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V.02.7 INCIDENTAL ENDOSONOGRAPHIC FINDING OF AN INTRA-CARDIAC MASS IN AN ASYMPTOMATIC PATIENT (VIDEO)
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Abstracts of the 20th National Congress of Digestive Diseases / Digestive and Liver Disease 46S (2014) S1–S144
V.02.7
V.02.9
INCIDENTAL ENDOSONOGRAPHIC FINDING OF AN INTRA-CARDIAC MASS IN AN ASYMPTOMATIC PATIENT (VIDEO)
ENDOSCOPIC TREATMENT OF A COLONIC PERFORATION AFTER PEG INSERTION
C.G. De Angelis ∗ , S.F. Manfrè, M. Bruno, P. Carucci, S. Gaia, M. Rizzetto
M. Rossi ∗ , M. Motter, G. Ghezzi, F. Armelao, C. Tieppo, G. Franceschini, R. Fasoli, R. Nienstedt, D. Giacomin, G. Depretis
Città della Salute e della Scienza, Turin, Italy
Ospedale S.Chiara, Trento, Italy
Background and aim: The patient, C.A., is a 75 years old male, referred to our centre for abdominal pain and a CT finding of a pancreatic cystic lesion. No cardiac or pulmonary symptoms. The previous medical history was mute except for arterial hypertension. Material and methods: The procedure was performed in deep sedation (Propofol e.v.), with a linear echoendoscope (Olympus GF-UCT 140 AL5). Results: The endosonographic finding was consistent with a small (2 cm) Intraductal Papillary Mucinous Neoplasia in the pancreatic head. On withdrawing the echoendoscope in the mediastinum, a homogeneous hyperechoic, 17 x 14 mm lesion was observed adherent to the left atrium wall. To distinguish between atrial thrombus and myxoma, the patient underwent Magnetic Resonance Imaging that diagnosed the presence of an atrial myxoma. Conclusions: Endoscopic Ultra Sound can sometimes incidentally discover diseases outside the gastro-intestinal tract that can significantly impact on patient management. In this subject the exploration of the mediastinum allowed to diagnose an otherwise undetected pathologic cardiac condition.
Background and aim: PEG (percutaneous endoscopic gastrostomy) is a validated method to ensure an enteral nutrition in disphagic patients. Material and methods: We describe a case of a rare late complication of PEG insertion, consisting in the occurrence of a colonic perforation by the PEG tube. We also show how the complication was successfully treated by mean of different endoscopic procedures. Results: In December 2009 a 78 years old man had a severe brain damage which caused a neurogenic dysphagia. For this reason he was fed through a naso-gastric tube until March 2010, when he underwent a PEG tube insertion with the pull method. Three months later, some spots of stools leaking from the cutaneous fistula were observed. A computer tomography of the abdomen showed the PEG tube crossing the transverse colon. A colonoscopy confirmed the abnormal placement of the PEG, that was endoscopically removed through the mouth. The gastrocolic fistula was subsequently closed at the gastric side by mean of multiple clips and a colostomic bag was applied. Due to persistence of stool leakege, a second colonoscopy allowed the positioning of multiple clips and injection of fibrin glue at the colonic side. Due to persistent disphagia, a new PEG was inserted approximately three months later. The second PEG procedure was complicated by the occurrence of a mild attack of acute pancreatitis, possibly secondary to the direct trauma caused by the needle used during the PEG insertion. Conclusions: 1) Colonic perforation by a PEG tube can be asymptomatic for a long period. 2) This type of complication can be successfully treated through endoscopic procedures, avoiding surgery. 3) Acute pancreatitis could be a complication of PEG insertion, possibly due to direct trauma by the needle employed during the insertion. 4) A second PEG can be successfully inserted in this type of circumstances.
V.02.8 LOOP-AND-LET-GO TECHNIQUE FOR OBSTRUCTING LIPOMA OF THE HEPATIC FLEXURE A. Salvai ∗ , M. Verra, M.A. Bonino, S. Arolfo, M. Bruno, C. De Angelis, A. Arezzo, M. Morino Dipartimento di Scienze Chirurgiche, Università di Torino, Torino, Italy Background and aim: We present the case of a 77 year old woman who came to the emergency department complaining of bowel obstruction in the last 3 days, and alternating bowel in the last weeks. Material and methods: After x-Rays confirmed the presence of ileal air-fluid levels, she performed a CT scan with virtual colonoscopy reconstruction which showed the presence of a lesion at the hepatic flexure completely obstructing the lumen and a wide sessile rectal neoplasm covering more than half circumference of the lumen itself. The colonoscopy examination, performed in emergency, confirmed the lesion with a round shape and covered with mucosa partially necrotic and partially regular. We therefore decided to perform endoscopic ultrasonography with a miniprobe confirming the suspicion of lipoma without malignancy features. The lesion appeared to adhere for about half the circumference to the wall. Results: In consideration of the operative risk, due to the numerous comorbidities, we opted for a conservative treatment on the spot with a tie at the base of the lipoma by Endo-loop, with the intention of dropping the lipoma by necrosis, using the “loop-and-let-go” technique. Bowel movements restored in the immediate hours after treatment with the help of Poli-Ethilen Glicole solution. A new colonoscopy was performed at 2 weeks experiencing partial revascularization of the lesion, to which a second Endo-loop was affixed at its base. After some days the patient evacuated and recovered the tumor which was histologically confirmed a colonic lipoma. Conclusions: This case demonstrates the effectiveness of the technique of endoscopic ligation and fall in two times or “loop-and-let-go” even in case of obstruction.
V.02.10 ENDOSCOPIC RESECTION OF LARGE ANORECTAL ADENOMA T. Staiano ∗ , F. Buffoli, G. Bianchi, R. Grassia, E. Iiritano Azienda Ospedaliera “Istituti Ospitalieri di Cremona”, Cremona, Italy Background and aim: 61 year old woman came under our observation for the presence of tenesmus, and rectal bleeding by approximately 1 year. Total colonoscopy is performed founding at the distal rectum, upstream of the dentate line, a neoplastic lesion type LST, granular, large nodules (0-Is + IIa) to 40×30 mm; the pit pattern resulted hardly assessable, in spite of the study with chrome computerized virtual endoscopy (gastroscope, the Pentax EG 2990 - HD EPK) due to superficial congestion caused by trauma from repeated trans-anal prolapse. Material and methods: It has been proceeded to endoscopic resection with hook knife, starting from the anal margin after infiltration of lidocaine 5%. Subsequent completion of the resection has been proceeded with a snare (Captivator snare, Boston Scientific, 30 mm). The intra-procedural bleeding was controlled with coagrasper (Olympus, soft coag, effect 5, 60 W). Results: The histological examination of the surgical specimen deposed for a serrated adenoma with low-grade dysplasia, with confirmation of curative resection (lateral resection margins (>2 mm) and vertical (>0.5 mm) free of tumor (R0), no invasion lymphatic and/or venous). Conclusions: The endoscopic advanced resection provides a safe and efficient treatment for excision of large anorectal polyps and it must be considered as a valid alternative to traditional surgery and TEM. The video shows all the execution steps of the resection.
Abstracts of the 20th National Congress of Digestive Diseases / Digestive and Liver Disease 46S (2014) S1–S144
V.02.7
V.02.9
INCIDENTAL ENDOSONOGRAPHIC FINDING OF AN INTRA-CARDIAC MASS IN AN ASYMPTOMATIC PATIENT (VIDEO)
ENDOSCOPIC TREATMENT OF A COLONIC PERFORATION AFTER PEG INSERTION
C.G. De Angelis ∗ , S.F. Manfrè, M. Bruno, P. Carucci, S. Gaia, M. Rizzetto
M. Rossi ∗ , M. Motter, G. Ghezzi, F. Armelao, C. Tieppo, G. Franceschini, R. Fasoli, R. Nienstedt, D. Giacomin, G. Depretis
Città della Salute e della Scienza, Turin, Italy
Ospedale S.Chiara, Trento, Italy
Background and aim: The patient, C.A., is a 75 years old male, referred to our centre for abdominal pain and a CT finding of a pancreatic cystic lesion. No cardiac or pulmonary symptoms. The previous medical history was mute except for arterial hypertension. Material and methods: The procedure was performed in deep sedation (Propofol e.v.), with a linear echoendoscope (Olympus GF-UCT 140 AL5). Results: The endosonographic finding was consistent with a small (2 cm) Intraductal Papillary Mucinous Neoplasia in the pancreatic head. On withdrawing the echoendoscope in the mediastinum, a homogeneous hyperechoic, 17 x 14 mm lesion was observed adherent to the left atrium wall. To distinguish between atrial thrombus and myxoma, the patient underwent Magnetic Resonance Imaging that diagnosed the presence of an atrial myxoma. Conclusions: Endoscopic Ultra Sound can sometimes incidentally discover diseases outside the gastro-intestinal tract that can significantly impact on patient management. In this subject the exploration of the mediastinum allowed to diagnose an otherwise undetected pathologic cardiac condition.
Background and aim: PEG (percutaneous endoscopic gastrostomy) is a validated method to ensure an enteral nutrition in disphagic patients. Material and methods: We describe a case of a rare late complication of PEG insertion, consisting in the occurrence of a colonic perforation by the PEG tube. We also show how the complication was successfully treated by mean of different endoscopic procedures. Results: In December 2009 a 78 years old man had a severe brain damage which caused a neurogenic dysphagia. For this reason he was fed through a naso-gastric tube until March 2010, when he underwent a PEG tube insertion with the pull method. Three months later, some spots of stools leaking from the cutaneous fistula were observed. A computer tomography of the abdomen showed the PEG tube crossing the transverse colon. A colonoscopy confirmed the abnormal placement of the PEG, that was endoscopically removed through the mouth. The gastrocolic fistula was subsequently closed at the gastric side by mean of multiple clips and a colostomic bag was applied. Due to persistence of stool leakege, a second colonoscopy allowed the positioning of multiple clips and injection of fibrin glue at the colonic side. Due to persistent disphagia, a new PEG was inserted approximately three months later. The second PEG procedure was complicated by the occurrence of a mild attack of acute pancreatitis, possibly secondary to the direct trauma caused by the needle used during the PEG insertion. Conclusions: 1) Colonic perforation by a PEG tube can be asymptomatic for a long period. 2) This type of complication can be successfully treated through endoscopic procedures, avoiding surgery. 3) Acute pancreatitis could be a complication of PEG insertion, possibly due to direct trauma by the needle employed during the insertion. 4) A second PEG can be successfully inserted in this type of circumstances.
V.02.8 LOOP-AND-LET-GO TECHNIQUE FOR OBSTRUCTING LIPOMA OF THE HEPATIC FLEXURE A. Salvai ∗ , M. Verra, M.A. Bonino, S. Arolfo, M. Bruno, C. De Angelis, A. Arezzo, M. Morino Dipartimento di Scienze Chirurgiche, Università di Torino, Torino, Italy Background and aim: We present the case of a 77 year old woman who came to the emergency department complaining of bowel obstruction in the last 3 days, and alternating bowel in the last weeks. Material and methods: After x-Rays confirmed the presence of ileal air-fluid levels, she performed a CT scan with virtual colonoscopy reconstruction which showed the presence of a lesion at the hepatic flexure completely obstructing the lumen and a wide sessile rectal neoplasm covering more than half circumference of the lumen itself. The colonoscopy examination, performed in emergency, confirmed the lesion with a round shape and covered with mucosa partially necrotic and partially regular. We therefore decided to perform endoscopic ultrasonography with a miniprobe confirming the suspicion of lipoma without malignancy features. The lesion appeared to adhere for about half the circumference to the wall. Results: In consideration of the operative risk, due to the numerous comorbidities, we opted for a conservative treatment on the spot with a tie at the base of the lipoma by Endo-loop, with the intention of dropping the lipoma by necrosis, using the “loop-and-let-go” technique. Bowel movements restored in the immediate hours after treatment with the help of Poli-Ethilen Glicole solution. A new colonoscopy was performed at 2 weeks experiencing partial revascularization of the lesion, to which a second Endo-loop was affixed at its base. After some days the patient evacuated and recovered the tumor which was histologically confirmed a colonic lipoma. Conclusions: This case demonstrates the effectiveness of the technique of endoscopic ligation and fall in two times or “loop-and-let-go” even in case of obstruction.
V.02.10 ENDOSCOPIC RESECTION OF LARGE ANORECTAL ADENOMA T. Staiano ∗ , F. Buffoli, G. Bianchi, R. Grassia, E. Iiritano Azienda Ospedaliera “Istituti Ospitalieri di Cremona”, Cremona, Italy Background and aim: 61 year old woman came under our observation for the presence of tenesmus, and rectal bleeding by approximately 1 year. Total colonoscopy is performed founding at the distal rectum, upstream of the dentate line, a neoplastic lesion type LST, granular, large nodules (0-Is + IIa) to 40×30 mm; the pit pattern resulted hardly assessable, in spite of the study with chrome computerized virtual endoscopy (gastroscope, the Pentax EG 2990 - HD EPK) due to superficial congestion caused by trauma from repeated trans-anal prolapse. Material and methods: It has been proceeded to endoscopic resection with hook knife, starting from the anal margin after infiltration of lidocaine 5%. Subsequent completion of the resection has been proceeded with a snare (Captivator snare, Boston Scientific, 30 mm). The intra-procedural bleeding was controlled with coagrasper (Olympus, soft coag, effect 5, 60 W). Results: The histological examination of the surgical specimen deposed for a serrated adenoma with low-grade dysplasia, with confirmation of curative resection (lateral resection margins (>2 mm) and vertical (>0.5 mm) free of tumor (R0), no invasion lymphatic and/or venous). Conclusions: The endoscopic advanced resection provides a safe and efficient treatment for excision of large anorectal polyps and it must be considered as a valid alternative to traditional surgery and TEM. The video shows all the execution steps of the resection.