981 Endoscopically Percutaneous Walled off Pancreatic Necrosectomy
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nodular lesions (EMR-F) combined with ablation of remaining Barrett’s mucosa. EMR-F may miss synchronous lesions that are not endoscopically apparent. There have been reports of sub-squamous recurrence of HGIN post-ablation. Circumfer- ential EMR (EMR-C) alone is an alternative therapeutic option but it is restricted due to complications, especially stricture formation in 40-50%. Aim: To test the feasibility and safety of single session EMR-C followed by covered metal stent placement in patients with HGIN and long segment BE. Methods: Patients with HIGN presenting to our center were consented. Patients were included if they had long segment BE (length O3cms) and pre-EMR pathology with at least high-grade dysplasia. EMR-C was performed with using band-ligation assisted mucosectomy technique followed by placement of a fully covered metal stent. The stent was anchored in place using an endoscopic suturing system. Stent removal was scheduled in 3-4 weeks and further endoscopic follow-up was in 2 months. Outcomes and complications were recorded. Results: 7 patients were treated (male Z5; median age 62). Median BE length was 6cms (range 4-10). Median procedure time was 104 minutes. Stents were anchored in 6/7 patients (median number of sutures was 2). Stents were removed or migrated in 17 days (6-25). On 2 month follow-up pathology, complete eradication of HGIN was seen in 7/7 (100%) patients and complete eradiation of BE in 5/7 (72%). Strictures formed in 2 patients (28%) and both were remediated with endoscopic dilation (1-2 sessions). No patients had long-term dysphagia. Stent migration was seen in 2 patients (1 patient did not have suturing for stent anchor performed). Conclusions: Single session circumferential EMR followed by stent placement ap- pears safe and feasible. Immediate stent placement post EMR may facilitate reduc- tion in stricture formation. Anchoring the stent is important to prevent migration. 979 Endoscopic Pyloromyotomy Through a Gastric Submucosal Tunnel Dissection for the Treatment of Gastroparesis After Surgical Vagal Lesion Dalton M. Chaves*, Eduardo G. De Moura, Luiz H. Mestieri, Everson L. Artifon, Paulo Sakai Gastrointestinal Endoscopy Unit, University of Sao Paulo Medical School, São Paulo, Brazil Pyloroplasty is a surgical technique used to treat pyloric stenosis for benign diseases, as hypertrophic pyloric stenosis, peptic ulcer scarring, systemic sclerosis and also during surgeries as vagotomy or gastric tube reconstruction after esophagectomy, leading to slow gastric emptying and gastric dilation. The Heineke-Mikulicz tech- nique is the gold standard for treating pyloric stenosis. It consists on a transverse incision of the pylorus with a longitudinal suture, preserving the mucosal layer. Endoscopic alternatives for surgical techniques are up to now Balloon dilation, Botulinum toxin injection or Full-thickness section of the pylorus. The technique presented in this video shows a totally endoscopic pyloromyotomy, through a submucosal gastric tunnel dissection, preserving the serosa intact and also main- taining the mucosal layer at the pyloric channel. This procedure was performed in a 38 yo female. The patient had gastroesophageal reflux disease in irregular treatment for 3 years. 3 months prior to the procedure, Barrett esophagus was diagnosed, and fundoplication was performed. 15 days after the surgery the patient presented with diarrhea, epigastric pain and abdominal distention. EGD showed gastric stasis. Had no changes in symptoms with prokynetic meds. Pyloromyotomy was then per- formed. After the pylorus identification, 2cm proximal to it, in the greater curvature of the stomach, a gastric submucosal space was tunneled up to the pylorus, using the following technique: A) Injection of the Methylene blue with saline solution in the submucosal to elevate it; B) Mucosal incision (1.5cm) to create an entry to the submucosal space, employing Flush knife; C) Dissection of the submucosal until identifying the pyloric muscle; D) Complete section of the pyloric muscle, keeping intact the adjacent serosa; E) Closure of the gastric tunneling with metallic clips. Patient was discharged 3 hours after the procedure, and for 12 hours was on n.p.o. Liquids were then offered for 48 hours and soft diet for 5 days. The patient had very good increase in her quality of life. This technique is feasible, easy to perform, and may be alternative to pyloroplasty in selected cases 980 Endoscopic Enucleation of Upper Gastrointestinal Submucosal Tumors Originated From Muscularis Propria Zhiguo Liu*, Gui Ren, Xiaoyin Zhang, Yanglin PAN, Xuegang Guo, Kaichun Wu Xijing Hosptial of Digestive Disease, Xi, China Background: Submucosal tumors originated from muscularis propria of upper gastrointestinal tract is difficult and challenging to remove by conventional endo- scopic submucosal dissection (cESD) method due to high perforation rate. Proper closure of mucosal defect is essential to prevent perforation related complication. Metallic clip is the most common method to close perforation. However, the failure rate is high since the size of mucosal defect is usually large. Endoscopic enucleation (EN) has been proposed previously to preserve mucosa and facility clip closure, but comparative studies had been scarce. In the current retrospective study, endoscopic enucleation was compared to conventional ESD to clarify its safety and efficacy in treating submucosal tumor. Methods: Endoscopic enucleation was attempted using needle-tip Hybrid knife and insulated-tip knife in 35 patients (12 male, mean 54.3+/- 11.6 years) with submucosal tumor of esophagus (11) or stomach (24) from Oct 2010 to Mar 2013. Thirty-five submucosal tumors from 35 patients (13 male, mean 50.4+/-11.3 years) removed by conventional ESD during the same period were included as control. Results: All tumors were successfully removed in EN group, while 1 patients in cESD group were transferred to emergency surgery due to un- successful closure of perforation (100% vs. 97.1%, pZ.310). The median size of the submucosal tumor was 18.0 mm (12.0-25.0) in EN group compared to 25.0 mm (12.0-30.0) in cESD group (pZ.260). The en bloc rate of was 97.1% compared to 82.9% in cESD group (pZ.046). Perforation rate was 22.9% in EN group compared to 31.4% in cESD group (pZ.612). Clip closure was attempted in 33 and 20 cases, respectively. Satisfactory closure was achieved in 32 patients (97.0%) in EN group compared to 9 patients (45.0%) in cESD group (pZ.000). Twelve patients with unsatisfactory closure were treated conservatively by extending fasting time and gastric tube drainage. The median procedure time was 28.0 min (IQV 20.0-38.0) in EN group compared to 57.0 min (33.0-79.0) in cESD group (pZ.000). The median mucosal closure time was 6.0 mm (4.0-9.0) in EN group compared to 11.0 mm (7.0- 24.5) in cESD group (pZ.001). Follow-up endoscopy revealed no tumor recurrence and complete healing of the iatrogenic ulcer. Conclusions: Endoscopic enucleation of submucosal tumors originated from muscularis propria of upper gastrointestinal tract appears to be safer and less time consuming compared to conventional ESD. Further prospective randomized controlled studies are required to confirm the safety and efficacy of this method. 981 Endoscopically Percutaneous Walled off Pancreatic Necrosectomy Jorge Cerecedo-Rodriguez*, Eduardo Alanis-Monroy, Andres Hernandez-Trejo, Maria D. Benitez-Tress-Faes, Jairo Barba-Mendoza Endoscopia HGZ 32, Instituto Mexicano del Seguro Social, Mexico City, Mexico We present the case of a 46-year-old male patient with infected walled of pancreatic necrosis after an onset of acute biliary pancreatitis. A left abdominal percutaneous drain was placed during a laparotomy, out of our institution, into the collection but since it had a small caliber it wasn’t functional. We exchanged that drain for an esophageal partially covered metallic self-expandable stent using the Seldinger’s technique, to allow a better drainage and to perform endoscopic necrosectomy. We documented the exchange technique, the aggressive necrosectomy and the positive outcome. 982 A New Technique for Exact Tumor Margin of Early Gastric Cancer : Fluorescein-Enhanced Autofluorescence Image MI-Young Kim*, Joo Young Cho, Jun-Hyung Cho Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Republic of Korea Background: Autofluorescence imaging (AFI) has been reported to be a clinically promising endoscopic system to diagnose gastrointestinal neoplasia. However, the use of AFI for gastric neoplasia is limited. Fluorescence-enhanced AFI is a novel method using additional intravenous injection of fluorescein to AFI. We report a new technique for exact tumor margin of early gastric cancer using fluorescein-enhanced AFI. Case: The patient was 67-year old female. She was admitted to our hospital for treatment of early gastric cancer. The lesion was about 1.8 cm, 0-Ip, located on the lesser curvature side of the antrum. Narrow band image showed demarcated tumor margin, irregular microvascular patterns and microsurface pattern. AFI depicted the tumor as purple areas in a green background. After intravenous fluorescein injec- tion, irregular tumor vessels were distinguished from normal mucosal and submu- cosal vessels. The tumor margin was determined by abnormal mucosal surface with uneven fluorescent pattern. After endoscopic submucosal dissection, the lateral extent of the tumor using fluorescein-enhanced AFI showed good concordance with pathology. Conclusion: Fluorescein-enhanced AFI seems to be a feasible and useful endoscopic system for determination of exact tumor margin in early gastric cancer. Our promising preliminary results warrant further clinical usefulness of fluorescein- enhanced AFI. 983 Buried Bumper Syndrome: Single Step Endoscopic Management and Replacement Paul Christiaens*, Peter Bossuyt, Pieter-Jan Cuyle, Veerle Moons, August -. Van Olmen IMELDA Hospital Bonheiden, Keerbergen, Belgium The buried bumper syndrome is a complication of PEG that occurs in 2 % to 6.1 % of patients because excessive external traction leads to erosion of the internal bumper into the gastric wall. A patient with a percutaneous endoscopic gastrostomy (PEG) AB186 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 www.giejournal.org Abstracts
Transcript of 981 Endoscopically Percutaneous Walled off Pancreatic Necrosectomy
Abstracts
nodular lesions (EMR-F) combined with ablation of remaining Barrett’s mucosa.EMR-F may miss synchronous lesions that are not endoscopically apparent. Therehave been reports of sub-squamous recurrence of HGIN post-ablation. Circumfer-ential EMR (EMR-C) alone is an alternative therapeutic option but it is restricted dueto complications, especially stricture formation in 40-50%. Aim: To test the feasibilityand safety of single session EMR-C followed by covered metal stent placement inpatients with HGIN and long segment BE. Methods: Patients with HIGN presentingto our center were consented. Patients were included if they had long segment BE(length O3cms) and pre-EMR pathology with at least high-grade dysplasia. EMR-Cwas performed with using band-ligation assisted mucosectomy technique followedby placement of a fully covered metal stent. The stent was anchored in place usingan endoscopic suturing system. Stent removal was scheduled in 3-4 weeks andfurther endoscopic follow-up was in 2 months. Outcomes and complications wererecorded. Results: 7 patients were treated (male Z5; median age 62). Median BElength was 6cms (range 4-10). Median procedure time was 104 minutes. Stents wereanchored in 6/7 patients (median number of sutures was 2). Stents were removed ormigrated in 17 days (6-25). On 2 month follow-up pathology, complete eradicationof HGIN was seen in 7/7 (100%) patients and complete eradiation of BE in 5/7 (72%).Strictures formed in 2 patients (28%) and both were remediated with endoscopicdilation (1-2 sessions). No patients had long-term dysphagia. Stent migration wasseen in 2 patients (1 patient did not have suturing for stent anchor performed).Conclusions: Single session circumferential EMR followed by stent placement ap-pears safe and feasible. Immediate stent placement post EMR may facilitate reduc-tion in stricture formation. Anchoring the stent is important to prevent migration.
979Endoscopic Pyloromyotomy Through a Gastric SubmucosalTunnel Dissection for the Treatment of Gastroparesis AfterSurgical Vagal LesionDalton M. Chaves*, Eduardo G. De Moura, Luiz H. Mestieri,Everson L. Artifon, Paulo SakaiGastrointestinal Endoscopy Unit, University of Sao Paulo MedicalSchool, São Paulo, BrazilPyloroplasty is a surgical technique used to treat pyloric stenosis for benign diseases,as hypertrophic pyloric stenosis, peptic ulcer scarring, systemic sclerosis and alsoduring surgeries as vagotomy or gastric tube reconstruction after esophagectomy,leading to slow gastric emptying and gastric dilation. The Heineke-Mikulicz tech-nique is the gold standard for treating pyloric stenosis. It consists on a transverseincision of the pylorus with a longitudinal suture, preserving the mucosal layer.Endoscopic alternatives for surgical techniques are up to now Balloon dilation,Botulinum toxin injection or Full-thickness section of the pylorus. The techniquepresented in this video shows a totally endoscopic pyloromyotomy, through asubmucosal gastric tunnel dissection, preserving the serosa intact and also main-taining the mucosal layer at the pyloric channel. This procedure was performed in a38 yo female. The patient had gastroesophageal reflux disease in irregular treatmentfor 3 years. 3 months prior to the procedure, Barrett esophagus was diagnosed, andfundoplication was performed. 15 days after the surgery the patient presented withdiarrhea, epigastric pain and abdominal distention. EGD showed gastric stasis. Hadno changes in symptoms with prokynetic meds. Pyloromyotomy was then per-formed. After the pylorus identification, 2cm proximal to it, in the greater curvatureof the stomach, a gastric submucosal space was tunneled up to the pylorus, usingthe following technique: A) Injection of the Methylene blue with saline solution inthe submucosal to elevate it; B) Mucosal incision (1.5cm) to create an entry to thesubmucosal space, employing Flush knife; C) Dissection of the submucosal untilidentifying the pyloric muscle; D) Complete section of the pyloric muscle, keepingintact the adjacent serosa; E) Closure of the gastric tunneling with metallic clips.Patient was discharged 3 hours after the procedure, and for 12 hours was on n.p.o.Liquids were then offered for 48 hours and soft diet for 5 days. The patient had verygood increase in her quality of life. This technique is feasible, easy to perform, andmay be alternative to pyloroplasty in selected cases
980Endoscopic Enucleation of Upper Gastrointestinal SubmucosalTumors Originated From Muscularis PropriaZhiguo Liu*, Gui Ren, Xiaoyin Zhang, Yanglin PAN, Xuegang Guo,Kaichun WuXijing Hosptial of Digestive Disease, Xi, ChinaBackground: Submucosal tumors originated from muscularis propria of uppergastrointestinal tract is difficult and challenging to remove by conventional endo-scopic submucosal dissection (cESD) method due to high perforation rate. Properclosure of mucosal defect is essential to prevent perforation related complication.Metallic clip is the most common method to close perforation. However, the failurerate is high since the size of mucosal defect is usually large. Endoscopic enucleation(EN) has been proposed previously to preserve mucosa and facility clip closure, butcomparative studies had been scarce. In the current retrospective study, endoscopicenucleation was compared to conventional ESD to clarify its safety and efficacy intreating submucosal tumor. Methods: Endoscopic enucleation was attempted using
AB186 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
needle-tip Hybrid knife and insulated-tip knife in 35 patients (12 male, mean 54.3+/-11.6 years) with submucosal tumor of esophagus (11) or stomach (24) from Oct2010 to Mar 2013. Thirty-five submucosal tumors from 35 patients (13 male, mean50.4+/-11.3 years) removed by conventional ESD during the same period wereincluded as control. Results: All tumors were successfully removed in EN group,while 1 patients in cESD group were transferred to emergency surgery due to un-successful closure of perforation (100% vs. 97.1%, pZ.310). The median size of thesubmucosal tumor was 18.0 mm (12.0-25.0) in EN group compared to 25.0 mm(12.0-30.0) in cESD group (pZ.260). The en bloc rate of was 97.1% compared to82.9% in cESD group (pZ.046). Perforation rate was 22.9% in EN group comparedto 31.4% in cESD group (pZ.612). Clip closure was attempted in 33 and 20 cases,respectively. Satisfactory closure was achieved in 32 patients (97.0%) in EN groupcompared to 9 patients (45.0%) in cESD group (pZ.000). Twelve patients withunsatisfactory closure were treated conservatively by extending fasting time andgastric tube drainage. The median procedure time was 28.0 min (IQV 20.0-38.0) inEN group compared to 57.0 min (33.0-79.0) in cESD group (pZ.000). The medianmucosal closure time was 6.0 mm (4.0-9.0) in EN group compared to 11.0 mm (7.0-24.5) in cESD group (pZ.001). Follow-up endoscopy revealed no tumor recurrenceand complete healing of the iatrogenic ulcer. Conclusions: Endoscopic enucleationof submucosal tumors originated from muscularis propria of upper gastrointestinaltract appears to be safer and less time consuming compared to conventional ESD.Further prospective randomized controlled studies are required to confirm thesafety and efficacy of this method.
981Endoscopically Percutaneous Walled off Pancreatic NecrosectomyJorge Cerecedo-Rodriguez*, Eduardo Alanis-Monroy,Andres Hernandez-Trejo, Maria D. Benitez-Tress-Faes,Jairo Barba-MendozaEndoscopia HGZ 32, Instituto Mexicano del Seguro Social, Mexico City,MexicoWe present the case of a 46-year-old male patient with infected walled of pancreaticnecrosis after an onset of acute biliary pancreatitis. A left abdominal percutaneousdrain was placed during a laparotomy, out of our institution, into the collection butsince it had a small caliber it wasn’t functional. We exchanged that drain for anesophageal partially covered metallic self-expandable stent using the Seldinger’stechnique, to allow a better drainage and to perform endoscopic necrosectomy. Wedocumented the exchange technique, the aggressive necrosectomy and the positiveoutcome.
982A New Technique for Exact Tumor Margin of Early Gastric Cancer :Fluorescein-Enhanced Autofluorescence ImageMI-Young Kim*, Joo Young Cho, Jun-Hyung ChoDigestive Disease Center, Soonchunhyang University Hospital, Seoul,Republic of KoreaBackground: Autofluorescence imaging (AFI) has been reported to be a clinicallypromising endoscopic system to diagnose gastrointestinal neoplasia. However, theuse of AFI for gastric neoplasia is limited. Fluorescence-enhanced AFI is a novelmethod using additional intravenous injection of fluorescein to AFI. We report a newtechnique for exact tumor margin of early gastric cancer using fluorescein-enhancedAFI. Case: The patient was 67-year old female. She was admitted to our hospital fortreatment of early gastric cancer. The lesion was about 1.8 cm, 0-Ip, located on thelesser curvature side of the antrum. Narrow band image showed demarcated tumormargin, irregular microvascular patterns and microsurface pattern. AFI depicted thetumor as purple areas in a green background. After intravenous fluorescein injec-tion, irregular tumor vessels were distinguished from normal mucosal and submu-cosal vessels. The tumor margin was determined by abnormal mucosal surface withuneven fluorescent pattern. After endoscopic submucosal dissection, the lateralextent of the tumor using fluorescein-enhanced AFI showed good concordance withpathology. Conclusion: Fluorescein-enhanced AFI seems to be a feasible and usefulendoscopic system for determination of exact tumor margin in early gastric cancer.Our promising preliminary results warrant further clinical usefulness of fluorescein-enhanced AFI.
983Buried Bumper Syndrome: Single Step Endoscopic Managementand ReplacementPaul Christiaens*, Peter Bossuyt, Pieter-Jan Cuyle, Veerle Moons,August -. Van OlmenIMELDA Hospital Bonheiden, Keerbergen, BelgiumThe buried bumper syndrome is a complication of PEG that occurs in 2 % to 6.1 % ofpatients because excessive external traction leads to erosion of the internal bumperinto the gastric wall. A patient with a percutaneous endoscopic gastrostomy (PEG)
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