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VHM15: DDW 2010 Update on Bariatric Endoscopic Suturing
Abstracts control motor driven spiral. The enteroscope was advanced using standard endoscope techniques to the proximal jejunum. Once in the proximal jejunum the spiral was rotated and small bowel was pleated on to the enteroscope. Advancement continued until the enteroscope was estimated to have reached the proximal ileum. The motorized spiral was then slowly rotated counter clockwise during unpleating/withdrawal of the enteroscope. Clinical implications: A motorized, self-propelled, single operator deep small bowel enterosocopy would be of significant clinical utility. The enteroscope appears to advance rapidly through the small bowel and allow slow careful withdrawal with full therapeutic capabilities with a 160 cm enteroscope. Altered anatomy ERCP and Roux-en-Y patients may also benefit from this technology. A single operator enteroscope that is simple, safe, rapid and offers deep small bowel enteroscopy with full therapeutic capabilities may change the current algorithm for approaching small bowel pathology
VHM11 Endoscopic Submucosal Dissection for Pharyngeal Squamous Cell Carcinoma Tsuneo Oyama, Yoko Kitamura Background: Recently, superficial pharyngeal SCC without lymph node metastasis has been increasingly diagnosed. The standard therapy for pharyngeal SCC is pharyngectomy. However, the procedure is associated with significant complications such as dysphasia, swallowing difficulties. On the other hand, ESD is an alternative treatment method for superficial esophageal, gastric and colonic cancers. ESD for pharyngeal SCC has not been performed because of technical limitations caused by the complicated structure of pharynx. We have developed ESD for pharyngeal SCC. Endoscopic methods: A Total of 43 patients who has superficial pharyngeal SCC has been treated by ESD in our hospital from 2006 to 2009. Marks were placed around the SCC after iodine staining. Mucosal incision and submucosal dissection was performed using a hook knife after 10 % glycerol injection. General anesthesia with endotracheal intubation should be performed to prevent suffocation during ESD. Enough working space could be kept by a special phayngoscope. And a pair of grasping forceps was used to make counter traction during ESD. Clinical implications: R0 resection rate was 100%. Local recurrence rate was 0%. And there wasn’t any severe complications. ESD is a novel treatment method for the superficial pharyngeal SCC.
VHM12 Endoscopic Closure of a Gastrocolonic Fistula Using a Cardiac Ventricular Septal Defect Occlusion Device Todd H. Baron Background: Gastrocolonic fistulae can be difficult to manage endoscopically. This 38 year-old woman underwent Roux-en-Y gastric bypass for obesity eight years prior. She complains of severe diarrhea, reflux, and intermittent vomiting since surgery. An upper GI barium contrast examination revealed a gastrocolonic fistula with the origin at the gastric pouch. A prior attempt at endoscopic closure using clips failed. Endoscopic methods: Using moderate sedation, a standard adult upper endoscope was passed to the gastric pouch where the fistula was idnetified. A 0.035‘ guidewire was advanced endoscopically and fluoroscopically across the fistula well into the colon. Over the wire a dedicated sheath was passed across the fistula into the colon. The guidewire was removed and a muscular ventricular septal defect occlusion device (Amplatzer) was passed through the sheath and deployed fuoroscopically and endoscopically. The device was released from the delivery system. Endoscopically it was in excellent position across the fistula tract. The patient is asymptomatic at 6 weeks. Clinical implications: This device appears to be a useful alternative in the endoscopic management of gastrocolonic fistula that complicate Roux-en-Y gastric bypass. It may also have applications for closure of other internal fistula, particularly from the stomach, since it is likely to embed into the gastric wall. In addition, this case illustrates that there are commercially available products used by interventionalists outside of gastroenterology that can be adapted for endoscopic use.
VHM13 Cap-Assisted EMR of a Sessile Lesion of the Right Colon Involving the Ileo-Cecal Valve Massimo Conio, Sabrina Blanchi, Alessandro Repici Background: A 52-years old man underwent screening colonoscopy. A 50 mm sessile polyps involving the ileocecal valve was diagnosed. Ileoscopy showed a 10 mm circumferential extension of the adenomatous lesion into the distal ileum. Capassisted endoscopic mucosal resection (EMR-C) was performed and the lesion was completely removed. Histology showed a tubulovillous adenoma. No residual/ recurrent lesion was observed 3 months later and the colonoscope could be introduced into the ileum. Endoscopy repeated 12 months later confirmed the complete healing. Endocopic methods: Colonoscopy was performed using highdefinition colonoscope with narrow band imaging (NBI - CF-H180, Olympus Optical Co., Ltd, Tokyo, Japan). The colonoscope tip was fitted with a plastic mucosectomy cap (MH-597, Olympus Optical Co., Ltd, Tokyo, Japan), outer diameter 17 mm and length 15 mm. Inside the distal end of the cap is a gutter which positions the opened polypectomy snare. Normal saline with epinephrine (1:200.000) was injected into and around the lesion. Indigo carmine (IC) was added for visual enhancement of the fluid cushion in contrast to the polyp. To minimize the risk of perforation, continuous suction was avoided. The opened snare was then firmly secured around the tissue and resection performed. Clinical implications: Patients with colon polyps infiltrating the ileum have not been considered candidates for EMR because of the risk of complications and the unfeasibility of complete resection. In our experience, EMR-C allowed a safe and effective treatment for large sessile adenomas of the cecum infiltrating the distal ileum, avoiding a right hemicolectomy.
VHM14 Endoscopic Resection of Giant Colon Polyps - Adjuvant Hemostatic Techniques Gottumukkala S. Raju, Andrew Dupont Background: Post polypectomy bleeding is a serious complication and the risk increases with the size of the polyps. A number of adjuvant endoscopic techniques have been described to reduce post polypectomy bleeding. Here we show three endoscopic techniques that are utilized to reduce post polypectomy bleeding along with a brief review of the literature. Endoscopic methods: This video demonstrates the following adjuvant endoscopic techniques to reduce post polypectomy bleeding: 1. Epinephrine induced volume reduction followed by snare resection of giant colon polyps (two cases). 2. Clip assisted snare resection of a giant pedunculated colon polyp. 3. Loop assisted snare resection of a giant pedunculated colon polyp. Clinical implications: This video demonstrates the role of all three adjuvant techniques utilized in the resection of giant colon polyps along with a brief review of the literature.
VHM15 DDW 2010 Update on Bariatric Endoscopic Suturing Marvin Ryou, Sohail Shaikh, Dan Azagury, Christopher Thompson Background: Endoscopic suturing has previously been used in bariatric endoscopy for revisions of dilated gastrojejunostomy, dilated gastric pouch, and intragastric fistulae repair. Endoscopic suturing has also been used for primary therapy of obesity. Endoscopic methods: Various methods of endoscopic suturing are described. The t-tag -based method is discussed and detailed in several current devices. The tissue-anchor method of plication creation is also discussed. Newer pre-clinical devices using running sutures are also discussed. The video also covers the themes of interrupted versus running sutures, partial thickness versus full thickness sutures, stomal revision versus pouch revision, the concept of stomal tissue stiffness, and volume reduction. Clinical implications: The potential of suturing-based technologies in bariatric endoscopy is bright. Advances in revisional therapy and primary therapy are ongoing.
ABSTRACTS SUBMITTED TO ASGE 2010 314a A Prospective Randomized Controlled Trial Comparing “0.4% Sodium Hyaluronate” Versus “Normal Saline Solution” for Endoscopic Submucosal Dissection in Gastric Neoplasia by Supervised Residents Takashi Kizu, Noriya Uedo, Rika Chatani, Takuya Inoue, Yoji Takeuchi, Koji Higashino, Ryu Ishihara, Hiroyasu Iishi Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) yields higher complete resection rates than conventional endoscopic mucosal resection methods. However, one of the problems with ESD is the difficulty of learning the procedure. Objective: To investigate whether the use of 0.4% sodium hyaluronate (SH) could improve self-completion rate compared with the use of
AB104 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
normal saline solution (NS). Patients and intervention: Patients with differentiatedtype mucosal EGC, smaller than 2 cm, without ulcers or scars, were treated by three supervised resident endoscopists. After stratification by the operator and location of the tumor, we randomize the lesions to SH or NS groups. Main outcome measurements: The primary end point was the difference in self-completion rate. The operator was changed to supervisor and the procedure was regarded as not “self-completed” under the following circumstances: (1) overtime: when time for each mucosal incision and submucosal dissection exceeded 1 hour; (2) inability to achieve hemostasis: when spurting hemorrhage could not be stopped; (3) perforation; and (4) judgment of supervisor: when supervisor judged that the operator needed to be changed. Secondary end points were operation time, number of injection, and volume of injection. All the patients gave their written informed consent. The study protocol was approved by the institutional review board at our
www.giejournal.org
VHM11 Endoscopic Submucosal Dissection for Pharyngeal Squamous Cell Carcinoma Tsuneo Oyama, Yoko Kitamura Background: Recently, superficial pharyngeal SCC without lymph node metastasis has been increasingly diagnosed. The standard therapy for pharyngeal SCC is pharyngectomy. However, the procedure is associated with significant complications such as dysphasia, swallowing difficulties. On the other hand, ESD is an alternative treatment method for superficial esophageal, gastric and colonic cancers. ESD for pharyngeal SCC has not been performed because of technical limitations caused by the complicated structure of pharynx. We have developed ESD for pharyngeal SCC. Endoscopic methods: A Total of 43 patients who has superficial pharyngeal SCC has been treated by ESD in our hospital from 2006 to 2009. Marks were placed around the SCC after iodine staining. Mucosal incision and submucosal dissection was performed using a hook knife after 10 % glycerol injection. General anesthesia with endotracheal intubation should be performed to prevent suffocation during ESD. Enough working space could be kept by a special phayngoscope. And a pair of grasping forceps was used to make counter traction during ESD. Clinical implications: R0 resection rate was 100%. Local recurrence rate was 0%. And there wasn’t any severe complications. ESD is a novel treatment method for the superficial pharyngeal SCC.
VHM12 Endoscopic Closure of a Gastrocolonic Fistula Using a Cardiac Ventricular Septal Defect Occlusion Device Todd H. Baron Background: Gastrocolonic fistulae can be difficult to manage endoscopically. This 38 year-old woman underwent Roux-en-Y gastric bypass for obesity eight years prior. She complains of severe diarrhea, reflux, and intermittent vomiting since surgery. An upper GI barium contrast examination revealed a gastrocolonic fistula with the origin at the gastric pouch. A prior attempt at endoscopic closure using clips failed. Endoscopic methods: Using moderate sedation, a standard adult upper endoscope was passed to the gastric pouch where the fistula was idnetified. A 0.035‘ guidewire was advanced endoscopically and fluoroscopically across the fistula well into the colon. Over the wire a dedicated sheath was passed across the fistula into the colon. The guidewire was removed and a muscular ventricular septal defect occlusion device (Amplatzer) was passed through the sheath and deployed fuoroscopically and endoscopically. The device was released from the delivery system. Endoscopically it was in excellent position across the fistula tract. The patient is asymptomatic at 6 weeks. Clinical implications: This device appears to be a useful alternative in the endoscopic management of gastrocolonic fistula that complicate Roux-en-Y gastric bypass. It may also have applications for closure of other internal fistula, particularly from the stomach, since it is likely to embed into the gastric wall. In addition, this case illustrates that there are commercially available products used by interventionalists outside of gastroenterology that can be adapted for endoscopic use.
VHM13 Cap-Assisted EMR of a Sessile Lesion of the Right Colon Involving the Ileo-Cecal Valve Massimo Conio, Sabrina Blanchi, Alessandro Repici Background: A 52-years old man underwent screening colonoscopy. A 50 mm sessile polyps involving the ileocecal valve was diagnosed. Ileoscopy showed a 10 mm circumferential extension of the adenomatous lesion into the distal ileum. Capassisted endoscopic mucosal resection (EMR-C) was performed and the lesion was completely removed. Histology showed a tubulovillous adenoma. No residual/ recurrent lesion was observed 3 months later and the colonoscope could be introduced into the ileum. Endoscopy repeated 12 months later confirmed the complete healing. Endocopic methods: Colonoscopy was performed using highdefinition colonoscope with narrow band imaging (NBI - CF-H180, Olympus Optical Co., Ltd, Tokyo, Japan). The colonoscope tip was fitted with a plastic mucosectomy cap (MH-597, Olympus Optical Co., Ltd, Tokyo, Japan), outer diameter 17 mm and length 15 mm. Inside the distal end of the cap is a gutter which positions the opened polypectomy snare. Normal saline with epinephrine (1:200.000) was injected into and around the lesion. Indigo carmine (IC) was added for visual enhancement of the fluid cushion in contrast to the polyp. To minimize the risk of perforation, continuous suction was avoided. The opened snare was then firmly secured around the tissue and resection performed. Clinical implications: Patients with colon polyps infiltrating the ileum have not been considered candidates for EMR because of the risk of complications and the unfeasibility of complete resection. In our experience, EMR-C allowed a safe and effective treatment for large sessile adenomas of the cecum infiltrating the distal ileum, avoiding a right hemicolectomy.
VHM14 Endoscopic Resection of Giant Colon Polyps - Adjuvant Hemostatic Techniques Gottumukkala S. Raju, Andrew Dupont Background: Post polypectomy bleeding is a serious complication and the risk increases with the size of the polyps. A number of adjuvant endoscopic techniques have been described to reduce post polypectomy bleeding. Here we show three endoscopic techniques that are utilized to reduce post polypectomy bleeding along with a brief review of the literature. Endoscopic methods: This video demonstrates the following adjuvant endoscopic techniques to reduce post polypectomy bleeding: 1. Epinephrine induced volume reduction followed by snare resection of giant colon polyps (two cases). 2. Clip assisted snare resection of a giant pedunculated colon polyp. 3. Loop assisted snare resection of a giant pedunculated colon polyp. Clinical implications: This video demonstrates the role of all three adjuvant techniques utilized in the resection of giant colon polyps along with a brief review of the literature.
VHM15 DDW 2010 Update on Bariatric Endoscopic Suturing Marvin Ryou, Sohail Shaikh, Dan Azagury, Christopher Thompson Background: Endoscopic suturing has previously been used in bariatric endoscopy for revisions of dilated gastrojejunostomy, dilated gastric pouch, and intragastric fistulae repair. Endoscopic suturing has also been used for primary therapy of obesity. Endoscopic methods: Various methods of endoscopic suturing are described. The t-tag -based method is discussed and detailed in several current devices. The tissue-anchor method of plication creation is also discussed. Newer pre-clinical devices using running sutures are also discussed. The video also covers the themes of interrupted versus running sutures, partial thickness versus full thickness sutures, stomal revision versus pouch revision, the concept of stomal tissue stiffness, and volume reduction. Clinical implications: The potential of suturing-based technologies in bariatric endoscopy is bright. Advances in revisional therapy and primary therapy are ongoing.
ABSTRACTS SUBMITTED TO ASGE 2010 314a A Prospective Randomized Controlled Trial Comparing “0.4% Sodium Hyaluronate” Versus “Normal Saline Solution” for Endoscopic Submucosal Dissection in Gastric Neoplasia by Supervised Residents Takashi Kizu, Noriya Uedo, Rika Chatani, Takuya Inoue, Yoji Takeuchi, Koji Higashino, Ryu Ishihara, Hiroyasu Iishi Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) yields higher complete resection rates than conventional endoscopic mucosal resection methods. However, one of the problems with ESD is the difficulty of learning the procedure. Objective: To investigate whether the use of 0.4% sodium hyaluronate (SH) could improve self-completion rate compared with the use of
AB104 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
normal saline solution (NS). Patients and intervention: Patients with differentiatedtype mucosal EGC, smaller than 2 cm, without ulcers or scars, were treated by three supervised resident endoscopists. After stratification by the operator and location of the tumor, we randomize the lesions to SH or NS groups. Main outcome measurements: The primary end point was the difference in self-completion rate. The operator was changed to supervisor and the procedure was regarded as not “self-completed” under the following circumstances: (1) overtime: when time for each mucosal incision and submucosal dissection exceeded 1 hour; (2) inability to achieve hemostasis: when spurting hemorrhage could not be stopped; (3) perforation; and (4) judgment of supervisor: when supervisor judged that the operator needed to be changed. Secondary end points were operation time, number of injection, and volume of injection. All the patients gave their written informed consent. The study protocol was approved by the institutional review board at our
www.giejournal.org