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A Novel Method of Endoscopic Treatment of a Periampullary Duodenal Diverticular Abscess
Abstracts
the operating room. We report a RD method performed by 2 GI endoscopists using 2 flexible endoscopes in the Endoscopy suite. Methods: Following IV sedation or general anesthesia, balloon dilation of a mature gastrostomy tract was performed. An Olympus ultraslim (GIF-XP160; OD 5.9 mm) or standard (GIF-H180; OD 9.8 mm) gastroscope was then inserted through the tract into the stomach and advanced to the esophagus. A second endoscopist inserted a gastroscope per orem. A. Savary or 035" guidewire was then passed retrograde. Blunt dissection was performed with biopsy forceps or endoscopic scissors under fluoroscopic and endoscopic guidance. Once a wire has traversed the stricture, antegrade fluoroscopy-assisted Savary dilation was performed. Technical successZrestoration of esophageal patency. Clinical successZimprovement in dysphagia scores by O 1 point per Mellow-Pinkas score (0-4; 4Zinability to swallow any substance). Results: From 2/05 to 12/07, 7 consecutive pts (3M, 4F, mean age 63 5.5) with complete proximal esophageal obstruction (Mellow-Pinkas 4) due to XRT had 8 attempts at RD. 6 pts had 7 prior failed attempts at antegrade dilation by ENT (nZ5) and GI (nZ2). Antegrade dilation was re-attempted in all patients immediately prior to RD. An ultraslim (nZ6) or standard gastroscope (nZ1) was used for retrograde access. Dissection with endoscopic scissors (nZ2) or biopsy forceps (nZ3) was performed in 5 (71%); retrograde probing alone with a Savary guidewire was done in 2 (29%). Technical success was 100%. In 6 pts subsequent antegrade dilations were needed (median of 3, range 1-19). At a mean 12.4 9.7 mo follow-up, clinical success was achieved in 6 (86%). Dysphagia scores improved by a mean of 2.3 1.7 points (pZ.026). Complications occurred in 4 (57%) all managed non-operatively: pneumomediastinum (nZ3) and pneumothorax (nZ1). Both pts who had scissor dissection developed complications. Conclusions: 1) For complete esophageal obstruction, RD performed by two endoscopists has a high technical success rate and is associated with significant improvement in dysphagia scores in most pts. 2) Complications may be managed non-operatively; careful pre-procedure counseling is necessary. 3) When necessary, dissection of fibrotic tissue should be done cautiously; scissor dissection may be associated with a higher risk
W1482 A Novel Method of Endoscopic Treatment of a Periampullary Duodenal Diverticular Abscess Asif M. Lakha, Baseer Qazi, Kenneth D. Chi Spontaneous perforation of a duodenal diverticular abscess is a rare complication with approximately 100 cases reported in the literature. Surgery was the preferred approach for treatment in the majority of cases. A 56 year old woman with a history of Peptic Ulcer Disease presented with severe pain in her epigastrium, associated with fever, chills and nausea for one day. Physical exam revealed epigastric tenderness without any rebound or guarding. Labs revealed normal CBC, CMP and lipase of 430 IU/L. CT scan of the abdomen revealed edema of the head of the pancreas and a collection of gas posterior to it. MRI of the abdomen revealed periampullary fluid filled structure consistent with a duodenal diverticulum. Upper endoscopy was performed. Medial to the major papilla, pus was seen exiting from a fistulous tract. Contrast injection revealed an abscess cavity with extravasation into the peritoneum. A diagnosis of a perforated periampullary duodenal diverticular abscess was made. A 10F 4 cm double pigtail stent was placed into the abscess cavity. This was followed by complete resolution of the patient’s symptoms and removal of the stent in a week.
W1483 Clinical Impact of Endoscopic Submucosal Dissection Using a Bipolar-Current Needle Knife for Superficial Esophageal Cancer Hirohisa Machida, Yasuaki Nagami, Yasuhiro Fujiwara, Masami Nakatani, Natsuhiko Kameda, Hirotoshi Okazaki, Hirokazu Yamagami, Tetsuya Tanigawa, Kenji Watanabe, Kazunari Tominaga, Toshio Watanabe, Nobuhide Oshitani, Tetsuo Arakawa Background: Endoscopic submucosal dissection (ESD) has become more widely accepted as an Endoscopic treatment modality of early-stage esophageal cancer with recent advancement of endoscopy and other related devices. It allows enbloc resections even for larger lesions, and permits improved pathologic evaluation. ESD, however, is associated with significant drawbacks, such as long procedure time or high procedure risks. Because a bipolar-current needle knife has been designed that high-frequency electricity flows from the knife to the sheath tip, the amount of high-frequency current sent from the knife tip to the muscle layer has been reduced. Therefore, a bipolar-current needle knife has been potentially safe, as compared with a monopolar-current device. Objective: The aim of this study was to clarify the efficacy and drawbacks of ESD using a bipolarcurrent needle knife for superficial esophageal cancer (SEC). Patients and Methods: Between May 2006 and October 2008, patients with 76 SECs underwent ESD in our institution and were included in this study. An ESD was performed by using a bipolar-current needle knife and a bipolar-current haemostatic forceps. For the widespread lesion, a monopolar-current device was also introduced for submucosal dissection. Until September 2007, 29 SECs were removed by ESD using a straight needle knife, the later 47 SECs were removed by ESD using a balltip needle knife. En-bloc resection rate, curative resection rate: defined as en-bloc resection with tumor-free margin), procedure time, tumor size and complication were evaluated, including a comparison between two groups; the lesion size was 20mm or less (group A) and over 20mm (group B) in diameter. Result: a total of 75 lesions were squamous cell carcinoma and one lesion was adenocarcinoma. Enbloc resection was achieved in all SECs. Curative resection rate was 92.1% in overall (OA), 91.2% in group A and 92.9% in group B, while procedure time was longer in group B; 99 min in OA, 71 min in group A and 139 min in group B. As complication, 3 mediastinal emphysema (1 in group A, 2 in group B) without perforation and 6 post-operative strictures in group B occurred. Mediastinal emphysemas were managed conservatively with supportive measures. For patients with stricture, Endoscopic balloon dilation was performed successfully. Conclusion: Although ESD for the widespread lesion tended to taking longer procedure time, to remove the superficial esophageal cancer less-invasively, ESD using a bipolar-current needle knife may be safe and effective option even for extensive esophageal cancer.
W1484 Endoscopic Closure of Gastrogastric Fistula After Gastric Bypass Surgery: A Case Series Atul Bhardwaj, Abraham Mathew Background: Gastrogastric fistula (GGF) is a known late complication of gastric bypass surgery. There is a paucity of data regarding its ideal management. We describe eight cases of GGF treated with endoscopic technique. Methods: A retrospective review was performed to find patients (pts) of GGF treated endoscopically at our institution (September 2004 to September 2008). At endoscopy the entire circumference of the fistula was abraded by aggressive cold biopsy. The fistula was then closed with endoclips. A follow up UGI series was ordered at 2 weeks. Results: GGF closure was attempted in 8 female pts (22 to 70 years). The presenting symptoms included nausea, abdominal pain and weight gain. All GGF were small (!1 cm). Endoscopic closure was initially successful in all. In 6 of the 8 pts the GGF remained closed at 2 weeks follow up. The two failed pts required surgery. Additional 2 pts had delayed failure in a few weeks, had recurring symptoms and needed surgical closure. Three pts remained asymptomatic with persistent closure of GGF at 24-36 months follow up (Figure 1). One patient was doing well with intact GGF closure on UGI series at 2 months. DISCUSSION: Despite advances in bariatric surgery, GGF occurs in 1-6% of patients after gastric bypass depending on the type of bypass and the surgical technique. Small GGF may be managed early on by using proton pump inhibitors and avoidance of non steroidal anti-inflammatory drugs. Endoscopic closure of GGF by fibrin glue or endoclips is a viable option for small GGF failing conservative therapy. Surgery remains the mainstay for large GGF and for those with failed endoscopic closure. Conclusion: The success rate of endoscopic closure of GGF with endoclips alone in our hands is up to 50%. We conclude that endoscopic therapy can successfully treat GGF and must be considered given its ease of performance compared to alternative therapy despite failure rate. We speculate that combination of fibrin glue, debridement and clipping may improve
www.giejournal.org
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB381
the operating room. We report a RD method performed by 2 GI endoscopists using 2 flexible endoscopes in the Endoscopy suite. Methods: Following IV sedation or general anesthesia, balloon dilation of a mature gastrostomy tract was performed. An Olympus ultraslim (GIF-XP160; OD 5.9 mm) or standard (GIF-H180; OD 9.8 mm) gastroscope was then inserted through the tract into the stomach and advanced to the esophagus. A second endoscopist inserted a gastroscope per orem. A. Savary or 035" guidewire was then passed retrograde. Blunt dissection was performed with biopsy forceps or endoscopic scissors under fluoroscopic and endoscopic guidance. Once a wire has traversed the stricture, antegrade fluoroscopy-assisted Savary dilation was performed. Technical successZrestoration of esophageal patency. Clinical successZimprovement in dysphagia scores by O 1 point per Mellow-Pinkas score (0-4; 4Zinability to swallow any substance). Results: From 2/05 to 12/07, 7 consecutive pts (3M, 4F, mean age 63 5.5) with complete proximal esophageal obstruction (Mellow-Pinkas 4) due to XRT had 8 attempts at RD. 6 pts had 7 prior failed attempts at antegrade dilation by ENT (nZ5) and GI (nZ2). Antegrade dilation was re-attempted in all patients immediately prior to RD. An ultraslim (nZ6) or standard gastroscope (nZ1) was used for retrograde access. Dissection with endoscopic scissors (nZ2) or biopsy forceps (nZ3) was performed in 5 (71%); retrograde probing alone with a Savary guidewire was done in 2 (29%). Technical success was 100%. In 6 pts subsequent antegrade dilations were needed (median of 3, range 1-19). At a mean 12.4 9.7 mo follow-up, clinical success was achieved in 6 (86%). Dysphagia scores improved by a mean of 2.3 1.7 points (pZ.026). Complications occurred in 4 (57%) all managed non-operatively: pneumomediastinum (nZ3) and pneumothorax (nZ1). Both pts who had scissor dissection developed complications. Conclusions: 1) For complete esophageal obstruction, RD performed by two endoscopists has a high technical success rate and is associated with significant improvement in dysphagia scores in most pts. 2) Complications may be managed non-operatively; careful pre-procedure counseling is necessary. 3) When necessary, dissection of fibrotic tissue should be done cautiously; scissor dissection may be associated with a higher risk
W1482 A Novel Method of Endoscopic Treatment of a Periampullary Duodenal Diverticular Abscess Asif M. Lakha, Baseer Qazi, Kenneth D. Chi Spontaneous perforation of a duodenal diverticular abscess is a rare complication with approximately 100 cases reported in the literature. Surgery was the preferred approach for treatment in the majority of cases. A 56 year old woman with a history of Peptic Ulcer Disease presented with severe pain in her epigastrium, associated with fever, chills and nausea for one day. Physical exam revealed epigastric tenderness without any rebound or guarding. Labs revealed normal CBC, CMP and lipase of 430 IU/L. CT scan of the abdomen revealed edema of the head of the pancreas and a collection of gas posterior to it. MRI of the abdomen revealed periampullary fluid filled structure consistent with a duodenal diverticulum. Upper endoscopy was performed. Medial to the major papilla, pus was seen exiting from a fistulous tract. Contrast injection revealed an abscess cavity with extravasation into the peritoneum. A diagnosis of a perforated periampullary duodenal diverticular abscess was made. A 10F 4 cm double pigtail stent was placed into the abscess cavity. This was followed by complete resolution of the patient’s symptoms and removal of the stent in a week.
W1483 Clinical Impact of Endoscopic Submucosal Dissection Using a Bipolar-Current Needle Knife for Superficial Esophageal Cancer Hirohisa Machida, Yasuaki Nagami, Yasuhiro Fujiwara, Masami Nakatani, Natsuhiko Kameda, Hirotoshi Okazaki, Hirokazu Yamagami, Tetsuya Tanigawa, Kenji Watanabe, Kazunari Tominaga, Toshio Watanabe, Nobuhide Oshitani, Tetsuo Arakawa Background: Endoscopic submucosal dissection (ESD) has become more widely accepted as an Endoscopic treatment modality of early-stage esophageal cancer with recent advancement of endoscopy and other related devices. It allows enbloc resections even for larger lesions, and permits improved pathologic evaluation. ESD, however, is associated with significant drawbacks, such as long procedure time or high procedure risks. Because a bipolar-current needle knife has been designed that high-frequency electricity flows from the knife to the sheath tip, the amount of high-frequency current sent from the knife tip to the muscle layer has been reduced. Therefore, a bipolar-current needle knife has been potentially safe, as compared with a monopolar-current device. Objective: The aim of this study was to clarify the efficacy and drawbacks of ESD using a bipolarcurrent needle knife for superficial esophageal cancer (SEC). Patients and Methods: Between May 2006 and October 2008, patients with 76 SECs underwent ESD in our institution and were included in this study. An ESD was performed by using a bipolar-current needle knife and a bipolar-current haemostatic forceps. For the widespread lesion, a monopolar-current device was also introduced for submucosal dissection. Until September 2007, 29 SECs were removed by ESD using a straight needle knife, the later 47 SECs were removed by ESD using a balltip needle knife. En-bloc resection rate, curative resection rate: defined as en-bloc resection with tumor-free margin), procedure time, tumor size and complication were evaluated, including a comparison between two groups; the lesion size was 20mm or less (group A) and over 20mm (group B) in diameter. Result: a total of 75 lesions were squamous cell carcinoma and one lesion was adenocarcinoma. Enbloc resection was achieved in all SECs. Curative resection rate was 92.1% in overall (OA), 91.2% in group A and 92.9% in group B, while procedure time was longer in group B; 99 min in OA, 71 min in group A and 139 min in group B. As complication, 3 mediastinal emphysema (1 in group A, 2 in group B) without perforation and 6 post-operative strictures in group B occurred. Mediastinal emphysemas were managed conservatively with supportive measures. For patients with stricture, Endoscopic balloon dilation was performed successfully. Conclusion: Although ESD for the widespread lesion tended to taking longer procedure time, to remove the superficial esophageal cancer less-invasively, ESD using a bipolar-current needle knife may be safe and effective option even for extensive esophageal cancer.
W1484 Endoscopic Closure of Gastrogastric Fistula After Gastric Bypass Surgery: A Case Series Atul Bhardwaj, Abraham Mathew Background: Gastrogastric fistula (GGF) is a known late complication of gastric bypass surgery. There is a paucity of data regarding its ideal management. We describe eight cases of GGF treated with endoscopic technique. Methods: A retrospective review was performed to find patients (pts) of GGF treated endoscopically at our institution (September 2004 to September 2008). At endoscopy the entire circumference of the fistula was abraded by aggressive cold biopsy. The fistula was then closed with endoclips. A follow up UGI series was ordered at 2 weeks. Results: GGF closure was attempted in 8 female pts (22 to 70 years). The presenting symptoms included nausea, abdominal pain and weight gain. All GGF were small (!1 cm). Endoscopic closure was initially successful in all. In 6 of the 8 pts the GGF remained closed at 2 weeks follow up. The two failed pts required surgery. Additional 2 pts had delayed failure in a few weeks, had recurring symptoms and needed surgical closure. Three pts remained asymptomatic with persistent closure of GGF at 24-36 months follow up (Figure 1). One patient was doing well with intact GGF closure on UGI series at 2 months. DISCUSSION: Despite advances in bariatric surgery, GGF occurs in 1-6% of patients after gastric bypass depending on the type of bypass and the surgical technique. Small GGF may be managed early on by using proton pump inhibitors and avoidance of non steroidal anti-inflammatory drugs. Endoscopic closure of GGF by fibrin glue or endoclips is a viable option for small GGF failing conservative therapy. Surgery remains the mainstay for large GGF and for those with failed endoscopic closure. Conclusion: The success rate of endoscopic closure of GGF with endoclips alone in our hands is up to 50%. We conclude that endoscopic therapy can successfully treat GGF and must be considered given its ease of performance compared to alternative therapy despite failure rate. We speculate that combination of fibrin glue, debridement and clipping may improve
www.giejournal.org
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB381