Circumferential Incision Research Articles

Preliminary experience of hybrid endoscopic submucosal dissection by duodenoscope for recurrent laterally spreading papillary lesions.

BACKGROUNDThe management strategies for recurrent ampullary adenoma after endoscopic papillectomy are still controversial. Patients with the recurrent papillary lesions need to receive repetitive endoscopic interventions due to the limitations of conventional endoscopic techniques.AIMTo assess the feasibility, efficacy, and safety of hybrid endoscopic submucosal dissection (ESD) by duodenoscope for recurrent, laterally spreading papillary lesions.METHODSWe enrolled two patients with recurrent, laterally spreading, duodenal papillary adenomas with no intraductal extension confirmed by follow-up between March 2017 and September 2018. After marking the resection borders of the lesion using a dual knife, a submucosal cushion was created by injecting a mixture of saline solution, methylene blue, and adrenaline. A total circumferential incision and submucosal excision was performed by dual knife combined with insulated-tip diathermic knife, and then the lesion was ligated and resected using an electric snare. Endoscopic hemostasis was applied during the endoscopic procedures. Moreover, the endoscopic retrograde cholangiopancreatography (ERCP) procedures, including selective cannulation and stent implantation of biliary and pancreatic ducts, were performed. Additionally, we performed endoclip closure for mucosal defect after ESD.RESULTSHybrid ESD using a duodenoscope and biliary and pancreatic stent placement were performed successfully in two patients. The endoscopic size of recurrent papillary lesions was no more than 2 cm. Generally, the average total procedure time was 95.5 min, and the procedure time of ESD and ERCP was 38.5 min and 15.5 min, respectively. No serious complications occurred during the intraoperative and postoperative periods. The histopathological examination revealed tubulovillous adenoma negative for neoplastic extension at the cut margin in both patients. The duodenoscopic follow-up and histopathology of biopsy specimens at 3 mo after ESD showed no residual or recurrent lesions in ampullary areas in both cases. Both cases have been followed up with no recurrence to June 2020.CONCLUSIONHybrid ESD by duodenoscope is technically challenging, and may be curative for recurrent, laterally spreading papillary adenomas < 2 cm. It should be performed cautiously in selected patients by experienced endoscopists.

S1872 Purely Endoscopic Appendectomy Using Double Balloon Endolumenal Interventional Platform

INTRODUCTION: Appendectomy traditionally performed through open or laparoscopic surgery and requires incisions (or punctures) of anterior abdominal wall causing post-surgical pain, risk of postoperative incisional hernias, restricting physical activity and delaying return to work post appendectomy. Previously reported Natural Orifice Translumenal Endoscopic Surgery (NOTES) appendectomy required incision of gastric or vaginal wall for advancement of the endoscope into peritoneal cavity with subsequent risk of intraperitoneal infection, adhesions and dyspareunia. A new double balloon endolumenal interventional platform (DBEIP) consists of a flexible overtube with 2 manually inflatable balloons, one behind the endoscope tip, the other with the ability to be advanced beyond the scope tip. Aim of the presentation: To describe purely endoscopic appendectomy using DBEIP. CASE DESCRIPTION/METHODS: The patient is a 51-year old women referred for endoscopic removal of cecal submucosal lesion. Colonoscope preloaded with DBEIP was advanced into the cecum. Submucosal mass was visualized in the cecum. Endoscopic ultrasound demonstrated hyperechoic lesion originating from submucosal layer. Circumferential incision around the lesion was performed. The lesion was attached with 2 endoscopic clips to a suture-loop mounted on fore- balloon of the DBEIP and pulled into colonic lumen. The lesion was carefully dissected from surrounding tissues. At this point it became evident that lesion originated inside the appendix. Using multidirectional dynamic retraction the appendix was pulled into cecum and removed en bloc. DBEIP served as a conduit to remove colonoscope and then to deliver endoscopic suturing device into the cecum. Full-thickness defect post appendectomy was completely closed with 2 continuous sutures. The patient had no pain post procedure and was discharged home from endoscopy unit on oral antibiotics. She restarted her regular physical activity and returned to work the morning after appendectomy. DISCUSSION: Purely endoscopic appendectomy using DBEIP is technically feasible, does not require advancement of the endoscope into the peritoneal cavity and abolishes incisions/punctures of the abdominal wall, eradicating the risk of post-surgical incisional hernias and intraperitoneal adhesions. Endoscopic appendectomy eliminates pain post appendectomy and need for hospital admission, enables early return to work and regular physical activity and can become a valuable alternative to surgical/laparoscopic/NOTES appendectomy.Figure 1.: Double balloon endolumenal interventional platform (DBEIP).Figure 2.: Endoscopic appendectomy - appendix is pulled into the cecum and dissected with hook knife.Figure 3.: Resected appendix.

Surgical Outcomes of Transvaginal Neobladder-Vaginal Fistula Repair After Radical Cystectomy with Ileal Orthotopic Neobladder: A Case-Control Study.

PurposeTo present surgical methods and outcomes in women with bladder cancer (BCa) requiring correction of neobladder-vaginal fistula (NVF) after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).Materials and MethodsThe medical records of 163 women who underwent RC with IONB for BCa between January 2010 and December 2018 were retrospectively reviewed. The presence of NVF was confirmed by cystoscopy and/or voiding cystography. NVF repair was performed using a transvaginal approach, which included circumferential incision of the fistula tract, creation of a plane between the neobladder serosa and the vaginal epithelium, and multi-layered transvaginal closure.ResultsDuring a median follow-up of 47.9 months, NVF was identified in 12 (8.8%) of the 163 included women. Eight (66.7%) fistulas were located in the proximal anterior vaginal wall and four (33.3%) in the vaginal apex. Median time from RC to NVF repair was 3.4 months (range, 2.1–5.6 months), median NVF size was 6.0 mm (range, 4.0–22.0 mm), and median duration of urethral Foley catheter indwelling was 24.0 days (range, 15.0–43.0 days). Initial repair of NVF was successful in ten (83.3%) patients. Two (16.7%) patients who relapsed retained IONB through the subsequent operation. Two (16.7%) patients developed severe urinary incontinence after NVF repair, requiring anti-incontinence surgery with a synthetic transobturator mid-urethral sling.ConclusionThe transvaginal approach for NVF repair is feasible, yielding successful surgical outcomes. However, women should be counseled about the risks of relapse and urinary incontinence.

147 EFFECTIVE UNDERWATER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR A SUPERFICIAL CERVICAL ESOPHAGEAL CANCER

Abstract Underwater method is now mainly used in endoscopic mucosal resection of colorectal and duodenal lesions based on the fact that mucosa and submucosa float into the lumen moving away from the muscularis propria after filling with water without submucosal injection. We performed underwater endoscopic submucosal dissection (ESD) for a cervical esophageal lesion. Methods Case report. Results An 81-year-old man with a history of drinking and smoking underwent endoscopy, revealing a 1/3 round superficial cancer in the cervical esophagus. ESD was performed under general anesthesia and tracheal intubation. The lumen was so narrow from natural constriction that a good view could not be secured under CO2 insufflation. Therefore, we tried the underwater method. As the lumen was expanded by filling with 0.9% saline solution, it was possible to secure a visual field. Because the submucosal layer floated up underwater, a circumferential incision and submucosal dissection were completed easily and quickly. Conclusion Endoscopic resection for lesions within a physiologic narrow space is difficult. The underwater method is reported to be useful for treatment of rectal tumors near the dentate line and cecal tumors in the appendiceal orifice. We found that the underwater method made ESD for the cervical esophageal cancer even easier by securing a good view. To our knowledge, this is the first report of underwater ESD for a cervical esophageal cancer.

A Novel Technique of Endoscopic Papillectomy with Hybrid Endoscopic Submucosal Dissection for Ampullary Tumors: A Proof-of-Concept Study (with Video).

Background: Endoscopic papillectomy (EP) carries a potential risk of procedure-related adverse events and incomplete resection. Since hybrid endoscopic submucosal dissection (ESD) had been established as an alternative option for relatively large and difficult gastrointestinal tumors, we evaluated a novel EP with hybrid ESD (hybrid ESD-EP) for curative safe margin in this proof-of-concept study. Methods: A total of eight cases who underwent hybrid ESD-EP between 2018 and 2020 were identified from our prospectively maintained database. Hybrid ESD-EP involved a (sub)circumferential incision with partial submucosal dissection, and subsequent snare resection of ampullary tumors, which was performed by two endoscopists with expertise in ESD or endoscopic retrograde cholangiopancreatography. Demographic data and clinicopathological outcomes were retrospectively evaluated. Results: En bloc resection was achieved by hybrid ESD-EP in all eight cases, with the median procedure time of 112 (range: 65–170) minutes. The median diameters of the resected specimens and tumors were 18 and 12 mm, respectively. All lateral margins were clear, whereas vertical margin was uncertain in three (38%), resulting in the complete resection rate of 63%. Postoperative bleeding and pancreatitis developed in each one (13%). No tumor recurrence was observed even in those cases with uncertain vertical margin, after a median follow-up of 244 (range, 97–678) days. Conclusions: Hybrid ESD-EP seems to be feasible and promising in ensuring the lateral resection margin. However, further investigations, especially to secure the vertical margin and to shorten the procedure time, should be required.

Microperforation due to segmental absence of intestinal musculature during endoscopic submucosal dissection forearlyesophageal cancer: a case study.

We report a case of a 75-year-old man found, during ESD for early esophageal cancer, with a segmental absence of intestinal musculature (SAIM) that caused a microperforation. A microperforation in the absence of muscle injury was encountered during an initial circumferential incision that was immediately closed with clips. The area of the SAIM was transparent, with portions of mediastinal organs seen through the submucosal layer, the movement of which was synchronized with respiration. The SAIM was subsequently completely closed prophylactically using clips. Our case shows that the rare existence of patients with SAIM should be considered when performing esophageal ESD, particularly if mediastinal organs are observed through a relatively transparent submucosal layer. The early detection of SAIM suggests this enabled us to avoid an esophageal perforation by dissecting the shallow submucosal layer. A microperforation during initial entry should alert experienced ESD endoscopists to the possibility of SAIM.

Protective Maneuver to Avoid Tumor Spillage during Laparoscopic Radical Hysterectomy: Vaginal Cuff Closure

To demonstrate the feasibility of a protective maneuver to avoid tumor exposure during laparoscopic radical hysterectomy. This video illustrates the vaginal cuff closure technique in cervical cancer surgery. The Oncologic Gynecology Department at the University Hospital La Fe. After the Laparoscopic Approach to Cervical Cancer trial [1], the laparoscopic approach to the surgical treatment of cervical cancer has been questioned: laparotomic surgery has been associated with a better cancer outcome. This publication has changed the current approach recommendation for performing radical hysterectomy from minimally invasive surgery to open surgery. There are some theories that might justify these findings. In minimally invasive surgery, the use of a uterine manipulator can condition the spread owing to erosion and friction caused on the tumor, even leading to the perforation of the tumor. In addition, intraperitoneal colpotomy can lead to pelvic peritoneum contamination by the tumor. To close the gap between laparoscopy and laparotomy, some protective maneuvers, such as vaginal cuff closure, have been proposed [2,3]. These strategies aim to reduce the possibility of manipulation or exposure of the tumor to the pelvis during colpotomy in laparoscopic radical hysterectomy. These protective maneuvers have been shown to decrease the relapse rate in retrospective studies [4]. However, prospective trials are needed to elucidate and confirm these findings. In this video, we explain step-by-step the technique of vaginal cuff closure before a radical hysterectomy performance for uterine cervical cancer. First, the nodal status is established by laparoscopic sentinel lymph node dissection and frozen section study. Bilateral pelvic lymphadenectomy is completed according to the size of the tumor. In the case of negative nodal status, the vaginal cuff is closed: Approximately 2 to 3 cm from the tumor (depending on its size), a circumferential incision of the vaginal mucosa is performed, followed by the dissection of the vaginal wall, which should be sufficient to allow a tension-free vaginal closure. The vaginal cuff is then closed with a running suture. A laparoscopic radical hysterectomy is then completed, and the surgical specimen is removed without any manipulation of the tumor. Avoiding manipulation of the tumor during cancer surgery is crucial. A vaginal cuff closure technique appears to be an easy protective maneuver that prevents tumor exposure and manipulation during laparoscopic radical hysterectomy.

Mo1689 DOUBLE SCOPE COLORECTAL ESD USING A GEL-BASED TAMIS ACCESS PLATFORM

Endoscopic submucosal dissection (ESD) is a promising endoscopic procedure that is increasingly being used for endoscopic resection of large colorectal lesions that may be difficult to remove en-bloc by snare polypectomy. The greatest challenge for ESD remains technical difficulty in achieving optimal traction. In the following study, we evaluate the use of Gel-based Transanal Access Platform, typically used for Transanal Minimally Invasive Surgery (TAMIS) to facilitate ESD of colorectal lesions by facilitating use of two separate endoscopes simultaneously. Patients undergoing colorectal ESD were consented for use of this device during their procedure. If difficulty with traction occurred during the submucosal dissection portion of the procedure, the device was employed as follows: A 4x4 cm Gel based-TAMIS access device was inserted into the anal canal. Two access holes were made in the gel cover 2cm apart with the pre-supplied trocars to allow for the passage of a 1T therapeutic gastroscope and an ultraslim gastroscope. After submucosal injection and circumferential incision, the pediatric forceps were passed through the working channel of the ultraslim scope, and the edge of the lesion was grasped and then manipulated to allow for dynamic traction of the lesion. Outcomes measured included procedure time, traction assessment, interference between two scopes and adverse events including anal discomfort and post procedure incontinence. Over the study period 5 subjects have required the TAMIS device to assist with traction. All cases have been performed by a single endoscopist. The average procedure time with use of the device over 5 cases was 19mins per 1cm of lesion. Traction was felt to be excellent in all cases. There was minimal to no interference with the second scope. All cases resulted in en-bloc and R0 resections. 1 case was a T2 cancer with R0 resection. 1 case was intramucosal cancer. 3 cases were tubulovillous adenoma with high grade dysplasia. There were no complications in all 5 cases. Zero patients complained of anorectal pain after the procedure or experienced incontinence. By using a commercially available Transanal Access Platform for the first time in an endoscopic procedure, there was greater ease performing ESD. This device allowed the insertion of an additional scope which provided more traction and assisted in resecting each lesion without any reported friction between the two scopes. The set-up of this device is simple and this device appears suitable not only for laparoscopic surgical procedures but also for endoscopic interventions. This is a lower cost option for ESD traction than other proprietary traction devices on the market. Further studies are underway to determine the technical success, easy of use, and safety of this dual scope with TAMIS platform technique for colorectal ESD.Second scope with Traction assisting with Dual Knife DissectionView Large Image Figure ViewerDownload Hi-res image Download (PPT)

V14-11 TRANSVESICAL ROBOT ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer (V14)1 Apr 2020V14-11 TRANSVESICAL ROBOT ASSISTED RADICAL PROSTATECTOMY Gongxian Wang*, Xiaochen Zhou, Bin Fu, and Cheng Zhang Gongxian Wang*Gongxian Wang* More articles by this author , Xiaochen ZhouXiaochen Zhou More articles by this author , Bin FuBin Fu More articles by this author , and Cheng ZhangCheng Zhang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000982.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To introduce the technique and report our initial experience of transvesical robot assisted radical prostatectomy (TvRARP). METHODS: 35 TvRARP for prostate cancer performed by a single surgical team between 2018 April and 2019 April were retrospectively reviewed. Preoperative data of patients [patient age (63.4, [49-73]) years, BMI (28.6 [22.1-35.4]) kg/m2, tPSA (10.8 [4.6-19.5]) ng/ml, biopsy Gleason score 6 (6∼7), prostate volume (30.6 [15.4-61.2]) ml and IIEF-5 score 15 (10∼20)] were collected. Preoperative study revealed 28 cases of cT2a and 7 case of cT2b. All patients were continent preoperatively. Surgical techniques: The surgery was performed with da Vinci Si system via 4 robotic ports and 2 assistant ports as the following: 1) cystotomy, further expended by bilateral suspension stitches. 2) A circumferential incision is made around the internal urethral orifice through the mucosa and muscular layer. 3) Initial dissection of the vas deferens and semi vesicles is carried out through the lower half of the circumferential incision around the internal urethral orifice. 4) Posterior dissection towards the apex of the prostate. 5) Dissection of bilateral NVB. 6) Anterior dissection towards the apex of the prostate. 7) Dissection and transection of the urethra. 8) Urethrovesical anastomosis. 9) 2-layer closure of bladder. RESULTS: All 35 cases were successfully performed robotically without conversion, transfusion or other major intraoperative and postoperative complications. Postoperative pathology confirmed 24 pT2a cases, 9 pT2b cases and 2 pT2c case [Gleason score 6 (6∼8)]. 4 case reported positive surgical margin (12.5%). Operative time was (130 [90-190]) min. Estimated blood loss was (100 [50-250]) ml. Urethral catheter was removed at postoperative 7-day. 32 patients achieved urinary continence (0 pads) immediately after the removal of urinary catheter, while 3 patient returned to full continence in 2 weeks postoperatively. During a mean follow up of 12 months (6∼18 months), no biochemical recurrence was noted (tPSA<0.2ng/ml). At 2-month postoperatively, IIEF-5 score was 15 (10∼19) and not statistically different from preoperative status (p > 0.05). CONCLUSIONS: Transvesical approach is a valid alternative of performing RARP in patients bearing localized low-risk prostate cancer. Tumor control and preservation of erectile function remains to be determined in long term follow up. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1309-e1309 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gongxian Wang* More articles by this author Xiaochen Zhou More articles by this author Bin Fu More articles by this author Cheng Zhang More articles by this author Expand All Advertisement PDF downloadLoading ...

Polydactyly Of The Foot Repair With Circumferential Racquet-Shaped Incision Technique And Collateral Ligament Reconstruction: Case Report And Literature Reviews

&#x0D; &#x0D; &#x0D; &#x0D; Introduction: Polydactyly of the foot is the most common anomaly in congenital diseases. This abnormality is characterized by the presence of additional digits outside the normal complement of the foot. Polydactyly has reported about 1 in 1,000 births. The Watanabe classification is used in assessing polydactyly in the feet as a fifth ray duplication. Various operating techniques can sometimes be an option. Each method has advantages and disadvantages that can be considered in the selection of surgical in the correction polydactyly.&#x0D; Patient and Method: we report a case of polydactyly of the foot reconstruction using circumferential racquet-shaped incision, osteotomy and collateral ligament reconstruction that was carried out at Bahteramas Hospital, Kendari. A circumferential racquet-shaped incision design was performed over the sixth MTP joint. Complete excision of the lateral sixth toe was performed, followed by osteotomy of the fifth metatarsal lateral head with a micro-sagittal oscillating saw. The collateral ligament was reconstructed using ligamentoperiosteal flap and fixed using syringe needle to replace K-Wire.&#x0D; Result : After postoperative control for 3 months the patient was declared good wound healingConclusion: Optimal surgical planning, good patient orientation and surgical techniques that are carefully considered are essential for optimal results. Herein, we report a case of polydactyly and racquet shaped incision technique performed to reconstruct the polydactyly.&#x0D; &#x0D; &#x0D; &#x0D;

Buried Penis Surgical Correction: Midline Incision Rotation Flaps

ObjectiveTo improve cosmetic and functional results of buried penis correction in boys using a modified universal surgical approach – Midline Incision Rotation Flaps. Materials and MethodsWe retrospectively analyzed results of 18 patients who underwent buried penis surgical treatment according to the Midline Incision Rotational Flaps technique from 2013 to 2016. The results were assessed by the surgeon 1, 3, 6 months after surgery, then yearly. Parents filled out postoperative survey after 1 month. The surgery commences with a midline longitudinal skin incision on the ventral surface. Following, a circumferential incision along the coronal edge allows to perform full degloving. Excessive subcutaneous fat tissues are removed from the peno-pubic area. Next stage is the formation of the peno-scrotal and peno-pubic angles by fixation of the skin at the base of the penis. Then, the edges of the skin flaps are opened, forming Byar's flaps. The skin defect along the ventral surface is covered with rotated triangular skin flaps with nourishing vessels. Uneven excessive skin is dissected and interrupted skin sutures are placed. Results and DiscussionThe median age of patients was 1.4 years with a median follow-up of 56 months (range 36-72). 16 patients (89%) obtained good results, and 2 patients (11%) - satisfactory. The results showed that size and appearance are close to natural and satisfying to parents of the patients. ConclusionThe suggested method of buried penis repair using Midline Incision Rotation Flaps technique allows to obtain the most satisfactory both cosmetic and functional results with minimal complication risk.

Reduction in the procedure time of hybrid endoscopic submucosal dissection for early gastric neoplasms: a multi-center retrospective propensity score-matched analysis

Background:Endoscopic submucosal dissection (ESD) for early gastric neoplasms is still a technically difficult and time-consuming procedure. Hybrid ESD (H-ESD) involves circumferential incision with partial submucosal dissection combined with subsequent mucosal resection by snaring, wherein the newly developed device allows us to perform H-ESD using a single device. This study aimed to determine the clinical outcomes of H-ESD compared with conventional ESD (C-ESD) for early gastric neoplasms.Methods:In this multi-center, retrospective study, using propensity score-matched analysis, we reviewed the charts of patients with early gastric neoplasms smaller than 20 mm treated with H-ESD or C-ESD at three hospitals between January 2017 and October 2018. The primary outcome was the procedure time, and the secondary outcomes were other factors, including the en bloc resection rate, complete resection rate, curative resection rate, and rate of adverse events.Results:Among 215 patients, 29 underwent H-ESD and 186 underwent C-ESD; 29 pairs were created by propensity score matching. In the H-ESD group, 82.8% of lesions met the absolute indication [mucosal lesions limited to 20-mm diameter, dominated by differentiated adenocarcinoma without ulcer (scar)] for endoscopic resection (ER). As a result, the procedure time of H-ESD was significantly shorter than that of C-ESD [20 (interquartile range, 12–27) min versus 40 (30–50) min; p < 0.001]. There was no significant difference in the secondary outcomes between the two groups.Conclusion:H-ESD contributed to reduced procedure time. Therefore, H-ESD could be an alternative endoscopic treatment for gastric neoplasms when the lesion fulfils the absolute indication for ER.

Prehospital amputation: An experimental comparison of techniques

ObjectivePrehospital limb amputation is a rare but potentially life-saving intervention. When patients cannot be extricated due to limb entrapment or have hemodynamic compromise that precludes a prolonged extrication, they may benefit from an emergent prehospital amputation. The objective was to experimentally compare three prehospital amputation techniques on porcine legs. MethodsThe three techniques studied were a scalpel with a Gigli saw, a hacksaw, and a reciprocating saw. For the first technique, a scalpel was used to make a circumferential incision in the soft tissue and a Gigli wire saw to cut through the bone. The second and third techniques only used a saw and did not require soft tissue incision with a scalpel. Three providers including an emergency medicine physician, a paramedic, and a medical student performed three amputations of each technique, resulting in twenty-seven total amputations. The primary outcome was amputation time. Secondary outcomes were rate of instrument malfunction and cleanliness of cut. ResultsThe primary outcome of amputation time was different between techniques. The Gigli saw technique took 32.86 ± 16.53 s (mean ± SD), hacksaw technique 6.28 ± 0.76 s, and reciprocating saw technique 2.84 ± 0.40 s. There were no differences in amputation time between participants for a given amputation technique. The Gigli saw technique had an instrument malfunction on 3/9 trials which was distinct from the other techniques. Differences in cleanliness of cut were nonsignificant. ConclusionsPrehospital limb amputation with a hacksaw or reciprocating saw may result in faster completion of the time-sensitive procedure with fewer instrument malfunctions.

2576 Right Sided Cornual Ectopic Pregnancy after Right Salpingectomy

Video Objective To present our experience of laparoscopic management of cornual ectopic pregnancy. Setting Tulip Multispeciality Hospital. Interventions Laparoscopic surgery as a treatment modality for cornual pregnancy. Laparoscopic wedge resection was carried out for corneal pregnancy. A circumferential incision was made above the base of the cornual pregnancy thus leaving behind sufficient serosal and myometrial tissue for closure with minimal distortion to the uterus. After extirpation of the cornual pregnancy, the myometrial defect was reconstituted with Vicryl 1-0 in two layers. Hemostasis was achieved by suturing. Conclusion We have to be aware that conual pregnancy can be presented even after salpingectomy and laparoscopic approach for cornual ectopic is minimally invasive, safe procedure if performed by a confident and experienced surgeon. To present our experience of laparoscopic management of cornual ectopic pregnancy. Tulip Multispeciality Hospital. Laparoscopic surgery as a treatment modality for cornual pregnancy. Laparoscopic wedge resection was carried out for corneal pregnancy. A circumferential incision was made above the base of the cornual pregnancy thus leaving behind sufficient serosal and myometrial tissue for closure with minimal distortion to the uterus. After extirpation of the cornual pregnancy, the myometrial defect was reconstituted with Vicryl 1-0 in two layers. Hemostasis was achieved by suturing. We have to be aware that conual pregnancy can be presented even after salpingectomy and laparoscopic approach for cornual ectopic is minimally invasive, safe procedure if performed by a confident and experienced surgeon.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy (VNOTES): A Walkthrough

Video Objective To present a thorough yet concise explanation of the methodology for the completion of a successful transvaginal hysterectomy via natural orifice transluminal endoscopic surgery. Design A narrated instructional video guide detailing each procedure (Canadian Task Force Classification III). Setting University Hospital, Baylor College of Medicine, Houston, Texas Patients Our patient is a 46-year-old G2P1011 who had two notable previous surgeries: a tubal ligation and an adnexa removal surgery. She possessed a narrow vagina and non-descent uterus while having a strong preference for maintaining a high level of cosmesis. Interventions A complete transvaginal hysterectomy utilizing solely natural orifice transluminal endoscopic surgery was performed on the patient. Transvaginal entry was established and with the gelpoint mini port in place we began circumferential dissection of the cervix anteriorly at the bladder fold. Utilizing the laparoscopic single tooth tenaculum, we hooked the anterior lip of the cervix for countertraction and hydro dissected the anterior cervix with 20 units of Vasopressin (Pitressin) in 20 ml of saline. Next, the monopolar hook was employed to cut the anterior colpotomy and begin the circumferential incision around the cervix. Following this, we used the LigaSure bipolar forceps to sever bilateral ureteral sacral ligament. The same strategy is used at the anterior cervix to separate the bladder from the uterus. Following bladder mobilization, the cardinal ligaments and uterine arteries were cauterized and transected by LigaSure. The right fallopian tube was removed utilizing the LigaSure first, before proceeding with the left fallopian tube; the pelvis was inspected with hemostasis noted throughout. Finally, the vaginal cuff was closed in traditional vaginal fashion after the deflation of the abdomen. Conclusion Despite certain drawbacks, utilizing pure natural orifice transluminal endoscopic surgery in hysterectomy is a safe and feasible procedure that maintains a high-level of cosmesis for patients while still offering the most minimally invasive route.

1696 Is It Technically Feasible to Use Duodenoscopy in Endoscopic Submucosal Dissection for the Recurrent Laterally Spreading Ampullary Adenomas?

INTRODUCTION: The management strategies of recurrent ampullary adenomas after endoscopic papillectomy is still a controversial issue regarding the best modality for treatment. The aim of the study is to assess the feasibility, efficacy and safety of duodenoscopic submucosal dissection (DESD) for the recurrent laterally spreading ampullary duodenal lesion. CASE DESCRIPTION/METHODS: We prospectively enrolled two patients with recurrent laterally spreading ampullary duodenal adenomas after successful papillectomy. Following marking the resection borders of the lesion using a Dual knife, a submucosal cushion is created by injecting a mixture of saline solution, methylene blue and adrenaline. A circumferential incision followed by submucosal dissection was performed using Dual knife and IT knife, then the lesion was resected using an electric snare. Hemostasis was applied using coagulation grasper during the procedure. Following dissection ERCP with biliary and pancreatic stenting was performed. Finally closure of the resection site was achieved using Endo-clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. DESD followed by biliary and pancreatic stenting was performed successfully for two patients with recurrent laterally spreading ampullary duodenal adenomas. Table 1 shows the procedure details for the initial papillectomy which showed En-bloc resection of both lesions. Table 2 shows detailed current characteristics and procedure details for the recurrent lesions. Figures 1 and 2 Show endoscopic procedures. The average total procedure time was 95.5 mins, and the procedure time of DESD and ERCP was 38.5 mins and 15.5 mins respectively with no serious intra-or post procedure complication. The histopathological examinations revealed tubulovillous adenoma with negative resection margins in case 1. Unfortunately specimen of case 2 was not retrieved successfully. Follow up at the third, sixth and twelfth month showed no residual or recurrent lesions in ampullary areas, biopsy of resection site showed inflammation with absence of adenomatous tissues in both cases. DISCUSSION: In conclusion, DESD is technically challenging, potentially effective and curative for laterally spreading duodenal ampullary adenomas within 2 cm in diameter. It should be performed cautiously in selected patients by experts with abundant experience in performing not only ESD but also ERCP. Watch the video: http://bit.ly/2Y4dE77.

347 Successful Removal of Anal Condyloma With Endoscopic Submucosal Dissection (ESD): A Novel Indication for ESD

INTRODUCTION: Endoscopic submucosal dissection (ESD) is a novel procedure that utilizes advanced surgical techniques to remove gastrointestinal tumors without the invasive nature of surgery. While there are many advantages to this procedure, one limitation that remains is that the standardization of ESD technique is yet to be well-defined, particularly in Western nations. Here, we present a case of a patient with a 30-mm anal condyloma who had complete resection of the pre-malignant lesion through ESD. CASE DESCRIPTION/METHODS: A 73-year-old female presented for screening colonoscopy. She was found to have an anal lesion on exam, biopsies showed anal condyloma with low-grade dysplasia. Given the extension of the lesion to the distal rectum, the decision was to perform dissection of the anal condyloma from the anorectal canal. Initially, the lesion was marked 5-6 mm away from its border, to allow for dissection with clear margins. In the next step, a 25-gauge needle was used to inject a solution containing Hetastarch and methylene blue. This was done to raise the lesion away from the muscularis propria layer. A circumferential incision was made, beginning at the anal aspect of the lesion. To make the final dissection, a dissection knife with an insulated ceramic tip was used in the forward view. This allowed for secure separation of the lesion in one piece, without any tissue injury. DISCUSSION: A 30 mm anal condyloma was procured. Pathology showed an anal condyloma with anal intraepithelial neoplasia grade I (AIN1). The lesion was negative for any high-grade dysplasia or carcinoma. Peripheral and deep margins were free of the lesion. The patient had mild rectal pain for three days after the procedure, which completely resolved with the application of lidocaine gel. ESD is a highly effective resection tool and should be considered for treatment of rectal condylomatous lesions. Watch the video: http://bit.ly/2LXfpkp

2146 Combined Novel Endoscopic Techniques in Esophageal Carcinoma Management

INTRODUCTION: A variety of techniques are currently being investigated to provide optimal resection of submucosal tumors by endoscopy. Specifically, peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic procedure which was originally established as a minimally invasive technique to treat achalasia and esophageal motility disorders. Due to its success in treatment of esophageal motility disorders, certain Centers of Excellence for advanced endoscopy have expanded the use of POEM in combination with other advanced endoscopic techniques for treating esophageal cancers. In this case, we present a 69-year-old male with squamous cell cancer (SCC) in the lower third of the esophagus who was successfully treated using combined endoscopic submucosal dissection (ESD), submucosal tunneling, and POEM techniques. CASE DESCRIPTION/METHODS: A 69-year-old male with a medical history of 50-pack-year tobacco abuse, chronic alcohol use, and chronic pancreatitis was initially evaluated with EGD and EUS for anorexia, weight loss, and pancreatic cysts. Initial EGD required biopsies of nodular esophageal mucosa revealing underlying squamous cell carcinoma in situ. Repeat endoscopy 2 months later revealed a large tumor circumferentially involving 80% of the lumen in the lower esophagus. Subsequently, the patient received therapeutic intervention combining ESD and POEM techniques for tumor resection, prognostication, and symptom relief. Lesion borders were marked, and a circumferential incision was made around the lesion lifting it from the muscularis propria allowing for successfully mass excision. The submucosal dissection combined with circumferential tunneling technique allowed for complete resection of the tumor. The patient reported post-procedure symptomatic relief and was able to resume oral intake. DISCUSSION: POEM is a combination of the pre-existing endoscopic myotomy procedures in conjunction with endoscopic submucosal tunneling techniques. Although POEM is labor intensive, its application gives precision by granting access to the neoplasms without affecting deeper esophageal layers. This promising advance in gastrointestinal procedures compared to esophagectomy has shown in reported studies to offer a lower morbidity rate while providing similar cancer-free survival. Our case demonstrates successful treatment using POEM and adjunct endoscopic therapies in submucosal tunneling and submucosal tunneling endoscopic resection (STER) in the treatment of large circumferential esophageal cancer.

1659 Double Scope Colorectal ESD Using a Gel-Based TAMIS Access Platform

INTRODUCTION: Endoscopic submucosal dissection (ESD) is a promising endoscopic procedure that is increasingly being used for endoscopic resection of large colorectal lesions that may be difficult to remove en-bloc by snare polypectomy. The greatest challenge for ESD remains technical difficulty in achieving optimal traction. In the following report, we discuss the use of Gel-based Transanal Access Platform, typically used for Transanal Minimally Invasive Surgery (TAMIS), being used to facilitate ESD of colorectal lesions by facilitating use of two separate endoscopes simultaneously. CASE DESCRIPTION/METHODS: The procedure was first performed on a patient presenting for resection of a 3 cm × 3 cm rectal lesion. Endoscopic ultrasound was performed and the lesion was classified as T1. A decision was made to perform ESD. A 4 × 4 cm Gel based-TAMIS access device was inserted into the anal canal prior to the start of the procedure. Two access holes were made in the gel cover 2 cm apart with the pre-supplied trocars to allow for the passage of a 1T therapeutic gastroscope and an ultraslim gastroscope. After submucosal injection and circumferential incision, the pediatric forceps were passed through the working channel of the ultraslim scope, and the edge of the lesion was grasped and then manipulated to allow for traction of the lesion. ESD was done using a needle type ESD-knife and resection en-bloc was achieved. There were no complications from the procedure and the patient has no anal pain. Histologic examination demonstrated R0 resection Two additional procedures were carried out on two patients with rectal lesions &gt;2 cm and en-bloc resection was achieved in both cases. Histologic examination in each showed tubulovillous adenoma with high grade dysplasia with clear margins. DISCUSSION: By using a commercially available Transanal Access Platform for the first time in an endoscopic procedure, the endoscopist noted more ease performing ESD. This device allowed the insertion of an additional scope which provided more traction and assisted in resecting each lesion without any reported friction between the two scopes. The set-up of this device is simple and this device appears suitable not only for laparoscopic surgical procedures but also for endoscopic interventions. Further studies are underway to determine the technical success, easy of use, and safety of this dual scope with TAMIS platform technique for colorectal ESD.

1494 Padlock Clip in the Management of Non-Lifting Part of Incompletely Resected Polyp With Central Fibrosis

INTRODUCTION: Removing nonlifting colon polyps with fibrosis secondary to prior intervention could be challenging. The novel over-the-scope Padlock clip was used in esophageal fistulas, refractory gastrointestinal bleeding, and GI defects closure. In this study, we describe our experience with Padlock clip in remeoving nonlifitng colon polyp. CASE DESCRIPTION/METHODS: A 69-year-old man is referred to our clinic to assist in the management of partially excised large, non-granular, broad-based Tubulovillous adenoma. The polyp was in cecum and measured about 5 cm. The patient underwent surveillance colonoscopy given personal history of colon polyps and paternal history of colorectal cancer. The referring physician attempted to remove by standard and Captivator snares using hot snare techniques. The polyp was not completely engaged, and the resected fragments were removed using roth net. We attempted to lift the polyp to remove using endoscopic submucosal dissection, but the scar mark could not be lifted. After marking around the polyp using electrosurgical knife (Figure 1), endoscopic submucosal dissection was done around the polyp with gradual extension of the circumferential mucosal incision, followed by hot snare-assisted resection of the lesion in a piecemeal fashion. The Non-lifting part of mucosal polyp was then grasped with raptor grasping device and Padlock clip was deployed on the polyp. The remnant polyp was successfully removed with hot snare utilizing “histlock resection device” and the margins were treated with tip of hot snare (Figure 2). Repeat colonoscopy after 3 months showed scar at previous polypectomy site with clean margins and no signs of recurrence (Figure 3). DISCUSSION: To our knowledge, this is the first study describing the use of of Padlock clip in the management of nonlifting colon polyp after incomplete resection using the conventional methods. The Padlock clip was used in the management of refractory gastrointestinal bleeding (post endoscopic mucosal resection, solitary rectal ulcer, and duodenal dieulafoy lesion), broncho-esophageal and tracheoesophageal fistulas closure, and wall defects closure in porcine. Further prospective studies are needed to assess its use in removing incompletely resected polyps.