Correct Placement Research Articles

MIGRATION OF CENTRAL VENOUS CATHETER LEADING TO MASSIVE PLEURAL EFFUSION: A CASE REPORT AND TIPS TO REMEMBER

Central venous cannulation is a common procedure done in hospitals both in operating room (OR) and Intensive care unit (ICU) settings to provide uid, blood and blood component infusions, and to monitor central venous pressure, and administration of intravenous drugs to the patients. Various non-invasive modalities are used for the successful positioning and conrmation of correct placement of needles, guidewires, and venous catheters, including intra atrial electrocardiography (ECG) guidance, ultrasound guidance, X-ray imaging, with contrast enhanced computed tomography remaining the gold standard for conrmation of catheter placement (1).

Assessment of the Tip Position of Central Venous Catheters Inserted Using Peres' Height Formula.

The tip of a central venous catheter (CVC) should be positioned in the proximity of the cavo-atrial junction (CAJ)where thelower third of the superior vena cava (SVC) and the upperright atrium (RA) are located to prevent life-threatening complications. This study aimed to determine the accuracy of Peres' height formula in predicting the correct insertion depth of CVC. Methods:A total of 332 patients were enrolled in this prospective observational study. All CVCs were inserted using Peres' formula. The 'correct' tip position of CVC was the placement of the CVC tip 1 cm above and 1 cm below the carina inCXR. Rates of correct placements for each side and site of catheter insertions, gender, and body mass index (BMI) differences were evaluated. The correct placement rate of all catheters was 74.4%. There were statistically significant correlations between the correct placement of right-sided jugular and subclavian catheters (p<0.001) and left-sided jugular and subclavian catheters (p=0.014). There was a statistically significant difference in male patients (p=0.047). Higher BMI resulted in a lower rate of correct placement with no statistically significant difference (p=0.457). Peres' formula can be easily used to determine the correct position of CVC tips with a success rate in the Turkish population. However, practitioners should be aware of the low accuracy rate ofPeres' formula in female patients (68.5%) and patients with BMI over 35 kg/m2 (62.5%).

Role of Lung Ultrasound in Confirmation of Double Lumen Endotracheal Tube Placement for Thoracic Surgeries: A Prospective Diagnostic Accuracy Study.

In thoracic surgeries requiring thoracotomy incisions, correct positioning of the double-lumen endotracheal tube (DLT) is mandatory. After the pandemic of novel COVID-19, using simple, noninvasive technology such as lung ultrasound (LUS) can be important in avoiding the possibility of spreading infectious diseases or contagious infections that can follow using fiberoptic bronchoscopy (FOB). We aimed to assess the accuracy of auscultation and LUS in relation to FOB in the assessment of DLT placement and to identify the possibility of using LUS as an alternative to FOB during DLT insertion. This diagnostic accuracy study was conducted according to STARD guidelines; enrolled 120 cases requiring DLT intubation. After DLT insertion, all patients were examined by stethoscope, then by LUS for determination of DLT position, and then confirmed by FOB in the same patient. Three patients dropped out due to failed intubation, and only 117 cases were analyzed. Time was significantly longer for LUS than for auscultation and FOB and was insignificantly different between auscultation and FOB. Auscultation had 76.14% sensitivity, 34.48% specificity, and 65.81% accuracy in the determination of correct DLT placement. LUS had 92.05% sensitivity, 79.31% specificity, and 88.89% accuracy in detecting correct DLT placement. There was substantial agreement between LUS and FOB (κ = 0.705) and poor agreement between auscultation and FOB (κ = 0.104). LUS can be used as a simple, noninvasive tool for detecting DLT placement with a substantial agreement with FOB.

Assembling A Puzzle

When we work on a puzzle (especially those with 1,000 pieces), my grandchildren and I make frequent checks on the finished picture to guide the placement of the pieces. Their perseverance on the task often depends on their age and the speed of progress on achieving the final goal. Hopefully, as we work together, important lessons in patience and collaboration will last beyond the finding and correct placement of the final pieces. I have had the benefit of witnessing discoveries in health care that evolved over decades and resulted in great leaps forward in the prevention, management, and, in some cases, cure of illnesses.

The Use of Commas in Secondary-Education Students and Its Relationship with Reading Comprehension: The Case of Spanish.

The correct use of punctuation marks in secondary-school students is essential for the comprehension of written texts and, therefore, for the students' academic success. However, the examination of this issue has often been overlooked in the literature. In the present study, we focused on the progression of comma usage (i.e., a punctuation mark that is often challenging to master) and examined its relation to reading comprehension. A sample of first- and fourth-year secondary-education students from Spain (N = 115) punctuated brief texts in which commas had been previously omitted. The original texts included various types of mandatory commas in Spanish. We also obtained a reading comprehension score from a standardized reading test. Results show that secondary-education students often did not correctly place the commas, with first-year secondary-education students only succeeding in the correct placement of commas 54.5% of the time in (Year 8 in the UK system). This figure increased to 80.9% in fourth-year secondary-education students (Year 11 in the UK system). As a control, this figure rose to 91.5% in first-year university students. Critically, better comprehenders were the ones with better use of punctuation marks (r = 0.33). These results are useful for developing teaching methods to improve writing/reading skills in secondary-school students.

The effectiveness of the wind barrier in mitigating soiling of a ground-mounted photovoltaic panel at different angles and particle injection heights

Soiling is one of the most important factors that reduce the efficiency of photovoltaic (PV) solar panels. An increase in the amount of dust particles resting on the surface of the PV panel leads to a significant reduction in efficiency and serious damage to the solar panel. In this research, a numerical study of the behavior of dust particles under different conditions was performed. Based on the CFD method, the dust deposition rate and wind flow domain around a ground-mounted PV panel were predicted. The current research also includes an optical study of the negative effect of the barrier by shading the PV panel, to ensure the correct placement of the barrier before proceeding with the numerical study. Seven tilt angles of the panel were considered, for all configurations the maximum is taken by the 50 μm particles, thus, it is concluded that the particle deposition rate is maximum on the PV when the tilt angle is 40° followed by 30°. The addition of a wind barrier at the front of the system reduced the quantity of particles that reached the surface of the PV, especially for large particles when the force of gravity is not taken into account. To ensure the validity of this barrier, the injection level of the particles was increased, the results were really interesting, the effectiveness of soiling reduction was not affected by a high rate, which is promising.

A study of BlockBuster laryngeal mask airway versus Fastrach/Intubating laryngeal mask airway as a conduit for blind oro-tracheal intubation: A prospective randomized controlled study

A Laryngeal Mask Airway (LMA) has two parts, a simple breathing tube and a mask. The mask at the laryngeal end of the tube aligns against the glottis and provides better channel of ventilation than the face mask. There have been modifications in the basic design of the LMA to incorporate gastric drainage channel and some devices are also equipped with a channel for intubation to secure airway by guiding endotracheal tube (ETT) through it. In this study we evaluated the performance of two LMA devices that can aid in rescue ventilation and are also equipped with a channel for intubation namely the BlockBuster LMA(2012) and the Fastrach/ Intubating LMA(1997) for blind oro-tracheal intubation in terms of First attempt success rate and Over-all success rate of intubation. A hundred consenting patients of age group 18-60 years and ASA status I or II, were randomly allocated into two groups Group BB (BlockBuster LMA) and Group FT (Fastrach LMA) with 50 patients each. Standard anesthesia technique was used for both groups. After insertion of airway device, cuff was inflated and ventilation was attempted (maximum 2 attempts). Once ventilation was achieved, ETT of appropriate size was inserted through LMA (maximum 2 attempts). The correct placement of ETT was confirmed by capnography. Data was collected for number of attempts of tracheal intubation, time taken for intubation and complications. First attempt success rate of intubation was more in Blockbuster LMA than Fastrach LMA. Over-all success rate of Intubation was 100% for both devices. Time taken for intubation and incidence of post-operative sore throat was less in BlockBuster LMA than Fastrach LMA(p-value&amp;#60;0.05). Blockbuster LMA is better conduit for oro-tracheal intubation than Fastrach LMA in terms of higher first attempt success rate, lesser time taken for intubation and lesser post-operative complications.

Comparative Effectiveness Research: A Roadmap to Sail the Seas of IBD Therapies.

The drug pipeline for the treatment of inflammatory bowel disease (IBD) has dramatically expanded over the last two decades, and it is expected to further grow in the upcoming years with the introduction of new agents with different mechanisms of action. However, such an increase of therapeutic options needs to be paralleled with an appropriate development of research to help physicians in the decision-making process when choosing which drug to prescribe. On the population level, comparative effectiveness research (CER) is intended to explore and identify relevant differences-in terms of both efficacy and safety outcomes-amongst different therapeutic regimens and/or strategies, in order to find the correct placement for each treatment in the therapeutic algorithm. CER revolves around three cornerstones: network meta-analyses, head-to-head trials and real-world studies, each of which has specific pros and cons, and can therefore offer answers to different questions. In this review, we aim to provide an overview on the methodological features specific to each of these research approaches, as well as to illustrate the main findings coming from CER on IBD target therapies (i.e., biologics and small molecules) and to discuss their appropriate interpretation.

Confirmation of Dual Lumen Cannula Position Before Extracorporeal Membrane Oxygenation Initiation Using a Microbubbles Contrast Technique.

Dual lumen cannulas (DLCs) for venovenous extracorporeal membrane oxygenation (ECMO) therapy are introduced in the right internal jugular vein, passing through the superior vena cava and the right atrium (RA) down to the inferior vena cava. The correct placement is challenging and needs careful positioning to limit mechanical complications. The outflow port needs to be located in the RA and directed toward the tricuspid valve (TV) to optimize therapy and reduce recirculation rate. Transesophageal echocardiography (TEE) is considered the standard to monitor insertion and optimal placement of this type of cannula. In addition to TEE 2D imaging, confirmation of optimal positioning is possible after ECMO initiation using color Doppler in a bicaval view to visualize the reinfusion jet located in the RA and pointing toward the TV. We present an example of DLC implantation where correct positioning was confirmed before ECMO initiation using a microbubbles contrast technique. Using TEE 2D imaging, in a bicaval (Figure 1, A and B) and modified bicaval view (Figure 1, C and D), we depict the contrast obtained while flushing the reinjection port of the DLC with saline, simulating the reinfusion jet adequately directed toward the TV (arrows in Figure 1, B and D). We use a 50 cc catheter tip syringe (conical tip) with 0.9% saline to rapidly flush the DLC. The turbulences and bubbles created provide sufficient contrast.Figure 1.: A: Bicaval view and (C) modified bicaval view without contrast; (B) bicaval and (C) modified bicaval view with contrast. DLC, dual lumen cannula; IVC, inferior vena cava; RA, right atrium; SVC, superior vena cava; TV, tricuspid valve.The authors believe that this technique helps to ensure immediate optimal efficiency of venovenous ECMO and avoid further correction of cannula position after ECMO initiation (See Video, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A878).

Abstract 310: Disparities Between Reported And Actual First Pass Discovered After Video Review Of Prehospital Intubations

Purpose: Often emphasized as a best practice in prehospital airway management, first-pass intubation success (FPS) depends upon paramedic self-reports. We sought to determine the accuracy of paramedic reports of FPS in prehospital airway management. Methods: We analyzed adult (age &gt;=18 years) prehospital airway management data from a ground EMS agency, including cases from 5/1/2020 to 2/28/2022. Paramedics performed all adult prehospital endotracheal intubations (ETI) using standard video laryngoscopy (Airtraq, Mountain View CA) with a hyperangulated blade. Paramedics did not use neuromuscular blocking agents for ETI. Real time video images were recorded for all cases. We excluded cases where the video was missing, data was not captured, or the video was of insufficient quality. Each video was reviewed by a single independent rater using the same objective definition of FPS as the paramedic. The primary outcome was FPS, defined as correct intratracheal placement on the first video laryngoscopy. We evaluated agreement between paramedic and reviewer-reported FPS using Cohen’s Kappa statistic. Results: There were a total of 514 ETI cases, including cardiac arrest, trauma, and non-arrest medical. Paramedic and reviewer reported FPS agreed in 429/514 (83.5%) and disagreed in 85 (16.5%). Of the discordant cases, the paramedic reported FPS but the reviewer disagreed in 78 (92%). Interrater agreement was strong; kappa 0.659 (95%CI 0.595 - 0.722). FPS discordance was not associated with patient age, sex, cardiac arrest status. Conclusions: Despite the computed Kappa statistic showing strong interrater reliability, the objective nature of the rating leaves very little room for discordance. The expected result would have been near compete agreement, however 15% of cases resulted in disagreement. Additionally, when there was disagreement, it overwhelmingly favored the clinician reporting FPS when the reviewer disagreed. Paramedics incorrectly reported FPS in 1 of 6 ETI. Independent review is essential in the assessment of prehospital ETI performance. Further study is needed to determine the reasons for the discordance that may include confusion about the FPS definition or incentivization (real or perceived) of reporting outcomes in a particular way.

Distal Biceps Repair: 2-Volar Incision Technique for Acute and Chronic Retracted Tears

Background: A distal biceps repair is performed after a rupture of the distal biceps tendon, an injury that typically affects the dominant arm of middle-aged men, resulting in weakness in supination and elbow flexion. A volar 2-incision technique minimizes skin incision length while optimizing exposure to anatomical structures through proper incision placement for acute repair and chronic reconstruction with graft. Indications: Retraction of the distal biceps away from its insertion on the proximal radius in the chronic setting can require a more extensile incision. Two transverse incisions are strategically placed on either side of the antecubital fossa to optimize exposure of the radial insertion site and proximally to retrieve the retracted tendon for either acute or chronic retracted distal biceps tears with or without graft reconstruction. Technique Description: A transverse incision is made in the forearm directly over the radial tuberosity. This facilitates direct exposure and drilling of a socket for placement of the distal biceps’ tendon with suture button and interference screw construct. A second proximal transverse incision is made to identify and retrieve the retracted tendon. The tendon is retrieved and prepared or reconstructed with graft for chronic cases with suture. The tendon and graft are tunneled under the skin bridge between the 2 incisions. The sutures are then loaded onto a titanium button, which is deployed onto the far cortex. The tendon is advanced into the tunnel, an interference screw is placed, and the sutures are tied. Results: Restoration of anatomy and correct placement of the 2 incisions is facilitated with this approach, restoring distal biceps function without requiring extensile volar exposure of the entirety of the length of the distal biceps tendon. Discussion/Conclusion: This technique mitigates the need for extensive dissection. It also facilitates improved visualization of relevant structures for cases with substantial tendon retraction, even in the case of chronic retracted tears requiring allograft reconstruction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Produktivitas dan Efisiensi Penggunaan Input Produksi Usahatani Padi di Desa Srikaton Kecamatan Buay Madang Timur

Efficiency of the use of inputs in the farming field in the effort to reach an optimal profit in the farming field and environment continuity in agriculture. The correct inputs placement will increase the efficiency and productivity in the rice farming field. This research aims to analyze the impact of the use of seeds, urea, phonska, sp36, pesticides, and labor on the productivity of rice farming and the efficiency level in the use of production factors in the rice farming field in Desa Srikaton, Buay Madang Timur District, East OKU Regency. The quantitative method is used in this research. The data are collected by using questionnaire. There are 60 participants which are determined by cluster sampling technique. Primary and secondary data are used as supporting data. The data are analyzed by using regression technique, using Cobb-Douglas production function model, and allocative efficiency analysis. The result shows that urea, phonska, pesticides, and labor had a positive impact on rice production, while seeds and sp36 had no effect on rice production. In Desa Srikaton rice farming field, the production inputs such as seeds, urea, sp36, pesticide, and labor have not efficient yet, while production inputs such as phonska fertilizer are not efficient.

V-022 HYBRID APPROACH E-TEP AND OPEN FOR COMBINED LUMBAR AND MIDLINE HERNIAS

Abstract Aim To present the case of a 61-year-old woman with a recurrent lumbar incisional hernia L4W3R (EHS Classification) associated with a primary midline hernia, as well as a proposed treatment by combined e-TEP and open approach. Material and Methods This is a 61-year-old woman with a personal history of obesity, with an open right nephrectomy and later onlay hernia repair. She had a large lumbar eventration with an 11 cm defect (L4W3) associated with a primary midline hernia with rectus diasasis. We performed a hybrid e-TEP approach for the midline hernia associated with lumbar open approach to perform a complete repair by reverse-TAR technique. Results The treatment of combined lateral and midline hernias remains controversial. In patients in whom the lateral hernia is the primary hernia, one of the proposed approaches would be to perform a posterior component separation from the lateral defect. This involves performing a reverse transverse abdominis release (reverse-TAR), opening the rectus sheath from the lateral preperitoneal plane. In obese patients and with large defects, performing this step can be highly complicated due to the difficulty for correct visualization of the area. Conclusions We propose this combined approach, performing a minimally invasive surgery for the dissection of the midline defect, which allows us to perform in a simpler way later the approach from the side, as well as a better exposure and visualization of the area; thus allowing, despite the technical difficulty, the correct placement of a large mesh, which widely covers all the defects.

O-Ring Aortic Banding Versus Traditional Transverse Aortic Constriction for Modeling Pressure Overload-Induced Cardiac Hypertrophy.

Aortic banding in mice is one of the most commonly used experimental models for cardiac pressure overload-induced cardiac hypertrophy and the induction of heart failure. The previously used technique is based on a threaded suture around the aortic arch tied over a blunted 27 G needle to create stenosis. This method depends on the surgeon manually tightening the thread and, thus, leads to high variance in the diameter size. A newly refined method described by Melleby et al. promises less variance and more reproducibility after surgery. The new technique, o-ring- aortic banding (ORAB), uses a non-slip rubber ring instead of a suture with a thread, resulting in reduced variation in pressure overload and reproducible phenotypes of cardiac hypertrophy. During surgery, the o-ring is placed between the brachiocephalic and left carotid arteries. Successful constriction is confirmed by echocardiography. After 1 day, correct placement of the ring results in an increased flow velocity in the transverse aorta over the o-ring-induced stenosis. After 2 weeks, impaired cardiac function is proven by decreased ejection fraction and increased wall thickness. Importantly, besides less variance in the diameter size, ORAB is associated with lower intra- and post-operative mortality rates compared with transverse aortic constriction (TAC). Thus, ORAB represents a superior method to the commonly used TAC surgery, resulting in more reproducible results and a possible reduction in the number of animals needed.

A review of environmental and economic aspects of medical devices, illustrated with a comparative study of double-lumen tubes used for one-lung ventilation

When health care management considers implementing a new technology such as a medical device, it is crucial to take workflow, clinical outcome, economy, and environmental impacts into consideration in the decision-making process. This study outlines the knowledge status of this complex challenge via a systematic literature review (SLR). The SLR found 133 of 1570 screened publications that covered relevant frameworks for choosing hospital equipment (i.e., related economics, life cycle assessment, waste generation and health issues). Yet, just five publications addressed choosing single-use vs. reuse of tubes or similar types of equipment by economic and environmental considerations through a systematic quantitative approach. The SLR reveals few publicly available peer-reviewed studies for the optimal sustainable choice of equipment. This study assesses environmental impacts of carbon dioxide (CO2) emissions as CO2-equivalents and resource consumption of a single-use double-lumen tube (DLT) combined with a reusable bronchoscope were compared to a single-use DLT with an integrated single-use camera. Camera DLTs exclude or minimize the need for a bronchoscope to verify correct tube placement during one-lung ventilation. The life cycle assessment shows that the materials and energy used and needed for personnel protective equipment and cleaning of the reusable bronchoscope contribute significantly to CO2-equivalent emissions. To ensure the sustainable choice of equipment this aspect must not be overlooked. Secondly, future reuse of plastic waste materials from the use can contribute significantly to better environmental performance.

Microphone location investigation for standard aircraft ground run-up noise measurements

The correct placement (height, orientation, and mounting techniques) for microphones used in standard data collection practices for aircraft environmental noise models is a topic of debate. Previous studies have demonstrated and quantified the dependence of spectral data recorded as a function of microphone placement variations and relative source origin. In this work, an in-depth investigation of microphone mounting effects is performed with an emphasis on (1) microphone height and (2) ground-mounting configuration for the purpose of quantifying ground run-up aircraft noise emissions for environmental noise model generation. Data for this investigation were collected on the T-7A Red Hawk in both standard (see ANSI S12.75-2012) and off-standard configurations for comparison.

O029 / #627 DEEP BRAIN STIMULATION FOR PARKINSON: AWAKE VS ASLEEP SURGICAL TECHNIQUE: TRACK 2: DEEP BRAIN STIMULATION FOR MOVEMENT DISORDERS

Electrical stimulation of deep brain nuclei is a well-stablished technique for the treatment of movement disorders, when refractory to medical management. In its early beginnings, functional neurosurgery relied in stereotactic atlases and intraoperative micro-registration in awake patients to achieve correct electrode placement (indirect method). However, the cumulative experience on target description and the evolution of MRI resolution have made it possible to accurately define the target preoperatively (direct method).

S2858 Post-ERCP Subcapsular Hepatic Hematoma

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic procedure used for management of biliary pathology. Rates of even the most common complications, including biliary perforation and pancreatitis, are low, however other complications can be life-threatening and must be kept in mind when evaluating a patient post-ERCP. Here, we describe a case of post-ERCP subcapsular hepatic hematoma (SHH). Case Description/Methods: A 39-year-old man with a history of hypertension, type II diabetes mellitus and alcohol use disorder complicated by chronic pancreatitis with multiple episodes of common bile duct (CBD) stricture status post multiple ERCPs presents with epigastric pain and right upper quadrant pain. He was admitted two weeks prior for epigastric pain, where he was found to have CBD stricture, and underwent ERCP with stent placement. Pain did not completely resolve after his last hospitalization and escalated to a 10/10. On arrival, he was afebrile with stable vitals. Physical exam demonstrated epigastric tenderness to palpation with voluntary guarding, but a soft abdomen without rebound tenderness. Labs significant for WBC count of 10.8 x 10^9/L, alkaline phosphatase of 117 U/L, and hemoglobin 11.7 g/dL. Abdominal ultrasound showed a 7.3 x 3.9 cm area of mixed echogenicity in the right liver lobe. Triple phase CT of the abdomen and pelvis showed a 9 x 6.5 x 2.5 cm heterogeneous subcapsular liver collection. He was given Zosyn, and WBCs downtrended. On day 3, liver function tests (LFTs) rose: aspartate aminotransferase was 397 U/L, alanine aminotransferase was 206 U/L, alkaline phosphatase was 571 U/L, and total bilirubin was 5.0 mg/dL. Repeat CT showed expected hematoma resolution with correct biliary stent placement. Antibiotics were re-started. LFTs and symptoms improved. He was discharged on a 14-day course of Levofloxacin and Metronidazole. (Figure) Discussion: SHH is a rare but known complication of ERCP. Hematomas can expand, resulting in significant anemia and LFT elevation, or become infected with resultant sepsis. Patients with SHH must be carefully monitored in the post-ERCP setting. This patient exhibited an elevated WBC count with delayed elevation in LFTs, concerning for potential infection of the hematoma, yet without overt signs of infection, including lack of fever. He was managed with antibiotics without hematoma drainage, demonstrating the efficacy of conservative management for such a potentially deadly complication of ERCP.Figure 1.: Triple phase computed tomography scan of the abdomen and pelvis demonstrating a right-sided subcapsular hematoma in segment 6 of the liver in the coronal (a) and transverse (b) planes (arrow).

S2590 Endoscopic Sengstaken-Blakemore Tube Placement for Variceal Hemorrhage: A Case Series

Introduction: Management of brisk variceal bleeding is challenging and nerve-racking for both gastroenterologists and intensivists. When visibility is hampered, a Sengstaken-Blakemore (SB) tube is used to tamponade as a temporary bridge to Transjugular intrahepatic portosystemic shunt (TIPS). Traditionally, the SB tube is placed blindly, or with the help of radiography to confirm gastric balloon location. Catastrophic complications are reported with blind approach including distension of the esophagus or trachea leading to rupture. Endoscopic SB placement has been described in literature as a successful technique. We report 3 cases with successful placement of SB tubes in massive variceal hemorrhage as a bridge to TIPS. Case Description/Methods: Case 1: A 36-year-old gentleman with alcoholic cirrhosis presented with hematemesis 2 days after undergoing variceal banding. Bleeding post-banding ulcers were confirmed with endoscopy and treated with hemoclips and epinephrine. Despite the intervention, the patient had recurrence of bleeding the following day with hematemesis. Repeat endoscopic intervention was limited due to poor visibility from brisk bleeding. An SB tube was placed endoscopically, and he underwent emergent TIPS that same day. The SB tube was removed 24 hours later with no recurrence of bleeding, and he was discharged to home. Case 2: A 68-year-old gentleman with alcoholic cirrhosis and history of variceal bleeding presented with hematemesis. Emergency endoscopy found massive bleeding, however the source of bleeding could not be located. An SB tube was endoscopically placed and an emergent TIPS was performed on the same day. The SB tube was removed 24 hours later with no recurrence of bleeding. After a 10-day hospital stay, he was ultimately discharged to hospice. Case 3: A middle-aged woman presented to the hospital with active variceal bleeding. She underwent successful endoscopic SB tube placement as a bridge to TIPS. Although she also had successful placement and no rebleeding, she ultimately succumbed to her disease. Discussion: Endoscopic SB tube placement is an effective bridge to emergent TIPS due to the improved hemostasis and decreased likelihood of rebleeding. This technique also limits the complications of blind placement, such as inadvertently distending the gastric balloon in the wrong location. Therefore, gastroenterologists should consider endoscopic placement of a SB tube when other endoscopic interventions fail to achieve hemostasis in variceal hemorrhage (Figure 1).Figure 1.: Endoscopic placement of a SB tube, confirming correct placement for hemostasis.

S1759 Management of Bouveret Syndrome: A Case Report

Introduction: Bouveret syndrome is an unusual complication of gallstone disease, causing less than 0.2% of small bowel obstructions. It often requires multidisciplinary approaches for treatment. We present here a unique case report of Bouveret syndrome, managed successfully using Holmium LASER alone. Case Description/Methods: A 74-year-old man presented to our hospital with vomiting, decreased appetite, periumbilical pain and nausea. He denied heartburn, fever, chills or jaundice. His past medical history was significant for cardiomyopathy (EF 35%), atrial fibrillation and ventricular tachycardia with AICD placement. He had been admitted 3 months prior with acute cholecystitis and elevated liver function tests. Due to cardiac comorbidities, he was treated with IV Zosyn, cholecystostomy tube and ERCP with sphincterotomy with improvement and he was discharged. 6 weeks later, a tube check confirmed correct placement of the tube and decompression of the gall bladder. This time, his pain differed from the right upper abdominal pain of prior admission. His tube drainage had reduced considerably in the previous day. Physical examination revealed epigastric and supraumbilical tenderness with no guarding or rebound. The cholecystostomy bag had purulent drainage. WBC count was 11.95 x 10,000/cu.mm; liver enzymes and S. Lipase were normal. CT scan showed a change in the position of a previously seen large gallstone, measuring 3.7 cm in diameter. During the previous admission, it was in the gall bladder neck. At this time, it was occupying the duodenal bulb lumen, indicating development of a cholecystoduodenal fistula, and causing complete obstruction. The surgical team recommended endoscopic treatment due to anticipated friability of the tissue (Figure). Endoscopic evaluation showed complete obstruction of the duodenal bulb by a large smooth stone, not allowing passage of even a guidewire beyond the stone. Lithotripsy was chosen to help relieve the obstruction. 410 micron and 990 micron Holmium LASER probes were used with assistance from Urology, via an antegrade approach from the pylorus through a gastroscope. After 2 sessions of lithotripsy 4 days apart, each breaking through pigmented and calcified stone, the stone passed through the small bowel, relieving the obstruction. Discussion: The patient did not require surgical intervention and has recovered well. This case illustrates the feasibility of Holmium LASER to treat heavily calcified and pigmented gallstones. Holmium LASER should be developed for use in GI Endoscopy.Figure 1.: Gallstone obstructing duodenal bulb; LASER lithotripsy of calcified and pigmented stone; residual ulcer in duodenal bulb after stone passed.