Standard Endoscopic Techniques Research Articles

Morphologic Factors Associated With Open Conversion During Holmium Laser Enucleation of the Prostate

OBJECTIVETo determine if there is an association between patient body habitus as measured by body mass index (BMI), body surface area (BSA), preoperative prostate volume, postoperative specimen weight, and open conversion with cystotomy or perineal urethrotomy (PU) during holmium laser enucleation of the prostate (HoLEP). We attempt to provide meaningful criteria to assist in preoperative patient counseling. MATERIALS AND METHODSThree hundred consecutive patients underwent HoLEP between August 3, 2018 and February 20, 2020 by a single surgeon. Patient metrics were recorded in a database including age, height, weight, preoperative prostate volume, postoperative specimen weight, catheter dependence, and transfusion requirement. Nine patients were identified who had cystotomy (8) or PU (1) performed during HoLEP secondary to inability to complete the procedure using standard endoscopic technique. Univariate and multivariate statistical analysis was performed. RESULTYounger age, higher BMI, higher BSA, and higher estimated prostate volume were associated with increased risk of open conversion during HoLEP. No patient with a BMI under 30 required open conversion. CONCLUSIONMen with BMI >30 kg/m2 or preoperative prostate volume >125 mL should be counseled on the possibility of open conversion with cystotomy or PU. Although the overall risk of conversion is low (3%), the risk may be as high as 10% for patients in the highest quartile of BMI (>30.5 kg/m2) and BSA (>2.2m2).

624 Clinical Outcomes and Endoscopist's Perception of the Use of Hemospray for Gastrointestinal Bleeding: Outcomes From a U.S. Academic Tertiary Care Medical Center

INTRODUCTION: Endoscopic management of gastrointestinal bleeding (GIB) has evolved with current standard treatment modalities including epinephrine injection, hemostatic clips, and thermal therapies. A growing body of evidence has demonstrated clinical efficacy of Hemospray in GIB. Recently, the FDA approved Hemospray for treatment of non-variceal GIB in the USA. METHODS: Consecutive patients treated with Hemospray for management of GIB between 10/2018 and 1/2019 were included in this prospective case series. IRB approval was obtained. Patient demographics, clinical parameters, outcomes, and endoscopist's perceptions on the ease of use of Hemospray were collected. Hemospray was used by an attending as monotherapy, dual therapy with other standard endoscopic techniques, or as a rescue therapy. RESULTS: Hemospray was used during 12 cases for GIB. Immediate hemostasis was achieved in 10/12 (83.3%) cases with an average time to hemostasis of 3 minutes and an average of 6.8 sprays used per endoscopy. The mean Blatchford score was 13.7 and the mean Rockall score was 6.3. Hemospray failed in one case of failed band ligation and in one case as rescue therapy for a Forest Class 1a duodenal ulcer. Hemospray was used as a primary modality in 3/12 cases, adjunctive therapy in 3/12 cases, and as rescue therapy in 6/12 cases. Etiologies of GIB included Forest 1a ulcers (n = 3), Forest 1b ulcers (n = 3), MW tear (n = 2), GAVE (n = 1), APC induced rectal ulcer (n = 1), post polypectomy bleed (n = 1) and esophageal variceal bleed (n = 1). No adverse events occurred. Interventional radiology was utilized in 5/12 cases. The 3 day and 7 day rebleeding rates were 0% (0/12) and 25% (3/12) respectively. All-cause mortality was 8% (1/12) at both 7 and 30 days. Hemospray was technically easier to use compared to clips (6/12), epinephrine (4/12), and thermal modalities (5/12) according to the attending endoscopists (Table 1). Difficulties reported during administration of Hemospray included a clogged catheter (n = 2) which required use of a second catheter. CONCLUSION: Hemospray is effective in achieving immediate hemostasis in non-variceal GIB with no adverse events in our cohort. Low 3 and 7 day rebleeding rates were below the predicted rebleeding rates. Overall, a majority of attending endoscopists reported that Hemospray was similar or easier to use than conventional methods of hemostasis. Our study is limited by our small patient cohort, but represents real US experience with this recently FDA approved GIB treatment modality.

3087 Combined Endoscopic and Surgical Management of Small Bowel Polyposis in a Patient With Peutz-Jeghers Syndrome

INTRODUCTION: A 55-year-old male with history of Peutz-Jeghers syndrome was referred for a colonoscopy for management of a large ileal polyp. Surgical history was notable for two laparatomies for small bowel obstructions in the setting of intussusception as well as multiple enterotomies for removal of polyps. CASE DESCRIPTION/METHODS: Colonoscopy confirmed a polypoid mass in the distal ileum that was partially obstructing. Endoscopic submucosal dissection of the polyp stalk was performed but revealed two feeding arteries as well as a thick muscular band, concerning for muscularis propria, that precluded further safe dissection. Hemoclips were placed on the feeding arteries in an attempt to cause necrosis of the lesion. After discharge the patient developed hematochezia. Repeat colonoscopy did not show any ongoing bleeding but the mass appeared to be necrotic. Repeat colonoscopy was planned in the operating room to evaluate the mass. If the necrosis was not complete, dissection of the stalk would be re-attempted with plans to convert to surgical resection if needed. On endoscopy, the mass appeared to have revitalized. Another attempt at submucosal dissection of the polyp stalk was performed. However as the area had already been dissected through, the submucosal plane was not easily identified in the stalk and did not feel that it was safe to continue the submucosal dissection. Subsequently, the patient was converted to surgical resection of the ileal polyp, which also revealed multiple polyps more proximally throughout the small bowel. The bowel resection included the initial large polyp and another large polyp at a prior ileal anastomosis that could not be removed without a resection. Multiple other polyps were removed via enterotomies. To clear the remaining small bowel of residual polyps, we performed a clean sweep. A pediatric colonoscope was introduced orally and the scope was able to be advanced distally to the ileal anastomosis by plicating the bowel over the scope. Multiple further polypectomies were then performed using standard endoscopic mucosal resection technique. On 3 month follow up MR enterography, there were no convincing polyps identified in the entire small bowel. DISCUSSION: This case demonstrates the importance of a multi-disciplinary approach to the management of this patient's polyposis. The combination of endoscopic and surgical approach allowed for effective management of both the large ileal polyp as well as his overall polyp burden. Watch the video: http://bit.ly/2JWHRA2

3124 Endoscopy in Patient With Situs Inversus Totalis

INTRODUCTION: Situs inversus totalis (SIT) is the complete transposition of the abdominal and thoracic organs. Due to the inherent anatomic differences, patients with situs inversus may pose a unique challenge when undergoing endoscopic procedures because physicians are trained to maneuver the endoscope in a certain manner. CASE DESCRIPTION/METHODS: A 51 year old male presents with a 3 year history of intermittent rectal bleeding. He denies abdominal pain, constipation, and diarrhea. On presentation, physical exam was normal. Although the patient was aware of his diagnosis of SIT at the time of endoscopy, he did not think it was necessary to inform physicians about his condition. In addition, multiple electrocardiograms had been read previously without complications. Laboratory evaluations were normal except for slightly elevated ALT and AST. EGD was performed and showed salmon-colored mucosa in the distal esophagus. Biopsies of the esophagus showed squamous epithelium with acute inflammation and reflux-associated changes, and no evidence of intestinal metaplasia. The stomach was diffusely erythematous and biopsies revealed chronic active gastritis with H. pylori-like organisms. Colonoscopy was normal with the exception of internal hemorrhoids. EGD and colonoscopy were both successfully performed in the standard manner. SIT was discovered during a liver ultrasound performed to further investigate the etiology of his elevated liver function tests. DISCUSSION: Situs inversus totalis may cause additional challenges for endoscopists. One study found that SIT prolonged cecal intubation times. Certain modifications to standard endoscopic technique have been proposed including turning the endoscope 180 degrees clockwise first in the stomach then again in the duodenum, as well as placing the patient in the right lateral decubitus position so that the maneuvers are performed inversely. In our case, the endoscopist was able to successfully navigate the endoscopic procedures without special maneuvers or changes in position and was unaware of the diagnosis of SIT until after the procedure. In conclusion, endoscopies and colonoscopies are feasible in patients with SIT. Various modifications to the endoscopic technique have been suggested, but may not always be required, to safely perform these procedures on patients with SIT.

2122 Novel Use of EndoRotor® Device to Clear Large Obscuring Clot in Patient With Upper Gastrointestinal Bleed

INTRODUCTION: Significant clot burden limits visibility and prevents finding intervenable lesions for hemostasis. Endoscopic tools and promotility agents are available to disrupt clots and increase visibility with varying degrees of success. The EndoRotor® device is a non-thermal, automated endoscopic resection system designed to remove benign mucosal tissue throughout the gastrointestinal tract. Here, we present a challenging case where standard endoscopic techniques failed to clear a large obscuring gastric clot and how novel application of the EndoRotor® allowed successful localization of the culprit lesion. CASE DESCRIPTION/METHODS: A 79 year old woman with a history of end stage renal disease and liver fibrosis presented with coffee ground emesis and melena. On admission, initial labs were notable for Hgb 9.7, Plts 129, INR 1.1. Patient was treated with IV pantoprazole and octreotide. EGD was notable for nonbleeding esophageal varices and a moderate size blood clot in the lesser curvature and fundus of stomach obscuring visualization and the procedure was terminated. Patient continued to pass melena with Hgb drop to 5.8 requiring 3 units pRBC and metoclopramide was added to her regimen to try to clear the large clot. Repeat EGD revealed an interval increase in size of blood clot. Despite irrigation and suction, area could not be cleared. Use of cold snare or Roth net removal were not feasible due to clot size and use of BioVac® was ineffective. A repeat EGD was performed the following day using the EndoRotor®. The combination of the EndoRotor device’s rotating cold blade and suctioning enabled the large clot to be liquefied. Fibrous tissue intermittently clogged the EndoRotor® suction channel but was easily cleared with flushing. After about 30 minutes, the large obstructing clot was completely cleared revealing a bezoar. The patient was kept NPO and continued on IV metoclopramide for 48 hours to clear the bezoar. An EGD was then repeated which revealed a 5 mm cratered ulcer in the posterior gastric wall with a nonbleeding visible vessel. Bipolar probe was applied successfully for hemostasis. DISCUSSION: Our case illustrates the challenges associated with a large clot obscuring visualization. Standard use of promotility agents with supportive care were not successful as the patient continued to intermittently bleed increasing the clot size . Our case is the first reported application of the EndoRotor® to safely to clear large blood clots in upper GI bleeding as an adjunct to our standard therapies.

The inaccuracy of the endoscopic anastomotic measurement techniques

Background: Roux-en-Y gastric bypass (RYGB) is a reliable treatment for obesity, and most of the people do lose weight after the surgery. However, there are risks for the failure to lose weight or weight regain. One of the primary reasons for weight regain after the RYGB is the size of the anastomosis at the gastrojejunostomy (GJ). There is no standard endoscopic technique for the measurement of this anastomosis. Consequently, many treatment plans may lead to ineffective intervention. This study was performed to identify the most accurate method to measure the luminal diameter of GJ endoscopically. This may allow better management of the patients with weight regain after the RYGB. Methods: Ten subjects were asked to endoscopically measure a ring of known diameter at the end of a plastic tube representing the esophagus using four commonly used endoscopic measuring techniques and a double channel endoscope. Subjects used (I) visual estimation (VE); (II) instrument reference (IR) to biopsy forceps; (III) esophageal dilating balloon (EDB); (IV) ruler made from an endoscopic retrograde cholangiopancreatography (ERCP) guide wire tip. The five models were presented in random order. The data was collected and saved in the institutional database. Results: A total of 10 participants, 9 surgeons and 1 gastroenterologist, participated in the study. Endoscopic experience was >1,000 scopes for 4 subjects; 250–500 for 3, and <100 for 3. The VE was the least accurate with an average diversion (AD) from the actual diameter of 6.25±4.95 mm (24.2%); followed by IR, 3.89±3.05 mm (14.8%); then the ruler, 2.4±1.9 mm (9.2%). The balloon measurement was the most accurate, with AD of 1.46±0.9 mm (7.2%). Of the 200 total measurements, 8 (4%) were accurate, 142 (71%) were underestimating, and 50 (25%) were overestimating. Underestimation was found in 82.5% (33/40) of each of the VE and IR methods; while it was less in the ruler method 60% (24/40); and least in the balloon method 40% (16/40). Additionally, the overestimation was highest in balloon method 55% (22/40), followed by ruler method 35% (14/40), then IR 15% (6/40); and lowest in VE 12.5% (5/40). Measurements of the largest model diameter (33 mm) were 98% underestimating; while only 2% were overestimating. In the smallest diameter model (13 mm), 16% of the measurements were underestimating; 2% were accurate, and 82% were overestimating. Conclusions: Endoscopic VE of anastomosis diameter is the least accurate method of measurement leading to the overestimation of the measurements. It is, therefore, highly recommended that endoscopists avoid using only VE entirely for the measurement of GJ. More objective methods may be considered for the measurement of GJ diameter.

Cholangioscopy-guided retrieval basket and snare for the removal of biliary stones and retained prostheses.

Background and AimsCertain pancreaticobiliary conditions remain challenging to treat using standard endoscopic techniques. Examples include difficult-to-remove gallstones and foreign objects in the bile ducts. Two tools designed for these purposes are the SpyGlass retrieval basket and the SpyGlass retrieval snare, which are passed through the cholangioscope channel for use under direct visualization. We present 3 cases in which these tools were used successfully.MethodsThree cases using the SpyGlass retrieval basket and retrieval snare were reviewed for efficacy.ResultsPatient 1 had hepatitis C cirrhosis and underwent liver transplantation with T tube placement at the site of biliary anastomosis. Image-guided T tube removal by interventional radiology was unsuccessful. Endoscopic removal with the SpyGlass retrieval snare was completed. Patient 2 presented with cholangitis from an impacted common bile duct stone. Fragmentation with electrohydraulic lithotripsy was performed, and the fragments were removed with the SpyGlass retrieval basket. Patient 3 presented for removal of a migrated biliary stent. The stent was placed a year prior during an ERCP for treatment of choledocholithiasis. Initial removal attempt at an area hospital failed, so the patient was referred to our center, where the Spyglass retrieval snare was used to remove the biliary stent.ConclusionsThis case series demonstrates initial successes treating biliary pathologic conditions with the SpyGlass retrieval basket and retrieval snare, 2 tools designed for use under direct visualization with the cholangioscope.

Ultrasound vs Endoscopy, Surgery, or Pathology for the Diagnosis of Small Bowel Crohn's Disease and its Complications.

In patients with inflammatory bowel disease, we strive to achieve mucosal healing, as this has been shown to decrease the risk of disease flares, hospitalization, and surgery. For this reason, we must use objective measures of mucosal healing to inform our clinical decision-making and can no longer rely on patient symptoms alone. Assessment of small bowel Crohn's disease (SBCD) is particularly challenging given its lack of accessibility via standard endoscopic techniques. Ultrasound (US) represents a readily available, cost-effective, minimally invasive, radiation-free alternative for the assessment of small bowel disease. In this study, we performed a systematic review to determine the accuracy of ultrasound in diagnosing SBCD and its complications as compared with endoscopic visualization, surgery, and/or pathology. We searched MEDLINE, EMBASE, and CENTRAL. Prospective cohort studies published up to March 2017 were reviewed. References meeting all eligibility criteria were assessed at the full-text level by 2 independent reviewers. Sensitivity and specificity were collected where available. A total of 2817 unique references were identified. Twenty-two studies were included. All studies were at low-moderate risk of bias based on the Quality Assessment of Diagnostic Accuracy Studies criteria. Transabdominal US (TAUS) yielded moderately high sensitivity and specificity for the diagnosis of SBCD and its postoperative recurrence. Detection was more accurate for severe postoperative recurrence. The diagnostic accuracy of US in stricture and abscess detection was high. Contrast enhancement improved the detection of abscess. Diagnostic detection of fistulas was of moderate accuracy. Entero-enteric fistulization and entero-mesenteric fistulization were most clearly identified. Ultrasound can be used to diagnose SBCD in those with known or suspected Crohn's disease. It can be used to detect postoperative recurrence and can accurately identify abscesses and fistulas, especially with the aid of contrast enhancement.

Microscopic colitis-microbiome, barrier function and associated diseases.

Microscopic colitis (MC) is a chronic inflammatory bowel disease (IBD) with little in terms of endoscopic abnormalities and is frequently associated with other autoimmune diseases. The peak incidence of the disease is in middle aged or older populations, mostly females. The pathogenesis of MC is complex, multifactorial and poorly understood. Current concepts revolve around innate immunity or microbiome alterations as well as gut barrier dysfunction, all of which lead to the development of subtle inflammatory lesions in gut mucosa. The results of numerous basic and clinical studies involving molecular techniques as well as advanced endoscopic imaging revealed the important role of both intrinsic (e.g., hormonal) as well as extrinsic (e.g., NSAIDs and PPIs) factors in the modulation of gastrointestinal microbiome and MC pathogenesis. Capsule endoscopy as well confocal endomicroscopy imaging, alongside standard endoscopic techniques offer new tools in the evaluation of MC patients and allow their better stratification for novel treatment protocols based on modulation of gut microbiome and barrier function.

An innovative robotic platform for magnetically-driven painless colonoscopy.

Colorectal cancer (CRC) represents a significant medical threat with a dramatic impact on the healthcare system with around 1.3 million patients worldwide, causing more than 700 thousand deaths annually. A key-aspect to successful and cost-effective disease management is represented by the early detection of CRC at asymptomatic stage. For this reason, population screening is highly recommended for patients older than 50 years or at high risk for familiarity. Currently, the standard endoscopic techniques do not meet this need. In recent years, innovative endoscopic robotic techniques and active locomotion devices have been developed as alternatives to conventional colonoscopy. The magnetically-driven robotic platform, presented by the authors, is conceived to perform less invasive and more comfortable colonoscopy with the aim to promote screening campaigns for detection of early colorectal neoplasm.

Novel biomarkers and endoscopic techniques for diagnosing pancreaticobiliary malignancy.

The UK incidence of pancreatic ductal adenocarcinoma is 9 per 100,000 population, and biliary tract cancer occurs at a rate of 1–2 per 100,000. The incidence of both cancers is increasing annually and these tumours continue to be diagnosed late and at an advanced stage, limiting options for curative treatment. Population-based screening programmes do not exist for these cancers, and diagnosis currently is dependent on symptom recognition, but often symptoms are not present until the disease is advanced. Recently, a number of promising blood and urine biomarkers have been described for pancreaticobiliary malignancy and are summarised in this review. Novel endoscopic techniques such as single-operator cholangioscopy and confocal endomicroscopy have been used in some centres to enhance standard endoscopic diagnostic techniques and are also evaluated in this review.

Endoscopic treatment of pancreatic duct stones under direct vision: Revolution or resignation? Systematic review.

The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a multidisciplinary approach. Extracorporeal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non-surgical treatment as a result of disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporeal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns to the spotlight. Herein, we reviewed the current data on direct pancreatoscopic treatment of MPD stones with a focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was done. Ten relevant publications meeting the inclusion criteria were identified (two prospective series, six retrospective trials, two case reports, n=87 patients). Successful ductal clearance for POP-guided treatment was reported as between 43% and 100% compared to ESWL with 59% to 80%. Adverse event rate for POP-guided therapy was reported as 0-13.5%. One study showed a noticeable higher adverse event rate of 43%. In this trial, POP was carried out after ESWL. There is no reported mortality following POP treatment. Available results are promising in terms of ductal clearance and pain relief compared to standard endoscopic techniques and ESWL as the current gold standard for lithotripsy. Interpretation of this data is limited by the small number of cases for POP and the lack of prospective randomized controlled trials.

737 A Comparison of Standard Endoscopic Submucosal Dissection Technique to the New Single Tunneling Technique in Giant Laterally Spreading Tumors

737 A Comparison of Standard Endoscopic Submucosal Dissection Technique to the New Single Tunneling Technique in Giant Laterally Spreading Tumors

Resection of a gastric fibroid inflammatory polyp by means of endoscopic submucosal dissection: how deep is deep enough?

Infl ammatory fi broid polyps (FIP) are rare mesenchymal tumors associated with mutations of the platelet-derived growth factor-α. Th ey derive from the submucosal layer and are mainly composed of loose connective tissue, vessels and an eosinophilic infl ammatory component. Th ey are found throughout the gastrointestinal tract, but most commonly in the gastric antrum and ileum. Macroscopically, they present as large polypoid lesions of 3-20 cm in size that maybe pedunculated and ulcerated. Case series and case reports have demonstrated the effi cacy of standard endoscopic techniques with snares and most recently with endoscopic submucosal dissection (ESD) in 5 cases [1,2]. We would like to share our experience in an asymptomatic 60-year-old woman who underwent ESD resection of a 4x3 cm pedunculated FIP located at the gastric antrum (Fig. 1, 2). Th e procedure was uneventful and macroscopically the lesion seemed to be completely resected. Surprisingly, the histology report showed positive deep margins. Due to the benign course of these lesions no additional surgery has been suggested and at one year of follow up there are no signs of endoscopic or histologic recurrence. Th is case illustrates that FIP may expand deep into the submucosal layer beyond the reach of invasive techniques such as ESD. Although the risk of recurrence is minimum, positive deep margins should prompt endoscopists for postoperative follow up since there is at least one report of tumor recurrence aft er endoscopic resection that was detected at 1 year of follow up [3].

PTH-041 Large (&lt;4 cm) and giant (≥4 cm) colorectal polyps: comparison of piecemeal resection outcomes

Introduction Piecemeal Endoscopic Mucosal Resection (p-EMR) is a standard and safe endoscopic technique for resection of large colorectal polyps (>2 cm). Limited data are available regarding p-EMR of giant polyps (>4 cm). Method A prospective study recording short and long-term outcomes after p-EMR for colorectal polyps > 2 cm between Jan 2010 and August 2012 was conducted. We compared two cohorts of patients: group-A with large polyps (2 to Results Group-B patients were older than group-A patients (mean 70.6 vs. 67.8 yrs, p = 0.01) and were more likely to have come from a tertiary referral source (p = 0.05). Large polyp referrals were almost twice as frequent as giant polyp referrals (218 vs. 123, p Endoscopic excision was complete in 89% in large (median time 18min) and in 70% in giant groups (median time 38min). All large polyps were excised in one session, whilst 4% of giant polyps required more than one session. Incomplete submucosal lift (46% vs 63%, p = 0.002) and difficult polyp position (45% vs 63%, p Conclusion Piecemeal resection is a safe and efficacious modality for the resection of colorectal polyps >4 cm. However, these giant polyps more often require spiral snare or hybrid resection techniques and their higher adenoma recurrence rate post p-EMR may dictate shorter surveillance intervals. Disclosure of interest None Declared.

La pose d’implants intra-prostatiques UroLift® est-elle une alternative chez les patients ayant une hyperplasie bénigne de la prostate ? Résultats initiaux et facteurs prédictifs d’échec

To report the results of UroLift(®) implants after a 2-year experience in the technique. The procedure was proposed between February 2012 and April 2014 in patients with symptomatic benign prostatic hyperplasia, as an alternative to standard endoscopic ablation techniques. Evaluation of BPH related symptoms relied on the IPSS and IPSS-QoL self-questionnaires, as well as on maximum uroflow (Qmax). Evaluation of erectile and ejaculatory functions relied on the IIEF5 and MSHQ-EjD self-questionnaires, respectively. A total of 23patients were treated during this period. Median age was 66years [53-78]. Median prostate volume was 38mL [20-80]. Preoperative IPSS and IPSS-QoL were 20 [9-29] and 5 [3-6], respectively. No severe adverse event was observed postoperatively. Median follow-up was 14 [5-31] months. At the end of follow-up, 19 (83%) patients reported sustained symptomatic improvement without any additional treatment. Median IPSS and IPSS-QoL were improved significantly (11 [1-27] and 2 [0-6], P<0.0001), with however no significant improvement in Qmax. Four patients needed additional treatment during the first postoperative year. Among them, 3 had a prostate volume>60mL. No patient reported retrograde ejaculation or worsened erectile function. UroLift(®) implants allowed symptomatic improvement in more than 80% of the patients after 1-year follow-up. A high prostate volume may potentially be predictive of symptomatic failure. 5.

A Case of Frontal Mococele Treated with Transblepharoplasty Approach Combined with Endoscopic Approach

In recent years, endoscopic sinus marsupialization has become the treatment of choice for the treatment of paranasal sinus mucoceles due to its noninvasiveness and successful outcome. However, mucoceles located at the lateral portion of the frontal sinus and protruding into the orbit with erosion of the frontal sinus floor arestill difficult to address with standard endoscopic sinus surgery techniques. Here, we report a case of a mucocele located atthe lateral side of the frontal sinus and successfully marsupialized with a transblepharoplasty approach combined with an endoscopic approach.

Excavated Duodenal Gastrointestinal Stromal Tumor (GIST) Diagnosed by Standard Endoscopic Biopsy

Introduction: An 83-year-old man presented with 1 month of slow gait associated with 2 weeks of fevers and weakness. He also reported a near syncopal episode associated with chest pain prior to admission. Physical exam revealed a systolic murmur and right upper quadrant abdominal tenderness. His blood work was notable for leukocytosis and an ESR of 102. Transthoracic echocardiogram showed 14mm linear echodensity on the aortic valve. A follow-up transesophageal echocardiogram did not show any evidence of vegetations. Computed tomography of the chest, abdomen and pelvis revealed a 4cm enhancing heterogeneous lesion thought to be in the head of the pancreas. Esophagogastroduodenoscopy with endoscopic ultrasound (EGD-EUS) showed a 3cm lesion in the second portion of the duodenum with a deep excavated necrotic center that was easily friable. There was no evidence of pancreatic mass on EUS. Multiple jumbo biopsies were taken from the edge of excavation using standard endoscopic technique, which showed duodenal mucosa with submucosal proliferation of uniform bland spindle cells with anuclear areas diffusely positive for CD117, negative for S-100, which was compatible with gastrointestinal stromal tumor (GIST). The patient underwent a Whipple procedure, which demonstrated that the GIST did not invade the duodenal mucosa or pancreas on pathology. C-Kit mutation was detected on genetic sequence analysis. This clinical vignette demonstrates a rare case of a duodenal GIST that was diagnosed by standard endoscopic biopsy. Typically, endoscopic forceps do not yield enough tissue for a definitive diagnosis. EUS with fine needle aspiration provides better results with one study showing up 82% sensitivity and 100% specificity for diagnosis of GIST. GISTs occurring in the duodenum represent only approximately 5% of all GISTs as well as 10% to 30% of all malignant duodenal tumors. GISTs are most commonly found in the stomach, accounting for 60-70% of all cases. The clinical presentation of GISTs ranges from incidental discovery on endoscopy to nonspecific symptoms or overt GI bleeding. Interestingly, our patient presented with features suggestive of endocarditis, which were subsequently found to be secondary to the duodenal GIST.Figure 1: Excavated duodenal GIST with necrotic center.

Su1749 Intestinal Anastomotic Ulcers in Children With Short Bowel Syndrome and Anemia Detected by Capsule Endoscopy

Anastomotic ulcers are a known cause of anemia in children with a history of intestinal resection. The etiology of these ulcers may be secondary to ischemia or small bowel bacterial overgrowth (SBBO). Surgical resection may be required in the setting of anemia requiring multiple blood transfusions. Colonoscopy can be used to diagnose these ulcers. However, following serial transverse enteroplasty procedures (STEP), the area of involvement may be difficult to visualize with standard endoscopic techniques.

Guide Wire Augmented Nasofrontal Sinusotomy (GWANS)

Endoscopic frontal sinus surgery remains as a very challenging technique with potential for serious morbidity and even mortality. The close proximity of orbital contents, the cribriform plate and the anterior skull base pose serious challenges in performing this operation safely. The frontal recess anatomy is even more treacherous in recurrent cases and in diseased processes such as polyps and other tumors blocking the nasofrontal recess. Guide Wire Augmented Nasofrontal Sinusotomy (GWANS) allows for real time surgical guidance allowing the surgeon to confidently dissect through diseased tissue knowing all along where the boundaries of the nasofrontal recess lies and thus avoid injuring vital structures. This is a new and adjunctive tool for augmenting the standard endoscopic nasofrontal sinusotomy technique.