- Email: [email protected]
NOTES Salvage of Direct EUS-Guided Gastrojejunostomy
Abstracts
visualization of lesions that are difficult to access. In order to access concealed areas by lifting and pressing the surrounding resected specimens during ESD, one side of the oblique-head cap is longer than the other. Result: In our preliminary study, a total of 6 cases were performed. The total procedure time was 42 min. In Three cases, ESD was completed without bleeding. In two cases (cases 2 and 4), hemostasis was achieved using only the diode laser. In the other case (case 6), the laser did not sufficiently control bleeding and so hemostatic forceps was used. There were no significant complications, such as delayed bleeding and perforation, in any of the cases. All cases were removed by en bloc resection. In pathologic mapping of the resected specimens, there were low-grade dysplasia (n Z 1), differentiated adenocarcinoma (n Z 3) and undifferentiated adenocarcinoma (n Z 2). The median size of the tumor was 12 mm (range 7-18 mm). 4 cases showed tumor-free resection margins. In two cases (case 1 and 3), the lateral margins showed tumor cell involvement. In all cases, there was no lymphatic or vascular invasion in the resected specimen. Conclusion: The novel laser system provides high-precision cutting and simultaneous hemostasis. ESD using this system is a safe and feasible method that minimizes immediate bleeding during procedure. And we anticipate that the tailored endoscopic cap application is useful.
NOTES Salvage of Direct EUS-Guided Gastrojejunostomy Irene Penas, Ramon Sanchez-Ocana*, Paula Gil-Simon, Pilar Diez-Redondo, Carlos De la Serna, Manuel Perez-Miranda GI and Hepatology, Rio Hortega Universitary Hospital, Valladolid, Valladolid, Spain Background: Lumen-apposing metal stents (LAMS) can be used for gastrojejunostomy (GJ) under NOTES (Barthet, GIE 2015) or EUS guidance (Khashab, GIE 2015). EUS-GJ requires both LAMS flanges properly placed. Proximal flange misplacement during LAMS deployment into the small bowel (Tyberg, GIE 2015) or the gallbladder (Ngamruenphong, GIE 2015) has occasionally been salvaged by a bridging tubular SEMS. However, the only two reported instances of distal LAMS flange misplacement during EUS-GJ resulted in procedural failure (Itoi, Gut 2015). We report a successful NOTES approach to salvage distal LAMS flange misplacement during EUS-GJ. Case Report: An 80 year old woman with metastatic pancreatic cancer and a biliary SEMS developed gastric outlet obstructive symptoms 4.5 months after diagnosis. Guidewire insertion through a 3rd duodenum stricture failed, despite all attempts. She was not a surgical candidate and direct EUS-GJ was chosen. Nondistended loops of small bowel were initially distended with saline injection thru 22G-needle prior to 19G puncture for enterography. Small bowel loops close to the duodenum were accessed free-hand with a cautery-tipped LAMS delivery catheter. After 15-10-mm LAMS deployment, the peritoneal cavity was identified endoscopically from the stomach through the LAMS. The EUS scope was exchanged for a therapeutic gastroscope. Following LAMS balloon expansion, the gastroscope was passed thru the transgastric LAMS into the peritoneum. A small bowel loop was targeted under NOTES peritoneoscopy & fluoroscopy, and after mildly being suctioned into the distal LAMS flange, its wall was cut with a needle-knife using high coagulation settings. A guidewire was passed thru the needle-knife into the loop under combined fluoroscopy. Another LAMS was advanced over-the-wire into the jejunal loop. After deployment of the distal flange, the gastroscope-stent delivery assembly was withdrawn towards the stomach, and the proximal flange of the second LAMS was deployed inside the originally misplaced transgastric LAMS. The entire procedure was performed in the Endoscopy Unit under antibiotic prophylaxis, CO2 insufflation and endoscopist-directed propofol sedation. Abdominal wall puncture for pneumperitoneum control was not required. No complications ensued. The patient started oral feeding within 24-hours and remained well throughout a 6week follow-up. Comments: A transgastric misplaced LAMS was used as an internal trocar for NOTES peritoneoscopy and successful LAMS-in-LAMS salvage of distal flange misplacement during EUS-GJ.
Endoscopic Submucosal Dissection of a Large Pseudo-Depressed Superficial Neoplasm of the Ileum Federico Iacopini*1, Cristina Grossi1, Takuji Gotoda2, Guido Costamagna3, Yutaka Saito4 1 Ospedale S. Giuseppe, ASL Roma H, Gastroenterology Unit, Rome, Italy; 2 Tokyo Medical University, Tokyo, Japan; 3Surgical Digestive Endoscopy, Gemelli Hospital, Rome, Italy; 4National Cancer Center Hospital, Tokyo, Japan Superficial neoplasms involving the ileocecal valve and the ileum pose a higher degree of complexity and are relative contraindications for endoscopic resection even for adenomas and intramucosal cancers. Piecemeal conventional snare resection is often incomplete with uncertain pathology requiring subsequent surgery in some cases. Endoscopic submucosal dissection (ESD) increases the possibility to achieve curative resections but has been rarely adopted in the small bowel due to the perceived high-risk of perforation related to the thin wall of the narrow lumen. A 73-year-old woman underwent colonoscopy for persistent diffuse abdominal pain. His medical history was unremarkable. A previous colonoscopy performed, routine laboratory tests, and the fecal occult blood test were normal. After reaching the cecum, retrograde ileoscopy diagnosed a 25-mm laterally spreading tumor with a non-granular pseudo-depression surface (LST-NG PD type) at 5 cm from the ileocecal valve. After 0.4% indigo-carmine dye spraying and narrow band imaging, the
AB638 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
lesion was delineated on the background villous mucosa and characterized as noninvasive: the pit pattern was small-tubular (type IIIs by Kudo); the microcapillary pattern showed thin vessels surrounding the crypts (type 3A by Sano). The ESD was performed with a pediatric high-definition colonoscope, a small-caliber-tip transparent hood, and CO2 insufflation. Resection moved progressively from the anal to the oral side using a no-insulated knife. A translucent mucoid-like 2-mm nodule was observed in the submucosa beneath the lesion. An en bloc ESD was achieved within 100 min. The resection site was closed by clips. No adverse events occurred. According to the Vienna classification, the histologic diagnosis of the resected specimen (30x25 mm) was an adenoma with low-grade dysplasia (both lateral and vertical margins were negative). The submucosal nodule was a Peyer’s patch. Followup endoscopy after 6 months revealed no residual tumor and no stricture. According to the Vienna classification, the histologic diagnosis of the resected specimen (30x25 mm) was an adenoma with low-grade dysplasia (both lateral and vertical margins were negative). The submucosal nodule was a Peyer’s patch. Follow-up endoscopy after 6 months revealed no residual tumor and no stricture. This case reinforces the concept that routine ileoscopy has its own clinical relevance, and suggests that the ESD in the ileum is feasible and may avoid surgery. However, ESD in the ileum requires a specific knowledge of the ileal wall structure and is more difficult and risky than in the colon.
First In Vivo Experience of Haemostatic Treatment With a New Therapeutic Laser System (With Video) Gian Eugenio Tontini*1, Paola Soriani1, Helmut Neumann2, Luca Carmignani3, Filippo Fagnani4, Luisa Spina1, Maria Laura Annunziata1, Sara Vavassori1, Luca Pastorelli5, Maurizio Vecchi5 1 Gastroenterology & Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy; 2Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany; 3Academic Urology Department, IRCCS Policlinico San Donato, Univesity of Milan, San Donato Milanese, Milano, Italy; 4Surgical Division, Quanta System S.p.A, Varese, Italy; 5Gastroenterology & Digestive Endoscopy Unit, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese, Milano, Italy Background and Aim: The Thulium laser system is an established therapeutic technology for surgical resection. By adjusting the power, its wavelength of 2 mm provides a precise control on penetration depth (0.2-0.4 mm) for ablation and vaporesection purposes in luminal endoscopy. Here, we report the first in vivo haemostatic treatment in humans, using this newly introduced tool during ongoing gastrointestinal bleeding, refractory to conventional haemostatic methods. Materials and Methods: We used this new therapeutic laser system in a 67-year old man with chronic duodenal bleeding. Six months before, the patient had undergone a rescue treatment with selective arterial embolization for persistent active bleeding despite several endoscopic attempts in huge and deep peptic ulcers located in the proximal duodenum. The patient developed large hyperplastic lesions placed along the proximal duodenum with chronic oozing, and unsatisfactory outcomes by means of standard thermal, cytochemical, and mechanical haemostatic approaches. The endoscopic examinations were performed using a high-definition videogastroscope and digitally video-recorded. Results: Under conscious sedation (midazolam iv.), the endoscope was advanced into the duodenum, thereby showing several bleeding spots within the aforementioned lesions. Then, a 550 um optical fiber was introduced into the working channel, placing the tip at a distance of approximately 1 cm from the endoscope and from each target. Using an integrated green aiming beam, the Thulium laser system was used as a paintbrush to carefully vaporise the mucosal surface under a 5 w continued modality. Focal administration of a 10 w power resulted in an immediate and persistent haemostatic ablation when active bleeding occurred from an exposed vessel. Only the proximal segment of the lesion was treated in this first course. After four and twelve weeks, the targeted area showed an initial mucosal healing, and laser treatments were applied onto more distal residual bleeding spots during each endoscopic session. Patient was always discharged home 4 hours after the procedure and no adverse event was recorded. Consistent with endoscopic results, both hemoglobin level and blood transfusion need have shown a progressive improvement. Conclusions: The Thulium laser system appears to be safe and effective for in vivo haemostatic therapy of active bleeding lesions in the upper GI-tract, which are not amendable with conventionally haemostatic therapies. Multicenter studies should now confirm these initial results in a prospective setting.
Gel Immersion Endoscopy With Water Replacement for Endoscopic Hemostasis Using Mono-Polar Hemostatic Forceps Tomonori Yano*1, Masahiro Okada1, Hisashi Fukuda1, Hirotsugu Sakamoto1, Manabu Nagayama1, Alan K. Lefor2, Hironori Yamamoto1 1 Medicine, Jichi Medical University, Shimotsuke-shi, Japan; 2Surgery, Jichi Medical University, Shimotsuke-shi, Japan Background: It is difficult to secure the visual field during endoscopy for gastrointestinal bleeding, because injected water is rapidly mixed with fresh blood. To secure
www.giejournal.org
visualization of lesions that are difficult to access. In order to access concealed areas by lifting and pressing the surrounding resected specimens during ESD, one side of the oblique-head cap is longer than the other. Result: In our preliminary study, a total of 6 cases were performed. The total procedure time was 42 min. In Three cases, ESD was completed without bleeding. In two cases (cases 2 and 4), hemostasis was achieved using only the diode laser. In the other case (case 6), the laser did not sufficiently control bleeding and so hemostatic forceps was used. There were no significant complications, such as delayed bleeding and perforation, in any of the cases. All cases were removed by en bloc resection. In pathologic mapping of the resected specimens, there were low-grade dysplasia (n Z 1), differentiated adenocarcinoma (n Z 3) and undifferentiated adenocarcinoma (n Z 2). The median size of the tumor was 12 mm (range 7-18 mm). 4 cases showed tumor-free resection margins. In two cases (case 1 and 3), the lateral margins showed tumor cell involvement. In all cases, there was no lymphatic or vascular invasion in the resected specimen. Conclusion: The novel laser system provides high-precision cutting and simultaneous hemostasis. ESD using this system is a safe and feasible method that minimizes immediate bleeding during procedure. And we anticipate that the tailored endoscopic cap application is useful.
NOTES Salvage of Direct EUS-Guided Gastrojejunostomy Irene Penas, Ramon Sanchez-Ocana*, Paula Gil-Simon, Pilar Diez-Redondo, Carlos De la Serna, Manuel Perez-Miranda GI and Hepatology, Rio Hortega Universitary Hospital, Valladolid, Valladolid, Spain Background: Lumen-apposing metal stents (LAMS) can be used for gastrojejunostomy (GJ) under NOTES (Barthet, GIE 2015) or EUS guidance (Khashab, GIE 2015). EUS-GJ requires both LAMS flanges properly placed. Proximal flange misplacement during LAMS deployment into the small bowel (Tyberg, GIE 2015) or the gallbladder (Ngamruenphong, GIE 2015) has occasionally been salvaged by a bridging tubular SEMS. However, the only two reported instances of distal LAMS flange misplacement during EUS-GJ resulted in procedural failure (Itoi, Gut 2015). We report a successful NOTES approach to salvage distal LAMS flange misplacement during EUS-GJ. Case Report: An 80 year old woman with metastatic pancreatic cancer and a biliary SEMS developed gastric outlet obstructive symptoms 4.5 months after diagnosis. Guidewire insertion through a 3rd duodenum stricture failed, despite all attempts. She was not a surgical candidate and direct EUS-GJ was chosen. Nondistended loops of small bowel were initially distended with saline injection thru 22G-needle prior to 19G puncture for enterography. Small bowel loops close to the duodenum were accessed free-hand with a cautery-tipped LAMS delivery catheter. After 15-10-mm LAMS deployment, the peritoneal cavity was identified endoscopically from the stomach through the LAMS. The EUS scope was exchanged for a therapeutic gastroscope. Following LAMS balloon expansion, the gastroscope was passed thru the transgastric LAMS into the peritoneum. A small bowel loop was targeted under NOTES peritoneoscopy & fluoroscopy, and after mildly being suctioned into the distal LAMS flange, its wall was cut with a needle-knife using high coagulation settings. A guidewire was passed thru the needle-knife into the loop under combined fluoroscopy. Another LAMS was advanced over-the-wire into the jejunal loop. After deployment of the distal flange, the gastroscope-stent delivery assembly was withdrawn towards the stomach, and the proximal flange of the second LAMS was deployed inside the originally misplaced transgastric LAMS. The entire procedure was performed in the Endoscopy Unit under antibiotic prophylaxis, CO2 insufflation and endoscopist-directed propofol sedation. Abdominal wall puncture for pneumperitoneum control was not required. No complications ensued. The patient started oral feeding within 24-hours and remained well throughout a 6week follow-up. Comments: A transgastric misplaced LAMS was used as an internal trocar for NOTES peritoneoscopy and successful LAMS-in-LAMS salvage of distal flange misplacement during EUS-GJ.
Endoscopic Submucosal Dissection of a Large Pseudo-Depressed Superficial Neoplasm of the Ileum Federico Iacopini*1, Cristina Grossi1, Takuji Gotoda2, Guido Costamagna3, Yutaka Saito4 1 Ospedale S. Giuseppe, ASL Roma H, Gastroenterology Unit, Rome, Italy; 2 Tokyo Medical University, Tokyo, Japan; 3Surgical Digestive Endoscopy, Gemelli Hospital, Rome, Italy; 4National Cancer Center Hospital, Tokyo, Japan Superficial neoplasms involving the ileocecal valve and the ileum pose a higher degree of complexity and are relative contraindications for endoscopic resection even for adenomas and intramucosal cancers. Piecemeal conventional snare resection is often incomplete with uncertain pathology requiring subsequent surgery in some cases. Endoscopic submucosal dissection (ESD) increases the possibility to achieve curative resections but has been rarely adopted in the small bowel due to the perceived high-risk of perforation related to the thin wall of the narrow lumen. A 73-year-old woman underwent colonoscopy for persistent diffuse abdominal pain. His medical history was unremarkable. A previous colonoscopy performed, routine laboratory tests, and the fecal occult blood test were normal. After reaching the cecum, retrograde ileoscopy diagnosed a 25-mm laterally spreading tumor with a non-granular pseudo-depression surface (LST-NG PD type) at 5 cm from the ileocecal valve. After 0.4% indigo-carmine dye spraying and narrow band imaging, the
AB638 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
lesion was delineated on the background villous mucosa and characterized as noninvasive: the pit pattern was small-tubular (type IIIs by Kudo); the microcapillary pattern showed thin vessels surrounding the crypts (type 3A by Sano). The ESD was performed with a pediatric high-definition colonoscope, a small-caliber-tip transparent hood, and CO2 insufflation. Resection moved progressively from the anal to the oral side using a no-insulated knife. A translucent mucoid-like 2-mm nodule was observed in the submucosa beneath the lesion. An en bloc ESD was achieved within 100 min. The resection site was closed by clips. No adverse events occurred. According to the Vienna classification, the histologic diagnosis of the resected specimen (30x25 mm) was an adenoma with low-grade dysplasia (both lateral and vertical margins were negative). The submucosal nodule was a Peyer’s patch. Followup endoscopy after 6 months revealed no residual tumor and no stricture. According to the Vienna classification, the histologic diagnosis of the resected specimen (30x25 mm) was an adenoma with low-grade dysplasia (both lateral and vertical margins were negative). The submucosal nodule was a Peyer’s patch. Follow-up endoscopy after 6 months revealed no residual tumor and no stricture. This case reinforces the concept that routine ileoscopy has its own clinical relevance, and suggests that the ESD in the ileum is feasible and may avoid surgery. However, ESD in the ileum requires a specific knowledge of the ileal wall structure and is more difficult and risky than in the colon.
First In Vivo Experience of Haemostatic Treatment With a New Therapeutic Laser System (With Video) Gian Eugenio Tontini*1, Paola Soriani1, Helmut Neumann2, Luca Carmignani3, Filippo Fagnani4, Luisa Spina1, Maria Laura Annunziata1, Sara Vavassori1, Luca Pastorelli5, Maurizio Vecchi5 1 Gastroenterology & Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy; 2Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany; 3Academic Urology Department, IRCCS Policlinico San Donato, Univesity of Milan, San Donato Milanese, Milano, Italy; 4Surgical Division, Quanta System S.p.A, Varese, Italy; 5Gastroenterology & Digestive Endoscopy Unit, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese, Milano, Italy Background and Aim: The Thulium laser system is an established therapeutic technology for surgical resection. By adjusting the power, its wavelength of 2 mm provides a precise control on penetration depth (0.2-0.4 mm) for ablation and vaporesection purposes in luminal endoscopy. Here, we report the first in vivo haemostatic treatment in humans, using this newly introduced tool during ongoing gastrointestinal bleeding, refractory to conventional haemostatic methods. Materials and Methods: We used this new therapeutic laser system in a 67-year old man with chronic duodenal bleeding. Six months before, the patient had undergone a rescue treatment with selective arterial embolization for persistent active bleeding despite several endoscopic attempts in huge and deep peptic ulcers located in the proximal duodenum. The patient developed large hyperplastic lesions placed along the proximal duodenum with chronic oozing, and unsatisfactory outcomes by means of standard thermal, cytochemical, and mechanical haemostatic approaches. The endoscopic examinations were performed using a high-definition videogastroscope and digitally video-recorded. Results: Under conscious sedation (midazolam iv.), the endoscope was advanced into the duodenum, thereby showing several bleeding spots within the aforementioned lesions. Then, a 550 um optical fiber was introduced into the working channel, placing the tip at a distance of approximately 1 cm from the endoscope and from each target. Using an integrated green aiming beam, the Thulium laser system was used as a paintbrush to carefully vaporise the mucosal surface under a 5 w continued modality. Focal administration of a 10 w power resulted in an immediate and persistent haemostatic ablation when active bleeding occurred from an exposed vessel. Only the proximal segment of the lesion was treated in this first course. After four and twelve weeks, the targeted area showed an initial mucosal healing, and laser treatments were applied onto more distal residual bleeding spots during each endoscopic session. Patient was always discharged home 4 hours after the procedure and no adverse event was recorded. Consistent with endoscopic results, both hemoglobin level and blood transfusion need have shown a progressive improvement. Conclusions: The Thulium laser system appears to be safe and effective for in vivo haemostatic therapy of active bleeding lesions in the upper GI-tract, which are not amendable with conventionally haemostatic therapies. Multicenter studies should now confirm these initial results in a prospective setting.
Gel Immersion Endoscopy With Water Replacement for Endoscopic Hemostasis Using Mono-Polar Hemostatic Forceps Tomonori Yano*1, Masahiro Okada1, Hisashi Fukuda1, Hirotsugu Sakamoto1, Manabu Nagayama1, Alan K. Lefor2, Hironori Yamamoto1 1 Medicine, Jichi Medical University, Shimotsuke-shi, Japan; 2Surgery, Jichi Medical University, Shimotsuke-shi, Japan Background: It is difficult to secure the visual field during endoscopy for gastrointestinal bleeding, because injected water is rapidly mixed with fresh blood. To secure
www.giejournal.org