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863 Doughnut Resection: Endoscopic Submucosal Dissection of Circumferential Lleo-Cecal Valve (ICV) Polyps
Abstracts mucosa helps avoid fluid leakage common in fibrotic lesions, maintaining the submucosal bleb. Furthermore, the pocket maintains ideal countertraction during dissection. The use of this pocket creation technique addresses many limitations of traditional ESD for these complex lesions.
860 Combined Endoscopic-Percutaneous Biliary Restoration After Severe Bile Duct Injury During Cholecystectomy Badih Joseph Elmunzer*, Derek Feussner, K. M. Payne, Satish Nadig, Ricardo Yamada Medical University of South Carolina, Charleston, SC Background: Prior to repair of cholecystectomy related biliary injuries, bile flow is ideally diverted into the GI tract to avoid volume and metabolic derangements. When the mechanism of injury is transection alone, biliary-duodenal continuity can be reestablished through an endoscopic-percutaneous rendezvous approach, wherein a guidewire is advanced endoscopically through the injury into the subhepatic space and grasped with a percutaneous snare. If the duct is both clipped and divided, however, options are limited. In this video, we present a case of nonoperative biliary restoration after complete duct ligation and transection in a poor surgical candidate. Case: A 43 year-old woman with Mirizzi syndrome underwent laparoscopic cholecystectomy that was complicated by a severe common hepatic duct injury. Endoscopic retrograde cholangiopancreatography revealed complete occlusion of the duct by surgical clips. Percutaneous transhepatic cholangiography (PTC) confirmed transection of the duct proximal to the clips. After percutaneous drainage, the patient was diagnosed with severe acquired immunodeficiency syndrome. Since we aimed to delay an operation for an extended period of time until immune recovery, a multi-disciplinary decision was made to attempt endoscopicpercutaneous reestablishment of biliary continuity. Endoscopic methods: Using digital cholangioscopy, the point of occlusion at the level of the surgical clip was identified. Under direct visualization, a radiofrequency-enhanced guidewire was used to puncture the top of the bile duct in the direction of the subhepatic space. This was unsuccessful and complicated by minor bleeding. Thus, a percutaneous antegrade puncture with the wire was successfully achieved after confirming an appropriate puncture site cholangioscopically. The wire was then retrieved into the lumen of the duodenum to facilitate PTC tube placement. Despite capping the PTC tube, high-volume external biliary drainage persisted through a percutaneous drain. Therefore the PTC tube was exchanged for a fully covered metallic stent, which resulted in immediate cessation of external drainage. After stent retrieval 6 months later, cholangiogram revealed a normal bile duct without stricture or leak. Repeat cholangioscopy demonstrated regenerative-appearing neo-duct wall replacing the region of prior discontinuity. The patient remains without obstruction 3 months later. Clinical implications: This case demonstrates the feasibility of endoscopic-percutaneous reestablishment of biliary-duodenal continuity after complete occlusion and transection of the bile duct and provides proof of principle that non-operative biliary restoration after this type of injury is possible.
861 Displaced Eus-Guided Gastroenterostomy Stent Rescued With Natural Orifice Transluminal Endoscopic Surgery Yen-I. Chen*, Yamile Haito-Chavez, Renata Pieratti Bueno, Majidah A. Bukhari, Olaya Isabella Brewer Gutierrez, Omid Sanaei, Lea Fayad, Mouen A. Khashab Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD Background: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel approach to gastric outlet obstruction (GOO). Using a lumen apposing metal stent (LAMS) a bypass can be created between the stomach and the small bowel. One of the major potential adverse events with EUS-GE is the misdeployment/displacement of the LAMS, which can lead to severe clinical consequences. We describe a case of EUS-GE complicated by stent displacement salvaged with NOTES (video 1). Case: A 68-year old gentleman with a history of unresectable cholangiocarcinoma was referred for GOO. A gastroscopy showed an obstruction in the second portion of the duodenum due to extrinsic compression from the advanced cancer. After discussion with patient and his family a decision was taken to palliate with EUS-GE. Endoscopic Methods: A gastroscope was advanced across the obstruction and fluid (methylene blue, normal saline, and contrast) was infused to optimize small bowel distention. Using fluoroscopy and EUS, a small bowel loop close to the stomach was punc-
AB112 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
tured with a 19-gauge needle. Blue tinged fluid was aspirated confirming the correct location of the puncture. A LAMS was then inserted directly using cauteryassistance and deployed successfully forming the GE. A wire guided dilating balloon was then inserted across the stent and inflated to 15 mm. Unfortunately, during dilation the patient retched displacing both the distal flange and the guidewire from the small bowel into the peritoneal space. A therapeutic gastroscope was advanced through the LAMS and peritoneoscopy performed. The puncture defect in the peritoneum was located and cannulated with an ERCP catheter pre loaded with a 0.035 inch guidewire, which was advanced into the small bowel under fluoroscopy. The displaced LAMS was removed with a biopsy forcep over the wire. A LAMS was then advanced over the wire into the small bowel and the distal flange deployed. The stent was then pulled back approximating the small bowel to the stomach followed by deployment of the proximal flange. Contrast injection showed excellent stent position without evidence of a leak. The patient was hospitalized with moderate abdominal pain due to focal peritonitis. He was placed on broad-spectrum antibiotics and improved rapidly. He was discharged 4 days later with minimal pain while tolerating a full stent diet. Clinical Implication: EUS-GE is promising for GOO; however, stent misdeployment/displacement is a feared complication with possible severe clinical consequences. Our case demonstrates that by using NOTES, rescue of a displaced GE stent is feasible and may potentially avoid the need for surgery.
862 Endoscopic Esophagoplasty for Megaesophagus With Sump Stasis in End-Stage Achalasia Fateh Bazerbachi1, Karthik Ravi1, Shanda H. Blackmon2, Louis M. Wong Kee Song*1 1 Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 2 Thoracic Surgery, Mayo Clinic, Rochester, MN Background/Case: A 79-year-old woman with long-standing achalasia status post open surgical esophagomyotomy in the 1970s presented with worsening dysphagia to solids and liquids, regurgitation and aspiration symptoms attributed to megaesophagus and sump formation. Although esophagectomy may be the only realistic option in achieving esophageal emptying in the setting of advanced achalasia with gross esophageal dilatation and sump formation, the patient was deemed a poor operative candidate for esophagectomy due to comorbidities. A novel approach of endoscopic esophagoplasty was proposed to plicate and reduce the esophageal sump and in so doing, straighten the esophagus to improve esophageal emptying. Endoscopic Methods: The lateral margins of the esophageal sump were marked with coagulation dots to serve as visual markers. Next, an endoscopic suturing device was used to place full-thickness running sutures in a triangular fashion to plicate the sump and straighten the esophagus. Sump reduction and improved esophageal emptying across the gastroesophageal junction were noted post esophagoplasty on esophagography. Clinical Implications: Endoscopic esophagoplasty is a promising novel technique for achalasia megaesophagus with sump formation in patients deemed poor surgical candidates for esophagectomy. Long-term follow-up will determine durability and sustained efficacy of the procedure.
863 Doughnut Resection: Endoscopic Submucosal Dissection of Circumferential Lleo-Cecal Valve (ICV) Polyps Stavros N. Stavropoulos*, Krishna C. Gurram, Rani J. Modayil, Erin K. Ly, Mohammad F. Ali, David Friedel Gastroenterology, Winthrop University Hospital, Mineola, NY ICV lesions are difficult to resect endoscopically and are often referred for laparoscopic colectomy which can have significant morbidity. ICV involvement (along with lesion size 5 cm) has been shown to be a predictor of EMR failure and high technical difficulty if ESD is utilized. Only few published studies have focused specifically on endoscopic resection of large lesions 4-5 cm, with extensive ICV involvement. The lesions in these studies were non- circumferential but in the largest ESD study about 1/4 of lesions extended to 75% of the ICV circumference and in the largest EMR study about 1/3 involved both lips of the ICV which caused technical success to drop from 93% to 29%. We will demonstrate the technique in a video and present data from 5 consecutive cases performed from 2/2016 to 10/2016 utilizing the ESD method for removing circumfrential ICV polyps.
www.giejournal.org
860 Combined Endoscopic-Percutaneous Biliary Restoration After Severe Bile Duct Injury During Cholecystectomy Badih Joseph Elmunzer*, Derek Feussner, K. M. Payne, Satish Nadig, Ricardo Yamada Medical University of South Carolina, Charleston, SC Background: Prior to repair of cholecystectomy related biliary injuries, bile flow is ideally diverted into the GI tract to avoid volume and metabolic derangements. When the mechanism of injury is transection alone, biliary-duodenal continuity can be reestablished through an endoscopic-percutaneous rendezvous approach, wherein a guidewire is advanced endoscopically through the injury into the subhepatic space and grasped with a percutaneous snare. If the duct is both clipped and divided, however, options are limited. In this video, we present a case of nonoperative biliary restoration after complete duct ligation and transection in a poor surgical candidate. Case: A 43 year-old woman with Mirizzi syndrome underwent laparoscopic cholecystectomy that was complicated by a severe common hepatic duct injury. Endoscopic retrograde cholangiopancreatography revealed complete occlusion of the duct by surgical clips. Percutaneous transhepatic cholangiography (PTC) confirmed transection of the duct proximal to the clips. After percutaneous drainage, the patient was diagnosed with severe acquired immunodeficiency syndrome. Since we aimed to delay an operation for an extended period of time until immune recovery, a multi-disciplinary decision was made to attempt endoscopicpercutaneous reestablishment of biliary continuity. Endoscopic methods: Using digital cholangioscopy, the point of occlusion at the level of the surgical clip was identified. Under direct visualization, a radiofrequency-enhanced guidewire was used to puncture the top of the bile duct in the direction of the subhepatic space. This was unsuccessful and complicated by minor bleeding. Thus, a percutaneous antegrade puncture with the wire was successfully achieved after confirming an appropriate puncture site cholangioscopically. The wire was then retrieved into the lumen of the duodenum to facilitate PTC tube placement. Despite capping the PTC tube, high-volume external biliary drainage persisted through a percutaneous drain. Therefore the PTC tube was exchanged for a fully covered metallic stent, which resulted in immediate cessation of external drainage. After stent retrieval 6 months later, cholangiogram revealed a normal bile duct without stricture or leak. Repeat cholangioscopy demonstrated regenerative-appearing neo-duct wall replacing the region of prior discontinuity. The patient remains without obstruction 3 months later. Clinical implications: This case demonstrates the feasibility of endoscopic-percutaneous reestablishment of biliary-duodenal continuity after complete occlusion and transection of the bile duct and provides proof of principle that non-operative biliary restoration after this type of injury is possible.
861 Displaced Eus-Guided Gastroenterostomy Stent Rescued With Natural Orifice Transluminal Endoscopic Surgery Yen-I. Chen*, Yamile Haito-Chavez, Renata Pieratti Bueno, Majidah A. Bukhari, Olaya Isabella Brewer Gutierrez, Omid Sanaei, Lea Fayad, Mouen A. Khashab Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD Background: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel approach to gastric outlet obstruction (GOO). Using a lumen apposing metal stent (LAMS) a bypass can be created between the stomach and the small bowel. One of the major potential adverse events with EUS-GE is the misdeployment/displacement of the LAMS, which can lead to severe clinical consequences. We describe a case of EUS-GE complicated by stent displacement salvaged with NOTES (video 1). Case: A 68-year old gentleman with a history of unresectable cholangiocarcinoma was referred for GOO. A gastroscopy showed an obstruction in the second portion of the duodenum due to extrinsic compression from the advanced cancer. After discussion with patient and his family a decision was taken to palliate with EUS-GE. Endoscopic Methods: A gastroscope was advanced across the obstruction and fluid (methylene blue, normal saline, and contrast) was infused to optimize small bowel distention. Using fluoroscopy and EUS, a small bowel loop close to the stomach was punc-
AB112 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
tured with a 19-gauge needle. Blue tinged fluid was aspirated confirming the correct location of the puncture. A LAMS was then inserted directly using cauteryassistance and deployed successfully forming the GE. A wire guided dilating balloon was then inserted across the stent and inflated to 15 mm. Unfortunately, during dilation the patient retched displacing both the distal flange and the guidewire from the small bowel into the peritoneal space. A therapeutic gastroscope was advanced through the LAMS and peritoneoscopy performed. The puncture defect in the peritoneum was located and cannulated with an ERCP catheter pre loaded with a 0.035 inch guidewire, which was advanced into the small bowel under fluoroscopy. The displaced LAMS was removed with a biopsy forcep over the wire. A LAMS was then advanced over the wire into the small bowel and the distal flange deployed. The stent was then pulled back approximating the small bowel to the stomach followed by deployment of the proximal flange. Contrast injection showed excellent stent position without evidence of a leak. The patient was hospitalized with moderate abdominal pain due to focal peritonitis. He was placed on broad-spectrum antibiotics and improved rapidly. He was discharged 4 days later with minimal pain while tolerating a full stent diet. Clinical Implication: EUS-GE is promising for GOO; however, stent misdeployment/displacement is a feared complication with possible severe clinical consequences. Our case demonstrates that by using NOTES, rescue of a displaced GE stent is feasible and may potentially avoid the need for surgery.
862 Endoscopic Esophagoplasty for Megaesophagus With Sump Stasis in End-Stage Achalasia Fateh Bazerbachi1, Karthik Ravi1, Shanda H. Blackmon2, Louis M. Wong Kee Song*1 1 Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 2 Thoracic Surgery, Mayo Clinic, Rochester, MN Background/Case: A 79-year-old woman with long-standing achalasia status post open surgical esophagomyotomy in the 1970s presented with worsening dysphagia to solids and liquids, regurgitation and aspiration symptoms attributed to megaesophagus and sump formation. Although esophagectomy may be the only realistic option in achieving esophageal emptying in the setting of advanced achalasia with gross esophageal dilatation and sump formation, the patient was deemed a poor operative candidate for esophagectomy due to comorbidities. A novel approach of endoscopic esophagoplasty was proposed to plicate and reduce the esophageal sump and in so doing, straighten the esophagus to improve esophageal emptying. Endoscopic Methods: The lateral margins of the esophageal sump were marked with coagulation dots to serve as visual markers. Next, an endoscopic suturing device was used to place full-thickness running sutures in a triangular fashion to plicate the sump and straighten the esophagus. Sump reduction and improved esophageal emptying across the gastroesophageal junction were noted post esophagoplasty on esophagography. Clinical Implications: Endoscopic esophagoplasty is a promising novel technique for achalasia megaesophagus with sump formation in patients deemed poor surgical candidates for esophagectomy. Long-term follow-up will determine durability and sustained efficacy of the procedure.
863 Doughnut Resection: Endoscopic Submucosal Dissection of Circumferential Lleo-Cecal Valve (ICV) Polyps Stavros N. Stavropoulos*, Krishna C. Gurram, Rani J. Modayil, Erin K. Ly, Mohammad F. Ali, David Friedel Gastroenterology, Winthrop University Hospital, Mineola, NY ICV lesions are difficult to resect endoscopically and are often referred for laparoscopic colectomy which can have significant morbidity. ICV involvement (along with lesion size 5 cm) has been shown to be a predictor of EMR failure and high technical difficulty if ESD is utilized. Only few published studies have focused specifically on endoscopic resection of large lesions 4-5 cm, with extensive ICV involvement. The lesions in these studies were non- circumferential but in the largest ESD study about 1/4 of lesions extended to 75% of the ICV circumference and in the largest EMR study about 1/3 involved both lips of the ICV which caused technical success to drop from 93% to 29%. We will demonstrate the technique in a video and present data from 5 consecutive cases performed from 2/2016 to 10/2016 utilizing the ESD method for removing circumfrential ICV polyps.
www.giejournal.org