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1035 Delayed Endoscopic Closure of a Giant Gastric Perforation
Abstracts
was performed to prevent abscess formation. We then refreshed the edges of the perforation using APC. This allows better tissue apposition and healing. We, using a twin grasper, approximated the gaping edges and pulled it inside the over the scope clip before clipping. In a similar fashion, we deployed multiple clips following the double layer suture technique. Finally, after closure of the perforation, we fed the patient using a nasojejunal tube. This was critical as early nutrition may promote wound healing. We repeated endoscopy after 3 days and found complete closure of the perforation. This was also confirmed using water-soluble contrast study, which showed no leak. He was treated with appropriate antibiotics. A repeat endoscopy performed at one month showed complete epithelization around the clips. The biopsied obtained from the mass showed adenocarcinoma. Conclusion: Our case illustrates endoscopic closure of large iatrogenic perforation may still be possible even when there is a delay in presentation. Over the scope clips may be useful to close such large perforation.
1036 Endoscopic Ultrasound Guided Coiling of Hepatic Artery Pseudo Aneurysm in Two Stages Malay Sharma*1, Rajendra Lingampalli1, Krishnaveni Janarthanan2, Saurabh Jindal1, Piyush Somani1 1 Jaswantrai speciality hospital, Meerut, UP, India; 2Department of gastroenterology, PSG Institute of Medical Sciences & Research, Meerut, Tamil Nadu, India
1035 Delayed Endoscopic Closure of a Giant Gastric Perforation Roy M. Soetikno*, Ravishankar Asokkumar, Christopher J. Khor Singapore General Hospital, Singapore, Singapore Background: Small iatrogenic perforation can be treated successfully using endoscopy. However, perforation can be large. We describe a case of delayed endoscopic closure of giant gastric perforation using multiple over the scope clips. Case: A 72-year-old man had an upper endoscopy because of hematemesis. A bleeding large mass was found in the distal esophagus and was treated using spraying hemostasis powder. During spraying, the patient moved abruptly and developed severe abdominal distention and acute respiratory failure. An abdominal X-Ray after stabilization showed pneumoperitoneum. The patient was treated conservatively with intravenous antibiotics and nil per oral because of his other co-morbidities. Although he improved clinically, the abdominal distention persisted. Hence, a computerized tomogram was performed 3 days later, which showed a large defect in the anterior aspect of the mid stomach. He was referred for endoscopic closure and herein; we describe the technique adopted for endoscopic treatment. Endoscopic technique: First, we evacuated the pneumoperitoneum before performing endoscopy. This may prevent gastric distention and air embolism during procedure. We used Co2 insufflation to prevent recurrent pneumoperitoneum. Secondly, after assessing the morphology of the perforation, we washed it thoroughly with saline. This
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Introduction: Hepatic artery pseudo-aneurysms are rare and have been reported after abdominal trauma and after abdominal surgery. Hepatic artery pseudo-aneurysms constitute 20% of all visceral artery aneurysms. It carries very high risk of rupture with severe bleeding into peritoneal cavity, bile duct or portal vein. Essentially all pseudo-aneurysms, whether symptomatic or not symptomatic require early treatment to prevent lethal complications. Surgical treatment consists of ligation or revascularization of the hepatic artery but is associated with higher morbidity compared to endovascular treatment. The goal of endovascular treatment of hepatic aneurysms is to obtain a complete, stable exclusion of the sac from arterial circulation with preservation of the parent vessel. Endovascular, percutaneous and endoscopic ultrasound (EUS) guided interventions are used in the treatment of visceral artery pseudo aneurysms. Case report: A 20 years old male presented with abdomen pain in right upper quadrant for two months. He had undergone ultrasound-guided aspiration of liver abscess two months ago. Ultrasound abdomen showed an aneurysm arising from hepatic artery. CT angiography of abdomen confirmed a saccular pseudo-aneurysm arising from proximal part of hepatic artery. The lesion was not considered feasible for percutaneous intervention. Interventional radiologist suggested hepatic artery stenting across the neck of aneurysm to block the flow of blood into the aneurysm and explained the associated risk of ischemia, infarction due to stent stenosis, thrombosis, and distal migration of stent. After discussing the pros and cons of EUS guided procedure, the patient chose EUS guided coil embolization. The sack packing with helical coils was planned. Packing with one coil of 10 mm and five coils of 6mm size through a 19-gauge needle caused 80% obliteration of the sac. Five days later EUS assessment showed the injected coils were collected into the most distal part of the aneurysm but the flow into a smaller cavity continued with high velocity. During the second attempt four coils of 10 mm size were deployed. Postcoiling EUS assessment still showed flow into the aneurysm. Three more coils of 8 mm size were placed and complete obliteration of aneurysm was confirmed by contrast injection and EUS. One week later followup colour doppler abdomen showed no flow in the pseudo-aneurysm. Conclusion: This case showed the practical problems of EUS guided coil embolization of hepatic artery aneurysm. Initial attempt resulted in 80% obliteration of aneurysm cavity but did not cause progressive thrombosis of rest of the cavity of the aneurysm. However, successful and complete obliteration of pseudo-aneurysm was achieved in second attempt of coiling.
1037 Insulated Tip Knife Tunneling Technique With Clip Traction for Safe Esd of Large Circumferential Esophageal Cancer Seiichiro Abe*1, Ichiro Oda1, Satoru Nonaka1, Haruhisa Suzuki1, Shigetaka Yoshinaga1, Amit Bhatt2, Yutaka Saito1 1 National Cancer Center Hospital, Tokyo, Japan; 2Cleveland Clinic, Cleveland, OH Introduction: Esophageal endoscopic submucosal dissection (ESD) is technically challenging because of the thin wall and narrow lumen of the esophagus. This makes it difficult to keep good traction and orientation during ESD, especially in large lesions. We describe a case of a successful ESD of a large circumferential squamous cell cancer (SCC) using insulated tip (IT) knife tunneling technique with clip retraction. Case Report: A 80 years old male underwent an EGD for evaluation of dyspepsia symptoms. A suspicious 70mm circumferential flat lesion was found involving the middle and lower esophagus. The lesion was iodine avoiding. Biopsies from the lesion showed SCC, and a CT scan was negative for nodal and distal
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB125
was performed to prevent abscess formation. We then refreshed the edges of the perforation using APC. This allows better tissue apposition and healing. We, using a twin grasper, approximated the gaping edges and pulled it inside the over the scope clip before clipping. In a similar fashion, we deployed multiple clips following the double layer suture technique. Finally, after closure of the perforation, we fed the patient using a nasojejunal tube. This was critical as early nutrition may promote wound healing. We repeated endoscopy after 3 days and found complete closure of the perforation. This was also confirmed using water-soluble contrast study, which showed no leak. He was treated with appropriate antibiotics. A repeat endoscopy performed at one month showed complete epithelization around the clips. The biopsied obtained from the mass showed adenocarcinoma. Conclusion: Our case illustrates endoscopic closure of large iatrogenic perforation may still be possible even when there is a delay in presentation. Over the scope clips may be useful to close such large perforation.
1036 Endoscopic Ultrasound Guided Coiling of Hepatic Artery Pseudo Aneurysm in Two Stages Malay Sharma*1, Rajendra Lingampalli1, Krishnaveni Janarthanan2, Saurabh Jindal1, Piyush Somani1 1 Jaswantrai speciality hospital, Meerut, UP, India; 2Department of gastroenterology, PSG Institute of Medical Sciences & Research, Meerut, Tamil Nadu, India
1035 Delayed Endoscopic Closure of a Giant Gastric Perforation Roy M. Soetikno*, Ravishankar Asokkumar, Christopher J. Khor Singapore General Hospital, Singapore, Singapore Background: Small iatrogenic perforation can be treated successfully using endoscopy. However, perforation can be large. We describe a case of delayed endoscopic closure of giant gastric perforation using multiple over the scope clips. Case: A 72-year-old man had an upper endoscopy because of hematemesis. A bleeding large mass was found in the distal esophagus and was treated using spraying hemostasis powder. During spraying, the patient moved abruptly and developed severe abdominal distention and acute respiratory failure. An abdominal X-Ray after stabilization showed pneumoperitoneum. The patient was treated conservatively with intravenous antibiotics and nil per oral because of his other co-morbidities. Although he improved clinically, the abdominal distention persisted. Hence, a computerized tomogram was performed 3 days later, which showed a large defect in the anterior aspect of the mid stomach. He was referred for endoscopic closure and herein; we describe the technique adopted for endoscopic treatment. Endoscopic technique: First, we evacuated the pneumoperitoneum before performing endoscopy. This may prevent gastric distention and air embolism during procedure. We used Co2 insufflation to prevent recurrent pneumoperitoneum. Secondly, after assessing the morphology of the perforation, we washed it thoroughly with saline. This
www.giejournal.org
Introduction: Hepatic artery pseudo-aneurysms are rare and have been reported after abdominal trauma and after abdominal surgery. Hepatic artery pseudo-aneurysms constitute 20% of all visceral artery aneurysms. It carries very high risk of rupture with severe bleeding into peritoneal cavity, bile duct or portal vein. Essentially all pseudo-aneurysms, whether symptomatic or not symptomatic require early treatment to prevent lethal complications. Surgical treatment consists of ligation or revascularization of the hepatic artery but is associated with higher morbidity compared to endovascular treatment. The goal of endovascular treatment of hepatic aneurysms is to obtain a complete, stable exclusion of the sac from arterial circulation with preservation of the parent vessel. Endovascular, percutaneous and endoscopic ultrasound (EUS) guided interventions are used in the treatment of visceral artery pseudo aneurysms. Case report: A 20 years old male presented with abdomen pain in right upper quadrant for two months. He had undergone ultrasound-guided aspiration of liver abscess two months ago. Ultrasound abdomen showed an aneurysm arising from hepatic artery. CT angiography of abdomen confirmed a saccular pseudo-aneurysm arising from proximal part of hepatic artery. The lesion was not considered feasible for percutaneous intervention. Interventional radiologist suggested hepatic artery stenting across the neck of aneurysm to block the flow of blood into the aneurysm and explained the associated risk of ischemia, infarction due to stent stenosis, thrombosis, and distal migration of stent. After discussing the pros and cons of EUS guided procedure, the patient chose EUS guided coil embolization. The sack packing with helical coils was planned. Packing with one coil of 10 mm and five coils of 6mm size through a 19-gauge needle caused 80% obliteration of the sac. Five days later EUS assessment showed the injected coils were collected into the most distal part of the aneurysm but the flow into a smaller cavity continued with high velocity. During the second attempt four coils of 10 mm size were deployed. Postcoiling EUS assessment still showed flow into the aneurysm. Three more coils of 8 mm size were placed and complete obliteration of aneurysm was confirmed by contrast injection and EUS. One week later followup colour doppler abdomen showed no flow in the pseudo-aneurysm. Conclusion: This case showed the practical problems of EUS guided coil embolization of hepatic artery aneurysm. Initial attempt resulted in 80% obliteration of aneurysm cavity but did not cause progressive thrombosis of rest of the cavity of the aneurysm. However, successful and complete obliteration of pseudo-aneurysm was achieved in second attempt of coiling.
1037 Insulated Tip Knife Tunneling Technique With Clip Traction for Safe Esd of Large Circumferential Esophageal Cancer Seiichiro Abe*1, Ichiro Oda1, Satoru Nonaka1, Haruhisa Suzuki1, Shigetaka Yoshinaga1, Amit Bhatt2, Yutaka Saito1 1 National Cancer Center Hospital, Tokyo, Japan; 2Cleveland Clinic, Cleveland, OH Introduction: Esophageal endoscopic submucosal dissection (ESD) is technically challenging because of the thin wall and narrow lumen of the esophagus. This makes it difficult to keep good traction and orientation during ESD, especially in large lesions. We describe a case of a successful ESD of a large circumferential squamous cell cancer (SCC) using insulated tip (IT) knife tunneling technique with clip retraction. Case Report: A 80 years old male underwent an EGD for evaluation of dyspepsia symptoms. A suspicious 70mm circumferential flat lesion was found involving the middle and lower esophagus. The lesion was iodine avoiding. Biopsies from the lesion showed SCC, and a CT scan was negative for nodal and distal
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB125