A 61-year-old man was referred to our institute for endoscopic ultrasound (EUS) evaluation of a subcentimeter subepithelial lesion of the duodenal bulb. Ultrasound imaging showed a homogeneous, hypoechoic lesion of 15 mm in diameter in the fourth layer of the inferior wall of the duodenal bulb ([Fig. 1 a, b]). EUS-guided fine needle aspiration showed a gastrointestinal stromal tumor (GIST) and a computed tomography scan confirmed only a localized lesion ([Fig. 1 c]). The growth in size of the GIST with respect to the previous examination was an indication for resection, which remains the only modality that can offer permanent cure of GISTs, and avoid tumor rupture and injuries to the pseudocapsule [1]. Given the wishes of the patient and in order to avoid major surgery, a multidisciplinary team (endoscopist, oncologist, and surgeon) proposed an endoscopic mini-invasive approach. The procedure was performed with the patient under general anesthesia and with the administration of prophylactic antibiotics. Dissection was performed using an O-type HybridKnife (Erbe Elektromedizin, Germany) and we infused only saline solution into the lumen in order to prevent retroperitoneal CO₂ leakage and the consequent subcutaneous emphysema. We performed a full-thickness resection with the aim of achieving a radical oncological resection ([Video 1]). The excision resulted in a complete duodenal wall defect, about 25 × 25 mm ([Fig. 2]), which was closed with three endosutures placed using the OverStitch endoscopic suturing system (Apollo Endosurgery, USA). Video 1 A gastrointestinal stromal tumor of the duodenal bulb is resected with a full-thickness mini-invasive endoscopic approach, with the defect being closed using the OverStitch device. In the post-procedural phase, the patient developed pain in the hypochondrium that was easily controlled with a single dose of ibuprofen; oral intake was restarted in the fourth postoperative day. In the following 2 months of follow-up, the patient remained asymptomatic. In conclusion, endoscopic full-thickness resection of a duodenal GIST appears to be safe, even if skill-demanding, and can be a valid mini-invasive alternative to surgery. Endoscopy_UCTN_Code_TTT_1AO_2AG

While coins are still the most common foreign bodies swallowed by children, ingestion of batteries has become more frequent among children due to the increasing access to electronic toys and devices. Coin battery ingestion is potentially life threatening for children. Aortoesophageal fistula is the most common cause of death in children who have swallowed coin batteries, and there have not been any reported survivors. A 3-year-old Caucasian girl presented to the emergency room of a community hospital complaining of abdominal pain. An abdominal X-ray showed a coin lithium battery located in the fundus of her stomach, and she was transferred to a referral pediatric hospital. In the following hours she developed massive hematemesis and severe hypovolemic shock. An emergency laparotomy was attempted, and the coin battery was removed. The initial surgery and multiple blood transfusions did not, however, improve the clinical situation. She was then referred to our tertiary referral center, where a multidisciplinary team decided to attempt a combined angiographic and endoscopic approach to resolve a life-threatening aortoesophageal fistula. A 3-year follow-up was uneventful. Coin batteries are designed for a wide variety of small appliances, such as hearing aids, watches, remote controls, and toys. Although a change in the clinical approach to battery ingestion is needed to avoid misdiagnosis or delayed treatment, primary prevention of battery ingestion would be even more effective than an improved treatment.

A 25-year-old woman with a history of Barrett’s esophagus with dysplasia underwent Ivor Lewis esophagectomy at the age of 18 years. After 24 months, she developed dysphagia, postprandial vomiting, and epigastric pain, with progressive weight loss. Upper gastrointestinal (GI) series showed delayed gastric emptying with pre-pyloric stagnation. After multiple, fruitless, endoscopic hydro-pneumatic dilations of the pylorus, the patient underwent Roux-en-Y gastrojejunostomy, with clinical benefit and weight regain. One year later, symptoms recurred, with nausea and recurrent postprandial pain that resolved after vomiting. Upper GI series revealed direct filling of the blind afferent cul-de-sac with no spilling over into the efferent limb ([Fig. 1]). In order to avoid further hazardous surgery, and considering the young age of the patient, we decided to proceed with a minimally invasive approach. We attempted to obliterate the afferent limb, preventing the food from collecting in its lumen, and allowing the intestinal transit entirely into the efferent limb. We used argon plasma coagulation to scar the entire cul-de-sac mucosal layer in order to promote cicatrization. We then proceeded to approximate the opposite enteric walls of the afferent limb, from the bottom to the top, by placing multiple purse-string sutures using the OverStitch Endoscopic Suturing System (Apollo Endosurgery, Inc., Austin, Texas, USA); total closure of the cul-de-sac was achieved ([Fig. 2], [Video 1]). Video 1 A novel endoluminal suturing system applied for the treatment of the “Candy cane” syndrome, allows a mini-invasive endoscopic solution with complete resolution of symptoms in a young patient with a history of multiple surgical procedures. After treatment, the patient had complete resolution of symptoms. At the 1-month follow-up, upper GI series showed direct transit of contrast dye into the efferent limb without any filling of the obliterated afferent lumen ([Fig. 3]). “Candy cane” syndrome is a poorly described surgical complication [1] [2] [3]. In the largest published case series (19 patients), Aryaie at al. reported a success rate of 94 % by laparoscopic resection of the redundant afferent limb [4]. In patients with “candy cane” syndrome, a minimally invasive endoscopic approach seems to be a valid alternative, especially in patients who are unfit for surgery and have critical medical conditions or a history of multiple surgical revisions. Endoscopy_UCTN_Code_TTT_1AQ_2AJ

A 46-year-old woman with diabetes mellitus type 2 was admitted for endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) because of the incidental diagnosis of a 5-cm pancreatic cystic lesion (PCL) in the pancreatic body, suspicious for pseudocyst ([Fig. 1]). The procedure was performed through the patient’s stomach with a standard 19-gauge needle. FNA/B targeting the pancreatic cystic wall was followed by several bites with a through-the-needle forceps (mini biopsy forceps, 0.8 mm in diameter; Endo-flex GmbH, Voerde, Germany) ([Fig. 2] and [Fig. 3], [Video 1]). Because of their small size, we treated these specimens as cytologic samples. They were collected in formalin, entrapped in fibrin coagulum after being centrifuged, and then embedded in paraffin for sectioning. The procedure ended with complete aspiration of the cystic fluid for cytologic, biochemical, and molecular biological testing. The results of pancreatic cystic wall FNA/B with the 19-gauge needle and cytologic analysis of the cystic fluid were both inadequate, but the through-the-needle forceps biopsy specimens yielded microhistologic samples of mucinous cylindric epithelium with mild dysplasia ([Fig. 4]). In the cystic fluid, the carcinoembryonic antigen level was 7300 ng/mL and the amylase level was 30 U/L. The result of testing for the K-ras mutation was negative. Mucinous cystic neoplasm was diagnosed, and the patient was referred for surgery, which confirmed the diagnosis. The cytohistologic diagnosis of PCLs is challenging. The cytologic testing of cystic fluid has a diagnostic yield of less than 50 %, and attempts have been made to improve these results with other techniques. Brush cytology (EchoBrush; Cook Medical, Bloomington, Indiana, USA) [1] and FNA/B targeting the pancreatic cystic walls with a standard needle [2] or ProCore needle (Cook Medical) [3] provide better results. Targeting the cystic wall appears to be the right choice because the cells from the cyst are there. Only two case reports (total of three patients) of EUS-guided through-the-needle forceps biopsy of PCLs have been published [4] [5], with the same results as in our case. For our patient, this promising new technique was the only one to result in an adequate cytohistologic diagnosis. Clinical studies are needed to validate our results. Endoscopy_UCTN_Code_TTT_1AS_2AD

A 48-year-old liver transplant patient with acute graft rejection, sepsis, and malnutrition was referred to our unit for a percutaneous endoscopic gastrostomy (PEG). The PEG procedure was uneventful, and a correct positioning of the bumper in the stomach was documented. Three days after the procedure, vomiting and abdominal distension occurred. A computed tomography (CT) scan with hydrosoluble contrast agent showed dislocation of the bumper into the transverse colon, with bowel opacification, due to the presence of a gastrocolic fistula. No leak of contrast into the peritoneal cavity was detected ([Fig. 1]). Endoscopy showed a transmural defect of 2 cm in diameter in the anterior wall of the gastric body ([Fig. 2]). To close the fistula, we first used forceps to scar the mucosal margins in order to promote cicatrization. We then approximated the opposite margins of the wall defect by placing three simple sutures using the OverStitch Endoscopic Suturing System (Apollo Endosurgery, Austin, Texas, USA) ([Video 1]). An intraprocedural contrast radiograph showed no colonic opacification. Video 1 Video showing endoscopic closure of the gastric aspect of the gastrocolic fistula using the OverStitch Endoscopic Suturing System. A same-session colonoscopy revealed, in the transverse colon, the bumper ([Fig. 3 a, b]), which was grasped and retrieved from the colon following sectioning of the extracorporeal PEG tube. The fistula was then closed with clips ([Fig. 3 c]). At the end of the procedure, contrast radiography found no leak of contrast from the colonic side of the fistula; the cutaneous side of the fistula healed by secondary intention. An endoscopic control after 10 days showed both gastric and colonic aspects of the fistula correctly repaired. Regular enteral feeding through nasogastric tube was resumed. A gastrocolic fistula is a rare complication of PEG and may require surgery [1]. Endoscopic management with clips has been described [2] [3], even if it may not be feasible in the event of a large fibrotic wall defect. In our case, we found that the OverStitch Endoscopic Suturing System is a feasible and effective treatment tool for a large gastrocolocutaneous fistula. Endoscopy_UCTN_Code_CPL_1AH_2AI