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Mo1570 Endoscopic Management of Upper GI Fistulae or Leaks: Exactly How Well Are WE Doing?
Abstracts
patient’s upper GI anatomy was the following: gastric bypass (nZ4), Whipple’s (nZ4), Billroth II (nZ5), Ivor-Lewis (nZ3), gastric sleeve with leak (nZ3), several anastomosis-undefined post-surgical status (nZ2). The technical success was 90%. In two patients transillumination was not obtainable and placement failed. The mean distance of DPEJ was 70 cm (range 45 to 110 cm) past the gastrojejunal anastomosis. The mean procedure time was 35 minutes (range 20-110). There were no major adverse events associated with the procedure. Conclusions: To the best of our knowledge this is the largest study using DPEJ in patients with complex surgically altered upper GI tract anatomy. The novel technique using overtube- and fluoroscopy was efficacious, safe and successful. Future comparative studies are now warranted
Mo1569 Barrett’s Esophagus After Sleeve Gastrectomy for Morbid Obesity: Preliminary Results Alfred Genco*1, Emanuele Soricelli1, Roberta Maselli1, Giovanni Casella1, Massimiliano Cipriano1, Giovanni Baglio2, Giuseppe Leone1, Nicola Basso1, Adriano Redler1 1 Department of Surgical Sciences, “Sapienza” University of Rome, Rome, Italy; 2Public Healthcare Agency of Lazio, Rome, Italy Introduction: Barrett’s esophagus (BE) is present in !1-4% of patients. Sleeve gastrectomy (SG) has been shown to be effective in weight loss and DMTII, but its effect on gastroesophageal-reflux-disease (GERD) has been inconsistent. Objectives: We investigated whether GERD after SG could predict progression to BE in a prospective cohort of patients. These are the early results of a prospective ongoing evaluation. Methods: SG patients were called and an upper endoscopy (UE) was performed (Group-A). The control group (Group-B) was composed by obese patients, who did not undergo bariatric-procedures. GERD-symptoms, PPI therapy and BMI were collected. Biopsies of the “Z line” were taken. BE was histologically evaluated and compared between the groups. Results: Group-A was composed by 106 patients (mean follow-up 51 months, M/F 30/76, BMI at SG 47.3kg/m2, follow-up BMI 31.3kg/m2), while Group-B by 98 patients (M/F 87/11, BMI 43.5kg/m2).In Group-A and Group-B GERD symptoms were present in 66% and 55%. An intrathoracic sleeve migration was noted in 78%. LA-esophagitis percentage was: LA-B 18.8% and 22.5%, LA-C 37.7% and 0%, LA-D 22.6% and 0%, in GroupA and GroupB respectively. BE Histological diagnosis was 16.98% in Group-A and 0.98% in GroupB. Conclusion: Our results show that 80% of patients submitted to SG had a mild-tosevere esophagitis, not corresponding to reflux symptoms, and 16.9% of them had a histologically confirmed Barrett esophagus. Whether these results will be confirmed, SG should be considered a reflux-inducing bariatric procedure, a very close followup should be performed to avoid Barrett-related dysplasia progression and a modification in the surgical procedure should be considered
Mo1570 Endoscopic Management of Upper GI Fistulae or Leaks: Exactly How Well Are WE Doing? Sami A. Almaskeen*, Atul Khanna, Laith H. Jamil, Kapil Gupta, Simon K. Lo Gastroenterology - Interventional Endoscopy, Cedars-Sinai Medical Center, Los Angeles, CA Background: Gastrointestinal perforation and fistulae are increasingly referred to GI interventionists for endoscopic treatment. These cases are typically difficult to manage, and the treatment options vary according to practice preference and individual experience. Aim: to examine our single center endoscopic experience in managing upper GI fistulae or leaks. Methods: Retrospective review of our records from 1/2012 to 11/2014. All upper endoscopies performed by our interventional GI group were reviewed individually through electronic medical records. Keywords in reports containing fistula, perforation, or leak would prompt further review to confirm appropriateness to include in this evaluation. All charts were traced to conclusions including death, definitive surgical intervention or successful complete closure. Results: 41 patients were identified. Fistulae or leaks were grouped by UGI regions: Esophagus (E)-11, Esophagogastric/esophagojejunal (EGJ)-7, gastric (G)-17, duodenal (D)-6. Seven patients are currently undergoing active treatment. Of 34 cases that had concluded their treatment courses, 10 (29.4%) had died; 6 (60%) of those deaths were felt to be the direct results of these fistulae or leaks. Duodenal leak was linked to high mortality (D-67%, E-57%, G-13%, EGJ-0%). 21/34 (61.7%) of completed cases had the defects successfully closed. Of the 4 location groups, EGJ defects seemed to have better outcome than the rest, although the difference did not reach statistical significance (Fisher’s exact test pZ0.06). In total, 149 endoscopic procedures were performed, with mean of 3.6 procedures per patient. There was no difference in the number of procedures per patient for each of the 4 groups (one way ANOVA, pZ0.23). The median number of days taken to conclude treatment in those 34 patients was 74.5 days (7-585). It took a significantly longer time (165 days) to close EGJ leaks than those in E, G or D (75, 62.5 and 54 days. One way ANOVA, pZ0.01). There was no difference in the number of days taken to complete the courses of treatment among the 4 groups (one way ANOVA, pZ0.79). Clips, over-the-scope clip (OTSC), suture (started only recently) and stents were the 4 methods used to close the leaks. Effective closure was eventually achieved by OTSC
AB470 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
in 5 and stents in 16 patients. The sizes of defects successfully closed by OTSC were all rated by endoscopists as small (%1 cm); those treated successfully by stenting included 5 defects rated as large. Conclusions: Upper GI leaks or fistulae carry high risks of mortality and prolonged morbidities. Endoscopic treatment is effective in closing 2/3 of these leaks, with stenting being the most effective modality. While EGJ leaks seem most favorable for endoscopic closure, they also require a significantly longer time to close than leaks in the other upper GI locations.
Results of endoscopic treatment in 34 upper GI leaks that had completed their courses of treatment Location
E
EGJ
G
D
P value
Median # sessions to effective closure Median # days to completing treatment course (including deaths) Median # days to successful closure Deaths
2 75
4 165
3 59
2 62
NS NS
75 4/7 (57%)
165 0/6 (0%)
62.5 2/15 (13%)
54 4/6 (67%)
0.01 –
Mo1571 Endoscopic Treatment of Intragastric Migration of Laparoscopic Adjustable Gastric Banding. the Experience of a Spanish Non Tertiary Hospital Marisa Arias, Luis R. Rábago*, Luis Alonso, Castillo Herrera, Ana Olivares, Alejandro Ortega, Miguel Perez, Jaime Vazquez-Echarri Gastroenterology, Hospital Severo Ochoa, Leganes, Spain Introduction: The intragastric band migration is an uncommon complication of Laparoscopic Adjustable Gastric Banding (LAGB) (0.5-11%) usually resolved by surgical approach. We describe our experience of its successful endoscopic removal. Patients and Methods: Since 2001 we treated 127 morbid obese patients (pts) by LAGB. Those pts with migration of gastric band into stomach more than 50% of circumference were treated. The procedure was performed under general anesthesia with an standard gastroscope. We did not use fluoroscopy.First the band is cut using the cable from mechanical lithotripsy basket (MTW) or a standard 0.035 inch guidewire. Second the wire is looped about the visible the band, grasped by the alligator forceps and brought out through the patient’s mouth. Then the two ends of the wire are placed into the metal sheath of the mechanical lithotriptor (MTW) with progressively tightening about the band in order to cut it. The remaining external tubing and external port is now excised and removed by surgeon. Finally the split band is removed using a polypectomy snare. We did not use fluoroscopy. Results: We found that 11 out of 127 LAGB (8,6%) become symptomatic due to gastric migration. 88.8% were females with average of 42.6 yo. The time between the band placement and endoscopic removal was 60,5 months (29-120). The symptoms were epigastric pain and weight regain as a sign of band dysfunction.Three pts were operated, one refused endoscopic treatment and the other were operated by band dysfunction finding out the gastric migration. 7 out of 9 LAGB (77.7%) were endoscopically removed in one session.We had two failures,1 out of 9 LAGB (11.1%) was not possible to cut and the other (11,1%) was split but not removed due to difficulties with ventilation by excessive gas insufflation. His recovery from the attempt was uneventful and she remains well after 7 years of follow up, waiting for their possible complete migration. No complications were noticed after the endoscopic removal and pts were discharged in average of 2,6 days(1-7). Mortality 0%. The band removal was accomplished in three steps: a) cutting the band of silicone in their middle part avoiding the plastic part near the external tube, b) seizing the end of the splitted band near the external tube, coming from the port and c) pulling the endoscope out steadily and forcefully to liberate the band from the gastric wall. Conclusions: More than 8,6% of LAGB will have gastric migration and develop symptoms .The endoscopic removal of LAGB is feasible, safe, but not easy, being a good alternative to surgery. We were able to remove 77,7% of LAGB, but the band should be migrated more than 50%. It is important to know very well the removal technique and their tricks. It is not necessary the use of intraoperative fluoroscopy and it seems to be safe to cut the band without their removal
Mo1572 A Validated, Computerized Cleansing Score for Video Capsule Endoscopy Amir Klein*1, Moshe Gizbar3, Michael J. Bourke1,2, Golo Ahlenstiel1,2 1 Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2University of Sydney, Sydney, NSW, Australia; 3, Sydney, NSW, Australia Background: Video capsule endoscopy (VCE) is a useful diagnostic tool for the investigation of small bowel (SB) pathology. The diagnostic yield (DY) of VCE, may be hampered by the presence of intestinal content or air bubbles. There is a lack of consensus regarding necessity of active bowel preparation and the optimal regimen.
www.giejournal.org
patient’s upper GI anatomy was the following: gastric bypass (nZ4), Whipple’s (nZ4), Billroth II (nZ5), Ivor-Lewis (nZ3), gastric sleeve with leak (nZ3), several anastomosis-undefined post-surgical status (nZ2). The technical success was 90%. In two patients transillumination was not obtainable and placement failed. The mean distance of DPEJ was 70 cm (range 45 to 110 cm) past the gastrojejunal anastomosis. The mean procedure time was 35 minutes (range 20-110). There were no major adverse events associated with the procedure. Conclusions: To the best of our knowledge this is the largest study using DPEJ in patients with complex surgically altered upper GI tract anatomy. The novel technique using overtube- and fluoroscopy was efficacious, safe and successful. Future comparative studies are now warranted
Mo1569 Barrett’s Esophagus After Sleeve Gastrectomy for Morbid Obesity: Preliminary Results Alfred Genco*1, Emanuele Soricelli1, Roberta Maselli1, Giovanni Casella1, Massimiliano Cipriano1, Giovanni Baglio2, Giuseppe Leone1, Nicola Basso1, Adriano Redler1 1 Department of Surgical Sciences, “Sapienza” University of Rome, Rome, Italy; 2Public Healthcare Agency of Lazio, Rome, Italy Introduction: Barrett’s esophagus (BE) is present in !1-4% of patients. Sleeve gastrectomy (SG) has been shown to be effective in weight loss and DMTII, but its effect on gastroesophageal-reflux-disease (GERD) has been inconsistent. Objectives: We investigated whether GERD after SG could predict progression to BE in a prospective cohort of patients. These are the early results of a prospective ongoing evaluation. Methods: SG patients were called and an upper endoscopy (UE) was performed (Group-A). The control group (Group-B) was composed by obese patients, who did not undergo bariatric-procedures. GERD-symptoms, PPI therapy and BMI were collected. Biopsies of the “Z line” were taken. BE was histologically evaluated and compared between the groups. Results: Group-A was composed by 106 patients (mean follow-up 51 months, M/F 30/76, BMI at SG 47.3kg/m2, follow-up BMI 31.3kg/m2), while Group-B by 98 patients (M/F 87/11, BMI 43.5kg/m2).In Group-A and Group-B GERD symptoms were present in 66% and 55%. An intrathoracic sleeve migration was noted in 78%. LA-esophagitis percentage was: LA-B 18.8% and 22.5%, LA-C 37.7% and 0%, LA-D 22.6% and 0%, in GroupA and GroupB respectively. BE Histological diagnosis was 16.98% in Group-A and 0.98% in GroupB. Conclusion: Our results show that 80% of patients submitted to SG had a mild-tosevere esophagitis, not corresponding to reflux symptoms, and 16.9% of them had a histologically confirmed Barrett esophagus. Whether these results will be confirmed, SG should be considered a reflux-inducing bariatric procedure, a very close followup should be performed to avoid Barrett-related dysplasia progression and a modification in the surgical procedure should be considered
Mo1570 Endoscopic Management of Upper GI Fistulae or Leaks: Exactly How Well Are WE Doing? Sami A. Almaskeen*, Atul Khanna, Laith H. Jamil, Kapil Gupta, Simon K. Lo Gastroenterology - Interventional Endoscopy, Cedars-Sinai Medical Center, Los Angeles, CA Background: Gastrointestinal perforation and fistulae are increasingly referred to GI interventionists for endoscopic treatment. These cases are typically difficult to manage, and the treatment options vary according to practice preference and individual experience. Aim: to examine our single center endoscopic experience in managing upper GI fistulae or leaks. Methods: Retrospective review of our records from 1/2012 to 11/2014. All upper endoscopies performed by our interventional GI group were reviewed individually through electronic medical records. Keywords in reports containing fistula, perforation, or leak would prompt further review to confirm appropriateness to include in this evaluation. All charts were traced to conclusions including death, definitive surgical intervention or successful complete closure. Results: 41 patients were identified. Fistulae or leaks were grouped by UGI regions: Esophagus (E)-11, Esophagogastric/esophagojejunal (EGJ)-7, gastric (G)-17, duodenal (D)-6. Seven patients are currently undergoing active treatment. Of 34 cases that had concluded their treatment courses, 10 (29.4%) had died; 6 (60%) of those deaths were felt to be the direct results of these fistulae or leaks. Duodenal leak was linked to high mortality (D-67%, E-57%, G-13%, EGJ-0%). 21/34 (61.7%) of completed cases had the defects successfully closed. Of the 4 location groups, EGJ defects seemed to have better outcome than the rest, although the difference did not reach statistical significance (Fisher’s exact test pZ0.06). In total, 149 endoscopic procedures were performed, with mean of 3.6 procedures per patient. There was no difference in the number of procedures per patient for each of the 4 groups (one way ANOVA, pZ0.23). The median number of days taken to conclude treatment in those 34 patients was 74.5 days (7-585). It took a significantly longer time (165 days) to close EGJ leaks than those in E, G or D (75, 62.5 and 54 days. One way ANOVA, pZ0.01). There was no difference in the number of days taken to complete the courses of treatment among the 4 groups (one way ANOVA, pZ0.79). Clips, over-the-scope clip (OTSC), suture (started only recently) and stents were the 4 methods used to close the leaks. Effective closure was eventually achieved by OTSC
AB470 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
in 5 and stents in 16 patients. The sizes of defects successfully closed by OTSC were all rated by endoscopists as small (%1 cm); those treated successfully by stenting included 5 defects rated as large. Conclusions: Upper GI leaks or fistulae carry high risks of mortality and prolonged morbidities. Endoscopic treatment is effective in closing 2/3 of these leaks, with stenting being the most effective modality. While EGJ leaks seem most favorable for endoscopic closure, they also require a significantly longer time to close than leaks in the other upper GI locations.
Results of endoscopic treatment in 34 upper GI leaks that had completed their courses of treatment Location
E
EGJ
G
D
P value
Median # sessions to effective closure Median # days to completing treatment course (including deaths) Median # days to successful closure Deaths
2 75
4 165
3 59
2 62
NS NS
75 4/7 (57%)
165 0/6 (0%)
62.5 2/15 (13%)
54 4/6 (67%)
0.01 –
Mo1571 Endoscopic Treatment of Intragastric Migration of Laparoscopic Adjustable Gastric Banding. the Experience of a Spanish Non Tertiary Hospital Marisa Arias, Luis R. Rábago*, Luis Alonso, Castillo Herrera, Ana Olivares, Alejandro Ortega, Miguel Perez, Jaime Vazquez-Echarri Gastroenterology, Hospital Severo Ochoa, Leganes, Spain Introduction: The intragastric band migration is an uncommon complication of Laparoscopic Adjustable Gastric Banding (LAGB) (0.5-11%) usually resolved by surgical approach. We describe our experience of its successful endoscopic removal. Patients and Methods: Since 2001 we treated 127 morbid obese patients (pts) by LAGB. Those pts with migration of gastric band into stomach more than 50% of circumference were treated. The procedure was performed under general anesthesia with an standard gastroscope. We did not use fluoroscopy.First the band is cut using the cable from mechanical lithotripsy basket (MTW) or a standard 0.035 inch guidewire. Second the wire is looped about the visible the band, grasped by the alligator forceps and brought out through the patient’s mouth. Then the two ends of the wire are placed into the metal sheath of the mechanical lithotriptor (MTW) with progressively tightening about the band in order to cut it. The remaining external tubing and external port is now excised and removed by surgeon. Finally the split band is removed using a polypectomy snare. We did not use fluoroscopy. Results: We found that 11 out of 127 LAGB (8,6%) become symptomatic due to gastric migration. 88.8% were females with average of 42.6 yo. The time between the band placement and endoscopic removal was 60,5 months (29-120). The symptoms were epigastric pain and weight regain as a sign of band dysfunction.Three pts were operated, one refused endoscopic treatment and the other were operated by band dysfunction finding out the gastric migration. 7 out of 9 LAGB (77.7%) were endoscopically removed in one session.We had two failures,1 out of 9 LAGB (11.1%) was not possible to cut and the other (11,1%) was split but not removed due to difficulties with ventilation by excessive gas insufflation. His recovery from the attempt was uneventful and she remains well after 7 years of follow up, waiting for their possible complete migration. No complications were noticed after the endoscopic removal and pts were discharged in average of 2,6 days(1-7). Mortality 0%. The band removal was accomplished in three steps: a) cutting the band of silicone in their middle part avoiding the plastic part near the external tube, b) seizing the end of the splitted band near the external tube, coming from the port and c) pulling the endoscope out steadily and forcefully to liberate the band from the gastric wall. Conclusions: More than 8,6% of LAGB will have gastric migration and develop symptoms .The endoscopic removal of LAGB is feasible, safe, but not easy, being a good alternative to surgery. We were able to remove 77,7% of LAGB, but the band should be migrated more than 50%. It is important to know very well the removal technique and their tricks. It is not necessary the use of intraoperative fluoroscopy and it seems to be safe to cut the band without their removal
Mo1572 A Validated, Computerized Cleansing Score for Video Capsule Endoscopy Amir Klein*1, Moshe Gizbar3, Michael J. Bourke1,2, Golo Ahlenstiel1,2 1 Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2University of Sydney, Sydney, NSW, Australia; 3, Sydney, NSW, Australia Background: Video capsule endoscopy (VCE) is a useful diagnostic tool for the investigation of small bowel (SB) pathology. The diagnostic yield (DY) of VCE, may be hampered by the presence of intestinal content or air bubbles. There is a lack of consensus regarding necessity of active bowel preparation and the optimal regimen.
www.giejournal.org