bluuebunny/crossref_metadata_2025_split huggingface dataset:
1683 Hybrid APC-Assisted EMR: A New Technique to Prevent Polyp Recurrence
Authors: Levenick John M. , Manzo Carl , Maranki Jennifer 
Published: October 2019

INTRODUCTION:
The importance of colonoscopy in the prevention of the development of colon cancer is readily recognized. Although there has been a decline in rates of colon cancer, 5% of people continue to develop colon cancer and 2.5% will die from it. Roughly 5% of polyps removed are laterally-spreading lesions (LSL) that are greater than 10mm in size. Most large LSLs are now removed endoscopically which allows for removal on an outpatient basis with an improved safety profile. However, one drawback is the rate of recurrence, quoted at 10–30%. A key aspect to EMR is adequately lifting the lesion using an inert dye such as methylene blue infused solution into the submucosal space with special attention to avoiding extramural injection. It was originally felt that APC fulguration could be used to treat remaining tissue post-EMR. However, recurrence rates using this technique remained high. Resection of 3–5 mm of normal tissue around the site also did not reduce recurrence though simple snare-tip soft coagulation of the edges improved recurrence rates. We hypothesize that high recurrence rates post-EMR polypectomy occur due to microscopic residual disease in the base and edges of the lesion and that using APC to treat the post-EMR site will decrease recurrence rates to less than 5%.

CASE DESCRIPTION/METHODS:
Once the LSL is detected and assessed, the patient is grounded and the ERBE Vio300D system is assembled. A solution of saline and methylene blue is made. Using the needleless waterjet of the Hybrid APC system, the lesion is lifted with an effect of 30–50, helping to prevent extramural injection and allowing for optimal lift. EMR is then performed in typical fashion. We often prefer to use the Endo Cut setting with an effect of 2, cut duration of 1, and cut interval of 4. After the neoplasia has been completely removed, the base and borders are relifted with the needleless waterjet . This additional lift helps to avoid deep mucosal injury. APC is then performed using a flow of 0.8 L/min and 30 watts. The entire base of the site and the circumferential borders of the lesions undergo APC in their entirety. Endoclips can be used to close the post-polypectomy site.

DISCUSSION:
Thus far at our institution, we have used hybrid APC assisted EMR in roughly 50 cases. All of these procedures were tolerated well, and only two of them were complicated by delayed post-polypectomy bleeding. We are hopeful that this method will reduce rates of recurrence and eventually possibly become standard of care for these lesions.
Watch the video: http://bit.ly/2xXmNUC.
1684 Paging Dr. MacGyver: A Novel Approach to Redeploying a Dislodged AXIOS Stent During a Pancreatic Necrosectomy
Authors: Reddy Rekha , Cheung Derrick 
Published: October 2019

INTRODUCTION:
Although multiple modalities exist for managing walled off and infected pancreatic necrosis, EUS-guided transmural drainage is often favored due to its minimally invasive and highly effective nature. The AXIOS stent has demonstrated clear superiority over double pigtail and fully covered self-expanding metal stents in this setting. Although the radial force from its wide luminal diameter and its dumbbell shape helps secure the stent in place, stent migration and dislodgement can still occur. Here, we present a case of stent dislodgement during a pancreatic necrosectomy, which was salvaged by stent extraction and endoscopic re-deployment using a stone extraction balloon catheter sheath.

CASE DESCRIPTION/METHODS:
A 68-year-old woman with a medical history notable for prior acute pancreatitis presented to the ED with abdominal pain, nausea, and vomiting. CT Abdomen revealed a large pancreatic fluid collection with surrounding necrosis. She was admitted to the SICU for management of necrotizing pancreatitis, and underwent cystgastrostomy with an AXIOS stent on day 14 of admission. During her necrosectomy one week later, the previously placed AXIOS stent was accidentally displaced into the stomach. The displaced stent was grasped with a rat tooth forceps and removed from the patient. One end of the extracted AXIOS stent was stretched so that it became thin enough to be inserted into an empty stone extraction balloon catheter sheath. The other end was then back-loaded into the larger channel of a double-channel gastroscope. The scope was then re-introduced and advanced into the pancreatic cyst cavity. A rat tooth forceps was inserted into the instrument channel and used to advance the back-loaded stent forward, re-deploying the stent under endoscopic guidance only, such that it again traversed the cystic cavity and stomach. The stent was then adjusted into its desired position using rat tooth forceps.

DISCUSSION:
As Interventional Endoscopy’s technologies continue to evolve, it will become increasingly important for the skilled endoscopist to understand the mechanics of the tools being used, and trouble shoot these technologies as unforeseen complications arise. The novel method for AXIOS stent re-deployment described here not only demonstrates this understanding, but also serves as an example of a cost saving recourse for dislodged AXIOS stent re-deployment. Indeed, in an era of cost-conscious care, one must trouble shoot in a manner that is both clinically effective and financially efficient.
Watch the video: http://bit.ly/2O2RYbW.
1687 Argon Plasma Coagulation-Based Removal of Partially-Covered Esophageal Self-Expanding Metal Stent for Anastomotic Leaks Despite Extended Embedment - Challenging Current Standards of Care
Authors: Malik Fahad , Kim Marina , Arya Mukul 
Published: October 2019

INTRODUCTION:
Benign esophageal anastomotic leaks can be effectively treated by the placement of esophageal stents. Endoscopic therapy for esophageal anastomotic leaks remains non-standardized. Partially covered self-expanding metal stents (PSEMS) are superior to fully covered stents in the treatment of anastomotic leaks by providing a better seal and therefore promoting quicker healing with shorter time to oral intake. However, the removal of partially covered SEMS is technically challenging due to these stents’ inherent risk of stimulating mucosal hyperplasia and without special technique will lead to esophageal perforation, avulsion or fistula formation during attempted removal. Generally, anastomotic leaks require at least 4 weeks of stent dwelling for clinical success with an average treatment time of 6–8 weeks with recommendations for stent removal by 3 months.

CASE DESCRIPTION/METHODS:
A 69-year-old man with esophageal adenocarcinoma of the distal esophagus status post neoadjuvant chemoradiation followed by Ivor-Lewis esophagectomy with pyloroplasty presented to the hospital with hematemesis and found to have developed two anastomotic leaks within one month of surgery. He was treated with PSEMS measuring 12.5 cm × 20 mm (25 mm at ends). Three months after placement, elective EGD revealed previously placed stent covering the anastamosis with tissue ingrowth at the uncovered ends. Coagulation using argon plasma at 0.8 liters/minute and 55 watts was performed to free the uncovered ends of the stent by destruction of ingrown tissue. The proximal end was freed, however, some tissue remained over the distal end even after extensive attempts at coagulation and debridement. Two days later, the procedure was repeated with continued fulguration to ablate the remaining ingrown tissue at the uncovered ends using argon plasma and a soft over-the-scope cap was used to remove the necrosed tissue. Stent was eventually removed with rat-tooth forceps.

DISCUSSION:
There are many described methods for partially covered esophageal stent removal. We propose a safe and effective method for the removal of partially covered esophageal SEMS with the use of Argon Plasma Coagulation, a soft over-the-scope cap and rat-tooth forceps after an extended stent dwelling time of three months. With this efficient, safe and effective method of stent removal, it is essential that the use of partially covered esophageal SEMS be standard of care in the temporary management of anastomotic leaks.
Watch the video: http://bit.ly/2SooiEC.
1688 Colonoscopic Resection of Appendiceal Endometriosis
Authors: Sharma Bashar , Dawood Enad , Nieto Jose 
Published: October 2019

INTRODUCTION:
We present a 66-year-old lady who presented with a polypoid lesion found on screening colonoscopy in the appendiceal orifice. On repeat colonoscopy, a partially inverted appendix was seen. Possible carcinoid was in the differential diagnosis as well as a submucosal lesion.

CASE DESCRIPTION/METHODS:
Using a double channel colonoscopy, the appendicealorifice and the partially inverted appendix were identified. 10 mls of ORISE lifting gel was injected submucosally. Then, using a 2-snare technique. 1 snare was passed over the appendix. The second snare was passed over the distal partially inverted appendix. Then using traction, the appendix was completely inverted into the lumen of the cecum. Afterwards, the snare, which was over the appendix, cut, was closed and standard polypectomy technique was used to cut the appendix. The appendix was then captured with the snare that was used for traction with the other open channel . Clips were deployed to close the defect The gross pathology was sent which revealed an infiltrated appendix with endometrial tissue consistent with appendiceal endometriosis. CT scan follow up did not reveal any evidence of perforation. Patient was discharged within 24 hours from the hospital.

DISCUSSION:
Endometriosis (EM) is the presence of endometrial tissue outside the uterine cavity. Appendiceal EM is rare and comprises about 3% of all gastrointestinal EM with an incidence of less than 1%. It is usually found incidentally during appendectomies or during colonoscopies if the appendicealorifice is found to be inverted. Appendectomies are usually preformed laparoscopically, few cases have been reported of endoscopic resection of an appendix. We are reporting the first case of appendiceal EM that was resected endoscopically.
Watch the video: http://bit.ly/2O2SEhu.
1690 Management of Non-Malignant Enterocutaneous Fistula Using Fully Covered Stent
Authors: Alshati Ali , Muilenburg Diego , Young Yashika , Weissman Simcha , Kachaamy Toufic 
Published: October 2019

INTRODUCTION:
Postoperative enterocutaneous fistula (ECF) has a reported prevalence of 3.6% in general surgery, and up to 35% in Crohn disease-related surgery. ECFs can be of low-output, drain < 200 mL/day, or of high-output, drain > 500 mL/day, which unlikely to heal spontaneously. ECFs can cause metabolic disturbances, fluid loss, and malnutrition.

CASE DESCRIPTION/METHODS:

Case 1: A 54-year-old man with a history of colonic transmural necrosis status post multiple surgeries and end transverse colostomy placement, presented with a two-week history of passing stool from the lateral aspect of his peristomal incision, consistent with enterocutaneous fistula. The 2 fistulae ends were seen on the skin, laterally to the stoma (Figure 2c), and both other ends were identified in the stoma lumen. CT fistulogram confirmed the fistulae. After advancing the endoscope into the stoma, a 2 cm friable stenosis was seen (Figure 1a). The fistulae tracts were treated with silver nitrate and were injected with fibrin glue. A 20 mm × 6 cm fully-covered stent was placed (Figure 1b) and sutured in place. A month later the fistulae had healed (Figure 2d), with no recurrence reported. Case 2: A 64-year-old man with a history of metastatic mucinous appendiceal cancer status post multiple abdominal surgeries, referred for his recurrent ECF. CT scan showed air tracking outside the colon at the level of the cutaneous fistula site. Water-soluble contrast pushed through the rectum showed an occlusion with contrast extravasation is seen in the fistula (Figure 3e). Sigmoidoscopy confirmed the site of obstruction and the area of leakage. A fully covered stent was placed to relieve the obstruction and cover the fistula (Figure 3f). Initially, the fistula output resolved, but when the stent was removed a month later, the fistula output returned. So, a stent was placed again and was sutured to the colon. The patient is now asymptomatic and having normal bowel movements.

DISCUSSION:
ECF can cause significant morbidity and affect the quality of life. Surgical repair of ECF has a recurrence rate as high as 36% and is associated with high mortality especially in malnourished patients. Thus, endoscopic intervention using fully-covered stents can be helpful in healing the fistulae. In these 2 cases, the placement of a fully-covered stent relieved the coexisting obstruction, diverted the flow away from the fistula, and simultaneously covered the fistula end. The patients experienced relief of fistula symptoms and avoided them major surgical intervention.
Watch the video: http://bit.ly/30BIvtw.
1691 Lumen-Apposing Metal Stent Assisted ERCP in Stenosis Associated With Silastic Ring in Vertical Banded Gastroplasty
Authors: Gajula Prianka , Dacha Sunil 
Published: October 2019

INTRODUCTION:
Lumen-apposing metal stent is being increasingly used for transmural drainage of pancreatic fluid collections (PFC). More recently, certain off label uses for LAMS are being explored1 such as benign gastrointestinal strictures, gastrojejunostomy, and gastro-gastrostomy. Here we present a case of LAMS-assisted ERCP for stenosis in a patient with silastic ring vertical banded gastroplasty.

CASE DESCRIPTION/METHODS:
An 82yo F with h/o breast cancer and diabetes mellitus type 2 was referred for EUS guided biopsy of a pancreatic head mass identified on CT scan of the abdomen, performed during evaluation of abdominal pain. The patient had normal liver enzymes. An EUS was planned for biopsy of pancreatic mass. At the time of the procedure, a benign-appearing, severe, intrinsic stenosis was found in the gastric body. An echoendoscope could not be advanced across this mid-gastric body stenosis, despite balloon dilation to 15mm. No significant mucosal disruption was seen. It was suspected that the stenosis was due to adhesions related to the silastic ring. A 15 mm × 10 mm LAMS was deployed across the stenosis to facilitate EUS. LAMS was dilated to 15 mm with balloon dilation under fluoroscopic guidance. An EUS scope could not be advanced despite dilation of LAMS to 15 mm. A duodenoscope could not be advanced, either. The plan was made to repeat EUS in 48 hrs. However, the patient developed obstructive jaundice, and an ERCP was planned instead. LAMS was removed prior to ERCP due to mild resistance to passage of the scope. This was done to prevent stent dislodgement. Following LAMS removal, a duodenoscope could be advanced across the stenosis with minimal resistance. An ERCP was successfully performed, which revealed a tight distal biliary stricture. Brush cytology was performed using a large caliber brush. A biliary stent was placed. Her immediate post-ERCP course was uncomplicated. She had normalization of her liver function tests. Final cytology results revealed pancreatic adenocarcinoma.

DISCUSSION:
ERCP is a challenging procedure in patients with previous bariatric surgery due to anatomical variations. LAMS have a high success rate for the drainage of PFCs. Many new off-label indications are being identified for LAMS, and the early results are promising1. We present an off-label use for LAMS placement, for facilitating ERCP in patients with stenosis related to silastic ring vertical banded gastroplasty.
Watch the video: http://bit.ly/2LuZ2Mo.
1693 Jejunal Lymphangioma: An Unusual Etiology for Iron Deficiency Anemia
Authors: Shah-Ghassemzadeh Nicole , Jackson Christian 
Published: October 2019

INTRODUCTION:
Lymphangiomas are benign tumors characterized by cystic dilation of lymphatic vessels, and can arise from any location throughout the lymphatic system. Small bowel lymphangiomas are rare, and are primarily described in children. When found in adults, these lesions are typically an incidental finding. Pathologic small bowel lymphangiomas are particularly unusual, and have been reported as a rare etiology of massive gastrointestinal bleeding and chronic anemia.

CASE DESCRIPTION/METHODS:
A 65yo African American man with a history of prostate cancer, coronary artery disease, hypertension, hyperlipidemia, and peripheral artery disease was hospitalized for a 6 month history of symptomatic anemia, without signs of overt gastrointestinal blood loss. Vital signs were stable upon presentation, and initial labs were significant for a hemoglobin 8.7, mean corpuscular volume 94, ferritin 28, and iron saturation of 3%. An esophagogastroduodenoscopy was performed which was significant for mild gastropathy, and a colonoscopy that showed mild diverticulosis, a 3 mm polyp and small internal hemorrhoids, without stigmata of recent bleeding. Iron therapy was initiated, and the patient was referred to the outpatient gastroenterology clinic for further workup. The patient next underwent capsule endoscopy which showed a friable small bowel mass, with evidence of active bleeding. A single balloon enteroscopy was then performed, which revealed a 4 cm circumferential, friable, granular mass in the mid-jejunum which was biopsied and tattooed with India Ink. Biopsies of the mass revealed benign small intestinal mucosa with prominent lymphangiectasia. The patient was then referred to surgical oncology and underwent a laparoscopic assisted enteroscopy which again demonstrated the previously seen lesion occupying 75% of the small bowel lumen. The lesion was further evaluated with endomicroscopy which revealed multiple dilated blood vessels and lymphatic channels, in a background of inflammation. The cells appeared organized and without atypical features. A small bowel resection was performed, and the surgical pathology revealed a benign lymphatic malformation involving the mucosa and submucosa consistent with a lymphangioma. No invasive features or malignant cells were identified.

DISCUSSION:
Small bowel lymphangiomas are a rare finding, and primarily found within the duodenum. We report an unusual case of a large jejunal lymphangioma presenting as iron deficiency anemia, which completely resolved after resection of the mass.
Watch the video: http://bit.ly/2LvNhpc.
1698 Endoscopic Placement of Sengstaken-Blakemore Tube
Authors: Rego Rayburn 
Published: October 2019

INTRODUCTION:
This video demonstrates the components of the Sengstaken-Blakemore tube, the errors in blind placement of the tube and how the tube can be successfully placed endoscopically, eliminating errors in placement that can turn out to be ineffective, even disastrous.

CASE DESCRIPTION/METHODS:
Please see method described in the video.

DISCUSSION:
Gastroenterologists are wary of this tube and are not familiar with how to use the Blakemore tube. This video demonstrates the components of the tube and how it can be placed endoscopically effectively and without causing harm. Placement of this tube in situations where banding of varices has failed can be life saving and could be a bridge to TIPS procedure.
Watch the video: http://bit.ly/2JGkyfe.
1701 An Aggressive Case of Recurrent Esophageal Stricture in a Patient With Acute Esophageal Necrosis
Authors: Lankarani Daisy S. , Makar Ranjit , Aziz Hamza , Maklad Muthena , Fayad Joseph M. 
Published: October 2019

INTRODUCTION:
Esophageal strictures are a known complication of acute esophageal necrosis (AEN). Our patient presented with dysphagia and after EGD was found to have AEN complicated by an esophageal stricture requiring recurrent dilation.

CASE DESCRIPTION/METHODS:
82 y/o male with PMH of HTN and prostate cancer was status post right sided orchiectomy for recurrent orchitis. After surgery, patient disclosed a 2-month history of dysphagia to solids. He reported food “getting stuck” and a 20 lb weight loss in 2 months. EGD showed white exudate in the proximal and mid esophagus that easily sloughed off. The mucosa was ulcerated with underlying granulation tissue (Figure 1). Brushings were negative for candida. Biopsy results from both proximal and distal esophagus showed marked necroinflammatory debris. Patient denied caustic ingestion. Serologic testing was normal. Patient was discharged on a liquid diet, pantoprazole 40 mg PO BID, sucralfate with EGD in 2 months. He returned 1 month later for worsening dysphagia. EGD revealed esophagitis in the mid and distal esophagus and a stricture at 36 cm (Figure 2). The white exudate had improved, but the mucosa was fibrosed. Using a Savary dilator, the stricture was dilated to 7 mm. Over the next 2 weeks, 3 EGD’s with dilation were required for recurrent stricture. On the 4th visit he reported retching and coffee ground emesis for 3 days. EGD revealed an esophageal tear at the stricture site (Figure 3). At the 5th visit, patient was asymptomatic and tolerating a clear liquid diet. EGD showed scarring and fibrosis of the esophageal mucosa and a stricture that was dilated to 12 mm. He will be followed closely due to concern for reformation of the stricture.

DISCUSSION:
AEN has been associated with infections, antibiotics, malignancy, prolonged vomiting etc. It is proposed that a low flow vascular state leaves the esophagus vulnerable to topical injury from acid reflux and pepsin. On EGD, a circumferential black discoloration with underlying friable hemorrhagic tissue is seen with a sharp transition point to normal appearing mucosa at the GE junction. The esophagus may have thick, white exudates that can be dislodged easily to reveal pink granulation tissue. Histology reveals necrosis of the esophageal mucosa and submucosa. Supportive care leads to endoscopic resolution in most patients. Esophageal stricture occurs in 25-40% of patients and requires dilation. Our patient required repetitive dilation as his stricture redeveloped rapidly. He may need PEG for nutritional support.
1704 A Case of Heterotopic Pancreas Discovered in the Distal Esophagus
Authors: Shamoon Dema , Sostre Vanessa , Patel Varun , Volfson Ariy 
Published: October 2019

INTRODUCTION:
Heterotopic pancreas (HP) is a congenital abnormality that represents ectopic pancreatic tissue that does not have anatomic, vascular or ductal continuity. The incidence is hard to determine, however, the prevalence of HP is 0.55% to 13.7% on autopsy, 0.2% to 0.5% of abdominal operations, and 0.9% of gastrectomies. HP is most commonly found in the stomach, duodenum, proximal jejunum and rarely, in the esophagus. Approximately 15 cases have been reported in the literature of HP located in the esophagus.

CASE DESCRIPTION/METHODS:
We present a case of a 70-year-old male with a past medical history significant for hypertension, hypercholesterolemia, melanoma, and atrial fibrillation who underwent an esophagogastroduodenoscopy (EGD) for evaluation of heartburn and nausea. Incidentally a 5 mm polypoid appearing lesion in the distal esophagus above the gastroesophageal junction was found. Biopsy results are usually nondiagnostic, however, in our patient, histology revealed squamous mucosa with active esophagitis and associated cardiac-type mucosa with focal pancreatic heterotopia and chronic inflammation in the distal esophagus.

DISCUSSION:
Complications may result from undiagnosed cases of HP including benign or malignant transformation of tissue, pseudocyst formation, pancreatitis, gastrointestinal bleeding, ulceration, gastric outlet obstruction, or intussusception. Treatment depends on the symptom and location. In asymptomatic patients, simple observation may be sufficient, however in patients with symptoms or complications, surgical or Ivor-Lewis Esophagectomy, or laparoscopic resection is recommended. In our case, the patient’s symptoms were treated conservatively with a proton pump inhibitor successfully.