Transcript M&M Template - Bon Secours Sisters

Advanced Endoscopy Techniques
Jayant P.Talreja, M.D.
Gastrointestinal Specialists, Inc.
Bon Secours St. Mary’s Hospital
How We Do It
Procedural Details
• Fiducials placed at time of
outpatient staging EUS in
anticipation of XRT
• Demarcate proximal/distal
borders
• 2 linear gold fiducials (0.35
mm x 1.0 cm) preloaded
separately into one 22 ga FNA
exchangeable needle with
delivery system and one
single 22g FNA needle
Fig 1: Preloaded FNA platform
with fiducials (inset: magnified
view of fiducial)
Key Features of Procedure
• Total delivery time 4-6 minutes
• Exchangeable needles allow for rapid and
accurate deployment without
scope/catheter repositioning
• Preloading multiple sterile needles
ensures clinical staff safety by avoiding
sequential loading of “dirty” needles
Obstructing Cancer
• Obstructing esophageal cancer may
preclude EUS delivery
• This requires direct visualized delivery
with fluoroscopic guidance
Baseline Characteristics
Characteristic
Total No. patients
Age, y (mean [range])
Gender
31
63 [41 – 79]
20 male (67%)
Type (no. [%])
Adenocarcinoma
Squamous Cell Carcinoma
24 (77%)
7 (23%)
Location of Tumor
Mid esophagus
Distal esophagus / GEJ
Gastric involvement
5 (17%)
18 (56%)
8 (28%)
Obstruction Preventing Echoendoscope
Passage
Number of Fiducials Placed (mean)
Proximal/Superior Border
Distal/Inferior Border
GA or IVCS
6 (22%)
1.2 [1-2]
1.3 [1-2]
19 IVCS (61%)
Procedural Characteristics
Characteristic
Immediate Complications (pain,
bleeding, perforation requiring
admission)
Delayed Complications (procedure
related admission within 30 days)
Technical Success (both
distal/proximal fiducials placed)
Time for Fiducial Placement (mean)
Time for Fiducial Placement (mean, per
fiducial)
0/31 (0%)
0/31 (0%)
30/31 (97%)
5.6 min (2 min – 28 min)
2.8 min (1.7 min – 6.5 min)
Fiducials & XRT Planning
Characteristic
Fiducial Retention at Time of XRT
Simulation
72/75 (96%)
Fiducial Retention at Completion of XRT
30/32 (94%)
Fiducial Alignment with FDG activity on
PET, superior (max tolerance 5 mm)
31/35 (89%)
Fiducial Alignment with FDG activity on
PET, inferior (max tolerance 5 mm)
33/40 (83%)
Summary
• Fiducials potentially enhance accuracy and
precision of tumor delineation, thereby
enhancing planning and delivery of XRT
• No extra procedure- done at staging EUS
• Minimal extra time, particularly using multiple
preloaded exchangeable needles
• Fiducials for esophageal cancer has high
technical success rate and is safe
• Similar success and feasibility with rectal lesions
Case Presentation
PATIENT: HM MRN: 28208668
HPI:
• 40yM history of laparoscopic sleeve gastrectomy on 4/22/13
• Post-op UGI series showed a leak proximal to stomach
body with pooling in LUQ
• Returned to OR on 4/27/13 – found to have old clot in upper
abdomen 1 cm distal to esophagus on left side of pouch
along seamguard line – irrigated and suctioned, not patched
or oversewn.
• CT 5/8 showed 4 X 6 cm foci of gas near suture line.
• 5/9 an 8 Fr drain was placed in the fluid collection producing
40cc of purulent bloody fluid/gas
• CT 5/13 showed decrease in size of collection.
• Transferred to BWH for endoscopic management of sleeve
gastrectomy leak
• On broad spectrum antibiotics and receiving J tube feeding
Case Presentation
EGD 5/20/13:
• Sleeve gastrectomy anatomy
• Instilled sterile saline colored with
methylene blue through the previously
placed percutaneous drain
• Contrast filled fundus but did not
extravasate
• Blue saline was seen entering the cardia
• Gastric fistula at cardia about 1 cm below
Z-line on the suture line
Case Presentation
EGD 5/20/13:
• Abraded the aperture of the fistula
with a cytology brush
• One Aponos over the scope padlock
clip was successfully placed
• Limited contrast injection confirmed
proper placement and no contrast
extravasation was seen.
Case Presentation
UGI Series 5/21:
•Persistent fistula between the
gastric cardia and the perigastric
abscess.
• The fistulous track appears to
be just inferior to the new clip
Case Presentation
EGD 5/22/13:
• Previously placed Aponos clip in
place
• No evidence of contrast extravasation
• Entire gastric pouch filled with
contrast