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EUS guided esophageal rendezvous in a patient with complete obstruction due to a peptic stricture
Abstracts the visual field in these situations, we presented a novel technique “Gel Immersion Endoscopy” at DDW 2015. Clear gel with an appropriate viscosity to prevent rapid mixing is injected through the accessory channel, instead of water. After gel injection, the bleeding source is clearly observed in the space occupied by the gel. Since the gel is originally made for patients with dehydration and dysphagia, the gel contains electrolytes and has much higher electrical conductivity than water. Therefore, in the gel, electrocoagulation using mono-polar devices is not effective due to dissipation of electrical energy. Endoscopic Methods: To avoid dissipation of electrical energy, after grasping the bleeding point in the gel, the gel around the tip of the device is replaced with water before applying electrocoagulation. This video shows a patient treated with this technique. Case: The patient is a 79-year-old man admitted with a fracture of the femur, referred for evaluation of hematochezia. Enhanced CT scan showed extravasation of contrast medium in the rectum, and we performed colonoscopy without preparation. A pulsatile visible vessel was observed near the dentate line in the rectum. Application of a hemo-clip resulted in pulsatile bleeding. Since the lumen of the rectum was filled with blood, it became to be difficult to secure the visual field. After gel injection, the visual field dramatically improved and the bleeding source was localized in the gel. During application of the second and third hemo-clips, the visual field was secured by continuous gel injection through the irrigation device. However, they failed to achieve hemostasis. We then used mono-polar hemostatic forceps. After grasping the bleeding point with hemostatic forceps in the gel, electrocoagulation was performed. However it failed to achieve hemostasis two times due to dissipation of electrical energy in the gel. To avoid dissipation, after grasping the bleeding point in the gel, we replaced the gel around the tip of the hemostatic forceps with water. Hemostasis was then achieved by effective electrocoagulation. Clinical Implications: Gel immersion endoscopy with water replacement is effective for endoscopic hemostasis using electrocoagulation in difficult situations.
gastric access across a complete esophageal stenosis in a patient with a peptic stricture. A 74 year old female with history of progressive dysphagia underwent upper endoscopy with failed serial dilations. On repeat EGD, she was noted to have a complete esophageal stenosis preventing even wire passage for balloon dilation. Subsequent upper endoscopy using needle knife type dissection of the esophageal septum was attempted. Despite use of a nasal endoscope through the previously placed gastrostomy site, direct visualization of the needle knife type device from the gastric side could still not be accomplished. Using transillumination and ballottment from the stomach to identify an appropriate site for needle puncture, a 19-gauge needle was then passed under fluoroscopic guidance. However, the needle could still not be directly visualized to gain gastric access. Using a linear echoendoscope immediately proximal to the esophageal septum, ultrasound visualization was then performed using agitated saline injection into the gastric cardia via the previously placed nasal endoscope. A 19 gauge needle was successfully passed into the gastric cardia through the esophageal stenosis. Once access was achieved, a wire was passed into the stomach from the esophagus to maintain access. The linear echoendoscope was then exchanged over the wire for a standard gastroscope. Balloon dilation of the esophageal stenosis to 6mm was then performed and followed by placement of a small caliber (10mm) metal stent. The patient returned for repeat endoscopy several months later, at which time she noted significant improvement in swallowing and cough. Her stent was subsequently upsized to an 18.5mm metal esophageal stent resulting in further dilation of the esophageal stenosis. Subsequent endoscopy was performed for stent removal, at which time the distal esophagus was noted to be widely patent, permitting passage of a standard gastroscope. This case highlights the utility of EUS as a modality to permit safe and efficient gastric access during difficult esophageal rendezvous.
Lolli-Polyp: Demonstration of Two Methods for Removal of Retained Endoclips Brian S. Lim*1,2, Priyanka Yaramada2, Agathon Girgis2 1 Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, CA; 2University of California, Riverside, School of Medicine, Riverside, CA
Managing Choledocholithiasis after Gastric Bypass: Laparoscopic Transgastric ERCP Russell Kirks*1, Imran Siddiqui1, Erin Baker1, Stephen Deal2, Ryan Swan1, John Martinie1, David A. Iannitti1, Dionisios Vrochides1 1 Department of General Surgery, Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Charlotte, NC; 2Carolinas Digestive Health Associates, PA, Charlotte, NC
Case: 72 year old female presented for surveillance colonoscopy. Prior colonoscopy was performed by another physician one year prior. Patient was told a polyp was resected and that a repeat exam was needed in one year. Colonoscopy revealed a retained endoclip in ascending colon and polypoid growth at the base. Endoscopic Methods: We used endoscopic mucosal resection (EMR) technique for the removal of this polyp-clip complex. Submucosal injection was performed to raise this complex then resected with snare en-bloc. New endoclips were placed due to bleeding. This polyp-clip complex had the appearance of a lollipop and the handle of this ‘lollipolyp’ could be easily grabbed with snare to accomplish retrieval and continued visualization of rest of the colon simultaneously. During withdrawal, we encountered another polyp. The lolli-polyp was dropped from snare and polyp was resected. The handle of lolli-polyp was picked up again for continued withdrawal. Pathology showed tubulovillous adenoma. Colonoscopy was repeated in 3 months. Two endoclips were still in place. Forceps were used to pull the endoclips off. This allowed for thorough biopsies of the base of previous EMR site; pathology was negative for adenoma. Discussion: Spontaneous sloughing of endoclips have been reported to occur at approximately 18 to 35 days depending on the design [1, 2]. However, a clip can still be retained after a few years [3]. A retrospective review of endoclip retention after EMR showed clip retention in 6/63 EMR cases at follow up colonoscopy in 3 to 6 months [4]. Removal of endoclips may be needed in following scenarios: (1) need for magnetic resonance imaging, (2) deployment in suboptimal location, (3) interference with other forms of hemostasis (e.g multipolar electrocautery probes or additional endoclips) for continued bleeding, (4) need for further biopsies and/or lesion removal underneath the clip(s). If detachment of endoclips is needed but there is no urgency, one can choose to wait for natural dislodgement. If the clips have to be taken off more urgently, removal with a foreign body grasper/forceps has been traditionally performed. Our video demonstrates removal by using EMR technique. This method is particularly useful if there is a lesion underneath the retained clip that needs to be resected. Based on the literature, intentional removal of endoclips has minimal risk [1, 5]. References: 1. Chuttani R, et al. Gastrointest Endosc 2006;63:746-50. 2. Shin EJ, et al. Gastrointest Endosc 2007;66:757-61. 3. Ooi BP, et al. Gastrointest Endosc 2010;72:1315-1316. 4. Chen WC, et al. Gastrointest Endosc 2013;77(5S):AB547. 5. Ginsberg GG, et al. Gastrointest Endosc 1994;40:220-2.
EUS guided esophageal rendezvous in a patient with complete obstruction due to a peptic stricture Dushant S. Uppal*, Daniel S. Strand, Bryan G. Sauer, Andrew Y. Wang, Vanessa M. Shami, James A. Mann University of Virginia, Charlottesville, VA Advanced endoscopic techniques to obtain gastric access across a complete esophageal obstruction due to peptic structuring have previously been described. We present the case of an endoscopic ultrasound guided esophageal rendezvous for
www.giejournal.org
Post-surgical anatomy poses an obstacle to the endoscopic management of choledocholithiasis in patients with a history of Roux-en-Y gastric bypass (RYBG). Multiple methods exist for access to the biliary tree in patients with history of RYGB and their utilization depends on surgeon preference and expertise, available consultant resources, and facility availability. Methods for access to the biliary tree in these patients include percutaneous transhepatic cholangiography (PTC), percutaneous access to the gastric remnant for ERCP, open or laparoscopic common bile duct exploration, laparoscopic-assisted transjejunal ERCP, double balloon enteroscopy for ERCP, and laparoscopic-assisted transgastric ERCP. Depending on patient-specific factors including the presence or severity of cholangitis, a combination of these approaches may be selectively employed for management of post-RYGB choledocholithiasis. The case presented is that of a 39 year old female with history of laparoscopic Roux-en-Y gastric bypass who presented with choledocholithiasis without significant intrahepatic biliary dilatation on transabdominal ultrasound. Neither chemical pancreatitis nor leukocytosis was detected, decreasing concern for biliary pancreatitis and cholangitis, respectively. In concert with the advanced endoscopy service, she underwent a laparoscopic-assisted transgastric ERCP via the gastric remnant with endoscopic sphincterotomy and ductal clearance; laparoscopic cholecystectomy was performed concomitantly. The laparoscopic-assisted approached described accomplishes several goals. In the setting of postoperative adhesions, it allows for mobilization of the gastric remnant and visually-guided placement of a gastric trocar through which ERCP can be performed. Technically, this is performed by laparoscopically placing gastric sutures and then passing the sutures through the abdominal wall to oppose the stomach to the abdominal wall for intra-gastric trocar placement. The laparoscopic approach also allows for cholecystectomy to remove the source of future choledocholithiasis. Should a distal biliary stricture be identified that is not amenable to endoscopic treatment, a laparoscopic biliary bypass can also be performed. Unlike PTC, transgastric ERCP includes ampullary evaluation and endoscopic treatment if needed. This laparoscopic-assisted endoscopic approach to the management of post-RYGB biliary disease allows for a full range of diagnostic and therapeutic modalities performed through surgical and gastroenterological cooperation.
The Endoscopic Zenker’s Diverticulotomy Toolbox Andrew C. Storm*1, Todd H. Baron2, Anna S. Griffith2, Hiroyuki Aihara1, Allison Schulman1, Christopher C. Thompson1 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2University of North Carolina, Chapel Hill, NC Background/Cases: Flexible endoscopic Zenker’s diverticulotomy is a safe and effective procedure for the management of a symptomatic Zenker’s diverticulum. Several tools are now available to perform this procedure including scope cap, various knives, clips and coagulation graspers. Novel cutting devices are also under pre-FDA evaluation for endoscopic use. This video reviews 3 cases of endoscopic Zenker’s diverticulotomy, showing the tools used and management of common adverse
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB639
gastric access across a complete esophageal stenosis in a patient with a peptic stricture. A 74 year old female with history of progressive dysphagia underwent upper endoscopy with failed serial dilations. On repeat EGD, she was noted to have a complete esophageal stenosis preventing even wire passage for balloon dilation. Subsequent upper endoscopy using needle knife type dissection of the esophageal septum was attempted. Despite use of a nasal endoscope through the previously placed gastrostomy site, direct visualization of the needle knife type device from the gastric side could still not be accomplished. Using transillumination and ballottment from the stomach to identify an appropriate site for needle puncture, a 19-gauge needle was then passed under fluoroscopic guidance. However, the needle could still not be directly visualized to gain gastric access. Using a linear echoendoscope immediately proximal to the esophageal septum, ultrasound visualization was then performed using agitated saline injection into the gastric cardia via the previously placed nasal endoscope. A 19 gauge needle was successfully passed into the gastric cardia through the esophageal stenosis. Once access was achieved, a wire was passed into the stomach from the esophagus to maintain access. The linear echoendoscope was then exchanged over the wire for a standard gastroscope. Balloon dilation of the esophageal stenosis to 6mm was then performed and followed by placement of a small caliber (10mm) metal stent. The patient returned for repeat endoscopy several months later, at which time she noted significant improvement in swallowing and cough. Her stent was subsequently upsized to an 18.5mm metal esophageal stent resulting in further dilation of the esophageal stenosis. Subsequent endoscopy was performed for stent removal, at which time the distal esophagus was noted to be widely patent, permitting passage of a standard gastroscope. This case highlights the utility of EUS as a modality to permit safe and efficient gastric access during difficult esophageal rendezvous.
Lolli-Polyp: Demonstration of Two Methods for Removal of Retained Endoclips Brian S. Lim*1,2, Priyanka Yaramada2, Agathon Girgis2 1 Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, CA; 2University of California, Riverside, School of Medicine, Riverside, CA
Managing Choledocholithiasis after Gastric Bypass: Laparoscopic Transgastric ERCP Russell Kirks*1, Imran Siddiqui1, Erin Baker1, Stephen Deal2, Ryan Swan1, John Martinie1, David A. Iannitti1, Dionisios Vrochides1 1 Department of General Surgery, Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Charlotte, NC; 2Carolinas Digestive Health Associates, PA, Charlotte, NC
Case: 72 year old female presented for surveillance colonoscopy. Prior colonoscopy was performed by another physician one year prior. Patient was told a polyp was resected and that a repeat exam was needed in one year. Colonoscopy revealed a retained endoclip in ascending colon and polypoid growth at the base. Endoscopic Methods: We used endoscopic mucosal resection (EMR) technique for the removal of this polyp-clip complex. Submucosal injection was performed to raise this complex then resected with snare en-bloc. New endoclips were placed due to bleeding. This polyp-clip complex had the appearance of a lollipop and the handle of this ‘lollipolyp’ could be easily grabbed with snare to accomplish retrieval and continued visualization of rest of the colon simultaneously. During withdrawal, we encountered another polyp. The lolli-polyp was dropped from snare and polyp was resected. The handle of lolli-polyp was picked up again for continued withdrawal. Pathology showed tubulovillous adenoma. Colonoscopy was repeated in 3 months. Two endoclips were still in place. Forceps were used to pull the endoclips off. This allowed for thorough biopsies of the base of previous EMR site; pathology was negative for adenoma. Discussion: Spontaneous sloughing of endoclips have been reported to occur at approximately 18 to 35 days depending on the design [1, 2]. However, a clip can still be retained after a few years [3]. A retrospective review of endoclip retention after EMR showed clip retention in 6/63 EMR cases at follow up colonoscopy in 3 to 6 months [4]. Removal of endoclips may be needed in following scenarios: (1) need for magnetic resonance imaging, (2) deployment in suboptimal location, (3) interference with other forms of hemostasis (e.g multipolar electrocautery probes or additional endoclips) for continued bleeding, (4) need for further biopsies and/or lesion removal underneath the clip(s). If detachment of endoclips is needed but there is no urgency, one can choose to wait for natural dislodgement. If the clips have to be taken off more urgently, removal with a foreign body grasper/forceps has been traditionally performed. Our video demonstrates removal by using EMR technique. This method is particularly useful if there is a lesion underneath the retained clip that needs to be resected. Based on the literature, intentional removal of endoclips has minimal risk [1, 5]. References: 1. Chuttani R, et al. Gastrointest Endosc 2006;63:746-50. 2. Shin EJ, et al. Gastrointest Endosc 2007;66:757-61. 3. Ooi BP, et al. Gastrointest Endosc 2010;72:1315-1316. 4. Chen WC, et al. Gastrointest Endosc 2013;77(5S):AB547. 5. Ginsberg GG, et al. Gastrointest Endosc 1994;40:220-2.
EUS guided esophageal rendezvous in a patient with complete obstruction due to a peptic stricture Dushant S. Uppal*, Daniel S. Strand, Bryan G. Sauer, Andrew Y. Wang, Vanessa M. Shami, James A. Mann University of Virginia, Charlottesville, VA Advanced endoscopic techniques to obtain gastric access across a complete esophageal obstruction due to peptic structuring have previously been described. We present the case of an endoscopic ultrasound guided esophageal rendezvous for
www.giejournal.org
Post-surgical anatomy poses an obstacle to the endoscopic management of choledocholithiasis in patients with a history of Roux-en-Y gastric bypass (RYBG). Multiple methods exist for access to the biliary tree in patients with history of RYGB and their utilization depends on surgeon preference and expertise, available consultant resources, and facility availability. Methods for access to the biliary tree in these patients include percutaneous transhepatic cholangiography (PTC), percutaneous access to the gastric remnant for ERCP, open or laparoscopic common bile duct exploration, laparoscopic-assisted transjejunal ERCP, double balloon enteroscopy for ERCP, and laparoscopic-assisted transgastric ERCP. Depending on patient-specific factors including the presence or severity of cholangitis, a combination of these approaches may be selectively employed for management of post-RYGB choledocholithiasis. The case presented is that of a 39 year old female with history of laparoscopic Roux-en-Y gastric bypass who presented with choledocholithiasis without significant intrahepatic biliary dilatation on transabdominal ultrasound. Neither chemical pancreatitis nor leukocytosis was detected, decreasing concern for biliary pancreatitis and cholangitis, respectively. In concert with the advanced endoscopy service, she underwent a laparoscopic-assisted transgastric ERCP via the gastric remnant with endoscopic sphincterotomy and ductal clearance; laparoscopic cholecystectomy was performed concomitantly. The laparoscopic-assisted approached described accomplishes several goals. In the setting of postoperative adhesions, it allows for mobilization of the gastric remnant and visually-guided placement of a gastric trocar through which ERCP can be performed. Technically, this is performed by laparoscopically placing gastric sutures and then passing the sutures through the abdominal wall to oppose the stomach to the abdominal wall for intra-gastric trocar placement. The laparoscopic approach also allows for cholecystectomy to remove the source of future choledocholithiasis. Should a distal biliary stricture be identified that is not amenable to endoscopic treatment, a laparoscopic biliary bypass can also be performed. Unlike PTC, transgastric ERCP includes ampullary evaluation and endoscopic treatment if needed. This laparoscopic-assisted endoscopic approach to the management of post-RYGB biliary disease allows for a full range of diagnostic and therapeutic modalities performed through surgical and gastroenterological cooperation.
The Endoscopic Zenker’s Diverticulotomy Toolbox Andrew C. Storm*1, Todd H. Baron2, Anna S. Griffith2, Hiroyuki Aihara1, Allison Schulman1, Christopher C. Thompson1 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2University of North Carolina, Chapel Hill, NC Background/Cases: Flexible endoscopic Zenker’s diverticulotomy is a safe and effective procedure for the management of a symptomatic Zenker’s diverticulum. Several tools are now available to perform this procedure including scope cap, various knives, clips and coagulation graspers. Novel cutting devices are also under pre-FDA evaluation for endoscopic use. This video reviews 3 cases of endoscopic Zenker’s diverticulotomy, showing the tools used and management of common adverse
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB639