Introduction

A 37-year-old woman was referred to our unit because of typical biliary colics with transient cholestasis. Her relevant medical history included a cholecystectomy and a sleeve gastrectomy, later on converted to a gastric bypass. After multidisciplinary discussion, we opted for an endoscopic ultrasound-directed transgastric ERCP (EDGE) using a 20/10 lumen-apposing metal stent (LAMS). Due to the previous sleeve gastrectomy, the LAMS had to be placed between the jejunum and the excluded antrum. According to international expert recommendations, the ERCP was scheduled two weeks post-LAMS placement to allow for tract maturation [1] . Nevertheless, the proximal flange of the LAMS dislocated during duodenoscope introduction and ended up in the peritoneal cavity. A decompressing needle was placed and the proximal flange was retrieved in the peritoneal cavity under fluoroscopic guidance, using a therapeutic gastroscope. After a non-successful attempt to reposition the proximal flange through the fistula tract in the jejunum, a guidewire was placed through the LAMS lumen in het excluded antrum. A bridging attempt with a 22mm x 10 cm fully covered enteral stent through the LAMS lumen failed. Subsequently, intraperitoneal endoscopic closure of the fistula towards the excluded antrum was performed with the X-tack system.
Next, we removed the LAMS and the enteral stent from the peritoneal cavity and completely sealed the fistula tract from the jejunal side with x-tack endosutures and clips. The patient was put on antibiotics and could start oral feeding the day after the procedure. Besides moderate abdominal pain the first 2 days after the procedure and a transient elevation of the CRP, the further clinical course was uneventful.

Aims & Methods

The rescue intervention was conducted with a gastroscope with 3,8 mm working channel. A 22 x 10 cm fully covered enteral SEMS was used in the attempt of bridging the excluded antrum. X-tack endosuture system was chosen to achieve the closure of the fistula.

Results

The X-tack system proved to be an effective tool in addressing not only the intraluminal perforation but also in the intraperitoneal endoscopic closure of the fistula extending towards the excluded antrum.

Conclusion

This case illustrates the potential of endoscopic suturing devices as minimally invasive alternatives to surgery for management of large iatrogenic perforations.

References

[1] S. Stefanovic et al., “International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process,” Am. J. Gastroenterol., Dec. 2023, doi: 10.14309/ajg.0000000000002571.

Disclosure

Nothing to disclosure

Introduction

Endoscopic Submucosal Dissection (ESD) is the best endoscopic technique that enables en bloc resection of superficial colorectal neoplasms.Despite its effectiveness, ESD is not very widespread in Western countries due to technical complexity, long procedure times, and a steep learning curve. These barriers have created a significant gap in adoption and outcomes between Eastern and Western centers. Underwater ESD (U-ESD) has been introduced to simplify the procedure. This study aimed to evaluate the effectiveness of U-ESD versus conventional gas-based ESD (G-ESD) in a Western center, focusing on procedural efficiency and safety.

Aims & Methods

This is a single-center, prospective randomized controlled trial conducted at Fondazione Campus Bio-Medico in Rome between December 2024 and April 2025.Forty patients with non-pedunculated colorectal lesions were randomly assigned in a 1:1 ratio to undergo either Underwater ESD (U-ESD) or conventional ESD with insufflation of Carbon Dioxide (CO2) (G-ESD).The primary outcome was total procedure time. Secondary outcomes included dissection speed, en bloc and R0 resection rates, use of hemostatic forceps, and the incidence of adverse events such as delayed bleeding, perforation, and post-ESD coagulation syndrome (PECS).

Results

A total of 40 patients referred to our endoscopic unit for ESD between December 2024 and April 2025. The mean size of the colorectal lesions was 57.4 mm and 40.7 mm in the U-ESD and G-ESD groups. The location of the lesions was in the rectum in 15% and 55% of the U-ESD and C-ESD groups, respectively; in the right side of the colon in 35% and 20% of the U-ESD and G-ESD groups, respectively. The morphology of LST was classified as LST-nongranular in 20 % and 25% of the U-ESD and G-ESD groups, respectively; as LST granular in 60% and 35% of the U-ESD and G-ESD groups, respectively. Fibrosis (grade 1 and 2) was present in 45% and 30% of the U-ESD and G-ESD groups, respectively. The mean total procedure time was shorter in the U-ESD group compared with the G-ESD group (53.3 ±33 minutes vs 78.7 ± 25.6 minutes; mean difference,–25.4 minutes; P=0.009).Mean dissection speed was faster in the U-ESD group compared with the G-ESD group (42 ± 26.3 mm2/min vs 13.3 ± 8 mm2/min; mean difference, 28.7 mm2/min; P= 0.001). En bloc and R0 resection rates in both groups were 100%. The use of a hemostatic forceps was significantly lower in U-ESD compared G-ESD (40% vs 90%, P= 0.001). Delayed bleeding occurred in only one patient in G-ESD group and was managed successfully by endoscopic clipping. No perforations occurred in either group. PECS was noted in only one patient in the G-ESD group.

Conclusion

UESD has shown a significantly shorter procedure time and faster dissection speed compared with GESD. These both empower the possibility of considering U-ESD as the preferred colorectal ESD method for colorectal lesions.