- Email: [email protected]
Weight Gain Following Bariatric Surgery As a Result of Large Gastric Stoma: Stomal Revision Using Endoscopic Suturing Technology
Abstracts
T1490 Per-Oral and Gastrostomy Assisted Full Thickness Gastric Resection Using SurgASSISTÒ Via a Modified Oro-Esophageal Overtube in a Porcine Model John a. Evans, Francis E. Rosato, Gregory G. Ginsberg
T1492 Evaluation of the Endscopic Submucosl Dissection (ESD) Method for Gastric Tumors Hiroshi Mizuta, Yoshinori Kuratani, Tomoko Onishi, Takayoshi Yamada, Yuichi Yokoyama, Satoru Tamura, Hiroshi Ueta, Saburo Onishi
Introduction: Intraluminal full-thickness gastric resection (FTGR) could be applicable for management of early gastric cancer and gastrointestinal stromal tumors. SurgASSISTÒ (Power Medical Interventions, Langhorne, PA) is a computer mediated, electromechanically powered, cutting/stapling device delivered on a flexible and steerable shaft to which interchangeable loading units of varying configuration, length, and application are affixed. Steering of the flex-shaft and operation of loading units are remote controlled. Aim: This feasibility study assessed applicability to intraluminal FTGR in a swine model. Methods: Four nonsurvival swine under general anesthesia were used. An oro-esophageal overtube (ID 27.2 mm/OD 32.2 mm) was placed followed by dual T-tag placement to abut the gastric wall to the abdominal wall. A balloon trochar(10 mm, US Surgical Autosuture) was inserted into the stomach under endoscopic guidance and served as an alternate port for instruments and endoscope (Olympus GIF-160 and XP-160). Under direct visualization the SurgASSISTwith a 55 mm straight-linear-cutter-stapler (SLCS55) loading unit was advanced via the overtube, into the esophagus and then to the stomach. We evaluated safety and efficacy of overtube placement, SLCS55 insertion, maneuverability in the stomach, parallel vs perpendicular optics, and various tissue grasping devices to achieve tenting of the gastric wall within the arms of the SLCS55 and performance of FTGR. Results: Overtube insertion was successful in all subjects and produced no mucosal tears in one, limited in two, and severe in one. The SLCS55 easily traversed the overtube, but required considerable manipulation under retrograde endoscopic visualization to traverse the esophagus and EG-junction. Maneuverability of the SLCS55 in the stomach was limited. Endoscopic guidance for attempted FTGR via both per-oral (parallel) and per gastrotomy port (perpendicular) orientations was satisfactory. Laparoscopic grasping forceps compared favorably to endoscopic grasping forceps. However, the depth of resected tissue could not be reliably predicted until post-resection specimen inspection. A FTGR was successful in two of four subjects. The resected tissues measured 6.0 cm by 1.8 cm and 6.0 cm by 2.1 cm. There was no pneumoperitoneum, intra- or extraluminal bleeding, or gastrotomy leak/failure. In the other two, depth of resection was submucosa. One subject arrested intraoperatively. Conclusion: Per-oral intraluminal FTGR is feasible. A large diameter overtube permits per-oral access. A gastrostomy port facilitates device positioning and tissue manipulation. Further refinements are needed to yield reliable results.
Introduction & Aim: Recently we can excise a big lesion en bloc by endscopic submucosal dissection (ESD) method using IT knife and Flex knife. In this study, we evaluated the indication for endoscopic treatment of early gastric cancer and gastric adenoma by analyzing of endoscopic resected specimens. Methods: From April 2000 to October 2005, we experienced 419 lesions of gastric tumors (early gastric cancer: 292, gastric adenoma: 127). 273 lesions were treated by ESD, and 146 lesions were treated by conventional EMR method (EMR). We evaluated the en bloc resection rate and the amputation stump negative rate of gastric tumors. We divided these lesions into two groups; group A: lesions of well differentiated adenocarcinoma or adenoma without ulceration and not more than 20 mm in diameter, group B: lesions of except for group A. Results: The en bloc resection rates of group A and B were 169/191 (88.5%), 65/82 (79.3%) respectively, in ESD group (p Z 0.5763). The en bloc resection rates of group A and B were 87/132 (65.9%), 0/14 (0 %) respectively, in EMR group (p Z 0.0029).In group A, there was no significant difference for the en bloc resection rate in compared ESD group (169/191) with EMR group (87/132) (p Z 0.0899). But, in group B, the en bloc resection rate was significantly higher in ESD group (65/82) than in EMR group (0/14) (p Z 0.0013).In group A, there was no significant difference for the local recurrence rate in compared ESD (4/191, 2.1%) with EMR (5/132, 3.8%) (p Z 0.4965). But, in group B, the local recurrence rate was significantly lower in ESD group (1/82, 1.2%) than in EMR group (3/14, 21.4%) (p Z 0.0016).Conclusions: It was difficult to en bloc resection in the lesions of more than 20 mm with ulcerations. ESD method decreased the recurrence rate, and increased en bloc resection rate and amputation stump negative rate. Furthermore, pathological findings such as depth of invasion, vertical and horizontal margin of the resected lesion, can be evaluated more precisely in the en bloc resected specimens.
T1491 Weight Gain Following Bariatric Surgery As a Result of Large Gastric Stoma: Stomal Revision Using Endoscopic Suturing Technology Marc F. Catalano, Thomas Y. Chua, Oscar a. Batista, Nalini M. Guda, Goran T. Rudic Obesity has reached epidemic proportions in US. Roux-en-Y gastric bypass (RYGB) is a commonly done surgical procedure with proven efficacy. RYGB involves creation of a small gastric pouch with a stomal diameter of approx 12 mm combined with distal small bowel bypass causing both volume restriction and malabsorption which results in weight loss. Complications of RYGB include dilation of the gastric stoma resulting in loss of the restrictive component which causes weight gain. Revision surgery is complex with high morbidity. Endoscopic stomal revision might be a reasonable alternative. Data on endoscopic stomal revision are limited. There are no data on feasibility of endoscopic suturing to reduce the stomal diameter and to see if this would result in resumption of weight loss. Methods: Patients noted to have weight gain after RYGB and noted to have stomal dilation on imaging and/ endoscopy were referred for endoscopic therapy. All procedures were done under general anesthesia. Standard upper endoscopy was initially performed and electrocautery with heater probe was used to denude the surface of the stoma to obtain proper surgical anastomosis with the suturing device. Using the Sew-Rite (Wilson-Cook, Salem, NC) endoscopic suturing device, suturing was done circumferentially to achieve a stomal diameter &12 mm. Successful endotherapy was defined as reduction of stomal diameter &12 mm and O75% loss of gained weight after initial weight loss. Results: 7 patients (6F, 1M, age 31-47) underwent endoscopic stomal revision over 2-year-period. Stomal diameter was S2 cm in all patients prior to endoscopic therapy. 5 of 7 patients underwent successful endoscopic revision of the gastric stoma. Revision was not possible in 2 patients due to extreme angulation of the stoma preventing successful placement of sutures. Post revision, the stomal diameter was 8-12 mm. All patients were followed at 4-8 week intervals and weight was recorded. Mean pre RYGB weight was 318 lbs. Following surgery, weight decreased to a mean of 168 lbs. After the initial weight loss, there was a mean weight gain of 72 lbs that was directly attributed to the large stoma size. There were no complications related to endoscopic stomal revision. Conclusions: 1) Endoscopic stomal revision using a suturing device is feasible and safe. 2) Endoscopic suturing of a large gastric stoma results in reclaiming the restrictive component of the bypass surgery as shown by subsequent weight loss, which is sustained. 3) Larger studies and longer term follow-up data are needed.
AB240 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
T1493 Hemodynamic Efficacy of the New ResolutionÒ Clip-Device Compared to Injection Therapy in Spurting Arterial Bleedings: A Prospective Experimental Trial Using the CompactEASIEÒSimulator Juergen Maiss, Christina Baumbach, Andreas Naegel, Yurdaguel Oeztuerk, Markus Wehler, Thomas Bernatik, Eckhart G. Hahn, Dieter Schwab Background: Peptic ulcers are the most frequent cause of GI-bleeding. Clipping was established as effective treatment beside injection therapy. In 2004 the new dsiposable ResolutionÒ clipping device (Boston Scientific)was introduced. Up to now, this new device was not compared with injection therapy in an experimental setting using objective parameters. Methods: In a prospective randomized trial, we compared the disposable Resolution clip device (Boston Scientific, n Z 40) vs. conventional injection therapy (n Z 40) in an experimental setting using the compactEASIEÒ-endoscopy simulator. The simulator was equipped with an upper GI-organ package for bleeding simulation. The artificial blood circulation system of the simulator was connected with a bloody arterial pressure monitoring system. Four investigators with different endoscopic experience participated. Each investigator treated 20 bleeding vessels by applicating one clip (n Z 10) or performing a 4-quadrant injection (n Z 10, 4 10 ml each) using a random list. Pressure curves in the system were measured one minute before and after treatment and represented changes in vessel diameter due to the treatment. Applicability of the new clip was rated by the endoscopist and the assisting nurse using a visual analogous scale (0-100, 100 Z best).Results: 40/40 clips and injection treatments respectively could be performed successfully. Both modalities led to a significant increase in peak pressure (Resolution-Clip 71.8 G 66.8 mmHg, p ! 0.001; Injection 71.9 G 53.8 mmHg, p ! 0.001) representing significant relative reduction of vessel diameter. There was no significant difference in peak pressure in between both treatments (p Z 0.995). The mean pressure during one minute (Clip 49.3 G 67.0 mmHg vs. Injection 19.9 G 41.6 mmHg) after treatment was significantly higher in clipping (pZ0.021). Both, assistance (84 G 13) and endoscopists (86 G 16) rated the applicability not significantly different (p Z 0.402).Conclusions: We could not reveal a difference in the hemostatic efficacy in both modalities in the maximum reduction of vessel diameter. Clipping seems to be superior to injection regarding the longer lasting effect of mean reduction of vessel diameter.
www.giejournal.org
T1490 Per-Oral and Gastrostomy Assisted Full Thickness Gastric Resection Using SurgASSISTÒ Via a Modified Oro-Esophageal Overtube in a Porcine Model John a. Evans, Francis E. Rosato, Gregory G. Ginsberg
T1492 Evaluation of the Endscopic Submucosl Dissection (ESD) Method for Gastric Tumors Hiroshi Mizuta, Yoshinori Kuratani, Tomoko Onishi, Takayoshi Yamada, Yuichi Yokoyama, Satoru Tamura, Hiroshi Ueta, Saburo Onishi
Introduction: Intraluminal full-thickness gastric resection (FTGR) could be applicable for management of early gastric cancer and gastrointestinal stromal tumors. SurgASSISTÒ (Power Medical Interventions, Langhorne, PA) is a computer mediated, electromechanically powered, cutting/stapling device delivered on a flexible and steerable shaft to which interchangeable loading units of varying configuration, length, and application are affixed. Steering of the flex-shaft and operation of loading units are remote controlled. Aim: This feasibility study assessed applicability to intraluminal FTGR in a swine model. Methods: Four nonsurvival swine under general anesthesia were used. An oro-esophageal overtube (ID 27.2 mm/OD 32.2 mm) was placed followed by dual T-tag placement to abut the gastric wall to the abdominal wall. A balloon trochar(10 mm, US Surgical Autosuture) was inserted into the stomach under endoscopic guidance and served as an alternate port for instruments and endoscope (Olympus GIF-160 and XP-160). Under direct visualization the SurgASSISTwith a 55 mm straight-linear-cutter-stapler (SLCS55) loading unit was advanced via the overtube, into the esophagus and then to the stomach. We evaluated safety and efficacy of overtube placement, SLCS55 insertion, maneuverability in the stomach, parallel vs perpendicular optics, and various tissue grasping devices to achieve tenting of the gastric wall within the arms of the SLCS55 and performance of FTGR. Results: Overtube insertion was successful in all subjects and produced no mucosal tears in one, limited in two, and severe in one. The SLCS55 easily traversed the overtube, but required considerable manipulation under retrograde endoscopic visualization to traverse the esophagus and EG-junction. Maneuverability of the SLCS55 in the stomach was limited. Endoscopic guidance for attempted FTGR via both per-oral (parallel) and per gastrotomy port (perpendicular) orientations was satisfactory. Laparoscopic grasping forceps compared favorably to endoscopic grasping forceps. However, the depth of resected tissue could not be reliably predicted until post-resection specimen inspection. A FTGR was successful in two of four subjects. The resected tissues measured 6.0 cm by 1.8 cm and 6.0 cm by 2.1 cm. There was no pneumoperitoneum, intra- or extraluminal bleeding, or gastrotomy leak/failure. In the other two, depth of resection was submucosa. One subject arrested intraoperatively. Conclusion: Per-oral intraluminal FTGR is feasible. A large diameter overtube permits per-oral access. A gastrostomy port facilitates device positioning and tissue manipulation. Further refinements are needed to yield reliable results.
Introduction & Aim: Recently we can excise a big lesion en bloc by endscopic submucosal dissection (ESD) method using IT knife and Flex knife. In this study, we evaluated the indication for endoscopic treatment of early gastric cancer and gastric adenoma by analyzing of endoscopic resected specimens. Methods: From April 2000 to October 2005, we experienced 419 lesions of gastric tumors (early gastric cancer: 292, gastric adenoma: 127). 273 lesions were treated by ESD, and 146 lesions were treated by conventional EMR method (EMR). We evaluated the en bloc resection rate and the amputation stump negative rate of gastric tumors. We divided these lesions into two groups; group A: lesions of well differentiated adenocarcinoma or adenoma without ulceration and not more than 20 mm in diameter, group B: lesions of except for group A. Results: The en bloc resection rates of group A and B were 169/191 (88.5%), 65/82 (79.3%) respectively, in ESD group (p Z 0.5763). The en bloc resection rates of group A and B were 87/132 (65.9%), 0/14 (0 %) respectively, in EMR group (p Z 0.0029).In group A, there was no significant difference for the en bloc resection rate in compared ESD group (169/191) with EMR group (87/132) (p Z 0.0899). But, in group B, the en bloc resection rate was significantly higher in ESD group (65/82) than in EMR group (0/14) (p Z 0.0013).In group A, there was no significant difference for the local recurrence rate in compared ESD (4/191, 2.1%) with EMR (5/132, 3.8%) (p Z 0.4965). But, in group B, the local recurrence rate was significantly lower in ESD group (1/82, 1.2%) than in EMR group (3/14, 21.4%) (p Z 0.0016).Conclusions: It was difficult to en bloc resection in the lesions of more than 20 mm with ulcerations. ESD method decreased the recurrence rate, and increased en bloc resection rate and amputation stump negative rate. Furthermore, pathological findings such as depth of invasion, vertical and horizontal margin of the resected lesion, can be evaluated more precisely in the en bloc resected specimens.
T1491 Weight Gain Following Bariatric Surgery As a Result of Large Gastric Stoma: Stomal Revision Using Endoscopic Suturing Technology Marc F. Catalano, Thomas Y. Chua, Oscar a. Batista, Nalini M. Guda, Goran T. Rudic Obesity has reached epidemic proportions in US. Roux-en-Y gastric bypass (RYGB) is a commonly done surgical procedure with proven efficacy. RYGB involves creation of a small gastric pouch with a stomal diameter of approx 12 mm combined with distal small bowel bypass causing both volume restriction and malabsorption which results in weight loss. Complications of RYGB include dilation of the gastric stoma resulting in loss of the restrictive component which causes weight gain. Revision surgery is complex with high morbidity. Endoscopic stomal revision might be a reasonable alternative. Data on endoscopic stomal revision are limited. There are no data on feasibility of endoscopic suturing to reduce the stomal diameter and to see if this would result in resumption of weight loss. Methods: Patients noted to have weight gain after RYGB and noted to have stomal dilation on imaging and/ endoscopy were referred for endoscopic therapy. All procedures were done under general anesthesia. Standard upper endoscopy was initially performed and electrocautery with heater probe was used to denude the surface of the stoma to obtain proper surgical anastomosis with the suturing device. Using the Sew-Rite (Wilson-Cook, Salem, NC) endoscopic suturing device, suturing was done circumferentially to achieve a stomal diameter &12 mm. Successful endotherapy was defined as reduction of stomal diameter &12 mm and O75% loss of gained weight after initial weight loss. Results: 7 patients (6F, 1M, age 31-47) underwent endoscopic stomal revision over 2-year-period. Stomal diameter was S2 cm in all patients prior to endoscopic therapy. 5 of 7 patients underwent successful endoscopic revision of the gastric stoma. Revision was not possible in 2 patients due to extreme angulation of the stoma preventing successful placement of sutures. Post revision, the stomal diameter was 8-12 mm. All patients were followed at 4-8 week intervals and weight was recorded. Mean pre RYGB weight was 318 lbs. Following surgery, weight decreased to a mean of 168 lbs. After the initial weight loss, there was a mean weight gain of 72 lbs that was directly attributed to the large stoma size. There were no complications related to endoscopic stomal revision. Conclusions: 1) Endoscopic stomal revision using a suturing device is feasible and safe. 2) Endoscopic suturing of a large gastric stoma results in reclaiming the restrictive component of the bypass surgery as shown by subsequent weight loss, which is sustained. 3) Larger studies and longer term follow-up data are needed.
AB240 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
T1493 Hemodynamic Efficacy of the New ResolutionÒ Clip-Device Compared to Injection Therapy in Spurting Arterial Bleedings: A Prospective Experimental Trial Using the CompactEASIEÒSimulator Juergen Maiss, Christina Baumbach, Andreas Naegel, Yurdaguel Oeztuerk, Markus Wehler, Thomas Bernatik, Eckhart G. Hahn, Dieter Schwab Background: Peptic ulcers are the most frequent cause of GI-bleeding. Clipping was established as effective treatment beside injection therapy. In 2004 the new dsiposable ResolutionÒ clipping device (Boston Scientific)was introduced. Up to now, this new device was not compared with injection therapy in an experimental setting using objective parameters. Methods: In a prospective randomized trial, we compared the disposable Resolution clip device (Boston Scientific, n Z 40) vs. conventional injection therapy (n Z 40) in an experimental setting using the compactEASIEÒ-endoscopy simulator. The simulator was equipped with an upper GI-organ package for bleeding simulation. The artificial blood circulation system of the simulator was connected with a bloody arterial pressure monitoring system. Four investigators with different endoscopic experience participated. Each investigator treated 20 bleeding vessels by applicating one clip (n Z 10) or performing a 4-quadrant injection (n Z 10, 4 10 ml each) using a random list. Pressure curves in the system were measured one minute before and after treatment and represented changes in vessel diameter due to the treatment. Applicability of the new clip was rated by the endoscopist and the assisting nurse using a visual analogous scale (0-100, 100 Z best).Results: 40/40 clips and injection treatments respectively could be performed successfully. Both modalities led to a significant increase in peak pressure (Resolution-Clip 71.8 G 66.8 mmHg, p ! 0.001; Injection 71.9 G 53.8 mmHg, p ! 0.001) representing significant relative reduction of vessel diameter. There was no significant difference in peak pressure in between both treatments (p Z 0.995). The mean pressure during one minute (Clip 49.3 G 67.0 mmHg vs. Injection 19.9 G 41.6 mmHg) after treatment was significantly higher in clipping (pZ0.021). Both, assistance (84 G 13) and endoscopists (86 G 16) rated the applicability not significantly different (p Z 0.402).Conclusions: We could not reveal a difference in the hemostatic efficacy in both modalities in the maximum reduction of vessel diameter. Clipping seems to be superior to injection regarding the longer lasting effect of mean reduction of vessel diameter.
www.giejournal.org