VideoGIE
use of TAUS in emergent ICU ERCP to aid in confirming bile duct access.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
DISCLOSURE Dr Sejpal is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication. Arvind J. Trindade, MD, Alexander Brun, MD, Arunan S. Vamadevan, MD, Kostas Sideridis, DO, Divyesh V. Sejpal, MD, Division of Gastroenterology, Paul H. Mayo, MD, Sameer Khanijo, MD, Seth J. Koenig, MD, Division of Pulmonology and Critical Care, Department of Medicine, Hofstra North Shore–LIJ School of
Medicine, North Shore–Long Island Jewish Health System, New Hyde Park, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.09.025
Closure of a large, persistent enterocutaneous fistula by use of a ventricular septal occluder
Figure 1. Deployment of the ventricular septal occluder. A, Endoscopic view of the umbrella within the jejunum. B, View of the umbrella on the skin surface.
Enterocutaneous fistulas are associated with a significant morbidity and a mortality of between 5% and 20%. The most common causes are iatrogenic (jejunal feeding), Crohn’s disease, radiotherapy-induced, and secondary to malignancy. These patients are often poor surgical candidates, and hence a minimally invasive technique for closure may offer significant benefits. In this video, we demonstrate the use of a ventricular septal occluder (Amplatzer; St Jude Medical, Plymouth, Minn) to close a jejunocutaneous fistula. This device is a self-expandable double umbrella–shaped polyestercovered nitinol wire mesh. An 80-year-old woman was seen for management of a chronic, iatrogenic jejunocutaneous fistula that resulted from a percutaneous jejunal feeding tube inserted to supplement oral feeding for 6 months after distal gastrectomy and Bilroth II anastomosis. The fistula was 30 cm from the gastrojejunal anastomosis in the afferent limb and measured 13 mm. The www.giejournal.org
ventricular septal occluder was deployed across the fistula with a procedure time of 8 minutes (Fig. 1; Video 1, available online at www.giejournal.org). Conscious sedation was used, and the patient was discharged home the same day. The patient recommenced her diet, and no leakage through the fistula was observed at her 2-week follow-up visit. We demonstrate the technical feasibility and efficacy of the ventricular septal occluder for the short-term closure of a large enterocutaneous fistula. This novel technique may be an alternative closure method in cases in which standard endoscopic methods do not provide resolution.
DISCLOSURE Mouen A. Khashab is a consultant for Boston Scientific and Olympus America and has received research support Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1269
VideoGIE
from Cook Medical. Payal Saxena has received consulting fees from Boston Scientific and has received research support from Cook Medical. All other authors disclosed no financial relationships relevant to this publication. Vivek Kumbhari, MD, Alan H. Tieu, MD, Payal Saxena, MD, Mouen A. Khashab, MD, Patrick I. Okolo III, MD, Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
http://dx.doi.org/10.1016/j.gie.2014.07.015
Wide-field endoscopic resection of a large laterally spreading adenoma that encompassed the major papilla by combined ampullectomy, EMR, and underwater EMR
Figure 1. A, A 5-cm laterally spreading adenoma that encompassed the major papilla and involved a periampullary diverticulum was found. B, A combination of ampullectomy, conventional EMR, and underwater EMR was used to achieve complete endoscopic resection of this complex adenoma.
Endoscopic ampullectomy, saline solution–assisted EMR, and underwater EMR (UEMR) are efficacious and relatively safe procedures when performed individually. Herein, we report on a hybrid procedure using all 3 techniques for the resection of a large, laterally spreading adenoma that involved the major papilla and a periampullary diverticulum. A therapeutic duodenoscope was used to perform ampullectomy and pancreatic duct stenting of the major papilla, as well as piecemeal EMR of a 5-cm laterally spreading adenoma. Sterile normal saline solution tinted with indigo carmine was used for submucosal lifting for ampullectomy and piecemeal EMR. However, a large portion of the lesion’s circumference could not be approached by
use of the duodenoscope. A gastroscope with a cap and a 15-mm “duck-bill” snare were used to perform piecemeal UEMR to complete wide-field endoscopic resection (Fig. 1; Video 1, available online at www.giejournal.org). General anesthesia was used for this procedure. Traditional ampullectomy and EMR of large ampullary adenomas by use of a duodenoscope can be augmented by forward-viewing UEMR for the complete removal of large laterally spreading duodenal adenomas. Expertise in all of these techniques is valuable because reliance on the side-viewing duodenoscope or forward-viewing gastroscope alone may not be sufficient to remove very large or complex mucosal neoplasms.
1270 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
use of TAUS in emergent ICU ERCP to aid in confirming bile duct access.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
DISCLOSURE Dr Sejpal is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication. Arvind J. Trindade, MD, Alexander Brun, MD, Arunan S. Vamadevan, MD, Kostas Sideridis, DO, Divyesh V. Sejpal, MD, Division of Gastroenterology, Paul H. Mayo, MD, Sameer Khanijo, MD, Seth J. Koenig, MD, Division of Pulmonology and Critical Care, Department of Medicine, Hofstra North Shore–LIJ School of
Medicine, North Shore–Long Island Jewish Health System, New Hyde Park, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.09.025
Closure of a large, persistent enterocutaneous fistula by use of a ventricular septal occluder
Figure 1. Deployment of the ventricular septal occluder. A, Endoscopic view of the umbrella within the jejunum. B, View of the umbrella on the skin surface.
Enterocutaneous fistulas are associated with a significant morbidity and a mortality of between 5% and 20%. The most common causes are iatrogenic (jejunal feeding), Crohn’s disease, radiotherapy-induced, and secondary to malignancy. These patients are often poor surgical candidates, and hence a minimally invasive technique for closure may offer significant benefits. In this video, we demonstrate the use of a ventricular septal occluder (Amplatzer; St Jude Medical, Plymouth, Minn) to close a jejunocutaneous fistula. This device is a self-expandable double umbrella–shaped polyestercovered nitinol wire mesh. An 80-year-old woman was seen for management of a chronic, iatrogenic jejunocutaneous fistula that resulted from a percutaneous jejunal feeding tube inserted to supplement oral feeding for 6 months after distal gastrectomy and Bilroth II anastomosis. The fistula was 30 cm from the gastrojejunal anastomosis in the afferent limb and measured 13 mm. The www.giejournal.org
ventricular septal occluder was deployed across the fistula with a procedure time of 8 minutes (Fig. 1; Video 1, available online at www.giejournal.org). Conscious sedation was used, and the patient was discharged home the same day. The patient recommenced her diet, and no leakage through the fistula was observed at her 2-week follow-up visit. We demonstrate the technical feasibility and efficacy of the ventricular septal occluder for the short-term closure of a large enterocutaneous fistula. This novel technique may be an alternative closure method in cases in which standard endoscopic methods do not provide resolution.
DISCLOSURE Mouen A. Khashab is a consultant for Boston Scientific and Olympus America and has received research support Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1269
VideoGIE
from Cook Medical. Payal Saxena has received consulting fees from Boston Scientific and has received research support from Cook Medical. All other authors disclosed no financial relationships relevant to this publication. Vivek Kumbhari, MD, Alan H. Tieu, MD, Payal Saxena, MD, Mouen A. Khashab, MD, Patrick I. Okolo III, MD, Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
http://dx.doi.org/10.1016/j.gie.2014.07.015
Wide-field endoscopic resection of a large laterally spreading adenoma that encompassed the major papilla by combined ampullectomy, EMR, and underwater EMR
Figure 1. A, A 5-cm laterally spreading adenoma that encompassed the major papilla and involved a periampullary diverticulum was found. B, A combination of ampullectomy, conventional EMR, and underwater EMR was used to achieve complete endoscopic resection of this complex adenoma.
Endoscopic ampullectomy, saline solution–assisted EMR, and underwater EMR (UEMR) are efficacious and relatively safe procedures when performed individually. Herein, we report on a hybrid procedure using all 3 techniques for the resection of a large, laterally spreading adenoma that involved the major papilla and a periampullary diverticulum. A therapeutic duodenoscope was used to perform ampullectomy and pancreatic duct stenting of the major papilla, as well as piecemeal EMR of a 5-cm laterally spreading adenoma. Sterile normal saline solution tinted with indigo carmine was used for submucosal lifting for ampullectomy and piecemeal EMR. However, a large portion of the lesion’s circumference could not be approached by
use of the duodenoscope. A gastroscope with a cap and a 15-mm “duck-bill” snare were used to perform piecemeal UEMR to complete wide-field endoscopic resection (Fig. 1; Video 1, available online at www.giejournal.org). General anesthesia was used for this procedure. Traditional ampullectomy and EMR of large ampullary adenomas by use of a duodenoscope can be augmented by forward-viewing UEMR for the complete removal of large laterally spreading duodenal adenomas. Expertise in all of these techniques is valuable because reliance on the side-viewing duodenoscope or forward-viewing gastroscope alone may not be sufficient to remove very large or complex mucosal neoplasms.
1270 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
