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1066 Metastatic Melanoma Presenting as Malignant Biliary Obstruction of the Common Bile Duct Demonstrated With Digital Spyglass Cholangioscopy
Abstracts
found to have dilated left intrahepatic ducts and elevated liver function tests on a routine MRI for pre-operative planning. He was asymptomatic without any nausea, vomiting, or abdominal pain. He presented for ERCP. There was a filling defect noted in the left hepatic duct on cholangiogram. Intraductal endoscopy was then utilized to visualize a frondular lesion within the left intrahepatic duct. Targeted biopsies were obtained. Pathology demonstrated metastatic high grade urothelial carcinoma consistent with metastatic carcinoma.
1063 Troubleshooting of Basket Impaction During Balloon Enteroscopy-Assisted ERCP Yasutsugu Asai*, Atsushi Sofuni, Takayoshi Tsuchiya, Shujiro Tsuji, Kentaro Kamada, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Shuntaro Mukai, Kenjiro Yamamoto, Yukitoshi Matsunami, Takao Itoi Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Nishishinjuku 6-7-1, Shinjuku-ku, Japan Background/Case: Complication of basket impaction is often seen during the endoscopic stone removal. However, it is not always to resolve the basket impaction.We encountered basket impaction during balloon enteroscopy-assisted ERCP in the patient with prior distal gastrectomy and Roux-en-Y reconstruction. Herein, we describe the tip of the troubleshooting of basket impaction in such difficult case. The case is an 81 years old woman, she had distal gastrectomy and Roux-en-Y reconstructive operation for gastric cancer. Cholangitis with the stone developed afterwards. Endoscopic stone removal was attempted in the previous hospital. However, since ERCP failed, the patient was referred to our hospital. Endoscopic Methods: ERCP was re-attempted in our hospital. We used Short-type single balloon enteroscope. 4 plastic stents（PS）were inserted in a common bile duct in another hospital, and the one of PS migrated into the bile duct. We removed these PS except migrated one. Cholangiography showed multiple bile duct stones. Then, next major papilla was dilated using large dilating balloon. Afterwards, balloon enteroscope could be directly inserted into the bile duct. Since we could find the large stone under direct vision, we tried to remove the stones with the 4 wire basket catheter. Although we could remove some stones, basket impaction was occurred. Thus, we attempted the resolve the basket impaction using a “through the scope” type endtriptor sheath. However, because of friction of the wire and insufficient total length of the basket wire, we couldn’t insert the wire through the sheath. Then, as I mentioned, after a silk thread was tied to the edge of the wire, ultraslim biopsy forceps was inserted through the endtriptor sheath to grasp the thread. Finally, endtriptor sheath was advanced over the wire and impacted stone was crushed without any adverse event and break of devices. Eventually, all stones were removed without any adverse event and patient was improving afterwards. Clinical Implications: We described the troubleshooting of basket impaction during balloon enteroscopy-assisted ERCP in the patient with prior distal gastrectomy and Roux-enY reconstruction. Our special technique seems to be useful for the endotherapy of impacted stone even in case of balloon enteroscopy-assisted ERCP.
1064 Ampullectomy Over Pancreatic Duct Guidewire Zhouwen Tang*, Jayaprakash Sreenarasimhaiah Digestive and Liver Disease, UT Southwestern Medical Center, Dallas, TX Pancreatic duct stenting is recommended to reduce risk of post ampullectomy pancreatitis. However, pancreatic duct access is challenging after ampullectomy due to small ductal orifice, cautery effect, and possible post ampullectomy bleeding or edema precluding visualization. Methods to aid in orifice identification include secretin infusion and methylene blue injection. We propose that initial guidewire cannulation of the pancreatic duct and maintaining guidewire access throughout the ampullectomy is both feasible and convenient as a method of ensuring easy pancreatic duct access without hindering ampullectomy or specimen retrieval. We present the case of a typical patient with ampullary adenoma needing ampullectomy and demonstrate our technique for ampullectomy over a pancreatic duct guidewire. A 37 year old man with a family history of colorectal cancer is diagnosed with familial adenomatous polyposis (FAP) on genetic testing. Baseline screening upper endoscopy showed multiple sessile polyps in the gastric body along with a 12 mm ampullary adenoma. The patient was then referred for endoscopic ampullectomy. The pancreatic duct is cannulated with a dome tip sphincterotome and a 0.035 inch biliary guidewire was passed deeply into the main pancreatic duct. The common bile duct was then cannulated using double wire technique. After billiary access is confirmed, a small biliary sphincterotomy is performed to prevent post ampullectomy bile duct obstruction. The biliary guidewire was then removed, leaving only the wire in the pancreatic duct. A 13 mm oval polypectomy snare was placed over the guidewire. With the tip almost but not completely closed, the snare is advanced over the guidewire and into the instrument channel. The snare is then opened in the lumen and maneuvered carefully around the ampulla. Care is taken to ensure captured tissue remained mobile so as to not trap underlying tissue. The ampul-
AB132 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
lectomy is then performed with combination cut and coagulation current. After resection, the partially closed snare is then easily removed over the wire and back through the instrument channel, leaving the resected ampulla still attached around the guidewire. A 5 French by 5 cm pancreatic duct stent is then advanced over the wire, through the resected ampulla and into the pancreatic duct as prophylaxis against post ampullectomy pancreatitis. The resected tissue was released into the lumen after guidewire removal and, in this case, the specimen was easily suctioned through the channel and into the tissue trap. For larger specimens, instruments such as a retrieval net can be used to remove the specimen. Initial pancreatic duct guidewire cannulation followed by ampullectomy over the guidewire ensures pancreatic duct access for prophylactic stenting after ampullectomy without interference with the ampullectomy or with specimen collection.
1065 Eus Guided Pancreaticogastrostomy in a Pediatric Patient Monica Saumoy*, Ming Ming Xu, Amy Tyberg, Michel Kahaleh Gastroenterology, New York Presbyterian, New York, NY A 14 yo M was admitted for acute pancreatitis secondary to pancreatic divisum. Two conventional endoscopic retrograde cholangiopancreatographies were attempted for management. However both were unsuccessful in cannulating the pancreatic duct despite secretin injection, spraying the papilla with methylene blue and precut minor papillotomy. Given the patient’s persistent abdominal pain and failure to thrive, an endoscopic ultrasound guided pancreaticogastrostomy was preformed for pancreatic duct drainage. Post procedure was complicated with a peripancreatic collection that was drained with a lumen apposing metal stent. One month after successful drainage, the patient’s abdominal pain resolved.
1066 Metastatic Melanoma Presenting as Malignant Biliary Obstruction of the Common Bile Duct Demonstrated With Digital Spyglass Cholangioscopy Prapimphan Aumpansub*1, Phonthep Angsuwatcharakon1, Nareumon Wisedopas2, Wiriyaporn Ridtitid1, Rungsun Rerknimitr1 1 Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; 2Department of Pathology, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand A 67-year-old woman presented with progressive jaundice for 2 months. Two years earlier, she underwent a complete removal of a 1 cm diameter melanoma from her left flank, which was confirmed to be malignant. Eight months later, computed tomography (CT) for re-evaluation demonstrated an interval growth of gallbladder polyp from 1.4 to 1.9 cm over 3 months and subsequent laparoscopic cholecystectomy was done. Metastatic melanoma to the gallbladder was proven by histopathology. She did well until the last 2 months when she developed jaundice with history of passing melena. Upon admission, her vital signs were stable but hemoglobin dropped from 11 to 6 g/dL. CT scan showed an enhancing intraductal mass measuring 3.8 cm in length at distal common bile duct (CBD) with progressive upstream dilatation of CBD, common hepatic duct and intrahepatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) was performed. Side-viewing duodenoscopy showed bleeding per ampulla. Cholangiogram demonstrated a large irregular filling defect measuring 4 cm in length at distal CBD. Biliary sphincterotomy was done and cholangioscopy was done by using the digital SpyGlass system which demonstrated a large irregular brownish intraductal papillary mass at distal CBD. Multiple biopsies were taken by SpyBite forceps. Then, self-expandable metallic stent (SEMS) was placed. Histopathology described pleomorphic, loosely cohesive cells with enlarged, hyperchromatic, and irregular nuclei of the tumor. The immunohistochemistry for melanoma associated markers with HMB-45 and Melan-A antigens were all positive confirming the diagnosis of metastatic malignant melanoma to CBD. After the procedure, her jaundice continued to improve, while melena stopped. Three months later, she developed metastatic melanoma to the nasopharynx and underwent complete excision. Following surgery, she refused chemotherapy. At one year follow-up, she denied symptoms of recurrent bile duct obstruction. CT scan showed only partial enhancing soft tissue at distal CBD with patent SEMS and aerobilia. Metastatic melanoma to the gallbladder and the common bile duct was extremely rare, reporting as 8% on autopsy cases of malignant melanoma. We detected the metastasis of malignant melanoma to common bile duct by using the digital SpyGlass cholangioscope. Although metastatic melanoma to the common bile duct is an uncommon incident, the possibility of metastatic melanoma to the extrahepatic biliary tree should be excluded in patients presenting with obstructive jaundice with a known history of malignant melanoma. Digital SpyGlass cholangioscopy is a useful tool for targeted tumor biopsy to confirm the diagnosis of metastatic melanoma to the common bile duct.
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found to have dilated left intrahepatic ducts and elevated liver function tests on a routine MRI for pre-operative planning. He was asymptomatic without any nausea, vomiting, or abdominal pain. He presented for ERCP. There was a filling defect noted in the left hepatic duct on cholangiogram. Intraductal endoscopy was then utilized to visualize a frondular lesion within the left intrahepatic duct. Targeted biopsies were obtained. Pathology demonstrated metastatic high grade urothelial carcinoma consistent with metastatic carcinoma.
1063 Troubleshooting of Basket Impaction During Balloon Enteroscopy-Assisted ERCP Yasutsugu Asai*, Atsushi Sofuni, Takayoshi Tsuchiya, Shujiro Tsuji, Kentaro Kamada, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Shuntaro Mukai, Kenjiro Yamamoto, Yukitoshi Matsunami, Takao Itoi Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Nishishinjuku 6-7-1, Shinjuku-ku, Japan Background/Case: Complication of basket impaction is often seen during the endoscopic stone removal. However, it is not always to resolve the basket impaction.We encountered basket impaction during balloon enteroscopy-assisted ERCP in the patient with prior distal gastrectomy and Roux-en-Y reconstruction. Herein, we describe the tip of the troubleshooting of basket impaction in such difficult case. The case is an 81 years old woman, she had distal gastrectomy and Roux-en-Y reconstructive operation for gastric cancer. Cholangitis with the stone developed afterwards. Endoscopic stone removal was attempted in the previous hospital. However, since ERCP failed, the patient was referred to our hospital. Endoscopic Methods: ERCP was re-attempted in our hospital. We used Short-type single balloon enteroscope. 4 plastic stents（PS）were inserted in a common bile duct in another hospital, and the one of PS migrated into the bile duct. We removed these PS except migrated one. Cholangiography showed multiple bile duct stones. Then, next major papilla was dilated using large dilating balloon. Afterwards, balloon enteroscope could be directly inserted into the bile duct. Since we could find the large stone under direct vision, we tried to remove the stones with the 4 wire basket catheter. Although we could remove some stones, basket impaction was occurred. Thus, we attempted the resolve the basket impaction using a “through the scope” type endtriptor sheath. However, because of friction of the wire and insufficient total length of the basket wire, we couldn’t insert the wire through the sheath. Then, as I mentioned, after a silk thread was tied to the edge of the wire, ultraslim biopsy forceps was inserted through the endtriptor sheath to grasp the thread. Finally, endtriptor sheath was advanced over the wire and impacted stone was crushed without any adverse event and break of devices. Eventually, all stones were removed without any adverse event and patient was improving afterwards. Clinical Implications: We described the troubleshooting of basket impaction during balloon enteroscopy-assisted ERCP in the patient with prior distal gastrectomy and Roux-enY reconstruction. Our special technique seems to be useful for the endotherapy of impacted stone even in case of balloon enteroscopy-assisted ERCP.
1064 Ampullectomy Over Pancreatic Duct Guidewire Zhouwen Tang*, Jayaprakash Sreenarasimhaiah Digestive and Liver Disease, UT Southwestern Medical Center, Dallas, TX Pancreatic duct stenting is recommended to reduce risk of post ampullectomy pancreatitis. However, pancreatic duct access is challenging after ampullectomy due to small ductal orifice, cautery effect, and possible post ampullectomy bleeding or edema precluding visualization. Methods to aid in orifice identification include secretin infusion and methylene blue injection. We propose that initial guidewire cannulation of the pancreatic duct and maintaining guidewire access throughout the ampullectomy is both feasible and convenient as a method of ensuring easy pancreatic duct access without hindering ampullectomy or specimen retrieval. We present the case of a typical patient with ampullary adenoma needing ampullectomy and demonstrate our technique for ampullectomy over a pancreatic duct guidewire. A 37 year old man with a family history of colorectal cancer is diagnosed with familial adenomatous polyposis (FAP) on genetic testing. Baseline screening upper endoscopy showed multiple sessile polyps in the gastric body along with a 12 mm ampullary adenoma. The patient was then referred for endoscopic ampullectomy. The pancreatic duct is cannulated with a dome tip sphincterotome and a 0.035 inch biliary guidewire was passed deeply into the main pancreatic duct. The common bile duct was then cannulated using double wire technique. After billiary access is confirmed, a small biliary sphincterotomy is performed to prevent post ampullectomy bile duct obstruction. The biliary guidewire was then removed, leaving only the wire in the pancreatic duct. A 13 mm oval polypectomy snare was placed over the guidewire. With the tip almost but not completely closed, the snare is advanced over the guidewire and into the instrument channel. The snare is then opened in the lumen and maneuvered carefully around the ampulla. Care is taken to ensure captured tissue remained mobile so as to not trap underlying tissue. The ampul-
AB132 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
lectomy is then performed with combination cut and coagulation current. After resection, the partially closed snare is then easily removed over the wire and back through the instrument channel, leaving the resected ampulla still attached around the guidewire. A 5 French by 5 cm pancreatic duct stent is then advanced over the wire, through the resected ampulla and into the pancreatic duct as prophylaxis against post ampullectomy pancreatitis. The resected tissue was released into the lumen after guidewire removal and, in this case, the specimen was easily suctioned through the channel and into the tissue trap. For larger specimens, instruments such as a retrieval net can be used to remove the specimen. Initial pancreatic duct guidewire cannulation followed by ampullectomy over the guidewire ensures pancreatic duct access for prophylactic stenting after ampullectomy without interference with the ampullectomy or with specimen collection.
1065 Eus Guided Pancreaticogastrostomy in a Pediatric Patient Monica Saumoy*, Ming Ming Xu, Amy Tyberg, Michel Kahaleh Gastroenterology, New York Presbyterian, New York, NY A 14 yo M was admitted for acute pancreatitis secondary to pancreatic divisum. Two conventional endoscopic retrograde cholangiopancreatographies were attempted for management. However both were unsuccessful in cannulating the pancreatic duct despite secretin injection, spraying the papilla with methylene blue and precut minor papillotomy. Given the patient’s persistent abdominal pain and failure to thrive, an endoscopic ultrasound guided pancreaticogastrostomy was preformed for pancreatic duct drainage. Post procedure was complicated with a peripancreatic collection that was drained with a lumen apposing metal stent. One month after successful drainage, the patient’s abdominal pain resolved.
1066 Metastatic Melanoma Presenting as Malignant Biliary Obstruction of the Common Bile Duct Demonstrated With Digital Spyglass Cholangioscopy Prapimphan Aumpansub*1, Phonthep Angsuwatcharakon1, Nareumon Wisedopas2, Wiriyaporn Ridtitid1, Rungsun Rerknimitr1 1 Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; 2Department of Pathology, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand A 67-year-old woman presented with progressive jaundice for 2 months. Two years earlier, she underwent a complete removal of a 1 cm diameter melanoma from her left flank, which was confirmed to be malignant. Eight months later, computed tomography (CT) for re-evaluation demonstrated an interval growth of gallbladder polyp from 1.4 to 1.9 cm over 3 months and subsequent laparoscopic cholecystectomy was done. Metastatic melanoma to the gallbladder was proven by histopathology. She did well until the last 2 months when she developed jaundice with history of passing melena. Upon admission, her vital signs were stable but hemoglobin dropped from 11 to 6 g/dL. CT scan showed an enhancing intraductal mass measuring 3.8 cm in length at distal common bile duct (CBD) with progressive upstream dilatation of CBD, common hepatic duct and intrahepatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) was performed. Side-viewing duodenoscopy showed bleeding per ampulla. Cholangiogram demonstrated a large irregular filling defect measuring 4 cm in length at distal CBD. Biliary sphincterotomy was done and cholangioscopy was done by using the digital SpyGlass system which demonstrated a large irregular brownish intraductal papillary mass at distal CBD. Multiple biopsies were taken by SpyBite forceps. Then, self-expandable metallic stent (SEMS) was placed. Histopathology described pleomorphic, loosely cohesive cells with enlarged, hyperchromatic, and irregular nuclei of the tumor. The immunohistochemistry for melanoma associated markers with HMB-45 and Melan-A antigens were all positive confirming the diagnosis of metastatic malignant melanoma to CBD. After the procedure, her jaundice continued to improve, while melena stopped. Three months later, she developed metastatic melanoma to the nasopharynx and underwent complete excision. Following surgery, she refused chemotherapy. At one year follow-up, she denied symptoms of recurrent bile duct obstruction. CT scan showed only partial enhancing soft tissue at distal CBD with patent SEMS and aerobilia. Metastatic melanoma to the gallbladder and the common bile duct was extremely rare, reporting as 8% on autopsy cases of malignant melanoma. We detected the metastasis of malignant melanoma to common bile duct by using the digital SpyGlass cholangioscope. Although metastatic melanoma to the common bile duct is an uncommon incident, the possibility of metastatic melanoma to the extrahepatic biliary tree should be excluded in patients presenting with obstructive jaundice with a known history of malignant melanoma. Digital SpyGlass cholangioscopy is a useful tool for targeted tumor biopsy to confirm the diagnosis of metastatic melanoma to the common bile duct.
www.giejournal.org