2737 An Over-the-Scope Clip Rescue of a Perforation During a Conversion Form ESD to EMR of a Symptomatic Large Bleeding Duodenal Lipoma

Abstract

INTRODUCTION: Lipomas are the second most common benign GI tumors. Their distribution varies vastly among different sections of the digestive system and their management is dictated by the location, size and whether they cause symptoms or not. Traditionally they were removed surgical but with the advancement of the technology and third space endoscopy, endoscopist are more experienced in endoscopic therapy of such lesions. CASE DESCRIPTION/METHODS: 53 yo male with PMHx of morbid obesity had a recent admission for acute blood loss upper GI bleeding (UGIB) with profound acute anemia and a hemoglobin of 6.3 requiring several blood transfusions. On gastroscopy he was found to have an ulcerated 6 cm duodenal pedunculated lesion with a recent bleeding described as a pigmented spot (Forrest IIc). Procedure: The endoscope with a distal cap attached was advanced into the stomach. In order to prevent possible GI hemorrhage, an endoloop was successfully placed on the base of the stalk. An attempt to snare the pedunculated mass with a large hexagonal snare failed given the size of the mass. Subsequently, submucosal dissection was started. Using the SB knife a alternating coag and cut modes were utilized to perform safe dissection. A shiny layer of fat was exposed in the middle of the polypoid lesion. Then the SB knife was switched to an IT knife to complete the dissection. Coag grasper was used to achieve hemostasis, the mass was captured and taken out with a snare. Ex vivo it measured 5.4 cm. After the dissection a 1 cm partial perforation was noted. The dual grasper was used to approximate the defect and a 12 mm OVESCO type was deployed to succefully close the defect. the scope was then withdrawn. The patient was admitted for monitoring and a contrast small bowel series. A gastrografin small bowel series confirmed a contained leak in the duodenum. The patient was NPO for 24 hours. A repeat study at that point showed resolution of the leak. A clear liquid diet was started and the patient was monitored for another 24 hours then was discharged home. DISCUSSION: With the emergence of new tools, technology and technics, third space endoscopy is leading to more invasive resection. This comes at a cost of increased complications. None the less these new advancement are putting at the endoscopist tools to manage these complications independently.