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⁎3482 Endoscopic removal of impacted sharp foreign body in esophagus.
*3481 NOVEL APPLICATIONS OF SOEHENDRA STENT RETRIEVER IN THERAPEUTIC ERCP. Arkan I. Alrashid, Russell D. Brown, Shylaja Sreekumar, Rama P. Venu, Univ of Illinois at Chicago, Chicago, IL. Introduction: Soehendra stent retrievers (SSR, Wilson-Cook Inc) were originally designed for stent retrieval. Recently SSR has been employed for dilation of strictures, but experience is limited. We have found SSR to be a valuable tool in several other maneuvers during therapeutic ERCP. Aim: To analyze the success, complications and clinical outcomes of newer applications of SSR during ERCP. Method: Patients with tight strictures of the bile and pancreatic ducts were studied. These strictures allowed guide wire access, but defied 5Fr catheter advancement and conventional balloon or catheter dilation. After wire access was achieved, The SSR was passed up to the distal margin of the stricture. Rotation and forward pressure were applied to the SSR to traverse the stricture slowly. Following dilation, stent placement was performed, and cytology obtained from the SSR threads. Patients with hilar tumors had Wallstent (WS) mesh space dilation using SSR for placement of a second WS. Patient demographics, indications, success of dilation and stenting, complications and procedure outcome were studied. Results: 37 patients underwent SSR use in the study period, 13 for stent retrieval alone. Twenty-four patients underwent SSR dilation as shown in the table below. 3 patients had pain during dilation requiring additional meperidine. In majority of patients (12/20), it was possible to place a stent of identical diameter to that of the SSR used. Cytology was positive for malignancy in 3 of 5 patients with cancer. Conclusions: Dilation using the Soehendra stent retriever is safe and highly successful (83%) for strictures defying conventional techniques. Novel applications including transpapillary pseudocyst drainage, Wallstent mesh dilation and tissue acquisition for cytology can also be performed successfully using this device. Indication PD Dilation PDDil+TP Drain* BD Dilation WS Mesh Dilation TOTAL
No.
Dil. success
10 3 9 2 24
8 3 8 2 21
(80%) (100%) (89%) (100%) (88%)
Stent success 8 3 8 1 20
(80%) (100%) (89%) (50%) (83%)
* Transpapillary pseudocyst drainage
*3482 ENDOSCOPIC REMOVAL OF IMPACTED SHARP FOREIGN BODY IN ESOPHAGUS. Yoon Tae Jeen, Hoon Jae Chun, Chang Don Kang, Jung Whan Lee, Hong Sik Lee, Chi Wook Song, Soon Ho Um, Sang Woo Lee, Jae Hyun Choi, Chang Duk Kim, Ho Sang Ryu, Jin Hae Hyun, Korea Univ Coll of Medicine, Seoul, South Korea. Background/Aims: Sharp impacted esophageal foreign bodies can be very difficult to manage. When attempting to remove such objects inappropriately, life threatening complications, such as perforation can occur. Therefore, surgical intervention generally affords a safer approach. The aim of this study is to evaluate the safety and efficacy of endoscopic removal of impacted sharp esophageal foreign bodies using dilation method with oral side balloon. Methods: Total of 17 patients(Male 6, Female 11) with impacted sharp esophageal foreign bodies underwent endoscopic extraction. The following technique was successfully performed at our hospital(Figure A,B). Oral side balloon(Top Co. Japan) for esophageal variceal sclerotherapy was attached on the distal part of endoscope. Under local anesthesia, endoscope was inserted near the proximal part of the esophageal foreign body. Then, oral side balloon was gradually dilated. Dilataion of proximal part of esophagus made it possible to release the impacted sharp foreign body from the esophageal wall. Results: The types of foreign bodies were fish bones(10 case), and press-through packages(7 cases). Endoscopic removal was successful in all 17 cases without complications such as perforation. Conclusion: This method using oral side balloon is safe and effective in removing impacted sharp esophageal foreign bodies avoiding surgery and possible perforation.
VOLUME 51, NO. 4, PART 2, 2000
*3483 A NOVEL METHOD OF VIRTUAL HISTOLOGY UTILIZING LASER-SCANNING CONFOCAL MICROSCOPY FOR UNTREATED FRESH SPECIMEN OF THE GASTROINTESTINAL MUCOSA. Takehisa Iwai, Tokyo Med and Dental Univ, Tokyo, Japan. Background: Histological examination for gastorintestinal superficial lesions has been mainly based upon the light micorscopic examination of a thin-slice specimen under H-E staining. However, it takes a couple of days to create a slide grass for microscopic study. In order to obtain a simultaneous microscopic image for an untreated specimen, the authors introduced a laserscanning confocal microscopic study for a fresh sample of gastrointestinal mucosa. Methods: Fresh and untreated mucosal specimens in the esophagus, stomach and colon obtained by pinch biopsy or EMR are based in normal saline and examined by utilizing the laser-scanning confocal microscopy (LCM) with collecting the reflective light of 488nm wave-length argon laser beam. Findings from the LCM image are compared with those of the conventional H-E staining in all specimens. Findings: Average scanning time of a specimen to obtain the LCM image was 1.6 seconds. The acquireed LCM images were corresponded well to the conventional H-E light microscopic imagnes in the esophagus, stomach and colon. Overall accuracy of LCM image for cancer diagnosis is 89.7%. Discussion: This novel method enables to obtain a simultaneous and a serial imaginary microscopic section on an actually non-cut fresh specimen, although the resolution of the obtained image is still limited. These early results encourage us to create an image relevant to conventional histology in accordance with the development of the LCM technology in the near future.
*3484 ENTERAL WALLSTENT FOR THE EMERGENCY TREATMENT OF ACUTE COLONIC OBSTRUCTION DUE TO MALIGNANT STRICTURES. Rodolfo Rocca, Claudio De Angelis, Franco Coppola, Claudio Barletti, Angelo Pera, Mario Rizzetto, Raffaello Sostegni, Patrizia Carucci, Alessandro Musso, Mara Falco, Giorgio Saracco, Mauriziano Hosp, Torino, Italy; Molinette Hosp, Torino, Italy. Background and aim: Acute large bowel obstruction is an emergency situation usually requiring surgical intervention. A new colonic, throughthe-scope metal stent has been described as effective in the treatment of obstructing colorectal cancer. Aim of our study was to evaluate the feasibility, efficacy and safety of emergency enteral stent placement for the preoperative management of neoplastic acute bowel obstruction. Methods: Sixteen consecutive patients (10M/6F, mean age 72, range 5889) with clinical and radiologic signs of acute colonic obstruction were included in the study. Before stent placement a CT scan was performed in order to evaluate the nature and the site of obstruction. The site of obstruction was rectum in 3 patients, sigmoid in 6 , descending in 3, splenic flexure in 1, trasversum in 1, hepatic flexure in 1 and a colorectal anastomotic recurrence in 1. Enteral stents (22 mm diameter and 6 or 9 cm in lenght) were used in all patients. A guide wire and a 5 Fr ERCP catheter were used to pass through the stricture and to inject contrast in order to visualise the proximal and distal extension of the tumor. Stent placement was then performed under endoscopic and fluoroscopic control advancing the stent over the guide wire. Results: Stent placement was successful in 14 out of 16 patients (87%). In one patient with a splenic flexure we were not able to pass with the guide wire over the stricture. In 1 patient the stent could not be advanced through a tortuous, fixed sigmoid stricture. No complications were observed. Thirteen patients recovered from mechanical obstruction and could receive bowel cleansing (in 1 patient bowel occlusion did not relieve after stent placement). In 4 patients the stent placement was considered to be a definitive palliative treatment. After a median time of 4 days (range 3-7) nine patients underwent a single stage surgery with end-to-end anastomosis without complications. Conclusion: Preoperative enteral placement seems a safe and effective technique to manage patients with acute large bowel malignant obstruction. It allows to perform a single stage curative resection even in patients admitted to emergency room for acute colonic obstruction. In patients with advanced neoplastc disease diagnosed after relief of bowel occlusion, the enteral stent could be considered a definitive palliative treatment alternative to defunctioning colostomy.
GASTROINTESTINAL ENDOSCOPY
AB105
No.
Dil. success
10 3 9 2 24
8 3 8 2 21
(80%) (100%) (89%) (100%) (88%)
Stent success 8 3 8 1 20
(80%) (100%) (89%) (50%) (83%)
* Transpapillary pseudocyst drainage
*3482 ENDOSCOPIC REMOVAL OF IMPACTED SHARP FOREIGN BODY IN ESOPHAGUS. Yoon Tae Jeen, Hoon Jae Chun, Chang Don Kang, Jung Whan Lee, Hong Sik Lee, Chi Wook Song, Soon Ho Um, Sang Woo Lee, Jae Hyun Choi, Chang Duk Kim, Ho Sang Ryu, Jin Hae Hyun, Korea Univ Coll of Medicine, Seoul, South Korea. Background/Aims: Sharp impacted esophageal foreign bodies can be very difficult to manage. When attempting to remove such objects inappropriately, life threatening complications, such as perforation can occur. Therefore, surgical intervention generally affords a safer approach. The aim of this study is to evaluate the safety and efficacy of endoscopic removal of impacted sharp esophageal foreign bodies using dilation method with oral side balloon. Methods: Total of 17 patients(Male 6, Female 11) with impacted sharp esophageal foreign bodies underwent endoscopic extraction. The following technique was successfully performed at our hospital(Figure A,B). Oral side balloon(Top Co. Japan) for esophageal variceal sclerotherapy was attached on the distal part of endoscope. Under local anesthesia, endoscope was inserted near the proximal part of the esophageal foreign body. Then, oral side balloon was gradually dilated. Dilataion of proximal part of esophagus made it possible to release the impacted sharp foreign body from the esophageal wall. Results: The types of foreign bodies were fish bones(10 case), and press-through packages(7 cases). Endoscopic removal was successful in all 17 cases without complications such as perforation. Conclusion: This method using oral side balloon is safe and effective in removing impacted sharp esophageal foreign bodies avoiding surgery and possible perforation.
VOLUME 51, NO. 4, PART 2, 2000
*3483 A NOVEL METHOD OF VIRTUAL HISTOLOGY UTILIZING LASER-SCANNING CONFOCAL MICROSCOPY FOR UNTREATED FRESH SPECIMEN OF THE GASTROINTESTINAL MUCOSA. Takehisa Iwai, Tokyo Med and Dental Univ, Tokyo, Japan. Background: Histological examination for gastorintestinal superficial lesions has been mainly based upon the light micorscopic examination of a thin-slice specimen under H-E staining. However, it takes a couple of days to create a slide grass for microscopic study. In order to obtain a simultaneous microscopic image for an untreated specimen, the authors introduced a laserscanning confocal microscopic study for a fresh sample of gastrointestinal mucosa. Methods: Fresh and untreated mucosal specimens in the esophagus, stomach and colon obtained by pinch biopsy or EMR are based in normal saline and examined by utilizing the laser-scanning confocal microscopy (LCM) with collecting the reflective light of 488nm wave-length argon laser beam. Findings from the LCM image are compared with those of the conventional H-E staining in all specimens. Findings: Average scanning time of a specimen to obtain the LCM image was 1.6 seconds. The acquireed LCM images were corresponded well to the conventional H-E light microscopic imagnes in the esophagus, stomach and colon. Overall accuracy of LCM image for cancer diagnosis is 89.7%. Discussion: This novel method enables to obtain a simultaneous and a serial imaginary microscopic section on an actually non-cut fresh specimen, although the resolution of the obtained image is still limited. These early results encourage us to create an image relevant to conventional histology in accordance with the development of the LCM technology in the near future.
*3484 ENTERAL WALLSTENT FOR THE EMERGENCY TREATMENT OF ACUTE COLONIC OBSTRUCTION DUE TO MALIGNANT STRICTURES. Rodolfo Rocca, Claudio De Angelis, Franco Coppola, Claudio Barletti, Angelo Pera, Mario Rizzetto, Raffaello Sostegni, Patrizia Carucci, Alessandro Musso, Mara Falco, Giorgio Saracco, Mauriziano Hosp, Torino, Italy; Molinette Hosp, Torino, Italy. Background and aim: Acute large bowel obstruction is an emergency situation usually requiring surgical intervention. A new colonic, throughthe-scope metal stent has been described as effective in the treatment of obstructing colorectal cancer. Aim of our study was to evaluate the feasibility, efficacy and safety of emergency enteral stent placement for the preoperative management of neoplastic acute bowel obstruction. Methods: Sixteen consecutive patients (10M/6F, mean age 72, range 5889) with clinical and radiologic signs of acute colonic obstruction were included in the study. Before stent placement a CT scan was performed in order to evaluate the nature and the site of obstruction. The site of obstruction was rectum in 3 patients, sigmoid in 6 , descending in 3, splenic flexure in 1, trasversum in 1, hepatic flexure in 1 and a colorectal anastomotic recurrence in 1. Enteral stents (22 mm diameter and 6 or 9 cm in lenght) were used in all patients. A guide wire and a 5 Fr ERCP catheter were used to pass through the stricture and to inject contrast in order to visualise the proximal and distal extension of the tumor. Stent placement was then performed under endoscopic and fluoroscopic control advancing the stent over the guide wire. Results: Stent placement was successful in 14 out of 16 patients (87%). In one patient with a splenic flexure we were not able to pass with the guide wire over the stricture. In 1 patient the stent could not be advanced through a tortuous, fixed sigmoid stricture. No complications were observed. Thirteen patients recovered from mechanical obstruction and could receive bowel cleansing (in 1 patient bowel occlusion did not relieve after stent placement). In 4 patients the stent placement was considered to be a definitive palliative treatment. After a median time of 4 days (range 3-7) nine patients underwent a single stage surgery with end-to-end anastomosis without complications. Conclusion: Preoperative enteral placement seems a safe and effective technique to manage patients with acute large bowel malignant obstruction. It allows to perform a single stage curative resection even in patients admitted to emergency room for acute colonic obstruction. In patients with advanced neoplastc disease diagnosed after relief of bowel occlusion, the enteral stent could be considered a definitive palliative treatment alternative to defunctioning colostomy.
GASTROINTESTINAL ENDOSCOPY
AB105