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VH23 Feasibility of the Endoscopic Treatment of Chronic Pancreatitis Complications as Well as Complications of the Endoscopic Treatment Itself
Abstracts
this situation, stone removal becomes difficult despite adequate sphincterotomy. These strictures are usually managed with balloon strictureplasty. In many cases, biliary stenting is subsequently performed as well. These interventions prolong procedure time and add extra cost. We have demonstrated a novel method of managing these strictures by cutting the biliary stricture using the sphincterotome-endoscopic biliary sphincterotome strictureplasty. The current case is a 33 year old patient with a benign distal biliary stricture. Endoscopic technique of strictureplasty is demonstrated. Endoscopic Methods: Biliary cannulation, sphincterotomy, and strictureplasty were achieved with a standard sphincterotome with 25mm cutting wire. CBD was cannulated with a sphincterotome, without a wire guide. Cholangiogram revealed a dilated CBD with suggestion of a distal stricture. An adequate sphincterotomy was performed. However, minimal bile and contrast drainage was observed. Cholangiogram revealed persistent stricture and CBD dilation. At this point, we performed an extended sphincterotomy; still, there was no free flow of bile or contrast noted. We advanced the sphincterotome, and positioned the tip at the proximal end of the stricture. Sphincterotome is bowed above and within the stricture, placing the cutting wire parallel to the superior border of the stricture. By applying electrical current and gently withdrawing the half-bowed sphincterotome through the stricture, a proximal to distal strictureplasty was performed. After this, spontaneous free drainage of bile and contrast was noted. Clinical Implications: Distal biliary strictures are not infrequently observed in sphincterotomy-naïve patients. These strictures likely develop due to chronic inflammation and scarring of the ductal and peri-ductal tissues induced by intraductal stones or sludge. Stone retrieval by extraction balloon and/or regular basket may be difficult. Balloon strictureplasty and biliary stenting are usually employed for such strictures. However, these procedures add cost, time, and need for follow-up procedures. We propose endoscopic sphincterotome strictureplasty as a simple, effective, alternative method of treating such strictures. Compared to endoscopic stenting, definitive treatment of the stricture with sphincterotome strictureplasty can be performed during the index ERCP. There is no requirement for additional endoscopic accessory or exchange. The current patient had a marked improvement symptoms, did not have any complications and did not require repeat ERCP as of her 12 month follow-up.
VH22 SpyGlass® Assisted Retrieval of a Deeply Migrated Left Hepatic Duct Stent Mukta Bapat, Suryaprakash Bhandari, Nitin Joshi, Dimple Aher, Vinay Dhir, Amit Maydeo Background: A 37 year old female patient was referred for removal of a migrated biliary stent that was placed for benign biliary stricture induced by chronic pancreatitis. She had mild abdominal pain and deranged liver biochemistry. Previous attempts at stent removal at another hospital had failed. At fluroscopy a 7Fr plastic stent was seen deep in left biliary system. Endoscopic Methods: At ERCP, cholangiogram revealed the stent deep in the left biliary system. Initial attempts to remove stent with balloon failed. SpyGlass® cholangioscope (Boston Scientific, Natick, Massachussates) was then used to locate the stent, however exact branch containing the stent could not be identified. A Soehendra biliary dilator with a terumo (0.025) guidewire was passed by the side of the stent under fluroscopic guidance in the left duct containing the stent. The SpyScope® was then loaded over the guidewire in the left biliary system.The distal opening of stent was identified end on and it was then cannulated with a stiff guidewire (Visiglide, 0.025, Olympus, Japan) under direct vision with spy cholangioscope. The SpyScope® was then gently removed keeping guidewire in place under fluroscopic control. Over this wire a 7Fr Soehendra retriever was engaged in the tip of the stent and the entire assembly was pulled out from the bile duct completely. Clinical Implications: Endoscopic removal of deeply migrated biliary stent can be challanging. In this case stent had migrated deep in left biliary system. Endoscopy under fluroscopic guidance was first used to locate the exact position of stent and SpyScope® provided direct vision inside biliary system to get access to the stent. Its four direction deflection ability facilitated direct canulation of stent. Sohendra stent retriever is of utmost use during such extractions.
VH23 Feasibility of the Endoscopic Treatment of Chronic Pancreatitis Complications as Well as Complications of the Endoscopic Treatment Itself Vila JJ, Kutz M, Basterra M, Gómez M, Bolado F, Fernández-Urién I, Jiménez FJ Background: Pancreatic ascites treatment by means of pancreatic stents is feasible in 81% of patients and curative in 45% of them. 5% of these stents experience internal migration which can be endoscopically solved in 80% of cases with a complication rate of 13%. We present the case of a patient with chronic pancreatitis in whom endoscopic treatment utility of its complications is clearly shown. Patient with records of ethanol chronic pancreatitis admitted for
www.giejournal.org
an acute pancreatitis bout with abdominal distension. CT showed ascites and cephalic pseudocyst. Amilase in ascitic fluid was 7479 U/L. Colangio-MRI identified a pancreatic duct dysruption and thus, taking these into account an ERCP was performed. Endoscopic Methods: ERCP showed a pancreatic prepapillary stenosis preventing advance of the guidewire. Minor papilla was cannulated and a pancreatolithiasis located in the dorsal duct was extracted after minor papilla sphincterotomy. A 7F caliber/15cm long pancreatic stent was inserted. After ERCP the patient had an uneventful recovery with resolution of pain and ascites. Two months later an ERCP was scheduled to extract the pancreatic stent. In this ERCP internal migration of the stent was found, with its duodenal end placed into a secondary branch. Extraction was attempted after sphincteroplasty, with different devices without success. In another ERCP and after migration of a second stent, extraction of both stents was achieved with a Dormia basket holding the stents from the caudal end, folding the stents and extracting the caudal end first. A covered metallic stent was deployed taking into account the aggressiveness of the extraction procedure, which was extracted 2 weeks later uneventfully. Clinical Methods: With this case the difficulties and also the effectiveness of endoscopic treatment of local complications of chronic pancreatitis is clearly demonstrated. Pancreatic endoscopic therapy in these patients is not easy and requires expertise in pancreatic ERCP taking into account that therapeutic techniques such as pancreatic sphincterotomy, pancreatic sphinteroplasty, deployment of stents and even pancreaticoscopy are usually needed. Beneficial clinical effects of the endoscopic treatment are evident since ERCP is a minimally aggressive method to treat pancreatic stenosis, lithiasis or pseudocysts avoiding pancreatic surgery with higher morbidity and mortality. But endoscopic therapy is not free of complications and internal migration is a challenging one since up to 20% of migrated stents cannot be endoscopically removed and surgery is needed.
VH24 Endoscopic Closure of the Enterocutaneous Fistula Daniil Rolshud, John M. Poneros, Amrita Sethi, Tamas A. Gonda Background: A 79 year old female with stage 1 colon cancer was treated with right hemicolectomy 6 months ago. Unfortunately, the surgery was complicated by an anastomotic leak and formation of an enterocutaneous fistula. Despite two subsequent surgeries the fistula failed to close. Patient continued to have significant output from the fistula. Endoscopic Methods: Colonoscopy was performed with a standard adult colonoscope. The side-to-side ileocolonic anastomosis was identified. To identify the location of the fistula diluted India ink was injected through the tract. A 20 gauge soft plastic IV angiocath was attached to a 12ml syringe filled with diluted India ink. The angiocath was inserted into the cutaneous orifice of the enterocutaneous fistula. Two mL of the diluted India ink was injected through the cutaneous orifice of the fistulous tract while the blind end of the ileocolostomy was carefully observed. A rush of the India ink was seen from the mucosal defect, confirming the location of the fistula. The opposing edges of the fistula were approximated by forceps with independently opening arms. The tissue was pulled into the cap and over the scope clip was deployed closing the fistula. Clinical Implications: Surgery is currently the most widely used method for closure of the enterocutaneous fistulas not responding to medical therapy. The clip that is delivered using the cap system fitted over the tip of the endoscope has a significantly larger “bite” and can be a very useful closure device when managing gastrointestinal fistulas. This method is a viable alternative to surgery. Small diameter fistulas are ideal for endoscopic closure.
VH25 Small Bowel Varices Diagnosed by Endoscopic Ultrasound during Deep Enteroscopy Adib Chaaya, Hiral Shah, Stephen Heller, Jeffrey L. Tokar Background: A 55 year old woman was referred to us for double balloon enteroscopy (DBE) for obscure-occult gastrointestinal bleeding. Her past medical history included non-alcoholic steatosis without clinical evidence of advanced hepatic fibrosis, HTN, hypercholesterolemia, GERD and chronic iron deficiency anemia. She denied any history of bleeding diatheses, alcohol use, malignancy, or use of non-steroidal anti-inflammatory, antiplatelet, or anticoagulant medications. Following an extensive but unrevealing diagnostic workup, she was referred to our institution for DBE. On upper DBE, the esophagus, stomach and duodenum were normal. In the distal jejunum, multiple discrete submucosal polypoid lesions which were not visualized on prior video capsule endoscopy were identified. The overlying mucosa appeared normal without ulceration or stigmata of recent bleed. Their appearance was not typical for any specific etiology. Endoscopic Methods: Given their atypical appearance, we opted to perform an endoscopic ultrasound using a high frequency miniprobe. The available US miniprobe was not long enough to use with the double balloon enteroscope. To accomplish endoscopic ultrasound, the overtube was advanced next to one of the submucosal lesions, the overtube balloon was inflated, and the enteroscope was withdrawn leaving the overtube in place. A longitudinal incision was made along the external portion of the overtube, using care not to
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB117
this situation, stone removal becomes difficult despite adequate sphincterotomy. These strictures are usually managed with balloon strictureplasty. In many cases, biliary stenting is subsequently performed as well. These interventions prolong procedure time and add extra cost. We have demonstrated a novel method of managing these strictures by cutting the biliary stricture using the sphincterotome-endoscopic biliary sphincterotome strictureplasty. The current case is a 33 year old patient with a benign distal biliary stricture. Endoscopic technique of strictureplasty is demonstrated. Endoscopic Methods: Biliary cannulation, sphincterotomy, and strictureplasty were achieved with a standard sphincterotome with 25mm cutting wire. CBD was cannulated with a sphincterotome, without a wire guide. Cholangiogram revealed a dilated CBD with suggestion of a distal stricture. An adequate sphincterotomy was performed. However, minimal bile and contrast drainage was observed. Cholangiogram revealed persistent stricture and CBD dilation. At this point, we performed an extended sphincterotomy; still, there was no free flow of bile or contrast noted. We advanced the sphincterotome, and positioned the tip at the proximal end of the stricture. Sphincterotome is bowed above and within the stricture, placing the cutting wire parallel to the superior border of the stricture. By applying electrical current and gently withdrawing the half-bowed sphincterotome through the stricture, a proximal to distal strictureplasty was performed. After this, spontaneous free drainage of bile and contrast was noted. Clinical Implications: Distal biliary strictures are not infrequently observed in sphincterotomy-naïve patients. These strictures likely develop due to chronic inflammation and scarring of the ductal and peri-ductal tissues induced by intraductal stones or sludge. Stone retrieval by extraction balloon and/or regular basket may be difficult. Balloon strictureplasty and biliary stenting are usually employed for such strictures. However, these procedures add cost, time, and need for follow-up procedures. We propose endoscopic sphincterotome strictureplasty as a simple, effective, alternative method of treating such strictures. Compared to endoscopic stenting, definitive treatment of the stricture with sphincterotome strictureplasty can be performed during the index ERCP. There is no requirement for additional endoscopic accessory or exchange. The current patient had a marked improvement symptoms, did not have any complications and did not require repeat ERCP as of her 12 month follow-up.
VH22 SpyGlass® Assisted Retrieval of a Deeply Migrated Left Hepatic Duct Stent Mukta Bapat, Suryaprakash Bhandari, Nitin Joshi, Dimple Aher, Vinay Dhir, Amit Maydeo Background: A 37 year old female patient was referred for removal of a migrated biliary stent that was placed for benign biliary stricture induced by chronic pancreatitis. She had mild abdominal pain and deranged liver biochemistry. Previous attempts at stent removal at another hospital had failed. At fluroscopy a 7Fr plastic stent was seen deep in left biliary system. Endoscopic Methods: At ERCP, cholangiogram revealed the stent deep in the left biliary system. Initial attempts to remove stent with balloon failed. SpyGlass® cholangioscope (Boston Scientific, Natick, Massachussates) was then used to locate the stent, however exact branch containing the stent could not be identified. A Soehendra biliary dilator with a terumo (0.025) guidewire was passed by the side of the stent under fluroscopic guidance in the left duct containing the stent. The SpyScope® was then loaded over the guidewire in the left biliary system.The distal opening of stent was identified end on and it was then cannulated with a stiff guidewire (Visiglide, 0.025, Olympus, Japan) under direct vision with spy cholangioscope. The SpyScope® was then gently removed keeping guidewire in place under fluroscopic control. Over this wire a 7Fr Soehendra retriever was engaged in the tip of the stent and the entire assembly was pulled out from the bile duct completely. Clinical Implications: Endoscopic removal of deeply migrated biliary stent can be challanging. In this case stent had migrated deep in left biliary system. Endoscopy under fluroscopic guidance was first used to locate the exact position of stent and SpyScope® provided direct vision inside biliary system to get access to the stent. Its four direction deflection ability facilitated direct canulation of stent. Sohendra stent retriever is of utmost use during such extractions.
VH23 Feasibility of the Endoscopic Treatment of Chronic Pancreatitis Complications as Well as Complications of the Endoscopic Treatment Itself Vila JJ, Kutz M, Basterra M, Gómez M, Bolado F, Fernández-Urién I, Jiménez FJ Background: Pancreatic ascites treatment by means of pancreatic stents is feasible in 81% of patients and curative in 45% of them. 5% of these stents experience internal migration which can be endoscopically solved in 80% of cases with a complication rate of 13%. We present the case of a patient with chronic pancreatitis in whom endoscopic treatment utility of its complications is clearly shown. Patient with records of ethanol chronic pancreatitis admitted for
www.giejournal.org
an acute pancreatitis bout with abdominal distension. CT showed ascites and cephalic pseudocyst. Amilase in ascitic fluid was 7479 U/L. Colangio-MRI identified a pancreatic duct dysruption and thus, taking these into account an ERCP was performed. Endoscopic Methods: ERCP showed a pancreatic prepapillary stenosis preventing advance of the guidewire. Minor papilla was cannulated and a pancreatolithiasis located in the dorsal duct was extracted after minor papilla sphincterotomy. A 7F caliber/15cm long pancreatic stent was inserted. After ERCP the patient had an uneventful recovery with resolution of pain and ascites. Two months later an ERCP was scheduled to extract the pancreatic stent. In this ERCP internal migration of the stent was found, with its duodenal end placed into a secondary branch. Extraction was attempted after sphincteroplasty, with different devices without success. In another ERCP and after migration of a second stent, extraction of both stents was achieved with a Dormia basket holding the stents from the caudal end, folding the stents and extracting the caudal end first. A covered metallic stent was deployed taking into account the aggressiveness of the extraction procedure, which was extracted 2 weeks later uneventfully. Clinical Methods: With this case the difficulties and also the effectiveness of endoscopic treatment of local complications of chronic pancreatitis is clearly demonstrated. Pancreatic endoscopic therapy in these patients is not easy and requires expertise in pancreatic ERCP taking into account that therapeutic techniques such as pancreatic sphincterotomy, pancreatic sphinteroplasty, deployment of stents and even pancreaticoscopy are usually needed. Beneficial clinical effects of the endoscopic treatment are evident since ERCP is a minimally aggressive method to treat pancreatic stenosis, lithiasis or pseudocysts avoiding pancreatic surgery with higher morbidity and mortality. But endoscopic therapy is not free of complications and internal migration is a challenging one since up to 20% of migrated stents cannot be endoscopically removed and surgery is needed.
VH24 Endoscopic Closure of the Enterocutaneous Fistula Daniil Rolshud, John M. Poneros, Amrita Sethi, Tamas A. Gonda Background: A 79 year old female with stage 1 colon cancer was treated with right hemicolectomy 6 months ago. Unfortunately, the surgery was complicated by an anastomotic leak and formation of an enterocutaneous fistula. Despite two subsequent surgeries the fistula failed to close. Patient continued to have significant output from the fistula. Endoscopic Methods: Colonoscopy was performed with a standard adult colonoscope. The side-to-side ileocolonic anastomosis was identified. To identify the location of the fistula diluted India ink was injected through the tract. A 20 gauge soft plastic IV angiocath was attached to a 12ml syringe filled with diluted India ink. The angiocath was inserted into the cutaneous orifice of the enterocutaneous fistula. Two mL of the diluted India ink was injected through the cutaneous orifice of the fistulous tract while the blind end of the ileocolostomy was carefully observed. A rush of the India ink was seen from the mucosal defect, confirming the location of the fistula. The opposing edges of the fistula were approximated by forceps with independently opening arms. The tissue was pulled into the cap and over the scope clip was deployed closing the fistula. Clinical Implications: Surgery is currently the most widely used method for closure of the enterocutaneous fistulas not responding to medical therapy. The clip that is delivered using the cap system fitted over the tip of the endoscope has a significantly larger “bite” and can be a very useful closure device when managing gastrointestinal fistulas. This method is a viable alternative to surgery. Small diameter fistulas are ideal for endoscopic closure.
VH25 Small Bowel Varices Diagnosed by Endoscopic Ultrasound during Deep Enteroscopy Adib Chaaya, Hiral Shah, Stephen Heller, Jeffrey L. Tokar Background: A 55 year old woman was referred to us for double balloon enteroscopy (DBE) for obscure-occult gastrointestinal bleeding. Her past medical history included non-alcoholic steatosis without clinical evidence of advanced hepatic fibrosis, HTN, hypercholesterolemia, GERD and chronic iron deficiency anemia. She denied any history of bleeding diatheses, alcohol use, malignancy, or use of non-steroidal anti-inflammatory, antiplatelet, or anticoagulant medications. Following an extensive but unrevealing diagnostic workup, she was referred to our institution for DBE. On upper DBE, the esophagus, stomach and duodenum were normal. In the distal jejunum, multiple discrete submucosal polypoid lesions which were not visualized on prior video capsule endoscopy were identified. The overlying mucosa appeared normal without ulceration or stigmata of recent bleed. Their appearance was not typical for any specific etiology. Endoscopic Methods: Given their atypical appearance, we opted to perform an endoscopic ultrasound using a high frequency miniprobe. The available US miniprobe was not long enough to use with the double balloon enteroscope. To accomplish endoscopic ultrasound, the overtube was advanced next to one of the submucosal lesions, the overtube balloon was inflated, and the enteroscope was withdrawn leaving the overtube in place. A longitudinal incision was made along the external portion of the overtube, using care not to
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB117