New approach in the management of proximally migrated stent with an obstructing anti-reflux valve
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necrosis and perforation of the intestinal wall. The diagnosis of amebic colitis rests on the demonstration of E. histolytica in the stool or colonic mucosa. The mainstay of treatment remains metronidazole, followed by a luminal agent (paromomycin, iodoquinol, or diloxanide furoate) to eradi- cate colonization. Amebic colitis rarely presents with continuous mucosal inflammation, making it indistinguishable from UC. Since the erroneous diagnosis of UC can lead to disastrous complications, it is imperative to exclude amebic colitis prior to undertaking steroid therapy, especially in patients with a prior history of travel to or residence in areas endemic for E. histolytica. Our case illustrates the need for high index of suspicion in immigrants and visitors from developing world for amebiasis in the dif- ferential diagnosis of pancolitis. 651 NEW APPROACH IN THE MANAGEMENT OF PROXIMALLY MIGRATED STENT WITH AN OBSTRUCTING ANTI-REFLUX VALVE Sanjay Nayyar, M.D., Archana Verma, M.D., Benjamin T. Go, M.D.*, Gonzalo Pandolfi, M.D., Frida Abrahamian, M.D., Bashar M. Attar, M.D. Cook County Hospital, Chicago, IL. Esophageal cancers are usually diagnosed at a late stage requiring palliative treatment. The use of self-expandable metallic stents (SEMS) have pro- duced impressive results in improving dysphagia. Even with the increasing use of SEMS, there are still complications. The most important include esophageal perforation, hemorrhage, stent migration and fistulization. We are reporting a case of proximal migration of SEMS with an antireflux valve (ARV) causing complete occlusion and management. The patient is a 60 year-old male who was diagnosed 4 weeks prior with an unresectable squamous carcinoma of the distal esophagus at another hospital. An esoph- ageal Z-stent with dua ARV was placed. Patient presented to our hospital 2 weeks after placement with inability to handle his secretions. EGD performed showed the stent located from 20 to 32 cm, with complete obstruction by the ARV. Attempts to remove the stent were unsuccessful due to siginificant inflammatory reaction at the proximal end of the stent but distal to the UES. A needle knife sphincterotome was used to carefully cut through the ARV to allow the passage of an ERCP catheter into the stomach. The ARV was then removed by piecemeal fashion with snare electrocautery to allow deployment of a second SEMS. The tumor extended from 34 to 41 cm with the GE junction at 40 cm and was dilated with a 12 mm balloon. A 14 cm Z-stent with ARV was deployed through the first stent with the proximal end at 27 cm and the distal end at 41 cm. Post-procedure gastrograffin showed ideal stent placement with passage of contrast into the stomach. Patient was discharged after 2 days without complications. While most stent migrations occur distally, they can rarely migrate proximally and be complicated by the ARV. In cases where the stent cannot be removed endoscopically, removal of the ARV can be done with a snare electrocautery to allow deployment of a second stent. The same technique can be utilized with a double channel scope to shorten an ARV after SEMS deployment. 652 GASTRIC NECROSIS: A COMPLICATION OF GASTRIC BANDING Gerald Fruchter, M.D.*, Vlado Simko, M.D., Hatem Shoukeir, M.D., Hueldine Webb, M.D., Ayse Aytaman, M.D. VA NY Harbor HCS, Brooklyn, NY. Background: Morbid obesity is a growing health problem in the United States. Patients, who fail conservative measures at weight loss, are potential candidates for bariatric surgery. Current weight reduction surgery tech- niques include gastric restriction procedures, gastric bypass, and biliopan- creatic bypass. We report a rare, potentially lethal, complication of gastric banding: gastric necrosis necessitating emergent laparotomy and gastrec- tomy. Case Report: A 55 year-old male with history of morbid obesity presented with 5 days of epigastric pain, progressive dysphagia, and vomiting. He had undergone a laparoscopic gastric banding 7 years prior with subsequent loss of 150lbs. Upon presentation, the patient was in no distress, weight 187lbs with stable vital signs. Abdominal exam revealed a soft, non- distended abdomen with mild epigastric tenderness, no guarding or re- bound with a LUQ subcutaneous reservoir. The WBC was 9.2. CXR and abdominal films were unremarkable. Esophagogram showed marked con- striction at the level of the gastric band encircling the fundus with signif- icant hang-up of barium. On the second day of hospital stay, WBC rose to 29.7; exam was unchanged. An abdominal CT scan was unrevealing except for a left lung base infiltrate. Antibiotics were initiated. The following day, patient’s WBC rose to 35.2 with an unchanged exam. Upper endoscopy revealed a distended proximal gastric pouch filled with coffee ground liquid and a large area of confluent ischemia covered by eschar as well as multiple small islands of ischemia. At surgery, there were multiple areas of necrosis in the serosal surface of the dilated fundus proximal to the strangulating ring as well as evidence of peritonitis. The stomach contained over 3 liters of sloughed gastric lining. A near total gastrectomy with roux-en-y gas- trojejunostomy was performed. Pathological exam revealed transmural hemorrhagic necrosis of the fundus with marked thinning and impending perforation. The patient had an uneventful post-op course. Discussion: Bariatric surgery is effective in treating morbid obesity. For gastric banding, revision is occasionally needed to address gastric slippage, stenosis, as well as stomal obstruction. In our case, gastric banding induced strangulation with resultant full-thickness gastric necrosis and peritonitis. Clinicians involved in management of patients who undergo bariatric surgery need to be aware of the potentially serious consequences inherent in this form of surgery. 653 SUPRAGLOTTIC LARYNGEAL STENOSIS-A RARE EXTRAESOPHAGEAL MANIFESTATION OF GERD Sailaja M. Cheruku, M.D., John O’Brien, M.D.*, Carl Malone, M.D. Southern Illinois University School of Medicine, Springfield, IL. A 60 year-old caucasian female admitted to hospital for progressive, severe shortness of breath, over the past 2–3 weeks. She was sleeping upright in a chair secondary to orthopnea. She has no history of recent fever or acute illness. Past medical history included chronic heart burn, hypertension and obesity. She denied tobacco, alcohol and illicit drug use. She took over the counter antacids for heart burn. On exam, she had audible inspiratory stridor and room air oxygen saturation was 80%. An urgent transnasal fiberoptic laryngoscopy showed inability to visualize true vocal cords and a large 23 cm mass along the right aryepiglottic fold extending back to posterior commissure completely obstructing the view of her glottis. The impression was supraglottic mass obstructing the air way. She underwent emergency tracheostomy and direct laryngoscopic biopsy of the mass. Histology showed severe inflammation with granulation tissue and no evidence of malignancy. Laboratory evaluation of anti nuclear antibody, anti neutrophil cytoplasmic antibody and angiotensin converting enzyme levels were normal. Her sedimentation rate was 22. A CT Scan of neck showed normal appearance of true vocal cords and severe supraglottic stenosis. In consideration of acid reflux induced ulceration, an upper endoscopy was performed, which demonstrated a hiatal hernia, normal esophagus, stomach and duodenum. She was given Pantoprazole twice daily and discharged home to follow up as out patient, as her post operative course was uneventful. Ten weeks after treatment with pantoprazole, she was evaluated with videostroboscopy and fiberoptic nasopharyngolaryn- goscopy, which demonstrated significant decrease in supraglottic swelling and inflammation. She denied any episodes of acid reflux. Despite discus- sions regarding surgery for acid reflux, the patient declined surgery. She is currently taking once a day pantoprazole. The Plan is to do supraglottic laryngectomy and removal of tracheostomy tube. Common otolaryngologic manifestations of GERD include cough, sore throat, hoarseness, laryngitis, chronic sinusitis, vocal cord nodules, globus, subglottic stenosis and rarely S216 Abstracts AJG – Vol. 98, No. 9, Suppl., 2003
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Transcript of New approach in the management of proximally migrated stent with an obstructing anti-reflux valve
necrosis and perforation of the intestinal wall. The diagnosis of amebiccolitis rests on the demonstration of E. histolytica in the stool or colonicmucosa. The mainstay of treatment remains metronidazole, followed by aluminal agent (paromomycin, iodoquinol, or diloxanide furoate) to eradi-cate colonization. Amebic colitis rarely presents with continuous mucosalinflammation, making it indistinguishable from UC. Since the erroneousdiagnosis of UC can lead to disastrous complications, it is imperative toexclude amebic colitis prior to undertaking steroid therapy, especially inpatients with a prior history of travel to or residence in areas endemic forE. histolytica. Our case illustrates the need for high index of suspicion inimmigrants and visitors from developing world for amebiasis in the dif-ferential diagnosis of pancolitis.
651
NEW APPROACH IN THE MANAGEMENT OF PROXIMALLYMIGRATED STENT WITH AN OBSTRUCTING ANTI-REFLUXVALVESanjay Nayyar, M.D., Archana Verma, M.D., Benjamin T. Go, M.D.*,Gonzalo Pandolfi, M.D., Frida Abrahamian, M.D.,Bashar M. Attar, M.D. Cook County Hospital, Chicago, IL.
Esophageal cancers are usually diagnosed at a late stage requiring palliativetreatment. The use of self-expandable metallic stents (SEMS) have pro-duced impressive results in improving dysphagia. Even with the increasinguse of SEMS, there are still complications. The most important includeesophageal perforation, hemorrhage, stent migration and fistulization. Weare reporting a case of proximal migration of SEMS with an antirefluxvalve (ARV) causing complete occlusion and management. The patient isa 60 year-old male who was diagnosed 4 weeks prior with an unresectablesquamous carcinoma of the distal esophagus at another hospital. An esoph-ageal Z-stent with dua ARV was placed. Patient presented to our hospital2 weeks after placement with inability to handle his secretions. EGDperformed showed the stent located from 20 to 32 cm, with completeobstruction by the ARV. Attempts to remove the stent were unsuccessfuldue to siginificant inflammatory reaction at the proximal end of the stentbut distal to the UES. A needle knife sphincterotome was used to carefullycut through the ARV to allow the passage of an ERCP catheter into thestomach. The ARV was then removed by piecemeal fashion with snareelectrocautery to allow deployment of a second SEMS. The tumor extendedfrom 34 to 41 cm with the GE junction at 40 cm and was dilated with a 12mm balloon. A 14 cm Z-stent with ARV was deployed through the firststent with the proximal end at 27 cm and the distal end at 41 cm.Post-procedure gastrograffin showed ideal stent placement with passage ofcontrast into the stomach. Patient was discharged after 2 days withoutcomplications. While most stent migrations occur distally, they can rarelymigrate proximally and be complicated by the ARV. In cases where thestent cannot be removed endoscopically, removal of the ARV can be donewith a snare electrocautery to allow deployment of a second stent. Thesame technique can be utilized with a double channel scope to shorten anARV after SEMS deployment.
652
GASTRIC NECROSIS: A COMPLICATION OF GASTRICBANDINGGerald Fruchter, M.D.*, Vlado Simko, M.D., Hatem Shoukeir, M.D.,Hueldine Webb, M.D., Ayse Aytaman, M.D. VA NY Harbor HCS,Brooklyn, NY.
Background: Morbid obesity is a growing health problem in the UnitedStates. Patients, who fail conservative measures at weight loss, are potentialcandidates for bariatric surgery. Current weight reduction surgery tech-niques include gastric restriction procedures, gastric bypass, and biliopan-creatic bypass. We report a rare, potentially lethal, complication of gastricbanding: gastric necrosis necessitating emergent laparotomy and gastrec-tomy.
Case Report: A 55 year-old male with history of morbid obesity presentedwith 5 days of epigastric pain, progressive dysphagia, and vomiting. He hadundergone a laparoscopic gastric banding 7 years prior with subsequentloss of 150lbs. Upon presentation, the patient was in no distress, weight187lbs with stable vital signs. Abdominal exam revealed a soft, non-distended abdomen with mild epigastric tenderness, no guarding or re-bound with a LUQ subcutaneous reservoir. The WBC was 9.2. CXR andabdominal films were unremarkable. Esophagogram showed marked con-striction at the level of the gastric band encircling the fundus with signif-icant hang-up of barium. On the second day of hospital stay, WBC rose to29.7; exam was unchanged. An abdominal CT scan was unrevealing exceptfor a left lung base infiltrate. Antibiotics were initiated. The following day,patient’s WBC rose to 35.2 with an unchanged exam. Upper endoscopyrevealed a distended proximal gastric pouch filled with coffee ground liquidand a large area of confluent ischemia covered by eschar as well as multiplesmall islands of ischemia. At surgery, there were multiple areas of necrosisin the serosal surface of the dilated fundus proximal to the strangulatingring as well as evidence of peritonitis. The stomach contained over 3 litersof sloughed gastric lining. A near total gastrectomy with roux-en-y gas-trojejunostomy was performed. Pathological exam revealed transmuralhemorrhagic necrosis of the fundus with marked thinning and impendingperforation. The patient had an uneventful post-op course.Discussion: Bariatric surgery is effective in treating morbid obesity. Forgastric banding, revision is occasionally needed to address gastric slippage,stenosis, as well as stomal obstruction. In our case, gastric banding inducedstrangulation with resultant full-thickness gastric necrosis and peritonitis.Clinicians involved in management of patients who undergo bariatricsurgery need to be aware of the potentially serious consequences inherentin this form of surgery.
653
SUPRAGLOTTIC LARYNGEAL STENOSIS-A RAREEXTRAESOPHAGEAL MANIFESTATION OF GERDSailaja M. Cheruku, M.D., John O’Brien, M.D.*, Carl Malone, M.D.Southern Illinois University School of Medicine, Springfield, IL.
A 60 year-old caucasian female admitted to hospital for progressive, severeshortness of breath, over the past 2–3 weeks. She was sleeping upright ina chair secondary to orthopnea. She has no history of recent fever or acuteillness. Past medical history included chronic heart burn, hypertension andobesity. She denied tobacco, alcohol and illicit drug use. She took over thecounter antacids for heart burn. On exam, she had audible inspiratorystridor and room air oxygen saturation was 80%. An urgent transnasalfiberoptic laryngoscopy showed inability to visualize true vocal cords anda large 23 cm mass along the right aryepiglottic fold extending back toposterior commissure completely obstructing the view of her glottis. Theimpression was supraglottic mass obstructing the air way. She underwentemergency tracheostomy and direct laryngoscopic biopsy of the mass.Histology showed severe inflammation with granulation tissue and noevidence of malignancy. Laboratory evaluation of anti nuclear antibody,anti neutrophil cytoplasmic antibody and angiotensin converting enzymelevels were normal. Her sedimentation rate was 22. A CT Scan of neckshowed normal appearance of true vocal cords and severe supraglotticstenosis. In consideration of acid reflux induced ulceration, an upperendoscopy was performed, which demonstrated a hiatal hernia, normalesophagus, stomach and duodenum. She was given Pantoprazole twicedaily and discharged home to follow up as out patient, as her post operativecourse was uneventful. Ten weeks after treatment with pantoprazole, shewas evaluated with videostroboscopy and fiberoptic nasopharyngolaryn-goscopy, which demonstrated significant decrease in supraglottic swellingand inflammation. She denied any episodes of acid reflux. Despite discus-sions regarding surgery for acid reflux, the patient declined surgery. She iscurrently taking once a day pantoprazole. The Plan is to do supraglotticlaryngectomy and removal of tracheostomy tube. Common otolaryngologicmanifestations of GERD include cough, sore throat, hoarseness, laryngitis,chronic sinusitis, vocal cord nodules, globus, subglottic stenosis and rarely
S216 Abstracts AJG – Vol. 98, No. 9, Suppl., 2003
