Digestive Endoscopy 2014; 26: 291–297
Letters, Techniques and Images 295
Reclosure of ruptured incision after peroral endoscopic myotomy using endoloops and metallic clips Since Inoue et al. introduced peroral endoscopic myotomy (POEM) into a clinic to treat esophageal achalasia in 2010, the procedure has been carried out in many countries around the world.1 As more and more POEM is being done, associated technical difficulties and complications may occur.2 To our knowledge, the present study is the first to report incision rupture after POEM. A 37-year-old man presented to our academic center after experiencing 25 years of dysphagia and 2 months of exacerbation. Barium swallow examination and esophageal manometry diagnosed the patient with type I esophageal achalasia and he agreed to receive POEM. POEM was carried out using the standard technique. After the operation, the patient received routine postoperative care. On the third day after the procedure, the patient had a fever (38.9°C, white blood cell count 18.24 × 109/L, % neutrophils 95.3%) and X-ray showed the absence of several metal clips at the proximal end of the longitudinal incision which revealed the incision rupture. Gastroesophageal endoscopy showed that the middle and proximal parts of the incision was ruptured. It was not possible to reclose the incision with routine clips because of the swollen mucosa around the defect. On endoscopy, an endoloop was inserted and snared the remaining clips in the distal part. In the middle, four clips were anchored onto the defect margins at full thickness and another endoloop was inserted to snare the clips tightly. The same procedure was done in the proximal part (Figs 1,2). After monitoring the patient’s condition for several days, he was discharged without any complaints or complications. In the present study, we propose reclosure of a mucosal incision after POEM using conventional endoloops and
Figure 2 Main steps of the reclosure procedure. (a) Rupture in the middle and proximal parts of the incision. (b) Failed attempt at closure with metallic clips because of the surrounding swollen mucosa. (c) An endoloop snared the remaining clips in the distal part of the incision. (d) Clips anchored the defect margins at full thickness. (e) An endoloop snared the clips in the middle part of the incision. (f) The proximal part of the incision was tightened with the same method.
hemostatic clips. It could reclose the incision regardless of the swollen tissue or the size of the longitudinal incision. Authors declare no conflict of interests for this article. Yin Zhang, Xiang Wang and Zhining Fan Department of Digestive Endoscopy and Medical Center for Digestive Diseases, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China doi: 10.1111/den.12223
REFERENCES 1 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265–71. 2 Ren Z, Zhong Y, Zhou P et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg. Endosc. 2012; 26: 3267–72.
Biliary tumor fragment of hepatocellular carcinoma containing lipiodol mimicking a bile duct stone
bs_bs_banner
Figure 1 Closure of the mucosal and submucosal incision by metallic clips after peroral endoscopic myotomy.
A 69-year-old man with liver cirrhosis caused by chronic hepatitis B virus infection was admitted to our center for the treatment of recurrent hepatocellular carcinoma (HCC) with
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
296
Letters, Techniques and Images
biliary invasion by transarterial chemoembolization (TACE). Contrast-enhanced computed tomography (CT) showed a 2.5-cm tumor in segment V of the liver (Fig. 1a). Selective TACE using epirubicin and lipiodol was carried out from the arterial branch of segment V. Nine days after carrying out TACE, the patient suffered epigastric pain with elevated serum bilirubin and biliary enzyme levels. CT revealed a high-density mass in the distal common bile duct (Fig. 1b). There were neither calcified bile duct stones nor gallbladder stones on the previous CT scan or abdominal ultrasonography. We therefore suspected that a biliary tumor thrombus of necrotic HCC containing lipiodol had spontaneously dropped and occluded the common bile duct. Emergent endoscopic retrograde cholangiopancreatography (ERCP) showed a blackish green mass impacted at Vater’s ampulla (Fig. 2a). ERCP showed two filling defects (10 × 6 mm and 15 × 8 mm) in the distal common bile duct (Fig. 2b). After endoscopic papillary balloon dilatation using an 8-mm balloon, a blackish green tissue that had pinkcolored contents was obtained using a tetra-type basket and an extract balloon catheter (Fig. 2c). Histopathological examination revealed HCC with extensive necrosis. It is rare for a fragment of biliary tumor thrombus to drop into the distal common bile duct in a patient with HCC.1–3 When patients complain of abdominal symptoms after TACE
Digestive Endoscopy 2014; 26: 291–297
Figure 2 (a) Blackish green mass impacted at Vater’s ampulla. (b) Cholangiogram shows two filling defects (10 × 6 mm and 15 × 8 mm) in the distal common bile duct (arrows). (c) Blackish green tissue with pink-colored contents was obtained (arrows).
we should recognize the risk of common bile duct obstruction caused by disrupted HCC fragments. Authors declare no conflict of interests for this article. Kazuyuki Matsumoto, Manabu Osanai and Hiroyuki Maguchi Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan doi: 10.1111/den.12226
REFERENCES 1 Sasaki T, Takahara N, Kawaguchi Y et al. Biliary tumor thrombus of hepatocellular carcinoma containing lipiodol mimicking a calcified bile duct stone. Endoscopy 2012; 44: 250–1. 2 Kogure H, Miyabayashi K, Tsujino T, Isayama H, Tateishi R, Koike K. Spontaneous dislodgement of a biliary tumor in a patient with hepatocellular carcinoma. Endoscopy 2011; 43: 232–3. 3 Miyahara K, Nouso K, Yamamoto K. Image of the month. Hepatocellular carcinoma mimicking bile duct stone. Clin. Gastroenterol. Hepatol. 2010; 8: 17.
Endoscopic removal of eroded gastric band using strangulation technique with a mechanical lithotriptor as a minimally invasive procedure
bs_bs_banner
Figure 1 (a) Contrast-enhanced computed tomography (CT) shows a 2.5-cm tumor in segment V of the liver (arrows). (b) CT reveals a high-density mass in the distal common bile duct (arrows).
There are devices that have been especially designed for the endoscopic removal of an eroded gastric band, such as special band cutters. However, not all endoscopic units have
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Letters, Techniques and Images 295
Reclosure of ruptured incision after peroral endoscopic myotomy using endoloops and metallic clips Since Inoue et al. introduced peroral endoscopic myotomy (POEM) into a clinic to treat esophageal achalasia in 2010, the procedure has been carried out in many countries around the world.1 As more and more POEM is being done, associated technical difficulties and complications may occur.2 To our knowledge, the present study is the first to report incision rupture after POEM. A 37-year-old man presented to our academic center after experiencing 25 years of dysphagia and 2 months of exacerbation. Barium swallow examination and esophageal manometry diagnosed the patient with type I esophageal achalasia and he agreed to receive POEM. POEM was carried out using the standard technique. After the operation, the patient received routine postoperative care. On the third day after the procedure, the patient had a fever (38.9°C, white blood cell count 18.24 × 109/L, % neutrophils 95.3%) and X-ray showed the absence of several metal clips at the proximal end of the longitudinal incision which revealed the incision rupture. Gastroesophageal endoscopy showed that the middle and proximal parts of the incision was ruptured. It was not possible to reclose the incision with routine clips because of the swollen mucosa around the defect. On endoscopy, an endoloop was inserted and snared the remaining clips in the distal part. In the middle, four clips were anchored onto the defect margins at full thickness and another endoloop was inserted to snare the clips tightly. The same procedure was done in the proximal part (Figs 1,2). After monitoring the patient’s condition for several days, he was discharged without any complaints or complications. In the present study, we propose reclosure of a mucosal incision after POEM using conventional endoloops and
Figure 2 Main steps of the reclosure procedure. (a) Rupture in the middle and proximal parts of the incision. (b) Failed attempt at closure with metallic clips because of the surrounding swollen mucosa. (c) An endoloop snared the remaining clips in the distal part of the incision. (d) Clips anchored the defect margins at full thickness. (e) An endoloop snared the clips in the middle part of the incision. (f) The proximal part of the incision was tightened with the same method.
hemostatic clips. It could reclose the incision regardless of the swollen tissue or the size of the longitudinal incision. Authors declare no conflict of interests for this article. Yin Zhang, Xiang Wang and Zhining Fan Department of Digestive Endoscopy and Medical Center for Digestive Diseases, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China doi: 10.1111/den.12223
REFERENCES 1 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265–71. 2 Ren Z, Zhong Y, Zhou P et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg. Endosc. 2012; 26: 3267–72.
Biliary tumor fragment of hepatocellular carcinoma containing lipiodol mimicking a bile duct stone
bs_bs_banner
Figure 1 Closure of the mucosal and submucosal incision by metallic clips after peroral endoscopic myotomy.
A 69-year-old man with liver cirrhosis caused by chronic hepatitis B virus infection was admitted to our center for the treatment of recurrent hepatocellular carcinoma (HCC) with
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
296
Letters, Techniques and Images
biliary invasion by transarterial chemoembolization (TACE). Contrast-enhanced computed tomography (CT) showed a 2.5-cm tumor in segment V of the liver (Fig. 1a). Selective TACE using epirubicin and lipiodol was carried out from the arterial branch of segment V. Nine days after carrying out TACE, the patient suffered epigastric pain with elevated serum bilirubin and biliary enzyme levels. CT revealed a high-density mass in the distal common bile duct (Fig. 1b). There were neither calcified bile duct stones nor gallbladder stones on the previous CT scan or abdominal ultrasonography. We therefore suspected that a biliary tumor thrombus of necrotic HCC containing lipiodol had spontaneously dropped and occluded the common bile duct. Emergent endoscopic retrograde cholangiopancreatography (ERCP) showed a blackish green mass impacted at Vater’s ampulla (Fig. 2a). ERCP showed two filling defects (10 × 6 mm and 15 × 8 mm) in the distal common bile duct (Fig. 2b). After endoscopic papillary balloon dilatation using an 8-mm balloon, a blackish green tissue that had pinkcolored contents was obtained using a tetra-type basket and an extract balloon catheter (Fig. 2c). Histopathological examination revealed HCC with extensive necrosis. It is rare for a fragment of biliary tumor thrombus to drop into the distal common bile duct in a patient with HCC.1–3 When patients complain of abdominal symptoms after TACE
Digestive Endoscopy 2014; 26: 291–297
Figure 2 (a) Blackish green mass impacted at Vater’s ampulla. (b) Cholangiogram shows two filling defects (10 × 6 mm and 15 × 8 mm) in the distal common bile duct (arrows). (c) Blackish green tissue with pink-colored contents was obtained (arrows).
we should recognize the risk of common bile duct obstruction caused by disrupted HCC fragments. Authors declare no conflict of interests for this article. Kazuyuki Matsumoto, Manabu Osanai and Hiroyuki Maguchi Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan doi: 10.1111/den.12226
REFERENCES 1 Sasaki T, Takahara N, Kawaguchi Y et al. Biliary tumor thrombus of hepatocellular carcinoma containing lipiodol mimicking a calcified bile duct stone. Endoscopy 2012; 44: 250–1. 2 Kogure H, Miyabayashi K, Tsujino T, Isayama H, Tateishi R, Koike K. Spontaneous dislodgement of a biliary tumor in a patient with hepatocellular carcinoma. Endoscopy 2011; 43: 232–3. 3 Miyahara K, Nouso K, Yamamoto K. Image of the month. Hepatocellular carcinoma mimicking bile duct stone. Clin. Gastroenterol. Hepatol. 2010; 8: 17.
Endoscopic removal of eroded gastric band using strangulation technique with a mechanical lithotriptor as a minimally invasive procedure
bs_bs_banner
Figure 1 (a) Contrast-enhanced computed tomography (CT) shows a 2.5-cm tumor in segment V of the liver (arrows). (b) CT reveals a high-density mass in the distal common bile duct (arrows).
There are devices that have been especially designed for the endoscopic removal of an eroded gastric band, such as special band cutters. However, not all endoscopic units have
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
