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1147 Resolution of a Persistent Mucosal Defect After Peroral Endoscopic Myotomy (POEM) With Clip Closure
Abstracts
one a clinical observership. Two delegates had some primary operator experience (5-10 and >10 POEM). Median score was 4 for realism of EndoGelTM orientation (35), mucosal lift (4-5), mucosal incision (3-5), submucosal expansion (3-5) and myotomy (3-5). Realism of submucosal dissection scored higher at 5 (3-5). Median score was 4 for feasibility of EndoGelTM orientation (3-5), mucosal lift (4-5), mucosal incision (1-5), submucosal expansion (3-5), submucosal dissection (1-5) and myotomy (3-5). This cohort found the EndogelTM simulator useful (median 4, range 4-5) and would use this again (median 4, 3-5). Delegates thought EndogelTM could be used to monitor progress in skill development (median 4, 3-5). Conclusion: This preliminary data supports EndogelTM as a feasible simulation model for POEM training and is useful for trainees of varied experience. Particular attractive features are the realism of submucosal dissection owing to the specifically designed liquid retaining submucosal plane of the layered polyvinyl alcohol hydrogel enabling precise dissection to be mastered. Additionally, EndogelTM is advantageous over porcine models in being reusable. EndogelTM provides a safe and efficacious environment for advanced endoscopic skill development in the West.
1147 Resolution of a Persistent Mucosal Defect After Peroral Endoscopic Myotomy (POEM) With Clip Closure Mayenaaz Sidhu*, David J. Tate, Michael J. Bourke Westmead Hospital, Sydney, New South Wales, Australia POEM is a minimally invasive and effective therapeutic modality for the treatment of achalsia and other spastic oesophageal disorders. It is a safe alternative to surgery. Recent data has confirmed a sustained benefit with this procedure particularly with regards to achalasia. Oesophageal leak post POEM especially at the submucosal tunnel site is a relative rare (<1%) but recognised complication. The aim of this video is to demonstrate how to recognise this complication and manage this with revision of the endoscopic clip closure.
1148 Endoscopic Jejuno-Jejunostomy Using a LumenApposing Self-Expandable Metal Stent for Treatment of Obstructed Efferent Loop After Subtotal Gastrectomy With Roux-En-Y-Reconstruction Armin Küllmer*, Andreas Wannhoff, Arthur Schmidt, Karel Caca Internal Medicine/Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Baden-Württemberg, Germany We here report on a case of a 58-year-old male, who underwent gastric resection with end-to-side gastrojejunostomy and Roux-en-Y reconstruction because of gastric cancer nine months ago. During follow-up he complained about epigastric postprandial pain and recurrent vomiting. Endoscopy revealed kinking of the efferent jejunal loop at site of the gastrojejunostomy, which caused food retention in the remaining parts of the stomach and in a dilated blind loop. For treatment of the obstructed/kinked efferent loop we decided to perform endoscopic jejuno-jejunostomy using a lumen-apposing stent (LAS). The kinked efferent loop therefore was endoscopically intubated and a filled 20mm balloon catheter was placed in the efferent loop. Then an endoscopic ultrasound (EUS) endoscope was inserted into the blind loop and the filled balloon catheter in the efferent loop was visualized on EUS and served as target for EUS guided puncture of the efferent loop. The lumen-apposing stent was inserted and the delivery device was advanced into the efferent loop via electrocautery. Finally the LAS (15 mm x 10 mm) was deployed and balloon dilation of the stent with a 15 mm balloon was performed. Endoscopic inspection on the following day revealed correct placement of the stent without any signs of perforation or bleeding. Further, no more food retention in the remaining parts of the stomach or in the blind loop were found. A contrast swallow examination showed rapid passage of the contrast from the stomach through the LAS into the efferent loop without filling of the blind loop. Symptoms soon improved after the procedure and the patient could be discharged. He did not develop any signs of recurrent loop obstruction during follow-up until now. There is no standard treatment of efferent loop obstruction. Surgery and stent placement in the efferent loop have been described. Surgery has a high perinterventional risk, stent placement at this location is usually not durable. Currently however, first cases on the successful use of LAS for the treatment of afferent loop syndrome have been reported. Based upon our experience from this case and considering the good outcome in our patient, the use of LAS might also be a safe and effective way to treat the efferent loop obstruction after gastrectomy. Further, the use of a filled balloon catheter might facilitate EUS-guided puncture of jejunal loops.
www.giejournal.org
1149 Treatment of Ectopic Varices Using Undiluted N-Butyl-2Cyanoacrylate Glue Ravishankar Asokkumar*, Ennaliza Salazar, Roy M. Soetikno Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore Background: Ectopic gastrointestinal varices are rare but can bleed severely. Hence, early diagnosis and treatment is crucial. Unlike esophageal varices, the therapeutic modalities for ectopic varices are not well established. We describe the techniques for safe and efficacious delivery of N-butyl cyanoacrylate glue for bleeding ectopic varix. Endoscopic Methods: We used undiluted N-butyl-2-cyanoacrylate glue for endoscopic treatment of ectopic varix. Undiluted N-butyl-2-cyanoacrylate glue, in contrast to the glue mixed with lipoidal, polymerizes rapidly and, thus potentially, reduces the risk of glue embolism. We injected glue in small aliquots (1mL) each time to further minimize the risk of embolization. We used the distal attachment cap and water jet in all cases in order to localize and visualize the varix better. We used the one hand endoscopy technique as described for treatment of gastric varix and maintained a straight scope position for small bowel and colonic varices. This technique provides the endoscopist to achieve a better control over the scope and allows successful injection of N-butyl cyanoacrylate glue into the ectopic varix. We used injection needles without a distal step to prevent varix laceration during glue injection and proceeded to inject from distal to proximal aspect intravariceally. Lastly, we always flushed the channel with 10ml of olive oil in order to prevent accidental gluing of the endoscope. Clinical Implications: Direct injection of undiluted N-butyl-2-cyanoacrylate glue and adherence to the recommended endoscopic technique may be safe and efficacious for treatment of ectopic varices.
1150 Outcomes of Nutritional Interventions to Treat Dysphagia in Esophageal Cancer: A Population-Based Study Rohan Modi*1, Sameh Mikhail2, Alice Hinton3, Kyle A. Perry4, Samer El-Dika5, Jon Walker5, Sean T. McCarthy5, Darwin L. Conwell5, Somashekar G. Krishna5 1 Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH; 3Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH; 4Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; 5Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH Background: Dysphagia is associated with significant morbidity in patients with esophageal cancer (EC) and requires nutritional intervention. Using a national database we sought to compare outcomes of nutritional interventions for EC patients hospitalized with dysphagia. Methods: The Nationwide Inpatient Sample (2002-2012) was utilized to include all adult inpatients ( 18 years of age) with EC and dysphagia that underwent nutritional interventions including feeding tube placement, esophageal stenting, or parenteral nutrition (PN). We examined temporal trends and performed multivariate analysis for mortality, length of stay (LOS), and cost of hospitalization. Results: A total of 509,593 patients had EC during the study period with 12,205 hospitalizations related to dysphagia. The percentage of all hospitalizations for EC (0.161% vs. 0.179 %; p < 0.001) and EC patients with dysphagia (1.52% vs. 3.28%, p < 0.001) doubled over the study period. Univariate analysis showed that the dysphagia group versus EC patients without dysphagia had lower mortality (4.39% vs. 9.13%) and total hospital costs ($15,171 vs. $16.726) with no difference in LOS (8.07 vs 7.92 days). The most common nutritional intervention was a feeding tube (27%), followed by esophageal stenting (13%), and PN (11%) with urban teaching hospitals having higher rates of interventions when compared to urban non-teaching and rural hospitals. Multivariate analysis was performed and placement of a feeding tube versus esophageal stenting had comparable inpatient mortality (Odds Ratio, OR 1.06, 95% CI: 0.49-2.32); however, PN was associated with higher mortality (OR 2.37, 95% CI: 1.22-4.63) and cost of hospitalization ($5,510, 95% CI: 2,262, 8,759). Finally, more patients developed sepsis on PN (6.1%, pZ0.0228) compared to feeding tube placement (2.5%) or esophageal stenting (1.8%). Conclusion: Hospitalizations for EC with dysphagia has doubled over the study period. Nutritional intervention with a feeding tube or esophageal stenting had no difference in mortality, while PN was associated with increased rates sepsis, higher mortality, and increased cost of hospitalization. These findings should be further explored to better define the most appropriate interventions and treatment setting for this patient population.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB153
one a clinical observership. Two delegates had some primary operator experience (5-10 and >10 POEM). Median score was 4 for realism of EndoGelTM orientation (35), mucosal lift (4-5), mucosal incision (3-5), submucosal expansion (3-5) and myotomy (3-5). Realism of submucosal dissection scored higher at 5 (3-5). Median score was 4 for feasibility of EndoGelTM orientation (3-5), mucosal lift (4-5), mucosal incision (1-5), submucosal expansion (3-5), submucosal dissection (1-5) and myotomy (3-5). This cohort found the EndogelTM simulator useful (median 4, range 4-5) and would use this again (median 4, 3-5). Delegates thought EndogelTM could be used to monitor progress in skill development (median 4, 3-5). Conclusion: This preliminary data supports EndogelTM as a feasible simulation model for POEM training and is useful for trainees of varied experience. Particular attractive features are the realism of submucosal dissection owing to the specifically designed liquid retaining submucosal plane of the layered polyvinyl alcohol hydrogel enabling precise dissection to be mastered. Additionally, EndogelTM is advantageous over porcine models in being reusable. EndogelTM provides a safe and efficacious environment for advanced endoscopic skill development in the West.
1147 Resolution of a Persistent Mucosal Defect After Peroral Endoscopic Myotomy (POEM) With Clip Closure Mayenaaz Sidhu*, David J. Tate, Michael J. Bourke Westmead Hospital, Sydney, New South Wales, Australia POEM is a minimally invasive and effective therapeutic modality for the treatment of achalsia and other spastic oesophageal disorders. It is a safe alternative to surgery. Recent data has confirmed a sustained benefit with this procedure particularly with regards to achalasia. Oesophageal leak post POEM especially at the submucosal tunnel site is a relative rare (<1%) but recognised complication. The aim of this video is to demonstrate how to recognise this complication and manage this with revision of the endoscopic clip closure.
1148 Endoscopic Jejuno-Jejunostomy Using a LumenApposing Self-Expandable Metal Stent for Treatment of Obstructed Efferent Loop After Subtotal Gastrectomy With Roux-En-Y-Reconstruction Armin Küllmer*, Andreas Wannhoff, Arthur Schmidt, Karel Caca Internal Medicine/Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Baden-Württemberg, Germany We here report on a case of a 58-year-old male, who underwent gastric resection with end-to-side gastrojejunostomy and Roux-en-Y reconstruction because of gastric cancer nine months ago. During follow-up he complained about epigastric postprandial pain and recurrent vomiting. Endoscopy revealed kinking of the efferent jejunal loop at site of the gastrojejunostomy, which caused food retention in the remaining parts of the stomach and in a dilated blind loop. For treatment of the obstructed/kinked efferent loop we decided to perform endoscopic jejuno-jejunostomy using a lumen-apposing stent (LAS). The kinked efferent loop therefore was endoscopically intubated and a filled 20mm balloon catheter was placed in the efferent loop. Then an endoscopic ultrasound (EUS) endoscope was inserted into the blind loop and the filled balloon catheter in the efferent loop was visualized on EUS and served as target for EUS guided puncture of the efferent loop. The lumen-apposing stent was inserted and the delivery device was advanced into the efferent loop via electrocautery. Finally the LAS (15 mm x 10 mm) was deployed and balloon dilation of the stent with a 15 mm balloon was performed. Endoscopic inspection on the following day revealed correct placement of the stent without any signs of perforation or bleeding. Further, no more food retention in the remaining parts of the stomach or in the blind loop were found. A contrast swallow examination showed rapid passage of the contrast from the stomach through the LAS into the efferent loop without filling of the blind loop. Symptoms soon improved after the procedure and the patient could be discharged. He did not develop any signs of recurrent loop obstruction during follow-up until now. There is no standard treatment of efferent loop obstruction. Surgery and stent placement in the efferent loop have been described. Surgery has a high perinterventional risk, stent placement at this location is usually not durable. Currently however, first cases on the successful use of LAS for the treatment of afferent loop syndrome have been reported. Based upon our experience from this case and considering the good outcome in our patient, the use of LAS might also be a safe and effective way to treat the efferent loop obstruction after gastrectomy. Further, the use of a filled balloon catheter might facilitate EUS-guided puncture of jejunal loops.
www.giejournal.org
1149 Treatment of Ectopic Varices Using Undiluted N-Butyl-2Cyanoacrylate Glue Ravishankar Asokkumar*, Ennaliza Salazar, Roy M. Soetikno Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore Background: Ectopic gastrointestinal varices are rare but can bleed severely. Hence, early diagnosis and treatment is crucial. Unlike esophageal varices, the therapeutic modalities for ectopic varices are not well established. We describe the techniques for safe and efficacious delivery of N-butyl cyanoacrylate glue for bleeding ectopic varix. Endoscopic Methods: We used undiluted N-butyl-2-cyanoacrylate glue for endoscopic treatment of ectopic varix. Undiluted N-butyl-2-cyanoacrylate glue, in contrast to the glue mixed with lipoidal, polymerizes rapidly and, thus potentially, reduces the risk of glue embolism. We injected glue in small aliquots (1mL) each time to further minimize the risk of embolization. We used the distal attachment cap and water jet in all cases in order to localize and visualize the varix better. We used the one hand endoscopy technique as described for treatment of gastric varix and maintained a straight scope position for small bowel and colonic varices. This technique provides the endoscopist to achieve a better control over the scope and allows successful injection of N-butyl cyanoacrylate glue into the ectopic varix. We used injection needles without a distal step to prevent varix laceration during glue injection and proceeded to inject from distal to proximal aspect intravariceally. Lastly, we always flushed the channel with 10ml of olive oil in order to prevent accidental gluing of the endoscope. Clinical Implications: Direct injection of undiluted N-butyl-2-cyanoacrylate glue and adherence to the recommended endoscopic technique may be safe and efficacious for treatment of ectopic varices.
1150 Outcomes of Nutritional Interventions to Treat Dysphagia in Esophageal Cancer: A Population-Based Study Rohan Modi*1, Sameh Mikhail2, Alice Hinton3, Kyle A. Perry4, Samer El-Dika5, Jon Walker5, Sean T. McCarthy5, Darwin L. Conwell5, Somashekar G. Krishna5 1 Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH; 3Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH; 4Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; 5Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH Background: Dysphagia is associated with significant morbidity in patients with esophageal cancer (EC) and requires nutritional intervention. Using a national database we sought to compare outcomes of nutritional interventions for EC patients hospitalized with dysphagia. Methods: The Nationwide Inpatient Sample (2002-2012) was utilized to include all adult inpatients ( 18 years of age) with EC and dysphagia that underwent nutritional interventions including feeding tube placement, esophageal stenting, or parenteral nutrition (PN). We examined temporal trends and performed multivariate analysis for mortality, length of stay (LOS), and cost of hospitalization. Results: A total of 509,593 patients had EC during the study period with 12,205 hospitalizations related to dysphagia. The percentage of all hospitalizations for EC (0.161% vs. 0.179 %; p < 0.001) and EC patients with dysphagia (1.52% vs. 3.28%, p < 0.001) doubled over the study period. Univariate analysis showed that the dysphagia group versus EC patients without dysphagia had lower mortality (4.39% vs. 9.13%) and total hospital costs ($15,171 vs. $16.726) with no difference in LOS (8.07 vs 7.92 days). The most common nutritional intervention was a feeding tube (27%), followed by esophageal stenting (13%), and PN (11%) with urban teaching hospitals having higher rates of interventions when compared to urban non-teaching and rural hospitals. Multivariate analysis was performed and placement of a feeding tube versus esophageal stenting had comparable inpatient mortality (Odds Ratio, OR 1.06, 95% CI: 0.49-2.32); however, PN was associated with higher mortality (OR 2.37, 95% CI: 1.22-4.63) and cost of hospitalization ($5,510, 95% CI: 2,262, 8,759). Finally, more patients developed sepsis on PN (6.1%, pZ0.0228) compared to feeding tube placement (2.5%) or esophageal stenting (1.8%). Conclusion: Hospitalizations for EC with dysphagia has doubled over the study period. Nutritional intervention with a feeding tube or esophageal stenting had no difference in mortality, while PN was associated with increased rates sepsis, higher mortality, and increased cost of hospitalization. These findings should be further explored to better define the most appropriate interventions and treatment setting for this patient population.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB153