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EUS assisted gastric pacemaker (neurostimulator) implantation for gastroparesis
AJG – September, 2000
Conclusions: Gastroenterologists have been assisting Otolaryngologists in the management of patients with head and neck cancer by placing PEG tubes. This fruitful collaboration may be extended to the placement of TEPs, as the endoscopic placement of TEP is simple, convenient, and easily accomplished. In addition one could avoid the need for general anesthesia. 645 EUS assisted gastric pacemaker (neurostimulator) implantation for gastroparesis G.S. Raju, MD, I. Sarosiek, MD, J. Forster, MD, S. Rosenthal, MD, Z. Lin MS, R. McCallum, MD. Department of Medicine, Radiology, and Surgery. Kansas Univ. Medical Ctr. Kansas City, KS. Introduction: Gastric neurostimulator implantation is one of the recent advances in the management of refractory gastroparesis. During the procedure electrodes are inserted into the muscular layer of the stomach. Care is taken to avoid penetration of the mucosa. Endoscopy and intra-operative surface ultrasound confirm positioning of the electrode. The former needs distension of the stomach, which interferes with the closure of abdomen from distended bowel loops, and, the latter produces an unsatisfactory image from reverberation artifacts. Endoscopic ultrasound overcomes both these problems as it provides excellent imaging of the layers of the stomach wall along with clear visualization of the mucosal aspect of the stomach. We describe the use of EUS to confirm the gastric pacemaker electrode placement. Materials and Methods: A 38-year-old woman with gastroparesis refractory to medical management was referred for gastric pacemaker implantation. A radial echo-endoscope was passed into the stomach under general anesthesia. Pacemaker wires were implanted into the stomach wall, avoiding mucosal puncture. The placement of the gastric pacemaker wires into the central muscular coat was confirmed by EUS. Endoscopic visualization of the area was also done to exclude mucosal penetration by the pacemaker wires. Once the positioning of the electrode was confirmed by endoscopy and also by the EUS, the wires were secured in the serosal layer. A total of 12 patients underwent gastric pacemaker implantation at our site. The last 5 underwent EUS assisted gastric pacemaker implantation. During the follow-up (3–12 mo), no problems were noted. Conclusions: EUS is useful to confirm the placement of the gastric neurostimulator (now approved to treat refractory gastroparesis) and is superior to imaging with intra-operative surface ultrasound. High frequency ultrasound probe may provide further improvement in the imaging. 646 Extra-corporeal shock wave lithotripsy (ESWL) plus a novel method of removal of a burrowed CBD stone in a patient with Mirizzi syndrome G. S. Raju, MD, Greg Crawford, RN, Brad Peck, RN, G. Cox, MD, E. Seigel, MD, B. Trasher, MD. Department of Medicine, Radiology and Urology, Kansas Univ. Medical Ctr. Kansas City, KS. Introduction: Open cholecystectomy is the treatment of choice for Mirizzi syndrome; laparoscopic cholecystectomy is not only unsuccessful in removing the burrowed stones in the cystic duct, but is also associated with a high risk of complications. Using a combination of ESWL & a novel endoscopic method, we were able to clear an impacted (burrowed) stone from the bile duct in a patient with Mirizzi syndrome following laparoscopic cholecystectomy. Materials and Methods: A 26 year-old-woman, with Mirizzi syndrome, underwent laparoscopic cholecystectomy & placement of a catheter into the cystic duct after a failed laparoscopic clearance of an impacted (burrowed) CBD stone at the cystic duct insertion. Even after multiple endoscopic & interventional radiological attempts, including mono-octanoin infusion in the hospital for 5 days, removal of the stone was unsuccessful. At this stage, she was referred to our center for another endoscopic attempt, as she refused surgery. After ESWL of the CBD stone, an ERCP was attempted to remove the stone. There was narrowing of the distal CBD, a low
Abstracts
2599
insertion of cystic duct, and the stone was in the common hepatic duct. With a balloon sweep, the stone moved down & got stuck in the narrow distal CBD. Repeat attempts to cannulate the CBD, even with a wire, were unsuccessful. A Jagwire was passed down the cystic duct through the cystic duct tract into the duodenum, & was brought out through the endoscope biopsy port. A balloon catheter was passed over the wire, from the abdominal wall, through the tract into the cystic duct. The balloon was inflated just above the stone in the CBD. After placing a clamp on the Jagwire, behind the balloon catheter & using a push & pull technique, the stone was removed from the CBD successfully. Half of the circumference of the stone was covered with ductal tissue indicating that the stone was burrowed in the wall of the duct. The patient tolerated the procedure well with out any complications. Conclusions: A combination of ESWL and a novel endoscopic technique helped to solve the issue. A collaborative effort (with radiologists & urologists) is useful in the management of difficult biliary stone disease.
647 Intestinal Spirochetosis: Is it a commensal or a pathogen? Q. Tawfik, MD, Ph.D., G.S. Raju, MD. Department of Medicine & Pathology. Kansas University Medical Center, Kansas City, KS. Introduction: Intestinal Spirochetosis: Is it a commensal or a pathogen in the HIV infected men? That is the question. We present a case of chronic diarrhea and intestinal spirochetosis in a patient with HIV infection. Eradication of infection lead to the resolution of diarrhea, thereby confirming the pathogenic role of this organism. Materials and Methods: A 39-year-old man with HIV infection, without AIDS, presented with eight weeks of chronic non-bloody diarrhea. He denied rectal or esophageal symptoms, constitutional symptoms, abdominal pain and weight loss. There was no history of laxative or antacid use. He has not been put on any new medications prior to the onset of diarrhea. There was no change in his dietary habits. His other medical problems include chronic hepatitis C with cirrhosis, ascites, hiatal hernia and cerebral aneurysm. His colonoscopic examination, including the biopsies, was normal four years prior to this presentation. He was on spironolactone, dapsone, zerit, acyclovir, epivir, and viracept. Examination was remarkable for mild hepatomegaly and minimal ascites. The colonic mucosa was normal on colonoscopy. Colonic biopsies with H & E stains showed luminal organisms consistent with intestinal spirochetosis, with moderate chronic inflammation of the lamina propria and mild eosinophilia. PAS and Warthin-Starry Silver strains confirmed intestinal spirochetosis. His diarrhea completely resolved after a two-week course of metronidazole 500 mg three times a day. Eradication of intestinal spirochetosis was confirmed by repeat colonoscopic examination with multiple biopsies. He did not have any recurrence of symptoms on follow-up (6 months). Conclusions: Documentation of intestinal spirochetosis in this patient with chronic diarrhea, quick resolution of the diarrhea with the eradication of infection, and no further recurrence of diarrhea on follow-up argues in favor of a pathogenic role rather than an innocent bystander (commensal).
648 Laparoscopy assisted endoscopy (LAE) to define the lower extent of obstructive hypopharyngeal cancer M. Moncure, MD, G.S.G.S. Raju, MD, I. Ahmed, MBBS, G. Crawford, RN, J. Hershberger, RN, T. Tsue, MD, A. Merati, MD. Department of Medicine, Surgery & Otolaryngology, University of Kansas Medical Center, Kansas City, KS. Introduction: Diagnosis of the pharyngo-esophageal cancer & its extent is relatively straightforward. In some patients, with near complete obstruction at the pharyngo-esophageal junction, it is impossible to define the lower extent of the hypopharyngeal cancer with conventional endoscopy. Approaching the lesion from below, with laparoscopic assisted endoscopy, may be useful in defining the lower extent of the disease in patients with
Conclusions: Gastroenterologists have been assisting Otolaryngologists in the management of patients with head and neck cancer by placing PEG tubes. This fruitful collaboration may be extended to the placement of TEPs, as the endoscopic placement of TEP is simple, convenient, and easily accomplished. In addition one could avoid the need for general anesthesia. 645 EUS assisted gastric pacemaker (neurostimulator) implantation for gastroparesis G.S. Raju, MD, I. Sarosiek, MD, J. Forster, MD, S. Rosenthal, MD, Z. Lin MS, R. McCallum, MD. Department of Medicine, Radiology, and Surgery. Kansas Univ. Medical Ctr. Kansas City, KS. Introduction: Gastric neurostimulator implantation is one of the recent advances in the management of refractory gastroparesis. During the procedure electrodes are inserted into the muscular layer of the stomach. Care is taken to avoid penetration of the mucosa. Endoscopy and intra-operative surface ultrasound confirm positioning of the electrode. The former needs distension of the stomach, which interferes with the closure of abdomen from distended bowel loops, and, the latter produces an unsatisfactory image from reverberation artifacts. Endoscopic ultrasound overcomes both these problems as it provides excellent imaging of the layers of the stomach wall along with clear visualization of the mucosal aspect of the stomach. We describe the use of EUS to confirm the gastric pacemaker electrode placement. Materials and Methods: A 38-year-old woman with gastroparesis refractory to medical management was referred for gastric pacemaker implantation. A radial echo-endoscope was passed into the stomach under general anesthesia. Pacemaker wires were implanted into the stomach wall, avoiding mucosal puncture. The placement of the gastric pacemaker wires into the central muscular coat was confirmed by EUS. Endoscopic visualization of the area was also done to exclude mucosal penetration by the pacemaker wires. Once the positioning of the electrode was confirmed by endoscopy and also by the EUS, the wires were secured in the serosal layer. A total of 12 patients underwent gastric pacemaker implantation at our site. The last 5 underwent EUS assisted gastric pacemaker implantation. During the follow-up (3–12 mo), no problems were noted. Conclusions: EUS is useful to confirm the placement of the gastric neurostimulator (now approved to treat refractory gastroparesis) and is superior to imaging with intra-operative surface ultrasound. High frequency ultrasound probe may provide further improvement in the imaging. 646 Extra-corporeal shock wave lithotripsy (ESWL) plus a novel method of removal of a burrowed CBD stone in a patient with Mirizzi syndrome G. S. Raju, MD, Greg Crawford, RN, Brad Peck, RN, G. Cox, MD, E. Seigel, MD, B. Trasher, MD. Department of Medicine, Radiology and Urology, Kansas Univ. Medical Ctr. Kansas City, KS. Introduction: Open cholecystectomy is the treatment of choice for Mirizzi syndrome; laparoscopic cholecystectomy is not only unsuccessful in removing the burrowed stones in the cystic duct, but is also associated with a high risk of complications. Using a combination of ESWL & a novel endoscopic method, we were able to clear an impacted (burrowed) stone from the bile duct in a patient with Mirizzi syndrome following laparoscopic cholecystectomy. Materials and Methods: A 26 year-old-woman, with Mirizzi syndrome, underwent laparoscopic cholecystectomy & placement of a catheter into the cystic duct after a failed laparoscopic clearance of an impacted (burrowed) CBD stone at the cystic duct insertion. Even after multiple endoscopic & interventional radiological attempts, including mono-octanoin infusion in the hospital for 5 days, removal of the stone was unsuccessful. At this stage, she was referred to our center for another endoscopic attempt, as she refused surgery. After ESWL of the CBD stone, an ERCP was attempted to remove the stone. There was narrowing of the distal CBD, a low
Abstracts
2599
insertion of cystic duct, and the stone was in the common hepatic duct. With a balloon sweep, the stone moved down & got stuck in the narrow distal CBD. Repeat attempts to cannulate the CBD, even with a wire, were unsuccessful. A Jagwire was passed down the cystic duct through the cystic duct tract into the duodenum, & was brought out through the endoscope biopsy port. A balloon catheter was passed over the wire, from the abdominal wall, through the tract into the cystic duct. The balloon was inflated just above the stone in the CBD. After placing a clamp on the Jagwire, behind the balloon catheter & using a push & pull technique, the stone was removed from the CBD successfully. Half of the circumference of the stone was covered with ductal tissue indicating that the stone was burrowed in the wall of the duct. The patient tolerated the procedure well with out any complications. Conclusions: A combination of ESWL and a novel endoscopic technique helped to solve the issue. A collaborative effort (with radiologists & urologists) is useful in the management of difficult biliary stone disease.
647 Intestinal Spirochetosis: Is it a commensal or a pathogen? Q. Tawfik, MD, Ph.D., G.S. Raju, MD. Department of Medicine & Pathology. Kansas University Medical Center, Kansas City, KS. Introduction: Intestinal Spirochetosis: Is it a commensal or a pathogen in the HIV infected men? That is the question. We present a case of chronic diarrhea and intestinal spirochetosis in a patient with HIV infection. Eradication of infection lead to the resolution of diarrhea, thereby confirming the pathogenic role of this organism. Materials and Methods: A 39-year-old man with HIV infection, without AIDS, presented with eight weeks of chronic non-bloody diarrhea. He denied rectal or esophageal symptoms, constitutional symptoms, abdominal pain and weight loss. There was no history of laxative or antacid use. He has not been put on any new medications prior to the onset of diarrhea. There was no change in his dietary habits. His other medical problems include chronic hepatitis C with cirrhosis, ascites, hiatal hernia and cerebral aneurysm. His colonoscopic examination, including the biopsies, was normal four years prior to this presentation. He was on spironolactone, dapsone, zerit, acyclovir, epivir, and viracept. Examination was remarkable for mild hepatomegaly and minimal ascites. The colonic mucosa was normal on colonoscopy. Colonic biopsies with H & E stains showed luminal organisms consistent with intestinal spirochetosis, with moderate chronic inflammation of the lamina propria and mild eosinophilia. PAS and Warthin-Starry Silver strains confirmed intestinal spirochetosis. His diarrhea completely resolved after a two-week course of metronidazole 500 mg three times a day. Eradication of intestinal spirochetosis was confirmed by repeat colonoscopic examination with multiple biopsies. He did not have any recurrence of symptoms on follow-up (6 months). Conclusions: Documentation of intestinal spirochetosis in this patient with chronic diarrhea, quick resolution of the diarrhea with the eradication of infection, and no further recurrence of diarrhea on follow-up argues in favor of a pathogenic role rather than an innocent bystander (commensal).
648 Laparoscopy assisted endoscopy (LAE) to define the lower extent of obstructive hypopharyngeal cancer M. Moncure, MD, G.S.G.S. Raju, MD, I. Ahmed, MBBS, G. Crawford, RN, J. Hershberger, RN, T. Tsue, MD, A. Merati, MD. Department of Medicine, Surgery & Otolaryngology, University of Kansas Medical Center, Kansas City, KS. Introduction: Diagnosis of the pharyngo-esophageal cancer & its extent is relatively straightforward. In some patients, with near complete obstruction at the pharyngo-esophageal junction, it is impossible to define the lower extent of the hypopharyngeal cancer with conventional endoscopy. Approaching the lesion from below, with laparoscopic assisted endoscopy, may be useful in defining the lower extent of the disease in patients with