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Sa1587 Aspiration Therapy in Super Obese Patients - Pilot Trial
Abstracts
Sa1584 Efficacy and Safety of the Band and Slough Technique for Endoscopic Management of Non Ampullary Duodenal Adenomas: a Case Series Thoyaja Koritala*1, Carla D. Ellis-, Jennifer Krolikowski-, Jill Burton-, Naresh T. Gunaratnam2,1 1 St Joseph Mercy Hospital, Ypsilanti, MI; 2Huron Gastroenterology, Ann Arbor, MI Background: Duodenal adenomas are found in 0.3-4.6% of patients presenting for EGD. Standard polypectomy with the use of electrocautery is typically used to resect the adenoma. However, complications including bleeding, perforation and pain can occur in up to 5% due to the thin duodenal wall. Banding the adenoma without the use of electrocautery (band and slough) may decrease complication rates without adversely affecting the outcome. Objective: To demonstrate the efficacy and safety of band and slough technique in the management of non ampullary duodenal adenomas. Design: Retrospective case series. Setting: Community based hospital between November 2011 to February 2013. Patients: 11 patients with non ampullary duodenal adenomas aged 43 to 88 years. Intervention: EGD was performed and the adenomas were banded using a variceal band ligator (Speedband Superview Super 7, Boston Scientific, Natick MA). The pseudopolyps created were not resected and were allowed to slough off spontaneously. Residual adenomas after banding were treated with argon plasma coagulation. Outcome Measurements: Complications including bleeding, perforation, pain, stricture formation, and number of sessions to achieve adenoma eradication were recorded. Results: Results are summarized in the table below. Number of patients 11Percentage of Males 45% Average age of patient 65 years Location of adenoma First and Second portion of the duodenum Number of patients with tubular adenomas 7Number of patients with tubulovillous adenomas (TVA) 3Number of patients with TVA with high grade dysplasia 1Mean of adenomas treated per patient 1.7Mean size of adenoma 9.7 mm Mean of treatment sessions per patient 1.3Mean of bands deployed per adenoma 3.7Mean of bands deployed per treatment session 4.5Biopsies at 8 weeks post treatment Complete histologic resolution in all patients Procedure related complications None Limitation: Small sample size. Conclusion: This preliminary series demonstrates that the band and slough technique is effective and safe in the treatment of non ampullary duodenal adenomas with up to 8 week follow up. Larger studies are necessary before considering the band and slough technique as first line endoscopic intervention for management of non ampullary duodenal adenomas.
Sa1585 Combined Endoscopic-Transumbilical (Single Port) Laparoscopic Surgery for Duodenal Tumors Wen LI*1, Zikai Wang1, Rong Liu2, Xiaohui Du3, Xiaopeng Wang1, Tingting Huang1, Xuan Su1, Lili Wu1, Xiuxue Feng1 1 Gastroenterology and Hepatology, the Chinese PLA General Hospital, Beijing, China; 2Department of Oncological Surgery, the Chinese PLA General Hospital, Beijing, China; 3Department of General Surgery, the Chinese PLA General Hospital, Beijing, China Background: As compared with the standard open and laparoscopic approach for resection of tumors in the duodenum and upper jejunum, there are more operative limitations with the endoscopic technique and on using transumbilical singleincision laparoscopy, Aims A prospective study to introduce our preliminary experience in endoscopic-transumbilical single-incision laparoscopic cooperative surgery (ETSLCS) for duodenal tumors. Methods: Between September, 2010 and July, 2013, 6 patients with duodenal neoplasia were included in the present study at the Chinese PLA general hospital. Laparoscopy-assisted endoscopic techniques (LAET) (i.e. endoscopic mucosal resection and endoscopic submucosal dissection) or endoscopy-assisted laparoscopic techniques (EALT) (i.e. partial resection and anastomosis of small intestine) were used. The main outcome measurements included: procedure related characteristics, tumor size, pathological features, resection margins, operative complications and follow-up evaluation. Results: ETSLCS were successfully performed in 66.7% (4/6) of our cases, including LAET: 3 & EALT: 1. Two cases with large duodenal adenoma (7 - 8 cm) and duodenal hamartomatous polyps were subjected to laparotomy due to tumor size and risk of bleeding, respectively. Amongst the 4 patients accepting ETSLCS, the average procedure time was 128 minutes (range, 30 - 210 minutes) and mean intra-operative blood loss measured 7.5 ml (range, 5 - 10 ml). The mean tumor size was 2.1 cm (range, 0.6 - 3.5 cm) with the en bloc resection rate at 100% (4/4). The histopathologic diagnoses were: duodenal neuroendocrine tumors 2; hamartomatous polyps 2. Bowel perforation (0.4 - 1.2 cm) occurred in one case during endoscopic submucosal dissection. It was managed with four endoclips. Delayed hemorrhage (1200 ml) was observed in one case, requiring endoscopic hemostasis and blood component transfusion. No local recurrence and distant metastasis occurred during a median follow-up of 21 months (range, 4 - 38 months). Conclusion: Combined endoscopic-laparoscopic technique for resection of duodenal tumors is feasible in selected patients. However, the operating difficulty and insufficiency of instruments constitute serious limitations for this modality. Keywords Duodenal tumor; endoscopic-transumbilical single-incision laparoscopic cooperative surgery; ETSLCS; laparoscopy-assisted endoscopic technique; LAET; endoscopy-assisted laparoscopic technique; EALT.
AB264 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Sa1586 Laparoscopy-Endoscopy Cooperative Surgery for Gastric Submucosal Tumor and Duodenal Epithelial Tumor Takuto Hikichi*1, Masaki Sato2, Ko Watanabe2, Jun Nakamura2, Yuichi Waragai2, Hitomi Kikuchi2, Tadayuki Takagi2, Rei Suzuki2, Mitsuru Sugimoto2, Naoki Konno2, Mika Takasumi2, Hiromasa Ohira2, Katsutoshi Obara1 1 Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan; 2Gastroenterology and Rheumatology, Fukushima Medical University, Fukushima, Japan Objective: Laparoscopy-endoscopy cooperative surgery (LECS) has been conducted to set the resection area for submucosal tumors (SMT). Duodenal endoscopic submucosal dissection presents a high risk of perforation and bleeding during and after operation. Therefore, we also introduced LECS for duodenal epithelial tumors. This study clarified the efficacy of LECS for gastric/ duodenal tumors. Methods: Excision results were examined for 12 cases of gastric SMT and 2 cases of duodenal epithelial tumors for which LECS was planned and for which endoscopic surgery was performed during September 2012 - November 2013. The LECS procedures were the following: for the stomach, mucosae were resected at all circumferences under peroral endoscopy with subsequent intentional perforation, full-thickness resection at all circumferences under combined peroral endoscopy and laparoscopy, and finally reefing under laparoscopy. For the duodenum, the duodenum was removed from the surrounding tissues under laparoscopy. Then the tumor was resected using EMR perorally. The resected part was reefed with clips and an indwelling snare with subsequent additional reinforcement from the serosal side under laparoscopy. Results: LECS was performed in 66.7% (8/12) of gastric SMT. Four cases in which only laparoscopy was performed instead of LECS consisted of 2 cases for which the part outside the stomach was large, 1 case of adhesion to the pancreas, and 1 case for which it was judged that suture under laparoscopy after endoscopic full-thickness resection would be difficult. All 8 cases in which LECS was performed were GIST present in the body of stomach, with mean tumor diameter of 23.0 mm (13-37) and mean resection diameter of 36.6 mm (30-41). The mean operation time was 228 min (172-337), which was longer than laparoscopic surgery over the last 10 years (mean: 123 min). Additionally, full-thickness resection at all circumferences was performed endoscopically to the greatest extent possible from the fourth case onward to extend the intervention procedures of endoscopists. The mean endoscopic procedure time was 21.8 min (15-25). Moreover, LECS was performed in one case of intramucosal adenocarcinoma and 1 case of adenoma in the descending part of duodenum. The lesions were resected completely at one time without intra-operative and post-operative perforation or bleeding. However, endoscope operation in the duodenum was difficult because an unusual supine position was used and the duodenum was taken from the abdominal wall. Conclusion: LECS for SMT with intraluminal growth was effective because detailed setting of the resection line was possible. Moreover, results suggest that peroral endoscopic treatment assisted by laparoscopy is safe and that it is likely to be effective for duodenal epithelial tumor.
Sa1587 Aspiration Therapy in Super Obese Patients - Pilot Trial Evzen Machytka*, Marek Buzga, Tomas Kupka, Martina Bojkova Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic Background and Aims: While bariatric surgery is the best option for weight loss in the super-obese population, patients with BMIO50 kg/m2 have a substantially higher rate of perioperative mortality than those with BMI!50 kg/m2. We evaluated a new device for the treatment of obesity, the AspireAssistÒ Aspiration Therapy Aspiration Therapy (Aspire Bariatrics, King of Prussia, PA) in super-obese patients BMIO55 kg/m2. Recent studies of AspireAssist in patients with initial BMIs of 35-55 kg/m2 demonstrate not only high efficacy, but also an excellent safety profile. The AspireAssist consists of an endoscopically-placed gastrostomy tube (A-TubeTM) and siphon assembly, with which patients aspirate gastric contents 20 min after meal consumption, removing about 30% of ingested calories. Aspiration Therapy is given in conjunction lifestyle modification. The implantation procedure does not require general anesthesia, is done on an outpatient basis, and is fully reversible. Methods: From September 2012 to June 2013, 6 subjects (4 men, 2 women), average age 45,3 years ( 32-63 years) were enrolled in this single arm study. The mean initial weight of the subjects were 184,3 kg (143 to 233); the mean BMI 63,6 kg/m2 ( 59,5 -71,9 ). Aspiration Therapy was started after the fistula healed (10-21 days post-post A-Tube placement). Lifestyle intervention was provided as a 10-session diet and behavioral modification program. Patients were monitored regularly for electrolytes and metabolites. Results: Mean weight loss after 3 months was 15,5 kg (6 patients), after 6 months, 24,6 kg ( 5 patients ), after 1 year of 42 kg (2 patients ). All patients have responded to this therapy, with no patient losing less than 10 kg in the first 3 months. No serious adverse events occurred. Three minor adverse events were reported: all minor infections at the wound site, resolved within 3-5 days by local ATB. Procedural success was 100%. To date, all patients are continuing with Aspiration Therapy (AT), and report a high level of satisfaction with AT. Conclusion: The results from this study demonstrate that the AspireAssist is technically feasible, safe with a
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Abstracts
low complication rate, and effective in the super-obese, either as a long-term therapy or a bridge therapy to bariatric surgery.
Sa1588 Eight Year Experience With Endoscopic Management of Eroded Gastric Bands Umit B. Dogan*1, Mustafa S. AKIN2, Mehmet B. Dal3 1 Gastroenterology, Mustafa Kemal University, Faculty of Medicine, Hatay, Turkey; 2Gastroenterology, Gaziosmanpasa University, Faculty of Medicine, Tokat, Turkey; 3General Surgery, Adana Numune Training and Research Hospital, Adana, Turkey Background/Aim: Intragastric band migration is a major long-term complication of gastric banding: its frequency ranges from 0.6-11% and always requires removal of the band. We review our eight year experience with endoscopic removal of eroded gastric bands. Methods: 110 morbidly obese patients underwent adjustable gastric banding between 2005 and 2013. Band or tube erosion occurred in 14 patients (12.7%). In addition, 10 such patients were referred to our department from other hospitals. To remove the migrated band, we used an endoscopic approach with a device designed to cut the band: the Gastric Band Cutter (AMI, Agency for Medical Innovation). Symptoms, time to erosion, interval between diagnosis and treatment, and complications of treatment were reviewed. Results: Erosions occurred with 16 of the A.M.I. soft gastric bands and 8 of the MiniMizer extra adjustable gastric bands. The median time interval from the initial gastric band placement to the diagnosis of band erosion was 40 months (range, 18-67 months), and the mean time from diagnosis to band removal was 4 months (range, 0-24 months). Upper abdominal pain was the most common symptom (37.5%). Port site infection (25%) and loss of restriction and weight regain (33.3%) were other common symptoms. In 23 of the 24 patients, we used the gastric band cutter to remove the band endoscopically. It was able to cut the band successfully in all cases except one, where twisting of the cutting wire required conversion from endoscopy to laparotomy. In two cases, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In one patient, we had to do surgery for intragastric penetration of the connecting tube broken close to the band. The median duration of endoscopic removal of the gastric band was 25 min (range 15-40 min). Our success rate was 87% in the single session with no complication. Conclusion: The Gastric Band Cutter was successful in dividing the band in all cases except one, although we could not always complete the procedure endoscopically. Endoscopic removal of a migrated band with the gastric band cutter appears to be effective and safe method for band erosion.
Sa1589 Gastric Balloon Treatment of 539 Overweight Patients. Research, Statistics, Problems, Complications, Successes, Failures and Long-Term Effects. Uyak, Medical One Hamburg/ Germany Deniz Uyak* Gastroenterology, Mang Medical One Hamburg, Hamburg, Germany We have had10 years of experience from 2003 to 2013 with gastric balloon treatment. Of 539 overweight patients BMI more than 27 were at Medical One in Germany. We have studied statistics and long-term effects, successes and failures, problems, complications and research. We conducted a hormone study between 2010-2011 at Medical One HAMBURG. Our question was: Is insulin resistance the preliminary stage of the metabolic syndrome and obesity?We looked at the results of treatment of borderline obesity, (87patients), obesity1st (168 Patients), obesity 2nd (187 Patients), obesity 3rd (97 Patients) degree and the difference between females and males. Results: Research: 5.8% of the patients were not resistant to insulin before treatment with the gastric balloon. 61.6% of the patients showed no resistance to insulin after weight loss. Statistics: We treated 539 Patients (416 female 77.18% and 123 male 22.82%). The average age was 40.16, average weight before treatment 102.69 kg, after 6 months treatment 92.36 kg. The average weight loss was 10, 33 kg, average waist girth reduction 9.83 cm, average BMI 3.89.. Maximum weight loss was 39.0 kg; maximum waist girth loss was 44 cm. There was no big difference in weight loss between women and men. The treatment lasted for 6.85 months. Problems and complications: 389 balloons removed. Early removal (in the first 3 weeks) in 11 cases 2.82 % (6 patients with psychological problems, 3 patients severe symptomsof vomiting, 1 patient showed renal insufficiency,1 patient diabetic gastropathy and renal insufficiency. 4 female patients became pregnant. In pregnant patients the balloon was removed 2, 3 and 6 months after becoming pregnant, 1 patient 3 months after delivery. It has few technical problems. There were no serious complications and no fatalities Successes and failures: 200 Patients (80%) of 250 who had more than 10% weight loss (successful), 50 Patients (20%) were failures.(6% lost no weight, 14% lost less than 10%). Successes in borderline obesity were 60%, obesity1st degree 90%, obesity 2nd 89% and obesity 3rd 62%. Long-term Effects: Three years after explantation (removal) long-term effects showed 18 (58.06%) from 31 patients have retained their weight and 13 (41.84%) have renewed weight gain. Conclusions: Intragastric balloon treatment is safe and effective for inducing an average of 10.33 kg weight loss and an average of 9.83 cm waist girth loss in six months and reducing metabolic parameters such as insulin resistance in obese patients. It has few technical problems, no serious complications and no fatalities. It does not interfere with pregnancy and shows good results after 3 years. Gastric balloon is not a cure for obesity, only a symptomatic treatment of obesity. Our goal, as always, had to lie in the research of obesity. KEY WORDS: gastric balloon treatment, insulin resistance, overweight
Sa1590 Endoscopic Vertical Gastroplasty, a Novel Technique for Treatment of Obese. Fifty Cases. Preliminary Report Roberto Fogel*, Vivian Fogel, Jenny Izarra Hospital de Clinicas Caracas, Aventura, FL
Figure. Gastric band cutter and endoscopic view of metallic tube (black arrow), cutting wire passed around the band (white arrow) and the intragastric cut band before and after extraction. (1) Handgrip with a tourniquet, (2) Cutting wire, (3) metallic tube.
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Introduction: Obesity and its associated comorbidities, have reached epidemic proportions. Bariatric surgery for severe obesity, performed either laparoscopically or open, has provided significant health benefits to patients. While these surgical procedures are presently the gold standard, they are not devoid of potentially severe complications. Emerging technologies have opened the door for endoscopic approaches to reproduce some of the benefits of weight loss surgery. We present our data from January 2012 to November 2013. Methods: Included are the first 50 patients treated with the U.S. Food and Drug administration-approved commercially available endoscopic suturing device (Overstitch; Apollo Endosurgery, Austin, TX) by performing an endoscopic vertical gastroplasty (EVG). We performed transoral endoscopic gastric volume reduction with a non absorbable 2-0 suture, by placing free-hand, full-thickness, closed spaced interrupted sutures through the gastric wall: these sutures extended from the antrum to the gastro-esophageal junction. Patients included 36 females and 14 males, ages ranging from 16 to 61 years; 8 patients had a BMI O 35 and 42 patients with BMI ! 35. All procedures were performed under general anesthesia. The median procedure time was 110 min. Complications included mild bleeding in 15 that did not require any intervention, and self-limited abdominal pain in one. All patients were discharged the same day. Results: During established follow up at 1, 3, 6 and 12 months, the average weight loss in pounds was 20.46 (nZ48), 35.13 (nZ39), 38.18 (nZ32) and 36.12 (nZ18), respectively. Conclusion: EVG appears to be an effective and safe method in the short-term treatment of obesity
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB265
Sa1584 Efficacy and Safety of the Band and Slough Technique for Endoscopic Management of Non Ampullary Duodenal Adenomas: a Case Series Thoyaja Koritala*1, Carla D. Ellis-, Jennifer Krolikowski-, Jill Burton-, Naresh T. Gunaratnam2,1 1 St Joseph Mercy Hospital, Ypsilanti, MI; 2Huron Gastroenterology, Ann Arbor, MI Background: Duodenal adenomas are found in 0.3-4.6% of patients presenting for EGD. Standard polypectomy with the use of electrocautery is typically used to resect the adenoma. However, complications including bleeding, perforation and pain can occur in up to 5% due to the thin duodenal wall. Banding the adenoma without the use of electrocautery (band and slough) may decrease complication rates without adversely affecting the outcome. Objective: To demonstrate the efficacy and safety of band and slough technique in the management of non ampullary duodenal adenomas. Design: Retrospective case series. Setting: Community based hospital between November 2011 to February 2013. Patients: 11 patients with non ampullary duodenal adenomas aged 43 to 88 years. Intervention: EGD was performed and the adenomas were banded using a variceal band ligator (Speedband Superview Super 7, Boston Scientific, Natick MA). The pseudopolyps created were not resected and were allowed to slough off spontaneously. Residual adenomas after banding were treated with argon plasma coagulation. Outcome Measurements: Complications including bleeding, perforation, pain, stricture formation, and number of sessions to achieve adenoma eradication were recorded. Results: Results are summarized in the table below. Number of patients 11Percentage of Males 45% Average age of patient 65 years Location of adenoma First and Second portion of the duodenum Number of patients with tubular adenomas 7Number of patients with tubulovillous adenomas (TVA) 3Number of patients with TVA with high grade dysplasia 1Mean of adenomas treated per patient 1.7Mean size of adenoma 9.7 mm Mean of treatment sessions per patient 1.3Mean of bands deployed per adenoma 3.7Mean of bands deployed per treatment session 4.5Biopsies at 8 weeks post treatment Complete histologic resolution in all patients Procedure related complications None Limitation: Small sample size. Conclusion: This preliminary series demonstrates that the band and slough technique is effective and safe in the treatment of non ampullary duodenal adenomas with up to 8 week follow up. Larger studies are necessary before considering the band and slough technique as first line endoscopic intervention for management of non ampullary duodenal adenomas.
Sa1585 Combined Endoscopic-Transumbilical (Single Port) Laparoscopic Surgery for Duodenal Tumors Wen LI*1, Zikai Wang1, Rong Liu2, Xiaohui Du3, Xiaopeng Wang1, Tingting Huang1, Xuan Su1, Lili Wu1, Xiuxue Feng1 1 Gastroenterology and Hepatology, the Chinese PLA General Hospital, Beijing, China; 2Department of Oncological Surgery, the Chinese PLA General Hospital, Beijing, China; 3Department of General Surgery, the Chinese PLA General Hospital, Beijing, China Background: As compared with the standard open and laparoscopic approach for resection of tumors in the duodenum and upper jejunum, there are more operative limitations with the endoscopic technique and on using transumbilical singleincision laparoscopy, Aims A prospective study to introduce our preliminary experience in endoscopic-transumbilical single-incision laparoscopic cooperative surgery (ETSLCS) for duodenal tumors. Methods: Between September, 2010 and July, 2013, 6 patients with duodenal neoplasia were included in the present study at the Chinese PLA general hospital. Laparoscopy-assisted endoscopic techniques (LAET) (i.e. endoscopic mucosal resection and endoscopic submucosal dissection) or endoscopy-assisted laparoscopic techniques (EALT) (i.e. partial resection and anastomosis of small intestine) were used. The main outcome measurements included: procedure related characteristics, tumor size, pathological features, resection margins, operative complications and follow-up evaluation. Results: ETSLCS were successfully performed in 66.7% (4/6) of our cases, including LAET: 3 & EALT: 1. Two cases with large duodenal adenoma (7 - 8 cm) and duodenal hamartomatous polyps were subjected to laparotomy due to tumor size and risk of bleeding, respectively. Amongst the 4 patients accepting ETSLCS, the average procedure time was 128 minutes (range, 30 - 210 minutes) and mean intra-operative blood loss measured 7.5 ml (range, 5 - 10 ml). The mean tumor size was 2.1 cm (range, 0.6 - 3.5 cm) with the en bloc resection rate at 100% (4/4). The histopathologic diagnoses were: duodenal neuroendocrine tumors 2; hamartomatous polyps 2. Bowel perforation (0.4 - 1.2 cm) occurred in one case during endoscopic submucosal dissection. It was managed with four endoclips. Delayed hemorrhage (1200 ml) was observed in one case, requiring endoscopic hemostasis and blood component transfusion. No local recurrence and distant metastasis occurred during a median follow-up of 21 months (range, 4 - 38 months). Conclusion: Combined endoscopic-laparoscopic technique for resection of duodenal tumors is feasible in selected patients. However, the operating difficulty and insufficiency of instruments constitute serious limitations for this modality. Keywords Duodenal tumor; endoscopic-transumbilical single-incision laparoscopic cooperative surgery; ETSLCS; laparoscopy-assisted endoscopic technique; LAET; endoscopy-assisted laparoscopic technique; EALT.
AB264 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Sa1586 Laparoscopy-Endoscopy Cooperative Surgery for Gastric Submucosal Tumor and Duodenal Epithelial Tumor Takuto Hikichi*1, Masaki Sato2, Ko Watanabe2, Jun Nakamura2, Yuichi Waragai2, Hitomi Kikuchi2, Tadayuki Takagi2, Rei Suzuki2, Mitsuru Sugimoto2, Naoki Konno2, Mika Takasumi2, Hiromasa Ohira2, Katsutoshi Obara1 1 Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan; 2Gastroenterology and Rheumatology, Fukushima Medical University, Fukushima, Japan Objective: Laparoscopy-endoscopy cooperative surgery (LECS) has been conducted to set the resection area for submucosal tumors (SMT). Duodenal endoscopic submucosal dissection presents a high risk of perforation and bleeding during and after operation. Therefore, we also introduced LECS for duodenal epithelial tumors. This study clarified the efficacy of LECS for gastric/ duodenal tumors. Methods: Excision results were examined for 12 cases of gastric SMT and 2 cases of duodenal epithelial tumors for which LECS was planned and for which endoscopic surgery was performed during September 2012 - November 2013. The LECS procedures were the following: for the stomach, mucosae were resected at all circumferences under peroral endoscopy with subsequent intentional perforation, full-thickness resection at all circumferences under combined peroral endoscopy and laparoscopy, and finally reefing under laparoscopy. For the duodenum, the duodenum was removed from the surrounding tissues under laparoscopy. Then the tumor was resected using EMR perorally. The resected part was reefed with clips and an indwelling snare with subsequent additional reinforcement from the serosal side under laparoscopy. Results: LECS was performed in 66.7% (8/12) of gastric SMT. Four cases in which only laparoscopy was performed instead of LECS consisted of 2 cases for which the part outside the stomach was large, 1 case of adhesion to the pancreas, and 1 case for which it was judged that suture under laparoscopy after endoscopic full-thickness resection would be difficult. All 8 cases in which LECS was performed were GIST present in the body of stomach, with mean tumor diameter of 23.0 mm (13-37) and mean resection diameter of 36.6 mm (30-41). The mean operation time was 228 min (172-337), which was longer than laparoscopic surgery over the last 10 years (mean: 123 min). Additionally, full-thickness resection at all circumferences was performed endoscopically to the greatest extent possible from the fourth case onward to extend the intervention procedures of endoscopists. The mean endoscopic procedure time was 21.8 min (15-25). Moreover, LECS was performed in one case of intramucosal adenocarcinoma and 1 case of adenoma in the descending part of duodenum. The lesions were resected completely at one time without intra-operative and post-operative perforation or bleeding. However, endoscope operation in the duodenum was difficult because an unusual supine position was used and the duodenum was taken from the abdominal wall. Conclusion: LECS for SMT with intraluminal growth was effective because detailed setting of the resection line was possible. Moreover, results suggest that peroral endoscopic treatment assisted by laparoscopy is safe and that it is likely to be effective for duodenal epithelial tumor.
Sa1587 Aspiration Therapy in Super Obese Patients - Pilot Trial Evzen Machytka*, Marek Buzga, Tomas Kupka, Martina Bojkova Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic Background and Aims: While bariatric surgery is the best option for weight loss in the super-obese population, patients with BMIO50 kg/m2 have a substantially higher rate of perioperative mortality than those with BMI!50 kg/m2. We evaluated a new device for the treatment of obesity, the AspireAssistÒ Aspiration Therapy Aspiration Therapy (Aspire Bariatrics, King of Prussia, PA) in super-obese patients BMIO55 kg/m2. Recent studies of AspireAssist in patients with initial BMIs of 35-55 kg/m2 demonstrate not only high efficacy, but also an excellent safety profile. The AspireAssist consists of an endoscopically-placed gastrostomy tube (A-TubeTM) and siphon assembly, with which patients aspirate gastric contents 20 min after meal consumption, removing about 30% of ingested calories. Aspiration Therapy is given in conjunction lifestyle modification. The implantation procedure does not require general anesthesia, is done on an outpatient basis, and is fully reversible. Methods: From September 2012 to June 2013, 6 subjects (4 men, 2 women), average age 45,3 years ( 32-63 years) were enrolled in this single arm study. The mean initial weight of the subjects were 184,3 kg (143 to 233); the mean BMI 63,6 kg/m2 ( 59,5 -71,9 ). Aspiration Therapy was started after the fistula healed (10-21 days post-post A-Tube placement). Lifestyle intervention was provided as a 10-session diet and behavioral modification program. Patients were monitored regularly for electrolytes and metabolites. Results: Mean weight loss after 3 months was 15,5 kg (6 patients), after 6 months, 24,6 kg ( 5 patients ), after 1 year of 42 kg (2 patients ). All patients have responded to this therapy, with no patient losing less than 10 kg in the first 3 months. No serious adverse events occurred. Three minor adverse events were reported: all minor infections at the wound site, resolved within 3-5 days by local ATB. Procedural success was 100%. To date, all patients are continuing with Aspiration Therapy (AT), and report a high level of satisfaction with AT. Conclusion: The results from this study demonstrate that the AspireAssist is technically feasible, safe with a
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Abstracts
low complication rate, and effective in the super-obese, either as a long-term therapy or a bridge therapy to bariatric surgery.
Sa1588 Eight Year Experience With Endoscopic Management of Eroded Gastric Bands Umit B. Dogan*1, Mustafa S. AKIN2, Mehmet B. Dal3 1 Gastroenterology, Mustafa Kemal University, Faculty of Medicine, Hatay, Turkey; 2Gastroenterology, Gaziosmanpasa University, Faculty of Medicine, Tokat, Turkey; 3General Surgery, Adana Numune Training and Research Hospital, Adana, Turkey Background/Aim: Intragastric band migration is a major long-term complication of gastric banding: its frequency ranges from 0.6-11% and always requires removal of the band. We review our eight year experience with endoscopic removal of eroded gastric bands. Methods: 110 morbidly obese patients underwent adjustable gastric banding between 2005 and 2013. Band or tube erosion occurred in 14 patients (12.7%). In addition, 10 such patients were referred to our department from other hospitals. To remove the migrated band, we used an endoscopic approach with a device designed to cut the band: the Gastric Band Cutter (AMI, Agency for Medical Innovation). Symptoms, time to erosion, interval between diagnosis and treatment, and complications of treatment were reviewed. Results: Erosions occurred with 16 of the A.M.I. soft gastric bands and 8 of the MiniMizer extra adjustable gastric bands. The median time interval from the initial gastric band placement to the diagnosis of band erosion was 40 months (range, 18-67 months), and the mean time from diagnosis to band removal was 4 months (range, 0-24 months). Upper abdominal pain was the most common symptom (37.5%). Port site infection (25%) and loss of restriction and weight regain (33.3%) were other common symptoms. In 23 of the 24 patients, we used the gastric band cutter to remove the band endoscopically. It was able to cut the band successfully in all cases except one, where twisting of the cutting wire required conversion from endoscopy to laparotomy. In two cases, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In one patient, we had to do surgery for intragastric penetration of the connecting tube broken close to the band. The median duration of endoscopic removal of the gastric band was 25 min (range 15-40 min). Our success rate was 87% in the single session with no complication. Conclusion: The Gastric Band Cutter was successful in dividing the band in all cases except one, although we could not always complete the procedure endoscopically. Endoscopic removal of a migrated band with the gastric band cutter appears to be effective and safe method for band erosion.
Sa1589 Gastric Balloon Treatment of 539 Overweight Patients. Research, Statistics, Problems, Complications, Successes, Failures and Long-Term Effects. Uyak, Medical One Hamburg/ Germany Deniz Uyak* Gastroenterology, Mang Medical One Hamburg, Hamburg, Germany We have had10 years of experience from 2003 to 2013 with gastric balloon treatment. Of 539 overweight patients BMI more than 27 were at Medical One in Germany. We have studied statistics and long-term effects, successes and failures, problems, complications and research. We conducted a hormone study between 2010-2011 at Medical One HAMBURG. Our question was: Is insulin resistance the preliminary stage of the metabolic syndrome and obesity?We looked at the results of treatment of borderline obesity, (87patients), obesity1st (168 Patients), obesity 2nd (187 Patients), obesity 3rd (97 Patients) degree and the difference between females and males. Results: Research: 5.8% of the patients were not resistant to insulin before treatment with the gastric balloon. 61.6% of the patients showed no resistance to insulin after weight loss. Statistics: We treated 539 Patients (416 female 77.18% and 123 male 22.82%). The average age was 40.16, average weight before treatment 102.69 kg, after 6 months treatment 92.36 kg. The average weight loss was 10, 33 kg, average waist girth reduction 9.83 cm, average BMI 3.89.. Maximum weight loss was 39.0 kg; maximum waist girth loss was 44 cm. There was no big difference in weight loss between women and men. The treatment lasted for 6.85 months. Problems and complications: 389 balloons removed. Early removal (in the first 3 weeks) in 11 cases 2.82 % (6 patients with psychological problems, 3 patients severe symptomsof vomiting, 1 patient showed renal insufficiency,1 patient diabetic gastropathy and renal insufficiency. 4 female patients became pregnant. In pregnant patients the balloon was removed 2, 3 and 6 months after becoming pregnant, 1 patient 3 months after delivery. It has few technical problems. There were no serious complications and no fatalities Successes and failures: 200 Patients (80%) of 250 who had more than 10% weight loss (successful), 50 Patients (20%) were failures.(6% lost no weight, 14% lost less than 10%). Successes in borderline obesity were 60%, obesity1st degree 90%, obesity 2nd 89% and obesity 3rd 62%. Long-term Effects: Three years after explantation (removal) long-term effects showed 18 (58.06%) from 31 patients have retained their weight and 13 (41.84%) have renewed weight gain. Conclusions: Intragastric balloon treatment is safe and effective for inducing an average of 10.33 kg weight loss and an average of 9.83 cm waist girth loss in six months and reducing metabolic parameters such as insulin resistance in obese patients. It has few technical problems, no serious complications and no fatalities. It does not interfere with pregnancy and shows good results after 3 years. Gastric balloon is not a cure for obesity, only a symptomatic treatment of obesity. Our goal, as always, had to lie in the research of obesity. KEY WORDS: gastric balloon treatment, insulin resistance, overweight
Sa1590 Endoscopic Vertical Gastroplasty, a Novel Technique for Treatment of Obese. Fifty Cases. Preliminary Report Roberto Fogel*, Vivian Fogel, Jenny Izarra Hospital de Clinicas Caracas, Aventura, FL
Figure. Gastric band cutter and endoscopic view of metallic tube (black arrow), cutting wire passed around the band (white arrow) and the intragastric cut band before and after extraction. (1) Handgrip with a tourniquet, (2) Cutting wire, (3) metallic tube.
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Introduction: Obesity and its associated comorbidities, have reached epidemic proportions. Bariatric surgery for severe obesity, performed either laparoscopically or open, has provided significant health benefits to patients. While these surgical procedures are presently the gold standard, they are not devoid of potentially severe complications. Emerging technologies have opened the door for endoscopic approaches to reproduce some of the benefits of weight loss surgery. We present our data from January 2012 to November 2013. Methods: Included are the first 50 patients treated with the U.S. Food and Drug administration-approved commercially available endoscopic suturing device (Overstitch; Apollo Endosurgery, Austin, TX) by performing an endoscopic vertical gastroplasty (EVG). We performed transoral endoscopic gastric volume reduction with a non absorbable 2-0 suture, by placing free-hand, full-thickness, closed spaced interrupted sutures through the gastric wall: these sutures extended from the antrum to the gastro-esophageal junction. Patients included 36 females and 14 males, ages ranging from 16 to 61 years; 8 patients had a BMI O 35 and 42 patients with BMI ! 35. All procedures were performed under general anesthesia. The median procedure time was 110 min. Complications included mild bleeding in 15 that did not require any intervention, and self-limited abdominal pain in one. All patients were discharged the same day. Results: During established follow up at 1, 3, 6 and 12 months, the average weight loss in pounds was 20.46 (nZ48), 35.13 (nZ39), 38.18 (nZ32) and 36.12 (nZ18), respectively. Conclusion: EVG appears to be an effective and safe method in the short-term treatment of obesity
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB265