- Email: [email protected]
1041 Endoscopic Biliary Reconstruction Post Pancreaticoduodenectomy
Abstracts
1038 Endoscopic Removal of a Giant Double-Headed Esophageal Fibrovascular Polyp Ekaterina Ivanova*, Evgeny Fedorov, Oleg I. Yudin, Michail Poltoratsky, Evgeny Gorbachev Endoscopy, Moscow University Hospital N 31, Moscow, Russian Federation Introduction: The surgical approach is generally recommended for the excision of giant esophageal fibrovascular polyps to ensure adequate hemostasis and clear resection of the base. Only single cases of merely endoscopic removal of this rare benign tumor have been described in the literature. Aims & Methods: To demonstrate possibilities of successful resection of a giant fibrovascular polyp of the esophagus via an endoscope. A 50-year-old man was admitted to our hospital with a 6-month history of globus sensation, mild intermittent dysphagia during swallowing, occasional heartburn and epigastric pain. In a barium swallow and repeated EGDs a giant double-headed polyp with smooth overlying mucosa, arising from the upper esophagus just near the level of the cricopharyngeus at the pharyngoesophageal junction and extending from 17 to 34 cm from the incisors settling in the distal esophagus was revealed. It had a broad 18mm basis, distal head 32 mm at its maximum diameter with 2 ulcerations on the apex, proximal head 25 mm in diameter and length, with the ramification at the distance of 45 mm from the stalk’s base. EUS detected the lesion originated from the submucosal layer with inhomogeneous echo-texture with both hyper- and hypoechoic features with a number of vascular structures within the stalk. Results: Removal of the polyp was performed under general anesthesia with elective intubation, started with GIF-H180 following by GIF-2T160, using the Maxim-402 electrosurgical unit and CO2 insufflation. The equipment for intervention included 4 endoloops, grasping forceps and large electrosurgical snare. At first, we applied two loops at the level of ramification, resected the first 75 mm fragment above the loop and removed it. Then, we placed 2 another loops at the very base of the pedicle and removed the second fragment, thus performed total polypectomy, leaving the ligated 10 mm long stalk stump in place. Neither bleeding nor other complications occurred. The total length of the resected esophageal lesion measured 135 mm. Histology showed the mixture of fibrous and adipose tissue accompanied by an abundant network of large vessels, covered by a normal squamous epithelium. The patient was discharged from the hospital on the 4th day. A month and 1.5 years later control EGDs were performed; they revealed just tiny scar at the level of the upper esophageal sphincter and no other changes of the esophageal wall. Conclusion: The removal of the giant esophageal polyp using modern endoscopic equipment can be safely performed without open surgery.
1039 Endoscopic Septotomy for Sleeve Gastrectomy Leak After Failed Stent Manoel Galvao Neto*3, Wasif M. Abidi1, Christopher C. Thompson1, Abdon Pacurucu2, Eduardo G. de Moura5, Joao Caetano Dallegrave Marchesini4, Josemberg M. Campos2 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2Federal University of Pernambuco, Recife, Brazil; 3Florida International University, Miami, FL; 4Marchesini Clinic, Salvador, Brazil; 5Sao Paulo University, Sao Paulo, Brazil Background: Chronic leaks after laparoscopic sleeve gastrectomy (LSG) are often recurrent and difficult to treat. This is a case of a 37 year-old female patient who developed a gastro-cutaneus fistula 13 days after LSG, treated with laparoscopy, washout and placement of a pig-tail drain. Two metal stents were used but failed to treat the persistent leak. Upper endoscopy showed a septum between the leak cavity and the lumen of the pouch and a distal stricture. Endoscopic therapy: Our patient was treated in three consecutive weekly sessions of septotomy and balloon dilatation. Sequential incisions on the septum were performed with an endoscopic knife or argon plasma coagulation in order to allow communication between both the cavity and gastric lumen. Dilations were performed with hydrostatic (20mm) and pneumatic balloons (30mm) in order to treat the distal stenosis and axis deviation. Gradual improvement was seen over the course of the three sessions as evidenced by decreased drain output and reflux symptoms. Follow up endoscopic and radiographic exams showed leak closure. Clinical implications: Endoscopic septotomy is a feasible option for persistent and chronic leaks. In addition, endoscopic management can avoid a surgical procedure, with its associated morbidity and mortality, even in complex clinical scenarios.
1040 Novel Forcep Strip Method for Gastric Submucosal Tumors Originating From Muscularis Propria Layer In Kyung Yoo*, Jae Hyung Lee, Seung Hun Kang, Seung Han Kim, Jae Min Lee, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hoon Jai Chun, Hongsik Lee, Chang Duck Kim, Jong-Jae Park, Sang Woo Lee Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea (the Republic of)
www.giejournal.org
Background/case: Resection of submucosal tumors by means of endoscopy has been reported using a variety of techniques. However, lesions originating from the muscularis propria layer are unlikely to be resected completely and safely. Here, we report the first series describing the new technique of endoscopic resection for submucosal tumors of the stomach using the simple and safe forcep strip technique. Endoscopic methods: Endoscopic submucosal tumor resection using hot biopsy forcep was attempted in ten consecutive patients in clinical indications for lesion removal. Following injection around the submucosal tumor, the adjacent mucosa or submucosa was grasped with the forceps and pulled away forming a “tent”. Electrocoagulating current was applied for dissection of tissue. For repeating described process, the tumor was dissected from the muscularis propria layer and then carefully removed using forcep. Results: All of the ten patients that underwent Forcep Strip Technique for the gastric submucosal tumors were successful, with the complete resection rate of 100%. There was no major bleeding and the procedure time was reduced compared to the conventional methods. No complications occurred and follow-up was unremarkable. It is possible to resect submucosal tumor any part of the stomach (fundus, cardia, body). On histology, all tumors were resected completely (eight gastrointestinal stromal tumor, two leiomyomas). Clinical implications: Forcep Strip Method appears to be an easy, safe, and effective procedure for treatment of gastric submucosal tumor originating from the muscularis propria layer.
1041 Endoscopic Biliary Reconstruction Post Pancreaticoduodenectomy Alvin Y. Ting*, David Devonshire, Michael P. Swan, Daniel Croagh Gastroenterology, Monash Health, Burwood, Victoria, Australia Background: A 29 year old female who previously underwent a pylorus preserving pancreaticoduodenectomy for an insulinoma 9 months previously presented with a biliary stricture causing obstructive jaundice. Attempts to traverse the stricture radiologically were unsuccessful. The stricture could not be reached with a paediatric colonoscope and she was considered for surgical revision of the hepaticojejunostomy. Prior to this, one final attempt at endoscopic revision of the hepaticojejunostomy was made. Endoscopic methods: Upsizing of the PTC tract with a 12Fr catheter by interventional radiology allowed insertion of a cholangioscope percutaneously to the level of the anastomosis. A single balloon enteroscope was advanced retrograde to the enteric side of the anastomosis. The exact position of the bilioenteric anastomosis was identified by transillumination from the cholangioscope. The sharp end of an ERCP wire was introduced through the cholangioscope and used to perforate the membrane covering the anastomosis under direct vision from the enteroscope. A covered SEMS was introduced over the wire through the PTC sheath and deployed across the stricture under endoscopic vision. Follow up cholangiogram at 1 week confirms ongoing patency of the stent and the external drain was removed. Follow up at 1 month revealed no clinical signs or symptoms of biliary obstruction. Clinical implications: This technique allowed the patient to undergo an endoscopic procedure as a day case which re-established biliary drainage and avoided major revisional surgery.
1042 Endoscopic Salvage of a Duodenal Stump Leak and Surgical Transection of the Ampulla Anthony Y. Teoh*, Shannon M. Chan, Hon Chi Yip, Philip W. Chiu, Enders K. Ng, James Y. Lau Surgery, Chinese University of Hong Kong, Hong Kong, NA, Hong Kong Case: A 50 year-old gentlemen with known history of abdominal liposarcoma underwent multiple debulking resection since 2005. Follow-up computed tomography (CT) showed extensive progression of the tumor at the left upper retroperitoneum and also between the pancreatic uncinate process and 3rd part of duodenum. Debulking of the tumor with resection of the uncinate process and the 2nd to 4th part of the duodenum was performed. However, the patient presented with obstructive jaundice on post-operative day 2 and CT scan showed the presence of a dilated common bile and a 3.5cm pancreatic collection. The effluent from the paraduodenal drain also resembled that of gastrointestinal contents. Features suggestive of a transected ampulla and leaking duodenal stump. Percutaneous biliary drainage was performed and the patient was subjected to 4 weeks of conservative management. Unfortunately, the duodenal stump leak failed to settle. Thus, a 2-stage procedure for endoscopic salvage of the condition was formulated. First, biliary drainage was achieved by EUS-guided choledochoduodenostomy using a lumen apposing stent. Then, the defect in the duodenal stump was closed by the over-thescope clip. Post-procedurally, the patient remained stable with decreasing output from the drains. Follow-up cholangiogram showed passage of contrast through the lumen apposing stent and the anastomosis without evidence of leakage. The patient was discharged 3 months after the initial surgery. Endoscopic methods: EUS-guided choledochoduodenostomy was performed with the lumen apposing stent that was delivered on a cautery-equipped delivery system. The echoendoscope was in a short-scope position, as adhesions from prior surgery prevent a long-scope position. Thus, the tip of the echoendoscope was pointing towards the 2nd part of the
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB195
1038 Endoscopic Removal of a Giant Double-Headed Esophageal Fibrovascular Polyp Ekaterina Ivanova*, Evgeny Fedorov, Oleg I. Yudin, Michail Poltoratsky, Evgeny Gorbachev Endoscopy, Moscow University Hospital N 31, Moscow, Russian Federation Introduction: The surgical approach is generally recommended for the excision of giant esophageal fibrovascular polyps to ensure adequate hemostasis and clear resection of the base. Only single cases of merely endoscopic removal of this rare benign tumor have been described in the literature. Aims & Methods: To demonstrate possibilities of successful resection of a giant fibrovascular polyp of the esophagus via an endoscope. A 50-year-old man was admitted to our hospital with a 6-month history of globus sensation, mild intermittent dysphagia during swallowing, occasional heartburn and epigastric pain. In a barium swallow and repeated EGDs a giant double-headed polyp with smooth overlying mucosa, arising from the upper esophagus just near the level of the cricopharyngeus at the pharyngoesophageal junction and extending from 17 to 34 cm from the incisors settling in the distal esophagus was revealed. It had a broad 18mm basis, distal head 32 mm at its maximum diameter with 2 ulcerations on the apex, proximal head 25 mm in diameter and length, with the ramification at the distance of 45 mm from the stalk’s base. EUS detected the lesion originated from the submucosal layer with inhomogeneous echo-texture with both hyper- and hypoechoic features with a number of vascular structures within the stalk. Results: Removal of the polyp was performed under general anesthesia with elective intubation, started with GIF-H180 following by GIF-2T160, using the Maxim-402 electrosurgical unit and CO2 insufflation. The equipment for intervention included 4 endoloops, grasping forceps and large electrosurgical snare. At first, we applied two loops at the level of ramification, resected the first 75 mm fragment above the loop and removed it. Then, we placed 2 another loops at the very base of the pedicle and removed the second fragment, thus performed total polypectomy, leaving the ligated 10 mm long stalk stump in place. Neither bleeding nor other complications occurred. The total length of the resected esophageal lesion measured 135 mm. Histology showed the mixture of fibrous and adipose tissue accompanied by an abundant network of large vessels, covered by a normal squamous epithelium. The patient was discharged from the hospital on the 4th day. A month and 1.5 years later control EGDs were performed; they revealed just tiny scar at the level of the upper esophageal sphincter and no other changes of the esophageal wall. Conclusion: The removal of the giant esophageal polyp using modern endoscopic equipment can be safely performed without open surgery.
1039 Endoscopic Septotomy for Sleeve Gastrectomy Leak After Failed Stent Manoel Galvao Neto*3, Wasif M. Abidi1, Christopher C. Thompson1, Abdon Pacurucu2, Eduardo G. de Moura5, Joao Caetano Dallegrave Marchesini4, Josemberg M. Campos2 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2Federal University of Pernambuco, Recife, Brazil; 3Florida International University, Miami, FL; 4Marchesini Clinic, Salvador, Brazil; 5Sao Paulo University, Sao Paulo, Brazil Background: Chronic leaks after laparoscopic sleeve gastrectomy (LSG) are often recurrent and difficult to treat. This is a case of a 37 year-old female patient who developed a gastro-cutaneus fistula 13 days after LSG, treated with laparoscopy, washout and placement of a pig-tail drain. Two metal stents were used but failed to treat the persistent leak. Upper endoscopy showed a septum between the leak cavity and the lumen of the pouch and a distal stricture. Endoscopic therapy: Our patient was treated in three consecutive weekly sessions of septotomy and balloon dilatation. Sequential incisions on the septum were performed with an endoscopic knife or argon plasma coagulation in order to allow communication between both the cavity and gastric lumen. Dilations were performed with hydrostatic (20mm) and pneumatic balloons (30mm) in order to treat the distal stenosis and axis deviation. Gradual improvement was seen over the course of the three sessions as evidenced by decreased drain output and reflux symptoms. Follow up endoscopic and radiographic exams showed leak closure. Clinical implications: Endoscopic septotomy is a feasible option for persistent and chronic leaks. In addition, endoscopic management can avoid a surgical procedure, with its associated morbidity and mortality, even in complex clinical scenarios.
1040 Novel Forcep Strip Method for Gastric Submucosal Tumors Originating From Muscularis Propria Layer In Kyung Yoo*, Jae Hyung Lee, Seung Hun Kang, Seung Han Kim, Jae Min Lee, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hoon Jai Chun, Hongsik Lee, Chang Duck Kim, Jong-Jae Park, Sang Woo Lee Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea (the Republic of)
www.giejournal.org
Background/case: Resection of submucosal tumors by means of endoscopy has been reported using a variety of techniques. However, lesions originating from the muscularis propria layer are unlikely to be resected completely and safely. Here, we report the first series describing the new technique of endoscopic resection for submucosal tumors of the stomach using the simple and safe forcep strip technique. Endoscopic methods: Endoscopic submucosal tumor resection using hot biopsy forcep was attempted in ten consecutive patients in clinical indications for lesion removal. Following injection around the submucosal tumor, the adjacent mucosa or submucosa was grasped with the forceps and pulled away forming a “tent”. Electrocoagulating current was applied for dissection of tissue. For repeating described process, the tumor was dissected from the muscularis propria layer and then carefully removed using forcep. Results: All of the ten patients that underwent Forcep Strip Technique for the gastric submucosal tumors were successful, with the complete resection rate of 100%. There was no major bleeding and the procedure time was reduced compared to the conventional methods. No complications occurred and follow-up was unremarkable. It is possible to resect submucosal tumor any part of the stomach (fundus, cardia, body). On histology, all tumors were resected completely (eight gastrointestinal stromal tumor, two leiomyomas). Clinical implications: Forcep Strip Method appears to be an easy, safe, and effective procedure for treatment of gastric submucosal tumor originating from the muscularis propria layer.
1041 Endoscopic Biliary Reconstruction Post Pancreaticoduodenectomy Alvin Y. Ting*, David Devonshire, Michael P. Swan, Daniel Croagh Gastroenterology, Monash Health, Burwood, Victoria, Australia Background: A 29 year old female who previously underwent a pylorus preserving pancreaticoduodenectomy for an insulinoma 9 months previously presented with a biliary stricture causing obstructive jaundice. Attempts to traverse the stricture radiologically were unsuccessful. The stricture could not be reached with a paediatric colonoscope and she was considered for surgical revision of the hepaticojejunostomy. Prior to this, one final attempt at endoscopic revision of the hepaticojejunostomy was made. Endoscopic methods: Upsizing of the PTC tract with a 12Fr catheter by interventional radiology allowed insertion of a cholangioscope percutaneously to the level of the anastomosis. A single balloon enteroscope was advanced retrograde to the enteric side of the anastomosis. The exact position of the bilioenteric anastomosis was identified by transillumination from the cholangioscope. The sharp end of an ERCP wire was introduced through the cholangioscope and used to perforate the membrane covering the anastomosis under direct vision from the enteroscope. A covered SEMS was introduced over the wire through the PTC sheath and deployed across the stricture under endoscopic vision. Follow up cholangiogram at 1 week confirms ongoing patency of the stent and the external drain was removed. Follow up at 1 month revealed no clinical signs or symptoms of biliary obstruction. Clinical implications: This technique allowed the patient to undergo an endoscopic procedure as a day case which re-established biliary drainage and avoided major revisional surgery.
1042 Endoscopic Salvage of a Duodenal Stump Leak and Surgical Transection of the Ampulla Anthony Y. Teoh*, Shannon M. Chan, Hon Chi Yip, Philip W. Chiu, Enders K. Ng, James Y. Lau Surgery, Chinese University of Hong Kong, Hong Kong, NA, Hong Kong Case: A 50 year-old gentlemen with known history of abdominal liposarcoma underwent multiple debulking resection since 2005. Follow-up computed tomography (CT) showed extensive progression of the tumor at the left upper retroperitoneum and also between the pancreatic uncinate process and 3rd part of duodenum. Debulking of the tumor with resection of the uncinate process and the 2nd to 4th part of the duodenum was performed. However, the patient presented with obstructive jaundice on post-operative day 2 and CT scan showed the presence of a dilated common bile and a 3.5cm pancreatic collection. The effluent from the paraduodenal drain also resembled that of gastrointestinal contents. Features suggestive of a transected ampulla and leaking duodenal stump. Percutaneous biliary drainage was performed and the patient was subjected to 4 weeks of conservative management. Unfortunately, the duodenal stump leak failed to settle. Thus, a 2-stage procedure for endoscopic salvage of the condition was formulated. First, biliary drainage was achieved by EUS-guided choledochoduodenostomy using a lumen apposing stent. Then, the defect in the duodenal stump was closed by the over-thescope clip. Post-procedurally, the patient remained stable with decreasing output from the drains. Follow-up cholangiogram showed passage of contrast through the lumen apposing stent and the anastomosis without evidence of leakage. The patient was discharged 3 months after the initial surgery. Endoscopic methods: EUS-guided choledochoduodenostomy was performed with the lumen apposing stent that was delivered on a cautery-equipped delivery system. The echoendoscope was in a short-scope position, as adhesions from prior surgery prevent a long-scope position. Thus, the tip of the echoendoscope was pointing towards the 2nd part of the
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB195