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P.07.14 ENDOSCOPIC PIECEMEAL RESECTION OF LARGE COLORECTAL ADENOMAS: A SYSTEMATIC TWO-STEP APPROACH
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Abstracts of the 19th National Congress of Digestive Diseases / Digestive and Liver Disease 45S (2013) S55–S218
of lidocain + adrenaline in order to have a local anesthesia and a safe use of APC. In case of extensive lesion (circumferential) we treat one quadrant at the time. Results: In one year we treated 33 male patients (18 HIV positive and 15 HIV negative): one with a circumferentially involment, 7 with half circumference and the others with a median of 3 lesions >5 mm. more than one condyloma >1 cm affecting one or more quadrant on the dentate line. We made a median of 1.5 treatments (range 1–5). In all patients we had a complete eradication of the lesions without sign of recurrence at six months endoscopic control. No complication occurred in our patients. Conclusions: Anorectal condyloma are lesions difficult to treat by endoscopy due to the difficulty to visualize the area and the high sensitivity of this area. Our experience demonstrates that the proposed endoscopic technique can improve the possibilities to treat the majority of these lesions (extensive or not) avoiding surgical approach.
P.07.14 ENDOSCOPIC PIECEMEAL RESECTION OF LARGE COLORECTAL ADENOMAS: A SYSTEMATIC TWO-STEP APPROACH L. Cipolletta ∗ , M.A. Bianco, G. Rotondano, F. Cipolletta, C. Cesaro Ospedale Maresca, Torre del Greco, Italy Background and aim: Piecemeal resection of colorectal lesions >30 mm may occasionally require multiple steps and not infrequently end up with standard surgery. Two-step EPMR, i.e. completion of the procedure within 4 to 6 weeks, would avoid excessive manipulation of the severed area thus reducing risk of complications and facilitate early identification and treatment of adenoma remnants thus reducing recurrence rate. Aim of the study is to evaluate the impact of systematic two-step EPMR on early morbidity and 12-mo outcomes. Material and methods: Patients with sessile polyps or laterally spreading tumours (LST) >30 mm were recruited in a prospective single-center study. EPMR was systematically performed in two scheduled sequential steps. At 1st step as much of the lesion as possible was removed, with obvious intent to complete resection; in the 2nd step, 4 to 6 weeks later, the procedure was completed. At this stage, magnified inspection of the resection area provided clues to simple biopsy (scar tissue devoid of any pattern) or further resection ± APC (adenoma remnants). Endoscopic follow-up was scheduled at 6 and 12 months after this second step (time zero). Results: Over 19 months, 54 patients were included (35 males, mean age 66.8 years, age range 27–82). There were 23 sessile polyps – mean size 42 (range 30–55) mm and 31 LSTs – mean size 49 (range 30–75) mm. Sessile lesions were located in the rectosigmoid (17) and proximal colon (6. LSTs were located in the proximal colon (13), left colon (5) and rectum (13). Standard technique by submucosal injection and snare resection was always employed. Intra-procedural bleeding was recorded in 7 pts, all successfully controlled by thermal therapy or clips. No delayed bleeding or perforation occurred. There was no procedure-related mortality. Final histology was low-grade adenoma (4 sessile and 17 LST), high grade adenoma/mucosal cancer (19 sessile and 13 LST) and submucosal cancer (1 G-mixed LST). Retreatment was deemed necessary in 19/54 pts during 2nd step. See table for 12-months outcomes. Table 1 Follow-up 4–6 weeks (2° step) 6 months* 12 months*
P.07.15 MEGASTENT® : A NEW OPTION FOR THE ENDOSCOPIC TREATMENT OF STAPLE-LINE LEAK AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY L. Magno ∗ ,1 , S. Ruggiero 1 , T. Russo 1 , T. Rappa 1 , A. Satriano 1 , P. Forestieri 2 , G. Galloro 1 1 Università Federico II di Napoli, Servizio Centralizzato di Endoscopia Digestiva Operatoria, Napoli, Italy; 2 Università Federico II di Napoli, Napoli, Italy
Background and aim: Laparoscopic sleeve gastrectomy (LSG) is being increasingly performed on obese patients. Among its complications, staple-line leak (SLL) is the most serious and life threatening. Here we evaluate the clinical outcome of a patient with SLL treated by a new, dedicated, selfexpanding metal stent. Moreover we compare the advantages of this stent to those traditionally used to treat this complication. Material and methods: A patient who underwent LSG for morbid obesity developed a SLL, treated by the endoscopic placement of a new, dedicated stent (Megastent® ). The stent was left in place for 60 days during which clinical and radiological controls were performed to monitor the stent’s position and to anticipate leak recurrence. Results: After stent removal, an upper gastrointestinal endoscopy showed healing of the leak. A contrast swallow performed the day after stent removal confirmed the absence of leak recurrence. On endoscopic follow-up two months later, complete healing of the leak was confirmed. Self-expandable metal stents permit a good management of this complication, as the temporary fistula-bypass enables enteral nutrition and, in selected cases, allows the patient to return home. Stent migration is the main complication of the procedure and it occurs in 30–50%. This highly variable rate can depend on the following: – stents are designed for esophageal stenosis and adapted to a different site and target; – stent placement along the sleeve does not ensure its proper containment; – coating prevents stents integration into the sleeve wall but allows migration. Recently, Taewoong Industries marketed Megastent® a new, C-SEMS dedicated to the treatment of leaks after LSG, resolving some of the mentioned problems. The two ends of the stent are flared, with a high edge profile permitting good anchorage. The body of the stent is longer than that of other esophageal stents, allowing the distal end to open into the duodenal bulb. The large diameter ensures optimal adherence of the stent to the sleeve wall, even in the antral segment. Conclusions: Stent placement, in selected patients, is a safe and effective treatment. While our data are limited to a single case they seem support the use of Megastent® as the best stenting option in the treatment of SLL after LSG. Further studies on larger series are needed to better evaluate patient outcome.
P.07.16 ENDOSCOPIC THERAPY OF BENIGN COLORECTAL ANASTOMOTIC STRICTURES: NOT ONLY BALLOON DILATATION P. Zecchin ∗ , F. Pincini, D. Fregonese Ospedale Camposampiero, Padova, Italy
Scheduled retreatment
Residual or recurrent adenoma
19/54 – –
– 8/54 (14.8%) 4/53 (7.5%)
*From the end of the procedure (time zero after second step).
Conclusions: Two-step EPMR of colorectal lesions ≥30 mm is safe and allows completion of the procedure at a later stage without jeopardizing positive long-term outcomes. This approach may potentially reduce the rate of “recurrent” adenoma by early inspection and retreatment of any residual tissue.
Background and aim: Postoperative colorectal anastomotic strictures is not rare and occurring from 3 to 30% according to various authors. Endoscopic balloon dilatation is a therapeutic strategy. In 1996 it was described by German authors a combined endoscopic therapy which included before a balloon dilatation an electroincision of scar tissue in anastomotic ring to reduce the risk of perforation. The aim of this series of patients is to show the outcome of using a double endoscopic technique for treatment benign anastomotic colorectal strictures. Material and methods: Between January 2009 and May 2012 were sent in our Unit 6 patients (3 female and 3 male) aged between 43 and 79 years, with benign anastomotic colorectal stricture with presence of radially scar tissue. All subjects had undergone recently left hemicolectomy (3 for adenocarcinoma
Abstracts of the 19th National Congress of Digestive Diseases / Digestive and Liver Disease 45S (2013) S55–S218
of lidocain + adrenaline in order to have a local anesthesia and a safe use of APC. In case of extensive lesion (circumferential) we treat one quadrant at the time. Results: In one year we treated 33 male patients (18 HIV positive and 15 HIV negative): one with a circumferentially involment, 7 with half circumference and the others with a median of 3 lesions >5 mm. more than one condyloma >1 cm affecting one or more quadrant on the dentate line. We made a median of 1.5 treatments (range 1–5). In all patients we had a complete eradication of the lesions without sign of recurrence at six months endoscopic control. No complication occurred in our patients. Conclusions: Anorectal condyloma are lesions difficult to treat by endoscopy due to the difficulty to visualize the area and the high sensitivity of this area. Our experience demonstrates that the proposed endoscopic technique can improve the possibilities to treat the majority of these lesions (extensive or not) avoiding surgical approach.
P.07.14 ENDOSCOPIC PIECEMEAL RESECTION OF LARGE COLORECTAL ADENOMAS: A SYSTEMATIC TWO-STEP APPROACH L. Cipolletta ∗ , M.A. Bianco, G. Rotondano, F. Cipolletta, C. Cesaro Ospedale Maresca, Torre del Greco, Italy Background and aim: Piecemeal resection of colorectal lesions >30 mm may occasionally require multiple steps and not infrequently end up with standard surgery. Two-step EPMR, i.e. completion of the procedure within 4 to 6 weeks, would avoid excessive manipulation of the severed area thus reducing risk of complications and facilitate early identification and treatment of adenoma remnants thus reducing recurrence rate. Aim of the study is to evaluate the impact of systematic two-step EPMR on early morbidity and 12-mo outcomes. Material and methods: Patients with sessile polyps or laterally spreading tumours (LST) >30 mm were recruited in a prospective single-center study. EPMR was systematically performed in two scheduled sequential steps. At 1st step as much of the lesion as possible was removed, with obvious intent to complete resection; in the 2nd step, 4 to 6 weeks later, the procedure was completed. At this stage, magnified inspection of the resection area provided clues to simple biopsy (scar tissue devoid of any pattern) or further resection ± APC (adenoma remnants). Endoscopic follow-up was scheduled at 6 and 12 months after this second step (time zero). Results: Over 19 months, 54 patients were included (35 males, mean age 66.8 years, age range 27–82). There were 23 sessile polyps – mean size 42 (range 30–55) mm and 31 LSTs – mean size 49 (range 30–75) mm. Sessile lesions were located in the rectosigmoid (17) and proximal colon (6. LSTs were located in the proximal colon (13), left colon (5) and rectum (13). Standard technique by submucosal injection and snare resection was always employed. Intra-procedural bleeding was recorded in 7 pts, all successfully controlled by thermal therapy or clips. No delayed bleeding or perforation occurred. There was no procedure-related mortality. Final histology was low-grade adenoma (4 sessile and 17 LST), high grade adenoma/mucosal cancer (19 sessile and 13 LST) and submucosal cancer (1 G-mixed LST). Retreatment was deemed necessary in 19/54 pts during 2nd step. See table for 12-months outcomes. Table 1 Follow-up 4–6 weeks (2° step) 6 months* 12 months*
P.07.15 MEGASTENT® : A NEW OPTION FOR THE ENDOSCOPIC TREATMENT OF STAPLE-LINE LEAK AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY L. Magno ∗ ,1 , S. Ruggiero 1 , T. Russo 1 , T. Rappa 1 , A. Satriano 1 , P. Forestieri 2 , G. Galloro 1 1 Università Federico II di Napoli, Servizio Centralizzato di Endoscopia Digestiva Operatoria, Napoli, Italy; 2 Università Federico II di Napoli, Napoli, Italy
Background and aim: Laparoscopic sleeve gastrectomy (LSG) is being increasingly performed on obese patients. Among its complications, staple-line leak (SLL) is the most serious and life threatening. Here we evaluate the clinical outcome of a patient with SLL treated by a new, dedicated, selfexpanding metal stent. Moreover we compare the advantages of this stent to those traditionally used to treat this complication. Material and methods: A patient who underwent LSG for morbid obesity developed a SLL, treated by the endoscopic placement of a new, dedicated stent (Megastent® ). The stent was left in place for 60 days during which clinical and radiological controls were performed to monitor the stent’s position and to anticipate leak recurrence. Results: After stent removal, an upper gastrointestinal endoscopy showed healing of the leak. A contrast swallow performed the day after stent removal confirmed the absence of leak recurrence. On endoscopic follow-up two months later, complete healing of the leak was confirmed. Self-expandable metal stents permit a good management of this complication, as the temporary fistula-bypass enables enteral nutrition and, in selected cases, allows the patient to return home. Stent migration is the main complication of the procedure and it occurs in 30–50%. This highly variable rate can depend on the following: – stents are designed for esophageal stenosis and adapted to a different site and target; – stent placement along the sleeve does not ensure its proper containment; – coating prevents stents integration into the sleeve wall but allows migration. Recently, Taewoong Industries marketed Megastent® a new, C-SEMS dedicated to the treatment of leaks after LSG, resolving some of the mentioned problems. The two ends of the stent are flared, with a high edge profile permitting good anchorage. The body of the stent is longer than that of other esophageal stents, allowing the distal end to open into the duodenal bulb. The large diameter ensures optimal adherence of the stent to the sleeve wall, even in the antral segment. Conclusions: Stent placement, in selected patients, is a safe and effective treatment. While our data are limited to a single case they seem support the use of Megastent® as the best stenting option in the treatment of SLL after LSG. Further studies on larger series are needed to better evaluate patient outcome.
P.07.16 ENDOSCOPIC THERAPY OF BENIGN COLORECTAL ANASTOMOTIC STRICTURES: NOT ONLY BALLOON DILATATION P. Zecchin ∗ , F. Pincini, D. Fregonese Ospedale Camposampiero, Padova, Italy
Scheduled retreatment
Residual or recurrent adenoma
19/54 – –
– 8/54 (14.8%) 4/53 (7.5%)
*From the end of the procedure (time zero after second step).
Conclusions: Two-step EPMR of colorectal lesions ≥30 mm is safe and allows completion of the procedure at a later stage without jeopardizing positive long-term outcomes. This approach may potentially reduce the rate of “recurrent” adenoma by early inspection and retreatment of any residual tissue.
Background and aim: Postoperative colorectal anastomotic strictures is not rare and occurring from 3 to 30% according to various authors. Endoscopic balloon dilatation is a therapeutic strategy. In 1996 it was described by German authors a combined endoscopic therapy which included before a balloon dilatation an electroincision of scar tissue in anastomotic ring to reduce the risk of perforation. The aim of this series of patients is to show the outcome of using a double endoscopic technique for treatment benign anastomotic colorectal strictures. Material and methods: Between January 2009 and May 2012 were sent in our Unit 6 patients (3 female and 3 male) aged between 43 and 79 years, with benign anastomotic colorectal stricture with presence of radially scar tissue. All subjects had undergone recently left hemicolectomy (3 for adenocarcinoma