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886 Submucosal Tunneling and Enbloc Endoscopic Resection Facilitates Laparoscopic Transgastric Removal of a Large GIST At the Esophagogastric Junction
Abstracts
anastomotic leak and abscess which resolved with drain placement. Three years later he was being evaluated for colostomy takedown. Lower GI series confirmed a high-grade obstruction at the colorectal anastomosis and contrast failed to pass through the stricture. Endoscopically, there appeared to be a complete obstruction at the level of the colorectal anastomosis. A second endoscope was then advanced through the colostomy in order to approximate the length of the stricture and guide therapy. Fluoroscopically this appeared to be less than 1 cm in length. A guidewire was advanced but could not pass through the stricture. Next, a needle knife was used without cautery in an attempt to pierce the fibrotic stricture, however this was unsuccessful. Therefore, careful dissection was performed using the endocut mode on the electrosurgical generator. The light from the antegrade scope was used to guide the orientation of the stricturoplasty. As the stricture was progressively dissected the needle knife was advanced through the stricture and visualized with the antegrade endoscope. The catheter was then advanced through the fibrotic stricture serving as a small dilation. A guidewire was then advanced through the stricture visualized endoscopically and fluoroscopically. The guidewire was then grasped with a snare inserted through the antegrade scope and the guidwire was withdrawn out of the colostomy. An 18 mm diameter by 10 cm long fully covered esophageal stent was advanced over the guidewire. The stent was carefully deployed using both endoscopes as well as fluoroscopy to ensure that there was adequate distance to avoid the dentate line. Once the stent was depoloyed, a waist was visualized at the colorectal anastomosis. Given the benign nature of the stricture and risk for stent migration, an endoscopic suturing device was used. Two sutures were placed from the antegrade position. Four weeks later the patient returned with rectal pain. Endoscopically, the stent had migrated distally. The colorectal anastomosis was widely patent and the stent was easily removed. 8 weeks later the anastomosis was narrowed to approximately 8 mm. Balloon dilation was performed up to 15 mm with an appropriate mucosal tear. Patient is being monitored closely and scheduled for colostomy takedown now that his anastomosis is patent. In conclusion, our video demonstrates endoscopic therapy in a benign colorectal anastomotic stricture. Needle knife stricturoplasty is safe in carefully selected cases. Endoscopic suturing can be considered especially in benign strictures. However, stents may migrate despite suture placement.
885 Gel Immersion Endoscopy: a Novel Method Using Gel to Secure the Visual Field During Endoscopy Tomonori Yano*1, Daiki Nemoto1, Kohei Ono1, Yasushi Miyata1, Norikatsu Numao1, Alan Lefor2, Hironori Yamamoto1 1 Medicine, Jichi Medical University, Shimotsuke-shi, Japan; 2Surgery, Jichi Medical University, Shimotsuke-shi, Japan Background: During endoscopy for GI bleeding or colonoscopy without preparation, it is often difficult to secure the visual field, because the injected water is rapidly mixed with fresh blood or feces. We developed a novel method to adequately secure the visual field in these situations. Method: To prevent rapid mixing with fresh blood or feces, we inject clear gel instead of water through the accessory channel. The gel has the appropriate viscosity to prevent rapid mixing and to be injectable through the accessory channel. In vitro, indigo carmine mixes slowly with the gel and rapidly mixes with water. To test gel immersion endoscopy in vitro, we used a vinyl tube as a GI bleeding model. After filling the lumen with indigo carmine, air insufflation and water injection is not effective to secure the visual field. However, after gel injection, the bleeding source is observed clearly in the space occupied by the gel. Case Reports: Case 1: Jejunal bleeding The patient is an 81-year-old man with recurrent obscure GI bleeding. Antegrade doubleballoon enteroscopy revealed jejunal bleeding from vascular lesion. After gel injection, the bleeding source was observed clearly, and endoscopic hemostasis was achieved. Case 2: Mallory-Weiss syndrome with a varixThe patient is a 58-year-old man with hepatic cirrhosis, admitted with hematemesis. Upper GI endoscopy revealed tears with a bleeding varix at the cardia. Water injection and carbon dioxide gas insufflation were not effective to secure the visual field. After gel injection, the visual field was secured and endoscopic hemostasis achieved. Case 3: Rectal bleeding The patient is an 81-year-old woman with hematochezia. Enhanced CT scan showed extravasation of contrast medium in the rectum, and colonoscopy performed without preparation. The lumen was filled with blood and feces making it difficult to secure the visual field. After gel injection, the bleeding source was observed clearly and endoscopic hemostasis achieved. Case 4: Large bowel obstruction The patient is an 86-year-old man with malignant obstruction of the sigmoid colon. Colonoscopy without preparation was performed to place a selfexpanding metallic stent. The visual field could not be secured due to contact bleeding and feces. After gel injection, the visual field improved, enabling safe passage of the guide-wire beyond the stenosis, and stent placement. Clinical Implications: This is the first description of gel immersion endoscopy, which facilitates securing the visual field, thus creating a space for endoscopic visualization and treatment in otherwise difficult situations.
www.giejournal.org
886 Submucosal Tunneling and Enbloc Endoscopic Resection Facilitates Laparoscopic Transgastric Removal of a Large GIST At the Esophagogastric Junction Payal Saxena*, Martin A. Makary, Vivek Kumbhari, Alan H. Tieu, Saowanee Ngamruengphong, Mohamad H. El Zein, Mouen Khashab Johns Hopkins, Baltimore, MD Background: A 74 year old male presenting with iron deficiency anemia had a large (6.6cm) gastrointestinal tumor (GIST) at the esophagogastric junction (EGJ) extending into the lesser curve. Endoscopic resection of GIST of the EGJ can be performed by the submucosal tunneling and endoscopic resection (STER) technique. However, the maximal reported lesion size is currently 3.3cm. Oncologic principles mandate enbloc resection with an intact capsule due to the malignant potential of the lesions. Therefore STER of large GIST is limited by the size of the mucosal tunnel entry. Laparoscopic wedge resection (LWR) techniques of large tumors at the EGJ is technically challenging with a risk of narrowing the lumen at the EGJ with surgical stapling, leading to dysphagia, injury to the lower esophageal sphincter (LES) leading to lifelong reflux and leak at the staple line. Furthermore, esophagogastrectomy may also be required for lesions at the EGJ. STER of such a lesion can release the tumor from the EGJ and facilitate easy access for transgastric laparoscopic resection and technique and avoiding the risks of standard LWR techniques. Endoscopic Methods: STER was performed by fitting a gastroscope with a distal cap and creating a mucosal bleb 5cm proximal to the EGJ with 0.3% indigocarmine/saline solution. A triangle tip knife was used to create a mucosal incision followed by a submucosal tunnel to the GIST. The overlying submucosal fibers and underlying muscle fibres were carefully dissected away from the lesion. The tumor capsule remained intact. Once the inferior aspect of the GIST was free from the EGJ, laparoscopy was performed and a gastrostomy formed on the anterior gastric wall. The GIST tumor was identified with the assistance of transillumination from the gastroscope. As the GIST lesion was free from the EGJ, surgical staples were easily placed at an appropriate angle to prevent narrowing of the EGJ. There was no need for surgical dissection of the angle of His or LES. The GIST was removed enbloc through the gastrotomy and laparoscopic port. The wounds were closed and the esophageal mucosal tunnel entry was closed with hemoclips. There was no tumor recurrence at 6 month follow up and the patient had no symptoms of reflux or dysphagia. Clinical Implications: Surgical removal of large subepithelial lesions at the EGJ is technically challenging and may be associated with adverse patient outcomes. Combining STER with surgical techniques offers a minimally invasive, safe and effective solution while avoiding the need for esophagogastrectomy.
887 Endoscopic Rendezvous Luminal Reconstitution Using a Novel Anastomotic Stent Aaron J. Small*1, Richard C. Thirlby2, Andrew S. Ross1 1 Gastroenterology, Virginia Mason Medical Center, Seattle, WA; 2General Surgery, Virginia Mason Medical Center, Seattle, WA Background/Case: Endoscopic techniques in surgically altered anatomy can be challenging, particularly in patients who have undergone Roux-en-Y (RNY) gastric bypass. We present a case of successful endoscopic creation of a gastrogastrostomy and closure of a high output gastrocutaneous fistula using a novel anastomotic stent in a patient who had undergone a RNY gastric bypass and subsequent pyloric exclusion for the treatment of a perforated duodenal ulcer. Endoscopic Methods: Initially, a gastro-gastric fistula was created using an endoscopic rendezvous technique. Subsequently, a gastrogastrostomy was created using a fully-covered, metal, self-expanding anastomotic stent. Subsequent closure of the gastrocutaneous fistula was achieved within 2 months. Clinical Implications: Endoscopic gastrogastrostomy is feasible and offers an alternative for luminal bypass for cutaneous fistula resolution in select patients.
888 Over -the-Scope Stent (Otss): a Novel Technique for Stent Elongation and Deployment Sami A. Almaskeen*, Simon K. Lo Gastroenterology - Interventional Endoscopy, Cedars-Sinai Medical Center, Los Angeles, CA Introduction: Stent migration has often been reported as a limitation of durability of success in the treatment of gastrointestinal leaks. Overlapping stents placement is often needed to treat large defects due to the relatively short-length of the currently available stents. Case: A 34 year-old female with gastric leak who failed endoscopic therapy with conventional stenting due to stent migration. A long, over-the-scope gastric stent using a novel technique was then used resulting in tissue healing. Discussion: Over-the-scope stent technique is an effective method for creating and placing an adjustable length stent, longer than the ones commercially available when conventional stenting fails and/or longer stent is needed.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB177
anastomotic leak and abscess which resolved with drain placement. Three years later he was being evaluated for colostomy takedown. Lower GI series confirmed a high-grade obstruction at the colorectal anastomosis and contrast failed to pass through the stricture. Endoscopically, there appeared to be a complete obstruction at the level of the colorectal anastomosis. A second endoscope was then advanced through the colostomy in order to approximate the length of the stricture and guide therapy. Fluoroscopically this appeared to be less than 1 cm in length. A guidewire was advanced but could not pass through the stricture. Next, a needle knife was used without cautery in an attempt to pierce the fibrotic stricture, however this was unsuccessful. Therefore, careful dissection was performed using the endocut mode on the electrosurgical generator. The light from the antegrade scope was used to guide the orientation of the stricturoplasty. As the stricture was progressively dissected the needle knife was advanced through the stricture and visualized with the antegrade endoscope. The catheter was then advanced through the fibrotic stricture serving as a small dilation. A guidewire was then advanced through the stricture visualized endoscopically and fluoroscopically. The guidewire was then grasped with a snare inserted through the antegrade scope and the guidwire was withdrawn out of the colostomy. An 18 mm diameter by 10 cm long fully covered esophageal stent was advanced over the guidewire. The stent was carefully deployed using both endoscopes as well as fluoroscopy to ensure that there was adequate distance to avoid the dentate line. Once the stent was depoloyed, a waist was visualized at the colorectal anastomosis. Given the benign nature of the stricture and risk for stent migration, an endoscopic suturing device was used. Two sutures were placed from the antegrade position. Four weeks later the patient returned with rectal pain. Endoscopically, the stent had migrated distally. The colorectal anastomosis was widely patent and the stent was easily removed. 8 weeks later the anastomosis was narrowed to approximately 8 mm. Balloon dilation was performed up to 15 mm with an appropriate mucosal tear. Patient is being monitored closely and scheduled for colostomy takedown now that his anastomosis is patent. In conclusion, our video demonstrates endoscopic therapy in a benign colorectal anastomotic stricture. Needle knife stricturoplasty is safe in carefully selected cases. Endoscopic suturing can be considered especially in benign strictures. However, stents may migrate despite suture placement.
885 Gel Immersion Endoscopy: a Novel Method Using Gel to Secure the Visual Field During Endoscopy Tomonori Yano*1, Daiki Nemoto1, Kohei Ono1, Yasushi Miyata1, Norikatsu Numao1, Alan Lefor2, Hironori Yamamoto1 1 Medicine, Jichi Medical University, Shimotsuke-shi, Japan; 2Surgery, Jichi Medical University, Shimotsuke-shi, Japan Background: During endoscopy for GI bleeding or colonoscopy without preparation, it is often difficult to secure the visual field, because the injected water is rapidly mixed with fresh blood or feces. We developed a novel method to adequately secure the visual field in these situations. Method: To prevent rapid mixing with fresh blood or feces, we inject clear gel instead of water through the accessory channel. The gel has the appropriate viscosity to prevent rapid mixing and to be injectable through the accessory channel. In vitro, indigo carmine mixes slowly with the gel and rapidly mixes with water. To test gel immersion endoscopy in vitro, we used a vinyl tube as a GI bleeding model. After filling the lumen with indigo carmine, air insufflation and water injection is not effective to secure the visual field. However, after gel injection, the bleeding source is observed clearly in the space occupied by the gel. Case Reports: Case 1: Jejunal bleeding The patient is an 81-year-old man with recurrent obscure GI bleeding. Antegrade doubleballoon enteroscopy revealed jejunal bleeding from vascular lesion. After gel injection, the bleeding source was observed clearly, and endoscopic hemostasis was achieved. Case 2: Mallory-Weiss syndrome with a varixThe patient is a 58-year-old man with hepatic cirrhosis, admitted with hematemesis. Upper GI endoscopy revealed tears with a bleeding varix at the cardia. Water injection and carbon dioxide gas insufflation were not effective to secure the visual field. After gel injection, the visual field was secured and endoscopic hemostasis achieved. Case 3: Rectal bleeding The patient is an 81-year-old woman with hematochezia. Enhanced CT scan showed extravasation of contrast medium in the rectum, and colonoscopy performed without preparation. The lumen was filled with blood and feces making it difficult to secure the visual field. After gel injection, the bleeding source was observed clearly and endoscopic hemostasis achieved. Case 4: Large bowel obstruction The patient is an 86-year-old man with malignant obstruction of the sigmoid colon. Colonoscopy without preparation was performed to place a selfexpanding metallic stent. The visual field could not be secured due to contact bleeding and feces. After gel injection, the visual field improved, enabling safe passage of the guide-wire beyond the stenosis, and stent placement. Clinical Implications: This is the first description of gel immersion endoscopy, which facilitates securing the visual field, thus creating a space for endoscopic visualization and treatment in otherwise difficult situations.
www.giejournal.org
886 Submucosal Tunneling and Enbloc Endoscopic Resection Facilitates Laparoscopic Transgastric Removal of a Large GIST At the Esophagogastric Junction Payal Saxena*, Martin A. Makary, Vivek Kumbhari, Alan H. Tieu, Saowanee Ngamruengphong, Mohamad H. El Zein, Mouen Khashab Johns Hopkins, Baltimore, MD Background: A 74 year old male presenting with iron deficiency anemia had a large (6.6cm) gastrointestinal tumor (GIST) at the esophagogastric junction (EGJ) extending into the lesser curve. Endoscopic resection of GIST of the EGJ can be performed by the submucosal tunneling and endoscopic resection (STER) technique. However, the maximal reported lesion size is currently 3.3cm. Oncologic principles mandate enbloc resection with an intact capsule due to the malignant potential of the lesions. Therefore STER of large GIST is limited by the size of the mucosal tunnel entry. Laparoscopic wedge resection (LWR) techniques of large tumors at the EGJ is technically challenging with a risk of narrowing the lumen at the EGJ with surgical stapling, leading to dysphagia, injury to the lower esophageal sphincter (LES) leading to lifelong reflux and leak at the staple line. Furthermore, esophagogastrectomy may also be required for lesions at the EGJ. STER of such a lesion can release the tumor from the EGJ and facilitate easy access for transgastric laparoscopic resection and technique and avoiding the risks of standard LWR techniques. Endoscopic Methods: STER was performed by fitting a gastroscope with a distal cap and creating a mucosal bleb 5cm proximal to the EGJ with 0.3% indigocarmine/saline solution. A triangle tip knife was used to create a mucosal incision followed by a submucosal tunnel to the GIST. The overlying submucosal fibers and underlying muscle fibres were carefully dissected away from the lesion. The tumor capsule remained intact. Once the inferior aspect of the GIST was free from the EGJ, laparoscopy was performed and a gastrostomy formed on the anterior gastric wall. The GIST tumor was identified with the assistance of transillumination from the gastroscope. As the GIST lesion was free from the EGJ, surgical staples were easily placed at an appropriate angle to prevent narrowing of the EGJ. There was no need for surgical dissection of the angle of His or LES. The GIST was removed enbloc through the gastrotomy and laparoscopic port. The wounds were closed and the esophageal mucosal tunnel entry was closed with hemoclips. There was no tumor recurrence at 6 month follow up and the patient had no symptoms of reflux or dysphagia. Clinical Implications: Surgical removal of large subepithelial lesions at the EGJ is technically challenging and may be associated with adverse patient outcomes. Combining STER with surgical techniques offers a minimally invasive, safe and effective solution while avoiding the need for esophagogastrectomy.
887 Endoscopic Rendezvous Luminal Reconstitution Using a Novel Anastomotic Stent Aaron J. Small*1, Richard C. Thirlby2, Andrew S. Ross1 1 Gastroenterology, Virginia Mason Medical Center, Seattle, WA; 2General Surgery, Virginia Mason Medical Center, Seattle, WA Background/Case: Endoscopic techniques in surgically altered anatomy can be challenging, particularly in patients who have undergone Roux-en-Y (RNY) gastric bypass. We present a case of successful endoscopic creation of a gastrogastrostomy and closure of a high output gastrocutaneous fistula using a novel anastomotic stent in a patient who had undergone a RNY gastric bypass and subsequent pyloric exclusion for the treatment of a perforated duodenal ulcer. Endoscopic Methods: Initially, a gastro-gastric fistula was created using an endoscopic rendezvous technique. Subsequently, a gastrogastrostomy was created using a fully-covered, metal, self-expanding anastomotic stent. Subsequent closure of the gastrocutaneous fistula was achieved within 2 months. Clinical Implications: Endoscopic gastrogastrostomy is feasible and offers an alternative for luminal bypass for cutaneous fistula resolution in select patients.
888 Over -the-Scope Stent (Otss): a Novel Technique for Stent Elongation and Deployment Sami A. Almaskeen*, Simon K. Lo Gastroenterology - Interventional Endoscopy, Cedars-Sinai Medical Center, Los Angeles, CA Introduction: Stent migration has often been reported as a limitation of durability of success in the treatment of gastrointestinal leaks. Overlapping stents placement is often needed to treat large defects due to the relatively short-length of the currently available stents. Case: A 34 year-old female with gastric leak who failed endoscopic therapy with conventional stenting due to stent migration. A long, over-the-scope gastric stent using a novel technique was then used resulting in tissue healing. Discussion: Over-the-scope stent technique is an effective method for creating and placing an adjustable length stent, longer than the ones commercially available when conventional stenting fails and/or longer stent is needed.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB177