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Usefulness of Slimmer and Open Cell Type Stent for Endoscopic Bilateral Stenting and Endoscopic Revision in Patients with Hilar Cholangiocarcinoma
Abstracts
W1489 Spray Cryotherapy for Palliation of Locally Advanced Adenocarcinoma in Barrett’s Esophagus David L. Kerstetter, Fadlallah Habr Background: Up to 60% of patients with esophageal cancer are deemed inoperable at the time of diagnosis due to either advanced stage or significant co-morbidities. Palliation remains the only therapeutic option for those patients. Currently, endoscopic palliative measures include stenting and photodynamic therapy. Although spray cryotherapy has been successfully used in ablating Barrett’s esophagus, and different grades of dysplasia, there has been only one published case describing complete remission of squamous cell carcinoma following cryoablation. However, there are no published reports on the effects of cryoablation in patients with esophageal adenocarcinoma, a rapidly rising cancer in the United States. This is the first case describing the use of spray cryotherapy for palliation of advanced esophageal adenocarcinoma. CASE PRESENTATION: An 80 year-old female presented with solid food dysphagia and weight loss. Esophagogastroduodenoscopy (EGD) revealed a 5 cm mass in the mid-esophagus which was confirmed to be adenocarcinoma on biopsy. Endoscopic ultrasound demonstrated invasion the adventitia consistent with a T3 tumor. Given her age and concomitant advanced lung disease, the patient was considered a poor surgical candidate and therefore, palliative therapy was contemplated. Using the CryoSpray Ablation System (CSA Medical, Baltimore, MD), the lesion was treated with four freeze-thaw cycles of 10-20 seconds each with 60 second interim thaws. Following the procedure, the patient had symptomatic improvement of her dysphagia and did not experience any adverse effects such as odynophagia or chest pain. Repeat EGD at week 12 revealed a reduction in the size of the tumor. Spray cryotherapy was repeated at weeks 12 and 16 without complications. After 3 treatments (week 20), complete endoscopic resolution of the lesion was noted, with regression of the Barrett’s mucosa and major improvement of her dysphagia. At week 28, a recurrent mass was seen on EGD in the mid-esophagus. This was treated with 3 sessions of spray cryotherapy at 4 week intervals with improvement of dysphagia after each application. Eleven months after her initial cryotherapy, the patient opted to have an esophageal stent due to tumor progression. Conclusion: While spray cryotherapy is safe and effective for the ablation of Barrett’s esophagus, it may be a promising new modality for the palliation of advanced esophageal cancer. Further studies are needed to further evaluate this palliative option.
W1491 ESD Assisted Laparoscopic Partial Gastrectomy for Gastric Submucosal Tumor Takashi Ogata, Hidenori Tomioka, Tetsuo Sumi, Kazuhiko Kasuya, Ichiro Sonoda, Yoshihiro Yasuda, Tetsuo Ishizaki, Tomohisa Nomura, Hironobu Koji, Motohide Shimazu, Akihiko Tsuchida, Tatsuya Aoki Introduction: Laparoscopic partial gastrectomy is frequently performed for the treatment of gastric submucosal tumor. Resection with an automatic suture instrument is associated with excessive removal of gastric mucosa, especially for intraluminal growing type of submucosal tumor, which may result in postoperative stenosis or distortion. On the other hand, endoscopic submucosal dissection(ESD) is the technique of endoscopic treatment for gastric cancer to cut the submucosal layer accurately around the cancer. We examined whether this ESD technique was able to be cut accurately around the gastric submucosal tumor when laparoscopic partial gastrectomy was done. Methods: 1) Under laparoscopy, an intestinal clamp was placed 10 cm off the ligament of Treitz gently so that the tract below the small intestine might not be dilated by intragastric insufflation of air. 2) An endoscope was inserted through the mouth into the stomach to define and mark the tumor edge using the laparoscopic light. For this laparoscopic light outside from the stomach, the tumor edge could be clarified endoscopically. 3) The submucosal layer was dissected circumferentially outside of the markings by the ESD technique. To add indigocarmine to a local injection fluid would help identify the line of laparoscopic resection. 4) The site of initial incision was determined by the laparoscope and pierced with the endoscope. 5) Starting from the pierced site, the seromuscular layer was resected with the vessel sealing system under observation with the laparoscope. The tumor turned outward to the abdominal cavity as resection proceeded. A portion of the circumference was left intact. 6) The stump was closed with an automatic suture instrument while lifting the intact portion. Results: Enbloc resection was succeeded by histologically. This procedure protected the mucosa around the major lesion from excessive removal when compared with conventional open surgery specimens. Conclusions: Markings made by laparoscopic light guidance and using ESD technique during laparoscopic gastrectomy allowed us to mark a clearer line to resect the submucosal gastric tumor and to avoid excessive removal of the stomach.
W1490 Role of Duodenal Stents in Palliation of Gastric Outlet Obstruction Mark Jarvis, Purushothaman Premchand, William E. Fickling Introduction: In patients with incurable gastroduodenal cancer presenting with obstruction, surgical gastrojejunostomy is the current treatment of choice. Duodenal stent placement is an alternative and our aim was to evaluate our experience of expandable metal endoluminal stents in the palliation of obstructing gastroduodenal cancer. Method A complete list of duodenal stent use from June 2005 to the present day in our unit patients was obtained from our endoscopy database. Endoscopy reports were reviewed with patient notes. Information obtained included indications, technical success, complications and patient survival. Results19 stents were deployed in 14 patients. They all had advanced cancer and were not candidates for potentially curative surgery. 4 patients had previous surgery at the stent site. The 4 restents were for tumour in growth. Results are summarised in table 1 Indication.5 patients had pancreatic cancer causing duodenal obstruction. 5 Patients had gastric cancer causing gastric outlet obstruction. 3 patients had duodenal obstruction, 1 with bleeding, from duodenal adenocarcinomas, both of which were thought to represent recurrence of bowel carcinomas. 1 patient had a malignant stricture at the anastomotic site following gastrectomy for gastro-oesophageal tumours. Technical success18/19(95%) procedures were a technical success. 1 stent failed to deploy properly, was removed and another successfully deployed. ComplicationsThere were no complicationsSurvival12/14 patients have died. Excluding the living patients mean survival was 133 days (range 1 to 395 days). Conclusion: In appropriate patients duodenal stenting has an excellent technical success rate with very low risk of complicationsand could avoid palliative surgical intervention in this group of patients Table 1. Duodenal stent outcome by indication. Patient Number OfTechnical Complication Survival Number Stents Success Rate %Rate % Days(Mean) Gastric cancer Pancreaticcancer Recurrenceat anastomosis Duodenal cancer Overall
5 5 1
9 5 1
89 100 100
0 0 0
75-395 (228) 6-205 (80) 94 (94)
3
4
100
0
1-54 (28)
14
19
95
0
(133)
www.giejournal.org
W1492 Usefulness of Slimmer and Open Cell Type Stent for Endoscopic Bilateral Stenting and Endoscopic Revision in Patients with Hilar Cholangiocarcinoma Hyung Wook Kim, Dae Hwan Kang, Cheol Woong Choi, Won Il Park, Gwang Ha Kim, Jae Seung Lee, Min Dae Kim, Jin Ho Lee, Dong Uk Kim, Jeung Ho Heo Background and Aims: Although endoscopic bilateral metal stenting in ‘‘stent in stent’’ fashion is currently used to treat patients with unresectable hilar cholangiocarcinoma, this method has limited application in case of tight stricture or revision of tumor recurrence, especially on the side where stenting is taken place first. This study evaluated the clinical efficacy of bilateral metal stenting using Zilver stent which is slimmer and open cell type. Methods: We conducted a prospective, uncontrolled study in a tertiary referral university hospital. In twenty eight patients with unresectable Bismuth type II or higher hilar cholangiocarcinoma, the endoscopic bilateral metal stenting in ‘‘stent in stent’’ method was performed. At first, Y stent with central wide open mesh was inserted and then, open cell type Zilver stent, which is preloaded in a slim delivery system (7 Fr) and easily dilated, was placed into the contralateral hepatic duct through the central portion of Y stent. Results: Technical success was achieved in 24 (85.7%) patients. Functional success was noted in 24 (100.0%) patients among 24 patients. Early complications such as pancreatitis and cholecystitis occurred in 2 (8.3%) patients. Late complications occurred in 9 (37.5%) patients. Cholecystitis occurred in 1 patient and was managed by percutaneous transhepatic gallbladder drainage. Stent obstruction by tumor ingrowth or overgrowth occurred in 8 out of 24 (33.3%) patients. These patients were managed by placement of bilateral plastic stents (4/8), percutaneous transhepatic biliary drainage (3/8), and combined method (1/8). Among 5 patients who were tried by endoscopic revision, 4 (80%) patients were managed endoscopically by bilateral plastic stents. Conclusions: Slimmer and open cell type Zilver stent is effective in endoscopic bilateral stenting for advanced hilar cholangiocarcinoma and endoscopic revision in case of tumor recurrence.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB383
W1489 Spray Cryotherapy for Palliation of Locally Advanced Adenocarcinoma in Barrett’s Esophagus David L. Kerstetter, Fadlallah Habr Background: Up to 60% of patients with esophageal cancer are deemed inoperable at the time of diagnosis due to either advanced stage or significant co-morbidities. Palliation remains the only therapeutic option for those patients. Currently, endoscopic palliative measures include stenting and photodynamic therapy. Although spray cryotherapy has been successfully used in ablating Barrett’s esophagus, and different grades of dysplasia, there has been only one published case describing complete remission of squamous cell carcinoma following cryoablation. However, there are no published reports on the effects of cryoablation in patients with esophageal adenocarcinoma, a rapidly rising cancer in the United States. This is the first case describing the use of spray cryotherapy for palliation of advanced esophageal adenocarcinoma. CASE PRESENTATION: An 80 year-old female presented with solid food dysphagia and weight loss. Esophagogastroduodenoscopy (EGD) revealed a 5 cm mass in the mid-esophagus which was confirmed to be adenocarcinoma on biopsy. Endoscopic ultrasound demonstrated invasion the adventitia consistent with a T3 tumor. Given her age and concomitant advanced lung disease, the patient was considered a poor surgical candidate and therefore, palliative therapy was contemplated. Using the CryoSpray Ablation System (CSA Medical, Baltimore, MD), the lesion was treated with four freeze-thaw cycles of 10-20 seconds each with 60 second interim thaws. Following the procedure, the patient had symptomatic improvement of her dysphagia and did not experience any adverse effects such as odynophagia or chest pain. Repeat EGD at week 12 revealed a reduction in the size of the tumor. Spray cryotherapy was repeated at weeks 12 and 16 without complications. After 3 treatments (week 20), complete endoscopic resolution of the lesion was noted, with regression of the Barrett’s mucosa and major improvement of her dysphagia. At week 28, a recurrent mass was seen on EGD in the mid-esophagus. This was treated with 3 sessions of spray cryotherapy at 4 week intervals with improvement of dysphagia after each application. Eleven months after her initial cryotherapy, the patient opted to have an esophageal stent due to tumor progression. Conclusion: While spray cryotherapy is safe and effective for the ablation of Barrett’s esophagus, it may be a promising new modality for the palliation of advanced esophageal cancer. Further studies are needed to further evaluate this palliative option.
W1491 ESD Assisted Laparoscopic Partial Gastrectomy for Gastric Submucosal Tumor Takashi Ogata, Hidenori Tomioka, Tetsuo Sumi, Kazuhiko Kasuya, Ichiro Sonoda, Yoshihiro Yasuda, Tetsuo Ishizaki, Tomohisa Nomura, Hironobu Koji, Motohide Shimazu, Akihiko Tsuchida, Tatsuya Aoki Introduction: Laparoscopic partial gastrectomy is frequently performed for the treatment of gastric submucosal tumor. Resection with an automatic suture instrument is associated with excessive removal of gastric mucosa, especially for intraluminal growing type of submucosal tumor, which may result in postoperative stenosis or distortion. On the other hand, endoscopic submucosal dissection(ESD) is the technique of endoscopic treatment for gastric cancer to cut the submucosal layer accurately around the cancer. We examined whether this ESD technique was able to be cut accurately around the gastric submucosal tumor when laparoscopic partial gastrectomy was done. Methods: 1) Under laparoscopy, an intestinal clamp was placed 10 cm off the ligament of Treitz gently so that the tract below the small intestine might not be dilated by intragastric insufflation of air. 2) An endoscope was inserted through the mouth into the stomach to define and mark the tumor edge using the laparoscopic light. For this laparoscopic light outside from the stomach, the tumor edge could be clarified endoscopically. 3) The submucosal layer was dissected circumferentially outside of the markings by the ESD technique. To add indigocarmine to a local injection fluid would help identify the line of laparoscopic resection. 4) The site of initial incision was determined by the laparoscope and pierced with the endoscope. 5) Starting from the pierced site, the seromuscular layer was resected with the vessel sealing system under observation with the laparoscope. The tumor turned outward to the abdominal cavity as resection proceeded. A portion of the circumference was left intact. 6) The stump was closed with an automatic suture instrument while lifting the intact portion. Results: Enbloc resection was succeeded by histologically. This procedure protected the mucosa around the major lesion from excessive removal when compared with conventional open surgery specimens. Conclusions: Markings made by laparoscopic light guidance and using ESD technique during laparoscopic gastrectomy allowed us to mark a clearer line to resect the submucosal gastric tumor and to avoid excessive removal of the stomach.
W1490 Role of Duodenal Stents in Palliation of Gastric Outlet Obstruction Mark Jarvis, Purushothaman Premchand, William E. Fickling Introduction: In patients with incurable gastroduodenal cancer presenting with obstruction, surgical gastrojejunostomy is the current treatment of choice. Duodenal stent placement is an alternative and our aim was to evaluate our experience of expandable metal endoluminal stents in the palliation of obstructing gastroduodenal cancer. Method A complete list of duodenal stent use from June 2005 to the present day in our unit patients was obtained from our endoscopy database. Endoscopy reports were reviewed with patient notes. Information obtained included indications, technical success, complications and patient survival. Results19 stents were deployed in 14 patients. They all had advanced cancer and were not candidates for potentially curative surgery. 4 patients had previous surgery at the stent site. The 4 restents were for tumour in growth. Results are summarised in table 1 Indication.5 patients had pancreatic cancer causing duodenal obstruction. 5 Patients had gastric cancer causing gastric outlet obstruction. 3 patients had duodenal obstruction, 1 with bleeding, from duodenal adenocarcinomas, both of which were thought to represent recurrence of bowel carcinomas. 1 patient had a malignant stricture at the anastomotic site following gastrectomy for gastro-oesophageal tumours. Technical success18/19(95%) procedures were a technical success. 1 stent failed to deploy properly, was removed and another successfully deployed. ComplicationsThere were no complicationsSurvival12/14 patients have died. Excluding the living patients mean survival was 133 days (range 1 to 395 days). Conclusion: In appropriate patients duodenal stenting has an excellent technical success rate with very low risk of complicationsand could avoid palliative surgical intervention in this group of patients Table 1. Duodenal stent outcome by indication. Patient Number OfTechnical Complication Survival Number Stents Success Rate %Rate % Days(Mean) Gastric cancer Pancreaticcancer Recurrenceat anastomosis Duodenal cancer Overall
5 5 1
9 5 1
89 100 100
0 0 0
75-395 (228) 6-205 (80) 94 (94)
3
4
100
0
1-54 (28)
14
19
95
0
(133)
www.giejournal.org
W1492 Usefulness of Slimmer and Open Cell Type Stent for Endoscopic Bilateral Stenting and Endoscopic Revision in Patients with Hilar Cholangiocarcinoma Hyung Wook Kim, Dae Hwan Kang, Cheol Woong Choi, Won Il Park, Gwang Ha Kim, Jae Seung Lee, Min Dae Kim, Jin Ho Lee, Dong Uk Kim, Jeung Ho Heo Background and Aims: Although endoscopic bilateral metal stenting in ‘‘stent in stent’’ fashion is currently used to treat patients with unresectable hilar cholangiocarcinoma, this method has limited application in case of tight stricture or revision of tumor recurrence, especially on the side where stenting is taken place first. This study evaluated the clinical efficacy of bilateral metal stenting using Zilver stent which is slimmer and open cell type. Methods: We conducted a prospective, uncontrolled study in a tertiary referral university hospital. In twenty eight patients with unresectable Bismuth type II or higher hilar cholangiocarcinoma, the endoscopic bilateral metal stenting in ‘‘stent in stent’’ method was performed. At first, Y stent with central wide open mesh was inserted and then, open cell type Zilver stent, which is preloaded in a slim delivery system (7 Fr) and easily dilated, was placed into the contralateral hepatic duct through the central portion of Y stent. Results: Technical success was achieved in 24 (85.7%) patients. Functional success was noted in 24 (100.0%) patients among 24 patients. Early complications such as pancreatitis and cholecystitis occurred in 2 (8.3%) patients. Late complications occurred in 9 (37.5%) patients. Cholecystitis occurred in 1 patient and was managed by percutaneous transhepatic gallbladder drainage. Stent obstruction by tumor ingrowth or overgrowth occurred in 8 out of 24 (33.3%) patients. These patients were managed by placement of bilateral plastic stents (4/8), percutaneous transhepatic biliary drainage (3/8), and combined method (1/8). Among 5 patients who were tried by endoscopic revision, 4 (80%) patients were managed endoscopically by bilateral plastic stents. Conclusions: Slimmer and open cell type Zilver stent is effective in endoscopic bilateral stenting for advanced hilar cholangiocarcinoma and endoscopic revision in case of tumor recurrence.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB383