Abstracts
create counter traction during ESD. However, sometimes we could not create good counter traction by changing the position of the patient. I developed a novel device to make good counter traction during ESD (Clip with line method). In 34 cases of esophageal and 24 cases of gastric cancer, ESD was performed with this new method and effective counter traction was achieved in all cases. Endoscopic methods: At first, a thin line was tied at the arm part of easy clip (HX-610-090S, Olympus, Tokyo). And the clip was returned to the cassette again. When effective counter traction was difficult to obtain during esophageal ESD, the clip with the line was attached to the oral side of the lesion. Next, the line was gradually pulled. Then the resected part was pulled to the oral side and effective counter traction was obtained. Also this method created a clearer visual field of submucosal layer to work in. The clip with line method is also useful for gastric ESD, when the cancer located in the greater curvature of gastric body. This is one of the most difficult locations to perform ESD. The clip with the line, attached to the anal side, created sufficient counter traction when the line was pulled gradually. This allows you to perform ESD more safely and with greater ease. Clinical implications: Clip with line method is effective in making sufficient counter traction for esophageal ESD as well as creating a clear visual field. They are very important factors to make ESD safer and easier. This method is effective in gastric ESD when the cancer is located on the greater curvature of the gastric body. The gastric body is one of the most difficult areas to perform ESD because there are lots of adipose tissue and thick vessels in the submucosal layer. However, establishing sufficient counter traction makes performing submucosal dissection easier. Therefore, Clip with line method is a very useful device for both esophageal and gastric ESD.
Sp709 Applications of a Novel Endoscopic Suturing Device in the GI Tract Rabindra R. Watson, Christopher C. Thompson Background: Complications of gastrointestinal surgery often require operative reintervention. Endoscopic suturing may provide a minimally-invasive treatment alternative. A novel endoscopic suturing device is evaluated in the treatment of a variety of post-surgical conditions. Endoscopic methods: The endoscopic suturing device being evaluated is a cap-based system mounted on a dualchannel gastroscope. It utilizes a tissue anchor passed between a curved suturing arm and anchor exchange to create full-thickness plications in the GI tract. The device is evaluated in three situations: 1) Oversewing of a recalcitrant marginal ulceration, 2) Stomal reduction for weight regain following Roux-en-y gastric bypass surgery, 3) Closure of a recto-vaginal fistula complicating a low anterior resection for rectal cancer. Clinical implications: The application of this novel endoscopic suturing device to a variety of lesions appears feasible. Simplicity of handle operation, precise suture placement with direct visualization, and the ability to reload and cinch sutures without removing the endoscope are favorable characteristics of this device. Further uses are currently being explored including pouch reduction after gastric bypass surgery, suturing of endoluminal stents in place, and closure of a variety of fistulas throughout the GI tract. In the future, broad applications may be envisioned encompassing perforation repair, primary treatment of obesity, and transluminal endoscopic surgery.
Sp710 Temporary Gastric Electrical Stimulation for Gastroparesis: Endoscopic Placement of Electrodes (ENDOStim) Sumanth R. Daram, Shou Jiang Tang, Thomas Abell Background: High frequency, low energy gastric electrical stimulation (GES) has been shown to be an effective management strategy for patients with medication refractory gastroparesis. However, placement of a permanent GES device requires surgery. Moreover, it has considerable cost considerations. More importantly, this mode of therapy may not be successful in all gastroparetic patients. We have previously demonstrated that patients likely to benefit from such an invasive and expensive procedure could be selected on the basis of their response to temporary GES. Electrodes for the purpose of temporary GES are usually placed percutaneously or through a PEG tube (PEGStim). We have demonstrated a less cumbersome and easier placement of these electrodes endoscopically. The present case is a female patient with Idiopathic Gastroparesis who underwent placement of temporary GES electrodes endoscopically. This innovative technique of endoscopic placement of electrodes for temporary GES is demonstrated. Endoscopic methods: Standard esophagogastroduodenoscopy (EGD) was initially performed. Then, an area as close as possible to the junction of the antrum and the body of the stomach, along the greater curvature was selected. Then, a temporary cardiac pacing lead was inserted through the accessory channel. The lead was implanted into the gastric mucosa with a clockwise corkscrew motion. Then, 3 endo-clips were applied to secure the lead in place within the stomach. Placing at least one clip near the distal metallic terminal part of the lead helped to achieve the desired electrical impedance. A naso-gastric transfer of the temporary leads was then performed. The above steps were then repeated for the placement of a second
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temporary pacing lead in the more proximal portion of the stomach along the greater curvature. The leads were then connected to an external Gastric Electrical Stimulation (GES) device that was placed in a cardiac telemetry pouch. Clinical implications: GES with a permanently implanted device has been shown to be an effective treatment for medication-refractory gastroparesis. Placement of a permanent GES device requires an elective surgical procedure. Temporary GES can help predict improvement in symptoms before surgical placement of GES device is undertaken. Electrodes for temporary GES can be placed through a PEG tube. However, in patients such as the present case, who do not have a pre-existing PEG tube, we have demonstrated that endoscopic placement of electrodes is technically feasible. Results obtained correlate with those obtained by PEGStim.In the present patient, temporary GES produced a rapid and marked improvement in her intractable symptoms caused by gastroparesis as well as an improvement in her EGG parameters and Gastric Emptying. She is likely to benefit from surgical placement of a permanent GES device. Thus, we propose ENDOStim as the preferred method of placement of electrodes for temporary GES.
Sp711 Complete Endoscopic Division of a Large Windsock Intraduodenal Diverticulum Using Combined Techniques Douglas A. Howell, David Y. Lo Background: Windsock intraduodenal diverticula are rare congenital webs usually located in the mid-portion of the second duodenum. Over time, the web elongates producing obstruction and intussusception. The original endoscopic treatment of this disorder was to amputate or fenestrate the tip of the diverticulum, but complications and failures have been reported. Cutting down from above using clips to prevent bleeding has more recently been presented, but complete division has not been done due to their long length. This case is of a 15 y.o. male with a 12 year history of intermittent vomiting and reflux which recently worsened to nightly upper abdominal pain with vomiting of small amounts of blood. Sideviewing endoscopy revealed a large windsock intraduodenal diverticulum, confirmed on barium swallow X-ray and CT scan. Patient then referred for endoscopic treatment. Endoscopic methods: The procedure begins with puncture at the tip of the diverticulum with a needle knife followed by guidewire insertion down the true duodenal lumen and extension with a sphincterotome. The endoscope is withdrawn leaving the guidewire in place and grasped at the patient’s mouth. The scope is reinserted into the true lumen. The free end of the guidewire is then grasped, pulled thru the biopsy channel. A sphincterotome incision is made from the true lumen side up to thick mouth of the windsock. The guidewire is again left in place as the scope is withdrawn, looping the wire around the windsock’s upper rim and held at the patient’s mouth. Finally, large clips are placed left and right of the guidewire loop to control bleeding and the remaining rim is divided with a needle knife. Additional clips are then placed. The final appearance is recorded six weeks with complete division and retraction of the walls of the diverticulum are noted. Clinical implications: The procedure this video presents depicts a combination of the two earlier techniques which resulted in complete division of the diverticular wall from its tip through the upper rim or mouth, while minimizing the risks of perforation and bleeding. Complete division permitted retraction of the diverticular wall and should avoid recurrent obstruction and intussusception permanently. The patient has had immediate and lasting relief.
Sp712 Endoscopic Closure of a Gastrotracheal Fistula Using a Cardiac Septal Occluder Device Hyun Soo Chung, Hyun Jung Lee, Jae Young Choi, Kyung Jong Lee, Hae Keum Kil, Yong Chan Lee Background: Anastomotic leak after esophagectomy and gastric pull-up surgery occurs in 5% to 29% of patients and is associated with a mortality rate of up to 60%. The treatment options are surgery, external drainage, and endoscopic treatment. we presents a gastrotracheal fistula that was successfully treated with a cardiac septal occluder device designed for percutaneous closure of atrial septal defects. The device was deployed under direct visualization through an endoscope and follow-up endoscopy showed complete closure of the fistula. At the immediate, 1- and 3-month follow-up, endoscopic and radiologic evaluation confirmed stable fistula closure by the occluder. Endoscopic methods: The procedure was performed with the patient under deep sedation, using a regular single-channel gastroscope. A guidewire was inserted into fistula orifice from the stomach side to tracheal side and the endoscope was withdrawn. And next, bronchoscope was inserted into trachea to grasp the end of the previously inserted guidewire and the bronchoscope was withdrawn. Then, the guidewire left in situ with both ends coming out of the mouth. The occluder was then introduced from the gastric side to the trachea on the guidewire under fluoroscopic and bronchoscopic control. Once the proper position was confirmed, an pediatric interventional cardiologist released the device by turning the cable counterclockwise, first on the tracheal side and then on the gastric side. Clinical implications: We described the successful use of a cardiac septal
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
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