Storm, Andrew C

Background Delayed bleeding is among the most common adverse events associated with endoscopic mucosal resection (EMR) of nonampullary duodenal polyps. We evaluated the rate of delayed bleeding and complete defect closure using a novel through-the-scope (TTS) suturing system for the closure of duodenal EMR defects. Methods We reviewed the electronic medical records of patients who underwent EMR for nonampullary duodenal polyps of ≥ 10 mm and prophylactic defect closure with TTS suturing between March 2021 and May 2022 at centers in the USA. We evaluated the rates of delayed bleeding and complete defect closure. Results 36 nonconsecutive patients (61 % women; mean [SD] age, 65 [12] years) underwent EMR of ≥ 10-mm duodenal polyps followed by attempted defect closure with TTS suturing. The mean (SD) lesion size was 29 (19) mm, defect size was 37 (25) mm; eight polyps (22 %) involved > 50 % of the lumen circumference. Complete closure was achieved in all cases (78 % with TTS suturing alone), using a median of one TTS suturing kit. There were no cases of delayed bleeding and no adverse events attributed to application of the TTS suturing device. Conclusion Prophylactic closure of nonampullary duodenal EMR defects using TTS suturing resulted in a high rate of complete closure and no delayed bleeding events.

Background Complete closure of large mucosal defects following colorectal endoscopic submucosal dissection (ESD) with through-the-scope (TTS) clips is oftentimes not possible. We aimed to report our early experience of using a novel TTS suturing system for the closure of large mucosal defects after colorectal ESD. Methods We performed a retrospective multicenter cohort study of consecutive patients who underwent attempted prophylactic defect closure using the TTS suturing system after colorectal ESD. The primary outcome was technical success in achieving complete defect closure, defined as a < 5 mm residual mucosal defect in the closure line using TTS suturing, with or without adjuvant TTS clips. Results 82 patients with a median defect size of 30 (interquartile range 25–40) mm were included. Technical success was achieved in 92.7 % (n = 76): TTS suturing only in 44 patients (53.7 %) and a combination of TTS suturing to approximate the widest segment followed by complete closure with TTS clips in 32 (39.0 %). Incomplete/partial closure, failure of appropriate TTS suture deployment, and the need for over-the-scope salvage closure methods were observed in 7.3 % (n = 6). One intraprocedural bleed, one delayed bleed, and three intraprocedural perforations were observed. There were no adverse events related to placement of the TTS suture. Conclusion The TTS suture system is an effective and safe tool for the closure of large mucosal defects after colorectal ESD and is an alternative when complete closure with TTS clips alone is not possible.

Abstract Background and study aim The role of esophageal overtubes in upper gastrointestinal endoscopic suturing is unknown. This study aimed to determine whether overtube use was associated with technical success or adverse events. Patients and methods A retrospective review of consecutive patients who underwent endoscopic suturing for various indications was performed. Results A total of 719 patients underwent endoscopic suturing for various indications, including endoscopic bariatric procedures in 262, stent fixation in 258, defect closure in 190, and hemostasis in nine. An overtube was used in 186 procedures (25.9 %). Technical success was achieved in all cases. Minor mucosal trauma occurred in 15 cases (8.1 %) with use of an overtube, and none without an overtube (P < 0.0001). No full-thickness esophageal perforation or hemorrhage related to overtube use or the suturing device occurred. Conclusions Endoscopic suturing can be performed safely for a variety of indications, including endoscopic bariatric procedures, defect repair, and stent fixation without an esophageal overtube. Minor esophageal mucosal trauma and equipment cost are increased when an overtube is used.

Background The overall effectiveness of aspiration therapy (AT) for obesity relies on optimal aspiration timing after a meal, which can vary depending on a patient’s rate of gastric emptying (GE). Our aim was to identify if baseline GE rates were associated with differences in aspiration efficiency (AE). Methods Subjects from an ongoing AT clinical trial were enrolled in this study. AE was calculated as the absolute gastric residual and calories aspirated at 20 and 40 min. Participants were then divided by baseline GE rate into two groups (slow vs fast). Wilcoxon rank-sum test was used to compare AE at 20 and 40 min between the groups. Exploratory linear regression was used to assess relationship between GE and AE. Results 7 patients (85% female) were coenrolled in the study. Mean age and body mass index were 39.8±9.44 and 43±5, respectively. AE did not significantly differ between the 20 and 40 min time points for the group as a whole (34.3% vs 36.9%; p>0.5). However, those with fast GE aspirated more calories than those with slow GE (20 min: 200 kcal vs 72.5 kcal; 40 min: 154 kcal vs 63 kcal) (p=0.05). On linear regression, delayed GE was associated with poorer aspiration (20 min: β=−107 calories; p=0.019; R2=0.7). 4/7 patients had significant differences in residual/caloric aspiration across the two time points. Conclusion Patients undergoing AT may benefit from a GE test to optimise their AE. Paradoxically faster GE times saw better aspiration. Prospective studies are revealing a personalised approach to obesity.

Abstract Background and study aims Little consideration has been given to selection of endoscopic ultrasound-guided fiducials for proton radiotherapy and the resulting perturbations in the therapy dose and pattern. Our aim was to assess the impact of perturbations caused by six fiducials of different composition and dimensions in a phantom gel model. Materials and methods The phantom was submerged in a water bath and irradiated with a uniform 10 cm × 10 cm field of 119.7 MeV monoenergetic spot scanning protons delivered through a 45 mm range shifter. The proton “Bragg Peak” was evaluated. Results Dose perturbations manifesting as dose reductions up to 30 % were observed. A carbon composite (1 × 5 mm) and gold (0.4 × 10 mm) fiducial with backload potential rather than dedicated EUS pre-loaded gold fiducial needles had the best performance in terms of minimizing the dose perturbation. Conclusions Our data demonstrate that a carbon composite fiducial has a less untoward effect on proton therapy dose distribution than dedicated EUS pre-loaded gold fiducial needles. Such information is important to consider when selecting fiducials specifically for proton therapy.

Abstract Background and study aims A novel intragastric trocar placed using a percutaneous endoscopic gastrostomy technique enables the use of laparoscopic tools and procedures, including tissue stapling, cutting, suturing, and retraction. The aim of this porcine study was to determine long-term success of crossing full-thickness sutures in closure of the tract upon trocar withdrawal. Methods 10 trocars were placed in 5 animals. Each animal underwent a standardized tissue resection using a 5-mm stapler under gastroscopic guidance, and two full-thickness, absorbable, crossing sutures were used to close the trocar tracts. The animals were monitored for 35 days and then euthanized for necropsy. Results All five animals survived without sign of infection or distress. Nine of the 10 trocar sites healed completely without any adverse findings. A single site developed a gastrocutaneous fistula. On necropsy, there was no evidence of intra-abdominal infection or abscess. Conclusions Full-thickness crossing sutures appeared to be effective in long-term closure of an intragastric trocar tract. Given the ease of placement and success of this simple closure method, this device may prove clinically useful to the endoscopist performing complex procedures in the endoscopy suite.