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!