Transgastric laparoscopic resection of a giant esophageal lipoma.

We present an unusual case of a giant, pedunculated esophageal lipoma originating in the mid-esophagus ball-valving through the gastroesophageal junction resulting in intermittent obstruction and hemorrhage. Endoscopic ultrasonography revealed a 1 cm in diameter vessel in the stalk of the polyp, and endoscopic resection was not performed. Transgastric laparoscopic resection with endoscopic guidance was successfully performed using 2 balloon-tipped laparoscopic trocars inserted laparoscopically into the gastric lumen through separate gastrotomies. Intraoperative esophagoscopy confirmed proper port placement and the exact location of the mass. Under direct visualization, a Snowden-Pencer grasper was used to pull the polyp down into the stomach and an Endo-GIA blue articulating stapler was used to transect its stalk. The polyp was retrieved via an endopouch placed through the intragastric laparoscopic port. We conclude that transgastric laparoscopy should be considered for the resection of a variety of pedunculated esophageal lesions when the use of standard endoscopic techniques is not possible.

Impact of a CT colonography screening program on endoscopic colonoscopy in clinical practice.

OBJECTIVE: The potential effect of CT colonography (CTC) on endoscopic colonoscopy (EC) has been the topic of much speculation. The aim of this study was to evaluate the impact of a CTC screening program on colonoscopy in clinical practice. METHODS: At our institution a third-party reimbursed CTC colorectal cancer (CRC) screening program was established in 2004. The number of CTC monthly exams performed, monthly EC total and screening exams performed, EC with polypectomy performed, and the number of referrals for EC screening exams requested were prospectively examined in the first 33 months after introduction of a CTC CRC screening program. RESULTS: The mean number of overall (378.5 vs 413.1) and screening (150.7 vs 162.9) colonoscopy exams performed per month did not change significantly after screening CTC was introduced. The mean number of monthly CTC exams performed rose significantly throughout the first year of the study from 39 initially to a peak of 147.6 cases per month but decreased slightly to 114.3 monthly exams at the end of 2006. A mean 10.0 patients per month were sent for EC after a positive CTC exam. The mean number of monthly colonoscopies with polypectomy remained constant after the introduction of CTC (197.0 vs 180.2). Monthly referrals for screening EC exams initially decreased but were unchanged 3 yr after institution of a CTC screening program (255.0 vs 253.5). CONCLUSIONS: (a) In our tertiary care center the initiation of a screening CTC program did not result in a decrease in the number of total colonoscopy exams, screening colonoscopy exams performed, nor requests for screening colonoscopy. (b) Only a small number of CTC exams were referred for EC with polypectomy, therefore a CTC screening program may not increase the overall number of therapeutic colonoscopies performed.

Endoscopic placement of the small-bowel video capsule by using a capsule endoscope delivery device.

BACKGROUND: Capsule endoscopy performed via the traditional peroral route is technically challenging in patients with dysphagia, gastroparesis, and/or abnormal upper-GI (UGI) anatomy. OBJECTIVE: To describe the indications and outcomes of cases in which the AdvanCE capsule endoscope delivery device, which has recently been cleared by the Food and Drug Administration, was used. DESIGN: Retrospective, descriptive, case series. SETTING: Tertiary care, university hospital. PATIENTS: We report a case series of 16 consecutive patients in whom the AdvanCE delivery device was used. The study period was May 2005 through July 2006. INTERVENTIONS: Endoscopic delivery of the video capsule to the proximal small bowel by using the AdvanCE delivery device. MAIN OUTCOME MEASUREMENTS: Indications, technique, and completeness of small bowel imaging in patients who underwent endoscopic video capsule delivery. RESULTS: The AdvanCE delivery device was used in 16 patients ranging in age from 3 to 74 years. The primary indications for endoscopic delivery included inability to swallow the capsule (10), altered UGI anatomy (4), and gastroparesis (2). Of the 4 patients with altered UGI anatomy, 3 had dual intestinal loop anatomy (ie, Bilroth-II procedure, Whipple surgery, Roux-en-Y gastric bypass) and 1 had a failed Nissen fundoplication. In all cases, the capsule was easily deployed without complication, and complete small intestinal imaging was achieved. LIMITATIONS: Small patient size. CONCLUSIONS: Endoscopic placement of the Given PillCam by use of the AdvanCE delivery device was safe and easily performed in patients for whom capsule endoscopy would otherwise have been contraindicated or technically challenging.

Clinical utility of videofluorography with concomitant Tensilon administration in the diagnosis of bulbar myasthenia gravis.

Myasthenia gravis (MG) classically presents with ocular, bulbar, and predominantly proximal muscle weakness. Isolated bulbar symptoms occur in less than 25% of cases and can mimic stroke (1-3). If left untreated, MG can lead to significant morbidity and mortality, including myasthenic crisis and recurrent aspiration pneumonia. We describe a case of a 68-year-old man who presented with isolated bulbar symptoms. We used a novel approach to diagnosis which included a videofluorographic swallow study with concomitant Tensilon (edrophonium) injection.

Colonic ischemia associated with naratriptan use.

A 54-year-old woman with acute onset of hematochezia and lower abdominal pain proved to have ischemic colitis associated with the use of naratriptan. The diagnosis was established by colonoscopy with biopsy. There were no other obvious risk factors for intestinal ischemia. The condition resolved within 4 days. Because the use of triptans for the treatment of migraine is increasing, health care providers should be aware of their potential for inducing ischemic colitis.