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World Journal of Gastrointestinal EndoscopyWorld J Gastrointest Endosc 2016 July 10; 8(13): 458-476

ISSN 1948-5190 (online)

Published by Baishideng Publishing Group Inc

EDITORS-IN-CHIEFAtsushi Imagawa, Kan-onjiJuan Manuel Herrerias Gutierrez, Sevilla

GUEST EDITORIAL BOARD MEMBERSChung-Yi Chen, Kaohsiung Ming-Jen Chen, TaipeiWai-Keung Chow, TaichungKevin Cheng-Wen Hsiao, TaipeiChia-Long Lee, HsinchuKuang-Wen Liao, Hsin-ChuYi-Hsin Lin, HsinchuPei-Jung Lu, TainanYan-Sheng Shan, TainanMing-Yao Su, Tao-YuanChi-Ming Tai, KaohsiungYao-Chou Tsai, New TaipeiYih-Huei Uen, TainanHsiu-Po Wang, TaipeiYuan-Huang Wang, TaipeiShu Chen Wei, TaipeiSheng-Lei Yan, ChanghuaHsu-Heng Yen, Changhua

MEMBERS OF THE EDITORIAL BOARD

Australia

John F Beltrame, AdelaideGuy D Eslick, SydneyVincent Lam, Sydney

Austria

Alexander Klaus, Vienna

Karl A Miller, HalleinMarkus Raderer, Vienna

Brazil

Vitor Arantes, Belo HorizonteDjalma E Coelho, Rio de janeiroDaniel C Damin, Porto AlegreWilliam Kondo, CuritibaFauze Maluf-Filho, Sao PauloJosé Luiz S Souza, Sao Paulo

CanadaSonny S Dhalla, BrandonChoong-Chin Liew, Richmond HillPing-Chang Yang, Hamilton

ChinaKin Wai Edwin Chan, Hong KongJun-Qiang Chen, NanningKent-Man Chu, Hong KongShi-Gang Ding, BeijingSong-Ze Ding, ZhengzhouXiang-Wu Ding, XiangyangYa-Dong Feng, NanjingXin Geng, TianjinChuan-Yong Guo, ShanghaiSong-Bing He, SuzhouHai Hu, ShanghaiSan-Yuan Hu, JinanZhao-Hui Huang, WuxiBo Jiang, GuangzhouBrian H Lang, Hong KongXue-Liang Li, NanjingZhi-Qing Liang, ChongqingZhi-Qiang Ling, Hangzhou

Chibo Liu, TaizhouXiao-Wen Liu, ShanghaiXing’ e Liu, HangzhouSamuel Chun-Lap Lo, Hong KongShen Lu, DalianHe-Sheng Luo, WuhanSimon SM Ng, Hong KongHong-Zhi Pan, HarbinBing Peng, ChengduGuo-Ming Shen, HefeiXue-Ying Shi, BeijingXiao-Dong Sun, HangzhouNa-Ping Tang, ShanghaiAnthony YB Teoh, Hong KongQiang Tong, WuhanDao-Rong Wang, YangzhouXian Wang, HangzhouXiao-Lei Wang, ShanghaiQiang Xiao, Nanning Zhu-Ping Xiao, JishouLi-Shou Xiong, GuangzhouYing-Min Yao, Xi’anBo Yu, BeijingQing-Yun Zhang, BeijingPing-Hong Zhou, ShanghaiYong-Liang Zhu, Hangzhou

CroatiaMario Tadic, Zagreb

Czech RepublicMarcela Kopacova, Hradec Králové

DenmarkJakob Lykke, Slagelse

I

Editorial Board2014-2017

The World Journal of Gastrointestinal Endoscopy Editorial Board consists of 330 members, representing a team of worldwide experts in gastrointestinal endoscopy. They are from 40 countries, including Australia (3), Austria (3), Brazil (6), Canada (3), China (62), Croatia (1), Czech Republic (1), Denmark (1), Ecuador (1), Egypt (3), France (1), Germany (8), Greece (10), Hungary (2), India (11), Indonesia (1), Iran (6), Iraq (1), Ireland (2), Israel (1), Italy (37), Japan (43), Lebanon (1), Lithuania (1), Malaysia (1), Mexico (4), Netherlands (1), Norway (2), Poland (4), Portugal (5), Romania (1), Singapore (3), Slovenia (2), South Korea (19), Spain (9), Thailand (2), Turkey (11), United Arab Emirates (1), United Kingdom (14), and United States (43).

January 6, 2014WJGE|www.wjgnet.com

World Journal ofGastrointestinal EndoscopyW J G E

EcuadorCarlos Robles-Medranda, Guayaquil

EgyptAsmaa G Abdou, Shebein ElkomAhmed AR ElGeidie, MansouraMohamed Abdel-Sabour Mekky, Assiut

FranceJean Michel Fabre, Montpellier

GermanyJorg G Albert, FrankfurtHüseyin Kemal Cakmak, KarlsruheRobert Grützmann, DresdenThilo Hackert, HeidelbergArthur Hoffman, FrankfurtThomas E Langwieler, NordhausenAndreas Sieg, HeidelbergJorg Rüdiger Siewert, Freiburg

GreeceSotirios C Botaitis, AlexandroupolisGeorge A Giannopoulos, PiraeusDimitris K Iakovidis, LamiaDimitrios Kapetanos, ThessalonikiJohn A Karagiannis, AthensGregory Kouraklis, AthensSpiros D Ladas, AthensTheodoros E Pavlidis, ThessalonikiDemitrios Vynios, PatrasElias Xirouchakis, Athens

HungaryLászló Czakó, SzegedLaszlo Herszenyi, Budapest

IndiaPradeep S Anand, BhopalDeepraj S Bhandarkar, MumbaiHemanga Kumar Bhattacharjee, New DelhiRadha K Dhiman, Chandigarh Mahesh K Goenka, KolkataAsish K Mukhopadhyay, KolkataManickam Ramalingam, CoimbatoreAga Syed Sameer, SrinagarOmar J Shah, SrinagarShyam S Sharma, JaipurJayashree Sood, New Delhi

IndonesiaAri F Syam, Jakarta

IranAlireza Aminsharifi, Shiraz

Homa Davoodi, GorganAhad Eshraghian, ShirazAli Reza Maleki, GorganYousef Rasmi, UrmiaFarhad Pourfarzi, Ardabil

Iraq

Ahmed S Abdulamir, Baghdad

Ireland

Ronan A Cahill, DublinKevin C Conlon, Dublin

Israel

Haggi Mazeh, Jerusalem

Italy

Ferdinando Agresta, Adria (RO)Alberto Arezzo, TorinoCorrado R Asteria, MantuaMassimiliano Berretta, Aviano (PN)Vittorio Bresadola, udineLorenzo Camellini, Reggio EmiliaSalvatore Maria Antonio Campo, RomeGabriele Capurso, RomeLuigi Cavanna, PiacenzaFrancesco Di Costanzo, FirenzeSalvatore Cucchiara, RomePaolo Declich, RhoMassimiliano Fabozzi, AostaEnrico Fiori, RomeLuciano Fogli, BolognaFrancesco Franceschi, RomeLorenzo Fuccio, BolognaGiuseppe Galloro, NaplesCarlo M Girelli, Busto ArsizioGaetano La Greca, CataniaFabrizio Guarneri, MessinaGiovanni Lezoche, AnconaPaolo Limongelli, NaplesMarco M Lirici, RomeValerio Mais, CagliariAndrea Mingoli, RomeIgor Monsellato, MilanMarco Moschetta, BariLucia Pacifico, RomeGiovanni D De Palma, NaplesPaolo Del Rio, ParmaPierpaolo Sileri, RomeCristiano Spada, RomeStefano Trastulli, TerniNereo Vettoretto, Chiari (BS)Mario Alessandro Vitale, RomeNicola Zampieri, Verona

Japan

Hiroki Akamatsu, OsakaShotaro Enomoto, WakayamaMasakatsu Fukuzawa, TokyoTakahisa Furuta, HamamatsuChisato Hamashima, Tokyo

Naoki Hotta, NagoyaHiroshi Kashida, Osaka-saayamaMotohiko Kato, SuitaYoshiro Kawahara, OkayamaHiroto Kita, TokyoNozomu Kobayashi, UtsunomiyaShigeo Koido, ChibaKoga Komatsu, YurihonjoKazuo Konishi, TokyoKeiichiro Kume, KitakyushuKatsuhiro Mabe, SapporoIruru Maetani, TokyoNobuyuki Matsuhashi, TokyoKenshi Matsumoto, TokyoSatohiro Matsumoto, SaitamaHiroto Miwa, NishinomiyaNaoki Muguruma, TokushimaYuji Naito, KyotoNoriko Nakajima, TokyoKatsuhiko Nosho, SapporoSatoshi Ogiso, KyotoKeiji Ogura, TokyoShiro Oka, HiroshimaHiroyuki Okada, OkayamaYasushi Sano, KobeAtsushi Sofuni, TokyoHiromichi Sonoda, OtsuHaruhisa Suzuki, TokyoGen Tohda, FukuiYosuke Tsuji, TokyoToshio Uraoka, TokyoHiroyuki Yamamoto, KawasakiShuji Yamamoto, ShigaKenjiro Yasuda, KyotoNaohisa Yoshida, KyotoShuhei Yoshida, ChibaHitoshi Yoshiji, Kashihara

Lebanon

Eddie K Abdalla, Beirut

Lithuania

Laimas Jonaitis, Kaunas

Malaysia

Sreenivasan Sasidharan, Minden

Mexico

Quintín H Gonzalez-Contreras, MexicoCarmen Maldonado-Bernal, MexicoJose M Remes-Troche, VeracruzMario A Riquelme, Monterrey

Netherlands

Marco J Bruno, Rotterdam

Norway

Airazat M Kazaryan, SkienThomas de Lange, Rud

II January 6, 2014WJGE|www.wjgnet.com

III January 6, 2014WJGE|www.wjgnet.com

PolandThomas Brzozowski, CracowPiotr Pierzchalski, KrakowStanislaw Sulkowski, BialystokAndrzej Szkaradkiewicz, Poznań

Portugal

Andreia Albuquerque, PortoPedro N Figueiredo, CoimbraAna Isabel Lopes, LisbonRui A Silva, PortoFilipa F Vale, Lisbon

Romania

Lucian Negreanu, Bucharest

Singapore

Surendra Mantoo, SingaporeFrancis Seow-Choen, SingaporeKok-Yang Tan, Singapore

Slovenia

Pavel Skok, MariborBojan Tepes, Rogaska Slatina

South Korea

Seung Hyuk Baik, SeoulJoo Young Cho, SeoulYoung-Seok Cho, UijeongbuHo-Seong Han, SeoulHye S Han, SeoulSeong Woo Jeon, DaeguWon Joong Jeon, JejuMin Kyu Jung, DaeguGwang Ha Kim, BusanSong Cheol Kim, SeoulTae Il Kim, SeoulYoung Ho Kim, DaeguHyung-Sik Lee, BusanKil Yeon Lee, SeoulSangKil Lee, Seoul

Jong-Baeck Lim, SeoulDo Youn Park, BusanDong Kyun Park, IncheonJaekyu Sung, Daejeon

Spain

Sergi Castellvi-Bel, BarcelonaAngel Cuadrado-Garcia, SanseAlfredo J Lucendo, TomellosoJosé F Noguera, ValenciaEnrique Quintero, TenerifeLuis Rabago, MadridEduardo Redondo-Cerezo, GranadaJuan J Vila, Pamplona

Thailand

Somchai Amornyotin, BangkokPradermchai Kongkam, Pathumwan

Turkey

Ziya Anadol, AnkaraCemil Bilir, RizeErtan Bulbuloglu, KahramanmarasVedat Goral, IzmirAlp Gurkan, IstanbulSerkan Kahyaoglu, AnkaraErdinc Kamer, IzmirCuneyt Kayaalp, MalatyaErdal Kurtoglu, TurkeyOner Mentes, AnkaraOrhan V Ozkan, Sakarya

United Arab Emirates

Maher A Abbas, Abu Dhabi

United Kingdom

Nadeem A Afzal, SouthamptonEmad H Aly, AberdeenGianpiero Gravante, LeicesterKarim Mukhtar, LiverpoolSamir Pathak, East YorkshireJayesh Sagar, FrimleyMuhammad S Sajid, Worthing, West Sussex

Sanchoy Sarkar, LiverpoolAudun S Sigurdsson, TelfordTony CK Tham, BelfastKym Thorne, SwanseaHer Hsin Tsai, HullEdward Tudor, TauntonWeiguang Wang, Wolverhampton

United States

Emmanuel Atta Agaba, BronxMohammad Alsolaiman, LehiErman Aytac, ClevelandJodie A Barkin, MiamiCorey E Basch, WayneCharles Bellows, albuquerqueJianyuan Chai, Long BeachEdward J Ciaccio, New YorkKonstantinos Economopoulos, BostonViktor E Eysselein, TorranceMichael R Hamblin, BostonShantel Hebert-Magee, OrlandoCheryl L Holt, College ParkTimothy D Kane, WashingtonMatthew Kroh, ClevelandI Michael Leitman, New YorkWanguo Liu, New OrleansCharles Maltz, New YorkRobert CG Martin, LouisvilleHiroshi Mashimo, West RoxburyAbraham Mathew, HersheyAmosy E M'Koma, NashvilleKlaus Monkemuller, BirminghamJames M Mullin, WynnewoodFarr Reza Nezhat, New YorkGelu Osian, BaltimoreEric M Pauli, HersheySrinivas R Puli, PeoriaIsaac Raijman, HoustonRobert J Richards, Stony BrookWilliam S Richardson, New OrleansBryan K Richmond, CharlestonPraveen K Roy, MarshfieldRodrigo Ruano, HoustonDanny Sherwinter, BrooklynBronislaw L Slomiany, NewarkAijaz Sofi, ToledoStanislaw P Stawicki, ColumbusNicholas Stylopoulos, BostonXiangLin Tan, New BrunswickWahid Wassef, WorcesterNathaniel S Winstead, Houma

Contents Biweekly Volume 8 Number 13 July 10, 2016

July 10, 2016|Volume 8|Issue 13|WJGE|www.wjgnet.com I

ORIGINAL ARTICLE

Retrospective Study458 Electrocauteryvs non-electrocauterydilationcathetersinendoscopicultrasonography-guidedpancreatic

fluid collection drainage

Kitamura K, Yamamiya A, Ishii Y, Nomoto T, Honma T, Yoshida H

466 Efficacy and safety of endoscopic submucosal dissection under general anesthesia

Yamashita K, Shiwaku H, Ohmiya T, Shimaoka H, Okada H, Nakashima R, Beppu R, Kato D, Sasaki T, Hoshino S, Nimura S,

Yamaura K, Yamashita Y

CASE REPORT472 Cut endotracheal tube for endoscopic removal of an ingested push-through pack

Tateno Y, Suzuki R

ContentsWorld Journal of Gastrointestinal Endoscopy

Volume 8 Number 13 July 10, 2016

EDITORS FOR THIS ISSUE

Responsible Assistant Editor: Xiang Li Responsible Science Editor: Xue-Mei GongResponsible Electronic Editor: Ya-Jing Lu Proofing Editorial Office Director: Xiu-Xia SongProofing Editor-in-Chief: Lian-Sheng Ma

NAMEOFJOURNALWorld Journal of Gastrointestinal Endoscopy

ISSNISSN 1948-5190 (online)

LAUNCHDATEOctober 15, 2009

FREQUENCYBiweekly

EDITORS-IN-CHIEFJuan Manuel Herrerias Gutierrez, PhD, Academic Fellow, Chief Doctor, Professor, Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen Macarena, Sevilla 41009, Sevilla, Spain

Atsushi Imagawa, PhD, Director, Doctor, Depart-ment of Gastroenterology, Mitoyo General Hospital, Kan-onji, Kagawa 769-1695, Japan

EDITORIALOFFICEJin-Lei Wang, Director

Xiu-Xia Song, Vice DirectorWorld Journal of Gastrointestinal EndoscopyRoom 903, Building D, Ocean International Center,No. 62 Dongsihuan Zhonglu, Chaoyang District, Beijing 100025, ChinaTelephone: +86-10-85381891Fax: +86-10-85381893E-mail: [email protected] Desk: http://www.wjgnet.com/esps/helpdesk.aspxhttp://www.wjgnet.com

PUBLISHERBaishideng Publishing Group Inc8226 Regency Drive, Pleasanton, CA 94588, USATelephone: +1-925-223-8242Fax: +1-925-223-8243E-mail: [email protected] Desk: http://www.wjgnet.com/esps/helpdesk.aspxhttp://www.wjgnet.com

PUBLICATIONDATEJuly 10, 2016

COPYRIGHT© 2016 Baishideng Publishing Group Inc. Articles published by this Open-Access journal are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.

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ABOUT COVER

July 10, 2016|Volume 8|Issue 13|WJGE|www.wjgnet.com II

Editorial Board Member of World JournalofGastrointestinalEndoscopy , JooYoungCho,MD,Professor,DigestiveDiseaseCenter,SoonchunhyangUniversityHospital,Seoul140-887,SouthKorea

World Journal of Gastrointestinal Endoscopy (World J Gastrointest Endosc, WJGE, online ISSN 1948-5190, DOI: 10.4253) is a peer-reviewed open access (OA) academic journal that aims to guide clinical practice and improve diagnostic and therapeutic skills of clinicians. WJGE covers topics concerning gastroscopy, intestinal endoscopy, colonoscopy, capsule endoscopy, laparoscopy, interventional diagnosis and therapy, as well as advances in technology. Emphasis is placed on the clinical practice of treating gastrointestinal diseases with or under endoscopy. We encourage authors to submit their manuscripts to WJGE. We will give priority to manuscripts that are supported by major national and international foundations and those that are of great clinical significance.

World Journal of Gastrointestinal Endoscopy is now indexed in Emerging Sources Citation Index (Web of Science), PubMed, and PubMed Central.

I-III EditorialBoard

AIM AND SCOPE

INDEXING/ABSTRACTING

FLYLEAF

Electrocautery vs non-electrocautery dilation catheters in endoscopic ultrasonography-guided pancreatic fluid collection drainage

Katsuya Kitamura, Akira Yamamiya, Yu Ishii, Tomohiro Nomoto, Tadashi Honma, Hitoshi Yoshida

Katsuya Kitamura, Akira Yamamiya, Yu Ishii, Tomohiro Nomoto, Tadashi Honma, Hitoshi Yoshida, Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo 142-8666, Japan

Author contributions: Kitamura K designed this study and collected and analyzed the data; Kitamura K drafted the manuscript and gave final approval of the version to be published; Kitamura K, Yamamiya A, Ishii Y, Nomoto T, Honma T and Yoshida H participated in this study as endoscopic ultrasonography operators or assistants.

Institutional review board statement: This study was approved by the Medical Ethics Committee of Showa University.

Informed consent statement: Informed, written consent was obtained from each patient prior to the procedure.

Conflict-of-interest statement: We have no financial relationships to disclose.

Data sharing statement: No additional data are available.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Unsolicited manuscript

Correspondence to: Katsuya Kitamura, MD, PhD, Lecturer, Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan. [email protected]: +81-3-37848535 Fax: +81-3-37847553

Received: February 14, 2016Peer-review started: February 16, 2016First decision: March 25, 2016Revised: May 13, 2016Accepted: May 31, 2016Article in press: June 2, 2016Published online: July 10, 2016

AbstractAIM: To investigate the safety and utility of an electro-cautery dilation catheter for endoscopic ultrasonography (EUS)-guided pancreatic fluid collection drainage.

METHODS: A single-center, exploratory, retrospective study was conducted between August 2010 and August 2014. This study was approved by the Medical Ethics Committee of our institution. Informed, written consent was obtained from each patient prior to the procedure. The subjects included 28 consecutive patients who underwent EUS-guided transmural drainage (EUS-TD) for symptomatic pancreatic and peripancreatic fluid collections (PFCs) by fine needle aspiration using a 19-gauge needle. These patients were retrospectively divided into two groups based on the use of an electrocautery dilation catheter as a fistula dilation device; 15 patients were treated with an electrocautery dilation catheter (electrocautery group), and 13 patients were treated with a non-electrocautery dilation catheter (non-electrocautery group). We evaluated the technical and clinical successes and the adverse events associated with EUS-TD for the treatment of PFCs between the two groups.

RESULTS: There were no significant differences in age, sex, type, location and diameter of PFCs between the groups. Thirteen patients (87%) in the electrocautery

ORIGINAL ARTICLE

458 July 10, 2016|Volume 8|Issue 13|WJGE|www.wjgnet.com

Submit a Manuscript: http://www.wjgnet.com/esps/Help Desk: http://www.wjgnet.com/esps/helpdesk.aspxDOI: 10.4253/wjge.v8.i13.458

World J Gastrointest Endosc 2016 July 10; 8(13): 458-465ISSN 1948-5190 (online)

© 2016 Baishideng Publishing Group Inc. All rights reserved.

Retrospective Study

group and 10 patients (77%) in the non-electrocautery group presented with infected PFCs. The technical success rates of EUS-TD for the treatment of PFCs were 100% (15/15) and 100% (13/13) for the electrocautery and the non-electrocautery groups, respectively. The clinical success rates of EUS-TD for the treatment of PFCs were 67% (10/15) and 69% (9/13) for the electrocautery and the non-electrocautery groups, respectively (P = 0.794). The procedure time of EUS-TD for the treatment of PFCs in the electrocautery group was significantly shorter than that of the non-electrocautery group (mean ± SD: 30 ± 12 min vs 52 ± 20 min, P < 0.001). Adverse events associated with EUS-TD for the treatment of PFCs occurred in 0 patients and 1 patient for the electrocautery and the non-electrocautery groups, respectively (P = 0.942).

CONCLUSION: EUS-TD using an electrocautery dilation catheter as a fistula dilation device for the treatment of symptomatic PFCs appears safe and contributes to a shorter procedure time.

Key words: Electrocautery dilation catheter; Endoscopic ultrasonography-guided transmural drainage; Fistula dilation device; Pancreatic and peripancreatic fluid collection; Procedure time

© The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.

Core tip: Endoscopic ultrasonography-guided transmural drainage using an electrocautery dilation catheter as a fistula dilation device for the treatment of symptomatic peripancreatic fluid collections appears to be safe and contributes to a shorter procedure time.

Kitamura K, Yamamiya A, Ishii Y, Nomoto T, Honma T, Yoshida H. Electrocautery vs non-electrocautery dilation catheters in endoscopic ultrasonography-guided pancreatic fluid collection drainage. World J Gastrointest Endosc 2016; 8(13): 458-465 Available from: URL: http://www.wjgnet.com/1948-5190/full/v8/i13/458.htm DOI: http://dx.doi.org/10.4253/wjge.v8.i13.458

INTRODUCTIONPancreatic and peripancreatic fluid collections (PFCs) are accumulations of liquid and/or necrotic tissue associated with acute pancreatitis, chronic pancreatitis, surgery, or abdominal trauma. The 1992 Atlanta Classification of acute pancreatitis was revised in 2012 to classify local complications caused by acute pancreatitis into the following 4 types: (1) acute peripancreatic fluid collection (APFC); within 4 wk of the onset of pancreatitis, without pancreatic and/or peripancreatic necrosis; (2) pancreatic pseudocyst (over 4 wk after the onset of pancreatitis without pancreatic and/or peripancreatic necrosis); (3) acute necrotic collection (ANC; within 4 wk of the onset of pancreatitis with pancreatic and/or peripancreatic

necrosis); and (4) walled-off necrosis (WON; over 4 wk after the onset of pancreatitis with pancreatic and/or peripancreatic necrosis)[1].

Endoscopic transmural drainage is a minimally in-vasive procedure for PFC. Endoscopic drainage for PFCs is superior to percutaneous drainage or surgery in terms of the duration of hospital stay and cost[2,3]. Recently, endoscopic ultrasonography-guided transmural drainage (EUS-TD) for the treatment of PFCs has been widely accepted[4-6]. However, it has been reported that EUS-TD for PFCs causes adverse events, such as bleeding and perforation, at a rate of 0%-21%[7,8], and the establish-ment of a safe procedure is necessary.

Electrocautery or non-electrocautery dilation catheters are currently used as fistula dilation devices for EUS-TD; however, few studies have investigated the safety and advantages of electrocautery dilation catheters for EUS-TD.

The aim of this study was to evaluate the safety and utility of an electrocautery dilation catheter as a fistula dilation device for EUS-TD in the treatment of PFCs.

MATERIALS AND METHODS This study was conducted as an exploratory retrospective study at Showa University Hospital, was approved by the Medical Ethics Committee of our institution, and was registered at the UMIN Clinical Trials Registry (UMIN 000018352). Informed, written consent was obtained from each patient prior to the procedure.

PatientsTwenty-eight consecutive patients who underwent EUS-TD at our institution between August 2010 and August 2014 were retrospectively analyzed. All of these patients underwent EUS-TD using an electrocautery or a non-electrocautery dilation catheter as a fistula dilation device after undergoing PFC puncture with a 19-gauge fine needle aspiration needle.

We used a non-electrocautery dilation catheter from August 2010 to April 2012 for 13 patients. An electro-cautery dilation catheter was used for 15 patients after May 2012, which is when the electrocautery dilation catheter became available as a treatment option at our institution. We conducted an exploratory retrospective study to compare the clinical outcomes between the electrocautery and the non-electrocautery groups. PFCs were classified into 4 types[1] according to the revised 2012 Atlanta Classification. We diagnosed PFCs using computed tomography, magnetic resonance imaging and EUS. We performed EUS-TD in patients with signs of infection, abdominal pain and an increase of PFC size (i.e., 6 cm or more). Signs of infection of PFCs were judged according to blood examination, blood culture examination and imaging results. We defined infected PFCs as those with bacteria present based on a culture examination of the PFC obtained by EUS-TD. Exclusion criteria of EUS-TD included coagulopathy, the interposition of blood vessels on the puncture tract for

Kitamura K et al . EUS-guided drainage using an electrocautery dilator

459WJGE|www.wjgnet.com July 10, 2016|Volume 8|Issue 13|

the PFC, and the inability to obtain informed consent.

DevicesA convex array echoendoscope, GF-UCT 240-AL5 (Oly-mpus Medical Systems Corp, Tokyo, Japan), was used for transmural drainage of the PFCs. A 19-gauge fine needle aspiration needle EchoTip® Ultra Endoscopic Ultrasound Needle (Cook Medical Inc., Bloomington Indiana, United States), Expect™ Endoscopic Ultrasound Aspiration Needle

(Boston Scientific, Natick, MA, United States) or EZ shot 2 (Olympus Medical Systems) was used to puncture the PFC.

As a guide wire (GW) for insertion into the PFC, a 0.035-inch Hydra Jagwire™ (Boston Scientific) and/or a 0.025-inch VisiGlide™ or a 0.025-inch VisiGlide 2™ (Olympus Medical Systems) was used.

An electrocautery dilation catheter, 6-Fr and/or 8.5-Fr Cyst-Gastro-Set (Endo-Flex GmbH, Voerde, Germany), was used to dilate the puncture tract of the PFC. The electrocautery dilation catheter is a wire-guided dilation catheter with a distal electrocautery tip. An 8.5-Fr catheter allows for the insertion of two GWs of 0.035 and 0.025- inches (Figure 1).

An Erbotom ICC200 (ERBE Elektromedizin GmbH, Tubingen, Germany) was used for cautery with the Endocut; the effect 3 current was set at an output limit of 120 W, and the forced coagulation current was set at an output limit of 30 W.

For the use of non-electrocautery dilation catheters, an MTW cannula (MTW Endoscopy, Dusseldorf, Germany) and a 6-F-10-Fr Soehendra® Biliary Dilation Catheter (Cook Medical) and/or an 8 mm-diameter balloon Non-Slip Bile Duct Dilation Catheter (Sumitomo Bakelite Co. Ltd., Tokyo, Japan) were used.

As a drainage catheter and stent, a 6-Fr pigtail naso-biliary catheter (Create Medic Co. LTD., Tokyo, Japan) and/or a 7-Fr 4 cm Zimmon® Biliary Stent Set (Cook Medical) or a Double Pigtail Stent delivery system Through Pass (Gadelius Medical K.K., Tokyo, Japan) were used.

ProcedureA convex array echoendoscope was used in all cases

of EUS-TD for the treatment of PFCs. All patients under-went endoscopic procedures under deep sedation with benzodiazepines and/or pentazocine as analgesics. Carbon dioxide inflation was used after May 2011. Antibiotics were initiated on the procedure day and were continued until improvement of the infection.

PFCs were accessed from the stomach or duodenum using a 19-gauge fine needle aspiration needle with EUS guidance. When the needle punctured the PFC, a 0.035-inch GW was inserted through the needle and advanced into the PFC under fluoroscopic guidance.

The puncture tract was dilated over the length of the GW using a 6-Fr and/or an 8.5-Fr electrocautery dilation catheter. After an 8.5-Fr electrocautery dilation catheter was inserted into the PFC over the 0.035-inch GW, another 0.025-inch GW was inserted into the PFC through the catheter lumen under fluoroscopic guidance. After the 0.035-inch and 0.025-inch GWs were inserted into the PFC, a 7-Fr 4 cm double pigtail stent (as an internal drain) and a 6-Fr drainage catheter (as an exter-nal drain) were inserted as far as possible.

According to the method for using a non-electrocautery dilation catheter, the puncture tract was dilated using an endoscopic retrograde cholangiopancreatography cannula and biliary dilation catheter with a balloon dilatation catheter over the GW. After another GW was inserted into the PFC through the fistulous tract, a 7-Fr 4 cm double pigtail stent and a 6-Fr drainage catheter were inserted as far as possible.

The external drainage catheter was placed during the first 1 to 2 wk, and the infected PFC was washed with saline. The stent of the internal drain was maintained for 3 to 6 mo and was removed after the resolution of the PFC.

Outcome measurementsThe primary endpoints were the technical and clinical successes of using an electrocautery dilation catheter as a fistula dilation device for EUS-TD in the treatment of PFCs.

Technical success was defined as good fistulous dilation and successful internal and/or external drain placement within the PFC.

Clinical success was defined as the resolution of the PFC and/or the improvement of the infected PFCs by the use of only the EUS-TD without the need for additional drainage or necrosectomy.

The secondary endpoints were the procedure time and the safety of EUS-TD for the treatment of PFCs using an electrocautery dilation catheter.

The procedure time was defined as the time from echoendoscopic insertion until the internal and/or external drain placement.

The safety of EUS-TD for the treatment of PFCs was evaluated according to the development of procedure-related adverse events, such as bleeding, perforation, stent migration, and free air in the abdomen.


Figure 1 View of an electrocautery dilation catheter tip of an 8.5-Fr Cyst-Gastro-Set (Endo-Flex GmbH, Voerde, Germany).


presented with infected PFCs (Table 1).

Technical and clinical successThe technical success rates of EUS-TD for the treatment of PFCs were 100% and 100% for the electrocautery and non-electrocautery groups, respectively. Transgastric puncture was carried out in 14 patients (93%) in the electrocautery group and in 13 patients (100%) in the non-electrocautery group (P = 0.942). Internal and external drain placements for PFCs were performed on 14 patients (93%) in the electrocautery group and on 11 patients (85%) in the non-electrocautery group (P = 0.896).

The clinical success rates of EUS-TD for the treatment of PFCs without the need for additional transmural drainage or necrosectomy were 67% (10/15) and 69% (9/13) for the electrocautery and non-electrocautery groups, respectively (P = 0.794).

In the non-electrocautery group, 1 patient required additional EUS-TD for the treatment of a pancreatic pseudocyst that showed exacerbation of infection due to the dislocation of the external drain, and 1 patient required additional endoscopic internal drainage through the fistula for WON that showed exacerbation of infection after external drain withdrawal.

In the electrocautery group, 5 patients required endoscopic necrosectomy for infections associated with WON and ANC due to the lack of efficacy of EUS-TD. In the non-electrocautery group, 1 patient required

Statistical analysisContinuous variables are expressed as the mean ± SD. Statistical analyses were performed using StatMate Ⅲ software (ATMS Co. Ltd., Tokyo, Japan). Data were analyzed using the Mann-Whitney U test and the χ 2 test. Differences of P < 0.05 were considered significant.

RESULTSA total of 28 consecutive patients who underwent EUS-TD for the treatment of symptomatic PFCs by fine needle aspiration using a 19-gauge needle were investigated in this study. After we obtained permission to use an electrocautery dilation catheter at our institution in May 2012, we used the dilation catheter for these patients. Fifteen patients were treated with an electrocautery dilation catheter for the fistulous dilation of PFCs (electrocautery group), and 13 patients were treated with a non-electrocautery dilation catheter (non-electrocautery group) (Figure 2). The mean follow-up period of all patients was 1001 ± 463 d.

Patient characteristicsPatient characteristics are presented in Table 1. There were no statistically significant differences in age, sex, type of PFC based on the revised Atlanta Classification, location and diameter of PFCs between the groups. Thirteen patients (87%) in the electrocautery group and 10 patients (77%) in the non-electrocautery group


Endoscopic ultrasonography-guided transmural drainageusing a 19-gauge fine aspiration needle for pancreatic fluid collectionn = 28

Use of an electrocautery dilation catheter as a fistula dilation device n = 15 (electrocautery group)

Use of a non-electrocautery dilation catheter as a fistula dilation devicen = 13 (non-electrocautery group)

Technical successn = 15 (100%)

Technical successn = 13 (100%)

Clinical successn = 10 (67%)

Clinical failuren = 5 (33%)

Clinical successn = 9 (69%)

Clinical failuren = 4 (31%)

Endoscopic necrosectomyn = 5 (33%)

EUS-TD n = 1Endoscopic fistulous drainage n = 1Endoscopic necrosectomy n = 1Surgical necrosectomy n = 1

Figure 2 Flow diagram of patient selection and procedural outcomes in this study.


endoscopic necrosectomy, and 1 patient underwent surgical necrosectomy for uncontrolled infected WON (Figure 2 and Table 2).

EUS-TD procedure timeThe procedure time for EUS-TD in the electrocautery group was significantly shorter than that of the non-electrocautery group (30 ± 12 min vs 52 ± 20 min, P < 0.001) (Table 2).

Adverse eventsNo adverse events occurred during the EUS-TD pro-cedure in the electrocautery group. One patient in the non-electrocautery group presented with free air in the abdomen during the procedure but was relieved conservatively. There were no procedure-related deaths in either of the groups (Table 2).

DISCUSSIONEndoscopic drainage has recently replaced percutaneous or surgical drainage as the initial approach for the treatment of PFCs. Percutaneous drainage of PFCs allows for improved drainage by using a drainage tube with a larger diameter. A single-center, retrospective study reported that endoscopic drainage has a similar clinical success rate, fewer required re-interventions, a shorter hospital stay, and a decreased number of follow-up abdominal imaging studies for symptomatic pancreatic pseudocysts compared with percutaneous drainage[2]. In a randomized trial for pancreatic pseudocyst drainage comparing endoscopic and surgical cystogastrostomy, endoscopic drainage was associated with shorter hospital stays, better physical and mental health of the patients, and lower costs[3].

Recently, EUS-TD has been widely accepted as a

minimally invasive procedure that allows the safe puncture of PFCs using a visualized approach. In a prospective randomized trial comparing EUS-TD and conventional endoscopic drainage for pancreatic pseudocysts, the technical success associated with EUS-TD was significantly greater than that of conventional endoscopic drainage, from which the authors concluded that EUS should be considered the first-line treatment modality for pancreatic pseudocysts[7].

A non-electrocautery dilation catheter has been used conventionally as a device for fistulous dilation for PFCs. However, sufficient dilation of the fistula site can be difficult using only a non-electrocautery dilation catheter. As a result, it may prove impossible to insert a drain catheter or a plastic stent into the cavities of PFCs using this method.

As an alternative to the non-electrocautery method, Azar et al[9] reported that 21 of 23 patients with PFCs underwent technically successful wire-guided pancreatic pseudocyst drainage using a modified needle knife. Additionally, Ahlawat et al[10] reported that 9 of 11 total PFC patients successfully underwent EUS-guided pseudocyst drainage using a single-step approach involving a cystotome to electrically enlarge the fistula site. However, misdirected PFC punctures may occur when using only a cystotome, as it is difficult to visualize the tip of an electrocautery catheter with EUS guidance. Our data show that the expansion of the puncture tract using dilator catheters after having punctured a PFC using a 19-gauge fine needle aspiration needle with EUS guidance is a safe and effective alternative procedure. An additional advantage of using a wire-guided electrocautery dilation catheter for EUS-TD in the treatment of PFCs is that we can penetrate the puncture tract without excessive resistance, which increases the efficiency of the procedure.

Prior to our study, few studies have compared the clinical effects of electrocautery and non-electrocautery dilation catheters as fistula dilation devices for EUS-guided transmural PFC drainage. Therefore, we retrospectively investigated the clinical outcomes and adverse events associated with the use of electrocautery and non-electrocautery dilation catheters for EUS-TD in the treatment of PFCs.

The technical success rate of EUS-TD for the treatment of symptomatic PFCs was 100% for the electrocautery and non-electrocautery groups. Moreover, the procedure time for EUS-TD in the electrocautery group was significantly shorter than that of the non-electrocautery group (30 ± 12 min vs 52 ± 20 min, P < 0.001). Median procedure times of EUS-TD using plastic stents for PFCs have been reported as 29.5 min (interquartile range: 23.5-42 min)[11] and 42.6 ± 14.2 min[12].

We used a 6-Fr and/or an 8.5-Fr wire-guided electro-cautery dilation catheter under fluoroscopic guidance to dilate the puncture tract of PFCs. An 8.5-Fr electrocautery dilation catheter offers the advantage of accommodating the insertion of a 0.035-inch and a 0.025-inch GW, and


Table 1 Baseline characteristics of the patients in the electrocautery and nonelectrocautery groups

Electrocautery group (n = 15)

Nonelectrocautery group (n = 13)

P value

Age: mean ± SD, yr 60 ± 14 64 ± 14 0.4891

Sex: male/female, n 12/3 11/2 0.8602

Type of PFC, n (%) 0.6152

WON 4 (27) 6 (46) Pancreatic pseudocyst 6 (40) 4 (31) ANC 4 (27) 3 (23) APFC 1 (6) 0Location of PFC, n (%) 0.9762

Head 3 (20) 3 (23) Body-tail 11 (73) 9 (69) Head-body-tail 1 (7) 1 (8)Diameter of PFC, mean ± SD, cm

7.2 ± 3.1 9.9 ± 3.7 0.0611

Infected PFC, n (%) 13 (87) 10 (77) 0.8602

1Mann-Whitney U test; 2χ 2 test. PFC: Pancreatic and peripancreatic fluid collection; WON: Walled-off necrosis; ANC: Acute necrotic collection; APFC: Acute peripancreatic fluid collection.


the placement of internal and external drain catheters is possible at the same time.

The procedure time of EUS-TD for PFCs using an electrocautery dilation catheter was shorter than that of a non-electrocautery dilation catheter in part because we could easily create a large fistulous tract without changing devices, which allowed for the quick insertion of a drain catheter and a plastic stent into the PFC by simultaneously inserting two GWs through the catheter into the cavity.

Seewald et al[13] also reported that eight out of eight patients were successfully treated without complications using a one-step, simultaneous double-wire technique for the treatment of pancreatic pseudocysts and abscess drainage; the mean procedural time was 32.5 min (range 25-45 min).

The main adverse events for EUS-TD are bleeding and perforation. In this study, the use of an electrocautery dilation catheter resulted in no adverse events.

We hypothesized that using a wire-guided electro-cautery dilation catheter under EUS and fluoroscopic guidance would allow us to safely expand the puncture tract.

The clinical success rates of EUS-TD for the treatment of PFCs without the need for additional treatments were 67% (10/15) in the electrocautery group and 69% (9/13) in the non-electrocautery groups, and there was no significant difference between the groups (P = 0.794).

The clinical success rate of EUS-guided or conventional transmural drainage for PFCs is related to the PFC type. In terms of clinical success rates of EUS-guided or conventional endoscopic transmural PFC drainage, the success rates for pancreatic pseudocysts are between 86% and 100%[7,14-18], whereas the success rate for WON with necrosis is between 25% and 72%[15,19-21]. A possible reason for the discrepancies in these results is that the

drainage effects of EUS-TD treatment of WON is poor due to the inclusion of necrotic material, which increases the risk of catheter and plastic stent occlusion. Because a plastic stent can be easily occluded by necrotic material, a novel, fully covered and self-expandable metal stent has become available to create a large fistulous site and reduce stent occlusion[22,23]. More recently, Rinninella et al[24] reported that EUS-TD for the treatment of PFCs using a lumen-apposing metal stent on an electrocautery-enhanced delivery system is a safe, effective, and mini-mally invasive treatment.

In our study, clinical failure of EUS-TD for the treatment of PFCs occurred in 6 patients with WON, 2 patients with ANC, and 1 patient with a pancreatic pseudocyst. The clinical success rate of EUS-TD was 91% (10/11) for patients with pancreatic pseudocysts and APFC and 53% (9/17) for patients with WON and ANC. Approximately 50% of patients who experienced poor outcomes from EUS-TD treatment for WON and ANC, which include necrotic material, required additional treatment in our study.

Recently, endoscopic transmural necrosectomy has been accepted as a step–up approach in patients with infected necrotizing pancreatitis, in whom EUS-TD treatment is insufficient[25]. In this report, the authors declared that an endoscopic step-up approach reduces mortality, major complications, hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotizing pancreatitis.

A limitation of this study is the single-center, small, and exploratory retrospective nature of the study. The difference in procedure time may be related to increased experience of the clinicians with the procedure. Multi-center, randomized, controlled trials are needed to confirm our findings.

In conclusion, EUS-TD using an electrocautery dilation


Table 2 Procedural outcomes of the patients in the electrocautery and nonelectrocautery groups

Electrocautery group (n = 15)

Nonelectrocautery group (n = 13)

P value

Technical success, n (%) 15 (100) 13 (100)Puncture tract, n (%) 0.9421

Transgastric 14 (93) 13 (100) Transduodenal 1 (7) 0 Drainage method, n (%) 0.8961

Internal and external drainage 14 (93) 11 (85) External drainage 1 (7) 2 (15)Clinical success, n (%) 10 (67) 9 (69) 0.7941

Procedure time, mean ± SD, min 30 ± 12 52 ± 20 < 0.0012

Adverse events, n 0.9421

Free air 0 1Procedure-related death, n 0 0Additional procedure, n 0.7941

EUS-TD 0 1 Endoscopic fistulous drainage 0 1 Endoscopic necrosectomy 5 1 Surgical necrosectomy 0 1

1χ 2 test; 2Mann-Whitney U test. EUS-TD: Endoscopic ultrasonography-guided transmural drainage.


catheter as a fistula dilation device for the treatment of PFCs appears to be safe and contributes to shorter procedure times.

ACKNOWLEDGMENTSWe express our deepest appreciation to Professor Kenichi Matsui and Professor Eiji Uchida, Office for Promoting Medical Research Showa University, for the statistical review of descriptions of study design.

COMMENTSBackgroundEndoscopic ultrasonography-guided transmural drainage (EUS-TD) has been widely accepted as a minimally invasive procedure for pancreatic and peripancreatic fluid collections (PFCs). However, EUS-TD for the treatment of PFCs may cause adverse events, such as bleeding and perforation; thus, the establishment of a safe procedure for EUS-TD is necessary. Few articles have investigated the clinical outcomes associated with the use of an electrocautery dilation catheter as a fistula dilation method for EUS-TD in the treatment of PFCs. The aim of this study was to evaluate the safety and efficacy of an electrocautery dilation catheter as a fistula dilation device for EUS-TD in the treatment of PFCs by fine needle aspiration using a 19-gauge needle.

Research frontiersElectrocautery or non-electrocautery dilation catheters are used as fistula dilation devices for EUS-TD in the treatment of PFCs; however, prior to this study, few studies have investigated the safety and efficacy of an electrocautery dilation catheter in this procedure.

Innovations and breakthroughsThe authors retrospectively compared the clinical outcomes between electrocautery and non-electrocautery dilation catheters for EUS-TD in the treatment of symptomatic PFCs. The results show that EUS-TD using an electrocautery dilation catheter as a fistula dilation device appears to be safe and contributes to shorter procedure times.

ApplicationsThe results of this exploratory retrospective study suggest that EUS-TD for the treatment of PFCs using an electrocautery dilation catheter as a fistula dilation device appears to be safe and contributes to shorter procedure times. However, multi-center, randomized, controlled trials are needed to confirm these findings.

TerminologyAn electrocautery dilation catheter was used to dilate the puncture tract of PFCs. This device is a wire-guided dilation catheter with a distal electrocautery tip. An 8.5-Fr electrocautery dilation catheter allows the simultaneous insertion of 0.035-inch and 0.025-inch guide wires, and the placement of internal and external drain catheters is possible at the same time.

Peer-reviewThis manuscript is generally well written. The data are of interest, although it is a rather specialized topic.

REFERENCES1 Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr

MG, Tsiotos GG, Vege SS. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111 [PMID: 23100216 DOI: 10.1136/gutjnl-2012-302779]

2 Akshintala VS, Saxena P, Zaheer A, Rana U, Hutfless SM, Lennon AM, Canto MI, Kalloo AN, Khashab MA, Singh VK.

A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts. Gastrointest Endosc 2014; 79: 921-928; quiz 983.e2, 983.e5 [PMID: 24315454 DOI: 10.1016/j.gie.2013.10.032]

3 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: 583-590.e1 [PMID: 23732774 DOI: 10.1053/j.gastro.2013.05.046]

4 Giovannini M, Bernardini D, Seitz JF. Cystogastrotomy entirely performed under endosonography guidance for pancreatic pseudocyst: results in six patients. Gastrointest Endosc 1998; 48: 200-203 [PMID: 9717789 DOI: 10.1016/S0016-5107(98)70165-8]

5 Seifert H, Dietrich C, Schmitt T, Caspary W, Wehrmann T. Endoscopic ultrasound-guided one-step transmural drainage of cystic abdominal lesions with a large-channel echo endoscope. Endoscopy 2000; 32: 255-259 [PMID: 10718392 DOI: 10.1055/s-2000-93]

6 Braden B, Dietrich CF. Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis: new technical developments. World J Gastroenterol 2014; 20: 16191-16196 [PMID: 25473173 DOI: 10.3748/wjg.v20.i43.16191]

7 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: 1102-1111 [PMID: 18640677 DOI: 10.1016/j.gie.2008.04.028]

8 Binmoeller KF, Weilert F, Shah JN, Bhat YM, Kane S. Endosono-graphy-guided transmural drainage of pancreatic pseudocysts using an exchange-free access device: initial clinical experience. Surg Endosc 2013; 27: 1835-1839 [PMID: 23299130 DOI: 10.1007/s00464-012-2682-9]

9 Azar RR, Oh YS, Janec EM, Early DS, Jonnalagadda SS, Edmundowicz SA. Wire-guided pancreatic pseudocyst drainage by using a modified needle knife and therapeutic echoendoscope. Gastrointest Endosc 2006; 63: 688-692 [PMID: 16564874 DOI: 10.1016/j.gie.2005.10.032]

10 Ahlawat SK, Charabaty-Pishvaian A, Jackson PG, Haddad NG. Single-step EUS-guided pancreatic pseudocyst drainage using a large channel linear array echoendoscope and cystotome: results in 11 patients. JOP 2006; 7: 616-624 [PMID: 17095841 DOI: 10.1055/s-2006-947743]

11 Lee BU, Song TJ, Lee SS, Park do H, Seo DW, Lee SK, Kim MH. Newly designed, fully covered metal stents for endoscopic ultrasound (EUS)-guided transmural drainage of peripancreatic fluid collections: a prospective randomized study. Endoscopy 2014; 46: 1078-1084 [PMID: 25412095 DOI: 10.1055/s-0034-1390871]

12 Mukai S, Itoi T, Baron TH, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Tanaka R, Umeda J, Tonozuka R, Honjo M, Gotoda T, Moriyasu F, Yasuda I. Endoscopic ultrasound-guided placement of plastic vs. biflanged metal stents for therapy of walled-off necrosis: a retrospective single-center series. Endoscopy 2015; 47: 47-55 [PMID: 25264765 DOI: 10.1055/s-0034-1377966]

13 Seewald S, Thonke F, Ang TL, Omar S, Seitz U, Groth S, Zhong Y, Yekebas E, Izbicki J, Soehendra N. One-step, simultaneous double-wire technique facilitates pancreatic pseudocyst and abscess drainage (with videos). Gastrointest Endosc 2006; 64: 805-808 [PMID: 17055880 DOI: 10.1016/j.gie.2006.07.049]

14 Kahaleh M, Shami VM, Conaway MR, Tokar J, Rockoff T, De La Rue SA, de Lange E, Bassignani M, Gay S, Adams RB, Yeaton P. Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy 2006; 38: 355-359 [PMID: 16680634 DOI: 10.1055/s-2006-925249]

15 Hookey LC, Debroux S, Delhaye M, Arvanitakis M, Le Moine O, Devière J. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006; 63: 635-643 [PMID:


COMMENTS


16564865 DOI: 10.1016/j.gie.2005.06.028]16 Weckman L, Kylänpää ML, Puolakkainen P, Halttunen J.

Endoscopic treatment of pancreatic pseudocysts. Surg Endosc 2006; 20: 603-607 [PMID: 16424988 DOI: 10.1007/s00464-005-0201-y]

17 Lopes CV, Pesenti C, Bories E, Caillol F, Giovannini M. Endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts. Arq Gastroenterol 2008; 45: 17-21 [PMID: 18425223 DOI: 10.1590/S0004-28032008000100004]

18 Giovannini M, Pesenti C, Rolland AL, Moutardier V, Delpero JR. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echo endoscope. Endoscopy 2001; 33: 473-477 [PMID: 11437038 DOI: 10.1055/s-2001-14967]

19 Baron TH, Harewood GC, Morgan DE, Yates MR. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002; 56: 7-17 [PMID: 12085029 DOI: 10.1067/mge.2002.125106]

20 Gardner TB, Chahal P, Papachristou GI, Vege SS, Petersen BT, Gostout CJ, Topazian MD, Takahashi N, Sarr MG, Baron TH. A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis. Gastrointest Endosc 2009; 69: 1085-1094 [PMID: 19243764 DOI: 10.1016/j.gie.2008.06.061]

21 Varadarajulu S, Bang JY, Phadnis MA, Christein JD, Wilcox CM. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest Surg 2011; 15: 2080-2088 [PMID: 21786063 DOI: 10.1007/s11605-011-1621-8]

22 Itoi T, Binmoeller KF, Shah J, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Moriyasu F. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided

pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012; 75: 870-876 [PMID: 22301347 DOI: 10.1016/j.gie.2011.10.020]

23 Yamamoto N, Isayama H, Kawakami H, Sasahira N, Hamada T, Ito Y, Takahara N, Uchino R, Miyabayashi K, Mizuno S, Kogure H, Sasaki T, Nakai Y, Kuwatani M, Hirano K, Tada M, Koike K. Preliminary report on a new, fully covered, metal stent designed for the treatment of pancreatic fluid collections. Gastrointest Endosc 2013; 77: 809-814 [PMID: 23453183 DOI: 10.1016/j.gie.2013.01.009]

24 Rinninella E, Kunda R, Dollhopf M, Sanchez-Yague A, Will U, Tarantino I, Gornals Soler J, Ullrich S, Meining A, Esteban JM, Enz T, Vanbiervliet G, Vleggaar F, Attili F, Larghi A. EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video). Gastrointest Endosc 2015; 82: 1039-1046 [PMID: 26014960 DOI: 10.1016/j.gie.2015.04.006]

25 van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, Dijkgraaf MG, van Eijck CH, Erkelens GW, van Goor H, Hadithi M, Haveman JW, Hofker SH, Jansen JJ, Laméris JS, van Lienden KP, Manusama ER, Meijssen MA, Mulder CJ, Nieuwenhuis VB, Poley JW, de Ridder RJ, Rosman C, Schaapherder AF, Scheepers JJ, Schoon EJ, Seerden T, Spanier BW, Straathof JW, Timmer R, Venneman NG, Vleggaar FP, Witteman BJ, Gooszen HG, van Santvoort HC, Fockens P. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13: 161 [PMID: 24274589 DOI: 10.1186/1471-230X-13-161]

P- Reviewer: Chow WK, Ding XW, Kayaalp C, Kleeff J S- Editor: Kong JX L- Editor: A E- Editor: Lu YJ



Efficacy and safety of endoscopic submucosal dissection under general anesthesia

Kanefumi Yamashita, Hironari Shiwaku, Toshihiro Ohmiya, Hideki Shimaoka, Hiroki Okada, Ryo Nakashima, Richiko Beppu, Daisuke Kato, Takamitsu Sasaki, Seiichiro Hoshino, Satoshi Nimura, Ken Yamaura, Yuichi Yamashita

Kanefumi Yamashita, Hironari Shiwaku, Toshihiro Ohmiya, Hideki Shimaoka, Hiroki Okada, Ryo Nakashima, Richiko Beppu, Daisuke Kato, Takamitsu Sasaki, Seiichiro Hoshino, Yuichi Yamashita, Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka 814-0180, Japan

Satoshi Nimura, Department of Pathology, Fukuoka University Faculty of Medicine, Fukuoka 814-0180, Japan

Ken Yamaura, Department of Anesthesiology, Fukuoka University Faculty of Medicine, Fukuoka 814-0180, Japan

Author contributions: Yamashita K and Shiwaku H equally contributed to this work; Yamashita K collected and analyzed the data and drafted the manuscript; Shiwaku H provided analytical oversight; Sasaki T designed and supervised the study; Nimura S, Yamaura K and Yamashita Y revised the manuscript for important intellectual content; Nimura S, Yamaura K and Yamashita Y offered the technical or material support; Ohmiya T, Shimaoka H, Okada H, Nakashima R, Beppu R, Kato D, Sasaki T and Hoshino S provided administrative support; all authors have read and approved the final version to be published.

Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the Fukuoka University Faculty of Medicine.

Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.

Conflict-of-interest statement: We have no financial relationships to disclose.

Data sharing statement: No additional data are available.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,

which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Unsolicited manuscript

Correspondence to: Hironari Shiwaku, MD, Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan. [email protected] Telephone: +81-92-8011011Fax: +81-92-8639759

Received: February 14, 2016Peer-review started: February 15, 2016First decision: March 23, 2016Revised: April 21, 2016Accepted: May 17, 2016Article in press: May 27, 2016Published online: July 10, 2016

AbstractAIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) under general anesthesia.

METHODS: From January 2011 to July 2014, 206 consecutive patients had undergone ESD under general anesthesia for neoplasms of the stomach, esophagus, and colorectum were enrolled in this retrospective study. The efficacy and safety of ESD under general anesthesia were assessed.

RESULTS: The en bloc resection rate of esophageal, gastric, and colorectal lesions was 100.0%, 98.3%, and 96.1%, respectively. The complication rate of perforation

ORIGINAL ARTICLE





Retrospective Study

and bleeding were 0.0% and 0.0% in esophageal ESD, 1.7% and 1.7% in gastric ESD, and 3.9% and 2.0% in colorectal ESD, respectively. No cases of aspiration pneumonia were observed. All complications were managed by conservative treatment, with no surgical intervention required.

CONCLUSION: With the cooperation of an anesthesiolo-gist, ESD under general anesthesia appears to be a useful method, decreasing the risk of complications.

Key words: Complication; Endoscopic submucosal dissection; General anesthesia; Conscious sedation


Core tip: Studies regarding endoscopic submucosal dissection (ESD) under general anesthesia in Japan are scarce because ESD is generally performed under conscious sedation. ESD requires minimal patient movement for optimal visualization, which may be hampered because of insufficient sedation. Thus, this retrospective study aimed to evaluate the efficacy and safety of ESD under general anesthesia in 206 consecutive patients. The complication rate was lower in our study than in previous studies. Moreover, no cases of aspiration pneumonia were observed. ESD under general anesthesia appears to be a useful method for reducing the risk of complications.

Yamashita K, Shiwaku H, Ohmiya T, Shimaoka H, Okada H, Nakashima R, Beppu R, Kato D, Sasaki T, Hoshino S, Nimura S, Yamaura K, Yamashita Y. Efficacy and safety of endoscopic submucosal dissection under general anesthesia. World J Gastrointest Endosc 2016; 8(13): 466-471 Available from: URL: http://www.wjgnet.com/1948-5190/full/v8/i13/466.htm DOI: http://dx.doi.org/10.4253/wjge.v8.i13.466

INTRODUCTIONEndoscopic submucosal dissection (ESD) is a well-esta-blished treatment for early-stage malignant lesions of the stomach, esophagus, and colorectum with no risk of lymphatic metastasis[1-4]. ESD requires precise and complicated maneuvers. Minimal patient movement for maintaining good visualization is important for a successful procedure, and intraoperative management of the patient’s general condition is very important for achieving safe ESD. In Japan, ESD is usually performed under conscious sedation in the endoscopy room. However, some issues are associated with this procedure, including patient movement because of insufficient effect of sedation and a risk of aspiration pneumonia. Any patient movement during the procedure can result in complications such as perforation and hemorrhage because of impaired visual control. Aspiration pneumonia can induce respiratory failure. Therefore, we perform ESD under general anesthesia with

mechanical ventilation. In this study, we retrospectively investigated the efficacy and safety of ESD under general anesthesia.

MATERIALS AND METHODSIndications for endoscopic submucosal dissection under general anesthesia at our institutionESD under general anesthesia is performed in cases in which the predicted procedure time is > 120 min, an insufficient effect of conscious sedation (such as that in heavy drinkers) was observed, or strict anesthetic management is required (such as that in high-risk cases affected by comorbidities).

PatientsWe retrospectively enrolled consecutive 206 patients who had undergone ESD under general anesthesia for neoplasms of the stomach, esophagus, and colorectum in accordance with our indications, except for two patients who rejected the treatment for neoplasms because of their old age, at the Fukuoka University Faculty of Medicine, Department of Gastroenterological Surgery between January 2011 and July 2014. Information collected from medical records included clinical and operative data.

General anesthesiaESD was performed under general anesthesia with endotracheal intubation by the anesthesiologist in the operation room. General anesthesia was induced with rocuronium and propofol and was maintained with propofol or sevoflurane, remifentanil, and intermittent rocuronium administration during the procedure. After endotracheal intubation, patients were placed in the left lateral position in cases of esophageal or gastric lesions or in the supine position in cases of colorectal lesions.

Endoscopic equipmentEsophageal and gastric lesion: A gastroscope (GIF H260Z; Olympus, Tokyo, Japan) was used for marking the lesion. The lesion’s circumference was marked using argon plasma coagulation (APC). ESD was conducted using a gastroscope (GIF Q260J; Olympus, Tokyo, Japan) with a distal attachment cap (DH-28GR; Fujifilm, Tokyo, Japan). Submucosal injections were performed using a 25-G needle (3 mm; Impact Flow, Top Corporation, Tokyo, Japan) for esophageal lesions, and a 25-G needle (4 mm; Impact Flow, Top Corporation) for gastric lesions. Incision and dissection were performed using two types of Flush Knife BT (2.0 and 2.5 mm, respectively, DK2618JB, Fujifilm Medical, Tokyo, Japan). An electrosurgical generator (VIO 300D; ERBE, Tübingen, Germany) was used for all ESD procedures. All visible vessels were coagulated with hemostatic forceps (Coagrasper; FD-410LR, Olympus).

Colorectal lesions: The endoscope used was a colo-noscope (PCF-Q260AZI; Olympus, Tokyo, Japan) with a distal attachment cap (DH-29GR; Fujifilm, Tokyo, Japan) for

Yamashita K et al . ESD under general anesthesia


marking of the lesion and ESD. The lesion’s circumference was marked using APC. Submucosal injections were performed using a 25-G needle (3 mm, Impact Flow, Top Corporation, Japan). Incision and dissection were performed with a Flush Knife BT (1.5 mm, DK2618JB, Fujifilm Medical, Tokyo, Japan). An electrosurgical generator (VIO 300D; ERBE, Tübingen, Germany) was used for all ESD procedures. All visible vessels were coagulated with hemostatic forceps (Coagrasper; FD-411UR, Olympus).

All ESD procedures were performed with carbon dioxide insufflation.

Ethical considerationsThe study was reviewed and approved by the Ethics Committee of the Fukuoka University Faculty of Medicine.

RESULTSEsophageal ESD under general anesthesiaWe performed esophageal ESD under general anesthesia for 58 esophageal neoplasms in 46 patients. The baseline clinical and operative characteristics of the patients are summarized in Table 1. The male:female ratio was 41:5 (89.1%/10.9%) and the mean age of the patients was 69.7 ± 10.0 years (range, 26-82 years). The number of patients who had preoperative comorbidities was 39 (84.8%). The diameter of the resected specimen was 32.9 ± 12.1 mm (range, 10-70 mm). The en bloc resection rate was 100.0%. The mean operating time was 164.5 ± 95.1 min (range, 40-468 min). The mean anesthesia time was 233.6 ± 95.0 min (range, 105-545 min). With regard to complications, no cases of perforation or bleeding were observed, and there was no

perioperative mortality (Table 1).

Gastric ESD under general anesthesiaWe performed gastric ESD under general anesthesia for 121 gastric neoplasms from 111 patients. The baseline clinical and operative characteristics of the patients are summarized in Table 2. The male:female ratio was 79:32 (71.2%/28.8%) and the patients’ mean age was 70.4 ± 10.2 years (range, 44-89 years). The number of patients who had preoperative comorbidities was 91 (75.2%). The diameter of the resected specimen was 39.5 ± 13.9 mm (range, 10-80 mm). The en bloc resection rate was 98.3%. The mean operating time was 188.4 ± 91.7 min (range, 50-615 min), and the mean anesthesia time was 254.5 ± 95.4 min (range, 110-680 min). With regard to complications, intraoperative bleeding occurred in 1 (0.8%) patient, delayed bleeding occurred in 1 (0.8%) patient, and intraoperative perforation occurred in 2 (1.7%) patients (Table 2). In all cases of intraoperative perforation, we were able to close the hole using endoclips. All complications were managed using conservative treatment, with no surgical intervention required. No perioperative mortality was observed.

Colorectal ESD under general anesthesiaWe performed colorectal ESD under general anesthesia for 51 colorectal neoplasms from 49 patients. Baseline clinical and operative characteristics of the patients are summarized in Table 3. The male:female ratio was 22:27 (44.9%/55.1%), and patient mean age was 66.7 ± 9.6 years (range, 42-87 years). The number of patients who had preoperative comorbidities was 32 (65.3%). The diameter of the resected specimen was 36.5 ± 11.3


Table 1 Baseline clinical and operational characteristics of patients undergoing esophageal endoscopic submucosal dissection

Age, (yr)1 69.7 ± 10.0Sex, n (%) Male 41 (89.1) Female 5 (10.9)Preoperative co-morbidities, n (%) 39 (84.8)ASA score, n (%) Ⅰ 8 (17.4) Ⅱ 37 (80.4) Ⅲ 1 (2.2)Histologic type, n (%) Squamous cell carcinoma 53 (91.4) Leiomyoma 2 (3.4) Others 3 (5.2)Mean diameter of resected specimen, (mm)1 32.9 ± 12.1en bloc resection rate, n (%) 58 (100)Duration of anesthesia, (min)1 233.6 ± 95.0Duration of operation, (min)1 164.5 ± 95.1Postoperative hospital stay (d)1 8.3 ± 2.3Complication rate, n (%) 0 (0.0)Intraoperative bleeding 0 (0.0)Delayed bleeding 0 (0.0)Intraoperative perforation 0 (0.0)

1Mean ± SD. ASA: American Society of Anesthesiologists score.

Table 2 Baseline clinical and operational characteristics of patients undergoing gastric endoscopic submucosal dissection


Age, (yr)1 70.4 ± 10.2Sex, n (%) Male 79 (71.2) Female 32 (28.8)Preoperative co-morbidities, n (%) 91 (75.2)ASA score, n (%) Ⅰ 20 (18.0) Ⅱ 88 (79.3) Ⅲ 3 (2.7)Histologic type, n (%) Differentiated type adenocarcinoma 102 (84.3) Undifferentiated type adenocarcinoma 8 (6.6) Others 10 (8.3)Mean diameter of resected specimen (mm)1 39.5 ± 13.9en bloc resection rate, n (%) 119 (98.3)Duration of anesthesia, (min)1 254.5 ± 95.4Duration of operation, (min)1 188.4 ± 91.7Postoperative hospital stay (d)1 7.5 ± 2.0Complication rate, n (%) 4 (3.3)Intraoperative bleeding 1 (0.8)Delayed bleeding 1 (0.8)Intraoperative perforation 2 (1.7)


therapeutic endoscopy was reported[7,9]; however, the safe use of propofol is limited.

The advantages of ESD under general anesthesia include optimal visualization in the absence of patient movement; the operator can concentrate on ESD maneuvers without having to attend to anesthetic management because of the assistance of an anesthesiologist; if complications, such as intraoperative perforation and bleeding occur, we can manage this with optimal visualization; there is no risk of aspiration pneumonia during the ESD procedure; and the supervisor can teach beginners without having to care regarding the patient’s consciousness.

The reported rate of perforation and bleeding of ESD is 5.0% and 2.1% in esophageal ESD[10], 0.3%-5.0% and 3.4%-5.8% in gastric ESD[1,11-14], and 1.4%-10.4% and 0.0%-12.0% in colorectal ESD[15-18], respectively.

However, the complication rate of perforation and bleeding in ESD under general anesthesia in our institution was 0.0% and 0.0% in esophageal ESD, 1.7% and 1.7% in gastric ESD, and 3.9% and 2.0% in colorectal ESD, respectively. Although half of ESDs were performed by an endoscopy fellow under direct supervision of an experienced endoscopist, the complication rate was lower in our study than that in previous reports.

If intraoperative perforation and bleeding occur, any patient movement during the procedure may cause difficulty in controlling the endoscope because of poor visualization. In our study, intraoperative massive blee-ding occurred in only one case of gastric ESD. Further-more we can safely and quickly control bleeding by maintaining optimal visualization. Moreover, in all cases of intraoperative perforation, we were able to close the hole using endoclips. Conservative treatment was sufficient for all complications, and no surgical intervention was required to manage any bleeding or perforation.

Aspiration pneumonia by vomiting can induce respir-atory failure. Aspiration pneumonia is reported to occur in 2.2%-6.6% of patients undergoing ESD[19-21]. Endotracheal intubation reportedly prevents aspiration, and positive pressure ventilation decreases the risk of air-related adverse events[4,22]. Here we experienced no cases of aspiration pneumonia performing ESD under general anesthesia.

In this study, 25.5% patients of all ESD procedure under general anesthesia required strict anesthetic management because of severe heart or lung disease (data not shown). However, no complications associated with general anesthesia were observed. Strict anesthetic management by an anesthesiologist may be important in patients with severe heart or lung disease.

Postoperative hospital stay in our study may be longer than that in other advanced nations. The average number of hospitalization days is more in Japan than in other advanced nations because of difference in the medical insurance system. Therefore, the length of hospitalization days in our study was not because of general anesthesia.

The limitation of ESD under general anesthesia is that it can be performed only in a limited number of institutions because it requires the cooperation of an anesthesiologist.

mm (range, 10-85 mm). The en bloc resection rate was 96.1%. The mean operating time was 199.4 ± 82.2 min (range, 68-465 min), and the mean anesthesia time was 262.1 ± 93.0 min (range, 130-630 min). With regard to complications, delayed bleeding occurred in 1 (2.0%) patient, and intraoperative perforation occurred in 2 (3.9%) patients (Table 3). Furthermore, in all cases of intraoperative perforation, we were able close the hole using endoclips. All complications were successfully managed using conservative treatment, with no surgical intervention required. No perioperative fatalities were observed.

DISCUSSIONIn Japan, ESD is usually performed under conscious sedation in the endoscopy room. Therefore, reports regarding ESD under general anesthesia in Japan are scarce[5,6].

ESD requires precise and complicated maneuvers with minimal patient movement for maintaining optimal visualization. However, such precise and complicated maneuvers are sometimes difficult to perform because of patient movement because of an insufficient effect of sedation. Benzodiazepines, such as diazepam and midazolam, have been used as standard sedation in patients undergoing endoscopic therapy. However, the range of effective doses of such agents considerably differs among patients; therefore, it is difficult to achieve a stable level of sedation[7]. Moreover, the dose is often increased to suppress body movement, resulting in oversedation and potentially causing hypoxemia and decreased levels of consciousness upon the patient’s return to the hospital ward[8]. Recently, the usefulness of propofol anesthesia for


Table 3 Baseline clinical and operational characteristics of patients undergoing colorectal endoscopic submucosal dissection

Age, (yr)1 66.7 ± 9.6Sex, n (%) Male 22 (44.9) Female 27 (55.1)Preoperative comorbidities, n (%) 32 (65.3)ASA score, n (%) Ⅰ 14 (28.6) Ⅱ 34 (69.4) Ⅲ 1 (2.0)Histologic type, n (%) Adenocarcinoma 18 (35.3) Adenoma 29 (56.9) Carcinoid 3 (5.9)Mean diameter of the resected specimen (mm)1 36.5 ± 11.3en bloc resection rate, n (%) 49 (96.1)Duration of anesthesia, (min)1 262.1 ± 93.0Duration of operation, (min)1 199.4 ± 82.2Postoperative hospital stay (d)1 7.4 ± 1.7Complication rate, n (%) 3 (5.9)Intraoperative bleeding 0 (0.0)Delayed bleeding 1 (2.0)Intraoperative perforation 2 (3.9)



With the cooperation of an anesthesiologist, ESD under general anesthesia will be a useful method for reducing ESD-related complications. Also, ESD under general anesthesia may be a favorable option for ESD beginners.

COMMENTSBackgroundStudies regarding endoscopic submucosal dissection (ESD) under general anesthesia in Japan are scarce because ESD is generally performed under conscious sedation. ESD requires minimal patient movement for optimal visualization, which may be hampered because of insufficient sedation.

Research frontiersThis study aimed to evaluate the efficacy and safety of ESD under general anesthesia.

Innovations and breakthroughsThe en bloc resection rate of esophageal, gastric, and colorectal lesions was 100.0%, 98.3%, and 96.1%, respectively. The complication rate of perforation and bleeding were 0.0% and 0.0% in esophageal ESD, 1.7% and 1.7% in gastric ESD, and 3.9% and 2.0% in colorectal ESD, respectively. No cases of aspiration pneumonia were observed. All complications were managed by conservative treatment, with no surgical intervention required.

ApplicationsWith the cooperation of an anesthesiologist, ESD under general anesthesia will be a useful method for reducing ESD-related complications.

Peer-reviewIn the article ESD under general anesthesia, authors tried to evaluate the efficacy and safety of ESD under general anesthesia in the retrospective manner.

REFERENCES1 Isomoto H, Shikuwa S, Yamaguchi N, Fukuda E, Ikeda K,

Nishiyama H, Ohnita K, Mizuta Y, Shiozawa J, Kohno S. Endoscopic submucosal dissection for early gastric cancer: a large-scale feasibility study. Gut 2009; 58: 331-336 [PMID: 19001058 DOI: 10.1136/gut.2008.165381]

2 Fernández-Esparrach G, Calderón A, de la Peña J, Díaz Tasende JB, Esteban JM, Gimeno-García AZ, Herreros de Tejada A, Martínez-Ares D, Nicolás-Pérez D, Nogales O, Ono A, Orive-Calzada A, Parra-Blanco A, Rodríguez Muñoz S, Sánchez Hernández E, Sánchez-Yagüe A, Vázquez-Sequeiros E, Vila J, López Rosés L. Endoscopic submucosal dissection. Endoscopy 2014; 46: 361-370 [PMID: 24671864 DOI: 10.1055/s-0034-1364921]

3 Maple JT, Abu Dayyeh BK, Chauhan SS, Hwang JH, Komanduri S, Manfredi M, Konda V, Murad FM, Siddiqui UD, Banerjee S. Endoscopic submucosal dissection. Gastrointest Endosc 2015; 81: 1311-1325 [PMID: 25796422 DOI: 10.1016/j.gie.2014.12.010]

4 Zhai YQ, Li HK, Linghu EQ. Endoscopic submucosal tunnel dissection for large superficial esophageal squamous cell neoplasms. World J Gastroenterol 2016; 22: 435-445 [PMID: 26755889 DOI: 10.3748/wjg.v22.i1.435]

5 Suzuki T, Minami H, Komatsu T, Masusda R, Kobayashi Y, Sakamoto A, Sato Y, Inoue H, Serada K. Prolonged carbon dioxide insufflation under general anesthesia for endoscopic submucosal dissection. Endoscopy 2010; 42: 1021-1029 [PMID: 21120775 DOI: 10.1055/s-0030-1255969]

6 Mori H, Kobara H, Muramatsu A, Inoue H, Kobayashi M, Nomura T, Hagiike M, Izuishi K, Suzuki Y, Gong J, Masaki T. Comparison of postoperative complications after endoscopic submucosal dissection: differences of insufflations and anesthesias.

Diagn Ther Endosc 2011; 2011: 709237 [PMID: 21785562 DOI: 10.1155/2011/709237]

7 Matsumoto K, Nagahara A, Matsumoto K, Akazawa Y, Komori H, Nakagawa Y, Takeda T, Ueyama H, Shimada Y, Asaoka D, Hojo M, Watanabe S. Optimization of Deep Sedation with Spontaneous Respiration for Therapeutic Endoscopy Combining Propofol and Bispectral Index Monitoring. Gastroenterol Res Pract 2015; 2015: 282149 [PMID: 26351450 DOI: 10.1155/2015/282149]

8 Patel S, Vargo JJ, Khandwala F, Lopez R, Trolli P, Dumot JA, Conwell DL, Zuccaro G. Deep sedation occurs frequently during elective endoscopy with meperidine and midazolam. Am J Gastroenterol 2005; 100: 2689-2695 [PMID: 16393221 DOI: 10.1111/j.1572-0241.2005.00320.x]

9 Imagawa A, Hata H, Nakatsu M, Matsumi A, Ueta E, Suto K, Terasawa H, Sakae H, Takeuchi K, Fujihara M, Endo H, Yasuhara H, Ishihara S, Kanzaki H, Jinno H, Kamada H, Kaji E, Moriya A, Ando M. A target-controlled infusion system with bispectral index monitoring of propofol sedation during endoscopic submucosal dissection. Endosc Int Open 2015; 3: E2-E6 [PMID: 26134767 DOI: 10.1055/s-0034-1377519]

10 Kim JS, Kim BW, Shin IS. Efficacy and safety of endoscopic submucosal dissection for superficial squamous esophageal neoplasia: a meta-analysis. Dig Dis Sci 2014; 59: 1862-1869 [PMID: 24619279 DOI: 10.1007/s10620-014-3098-2]

11 Furuhata T, Kaise M, Hoteya S, Iizuka T, Yamada A, Nomura K, Kuribayashi Y, Kikuchi D, Matsui A, Ogawa O, Yamashta S, Mitani T. Postoperative bleeding after gastric endoscopic submucosal dissection in patients receiving antithrombotic therapy. Gastric cancer 2016 Jan 11; Epub ahead of print [PMID: 26754296 DOI: 10.1007/s10120-015-0588-7]

12 Akahoshi K, Motomura Y, Kubokawa M, Gibo J, Kinoshita N, Osada S, Tokumaru K, Hosokawa T, Tomoeda N, Otsuka Y, Matsuo M, Oya M, Koga H, Nakamura K. Endoscopic Submucosal Dissection for Early Gastric Cancer using the Clutch Cutter: a large single-center experience. Endosc Int Open 2015; 3: E432-E438 [PMID: 26528497 DOI: 10.1055/s-0034-1392509]

13 Tsuji Y, Ohata K, Ito T, Chiba H, Ohya T, Gunji T, Matsuhashi N. Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions. World J Gastroenterol 2010; 16: 2913-2917 [PMID: 20556838]

14 Gotoda T. Endoscopic resection of early gastric cancer. Gastric Cancer 2007; 10: 1-11 [PMID: 17334711 DOI: 10.1007/s10120 -006-0408-1]

15 Tanaka S, Oka S, Kaneko I, Hirata M, Mouri R, Kanao H, Yoshida S, Chayama K. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66: 100-107 [PMID: 17591481 DOI: 10.1016/j.gie.2007.02.032]

16 Tamegai Y, Saito Y, Masaki N, Hinohara C, Oshima T, Kogure E, Liu Y, Uemura N, Saito K. Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 2007; 39: 418-422 [PMID: 17516348 DOI: 10.1055/s-2007-966427]

17 Isomoto H, Nishiyama H, Yamaguchi N, Fukuda E, Ishii H, Ikeda K, Ohnita K, Nakao K, Kohno S, Shikuwa S. Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 2009; 41: 679-683 [PMID: 19670135 DOI: 10.1055/s-0029-1214979]

18 Yoshida N, Yagi N, Naito Y, Yoshikawa T. Safe procedure in endoscopic submucosal dissection for colorectal tumors focused on preventing complications. World J Gastroenterol 2010; 16: 1688-1695 [PMID: 20379999]

19 Park CH, Kim H, Kang YA, Cho IR, Kim B, Heo SJ, Shin S, Lee H, Park JC, Shin SK, Lee YC, Lee SK. Risk factors and prognosis of pulmonary complications after endoscopic submucosal dissection for gastric neoplasia. Dig Dis Sci 2013; 58: 540-546 [PMID: 22996790 DOI: 10.1007/s10620-012-2376-0]

20 Watari J, Tomita T, Toyoshima F, Sakurai J, Kondo T, Asano H, Yamasaki T, Okugawa T, Tanaka J, Daimon T, Oshima T, Fukui H, Hori K, Matsumoto T, Miwa H. The incidence of “silent” free air and aspiration pneumonia detected by CT after gastric endoscopic submucosal dissection. Gastrointest Endosc 2012; 76: 1116-1123


COMMENTS


[PMID: 23164512 DOI: 10.1016/j.gie.2012.07.043]21 Saito I, Tsuji Y, Sakaguchi Y, Niimi K, Ono S, Kodashima S,

Yamamichi N, Fujishiro M, Koike K. Complications related to gastric endoscopic submucosal dissection and their managements. Clin Endosc 2014; 47: 398-403 [PMID: 25324997 DOI: 10.5946/

ce.2014.47.5.398]22 Linghu E, Feng X, Wang X, Meng J, Du H, Wang H. Endoscopic

submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 60-62 [PMID: 23254407 DOI: 10.1055/s-0032-1325965]

P- Reviewer: Kvolik S, Mentes O S- Editor: Qi Y L- Editor: A E- Editor: Lu YJ



Cut endotracheal tube for endoscopic removal of an ingested push-through pack

Yuki Tateno, Ryoji Suzuki

Yuki Tateno, Ryoji Suzuki, Miyake Central Clinic, Tokyo 100-1101, Japan

Author contributions: Tateno Y and Suzuki R treated the patient, recorded the data, and wrote the report; all authors approved the final version of the article for publication.

Institutional review board statement: This case report was reviewed and approved by the Institutional Review Board of Miyake Central Clinic.

Informed consent statement: The patient described in this case report provided written informed consent prior to this submission.

Conflict-of-interest statement: No funding was received for this case report.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Yuki Tateno, MD, Miyake Central Clinic, 937 Kamitsuki, Miyake, Tokyo 100-1101, Japan. [email protected]: +81-4994-20016Fax: +81-4994-21005

Received: March 5, 2016Peer-review started: March 7, 2016First decision: April 6, 2016Revised: April 14, 2016Accepted: May 7, 2016Article in press: May 9, 2016Published online: July 10, 2016

AbstractA 52-year-old female presented to our clinic after accidentally

ingesting a push-through pack (PTP). After determining that the PTP was present in the stomach, we successfully and safely removed it endoscopically by using a handmade endoscopic hood fashioned from a cut endotracheal tube. Foreign body ingestion is a common clinical problem, and most ingested foreign bodies pass spontaneously. However, the ingestion of sharp objects, such as PTPs, increases the risk of complications, and urgent endoscopy is recommended to remove such objects. Previous studies have reported the use of other devices, both commercial and handmade, for the safe endoscopic removal of foreign bodies. The novel design of our handmade hood for the removal of the PTP, which was fashioned from a cut endotracheal tube, was beneficial in terms of maintaining a wide visual field, patient safety and tolerance, and easy preparation compared to previously reported commercial and handmade devices. It may be a viable and safe device for the retrieval of PTPs and other sharp foreign bodies.

Key words: Foreign body ingestion; Endoscopic removal; Push-through pack; Sharp object; Handmade


Core tip: Here, we report the successful and safe endo-scopic removal of a push-through pack (PTP) from the stomach using a handmade endoscopic hood fashioned from a cut endotracheal tube. This novel design was beneficial in terms of maintaining a wide visual field, patient safety and tolerance, and easy preparation, compared to previously reported commercial or handmade devices. It may be a viable and safe device for the retrieval of PTPs and other sharp foreign bodies.

Tateno Y, Suzuki R. Cut endotracheal tube for endoscopic removal of an ingested push-through pack. World J Gastrointest Endosc 2016; 8(13): 472-476 Available from: URL: http://www.wjgnet.com/1948-5190/full/v8/i13/472.htm DOI: http://dx.doi.org/10.4253/wjge.v8.i13.472

CASE REPORT





INTRODUCTIONForeign body ingestion is commonly encountered in clinical practice, and most (≥ 80%) foreign bodies pass spontaneously without the need for intervention[1]. However, the ingestion of sharp and pointed objects, such as animal/fish bones, needles, and push-through packs (PTPs), increases the risk of perforation or obstruction by as much as 35%[1].

PTPs are commonly used in Japan[2] and South Korea[3] for the packaging of drugs. PTPs have three or four sharp edges that, when they are accidentally ingested, can perforate the small intestine[4]. Therefore, PTPs that have passed into the stomach or proximal duodenum should be immediately retrieved endoscopically, provided this procedure can be performed safely[1]. Flexible endoscopy is the ideal choice for both diagnostic and therapeutic purposes in the management of upper gastrointestinal foreign bodies, with a reported success rate of over 95% and minimal complications[5]. The risk of mucosal injury during retrieval can be minimized during extraction by orienting the sharp points of the object with handmade and commercial accessory instruments[1], such as an overtube[3], a latex hood over the endoscope[6], a latex glove[7], or a condom[8].

Here, we report the successful and safe endoscopic removal of a PTP from the stomach using a novel hand-made endoscopic hood fashioned from a cut endotracheal tube.

CASE REPORTA 52-year-old female with no medical history of dementia or psychological impairment presented to our clinic due to the accidental ingestion of a PTP 2 h previously. She complained of sharp intermittent pain in the substernal region. She was alert, with a temperature of 36.5 ℃, blood pressure of 120/80 mmHg, regular pulse of 96 bpm, and respiration of 18 breaths/min; there were no signs of abdominal tenderness or peritoneal irritation. Abdominal computed tomography showed no signs of perforation or the presence of a PTP. These findings, coupled with the fact that she had swallowed the PTP only 2 h before presentation, led us to suspect that the PTP was lodged in her esophagus or stomach. Urgent endoscopy revealed the PTP in the stomach (Figure 1).

We did not possess an overtube or commercial device for the removal of foreign bodies because our clinic is located on a remote island in Japan and is not sufficiently equipped for such medical emergencies. Therefore, to remove the PTP, a handmade hood protector was fashioned from a cut endotracheal tube (Teleflex, Endosoft 8.5; Willy Rüsch GmbH, Kernen im Remstal, Germany) (Figures 2 and 3) with an internal diameter of 8.5 mm, an external diameter of 11.3 mm, and a cuff composed of polyvinyl chloride. The hood was fastened to the distal end of the endoscope (GIF-H260; Olympus Corporation, Tokyo, Japan), which was 9.8 mm in diameter, without the use of rubber bands or string. The

cut cuff used to cloak the PTP edges was approximately 30 mm in diameter (Figure 4). The scope was inserted without the use of general anesthesia or sedation, and the PTP was captured using biopsy forceps, pulled into the cut cuff of the handmade hood, avoiding the inside of the tube (Figure 5), and extracted. All four edges of the PTP were cloaked with the cuff during retrieval (Figure 6). The size of the impacted PTP was 19 mm × 16 mm (Figure 7). Following PTP removal, endoscopic evaluation of the esophagus showed no signs of mucosal damage, ulceration, bleeding, or perforation. The complete endoscopic procedure took only 20 min; the inspection time was thought to be acceptable without sedation. The patient was immediately discharged after endoscopy without any complications.

Tateno Y et al . Cut endotracheal tube for ingested PTP


Figure 1 Endoscopic image of the push-through pack in the stomach.

Figure 2 An endotracheal tube was cut into three sections, and the middle section (white arrow) was used as an endoscopic hood. The red lines show the locations of the cuts made in the tube.

Figure 3 An endoscopic hood made from the cut endotracheal tube hood. The middle section of the cut endotracheal tube is shown in Figure 1.

DISCUSSIONWe successfully removed an ingested PTP from the stomach using a novel endoscopic hood fashioned from a cut endotracheal tube. A wide variety of handmade and commercial devices have been used for the endoscopic removal of foreign bodies[1,3,6,7-11], including an overtube[3], a latex protector hood fitted over an endoscope[6], a latex glove[7], and a condom[8]. To the best of our knowledge, this is the first case report of the removal of an ingested foreign body using a handmade endoscopic hood cut from an endotracheal tube.

Our novel endoscopic hood was fashioned by cutting an endotracheal tube (CET hood), which consisted of a stalk-like tube and a petal-like cuff. This characteristic shape offers some advantages in the retrieval of PTPs. First, a CET hood can maintain a good visual field and wide working space. Previous reports showed that a transparent cap and overtube improve the visual field and working space[3,12]. The CET hood contained a tube that resembled the stalk of a flower and offered advantages similar to those of a transparent cap attached to the end of the endoscope. Although we were concerned that the cuff would obscure the visual field, the tube had adequate length and sufficient hardness to resist hood collapse and maintain the visual field. Second, the

CET hood was able to cloak the PTP, which had a wider diameter than the endoscope. The endoscopic removal of a PTP with a wider diameter than the internal diameter of the overtube will occasionally fail because the uncloaked edges can cause mucosal injury during retrieval[3,8]. The internal diameter of the overtube used in this case was approximately 15 mm[3]. Even if the diameter of the PTP exceeds 15 mm, as in our patient (19 mm), the flexibility of the tube may enable the operator to bend and pull the overtube[3]. However, care should be taken not to cause mucosal injury by pinching the mucosa between the PTP and overtube. A bell-shaped simple latex protector hood[6] or handmade hood constructed from a condom[8] have been reported to be more suitable devices in cases that require a wide cover hood. The CET hood used in this case also contained a wide covering protector approximately 30 mm in diameter, which offered the same advantages as these devices. Third, the level of difficulty in the insertion and removal of an endoscope fitted with a CET hood was not different from that observed with typical endoscopic inspection. Lin[8] reported the use of a condom protector hood for the successful removal of a PTP without complications, which exhibited good tolerance due to the thinness of the material. Endoscopic treatment using a CET hood minimizes patient discomfort during its insertion through


Figure 4 The cut cuff used to cloak the push-through pack was appro-ximately 30 mm in diameter.

Figure 5 An endoscopic image. The push-through pack in the stomach was grasped with biopsy forceps and pulled into the cut cuff, not inside the tube.

Figure 6 All four edges of the push-through pack were drawn into the cut cuff.

Figure 7 The size of the impacted push-through pack was 19 mm × 16 mm.


TreatmentPTP was successfully and safely removed endoscopically using a handmade endoscopic hood fashioned from a cut endotracheal tube.

Related reportsPrevious studies reported other devices, both commercial and handmade, for safe endoscopic removal of foreign bodies.

Term explanationPTPs are commonly used in Japan and South Korea for packaging of drugs. PTPs have three or four sharp edges and, when accidentally ingested, can perforate the small intestine.

Experiences and lessonsThe authors’ novel handmade device conveyed some advantages, as compared to previously reported commercial and handmade devices, and can be an alternative device for retrieval of PTPs and other sharp foreign bodies.

Peer-reviewThe paper is an interesting case report.

REFERENCES1 Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee

S, Ben-Menachem T, Decker GA, Fanelli RD, Fisher LR, Fukami N, Harrison ME, Jain R, Khan KM, Krinsky ML, Maple JT, Sharaf R, Strohmeyer L, Dominitz JA. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011; 73: 1085-1091 [PMID: 21628009 DOI: 10.1016/j.gie.2010.11.010]

2 Kumagai M, Ikeda K, Oshima T, Nakatsuka S, Takasaka T. A press-through-pack in the larynx. Tohoku J Exp Med 1997; 183: 293-295 [PMID: 9549829 DOI: 10.1620/tjem.183.293]

3 Seo YS, Park JJ, Kim JH, Kim JY, Yeon JE, Kim JS, Byun KS, Bak YT. Removal of press-through-packs impacted in the upper esophagus using an overtube. World J Gastroenterol 2006; 12: 5909-5912 [PMID: 17007065]

4 Hashizume T, Tokumaru AM, Harada K. Small intestine perforation due to accidental press-through package ingestion in an elderly patient with Lewy body dementia and recurrent cardiopulmonary arrest. BMJ Case Rep 2015; 2015: bcr2015212723 [PMID: 26678691 DOI: 10.1136/bcr-2015-212723]

5 Yao CC, Wu IT, Lu LS, Lin SC, Liang CM, Kuo YH, Yang SC, Wu CK, Wang HM, Kuo CH, Chiou SS, Wu KL, Chiu YC, Chuah SK, Tai WC. Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract of Adults. Biomed Res Int 2015; 2015: 658602 [PMID: 26258140 DOI: 10.1155/2015/658602]

6 Bertoni G, Sassatelli R, Conigliaro R, Bedogni G. A simple latex protector hood for safe endoscopic removal of sharp-pointed gastroesophageal foreign bodies. Gastrointest Endosc 1996; 44: 458-461 [PMID: 8905368 DOI: 10.1016/S0016-5107(96)70099-8]

7 Kao LS, Nguyen T, Dominitz J, Teicher HL, Kearney DJ. Modification of a latex glove for the safe endoscopic removal of a sharp gastric foreign body. Gastrointest Endosc 2000; 52: 127-129 [PMID: 10882983 DOI: 10.1067/mge.2000.106689]

8 Lin LF. Condoms used to assist difficult endoscopic removal of impacted upper esophageal foreign bodies. Advances in Digestive Medicine 2016; 3: 24-27 [DOI: 10.1016/j.aidm.2014.07.007]

9 Ginsberg GG. Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995; 41: 33-38 [PMID: 7698622 DOI: 10.1016/S0016-5107(95)70273-3]

10 Smith MT, Wong RK. Foreign bodies. Gastrointest Endosc Clin N Am 2007; 17: 361-382, vii [PMID: 17556153 DOI: 10.1016/j.giec.2007.03.002]

11 Chiu KW, Lu LS, Wu TC, Chiou SS. Novel low-cost endoscopic cap for esophageal foreign objects: a case report. Medicine (Baltimore) 2015; 94: e796 [PMID: 25929932 DOI: 10.1097/

a narrow segment, such as the pharynx, because the cut cuff of a CET hood is sufficiently flexible to pass through the pharynx. In addition, a CET hood is suitable for emergency endoscopy due to the simple method of preparation and availability in an inadequately equipped medical institution.

Other articles have described the use of a handmade protector or hood for the endoscopic removal of foreign bodies[1,3,6,7-11]. Handmade devices must be easily and swiftly prepared for use in emergency endoscopy[1,11]. The preparation of a CET hood is relatively simple because it requires only the cutting and fitting of the apparatus to the endoscope. Of course, commercial devices are the simplest to use and prepare[6]; however, not all medical institutions have these devices on hand. Although the ingestion of foreign bodies can occur anywhere, it is impractical for all medical institutions, especially those in developing countries or remote areas, to maintain a sufficient supply of commercial devices for the retrieval of foreign bodies. Therefore, under such circumstances, a CET hood can be easily fashioned from an endotracheal tube, which is readily available in most medical institutions.

However, the level of protection provided for the removal of sharp foreign bodies, such as needles or bones, should be determined in future studies. Further research should compare materials with varying cuff thicknesses (approximately 0.05 mm)[13] compared to surgical gloves (approximately 0.29 mm)[8] and a latex hood (2 mm), such as that manufactured by Kimberly/Ballard Medical Products (Draper, UT, United States)[8].

In conclusion, we report the successful and safe endoscopic removal of a PTP from a patient’s stomach using a handmade endoscopic hood fashioned from a cut endotracheal tube. This novel handmade device offered some advantages compared to previously reported commercial and handmade devices and may be an alternative device for the retrieval of PTPs and other sharp foreign bodies.

COMMENTSCase characteristicsA 52-year-old female presented after accidentally ingesting a push-through pack (PTP).

Clinical diagnosisAccidental ingestion of PTP in the stomach.

Differential diagnosisAccidental ingestion of PTP in the esophagus or small intestine.

Laboratory diagnosisAll laboratory tests were within normal limits.

Imaging diagnosisAbdominal computed tomography showed no signs of perforation or the presence of a PTP, and urgent endoscopy revealed the PTP in the stomach.


COMMENTS


MD.0000000000000796]12 Hyun JJ, Chun HJ, Keum B, Seo YS, Kim YS, Jeen YT, Lee

HS, Um SH, Kim CD, Ryu HS. Alternative salvage technique for removing large sharp foreign body near upper esophageal sphincter. Surg Laparosc Endosc Percutan Tech 2012; 22: e48-e52

[PMID: 22318080 DOI: 10.1097/SLE.0b013e31824205a6]13 Lorente L, Blot S, Rello J. New issues and controversies in the

prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 2010; 182: 870-876 [PMID: 20448095 DOI: 10.1164/rccm.201001-0081CI]

P- Reviewer: Akere A, Farhat S S- Editor: Ji FF L- Editor: A E- Editor: Lu YJ




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