Gif q190

Placement and removal of the E-VAC system was performed as following: A polyurethane foam sponge (pore size 400–600 μm; KCI, Wiesbaden Germany, Smith & Nephew, Hamburg, Germany) was adapted to the particular wound size as estimated by the endoscopist. The sponge size was required to be smaller than the wound cavity to promote collapse and subsequent closure of the fistula. The sponge was fixed to the tip of a duodenal tube with a mersilene suture (Freka Tube, 15 Ch; Fresenius Kabi, Bad Homburg, Germany; 0.35 mm; Johnson & Johnson, St-Stevens-Woluwe, Belgium). The sponge was grasped with grasping forceps (Olympus, Hamburg, Germany; Boston Scientific, Marlborough, Massachussets, United States) and introduced either into the necrotic cavity or in the colonic lumen under vision using a regular orthograde endoscope (Gif-Q165, Gif-Q180H, Gif-Q190; Olympus). Continuous or intermittent suction of 50 to 100 mm Hg was applied using a vacuum pump (KCI, Smith & Nephew). For sponge removal the suction was discontinued and the tube was grasped with grasping forceps close to the distal end pulled out of the wound cavity. The sponge was exchanged approximately twice a week until the base of the cavity appeared to be firmly closed or the cavity was completely epithelialized/granulated. All procedures were performed by or in the presence of an experienced endoscopist (> 200 colonoscopies/year).

DGE entails direct puncture of a small bowel loop adjacent to the gastric wall using a therapeutic echoendoscope ( 
Fig. 1). To facilitate the puncture, a forward-viewing gastroscope (GIF-Q180 or GIF-Q190, Olympus Corporation, Tokyo, Japan) is first inserted and fluid infused into the small bowel distal to the obstruction. Generally, a total of 500 ml of fluid using a combination of saline, methylene blue, and contrast is infused. A 19-gauge needle can then be used as a “finder” needle to locate a small bowel loop closest to the stomach with aspiration of blue-tinged fluid confirming the correct puncture site. The puncture position may then be confirmed via enterogram. The needle is withdrawn while keeping the endoscope in a stable position. A cautery-assisted LAMS (Axios stent, Boston Scientific Corporation Inc., Marlborough, MA, USA) is then inserted directly across the stomach and into the small bowel followed by stent deployment forming the gastroenterostomy.