Content uploaded by Terry Wong
Author content
All content in this area was uploaded by Terry Wong on Sep 01, 2020
Content may be subject to copyright.
Methods This case involved a 66 year old male of Indian ori-
gin with a history of CSI, Gilbert’s syndrome, urticaria,
angioedema, and gallstone disease. He presented with a three
week history of malaise, fever, anorexia and jaundice. His
liver function tests demonstrated obstructive jaundice (bilirubin
76 mmol/L, ALT 116 munit/L, ALP 637 munit/L). A CT identi-
fied biliary obstruction at the liver hilum. A subsequent
MRCP identified the cause of biliary obstruction to be a 23
mm gallstone impacted in the common hepatic duct. An out-
patient ERCP was performed with the patient in a prone posi-
tion using a therapeutic duodenoscope (Olympus TJF-240)
with their body turned to the right. After the duodenoscope
was navigated into the stomach, it was torqued to the left
which allowed the pylorus to be identified. The duodenoscope
was then navigated to the second part of the duodenum. Ini-
tially a ‘short scope’position was adopted but this was found
to be unstable and resulted in the duodenoscope falling back
into the stomach. As a result, a ‘long scope’position was
adopted for the remainder of the procedure.
Results In a ‘long scope’position wire guided cannulation
(0.035 Boston Dreamwire) was performed. A cholangiogram
confirmed the MRCP findings. After a sphincterotomy was
performed (Boston Dreamtome) a 10Fr × 7 cm straight plas-
tic stent (Boston) was inserted. The procedure was uncompli-
cated and the patient was discharged following ERCP; post
ERCP pancreatitis was not observed. The patient’s liver func-
tion tests subsequently normalised.
Conclusions A PUBMED and EMBASE literature search has
identified that 10 cases of ERCP have been described in
patients with CSI (Hu et all 2015, Sharma et al 2018). This
case, however, is the first reported case from a hospital within
the UK and indeed the first ever in which video footage has
been obtained during both intubation and cannulation. As per
previous reports, the patient was placed prone with the endo-
scopist turning 180°to the right as compared to ERCP with
conventional anatomy. Despite adopting this position, we
found that a ‘short scope’position was unstable and cannula-
tion was achieved after a ‘long scope’position was adopted.
Whilst the procedure was technically challenging it was felt to
be of a similar difficulty to ERCP procedures in other altered
anatomical states. We hope the video footage obtained during
this procedure will help other endoscopists successfully per-
form ERCP when faced with a patient with CSI.
PTH-065 NEEDLE KNIFE FISTULOTOMY IN ERCP: SINGLE
ENDOSCOPIST’S EXPERIENCE
Ratul Adhikary, Srisha Hebbar Umair,*. Royal Stoke University Hospital, Newcastle under
Lyme, UK
10.1136/gutjnl-2019-BSGAbstracts.90
Introduction Needle knife fistulotomy (NKF) is a recognised
technique used for difficult biliary cannulation.
1
Various stud-
ies have shown that early usage of the technique is safe and
successful when compared to persistent standard cannulation
attempts
2
. The decision when to turn to the needle knife
however is very operator dependent. We will review the data
from an experienced ERCPist to see how ones decision to opt
for precut may have changed over time as well as the success
and complication rates that go along with it. Then using vid-
eos of previous procedures we will discuss what criteria we
look for and the techniques we use to perform the optimum
fistulotomy.
Methods We reviewed all the ERCP procedures done by an
experienced endoscopist in one centre over four and a half
years. We looked at the reports to find out the frequency
with which NKF was performed, as well as the success and
complication rates.
Abstract PTH-065 Figure 1 Precuts performed over time
Results Over 55 months, one ERCPist carried out 700
ERCP`s. In 110 of those procedures, NKF was performed.
The majority of cases were for choledocolithiasis and strictur-
ing disease (66 cases and 21 cases respectively). The NKF suc-
cess rate in the first attempt was 83.6% (92 of the 110
cases). 56% (10) of failed cannulation had repeat ERCP, and
biliary cannulation was achieved in all. The overall success
rate was 92.7%. Over the given time period, we can see a
general trend for an increased ratio of needle knife procedures
performed per 100 ERCP’s done (figure 1). 4 cases of delayed
complications were encountered in total (3 cases of post-
ERCP pancreatitis and 1 case of a contained duodenal
perforation).
Conclusion The increased proportion of fistulotomies over
time may demonstrate more confidence in the technique, and
so it is more readily considered as an option in cases of diffi-
cult access. Also, it may represent an increased awareness of
which ampullas are more amenable to precut rather than con-
ventional cannulation techniques and this is something we will
go on to discuss in our video presentation.
REFERENCES
1. Pier Alberto Testoni, et al. 2016 ‘Papillary cannulation and sphincterotomy techni-
ques at ERCP: european society of gastrointestinal endoscopy (ESGE) clinical
guideline’.Endoscopy 48(7):657–83.
2. Tang Z, Yang Y, Yang Z, Meng W, Li X. 2018 ‘Early precut sphincterotomy does
not increase the risk of adverse events for patients with difficult biliary access: A
systematic review of randomized clinical trials with meta-analysis and trial sequen-
tial analysis.’Medicine (Baltimore) 97(36):e12213.
PTH-066 CHOLANGIOSCOPIC MANAGEMENT OF PROXIMALLY
MIGRATED BILIARY STENT USING A NOVEL THROUGH
THE CHOLANGIOSCOPE SNARE
1
Sreelakshmi Kotha*,
1
Philip Berry,
2
George Webster,
1
Terry Wong.
1
Guy’s And St Thomas’
Hospital, London, UK;
2
UCLH, London, UK
10.1136/gutjnl-2019-BSGAbstracts.91
Migration of biliary stent occurs in 5–10% of cases. However,
proximal migration of pigtail stents is rare.
Abstracts
GUT 2019;68(Suppl 2):A1–A269 A45
on September 1, 2020 by guest. Protected by copyright.http://gut.bmj.com/Gut: first published as 10.1136/gutjnl-2019-BSGAbstracts.91 on 1 June 2019. Downloaded from
Retrieval of these stents can be challenging and requires
utilisation of various endoscopic grasping devices. With
increasing use of ERCP and biliary stents this is being encoun-
tered more frequently. Most stents can be retrieved with con-
ventional grasping devices like stent grabbers or biopsy
forceps. However, some case may require the use of novel
through the cholangioscope devices.
We present a 37-year-old lady who presented with choledo-
cholithiasis and 4 conventional ERCPs were not successful in
clearing the CBD stones. At spy glass cholangiscopy we dis-
covered a proximally migrated biliary stent. This video dem-
onstrates a novel technique to retrieve the migrated biliary
stent.
PTH-067 TREATMENT OF BLUE RUBBER BLEB NEVUS SYNDROME
IN A PAEDIATRIC PATIENT ASSISTED BY DOUBLE-
BALLOON ENTEROSCOPE
1
Nikolaos Lazaridis*,
1
Alberto Murino,
1
Nikolaos Koukias,
1
Deborah Costa,
1
Andrea Telese,
1
Claudia Coppo,
1
Regina Raymond,
2
Daniel Crespi,
2
Mark Furman,
1
Edward J Despott.
1
The
Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London (UCL)
Institute For Liver and Digestive Health, London, UK;
2
Centre for Paediatric
Gastroenterology, The Royal Free Hospital and University College London (UCL) Institute for
Liver and Digestive Health, London, UK
10.1136/gutjnl-2019-BSGAbstracts.92
Introduction Blue rubber bleb nevus syndrome (BRBNS) is an
extremely rare systemic vascular disorder characterised by mul-
tiple cutaneous and gastrointestinal venous malformations.
Patients present with fatigue, iron deficiency anaemia (IDA)
and occult or overt gastrointestinal (GI) bleeding. Patients are
usually treated with conservative management including iron
supplementation and blood transfusions. However, endoscopic
(argon plasma coagulation, sclerotherapy, polypectomy, band
ligation etc), radiological and surgical approaches are preferred
for severe cases.
Aims and Methods A 7-year-old female patient with iron defi-
ciency anaemia and multiple cutaneous lesions was diagnosed
with BRBNS at a local hospital. The patient was referred to
our institution for further management due to blood transfu-
sions dependence and PR bleeding. A small bowel capsule
endoscopy (SBCE) revealed two vascular lesions in the small
bowel.
Results An anterograde double-balloon enteroscopy (DBE) was
the performed under general anaesthesia. Two 20 mm vascular
lesions were identified in the gastric body. A loop ligating
device (Olympus, Tokyo, Japan) was applied around the base
of each lesion then tightened and completely detached. No
further vascular malformations were found in the duodenum,
jejunum and proximal ileum. Although the number of units of
blood transfusion decreased over the next 6 months a follow-
up retrograde DBE was performed due to persistent anaemia.
Six lesions were identified in the transverse colon (2), caecum
(1) and distal ileum (3). Ligation loop was used for 2 colonic
lesions while two ileac rubber blub lesions were treated with
both ligation loop and metallic clips. Since the 2 remaining
lesions were flat and floppy, loop ligation was not technically
feasible. No immediate and post procedural complications
(including delayed bleeding) occurred.
Conclusion DBE facilitated loop ligation appears to be a safe
and minimally invasive option in patients affected by BRBNS
reducing the blood transfusion dependence.
PTH-068 SPORADIC LATERALLY SPREADING NONAMPULLARY
DUODENAL ADENOMAS: THE ROLE OF SALINE-
IMMERSION THERAPEUTIC ENDOSCOPY
Nikolaos Lazaridis*, Alberto Murino, Nikolaos Koukias, Andrea Telese, Deborah Costa,
Claudia Coppo, Regina Raymond, Edward J Despott. The Royal Free Unit for Endoscopy,
The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive
Health, London, UK
10.1136/gutjnl-2019-BSGAbstracts.93
Introduction Sporadic laterally spreading nonampullary duode-
nal adenomas (SLSNDA) are an uncommon incidental finding
during oesophagogastroduodenoscopy. Endoscopic mucosal
resection (EMR) in the duodenum is challenging due to
increased risk of perforation and bleeding. Underwater EMR
(UEMR) is a novel and effective endoscopic resection techni-
que performed without submucosal injection. Saline-immersion
therapeutic endoscopy (SITE) is an evolution of UEMR and
saline solution is used instead of water to minimise the risk
of water intoxication.
Aims and methods Our aim was to evaluate the efficacy and
safety of SITE-EMR for SLSNDA via a retrospective review of
SLSNDA resected by SITE-EMR at our institution from May
2017 to October 2018. Demographic, clinical, endoscopic
findings and follow-up data were analysed.
Results
Nine SLSNDA (median size 25 mm) were found in eight
patients (4 male, median age: 69 year-old). One was located
in D1, 4 in D2 and 4 in D3. En-bloc resection was achieved
in two lesions (23%) while wide-field resection was performed
in seven lesions (77%). Complete resection was achieved in
seven patients (87.5%). A circumferential lesion involving the
whole duodenal bulb was found in one case and SITE-EMR
technique was not feasible as well as other alternative endo-
scopic resection techniques due to severe fibrosis; the patient
was therefore referred for surgery and excluded from further
analysis. Histological results revealed six (75%) tubulo-villous
adenomas with low-grade dysplasia and two tubular adenomas
low-grade dysplasia (25%). Immediate complications including
perforation and bleeding did not occur. One patient (12.5%)
presented with delayed GI bleeding 24hours post procedure
and was treated successfully with endoclips. Three cases
(37.5%) of recurrences were identified at 3 months follow-up
requiring further endoscopic treatment. No further recurrence
was identified at 6 and 12 months follow-up in any patient.
Conclusion SITE-EMR of SLSNDA appears to be a safe and
effective management with low recurrence rates at long term
follow-up.
PTH-069 SIMULATED CASES; A TOOL TO TEACH ENDOSCOPY
NON-TECHNICAL SKILLS
1
Louise Macdougall*,
1
Peter Coyne,
2
Mike Bradburn,
1
Christopher Mountford.
1
Newcastle
upon Tyne Hospitals NHSFT, Newcastle-upon-tyne, UK;
2
Northumbria Healthcare NHSFT,
Newcastle-upon-tyne, UK
10.1136/gutjnl-2019-BSGAbstracts.94
Introduction There has been growing awareness of the impor-
tance of non-technical skills (NTS) in endoscopy however
training in this area varies and may not be explicit in many
departments. It is important that this is recognised and efforts
are made to improve awareness. In the Northern Deanery the
REST (regional endoscopic skills training) course has been
Abstracts
A46 GUT 2019;68(Suppl 2):A1–A269
on September 1, 2020 by guest. Protected by copyright.http://gut.bmj.com/Gut: first published as 10.1136/gutjnl-2019-BSGAbstracts.91 on 1 June 2019. Downloaded from
