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1083 Submucosal Tunneling Endoscopic Septum Division for Esophageal Diverticulum
Abstracts
hyaluronate acid solution. After separation from surrounding normal mucosa, S-O clip was attached to the edge of the exfoliated mucosa. Another regular clip was used to hold the distal nylon loop attached to the S-O clip, and applied to the proximal duodenal wall opposite the lesion, enabling good traction and submucosal layer visualization. We completed ESD safely without perforation. We covered the mucosal defect with PGA sheets (NeoveilÒ 015, Gunze Limited, Japan) and fibrin glue (BeriplastÒ P, CSL Berling, USA). Clinical implications: The S-O clip could make ESD procedure easier and safer by keeping good traction. The usefulness is already demonstrated in colonic ESD1). However, this clip would be feasible and useful in the lesions in GI tract other than colon. Reference: 1) Ritsuno H, Sakamoto N, Osada T, et al. Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S–O clip. Surg Endosc. 2014;28:3143-9.
1083 Submucosal Tunneling Endoscopic Septum Division for Esophageal Diverticulum Ming-Yan Cai*, Ping-Hong Zhou, Mei-Dong Xu, Quan-Lin Li Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Objective: Submucosal tunneling endoscopic septum division (STESD) is a newly described endoscopic minimal invasive intervention for esophageal diverticulum. This study is to evaluate its efficacy for esophageal diverticulum. Methods: There were six consecutive patients with symptomatic esophageal diverticulum who received STESD in a tertiary care center (Shanghai, China) during April 2016 to November 2016. The symptoms were scored as dysphagia, heartburn, regurgitation, weight loss and retrosternal pain with each ranging from 0 to 3 (maximum score 15, minimum score 0). STESD was performed as following: a) mucosal entry was made 3 cm from the septum of esophageal diverticulum b) submucosal tunnel was created towards the septum c) after the satisfactory exposure of the septum, endoscopic division was made down to the bottom of the diverticulum d) mucosal closure of the tunnel entry. Results: There were four male patients and two female. Four patients (4/6, 66.7%) were epiphrenic diverticulum, the rest two were Zenker’s diverticulum (2/6, 33.3%). The mean procedure time was 68.5 min (range, 33-135min, SD, 43.3). The mean time of hospital stay was 5.2 days (range, 3-9, SD, 2.0). All patients had symptom relief after the procedure. The mean symptom score was 4.8 (SD, 4.4; range, 1-13) before and 1.0 (SD, 1.5, range 0-4) after the procedure. One patient was accompanied with achalasia and she received peroral endoscopic myotomy combined with STESD. One patient with Zenker’s diverticulum reported foreign body sensation after operation and experienced relief shortly. No major adverse event was found during hospital stay and after discharge. Conclusions: Submucosal tunneling endoscopic septum division is efficient and safe to relieve symptomatic esophageal diverticulum in short term. More observations of long-term outcome are needed.
1084 Endoscopic Submucosal Dissection for Cardiac Epithelial Neoplasms Over Whole Circumference Yuan Chu, Xu meidong* Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Background: A 65-year-old male who complained of epigastric discomfort for near 1 year was found cardiac mucosal erosion occupying whole circumference under gastroduodenoscopy. The pathology of biopsied lesion was high-grade intraepithelial neoplasia. The patient received endoscopic submucosal dissection (ESD). Method: Evaluation by narrow band imaging and magnifying endoscopy; Treated by endoscopic submucosal dissection (ESD). Results: A successful en-bloc resection was accomplished without operative complications. The final pathological diagnose was adenocarcinoma (mostly limited to lamina propria with focal muscularis mucosa invasion). No vascular and lymphatic invasion was found. The follow-up period was 10 days by December 1st. No delay hemorrhage was found. Conclusion: This is a successful ESD procedure for a difficult cardiac whole-circumference lesion with standard process of lesion evaluation by white-light and NBI & ME, marking, injection & elevation, incision, dissection and hemostasis. To achieve an en-bloc resection for such a huge lesion, careful and technical procedure should be performed all along the resection.
1085 Underwater Endoscopic Submucosal Dissection of a Non-Polypoid Superficial Tumor Spreading Into the Appendix Federico Iacopini*1, Takuji Gotoda2, Fabrizio Montagnese1, Cristina Grossi1, Walter Elisei1, Guido Costamagna4, Yutaka Saito3 1 Ospedale S. Giuseppe, ASL Roma H, Gastroenterology Unit, Rome, Italy; 2 Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan; 3Endoscopy Division, National Cancer
AB136 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Center Hospital, Tokyo, Japan; 4Surgical Digestive Endoscopy; Policlinico Gemelli, Università Cattolica, Rome, Italy Superficial tumors at the appendix are mostly off limits for endoscopic resection because of the technical challenge of a complete resection and perforation risk due to a geometrically difficult anatomy. A 72-year-old man underwent colonoscopy and a laterally spreading tumor invading the appendix was diagnosed. Colonoscopy was rescheduled with a pediatric scope (PCF-H180AI, Olympus, Japan) and a short-tip hood (ST-hood, Fujifilm, Japan). The appendix was intubated, distended by water, and a 25 mm neoplasm was visualized spreading half in the cecum and half into the appendix. ESD was performed underwater to avoid air over-inflation and pain. Mucosal incision started into the appendiceal lumen, SM dissection was conducted from the cecum to the appendixwith a 1.5 mm knife (Dualknife, KD-650U, Olympus) and small insulated-tip knife (IT-knife nano, Olympus). SM fibrosiswas severe and diffuse. ESD was en bloc within 107 min. Postoperative fever, mild pain and rebound tenderness in the right ileal fossa occurred after 8 hours and resolved within 24 hours with conservative treatment. Histology showed the curative resection of an adenoma withhigh-grade dysplasia. Follow-up showed a scar without residual tumor and stricture. Superficial appendiceal tumors are mostly off limits for endoscopic resection. Extension can be limited to the orifice or may spread into the appendix. Visible and reachable appendiceal tumor margins are determinant for the feasibility of endoscopic resection. Few cases have been reported and most have been conducted by underwater EMR or ESD with a partial invagination of the appendix into the cecum. This case suggests that the appendix can be intubated to evaluate tumor extension and conduct the resection. The ESD approach was analogous to that standardized for the esophagus: mucosal incision firstly at the distal edge, SM dissection in a straightforward direction. ESD may expand the indications of endoscopic resection for appendiceal tumors. Manipulation of knives is probably less dependent to space restrictions than snare opening and ESD may guarantee higher curative resection rates.
1086 Using the Light at the End of the Tunnel: Salvaging a Submucosal Tunnelling Endoscopic Resection (STER) for Large Submucosal Lesions Amit P. Desai*, Tina Park, Sunil Amin, Amrita Sethi Digestive and Liver Disease, New York Presbyterian Hospital - Columbia University Medical Center, New York City, NY A 32 year old female with dysphagia was referred for management of a submucosal gastric cardia mass 1 cm distal to the gastro-esophageal junction. Fine needle aspiration revealed possible gastro-intestinal stromal tumor or leiomyoma. The patient was referred for surgery. However, given the anatomic location, a complicated wedge resection with high risk of morbidity would need to be performed. Therefore, the patient was referred to our institution for endoscopic management. Given the symptoms, location and morbidity associated with surgical management, the decision was made to pursue submucosal tunneling endoscopic resection (STER). The patient was brought to our endoscopy suite and preparations were made for STER. An esophageal mucosal bleb and proximal mucosotomy was created 5 cm proximal to the lesion to gain access to the submucosa. The tunnel was extended through the esophagus into the gastric mucosa, where the smooth, encapsulated mass was encountered. Careful endoscopic dissection was performed to separate the lesion from the surrounding submucosal space. However, during this dissection, an inadvertent distal mucosotomy was noticed at the end of the tunnel. Given patient stability, the submucosal dissection was continued until the mass was completely dissected. However, the mass was larger than the diameter of the tunnel, making retrieval difficult. In order to remove the lesion, the inadvertent distal mucosotomy was intentionally lengthened. The encapsulated lesion was then gently pushed through the distal mucostomy into the stomach using the gastroscope. The proximal and distal mucosotomies were then closed. Upon retrieval, the mass measured 4 cm. Final pathology revealed a leiomyoma with negative margins. The patient was discharged the following day and was asymptomatic on follow up. Large gastric cardia lesions can be difficult to manage given the anatomic location. STER offers a possible endoscopic method for lesion removal. However, ensuring the tunnel is adequate for lesion removal can be difficult. Creation of a proximal and distal mucosotomy can aid in the removal of these large lesions.
1087 Per-Oral Endoscopic Pyloromyotomy (G-POEM) With Over the Scope Clip (OTSC) Closure for Refractory Gastroparesis Sunil Amin*, Amit P. Desai, Amrita Sethi Gastroenterology, Columbia University Medical Center, New York, NY A 61-year-old man with HIV and chronic inflammatory demyelinating polyneuropathy presented with medically refractory gastroparesis. Endoscopic therapy was initially successful with the placement of a transpyloric stent; however, symptom relief was transient as the stent migrated distally despite being sutured in place. The decision was thus made to proceed with endoscopic per-oral pyloromyotomy
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hyaluronate acid solution. After separation from surrounding normal mucosa, S-O clip was attached to the edge of the exfoliated mucosa. Another regular clip was used to hold the distal nylon loop attached to the S-O clip, and applied to the proximal duodenal wall opposite the lesion, enabling good traction and submucosal layer visualization. We completed ESD safely without perforation. We covered the mucosal defect with PGA sheets (NeoveilÒ 015, Gunze Limited, Japan) and fibrin glue (BeriplastÒ P, CSL Berling, USA). Clinical implications: The S-O clip could make ESD procedure easier and safer by keeping good traction. The usefulness is already demonstrated in colonic ESD1). However, this clip would be feasible and useful in the lesions in GI tract other than colon. Reference: 1) Ritsuno H, Sakamoto N, Osada T, et al. Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S–O clip. Surg Endosc. 2014;28:3143-9.
1083 Submucosal Tunneling Endoscopic Septum Division for Esophageal Diverticulum Ming-Yan Cai*, Ping-Hong Zhou, Mei-Dong Xu, Quan-Lin Li Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Objective: Submucosal tunneling endoscopic septum division (STESD) is a newly described endoscopic minimal invasive intervention for esophageal diverticulum. This study is to evaluate its efficacy for esophageal diverticulum. Methods: There were six consecutive patients with symptomatic esophageal diverticulum who received STESD in a tertiary care center (Shanghai, China) during April 2016 to November 2016. The symptoms were scored as dysphagia, heartburn, regurgitation, weight loss and retrosternal pain with each ranging from 0 to 3 (maximum score 15, minimum score 0). STESD was performed as following: a) mucosal entry was made 3 cm from the septum of esophageal diverticulum b) submucosal tunnel was created towards the septum c) after the satisfactory exposure of the septum, endoscopic division was made down to the bottom of the diverticulum d) mucosal closure of the tunnel entry. Results: There were four male patients and two female. Four patients (4/6, 66.7%) were epiphrenic diverticulum, the rest two were Zenker’s diverticulum (2/6, 33.3%). The mean procedure time was 68.5 min (range, 33-135min, SD, 43.3). The mean time of hospital stay was 5.2 days (range, 3-9, SD, 2.0). All patients had symptom relief after the procedure. The mean symptom score was 4.8 (SD, 4.4; range, 1-13) before and 1.0 (SD, 1.5, range 0-4) after the procedure. One patient was accompanied with achalasia and she received peroral endoscopic myotomy combined with STESD. One patient with Zenker’s diverticulum reported foreign body sensation after operation and experienced relief shortly. No major adverse event was found during hospital stay and after discharge. Conclusions: Submucosal tunneling endoscopic septum division is efficient and safe to relieve symptomatic esophageal diverticulum in short term. More observations of long-term outcome are needed.
1084 Endoscopic Submucosal Dissection for Cardiac Epithelial Neoplasms Over Whole Circumference Yuan Chu, Xu meidong* Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Background: A 65-year-old male who complained of epigastric discomfort for near 1 year was found cardiac mucosal erosion occupying whole circumference under gastroduodenoscopy. The pathology of biopsied lesion was high-grade intraepithelial neoplasia. The patient received endoscopic submucosal dissection (ESD). Method: Evaluation by narrow band imaging and magnifying endoscopy; Treated by endoscopic submucosal dissection (ESD). Results: A successful en-bloc resection was accomplished without operative complications. The final pathological diagnose was adenocarcinoma (mostly limited to lamina propria with focal muscularis mucosa invasion). No vascular and lymphatic invasion was found. The follow-up period was 10 days by December 1st. No delay hemorrhage was found. Conclusion: This is a successful ESD procedure for a difficult cardiac whole-circumference lesion with standard process of lesion evaluation by white-light and NBI & ME, marking, injection & elevation, incision, dissection and hemostasis. To achieve an en-bloc resection for such a huge lesion, careful and technical procedure should be performed all along the resection.
1085 Underwater Endoscopic Submucosal Dissection of a Non-Polypoid Superficial Tumor Spreading Into the Appendix Federico Iacopini*1, Takuji Gotoda2, Fabrizio Montagnese1, Cristina Grossi1, Walter Elisei1, Guido Costamagna4, Yutaka Saito3 1 Ospedale S. Giuseppe, ASL Roma H, Gastroenterology Unit, Rome, Italy; 2 Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan; 3Endoscopy Division, National Cancer
AB136 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Center Hospital, Tokyo, Japan; 4Surgical Digestive Endoscopy; Policlinico Gemelli, Università Cattolica, Rome, Italy Superficial tumors at the appendix are mostly off limits for endoscopic resection because of the technical challenge of a complete resection and perforation risk due to a geometrically difficult anatomy. A 72-year-old man underwent colonoscopy and a laterally spreading tumor invading the appendix was diagnosed. Colonoscopy was rescheduled with a pediatric scope (PCF-H180AI, Olympus, Japan) and a short-tip hood (ST-hood, Fujifilm, Japan). The appendix was intubated, distended by water, and a 25 mm neoplasm was visualized spreading half in the cecum and half into the appendix. ESD was performed underwater to avoid air over-inflation and pain. Mucosal incision started into the appendiceal lumen, SM dissection was conducted from the cecum to the appendixwith a 1.5 mm knife (Dualknife, KD-650U, Olympus) and small insulated-tip knife (IT-knife nano, Olympus). SM fibrosiswas severe and diffuse. ESD was en bloc within 107 min. Postoperative fever, mild pain and rebound tenderness in the right ileal fossa occurred after 8 hours and resolved within 24 hours with conservative treatment. Histology showed the curative resection of an adenoma withhigh-grade dysplasia. Follow-up showed a scar without residual tumor and stricture. Superficial appendiceal tumors are mostly off limits for endoscopic resection. Extension can be limited to the orifice or may spread into the appendix. Visible and reachable appendiceal tumor margins are determinant for the feasibility of endoscopic resection. Few cases have been reported and most have been conducted by underwater EMR or ESD with a partial invagination of the appendix into the cecum. This case suggests that the appendix can be intubated to evaluate tumor extension and conduct the resection. The ESD approach was analogous to that standardized for the esophagus: mucosal incision firstly at the distal edge, SM dissection in a straightforward direction. ESD may expand the indications of endoscopic resection for appendiceal tumors. Manipulation of knives is probably less dependent to space restrictions than snare opening and ESD may guarantee higher curative resection rates.
1086 Using the Light at the End of the Tunnel: Salvaging a Submucosal Tunnelling Endoscopic Resection (STER) for Large Submucosal Lesions Amit P. Desai*, Tina Park, Sunil Amin, Amrita Sethi Digestive and Liver Disease, New York Presbyterian Hospital - Columbia University Medical Center, New York City, NY A 32 year old female with dysphagia was referred for management of a submucosal gastric cardia mass 1 cm distal to the gastro-esophageal junction. Fine needle aspiration revealed possible gastro-intestinal stromal tumor or leiomyoma. The patient was referred for surgery. However, given the anatomic location, a complicated wedge resection with high risk of morbidity would need to be performed. Therefore, the patient was referred to our institution for endoscopic management. Given the symptoms, location and morbidity associated with surgical management, the decision was made to pursue submucosal tunneling endoscopic resection (STER). The patient was brought to our endoscopy suite and preparations were made for STER. An esophageal mucosal bleb and proximal mucosotomy was created 5 cm proximal to the lesion to gain access to the submucosa. The tunnel was extended through the esophagus into the gastric mucosa, where the smooth, encapsulated mass was encountered. Careful endoscopic dissection was performed to separate the lesion from the surrounding submucosal space. However, during this dissection, an inadvertent distal mucosotomy was noticed at the end of the tunnel. Given patient stability, the submucosal dissection was continued until the mass was completely dissected. However, the mass was larger than the diameter of the tunnel, making retrieval difficult. In order to remove the lesion, the inadvertent distal mucosotomy was intentionally lengthened. The encapsulated lesion was then gently pushed through the distal mucostomy into the stomach using the gastroscope. The proximal and distal mucosotomies were then closed. Upon retrieval, the mass measured 4 cm. Final pathology revealed a leiomyoma with negative margins. The patient was discharged the following day and was asymptomatic on follow up. Large gastric cardia lesions can be difficult to manage given the anatomic location. STER offers a possible endoscopic method for lesion removal. However, ensuring the tunnel is adequate for lesion removal can be difficult. Creation of a proximal and distal mucosotomy can aid in the removal of these large lesions.
1087 Per-Oral Endoscopic Pyloromyotomy (G-POEM) With Over the Scope Clip (OTSC) Closure for Refractory Gastroparesis Sunil Amin*, Amit P. Desai, Amrita Sethi Gastroenterology, Columbia University Medical Center, New York, NY A 61-year-old man with HIV and chronic inflammatory demyelinating polyneuropathy presented with medically refractory gastroparesis. Endoscopic therapy was initially successful with the placement of a transpyloric stent; however, symptom relief was transient as the stent migrated distally despite being sutured in place. The decision was thus made to proceed with endoscopic per-oral pyloromyotomy
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