Digestive and Liver Disease - Volume 48 - Supplement 2

e122

Abstracts of the 22

National Congress of Digestive Diseases / Digestive and Liver Disease 48S2 (2016) e67–e231

V.01.9

ENDOSCOPIC CLOSURE OF IATROGENIC DUODENAL

PERFORATION SUCCESSFULLY TREATED WITH A NEW OVER-THE-

SCOPE CLIP

Anderloni A.

, Bianchetti M.*

, Di Leo M.

, Repici A.

Istituto clinico Humanitas, Milano, Italy,

Istituto clinico Humanitas -

Mater Domini, Castellanza, Italy

Background and aim:

Although rare (0,09%), duodenal perforation is

one of the most critical complication of endoscopic ultrasound (EUS),

with significant morbidity and mortality. With the introduction of

“over the scope” systems, clips and stents, endoscopic management

has become the treatment of choice of the gastrointestinal

perforation in the place of traditional surgical procedures.

Material and methods:

We present a case of a 62-years old man

with jaundice, referred to our unit to undergo EUS-FNA of solid

lesion of pancreatic head followed by ERCP for biliary drainage. The

patient underwent EUS performed with a linear echoendoscope

(GF-UCT140, Olympus Optical Co., Ltd., Tokyo, Japan) under CO2

insufflation and deep sedation with propofol. During the scope

withdrawal in the duodenum, we noticed a full thickness break

of about 13 mm diameter at the upper duodenal knee. Then the

echoendoscope was immediately retrieved.

Results:

With a diagnostic gastroscope loaded with the new OTSC

Padlock Clip (C910001, Aponos Medical Co., Kingston, USA) we

reached the perforation site in the duodenum. The Padlock clip is a

new OTSC device ergonomically designed to be placed on the tip of

the scope without occupying the operative working channel. Since

the diameter of the hole was too wide to be aspirated into the cap,

we used a twin grasper to approach the edges of the perforation

before releasing the OTSC (Video). X-ray with Gastrografin (Bayer

AG, Germany, Leverkusen, Germany) showed the complete closure

of the perforation with no contrast medium leakage. Broad-

spectrum antibiotics were administered intravenously and a CT-scan

performed three hours later confirmed the efficacy of the maneuver.

The patient remained afebrile, asymptomatic with stabile vital

signs. Semiliquid diet was allowed 24 hours later. Three days later,

the patient underwent percutaneous transhepatic cholangiography

and biliary drainage with positioning of a metallic stent. On day 7

postoperatively, the patient was discharged asymptomatic and with

reduction of bilirubin level.

Conclusions:

OTSC is a potentially surgery-sparing device and can

be a useful tool for the immediate closure of duodenal defects. OTSC

should be ready accessible and endoscopist should be trained in

their appropriate use. The Padlock Clip is a new OTSC device readily

deployed, ergonomically designed, that does not occupy a working

channel making the interventional procedure more quick and easy

to perform, with a high technical and clinical success rate.

V.01.10

“DISSECTING THE STONE”: SUCCESSFUL ENDOSCOPIC “LITHO

HYDRO-JET TRIPSY, LHJT” OF A BOUVERET SYNDROME

Staiano T.*

, Repici A.

, Mutignani M.

, Martinotti M.

, Rispo A.

Buffoli F.

S.C. Chirurgia Generale A.O. Istituti Ospitalieri di Cremona, Cremona,

Italy,

S.C. Endoscopia Diagnostica e Chirurgia Endoscopica Fondazione

IRCCS Istituto Nazionale dei Tumori, Milano, Italy,

U.O. Endoscopia

Digestiva IRCCS Humanitas, Rozzano, Italy,

S.C. Endoscopia

Diagnostica e Interventistica A.O. Niguarda Ca’ Granda, Milano, Italy,

DAI Gastroenterologia, Endocrinologia, Chiururgia A.O.U Federico

II, Napoli, Italy,

S.C. Endoscopia Digestiva e Gastroenterologia A.O.

Istituti Ospitalieri di Cremona, Cremona, Italy

Background and aim:

Bouveret’s syndrome, is an uncommon

cause for small bowel obstruction. Less than 3% of cases are due

to a gallstone impacted in the duodenum or pylorus resulting in

a gastric outlet obstruction following the passage of a gallstone

from the gallbladder to the duodenum via a cholecystoduodenal

or choledochoduodenal fistula. Most of the successful therapeutic

maneuvers described involve open surgical removal of the stone

through either a gastrotomy or duodenotomy, and reported

morbidity is not insignificant. We report a case of successful

endoscopic removal of a large stone impacted in the duodenal bulb

by means of a modified intracorporeal lithotripsy using hydro-jet

probe connected to an electrosurgical surgical unit.

Material and methods:

An 86 yo woman was admitted to our

hospital for severe epigastric pain, vomiting and nausea. Abdominal

US (Fig 1A) suggested the diagnosis of a biliary fistula and CT scan

detected pneumobilia, a thickened pyloric wall in continuity with

the the gallbladder and stone impacted in the duodenal bulb (Fig. 1

B). EGDs revealed a large (50 x 60 mm) gallstone impacted in the

duodenal bulb (Fig. 1 C), prohibiting passage of the endoscope

downstream. Because of the size and location of the stone,

fragmentation with mechanical lithotripsy was not feasible.

Therefore, we performed intracorporeal endoscopic modified

electrohydraulic lithotripsy using an ERBE JET

flexible probe (

∅

1,3

mm; L 2,2 m) for ERBEHydro-Jet connected to electrosurgical unit at

a setting of 50 watts. The probe was advanced through the operative

channel and the cut distal end was applied to the stone for lithotripsy

(Hydro-Jet Lithotripsy, HJL). HJL was repeatedly applied to the stone

with subsequent applications to break the stone into multiple

fragments (Fig. 1 D, VIDEO).

Results:

Loose stone bigger fragments were dragged into the stomach

with a snare, in order to prevent escape into the small bowel with

consequent obstruction of the terminal ileum due to gallstone ileus.

The patient improved clinically. The patient was fully recovered and

was discharged after 6 days of hospitalisation.

Conclusions:

Here, we described the first case of lithotripsy using

an ERBE JET

hydro-jet flexible probe for a successful endotherapy

of Bouveret syndrome. The limitation of this method is the risk

involved with inadvertent focusing of the “hydro-jet waves” onto

the surrounding tissue with consequent bleeding and perforation.

Key factors for a successful endotherapy are: excellent stone

visualization, adequate water immersion of the stone, correct

technique (adequate devices handling and electrosurgical setting)

and a skilled endoscopist. In conclusion, endoscopic management

of Bouveret’s syndrome offers an exceptional minimally invasive

option compared to surgery.