Endoscopic modification of a Billroth II gastrojejunostomy by using metallic clips

Brief Reports

S Zanati, R Ganc, P Kortan

REFERENCES 1. Anthony T, Kim L. Gastrointestinal carcinoid tumors and the malignant carcinoid syndrome. In: Feldman M, Friedman LS, Sleisenger MH, editors. Sleisenger and Fordtran’s gastrointestinal disease and liver pathology. 7th ed. Philadelphia: Saunders; 2002. p. 2151-68. 2. Kulke M, Mayer R. Carcinoid tumors. N Engl J Med 1999; 340:858-68. 3. Shebani K, Souba W, Finkelstein D, Stark P, Elgadi K, Tanabe K, et al. Prognosis and survival in patients with gastrointestinal tract carcinoid tumors. Ann Surg 1999;229: 815-23. 4. Tang S, Jutabha R. Recurrent hemorrhage caused by ileal carcinoid. Gastrointest Endosc 2002;55:559. 5. Miller GA, Borten MM. Primary carcinoid tumor of the ileum associated with massive gastrointestinal hemorrhage. Aust N Z J Surg 1991;61:645-6. 6. Lingenfelser T, Ell C. Lower intestinal bleeding. Best Pract Res Clin Gastroenterol 2001;15:135-53. 7. Van Gossum A. Obscure digestive bleeding. Best Pract Res Clin Gastroenterol 2001;15:155-74. 8. Lewis S, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study. Gastrointest Endosc 2002;56: 349-53. 9. Eii C, Remke S, May A, Helou L, Henrich R, Mayer G. The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding. Endoscopy 2002;34:685-9. 10. Scapa E, Jacob H, Lewkowicz , Migdal M, Gat D, Gluckhovski A, et al. Initial experience of wireless-capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small bowel pathology. Am J Gastroenterol 2002; 97:2776-9. 11. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small bowel bleeding. N Engl J Med 2001;344:232-3. 12. Hartmann D, Schilling D, Bolz G, Hahne M, Jakobs R, Siegel E, et al. Capsule endoscopy versus push enteroscopy in patients with occult gastrointestinal bleeding. Z Gastroenterol 2003;41:377-82. 13. Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Gut 2003;52:1122-6. 14. Lewis B, Goldfarb N. Review article: the advent of capsule endoscopy: a not-so-futuristic approach to obscure gastrointestinal bleeding. Aliment Pharmacol Ther 2003;17: 1088-96. 15. Van Gossum A, Hittelet A, Schmit A, Francois E, Deviere J. A prospective comparative study of push and wireless-capsule enteroscopy in patients with obscure digestive bleeding. Acta Gastroenterol Belg 2003;66:199-205. 16. Madisch A, Schimming W, Kinzel F, Schneider R, Aust D, Ockert DM, et al. Locally advanced small-bowel adenocarcinoma missed primarily by capsule endoscopy but diagnosed by push enteroscopy. Endoscopy 2003;35: 861-4. 17. Zuckerman G, Prakash C, Askin M, Lewis B. American Gastroenterological Association Medical position statement: evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000;118:197200.

Endoscopic modification of a Billroth II gastrojejunostomy by using metallic clips The efficacy of endoclip application for the treatment of GI bleeding is well established.1-5 Effectiveness combined with low cost and an excellent safety profile have made the endoclip a worthwhile addition to the modern armamentarium of hemostatic devices. The endoclip also has non-hemostatic applications: closure of perforations,6-8 anastomotic leaks,9 and fistulas10; prevention of postpolypectomy bleeding11; and a marking device for followup endoscopy, surgical resection, and radiation therapy.12,13 Duodenal folds have been affixed with clips to facilitate bile duct cannulation.14 However, there are relatively few reports in which endoclips have been used to manipulate GI anatomy. The present report describes the successful modification of post-surgical anatomy by deployment of endoclips. Case report. An 82-year-old man was hospitalized with melena and anemia. At endoscopy, a 2-cm ulcer was identified on the greater curve of the stomach; biopsy specimens revealed moderately differentiated adenocarcinoma. Laparoscopic distal gastrectomy was attempted, but a small tear in the splenic capsule necessitated conversion to an open procedure, at which splenectomy, distal pancreatectomy, and a Billroth II gastrojejunostomy were performed. Histopathologic assessment of the resection specimen revealed a 4.3 cm 3 2.9 cm 3 1.0-cm adenocarcinoma invading through the gastric wall with perigastric vein invasion and metastatic deposits in two of 7 excised lymph nodes. The postoperative recovery was complicated by recurrent post-prandial vomiting and aspiration pneumonia. Barium contrast radiography via a nasogastric tube demonstrated filling of the gastric remnant and afferent loop but no barium in the efferent loop after 3 hours (Fig. 1). Mechanical obstruction at the gastrojejunal anastomosis was presumed. Management included fasting and total parenteral nutrition in anticipation of spontaneous resolution of the obstruction as the post-surgical edema subsided. However, repeated attempts at feeding resulted in vomiting, and barium contrast radiography 5 weeks after surgery confirmed persistence of the efferent loop obstruction. An upper endoscopy demonstrated a normal-appearing gastric remnant and a widely patent afferent limb. The efferent limb was difficult to locate and intubate, being slitlike, with its orifice hidden by the surgical anastomosis (Fig. 2). However, there was no evidence of edema or stricture formation. A redundant jejunal fold could be raised by using a biliary guidewire/guide catheter to open Reprint requests: Paul Kortan, MD, Centre for Therapeutic Endoscopy and Endoscopic Oncology, Victoria Wing 16-048, St. Michael’s Hospital, Toronto, Ontario, Canada M5B 1W8. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)01817-6

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Figure 1. Barium contrast radiograph demonstrating gastric outlet obstruction. Figure 3. Endoscopic view showing elevation of redundant jejunal fold with guide catheter to expose efferent limb.

Figure 2. Endoscopic view showing guide catheter in hidden efferent limb. the inlet to the efferent limb (Fig. 3). The attending surgeon, present at the endoscopy, agreed that revision of the anastomosis was necessary to relieve the gastric outlet obstruction. However, the risk of re-operation was considered high because of the poor nutritional status and advanced age of the patient. Thus, a decision was made, with the patient’s consent, to attempt endoscopic revision of the anastomosis by using hemostatic clips. Five clips (Endoclip; Olympus America Corp., Melville, N.Y.) were applied to pin back the redundant fold (Figs. 4 and 5). Thereafter, the inlet to the efferent limb was seen to be patent (Fig. 5) and the angle between the gastric lumen and the efferent limb was substantially reduced. The patient tolerated fluids and progressed quickly to a soft diet. At contrast radiography, barium flowed into the efferent limb, although the anastomosis remained narrowed (Fig. 6). After discharge, the patient tolerated a full diet without recurrence of vomiting. Metastatic disease developed, and he died from complications of advanced malignancy at 6 months after surgery. 486

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Figure 4. Endoscopic view showing partial elevation of redundant jejunal fold with application of two endoclips. Discussion. The hemostatic clip has proved to be an amazingly versatile device. The first description of a nonhemostatic application is that of Binmoeller et al.6 in 1993 who used endoclips to close a 5-mm perforation caused by a polypectomy. This was followed by many similar reports: Tsunada et al.8 reported 7 cases in which gastric perforations from EMR for gastric tumors were successfully closed with endoclips; Rodella et al.9 reported closure of anastomotic leaks. The length of time a clip will remain attached to the gut wall is unpredictable. Clips applied for hemostasis have been found to dislodge within 1 to 3 weeks, with re-epithelialization of the lesion.6 However, clips have remained in situ for as long as 26 months.15 There is no report of a serious complication arising from the use of endoclips for any indication. The clips currently in use grasp only the mucosal and submucosal layers of the VOLUME 60, NO. 3, 2004

Brief Reports

S Zanati, R Ganc, P Kortan

The present case is a further example of the diverse therapeutic applications of the hemostatic clip. Further improvements in the design of the endoclip could expand the range of applications, including larger and stronger clips, as well as simplification of the mechanism for deployment. Simon A. Zanati, MD Ricardo L. Ganc, MD Paul Kortan, MD The Centre for Therapeutic Endoscopy and Endoscopic Oncology St Michael’s Hospital University of Toronto Ontario, Canada

REFERENCES Figure 5. Endoscopic view showing fixation of redundant jejunal fold to open lumen of efferent limb.

Figure 6. Radiograph demonstrating flow of barium into distal small bowel.

gut wall.16 Thus, in the present case, there was little concern that attempts to modify the gastroenterostomy with hemostatic clips would result in tissue injury or perforation. For this novel clinical application, multiple endoclips were deployed to raise a redundant jejunal fold at the Billroth II gastrojejunal anastomosis, thereby alleviating the post-surgical mechanical obstruction, as documented by barium contrast radiography and dramatic clinical improvement. The rational for deployment of several clips was that this would reduce the tissue tension exerted on individual clips, thereby improving durability. Despite a concern that dislodgement of clips might negate the benefit, anastomotic function was sustained for the 6 months that the patient survived after surgery. Because palliation was the goal, upper endoscopy was not repeated to assess clip position. Placement of a self-expanding metallic stent was considered but rejected because of the likelihood of distal migration in the absence of a fixed stricture. VOLUME 60, NO. 3, 2004

1. Binmoeller KF, Thonke F, Soehendra N. Endoscopic hemoclip treatment for gastrointestinal bleeding. Endoscopy 1993;25: 167-70. 2. Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus. Surg Endosc 1998;2:13-7. 3. Chung IK, Ham JS, Kim HS, Park SH, Lee MH, Kim SJ. Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline-epinephrine injection and a combination of the two for the management of bleeding peptic ulcers. Gastrointest Endosc 1999;491:13-8. 4. Cipolletta L, Bianco MA, Marmo R, Rotondano G, Piscopo R, Vingiani AM, et al. Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective randomized trial. Gastrointest Endosc 2000;53: 147-51. 5. Buffoli F, Graffeo N, Nicosia F, Gentile C, Cesari P, Roli F, et al. Peptic ulcer bleeding: comparison of two hemostatic procedures. Am J Gastroenterol 2001;96:89-94. 6. Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993;39:172-4. 7. Wewalka FW, Clodi PH, Haidinger D. Endoscopic clipping of a perforation after pneumatic dilation for achalasia. Endoscopy 1995;27:608-11. 8. Tsunada S, Ogata S, Ohyama T, Ootani H, Oda K, Kikkawa A, et al. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003;57:948-51. 9. Rodella L, Laterza E, De Manzoni G, Kind R, Lombardo F, Catalano F, et al. Endoscopic clipping of anastomotic leakages in esophagogastric surgery. Endoscopy 1998;30:453-6. 10. Van Bodegraven AK, Kuipers EJ, Bonenkamp HJ, Meuwissen SGM. Esophagopleural fistuli treated endoscopically with argon beam electrocoagulation and clips. Gastrointest Endosc 1999;50:410-4. 11. Cippolletta L, Bianco MA, Rotondano G, Catalano M, Prisco A, De Simone T. Endoclip-assisted resection of large pedunculated polyps using a needle-knife. Gastrointest Endosc 1999;50:405-7. 12. Devereaux CE, Binmoeller KF. Endoclip: closing the surgical gap. Gastrointest Endosc 1999;50:440-2. 13. Weyman RL, Rao SSC. A novel clinical application for endoscopic mucosal clipping. Gastrointest Endosc 1999;49: 522-4. 14. Scotiniotis I, Ginsberg GG. Endoscopic clip-assisted biliary cannulation: externalization and fixation of the papilla of Vater from within a duodenal diverticulum using the GASTROINTESTINAL ENDOSCOPY

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endoscopic clip fixing device. Gastrointest Endosc 1999;50: 431-3. 15. Iida Y, Miura S, Munemoto Y, Ayakawa T, Mori S, Kawashima H, et al. Endoscopic resection of large colorectal polyps using a clipping method. Dis Colon Rectum 1994;37:179-80. 16. Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus. Surg Endosc 1988;2:13-7.

Gallbladder perforation associated with gastric EMR for gastric adenoma EMR is a useful therapeutic alternative to open surgery for certain gastric neoplasms.1,2 Major complications of EMR include hemorrhage and perforation. This report describes a highly unusual case of perforation of the stomach and the gallbladder, with consequent bile peritonitis, caused by marking the mucosa around a gastric lesion for EMR. Case report. A 61-year-old man, after informed consent was obtained, underwent EMR for a gastric adenoma on the anterior wall near the angulus (Fig. 1). As four sites were being marked electrosurgically with a needle knife to outline the resection margin, the patient complained of severe upper abnormal pain. Free air was detected bilaterally under the diaphragm on a plain radiograph, and mucosal plication was performed at two confirmed sites of perforation among the four sites marked. Fever (38.48C) and leukocytosis developed on the same day. Oral intake was withheld, and an antibiotic (meropenem, 1 g/d) and a proton pump inhibitor (omeplazone, 40 mg/d) were administered. The fever resolved on day 3 after EMR, and the white blood cell count normalized, but the serum C-reactive protein increased to 13.0 mg/dL (normal: <0.4 mg/dL). In addition, CT detected bilateral pleural effusion, ascites, and a greater volume of free air in the abdominal cavity. On day 5 after EMR, fever recurred, there was a slight increase in abdominal tenderness, and a diagnosis of peritonitis was made. At laparotomy (day 7), 1750 mL of yellow, slightly turbid fluid was removed from the abdomen and the abdominal organs were covered with yellow pus, findings indicative of bile peritonitis. Three perforations, each about 1 mm in diameter and accompanied by mild hemorrhage, were observed on the anterior wall of the stomach near the angulus. The thickness of the wall at the sites of perforation was 2 mm. Inflammation accompanied by subserous hemorrhage also was noted. Manual compression of the gallbladder resulted in flow of bile into the abdomen, and cholecystectomy was performed. Examination of the excised gallbladder revealed thickening from edema and

Reprint requests: Masahide Hamaguchi, MD, Department of Gastroenterology, Murakami Memorial Hospital, Asahi University, 3-23 Hashimoto-cho, Gifu 500-8523, Japan. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)01816-4 488

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Figure 1. Endoscopic view of gastric adenoma on anterior wall of antrum near angulus after spraying with indigo carmine dye.

Figure 2. Photomicrograph of resected gallbladder, showing inflammatory infiltrate and perforated ulcer (arrows) (H&E, orig. mag. 320).

three sites of external injury, one of which included the perforation (Fig. 2). Histopathologic evaluation of the resected gallbladder revealed mild infiltration with acute inflammatory cells and an ulcer at the site of perforation. Examination of the stomach demonstrated atrophic, metaplastic changes, together with subserosal infiltration and hemorrhage. Our technique for EMR of gastric mucosal neoplasms is based on the strip-off biopsy method.1 EMR is performed with a two-channel upper endoscope (GIF-2TK200; Olympus Optical Co., Ltd., Tokyo, Japan). After identification, lesions are evaluated with contrast chromoscopy by using indigo carmine dye.3 The circumferential margin then is marked with a needle knife (Olympus) by using coagulation current. The length of the needle itself is 4 mm (Fig. 3). After fully marking the margin, saline solution with VOLUME 60, NO. 3, 2004