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Mo1508 Adventures in the Gallbladder! Initial Experience of Advanced Gallbladder Interventions After Gallbladder Stenting
Abstracts
Mo1507 A Comparative Randomized Trial of Pre-Emptive Dexamethasone for Relief of Pain After Endoscopic Submucosal Dissection for Early Gastric Neoplasm Jeung Hui Pyo*, Hyuk Lee, Yang Won Min, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
advanced gallbladder interventions were feasible and safe. An array of procedures can be performed such as stone removal, laser lithotripsy, magnifying narrow band imaging, confocal microscopy, EUS and cholecystogram. This opens up exciting possibilities for endoscopic treatment of gallbladder stones and polyps.
Background and Aims: Although pain is a common complication of endoscopic submucosal dissection (ESD), management strategies are inadequate. Our prior research indicated that single-dose postoperative intravenous dexamethasone after ESD effectively relieved epigastric pain (Surg Endosc. 2014 Aug;28(8):2334-41). Transmission of pain signals evoked by tissue damage leads to sensitization of the peripheral and central pain pathways. Pre-emptive analgesia is a treatment that is initiated before the surgical procedure in order to reduce this sensitization. In this respect, it was known that preoperative administration of dexamethasone appears to produce a more consistent analgesic effect compared with intraoperative administration. Therefore, we aimed to compare the clinical effect of the pre-emptive and postoperative dexamethasone on pain after ESD for early gastric neoplasm. Methods: Forty patients with early gastric neoplasm scheduled for ESD were randomized into two groups: group I patients (n Z 20) were given 0.15 mg/kg dexamethasone intravenously before ESD and placebo after ESD, while group II patients (n Z 20) received a matching to pre-ESD placebo and post-ESD dexamethasone at the same scheme. In this double-blinded, placebo-controlled trial, patients completed a questionnaire about present pain intensity (PPI) and short-form McGill pain (SF-MP) categories for immediate and 6-, 12-, and 24-h postoperative periods. The primary outcome variable was PPI at 6 h following ESD. Secondary outcome variables included pain medication, SF-MP scores, complications, second-look endoscopic findings, and length of stay. Results: The mean 6-h PPI value was significantly lower (p Z 0.037) in the group I (1.32 0.15) than in the group II (1.81 0.17). The total 6-h SF-MP score, especially the sensory domain, was higher (p Z 0.031) in the group II (9.83 0.81) than in the group I (7.54 0.63). Frequency of additional tramadol injection for epigastric pain relief was not different between two groups (10.0% vs. 15.0%, p Z 0.633). No differences were noted between groups in length of stay or complications, including acute or delayed bleeding. The distribution of artificial ulcer patterns at 48-h post-ESD as determined by second-look endoscopy was similar in both groups. Conclusion: Our data suggest that pre-emptive administration of dexamethasone appears to produce a more superior analgesic effect compared with postoperative administration in ESD for early gastric neoplasm.
Mo1508 Adventures in the Gallbladder! Initial Experience of Advanced Gallbladder Interventions After Gallbladder Stenting Shannon M. Chan*1,2, Anthony Y. Teoh1,2, James Y. Lau1,2, Philip W. Chiu1,2, Enders K. Ng1,2 1 General Surgery, Prince of Wales Hospital, Hong Kong, Hong Kong; 2 General Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong Background and Aims: Traditionally, endoscopy of the gallbladder is not possible. However, the recent development of endosonographic (EUS) - guided gallbladder drainage with a lumen apposing stent (AXIOS, Xlumena, USA) made endoscopic assessment and advanced gallbladder interventions via the stent possible. The aim of this study was to assess the feasibility and safety of cholecystoscopy and the types of interventions that can be performed in these patients. Methods: This was a retrospective review conducted in the Prince of Wales Hospital from 1st June, 2012 to 31st October 2014. All patients that suffered from acute cholecystitis with EUS-guided transgastric or transduodenal gallbladder drainage and placement of a lumen apposing stent (AXIOS, Xlumena, USA) were included. Cholecystoscopy was performed in these patients 3 months after insertion to check for clearance of stones and removal of stent. Patients’ demographic data, the feasibility, complications and types of intervention were recorded. Results: 17 patients had the lumen-apposing stent inserted within the study period. 15 cholecystoscopes were performed, 2 on the same patient and 2 were unsuccessful. 1 was due to obstruction by gallstone, the other was due to angulation. Two of the procedures were performed a few days after insertion of AXIOS stent for clearance of sludge and stones to facilitate drainage. 4 cases had residual gallstones removed. One patient had a 2cm gallstone with laser lithotripsy performed and complete stone removal. Cholecystogram was performed in 6 patients, one of which showed common bile duct stone (CBD). ERCP was performed in the same session and the CBD stone removed. Magnifying endoscopy was performed in 8 patients and confocal microscopy and EUS in one. A highly suspicious polypoid growth was detected in one patient with confocal imaging and biopsy showing adenomatous fragments with high-grade dysplasia. Invasion of the muscularis propria was also suspected on EUS. One patient suffered from cholangitis after the procedure. Conclusion: Cholecystoscopy and
AB446 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Mo1509 The Usefulness of the Clip-and-snare Method With a Pre-Looping Technique During Colorectal Endoscopic Submucosal Dissection Hiroyoshi Nakanishi*, Shinya Yamada, Naohiro Yoshida, Shigetsugu Tsuji, Yasuhito Takeda, Hisashi Doyama Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa-shi, Japan Background and Aims: Colorectal endoscopic submucosal dissection (ESD) is technically challenging. The clip-and-snare method (CSM), a traction method used during gastric ESD, is one of the more promising techniques to achieve ESD more easily and safely (Yasuda M. et al. Gastrointest Endosc 2012;75:AB244). However, this method requires additional forceps to deliver the snare to the clip and is sometimes difficult. We improved this process by using a pre-looping technique (PLT) (Yoshida N. et al. Endoscopy, in press). The aim of this study was to verify the usefulness of the CSM with PLT for colorectal ESD. Methods: We compared 18 colorectal tumors treated using the CSM with PLT during ESD from November 2013 to September 2014 with 18 matched tumors as controls treated without this method from August 2009 to November 2013. Matching factors were the location, size, and presence of fibrosis. We evaluated the ESD time, the en bloc resection rate, and the complication rate. The procedure of the CSM with PLT was as follows: After circumferential cutting, the scope was withdrawn once to pre-loop a snare (SD221U-25; Olympus Medical Systems, Tokyo, Japan) over the attachment on the tip of the scope. The scope and snare were reinserted up to the tumor. A reusable clip deployment device (EZ Clip; Olympus) and a hemoclip (HX-610-090; Olympus) were inserted through the endoscope channel and used to grasp the mucosal flap of the tumor. The pre-looping snare was then loosened from the attachment, with care taken not to release the hemoclip completely from the device, and then moved along the device toward the hemoclip. We then tightened the snare to grasp the
www.giejournal.org
Mo1507 A Comparative Randomized Trial of Pre-Emptive Dexamethasone for Relief of Pain After Endoscopic Submucosal Dissection for Early Gastric Neoplasm Jeung Hui Pyo*, Hyuk Lee, Yang Won Min, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
advanced gallbladder interventions were feasible and safe. An array of procedures can be performed such as stone removal, laser lithotripsy, magnifying narrow band imaging, confocal microscopy, EUS and cholecystogram. This opens up exciting possibilities for endoscopic treatment of gallbladder stones and polyps.
Background and Aims: Although pain is a common complication of endoscopic submucosal dissection (ESD), management strategies are inadequate. Our prior research indicated that single-dose postoperative intravenous dexamethasone after ESD effectively relieved epigastric pain (Surg Endosc. 2014 Aug;28(8):2334-41). Transmission of pain signals evoked by tissue damage leads to sensitization of the peripheral and central pain pathways. Pre-emptive analgesia is a treatment that is initiated before the surgical procedure in order to reduce this sensitization. In this respect, it was known that preoperative administration of dexamethasone appears to produce a more consistent analgesic effect compared with intraoperative administration. Therefore, we aimed to compare the clinical effect of the pre-emptive and postoperative dexamethasone on pain after ESD for early gastric neoplasm. Methods: Forty patients with early gastric neoplasm scheduled for ESD were randomized into two groups: group I patients (n Z 20) were given 0.15 mg/kg dexamethasone intravenously before ESD and placebo after ESD, while group II patients (n Z 20) received a matching to pre-ESD placebo and post-ESD dexamethasone at the same scheme. In this double-blinded, placebo-controlled trial, patients completed a questionnaire about present pain intensity (PPI) and short-form McGill pain (SF-MP) categories for immediate and 6-, 12-, and 24-h postoperative periods. The primary outcome variable was PPI at 6 h following ESD. Secondary outcome variables included pain medication, SF-MP scores, complications, second-look endoscopic findings, and length of stay. Results: The mean 6-h PPI value was significantly lower (p Z 0.037) in the group I (1.32 0.15) than in the group II (1.81 0.17). The total 6-h SF-MP score, especially the sensory domain, was higher (p Z 0.031) in the group II (9.83 0.81) than in the group I (7.54 0.63). Frequency of additional tramadol injection for epigastric pain relief was not different between two groups (10.0% vs. 15.0%, p Z 0.633). No differences were noted between groups in length of stay or complications, including acute or delayed bleeding. The distribution of artificial ulcer patterns at 48-h post-ESD as determined by second-look endoscopy was similar in both groups. Conclusion: Our data suggest that pre-emptive administration of dexamethasone appears to produce a more superior analgesic effect compared with postoperative administration in ESD for early gastric neoplasm.
Mo1508 Adventures in the Gallbladder! Initial Experience of Advanced Gallbladder Interventions After Gallbladder Stenting Shannon M. Chan*1,2, Anthony Y. Teoh1,2, James Y. Lau1,2, Philip W. Chiu1,2, Enders K. Ng1,2 1 General Surgery, Prince of Wales Hospital, Hong Kong, Hong Kong; 2 General Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong Background and Aims: Traditionally, endoscopy of the gallbladder is not possible. However, the recent development of endosonographic (EUS) - guided gallbladder drainage with a lumen apposing stent (AXIOS, Xlumena, USA) made endoscopic assessment and advanced gallbladder interventions via the stent possible. The aim of this study was to assess the feasibility and safety of cholecystoscopy and the types of interventions that can be performed in these patients. Methods: This was a retrospective review conducted in the Prince of Wales Hospital from 1st June, 2012 to 31st October 2014. All patients that suffered from acute cholecystitis with EUS-guided transgastric or transduodenal gallbladder drainage and placement of a lumen apposing stent (AXIOS, Xlumena, USA) were included. Cholecystoscopy was performed in these patients 3 months after insertion to check for clearance of stones and removal of stent. Patients’ demographic data, the feasibility, complications and types of intervention were recorded. Results: 17 patients had the lumen-apposing stent inserted within the study period. 15 cholecystoscopes were performed, 2 on the same patient and 2 were unsuccessful. 1 was due to obstruction by gallstone, the other was due to angulation. Two of the procedures were performed a few days after insertion of AXIOS stent for clearance of sludge and stones to facilitate drainage. 4 cases had residual gallstones removed. One patient had a 2cm gallstone with laser lithotripsy performed and complete stone removal. Cholecystogram was performed in 6 patients, one of which showed common bile duct stone (CBD). ERCP was performed in the same session and the CBD stone removed. Magnifying endoscopy was performed in 8 patients and confocal microscopy and EUS in one. A highly suspicious polypoid growth was detected in one patient with confocal imaging and biopsy showing adenomatous fragments with high-grade dysplasia. Invasion of the muscularis propria was also suspected on EUS. One patient suffered from cholangitis after the procedure. Conclusion: Cholecystoscopy and
AB446 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Mo1509 The Usefulness of the Clip-and-snare Method With a Pre-Looping Technique During Colorectal Endoscopic Submucosal Dissection Hiroyoshi Nakanishi*, Shinya Yamada, Naohiro Yoshida, Shigetsugu Tsuji, Yasuhito Takeda, Hisashi Doyama Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa-shi, Japan Background and Aims: Colorectal endoscopic submucosal dissection (ESD) is technically challenging. The clip-and-snare method (CSM), a traction method used during gastric ESD, is one of the more promising techniques to achieve ESD more easily and safely (Yasuda M. et al. Gastrointest Endosc 2012;75:AB244). However, this method requires additional forceps to deliver the snare to the clip and is sometimes difficult. We improved this process by using a pre-looping technique (PLT) (Yoshida N. et al. Endoscopy, in press). The aim of this study was to verify the usefulness of the CSM with PLT for colorectal ESD. Methods: We compared 18 colorectal tumors treated using the CSM with PLT during ESD from November 2013 to September 2014 with 18 matched tumors as controls treated without this method from August 2009 to November 2013. Matching factors were the location, size, and presence of fibrosis. We evaluated the ESD time, the en bloc resection rate, and the complication rate. The procedure of the CSM with PLT was as follows: After circumferential cutting, the scope was withdrawn once to pre-loop a snare (SD221U-25; Olympus Medical Systems, Tokyo, Japan) over the attachment on the tip of the scope. The scope and snare were reinserted up to the tumor. A reusable clip deployment device (EZ Clip; Olympus) and a hemoclip (HX-610-090; Olympus) were inserted through the endoscope channel and used to grasp the mucosal flap of the tumor. The pre-looping snare was then loosened from the attachment, with care taken not to release the hemoclip completely from the device, and then moved along the device toward the hemoclip. We then tightened the snare to grasp the
www.giejournal.org