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1043 Submucosal Tunneling Endoscopic Resection of a Gigantic Esophageal Leiomyoma
Abstracts
the abdominal wall may decrease the risk of postoperative peritonitis, secondary to stool leakage or to tube dislocation.
1042 Treatment of Zenker’s Diverticulum by a Novel Technique of Endoscopic Tunneling Ting Xie*, Sachin Mulmi Shrestha, Qin Lu, Ruihua Shi Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China Background: Zenker’s Diverticulum (ZD) is a protrusion of mucosa in esophagus caused by high pressures during swallowing through an area known as Killian’s triangle. Previously, the treatment of ZD was done by open surgery, with the advancement of endoscopic treatments in recent years, the ZD could be treated by endoscopy so we have performed a novel treatment technique, myotomy via endoscopic tunneling similar to current Per Oral Endoscopic Myotomy (POEM). Case and method: We hereby, present a case of a 75 years old male patient diagnosed with ZD who had symptoms of dysphagia since 2 years and the symptom was progressive. In this new technique, cricopharyngeus muscle is dissected by maintaining the integrity of the mucosal surface which is performed in four steps: 1. Mucosal incision-Submucosal injection of normal saline, Methylene Blue and Adrenaline was given on 2cm above the Zenker’s diverticulum (16 cm from the incisors) to create a wheal then the horizontal incision was given by Dual knife at the tunnel entry; 2. Submucosal tunneling- A submucosal horizontal tunnel was created alongside the border of the cricopharyngeus muscle. A submucosal horizontal tunnel is created by using a technique similar to POEM; 3. Septum division- Cricopharyngeus muscle was fully exposed then muscle layer was dissected via Triangle knife. The range of dissection was extended from esophagus to smooth muscle to the base of the sac; 4. Mucosal closure- The dissected site was clipped by rotator hemoclips. Patient was discharged after 4 days. Follow up in half month, one month and half year showed no discomfort, ease in intake of food and liquid and increase in weight. Conclusion: With reference to this patient, this technique is safe and has greater significance for treatment on relieving the discomforts of the patient. As tunnel opening is relatively high in position, the selection of hemoclips with short handle is necessary to avoid any discomfort to the patient.
1043 Submucosal Tunneling Endoscopic Resection of a Gigantic Esophageal Leiomyoma Saowonee Ngamruengphong*, Yuri Hanada, Olaya Isabella Brewer Gutierrez, Omid Sanaei, Majidah A. Bukhari, Yen-I. Chen, Vivek Kumbhari, Mouen A. Khashab Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD Submucosal tunneling endoscopic resection (STER) for removal of upper GI tumors arising from the muscularis propria has been demonstrated to be effective and safe. The largest tumor reported to be resected by STER was 6 cm in size. We demonstrated the technique of STER for removal of a 10 cm esophageal leiomyoma and management of a large mucosotomy. A 66 year-old female presented with dysphagia. CT scan revealed a 10x4x3 cm mass with central calcification in the mid esophagus. EGD found a large esophageal subepithelial lesion at 20–30 cm from incisors. EUS revealed a homogenous hypoechoic lesion with central calcification arising from muscularis propria. The results of EUS-FNA were consistent with leiomyoma. The patients refused surgical resection. STER procedure was offered. To begin STER, mucosal incision was created 3 cm proximal to the lesion. Mucosal incision was made with a triangular tip knife using dry cut mode. Following entering submucosal, submucosal fiber was dissected using spray coagulation to gain access to submucosal tunnel and was continued to the level of the lesion. The lesion was dissected away from submucosal fiber, mucosa and muscularis propria. Particular care was taken not to injure mucosal layer to avoid full thickness perforation. The lesion was resected completely en bloc. Due to the size mismatch between the submucosal tunnel and the lesion, the lesion could not be removed from the tunnel. The tumor was then fragmented with a needle knife and snare cautery. The tumor pieces were removed from the tunnel. A large defect was seen in the muscle layer of esophagus after resection of the tumor without evidence of residual tumor. Careful examination of the esophageal mucosa revealed an area suspicious for thermal injury at 3 cm distal to the mucosotomy site. We placed three endoscopic clips prophylactically at this area to prevent delayed perforation. To complete the procedure, the mucosotomy was closed. We successfully placed 8 endoscopic clips for mucosal incision closure. On post-op day 1, esophagram revealed filling of contrast in the submucosal cavity, consistent with esophageal leak. Urgent EGD noted that endoclips fell off and a large mucosal defect was seen. A 23 mm diameter fully covered metal stent with 25 mm diameter flange was deployed across the mucosal defect. The patient tolerated soft diet and was discharged home on post-op day 6. Repeat EGD at 4-week with stent removal was performed. The mucosal defect was well healed. Contrast injection revealed no leak. The patient had resolution of dysphagia.
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1044 Elective Two-Stage Tunnelling Esd (ETSD) for Giant Circumferential Rectal Lateral Spreading Tumor (LST) Amol Bapaye*, Mahesh Mahadik, Nachiket Dubale, Rajendra Pujari Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India Background and Aim: Endoscopic Submucosal Dissection (ESD) for large rectal lateral spreading tumors (LST) is time consuming, often involves prolonged anesthesia, may lead to operator fatigue and thereby may adversely affect procedure outcomes. Piecemeal endoscopic mucosal resection (EMR-P) is an alternative but it only allows piecemeal resection. Risk of recurrence is therefore higher and accurate histology reporting may be compromised. To reduce procedure times and improve outcomes, tunnelling endoscopic submucosal dissection (ETSD) has been suggested as a more efficient alternative. Despite these modifications, ESD for such large tumors remains a technical challenge. We believe that by electively splitting the procedure in two sessions 48-hours apart, this difficulty may be somewhat resolved without significantly compromising on the quality of resection. The present video demonstrates an elective two-stage ETSD technique used to resect a large circumferential rectal LST. Methods: 58-year female – increased stool frequency, mucus and blood in stool. Colonoscopy – circumferential rectal LST from anorectal junction to 13cm proximally. Narrow band imaging (NBI) – type II/III pit pattern. Earlier biopsy – tubulovillous adenoma with moderate dysplasia. Rectal endosonography (EUS) – mucosal lesion. Patient consented for two-stage ETSD. Two stages performed 48hours apart. First stage - mucosal incisions taken at anorectal junction on posterior wall on anal side and proximal to lesion on oral side. Submucosal (SM) tunnel was created from anal to oral direction to connect both incisions. SM dissection was extended laterally under mucosal surface to widen tunnel. After 60% dissection of circumference, mucosa was divided at both lateral margins from anal to oral side to complete the resection. 48-hours later, similar technique was used anteriorly to complete the residual dissection. Results: Complete LST resection was performed in two pieces. Procedure times – 120 and 150 min for both sessions respectively. No adverse events. Final histology – tubulovillous adenoma with foci of high grade dysplasia, lateral and deep margins free. One-month sigmoidoscopy – mild luminal narrowing, easy scope passage, no residual tumor and healing ESD scar. One-year colonoscopy – SM scarring, no recurrence. Conclusion: Two-stage tunnelling ETSD may be safe and effective for complete resection of large circumferential rectal LST’s. Technique is efficient, may reduce procedure time and operator fatigue; and may improve outcomes without compromising on the quality of the resection.
1045 Endoscopic Fenestration of a Symptomatic Esophageal Duplication Cyst Theodore James*, Ian S. Grimm, Todd H. Baron Gastroenterology, University of North Carolina, Chapel Hill, NC A 52 year-old female with a past medical history of gastroesophageal reflux and hypertension presented with a chief complaint of gradual onset substernal chest pressure and intermittent dysphagia. Cardiac evaluation of her symptoms was negative. CT scan of the chest demonstrated a mass in the posterior mediastinum which was compliant with the distal esophagus. Upper endoscopy with endoscopic ultrasound (EUS) demonstrated an anechoic cyst located between the left atrium and esophagus; the cyst was clearly associated with the esophageal wall. Following discussion at thoracic tumor board, the patient was referred for endoscopic management of the cyst. Electrocautery knife was used to make an incision into the distal esophagus with EUS serving to guide instrument placement. Hook knife was selected in order to create a larger opening into the cyst and decrease the risk of abscess formation. Following incision into the cyst, copious mucinous fluid drained into the esophageal lumen. The upper endoscope was then re-inserted and was used to view the inside of the cystic cavity. The cavity was lavaged with saline and NAcetylcysteine. Biopsies were taken from the lining of the cyst cavity with standard biopsy forceps. Use of endoclips at the base of the incision was critical to prevent further dissection of the esophageal lumen which could lead to perforation. Histopathologic staining from the biopsy tissue was consistent with an esophageal duplication cyst. Upper endoscopy with EUS was repeated 4 weeks after the initial procedure and the site of the former cyst was now demonstrated to be a simple diverticula. Repeat EUS demonstrated complete resolution of the fluid-filled cyst. The entire procedure was completed as an outpatient and there were no adverse events. Esophageal duplication cysts are the embryological remnant of the primitive diverticula which normally forms the dorsal esophagus and ventral respiratory tract. They are benign mediastinal masses that usually present in infancy in childhood and involve the distal third of the esophagus. Endoscopic fenestration by a skilled therapeutic endoscopist is safe and efficacious in the management of these cysts. This approach allows for an outpatient procedure with decreased postoperative recovery time. The endoscopic cavity should be completely debrided in order to decrease the risk of infection following the procedure and the base of the cyst should be clipped to prevent spontaneous dissection and perforation of the esophagus. Previous case reports have described resection or banding of esophageal duplication cysts, however this is the first video case report to describe endoscopic fenestration in the management of these cysts.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB127
the abdominal wall may decrease the risk of postoperative peritonitis, secondary to stool leakage or to tube dislocation.
1042 Treatment of Zenker’s Diverticulum by a Novel Technique of Endoscopic Tunneling Ting Xie*, Sachin Mulmi Shrestha, Qin Lu, Ruihua Shi Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China Background: Zenker’s Diverticulum (ZD) is a protrusion of mucosa in esophagus caused by high pressures during swallowing through an area known as Killian’s triangle. Previously, the treatment of ZD was done by open surgery, with the advancement of endoscopic treatments in recent years, the ZD could be treated by endoscopy so we have performed a novel treatment technique, myotomy via endoscopic tunneling similar to current Per Oral Endoscopic Myotomy (POEM). Case and method: We hereby, present a case of a 75 years old male patient diagnosed with ZD who had symptoms of dysphagia since 2 years and the symptom was progressive. In this new technique, cricopharyngeus muscle is dissected by maintaining the integrity of the mucosal surface which is performed in four steps: 1. Mucosal incision-Submucosal injection of normal saline, Methylene Blue and Adrenaline was given on 2cm above the Zenker’s diverticulum (16 cm from the incisors) to create a wheal then the horizontal incision was given by Dual knife at the tunnel entry; 2. Submucosal tunneling- A submucosal horizontal tunnel was created alongside the border of the cricopharyngeus muscle. A submucosal horizontal tunnel is created by using a technique similar to POEM; 3. Septum division- Cricopharyngeus muscle was fully exposed then muscle layer was dissected via Triangle knife. The range of dissection was extended from esophagus to smooth muscle to the base of the sac; 4. Mucosal closure- The dissected site was clipped by rotator hemoclips. Patient was discharged after 4 days. Follow up in half month, one month and half year showed no discomfort, ease in intake of food and liquid and increase in weight. Conclusion: With reference to this patient, this technique is safe and has greater significance for treatment on relieving the discomforts of the patient. As tunnel opening is relatively high in position, the selection of hemoclips with short handle is necessary to avoid any discomfort to the patient.
1043 Submucosal Tunneling Endoscopic Resection of a Gigantic Esophageal Leiomyoma Saowonee Ngamruengphong*, Yuri Hanada, Olaya Isabella Brewer Gutierrez, Omid Sanaei, Majidah A. Bukhari, Yen-I. Chen, Vivek Kumbhari, Mouen A. Khashab Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD Submucosal tunneling endoscopic resection (STER) for removal of upper GI tumors arising from the muscularis propria has been demonstrated to be effective and safe. The largest tumor reported to be resected by STER was 6 cm in size. We demonstrated the technique of STER for removal of a 10 cm esophageal leiomyoma and management of a large mucosotomy. A 66 year-old female presented with dysphagia. CT scan revealed a 10x4x3 cm mass with central calcification in the mid esophagus. EGD found a large esophageal subepithelial lesion at 20–30 cm from incisors. EUS revealed a homogenous hypoechoic lesion with central calcification arising from muscularis propria. The results of EUS-FNA were consistent with leiomyoma. The patients refused surgical resection. STER procedure was offered. To begin STER, mucosal incision was created 3 cm proximal to the lesion. Mucosal incision was made with a triangular tip knife using dry cut mode. Following entering submucosal, submucosal fiber was dissected using spray coagulation to gain access to submucosal tunnel and was continued to the level of the lesion. The lesion was dissected away from submucosal fiber, mucosa and muscularis propria. Particular care was taken not to injure mucosal layer to avoid full thickness perforation. The lesion was resected completely en bloc. Due to the size mismatch between the submucosal tunnel and the lesion, the lesion could not be removed from the tunnel. The tumor was then fragmented with a needle knife and snare cautery. The tumor pieces were removed from the tunnel. A large defect was seen in the muscle layer of esophagus after resection of the tumor without evidence of residual tumor. Careful examination of the esophageal mucosa revealed an area suspicious for thermal injury at 3 cm distal to the mucosotomy site. We placed three endoscopic clips prophylactically at this area to prevent delayed perforation. To complete the procedure, the mucosotomy was closed. We successfully placed 8 endoscopic clips for mucosal incision closure. On post-op day 1, esophagram revealed filling of contrast in the submucosal cavity, consistent with esophageal leak. Urgent EGD noted that endoclips fell off and a large mucosal defect was seen. A 23 mm diameter fully covered metal stent with 25 mm diameter flange was deployed across the mucosal defect. The patient tolerated soft diet and was discharged home on post-op day 6. Repeat EGD at 4-week with stent removal was performed. The mucosal defect was well healed. Contrast injection revealed no leak. The patient had resolution of dysphagia.
www.giejournal.org
1044 Elective Two-Stage Tunnelling Esd (ETSD) for Giant Circumferential Rectal Lateral Spreading Tumor (LST) Amol Bapaye*, Mahesh Mahadik, Nachiket Dubale, Rajendra Pujari Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India Background and Aim: Endoscopic Submucosal Dissection (ESD) for large rectal lateral spreading tumors (LST) is time consuming, often involves prolonged anesthesia, may lead to operator fatigue and thereby may adversely affect procedure outcomes. Piecemeal endoscopic mucosal resection (EMR-P) is an alternative but it only allows piecemeal resection. Risk of recurrence is therefore higher and accurate histology reporting may be compromised. To reduce procedure times and improve outcomes, tunnelling endoscopic submucosal dissection (ETSD) has been suggested as a more efficient alternative. Despite these modifications, ESD for such large tumors remains a technical challenge. We believe that by electively splitting the procedure in two sessions 48-hours apart, this difficulty may be somewhat resolved without significantly compromising on the quality of resection. The present video demonstrates an elective two-stage ETSD technique used to resect a large circumferential rectal LST. Methods: 58-year female – increased stool frequency, mucus and blood in stool. Colonoscopy – circumferential rectal LST from anorectal junction to 13cm proximally. Narrow band imaging (NBI) – type II/III pit pattern. Earlier biopsy – tubulovillous adenoma with moderate dysplasia. Rectal endosonography (EUS) – mucosal lesion. Patient consented for two-stage ETSD. Two stages performed 48hours apart. First stage - mucosal incisions taken at anorectal junction on posterior wall on anal side and proximal to lesion on oral side. Submucosal (SM) tunnel was created from anal to oral direction to connect both incisions. SM dissection was extended laterally under mucosal surface to widen tunnel. After 60% dissection of circumference, mucosa was divided at both lateral margins from anal to oral side to complete the resection. 48-hours later, similar technique was used anteriorly to complete the residual dissection. Results: Complete LST resection was performed in two pieces. Procedure times – 120 and 150 min for both sessions respectively. No adverse events. Final histology – tubulovillous adenoma with foci of high grade dysplasia, lateral and deep margins free. One-month sigmoidoscopy – mild luminal narrowing, easy scope passage, no residual tumor and healing ESD scar. One-year colonoscopy – SM scarring, no recurrence. Conclusion: Two-stage tunnelling ETSD may be safe and effective for complete resection of large circumferential rectal LST’s. Technique is efficient, may reduce procedure time and operator fatigue; and may improve outcomes without compromising on the quality of the resection.
1045 Endoscopic Fenestration of a Symptomatic Esophageal Duplication Cyst Theodore James*, Ian S. Grimm, Todd H. Baron Gastroenterology, University of North Carolina, Chapel Hill, NC A 52 year-old female with a past medical history of gastroesophageal reflux and hypertension presented with a chief complaint of gradual onset substernal chest pressure and intermittent dysphagia. Cardiac evaluation of her symptoms was negative. CT scan of the chest demonstrated a mass in the posterior mediastinum which was compliant with the distal esophagus. Upper endoscopy with endoscopic ultrasound (EUS) demonstrated an anechoic cyst located between the left atrium and esophagus; the cyst was clearly associated with the esophageal wall. Following discussion at thoracic tumor board, the patient was referred for endoscopic management of the cyst. Electrocautery knife was used to make an incision into the distal esophagus with EUS serving to guide instrument placement. Hook knife was selected in order to create a larger opening into the cyst and decrease the risk of abscess formation. Following incision into the cyst, copious mucinous fluid drained into the esophageal lumen. The upper endoscope was then re-inserted and was used to view the inside of the cystic cavity. The cavity was lavaged with saline and NAcetylcysteine. Biopsies were taken from the lining of the cyst cavity with standard biopsy forceps. Use of endoclips at the base of the incision was critical to prevent further dissection of the esophageal lumen which could lead to perforation. Histopathologic staining from the biopsy tissue was consistent with an esophageal duplication cyst. Upper endoscopy with EUS was repeated 4 weeks after the initial procedure and the site of the former cyst was now demonstrated to be a simple diverticula. Repeat EUS demonstrated complete resolution of the fluid-filled cyst. The entire procedure was completed as an outpatient and there were no adverse events. Esophageal duplication cysts are the embryological remnant of the primitive diverticula which normally forms the dorsal esophagus and ventral respiratory tract. They are benign mediastinal masses that usually present in infancy in childhood and involve the distal third of the esophagus. Endoscopic fenestration by a skilled therapeutic endoscopist is safe and efficacious in the management of these cysts. This approach allows for an outpatient procedure with decreased postoperative recovery time. The endoscopic cavity should be completely debrided in order to decrease the risk of infection following the procedure and the base of the cyst should be clipped to prevent spontaneous dissection and perforation of the esophagus. Previous case reports have described resection or banding of esophageal duplication cysts, however this is the first video case report to describe endoscopic fenestration in the management of these cysts.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB127