- Email: [email protected]
872 Pilot Study Using a Novel Endoscopic Suturing Technique for the Treatment of Refractory Gerd
Abstracts
Aim: To describe a novel step-wise endoscopic management approach of severe BCS in a post-liver transplant patient with RY anatomy. Case: A 41-year-old female post OLT with RY reconstruction for PSC, presented with recurrent cholangitis due to BCS. She had a total of 7 enteroscopy-assisted ERCPs without successful clinical results. She was referred to our center for further management. MRCP revealed an extensive burden of large intrahepatic stones. The plan was to create an endoscopic gastrojejunostomy (GJ) fistula using a lumen apposing metal stent (LAMS) close to the hepaticojejunostomy (HJ), to permit subsequent endoscopic management of BCS with conventional ERCP and electrohydraulic lithotripsy (EHL). EUS-GJ was initially created using a 15 mm LAMS with electrocautery enhanced delivery system. During the ERCP 4 weeks later, a therapeutic gastroscope was advanced though the fistula and stent into the HJ, which was few centimeters distal to the created endoscopic GJ. Cholangiogram revealed dilated intrahepatic ducts with multiple small and large filling defects consistent with intrahepatic stones. The digital single operator cholangioscope (DSOC) was advanced over the guidewire into the intrahepatic ducts. Multiple large stones were visualized in the intrahepatics. An EHL probe was introduced though the working channel of the cholangioscope, with tip positioned directly at the stone. The stones were fragmented into small pieces. The DSCO was advanced into secondary and tertiary branches of the right intrahepatic duct under fluoroscopic and cholangioscopic guidance. The right intrahepatic system was packed with large stones. Large stones throughout the intrahepatic system were successfully fragmented. A 7 Fr x 9 cm plastic biliary stent was placed into the left intrahepatic duct and a 8 mm x 60 mm fully covered self expandable metallic stent was placed in the right intrahepatic duct to facilitate passage of the fragmented stones. Patient developed mild post procedural cholangitis which was successfully treated conservatively with antibiotics. ERCP was performed again 8 weeks later. Contrast injection and cholangioscopy confirmed no residual of stones. Conclusion: EUS-guided alteration of complex surgical anatomy with creation of endoscopic gastrojejunostomy is feasible and allows easy access to the bilio-enteric anastomosis. This permits the use of standard ERCP equipment and, thus, performance of intricate biliary interventions and management of challenging biliary pathologies such as BCS and difficult biliary stone.
872 Pilot Study Using a Novel Endoscopic Suturing Technique for the Treatment of Refractory Gerd Matthew A. Chin*1, Jimin Han2, Reem Z. Sharaiha3, Christopher Gostout4, Kenneth J. Chang1 1 Chao Comprehensive Digestive Diseases Center, University of California, Irvine, Orange, CA; 2Gastroenterology, Catholic University of Daegu, School of Medicine, Nam-gu, Daegu, Korea (the Republic of); 3 Gastroenterology, Weill Cornell School of Medicine, New York City, NY; 4 Gastroenterology, Mayo Clinic, Rochester, MN Background and study aims: There is increasing interest in endoluminal therapies for patients with gastroesophageal reflux disease (GERD). When symptoms remain refractory despite previous endoscopic procedures, or in those with altered surgical anatomy, endoscopic options are limited. The aim of this preliminary study was to determine the feasibility, safety, and efficacy of endoscopic augmentation of the gastroesophageal junction (GEJ) using a full thickness endoscopic suturing device for the treatment of refractory GERD. Patients and methods: Patients with refractory GERD symptoms, including those who had previously undergone surgical or endoluminal therapies, underwent endoscopic augmentation of GEJ between 2014 and 2016. Change in pre- and post-procedure GERD-HRQL scores was used to determine success. Other outcomes such as procedure time, PPI usage, and adverse events were collected and described. Differences were evaluated using the Wilcoxon signed-rank test. Technique: APC marking of the lesser curve at the GEJ was done to guide suture placement. Using a double-channel gastroscope affixed with the endoscopic suturing platform, interrupted sutures were placed in the antegrade position in two layers hemi-circumferentially along the lesser curve between 12 o’clock and 6 o’clock in order to achieve the effect of a narrowed and elongated GEJ. All procedures were performed under general anesthesia in the supine position. Routine antibiotic prophylaxis was administered. Post-procedure, all patients were admitted for 23-hour observation and an upper GI series was obtained prior to discharge to rule out leakage. Results: Ten patients were included. 7/10 patients had at least one previous anti-reflux procedure including Nissen fundoplication (NZ3), transoral incisionless fundoplication (NZ2), and radiofrequency augmentation (NZ2). The procedure was also feasible in one patient with a history of distal esophagectomy. The procedure time ranged from 20-103 minutes and was shorter when a helical retractor was used (60 vs 98 minutes, pZ<0.001). The number of plications ranged from 2 to 8 per patient. Technical success was achieved in all. Median follow-up was 2.5 (range 1-4) months. The median pre-procedure GERDHRQL improved from 20 (range 11-45) to a post-procedure score of 10 (range 0-25). (pZ0.008). Scores improved in all patients, including those who had reduced doses of PPIs (NZ2). Adverse events were limited to one patient (nausea). Conclusions: The use of a novel endoscopic suturing technique for the treatment of refractory GERD is feasible and appears safe. Short term efficacy is suggested by improved
www.giejournal.org
patient-reported quality of life scores in all subjects. The technique can be applied to those who have previously failed endoluminal therapies or have altered surgical anatomy. While promising, further work is necessary to confirm long-term objective response.
873 Endoscopic Ultrasound-Guided Drainage of a Perforated Gallbladder With Resultant Liver Abscess Using a Lumen Apposing Stent Bharat Rao, Mrinal Garg, Shailendra Singh, Abhishek Gulati, Shyam Thakkar* Gastroenterology, Allegheny Health Network, Pittsburgh, PA Background/Case: Percutaneous cholecystostomy tubes are often placed for those medically unfit for cholecystectomy. These may cause significant discomfort and can negatively impact a patient’s quality of life including those with terminal illnesses receiving palliative care. Endoscopic transmural drainage offers an alternative option for such patients. We describe our experience using a lumen apposing metal stent (LAMS) for drainage of a perforated gallbladder (GB) with resultant liver abscess formation. A 61-year-old woman with unresectable pancreatic cancer and prior placed covered metal stent in the common bile duct was being treated with chemotherapy and developed complicated acute cholecystitis with perforation and liver abscess formation. As she was not medically fit for surgery and declined percutaneous tubes for drainage, the decision was made for endoscopic drainage utilizing a LAMS with an attached electrocautery device. Technique Highlights: On endoscopic ultrasound (EUS), a distended GB was localized with posterior wall perforation in direct communication with the liver abscess. Under EUS-guidance, a 15 mm LAMS was entered into the GB lumen with the attached electrocautery system. The distal and proximal ends were deployed by EUS and endoscopic visualization respectively. The saddle section was then dilated to 15 mm. An adult endoscope was introduced and the site of perforation was visualized. The GB and abscess cavity were lavaged using a catheter over a wire to minimize complications. A 7 Fr by 5 cm double pigtail plastic stent was placed through the LAMS to preserve patency. After the procedure, there was a complete evacuation of the abscess cavity on imaging. The patient did well with resolution of her acute cholecystitis abscess. The patient presented one month later with imaging findings suspicious of stent obstruction. Endoscopic reevaluation was performed. Previously placed pigtail stent had spontaneously migrated and enteric contents were noted in the GB lumen. Contents were removed using a rat tooth forceps, the cavity was lavaged, and another double pigtail plastic stent was placed through the LAMS. The patient has been without complications thereafter and was safely able to resume palliative chemotherapy. Clinical Implications: Our case showed it to be technically feasible to achieve adequate drainage using a LAMS even for a complicated case of GB perforation with liver abscess formation. Avoidance of a percutaneous tube allowed for improved quality of life in a patient undergoing palliative treatment. Double pigtail insertion through LAMS may be needed to ensure stent patency and stability. Larger prospective studies are needed to further evaluate the technical feasibility and longterm outcomes in patients with LAMS for GB drainage including those with complicated cases of cholecystitis and abscess formation.
874 A Hybrid Endoscopic Technique to Close Tracheoesophageal Fistula Maoyin Pang*1, Bhaumik Brahmbhatt1, Monia E. Werlang2, Omar Y. Mousa1, Timothy A. Woodward1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Internal Medicine, Mayo Clinic, Jacksonville, FL
Tracheoesophageal fistula (TEF) is a congenital or acquired pathological entity characterized by the presence of an abnormal communication between the posterior aspect of the trachea and the anterior wall of the esophagus. Acquired TEF is not an uncommon complication secondary to mechanical ventilation, trauma, esophageal tumor, prior laryngectomy and esophagectomy. Given the interference of feeding and possible fatal pulmonary adverse event, prompt closure of TEFs is critical. Although endoscopic approach to TEFs has been optimized over the past years, recurrent TEFs remain a therapeutic challenge with literature reports up to 20% recurrence.[1,2] Here we present a new hybrid approach with endoscopic management of an acquired TEF. A 56-year-old male with history of laryngeal malignancy status post laryngectomy, permanent tracheostomy and tracheoesophageal voice prosthesis placed 12 years ago, presented to our clinic for consideration of endoscopic closure of his TEF. It was unclear when the fistula had formed, but it has been causing aspiration of both liquid and solid foods for several months. A recent video fluoroscopic swallow study showed a leak of barium into the trachea at the level of the stoma. An upper endoscopy was then performed, showing a 5mm fistula in the upper third of the esophagus, 20cm from the incisors. With the hypothesis to
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB115
Aim: To describe a novel step-wise endoscopic management approach of severe BCS in a post-liver transplant patient with RY anatomy. Case: A 41-year-old female post OLT with RY reconstruction for PSC, presented with recurrent cholangitis due to BCS. She had a total of 7 enteroscopy-assisted ERCPs without successful clinical results. She was referred to our center for further management. MRCP revealed an extensive burden of large intrahepatic stones. The plan was to create an endoscopic gastrojejunostomy (GJ) fistula using a lumen apposing metal stent (LAMS) close to the hepaticojejunostomy (HJ), to permit subsequent endoscopic management of BCS with conventional ERCP and electrohydraulic lithotripsy (EHL). EUS-GJ was initially created using a 15 mm LAMS with electrocautery enhanced delivery system. During the ERCP 4 weeks later, a therapeutic gastroscope was advanced though the fistula and stent into the HJ, which was few centimeters distal to the created endoscopic GJ. Cholangiogram revealed dilated intrahepatic ducts with multiple small and large filling defects consistent with intrahepatic stones. The digital single operator cholangioscope (DSOC) was advanced over the guidewire into the intrahepatic ducts. Multiple large stones were visualized in the intrahepatics. An EHL probe was introduced though the working channel of the cholangioscope, with tip positioned directly at the stone. The stones were fragmented into small pieces. The DSCO was advanced into secondary and tertiary branches of the right intrahepatic duct under fluoroscopic and cholangioscopic guidance. The right intrahepatic system was packed with large stones. Large stones throughout the intrahepatic system were successfully fragmented. A 7 Fr x 9 cm plastic biliary stent was placed into the left intrahepatic duct and a 8 mm x 60 mm fully covered self expandable metallic stent was placed in the right intrahepatic duct to facilitate passage of the fragmented stones. Patient developed mild post procedural cholangitis which was successfully treated conservatively with antibiotics. ERCP was performed again 8 weeks later. Contrast injection and cholangioscopy confirmed no residual of stones. Conclusion: EUS-guided alteration of complex surgical anatomy with creation of endoscopic gastrojejunostomy is feasible and allows easy access to the bilio-enteric anastomosis. This permits the use of standard ERCP equipment and, thus, performance of intricate biliary interventions and management of challenging biliary pathologies such as BCS and difficult biliary stone.
872 Pilot Study Using a Novel Endoscopic Suturing Technique for the Treatment of Refractory Gerd Matthew A. Chin*1, Jimin Han2, Reem Z. Sharaiha3, Christopher Gostout4, Kenneth J. Chang1 1 Chao Comprehensive Digestive Diseases Center, University of California, Irvine, Orange, CA; 2Gastroenterology, Catholic University of Daegu, School of Medicine, Nam-gu, Daegu, Korea (the Republic of); 3 Gastroenterology, Weill Cornell School of Medicine, New York City, NY; 4 Gastroenterology, Mayo Clinic, Rochester, MN Background and study aims: There is increasing interest in endoluminal therapies for patients with gastroesophageal reflux disease (GERD). When symptoms remain refractory despite previous endoscopic procedures, or in those with altered surgical anatomy, endoscopic options are limited. The aim of this preliminary study was to determine the feasibility, safety, and efficacy of endoscopic augmentation of the gastroesophageal junction (GEJ) using a full thickness endoscopic suturing device for the treatment of refractory GERD. Patients and methods: Patients with refractory GERD symptoms, including those who had previously undergone surgical or endoluminal therapies, underwent endoscopic augmentation of GEJ between 2014 and 2016. Change in pre- and post-procedure GERD-HRQL scores was used to determine success. Other outcomes such as procedure time, PPI usage, and adverse events were collected and described. Differences were evaluated using the Wilcoxon signed-rank test. Technique: APC marking of the lesser curve at the GEJ was done to guide suture placement. Using a double-channel gastroscope affixed with the endoscopic suturing platform, interrupted sutures were placed in the antegrade position in two layers hemi-circumferentially along the lesser curve between 12 o’clock and 6 o’clock in order to achieve the effect of a narrowed and elongated GEJ. All procedures were performed under general anesthesia in the supine position. Routine antibiotic prophylaxis was administered. Post-procedure, all patients were admitted for 23-hour observation and an upper GI series was obtained prior to discharge to rule out leakage. Results: Ten patients were included. 7/10 patients had at least one previous anti-reflux procedure including Nissen fundoplication (NZ3), transoral incisionless fundoplication (NZ2), and radiofrequency augmentation (NZ2). The procedure was also feasible in one patient with a history of distal esophagectomy. The procedure time ranged from 20-103 minutes and was shorter when a helical retractor was used (60 vs 98 minutes, pZ<0.001). The number of plications ranged from 2 to 8 per patient. Technical success was achieved in all. Median follow-up was 2.5 (range 1-4) months. The median pre-procedure GERDHRQL improved from 20 (range 11-45) to a post-procedure score of 10 (range 0-25). (pZ0.008). Scores improved in all patients, including those who had reduced doses of PPIs (NZ2). Adverse events were limited to one patient (nausea). Conclusions: The use of a novel endoscopic suturing technique for the treatment of refractory GERD is feasible and appears safe. Short term efficacy is suggested by improved
www.giejournal.org
patient-reported quality of life scores in all subjects. The technique can be applied to those who have previously failed endoluminal therapies or have altered surgical anatomy. While promising, further work is necessary to confirm long-term objective response.
873 Endoscopic Ultrasound-Guided Drainage of a Perforated Gallbladder With Resultant Liver Abscess Using a Lumen Apposing Stent Bharat Rao, Mrinal Garg, Shailendra Singh, Abhishek Gulati, Shyam Thakkar* Gastroenterology, Allegheny Health Network, Pittsburgh, PA Background/Case: Percutaneous cholecystostomy tubes are often placed for those medically unfit for cholecystectomy. These may cause significant discomfort and can negatively impact a patient’s quality of life including those with terminal illnesses receiving palliative care. Endoscopic transmural drainage offers an alternative option for such patients. We describe our experience using a lumen apposing metal stent (LAMS) for drainage of a perforated gallbladder (GB) with resultant liver abscess formation. A 61-year-old woman with unresectable pancreatic cancer and prior placed covered metal stent in the common bile duct was being treated with chemotherapy and developed complicated acute cholecystitis with perforation and liver abscess formation. As she was not medically fit for surgery and declined percutaneous tubes for drainage, the decision was made for endoscopic drainage utilizing a LAMS with an attached electrocautery device. Technique Highlights: On endoscopic ultrasound (EUS), a distended GB was localized with posterior wall perforation in direct communication with the liver abscess. Under EUS-guidance, a 15 mm LAMS was entered into the GB lumen with the attached electrocautery system. The distal and proximal ends were deployed by EUS and endoscopic visualization respectively. The saddle section was then dilated to 15 mm. An adult endoscope was introduced and the site of perforation was visualized. The GB and abscess cavity were lavaged using a catheter over a wire to minimize complications. A 7 Fr by 5 cm double pigtail plastic stent was placed through the LAMS to preserve patency. After the procedure, there was a complete evacuation of the abscess cavity on imaging. The patient did well with resolution of her acute cholecystitis abscess. The patient presented one month later with imaging findings suspicious of stent obstruction. Endoscopic reevaluation was performed. Previously placed pigtail stent had spontaneously migrated and enteric contents were noted in the GB lumen. Contents were removed using a rat tooth forceps, the cavity was lavaged, and another double pigtail plastic stent was placed through the LAMS. The patient has been without complications thereafter and was safely able to resume palliative chemotherapy. Clinical Implications: Our case showed it to be technically feasible to achieve adequate drainage using a LAMS even for a complicated case of GB perforation with liver abscess formation. Avoidance of a percutaneous tube allowed for improved quality of life in a patient undergoing palliative treatment. Double pigtail insertion through LAMS may be needed to ensure stent patency and stability. Larger prospective studies are needed to further evaluate the technical feasibility and longterm outcomes in patients with LAMS for GB drainage including those with complicated cases of cholecystitis and abscess formation.
874 A Hybrid Endoscopic Technique to Close Tracheoesophageal Fistula Maoyin Pang*1, Bhaumik Brahmbhatt1, Monia E. Werlang2, Omar Y. Mousa1, Timothy A. Woodward1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Internal Medicine, Mayo Clinic, Jacksonville, FL
Tracheoesophageal fistula (TEF) is a congenital or acquired pathological entity characterized by the presence of an abnormal communication between the posterior aspect of the trachea and the anterior wall of the esophagus. Acquired TEF is not an uncommon complication secondary to mechanical ventilation, trauma, esophageal tumor, prior laryngectomy and esophagectomy. Given the interference of feeding and possible fatal pulmonary adverse event, prompt closure of TEFs is critical. Although endoscopic approach to TEFs has been optimized over the past years, recurrent TEFs remain a therapeutic challenge with literature reports up to 20% recurrence.[1,2] Here we present a new hybrid approach with endoscopic management of an acquired TEF. A 56-year-old male with history of laryngeal malignancy status post laryngectomy, permanent tracheostomy and tracheoesophageal voice prosthesis placed 12 years ago, presented to our clinic for consideration of endoscopic closure of his TEF. It was unclear when the fistula had formed, but it has been causing aspiration of both liquid and solid foods for several months. A recent video fluoroscopic swallow study showed a leak of barium into the trachea at the level of the stoma. An upper endoscopy was then performed, showing a 5mm fistula in the upper third of the esophagus, 20cm from the incisors. With the hypothesis to
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB115