Ilaria Tarantino, MD, from the Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione, in Palermo, Italy presents this video case “Clipping and transection of a crossing blood vessel during transgastric endoscopic necrosectomy.”

A 52-year-old woman with pancreatic  insufficiency was referred to our institute for EUS-guided drainage of  an infected walled off pancreatic necrosis (WOPN). The patient had undergone distal pancreatectomy and splenectomy 2 years ago and developed an 11 cm WOPN.

Collection was accessed from the stomach using a therapeutic linear echoendoscope (GF-UC140P, Olympus Medical Systems, Center Valley, Pennsylvania, USA) and a lumen-apposing 15 mm x 10 mm FCSEMS (Hot AXIOS, Boston Scientific, Marlborough, Massachusetts, USA). After AXIOS stent deployment echoendoscope was removed, a standard gastroscope was inserted and the lumen of the stent was balloon-dilated up to 15 mm.

At the entrance of the WOPN a crossing blood vessel was seen next to the edge of the stent distal flange. We placed 4 clips (Resolution Clip, Boston Scientific, Marlborough, Massachusetts, USA) at the visible ends of the vessel to prevent bleeding. Then we proceeded with coagulation and  sectioning of the vessel between clips with a monopolar coagulating forceps (Coagrasper, Olympus Medical Systems, Center Valley, Pennsylvania, USA; VIO 300 D, forced coagulation, Effect 1, 60 watts; ERBE Elektromedizin GmbH, Tübingen, Germany). Endoscopic necrosectomy was performed in 4 following sessions, AXIOS was removed and the patient recovered well.

This video shows a new technique that allows efficient management of an unexpected event that has not been previously reported: a crossing blood vessel in the middle of the cystogastrostomy.

Modern GI endoscopy lets us face new scenarios, often with unknown problems. To solve them I think that we need to be open minded to take cues from other disciplines like surgery that can inspire new endoscopic techniques.

Gastrointestinal endoscopy is getting more and more “aggressive” becoming capable of treating many pathologies that could have been treated only by surgery until a few years ago. Suturing, creation of anastomoses, dissection, bipolar coagulation are only some examples of surgical techniques that, thanks to technological advancements, have been transferred into gastrointestinal endoscopy. Actually what we did to treat that vessel merely came from a “surgical idea.” To transect a vessel between clips is routinely done during laparoscopic surgery and can be applied during interventional GI endoscopy.

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