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Sp273: Endoscopic Submucosal Myotomy for the Treatment of Achalasia
ASGE ENDOSCOPIC VIDEO FORUM ABSTRACTS PRESENTED VIDEOS Sp269 Harnessing the Power of Magnets: Novel Uses in Advanced Endoscopic Therapies Marvin K. Ryou*, Padraig Cantillon-Murphy, Sohail Shaikh, Dan Azagury, Gabriel Ha, Jeffrey Lang, Christopher Thompson
Sp272 “Tulip Bundle Technique” A Novel Technique for Closing Perforations Caused by Endoscopic Resection, by Placement of Clips and Approximation with Endoloops Roos E. Pouw*, Fiebo J. ten Kate, Jacques J. Bergman
Background: Magnets have previously been shown to be useful in endoscopic foreign body removal, EMR, and also in a NOTES surgical/navigation system. Endoscopic methods: Three endoscopic applications are presented that feature the novel use of rare-earth magnets. (1) NOTES magnetic retraction using and external magnet interacting with smaller endoscopically delivered magnets affixed to organs requiring retraction. (2) Magnetically, retrievable pancreaticobiliary stents, obviating the need for a follow-up endoscopy. (3) Compression anastomosis using endoscopically delivered, smart, self-assembling magnets. Clinical implications: The applications presented herin offer potential solutions to (1) NOTES retraction, (2) pancreaticobiliary stent retrieval, and (3) endoscopoic means of gastrojejunostomy and cholecysto-gastrostomy creation.
Background: Endoscopic resection in the gastrointestinal tract may be complicated by a perforation. Next to conservative and surgical management, perforations can also be treated endoscopically. Endoscopic treatment may be useful in elderly patients who are unfit for surgery and in the case of perforations that are too large for conservative treatment. Aim of this video was to present two cases of endoscopic resection complicated by a large perforation, which were both treated with the “tulip bundle technique”. Endoscopic methods: For the “tulip bundle technique” clips were placed around the luminal defect on the edges of the perforation. Then an endoloop was introduced, opened and placed around the clips. By closing the endoloop, the clips were bundled together and the wound edges were approximated. After closure of the defect a watery contrast swallowing examination was performed to check for signs of leakage and patients were submitted with nil per os, a naso-gastric suction tube and intravenous administration of PPI’s and antibiotics. Both patients were discharged home after 6 and 7 days. Clinical implications: Based on these experiences, the ‘tulip bundle technique’ appears to be a useful technique to endoscopically close large luminal defects that may complicate endoscopic resection.
Sp270 From Bypass to Thruway: Endoscopic Creation of a GastroGastric Conduit for Reversal of Gastric Bypass Mihir S. Wagh*, D. Eli Penn, Chris E. Forsmark Background: A 44 year old female with a past history of Roux-en-Y gastric bypass underwent an emergent antrectomy for a perforated peptic ulcer. This resulted in a completely excluded remnant stomach which required a permanent surgical gastrostomy tube for drainage. She was felt to be a poor surgical candidate and endoscopic reversal of the gastric bypass was requested due to persistent obstructive symptoms. Endoscopic methods: Simultaneous antegrade and retrograde endoscopy via the mouth and G-tube tract was used to connect the gastric pouch to the excluded stomach. A 19-gauge EUS needle was advanced from the gastric pouch and was seen entering the excluded gastric remnant on simultaneous retrograde endoscopy and fluoroscopy. The newly created gastro-gastric tract was successfully balloon dilated over a wire. The retrograde endoscope could then be advanced into the gastric pouch through the newly created gastro-gastric conduit. A 10 mm by 4 cm fully covered metal biliary stent was placed across this tract, reconnecting the pouch to the excluded gastric remnant. The G-tube was clamped and there was prompt relief of symptoms after stent placement. The stent was electively removed after one week as planned. The gastro-gastric tract was widely patent and was serially dilated with CRE balloons. Clinical implications: We demonstrate the successful creation of a gastro-gastric conduit after gastric bypass using simultaneous antegrade and retrograde endoscopy (SARE) with fluoroscopic guidance. This technique can be used to reconnect the gastric pouch with the excluded stomach for endoscopic reversal of gastric bypass surgery, if required in select patients.
Sp271 Gastric Endoscopic Submucosal Dissection (ESD) with a New Traction Method: The Clip-Band Technique Adolfo Parra-Blanco*, David Nicola´s-Pe´rez, Maria Rosa Arnau, Antonio Gimeno-Garcı´a, Luis Rodrigo Sa´ez, Enrique Quintero Background: ESD is technically challenging. The most difficult part is the submucosal dissection. Several traction methods have been proposed to improve visibility of the submucosal dissection plane. We propose a new and simple, traction method for gastric ESD, which we have tried before in a feasibility study in a live porcine model. We present a case series of four patients (five lesions) who underwent gastric ESD with a new traction method. Resection could be achieved in all cases without significant complications, and there has been no recurrence in a mean 14 month follow up. The mean time for circumferential cutting was 16 minutes (2-27), and the mean time for submucosal dissection was 26 min (6-55). The mean diameter of lesions was 24 mm (16-40). Endoscopic methods: This new method includes the use of two reopenable clips and a rubber band (4-6 mm), and it begins when the circumferential cutting has been completed. Outside the endoscope, the band is clamped with the first clip. Then they are inserted in the channel, and the clip and band are attached to inner margin of the resected mucosa. Thereafter, the band is clamped with the second clip, which is advanced to the distal normal mucosa, where it is attached. The dissection can be continued now, with improved visibility of the submucosa. Clinical implications: Submucosal dissection is the most difficult stage of ESD, especially for beginners, and this can lead to incomplete resections. Our case series shows that this method is feasible in humans, and that ESD can be completed safely and reasonably quickly. The method proposed may enable beginners to attempt gastric ESD.
www.giejournal.org
Sp273 Endoscopic Submucosal Myotomy for the Treatment of Achalasia Stavros N. Stavropoulos*, Harris, Hida S, Brathwaite, Demetriou CA, Grendell, JH Background: Surgical myotomy is recommended as the primary therapy for low surgical risk achalasia patients. However, it has a 5-10% perforation risk, a high incidence of acid reflux without concomitant fundoplication and 25-38% long term relapse. Endoscopic needle-knife myotomy for achalasia was described in a 1980 study but this study was never replicated. Submucosal endoscopy with mucosal flap was recently reported as a technique to ensure secure closure after interventions involving the muscularis. In 2007, Pasricha et al reported use of this approach to perform endoscopic myotomy in a porcine survival model. In 2009, Inoue et al reported in abstract form the first human application of this technique. No other human cases have been reported. We present our experience with the first clinical application of this technique in a 42 y.o. man with achalasia referred for myotomy. Endoscopic methods: Informed consent and IRB permission was obtained to perform endoscopic submucosal myotomy. A submucosal tunnel was created and intubated as previously described. The circular muscle was incised over a length of 6 cm. The tunnel was closed with clips. No complications noted. The patient was discharged on postoperative day 2. Dysphagia resolved and manometry and barium esophagography demonstrated marked improvement. Clinical implications: Further study of endoscopic submucosal myotomy is warranted based on favorable preliminary experience. A feasibility study is currently under way at our institution.
Sp274 Gallstone Ileus: Endoscopic Management Haritha Avula*, Michael Chiorean, Glen Lehman, Lee McHenry Background: 55 year old woman presented with intermittent periumbilical abdominal pain and nausea of two months duration. She had extensive prior abdominal surgical history including ovarian cancer resection complicated by colonic perforation. This was treated with segmental colonic resection and temporizing ileostomy. Subsequently ileostomy take down and ileo-ileal anastamosis was performed. Last surgery was approximately 1 year ago. CT scan of the abdomen on presentation and on repeat scan 1 month later showed a large stone measuring 3 by 2 cm with a characteristic central hypodense core in the distal ileum. In addition a mild dilation of the ileum up to 3.2 cm was noted. There were no stones in a small gallbladder. Of note on a CAT scan done 6 months prior to presentation, similar appearing stone was noted in the gallbladder. Patient’s clinical presentation in conjunction with serial CAT scan findings was consistent with intermittent ileus secondary to a large gallstone, which passed spontaneously in to the ileum. Endoscopic management was felt to be less invasive option compared to surgery due to prior extensive abdominal surgical history. Endoscopic methods: Retrograde double balloon enteroscopy was performed to access the ileum. At approximately 30 cm proximal to the ileocecal valve, significant resistance to advancement of the enteroscope was
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB99
Sp272 “Tulip Bundle Technique” A Novel Technique for Closing Perforations Caused by Endoscopic Resection, by Placement of Clips and Approximation with Endoloops Roos E. Pouw*, Fiebo J. ten Kate, Jacques J. Bergman
Background: Magnets have previously been shown to be useful in endoscopic foreign body removal, EMR, and also in a NOTES surgical/navigation system. Endoscopic methods: Three endoscopic applications are presented that feature the novel use of rare-earth magnets. (1) NOTES magnetic retraction using and external magnet interacting with smaller endoscopically delivered magnets affixed to organs requiring retraction. (2) Magnetically, retrievable pancreaticobiliary stents, obviating the need for a follow-up endoscopy. (3) Compression anastomosis using endoscopically delivered, smart, self-assembling magnets. Clinical implications: The applications presented herin offer potential solutions to (1) NOTES retraction, (2) pancreaticobiliary stent retrieval, and (3) endoscopoic means of gastrojejunostomy and cholecysto-gastrostomy creation.
Background: Endoscopic resection in the gastrointestinal tract may be complicated by a perforation. Next to conservative and surgical management, perforations can also be treated endoscopically. Endoscopic treatment may be useful in elderly patients who are unfit for surgery and in the case of perforations that are too large for conservative treatment. Aim of this video was to present two cases of endoscopic resection complicated by a large perforation, which were both treated with the “tulip bundle technique”. Endoscopic methods: For the “tulip bundle technique” clips were placed around the luminal defect on the edges of the perforation. Then an endoloop was introduced, opened and placed around the clips. By closing the endoloop, the clips were bundled together and the wound edges were approximated. After closure of the defect a watery contrast swallowing examination was performed to check for signs of leakage and patients were submitted with nil per os, a naso-gastric suction tube and intravenous administration of PPI’s and antibiotics. Both patients were discharged home after 6 and 7 days. Clinical implications: Based on these experiences, the ‘tulip bundle technique’ appears to be a useful technique to endoscopically close large luminal defects that may complicate endoscopic resection.
Sp270 From Bypass to Thruway: Endoscopic Creation of a GastroGastric Conduit for Reversal of Gastric Bypass Mihir S. Wagh*, D. Eli Penn, Chris E. Forsmark Background: A 44 year old female with a past history of Roux-en-Y gastric bypass underwent an emergent antrectomy for a perforated peptic ulcer. This resulted in a completely excluded remnant stomach which required a permanent surgical gastrostomy tube for drainage. She was felt to be a poor surgical candidate and endoscopic reversal of the gastric bypass was requested due to persistent obstructive symptoms. Endoscopic methods: Simultaneous antegrade and retrograde endoscopy via the mouth and G-tube tract was used to connect the gastric pouch to the excluded stomach. A 19-gauge EUS needle was advanced from the gastric pouch and was seen entering the excluded gastric remnant on simultaneous retrograde endoscopy and fluoroscopy. The newly created gastro-gastric tract was successfully balloon dilated over a wire. The retrograde endoscope could then be advanced into the gastric pouch through the newly created gastro-gastric conduit. A 10 mm by 4 cm fully covered metal biliary stent was placed across this tract, reconnecting the pouch to the excluded gastric remnant. The G-tube was clamped and there was prompt relief of symptoms after stent placement. The stent was electively removed after one week as planned. The gastro-gastric tract was widely patent and was serially dilated with CRE balloons. Clinical implications: We demonstrate the successful creation of a gastro-gastric conduit after gastric bypass using simultaneous antegrade and retrograde endoscopy (SARE) with fluoroscopic guidance. This technique can be used to reconnect the gastric pouch with the excluded stomach for endoscopic reversal of gastric bypass surgery, if required in select patients.
Sp271 Gastric Endoscopic Submucosal Dissection (ESD) with a New Traction Method: The Clip-Band Technique Adolfo Parra-Blanco*, David Nicola´s-Pe´rez, Maria Rosa Arnau, Antonio Gimeno-Garcı´a, Luis Rodrigo Sa´ez, Enrique Quintero Background: ESD is technically challenging. The most difficult part is the submucosal dissection. Several traction methods have been proposed to improve visibility of the submucosal dissection plane. We propose a new and simple, traction method for gastric ESD, which we have tried before in a feasibility study in a live porcine model. We present a case series of four patients (five lesions) who underwent gastric ESD with a new traction method. Resection could be achieved in all cases without significant complications, and there has been no recurrence in a mean 14 month follow up. The mean time for circumferential cutting was 16 minutes (2-27), and the mean time for submucosal dissection was 26 min (6-55). The mean diameter of lesions was 24 mm (16-40). Endoscopic methods: This new method includes the use of two reopenable clips and a rubber band (4-6 mm), and it begins when the circumferential cutting has been completed. Outside the endoscope, the band is clamped with the first clip. Then they are inserted in the channel, and the clip and band are attached to inner margin of the resected mucosa. Thereafter, the band is clamped with the second clip, which is advanced to the distal normal mucosa, where it is attached. The dissection can be continued now, with improved visibility of the submucosa. Clinical implications: Submucosal dissection is the most difficult stage of ESD, especially for beginners, and this can lead to incomplete resections. Our case series shows that this method is feasible in humans, and that ESD can be completed safely and reasonably quickly. The method proposed may enable beginners to attempt gastric ESD.
www.giejournal.org
Sp273 Endoscopic Submucosal Myotomy for the Treatment of Achalasia Stavros N. Stavropoulos*, Harris, Hida S, Brathwaite, Demetriou CA, Grendell, JH Background: Surgical myotomy is recommended as the primary therapy for low surgical risk achalasia patients. However, it has a 5-10% perforation risk, a high incidence of acid reflux without concomitant fundoplication and 25-38% long term relapse. Endoscopic needle-knife myotomy for achalasia was described in a 1980 study but this study was never replicated. Submucosal endoscopy with mucosal flap was recently reported as a technique to ensure secure closure after interventions involving the muscularis. In 2007, Pasricha et al reported use of this approach to perform endoscopic myotomy in a porcine survival model. In 2009, Inoue et al reported in abstract form the first human application of this technique. No other human cases have been reported. We present our experience with the first clinical application of this technique in a 42 y.o. man with achalasia referred for myotomy. Endoscopic methods: Informed consent and IRB permission was obtained to perform endoscopic submucosal myotomy. A submucosal tunnel was created and intubated as previously described. The circular muscle was incised over a length of 6 cm. The tunnel was closed with clips. No complications noted. The patient was discharged on postoperative day 2. Dysphagia resolved and manometry and barium esophagography demonstrated marked improvement. Clinical implications: Further study of endoscopic submucosal myotomy is warranted based on favorable preliminary experience. A feasibility study is currently under way at our institution.
Sp274 Gallstone Ileus: Endoscopic Management Haritha Avula*, Michael Chiorean, Glen Lehman, Lee McHenry Background: 55 year old woman presented with intermittent periumbilical abdominal pain and nausea of two months duration. She had extensive prior abdominal surgical history including ovarian cancer resection complicated by colonic perforation. This was treated with segmental colonic resection and temporizing ileostomy. Subsequently ileostomy take down and ileo-ileal anastamosis was performed. Last surgery was approximately 1 year ago. CT scan of the abdomen on presentation and on repeat scan 1 month later showed a large stone measuring 3 by 2 cm with a characteristic central hypodense core in the distal ileum. In addition a mild dilation of the ileum up to 3.2 cm was noted. There were no stones in a small gallbladder. Of note on a CAT scan done 6 months prior to presentation, similar appearing stone was noted in the gallbladder. Patient’s clinical presentation in conjunction with serial CAT scan findings was consistent with intermittent ileus secondary to a large gallstone, which passed spontaneously in to the ileum. Endoscopic management was felt to be less invasive option compared to surgery due to prior extensive abdominal surgical history. Endoscopic methods: Retrograde double balloon enteroscopy was performed to access the ileum. At approximately 30 cm proximal to the ileocecal valve, significant resistance to advancement of the enteroscope was
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB99