⁎3497 Endoscopic repair of perforated gut using endoscopic sewing machine.

*3497 ENDOSCOPIC REPAIR OF PERFORATED GUT USING ENDOSCOPIC SEWING MACHINE. Amjad Awan, Sritharan S. Kadirkamanathan, Feng Gong, Mark Appleyard, Janet Murfitt, Paul Swain, Univ of New mexico, Abuquerque; Royal London Hosp, London, United Kingdom; Univ Coll, London, United Kingdom. BACKGROUND: Endoscopic repair of the perforated gut has been reported in rare cases. Various techniques have been used to close the gut perforations via an endoscope. We describe three cases of endoscopic repair of oesophageal and gastric perforations using an endoscopic sewing machine. CASE 1: A 54 year old man had a partial gastrectomy for gastric cancer. A postoperative fistulous leak between the gastrojejunostomy and the chest was demonstrated by contrast study. Six stitches were placed to close the leak using the endoscopic sewing machine. Post procedure contrast x-ray showed that the leak had sealed. CASE 2: A 70 year old man with carcinoma of the oesophagus had a distal oesophageal perforation during Savary dilatation. Three stitches were placed with endoscopic sewing machine to close the perforation. A repeat contrast study showed no leak. Patient died three months later in hospital due to unrelated causes. CASE 3: A 54 year old man with lymphoma of the oesophagus and stomach developed a fistula between the oesophagus and the mediastinum. Covered metal stents were placed twice previously and had fallen into the stomach. A covered Z stent [Wilson Cook] was sewn to the oesophagus using the endoscopic sewing machine. The stent remained in position and the fistula healed nicely. The patient who had been in the intensive care unit for three months was able to leave intensive care unit. CONCLUSION: Successful closure of the gut perforations was possible using endoscopic sewing machine. *3498 NEW SELF-EXPANDING NITINOL STENT FOR THE PALLIATION OF MALIGNANT ESOPHAGEAL AND CARDIAC STENOSES. Young Yoon Ko, Jin Hong Kim, Kwang Jae Lee, Byung Moo Yoo, Younf Soo Kim, Ki Baik Hahm, Sung Won Cho, Ajou Univ Sch of Medicine, Suwon, South Korea. Aim: The aim of this study was to evaluate the relative value of newly developed self-expanding nitinol stent, compared with convetional selfexpanding metal stents(SEMS) in esophageal and cardiac stenoses. Methods: We tried to insert new covered self-expanding nitinol stent(NitiS stent, Taewoong Inc., Seoul, Korea) in 26 cases(nitinol stent group: esophagus in 14, cardia in 12) and conventional SEMS in 33 cases(conventional stent group: esophagus in 19, cardia in 14). Underlying causes of esophageal stenoses were esophageal cancer in 32 and esophageal invasion of lung cancer in 1. Causes of cardiac stenosis were gastric cancer in 25 and extrinsic compression of hepatoma in 1. Results: 1) Used stents in conventional stent group were modified Z stent in 24, Endocoil stent in 2, Cuffed stent in 2, Ultraflex stent in 24, and Wall stent in 3. Mean stent length was 8.2cm in nitinol stent group and 10.1cm in conventional stent group. Age (median: 64 years), sex (M:F=69:31), dysphagia score(median: 3), type of pretreatment, stricture length, stricture location, and stent length were comparable in both stent groups. 2) The success rate of stent insertion was 100% in both stent groups without procedure-related mortality. 3) After stent placement in esophageal and cardiac stenosis, mean dysphagia score was significantly improved in both groups(nitinol stent group; from 2.26±1.0 to 1.09±0.84, p<0.05, conventional stent group: from 3.25±0.44 to 2.22±0.79, p<0.001). 4) Early complication rate was 7.7%(2/26) in nitinol stent group(severe chest pain in 1, intractable hiccup in 1) and 33.3%(11/33) in conventional stent group(severe chest pain in 10, migration in 1). This rate was significantly lower in nitinol stent group(0.018). 5) Late complication rate was 34.6%(9/26) in nitinol stent group(stent dysfunction in 5, tumor overgrowth in 2, tumor ingrowth in 2) and 33.3%(11/33) in conventional stent group(obstruction in 3, migration in 6, bleeding in 1, GERD in 1). Conclusion: New covered self-expanding nitinol stent is as effective as conventional SEMS in management of dysphagia in malignant esophageal and cardiac stenoses with significantly lower early complications and comparable late complications, when compare with conventional SEMS. *3499 THERAPEUTIC ERCP IN THE SETTING OF LONG LIMB SURGICAL BYPASS: IMPROVED SUCCESS AND OUTCOME OF THERAPEUTIC PROCEDURES. Phyllidia M. Ku, Eric Elton, Robert M. Dy, Brian L. Hanson, David J. Desilets, Douglas A. Howell, Maine Med Ctr, Portland, ME. INTRODUCTION: We reported initial ERCP experience in 18 long-limb surgical bypasses (Gastrointest Endosc 1998;47: 62-7). Only 6 had intact papillas and only 3 required sphincterotomy (ES). We report additional

VOLUME 51, NO. 4, PART 2, 2000

experience. PATIENTS & METHODS: From 4/93-8/99, 47 pts (male 18, female 29, age 24-80) were referred for consideration of therapeutic ERCP with long-limb surgical bypasses: 8 with gastric bypass; 16 with Whipple’s, 11 with hepatojejunostomy; and 12 with post-gastrectomy Roux-en-Ys. Indications: pain (n=26), jaundice (n=17), recurrent or chronic pancreatitis (n=11), suspected CD stones (n=7), and anastomotic bleeding (n=1). An enteroscope was used in 13, a pediatric colonoscope in 17 and a duodenoscope in 17. RESULTS: The papilla or pancreaticobiliary anastomosis was reached in 41 of 47 (87%). The overtube was used with 5 and only in the setting of an intact stomach. 6 failures were due to inability to pass into the afferent limb. 2 failures were due to inability to locate the PD anastomoses. 20 patients had intact papillas (12 with Roux-en-Ys, 8 with gastric bypass). Cannulation failed in 4 of these 20 (20%) due to an inability to align the long front viewing instruments. 7 pts with intact papillas needed ES; 3 methods were used: (1) Following guidewire and temporary stent placement, a stent guided needle-knife ES was used when alignment could be achieved (n=4); (2) A wire-guided B-II type sphinctertome was used (n=1). (3) One patient failing guidewire placement underwent successful needle knife ES only. The final patient required a combined procedure with PTC guidewire placement followed by B-II type ES at a second ERCP. Among the 35 cannulated patients, successful Rx followed in 34: stents in 16 (10 biliary plastic stents, 2 PD stents, 4 Wallstents); biliary dilatation in 6; stone extraction 3; tissue sampling 3; pancreatic dilatation 1; duodenal dilatation 1. In 1 patient, coagulation of a visible vessel required surgical treatment for recurrence. No post-ERCP pancreatitis, bleeding, or perforation was noted. CONCLUSION: Although technically difficult, successful therapeutic ERCP is generally possible with long limb surgical bypasses with a high success rate and a low complication rate. The intact papilla greatly exacerbates these difficulties and occasionally requires percutaneous wire placement for assistance. The development of a colonoscope length, oblique-viewing enteroscope with an elevator should greatly enhance therapeutic ERCP in these patients. *3500 ARGON PLASMA COAGULATION ASSISTED RESECTION OF LARGE SESSILE COLONIC POLYPS: A RANDOMISED TRIAL. Jim C. Brooker, Syed G. Shah, Christopher B. Williams, Brian P. Saunders, St Mark’s Hosp, London, United Kingdom; Wolfson Unit, St Mark’s Hosp, London, United Kingdom. BACKGROUND: Large sessile adenomas account for up to 3.7% of polyps found at colonoscopy. Removal by piecemeal snare excision and EMR techniques is widely practised, but recurrence is reported in up to 28%, probably because of residual foci of adenoma tissue. AIMS: To evaluate the safety and efficacy (recurrence rate) of APC when combined with piecemeal resection of large sessile polyps. METHODS: Consecutive patients with large sessile polyps requiring piecemeal resection were placed into two groups depending on the endoscopist’s assessment of completeness of excision. If complete excision was not possible with the snare alone, APC was applied. If complete excision was achieved, the patient was randomised to APC or no-APC. The procedures were performed by 2 experienced endoscopists (BPS & CBW). APC was set at 65W power, and applied to the polypectomy base and margin. Patients were contacted at 2 weeks, and followed up endoscopically at 6-12 weeks and 1 year. At follow-up, biopsies were taken from the polypectomy site and any recurrent adenoma was resected and treated with APC. RESULTS: 13 patients have had at least one follow up endoscopy, table 1. At initial polypectomy 5 had minor procedural bleeding (3 in APC patients) which settled with topical adrenaline (3) or spontaneously (2). 1 patient had minor bleeding and another had fever for 24 hours after APC had been used for recurrence at follow up. There were no major complications. No polyps have needed surgical excision. CONCLUSIONS: APC appears safe and may help to reduce recurrence of large sessile polyps after piecemeal resection.

Table 1 Complete excision (randomized) APC (n=4) Median age Male Proximal location Median size (mm) Histology* Recurrence 3/12

Incomplete

No APC (n=4)

56.5 (49-73) 2 4 30 (15-50) 3TA,1TVA

54 (53-78) 1 2 30 (15-40) 2TA,1TVA,1S

1

3

APC (n=5) 68 (66-79) 2 1 20 (14-30) 1TA,1TVA, 2VA,1S 2

*TA=tubular;TVA=tubulovillous;V=villous;S=serrated

GASTROINTESTINAL ENDOSCOPY

AB109