bluuebunny/crossref_metadata_2025_split huggingface dataset:
2123 The Vanishing Gastrojejunostomy: A Case Report
Authors: Phan Ethan , Patel Pratik , Gollol Raju Narasimha Swamy , Mudireddy Prashant 
Published: October 2019

INTRODUCTION:
Gastrojejunal anastomotic strictures or stenoses are well recognized complications from Roux-en-Y gastric bypass surgery. Endoscopy remains an effective and safe means to diagnose these complications, which can occur as early as one month after surgery. The two main treatment modalities include endoscopy, either with balloon or bouginage dilators, or open versus laparoscopic surgery. Despite direct visualization, endoscopy could easily miss a severely stenotic anastomosis, as illustrated in the case of our a patient with gastrojejunal stenosis status post gastric bypass surgery.

CASE DESCRIPTION/METHODS:
43-year-old man with past medical history of morbid obesity s/p laparoscopic Roux-en-Y was admitted for acute nausea and vomiting. The Rouz-en-Y was performed one month ago and he initially was doing well with expected weight loss. Over the last 10 days, he had persistent nausea, vomiting, and anorexia. Labs were unremarkable at presentation. Initially, the surgical team was consulted and performed an EGD which revealed severe stenosis at the gastrojejunal anastomosis site; a balloon dilator was not able to be passed through the stenosis. The following day, gastroenterology team performed a repeat EGD, which revealed a large hematoma in the gastric body and epinephrine was injected. Initially, the gastrojejunal anastomosis was not clearly visualized despite partial dislodgement of the clot. However, under fluoroscopy, a closed, possible anastomotic site was identified and a wire was advanced through with contrast injection for verification that the wire was in fact in the bowel lumen. The anastomosis was then dilated and an AXIOS stent was placed across the anastomosis. The patient recovered well post-operatively, tolerating PO intake and was discharged. At follow up, the stent was successfully removed via rat-toothed forceps without complication. The anastomotic site was friable, but was wide open and a standard gastroscope was easily advanced through without complications.

DISCUSSION:
Gastrojejunal anastomotic stenosis is a known complication of Roux-en-Y gastric bypass surgeries. Its etiology is not completely understood and likely multifactorial but treatment options include endoscopic dilation and surgery. For our patient, fluoroscopic guidance with wire placement through the anastomotic site was required for successful deployment of the AXIOS stent. Therefore, endoscopic diagnosis should be considered as a safe modality for diagnosis and intervention for these complications.
2129 Lumen-Apposing Metal Stent for Benign Gastric Outlet Obstruction!
Authors: Alsheikh Mira , Kamar Khalil , Haddad Fady , Andrawes Sherif 
Published: October 2019

INTRODUCTION:
Lumen-apposing metal stent (LAMS) placement via endoscopic ultrasound (EUS)-guided gastroenterostomy has recently emerged as a promising technique for the management of malignant gastric outlet obstruction (GOO). This is safe, effective and technically feasible if performed by trained advanced endoscopists. Despite that LAMS use in malignant GOO is well defined, it is rarely performed for benign etiologies of GOO and only 4 cases have been reported in the literature. We report the case of a patient with GOO secondary to benign duodenal stricture that was successfully managed by LAMS placement.

CASE DESCRIPTION/METHODS:
A 60-year-old man with history of recurrent duodenal ulcers presented for vomiting and food intolerance for few days. Two years ago he had a GOO secondary to his ulcer disease and was managed by surgical gastrojejunostomy (GJ). A subsequent marginal ulcer perforation required resection of the GJ with small bowel anastomosis and insertion of a GJ tube. Upon presentation, physical examination was notable for epigastric tenderness with no rebound or rigidity. Contrast computed tomography (CT) scan of the abdomen showed a markedly distended stomach and proximal duodenum with focal narrowing near the pancreatic head (Figure 1). Enteric contrast reached the rectum indicating the absence of complete obstruction. Upper endoscopy showed retained solid material in stomach and an almost completely occluded “pin hole” duodenal lumen that could not be traversed with the endoscope. A wire-guided through the scope dilation with a balloon was performed in conjunction with fluoroscopy but was unsuccessful (Figure 2) so a 10 mm × 15 mm EUS-guided LAMS was successfully deployed. Patient’s symptoms resolved and he was able to tolerate diet.

DISCUSSION:
GOO usually occurs secondary to malignancy-related mass effect or luminal invasion. Less commonly GOO can be attributed to benign etiologies namely ulcers, caustic ingestion and inflammation. Often managed by endoscopic balloon dilation, benign strictures can recur. Other less favored options include self-expandable metal stents which use is limited by a high rate of migration and failure and surgical approach which provides definitive treatment but is associated with a high risk of mortality and morbidity. LAMS is a novel and appealing less invasive approach proven to be a safe alternative allowing early restoration of enteral luminal access with good short term success and satisfying safety profile. Further studies and long term follow up are recommended.
2130 Future of Endoscopy: Hybrid Argon Plasma Coagulation for Treatment of Intestinal Metaplasia of the Stomach
Authors: Estifan Elias , Mohamed Abdalla , Cavanagh Yana , Grossman Matthew 
Published: October 2019

INTRODUCTION:
Hybrid Argon Plasma Coagulation (Hybrid APC) is an advancement on standard APC technology; application of APC is preceded by high pressure needleless submucosal injection, with the same catheter. APC is indicated for the ablation of benign and dysplastic mucosal lesions such as vascular malformations and Barrett’s mucosa. Hybrid APC offers an advantage over efficacy and safety advantages over standard APC. The submucosal injection acts as a heat sink and disperses excess energy to ensure that the underlying layers (i.e.: muscularis propria) are unaffected. Only the mucosal layer is coagulated, in its entirety.

CASE DESCRIPTION/METHODS:
An 81 years-old Hispanic Male was found to have a 1.2 cm mucosal nodule along the incisura of the stomach (Figure 1). He underwent endoscopic ultrasound (EUS) of the lesion, which confirmed the presence of an isolated gastric nodule with no deep invasion of the muscularis propria, consistent with a T1N0Mx endoscopic staging. He subsequently underwent endoscopic submucosal dissection (ESD) of the lesion. Pathology of the specimen revealed multifocal high-grade dysplasia, arising in the background of extensive intestinal metaplasia. The deep margin was clear; however, the lateral resection margins showed focal involvement of intestinal metaplasia with low-grade dysplasia. In light of the diffuse mucosal dysplasia, the patient was successfully treated with widespread Hybrid APC of the residual intestinal metaplasia (Figures 2 and 3).

DISCUSSION:
Hybrid APC is an effective and efficient treatment modality for mucosal lesions. In one series of 50 patients; 96% achieved complete macroscopic remission of Barrett’s mucosa after a median of 3.5 APC sessions and 85% achieved complete histological remission. Hybrid APC is a promising technology as thermal injury depth is targeted and reduces deep injury as well as subsequent complications when it compared with Standard APC. Applications of hybrid APC will likely continue to grow as this modality is adopted into common parlance. This case is the first to describe the use of Hybrid APC for definitive treatment of intestinal metaplasia.
2133 Hybrid Argon Plasma Coagulation Therapy for Early Esophageal Squamous Cell Carcinoma
Authors: Estifan Elias , Cavanagh Yana , Grossman Matthew 
Published: October 2019

INTRODUCTION:
Squamous cell carcinoma is common in Asia, accounting for most cases of esophageal cancer throughout the world, whereas adenocarcinoma is more common in the Western world. Overall, neoplasms of the esophagus carry a poor prognosis. Treatment options depend on the stage of the disease. Endoscopic therapy may be considered for early disease as endoscopic resection is a safe and minimally invasive treatment option for Tis and T1a esophageal malignancies. Esophagectomy is necessary for invasive disease.

CASE DESCRIPTION/METHODS:
A 56 years-old male was found to have non-circumferential mucosal irregularities between 25-27 cm from the incisors (Figure 1). Biopsy of the irregular mucosa revealed atypical squamous proliferation, consistent with squamous cell carcinoma in-situ (Tis). Subsequent endoscopic ultrasound (EUS) evaluation revealed thickened mucosa without the involvement of the deep mucosa or muscularis propria. Endoscopic mucosal resection (EMR) was performed and pathology confirmed clear margins. Subsequent surveillance EGD revealed the persistence of atypical squamous mucosa however extensive post-EMR scarring prevented repeat mucosal resection. The patient refused surgical intervention and the decision was made to pursue hybrid APC ablation of the remaining esophageal mucosa. The esophageal mucosa was lavaged with Lugoll’s Iodine to expose the affected squamous epithelium. The affected areas were then lifted with a solution of saline and methylene blue and ablated using argon plasma coagulation at 50 W (Figure 2).

DISCUSSION:
APC has been successfully used in similar applications; to ablate tissue margins after endoscopic resection of early neoplasia. The development of hybrid APC and its inherent improved safety profile allows for an extension of its application to include primary treatment of dysplastic and neoplastic lesions. In one recent study, tissue damage was limited to the submucosal layer regardless of application time. This case describes an effective novel use of Hybrid APC for treatment of Tis esophageal squamous cell carcinoma.
2134 Drainage of a Mediastinal Abscess After Esophagectomy Using a Lumen-Apposing Metal Stent
Authors: Elfanagely Yousef , Shahid Haroon , Kahaleh Michel , Sarkar Avik , Tyberg Amy 
Published: October 2019

INTRODUCTION:
Endoscopic ultrasound (EUS) is an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy1. Therapeutic EUS has found a role in management of pancreatic fluid collections, biliary and pancreatic duct drainage, and drainage of mediastinal and intra-abdominal abscesses and collections1. We present a case of a mediastinal abscess drainage after esophagectomy using a Lumen-apposing metal. To our knowledge, this is the second case using a Lumen-apposing metal stent for mediastinal collections2.

CASE DESCRIPTION/METHODS:
Case Summary: This is a case of a 75-year-old man with esophageal adenocarcinoma s/p transhiatal esophagectomy complicated by recurrent pleural effusions, ischemic colitis requiring right hemicolectomy and end ileostomy who presented to the ED from rehab because of abnormal lab findings of hypernatremia and leukocytosis. During his hospital stay, the patient developed persistent fevers and leukocytosis. A CT scan of the chest revealed a large posterior mediastinal collection adjacent to the gastric pull-through that coursed inferiorly into the peritoneum. The collection measured 8 cm × 4.1 cm x 12 cm in size and was presumed to be the source of infection. The case was discussed amongst the surgical oncologist, thoracic surgeon, interventional radiologist, and advanced endoscopists. Options for drainage included repeat surgery, percutaneous drain placement, and endoscopic drainage. The consensus opinion was to drain the collection internally by endoscopic ultrasound. The patient underwent a successful EUS-guided abscess drainage with a lumen apposing metal stent. The patient drastically improved after internal drainage with the lumen apposing metal stent. Fevers and leukocystosis resolved. Follow-up CT scan of the chest 10 days later demonstrated a resolution of the mediastinal collection.

DISCUSSION:
Conclusion: Although developed for drainage of pancreatic fluid collections, this case demonstrates that lumen apposing metal stents can be safely used to drain mediastinal collections. Our literature review identified one other case that utilized a lumen-apposing metal stent to drain a mediastinal abscess2. This stent seems to be useful and safe for mediastinal drainage. We recommend a multidisciplinary discussion with surgeons and radiologists when dealing with large mediastinal collections that require drainage.
2135 A Rare Case of Dysphagia From a Cricopharyngeal Septal Cyst Within a Zenker’s Diverticulum Treated With EUS-FNA and Endoscopic Incisional Therapy
Authors: Al-Salameh Nizar , Khalid Ammara , Basi Puneet , Khara Harshit S. 
Published: October 2019

INTRODUCTION:
Zenker’s diverticulum (ZD) occurs mostly in elderly patients and may manifest with dysphagia, halitosis, regurgitation, and aspiration. We present a rare cause of esophageal dysphagia from an obstructing cyst on the cricopharyngeal septum within the Zenker’s diverticulum, successfully treated with endoscopic ultrasound guided drainage and endoscopic incisional therapy.

CASE DESCRIPTION/METHODS:
A 68-year-old female was referred for endoscopic treatment of a suspected Zenker’s diverticulum seen on esophagram. On endoscopic exam, she was found to have an obstructing Zenker’s diverticulum in the proximal esophagus with a cystic structure on the cricopharyngeal septum (image 1). Endoscopic ultrasound exam was done to characterize the cystic lesion which showed a 14 mm anechoic round cyst originating in the deep mucosa (image 2). Color Doppler did not find any significant vascular flow within the cyst, which was then aspirated under EUS guidance and cytology confirmed a benign cyst. After cyst decompression, the Zenker’s diverticulum was successfully treated using flexible endoscopic incisional therapy with the SB knife (image 3). Patient had complete resolution of her dysphagia with no symptom recurrence.

DISCUSSION:
Zenker’s diverticulum has been successfully treated with surgical and endoscopic techniques, but the presence of incidental cystic or vascular lesions highlight the need for endoscopic evaluation and use of adjunct tools such as endoscopic ultrasound to rule out vascular flow and assist in drainage before endoscopic therapy can be pursued. We report a unique case of cricopharyngeal septal cyst as the cause of symptomatic dysphagia within a Zenker’s diverticulum which was successfully treated with endoscopic interventional tools.
2137 The Game Changing Utility of EUS-FNA for Pancreatic Evaluation: Not All Pancreas Masses on CT Are Pancreas Tumors!
Authors: Park Steven , Perez-Colon Anjanet , Foor-Pessin Caitlin , Kothari Truptesh , Fultz Patrick J. , Galka Eva , Kaul Vivek , Kothari Shivangi 
Published: October 2019

INTRODUCTION:
A pancreatic mass seen on cross-sectional imaging with liver lesions or lymphadenopathy is concerning for a pancreatic malignancy. Previous reports have discussed the utility of EUS-FNA for evaluation of pancreatic masses; this case series aims to reinforce the game-changing utility of EUS-FNA for the clarification of suspected pancreatic neoplasia.

CASE DESCRIPTION/METHODS:
Case #1: A 68-year-old woman undergoing evaluation for hematuria was found to have two enhancing liver lesions, two pulmonary nodules, and a low attenuation zone in the uncinate process of the pancreas on CT (Image 1). Physical exam and laboratory tests were unremarkable. A pancreas protocol CT at our center confirmed the above findings and the patient was referred for EUS-FNA. On EUS, pancreatic anatomy was completely normal and no mass was identified. Subsequent evaluation with a triphasic MRI (Image 2) concluded that the liver lesions were atypical hemangiomas and the pancreas had focal fatty replacement that can mimic a pancreatic tumor. A repeat EUS at 6 months was unremarkable and the patient is doing well. Case #2: A 56-year-old woman with history of melanoma presented with RUQ pain and +30lbs weight loss over the previous 5 months. Physical examination was unremarkable and laboratory tests were notable for elevated LFTs. CT (Image 3) revealed a homogeneously enhancing retroperitoneal mass arising between the pancreatic uncinate and D3 with several enlarged mesenteric lymph nodes, suspected to be pancreatic neoplasm. Further evaluation with EUS revealed a 3.5 cm heterogenous periduodenal mass abutting D2 and enlarged peri-gastric lymph nodes. FNA was performed and histopathology identified the mass as gastrointestinal stromal tumor (GIST) with reactive lymph nodes. The patient was started on neoadjuvant Imatinib with approximately 25% shrinkage of the mass appreciated in the first 2 months. Afterward, the patient underwent pancreaticoduodenectomy and surgical pathology revealed a mixed subtype duodenal GIST with a low mitotic rate.

DISCUSSION:
We report 2 cases of suspected metastatic pancreatic carcinoma whose diagnoses were elucidated as focal fatty replacement and duodenal GIST, respectively, with the help of EUS +/- FNA. Pancreatic lesions found on cross-sectional imaging that are thought to be primary pancreatic neoplasms should be further evaluated by EUS. EUS with/without FNA can be a game-changing imaging modality in such cases, providing an accurate diagnosis and helping guide appropriate management.
2139 Endoscopic Closure of Post-Operative Duodenal-Enteric Fistula Following Repair of Abdominal Gunshot Wounds
Authors: Kruchko David H. , Shah Natasha , Hoff Ryan T. , Lakha Asif 
Published: October 2019

INTRODUCTION:
Gastrointestinal defects including enteric duodenal fistulas cause complications such as infection and multiorgan failure, which may lead to death. The gold standard is surgical closure; however, this requires repeat surgeries and may lead to post-operative complications. The over the scope clip (OTSC) is known to be an effective and safe modality for GI defects such as perforation and GI tract leaks, but studies have shown limited success for closure of gastrointestinal fistulous tracts and is dependent on the anatomical location and size of the defect. We report a case where an OTSC was used successfully for immediate closure of a duodenal-enteric fistula caused by a gunshot wound, which saved the patient from undergoing additional surgery.

CASE DESCRIPTION/METHODS:
A 41-year-old man presented with multiple gunshot wounds to the abdomen. An emergent exploratory laparotomy was performed, with partial small bowel resection for gunshot wounds to the jejunum and ileum. His post-operative course was complicated by an intra-abdominal abscess. A sinogram revealed a duodenal-enteric fistula with a fluid collection, requiring Jackson Pratt drain placement and antibiotic therapy (A). Given the lack of improvement, the patient was taken for esophagogastroduodenoscopy (EGD). A 10 mm fistulous tract was identified at the junction of the 2nd and 3rd portion of the duodenum (B). A 12/6t OTSC was deployed over a pediatric colonoscope. The scope was passed to the level of the fistula, with fluoroscopy for localization. Using suction, the fistula was pulled into the cap of the OTSC device and the clip was successfully deployed, closing the fistula (C). Clip placement was confirmed via fluoroscopy. The next day, upper gastrointestinal stomach X-Ray was completed and did not show extravasation to suggest a leak at the duodenum. His diet was advanced and after a prolonged hospital course, he was discharged.

DISCUSSION:
This case highlights the use of OTSC for a fistula caused by trauma rather than common causes such as bariatric surgery, percutaneous gastrostomy tube placement, or an underlying malignancy. Although technically challenging, when used as primary therapy, OTSC closure of an enteric fistulous tract has the potential to reduce the need for an emergent surgery. Therefore, OTSC closure should be considered an effective therapeutic modality in patients with trauma-related abdominal enteric fistulas.
2146 Combined Novel Endoscopic Techniques in Esophageal Carcinoma Management
Authors: Ali Osman , Khan Imran , Kim Raymond E. 
Published: October 2019

INTRODUCTION:
A variety of techniques are currently being investigated to provide optimal resection of submucosal tumors by endoscopy. Specifically, peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic procedure which was originally established as a minimally invasive technique to treat achalasia and esophageal motility disorders. Due to its success in treatment of esophageal motility disorders, certain Centers of Excellence for advanced endoscopy have expanded the use of POEM in combination with other advanced endoscopic techniques for treating esophageal cancers. In this case, we present a 69-year-old male with squamous cell cancer (SCC) in the lower third of the esophagus who was successfully treated using combined endoscopic submucosal dissection (ESD), submucosal tunneling, and POEM techniques.

CASE DESCRIPTION/METHODS:
A 69-year-old male with a medical history of 50-pack-year tobacco abuse, chronic alcohol use, and chronic pancreatitis was initially evaluated with EGD and EUS for anorexia, weight loss, and pancreatic cysts. Initial EGD required biopsies of nodular esophageal mucosa revealing underlying squamous cell carcinoma in situ. Repeat endoscopy 2 months later revealed a large tumor circumferentially involving 80% of the lumen in the lower esophagus. Subsequently, the patient received therapeutic intervention combining ESD and POEM techniques for tumor resection, prognostication, and symptom relief. Lesion borders were marked, and a circumferential incision was made around the lesion lifting it from the muscularis propria allowing for successfully mass excision. The submucosal dissection combined with circumferential tunneling technique allowed for complete resection of the tumor. The patient reported post-procedure symptomatic relief and was able to resume oral intake.

DISCUSSION:
POEM is a combination of the pre-existing endoscopic myotomy procedures in conjunction with endoscopic submucosal tunneling techniques. Although POEM is labor intensive, its application gives precision by granting access to the neoplasms without affecting deeper esophageal layers. This promising advance in gastrointestinal procedures compared to esophagectomy has shown in reported studies to offer a lower morbidity rate while providing similar cancer-free survival. Our case demonstrates successful treatment using POEM and adjunct endoscopic therapies in submucosal tunneling and submucosal tunneling endoscopic resection (STER) in the treatment of large circumferential esophageal cancer.