles, stones, or neoplasm. A slow, steady injection of contrast usually yields better results and is preferable for cholangiopancreatography as it also helps to reduce the risk of PEP by minimizing the volume of contrast and number of contrast injections. Repositioning of the x-ray tube or patient can help achieve adequate ductal filling and fluoroscopic visualization, using gravity to assist in filling of the desired ducts [30]. The endoscopist must be familiar with biliary and pancreatic anatomy to correctly differentiate normal from abnormal findings (Fig. 18.3a, b). Variation in biliary anatomy occurs in up to 40% of the population, with the most common variant being drainage of the right posterior duct into the left hepatic duct (13–19%). A “triple confluence” or “trifurcation” of the right anterior duct, right posterior duct, and left hepatic duct occurs in approximately 11% of patients [10].

Cannulation Methods To best facilitate cannulation, the duodenoscope should be in en face position with the duodenal papilla in the upper half of

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the endoscopic view screen. The 12 o’clock position is marked along the long axis of the papilla, which may or may not coincide with the course of the intramural portion of the CBD depending on the length and characteristics of the papilla [31]. The goal of selective cannulation should be to access the desired duct expediently and with minimal trauma or inflammation to the surrounding tissues. To achieve selective cannulation of the CBD, the wire or cannula is directed toward 11–12 o’clock, whereas pancreatic duct cannulation is directed toward 1–3 o’clock. If pancreatic cannulation is difficult, cannulation from the “long scope” position can be attempted [5]. Either a catheter-first or wire-first method can be used. The device used for initial cannulation varies depending on endoscopist preference and whether the patient has previously had a sphincterotomy, with options including a straight-, rounded-, or tapered-tip cannula, sphincterotome, or balloon catheter (Fig.  18.5). Catheter sizes are typically 4–7 French (Fr), accepting guidewires up to 0.035 inch [24]. A sphincterotome is commonly used as the cannulation instrument of choice due to its upward curve, additional maneuverability by “bowing” the catheter with the sphincterotomy wire, and improved resource utilization as sphincterotomy will often be subsequently performed. Triple-lumen sphincterotomes allow for simultaneous injection of contrast without removal of the guidewire. “Rapid exchange” or “short wire” systems are available which allow the guidewire to be separated from the catheter external to the endoscope, shortening the length required for instrument exchange and allowing the endoscopist to manipulate the guidewire. Gentle contrast injection can be performed to assist in visualization during cannulation, keeping in mind that injection of the pancreatic duct is associated with PEP, but in some studies, deep wire cannulation of the pancreatic duct was a stronger predictor [32]. Deep cannulation with a guidewire prior to a catheter is associated with a lower rate of PEP; thus, the endoscopist should be mindful of the risks regardless of their approach [24].

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Figure 18.5  Examples of instruments for use with ERCP.  There are a large variety of instruments used with ERCP including those that aid in cannulation such as guidewires, cannulas, sphincterotomes, or needle knives; instruments to obtain tissue such as cytology brushes, biopsy forceps, or needles which can be used for aspiration or injection; balloon catheters for dilation or removal of stones, wire baskets for stone removal, and a variety of stents. A direct cholangiopancreatography system has its own light source, optics, and channels for aspiration, insufflation, and specialized instruments

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Instrument channel Aspiration Light & irrigation channels & camera

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Guidewires are available from multiple manufacturers in a variety of sizes, lengths, and other properties. Some are stiff to facilitate device exchanges and reduce lateral motion, whereas others are soft and flexible to facilitate cannulation or traverse a stricture. Wires may have a hybrid or completely hydrophilic coating. A coated guidewire rated for use with electrocautery is recommended for use during sphincterotomy, and an external securement device is recommended for wire safety [24]. The guidewire should be introduced with fluoroscopic visualization to verify passage of the wire into the desired duct.

Difficult Cannulation Difficult cannulation is encountered in approximately 10% of cases, but there is not always an apparent cause [31]. There are many techniques which can be used during a difficult cannulation. Medications such as glucagon or hyoscyamine can be given to help slow smooth muscle contractions and make cannulation easier, or the papilla can be sprayed with methylene blue and a secretion agent given (see section “Medications”). Exchanging the catheter or guidewire for a different size or configuration can be helpful. If the papilla is very small, an ultratapered sphincterotome or wire-first approach may be helpful. Care must be taken if the papilla is within a periampullary diverticulum as the anatomy can appear distorted, although the relationship between the bile duct and the pancreatic duct at the papilla is usually preserved. If the pancreatic duct can be cannulated but there is difficulty selecting the CBD, there are multiple options including approaching from a more inferior direction, a double-­wire method, use of a different wire, or pancreatic stenting. The double-wire method can either occlude the pancreatic duct allowing the second wire to be guided into the CBD or can straighten the angle to help achieve cannulation of the CBD.  A pancreatic stent facilitates cannulation by allowing cannulation next to the stent or a needle knife sphincterotomy over the stent [31]. Pre-cannulation or “precut” sphincterotomy can be considered if a stone is impacted

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in the ampulla (see section “Sphincterotomy”). EUS-guided cannulation is another alternative in centers where EUS is available [15]. If cannulation attempts continue to be unsuccessful and the indication for ERCP is not emergent, the procedure can be aborted and reattempted after >48 hours to allow any edema to improve and is usually successful [31]. A pancreatic stent or rectal indomethacin should be considered to reduce the risk of PEP in difficult cannulations (see section “Complications of ERCP”).

Sphincterotomy Basic Principles of Sphincterotomy A sphincterotomy can be done for multiple indications including access to the biliary or pancreatic ducts for instrumentation or cholangioscopy, clearance of stones, stent placement, or treatment of SOD. The technique involves division of the muscle fibers of the sphincter of Oddi using electrosurgical current, which can be derived from instruments such as a needle knife or a sphincterotome wire which is “bowed” across the tissue to be divided. There are multiple types of sphincterotome, most with 2–3 cm of solid or braided distal wire which is attached to an electrosurgical unit. Braided wire does not break as easily as a monofilament wire but is rarely used because it increases the risk of thermal injury to the surrounding tissues [33]. Typically, less than one-third of the sphincterotomy wire is inserted into the papilla to reduce the risk of a “zipper” sphincterotomy in which the cutting is not well controlled. Modern electrosurgical units (Erbe USA, Inc., Marietta, GA, USA) have improved the ability to control the sphincterotomy with variety of modes and features such as microprocessor autoregulation using parameters including tissue impedance to produce the desired tissue effect [33, 34]. Coagulation, cut, blended, or pulsed modes are common; pure cut mode for sphincterotomy is associated with a higher rate of bleeding, and pure coagulation mode is thought to contribute to edema; therefore, many endoscopists

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favor a blended or pulse mode for biliary sphincterotomy [34]. If oozing occurs during sphincterotomy, it can be treated by spraying the incised papilla with epinephrine diluted 1:20,000 units in a 20 mL syringe [31]. Alternatives to sphincterotomy should be considered in patients with coagulopathy, those needing to restart ­anticoagulation within 72  hours of sphincterotomy, and in patients with cirrhosis. If sphincterotomy is performed in cirrhotic patients, some advocate using an alternating pulse-cut current instead of a blended current to reduce bleeding risk [26]. One alternative to sphincterotomy in these patients is endoscopic papillary balloon dilation (see section “Dilation”). It carries a higher rate of PEP so is generally not the procedure of choice but is preferable to sphincterotomy in coagulopathic patients [26]. Sphincterotomy should not be performed if the anatomy cannot be clearly delineated or the sphincterotome positioned appropriately. If there is concern about the size of the sphincterotomy needed (e.g., to remove large stones), then the technique can be combined with balloon dilation or dilation used as an alternative [33].

Biliary Sphincterotomy To perform a biliary sphincterotomy, the cut is typically directed toward the 11 o’clock position, cutting the intramural portion of the CBD.  Many endoscopists use a blended setting for the electrocautery unit at 15–20 joules or use an autoregulated setting [4]. Selective cannulation of the CBD prior to sphincterotomy is necessary to reduce the risk of PEP.  Typical sphincterotomy length is approximately 1  cm, with free flow of bile, and a 10 mm balloon should pass easily. The cut should not pass the impression of the CBD on the duodenum since this risks retroperitoneal perforation, but since the impression can be difficult to see, the transverse fold superior to the papilla can be used as a marker with the cut extending to but not beyond the fold (Fig. 18.6a–d) [5].

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Figure 18.6  (a–d) Biliary sphincterotomy. A biliary sphincterotomy can be performed after the papilla is located (a) and the common bile duct successfully cannulated (b). The sphincterotomy is directed toward the 11 o’clock position (c) and should not be extended past the intramural portion of the common bile duct, for which the transverse fold of the duodenum (depicted in B by a red dashed line) can be used as a marker. The completed biliary sphincterotomy (d) typically extends to, but not past the transverse duodenal fold

Pancreatic Sphincterotomy To perform a pancreatic sphincterotomy, the cut is typically directed toward the 12 o’clock position or performed over a stent in the pancreatic duct using a needle knife. The pancreatic sphincterotomy is usually 5–10  mm [5]. Some advocate

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the use of pure cut mode for pancreatic sphincterotomy to reduce the risk of future stenosis [24].

Needle Knife or Precut Sphincterotomy In some circumstances such as when selective ductal cannulation cannot be achieved due to an impacted stone in the common bile duct, precut sphincterotomy can be performed with a needle knife or special precut (Erlangen-type) sphincterotome where the wire extends to within 1 mm of the tip of the catheter. The precut sphincterotome has the advantage of being able to complete the sphincterotomy with the same instrument but may place the cutting wire closer to the pancreatic duct orifice [35]. Needle knives are available in a variety of lengths and diameters, and some have more than one lumen to allow for wire probing of the papilla [35]. Precut sphincterotomy is performed without a wire in place and can be performed with or without a stent in place. Only a few millimeters of the needle knife wire should be exposed, and the cut should be made in short 1–2 mm increments. For biliary sphincterotomy, the desired duct is suspected to be unroofed by visualization of biliary epithelium or bile drainage, and then advancement of a wire and the catheter can be attempted, taking care not to have submucosal insertion of the wire or submucosal injection of contrast. Once access has been achieved, completion of the sphincterotomy can be performed with a sphincterotome in standard fashion. Some studies indicate a higher rate of successful precut cannulation with a pancreatic stent in place [35]. A precut fistulotomy can be performed in cases where the intramural bile duct is dilated or impacted with a stone. Either an upward or downward motion can be used starting from a few millimeters above the papilla or below the transverse duodenal fold. Care should be taken not to stray from the 11o’clock axis as it could result in retroperitoneal perforation [35].

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Needle knife and precut techniques are less frequently used because they have an increased complication rate of 5–30%, including perforation and PEP [5, 11]. A similar technique of transpancreatic sphincterotomy has been described by Goff, using a standard sphincterotome with the tip in the pancreatic orifice to make small cuts in the septum between the pancreatic and common bile duct until the biliary orifice is exposed. This technique is reported to have similar complication profiles to needle knife sphincterotomy, although the long-term effects of performing a concurrent pancreatic sphincterotomy are unclear [35].

Dilation Standard Biliary or Pancreatic Balloon Dilation For strictures within the biliary or pancreatic ducts, a through-­ the-­scope balloon dilator or a tapered bougie dilator can be used over a guidewire. Balloon dilation is a common method, with standard balloons measuring 4–10 mm diameter and up to 6 cm in length. The balloon catheter is positioned over a guidewire across the stricture using fluoroscopy and then inflated with diluted contrast solution in the balloon. As hydrostatic pressure is exerted circumferentially, the “waist” of the stricture should disappear on fluoroscopy, allowing for a controlled dilation [5, 24]. Tapered Soehendra dilators (Cook Medical, Bloomington, IN, USA) can be passed over a guidewire and are available from 6 to 11.5 Fr, but the 10–11.5 Fr sizes must be passed with a therapeutic duodenoscope [24]. Care should be taken not to over-dilate the duct as this risks perforation.

 ndoscopic Sphincteroplasty or Papillary Large E Balloon Dilation In contrast to standard ductal dilation techniques, endoscopic sphincterotomy or endoscopic papillary large balloon dilation

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(EPLBD) is performed across the duodenal papilla in place of or to enlarge an existing sphincterotomy. The technique uses a pyloric or esophageal dilation balloon 12–20  mm in diameter which is passed over a guidewire in the CBD [5]. A minimal sphincterotomy can be used (approximately ­one-­third of the possible length) to help direct the dilation of the sphincter of Oddi toward the biliary side and to reduce the risk of complications. Dilation should be tailored to the size of the distal CBD and the stones to be extracted, not going beyond the diameter of the distal CBD due to the risk of perforation [36]. If the waist of the stricture does not disappear with the balloon up to 75% of its maximal pressure rating, dilation should be halted [36]. The risks and benefits of this technique should be weighed as it has a higher rate of PEP than a cut sphincterotomy but a lower rate of perforation and bleeding [4, 5]. EPLBD may be advantageous in place of a sphincterotomy in patients with coagulopathy, but the sphincter of Oddi should only be dilated to 10  mm to reduce the risk of bleeding, and the patient should be informed prior to the procedure of the higher risk of pancreatitis and cholecystitis associated with dilation [37]. EPLBD is generally reserved for patients with stones less than 10  mm and minimally dilated bile ducts (65% in nondilated ducts and  >95% in dilated biliary ducts [40]. For the rendezvous technique, a wire or stent is placed across the ampulla via a percutaneous approach, facilitating later ERCP cannulation and interventions [11]. At the time of ERCP, a guidewire can be placed through the existing stent or drain and snared with the duodenoscope [40].

Options for Surgically Altered Anatomy Multiple techniques exist to allow endoscopic access for patients with surgically altered anatomy, including balloon enteroscopy or laparoscopic-assisted approaches (Chap. 21).

Sphincter of Oddi Manometry ERCP can be used for diagnosis of Sphincter of Oddi dysfunction and subsequent treatment with sphincterotomy [5]. Manometry at the sphincter of Oddi with selective cannulation of the bile and pancreatic ducts is crucial to making the diagnosis. The manometry is performed using a specialized pancreaticobiliary manometry catheter which uses water perfusion to measure pressures. Catheters typically have 2–3 side ports to allow for simultaneous pressure readings and utilize the same manometry recording system used for esophageal manometry [24]. Newer systems are also available that are designed to help reduce the incidence of post-manometry pancreatitis [20].

Direct Cholangiopancreatoscopy Directly visualizing the CBD and pancreatic duct can be a helpful adjunct to many ERCP techniques, but older systems used a mother-daughter scope configuration which could be challenging. Newer systems (SpyGlass™, Boston Scientific) have been designed to pass through the working channel of a therapeutic duodenoscope, with the system also containing a very small (1.2  mm) channel which requires specialized

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instruments. The available instrument variety continues to broaden, currently including forceps, brushes, and laser or hydraulic lithotripters which can be used under direct visualization within the biliary or pancreatic ducts [24].

Endoscopic Ultrasound (EUS) Many of the techniques utilized during ERCP can be augmented by EUS when it is available (see Chap. 19).

Radiofrequency Ablation (RFA) and Photodynamic Therapy An endobiliary probe is now available for radiofrequency ablation of malignant biliary strictures during ERCP.  Initial results appear promising, although this technology is not yet widely available and experience is limited to specialized centers [34]. Photodynamic therapy has also been successfully used in conjunction with ERCP; the tissue to be treated is photosensitized using an intravenous agent, and then a specific wavelength of light is applied with a probe.

Confocal Laser Endomicroscopy Some centers with advanced endoscopy abilities offer confocal laser endomicroscopy for in vivo assessment of gastrointestinal histology, which when combined with ERCP can include biliary or pancreatic ductal histology. It is a fairly new technology which is currently not widely available.

Complications of ERCP Overall Risk of Complications or Mortality ERCP has a higher risk of complications when compared to other forms of endoscopy, with an overall 5–10% risk of

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adverse events [32]. Risk of death is less than 0.5% and is typically associated with cardiopulmonary events [32]. Risk factors associated with adverse events include SOD, cirrhosis, difficult cannulation, precut sphincterotomy, percutaneous biliary access, or lower ERCP case volume by the endoscopist [32]. Older age and the number of medical comorbidities have not been shown to be independent risk factors for undergoing ERCP [32].

 ardiopulmonary Events and Anesthesia-Related C Complications The risk of adverse cardiopulmonary events and anesthesia-­ related events associated with ERCP is similar to other endoscopic procedures. If patients are appropriately selected for the type of anesthesia administered, there does not appear to be an increased risk of airway complication or aspiration with prone positioning under monitored anesthesia care versus general anesthesia [25].

Post-ERCP Pancreatitis One of the most feared complications of ERCP is post-ERCP pancreatitis. Although mortality is rare, the overall reported rate of PEP is 1.3–6.7%, making it one of the most common post-ERCP complications [4, 11]. The etiology of PEP is likely edema of the pancreatic orifice from manipulation or aggressive injection of contrast that results in obstruction. There are multiple factors known to increase the risk of PEP, most notably SOD which has had high rates in association with sphincter of Oddi manometry (Table  18.3) [20]. PEP should be differentiated from mild elevation in post-­procedure lipase or amylase, as these are present in most patients. PEP is usually defined as moderate to severe abdominal pain with a serum lipase or amylase elevation requiring an additional two or more days of hospitalization [4, 32]. This requires prompt diagnosis and treatment as one in five cases will be

Instrumentation of the pancreatic duct (wire passage, contrast injection) Difficult or failed cannulation Pancreatic sphincterotomy Precut sphincterotomy Balloon dilation of intact biliary sphincter (EPLBD) Metallic biliary stent Wire-first cannulation (slightly lower risk) Early use of precut sphincterotomy (may decrease risk)

No stent placement after instrumentation or PD cannulation Stent placement in high-risk patients can reduce risk of PEP by 2/3 and decrease severity

Conflicting or lack of evidence for most agents Rectal indomethacin has the most support for its use

Pharmacologic agents

Data from: Srinivasan and Freeman [32]; and Campbell et al. [43] PEP Post-ERCP pancreatitis, EPLBD endoscopic papillary large balloon dilation, PD pancreatic duct. Normal font, items associated with increased risk of PEP. Italics, items associated with decreased risk of PEP

Sphincter of Oddi dysfunction Female Young age Normal bilirubin Previous PEP

Table 18.3  The “four Ps” of post-ERCP pancreatitis Patient factors Procedural factors Pancreatic stents

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severe [5, 41]. Amylase and lipase can be obtained a few hours after ERCP in high-risk patients. If they are normal, the risk of PEP is low; if elevated, the patient should be admitted for further monitoring and treatment [32]. Care for PEP is supportive and analogous to other forms of pancreatitis. Potential preventative agents that have been studied include IL-10, allopurinol, somatostatin, octreotide, gabexate, heparin, and nitroglycerin, but none of these have been clearly proven beneficial [41]. Perhaps the most studied pharmacological agent for the prevention of PEP is rectally administered indomethacin. Multiple randomized controlled trials have shown statistically significant reduction of PEP with indomethacin, although some have called into question the quality of these studies [32]. Techniques which have shown some benefit in reducing pancreatitis include selective bile duct cannulation prior to contrast injection, stenting of the pancreatic duct for difficult cannulation of the CBD, and limiting contrast injection into the pancreatic duct [4]. Placement of a pancreatic duct stent has been shown in multiple studies to help reduce the risk of PEP and therefore is recommended in cases of injection into the pancreatic duct or extensive manipulation at the papilla which may result in edema and pancreatic duct occlusion [5, 7].

Cholecystitis and Cholangitis The development of acute cholecystitis or cholangitis after ERCP is associated with instrumentation or inadequate biliary drainage. Risk can be reduced by limiting contrast ­injection into the gallbladder or above strictures and adequately draining the biliary system if there is concern for infection [4].

Post-ERCP Cholecystitis Post-ERCP cholecystitis can be managed by cholecystectomy or cholecystostomy depending on patient factors and stability. Acute cholecystitis is reported in 0.1–0.5% of post-ERCP patients [42].

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Post-ERCP Cholangitis The key to treatment of cholangitis (post-ERCP or otherwise) is adequate biliary drainage. Post-ERCP cholangitis occurs in 0.3–1.4% of patients, with late infection after stent placement in 2 g/dl [41]. Hemorrhage occurs in 0.3–2% of patients and is associated with instrumentation during ERCP, coagulopathy, anticoagulation therapy less than 3  days post-ERCP, cholangitis, bleeding during sphincterotomy, and lower endoscopist case volume [11, 32, 43]. Immediate and delayed bleeding occur with approximately equal frequency [42]. Many sphincterotomies will have a small amount of oozing, but only 0.5% will have clinically significant bleeding, with the most common location being

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the apex of the sphincterotomy [5]. Bleeding during ERCP can be treated with a variety of techniques such as sclerotherapy with injection of epinephrine, thermal hemostasis (APC, electrocautery), balloon tamponade, or endoscopic clip placement. A pancreatic stent may be advisable if large volume sclerotherapy injection or electrocautery is used due to the risk of edema and pancreatic duct occlusion [5]. Angiography or surgery is rarely necessary since endoscopic management successful in up to 90% of cases [4, 42]. If endoscopic measures fail, ligation or selective embolization of the GDA can be used to control bleeding as this provides the blood supply to the ampulla [42].

Perforation Perforation is a rare complication of ERCP occurring in 0.1– 1.4% of patients and is usually retroperitoneal in location [11, 43]. There is a higher risk of perforation in patients with postsurgical anatomy, intramural contrast injection, or sphincterotomy (highest with precut sphincterotomy) [43]. Perforation requires a high index of suspicion to detect but can be difficult because up to one-third of post-ERCP patients report abdominal pain after sphincterotomy [42]. Patient presentation and subsequent treatment can vary depending on the location and severity of the perforation. The Stapfer classification system is commonly used, which delineates four types of perforation [45]. Type I perforation is observed when the lateral or medial duodenal wall is perforated by forceful advancement of the duodenoscope. Free intraperitoneal perforation—indicated by large volume pneumoperitoneum, free fluid, or extravasation of contrast intra-abdominally—is an indication for emergent surgery and is best treated by wide drainage. Major surgical resection carries a significant risk of morbidity and mortality; therefore, drainage is preferred with planned future resection if indicated [4]. Cholecystectomy and common bile duct exploration should be considered in cases

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where the ERCP was performed for biliary obstruction or stones [42]. Closure of perforations recognized at the time of endoscopy has been reported in experienced hands but currently is not the standard of practice [42, 46]. Type II perforation involves the medial 2nd portion of the duodenum into the retroperitoneum, occurring with sphincterotomy or sphincteroplasty. Periampullary duodenal perforations recognized at the time of ERCP and if recognized early can be treated with stenting and close observation [42]. Perforation of tiny instruments such as guidewires usually does not cause clinical signs of perforation but should be promptly removed [5]. Large volume retroperitoneal air is less concerning as it correlates more with the volume of insufflation during the procedure than with the risk of complication, and up to 29% of asymptomatic patients have post-ERCP pneumoretroperitoneum 24 hours after ERCP [42]. Clinically insignificant pneumatosis can also occur [42]. Retroperitoneal duodenal perforation may present with back pain, fever, tachycardia, leukocytosis, or peritonitis. Confirmation of the diagnosis is usually made with a CT scan, and treatment is largely supportive or with percutaneous drainage, rarely requiring surgical exploration [41]. Bile duct perforations are almost always diagnosed at the time of the procedure due to extravasation of contrast. Most can be managed with ­percutaneous or endoscopic biliary drainage and percutaneous drainage of any fluid collections [42].

Miscellaneous Complications Recurrent Biliary or Pancreatic Stones Recurrence of stones is associated with multiple risk factors for biliary stasis such as periampullary diverticula, papillary stenosis, biliary stricture or tumor, and angulation of the common bile duct (>145°) [11]. Additional risk factors include multiple common bile duct stones, biliary dilatation >13 mm, open cholecystectomy, lithotripsy, and hepatolithiasis [11].

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Treatment usually entails ERCP but may require surgery in refractory cases.

Papillary Stenosis Up to 16% of patients after biliary sphincterotomy can develop papillary stenosis [33]. This can usually be treated with repeat sphincterotomy or balloon dilation [33].

Equipment Malfunctions Multiple types of instrument malfunction have been reported. Rupture of a stone extraction balloon is common, occurring on the edges of stones or the channel elevator. This problem is easily manageable by replacing the balloon catheter. Stents can migrate into the biliary or more commonly the pancreatic duct and can usually be retrieved endoscopically. If a stent migrates out of the duct into the duodenum, it will usually pass without intervention or can be endoscopically removed if it is not progressing. Wire baskets can become entrapped during stone retrieval and can be released via endoscopic methods such as enlarging the sphincterotomy, direct choledochoscopy, lithotripsy, or percutaneous retrieval [42]. Retrieval of a broken wire basket can be attempted with a Soehendra lithotripter (Cook Medical) or surgical removal if endoscopic attempts are unsuccessful. If a wire is fragmented, removal is recommended to prevent complications such as perforation, pancreatitis, abscess, or fistula, although there are reported cases of observation [42].

Summary and Future Directions Endoscopic retrograde cholangiopancreatography has an instrumental role in many conditions, and it is likely to have an increased therapeutic role in the treatment of both benign

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and malignant diagnoses as instrumentation and techniques continue to expand. As the indications for ERCP widen, it will be necessary to advance the training in ERCP techniques, likely in the setting of fellowship programs or with the aid of simulation technology. Although future directions are difficult to predict, robotic endoscopy appears to be on the horizon and could be another means to expand the possibilities of ERCP.  Like other fields, innovation continues to overlap disciplines such as endoscopy, surgery, and interventional radiology, making interdisciplinary collaboration a central aspect of patient care.

Pearls and Pitfalls

1. ERCP is a versatile procedure with many indications, most of which are therapeutic rather than diagnostic. There are few contraindications to ERCP. 2. X-ray radiation is used during ERCP; therefore, it is essential for the endoscopist to be familiar with techniques for the safe and effective use of radiation for cholangiopancreatography. 3. Treatment of choledocholithiasis is the most common indication for ERCP. 4. Post-ERCP pancreatitis is a common complication of ERCP which can vary in severity. There are multiple approaches for prevention, including pancreatic duct stenting and rectal indomethacin. 5. A skilled endoscopist has many techniques at their disposal which can be applied via ERCP, including techniques for stone removal, sphincterotomy, stenting, dilation, and tissue sampling. 6. The role of fellowship training and simulation technology is likely to expand as the complexity of procedures accomplished with ERCP increases.

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References 1. McHenry L Jr, Lehman GA. Approaching 50 years: the history of ERCP.  In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 1–6. 2. Staritz M, Ewe K, Meyer zum Buschenfelde KH.  Endoscopic papillary dilation (EPD) for the treatment of common bile duct stones and papillary stenosis. Endoscopy. 1983;15(Suppl 1):197–8. 3. Mounzer R, Wani S. ERCP training. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 68–79. 4. Fundamentals of Endoscopic Surgery: Online Study Guide. Module 8: ERCP (http://www.fesdidactic.org/). Society of American Gastrointestinal and Endoscopic Surgeons; 2018. 5. Pearl J. Techniques of endoscopic retrograde cholangiopancreatography. In: Marks JM, Dunkin BJ, editors. Principles of flexible endoscopy for surgeons. New York: Springer; 2013. p. 215–26. 6. ASGE Standards of Practice Committee, Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, et al. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc. 2015;81(4):795–803. 7. Solomon S, Baillie J.  Indications for and contraindications to ERCP.  In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 54–8. 8. Yen A, Leung J.  Stone extraction. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadlephia: Elsevier; 2019. p. 160–70. 9. Winder J, Pauli E. Common bile duct stones: health care problem and incidence. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New York: Springer Science+Business Media; 2015. p. 5–16. 10. Jaiswal S, Chamarthi S.  Bile duct stones: making the radio logic diagnosis. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New York: Springer Science+Business Media; 2015. p. 17–26. 11. Narula V, Fung E, Overby W, Stefanidis D, Richardson W.  Practice management guidelines for choledocholithiasis. SAGES Guideline Committee, Publication pending. 12. Tsitouridis I, Lazaraki G, Papastergiou C, Pagalos E, Germanidis G. Low conjunction of the cystic duct with the common bile duct: does it correlate with the formation of common bile duct stones? Surg Endosc. 2017;21(1):48–52.

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13. Li Z, Sun J, Li B, Dai X, Yu A, Li Z. Meta-analysis of single-stage versus two-staged management for concomitant gallstones and common bile duct stones. J Minim Access Surg. 2019. [Epub ahead of print]. 14. Singh A, Kilambi R. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: a systematic review and meta-analysis of randomized trials with trial sequential analysis. Surg Endosc. 2018;32(9):3763–76. 15. Peck J, Latchana N, El-Dika S, Sharma S. Making the diagnosis: gastroenterology. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New York: Springer Science+Business Media; 2015. p. 27–36. 16. Dowell J, Weinstein J, Lim A, Guy G.  Percutaneous methods of common bile duct stone retreival. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New York: Springer Science+Business Media; 2015. p. 77–84. 17. Pidlaoan V, Krishna S.  Management of medical complications of gallstone disease. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New York: Springer Science+Business Media; 2015. p. 113–28. 18. Reddy D, Rao G, Banerjee R. Tropical parasitic infestations. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 464–8. 19. Costamagna G, Boskoski I, Familiari P. Benign biliary strictures. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 417–21. 20. Purnak T, Fogel E.  Sphincter of oddi manometry. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 132–6. 21. Cotton PB, Durkalski V, Romagnuolo J, Pauls Q, Fogel E, Tarnasky P, et  al. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. JAMA. 2014;311(20):2101–9. 22. Tarantino I, Baron T, Ligresti D. Biliary surgery adverse events, including liver transplantation. In: Baron TH, Kozarek RA, Carr-­ Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 422–31. 23. Chahal P, Baron T.  ERCP and EUS for acute and chronic adverse events of pancreatic surgery and pancreatic trauma. In:

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Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 432–40. 24. Ahlawat S, Al-Kasas F. Endoscopes, guidewires, and accessories. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 30–43. 25. Maple J. Patient preparation. In: Baron TH, Kozarek RA, Carr-­ Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 80–5. 26. Beal E, Black S.  Management of choledocholithiasis in the cirrhotic patient. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New York: Springer Science+Business Media; 2015. p. 151–60. 27. Lahoti S, Catalano MF, Geenen JE, Hogan WJ.  A prospective, double-blind trial of L-hyoscyamine versus glucagon for the inhibition of small intestinal motility during ERCP. Gastrointest Endosc. 1997;46(2):139–42. 28. Chang FY, Guo WS, Liao TM, Lee SD.  A randomized study comparing glucagon and hyoscine N-butyl bromide before endoscopic retrograde cholangiopancreatography. Scand J Gastroenterol. 1995;30(3):283–6. 29. Yaghoobi M, Rolland S, Waschke K, McNabb-Baltar J, Martel M, Bijarchi R, et al. Meta-analysis: rectal indomethacin for prevention of post-ERCP pancreatitis. Aliment Pharmacol Ther. 2013;38:995–1001. 30. Lin E, Schueler BA. Radiologic issues and radiation safety during ERCP. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 4–29. 31. Bourke M, Ma M. Cannulation of the major papilla. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 108–22. 32. Srinivasan I, Freeman M. Adverse events of ERCP: prediction, prevention, and management. In: Baron TH, Kozarek RA, Carr-­ Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 59–67. 33. Neuhaus H. Biliary sphincterotomy. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 137–47. 34. Benias P, Carr-Locke DL.  Principles of electrosurgery. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 86–92.

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35. Chandran S, May G, Kortan P. Access (precut) papillotomy. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 123–30. 36. Shim C. Balloon dilation of the native and postsphincterotomy papilla. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 148–59. 37. Oza V, Meyer M. Special considerations for the gastroenterologist. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New  York: Springer Science+Business Media; 2015. p. 63–6. 38. Shakhatreh M, Groce R. Gastroenterologic treatment and outcomes. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New  York: Springer Science+Business Media; 2015. p. 85–92. 39. Irani S, Kozarek R.  Papillectomy and ampullectomy. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019. p. 230–41. 40. Majdalany B, Spain J.  Percutaneous biliary access: consider ations, techniques, and complications. In: Hazey JW, Conwell D, Guy G, editors. Multidisciplinary management of common bile duct stones. New York: Springer Science+Business Media; 2015. p. 49–62. 41. Hadj A, Nikfarjam M. Post-procedural considerations. In: Marks JM, Dunkin BJ, editors. Principles of flexible endoscopy for surgeons. New York: Springer; 2013. p. 55–62. 42. Warren J, Hardy D, MacFayden B.  Management of endoscopic complications. In: Marks JM, Dunkin BJ, editors. Principles of flexible endoscopy for surgeons. New  York: Springer; 2013. p. 227–50. 43. Campbell M, Sanchez J, Rasheid S, Tummel E, Velanovich V. Pre-procedural considerations. In: Marks JM, Dunkin BJ, editors. Principles of flexible endoscopy for surgeons. New  York: Springer; 2013. p. 27–44. 44. Thaker AM, Muthusamy VR, Sedarat A, Watson RR, Kochman ML, Ross AS, et  al. Duodenoscope reprocessing practice patterns in U.S. endoscopy centers: a survey study. Gastrointest Endosc. 2018;88(2):316–22. 45. Kumbhari V, Sinha A, Reddy A, Afghani E, Cotsalas D, Patel YA, et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc. 2016;83(5):934–43.

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46. Park S. Recent advanced endoscopic management of endoscopic retrograde cholangiopancreatography related duodenal perforations. Clin Endosc. 2016;49:376–82. 47. ASGE Standards of Practice Committee, Maple JT, Ben-­ Menachem T, Anderson MA, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Strohmeyer L, Dominitz JA.  The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1–9. 48. Novak DJ, Al-Kawas F.  Endoscopic management of bile duct obstruction and sphincter of Oddi dysfunction. In: Bayless TM, Diehl AM, editors. Advanced therapy in gastroenterology and liver disease. Hamilton: BC Decker; 2005. p. 766–73.

Chapter 19 Management of Pancreatico-Biliary Disease: Endoscopic Ultrasound (EUS) Robert D. Fanelli, Stephanie M. Fanelli, and Josephine A. Fanelli

Learning Objectives

1. Identify common clinical scenarios where endoscopic ultrasound (EUS) lends enhanced diagnostic value over other modalities commonly employed in pancreaticobiliary disease. 2. Compare the effectiveness of EUS in the diagnosis and its place in the treatment algorithm for common bile duct stones (CBDS) in comparison with laboratory studies, transabdominal ultrasound (TUS),

R. D. Fanelli (*) The Guthrie Clinic, Department of Surgery, Geisinger Commonwealth School of Medicine, Sayre, PA, USA S. M. Fanelli The Ohio State University College of Medicine, School of Health and Rehabilitation Sciences, Columbus, OH, USA J. A. Fanelli The Guthrie Clinic, Division of Endocrinology and Metabolism, Department of Medicine, Sayre, PA, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_19

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computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP). 3. Consider the role of EUS in your approach to the management of the wide variety of pancreaticobiliary conditions and lesions encountered in the practice of General Surgery, Gastrointestinal Surgery, and Minimally Invasive Surgery.

EUS as a Diagnostic Modality Because of the proximity of the ultrasound transducer to the biliary tree when the echoendoscope is within the duodenum, the loss of echo due to distance is eliminated in comparison to TUS.  Thus, high-frequency ultrasound can be used, up to 10 MHz, increasing resolution dramatically over TUS.  EUS provides excellent accuracy in the diagnoses of CBDS (Fig. 19.1). Given a sensitivity of 89–98% and a specificity of 94–100% [1–3], EUS is comparable to ERCP in the diagnosis of CBD stones, but EUS less often is associated with adverse events (AEs) than ERCP (in particular, postERCP pancreatitis). Diagnostic EUS is an effective tool that prevents unnecessary ERCP in patients who do not have CBDS, eliminating ERCP-related AEs in those shown not to have CBDS by EUS.  Using this approach based on EUSdirected ERCP, unnecessary ERCP was avoided in 30–75% of patients initially suspected of having CBDS, resulting in fewer AEs and lower cost than when direct ERCP was utilized as a diagnostic tool [4–6]. Patients in whom CBDS already have been demonstrated, or in those needing bile duct decompression for biliary sepsis, direct ERCP remains more cost-effective [4, 5]. In the setting of biliopancreatic neoplasia, EUS provides tissue sampling opportunities using fine needle aspiration (FNA) and fine needle biopsy (FNB), and for cystic lesions, cyst aspiration for fluid cytology and biochemical analysis. The diagnostic yield for EUS exceeds

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Figure 19.1 Shadowing CBD stone (red arrow) identified in a dilated bile duct during radial EUS examination

that of other modalities, as does its capabilities for achieving sampling in lesions obscured from transabdominal access [7]. The diagnostic value of EUS is better appreciated when it is compared with other modalities commonly used in the clinical evaluation of patients with biliopancreatic disease. A comparison is shown in Table 19.1.

Competing Diagnostic Modalities Clinical Presentation CBDS may be clinically silent, or might manifest as biliary colic, jaundice, biliary stricture, pancreatitis, cholangitis, sepsis, or be found synchronously with biliopancreatic malignancy. Biliary pancreatitis and ascending cholangitis traditionally have been accepted as evidence supporting the diagnosis of CBDS by virtue of their presence. However,

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Table 19.1  Sensitivity and specificity ranges for studies commonly used when evaluating patients for CBDS Laboratory studies for detecting Sensitivity Specificity CBDS (%) (%) Total bilirubin (TB)

34–49

60–88

Alkaline phosphatase (AP)

41–80

88–73

Gamma glutamyl transpeptidase (GGT)

63–84

72–73

Aspartate transaminase (AST)

44–64

79–86

Alanine transaminase (ALT)

50–72

68–81

At least one component elevated from the panel TB − AP − GGT − AST − ALT

52–88

53–91

Imaging studies for detecting CBDS

Sensitivity (%)

Specificity (%)

Transabdominal ultrasound (US)

20–58

68–91

Computed tomography (CT)

50–88

84–98

Magnetic resonance cholangiopancreatography (MRCP)

85–95

91–100

Endoscopic retrograde cholangiopancreatography (ERCP)

89–93

98–100

Endoscopic ultrasound (EUS)

89–98

94–100

Adapted with permission of Springer Nature from Fanelli and Andrew [48]

biliary pancreatitis is not a good indicator of the presence of CBDS. Pancreatitis often occurs after small stones pass through the ampulla, so resolving biliary pancreatitis is an indicator that invasive CBD evaluation, like ERCP, may not be necessary [8]. A prospective population-based cohort study of 1171 patients revealed that CBDS were not significantly predicted by biliary pancreatitis or cholecystitis, and that the highest predictability of CBDS was seen in electively treated patients with elevated liver chemistries

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without pancreatitis or cholecystitis [9]. This and other studies suggest that patients presenting with biliary pancreatitis undergo invasive biliary intervention more often than needed [8]. EUS represents a safe and effective alternative approach for the evaluation of patients with biliary pancreatitis, and those considered at high risk for CBDS, that avoids the associated risks and complications of direct ERCP. Cholangitis, on the other hand, is associated with a very high risk of persistent CBDS. Patients who present with biliary sepsis should undergo ERCP without much further investigation, as the emphasis is less on diagnosis and more on therapy for sepsis [10, 11]. The finding of jaundice combined with right upper quadrant abdominal pain suggests the presence of CBDS. A prospective study showed that jaundice is significant as a predictor of CBDS on univariate analysis but fails to reach significance when multiple logistic regression analysis is applied [10]. Patients with jaundice alone, without other signs of biliary obstruction, should undergo evaluation for non-­ biliary causes of jaundice before invasive evaluation of the biliary tree.

Biochemical Testing Obstruction from CBDS may be intermittent; CBDS may become trapped within the CBD in a completely obstructing, partially obstructing, or non-obstructing manner. Therefore, liver chemistry measurements may vary and may be ­unreliable indicators of CBDS. The diagnostic utility of liver chemistries is further limited by the lag time that exists between actual mechanical obstruction and rising and falling chemistry levels [12]. Partially obstructing and non-obstructing CBDS may be associated with normal liver chemistries, especially early in obstruction, where biochemical lag is common [9]. False negative liver chemistry results occur infrequently. In a study involving routine MRCP performed for patients with gallstone disease, only 4% of patients with normal liver

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chemistries had CBDS, suggesting a negative predictive value of 96% [13]. Improved liver chemistries along with improved clinical symptoms suggest spontaneous clearance of CBDS, and increasing chemistry levels suggest retained CBDS [14, 15]. Liver chemistries alone cannot be relied upon to accurately direct the patient to ERCP for suspected CBDS.  Individual liver chemistries have greater utility in excluding CBDS than in predicting them. Bilirubin, alkaline phosphatase, γ-glutamyl transpeptidase (GGT), AST, and ALT each have a positive predictive value between 25% and 50%, and each has a negative predictive value between 94% and 99% [9–11, 13, 16–18]. As the number of individual liver chemistries that are abnormal increases, so does the risk of CBDS.

Transabdominal Ultrasound Transabdominal ultrasound (TUS) frequently is used in the evaluation of abdominal pain suspected to be of biliary origin. TUS is not well suited for direct identification of CBDS. Sensitivity and specificity for TUS in detecting CBDS ranges from 20% to 58%, and 68% to 91%, respectively [12, 16], and is attributed to the many physical limitations plaguing TUS.  A refractive border between the CBD wall and CBDS is absent, making delineation of stones difficult using TUS.  Body fat and intestinal gas interfere with TUS, and CBDS located in the intraduodenal or intrapancreatic CBD are difficult to identify on TUS. TUS is extremely dependent on technician experience; Rickes and associates ­demonstrated that experienced sonographers are more accurate in diagnosing CBDS (83% vs. 64%) compared to their less experienced colleagues [19]. TUS is useful in detecting signs which are suggestive of CBDS, however. The finding of a normal CBD on TUS in the setting of normal liver chemistries has a negative predictive value for CBDS of 95%, whereas a dilated CBD on TUS in the same clinical and laboratory value setting raises the risk of CBDS to intermediate [11, 14, 20, 21].

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Computed Tomography CT has not proven to be particularly definitive in diagnosing CBDS, where its sensitivity and specificity for detecting CBDS range from 50% to 88% and 84% to 98%, respectively [22, 23]. Sensitivity is diminished further when CBDS are composed of cholesterol, the most common type of secondary stones found in developed countries. The size of CBDS affects diagnosis as well. Stones smaller than 5 mm are underdiagnosed on CT compared with stones larger than 5  mm (57% vs. 81%) [22]. CT often is performed early in the evaluation of patients with abdominal pain, but in patients at risk for CBDS, a negative CT does not exclude CBDS.  If the suspicion for CBDS remains high, a negative CT should not preclude further study with EUS.

Magnetic Resonance Cholangiopancreatography MRCP is most often utilized to evaluate patients at intermediate risk for CBDS. Low risk patients will not benefit from MRCP, and high risk patients typically benefit most from EUS-directed ERCP, direct ERCP, or surgical common bile duct exploration. The sensitivity of MRCP in detecting CBDS is 85–95% and its specificity is 91–100% [2, 11, 16, 24–28]. Sensitivity is lower when smaller stones are present but is dependent also on slice thickness and image acquisition techniques. When MRCP slice thickness is 5  mm, sensitivity for detecting CBDS smaller than 6  mm is 33–71% [16, 26], whereas a slice thickness of 3  mm is associated with 100% sensitivity for CBDS as small as 3 mm [29]. Clinical improvement, normalization of abnormal laboratory values, and a negative thin-slice MRCP indicate clearance of CBDS [15]. When EUS is unavailable, diagnostic algorithms favor MRCP over ERCP for patients with suspected CBDS. MRCP is noninvasive and has almost no associated complications compared with ERCP which has a serious AEs rate of 1–7% [10]. MRCP for the evaluation of patients with suspected CBDS and moderate risk factors helps avoid unnecessary

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ERCP in the 43–80% of patients who will have a negative MRCP in this setting [21, 25, 26, 30]. Liberal use of MRCP in intermediate risk patients may limit the need for EUS in some scenarios, but cost, available expertise, and the ability to follow diagnostic EUS with therapeutic ERCP at the same setting typically influence MRCP utilization in centers where all modalities are available.

Endoscopic Retrograde Cholangiopancreatography ERCP is both diagnostic and therapeutic, and still holds this advantage over almost all other modalities. As a diagnostic tool, ERCP has a sensitivity for CBDS of 89–93% and a specificity of 98–100% [11, 16, 26]. ERCP may miss smaller CBDS, but the clinical significance of these small stones is unclear [11, 31], especially when most endoscopists perform empiric biliary sphincterotomy and duct sweeping even if no stones are identified. Although ERCP is of great utility in the management of CBDS, as a diagnostic modality, it is associated with morbidity ranging from 2% to 7%. ERCP-related AEs include pancreatitis, hemorrhage, and duodenal perforation among others. Mortality from diagnostic ERCP is approximately 1%. ERCP is costly for management of patients at low and moderate risk for CBDS, but when utilized for patients whose risk of CBDS exceeds 80%, ERCP remains a cost-effective choice [32]. AEs related to ERCP can be limited with the use of rectally administered nonsteroidal agents, placement of prophylactic pancreatic stents, and eliminated by utilizing less invasive studies or approaches such as EUS-directed ERCP, an approach that lessens utilization of ERCP by 30–80%, largely by eliminating the need for diagnostic ERCP in patients in whom no CBDS are found during EUS [4, 21, 25, 26, 30]. ERCP has evolved to nearly an entirely therapeutic role as the superior performance and safety parameters of EUS for diagnosis, and for selecting patients who require ERCP for treatment, are difficult to ignore (Fig. 19.2).

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Figure 19.2 Small CBD stone (red arrow) identified in mildly dilated bile duct during radial EUS examination

EUS as a Therapeutic Modality EUS has wide application in the evaluation and treatment of abnormalities of the gastrointestinal tract. Target lesions are those within the luminal organs of the foregut, and rectum, and those solid organs within reasonable approximation to these points of entry. Sonographic evaluation and sampling enhances diagnostic accuracy for mucosal lesions, ­submucosal nodules, solid tumors of the pancreas, liver, bile ducts, gallbladder, lymph nodes, and other structures, and promotes accurate staging of thoracic and abdominal malignancies. EUS is used often to evaluate inflammatory conditions like pancreatitis, and for draining inflammatory collections. Newer techniques, like placement of EUS guided LAMS, permit creation of pathways not native to the gastrointestinal tract [33–35].

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Native GI Anatomy Rendezvous In patients with CBDS, ERCP cannulation is achieved in over 95% of procedures. Acute edema, duodenal diverticulae, and stenotic papillae often are encountered, and these each diminish the rates of successful cannulation during ERCP. In these situations, EUS can be utilized for rendezvous to facilitate ERCP by placing a transampullary guidewire [36, 37]. Rendezvous is performed using a linear echoendoscope, which provides constant visualization of needle passage. With the echoendoscope positioned in the stomach or duodenum, the biliary system is punctured directly using a 22G or 19G needle placed transhepatically into the left intrahepatic biliary system, or transduodenally into the common bile duct, followed by placement of a 0.018″ or 0.035″ guidewire through the needle antegrade through the papilla into the duodenum. The echoendoscope then is withdrawn, leaving the guidewire in place, and a therapeutic duodenoscope then is passed into the duodenum, the guidewire is grasped, and ERCP completed.

Choledochoduodenostomy In the setting of intact native anatomy, an alternative to rendezvous is the creation of a EUS-directed choledochoduodenostomy, especially useful when access to the papilla is not possible due to duodenal obstruction [37]. This consideration is particularly suitable for elderly patients with a bile duct ≥12  mm in diameter, since there are long-term concerns about development of sump syndrome in this cohort. This technique is accomplished through direct needle puncture from the duodenum into the dilated common bile duct (CBD) using a 19G needle, followed by passage of an 0.035″ guidewire that ascends the CBD.  Tapered dilators, balloon dilators, or a stent changer can be used to create a pathway between the duodenum and bile duct, and a covered self-­ expanding metal stent (SEMS) is then deployed.

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Surgically Altered GI Anatomy Although there are a variety of postsurgical anatomical arrangements encountered during therapeutic endoscopy, the most commonly seen are those occurring after Roux-en-Y gastric bypass (RYGB) and after pancreatic resection. In gastric bypass patients with an intact gallbladder who have CBDS requiring treatment at the time of planned cholecystectomy, laparoscopic-assisted ERCP at the time of laparoscopic cholecystectomy is the preferred approach. In this situation, the excluded stomach is accessed intraoperatively to permit ERCP.

Gastrogastric Anastomosis In post-cholecystectomy RYGB patients with CBDS, intraoperative laparoscopic-assisted ERCP is still an option, but EUS-directed therapy has expanded the options available to patients. There are two approaches to RYGB patients with CBDS; the one chosen depends on the urgency of decompression. In patients with CBDS, minimal or resolved symptoms, and no cholangitis, EUS-guided gastrogastrostomy using lumen apposing metal stents (LAMS) permits endoscopic access to the excluded stomach [38]. Using a linear echoendoscope positioned in the gastric pouch, the excluded stomach is identified sonographically and a 19G needle is used to puncture the remnant stomach. A 0.035″ wire is advanced into the remnant stomach, and LAMS is deployed, creating a gastrogastric anastomosis (GGA). The largest diameter LAMS currently available is 15 mm and attempts to pass a standard adult duodenoscope immediately after GGA often results in stent dislodgement and free perforation due to resistance and the angle of entry within the stent as the endoscope is advanced; balloon dilation to fully expand LAMS immediately after deployment has not altered this outcome. Therefore, it is necessary to wait a period of 2–4 weeks prior to performing ERCP through LAMS via the GGA.  It is possible to perform immediate ERCP through

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LAMS when necessary if a pediatric duodenoscope or standard upper gastroscope is used, but pediatric duodenoscopes are not readily available in most endoscopy units and their accessories are limited, and forward viewing gastroscopes make ERCP quite difficult. Once access to the remnant stomach is no longer needed, LAMS are removed and the GGA typically will close spontaneously. It is important to note that LAMS should not be removed earlier than 4  weeks after placement in this setting, and a longer period of time may be advised in patients with poor wound healing or profound malnutrition. A 20  mm LAMS (Axios™, Boston Scientific, Natick, MA, USA) has recently received regulatory approval; this larger device may facilitate immediate ERCP.

Hepaticogastrostomy In patients requiring immediate decompression, especially in the setting of even mild ductal dilation, we prefer EUS-­guided hepaticogastrostomy (HG) for decompressive access [39]. The initial puncture and wire placement are similar to what we described earlier for the rendezvous technique, utilizing a transgastric transhepatic approach through the left lobe of the liver. In this setting, it is not necessary to advance the guidewire across the papilla, although that does not ­contraindicate this approach if transampullary wire placement does occur. After placing the guidewire into the biliary tree, the tract is dilated using a 4–6 mm diameter balloon, and a fully covered self-expanding metal stent (SEMS) is advanced into position and deployed; 10  mm stents that are 6–8  cm in length most commonly are used. This approach provides immediate decompression and establishes a portal for later therapeutic measures, tissue sampling, etc. once a healed fistula has been established. Stone removal may be accomplished after balloon dilation of the ampulla, by advancing stone balloons antegrade through the HG stent and pushing CBDS into the duodenum. Cholangioscopy may be performed via the HG stent for sampling neoplasia, or to facilitate stone extraction,

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and adjuncts like mechanical contact lithotripsy lend themselves well at this point. When placed for benign conditions, the HG stent may be removed after 4 weeks so that a fistulous tract has been established, but in the case of malignant obstruction, HG SEMS commonly are left in place permanently. There are several AEs that accompany the above procedures. Placement of LAMS to create GGA can be associated with free GI tract leak and subsequent peritonitis, usually due to issues complicating stent deployment, or as the result of LAMS dislodgement prior to maturation of the tract. Additionally, there is the concern for a persistent GGA after stent removal, which in the case of RYGB for weight loss could lead to weight regain and gastrojejunal anastomotic ulceration. The persistent GGA typically can be managed endoscopically using over the scope clipping devices or endoscopic suturing devices. The AEs most commonly related to HG are bile peritonitis, which can develop during initial puncture of the obstructed biliary tree, dilation of the tract, or loss of access before stent deployment. Issues with stent deployment itself can result in bile peritonitis or free foreign body if the stent is lost to the peritoneal space. Because these techniques are technically challenging and may require a robust set of endoscopic skills to manage completely, these advanced techniques are best left to endoscopists with a rich experience in advanced endoscopic techniques.

EUS-Guided Gallbladder Drainage EUS-guided gallbladder drainage (EUSGBD), first described in 2007 [40], involves transgastric or transduodenal needle puncture of the gallbladder and transmural placement of stents [41]. Stenting is required whenever two structures are not inherently attached, as in the case of the gallbladder and the duodenum. 4  cm long fully covered SEMS, or 1 cm long LAMS, are utilized most commonly, and both usually are 10  mm diameter devices [42]. EUSGBD

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primarily is performed to treat clinically severe acute cholecystitis in patients who are not operative candidates due to age, illness, sepsis, or other factors. Creation of the stented cholecystoduodenostomy can interfere with or preclude safely performing subsequent cholecystectomy, so candidates must be those in whom subsequent cholecystectomy will not be pursued. EUSGBD also allows internalization of drainage in patients who are deemed not to be operative candidates and who are dependent on percutaneous cholecystostomy catheters as a means to reduce the morbidity associated with percutaneous drains [43].

 US-Guided Drainage of Pancreatic Fluid E Collections Pancreatic fluid collections may result from clinically severe acute pancreatitis, and may be classified either as pancreatic pseudocysts or walled-off pancreatic necrosis (WOPN). EUS-­ guided transmural drainage has been shown to be superior to non-EUS guided endoscopic drainage and radiologic drainage of pancreatic pseudocysts [44], and is considered at least equivalent to surgical cystgastrostomy [45] (Fig.  19.3). The development of larger diameter 15 mm LAMS has simplified the endoscopic drainage of WOPN [46, 47]. The large diameter of current LAMS facilitates the drainage of fluid and debris, while permitting the influx of gastric acid which speeds resolution without the absolute requirement for direct endoscopic necrosectomy (DEN) (Fig.  19.4). If DEN is deemed necessary, a standard or therapeutic gastroscope can be advanced into the necrotic cavity of the fluid collection, and grasping devices, snares, nets, and power irrigation devices used to remove necrotic debris. The duration that LAMS is left in place is highly individualized, depending on the size of the collection, rapidity of debridement, and other important clinical factors. Wire-guided balloon dilation is useful when immediate DEN is planned. Placement of a double pigtail biliary stent in the center of LAMS when used to drain pancreatic fluid collections may facilitate debridement.

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Figure 19.3 Needle puncture of pancreatic pseudocyst with advancement of guidewire in anticipation of placement of LAMS for drainage

Figure 19.4 Endoscopic view immediately after deployment of LAMS to facilitate DEN. Note that a guidewire remains in place to guide balloon dilation or double pigtail biliary stent placement

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Pearls and Pitfalls

1. EUS has superior sensitivity and specificity, 89–98% and 84–100% respectively, for the diagnosis of CBDS compared with clinical presentation, biochemical testing, transabdominal ultrasound, computed tomography, and magnetic resonance imaging/MRCP. 2. EUS is marginally superior to ERCP for the diagnosis of CBDS, but affords patients suspected of having CBDS a significant margin of safety over diagnostic ERCP. ERCP, like surgical common bile duct exploration, should be reserved for the definitive treatment of patients confirmed to have CBDS. 3. EUS-guided rendezvous for treatment of bile duct stones is useful for patients with native gastrointestinal anatomy who have an accessible papilla but have failed ERCP cannulation. 4. EUS directed therapy in patients with surgically altered anatomy may permit treatment of CBDS without the need for reoperation in patients who already have undergone cholecystectomy, but in patients with CBDS who require cholecystectomy, surgical CBD exploration or intraoperative ERCP via the gastric remnant remains preferable. 5. EUS directed HG and EUSGBD are effective methods of achieving biliary decompression in carefully selected patient in whom operative therapy would be too invasive. 6. Drainage of pancreatic pseudocysts and walled off pancreatic necrosis now is widely available and has been simplified by the introduction of LAMS.

References 1. ASGE Standards of Practice Committee, Maple JT, Ben-­ Menachem T, Anderson MA, Appalaneni V, Banerjee S, et  al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1–9.

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2. Schmidt S, Chevallier P, Novellas S, Gelsi E, Vanbiervliet G, Tran A, et  al. Choledocholithiasis: repetitive thick-slab single-shot projection magnetic resonance cholangiopancreaticography versus endoscopic ultrasonography. Eur Radiol. 2007;17(1):241–50. 3. Aljebreen A, Azzam N, Eloubeidi MA.  Prospective study of endoscopic ultrasound performance in suspected choledocholithiasis. J Gastroenterol Hepatol. 2008;23(5):741–5. 4. Petrov MS, Savides TJ.  Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. Br J Surg. 2009;96(9):967–74. 5. Ang TL, Teo EK, Fock KM.  Endosonography- vs. endoscopic retrograde cholangiopancreatography-based strategies in the evaluation of suspected common bile duct stones in patients with normal transabdominal imaging. Aliment Pharmacol Ther. 2007;26(8):1163–70. 6. Lee YT, Chan FKL, Leung WK, Chan HLY, Wu JCY, Yung MY, et  al. Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study. Gastrointest Endosc. 2008;67(4):660–8. 7. Turner BG, Cizginer S, Agarwal D, Yang J, Pitman MB, Brugge WR.  Diagnosis of pancreatic neoplasia with EUS and FNA: a report of accuracy. Gastrointest Endosc. 2010;71(1):91–8. 8. Borie F, Fingerhut A, Millat B. Acute biliary pancreatitis, endoscopy, and laparoscopy. Surg Endosc. 2003;17(8):1175–80. 9. Videhult P, Sandblom G, Rudberg C, Rasmussen IC.  Are liver function tests, pancreatitis and cholecystitis predictors of common bile duct stones? Results of a prospective, population-based, cohort study of 1171 patients undergoing cholecystectomy. HPB (Oxford). 2011;13(8):519–27. 10. Sheen AJ, Asthana S, Al-Mukhtar A, Attia M, Toogood GJ.  Preoperative determinants of common bile duct stones during laparoscopic cholecystectomy. Int J Clin Pract. 2008;62(11):1715–9. 11. ASGE Standards of Practice Committee, Maple JT, Ben-­ Menachem T, Anderson MA, Appalaneni V, et  al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1–9. 12. Einstein DM, Lapin SA, Ralls PW, Halls JM. The insensitivity of sonography in the detection of choledocholithiasis. AJR Am J Roentgenol. 1984;142:725.

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13. Nebiker CA, Baierlein SA, Beck S, von Flue M, Ackermann C, Peterli R.  Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy? Langenbeck’s Arch Surg. 2009;394(6):1005–10. 14. Almadi M, Barkun JS, Barkun AN.  Management of suspected stones in the common bile duct. CMAJ. 2012;184(8):884–92. 15. Sakai Y, Tsuyuguchi T, Yukisawa S, Tsuchiya S, Sugiyama H, Miyakawa K, et  al. Diagnostic value of magnetic resonance cholangiopancreatography for clinically suspicious spontaneous passage of bile duct stones. J Gastroenterol Hepatol. 2008;23(5):736–40. 16. Desai R, Shokouhi BN.  Common bile duct stones  – their presentation, diagnosis and management. Indian J Surg. 2009;71(5):229–37. 17. Peng WK, Sheikh Z, Paterson-Brown S, Nixon SJ. Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis. Br J Surg. 2005;92(10):1241–7. 18. Yang M-H, Chen T-H, Wang S-E, Tsai Y-F, Su C-H, Wu C-W, et  al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2008;22(7):1620–4. 19. Rickes S, Treiber G, Monkemuller K, Peitz U, Csepregi A, Kahl S, et  al. Impact of the operator’s experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis: a prospective comparison using endoscopic retrograde cholangiography as the gold standard. Scand J Gastroenterol. 2006;41(7):838–43. 20. Grönroos JM, Haapamäki MM, Gullichsen R.  Effect of the diameter of the common bile duct on the incidence of bile duct stones in patients with recurrent attacks of right epigastric pain after cholecystectomy. Eur J Surg. 2001;167(10):767–9. 21. Al-Jiffry BO, Elfateh A, Chundrigar T, Othman B, Almalki O, Rayza F, et  al. Non-invasive assessment of choledocholithiasis in patients with gallstones and abnormal liver function. World J Gastroenterol. 2013;19(35):5877–82. 22. Tseng CW, Chen CC, Chen TS, Chang FY, Lin HC, Lee SD. Can computed tomography with coronal reconstruction improve the diagnosis of choledocholithiasis? J Gastroenterol Hepatol. 2008;23(10):1586–9. 23. Lee JK, Kim TK, Byun JH, Kim AY, Ha HK, Kim PN, et  al. Diagnosis of intrahepatic and common duct stones: combined

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unenhanced and contrast-enhanced helical CT in 1090 patients. Abdom Imaging. 2006;31(4):425–32. 24. Topal B, Van de Moortel M, Fieuws S, Vanbeckevoort D, Van Steenbergen W, Aerts R, et  al. The value of magnetic resonance cholangiopancreatography in predicting common bile duct stones in patients with gallstone disease. Br J Surg. 2003;90(1):42–7. 25. Boraschi P, Gigoni R, Braccini G, Lamacchia M, Rossi M, Falaschi F. Detection of common bile duct stones before laparoscopic cholecystectomy. Acta Radiol. 2002;43(6):593–8. 26. Raval B, Kramer L.  Advances in the imaging of common duct stones using magnetic resonance cholangiography, endoscopic ultrasonography, and laparoscopic ultrasonography. Semin Laparosc Surg. 2000;7(4):232–6. 27. Stiris MG, Tennøe B, Aadland E, Lunde OC.  MR cholangiopancreaticography and endoscopic retrograde cholangiopancreaticography in patients with suspected common bile duct stones. Acta Radiol. 2000;41(3):269–72. 28. Kejriwal R, Liang J, Andrewson G, Hill A. Magnetic resonance imaging of the common bile duct to exclude choledocholithiasis. ANZ J Surg. 2004;74(8):619–21. 29. Mendler MH, Bouillet P, Sautereau D, Chaumerliac P, Cessot F, Le Sidaner A, et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol. 1998;93(12):2482–90. 30. Sharma SK, Larson KA, Adler Z, Goldfarb MA. Role of endoscopic retrograde cholangiopancreatography in the management of suspected choledocholithiasis. Surg Endosc. 2003;17(6):868–71. 31. Kubota Y, Takaoka M, Yamamoto S, Shibatani N, Shimatani M, Takamido S, et  al. Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation. J Gastroenterol Hepatol. 2002;17(6):708–12. 32. Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL.  Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc. 2001;15(1):4–13. 33. Mukai S, Itoi T, Tsuchiya T, Tanaka R, Tonozuka R. EUS-guided intrahepatic bile duct stone extraction via choledochoduodenostomy created by a lumen-apposing metal stent. Gastrointest Endosc. 2016;83(4):832–3.

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34. Overby DW, Richardson W, Fanelli R.  Choledocholithiasis after gastric bypass: a growing problem. Surg Obes Relat Dis. 2014;10(4):652–3. 35. Menon S.  EUS in biliary stone disease. Gastrointest Endosc. 2008;68(4):810; author reply -1. 36. Tsuchiya T, Itoi T, Sofuni A, Tonozuka R, Mukai S. Endoscopic ultrasonography-guided rendezvous technique. Dig Endosc. 2016;28 Suppl 1:96–101. 37. Tyberg A, Desai AP, Kumta NA, Brown E, Gaidhane M, Sharaiha RZ, et  al. EUS-guided biliary drainage after failed ERCP: a novel algorithm individualized based on patient anatomy. Gastrointest Endosc. 2016;84(6):941–6. 38. Tyberg A, Nieto J, Salgado S, Weaver K, Kedia P, Sharaiha RZ, et  al. Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc. 2017;50(2):185–90. 39. Siripun A, Sripongpun P, Ovartlarnporn B.  Endoscopic ultrasound-­guided biliary intervention in patients with surgically altered anatomy. World J Gastrointest Endosc. 2015;7(3):283–9. 40. Baron TH, Topazian MD.  Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease. Gastrointest Endosc. 2007;65(4):735–7. 41. Baron TH, Grimm IS, Swanstrom LL. Interventional approaches to gallbladder disease. N Engl J Med. 2015;373(4):357–65. 42. Irani S, Baron TH, Grimm IS, Khashab MA.  EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video). Gastrointest Endosc. 2015;82(6):1110–5. 43. Law R, Grimm IS, Stavas JM, Baron TH. Conversion of percutaneous cholecystostomy to internal transmural gallbladder drainage using an endoscopic ultrasound-guided, lumen-apposing metal stent. Clin Gastroenterol Hepatol. 2016;14(3):476–80. 44. Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM.  Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc. 2008;68(6):1102–11. 45. Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583–90.e1. 46. Siddiqui AA, Kowalski TE, Loren DE, Khalid A, Soomro A, Mazhar SM, et  al. Fully covered self-expanding metal stents

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versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc. 2017;85(4):758–65. 47. Sharaiha RZ, Tyberg A, Khashab MA, Kumta NA, Karia K, Nieto J, et  al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol. 2016;14(12):1797–803. 48. Fanelli RD, Andrew BD.  Making the diagnosis: surgery, a rational approach to the patient with suspected CBD stones. In: Hazey JW, Conwell DL, Guy GE, editors. Management of common bile duct stones: an interdisciplinary textbook. Cham: Springer International Publishing Company; 2016. p. 37–48.

Chapter 20 Management of Pancreaticobiliary Disease: Pseudocyst Garrett Filas Mortensen, Vladimir Davidyuk, and Gary C. Vitale

Learning Objectives

1. To outline the indications for endoscopic drainage of pseudocysts. 2. To articulate the benefits of endoscopic versus operative debridement of pancreatic necrosis. 3. To understand follow-up recommendations and stent management recommendations following endoscopic cyst-gastrostomy.

G. F. Mortensen Medical Associates Department of Surgery, Dubuque, IA, USA ERCP and Pancreaticobiliary Surgery, University of Louisville, Louisville, KY, USA V. Davidyuk ERCP and Pancreaticobiliary Surgery, University of Louisville, Louisville, KY, USA Albany Medical Center, Department of Surgery, Albany, NY, USA G. C. Vitale (*) University of Louisville School of Medicine, Department of Surgery, Louisville, KY, USA © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_20

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4. To outline potential complications of endoscopic pseudocyst drainage and to understand their subsequent management.

Introduction The diagnoses of pancreatic pseudocyst, organized necrosis, and pancreatic abscess fit under the heading of pancreatic fluid collection (PFC) that occurs as a sequelae of injury to the pancreatic main or side duct. Injury comes from a variety of causes, but in general, endoscopically directed therapy’s goal is drainage. This chapter discusses several different methods to accomplish this. Any PFC should be thoroughly assessed as to the origin of the collection such as injury or cystic neoplasm, whether the collection has solid component or is purely or mostly liquid. The anatomy of the pancreatic duct and its connection to the collection is another important aspect that predicts the success of long-term drainage and recurrence.

Indications for Drainage The drainage of a PFC should be individually assessed with every patient and based on symptomatology and infection rather than mere presence on imaging studies. Many patients may be asymptomatic with substantial (>6  cm) sized ­collections and remain that way with minimal risk of bleeding, infection, or rupture [1]. Expectant observation of an asymptomatic PFC must be weighed against the risks of drainage, mainly infection and bleeding. Infection of a PFC is an indication for drainage. In the asymptomatic patient, enlargement on imaging over time or partial gastric outlet obstruction may also represent indications for drainage. In necrotizing cases, allowing as much time as possible for cyst evolution, liquefaction, and organization of the necrotic debris is very important [2, 3]. Some necrotic collections will

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resolve spontaneously, while others will evolve from a diffuse, indistinct necrotic mass to a well-formed pseudocyst with homogeneous contents.

Pre-procedure Imaging Before attempting drainage, the collection should be evaluated for several factors. It is important to ensure that the collection is not a cystic neoplasm. If there is not a well-documented injury of either acute or chronic pancreatitis, there should be high suspicion for the possibility of a cystic neoplasm. Further evaluation with magnetic resonance imaging (MRI) or endoscopic ultrasound (EUS) with aspiration should be completed. There should be a good understanding of the individual collection in regard to its solid and liquid components as well as the surrounding anatomy such as bowel lumen and ductal and vascular structures. We generally evaluate PFCs through a three-phase protocol computed tomography (CT). In addition to a full evaluation with a history and physical exam, laboratory studies to evaluate the liver, pancreas, and coagulation should be undertaken (i.e., comprehensive metabolic panel, lipase, and prothrombin time).

Consent A full consent process includes a discussion of the potential complications of bleeding, perforation, infection, and the potential need for surgical intervention. The possibility of an immediate open operation and drainage should be discussed in the event that severe complications such as bleeding, perforation, or loss of access occur. In higher risk cases, this surgical consent should be obtained prior to the endoscopic intervention, since the patient could potentially need to go direct to surgery during same anesthesia. Although the risk is low, if it occurs, the presence of a pre-procedure surgical consent documenting discussion may be helpful for patient/ family acceptance and legal issues.

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Transpapillary Pseudocyst Drainage A careful review of patient’s imaging is necessary to delineate the relationship of the pancreatic pseudocyst to the pancreas. Transpapillary drainage of pseudocysts is likely to be successful in cases where a definite or suspected communication to the pancreatic duct (PD) exists [4]. If there is no communication, then a transgastric or a trans-duodenal approach is more appropriate. If a trans-enteric route is not easily accomplished, a trial of pancreatic stenting via endoscopic retrograde cholangiopancreatography (ERCP) even in the absence of demonstrated direct communication to the pseudocyst helps. Decompression of the ductal system reduces pressure in the pancreatic duct which seems to be therapeutic in some cases [2, 4]. The transpapillary approach is also appropriate in cases with trauma to the pancreatic duct or pancreatic ascites associated with disrupted pancreatic duct.

Necessary Equipment 1. A dedicated fluoroscopy room that is capable of both fluoroscopy and endoscopy. Alternatively, the procedure could be done in endoscopy or the operating room with a C-arm and a fluoroscopy-compatible Table. 2. A side-viewing endoscope with a 3.7 mm working channel. Linear EUS scope is optional and extends indications to cysts adjacent to but not indenting the bowel lumen. 3. Catheters and sphincterotomes for accessing the pancreatic duct. A 0.035 in wire is generally used; however, wires with a smaller diameter may be necessary. An angled-tip wire frequently is necessary to navigate the tortuous pancreatic duct. 4. Contrast agent such as iohexol for pancreatography. Intravenous glucagon can be used to decrease duodenal peristalsis to aid cannulation.

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Patient Preparation 1. Patient should be thoroughly informed of the risks and benefits of the procedure. There is always a small risk of perforation or bleeding. Occasionally this intervention can lead to exacerbation of pancreatitis. Patients need to be advised that the stent will need to be re-evaluated at repeat endoscopy within 2 months and sometimes multiple interventions are necessary. 2. We recommend general anesthesia for this procedure. Patients with pancreatic disease are frequently in poor health and often suffer from alcoholism. They may be difficult to sedate or may experience hemodynamic instability. Intubation also decreases the respiratory motion and makes cannulation of the pancreatic duct easier. 3. After intubation, the patient should be placed in a semi-­ prone position, with the right side elevated by a roll placed lengthwise under the torso. The head is turned to the right. The left arm is placed at the patient’s side.

Transpapillary Drainage Step-by-Step 1. The duodenoscope is introduced through the mouth and advanced through the esophagus and stomach and positioned in the duodenum. Due to the side-viewing nature of the duodenoscope, this is essentially a blind maneuver. Advancing the scope through the pylorus is akin to walking through a doorway while looking at the ceiling. 2. A sphincterotome and guidewire are used to cannulate the PD under fluoroscopic guidance. The PD is generally oriented in the ampulla at 2–3 o’clock position. In the case of a difficult cannulation, different catheters and wires should be tried. Once the duct is cannulated, a pancreatogram is done to delineate the pancreatic duct and the pseudocyst cavity. 3. A pancreatic sphincterotomy is then performed using with the sphincterotome oriented to the 3 o’clock position.

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4. The wire should be advanced into the distal pancreatic duct beyond the pseudocyst cavity, and a 7 Fr pancreatic stent is advanced over the wire. The stent should be long enough to cross the site of the pseudocyst or duct disruption. Stents as long at 18 cm may be used for pseudocysts in the tail of the pancreas. 5. When the guidewire cannot be passed into the pseudocyst cavity or into the distal duct, a pancreatic stent should be placed in the duct as close as possible to the pseudocyst.

Post-procedure Management 1. The pseudocyst should be evaluated by CT scan several weeks after drainage. 2. When successful, most cysts demonstrate rapid resolution. 3. Repeat ERCP and stent removal should be done 6–8 weeks after the initial procedure. The stent may need to be replaced if significant pseudocyst remains. 4. If the tail of the pancreas is not visualized at initial ERCP, then the distal duct may be obstructed and feeding the pseudocyst. An MRCP should be used to delineate the anatomy, and transmural drainage may be necessary for these patients.

 ransmural Pseudocyst Drainage Using T Side-­Viewing Scope Patients with pseudocysts that abut the gastric or duodenal wall without communication to the pancreatic duct are best suited for transmural drainage. CT imaging should be done to determine whether the pseudocyst indents the lumen which is necessary to safely do the procedure.

Necessary Equipment 1. Fluoroscopy table setup, side-viewing endoscope as noted above for transpapillary drainage.

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2. A Cremer cystotome (Cook Medical, Bloomington, IN, USA) is our preferred method for draining pseudocysts. It combines a removable needle knife with a 10 Fr electrocautery ring to enlarge the cyst-gastrostomy. It also allows advancement of the guidewire into the cyst cavity without removing the catheter. 3. Double-pigtail 10 Fr plastic stents are used to keep the cyst-enterostomy open.

Patient Preparation 1. Informed consent should be obtained after a detailed discussion with the patient about the risks of the procedure. 2. We recommend general anesthesia for this procedure. This decreases the risk of aspiration after the cyst is accessed and fluid flows into the stomach. It also prevents patient movement which can lead to loss of access to the cyst during critical portions of the procedure. 3. The patient is usually placed in the semi-prone position as noted above. This procedure can also be done in the supine position.

Transmural Drainage Step-by-Step 1. The side-viewing scope is advanced into the stomach or duodenum, and the indentation of the pseudocyst is identified (Fig. 20.1). This should correspond to the location of the cyst on CT scan. The site of the cyst-enterostomy should be chosen using both endoscopic view and pre-procedure imaging. The goal is to find the area of greatest indentation and the thinnest cyst wall. 2. The needle knife is then used to puncture into the pseudocyst while using the cut function on the electrocautery (Fig. 20.2). The catheter is then advanced into the pseudocyst. It is important to keep knife perpendicular to cyst. 3. A 450 cm, 0.035in guidewire with a flexible tip is advanced through the catheter under fluoroscopic guidance, and the

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Figure 20.1  Endoscopic view of a large pancreatic pseudocyst bulging into the gastric lumen

Figure 20.2  Needle knife cystotome entering into pseudocyst using cautery

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Figure 20.3  Fluoroscopic image of wire placement into pseudocyst through gastric wall. Note the anticipated coiling of the wire within the cyst cavity

needle knife catheter is removed. The guidewire should coil within the cyst cavity (Fig. 20.3). 4. The cystotome catheter is then advanced, and the external circumferential electrocautery ring is used to enlarge the cyst-gastrostomy using the coagulation function on the cautery (Fig. 20.4). 5. If necessary, a controlled radial expansion balloon can be passed over the wire and is used to further expand the size of the cyst-gastrostomy (Figs. 20.5 and 20.6). 6. A stent guide and a 10 Fr double-pigtail stent of appropriate length are advanced into the cyst cavity. The pigtails anchor the stent within the cyst and the enteric lumen (Fig. 20.7). 7. We then use a sphincterotome catheter to advance the wire along the existing stent with fluoroscopic guidance and place a second double-pigtail catheter. Two stents are used to facilitate drainage alongside the stents as well as through them.

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Figure 20.4  Circumferential cautery of a cystotome is used to widen the cyst-gastrostomy

Figure 20.5  Controlled radial expansion balloon dilatation of cyst gastrostomy

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Figure 20.6  Endoscopic appearance of cyst-gastrostomy tract following balloon dilatation

Figure 20.7  Gastric portion of a 10 Fr double-pigtail stent placed through cyst gastrostomy into pseudocyst. Note prompt drainage of fluid through and around the stent and into the gastric lumen

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8. Covered metallic stents can alternatively be used, but for security, double-pigtail stent(s) should be placed through them to anchor it and reduce chance of migration. Internal migration can be a particularly troubling complication of metal stents (Figs. 20.1, 20.2, 20.3, 20.4, 20.5, 20.6, and 20.7).

Post-procedure Management We recommend repeat CT scan at 2–3 months. The double-­ pigtail stents are generally safe to stay in place for a 1 year, because even in the case of occlusion, drainage continues between the stents. We generally leave the stents in until cyst is fully drained or for 1 year and then remove them.

 ransmural Drainage Using Endoscopic T Ultrasound An echoendoscope should be used if there is not a significant indentation into the stomach or duodenal lumen to otherwise safely identify the pseudocyst endoscopically. Using ultrasound also allows identification of any vascular structures and the distance of the common wall between the pseudocyst lumen and the gastrointestinal tract. A thickness less than 1 cm is ideal. Some endoscopists prefer to use the echoendoscope for all drainage procedures. Double-pigtail stents or a self-expanding lumen apposing metal stent (LAMS) can be used. Success rate for EUS drainage has been over 90% with a less than 5% complication rate [5].

Double-Pigtail Stent Technique Necessary Equipment 1. A dedicated fluoroscopy and endoscopy suite. 2 . A therapeutic linear echoendoscope with a working channel of 3.7–3.8 mm.

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3. 19 gauge FNA needle to allow for 0.035 wire 4 . Either 0.035 or 0.025 guidewire. 5. Over the wire biliary balloon dilator or Soehendra biliary dilators. 6. Double-pigtail stents of sized either 7, 8, 8.5, or 10 Fr.

Patient Preparation 1. Informed consent should be obtained after a detailed discussion with the patient about the risks of the procedure including bleeding, infection, perforation, and possible need for open operation. 2. General anesthesia and the risks involved should also be discussed. We recommended general anesthesia as this decreases the risk of aspiration after cyst decompression and also decreases spontaneous movement and possible decannulation during access. 3. The position of the patient can vary from either supine or semi-prone and may vary based on the location of the pseudocyst and patient comfort and padding.

 ransmural Drainage: Double-Pigtail Stent T Technique Step-by-Step 1. The echoendoscope is advanced into the stomach or duodenum, and the location of the pseudocyst is identified. Doppler should be used to identify any blood vessels in the needle path. The thickness of the common wall should be measured, and the location with the thinnest wall should be used. Ideally this should be less than 1 cm. 2. A 19 gauge FNA needle is introduced into the cyst under direct EUS guidance, and a 0.035 inch guidewire is then introduced through the needle and coiled in the pseudocyst under fluoroscopic guidance. The needle is then removed. 3. The cystostomy is then enlarged using a variety of techniques.

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(a) Soehendra dilators can be used to dilate the cystostomy, but they are limited by diameter of operating channel. These are tapered dilators that go over the wire and can dilate the tract up to 11.5 Fr. (b) Preferably, an over-the-wire controlled radial expansion dilating balloon can be used to dilate the tract to a larger diameter. (c) Historically, an over-the-wire needle knife or sphincterotome can be used to enlarge the opening, but it is not our preferred approach as bleeding rate seems to be higher using these instruments. 4. A cystotome can be used, with or without ultrasound guidance, to access the cyst cavity and to enlarge the tract. The pseudocyst is entered with the tip of the cystotome using the cut function. The inner cannula is then replaced with a 0.035 inch guidewire which is coiled in the pseudocyst under fluoroscopy. The outer sheath circumferential electrocautery is then used to cauterize and enlarge the tract and removed for further dilation and stent placement. 5. A stent guide is then placed over the wire, and a double-­ pigtail stent is placed over the wire. 6. Another wire is then placed alongside the stent, and a second double-pigtail stent is placed. 7. Covered metallic stents can be used, but due to their high risk of migration, placement of double-pigtail stents through them is now standard. Their utility lies in expanding the opening to prepare for trans-enteral endoscopic debridement of necrosis. They should be used only temporarily to create the fistula and then be replaced by multiple plastic double-pigtail stents for longer-term management. They are subject to same complication issues as mentioned for the LAMS noted below.

Post-procedure Management We recommend repeat CT scan at 2–3 months. These stents are safe to stay in for as long as 1 year, because even in the case of occlusion, drainage continues between the stents. We

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generally remove stents at 1  year. The reason for leaving them in longer is that this provides drainage for the disconnected tail of pancreas tissue and may reduce early recurrence. Longer-term atresia or scarring of the remaining pancreas may occur, or the fistula created by the stent may become more permanent, and risk of recurrence is reduced. The use of double-pigtail plastic stents reduces recurrence and avoids migration. Internal migration of the stent, however, may require surgical intervention and intermittent CT, and endoscopic surveillance is indicated in hopes to catch this migration in progress before the stent becomes irretrievable.

Lumen-Apposing Metal Stent Technique An alternative to the plastic double-pigtail stents are self-­ expandable LAMS [6, 7]. The first and most common LAMS is the AXIOS™ stent (Boston Scientific, Natick, MA, USA). It is a short, barbell-shaped, fully covered metallic stent. The wide flanges on either end of the stent help hold it in place once it is deployed. Traditionally, LAMS is advanced over a wire after accessing the cyst with a 19 gauge needle. The newest deployment system does not require separate needle access or an exchange over a wire.

Necessary Equipment 1. A dedicated fluoroscopy and endoscopy suite as noted above. 2 . A therapeutic linear echoendoscope with a working channel of 3.7–3.8 mm. 3. Stent delivery system with a preloaded LAMS of appropriate size.

Patient Preparation Similar to above, a detailed consent should be obtained. We generally prefer general anesthesia. Patient is generally in the supine or left lateral decubitus position.

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LAMS Deployment Step-by-Step 1. The echoendoscope is used to identify the optimal site for cyst drainage as noted above. 2. The catheter is advanced against the gastrointestinal wall until it is visible on ultrasound, and the cut setting is used to create the cyst-enterostomy and push the catheter into the cyst. 3. The catheter is locked, and the distal stent flange is deployed by pulling on the deployment hub. The flange should be visible on ultrasound opening up within the cyst cavity. 4. The endoscope is pulled back slightly to bring the distal flange against the cyst wall using ultrasound guidance. A black catheter shaft should be visible on endoscopic view. If it is not visible, then the catheter can be unlocked and pulled back slightly. Care must be taken not to pull back aggressively as one risks tearing the stent through the cyst wall, particularly if the collection is not well matured. 5. The stent deployment hub is then pulled up to release the proximal flange within the gastrointestinal lumen as the scope is pulled back. 6. LAMS comes in 1 cm, 1.5 cm, and 2 cm diameters.

Additional Interventions Graspers and snares can be used to break up walled-off necrosis after the stent is placed [3]. The cyst cavity can also be entered with the endoscope through the stent itself for additional interventions and debridement.

Post-procedure Management We recommend repeat CT scan in approximately 3  weeks. Due to rapid resolution of the cyst with large diameter stents and potential pressure from the stent on surrounding vessels, LAMS should be removed as soon as the cavity resolves.

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Complications of Lumen-Apposing Metal Stents The most common complications include bleeding (0–25%), perforation (0–3%), migration (0–19%), buried stent (0–17%), and failure to deploy (0–9%). Removal of LAMS as soon as possible is recommended to reduce risk of these complications, particularly bleeding. 1. Bleeding may be due to mucosal oozing, erosion into the splenic artery or its branches, or bleeding from within the pancreatic fluid collection. (a) Mucosal bleeding usually stops with radial force from the lumen-apposing metal stent. (b) Bleeding from within the necrotic fluid collection is usually not amenable to endoscopic control, and angio-embolization or surgery may be necessary. (c) Recommend to do CT scans in 3–4 weeks, and remove the stent as soon as the fluid collection has resolved. 2. Stent migration can occur immediately or several weeks later and can migrate into the lumen or into the fluid cavity. Endoscopic removal should be attempted as soon as migration is recognized. (a) If migration has occurred into the bowel lumen and not able to be retrieved endoscopically, then serial X-ray should be done to confirm passage. Bowel obstruction can occur and require surgical intervention. (b) For migration into the cyst cavity, the cyst-gastrostomy tract should be reestablished endoscopically, and stent should be retrieved using snare or forceps. If this is not successful, then surgery is indicated. 3. Buried stent occurs when enteric mucosa grows over the stent. Needle knife or argon plasma can be used to uncover the stent, and snare or forceps can be used to remove the stent. 4. The perforation risk specific to pseudocyst drainage can involve the stomach or separation of the walls of the stomach and the cyst.

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(a) This risk can be minimized by carefully selecting a site for the cyst-gastrostomy where less than 1 cm separation between the lumen of the stomach and cyst cavity exists. If the perforation is recognized at the time of procedure and it is small, then over the scope clips or endoscopic suturing may be attempted to close the defect. (b) Patients should be evaluated with a CT scan to determine the extent of perforation. Stable patients may be managed with nonsurgical measures such as antibiotics and nasogastric suction. Surgery is warranted if perforation is large or in patients with worsening clinical status. 5. Stent occlusion should be suspected if the patient does not show expected decrease in cyst size or has a worsening clinical course after initial improvement. (a) Placement of double-pigtail stents through the cyst lumen may decrease the risk of stent occlusion [8]. (b) Treatment of an occluded stent involves removal of debris from stent lumen using forceps, snares, or nets.

Discussion Timing of pseudocyst drainage is one of difficult balance. Waiting too long is complicated by cyst infection, hemorrhage, or leakage into peritoneal cavity by necrosis of cyst wall. These occurrences can make further interventions more complicated and reduce management options. Draining pseudocysts or necrosis too early on the other hand is more difficult, increases complications, and may result in an inadequate drainage. Early drainage also does not take into account the natural history of spontaneous involution of these collections which occurs frequently enough that expectant observation is often an appropriate course of action. If the patient is stable,

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without infection or obstructing symptoms, then observation is appropriate, even for large cysts. As long as serial imaging demonstrates stability, slow improvement, or increased homogeneity and liquefaction of necrosis, observation is warranted. Deciding which procedure to use is dependent on anatomy and operator experience, particularly with EUS. Although the all-in-one LAMS approach is relatively easy, the cost of the stent plus the need to remove it so quickly argues against its use in straightforward cases. Multiple double-pigtail stents, whether placed with or without EUS control, will provide a cyst-enterostomy fistula. This permits rapid cyst drainage as well as debridement of necrotic material over time. These plastic stents are relatively inexpensive and can be left for long periods of time or exchanged, while the cyst involutes. It is, however, prudent for surgeons doing endoscopic drainage of pseudocysts to obtain training in EUS in order to be fully equipped to handle all aspects of these cases.

Pearl and Pitfalls

1. Endoscopic management of pseudocyst should not be attempted without endoscopic ultrasound unless there is a clear and visible bulge seen in the stomach or duodenum at the time of endoscopy. 2. If gastric varices are present, then endoscopic ultrasound approach is mandated. 3. If cyst is located in the pancreatic neck or head area, a transpapillary stenting approach should be tried first prior to considering transgastric drainage. 4. For larger cysts, two stents side by side are warranted to allow drainage between the stents long term. If the stents obstruct, they do not need an exchange if there are two side by side.

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5. Balloon dilatation after creation of the endoscopic cyst-­gastrostomy is helpful to allow entrance of the tip of the scope into the pseudocyst. The technique is to use a dilating balloon of the same diameter or slightly larger than the scope and push the scope into the pseudocyst immediately following the balloon under fluoroscopic guidance. 6. Aggressive debridement of necrosis is not necessary and can lead to hemorrhage. Breaking up the necrotic tissue with large drainage catheters (10 Fr) is often satisfactory.

References 1. Samuelson AL, Shah RJ. Endoscopic management of pancreatic pseudocysts. Gastroenterol Clin N Am. 2012;41:47–62. 2. Sharma SS, Bhargawa N, Govil A. Endoscopic drainage of pancreatic pseudocysts: a long-term follow-up. Endoscopy. 2002;34(3):203–7. 3. Tarleja JP, Kahale M.  Endotherapy for pancreatic necrosis and abscess: endoscopic drainage and necrosectomy. J Hepato-­ Biliary-­Pancreat Surg. 2009;16(5):605–12. 4. Vitale GC, Davis BR, Vitale M, Tran TC, Clemons R. Natural orifice transluminal endoscopic drainage for pancreatic abscesses. Surg Endosc. 2009;23(1):140–6. 5. Ahn JY, Seo DW, Eum J, Song TJ, Moon SH, Park DH, et  al. Single-step EUS-guided transmural drainage of pancreatic pseudocysts: analysis of technical feasibility, efficacy, and safety. Gut Liver. 2010;4(4):524–9. 6. DeSimone ML, Asombang AW, Berzin TM.  Lumen apposing metal stents for pancreatic fluid collections: recognition and management of complications. World J Gastrointest Endosc. 2017;9(9):456–63. 7. Itoi T, Nageshwar Reddy D, Yasuda I.  New fully covered self-­ expandable metal stent for endoscopic ultrasonography-guided intervention in infectious walled-off pancreatic necrosis. J Hepatobiliary Pancreat Sci. 2013;20(3):403–6. 8. Aburajab M, Smith Z, Khan A, Dua K.  Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocyst. Gastrointest Endosc. 2018 May;87(5):1248–55.

Chapter 21 Pancreaticobiliary Options in Patients with Altered Surgical Anatomy Konstantinos Spaniolas and Anthony J. Hesketh

Learning Objectives

1. Understand the effect of different post-surgery configurations on biliopancreatic access. 2. Discuss alternative endoscopic modalities for biliopancreatic access. 3. Discuss combination of surgical and endoscopic methods for alternative biliopancreatic access.

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a widely accepted and highly successful procedure for evaluating and treating biliopancreatic disorders. However, conventional ERCP in patients with surgically K. Spaniolas (*) · A. J. Hesketh Stony Brook University, Department of Surgery, Stony Brook, NY, USA e-mail: [email protected] © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_21

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altered gastrointestinal anatomy can be technically difficult with a high rate of complications. Technical failures are reported as high as 67%, perforation rates may be as high as 17%, and mortality 3%. Although biliary drainage procedures such as percutaneous transhepatic cholangiography and surgical biliary exploration may serve as alternative means to accessing the biliary tree, they too are associated with high morbidity and mortality rates [1]. Consequently, this chapter will highlight alternative endoscopic options for accessing the biliopancreatic tree in patients with altered surgical anatomy. Surgically altered gastrointestinal anatomy is frequently encountered by the endoscopist in patients who have previously undergone foregut surgery (Fig. 21.1a–f). Billroth I or II reconstructions may be encountered in patients who previously underwent antrectomy for complicated peptic ulcer disease, although these operations have become increasingly rare with advances in medical management. Roux-en-Y anatomy, with or without a native papilla and with variable length limbs, poses a more commonly encountered barrier for the endoscopist accessing the biliopancreatic tree. Roux-en-Y anatomy may be utilized for the reconstructive component of various operations, including total or partial gastrectomy, gastric bypass for obesity, pancreaticoduodenectomy, liver transplant, and other biliary reconstructions. The length of the biliopancreatic limb encountered in Roux-en-Y anatomy or the afferent limb of Billroth II anatomy can make accessing the biliary tree with a standard duodenoscope particularly complex, confounded by the reversed papillary orientation encountered during the retrograde approach. Although the linear reconstructed anatomy of the gastroduodenostomy encountered in a Billroth I reconstruction may make positioning the ERCP catheter along the axis of the bile duct technically challenging, this chapter will focus on biliopancreatic access in the longer intestinal limbs encountered in Roux-en-Y and Billroth II anatomies.

Afferent Efferent limb limb

Efferent limb

Afferent limb

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Efferent Afferent limb limb Efferent limb

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Efferent limb Braun anastamosis

Afferent limb

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Excluded stomach

Figure 21.1 (a–f) Altered surgical anatomy common encountered in patients requiring ERCP. (a) Billroth II, (b) Billroth II with Braun anastomosis, (c) hepaticojejunostomy with Roux-en-Y reconstruction, (d) pancreaticoduodenectomy with Roux-en-Y reconstruction, (e) pylorus-preserving pancreaticoduodenectomy, (f) Roux-en-Y gastric bypass

d

Afferent limb

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Roux-en-Y Anatomy With a 100–150 cm afferent limb and a 60–100 cm biliopancreatic limb, it is not possible to reach the papilla with a duodenoscope using standard endoscopic techniques. Furthermore, the acute angle of the jejunojejunostomy can be difficult to navigate, particularly with a side-viewing endoscope. Endoscopic and surgical assistive techniques are employed to successfully navigate Roux-en-Y anatomy. These include the use of longer enteroscopes, overtube-assisted enteroscopy, endoscopic ultrasound, and surgical gastroenterotomy. When deciding on the appropriate approach for a particular patient, it is important to discuss specifics about their anatomy with the original operative surgeon, to read their operative reports, and to study preprocedural imaging. Factors that may influence ultimate choice of approach include the length of the afferent limb, the presence of a native papilla versus a biliopancreatic anastomosis, the likelihood of therapeutic maneuvers and need for subsequent biliopancreatic access, the patient’s surgical risk, and the local availability of resources and expertise. When accessing a native papilla, it is best to attempt enteroscopy with a standard duodenoscope as the sideviewing scope and instrument elevator simplify cannulation of the bile duct. While transoral duodenoscopy with a standard side-­viewing duodenoscope may be possible in short afferent limb anatomy, it is only successful in one-third of overall attempts in patients with Roux-en-Y anatomy [2]. Alternatively, bilioenteric or pancreaticoenteric anastomoses are more sufficiently cannulated using forward-viewing endoscopes. Enteroscopes or colonoscopes may be utilized for short limb anatomy, and deep enteroscopic techniques such as balloon-­assisted or spiral enteroscopy are able to reach and cannulate the papilla in 84% and 94% of cases, respectively [3]. Successful utilization of forward-viewing enteroscopes may be limited by tip deflection during accessory use through the working channel, and overall maneuverability is restrained by scope torsion and loop formation.

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The absence of an instrument elevator may also impede successful biliary cannulation. If unable to access the papilla, forward-viewing endoscopes may be utilized to place a guidewire or an anchoring stone-extracting balloon in the stomach or biliopancreatic limb, over which a side-viewing duodenoscope may then be passed. Utilization of this technique allows for successful native papillary access in many patients with long-­limb Roux-en-Y anatomy [4].

Overtube-Assisted Enteroscopy Deep enteroscopy may be performed with double-balloon, single-balloon, or spiral enteroscopes. These techniques utilize the assistance of a balloon-fitted or spiral overtube, which serve to withdraw and pleat loops of small bowel over the enteroscope. Deep enteroscopy brings with it the same limitations as other forward-viewing enteroscopic techniques, namely, limited maneuverability, a lacking instrument elevator, and few accessories capable of traversing the scope length (Fig.  21.2). The overall success rate of overtube-­ assisted ERCP in patients with altered surgical anatomy approaches 75%. Successful access is more likely in Billroth II and Roux-en-Y hepaticojejunostomy reconstructions compared with the longer limb and native papillary anatomy of Roux-en-Y gastric bypass patients [5]. In double-balloon enteroscopy, the enteroscope is advanced while repeatedly inflating/deflating balloons at the distal tip of both the overtube and enteroscope. Single-­ balloon enteroscopy employs a similar technique; except rather than using a balloon at the tip of the enteroscope as a distal anchor for the advancement of the overtube, the flexible tip of the scope itself serves to anchor the small bowel. These enteroscopes are typically 200  cm in length, limiting their use with conventional accessories. However, a 155  cm double-balloon enteroscope (EI-580BT; Fujifilm, Tokyo, Japan) is available which is compatible with shorter ERCP accessories [6]. Additionally, the double-balloon

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Figure 21.2  Single-balloon enteroscopy-assisted ERCP in a Rouxen-Y gastric bypass patient. Enteroscope cannulation of the biliary tree in a looped position. Note that the bile duct is being cannulated from below (inferiorly) taking a straight, retrograde approach to the ampulla. (Used with permission of Elsevier from Moreels [8])

overtube may be modified by leaving it in place and cutting it on the side opposite of the balloon pressure line, allowing for the passage and advancement of a standard upper endoscope while maintaining balloon inflation [7]. Successful cannulation by double-balloon enteroscopy is observed in greater than 80% of cases [8], whereas the success rate of single-­balloon enteroscopy is slightly less, in the range of 60–80% [9]. Spiral enteroscopy is a recently developed technique that utilizes an overtube equipped with a 21 cm soft, hollow spiral at the distal end (Fig. 21.3) [10]. Rotation of the spiral overtube draws the small bowel proximally and pleats it over the tube. It is technically simpler to use than balloon-assisted enteroscopy with a shorter learning curve. It has a similar efficacy to balloon-assisted enteroscopy

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Figure 21.3  The Endo-Ease Discovery SB® spiral overtube can be intubated with an enteroscope to permit advancement of a short scope deep into the small bowel. (Used with permission of Spirus Medical, LLC, West Bridgewater, MA, USA)

with up to 80% success rate [11]. A motorized spiral overtube has also been developed which can be used to evaluate as far as 250 cm distal to the ligament of Treitz within 20 minutes [12].

Laparoscopic-Assisted Transgastric ERCP For clinical scenarios in which deep enteroscopy cannot be performed, surgical assistance may be required for transgastric endoscopic access. Laparoscopic-assisted transgastric ERCP is especially useful in the evaluation and management of biliopancreatic disease in post-Roux-en-Y gastric bypass patients as it allows direct endoscopic access to the bypassed stomach. Transgastric ERCP was first described using a formal gastrostomy which could then be endoscopically intubated after allowing time for tract maturation, although contemporary laparoscopic-assisted techniques allow for the immediate passage of a duodenoscope. ERCP can be performed intraoperatively, or mature gastrostomies may be accessed after dilation of the gastrocutaneous tract. Methods utilizing deep enteroscopy have been described to create a percutaneous endoscopic gastrostomy within the remnant stomach, deploying a self-expanding metal stent to enable simultaneous passage of a duodenoscope for antegrade access (Fig.  21.4) [13]. Regardless of technique, transgastric

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Figure 21.4 Percutaneous transgastric stent and gastrointestinal T-anchors permit direct access to the remnant stomach allowing ERCP with traditional equipment. (Courtesy of Eric M. Pauli, MD)

access has the advantages of allowing the use of a standard side-viewing duodenoscope, compatible with conventional accessories, as well as approaching the papilla in its traditional, non-reversed orientation. The main difference in performing the procedure is that the patient remains in a supine position rather than a modified swimmers (prone) position. The endoscopist must alter their position relative to the patient, and the endoscope approach to the papilla will be at a slightly different angle, which can make cannulation slightly harder than peroral performed ERCP. Although this approach is more invasive, it has a higher rate of success compared with balloon-assisted enteroscopy [14], as high as 98.5% in Roux-­ en-­Y gastric bypass patients [15].

Technique To perform laparoscopic-assisted transgastric ERCP, three 5 mm trocars are placed in an orientation similar to laparoscopic gastrostomy, and pneumoperitoneum is achieved. Stay sutures are placed on opposite sides of the anterior gastric

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Figure 21.5 (a, b) Laparoscopic gastric access for transgastric ERCP. (a) Sutures anchor the remnant stomach to the anterior abdominal wall. (b) A 15 mm laparoscopic trocar is placed intragastric allowing for secure transgastric access during endoscopic manipulations. (Both: Used under the Creative Commons Attribution License 4.0 from Habenicht Yancey et al. [25])

wall close to the greater curve and exteriorized through the anterior abdominal wall to secure the transgastric access during endoscopic manipulations (Fig.  21.5a, b). Heavy sutures, such as 1-0 polyglactin, are placed through the gastric wall laparoscopically and then retrieved percutaneously using an endoscopic suture passer. A purse-string suture can also be placed to help with gas seal during endoscopy, but this is often not required and may in fact preclude subsequent access by preventing tract dilation. Electrocautery is then used to create a gastrotomy at this site through which a left upper quadrant 15 mm trocar is placed intragastric. It is often useful to place this trocar with an angle toward the antrum, as it will further facilitate advancement of the endoscope in the duodenum. Angulation of the trocar away toward the fundus can make subsequent steps difficult. Tension is placed on the stay sutures and/or the purse string to maintain insufflation, and a bowel clamp can be placed on the biliopancreatic limb proximal to the jejunojejunostomy to prevent distal bowel distention. The sterile field is then redraped, exposing only the 15  mm trocar, through which a side-viewing duodenoscope can then be advanced and an ERCP performed

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Figure 21.6  Laparoscopic-assisted transgastric ERCP. Laparoscopic port placed lateral to the anticolic, antigastric alimentary limb but directed toward the duodenum to permit correct endoscope manipulation without excessive torque on the gastric wall

(Fig.  21.6). Alternatively, a sterile ultrasound sheath can be placed over the 15  mm port, and the duodenoscope passed through the sheath and into the port. Insufflation with CO2 should be utilized whenever available to minimize bowel distention. Upon completion of the ERCP and removal of the scope, the drapes may be removed and the gastrotomy closed with sutures or the endoscopic stapler. For patients that may need multiple repeated ERCP or subsequent stent removal, placement of a gastrostomy tube at this time for subsequent access can be performed. In the rare instance that a gastrotomy cannot be created, such as when a remnant stomach is absent or inadequate from previous total, partial, or sleeve gastrectomy, a similar technique may be employed using a jejunostomy just distal to the ligament of Treitz. This approach may be limited by the

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skill of the endoscopist, however, as it requires a retrograde approach to the papilla. Such an approach may also be utilized if a patient already has the presence of a mature jejunostomy tract that can be dilated [16].

I nternal Endoscopic Ultrasound-Directed Transgastric ERCP Over the previous decade, advances in endoscopy have allowed for the development of fully endoscopic procedures to access to the remnant stomach. While most of these procedures rely on the creation of an external gastrostomy for endoscopic intubation of the remnant, the endoscopic creation and utilization of a gastrogastric fistula to access the remnant stomach have recently been described. This method, termed internal endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE), utilizes EUS to locate and access the excluded stomach from the gastric pouch or afferent limb (generally the blind end or “candy cane” portion), allowing for the creation of a tract using a lumen-apposing metal stent (LAMS). The tract eventually epithelializes, forming a fistula that may then be repeatedly intubated for ampullary access with conventional, transoral duodenoscopy and standard anatomical orientation. When ampullary access is no longer required or anticipated, the LAMS may be removed and fistula endoscopically closed with over the scope clips or an endoscopic suturing device. The creation of the gastrogastric or enterogastric fistula carries with it a theoretical risk of weight regain by reversing surgical bypass anatomy. Although this fistula is only designed to be temporarily patent and can be closed once access is no longer required, long-term outcomes of EDGE remain unclear. Rates of other adverse events, such as bleeding, perforation, peritonitis, and stent migration, are not yet well-­ defined. After removal of the LAMS and fistula closure, 88% have no demonstrable leak on early upper GI series, but long-term closure maintenance is unknown. Successful

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ampullary access is seen in 91% [17]. Early data suggest that EDGE has a similar success rate to LA-ERCP with shorter procedure times and hospital stay, but appropriately controlled trials and importantly long-term follow-up are lacking [18]. Consideration should also be given to the fact that many RYGB patients requiring ERCP for choledocholithiasis have an in situ gallbladder and require laparoscopy for cholecystectomy. In this situation, the risk and cost of LAMS placement can be avoided, making LA-ERCP the logical choice over EDGE.

Technique The excluded stomach is first localized with a linear echoendoscope via the pouch or proximal afferent limb. The remnant is then accessed with a 19-gauge EUS needle, and position is confirmed by contrast injection. A 0.035″ wire is then advanced into the excluded stomach, and electrocautery is used to enlarge the tract. This tract is then dilated with a 4  mm balloon, followed by deployment of a 15  mm LAMS under fluoroscopic, endoultrasonographic, and direct endoscopic visualization. The lumen of the stent is then dilated to its final diameter with a control radial expansion dilating balloon (Fig. 21.7a–c). Second-generation delivery systems have built-in cautery and permit LAMS deployment without the need for a guidewire or balloon dilation (Chap. 17). Conventional EUS or ERCP may be utilized during the index or subsequent procedures. If endoscopy across the stent is performed immediately after placement, care must be taken to avoid stent dislodgement which can result in gross ­pneumoperitoneum (capnoperitoneum) and free leak from the afferent limb and remnant stomach into the peritoneal cavity. Once ampullary access is no longer desired, the LAMS may be removed using a snare and the fistula closed with an over-the-scope clip or endoscopic suturing. Alternatively, the fistula may be allowed to close by secondary intention.

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Figure 21.7 (a–c) Endoscopic creation of a gastro-gastric fistula during the internal EUS-directed transgastric ERCP procedure. (a) Lumen-­apposing metal stent (LAMS) placed under endoscopic and EUS guidance. (b) Fluoroscopic balloon dilation of the LAMS to enlarge the tract. Note the guidewire coiling in the excluded stomach. (c) The LAMS may then be accessed for conventional ERCP by antegrade passage of the duodenoscope and may be left in place for future ampullary access. (All: Used with permission of Elsevier from Kedia et al. [26])

 ndoscopic Ultrasound-Guided Biliary E Drainage Overtube-assisted enteroscopy has substantially increased the success rates of biliary drainage procedures in patients with altered surgical anatomy while minimizing the complications

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seen with more invasive techniques. Occasionally, situations may develop where alternative means of accessing the biliary tree are necessary, as in nonoperative candidates in whom deep enteroscopy has failed. Endoscopic ultrasound-­guided biliary drainage (EUS-BD) was first reported in 2001 and has emerged as a safe and effective alternative for failed overtube-assisted enteroscopic ERCP.  This method, which utilizes a curvilinear array echoendoscope to visualize and then transmurally access the biliary tree, has a reported success rate of 90% with a complication rate of 18% in patients with altered surgical anatomy [19]. Although it has not been established with randomized controlled trials, EUS-BD may in fact have a higher clinical efficacy rate and shorter procedural time compared with overtube-assisted enteroscopic ERCP (OAE-ERCP) [20]. EUS-BD can be further subdivided into three distinct techniques: EUS-guided rendezvous, EUS-guided antegrade stenting, and EUS-guided transmural stenting.

EUS-Guided Rendezvous Technique In the EUS-guided rendezvous technique, extra- or intrahepatic bile ducts are accessed with a 19-gauge needle under EUS guidance in a transgastric (remnant), transesophageal, or transjejunal (afferent limb). Extrahepatic ducts are preferred owing to their larger size and shorter distance to the ampulla, but in the RYGB patient, the left intrahepatic ducts are generally the easiest to access. Bile is aspirated, and a cholangiogram is performed to confirm proper positioning. A guidewire is passed across the papilla, and this wire then may be used to facilitate bile duct cannulation using deep enteroscopy. This method may be considered when selective cannulation of the bile duct fails during OAE-ERCP; correspondingly, its potential limitation is that it requires the papilla to be endoscopically accessible. The EUS-guided

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rendezvous technique is reportedly successful in 90% of cases with a complication rate of 13% [21].

EUS-Guided Antegrade Stenting In EUS-guided antegrade stenting, an intrahepatic bile duct is accessed in a similar manner as described above, followed by passage of a guidewire over which a 4F cannula can then be advanced. After dilation of the papilla and intrahepatic ducts with a 4 mm balloon, a stent catheter is advanced, and a metal stent is deployed along this fistula tract across the ampulla or anastomosis. Contrary to the rendezvous technique, this method has the benefit of being able to stent even when the papilla is endoscopically inaccessible. This benefit comes at a cost, however, as complications may be seen in as many as 33% of cases. Bleeding, bile leakage, pneumoperitoneum, stent migration, and cholangitis were the most commonly reported adverse events. EUS-guided antegrade stenting is successful in 91% of cases [21].

EUS-Guided Transmural Stenting EUS-guided transmural stenting is performed by accessing the biliary tree using EUS guidance and creating a tract between the biliary system and the gastrointestinal tract, usually as a hepaticogastrostomy or hepaticojejunostomy. The tract is then dilated, usually with a balloon rather than sequential dilations to prevent separation of the biliary and gastrointestinal tracts, followed by the placement of a metal stent that is long enough to prevent proximal migration into the peritoneum. Transmural stenting is highly successful, with a reported failure rate of only 4%, but the overall rate and types of complications from transmural stenting are similar to those of antegrade stenting [21].

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Billroth II Anatomy As in Roux-en-Y anatomy, a retrograde approach to the papilla is required in patients with Billroth II anatomy. This approach, via the afferent loop which can be quite long, requires cannulation of the papilla from an inverted position (Fig. 21.8), mandating an experienced endoscopist and resulting in a higher failure rate compared to conventional ERCP. Most endoscopists recommend using side-viewing duodenoscopes, although forward-viewing scopes may offer some benefit in recognizing and cannulating the afferent limb and Major papilla

Fluoroscopy

Normal anatomy

Billroth II anatomy

Figure 21.8  Endoscopic and fluoroscopic views of normal (top) and Billroth II (bottom) anatomy. Note the retrograde approach to the ampulla and reversed orientation of the common bile duct direction (arrows) in Billroth II anatomy. (All: Used with permission of Elsevier from Enestvedt et al. [1])

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Figure 21.9 (a, b) Cap-assisted ERCP. (a) Distal cap attachment affixed to a standard diagnostic upper endoscope. (b) Endoscopic view of cap-assisted CBD cannulation with a straight ERCP catheter from an inferior position. (Both: Courtesy of Eric M. Pauli, MD)

are better suited to reach the papilla in long afferent limbs. Cannulating the papilla may prove more challenging with a forward-viewing scope, however, given the approach angle and lack of an instrument elevator. It is therefore suggested that forward-viewing scopes be reserved for failed duodenoscope attempts or for specialists with less experience in this approach. Although both duodenoscopes and forward-­ viewing enteroscopes have similar success rates in experienced hands [22], duodenoscopes may result in a higher rate of jejunal perforation (2%) [23, 24], warranting caution in their use among less experienced specialists. The use of cap-­ assisted ERCP with a forward-viewing gastroscope may serve as a helpful alternative when side-viewing duodenoscopy has failed (Fig. 21.9a, b).

Technique Intubating and advancing along the afferent loop can pose a challenge to even the most experienced endoscopist. This loop, usually adjacent to the greater curve, may be successfully accessed with simple adjustments in patient positioning, such as turning the patient prone or supine from left lateral decubitus. Supine positioning may also enhance

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radiologic identification and allows for external compressive maneuvers. For more challenging anatomy, other techniques may be necessary. Fluoroscopy may be utilized to ensure that the endoscope is proceeding in the expected orientation for the afferent limb, and insufflation or contrast injection through the working channel may clarify anatomy. A guidewire may be used to cannulate the afferent loop, followed by a bougie-­ type dilator to act as a straightener. Alternatively, a retrieval balloon can be inserted over a guidewire, inflated, radiologically confirmed to be in the appropriate location, and then retracted into the working channel as the scope is advanced along the afferent limb in a Seldinger-type maneuver. Progression through the afferent loop into the duodenal stump may require straightening and loop reduction maneuvers similar those during colonoscopy. A cap-fitted enteroscope may allow for better visualization and navigation of jejunal folds with less insufflation, minimizing loop formation. As previously discussed, cannulating the papilla can be challenging due to its reverse orientation compared to standard ERCP. In this orientation, the angle of the bile duct is more acute, often resulting in favorable cannulation of the pancreatic duct. A straight catheter may be better suited to approach the bile duct at its 5 or 6 o’clock position, or the catheter may be modified by bending the tip into an S-shape to facilitate cannulation.

Selection of Approach The decision on how to approach the biliary tree in a patient with altered surgical anatomy is dependent on the type of anatomy, local expertise, safety concerns, and respective success rates. Typically, modalities with higher success rates have correspondingly higher complication rates. Therefore, more invasive techniques, such as laparoscopic-assisted transgastric and EUS-guided biliary interventions, should be reserved for cases in which deep enteroscopy fails.

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As practice patterns currently stand, OAE-ERCP is often available and remains the technique of choice for biliopancreatic access in patients with altered surgical anatomy. For patients with Roux-en-Y gastric bypass, laparoscopic transgastric ERCP is commonly performed and is the often the procedure of choice for patients who would also require cholecystectomy and can therefore be managed in one setting. The market for dedicated ERCP devices compatible for use through enteroscopes is growing, and new scopes and devices for manipulation in long surgical limbs are continually being developed. Severe complications resulting from OAE-ERCP are extremely rare, and its lack of invasiveness allows for repeated treatments, which is particularly useful in the management of benign biliary diseases.

Pearls and Pitfalls

1. Optimal approach for biliary access in patients with altered surgical anatomy should be based on local availability of resources. 2. For patients with a history of Roux-en-Y gastric bypass who need cholecystectomy, laparoscopicassisted transgastric ERCP may allow for concurrent management of biliary disease in one setting. 3. Laparoscopic transgastric access allows for the use of standard side-viewing equipment and a less complex endoscopic approach at the expense of a surgical intervention. 4. Deep enteroscopy approaches are often highly successful in biliary access after Roux-en-Y gastric bypass. 5. Previous experience and expertise are key factors for the success of enteroscopy-assisted biliary access. 6. Direct transluminal biliary access is possible but associated with high complication rates.

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References 1. Enestvedt BK, Kothari S, Pannala R, Yang J, Fujii-Lau LL, Hwang JH, et al. Devices and techniques for ERCP in the surgically altered GI tract. Gastrointest Endosc. 2016;83(6):1061–75. 2. Hintze RE, Adler A, Veltzke W, Abou-Rebyeh H.  Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with Billroth II or Roux-en-Y gastrojejunostomy. Endoscopy. 1997;29(2):69–73. 3. Elton E, Hanson BL, Qaseem T, Howell DA.  Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients. Gastrointest Endosc. 1998;47(1):62–7. 4. Wright BE, Cass OW, Freeman ML.  ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Gastrointest Endosc. 2002;56(2):225–32. 5. Skinner M, Popa D, Neumann H, Wilcox CM, Mönkemüller K.  ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy. 2014;46(7):560–72. 6. Shimatani M, Matsushita M, Takaoka M, Koyabu M, Ikeura T, Kato K, et  al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy. 2009;41(10):849–54. 7. Franco MC, Safatle-Ribeiro AV, Gusmon CC, Ribeiro MS, Maluf-­ Filho F.  ERCP with balloon-overtube-assisted enteroscopy in postsurgical anatomy. Gastrointest Endosc. 2016;83(2):462–3. 8. Moreels TG.  Altered anatomy: enteroscopy and ERCP procedure. Best Pract Res Clin Gastroenterol. 2012;26(3):347–57. 9. Inamdar S, Slattery E, Sejpal DV, Miller LS, Pleskow DK, Berzin TM, et al. Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc. 2015;82(1):9–19. 10. Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN. Spiral enteroscopy-assisted ERCP in bariatric-­ length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc. 2018;87(5):1241–7. 11. Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et  al. A multicenter, U.S. experience of single-balloon, double-­ balloon, and rotational overtube-assisted enteroscopy ERCP in

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patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77(4):593–600. 12. Neuhaus H, Beyna T, Schneider M, Devière J. Novel motorized spiral enteroscopy: first clinical case. VideoGIE. 2016;1(2):32–3. 13. Law R, Wong Kee Song LM, Petersen BT, Baron TH.  Single-­ session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy. 2013;45(8):671–5. 14. Schreiner MA, Chang L, Gluck M, Irani S, Gan SI, Brandabur JJ, et  al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc. 2012;75(4):748–56. 15. Banerjee N, Parepally M, Byrne TK, Pullatt RC, Coté GA, Elmunzer BJ.  Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis. 2017;13(7):1236–42. 16. Baron TH, Chahal P, Ferreira LE. ERCP via mature feeding jejunostomy tube tract in a patient with Roux-en-Y anatomy (with video). Gastrointest Endosc. 2008;68(1):189–91. 17. Tyberg A, Nieto J, Salgado S, Weaver K, Kedia P, Sharaiha RZ, et  al. Endoscopic Ultrasound (EUS)-directed Transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc. 2017;50(2):185–90. 18. Kedia P, Tarnasky PR, Nieto J, Steele SL, Siddiqui A, Xu MM, et  al. EUS-directed Transgastric ERCP (EDGE) versus laparoscopy-­ assisted ERCP (LA-ERCP) for Roux-en-Y Gastric Bypass (RYGB) anatomy: a multicenter early comparative experience of clinical outcomes. J Clin Gastroenterol. 2019;53(4):304–8. 19. Siripun A, Sripongpun P, Ovartlarnporn B.  Endoscopic ultrasound-­guided biliary intervention in patients with surgically altered anatomy. World J Gastrointest Endosc. 2015;7(3):283–9. 20. Khashab MA, El Zein MH, Sharzehi K, Marson FP, Haluszka O, Small AJ, et al. EUS-guided biliary drainage or enteroscopy-­ assisted ERCP in patients with surgical anatomy and biliary obstruction: an international comparative study. Endosc Int Open. 2016;4(12):E1322–E7. 21. Wang K, Zhu J, Xing L, Wang Y, Jin Z, Li Z.  Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc. 2016;83(6):1218–27.

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22. Kim MH, Lee SK, Lee MH, Myung SJ, Yoo BM, Seo DW, et al. Endoscopic retrograde cholangiopancreatography and needle-­ knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope. Endoscopy. 1997;29(2):82–5. 23. Bove V, Tringali A, Familiari P, Gigante G, Boškoski I, Perri V, et al. ERCP in patients with prior Billroth II gastrectomy: report of 30 years’ experience. Endoscopy. 2015;47(7):611–6. 24. Faylona JM, Qadir A, Chan AC, Lau JY, Chung SC. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy. 1999;31(7):546–9. 25. Habenicht Yancey K, McCormack LK, McNatt SS, Powell MS, Fernandez AZ, Westcott CJ.  Laparoscopic-assisted transgastric ERCP: a single-institution experience. J Obesity. 2018;2018:8275965. 26. Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ, Kahaleh M.  EUS-directed transgastric ERCP for Roux-­ en-­Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc. 2015;82(3):560–5.

Chapter 22 Enteral Feeding Access: Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Bipan Chand and Vineeth Sudhindran

Abbreviations DPEJ PEG PEG-J

Direct Percutaneous Endoscopic Jejunostomy Percutaneous Endoscopic Gastrostomy Percutaneous Endoscopic Gastrostomy-Jejunostomy

Learning Objectives

1. To outline the current standards of practice regarding enteral access via a DPEJ for surgical endoscopists. 2. To discuss the indications, contraindications, preprocedural considerations, and technique for performing a DPEJ.

B. Chand (*) Loyola University Medical Center, Department of Surgery, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA e-mail: [email protected] V. Sudhindran Department of General Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India © Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020 P. Nau et al. (eds.), The SAGES Manual of Flexible Endoscopy, https://doi.org/10.1007/978-3-030-23590-1_22

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3. To review the outcomes associated with DPEJ. . To understand the principles needed to prevent and 4 treat the various complications that may occur with DPEJ.

Introduction Enteral access is fundamental to providing nutritional support to patients who are unable to maintain adequate oral intake. It is preferred over parenteral nutrition since it preserves gut function, integrity, and local defense. Enteral feeding is especially important for critically ill patients since maintaining nutritional status is integral to reducing the severity of and minimizing the rates of complications caused by underlying illnesses. A variety of approaches exist for enteral tube placement. In patients expected to resume adequate oral nutrition within 4 weeks, feeding tubes may be placed via the nasoenteric or oroenteric routes (e.g., Ryle’s or Dobhoff tube). Direct access to the stomach or small bowel is preferred for long-term feeding given its better tolerance. The percutaneous endoscopic gastrostomy (PEG) is the most widely performed procedure to achieve direct access to the stomach. The procedure is well tolerated and has low procedurerelated morbidity. The procedure is often accomplished under moderate sedation in a monitored procedural environment such as the endoscopy suite or intensive care unit. For post-pyloric access, a transgastric feeding tube may be advanced through the pylorus into the small bowel to create a percutaneous endoscopic gastrojejunostomy (PEG-J) for long-term enteral nutrition in patients suffering from severe gastroesophageal reflux, gastroparesis, or repeated aspiration. The direct percutaneous endoscopic jejunostomy (DPEJ) procedure evolved as a modification of conventional PEG techniques.

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Indications The DPEJ has indications similar to the PEG and PEG-J such as impaired swallowing caused by neurological conditions, neoplastic disease or severe trauma involving the head and neck, and miscellaneous catabolic conditions requiring supplemental feeding as seen in many critically ill patients. In practice, the DPEJ is considered in situations where placing a PEG or PEG-J tube is difficult or unsuitable. This may include situations in patients with altered anatomy (e.g., post Roux-en-Y gastrojejunostomy or gastrectomy) or delayed gastric emptying (e.g., gastroparesis). Jejunal feeding is also recommended for patients who cannot tolerate gastric feeds and those that have recurrent aspiration [1]. Jejunal feeding is recommended for patients with severe chronic pancreatitis where minimal stimulation of the exocrine pancreas is preferred [2]. Whereas oral and gastric feeds stimulate all three phases of the pancreatic secretion, postpyloric feeds have less impact on normal gut hormone and pancreas secretion. This route also has the ability to instill a complete nutritional mixture at a lower cost. DPEJ also represents a reliable and cost-effective alternative to PEG for gastrointestinal decompression in patients with benign or malignant gastrointestinal obstruction [3]. Placement under radiological guidance further enhances safety and effectiveness in certain scenarios [4]. The DPEJ can also be used for long-term levodopa infusion to treat severe Parkinson’s disease in which patients are unable to ingest the drug when fed directly into the stomach due to dyskinesia and vomiting [5].

Contraindications DPEJ should not be offered if the patient has a need for enteral access