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Unsedated Transnasal Gastroscopy (T-EGD): Three Years Experience (2002-2004) in Operative Digestive Endoscopy Through Trans-Nasal Route
Abstracts
T1326 Unsedated Transnasal Gastroscopy (T-EGD): Three Years Experience (2002-2004) in Operative Digestive Endoscopy Through Trans-Nasal Route Fausto Barberani, Alessandro Gigliozzi, Maurizio Giovannone, Mauro Tosoni, Sandro Boschetto
T1328 In Vivo Full-Thickness Endoluminal Gastroplication Using Tissue Anchors in a Live Pig Model Jose G. De la Mora, Elizabeth Rajan, David Rea, Thomas C. Smyrk, Lori J. Herman, Jodie L. Deters, Mary A. Knipschield, Christopher J. Gostout
T-EGD was first performed by Shaker in 1994 and proposed in Italy by Barberani with his own and innovative techniques, in 1998 (1,2). Our previous studies demonstrated that T-EGD is safer, better tolerated and cheaper than conventional one. There are only few records concerning T-EGD in operative endoscopy (PEG, Dilation on guide wire) when oral route is unavailable [3]. Aim of this study is to assess operative power of T-EGD in upper GI diseases. Material and Methods: 164 pts previously underwent to diagnostic unsedated T-EGD, were guided to a second T-EGD when endoscopic therapy was required. The procedures were performed according to Barberani’s technique: without topical anesthesia on left decubitus, evaluating both the naryx to choose the best way approaching middle or inferior meatus of the nose. Consent was obtained. A 6 mm Pentax video EG1840EG1870K with 2 mm operative channel was utilized. As additionals: injecting needle and snare Olympus and Deltamed, a 1.8 mm Deltamed Roth Net, a Boston CRE and Deltamed pneumatic dilator, a 1.8 mm Erbe Argon APC probe, Corpak-Peg16 Fr [4]. Results: We performed 164 therapies (age 23-91): 51 Injective therapy (42 PU, 6 achalasia, 3 varix); 9 esophageal dilation (6 benign stenosis, 3 malignant); 43 (5-25 mm) polipectomies (30 gastric, 12 esophageal, 1 duodenal); 23 Argon (12 angiodisplasya, 6 gastric fundic polyps, 1 GC, 4 Barrett esophagus); 16 prosthesis (15 PEG, 1 esoph prosth); 6 foreign bodies mobilization; 16 on the wire transnasal placing of nutritional naso duodenal tube. No complications were recorded. No changes in vital parameters. Conclusions: The large experience conducted in diagnostic T-EGD has leaded us to explore operative power of this technique thanks to the availability of hi-tech additionals:polyps’net recovery, decreasing volume, give this procedure sure and avoid accidental inhalation, guide wire inserted during T-EGD makes easy and safe pneumatic dilation of the esophagus, the APC fine probe treatments resulted definitively at the follow-up as well as the type of PEG and the injective therapy in bleeding and achalasyc pts, show safety, feasibility and tolerance of T-EGD not only in diagnostic procedure but also as possible tool for endoscopic therapy in selected patients. 1) Barberani F, et al. It. J. of Gastroent & Hepatol. 30 suppl 2; A 173, 1998. 2) Boschetto S, et al. Am. J. Gastroent. vol. 95, n 9; A132, 2000. 3) Dean R, et al. Gastroint. Endoscopy vol. 44 n.4: 422-4, 1996. 4) Barberani F, et al. Giorn. It. End. Dig. n 1, vol. 26: 9-17, 2003.
Background: Long-term success of gastric wall apposition performed by flexible endoscopy is dependent on fold permanence. Prior work by our group demonstrated that only full-thickness folds with serosal apposition are durable. Aim: To study feasibility of different tissue anchors to create a full thickness inverted fold and the durability of each single fold plication. Material & Methods: Four 35-45 Kg female pigs were used. Under anesthesia a midline abdominal incision was performed. A 5-cm incision parallel to the greater curvature of the stomach was made. The posterior wall was exposed and longitudinal folds were created by indenting the wall from the serosal side (inverted fold) 1.5 cm in height and 5 cm long. Anchors were deployed to traverse the inverted gastric wall, including apposing serosal surfaces within the fold. Anchors were 1 cm apart with 3-4 of the same type used per fold. 4-6 folds were made in each pig. Four types of paired anchors joined with suture (prolene 2-0) were used: T-bar (T); polypropylene mesh pledget (TM); plastic star-shaped buttons (S) and a self-expanding nitinol basket (B). Suture (vicryl 2-0) for incision closure was used to control for tissue reaction. Follow-up endoscopy was done at 15, 30 and 60 days. Two pigs were sacrificed each at 30 and 60 days. Macroscopic description of the folds was done and samples of the folds sent for histology. Results: Day 15: all folds were still present endoscopically. Day 30: S and B folds were unchanged, TM folds were reduced in height, and T folds had flattened. Day 60: only S & B folds remained. Histologically, all B folds included the muscle layer (30 & 60 day specimens) and one developed serosal fusion (30-day specimen). Only one S fold included the muscle layer with serosal fusion at 60 days. Conclusions: The durability of endoluminally placed full thickness inverted folds remains a challenge. Serosal apposition remains requisite for fold permanence. The use of tissue anchors such as the S and B designs may help achieve greater durability for endoscopic gastric remodeling by tissue apposition.
T1329 Argon Plasma Coagulation with or without Saline Immersion: Comparative In Vivo Study on Tissue Effects Jose G. De la Mora, Alma P. Romero, Lori J. Herman, Jodie L. Deters, Mary A. Knipschield, Christopher J. Gostout
T1327 Endoscopic Resection of Upper-GI Mesenchymal Tumors Arising in Muscularis Propria Joon Hyuck Choi, Jin Hong Kim, Jae Youn Cheong, Kee Myung Lee, Byung Moo Yoo, Kwang Jae Lee, Ki Baik Hahm, Sung Won Cho Background: The management of submucosal tumors should ideally be based on a pathologic diagnosis, because endoscopic findings of a small size do not preclude malignant behavior. The aim of this study was to evaluate the feasibility, safety and effectiveness of endoscopic resection for pathologic diagnosis and complete eradication of the upper-GI mesenchymal tumors arising in the muscularis propria. Methods: 50 patients (22 men, 28 women; mean age 46.5 G 12.1 years), in whom upper-GI mesenchymal tumors were suspected to have arisen in the muscularis propria by endoscopic ultrasonography (EUS), were enrolled in this prospective study. EUS findings for endoscopic resection included well marginated submucosal tumors arising in the muscularis propria, an endoluminal growth pattern, greater than 1 cm and less than 5 cm in size. Snare polypectomy and incisional enucleation were used as endoscopic resection methods. Results: Snare polypectomy was performed in 19 patients and endoscopic incisional enucleation in 31 patients. The success rate of endoscopic resection was 84.0% (snare polypectomy 100%, endoscopic incisional enucleation 74.2%). The accuracy of EUS was 88% (44/50) for the detection of mesenchymal tumors arising the muscularis propria. In pathological findings, all esophageal mesenchymal tumors (n Z 11, mean size 18.5 G 7.0 cm) were leiomyoma; gastric mesenchymal tumors (n Z 39, mean size 17.1 G 7.1 cm) included leiomyoma (n Z 19), GIST (n Z 13), ectopic pancreas (n Z 3), lipoma (n Z 2), glomus tumor (n Z 1), and submucosal cyst (n Z 1). Perforation occurred in 3 patients. There was no serious bleeding which required transfusion. Conclusion: Endoscopic resection of the upper-GI mesenchymal tumors arising in the muscularis propria appears to be an effective method for an accurate histopathological diagnosis and eradication of the tumor, if appropriate indication is selected in experienced hands.
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Background: Isolated reports suggest that argon plasma coagulation (APC) under saline immersion can deliver energy more evenly to a larger area and in a more superficial manner with less risk of perforation. This manner of application has been used in the rectum and bladder. Our aim was to study the effects of APC with saline immersion in vivo compared to conventional APC application in the stomach and at different power settings. Material and Methods: Two 40-45 kg female domestic pigs were used. An ICC 300 machine and end firing probe (ERBE, Marietta, GA) were utilized. APC was endoscopically performed in the gastric antrum at fixed distance from the mucosa with increasing energy levels in regular (R) fashion and under saline immersion (I), in parallel rows. Three to four rows were made for each group in each animal, so that 6-7 samples could be analyzed. The animals were sacrificed immediately after and the treated areas were excised. Diameter was measured with a micrometer and the tissue was then fixed in formalin for histologic study. Depth of thermal injury was established histologically (in relation to wall layer). Depth and diameter were compared between both groups. Results: average diameter (table below; values Z mm) was greater in the R group and increased with increasing power settings. Depth was not statistically different between groups at any power setting. A thermal mucosal effect was evident starting at 15 W in both groups. Submucosal injury was identified at 90 W only in the R group. Histologically, the mucosal thermal damage was attenuated along the borders in some samples from the I group. Macroscopically a white uniform coagulum with an erythematous rim was evident along the margins in the I group in contrast to a charred coagulum seen in the R group. Conclusions: These results do not support the theoretical tissue effects from APC performed under saline immersion. APC performed under saline immersion does not appear to have any advantages for clinical use.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB223
T1326 Unsedated Transnasal Gastroscopy (T-EGD): Three Years Experience (2002-2004) in Operative Digestive Endoscopy Through Trans-Nasal Route Fausto Barberani, Alessandro Gigliozzi, Maurizio Giovannone, Mauro Tosoni, Sandro Boschetto
T1328 In Vivo Full-Thickness Endoluminal Gastroplication Using Tissue Anchors in a Live Pig Model Jose G. De la Mora, Elizabeth Rajan, David Rea, Thomas C. Smyrk, Lori J. Herman, Jodie L. Deters, Mary A. Knipschield, Christopher J. Gostout
T-EGD was first performed by Shaker in 1994 and proposed in Italy by Barberani with his own and innovative techniques, in 1998 (1,2). Our previous studies demonstrated that T-EGD is safer, better tolerated and cheaper than conventional one. There are only few records concerning T-EGD in operative endoscopy (PEG, Dilation on guide wire) when oral route is unavailable [3]. Aim of this study is to assess operative power of T-EGD in upper GI diseases. Material and Methods: 164 pts previously underwent to diagnostic unsedated T-EGD, were guided to a second T-EGD when endoscopic therapy was required. The procedures were performed according to Barberani’s technique: without topical anesthesia on left decubitus, evaluating both the naryx to choose the best way approaching middle or inferior meatus of the nose. Consent was obtained. A 6 mm Pentax video EG1840EG1870K with 2 mm operative channel was utilized. As additionals: injecting needle and snare Olympus and Deltamed, a 1.8 mm Deltamed Roth Net, a Boston CRE and Deltamed pneumatic dilator, a 1.8 mm Erbe Argon APC probe, Corpak-Peg16 Fr [4]. Results: We performed 164 therapies (age 23-91): 51 Injective therapy (42 PU, 6 achalasia, 3 varix); 9 esophageal dilation (6 benign stenosis, 3 malignant); 43 (5-25 mm) polipectomies (30 gastric, 12 esophageal, 1 duodenal); 23 Argon (12 angiodisplasya, 6 gastric fundic polyps, 1 GC, 4 Barrett esophagus); 16 prosthesis (15 PEG, 1 esoph prosth); 6 foreign bodies mobilization; 16 on the wire transnasal placing of nutritional naso duodenal tube. No complications were recorded. No changes in vital parameters. Conclusions: The large experience conducted in diagnostic T-EGD has leaded us to explore operative power of this technique thanks to the availability of hi-tech additionals:polyps’net recovery, decreasing volume, give this procedure sure and avoid accidental inhalation, guide wire inserted during T-EGD makes easy and safe pneumatic dilation of the esophagus, the APC fine probe treatments resulted definitively at the follow-up as well as the type of PEG and the injective therapy in bleeding and achalasyc pts, show safety, feasibility and tolerance of T-EGD not only in diagnostic procedure but also as possible tool for endoscopic therapy in selected patients. 1) Barberani F, et al. It. J. of Gastroent & Hepatol. 30 suppl 2; A 173, 1998. 2) Boschetto S, et al. Am. J. Gastroent. vol. 95, n 9; A132, 2000. 3) Dean R, et al. Gastroint. Endoscopy vol. 44 n.4: 422-4, 1996. 4) Barberani F, et al. Giorn. It. End. Dig. n 1, vol. 26: 9-17, 2003.
Background: Long-term success of gastric wall apposition performed by flexible endoscopy is dependent on fold permanence. Prior work by our group demonstrated that only full-thickness folds with serosal apposition are durable. Aim: To study feasibility of different tissue anchors to create a full thickness inverted fold and the durability of each single fold plication. Material & Methods: Four 35-45 Kg female pigs were used. Under anesthesia a midline abdominal incision was performed. A 5-cm incision parallel to the greater curvature of the stomach was made. The posterior wall was exposed and longitudinal folds were created by indenting the wall from the serosal side (inverted fold) 1.5 cm in height and 5 cm long. Anchors were deployed to traverse the inverted gastric wall, including apposing serosal surfaces within the fold. Anchors were 1 cm apart with 3-4 of the same type used per fold. 4-6 folds were made in each pig. Four types of paired anchors joined with suture (prolene 2-0) were used: T-bar (T); polypropylene mesh pledget (TM); plastic star-shaped buttons (S) and a self-expanding nitinol basket (B). Suture (vicryl 2-0) for incision closure was used to control for tissue reaction. Follow-up endoscopy was done at 15, 30 and 60 days. Two pigs were sacrificed each at 30 and 60 days. Macroscopic description of the folds was done and samples of the folds sent for histology. Results: Day 15: all folds were still present endoscopically. Day 30: S and B folds were unchanged, TM folds were reduced in height, and T folds had flattened. Day 60: only S & B folds remained. Histologically, all B folds included the muscle layer (30 & 60 day specimens) and one developed serosal fusion (30-day specimen). Only one S fold included the muscle layer with serosal fusion at 60 days. Conclusions: The durability of endoluminally placed full thickness inverted folds remains a challenge. Serosal apposition remains requisite for fold permanence. The use of tissue anchors such as the S and B designs may help achieve greater durability for endoscopic gastric remodeling by tissue apposition.
T1329 Argon Plasma Coagulation with or without Saline Immersion: Comparative In Vivo Study on Tissue Effects Jose G. De la Mora, Alma P. Romero, Lori J. Herman, Jodie L. Deters, Mary A. Knipschield, Christopher J. Gostout
T1327 Endoscopic Resection of Upper-GI Mesenchymal Tumors Arising in Muscularis Propria Joon Hyuck Choi, Jin Hong Kim, Jae Youn Cheong, Kee Myung Lee, Byung Moo Yoo, Kwang Jae Lee, Ki Baik Hahm, Sung Won Cho Background: The management of submucosal tumors should ideally be based on a pathologic diagnosis, because endoscopic findings of a small size do not preclude malignant behavior. The aim of this study was to evaluate the feasibility, safety and effectiveness of endoscopic resection for pathologic diagnosis and complete eradication of the upper-GI mesenchymal tumors arising in the muscularis propria. Methods: 50 patients (22 men, 28 women; mean age 46.5 G 12.1 years), in whom upper-GI mesenchymal tumors were suspected to have arisen in the muscularis propria by endoscopic ultrasonography (EUS), were enrolled in this prospective study. EUS findings for endoscopic resection included well marginated submucosal tumors arising in the muscularis propria, an endoluminal growth pattern, greater than 1 cm and less than 5 cm in size. Snare polypectomy and incisional enucleation were used as endoscopic resection methods. Results: Snare polypectomy was performed in 19 patients and endoscopic incisional enucleation in 31 patients. The success rate of endoscopic resection was 84.0% (snare polypectomy 100%, endoscopic incisional enucleation 74.2%). The accuracy of EUS was 88% (44/50) for the detection of mesenchymal tumors arising the muscularis propria. In pathological findings, all esophageal mesenchymal tumors (n Z 11, mean size 18.5 G 7.0 cm) were leiomyoma; gastric mesenchymal tumors (n Z 39, mean size 17.1 G 7.1 cm) included leiomyoma (n Z 19), GIST (n Z 13), ectopic pancreas (n Z 3), lipoma (n Z 2), glomus tumor (n Z 1), and submucosal cyst (n Z 1). Perforation occurred in 3 patients. There was no serious bleeding which required transfusion. Conclusion: Endoscopic resection of the upper-GI mesenchymal tumors arising in the muscularis propria appears to be an effective method for an accurate histopathological diagnosis and eradication of the tumor, if appropriate indication is selected in experienced hands.
www.mosby.com/gie
Background: Isolated reports suggest that argon plasma coagulation (APC) under saline immersion can deliver energy more evenly to a larger area and in a more superficial manner with less risk of perforation. This manner of application has been used in the rectum and bladder. Our aim was to study the effects of APC with saline immersion in vivo compared to conventional APC application in the stomach and at different power settings. Material and Methods: Two 40-45 kg female domestic pigs were used. An ICC 300 machine and end firing probe (ERBE, Marietta, GA) were utilized. APC was endoscopically performed in the gastric antrum at fixed distance from the mucosa with increasing energy levels in regular (R) fashion and under saline immersion (I), in parallel rows. Three to four rows were made for each group in each animal, so that 6-7 samples could be analyzed. The animals were sacrificed immediately after and the treated areas were excised. Diameter was measured with a micrometer and the tissue was then fixed in formalin for histologic study. Depth of thermal injury was established histologically (in relation to wall layer). Depth and diameter were compared between both groups. Results: average diameter (table below; values Z mm) was greater in the R group and increased with increasing power settings. Depth was not statistically different between groups at any power setting. A thermal mucosal effect was evident starting at 15 W in both groups. Submucosal injury was identified at 90 W only in the R group. Histologically, the mucosal thermal damage was attenuated along the borders in some samples from the I group. Macroscopically a white uniform coagulum with an erythematous rim was evident along the margins in the I group in contrast to a charred coagulum seen in the R group. Conclusions: These results do not support the theoretical tissue effects from APC performed under saline immersion. APC performed under saline immersion does not appear to have any advantages for clinical use.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB223