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Advanced Endoscopic Management of Boerhaave Syndrome With Large Mallory Weiss Tear
Abstracts events. Endoscopic Methods: Placement and use of a scope cap is first shown. Methods using an insulated tip knife, and using a hook knife are demonstrated. Management of intraprocedural bleeding may employ either coagulation graspers, or clip placement and both techniques are explained. Finally, novel electrocautery cutting shears now under study for use in Zenker’s diverticulotomy are shown. Clinical Implications: As flexible endoscopic diverticulotomy gains popularity over more invasive surgical techniques, the therapeutic endoscopist must be aware of the tools available, and procedural adverse event management. New tools in development will likely continue to make the Zenker’s procedure easier, quicker and safer for patients.
Retrograde Piecemeal Resection of a Large Pyloro-Duodenal Polyp in a Patient With Roux-en-Y Gastric Bypass Using Single Balloon Enteroscopy Dushant S. Uppal*, Daniel S. Strand, Andrew Y. Wang Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA A 65-year-old male with diabetes and hypertension had a Roux-en-Y gastric bypass for obesity in 2007. He presented with complaints of intermittent right-upperquadrant abdominal pain and bloating. A CT scan revealed evidence of an enhancing pyloro-duodenal lesion at the area of the excluded stomach. The patient was referred to our institution and outpatient “per os” single balloon enteroscopy (SBE) was performed for further evaluation and for possible resection of the lesion, if necessary. Using SBE with a low profile cap, the excluded remnant stomach was reached with difficulty given a long roux-limb and significant looping. SBE found a large, 4-cm, sessile polyp that arose from the duodenal bulb that was also causing partial obstruction of the pyloric channel. It was determined that endoscopic resection was indicated as it would treat the pyloric obstruction and as it would provide pathological diagnosis. Carbon dioxide gas was removed and water infused with care given to watch the amount of water infused and removed. Underwater endoscopic mucosal resection (U-EMR) was performed using a 15-mm, crescentshaped snare without submucosal injection. UEMR was helpful as fine scope manipulation was difficult using an enteroscope. U-EMR helped to “float” large mucosal portions of the polyp towards the scope for piecemeal resection. A type of cutting current was used for U-EMR. A portion of the polyp was flat and difficult to approach. Even with U-EMR this area could not be grasped with the snare. Hot biopsy forceps avulsion was performed removing these flat areas using a blended cutting current. Finally, snare resection of a portion of the polyp that traversed the pyloric ring was performed, completing the piecemeal resection. Closed hot biopsy forceps were used to coagulate small exposed vessels in the resection base, some of which were oozing. Furthermore, as this area was reached only with difficulty by using SBE, we sought to minimize the risk of delayed bleeding by coagulating any prominent visible vessels. Final endoscopic views revealed complete macroscopic resection with improved patency of the pyloric channel. Follow-up 1-2 weeks later found that the patient’s vague abdominal symptoms had resolved following this procedure. This case highlights the utility of SBE-assisted retrograde U-EMR of a large pyloro-duodenal polyp in a patient with Roux-en-Y gastric bypass and altered gastroduodenal anatomy. U-EMR was very helpful in this case as it enabled piecemeal resection of this large duodenal bulb polyp using an enteroscope and without the need for submucosal lifting. U-EMR also obviated the need for luminal distension, which potentially reduced the risk of duodenal perforation.
Digital Peroral Cholangioscopy with Holmium Laser Lithotripsy to Manage Complex Biliary Calculi Jason Behary*, Philip I. Craig Department of Gastroenterology and Hepatology, St George Hospital, Sydney, New South Wales, Australia Digital peroral cholangiscopy with holmium laser lithotripsy is a technique effective for the management of complex extra- and intra-hepatic biliary calculi. A combination of direct imaging and fluoroscopic guidance ensures safety when compared to other techniques.
Advanced Endoscopic Management of Boerhaave Syndrome With Large Mallory Weiss Tear Gabriel D. Lang*, Faris Murad Gastroenterology, Washington University School of Medicine in Saint Louis, Saint Louis, MO Introduction: Boerhaave Syndrome is a spontaneous effort rupture of the esophagus associated with negative intrathoracic pressure. It can lead to chemical mediastinitis, mediastinal emphysema, and mediastinal necrosis. Various endoscopic methods have been used to treat Boerhaave syndrome. The mainstay of endoscopic treatment is esophageal stenting, which is complicated by a high rate of stent migration necessitating re-intervention. Case reports describe success with over the scope clips, fibrin glue, and hemostatic clips. Best outcomes are seen with immediate management. Here we present a case of endoscopic management of Boerhaave
AB640 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
Syndrome with a large Mallory-Weiss tear. Case: A 55 year-old male with gastroesophageal reflux disease presents with multiple episodes of retching after a food impaction. After ten retches, he developed hematemesis. He subsequently presented to the hospital where he was noted to be anemic and hypotensive. On arrival, a CT scan was obtained which demonstrated findings concerning for an esophageal perforation. Given the patient’s hematemesis and suspected esophageal perforation, the decision was made to attempt endoscopic management. Upper endoscopy was remarkable for a deep Mallory-Weiss tear in the distal esophagus with active oozing of blood. A perforation could not be excluded. Given the diameter and length of the tear, the decision was made to close the mucosal defect via endosuturing. The procedure was complicated by poor visualization due to active oozing of blood as well as the narrow lumen of the esophagus. Ultimately, endosuturing was successfully performed. At the end of the procedure, the bleeding had resolved and the mucosal defect was closed. Forty-eight hours later, no extravasation of contrast was noted on the esophogram and the patient’s diet was advanced without incident. Discussion: Endoscopic management of Boerhaave Syndrome is feasible, but should be discussed with thoracic surgery. Endosuturing affords the ability to approximate large defects and manage bleeding, while avoiding the retreatments associated with stent placement.
“His Breath Smells Like Crap” Gabriel D. Lang*, Faris Murad Gastroenterology, Washington University School of Medicine in Saint Louis, Saint Louis, MO Introduction: Pancreatico-colonic fistula is an infrequent but well recognized complication of severe acute pancreatitis. It can lead to thrombosis of mesenteric vessels and severe infectious consequences, given the polymircobrial organisms within the colon. Conservative management is typically not possible as spontaneous closure is rare. Pancreatico-colonic fistulas typically require intervention as persistent infection carries high morbidity and mortality. Here we present a case of endoscopic management of a pancreatico-colonic fistula. Case: A 63 year-old male with necrotizing pancreatitis secondary to gallstones presents four weeks post discharge with lethargy, fever, and hypotension. Cross sectional imaging on admission showed worsening necrotizing pancreatitis and large fluid and gas collection in the pancreatic bed. Given ongoing fevers and hemodynamic instability, endoscopic drainage was undertaken. Endoscopic Ultrasound guided access to the collection was performed. After gastrotomy creation, feculent material was noted to be draining from the cavity. Given the poor visualization and presence of a pancreatico-colonic fistula, colorectal surgery was consulted to perform a diverting end ileostomy. Ten days post-operatively, direct endoscopic pancreatic necrosectomy was performed. After endoscopic therapy, the patient had rapid clinical improvement. Conclusion: Colonic involvement of pancreatic fluid collections causes substantial morbidity and mortality due to complications such as ileus, obstruction, hemorrhage, and fistula formation. If colonic fistulization is present, a surgical diversion procedure should be considered to allow for better visualization during endoscopic necrosectomy. Combined surgical and endoscopic management of pancreatico-colonic fistula is feasible.
EUS-Guided Lumen Apposing Metal Stent Placement for the Retrieval of a Migrated Plastic Cystogastrostomy Stent Andrew S. Nett*1, Erik-Jan Wamsteker1, Timothy L. Frankel2, Anoop Prabhu1 1 Gastroenterology, University of Michigan, Ann Arbor, MI; 2Surgery, University of Michigan, Ann Arbor, MI Background/Case: Endoscopic ultrasound-guided transmural drainage may be performed for the management of acute peri-pancreatic fluid collections following pancreatic resection surgery. A 65 year old male with a history of renal cell carcinoma presented with recurrent disease including a metastasis to the pancreatic tail. For management, the patient underwent a right radical nephrectomy, distal pancreatectomy, and splenectomy that was complicated by a symptomatic, acute peri-pancreatic fluid collection suggestive of a pancreatic duct leak. Drainage was pursued via attempted endoscopic cystogastrostomy, which was complicated by inadvertent migration of a double pigtail plastic stent into the peri-pancreatic fluid collection cavity. After discussion with the patient’s surgeon, a decision was made to place a fully covered, lumen apposing metal stent in attempt to both salvage the prior attempted cystogastrostomy and to retrieve the migrated stent. Endoscopic Methods: Endoscopic ultrasound examination revealed a 10 cm peripancreatic fluid collection abutting the lesser curvature of the stomach. Transgastric puncture of the fluid collection was performed with a 19-guage FNA needle. A 0.035 inch guidewire was advanced through the needle and coiled into the fluid collection. The tract was then serially dilated to a maximum diameter of 6mm. Following tract dilation, a fully covered, lumen apposing metal stent with an internal diameter of 15mm was deployed across the tract under endoscopic, EUS, and fluoroscopic guidance. The metal stent lumen was dilated to 8mm using a TTS biliary dilating balloon. A pediatric upper endoscope was then inserted into the fluid collection cavity. Extensive lavage and exploration of the cavity was performed to localize the stent and to delineate any adjacent vascular structures and fresh suture material. The stent was then retrieved with a polypectomy snare and removed through the lumen apposing
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Retrograde Piecemeal Resection of a Large Pyloro-Duodenal Polyp in a Patient With Roux-en-Y Gastric Bypass Using Single Balloon Enteroscopy Dushant S. Uppal*, Daniel S. Strand, Andrew Y. Wang Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA A 65-year-old male with diabetes and hypertension had a Roux-en-Y gastric bypass for obesity in 2007. He presented with complaints of intermittent right-upperquadrant abdominal pain and bloating. A CT scan revealed evidence of an enhancing pyloro-duodenal lesion at the area of the excluded stomach. The patient was referred to our institution and outpatient “per os” single balloon enteroscopy (SBE) was performed for further evaluation and for possible resection of the lesion, if necessary. Using SBE with a low profile cap, the excluded remnant stomach was reached with difficulty given a long roux-limb and significant looping. SBE found a large, 4-cm, sessile polyp that arose from the duodenal bulb that was also causing partial obstruction of the pyloric channel. It was determined that endoscopic resection was indicated as it would treat the pyloric obstruction and as it would provide pathological diagnosis. Carbon dioxide gas was removed and water infused with care given to watch the amount of water infused and removed. Underwater endoscopic mucosal resection (U-EMR) was performed using a 15-mm, crescentshaped snare without submucosal injection. UEMR was helpful as fine scope manipulation was difficult using an enteroscope. U-EMR helped to “float” large mucosal portions of the polyp towards the scope for piecemeal resection. A type of cutting current was used for U-EMR. A portion of the polyp was flat and difficult to approach. Even with U-EMR this area could not be grasped with the snare. Hot biopsy forceps avulsion was performed removing these flat areas using a blended cutting current. Finally, snare resection of a portion of the polyp that traversed the pyloric ring was performed, completing the piecemeal resection. Closed hot biopsy forceps were used to coagulate small exposed vessels in the resection base, some of which were oozing. Furthermore, as this area was reached only with difficulty by using SBE, we sought to minimize the risk of delayed bleeding by coagulating any prominent visible vessels. Final endoscopic views revealed complete macroscopic resection with improved patency of the pyloric channel. Follow-up 1-2 weeks later found that the patient’s vague abdominal symptoms had resolved following this procedure. This case highlights the utility of SBE-assisted retrograde U-EMR of a large pyloro-duodenal polyp in a patient with Roux-en-Y gastric bypass and altered gastroduodenal anatomy. U-EMR was very helpful in this case as it enabled piecemeal resection of this large duodenal bulb polyp using an enteroscope and without the need for submucosal lifting. U-EMR also obviated the need for luminal distension, which potentially reduced the risk of duodenal perforation.
Digital Peroral Cholangioscopy with Holmium Laser Lithotripsy to Manage Complex Biliary Calculi Jason Behary*, Philip I. Craig Department of Gastroenterology and Hepatology, St George Hospital, Sydney, New South Wales, Australia Digital peroral cholangiscopy with holmium laser lithotripsy is a technique effective for the management of complex extra- and intra-hepatic biliary calculi. A combination of direct imaging and fluoroscopic guidance ensures safety when compared to other techniques.
Advanced Endoscopic Management of Boerhaave Syndrome With Large Mallory Weiss Tear Gabriel D. Lang*, Faris Murad Gastroenterology, Washington University School of Medicine in Saint Louis, Saint Louis, MO Introduction: Boerhaave Syndrome is a spontaneous effort rupture of the esophagus associated with negative intrathoracic pressure. It can lead to chemical mediastinitis, mediastinal emphysema, and mediastinal necrosis. Various endoscopic methods have been used to treat Boerhaave syndrome. The mainstay of endoscopic treatment is esophageal stenting, which is complicated by a high rate of stent migration necessitating re-intervention. Case reports describe success with over the scope clips, fibrin glue, and hemostatic clips. Best outcomes are seen with immediate management. Here we present a case of endoscopic management of Boerhaave
AB640 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
Syndrome with a large Mallory-Weiss tear. Case: A 55 year-old male with gastroesophageal reflux disease presents with multiple episodes of retching after a food impaction. After ten retches, he developed hematemesis. He subsequently presented to the hospital where he was noted to be anemic and hypotensive. On arrival, a CT scan was obtained which demonstrated findings concerning for an esophageal perforation. Given the patient’s hematemesis and suspected esophageal perforation, the decision was made to attempt endoscopic management. Upper endoscopy was remarkable for a deep Mallory-Weiss tear in the distal esophagus with active oozing of blood. A perforation could not be excluded. Given the diameter and length of the tear, the decision was made to close the mucosal defect via endosuturing. The procedure was complicated by poor visualization due to active oozing of blood as well as the narrow lumen of the esophagus. Ultimately, endosuturing was successfully performed. At the end of the procedure, the bleeding had resolved and the mucosal defect was closed. Forty-eight hours later, no extravasation of contrast was noted on the esophogram and the patient’s diet was advanced without incident. Discussion: Endoscopic management of Boerhaave Syndrome is feasible, but should be discussed with thoracic surgery. Endosuturing affords the ability to approximate large defects and manage bleeding, while avoiding the retreatments associated with stent placement.
“His Breath Smells Like Crap” Gabriel D. Lang*, Faris Murad Gastroenterology, Washington University School of Medicine in Saint Louis, Saint Louis, MO Introduction: Pancreatico-colonic fistula is an infrequent but well recognized complication of severe acute pancreatitis. It can lead to thrombosis of mesenteric vessels and severe infectious consequences, given the polymircobrial organisms within the colon. Conservative management is typically not possible as spontaneous closure is rare. Pancreatico-colonic fistulas typically require intervention as persistent infection carries high morbidity and mortality. Here we present a case of endoscopic management of a pancreatico-colonic fistula. Case: A 63 year-old male with necrotizing pancreatitis secondary to gallstones presents four weeks post discharge with lethargy, fever, and hypotension. Cross sectional imaging on admission showed worsening necrotizing pancreatitis and large fluid and gas collection in the pancreatic bed. Given ongoing fevers and hemodynamic instability, endoscopic drainage was undertaken. Endoscopic Ultrasound guided access to the collection was performed. After gastrotomy creation, feculent material was noted to be draining from the cavity. Given the poor visualization and presence of a pancreatico-colonic fistula, colorectal surgery was consulted to perform a diverting end ileostomy. Ten days post-operatively, direct endoscopic pancreatic necrosectomy was performed. After endoscopic therapy, the patient had rapid clinical improvement. Conclusion: Colonic involvement of pancreatic fluid collections causes substantial morbidity and mortality due to complications such as ileus, obstruction, hemorrhage, and fistula formation. If colonic fistulization is present, a surgical diversion procedure should be considered to allow for better visualization during endoscopic necrosectomy. Combined surgical and endoscopic management of pancreatico-colonic fistula is feasible.
EUS-Guided Lumen Apposing Metal Stent Placement for the Retrieval of a Migrated Plastic Cystogastrostomy Stent Andrew S. Nett*1, Erik-Jan Wamsteker1, Timothy L. Frankel2, Anoop Prabhu1 1 Gastroenterology, University of Michigan, Ann Arbor, MI; 2Surgery, University of Michigan, Ann Arbor, MI Background/Case: Endoscopic ultrasound-guided transmural drainage may be performed for the management of acute peri-pancreatic fluid collections following pancreatic resection surgery. A 65 year old male with a history of renal cell carcinoma presented with recurrent disease including a metastasis to the pancreatic tail. For management, the patient underwent a right radical nephrectomy, distal pancreatectomy, and splenectomy that was complicated by a symptomatic, acute peri-pancreatic fluid collection suggestive of a pancreatic duct leak. Drainage was pursued via attempted endoscopic cystogastrostomy, which was complicated by inadvertent migration of a double pigtail plastic stent into the peri-pancreatic fluid collection cavity. After discussion with the patient’s surgeon, a decision was made to place a fully covered, lumen apposing metal stent in attempt to both salvage the prior attempted cystogastrostomy and to retrieve the migrated stent. Endoscopic Methods: Endoscopic ultrasound examination revealed a 10 cm peripancreatic fluid collection abutting the lesser curvature of the stomach. Transgastric puncture of the fluid collection was performed with a 19-guage FNA needle. A 0.035 inch guidewire was advanced through the needle and coiled into the fluid collection. The tract was then serially dilated to a maximum diameter of 6mm. Following tract dilation, a fully covered, lumen apposing metal stent with an internal diameter of 15mm was deployed across the tract under endoscopic, EUS, and fluoroscopic guidance. The metal stent lumen was dilated to 8mm using a TTS biliary dilating balloon. A pediatric upper endoscope was then inserted into the fluid collection cavity. Extensive lavage and exploration of the cavity was performed to localize the stent and to delineate any adjacent vascular structures and fresh suture material. The stent was then retrieved with a polypectomy snare and removed through the lumen apposing
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