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1000 Adventures in the Gallbladder! Initial Experience of Advanced Gallbladder Interventions After Gallbladder Stenting
Abstracts
1000 Adventures in the Gallbladder! Initial Experience of Advanced Gallbladder Interventions After Gallbladder Stenting Shannon M. Chan*, Anthony Y. Teoh, Philip W. Chiu, Enders K. Ng, James Y. Lau General Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
Pathology of Non-Neoplastic Biopsies
998 Incision Therapy for an Unusual Esophageal Stricture Milan S. Bassan*1,2, Mohit P. Shetti1, Paul D. Edwards1, David Abi-Hanna1, Jenn Koo1,2 1 Gastroenterology and Hepatology, Liverpool Hospital, Liverpool, NSW, Australia; 2University of New South Wales, Sydney, NSW, Australia Introduction: Benign esophageal strictures are most commonly related to prolonged GERD, iatrogenic (post surgical, radiotherapy related or following endoscopic therapies) or caustic ingestion. Standard bougie or balloon based techniques are usually highly effective in achieving resolution of the stricture however some strictures may be refractory to these approaches and further intervention is required. CASE: A 39 year old male with progressive dysphagia to solids who could barely manage soft food at the time of initial presentation. He had a prolonged hospitalisation with typhoid in 1996 during which time he had significant odynophagia. There was no history of GERD, radiotherapy or caustic ingestion). He was found to have a severe benign proximal esophageal stricture that was refractory to both balloon and bougie dilation. Needle knife incision (NKI) therapy was successfully performed. Endoscopic Method: A series of linear incisions, perpendicular to the esophageal wall were made using a standard ERCP needle knife. Swift coag (Effect 3, 40W) was used for diathermy. The depth of incision was determined by using the esophageal wall distal to the stricture as the critical landmark. This technique has mainly been described in post-anastomotic strictures. In a randomized controlled trial similar outcomes were demonstrated with NKI and Savary bougienage. The risk or perforation has been reported as being low (1%-2%) but rates of restenosis have been reported as high as 50%. Clinical Implications: Needle knife incision therapy is a useful technique to treat benign esophageal strictures refractory to standard therapy. Typhoid is a rare cause of esophageal stricture formation but should be considered in the appropriate clinical context.
999 Endoscopic Treatment of a Refractory Esophageal Fistula Fernando P. Marson*, Kiyoshi Hashiba, Horus A. Brasil, Juliana Valenciano, Gisele D. Leite, Pablo R. Siqueira Serviço de Endoscopia Digestiva, Hospital Sirio Libanês, São Paulo, Brazil Background: A 53 y/o male underwent esophagostomy, gastrostomy and bilateral chest drainage for treatment of Boerhaave Syndrome. The patient was discharged one month later after closure of the gastrostomy and esophagostomy. As the patient advanced to a normal oral diet, he presented with progressive leakage of saliva at the esophagostomy scar. Endoscopic and radiologic findings revealed a 2 cm cervical esophageal fistula. Endoscopic Methods: Endoscopic treatment with clips, covered SEMS and acellular biomaterial plug were attempted without success. A technique based on the gastropexy used during PEG placement was used to approximate healthy tissue surrounding the fistula. Progressive decrease in the fistula output was observed in the following days. Ten days after the procedure a complete fistula closure was noted. Follow up after 6 months revealed no fistula recurrence. Clinical Implications: This technique allowed the successful closure of a refractory cervical esophageal fistula using basic endoscopic equipment.
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Background and Aims: Traditionally, endoscopy of the gallbladder is not possible. However, the recent development of endosonographic (EUS) - guided gallbladder drainage with a lumen apposing stent (AXIOS, Xlumena, USA) made endoscopic assessment and advanced gallbladder interventions via the stent possible. The aim of this study was to assess the feasibility and safety of cholecystoscopy and the types of interventions that can be performed in these patients. Methods: This was a retrospective review conducted in the Prince of Wales Hospital from 1st June, 2012 to 31st October 2014. All patients that suffered from acute cholecystitis with EUS-guided transgastric or transduodenal gallbladder drainage and placement of a lumen apposing stent (AXIOS, Xlumena, USA) were included. Cholecystoscopy was performed in these patients 3 months after insertion to check for clearance of stones and removal of stent. Patients’ demographic data, the feasibility, complications and types of intervention were recorded. Results: 17 patients had the lumen-apposing stent inserted within the study period. 15 cholecystoscopes were performed, 2 on the same patient and 2 were unsuccessful. 1 was due to obstruction by gallstone, the other was due to angulation. Two of the procedures were performed a few days after insertion of AXIOS stent for clearance of sludge and stones to facilitate drainage. 4 cases had residual gallstones removed. One patient had a 2cm gallstone with laser lithotripsy performed and complete stone removal. Cholecystogram was performed in 6 patients, one of which showed common bile duct stone (CBD). ERCP was performed in the same session and the CBD stone removed. Magnifying endoscopy was performed in 8 patients and confocal microscopy and EUS in one. A highly suspicious polypoid growth was detected in one patient with confocal imaging and biopsy showing adenomatous fragments with high-grade dysplasia. Serosal invasion was also suspected on EUS. One patient suffered from cholangitis after the procedure. Conclusion: Cholecystoscopy and advanced gallbladder interventions were feasible and safe. An array of procedures can be performed such as stone removal, laser lithotripsy, magnifying narrow band imaging, confocal microscopy, EUS and cholecystogram. This opens up exciting possibilities for endoscopic treatment of gallbladder stones and polyps.
1001 Endoscopic Intraluminal Therapy of a Dislocated Magnetic Antireflux Device Causing Severe Dysphagia Alexander Meining*1, Margit Bauer2, Hubertus Feussner2 1 Medical Department I, Ulm University, Ulm, Germany; 2Surgical Department, Technical University Munich, Munich, Germany Background and Case: Magnetic sphincter augmentation is frequently used for laparoscopic therapy of gastroesophageal reflux disease. We report the case of a 59 year old female with severe and progressive dysphagia for fluids as well as solid food and subsequent weight loss of 10kg within 7 weeks. The patient had had an uncomplicated implantation of a magnetic anti-reflux device two years before. Endoscopic Procedure EGD revealed several beans of the magnetic band in the lumen encumbering the passage to the normal stomach. For removal of the ring, a standard forceps was placed into the stomach as an auxiliary instrument. With that first forceps the magnetic ring could be held under tension in such a way that the linking between two beans could be picked up with a prototype clip cutter. Three times an electric tension was applied so the band could be severed. As soon as this was achieved, the whole device was relatively mobile and the complete magnetic chain could be extracted with only minimal resistance. After the procedure, the patient had a full recovery with no complications or clinical sequelae. Conclusion: This case demonstrates that magnetic reflux devices may penetrate into the lumen causing severe dysphagia. A complete endoscopic removal of the device is feasible by using a newly designed clip cutter.
1002 Circumferential Endoscopic Submucosal Dissection of a Squamous Cell Carcinoma in a Cirrhotic Patient With Esophageal Varices Manol Jovani, Andrea Anderloni, Silvia Carrara, Elisa Chiara Ferrara, Camilla Ciscato, Ivana Bravata’, Alessandra Loriga, Giuseppe Strangio, Alessandro Repici* Gastroenterology; Digestive Endoscopy Service, Humanitas Research Hospital, Rozzano, Milano, Italy A 47 years old male, recently diagnosed with alcohol-related cirrhosis and mild renal insufficiency, underwent upper gastrointestinal endoscopy as part of the routine examinations for entering the orthotopic liver transplant (OLT) list. Squamous cell carcinoma (SCC) of the distal esophagus (almost circumferential in its extent, with a length of nearly 3 cm) and F2 esophageal varices (EV) were found. Further examinations (CT-scan, EUS) showed that the neoplasia was limited to the mucosa. The
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB183
1000 Adventures in the Gallbladder! Initial Experience of Advanced Gallbladder Interventions After Gallbladder Stenting Shannon M. Chan*, Anthony Y. Teoh, Philip W. Chiu, Enders K. Ng, James Y. Lau General Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
Pathology of Non-Neoplastic Biopsies
998 Incision Therapy for an Unusual Esophageal Stricture Milan S. Bassan*1,2, Mohit P. Shetti1, Paul D. Edwards1, David Abi-Hanna1, Jenn Koo1,2 1 Gastroenterology and Hepatology, Liverpool Hospital, Liverpool, NSW, Australia; 2University of New South Wales, Sydney, NSW, Australia Introduction: Benign esophageal strictures are most commonly related to prolonged GERD, iatrogenic (post surgical, radiotherapy related or following endoscopic therapies) or caustic ingestion. Standard bougie or balloon based techniques are usually highly effective in achieving resolution of the stricture however some strictures may be refractory to these approaches and further intervention is required. CASE: A 39 year old male with progressive dysphagia to solids who could barely manage soft food at the time of initial presentation. He had a prolonged hospitalisation with typhoid in 1996 during which time he had significant odynophagia. There was no history of GERD, radiotherapy or caustic ingestion). He was found to have a severe benign proximal esophageal stricture that was refractory to both balloon and bougie dilation. Needle knife incision (NKI) therapy was successfully performed. Endoscopic Method: A series of linear incisions, perpendicular to the esophageal wall were made using a standard ERCP needle knife. Swift coag (Effect 3, 40W) was used for diathermy. The depth of incision was determined by using the esophageal wall distal to the stricture as the critical landmark. This technique has mainly been described in post-anastomotic strictures. In a randomized controlled trial similar outcomes were demonstrated with NKI and Savary bougienage. The risk or perforation has been reported as being low (1%-2%) but rates of restenosis have been reported as high as 50%. Clinical Implications: Needle knife incision therapy is a useful technique to treat benign esophageal strictures refractory to standard therapy. Typhoid is a rare cause of esophageal stricture formation but should be considered in the appropriate clinical context.
999 Endoscopic Treatment of a Refractory Esophageal Fistula Fernando P. Marson*, Kiyoshi Hashiba, Horus A. Brasil, Juliana Valenciano, Gisele D. Leite, Pablo R. Siqueira Serviço de Endoscopia Digestiva, Hospital Sirio Libanês, São Paulo, Brazil Background: A 53 y/o male underwent esophagostomy, gastrostomy and bilateral chest drainage for treatment of Boerhaave Syndrome. The patient was discharged one month later after closure of the gastrostomy and esophagostomy. As the patient advanced to a normal oral diet, he presented with progressive leakage of saliva at the esophagostomy scar. Endoscopic and radiologic findings revealed a 2 cm cervical esophageal fistula. Endoscopic Methods: Endoscopic treatment with clips, covered SEMS and acellular biomaterial plug were attempted without success. A technique based on the gastropexy used during PEG placement was used to approximate healthy tissue surrounding the fistula. Progressive decrease in the fistula output was observed in the following days. Ten days after the procedure a complete fistula closure was noted. Follow up after 6 months revealed no fistula recurrence. Clinical Implications: This technique allowed the successful closure of a refractory cervical esophageal fistula using basic endoscopic equipment.
www.giejournal.org
Background and Aims: Traditionally, endoscopy of the gallbladder is not possible. However, the recent development of endosonographic (EUS) - guided gallbladder drainage with a lumen apposing stent (AXIOS, Xlumena, USA) made endoscopic assessment and advanced gallbladder interventions via the stent possible. The aim of this study was to assess the feasibility and safety of cholecystoscopy and the types of interventions that can be performed in these patients. Methods: This was a retrospective review conducted in the Prince of Wales Hospital from 1st June, 2012 to 31st October 2014. All patients that suffered from acute cholecystitis with EUS-guided transgastric or transduodenal gallbladder drainage and placement of a lumen apposing stent (AXIOS, Xlumena, USA) were included. Cholecystoscopy was performed in these patients 3 months after insertion to check for clearance of stones and removal of stent. Patients’ demographic data, the feasibility, complications and types of intervention were recorded. Results: 17 patients had the lumen-apposing stent inserted within the study period. 15 cholecystoscopes were performed, 2 on the same patient and 2 were unsuccessful. 1 was due to obstruction by gallstone, the other was due to angulation. Two of the procedures were performed a few days after insertion of AXIOS stent for clearance of sludge and stones to facilitate drainage. 4 cases had residual gallstones removed. One patient had a 2cm gallstone with laser lithotripsy performed and complete stone removal. Cholecystogram was performed in 6 patients, one of which showed common bile duct stone (CBD). ERCP was performed in the same session and the CBD stone removed. Magnifying endoscopy was performed in 8 patients and confocal microscopy and EUS in one. A highly suspicious polypoid growth was detected in one patient with confocal imaging and biopsy showing adenomatous fragments with high-grade dysplasia. Serosal invasion was also suspected on EUS. One patient suffered from cholangitis after the procedure. Conclusion: Cholecystoscopy and advanced gallbladder interventions were feasible and safe. An array of procedures can be performed such as stone removal, laser lithotripsy, magnifying narrow band imaging, confocal microscopy, EUS and cholecystogram. This opens up exciting possibilities for endoscopic treatment of gallbladder stones and polyps.
1001 Endoscopic Intraluminal Therapy of a Dislocated Magnetic Antireflux Device Causing Severe Dysphagia Alexander Meining*1, Margit Bauer2, Hubertus Feussner2 1 Medical Department I, Ulm University, Ulm, Germany; 2Surgical Department, Technical University Munich, Munich, Germany Background and Case: Magnetic sphincter augmentation is frequently used for laparoscopic therapy of gastroesophageal reflux disease. We report the case of a 59 year old female with severe and progressive dysphagia for fluids as well as solid food and subsequent weight loss of 10kg within 7 weeks. The patient had had an uncomplicated implantation of a magnetic anti-reflux device two years before. Endoscopic Procedure EGD revealed several beans of the magnetic band in the lumen encumbering the passage to the normal stomach. For removal of the ring, a standard forceps was placed into the stomach as an auxiliary instrument. With that first forceps the magnetic ring could be held under tension in such a way that the linking between two beans could be picked up with a prototype clip cutter. Three times an electric tension was applied so the band could be severed. As soon as this was achieved, the whole device was relatively mobile and the complete magnetic chain could be extracted with only minimal resistance. After the procedure, the patient had a full recovery with no complications or clinical sequelae. Conclusion: This case demonstrates that magnetic reflux devices may penetrate into the lumen causing severe dysphagia. A complete endoscopic removal of the device is feasible by using a newly designed clip cutter.
1002 Circumferential Endoscopic Submucosal Dissection of a Squamous Cell Carcinoma in a Cirrhotic Patient With Esophageal Varices Manol Jovani, Andrea Anderloni, Silvia Carrara, Elisa Chiara Ferrara, Camilla Ciscato, Ivana Bravata’, Alessandra Loriga, Giuseppe Strangio, Alessandro Repici* Gastroenterology; Digestive Endoscopy Service, Humanitas Research Hospital, Rozzano, Milano, Italy A 47 years old male, recently diagnosed with alcohol-related cirrhosis and mild renal insufficiency, underwent upper gastrointestinal endoscopy as part of the routine examinations for entering the orthotopic liver transplant (OLT) list. Squamous cell carcinoma (SCC) of the distal esophagus (almost circumferential in its extent, with a length of nearly 3 cm) and F2 esophageal varices (EV) were found. Further examinations (CT-scan, EUS) showed that the neoplasia was limited to the mucosa. The
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB183