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1053 The Last Frontier of the Nonpolypoid Gastrointestinal Neoplasms and Flat Dysplasia of the Anal Canal
Abstracts
1050 Endoscopic Resection of Gastric Subepithelial Tumor Originating From the Muscularis Propria Layer: Clip-And-Cut Method Eun Jeong Gong, Do Hoon Kim*, Hwoon-Yong Jung Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, — Select —, Korea (the Republic of) Background: Advances in endoscopic techniques enabled endoscopic removal of gastric subepithelial tumors (SETs) originating from the muscularis propria layer. Endoscopic full-thickness resection is usually performed for gastric SETs at the fundus, as submucosal tunneling is not feasible in this location of the stomach. However, the closure of perforation occurred during full-thickness resection often requires specific skills or devices. Case: A 70-year-old man presented to our hospital with incidentally found gastric SET. On endoscopy, about 2.5 cm sized protruding lesion covered with surface erosions was noted in the fundus. Endoscopic ultrasonography revealed homogeneous hypoechoic lesion originating from the muscularis propria layer. There was no evidence of regional lymph node enlargement or distant metastasis on computed tomography scan. We performed endoscopic resection with clip-and-cut method, and the lesion was resected successfully. Histological diagnosis was made as gastriointestinal stromal tumor of very low risk. Pneumoperitoneum was not evident. Endoscopic methods: After circumferential incision, the submucosal layer and muscularis propria layer were dissected. Counter traction was made by clip with line method to facilitate the dissection and better visualization of the field. When iatrogenic perforation occurred during resection, the gastric wall defect was closed with endoclips simultaneously. Dissection and the near-complete closure of perforations were performed in a stepwise manner. Complete resection of the tumor as well as defect closure was achieved by repeating the procedure of clipand-cut without laparoscopic assistance. Clinical implications: Stepwise clipping made the closure of perforation easier and reduced the amount of air leakage. Endoscopic resection with clip-and-cut method is useful for removal of gastric SETs originating from the muscularis propria without laparoscopic assistance.
1051 Eus-Guided Transgastric Placement of Temporary Enteral Covered Self-Expandable Metal Stent (CSEMS) to Perform Through-The-Stent Ercp in Roux-En-Y-Gastric Bypass (RYGB) Ramon Sanchez-Ocana*, Marta Cimavilla, Paula Gil-Simon, Carlos De la Serna, Manuel Perez-Miranda Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Valladolid, Spain Introduction: RYGB is associated with gallstone disease. RYGB makes ERCP laborintensive and prone to failure, even despite enteroscopy assistance. ERCP in RYGB usually requires percutaneous approaches (through laparoscopy, laparotomy or interventional gastrostomy). We present a novel, modified EUS-guided approach to facilitate ERCP after RYGB. Description: 66 year old female with prior cholecystectomy and RYGB presenting with cholangitis and documented common bile duct stone. She was offered and consented to an experimental EUS-guided approach to facilitate ERCP. From the proximal stomach the excluded gastric antrum is located and punctured under EUS with a 19G needle. Saline and contrast is injected through the needle to distend the antrum and provide fluoroscopic guidance. A guidewire is coiled in the antrum. The puncture tract is sequentially dilated with a 6F cystotome and a 4-mm balloon prior to through-the-scope insertion of an enteral cSEMS 22 x 90-mm. The cSEMS is deployed across the gastric wall under combined EUS and fluroscopy and then balloon expanded over. After allowing the fistula to mature for 5 days, ERCP is performed with a standard adult duodenoscope through the gastrogastric cSEMS. Sphincterotomy and common bile duct stone removal are performed. The duodenoscope is removed through the cSEMS, which is then exchanged in the same session for double pig-tail stent. There were no complications. The pig-tail stent was removed electively at three months without difficulty. Conclusions: This EUS-guided technique to “bypass the bypass” has been described in a pilot study using lumen-apposing metal stents (LAMS), (Kedia-et-al, GIE-2015). Our case further suggests that intentional interventional gastrostomy (such as in PEG or pseudocyst drainage) can be used as a temporary internal access port for biliary access in RYGB. Currently available LAMS are limited by narrow diameters (up to16-mm only) and short lengths (up to 30-mm only). These features make them prone to migration (60%) during through-the-stent passage of adult duodenoscopes. Covered enteral SEMS are larger, longer and less costly than LAMS, making them perhaps better suited to create a temporary gastro-gastric conduit under EUS-guidance to facilitate biliary access in RYGB. This relatively simple intervention has the potential to simplify the emerging problem of ERCP in RYGB patients, provided that feasibility and reproducibility are further confirmed.
www.giejournal.org
1052 Use of Endoscopic Ultrasound in FNAC of Pleural Deposits Malay Sharma*1, Krishnaveni Janarthanan2, Piyush Somani1, Rajendra Lingampalli1, Saurabh Jindal1, Ravi Kanth3 1 Jaswantrai speciality hospital, Meerut, UP, India; 2Department of Gastroenterology, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India; 3Department of gastroenterology, Base Hospital, Delhi, Delhi, India Introduction: Thoracoscopy is an invasive endoscopic technique used by the pulmonologists to assess pleural disease and for tissue acquisition. However, it has its own contraindications. Endoscopic ultrasound guided Fine needle aspiration cytology (EUS FNAC) of pleural nodules is a less invasive procedure. It can offer access to pleural deposits after a thorough assessment and planning with CTchest. The pleura has three surfaces- the costal, diaphragmatic and mediastinal, and three recesses costo-mediastinal, costo-diaphragmatic and mediastino-diaphragmatic. The presence of pleural effusion makes them easily identifiable on EUS. Case Report: We report our experience of four cases of pleural deposits diagnosed by EUS FNAC. Case 1: A 50 year old smoker was evaluated for cough and weight loss and was found to have 5x4 cm lesion in apex of lung with pleural effusion. He had respiratory distress and hypoxemia and EUS was done. There was a hypoechoic lesion between the esophagus and chest wall above the aorta.FNAC showed nonsmall cell lung cancer. Case 2: A50 year old man presented with breathlessness and chest pain. He was a smoker. CT chest revealed a mass lesion in right lung with pleural effusion and nodules. He was unfit for bronchoscopic examination. EUS was done under mild sedation. It showed a 1.7 x1cm hypoechoic deposit on the mediastinal pleura. FNAC was diagnostic of nonsmall cell lung cancer. Case 3: A 60 year old lady presented with recurrent pleural effusion. Pleural tap revealed exudative lesion. She had significant respiratory distress and was morbidly obese (weight 124 kg). An EUS guided examination was done without any sedation. EUS revealed massive pleural effusion and 5 x 6 cm deposit on the mediastinal aspect of the pleura. FNAC showed multiple caseating granulomas suggestive of tuberculosis . Case 4: A 65 year old man, a smoker for 40 years presented with breathlessness. A CT chest showed a mass above right lobe of liver and right sided pleural effusion. He was having low base line oxygen saturation and could not be stabilized even after supportive therapy. A EUS guided examination was done without sedation. Hypoechoic deposit was seen extending from diaphragmatic aspect to mediastinal aspect of pleura. FNAC was diagnostic of nonsmall cell lung cancer. Conclusion: All four patients with contraindications for thoracoscopy underwent EUS guided FNAC with no complications and diagnostic tissue yield was obtained. It can be considered as an alternative to thoracoscopy. The procedure time is short,with minimal complications and can be done with mild sedation.
1053 The Last Frontier of the Nonpolypoid Gastrointestinal Neoplasms and Flat Dysplasia of the Anal Canal Roy M. Soetikno*1, Dean Fong2, Tohru Sato3, Tonya R. Kaltenbach1 1 Endoscopy, VA Palo Alto HCS, Palo Alto, CA; 2Pathology, VA Palo Alto HCS, Palo Alto, CA; 3Endoscopy, VA Palo Alto HCS, Palo Alto, CA Background: The incidence of canal cancer has been increasing. Anal cancer occurs most common in the older adults, within the age group that typically receives screening colonoscopy. Its early detection leads to improved survival. Unfortunately, while approximately 14 million of colonoscopy are performed per year in the US, the literature on the endoscopic detection and management of anal intraepithelial neoplasia is very sparse. The purpose of this case series is to describe the endoscopic detection and potential endoscopic management of anal intraepithelial neoplasia. Cases: The study is based on the observation by 3 endoscopists and a group of dedicated pathologists. Seven patients with mean age of 55 years, all male, one with HIV, less than a half had visible genital herpes, and almost all had no referable symptoms to the anal region were studied. Institutional IRB was approved. Endoscopy: The anal canal is carefully examined during retroflexion and anteflexion. Sufficient air insufflation was used. When the mucosa appeared to loose its typical smooth glistening appearance, the canal was re-examined using a cap, the narrow band imaging, additional magnification, and under water. After confirmation of the diagnoses of dysplasia, the mucosa was resected using endoscopic mucosal resection technique. Diluted lidocaine was used to inject the submucosa. Stiff snare was used. Argon plasma coagulation was used to coagulate visible vessels and/or potential remnants. The pathology was studied by two pathologists. Clinical Implication: Colonoscopy provides a great opportunity to visualize the anal canal and to detect anal neoplasms, including in its early form – the anal intraepithelial neoplasms, which typically are flat.
1054 Endoscopic Management of an Hourglass Gastric Stricture in the Excluded Stomach After Gastric Bypass Joshua C. Obuch*, Mihir S. Wagh Medicine- Gastroenterology, University of Colorado Hospital, Auroa, CO
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB129
1050 Endoscopic Resection of Gastric Subepithelial Tumor Originating From the Muscularis Propria Layer: Clip-And-Cut Method Eun Jeong Gong, Do Hoon Kim*, Hwoon-Yong Jung Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, — Select —, Korea (the Republic of) Background: Advances in endoscopic techniques enabled endoscopic removal of gastric subepithelial tumors (SETs) originating from the muscularis propria layer. Endoscopic full-thickness resection is usually performed for gastric SETs at the fundus, as submucosal tunneling is not feasible in this location of the stomach. However, the closure of perforation occurred during full-thickness resection often requires specific skills or devices. Case: A 70-year-old man presented to our hospital with incidentally found gastric SET. On endoscopy, about 2.5 cm sized protruding lesion covered with surface erosions was noted in the fundus. Endoscopic ultrasonography revealed homogeneous hypoechoic lesion originating from the muscularis propria layer. There was no evidence of regional lymph node enlargement or distant metastasis on computed tomography scan. We performed endoscopic resection with clip-and-cut method, and the lesion was resected successfully. Histological diagnosis was made as gastriointestinal stromal tumor of very low risk. Pneumoperitoneum was not evident. Endoscopic methods: After circumferential incision, the submucosal layer and muscularis propria layer were dissected. Counter traction was made by clip with line method to facilitate the dissection and better visualization of the field. When iatrogenic perforation occurred during resection, the gastric wall defect was closed with endoclips simultaneously. Dissection and the near-complete closure of perforations were performed in a stepwise manner. Complete resection of the tumor as well as defect closure was achieved by repeating the procedure of clipand-cut without laparoscopic assistance. Clinical implications: Stepwise clipping made the closure of perforation easier and reduced the amount of air leakage. Endoscopic resection with clip-and-cut method is useful for removal of gastric SETs originating from the muscularis propria without laparoscopic assistance.
1051 Eus-Guided Transgastric Placement of Temporary Enteral Covered Self-Expandable Metal Stent (CSEMS) to Perform Through-The-Stent Ercp in Roux-En-Y-Gastric Bypass (RYGB) Ramon Sanchez-Ocana*, Marta Cimavilla, Paula Gil-Simon, Carlos De la Serna, Manuel Perez-Miranda Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Valladolid, Spain Introduction: RYGB is associated with gallstone disease. RYGB makes ERCP laborintensive and prone to failure, even despite enteroscopy assistance. ERCP in RYGB usually requires percutaneous approaches (through laparoscopy, laparotomy or interventional gastrostomy). We present a novel, modified EUS-guided approach to facilitate ERCP after RYGB. Description: 66 year old female with prior cholecystectomy and RYGB presenting with cholangitis and documented common bile duct stone. She was offered and consented to an experimental EUS-guided approach to facilitate ERCP. From the proximal stomach the excluded gastric antrum is located and punctured under EUS with a 19G needle. Saline and contrast is injected through the needle to distend the antrum and provide fluoroscopic guidance. A guidewire is coiled in the antrum. The puncture tract is sequentially dilated with a 6F cystotome and a 4-mm balloon prior to through-the-scope insertion of an enteral cSEMS 22 x 90-mm. The cSEMS is deployed across the gastric wall under combined EUS and fluroscopy and then balloon expanded over. After allowing the fistula to mature for 5 days, ERCP is performed with a standard adult duodenoscope through the gastrogastric cSEMS. Sphincterotomy and common bile duct stone removal are performed. The duodenoscope is removed through the cSEMS, which is then exchanged in the same session for double pig-tail stent. There were no complications. The pig-tail stent was removed electively at three months without difficulty. Conclusions: This EUS-guided technique to “bypass the bypass” has been described in a pilot study using lumen-apposing metal stents (LAMS), (Kedia-et-al, GIE-2015). Our case further suggests that intentional interventional gastrostomy (such as in PEG or pseudocyst drainage) can be used as a temporary internal access port for biliary access in RYGB. Currently available LAMS are limited by narrow diameters (up to16-mm only) and short lengths (up to 30-mm only). These features make them prone to migration (60%) during through-the-stent passage of adult duodenoscopes. Covered enteral SEMS are larger, longer and less costly than LAMS, making them perhaps better suited to create a temporary gastro-gastric conduit under EUS-guidance to facilitate biliary access in RYGB. This relatively simple intervention has the potential to simplify the emerging problem of ERCP in RYGB patients, provided that feasibility and reproducibility are further confirmed.
www.giejournal.org
1052 Use of Endoscopic Ultrasound in FNAC of Pleural Deposits Malay Sharma*1, Krishnaveni Janarthanan2, Piyush Somani1, Rajendra Lingampalli1, Saurabh Jindal1, Ravi Kanth3 1 Jaswantrai speciality hospital, Meerut, UP, India; 2Department of Gastroenterology, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India; 3Department of gastroenterology, Base Hospital, Delhi, Delhi, India Introduction: Thoracoscopy is an invasive endoscopic technique used by the pulmonologists to assess pleural disease and for tissue acquisition. However, it has its own contraindications. Endoscopic ultrasound guided Fine needle aspiration cytology (EUS FNAC) of pleural nodules is a less invasive procedure. It can offer access to pleural deposits after a thorough assessment and planning with CTchest. The pleura has three surfaces- the costal, diaphragmatic and mediastinal, and three recesses costo-mediastinal, costo-diaphragmatic and mediastino-diaphragmatic. The presence of pleural effusion makes them easily identifiable on EUS. Case Report: We report our experience of four cases of pleural deposits diagnosed by EUS FNAC. Case 1: A 50 year old smoker was evaluated for cough and weight loss and was found to have 5x4 cm lesion in apex of lung with pleural effusion. He had respiratory distress and hypoxemia and EUS was done. There was a hypoechoic lesion between the esophagus and chest wall above the aorta.FNAC showed nonsmall cell lung cancer. Case 2: A50 year old man presented with breathlessness and chest pain. He was a smoker. CT chest revealed a mass lesion in right lung with pleural effusion and nodules. He was unfit for bronchoscopic examination. EUS was done under mild sedation. It showed a 1.7 x1cm hypoechoic deposit on the mediastinal pleura. FNAC was diagnostic of nonsmall cell lung cancer. Case 3: A 60 year old lady presented with recurrent pleural effusion. Pleural tap revealed exudative lesion. She had significant respiratory distress and was morbidly obese (weight 124 kg). An EUS guided examination was done without any sedation. EUS revealed massive pleural effusion and 5 x 6 cm deposit on the mediastinal aspect of the pleura. FNAC showed multiple caseating granulomas suggestive of tuberculosis . Case 4: A 65 year old man, a smoker for 40 years presented with breathlessness. A CT chest showed a mass above right lobe of liver and right sided pleural effusion. He was having low base line oxygen saturation and could not be stabilized even after supportive therapy. A EUS guided examination was done without sedation. Hypoechoic deposit was seen extending from diaphragmatic aspect to mediastinal aspect of pleura. FNAC was diagnostic of nonsmall cell lung cancer. Conclusion: All four patients with contraindications for thoracoscopy underwent EUS guided FNAC with no complications and diagnostic tissue yield was obtained. It can be considered as an alternative to thoracoscopy. The procedure time is short,with minimal complications and can be done with mild sedation.
1053 The Last Frontier of the Nonpolypoid Gastrointestinal Neoplasms and Flat Dysplasia of the Anal Canal Roy M. Soetikno*1, Dean Fong2, Tohru Sato3, Tonya R. Kaltenbach1 1 Endoscopy, VA Palo Alto HCS, Palo Alto, CA; 2Pathology, VA Palo Alto HCS, Palo Alto, CA; 3Endoscopy, VA Palo Alto HCS, Palo Alto, CA Background: The incidence of canal cancer has been increasing. Anal cancer occurs most common in the older adults, within the age group that typically receives screening colonoscopy. Its early detection leads to improved survival. Unfortunately, while approximately 14 million of colonoscopy are performed per year in the US, the literature on the endoscopic detection and management of anal intraepithelial neoplasia is very sparse. The purpose of this case series is to describe the endoscopic detection and potential endoscopic management of anal intraepithelial neoplasia. Cases: The study is based on the observation by 3 endoscopists and a group of dedicated pathologists. Seven patients with mean age of 55 years, all male, one with HIV, less than a half had visible genital herpes, and almost all had no referable symptoms to the anal region were studied. Institutional IRB was approved. Endoscopy: The anal canal is carefully examined during retroflexion and anteflexion. Sufficient air insufflation was used. When the mucosa appeared to loose its typical smooth glistening appearance, the canal was re-examined using a cap, the narrow band imaging, additional magnification, and under water. After confirmation of the diagnoses of dysplasia, the mucosa was resected using endoscopic mucosal resection technique. Diluted lidocaine was used to inject the submucosa. Stiff snare was used. Argon plasma coagulation was used to coagulate visible vessels and/or potential remnants. The pathology was studied by two pathologists. Clinical Implication: Colonoscopy provides a great opportunity to visualize the anal canal and to detect anal neoplasms, including in its early form – the anal intraepithelial neoplasms, which typically are flat.
1054 Endoscopic Management of an Hourglass Gastric Stricture in the Excluded Stomach After Gastric Bypass Joshua C. Obuch*, Mihir S. Wagh Medicine- Gastroenterology, University of Colorado Hospital, Auroa, CO
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB129