Endoscopic Snare Research Articles

Endoscopic hemoclips to immediately close gastric perforation from a failed attempt at PEG in a morbidly obese patient

A serious, immediate complication of percutaneous endoscopic gastrostomy (PEG), associated with morbid obesity, that was successfully treated by endoscopic hemoclips is reported. A 52-year-old, morbidly obese woman (body mass index [BMI] 1⁄4 35.6 kg/m) without prior abdominal surgery or gastrointestinal diseases was referred for PEG after tracheostomy for prolonged ventilator-dependent respiratory failure after admission for diabetic ketoacidosis. Before this admission, she had refused referral for bariatric surgery for her morbid obesity associated with diabetes mellitus and hypertension. Esophagogastroduoderoscopy (EGD) during PEG revealed no gastrointestinal abnormalities. The PEG site was identified in the distal gastric body by transillumination and manual external pressure. PEG was performed conventionally by passing a catheter through abdominal/gastric walls into gastric lumen, passing a guidewire through the catheter, grasping the guidewire by endoscopic snare, and pulling the guidewire outside the mouth. A 20 French PEG tube (EndoVive Standard PEG kit, Boston Scientific, Spencer, IN) was tied to the guidewire and pulled through the mouth, into gastric lumen and through the gastric wall, but became stuck in the thick abdominal wall fat. The PEG tube could not be delivered anterograde through the skin, despite an adequately-sized skin incision, using multiple attempts at

Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis

Local recurrence has been observed after endoscopic mucosal resection (EMR) of nonpedunculated colorectal lesions. The indications for follow-up colonoscopy and the optimal time interval are currently unclear. The aims of this systematic review were to assess the frequency of local recurrence after EMR, to identify risk factors for recurrence, and to provide follow-up recommendations. A literature search was performed in PubMed, EMBASE, and the Cochrane Library. EMR was defined as endoscopic snare resection after submucosal fluid injection for removal of nonpedunculated adenomas and early carcinomas. Local recurrence was subdivided into early recurrence (detected at the first follow-up colonoscopy) and late recurrence (detected after ≥ 1 previous normal colonoscopy). A random effects meta-analysis was performed to calculate the pooled estimate of risk of recurrence. A total of 33 studies were included. The mean recurrence risk after EMR was 15 % (95 % confidence interval [CI] 12 % - 19 %). Recurrence risk was higher after piecemeal resection (20 %; 95 %CI 16 % - 25 %) than after en bloc resection (3 %; 95 %CI 2 % - 5 %; P < 0.0001). In 15 studies that differentiated between early and late recurrences, 152/173 recurrences (88 %) occurred early. In four studies with follow-up at 3, 6, and ≥ 12 months, 19/25 (76 %) recurrences were detected at 3 months, increasing to 24 (96 %) at 6 months. In multivariable analysis, only piecemeal resection was associated with recurrence (3 of 3 studies). Local recurrence after EMR of nonpedunculated colorectal lesions occurs in 3 % of en bloc resections and 20 % of piecemeal resections. Piecemeal resection was the only independent risk factor for recurrence. As more than 90 % of recurrences are detected at 6 months after EMR, we propose that 6 months is the optimal initial follow-up interval.

Endosonographic preoperative evaluation for tumors of the ampulla of vater using endoscopic ultrasonography and intraductal ultrasonography.

Background/AimsIn recent years, endoscopic snare papillectomy has been performed to treat tumors of the ampulla of Vater. This procedure requires accurate preoperative evaluation. In this study, we diagnosed the focal extension of such tumors by using endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS), and examined the indications for endoscopic snare papillectomy.MethodsThe subjects were 48 patients with a papillary tumor (13 patients, surgical resection; 35 patients, endoscopic snare papillectomy) who were evaluated preoperatively with EUS and IDUS. The tumor-node-metastasis classification was used for the endosonographic evaluation and pathological diagnosis of these tumors.ResultsThe diagnostic accuracy of EUS was 97% for diagnosing adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 50% for pT3-4 tumors, for an overall accuracy of 85% for T-staging. The diagnostic accuracy of IDUS was 94% for adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 100% for pT3-4 tumors, for an overall accuracy of 80% for T-staging.ConclusionsEUS and IDUS are highly capable of evaluating tumors of the ampulla of Vater preoperatively. However, these techniques are not sufficient for evaluating the focal extension of carcinomas preoperatively. Currently, endoscopic snare papillectomy is adequate for treating adenomas and pTis tumors.

Proximal migration of a 5 French pancreatic stent during bile stone extraction: A successful retrieval using mini-snare

Pancreatic stents are used for a variety of conditions during therapeutic endoscopic retrograde cholangio pancreatography (ERCP). Pancreatic duct stenting reduces the incidence of post-ERCP pancreatitis and facilitate bilitary cannulation in difficult cases. Proximal migration of a pancreatic stent during bile duct stone extraction is an infrequent event, but its management can be technically challenging. We present a case that a double flanged pancreatic stent (5 French (Fr), 5 cm) was placed to facilitate the bilitary cannulation during the bile duct stone extraction. The pancreatic duct stent migrated into the proximal pancreas duct at the end of the bile duct stone clearance. After two unsuccessful attempts to remove the impacted stent with a balloon catheter and forceps, wire-guided endoscopic snare retrieval was conducted. Firstly, a guide wire was placed in the pancreatic duct and a soft mini-snare was passed over the guide wire. Then, the mini-snare was advanced into the proximal pancreatic duct over the guide wire and the proximally migrated stent was removed successfully with the mini-snare. Wire-guided endoscopic snare retrieval of proximally migrated pancreatic stents is safe and effective. The successful case of the retrieval with mini-snare provides another option for proximal migration retrieval of pancreatic stent retrieval. Further studies are needed to confirm its effectiveness and elucidate its associated complications.

Pyogenic Granuloma of the Ampulla of Vater

BackgroundPyogenic granuloma (PG), also called lobular capillary hemangioma, is a benign vascular proliferation in skin or oral mucosa after local trauma or irritation. PG is rarely reported in the gastrointestinal (GI) tract. Patient and methodsA sixty-three-year-old woman presented with recurrrent melena and anemia. 1 cm Erythematous semi-pedunculated polypoid lesion was seen on the ampulla of Vater. The mucosal patterns were not suggestive of adenoma or that of an invasive lesion. The polypoid lesion was completely removed en bloc using an endoscopic snare with coagulation current. Immediate post-polypectomy pulsatile bleeding developed and hemostasis was achieved with endoclip application without pre-injection. ResultsPathology showed ampullary PG. To date, the patient has not developed further GI bleeding and her anemia resolved. ConclusionsTo the best of our knowledge, this is the first reported case of ampullary PG. In the medical literature, less than two dozen cases of PG are reported in the esophagus, stomach, small bowel, and colon. These patients usually present with gross or occult GI bleeding and anemia. GI PG can be curatively treated with endoscopic polypectomy or surgical resection.

Successful non-operative management of left atrioesophageal fistula following catheter ablation

Atrioesophageal fistula (AEF) is a potentially lethal complication of catheter radiofrequency ablation for atrial fibrillation. A 49-year-old man with paroxysmal atrial fibrillation who underwent catheter ablation around the pulmonary vein was admitted 31days after the procedure, suffering seizures and fever. Magnetic resonance imaging of the brain showed ischemia and multiple lesions of acute infarction in the right occipital lobe of the cerebrum. Computed tomography (CT) of the chest showed a small accumulation of air between the posterior left atrium and the esophagus, suggesting an AEF. Endoscopic snaring of the esophageal mucosa, repeated a few times, supported by nil by mouth and antibiotic therapy, resulted in improvement of his condition with no recurrence of symptoms. Subsequent chest CT scans confirmed disappearance of the leaked air and the patient was discharged home 45days after admission with no neurological compromise.

Thinking Out of the Box: Pica-related Foreign Body Ingestion as a Source of GI Bleed

Purpose: A 47-year-old male with a history of CVA, cognitive impairment, and pica presented with 2 days of 3-4 large bloody bowel movements. Exam: Pale; tachycardic, HR 116, BP 100/60; abdomen nondistended, non- tender, normal bowel sounds; bright red blood clots per rectum. Neurological: Awake, but neither alert nor oriented; non-verbal; left cranial nerve III palsy. Patient witnessed to ingest paper and other objects within reach in the emergency room. Labs: BUN 74 mg/dL, Cr 3.18 mg/dL. WBC 14.1, Hb 8.8 g/dL, Hct 26.1%, MCV 91.9 fL, INR 1.10. The patient was admitted to intensive care for active hematochezia and borderline hemodynamic instability. Nasogastric tube placement and endoscopy ruled out upper gastrointestinal tract as source of bleed. Colonoscopy revealed a toothpick lodged in the colon with surrounding edema and mild bleeding, which was removed via endoscopic snare. Follow-up abdominal films were negative for additional foreign bodies. Post toothpick retrieval, hemoglobin remained stable; no further bloody bowel movements were noted. Gastrostomy tube was inserted and the patient was transferred to a supervised facility. Discussion: The majority of ingested foreign bodies pass through the GI tract without medical or surgical consequences. However, sharp objects such as toothpicks, which account for 9% of foreign bodies ingested, are associated with high risk of complications such as perforation, fistula formation and bleeding. Adults who ingest such foreign objects usually have a psychiatric disorder, mental retardation, or substance abuse which makes obtaining history and eventual diagnosis challenging. Early diagnosis and retrieval of foreign objects are imperative, especially in patients with perforation, which is associated with high morbidity rate. Initial diagnostic evaluation includes radiography, which is only useful if the ingested object is radioopaque. Endoscopy, which can be diagnostic and therapeutic for visualization, and extraction with a polypectomy snare should be attempted prior to surgical intervention. If the cause of uncontrolled bleeding is not elucidated with colonoscopy, definitive diagnosis may be made via laparotomy, and is indicated in peritonitis, abscess, and fistula formation as well. The management of GIB secondary to foreign object ingestion is similar to GIB of other etiologies, except in the need for retrieval of the culprit foreign body. Fluid and blood product resuscitation is indicated for hemodynamically unstable patients. In conclusion, in patients with intractable bleeding, it is important to consider foreign body ingestion as a cause of GIB, especially in patients who have a propensity to ingest non-nutritive substances, as seen in patients with pica.

Management after endoscopic snare papillectomy for ampullary adenomas.

This study was designed to investigate clinicopathological features of patients who underwent endoscopic snare papillectomy (ESP) and to suggest how to manage patients after the procedure according to the pathological findings. Seventy-nine patients underwent ESP for ampullary tumors in 7 tertiary medical centers in Korea. We retrospectively reviewed the medical records of each patient and analyzed the data. Complete resection and complication rates of ESP were 76% and 21.7%, respectively; and pancreatitis rate was 11.5%. ESP-related mortality rate was 2.5% (n=2; 1 perforation and 1 pancreatitis). According to the pathological findings, endoscopic management was performed in 62/65 (95.4%) of low grade dysplasia (LGD) and 9/14 (64.3%) of high grade dysplasia (HGD)/cancer on pre-ESP; in 57/62 (92.0%) of LGD and 13/16 (81.3%) of HGD/cancer on ESP; and in 11/13(84.7%) of LGD and 0/6(0%) of HGD/cancer on follow-up biopsy. The rates of incomplete resection according to the pre-ESP pathological findings were 18.4% (12/65) in the LGD group and 50% (7/14) in the HGD/cancer group (p=0.033). HGD or cancer required surgical management. Moreover, pre-procedural HGD/cancer was associated with a high rate of incomplete resection after ESP. Therefore, if the pre-ESP pathological results revealed HGD/cancer, a careful endoscopic follow-up with imaging study or an early surgical intervention should be considered.

Usefulness of pancreatic duct wire-guided endoscopic papillectomy for ampullary adenoma for preventing post-procedure pancreatitis

After endoscopic papillectomy, pancreatic duct stenting is important in preventing pancreatitis, but duct cannulation can be difficult following conventional snare resection. Pancreatic duct wire-guided endoscopic snaring before resection can reduce the post-procedure stenting failure rate. We evaluated the usefulness of this approach. Pancreatic duct wire-guided endoscopic papillectomy was performed in 72 patients with ampullary adenoma. The snare loop was passed over a guide wire inserted into the pancreatic duct. After resection, a pancreatic stent was immediately placed along or alongside the guide wire. Pancreatic duct stenting was successful in all patients after endoscopic papillectomy. Post-procedure pancreatitis occurred in 6/72 (8 %), but was mild and resolved with conservative treatment. Complete endoscopic resection of ampullary adenoma was achieved in 65/72 (90 %), with en bloc resection in 60/72 (83 %). There was no procedure-associated mortality. Follow-up (mean 23.7 months) showed recurrence in 5/65 (8 %) who had undergone complete resection. Pancreatic duct wire-guided endoscopic snare papillectomy for ampullary adenoma effectively facilitated pancreatic duct stenting to prevent severe post-procedure pancreatitis.

A Gangliocytic Paraganglioma of the Ampulla of Vater Treated by Endoscopic Snare Papillectomy

A Gangliocytic Paraganglioma of the Ampulla of Vater Treated by Endoscopic Snare Papillectomy

Prophylactic pancreatic duct stent placement after endoscopic snare papillectomy of duodenal major papillary tumors; prospective, randomized study, preliminary report

Prophylactic pancreatic duct stent placement after endoscopic snare papillectomy of duodenal major papillary tumors; prospective, randomized study, preliminary report

Peutz–Jeghers Syndrome in Capsule Endoscopy and Balloon Enteroscopy

Peutz–Jeghers syndrome (PJS) is a rare autosomal-dominant inherited disorder characterized by gastrointestinal hamartomas, mucocutaneous pigmentation, and an elevated cancer risk. Moreover, intussusception risk may be as high as 50% at the age of 20 years and is caused by large polyps. There is some evidence that endoscopic surveillance of PJS patients with removal of small intestinal polyps with a diameter of more than 15 mm efficiently prevents intussusceptions. In recent years, capsule endoscopy (CE) has largely replaced small-bowel radiography techniques to screen for small-bowel polyps. Magnetic resonance imaging may be equally efficient as CE for screening of large polyps. Balloon enteroscopy may be used for endoscopic snare resection of polyps. This article is part of an expert video encyclopedia.

Efficacy and Safety of Endoscopic Treatment for Nonampullary Sporadic Duodenal Adenomas

Nonampullary sporadic duodenal adenomas (NSDAs) are uncommon mucosal neoplasms with malignant potential. Recently, endoscopic treatment is used for NSDA with increasing frequency. This study therefore aimed to evaluate the efficacy and safety of endoscopic treatment for NSDA. A total of 36 NSDAs in 35 consecutive patients were endoscopically eradicated at Samsung Medical Center between October 1994 and May 2011. Data on patient demographics, tumor characteristics, and endoscopic treatment outcomes were obtained and retrospectively analyzed. Of all patients, 19 (52.8 %) were male. The mean age was 56.0 ± 12.2 (SD) years. Of the 36 NSDAs, 23 lesions were removed by endoscopic resection (ER) including endoscopic mucosal resection (EMR, n = 20) and snare polypectomy (n = 3). In the 23 cases treated with ER, en bloc resection was achieved in 20 (87.0 %). All cases undergoing en bloc resection showed tumor-free resection margins. Thirteen lesions were ablated by argon plasma coagulation (APC). During EMR, bleeding occurred in two cases and perforation occurred in one case. One patient bled during APC. All complications were successfully managed with endoscopic treatment without surgical intervention. During a median follow-up period of 11.4 months (range, 1.8-182.4 months), local recurrence occurred in one patient treated with APC (1/10, 10.0 %). Among patients undergoing ER, no local recurrence occurred but one patient treated with EMR experienced metachronous recurrence. Endoscopic treatment, including EMR, snare polypectomy, and APC, was an effective and safe treatment for NSDA. Further multi-center large prospective studies are warranted to establish appropriate treatment guidelines for NSDA.

Combined laparoscopic and endoscopic excision of a gastric gist

We read with interest the article by K. De Vogelaere, Laparoscopic resection of gastric gastrointestinal stromal tumors (GIST) is safe and effective, irrespective of tumor size, published in Surgical Endoscopy 2012;26:2339–2345. We agree with the authors that the laparoscopic approach can be safely and effectively used to remove gastric stromal tumors irrespective of tumor size. Data from the literature show that the long-term results of the laparoscopic procedure are comparable with those reported after traditional open resection of gastric GIST [1–6]. Concerning the technique described by the authors, we think that for tumor located in the anterior wall, the wedge resection is the best technique to be used. For tumors located in the posterior wall, the technique described in the article is a good option for large tumors. For endophitic small tumors of the posterior stomach wall, however, another laparoscopic approach can be used. We have experienced and published an endoscopic–laparoscopic approach that allowed us to perform a mini-invasive surgery for tumors smaller than 2 cm in diameter located in the posterior wall of the stomach. By our proposed technique, laparoscopic removal of GIST was performed also for a patient with a tumor located close to the esophagogastric junction, which the authors ruled out in their series, probably because these tumors are technically challenging with the laparoscopic approach they reported. The technique we have published was performed using two 5-mm radially expandable trocars inserted through the abdominal and gastric walls to have very small incisions in the gastric wall. An endoscopic polipectomy snare introduced per mouth was maneuvered by an endoscopist, who grasped and tractioned the gastric iuxtacardial lesion. A harmonic scalpel device inserted through the 5-mm laparoscopic trocar was used to remove the gastric tumor with a submucosal resection. The resection of the lesion was accomplished thanks to the traction made by the endoscopist through the polipectomy snare, which allowed an excellent exposure of the dissection site. The specimen then was pulled away from the mouth after its introduction into a small plastic bag. After withdrawal of the expandable trocars, the gastric holes were closed with monofilament nonabsorbable sutures. A nasogastric tube was left in place for 2 days. The postoperative phase was uneventful. This laparoscopic–endoscopic technique made possible a complete resection of the submucosal GIST, which otherwise could have been more challenging with marked intraoperative risk of complications (e.g., perforation), considering the iuxtacardial location of the tumor. Our technique allows all the advantages of the laparoscopic surgery, avoids the gastrotomy, and at the same time satisfies the principles of oncologic surgery. In addition, GIST located in the iuxtacardial region may be resected safely and with less morbidity than with other laparoscopic or open approaches.

Can Endoscopic Submucosal Dissection Technique Be an Alternative Treatment Option for a Difficult Giant (≥30 mm) Pedunculated Colorectal Polyp?

Snare polypectomy of a giant pedunculated colorectal polyp is sometimes technically demanding, and, therefore, piecemeal resection is inevitable, despite the relative risk of invasive cancer and postpolypectomy bleeding. The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection in comparison with conventional snare polypectomy for giant pedunculated polyps We retrospectively reviewed the clinical outcomes and complications of endoscopic polypectomy for giant pedunculated polyps from October 2006 to November 2011. All the patients who underwent endoscopic submucosal dissection (n = 23) or snare polypectomy (n = 20) for pedunculated polyps ≥ 3 cm were enrolled consecutively. In the case of a giant pedunculated polyp with 1) poor visualization of the stalk, 2) technical difficulties in snare positioning for en bloc resection, or 3) need for trimming of the head, we did not attempt piecemeal snare polypectomy, and we performed endoscopic submucosal dissection instead. (These were arbitrarily defined as "difficult" giant pedunculated polyps.) Data on the patient's demography, endoscopic and histopathologic findings, clinical outcomes, and complications were analyzed. Among the 43 giant pedunculated polyps, 23 polyps were defined as "difficult" polyps and were removed with endoscopic submucosal dissection. Subpedunculated (stalk <1 cm) type was more common in the "difficult" polyp group (p = 0.01). The overall incidence of cancer was 18.6% (8/43). En bloc resection rates were 100% (23/23) in the endoscopic submucosal dissection group and 90% (18/20) in the snare polypectomy group. The procedure times of snare polypectomy and endoscopic submucosal dissection group did not differ significantly (41.7 ± 13.7 minutes vs 44.9 ± 35.6 minutes, p = 0.70). Postpolypectomy bleeding was noted in 1 case (4.3%) in the endoscopic submucosal dissection group and in 3 cases (15%) in the snare polypectomy group. Endoscopic submucosal dissection, as well as the snare polypectomy for giant pedunculated polyps, appeared to be effective without major complications and can be an alternative option to achieve en bloc resection, particularly for difficult cases, such as giant subpedunculated polyps.

Mo1447 Prophylactic Pancreatic Duct Stent Placement After Endoscopic SNARE Papillectomy of Duodenal Major Papillary Tumors; Prospective, Randomized Study, Preliminary Report

Mo1447 Prophylactic Pancreatic Duct Stent Placement After Endoscopic SNARE Papillectomy of Duodenal Major Papillary Tumors; Prospective, Randomized Study, Preliminary Report

Mo1448 Utility of the Short Single-Balloon Enteroscope (Short-SBE) to Perform Therapeutic ERCP in Patients With Surgically Altered Anatomy

Digestive Disease Center, Soonchunhyang University, College of Medicine, Seoul, Republic of Korea Introduction Endoscopic snare papillectomy (ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, post-ESP pancreatitis is a common and serious complication. Since one prospective randomized controlled trial showed that pancreatic duct stent placement reduced post-ESP pancreatitis, almost physicians have tried to place pancreatic duct stent after EPS. Aims and Methods: The aim of this prospective, randomized trial is to compare the rates of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic duct stent placement. Consecutive patients who were to undergo ESP were randomized to pancreatic duct stent placement group (stent group) after endoscopic snare papillectomy or to no pancreatic duct stent placement group (no stent group). Result The groups were similar with regard to patient demographics. In total, 24 patients were enrolled. Fourteen patients were assigned to the stent group and 10 patients to the no stent group. Post-ESP pancreatitis developed in 5 patients (20.8 %, 5/24), 3 cases occurred in the stent group and 2 case occurred in the no stent group. One case of moderate grade pancreatitis developed in the stent group. The overall incidence of post-EPS pancreatitis was 21.4% (3/14) in the stent group and 20.0 % (2/10) in the no stent group (p 0.932). The rates of hyperamylasemia were 14.3% (2/14) in the stent group and 0.0% (0/10) in the no stent group (p 0.493). There was no significant difference in other complications (ex, bleeding and perforation etc.) between the groups. Conclusion: There was no significant difference in the occurrence of post-ESP pancreatitis and hyperamylasemia between patients with and without pancreatic duct stent placement after endoscopic snare papillectomy. Our findings suggest that a pancreatic duct stent placement after ESP did not confer a protective effect in reducing post-ESP pancreatitis. Therefore, more large scaled prospective, randomized controlled studies regarding the effectiveness of pancreatic duct stent placement to reduce the incidence rates of post-ESP pancreatitis are needed.

Endoscopic snare papillectomy: a possible radical treatment for a subgroup of T1 ampullary adenocarcinomas

Pancreaticoduodenectomy is the standard care for invasive ampullary adenocarcinomas. However, endoscopic snare papillectomy (ESP) might play a curative role in very selected patients. We studied a series of 15 patients with T1 ampullary adenocarcinoma who were treated by ESP alone and followed up for a mean of 29.6 ± 21.9 months (range 8 - 81 months). ESP was curative for eight patients (57.1 %). No tumor-related death was observed in patients with a cancer infiltration depth of ≤ 4 mm. According to this preliminary experience, we suggest that this measurable variable threshold should be considered as a possible basis for future large-scale studies.

Systematic pancreatic stenting after endoscopic snare papillectomy may reduce the risk of postinterventional pancreatitis

Pancreatitis is the most feared complication of endoscopic papillectomy (EP). Prevention by pancreatic duct stenting following EP has been advocated but not proven by a randomized trial. The purpose of the present retrospective review is to compare a period of systematic stenting with the period before in which stents were placed selectively. A total of 107 patients undergoing EP from February 1999 to December 2009 were retrospectively reviewed. After an initial period with selective stenting (dilated duct, previous pancreatitis) between 1999 and 2002 (n = 24, group 1), stents were placed routinely after EP unless pancreas divisum was diagnosed (2002-2009; n = 83, group 2) to reduce postpapillectomy acute pancreatitis (PAP). PAP rates defined by Consensus Criteria were compared in the two periods. Five patients in group 1 were selected to receive a pancreatic stent (21%); in group 2 stenting was successful in 75 of 78 patients (success rate 96%) without pancreas divisum (n = 5). Overall, PAP occurred in 11% of patients. PAP rate was significantly reduced after introduction of systematic pancreatic stenting (5 vs 25%; p = 0.01) and occurred less often in stented than in nonstented patients: (5% (4/80) vs 27% (6/22), p = 0.0019). PAP also occurred in one of five patients with pancreas divisum. Selective stenting of patients also was an independent risk factor for PAP (OR 13, p = 0.001) in a multivariate analysis. Attempts at systematic stenting after EP pancreatic stenting appears to prevent PAP. Results should be corroborated by a randomized trial.

Gastrojejunostomy stomal polyp presenting as stomal obstruction and its endoscopic management

ABSTRACTWe report the case of a 42-year-old male who presented with postprandial, non bilious, non projectile vomiting for 4 months. Patient underwent gastrojejunostomy 10 years back for post corrosive gastric outlet obstruction. General physical and systemic examinations were within normal limits. Routine laboratory investigations including complete blood count, liver and renal function tests were also within normal limits. Upper gastrointestinal endoscopy revealed solitary pedunculated polyp at the gastrojejunostomy site almost completely obstructing the lumen at the gastrrojejunostomy site. Endoscopic snare polypectomy of the gastrojejunostomy site polyp was done. Histopathological examination of the polyp was suggestive of hyperplastic polyp. After snare polypectomy patient became asymptomatic and is doing well at 6 months of follow up. (J Dig Endosc 2013;4(2):42-43)