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V.02.5 AN UNUSUAL ACUTE PANCREATITIS CAUSED BY A DUODENAL DIVERTICULAR ABSCESS SUCCESSFULLY
Abstracts of the 20th National Congress of Digestive Diseases / Digestive and Liver Disease 46S (2014) S1–S144 V.02.4 EUS-GUIDED FINE NEEDLE TISSUE ACQUISITION OF A SUBEPITHELIAL LESION IN THE DISTAL ILEUM USING THE FORWARD VIEWING ECHOENDOSCOPE F. Attili ∗,1 , D. Galasso 1 , F. Scaldaferri 2 , G. Vanella 1 , G. Ianiro 1 , G. Costamagna 1 , A. Larghi 1 1 Digestive
Endoscopy Unit, catholic University, Rome, Italy; 2 Division of Gastroenterology, Catholic University, Rome, Italy Background and aim: The role of EUS-FNA for diseases of the colon and the rectum is still limited, mainly due to the technical difficulty of inserting a conventional linear EUS (CLA-EUS) with an oblique optics above the sigmoid tract. We recently described two patients in whom we successfully performed FNA of extracolonic lesions adjacent to the ascending and descending colon with a new forward viewing therapeutic linear echoendoscope (FV-EUS). We, herein, report the first case of EUS-FNA of a distal ileal lesion performed using the FV-EUS scope. Material and methods: A 68 years old woman with a 13 years history of ulcerative colitis was found on routine surveillance colonoscopy to have a 1.5 cm lesion in the terminal ileum that presented characteristics suggestive for a subepithelial lesion (SEL) with normal appearing overlying mucosal layer. To exclude extrinsic compression a computed tomography was done and confirmed the presence of a wall thickening/lesion at the level of terminal ileum, in proximity of the ileocecal valve. After informed consent was obtained, the FV-EUS (XGIF-UCT160J-AL5, Olympus Medical Systems Europe, Hamburg, Germany) was used with the intention to reach and intubate the ileocecal valve in order to evaluate and sample the lesion. Results: Using the FV-EUS the cecum was easily reached. The terminal ileum was, then, intubated and a 14x10 mm hypoechoic lesion confined to the third wall layer was detected. EUS-guided fine needle tissue acquisition using a 19 gauge needle was performed and tissue sample obtained, which revealed a serotonin secreting neuroendocrine tumor (SeS-NET) with ≤1% Ki67 proliferation index corresponding to a G1 tumor. Patient subsequently underwent right emicolectomy and definitive surgical specimen evaluation confirmed a G1 SeS-NET with lymph node metastastis (pT3N1). Conclusions: This report demonstrate that the frontal endoscopic view of the FV-EUS, coupled with the exit of the working channel at the tip of the echeondoscope allowed the easy performance of a colonoscopy with Ileocecal valve intubation followed by sampling of a subepithelial lesion of the distal ileum.
V.02.5 AN UNUSUAL ACUTE PANCREATITIS CAUSED BY A DUODENAL DIVERTICULAR ABSCESS SUCCESSFULLY M. Rossi ∗ , G. Ghezzi, M. Motter, F. Armelao, G. Franceschini, C. Tieppo, D. Giacomin, R. Nienstedt, G. De Pretis
S51
large cavity, with regular edges. Three 7-french plastic double pig-tail stents were placed and a nasocystic catheter was inserted to wash the lumen of the diverticulum and to remove pus and debris. Large-spectrum antibiotics (tazobactam, piperacillin, metronidazole and levofloxacin) was administered for fourteen days. The patient went slowly into remission after about 10 days. At the endoscopic control the stents were not in place any longer, due to spontaneous migration. Conclusions: An infected duodenal diverticulum with a pus collection may represent an unusual trigger of an acute pancreatitis attack; the endoscopic drainage of the diverticulum may be a successful management of the condition.
V.02.6 SCISSOR-SHAPED SB KNIFE WITH THE DIVERTICULOSCOPE ASSISTANCE FOR ZENKER DIVERTICULUM SEPTOTOMY F. Iacopini ∗,1 , G. Costamagna 2 , W. Elisei 1 , A. Scozzarro 1 1 Gastroenterologia
ed Endoscopia, Ospedale S. Giuseppe, Albano L., Roma, Italy; 2 Endoscopia Digestiva Chirurgica, Policlinico Gemelli, Università Cattolica, Roma, Italy Background and aim: Flexible endoscopic septotomy of Zenker diverticulum is an established alternative to open surgery and rigid endostapling. The technique of flexible endoscopy septotomy has not been standardized and differentiates due to the use of different devices to maintain the operative field open while the cut of the septum is performed by various needle-knives. A new scissor-shaped monopolar rotable insulated device with claw-curved blades developed for endoscopic submucosal dissection (SB knife, Sumitomo, Bakelite, Tokyo, Japan) may be an improvement of the technique. Material and methods: Septotomy of Zenker diverticulum was performed by the diverticuloscope-assisted technique (Costamagna G, et al. Endoscopy 2007): 1) placement of the diverticuloscope (ZD overtube; Cook Endoscopy, Winston-Salem, USA) to stretch and fix the septum; 2) septotomy with electrocautery (Endocut I, setting 1-3-3; VIO 200; ERBE, Tübingen, Germany) using the standard-type 7 mm SB knife; for the whole thickness of the cricopharyngeal muscle. Results: Septotomy was performed in two patients: 1) a 52 y.o. man with a 25 mm ZD, oropharyngeal dysphagia for solids, and undigested food regurgitation at each meal; 2) a 83 y.o. man with a 20 mm ZD, dysphagia for solids, globus sensation, weight loss during the last 12 months. The diverticuloscope was easily and correctly placed. The SB knife was rotated perpendicular to the septum and positioned at its midline. The cut was performed in a stepwise fashion grasping the tissue and pulling it toward the tip of the endoscope to reduce thermic injury of the underlying tissue (see Figure). Septotomy was conducted until all fibers of the cricopharyngeal muscle were ablated, in both cases up to the bottom of the ZD. No adverse events occurred. The oral diet was resumed after 24 hours. Both patients were asymptomatic at 3 months after the procedure.
Ospedale Santa Chiara, Trento, Italy Background and aim: Acute pancreatits is secondary to biliary stones in the majority of cases; nevertheless, unusual etiologies must always be kept in mind, especially when an endoscopic treatment is feasible. Material and methods: We describe the case of an unusual pancreatitis with favorable outcome triggered by a superinfection of a duodenal diverticulum successfully treated by endoscopic drainage of the cavity. Results: A 65-year-old woman with a past medical history of partial gastrectomy (according to Billroth II) was admitted to our hospital with a 24 hours history of abdominal pain and fever. Abnormal laboratory values included: serum amylase: 1060 (normal value 8–53), C-reactive protein: 50.63 (normal value <6.00), WBC: 14.9×109 /L (normal value 4–10), ALT: 55 U/L (normal value 5-40). Computed tomography of the abdomen showed images consisting with acute pancreatitis. The day after the admission the patients underwent endoscopic retrograde cholangiopancreatography (ERCP), which showed the following findings: the papilla was not identified, but an opening leaking pus in the second part of the duodenum was observed; the surrounding mucosa was reddened and showed edema and erosions. Under fluoroscopic control, the duodenal opening was cannulated and opacified and revealed a
Conclusions: SB knife may be safer than needle knives but its potential advantages do not cancel the technical and clinical importance of the diverticuloscope. Actually, the SB knife can increase safety and completeness of myotomy of the more difficult cap-assisted technique3 in countries where the diverticuloscope is not commercially available. Prospective studies are necessary to establish the conditions in which the SB knife should be preferred for ZD septotomy.
Endoscopy Unit, catholic University, Rome, Italy; 2 Division of Gastroenterology, Catholic University, Rome, Italy Background and aim: The role of EUS-FNA for diseases of the colon and the rectum is still limited, mainly due to the technical difficulty of inserting a conventional linear EUS (CLA-EUS) with an oblique optics above the sigmoid tract. We recently described two patients in whom we successfully performed FNA of extracolonic lesions adjacent to the ascending and descending colon with a new forward viewing therapeutic linear echoendoscope (FV-EUS). We, herein, report the first case of EUS-FNA of a distal ileal lesion performed using the FV-EUS scope. Material and methods: A 68 years old woman with a 13 years history of ulcerative colitis was found on routine surveillance colonoscopy to have a 1.5 cm lesion in the terminal ileum that presented characteristics suggestive for a subepithelial lesion (SEL) with normal appearing overlying mucosal layer. To exclude extrinsic compression a computed tomography was done and confirmed the presence of a wall thickening/lesion at the level of terminal ileum, in proximity of the ileocecal valve. After informed consent was obtained, the FV-EUS (XGIF-UCT160J-AL5, Olympus Medical Systems Europe, Hamburg, Germany) was used with the intention to reach and intubate the ileocecal valve in order to evaluate and sample the lesion. Results: Using the FV-EUS the cecum was easily reached. The terminal ileum was, then, intubated and a 14x10 mm hypoechoic lesion confined to the third wall layer was detected. EUS-guided fine needle tissue acquisition using a 19 gauge needle was performed and tissue sample obtained, which revealed a serotonin secreting neuroendocrine tumor (SeS-NET) with ≤1% Ki67 proliferation index corresponding to a G1 tumor. Patient subsequently underwent right emicolectomy and definitive surgical specimen evaluation confirmed a G1 SeS-NET with lymph node metastastis (pT3N1). Conclusions: This report demonstrate that the frontal endoscopic view of the FV-EUS, coupled with the exit of the working channel at the tip of the echeondoscope allowed the easy performance of a colonoscopy with Ileocecal valve intubation followed by sampling of a subepithelial lesion of the distal ileum.
V.02.5 AN UNUSUAL ACUTE PANCREATITIS CAUSED BY A DUODENAL DIVERTICULAR ABSCESS SUCCESSFULLY M. Rossi ∗ , G. Ghezzi, M. Motter, F. Armelao, G. Franceschini, C. Tieppo, D. Giacomin, R. Nienstedt, G. De Pretis
S51
large cavity, with regular edges. Three 7-french plastic double pig-tail stents were placed and a nasocystic catheter was inserted to wash the lumen of the diverticulum and to remove pus and debris. Large-spectrum antibiotics (tazobactam, piperacillin, metronidazole and levofloxacin) was administered for fourteen days. The patient went slowly into remission after about 10 days. At the endoscopic control the stents were not in place any longer, due to spontaneous migration. Conclusions: An infected duodenal diverticulum with a pus collection may represent an unusual trigger of an acute pancreatitis attack; the endoscopic drainage of the diverticulum may be a successful management of the condition.
V.02.6 SCISSOR-SHAPED SB KNIFE WITH THE DIVERTICULOSCOPE ASSISTANCE FOR ZENKER DIVERTICULUM SEPTOTOMY F. Iacopini ∗,1 , G. Costamagna 2 , W. Elisei 1 , A. Scozzarro 1 1 Gastroenterologia
ed Endoscopia, Ospedale S. Giuseppe, Albano L., Roma, Italy; 2 Endoscopia Digestiva Chirurgica, Policlinico Gemelli, Università Cattolica, Roma, Italy Background and aim: Flexible endoscopic septotomy of Zenker diverticulum is an established alternative to open surgery and rigid endostapling. The technique of flexible endoscopy septotomy has not been standardized and differentiates due to the use of different devices to maintain the operative field open while the cut of the septum is performed by various needle-knives. A new scissor-shaped monopolar rotable insulated device with claw-curved blades developed for endoscopic submucosal dissection (SB knife, Sumitomo, Bakelite, Tokyo, Japan) may be an improvement of the technique. Material and methods: Septotomy of Zenker diverticulum was performed by the diverticuloscope-assisted technique (Costamagna G, et al. Endoscopy 2007): 1) placement of the diverticuloscope (ZD overtube; Cook Endoscopy, Winston-Salem, USA) to stretch and fix the septum; 2) septotomy with electrocautery (Endocut I, setting 1-3-3; VIO 200; ERBE, Tübingen, Germany) using the standard-type 7 mm SB knife; for the whole thickness of the cricopharyngeal muscle. Results: Septotomy was performed in two patients: 1) a 52 y.o. man with a 25 mm ZD, oropharyngeal dysphagia for solids, and undigested food regurgitation at each meal; 2) a 83 y.o. man with a 20 mm ZD, dysphagia for solids, globus sensation, weight loss during the last 12 months. The diverticuloscope was easily and correctly placed. The SB knife was rotated perpendicular to the septum and positioned at its midline. The cut was performed in a stepwise fashion grasping the tissue and pulling it toward the tip of the endoscope to reduce thermic injury of the underlying tissue (see Figure). Septotomy was conducted until all fibers of the cricopharyngeal muscle were ablated, in both cases up to the bottom of the ZD. No adverse events occurred. The oral diet was resumed after 24 hours. Both patients were asymptomatic at 3 months after the procedure.
Ospedale Santa Chiara, Trento, Italy Background and aim: Acute pancreatits is secondary to biliary stones in the majority of cases; nevertheless, unusual etiologies must always be kept in mind, especially when an endoscopic treatment is feasible. Material and methods: We describe the case of an unusual pancreatitis with favorable outcome triggered by a superinfection of a duodenal diverticulum successfully treated by endoscopic drainage of the cavity. Results: A 65-year-old woman with a past medical history of partial gastrectomy (according to Billroth II) was admitted to our hospital with a 24 hours history of abdominal pain and fever. Abnormal laboratory values included: serum amylase: 1060 (normal value 8–53), C-reactive protein: 50.63 (normal value <6.00), WBC: 14.9×109 /L (normal value 4–10), ALT: 55 U/L (normal value 5-40). Computed tomography of the abdomen showed images consisting with acute pancreatitis. The day after the admission the patients underwent endoscopic retrograde cholangiopancreatography (ERCP), which showed the following findings: the papilla was not identified, but an opening leaking pus in the second part of the duodenum was observed; the surrounding mucosa was reddened and showed edema and erosions. Under fluoroscopic control, the duodenal opening was cannulated and opacified and revealed a
Conclusions: SB knife may be safer than needle knives but its potential advantages do not cancel the technical and clinical importance of the diverticuloscope. Actually, the SB knife can increase safety and completeness of myotomy of the more difficult cap-assisted technique3 in countries where the diverticuloscope is not commercially available. Prospective studies are necessary to establish the conditions in which the SB knife should be preferred for ZD septotomy.