VideoGIE
Sleeve endoscopic esophageal mucosotomy
Figure 1. Biological matrix was manually attached in a piecewise fashion to a fully covered stent to allow for expansion.
Complete circumferential endoscopic submucosal dissection (ESD) techniques have been used recently to remove specimens en bloc. Although evaluation of margins remains a benefit, scar formation and strictures remain major problems. Stenting with or without biologic matrix may be helpful in preventing strictures, but deployment remains problematic. We present a modified technique of circumferential ESD with a novel over-the-scope stent technique to place a biologic matrix into the mucosal defect. A 12-cm segment of circumferential Barrett’s esophagus with multifocal intramucosal cancer was resected endoscopically by using a modified ESD technique. A novel, over-the-scope technique of deploying a metal stent fully covered with a biologic scaffold is shown (Fig. 1; Video 1, available online at www.giejournal.org). The patient was treated with systemic steroids for 2 weeks. The stent was removed after 5 weeks, and EGD showed partial growth of the matrix on the esophageal muscular wall with no stricture. At 3 months, mild stricturing was treated
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.
with balloon dilation. At 6 months, EGD showed a smooth mucosal lining with healing ulceration. Biopsies showed no Barrett’s esophagus. Sleeve endoscopic esophageal mucosotomy is feasible for extended esophageal mucosectomy but with a high stricture rate. Our over-the-scope technique of deploying the biologic matrix with a stent represents a potential solution. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Ahmed M. Sharata, MD, Christy M. Dunst, MD, Foundation for Surgical Innovation and Education; Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Radu Pescarus, MD, Eran Shlomovitz, MD, Ashwin Kurian, MD, Department of Surgery, Providence Portland Medical Center, Kevin M. Reavis, MD, Lee L. Swanström, MD, Foundation for Surgical Innovation and Education; Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Portland, Oregon, USA Presented at Digestive Disease Week, May 3-6, 2010, Chicago, Illinois, USA. http://dx.doi.org/10.1016/j.gie.2014.09.045
“Unchaining” a stuck early gastric cancer by endoscopic submucosal dissection EMR removes GI lesions by use of a snare. However, EMR presents a decreasing en bloc resection rate for lesions larger than 2 cm, of irregular shape, or with underlywww.giejournal.org
ing fibrosis. Endoscopic submucosal dissection (ESD) is performed with a dissection knife by a freehand technique. It has demonstrated a significantly increased en bloc Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1253
VideoGIE
Figure 1. Almost complete endoscopic mucosal dissection showing a lesion “chained” to the wall through a staple line.
resection rate for lesions larger than 2 cm independently of shape or presence of fibrosis. However, ESD presents a higher risk of adverse events. A 67-year-old man with a medical history of distal gastrectomy received a diagnosis of metachronous early gastric cancer at the cardia. The patient refused total gastrectomy and was referred for ESD. The procedure was performed according to a standard technique including marking, incision, and dissection. There was a central area that could not be removed with the knife even by exertion of mechanical pressure. At this area we found several metallic structures consistent with a staple line (Fig. 1). We managed to dislodge some of the staples,
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.
creating a thinner area that could be resected by use of a snare (Video 1, available online at www.giejournal.org). Pathologic examination revealed a well-differentiated adenocarcinoma with focal infiltration of the lamina propria, free vertical and lateral margins, and no lymphovascular invasion. The fibrous pedicle was free of disease. Follow-up endoscopy showed no residual lesion. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Andres Sanchez-Yague, MD, Angel GonzalezCanoniga, RN, Andres M. Sanchez-Cantos, MD, Hospital Costa del Sol, Marbella, Spain, Roy Soetikno, MD, Veterans Affairs Palo Alto and Stanford University, Palo Alto, California, USA
http://dx.doi.org/10.1016/j.gie.2014.07.010
Anchor technique: prevention of intraluminal stent migration with the help of loop and clips One of the nonsurgical treatments for strictures, regardless of the underlying cause, is stent placement as an alternative to surgery. The most common adverse event of stent placement is stent migration. The procedure was performed at Lenox Hill Hospital. A 50-year-old male with Roux-en-Y gastric bypass devel-
oped dysphagia and vomiting 2 months after surgery. At another institution, the patient had placement of an esophageal fully covered stent (23 mm 105 mm) (Wallflex; Boston Scientific, Natick, Mass), which was secured with a suture device. After 2 weeks, the stent migrated and was removed from the jejunum. After 1 week, the
1254 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
Sleeve endoscopic esophageal mucosotomy
Figure 1. Biological matrix was manually attached in a piecewise fashion to a fully covered stent to allow for expansion.
Complete circumferential endoscopic submucosal dissection (ESD) techniques have been used recently to remove specimens en bloc. Although evaluation of margins remains a benefit, scar formation and strictures remain major problems. Stenting with or without biologic matrix may be helpful in preventing strictures, but deployment remains problematic. We present a modified technique of circumferential ESD with a novel over-the-scope stent technique to place a biologic matrix into the mucosal defect. A 12-cm segment of circumferential Barrett’s esophagus with multifocal intramucosal cancer was resected endoscopically by using a modified ESD technique. A novel, over-the-scope technique of deploying a metal stent fully covered with a biologic scaffold is shown (Fig. 1; Video 1, available online at www.giejournal.org). The patient was treated with systemic steroids for 2 weeks. The stent was removed after 5 weeks, and EGD showed partial growth of the matrix on the esophageal muscular wall with no stricture. At 3 months, mild stricturing was treated
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.
with balloon dilation. At 6 months, EGD showed a smooth mucosal lining with healing ulceration. Biopsies showed no Barrett’s esophagus. Sleeve endoscopic esophageal mucosotomy is feasible for extended esophageal mucosectomy but with a high stricture rate. Our over-the-scope technique of deploying the biologic matrix with a stent represents a potential solution. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Ahmed M. Sharata, MD, Christy M. Dunst, MD, Foundation for Surgical Innovation and Education; Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Radu Pescarus, MD, Eran Shlomovitz, MD, Ashwin Kurian, MD, Department of Surgery, Providence Portland Medical Center, Kevin M. Reavis, MD, Lee L. Swanström, MD, Foundation for Surgical Innovation and Education; Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Portland, Oregon, USA Presented at Digestive Disease Week, May 3-6, 2010, Chicago, Illinois, USA. http://dx.doi.org/10.1016/j.gie.2014.09.045
“Unchaining” a stuck early gastric cancer by endoscopic submucosal dissection EMR removes GI lesions by use of a snare. However, EMR presents a decreasing en bloc resection rate for lesions larger than 2 cm, of irregular shape, or with underlywww.giejournal.org
ing fibrosis. Endoscopic submucosal dissection (ESD) is performed with a dissection knife by a freehand technique. It has demonstrated a significantly increased en bloc Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1253
VideoGIE
Figure 1. Almost complete endoscopic mucosal dissection showing a lesion “chained” to the wall through a staple line.
resection rate for lesions larger than 2 cm independently of shape or presence of fibrosis. However, ESD presents a higher risk of adverse events. A 67-year-old man with a medical history of distal gastrectomy received a diagnosis of metachronous early gastric cancer at the cardia. The patient refused total gastrectomy and was referred for ESD. The procedure was performed according to a standard technique including marking, incision, and dissection. There was a central area that could not be removed with the knife even by exertion of mechanical pressure. At this area we found several metallic structures consistent with a staple line (Fig. 1). We managed to dislodge some of the staples,
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.
creating a thinner area that could be resected by use of a snare (Video 1, available online at www.giejournal.org). Pathologic examination revealed a well-differentiated adenocarcinoma with focal infiltration of the lamina propria, free vertical and lateral margins, and no lymphovascular invasion. The fibrous pedicle was free of disease. Follow-up endoscopy showed no residual lesion. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Andres Sanchez-Yague, MD, Angel GonzalezCanoniga, RN, Andres M. Sanchez-Cantos, MD, Hospital Costa del Sol, Marbella, Spain, Roy Soetikno, MD, Veterans Affairs Palo Alto and Stanford University, Palo Alto, California, USA
http://dx.doi.org/10.1016/j.gie.2014.07.010
Anchor technique: prevention of intraluminal stent migration with the help of loop and clips One of the nonsurgical treatments for strictures, regardless of the underlying cause, is stent placement as an alternative to surgery. The most common adverse event of stent placement is stent migration. The procedure was performed at Lenox Hill Hospital. A 50-year-old male with Roux-en-Y gastric bypass devel-
oped dysphagia and vomiting 2 months after surgery. At another institution, the patient had placement of an esophageal fully covered stent (23 mm 105 mm) (Wallflex; Boston Scientific, Natick, Mass), which was secured with a suture device. After 2 weeks, the stent migrated and was removed from the jejunum. After 1 week, the
1254 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
