- Email: [email protected]
T1598: Novel Approach to Refractory Fecal Impaction Using Large-Volume Wide-Caliber Irrigation With BioVac
Abstracts T1595 Three Dimensional Image Overlay Navigation Using Magnetic Endoscope Detection System for NOTES® and SILS Maki Sugimoto, Yoshinori Morita, Tsuyoshi Sanuki, Hiromu Kutsumi, Takeshi Azuma AIM: NOTES and SILS (Single incision laparoscopic surgery) are novel challenging minimally invasive endoscopic surgery. The first barrier of NOTES and SILS is unpredictable nature of scope and working devices, these forced situations may result in an incomplete or lengthy procedure within such narrow and dark endoscopic viewing. For overcome these limitations, we developed novel 3-D endoscopic navigation system using magnetic scope detection system. It was able to depict real-time position and movement of the endoscope threedimensionally in the abdominal cavity.METHOD: Under general anesthesia, we performed transgastric NOTES cholecystectomy, gastrojejunostomy, appendectomy in survived 10 porcine and canine experiments. By using a magnetic endoscope observation device, the shape and position of endoscopes (flexible endoscope in NOTES, and laparoscope in SILS) were reconstructed and projected on to the abdominal wall in real time throughout the examination. RESULT: Using a low intensity magnetic field, this 3-D Imager enabled to display a 3-D view of the endoscope on the abdominal wall, by means of electromagnetic transmission coils built into the endoscope. Shorter procedure time was acquired. All procedures were completed without complications. DISSCUSION:This magnetic endoscope navigation system was useful for physicians to see the location and shape of the scope from the outside during an endoscopic examination without the risk of x-ray exposure. Moreover we developed a new integrating navigation system that virtual 3D anatomy regenerated from MDCT data in DICOM image viewer OsiriX and 3D scope navigation could be superimposed in a monitor screen by detecting the distance between a scope position and skin surface using additional magnetic markers outside the body. It revealed accurate relations of the patient anatomy and scope orientationCONCLUSION:For development of the innovative surgical technology, the limitations in NOTES and SILS should be overcome using such navigation systems in the meaning of safety.
components of gastric electro-mechanical activity. Although novel endoscopic techniques have been developed for temporary stimulation requiring external wires, permanent GES requires surgical implantation of a large, battery-based neurostimulator device. We have developed two new miniature gastric stimulators, one with a wirelessly rechargeable battery and the other wirelesslypowered without a battery.Method: Both designs were manufactured on printed circuit boards with wrapped antennas and packaged in soft polymer supporting 2 wires for electrode connection. Each design provides three settings (Table 1) and has a size of 12mmx3.7mmx0.9mm. In the first design, a rechargeable battery drives a reprogrammable pulse generator, while a magnetic reed switch permits alternation between charging and stimulation. In the second design, required pulse trains are generated through charge pump circuitry and a microcontroller that harvests radio-frequency energy from an external antenna. An acute pig model was employed with approval from and following protocols by the Animal Control Board of the University of Mississippi Medical Center. A 40kg anesthetized pig was endoscopically implanted with the electrical stimulator, and using electrodes attached serosally and mucosally, EGG recordings was made in response to stimulations. Mucosal and serosal EGG recording were analyzed by signal averaging for mean frequency and amplitude, as well as their ratio (FAR).Results: Shown in Table 2, both miniaturized models for electrical stimulation delivery produced changes in EGG, especially in FAR.Conclusion: We have demonstrated the feasibility of two types of miniature gastric stimulators in animal tests with successful modulation of gastric electrical activities. These stimulators offer the possible applications to endoscopic implantation of wireless systems. Table 1: Setting in each design. Dose Low Medium High
Pulse frequency Pulse duty cycle Pulse “On” time Pulse “Off” time 14Hz 28Hz 55Hz
0.46% 0.92% 1.82%
0.1s 1.0s 4.0s
5.0s 4.0s 1.0s
Table 2: Measurement results. Electrical Current
T1596 Predictors of Diagnostic Yield of Video Capsule Endoscopy in Southwest Ohio Veteran Population Chike C. Anusionwu, Khurram Bari, Sangeeta Agrawal, Salma Akram Background: Video capsule endoscopy (VCE) is an effective, minimally invasive technique that has revolutionized the study of small bowel (SB) pathology. However, there is paucity of data on which clinical factors predict higher yield of VCE to detect SB pathology. Aim:To determine the diagnostic yield of VCE and its predictors in the veterans seen at Dayton Veterans Affairs Medical Center(VAMC).Methods:All patients who underwent VCE from June 2007- August 2009 at the Dayton VAMC were included in the study. Data on patient demographics, indication for procedure, clinical setting of procedure, medication use at time of procedure, co-morbidities and VCE findings was collected by retrospective chart review. Univariate analysis was used to determine if any clinical or demographic variables were associated with VCE findings in these patients.Results: A total of 136 patients (95% male, n⫽129),74% Caucasian (n⫽100) with median age of 63 years (interquartile range{IQR}, 56-75 years) were studied. The median follow-up was 9 months (IQR, 4-14 months). All patients had previously undergone esophagogastroduodenoscopy and colonoscopy with negative results. VCE was carried out in an inpatient setting in 37 patients (27%). The median hemoglobin at the time of VCE was 10.7g/dl (IQR, 8.5-11.9 g/dl). The indication for the procedure was iron deficiency anemia in 88 patients (65%), overt bleeding (OB) in 33 patients (24%) and others ( e.g suspected mass in SB (n⫽6), chronic abdominal pain (n⫽5), suspected Crohn’s disease(n⫽2) and chronic diarrhea(n⫽2) in 15 patients (11%). Positive findings were identified in 66 patients (49%). The commonest findings were non-bleeding arteriovenous malformations (AVM) (n⫽26,19%), followed by SB mucosal irregularity (n⫽20,15%), bleeding AVM(n⫽ 8, 6%), SB ulceration (n⫽7, 5%), and SB mass (n⫽5, 4%). Female sex (9.1% vs. 1.4%, p⫽0.06), increasing age (p⫽0.19), use of non-steroidal anti-inflammatory drugs/aspirin (53% vs. 40%,p⫽0.17 ) and the presence of liver disease (13.6% vs. 5.7%,p⫽0.15 ) were non-significantly more likely to predict a positive yield on VCE.Conclusions: In our study population, gender, increasing age of patients, use of NSAIDS/aspirin and the presence of liver disease more likely led to positive yield on VCE. The explanation for the above findings is not entirely clear. Larger scale studies are needed to confirm the value of these clinical factors in determining positive diagnostic yield.
T1597 Miniature Wireless Gastric Electrical Stimulators Sanchali Deb, Thomas L. Abell, Filip To, Danielle C. Spree, Christopher J. Lahr, Wen-Ding Huang, J. C. Chiao Introduction: Gastric electrical stimulation (GES), an accepted therapy for drug refractory gastroparesis, applies electrical stimulation to tissues to help control
AB318 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
EGG Signal Summary
Stimulator
Power source
Dose
Mucosa
Serosa
Mean Freq. (Hz)
Freq. Range (Hz)
Mean Amp. (V)
Amp. Range (V)
#1
Rechargeable
Low
3.45mA
1.7mA
3.5
3.0-4.0
0.20
0.200.21 0.150.20 0.150.20 N/A
#2
Rechargeable
Medium
3.63mA
1.93mA
3.08
3.0-3.3
0.17
#3
Rechargeable
High
3.63mA
1.93mA
3.75
3.5-4.0
0.14
#4
Batteryless
Low
5.00mA
2.26mA
N/A
N/A
N/A
#5
Batteryless
Medium
5.00mA
2.26mA
3.00
3.0-3.1
0.06
#6
Batteryless
High
5.00mA
2.26mA
3.83
3.0-5.0
0.1
0.060.07 0.080.13
FAR (Hz/V) 17.5 18.1
Note Serosal EGG recording
26.8 N/A
50 38.3
EGG was not recorded Mucosal EGG recording
T1598 Novel Approach to Refractory Fecal Impaction Using LargeVolume Wide-Caliber Irrigation With BioVac Snorri Olafsson, Zebayel B. Akele, Carl Robinson, Christian S. Jackson, Amy Strickland Introduction:Fecal impaction is a solid, immobile bulk of stool. If traditional therapy with laxatives, manual fragmentation, enemas, sigmoidoscopy, and polyethylene glycol fail, surgery may be required. BioVac (BV) was developed to improve visibility in GI bleeding. We successfully used it off-label for resistant fecal impaction.Method:The BV (US Endoscopy) is a suction irrigation device fitted to the accessory biopsy port providing wider caliber for greater volume irrigation and suctioning. A therapeutic upper scope or a colonoscope should be used; the larger the channel the better the system works. The cleaning process is prolonged and requires great patience. Often one hour or more is needed and we have used up to 320 syringes a` 60 mL for a total of almost 20 L of water. The water should preferably be lukewarm so the patient does not get chilled. Using CO2 for insufflation is an advantage to prevent abdominal distension.Patients:We have treated four women with severe constipation. They had severe abdominal distension and traditional impaction therapy had failed. One was 56 y/o with scleroderma where a colovesical fistula was visualized after cleaning and the patient could go to surgery. Another was a 82 y/o with idiopathic pseudoobstruction full of hard stool in the left colon. It was cleaned with 2 sessions of BV. A few months later she came with impaction in right colon only, again successfully treated with BV. A 24 y/o with previous surgery for Hirschsprung’s disease who had no BM for 2 months after child delivery. Admitted twice to another hospital with no resolution. BV with 19.2 L of water resulted in passage of copious stool and patient was discharged home the following day. A 79 y/o with Parkinson’s disease and no BM for 1 month received BV and after that massive 17 cm colon distension went from 17 cm to 10 cm and she was discharged with resolution of the fecal impaction.Additionally
www.giejournal.org
Abstracts we have treated a 56 y/o man with enterocutaneous fistula. Golytely given p.o. went through the fistula. The proximal right colon was covered with hard stool due to disuse and we were only able to clean it with BV to exclude a fistula there. The surgeons then knew it came from the small intestine and could operate.Conclusions:We present a novel method using an irrigation system originally designed for improving visualization during GI bleeding to successfully treat fecal impaction when standard methods have failed. Surgery was avoided in 3 out of 5 patients, and helped surgeons plan for surgery in two. Patients with fecal impaction refractory to standard therapy may be treated successfully using BV as an alternative to surgical intervention.
T1599 The Efficacies of Magnifying Endoscopy With Fujinon Intelligence Color Enhancement Compared to Narrow Banding Imaging Naohisa Yoshida, Yuji Naito, Munehiro Kugai, Ken Inoue, Yasutaka Morimoto, Kazuhiko Uchiyama, Osamu Handa, Tomohisa Takagi, Takeshi Ishikawa, Hideyuki Konishi, Naoki Wakabayashi, Nobuaki Yagi, Satoshi Kokura, Toshikazu Yoshikawa Introduction: Magnifying endoscopy with Fujinon intelligent color enhancement (FICE) is a new imaging technique that enhances mucosal and vascular pattern. As another visual enhanced endoscopic tool, narrow banding imaging (NBI) was used and the NBI findings of colorectal tumor are associated with histopathological findings. In the current study, the efficacies of magnifying endoscopy with FICE system are evaluated compared to NBI. Methods: A total of 100 colorectal tumors, which were examined by magnifying endoscopy with NBI and FICE at Kyoto Prefectural University of Medicine between 2007 and 2009, were analyzed: 47 tubular adenomas (TA), 49 carcinomas with intramucosal to shallow submucosal invasion (M-sSM), 13 carcinomas with massive submucosal invasion (mSM). Magnifying endoscopy with NBI was performed in 65 lesions and that with FICE was performed in 35 lesions. The classification of NBI and FICE were performed with pit visibility, vessel diameter and irregularity and they were divided into three types: type B, type C1-2, type C3 according to previous report. The correlation between magnifying endoscopic findings and histopathological findings were evaluated in NBI and FICE. Results: In lesions using NBI, TA and M-sSM were observed in all 26 lesions of type B. TA and MsSM were observed in 90% and 10% of type C1-2 (30 lesions). mSM were observed in 87 % of type C3 (7 lesions). On the other hand, in lesions using FICE, TA and M-sSM were observed in all 19 lesions of type B. TA and M-sSM were observed in 85% of both type C1-2 (13 lesions). mSM were observed in 15% of type C1-2 (13 lesions). mSM were observed in 67 % of type C3 (3 lesions). In both NBI and FICE, the correlation to histopathological findings was recognized. Moreover, there were no significant differences between NBI and FICE. Conclusions: FICE magnification findings of colorectal tumors were associated with histopathological diagnosis. At present, improved FICE system has been analyzed compared to present FICE and NBI.
T1600 A New Noninvasive Modality for Recording Sequential Images and the pH of the Small Bowel Hiroshi Iida, Masahiko Inamori, Kunihiro Hosono, Hiroki Endo, Yasunari Sakamoto, Tomoko Koide, Chikako Tokoro, Yasunobu Abe, Atsushi Nakajima [Background]Before the introduction of capsule endoscopy (CE) and doubleballoon endoscopy (DBE), there were no effective modalities for the evaluation of the small bowel. Recently, the SmartPill, a wireless pH/pressure recording capsule, has been utilized to measure the gastric emptying time and the whole gut transit time. However, there are few studies on the small bowel pH and the relation between the small bowel pH and small bowel disease. We have designed a new noninvasive modality for recording sequential images and the pH of the small bowel.[Aims]To investigate the relationship between small bowel images and the small bowel pH, we designed a new modality, the pH capsule, to noninvasively record sequential images and the pH.[Methods]Five healthy male volunteers swallowed the “pH capsule” with 50cc water. The “pH capsule” transmitted the acquired images and the pH to the recorder unit located outside the body for about ten hours while the patients were fasting. [Results]Five male subjects completed this study. The images and pH of the entire small bowel were monitored continuously for 10 hours. The intragastric pH was low and the pH rose in the duodenum, and continued to increase until the terminal ileum. The average pH from the duodenum to the terminal ileum was 7.9.[Conclusion]We could noninvasively monitor sequential images and the pH of the small intestine with this new modality. Thus, the pH capsule is expected to become a valuable tool for the assessment of small bowel disease.
www.giejournal.org
T1601 Radiofrequency Ablation (RFA) of Barrett’s Esophagus: A SingleCenter Experience Anthony Infantolino, Nilay H. Kavathia, Amy Rubin, Chien-Lin J. Chen, Juan P. Palazzo, Sidney Cohen, Samuel Giordano, Cynthia L. Miller Background: Barrett’s Esophagus (BE) is associated with an increased risk of esophageal adenocarcinoma (EAC). BE with High Grade Dysplasia (HGD) confers a significant risk of disease progression to EAC. Multifocal Low Grade Dysplasia (MLGD) has been shown to carry a high progression risk as well. Current management includes extensive surveillance with endoscopy and biopsy (bx), often resulting in surgical resection with a significant morbidity and a mortality rates. Early ablative modalities have largely fallen out of favor due to suboptimal safety, efficacy or durability outcomes. However, a recent multicenter study (NEJM- May 28, 2009 pp2277-2288) evaluating RFA for dysplastic BE demonstrated encouraging results.Aim: Determine if these multicenter results are reproducible at a single university medical center, utilizing one gastroenterologist.Methods: Patients (pts) were from a single center and had bx proven BE (confirmed by an expert GI pathologist) with or without dysplasia. Pts with HGD/MLGD underwent HD white light/NBI EGD/ and EUS. Endoscopic mucosal resection (EMR) was performed for all visible nodules. All underwent ˆ RRX HALO360 device, and then subsequent RFA initial RFA with the BA treatments with the HALO90 device every 3 months until all BE was endoscopically eradicated. Bx were obtained to confirm histological eradication. Eradication was defined as CR-D: all bx fragments negative for dysplasia and CRIM : all bx fragments negative for intestinal metaplasia (IM). Pts were maintained on high dose PPI/H2 therapy and followed by endoscopy with bx to asses for recurrent BE and/or dysplasia. Results: 51 patients underwent RFA, 89% were male, mean age 66.1 ⫹/- 1.1 yrs, and mean BE segment length 6.6 ⫹/- 1.1 cm. Of the 38 pts (31 dysplastic BE, 7 non-dysplastic BE (NDBE)) who have undergone at least 1 RFA treatment with at least 1 follow-up bx, CR-D⫽84% and CR-IM⫽71%. CR-IM in dysplastic vs. NDBE patients was equivocal at 71%. Pts underwent a mean of 3.0⫹/-0.2 RFA sessions and had a mean of 15.5 ⫹/-1.4 months follow-up. One pt (⬍2%) developed an asymptomatic esophageal stricture, and another did not tolerate sedation.Conclusion: In this single center/ single endoscopist observational study, CR-D and CR-IM, was achieved in 84% and 71% of pts, respectively. Adverse events were rare (⬍2%) and mild. These results are comparable to existing reports and support reproducibility of published data outside of a randomized control trial. This experience, combined with the existing literature, supports RFA as a proven management option for DBE and NDBE. These studies also suggest that surveillance alone may no longer be the first option for DBE.
T1602 The Efficacy of Hybrid Covered and Uncovered Self Expandable Metal Stent for Palliative Treatment of Malignant Gastroduodenal Obstruction Cheol Woong Choi, Dae Hwan Kang, Hyung Wook Kim, Kee Tae Park, Jin Ho Lee, Su Bum Park, Eul Jo Jeong, Yong Mok Bae Background: Self expandable metal stent (SEMS) has emerged as an effective palliative treatment of malignant gastroduodenal obstruction resulting from gastric or periampullary malignancy. However, most SEMS have been associated with significant tumor ingrowth or relatively frequent migration. Objective: To evaluate the efficacy and safety of a hybrid SEMS (Comvi).Design: Prospective multicenter study.Setting: Two university hospitals and two referral hospitals.Patients: Fifty consecutive patients with malignant gastroduodenal obstruction.Intervention: Placement of a hybrid SEMS composing of an outer uncovered stent and an inner covered stent which are overlapped each other.Main Outcome Measurements: Palliation efficacy and complications.Results: Technical and clinical success was achieved in 100% and 88% of the patients. There was no procedure related complication. Five (10%) stent migration occurred, within 2 weeks in 4 patients. Stent collapse developed in 5 patients after 1 month. Reintervention for migration, stent collapse, and tumor overgrowth was required in 14 (28%) patients. Limitations: Lack of a control group.Conclusion: Endoscopic placement of a hybrid stent was is a safe and effective modality for the palliation of malignant gastroduodenal obstruction. However, migration, especially within 2 weeks or stent collapse has still remained as unresolved problem. Fixing device or modifying design should be considered to decrease these demerits and reintervention. Clinical outcomes in 50 patients treated with hybrid SEMS Technical success, no. (%)
50 (100)
Clinical success, no. (%) Median GOOSS, pre/postprocedure (p value) Complications, no. (%) Procedure related complication Stent migration (gastric/nongastric cancer) Tumor overgrowth (gastric/nongastric cancer) Stent collapse (gastric/nongastric cancer)
44 (88) 0 (0-1) 14 (28) 0 5 (4/1) 4 (2/2) 5 (5/0)
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB319
components of gastric electro-mechanical activity. Although novel endoscopic techniques have been developed for temporary stimulation requiring external wires, permanent GES requires surgical implantation of a large, battery-based neurostimulator device. We have developed two new miniature gastric stimulators, one with a wirelessly rechargeable battery and the other wirelesslypowered without a battery.Method: Both designs were manufactured on printed circuit boards with wrapped antennas and packaged in soft polymer supporting 2 wires for electrode connection. Each design provides three settings (Table 1) and has a size of 12mmx3.7mmx0.9mm. In the first design, a rechargeable battery drives a reprogrammable pulse generator, while a magnetic reed switch permits alternation between charging and stimulation. In the second design, required pulse trains are generated through charge pump circuitry and a microcontroller that harvests radio-frequency energy from an external antenna. An acute pig model was employed with approval from and following protocols by the Animal Control Board of the University of Mississippi Medical Center. A 40kg anesthetized pig was endoscopically implanted with the electrical stimulator, and using electrodes attached serosally and mucosally, EGG recordings was made in response to stimulations. Mucosal and serosal EGG recording were analyzed by signal averaging for mean frequency and amplitude, as well as their ratio (FAR).Results: Shown in Table 2, both miniaturized models for electrical stimulation delivery produced changes in EGG, especially in FAR.Conclusion: We have demonstrated the feasibility of two types of miniature gastric stimulators in animal tests with successful modulation of gastric electrical activities. These stimulators offer the possible applications to endoscopic implantation of wireless systems. Table 1: Setting in each design. Dose Low Medium High
Pulse frequency Pulse duty cycle Pulse “On” time Pulse “Off” time 14Hz 28Hz 55Hz
0.46% 0.92% 1.82%
0.1s 1.0s 4.0s
5.0s 4.0s 1.0s
Table 2: Measurement results. Electrical Current
T1596 Predictors of Diagnostic Yield of Video Capsule Endoscopy in Southwest Ohio Veteran Population Chike C. Anusionwu, Khurram Bari, Sangeeta Agrawal, Salma Akram Background: Video capsule endoscopy (VCE) is an effective, minimally invasive technique that has revolutionized the study of small bowel (SB) pathology. However, there is paucity of data on which clinical factors predict higher yield of VCE to detect SB pathology. Aim:To determine the diagnostic yield of VCE and its predictors in the veterans seen at Dayton Veterans Affairs Medical Center(VAMC).Methods:All patients who underwent VCE from June 2007- August 2009 at the Dayton VAMC were included in the study. Data on patient demographics, indication for procedure, clinical setting of procedure, medication use at time of procedure, co-morbidities and VCE findings was collected by retrospective chart review. Univariate analysis was used to determine if any clinical or demographic variables were associated with VCE findings in these patients.Results: A total of 136 patients (95% male, n⫽129),74% Caucasian (n⫽100) with median age of 63 years (interquartile range{IQR}, 56-75 years) were studied. The median follow-up was 9 months (IQR, 4-14 months). All patients had previously undergone esophagogastroduodenoscopy and colonoscopy with negative results. VCE was carried out in an inpatient setting in 37 patients (27%). The median hemoglobin at the time of VCE was 10.7g/dl (IQR, 8.5-11.9 g/dl). The indication for the procedure was iron deficiency anemia in 88 patients (65%), overt bleeding (OB) in 33 patients (24%) and others ( e.g suspected mass in SB (n⫽6), chronic abdominal pain (n⫽5), suspected Crohn’s disease(n⫽2) and chronic diarrhea(n⫽2) in 15 patients (11%). Positive findings were identified in 66 patients (49%). The commonest findings were non-bleeding arteriovenous malformations (AVM) (n⫽26,19%), followed by SB mucosal irregularity (n⫽20,15%), bleeding AVM(n⫽ 8, 6%), SB ulceration (n⫽7, 5%), and SB mass (n⫽5, 4%). Female sex (9.1% vs. 1.4%, p⫽0.06), increasing age (p⫽0.19), use of non-steroidal anti-inflammatory drugs/aspirin (53% vs. 40%,p⫽0.17 ) and the presence of liver disease (13.6% vs. 5.7%,p⫽0.15 ) were non-significantly more likely to predict a positive yield on VCE.Conclusions: In our study population, gender, increasing age of patients, use of NSAIDS/aspirin and the presence of liver disease more likely led to positive yield on VCE. The explanation for the above findings is not entirely clear. Larger scale studies are needed to confirm the value of these clinical factors in determining positive diagnostic yield.
T1597 Miniature Wireless Gastric Electrical Stimulators Sanchali Deb, Thomas L. Abell, Filip To, Danielle C. Spree, Christopher J. Lahr, Wen-Ding Huang, J. C. Chiao Introduction: Gastric electrical stimulation (GES), an accepted therapy for drug refractory gastroparesis, applies electrical stimulation to tissues to help control
AB318 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
EGG Signal Summary
Stimulator
Power source
Dose
Mucosa
Serosa
Mean Freq. (Hz)
Freq. Range (Hz)
Mean Amp. (V)
Amp. Range (V)
#1
Rechargeable
Low
3.45mA
1.7mA
3.5
3.0-4.0
0.20
0.200.21 0.150.20 0.150.20 N/A
#2
Rechargeable
Medium
3.63mA
1.93mA
3.08
3.0-3.3
0.17
#3
Rechargeable
High
3.63mA
1.93mA
3.75
3.5-4.0
0.14
#4
Batteryless
Low
5.00mA
2.26mA
N/A
N/A
N/A
#5
Batteryless
Medium
5.00mA
2.26mA
3.00
3.0-3.1
0.06
#6
Batteryless
High
5.00mA
2.26mA
3.83
3.0-5.0
0.1
0.060.07 0.080.13
FAR (Hz/V) 17.5 18.1
Note Serosal EGG recording
26.8 N/A
50 38.3
EGG was not recorded Mucosal EGG recording
T1598 Novel Approach to Refractory Fecal Impaction Using LargeVolume Wide-Caliber Irrigation With BioVac Snorri Olafsson, Zebayel B. Akele, Carl Robinson, Christian S. Jackson, Amy Strickland Introduction:Fecal impaction is a solid, immobile bulk of stool. If traditional therapy with laxatives, manual fragmentation, enemas, sigmoidoscopy, and polyethylene glycol fail, surgery may be required. BioVac (BV) was developed to improve visibility in GI bleeding. We successfully used it off-label for resistant fecal impaction.Method:The BV (US Endoscopy) is a suction irrigation device fitted to the accessory biopsy port providing wider caliber for greater volume irrigation and suctioning. A therapeutic upper scope or a colonoscope should be used; the larger the channel the better the system works. The cleaning process is prolonged and requires great patience. Often one hour or more is needed and we have used up to 320 syringes a` 60 mL for a total of almost 20 L of water. The water should preferably be lukewarm so the patient does not get chilled. Using CO2 for insufflation is an advantage to prevent abdominal distension.Patients:We have treated four women with severe constipation. They had severe abdominal distension and traditional impaction therapy had failed. One was 56 y/o with scleroderma where a colovesical fistula was visualized after cleaning and the patient could go to surgery. Another was a 82 y/o with idiopathic pseudoobstruction full of hard stool in the left colon. It was cleaned with 2 sessions of BV. A few months later she came with impaction in right colon only, again successfully treated with BV. A 24 y/o with previous surgery for Hirschsprung’s disease who had no BM for 2 months after child delivery. Admitted twice to another hospital with no resolution. BV with 19.2 L of water resulted in passage of copious stool and patient was discharged home the following day. A 79 y/o with Parkinson’s disease and no BM for 1 month received BV and after that massive 17 cm colon distension went from 17 cm to 10 cm and she was discharged with resolution of the fecal impaction.Additionally
www.giejournal.org
Abstracts we have treated a 56 y/o man with enterocutaneous fistula. Golytely given p.o. went through the fistula. The proximal right colon was covered with hard stool due to disuse and we were only able to clean it with BV to exclude a fistula there. The surgeons then knew it came from the small intestine and could operate.Conclusions:We present a novel method using an irrigation system originally designed for improving visualization during GI bleeding to successfully treat fecal impaction when standard methods have failed. Surgery was avoided in 3 out of 5 patients, and helped surgeons plan for surgery in two. Patients with fecal impaction refractory to standard therapy may be treated successfully using BV as an alternative to surgical intervention.
T1599 The Efficacies of Magnifying Endoscopy With Fujinon Intelligence Color Enhancement Compared to Narrow Banding Imaging Naohisa Yoshida, Yuji Naito, Munehiro Kugai, Ken Inoue, Yasutaka Morimoto, Kazuhiko Uchiyama, Osamu Handa, Tomohisa Takagi, Takeshi Ishikawa, Hideyuki Konishi, Naoki Wakabayashi, Nobuaki Yagi, Satoshi Kokura, Toshikazu Yoshikawa Introduction: Magnifying endoscopy with Fujinon intelligent color enhancement (FICE) is a new imaging technique that enhances mucosal and vascular pattern. As another visual enhanced endoscopic tool, narrow banding imaging (NBI) was used and the NBI findings of colorectal tumor are associated with histopathological findings. In the current study, the efficacies of magnifying endoscopy with FICE system are evaluated compared to NBI. Methods: A total of 100 colorectal tumors, which were examined by magnifying endoscopy with NBI and FICE at Kyoto Prefectural University of Medicine between 2007 and 2009, were analyzed: 47 tubular adenomas (TA), 49 carcinomas with intramucosal to shallow submucosal invasion (M-sSM), 13 carcinomas with massive submucosal invasion (mSM). Magnifying endoscopy with NBI was performed in 65 lesions and that with FICE was performed in 35 lesions. The classification of NBI and FICE were performed with pit visibility, vessel diameter and irregularity and they were divided into three types: type B, type C1-2, type C3 according to previous report. The correlation between magnifying endoscopic findings and histopathological findings were evaluated in NBI and FICE. Results: In lesions using NBI, TA and M-sSM were observed in all 26 lesions of type B. TA and MsSM were observed in 90% and 10% of type C1-2 (30 lesions). mSM were observed in 87 % of type C3 (7 lesions). On the other hand, in lesions using FICE, TA and M-sSM were observed in all 19 lesions of type B. TA and M-sSM were observed in 85% of both type C1-2 (13 lesions). mSM were observed in 15% of type C1-2 (13 lesions). mSM were observed in 67 % of type C3 (3 lesions). In both NBI and FICE, the correlation to histopathological findings was recognized. Moreover, there were no significant differences between NBI and FICE. Conclusions: FICE magnification findings of colorectal tumors were associated with histopathological diagnosis. At present, improved FICE system has been analyzed compared to present FICE and NBI.
T1600 A New Noninvasive Modality for Recording Sequential Images and the pH of the Small Bowel Hiroshi Iida, Masahiko Inamori, Kunihiro Hosono, Hiroki Endo, Yasunari Sakamoto, Tomoko Koide, Chikako Tokoro, Yasunobu Abe, Atsushi Nakajima [Background]Before the introduction of capsule endoscopy (CE) and doubleballoon endoscopy (DBE), there were no effective modalities for the evaluation of the small bowel. Recently, the SmartPill, a wireless pH/pressure recording capsule, has been utilized to measure the gastric emptying time and the whole gut transit time. However, there are few studies on the small bowel pH and the relation between the small bowel pH and small bowel disease. We have designed a new noninvasive modality for recording sequential images and the pH of the small bowel.[Aims]To investigate the relationship between small bowel images and the small bowel pH, we designed a new modality, the pH capsule, to noninvasively record sequential images and the pH.[Methods]Five healthy male volunteers swallowed the “pH capsule” with 50cc water. The “pH capsule” transmitted the acquired images and the pH to the recorder unit located outside the body for about ten hours while the patients were fasting. [Results]Five male subjects completed this study. The images and pH of the entire small bowel were monitored continuously for 10 hours. The intragastric pH was low and the pH rose in the duodenum, and continued to increase until the terminal ileum. The average pH from the duodenum to the terminal ileum was 7.9.[Conclusion]We could noninvasively monitor sequential images and the pH of the small intestine with this new modality. Thus, the pH capsule is expected to become a valuable tool for the assessment of small bowel disease.
www.giejournal.org
T1601 Radiofrequency Ablation (RFA) of Barrett’s Esophagus: A SingleCenter Experience Anthony Infantolino, Nilay H. Kavathia, Amy Rubin, Chien-Lin J. Chen, Juan P. Palazzo, Sidney Cohen, Samuel Giordano, Cynthia L. Miller Background: Barrett’s Esophagus (BE) is associated with an increased risk of esophageal adenocarcinoma (EAC). BE with High Grade Dysplasia (HGD) confers a significant risk of disease progression to EAC. Multifocal Low Grade Dysplasia (MLGD) has been shown to carry a high progression risk as well. Current management includes extensive surveillance with endoscopy and biopsy (bx), often resulting in surgical resection with a significant morbidity and a mortality rates. Early ablative modalities have largely fallen out of favor due to suboptimal safety, efficacy or durability outcomes. However, a recent multicenter study (NEJM- May 28, 2009 pp2277-2288) evaluating RFA for dysplastic BE demonstrated encouraging results.Aim: Determine if these multicenter results are reproducible at a single university medical center, utilizing one gastroenterologist.Methods: Patients (pts) were from a single center and had bx proven BE (confirmed by an expert GI pathologist) with or without dysplasia. Pts with HGD/MLGD underwent HD white light/NBI EGD/ and EUS. Endoscopic mucosal resection (EMR) was performed for all visible nodules. All underwent ˆ RRX HALO360 device, and then subsequent RFA initial RFA with the BA treatments with the HALO90 device every 3 months until all BE was endoscopically eradicated. Bx were obtained to confirm histological eradication. Eradication was defined as CR-D: all bx fragments negative for dysplasia and CRIM : all bx fragments negative for intestinal metaplasia (IM). Pts were maintained on high dose PPI/H2 therapy and followed by endoscopy with bx to asses for recurrent BE and/or dysplasia. Results: 51 patients underwent RFA, 89% were male, mean age 66.1 ⫹/- 1.1 yrs, and mean BE segment length 6.6 ⫹/- 1.1 cm. Of the 38 pts (31 dysplastic BE, 7 non-dysplastic BE (NDBE)) who have undergone at least 1 RFA treatment with at least 1 follow-up bx, CR-D⫽84% and CR-IM⫽71%. CR-IM in dysplastic vs. NDBE patients was equivocal at 71%. Pts underwent a mean of 3.0⫹/-0.2 RFA sessions and had a mean of 15.5 ⫹/-1.4 months follow-up. One pt (⬍2%) developed an asymptomatic esophageal stricture, and another did not tolerate sedation.Conclusion: In this single center/ single endoscopist observational study, CR-D and CR-IM, was achieved in 84% and 71% of pts, respectively. Adverse events were rare (⬍2%) and mild. These results are comparable to existing reports and support reproducibility of published data outside of a randomized control trial. This experience, combined with the existing literature, supports RFA as a proven management option for DBE and NDBE. These studies also suggest that surveillance alone may no longer be the first option for DBE.
T1602 The Efficacy of Hybrid Covered and Uncovered Self Expandable Metal Stent for Palliative Treatment of Malignant Gastroduodenal Obstruction Cheol Woong Choi, Dae Hwan Kang, Hyung Wook Kim, Kee Tae Park, Jin Ho Lee, Su Bum Park, Eul Jo Jeong, Yong Mok Bae Background: Self expandable metal stent (SEMS) has emerged as an effective palliative treatment of malignant gastroduodenal obstruction resulting from gastric or periampullary malignancy. However, most SEMS have been associated with significant tumor ingrowth or relatively frequent migration. Objective: To evaluate the efficacy and safety of a hybrid SEMS (Comvi).Design: Prospective multicenter study.Setting: Two university hospitals and two referral hospitals.Patients: Fifty consecutive patients with malignant gastroduodenal obstruction.Intervention: Placement of a hybrid SEMS composing of an outer uncovered stent and an inner covered stent which are overlapped each other.Main Outcome Measurements: Palliation efficacy and complications.Results: Technical and clinical success was achieved in 100% and 88% of the patients. There was no procedure related complication. Five (10%) stent migration occurred, within 2 weeks in 4 patients. Stent collapse developed in 5 patients after 1 month. Reintervention for migration, stent collapse, and tumor overgrowth was required in 14 (28%) patients. Limitations: Lack of a control group.Conclusion: Endoscopic placement of a hybrid stent was is a safe and effective modality for the palliation of malignant gastroduodenal obstruction. However, migration, especially within 2 weeks or stent collapse has still remained as unresolved problem. Fixing device or modifying design should be considered to decrease these demerits and reintervention. Clinical outcomes in 50 patients treated with hybrid SEMS Technical success, no. (%)
50 (100)
Clinical success, no. (%) Median GOOSS, pre/postprocedure (p value) Complications, no. (%) Procedure related complication Stent migration (gastric/nongastric cancer) Tumor overgrowth (gastric/nongastric cancer) Stent collapse (gastric/nongastric cancer)
44 (88) 0 (0-1) 14 (28) 0 5 (4/1) 4 (2/2) 5 (5/0)
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB319