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1117 Overtube Assisted EUS With FNA for Esophageal Stenosis
Abstracts
large polyps. In these patients, EUS should be considered during surveillance endoscopy to detect cancers developing beneath or within the mucosa.
1117 Overtube Assisted EUS With FNA for Esophageal Stenosis Alvaro Martínez- Alcalá*, Krupali Thaker, Joel Augustus, Klaus E. Monkemuller, Ali M. Ahmed Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Birmingham, alabama, United States Minor Outlying Islands An 82-year-old black female presented to the hospital for three weeks of abdominal pain, weight loss and early satiety. CT imaging demonstrated a 3 cm pancreatic body mass. The patient was scheduled for EUS with general anesthesia. As practice for the endoscopist an EGD was performed prior to the EUS. This revealed a challenging esophageal intubation at the oropharynx requiring mild forward pressure and deflation of the tracheal cuff in order to pass the adult endoscope. Passage of the EUS into the stomach proved impossible. The echoendoscope was removed and a gastric overtube was placed into the oropharynx and through the esophagus under direct visualization with the adult endoscope. After appropriate positioning of the overtube the EUS was successfully placed within the lumen of the overtube enabling EUS identification of a hypoechoic 28x24 mm pancreatic tail mass and FNA with 25 G needle was performed. On site cytopathology was present and the first pass was positive for adenocarcinoma. This demonstrates the successful use of an overtube to assist safe passage of larger, difficult to manipulate endoscopes without forward view through esophageal stenosis in order to obtain a diagnosis and reduces need for repeat procedures.
1118 Endoscopic Full Thickness Resection of a Large Inverted Appendix Using a Colonoscope Ghassan M. Hammoud*1, Jacob Quick2, Sami Samiullah1, Jamal A. Ibdah1 1 Gastroenterology, University of Missouri School of Medicine, Columbia, MO; 2Surgery, University of Missouri School of Medicine, Columbia, MO Appendix contains a large amount of lymphoid tissue and has an average length of 7 to 8.5 cm in humans. It arises from cecum at the confluence of the three cecal taeniae. It usually lies intraperitoneal retrocecally or in lesser pelvis. The appendix is inverted into cecum in 0.01 percent of the cases. It can be mistaken for a cecal polyp upon colonoscopy. A 66-year-old female with past medical history of nephrolithasis presented with recurrent right lower quadrant pain for 2-3 months. The pain had worsened acutely over a few days. Her physical exam was consistent with right lower quadrant tenderness. She underwent a CT scan of abdomen and pelvis and was diagnosed with a tubular structure in the cecum. She was referred to our therapeutic endoscopy service for removal of a large cecal polyp. A colonoscopy was performed and a 8 cm tubular structure arising from appendicial orifice was seen. The overlying mucosa was normal and a diagnosis of inverted appendix was made. After consultation with our surgical team and the patient, decision was made to remove the appendix endoscopically. A repeat colonoscopy was performed. Using an PolyLoop device the base of the appendix was captured by three PolyLoops placed above each other. The appendix appeared to turn blue from compromised vascular flow. Next using ERBE; setting at forced coag effect 2, W80 and using a stiff 10 mm snare the base of the appendix was captured above the Polyloops and resected using electrocautery. No bleeding was encountered. Next an over the scope OVESCO clip was applied over the tip of the remnant. The pathology confirmed the findings of inverted appendix. The patient did very well post procedure with resolution of her intermittent severe right lower quadrant pain. Endoscopic full thickness resection of symptomatic inverted appendix is feasible and safe. The use of endoscopic PolyLoops and over the scope clips are recommended to ensure no dehiscence of appendicial lumen and prevent delayed bleeding. Informative discusson with the patient and surgeon regarding risks and benefits are mandartory for better outcome. Failure to recognize the entity and inadvertent simple polypectomy will lead to perforation.
1119 Using Two Endoloops to Secure the Appendiceal Stump During Colonoscopic Removal of an Inverted Appendix: A Case Report With Video Kasidit Norasettkul*1, Rungsun Rerknimitr1, Rapat Pittayanon1, Nareumon Wisedopas2, Panida Piyachaturawat1 1 Division of Gastroenterology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Banngkok, Thailand; 2King Chulalongkorn Memorial Hospital, Bangkok, Thailand
AB146 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
A 54-year-old woman had a history of non-specific intermittent lower abdominal pain and loose stool for 3 months. She was scheduled for a colonoscopy. On the colonoscopy day, she still had mild lower abdominal pain without fever. However, she could complete bowel preparation. The abdominal sign revealed mild tender without guarding. After the completion of inform and consent to the patient, colonoscopy with minimal air-inflation was eventually performed. Colonoscopy showed a 3-cm polypoid lesion overlying with normal colonic mucosa originated from the appendiceal orifice which was compatible with an inverted appendix. After a careful consideration about a history of lower abdominal pain, colonoscopic appendectomy was performed. The first endoloop was placed around the base of the appendix. The appendix was cut just above the loop by using a polypectomy snare. Then the second endoloop was applied to secure the appendiceal stump (as showed in the video). The histopathology confirmed as mild appendicitis. No immediate or delayed complications occurred. Her abdominal pain resolved. Inverted appendix is an uncommon condition that rarely detected during colonoscopy. Because of its uncommon presentation, the data about etiology, management, and its prognosis are not well established. Some case reports showed endometriosis as a cause of an inverted appendix. Hypothetically, colonic mucosal biopsy is insufficient to diagnose inflammation at the serosal side of inverted appendicitis. Some experts recommended for an endoscopic removal of inverted appendix to get more accurate histopathology. Although adverse events from inverted appendix was quite low, a few cases of intussusception were reported. Colonoscopic appendectomy is one of the treatment options. The first case of an appendix removed endoscopically was reported in 1976. In the past, there was a significant risk of perforation if colonoscopic appendectomy was done without any stump securing device. Fortunately, to date, there are special devices such as endoloops and clips that can reduce the risk of perforation. We reported a case of inverted appendix undergoing colonoscopic appendectomy by using two endoloops to secure the appendiceal stump. Currently, there has been no report on the complications of inverted appendix removed by a colonoscopic appendectomy with a stump secured by an endoloop, however, a risk of delayed stump leakage is always a concern. Therefore we placed double endoloops to ensure the complete stump closure.
1120 Closure of Large Colonic Defects Using Submucosal Buttressed Clips Shai Friedland* Gastroenterology, Stanford University and VA Palo Alto, Palo Alto, CA Background: Clip closure is often performed after endoscopic resection to prevent or treat bleeding and perforation. Clip closure of colonic defects larger than 2cm is technically challenging as clips may slip off the mucosa. Methods: A biopsy forceps is used to remove a small piece of normal mucosa 5mm away from each side of the resection margin. Clips are applied directly to the exposed submucosa to approximate the edges of the defect. The process is repeated until the defect is completely closed. Results: The video demonstrates 4 cases of successful large defect closure using the submucosal buttressed clip technique. All of the patients had uneventful post-procedure courses. Conclusion: Large colonic resection defects can be closed using submucosal buttressed clips. The technique is efficient and does not require specialized equipment or training.
1121 Endoscopic Treatment of Internal Hemorrhoids Using a Bipolar System Shaffer R. Mok*, Amitpal S. Johal, David L. Diehl, Harshit S. Khara Gastronterology and Hepatology, Geisinger Medical Center, Danville, PA Introduction: Hemorrhoids occur in 4% of the population and are present in 39-45% of colonoscopies. Internal hemorrhoids have been categorized further using the Banov classification, which has grades I-IV. While grades III-IV have typically been managed surgically, grades I-II can be treated by endoscopic means. Numerous endoscopic methods have been described to treat internal hemorrhoids, but these technologies are fraught with high rates of post-procedural pain. The Hemorrhoidal Endoscopic Therapy (HET) is a bipolar system that uses a novel anoscope with built-in illumination and consistent compression apparatus. This allows for stable energy delivery, which causes lower rates of collateral damage and therefore less post-procedural pain. Methods: This video demonstrates appropriate patient selection, positioning, equipment, set-up and procedural nuisances necessary for obtaining success using this HET system. Specifically, we emphasize various techniques that can be implemented for proper tissue apposition of the hemorrhoidal cushions with the HET probe. Case: We describe a 33-year-old female who presented with blood per rectum with straining. The patient underwent a colonoscopic examination with two grade I hemorrhoids in the right anterior and posterior cushions, and one grade II hemorrhoid in the left lateral cushion with a hypertrophied anal papilla. No additional bleeding lesions seen throughout the colon. She then underwent the HET procedure as a method of treatment for her symptomatic hemorrhoids. Using a through-the-speculum grasper, to allow for tissue apposition, electrocautery energy was delivered using a bipolar current to each of
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large polyps. In these patients, EUS should be considered during surveillance endoscopy to detect cancers developing beneath or within the mucosa.
1117 Overtube Assisted EUS With FNA for Esophageal Stenosis Alvaro Martínez- Alcalá*, Krupali Thaker, Joel Augustus, Klaus E. Monkemuller, Ali M. Ahmed Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Birmingham, alabama, United States Minor Outlying Islands An 82-year-old black female presented to the hospital for three weeks of abdominal pain, weight loss and early satiety. CT imaging demonstrated a 3 cm pancreatic body mass. The patient was scheduled for EUS with general anesthesia. As practice for the endoscopist an EGD was performed prior to the EUS. This revealed a challenging esophageal intubation at the oropharynx requiring mild forward pressure and deflation of the tracheal cuff in order to pass the adult endoscope. Passage of the EUS into the stomach proved impossible. The echoendoscope was removed and a gastric overtube was placed into the oropharynx and through the esophagus under direct visualization with the adult endoscope. After appropriate positioning of the overtube the EUS was successfully placed within the lumen of the overtube enabling EUS identification of a hypoechoic 28x24 mm pancreatic tail mass and FNA with 25 G needle was performed. On site cytopathology was present and the first pass was positive for adenocarcinoma. This demonstrates the successful use of an overtube to assist safe passage of larger, difficult to manipulate endoscopes without forward view through esophageal stenosis in order to obtain a diagnosis and reduces need for repeat procedures.
1118 Endoscopic Full Thickness Resection of a Large Inverted Appendix Using a Colonoscope Ghassan M. Hammoud*1, Jacob Quick2, Sami Samiullah1, Jamal A. Ibdah1 1 Gastroenterology, University of Missouri School of Medicine, Columbia, MO; 2Surgery, University of Missouri School of Medicine, Columbia, MO Appendix contains a large amount of lymphoid tissue and has an average length of 7 to 8.5 cm in humans. It arises from cecum at the confluence of the three cecal taeniae. It usually lies intraperitoneal retrocecally or in lesser pelvis. The appendix is inverted into cecum in 0.01 percent of the cases. It can be mistaken for a cecal polyp upon colonoscopy. A 66-year-old female with past medical history of nephrolithasis presented with recurrent right lower quadrant pain for 2-3 months. The pain had worsened acutely over a few days. Her physical exam was consistent with right lower quadrant tenderness. She underwent a CT scan of abdomen and pelvis and was diagnosed with a tubular structure in the cecum. She was referred to our therapeutic endoscopy service for removal of a large cecal polyp. A colonoscopy was performed and a 8 cm tubular structure arising from appendicial orifice was seen. The overlying mucosa was normal and a diagnosis of inverted appendix was made. After consultation with our surgical team and the patient, decision was made to remove the appendix endoscopically. A repeat colonoscopy was performed. Using an PolyLoop device the base of the appendix was captured by three PolyLoops placed above each other. The appendix appeared to turn blue from compromised vascular flow. Next using ERBE; setting at forced coag effect 2, W80 and using a stiff 10 mm snare the base of the appendix was captured above the Polyloops and resected using electrocautery. No bleeding was encountered. Next an over the scope OVESCO clip was applied over the tip of the remnant. The pathology confirmed the findings of inverted appendix. The patient did very well post procedure with resolution of her intermittent severe right lower quadrant pain. Endoscopic full thickness resection of symptomatic inverted appendix is feasible and safe. The use of endoscopic PolyLoops and over the scope clips are recommended to ensure no dehiscence of appendicial lumen and prevent delayed bleeding. Informative discusson with the patient and surgeon regarding risks and benefits are mandartory for better outcome. Failure to recognize the entity and inadvertent simple polypectomy will lead to perforation.
1119 Using Two Endoloops to Secure the Appendiceal Stump During Colonoscopic Removal of an Inverted Appendix: A Case Report With Video Kasidit Norasettkul*1, Rungsun Rerknimitr1, Rapat Pittayanon1, Nareumon Wisedopas2, Panida Piyachaturawat1 1 Division of Gastroenterology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Banngkok, Thailand; 2King Chulalongkorn Memorial Hospital, Bangkok, Thailand
AB146 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
A 54-year-old woman had a history of non-specific intermittent lower abdominal pain and loose stool for 3 months. She was scheduled for a colonoscopy. On the colonoscopy day, she still had mild lower abdominal pain without fever. However, she could complete bowel preparation. The abdominal sign revealed mild tender without guarding. After the completion of inform and consent to the patient, colonoscopy with minimal air-inflation was eventually performed. Colonoscopy showed a 3-cm polypoid lesion overlying with normal colonic mucosa originated from the appendiceal orifice which was compatible with an inverted appendix. After a careful consideration about a history of lower abdominal pain, colonoscopic appendectomy was performed. The first endoloop was placed around the base of the appendix. The appendix was cut just above the loop by using a polypectomy snare. Then the second endoloop was applied to secure the appendiceal stump (as showed in the video). The histopathology confirmed as mild appendicitis. No immediate or delayed complications occurred. Her abdominal pain resolved. Inverted appendix is an uncommon condition that rarely detected during colonoscopy. Because of its uncommon presentation, the data about etiology, management, and its prognosis are not well established. Some case reports showed endometriosis as a cause of an inverted appendix. Hypothetically, colonic mucosal biopsy is insufficient to diagnose inflammation at the serosal side of inverted appendicitis. Some experts recommended for an endoscopic removal of inverted appendix to get more accurate histopathology. Although adverse events from inverted appendix was quite low, a few cases of intussusception were reported. Colonoscopic appendectomy is one of the treatment options. The first case of an appendix removed endoscopically was reported in 1976. In the past, there was a significant risk of perforation if colonoscopic appendectomy was done without any stump securing device. Fortunately, to date, there are special devices such as endoloops and clips that can reduce the risk of perforation. We reported a case of inverted appendix undergoing colonoscopic appendectomy by using two endoloops to secure the appendiceal stump. Currently, there has been no report on the complications of inverted appendix removed by a colonoscopic appendectomy with a stump secured by an endoloop, however, a risk of delayed stump leakage is always a concern. Therefore we placed double endoloops to ensure the complete stump closure.
1120 Closure of Large Colonic Defects Using Submucosal Buttressed Clips Shai Friedland* Gastroenterology, Stanford University and VA Palo Alto, Palo Alto, CA Background: Clip closure is often performed after endoscopic resection to prevent or treat bleeding and perforation. Clip closure of colonic defects larger than 2cm is technically challenging as clips may slip off the mucosa. Methods: A biopsy forceps is used to remove a small piece of normal mucosa 5mm away from each side of the resection margin. Clips are applied directly to the exposed submucosa to approximate the edges of the defect. The process is repeated until the defect is completely closed. Results: The video demonstrates 4 cases of successful large defect closure using the submucosal buttressed clip technique. All of the patients had uneventful post-procedure courses. Conclusion: Large colonic resection defects can be closed using submucosal buttressed clips. The technique is efficient and does not require specialized equipment or training.
1121 Endoscopic Treatment of Internal Hemorrhoids Using a Bipolar System Shaffer R. Mok*, Amitpal S. Johal, David L. Diehl, Harshit S. Khara Gastronterology and Hepatology, Geisinger Medical Center, Danville, PA Introduction: Hemorrhoids occur in 4% of the population and are present in 39-45% of colonoscopies. Internal hemorrhoids have been categorized further using the Banov classification, which has grades I-IV. While grades III-IV have typically been managed surgically, grades I-II can be treated by endoscopic means. Numerous endoscopic methods have been described to treat internal hemorrhoids, but these technologies are fraught with high rates of post-procedural pain. The Hemorrhoidal Endoscopic Therapy (HET) is a bipolar system that uses a novel anoscope with built-in illumination and consistent compression apparatus. This allows for stable energy delivery, which causes lower rates of collateral damage and therefore less post-procedural pain. Methods: This video demonstrates appropriate patient selection, positioning, equipment, set-up and procedural nuisances necessary for obtaining success using this HET system. Specifically, we emphasize various techniques that can be implemented for proper tissue apposition of the hemorrhoidal cushions with the HET probe. Case: We describe a 33-year-old female who presented with blood per rectum with straining. The patient underwent a colonoscopic examination with two grade I hemorrhoids in the right anterior and posterior cushions, and one grade II hemorrhoid in the left lateral cushion with a hypertrophied anal papilla. No additional bleeding lesions seen throughout the colon. She then underwent the HET procedure as a method of treatment for her symptomatic hemorrhoids. Using a through-the-speculum grasper, to allow for tissue apposition, electrocautery energy was delivered using a bipolar current to each of
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