Interesting cases |
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many of these videos are also available at youtube
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Malignant involvement of the GI tract causing fistula is rare and can lead to infections, malnutrition, and poor quality of life, and can sometimes become life threatening. Surgical treatment can be challenging, especially in patients with severe malnutrition and poor functional status. Endoscopic management can improve the patient’s nutrition, allowing the patient to have definitive treatment, whether surgical or systemic therapy. We present a patient with gastric fistula due to involvement with lymphoma who was successfully treated endoscopically and then with systemic therapy
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A 66-year-old man with uncontrolled diabetes mellitus and prior cholecystectomy presented to an outside hospital with symptoms of intractable abdominal pain, nausea, and vomiting. He received a diagnosis of acute pancreatitis and was treated conservatively and eventually discharged. He continued to have persistent symptoms and was admitted again. An abdominal CT scan revealed a pancreatic fluid collection (PFC) with evidence of solid debris. The patient was transferred to our facility for further evaluation and treatment.
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A 65-year-old woman underwent screening colonoscopy and was found to have a 60-mm polyp that was removed in piecemeal fashion by another gastroenterologist. The initial pathologic examination noted tubular adenoma with high-grade dysplasia. Repeated surveillance colonoscopy 3 months later noted a 20-mm area of residual focus that was draping over a fold. Examination of repeated biopsy specimens taken at that time noted tubular adenoma without high-grade dysplasia or malignancy (Fig. 1A). Owing to risk factors, such as prior high-grade dysplasia and the location and characteristics of the polyp, the patient was referred to a colorectal surgeon for evaluation.
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An 89-year-old woman presented with acute nausea and epigastric pain. As part of her workup, abdominal ultrasound was performed which revealed gallbladder wall thickening, pericholecystic fluid, sludge, common bile duct dilatation of 12 mm, and peripancreatic fluid. These findings were suggestive of biliary obstruction from acute pancreatitis. One year prior, she had a similar presentation but was deemed a poor surgical candidate and underwent percutaneous cholecystostomy drainage. On this admission, the patient was again considered unfit for surgery on the basis of her age and severe dementia. A percutaneous cholecystostomy drain was again recommended, but her family declined this option. (vide0 at VideoGIE)
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A 94-year-old woman presented with a 2-month history of dysphagia to solids and a 6.8-kg weight loss. EGD revealed extrinsic compression of the cardia of the stomach Anteroposterior CT demonstrated a large cystic lesion arising from the body of the pancreas, causing extrinsic compression on the stomach EUS with FNA was then done and twasconsistent with a mucinous cyst. The patient was considered a poor surgical candidate; therefore, cystgastrostomy by an electrocautery-enhanced lumen-apposing metal stent (LAMS) delivery system was deemed the best approach for palliative decompression (Video available at VideoGIE
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Bile duct stones can be problematic and can usually be removed via a procedure called ERCP. However, some stones can not be removed via traditional techniques and require the use of cholangioscopy.
In this case we used a holmium laser to crush a stone. This isn't a technique which is considered first line, but it is a good salvage technique. |
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For many patients, gallbladder surgery is needed to treat chronic gallstone disease. This is currently the best way to treat gallstones, however in some circumstances a patient may not be a good candidate for surgery. With advances in endoscopic accessories, we can now place a stent that drains the gall bladder directly into the intestine or stomach.
*this is not the preferred method of gall bladder drainage and should only be used in very limited circumstances* |
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Pancreatic cysts are common and are typically benign, however a small number of them can become malignant and therefore evaluation with EUS and FNA (Fine needle aspiration) can be advised. In this particular case we used a new microforceps which fits through a needle that allows us to obtain tissue from the cyst wall
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Pancreatic pseudocysts are mature fluid collections which can result from pancreatitis. At times they become large enough to cause pain and difficulty in eating.. They may also become infected and develop debris in them. Historically surgery was the best way to take care of these collections, however now with new devices endoscopic drainage is the standard of care. In this case we managed a cyst with the stent and then removed some solid debris..
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This video demonstrates a tumor in the pancreas which started from the body of the pancreas and extended to the tail. A diagnosis was made off of biopsy via a technique called FNA (fine needle aspiration)
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This video shows a mass at the head of the pancreas with fine needle aspiration. At the 25th second you see a nice example of the stack sign which shows the pancreatic duct, CBD and portal vein. As we follow the portal vein we find the tumor which leaves a 2mm gap from the vein. FNA is performed and the specimen revealed adenocarcinoma.
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In this video we find a small tumor at the level of the incissura. Using a Wilson Cook Duette, the lesion is captured with a a band and then ultimately resected using a hot snare (which is included in the kit). At the end no perforation is noted and the lesion is removed
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