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Sp705 Endoscopic Resection of a Symptomatic Esophageal Granular Cell Tumor
Abstracts
implications: We present a rare case of IPMN with simultaneous multi-organ fistulization. In this case the fistulization occurred by mechanical penetration in the absence of malignant transformation. IPMN fistulization has been described, although it is a rare clinical entity. There have been very few reported cases of multi-organ fistulization. We demonstrated a multi-modality approach to diagnosis using direct pancreatoscopy, EUS, and ERCP.
Sp704 Prototype Forward Viewing Linear Array Echoendoscope for Management of Upper GI Bleeding Aparna Repaka, Wajeeh Salah, Ashley Faulx, Gerard Isenberg, Amitabh Chak, Richard C.K. Wong Background: Real time EUS imaging of submucosal arteries would be an advance in the management of upper GI bleeding, as it may allow for targeting of therapy and assessment of cessation of blood flow post therapy. However, curvilinear array echoendoscopes currently in use are inadequate. The oblique view limits endoscopic imaging and delivery of therapy. We present for the first time, in a human study, the feasibility of visualizing submucosal arteries with, and delivery of guided hemostatic therapy using a prototype forward-viewing echoendoscope. A 58 year old female patient presented with hematemesis, melena and a 4 gram drop in hemoglobin. She was admitted to the intensive care unit, and resuscitated with blood and IV fluid. Endoscopic methods: Endoscopy was performed with a prototype forward-viewing therapeutic echoendoscope, XGIF-UCT160J-AL5; (Olympus Inc, Tokyo, Japan), which has a 90° US scanner with color Doppler, and a 3.7-mm working channel, without an elevator. An actively bleeding Dieulafoy lesion was seen in the post bulbar duodenum. Thermal therapy with a 10Fr heater probe was performed for hemostasis. Despite adequate post-treatment visual appearance, subsurface arterial blood flow was audible with a through-the-scope doppler ultrasound probe. High resolution endosonographic exam demonstrated multiple deep and superficial blood vessels with active blood flow. Superficial blood vessel’s of upto 0.8 mm in diameter were seen at a depth of upto 3mm. Additional thermal therapy was applied with the heater probe with simultaneous endoscopic and sonographic visualization. Post treatment, doppler flow was absent at shallow depth, and sonographic exam of the the site demonstrated no superficial blood flow. Clinical implications: Real-time sonographic imaging of submucosal blood flow in a bleeding lesion appears feasible with a forward-viewing echoendoscope. Precise targeting of therapy with this echoendoscope is a possibility. This could potentially improve efficacy of hemostasis in GI bleeding, leading to a decrease in re-bleeding rates, and mortality. Larger studies are necessary to delineate efficacy, appropriate indications and limitations of management of GI bleeding with this prototype echoendoscope.
Sp705 Endoscopic Resection of a Symptomatic Esophageal Granular Cell Tumor Stephen Kucera, Neil R. Sharma, Jason Klapman Background: 27 year female presented with intermittent solid food dysphagia. Her symptoms began after laparoscopic band placement for morbid obesity. Her dysphagia persisted despite multiple reductions in the band volume. Upper endoscopy revealed a large, subepithelial lesion in the distal esophagus, which was considered the source of her symptoms. Endoscopic methods: Further assessment of the lesion was performed with endoscopic ultrasound. Endoscopic ultrasound identified a 1.9 x 0.8 cm homogenous, hypoechoic lesion completely contained within the submucosa. Fine needle aspiration was performed and cytology was suggestive of a granular cell tumor. Endoscopic resection was attempted and resulted in complete resection. Submucosal injection lifted the lesion. The lesion was entrapped in a large, barbed snare and completely resected en bloc. No complications occurred. Clinical implications: Granular cell tumors (GCTs) were described first by Abrikossoff in 1926 with the first case involving the esophagus reported in 1931. GCTs are almost always benign and rarely symptomatic. In the esophagus, size greater than 1 cm has been associated with dysphagia. Endoscopic resection can be considered for symptomatic tumors if tumor size is less than 2 cm and if endoscopic ultrasound excludes invasion or attachment to the muscularis propria. We performed a successful endoscopic resection of a large, symptomatic granular cell tumor of the esophagus. Resection resulted in resolution of the patient’s symptoms of dysphagia.
esophagomyotomy is performed if symptoms cannot be relieved by conservative treatment. Efforts to push the boundaries of flexible endoscopy led to the development of a novel endoscopic treatment for achalasia. The feasibility of submucosal esophageal myotomies was demonstrated in a survival animal model and recently, the first clinical series observed favorable results in humans. We describe our early experience and stepwise approach for per oral endoscopic esophageal myotomy as less invasive treatment option for symptomatic achalasia or nutcracker esophagus within an ongoing IRB approved clinical study. Endoscopic methods: Five patients (mean age: 64 ⫾ 11 years; mean BMI 25.3⫾2.0 kg/m2) with symptomatic achalasia were enrolled in an institutional review board approved study and underwent POEM. After mucosal incision approximately 8 cm above the gastro-esophageal junction (GEJ), a submucosal esophageal tunnel was created down to the gastric cardia using hook needleknife cautery. Subsequently, dissection of the inner circular esophageal muscle layer was performed from approximately 4 cm above to 3 cm below the LES. The mucosal entry was then closed by conventional hemostatic clips. Consecutively, passage of the endoscope through the GEJ was evaluated. All patients had postoperative barium esophagograms prior to discharge and clinical follow-up two weeks postoperatively. Clinical implications: All (5/5) patients underwent successful POEM treatment. After the procedure smooth passage of the endosocope through the GEJ was possible in all patients. Mean operative time ranged from 120 to 240 minutes. No leaks were detected in the barium swallow studies and no clinical complications were observed. Mean length of stay was 1.2⫾0.4 days. At the initial follow-up all patients reported immediate symptom relief. This initial observation indicates the safety of the POEM procedure and early clinical results appeared to be promising. Although further evaluation and long-term data are mandatory, POEM could become an important treatment for patients suffering from achalasia.
Sp707 How to Successfully Manage Novel Technical Challenges in Per Oral Endoscopic Myotomy for Achalasia Erwin Rieder, Christy M. Dunst, Silvana Perretta, Gianfranco Donatelli, Lee L. Swanstrom Background: Achalasia is a primary esophageal motility disorder and surgical disruption of the lower esophageal sphincter is usually performed, when conservative approaches failed to be sufficient. Since the first report of laparoscopic Heller myotomy in 1991, minimally invasive techniques have been increasingly used for definitive treatment of achalasia. Efforts in natural orifice translumenal surgery (NOTES) led to the development of novel methods such as submucosal endoscopic myotomy in an animal model. Recently, the clinical implementation of per oral endoscopic myotomy (POEM) was demonstrated. The clinical implementation of such novel procedures might conceal a novel variety of challenges, which have not been dealt with before. We describe the successful management of unexpected difficulties as well as lessons learned in an early clinical series of per oral endoscopic myotomies for the treatment of achalasia. Endoscopic methods: We studied the initial five patients, enrolled in an institutional review board approved trial, who had per oral endoscopic myotomy for symptomatic achalasia. A conventional flexible endoscope with a transparent cap mounted onto the distal end was used. After mucosal incision and entry into the submucosal space, a tunnel within the esophageal wall was created using a blunt dissection or hook needle-knife cautery. The inner circular muscle fibers at the lower esophageal sphincter were then divided at a length of approximately 7 cm. The mucosal incision was then closed using hemostatic clips. All interventions were videotaped and analyzed on unexpected technical difficulties as well as their management were analyzed. Clinical implications: POEM could be successfully performed in all patients (5/5) and resulted in immediate smooth passage of the endoscope through the gastro-esophageal sphincter. Although no clinical complications were observed, novel intraoperative technical challenges were observed. The transparent cap used on the endoscope loosened three times during retrograde movements and was subsequently lost within the submucosal tunnel. Several attempts to remove the submucosal foreign body with graspers or an endoscopic net failed as the cap twisted and was caught underneath the mucosa. With the aid of a balloon catheter the lost cap was finally lined-up with the endoscope and could be safely removed without injuring the esophageal mucosa. POEM appears to be an appealing therapeutic approach for achalasia and the knowledge of basic rescue maneuvers in case of technical challenges might be essential to shorten the learning curve of endoscopists and ensure patient’s safety.
Sp706 Per Oral Endoscopic Myotomy – A Stepwise Approach Erwin Rieder, Lee L. Swanstrom, Christy M. Dunst
Sp708 Clip with Line Method – A Novel Device To Make Counter Traction During ESD Tsuneo Oyama
Background: Esophageal achalasia is an esophageal motility disorder where the lower esophageal sphincter (LES) fails to relax in response to swallowing with no fully understood underlying cause. Dependent on severity, initial treatment is usually based on medication, Botox injection or esophageal dilatation. Surgical
Background: The most important factor in making ESD safer and easier is to maintain good counter traction during ESD. However, making counter traction is sometimes difficult; the resected area is easily turned to distal side and counter traction is often lost in this situation. Previously, gravity was the only way to
AB104 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
implications: We present a rare case of IPMN with simultaneous multi-organ fistulization. In this case the fistulization occurred by mechanical penetration in the absence of malignant transformation. IPMN fistulization has been described, although it is a rare clinical entity. There have been very few reported cases of multi-organ fistulization. We demonstrated a multi-modality approach to diagnosis using direct pancreatoscopy, EUS, and ERCP.
Sp704 Prototype Forward Viewing Linear Array Echoendoscope for Management of Upper GI Bleeding Aparna Repaka, Wajeeh Salah, Ashley Faulx, Gerard Isenberg, Amitabh Chak, Richard C.K. Wong Background: Real time EUS imaging of submucosal arteries would be an advance in the management of upper GI bleeding, as it may allow for targeting of therapy and assessment of cessation of blood flow post therapy. However, curvilinear array echoendoscopes currently in use are inadequate. The oblique view limits endoscopic imaging and delivery of therapy. We present for the first time, in a human study, the feasibility of visualizing submucosal arteries with, and delivery of guided hemostatic therapy using a prototype forward-viewing echoendoscope. A 58 year old female patient presented with hematemesis, melena and a 4 gram drop in hemoglobin. She was admitted to the intensive care unit, and resuscitated with blood and IV fluid. Endoscopic methods: Endoscopy was performed with a prototype forward-viewing therapeutic echoendoscope, XGIF-UCT160J-AL5; (Olympus Inc, Tokyo, Japan), which has a 90° US scanner with color Doppler, and a 3.7-mm working channel, without an elevator. An actively bleeding Dieulafoy lesion was seen in the post bulbar duodenum. Thermal therapy with a 10Fr heater probe was performed for hemostasis. Despite adequate post-treatment visual appearance, subsurface arterial blood flow was audible with a through-the-scope doppler ultrasound probe. High resolution endosonographic exam demonstrated multiple deep and superficial blood vessels with active blood flow. Superficial blood vessel’s of upto 0.8 mm in diameter were seen at a depth of upto 3mm. Additional thermal therapy was applied with the heater probe with simultaneous endoscopic and sonographic visualization. Post treatment, doppler flow was absent at shallow depth, and sonographic exam of the the site demonstrated no superficial blood flow. Clinical implications: Real-time sonographic imaging of submucosal blood flow in a bleeding lesion appears feasible with a forward-viewing echoendoscope. Precise targeting of therapy with this echoendoscope is a possibility. This could potentially improve efficacy of hemostasis in GI bleeding, leading to a decrease in re-bleeding rates, and mortality. Larger studies are necessary to delineate efficacy, appropriate indications and limitations of management of GI bleeding with this prototype echoendoscope.
Sp705 Endoscopic Resection of a Symptomatic Esophageal Granular Cell Tumor Stephen Kucera, Neil R. Sharma, Jason Klapman Background: 27 year female presented with intermittent solid food dysphagia. Her symptoms began after laparoscopic band placement for morbid obesity. Her dysphagia persisted despite multiple reductions in the band volume. Upper endoscopy revealed a large, subepithelial lesion in the distal esophagus, which was considered the source of her symptoms. Endoscopic methods: Further assessment of the lesion was performed with endoscopic ultrasound. Endoscopic ultrasound identified a 1.9 x 0.8 cm homogenous, hypoechoic lesion completely contained within the submucosa. Fine needle aspiration was performed and cytology was suggestive of a granular cell tumor. Endoscopic resection was attempted and resulted in complete resection. Submucosal injection lifted the lesion. The lesion was entrapped in a large, barbed snare and completely resected en bloc. No complications occurred. Clinical implications: Granular cell tumors (GCTs) were described first by Abrikossoff in 1926 with the first case involving the esophagus reported in 1931. GCTs are almost always benign and rarely symptomatic. In the esophagus, size greater than 1 cm has been associated with dysphagia. Endoscopic resection can be considered for symptomatic tumors if tumor size is less than 2 cm and if endoscopic ultrasound excludes invasion or attachment to the muscularis propria. We performed a successful endoscopic resection of a large, symptomatic granular cell tumor of the esophagus. Resection resulted in resolution of the patient’s symptoms of dysphagia.
esophagomyotomy is performed if symptoms cannot be relieved by conservative treatment. Efforts to push the boundaries of flexible endoscopy led to the development of a novel endoscopic treatment for achalasia. The feasibility of submucosal esophageal myotomies was demonstrated in a survival animal model and recently, the first clinical series observed favorable results in humans. We describe our early experience and stepwise approach for per oral endoscopic esophageal myotomy as less invasive treatment option for symptomatic achalasia or nutcracker esophagus within an ongoing IRB approved clinical study. Endoscopic methods: Five patients (mean age: 64 ⫾ 11 years; mean BMI 25.3⫾2.0 kg/m2) with symptomatic achalasia were enrolled in an institutional review board approved study and underwent POEM. After mucosal incision approximately 8 cm above the gastro-esophageal junction (GEJ), a submucosal esophageal tunnel was created down to the gastric cardia using hook needleknife cautery. Subsequently, dissection of the inner circular esophageal muscle layer was performed from approximately 4 cm above to 3 cm below the LES. The mucosal entry was then closed by conventional hemostatic clips. Consecutively, passage of the endoscope through the GEJ was evaluated. All patients had postoperative barium esophagograms prior to discharge and clinical follow-up two weeks postoperatively. Clinical implications: All (5/5) patients underwent successful POEM treatment. After the procedure smooth passage of the endosocope through the GEJ was possible in all patients. Mean operative time ranged from 120 to 240 minutes. No leaks were detected in the barium swallow studies and no clinical complications were observed. Mean length of stay was 1.2⫾0.4 days. At the initial follow-up all patients reported immediate symptom relief. This initial observation indicates the safety of the POEM procedure and early clinical results appeared to be promising. Although further evaluation and long-term data are mandatory, POEM could become an important treatment for patients suffering from achalasia.
Sp707 How to Successfully Manage Novel Technical Challenges in Per Oral Endoscopic Myotomy for Achalasia Erwin Rieder, Christy M. Dunst, Silvana Perretta, Gianfranco Donatelli, Lee L. Swanstrom Background: Achalasia is a primary esophageal motility disorder and surgical disruption of the lower esophageal sphincter is usually performed, when conservative approaches failed to be sufficient. Since the first report of laparoscopic Heller myotomy in 1991, minimally invasive techniques have been increasingly used for definitive treatment of achalasia. Efforts in natural orifice translumenal surgery (NOTES) led to the development of novel methods such as submucosal endoscopic myotomy in an animal model. Recently, the clinical implementation of per oral endoscopic myotomy (POEM) was demonstrated. The clinical implementation of such novel procedures might conceal a novel variety of challenges, which have not been dealt with before. We describe the successful management of unexpected difficulties as well as lessons learned in an early clinical series of per oral endoscopic myotomies for the treatment of achalasia. Endoscopic methods: We studied the initial five patients, enrolled in an institutional review board approved trial, who had per oral endoscopic myotomy for symptomatic achalasia. A conventional flexible endoscope with a transparent cap mounted onto the distal end was used. After mucosal incision and entry into the submucosal space, a tunnel within the esophageal wall was created using a blunt dissection or hook needle-knife cautery. The inner circular muscle fibers at the lower esophageal sphincter were then divided at a length of approximately 7 cm. The mucosal incision was then closed using hemostatic clips. All interventions were videotaped and analyzed on unexpected technical difficulties as well as their management were analyzed. Clinical implications: POEM could be successfully performed in all patients (5/5) and resulted in immediate smooth passage of the endoscope through the gastro-esophageal sphincter. Although no clinical complications were observed, novel intraoperative technical challenges were observed. The transparent cap used on the endoscope loosened three times during retrograde movements and was subsequently lost within the submucosal tunnel. Several attempts to remove the submucosal foreign body with graspers or an endoscopic net failed as the cap twisted and was caught underneath the mucosa. With the aid of a balloon catheter the lost cap was finally lined-up with the endoscope and could be safely removed without injuring the esophageal mucosa. POEM appears to be an appealing therapeutic approach for achalasia and the knowledge of basic rescue maneuvers in case of technical challenges might be essential to shorten the learning curve of endoscopists and ensure patient’s safety.
Sp706 Per Oral Endoscopic Myotomy – A Stepwise Approach Erwin Rieder, Lee L. Swanstrom, Christy M. Dunst
Sp708 Clip with Line Method – A Novel Device To Make Counter Traction During ESD Tsuneo Oyama
Background: Esophageal achalasia is an esophageal motility disorder where the lower esophageal sphincter (LES) fails to relax in response to swallowing with no fully understood underlying cause. Dependent on severity, initial treatment is usually based on medication, Botox injection or esophageal dilatation. Surgical
Background: The most important factor in making ESD safer and easier is to maintain good counter traction during ESD. However, making counter traction is sometimes difficult; the resected area is easily turned to distal side and counter traction is often lost in this situation. Previously, gravity was the only way to
AB104 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org