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Gastrointestinal Findings of Patients with Autoimmune Pancreatitis
Abstracts
T1353 Continuous Access Technique for Dilation, Evaluation, and Stent Palliation of Malignant Luminal Digestive Tract Strictures Ann Marie Joyce, Michael L. Kochman, Nuzhat Ahmad, Gregory G. Ginsberg Introduction: Endoluminal stent placement is an effective means of palliating malignant stenoses. Malignant stenoses in which there is complete obstruction, fistula, and/or inability to pass the endoscope present challenges to endoluminal stent therapy. It is advantageous to advance the endoscope through these malignant stenoses to precisely appreciate their localization, length, and configuration. These factors impact on stent selection and deployment. We define, and describe our experience with, a technique to establish and maintain continuous access to facilitate evaluation and stent placement in challenging malignant stenoses. Methods: The continuous access technique employs advancement of an 0.035$ Teflon coated coiled steel or hydrophilic coated nitinol guidewire under endoscopic and fluoroscopic guidance through the stenosis. A guidewire-compatible graded radial diameter through-the-scope balloon dilator is then advanced into the stenosis. Incremental balloon dilation is performed to 1-mm above the outside diameter of the endoscope. Then, with the inflated dilator snug to the tip of the endoscope, using the balloon dilator as an obturator tip, this assembly is advanced over the guidewire through the stenosis. The dilation catheter is then removed; the distal margin of the tumor marked; and stent placement performed. This Continuous Access (CA) technique was defined and detailed in the records of stent placement beginning in February 1999. We reviewed the records for techniques of all stent placements by two clinicians from Feb 1999 through Aug 2004. Results: There were 126 attempted stent placements for malignant strictures (96 Esophageal/EG junction, 22 Gastroduodenal, 8 Colorectal). In 75 (60%) the endoscope traversed the stricture with no dilation. In 13 (10%) the scope traversed after standard dilation was performed. In 8 (6%) stents were placed after only a guidewire was advanced across the stricture under fluoroscopic guidance. In 30 (24%), inability to advance the scope with or without standard dilation prompted use of the CA technique. CA technique was successful in traversing the stricture in 29 (1 failure,esophageal). A stent was successfully placed in all but one patient. There were no procedure related complications. Conclusion: The continuous access technique safely and effectively facilitates scope passage through strictures thereby enhancing precision in stent selection and deployment for palliation of challenging malignant stenoses.
T1355 Endoscopic Submucosal Dissection (ESD) Against Early Gastric Cancer Using Modified Intra-Gastric Lifting Method with Re-Opening Clip Device Yoshiro Kawahara, Atsushi Imagawa, Ryuta Takenaka, Shigeatsu Fujiki, Yasushi Shiratori Backgrounds: En-bloc resection is beneficial for accurate histological assessment of resected specimen of Endoscopic mucosal resection (EMR). Variable EMR methods were developed. Conventional EMR is technically simple and convenient, but the size of specimen obtained with this procedure is very limited. Endoscopic submucosal dissection (ESD) procedure using IT knife, Hook knife, Flex knife, etc. has already reported and it is actually useful for some expert endoscopists. However, it is difficult for general endoscopists to use it safely. Previously, Oyama et al. reported intra-gastric lifting method using conventional hemoclip device. This method is very effective, but it is complicated. So this method has not spread. Therefore we developed a safe and easy technique of the ESD using a modified intra-gastric lifting method with re-opening clip device (Resolution clip device, Boston Scientific, MA, USA). Methods: A flexible over tube was inserted with the endoscope. After place a marking around lesion, 10% glycerin with epinephrine and indigocarmine was injected into the submucosa. The circumferential cutting around the lesion was placed by the IT-knife, and then the endoscope was pulled out once. Next, Resolution clip device was inserted through a working channel till the outside of endoscope tip, then attach the nylon thread to the hole of the clip. Using this re-opening clip, the anal side of the lesion was grabbed exactly and the clip with thread was released. Since thread was come from oral side, counter traction was applied to the tissue. This counter traction created a greater view and wide margin of the submucosal cutting area, and the submucosal dissection was performed safely. Results: 15 cases of early gastric cancer patients received ESD using this method. En-bloc resection of the lesion succeeded in 14 cases. Dissection of the submucosa was very easily and quickly carried out. Operating time was approximately 50 minutes and shorter than conventional procedure. Minor bleeding including oozing occurred in 13.3% and no perforation encountered. Conclusion: Here we present a new technique of ESD using a modified intra-gastric lifting method with re-opening clip device, which can realize safer, easier, and less time-consuming ESD compared to previous methods. By using this method, general endoscopists may also be able to perform ESD safely.
T1354 Gastrointestinal Findings of Patients with Autoimmune Pancreatitis Terumi Kamisawa, Hitoshi Nakajima, Atsutake Okamoto Background and Study Aims: Autoimmune pancreatitis (AIP) is a recently proposed clinical entity in which autoimmune mechanisms are involved in pathogenesis. Although radiological findings in patients with AIP have been well evaluated, few studies have focused on gastrointestinal findings of AIP. The aim of this study is to examine and compare endoscopic and histological findings of the gastrointestinal tract in patients with autoimmune pancreatitis. Patients and Methods: We encountered 24 patients with AIP, diagnosed from the following criteria: enlargement of the pancreas (n Z 23), irregular narrowing of the main pancreatic duct (n Z 24), hypergammaglobulinemia (n Z 14), presence of autoantibodies (n Z 15), lymphoplasmacytic infiltration with fibrosis of the pancreas (n Z 11), and responsiveness to steroid therapy (n Z 11). We examined endoscopic findings of the stomach (n Z 10), duodenum (n Z 18), major duodenal papilla (n Z 18) and colon (n Z 5). These were compared with histological findings of the gastric mucosa (n Z 13), duodenal mucosa (n Z 9), major duodenal papilla (n Z 3), and colonic mucosa (n Z 3). Immunohistochemical studies using anti-CD4-T, CD8-T, IgG4 antibodies were performed in these specimens. Results: Slightly pale, thickened mucosa with loss of visible vascular pattern was observed focally in the stomach (n Z 4) and colon (n Z 2) on endoscopy. Moderate or slight swelling of the major duodenal papilla was detected in 5 patients. Moderate to slight lymphoplasmacytic infiltration was observed in the lamina propria of the gastric and colonic mucosa, and the major duodenal papilla. Infiltration of abundant IgG4positive plasma cells (more than 10/high power field) association with numerous CD4- or CD8-positive T lymphocytes was observed in the lamina propria of the stomach (n Z 7) and colon (n Z 2), and the major duodenal papilla (n Z 3), which was not observed in those of other diseases. Infiltration of abundant these inflammatory cells disappeared in the rebiopsied gastric mucosa after steroid therapy. Conclusions: Although no specific endoscopic findings in the stomach and colon were apparent in autoimmune pancreatitis, slightly pale, thickened mucosa with loss of visible vascular pattern was focally observed in some cases. This indistinct change on endoscopy seems to be induced by infiltration of abundant IgG4-positive plasma cells associated with CD4- or CD8-positive T lymphocytes in the lamina propria of the stomach and colon.
AB230 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1356 Toward Painless Colonoscopy: Propofol Plus Carbon Dioxide Mubashir H. Khan, William Kessler, Mouen Khashab, Viju Deenadayalu, Douglas Rex Background: Carbon dioxide insufflation during colonoscopy with narcotics and benzodiazepines has been shown to reduce post-procedure pain. The effect of carbon dioxide on pain after colonoscopy with propofol has not been measured. Aim: Determine the effect of carbon dioxide insufflation compared to air on post-procedure pain in patients undergoing colonoscopy with propofol. Methods: Seventy healthy outpatients scheduled for colonoscopy were randomized to air (n Z 42) vs. CO2 (n Z 38) insufflation. All were given propofol targeted to deep sedation by registered nurses supervised by endoscopists (NAPS). Post procedure, patients were monitored until discharge, (defined as alert, able to drink, able to walk, and absence of severe pain) and then were asked to rate intensity of pain on 100 mm visual analogue scales. Results: No significant difference was found between the CO2 and Air groups for ‘pain during procedure’ (p Z 0.55). For the post-procedure period, air was associated with more severe ‘worst pain score’ (p Z 0.002), higher ‘average pain score’ (p Z 0.004), and greater ‘pain at discharge’ (p Z 0.004) compared to CO2. Conclusion: Carbon dioxide insufflation reduces pain after colonoscopy with propofol. Propofol plus carbon dioxide provides the opportunity for near painless colonoscopy.
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T1353 Continuous Access Technique for Dilation, Evaluation, and Stent Palliation of Malignant Luminal Digestive Tract Strictures Ann Marie Joyce, Michael L. Kochman, Nuzhat Ahmad, Gregory G. Ginsberg Introduction: Endoluminal stent placement is an effective means of palliating malignant stenoses. Malignant stenoses in which there is complete obstruction, fistula, and/or inability to pass the endoscope present challenges to endoluminal stent therapy. It is advantageous to advance the endoscope through these malignant stenoses to precisely appreciate their localization, length, and configuration. These factors impact on stent selection and deployment. We define, and describe our experience with, a technique to establish and maintain continuous access to facilitate evaluation and stent placement in challenging malignant stenoses. Methods: The continuous access technique employs advancement of an 0.035$ Teflon coated coiled steel or hydrophilic coated nitinol guidewire under endoscopic and fluoroscopic guidance through the stenosis. A guidewire-compatible graded radial diameter through-the-scope balloon dilator is then advanced into the stenosis. Incremental balloon dilation is performed to 1-mm above the outside diameter of the endoscope. Then, with the inflated dilator snug to the tip of the endoscope, using the balloon dilator as an obturator tip, this assembly is advanced over the guidewire through the stenosis. The dilation catheter is then removed; the distal margin of the tumor marked; and stent placement performed. This Continuous Access (CA) technique was defined and detailed in the records of stent placement beginning in February 1999. We reviewed the records for techniques of all stent placements by two clinicians from Feb 1999 through Aug 2004. Results: There were 126 attempted stent placements for malignant strictures (96 Esophageal/EG junction, 22 Gastroduodenal, 8 Colorectal). In 75 (60%) the endoscope traversed the stricture with no dilation. In 13 (10%) the scope traversed after standard dilation was performed. In 8 (6%) stents were placed after only a guidewire was advanced across the stricture under fluoroscopic guidance. In 30 (24%), inability to advance the scope with or without standard dilation prompted use of the CA technique. CA technique was successful in traversing the stricture in 29 (1 failure,esophageal). A stent was successfully placed in all but one patient. There were no procedure related complications. Conclusion: The continuous access technique safely and effectively facilitates scope passage through strictures thereby enhancing precision in stent selection and deployment for palliation of challenging malignant stenoses.
T1355 Endoscopic Submucosal Dissection (ESD) Against Early Gastric Cancer Using Modified Intra-Gastric Lifting Method with Re-Opening Clip Device Yoshiro Kawahara, Atsushi Imagawa, Ryuta Takenaka, Shigeatsu Fujiki, Yasushi Shiratori Backgrounds: En-bloc resection is beneficial for accurate histological assessment of resected specimen of Endoscopic mucosal resection (EMR). Variable EMR methods were developed. Conventional EMR is technically simple and convenient, but the size of specimen obtained with this procedure is very limited. Endoscopic submucosal dissection (ESD) procedure using IT knife, Hook knife, Flex knife, etc. has already reported and it is actually useful for some expert endoscopists. However, it is difficult for general endoscopists to use it safely. Previously, Oyama et al. reported intra-gastric lifting method using conventional hemoclip device. This method is very effective, but it is complicated. So this method has not spread. Therefore we developed a safe and easy technique of the ESD using a modified intra-gastric lifting method with re-opening clip device (Resolution clip device, Boston Scientific, MA, USA). Methods: A flexible over tube was inserted with the endoscope. After place a marking around lesion, 10% glycerin with epinephrine and indigocarmine was injected into the submucosa. The circumferential cutting around the lesion was placed by the IT-knife, and then the endoscope was pulled out once. Next, Resolution clip device was inserted through a working channel till the outside of endoscope tip, then attach the nylon thread to the hole of the clip. Using this re-opening clip, the anal side of the lesion was grabbed exactly and the clip with thread was released. Since thread was come from oral side, counter traction was applied to the tissue. This counter traction created a greater view and wide margin of the submucosal cutting area, and the submucosal dissection was performed safely. Results: 15 cases of early gastric cancer patients received ESD using this method. En-bloc resection of the lesion succeeded in 14 cases. Dissection of the submucosa was very easily and quickly carried out. Operating time was approximately 50 minutes and shorter than conventional procedure. Minor bleeding including oozing occurred in 13.3% and no perforation encountered. Conclusion: Here we present a new technique of ESD using a modified intra-gastric lifting method with re-opening clip device, which can realize safer, easier, and less time-consuming ESD compared to previous methods. By using this method, general endoscopists may also be able to perform ESD safely.
T1354 Gastrointestinal Findings of Patients with Autoimmune Pancreatitis Terumi Kamisawa, Hitoshi Nakajima, Atsutake Okamoto Background and Study Aims: Autoimmune pancreatitis (AIP) is a recently proposed clinical entity in which autoimmune mechanisms are involved in pathogenesis. Although radiological findings in patients with AIP have been well evaluated, few studies have focused on gastrointestinal findings of AIP. The aim of this study is to examine and compare endoscopic and histological findings of the gastrointestinal tract in patients with autoimmune pancreatitis. Patients and Methods: We encountered 24 patients with AIP, diagnosed from the following criteria: enlargement of the pancreas (n Z 23), irregular narrowing of the main pancreatic duct (n Z 24), hypergammaglobulinemia (n Z 14), presence of autoantibodies (n Z 15), lymphoplasmacytic infiltration with fibrosis of the pancreas (n Z 11), and responsiveness to steroid therapy (n Z 11). We examined endoscopic findings of the stomach (n Z 10), duodenum (n Z 18), major duodenal papilla (n Z 18) and colon (n Z 5). These were compared with histological findings of the gastric mucosa (n Z 13), duodenal mucosa (n Z 9), major duodenal papilla (n Z 3), and colonic mucosa (n Z 3). Immunohistochemical studies using anti-CD4-T, CD8-T, IgG4 antibodies were performed in these specimens. Results: Slightly pale, thickened mucosa with loss of visible vascular pattern was observed focally in the stomach (n Z 4) and colon (n Z 2) on endoscopy. Moderate or slight swelling of the major duodenal papilla was detected in 5 patients. Moderate to slight lymphoplasmacytic infiltration was observed in the lamina propria of the gastric and colonic mucosa, and the major duodenal papilla. Infiltration of abundant IgG4positive plasma cells (more than 10/high power field) association with numerous CD4- or CD8-positive T lymphocytes was observed in the lamina propria of the stomach (n Z 7) and colon (n Z 2), and the major duodenal papilla (n Z 3), which was not observed in those of other diseases. Infiltration of abundant these inflammatory cells disappeared in the rebiopsied gastric mucosa after steroid therapy. Conclusions: Although no specific endoscopic findings in the stomach and colon were apparent in autoimmune pancreatitis, slightly pale, thickened mucosa with loss of visible vascular pattern was focally observed in some cases. This indistinct change on endoscopy seems to be induced by infiltration of abundant IgG4-positive plasma cells associated with CD4- or CD8-positive T lymphocytes in the lamina propria of the stomach and colon.
AB230 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1356 Toward Painless Colonoscopy: Propofol Plus Carbon Dioxide Mubashir H. Khan, William Kessler, Mouen Khashab, Viju Deenadayalu, Douglas Rex Background: Carbon dioxide insufflation during colonoscopy with narcotics and benzodiazepines has been shown to reduce post-procedure pain. The effect of carbon dioxide on pain after colonoscopy with propofol has not been measured. Aim: Determine the effect of carbon dioxide insufflation compared to air on post-procedure pain in patients undergoing colonoscopy with propofol. Methods: Seventy healthy outpatients scheduled for colonoscopy were randomized to air (n Z 42) vs. CO2 (n Z 38) insufflation. All were given propofol targeted to deep sedation by registered nurses supervised by endoscopists (NAPS). Post procedure, patients were monitored until discharge, (defined as alert, able to drink, able to walk, and absence of severe pain) and then were asked to rate intensity of pain on 100 mm visual analogue scales. Results: No significant difference was found between the CO2 and Air groups for ‘pain during procedure’ (p Z 0.55). For the post-procedure period, air was associated with more severe ‘worst pain score’ (p Z 0.002), higher ‘average pain score’ (p Z 0.004), and greater ‘pain at discharge’ (p Z 0.004) compared to CO2. Conclusion: Carbon dioxide insufflation reduces pain after colonoscopy with propofol. Propofol plus carbon dioxide provides the opportunity for near painless colonoscopy.
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