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	<channel>
		<title>The Digital Atlas of Video Education - Gastroenterology</title>
		<link>http://daveproject.org/</link>
		<description> The DAVE Project - Gastroenterology  is a collection of teaching tools. The focus is gastrointestinal endoscopic video clips and presentations using the full spectrum 
		endoscopic imaging supported by pathologic, radiologic, and surgical images. Physicians are able to submit, for consideration, new entries to enrich and expand the atlas. 
		</description>
		<language>en-us</language>
		<webMaster>dcollier@daveproject.org (Dan Collier)</webMaster>
		<ttl>60</ttl>
		<copyright>Copyright held by original authors. Released under a Creative Commons license.</copyright>
		
			<item>
				<title>VCE versus Colonoscopy for the Detection of Polyps and Cancer</title>
				<pubDate>Sat, 05 Jun 2010 04:06:51 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=934</guid>
				<description><![CDATA[Dr Prakash Viswanathan, Fellow at Stony Brook University Medical Center, presents journal club on the NEJM article published September 2009 titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/19605831>Capsule endoscopy versus colonoscopy for the detection of polyps and cancer</a>".]]></description>
				<dc:creator>Prakash Viswanathan, MD, Fellow, Stony Brook University Medical Center</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=934</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/viswanathan-cjc-20100602.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=934" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/viswanathan-cjc-20100602.jpeg</media:thumbnail>
				<media:people role="producer">Prakash Viswanathan, MD, Fellow, Stony Brook University Medical Center</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Prakash Viswanathan, Fellow at Stony Brook University Medical Center, presents journal club on the NEJM article published September 2009 titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/19605831>Capsule endoscopy versus colonoscopy for the detection of polyps and cancer</a>".]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/viswanathan-cjc-20100602.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Preoperative biliary drainage for cancer of the head of the pancreas</title>
				<pubDate>Sat, 05 Jun 2010 04:06:37 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=933</guid>
				<description><![CDATA[Dr Leena Sayedy, Fellow at Stony Brook University Medical Center, presents journal club on the NEJM article published in January 2010 titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/20071702>Preoperative biliary drainage for cancer of the head of the pancreas</a>".]]></description>
				<dc:creator>Leena Sayedy, MD, Fellow, Stony Brook University Medical Center</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=933</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/sayedy-cjc-20100602.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=933" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/sayedy-cjc-20100602.jpeg</media:thumbnail>
				<media:people role="producer">Leena Sayedy, MD, Fellow, Stony Brook University Medical Center</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Leena Sayedy, Fellow at Stony Brook University Medical Center, presents journal club on the NEJM article published in January 2010 titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/20071702>Preoperative biliary drainage for cancer of the head of the pancreas</a>".]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/sayedy-cjc-20100602.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Neuroendocrine Tumors of the Gastrointestinal Tract</title>
				<pubDate>Sat, 05 Jun 2010 04:06:44 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=932</guid>
				<description><![CDATA[Dr Vikram Deshpande, Assistant Professor of Pathology at Massachusetts General Hospital, reviews the pathology of GI neuroendocrine tumors. The presentation was recorded 25 May 2010.]]></description>
				<dc:creator>Vikram Deshpande, MD, Assistant Professor of Pathology, Harvard Medical School</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=932</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/deshpande_cfc_20100525.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=932" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/deshpande_cfc_20100525.jpeg</media:thumbnail>
				<media:people role="producer">Vikram Deshpande, MD, Assistant Professor of Pathology, Harvard Medical School</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Vikram Deshpande, Assistant Professor of Pathology at Massachusetts General Hospital, reviews the pathology of GI neuroendocrine tumors. The presentation was recorded 25 May 2010.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/deshpande_cfc_20100525.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Cases from Bigelow Rounds</title>
				<pubDate>Sat, 05 Jun 2010 04:06:48 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=931</guid>
				<description><![CDATA[Dr Esperance Shaefer, GI Fellow at Massachusetts General Hospital, presents selected clinical cases. The presentation was recorded 25 May 2010.]]></description>
				<dc:creator>Esperance Schaefer, MD, MPH, GI Fellow, Massachusetts General Hospital</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=931</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/schaefer_cfc_20100525.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=931" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/schaefer_cfc_20100525.jpeg</media:thumbnail>
				<media:people role="producer">Esperance Schaefer, MD, MPH, GI Fellow, Massachusetts General Hospital</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Esperance Shaefer, GI Fellow at Massachusetts General Hospital, presents selected clinical cases. The presentation was recorded 25 May 2010.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/schaefer_cfc_20100525.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Esophageal stent for esophageal cancer following gastric bypass</title>
				<pubDate>Wed, 02 Jun 2010 12:06:15 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=929</guid>
				<description><![CDATA[The patient is a 66 year old male referred for evaluation of dysphagia.  His medical history is notable for obesity and longstanding gastroesophageal reflux disease.  He had undergone laparoscopic Roux en Y gastric bypass and Nissen fundoplication 5 years prior.
Endoscopy demonstrated an adenocarcinoma at the gastroesophageal junction, staged as a T3 lesion by radial echoendosonography.  The hypoechoic tumor can be seen extending through the muscularis propria layer of the esophagus.
Despite treatment with chemotherapy and radiation, the patient experienced progressive disease, and several months later an esophageal stent placement was requested for palliation of dysphagia.
Repeat endoscopy demonstrates an obstructing tumor in the distal esophagus.  An ultraslim endoscope was selected for this examination, and this was used to gently dissect alongside the tumor through the narrow, residual esophageal lumen.  Distal to the obstruction, the patient&#39;s anatomy was consistent with prior gastric bypass.  The gastrojejunal anastomosis is visualized, and is measured at 5 cm beyond the distal extent of tumor.  
A Savary guidewire is advanced through the working channel of the scope and positioned distal to the obstruction.  The scope is then slowly withdrawn, leaving the wire in place.  Here, the region of tumor is visualized during withdrawal.
A partially covered metal stent, 10 cm in length, was selected in this case.  The stent delivery system is advanced over the wire and across the region of tumor under fluoroscopic visualization.  Paper clips have been taped to the patient&#39;s skin to externally mark the proximal and distal stent margins.
The esophagus is reintubated with the ultraslim endoscope, which is positioned alongside the stent delivery catheter  for direct visualization of stent deployment.  During slow deployment, fluoroscopic monitoring confirms appropriate continued position of the semi-deployed stent.
Following stent deployment and removal of the delivery catheter and guidewire, the stent is gently traversed with the ultraslim endoscope.  This demonstrates luminal patency, as well as appropriate position across the region of obstruction and proximal to the gastrojejunal anastomosis.  Final fluoroscopy demonstrates a waist in the midportion of the stent.
This case demonstrates placement of a palliative permanent esophageal stent following Roux en Y gastric bypass.  The post-operative anatomy was clearly defined in order to guide stent position, and  to select a stent length which minimized distal overlap.  There has been speculation that diversion of gastric acid contents will over the long term decrease the incidence of esophageal adenocarcinoma in patients with GERD who undergo gastric bypass.  As this case demonstrates, patients with long-standing pre-operative GERD may not be immune to long-term complications of acid reflux, even following successful bypass surgery.]]></description>
				<dc:creator>Patrick Yachimski, MD, Assistant Professor of Medicine, Vanderbilt University Medical Center</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=929</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/pyachimski-RYGBstent3.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=929" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/uvs100603-003.BMP</media:thumbnail>
				<media:people role="producer">Patrick Yachimski, MD, Assistant Professor of Medicine, Vanderbilt University Medical Center</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[The patient is a 66 year old male referred for evaluation of dysphagia.  His medical history is notable for obesity and longstanding gastroesophageal reflux disease.  He had undergone laparoscopic Roux en Y gastric bypass and Nissen fundoplication 5 years prior.
Endoscopy demonstrated an adenocarcinoma at the gastroesophageal junction, staged as a T3 lesion by radial echoendosonography.  The hypoechoic tumor can be seen extending through the muscularis propria layer of the esophagus.
Despite treatment with chemotherapy and radiation, the patient experienced progressive disease, and several months later an esophageal stent placement was requested for palliation of dysphagia.
Repeat endoscopy demonstrates an obstructing tumor in the distal esophagus.  An ultraslim endoscope was selected for this examination, and this was used to gently dissect alongside the tumor through the narrow, residual esophageal lumen.  Distal to the obstruction, the patient&#39;s anatomy was consistent with prior gastric bypass.  The gastrojejunal anastomosis is visualized, and is measured at 5 cm beyond the distal extent of tumor.  
A Savary guidewire is advanced through the working channel of the scope and positioned distal to the obstruction.  The scope is then slowly withdrawn, leaving the wire in place.  Here, the region of tumor is visualized during withdrawal.
A partially covered metal stent, 10 cm in length, was selected in this case.  The stent delivery system is advanced over the wire and across the region of tumor under fluoroscopic visualization.  Paper clips have been taped to the patient&#39;s skin to externally mark the proximal and distal stent margins.
The esophagus is reintubated with the ultraslim endoscope, which is positioned alongside the stent delivery catheter  for direct visualization of stent deployment.  During slow deployment, fluoroscopic monitoring confirms appropriate continued position of the semi-deployed stent.
Following stent deployment and removal of the delivery catheter and guidewire, the stent is gently traversed with the ultraslim endoscope.  This demonstrates luminal patency, as well as appropriate position across the region of obstruction and proximal to the gastrojejunal anastomosis.  Final fluoroscopy demonstrates a waist in the midportion of the stent.
This case demonstrates placement of a palliative permanent esophageal stent following Roux en Y gastric bypass.  The post-operative anatomy was clearly defined in order to guide stent position, and  to select a stent length which minimized distal overlap.  There has been speculation that diversion of gastric acid contents will over the long term decrease the incidence of esophageal adenocarcinoma in patients with GERD who undergo gastric bypass.  As this case demonstrates, patients with long-standing pre-operative GERD may not be immune to long-term complications of acid reflux, even following successful bypass surgery.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/pyachimski-RYGBstent3.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>EUS guided Choledochoduodenostomy</title>
				<pubDate>Wed, 02 Jun 2010 12:06:10 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=930</guid>
				<description><![CDATA[In this video we will describe a novel technique of EUS guided choledochoduodenostomy as a 1-step procedure using a echoendoscope.

We perform this procedure in patients with unresectable malignancy causing obstructive jaundice. In patients where standard ERCP or EUS guided rendezvous has failed or is not an option.  A detailed discussion with the family and the patient regarding the novel nature of the technique is explained. The risks, benefits and alternatives are also discussed in detail with the patient.

We perform all procedures under general anesthesia for technical considerations and gastric outlet obstruction. Antibiotics are given to all patients. We prefer a therapeutic echoendoscope because of larger channel size. A 19 G needle gives an option of using different guide wires and hence is preferred.

This is a 66-year old female patient who presented with obstructive jaundice and elevated liver enzymes.  CT scan showed pancreatic head mass with biliary obstruction, gastric outlet obstruction and encasement of superior mesenteric artery.  Standard ERCP fails due to inability to pass the duodenoscope in the malignant obstruction of the duodenum. An enteral self-expanding metallic stent is placed. Repeat attempt at Standard ERCP through the mesh of the stent also fails. 
Using a therapeutic echoendoscope the bile duct is visualized from the duodenal bulb. Echoendoscope is positioned such that the needle points towards the intra-hepatic ducts. With a 19 g needle, bile duct is accessed and a 0.021-inch hydrophilic guide wire is passed towards the intra-hepatic ducts. Contrast is injected to confirm intraductal location of the needle and identify the bile duct anatomy.  The tract is created at the puncture site using a needle knife over the guide wire.  A 10 mm x 4 cm uncovered self-expanding metallic stent is advanced over the guide wire.  Under fluoroscopy guidance the stent is deployed in a standard fashion.  A second 10 mm x 4 cm uncovered self-expanding metallic stent is advanced through the first stent and again deployed standard fashion to overlap the first stent, which theoretically can decrease the risk of biliary leak. 
Patient was observed overnight and was discharged the next day without any complications. Two days post procedure patients liver enzymes decreased significantly. Patient is doing fine at one month follow up with no repeat interventions. 
In summary this case illustrates and effective and feasible technique for one step biliary drainage in selected patients. This technique can be performed in the same session as the initially failed ERCP and provides and alternative to percutaneous drainage. More prospective data and studies are needed to further evaluate this technique.]]></description>
				<dc:creator>Kapil Gupta, M.D., Assistant Professor of Medicine, Hennepin County Medical Center, University of Minnesota</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=930</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/gupta-EUScholedochoeditMAY.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=930" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/uvs100603-001.BMP</media:thumbnail>
				<media:people role="producer">Kapil Gupta, M.D., Assistant Professor of Medicine, Hennepin County Medical Center, University of Minnesota</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[In this video we will describe a novel technique of EUS guided choledochoduodenostomy as a 1-step procedure using a echoendoscope.

We perform this procedure in patients with unresectable malignancy causing obstructive jaundice. In patients where standard ERCP or EUS guided rendezvous has failed or is not an option.  A detailed discussion with the family and the patient regarding the novel nature of the technique is explained. The risks, benefits and alternatives are also discussed in detail with the patient.

We perform all procedures under general anesthesia for technical considerations and gastric outlet obstruction. Antibiotics are given to all patients. We prefer a therapeutic echoendoscope because of larger channel size. A 19 G needle gives an option of using different guide wires and hence is preferred.

This is a 66-year old female patient who presented with obstructive jaundice and elevated liver enzymes.  CT scan showed pancreatic head mass with biliary obstruction, gastric outlet obstruction and encasement of superior mesenteric artery.  Standard ERCP fails due to inability to pass the duodenoscope in the malignant obstruction of the duodenum. An enteral self-expanding metallic stent is placed. Repeat attempt at Standard ERCP through the mesh of the stent also fails. 
Using a therapeutic echoendoscope the bile duct is visualized from the duodenal bulb. Echoendoscope is positioned such that the needle points towards the intra-hepatic ducts. With a 19 g needle, bile duct is accessed and a 0.021-inch hydrophilic guide wire is passed towards the intra-hepatic ducts. Contrast is injected to confirm intraductal location of the needle and identify the bile duct anatomy.  The tract is created at the puncture site using a needle knife over the guide wire.  A 10 mm x 4 cm uncovered self-expanding metallic stent is advanced over the guide wire.  Under fluoroscopy guidance the stent is deployed in a standard fashion.  A second 10 mm x 4 cm uncovered self-expanding metallic stent is advanced through the first stent and again deployed standard fashion to overlap the first stent, which theoretically can decrease the risk of biliary leak. 
Patient was observed overnight and was discharged the next day without any complications. Two days post procedure patients liver enzymes decreased significantly. Patient is doing fine at one month follow up with no repeat interventions. 
In summary this case illustrates and effective and feasible technique for one step biliary drainage in selected patients. This technique can be performed in the same session as the initially failed ERCP and provides and alternative to percutaneous drainage. More prospective data and studies are needed to further evaluate this technique.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/gupta-EUScholedochoeditMAY.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Ampullectomy: The use of methylene blue to aid in location of pancreatic orifice after ampullectomy</title>
				<pubDate>Tue, 01 Jun 2010 02:06:31 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=928</guid>
				<description><![CDATA[This 87-year-old female first presented to us with biliary obstruction 2 weeks after having aortic valve replacement.  Plastic biliary stent was placed to relieve the obstruction and biopsies at the time revealed ampullary adenoma.  Repeat ERCP with stent exchange and biopsies was performed confirming adenomatous tissue and EUS did not reveal any evidence of invasion of the adenoma.   After multiple discussions with the patient and referring physicians she has chosen to undergo ampullectomy.  

After removing the biliary stent, inspection of the ampulla shows an abnormal papilla with adenomatous growth.  We were able to cannulate the pancreatic duct prior to ampullectomy and injected contrast mixed with methylene blue into the pancreatic duct to facilitate finding the pancreatic orifice after ampullectomy.  

We believe starting from the top, at the proximal edge of the ampulla gives the best results for snare ampullectomy.  During manipulation of the ampulla with the snare methylene blue can be seen coming from the pancreatic orifice. We took care trying to ensure an enbloc resection could be achieved with careful scope manipulation until we felt the snare was around the entire ampulla.  Slow closure of the snare keeps it from slipping off of the ampulla.  Ampullectomy was the next step.  Combination of coagulation and cutting current was used with the ampullectomy.    Immediately after resection removal of the specimen was undertaken with Roth retrieval net to ensure collection of the specimen for pathological review

Now with inspection of the ampullary bed the biliary orifice can easily be seen.  A hint of the methylene blue is seen below and to the right of the biliary orifice.  This will aid us in arguably the most important part of this procedure, ensuring pancreatic drainage.   Using an ultra-tapered cannula and 0.025&#8221; jagwire the pancreatic duct is cannulated.  Methlythene blue can be seen extruding from the pancreatic orifice.  With endoscopic manipulation we were able to deeply cannulate this tortuous pancreatic duct for placement of a 5fr x 3cm pancreatic duct stent, which had been modified by cutting off the internal phalanges.  Pancreatic secretions could be seen flowing from the stent after placement.  

Here you can see the pancreatic stent in place and we are deploying a 10fr x 6cm plastic biliary stent in the common bile duct with good flow of bile and contrast after placement.  There was some concern for residual tissue adenomatous tissue so APC was applied to the edge of the ampullary bed.  We have protected both the pancreatic and biliary orifices from stricture by placing a stent in each.    

The patient did well throughout the procedure.  She did have some post procedure bleeding as evidenced by drop in HCT and melena.  On EGD with duodenoscope there was no sign of bleeding and no intervention was needed.  Pathology revealed ampullary adenoma without invasion.  She will have KUB in 2 weeks to ensure migration of pancreatic stent and repeat ERCP with biliary sphincterotomy in 8 weeks.  We feel this is a good example of the use of methlyene blue to facilitate locating the pancreatic duct orifice after ampullectomy, and should be considered if pancreatic cannulation can be achieved prior to ampullectomy.]]></description>
				<dc:creator>Bennett Hooks, MD, Advanced Endoscopy Fellow, University of Texas Health Science Center San Antonio, Sandeep N. Patel, DO, Director of Pancreatobiliary Endoscopy, University of Texas Health Science Center San Antonio</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=928</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/bennetthooks-Ampullectomy4.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=928" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/bennetthooks-Ampullectomy4.jpeg</media:thumbnail>
				<media:people role="producer">Bennett Hooks, MD, Advanced Endoscopy Fellow, University of Texas Health Science Center San Antonio, Sandeep N. Patel, DO, Director of Pancreatobiliary Endoscopy, University of Texas Health Science Center San Antonio</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[This 87-year-old female first presented to us with biliary obstruction 2 weeks after having aortic valve replacement.  Plastic biliary stent was placed to relieve the obstruction and biopsies at the time revealed ampullary adenoma.  Repeat ERCP with stent exchange and biopsies was performed confirming adenomatous tissue and EUS did not reveal any evidence of invasion of the adenoma.   After multiple discussions with the patient and referring physicians she has chosen to undergo ampullectomy.  

After removing the biliary stent, inspection of the ampulla shows an abnormal papilla with adenomatous growth.  We were able to cannulate the pancreatic duct prior to ampullectomy and injected contrast mixed with methylene blue into the pancreatic duct to facilitate finding the pancreatic orifice after ampullectomy.  

We believe starting from the top, at the proximal edge of the ampulla gives the best results for snare ampullectomy.  During manipulation of the ampulla with the snare methylene blue can be seen coming from the pancreatic orifice. We took care trying to ensure an enbloc resection could be achieved with careful scope manipulation until we felt the snare was around the entire ampulla.  Slow closure of the snare keeps it from slipping off of the ampulla.  Ampullectomy was the next step.  Combination of coagulation and cutting current was used with the ampullectomy.    Immediately after resection removal of the specimen was undertaken with Roth retrieval net to ensure collection of the specimen for pathological review

Now with inspection of the ampullary bed the biliary orifice can easily be seen.  A hint of the methylene blue is seen below and to the right of the biliary orifice.  This will aid us in arguably the most important part of this procedure, ensuring pancreatic drainage.   Using an ultra-tapered cannula and 0.025&#8221; jagwire the pancreatic duct is cannulated.  Methlythene blue can be seen extruding from the pancreatic orifice.  With endoscopic manipulation we were able to deeply cannulate this tortuous pancreatic duct for placement of a 5fr x 3cm pancreatic duct stent, which had been modified by cutting off the internal phalanges.  Pancreatic secretions could be seen flowing from the stent after placement.  

Here you can see the pancreatic stent in place and we are deploying a 10fr x 6cm plastic biliary stent in the common bile duct with good flow of bile and contrast after placement.  There was some concern for residual tissue adenomatous tissue so APC was applied to the edge of the ampullary bed.  We have protected both the pancreatic and biliary orifices from stricture by placing a stent in each.    

The patient did well throughout the procedure.  She did have some post procedure bleeding as evidenced by drop in HCT and melena.  On EGD with duodenoscope there was no sign of bleeding and no intervention was needed.  Pathology revealed ampullary adenoma without invasion.  She will have KUB in 2 weeks to ensure migration of pancreatic stent and repeat ERCP with biliary sphincterotomy in 8 weeks.  We feel this is a good example of the use of methlyene blue to facilitate locating the pancreatic duct orifice after ampullectomy, and should be considered if pancreatic cannulation can be achieved prior to ampullectomy.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/bennetthooks-Ampullectomy4.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Pelvic organ prolapse: posterior compartment</title>
				<pubDate>Mon, 24 May 2010 03:05:20 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=927</guid>
				<description><![CDATA[Dr Milena Weinstein, urogynecologist in the Vincent Department of Obstetrics and Gynecology at Massachusetts General Hospital, delivered clinical grand rounds for the MGH GI unit on the topic of pelvic organ prolapse. The presentation was recorded 18 May 2010.]]></description>
				<dc:creator>Milena Weinstein, MD, Instructor in Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=927</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/weinstein-cgr-20100518.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=927" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/weinstein-cgr-20100518.jpg</media:thumbnail>
				<media:people role="producer">Milena Weinstein, MD, Instructor in Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Milena Weinstein, urogynecologist in the Vincent Department of Obstetrics and Gynecology at Massachusetts General Hospital, delivered clinical grand rounds for the MGH GI unit on the topic of pelvic organ prolapse. The presentation was recorded 18 May 2010.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/weinstein-cgr-20100518.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Spiral Enteroscopy, Assisted Rendezvous ERCP</title>
				<pubDate>Wed, 19 May 2010 09:05:53 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=926</guid>
				<description><![CDATA[This is a 61 year old female with a history of pancreatic CA, s/p pylorus preserving Whipple, chemotherapy and radiation 20 years prior.  She clinically has no evidence of disease.  She has a 2 yr history of recurrent attacks of severe abdominal pain.  These attacks of pain were self-limited episodes that lasted several hours.  She was ultimately admitted to our hospital with abdominal pain, fever and jaundice.  CT scan revealed a dilated common bile duct with surrounding inflammatory changes consistent with cholangitis.  MRCP revealed the presence of a stricture at the choledochojejunal anastomosis.  Spiral enteroscopy was performed.  We were able to reach the blind end of the afferent limb, but were unable to identify the choledochojejunal anastomosis presumably due to the stricture.  A percutaneous transhepatic cholangiogram confirmed the presence of a choledochojejunal stricture.  An internal/external drain was successfully placed.  

Spiral enteroscopy was then performed again.  We were able to identify the internal/external drain at the site of the choledochojejunal anastomosis.   A 600 cm wire was then inserted into the internal external drain.  The wire was then successfully grasped using a standard endoscopic snare.  The snare was then withdrawn into the enteroscope, bringing the wire along with it.  The enteroscope was then slowly withdrawn through the overtube, carefully leaving the wire and the overtube in place.  The end of the internal/external drain was then marked with a radiopaque marker on the skin.  A 10 mm x 60 mm partially covered biliary Wallflex stent was then inserted over the wire through the enteroscope overtube.  The stent was then slowly advanced into the bile duct while slowly withdrawing the internal/external drain.  The stent was then carefully deployed under fluoroscopic guidance.  Fluoroscopy confirmed successful stent deployment, with the stricture appearing in the middle of the deployed stent.   

The enteroscope was then reinserted into the overtube.    The biliary stent was seen protruding into the lumen of the afferent limb.  Careful intubation of the stent revealed normal biliary epithelium.  Suction revealed the prompt flow of clear yellow bile.

The patient tolerated the procedure well.  She was discharged 48 hours after the procedure.   Her cholangitis had completely resolved and her episodes of abdominal pain never recurred again.

A CT scan performed 3 months later confirmed optimal placement of the biliary stent.
?In summary, spiral enteroscopy can be used to perform an ERCP in a patient with surgically altered anatomy.]]></description>
				<dc:creator>Satish Nagula, MD, Assistant Professor of Medicine, Stony Brook University Medical Center, Jonathan Buscaglia, MD,, Stony Brook University Medical Center</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=926</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/satish.nagula_Spiral-Rendezvous-ERCP.mp4.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=926" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/satish.nagula-SpiralRendezvousERCP.jpeg</media:thumbnail>
				<media:people role="producer">Satish Nagula, MD, Assistant Professor of Medicine, Stony Brook University Medical Center, Jonathan Buscaglia, MD,, Stony Brook University Medical Center</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[This is a 61 year old female with a history of pancreatic CA, s/p pylorus preserving Whipple, chemotherapy and radiation 20 years prior.  She clinically has no evidence of disease.  She has a 2 yr history of recurrent attacks of severe abdominal pain.  These attacks of pain were self-limited episodes that lasted several hours.  She was ultimately admitted to our hospital with abdominal pain, fever and jaundice.  CT scan revealed a dilated common bile duct with surrounding inflammatory changes consistent with cholangitis.  MRCP revealed the presence of a stricture at the choledochojejunal anastomosis.  Spiral enteroscopy was performed.  We were able to reach the blind end of the afferent limb, but were unable to identify the choledochojejunal anastomosis presumably due to the stricture.  A percutaneous transhepatic cholangiogram confirmed the presence of a choledochojejunal stricture.  An internal/external drain was successfully placed.  

Spiral enteroscopy was then performed again.  We were able to identify the internal/external drain at the site of the choledochojejunal anastomosis.   A 600 cm wire was then inserted into the internal external drain.  The wire was then successfully grasped using a standard endoscopic snare.  The snare was then withdrawn into the enteroscope, bringing the wire along with it.  The enteroscope was then slowly withdrawn through the overtube, carefully leaving the wire and the overtube in place.  The end of the internal/external drain was then marked with a radiopaque marker on the skin.  A 10 mm x 60 mm partially covered biliary Wallflex stent was then inserted over the wire through the enteroscope overtube.  The stent was then slowly advanced into the bile duct while slowly withdrawing the internal/external drain.  The stent was then carefully deployed under fluoroscopic guidance.  Fluoroscopy confirmed successful stent deployment, with the stricture appearing in the middle of the deployed stent.   

The enteroscope was then reinserted into the overtube.    The biliary stent was seen protruding into the lumen of the afferent limb.  Careful intubation of the stent revealed normal biliary epithelium.  Suction revealed the prompt flow of clear yellow bile.

The patient tolerated the procedure well.  She was discharged 48 hours after the procedure.   Her cholangitis had completely resolved and her episodes of abdominal pain never recurred again.

A CT scan performed 3 months later confirmed optimal placement of the biliary stent.
?In summary, spiral enteroscopy can be used to perform an ERCP in a patient with surgically altered anatomy.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/satish.nagula_Spiral-Rendezvous-ERCP.mp4.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>In Search of Novel Risk Determinants for Pancreatic Cancer</title>
				<pubDate>Wed, 19 May 2010 07:05:10 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=923</guid>
				<description><![CDATA[Dr Brian Wolpin, Instructor in Medcine at Harvard Medical School and Dana-Farber Cancer Institute, delivered clinical grand rounds at Massachusetts General Hospital GI Unit on 11 May 2010. The topic was risk markers for development of pancreatic cancer.]]></description>
				<dc:creator>Brian M. Wolpin, MD,, Brigham and Women's Hospital</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=923</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/wolpin-cgr-20100511.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=923" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/wolpin-cgr-20100511.jpeg</media:thumbnail>
				<media:people role="producer">Brian M. Wolpin, MD,, Brigham and Women's Hospital</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Brian Wolpin, Instructor in Medcine at Harvard Medical School and Dana-Farber Cancer Institute, delivered clinical grand rounds at Massachusetts General Hospital GI Unit on 11 May 2010. The topic was risk markers for development of pancreatic cancer.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/wolpin-cgr-20100511.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>History of peptic ulcer disease and pancreatic cancer risk in men</title>
				<pubDate>Wed, 19 May 2010 06:05:21 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=924</guid>
				<description><![CDATA[Dr Mark Wilkinson, GI Fellow at Stony Brook Medical Center, reviews the recent article from the journal Gastroenterology titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/19818786>History of peptic ulcer disease and pancreatic cancer risk in men</a>". This journal club was recorded 28 April 2010.]]></description>
				<dc:creator>Mark Wilkinson, MD, GI Fellow, Stony Brook University Medical Center</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=924</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/wilkinson-cjc-20100428.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=924" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/wilkinson-cjc-20100428.jpeg</media:thumbnail>
				<media:people role="producer">Mark Wilkinson, MD, GI Fellow, Stony Brook University Medical Center</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Mark Wilkinson, GI Fellow at Stony Brook Medical Center, reviews the recent article from the journal Gastroenterology titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/19818786>History of peptic ulcer disease and pancreatic cancer risk in men</a>". This journal club was recorded 28 April 2010.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/wilkinson-cjc-20100428.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Treatment with Monoclonal Antibodies Against Clostridium Difficile Toxins</title>
				<pubDate>Wed, 19 May 2010 06:05:44 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=925</guid>
				<description><![CDATA[Dr Katherine Freeman, GI Fellow at Stony Brook Medical Center, reviews the recent article from the New England Journal of Medicine titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/20089970>Treatment with Monoclonal Antibodies Against Clostridium Difficile Toxins</a>". This journal club was recorded 28 April 2010.]]></description>
				<dc:creator>Katherine Freeman, MD, GI Fellow, Stony Brook University Medical Center</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=925</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/freeman-cjc-20100411.mov.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=925" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/freeman-cjc-20100411.jpeg</media:thumbnail>
				<media:people role="producer">Katherine Freeman, MD, GI Fellow, Stony Brook University Medical Center</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Dr Katherine Freeman, GI Fellow at Stony Brook Medical Center, reviews the recent article from the New England Journal of Medicine titled "<a href=http://www.ncbi.nlm.nih.gov/pubmed/20089970>Treatment with Monoclonal Antibodies Against Clostridium Difficile Toxins</a>". This journal club was recorded 28 April 2010.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/freeman-cjc-20100411.mov.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>EUS-guided transesophageal coiling and cyanoacrylate glue obliteration of gastric fundal varices</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=896</guid>
				<description><![CDATA[Using a curved linear array echoendoscope, the gastric fundus can be imaged with the transducer positioned in the distal esophagus.   Transesophageal  access offers an alternative route to treat gastric fundal varices under EUS-guidance without entering the stomach.

This anatomical cartoon illustrates  transesohageal access to the gastric fundus from   the distal esophagus.

On radial EUS imaging the fundus is seen from the distal esophagus on the patient&#39;s left side.  The esophageal and stomach walls are shown.   Sandwiched between the two is the diaphragmatic crus muscle, seen as a thick hypoechoic band.  

On linear EUS imaging the transducer is withdrawn from the stomach into the distal esophagus.  We see the fundus from the esophagus.   The esophageal and gastric walls are shown, and  interposed between the two is the diaphragmatic crus. The transesophageal access path to the fundus is shown. 

There are several advantages to a transesophageal approach to gastric fundal varices.   The endoscope is orthograde in the esophagus, thus retroflexion in the stomach is not required to access varices.  Treatment is not hindered by gastric contents, such as blood and food.    There is no disruption of the thinned gastric mucosa overlying the varix, and therefore no risk of bleeding complicating puncture. The deeper feeder vessels are easily accessed.    

The rationale for coil placement before glue injection is that it provides a scaffold to retain glue at the site of intravariceal injection.  This  reduces the risk of embolization.  The coil contributes to varix obliteration

A coil is deployed in a container of blood, followed by 1 cc of glue.  The glue adheres to the synthetic  fibers on the coil.   Coil and adherent glue are removed in one piece from the container.  The glue is firmly adherent to the coil. 

The aim of the study was to evaluate  the technical feasibility and outcomes of  EUS&#8211;guided transesophageal injection of gastric varices with coils and cyanoacrylate glue.

A front-view forward array echoendoscope with color Doppler was used  

The varix was punctured with a 19G FNA needle under EUS guidance using a transesophageal  approach .  A single embolization coil , 12-20 mm  in diameter was deployed into the varix followed by 1.0 mL: of 2-Octyl-cyanoacrylate.

The tip of the front view, forward array echoendoscope  is shown here, with overlapping optical and ultrasound imaging planes

The coil is delivered through a standard 19 G FNA needle with the pushing stylet.

Gastroscopy is performed with the front view echoendoscope.  The fundal varices are seen on transesophageal imaging.  The gastric wall is deep to the varices.   The varix is targeted with the 19 G needle and a coil is deployed, seen well by its echogenicity.  1 ml of glue is injected.  The glue creates intense acoustic shadowing a it fills the varix lumen.  

Instrumental palpation shows the varix to be &#8220;hard&#8221;.

In this second case we see a conglomerate of fundal varices with a white nipple sign.  The varix deep to the crus muscle is targeted with the 19 G needle.  A coil is deployed and unravels in the varix lumen.  This is followed by 1 ml of glue, creating acoustic shadowing.  

In this third case there is active bleeding from a flat fundal varix .   The  varix is targeted under EUS-guidance using a transesophageal approach.  One coil is deployed followed by 1 ml of glue.  The bleeding stops immediately and glue is seen extruding from the rupture site of the fundal varix. 

Over a period of weeks the coil and glue are treated like a foreign body and spontaneously extrude into the gastric lumen.  At two months the varices are barely visible and replaced by scar.  

The results in 8 patients with bleeding fundal varices are shown.  

In conclusion, EUS-guided transesophageal access to fundal varices is feasible and appears safe.  Transesophageal delivery of coils and glue is feasible and appears safe. The transesophageal approach has several practical advantages over conventional access to fundal varices in retroflexion    Coil deployment prior to glue oblieration  may eliminate the risk of glue embolization.]]></description>
				<dc:creator>Kenneth F. Binmoeller, MD,, California Pacific Medical Center</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=896</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/E01_DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=896" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/E01_DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Kenneth F. Binmoeller, MD,, California Pacific Medical Center</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Using a curved linear array echoendoscope, the gastric fundus can be imaged with the transducer positioned in the distal esophagus.   Transesophageal  access offers an alternative route to treat gastric fundal varices under EUS-guidance without entering the stomach.

This anatomical cartoon illustrates  transesohageal access to the gastric fundus from   the distal esophagus.

On radial EUS imaging the fundus is seen from the distal esophagus on the patient&#39;s left side.  The esophageal and stomach walls are shown.   Sandwiched between the two is the diaphragmatic crus muscle, seen as a thick hypoechoic band.  

On linear EUS imaging the transducer is withdrawn from the stomach into the distal esophagus.  We see the fundus from the esophagus.   The esophageal and gastric walls are shown, and  interposed between the two is the diaphragmatic crus. The transesophageal access path to the fundus is shown. 

There are several advantages to a transesophageal approach to gastric fundal varices.   The endoscope is orthograde in the esophagus, thus retroflexion in the stomach is not required to access varices.  Treatment is not hindered by gastric contents, such as blood and food.    There is no disruption of the thinned gastric mucosa overlying the varix, and therefore no risk of bleeding complicating puncture. The deeper feeder vessels are easily accessed.    

The rationale for coil placement before glue injection is that it provides a scaffold to retain glue at the site of intravariceal injection.  This  reduces the risk of embolization.  The coil contributes to varix obliteration

A coil is deployed in a container of blood, followed by 1 cc of glue.  The glue adheres to the synthetic  fibers on the coil.   Coil and adherent glue are removed in one piece from the container.  The glue is firmly adherent to the coil. 

The aim of the study was to evaluate  the technical feasibility and outcomes of  EUS&#8211;guided transesophageal injection of gastric varices with coils and cyanoacrylate glue.

A front-view forward array echoendoscope with color Doppler was used  

The varix was punctured with a 19G FNA needle under EUS guidance using a transesophageal  approach .  A single embolization coil , 12-20 mm  in diameter was deployed into the varix followed by 1.0 mL: of 2-Octyl-cyanoacrylate.

The tip of the front view, forward array echoendoscope  is shown here, with overlapping optical and ultrasound imaging planes

The coil is delivered through a standard 19 G FNA needle with the pushing stylet.

Gastroscopy is performed with the front view echoendoscope.  The fundal varices are seen on transesophageal imaging.  The gastric wall is deep to the varices.   The varix is targeted with the 19 G needle and a coil is deployed, seen well by its echogenicity.  1 ml of glue is injected.  The glue creates intense acoustic shadowing a it fills the varix lumen.  

Instrumental palpation shows the varix to be &#8220;hard&#8221;.

In this second case we see a conglomerate of fundal varices with a white nipple sign.  The varix deep to the crus muscle is targeted with the 19 G needle.  A coil is deployed and unravels in the varix lumen.  This is followed by 1 ml of glue, creating acoustic shadowing.  

In this third case there is active bleeding from a flat fundal varix .   The  varix is targeted under EUS-guidance using a transesophageal approach.  One coil is deployed followed by 1 ml of glue.  The bleeding stops immediately and glue is seen extruding from the rupture site of the fundal varix. 

Over a period of weeks the coil and glue are treated like a foreign body and spontaneously extrude into the gastric lumen.  At two months the varices are barely visible and replaced by scar.  

The results in 8 patients with bleeding fundal varices are shown.  

In conclusion, EUS-guided transesophageal access to fundal varices is feasible and appears safe.  Transesophageal delivery of coils and glue is feasible and appears safe. The transesophageal approach has several practical advantages over conventional access to fundal varices in retroflexion    Coil deployment prior to glue oblieration  may eliminate the risk of glue embolization.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/E01_DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>An unusual cause of dysphagia</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=898</guid>
				<description><![CDATA[This was a 30 year-old Caucasian-American male who had a past medical history that was significant for community acquired pneumonia and migraines. He presented to the clinic with a chief complaint of dysphagia for solids and weight loss. Chest x-rays both of the PA and lateral view were negative and without lymphadenopathy. A CT scan of the thorax was performed and was significant for the presence of a  2.8  x  2.9  cm  mass in the sub carinal region causing external compression of the esophagus.
An upper endoscopy was performed which revealed intraluminal bulging as seen here. 
Linear endoscopic ultrasound was performed and was significant for the presence of a 3 x 3cm mediastinal mass extending into the esophagus, creating external compression.
FNA was then performed with a 19 gauge needle. The specimen was significant for the presence of pus. Numerous passes revealed similar findings.
On endoscopic inspection of the FNA site, there was a small area of purulent discharge noted as seen here.  As a result of this finding, jumbo biopsies were used to take biopsies of the overlying mucosa as well as deep well  biopsies. This was done in an attempt to deroof the abscess cavity. As deeper biopsies were taken there was large amount of pus seen flowing from the lesion. 
Given the location of the lesion and the presence of pus histoplasmosis was suspected as the etiology. Cultures and serum testing confirmed presence of active histoplasmosis.
Pulmonary histoplasmosis is rarely complicated by large, encapsulated, caseous mediastinal lymph nodes. This is also known as mediastinal granuloma. Overall, mediastinal granuloma causes low morbidity and is amenable to treatment.  Compression of compliant structures such as the esophagus, pulmonary vessels, and occasionally the airways may result in a variety of symptoms including chest pain, cough, odynophagia, or as in our patient dysphagia. Rarely a bronchoesophageal or tracheoesophageal fistula may occur.
Our patient was treated with voriconazole and at present he is doing well.]]></description>
				<dc:creator>Mankawal S. Sachdev, MD,,</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=898</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/E04_DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=898" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/E04-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Mankawal S. Sachdev, MD,,</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[This was a 30 year-old Caucasian-American male who had a past medical history that was significant for community acquired pneumonia and migraines. He presented to the clinic with a chief complaint of dysphagia for solids and weight loss. Chest x-rays both of the PA and lateral view were negative and without lymphadenopathy. A CT scan of the thorax was performed and was significant for the presence of a  2.8  x  2.9  cm  mass in the sub carinal region causing external compression of the esophagus.
An upper endoscopy was performed which revealed intraluminal bulging as seen here. 
Linear endoscopic ultrasound was performed and was significant for the presence of a 3 x 3cm mediastinal mass extending into the esophagus, creating external compression.
FNA was then performed with a 19 gauge needle. The specimen was significant for the presence of pus. Numerous passes revealed similar findings.
On endoscopic inspection of the FNA site, there was a small area of purulent discharge noted as seen here.  As a result of this finding, jumbo biopsies were used to take biopsies of the overlying mucosa as well as deep well  biopsies. This was done in an attempt to deroof the abscess cavity. As deeper biopsies were taken there was large amount of pus seen flowing from the lesion. 
Given the location of the lesion and the presence of pus histoplasmosis was suspected as the etiology. Cultures and serum testing confirmed presence of active histoplasmosis.
Pulmonary histoplasmosis is rarely complicated by large, encapsulated, caseous mediastinal lymph nodes. This is also known as mediastinal granuloma. Overall, mediastinal granuloma causes low morbidity and is amenable to treatment.  Compression of compliant structures such as the esophagus, pulmonary vessels, and occasionally the airways may result in a variety of symptoms including chest pain, cough, odynophagia, or as in our patient dysphagia. Rarely a bronchoesophageal or tracheoesophageal fistula may occur.
Our patient was treated with voriconazole and at present he is doing well.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/E04_DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Endoscopic management of iatrogenic peripancreatic abscess</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=899</guid>
				<description><![CDATA[This video aims to demonstrate the EUS-assisted access to a peripancreatic abscess and subsequent drainage into the stomach in addition to the use of hydrogen peroxide to facilitate removal of necrotic debris.

A 26 year old female patient presented with LUQ abdominal pain of two months duration. Her past medical history was significant for obesity, endometriosis and a cholecystectomy.

A CT scan of the abdomen showed a 2 cm cystic lesion in the pancreatic tail with no septation. The patient underwent laparoscopic distal pancreatectomy and splenectomy and pathology confirmed the diagnosis of mucinous cystic neoplasm.

Three weeks postoperatively the patient was diagnosed with a subphrenic abscess after she presented with fevers and abdominal pain. The abscess was initially drained percutaneously.

An ERCP showed subtle contrast extravasation in the tail of the pancreas as noted by the arrows. A 5 x 9 Hobbs pancreatic stent was then placed.

Despite multiple courses of antibiotics and upsizing of the percutaneous drains on two occasions, the patient continued to have fevers. Repeat imaging studies showed persistence of the abscess and we were asked to evaluate for possible endoscopic drainage.

Upon entering the stomach, extrinsic compression in the fundus was noted along the greater curvature. Endosonographic evaluation revealed a large cystic lesion with debris and air. One pass was made using the 19G needle. Contrast was injected and fluoroscopic images revealed a cystic lesion with internal debris. The previously placed percutaneous drain was located within the lesion but contrast was not draining through it suggesting an occlusion.

A 0.035 guidewire was then advanced into the fluid collection forming several loops. A 10 mm dilating balloon was advanced over the wire across the gastric wall into the fluid collection creating a cystgastrostomy. Large amounts of pus poured out of the fistula and a 10 x 4 double pigtail stent was inserted.

The linear echoendoscope was then substituted with a therapeutic gastroscope and the fistula was dilated   further to 14mm. At that point we were able to drive the scope into the abcess and normal saline was used to irrigate the area. The architecture of the abscess was very complex with large amounts of pus and  solid debris in addition to a very friable mucosa. The previously placed percutaneous drain was visualized.
We were then able to remove some debris from the abscess using a variety of instruments such as the alligator forceps shown in these images. However the necrotic material appeared to be glued to the abscess wall and attempts at clearing the area were discontinued due to the risk of bleeding from a potential underlying vessel. 

At that point 2 additional double pigtail stents were placed for a total of three stents to maintain the patency of the fistula. Finally an 8.5Fr nasocystic drain was placed in order to irrigate the abscess and the scope was withdrawn under fluoroscopy. 

The patient tolerated the procedure well. A repeat CT scan 24 hour post procedure showed that the stents were in place and that there was a decrease in the fluid component of the abscess.

Three days later, the patient was brought back to the GI lab to further debreed the abscess. Large amounts debris were remaining  and surgical clips were visible. The abscess cavity was then treated with 0.1% hydrogen peroxide to help in tissue desiccation. Approximately 200 cc of 0.1% hydrogen peroxide were irrigated into the cavity over the course of the procedure. The hydrogen peroxide helped in loosening the necrotic contents of the abscess and a large amount of debris was then removed using alligator forceps as shown in these images. 
By the end of the procedure, the cavity appeared to have lost over 60% of its necrotic contents. A total of 3 double pigtail stents were kept in order to maintain the cystgastrostomy site. 

The patient tolerated the procedure well and no significant side effects were noted. Her symptoms completely resolved. She completed her course of antibiotics and was discharged home. 
 
A CT scan obtained 4 weeks later showed near complete resolution of the abscess. The double pigtail stents were still in place as seen on this cut.

One last procedure was performed one week after the CT scan. A 27 Fr gastroscope was advanced through the fistula to the abscess cavity.  Large amounts of granulation tissue were noted along the walls of the abscess but no debris were found. The percutaneous drain was still in place. A guidewire was then advanced into the cavity and the drain was then withdrawn leaving a fistula tract with the skin.

The patient had an excellent clinical course free of complications. The skin fistula healed properly. She was followed up in the outpatient setting on a monthly basis. 

A final CT scan two months later showed complete resolution of the abscess.

In  summary this video demonstrated the successful endoscopic treatment of an iatrogenic peripancreatic abscess after failed percutaneous drainage. This allowed the patient to avoid a more invasive surgery. The video also demonstrated the safe use of hydrogen peroxide to help in tissue desiccation therefore facilitating the extraction of debris.]]></description>
				<dc:creator>Elie Aoun, MD,, University of Pittsburgh</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=899</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/E05-DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=899" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/E05-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Elie Aoun, MD,, University of Pittsburgh</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[This video aims to demonstrate the EUS-assisted access to a peripancreatic abscess and subsequent drainage into the stomach in addition to the use of hydrogen peroxide to facilitate removal of necrotic debris.

A 26 year old female patient presented with LUQ abdominal pain of two months duration. Her past medical history was significant for obesity, endometriosis and a cholecystectomy.

A CT scan of the abdomen showed a 2 cm cystic lesion in the pancreatic tail with no septation. The patient underwent laparoscopic distal pancreatectomy and splenectomy and pathology confirmed the diagnosis of mucinous cystic neoplasm.

Three weeks postoperatively the patient was diagnosed with a subphrenic abscess after she presented with fevers and abdominal pain. The abscess was initially drained percutaneously.

An ERCP showed subtle contrast extravasation in the tail of the pancreas as noted by the arrows. A 5 x 9 Hobbs pancreatic stent was then placed.

Despite multiple courses of antibiotics and upsizing of the percutaneous drains on two occasions, the patient continued to have fevers. Repeat imaging studies showed persistence of the abscess and we were asked to evaluate for possible endoscopic drainage.

Upon entering the stomach, extrinsic compression in the fundus was noted along the greater curvature. Endosonographic evaluation revealed a large cystic lesion with debris and air. One pass was made using the 19G needle. Contrast was injected and fluoroscopic images revealed a cystic lesion with internal debris. The previously placed percutaneous drain was located within the lesion but contrast was not draining through it suggesting an occlusion.

A 0.035 guidewire was then advanced into the fluid collection forming several loops. A 10 mm dilating balloon was advanced over the wire across the gastric wall into the fluid collection creating a cystgastrostomy. Large amounts of pus poured out of the fistula and a 10 x 4 double pigtail stent was inserted.

The linear echoendoscope was then substituted with a therapeutic gastroscope and the fistula was dilated   further to 14mm. At that point we were able to drive the scope into the abcess and normal saline was used to irrigate the area. The architecture of the abscess was very complex with large amounts of pus and  solid debris in addition to a very friable mucosa. The previously placed percutaneous drain was visualized.
We were then able to remove some debris from the abscess using a variety of instruments such as the alligator forceps shown in these images. However the necrotic material appeared to be glued to the abscess wall and attempts at clearing the area were discontinued due to the risk of bleeding from a potential underlying vessel. 

At that point 2 additional double pigtail stents were placed for a total of three stents to maintain the patency of the fistula. Finally an 8.5Fr nasocystic drain was placed in order to irrigate the abscess and the scope was withdrawn under fluoroscopy. 

The patient tolerated the procedure well. A repeat CT scan 24 hour post procedure showed that the stents were in place and that there was a decrease in the fluid component of the abscess.

Three days later, the patient was brought back to the GI lab to further debreed the abscess. Large amounts debris were remaining  and surgical clips were visible. The abscess cavity was then treated with 0.1% hydrogen peroxide to help in tissue desiccation. Approximately 200 cc of 0.1% hydrogen peroxide were irrigated into the cavity over the course of the procedure. The hydrogen peroxide helped in loosening the necrotic contents of the abscess and a large amount of debris was then removed using alligator forceps as shown in these images. 
By the end of the procedure, the cavity appeared to have lost over 60% of its necrotic contents. A total of 3 double pigtail stents were kept in order to maintain the cystgastrostomy site. 

The patient tolerated the procedure well and no significant side effects were noted. Her symptoms completely resolved. She completed her course of antibiotics and was discharged home. 
 
A CT scan obtained 4 weeks later showed near complete resolution of the abscess. The double pigtail stents were still in place as seen on this cut.

One last procedure was performed one week after the CT scan. A 27 Fr gastroscope was advanced through the fistula to the abscess cavity.  Large amounts of granulation tissue were noted along the walls of the abscess but no debris were found. The percutaneous drain was still in place. A guidewire was then advanced into the cavity and the drain was then withdrawn leaving a fistula tract with the skin.

The patient had an excellent clinical course free of complications. The skin fistula healed properly. She was followed up in the outpatient setting on a monthly basis. 

A final CT scan two months later showed complete resolution of the abscess.

In  summary this video demonstrated the successful endoscopic treatment of an iatrogenic peripancreatic abscess after failed percutaneous drainage. This allowed the patient to avoid a more invasive surgery. The video also demonstrated the safe use of hydrogen peroxide to help in tissue desiccation therefore facilitating the extraction of debris.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/E05-DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Experience with a prototype forward-viewing curvilinear array therapeutic echoendoscope for interventional EUS: A case series</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=900</guid>
				<description><![CDATA[Experience with a prototype forward-viewing curvilinear array therapeutic echoendoscope for interventional EUS: a case series.

Interventional EUS offers a minimally invasive alternative to traditional surgical and/or radiologic interventions for the treatment of pancreaticobiliary disorders.  These procedures are typically performed with oblique-viewing instruments.

However, standard oblique-viewing echoendoscopes are limited by impaired endoscopic visualization, difficult orientation for drainage procedures and difficulty passing accessories through the endoscope channel.

Recent development of a forward-viewing therapeutic echoendoscope may offer advantages over standard oblique viewing instruments by improving endoscopic visualization, optimizing access to pseudocysts, bile ducts and pancreatic duct for drainage procedures, allowing passage of larger, stiffer accessories through the endoscope channel and avoiding the need to exchange endoscopes.

The GIF UCT 160J-AL5 is a prototype instrument with forward viewing 120 degree field of view and a 3.7mm accessory channel.  The instrument does not have an elevator.  The US scanning range is 90 degrees with a frequency range of 5, 6, 7.5 and 12 MHz.

Recent case series have demonstrated the efficacy of this instrument for drainage of a pelvic abscess, an obstructed bile duct and pseudocysts.

In this video, we will demonstrate the following EUS techniques using the prototype instrument.  EUS-guided biliary rendezvous after failed ERCP, transmural pseudocyst drainage, and EUS-guided fiducial placement for locally advanced pancreatic cancer.

Furthermore, we will describe our experience with the prototype instrument in nine consecutive interventional cases.

Let us start with the rendezvous

A 75 year old male presents with obstructive jaundice and an EUS demonstrating a mass in the head of the pancreas invading the duodenal wall and ampulla.  Invasion and distortion of the ampulla precludes a successful ERCP resulting in submucosal injections.  A rendezvous procedure is then attempted.

Doppler imaging with the prototype instrument demonstrates the portal vein, a dilated common bile duct and adjacent cystic duct

FNA of the bile duct is performed with a 22 gauge needle for antegrade access.

Contrast is then injected through the needle to perform a cholangiogram.  Note the position of the echoendoscope in the duodenal bulb, parallel to the bile duct and pointing toward the papilla.  This position is helpful for facilitating passage of the guidewiire across the papilla.  This is in contrast to the position of an oblique-viewing instrument, seen here in a different case, orienting perpendicular to the duct.

A 0.018 inch guidewire is then advanced through the needle across the stricture into the second portion of the duodenum.

The echoendoscope is then exchanged for a duodenoscope to perform the ERCP.  

Here, the guidewire is observed traversing the wall of the duodenal bulb.  

Upon advancing the duodenoscope into the second portion of the duodenum, the guidewire is observed crossing the papilla.  Note the infiltrating tumor at the level of the ampulla.

The guidewire is then grasped with biopsy forceps and withdrawn into the endoscope.  

A papillotome is then advanced over the guidewire into the bile duct.  Once the papillotome is advanced above the stricture, the guidewire is removed and a second guidewire is advanced through the papillotome into the bile duct.  At the close of the procedure, a 10x60mm uncovered metal stent is deployed for biliary drainage.

In the second case we will demonstrate EUS-guided transmural drainage of an infected pseudocyst

An 80 year old male with history of metastatic pancreatic cancer and prior ERCP for placement of metal biliary stent presents with worsening abdominal pain, fever and leukocytosis.  An abdominal CT reveals pancreatic ductal dilation and development of a pseudocyst adjacent to the tail of the pancreas.

EUS reveals a 9x6cm pseudocyst with heterogeneous internal debris

The pseudocyst is punctured with a 19 gauge needle. 

Contrast is then injected demonstrating a cystic cavity with internal debris.

A 0.035 inch guidewire is then advanced through the needle into the pseudocyst forming several loops.

A 10mm dilating balloon is advanced over the guidewire, puncturing the gastric and pseudocyst walls.  Note the orientation of the echoendoscope and its ability to transmit the force of the puncture into the intestinal wall.  

The balloon is dilated to create the cystgastrostomy.

Upon deflation of the balloon, a large amount of pus is observed draining from the pseudocyst into the stomach.
The diameter of the cystgastrostomy is then increased with a 15mm balloon to further facilitate drainage.

A 10F double pigtail silicone stent is then placed over the guidewire,  followed by placement of two additional double pigtail stents to maintain patency of the fistulous tract.

The patient tolerated the procedure well and a follow up CT scan four weeks later revealed near complete resolution of the pseudocsyt

In the last case, we will demonstrates EUS-guided fiducial placement for stereotactic body radiotherapy in a locally advanced pancreatic cancer

A 75 year male with locally advanced pancreatic cancer presents for EUS guided fiducial placement.  A hypoechoic mass is observed in the head of the pancreas invading the duodenal wall.  A previously placed PTC is observed.

A 0.8x5.0mm gold fiducial was back-loaded into a 19 gauge Echotip needle and advanced through the accessory channel without resistance.  The needle is then advanced into the mass and deployed without difficulty.  On these fluoroscopic images, you can see the fiducial being deployed into the mass within the head of the pancreas.

A second fiducial is then placed within a malignant appearing lymph node immediately adjacent to the mass.  The fluoroscopic images demonstrate the fiducials positioned approximately two centimeters apart.

To date, we have performed nine interventional EUS procedures with the prototype instrument to include three celiac plexus neurolyses, three transmural cystgastrostomies for pseudocyst drainage, two rendezvous procedures and one fiducial placement.  The single failure occurred in a pancreatic rendezvous case secondary to failure in antegrade traversal of the stricture with a guidewire.  We observed improved endoscopic visualization and orientation for drainage procedures with the prototype instrument.  In addition, there were no complications.  

In summary, we have demonstrated three techniques in interventional  EUS using a prototype forward-viewing echoendoscope.  The superior endoscopic visualization and orientation for drainage procedures offers advantages over the current oblique-viewing instruments.  In our case series, success was achieved in nearly 90% of the cases without a single complication.  Further studies are needed to evaluate the efficacy of this prototype instrument and its potential to replace the current oblique-viewing therapeutic echoendoscope.]]></description>
				<dc:creator>Michael K Sanders, MD,,</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=900</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/E06-DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=900" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/E06-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Michael K Sanders, MD,,</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Experience with a prototype forward-viewing curvilinear array therapeutic echoendoscope for interventional EUS: a case series.

Interventional EUS offers a minimally invasive alternative to traditional surgical and/or radiologic interventions for the treatment of pancreaticobiliary disorders.  These procedures are typically performed with oblique-viewing instruments.

However, standard oblique-viewing echoendoscopes are limited by impaired endoscopic visualization, difficult orientation for drainage procedures and difficulty passing accessories through the endoscope channel.

Recent development of a forward-viewing therapeutic echoendoscope may offer advantages over standard oblique viewing instruments by improving endoscopic visualization, optimizing access to pseudocysts, bile ducts and pancreatic duct for drainage procedures, allowing passage of larger, stiffer accessories through the endoscope channel and avoiding the need to exchange endoscopes.

The GIF UCT 160J-AL5 is a prototype instrument with forward viewing 120 degree field of view and a 3.7mm accessory channel.  The instrument does not have an elevator.  The US scanning range is 90 degrees with a frequency range of 5, 6, 7.5 and 12 MHz.

Recent case series have demonstrated the efficacy of this instrument for drainage of a pelvic abscess, an obstructed bile duct and pseudocysts.

In this video, we will demonstrate the following EUS techniques using the prototype instrument.  EUS-guided biliary rendezvous after failed ERCP, transmural pseudocyst drainage, and EUS-guided fiducial placement for locally advanced pancreatic cancer.

Furthermore, we will describe our experience with the prototype instrument in nine consecutive interventional cases.

Let us start with the rendezvous

A 75 year old male presents with obstructive jaundice and an EUS demonstrating a mass in the head of the pancreas invading the duodenal wall and ampulla.  Invasion and distortion of the ampulla precludes a successful ERCP resulting in submucosal injections.  A rendezvous procedure is then attempted.

Doppler imaging with the prototype instrument demonstrates the portal vein, a dilated common bile duct and adjacent cystic duct

FNA of the bile duct is performed with a 22 gauge needle for antegrade access.

Contrast is then injected through the needle to perform a cholangiogram.  Note the position of the echoendoscope in the duodenal bulb, parallel to the bile duct and pointing toward the papilla.  This position is helpful for facilitating passage of the guidewiire across the papilla.  This is in contrast to the position of an oblique-viewing instrument, seen here in a different case, orienting perpendicular to the duct.

A 0.018 inch guidewire is then advanced through the needle across the stricture into the second portion of the duodenum.

The echoendoscope is then exchanged for a duodenoscope to perform the ERCP.  

Here, the guidewire is observed traversing the wall of the duodenal bulb.  

Upon advancing the duodenoscope into the second portion of the duodenum, the guidewire is observed crossing the papilla.  Note the infiltrating tumor at the level of the ampulla.

The guidewire is then grasped with biopsy forceps and withdrawn into the endoscope.  

A papillotome is then advanced over the guidewire into the bile duct.  Once the papillotome is advanced above the stricture, the guidewire is removed and a second guidewire is advanced through the papillotome into the bile duct.  At the close of the procedure, a 10x60mm uncovered metal stent is deployed for biliary drainage.

In the second case we will demonstrate EUS-guided transmural drainage of an infected pseudocyst

An 80 year old male with history of metastatic pancreatic cancer and prior ERCP for placement of metal biliary stent presents with worsening abdominal pain, fever and leukocytosis.  An abdominal CT reveals pancreatic ductal dilation and development of a pseudocyst adjacent to the tail of the pancreas.

EUS reveals a 9x6cm pseudocyst with heterogeneous internal debris

The pseudocyst is punctured with a 19 gauge needle. 

Contrast is then injected demonstrating a cystic cavity with internal debris.

A 0.035 inch guidewire is then advanced through the needle into the pseudocyst forming several loops.

A 10mm dilating balloon is advanced over the guidewire, puncturing the gastric and pseudocyst walls.  Note the orientation of the echoendoscope and its ability to transmit the force of the puncture into the intestinal wall.  

The balloon is dilated to create the cystgastrostomy.

Upon deflation of the balloon, a large amount of pus is observed draining from the pseudocyst into the stomach.
The diameter of the cystgastrostomy is then increased with a 15mm balloon to further facilitate drainage.

A 10F double pigtail silicone stent is then placed over the guidewire,  followed by placement of two additional double pigtail stents to maintain patency of the fistulous tract.

The patient tolerated the procedure well and a follow up CT scan four weeks later revealed near complete resolution of the pseudocsyt

In the last case, we will demonstrates EUS-guided fiducial placement for stereotactic body radiotherapy in a locally advanced pancreatic cancer

A 75 year male with locally advanced pancreatic cancer presents for EUS guided fiducial placement.  A hypoechoic mass is observed in the head of the pancreas invading the duodenal wall.  A previously placed PTC is observed.

A 0.8x5.0mm gold fiducial was back-loaded into a 19 gauge Echotip needle and advanced through the accessory channel without resistance.  The needle is then advanced into the mass and deployed without difficulty.  On these fluoroscopic images, you can see the fiducial being deployed into the mass within the head of the pancreas.

A second fiducial is then placed within a malignant appearing lymph node immediately adjacent to the mass.  The fluoroscopic images demonstrate the fiducials positioned approximately two centimeters apart.

To date, we have performed nine interventional EUS procedures with the prototype instrument to include three celiac plexus neurolyses, three transmural cystgastrostomies for pseudocyst drainage, two rendezvous procedures and one fiducial placement.  The single failure occurred in a pancreatic rendezvous case secondary to failure in antegrade traversal of the stricture with a guidewire.  We observed improved endoscopic visualization and orientation for drainage procedures with the prototype instrument.  In addition, there were no complications.  

In summary, we have demonstrated three techniques in interventional  EUS using a prototype forward-viewing echoendoscope.  The superior endoscopic visualization and orientation for drainage procedures offers advantages over the current oblique-viewing instruments.  In our case series, success was achieved in nearly 90% of the cases without a single complication.  Further studies are needed to evaluate the efficacy of this prototype instrument and its potential to replace the current oblique-viewing therapeutic echoendoscope.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/E06-DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>EUS guided confocal laser endomicroscopy of the pancreas</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=901</guid>
				<description><![CDATA[EUS guided probe confocal laser endomicroscopy (abbreviated pCLE) is performed in a feasibility study of three pancreas lesions, including a neuroendocrine tumor, adenocarcinoma and a solid-pseudopapillary neoplasm. 

2.5 ml of 10% fluorescein was given intravenously as a contrast agent for pCLE imaging.  The confocal probe was passed through a 19 G needle under EUS guidance in an HIC approved protocol.  Fine needle aspiration of the lesion was performed for cytologic diagnosis at the conclusion of pCLE imaging.  

A locking device at the needle handle aligns the probe and needle tips.   The probe has a metallic tip to prevent shearing from the beveled needle.  The probe was withdrawn approximately 5 cm when advancing the EUS needle.  The needle and probe were removed after imaging and another needle was used for fine needle aspiration.

The prototype CLE probes have a diameter of .85 mm, a resolution of 3.5 microns and a working distance between 0 and 100 microns.  They can be visualized with ultrasound or fluoroscopy.

The first case is a 42 year old female with abdominal pain and a well circumscribed mass in the pancreas tail on CT scan.

EUS examination with the linear echoendoscope reveals a well circumscribed, rounded, 5 cm, mildly hypoechoic mass in the pancreas tail.   Within the mass a 1.8  cm heterogeneous area and a 1 cm cystic space are seen.  IV fluorescein is administered.  The 19 gauge EUS needle containing the confocal probe is passed into the mass through the stomach wall.  When in the target, the probe is advanced to the needle tip and confocal imaging is performed. 

CLE reveals blood vessels and dark clumps within the lesion. 

An example of a blood vessel is demonstrated.  Here another blood vessel is seen. Dark clumps are shown here.

Cytology revealed a pancreatic endocrine tumor with uniform neoplastic cells with a plasmacytoid appearance seen on H and E stain.  

The second case is a 64 year old female who presented with abdominal pain and a pancreas body mass identified on CT scan.

EUS examination identifies a 4 cm hypoechoic mass in the pancreas neck/body with extension along and encasement of the superior mesenteric artery as seen here.  The 19 gauge needle containing the CLE probe was passed into the mass through the gastric wall.

CLE imaging revealed fibers possibly representing scar tissue and black cells.

Linear fibers are demonstrated here along with dark cells periodically in movement.

Cytology identified ductal epithelial cells with disorderly arrangement, nuclear enlargement and hyperchromasia, diagnosing adenocarcinoma.

The final case is a 30 year old female with an incidentally detected pancreas head mass seen on CT scan.

EUS reveals a  3.4 cm heterogeneous, rounded,  hypoechoic mass in the head of the pancreas with a central shadowing calcification.  The 19 G needle and probe are passed into the mass through the duodenum.

CLE imaging reveals blood vessels and dark clumps within the mass.

Here the dark areas are demonstrated along with blood vessels. 

Cytology revealed branching fibrovascular papillae lined with neoplastic cells, surrounded by a myxoid stroma, diagnostic of a solid-pseudopapillary neoplasm.  

In conclusion, this pilot study demonstrates the first clinical use of confocal laser endomicroscopy via a needle under EUS guidance.  Access to pancreas lesions was technically feasible in all cases with no adverse events encountered.  Visualization of structures including fibers, blood vessels and dark clumps and cells was achieved with good image quality.

This technology may permit real-time CLE imaging of multiple areas accessible via EUS-FNA.  Further study correlating CLE, cytology and surgical pathology findings is warranted.]]></description>
				<dc:creator>Harry Aslanian, M.D., Associate Professor of Medicine, Yale University</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=901</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/E08-DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=901" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/vlcsnap-00003-19-46-16.jpg</media:thumbnail>
				<media:people role="producer">Harry Aslanian, M.D., Associate Professor of Medicine, Yale University</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[EUS guided probe confocal laser endomicroscopy (abbreviated pCLE) is performed in a feasibility study of three pancreas lesions, including a neuroendocrine tumor, adenocarcinoma and a solid-pseudopapillary neoplasm. 

2.5 ml of 10% fluorescein was given intravenously as a contrast agent for pCLE imaging.  The confocal probe was passed through a 19 G needle under EUS guidance in an HIC approved protocol.  Fine needle aspiration of the lesion was performed for cytologic diagnosis at the conclusion of pCLE imaging.  

A locking device at the needle handle aligns the probe and needle tips.   The probe has a metallic tip to prevent shearing from the beveled needle.  The probe was withdrawn approximately 5 cm when advancing the EUS needle.  The needle and probe were removed after imaging and another needle was used for fine needle aspiration.

The prototype CLE probes have a diameter of .85 mm, a resolution of 3.5 microns and a working distance between 0 and 100 microns.  They can be visualized with ultrasound or fluoroscopy.

The first case is a 42 year old female with abdominal pain and a well circumscribed mass in the pancreas tail on CT scan.

EUS examination with the linear echoendoscope reveals a well circumscribed, rounded, 5 cm, mildly hypoechoic mass in the pancreas tail.   Within the mass a 1.8  cm heterogeneous area and a 1 cm cystic space are seen.  IV fluorescein is administered.  The 19 gauge EUS needle containing the confocal probe is passed into the mass through the stomach wall.  When in the target, the probe is advanced to the needle tip and confocal imaging is performed. 

CLE reveals blood vessels and dark clumps within the lesion. 

An example of a blood vessel is demonstrated.  Here another blood vessel is seen. Dark clumps are shown here.

Cytology revealed a pancreatic endocrine tumor with uniform neoplastic cells with a plasmacytoid appearance seen on H and E stain.  

The second case is a 64 year old female who presented with abdominal pain and a pancreas body mass identified on CT scan.

EUS examination identifies a 4 cm hypoechoic mass in the pancreas neck/body with extension along and encasement of the superior mesenteric artery as seen here.  The 19 gauge needle containing the CLE probe was passed into the mass through the gastric wall.

CLE imaging revealed fibers possibly representing scar tissue and black cells.

Linear fibers are demonstrated here along with dark cells periodically in movement.

Cytology identified ductal epithelial cells with disorderly arrangement, nuclear enlargement and hyperchromasia, diagnosing adenocarcinoma.

The final case is a 30 year old female with an incidentally detected pancreas head mass seen on CT scan.

EUS reveals a  3.4 cm heterogeneous, rounded,  hypoechoic mass in the head of the pancreas with a central shadowing calcification.  The 19 G needle and probe are passed into the mass through the duodenum.

CLE imaging reveals blood vessels and dark clumps within the mass.

Here the dark areas are demonstrated along with blood vessels. 

Cytology revealed branching fibrovascular papillae lined with neoplastic cells, surrounded by a myxoid stroma, diagnostic of a solid-pseudopapillary neoplasm.  

In conclusion, this pilot study demonstrates the first clinical use of confocal laser endomicroscopy via a needle under EUS guidance.  Access to pancreas lesions was technically feasible in all cases with no adverse events encountered.  Visualization of structures including fibers, blood vessels and dark clumps and cells was achieved with good image quality.

This technology may permit real-time CLE imaging of multiple areas accessible via EUS-FNA.  Further study correlating CLE, cytology and surgical pathology findings is warranted.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/E08-DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Endoscopic submucosal dissection of a giant rectal adenoma using a Flush-knife</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=902</guid>
				<description><![CDATA[We report the case of an endoscopic submucosal dissection of a granular type adenoma spreading over eight tenths of the rectum, and sparing a healthy strip of the posterior rectal aspect, in a 75-year-old man, using an electrosurgical endo-knife with a water-jet function, the Flush-knife.. 
Here we can see through both a direct and retroflex view this almost circumferential lesion. Here this healthy strip of mucosa is clearly visible. The injection of saline and of hyaluronic acid is started at the lower part of the lesion on its left border at the level of the anorectal junction. A circumferential incision is performed. Using the grasper, hemostatic maneuvers are carried out either prophylactically or curatively at the level of the vessels situated at the anorectal junction. To do so, a soft coagulation current is used. Then the procedure is continued with the circumferential dissection of the anorectal junction, hence exposing larger vessels that are managed by hemostatic forceps in a prophylactic fashion. Then the incision of the lesion&#39;s left border is started. A small polyp is encountered and resected. Here is the lesion&#39;s right border.
Then a tunnelization is begun underneath the lesion on the patient&#39;s right side. Here the vessels that originate from the muscularis propria and divide within the submucosa present a kind of vine stock aspect. The muscularis propria is down, below. The submucosa and the lesion are above on this view. The coagulation is performed with a forced coagulation current using the Flush-knife. The forced coagulation is also used for the dissection. When using the hemostatic forceps, it is a soft coagulation current that is used. Here again the vine stock aspect is visible; we see the vessel&#39;s retraction induced by the soft coagulation current. We see here the right margin of the lesion that is incised towards its upper section with an Endo-cut current E 2 3 3. The dissection is continued to the left margin. Above we can see the anterior surface, the muscularis propria, and below the lesion that is attached to the wall by large vessels. With a large foreign body grasper, the en-bloc resected lesion is retrieved. Here we can see the rectum&#39;s aspect following the resection with the healthy mucosal strip remaining. The histology confirms that the lesion was a tubulovillous and serrated adenoma with focal high-grade dysplasia. The deep and lateral resection margins were perfectly healthy. The lesion measured 15 by 10cm. The whole procedure took 4 hours and 30 minutes. CO2 was insufflated. During the 6 months that followed, the patient was treated three times with balloon dilations up to 20mm in order to facilitate the passage of faeces. Apart from a residual ulceration, the endoscopic and histological controls did not show any recurrences at 6 months. In conclusion, ESD with Flush-knife provided a safe and successfull en-bloc resection of this large rectal adenoma.]]></description>
				<dc:creator>Dimitri Coumaros, MD,, University Louis Pasteur, Strasbourg, France</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=902</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/L11-DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=902" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/L11-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Dimitri Coumaros, MD,, University Louis Pasteur, Strasbourg, France</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[We report the case of an endoscopic submucosal dissection of a granular type adenoma spreading over eight tenths of the rectum, and sparing a healthy strip of the posterior rectal aspect, in a 75-year-old man, using an electrosurgical endo-knife with a water-jet function, the Flush-knife.. 
Here we can see through both a direct and retroflex view this almost circumferential lesion. Here this healthy strip of mucosa is clearly visible. The injection of saline and of hyaluronic acid is started at the lower part of the lesion on its left border at the level of the anorectal junction. A circumferential incision is performed. Using the grasper, hemostatic maneuvers are carried out either prophylactically or curatively at the level of the vessels situated at the anorectal junction. To do so, a soft coagulation current is used. Then the procedure is continued with the circumferential dissection of the anorectal junction, hence exposing larger vessels that are managed by hemostatic forceps in a prophylactic fashion. Then the incision of the lesion&#39;s left border is started. A small polyp is encountered and resected. Here is the lesion&#39;s right border.
Then a tunnelization is begun underneath the lesion on the patient&#39;s right side. Here the vessels that originate from the muscularis propria and divide within the submucosa present a kind of vine stock aspect. The muscularis propria is down, below. The submucosa and the lesion are above on this view. The coagulation is performed with a forced coagulation current using the Flush-knife. The forced coagulation is also used for the dissection. When using the hemostatic forceps, it is a soft coagulation current that is used. Here again the vine stock aspect is visible; we see the vessel&#39;s retraction induced by the soft coagulation current. We see here the right margin of the lesion that is incised towards its upper section with an Endo-cut current E 2 3 3. The dissection is continued to the left margin. Above we can see the anterior surface, the muscularis propria, and below the lesion that is attached to the wall by large vessels. With a large foreign body grasper, the en-bloc resected lesion is retrieved. Here we can see the rectum&#39;s aspect following the resection with the healthy mucosal strip remaining. The histology confirms that the lesion was a tubulovillous and serrated adenoma with focal high-grade dysplasia. The deep and lateral resection margins were perfectly healthy. The lesion measured 15 by 10cm. The whole procedure took 4 hours and 30 minutes. CO2 was insufflated. During the 6 months that followed, the patient was treated three times with balloon dilations up to 20mm in order to facilitate the passage of faeces. Apart from a residual ulceration, the endoscopic and histological controls did not show any recurrences at 6 months. In conclusion, ESD with Flush-knife provided a safe and successfull en-bloc resection of this large rectal adenoma.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/L11-DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Endoscopic rendezvous for complete colonic obstruction</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=903</guid>
				<description><![CDATA[A 50 year old man has a past medical history of bilateral congenital glaucoma causing him to be legally blind and metastatic rectal cancer to the liver.
The patient&#39;s cancer was diagnosed because he had developed rectal obstruction.  As a result, he underwent a diverting transverse loop colostomy.  The patient had difficulty managing his ostomy because of his blindness.  He requested resection of his rectal tumor in order to reverse his colostomy.   Sixteen months after his previous surgery, he underwent a low anterior resection, reversal of his colostomy, and creation of a temporary loop ileostomy. 
Six months later, a barium enema was performed prior to his ileostomy takedown and the barium enema showed a widely patent rectal anastomosis.  
The patient was brought to the operating room for closure of his ileostomy.  On post-operative day four, the patient developed nausea, vomiting, and abdominal distention.
An abdominal radiograph showed a large bowel obstruction
An abdominal CT revealed an obstruction of the transverse colon with retained contrast in the ascending colon.  
A colonoscopy confirmed a complete obstruction at the prior transverse colostomy site.  The patient declined surgical diversion due to difficulty caring for his previous ostomy.  Endoscopic management of the obstruction was attempted under fluoroscopy, however, it was unsuccessful.  
As a result, a cecostomy tube was placed for decompression.
Total parenteral nutrition was started and the patient continued to decline surgical intervention.  The cecostomy fistula was allowed to mature over four weeks and then endoscopic management was reattempted.
  A colonoscope was inserted through the rectum and advanced to the level of the obstruction.
  The 12Fr cecostomy tube was removed and a 0.035 guidewire was inserted into the right colon.  A balloon dilator was passed over the guidewire and the cecostomy fistula was sequentially dilated to 12mm.  An ultra-slim gastroscope, 5.9mm in diameter, was piggybacked behind the balloon dilator into the right colon.  The ultra-slim gastroscope was then advanced to the proximal side of the obstruction.  Direct transillumination of both endoscopes was visualized.    The sharp end of a Savary guidewire was inserted through the colonoscope and was used to pierce through the distal side of the obstruction.  Using the ultra-slim gastroscope, a snare was placed around the Savary guidewire to stabilize it.  Transillumination of the colonoscope is visualized in the proximal colon.  The balloon dilator was advanced alongside the Savary guidewire, through the obstruction which was then dilated to 12mm.
A balloon dilator was then placed through the colonoscope and dilation again was performed.  The colonoscope was then able to be advanced through the obstruction to the cecum.  The ultra-slim gastroscope was then well visualized by the colonoscope.  The colonoscope was then withdrawn to the site of the cecostomy fistula.  The ultra-slim gastroscope was then removed from the fistula.  With the colonoscope in the ascending colon, the fistula was then closed with 4 clips.  The colonoscope was then withdrawn to the transverse colon.  The site of the obstruction was then balloon dilated to 18mm.  The patient tolerated the procedure without complication.  
The next day, the patient was started on a clear liquid diet and it was advanced to a regular diet accordingly.  The patient underwent a colonoscopy three weeks later and the site of the prior obstruction was widely patent.  The patient remained asymptomatic and was able to reinstitute chemotherapy.
Benign colonic strictures are an infrequent complication after colonic surgery.  The development of complete colonic obstruction is even rarer.  In this case, we performed a rendezvous colonoscopy in order to alleviate the colonic obstruction.  A retrograde colonoscopy was performed via the usual route and an antegrade colonoscopy was performed by accessing the proximal colon through the cecostomy fistula.  Direct transillumination of both endoscopes was followed by puncturing the obstructing mucosa with a Savary guidewire.  Balloon dilation was then performed, restoring bowel continuity.  This procedure obviated the need for surgical intervention for a case of complete colonic obstruction.]]></description>
				<dc:creator>Evan B. Grossman, MD,,</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=903</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/L12-DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=903" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/L12-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Evan B. Grossman, MD,,</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[A 50 year old man has a past medical history of bilateral congenital glaucoma causing him to be legally blind and metastatic rectal cancer to the liver.
The patient&#39;s cancer was diagnosed because he had developed rectal obstruction.  As a result, he underwent a diverting transverse loop colostomy.  The patient had difficulty managing his ostomy because of his blindness.  He requested resection of his rectal tumor in order to reverse his colostomy.   Sixteen months after his previous surgery, he underwent a low anterior resection, reversal of his colostomy, and creation of a temporary loop ileostomy. 
Six months later, a barium enema was performed prior to his ileostomy takedown and the barium enema showed a widely patent rectal anastomosis.  
The patient was brought to the operating room for closure of his ileostomy.  On post-operative day four, the patient developed nausea, vomiting, and abdominal distention.
An abdominal radiograph showed a large bowel obstruction
An abdominal CT revealed an obstruction of the transverse colon with retained contrast in the ascending colon.  
A colonoscopy confirmed a complete obstruction at the prior transverse colostomy site.  The patient declined surgical diversion due to difficulty caring for his previous ostomy.  Endoscopic management of the obstruction was attempted under fluoroscopy, however, it was unsuccessful.  
As a result, a cecostomy tube was placed for decompression.
Total parenteral nutrition was started and the patient continued to decline surgical intervention.  The cecostomy fistula was allowed to mature over four weeks and then endoscopic management was reattempted.
  A colonoscope was inserted through the rectum and advanced to the level of the obstruction.
  The 12Fr cecostomy tube was removed and a 0.035 guidewire was inserted into the right colon.  A balloon dilator was passed over the guidewire and the cecostomy fistula was sequentially dilated to 12mm.  An ultra-slim gastroscope, 5.9mm in diameter, was piggybacked behind the balloon dilator into the right colon.  The ultra-slim gastroscope was then advanced to the proximal side of the obstruction.  Direct transillumination of both endoscopes was visualized.    The sharp end of a Savary guidewire was inserted through the colonoscope and was used to pierce through the distal side of the obstruction.  Using the ultra-slim gastroscope, a snare was placed around the Savary guidewire to stabilize it.  Transillumination of the colonoscope is visualized in the proximal colon.  The balloon dilator was advanced alongside the Savary guidewire, through the obstruction which was then dilated to 12mm.
A balloon dilator was then placed through the colonoscope and dilation again was performed.  The colonoscope was then able to be advanced through the obstruction to the cecum.  The ultra-slim gastroscope was then well visualized by the colonoscope.  The colonoscope was then withdrawn to the site of the cecostomy fistula.  The ultra-slim gastroscope was then removed from the fistula.  With the colonoscope in the ascending colon, the fistula was then closed with 4 clips.  The colonoscope was then withdrawn to the transverse colon.  The site of the obstruction was then balloon dilated to 18mm.  The patient tolerated the procedure without complication.  
The next day, the patient was started on a clear liquid diet and it was advanced to a regular diet accordingly.  The patient underwent a colonoscopy three weeks later and the site of the prior obstruction was widely patent.  The patient remained asymptomatic and was able to reinstitute chemotherapy.
Benign colonic strictures are an infrequent complication after colonic surgery.  The development of complete colonic obstruction is even rarer.  In this case, we performed a rendezvous colonoscopy in order to alleviate the colonic obstruction.  A retrograde colonoscopy was performed via the usual route and an antegrade colonoscopy was performed by accessing the proximal colon through the cecostomy fistula.  Direct transillumination of both endoscopes was followed by puncturing the obstructing mucosa with a Savary guidewire.  Balloon dilation was then performed, restoring bowel continuity.  This procedure obviated the need for surgical intervention for a case of complete colonic obstruction.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/L12-DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Harnessing the power of magnets: Novel uses in advanced endoscopic therapies</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=904</guid>
				<description><![CDATA[Background/ Case: 
Magnets have previously been shown to be useful in endoscopic foreign body removal, EMR, and also in a NOTES surgical/navigation system.


Endoscopic Methods: 
Thre endoscopic applications are presented that feature the novel use of rare-earth magnets. (1) NOTES magnetic retraction using and external magnet interacting with smaller endoscopically delivered magnets affixed to organs requiring retraction. (2) Magnetically, retrievable pancreaticobiliary stents, obviating the need for a follow-up endoscopy. (3) Compression anastomosis using endoscopically delivered, smart, self-assembling magnets.


Clinical Implications:
The applications presented herin offer potential solutions to (1) NOTES retraction, (2) pancreaticobiliary stent retrieval, and (3) endoscopoic means of gastrojejunostomy and cholecysto-gastrostomy creation.]]></description>
				<dc:creator>Marvin Ryou, MD,, Brigham and Women's Hospital</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=904</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/N08-DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=904" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/N08-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Marvin Ryou, MD,, Brigham and Women's Hospital</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Background/ Case: 
Magnets have previously been shown to be useful in endoscopic foreign body removal, EMR, and also in a NOTES surgical/navigation system.


Endoscopic Methods: 
Thre endoscopic applications are presented that feature the novel use of rare-earth magnets. (1) NOTES magnetic retraction using and external magnet interacting with smaller endoscopically delivered magnets affixed to organs requiring retraction. (2) Magnetically, retrievable pancreaticobiliary stents, obviating the need for a follow-up endoscopy. (3) Compression anastomosis using endoscopically delivered, smart, self-assembling magnets.


Clinical Implications:
The applications presented herin offer potential solutions to (1) NOTES retraction, (2) pancreaticobiliary stent retrieval, and (3) endoscopoic means of gastrojejunostomy and cholecysto-gastrostomy creation.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/N08-DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Endoscopic management of an infected pseudocyst with cystgastrostomy and necrosectomy without EUS guidance</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=905</guid>
				<description><![CDATA[The treatment of pancreatic pseudocysts has historically been managed by surgeons; however, endoscopic drainage of pancreatic pseudocysts by expert endoscopists has become an accepted alternative to surgery when an intervention is indicated. Its advantage over percutaneous drainage is the ability to place multiple internal drains with minimal patient discomfort through one puncture site and the avoidance of the development of a pancreaticocutaneous fistula. 

Today, I will be presenting a case of a 37 year-old male with no significant past medical history who developed acute pancreatitis after vacationing in the Bahamas.  His pancreatitis was complicated by the formation of a pancreatic pseudocyst.  The patient was treated with conservative therapy and had a peripherally inserted central catheter placed for the administration of central parenteral nutrition.  He later presented at our institution six weeks after his initial diagnosis of acute pancreatitis with symptoms of worsening nausea and vomiting and was found to have an elevated white blood cell count.  Computed tomography demonstrated an enlarging pseudocyst measuring 27 cm with a mature wall that was displacing the transverse colon and stomach.  Because of his poor nutritional status, he was deemed a poor surgical candidate and was referred for endoscopic drainage of his pseudocyst.

Endoscopy revealed a large pseudocyst bulge in the gastric antrum resulting in a narrowed pylorus with gastric outlet obstruction.  

ERCP was able to be performed and demonstrated no evidence of extravasation of contrast to suggest a pancreatic duct leak or communication of the main pancreatic duct with the pseudocyst.

The endoscope was withdrawn into the stomach and the most inferior portion of the convex bulge was chosen to access the pseudocyst. A needle-knife was used to incise the pseudocyst resulting in prompt drainage of a steady stream of grayish thick liquid.  

A guidewire was then passed into the cyst cavity as the cyst contents continued to drain.  

The puncture site was then dilated using an 18mm CRE balloon over the guidewire resulting in the creation of a large cyst gastrostomy and dramatic drainage of pseudocyst fluid.  A total of 4,700 cc of fluid was drained. 

 To keep the cystgastrostomy patent, a 30 french (10mm x 8cm) fully covered self expanding metal stent was deployed across the cystgastrostomy.  During the procedure, there was a noticeable improvement in the shape of the stomach.  Following the procedure the patient had instant relief of his symptoms.  

A repeat CT performed 1 day after his procedure showed marked improvement in the size of the pseudocyst with the stent in place. The patient was started on a regular diet and was discharged from the hospital.  

A followup CT 1 month later showed that the pseudocyst was even smaller in size, but there was a considerable amount of organized debris in the pseudocyst.  The patient was referred back for endoscopic treatment.
 
Repeat endoscopy demonstrated an occluded stent that had partially migrated into the stomach, but was still bridging the cystgastrostomy.  The stent was removed with a snare and the pseudocyst was careful inspected and generously irrigated with saline mixed with gentamycin.  The cyst was entered and the walls of the cyst cavity appeared healthy with mild bleeding indicating the viability of the tissue. The necrotic debris was partially debrided using a variety of techniques.  A Roth net was used grab necrotic debris and transfer it to the stomach. 

A tripod retriever was later used to grasp necrotic tissue and extract the debris from the patient. 

Another metal stent was placed at the end of the procedure to ensure adequate drainage from the cyst cavity.

This case highlights the usefulness of endoscopic drainage of pancreatic pseudocysts.  The large size of the pseudocyst and obvious location allowed for the cyst to be drained without the guidance of endoscopic ultrasound.  Our patient had an immediate relief in symptoms after drainage.  Furthermore, endoscopic management obviated the need for surgery, particularly with the patient&#39;s poor nutritional status.  In expert hands, endoscopic drainage of pancreatic pseudocysts is an acceptable alternative to surgery to optimize patient outcomes.]]></description>
				<dc:creator>Vinay Chandrasekhara, M.D.,,</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=905</link>
				<media:content url="http://daveproject.org/media/videos/512k/480x320/flash/O04-DDW2010.mpg.flv" type="video/x-flash" playerUrl="http://daveproject.org/ViewFilms.cfm?film_id=905" playerHeight="480" playerWidth="320" expression="full"></media:content>
				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/O04-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Vinay Chandrasekhara, M.D.,,</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[The treatment of pancreatic pseudocysts has historically been managed by surgeons; however, endoscopic drainage of pancreatic pseudocysts by expert endoscopists has become an accepted alternative to surgery when an intervention is indicated. Its advantage over percutaneous drainage is the ability to place multiple internal drains with minimal patient discomfort through one puncture site and the avoidance of the development of a pancreaticocutaneous fistula. 

Today, I will be presenting a case of a 37 year-old male with no significant past medical history who developed acute pancreatitis after vacationing in the Bahamas.  His pancreatitis was complicated by the formation of a pancreatic pseudocyst.  The patient was treated with conservative therapy and had a peripherally inserted central catheter placed for the administration of central parenteral nutrition.  He later presented at our institution six weeks after his initial diagnosis of acute pancreatitis with symptoms of worsening nausea and vomiting and was found to have an elevated white blood cell count.  Computed tomography demonstrated an enlarging pseudocyst measuring 27 cm with a mature wall that was displacing the transverse colon and stomach.  Because of his poor nutritional status, he was deemed a poor surgical candidate and was referred for endoscopic drainage of his pseudocyst.

Endoscopy revealed a large pseudocyst bulge in the gastric antrum resulting in a narrowed pylorus with gastric outlet obstruction.  

ERCP was able to be performed and demonstrated no evidence of extravasation of contrast to suggest a pancreatic duct leak or communication of the main pancreatic duct with the pseudocyst.

The endoscope was withdrawn into the stomach and the most inferior portion of the convex bulge was chosen to access the pseudocyst. A needle-knife was used to incise the pseudocyst resulting in prompt drainage of a steady stream of grayish thick liquid.  

A guidewire was then passed into the cyst cavity as the cyst contents continued to drain.  

The puncture site was then dilated using an 18mm CRE balloon over the guidewire resulting in the creation of a large cyst gastrostomy and dramatic drainage of pseudocyst fluid.  A total of 4,700 cc of fluid was drained. 

 To keep the cystgastrostomy patent, a 30 french (10mm x 8cm) fully covered self expanding metal stent was deployed across the cystgastrostomy.  During the procedure, there was a noticeable improvement in the shape of the stomach.  Following the procedure the patient had instant relief of his symptoms.  

A repeat CT performed 1 day after his procedure showed marked improvement in the size of the pseudocyst with the stent in place. The patient was started on a regular diet and was discharged from the hospital.  

A followup CT 1 month later showed that the pseudocyst was even smaller in size, but there was a considerable amount of organized debris in the pseudocyst.  The patient was referred back for endoscopic treatment.
 
Repeat endoscopy demonstrated an occluded stent that had partially migrated into the stomach, but was still bridging the cystgastrostomy.  The stent was removed with a snare and the pseudocyst was careful inspected and generously irrigated with saline mixed with gentamycin.  The cyst was entered and the walls of the cyst cavity appeared healthy with mild bleeding indicating the viability of the tissue. The necrotic debris was partially debrided using a variety of techniques.  A Roth net was used grab necrotic debris and transfer it to the stomach. 

A tripod retriever was later used to grasp necrotic tissue and extract the debris from the patient. 

Another metal stent was placed at the end of the procedure to ensure adequate drainage from the cyst cavity.

This case highlights the usefulness of endoscopic drainage of pancreatic pseudocysts.  The large size of the pseudocyst and obvious location allowed for the cyst to be drained without the guidance of endoscopic ultrasound.  Our patient had an immediate relief in symptoms after drainage.  Furthermore, endoscopic management obviated the need for surgery, particularly with the patient&#39;s poor nutritional status.  In expert hands, endoscopic drainage of pancreatic pseudocysts is an acceptable alternative to surgery to optimize patient outcomes.]]></media:text>
				<enclosure url="http://daveproject.org/media/videos/512k/480x320/flash/O04-DDW2010.mpg.flv" type="video/x-flash"  length="54321" />
			</item>
			
			<item>
				<title>Image guided technology in endoscopy</title>
				<pubDate>Mon, 03 May 2010 11:05:13 EST</pubDate>
				<guid>http://daveproject.org/viewfilms.cfm?film_id=906</guid>
				<description><![CDATA[Consider the benefits of looking inside the human body during an interventional procedure and seeing in real-time all anatomic structures in precise three-dimensional detail.  This is what Image Guided Intervention technology provides its users.  

Image guided technologies allow for integration of imaging modalities and interventional procedures.  Image guidance has been utilized in the fields of neurosurgery, general surgery and surgical oncology.  Image guided techniques have been used for diagnosis, surgical guidance, intraoperative management, and therapy guidance.
Until now, image guided intervention has been limited to non-flexible surgical tools.  However, this technology may be useful for several endoscopic applications including training in EUS, ERCP, and colonoscopy as well as serving as a reference during complex therapeutic procedures.
In order to bring Image guided intervention to flexible endoscopy, multiple barriers were overcome.   These included the need for a real time lag free display, rapid system setup, and practical accommodation of the patient.   In addition, for the technique to be widely utilized, functions such as probe calibration, organ segmentation and model building needed to be efficient, accurate, and robust.  Our group implemented this technology with Department of Defense funds and no specific industry support.
The initial application for image-guided intervention in endoscopy was Image Registered Gastroscopic Ultrasound or IRGUS fine needle aspiration of lesions in the pancreas.  This is accomplished by selecting patients who are referred for endoscopic ultrasound due to a lesion visualized on computed tomography (CT) scan.  
The CT scan is then reprocessed using a computer algorithm.  The images then undergo a process known as segmentation.  This is where abdominal, pelvic and thoracic structures are identified on CT scan and 3-dimentionally reconstructed into a computer-enhanced model.  The major blood vessels, kidneys, pancreas, pancreatic lesion and any other internal structures that would enhance the endoscopists&#39; performance are segmented into the 3D model.  
Once the segmentation process is complete, the standard linear echoendoscope is prepared by attaching a small, 6 mm, commercially available, electromagnetic sensor.
The stretcher is outfitted with a transmitter that generates a localized electromagnetic field around the patient allowing the sensor coordinates to be measured with respect to the transmitter.
While the patient is being sedated, the calibration and registration process begin.  Calibration is the method of determining the sensor position and orientation on the echoendoscope with respect to the ultrasound plane.  Registration is the process in which the CT scan and 3D reconstructed model are precisely aligned with the patients&#39; body in real time.
In summary, the CT scan 3D model and endoscope coordinates are processed by the computer that then displays in real time the composite image of the 3D model with endoscope position, ultrasound image, and CT image that matches the ultrasound image plane.
When the procedure begins, the IRGUS system is immediately ready to provide navigation and orientation.  Over 30 porcine models were utilized before entry into human patients.  The footage you are witnessing is from one of the first 5 patients in the world to have their procedure performed with the IRGUS system.  
As the endoscopist moves the endoscope, the CT scan, 3D model, and ultrasound move through the body as one.  You can clearly visualize the kidneys, aorta, spleen, lungs and pancreas.  Endoscope orientation is never lost with the quick, real time, lag-free display.  This appears especially useful when endosonographic conditions are suboptimal due to calcifications or other artifacts.  Here the pancreatic lesion is identified in green.  The CT image, 3D reconstructed image, and ultrasound image are all linked on the lesion in real time.    
Image registration is also being utilized and developed to enhance the emerging field of Natural Orifice Transluminal Endoscopic Surgery (NOTES).  As orientation and navigation are essential to identifying abdominal and pelvic structures, image registration becomes a valuable tool.  In a recent study using a cadaver model, image guidance allowed NOTES surgeons to decrease their time for organ identification, improved their efficiency, and even allowed for the successful identification of organs that were easily missed when the image registration system was not utilized. 
Future applications of image guidance in endoscopy lie within the realm of endoscopic retrograde cholangiopancreaotography (ERCP) and colonoscopy.  Improvements in image guidance are being made each day, as our understanding, knowledge, and technologies develop.  We view this as an integral part of training as it may shorten the learning curve and serve as a real time reference.
Currently, data is being gathered from multiple ongoing image guided endoscopic projects to determine how best to use advanced image guided technology to meet the ultimate goal of safe, efficient, and high-quality patient care.]]></description>
				<dc:creator>Keith L. Obstein, MD,, Brigham and Women's Hospital</dc:creator>
				<link>http://daveproject.org/viewfilms.cfm?film_id=906</link>
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				<media:thumbnail height="180" width="120">http://daveproject.org/media/images/clip_img/180x120/O06-DDW2010.jpeg</media:thumbnail>
				<media:people role="producer">Keith L. Obstein, MD,, Brigham and Women's Hospital</media:people>
				<media:category>Science : Educational Resources : Gastroenterology</media:category>
				<creativeCommons:license>http://creativecommons.org/licenses/by-nc-sa/2.0/</creativeCommons:license>
				<media:text><![CDATA[Consider the benefits of looking inside the human body during an interventional procedure and seeing in real-time all anatomic structures in precise three-dimensional detail.  This is what Image Guided Intervention technology provides its users.  

Image guided technologies allow for integration of imaging modalities and interventional procedures.  Image guidance has been utilized in the fields of neurosurgery, general surgery and surgical oncology.  Image guided techniques have been used for diagnosis, surgical guidance, intraoperative management, and therapy guidance.
Until now, image guided intervention has been limited to non-flexible surgical tools.  However, this technology may be useful for several endoscopic applications including training in EUS, ERCP, and colonoscopy as well as serving as a reference during complex therapeutic procedures.
In order to bring Image guided intervention to flexible endoscopy, multiple barriers were overcome.   These included the need for a real time lag free display, rapid system setup, and practical accommodation of the patient.   In addition, for the technique to be widely utilized, functions such as probe calibration, organ segmentation and model building needed to be efficient, accurate, and robust.  Our group implemented this technology with Department of Defense funds and no specific industry support.
The initial application for image-guided intervention in endoscopy was Image Registered Gastroscopic Ultrasound or IRGUS fine needle aspiration of lesions in the pancreas.  This is accomplished by selecting patients who are referred for endoscopic ultrasound due to a lesion visualized on computed tomography (CT) scan.  
The CT scan is then reprocessed using a computer algorithm.  The images then undergo a process known as segmentation.  This is where abdominal, pelvic and thoracic structures are identified on CT scan and 3-dimentionally reconstructed into a computer-enhanced model.  The major blood vessels, kidneys, pancreas, pancreatic lesion and any other internal structures that would enhance the endoscopists&#39; performance are segmented into the 3D model.  
Once the segmentation process is complete, the standard linear echoendoscope is prepared by attaching a small, 6 mm, commercially available, electromagnetic sensor.
The stretcher is outfitted with a transmitter that generates a localized electromagnetic field around the patient allowing the sensor coordinates to be measured with respect to the transmitter.
While the patient is being sedated, the calibration and registration process begin.  Calibration is the method of determining the sensor position and orientation on the echoendoscope with respect to the ultrasound plane.  Registration is the process in which the CT scan and 3D reconstructed model are precisely aligned with the patients&#39; body in real time.
In summary, the CT scan 3D model and endoscope coordinates are processed by the computer that then displays in real time the composite image of the 3D model with endoscope position, ultrasound image, and CT image that matches the ultrasound image plane.
When the procedure begins, the IRGUS system is immediately ready to provide navigation and orientation.  Over 30 porcine models were utilized before entry into human patients.  The footage you are witnessing is from one of the first 5 patients in the world to have their procedure performed with the IRGUS system.  
As the endoscopist moves the endoscope, the CT scan, 3D model, and ultrasound move through the body as one.  You can clearly visualize the kidneys, aorta, spleen, lungs and pancreas.  Endoscope orientation is never lost with the quick, real time, lag-free display.  This appears especially useful when endosonographic conditions are suboptimal due to calcifications or other artifacts.  Here the pancreatic lesion is identified in green.  The CT image, 3D reconstructed image, and ultrasound image are all linked on the lesion in real time.    
Image registration is also being utilized and developed to enhance the emerging field of Natural Orifice Transluminal Endoscopic Surgery (NOTES).  As orientation and navigation are essential to identifying abdominal and pelvic structures, image registration becomes a valuable tool.  In a recent study using a cadaver model, image guidance allowed NOTES surgeons to decrease their time for organ identification, improved their efficiency, and even allowed for the successful identification of organs that were easily missed when the image registration system was not utilized. 
Future applications of image guidance in endoscopy lie within the realm of endoscopic retrograde cholangiopancreaotography (ERCP) and colonoscopy.  Improvements in image guidance are being made each day, as our understanding, knowledge, and technologies develop.  We view this as an integral part of training as it may shorten the learning curve and serve as a real time reference.
Currently, data is being gathered from multiple ongoing image guided endoscopic projects to determine how best to use advanced image guided technology to meet the ultimate goal of safe, efficient, and high-quality patient care.]]></media:text>
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