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907 Endoscopic Resection of Subtotal and Complete Circumferential Colonic Advanced Mucosal Neoplasia
Abstracts
907 Endoscopic Resection of Subtotal and Complete Circumferential Colonic Advanced Mucosal Neoplasia Nicholas J. Tutticci*1, Rebecca Sonson1, Michael J. Bourke1,2 1 Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2University of Sydney, Sydney, NSW, Australia Colorectal cancer (CRC) morbidity and mortality is reduced by colonoscopy and polypectomy. The majority of polyps encountered at colonoscopy are diminutive in size and readily removed with conventional snare polypectomy. Although large laterally spreading tumors (LSTs) are uncommon they represent a significant risk of progression to invasive disease and can be safely and effectively treated endoscopically with a favourable morbidity and cost profile when compared to surgical resection. Endoscopic mucosal resection (EMR) is an established effective outpatient treatment modality for colonic advanced mucosal neoplasia (AMN - sessile or flat lesions R 20mm in size) without submucosal invasive adenocarcinoma. Subtotal and circumferential colonic involvement by AMN is uncommon and data on technical success rates and outcomes for lesions of this extent, is limited. Advances in endoscopic resection technique and management of adverse outcomes have been made in recent years. Theoretically there is no upper size limit to which piecemeal EMR can be applied. Herein we present a series of five extensive colonic LSTs with long term follow up. The video demonstrates resection techniques and management of adverse events. In addition to the recognised EMR adverse events, bleeding and deep injury, luminal stenosis can result from both subtotal and complete circumferential resection mandating a pre-emptive post resection endoscopic balloon dilation regimen.
908 Avulsion: a Novel Technique to Achieve Complete Resection of Difficult Colon Polyps Sherif a. Andrawes, Gregory B. Haber* Gastroenterology and Hepatology, Center for Advanced Therapeutic Endoscopy, Lenox Hill Hospital, New York, NY Colonoscopy has been shown to reduce the incidence of colorectal cancer through removal of premalignant lesions. However, there are multiple impediments to the access and removal of some polyps. While these impediments relate principally to size, but can also include location, flat or sessile contour, laterally extending polyps, associated fibrosis from unsuccessful attempt to removal, depth of neoplasm seen in inability to raise the polyp with a submucosal injection (Non-Lifting Sign) or inability to entrap the target lesion by a snare. The removal of large (R2 cm), sessile nonpolypoid colorectal lesions can be challenging even for the expert endoscopist. Recurrence is assumed to occur as a result of residual neoplastic tissue and therefore current polypectomy techniques are aimed to achieve complete resection. Endoscopic mucosal resection (EMR) through snare cautery polypectomy with or without argon plasma coagulation (APC) is the mainstay of current treatment. In the present video, we describe "Avulsion", a new technique used as an adjunct to EMR to achieve complete removal of difficult colon polyps. Avulsion is literally defined as " shearing off / detaching off / separating off " tissues. In the context of polypectomy we have coined the term "Avulsion" to describe a combination of mechanical shearing force with the simultaneous delivery of thermal energy. It can be used to resect residual fragments of large, laterally spreading adenomas and smaller lesions located in difficult to reach areas such as the ileocecal valve (ICV), appendiceal orifice or in an angulated area of the colon where maintaining good scope position is challenging (i.e. hepatic flexure). The aim of this video is to demonstrate the use of the avulsion technique.
909 A Novel Method for ERCP in the Gastric Bypass Patient Christopher C. Thompson*, Marvin Ryou, Nitin Kumar, James Slattery, Hiroyuki Aihara, Michele B. Ryan Medicine, Brigham and Women, Boston, MA Background: ERCP in the Roux-en-Y gastric bypass (RYGB) patient is arduous with low success rates. Device-assisted enteroscopy has been reported to improve success, although failure to reach the papilla is frequent and cannulation is challenging with a forward-viewing endoscope. Single-session transgastric ERCP has also been described, but similarly relies on the success of device-assisted enteroscopy to reach the remnant, and is time-consuming. Methods: This video describes a new method for ERCP in the RYGB patient that relies on EUS-guided access to the gastric remnant to assist in percutaneous remnant gastrostomy placement. A linear echoendoscope was inserted into the gastric remnant. A 22-gauge needle was used to access the remnant. Contrast was injected into the gastric remnant under fluoroscopic visualization, followed by carbon dioxide insufflation via EUS needle to distend the remnant. The location of the remnant was externally marked. The abdominal wall was prepared for gastrostomy, and four T-tags were inserted using this method to affix the remnant to the abdominal wall. A bubble test and contrast injection were used to confirm position prior to each T-tag placement. An introducer needle was then advanced into the remnant and a guidewire was placed through the
AB182 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
needle. A scalpel was used to make a 1 cm incision along the wire. A fully covered esophageal stent was angled toward the pylorus over the wire and deployed under fluoroscopic visualization. A dilation balloon was inserted into the stent and inflated to 18 mm. An additional incision was performed over the stent to facilitate stent expansion. To perform ERCP, a duodenoscope was inserted into the remnant through the stent. After ERCP was carried out, a G-tube was placed into the gastrostomy. The stent was then removed and an external bumper placed. Conclusion: EUS-guided percutaneous gastric access for ERCP can be performed safely, effectively, and efficiently in a single-session. Additionally, if repeat ERCP is needed, access is readily available.
910 Percutaneous Through-the-Stent Assisted ERCP in Patients With Roux-en-Y Gastric Bypass Payal Saxena*, Alba Azola, Vivek Kumbhari, Mouen Khashab Medicine, Division of Gastroenterology, Johns Hopkins, Baltimore, MD Background: In USA, 35% of all men and women meeting criteria for obesity. Rouxen-Y gastric bypass (RYGB) is the most commonly performed bariatric surgery accounting for 60% of all bariatric procedures. ERCP in patients post RYGB is challenging due to lengthy roux limbs, use of forward viewing endoscopes without an elevator and limitation of available accessories. Current available methods for ERCP in such patients include laparoscopy-assisted, enteroscopy-assisted and gastrostomyassisted ERCP. Laparoscopy-assisted procedures have high technical success rates but are invasive and require coordination between surgeon and endoscopist. Enteroscopy-assisted ERCP has suboptimal papillary cannulation rates of 60%. Gastrostomy-assisted ERCP has high technical success rates as the procedure can be performed with a side-viewing duodenoscope using standard endoscopic accessories. Furthermore, placement of a gastrostomy tube allows for repeat procedures when required. The aim of this video is to demonstrate ERCP via percutaneous endoscopic gastrostomy (PEG) and fully covered self-expandable metallic stent (SEMS) placed during single balloon enteroscopy in a patient with RYGB who presented with recurrent episodes of biliary colic. MRCP confirmed a stone in the distal common bile duct. Endoscopic Methods: Single-balloon-assisted enteroscopy was performed to the excluded stomach. The gastric body was transilluminated and a PEG tube was placed over a long wire through the single-balloon overtube. The patient was brought back in 2 weeks for ERCP through the gastrostomy due to recurrent symptoms. The PEG was removed and gastrostomy dilated using a controlled radial expansion balloon. A SEMS was placed across the gastrostomy to avoid perforation as the tract was likely premature. The stent was dilated using a high pressure burst balloon dilator. The duodenoscope was advanced through the SEMS but the pylorus was difficult to identify. A wire was passed through the duodenoscope and grasped with a snare passed through the enteroscope to direct the duodenoscope to the major papilla. ERCP was successfully performed and stone extracted. The PEG tube was removed 2 weeks post procedure. Clinical Implications: We have demonstrated an endoscopic technique of ERCP in patients with RYGB anatomy. Placement of a PEG tube facilitates repeat procedures when required (incomplete bile duct clearance, removal of prophylactic pancreatic stent). Performing ERCP through a stent placed across the gastrostomy reduces the risk of detachment of the stomach from the gastric wall which can lead to perforation. If urgent ERCP is required (jaundice, cholangitis) we recommend the use of T-tags to anchor the stomach to the abdominal wall to enable ERCP within the same session.
911 Transenteric Anastomosis With Lumen-Apposing Metal Stent (Lams) As Conduit for Iterative Endotherapy of Malignant Biliary Obstruction in Altered Anatomy Manuel Perez-Miranda*, RAMÓN SáNchez-Ocaña, Carlos De La Serna, Pilar Diez-Redondo, Henar NuñEz, Maria Antonia Vallecillo Hospital del Rio Hortega, Valladolid, Spain Background: Biliary decompression in Roux-en-Y patients usually involves enteroscopy, percutaneous transhepatic biliary drainage (PTBD), or EUS-guided biliary drainage (EUS-BD). Percutaneous endoscopic gastrostomy with self-expandable metal stent (SEMS) placement across the percutaneous track is another recently reported option. We describe a related concept based on interventional EUS, EUSguided transenteric anastomosis to allow endoscopic access for biliary drainage in a Roux-en-Y patient with recurrent malignancy. Prior to human application procedural steps were tested and refined in a porcine model of EUS-guided gastro-jejunostomy (4 LAMS anastomosis, 1 acute and 3 one week survival, showing no leakage or peritonitis at necropsy). Case Report: 65 y.o. male with Klastkin IIIB, left hepatectomy and trisegmental hepatico-jejunostomy to the right liver. Relapsing obstructive jaundice 12 months later caused by anastomotic recurrence. Three consecutive attempts at palliation failed: EUSBD hepaticogastrostomy to a single radical, PTBD with external drain dislodgement, and enteroscopy-based ERCP with failed stent insertion despite guidewire access. The enteroscope was removed leaving a nasobiliary drain in the afferent loop. With a linear EUS scope in the duodenum, saline was instilled through the drain. The jejunum was punctured with a 19G needle, and serial OTW dilation and 10x15 mm LAMS placement under combined EUS &
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907 Endoscopic Resection of Subtotal and Complete Circumferential Colonic Advanced Mucosal Neoplasia Nicholas J. Tutticci*1, Rebecca Sonson1, Michael J. Bourke1,2 1 Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2University of Sydney, Sydney, NSW, Australia Colorectal cancer (CRC) morbidity and mortality is reduced by colonoscopy and polypectomy. The majority of polyps encountered at colonoscopy are diminutive in size and readily removed with conventional snare polypectomy. Although large laterally spreading tumors (LSTs) are uncommon they represent a significant risk of progression to invasive disease and can be safely and effectively treated endoscopically with a favourable morbidity and cost profile when compared to surgical resection. Endoscopic mucosal resection (EMR) is an established effective outpatient treatment modality for colonic advanced mucosal neoplasia (AMN - sessile or flat lesions R 20mm in size) without submucosal invasive adenocarcinoma. Subtotal and circumferential colonic involvement by AMN is uncommon and data on technical success rates and outcomes for lesions of this extent, is limited. Advances in endoscopic resection technique and management of adverse outcomes have been made in recent years. Theoretically there is no upper size limit to which piecemeal EMR can be applied. Herein we present a series of five extensive colonic LSTs with long term follow up. The video demonstrates resection techniques and management of adverse events. In addition to the recognised EMR adverse events, bleeding and deep injury, luminal stenosis can result from both subtotal and complete circumferential resection mandating a pre-emptive post resection endoscopic balloon dilation regimen.
908 Avulsion: a Novel Technique to Achieve Complete Resection of Difficult Colon Polyps Sherif a. Andrawes, Gregory B. Haber* Gastroenterology and Hepatology, Center for Advanced Therapeutic Endoscopy, Lenox Hill Hospital, New York, NY Colonoscopy has been shown to reduce the incidence of colorectal cancer through removal of premalignant lesions. However, there are multiple impediments to the access and removal of some polyps. While these impediments relate principally to size, but can also include location, flat or sessile contour, laterally extending polyps, associated fibrosis from unsuccessful attempt to removal, depth of neoplasm seen in inability to raise the polyp with a submucosal injection (Non-Lifting Sign) or inability to entrap the target lesion by a snare. The removal of large (R2 cm), sessile nonpolypoid colorectal lesions can be challenging even for the expert endoscopist. Recurrence is assumed to occur as a result of residual neoplastic tissue and therefore current polypectomy techniques are aimed to achieve complete resection. Endoscopic mucosal resection (EMR) through snare cautery polypectomy with or without argon plasma coagulation (APC) is the mainstay of current treatment. In the present video, we describe "Avulsion", a new technique used as an adjunct to EMR to achieve complete removal of difficult colon polyps. Avulsion is literally defined as " shearing off / detaching off / separating off " tissues. In the context of polypectomy we have coined the term "Avulsion" to describe a combination of mechanical shearing force with the simultaneous delivery of thermal energy. It can be used to resect residual fragments of large, laterally spreading adenomas and smaller lesions located in difficult to reach areas such as the ileocecal valve (ICV), appendiceal orifice or in an angulated area of the colon where maintaining good scope position is challenging (i.e. hepatic flexure). The aim of this video is to demonstrate the use of the avulsion technique.
909 A Novel Method for ERCP in the Gastric Bypass Patient Christopher C. Thompson*, Marvin Ryou, Nitin Kumar, James Slattery, Hiroyuki Aihara, Michele B. Ryan Medicine, Brigham and Women, Boston, MA Background: ERCP in the Roux-en-Y gastric bypass (RYGB) patient is arduous with low success rates. Device-assisted enteroscopy has been reported to improve success, although failure to reach the papilla is frequent and cannulation is challenging with a forward-viewing endoscope. Single-session transgastric ERCP has also been described, but similarly relies on the success of device-assisted enteroscopy to reach the remnant, and is time-consuming. Methods: This video describes a new method for ERCP in the RYGB patient that relies on EUS-guided access to the gastric remnant to assist in percutaneous remnant gastrostomy placement. A linear echoendoscope was inserted into the gastric remnant. A 22-gauge needle was used to access the remnant. Contrast was injected into the gastric remnant under fluoroscopic visualization, followed by carbon dioxide insufflation via EUS needle to distend the remnant. The location of the remnant was externally marked. The abdominal wall was prepared for gastrostomy, and four T-tags were inserted using this method to affix the remnant to the abdominal wall. A bubble test and contrast injection were used to confirm position prior to each T-tag placement. An introducer needle was then advanced into the remnant and a guidewire was placed through the
AB182 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
needle. A scalpel was used to make a 1 cm incision along the wire. A fully covered esophageal stent was angled toward the pylorus over the wire and deployed under fluoroscopic visualization. A dilation balloon was inserted into the stent and inflated to 18 mm. An additional incision was performed over the stent to facilitate stent expansion. To perform ERCP, a duodenoscope was inserted into the remnant through the stent. After ERCP was carried out, a G-tube was placed into the gastrostomy. The stent was then removed and an external bumper placed. Conclusion: EUS-guided percutaneous gastric access for ERCP can be performed safely, effectively, and efficiently in a single-session. Additionally, if repeat ERCP is needed, access is readily available.
910 Percutaneous Through-the-Stent Assisted ERCP in Patients With Roux-en-Y Gastric Bypass Payal Saxena*, Alba Azola, Vivek Kumbhari, Mouen Khashab Medicine, Division of Gastroenterology, Johns Hopkins, Baltimore, MD Background: In USA, 35% of all men and women meeting criteria for obesity. Rouxen-Y gastric bypass (RYGB) is the most commonly performed bariatric surgery accounting for 60% of all bariatric procedures. ERCP in patients post RYGB is challenging due to lengthy roux limbs, use of forward viewing endoscopes without an elevator and limitation of available accessories. Current available methods for ERCP in such patients include laparoscopy-assisted, enteroscopy-assisted and gastrostomyassisted ERCP. Laparoscopy-assisted procedures have high technical success rates but are invasive and require coordination between surgeon and endoscopist. Enteroscopy-assisted ERCP has suboptimal papillary cannulation rates of 60%. Gastrostomy-assisted ERCP has high technical success rates as the procedure can be performed with a side-viewing duodenoscope using standard endoscopic accessories. Furthermore, placement of a gastrostomy tube allows for repeat procedures when required. The aim of this video is to demonstrate ERCP via percutaneous endoscopic gastrostomy (PEG) and fully covered self-expandable metallic stent (SEMS) placed during single balloon enteroscopy in a patient with RYGB who presented with recurrent episodes of biliary colic. MRCP confirmed a stone in the distal common bile duct. Endoscopic Methods: Single-balloon-assisted enteroscopy was performed to the excluded stomach. The gastric body was transilluminated and a PEG tube was placed over a long wire through the single-balloon overtube. The patient was brought back in 2 weeks for ERCP through the gastrostomy due to recurrent symptoms. The PEG was removed and gastrostomy dilated using a controlled radial expansion balloon. A SEMS was placed across the gastrostomy to avoid perforation as the tract was likely premature. The stent was dilated using a high pressure burst balloon dilator. The duodenoscope was advanced through the SEMS but the pylorus was difficult to identify. A wire was passed through the duodenoscope and grasped with a snare passed through the enteroscope to direct the duodenoscope to the major papilla. ERCP was successfully performed and stone extracted. The PEG tube was removed 2 weeks post procedure. Clinical Implications: We have demonstrated an endoscopic technique of ERCP in patients with RYGB anatomy. Placement of a PEG tube facilitates repeat procedures when required (incomplete bile duct clearance, removal of prophylactic pancreatic stent). Performing ERCP through a stent placed across the gastrostomy reduces the risk of detachment of the stomach from the gastric wall which can lead to perforation. If urgent ERCP is required (jaundice, cholangitis) we recommend the use of T-tags to anchor the stomach to the abdominal wall to enable ERCP within the same session.
911 Transenteric Anastomosis With Lumen-Apposing Metal Stent (Lams) As Conduit for Iterative Endotherapy of Malignant Biliary Obstruction in Altered Anatomy Manuel Perez-Miranda*, RAMÓN SáNchez-Ocaña, Carlos De La Serna, Pilar Diez-Redondo, Henar NuñEz, Maria Antonia Vallecillo Hospital del Rio Hortega, Valladolid, Spain Background: Biliary decompression in Roux-en-Y patients usually involves enteroscopy, percutaneous transhepatic biliary drainage (PTBD), or EUS-guided biliary drainage (EUS-BD). Percutaneous endoscopic gastrostomy with self-expandable metal stent (SEMS) placement across the percutaneous track is another recently reported option. We describe a related concept based on interventional EUS, EUSguided transenteric anastomosis to allow endoscopic access for biliary drainage in a Roux-en-Y patient with recurrent malignancy. Prior to human application procedural steps were tested and refined in a porcine model of EUS-guided gastro-jejunostomy (4 LAMS anastomosis, 1 acute and 3 one week survival, showing no leakage or peritonitis at necropsy). Case Report: 65 y.o. male with Klastkin IIIB, left hepatectomy and trisegmental hepatico-jejunostomy to the right liver. Relapsing obstructive jaundice 12 months later caused by anastomotic recurrence. Three consecutive attempts at palliation failed: EUSBD hepaticogastrostomy to a single radical, PTBD with external drain dislodgement, and enteroscopy-based ERCP with failed stent insertion despite guidewire access. The enteroscope was removed leaving a nasobiliary drain in the afferent loop. With a linear EUS scope in the duodenum, saline was instilled through the drain. The jejunum was punctured with a 19G needle, and serial OTW dilation and 10x15 mm LAMS placement under combined EUS &
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