Abstracts

916Endoscopic Ultrasound-Guided Pancreatic Duct Rendezvous inChild With Traumatic PD DisruptionKentaro Ishii*, Takao Itoi, Atsushi Sofuni, Fumihide Itokawa,Takayoshi Tsuchiya, Toshio Kurihara, Shujiro Tsuji, Nobuhito Ikeuchi,Junko Umeda, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo,Shuntaro Mukai, Fuminori MoriyasuDepartment of Gastroenterology and Hepatology, Tokyo MedicalUniversity, Tokyo, JapanBackground and Patient: Endoscopic retrograde cholangiopancreatography (ERCP)for a patient with traumatic pancreatic duct (PD) disruption is minimally invasivebut always challenging. Here, we describe the successful PD stenting in a 9-year-oldboy in whom the PD was disrupted by trauma and the initial ERCP failed. The boyfell down and seriously hurt his abdomen on the way home from school. He laterdeveloped pancreatic injury and complete PD disruption. Transpapillary PD stentingfailed in the previous hospital. Endoscopic Methods: ERCP was re-attempted in ourhospital. Endoscopic retrograde pancreatography revealed the complete PDdisruption and pooling of contrast medium at the pancreatic body. A guidewire(GW) could not be advanced into the distal PD. Thus, a therapeutic curved lineararray echoendoscope was positioned in the stomach. After excluding the bloodvessels by Doppler ultrasonography, the distal PD was punctured transluminallyusing a 22-guage fine needle aspiration (FNA) needle under endoscopic ultrasound(EUS) guidance. PD access was confirmed by EUS imaging and fluoroscopy. Acontrast agent was injected via the FNA needle. Then, a 0.018-inch GW was insertedinto the PD. However, the GW could not be advanced to the proximal PD from thePD disruption site even with a hydrophilic GW. Therefore, the GW was left in thedisruption cavity as long as possible and the echoendoscope was removed. Theechoendoscope was then advanced to the major papilla. Thereafter, the GW couldbe grasped with a biopsy forceps and pulled out through the working channel. A 9-Frdilation catheter was inserted into the PD over the rendezvous GW, and anotherwire could be inserted into the distal PD through the dilation catheter (i.e., over-the-wire double GW technique). Finally, a 5-Fr PD stent was retrogradely inserted intothe distal PD across the disruption cavity. The PD stent was changed every 1 or 2months, and removed after 7 months. The patient has remained symptom-free.Clinical Implications: EUS-PD rendezvous appears to be useful even in a child inwhom the PD was disrupted by trauma and the initial ERCP failed.

917EUS-Guided AngiotherapyAndrew Storm*, Vivek Kumbhari, Payal Saxena, Marcia I. Canto, Alba Azola,Ahmed a. Messallam, Anne Marie Lennon, Mouen KhashabGastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore,MDBackground: Interventional endoscopic ultrasound has an increasing role in thera-peutic endoscopy, as it has expanded to include drainage of fluid collections,biliary drainage, delivery of local intra-lesional therapies and vascular therapy. EUS-guided angiotherapy is a growing concept which allows for precise delivery ofintravascular therapies to afferent vessels and real-time confirmation of thrombosisand hemostasis. Gastrointestinal vascular lesions including varices and bleeding tu-mors are relatively unexplored targets for EUS-guided angiotherapy. Endoscopicmethods: We reviewed three cases using EUS-guided angiotherapy for managementof large gastric varices, large rectal varices and a non-operative bleeding gastroin-testinal stromal tumor (GIST). The first case of a 43-year-old female with alcoholiccirrhosis, portal hypertension and large gastric varices with recent bleeding that wastreated with EUS-guided injection of three 10mm coils and 2mL of cyanoacrylatewith complete variceal obliteration seen on color doppler. The patient was dis-charged 3 days later and experienced no further bleeding at 3 month follow-up. Thesecond case, a 78-year-old female with cirrhosis and large volume hematochezia wasfound to have large rectal varices. The largest was injected with one 10mm coil and1mL of cyanoacrylate with negative doppler. The patient experienced temporaryanal pruritis, which resolved with topical therapy and she experienced no furtherbleeding at 6 month follow-up. Finally, a 94-year-old male with a bleeding non-operative GIST with symptomatic anemia presented after 6 failed attempts at he-mostasis with endoclips, over-the-scope clip and endoloop ligation. EUS with colordoppler localized a target artery within the tumor and 2mL of cyanoacrylate wasinjected. At 3 month follow up he had experienced no further bleeding and hadimprovement in his anemia. Clinical implications: EUS-guided angiotherapy may beused in gastric varices, rectal varices and bleeding GIST with real time confirmationof vessel obliteration. Injection of both coils and cyanoacrylate minimizes glue vol-ume and forms a scaffold which potentially decreases the risk of embolization. EUS-guided angiotherapy is feasible, safe and effective and will likely have an increasingrole in the management of undiagnosed and refractory gastrointestinal bleeding.

AB184 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014

918Endoscopic Full Thickness Resection for GISTs. NOTES Here andNow for the GastroenterologistStavros N. Stavropoulos*1, Rani J. Modayil1, David Friedel1,Collin E. Brathwaite21Medicine, Winthrop University Hospital, Mineola, NY; 2Surgery,Winthrop University Hospital, Mineola, NYMost upper GI SETs are gastrointestinal stromal tumors (GISTs), which are poten-tially malignant. Since risk stratification is dependent on size and mitotic rate,evaluation of SETs includes endoscopic sampling via EUS-FNA or core biopsy, "well"biopsies or methods to remove the overlying mucosa followed by direct tumorsampling. These conventional methods only yield a definitive diagnosis in 60-70% ofcases and do not provide sufficient tissue for mitotic rate assessment. Therefore,NCCN guidelines recommend surgical resection of all SETs that are known or sus-pected GISTs R2cm and lifelong endoscopic surveillance of those!2cm. Thisapproach generates a large burden of surgery and endoscopy for SETs!5cm themajority of which are low risk. Furthermore, for SETs at the GE junction esophagusor cardia laparoscopic "wedge" resection may be challenging or impossible. Over thepast decade endoscopists mostly from Asia have extended the technique of ESD(endoscopic submucosal dissection) to enucleation of SETs. However, the concernwith using ESD to enucleate muscularis propria (MP) based SETs is that microscopicresidual tumor may remain in the MP especially in tumors with extraluminalcomponent. Novel closure devices and methods spawned by NOTES research haveled to development of endoscopic full thickness resection (EFTR) techniques forSETs. Direct transmural EFTR has been reported by groups in Asia in 2012. Unliketraditional ESD, EFTR can achieve complete en bloc resection of MP-based SETsalong with the associated MP thus ensuring R0 curative resection. We present avideo of complete en bloc endoscopic resection of a 4.5cm gastric GIST with a largeextraluminal component using EFTR. This is one of the early cases in our series of 25full thickness SET resections. This case, performed in 12/2012 likely represents thefirst EFTR in the US of a GIST with large extraluminal component. Completeresection was achieved in 68min with no adverse events. Primary closure wasachieved using the omental patch method. Histopathological examination revealed alow risk GIST. No further endoscopic surveillance was deemed necessary. Thesetechniques represent a NOTES approach to resection of tumors!5cm. Advantagesinclude: 1. Incisionless approach 2. Wedge resection of SETs in areas that challengelaparoscopic "wedge" resection such as the GE junction, esophagus and gastriccardia. 3. Reliable diagnosis and mitotic rate assessment which along with completeresection obviates lifelong endoscopic surveillance for low risk tumors. 4. Despitethe efficacy of techniques such as omental patch, closure can be challenging inEFTR. The advent of endoscopic suturing should further increase EFTR safety andaccelerate its adoption

919Acute Duodenal Diverticulitis Treated With Endoscopic TherapyWajeeh Salah*, Rahul Pannala, M Edwyn Harrison, Douglas O. FaigelGastroenterology, Mayo Clinic Phoenix, Phoenix, AZThe duodenum is the second most common location for intestinal diverticula. Mostdiverticula are extraluminal and form as the result of a herniation of mucosa andsubmucosa through a defect in the muscular wall of the duodenum. Duodenaldiverticula are usually asymptomatic but complications can develop in 5% of patients. Duodenal diverticulitis is the most rare of these complications and may occur fromstasis and impaction of bowel contents within the diverticulum.55 year-old womanwith no significant PMHx presented with 1 day of acute onset sharp right upperquadrant abdominal pain. Pain was associated with nausea, fever, tachycardia and anelevated WBC count (17.3 k). Total bilirubin, transaminases, alkaline phosphatase,amylase and lipase all within normal limits. Patient started on IV fluids, broad-spectrum antibiotics and admitted for further care. Abdominal CT scan was per-formed and showed 2.6 cm cystic structure containing gas adjacent to the pancreas.Diagnosis of duodenal diverticulitis was made. Supportive care with IV fluids andbroad-spectrum antibiotics continued. However, the patient continued to be febrile,have an elevated WBC count and worsening abdominal pain. Surgical consultationwas obtained, and the decision was made to attempt endoscopic treatment. Anupper endoscopy with a duodenoscope was performed. A large diverticulum wasseen near the ampulla. A large amount of food and debris was seen impacted in thediverticular cavity. The diverticulum was disimpacted using a 12 mm balloon cath-eter. A large amount of pus and debris was extracted from the diverticular cavity. Thediverticulum was irrigated with sterile water and two 7 fr x 4 cm double pigtail plasticstents were placed. The patient had marked improvement of abdominal pain andresolution of fevers immediately post-endoscopic therapy. WBC count improved andwas near normal 1 day after endoscopic treatment. The patient returned for follow-up CT scan 2 weeks later which showed resolution of the previously seen foci of airand a smaller size diverticulum. Upper endoscopy with a duodenoscope was per-formed 3 weeks after the initial therapy for stent removal and follow-up assessmentof the diverticulum. Stents removed and diverticulum irrigated and did not show anyresidual pus or debris. In summary, duodenal diverticulitis is a rare complication ofperiampullary diverticula and can result from stasis and impaction of bowel contentswithin the diverticulum. Endoscopic therapies for acute duodenal diverticulitisinclude drainage, debridement, irrigation and stent placement to facilitate continued

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