Digestive Endoscopy 2014; 26: 603–609
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Letters, Techniques and Images 607
Figure 1 Endoscopic views of rectal retroflexion showing (A) laterally spreading tumor margins over the dentate line and internal hemorrhoidal vessels and (B) endoscopic submucosal dissection (ESD) with a water-jet HybridKnife® T-Type (Erbe, Tübingen, Germany), followed by (C) multifocal oozing bleeding at the base of the post-ESD ulcer among the internal hemorrhoidal veins.
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To obtain complete hemostasis, and to avoid major bleeding from the internal hemorrhoids, Hemospray (Cook Medical, Winston-Salem, NC, USA) treatment was attempted. A 7-Fr catheter was advanced approximately 2 cm out of the scope and placed approximately 2 cm from the post-ESD ulcer. Multiple consecutive bursts created a hemostatic powder barrier, which successfully stopped all bleeding (Fig. 2). There were no adverse events or late recurrent bleeding. Endoscopic resection at the anorectal junction is technically challenging, and intraprocedural or delayed bleeding can occur.1 Hemospray is a novel inorganic mineral powder licensed for endoscopic treatment of non-variceal upper gastrointestinal bleeding that, when put in contact with blood, forms a coherent and adhesive hemostatic barrier. Furthermore, Hemospray application for lower gastrointestinal bleeding has also been reported.2–4 In our case, Hemospray was used to stop diffuse post-ESD oozing bleeding among the veins of the internal hemorrhoidal plexus. In conclusion, the present case suggests a new and potentially useful application of Hemospray for the treatment of difficult-to-treat post-ESD bleeding. Authors declare no conflict of interests for this article.
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Gabriele Curcio, Antonino Granata and Mario Traina Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy doi: 10.1111/den.12301
Figure 2 Endoscopic views of (A) Hemospray (Cook Medical, Winston-Salem, NC, USA) treatment of post-endoscopic submucosal dissection bleeding during spray bursts, (B) at the end of the procedure, and (C) the day after the procedure.
REFERENCES 1 Holt BA, Bassan MS, Sexton A, Williams SJ, Bourke MJ. Advanced mucosal neoplasia of the anorectal junction: Endoscopic resection technique and outcomes (with videos). Gastrointest. Endosc. 2014; 79: 119–26. 2 Soulellis CA, Carpentier S, Chen YI, Fallone CA, Barkun AN. Lower GI hemorrhage controlled with endoscopically applied TC-325 (with videos). Gastrointest. Endosc. 2013; 77: 504–7. 3 Holster IL, Brullet E, Kuipers EJ, Campo R, Fernández-Atutxa A, Tjwa ET. Hemospray treatment is effective for lower gastrointestinal bleeding. Endoscopy 2013; 46: 75–8. 4 Granata A, Curcio G, Azzopardi N, Barresi L, Tarantino I, Traina M. Hemostatic powder as rescue therapy in a patient with H1N1 influenza with uncontrolled colon bleeding. Gastrointest. Endosc. 2013; 78: 451.
Temporary insertion of a covered self-expandable metal stent for spontaneous esophageal rupture A 56-year-old man presented to the emergency room of Osaka Medical College Hospital with epigastric pain and dyspnea after vomiting. Radiography, computed tomography, endoscopy, and esophagography revealed spontaneous esophageal rupture with pyothorax and pneumothorax caused by perforation into the left thoracic cavity (Fig. 1). On esophagography, contrast medium was found to diffuse swiftly to the left thoracic cavity, and the aspiration tube inserted into the left thoracic cavity drained hemorrhagic
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
608
Letters, Techniques and Images
b
a
c
Figure 1 (a) Radiography and (b) computed tomography of the chest indicates left pneumothorax (red arrows) and pleural effusion. (c) Esophagoscopy reveals a longitudinal cratered ulcer with a perforation on the lower esophagus. Yellow arrow indicates the perforated hole. a
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Digestive Endoscopy 2014; 26: 603–609
On day 31 post-stenting, the pneumothorax had resolved and the drainage from the left thoracic cavity had almost disappeared; hence, we removed the stent using an endoscope. Immediately after the stent was removed, esophagography revealed no leakage of contrast medium from the esophagus (Fig. 2a). The esophageal perforation had been closed by the surrounding epithelium (Fig. 2b). Subsequently, the patient resumed consumption of solid food, and his course was uneventful. In the present case, because the inflammation did not reach most parts of the mediastinum, we temporarily inserted a covered SEMS closing the esophageal perforation, and treated the left pyothorax through drainage. The methods of treatment for this condition vary according to the level of severity of the rupture and the complications present, and include conservative treatment, endoscopic stenting, and surgical treatment. However, the treatment policy also varies in each situation.1,2 At present, as a result of the marked developments in medical technology and endoscopic devices, conservative treatment for this condition is believed to be possible in more broad situations. Authors declare no conflict of interests for this article. Kazuhiro Ota, Toshihisa Takeuchi and Kazuhide Higuchi Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan doi: 10.1111/den.12310
REFERENCES 1 Schweigert M, Beattie R, Solymosi N et al. Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): An international study comparing the outcome. Am. Surg. 2013; 79: 634–40. 2 Gubler C, Bauerfeind P. Self-expandable stents for benign esophageal leakages and perforations: Long-term single-center experience. Scand. J. Gastroenterol. 2014; 49: 23–9.
Figure 2 (a) Esophagography immediately after the stent was removed reveals that contrast medium did not leak from the esophagus. (b) Esophagoscopy after removing the stent reveals that the esophageal perforation had become closed by the surrounding epithelium.
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pleural effusion that smelled of gastric acid. The pneumothorax did not improve despite thoracic aspiration and therefore it was necessary to quickly close the perforation. The esophageal perforation was closed through the insertion of a covered self-expandable metal stent (covered SEMS; diameter 22 mm, length 100 mm; CHOOSTENT® Esophagus Valve [CCC]; M.I. Tech, Seoul, Korea).
Magnifying narrow band imaging of pyloric gland adenoma in a patient with familial adenomatous polyposis Gastric fundic gland polyps (FGP) are the most frequent type of gastric lesions observed in familial adenomatous polyposis (FAP). However, gastric neoplasms have often been reported in patients with FAP.1 A 37-year-old woman with FAP was admitted to Ishikawa Prefectural Central Hospital for further investigation of gastric lesions. Endoscopy revealed a 20-mm polypoid lesion on the greater curvature of the upper body (Fig. 1a). This lesion was pale colored with translucency, and multiple FGP were seen in the non-atrophic mucosa. Examination with magnifying narrow band imaging (M-NBI) revealed a clear demarcation line (DL) (Fig. 1b).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
A
A
B
Letters, Techniques and Images 607
Figure 1 Endoscopic views of rectal retroflexion showing (A) laterally spreading tumor margins over the dentate line and internal hemorrhoidal vessels and (B) endoscopic submucosal dissection (ESD) with a water-jet HybridKnife® T-Type (Erbe, Tübingen, Germany), followed by (C) multifocal oozing bleeding at the base of the post-ESD ulcer among the internal hemorrhoidal veins.
C
B
C
To obtain complete hemostasis, and to avoid major bleeding from the internal hemorrhoids, Hemospray (Cook Medical, Winston-Salem, NC, USA) treatment was attempted. A 7-Fr catheter was advanced approximately 2 cm out of the scope and placed approximately 2 cm from the post-ESD ulcer. Multiple consecutive bursts created a hemostatic powder barrier, which successfully stopped all bleeding (Fig. 2). There were no adverse events or late recurrent bleeding. Endoscopic resection at the anorectal junction is technically challenging, and intraprocedural or delayed bleeding can occur.1 Hemospray is a novel inorganic mineral powder licensed for endoscopic treatment of non-variceal upper gastrointestinal bleeding that, when put in contact with blood, forms a coherent and adhesive hemostatic barrier. Furthermore, Hemospray application for lower gastrointestinal bleeding has also been reported.2–4 In our case, Hemospray was used to stop diffuse post-ESD oozing bleeding among the veins of the internal hemorrhoidal plexus. In conclusion, the present case suggests a new and potentially useful application of Hemospray for the treatment of difficult-to-treat post-ESD bleeding. Authors declare no conflict of interests for this article.
bs_bs_banner
Gabriele Curcio, Antonino Granata and Mario Traina Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy doi: 10.1111/den.12301
Figure 2 Endoscopic views of (A) Hemospray (Cook Medical, Winston-Salem, NC, USA) treatment of post-endoscopic submucosal dissection bleeding during spray bursts, (B) at the end of the procedure, and (C) the day after the procedure.
REFERENCES 1 Holt BA, Bassan MS, Sexton A, Williams SJ, Bourke MJ. Advanced mucosal neoplasia of the anorectal junction: Endoscopic resection technique and outcomes (with videos). Gastrointest. Endosc. 2014; 79: 119–26. 2 Soulellis CA, Carpentier S, Chen YI, Fallone CA, Barkun AN. Lower GI hemorrhage controlled with endoscopically applied TC-325 (with videos). Gastrointest. Endosc. 2013; 77: 504–7. 3 Holster IL, Brullet E, Kuipers EJ, Campo R, Fernández-Atutxa A, Tjwa ET. Hemospray treatment is effective for lower gastrointestinal bleeding. Endoscopy 2013; 46: 75–8. 4 Granata A, Curcio G, Azzopardi N, Barresi L, Tarantino I, Traina M. Hemostatic powder as rescue therapy in a patient with H1N1 influenza with uncontrolled colon bleeding. Gastrointest. Endosc. 2013; 78: 451.
Temporary insertion of a covered self-expandable metal stent for spontaneous esophageal rupture A 56-year-old man presented to the emergency room of Osaka Medical College Hospital with epigastric pain and dyspnea after vomiting. Radiography, computed tomography, endoscopy, and esophagography revealed spontaneous esophageal rupture with pyothorax and pneumothorax caused by perforation into the left thoracic cavity (Fig. 1). On esophagography, contrast medium was found to diffuse swiftly to the left thoracic cavity, and the aspiration tube inserted into the left thoracic cavity drained hemorrhagic
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
608
Letters, Techniques and Images
b
a
c
Figure 1 (a) Radiography and (b) computed tomography of the chest indicates left pneumothorax (red arrows) and pleural effusion. (c) Esophagoscopy reveals a longitudinal cratered ulcer with a perforation on the lower esophagus. Yellow arrow indicates the perforated hole. a
b
Digestive Endoscopy 2014; 26: 603–609
On day 31 post-stenting, the pneumothorax had resolved and the drainage from the left thoracic cavity had almost disappeared; hence, we removed the stent using an endoscope. Immediately after the stent was removed, esophagography revealed no leakage of contrast medium from the esophagus (Fig. 2a). The esophageal perforation had been closed by the surrounding epithelium (Fig. 2b). Subsequently, the patient resumed consumption of solid food, and his course was uneventful. In the present case, because the inflammation did not reach most parts of the mediastinum, we temporarily inserted a covered SEMS closing the esophageal perforation, and treated the left pyothorax through drainage. The methods of treatment for this condition vary according to the level of severity of the rupture and the complications present, and include conservative treatment, endoscopic stenting, and surgical treatment. However, the treatment policy also varies in each situation.1,2 At present, as a result of the marked developments in medical technology and endoscopic devices, conservative treatment for this condition is believed to be possible in more broad situations. Authors declare no conflict of interests for this article. Kazuhiro Ota, Toshihisa Takeuchi and Kazuhide Higuchi Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan doi: 10.1111/den.12310
REFERENCES 1 Schweigert M, Beattie R, Solymosi N et al. Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): An international study comparing the outcome. Am. Surg. 2013; 79: 634–40. 2 Gubler C, Bauerfeind P. Self-expandable stents for benign esophageal leakages and perforations: Long-term single-center experience. Scand. J. Gastroenterol. 2014; 49: 23–9.
Figure 2 (a) Esophagography immediately after the stent was removed reveals that contrast medium did not leak from the esophagus. (b) Esophagoscopy after removing the stent reveals that the esophageal perforation had become closed by the surrounding epithelium.
bs_bs_banner
pleural effusion that smelled of gastric acid. The pneumothorax did not improve despite thoracic aspiration and therefore it was necessary to quickly close the perforation. The esophageal perforation was closed through the insertion of a covered self-expandable metal stent (covered SEMS; diameter 22 mm, length 100 mm; CHOOSTENT® Esophagus Valve [CCC]; M.I. Tech, Seoul, Korea).
Magnifying narrow band imaging of pyloric gland adenoma in a patient with familial adenomatous polyposis Gastric fundic gland polyps (FGP) are the most frequent type of gastric lesions observed in familial adenomatous polyposis (FAP). However, gastric neoplasms have often been reported in patients with FAP.1 A 37-year-old woman with FAP was admitted to Ishikawa Prefectural Central Hospital for further investigation of gastric lesions. Endoscopy revealed a 20-mm polypoid lesion on the greater curvature of the upper body (Fig. 1a). This lesion was pale colored with translucency, and multiple FGP were seen in the non-atrophic mucosa. Examination with magnifying narrow band imaging (M-NBI) revealed a clear demarcation line (DL) (Fig. 1b).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
