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852 Clear: Cardia Ligation Anti-Reflux Procedure for Gerd
Abstracts
tomography demonstrated a well-circumscribed 4 cm submucosal mass of fatty density. Endoscopic ultrasound revealed a homogeneous, hyperechoic, and round mass in the submucosal layer of the gastric antrum consistent with a lipoma causing gastric outlet obstruction. Endoscopic Methods: The mucosa overlying the lipoma was first lifted by injecting methylene blue mixed with hydroxyethyl starch. The margins of the lesion were then marked with cautery (Video 1). An ESD knife using electrosurgery current was used to perform a circumferential incision. A 33mm snare was then inserted and the mucosa unroofed in a piecemeal fashion. The groove created by the mucosal incision allowed for the snare to catch on to the edges of the lesion, thereby facilitating the unroofing process. An ESD knife was then used to further expose the deeper margins of the lipoma. An endoscopic loop device was inserted and opened beyond the size of the mass, followed by careful closure of the loop at the base of the lipoma. This ligation was performed to cut off the blood supply to the lipoma, allowing the lesion to slough off the stomach wall. Repeat endoscopy four weeks later showed no residual lipomatous tissue, and an incision scar was noted in the gastric antrum. The patient’s symptoms of gastric outlet obstruction had completely resolved. Clinical Implication: Management of gastric lipoma with a hybrid technique of unroofing followed by loop ligation appears to be effective and safe. Possible advantages associated with this technique include a relatively short procedure time (especially when compared to ESD) and the ability to achieve complete resection with minimal risk of viscus perforation.
850 A Novel Through the Snare Technique for Percutaneous Endoscopic Gastro-Jejunostomy Tube Placement Gabriel Lang*, Daniel Mullady, Vladimir M. Kushnir Washington University, Saint Louis, MO Percutaneous endoscopic gastro-jejunostomy (PEG-J) tube placement is an increasingly in demand procedure, but due to technical difficulty and its time consuming nature, is often referred to surgeons and interventional radiologists. The most common procedural complications include loop formation within the stomach which causes retraction of either the guidewire or jejunal extension tubing out of the small bowel as well as displacement of the jejunal extension tubing out of the small bowel during withdrawal of the endoscope. Here we present a through the snare technique for PEG-J placement which decreases procedure length and is easier to perform than the traditional methods. A 52-year-old male presents with his first episode of alcohol induced pancreatitis complicated by symptoms of gastric outlet obstruction. A 24 Fr PEG tube was placed in the traditional fashion. The upper endoscopy revealed a luminal stenosis in the second portion of the duodenum secondary to acute inflammation from acute pancreatitis. Next, a snare was placed through the PEG tube and opened. The endoscope is advanced through the snare and a guidewire is placed into the small bowel. The endoscope is then exchanged and the wire left in place. As the endoscope is withdrawn, through the snare, the snare is closed and the wire brought out through the PEG tube. The end of the wire not within the small bowel is then pulled back in order to straighten the guidewire. The jejunal extension tube is then advanced over the guidewire. The patient tolerated the procedure well. The procedure duration was 18 minutes. The PEG portion was immediately used for decompression and the patient was discharged after his jejunal feeds were advanced to a goal rate. This novel method for PEG-J placement is technically simple and virtually eliminates looping of the guidewire. Furthermore, it obviates the need for the use of a second endoscope as well as fluoroscopy, which may not be readily available at all centers.
852 Clear: Cardia Ligation Anti-Reflux Procedure for Gerd Ram Chuttani*, Diogo T. de Moura, Jonah Cohen Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA Background: Several endoscopic solutions for gastroesophageal reflux disease (GERD) have been proposed. Recently, an innovative procedure called Anti-Reflux MucoSectomy (ARMS) was described that significantly reduced GERD symptoms. This involved 270-degree endoscopic submucosal dissection at the gastric cardia with subsequent scarring resulting in gastroesophageal (GE) junction narrowing and augmentation of the flap valve. We describe a novel evolution of the ARMS procedure: the Cardia Ligation Endoscopic Anti-Reflux (CLEAR) procedure. Case 1: A 48 year-old male with a history of severe chronic GERD presented for consideration of non-surgical GERD therapy. Upper endoscopy showed mild esophagitis. Esophageal manometry was normal and a 48-hr pH monitoring study revealed a DeMeester Score of 31.3. Endoscopic Methods: The CLEAR procedure was developed as an evolution of the ARMS procedure. Multiple band ligations at the cardia in a 270degree fashion, without resection, were performed. The aim was to leverage a similar physiologic wound healing response as mucosectomy. This was accomplished via band ligations of the gastric cardia resulting in tissue necrosis and scar
AB110 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
formation. This narrowed the GE junction and enhanced the flap valve system. As no resection was performed, the risks of bleeding and perforation were minimized in the CLEAR procedure. Furthermore, the requisite endoscopist technical skillset is widely available. First, argon plasma coagulation was applied to the gastric cardia in retroflexion to mark the flap valve. Five endoscopic bands were successfully placed in adjacent fashion over 270-degrees at the lesser curvature of the cardia, opposite the flap valve. The patient’s reflux symptoms completely resolved within 48 hours of the procedure. Mild recurrence two weeks later was treated with a repeat CLEAR procedure and four additional bands. At four months follow-up his symptoms remain improved with significant reduction in PPI usage and 48-hr pH monitoring revealing the DeMeester Score reduced from 31.3 to 15.5. Case 2: A 38 year-old woman with severe GERD and regurgitation had esophagitis and a gaping lower esophageal sphincter (LES) on endoscopy. Forty-eight hour pH monitoring revealed a DeMeeester score of 57.3. The CLEAR procedure was successfully performed, this time with the placement of seven bands in a 360degree fashion to further augment the LES. The patient remains asymptomatic one week post-procedure at the time of video abstract submission. Clinical Implications: The CLEAR procedure presents a promising novel endoscopic therapy for GERD. Future work will involve optimization of this technique and expanded clinical trials.
854 What Can You Do for Post-Whipple Benign Goo (Gastric Outlet Obstruction)? Vent With Temporary Bilateral Fully-Covered Metal Stents Shayan S. Irani* Gastroenterology, Virginia Mason Medical Center, Seattle, WA Background & Aims: Nausea and vomiting persisting more than 2 weeks postWhipple besides prolonging hospitalization, can delay adjuvant therapy. This is usually managed with temporary feeding tubes and decompressive tubes (NG/PEG). Inability to eat however significantly affects quality of life. Dilations can be helpful once healing has occurred. We present 5 cases of post-Whipple benign obstruction ongoing for more than 2 weeks, treated with temporary placement of bilateral fully covered self-expandable metal stents (FCSEMS) (esophageal +/- biliary). Cases and Endoscopic Methods: Case 1: 72 year old female with extended Whipple and subtotal gastrectomy, developed a large dehiscence of the gastric suture line, which evolved over the next 6 weeks to a severe gastric outlet obstruction (GOO). This was treated with placement of a biliary FCSEMS into the afferent limb and an esophageal FCSEMS into the efferent limb. To prevent proximal/gastric migration, the SEMS were stitched to the gastric wall. To prevent distal/jejunal migration, the SEMS are stitched to each other and via a separate suture to a gastrostomy tube. She was able to start an oral diet within 2 days and 9 weeks later the stents were easily removed. Case 2: A 72 year old female underwent a Whipple operation for pancreatic cancer. Despite 18 days of NG decompression and NJ feeds, nausea vomiting persisted. An upper gi series confirmed GOO. Bilateral esophageal FCSEMS were secured as described above. An oral diet was resumed within 3 days and stents were removed in 6 weeks. Results: Five patients (3 F, 2 M) with a median age of 72 years (70- 81) underwent bilateral FCSEMS to treat benign GOO post-Whipple from June 2014 to July 2016. Median days after surgery when stents were placed was 23 days (14-60). Most commonly 18mm esophageal FCSEMS was used, however, in 1 case with a very tight stricture, a 10mm biliary stent was placed in the afferent limb. Technical and clinical success was 100%. Patients resumed solid food by a median of 3 days. Median stent dwell time was 40 days (30-76). There were 2 patients who experienced asymptomatic proximal stent migration (found at endoscopy to remove stents). No distal migrations were seen. There were no adverse events and no recurrent obstructions, for a median follow up of 56 weeks. Conclusions: Temporary placement of bilateral FCSEMS can help return patients to an oral diet quickly in event of post-Whipple, benign GOO. Stent migration can be prevented by suturing stents to gastric wall to prevent proximal migration, to each other and maybe to the gastrostomy tube to prevent distal migration. Recurrence of obstruction seems to be uncommon. A prospective study comparing NG plus NJ tube vs. metal stents would be useful.
855 Endoscopic Management of Duodenal Atresia in an Adult Rajesh N. Keswani* Medicine, Northwestern University, Chicago, IL Background/Case: A 45 year old female with a history of duodenal atresia treated via gastrojejunostomy at birth presented with increasing abdominal distention. Crosssectional imaging revealed a massively dilated proximal duodenum, filling her abdomen. On endoscopy, we found a strictured antrum/pylorus and a markedly enlarged proximal duodenum which was filled with bile. Furthermore, the second portion of the duodenum had a complete cut-off consistent with atresia. We
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tomography demonstrated a well-circumscribed 4 cm submucosal mass of fatty density. Endoscopic ultrasound revealed a homogeneous, hyperechoic, and round mass in the submucosal layer of the gastric antrum consistent with a lipoma causing gastric outlet obstruction. Endoscopic Methods: The mucosa overlying the lipoma was first lifted by injecting methylene blue mixed with hydroxyethyl starch. The margins of the lesion were then marked with cautery (Video 1). An ESD knife using electrosurgery current was used to perform a circumferential incision. A 33mm snare was then inserted and the mucosa unroofed in a piecemeal fashion. The groove created by the mucosal incision allowed for the snare to catch on to the edges of the lesion, thereby facilitating the unroofing process. An ESD knife was then used to further expose the deeper margins of the lipoma. An endoscopic loop device was inserted and opened beyond the size of the mass, followed by careful closure of the loop at the base of the lipoma. This ligation was performed to cut off the blood supply to the lipoma, allowing the lesion to slough off the stomach wall. Repeat endoscopy four weeks later showed no residual lipomatous tissue, and an incision scar was noted in the gastric antrum. The patient’s symptoms of gastric outlet obstruction had completely resolved. Clinical Implication: Management of gastric lipoma with a hybrid technique of unroofing followed by loop ligation appears to be effective and safe. Possible advantages associated with this technique include a relatively short procedure time (especially when compared to ESD) and the ability to achieve complete resection with minimal risk of viscus perforation.
850 A Novel Through the Snare Technique for Percutaneous Endoscopic Gastro-Jejunostomy Tube Placement Gabriel Lang*, Daniel Mullady, Vladimir M. Kushnir Washington University, Saint Louis, MO Percutaneous endoscopic gastro-jejunostomy (PEG-J) tube placement is an increasingly in demand procedure, but due to technical difficulty and its time consuming nature, is often referred to surgeons and interventional radiologists. The most common procedural complications include loop formation within the stomach which causes retraction of either the guidewire or jejunal extension tubing out of the small bowel as well as displacement of the jejunal extension tubing out of the small bowel during withdrawal of the endoscope. Here we present a through the snare technique for PEG-J placement which decreases procedure length and is easier to perform than the traditional methods. A 52-year-old male presents with his first episode of alcohol induced pancreatitis complicated by symptoms of gastric outlet obstruction. A 24 Fr PEG tube was placed in the traditional fashion. The upper endoscopy revealed a luminal stenosis in the second portion of the duodenum secondary to acute inflammation from acute pancreatitis. Next, a snare was placed through the PEG tube and opened. The endoscope is advanced through the snare and a guidewire is placed into the small bowel. The endoscope is then exchanged and the wire left in place. As the endoscope is withdrawn, through the snare, the snare is closed and the wire brought out through the PEG tube. The end of the wire not within the small bowel is then pulled back in order to straighten the guidewire. The jejunal extension tube is then advanced over the guidewire. The patient tolerated the procedure well. The procedure duration was 18 minutes. The PEG portion was immediately used for decompression and the patient was discharged after his jejunal feeds were advanced to a goal rate. This novel method for PEG-J placement is technically simple and virtually eliminates looping of the guidewire. Furthermore, it obviates the need for the use of a second endoscope as well as fluoroscopy, which may not be readily available at all centers.
852 Clear: Cardia Ligation Anti-Reflux Procedure for Gerd Ram Chuttani*, Diogo T. de Moura, Jonah Cohen Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA Background: Several endoscopic solutions for gastroesophageal reflux disease (GERD) have been proposed. Recently, an innovative procedure called Anti-Reflux MucoSectomy (ARMS) was described that significantly reduced GERD symptoms. This involved 270-degree endoscopic submucosal dissection at the gastric cardia with subsequent scarring resulting in gastroesophageal (GE) junction narrowing and augmentation of the flap valve. We describe a novel evolution of the ARMS procedure: the Cardia Ligation Endoscopic Anti-Reflux (CLEAR) procedure. Case 1: A 48 year-old male with a history of severe chronic GERD presented for consideration of non-surgical GERD therapy. Upper endoscopy showed mild esophagitis. Esophageal manometry was normal and a 48-hr pH monitoring study revealed a DeMeester Score of 31.3. Endoscopic Methods: The CLEAR procedure was developed as an evolution of the ARMS procedure. Multiple band ligations at the cardia in a 270degree fashion, without resection, were performed. The aim was to leverage a similar physiologic wound healing response as mucosectomy. This was accomplished via band ligations of the gastric cardia resulting in tissue necrosis and scar
AB110 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
formation. This narrowed the GE junction and enhanced the flap valve system. As no resection was performed, the risks of bleeding and perforation were minimized in the CLEAR procedure. Furthermore, the requisite endoscopist technical skillset is widely available. First, argon plasma coagulation was applied to the gastric cardia in retroflexion to mark the flap valve. Five endoscopic bands were successfully placed in adjacent fashion over 270-degrees at the lesser curvature of the cardia, opposite the flap valve. The patient’s reflux symptoms completely resolved within 48 hours of the procedure. Mild recurrence two weeks later was treated with a repeat CLEAR procedure and four additional bands. At four months follow-up his symptoms remain improved with significant reduction in PPI usage and 48-hr pH monitoring revealing the DeMeester Score reduced from 31.3 to 15.5. Case 2: A 38 year-old woman with severe GERD and regurgitation had esophagitis and a gaping lower esophageal sphincter (LES) on endoscopy. Forty-eight hour pH monitoring revealed a DeMeeester score of 57.3. The CLEAR procedure was successfully performed, this time with the placement of seven bands in a 360degree fashion to further augment the LES. The patient remains asymptomatic one week post-procedure at the time of video abstract submission. Clinical Implications: The CLEAR procedure presents a promising novel endoscopic therapy for GERD. Future work will involve optimization of this technique and expanded clinical trials.
854 What Can You Do for Post-Whipple Benign Goo (Gastric Outlet Obstruction)? Vent With Temporary Bilateral Fully-Covered Metal Stents Shayan S. Irani* Gastroenterology, Virginia Mason Medical Center, Seattle, WA Background & Aims: Nausea and vomiting persisting more than 2 weeks postWhipple besides prolonging hospitalization, can delay adjuvant therapy. This is usually managed with temporary feeding tubes and decompressive tubes (NG/PEG). Inability to eat however significantly affects quality of life. Dilations can be helpful once healing has occurred. We present 5 cases of post-Whipple benign obstruction ongoing for more than 2 weeks, treated with temporary placement of bilateral fully covered self-expandable metal stents (FCSEMS) (esophageal +/- biliary). Cases and Endoscopic Methods: Case 1: 72 year old female with extended Whipple and subtotal gastrectomy, developed a large dehiscence of the gastric suture line, which evolved over the next 6 weeks to a severe gastric outlet obstruction (GOO). This was treated with placement of a biliary FCSEMS into the afferent limb and an esophageal FCSEMS into the efferent limb. To prevent proximal/gastric migration, the SEMS were stitched to the gastric wall. To prevent distal/jejunal migration, the SEMS are stitched to each other and via a separate suture to a gastrostomy tube. She was able to start an oral diet within 2 days and 9 weeks later the stents were easily removed. Case 2: A 72 year old female underwent a Whipple operation for pancreatic cancer. Despite 18 days of NG decompression and NJ feeds, nausea vomiting persisted. An upper gi series confirmed GOO. Bilateral esophageal FCSEMS were secured as described above. An oral diet was resumed within 3 days and stents were removed in 6 weeks. Results: Five patients (3 F, 2 M) with a median age of 72 years (70- 81) underwent bilateral FCSEMS to treat benign GOO post-Whipple from June 2014 to July 2016. Median days after surgery when stents were placed was 23 days (14-60). Most commonly 18mm esophageal FCSEMS was used, however, in 1 case with a very tight stricture, a 10mm biliary stent was placed in the afferent limb. Technical and clinical success was 100%. Patients resumed solid food by a median of 3 days. Median stent dwell time was 40 days (30-76). There were 2 patients who experienced asymptomatic proximal stent migration (found at endoscopy to remove stents). No distal migrations were seen. There were no adverse events and no recurrent obstructions, for a median follow up of 56 weeks. Conclusions: Temporary placement of bilateral FCSEMS can help return patients to an oral diet quickly in event of post-Whipple, benign GOO. Stent migration can be prevented by suturing stents to gastric wall to prevent proximal migration, to each other and maybe to the gastrostomy tube to prevent distal migration. Recurrence of obstruction seems to be uncommon. A prospective study comparing NG plus NJ tube vs. metal stents would be useful.
855 Endoscopic Management of Duodenal Atresia in an Adult Rajesh N. Keswani* Medicine, Northwestern University, Chicago, IL Background/Case: A 45 year old female with a history of duodenal atresia treated via gastrojejunostomy at birth presented with increasing abdominal distention. Crosssectional imaging revealed a massively dilated proximal duodenum, filling her abdomen. On endoscopy, we found a strictured antrum/pylorus and a markedly enlarged proximal duodenum which was filled with bile. Furthermore, the second portion of the duodenum had a complete cut-off consistent with atresia. We
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