- Email: [email protected]
Successful endoscopic treatment of a double duodenal web in an infant
Brief Reports 14. Kahaleh M, Hernandes AJ, Tokar J, et al. EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts. Gastrointest Endosc 2007;65:224-30. 15. Barkay O, Sherman S, McHenry Lee, et al. Therapeutic EUS-assisted endoscopic retrograde pancreatography after failed pancreatic duct cannulation at ERCP. Gastrointest Endosc 2010;71:1166-73. 16. Simmons DT, Baron TH, LeRoy A, et al. Percutaneous pancreatography for treatment of complicated pancreatic duct strictures. Pancreatology 2008;8:194-8.
Current affiliations: Department of Gastroenterology and Hepatology (T.I., K.I., A.S., F.I.), Tokyo Medical University, Tokyo, Japan, Shizuoka General Hospital (M.K., K.M.), Shizuoka, Japan. Reprint requests: Takao Itoi, MD, Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.07.010
Successful endoscopic treatment of a double duodenal web in an infant Arrigo Barabino, MD, Paolo Gandullia, MD, Serena Arrigo, MD, Silvia Vignola, MD, Girolamo Mattioli, MD, Claudia Grattarola, MD Genoa, Italy
Figure 1. An upper GI radiograph before endoscopic therapy. Figure 2. The insulated-tip diathermic knife and the proximal duodenal web with the little central opening.
Duodenal webs are congenital disorders causing partial duodenal endoluminal obstruction. Projectile vomiting, often bile stained, is the major presenting symptom. The experience of endoscopic treatment in pediatric patients is limited. We report a case of a female infant with a double duodenal web, endoscopically treated by using a device normally used for mucosectomy in adults.
CASE REPORT An 11-month-old female, born of an uncomplicated, full-term gestation, was seen in our unit for recurrent, projectile, sometimes bile-stained vomiting. Physical examination and laboratory test evaluation were unremarkable. The patient weighed 8.180 kg (10th percentile), and her height was 70.5 cm (10th-25th percentile). Upper GI radiographs demonstrated a dilated duodenum with a curvilinear stop in its second segment, consistent with a duodenal web (Fig. 1). Therapeutic endoscopy under general anesthesia was performed, with pediatric surgeons in www.giejournal.org
attendance in case of failure or complications. A standard videogastroscope (8.6 mm A, GIF 160; Olympus, Milan, Italy) was used. The duodenal web, with a central aperture of nearly 2 mm in diameter, was confirmed. The papilla of Vater was not detected. An insulated-tip diathermic knife (ITDK; M.G. Lorenzatto, Turin, Italy), inserted through the endoscope channel and connected to an electrosurgical intelligent workstation (ICC 200 E; ERBE, Marietta, GA), was placed into the opening (Fig. 2). Afterward, a mixed cutting and cautery of the web was done, with the ENDO-CUT mode set at 80/40 W, respectively. To avoid potential trauma of the Vater papilla, thought to be posterior and adjacent to the left side, we then performed a radial membranotomy at the 3-o’clock position. When the opening was large enough, we noticed another distal, translucent, fibrous membrane with vessels into its thickness (Fig. 3). It had an eccentric, wide opening that required a short incision at the 3-o’clock position for easy passage by the instrument, which eventually Volume 73, No. 2 : 2011 GASTROINTESTINAL ENDOSCOPY 401
Brief Reports
Figure 3. A close view of the distal, fibrous duodenal web with the large, eccentric opening. Figure 5. Upper GI radiograph obtained 1 month after membranotomy.
Figure 4. The distal view after endoscopic treatment. Arrows: A, Proximal duodenal web. B, Distal duodenal web. C, membranotomy of the proximal duodenal web at the 3-o’clock position.
reached the third duodenal segment (Fig. 4). The papilla of Vater was not identified. Although the patient remained asymptomatic, serum amylase and lipase levels, checked 6 hours after the procedure, were both increased (753 IU/L [normal ⬍100 IU/L] and 1942 IU/L [⬍60], respectively), with normal liver function test results. With fasting maintained, the pancreatic profile recovered within 24 hours, and the baby was able to tolerate a full, normal diet the day after. The patient was discharged on day 3. One month later, the patient weighed 8.7 kg (10-25th percentile), and upper GI radiographs performed at that time showed an evident reduction of the duodenal dilatation and reversion of the previous stop (Fig. 5). The girl has remained asymptomatic with good growth for 6 months of follow-up.
described in pediatric patients so far. We were able to obtain a successful result by using an ITDK normally used in adults for mucosectomy. The device has an insulated ball in its tip to avoid lesions beyond the diaphragm. In respect to a sphincterotome, the ITDK is, for us, much safer against forward perforation, is easier to handle, and allows better cutting control. In our case, ITDK was particularly useful because another duodenal web was found distally. A double duodenal web as a cause of intrinsic duodenal obstruction is a rare malformation,5 and, to our knowledge, this is the first pediatric case with a double duodenal web successfully reversed with endoscopic treatment. The Vater papilla was not identified, but it was thought to be in the left side of the narrow space between the two duodenal webs. Considering the total heat energy delivered during the procedure in so little a patient, we hypothesize that the postoperative increase of the pancreatic enzyme levels was probably related to a “transmural burn syndrome”6 because of thermal injury and edema of the contiguous glandular parenchyma. Our experience adds information about operative endoscopy for duodenal webs in children. We suggest the use of an ITDK to avoid potential injury beyond the diaphragm and alert the reader about the potential pancreatic damage from electrical current. The decision to approach a duodenal web endoscopically in children should take into account the technical skill of the endoscopist and the ready availability of pediatric surgeons.
DISCUSSION
DISCLOSURE
The reported endoscopic treatment of duodenal webs in newborns and children is limited. Laser therapy,1 sphincterotome incision,2 high-frequency-wave snare/ cutter,3 and hot biopsy forceps with dilatation4 have been
All authors disclosed no financial relationships relevant to this publication.
402 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 2 : 2011
Abbreviation: ITDK, insulated-tip diathermic knife.
www.giejournal.org
Brief Report
REFERENCES 1. Kay GA, Lobe TE, Custer MD, et al. Endoscopic laser ablation of obstructing congenital duodenal webs in the newborn: a case report of limited success with criteria for patient selection. J Pediatr Surg 1992;27:279-81. 2. Torroni F, De Angelis P, Caldaro T, et al. Endoscopic membranectomy of duodenal diaphragm: pediatric experience. Gastrointest Endosc 2006;63: 530-1. 3. Nose S, Kubota A, Kawahara H, et al. Endoscopic membranectomy with a high-frequency-wave snare/cutter for membranous stenosis in the upper gastrointestinal tract. J Pediatr Surg 2005;40:1486-8. 4. Beeks A, Gosche J, Giles H, et al. Endoscopic dilatation and partial resection of a duodenal web in an infant. J Pediatr Gastroenterol Nutr 2009;48: 378-81.
5. Reiner RG, Alp MH, O’Brien JA, et al. Double duodenal diaphragm: report of a case. Aust N Z J Surg 1978;48:310-3. 6. Morris ML, Tucker RD, Baron TH, et al. Electrosurgery in gastrointestinal endoscopy: principles to practice. Am J Gastroenterol 2009;104:1563-74. Gastroenterology and Endoscopy Unit (A.B., P.G., S.A., S.V.), Pediatric Surgery (G.M.), Anesthesiology Department (C.G.), G. Gaslini Institute for Children, Genoa, Italy. Reprint requests: Arrigo Barabino, MD, Gastroenterology and Endoscopy Unit, G. Gaslini Institute for Children, Largo G. Gaslini 5, 16148 Genoa, Italy. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.06.052
String capsule endoscopy: a novel application for the preoperative identification of a small-bowel obscure GI bleeding source (with video) Bilal Khan, MD, Francisco C. Ramirez, MD, Masud Shaukat, MD, Nooman Gilani, MD, Deepa K. Shah, MD Phoenix, Arizona, USA
Wireless video capsule endoscopy has revolutionized the field of GI endoscopy for evaluation of small-bowel pathology1,2 and is often beneficial for evaluation of obscure GI bleeding (OGIB).3 There are instances, however, in which the source may not be clearly identified or the precise anatomical location cannot be determined. In these elusive cases, surgery may be needed to provide the definitive diagnosis and therapy. We describe a case with a novel application of string capsule endoscopy (SCE) in which long strings were attached to a small-bowel wireless capsule endoscopy device (Pillcam SB; Given Imaging Limited, Yoqneam, Israel) (Fig. 1) to help in the identification of the anatomical source of an elusive OGIB located in the ileum.
CASE REPORT A 62-year-old man presented with a 1-day history of melena followed by hematochezia. On presentation, he was orthostatic. His abdominal examination was unremarkable, and rectal examination revealed maroon-colored stools. His hemoglobin level had dropped to 8.7 mg/dL from a baseline of 15 mg/dL. A colonoscopy after a rapid purge revealed flecks of blood in the ascending colon and cecum. Terminal ileum intubation up to 10 cm revealed no source of bleeding. EGD showed a flat, 6-mm clean-base gastric ulcer, which was an unlikely cause of this massive bleed. The patient continued to have rectal bleeding requiring the transfusion of a total of 7 units of packed red blood cells. A tagged red blood cell scan suggested bleeding at www.giejournal.org
the level of splenic flexure, prompting a repeat colonoscopy that was again unremarkable. Findings of a mesenteric angiogram and push enteroscopy up to the midjejunum were negative. Small-bowel capsule endoscopy revealed the presence of fresh blood in mid-small bowel (first time of identification at 03:17:41 after capsule ingestion) (Video 1, available online at www.giejournal.org) and throughout the remaining small bowel, but the exact bleeding site was not clearly identified. The small-bowel time at which the bleeding was detected was 163 minutes, and the total small-bowel transit time (first duodenal image to first cecal image) was 229 minutes. Findings of a single-balloon antegrade enteroscopy to the proximal ileum were also negative. Exploratory laparotomy with intraoperative enteroscopy was scheduled. Preoperatively, we used the concept of SCE used for the evaluation of the esophagus4-8 but instead attached longer strings to the small-bowel wireless capsule endoscopy device (Pillcam SB; Given Imaging Limited). We used the real-time viewer to follow and identify any abnormality in the small bowel. Based on the time at which fresh blood had been identified at the index capsule endoscopy (03:17:11), pictures were first intermittently observed for the presence of lesions and/or fresh blood up to the 02:00-hour mark. After that, the pictures were monitored live as the capsule traveled down the small bowel. Intermittently, the strings were pulled back to keep the strings “straight.” Although no active bleeding was noted, a suspected mucosal break with specks of blood was noted at about 03:23:05 hours into the study. Volume 73, No. 2 : 2011 GASTROINTESTINAL ENDOSCOPY 403
Current affiliations: Department of Gastroenterology and Hepatology (T.I., K.I., A.S., F.I.), Tokyo Medical University, Tokyo, Japan, Shizuoka General Hospital (M.K., K.M.), Shizuoka, Japan. Reprint requests: Takao Itoi, MD, Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.07.010
Successful endoscopic treatment of a double duodenal web in an infant Arrigo Barabino, MD, Paolo Gandullia, MD, Serena Arrigo, MD, Silvia Vignola, MD, Girolamo Mattioli, MD, Claudia Grattarola, MD Genoa, Italy
Figure 1. An upper GI radiograph before endoscopic therapy. Figure 2. The insulated-tip diathermic knife and the proximal duodenal web with the little central opening.
Duodenal webs are congenital disorders causing partial duodenal endoluminal obstruction. Projectile vomiting, often bile stained, is the major presenting symptom. The experience of endoscopic treatment in pediatric patients is limited. We report a case of a female infant with a double duodenal web, endoscopically treated by using a device normally used for mucosectomy in adults.
CASE REPORT An 11-month-old female, born of an uncomplicated, full-term gestation, was seen in our unit for recurrent, projectile, sometimes bile-stained vomiting. Physical examination and laboratory test evaluation were unremarkable. The patient weighed 8.180 kg (10th percentile), and her height was 70.5 cm (10th-25th percentile). Upper GI radiographs demonstrated a dilated duodenum with a curvilinear stop in its second segment, consistent with a duodenal web (Fig. 1). Therapeutic endoscopy under general anesthesia was performed, with pediatric surgeons in www.giejournal.org
attendance in case of failure or complications. A standard videogastroscope (8.6 mm A, GIF 160; Olympus, Milan, Italy) was used. The duodenal web, with a central aperture of nearly 2 mm in diameter, was confirmed. The papilla of Vater was not detected. An insulated-tip diathermic knife (ITDK; M.G. Lorenzatto, Turin, Italy), inserted through the endoscope channel and connected to an electrosurgical intelligent workstation (ICC 200 E; ERBE, Marietta, GA), was placed into the opening (Fig. 2). Afterward, a mixed cutting and cautery of the web was done, with the ENDO-CUT mode set at 80/40 W, respectively. To avoid potential trauma of the Vater papilla, thought to be posterior and adjacent to the left side, we then performed a radial membranotomy at the 3-o’clock position. When the opening was large enough, we noticed another distal, translucent, fibrous membrane with vessels into its thickness (Fig. 3). It had an eccentric, wide opening that required a short incision at the 3-o’clock position for easy passage by the instrument, which eventually Volume 73, No. 2 : 2011 GASTROINTESTINAL ENDOSCOPY 401
Brief Reports
Figure 3. A close view of the distal, fibrous duodenal web with the large, eccentric opening. Figure 5. Upper GI radiograph obtained 1 month after membranotomy.
Figure 4. The distal view after endoscopic treatment. Arrows: A, Proximal duodenal web. B, Distal duodenal web. C, membranotomy of the proximal duodenal web at the 3-o’clock position.
reached the third duodenal segment (Fig. 4). The papilla of Vater was not identified. Although the patient remained asymptomatic, serum amylase and lipase levels, checked 6 hours after the procedure, were both increased (753 IU/L [normal ⬍100 IU/L] and 1942 IU/L [⬍60], respectively), with normal liver function test results. With fasting maintained, the pancreatic profile recovered within 24 hours, and the baby was able to tolerate a full, normal diet the day after. The patient was discharged on day 3. One month later, the patient weighed 8.7 kg (10-25th percentile), and upper GI radiographs performed at that time showed an evident reduction of the duodenal dilatation and reversion of the previous stop (Fig. 5). The girl has remained asymptomatic with good growth for 6 months of follow-up.
described in pediatric patients so far. We were able to obtain a successful result by using an ITDK normally used in adults for mucosectomy. The device has an insulated ball in its tip to avoid lesions beyond the diaphragm. In respect to a sphincterotome, the ITDK is, for us, much safer against forward perforation, is easier to handle, and allows better cutting control. In our case, ITDK was particularly useful because another duodenal web was found distally. A double duodenal web as a cause of intrinsic duodenal obstruction is a rare malformation,5 and, to our knowledge, this is the first pediatric case with a double duodenal web successfully reversed with endoscopic treatment. The Vater papilla was not identified, but it was thought to be in the left side of the narrow space between the two duodenal webs. Considering the total heat energy delivered during the procedure in so little a patient, we hypothesize that the postoperative increase of the pancreatic enzyme levels was probably related to a “transmural burn syndrome”6 because of thermal injury and edema of the contiguous glandular parenchyma. Our experience adds information about operative endoscopy for duodenal webs in children. We suggest the use of an ITDK to avoid potential injury beyond the diaphragm and alert the reader about the potential pancreatic damage from electrical current. The decision to approach a duodenal web endoscopically in children should take into account the technical skill of the endoscopist and the ready availability of pediatric surgeons.
DISCUSSION
DISCLOSURE
The reported endoscopic treatment of duodenal webs in newborns and children is limited. Laser therapy,1 sphincterotome incision,2 high-frequency-wave snare/ cutter,3 and hot biopsy forceps with dilatation4 have been
All authors disclosed no financial relationships relevant to this publication.
402 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 2 : 2011
Abbreviation: ITDK, insulated-tip diathermic knife.
www.giejournal.org
Brief Report
REFERENCES 1. Kay GA, Lobe TE, Custer MD, et al. Endoscopic laser ablation of obstructing congenital duodenal webs in the newborn: a case report of limited success with criteria for patient selection. J Pediatr Surg 1992;27:279-81. 2. Torroni F, De Angelis P, Caldaro T, et al. Endoscopic membranectomy of duodenal diaphragm: pediatric experience. Gastrointest Endosc 2006;63: 530-1. 3. Nose S, Kubota A, Kawahara H, et al. Endoscopic membranectomy with a high-frequency-wave snare/cutter for membranous stenosis in the upper gastrointestinal tract. J Pediatr Surg 2005;40:1486-8. 4. Beeks A, Gosche J, Giles H, et al. Endoscopic dilatation and partial resection of a duodenal web in an infant. J Pediatr Gastroenterol Nutr 2009;48: 378-81.
5. Reiner RG, Alp MH, O’Brien JA, et al. Double duodenal diaphragm: report of a case. Aust N Z J Surg 1978;48:310-3. 6. Morris ML, Tucker RD, Baron TH, et al. Electrosurgery in gastrointestinal endoscopy: principles to practice. Am J Gastroenterol 2009;104:1563-74. Gastroenterology and Endoscopy Unit (A.B., P.G., S.A., S.V.), Pediatric Surgery (G.M.), Anesthesiology Department (C.G.), G. Gaslini Institute for Children, Genoa, Italy. Reprint requests: Arrigo Barabino, MD, Gastroenterology and Endoscopy Unit, G. Gaslini Institute for Children, Largo G. Gaslini 5, 16148 Genoa, Italy. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.06.052
String capsule endoscopy: a novel application for the preoperative identification of a small-bowel obscure GI bleeding source (with video) Bilal Khan, MD, Francisco C. Ramirez, MD, Masud Shaukat, MD, Nooman Gilani, MD, Deepa K. Shah, MD Phoenix, Arizona, USA
Wireless video capsule endoscopy has revolutionized the field of GI endoscopy for evaluation of small-bowel pathology1,2 and is often beneficial for evaluation of obscure GI bleeding (OGIB).3 There are instances, however, in which the source may not be clearly identified or the precise anatomical location cannot be determined. In these elusive cases, surgery may be needed to provide the definitive diagnosis and therapy. We describe a case with a novel application of string capsule endoscopy (SCE) in which long strings were attached to a small-bowel wireless capsule endoscopy device (Pillcam SB; Given Imaging Limited, Yoqneam, Israel) (Fig. 1) to help in the identification of the anatomical source of an elusive OGIB located in the ileum.
CASE REPORT A 62-year-old man presented with a 1-day history of melena followed by hematochezia. On presentation, he was orthostatic. His abdominal examination was unremarkable, and rectal examination revealed maroon-colored stools. His hemoglobin level had dropped to 8.7 mg/dL from a baseline of 15 mg/dL. A colonoscopy after a rapid purge revealed flecks of blood in the ascending colon and cecum. Terminal ileum intubation up to 10 cm revealed no source of bleeding. EGD showed a flat, 6-mm clean-base gastric ulcer, which was an unlikely cause of this massive bleed. The patient continued to have rectal bleeding requiring the transfusion of a total of 7 units of packed red blood cells. A tagged red blood cell scan suggested bleeding at www.giejournal.org
the level of splenic flexure, prompting a repeat colonoscopy that was again unremarkable. Findings of a mesenteric angiogram and push enteroscopy up to the midjejunum were negative. Small-bowel capsule endoscopy revealed the presence of fresh blood in mid-small bowel (first time of identification at 03:17:41 after capsule ingestion) (Video 1, available online at www.giejournal.org) and throughout the remaining small bowel, but the exact bleeding site was not clearly identified. The small-bowel time at which the bleeding was detected was 163 minutes, and the total small-bowel transit time (first duodenal image to first cecal image) was 229 minutes. Findings of a single-balloon antegrade enteroscopy to the proximal ileum were also negative. Exploratory laparotomy with intraoperative enteroscopy was scheduled. Preoperatively, we used the concept of SCE used for the evaluation of the esophagus4-8 but instead attached longer strings to the small-bowel wireless capsule endoscopy device (Pillcam SB; Given Imaging Limited). We used the real-time viewer to follow and identify any abnormality in the small bowel. Based on the time at which fresh blood had been identified at the index capsule endoscopy (03:17:11), pictures were first intermittently observed for the presence of lesions and/or fresh blood up to the 02:00-hour mark. After that, the pictures were monitored live as the capsule traveled down the small bowel. Intermittently, the strings were pulled back to keep the strings “straight.” Although no active bleeding was noted, a suspected mucosal break with specks of blood was noted at about 03:23:05 hours into the study. Volume 73, No. 2 : 2011 GASTROINTESTINAL ENDOSCOPY 403