An ERCP was attempted but neither major nor minor papilla could be cannulated. The video ... blue, we could identify bluish output, suggesting gastric fistula.
Abstracts
with assistance of cholangioscopy are new excellent alternatives but still are expensive procedures, not widely available in all hospitals.7 In this case report with very skilled maneuvers the proximal CBD was canulated with a guidewire and the posterior placement of a fully covered metallic stent was done. This way a severe complication was solved without surgery, need of a complex rendezvous techniques nor cholangioscopy; demonstrating that an skilled endoscopist can sometimes solve the most extreme situations with only the basics elements required in the ERCP room.
976 SEALING THE LEAKING PANCREATIC DUCT WITH ENDO PROSTHESIS IN FAILED ERCP Anoop K. Koshy*, Harshavardhan B. Rao, Arjun Prakash, Rama P. Venu Gastroenterology, Amrita Institute of Medical Sciences, Kochi, Kerala, India Pancreatic Duct (PD) leak leading to pancreatic ascites is a serious complication of chronic pancreatitis. Endoscopic management has been found to be feasible and safe in these patients and includes Endoscopic Retrograde Cholangio Pancreaticography (ERCP) with selective cannulation of the pancreatic duct and trans-papillary drainage by a pancreatic sphincterotomy followed by stent placement ideally bridging the location of the leak. Endoscopic ultrasound (EUS) guided rendezvous procedures are a promising alternative in patients who have a failed ERCP. A dilated Pancreatic duct(PD) is ideal for a successful EUS guided rendezvous procedure. Till date, EUS guided rendezvous procedures have not been reported for patients with pancreatic ascites. We report a modified EUS guided rendezvous technique which was successfully performed to treat a patient with pancreatic ascites especially in the setting of a non-dilated PD. In this patient, ERCP was unsuccessful and he was a high risk surgical candidate. Case details 64 year old male from Kerala , India Clinical history: Intermittent abdominal pain and progressive abdominal distension. Past medical history: No other significant illnesses. History of alcohol abuse for more than 30 years. Relevant Laboratory studies showed: Hemoglobin: 13.5 g/dl. Platelet count: 522,000/ mL. Serum Bilirubin: 0.42 mg/dl. Serum Albumin: 2.78 g/dl. INR: 1.12. Ascitic fluid analysis: Total protein: 3.6 g/dL. Cell count: 200 cells/ mm3. Amylase: 20,000 U/L. CT Abdomen: Atrophic pancreas with parenchymal calcifications and gross ascites. MRI-MRCP: Non dilated pancreatic duct. No strictures. Suspicious leak from the neck of the pancreas. An ERCP was attempted but neither major nor minor papilla could be cannulated. The video demonstrates a Modified EUS guided rendezvous procedure which was successfully performed in this patient with pancreatic ascites and a non-dilated PD which can be viable alternative for patients with a failed ERCP.
977 ENDOSCOPIC VACUUM THERAPY FOR ESOPHAGEAL POST-MEGASTENT PERFORATION. Vitor O. Brunaldi*, Daniel Riccioppo, Diogo T. de Moura, Mauricio K. Minata, Flávio Hiroshi A. Morita, Rodrigo S. Rocha, Galileu F. Farias, Marco Aurélio Santo, Eduardo G. de Moura Gastroenterology Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil We report a case of a 55 years-old female patient who underwent a sleeve gastrectomy due to class III obesity. She had a past medical history of a kidney transplant due to end-stage chronic kidney disease. Seven days after surgery after the bariatric procedure, the drain output increased suddenly and after ingestion of methylene blue, we could identify bluish output, suggesting gastric fistula. The patient was clinically stable so we decided for conservative treatment. We promptly put the patient on broad-spectrum antibiotics and NPO and referred her to Endoscopy unit for stent placement. A large bariatric self-expandable metallic stent (28mmx24cm) was chosen and successfully deployed to completely occlude the orifice at the proximal corpus. We initiated liquid diet a day after SEMS placement but she experienced another increase in the drain output. Therefore, we kept her on NPO and endoscopically placed a nasoenteral feeding tube. She was discharged one week after SEMS placement and returned for clinical consultation three days later. She complained of the darkish and high volume drain output. She was readmitted for endoscopic assessment of the SEMS. During the procedure, we identified a large perforation in the distal esophagus where the SEMS was anchored. The patient was then conducted to emergency surgery. Intraoperatively, we could identify both esophageal perforation and gastric fistula. We were able to repair both defects and place mediastinum and peritoneal drains. Also, we performed a jejunostomy for feeding. Postoperatively, she was referred to ICU and needed vasoactive drugs for 4 days. Ten days after surgery, we performed an endoscopy to remove the SEMS, and we were able to identify the esophageal perforation and the mediastinum drain. Then, we pulled out the drain from the leak and initiated the endoscopic vacuum therapy for the perforation with drain exchanges every 3-5 days. Eight drain exchanges and fifty days were needed to achieve complete closure of the esophageal perforation. The treatment of the gastric fistula entailed removal of staples and two sessions of septotomy. Control EGD and upper GI contrast series showed no signs of leaks. The patient was discharged three months after the sleeve gastrectomy with oral diet and asymptomatic.
AB140 GASTROINTESTINAL ENDOSCOPY Volume 87, No. 6S : 2018
978 CLIP-ASSISTED EMR: A NEW RESECTION TECHNIQUE FOR TREATING FLAT REMNANTS OF COLONIC POLYP TISSUE DURING PIECEMEAL EMR Matthijs P. Schwartz* Gastroenterology & Hepatology, Meander Medical Center, Amersfoort, Netherlands EMR (endoscopic mucosal resection) is the preferred endoscopic treatment of large sessile colonic polyps. Although safe and effective, local recurrence rates after EMR are high (ranging from 10-30% in various reports), especially after piecemeal resections. During piecemeal EMR small, often flat pieces of polyp tissue can remain, which may be difficult to remove with a snare. After unsuccessful attempts at snare resection thermal ablative treatment, using snare tip coagulation or APC (argon plasma coagulation), is often used. However, the use of APC has also been identified as a risk factor for polyp recurrence after EMR. Therefore, better resection techniques of polyp remnants are desirable. We describe a new EMR technique in two cases both with lateral spreading colonic polyps: a patient with an adenomatous, Paris-classification IIa / IIc lesion and a patient with Serrated Polyposis Syndrome and a Paris IIa lesion. In both cases a residual, centrally located, flat polyp fragment was present during piecemeal EMR for which multiple, unsuccessful attempts at snare resection were undertaken. An endoclip was placed at the aboral side of the polyp fragment (Video), carefully positioned to avoid touching polyp tissue. Placement of the clip resulted in tenting of the submucosa and lifting of the polyp tissue island, which now could be easily resected with the conventional snare. Clip-assisted EMR may be considered as an endoscopic option to treat residual polyp, after unsuccessful snare resection attempts. The safety and effectiveness of this new technique, especially its capacity to prevent recurrences, should be investigated in prospective studies.
979 THAT’S NO MOON: TRANS-ORAL EXCISION OF AN ESOPHAGEAL GIANT FIBROVASCULAR POLYP IN A PEDIATRIC PATIENT Cheyenne C. Sonntag*, Rachel E. Hanke, Ryan M. Juza, Vamsi V. Alli, Mary C. Santos, Eric M. Pauli Surgery, Penn State Hershey Medical Center, Hummelstown, PA
Giant fibrovascular polyps are rare benign tumors that most commonly arise in the upper-third of the esophagus. These slow-growing tumors are predominantly diagnosed in the sixth or seventh decade of life. Patients may present with progressive dysphagia, anemia, hematemesis, or even regurgitation and fatal asphyxiation. Here we discuss the presentation, work-up and diagnosis of a giant fibrovascular polyp arising from the thoracic esophagus in a 17 year-old male. Due to the location of the stalk with relation to the thoracic aorta a thoracoscopic approach was deemed inappropriate. Endoscopic resection methods previously described in the literature include loop snare, cautery and ultrasonic shears. Here a trans-oral resection was performed utilizing a laparoscopic bariatric stapling device with a vascular load to ligate the stalk. Per-oral extraction was performed using a 30mm oval snare around the mass, gentle scope withdrawal and aggressive jaw thrust. The mass measured 12x7x4 cm and final pathology confirmed benign fibrovascular polyp. Two regions along the staple line were concerning for possible delayed bleeding and were addressed with through-the-scope and over-the-scope clip applications. Postoperatively the patient tolerated clear liquids and was discharged in 24 hours on a postPOEM diet.
980 INSULATED-TIP (IT) KNIFE- ALTERNATIVE METHOD OF MARSUPIALISING A SYMPTOMATIC DUODENAL DUPLICATION CYST IN A 15-MONTH OLD BOY. Ennaliza Salazar*1, Eliza I-Lin Sin2, Yee Low2, Christopher Jen Lock Khor1 1 Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore; 2KK Women’s and Children’s Hospital, Singapore, Singapore Background: Duodenal duplication cyst is rare, accounting for 2-12% of duplication of the alimentary tract. More than half are symptomatic within the first two decades of life. Due to the close proximity of major structures around the duodenal C-loop, endoscopic incision of the duplication cyst is the preferred choice of treatment in symptomatic patients. Definitive endoscopic therapy has been reported with the use of needle knife, sphincterotomes or polypectomy snares. Here, we describe a case where marsupialization of duplication cyst was performed using insulated -tip (IT) knife . Case: AT was a 15-month old boy who presented to other hospital for abdominal pain with hematemesis and acute pancreatitis on separate occasions. He was referred for evaluation of suspected Todani type III choledochal cyst. Ultrasound (US) abdomen showed a double-layered wall characteristic of enteric duplication cyst. MRCP was performed to characterize the lesion and showed a 5.2 x 4.0 x 1.6 cm rounded cystic structure posterior to the second part of the duodenum. A
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