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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
14.
2156 Innovative Use of Linear EUS Weinberger, Jonathan; Grunwald, Matthew; Waintraub, Daniel J. ...
The American journal of gastroenterology,
10/2019, Volume:
114, Issue:
1
Journal Article
Peer reviewed
INTRODUCTION:
Therapeutic echoendoscopic ultrasonography (EUS) is vital in the diagnosis, staging, and tissue acquisition of gastrointestinal (GI) malignancies. However, its use is typically limited ...to upper GI tract and rectum due to limited visualization and instrument length. We present a case of evaluating an extraluminal lesion adjacent to the distal small bowel, utilizing a linear echoendoscope.
CASE DESCRIPTION/METHODS:
65 year old male with a history of cecal perforation in the setting of ischemic colitis (no pathologic evidence of malignancy), status post right hemicolectomy, COPD, DM and CHF was admitted with right sided abdominal pain without change in bowel habits. CT scan revealed a mass in the mid abdomen. The mass appeared inseparable from the small bowel (ileum) just proximal to the ileocolic anastomosis; however, it was unclear if the mass was extraluminal or invading the lumen. Colonoscopy was performed and there was no evidence of an intraluminal mass. Interventional radiology was contacted for biopsy of the mass, however, there was no safe window for biopsy. GI was re-consulted and a decision was made to attempt an EUS with fine needle biopsy (FNB) in order to avoid diagnostic laparoscopy. Ileum was intubated with a pediatric colonoscope and a 0.035 inch guidewire was advanced into the small bowel. Two endoclips were placed proximal to the ileocolic anastomosis for fluoroscopic guidance. The colonoscope was then exchanged for a linear echoendoscope which was advanced alongside the guidewire with an inflated forward balloon using endoscopic and fluoroscopic guidance. The mass was identified and FNB was performed. Cytology revealed atypical lymphoid cells consistent with high grade diffuse large B cell lymphoma.
DISCUSSION:
Linear echoendoscope is often used for evaluation of distal colonic lesions. Traditionally the miniprobe is used for diagnosis of lesions not reachable with a linear endoscope, but lacks the ability for tissue acquisition. Recently, a forward viewing echoendoscope has been developed however it is not yet widely available. We describe a case of an innovative use of linear echoendoscope in the proximal colon/distal small bowel, sparing a more invasive surgical procedure. In addition, we describe a novel use a forward balloon as a safety mechanism for advancing a side viewing endoscope in areas of limited visualization.
INTRODUCTION:
Sigmoid volvulus (SV) occurs when the colon twists about its mesentery which can compromise vascular perfusion leading to ischemia. Mortality rate (MR) is up to 60%, requiring emergent ...endoscopic (ES) detorsion via flexible sigmoidoscopy (FS) with placement of a rectal tube. Recurrence is high, ultimately requiring surgical management. The mean age of presentation is 70 with high likelihood of multiple comorbidities, resulting in high surgical risk. We present a case of ES therapy of recurrent SV.
CASE DESCRIPTION/METHODS:
88-year-old man with colon cancer status post left hemicolectomy (LH), coronary artery disease on antiplatelet agents, atrial fibrillation on anticoagulation, congestive heart failure, and chronic pulmonary disease, presented with abdominal pain, distention and obstipation for two days. The patient had a history of three episodes of SV requiring ES detorsion since LH. Abdominal x-ray revealed a markedly dilated sigmoid colon. Emergent FS was performed with insertion of a 36 French (Fr) catheter resulting in decompression. Computed tomography (CT) was unrevealing for other pathology. Colonoscopy showed a severely redundant, tortuous and dilated colon without other abnormalities. Subsequently, ES sigmoidopexy was performed under fluoroscopy to minimize looping and confirm SV detorsion. Six T-fasteners (TF) were placed cephalocaudally, 5-10 cm apart, with the first TF upstream to proximal region of twisting and the sixth TF downstream to distal region of twisting. A 16 Fr percutaneous endoscopic colostomy (PEC) tube was then inserted as a decompression valve. The tube was affixed to the abdominal wall with two additional TFs inserted adjacent to the third TF to create a triangle within the region of previously dilated lumen. The eight TFs and PEC tube were tightened to abdominal wall, and the tube was connected to a Foley drainage bag. Follow up CT scan confirmed resolution of SV. The patient improved clinically and was discharged home after having formed bowel movements.
DISCUSSION:
Due to high MR, a high index of suspicion for SV is necessary in elderly patients presenting with abdominal distention. Although several case series exist describing ES sigmoidopexy and laparoscopically-assisted PEC tube insertion, to our knowledge this is the only described case of definitive ES therapy using both surgical and ES techniques. While additional cases are required to assess safety and efficacy, this technique may be an addition to the ES armamentarium in managing SV.
INTRODUCTION:
Efferent loop syndrome (ELS) is a rare post gastrectomy syndrome that can occur following Billroth-II or Roux-en-Y reconstruction. The most common loop syndrome after gastric surgery is ...afferent loop syndrome (ALS), however efferent loop syndrome has been reported. ELS may occur due to a mechanical obstruction of the efferent limb due to an anastomotic stricture, malignancy, volvulus, intussusception, internal hernia or abdominal adhesion after surgery. Presentations include abdominal distension and vomiting and rarely pancreatitis or cholangitis. We present a case of efferent loop syndrome managed with an Axios lumen apposing metal stent (LAMS).
CASE DESCRIPTION/METHODS:
79 year-old male with a history of gastric adenocarcinoma status post distal gastrectomy with Billroth-II reconstruction one month prior to admission presented with abdominal pain and nausea. Computed tomography of the abdomen revealed distended stomach with contrast, dilated biliary limb with collapsed distal jejunum and no passage of contrast distal to the anastomosis (Image 1). Upper endoscopy (EGD) revealed a friable gastrojejunostomy anastomosis with a patent afferent limb and a nearly obstructed stenosis at the efferent limb suture line. A 20 × 10 mm A-LAMS was deployed across the stenosed efferent limb under direct visualization and fluoroscopic guidance (Images 2 and 3). Follow up upper gastrointestinal series confirmed brisk passage of contrast into the efferent limb. The patient clinically improved and a repeat EGD revealed a patent efferent limb and a dislodged Axios LAMS which was endoscopically removed.
DISCUSSION:
ELS and ALS can be managed surgically or endoscopically. Endoscopic options include dilation and enteral stenting. Dilation may require multiple sessions and stenting utilizing self-expanding metallic stents (SEMS) may be limited by tumor in-growth in the setting of malignant obstruction. LAMS creates a de-novo fistulous tract to bypass an obstruction while its saddle shape provides anti-migratory properties and allows apposition of two gastrointestinal lumens. While LAMS has been reported in ALS, there are only rare reports in the management of ELS. Our case highlights a case of successful management of ELS with Axio LAMS.
INTRODUCTION:
Laparoscopic adjustable gastric band (LAGB) placement is a commonly performed surgical weight loss procedure. Erosion of the band through the gastric wall is an uncommon albeit ...life-threatening complication that can present with abdominal pain and weight gain, potentially leading to peritonitis. Diagnosis is made with imaging such as computed tomography (CT) and may be managed by endoscopic or surgical intervention. We report a case of a LAGB that eroded through the gastric wall and migrated into the jejunum, managed with successful endoscopic retrieval.
CASE DESCRIPTION/METHODS:
58-year-old male with a history of class III obesity status post LAGB placement in 2008 presented with two months of abdominal pain, nausea, vomiting and weight loss. CT abdomen revealed mural thickening of gastric cardia with distal end of the gastric band tubing attached to a band in the jejunum and proximal end of tubing attached to a subcutaneous port (Figure 1). Fluoroscopy-guided enteroscopy revealed multiple mucosal ulcerations due to tracking of the displaced gastric band tubing. The tubing was noted to enter the gastric cavity at the cardia, extending into the proximal jejunum where the deflated gastric band was identified. A snare was used to pull the band into the gastric cavity. An upper endoscope was then inserted alongside the enteroscope (Figure 2). A 0.025 inch guidewire was placed around the tubing and captured with a snare. The distal end of the guidewire was then removed along with the gastroscope through the oral cavity. Both ends of the guidewire were loaded into a Sohendra rescue lithotripter which was then used to severe the lap band tubing approximately 10 cm from the point of entry into the gastric cavity. The resected band remained secure in the snare and was removed along with the enteroscope from the oral cavity (Figure 3). The subcutaneous port with residual gastric tubing was surgically removed two weeks later.
DISCUSSION:
LAGB erosion is an uncommon late complication of band placement. Endoscopic removal of an eroded band represents an important modality for the management of this complication and an important minimally-invasive alternative to surgery. While patients typically present with weight gain, our patient presented with weight loss likely due to intermittent obstruction. There are several reported cases of endoscopic retrieval. Our case highlights that endoscopic management should be considered as the initial treatment for eroded LAGB.
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