Sp811 Mucin Producing Intrahepatic Biliary Papillomatosis in a Young Female Patient

disrruption with normal squamous epithelium on histology. Clinical Implications:Fully covered expandable esophageal stents are increasingly being used foresophageal perforation/leaks/fistula. To our knowledge, no case has beenreported where fully-covered self-expanding metal stents (SEMS) were used tomanage an esophageal disruption with total circumferential loss of a segment ofthe esophagus so close to the UES. In this case, SEMS were removed three and ahalf years after deployment with regeneration of neo-esophagus showingsquamous epithelium on histology. To our knowledge, this is also the first casewhere SEMS were kept in place for over 3 years and then successfully removed.This case also illustrates the techniques of how to precisely positioning the stentin the hypopharynx and the techniques of removing embedded stents.

Sp808Combined Otolaryngologic and Endoscopic Treatment of aBenign Esophageal ObstructionChristopher W. Hammerle, Simon K. LoBackground: A 72 year-old male with a history of squamous cell carcinoma ofthe hypopharynx developed progressive dysphagia. He was previously treatedwith chemotherapy and radiation, and radiographs demonstrate a completeobstruction in the proximal esophagus. A procedure is planned to recanalize thelumen utilizing a combined surgical and endoscopic approach from antegradeand retrograde directions. Endoscopic Methods: An otolaryngologist uses a rigidlaryngoscope to evaluate the upper esophagus. He then uses a carbon dioxidelaser to burn away the proximal end of the obstruction. Using an ultra-thinupper endoscope, the endoscopist simultaneously works to cauterize the tissuefrom below. A blunt-tipped needle knife is used. When communication isestablished from above and below, a balloon is used to dilate the tract, followedby deployment of a metal esophageal stent. Clinical Implications: Esophagealstrictures are common following radiation therapy for head and neck cancers.Though rare, complete obstruction can occur. This poses a unique treatmentchallenge, because without a lumen, traditional dilating techniques cannot beused. In these cases, blind puncture is required which can be difficult becausethe lumen orientation is not always clear. In our case, we use the surgical laseraiming light from above to guide our blind puncture.

Sp809Resections of Difficult Barrett’s Cancer UsingUniversal-Endoscopic Submucosal Dissection (U-ESD)Roy M. Soetikno, Tonya Kaltenbach, Andres Sanchez Yague,Chika Kusano, Takuji Gotoda, Shin KonoBackground: Endoscopic Submucosal Dissection is a resection techniquedesigned to remove early gastrointestinal cancer en bloc. ESD is necessaryespecially in the upper gastrointestinal tract because piecemeal resection isassociated with high risk of local recurrence. ESD is standard practice for theresection of early gastrointestinal cancer in Japan and is frequently used for theresection of esophageal and colorectal early cancers. However, the adaptation ofESD globally has been limited because ESD requires multiple steps that can bedifficult to learn and practice. In this presentation, we will share the endoscopicsubmucosal dissection of complex early Barrett’s cancers; one with history ofradiation and another with grade 1 varices. Endoscopic Methods: We used asimpler ESD technique, called the Universal ESD, using tools that are available inthe western countries. The technique is intended to be performed within ashorter time than standard ESD. Dissection is minimized in order to reduce therisks of bleeding and perforation. Two Barrett’s early cancers were resected. Theprocedures are shown in detail, beginning from detailed imaging of the lesionwith white light and image enhancement, submucosal injection, circumferentialincision, submucosal dissection, snaring and coagulation of bleeding and non-bleeding vessels. In addition, the technique of prophylaxis clipping to preventbleeding is shown. Clinical Implications: Universal-ESD can be safe, effective,and applicable to a variety of clinical situations worldwide. If properly used, it isideal for treating early cancers in the Western countries.

Sp810Biodegradable, Self-Expanding Stent for Transgastric Drainagein Necrotizing Pancreatitis (NP)Palle N. SchmidtBackground: Several reports have documented the efficacy and low complicationrate of endoscopic treatment in complicated acute pancreatitis. The treatmentconsists of transmural drainage of fluid collections and debridement ofpancreatic and fat necrosis inside the collections. Small-caliber plastic stents havemostly been used to secure patency of the stoma, but are inadequate to preventretention and secondary infection. Individual case-reports have documented thefeasibility and efficacy of fully-covered self-expanding metal stents, but thesehave to be removed during the treatment course and may migrate into or out ofthe collection. This video shows the first experience with endoscopic drainage

and necrosectomy in humans using a novel, biodegradable, self-expanding stent.The stent was used to drain three walled-off necroses (largest diameter: 17, 20,and 21cm, respectively) in three patients with necrotizing gallstone pancreatitis.Endoscopic Methods: EUS-guided (Olympus GF-UCT140-AL5 / Aloka SSD-5000),transgastric drainage of the walled-off necroses was performed by: 1) Needlepuncture (ECHO-HD-19-A; Cook Medical), 2) fluid aspiration for culture, 3)insertion of guidewire (0,035 ” Dreamwire; Boston Scientific), 4) needle knifeincision (Huibregtse Triple Lumen; Cook Medical), 5) balloon dilatation of stomato 18, 13, and 20mm, respectively (CRE Wireguided; Boston Scientific), 6)insertion of the novel, biodegradable, self-expanding stent (material:polydioxanone, diameter: 25mm) through the stoma, 7) insertion of a nasalflushing catheter through the stent, 8) flushing of the cavity with antibioticsdepending on culture, 9) endoscopic necrosectomy through stent using atherapeutic gastroscope (Olympus GIF-QT160) and cold snare, and 10) regularendoscopic follow-up until complete healing of the necrotic cavity. ClinicalImplications: This small case series demonstrate the feasibility, efficacy, andsafety of transgastric drainage of walled-off necroses using a biodegradable, self-expanding stent. This new stent type keeps the transmural stoma open untilhealing of the necrotic cavity, and thereby reduces the risk of retention andsecondary infection. This may lead to a reduction in the number of endoscopicinterventions in these often critically ill patients. Further, the study documentsthat endoscopic necrosectomy may be performed through the stent without therisk of stent migration. Whether the need for endoscopic necrosectomy ingeneral may also be reduced due to the improved drainage has to be proven infuture trials.

Sp811Mucin Producing Intrahepatic Biliary Papillomatosis in aYoung Female PatientKashif Ahmed, Jiang Wang, Ali Raza, Milton T. SmithBackground: A 29 year old female with ulcerative colitis presented with pain,obstructive jaundice, weight loss, after ERCP attempt. Exam demonstrated a thinjaundiced female with mild tenderness to palpation of the right upper quadrant.Laboratory data demonstrated abnormal liver enzymes with markedhyperbilirubinemia. CT and MRCP demonstrated dilation and irregularity of theextra and left intrahepatic ductal system. These ductal irregularities brought upconcern for possible PSC. She was taken for a repeat ERCP and cholangioscopyas described below. She underwent PTC drainage, but because of symptoms andbiopsy concerns of high grade dysplasia it was elected to evaluate for livertransplantation which she received 14 months after initial presentation.Examination of the explanted liver demonstrated an 18cm cystic mass containingabundant amounts of tan mucoid material. Large mucin pools containing cancerglands were noted with focal areas of invasion. Currently she is 18 monthspost-transplant. Endoscopic Methods: At ERCP, a copious amount of thick cloudymucus, as typically seen in pancreatic IPMN was identified covering the majorpapilla. There was evidence of previous biliary sphincterotomy. The mucous wasclearly seen flowing from the biliary orifice. Pancreatogram was normal in thehead, body, and tail. Cholangiogram revealed large filling defects in the commonduct, compatible with the mucus seen grossly. The intrahepatic ducts appearedgrossly dilated as well. On cholangioscopy papillary projections were seen in thecommon duct and in the dilated left intraheptic duct. Histologic examinationdemonstrated multiple fragments of papillary epithelial neoplasm with focalareas of acute inflammation and focal areas of high-grade dysplasia. Nodiagnostic evidence of invasive carcinoma was identified. Based on morphologyand endoscopic findings a diagnosis of biliary papillomatosis was rendered.Clinical Implications: MPIBP is a rare disease. The exact pathogenesis is stillunknown, however it is postulated long-term stimulation of the bile duct bystones, infection, or pancreatic juice and subsequent reactive biliary hyperplasiamay contribute. The symptoms are usually secondary to inspissated mucusproduced by the tumors that leads to chronic incomplete obstruction of the bileduct, which finally results in diffuse cyst-like dilatation of biliary tree. It is usuallyconfined to a segment or section of the intrahepatic bile ducts, but may alsoinvolve the extrahepatic bile duct and adjacent lobes. Cholangioscopy is helpfulbecause it is useful for obtaining directed biopsies to determine the types oftumor and also aids in determining the extent of involvement. MPIBP is lessinvasive than cholangiocarcinoma and rarely metastasizes. Thus treatmentoptions include: A complete local resection, drainage for palliation, or livertransplantation.

Sp812A Hybrid Percutaneous and Endoscopic Approach for theComplete Clearance of Gallstones from the Gallbladder andBiliary TreeBarham K. Abu Dayyeh, Todd H. BaronBackground: Gallstone disease is common and costly. Cholecystectomy is thepreferred method of treatment. Alternatives to cholecystectomy, however, areneeded in patients with high surgical risks. Available alternatives includepercutaneous cholecystostomy, endoscopic retrograde cholangiopancreatography

Abstracts Abstracts

www.giejournal.org Volume 75, No. 4S : 2012 GASTROINTESTINAL ENDOSCOPY AB107