UEG Week 2017 Video Cases

Wednesday, November 01, 2017 10:30-12:00

Video Case Session - Room F1_

VC01 SUBMUCOSAL TUNNELING ENDOSCOPIC RESECTION OF A LARGE OESOPHAGEAL LEIOMYOMA

M. Sidhu¹, D.J. J. Tate², M.J. Bourke³

¹Westmead Hospital, Westmead/Australia

²Department Of Gastroenterology And Hepatology, Westmead Hospital, Sydney/Australia/NSW

³Gastroenterology And Hepatology, Westmead Hospital, University of Sydney, Sydney/Australia

Contact E-mail Address: [e-mail]

Introduction: Leiomyomas are benign submucosal tumours and although rare in the upper GI tract are most commonly found in the oesophagus. As these tumours usually involve the deep layers with extesion into the muscularis propria endoscopic resection of these large tumours has been of limited with patient's requiring invasive surgery. However the recent development of a new endoscopic technique, Submucosal Tunneling Endoscopic Resection (STER) has now allowed the ability to resect these tumours safely without the associated morbidity of surgery.

Aims & Methods: Aims: 1) Discuss management of submucosal tumours in the upper GI tract. 2) Demonstrate the STER technique in resection large leiomyomas in the eosophagus. 3) How to treat peri-procedural complications such as bleeding associated with this technique. Methods: Endoscopic Video demonstrating the above.

Results: This video will demonstrate: 1) The successful endoscopic resection of a large leiomyoma of the oesophagus using the STER technique. 2) How to treat associated peri-procedural complications such as minor bleeding during the procedure.

Conclusion: STER is safe and effective therapeutic modality in treating large submucosal tumours of the Upper GI tract.

Disclosure of Interest: All authors have declared no conflicts of interest.

VC02 TEMPORARY BILIARY METAL STENT PLACEMENT IN THE CYSTIC DUCT AS AN AID TO CHOLANGIOSCOPY-GUIDED LASER LITHOTRIPSY OF MIRIZZI SYNDROME (MS)

R. Sanchez-Ocana, M. Jimenez-Palacios, P. Gil-Simon, C. De La Serna-Higuera, M. Perez-Miranda

Gastroenterology, Hospital Universitario Rio Hortega, Valladolid/Spain

Contact E-mail Address: [e-mail]

Introduction: Cholangioscopy-guided lithotripsy is a minimally invasive alternative to surgical treatment of Mirizzi Syndrome (MS). Cholangioscopic lithotripsy and cystic duct clearance is usually labor intensive and may require several treatment sessions.

Aims & Methods: A 54 year-old man underwent single-operator cholangioscopy and Holmium laser lithotripsy (LL) for type I MS. Stone fragments failed to be cleared from the cystic duct. A biliary fully covered self-expandable metal stent (FC-SEMS) was placed across the cyst duct, whereas the common bile duct (CBD) was drained with a plastic stent. The FC-SEMS was removed at follow-up ERCP. Stone fragments were easily cleared through the temporarily expanded cystic duct.

Results: Endoscopic therapy was carried out in three sessions. At baseline ERCP, a 16-mm stone pressing on the CBD was noted and urgent decompression of the CBD was achieved with a 10F plastic stent. Two weeks later, elective single-operator cholangioscopy with successful LL fragmentation of the stone was performed. Larger stone fragments were individually removed under cholangioscopy using a tripod forceps. However, complete clearance using balloon catheters or Dormia baskets under fluoroscopy could not be achieved, because stone fragments became impacted into the narrow cystic duct. Eventually a 10x80 mm FC-SEMS was placed into the cystic duct past stone fragments. A double pig-tail stent was placed through it in order to drain the gallbladder, and a standard plastic biliary stent was placed in the CBD. At follow-up 8-weeks later, the cystic duct stents were removed. Stone fragments could be cleared easily from the cystic duct, which had become enlarged by the FC-SEMS. The patient was scheduled for cholecystectomy.

Conclusion: In this case, after successful, labor-intensive laser fragmentation of a relatively large cystic duct stone, final treatment success of MS was compromised because of aggregation and impaction of multiple small, hard stone fragments into a narrow cystic duct. As an alternative to a repeat session of cholangioscopy-guided LL, FC-SEMS insertion into the cystic duct past the stone fragments was technically easy and proved eventually effective. According to this novel strategy, temporary expansion of the cystic duct using a FC-SEMS might be considered as an adjunct to LL in selected difficult cases of MS, similarly to what has been shown for CBD stones impacted above a biliary stricture.

Disclosure of Interest: All authors have declared no conflicts of interest.

References

1. Bhandari S, Bathini R, Sharma A, Maydeo A. Usefulness of single-operator cholangioscopy-guided laser lithotripsy in patients with Mirizzi syndrome and cystic duct stones: experience at a tertiary care center. Gastrointest Endosc 2016;84:56-61.

2. Hartery K, Lee CS, Doherty GA et al. Covered self-expanding metal stents for the management of common bile duct stones. Gastrointest Endosc 2017;85:181-186.

VC03 METACHRONOUS DEPLOYMENT OF FOUR PLASTIC AND FOUR METALLIC STENTS IN THE PATIENT WITH HILAR BILE DUCT CARCINOMA SUCCESSFULLY ACHIEVED ONLY VIA ENDOSCOPIC PROCEDURE

H. Kawamoto

Internal Medicine, Kawasaki General Medical Center, Kawasaki Medical School, Okayama/Japan

Contact E-mail Address: [e-mail]

Introduction: Endoscopic biliary decompression performed on the patient with hilar biliary strictures is technically demanding. We successfully deployed four plastic stents (PS) and four metallic stents (MS) metachronouly on the same patient to ameliorate jaundice and cholangitis.We will present the procedure in detail with video.

Aims & Methods: Seventy-two year old patient with jaundice was referred to our hospital. He had hilar bile duct carcinoma and his serum bilirubin level was 23.5 mg/dl. Since the carcinoma involved the bifurcation of bile duct, the intrahepatic bile ducts were dilated markedly. Furthermore, since the left portal vein was obliterated by the tumor invasion, the left lobe of the liver became very atrophic. At that time, cholangitis was not complicated. To ameliorate jaundice, we inserted two PSs (ThroughPass K-hilar, Gadelius Medical, Tokyo, Japan) into the right anterior branch (B8) and posterior branch (B6), respectively, because we thought the decompression of left intrahepatic ducts was meaningless. Even after successful deployment of plastic stents, the decrease of serum bilirubin level was far from easy despite the exchange of PSs. To make matters worse, the patient suffered from fever due to segmental cholangitis. The CT disclosed the cholangitis in the left lobe. Therefore, we added two more PSs in the B2 and B3 branches of the left lobe. The correct position of four PSs was certified under CT imaging. His cholangitis and jaundice was once improved, but one month later, recurrent cholangitis happened due to hemobilia. Since cholangitis did not improve despite the exchange of four PSs, we employed four MSs (Zeostent, Tokyo, Japan) to ameliorate jaundice and cholangitis. We employed a partial stent-in-stent (PSIS) procedure, because we had to decompress four individual segments to avoid recurrent cholangitis. After inserting 3 guidewires (GW) into B2, B3, and B6, we deployed the first MS in B6. As a reference GW, two previously inserted GW were useful to negotiate the strictures through the MS interstices, because a confluence of GW and MS is a site to be negotiated. After deployment of MS in the B3 and B2, we inserted GW into B8 branch, because it was an easy branch in this patient. Finally, we achieved successful deployment of the fourth MS.

Results: After deployment, the general condition of the patient improved. He has been well for more than 12 months.

Conclusion: Four-branched PSIS deployment of laser-etching MS is feasible and more advantageous than side-by-side method because of no excessive dilatation of the hilum through multiple MS.

Disclosure of Interest: H. Kawamoto: Advisor Piolax Medical Devices, Gadelius Medical

VC04 CHRONIC TRACHEOESOPHAGEAL FISTULA SUCCESSFULLY TREATED USING AMPLATZER SEPTAL OCCLUDER

M. Amata¹, C. Gandolfo², L. De Monte³, A. Granata¹, D. Ligresti¹, L. Barresi¹, I. Tarantino¹, M. Traina¹

¹Endoscopy Service, IRCSS - ISMETT, Palermo/Italy

²Chief Of Interventional Cardiology, IRCSS - ISMETT, Palermo/Italy

³Thoracic Surgery And Lung Transplantation, IRCCS - ISMETT, Palermo/Italy

Contact E-mail Address: [e-mail]

Aims & Methods: ASO has been used in off-label closure of GI fistulae (2). It's composed by a nitinol mesh with 2 self-expandable disks connected by a waist (dumbblell shape) (3). ASO permits the mechanical closure of the two fistula sides making a potentially platform for next tissue ingrowth (4). In our report, endoscopic TEF obliteration using ASO was performed in a 44-years-old male patient with tracheostomy and a long intubation story due to thoracic politrauma with left-residual hemiparesis. Following several aspiration pneumonia episodes, TEF was diagnosed and subsequently referred to surgery (anterior cervicotomy with fistuloraffia). After 7 months the patient developed dysphagia. Endoscopy showed recurrence of TEF that was unsuccessfully treated by acrylic glue's submucosal injection. According to the poor clinical conditions and the failure of surgical and endoscopic therapy, ASO positioning was planned. The procedure was performed using a gastroscope (GIF-1TH190, Olympus Europe) and a bronchoscope (BF-1T180, Olympus Europe). TEF was cannulated by a papillotome (TRUETome, 30 mm, Boston Scientific) and a 0,025in guidewire (Jagwire, Boston Scientific) was inserted into the left main bronchial segment. The wire was then grasped with a biopsy forceps (EndoJaw, FB-231D, Olympus Europe) through the bronchoscope providing a countertraction by maintaining a straightened position. Under fluoroscopic view, ASO catheter was then introduced over the wire. Under direct endoscopic control, we released both ends of ASO in trachea and esophagus, respectively. Final contrast medium injection confirmed successful TEF closure. Procedure was uneventfull.

Introduction: Tracheoesophageal fistula (TEF) can be congenital or acquired, malignant or nonmalignant and often caused by tracheitis necrosis following prolonged intubation, tracheostomy or intubation maneuvers. After TEF diagnosis, enteral feeding and dietary support combined with surgery is the gold standard. However, in selected patients, a mini- invasive approach, such as endoscopic therapy, ensures a successful healing of TEF. This video case confirms the feasibility of the Amplatzer septal occluder (ASO) device (AGA Medical Corp, Plymouth, Minn), commonly adopted to close cardiac septal defects(1).

Conclusion: TEF is a serious life threatening condition that usually appears in critically ill patients with prolonged story of mechanical ventilation. In selected tertiary-care center, where advanced endoscopic and cath lab suites are available, ASO placement is feasible and safe and provides fistula closure especially for patients in critical conditions with severe comorbidities and TEF recurrence.

Results: The patient was discharged in 7 days without symptoms. A 4-weeks clinical, endoscopic and radiologic revaluation, confirmed TEF was closed and patient remained asymptomatic.

Disclosure of Interest: All authors have declared no conflicts of interest.

References

1 A. Repici et all. First human case of esophagus-tracheal fistula closure by using a cardiac septal occluder (with video), Gastrointestinal Endoscopy (April 2010).

2 Coppola F. et al. Cardiac septal umbrella for closure of a tracheoesophageal fistula. Endoscopy 2010.

3 Gastrointestinal Endoscopy, Volume 76, Issue 2, August 2012, Page 244-251.

4 Paulo Rogério Scordamaglio et all. Endoscopic treatment of tracheobronchial tree fistulas using atrial septal defect occluders: preliminary results. J. bras. Pneumol (Nov 2009).

VC05 A NOVEL SCISSOR AND LOOP TECHNIQUE FOR ENDOSCOPIC RESECTION AND CLOSURE OF ESD DEFECTS: A VIDEO ABSTRACT ON THE RESECTION OF A GASTRIC SUBMUCOSAL TUMOUR

K. Kandiah¹, S. Subramaniam¹, D. Poller², A. Higginson³, P. Bhandari¹

¹Gastroenterology, Queen Alexandra Hospital, Portsmouth, Portsmouth/United Kingdom

²Pathology, Queen Alexandra Hospital, Portsmouth/United Kingdom

³Radiology, Queen Alexandra Hospital, Portsmouth/United Kingdom

Contact E-mail Address: [e-mail]

Introduction: Endoscopic submucosal dissection (ESD) was a technique developed in Japan to enable curative en-bloc resection of early gastrointestinal neoplasia. This technique has been slow to be adopted in the West due to the lack of training, endoscopic knives requiring significant manual dexterity and a high rate of complications. Efforts have been made to improve training but until recently, there have been few advances improving endoscopic knife technology and the development of devices to reduce complications of ESD.

Aims & Methods: We present a video with the aim to demonstrate the utility of a novel scissor-type knife and a large defect ligation device in the endoscopic resection of a large gastric submucosal tumour. Various types of endoscopic knives such as the insulated tip, hook, triangular tip and needle knives have traditionally been used in ESD. The scissor-type knife was developed to facilitate the accurate grasping of tissue prior to dissection. The outer segment of the scissor arms are insulated and the inner segment of the arms have thin cutting blades that allow for submucosal dissection. This knife is rotatable on its own axis enabling dissection of difficult to access tissue. The novel large defect-ligating device is able to deploy and reattach the ligating loop. This feature enables the positioning of the loop before securing it to the margins of the resection base using endoscopic clips. Once the ligation loop is secured along the resection margins, the ligating device catheter is reintroduced to hook the tail of the loop and approximate the resection margins.

Results: A 72-year-old man was incidentally found to have a large gastric submucosal tumour in the upper body (lesser curve) of his stomach. The lesion was assessed endoscopically and the surface pattern on enhanced imaging showed normal gastric mucosa. Endoscopic ultrasound showed that the lesion was clear of submucosa. The case was discussed in the cancer multi-disciplinary team meeting (MDT). Both the MDT and the patient agreed that the best option was to proceed with endoscopic resection. The access to the proximal aspect of the polyp base that is facing the fundus was difficult with the traditional endoscopic needle type and insulated tip knives. A scissor-type knife enabled controlled and measured mucosal incision and submucosal dissection even on retroflexion. Haemostasis was maintained using the scissor type knife, which is able to carry out the function of a haemostatic forceps, negating the need to change instruments during the procedure. The large resection defect was then closed using a novel ligating device that is approximated like a purse string. There were no immediate or late complications of the procedure. The patient was discharged home the next morning.

Conclusion: Novel scissor-type knives are technically easy to use even when the access is challenging. This type of knife can perform mucosal incision, submucosal dissection and maintain haemostasis effectively. A detachable large defect ligator is a simple device that can effectively close large ESD defects. Both novel devices have the potential to help facilitate the uptake of ESD in the West.

Disclosure of Interest: All authors have declared no conflicts of interest.

VC06 RENDEZVOUS BILIARY RECANALIZATION OF COMPLETE BILIARY OBSTRUCTION WITH DIRECT PERORAL AND PERCUTANEOUS TRANSHEPATIC CHOLANGIOSCOPY

M. Bukhari, Y. Haito-Chavez, S. Ngamruengphong, O. I. Brewer Gutierrez, Y. Chen, M. A. Khashab

Dept. Of Gastroenterology, Johns Hopkins, Baltimore/United States of America

Contact E-mail Address: [e-mail]

Introduction: Anastomotic biliary stricture post liver transplantation remains one of the major cause of morbidity and mortality. The reported incidence of biliary stricture is range from 16-32%. Currently, endoscopic therapy is the first line modality for biliary strictures. Endoscopic treatment relies on traversing a guidewire across the stricture, followed by subsequent stricture dilation and stents placement. Cannulation of the biliary stricture is challenging procedure in patients with complete anastomotic obstruction. Percutaneous transhepatic therapy is considered when endoscopic approach has failed. Several techniques to traverse complete anastomotic obstruction have been reported, including the use of video cholangioscopy, magnetic compression anastomosis, or needle knife puncture. However, blind needle puncture has high risk of complications. Complete endoscopic recanalization using a cholangioscopy assisted rendezvous technique has not been previously reported

Aims & Methods: To describe a novel technique to facilitate cannulation of complete biliary obstruction post liver transplantation

Results: A 36-year-old female who have undergone a combined liver and kidney transplantation for Joubert syndrome, presented with biliary obstruction due to anastomotic stricture. ERCP revealed complete anastomotic obstruction, that precluded passage of the guidewire despite using single operator cholangioscopy (DSOC). A percutaneous transhepatic biliary drainage (PTBD) was performed, during PTBD, multiple attempts to traverse the stricture was unsuccessful. A decision was made to perform a rendezvous technique under direct cholangioscopy approach. Contrast was injected though the PTBD catheter, cholangiogram confirmed complete biliary obstruction. Direct peroral cholangioscopy was performed with ultrathin endoscope. Both scopes were brought into perfect alignment under fluoroscopy. Proper alignment was confirmed by the trans illumination and probing techniques. The stricture was puncture under direct visualization using free hand needle knife. After needle puncture, a guidewire still could not pass. Methylene blue was injected to the bile duct though the transhepatic route. A 23 G sclerotherapy needle was advanced though the puncture hole. After needle puncture, methylene blue was flowed though the hole. The guidewire was advanced though the transhepatic route. The tip of wire was captured by a snare and pulled out though the duodenoscope. The anastomotic stricture was then dilated sequentially with balloon and multiple plastic stents were placed. ERCP performed 6 months later, the stents were removed. Cholangiogram revealed improvement of the stricture.The stricture was dilated and stented with excellent bile and contrast drainage

Conclusion: Combined anterograde and retrograde cholangioscopy technique facilitates safe recanalization of complete biliary obstruction. It should be considered when conventional techniques fail

Disclosure of Interest: M.A. Khashab: Mouen Khashab is a consultant for Boston Scientific. All other authors have declared no conflicts of interest.

VC07 EUS GUIDED CONTINUOUS CATHETER THROMBOLYSIS OF PORTAL VENOUS SYSTEM

M. Sharma¹, S. Jindal¹, P. Somani¹, K. Sampath², V. V. Mahesh²

¹Department Of Gastroenterology, Jaswant Rai Specialty Hospital, Meerut/India

²Department Of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut/India

Contact E-mail Address: [e-mail]

Introduction: Acute portal vein thrombosis (PVT) is an uncommon and insidious disease that is potentially lethal due to delay in diagnosis and therapy. It can be associated with significant morbidity and mortality There are no uniform protocols practiced for the effective management of acute portal vein thrombosis. Treatment of PVT currently ranges from observation with no active therapy to anticoagulation or thrombolytic therapy, thrombectomy, and transjugular intrahepatic portosystemic shunt placement. The goal for treatment consists of resolution of symptoms, prevention and treatment of mesenteric ischemia, and prevention of thrombus extension. Uually, systemic anticoagulation is used. Catheter-based interventional therapy offers a safe and effective option for treatment of symptomatic portomesenteric venous thrombosis refractory to medical therapy.

Aims & Methods: An 18 years-old female presented with intractable upper abdominal pain and vomiting. Abdominal ultrasound, CT scan and MRI showed extensive thrombosis of portal venous system without bowel infarction. A diagnosis of acute portal vein thrombosis was made and she was started on anticoagulants. The intractable pain persisted and EUS guided thrombolysis was planned. A window of patent superior mesenteric vein (SMV) was selected for EUS guided puncture. The puncture was made through the pancreas into SMV with a 22-gauge EUS FNA needle. A 0.018 inch guide wire was placed into a tributary of superior mesenteric vein. A tapered tip cannula was advanced over the wire and cannula was positioned in the vein. The cannula was routed through the nose and a syringe pump was fitted for infusion of thrombolytic agent. Continuous catheter guided thrombolytic therapy was started with streptokinase at a dose of 30000 IU/hr with systemic anticoagulation with low molecular weight heparin. The symptoms of the patient disappeared within four hours. But the infusion was continued and follow-up of the characteristics of the thrombus were done by daily ultrasound and CT scan after 48 hours. The patient had melena after 72 hours and the anti-coagulant infusion was stopped. She required four units of packed cells for hemodynamic stabilization. The catheter was removed after six hours of stopping the infusion. After removal of the catheter side viewing endoscopy was done which showed there was active bleeding from the site of injection. Adrenaline Injection failed to stop the bleed. Two clips were applied but the bleed continued. A G-EYE balloon was inflated for five minutes in duodenum. No further undue bleeding was noted. Her prothrombotic workup suggested the deficiency of protein C and protein S. The patient was discharged on 7th day with a satisfactory clinical and radiological response. A follow-up after three weeks showed flow in splenic and portal vein.

Results: The intractable upper abdominal pain with high index of suspicion showed an extensive thrombus in portal vein which was managed conservatively without any response. EUS guided thrombolysis showed a remarkable improvement.

Conclusion: This case shows a life threatening situation with impending bowel gangrene in which EUS guided continuous catheter thrombolysis was done. The most important possible complication was bleeding from the site of puncture into the portal vein. It was tackled by the methods mentioned above. Further studies will be required for this new method of thrombolysis.

Disclosure of Interest: All authors have declared no conflicts of interest.

VC08 PER RECTAL ENDOSCOPIC MYOTOMY (PREM) FOR PEDIATRIC HIRSCHSPRUNG’S DISEASE

A. Bapaye¹, M. R. Mahadik², R. Pujari², S. Date², N. Dubale², T. K. Bharadwaj³, S. G. Vare², J. A. Bapaye³

¹Shivanand Desai Center For Digestive Disorders, Deenanath Mangeshkar Hospital Digestive Diseases & Endoscopy, Pune/India

²Shivanand Desai Center For Digestive Disease,pune, Deenanath Mangeshkar Hospital, pune/India

³Shivanand Desai Center For Digestive Disease,pune, Deenanath Mangeshkar Hospital, Pune/India

Contact E-mail Address: [e-mail]

Introduction: Hirschsprung’s disease (HD) is a congenital disorder characterized by absence of intrinsic ganglion cells in submucosal(SM) & myenteric plexuses of hindgut.It presents with constipation, intestinal obstruction &/or megacolon. It Commonly involves rectosigmoid region (short segment).It is Commonly diagnosed in infancy,few skip detection until adulthood. Standard treatment includes single or multi-stage pull-through (short segment HD) or posterior anorectal surgical myotomy (ultrashort segment). The rationale is disruption of muscle and sphincter for spastic bowel segments similar to that achieved in per oral endoscopic myotomy(POEM) and per oral endoscopic pyloromyotomy (POEP) in achalasia and gastroparesis.Per rectal endoscopic myotomy(PREM) for adult Hirschsprung’s disease has been recently reported by us.

Aims & Methods: The current case demonstrates the first pediatric case of hirchsprung's disease treated by per rectal endoscopic myotomy(PREM)8 years male, long standing constipation since neonatal period.His Stool frequency was once or twice a week with combination of two laxatives. Barium enema was classical of Hirschsprung's disease. Bowel preparation was difficult in view of long standing constipation(double-dose PEG solution. Colonoscopy showed Spastic non-distensible empty rectum and Grossly dilated sigmoid & proximal colon. HPE showed absent ganglion cells at 5 cm while they were present at 8 cm. Ano-rectal Manometry showed absence of rectoanal inhibitory reflex(RAIR). Diagnosis of Hirschsprung’s disease was thus confirmed. Based on our previous experience patient was offered Per-rectal endoscopic myotomy (PREM). Informed written consent was taken from patient’s parents.HD Gastroscope (GIF-HQ190, Olympus Corp., Japan) with distal transparent hood and CO2 insufflation was used throughout procedure. General anesthesia + endotracheal intubation and Prone position was used for procedure.By implementing principles of third space endoscopy, per rectal endoscopic myotomy 10 cm in length was successfully carried out. Mucosal incision was closed by hemoclips.

Results: The patient was kept Nil orally x 12 hours and was started on clear liquids thereafter and build up to soft diet over 48hours. Erect X ray abdomen showed no pneumoperitoneum. First bowel movement occurred after 28 hours.He was prescribed oral lactulose 15 ml twice daily and IV antibiotics for 48 hours.He was discharged on 4th POD.The patient is passing one to two semisolid soft stools / day on 15 ml lactulose daily, no abdominal pain, no incontinence. Sigmoidoscopy done at 2 weeks in unprepared colon showed complete healing with stool in rectum and rectum capacious. We have Current follow up of 10 weeks and the patient is doing well.

Conclusion: Current video case demonstrates the safety and efficacy of PREM in pediatric Hirschsprung’s disease

Disclosure of Interest: A. Bapaye: Speaker-Boston scientific corporation, Olympus, Cook medical,T aewoong medical

All other authors have declared no conflicts of interest.

References

Bapaye A, Wagholikar G, Jog S, Kothurkar A, Purandare S, Dubale N, Pujari R, Mahadik M, Vyas V, Bapaye J (2016) Per rectal endoscopic myotomy for the treatment of adult Hirschsprung's disease: First human case (with video). Dig Endosc 28 (6):680-684. doi:10.1111/den.12689

VC09 COMBINED LAPAROSCOPIC AND ENDOSCOPIC FULL THICKNESS RESECTION APPROACH FOR GASTRO-INTESTINAL STROMAL TUMOR (GIST). SERIES OF 3 CASES WITH VIDEO

J. Gonzalez¹, L. Beyer², S. Berdah², M. Barthet¹

¹Gastroenterology, AMU, AP-HM, Hôpital Nord, Marseille/France

²Digestive Surgery, AMU, AP-HM, Hôpital Nord, Marseille/France

Contact E-mail Address: [e-mail]

Introduction: Eso-gastric junction (EGJ) location is rare for gastro-intestinal stromal tumors (GIST) and resection remains highly challenging for posterior/fundic intraluminal tumors. Laparoscopic endoscopic cooperative surgery (LECS) is a new combined minimally invasive resection method for such situations. The aim is to report our growing experience on LECS in difficult gastric GISTs resections, presenting one video and the outcomes of 3 cases.

Aims & Methods: Between 2014 and 2016, three patients with posterior EGJ GISTs have been operated in our center. They initially presented with unspecific abdominal pain in 2 cases and melena in one case. The diagnosis was made by upper GI endoscopy, and all the patients underwent a complete check-up including endoscopic ultra-sound with fine needle aspiration (EUS-FNA) and CT-scan. All the tumors were low grade (Ki67 < 5%) without metastases. Each case was then discussed in multidisciplinary meeting including endoscopists and surgeons, with patients’ informed consent approved. The procedure was performed in the operating room, involving a digestive surgeon and an endoscopist that used a large channel gastroscope. The LECS technique steps were: 1/ surgical liberation of the esophagus the His angle by laparoscopy; 2/ full thickness incision interesting the ¾ of the lesion, by endoscopy (Hook knife, Olympus, Japan); 3/ Exposition of the tumor pedicle to the surgeon using forceps; 4/ Linear stapling and resection of the lesion; 5/ Removal of the tumor and gastrotomy closure with separated suture.

Results: In total 3 patients (2M, 1W) aged of 31, 59 and 73 years old were operated according to this laparoscopic/endoscopic collaborative technique. The lesions measured 5.5 cm, 4.5 cm, and 6 cm, respectively. The mean procedural time was 106 minutes, without intra-operative complication. The clinical course was simple with early refeeding and the patients were discharged at post-operative day 5. The final pathological analysis confirmed the diagnosis of GIST, all of them being completely resected with safe margins, and low grade. None had recurrence, after a follow-up of 12 to 28 months.

Conclusion: LECS following a rigorous surgical protocol is safe and offers easiest accessibility and lower morbidity for complicated gastric GISTs resection. These cases underline the importance of collaboration between surgeons and endoscopists, especially in complex situations.

Disclosure of Interest: M. Barthet: Consultant for boston Scientific. All other authors have declared no conflicts of interest.

VC10 TRACTION STRATEGY WITH CLIPS AND RUBBER BAND ALLOWS COMPLETE EN BLOC ENDOSCOPIC SUBMUCOSAL DISSECTION OF LATERALLY SPREADING TUMORS INVADING THE APPENDIX.

M. Pioche¹, J. Jacques², J. Rivory¹, J.C. Saurin³, R. Legros⁴, T. Ponchon¹

¹Hepatogastroenterology, Hopital Edouard Herriot, LYON/France

²Hepato-gastro-enterology, CHU Limoges - Hepato-Gastro-Enterology, CHU Limoges; Limoges/FR, Limoges/France

³E. Herriot Hospital. Gastroenterology, Hospices Civils De Lyon, Lyon Cedex/France

⁴Chu Limoges, Limoges/France

Contact E-mail Address: [e-mail]

Introduction: Endoscopic submucosal dissection is now the reference method to allow En Bloc resection of large colorectal neoplasia[1]. Nevertheless, appendix invasion is still considered a contraindication of resection because of the risk of perforation and the difficulty to find the submucosal space at the bottom of the appendix. We report here the case of a 72 years old men referred for resection of a 4 cm granular LST of the cecum. The lesion was developed on the appendix orifice invading it deeply.

Aims & Methods: The patient was referred for a granular homogenous type laterally spreading tumours with appendix invasion and we tried ESD in order to avoid surgery. As previously demonstrated, we used a traction strategy with two clips and rubber band[1]. After complete circumferential incision and trimming, we caught the lesion edge with a first clip grasping the rubber band. A second clip was then used to catch the rubber band and to move it at the opposite wall of the colon. Once the traction seemed good, the second clip was fixed on the opposite wall mucosa and released. This traction is adaptive using inflation and deflation since the rubber band is more or less stretched according to the volume of CO2 inflated. Inflating a lot, a strong traction was obtained and allowed to extract the appendicular mucosa outside of the appendix orifice. Finally, the complete appendicular mucosa was stretch and we were able to cut the deep fibrotic fibers fixing the mucosa to the bottom of the appendix. Once the appendix was strongly stretched we could dissect the bottom of the appendix and get the full specimen En Bloc with free margin.

Results: This traction technique allowed to resect En Bloc this large specimen although it involed the appendix. The resection was complete without hole into the appendix mucosa. The appendix orifice was closed with clips without any delayed perforation or appendicitis. The final histology was a high grade dysplasia LST involving the appendix fully resected with margins. This traction technique allows to improve exposition of submucosal fibers and in particular cases like fibrosis or appendix involvment, it appears strongly requested to expose the submucosal adherence.

Conclusion: Double clip and rubber band traction improves submucosal stretching to allow ESD in the colon. In particular case like appendix involvment, this technique is very important to strecth the submucosal fibers and extract the lesion from the appendix orifice.

Disclosure of Interest: All authors have declared no conflicts of interest.

References

Jacques J, et al. A combination of pocket, double-clip countertraction, and isolated HybridKnife as a quick and safe strategy for colonic endoscopic submucosal dissection. Endoscopy 2017; 49: E134–E135