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1054 Endoscopic Management of an Hourglass Gastric Stricture in the Excluded Stomach After Gastric Bypass
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.
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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
Abstracts
Background: Hourglass strictures of the stomach have been reported in patients who have undergone bariatric surgery. Here we present a patient who had Rouxen-Y gastric bypass, presenting 15 years later with excluded stomach dilation found to have a mid gastric body stricture. Aim: To review the endoscopic management of a mid gastric body stricture in a patient with Roux-en-Y gastric bypass. Case Presentation: A 60 year old female with a history of Roux-en-Y gastric bypass in 2001 presented with sharp left upper quadrant subcostal abdominal pain and distention for 1 week. CT scan of the abdomen was performed showing dilation of the excluded stomach prompting urgent gastrostomy tube placement for decompression. An upper GI series showed the presence of a gastro-gastric fistula. Endoscopy was performed for further evaluation of anatomy and possible fistula closure. Multiple fistulas were noted in the gastric pouch, with one extending to the excluded stomach. A pinhole stricture was identified, with fluoroscopic evaluation determining this to be an hourglass stricture in the mid body of the gastric remnant. Serial endoscopic dilations were performed over several weeks, with stricturoplasty performed after maximum dilation to 20 mm. After stricturoplasty, the patient had resolution of her symptoms and her gastrostomy tube removed. Conclusions: Careful assessment of anatomy is necessary to safely perform endoscpic evaluation in post bariatric surgery patients given altered landmarks and potential for abnormal fistulous connections. Serial dilation of hourglass strictures is safe and effective, and stricturoplasty may provide more durable results than dilation alone. These techniques can help circumvent surgical management in patients with hourglass strictures of the excluded stomach.
1055 A New Rare Genus of Spindle Cell Tumors of the Gi Tract, the Use of Endoscopic Submucosal Dissection for Management of Gastric Plexiform Fibromyxoma Youssef El Douaihy*2, Jean M. Chalhoub2, Vera Zaraket1, Lilliane Deeb1, Sherif A. Andrawes1 1 Gastroentrrology and Liver Disease, Staten Island University HospitalNorthwell Health System, Staten Island, NY; 2Internal Medicine, Staten Island University Hospital- Northwell Health System, Staten Island, NY Case presentation: A 24-year-old woman with a past medical history of Polycystic Ovarian Syndrome presented for persistent epigastric abdominal pain. Physical examination and laboratory workup were unremarkable. She was diagnosed with dyspepsia and started on medical therapy with Proton Pump Inhibitors, however there was no improvement of symptoms. The patient underwent EGD, which revealed a 2 cm subepithelial lesion with a central ulceration in the posterior wall of the gastric antrum. She was referred for Endoscopic ultrasound (EUS) that revealed a 3 x 2 cm hypoechoic, homogeneous mass attached to the muscularis propria of the antrum. FNA was performed which revealed spindle cell neoplasm with inconclusive staining for neither Gastrointestinal Stromal Tumor (GIST) nor leiomyoma. There was a concern for GIST given the size of the lesion and appearance on EUS. She underwent Endoscopic Submucosal Dissection (ESD) with removal of the lesion enbloc. The lesion appeared encapsulated and measured 3 cm after resection. Pathology revealed a gastric plexiform fibromyxoma with negative staining for GIST markers. Plexiform fibromyxoma is a relatively new pathological subtype classification of spindle cell tumors. Plexiform fibromyxoma is a rare, benign mesenchymal neoplasm that favors growth in the gastric antrum and has potential for misdiagnosis as a GIST. The histology of the tumor is characterized by interlinked fascicular growth of cytologically bland spindled cells within a variably myxoid stroma and a peculiar plexiform growth pattern. We report a unique case of gastirc Plexiform Fibromyxoma as a relatively new pathological grouping of gastric spindle cell tumors. There are few cases reported in the literature, to-date, all treated by surgical resection. This case presents Plexiform Fibromyxoma that was treated using Endoscopic Submucosal Dissection (ESD).
1056 The Incredible Shrinking Waistline: Lumen Apposing Metal Stent (LAMS) Treatment of Massive Ascites Emmanuel Coronel*2, Andrew Aronsohn2, Andres Gelrud1, Uzma D. Siddiqui1 1 Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, IL; 2Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, IL Ascites is an uncommon presentation post pancreatitis. The usual etiologies include pancreatic duct leaks, portal vein thrombosis and overly aggressive fluid resuscitation in the acute setting of pancreatitis. This is the case of a 67-year-old woman with a history of severe acute necrotizing pancreatitis 5 years ago, complicated with walled-off necrosis that required percutaneous and transgastric drainage. She finally recovered after a long hospitalization. She was doing well for all these years, until recently, where she reported having developed rapidly progressing abdominal distention. On physical exam, she was found to have tense ascites and a paracentesis was performed which showed straw colored fluid with a serum-ascites albumin gradient (SAAG) of over 1.1 and a very low amylase level. She had no history
AB130 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
of liver disease. Abdominal imaging showed a 5x7 cm pancreatic fluid collection (PFC) that was causing severe compression of the portal vein, causing portal hypertension and large ascites. We performed an endoscopic ultrasound guided PFC drainage using a cautery enhanced lumen apposing metal stent (LAMS). After four weeks, her ascites completely resolved and abdominal imaging showed that the portal vein was widely patent. We removed the LAMS endoscopically after 6 weeks post procedure and the patient continues to do well. Conclusion: The majority of PFCs are usually indolent and indications for drainage include symptoms and/or infection. EUS guided drainage was initially performed by placing multiple plastic stents, however LAMS were developed specifically for PFC drainage. Recent studies have shown that these stents can be placed safely and effectively with resolution rates of over 90 percent.
1057 Eus of Peripancreatic Pseudoaneurysms Piyush Somani*, Malay Sharma, Javed Pottachilakath Department of gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar pradesh, India Introduction: Peripancreatic pseudoaneurysms are associated mostly with pancreatitis and pancreatobiliary surgery. Investigation of choice is CT angiogram with or without a formal angiogram. Pseudo aneurysms may occur in both acute and chronic pancreatitis; they are more common in chronic pancreatitis and are often associated with pseudocysts. The pseudoaneurysm may rupture either into the pseudocyst or directly into an adjacent viscus, peritoneal cavity, or pancreatic duct. The splenic artery is the most common artery involved. Rupture with bleeding into the gastrointestinal tract can occur directly or indirectly. Gastrointestinal bleeding is the most common presentation overall. The role of EUS in diagnosis and treatment of peripancreatic pseudoaneurysms is unclear. Objective: To evaluate the role, feasibility, yield and safety of EUS in the diagnosis and treatment of peripancreatic pseudoaneurysms. Materials and methods: We present a retrospective series of 15 patients with peripancreatic pseudoaneurysms diagnosed on EUS over an 8 year period. EUS was performed with a linear/radial echoendoscope. The most common artery involved was splenic artery with 8 patients followed by Gastroduodenal artery with 5 patients and hepatic artery with 2 patient involved. The most common indication for performing the EUS was overt obscure upper gastrointestinal bleeding followed by occult gastrointestinal bleeding and as part of evaluation of idiopathic acute recurrent pancreatitis. Results: EUS was successful in all cases. Peripancreatic pseudo aneurysms was associated with chronic pancreatitis in 9 patients and acute pancreatitis in 4 patients. 9 patients were associated with pseudocyst. The most common presentation of peripancreatic pseudo aneurysms was gastrointestinal bleeding in 12 patients. Gastrointestinal bleeding was present in the form of hematemesis in 5 patients, melena in 3 patients, and haematochezia in one patient. 2 patients with splenic artery aneurysm underwent EUS guided thrombin and coiling. One patient with hepatic artery aneurysm underwent EUS guided coiling and glue. 7 patients underwent angioembolization while surgery was performed in 5 patients. The characteristic appearance on EUS is thick outer hypoechoic wall with a central anechoic area that appeared as a ‘‘donut’’. Conclusions: EUS can play an important role in diagnosis and treatment of pseudoaneurysms in acute/chronic pancreatitis. EUS should be considered in patient presenting with obscure overt/occult gastrointestinal bleeding to know the etiology in acute/chronic pancreatitis. Therapeutic role of EUS in pseudoaneurysms should be explored further.
1058 Endoscopic Suturing for a Massively Bleeding Marginal Ulcer 10 Days Post Roux-En-Y Gastric Bypass Sindhu Barola1, Abhishek Agnihotri1, Michael Schweitzer2, Thomas Magnuson2, Yen-I. Chen1, Saowonee Ngamruengphong1, Mouen A. Khashab1, Vivek Kumbhari*1 1 Gastroenterology, Johns Hopkins Medicine, Baltimore, MD; 2Surgery, Johns Hopkins Medicine, Baltimore, MD The postoperative marginal ulcer at the gastrojejunal (GJ) anastomosis is not uncommonly encountered post Roux-en-Y gastric bypass (RYGB). Reported incidence varies widely 0.6 to 16%. Most marginal ulcerations occur between 2 and 6 months postoperatively, with 95% occurring within 12 months. Ulcers can be due to reaction to foreign body such as non-absorbable sutures, staples, and implanted bands or mesh, local ischemia, micro insufficiency, bile acid reflux, tension on the Roux limb and Helicobacter pylori infection. Bleeding ulcers have traditionally been treated endoscopically by injecting epinephrine, bipolar hemostasis or hemostatic clips. We present a video of endoscopic suturing of a massively bleeding marginal ulcer 10 days post RYGB. A 56-year-old female with body mass index of 44 kg/m2 underwent her fourth endoscopy for investigation and management of hematemesis within 10 days of her RYGB. On each endoscopy she was found to have a large bleeding vessel arising from an anastomotic ulcer. This was unsuccessfully treated with endoscopic epinephrine injection and bipolar coagulation of bleeding vessel. She presented with recurrent hematemesis, and her Hb dropped from 11 g/dL to 8 g/dL. Endoscopy revealed large amount of blood clot occupying the entire gastric pouch. The clots were entirely removed with a net. There was a 2 x 2 cm a deep ulcer at the 12 o’clock
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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
Abstracts
Background: Hourglass strictures of the stomach have been reported in patients who have undergone bariatric surgery. Here we present a patient who had Rouxen-Y gastric bypass, presenting 15 years later with excluded stomach dilation found to have a mid gastric body stricture. Aim: To review the endoscopic management of a mid gastric body stricture in a patient with Roux-en-Y gastric bypass. Case Presentation: A 60 year old female with a history of Roux-en-Y gastric bypass in 2001 presented with sharp left upper quadrant subcostal abdominal pain and distention for 1 week. CT scan of the abdomen was performed showing dilation of the excluded stomach prompting urgent gastrostomy tube placement for decompression. An upper GI series showed the presence of a gastro-gastric fistula. Endoscopy was performed for further evaluation of anatomy and possible fistula closure. Multiple fistulas were noted in the gastric pouch, with one extending to the excluded stomach. A pinhole stricture was identified, with fluoroscopic evaluation determining this to be an hourglass stricture in the mid body of the gastric remnant. Serial endoscopic dilations were performed over several weeks, with stricturoplasty performed after maximum dilation to 20 mm. After stricturoplasty, the patient had resolution of her symptoms and her gastrostomy tube removed. Conclusions: Careful assessment of anatomy is necessary to safely perform endoscpic evaluation in post bariatric surgery patients given altered landmarks and potential for abnormal fistulous connections. Serial dilation of hourglass strictures is safe and effective, and stricturoplasty may provide more durable results than dilation alone. These techniques can help circumvent surgical management in patients with hourglass strictures of the excluded stomach.
1055 A New Rare Genus of Spindle Cell Tumors of the Gi Tract, the Use of Endoscopic Submucosal Dissection for Management of Gastric Plexiform Fibromyxoma Youssef El Douaihy*2, Jean M. Chalhoub2, Vera Zaraket1, Lilliane Deeb1, Sherif A. Andrawes1 1 Gastroentrrology and Liver Disease, Staten Island University HospitalNorthwell Health System, Staten Island, NY; 2Internal Medicine, Staten Island University Hospital- Northwell Health System, Staten Island, NY Case presentation: A 24-year-old woman with a past medical history of Polycystic Ovarian Syndrome presented for persistent epigastric abdominal pain. Physical examination and laboratory workup were unremarkable. She was diagnosed with dyspepsia and started on medical therapy with Proton Pump Inhibitors, however there was no improvement of symptoms. The patient underwent EGD, which revealed a 2 cm subepithelial lesion with a central ulceration in the posterior wall of the gastric antrum. She was referred for Endoscopic ultrasound (EUS) that revealed a 3 x 2 cm hypoechoic, homogeneous mass attached to the muscularis propria of the antrum. FNA was performed which revealed spindle cell neoplasm with inconclusive staining for neither Gastrointestinal Stromal Tumor (GIST) nor leiomyoma. There was a concern for GIST given the size of the lesion and appearance on EUS. She underwent Endoscopic Submucosal Dissection (ESD) with removal of the lesion enbloc. The lesion appeared encapsulated and measured 3 cm after resection. Pathology revealed a gastric plexiform fibromyxoma with negative staining for GIST markers. Plexiform fibromyxoma is a relatively new pathological subtype classification of spindle cell tumors. Plexiform fibromyxoma is a rare, benign mesenchymal neoplasm that favors growth in the gastric antrum and has potential for misdiagnosis as a GIST. The histology of the tumor is characterized by interlinked fascicular growth of cytologically bland spindled cells within a variably myxoid stroma and a peculiar plexiform growth pattern. We report a unique case of gastirc Plexiform Fibromyxoma as a relatively new pathological grouping of gastric spindle cell tumors. There are few cases reported in the literature, to-date, all treated by surgical resection. This case presents Plexiform Fibromyxoma that was treated using Endoscopic Submucosal Dissection (ESD).
1056 The Incredible Shrinking Waistline: Lumen Apposing Metal Stent (LAMS) Treatment of Massive Ascites Emmanuel Coronel*2, Andrew Aronsohn2, Andres Gelrud1, Uzma D. Siddiqui1 1 Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, IL; 2Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, IL Ascites is an uncommon presentation post pancreatitis. The usual etiologies include pancreatic duct leaks, portal vein thrombosis and overly aggressive fluid resuscitation in the acute setting of pancreatitis. This is the case of a 67-year-old woman with a history of severe acute necrotizing pancreatitis 5 years ago, complicated with walled-off necrosis that required percutaneous and transgastric drainage. She finally recovered after a long hospitalization. She was doing well for all these years, until recently, where she reported having developed rapidly progressing abdominal distention. On physical exam, she was found to have tense ascites and a paracentesis was performed which showed straw colored fluid with a serum-ascites albumin gradient (SAAG) of over 1.1 and a very low amylase level. She had no history
AB130 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
of liver disease. Abdominal imaging showed a 5x7 cm pancreatic fluid collection (PFC) that was causing severe compression of the portal vein, causing portal hypertension and large ascites. We performed an endoscopic ultrasound guided PFC drainage using a cautery enhanced lumen apposing metal stent (LAMS). After four weeks, her ascites completely resolved and abdominal imaging showed that the portal vein was widely patent. We removed the LAMS endoscopically after 6 weeks post procedure and the patient continues to do well. Conclusion: The majority of PFCs are usually indolent and indications for drainage include symptoms and/or infection. EUS guided drainage was initially performed by placing multiple plastic stents, however LAMS were developed specifically for PFC drainage. Recent studies have shown that these stents can be placed safely and effectively with resolution rates of over 90 percent.
1057 Eus of Peripancreatic Pseudoaneurysms Piyush Somani*, Malay Sharma, Javed Pottachilakath Department of gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar pradesh, India Introduction: Peripancreatic pseudoaneurysms are associated mostly with pancreatitis and pancreatobiliary surgery. Investigation of choice is CT angiogram with or without a formal angiogram. Pseudo aneurysms may occur in both acute and chronic pancreatitis; they are more common in chronic pancreatitis and are often associated with pseudocysts. The pseudoaneurysm may rupture either into the pseudocyst or directly into an adjacent viscus, peritoneal cavity, or pancreatic duct. The splenic artery is the most common artery involved. Rupture with bleeding into the gastrointestinal tract can occur directly or indirectly. Gastrointestinal bleeding is the most common presentation overall. The role of EUS in diagnosis and treatment of peripancreatic pseudoaneurysms is unclear. Objective: To evaluate the role, feasibility, yield and safety of EUS in the diagnosis and treatment of peripancreatic pseudoaneurysms. Materials and methods: We present a retrospective series of 15 patients with peripancreatic pseudoaneurysms diagnosed on EUS over an 8 year period. EUS was performed with a linear/radial echoendoscope. The most common artery involved was splenic artery with 8 patients followed by Gastroduodenal artery with 5 patients and hepatic artery with 2 patient involved. The most common indication for performing the EUS was overt obscure upper gastrointestinal bleeding followed by occult gastrointestinal bleeding and as part of evaluation of idiopathic acute recurrent pancreatitis. Results: EUS was successful in all cases. Peripancreatic pseudo aneurysms was associated with chronic pancreatitis in 9 patients and acute pancreatitis in 4 patients. 9 patients were associated with pseudocyst. The most common presentation of peripancreatic pseudo aneurysms was gastrointestinal bleeding in 12 patients. Gastrointestinal bleeding was present in the form of hematemesis in 5 patients, melena in 3 patients, and haematochezia in one patient. 2 patients with splenic artery aneurysm underwent EUS guided thrombin and coiling. One patient with hepatic artery aneurysm underwent EUS guided coiling and glue. 7 patients underwent angioembolization while surgery was performed in 5 patients. The characteristic appearance on EUS is thick outer hypoechoic wall with a central anechoic area that appeared as a ‘‘donut’’. Conclusions: EUS can play an important role in diagnosis and treatment of pseudoaneurysms in acute/chronic pancreatitis. EUS should be considered in patient presenting with obscure overt/occult gastrointestinal bleeding to know the etiology in acute/chronic pancreatitis. Therapeutic role of EUS in pseudoaneurysms should be explored further.
1058 Endoscopic Suturing for a Massively Bleeding Marginal Ulcer 10 Days Post Roux-En-Y Gastric Bypass Sindhu Barola1, Abhishek Agnihotri1, Michael Schweitzer2, Thomas Magnuson2, Yen-I. Chen1, Saowonee Ngamruengphong1, Mouen A. Khashab1, Vivek Kumbhari*1 1 Gastroenterology, Johns Hopkins Medicine, Baltimore, MD; 2Surgery, Johns Hopkins Medicine, Baltimore, MD The postoperative marginal ulcer at the gastrojejunal (GJ) anastomosis is not uncommonly encountered post Roux-en-Y gastric bypass (RYGB). Reported incidence varies widely 0.6 to 16%. Most marginal ulcerations occur between 2 and 6 months postoperatively, with 95% occurring within 12 months. Ulcers can be due to reaction to foreign body such as non-absorbable sutures, staples, and implanted bands or mesh, local ischemia, micro insufficiency, bile acid reflux, tension on the Roux limb and Helicobacter pylori infection. Bleeding ulcers have traditionally been treated endoscopically by injecting epinephrine, bipolar hemostasis or hemostatic clips. We present a video of endoscopic suturing of a massively bleeding marginal ulcer 10 days post RYGB. A 56-year-old female with body mass index of 44 kg/m2 underwent her fourth endoscopy for investigation and management of hematemesis within 10 days of her RYGB. On each endoscopy she was found to have a large bleeding vessel arising from an anastomotic ulcer. This was unsuccessfully treated with endoscopic epinephrine injection and bipolar coagulation of bleeding vessel. She presented with recurrent hematemesis, and her Hb dropped from 11 g/dL to 8 g/dL. Endoscopy revealed large amount of blood clot occupying the entire gastric pouch. The clots were entirely removed with a net. There was a 2 x 2 cm a deep ulcer at the 12 o’clock
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