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

A 70-year-old woman with jaundice who had been diagnosed with unresectable malignant distal biliary stricture underwent endoscopic ultrasound (EUS)-guided gallbladder drainage following failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided bile duct drainage was impractical because of the presence of an intervening vessel, and an EUS-guided cholecystogastrostomy was created with placement of an 8 × 8-mm lumen-apposing metal stent (LAMS) [1]. After 1 month, the patient complained of a recurrence of her jaundice and was scheduled for follow-up endoscopy. This revealed that the proximal flange of the stent was completely buried in the gastric wall ([Fig. 1]). A linear echoendoscope was then used, and a bending cannula (SwingTip; Olympus) was smoothly inserted through the fistula into the buried LAMS under combined fluoroscopic guidance. Injection of contrast medium revealed a distended gallbladder and slightly dilated intrahepatic biliary tree with no contrast leakage, confirming that the distal flange was still in the correct place ([Fig. 2]). A 0.035-inch guidewire was then passed through the cannula and coiled within the gallbladder. The delivery catheter of a 10 × 10-mm electrocautery-tipped LAMS (AXIOS-EC; Boston Scientific) was advanced over the wire into the gallbladder without energizing the device ([Video 1]). The distal flange of the second LAMS was deployed in the gallbladder beyond the distal flange of the buried LAMS under fluoroscopic guidance. Slight traction was applied on the endoscope–stent coupled system, which allowed the proximal flange of the second LAMS to be deployed in the gastric cavity under endoscopic vision ([Fig. 3]). A through-the-LAMS-in-LAMS cholangiogram confirmed that the stent was correctly in place and that there was no contrast leakage. The post-procedure course was uneventful. Video 1 Video showing a salvage procedure for a buried lumen-apposing metal stent (LAMS) after an endoscopic ultrasound-guided gallbladder drainage: the LAMS-in-LAMS technique. The second LAMS (red dashed line) has both larger flanges and a longer body than the first LAMS (arrows). This ensures a perfect fit for the two coaxial stents. A buried LAMS is a rare complication, previously reported for various indications and managed, when possible, by endoscopic stent removal [2] [3] [4]. In fact, stent removal is not only a technically demanding procedure but also, in the setting of biliary drainage, it increases the risk of bile leakage and subsequent peritonitis. The above-described LAMS-in-LAMS technique allows the endoscopist to re-create a safe drainage conduit without the need to remove the buried stent. Endoscopy_UCTN_Code_CPL_1AL_2AD

Tracheoesophageal fistula (TEF) is a serious life-threatening condition that appears in critically ill patients with a prolonged history of mechanical ventilation. Enteral feeding and dietary support combined with surgery is the gold standard. In selected patients, TEF healing can be ensured by a mini-invasive approach using an Amplatzer septal occluder (AGA Medical Corporation), intended for cardiac septal defect closure [1]. The Amplatzer septal occluder, which is composed of a nitinol mesh, has two self-expandable disks connected by a thin diameter waist ([Fig. 1]) and ensures mechanical closure of the two sides of the fistula, making a potential platform for subsequent tissue ingrowth [2]. This technique was used in a 44-year-old man with tracheostomy and a history of protracted invasive lung support. He had been diagnosed as having a TEF after numerous episodes of aspiration pneumonitis and had subsequently undergone anterior cervicotomy with surgical closure of the fistula. After 7 months, his dysphagia relapsed. Endoscopy confirmed recurrence of the TEF ([Fig. 2]), which was initially treated unsuccessfully by submucosal injection of acrylic glue. Given the poor clinical condition of the patient and the failure of both surgical and endoscopic therapy, it was decided to try positioning of an Amplatzer septal occluder ([Video 1]). The procedure was performed using a gastroscope (GIF-1TH190; Olympus Europe) and a bronchoscope (BF-1T180; Olympus Europe). The TEF was cannulated using a papillotome (TRUETome; Boston Scientific) and a 0.025-inch guidewire (Jagwire; Boston Scientific) was inserted into the bronchial segment. The wire was then grasped with a biopsy forceps (Endo-Jaw; Olympus Europe) passed through the bronchoscope, providing countertraction by maintaining a straightened position. The septal occluder catheter was introduced and the two ends were released into the trachea and esophagus, respectively ([Fig. 3]). Successful closure of the TEF was confirmed by contrast medium injection ( [Fig. 4]). The procedure was uneventful. Video 1 An Amplatzer septal occluder is placed for the treatment of a chronic tracheoesophageal fistula, a mini-invasive approach in a critically ill patient. Repeat endoscopy 4 weeks later showed that the stent remained in the correct position and the patient has remained asymptomatic during 12 months of follow-up. In selected tertiary care centers, where advanced endoscopic and catheter lab suites are available, placement of an Amplatzer septal occluder is feasible and safe [3] [4], offering potential fistula closure, especially in patients in a critical condition, with severe comorbidities and recurrence of a TEF. Endoscopy_UCTN_Code_TTT_1AO_2AI