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1049 Multiple Tunneling Technique for Treatment of Rectal Circumferential Lateral Spreading Tumor With Endoscopic Submucosal Dissection
Abstracts
CT showed the thoracoabdominal endograft in proper position; the excluded aneurysmal sac demonstrated increased enhancement and enlargement compared to prior exams, measuring 3.8 cm. No contrast extravasated into the sac. Blood cultures grew Bacteroides fragilis. Given multiple co-morbidities, advanced age and American Society of Anesthesiologists (ASA) score of IV, minimally invasive treatment of a presumed mycotic aneurysm was undertaken. Endoscopic methods: Under general anesthesia a linear echoendoscope was passed into the esophagus. A collection was adjacent to the esophagus around the aorta and vascular stent graft, without vascular flow by color Doppler imaging. A 19-gauge needle was passed through the endoscope, across the esophageal wall into the collection. Gross pus was aspirated, which subsequently grew Bacteroides fragilis. A 0.025’’ guidewire was advanced into the collection through the needle. Over the guidewire a 10mm diameter by 1cm long fully covered stent was deployed across the esophageal wall. There was marked clinical improvement. Follow-up CT 48 hours later showed resolution of the excluded aneurysm sac collection. Three days later the stent was endoscopically removed, and the endoscope advanced into the mycotic cavity where the vascular stent was visualized. After irrigation with sterile saline the esophageal tract was endoscopically closed. Barium swallow showed no leak. The patient was discharged home 11 days postprocedurally and remains well 27 days after initial endoscopic drainage. Long-term suppressive antibiotics will be administered. Clinical implications: Endograft infection occurs in 0.2% to 0.7% of patients and represent a difficult management problem. Presentations include chronic sepsis, severe acute sepsis and aortoenteric fistulae. Infections are often delayed; in one study up to 72 months after graft placement. Surgery with graft explant is the primary treatment, though with high mortality. Percutaneous therapy is primarily reserved for nonoperative patients, though the abscess was not accessible percutaneously in our patient. Endoscopic ultrasound-guided interventions are increasingly used for drainage of collections in close proximity to gastrointestinal lumens. We are unaware of prior reports of transesophageal drainage of endograft infections. Confirmation of lack of communication between the aneurysmal sac and the aorta is mandatory using contrast imaging studies, including Doppler ultrasound at the time of endoscopic drainage.
1049 Multiple Tunneling Technique for Treatment of Rectal Circumferential Lateral Spreading Tumor With Endoscopic Submucosal Dissection Fatih Aslan*1, Melek Kucuk1, Zehra Akpinar1, Derya A. Yurtlu2, Emrah Alper1, Nese Ekinci3, Belkis Unsal1 1 Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey; 2Anesthesiology and Reanimation, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey; 3Pathology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
1048 Submucosal Tunneling Technique Using Insulated -Tip Knife in Complete Circumferential ESD for a Giant Rectal LST Kenichiro Imai*, Kinichi Hotta, Sayo Ito, Yuichiro Yamaguchi, Noboru Kawata, Naomi Kakushima, Masaki Tanaka, Kohei Takizawa, Hiroyuki Matsubayashi, Hiroyuki Ono Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Japan
1050 Misplaced “Bear Claw” in a Bleeding Gastric Ulcer: What Next? Ravishankar Asokkumar*1, Roy M. Soetikno1,2 1 Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; 2National Cancer Centre, Singapore, Singapore
Background: Because of technical difficulties due to lesion size, many large LSTs continue to be referred for surgery even if the estimated risk for metastasis is quite low. ESD has been used for curative treatment for large colorectal neoplasms, with morbidity and cost advantages in comparison with surgery. The indication of ESD for circumferential LSTs is uncertain due to limited number of reported cases and lack of outcome data. Herein, we demonstrated submucosal tunneling technique using insulated –tip knife in complete circumferential ESD for a giant rectal LST. Case presentation: A 70-year-old woman was referred to our hospital for surgery of a large rectal tumor. Colonoscopy showed a 15-cm LST that involved complete circumference of the upper rectum. By magnified endoscopy, we diagnosed it as a mucosal cancer, so decided to perform circumferential ESD for complete resection. During submucosal tunneling ESD procedure, the following steps were performed: (1) circumferential mucosal incisions were made at the anal and oral side of the lesion, (2) submucosal tunnel were created from the anal to oral side using a insulated-tip knife, (3) submucosal dissection was performed with getting into the submucosal tunnel, maintaining good traction from gravity force by patient’s position changes. Submucosal tunneling ESD achieved complete en bloc resection without complications. The resected specimen was shown in covering a 30–ml syringe and 15 cm in length. Histological findings revealed well differentiated tubular adenocarcinoma in situ, with negative lateral and vertical margins. Technical highlight: To the best of knoledge, this is the first case of submucosal tunneling technique applied in colorectal ESD. Submucosal tunneling procedure using insulated-tip knife may be safe due to reduced risk for perforation. Good traction from gravity force was maintained by the weight of large mucosal flap and by patient’s position changes. Conclusion: This case illustrates submucosal tunneling technique using insulated–tip knife in complete circumferential ESD for 15-cm giant rectal LST. Submucosal tunneling technique using insulated-knife may be a potential feasible method in circumferential colorectal ESD.
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Background: Endoscopic submucosal dissection (ESD) is an effective and safe method, enabling en-bloc resection of lesions, even large premalignant or early malignant lesions. There are different techniques to remove large colorectal lesions with ESD as en-bloc. We report a successful resection of a circumferential laterally spreading tumor (LST) in colon 10 cm in size by colorectal ESD with a different and a new technique which is used for the first time. Methods: Procedures were performed after the patient was sedated with spinal anesthesia by anesthetist at the endoscopy unit. To achieve en-bloc resection and benefit from gravity ESD was planned as follows; first to open 3 different tunnels from the beginning of the lesion towards proximal site according to the gravity and maneuver of the endoscope and then to connect the tunnels. At the beginning; a mixture of sodium hyaluronate, indigocarmine and epinephrine was injected for submucosal elevation. After 2-3 cm of dissection the mixture of saline, epinephrine and indigocarmine was used for easier and quicker injection. Time between the initial incision and separation of the lesion from normal tissue was recorded as duration of procedure. Results: Case: The colonoscopic examination of a 68 years old woman revealed a flat lesion with polypoid, features at some areas starting at 2 cm from the anal canal extending 10 cm proximally. After the ESD procedure, the resected tumor was taken out as en-bloc and measured 151*97 mm. The procedure time was 273 minutes. Pathologic examination showed intramucosal carcinoma, lateral and vertical margins were clear. No complication occurred during or after the procedures. Two months later no residual tissue was seen on control colonoscopic examinations. Discussion: The lumen of colon is narrow and thin, with standard ESD technique the dissected lesion can completely block the lumen, decrease maneuver capacity of the endoscope and the procedure time may extend because of loss of orientation during the procedure. Multiple tunneling method can be used for an effective and controlled dissection of giant circumferential lesions which can be successfully removed en-bloc.
Background: The over the scope clip (OTSC) with its large claw captures a large amount of tissue and clamp deeply below the vessel. In acute bleeding, proper deployment technique and accurate clip placement is crucial. However, when misplaced, removal of OTSC can be extremely difficult. In this case, we describe the endoscopic technique to manage a misplaced OTSC and treat a large bleeding gastric ulcer. Case: A 91 year old female with a history of NSAID intake for hip fracture presented with hematemesis. Her haemoglobin dropped to 5.6 g/dl. After stabilization, an endoscopy was performed and showed a large (3cm), deep fibrotic ulcer with visible vessel in the incisura. Endoscopic methods: We used OTSC because of the large size and fibrotic base of the ulcer. The size of the clip was chosen based on the ulcer characteristics. We placed the bleeding vessel at the center of the cap and a continuous suction was applied before clip deployment. However, the fibrotic ulcer failed to invert completely with suction alone resulting in OTSC misplacement. Our attempts to stop the bleeding were unsuccessful as the misplaced OTSC obstructed the ulcer field. We then used APC to break the hinge of OTSC. In the setting of acute bleeding, APC alone was inadequate as prolonged administration was needed. We, using a rat tooth forceps, applied continuous traction and displaced OTSC re-exposing the ulcer field. We used a second OTSC to secure hemostasis. Using an anchor, we hooked the ulcer base and pulled it inside the cap before clipping. The bleeding stopped completely after secure clipping. Clinical Implication: The use of OTSC, in contrast to through the scope, may be effective in achieving hemostasis for complex gastric ulcers. The size of the OTSC clip and the technique of deployment should be tailored based on ulcer characteristics to avoid misplacement. In deep fibrotic ulcers, where suction alone is insufficient, an anchor can be used to invert the ulcer inside the cap before clipping. During acute bleeding repositioning a misplaced clip, when possible, may be adequate to re-expose the ulcer than clip dislodgment as the latter can prolong definitive treatment. Thus, proper deployment technique and appropriate use of accessories can avoid misplacement and make OTSC successful.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB197
CT showed the thoracoabdominal endograft in proper position; the excluded aneurysmal sac demonstrated increased enhancement and enlargement compared to prior exams, measuring 3.8 cm. No contrast extravasated into the sac. Blood cultures grew Bacteroides fragilis. Given multiple co-morbidities, advanced age and American Society of Anesthesiologists (ASA) score of IV, minimally invasive treatment of a presumed mycotic aneurysm was undertaken. Endoscopic methods: Under general anesthesia a linear echoendoscope was passed into the esophagus. A collection was adjacent to the esophagus around the aorta and vascular stent graft, without vascular flow by color Doppler imaging. A 19-gauge needle was passed through the endoscope, across the esophageal wall into the collection. Gross pus was aspirated, which subsequently grew Bacteroides fragilis. A 0.025’’ guidewire was advanced into the collection through the needle. Over the guidewire a 10mm diameter by 1cm long fully covered stent was deployed across the esophageal wall. There was marked clinical improvement. Follow-up CT 48 hours later showed resolution of the excluded aneurysm sac collection. Three days later the stent was endoscopically removed, and the endoscope advanced into the mycotic cavity where the vascular stent was visualized. After irrigation with sterile saline the esophageal tract was endoscopically closed. Barium swallow showed no leak. The patient was discharged home 11 days postprocedurally and remains well 27 days after initial endoscopic drainage. Long-term suppressive antibiotics will be administered. Clinical implications: Endograft infection occurs in 0.2% to 0.7% of patients and represent a difficult management problem. Presentations include chronic sepsis, severe acute sepsis and aortoenteric fistulae. Infections are often delayed; in one study up to 72 months after graft placement. Surgery with graft explant is the primary treatment, though with high mortality. Percutaneous therapy is primarily reserved for nonoperative patients, though the abscess was not accessible percutaneously in our patient. Endoscopic ultrasound-guided interventions are increasingly used for drainage of collections in close proximity to gastrointestinal lumens. We are unaware of prior reports of transesophageal drainage of endograft infections. Confirmation of lack of communication between the aneurysmal sac and the aorta is mandatory using contrast imaging studies, including Doppler ultrasound at the time of endoscopic drainage.
1049 Multiple Tunneling Technique for Treatment of Rectal Circumferential Lateral Spreading Tumor With Endoscopic Submucosal Dissection Fatih Aslan*1, Melek Kucuk1, Zehra Akpinar1, Derya A. Yurtlu2, Emrah Alper1, Nese Ekinci3, Belkis Unsal1 1 Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey; 2Anesthesiology and Reanimation, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey; 3Pathology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
1048 Submucosal Tunneling Technique Using Insulated -Tip Knife in Complete Circumferential ESD for a Giant Rectal LST Kenichiro Imai*, Kinichi Hotta, Sayo Ito, Yuichiro Yamaguchi, Noboru Kawata, Naomi Kakushima, Masaki Tanaka, Kohei Takizawa, Hiroyuki Matsubayashi, Hiroyuki Ono Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Japan
1050 Misplaced “Bear Claw” in a Bleeding Gastric Ulcer: What Next? Ravishankar Asokkumar*1, Roy M. Soetikno1,2 1 Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; 2National Cancer Centre, Singapore, Singapore
Background: Because of technical difficulties due to lesion size, many large LSTs continue to be referred for surgery even if the estimated risk for metastasis is quite low. ESD has been used for curative treatment for large colorectal neoplasms, with morbidity and cost advantages in comparison with surgery. The indication of ESD for circumferential LSTs is uncertain due to limited number of reported cases and lack of outcome data. Herein, we demonstrated submucosal tunneling technique using insulated –tip knife in complete circumferential ESD for a giant rectal LST. Case presentation: A 70-year-old woman was referred to our hospital for surgery of a large rectal tumor. Colonoscopy showed a 15-cm LST that involved complete circumference of the upper rectum. By magnified endoscopy, we diagnosed it as a mucosal cancer, so decided to perform circumferential ESD for complete resection. During submucosal tunneling ESD procedure, the following steps were performed: (1) circumferential mucosal incisions were made at the anal and oral side of the lesion, (2) submucosal tunnel were created from the anal to oral side using a insulated-tip knife, (3) submucosal dissection was performed with getting into the submucosal tunnel, maintaining good traction from gravity force by patient’s position changes. Submucosal tunneling ESD achieved complete en bloc resection without complications. The resected specimen was shown in covering a 30–ml syringe and 15 cm in length. Histological findings revealed well differentiated tubular adenocarcinoma in situ, with negative lateral and vertical margins. Technical highlight: To the best of knoledge, this is the first case of submucosal tunneling technique applied in colorectal ESD. Submucosal tunneling procedure using insulated-tip knife may be safe due to reduced risk for perforation. Good traction from gravity force was maintained by the weight of large mucosal flap and by patient’s position changes. Conclusion: This case illustrates submucosal tunneling technique using insulated–tip knife in complete circumferential ESD for 15-cm giant rectal LST. Submucosal tunneling technique using insulated-knife may be a potential feasible method in circumferential colorectal ESD.
www.giejournal.org
Background: Endoscopic submucosal dissection (ESD) is an effective and safe method, enabling en-bloc resection of lesions, even large premalignant or early malignant lesions. There are different techniques to remove large colorectal lesions with ESD as en-bloc. We report a successful resection of a circumferential laterally spreading tumor (LST) in colon 10 cm in size by colorectal ESD with a different and a new technique which is used for the first time. Methods: Procedures were performed after the patient was sedated with spinal anesthesia by anesthetist at the endoscopy unit. To achieve en-bloc resection and benefit from gravity ESD was planned as follows; first to open 3 different tunnels from the beginning of the lesion towards proximal site according to the gravity and maneuver of the endoscope and then to connect the tunnels. At the beginning; a mixture of sodium hyaluronate, indigocarmine and epinephrine was injected for submucosal elevation. After 2-3 cm of dissection the mixture of saline, epinephrine and indigocarmine was used for easier and quicker injection. Time between the initial incision and separation of the lesion from normal tissue was recorded as duration of procedure. Results: Case: The colonoscopic examination of a 68 years old woman revealed a flat lesion with polypoid, features at some areas starting at 2 cm from the anal canal extending 10 cm proximally. After the ESD procedure, the resected tumor was taken out as en-bloc and measured 151*97 mm. The procedure time was 273 minutes. Pathologic examination showed intramucosal carcinoma, lateral and vertical margins were clear. No complication occurred during or after the procedures. Two months later no residual tissue was seen on control colonoscopic examinations. Discussion: The lumen of colon is narrow and thin, with standard ESD technique the dissected lesion can completely block the lumen, decrease maneuver capacity of the endoscope and the procedure time may extend because of loss of orientation during the procedure. Multiple tunneling method can be used for an effective and controlled dissection of giant circumferential lesions which can be successfully removed en-bloc.
Background: The over the scope clip (OTSC) with its large claw captures a large amount of tissue and clamp deeply below the vessel. In acute bleeding, proper deployment technique and accurate clip placement is crucial. However, when misplaced, removal of OTSC can be extremely difficult. In this case, we describe the endoscopic technique to manage a misplaced OTSC and treat a large bleeding gastric ulcer. Case: A 91 year old female with a history of NSAID intake for hip fracture presented with hematemesis. Her haemoglobin dropped to 5.6 g/dl. After stabilization, an endoscopy was performed and showed a large (3cm), deep fibrotic ulcer with visible vessel in the incisura. Endoscopic methods: We used OTSC because of the large size and fibrotic base of the ulcer. The size of the clip was chosen based on the ulcer characteristics. We placed the bleeding vessel at the center of the cap and a continuous suction was applied before clip deployment. However, the fibrotic ulcer failed to invert completely with suction alone resulting in OTSC misplacement. Our attempts to stop the bleeding were unsuccessful as the misplaced OTSC obstructed the ulcer field. We then used APC to break the hinge of OTSC. In the setting of acute bleeding, APC alone was inadequate as prolonged administration was needed. We, using a rat tooth forceps, applied continuous traction and displaced OTSC re-exposing the ulcer field. We used a second OTSC to secure hemostasis. Using an anchor, we hooked the ulcer base and pulled it inside the cap before clipping. The bleeding stopped completely after secure clipping. Clinical Implication: The use of OTSC, in contrast to through the scope, may be effective in achieving hemostasis for complex gastric ulcers. The size of the OTSC clip and the technique of deployment should be tailored based on ulcer characteristics to avoid misplacement. In deep fibrotic ulcers, where suction alone is insufficient, an anchor can be used to invert the ulcer inside the cap before clipping. During acute bleeding repositioning a misplaced clip, when possible, may be adequate to re-expose the ulcer than clip dislodgment as the latter can prolong definitive treatment. Thus, proper deployment technique and appropriate use of accessories can avoid misplacement and make OTSC successful.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB197