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1157 Under Water Injection of Fundal Varices
Abstracts
KM curves: Recurrence free survival analysis
1156 Endoscopic Removal of Luminal Gossypiboma With Laparoscopic Assistance Malay Sharma*, Rajendra Lingampalli, Saurabh Jindal, Piyush Somani, Medhavi Tomar Jaswantrai speciality hospital, Meerut, UP, India Introduction: Gossypiboma is the most commonly retained foreign material in the body after surgical operations. Gossypiboma is a term used to denote a mass of cotton material usually gauze, sponges and towels which are inadvertently left in the body cavity at the end of a surgical operation. A retained piece of cotton material evokes an exudative reaction, which leads to the formation of abscesses. Fibrotic reaction leads to adhesions and mass lesions. Sometimes gossypiboma migrates into bowel lumen with intact fistulous tract. Rarely, gossypiboma migrates into bowel lumen without leaving any opening in intestinal wall. Case Report: A 35 years old female presented with right upper quadrant pain abdomen for last 3 months and vomiting for last 1 week. She had undergone open cholecystectomy 5 months back for symptomatic gallstone disease. A firm non tender lump was palpable in right hypochondrium. Contrast enhanced computed tomography (CECT) abdomen showed a heterogenous lesion with metallic marker in it, in the first, second and third part of duodenum suggestive of gossypiboma. Upper GI endoscopy showed a gauze piece in the first part of duodenum and an ulcer near it. The scope could not be negotiated beyond the gauze piece. No fistula or extra luminal leak of oral contrast on CECT abdomen. An endoscopic removal of gauze piece was planned. The gauze piece was caught with a snare and pulled out. It came out with a jerk all the way up to the middle part of esophagus and got impacted. It could not be retrieved or pushed back into stomach. Laparoscopic gastrostomy was done and gauze piece was retrieved from stomach. Intra operative endoscopy showed a large excavating ulcer in anteroinferior wall of first part of duodenum. No perforation was noted. Conclusion: Endoscopic removal can be attempted for a luminal gossypiboma without fistula tract or extraluminal leak of contrast. In case of endoscopic removal if impaction occurs, laparoscopic assistance can be taken. In this case, endoscopic removal of gossypiboma from duodenum to stomach made this a more convenient procedure for laparoscopic removal of gossypiboma.
1157 Under Water Injection of Fundal Varices Ahmed a. Monis*2, Moamen M. Gabr1 1 Gastroenterology and Hepatology, Tanta University, Tanta, Egypt; 2 Internal Medicine, Ain Shams University, Cairo, EgyptThese are 3 cases from a case series of originally 20 patients who underwent under water injection of fundal varices (FV).
AB158 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Case 1: A 55 years old male patient with past medical history of cirrhosis Hepatitis C related presented to our center for follow up of esophageal varices. He has history of esophageal varices with multiple sessions of endoscopic band ligation. LFTs were remarkable for: AST 54, ALT 61, Serum Albumin 2, Total Bilirubin 2.1 and INR 1.4. EGD was performed that was notable for obliterated EV then once the scope was introduced into the stomach we noticed large FV. Decision was made to inject FV using under water injection technique With the pt in left lateral position and after intubation of the stomach, gastric deflation was performed with suction of gastric air then 150 ccs of distilled water were injected in the stomach. A 23Gx130 cm injection needle connected to a 3 cm syringe loaded with a mixture of 1 cm lipiodol and 2 cm Cyanoacrylate was used for injection of the FV under water visualization. Minimal bleeding was observed at the site of injection that stopped within few seconds with no need for any intervention. A Blue cyanoacrylate glue plug was seen at the site of injection after needle withdrawal denoting adequate variceal filling with glue. Follow-up EGD at 1 month showed satisfactory occlusion of the previously injected FV. No complications were observed. Case 2: A 53 years old male patient with history of cirrhosis and Hepatitis C presented to our center for follow up of FV. EGD was performed that was notable for huge tortious FV. Under water injection technique was applied. Filling of the varices with the glue was noticed with minimal selfcontrolled bleeding and the blue cyanoacrylate plug denotes successful variceal injection. Case 3: A 50 years old male patient with history of liver fibrosis, Schistosomiasis presented to our center for follow up of FV. EGD was performed that was notable for tortious FV. Under water injection technique was applied. Filling of the varices with the glue was noticed with minimal bleeding. At the end of the procedure the stomach was deflated of water and the site of injection was observed for any complications. Endoscopic glue injection (with/without coiling) is the standard management of risky FV. Despite its feasibility some common limitations and complications still exist especially with high volume of cases in endemic areas. This includes immediate bleeding, glue extravasation and under injection of FV with the risk of rupture and rebleeding. Endoscopic injection of FV under water is a simple technique that decreases the risk of extravasated glue adhering to the scope, decreases immediate bleeding during injection, and the blue cyanoacrylate plug at injection site can be considered an indicator of sufficient variceal filling with glue.
1158 A Dimple in a Polyp Malay Sharma*1, Krishnaveni Janarthanan2, Rajendra Lingampalli1, Saurabh Jindal1 1 Jaswantrai speciality hospital, Meerut, UP, India; 2Department of gastroenterology, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India Introduction: Heterotopic gastric mucosa is the presence of normal gastric mucosa in abnormal locations of the gastrointestinal tract. It may involve any part of the gastrointestinal tract. Endoscopic findings maybe varied, presenting as salmon red patches, nodularity, polyps or ulcers . Rare endoscopy findings like a single giant polyp in the duodenum and. as a solitary large submucosal tumour-like mass with central depression have been described. Endosonography in the evaluation of submucosal lesions is a well established entity but literature regarding EUS description of HGM is rare. Cystic submucosal tumour has been subclassified endosonographically as simple cystic , multicystic and solid cystic. HGM may be simple cystic or solid cystic type. Case report: We present an interesting endoscopy and endosonography video of a 40 year old woman who presented with dyspepsia. She had no pain or gastrointestinal bleed. Endoscopy showed a smooth polyp in the second part of the duodenum. It had a central opening extruding clear material similar to a fishmouth appearance of IPMN. Ampulla was seen seperately. Endoscopic ultrasound was done with a linear echoendoscope. The lesion was arising from the submucosa of the duodenum and had anechoic central area. It was classical of a cystic submucosal tumour-simple cystic type. The central opening was possibly caused by the mucus secreting glands in gastric heterotopia. She later underwent a polypectomy and the biopsies were diagnostic of heterotopic gastric mucosa. Conclusion: Differential diagnosis of heterotopic gastric mucosa maybe considered in polyps with a central opening in the duodenum. Endosonography is advantageous in characterisation of the lesion and guiding decision on intervention like polypectomy or endoscopic resection.
1159 Endoscopic Management of Gastric Wall Abscess, a Rare Late Complication of Laparoscopic Adjustable Gastric Banding Hossein Movahed*1, Mohamed M. Abdelfatah1, Sirish Sanaka1, Amit Raina1,2 1 East Carolina University/Vidant Medical Center, Greenville, NC; 2The Center for Comprehensive Pancreatic Care, The Melissa L. Posner Institute for Digestive Health & Liver Disease at Mercy, Baltimore, MD
www.giejournal.org
KM curves: Recurrence free survival analysis
1156 Endoscopic Removal of Luminal Gossypiboma With Laparoscopic Assistance Malay Sharma*, Rajendra Lingampalli, Saurabh Jindal, Piyush Somani, Medhavi Tomar Jaswantrai speciality hospital, Meerut, UP, India Introduction: Gossypiboma is the most commonly retained foreign material in the body after surgical operations. Gossypiboma is a term used to denote a mass of cotton material usually gauze, sponges and towels which are inadvertently left in the body cavity at the end of a surgical operation. A retained piece of cotton material evokes an exudative reaction, which leads to the formation of abscesses. Fibrotic reaction leads to adhesions and mass lesions. Sometimes gossypiboma migrates into bowel lumen with intact fistulous tract. Rarely, gossypiboma migrates into bowel lumen without leaving any opening in intestinal wall. Case Report: A 35 years old female presented with right upper quadrant pain abdomen for last 3 months and vomiting for last 1 week. She had undergone open cholecystectomy 5 months back for symptomatic gallstone disease. A firm non tender lump was palpable in right hypochondrium. Contrast enhanced computed tomography (CECT) abdomen showed a heterogenous lesion with metallic marker in it, in the first, second and third part of duodenum suggestive of gossypiboma. Upper GI endoscopy showed a gauze piece in the first part of duodenum and an ulcer near it. The scope could not be negotiated beyond the gauze piece. No fistula or extra luminal leak of oral contrast on CECT abdomen. An endoscopic removal of gauze piece was planned. The gauze piece was caught with a snare and pulled out. It came out with a jerk all the way up to the middle part of esophagus and got impacted. It could not be retrieved or pushed back into stomach. Laparoscopic gastrostomy was done and gauze piece was retrieved from stomach. Intra operative endoscopy showed a large excavating ulcer in anteroinferior wall of first part of duodenum. No perforation was noted. Conclusion: Endoscopic removal can be attempted for a luminal gossypiboma without fistula tract or extraluminal leak of contrast. In case of endoscopic removal if impaction occurs, laparoscopic assistance can be taken. In this case, endoscopic removal of gossypiboma from duodenum to stomach made this a more convenient procedure for laparoscopic removal of gossypiboma.
1157 Under Water Injection of Fundal Varices Ahmed a. Monis*2, Moamen M. Gabr1 1 Gastroenterology and Hepatology, Tanta University, Tanta, Egypt; 2 Internal Medicine, Ain Shams University, Cairo, EgyptThese are 3 cases from a case series of originally 20 patients who underwent under water injection of fundal varices (FV).
AB158 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Case 1: A 55 years old male patient with past medical history of cirrhosis Hepatitis C related presented to our center for follow up of esophageal varices. He has history of esophageal varices with multiple sessions of endoscopic band ligation. LFTs were remarkable for: AST 54, ALT 61, Serum Albumin 2, Total Bilirubin 2.1 and INR 1.4. EGD was performed that was notable for obliterated EV then once the scope was introduced into the stomach we noticed large FV. Decision was made to inject FV using under water injection technique With the pt in left lateral position and after intubation of the stomach, gastric deflation was performed with suction of gastric air then 150 ccs of distilled water were injected in the stomach. A 23Gx130 cm injection needle connected to a 3 cm syringe loaded with a mixture of 1 cm lipiodol and 2 cm Cyanoacrylate was used for injection of the FV under water visualization. Minimal bleeding was observed at the site of injection that stopped within few seconds with no need for any intervention. A Blue cyanoacrylate glue plug was seen at the site of injection after needle withdrawal denoting adequate variceal filling with glue. Follow-up EGD at 1 month showed satisfactory occlusion of the previously injected FV. No complications were observed. Case 2: A 53 years old male patient with history of cirrhosis and Hepatitis C presented to our center for follow up of FV. EGD was performed that was notable for huge tortious FV. Under water injection technique was applied. Filling of the varices with the glue was noticed with minimal selfcontrolled bleeding and the blue cyanoacrylate plug denotes successful variceal injection. Case 3: A 50 years old male patient with history of liver fibrosis, Schistosomiasis presented to our center for follow up of FV. EGD was performed that was notable for tortious FV. Under water injection technique was applied. Filling of the varices with the glue was noticed with minimal bleeding. At the end of the procedure the stomach was deflated of water and the site of injection was observed for any complications. Endoscopic glue injection (with/without coiling) is the standard management of risky FV. Despite its feasibility some common limitations and complications still exist especially with high volume of cases in endemic areas. This includes immediate bleeding, glue extravasation and under injection of FV with the risk of rupture and rebleeding. Endoscopic injection of FV under water is a simple technique that decreases the risk of extravasated glue adhering to the scope, decreases immediate bleeding during injection, and the blue cyanoacrylate plug at injection site can be considered an indicator of sufficient variceal filling with glue.
1158 A Dimple in a Polyp Malay Sharma*1, Krishnaveni Janarthanan2, Rajendra Lingampalli1, Saurabh Jindal1 1 Jaswantrai speciality hospital, Meerut, UP, India; 2Department of gastroenterology, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India Introduction: Heterotopic gastric mucosa is the presence of normal gastric mucosa in abnormal locations of the gastrointestinal tract. It may involve any part of the gastrointestinal tract. Endoscopic findings maybe varied, presenting as salmon red patches, nodularity, polyps or ulcers . Rare endoscopy findings like a single giant polyp in the duodenum and. as a solitary large submucosal tumour-like mass with central depression have been described. Endosonography in the evaluation of submucosal lesions is a well established entity but literature regarding EUS description of HGM is rare. Cystic submucosal tumour has been subclassified endosonographically as simple cystic , multicystic and solid cystic. HGM may be simple cystic or solid cystic type. Case report: We present an interesting endoscopy and endosonography video of a 40 year old woman who presented with dyspepsia. She had no pain or gastrointestinal bleed. Endoscopy showed a smooth polyp in the second part of the duodenum. It had a central opening extruding clear material similar to a fishmouth appearance of IPMN. Ampulla was seen seperately. Endoscopic ultrasound was done with a linear echoendoscope. The lesion was arising from the submucosa of the duodenum and had anechoic central area. It was classical of a cystic submucosal tumour-simple cystic type. The central opening was possibly caused by the mucus secreting glands in gastric heterotopia. She later underwent a polypectomy and the biopsies were diagnostic of heterotopic gastric mucosa. Conclusion: Differential diagnosis of heterotopic gastric mucosa maybe considered in polyps with a central opening in the duodenum. Endosonography is advantageous in characterisation of the lesion and guiding decision on intervention like polypectomy or endoscopic resection.
1159 Endoscopic Management of Gastric Wall Abscess, a Rare Late Complication of Laparoscopic Adjustable Gastric Banding Hossein Movahed*1, Mohamed M. Abdelfatah1, Sirish Sanaka1, Amit Raina1,2 1 East Carolina University/Vidant Medical Center, Greenville, NC; 2The Center for Comprehensive Pancreatic Care, The Melissa L. Posner Institute for Digestive Health & Liver Disease at Mercy, Baltimore, MD
www.giejournal.org