HowIt’sDone:ChallengingEndoscopicCases
LaithHJamil,M.D.FASGE,FACGAssociateDirectorofInterventionalEndoscopy
AssociateClinicalProfessorCedarsSinaiMedicalCenter
Objectives
DiscussvideoofForeignbodyremovalDiscussvideoofmigratedesophagealstentDiscussanElusiveNETDiscussachallengingcoloncancercaseGastricAdenomawithLGDTreatedwithESDRemovalofanintragastric balloonDiscussairwayintubationinchallengingpatients
ConflictsofInterest
• None
EndoscopicRetrievalofIngestedPaperclips
EricaCohen,LaithHJamil,AliRezaie
Case
• A26yearoldmalewithH/OPTSD,presentsafteringesting20paperclipfragments• HewascomplainingofdiffuseAP,andscantbloodyemesis• Thiswasthesecondtimeinthelast12months!
Video
FU
• Patienthospitalizeduntilallremainingpaperclipswereexpelled(5days)• Nocomplications• Psychiatricservicesprovided
MigratedEsophagealStentRetrievedViaOralDouble
BalloonEnteroscopyLaithHJamil,M.D.
Case• A 72 year old female, 18 years post Billroth II for PUD, with
symptoms of GOO, failed repeated dilation of GJ anastomosis• An 18mm X 12cm fully covered esophageal stent, was placed
across the anastomosis, with suturing • Stent migrated 3 weeks later. Patient was asymptomatic and
the stent was observed for 4 weeks and did not pass spontaneously
Video
Follow-up• Patient was discharged the following day with no symptoms• She presented 2 ½ months later with cholangitis, and the GJ
anastomosis was still patent
Technique Highlights• The use of the DBE allows for removal of a migrated
esophageal stent through the over-tube portion without causing harm to the small bowel• The scope can then be re-introduced to evaluate the area and
ensure there is no complication or underlying etiology for the stent to not have migrated spontaneously •
Conclusions• Oral DBE is safe and effective in removing a migrated
esophageal stent into the small bowel, in patients who are asymptomatic• Technique can be used to potentially removed other FBs that
migrate into the SB
ElusivePrimaryNETLaithHJamil,MD
Case
• 72F foundtohaveNETtoliveronaCTscanperformedforothermedicalproblems• SheunderwentanEGD/EUS,peroutsidereportnegative• Referredforawirelesscapsuleenteroscopy
WCE• Thefirstduodenalimageisat10minutes23seconds• Ulceratedsubmucosal massfoundat1hour51minutes25seconds
OralDBE
• OralDBEwithtattoomarkintheproximalileum.Negative
WCE
• Firstduodenalimageisat1hour23minutes16seconds• Asmallpolypoid lesionnotedinthejejunumat5hours28minutes3seconds.Thiswassmallerthantheoneseenpreviouslyandnoulcerationswerenoted
DBEs
• RepeatOralDBEtotattoomarknegative• RetrogradeDBEtotattoomarknegative
• Nowwhat?
EGD
• GIF-H190 scopewasadvancedintheoropharynxtothe2ndportionoftheduodenum• The2ndportionoftheduodenumandduodenalbulbappearednormal
SideViewingScope
• Intheduodenalbulbjustdownstreamfromthepylorus,therewasanulceratedmass
EUS
• 18.1x5.7mmextendingtotheMP,buttheMPappearedtobeintact• NoregionalLAP
Path
Duodenalbulbmass,biopsy:- Welldifferentiatedneuroendocrine(carcinoid)tumor- Tumorispresentinthesubmucosaandextendstothedeepedgesofthebiopsy- Lowgrade(G1)- Mitosis:Notidentified- Ki-67proliferativeindex:<2%
Surgery
Well-differentiatedneuroendocrinetumorinduodenum- Size:1.4cminmaximumdimension- Depthofinvasion:involvesmuscularis propria- Resectionmargins:Duodenalmarginclosest;clearance0.2cm- Tumornecrosis:Notidentified- Lymphovascular invasion:Notidentified- Mitoticcount:Lessthan1mitosisper10highpowerfields- Ki-67proliferationindex:pendingbycomputerassistedimageanalysis- Lymphnodestatus:Sevenlymphnodesretrieved,allnegativeforneuroendocrinetumor(0/7)- AJCC PathologicStage(7thed.,2010):pT2N0M1
PETPositiveinthePancreasandataPreviousPolypectomySite
LaithHJamil
Case
• 60-year-oldmaleunderwentacolonoscopywithpolypectomy ofasigmoidpolyp7yearspriorthatshowedintramucosal cancer• Followupcolonoscopiesupto2yearspriorshowednoevidenceofrecurrence• Imaging1yearpriortoR/Odiverticulitisshowednoevidenceofanytumor
Now
• Hecomplainedofbackpainfor2weeksandunderwentimagingstudies• Apancreaticlesionandaliverlesion• Biopsyoftheliverlesionsshowedmoderatelydifferentiatedadenocarcinoma,intestinaltype• PETCTscanshowedmetabolicactivityinpancreaticheadmass,lesionsintheliver,retroperitoneallymphnodes,andproximalsigmoidcolonactivity
Colonoscopy
EUS
Path
• A.Colon,sigmoid,25cm,biopsy:• - Superficialfragmentsofadenocarcinoma
• B.Pancreas/peripancreatic,mass,corebiopsy:• - Adenocarcinoma,moderatelydifferentiated,compatiblewithcolonicprimary
GastricAdenomawithLGDLaithHJamil
Case
• A75yearoldChinesemaleunderwentanendoscopyandnotedtohavea2.5X1.5cmsessilelesionintheantrum• Bx:AdenomawithLGD
EndoscopicSubmucosalDissection
FinalPath
Antral mucosawithLGD/tubularadenomatouschange- NoHGDorinvasivecarcinomaidentified- Allmarginsnegativefordysplasia- Nearestapproachofdysplasiatoperipheralmargin:4mm
Intragastric BalloonRemovalLaithHJamil
Case
• 45-year-oldfemaleunderwentagastricballoonplacement1yearpriortopresentation• ItwasanadjustableSpatz 3balloonplacedintheUnitedKingdom• NotavailableintheU.S.• EvaluatedbysurgeryforAbdominoplastyandadvisedtohavetheballoonremoved• Endoscopyperformednotedtheinflatedballoon.Itwaspuncturedanddeflatedbutcouldnotberemovedendoscopically.Perreport,itcouldbepulledintotheesophagusbutnotout
BalloonsareDifferent
• Eachballoonhasitsownmethodofremoval• Needtobefamiliarwithtechnique• Seekoutmedicalresourcesi.e youtube!• LengthydiscussionwithpatientssurgeonintheU.K.priortotheprocedure!• Wastoldneedspecialequipment,butadvisedofalternativeoptionsthatmaywork!
Spatz 3AdjustableBalloon
Endoscopy
EndotrachealIntubationUsingaFlexibleGastroscope
LaithHJamil,MD
Case
• A93yearoldfemale,postcholecystectomywasreferredforsuspectedcholedocholithaisis• MACwithpropaphol wasused• EUS confirmedcholedocholithiais
Case
• PatientdevelopedO2 desaturation• Difficultintubation
TechniqueHighlights
• Thesmallerdiameterendoscope(4.9mmto5.5mmouterdiameterscopes)iswelllubricatedandadvancedthroughanadultendotrachealtube(6.5mmto8mminnerdiameter)
TechniqueHighlights
• Thescopeisthenadvancedintotheoropharynx,throughthevocalcords,toabovethecarina• Theanesthesiologistthenadvancestheendotrachealtubeoverthescopeandpositionsitabovethecarina.Thescopeisthenwithdrawn
Conclusions
• Thegastroscopes usuallyusealargerscreenmonitor,andhavebettertipcontrol• ThusthesmallerdiameterEGDscopecanbeusedforflexiblescopeairwayintubationinadifficultairwayintubationsituationorincertaincircumstancessuchasavoidingrepositioningthepatientortoavoidremovingtheendoscope
ThankYou!