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Sp275: Endoscopic Submucosal Dissection (ESD) of a Giant Rectal Adenoma (15X10 cm) Using a Flush-Knife
Abstracts encountered. The resistance was due to a high grade ileal stricture. This could be an ileo-ileal anastamotic stricture or an inflammatory stricture due to chronically lodged gallstone in the ileum. The ileal stricture was successfully balloon dilated serially from 12 to 18 mm. Once double balloon enteroscope successfully traversed the dilated stricture, a large stone was visualized in immediate proximity. The size of the stone was deemed relatively large to be easily extracted through the freshly dilated high grade stricture. Stone fragmentation was performed with combination of electrohydraulic and mechanical lithotriptor, resulting in successful extraction of stone fragments across the stricture. Clinical implications: This case illustrates further expansion of therapeutic armentorium of the double balloon enteroscopy. This is a reasonable less invasive option in any patients with gallstone ileus, especially those who are high risk surgical candidates.
Sp275 Endoscopic Submucosal Dissection (ESD) of a Giant Rectal Adenoma (15X10 cm) Using a Flush-Knife Dimitri Coumaros*, T. Toyonaga, M. Man Background: Our objective is to demonstrate the usefulness of the Flush-knife (Fujinon) in an ESD of a tumor spreading over 8/10ths of the rectum, creating a 1.5cm large mucosal strip on the posterior surface, in a 75-year-old man. Endoscopic methods: A colonoscope with a 11.3mm diameter (EC 530 MP Fujinon), a 4mm distal cap, a generator (VIO 200 ERBE), a grasper (Coagrasper, Olympus) for Soft coagulation, effect (E) 5, 100 W, a 1.5mm long Flush-knife, a pump (JW-2, Fujinon), were used to incise the mucosa with Endocut current I, E 2, interval 3, duration 3, and for the dissection of the submucosa, a Forced coagulation, E 2, 40 W. CO2 was insufflated (CO2 Efficient, EZEM). Clinical implications: Serum saline, then hyaluronic acid were injected submucosally with a 23 G needle. After incising with the Flush-knife, the serum saline was injected with the same knife. The incision and the dissection were started at the anorectal junction, hence separating the lesion from the mucosal strip. Tunnelization made the vessels appear. Their coagulation was performed with the Flush-knife or the grasper. To allow the dissection and know where it should be ended, a gradual incision of the lesion’s superior margin was performed. The procedure was achieved within 4 hours and a half. The lesion removed en bloc was a tubulovillous and serrated adenoma presenting with a focal high-grade dysplasia. The resection margins were healthy. During the following 6 months, 3 balloon dilatations of a low rectal stenosis were performed. No recurrence was identified.
Sp276 Endoscopic Rendezvous for Complete Colonic Obstruction Evan B. Grossman*, Mark Schattner, Christopher J. DiMaio, Hans Gerdes, W. Douglas Wong, Arnold J. Markowitz Background: A 50 year old man with metastatic rectal cancer to the liver underwent a diverting transverse loop colostomy due to rectal obstruction. The patient requested resection of his rectal tumor due to difficulty managing his ostomy because of congenital blindness. Sixteen months after his previous surgery, he underwent a low anterior resection, reversal of his transverse colostomy, and creation of a temporary loop ileostomy. Six months later, prior to his ileostomy takedown, a barium enema showed a widely patent rectal anastomosis. The patient was brought to the operating room for closure of his ileostomy. On post-operative day four, the patient developed nausea, vomiting, and abdominal distention. Abdominal imaging revealed a large bowel obstruction. A colonoscopy revealed an obstruction at the previous transverse colostomy site. The patient declined surgical diversion due to difficulty caring for his previous ostomy. Endoscopic methods: A rendezvous (antegrade-retrograde colonoscopy) was performed. A colonoscope was inserted through the rectum and advanced to the site of obstruction. A previously placed cecostomy tube was removed, and an ultra-slim gastroscope was inserted through the cecostomy fistula. Direct transillumination of both endoscopes was visualized across the obstructing mucosa. A Savary guidewire was used to pierce through the obstructing mucosa. Balloon dilation was then performed, resolving the obstruction. Clinical implications: A complete large bowel obstruction was resolved endoscopically, obviating the need for surgery.
Sp277 Image Guided Technology in Endoscopy Keith L. Obstein*, Jayender J, Patil VD, San Jose-Estepar R, Spofford IS, Lengyel BI, Ryan MB, Vosburgh KG, Thompson CC Background: Image guided technologies allow for integration of imaging modalities and interventional procedures. Image guidance has been utilized in the fields of neurosurgery, general surgery and surgical oncology. Until now, image guided intervention has been limited to non-flexible surgical tools. This technology has been modified for several potential endoscopic applications including training in EUS, ERCP, NOTES, and colonoscopy as well as serving as
AB100 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
a reference during complex therapeutic procedures. Endoscopic methods: Preprocedure radiologic images from patients are obtained and a computer generated 3D reconstruction is constructed. A miniature probe is attached to the tip of a standard endoscope and a transmitter is placed under the patient. Endoscope coordinates are processed by the computer that then displays in real time the composite image of the 3D model with endoscope position, radiologic image, and ultrasound/fluoroscopic image (if performing EUS or ERCP). As the endoscopist moves the endoscope, the radiologic image(s) and 3D model move through the body as one. Clinical implications: The use of image guided technologies in endoscopy have the potential to enhance patient safety and endoscopist efficiency. The technology may be beneficial in a variety of endoscopic applications including EUS, ERCP, colonoscopy, and NOTES. Image guidance may shorten trainee learning curves, serve as a reference during complex therapeutic procedures, allow for visualization when certain endoscopic conditions are suboptimal (such as calcifications or artifacts in EUS), and improve intraoperative patient management.
Sp278 New Techniques in Gastrointestinal Hemostasis Sohail N. Shaikh*, Marvin Ryou, Dan E. Azagury, Christopher C. Thompson Background: Gastrointestinal bleeding accounts for over 500,000 hospitalizations annually in the U.S. and carries significant morbidity and mortality. Various methods and techniques have been developed to enhance endoscopic hemostasis, however, there has been little change in overall outcome in recent decades. Endoscopic methods: New devices for hemorrhage control are currently under development, including: memory clips; flexible suturing devices; high compression cautery; injectable polymers; and telecommunicating biosensors. These are discussed in detail. Clinical implications: These new hemostatic devices may extend endsocopic therapy to new populations and have the ability to improve outcomes in the management of GI bleeding.
Sp279 Endoscopic Management of an Infected Pseudocyst with Cystgastrostomy and Necrosectomy Without EUS Guidance Vinay Chandraesekhara*, Patrick I. Okolo III Background: Treatment of pancreatic pseudocysts has historically been managed by surgeons; however, endoscopic drainage of pancreatic pseudocysts by expert endoscopists has become an accepted alternative to surgery when an intervention is indicated. Endoscopic Ultrasound is often used to guide pseudocyst drainage. We present a case of a large pseudocyst with obvious compression of the gastric wall that was effectively managed with needle-knife decompression, cystgastrostomy and necrosectomy. Endoscopic methods: Kneedle-knife incision of the gastric wall and cystgastrostomy formation. Endoscopic necrosectomy with debridement of pancreatic necrosis. Clinical implications: Endoscopic cystgastrostomy and endoscopic debridement of pancreatic necrosis is an alternative, less invasive treatment option for the management of pancreatic pseudocysts.
Sp281 Endoscopic Management of Pancreaticojejunostomy Strictures Brett J. Partridge*, Jeffrey L. Tokar, Stephen J. Heller, Jonathan Kennish, Oleh Haluszka Background: Pancreaticojejunostomy strictures occur in a minority of patients following a pancreaticoduodenectomy (Whipple procedure), but, when encountered, are a challenging complication frequently managed surgically. We report two cases that demonstrate our strategy for endoscopic management of pancreaticojejunostomy strictures. Case 1: The patient is a 37 year-old woman referred for chronic relapsing abdominal pain 3 years after a Whipple for Intraductal Papillary Mucinous Neoplasm. At ERCP, a stenotic pancreaticojejunostomy orifice was identified within the afferent limb. Access to the pancreatic duct could only be obtained using a metal stent retriever with a threaded tip. Subsequent pancreatic stent placement resulted in clinical improvement. Case 2: The patient is a 73 year-old woman with recurrent pancreatitis 4 years after a Whipple for a neuroendocrine tumor. The stenotic pancreaticojejunostomy anastomosis could not be identified at ERCP. Successful endoscopic therapy was achieved using transgastric EUS and double-balloon endoscopy, resulting in symptom resolution. Endoscopic methods: Initial endoscopy is performed via device-assisted enteroscopy to attempt to visualize the desired anastomosis. If the anastomosis is identified, traditional ERCP techniques are utilized. If the anastomosis cannot be identified, EUS-guided pancreatic duct access is achieved. Subsequent endoscopic therapies are delivered using the echoendoscope and device-assisted enteroscope under fluoroscopy. Clinical implications: Pancreaticojejunostomy strictures are a challenging late complication of the Whipple procedure. Historically, most cases
www.giejournal.org
Sp275 Endoscopic Submucosal Dissection (ESD) of a Giant Rectal Adenoma (15X10 cm) Using a Flush-Knife Dimitri Coumaros*, T. Toyonaga, M. Man Background: Our objective is to demonstrate the usefulness of the Flush-knife (Fujinon) in an ESD of a tumor spreading over 8/10ths of the rectum, creating a 1.5cm large mucosal strip on the posterior surface, in a 75-year-old man. Endoscopic methods: A colonoscope with a 11.3mm diameter (EC 530 MP Fujinon), a 4mm distal cap, a generator (VIO 200 ERBE), a grasper (Coagrasper, Olympus) for Soft coagulation, effect (E) 5, 100 W, a 1.5mm long Flush-knife, a pump (JW-2, Fujinon), were used to incise the mucosa with Endocut current I, E 2, interval 3, duration 3, and for the dissection of the submucosa, a Forced coagulation, E 2, 40 W. CO2 was insufflated (CO2 Efficient, EZEM). Clinical implications: Serum saline, then hyaluronic acid were injected submucosally with a 23 G needle. After incising with the Flush-knife, the serum saline was injected with the same knife. The incision and the dissection were started at the anorectal junction, hence separating the lesion from the mucosal strip. Tunnelization made the vessels appear. Their coagulation was performed with the Flush-knife or the grasper. To allow the dissection and know where it should be ended, a gradual incision of the lesion’s superior margin was performed. The procedure was achieved within 4 hours and a half. The lesion removed en bloc was a tubulovillous and serrated adenoma presenting with a focal high-grade dysplasia. The resection margins were healthy. During the following 6 months, 3 balloon dilatations of a low rectal stenosis were performed. No recurrence was identified.
Sp276 Endoscopic Rendezvous for Complete Colonic Obstruction Evan B. Grossman*, Mark Schattner, Christopher J. DiMaio, Hans Gerdes, W. Douglas Wong, Arnold J. Markowitz Background: A 50 year old man with metastatic rectal cancer to the liver underwent a diverting transverse loop colostomy due to rectal obstruction. The patient requested resection of his rectal tumor due to difficulty managing his ostomy because of congenital blindness. Sixteen months after his previous surgery, he underwent a low anterior resection, reversal of his transverse colostomy, and creation of a temporary loop ileostomy. Six months later, prior to his ileostomy takedown, a barium enema showed a widely patent rectal anastomosis. The patient was brought to the operating room for closure of his ileostomy. On post-operative day four, the patient developed nausea, vomiting, and abdominal distention. Abdominal imaging revealed a large bowel obstruction. A colonoscopy revealed an obstruction at the previous transverse colostomy site. The patient declined surgical diversion due to difficulty caring for his previous ostomy. Endoscopic methods: A rendezvous (antegrade-retrograde colonoscopy) was performed. A colonoscope was inserted through the rectum and advanced to the site of obstruction. A previously placed cecostomy tube was removed, and an ultra-slim gastroscope was inserted through the cecostomy fistula. Direct transillumination of both endoscopes was visualized across the obstructing mucosa. A Savary guidewire was used to pierce through the obstructing mucosa. Balloon dilation was then performed, resolving the obstruction. Clinical implications: A complete large bowel obstruction was resolved endoscopically, obviating the need for surgery.
Sp277 Image Guided Technology in Endoscopy Keith L. Obstein*, Jayender J, Patil VD, San Jose-Estepar R, Spofford IS, Lengyel BI, Ryan MB, Vosburgh KG, Thompson CC Background: Image guided technologies allow for integration of imaging modalities and interventional procedures. Image guidance has been utilized in the fields of neurosurgery, general surgery and surgical oncology. Until now, image guided intervention has been limited to non-flexible surgical tools. This technology has been modified for several potential endoscopic applications including training in EUS, ERCP, NOTES, and colonoscopy as well as serving as
AB100 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
a reference during complex therapeutic procedures. Endoscopic methods: Preprocedure radiologic images from patients are obtained and a computer generated 3D reconstruction is constructed. A miniature probe is attached to the tip of a standard endoscope and a transmitter is placed under the patient. Endoscope coordinates are processed by the computer that then displays in real time the composite image of the 3D model with endoscope position, radiologic image, and ultrasound/fluoroscopic image (if performing EUS or ERCP). As the endoscopist moves the endoscope, the radiologic image(s) and 3D model move through the body as one. Clinical implications: The use of image guided technologies in endoscopy have the potential to enhance patient safety and endoscopist efficiency. The technology may be beneficial in a variety of endoscopic applications including EUS, ERCP, colonoscopy, and NOTES. Image guidance may shorten trainee learning curves, serve as a reference during complex therapeutic procedures, allow for visualization when certain endoscopic conditions are suboptimal (such as calcifications or artifacts in EUS), and improve intraoperative patient management.
Sp278 New Techniques in Gastrointestinal Hemostasis Sohail N. Shaikh*, Marvin Ryou, Dan E. Azagury, Christopher C. Thompson Background: Gastrointestinal bleeding accounts for over 500,000 hospitalizations annually in the U.S. and carries significant morbidity and mortality. Various methods and techniques have been developed to enhance endoscopic hemostasis, however, there has been little change in overall outcome in recent decades. Endoscopic methods: New devices for hemorrhage control are currently under development, including: memory clips; flexible suturing devices; high compression cautery; injectable polymers; and telecommunicating biosensors. These are discussed in detail. Clinical implications: These new hemostatic devices may extend endsocopic therapy to new populations and have the ability to improve outcomes in the management of GI bleeding.
Sp279 Endoscopic Management of an Infected Pseudocyst with Cystgastrostomy and Necrosectomy Without EUS Guidance Vinay Chandraesekhara*, Patrick I. Okolo III Background: Treatment of pancreatic pseudocysts has historically been managed by surgeons; however, endoscopic drainage of pancreatic pseudocysts by expert endoscopists has become an accepted alternative to surgery when an intervention is indicated. Endoscopic Ultrasound is often used to guide pseudocyst drainage. We present a case of a large pseudocyst with obvious compression of the gastric wall that was effectively managed with needle-knife decompression, cystgastrostomy and necrosectomy. Endoscopic methods: Kneedle-knife incision of the gastric wall and cystgastrostomy formation. Endoscopic necrosectomy with debridement of pancreatic necrosis. Clinical implications: Endoscopic cystgastrostomy and endoscopic debridement of pancreatic necrosis is an alternative, less invasive treatment option for the management of pancreatic pseudocysts.
Sp281 Endoscopic Management of Pancreaticojejunostomy Strictures Brett J. Partridge*, Jeffrey L. Tokar, Stephen J. Heller, Jonathan Kennish, Oleh Haluszka Background: Pancreaticojejunostomy strictures occur in a minority of patients following a pancreaticoduodenectomy (Whipple procedure), but, when encountered, are a challenging complication frequently managed surgically. We report two cases that demonstrate our strategy for endoscopic management of pancreaticojejunostomy strictures. Case 1: The patient is a 37 year-old woman referred for chronic relapsing abdominal pain 3 years after a Whipple for Intraductal Papillary Mucinous Neoplasm. At ERCP, a stenotic pancreaticojejunostomy orifice was identified within the afferent limb. Access to the pancreatic duct could only be obtained using a metal stent retriever with a threaded tip. Subsequent pancreatic stent placement resulted in clinical improvement. Case 2: The patient is a 73 year-old woman with recurrent pancreatitis 4 years after a Whipple for a neuroendocrine tumor. The stenotic pancreaticojejunostomy anastomosis could not be identified at ERCP. Successful endoscopic therapy was achieved using transgastric EUS and double-balloon endoscopy, resulting in symptom resolution. Endoscopic methods: Initial endoscopy is performed via device-assisted enteroscopy to attempt to visualize the desired anastomosis. If the anastomosis is identified, traditional ERCP techniques are utilized. If the anastomosis cannot be identified, EUS-guided pancreatic duct access is achieved. Subsequent endoscopic therapies are delivered using the echoendoscope and device-assisted enteroscope under fluoroscopy. Clinical implications: Pancreaticojejunostomy strictures are a challenging late complication of the Whipple procedure. Historically, most cases
www.giejournal.org