Pediatric Gastroscope Research Articles

A169 A RARE MANIFESTATION OF ENTERITIS DUE TO IMMUNE CHECKPOINT INHIBITOR: CASE REPORT OF PYLORIC STRICTURE

Abstract Background Immune checkpoint inhibitors (ICI) are immunomodulatory antibodies used to enhance the immune response against tumor cells that have revolutionized the treatment of various malignancies. ICIs pose a risk of immune-related adverse events in various organs including the gastrointestinal tract, with diarrhea and colitis being most common. ICIs can rarely cause involvement of the upper gastrointestinal tract, with case reports of gastritis, duodenitis, and esophagitis. There are very rare reports of strictures caused by ICIs, more frequently in the lower gastrointestinal tract, and only a few reports in the esophagus or duodenum. Aims We report a rare case of an upper gastrointestinal stricture due to ICI at the pylorus. Methods Case report. Results A 38-year-old woman with breast cancer on ICI pembrolizumab presented with several weeks of nausea and early satiety. She had started pembrolizumab 8 months prior, underwent neoadjuvant chemotherapy and mastectomy months ago, and completed radiation 6 weeks earlier. She also described nocturnal reflux and heartburn, but no vomiting, weight loss, or other gastrointestinal symptoms. Her examination was normal and recent bloodwork only showed a mild normocytic anemia. EGD (esophagogastroduodenoscopy) showed friable circumferential ulceration of the distal antrum with surrounding erythema and luminal narrowing from the pyloric channel to duodenum. 1-centimetre gastroscope was not passable but 4.9-millimetre pediatric gastroscope passed into the duodenum where there were no abnormalities past the duodenal bulb. Pathology showed granulation tissue, fibrinopurulent exudate, and antral mucosa with chronic active inflammation negative for Helicobacter pylori and malignancy. Oncology felt that radiation was too far from the pylorus to be responsible for the findings. High-dose proton pump inhibitor (PPI) and soft diet were recommended with minimal symptomatic improvement. 2 months later, she developed weight loss and repeat EGD showed minimal endoscopic improvement (Figure 1). ICI-related enteritis was suspected and she was started on prednisone 50 mg daily. Her appetite and nausea significantly improved. Steroid taper was planned for 8 weeks. At 3 months, symptoms recurred with prednisone taper. EGD showed only mild improvement of the duodenal stricture. Prednisone dose was increased. On repeat EGD at 7 months, the pylorus was patent with only granular inflammation predominantly in the apex of the duodenal bulb. She tolerated a slower prednisone taper thereafter. Conclusions ICI-related inflammation is common in the lower gastrointestinal tract and can less commonly affect the upper gastrointestinal tract. This is a rare report of upper gastrointestinal stricture and the first report known to us of pyloric stricture caused by ICI. Treatment may be challenging, but was achieved with PPI and high-dose steroids with slow taper. Funding Agencies None

Median effective dose (ED50) of esketamine combined with propofol for children to inhibit response of gastroscope insertion

BackgroundPropofol is the most commonly used drug for procedural sedation during gastroscopy. However, independent use of propofol can lead to increased dosage and additional side effects. Esketamine was found to be exceptional in combination with propofol for painless gastroscopy. No studies have calculated the median effective dose (ED50) of esketamine combined with propofol in pediatric painless gastroscopy. Here, we designed a research to study the ED50 of esketamine combined with propofol using the Dixon and Massey up-and-down sequential method for inhibiting the response of gastroscope insertion.MethodsChildren who met the inclusion and exclusion criteria were included in this study. Propofol and esketamine were used as anesthetics for painless gastroscopy in children. To explore the ED50, the initial propofol dose was set at 3 mg/kg in all children. The first child was given an esketamine dose of 0.1 mg/kg, followed by 30 s of slow bolus injection propofol. If anesthesia induction failed (coughing or body movement of children during gastroscope insertion), the esketamine dose was elevated in the next child, with a interval difference of 0.05 mg/kg. Otherwise, if the anesthesia induction was successful, the next dosage was reduced by 0.05 mg/kg. The study was stopped if nine crossover inflection points were reached. The ED50 of esketamine was calculated using probit regression, and the blood pressure, pulse oxygen saturation, heart rate, recovery time, and side effects were recorded in all children.ResultsA total of 26 children were included in this study. The ED50 of esketamine combined with 3 mg/kg propofol was 0.143 mg/kg (95% CI 0.047–0.398 mg/kg). The total consumption of propofol was 16.04 ± 5.37 mg. The recovery time was 16.38 ± 8.70 min. Adverse effects recorded were delayed awakening in two cases and increased oral secretions of another child during the examination inducing cough and hypoxemia (86% was the lowest).DiscussionThe ED50 of esketamine was 0.143 mg/kg when combined with 3 mg/kg propofol for successful sedation in pediatric gastroscope insertion. This sub-anaesthetic dose of esketamine was safe and efficacious with few complications in pediatric painless gastroscopy.Trial registrationThe study was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn; registration number: ChiCTR2100052830 on 06/11/2021).

Intrapapillary capillary loop abundance on nonmagnified blue laser imaging in esophageal intramural pseudodiverticulosis.

To the Editor: A 61-year-old male patient with critical alcohol consumption presented with progressive dysphagia and several self-resolved bolus impactions. Index endoscopy indicated a high-grade stricture at 22 cm, warranting passage with a pediatric gastroscope, along with small openings consistent with esophageal intramural pseudodiverticulosis (EIPD). In the distal esophagus, a Schatzki ring emerged with additional pseudodiverticulae. The patient underwent esophageal bougienage to 14 mm. Image-enhanced endoscopy before scheduled repeat bougienage was perfomed, highlighting proximal EIPD on linked color imaging (Fig. 1A).1 Furthermore, linked color imaging illustrated diffuse spots correlating with what has been designated as the “faux uni” pattern on white light endoscopy.2 Apart from illustrating active movements with variations of orifice sizes, further characterization using blue laser imaging (BLI) confirmed absent submucosal vessels, while dot-shaped and line-shaped congested intrapapillary capillary loops (IPCL) were clearly appreciated (Fig. 1B). This finding was accentuated in scarred and pseudodiverticula-bearing segments, suggesting EIPD inflammation-driven microvascular alterations (Fig. 1C). Notwithstanding that IPCL changes notably on magnification endoscopy have been reported in other benign esophageal diseases, such as eosinophilic and/or lymphocytic esophagitis (both excluded in this patient), IPCL alterations have never been reported in EIPD nor in any other chronic inflammatory esophageal disorder on nonmagnified conditions (Fig. 1D). Of note, pathology indicating unspecific chronic inflammation did exclude dysplastic changes.Figure 1.: (A) Linked color imaging (LCI) illustrating esophageal intramural pseudodiverticulosis with several small pseudodivertiular openings alongside diffuse so-called “faux uni” spots. (B) Blue laser imaging (BLI) confirmative of absence of submucosal vessels, while dot-shaped and line-shaped congested intrapapillary capillary loops (IPCL) were noted, potentially correlating with type 2 IPLCs (dilation and elongation) on magnified endoscopy. (C, D) This latter abundance in IPCL potentially attributable to inflammation-driven microvascular alterations was concentrated in segments with marked intramural pseudodiverticulosis and clearly discernible under nonmagnification endoscopy.While the concept of IPCLs, relying on magnification image-enhanced endoscopy, has been developed to highlight early squamous cell dysplasia and neoplasia, its potential role in chronic inflammatory esophageal diseases awaits further evolution.3 Albeit not validated for nonenhanced endoscopic assessment, the findings in this patient may suggest IPLC type 2 with uniform dilation and elongation, likewise suggesting a benign condition.4 Conflicts of interest The authors report no conflicts of interest.

S2852 Dislodged Esophageal Stent Extracted via PEG Tube Site: An Uncommon Solution for a Real Life Problem

Introduction: Esophageal stents have been used for management of refractory benign strictures and has risk of stent migration even with endoscopic suturing or clipping techniques. With esophageal stricture present, the retrieval of the migrated stent becomes a dilemma. We present one such case that required retrieval of the migrated stent through a pre-existing percutaneous endoscopic gastrostomy (PEG) tube site. Case Description/Methods: A 62-year-old man with history of supraglottic small cell carcinoma treated with chemo-radiation therapy developed a severe benign esophageal stricture. He had multiple esophageal dilations and steroid injections which failed and eventually treated by esophageal stent placement with stent fixation via endoscopic suturing. He presented with food impaction and esophagogastroduodenoscopy (EGD) found a severe distal esophageal stricture which could only be traversed with a pediatric gastroscope. The previously placed 20mmx80mm fully covered self-expanding metal stent (FCSEMS) had migrated into the stomach (Figure 1a). Exhaustive attempts at endoscopic retrieval past the esophageal stricture was unsuccessful. He had a pre-existing 20Fr PEG tube and the PEG tract was gradually dilated to 15mm. An adult gastroscope was passed through the PEG site and a raptor forceps was used to grab and extract the forceps successfully (Figure 1b-c). A new 24Fr PEG tube was placed. Mild oozing was seen in the tract, otherwise patient tolerated the procedure well. He was referred to discuss surgical options for further treatment of his esophageal stricture. (Figure) Discussion: Esophageal stents are being increasingly utilized in the management of not only malignant strictures, but also benign esophageal disease such as recurrent esophageal strictures, anastomotic leaks, perforations and fistulae. Stent migration may occur frequently in benign disease with risk factors being use of FCSEMS, distal location and previous migration. An unretrieved stent may cause small bowel obstruction. Anchoring stents with endoscopic suturing, and clips may reduce the risk of migration. If unable to be removed endoscopically then a surgical approach will be needed. Luckily, the presence of a mature gastrostomy tract provided an alternate extraction route for our patient. Risks associated with this modality include bleeding, gastrostomy site disruption, gastric perforation and peritonitis. Increased physician awareness of endoscopic options in such a case may obviate the need for surgical intervention.Figure 1.: Endoscopic image of dislodged esophageal stent in stomach (a). Endoscopic image of adult gastroscope passed through PEG site dilated with CRE balloon (b). Image of dislodged esophageal stent retrieved via dilated PEG site (c).

A New Scope of Practice: Adult Pulmonary Aspiration Managed With a Pediatric Gastroscope: A Case Report.

Pulmonary aspiration continues to be a major cause of anesthesia-related mortality. Anesthesiologists are encouraged to perform bronchoscopy to manage aspiration of particulate matter; however, they have limited training and experience in clearing luminal obstructions endoscopically. In our report, an adult with achalasia aspirated during induction for a per-oral endoscopic myotomy (POEM), resulting in desaturation and high airway pressures. Bronchoscopy by the anesthesiologist was ineffective. However, bronchoscopy by the gastroenterologist using a pediatric gastroscope cleared the bronchi of debris and led to immediate clinical improvement. Anesthesiologists, faced with particulate matter aspiration, could consider assistance from a gastrointestinal endoscopist.

S2506 Use of the Pediatric Gastroscope for Endoscopic Decompression of a Right Hydronephrosis Caused by a Peripancreatic Fluid Collection in a Patient With Severe Acute Pancreatitis

Introduction: Peri-pancreatic fluid collections can cause symptoms by compressing adjacent organs. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The treatment of such complication requires drainage of the collection with placement of stents between the cavity and the lumen. Case Description/Methods: A middle-aged man developed gallstone pancreatitis complicated by a large peri-pancreatic fluid collection (pancreatic pseudocyst). Four months later, he developed a right hydronephrosis caused by compression of the right ureter by the fluid collection surrounding it. He therefore underwent EUS guided cyst-gastrostomy with placement of a 20x10mm AXIOS stent and two plastic stents in the direction of the ureteral compression. In a second procedure two weeks later the XP190N pediatric gastroscope was passed through the AXIOS stent into the cavity and into the tract leading to the ureteral compression. This allowed for placement of a wire under fluoroscopic and endoscopic guidance with deployment of two plastic biliary stents. Total decompression of the ureter and resolution of the hydronephrosis ensued. Discussion: The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection, pain, or compression of adjacent organs may require intervention. Treatment may include endoscopic or percutaneous catheter drainage, and later endoscopic or surgical necrosectomy. Endoscopic drainage is now the preferred approach. This case highlights the use of the XP190N pediatric gastroscope to guide deployment of a wire through a narrow fistulous tract inside the peripancreatic cavity; this allows for deployment of stents to decompress the obstruction of the right ureter. Usage of the pediatric gastroscope in this case afforded multiple advantages including enhanced navigation capabilities due to its smaller size and excellent optics; dye was directly flushed trough the channel of the scope, thus affording fluoroscopic guidance. Also, a small snare was used for necrosectomy and removal of debris. Finally, the wire was placed into the desired position for precise stents deployment. The armamentarium of dedicated endoscopic equipment for treatment of peri-pancreatic fluid collections is limited, therefore, the pediatric gastroscope should be kept in mind for use in selected cases.Figure 1.: Upper left: Peripancreatic fluid collection. Upper right: Passage of a pediatric gastroscope through the AXIOS stent with wire placement in the peri-ureteral space. Lower left: Two plastic stent deployed for decompression of the ureteral obstruction. Lower right: Total resolution of the obstruction of the right ureter.

Unusual way of securing the airway using gastroscope and cystoscope as an alternative to fiberoptic intubation

Difficult airway still is one of the dreaded crises in anesthesia. A well-formulated plan with all the necessary equipment should be ready when such situations are anticipated, but unanticipated difficulties can arise, and managing such cases is a nightmare for the anesthesiologist. Most hospitals in the developing countries are not equipped technically with all the modern equipment and gadgets as far as anesthesia is concerned. In a resource-constrained area, the skill and innovative ideas of the anesthesiologist often emerge as an alternative option in dealing with such cases. Here, we describe two cases of difficult intubation by conventional approach, which were managed successfully using a pediatric gastroscope and a flexible cystoscope as an alternative to fiberoptic bronchoscope.

S1981 Beyond SCC: Basaloid Squamous Cell Carcinoma of the Esophagus

INTRODUCTION: Basaloid squamous cell carcinoma (BSCC) is an aggressive and poorly differentiated variant of squamous cell carcinoma that has both basaloid and squamous components. Its first description suggests that the tumor originates from totipotential cells in the basal layer of squamous epithelium. CASE DESCRIPTION/METHODS: A 57-year old African American female with a history of chronic GERD and stroke was referred for 3 months of dysphagia to solids, a weight loss of 30 lbs, and abnormal barium swallow. She denied alcohol use and smoking. Barium swallow from the referring facility showed segmental narrowing and a long irregular distal esophageal stricture. Upper endoscopy revealed a circumferential ulcerated mass at 25 cm up to 32 cm from the incisors, preventing passage of the adult gastroscope. This was exchanged for a pediatric gastroscope. A patch of nodular mucosa with ulceration was seen at 23 cm from the incisors. Pathology showed moderately to poorly differentiated basaloid squamous cell carcinoma. DISCUSSION: BSCC is predominantly seen in the upper aerodigestive tract (nasopharynx, tongue, larynx, trachea), where it can be associated with human papillomavirus (HPV). Esophageal BSCC is very rare, accounting for only 0.068-4.0% of esophageal carcinomas, and its associated with HPV is less certain. Patients with esophageal BSCC are older, have higher proliferative activity, and higher apoptotic indices when compared to typical squamous cell cancer of the esophagus. Like our case, patients with esophageal BSCC often present with dysphagia and weight loss. On endoscopy, deeply invasive, large bulky ulcerated fungating masses are seen. Histologically, BSCC consists of small basaloid cells with oval to round nuclei, pale chromatin, and scant basophilic cytoplasm. The cells are arranged in solid or cribriform lobules with comedo-necrosis. On immunohistochemistry stains, there is poor reactivity for cytokeratin 13 and 14, antibodies that are typical of squamous cell epithelia. Widespread metastases are usually present upon diagnosis. However, if curative resection is possible, the prognosis of patients with esophageal BSCC is similar to that of patients with typical SCC.Figure 1.: Proximal end of the esophageal tumor.Figure 2.: Distal end of the esophageal tumor.

1771 Eosinophilic Esophagitis Presenting With Esophageal Wall Dissection

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated, inflammatory disease with a wide spectrum of presentation from mild dysphagia to food impaction. We describe the presentation and management of a patient whose initial presentation of EoE included the rare complication of esophageal dissection. CASE DESCRIPTION/METHODS: A 30-year old Caucasian male presented to the emergency department after 10 days of dysphagia and odynophagia. His physical exam was normal. Initial laboratory evaluation revealed mildly elevated troponin I and leukocytosis. CT imaging with IV contrast showed an air-fluid level within the distal esophagus. EGD could only be completed with a pediatric gastroscope (5.4-mm) due to severe, diffuse narrowing of the esophagus. The entire esophagus had findings of EoE including edema, furrowing, and circumferential rings. The lumen of the proximal esophagus was 12-15 mm with acute narrowing to 7mm at 27-cm. Most notable was a 1-cm x 2-cm hole at 25-cm which communicated with a fluid-filled, granulation tissue lined space that paralleled the distal esophagus (Figure 1). Biopsies showed >50 Eos/hpf consistent with EoE. The patient was started on broad-spectrum antibiotics, IV proton pump inhibitor therapy, topical steroid and kept NPO. CT imaging with IV and gastrograffin contrast demonstrated a long segment intramural dissection with a double-barreled esophageal lumen (Figure 2). Following consultation with cardiothoracic surgery, endoscopic management was pursued. Endoscopic suturing was not attempted given severe luminal narrowing. The tissue proved too fibrotic for hemostasis clips. A through-the-scope, fully-covered self-expanding esophageal stent (FCSEMS) was deployed across the defect and a feeding tube was inserted. An elemental diet was started. Follow-up imaging showed obliteration of the false lumen by post-procedure day 9 (Figure 3). Repeat EGD one month later showed an intact lumen but with delicate-appearing granulation tissue at the location of the previous hole (Figure 4), thus another FCSEMS was placed and elemental diet was resumed with plans for repeat EGD in 4 weeks. DISCUSSION: Intramural esophageal dissection is a rare, potentially life-threatening complication of EoE which can be medically and endoscopically managed. “The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the United States Air Force, the Department of the Navy, Department of Defense, or the U.S. Government.”

1733 Wonder Neutralization: Esophageal Stents in Caustic Injury

INTRODUCTION: Introduction Common causes for benign esophageal strictures (ES) are post -surgery, caustic ingestions and radiation therapy. Caustic strictures of the gastrointestinal tract can be a challenge to treat even after multiple endoscopic treatments due to its inherent relapsing nature. We report here our experience with self-expandable metallic stents (SEMS) in a patient with corrosive stricture of the esophagus. CASE DESCRIPTION/METHODS: Case A 25-year-old female with 2-year history of refractory ES due to caustic injury presented for endoscopic treatment. Patient had multiple endoscopic dilation attempts in past. Pediatric gastroscope showed esophageal stricture starting at 20 cm from the incisors however it could not traverse through the stricture. Under fluoroscopic guidance a 0.035 in x 260 cm guidewire was placed in the stomach. The proximal end of stricture was occluded by biliary 8.5 mm stone extraction balloon and contrast was injected through balloon catheter under fluoroscopy guidance showing 12 cm long significantly narrowed ES. A 18 mm × 103 mm fully covered esophageal metal stent (FCEMS) was placed under fluoroscopic guidance keeping the distal end of the stent above the gastroesophageal junction. Four days later, follow up EGD showed previously placed FCEMS was patent and widely open. The distal end of the stent was at 27cm and GEJ was at 35cm from entry point. Under fluoroscopic imaging and wire guidance another FCEMS (18 mm × 153 mm) was placed successfully to treat the left-over portion of the stricture below the previously placed stent. The second stent was deployed with in the first stent with its distal end at GEJ. Post stent placement, endoscopic and fluoroscopic imaging’s were satisfactory. At 2 weeks follow up, patient revealed significant improvement in her symptoms and ability to tolerate soft diet. DISCUSSION: Discussion ES secondary to caustic injury tend to require multiple dilation procedures, multiple hospitalizations with associated risks and cost, affecting patient’s quality of life. There is a need for novel therapeutic strategies that will provide a long-term solution. Our case highlights the growing interest and utility of multiple FCEMS in the treatment of severe and long ES. The deployment of multiple FCEMSs in our patient with long history of ES related dysphagia dramatically improved her symptoms and patency of esophagus.

Cervical Esophageal Perforation during Gastroscopy in Adults:Case Report - Report of Two Cases

Cervical esophageal perforation is rare and associated with a high morbidity and mortality >20% if misdiagnosed. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract. We describe two cases of cervical esophageal perforations during negotiating the cricopharynx. Both patients had malignant stricture in mid and lower esophagus, respectively, and developed iatrogenic perforation during palliative metallic stenting – one of the two by a pediatric gastroscope. Both the patients were diagnosed as having esophageal perforation in the first 6 h after procedure and successfully managed with medical management. Patients with small perforations and minimal extraesophageal involvement may be managed with nonoperative treatment.

Temporary EUS-Guided Hepaticogastrostomy With Electrohydraulic Shockwave Lithotripsy for Management of Altered Anatomy Choledocholithiasis: 2017 Presidential Poster Award

ERCP is challenging in patients with gastric bypass due to altered anatomy. We report a case of symptomatic choledocholithiasis requiring temporary placement of EUS-guided hepaticogastrostomy with a fully covered metal stent and electrohydraulic lithotripsy. This is a 71-year-old female with a history of multiple abdominal surgeries, including Roux-en-Y gastric bypass with Fobi pouch, appendectomy, cholecystectomy, and adhesiolysis who presented with 4 months right upper quadrant abdominal pain and a 1 week hx of jaundice. MRCP revealed intra and extrahepatic ductal dilatation with a 1.1cm obstructing stone in a tortuous CBD. A double balloon enteroscopy assisted ERCP was considered but initial endoscopy revealed a stricture at the GJ anastomosis thought to be related to complications from the fobi pouch. Given the complex anatomy, surgery was consulted to coordinate a laparoscopic-assisted ERCP. However, due to her extensive surgical history and multiple repeated open abdominal surgeries, they strongly advocated for a non-surgical approach. Interventional radiology was then consulted for a percutaneous approach, but explained that they would require multiple procedures for percutaneous tract dilation before the point that stone extraction could be attempted. As a result, an EUS guided approach was performed via creation of a hepaticogastrostomy. The procedure was performed by puncturing a dilated radical of the left intrahepatic system with a 19G FNA needle. A 0.035mm guidewire was passed antegrade down into the tortuous bile duct. A 6mm balloon catheter was passed into the bile duct and used to dilate the tract. A 10mmx8cm fully covered metal biliary stent was placed from the gastric pouch to the intrahepatic ducts with confirmation made with cholangiogram. A pediatric gastroscope was then passed through the stent and eventually into the distal CBD where the stone was seen. Under direct visualization saline assisted electrohydraulic shockwave lithotripsy was performed to fragment the stone. The stone pieces were pushed and flushed through the ampulla. Two months later, patient underwent repeat EGD. The stent was subsequently removed without any complications and today she continues to do well. This case illustrates that lithotripsy through a temporarily placed EUS-guided hepaticogastrostomy may be safe and effective approach for altered anatomy patients who cannot undergo more traditional approaches for management of complex choledocholithiasis.Figure: MRCP Showing 10.4mm CBD Stone.Figure. CBD: Stone Before Lithotripsy.Figure. CBD: Stone After Lithotripsy.

A Novel Endoscopic Technique to Diagnose Gastric Cancer in Excluded Stomach after Roux-en-Y Gastric Bypass

Access to the bypassed portion of the stomach after Roux-en-Y gastric bypass remains a challenge. We present a case of 64-year-old woman who presented with gastric outlet obstruction. We used a novel endoscopic technique to access the bypassed stomach by creating a jejunogastrostomy using a specialized stent, which allowed the insertion of a pediatric gastroscope to examine the bypassed portion of the stomach. Stomach biopsies revealed poorly differentiated adenocarcinoma with signet cell features.

Intraductal Fenestration of Biliary Metal Stents Using Argon Plasma to Facilitate Bilateral Hilar Stenting

Background: When placed across the biliary confluence, uncovered self-expanding metal stents (SEMS) may impede access to the contralateral intrahepatic ducts. In particular it is difficult to place additional plastic or metal stents across multiple adjacent cells of a hilar SEMS. Argon plasma has been used to trim biliary SEMS. However, the use of argon plasma for intraductal fenestration of biliary metal stents has not been described. Case report: A 38-year-old man with hilar cholanogiocarcinoma presented with cholangitis and right lobe liver abscesses. He had been previously treated with placement of multiple closed-cell, uncovered SEMS extending from duodenum to left hepatic duct. A percutaneous transhepatic catheter was placed into an abscess cavity, which communicated with right hepatic ducts. Subsequently a percutaneous transhepatic guidewire was advanced through the hilar SEMS interstices and into the duodenum. During ERCP a temporary plastic stent was placed into the left main duct for venting of argon gas. The percutaneous guidewire was then grasped with a snare and brought out via the mouth. Choledochoscopy was then performed using a pediatric gastroscope which was advanced over the guidewire into the existing SEMS up to the level of the hilum. Metal struts of the embedded SEMS were seen crisscrossing over the right duct orifice. The visible SEMS wires were fenestrated using a pediatric argon plasma coagulation probe at power of 80 W and flow 0.3 L/min, and further unwoven with a pediatric biopsy forceps. Argon gas vented from the percutaneous biliary sheath as well as the left hepatic duct stent. Subsequently plastic stents were placed via a duodenoscope into 4 separate right intrahepatic ducts, each of which was accessed across adjacent interstices of the SEMS. The patient had rapid clinical improvement and a follow-up computed tomography at 4 weeks showed resolution of liver abscesses. Conclusion: Fenestration of hilar biliary SEMS using argon plasma under direct endoscopic visualization can facilitate bilateral hilar stent placement in patients with complex malignant obstruction of the central intrahepatic ducts. Argon plasma has been used to trim biliary and rectal SEMS. The use of argon plasma for endoscopic fenestration of duodenal stents to facilitate ERCP has also been reported. Our case extends the application of this technique by describing intraductal fenestration of an indwelling biliary SEMS to accomplish bilateral hilar stenting.

Otolaryngologist-assisted fluoroscopic-guided nasogastric tube placement in the postoperative laryngectomy patient.

Laryngoscope, 124:916–920, 2014

Pregnancy in homozygous familial hypercholesterolemia – a successful case

Pregnancy in homozygous familial hypercholesterolemia – a successful case

Evaluation of Endoscopic Full-Thickness Plication on Anti-Reflux Valve Competency

We sought to investigate the efficacy of endoscopically created, full-thickness plications on the competency of the anti-reflux barrier when placed at different positions on the stomach adjacent to the gastroesophageal junction. Explanted human cadaver stomachs and esophagi were used. An endoscopic plication system (Plicator, NDO Surgical, Mansfield, Massachusetts) was then fitted over a pediatric gastroscope and passed through the esophagus into the stomach. A full-thickness plication implant was then deployed at 1 of 3 positions (fundus, anterior, and between the anterior and the lesser curvature) on the explanted stomach within 1 cm of the gastroesophageal junction. Intragastric pressure was measured before and after plication at the time of visible reflux from the esophagus (reflux threshold) using a water-perfused manometer. Five explanted stomachs were used. The mean reflux threshold before plication (baseline) was 1.7 mm Hg. A single plication at each position resulted universally in a significantly increased reflux threshold over the baseline value (p < 0.006). The greatest reflux threshold was observed when plication was performed on the anterior wall of the stomach, although this reflux pressure did not achieve statistical significance over the other 2 positions. A second plication performed adjacent to the initial plication at the fundus (n = 2) and anterior (n = 2) positions did increase reflux threshold; however, this increase also failed to achieve statistical significance. These results suggest that an endoscopic, full-thickness plication system can inhibit gastroesophageal reflux effectively in an explanted stomach model. Although anterior plication resulted in the greatest intragastric pressure at reflux, it was not significantly different from intragastric pressure recorded at the other plication positions. A second plication adjacent to the first showed incremental effect, but larger studies are warranted to understand its clinical significance.

Extended application of the Olympus linear echobronchovideoscope (BF-UC160F-OL8) in the upper gastrointestinal tract - Study on visualization of the celiac axis and EUS-FNA of lymph nodes beyond the stenosis in esophageal cancers

Introduction: Malignant lymph nodes (LN) in esophageal cancer (EC) necessitate neoadjuvant chemo- and/or radiotherapy for curative surgery. However, cytological diagnosis is often impossible due to inability to perform LN EUS-FNA beyond non-traversable stenosis with linear echoendoscopes (ø 11.8mm). Aim: To study the ability of the linear echobronchovideoscope (CEBUS) to visualize the celiac axis (CA) and passage through stenotic EC for CEBUS-guided FNA of LN. Method: Consecutive patients with no surgical history who underwent EUS for non-EC indications were recruited for the CA study (Group A); patients with stenotic EC for the EUS-FNA study (Group B). (1) CEBUS (ø 6.2mm) was inserted transorally up to 50cm to visualize CA. (2) For patients with stenotic EC, a pediatric gastroscope was first used to place a 0.035“ guidewire. A 5F Teflon catheter was inserted through the working channel of CEBUS to enable retrograde insertion of guidewire through CEBUS. After the guidewire appeared, CEBUS was then carefully advanced over the guidewire through the stenosis. (3) EUS-FNA was performed on LN beyond the stenosis using TBNA needle. Results: 17 patients were recruited for the CA study (12M:5F; median age 62.7 years, range 43.6–86.6) (A). Two patients had EC, both with non-traversable stenosis (B). In Group A, CA was visualized in 15/17 (88.2%) patients. No difficulty in intubation was encountered. The median length of the scope was 48cm (range 41–50) upon CA visualization. In Group B, CEBUS was passed through the stenosis with EUS-FNA of LN successfully performed in the 2 patients. There was no complication. Conclusion: CEBUS was able to visualize CA in the majority of patients. CEBUS and CEBUS-guided FNA were feasible in patients with stenotic EC without the need for predilation. Despite the floppy shaft of CEBUS, narrow viewing angle and less echo-penetration, FNA of LN was feasible.

Bilateral Pyelocutaneous Ileal Conduit in a Diffuse Neoplasia of Urinary Tract

We present a surgic solution that we adopted in a case of diffuse neoplasia from the upper urinary tract to the bladder and the prostatic urethra. Case 67 year-old male, has been submitted to bladder mapping with results of diffuse CIS and sequential immunotherapy with BCG. The three month control had pathological findings of CIS in the bladder and in the prostatic urethra. The staging has shown neoplasia in both kidneys. We had performed a cystoprostatectomy with a bilateral ureterectomy and cleaning of the intrarenal tissue. We had performed a bilateral pyelocutaneous ileal conduit in accord with Holland. Results The kidney parameters at 6 months were normal and the patient was well. The control, in general anesthesia with a pediatric gastroscope, in the pelvis and calyx with x-ray facility, didn't show a recidive in the kidney. Otherwise in annual control a little neoplasia in the right kidney was found. In the successive control at 18 and at 24 months we had found no signs of neoplasia. Conclusions Despite this extreme case, in which the neoplasia is in all of the urinary tract, it is possible to preserve the kidneys, to have a good oncological result and to preserve the renal function with a good quality of life, to avoid or to delay the bilateral nefrectomy.

7076 Unsedated peroral ultrathin videoendoscopyassisted delivery of an esophageal manometry catheter.

Unsedated endoscopy with an ultrathin scope has several potential advantages over conventional endoscopy due to avoidance of adverse side effects and morbidity associated with sedation. Less intensive patient monitoring and less expense may be additional benefits.We report the first case of an unsedated peroral ultrathin vidco-endoscopy assisted delivery of an esophageal manometry catheter. Case Report: A 77-year-old male was referred for esophageal manometry by his surgeon prior to revision of a Nissen fundoplication which he had undergone two years previously for a large hiatus hernia and gastroesophageal reflux symptoms.A recent upper gastrointestinal series showed that the large hiatus hernia was still present and questionable upper esophegeal dysmotility was also reported. The patient's complaints of epigastric fullness and inability to take a deep breath were similar to what he had experienced before the fundoplication. The manometry catheter could not be advanced beyond 40 cm from the incisors presumably due to inability to pass through the hiatus hernia. A few days later an unsedated peroral endoscopy using the ultrathin (6 mm in diameter) videoendoscope (Pentax Ultraslim videogastroscope, EG- 1840, Orangeburg, N.Y.) was performed to guide the manometry catheter into the stomach. A pediatric gastroscope snare was passed through the ultrathin scope to hold the tip of the manometry catheter. Then both the ultrathin endoscope with attached manometry catheter were passed under direct vision into the stomach and the catheter was subsequently disengaged by opening the snare. The patient tolerated the procedure well. Conclusion: This is the first report of an sedated peroral ultrathin videoendoscopy-assisted delivery of an esophageal catheter. This case is an example of how unsedated ultrathin video-endoscopy is a potentially useful technique that can assist in the delivery of diagnostic and/or therapeutic devices.