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915 Closure of a Persistent Esophagopleural Fistula Using an Atrial Septal Occluder Device
Abstracts ESD knife. The lodged fish bone was then identified embedded into the submucosal plane of esophagus and removed with forceps. The mucosal defect was subsequently closed with endoscopic clips. Patient recovered uneventfully after the endoscopic procedure and was able to resume diet 5 days later. Clinical implications: ESD has been utilized in the current case for removal of esophageal foreign body, avoiding the need for surgical exploration of the esophagus. With increasing experience and further maturity of the technique, a wider variety of clinical conditions other than tumor resection could be tackled with endoscopic surgery. Conclusion: ESD could be used in removal of deeply embedded foreign body in esophagus, thus avoiding the need of open surgical exploration procedure.
913 Novel Technique for Flexible Endoscopic Zenker’s Diverticulum Repair Bhaumik Brahmbhatt*, Michael J. Bartel, Abhishek Bhurwal, Krupa Patel, Timothy A. Woodward Gastroenterology, Mayo Clinic, Jacksonville, FL Background: Zenker’s Diverticulum (ZD), also known as Crico-pharyngeal (CP) diverticulum, is an outpouching of mucosa through Killian’s triangle. There are distinct indications for flexible endoscopic ZD repair, which has been performed since 1990’s by cutting the CP muscle bar and septum between the esophagus and diverticulum creating a common cavity.1 According to a recent systematic review, on average 1-2 treatment sessions are required to achieve clinical resolution in more than 90% of cases, while recurrence or persistence was under 20%.1 We hypothesized that instead of incising the CP muscle, as performed historically, a wedgeshaped excision of the CP muscle would decrease the recurrence or persistence rate of clinical symptoms following repair of ZD. Endoscopic method: The ZD repair was performed during general anesthesia with endotracheal intubation utilizing cap-assisted upper endoscopy (EGD). A guidewire was placed in the esophageal lumen to protect the anterior esophageal wall during electrocautery. The CP muscle was fixed with a suture utilizing an endoscopic suturing device. The suture was secured with a clamp providing gentle traction outside the endoscope, exposing the CP muscle bar during subsequent electrocautery excision. The dissection was targeted inferomedially on either side of the suture creating a wedge shaped incision. Next, a snare is passed first through the endoscopic channel and then over the guidewire down to the base of the wedge-shaped incision to perform its snare resection in order to unify the lumen of diverticulum and esophagus. In our practice, all patients are admitted for observation overnight following ZD repair and kept nil per os. Clear liquids are introduced the following day, and if tolerated, the patient is discharged home with outpatient follow up. Clinical implications: Till date we have performed 6 volumetric resections of CP muscle; without any immediate or delayed complication and with complete resolution of their symptoms. In our limited experience a volumetric resection of cricopharyngeal muscle is safe; however, prospective data of this technique in comparison with conventional method is needed to determine its safety and efficacy. Reference: 1. Ryan L, David A.K, Todd H.B; Zenker’s Diverticulum; Clinical Gastroenterology and Hepatology 2014;12:1773-1782
914 EUS-Guided FNA of Pericardial Mass Piyush Somani, Malay Sharma*, Amol Patil, Avinash Kumar Department of gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India Primary malignant pericardial mesothelioma is extremely rare. Diagnosing pericardial disease can be challenging, with an antemortem diagnosis of pericardial mesothelioma obtained in only 10-20% of cases. Because of the proximity of the heart to the esophagus, transesophageal EUS-guided access to the heart has been described safely in animal models and humans. There are few case reports of EUS guided FNA of atrial tumour and pericardial tumour. We describe a case report of pericardial mesothelioma diagnosed by EUS-FNA.
915 Closure of a Persistent Esophagopleural Fistula Using an Atrial Septal Occluder Device Lady Katherine Mejia-Perez*1, Bradley Confer2, Tyler Stevens2, John J. Vargo2, Joe Veniero2, Usman Ahmad2, Siva Raja2, Sudish Murthy2, Daniel Raymond2, Amit Bhatt2 1 Facultad de Medicina, Universidad de los Andes, Bogota, Colombia; 2 Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH Background: An esophagopleural fistula (EPF) is an abnormal communication between the esophagus and pleural cavity, that may develop secondary to cancer, surgery, radiation therapy, or esophageal injury. Endoclip closure and esophageal stent placement are commonly employed interventions for EPF, but have poor success rates. Here, we present the successful treatment of an EPF refractory to esophageal stent placement, by using an atrial septal occluder device. Case presentation: A 55-year-old male with a history of squamous cell lung cancer, treated with right middle lobectomy, chemotherapy and radiation, developed a radiationinduced esophageal stricture. The patient underwent endoscopic balloon dilation of
AB184 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
his esophageal stricture and subsequently developed an EPF. Despite 9 months of covered esophageal stent treatment, the fistula persisted, and the patient was referred for further management. An esophagram and CT scan confirmed the presence of the fistula, and an upper endoscopy revealed a 5mm fistulous opening in the proximal esophagus. Due to the recessed position and fibrotic nature of the fistula endoclip closure was unlikely to be beneficial. After a multidisciplinary discussion, the patient underwent a Eloesser flap thoracostomy and biopsy of the esophageal fistula. The biopsy of the fistula was benign, and under endoscopic guidance an atrial septal occluder device was placed through fistula and deployed. An initial esophagogram performed 1 week after deployment showed a persistent leak, but time was allowed to achieve tissue ingrowth of the device, and at 4 weeks an esophagogram confirmed closure of the fistula. Endoscopic methods: The cavernostomy wound was unpacked. An upper endoscope was placed into the esophagus for visualization. Under endoscopic guidance an atrial septal occluder device was passed through the fistula and into the esophagus. The proximal end of the occluder was deployed and pulled against the esophageal wall. The distal end was then deployed in a standard fashion. Once the occluder was deployed, the distal end was sutured to the chest wall in 2 locations using 4-0 Polysorb suture, in order to assure anchoring and prevent disruption with dressing changes. Clinical implications: Deployment of an atrial septal occluder device should be considered for the treatment of persistent esophagopleural fistulas that fail conventional treatment. It provides both mechanical occlusion and coverage by fibrous connective tissue, resulting in tissue ingrowth and closure of defects.
916 Two Staged Endoscopic Approach for the Management of a Large Symptomatic Epiphrenic Diverticulum in the Setting of Achalasia Mouen A. Khashab*1, Alan H. Tieu2, Saowanee Ngamruengphong2, Yamile Haito Chavez2, Yen-I. Chen1, Majidah Bukhari1, Vivek Kumbhari2 1 Medicine, Johns Hopkins Hospital, Baltimore, MD; 2DIvision of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD Background: A 60 yr old female presents for management of longstanding dysphagia, regurgitation and three admissions for the management of aspiration pneumonia. She has a prior diagnosis of achalasia (subtype I) with an Eckart score of 9. At EGD she was found to have a large epiphrenic diverticulum. Our patient was not agreeable to surgical therapy and hence a two stage endoscopic approach was developed. First, a peroral endoscopic myotomy (POEM) would be performed to decrease resistance to flow of oral contents through the lower esophageal sphincter (LES). Then, the patient would return for endoscopic creation of a fistula from the esophageal diverticulum to the gastric fundus and the two lumens would be kept approximated with a lumen opposing metallic stent (LAMS). The objectives of this video are to demonstrate a purely endoscopic strategy for the management of an epiphrenic diverticulum in the context of idiopathic achalasia. Endoscopic methods: Stage 1: A POEM was performed with a 6cm esophageal myotomy and 3cm gastric myotomy. As anticipated, despite a technically successful procedure, she had residual symptoms. Stage 2: The stomach was filled with water to optimize sonographic views. A linear echoendoscope was inserted into the diverticulum and the diverticulum was filled with contrast so that its dependent portion could be identified endoscopically and fluoroscopically. Then, transesophageal puncture with a 19-gauge needle was performed and contrast was injected and confirmed entry into the stomach fluoroscopically. A 0.025 inch stiff guidewire was inserted and coiled within the stomach. The fistula was then dilated using a 4 x 40mm biliary dilation balloon. At this time, an ultra-slim gastroscope was simultaneously inserted perorally into the stomach and retroflexed such that an adequate view of the fistula could be obtained. A LAMS (15mm lumen, 10mm in length and 24mm flares) was deployed creating an esophagogastric anastomosis. The stent lumen was dilated to 15mm using a radial expansion balloon. An UGI series demonstrated a patent stent with no extravasation. The patient was discharged after an overnight stay. An EGD was performed at 3 months with removal of the LAMS. At 6 month follow-up the patient remained symptom free. Clinical implications: We herein demonstrate a purely endoscopic approach for the management of a large epiphrenic diverticulum. Although her symptoms were palliated, she remains at considerable risk of developing complications related to reflux of gastric contents. Measures to minimize this (lifestyle modifications, PPI etc) are mandatory.
917 Taking the EDGE off James F. Crismale*1, Brian P. Riff1, Myron Schwartz2, Christopher J. DiMaio1 1 Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY; 2Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY Case: A 49-year-old woman with a history of Roux-en-Y gastric bypass (RYGB) presented to an outside hospital with ascending cholangitis. Her RYGB anatomy precluded conventional ERCP; the outside hospital team therefore performed internal EUS-directed transgastric ERCP (EDGE) to obtain biliary access. ERCP was
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913 Novel Technique for Flexible Endoscopic Zenker’s Diverticulum Repair Bhaumik Brahmbhatt*, Michael J. Bartel, Abhishek Bhurwal, Krupa Patel, Timothy A. Woodward Gastroenterology, Mayo Clinic, Jacksonville, FL Background: Zenker’s Diverticulum (ZD), also known as Crico-pharyngeal (CP) diverticulum, is an outpouching of mucosa through Killian’s triangle. There are distinct indications for flexible endoscopic ZD repair, which has been performed since 1990’s by cutting the CP muscle bar and septum between the esophagus and diverticulum creating a common cavity.1 According to a recent systematic review, on average 1-2 treatment sessions are required to achieve clinical resolution in more than 90% of cases, while recurrence or persistence was under 20%.1 We hypothesized that instead of incising the CP muscle, as performed historically, a wedgeshaped excision of the CP muscle would decrease the recurrence or persistence rate of clinical symptoms following repair of ZD. Endoscopic method: The ZD repair was performed during general anesthesia with endotracheal intubation utilizing cap-assisted upper endoscopy (EGD). A guidewire was placed in the esophageal lumen to protect the anterior esophageal wall during electrocautery. The CP muscle was fixed with a suture utilizing an endoscopic suturing device. The suture was secured with a clamp providing gentle traction outside the endoscope, exposing the CP muscle bar during subsequent electrocautery excision. The dissection was targeted inferomedially on either side of the suture creating a wedge shaped incision. Next, a snare is passed first through the endoscopic channel and then over the guidewire down to the base of the wedge-shaped incision to perform its snare resection in order to unify the lumen of diverticulum and esophagus. In our practice, all patients are admitted for observation overnight following ZD repair and kept nil per os. Clear liquids are introduced the following day, and if tolerated, the patient is discharged home with outpatient follow up. Clinical implications: Till date we have performed 6 volumetric resections of CP muscle; without any immediate or delayed complication and with complete resolution of their symptoms. In our limited experience a volumetric resection of cricopharyngeal muscle is safe; however, prospective data of this technique in comparison with conventional method is needed to determine its safety and efficacy. Reference: 1. Ryan L, David A.K, Todd H.B; Zenker’s Diverticulum; Clinical Gastroenterology and Hepatology 2014;12:1773-1782
914 EUS-Guided FNA of Pericardial Mass Piyush Somani, Malay Sharma*, Amol Patil, Avinash Kumar Department of gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India Primary malignant pericardial mesothelioma is extremely rare. Diagnosing pericardial disease can be challenging, with an antemortem diagnosis of pericardial mesothelioma obtained in only 10-20% of cases. Because of the proximity of the heart to the esophagus, transesophageal EUS-guided access to the heart has been described safely in animal models and humans. There are few case reports of EUS guided FNA of atrial tumour and pericardial tumour. We describe a case report of pericardial mesothelioma diagnosed by EUS-FNA.
915 Closure of a Persistent Esophagopleural Fistula Using an Atrial Septal Occluder Device Lady Katherine Mejia-Perez*1, Bradley Confer2, Tyler Stevens2, John J. Vargo2, Joe Veniero2, Usman Ahmad2, Siva Raja2, Sudish Murthy2, Daniel Raymond2, Amit Bhatt2 1 Facultad de Medicina, Universidad de los Andes, Bogota, Colombia; 2 Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH Background: An esophagopleural fistula (EPF) is an abnormal communication between the esophagus and pleural cavity, that may develop secondary to cancer, surgery, radiation therapy, or esophageal injury. Endoclip closure and esophageal stent placement are commonly employed interventions for EPF, but have poor success rates. Here, we present the successful treatment of an EPF refractory to esophageal stent placement, by using an atrial septal occluder device. Case presentation: A 55-year-old male with a history of squamous cell lung cancer, treated with right middle lobectomy, chemotherapy and radiation, developed a radiationinduced esophageal stricture. The patient underwent endoscopic balloon dilation of
AB184 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
his esophageal stricture and subsequently developed an EPF. Despite 9 months of covered esophageal stent treatment, the fistula persisted, and the patient was referred for further management. An esophagram and CT scan confirmed the presence of the fistula, and an upper endoscopy revealed a 5mm fistulous opening in the proximal esophagus. Due to the recessed position and fibrotic nature of the fistula endoclip closure was unlikely to be beneficial. After a multidisciplinary discussion, the patient underwent a Eloesser flap thoracostomy and biopsy of the esophageal fistula. The biopsy of the fistula was benign, and under endoscopic guidance an atrial septal occluder device was placed through fistula and deployed. An initial esophagogram performed 1 week after deployment showed a persistent leak, but time was allowed to achieve tissue ingrowth of the device, and at 4 weeks an esophagogram confirmed closure of the fistula. Endoscopic methods: The cavernostomy wound was unpacked. An upper endoscope was placed into the esophagus for visualization. Under endoscopic guidance an atrial septal occluder device was passed through the fistula and into the esophagus. The proximal end of the occluder was deployed and pulled against the esophageal wall. The distal end was then deployed in a standard fashion. Once the occluder was deployed, the distal end was sutured to the chest wall in 2 locations using 4-0 Polysorb suture, in order to assure anchoring and prevent disruption with dressing changes. Clinical implications: Deployment of an atrial septal occluder device should be considered for the treatment of persistent esophagopleural fistulas that fail conventional treatment. It provides both mechanical occlusion and coverage by fibrous connective tissue, resulting in tissue ingrowth and closure of defects.
916 Two Staged Endoscopic Approach for the Management of a Large Symptomatic Epiphrenic Diverticulum in the Setting of Achalasia Mouen A. Khashab*1, Alan H. Tieu2, Saowanee Ngamruengphong2, Yamile Haito Chavez2, Yen-I. Chen1, Majidah Bukhari1, Vivek Kumbhari2 1 Medicine, Johns Hopkins Hospital, Baltimore, MD; 2DIvision of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD Background: A 60 yr old female presents for management of longstanding dysphagia, regurgitation and three admissions for the management of aspiration pneumonia. She has a prior diagnosis of achalasia (subtype I) with an Eckart score of 9. At EGD she was found to have a large epiphrenic diverticulum. Our patient was not agreeable to surgical therapy and hence a two stage endoscopic approach was developed. First, a peroral endoscopic myotomy (POEM) would be performed to decrease resistance to flow of oral contents through the lower esophageal sphincter (LES). Then, the patient would return for endoscopic creation of a fistula from the esophageal diverticulum to the gastric fundus and the two lumens would be kept approximated with a lumen opposing metallic stent (LAMS). The objectives of this video are to demonstrate a purely endoscopic strategy for the management of an epiphrenic diverticulum in the context of idiopathic achalasia. Endoscopic methods: Stage 1: A POEM was performed with a 6cm esophageal myotomy and 3cm gastric myotomy. As anticipated, despite a technically successful procedure, she had residual symptoms. Stage 2: The stomach was filled with water to optimize sonographic views. A linear echoendoscope was inserted into the diverticulum and the diverticulum was filled with contrast so that its dependent portion could be identified endoscopically and fluoroscopically. Then, transesophageal puncture with a 19-gauge needle was performed and contrast was injected and confirmed entry into the stomach fluoroscopically. A 0.025 inch stiff guidewire was inserted and coiled within the stomach. The fistula was then dilated using a 4 x 40mm biliary dilation balloon. At this time, an ultra-slim gastroscope was simultaneously inserted perorally into the stomach and retroflexed such that an adequate view of the fistula could be obtained. A LAMS (15mm lumen, 10mm in length and 24mm flares) was deployed creating an esophagogastric anastomosis. The stent lumen was dilated to 15mm using a radial expansion balloon. An UGI series demonstrated a patent stent with no extravasation. The patient was discharged after an overnight stay. An EGD was performed at 3 months with removal of the LAMS. At 6 month follow-up the patient remained symptom free. Clinical implications: We herein demonstrate a purely endoscopic approach for the management of a large epiphrenic diverticulum. Although her symptoms were palliated, she remains at considerable risk of developing complications related to reflux of gastric contents. Measures to minimize this (lifestyle modifications, PPI etc) are mandatory.
917 Taking the EDGE off James F. Crismale*1, Brian P. Riff1, Myron Schwartz2, Christopher J. DiMaio1 1 Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY; 2Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY Case: A 49-year-old woman with a history of Roux-en-Y gastric bypass (RYGB) presented to an outside hospital with ascending cholangitis. Her RYGB anatomy precluded conventional ERCP; the outside hospital team therefore performed internal EUS-directed transgastric ERCP (EDGE) to obtain biliary access. ERCP was
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