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e120
Abstracts of the 22
nd
National Congress of Digestive Diseases / Digestive and Liver Disease 48S2 (2016) e67–e231
lateral-viewing duodenoscopy and colonoscopy excluded polyposis
syndromes; Lynch syndrome was present in one patient. EB ablation
was considered because of complicated advanced liver disease (#3),
previous mucosal resection complicated with bleeding (#1) and
suboptimal lifting (#1). Lesions were located at post-pyloric area
(#1), anterior wall of the bulb (#1) and descending duodenum (#3),
respectively. During upper endoscopy under conscious sedation, a
multiband ligator was used to lift flat lesions. Snare resection was
avoided in all cases. Chromoendoscopy and sampling were used
to better assess marginal area of the polyps before ablation and to
exclude residual or recurrent adenoma. Endoscopic controls were
planned at 2 and 6 months until eradication and yearly thereafter.
Results:
Complete ablation was achieved in all patients in one
session. One (#3) or three (#2) bandswere needed. No periprocedural
complications occurred. At a median of 12 months (5-29) follow-up,
no recurrent adenoma was detected.
Conclusions:
EB ablation represents a safe and effective option
to treat small duodenal flat lesions in patients at high risk for
complications.
V.01.4
EUS-GUIDED DRAINAGE OF AN INFECTED PANCREATIC
PSEUDOCYST AND SUCCESSIVE TREATMENT WITH HEMOSTATIC
POWDER FOR A LATE INTRACYSTIC BLEEDING
Togliani T.*, Mantovani N., Vitetta E., Savioli A., Troiano L., Pilati S.
S.S.D. di Endoscopia Digestiva, Azienda Ospedaliera Carlo Poma,
Mantova, Italy
Background and aim:
EUS-guided drainage is an effective treatment
for infected pancreatic pseudocysts but complications such as
bleeding, perforation, pancreatitis or stent migration can occur.
Material and methods:
A 68-year-old patient developed the
infection of a 10 cm pseudocyst in the body of the pancreas two
months after an acute pancreatitis. A transgastric EUS-guided
placement of a covered double flanged self-expandable metal stent
(Taewoong Nagi stent, 16 mm wide, 2 cm long) was done. After its
release, the stent was dilated with a 12mm TTS balloon for allowing
a fast and complete outlet of the purulent material. Symptoms
rapidly improved but seven days later the patient developed
hematemesis; EGDS showed blood in the stomach without visible
bleeding lesions. Thus the pseudocystic cavity was explored with a
standard gastroscope: some fresh blood and a few small adherent
clots were present in the pseudocyst. The fearsome rupture of a large
vessel such as the splenic artery seemed improbable and an urgent
radiologic or surgical intervention was not ruled out. The erosion of
some small vessels within the pseudocystic wall appeared the most
likely cause of hemorrhage and we treated the pseudocystic cavity
with hemostatic powder (Endo Clot).
Results:
This is a case report of an EUS-guided drainage of an infected
pancreatic pseudocyst; the use of a large self expandable metal stent
allowed us to get a rapid and complete emptying of the purulent
collection, with a prompt clinical (fever, pain and leukocytosis
improved after two days) and technical (a CT scan effected five days
after the procedure showed a complete resolution of the collection)
success. This treatment was complicated by a late intracystic
bleeding one week after the stent placement: the presence of a wide
stent allowed us to enter the cavity and to perform a topic treatment
with an hemostatic powder. Neither recurrence of fluid development
nor relapse of intracystic bleeding occurred in the following weeks.
Conclusions:
EUS-guided placement of a large self expandable
metal stent is still the best choice for treating infected pancreatic
pseudocysts. The occurrence of mild intracystic bleeding can be
endoscopically managed and the treatment with hemostatic powder
is a promising option.
V.01.5
A SIMPLE AND SAFE METHOD FOR REMOVAL OF AN ESOPHAGEAL
FISTULIZING FULLY-COVERED SELF-EXPANDING METAL STENT
Arena M.*, Viaggi P., Morandi E., Carlucci P., Zaffaroni M.,
Opocher E., Luigiano C.
Azienda Ospedaliera San Paolo, Milano, Italy
Background and aim:
Malignant dysphagia can be due to
esophageal cancer or neoplastic extrinsic compression. Treatment
of patients with unresectable malignant stenosis is palliative. Self-
expandable metal stents (SEMS) are nowadays recommended as
preferred method for palliation of malignant dysphagia. Potential
stent-related complications include ob¬struction, perforation,
migration,
esophageal-respiratory
fistulas.
Stent-associated
esophageal-respiratory fistulas developed in 4% of patients with
esophageal stenting. We describe a simple and safe method to
remove a fistulising esophageal SEMS.
Material and methods:
A 62 years old man with unresectable
mediastinal mass stenosing the esophagus was treated with fully
covered SEMS placement (FCSEMS) and following chemotherapy.
After about five months recurrent dysphagia and pneumonia
occurred. A contrast-swallow showed extra luminal spreading
of contrast from the proximal end of FCSEMS into the trachea.
Bronchoscopy demonstrated the presence of tracheoesofageal fistula
(TEF) with half of the proximal edge of the FCSEMS prolapsing into
the tracheal lumen. A computed tomography confirmed the leak of
the proximal esophageal wall with the FCSEMS penetrating through
the posterior tracheal wall. The patient was unfit for any surgical
intervention, so we decided to remove FCSEMS with a previous
overtube placement, to reduce traumatic risks and treat TEF with a
new esophageal and a tracheal FCSEMSs.
Results:
Initially the distal end of the stent was grasped using a rat-
tooth forceps and pushed distally. An overtube was used to protect
the esophageal mucosa during removal. The scope was withdrawn
and the overtube was pre-loaded onto the scope. The scope was
reinserted and overtube advanced into place. The proximal retrieval
lasso was grasped and the stent was successfully retracted into
the overtube. Then both scope and overtube with the FCSEMS
inside were removed. No other damage to the esophageal wall was
noted. Finally a new esophageal FCSEMS and a tracheal FCSEMS
were placed. No complications occurred. Patient had symptomatic
improvement.
Conclusions:
Stent-associated tracheoesophageal fistula is
uncommon complication and can often present as a potentially
life threatening emergency. Addi¬tional insertion of FCSEMS is an
effective treat¬ment in this case, but initial FCSEMS removal could
be traumatic and could lead to further tissue damage. We describe a
simple and safe method to remove a fistulising esophageal FCSEMS
before a new stent insertion and fistula treatment.
V.01.6
STONE IMPACTION IN THE PAPILLA: IS AN URGENT ERCP
INDICATED?
Rossi M.*, Fasoli R., Franceschini G., Tasini E., Agugiaro F.,
De Pretis G.
Ospedale Santa Chiara, Trento, Italy
Background and aim:
Indications to urgent endoscopic retrograde
cholangiopancreatography (Ercp) include acute cholangitis, early
biliary pancreatitis and acute pancreatitis associated with biliary
obstruction.
Stone impaction in the papilla may be responsible of intractable
pain and biliary obstruction.
Indication to Ercp in these cases is universally recognized but
recommendations regarding its timing are not clear.