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Transgastric Endoscopic Gastrojejunostomy Using Endoclips and Detachable Snares - A Feasibility Experiment in a Porcine Model
Abstracts
T1533 Endoscopic Position Verification of Enteral Feeding Tubes By Transnasal Re-Endoscopy. A Controlled Study of Patients Hospitalized in the Intensive Care Unit Nico Wiegand, Stephan M. Wildi, Fabiola Delco, Michael Fried, Peter Bauerfeind
gastrojejunal anastomosis was confirmed to be intact. Conclusions: Although transgastric endoscopic gastrojejunostomy is technically feasible, it is extreme difficulty to perform with the currently available instruments and devices. Further research and development is necessary to refine this procedure.
Background: In critically ill patients, correct placement of enteral feeding tubes is usually ascertained radiologically. Transnasal re-endoscopy may represent a quick and reliable method to verify tube position and make radiation exposure unnecessary. Aim: To study the feasibility and value of endoscopic position verification of enteral feeding tubes by transnasal re-endoscopy. Methods: Immediately after transnasal endoscopic placement of an enteral feeding tube, correct position was determined by re-endoscopy through the opposite nasal passage. In case of incorrect position, re-placement was undertaken until correct position was achieved. Plain abdominal x-ray after tube perfusion with a contrast medium served as gold standard. Results: A total of 120 consecutive examinations (79 men, median age 56 years, range 17-88) were analyzed. In 95 patients (79%), endoscopic ascertainment confirmed correct position. In 25 patients, position was incorrect and endoscopic placement was repeated (1 and 2 attempts in 22 and 3 patients, respectively). The average additional time spent on endoscopic control and repositioning when indicated was 3.1 minutes (1-22 minutes). Eventually, radiologic comparison showed correct position in 118 patients (98%) whereas in 2 cases, the feeding tube got displaced in the meantime. The estimated cost-savings per case were approximately 350 USD. Conclusions: Endoscopic position ascertainment of enteral feeding tubes by re-endoscopy is feasible and very accurate, leads to a high rate of successful feeding tube placements, and has the potential for substantial cost-savings.
Fig 1
T1535 How Can We Overcome the Difficult Cases in Early Gastric Cancer Treatment with ESD Method?: Challenging New Technique with Double Scope ESD Yoshinori Morita, Ikuya Miki, Toshifumi Mitani, Masanori Toyoda, Toshio Tanaka, Naomi Torio, Daisuke Shirasaka, Masaru Yoshida, Takao Tamura, Hiromu Kutsumi, Nobuo Aoyama, Takeshi Azuma
T1534 Transgastric Endoscopic Gastrojejunostomy Using Endoclips and Detachable Snares - A Feasibility Experiment in a Porcine Model Philip W. Chiu, Chris K. Yau, Wilfred L. Mui, Frances K. Cheung, Candice C. Lam, Wing Tai Siu, Enders K. Ng Background: We aimed to test the feasibility of performing transgastric gastrojejunostomy using the currently available endoscopic facilities with a view to investigate the limits of these devices. Method: We performed all the procedures under general anesthesia on a porcine model. We employed a double channel endoscopy (XQ240-2T, Olympus) and inserting a long overtube down to the esophagus. The stomach was first flushed with neomycin solution, and the initial gastric puncture was performed using needle knife papillotome. After entrance into the peritoneal cavity, a guidewire was passed through and the needle knife was exchanged with a sphincterotome and gastrotomy extended. The endoscope then passed via the gastrotomy into the peritoneal cavity. A loop of jejunum was grasped and drawn into the stomach. The jejunum was first fixed to the edge of the gastrotomy with endoclips and detachable snare (Fig 1). The jejunum was then opened with needle knife, and a gastrojejunal anastomosis was performed using endoclips. The pigs were allowed to eat on day 2, and survived for 2 weeks before euthanasia. Results: A gastrojejunostomy was completed on three pigs. The average operative time was 120 minutes. On post-mortem examination 2 weeks later, the
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Background: The arrival of endoscopic submucosal dissection (ESD) method has enabled en-bloc resection of early gastric cancer (EGC) regardless of tumor size. However, ESD requires a long procedure time and a high technical skill in holding endoscopy at appropriate location and handling fluently with a precise motion, and sometimes brings about severe complications such as bleeding or perforation, especially in the case of quite a large lesion (more than 50 mm), difficult location (more than 30mm lesion at the greater curvature of corpus), and severe fibrosis (ulcer scar), which cases consist of around 5% of our 300 experiences. Conventional ESD method with single scope (S-ESD) is often difficult to keep a clear view for which to dissect submucosal layer exactly and detect vessels before bleeding. Aim: In order to achieve a safer ESD treatment during a shorter procedure, we developed double scope ESD (D-ESD) using flexible large lumen overtube. This study introduced our preliminary experience and evaluated the feasibility, efficacy and procedure time. Method: Three consecutive patients with differentiated mucosal EGC judged by biopsy and EUS were enrolled, whose lesions have some difficulties that cannot be conquered with conventional S-ESD due to the followings reasons: 1. Tumor size is larger than 50 mm, 2. Tumor has ulcerative change 3. Tumor over 30 mm is located at the greater curvature of corpus. D-ESD was performed by two kinds of endoscopy. One is quite a thin scope (EVIS N260, Olympus), which assists in holding clear view by catching and lifting the targeted lesion. Another has water-jet function (EVIS Q260J, Olympus), which enables easy detection of oozing point. VIO300D (ERBE) was used for an electrical power source. Mucosal cutting and dissection was performed by insulation-tipped knife (IT knife, Olympus). Results: The mean procedure time was 58 min. All the patients achieved complete resection without massive bleeding or perforation. Injuries of the hypopharynx and the esophagus by the overtube were not observed. IT knife could be moved in the parallel line to submucosal layer. Vessels in submucosal layer were easily detected, and severe bleeding could be avoided by pre-coagulation. Water-jet enabled to detect the just point of minor bleeding in a clear view. All the lesions were tolerable for the histopathological evaluation, which were welldifferentiated tubular adenocarcinomas within mucosal invasion without vessel invasion. Conclusion: D-ESD can provide a good feasibility and efficacy even in the difficult cases of EGC, which can expand the indication to lesions that are considered impossible to treat by conventional S-ESD.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB251
T1533 Endoscopic Position Verification of Enteral Feeding Tubes By Transnasal Re-Endoscopy. A Controlled Study of Patients Hospitalized in the Intensive Care Unit Nico Wiegand, Stephan M. Wildi, Fabiola Delco, Michael Fried, Peter Bauerfeind
gastrojejunal anastomosis was confirmed to be intact. Conclusions: Although transgastric endoscopic gastrojejunostomy is technically feasible, it is extreme difficulty to perform with the currently available instruments and devices. Further research and development is necessary to refine this procedure.
Background: In critically ill patients, correct placement of enteral feeding tubes is usually ascertained radiologically. Transnasal re-endoscopy may represent a quick and reliable method to verify tube position and make radiation exposure unnecessary. Aim: To study the feasibility and value of endoscopic position verification of enteral feeding tubes by transnasal re-endoscopy. Methods: Immediately after transnasal endoscopic placement of an enteral feeding tube, correct position was determined by re-endoscopy through the opposite nasal passage. In case of incorrect position, re-placement was undertaken until correct position was achieved. Plain abdominal x-ray after tube perfusion with a contrast medium served as gold standard. Results: A total of 120 consecutive examinations (79 men, median age 56 years, range 17-88) were analyzed. In 95 patients (79%), endoscopic ascertainment confirmed correct position. In 25 patients, position was incorrect and endoscopic placement was repeated (1 and 2 attempts in 22 and 3 patients, respectively). The average additional time spent on endoscopic control and repositioning when indicated was 3.1 minutes (1-22 minutes). Eventually, radiologic comparison showed correct position in 118 patients (98%) whereas in 2 cases, the feeding tube got displaced in the meantime. The estimated cost-savings per case were approximately 350 USD. Conclusions: Endoscopic position ascertainment of enteral feeding tubes by re-endoscopy is feasible and very accurate, leads to a high rate of successful feeding tube placements, and has the potential for substantial cost-savings.
Fig 1
T1535 How Can We Overcome the Difficult Cases in Early Gastric Cancer Treatment with ESD Method?: Challenging New Technique with Double Scope ESD Yoshinori Morita, Ikuya Miki, Toshifumi Mitani, Masanori Toyoda, Toshio Tanaka, Naomi Torio, Daisuke Shirasaka, Masaru Yoshida, Takao Tamura, Hiromu Kutsumi, Nobuo Aoyama, Takeshi Azuma
T1534 Transgastric Endoscopic Gastrojejunostomy Using Endoclips and Detachable Snares - A Feasibility Experiment in a Porcine Model Philip W. Chiu, Chris K. Yau, Wilfred L. Mui, Frances K. Cheung, Candice C. Lam, Wing Tai Siu, Enders K. Ng Background: We aimed to test the feasibility of performing transgastric gastrojejunostomy using the currently available endoscopic facilities with a view to investigate the limits of these devices. Method: We performed all the procedures under general anesthesia on a porcine model. We employed a double channel endoscopy (XQ240-2T, Olympus) and inserting a long overtube down to the esophagus. The stomach was first flushed with neomycin solution, and the initial gastric puncture was performed using needle knife papillotome. After entrance into the peritoneal cavity, a guidewire was passed through and the needle knife was exchanged with a sphincterotome and gastrotomy extended. The endoscope then passed via the gastrotomy into the peritoneal cavity. A loop of jejunum was grasped and drawn into the stomach. The jejunum was first fixed to the edge of the gastrotomy with endoclips and detachable snare (Fig 1). The jejunum was then opened with needle knife, and a gastrojejunal anastomosis was performed using endoclips. The pigs were allowed to eat on day 2, and survived for 2 weeks before euthanasia. Results: A gastrojejunostomy was completed on three pigs. The average operative time was 120 minutes. On post-mortem examination 2 weeks later, the
www.giejournal.org
Background: The arrival of endoscopic submucosal dissection (ESD) method has enabled en-bloc resection of early gastric cancer (EGC) regardless of tumor size. However, ESD requires a long procedure time and a high technical skill in holding endoscopy at appropriate location and handling fluently with a precise motion, and sometimes brings about severe complications such as bleeding or perforation, especially in the case of quite a large lesion (more than 50 mm), difficult location (more than 30mm lesion at the greater curvature of corpus), and severe fibrosis (ulcer scar), which cases consist of around 5% of our 300 experiences. Conventional ESD method with single scope (S-ESD) is often difficult to keep a clear view for which to dissect submucosal layer exactly and detect vessels before bleeding. Aim: In order to achieve a safer ESD treatment during a shorter procedure, we developed double scope ESD (D-ESD) using flexible large lumen overtube. This study introduced our preliminary experience and evaluated the feasibility, efficacy and procedure time. Method: Three consecutive patients with differentiated mucosal EGC judged by biopsy and EUS were enrolled, whose lesions have some difficulties that cannot be conquered with conventional S-ESD due to the followings reasons: 1. Tumor size is larger than 50 mm, 2. Tumor has ulcerative change 3. Tumor over 30 mm is located at the greater curvature of corpus. D-ESD was performed by two kinds of endoscopy. One is quite a thin scope (EVIS N260, Olympus), which assists in holding clear view by catching and lifting the targeted lesion. Another has water-jet function (EVIS Q260J, Olympus), which enables easy detection of oozing point. VIO300D (ERBE) was used for an electrical power source. Mucosal cutting and dissection was performed by insulation-tipped knife (IT knife, Olympus). Results: The mean procedure time was 58 min. All the patients achieved complete resection without massive bleeding or perforation. Injuries of the hypopharynx and the esophagus by the overtube were not observed. IT knife could be moved in the parallel line to submucosal layer. Vessels in submucosal layer were easily detected, and severe bleeding could be avoided by pre-coagulation. Water-jet enabled to detect the just point of minor bleeding in a clear view. All the lesions were tolerable for the histopathological evaluation, which were welldifferentiated tubular adenocarcinomas within mucosal invasion without vessel invasion. Conclusion: D-ESD can provide a good feasibility and efficacy even in the difficult cases of EGC, which can expand the indication to lesions that are considered impossible to treat by conventional S-ESD.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB251