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1005 Double-Tunnel Submucosal Endoscopic Resection of the Esophageal Leiomyoma
Abstracts
patient was a poor candidate for surgery, hence an attempt of endoscopic removal was considered appropriate. The patient underwent endoscopic band ligation (EBL) of the EV and complete circumferential endoscopic submucosal dissection (ESD) with hybrid knife of the SCC lesion, in a single piece. A self-expanding metal stent was placed in order to prevent stricture development and was removed four weeks later, with conservation of the esophageal lumen. Unfortunately at histologic examination the proximal margins of the specimen were positive for high grade dysplasia. The patient was therefore referred for esophageal resection, before entering the OLT list. This is the first case reporting the technical feasibility of circumferential ESD with hybrid knife for esophageal SCC associated with EBL in difficult contexts such as cirrhosis with EV.
because subcostal incision was performed at prior operation, approximation and closure of the abdominal wall after re-operation seemed risky. The surgeon and the endoscopist discussed the risk and the benefit of surgical bypass and EUS-guided hepaticoduodenostomy with a fully covered metal stent. The patient wanted to have internal drainage without further surgical treatment. Therefore, we decided to perform a novel procedure- EUS-guided hepaticoduodenostomy with assistance of PTBD. The procedure successfully created endoscopic hepaticoduodenostomy of injured bile duct with a fully covered metal stent under endoscopic and fluoroscopic guidance. In conclusion, EUS-guided hepaticoduodenostomy with a fully covered metal stent can be an alternative treatment option for the management of transection injury of bile duct following cholecystectomy.
1003 Case Series of Laparoscopic Assisted Endoscopic Submucosal Dissection (LAESD) Hisatomo Ikehara*, Toshihiro Okada, Kazuhiro Suzumura, Seikan Hai, Toshihiko Tomita, Tadayuki Oshima, Hirokazu Fukui, Jiro Watari, Jiro Fujimoto, Hiroto Miwa Hyogo college of medicine, Nishinomiya, Japan
1005 Double-Tunnel Submucosal Endoscopic Resection of the Esophageal Leiomyoma Evgeny Fedorov*, Roman Plakhov, Stanislav Budzinskiy, Evgeny Gorbachev Moscow University Hospital N31, Moscow, Russian Federation
Background and Aim: Endoscopic submucosal dissection (ESD) is widely accepted as less invasive treatment for early gastric cancer. However, regarding duodenal neoplasms, high perforation rate of duodenal ESD has been reported. Duodenal perforation causes severe peritonitis in some cases. Laparoscopic assisted endoscopic submucosal dissection (LAESD) is newly developed local resection method for duodenal tumor. The aim of this study was to evaluate the efficacy and safety of LAESD. Patients and Methods: From October 2012 to June 2014, six patients underwent LAESD for duodenal tumor. LAESD method consists of following steps. Initially, the tumor location is confirmed by laparoscopy and endoscopy. At first, tumor is removed by ESD method. Laparoscopic serosal suturing is performed for mucosal defect to cover the dissected area. Finally, endoscopic mucosal closure is performed. The resected specimen was carried out via the per-oral route. Results: LAESD was performed on six consecutive patients with six epithelial neoplasms who had preoperative diagnoses of intramucsal cancer by magnifying endoscopy. All of six patients were male. All targeted lesions consisted as mucosal cancer or adenoma. The mean size (SD) of tumor was 22.8. Locations of lesions were as follows: one lesion in the SDA; and four lesions in the second portion of the duodenum; and one lesion in the third portion of the duodenum. Among these patients, two perforations were observed during the endoscopic resection. Of these two lesions, one lesion was removed endoscopically and carried out via the per-oral route. Another lesion was removed laparoscopically and carried our through the port. The mean operation time was 225 90.4 (range: 107-298) min. Estimated blood loss was little during the operation. En-broc resection rate was 83%. In all postoperative course, no delayed perforation was observed. The mean postoperative stay was 6 days. Pathological result showed as four mucosal cancers and two adenomas. No lymph-vascular involvement was observed. During the follow up period, no tumor recurrence was observed. Conclusion: In this cases series, LAESD was successfully achieved to an intramucosal duodenal cancers and adenomas that would have been difficult to treat with ESD alone. LAESD for duodenal neoplasms seems promising treatment to reduce the risk of delayed perforation.
1004 Endoscopic Ultrasound-Guided Hepaticoduodenostomy: Management of Transection Injury of Bile Duct Following Cholecystectomy Min Keun Cho*, Charles J. Cho, Do Hyun Park Internal Medicine, Asan Medical Center, Seoul, Korea (the Republic of) Treatment of bile duct injury following cholecystectomy is a clinical challenge because it requires additional treatment and result in considerable morbidity. Recently, endoscopic stent insertion has become a technically feasible treatment option for the treatment of bile duct injury following cholecystectomy. Still, most cases of transection injury of the bile duct require surgical management. However, surgery is not feasible in certain clinical situation as in the following clinical case. In addition, anastomosing transected bile duct with small bowel is not possible with conventional endoscopic modality. In this video case, we present an endoscopic ultrasound-guided treatment of transection injury of bile duct following cholecystectomy, creating hepaticoduodenostomy with a fully covered metal stent. A 43-year-old woman was referred to our hospital because of transection injury of right anterior segmental bile duct following cholecystectomy. 8 days before the admission, the patient underwent open cholecystectomy at the other hospital under impression of chronic cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) shows abrupt narrowing of right anterior segmental bile duct, suggesting a transection injury. In addition, anomalous connection between right posterior segmental intrahepatic bile duct and left intrahepatic bile duct was noted. The initial treatment plan was to solve the problem by creating a hepaticojejunostomy or resecting the involved hepatic segment. However, the initial surgical plans were hampered by several limitations. First, sufficient length of remaining bile duct to be connected to jejunum was not available. Second, severe adhesion was noted during previous operation. Third,
AB184 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Aims: The new technique of submucosal endoscopic tumor resection (SETR) allows to remove tumors of esophagus originating from the muscularis propria using the submucosal tunnel. Methods: In 54 year-old female, the 30-mm submucosal tumor (SMT) of the distal esophagus was found one year ago before admission. All this time, she complained of dysphagia and progressive cancerophobia. In our hospital pt. underwent re-endoscopy and EUS, where we revealed the tumor of the distal esophagus, originating from the muscularis propria, and located in the close proximity to the aorta, with hypoechoic echo-structure and anechoic areas, suggestive for GIST or leiomyoma. Results: SETR was performed under general anesthesia with endotracheal intubation using a gastroscope with the distal cup. For dissection we used Triangle Tip Knife and IT Knife. Coagulating forceps were used for hemostasis. Saline solution with indigo carmine was injected submucosally. The longitudinal mucosal incision was made 5 cm orally to the proximal margin of the SMT. The submucosal tunnel was created, advanced towards the SMT and then extended beyond the tumor to secure enough working space to finally resect the tumor. Utilization of a cap facilitated a process of dissection. It was revealed that the tumor had egg-shape appearance with actual size 40x21 mm, extending outside the wall of the digestive tract (extraluminal growth) and located in the posterior mediastinum in the close proximity to the thoracic aorta. Step by step the quarter of SMT was dissected through the submucosal tunnel and the rest three quarters - through the 2 cm window in the muscularis propria of the esophagus, thus creating the 2nd tunnel into the mediastinum. The tumor was finally resected in 3 fragments with polypectomy snare, being extracted through the muscle and mucosal accesses. The potential bleeding areas in both tunnels were thoroughly coagulated to prevent later bleeding. The mucosal entry was closed tightly with 8 endoscopic clips. The total intervention time was 220 minutes. Carboxyperitoneum was eliminated through the Veress needle after puncture of the abdominal wall. There were no postoperative complications. The patient was fasted for 1 day. Proton pump inhibitors and antibiotics were used. On histology and immunohistochemistry (expression of CD117, DOG-1, CD 34 was absent; active expression of actin, non-uniformly - vimentin; Ki 67 less than 1%; no mitosis) esophageal leiomyoma was found. Control endoscopy at 5 months after intervention revealed a mild scar without restriction or distortion of the esophagus. Conclusions: Thus SETR is an effective method for removing oesophageal SMT originating from the muscularis propria. This technique is an alternative to surgical operations.
1006 PerOral Transhepatic Cholangioscopy and Antegrade Sphincterotomy via EUS-Guided Anastomosis Ramon Sanchez-Ocana, Irene PeñAs, Carlos De La Serna, Manuel Perez-Miranda* GI and Hepatology, Rio Hortega Universitary Hospital, Valladolid, Spain Background: Patients with altered GI anatomy and biliary obstruction are challenging. Percutaneous, intraoperative or enteroscopy-based approaches have limitations. We describe single session antegrade sphincterotomy using per-oral transhepatic cholangioscopy through EUS anastomosis in a Roux-en-Y patient with strictured surgical sphincteroplasty. Case Report: 52 y.o. male with Roux-en-Y total gastrectomy and esophagojejunostomy 14 years earlier for a T2N1 gastric adenocarcinoma. He underwent open cholecystectomy with CBD stone removal and sphincteroplasty 7 months earlier. He had three cholangitis requiring hospital admission O 5 days. MRI showed dilated bile duct with an abrupt cut-off at the papilla and small CBD stones. Transjejunal EUS-guided puncture of the left intrahepatic duct with a 19G needle and a linear-array echoendoscope allowed cholangiography. The puncture tract was dilated over-the-wire with a 6mm balloon, and a 60x10mm fullly covered Self Expandable Metal Stent (SEMS) with antimigration flaps was placed transhepatically over the puncture tract. This EUS-guided hepaticojejunostomy was balloon dilated up two 10 mm. The echoendoscope was exchanged for a transnasal gastroscope, which was passed antegradely through the cSEMS into the CBD. Cholangioscopyguided attempts at guidewire passage resulted in failure. A needle-knife was used under fluoroscopy and cholangioscopy to access the duodenum antegradely from
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patient was a poor candidate for surgery, hence an attempt of endoscopic removal was considered appropriate. The patient underwent endoscopic band ligation (EBL) of the EV and complete circumferential endoscopic submucosal dissection (ESD) with hybrid knife of the SCC lesion, in a single piece. A self-expanding metal stent was placed in order to prevent stricture development and was removed four weeks later, with conservation of the esophageal lumen. Unfortunately at histologic examination the proximal margins of the specimen were positive for high grade dysplasia. The patient was therefore referred for esophageal resection, before entering the OLT list. This is the first case reporting the technical feasibility of circumferential ESD with hybrid knife for esophageal SCC associated with EBL in difficult contexts such as cirrhosis with EV.
because subcostal incision was performed at prior operation, approximation and closure of the abdominal wall after re-operation seemed risky. The surgeon and the endoscopist discussed the risk and the benefit of surgical bypass and EUS-guided hepaticoduodenostomy with a fully covered metal stent. The patient wanted to have internal drainage without further surgical treatment. Therefore, we decided to perform a novel procedure- EUS-guided hepaticoduodenostomy with assistance of PTBD. The procedure successfully created endoscopic hepaticoduodenostomy of injured bile duct with a fully covered metal stent under endoscopic and fluoroscopic guidance. In conclusion, EUS-guided hepaticoduodenostomy with a fully covered metal stent can be an alternative treatment option for the management of transection injury of bile duct following cholecystectomy.
1003 Case Series of Laparoscopic Assisted Endoscopic Submucosal Dissection (LAESD) Hisatomo Ikehara*, Toshihiro Okada, Kazuhiro Suzumura, Seikan Hai, Toshihiko Tomita, Tadayuki Oshima, Hirokazu Fukui, Jiro Watari, Jiro Fujimoto, Hiroto Miwa Hyogo college of medicine, Nishinomiya, Japan
1005 Double-Tunnel Submucosal Endoscopic Resection of the Esophageal Leiomyoma Evgeny Fedorov*, Roman Plakhov, Stanislav Budzinskiy, Evgeny Gorbachev Moscow University Hospital N31, Moscow, Russian Federation
Background and Aim: Endoscopic submucosal dissection (ESD) is widely accepted as less invasive treatment for early gastric cancer. However, regarding duodenal neoplasms, high perforation rate of duodenal ESD has been reported. Duodenal perforation causes severe peritonitis in some cases. Laparoscopic assisted endoscopic submucosal dissection (LAESD) is newly developed local resection method for duodenal tumor. The aim of this study was to evaluate the efficacy and safety of LAESD. Patients and Methods: From October 2012 to June 2014, six patients underwent LAESD for duodenal tumor. LAESD method consists of following steps. Initially, the tumor location is confirmed by laparoscopy and endoscopy. At first, tumor is removed by ESD method. Laparoscopic serosal suturing is performed for mucosal defect to cover the dissected area. Finally, endoscopic mucosal closure is performed. The resected specimen was carried out via the per-oral route. Results: LAESD was performed on six consecutive patients with six epithelial neoplasms who had preoperative diagnoses of intramucsal cancer by magnifying endoscopy. All of six patients were male. All targeted lesions consisted as mucosal cancer or adenoma. The mean size (SD) of tumor was 22.8. Locations of lesions were as follows: one lesion in the SDA; and four lesions in the second portion of the duodenum; and one lesion in the third portion of the duodenum. Among these patients, two perforations were observed during the endoscopic resection. Of these two lesions, one lesion was removed endoscopically and carried out via the per-oral route. Another lesion was removed laparoscopically and carried our through the port. The mean operation time was 225 90.4 (range: 107-298) min. Estimated blood loss was little during the operation. En-broc resection rate was 83%. In all postoperative course, no delayed perforation was observed. The mean postoperative stay was 6 days. Pathological result showed as four mucosal cancers and two adenomas. No lymph-vascular involvement was observed. During the follow up period, no tumor recurrence was observed. Conclusion: In this cases series, LAESD was successfully achieved to an intramucosal duodenal cancers and adenomas that would have been difficult to treat with ESD alone. LAESD for duodenal neoplasms seems promising treatment to reduce the risk of delayed perforation.
1004 Endoscopic Ultrasound-Guided Hepaticoduodenostomy: Management of Transection Injury of Bile Duct Following Cholecystectomy Min Keun Cho*, Charles J. Cho, Do Hyun Park Internal Medicine, Asan Medical Center, Seoul, Korea (the Republic of) Treatment of bile duct injury following cholecystectomy is a clinical challenge because it requires additional treatment and result in considerable morbidity. Recently, endoscopic stent insertion has become a technically feasible treatment option for the treatment of bile duct injury following cholecystectomy. Still, most cases of transection injury of the bile duct require surgical management. However, surgery is not feasible in certain clinical situation as in the following clinical case. In addition, anastomosing transected bile duct with small bowel is not possible with conventional endoscopic modality. In this video case, we present an endoscopic ultrasound-guided treatment of transection injury of bile duct following cholecystectomy, creating hepaticoduodenostomy with a fully covered metal stent. A 43-year-old woman was referred to our hospital because of transection injury of right anterior segmental bile duct following cholecystectomy. 8 days before the admission, the patient underwent open cholecystectomy at the other hospital under impression of chronic cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) shows abrupt narrowing of right anterior segmental bile duct, suggesting a transection injury. In addition, anomalous connection between right posterior segmental intrahepatic bile duct and left intrahepatic bile duct was noted. The initial treatment plan was to solve the problem by creating a hepaticojejunostomy or resecting the involved hepatic segment. However, the initial surgical plans were hampered by several limitations. First, sufficient length of remaining bile duct to be connected to jejunum was not available. Second, severe adhesion was noted during previous operation. Third,
AB184 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Aims: The new technique of submucosal endoscopic tumor resection (SETR) allows to remove tumors of esophagus originating from the muscularis propria using the submucosal tunnel. Methods: In 54 year-old female, the 30-mm submucosal tumor (SMT) of the distal esophagus was found one year ago before admission. All this time, she complained of dysphagia and progressive cancerophobia. In our hospital pt. underwent re-endoscopy and EUS, where we revealed the tumor of the distal esophagus, originating from the muscularis propria, and located in the close proximity to the aorta, with hypoechoic echo-structure and anechoic areas, suggestive for GIST or leiomyoma. Results: SETR was performed under general anesthesia with endotracheal intubation using a gastroscope with the distal cup. For dissection we used Triangle Tip Knife and IT Knife. Coagulating forceps were used for hemostasis. Saline solution with indigo carmine was injected submucosally. The longitudinal mucosal incision was made 5 cm orally to the proximal margin of the SMT. The submucosal tunnel was created, advanced towards the SMT and then extended beyond the tumor to secure enough working space to finally resect the tumor. Utilization of a cap facilitated a process of dissection. It was revealed that the tumor had egg-shape appearance with actual size 40x21 mm, extending outside the wall of the digestive tract (extraluminal growth) and located in the posterior mediastinum in the close proximity to the thoracic aorta. Step by step the quarter of SMT was dissected through the submucosal tunnel and the rest three quarters - through the 2 cm window in the muscularis propria of the esophagus, thus creating the 2nd tunnel into the mediastinum. The tumor was finally resected in 3 fragments with polypectomy snare, being extracted through the muscle and mucosal accesses. The potential bleeding areas in both tunnels were thoroughly coagulated to prevent later bleeding. The mucosal entry was closed tightly with 8 endoscopic clips. The total intervention time was 220 minutes. Carboxyperitoneum was eliminated through the Veress needle after puncture of the abdominal wall. There were no postoperative complications. The patient was fasted for 1 day. Proton pump inhibitors and antibiotics were used. On histology and immunohistochemistry (expression of CD117, DOG-1, CD 34 was absent; active expression of actin, non-uniformly - vimentin; Ki 67 less than 1%; no mitosis) esophageal leiomyoma was found. Control endoscopy at 5 months after intervention revealed a mild scar without restriction or distortion of the esophagus. Conclusions: Thus SETR is an effective method for removing oesophageal SMT originating from the muscularis propria. This technique is an alternative to surgical operations.
1006 PerOral Transhepatic Cholangioscopy and Antegrade Sphincterotomy via EUS-Guided Anastomosis Ramon Sanchez-Ocana, Irene PeñAs, Carlos De La Serna, Manuel Perez-Miranda* GI and Hepatology, Rio Hortega Universitary Hospital, Valladolid, Spain Background: Patients with altered GI anatomy and biliary obstruction are challenging. Percutaneous, intraoperative or enteroscopy-based approaches have limitations. We describe single session antegrade sphincterotomy using per-oral transhepatic cholangioscopy through EUS anastomosis in a Roux-en-Y patient with strictured surgical sphincteroplasty. Case Report: 52 y.o. male with Roux-en-Y total gastrectomy and esophagojejunostomy 14 years earlier for a T2N1 gastric adenocarcinoma. He underwent open cholecystectomy with CBD stone removal and sphincteroplasty 7 months earlier. He had three cholangitis requiring hospital admission O 5 days. MRI showed dilated bile duct with an abrupt cut-off at the papilla and small CBD stones. Transjejunal EUS-guided puncture of the left intrahepatic duct with a 19G needle and a linear-array echoendoscope allowed cholangiography. The puncture tract was dilated over-the-wire with a 6mm balloon, and a 60x10mm fullly covered Self Expandable Metal Stent (SEMS) with antimigration flaps was placed transhepatically over the puncture tract. This EUS-guided hepaticojejunostomy was balloon dilated up two 10 mm. The echoendoscope was exchanged for a transnasal gastroscope, which was passed antegradely through the cSEMS into the CBD. Cholangioscopyguided attempts at guidewire passage resulted in failure. A needle-knife was used under fluoroscopy and cholangioscopy to access the duodenum antegradely from
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