V.1.7 HOLMIUM LASER INTRACORPOREAL LITHOTRIPSY SPYGLASS SYSTEM ASSISTED: A CASE REPORT

Abstracts / Digestive and Liver Disease 42S (2010) S61–S192 antegrade-retrograde endoscopic rendezvous technique previously described for dilating complex esophageal strictures. Material and methods: In our case the patient was a 65-year-old male. The patient had undergone left colectomy for a carcinoma in 2008, and after few months developed anastomotic stricture with no hystologic evidence of malignity. An Hartmann procedure was performed to relieve the occlusion. In February 2009, immediately after the recanalization, the patient developed a new anastomotic stricture. An endoscopic dilation attempt failed to restore patency of the anasomosis. In August 2009 a rendez-vous technique was applied. The procedure consisted in a double access with an endoscope inserted through the anus and another through the stoma to reach both sides of the anastomosis. After a trans-illumination point was identified, a breach was obtained by cutting the wall with a needle knife. Then, a 0.035 guidewire was inserted through the breach under fluoroscopic guidance and captured with a biopsy forceps on the other side of the anastomosis. Over the wire a sphyncterotome was used to enlarge the breach and a mechanical dilation with Savary dilators to 9 mm was performed. A nasogastric tube was left in place through the new communication stoma for two days, and then a self expanding metal stent was placed through the stricture. The stent was removed after 3 weeks. Results: No complication related to the procedure were registered. The canalization was good after the stent was removed as shown by a gastrographyn enema. Conclusions: In literature there are few reports of endoscopic treatment of complete colonic anastomotic obstruction, and in the majority only a dilation with balloon or mechanical is reported. This rendez-vous technique has been described previously for dilation of complex obstructing esophageal strictures. In difficult cases, with completely closed anastomotic strictures and a proximal access given by ileo or colostomy a rendez-vous approach can be useful to obtain recanalization. # O. Therapeutic endoscopy - 2. Stenosis palliation

V.1.5 SPY GLASS CHOLANGIOPANCREATOSCOPY FOR THE DIAGNOSIS OF BILIARY-PANCREATIC DUCTS DISORDERS A. Sedici ∗ Ospedale “SS Filippo e Nicola”, Avezzano (AQ) Background and aim: The cholangioscopy with “Spy-Glass® ” (4) is an advanced technological platform, designed to implement the diagnostic accuracy during ERCP. Is performed by a single operator (5-6) through the “SpyScope® ” device that allows to access and operate within the bile ducts. Aim: To evaluate a single-operator endoscope, “Spy-Glass® ”, for its performance, feasibility and safety in the management of pancreaticobiliary disease. Material and methods: In our center the “Spy-Glass® ” has been used mainly in order to achieve diagnostic accuracy in all those pathological conditions, both benign and malignant, those of doubtful interpretation on CT, MRCP, ERCP, EUS (7-8). Special attention was given to all those paintings clinical-instrumental stricture of the bile ducts in which, through the use of “Spy-Glass® ” associated with the implementation of targeted biopsies, have been avoided unnecessary surgical exploration. For this purpose, were enrolled 14 consecutive eligible patients from January 2009 to October 2009 with indications that included benign and malignant diseases obstructive is not obstructive. Results: The feasibility and technical success of the procedure has so far been 100%. We believe, however, that the maneuver preparatory to access the “Spy-Scope® ” in the ducts, access constitutes a “step” difficult and complex, and in 3 cases we had to use wire-guided access. Preliminary results with respect to sensitivity and specificity of the diagnosis morphological of the cholangioscopy was 92.8% (13 cases out of 14), in a case of false positive histology showed to treaties of sclerosing cholangitis (PSC). Conclusions: The “Spy-Glass® ” is a platform “endoscopic” high-tech, “single-operator”, which allows a direct intraluminal view of the biliarypancreatic duct system. This innovative system is radically transforming “the imaging” diagnostic biliary-pancreatic, providing both a significant addition to ERCP, which will be increasingly integral part. # S. New technology - 1. Magnification, NBI, FICE, i-Scan, confocal, cytoendoscopy

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V.1.6 ADJUSTABLE TOTALLY IMPLANTABLE INTRAGASTRIC PROSTHESIS (ATIIP)-ENDOGAST® M. Del Piano 1 , M. Balzarini ∗ ,1 , M. Ballaré 1 , M. Orsello 1 , F. Montino 1 , G. Gaggiotti 2 1 SCDO di Gastroenterologia Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara; 2 Centro di Riferimento Regionale Chirurgia Obesità, INRCA - IRCCS, Ancona

Background and aim: The Adjustable Totally Implantable Intragastric Prosthesis (ATIIP) - Endogast® is a new mini-invasive technique for the treatment of Morbid Obesity (G. Gaggiotti. Minimally Invasive Therapy. 2005;4:324). The permanent presence of an air inflated prosthesis inside the gastric corpusfundus area and the fixation of the stomach to the abdominal wall are the principles why the technique has been developed. The prosthesis is connected to a subcutaneous totally implantable system. The aim of the ATIIP is to induce an early satiety interfering with the satiety control process related the corpus-fundus area of the stomach. The ATIIP technique uses a specific device (Endogast® -Districlass Médical S.A.-France). The device consists of the main following parts: a polyurethane rugby shaped balloon prosthesis; a 15 cm polyurethane catheter attached to the midpoint of the prosthesis; a guide-wire and a needle cannula; a retention silicone cylinder; a protective plastic tube; a stainless steel cone-shaped chamber. Material and methods: Two male (age 43 and 38) obese (BMI 52 and 47) patients underwent ATIIP. The procedure is realized in the operating theatre. General anaesthesia is recommended. The procedure is realized using a combined surgical and endoscopic procedure in two subsequent phases. Results: Phase 1: the prosthesis implantation is realised utilising PEG concepts. Endoscopic localization of the abdominal entry site located 1 cm below the xifoideous process. Prosthesis positioning inside the overtube. Insertion of the needle cannula into the stomach. Passage of a guide wire into the stomach. The guide wire and the catheter of the prosthesis are assembled. Insertion of the prosthesis into the stomach through the mouth. Endoscopic check of the intragastric prosthesis. Cutting and eliminating the polyurethane catheter except for 10 cm. Phase 2: Preparation of a subcutaneous pocket for positioning the Port. Subcutaneous tunnelization of the polyurethane catheter. Insertion of the retention silicone cylinder into the distal part of the polyurethane catheter. Assembly of the Port with the catheter and its positioning in the subcutaneous pocket. Prosthesis inflation to verify the prosthesis integrity. When the prosthesis is inflated, its upper part reaches the fundus area. Conclusions: In both patients the procedure was easy feasible and safe. # S. New technology - 1. Magnification, NBI, FICE, i-Scan, confocal, cytoendoscopy

V.1.7 HOLMIUM LASER INTRACORPOREAL LITHOTRIPSY SPYGLASS SYSTEM ASSISTED: A CASE REPORT R. Manta ∗ , E. Dabizzi, G. Olivetti, M. Manno, H. Bertani, R. Conigliaro Nuovo Ospedale Civile S. Agostino Estense di Baggiovara, Modena Background and aim: Endoscopic biliary lithotripsy, with mechanical techniques can sometimes fail, due to stone size or to an inadequate pressure applied. Non-surgical options are both extra- and intracorporeal lithotripsy. A new laser, Holmium, has been used both in urology and endoscopy, recently. Single operator cholangioscopy is a new way for direct visual examination of bile ducts, useful also in therapeutic maneuvers. Material and methods: We report a case of a 45 yo moderate obese woman, referred to the Emergency Room of our Hospital for recurrent right quadrant abdominal pain and fever, underwent cholecystectomy in 2002. She underwent a fast track abdominal ultrasound, showing a dilation of common bile duct (CBD) (18 mm), with a >16 mm stone inside. Therefore, she underwent a ERC, confirming US findings. After several attempts, we couldn’t capture the stone in the basket in order to pull it away or, at least, to treat it by conventional mechanical lithotripsy. So we decided to perform an intracorporeal lithothripsy with a holmium laser beam: to achieve a direct contact with the stone, we used Spyglass Direct Visualisation System, a single-operator cholangioscopy

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Abstracts / Digestive and Liver Disease 42S (2010) S61–S192

system, with a reusable probe for direct visual guidance, introduced through the duodenoscope. Results: A red aiming beam was used to target the laser. Energy was delivered under continuous water (saline) infusion, through the dedicated irrigation channels. The laser created some drilling tracts on the stone surface, and then it broke up into small pieces. So it was easily removed with the basket. The holmium laser characteristics guaranteed any injuries for the patient. After passing with a Fogarty balloon, the ERC showed a good cholangiography, without minus images. The patient was discharged after 2 days, in good general conditions. Conclusions: The Holmium laser beam is a new very effective alternative for intracorporeal lithotripsy: it can destroy biliary stones, with an effect less dependent on stone composition. It is safe and feasible, offering an efficient treatment of both single and multiple stones. Therefore, the association with the Spyglass Direct Visualisation System can enhance the manoeuvrability of the probe and the outcome of the lithotripsy. # S. New technology - 1. Magnification, NBI, FICE, i-Scan, confocal, cytoendoscopy

V.1.8 GI ENDOSCOPY TO FIGHT OBESITY: TRANSORAL GASTROPLASTY (TOGA) P. Familiari ∗ ,1 , V. Perri 1 , I. Boskoski 1 , A. Iaconelli 2 , A. Tringali 1 , C. Spada 1 , M. Marchese 1 , G. Costamagna 1 1 Endoscopia Digestiva Chirurgica, Policlinico Universitario “A. Gemelli”, Università Cattolica del Sacro Cuore, Roma; 2 Malattie del Ricambio Policlinico Universitario “A. Gemelli” - Università Cattolica del Sacro Cuore, Roma

Background and aim: Bariatric surgery (BS) results in substantial and sustained weight loss, with resolution of many comorbidities. However, BS is associated with a variety of severe complications. Transoral Gastroplasty (TOGa) is a minimally invasive, endoscopic procedure, recently developed for the treatment of morbid obesity. TOGa replicates a well established bariatric operation, by transorally creating a small gastric pouch that is able to give the patients a feeling of satiety after small meals. The video demonstrates this procedure and the results at mid-term follow-up. Material and methods: TOGa uses 2 flexible staplers (sleeve and restrictor) to respectively create the sleeve along the lesser gastric curvature, and restrict the outlet of this new pouch. The 19mm “sleeve” stapler contains an insertion channel for a 5.9 or 8.6mm endoscope. The anterior and posterior gastric walls are acquired into 2 vacuum pods on the stapler’s head. The vacuum pods contain a stapler cartridge. After tissue acquisition, the stapler’s head is clamped and the staples fired, to create the gastric sleeve. The “restrictor” stapler (smaller in diameter) includes a vacuum pod and a stapler assembly, used to create 2 restriction folds at the very end of the gastric sleeve. After the procedure, the amount of food that the patient can eat is limited by the size of the gastric pouch. After TOGa, patients are asked to follow dietary restrictions and to exercise. The TOGa system is under evaluation in a pilot, prospective, single arm trial (Inclusion criteria: BMI between 40 and 55 kg/m2 , no hiatal hernia and compliance with the standard physical, surgical, nutritional and psychological criteria for BS). Results: The anatomical alterations of TOGa are sustained, and the dimensions of the gastric pouch stable overtime. A persisting feeling of satiety after small meals is stated by most patients, notwithstanding a progressive dilation of the sleeve outlet has been observed during follow-up (using EGD and Barium UGI). Small dehiscences (about 1cm) of the staple line are noticeable in many patients, but they do not apparently correlate with weight loss. Conclusions: TOGa is feasible and safe. The gastric sleeve is long-lasting overtime, with significant benefits in terms of weight loss. TOGa system is intuitive to handle and the procedure relatively easy to perform. TOGa may represent an alternative to laparoscopic gastric banding in selected obese patients. # U. Obesity and nutrition

V.2.1 ENDOSCOPIC SUBMUCOSAL DISSECTION OF LEIOMYOMA OF THE ESOPHAGO-GASTRIC JUNCTION E. Abate ∗ , E. Asti, A. Sironi, S. Siboni, D. Bona, M. Nencioni, L. Bonavina IRCCS Policlinico San Donato, Università di Milano, Milano Background and aim: Upper gastrointestinal submucosal tumors (SMT) can be found incidentally during endoscopic examination. Overall prevalence is 0.4%. They are usually asymptomatic but removal can be necessary when the lesion is large or rapidly increasing in size. Resection can be achieved by open/laparoscopic surgery, endoscopic procedures such as polypectomy or band ligation, or a hybrid approach. The aim of this study was to show feasibility and safety of endoscopic excision of an esophageal leiomyoma completely performed in retroflexed view. Material and methods: We report a case of a 39-year-old lady with a 40 mm x 25 mm leiomyoma of the esophagogastric junction found during a videoesophagram with barium swallow performed to investigate persistent heartburn and regurgitation. Upper gastrointestinal endoscopy and endoscopic ultrasound were used to better define size and depth of invasion of the esophageal wall. After submucosal injection of 10 ml of diluted epinephrine, enucleation was carried out using an insulation-tipped diathermic electrosurgical knife (IT-Knife 2, Olympus® ) at 100 Watt and a hook knife (Olympus Optical® ) at 60 Watt. Results: The procedure was performed under general anesthesia with the patient in the supine position. A standard 9 mm endoscope provided with a soft transparent hood attached to its tip was advanced over an overtube into the stomach and then retroflexed. The dissection started along the lower border of the lesion and then extended circumferentially. Once the submucosal layer was reached, the tumor was gradually dissected away from the muscular layer and then removed using an endoscopic bag. Complete en bloc resection was achieved. Eventually the mucosal margins were sutured using 3 endoscopic clips. Histological examination was consistent with leiomyoma. Postoperatively, symptomatic pneumoperitoneum probably related to air leak through the remaining gastric wall developed and it was treated with paracentesis. The patient was discharged on postoperative day 2. An upper GI endoscopy at 3 months showed complete healing of the mucosa. Twenty-four hour pH monitoring showed a normal esophageal acid exposure. Conclusions: Excision of submucosal esophageal benign tumor can be safely and effectively performed using only the endoscopic approach. Key factor for the technical success of the procedure is the correct use of the IT-Knife focusing on fine movements of the endoscope. # A. Oesophagus - 2. Endoscopic therapies

V.2.2 FIBRIN GLUE ASSISTED ENDOSCOPIC SUBMUCOSAL DISSECTION OF AN EARLY SQUAMOUS NEOPLASIA OF THE ESOPHAGUS IN A PATIENT WITH F2 GRADE ESOPHAGEAL VARICES A. Repici ∗ ,1 , N. Pagano 1 , G. Gullotti 2 , A. Princiotta 2 , G. Rando 1 , A. Carlino 1 , S. Danese 1 , G. Strangio 1 , F. Romeo 1 , A. Malesci 1 1 Istituto

Clinico Humanitas, Rozzano (MI); 2 Policlinico Universitario,

Messina Background and aim: Endoscopic mucosal resection is becoming an established technique for treatment of superficial SCC of the esophagus even on varices. Endoscopic submucosal dissection allows en-bloc resection of lesions greater than 20 millimetres through the whole gastrointestinal tract, and has been applied also to resection of SCC of the esophagus. Material and methods: We report the case of a 50-year-old Caucasian male affected with HCV-related hepatic cirrhosis. An upper endoscopy performed for screening of portal hypertension found a lesion of 30 mm that occupied about half the circumference, together with F2 varices. An ESD approach was decided without previous banding of varices to avoid delay in the resection of the lesion and eventual retraction of the esophagus due to scar of the banding. ESD was performed by using a hook-knife (Olympus KD-620-LR) and a distal attachment (D-201-10704) on the tip of the scope. A mixture of low