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Novel Motorized Spiral Enteroscopy: First Clinical Case
Abstracts
and longitudinal muscle layer of muscularis propria. These features help in differentiation between SRUS and rectal cancer.
Novel Motorized Spiral Enteroscopy: First Clinical Case Horst Neuhaus*1, Torsten Beyna1, Markus Schneider1, Jacques Deviere2 1 Department of Gastroenterology, Evangelisches Krankenhaus, Duesseldorf, NRW, Germany; 2Gastroenterology and HepatoPancreatology, Universite Libre des Bruxelles, Brussels, Belgium A novel reusable endoscope (Olympus Corp.) with an integral motor was developed for rotating a disposable short spiral overtube mounted on the insertion tube portion. The drive motor located in the endoscope handle is activated via foot pedals and controls the direction and speed of rotation of a coupler located in the middle of the endoscope’s insertion tube. The rotation coupler is the only portion of the endoscope that rotates; the distal and proximal portions of the insertion tube do not rotate. Other than the presence of the drive motor and the rotation coupler, the endoscope design is the same as that of conventional flexible endoscopes. The single-use spiral assembly is comprised of corrugated tubing with an atraumatic plastic spiral bonded to its exterior. It relies on rotation of the spiral component to “pleat” or “unpleat” the bowel either on or off the insertion tube as the spiral thread rotates in a clockwise or counter-clockwise direction, respectively. The operator can monitor how much torque is being applied to the small bowel by observing the system’s “visual force gauge”. This display provides the operator with a visual indication of the direction of rotation and the force of rotation throughout the examination. The clinical case represents the first use of this device in humans. Enteroscopy was indicated for treatment of angiodysplasias in the jejunum identified by small bowel capsule endoscopy in a 48 year old patient with iron deficiency anaemia. The novel motorized enteroscope could be smoothly inserted approximately 250 cm distal of the ligament of Treitz within 20 minutes. The technique allowed controlled movement of the tip of the endoscope and it provided an excellent visualization of the intubated small bowel. An angiodysplasia was detected and treated with argon plasma coagulation. Careful removal of the endoscope with counter-clockwise rotation of the spiral revealed no iatrogenic mucosal trauma. No adverse events were registered.
Needle Knife Polypectomy in the Duodenum Assisted by Peristaltic Tension David O. Prichard*1, Fergal Donnellan2 1 Gastroenterology, Mayo Clinic Health System La Crosse, La Crosse, WI; 2 Gastroenterology, Vancouver General Hospital, Vancouver, BC, Canada A 46 year old lady was referred for investigation of iron deficiency anemia. History and examination revealed no etiology. Fecal immunohistochemial testing was positive and endoscopic evaluation was recommended. EGD revealed a 0-1p polyp arising from the inferolateral wall of the second portion of the duodenum. Encompasing the polyp stalk with a snare proved impossible despite attempts at repositioning the polyp. Hemostasis clips were applied and the stalk transected using a needle knife. No iatrogenic trauma or post-polypectomy hemorrhage occurred. Histology demonstrated a fibroepithelial polyp with Brunner’s Gland hyperplasia. Pedunculated Brunner’s gland adenomas arising from the second portion of the duodenum are rare. These hamartomatous polyps rarely become malignant and are usually asymptomatic. Gastrointestinal bleeding or obstruction may necessitate resection. Snare polypectomy of pedunculated polyps in the duodenum can be difficult due to distal migration of the lesion and angulation of the bowel. If used with caution, needle knife transection facilitates polypectomy. In this case, safe transection was aided by peristaltic tension placed on the stalk. The greatest risk with this technique is inadvertent thermal damage to the bowel wall and/or perforation. A ball-tip or hook-tip needle-knife may reduce this risk.
The Application of New Diagnostic and Therapeutic Techniques in A Case of Zollinger-Ellison Syndrome Roy M. Soetikno*1,2, Damien Tan1, Ahmed Alsageh1, Christopher Jen Lock Khor1, Wei Qiang Leow3, Cheow P. Chung4 1 Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; 2National Cancer Centre, Singapore, Singapore; 3 Department of Pathology, Singapore General Hospital, Singapore, Singapore; 4Department of Hepatopancreaticobiliary Surgery, Singapore General Hospital, Singapore, Singapore Background: Zollinger-Ellison syndrome (ZES) is a rare disease and most physicians have not encountered or managed a case. We, in this case, using a multimedia presentation illustrate the features of ZES and its current management. Case: A 68year-old male presented with an episode of upper gastrointestinal bleeding. He had a history of recurrent gastroduodenal ulcers (8 years ago) and high serum gastrin but was lost to follow up. He was still taking proton pump inhibitors. Endoscopy showed
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a large duodenal ulcer. We performed a Dotatate PET scan, which showed a localized duodenal lesion. Endoscopy Method: An upper endoscopy, on entering the stomach, showed markedly thickened gastric folds suggesting parietal cell hyperplasia. We performed an endoscopic ultrasound (EUS) and identified a subcentimeter hypoechoic lesion in the distal bulb of the duodenum. The lesion extended into the submucosa, but did not invade into the muscularis propria or lymph nodes. We using a mini probe ultrasound precisely localized and demarcated the lesion. A biopsy to mark the lesion and to confirm the diagnosis was performed. Immunohistochemistry staining of the biopsy tissue and high serum gastrin level confirmed the diagnosis of a gastrinoma. We, using the hybrid endoscopic submucosal dissection technique (ESD), resected the lesion en-bloc. On pathology, complete resection of the low grade gastrinoma was confirmed. Clinical Implication: ZES is still an enigma, but newer techniques are now available to make its diagnosis and therapy better. Dotatate PET/CT is a useful modality in characterization, localization and detection of neuroendocrine tumor. Endoscopic resection can be curative and is the recommended choice of treatment for localized duodenal gastrinoma. Thus, our case illustrates the classical endoscopic findings and successful use of new modalities like Dotapeptide PET, EUS, and ESD in the management of ZES.
Novel Technique to Relax the Lower Esophageal Sphincter (LES) During a Challenging Per Oral Endoscopic Myotomy (POEM) Majidah Bukhari*1, Vivek Kumbhari1, Yamile Haito Chavez1, Yan Chen1, Saowanee Ngamruengphong1, Mouen A. Khashab1, Payal Saxena2 1 Johns Hopkins, Baltimore, MD; 2GI, Royal Prince Alfred, Camperdown, South Australia, Australia Background: Amyl nitrite is a potent short acting vasodilator. It is used during the radiologic esophagogram test in order to distinguish patient with pseudoachalasia from those with idiopathic achalasia since amyl nitrite has a transient effect on the lower esophageal sphincter (LES). The study by Dodds et al revealed that the LES pressure decrease substantially in response to amyl nitrite inhalation and the diameter of the LES increase by more than 3 mm in patients with idiopathic achalasia. Treatment of achalsia is currently aimed at decrease the resting pressure in the LES. Peroral endoscopic myotomy (POEM) is an endoscopic procedure to the treatment of achalasia. During submucosal tunneling, dissection should be carried out closed to the muscle layer surface to avoid mucosal injury. When the LES is tight or esophageal spasm occur during POEM procedure the dissection of the fibers can be challenging to perform safely without a risk of mucosal injury. In this video we demonstrate two cases of utilizing amyl nitrite inhalations to relax the lower esophageal sphincter to facilitate submucosal tunnelling during POEM. Cases: The first case is a 59-year-old male presented for management of long standing dysphagia and regurgitation associated with 30-pounds weight loss over a year. He was diagnosed with type III achalasia and hypertensive LES. He underwent POEM. During the sub mucosal tunneling the distal esophagus became spastic avoiding the advancement of the endoscope and the LES was tight. Amyl nitrite was used to relax the LES. A 10 cc syringe was connected to the ventilation circuit. One ampule of amyl nitrite was placed inside the syringe. Patient was ventilated with a bag for 10 minuets. We administrated 2 ampules of amyl nitrite to relax the LES effectively and to facilitate the submucosal tunneling step during POEM. The second case is a 38year-old female with type II achalasia with Eckardt score of 9. During POEM procedure the LES found to be tight preventing effective and safe submucoal tunneling at the level of the gastroesophageal junction. A total of 9 ampules were given to relax the LES and facilitate the submuocal dissection and tunneling safely. Both patients were admitted to the hospital for observation. Cine eophagogram 24 hours later showed no leak. They discharged home on soft diet and they retained in clinic 4 weeks later with complete resolution of the symptoms. Conclusion: Amyl nitrite is safe and effective method to relax the lower esophageal pressure during a challenging POEM.
Endoscopic Submucosal Dissection Using a Novel Diode Laser System With 3D-Printer Endoscopic Cap Weon-Jin Ko*, Chang-Il Kwon, Kim WonHee, Ga Won Song, Joo Young Cho CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background: Endoscopic submucosal dissection (ESD) is a standard treatment for selected patients with gastric epithelial neoplasia. However, immediate bleeding has been reported in 12-20% of patients, making it the most common ESD complication. Immediate bleeding can prevent a clear view of the operative field without hemostasis. Repetitive hemostasis may prolong procedure times, which is a major obstacle to successful ESD. The diode laser system emits a continuous wave delivered through a thin, flexible laser fiber. Because of rapid vaporization with effective hemostasis, this system is suitable for tissue resection without deep injury. To our knowledge, this is the first trial of use of this system for therapeutic GI endoscopy in humans. Method: We reformed the laser used cosmetically in Korea to build a diode laser for therapeutic endoscopy. But laser cannot adjust the direction. It is in a straight line. So we develop the endoscopic cap using 3D-printer to improve
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB637
and longitudinal muscle layer of muscularis propria. These features help in differentiation between SRUS and rectal cancer.
Novel Motorized Spiral Enteroscopy: First Clinical Case Horst Neuhaus*1, Torsten Beyna1, Markus Schneider1, Jacques Deviere2 1 Department of Gastroenterology, Evangelisches Krankenhaus, Duesseldorf, NRW, Germany; 2Gastroenterology and HepatoPancreatology, Universite Libre des Bruxelles, Brussels, Belgium A novel reusable endoscope (Olympus Corp.) with an integral motor was developed for rotating a disposable short spiral overtube mounted on the insertion tube portion. The drive motor located in the endoscope handle is activated via foot pedals and controls the direction and speed of rotation of a coupler located in the middle of the endoscope’s insertion tube. The rotation coupler is the only portion of the endoscope that rotates; the distal and proximal portions of the insertion tube do not rotate. Other than the presence of the drive motor and the rotation coupler, the endoscope design is the same as that of conventional flexible endoscopes. The single-use spiral assembly is comprised of corrugated tubing with an atraumatic plastic spiral bonded to its exterior. It relies on rotation of the spiral component to “pleat” or “unpleat” the bowel either on or off the insertion tube as the spiral thread rotates in a clockwise or counter-clockwise direction, respectively. The operator can monitor how much torque is being applied to the small bowel by observing the system’s “visual force gauge”. This display provides the operator with a visual indication of the direction of rotation and the force of rotation throughout the examination. The clinical case represents the first use of this device in humans. Enteroscopy was indicated for treatment of angiodysplasias in the jejunum identified by small bowel capsule endoscopy in a 48 year old patient with iron deficiency anaemia. The novel motorized enteroscope could be smoothly inserted approximately 250 cm distal of the ligament of Treitz within 20 minutes. The technique allowed controlled movement of the tip of the endoscope and it provided an excellent visualization of the intubated small bowel. An angiodysplasia was detected and treated with argon plasma coagulation. Careful removal of the endoscope with counter-clockwise rotation of the spiral revealed no iatrogenic mucosal trauma. No adverse events were registered.
Needle Knife Polypectomy in the Duodenum Assisted by Peristaltic Tension David O. Prichard*1, Fergal Donnellan2 1 Gastroenterology, Mayo Clinic Health System La Crosse, La Crosse, WI; 2 Gastroenterology, Vancouver General Hospital, Vancouver, BC, Canada A 46 year old lady was referred for investigation of iron deficiency anemia. History and examination revealed no etiology. Fecal immunohistochemial testing was positive and endoscopic evaluation was recommended. EGD revealed a 0-1p polyp arising from the inferolateral wall of the second portion of the duodenum. Encompasing the polyp stalk with a snare proved impossible despite attempts at repositioning the polyp. Hemostasis clips were applied and the stalk transected using a needle knife. No iatrogenic trauma or post-polypectomy hemorrhage occurred. Histology demonstrated a fibroepithelial polyp with Brunner’s Gland hyperplasia. Pedunculated Brunner’s gland adenomas arising from the second portion of the duodenum are rare. These hamartomatous polyps rarely become malignant and are usually asymptomatic. Gastrointestinal bleeding or obstruction may necessitate resection. Snare polypectomy of pedunculated polyps in the duodenum can be difficult due to distal migration of the lesion and angulation of the bowel. If used with caution, needle knife transection facilitates polypectomy. In this case, safe transection was aided by peristaltic tension placed on the stalk. The greatest risk with this technique is inadvertent thermal damage to the bowel wall and/or perforation. A ball-tip or hook-tip needle-knife may reduce this risk.
The Application of New Diagnostic and Therapeutic Techniques in A Case of Zollinger-Ellison Syndrome Roy M. Soetikno*1,2, Damien Tan1, Ahmed Alsageh1, Christopher Jen Lock Khor1, Wei Qiang Leow3, Cheow P. Chung4 1 Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; 2National Cancer Centre, Singapore, Singapore; 3 Department of Pathology, Singapore General Hospital, Singapore, Singapore; 4Department of Hepatopancreaticobiliary Surgery, Singapore General Hospital, Singapore, Singapore Background: Zollinger-Ellison syndrome (ZES) is a rare disease and most physicians have not encountered or managed a case. We, in this case, using a multimedia presentation illustrate the features of ZES and its current management. Case: A 68year-old male presented with an episode of upper gastrointestinal bleeding. He had a history of recurrent gastroduodenal ulcers (8 years ago) and high serum gastrin but was lost to follow up. He was still taking proton pump inhibitors. Endoscopy showed
www.giejournal.org
a large duodenal ulcer. We performed a Dotatate PET scan, which showed a localized duodenal lesion. Endoscopy Method: An upper endoscopy, on entering the stomach, showed markedly thickened gastric folds suggesting parietal cell hyperplasia. We performed an endoscopic ultrasound (EUS) and identified a subcentimeter hypoechoic lesion in the distal bulb of the duodenum. The lesion extended into the submucosa, but did not invade into the muscularis propria or lymph nodes. We using a mini probe ultrasound precisely localized and demarcated the lesion. A biopsy to mark the lesion and to confirm the diagnosis was performed. Immunohistochemistry staining of the biopsy tissue and high serum gastrin level confirmed the diagnosis of a gastrinoma. We, using the hybrid endoscopic submucosal dissection technique (ESD), resected the lesion en-bloc. On pathology, complete resection of the low grade gastrinoma was confirmed. Clinical Implication: ZES is still an enigma, but newer techniques are now available to make its diagnosis and therapy better. Dotatate PET/CT is a useful modality in characterization, localization and detection of neuroendocrine tumor. Endoscopic resection can be curative and is the recommended choice of treatment for localized duodenal gastrinoma. Thus, our case illustrates the classical endoscopic findings and successful use of new modalities like Dotapeptide PET, EUS, and ESD in the management of ZES.
Novel Technique to Relax the Lower Esophageal Sphincter (LES) During a Challenging Per Oral Endoscopic Myotomy (POEM) Majidah Bukhari*1, Vivek Kumbhari1, Yamile Haito Chavez1, Yan Chen1, Saowanee Ngamruengphong1, Mouen A. Khashab1, Payal Saxena2 1 Johns Hopkins, Baltimore, MD; 2GI, Royal Prince Alfred, Camperdown, South Australia, Australia Background: Amyl nitrite is a potent short acting vasodilator. It is used during the radiologic esophagogram test in order to distinguish patient with pseudoachalasia from those with idiopathic achalasia since amyl nitrite has a transient effect on the lower esophageal sphincter (LES). The study by Dodds et al revealed that the LES pressure decrease substantially in response to amyl nitrite inhalation and the diameter of the LES increase by more than 3 mm in patients with idiopathic achalasia. Treatment of achalsia is currently aimed at decrease the resting pressure in the LES. Peroral endoscopic myotomy (POEM) is an endoscopic procedure to the treatment of achalasia. During submucosal tunneling, dissection should be carried out closed to the muscle layer surface to avoid mucosal injury. When the LES is tight or esophageal spasm occur during POEM procedure the dissection of the fibers can be challenging to perform safely without a risk of mucosal injury. In this video we demonstrate two cases of utilizing amyl nitrite inhalations to relax the lower esophageal sphincter to facilitate submucosal tunnelling during POEM. Cases: The first case is a 59-year-old male presented for management of long standing dysphagia and regurgitation associated with 30-pounds weight loss over a year. He was diagnosed with type III achalasia and hypertensive LES. He underwent POEM. During the sub mucosal tunneling the distal esophagus became spastic avoiding the advancement of the endoscope and the LES was tight. Amyl nitrite was used to relax the LES. A 10 cc syringe was connected to the ventilation circuit. One ampule of amyl nitrite was placed inside the syringe. Patient was ventilated with a bag for 10 minuets. We administrated 2 ampules of amyl nitrite to relax the LES effectively and to facilitate the submucosal tunneling step during POEM. The second case is a 38year-old female with type II achalasia with Eckardt score of 9. During POEM procedure the LES found to be tight preventing effective and safe submucoal tunneling at the level of the gastroesophageal junction. A total of 9 ampules were given to relax the LES and facilitate the submuocal dissection and tunneling safely. Both patients were admitted to the hospital for observation. Cine eophagogram 24 hours later showed no leak. They discharged home on soft diet and they retained in clinic 4 weeks later with complete resolution of the symptoms. Conclusion: Amyl nitrite is safe and effective method to relax the lower esophageal pressure during a challenging POEM.
Endoscopic Submucosal Dissection Using a Novel Diode Laser System With 3D-Printer Endoscopic Cap Weon-Jin Ko*, Chang-Il Kwon, Kim WonHee, Ga Won Song, Joo Young Cho CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background: Endoscopic submucosal dissection (ESD) is a standard treatment for selected patients with gastric epithelial neoplasia. However, immediate bleeding has been reported in 12-20% of patients, making it the most common ESD complication. Immediate bleeding can prevent a clear view of the operative field without hemostasis. Repetitive hemostasis may prolong procedure times, which is a major obstacle to successful ESD. The diode laser system emits a continuous wave delivered through a thin, flexible laser fiber. Because of rapid vaporization with effective hemostasis, this system is suitable for tissue resection without deep injury. To our knowledge, this is the first trial of use of this system for therapeutic GI endoscopy in humans. Method: We reformed the laser used cosmetically in Korea to build a diode laser for therapeutic endoscopy. But laser cannot adjust the direction. It is in a straight line. So we develop the endoscopic cap using 3D-printer to improve
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB637