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Migrated Esophageal Stent Retrieved Via Oral Double Balloon Enteroscopy
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
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