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Sp697 EUS-Guided Transgastric Pancreatic Duct Stent Placement
ASGE ENDOSCOPIC VIDEO FORUM ABSTRACTS ABSTRACTS FOR PRESENTED VIDEOS
Sp694 Ultrasound Guided Ethanol Ablation of Insulinomas: A New Treatment Option Michael Levy, Mark Topazian Background: Insulinomas account for the majority of functioning islet cell tumors of the pancreas. Surgical enucleation or resection is the standard therapy. We describe treatment by direct EUS and intraoperative ultrasound (IOUS) guided fine needle injection (FNI) of ethanol. In this video we describe the methods and outcomes following EUS and IOUS-guided ethanol injection of insulinomas. To do so we identified patients with symptomatic insulinomas who underwent EUS or IOUS guided ethanol injection. Patients were contacted and charts reviewed to determine outcomes. Endoscopic methods: Six patients (mean age 70; range 57-82) underwent EUS (n⫽4) or IOUS (n⫽2) FNI of 99% ethanol. Surgery was not performed because of comorbidities (n⫽2), recent incomplete resection (n⫽1), or tumor location requiring pancreaticoduodenectomy (n⫽3). Tumors were located in the pancreatic head (n⫽4), body (n⫽1), or tail (n⫽1) and measured 16.6mm (range 11-21) at EUS. For the 2 patients undergoing IOUS, 1 treatment session was performed. For the 4 patients undergoing EUS FNI, a mean of 2.3 (range 1-3) treatment sessions was performed with 3 (range 2-5) injections per session. A volume of 0.75ml (0.12-3.0) and 1.2ml (0.8-1.5) was injected via EUS and IOUS, respectively, per session. No complication developed during or following EUS FNI. Following IOUS one patient had minor bleeding and the other developed a 1.7cm fluid collection in the ablative bed and an 8 cm pseudocyst, which did not require intervention. Clinical implications: Our experience suggests the safety and efficacy of direct EUS or IOUS guided FNI of ethanol for treatment of symptomatic insulinoma. This modality may be appropriate for lesions requiring extensive resection and for poor operative candidates. Further study is needed to refine the technique and clarify its clinical role.
Sp695 EUS Guided Fistulization of Postoperative Colorectal Stenosis in an Infant with Hirschspring’s Disease Everson L. A. Artifon, Renato Baracat, Flávio Coelho Ferreira, Fabio Hondo, Luciano Okawa, Jonas Takada, Eduardo B. da Silveira, Eduardo G. H. Moura, Paulo Sakai Background: Hirschsprung disease consists of a congenital absence of the colonic ganglionic cells of the submucosal and mioenteric plexus, that may be treated by surgical procedure. However the stenosis of the colo-rectal anastomosis is a possible complication that can be treated by endoscopy. We describe a 3 year-old male child patient who underwent proctosigmoidectomy with recto-colonic anastomosis and ileostomy due to Hirschsprung disease. The patient developed a latter stenosis of the recto-colonic anastomosis, and subsequent arrest in growth and weight gain. Then, after multi-disciplinary discussion, the patient was submitted to the endoscopic treatment by means of EUS-guided fistulization between both stumps. Endoscopic methods: The procedure was done with simultaneous colonoscopy and EUS. The proximal stump was identified with the pediatric colonoscope and water mixed with air bubbles was used to facilitate the accuracy of the proximal stump. EUS was used to identify the proximal stump and a 19G needle was used to access this area with passage of a 0,035’ guide-wire. Balloon dilation was made to increase the orifice between the two stumps and a partially covered metal stent was passed successfully. After 2 months the SEMS was removed and the child was then referred to surgery with stabilization of the weight and improvement in nutritional status. Clinical implications: This method allowed the stabilization of the weight and improvement in nutritional status of a patient with stenosis of a colorectal anastomosis and it was proved to be a feasible, safe and efficient method of EUS-guided fistulization with possible application on other case scenarios.
Sp696 Switching it up. EUS-Guided Antegrade Clearance of Biliary Stones in “Duodenal Switch” Surgically Altered Anatomy Stavros N. Stavropoulos, Teodor C. Pitea, Jessica L. Widmer, Michael D. Harris, Michael E. Khalife, James H. Grendell Background: A 52 year old obese woman post “duodenal switch” bariatric surgery presented with pain, fever and LFT, amylase, lipase elevations suggestive of cholangitis. MRCP detected cholelithiasis, CBD stones, a 7 mm CBD and no intrahepatic biliary dilation. In patients with “duodenal switch” anatomy, ERCP is not feasible due to very long enteral limbs. Alternatives include surgical CBD
exploration or percutaneous drainage, procedures with significant morbidity, especially in patients with cholangitis, morbid obesity, non-dilated ducts and RUQ scarring from prior surgery. Laparoscopy-assisted ERCP via enterotomy has only appeared in few case reports and requires coordination of expert surgeon and endoscopist. Based on our significant experience, high safety and efficacy with EUS-assisted biliary access in patients with failed ERCP, we proposed EUSassisted transhepatic CBD stone clearance. The patient, surgical and interventional radiology teams agreed to proceed with this novel approach. Endoscopic methods: A peripheral left system biliary duct with a lumen of only 1.5 mm in diameter was punctured with a 21 Ga needle under EUS guidance. Contrast opacification of the biliary tree via the needle revealed multiple filling defects at the distal CBD. A 0.018 inch wire was inserted via the needle, into the biliary system and advanced under fluoroscopy until it exited the papilla into the duodenum. The tract was dilated to 7 Fr using a Sohendra stent extractor. Balloon sphincteroplasty to 10 mm was performed. An extraction balloon was then used to push the stones into the duodenum. A final cholangiogram confirmed ductal clearance. The gastric puncture site was closed with endoclips. We expected that the 7 Fr tract through the liver would rapidly seal, preventing any significant bile leak, since the generous sphincteroplasty ensured excellent antegrade biliary drainage. Laparoscopic cholecystectomy was performed on the following day and the patient was discharged on hospital day 3. Clinical implications: To the best of our knowledge this is the first reported case of successful, single session, transhepatic CBD stone clearance in a patient with endoscopically inaccessible papilla. It builds on our extensive experience with EUS guided biliary access in patient with failed ERCP. EUS-assisted biliary access is increasingly used at tertiary referral centers. In expert hands, it provides a safe and potentially superior alternative to PTC and surgery. Our report suggests that expanding the indications of this technique to treatment of stones should be explored as part of a multidisciplinary approach with interventional radiology and surgery.
Sp697 EUS-Guided Transgastric Pancreatic Duct Stent Placement Jennifer Maranki, Bryan Sauer, Vanessa Shami, Paul Yeaton Background: Case 1 involves a 37 year old woman with pancreatitis, pseudocyst, and portal vein thrombosis is admitted with abdominal pain and intolerance to tube feeds. CT scan reveals a dilated pancreatic duct and pseudocysts. Conventional ERCP fails due to duodenal edema. EUS-guided transgastric pancreatic duct stent placement is performed, resulting in improved pain, resolution of portal vein thrombosis. Case 2 involves a 69 year old woman with a history of a Whipple who presented with acute pancreatitis, with a CT scan showing a dilated pancreatic duct and a PD stone. EUS-guided transgastric pancreatic duct stent placement is performed, resulting in improved pain, normalization of the pancreatic duct, and resolution of stone. Endoscopic methods: Endoscopic ultrasound is used to identify the dilated pancreatic duct. A 19 gauge needle is used to puncture the duct and a pancreatogram is obtained. A wire is advanced into the duct and transpapillary into the duodenum.Under fluoroscopic guidance, the tract is dilated with bougies and dilating balloons, and a double pigtail stent is placed under fluoroscopic and endoscopic guidance across the pancreaticogastrostomy, with the distal end of the stent in the duodenum. Clinical implications: EUS-guided pancreaticogastrostomy stent placement is a feasible approach in a distinct population of patients with pancreatitis. It is an option for those with altered surgical anatomy as well as for those in whom the clinical condition precludes access to the major papilla by conventional techniques, such as in patients with duodenal edema or gastric outlet obstruction. Case series have been reported that demonstrate it to result in clinical success with an acceptable rate of complications.
Sp698 EUS-Guided Sutured Gastroplexy for ERCP in Patients with Roux-en-Y Gastric Bypass: A Novel Single-Setting Minimally Invasive Approach to Post-Bariatric ERCP Rajeev Attam, Daniel Leslie, Sayeed Ikramuddin, Mustafa Arain, Rafael Andrade, Martin Freeman Background: ERCP in patients with Roux en Y gastric bypass anatomy is a technical challenge. The various options available to access major papilla include deep enteroscopy and surgically or radiologically placed gastrostomy tube. Deep enteroscopy is not successful in reaching papilla in all patients and does not allow the use of a side viewing duodenoscope with an elevator making biliary and pancreatic cannulation difficult. Surgically or radiologically placed gastrostomy tube have their own associated risks and invasiveness. Also, one has
AB102 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Sp694 Ultrasound Guided Ethanol Ablation of Insulinomas: A New Treatment Option Michael Levy, Mark Topazian Background: Insulinomas account for the majority of functioning islet cell tumors of the pancreas. Surgical enucleation or resection is the standard therapy. We describe treatment by direct EUS and intraoperative ultrasound (IOUS) guided fine needle injection (FNI) of ethanol. In this video we describe the methods and outcomes following EUS and IOUS-guided ethanol injection of insulinomas. To do so we identified patients with symptomatic insulinomas who underwent EUS or IOUS guided ethanol injection. Patients were contacted and charts reviewed to determine outcomes. Endoscopic methods: Six patients (mean age 70; range 57-82) underwent EUS (n⫽4) or IOUS (n⫽2) FNI of 99% ethanol. Surgery was not performed because of comorbidities (n⫽2), recent incomplete resection (n⫽1), or tumor location requiring pancreaticoduodenectomy (n⫽3). Tumors were located in the pancreatic head (n⫽4), body (n⫽1), or tail (n⫽1) and measured 16.6mm (range 11-21) at EUS. For the 2 patients undergoing IOUS, 1 treatment session was performed. For the 4 patients undergoing EUS FNI, a mean of 2.3 (range 1-3) treatment sessions was performed with 3 (range 2-5) injections per session. A volume of 0.75ml (0.12-3.0) and 1.2ml (0.8-1.5) was injected via EUS and IOUS, respectively, per session. No complication developed during or following EUS FNI. Following IOUS one patient had minor bleeding and the other developed a 1.7cm fluid collection in the ablative bed and an 8 cm pseudocyst, which did not require intervention. Clinical implications: Our experience suggests the safety and efficacy of direct EUS or IOUS guided FNI of ethanol for treatment of symptomatic insulinoma. This modality may be appropriate for lesions requiring extensive resection and for poor operative candidates. Further study is needed to refine the technique and clarify its clinical role.
Sp695 EUS Guided Fistulization of Postoperative Colorectal Stenosis in an Infant with Hirschspring’s Disease Everson L. A. Artifon, Renato Baracat, Flávio Coelho Ferreira, Fabio Hondo, Luciano Okawa, Jonas Takada, Eduardo B. da Silveira, Eduardo G. H. Moura, Paulo Sakai Background: Hirschsprung disease consists of a congenital absence of the colonic ganglionic cells of the submucosal and mioenteric plexus, that may be treated by surgical procedure. However the stenosis of the colo-rectal anastomosis is a possible complication that can be treated by endoscopy. We describe a 3 year-old male child patient who underwent proctosigmoidectomy with recto-colonic anastomosis and ileostomy due to Hirschsprung disease. The patient developed a latter stenosis of the recto-colonic anastomosis, and subsequent arrest in growth and weight gain. Then, after multi-disciplinary discussion, the patient was submitted to the endoscopic treatment by means of EUS-guided fistulization between both stumps. Endoscopic methods: The procedure was done with simultaneous colonoscopy and EUS. The proximal stump was identified with the pediatric colonoscope and water mixed with air bubbles was used to facilitate the accuracy of the proximal stump. EUS was used to identify the proximal stump and a 19G needle was used to access this area with passage of a 0,035’ guide-wire. Balloon dilation was made to increase the orifice between the two stumps and a partially covered metal stent was passed successfully. After 2 months the SEMS was removed and the child was then referred to surgery with stabilization of the weight and improvement in nutritional status. Clinical implications: This method allowed the stabilization of the weight and improvement in nutritional status of a patient with stenosis of a colorectal anastomosis and it was proved to be a feasible, safe and efficient method of EUS-guided fistulization with possible application on other case scenarios.
Sp696 Switching it up. EUS-Guided Antegrade Clearance of Biliary Stones in “Duodenal Switch” Surgically Altered Anatomy Stavros N. Stavropoulos, Teodor C. Pitea, Jessica L. Widmer, Michael D. Harris, Michael E. Khalife, James H. Grendell Background: A 52 year old obese woman post “duodenal switch” bariatric surgery presented with pain, fever and LFT, amylase, lipase elevations suggestive of cholangitis. MRCP detected cholelithiasis, CBD stones, a 7 mm CBD and no intrahepatic biliary dilation. In patients with “duodenal switch” anatomy, ERCP is not feasible due to very long enteral limbs. Alternatives include surgical CBD
exploration or percutaneous drainage, procedures with significant morbidity, especially in patients with cholangitis, morbid obesity, non-dilated ducts and RUQ scarring from prior surgery. Laparoscopy-assisted ERCP via enterotomy has only appeared in few case reports and requires coordination of expert surgeon and endoscopist. Based on our significant experience, high safety and efficacy with EUS-assisted biliary access in patients with failed ERCP, we proposed EUSassisted transhepatic CBD stone clearance. The patient, surgical and interventional radiology teams agreed to proceed with this novel approach. Endoscopic methods: A peripheral left system biliary duct with a lumen of only 1.5 mm in diameter was punctured with a 21 Ga needle under EUS guidance. Contrast opacification of the biliary tree via the needle revealed multiple filling defects at the distal CBD. A 0.018 inch wire was inserted via the needle, into the biliary system and advanced under fluoroscopy until it exited the papilla into the duodenum. The tract was dilated to 7 Fr using a Sohendra stent extractor. Balloon sphincteroplasty to 10 mm was performed. An extraction balloon was then used to push the stones into the duodenum. A final cholangiogram confirmed ductal clearance. The gastric puncture site was closed with endoclips. We expected that the 7 Fr tract through the liver would rapidly seal, preventing any significant bile leak, since the generous sphincteroplasty ensured excellent antegrade biliary drainage. Laparoscopic cholecystectomy was performed on the following day and the patient was discharged on hospital day 3. Clinical implications: To the best of our knowledge this is the first reported case of successful, single session, transhepatic CBD stone clearance in a patient with endoscopically inaccessible papilla. It builds on our extensive experience with EUS guided biliary access in patient with failed ERCP. EUS-assisted biliary access is increasingly used at tertiary referral centers. In expert hands, it provides a safe and potentially superior alternative to PTC and surgery. Our report suggests that expanding the indications of this technique to treatment of stones should be explored as part of a multidisciplinary approach with interventional radiology and surgery.
Sp697 EUS-Guided Transgastric Pancreatic Duct Stent Placement Jennifer Maranki, Bryan Sauer, Vanessa Shami, Paul Yeaton Background: Case 1 involves a 37 year old woman with pancreatitis, pseudocyst, and portal vein thrombosis is admitted with abdominal pain and intolerance to tube feeds. CT scan reveals a dilated pancreatic duct and pseudocysts. Conventional ERCP fails due to duodenal edema. EUS-guided transgastric pancreatic duct stent placement is performed, resulting in improved pain, resolution of portal vein thrombosis. Case 2 involves a 69 year old woman with a history of a Whipple who presented with acute pancreatitis, with a CT scan showing a dilated pancreatic duct and a PD stone. EUS-guided transgastric pancreatic duct stent placement is performed, resulting in improved pain, normalization of the pancreatic duct, and resolution of stone. Endoscopic methods: Endoscopic ultrasound is used to identify the dilated pancreatic duct. A 19 gauge needle is used to puncture the duct and a pancreatogram is obtained. A wire is advanced into the duct and transpapillary into the duodenum.Under fluoroscopic guidance, the tract is dilated with bougies and dilating balloons, and a double pigtail stent is placed under fluoroscopic and endoscopic guidance across the pancreaticogastrostomy, with the distal end of the stent in the duodenum. Clinical implications: EUS-guided pancreaticogastrostomy stent placement is a feasible approach in a distinct population of patients with pancreatitis. It is an option for those with altered surgical anatomy as well as for those in whom the clinical condition precludes access to the major papilla by conventional techniques, such as in patients with duodenal edema or gastric outlet obstruction. Case series have been reported that demonstrate it to result in clinical success with an acceptable rate of complications.
Sp698 EUS-Guided Sutured Gastroplexy for ERCP in Patients with Roux-en-Y Gastric Bypass: A Novel Single-Setting Minimally Invasive Approach to Post-Bariatric ERCP Rajeev Attam, Daniel Leslie, Sayeed Ikramuddin, Mustafa Arain, Rafael Andrade, Martin Freeman Background: ERCP in patients with Roux en Y gastric bypass anatomy is a technical challenge. The various options available to access major papilla include deep enteroscopy and surgically or radiologically placed gastrostomy tube. Deep enteroscopy is not successful in reaching papilla in all patients and does not allow the use of a side viewing duodenoscope with an elevator making biliary and pancreatic cannulation difficult. Surgically or radiologically placed gastrostomy tube have their own associated risks and invasiveness. Also, one has
AB102 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org