- Email: [email protected]
Endoscopic Management of a Type III Choledochal Cyst
Abstracts
metal stent. The patient had clinical improvement and imaging performed 4 weeks post-procedure showed near complete fluid collection resolution. Clinical Implications: Endoscopic cystogastrostomy performed for the management of an acute post-surgical peri-pancreatic fluid collection can be complicated by migration of a double pigtail plastic stent into the fluid cavity. Placement of a fully covered lumen-apposing metal stent can both facilitate retrieval of the migrated stent as well as effectively treat the acute post-surgical peri-pancreatic fluid collection.
Over the Scope Clip Assisted Resection of a Gastric Submucosal Nodule Tejal Mistry*1, Michael Swaby2, Shashideep Singhal1 1 Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX; 2Pathology, University of Texas Health Science Center at Houston, Houston, TX
Gastric submucosal nodules are common incidental findings during an upper endoscopy. A 61 year old female with refractory dyspepsia presented for upper endoscopy which showed an incidental gastric submucosal nodule. Management options include endoscopic ultrasound with continued surveillance in lesions with low malignant potential and surgical resection for high risk nodules. EUS showed a 1.4 cm nodule arising from muscularis propria. FNA was inconclusive. We performed an Over The Scope Clip (OTSC) assisted endoscopic resection of gastric submucosal nodule. The nodule was suctioned into the cap and 12/6 gc OTSC was placed over the nodule. Nodule was removed using a hot snare over the clip which was left in place. This technique provides a safe, potentially curative, one step procedure for management of small gastric submucosal nodules and provides histological diagnosis.
Spying a Biliary Stricture Through a Colonoscope in a Patient with Roux-en-Y Hepaticojejunostomy Ravishankar Asokkumar*1, Damien Tan1, Christopher Jen Lock Khor1, Roy M. Soetikno1,2 1 Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; 2National Cancer Centre, Singapore, Singapore Background: Endoscopic bile duct assessment in patients with altered surgical anatomy can be challenging. It is impossible to perform endoscopic retrograde cholangiopancreatography (ERCP) using a standard side viewing scope. However, diagnostic and therapeutic endoscopy for biliary pathology may be required in such patients. We describe the use of colonoscope-assisted cholangioscopy to evaluate a biliary stricture in a patient with Roux-en-Y hepatico-jejunostomy. Case: A 57-yearold male presented with three months history of abdominal pain and significant weight loss. He underwent pylorus preserving pancreatico-duodenectomy 5 years ago for distal common bile duct cholangiocarcinoma. His liver function test showed cholestasis (Bil- 35 umol/l, ALP- 2215 u/l, GGT-1476 u/l). Magnetic resonance cholangiopancreatography showed a stricture at the confluence of the hepatic ducts. We performed a radial endoscopic ultrasound, which showed a hyperechoic lesion with acoustic shadow suggestive of stones in the right hepatic duct. Endoscopic Methods: We used a paediatric colonoscope equipped with cap and water jet function. We maintained a straight scope configuration through out the procedure. The hepaticojejunostomy site was cannulated using a standard cannula and a cholangiogram was performed which confirmed the presence of a tight stricture at the confluence of the ducts. The stricture was dilated using a balloon dilator and biliary brushings were obtained. We then placed a plastic stent for drainage. Presence of atypical cells in cytology warranted endoscopic stricture visualization. We used a therapeutic adult colonoscope equipped with cap. We easily reached the hepaticojejunostomy site by maintaining a straight scope configuration. We, after removing the stent, introduced the new cholangioscopy system through the working channel of the adult colonoscope and advanced it into the bile ducts. The cholangioscope showed multiple stones and a benign stricture in the right hepatic duct. We removed the stones completely using a balloon catheter and confirmed it using the cholangioscope. Clinical Implications: Endoscopic bile duct assessment, in patients with altered surgical anatomy, is possible using a colonoscope. The use of cap in a colonoscope may supplant the elevator function of a side viewing scope. Maintaining a straight scope configuration and using a therapeutic channel colonoscope can enable us perform cholangioscopy. Thus, proper technique and use of accessories may make bile duct evaluation successful in surgically altered anatomy.
Endoscopic Retrieval of Ingested Paperclips Using a Refridgerator Magnet Erica R. Cohen*, Laith H. Jamil, Ali Rezaie Gastroenterology, Cedars Sinai Medical Center, Los ANgeles, CA Case: A 26-year-old man with a history of anxiety, post-traumatic stress disorder, and depression presented with abdominal pain and emesis after intentionally ingesting >20 paperclip fragments. He underwent endoscopic retrieval 5 months prior after a similar presentation. Radiographs revealed grouped metallic fragments in the
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stomach and throughout the small bowel without evidence of pneumoperitoneum. On endoscopic evaluation of the stomach, a cluster of intertwined paperclip fragments were visualized, partially obscured by debris. A solitary fragment was identified in the pylorus and the duodenum was unremarkable. Endoscopic Techniques: An over-tube was placed to facilitate repeated entry into the stomach and protect the esophagus. To mitigate iatrogenic trauma and expedite the procedure, we employed the use of an endoscopically-introduced magnet to retrieve the paperclips en bloc. A magnet was obtained from the staff kitchen refrigerator, cleaned, and placed into a Roth net. It was easily advanced under endoscopic visualization into the stomach and immediately attached to the paperclips, which were removed. The magnet was then re-introduced and advanced to the pylorus to remove the larger solitary fragment. Follow-up: A post-procedure abdominal radiograph confirmed removal of all foreign bodies from the stomach. The remaining fragments were expelled through the feces over the subsequent 5 days. There were no adverse events from the procedure. Intensive psychiatric services were provided during his hospital stay. Clinical Implications: Intentional metallic foreign body ingestions are common, especially in children, the prison, and psychiatric populations. Endoscopic intervention is frequently required. Reasons for unsuccessful retrieval include challenges due to the shape of the object, the number of objects ingested, or incomplete visualization due to debris. Although this technique was first described in the 1940s1, our experience suggests that magnet-assisted retrieval is an underutilized but useful addition to conventional endoscopic techniques. It is an easy, cost-effective, and time efficient method for the removal of potentially harmful foreign bodies in the gastrointestinal tract. 1. Equen M. A new magnet for the removal of foreign bodies from the food and air passages. JAMA 1945;127:87-8.
Migrated Esophageal Stent Retrieved Via Oral Double Balloon Enteroscopy Laith H. Jamil* Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA Fully covered esophageal stents (FCES) can migrate into the small bowel (SB) and cause obstruction and perforation (1,2). Double balloon enteroscopy (DBE) has been used to removed foreign bodies that have migrated into the SB (3,4). In patients with a migrated FCES with symptoms, patients will likely require emergency surgery. In asymptomatic patients, it is not known whether to observe and see if the stent passes spontaneously, and if so, how long to observe, or attempt to retrieve the stent endoscopically. A 72 year old female with history of Billroth II surgery 18 years prior to presentation for peptic ulcer disease had been complaining of symptoms of gastric outlet obstruction secondary to stenosis of the GJ anastomosis. Multiple upper endoscopies with dilation had failed to relieve her symptoms. Patient underwent an EGD and an 18 mm X 12 cm FCES was placed across the anastomosis, and endoscopically sutured to the gastric wall. The plan was for stent removal in 3 months. Three weeks later patient underwent an upper GI study that showed the stent had migrated to the mid jejunum and was not obstructing the flow of contrast. Imaging over the following 2 weeks showed the stent to have migrated to the distal jejunum, where it stayed for an additional 2 weeks. Patient then presented for DBE in an attempt to remove the stent. After reaching the stent via the oral route, the overtube was advanced as close as possible to the tip of the scope. The thread on the proximal end of the stent was grasped with a grasping forceps and pulled inside the scope channel so as to cone the proximal end of the stent. The scope, with the stent, was pulled inside the overtube, leaving the overtube in place, and removed from the patient and the stent was checked to make sure it was intact. The abdominal cavity was evaluated under fluoroscopy with no apparent complication. The scope was then re-advanced through the overtube to the site where the stent was. Ulcerations were noted with no apparent perforation. Under fluoroscopy, contrast was injected to confirm that there was no perforation. Tattoo spot injection was then performed at the site were the stent was. The patient did well and was discharged home the following day. She presented 2 1/2 months later with cholangitis, and the GJ anastomosis was still patent on endoscopy. In conclusion, in asymptomatic patients with a migrated fully covered esophageal stent, that does not appear to be spontaneously migrating downstream, removal via DBE should be considered. References: 1 Karagul S, et al Int J Surg Case Rep. 2015;11:113-6. 2 Macdonald AJ et al Endoscopy. 2007 Feb;39 Suppl 1:E190. 3 Kim DJ et al, Clin Endosc. 2015 Sep;48(5):444-6. 4 Chen WC et al J Laparoendosc Adv Surg Tech A. 2015 May;25(5):392-5.
Endoscopic Management of a Type III Choledochal Cyst Gabriel D. Lang*, Vladimir Kushnir Gastroenterology, Washington University School of Medicine in Saint Louis, Saint Louis, MO Introduction: Biliary cysts are cystic dilations which occur singly or in multiples throughout the intra and extra- hepatic biliary tree. They are associated with ductal strictures, stone formation, cholangitis, secondary biliary cirrhosis and
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB641
Abstracts
malignancy. Type III choledochal cysts are the least common biliary cyst subtype. They have a female predominance and are the most likely to present at an older age. The most common clinical presentation is acute pancreatitis. The overall incidence of adenocarcinoma is approximately 2.5%. Given the low risk of malignancy, these lesions can be treated endoscopically with ERCP. Here we present a case of endoscopic management of a type III choledochal cyst. Case: A 62 year old female with a history of acute pancreatitis of unknown etiology was found to have a duodenal cystic lesion suggestive of a type III choledochal cyst on cross sectional imaging. The patient was referred for endoscopic management. The cholangiogram revealed a 12 mm cystic structure, off of which the bile and pancreatic ducts were filling. The bile duct proximal to the cystic structure was dilated to 9 mm. Initial attempt at performing a biliary sphincterotomy was limited by guidewire looping in the cystic cavity. In an attempt to straighten the bile duct orientation, a pancreatic duct stent was successfully placed. Afterwards, biliary cannulation was achieved and a complete sphincterotomy was performed. A repeat ERCP was performed two and a half weeks later. It revealed no evidence of residual choledochocele as well as resolution of biliary dilation. Six months later, the patient had no further episodes of pancreatitis. Her liver function tests were normal and she had no abdominal pain. Conclusion: Endoscopic management of type III choledochal cysts is feasible. Typical ERCP maneuvers can be more challenging secondary to guidewire looping in the cystic cavity. A PD stent may be beneficial to help straighten the bile duct orientation in cases of guidewire looping in a cystic cavity.
Hepatico-Colonic-Cutaneous Fistula: A Rare Entity Treated by ERCP Everson L. Artifon*, Luiz H. Mestieri, Joel Oliveira GI Endoscopy Service, Hospital Ana Costa, Santos, Brazil A 53 year-old woman diagnosed with choledocholithiasis was submitted to an elective laparoscopic cholecystectomy. After two days, presented with abdominal pain, leucocytosis and subhepatic collection in ultrasonography. An emercency laparoscopy was performed and the collection was drained. 35 days later, she presented at the emergency department with bilious enteric secretion through the drain orifice. Transcutaneous fistulography showed contrast media on the colon and the biliary tree. As the patient did not have symptoms of peritonitis, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and confirmed a right hepatic duct fistula with the colon. Papilotomy was performed and a 10Fr/12cm plastic stent was inserted. The patient was submitted to a colonoscopy 35 days later, which showed no signs of fistula. Another 40 days later an ERCP was performed, the stent was removed and no evidence of fistula was seen. The patient had an uneventful evaluation with closure of the cutaneous fistula. The hepaticocolonic fistula is a very rare disease, usually secondary to a local infectious process (cholecystitis), and iatrogenic causes. The most common types are the choledochoduodenal (70%) and choledochocolonic (26%). It is an unusual complication after cholecystectomy, and its mechanism consist in the formation of an internal biliary collection secondary to biliary leak that erodes into the colon, forming the fistula. The clinical signs include right upper quadrant pain, vomiting, nausea, with or without peritoneal signs, and even sepsis. In the diagnostic management are included ultrasound, computed tomography, percutaneous transhepatic cholangiography, magnetic resonance cholangiopancreatography, and ERCP. The gold standard treatment is surgical (open cholecystectomy and segmental colonic resection), however ERCP and sphincterotomy may reduce the intrabiliary pressure and help the fistula close, and this can be the treatment of choice in some cases. There are very few cases of bilio-colonic fistula demonstrated in the literature and most of them were treated by surgery. On the other hand this described case was treated successful by using ERCP approach.
Closure of Medium Size Iatrogenic Perforations During Endoscopy Andres Sanchez-Yague*1, Damien Tan2,3, Christopher Jen Lock Khor2,3, Cristina Lopez Muñoz1, Andres Sanchez-Cantos1, Roy M. Soetikno2,3 1 Gastroenterlogy unit, Hospital Costa del Sol, Marbella, Spain; 2 Singapore General Hospital, NCCS, Singapore, Singapore; 3Duke-NUS, Singapore, Singapore Background: Iatrogenic perforations represent one of the most dreadful complications in endoscopy. Fresh perforations may be small, medium or large. Endoscopic clips have a limited efficacy to close medium and large perforations that usually require surgery. Endoscopic Methods: Over-the-scope clips may be used to close medium perforations. Using a twin grasping forceps to approximate the edges of medium size perforations is possible to close the defect and pull it into the cap prior to deployment of an over-the-scope-clip. Clinical Implications: Over-the-scopeclips present a larger diameter than regular endoscopic clips and allow a deeper insertion through all the layers of the gastrointestinal wall. Using the twin grasping forceps permits a tight approach of the perforation edges prior to release of the over-the-scope-clip.
AB642 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
Endoscopic Ultrasound Guided Insertion of Self-Expandable Metallic Stent and Direct Endoscopic Necrosectomy in the Management of Infected Walled-off Pancreatic Necrosis Tiing Leong Ang*, Andrew Kwek Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore Background: Direct endoscopic necrosectomy (DEN) is now accepted as a minimally invasive treatment options for infected walled-off necrosis (WON). DEN is indicated when there is inadequate response to endoscopic ultrasound (EUS)guided transmural drainage alone. For transmural drainage, double pigtail plastic stents were used traditionally to drain the collection. In recent years, with the development of removable fully covered self-expandable stents (FCSEMS) customized for drainage, FCSEMS are increasingly utilized. The large diameter facilitates both the drainage process as well as repeat entry of the endoscope into the WON cavity for DEN. We present four cases of infected WON who underwent EUS-guided insertion of large diameter FCSEMS followed by DEN. Clinical success was achieved in all cases with no complications. Endoscopic Methods: A19-G FNA needle is used to puncture the WON under EUS guidance. A 0.035-inch guide-wire is introduced through the needle and is coiled within the WON cavity under fluoroscopic guidance. The puncture tract is dilated with a 6Fr biliary dilator, followed by balloon dilatation to 10mm. A 20mm by 16mm FCSEMS constrained in a 10.5Fr catheter is then inserted over the guidewire under combined endoscopic and fluoroscopic view and deployed for initial drainage. When there is a lack of clinical response to transmural drainage alone, a gastroscope is inserted through the FCSEMS into the WON cavity and DEN is performed by using an extraction basket. It is crucial to perform gentle debridement, and not to forcibly pull apart solid material adherent to the wall of the WON, as this may lead to severe bleeding and perforation. When multiple sessions are planned, access is easily maintained by FCSEMS. If plastic stents are used, there is a tendency for the WON opening to narrow and repeat balloon dilatation may be needed. Once the WON cavity has been successfully debrided, the FCSEMS is left in place for continued drainage as the cavity closes, before being removed at 2 months by using a rat-tooth forceps. Using this approach, 4 patients (mean age: 54 years, range: 24 – 75) with WON (mean diameter: 10 cm; range: 5 – 16 cm) were successfully treated with no complications. Clinical Implications: DEN is now accepted as a minimally invasive treatment option for WON. The technique of EUS-guided insertion of FCSEMS with DEN is illustrated. Customized large diameter FCSEMS can facilitate endoscopic drainage and necrosectomy.
Corrosive Pyloric Stricture Dilation - A Novel Technique: Case Series Piyush Somani*, Malay Sharma, Amol Patil, Avinash Kumar Department of gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India Corrosive induced gastrointestinal mucosal injuries are common in developing nations. Pyloric strictures although less common than esophageal strictures are associated with more morbidity due to frequent need of surgical management. There are limited treatment options for pyloric strictures like balloon dilation and surgery. Feeding jejunstomy appears to be the only option in early pyloric strictures (<8 weeks). In this case series of ten patients we describe a novel technique of early corrosive stricture dilation. This novel technique can be performed in pyloric strictures where surgery seems to be the only option. This technique not only helps in feeding but also in the definitive treatment of corrosive induced pyloric stricture unlike feeding jejunostomy.
The EUS-guided Biliary Drainage by Hepaticogastrostomy Xiao-Yan Wang* Gastroenterology, The Third Hospital of Xiangya of Central South University, Changsha, Hunan, China We hearby report a 51 year old male who had pancreatic head carcinoma diagnosed for 10 months and progressive jaundice for 2 weeks. The patient received chemoradiotherapy and uncovered metallic stents in the right hepatic duct. To reduce progressive jaundice, ERCP was performed, but unsuccessfully. He was diagnosed as pancreatic head carcinoma and obstructive jaundice. The treatment for the patient was EUS-guided biliary drainage via hepaticgastrostomy. The detailed procedure including puncturing the intrahepatic bile duct, resecting the gastric and left hepatic tissue, placing the covered stent. The case was performed safely and successfully without any complication. To conclude, biliary drainage using hepaticogastrostomy is good for typeI bismuth of hilar obstruction. Furthermore, selecting the proper hepatic duct is of great importance to this procedure. To our experience, the ideal duct should be at horizontal disposition and about 1cm in diameter, also not too close to either hepatic porta or left hepatic surface. Regular follow-up is necessary to prevent the stent from migrating to hepatic duct or small intestine.
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metal stent. The patient had clinical improvement and imaging performed 4 weeks post-procedure showed near complete fluid collection resolution. Clinical Implications: Endoscopic cystogastrostomy performed for the management of an acute post-surgical peri-pancreatic fluid collection can be complicated by migration of a double pigtail plastic stent into the fluid cavity. Placement of a fully covered lumen-apposing metal stent can both facilitate retrieval of the migrated stent as well as effectively treat the acute post-surgical peri-pancreatic fluid collection.
Over the Scope Clip Assisted Resection of a Gastric Submucosal Nodule Tejal Mistry*1, Michael Swaby2, Shashideep Singhal1 1 Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX; 2Pathology, University of Texas Health Science Center at Houston, Houston, TX
Gastric submucosal nodules are common incidental findings during an upper endoscopy. A 61 year old female with refractory dyspepsia presented for upper endoscopy which showed an incidental gastric submucosal nodule. Management options include endoscopic ultrasound with continued surveillance in lesions with low malignant potential and surgical resection for high risk nodules. EUS showed a 1.4 cm nodule arising from muscularis propria. FNA was inconclusive. We performed an Over The Scope Clip (OTSC) assisted endoscopic resection of gastric submucosal nodule. The nodule was suctioned into the cap and 12/6 gc OTSC was placed over the nodule. Nodule was removed using a hot snare over the clip which was left in place. This technique provides a safe, potentially curative, one step procedure for management of small gastric submucosal nodules and provides histological diagnosis.
Spying a Biliary Stricture Through a Colonoscope in a Patient with Roux-en-Y Hepaticojejunostomy Ravishankar Asokkumar*1, Damien Tan1, Christopher Jen Lock Khor1, Roy M. Soetikno1,2 1 Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; 2National Cancer Centre, Singapore, Singapore Background: Endoscopic bile duct assessment in patients with altered surgical anatomy can be challenging. It is impossible to perform endoscopic retrograde cholangiopancreatography (ERCP) using a standard side viewing scope. However, diagnostic and therapeutic endoscopy for biliary pathology may be required in such patients. We describe the use of colonoscope-assisted cholangioscopy to evaluate a biliary stricture in a patient with Roux-en-Y hepatico-jejunostomy. Case: A 57-yearold male presented with three months history of abdominal pain and significant weight loss. He underwent pylorus preserving pancreatico-duodenectomy 5 years ago for distal common bile duct cholangiocarcinoma. His liver function test showed cholestasis (Bil- 35 umol/l, ALP- 2215 u/l, GGT-1476 u/l). Magnetic resonance cholangiopancreatography showed a stricture at the confluence of the hepatic ducts. We performed a radial endoscopic ultrasound, which showed a hyperechoic lesion with acoustic shadow suggestive of stones in the right hepatic duct. Endoscopic Methods: We used a paediatric colonoscope equipped with cap and water jet function. We maintained a straight scope configuration through out the procedure. The hepaticojejunostomy site was cannulated using a standard cannula and a cholangiogram was performed which confirmed the presence of a tight stricture at the confluence of the ducts. The stricture was dilated using a balloon dilator and biliary brushings were obtained. We then placed a plastic stent for drainage. Presence of atypical cells in cytology warranted endoscopic stricture visualization. We used a therapeutic adult colonoscope equipped with cap. We easily reached the hepaticojejunostomy site by maintaining a straight scope configuration. We, after removing the stent, introduced the new cholangioscopy system through the working channel of the adult colonoscope and advanced it into the bile ducts. The cholangioscope showed multiple stones and a benign stricture in the right hepatic duct. We removed the stones completely using a balloon catheter and confirmed it using the cholangioscope. Clinical Implications: Endoscopic bile duct assessment, in patients with altered surgical anatomy, is possible using a colonoscope. The use of cap in a colonoscope may supplant the elevator function of a side viewing scope. Maintaining a straight scope configuration and using a therapeutic channel colonoscope can enable us perform cholangioscopy. Thus, proper technique and use of accessories may make bile duct evaluation successful in surgically altered anatomy.
Endoscopic Retrieval of Ingested Paperclips Using a Refridgerator Magnet Erica R. Cohen*, Laith H. Jamil, Ali Rezaie Gastroenterology, Cedars Sinai Medical Center, Los ANgeles, CA Case: A 26-year-old man with a history of anxiety, post-traumatic stress disorder, and depression presented with abdominal pain and emesis after intentionally ingesting >20 paperclip fragments. He underwent endoscopic retrieval 5 months prior after a similar presentation. Radiographs revealed grouped metallic fragments in the
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stomach and throughout the small bowel without evidence of pneumoperitoneum. On endoscopic evaluation of the stomach, a cluster of intertwined paperclip fragments were visualized, partially obscured by debris. A solitary fragment was identified in the pylorus and the duodenum was unremarkable. Endoscopic Techniques: An over-tube was placed to facilitate repeated entry into the stomach and protect the esophagus. To mitigate iatrogenic trauma and expedite the procedure, we employed the use of an endoscopically-introduced magnet to retrieve the paperclips en bloc. A magnet was obtained from the staff kitchen refrigerator, cleaned, and placed into a Roth net. It was easily advanced under endoscopic visualization into the stomach and immediately attached to the paperclips, which were removed. The magnet was then re-introduced and advanced to the pylorus to remove the larger solitary fragment. Follow-up: A post-procedure abdominal radiograph confirmed removal of all foreign bodies from the stomach. The remaining fragments were expelled through the feces over the subsequent 5 days. There were no adverse events from the procedure. Intensive psychiatric services were provided during his hospital stay. Clinical Implications: Intentional metallic foreign body ingestions are common, especially in children, the prison, and psychiatric populations. Endoscopic intervention is frequently required. Reasons for unsuccessful retrieval include challenges due to the shape of the object, the number of objects ingested, or incomplete visualization due to debris. Although this technique was first described in the 1940s1, our experience suggests that magnet-assisted retrieval is an underutilized but useful addition to conventional endoscopic techniques. It is an easy, cost-effective, and time efficient method for the removal of potentially harmful foreign bodies in the gastrointestinal tract. 1. Equen M. A new magnet for the removal of foreign bodies from the food and air passages. JAMA 1945;127:87-8.
Migrated Esophageal Stent Retrieved Via Oral Double Balloon Enteroscopy Laith H. Jamil* Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA Fully covered esophageal stents (FCES) can migrate into the small bowel (SB) and cause obstruction and perforation (1,2). Double balloon enteroscopy (DBE) has been used to removed foreign bodies that have migrated into the SB (3,4). In patients with a migrated FCES with symptoms, patients will likely require emergency surgery. In asymptomatic patients, it is not known whether to observe and see if the stent passes spontaneously, and if so, how long to observe, or attempt to retrieve the stent endoscopically. A 72 year old female with history of Billroth II surgery 18 years prior to presentation for peptic ulcer disease had been complaining of symptoms of gastric outlet obstruction secondary to stenosis of the GJ anastomosis. Multiple upper endoscopies with dilation had failed to relieve her symptoms. Patient underwent an EGD and an 18 mm X 12 cm FCES was placed across the anastomosis, and endoscopically sutured to the gastric wall. The plan was for stent removal in 3 months. Three weeks later patient underwent an upper GI study that showed the stent had migrated to the mid jejunum and was not obstructing the flow of contrast. Imaging over the following 2 weeks showed the stent to have migrated to the distal jejunum, where it stayed for an additional 2 weeks. Patient then presented for DBE in an attempt to remove the stent. After reaching the stent via the oral route, the overtube was advanced as close as possible to the tip of the scope. The thread on the proximal end of the stent was grasped with a grasping forceps and pulled inside the scope channel so as to cone the proximal end of the stent. The scope, with the stent, was pulled inside the overtube, leaving the overtube in place, and removed from the patient and the stent was checked to make sure it was intact. The abdominal cavity was evaluated under fluoroscopy with no apparent complication. The scope was then re-advanced through the overtube to the site where the stent was. Ulcerations were noted with no apparent perforation. Under fluoroscopy, contrast was injected to confirm that there was no perforation. Tattoo spot injection was then performed at the site were the stent was. The patient did well and was discharged home the following day. She presented 2 1/2 months later with cholangitis, and the GJ anastomosis was still patent on endoscopy. In conclusion, in asymptomatic patients with a migrated fully covered esophageal stent, that does not appear to be spontaneously migrating downstream, removal via DBE should be considered. References: 1 Karagul S, et al Int J Surg Case Rep. 2015;11:113-6. 2 Macdonald AJ et al Endoscopy. 2007 Feb;39 Suppl 1:E190. 3 Kim DJ et al, Clin Endosc. 2015 Sep;48(5):444-6. 4 Chen WC et al J Laparoendosc Adv Surg Tech A. 2015 May;25(5):392-5.
Endoscopic Management of a Type III Choledochal Cyst Gabriel D. Lang*, Vladimir Kushnir Gastroenterology, Washington University School of Medicine in Saint Louis, Saint Louis, MO Introduction: Biliary cysts are cystic dilations which occur singly or in multiples throughout the intra and extra- hepatic biliary tree. They are associated with ductal strictures, stone formation, cholangitis, secondary biliary cirrhosis and
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB641
Abstracts
malignancy. Type III choledochal cysts are the least common biliary cyst subtype. They have a female predominance and are the most likely to present at an older age. The most common clinical presentation is acute pancreatitis. The overall incidence of adenocarcinoma is approximately 2.5%. Given the low risk of malignancy, these lesions can be treated endoscopically with ERCP. Here we present a case of endoscopic management of a type III choledochal cyst. Case: A 62 year old female with a history of acute pancreatitis of unknown etiology was found to have a duodenal cystic lesion suggestive of a type III choledochal cyst on cross sectional imaging. The patient was referred for endoscopic management. The cholangiogram revealed a 12 mm cystic structure, off of which the bile and pancreatic ducts were filling. The bile duct proximal to the cystic structure was dilated to 9 mm. Initial attempt at performing a biliary sphincterotomy was limited by guidewire looping in the cystic cavity. In an attempt to straighten the bile duct orientation, a pancreatic duct stent was successfully placed. Afterwards, biliary cannulation was achieved and a complete sphincterotomy was performed. A repeat ERCP was performed two and a half weeks later. It revealed no evidence of residual choledochocele as well as resolution of biliary dilation. Six months later, the patient had no further episodes of pancreatitis. Her liver function tests were normal and she had no abdominal pain. Conclusion: Endoscopic management of type III choledochal cysts is feasible. Typical ERCP maneuvers can be more challenging secondary to guidewire looping in the cystic cavity. A PD stent may be beneficial to help straighten the bile duct orientation in cases of guidewire looping in a cystic cavity.
Hepatico-Colonic-Cutaneous Fistula: A Rare Entity Treated by ERCP Everson L. Artifon*, Luiz H. Mestieri, Joel Oliveira GI Endoscopy Service, Hospital Ana Costa, Santos, Brazil A 53 year-old woman diagnosed with choledocholithiasis was submitted to an elective laparoscopic cholecystectomy. After two days, presented with abdominal pain, leucocytosis and subhepatic collection in ultrasonography. An emercency laparoscopy was performed and the collection was drained. 35 days later, she presented at the emergency department with bilious enteric secretion through the drain orifice. Transcutaneous fistulography showed contrast media on the colon and the biliary tree. As the patient did not have symptoms of peritonitis, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and confirmed a right hepatic duct fistula with the colon. Papilotomy was performed and a 10Fr/12cm plastic stent was inserted. The patient was submitted to a colonoscopy 35 days later, which showed no signs of fistula. Another 40 days later an ERCP was performed, the stent was removed and no evidence of fistula was seen. The patient had an uneventful evaluation with closure of the cutaneous fistula. The hepaticocolonic fistula is a very rare disease, usually secondary to a local infectious process (cholecystitis), and iatrogenic causes. The most common types are the choledochoduodenal (70%) and choledochocolonic (26%). It is an unusual complication after cholecystectomy, and its mechanism consist in the formation of an internal biliary collection secondary to biliary leak that erodes into the colon, forming the fistula. The clinical signs include right upper quadrant pain, vomiting, nausea, with or without peritoneal signs, and even sepsis. In the diagnostic management are included ultrasound, computed tomography, percutaneous transhepatic cholangiography, magnetic resonance cholangiopancreatography, and ERCP. The gold standard treatment is surgical (open cholecystectomy and segmental colonic resection), however ERCP and sphincterotomy may reduce the intrabiliary pressure and help the fistula close, and this can be the treatment of choice in some cases. There are very few cases of bilio-colonic fistula demonstrated in the literature and most of them were treated by surgery. On the other hand this described case was treated successful by using ERCP approach.
Closure of Medium Size Iatrogenic Perforations During Endoscopy Andres Sanchez-Yague*1, Damien Tan2,3, Christopher Jen Lock Khor2,3, Cristina Lopez Muñoz1, Andres Sanchez-Cantos1, Roy M. Soetikno2,3 1 Gastroenterlogy unit, Hospital Costa del Sol, Marbella, Spain; 2 Singapore General Hospital, NCCS, Singapore, Singapore; 3Duke-NUS, Singapore, Singapore Background: Iatrogenic perforations represent one of the most dreadful complications in endoscopy. Fresh perforations may be small, medium or large. Endoscopic clips have a limited efficacy to close medium and large perforations that usually require surgery. Endoscopic Methods: Over-the-scope clips may be used to close medium perforations. Using a twin grasping forceps to approximate the edges of medium size perforations is possible to close the defect and pull it into the cap prior to deployment of an over-the-scope-clip. Clinical Implications: Over-the-scopeclips present a larger diameter than regular endoscopic clips and allow a deeper insertion through all the layers of the gastrointestinal wall. Using the twin grasping forceps permits a tight approach of the perforation edges prior to release of the over-the-scope-clip.
AB642 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
Endoscopic Ultrasound Guided Insertion of Self-Expandable Metallic Stent and Direct Endoscopic Necrosectomy in the Management of Infected Walled-off Pancreatic Necrosis Tiing Leong Ang*, Andrew Kwek Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore Background: Direct endoscopic necrosectomy (DEN) is now accepted as a minimally invasive treatment options for infected walled-off necrosis (WON). DEN is indicated when there is inadequate response to endoscopic ultrasound (EUS)guided transmural drainage alone. For transmural drainage, double pigtail plastic stents were used traditionally to drain the collection. In recent years, with the development of removable fully covered self-expandable stents (FCSEMS) customized for drainage, FCSEMS are increasingly utilized. The large diameter facilitates both the drainage process as well as repeat entry of the endoscope into the WON cavity for DEN. We present four cases of infected WON who underwent EUS-guided insertion of large diameter FCSEMS followed by DEN. Clinical success was achieved in all cases with no complications. Endoscopic Methods: A19-G FNA needle is used to puncture the WON under EUS guidance. A 0.035-inch guide-wire is introduced through the needle and is coiled within the WON cavity under fluoroscopic guidance. The puncture tract is dilated with a 6Fr biliary dilator, followed by balloon dilatation to 10mm. A 20mm by 16mm FCSEMS constrained in a 10.5Fr catheter is then inserted over the guidewire under combined endoscopic and fluoroscopic view and deployed for initial drainage. When there is a lack of clinical response to transmural drainage alone, a gastroscope is inserted through the FCSEMS into the WON cavity and DEN is performed by using an extraction basket. It is crucial to perform gentle debridement, and not to forcibly pull apart solid material adherent to the wall of the WON, as this may lead to severe bleeding and perforation. When multiple sessions are planned, access is easily maintained by FCSEMS. If plastic stents are used, there is a tendency for the WON opening to narrow and repeat balloon dilatation may be needed. Once the WON cavity has been successfully debrided, the FCSEMS is left in place for continued drainage as the cavity closes, before being removed at 2 months by using a rat-tooth forceps. Using this approach, 4 patients (mean age: 54 years, range: 24 – 75) with WON (mean diameter: 10 cm; range: 5 – 16 cm) were successfully treated with no complications. Clinical Implications: DEN is now accepted as a minimally invasive treatment option for WON. The technique of EUS-guided insertion of FCSEMS with DEN is illustrated. Customized large diameter FCSEMS can facilitate endoscopic drainage and necrosectomy.
Corrosive Pyloric Stricture Dilation - A Novel Technique: Case Series Piyush Somani*, Malay Sharma, Amol Patil, Avinash Kumar Department of gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India Corrosive induced gastrointestinal mucosal injuries are common in developing nations. Pyloric strictures although less common than esophageal strictures are associated with more morbidity due to frequent need of surgical management. There are limited treatment options for pyloric strictures like balloon dilation and surgery. Feeding jejunstomy appears to be the only option in early pyloric strictures (<8 weeks). In this case series of ten patients we describe a novel technique of early corrosive stricture dilation. This novel technique can be performed in pyloric strictures where surgery seems to be the only option. This technique not only helps in feeding but also in the definitive treatment of corrosive induced pyloric stricture unlike feeding jejunostomy.
The EUS-guided Biliary Drainage by Hepaticogastrostomy Xiao-Yan Wang* Gastroenterology, The Third Hospital of Xiangya of Central South University, Changsha, Hunan, China We hearby report a 51 year old male who had pancreatic head carcinoma diagnosed for 10 months and progressive jaundice for 2 weeks. The patient received chemoradiotherapy and uncovered metallic stents in the right hepatic duct. To reduce progressive jaundice, ERCP was performed, but unsuccessfully. He was diagnosed as pancreatic head carcinoma and obstructive jaundice. The treatment for the patient was EUS-guided biliary drainage via hepaticgastrostomy. The detailed procedure including puncturing the intrahepatic bile duct, resecting the gastric and left hepatic tissue, placing the covered stent. The case was performed safely and successfully without any complication. To conclude, biliary drainage using hepaticogastrostomy is good for typeI bismuth of hilar obstruction. Furthermore, selecting the proper hepatic duct is of great importance to this procedure. To our experience, the ideal duct should be at horizontal disposition and about 1cm in diameter, also not too close to either hepatic porta or left hepatic surface. Regular follow-up is necessary to prevent the stent from migrating to hepatic duct or small intestine.
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