Guide to Complex Interventional Endoscopic Procedures [1st ed. 2021.] 9783030809492, 3030809498

Citation preview

Guide to Complex Interventional Endoscopic Procedures Kelly Esponda Stephanie Shea Cristina Demone Editors

123

Guide to Complex Interventional Endoscopic Procedures

Kelly Esponda  •  Stephanie Shea Cristina Demone Editors

Guide to Complex Interventional Endoscopic Procedures

Editors Kelly Esponda Robert Wood Johnson University Hospital New Brunswick, NJ USA

Stephanie Shea Robert Wood Johnson University Hospital New Brunswick, NJ USA

Cristina Demone Robert Wood Johnson University Hospital New Brunswick, NJ USA

ISBN 978-3-030-80948-5    ISBN 978-3-030-80949-2 (eBook) https://doi.org/10.1007/978-3-030-80949-2 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to all the people that have contributed to our knowledge and supported us on this journey. First and foremost to the nursing and Certified Endoscopy tech staff at Robert Wood Johnson University Hospital, without you we would have not been able to build such a successful interventional endoscopy program. Your thirst for knowledge inspired this book. Thank you to Amy Jablonski who led the development of the interventional endoscopy nursing program. Your hard work and dedication to this field is an inspiration to us all. Thank you to the interventional endoscopy physicians who push us each day to expand our knowledge and create an environment of learning. This is what we do!

About the Book

Interventional endoscopy offers patients a safer and more cost-effective treatment option. These procedures are new and on the rise. This manual will walk you through the setup, supplies, nursing considerations, troubleshooting, and steps to successfully assist during these cutting-edge interventional GI procedures that are being performed. The book will contribute, as the first of its kind, by helping endoscopic surgical centers to prepare for and train staff in order to offer these procedures to their patients. It will go into detail on each procedure about what the procedure is and why a patient would benefit from it. Pictures will be included to demonstrate what the procedure will look like. It is a detailed step-by-step manual including photos on each case describing the setup, pre-, intra-, and post-procedure care and responsibilities. This book includes a full range of highly advanced procedures that are on the forefront of medicine. It will help nurses and technicians who are being trained to assist in these new, complex procedures by following a step-by-step guide.

Abbreviations and Endoscopy Terminology Double Dip Patient is Scheduled for Both Colonoscopy and Endoscopy Duey Short for Duodenum EFTR Endoscopic Full-Thickness Resection EGD Esophagogastroduodenoscopy EGDE EUS-Directed Transgastric ERCP EMR Endoscopic Mucosal Resection ERCP Endoscopic Retrograde Cholangio-pancreatography ESD Endoscopic Submucosal Dissection ESG Endoscopic Sleeve Gastroplasty G POEM Gastric Myotomy GEJ Gastric Esophageal Junction POEM Per Oral Endoscopic Myotomy SCD Sequential Compression Device STER Submucosal Tunneling of Endoscopic Resection TIF Transoral Incisionless Fundoplication UES Upper Esophageal Sphincter Z POEM Zenker’s Diverticulum Myotomy vii

Contents

1 Endoscopic Resections ������������������������������������������������������������������������������   1 Cristina Demone, Kelly Esponda, and Stephanie Shea 2 Peroral Endoscopic Myotomy (POEM) ��������������������������������������������������  35 Cristina Demone, Kelly Esponda, and Stephanie Shea 3 Transoral Incisionless Fundoplication (TIF)������������������������������������������  49 Cristina Demone, Kelly Esponda, and Stephanie Shea 4 Endoscopic Retrograde Cholangiopancreatography������������������������������  59 Cristina Demone, Kelly Esponda, and Stephanie Shea 5 Endoscopic Ultrasound Procedures ��������������������������������������������������������  83 Cristina Demone, Kelly Esponda, and Stephanie Shea 6 Pancreatic Fluid Collection Procedures�������������������������������������������������� 107 Cristina Demone 7 Endo-Bariatric Procedures ���������������������������������������������������������������������� 115 Cristina Demone, Kelly Esponda, and Stephanie Shea 8 Case Studies������������������������������������������������������������������������������������������������ 131 Cristina Demone, Kelly Esponda, Stephanie Shea, Michel Kahaleh, Amy Tyberg, Avik Sarkar, and Haroon Shahid

ix

About the Editors

Kelly Esponda  is a Certified Senior Endoscopy Technician with over 15 years of OR and Endoscopy experience. A graduate of NYU Associates Surgical Technologist program, she worked in the operating room at Memorial Sloan Kettering SDH center until she saw the light of the Endoscope. Truly fascinated by an ever-growing specialty she was fortunate enough to find herself working alongside Dr. Michel Kahaleh at Weill Cornell NY Presbyterian Hospital’s Endoscopy Suite where she quickly became part of his team and essentially his “right” hand. She has worked with Dr. Kahaleh for the past 10 years, following him to Robert Wood Johnson University Hospital in New Brunswick, NJ. She resides with her husband and children in Manhattan, NY. Kelly truly loves what she does and it was evident to her colleagues especially Dr. Kahaleh as he invited her to help train and educate other endoscopists and their staff nationally and internationally. Together they have been invited to proctor and assist at Kaiser Permanente West LA Hospital. Kelly was a professor in third space and POEM courses held in Posadas, Argentina, where she taught and trained endoscopy staff. She was named Director of the Nurses and Technician course held in Reynosa, Mexico, leading to her getting invited to La Paz, Bolivia, where she helped to build their endoscopic myotomy program. In addition, she had the honor of traveling to Seoul, Korea, where she trained the staff on Pancreatic and Biliary Ablation. Kelly works tirelessly to train and orient new staff all over the world on these cutting-edge procedures. With the growing number of physicians performing these procedures and the need for more education, Kelly cannot be everywhere. This book is literally her blood, sweat, and tears of working with a world-renowned endoscopist. Stephanie Shea  is a Registered Nurse with over 18 years of experience. She currently resides in New Jersey with her family. Stephanie is the Director of Operations over the bustling state-of-the-art Endoscopy suite at Robert Wood Johnson University Hospital. In her current position she is responsible for leading multiple health care disciplines including nurses, physicians, APNs, PAs, radiology technicians, and nursing assistants. She works with other hospital leadership to develop strategic plans to operate and grow the Endoscopy suite and its services. She collaborates with physicians on a daily basis to provide support and resources to care for patients. She also fosters the units’

xi

About the Editors

xii

growth and development by bringing in new medical devices and using evidence-­ based practice to successfully implement change in a rapidly growing unit. Cristina Demone  is a Registered Nurse with a Bachelor of Science from Rutgers University and Seton Hall School of Nursing. She has 15 years of hands on experience, most being in the Emergency Department. After 15 years of hospital nursing experience, an opportunity presented itself to work in the Endoscopy Department. Initially she was hesitant at first, due to what felt like overwhelming training and another language altogether. Never one to shy away from a challenge, she tackled it and ended up loving it. She also has extensive training in Cardiology and Interventional Radiology. Cristina is certified in Advanced Cardiac Life Support, Pediatric Advanced Life Support, and Emergency Nursing. Cristina currently works as the coordinator in a state-of-the-art Interventional Endoscopy Department. She is pursuing a master’s degree in nursing to become an adult and gerontology acute care nurse practitioner. Cristina has a zest for life and is passionate about being a nurse.

Contributors Cristina  Demone  Robert Brunswick, NJ, USA

Wood

Johnson

University

Hospital,

New

Kelly  Esponda  Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Michel Kahaleh, MD  Advanced Endoscopy Research Program at the Department of Medicine, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA Avik Sarkar  Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Haroon  Shahid, MD  Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA Stephanie  Shea  Robert Brunswick, NJ, USA

Wood

Johnson

University

Hospital,

New

Amy Tyberg  Robert Wood Johnson University Hospital, New Brunswick, NJ, USA

1

Endoscopic Resections Cristina Demone, Kelly Esponda, and Stephanie Shea

1.1

EMR (Endoscopic Mucosal Resection)

Endoscopic mucosal resection (EMR) (Fig. 1.1) is a procedure that is used specifically to remove lesions located within the gastrointestinal (GI) tract but does NOT affect areas beyond the outer walls of the GI tract or GI lumen (interior area of a tubular organ which is surrounded by body tissue). The procedure involved injecting a solution that aims to strengthen and thicken a section of the GI tract, just beneath the location of the lesion. This will create a fluid cushion that allows the lesion to be safely removed. The entire procedure is minimally invasive, making use of an endoscope for its entirety. This procedure can be safely performed on lesions located within the esophagus, stomach, small intestine, and large intestine. Medications • Protonix 40 mg IV Push—only given for esophageal procedures • Methylene Blue 2 mL diluted in a 1 L bag of 0.9% normal saline (NS) (Fig. 1.2) Esophageal and Colonic EMR Set-up and Supplies • Adult EGD or colonic scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • CO2 insufflator • Duette Kit includes bander with bands and snare (Fig. 1.3) • Injection needle with lifting agent (Figs. 1.4 and 1.5) • APC—Straight fire Grounding Pad C. Demone · K. Esponda · S. Shea (*) Robert Wood Johnson University Hospital, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_1

1

2

C. Demone et al.

a

b

c

d

e

f

Fig. 1.1  The process of endoscopic mucosal resection (EMR). (a) The lesion before resection. (b) Inject saline solution at the submucosa. (c) Release the snare, then re-tighten and resect the lesion. (d) The wound after resection. (e) Seal the wound with metallic clips. (f) The lesion. (©Dr Michel Kahaleh [1]) Fig. 1.2  Methylene Blue 2 mL in 1 L NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

1  Endoscopic Resections

3

Fig. 1.3  Duette Kit includes bands and snare. (©Cristina Demone, Kelly Esponda, Stephanie Shea) Fig. 1.4  Lifting agent. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

4

C. Demone et al.

Fig. 1.5  Injection needle with Lifting Agent Set-Up. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Grounding pad on patient. • Patient needs to be on a fluoroscopy bed. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • Be prepared to suture and/or stent defect. • DVT prophylaxis as needed (such as sequential compression device, SCD). • Consider admission for observation, pain control, and hydration.

1  Endoscopic Resections

5

1.1.1 Patient Teaching and Discharge Instructions 1.1.1.1 General Guidelines for Your Endoscopic Mucosal Resection (EMR) What Is an EMR? EMR is a procedure that lets physicians remove tumors just beneath the gastrointestinal wall without surgery. Using an endoscope—a flexible, tube like instrument our gastroenterologists can see inside the body with a high degree of detail. At the same time, they can remove growths such as upper GI or colon polyps that might require surgery. Why It Is Performed They may use EMR to remove some precancerous and early stage cancers from the esophagus or colon wall. EMR is most effective for tumors that: • Have not yet reached deeper layers of the GI wall • Are larger than 2 cm May treat: • Barrett’s esophagus • Precancerous or superficial cancerous tumors such as gastric or small bowel lesions • Early stage esophageal cancer or colon cancer Prior to Your Procedure Prep/Diet • For a lower GI tract procedure, follow a liquid diet plus a laxative or enema to cleanse the bowel, do not eat or drink anything 12 h before the procedure. • The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free): –– Water (plain, carbonated, or flavored) –– Fruit juices without pulp, such as apple or white grape juice –– Fruit flavored beverages, such as fruit punch or lemonade –– Carbonated drinks, including dark sodas (cola and root beer) –– Gelatin (not red) –– Tea or coffee without milk or cream –– Sports drinks (no red) –– Clear, fat-free broth (bouillon or consommé) –– Honey or sugar –– Hard candy, such as lemon drops or peppermint rounds –– Ice pops without milk, bits of fruit, seeds, or nuts

6

C. Demone et al.

• For an upper GI tract procedure, do not eat or drink for 12 h before the procedure to clear your esophagus of food products. Medications • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Tell your doctor if you have allergies. Day of Procedure Your procedure will be done at (hospital name) in the endoscopy suite. If you are going to be late to your appointment or have any questions on the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history, including any medications you have taken. Please arrange for someone to drive you home after your procedure. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During EMR: • We will start an IV into your vein to administer fluids, anesthesia, and antibiotics. • Your doctor will pass the endoscope through your mouth or anus, depending on the location of the tumor. Your doctor will observe the images on a screen. • Sometimes they will apply suction to the top of the tumor, further lifting it up and away from the other tissue. • The doctor will then feed a thin wire rope through the endoscope and place it around the base of the tumor. An electrical current in the wire will cut the tumor from the body and seal the cut at the same time. • The tumor will be retrieved by suction or a specialized retrieval tool through the endoscope. • A laboratory examination will confirm that the procedure completely removed the tumor. Post-procedure One the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you.

1  Endoscopic Resections

7

Do not drive, operate heavy machinery, or drink alcohol for 12 h after. You should go home and rest after your procedure. It is important to drink lots of fluids to rehydrate. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Sore throat • Nausea or vomiting • Excessive gas, bloating, or cramping Medications After Discharge Your doctor may prescribe a proton pump inhibitor to reduce the amount of acid your stomach produces. You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

Follow-Up Contact your physician to schedule a follow-up appointment for 1 month after your procedure.

8

C. Demone et al.

a

b

c

d

e

f

Fig. 1.6  Endoscopic submucosal dissection (ESD) technique in early gastric cancer located at the incisura. (a) Mucosal lesion, spanning approximately 2 cm in white light view. (b) Mucosal lesion, giving cause for concern, in narrow band image view. (c) Perimeter of planned incision marked with electrocautery. (d) After circumferential incision. (e) After completion of dissection. (f) Resection specimen 34 mm × 29 mm. (©Dr Michel Kahaleh [1])

1.2

ESD (Endoscopic Submucosal Dissection)

Endoscopic submucosal dissection (ESD) (Fig. 1.6) is a procedure that is used to remove tumors or lesions within the gastrointestinal (GI) tract that have affected the deepest parts of the walls along the GI tract. When compared to endoscopic mucosal resection (EMR), ESD allows the removal of lesions that are much deeper in the GI walls, as well as allowing physicians to remove the targeted lesion in a single piece. This procedure consists of using a set of special knives to remove the lesion or tumor from the GI walls in a very precise manner. This technique allows the lesion or tumor to be removed with minimal damage to the GI wall, upholding the integrity of the affected organ. Medications • Levaquin Intravenous Piggyback (IVPB) • Scopolamine Transdermal—only given for esophageal procedures (applied prior to arrival) • Protonix 40 mg IV Push—only given for esophageal procedures • Methylene Blue 2 mL diluted in 1 l of 0.9% NS (Fig. 1.7) • Gentamycin intraluminal flush—2 syringes of Gentamycin 40  mg diluted in 60 mL 0.9% NS (Fig. 1.8) Esophageal ESD Set-up and Supplies • Adult EGD scope

1  Endoscopic Resections Fig. 1.7  Methylene Blue 1.5 mL in 1 L NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 1.8  Lifting agent and 2 syringes Gentamycin 40 mg diluted in 60 mL NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

9

10

C. Demone et al.

• Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE ­system) (Fig. 1.9) • CO2 insufflator • IT Nano Knife—IT Knife 2 (Fig. 1.10) • Dual Knife—(meant for when tissue is very thick) just smaller (Fig. 1.10) • Coagrasper 4 mm (colon length) (Figs. 1.11 and 1.12) • Hybrid T knife and electrosurgical generator cartridge • Distal tip attachment 11.35 • Injection needle with lifting agent (Fig. 1.13) • APC—straight fire grounding pad Colonic ESD Set-up and Supplies • Colon scope—per physician preference • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) (Fig. 1.9) • CO2 insufflator • Dual knife (Fig. 1.10) • Dual J Knife w/Accessory Port tubing (Fig. 1.10) Fig. 1.9 Electrosurgical generator with pure cut/ sinusoidal waveform (such as ERBE system) set-up for resections. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

1  Endoscopic Resections

11

Fig. 1.10  Accessory Port Tubing, Dual J knife, IT knife nano. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 1.11 Coagrasper. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

12

C. Demone et al.

Fig. 1.12 Emergency coagulation (Coagrasper). (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• 1T Nano knife with compatible irrigation machine for Dual J injection port (Fig. 1.10) • Coagrasper 4 mm (colon length) (Figs. 1.11 and 1.12) Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Grounding pad on patient. • Patient needs to be on a fluoroscopy bed. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • Be prepared to suture and/or stent defect. • DVT prophylaxis as needed (such as sequential compression device, SCD). • Patient will be admitted for observation, pain control, and hydration.

1  Endoscopic Resections

13

Fig. 1.13  Injection needle with Lifting Agent Set-Up. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

1.2.1 Patient Teaching and Discharge Instructions 1.2.1.1 General Guidelines for Your Endoscopic Submucosal Dissection (ESD) Why It’s Performed ESD is a procedure to remove deep tumors from the gastrointestinal tract. Gastroenterologist use endoscopes to perform ESD. ESD treats: • Barrett’s esophagus • Early stage cancerous tumors or colon polyps • Tumors of the esophagus, stomach, or colon that have not yet entered the deeper layer of the GI wall with minimal or no risk of cancer spreading • Staging of cancer to develop treatment plans

14

C. Demone et al.

Prior to Procedure Prep/Diet • For a lower GI tract procedure, follow a liquid diet plus a laxative or enema to cleanse the bowel, do not eat or drink anything 12 h before the procedure. • The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free): –– Water (plain, carbonated, or flavored) –– Fruit juices without pulp, such as apple or white grape juice –– Fruit flavored beverages, such as fruit punch or lemonade –– Carbonated drinks, including dark sodas (cola and root beer) –– Gelatin (not red) –– Tea or coffee without milk or cream –– Sports drinks (no red) –– Clear, fat-free broth (bouillon or consommé) –– Honey or sugar –– Hard candy, such as lemon drops or peppermint rounds –– Ice pops without milk, bits of fruit, seeds, or nuts • For an upper GI tract procedure, do not eat or drink for 12 h before the procedure to clear your esophagus of food products. Medications • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Tell your doctor if you have allergies. Day of Procedure Your procedure will be done at (hospital name) in the endoscopy suite. If you are going to be late to your appointment or have any questions on the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive, you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During ESD:

1  Endoscopic Resections

15

• An IV will be placed to administer IV fluids and medications. • Your endoscopist will insert a high definition scope through your mouth or rectum. The scope will show the doctor images on a screen connected to it. • The tumor will be located. • In order to minimize damage to surrounding tissue the doctor will use a solution to lift the tumor away from the wall. • An electrosurgical knife will be used to cut tumor tissue free from the wall and then continue to use the electrosurgical knife to cut away the tumor. The use of this knife with electricity helps to stops any active bleeding by heating the tissue. • Your doctor will pass the tumor through the scope and send the tissue for biopsy. Post-procedure Once the procedure is finished, you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you before you leave. After the procedure you might have a brief stay in the hospital or you may be discharged home if you feel well. You will receive antibiotics for 3–5 days and medications for symptom relief if you need them. If you are discharged home, do not drive, operate heavy machinery, or drink alcohol for 12 h. You should go home and rest after your procedure. If you are admitted, you may require a contrast study (i.e. esophogram) prior to advancing your diet. It is important to drink lots of fluids to rehydrate. Discuss with your doctor when you should resume a diet and if there are any specific instructions on diet advancement. If your doctor allows you to eat, we recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Sore throat • Nausea or vomiting • Excessive gas, bloating, or cramping

16

C. Demone et al.

Medications After Discharge Your doctor may prescribe the following medications to you after your procedure for you to take at home: • Antacids • Antibiotics (3–5 days) You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

Follow-Up You will follow up with your doctor 1 month after your procedure.

1.3

STER (Submucosal Tunneling Endoscopic Resection)

Submucosal tunneling with endoscopic resection (STER) (Fig. 1.14) is a procedure used to remove tumors from the gastrointestinal (GI) tract. STER, along with endoscopic submucosal dissection (ESD) are the two most widely accepted techniques of removing tumors that have affected the esophagus, stomach, small intestine, and large intestine. This procedure consists of creating a tunnel within the walls of the GI lumen, which will lead directly to the tumor below. Through the tunnel, an endoscope is sent through and is used to remove the tumor from inside the tunnel. After the procedure, the tunnel is closed off internally by endoscopic sutures. Medications • Levaquin Intravenous Piggyback (IVPB) • Scopolamine Transdermal—only given for esophageal procedures • Protonix 40 mg IV Push—only given for esophageal procedures • Methylene Blue 2 mL diluted in a 1 L bag of 0.9%NS • Gentamycin intraluminal flush—2 syringes Gentamycin 40 mg diluted in 60 mL 0.9% NS (Fig. 1.15)

1  Endoscopic Resections

17

a

b

c

d

e

f

Fig. 1.14  Submucosal tunneling endoscopic resection (STER) to remove an esophageal submucosal tumor (SMT) originating from the muscularis propria (MP) layer. (a) An esophageal SMT was detected by endoscopy. (b) Submucosal injection at 5 cm proximal to the tumor and a 2-cm longitudinal mucosal incision was made as the tunnel entry. (c) Tumor dissection and exposure. (d) Submucosal tunnel after tumor removal. (e) Closure of the tunnel entry with several clips. (f) Complete resection of the esophageal SMT. (©Dr Michel Kahaleh [1])

18

C. Demone et al.

Fig. 1.15  Gentamycin intraluminal flush—2 syringes Gentamycin 40 mg diluted in 60 mL 0.9% NS and Lifting Agent. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Esophageal STER Set-up and Supplies • Adult EGD scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) (Fig. 1.16) • CO2 insufflator • IT Nano Knife and IT 2 (Fig. 1.17) • Dual knife (meant for when tissue is very thick) just smaller • Coagrasper 4 mm (colon length) (Figs. 1.18 and 1.19) • Dual knife with accessory tubing kit (Fig. 1.17) • T knife and IT knife (Fig. 1.17) used with electrosurgical senerator with pure cut/ sinusoidal waveform (such as ERBE system)—injects, coagulates, and cuts • Distal tip attachment 11.35 (Fig. 1.20) • Injection needle with lifting agent (Fig. 1.21) • APC—Straight fire grounding pad • Emergency coagulation (Figs. 1.18 and 1.19)

1  Endoscopic Resections

19

Fig. 1.16 Electrosurgical generator with pure cut/ sinusoidal waveform (such as ERBE system) set-up for resections. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Colonic STER Set-up and Supplies • Colon Scope—per physician preference • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) (Fig. 1.21) • CO2 insufflator • Dual knife (Fig. 1.17) • Dual J Knife w/accessory port tubing (Fig. 1.17) • 1T Nano knife with compatible Irrigation Machine for Dual J injection port (Fig. 1.17) • Emergency coagulation (Figs. 1.18 and 1.19) Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Grounding pad on patient. • Patient needs to be on a fluoroscopy bed.

20

C. Demone et al.

Fig. 1.17  Accessory port tubing, Dual Knife J, IT knife nano, IT Knife2. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

1  Endoscopic Resections

21

Fig. 1.18 Emergency coagulation. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• • • • • • •

Bair hugger for body warmth. Consider Foley protocol if procedure exceeds 2 h. Be prepared to suture and/or stent defect. DVT prophylaxis as needed (such as sequential compression device, SCD). Patient will be admitted for observation, pain control, and hydration. Be prepared to suture and/or stent defect. Upon discharge after colonic STER—stool softener and antibiotic.

1.3.1 Patient Teaching and Discharge Instructions 1.3.1.1 General Guidelines for Your Submucosal Tunnel Endoscopic Resection (STER) Why It Is Performed STER is an improved and an effective technique for treating esophageal submucosal tumors (SMTs). SMTs are primarily benign tumors, but some may have a malignant potential. The gastroenterologist uses an endoscope to perform this procedure. An

22

C. Demone et al.

Fig. 1.19 Coagrasper. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

endoscope is a flexible, tube like instrument the gastroenterologists use to see inside the body with a high degree of detail. This design makes it possible for many patients to avoid a more invasive surgical procedure. The result may be a shorter treatment time and faster recover. Our doctors perform STER to treat the following: • Tumors of the esophagus, stomach, or colon. Prior to Procedure Prep/Diet • For a lower GI tract procedure, follow a liquid diet plus a laxative or enema to cleanse the bowel, do not eat or drink anything 12 h before the procedure. • The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free): –– Water (plain, carbonated, or flavored) –– Fruit juices without pulp, such as apple or white grape juice

1  Endoscopic Resections

23

Fig. 1.20 Distal attachment (11.35 mm). (©Cristina Demone, Kelly Esponda, Stephanie Shea)

–– Fruit flavored beverages, such as fruit punch or lemonade –– Carbonated drinks, including dark sodas (cola and root beer) –– Gelatin (not red) –– Tea or coffee without milk or cream –– Sports drinks (no red) –– Clear, fat-free broth (bouillon or consommé) –– Honey or sugar –– Hard candy, such as lemon drops or peppermint rounds –– Ice pops without milk, bits of fruit, seeds, or nuts • For an upper GI tract procedure, do not eat or drink for 12 h before the procedure to clear your esophagus of food products. Medications • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic, please refer to the specific instructions provided at time of scheduling the procedure. • If you are taking a blood thinner such as Rivaroxaban (Xarelto), Apixaban (Eliquis), Warfarin (Coumadin), or Clopidogrel (Plavix), etc. contact your pre-

24

C. Demone et al.

Fig. 1.21  Injection needle with Lifting Agent Set-Up. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

scribing physician for instructions on when to stop taking this medication prior to your procedure. • Tell your doctor if you have any allergies. Day of Procedure Your procedure will be done at (hospital name) in the endoscopy suite. If you are going to be late to your appointment or have any questions on the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During STER: • We will start an IV in your vein to administer fluids, anesthesia, and antibiotics. • Your doctor will pass the endoscope through your mouth or rectum and the images will be observed on a screen. • An initial incision will be made in the internal lining of the GI tract. This permits exposure of the tumor. • The submucosal tumor is then removed under direct endoscopic visualization.

1  Endoscopic Resections

25

• The site the tumor was removed from is then closed using clips or suturing. • A stent may be placed if necessary based on the surgical site. • The tissue will be removed from the body through the endoscope and sent to a laboratory. Examination under a microscope can confirm whether the procedure completely removed the tumor. Post-procedure Once the procedure is finished, you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. Please be advised, it is not uncommon after receiving anesthesia to forget some of the conversation had with your doctor. For this reason, we suggest a family member or friend be present for this conversation. After the procedure you might have a brief stay in the hospital or you may be discharged home if you feel well. You will receive antibiotics for 3–5 days and medications for symptom relief if you need them. If you are discharged home, do not drive, operate heavy machinery, or drink alcohol for 12 h. You should go home and rest after your procedure. It is important to drink lots of fluids to rehydrate. Discuss with your doctor when you should resume a diet and if there are any specific instructions on diet advancement. If your doctor allows you to eat, we recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Commonly Reported Post-procedure Symptoms • Sore throat • Nausea or vomiting • Excessive gas, bloating, or cramping • For colonic STER you may have loose stool Note: These symptoms usually resolve on their own within 24–72 h after your procedure.

26

C. Demone et al.

Medications After Discharge Your doctor may prescribe a proton pump inhibitor (PPI) such as pantoprazole to reduce the amount of acid your stomach produces to aid in healing post-procedure. If the procedure is done in the colon, you may go home on a stool softener. You can resume your daily medications following your procedure. If you are taking any medications that thin your blood, please discuss with your doctor when to resume these medications, such as Rivaroxaban (Xarelto), Apixaban (Eliquis), Warfarin (Coumadin), or Clopidogrel (Plavix). If experiencing gas or gas pains post-procedure, you may trial over the counter (OTC) GasX for symptom relief. Follow-Up Contact your physician to schedule a follow-up appointment.

1.4

EFTR (Endoscopic Full-Thickness Resection)

Endoscopic full-thickness resection (EFTR) (Fig. 1.22) is a procedure similar to the above mentioned endoscopic submucosal dissection (ESD). Wherein a lesion that has affected the GI tract from the lumen through the outer wall is removed from the gastrointestinal (GI) tract. This procedure differs from ESD by creating a hole within the GI tract. This hole is then used to remove the lesion. After the procedure, the hole is closed by endoscopic sutures. This procedure can be safely performed on lesions and tumors located within the esophagus, stomach, small intestine, and large intestine. Medications • Levaquin Intravenous Piggyback (IVPB) • Scopolamine Transdermal—only given for esophageal procedures • Protonix 40 mg IV Push—only given for esophageal procedures • Methylene Blue 2 mL diluted in a 1 L bag of 0.9% NS • Gentamycin intraluminal flush—2 syringes Gentamycin 40 mg diluted in 60 mL of 0.9% NS (Fig. 1.23) Esophageal EFTR Set-up and Supplies • Adult EGD scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) (Fig. 1.24) • CO2 insufflator • FTRD Kit (Esophageal)

1  Endoscopic Resections

27

a

b

c

d

e

f

Fig. 1.22  Endoscopic full-thickness resection (EFTR) procedures. (a, b) An oval submucosal tumor was located in the middle third of stomach, and EUS [mini-probe] showed it was homogenously hypoechoic originating from muscularis propria. (c, d) Circumferential incision and deep submucosal dissection. (e, f) After complete removal with full-thickness resection, the defect was closed with clips and an endoloop. (g) The endoscopic appearance of the wound at 3 month after EFTR. (©Dr Michel Kahaleh [1])

28

C. Demone et al.

g

Fig. 1.22 (continued) Fig. 1.23 Gentamycin intraluminal flush—2 syringes 40 mg Gentamycin in 60 mL NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Colonic EFTR Set-up and Supplies • Colon scope—per physician preference • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) (Fig. 1.24) • CO2 insufflator • FTRD Kit (Colonic) (Fig. 1.25) includes FTRD System, Marking Probe, Grasper (Fig. 1.26) Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Grounding pad on patient. • Patient needs to be on a fluoroscopy bed. • Bair hugger for body warmth.

1  Endoscopic Resections

29

Fig. 1.24 Electrosurgical generator with pure cut/ sinusoidal waveform (such as ERBE system) set-up for resections. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 1.25  FTRD colonic kit includes FTRD system, marking probe and grasper. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

30

C. Demone et al.

Fig. 1.26 FTRD System, Marking Probe, Grasper. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• • • •

Consider Foley protocol if procedure exceeds 2 h. Be prepared to suture and/or stent defect. DVT prophylaxis as needed (such as sequential compression device, SCD). Patient will be admitted for observation, pain control, and hydration.

1.4.1 Patient Teaching and Discharge Instructions 1.4.1.1 General Guidelines for Your Endoscopic Full-Thickness Resection (EFTR) Why It Is Performed EFTR is done to remove growths deep in the wall of the GI tract. Gastroenterologists use an endoscope to look inside your body. With EFTR, physicians may be able to identify the source of a gastrointestinal problem, such as a postsurgical complications such as a perforation (tear). Stomach, small bowel, or colon polyp removal, closing holes or openings between organs or tissues. At the same time they can remove growths, such as colon polyps or tumors. In EFTR, specially designed endoscopes are used that include a device to remove a tumor (such as a benign or cancerous growth). This design makes it possible for many patients to avoid a more invasive surgical procedure. The result may be a shorter treatment time and faster recover. EFTR is very effective for removing tumors located deep in the GI wall. Because of the location of these growths, other procedures could cause complication, such as tearing or perforation of tissue. Our doctors perform EFTR to treat the following: • • • •

GI bleeding Postsurgical complications such as a perforation (tear) Stomach, small bowel, or colon polyp removal Closing holes or openings between organs or tissues

1  Endoscopic Resections

31

Prior to Procedure Prep/Diet • For a lower GI tract procedure, follow a liquid diet plus a laxative or enema to cleanse the bowel, do not eat or drink anything 12 h before the procedure. • The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free): –– Water (plain, carbonated, or flavored) –– Fruit juices without pulp, such as apple or white grape juice –– Fruit flavored beverages, such as fruit punch or lemonade –– Carbonated drinks, including dark sodas (cola and root beer) –– Gelatin (not red) –– Tea or coffee without milk or cream –– Sports drinks (no red) –– Clear, fat-free broth (bouillon or consommé) –– Honey or sugar –– Hard candy, such as lemon drops or peppermint rounds –– Ice pops without milk, bits of fruit, seeds, or nuts • For an upper GI tract procedure, do not eat or drink for 12 h before the procedure to clear your esophagus of food products. Medications • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Tell your doctor if you have allergies. Day of Procedure Your procedure will be done at (hospital name) in the endoscopy. If you are going to be late to your appointment or have any questions on the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. Bring with you a photo ID, insurance card, and a list of medications that you take with you.

32

C. Demone et al.

During EFTR: • We will start an IV in your vein to administer fluids, anesthesia, and antibiotics. • Your doctor will pass the endoscope through your mouth or anus and the images will be observed on a screen. • The doctor will locate and mark the edges of the tumor with a tool inserted through the endoscope. • Tiny forceps will be used to grasp the tumor. • Forceps will be used to pull the tumor up into the tube of the endoscope until the edges of the tumor are visible in the tube. • A special clip on the endoscope will be used to cut the tissue from the body. The clip will remain safely in the body, acting as a suture. • The tissue will be carefully removed through the endoscope. In a laboratory, a technician will examine it under a microscope. The lab will confirm that the tumor was completely removed. Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. You will be admitted to the hospital. Common Side Effects • Sore throat • Nausea or vomiting • Excessive gas, bloating, or cramping • Mild abdominal pain or rectal pain Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

1  Endoscopic Resections

33

Follow-Up Contact your physician to schedule a follow-up appointment.

Reference 1. Kahaleh, M. (2021). Dr. Michel Kahaleh New Jersey gastroenterologist & world renowned endoscopist. Retrieved from https://www.michelkahaleh.com/

2

Peroral Endoscopic Myotomy (POEM) Cristina Demone, Kelly Esponda, and Stephanie Shea

2.1

Z-POEM (Zenker’s Peroral Endoscopic Myotomy)

Zenker’s diverticulum (Fig.  2.1) is a condition that affects the patient’s throat, leading to the inability to eat and possible lung infections. Zenker’s diverticulum is a pharyngeal pouch where a single outpouching of the mucous membrane is located just outside the throat. This pouch will block food from going down into the stomach, and the food collects in the pouch, which can lead to further complications. Both Z-POEM and septotomy procedures consist of creating a small incision in the pharyngeal pouch that separates it from the esophageal lumen. Thus, allowing food to pass through the esophagus and prevent the pharyngeal pouch from further accumulating food.

2.2

E-POEM (Esophageal Peroral Endoscopic Myotomy)

A peroral endoscopic myotomy (POEM) (Fig. 2.2) is performed when a patient is suffering from swallowing disorders such as achalasia. Complications can occur in the esophagus if the muscles contract or tighten abnormally, making it difficult for the patient to swallow food. The procedure is minimally invasive and is shown to offer faster recovery and less post-procedure pain when compared to its surgical alternative, Heller Myotomy. The procedure consists of creating a small tunnel within the walls of the esophagus, which will be used by the endoscope to open up and reduce resistance between

C. Demone · K. Esponda (*) · S. Shea Robert Wood Johnson University Hospital, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_2

35

36

C. Demone et al.

a

b

c

Lateral pharyngeal pouch

Kilian-Jamieson diverticulum

Cricopharyngeus muscle (bar)

Zenker’s diverticulum Zenker’s diverticulum

Fig. 2.1  Zenker’s diverticulum, Killian–Jamieson diverticulum, and cricopharyngeal bar. (a) Zenker’s diverticulum, (b) Zenker’s diverticulum and Killian–Jamieson diverticulum, and (c) cricopharyngeal bar. (©Dr. Michel Kahaleh [1])

a

b

c

d

e

Fig. 2.2  Peroral endoscopic myotomy: (a) entry to submucosal space. (b) Submucosal tunneling. (c) Endoscopic myotomy, with a total length of 10 cm. (d) Long endoscopic myotomy of inner circular muscle bundles, leaving the outer longitudinal muscle layer intact. (e) Closure of mucosal entry. (©Dr. Michel Kahaleh [1])

the muscles of the lower esophageal wall and the gastroesophageal sphincter (the connection point between the stomach and the esophagus). The opening will allow food to pass through the esophagus and into the stomach with ease. After the procedure is completed, the tunnel opening is then closed.

2.3

G-POEM (Gastric Peroral Endoscopic Myotemy)

Gastric peroral endoscopic myotomy (G-POEM) (Fig.  2.3) is performed to treat gastroparesis. Gastroparesis occurs when the muscles of the stomach have difficulty contracting, making it difficult for food to leave the stomach and enter the small intestine. The word gastroparesis translates to “a weak stomach,” and the illness can lead to abdominal pain, bloating, nausea, and vomiting. The procedure is done by creating a tunnel in the stomach wall, using the endoscope to cut the muscles of the pylorus, the connection point between the stomach and small intestine, which will allow food to pass through easier. After the procedure is done, the tunnel opening used by the endoscope is then closed to ensure the integrity.

2  Peroral Endoscopic Myotomy (POEM)

37

a

b

c

d

e

f

Fig. 2.3  Steps of G-POEM procedure. (a) Selection of targeted gastric wall and creation of submucosal bleb. (b) Longitudinal mucosal incision. (c) Creation of submucosal tunnel. (d) Identifying the PMR. (e) Endoscopic pyloromyotomy. (f) Mucosal access closure using clips. (©Dr. Michel Kahaleh [1])

Medications • Levaquin Intravenous Piggyback (IVPB)—on call to procedure. • Scopolamine transdermal—only given for esophageal procedures. • Protonix 40 mg IV Push—only given for esophageal procedures. • Methylene Blue 2 ml diluted in a 1 l bag of 0.9% NS. • Gentamycin intraluminal flush—two syringes gentamycin 40  mg diluted in 60 ml of 0.9% NS. • Zofran IV Push. Set-up and Supplies • EGD scope. • 2T scope if G-POEM or posterior E-POEM • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) (Figs. 2.4, 2.5, and 2.6). • CO2 insufflator. • 14G Angiocath (may need for needle decompression) • Disposable distal attachment size 11.35 mm (placed on scope after initial EGD) (Fig. 2.4). • Grounding pad. • Secondary tubing. • Injection needle (Figs. 2.4 and 2.5). • Fill three (3) 10 ml syringes with methylene blue diluted with 0.9% NS (Fig. 2.7). • Two (2) 10 ml syringes of 0.9% NS (Fig. 2.7). • One (1) 30 ml syringe of 0.9% NS with a blue tip (Fig. 2.7). • Two (2) syringes of gentamicin 40 mg diluted in 60 ml of 0.9%NS (Fig. 2.8).

38

C. Demone et al.

Fig. 2.4  E-POEM supplies: Coagrasper, injection needle, distal attachment, hybrid T-knife, electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) jet cartridge. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• • • • • •

Gauze. Emesis basin with 0.9% normal saline (Fig. 2.7). Hybrid T type knife/cartridge for jet (Figs. 2.4, 2.5, 2.9, and 2.10). IT knife 24 mm—for G-POEM (Fig. 2.5). Coagrasper 4 mm (colon length) (Figs. 2.4 and 2.5). Hemostasis clips 16 mm 7–10 each (Figs. 2.11, 2.12, 2.13, and 2.14).

2  Peroral Endoscopic Myotomy (POEM)

39

Fig. 2.5  G-POEM and Z-POEM set-up: injection needle, IT 2 knife, distal cap, electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) jet cartridge attached, T-knife, Coagrasper. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Nursing Considerations • IV hydration pre-procedure. • Make sure patient took scopolamine the day prior to procedure to prevent nausea and vomiting as ordered. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Intraprocedure assess patient for crepitus and rise in end tidal CO2. • 18 gauge Angiocath present in room for needle decompression. • Use CO2 during procedure for insufflation not air. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • Be prepared to suture and/or stent defect. • DVT prophylaxis as needed (such as sequential compression device, SCD). • Procedure done on fluoroscopy bed if available to allow for image post-­procedure to evaluate myotomy site.

40

C. Demone et al.

Fig. 2.6  Methylene Blue 1.5 ml in 1 L NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• Patient will be admitted for observation, pain control, and hydration. • Post-procedure a barium swallow may be indicated to make sure there are no defects in the myotomy location.

2.3.1 Patient Teaching and Discharge Instructions 2.3.1.1 General Guidelines for Peroral Endoscopic Myotomy (POEM) Why It Is Performed Our doctors perform POEM to treat the following conditions: • Achalasia (POEM). • Gastroparesis (G-POEM). • Zenker’s diverticulum (Z-POEM). Prior to Procedure Prep/Diet • You may only have a liquid diet for 2 days prior to procedure.

2  Peroral Endoscopic Myotomy (POEM)

41

Fig. 2.7  Fill three (3) 10 ml syringes with methylene blue diluted with 0.9% NS, two (2) 10 ml syringes of 0.9% NS, one (1) 30 ml syringe of 0.9% NS with a blue tip, Emesis basin with 0.9% normal saline. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• You may not eat or drink for 12 h prior to your procedure. This ensures that your esophagus is clear of food products. The following foods are allowed in a clear liquid diet: (If you are diabetic, you can follow this diet as long as it is sugar free) • • • • • • • • • • •

Water (plain, carbonated, or flavored). Fruit juices without pulp, such as apple or white grape juice. Fruit flavored beverages, such as fruit punch or lemonade. Carbonated drinks, including dark sodas (cola and root beer). Gelatin. Tea or coffee without milk or cream. Strained tomato or vegetable juice. Sports drinks. Clear, fat-free broth (bouillon or consommé). Honey or sugar. Hard candy, such as lemon drops or peppermint rounds. Ice pops without milk, bits of fruit, seeds, or nuts.

42

C. Demone et al.

Fig. 2.8  Two (2) syringes of gentamicin 40 mg diluted in 60 ml of 0.9%NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Medications • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic, please refer to the specific instructions provided at the time of scheduling the procedure. • If you are taking a blood thinner such as Rivaroxaban (Xarelto), Apixaban (Eliquis), Warfarin (Coumadin), or Clopidogrel (Plavix), etc. contact your prescribing physician for instructions on when to stop taking this medication prior to your procedure. • Tell your doctor if you have any allergies. Day of Procedure Your procedure will be done at (hospital name) in the endoscopy suite.

2  Peroral Endoscopic Myotomy (POEM)

43

Fig. 2.9  Hybrid T type knife/cartridge for jet (Figs.  2.7 and 2.8). (©Cristina Demone, Kelly Esponda, Stephanie Shea) Fig. 2.10  Hybrid T-Knife. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

44 Fig. 2.11  Pump setting for IT knife for POEMs. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 2.12  Pump cartridge settings for pump electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system and methylene blue). (©Cristina Demone, Kelly Esponda, Stephanie Shea)

C. Demone et al.

2  Peroral Endoscopic Myotomy (POEM)

45

Fig. 2.13  Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) pedal set-up at head of bed. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

If you are going to be late to your appointment or have any questions on the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive, you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Please bring a photo ID, insurance card, and a list of medications that you take with you. During POEM • An IV will be inserted to administer IV fluids and medications. • Your doctor will pass the high definition endoscope through your mouth and into the esophagus where the procedure will take place. Your doctor will use the scope to observe images on a monitor that is connected during your procedure. • There would not be any incisions or cuts outside your gastrointestinal tract. • An initial incision will be made in the internal lining of the esophagus (for POEM or Z-POEM) or stomach (for G-POEM). This permits entry of the endoscope to within the wall of the esophagus or stomach, where the muscle will be exposed. • At this point, a myotomy (cutting of the muscle) will be performed. • At the conclusion of the procedure, the incision will be closed with standard endoscopic clips. (Please note, these clips are meant to fall off on their own over the next few weeks to months.) • Once clips/sutures are placed to close the incision, we will inject contrast to ensure there is no leak at the closure site. In the rare event that we notice leaking of contrast on X-ray (during procedure), we will place additional clips/sutures until leaking is no longer visualized. Post-procedure Once the procedure is finished, you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. Please be advised, it is not uncommon after receiving anesthesia to forget some of the conversation had with

46

C. Demone et al.

Fig. 2.14  Hemostasis clips. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

your doctor. For this reason, we suggest a family member or friend be present for this conversation. You may be admitted for observation overnight. Following the procedure, you will be on a clear liquid diet for 72 h after your procedure, followed by a full liquid diet for 3 days, followed thereafter by a soft diet for the next 1–2 weeks. (See below for special diet instructions post-POEM.) Commonly Reported Post-procedure Symptoms • Chest or abdominal discomfort. • Acid reflux. • Gas/gas pains.

2  Peroral Endoscopic Myotomy (POEM)

47

Note: These symptoms usually resolve on their own within 24–72 h after your procedure. **Please do not hesitate to return to our Emergency Department for any of the following signs and symptoms after your procedure: fevers, severe chest or abdominal pain, shortness of breath, intractable nausea, and vomiting**. Medications After Discharge Your doctor may prescribe or recommend the following medications to you after your procedure: • Antacids (PPI, typically Protonix) twice a day. • Antibiotics (often Levaquin) for 5 days. • Liquid Tylenol/other pain medication as required and prescribed on a case dependent basis. • Anti-nausea medication (Zofran). If experiencing gas or gas pains post-procedure, you may trial over the counter (OTC) GasX for symptom relief. You can resume your daily medications following your procedure. If you are taking any medications that thin your blood, please discuss with your doctor when to resume these medications, such as Rivaroxaban (Xarelto), Apixaban (Eliquis), Warfarin (Coumadin), or Clopidogrel (Plavix). Post-procedure Diet • You will begin a clear liquid diet for the first 3 days. –– The following foods are allowed in a clear liquid diet: Water (plain, carbonated, or flavored). Fruit juices without pulp, such as apple or white grape juice. Fruit flavored beverages, such as fruit punch or lemonade. Carbonated drinks, including dark sodas (cola and root beer). Gelatin. Tea or coffee without milk or cream. Strained tomato or vegetable juice. Sports drinks. Bone broth. Honey or sugar. Hard candy, such as lemon drops or peppermint rounds. Ice pops without milk, bits of fruit, seeds, or nuts. Crystal light. Jello. Gummy vitamins. • After the first 3 days, you will then follow a full liquid diet for the next 3 days. –– The following foods are allowed in a full liquid diet: Blended soups.

48

C. Demone et al.

Skim milk. Protein Shakes. Low-fat yogurt. • Then, you will advance to a soft diet on day 7 and continue for 2–3 weeks. –– The following foods are allowed on a soft diet: Pureed meats. Scrambled eggs. Cottage cheese. Fruits. Vegetables. Oatmeal. • After 2–3 weeks of a soft diet, you may slowly advance to a regular diet. –– It is recommended to chew foods well, take small bites and be wary of difficult foods to swallow such as tough meats and breads. Follow-Up You will follow up in the office or via telemedicine 4 weeks after your procedure, or sooner if advised by your doctor. Our clinic team will contact you to arrange this appointment within a few business days of your procedure. At this follow-up, your doctor will discuss any symptoms and recommended next steps, such as repeating an esophagram or upper GI series (both are X-ray studies) and/or repeat endoscopy for surveillance. We typically do proceed with a repeat endoscopy 6–8 weeks following your POEM for surveillance. If you do not receive a call from our clinic within 1 week of your procedure, please call at the phone number listed below.

Reference 1. Kahaleh, M. (2021). Dr. Michel Kahaleh New Jersey gastroenterologist & world renowned endoscopist. Retrieved from https://www.michelkahaleh.com/

3

Transoral Incisionless Fundoplication (TIF) Cristina Demone, Kelly Esponda, and Stephanie Shea

TIF is used to treat GERD. The procedure reconstructs an anti-reflux valve at the gastroesophageal junction and reduces hiatal hernia. This is done for hiatal hernias less than 2 cm. Medications • Scopolamine Transdermal—applied prior to procedure • Protonix 40 mg IV Push • Zofran IV Push Set-up and Supplies • Adult EGD scope with irrigation • Implantable Fastener Kit including: EsophyX Device and implantable fasteners (Fig. 3.1) • Two CO2 insufflation devices and tubing (Fig. 3.2) • Mineral oil for device lubrication (Figs. 3.3 and 3.4) • Y-opsy (Fig. 3.3) • Two suction sources and two sets of suction tubing (Figs. 3.5, 3.6, 3.7, 3.8, 3.9, 3.10, 3.11, and 3.12)

C. Demone (*) · K. Esponda · S. Shea Robert Wood Johnson University Hospital, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_3

49

50

C. Demone et al.

Fig. 3.1  Implantable Fastener Kit including: EsophyX Device and implantable fasteners. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Nursing Considerations • IV hydration pre-procedure. • Make sure patient took scopolamine the day prior to procedure to prevent nausea and vomiting as ordered. If patient is retching and vomiting it may disrupt fundoplication. • If patient is on a blood thinner note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Patient should lie in left lateral position. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • DVT prophylaxis as needed (such as sequential compression device, SCD). • Discharge home on medications: –– Anti-emetics—to prevent any nausea and vomiting. –– BID PPI (same as per pre-procedure). –– Pain medication—patient may experience left shoulder pain, sore throat, and substernal pain post-procedure. • Post-procedure diet instructions—2 weeks liquid and soft diet increase as tolerated over 4 weeks to return to regular meals.

3  Transoral Incisionless Fundoplication (TIF)

51

Fig. 3.2 CO2 set-up: Two devices required. One for scope and 1 for EsophyX Device. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

3.1

Patient Teaching and Discharge Instructions

3.1.1 G  eneral Guidelines for Your Transoral Incisionless Fundoplication 3.1.1.1 Why It Is Performed Our gastroenterologists use the TIF device for patients who have heartburn or regurgitation after eating. Those symptoms occur because a malfunctioning valve allows stomach acid back into the esophagus. Patients with GERD symptoms who respond to proton-pump inhibitors or other antacid medications but who wish to avoid these options are also candidates for TIF. In some cases, medications are no longer effective or do not provide complete relief. For these patients, valve repair may be the only option. Doctors can use TIF instead of Nissen fundoplication to avoid unwanted side effects that Nissen fundoplication may produce including trouble swallowing,

52

C. Demone et al.

Fig. 3.3  Y-opsy valve, Mineral Oil. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 3.4  EsophyX Device (working channel and loading dock for fastener) being lubricated with mineral oil. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

3  Transoral Incisionless Fundoplication (TIF)

53

Fig. 3.5  After lubricating loading dock attach implantable fastener to EsophyX Device. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 3.6  EsophyX Device in unlock position with tissue helix inside of device. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

difficulty eating for several months, trapped air resulting in belching or bloating, and hernia at the incision site.

3.1.1.2 Prior to Procedure • You may undergo pH monitoring using wireless pH testing (BRAVO test). We use this test to document the severity of the condition and to ensure you are a good candidate for the procedure.

54

C. Demone et al.

Fig. 3.7  Slide EsophyX Device down towards biopsy cap of endoscope. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• You may also have a special video X-ray test to examine your anatomy. This test lets your doctor look at the functioning of your esophagus and valve. Your doctor can also assess the size of the hiatal hernia, if present. • Tell your doctor if you have any allergies. • Follow your doctor’s instructions about whether to take your prescription medications. –– If you normally take blood pressure medications you can take them in morning before the procedure with small sips of water. –– If you take medication for your blood sugar (any pills or insulin), do not take them the morning of the procedure. –– If you take any medications to thin your blood check with your doctor to see if you should stop these medications prior to the procedure. • You should have nothing to eat after midnight.

3  Transoral Incisionless Fundoplication (TIF)

55

Fig. 3.8  Generously lubricate knuckle of the EsophyX Device. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 3.9  Stopcock connected to EsophyX Device and second suction canister with invaginator in off position. (©Cristina Demone, Kelly Esponda, Stephanie Shea) Fig. 3.10 Stopcock connected to EsophyX Device and second suction canister with invaginator in on position. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

3.1.1.3 Day of the Procedure Your procedure will be done at (hospital name) in the endoscopy suite. If you are going to be late to your appointment or have any questions on the day of the procedure please call.

56

C. Demone et al.

Fig. 3.11  Second CO2 machine with settings on medium to attach to Y-opsy cap. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. • Be prepared to stay overnight for observation post-procedure. During TIF • We will start an IV into your vein to administer fluids and anesthesia. • We will pass the endoscope into your mouth through the TIF device. Your doctor will observe images on a screen. • The doctor will insert the TIF device with the endoscope into the stomach. The endoscope is turned to point toward the top of the stomach. This angle enables the doctor to see the opening of the esophagus and stomach. • The TIF device will then be used to grab the end of your esophagus, bring it down, and wrap the top of the stomach about 270° around it. • The new valve will be secured with durable plastic fasteners that remain in the body. • The TIF device and endoscope will be removed through the newly created valve and out of the mouth.

3  Transoral Incisionless Fundoplication (TIF)

57

Fig. 3.12  Y-opsy attached to biopsy channel and CO2 insufflator. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

3.1.1.4 Post-procedure After the procedure you might have a brief stay in the hospital or you may be discharged home if you feel well. You will receive antibiotics for 2–3 days and medications for symptom relief if you need them. 3.1.1.5 Common Side Effects • Sore throat • Shoulder pain • Minimal chest pain • Minimal chance of bleeding 3.1.1.6 Medications After Discharge • Antacid medications: please continue pre-procedure dose until your first office visit. • Only as needed medications: –– Pain: Liquid Tylenol with codeine up to 15 ml every 6 h OR Tramadol (crushed) 1–2 tablets every 6 h –– Proton-pump inhibitor: Your doctor may prescribe a liquid PPI for you to take after the procedure.

58

C. Demone et al.

You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly Prescribed Blood Thinners • Rivaroxaban (Xarelto) • Dabigatran (Pradaxa) • Apixaban (Eliquis) • Heparin • Warfarin (Coumadin) • Clopidogrel (Plavix) • Aspirin • Enoxaparin (Lovenox) • Ticagrelor (Brilinta)

4

Endoscopic Retrograde Cholangiopancreatography Cristina Demone, Kelly Esponda, and Stephanie Shea

An ERCP is preformed to evaluate, detect, and therapeutically treat abnormalities of the gallbladder, pancreas, liver, and the ducts that drain these organs. Endoscopic retrograde cholangiopancreatography (ERCP) is performed to alleviate obstructions found in the ducts which drain our liver, gallbladder, and pancreas. During an ERCP access is obtained to the bile duct or the pancreatic duct after performing a sphincterotomy, a technique to enlarge the opening of the duct. A balloon device high in the branches of the duct is used to pull back down to remove stones, debris, and sludge which is causing the obstruction. If there is a case where the duct is presenting with stricture or a narrowing of the duct due to cancer or being inflamed, a stent is placed which crosses the stricture or narrowing area and allows for continued drainage. When necessary biopsies are obtained of both the bile and pancreatic ducts (Fig. 4.1).

4.1

Transpapillary ERCP–Conventional ERCP

Medications • Indomethacin rectal—to prevent pancreatitis • Have glucagon ready—reduces peristalsis of small bowel Set-up and Supplies • EGD and duodenal scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • CO2 insufflator C. Demone · K. Esponda · S. Shea (*) Robert Wood Johnson University Hospital, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_4

59

60

C. Demone et al.

Fig. 4.1  Gallstones. (©Dr. Michel Kahaleh [1])

• • • • • • • • • • •

Endoscopic ultrasound machine, EUS guided procedure Three (3)—10 ml syringes filled with 5 ml contrast and 5 ml 0.9% NS (Fig. 4.2) One (1)—10 ml syringe with 0.9% NS (Fig. 4.2) One (1)—60 ml syringe with 0.9% NS (Fig. 4.2) One (1)—specimen cup with contrast (Fig. 4.2) One (1)—specimen cup with 0.9% NS (Fig. 4.2) One (1)—emesis basin with 0.9% NS (Fig. 4.2) Contrast (Fig. 4.3) 4 × 4 gauze Tome (MD preference) Wire (MD preference)

Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Grounding pad on patient if it is their first ERCP and have not had a sphincterotomy (done prior to ERCP), uses cautery to cut the muscle that lies at the juncture of the intestine with both the bile and pancreatic duct. • Patient needs to be on a fluoroscopy bed. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • Be prepared to suture and/or stent defect. • DVT prophylaxis as needed (such as sequential compression device, SCD).

4  Endoscopic Retrograde Cholangiopancreatography Fig. 4.2  Basic ERCP set-up: 3—10 ml syringes filled with 5 ml contrast and 5 ml 0.9% NS, 1—10 ml syringe with 0.9% NS, 1—60 ml syringe with 0.9% NS, 1—specimen cup with contrast, 1—specimen cup with 0.9% NS, 1—emesis basin with 0.9% NS, contrast, bottle of 0.9%NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 4.3 Contrast. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

61

62

C. Demone et al.

4.1.1 Patient Teaching and Discharge Instructions 4.1.1.1 General Guidelines for Your Endoscopic Retrograde Cholangiopancreatography (ERCP) ERCP is an endoscopic procedure that allows your doctor to treat and diagnose problems in the liver, gallbladder, bile ducts, and pancreas. Most common reasons to get an ERCP are for jaundice, gallstones, or tumors in the pancreas, liver, or gallbladder. It is used to evaluate a number of digestive disorders. Your gastroenterologist may use ERCP to evaluate: • • • •

Disease of the pancreas Diseases of the liver Diseases of the bile ducts It may be used to find causes from abnormal blood tests, ultrasound tests, or CT scans.

Prior to Procedure • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners, contact your prescribing physician for instructions on when to stop taking this medication. • Do not eat or drink anything 12 h before your procedure to clear your esophagus of food products. • Tell your doctor if you have allergies. Day of Procedure Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During ERCP: • We will start an IV. • A small plastic mouthpiece will be placed between your teeth to prevent damage to the endoscope. • The endoscope will be inserted through your mouth to your esophagus, stomach, and duodenum.

4  Endoscopic Retrograde Cholangiopancreatography

63

• The doctor will then cut an opening to access your bile duct. • Dye will be injected in the bile duct and it will be examined under X-ray. Interventions may be done such as placing a stent or removing stones by sweeping a balloon down bile duct. Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your colonoscopy. You should go home and rest after your procedure. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Nausea or vomiting • Excessive gas, bloating, or cramping • Throat discomfort • Pancreatitis: This happens when the duct to the pancreas is irritated by dye or stents used during the ERCP. Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood, discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

64

C. Demone et al.

Follow-Up Contact your physician to schedule a follow-up appointment.

4.2

Endoscopic Ultrasound (EUS) Guided ERCP

An EUS guided ERCP is performed when a traditional ERCP fails due to anatomical problems. The biliary duct is accessed under EUS guidance followed by guidewire placement and fistula dilation with stent placement. Medications • Indomethacin rectal—to prevent pancreatitis • Have glucagon ready—reduces peristalsis of small bowel Set-Up and Supplies • EGD and duodenal scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • CO2 insufflator • Endoscopic ultrasound machine—EUS guided procedure • Three (3)—10 ml syringes filled with 5 ml contrast and 5 ml 0.9% NS (Fig. 4.4) • One (1)—10 ml syringe with 0.9% NS (Fig. 4.4) • One (1)—60 ml syringe with 0.9% NS (Fig. 4.4) • One (1)—specimen cup with contrast (Fig. 4.4) • One (1)—specimen cup with 0.9% NS (Fig. 4.4) • One (1)—emesis basin with 0.9% NS (Fig. 4.4) • Contrast (Fig. 4.5) • 4 × 4 gauze • Tome (MD preference) • Wire (MD preference) • VisiGlide wire 0.035 straight tip (Fig. 4.6) • 19g access needle (Fig. 4.7) • Gore stent for draining the duct (Fig. 4.8) • Hot Axios to drain fluid collection (Fig. 4.9) • Needle knife (Fig. 4.10) • Hurricane Balloon 4 × 4 (Fig. 4.11) • CRE wire guided balloon and inflation device (balloon size depends on stent placed) (Fig. 4.12) Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure.

4  Endoscopic Retrograde Cholangiopancreatography Fig. 4.4  Basic ERCP set-up: 3—10 ml syringes filled with 5 ml contrast and 5 ml 0.9% NS, 1—10 ml syringe with 0.9% NS, 1—60 ml syringe with 0.9% NS, 1—specimen cup with contrast, 1—specimen cup with 0.9% NS, 1—emesis basin with 0.9% NS, contrast, bottle of 0.9%NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 4.5 Contrast. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

65

66

C. Demone et al.

Fig. 4.6  VisiGlide wire. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• Use CO2 during procedure for insufflation not air. • Grounding pad on patient if it is their first ERCP and have not had a sphincterotomy (done prior to ERCP), uses cautery to cut the muscle that lies at the juncture of the intestine with both the bile and pancreatic duct. • Patient needs to be on a fluoroscopy bed. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • Be prepared to suture and/or stent defect. • DVT prophylaxis as needed (such as sequential compression device, SCD).

4.2.1 Patient Teaching and Discharge Instructions 4.2.1.1 General Guidelines for Your Endoscopic Retrograde Cholangiopancreatography (ERCP) ERCP is an endoscopic procedure that allows your doctor to treat and diagnose problems in the liver, gallbladder, bile ducts, and pancreas. Most common reasons to get an ERCP is for jaundice, gallstones, or tumors in the pancreas, liver or gallbladder.

4  Endoscopic Retrograde Cholangiopancreatography

67

Fig. 4.7  19g access needle. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

It is used to evaluate a number of digestive disorders. Your gastroenterologist may use ERCP to evaluate: • • • •

Disease of the pancreas Diseases of the liver Diseases of the bile ducts It may be used to find causes from abnormal blood tests, ultrasound tests, or CT scans.

Prior to Procedure • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water.

68

C. Demone et al.

Fig. 4.8  Gore Stent. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Do not eat or drink anything 12 h before your procedure to clear your esophagus of food products. • Tell your doctor if you have allergies. Day of Procedure Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you who

4  Endoscopic Retrograde Cholangiopancreatography

69

Fig. 4.9  Axios Stent. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During ERCP: • We will start an IV. • A small plastic mouthpiece will be placed between your teeth to prevent damage to the endoscope. • The endoscope will be inserted through your mouth to your esophagus, stomach, and duodenum. • The doctor will then cut an opening to access your bile duct. • Dye will be injected in the bile duct and it will be examined under X-ray. Interventions may be done such as placing a stent or removing stones by sweeping a balloon down bile duct.

70

C. Demone et al.

Fig. 4.10  Needle Knife. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your colonoscopy. You should go home and rest after your procedure. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages.

4  Endoscopic Retrograde Cholangiopancreatography

71

Fig. 4.11  Hurricane Balloon. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Nausea or vomiting • Excessive gas, bloating, or cramping • Throat discomfort • Pancreatitis: This happens when the duct to the pancreas is irritated by dye or stents used during the ERCP.

72

C. Demone et al.

Fig. 4.12  CRE wire guided balloon and inflation device (balloon size depends on stent placed). (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

Follow-Up Contact your physician to schedule a follow-up appointment.

4  Endoscopic Retrograde Cholangiopancreatography

4.3

73

 ndoscopic Ultrasound Directed Transgastric E ERCP (EDGE)

An EDGE procedure is performed in patients with an altered anatomy due to a previous surgery. Used for patients who have developed gallstones after a gastric bypass. An EUS-­ directed transgastric ERCP, or EDGE, creates a stent bridge from the native stomach to the bypassed stomach (Fig.  4.13). Rapid detection of gallstone location, optimal stent placement is achieved with the guidance of the EUS image and endoscope. The stent shortens the distance required to access the ampulla, making gallstone removing much easier. Medications • Indomethacin rectal—to prevent pancreatitis • Glucagon ready—assists in reduction of peristalsis of small bowel Set-up and Supplies • EGD and duodenal scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • CO2 insufflator • Endoscopic ultrasound machine—EUS guided procedure • Three (3)—10 ml syringes filled with 5 ml contrast and 5 ml 0.9% NS (Fig. 4.14) • One (1)—10 ml syringe with 0.9% NS (Fig. 4.14) • One (1)—60 ml syringe with 0.9% NS (Fig. 4.14) • One (1)—specimen cup with contrast (Fig. 4.14) Fig. 4.13  Stent access from native stomach to bypassed stomach. (©Dr. Michel Kahaleh [1])

74

C. Demone et al.

Fig. 4.14  Basic ERCP set-up: 3—10 ml syringes filled with 5 ml contrast and 5 ml 0.9% NS, 1—10 ml syringe with 0.9% NS, 1—60 ml syringe with 0.9% NS, 1—specimen cup with contrast, 1—specimen cup with 0.9% NS, 1—emesis basin with 0.9% NS, contrast, bottle of 0.9%NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 4.15 Contrast. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• • • • • •

One (1)—specimen cup with 0.9% NS (Fig. 4.14) One (1)—emesis basin with 0.9% NS (Fig. 4.14) Contrast (Fig. 4.15) 4 × 4 gauze Tome (MD preference) Wire (MD preference)

4  Endoscopic Retrograde Cholangiopancreatography

75

Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Grounding pad on patient if it is their first ERCP and have not had a sphincterotomy (done prior to ERCP), uses cautery to cut the muscle that lies at the juncture of the intestine with both the bile and pancreatic duct. • Patient needs to be on a fluoroscopy bed. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • Be prepared to suture and/or stent defect. • DVT prophylaxis as needed (such as sequential compression device, SCD).

4.3.1 Patient Teaching and Discharge Instructions 4.3.1.1 General Guidelines for Your Endoscopic Retrograde Cholangiopancreatography (ERCP) ERCP is an endoscopic procedure that allows your doctor to treat and diagnose problems in the liver, gallbladder, bile ducts, and pancreas. Most common reasons to get an ERCP are for jaundice, gallstones, or tumors in the pancreas, liver, or gallbladder. It is used to evaluate a number of digestive disorders. Your gastroenterologist may use ERCP to evaluate: • • • •

Disease of the pancreas Diseases of the liver Diseases of the bile ducts It may be used to find causes from abnormal blood tests, ultrasound tests, or CT scans.

Prior to Procedure • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners, contact your prescribing physician for instructions on when to stop taking this medication.

76

C. Demone et al.

• Do not eat or drink anything 12 h before your procedure to clear your esophagus of food products. • Tell your doctor if you have allergies. Day of Procedure Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During ERCP: • We will start an IV. • A small plastic mouthpiece will be placed between your teeth to prevent damage to the endoscope. • The endoscope will be inserted through your mouth to your esophagus, stomach, and duodenum. • The doctor will then cut an opening to access your bile duct. • Dye will be injected in the bile duct and it will be examined under X-ray. Interventions may be done such as placing a stent or removing stones by sweeping a balloon down bile duct. Post-procedure One the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your colonoscopy. You should go home and rest after your procedure. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Nausea or vomiting • Excessive gas, bloating, or cramping • Throat discomfort

4  Endoscopic Retrograde Cholangiopancreatography

77

• Pancreatitis: This happens when the duct to the pancreas is irritated by dye or stents used during the ERCP. Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • •

Rivaroxaban (Xarelto)Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

Follow-Up Contact your physician to schedule a follow-up appointment.

4.4

Endoscopic Guided Pancreatic Duct Access

This technique is used for the patient who cannot have an endoscopic retrograde cholangiopancreatography (ERCP) to remove an obstruction from the pancreatic duct or bile duct nor have surgery performed to place a drainage center into their skin. The obstruction could be routed to drain into either the stomach or small intestine. An EUS guided biliary and pancreatic duct drainage uses an endoscope to identify where the drainage stent needs to be placed to create drainage. Set-up and Supplies • Linear scope • Fluoroscopy • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • CO2 insufflator\22g access needle • 22 gauge access needle (Fig. 4.16) • 0.18 wire (such as Novagold) (Fig. 4.17) • 4 × 4 Biliary dilation balloon—Hurricane (Fig. 4.18) • Needle knife (on standby) (Fig. 4.19) • Autotome rapid exchange 44 (Fig. 4.20)

78

C. Demone et al.

Fig. 4.16  22 gauge access needle. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Patient needs to be on a fluoroscopy bed. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. DVT prophylaxis as needed (such as sequential compression device, SCD).

4  Endoscopic Retrograde Cholangiopancreatography

Fig. 4.17  18 wire (such as Novagold). (©Cristina Demone, Kelly Esponda, Stephanie Shea)

79

80

C. Demone et al.

Fig. 4.18  4  ×  4 Biliary dilation balloon—Hurricane. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

4  Endoscopic Retrograde Cholangiopancreatography

Fig. 4.19  Needle knife. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

81

82

C. Demone et al.

Fig. 4.20  Autotome rapid exchange 44. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Reference 1. Kahaleh, M. (2021). Dr. Michel Kahaleh New Jersey gastroenterologist & world renowned endoscopist. Retrieved from https://www.michelkahaleh.com/

5

Endoscopic Ultrasound Procedures Cristina Demone, Kelly Esponda, and Stephanie Shea

5.1

Celiac Plexus Block

Used to temporally improve pain control in pancreatic cancer. Performed by injecting local anesthetic into the celiac plexus with intention to interrupt nerve fibers and decrease the feeling of pain. Medications • One (1)—12 mL syringe with 0.9 NS (Fig. 5.1) • Four (4)—5 mL syringes with 0.25% bupivacaine (Fig. 5.1) • Two (2)—40 mg vials of triamcinolone (Fig. 5.1) • 1 L NS 0.9% IVF Set-up and Supplies • EGD scope • Linear scope • CO2 insufflator • Endoscopic ultrasound machine • Stopcock system for medication administration (Fig. 5.1) • Celiac Plexus Needle (Fig. 5.2) Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. C. Demone · K. Esponda (*) · S. Shea Robert Wood Johnson University Hospital, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_5

83

84

C. Demone et al.

Fig. 5.1  Celiac plexus block medication set-up with stopcock system: 1—12 mL syringe with 0.9% NS, 4—5 mL syringes with 0.25% bupivacaine, 2—40 mg vials of triamcinolone. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

• Use CO2 during procedure for insufflation not air. • Of concern if patient exhibits pain in recovery physician should be notified. Pain relief should be immediate this may signify the wrong area was injected. • Of concern is the complication of hypertension. To monitor for this a separate recovery protocol should be in place consisting of vital signs every 5 minutes for half hour then every 15 minutes for 1 hour followed by every 30 minutes for 90 minutes. • 2 additional liters of NS. • Recovery time 3 h.

5.1.1 Patient Teaching and Discharge Instructions 5.1.1.1 General Guidelines for Your Celiac Plexus Block Why It Is Performed A celiac plexus block is performed by endoscopically injecting medication into the celiac plexus nerves (a bundle of nerves that surround the aorta) that carry pain information. This injection will help to relieve abdominal pain that is caused

5  Endoscopic Ultrasound Procedures

85

Fig. 5.2  Celiac plexus needle. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

by cancer or chronic pancreatitis. Pain relief is individual to each person. For some pain can be relieved for weeks and for others the pain can be relieved for years. Prior to Procedure • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure.

86

C. Demone et al.

–– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Do not eat or drink anything 12 h before your procedure to clear your esophagus of food products. • Tell your doctor if you have allergies. Day of Procedure Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During the celiac plexus block: • We will start an IV in your vein to administer fluids and anesthesia. • A small plastic mouthpiece will be placed between your teeth to prevent damage to the endoscope. • The endoscope ultrasound endoscope will be inserted through your mouth to your esophagus. • When the endoscopist visualizes the celiac nerve the medications will be injected through a needle. Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. You will stay in the recovery area after your procedure for 3 h and to be monitored and receive IV hydration. Your doctor will discuss the procedure with you. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your colonoscopy. You should go home and rest after your procedure. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

5  Endoscopic Ultrasound Procedures

87

Common Side Effects • Nausea, vomiting, and diarrhea • Excessive gas, bloating, or cramping • Throat discomfort • Low blood pressure and dizziness Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

Follow-up Contact your physician to schedule a follow-up appointment.

5.2

Celiac Plexus Neurolysis

Used to improve pain control in pancreatic cancer. Is used as a permanent pain solution. Performed by injecting local anesthetic and absolute alcohol into the celiac plexus with intention to ablate the tissue transmitting the pain. Medications • One (1)—12 mL syringe with 0.9% NS (Fig. 5.3) • Two (2)—5 mL syringes with 0.25% Bupivacaine (Fig. 5.3) • One (1)—20 mL dehydrated alcohol (Fig. 5.3) • 1 L of NS 0.9% IVF Set-up and Supplies • Linear scope • CO2 insufflator • Endoscopic ultrasound machine • EGD scope and EUS linear scope • Celiac Plexus Neurolysis Needle (Fig. 5.4)

88

C. Demone et al.

Fig. 5.3  Celiac plexus neurolysis medication set-up with stopcock system: 1—12 mL syringe with 0.9% NS, 2—5 mL syringes with 0.25% Bupivacaine, 1—20 mL dehydrated alcohol. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Of concern if patient exhibits pain in recovery physician should be notified. Pain relief should be immediate this may signify the wrong area was injected. • Concerns for orthostatic hypotension and di- should have separate recovery protocol. • 2 additional liters of NS. • Recovery time 3 h.

5.2.1 Patient Teaching and Discharge Instructions 5.2.1.1 General Guidelines for Your Celiac Plexus Neurolysis Why It Is Performed A celiac plexus block is performed by endoscopically injecting medication into the celiac plexus nerves (a bundle of nerves that surround the aorta) that carry pain information. This injection will permanently block the abdominal pain that is caused by cancer or chronic pancreatitis.

5  Endoscopic Ultrasound Procedures

89

Fig. 5.4  Celiac plexus neurolysis needle. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

Prior to Procedure • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication.

90

C. Demone et al.

• Do not eat or drink anything 12 h before your procedure to clear your esophagus of food products. • Tell your doctor if you have allergies. Day of Procedure Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During the celiac plexus block: • We will start an IV in your vein to administer fluids and anesthesia. • A small plastic mouthpiece will be placed between your teeth to prevent damage to the endoscope. • The endoscope ultrasound endoscope will be inserted through your mouth to your esophagus. • When the endoscopist visualizes the celiac nerve the medications will be injected through a needle. Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. You will stay in the recovery area after your procedure for 3 h and to be monitored and receive IV hydration. Your doctor will discuss the procedure with you. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your colonoscopy. You should go home and rest after your procedure. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Nausea, vomiting, and diarrhea • Excessive gas, bloating, or cramping • Throat discomfort • Low blood pressure and dizziness

5  Endoscopic Ultrasound Procedures

91

Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

Follow-up Contact your physician to schedule a follow-up appointment.

5.3

Endoscopic Ultrasound Guided Liver Biopsy

Endoscopic ultrasound (EUS) with fine-needle aspiration is a procedure used to collect tissue biopsies from lesions around the GI tract and is a minimally invasive technique. During this procedure, a special type of endoscope with an ultrasound is advanced down the esophagus into the stomach or intestines. Now with both visual and ultrasound guidance from within the body, the deepest layers of the gastrointestinal tract along with the nearby structures such as the pancreas, liver, and lymph nodes are able to be visualized. After these targets are visualized a needle is advanced from the scope channel into the lesion under ultrasound guidance and obtain the cells to be examined by the pathologist. Medications • Heparin (500 units in 5 mL)—to flush needle Set-up and Supplies • Linear scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • CO2 insufflator • Endoscopic ultrasound machine • 19 g FNB Needle—remove stylet (Fig. 5.5) • Suction syringe—fill with 2 mL of water and 20 mL of suction (Fig. 5.5)

92

C. Demone et al.

Fig. 5.5  19 g FNB needle with 2 mL of 0.9% NS in syringe with suction. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air.

5.3.1 Patient Teaching and Discharge Instructions 5.3.1.1 General Guidelines for Your Endoscopic Ultrasound (EUS) Why It Is Performed EUS is a low risk diagnostic procedure. It combines 2 procedures: • Endoscopy during which your doctor inserts a thin lighted tube into your body • Ultrasound which uses high-frequency sound waves to obtain detailed images EUS is used to evaluate and diagnose upper and lower digestive tract disorders including:

5  Endoscopic Ultrasound Procedures

93

• Detect small tumors or fluid collections • Stage gastrointestinal cancers • Detect stones in the biliary duct Prior to Procedure Prep/Diet

• For a lower GI tract procedure, follow a liquid diet plus a laxative or enema to cleanse the bowel, do not eat or drink anything 12 h before the procedure. • The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free): –– Water (plain, carbonated, or flavored) –– Fruit juices without pulp, such as apple or white grape juice –– Fruit flavored beverages, such as fruit punch or lemonade –– Carbonated drinks, including dark sodas (cola and root beer) –– Gelatin (not red) –– Tea or coffee without milk or cream –– Sports drinks (no red) –– Clear, fat-free broth (bouillon or consommé) –– Honey or sugar –– Hard candy, such as lemon drops or peppermint rounds –– Ice pops without milk, bits of fruit, seeds, or nuts • For an upper GI tract procedure, do not eat or drink for 12 h before the procedure to clear your esophagus of food products. Medications

• If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Tell your doctor if you have allergies. Day of Procedure Your procedure will be done at hospital name in the endoscopy suite. If you are going to be late to your appointment or have any questions the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you

94

C. Demone et al.

who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During EUS: • We will start an IV in your vein to administer fluids, anesthesia, and antibiotics. • Your doctor will pass the endoscope through either your mouth or your rectum. Your doctor will observe the images on a nearby monitor. Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your procedure. You should go home and rest after your procedure. After your procedure it is important to drink lots of fluids to rehydrate. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Sore throat • Nausea or vomiting • Excessive gas, bloating, or cramping Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix)

5  Endoscopic Ultrasound Procedures

95

• Aspirin • Enoxaparin (Lovenox) • Ticagrelor (Brilinta) Follow-up Contact your physician to schedule a follow-up appointment.

5.3.2 Patient Teaching and Discharge Instructions 5.3.2.1 General Guidelines for Your Endoscopic Ultrasound (EUS) Why It Is Performed EUS is a low risk diagnostic procedure. It combines 2 procedures: • Endoscopy during which your doctor inserts a thin lighted tube into your body • Ultrasound which uses high-frequency sound waves to obtain detailed images EUS is used to evaluate and diagnose upper and lower digestive tract disorders including: • • • •

Detect small tumors To access fluid collections and create internal drainage system Stage gastrointestinal cancers Detect stones in the biliary duct

Prior to Procedure Prep/Diet

• For a lower GI tract procedure, follow a liquid diet plus a laxative or enema to cleanse the bowel, do not eat or drink anything 12 h before the procedure. • The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free): –– Water (plain, carbonated, or flavored) –– Fruit juices without pulp, such as apple or white grape juice –– Fruit flavored beverages, such as fruit punch or lemonade –– Carbonated drinks, including dark sodas (cola and root beer) –– Gelatin (not red) –– Tea or coffee without milk or cream –– Sports drinks (no red) –– Clear, fat-free broth (bouillon or consommé) –– Honey or sugar –– Hard candy, such as lemon drops or peppermint rounds –– Ice pops without milk, bits of fruit, seeds, or nuts

96

C. Demone et al.

• For an upper GI tract procedure, do not eat or drink for 12 h before the procedure to clear your esophagus of food products. Medications

• If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Tell your doctor if you have allergies. Day of Procedure Your procedure will be done at hospital name in the endoscopy suite. If you are going to be late to your appointment or have any questions on the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you. During EUS: • We will start an IV in your vein to administer fluids, anesthesia, and antibiotics. • Your doctor will pass the endoscope through either your mouth or your rectum. Your doctor will observe the images on a nearby monitor. Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your procedure. You should go home and rest after your procedure. After your procedure it is important to drink lots of fluids to rehydrate. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for:

5  Endoscopic Ultrasound Procedures

• • • • •

97

Severe or new onset abdominal pain that does not improve by passing gas Rectal bleeding that turns the entire toilet bowel red Fever greater than 101.5 or chills Vomiting blood, black or coffee ground looking material Severe dizziness, fainting, or chest pain

Common Side Effects • Sore throat • Nausea or vomiting • Excessive gas, bloating, or cramping Medications After Discharge You can resume your daily medications following your procedure. If you are taking any medications that thin your blood discuss with your doctor when to resume these medications. Commonly prescribed blood thinners: • • • • • • • • •

Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Heparin Warfarin (Coumadin) Clopidogrel (Plavix) Aspirin Enoxaparin (Lovenox) Ticagrelor (Brilinta)

Follow-up Contact your physician to schedule a follow-up appointment.

5.4

Cyst-Gastrostomy

Patients who suffer from pancreatitis, or inflammation of the pancreas, are at risk of developing Pancreatic Pseudocysts, which is a walled off collection of fluid around the pancreas. Patients who suffer from pancreatitis are at risk of developing pancreatic pseudocysts (Fig. 5.6). This collection of fluid can cause pain in the patient or result in an internal infection around the pancreas or in other places in the body. Using an endoscopic ultrasound, the physician can identify the location of all the fluid build-up within the body. Then the physician will use an endoscope to place a stent, or a tiny tube, to allow the fluid to drain directly into the gastrointestinal tract. So the patient will be able to pass and process the fluid on their own. Medications • Indomethacin rectal—to prevent pancreatitis • Glucagon 1 mg—reduces peristalsis of small bowel

98

C. Demone et al.

Fig. 5.6  Pancreatic fluid collection during cyst-gastrostomy. (© Dr Michel Kahaleh [1])

Fig. 5.7  10 mL syringe filled with 0.9% NS, One (1)—60 mL syringe filled with 0.9% NS. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

Set-up and Supplies • EGD and duodenal scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • Carbon dioxide insufflation • Endoscopic ultrasound machine • Three (3)—10 mL syringes with contrast diluted with 0.9% NS • One (1)—10 mL syringe filled with 0.9% NS (Fig. 5.7) • One (1)—60 mL syringe filled with 0.9% NS (Fig. 5.7) • Contrast (Fig. 5.8) • 1 L 0.9% normal saline • 4 × 4 gauze • Tome (MD preference) • Wire (MD preference) • VisiGlide wire 0.035 straight length (Fig. 5.9) • 19 g access needle (Fig. 5.10) • Gore stent for draining the duct (Fig. 5.11) • Hot Axios to drain fluid collection (Fig. 5.12) • Needle knife (Fig. 5.13)

5  Endoscopic Ultrasound Procedures

99

Fig. 5.8  Contrast. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 5.9  VisiGlide 0.035″ wire. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

• Hurricane balloon 4 × 4 (Fig. 5.14) • CRE wire guided balloon and inflation device (balloon size depends on stent placed) (Fig. 5.15) Nursing Considerations • IV hydration pre-procedure. • If patient is on a blood thinner, note date last taken.

100

C. Demone et al.

Fig. 5.10  19 g access needle. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

• • • • • •

Assess patient for abdominal distention before, during, and after procedure. Use CO2 during procedure for insufflation not air. Patient needs to be on a fluoroscopy bed. Bair hugger for body warmth. Consider Foley protocol if procedure exceeds 2 h. DVT prophylaxis as needed (such as sequential compression device, SCD).

5.4.1 Patient Teaching and Discharge Instructions 5.4.1.1 General Guidelines for Your Endoscopic Ultrasound (EUS) Why It Is Performed EUS is a low risk diagnostic procedure. It combines 2 procedures:

5  Endoscopic Ultrasound Procedures

101

Fig. 5.11  Gore stent for draining the duct. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

• Endoscopy during which your doctor inserts a thin lighted tube into your body • Ultrasound which uses high-frequency sound waves to obtain detailed images EUS is used to evaluate and diagnose upper and lower digestive tract disorders including: • • • •

Detect small tumors To Stage gastrointestinal cancers Detect stones in the biliary duct

Prior to Procedure Prep/Diet

• For a lower GI tract procedure, follow a liquid diet plus a laxative or enema to cleanse the bowel, do not eat or drink anything 12 h before the procedure.

102

C. Demone et al.

Fig. 5.12  Hot axios stent. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

• The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free): –– Water (plain, carbonated, or flavored) –– Fruit juices without pulp, such as apple or white grape juice –– Fruit flavored beverages, such as fruit punch or lemonade –– Carbonated drinks, including dark sodas (cola and root beer) –– Gelatin (not red) –– Tea or coffee without milk or cream –– Sports drinks (no red) –– Clear, fat-free broth (bouillon or consommé) –– Honey or sugar –– Hard candy, such as lemon drops or peppermint rounds –– Ice pops without milk, bits of fruit, seeds, or nuts

5  Endoscopic Ultrasound Procedures

103

Fig. 5.13  Needle knife. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

• For an upper GI tract procedure, do not eat or drink for 12 h before the procedure to clear your esophagus of food products. Medications

• If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure.

104

C. Demone et al.

Fig. 5.14  Hurricane balloon. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

–– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners contact your prescribing physician for instructions on when to stop taking this medication. • Tell your doctor if you have allergies. Day of Procedure Your procedure will be done at hospital name in the endoscopy suite. If you are going to be late to your appointment or have any questions on the day of the procedure please call. Arrive 1½ h prior to your scheduled procedure time. When you arrive you will register and give your medical history. You will need a responsible adult with you who will accompany you home. Bring with you a photo ID, insurance card, and a list of medications that you take with you.

5  Endoscopic Ultrasound Procedures

105

Fig. 5.15  CRE inflation device and balloon. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

During EUS: • We will start an IV in your vein to administer fluids, anesthesia, and antibiotics. • Your doctor will pass the endoscope through either your mouth or your rectum. Your doctor will observe the images on a nearby monitor. Post-procedure Once the procedure is finished you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. You may be admitted after your procedure for observation and further intervention if indicated. Do not drive, operate heavy machinery, or drink alcohol for 12 h after your procedure. You should go home and rest after your procedure. After your procedure it is important to drink lots of fluids to rehydrate. We recommend that you eat something light since you have not eaten for over 12 h. Avoid fried foods, fatty foods, and large quantities of food. Things such as scrambled eggs, toast, a sandwich are good choices. You may eat more food once you have tried something light to make sure you do not become sick to your stomach. You may also have excess gas, so you may choose to avoid foods that cause additional gas, such as beans or carbonated beverages. Call your doctor right away for: • • • • •

Severe or new onset abdominal pain that doesn’t improve by passing gas. Rectal bleeding that turns the entire toilet bowl red. Fever greater than 101.5 or chills. Vomiting blood, black or coffee-ground looking material. Severe dizziness, fainting or chest pain.

Reference 1. Kahaleh, M. (2021). Dr. Michel Kahaleh New Jersey gastroenterologist & world renowned endoscopist.

6

Pancreatic Fluid Collection Procedures Cristina Demone

Necrosectomy is performed in patients who have suffered from severe pancreatitis and have pancreatic necrosis. Used to remove necrotic tissue and fluid from the collection. It is possible for the fluid build-up caused by pancreatitis (pancreatic pseudocysts) (Fig. 6.1) to harden and become a gel-like substance, even after a stent has been implanted. If the build-up solidifies into a gel-like state, the fluid will not be able to drain through the stent (Fig.  6.2) and into the gastrointestinal tract. To remove the build-up, a necrosectomy must be performed, this involves using an endoscope to pass into where the stent had been implanted and remove the gel-like build-up one small section at a time. While this process can take multiple sessions, it is necessary as to allow the fluid to drain and stop from building up, which can lead to further complications.

6.1

Set-up

• 1 T scope • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system) • CO2 insufflator • Roth Net Retriever (Fig. 6.3) • Rat Tooth Forceps (Fig. 6.4) • Spiral Snare (Fig. 6.5) • Trapezoid Basket (Fig. 6.6)

C. Demone (*) Robert Wood Johnson University Hospital, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_6

107

108 Fig. 6.1  Removal of necrotic collection. (© Michel Kahaleh [1])

Fig. 6.2  Axios stent in pancreatic collection post-necrosectomy. (© Michel Kahaleh [1])

• • • •

Hydra Jagwire (Fig. 6.7) Hydrogen peroxide with sterile water 1:5 concentration (Fig. 6.8) Two (2) 60 mL syringes (10 mL H2O2 in 50 mL NS) Fluoroscopy

C. Demone

6  Pancreatic Fluid Collection Procedures

Fig. 6.3  Roth Net. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

6.2 • • • • • • • • • •

Nursing Considerations

Patients are admitted typically with septic pancreatitis. Patients often return for multiple procedures to clean out necrosis. First procedure involves placing of axios for access to collection. If patient is on a blood thinner, note date last taken. Assess patient for abdominal distention before, during, and after procedure. Use CO2 during procedure for insufflation not air. Patient needs to be on a fluoroscopy bed. Bair hugger for body warmth. Consider Foley protocol if procedure exceeds 2 h. DVT prophylaxis as needed (such as sequential compression device, SCD).

109

110 Fig. 6.4  Rat Tooth. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

C. Demone

6  Pancreatic Fluid Collection Procedures Fig. 6.5  Spiral Snare. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

111

112

Fig. 6.6  HydraJagwire. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

C. Demone

6  Pancreatic Fluid Collection Procedures

Fig. 6.7  Trapezoid Basket. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

113

114

C. Demone

Fig. 6.8 Hydrogen peroxide, sterile water to be mixed in 1:5 concentration. (© Cristina Demone, Kelly Esponda, Stephanie Shea)

Reference 1. Kahaleh, M. (2021). Dr. Michel Kahaleh New Jersey gastroenterologist & world renowned endoscopist. Retrieved from https://www.michelkahaleh.com/

7

Endo-Bariatric Procedures Cristina Demone, Kelly Esponda, and Stephanie Shea

7.1

Endoscopic Sleeve Gastroplasty (ESG)

An endoscopic sleeve gastroplasty is a procedure which reduces the capacity of the patient’s stomach. By reducing the volume of the stomach, patients will become fuller faster and have a reduced calorie intake. Accompanied with proper diet and exercise, patients who undergo an endoscopic sleeve gastroplasty can expect to accelerate their weight-loss therapy. While other similar procedures will remove large sections of stomach tissue, the endoscopic sleeve gastroplasty is carried out by folding the stomach into itself and stitching the stomach into a tube shape (Figs. 7.1 and 7.2). Effectively reducing the stomach capacity by 70%. The endoscopic sleeve gastroplasty is a preferred bariatric therapy tool, as patients are able to achieve their weight-loss goals with their own efforts. With the help of a team comprised of gastroenterologists, nutritionists, endocrinologists, psychiatrists, and exercise therapists, the patient will be guided on how to properly lose their weight after completing an endoscopic sleeve gastroplasty. The endoscopic sleeve gastroplasty is a preferred bariatric therapy tool, as patients are able to achieve their weight-loss goals with their own efforts. With the help of a team comprised of gastroenterologists, nutritionists, endocrinologists, psychiatrists, and exercise therapists, the patient will be guided on how to properly lose their weight after completing an endoscopic sleeve gastroplasty.

C. Demone · K. Esponda · S. Shea (*) Robert Wood Johnson University Hospital, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_7

115

116

C. Demone et al.

Fig. 7.1  Stomach with dots representing sutured area and cross-sectional view represents what is left of stomach after ESG. (©Dr. Michel Kahaleh [1])

Fig. 7.2  Suturing technique. (©Dr. Michel Kahaleh [1])

Medications • Levaquin Intravenous Piggyback (IVPB). • Scopolamine Transdermal—only given for esophageal procedures. • Protonix 40 mg IV Push—only given for esophageal procedures. • Gentamycin intraluminal flush—2 syringes Gentamycin 40 mg diluted in 60 mL of 0.9% NS (Fig. 7.3). Set-up and Supplies • EGD scope. • Double channel upper scope. • Electrosurgical generator with pure cut/sinusoidal waveform (such as ERBE system). • CO2 insufflator. • One (1) overstitch device (Figs. 7.4 and 7.5). • Five–twelve (5–12) cinches (Fig. 7.6). • Five–twelve (5–12) sutures (Fig. 7.6). • One (1) tissue helix (Fig. 7.7). • APC straight fire catheter. • Grounding pad. • One (1) kidney basin. • One (1) 60 mL syringe with blue tip. • Lubricant.

7  Endo-Bariatric Procedures

117

Fig. 7.3 Gentamycin intraluminal flush—2 syringes 40 mg Gentamycin in 60 mL NS. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 7.4 Overstitch Device. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Nursing Considerations • Pre-procedure work up includes nutritional consult and psychiatry consult. • IV hydration pre-procedure. • Make sure patient took scopolamine and Emend the day prior to procedure to prevent nausea and vomiting as ordered. • If patient is on a blood thinner, note date last taken. • Assess patient for abdominal distention before, during, and after procedure. • Use CO2 during procedure for insufflation not air. • Bair hugger for body warmth. • Consider Foley protocol if procedure exceeds 2 h. • DVT prophylaxis as needed (such as sequential compression device, SCD). • Patient should lie in left lateral position.

118 Fig. 7.5 Overstitch Device. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

Fig. 7.6  Cinch, Suture. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

C. Demone et al.

7  Endo-Bariatric Procedures

119

Fig. 7.7  Tissue Helix. (©Cristina Demone, Kelly Esponda, Stephanie Shea)

• Keep track of number of sutures used intra-procedure and document. • Patient will be admitted for observation, pain control, and hydration.

7.2

Patient Teaching and Discharge Instructions

7.2.1 G  eneral Guidelines for Your Endoscopic Sleeve Gastroplasty 7.2.1.1 Why It Is Performed Endoscopic sleeve gastroplasty is a newer type of weight-loss procedure. It reduces the size of your stomach using an endoscopic suturing device without the need for surgery. 7.2.1.2 The Day Prior Diet • Please go on a clear liquid diet, the day prior to your procedure (anything you can see through only). • The following foods are allowed in a clear liquid diet (if you are diabetic, you can follow this diet as long as it is sugar free):

120

C. Demone et al.

–– Water (plain, carbonated, or flavored). –– Fruit juices without pulp, such as apple or white grape juice. –– Fruit flavored beverages, such as fruit punch or lemonade. –– Carbonated drinks, including dark sodas (cola and root beer). –– Gelatin (not red). –– Tea or coffee without milk or cream. –– Sports drinks (no red). –– Clear, fat free broth (bouillon or consommé). –– Honey or sugar. –– Hard candy, such as lemon drops or peppermint rounds. –– Ice pops without milk, bits of fruit, seeds, or nuts. • You should have nothing to eat after midnight. Medications • If you are taking medications for high blood pressure, seizures, or if you are taking prednisone, you may take these medications the morning of the procedure or at least 2 h before the procedure with a small sip of water. • If you are diabetic: –– If you take a “sugar” pill, do not take it on the day of your procedure. –– If you are taking regular insulin (R), do not take it on the day of your procedure. –– If you are taking any other insulin preparation, please contact your prescribing physician for instructions. • If you are taking Coumadin, Plavix, or other blood thinners, contact your prescribing physician for instructions on when to stop taking this medication. • Tell your doctor if you have allergies. • Place the scopolamine patch at around 6 p.m. the night before the procedure behind your ear as directed.

7.2.1.3 The Day of the Procedure Your procedure will be done at (hospital name) in the endoscopy suite. If you are going to be late to your appointment or have any questions on the day of the procedure, please call. • Take the EMEND (aprepitant) capsule at 6 a.m. the day of the procedure, with a little bit of water. Arrive 1 ½ h prior to your scheduled procedure time. When you arrive, you will register and give your medical history. During endoscopic sleeve gastroplasty: • We will start an IV in your vein to administer fluids, anesthesia, and antibiotics. • The procedure is done using and endoscope with a camera and an endoscopic suturing device.

7  Endo-Bariatric Procedures

121

• The endoscope is inserted down your throat into the stomach. The tiny camera allows the doctor to see and operate without making incisions. • Using the endoscope the doctor places approximately 12 sutures in the stomach, leaving it shaped like a tube. This restricts the amount of calories your body absorbs.

7.2.1.4 Post-Procedure Once the procedure is finished, you will recover from anesthesia in the endoscopy unit. Your doctor will discuss the procedure with you. You may have a brief stay in the hospital or you may be discharged home if you feel well. 7.2.1.5 Common Side Effects • Stomach spasm. • Nausea. • Trapped gas. • Dehydration. 7.2.1.6 Medications After Discharge You will be given a variety of medications, below is a schedule of when to take each one. Regular Meds (please take regularly post-procedure) –– Anti-acid medications (prilosec, nexium, or omeprazole), twice a day for 2 weeks. –– Antibiotics (Augmentin or Levaquin) as prescribed for 3 days. Only as needed medications: • Pain (Pain medications will be prescribed on the day of the procedures) Liquid Tylenol with codeine up to 15 mL every 6 h OR Tramadol (crushed) 1 to 2 tablets every 6 h. Nausea: • • • •

Levsin may be prescribed for up to a week. Scopolamine patch to be changed every 72 h. Zofran (Ondansetron) 5 mL (4 mg) every 4 h or 8 mg every 8 h. Compazine (prochlorperazine) suppository 25 mg (one suppository) every 12 h. Constipation:

• Miralax 1 capful every day (dissolve in 4 oz. of water).

122

C. Demone et al.

7.2.1.7 Follow-Up It is important you get your upper GI series (X-ray) scheduled within 1  week post-procedure. • • • • •

1 month office visit 3 month office visit 6 month office visit 9 month phone call 1 year office visit.

7.2.1.8 Nutrition It is very important you follow up with nutrition, twice a month at least for the first 3  months, and then once a month after that (as deemed necessary by the nutritionist). Nutritionists/Dieticians: For a complete list of nutritionists/dieticians, please contact your insurance company. You are responsible for confirming that the provider you have chosen accepts your insurance. If your insurance requires a referral to see a specialist, please contact the referral department at (555)555-5555 with the following information to obtain a referral: • • • • •

Name of the physician. Specialty of the physician. Address of the physician. Phone number of the physician. Date of your appointment.

7.3

Information and Dietary Guidelines

• Your new stomach pouch will hold about 4 oz. of food. • Follow the diet progression included in this packet to allow for optimal weight loss and healing of your stomach pouch. • Even if you think you feel well enough to advance your diet early, it is important to follow the diet below. • Surgery is a weight-loss “tool.” Healthy food choices and exercise will help you maximize your weight loss and maintain your nutritional health. • Taking a (chewable) multivitamin and calcium + vitamin D supplement after surgery will help maintain optimal nutritional status. After 1  month, you may switch to pill form. DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT/12  A.M.  THE DAY OF SURGERY.

7  Endo-Bariatric Procedures

123

7.3.1 Post-Operative Diet Progression 1. Days 1–2: Clear liquids. 2. Days 3–14: Full liquids. 3. Week 3: Soft foods. 4. Week 4: Continue soft foods; add cooked vegetables and soft fruits. 5. Week 6: Add starches (whole grain recommended).

7.3.1.1 Post-Op Days 1 and 2 CLEAR Liquids (non-carbonated, no sugar, no caffeine) • • • •

CLEAR liquid protein supplements (try isopure ready to drink). Broth (chicken, beef, or vegetable). Sugar free popsicles or fruit ices without pulp. Water, tea, crystal Light, or other sugar free non-carbonated drinks.

Remember: • Your goal is to allow your gastrointestinal tract to rest and heal. • Sip beverages slowly throughout the day—no more than 2 oz. at a time. • STOP drinking before you feel overly full.

7.3.1.2 Days 3–14 FULL Liquids • • • •

All the above clear liquids. Protein liquid supplements (protein shakes—see guide at end of handout). Fat free cream or pureed soups (no chunks). Low fat plain yogurts or plain, low fat Greek yogurt.

7.3.1.3 Start of Week 3 (Day 15) Advance diet to replace full liquids with soft foods (as tolerated). Soft foods: Focus on protein sources that are soft, moist, diced, ground, or pureed • All above beverages/foods. • Eggs, ground poultry, soft moist fish (fat free gravy or bouillon/broth/light sauce to moisten if needed). • Cooked beans/bean soup. • Tuna fish with light mayo. • Skim milk cottage cheese, skim milk ricotta cheese, or low fat soft cheese.

7.3.1.4 Start of Week 4 (Day 22) Advance diet to include cooked/soft fruit and vegetables (as tolerated). Soft foods continued: Add cooked, soft vegetables, and soft and/or peeled fruit

124

C. Demone et al.

• All above beverages/foods. • Well cooked, soft vegetables. • Soft and/or peeled fruit.

7.3.1.5 Start of Week 6 (Day 36) Advance diet to include starches (in limited amounts) • All above beverages/foods. • Add rice, bread, pasta—preferably in whole grain form and in small amounts (quinoa, whole wheat bread, brown rice). • Eat protein and vegetables at meal before the starch. • Raw vegetables/salads permitted as tolerated—consult with surgeon. A Few Guidelines • Do not drink during mealtime. Wait 30 min after each meal to consume liquids. • Eating behavior: chew thoroughly (20 chews!), eat slowly, take small bites. • Always eat protein first at meals, followed by vegetables and lastly starch, only if you are still hungry. • Your daily protein goal is 60 g for women and 70 g for men. It is ok if you are not always meeting that goal, but remember to prioritize protein foods over other foods. Aim for 6–8 glasses/36–64 oz. of liquids per day (this includes water, protein shakes, etc.) Listen to your body—stop eating when you are “comfortably full.” Your tolerance may be limited to 2 tablespoons at each meal. Required Nutrient Supplements 1. Chewable supplement, vitamin mineral supplement (2× per day—CONFIRM with your surgeon). 2. Chewable or liquid calcium citrate with vitamin D. Shopping List Have these items ready BEFORE surgery. • • • • • • •

beef, chicken, vegetable broth (canned or bouillon), sugar free gelatin, sugar free, non-carbonated beverages, sugar free popsicles, liquid protein supplements—added at full liquid phase/day 3, chewable/liquid multivitamin/mineral supplement, chewable/liquid calcium citrate with vitamin D supplement.

7  Endo-Bariatric Procedures

125

Protein Shake Guide Choose a shake with: about 150 calories/15 g of protein or more/15 g of carbs or less product Isopure (clear protein drink) Atkins advantage Carnation instant breakfast no sugar added Designer whey/Aria GNC Total lean Glucerna hunger smart/boost calorie smart Muscle Milk light Myoplex carb control Pure protein Premier protein Kosher/soy protein: Maxi Health Naturemax

Formula Ready to drink RTD RTD/powder

Calories 100–160 150 150

Protein 20–40 15 13

Carbs 0–5 2 16

Powder RTD/powder RTD

80–100 170 180

14–18 25 15

3 6 16

RTD/powder RTD RTD RTD Powder

160 150 170 160 175

20 25 23–35 30 29

9 5 3 5 14

7.3.1.6 Post-Operative Days 1 and 2 CLEAR Liquids (Non-carbonated, no sugar, no caffeine) –– –– –– ––

Liquid protein supplements. Chicken, beef, or vegetable broth. Sugar free popsicles or fruit Ices without pulp. Tea, crystal light, or other sugar free non-carbonated drinks.

A Few Guidelines Your goal is to allow your gastrointestinal tract to rest and heal • • • •

Sip water and other non-caloric/non-carbonated beverages throughout the day. SIP no more than 2 oz. at a time (or stop when full if less than 2 oz). STOP drinking before you feel overly full. Drink your protein drink 1–2 oz. at a time and drink throughout the day in order to meet your daily protein need of 60 g per day for women and 70 g per day for men.

7.3.1.7 Post-Operative Days 3 Through 14 CLEAR Liquids (Non-carbonated, no sugar, no caffeine) –– –– –– ––

Liquid protein supplements. Chicken, beef, or vegetable broth. Sugar free popsicles or fruit ices without pulp. Tea, crystal light, or other sugar free non-carbonated drinks.

126

C. Demone et al.

↓ PROGRESS to FULL Liquid –– All the above clear liquids. –– Protein liquid supplements (≤20 g of protein and ≤15 g of carbohydrate/serving). –– Skim, 1% or soy milk mixed with whey or soy protein powders (limited to 20 g protein/serving). –– Fat free cream soups. –– Fat free, plain yogurts or plain, non-fat Greek yogurt. A Few Guidelines • Your goal is to consume a minimum of 64 fluid oz. per day (1/2 clear liquid and 1/2 full liquid). • Sip water and other non-caloric/non-carbonated beverages throughout the day. • SIP no more than 2 oz. at a time (or stop when full if less than 2 oz). • STOP drinking before you feel overly full. • Drink your protein drink 1–2 oz. at a time and drink throughout the day in order to meet your daily protein need of 60 g per day for women and 70 g per day for men. Required Nutrient Supplements • Chewable supplement, vitamin mineral supplement (2× per day—CONFIRM with your surgeon). • Chewable or liquid calcium citrate with vitamin D.

7.3.1.8 Post-Operative Start of Week 3 Continue CLEAR Liquids/48–64  oz per day (non-carbonated, no sugar, no caffeine) –– Water is preferred choice. –– Chicken, beef, or vegetable broth. –– Sugar free popsicles or fruit ices without pulp. –– Tea, crystal light, or other sugar free non-carbonated drinks. ↓ Start to REPLACE FULL Liquids with soft, moist, diced, ground or pureed proteins, if tolerated –– Eggs, ground poultry, soft moist fish (fat free gravy or Bouillon/broth to moisten if needed). –– Cooked beans of hearty bean soups. –– Skim milk cottage cheese, skim milk Ricotta cheese, or low fat cheese. –– Fat free plain or Greek yogurt (pending surgeon’s approval).

7  Endo-Bariatric Procedures

127

A Few Guidelines • Your goal is to consume a minimum of 64 fluid oz. of clear liquids per day. • DO NOT DRINK FLUIDS DURING YOUR MEALS wait at least 30 min after each meal to consume liquids. • 4–6 Small meals per day are advised • Protein at each meal is recommended. Daily requirement: Women 60  g and men 70 g. • Chew THOROUGHLY (chew enough to produce a puree consistency before you swallow). • Be aware, your tolerance may be limited to 1–2 T at each meal. Required Nutrient Supplements • Chewable supplement, vitamin mineral supplement (1 tablet per day). • Chewable or liquid calcium citrate with vitamin D.

7.3.1.9 Post-Operative Week 4–5 Continue LIQUIDS to achieve proper hydration/64 oz per day –– Water is preferred choice. –– Coffee, tea, crystal light, or other sugar free, non-carbonated drinks. ↓ ADVANCE YOUR DIET TO INCLUDE WELL COOKED, SOFT VEGETABLES, and SOFT and/or PEELED FRUIT –– Eggs, ground poultry, soft moist fish (fat free gravy or Bouillon/broth to moisten if needed). –– Cooked beans of hearty bean soups. –– Skim cottage cheese, skim milk Ricotta cheese, or low fat cheese. –– Fat free plain or Greek yogurt (pending surgeon’s approval). –– Well cooked, soft vegetables. –– Soft and/or peeled fruit. A Few Guidelines • Your goal is to consume a minimum of 64 fluid oz. of liquids per day which is essential especially during rapid weight loss. • DO NOT DRINK FLUIDS DURING YOUR MEALS wait at least 30 min after each meal to consume liquids. • 4–6 Small meals per day are advised • Protein at each meal is recommended. Daily requirement: Women 60  g and men 70 g. • Chew THOROUGHLY or “>20 Times” before you swallow (chew enough to produce a pure consistency before you swallow). • Be aware, your tolerance may be limited to 1–2 T at each meal.

128

C. Demone et al.

Required Nutrient Supplements • Chewable supplement, vitamin mineral supplement (1 tablet per day). • Chewable or liquid calcium citrate with vitamin D.

7.3.1.10 Post-Operative Week 6 Continue LIQUIDS to achieve proper hydration/minimum of 64 oz per day –– Water is preferred choice. –– Coffee, tea, crystal light, or other sugar free, non-carbonated drinks. ADVANCE YOUR DIET TO INCLUDE STARCHES –– Eggs, ground meats, poultry, soft moist fish (fat free gravy or Bouillon/broth to moisten if needed). –– Cooked beans or hearty bean soups. –– Cottage cheese, skim milk Ricotta cheese, or low fat cheese. –– Fat free plain or Greek yogurt. –– Well cooked, soft vegetables. –– Soft and/or peeled fruit. –– Add rice, bread, pasta preferably in a whole grain form if you are comfortably consuming your daily requirement of protein (i.e. 60 g per day for women and 70 g per day for men). A Few Guidelines • Consuming a minimum of 64 fluid oz. of liquids per day is essential especially during rapid weight loss. • DO NOT DRINK FLUIDS DURING YOUR MEALS (wait at least 30 min after each meal to consume liquid). • 4–6 Small meals per day are advised • Protein at each meal is recommended. Daily requirement: Women 60  g and men 70 g. • Chew THOROUGHLY or “>20 Times” before you swallow (chew enough to produce a puree consistency before you swallow). • Be aware, your tolerance may be limited to 1–2 T at each meal. Required Nutrient Supplements • Chewable supplement, vitamin mineral supplement (1 tablet per day). • Chewable or liquid calcium citrate with vitamin D.

7.4

Frequently Asked Questions

1. How much pain or nausea will I be in? This varies from person to person. Generally the pain feels sharp and cramp like. It should not last for more than a few days. The pain medications given

7  Endo-Bariatric Procedures

129

should help. You can alternate between Tylenol with codeine and tramadol (take every 3 h). You can also just take liquid Tylenol. For nausea there are three medications prescribed, so you can alternate between them. The nausea again should only last 2–3 days. 2. I am feeling tired or fatigued after the procedure? You are likely dehydrated. Make sure you have a sip to sips of water every 5–10 min. Start taking a multivitamin if you have not already. You need water infused with electrolytes. 3. I have a fever is that normal? A fever post-procedure the first 3 days is normal, if persistent please call the office. You can take Tylenol every 6 h (remember there is Tylenol in the codeine so DO NOT take both). 4. How much pain is “ok”? Discomfort is normal post-procedure, pain that persist, worsens or if you abdominal distension you need to call the office. Remember you can take Tylenol with codeine or liquid Tylenol. You can alternate with tramadol. 5. I have double vision, what does this mean? This is a side effect from the scopolamine patch, remove the patch and if it still persists, please call the office. 6. I have not had a bowel movement in a few days? Have you tried taking the miralax, increase from daily to twice a day and add senna 1–2 tabs at bedtime. Again increase your water intake. 7. When is it ok to resume exercise? You can resume light exercise day 5—no abdominal exercises. No heavy lifting until post your 1 month follow-up visit. 8. I feel acid or chest discomfort? If you are on once a day acid medication, increase to twice a day. You may also add Zantac or Pepcid at night (start at 75 mg and increase as needed to max 300 mg at bedtime). 9. I am still hungry? You need to increase your protein intake. Liquids also do not make one full. Once you start eating solids, this should resolve as well. Remember not to over think and worry about the size of the stomach. It definitely is smaller! 10. I do not feel full? (Same as above). Do not push your limit and test your capacity—as your stomach is still small even if you do not feel discomfort as a form of restriction. We do not want you to feel pain, so do not eat until you get there. This will tear and stretch your stomach. 11. When can I have alcohol and will the procedure affect my tolerance? NO alcohol for 3 months. However it is recommend to minimize or avoid all alcohol for 6  months for better weight loss. Your tolerance may be affected, proceed with caution. 12. When can I resume sexual activity? Nothing strenuous, but generally 2–3 weeks post-procedure.

130

C. Demone et al.

13. How often should I follow up with nutrition? It is your responsibility to call to make appointments—Strongly recommend following up with the nutritionist at least 1–2 times a month. It is also recommended to call and set these apt ups prior to the procedure in order to get timely appointments. 14. When can I fly? You can fly on day 5 post-procedure. This is just to make sure all is well. You need to have had your upper GI series before your travel. 15. How soon can I return to work? This is completely up to you. People vary and can return from the very next day to a few days later.

Reference 1. Kahaleh, M. (2021). Dr. Michel Kahaleh New Jersey gastroenterologist & world renowned endoscopist. Retrieved from https://www.michelkahaleh.com/

8

Case Studies Cristina Demone, Kelly Esponda, Stephanie Shea, Michel Kahaleh, Amy Tyberg, Avik Sarkar, and Haroon Shahid

Endoscopic Mucosal Resection A 72-year-old patient with known Barrett’s esophagus is referred for a 1 cm nodule above the esophagogastric (EG) junction, biopsy revealed a high grade dysplasia, no features of malignancy. An endoscopic ultrasound showed that the small lesion is superficial and was classified T1a. After multidisciplinary meeting with surgery and oncology, the patient was referred to advanced endoscopy. Physical examination is normal. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. EMR with cap technique since small and superficial nodule.

C. Demone · K. Esponda · S. Shea · A. Tyberg · A. Sarkar Robert Wood Johnson University Hospital, New Brunswick, NJ, USA e-mail: [email protected]; [email protected] M. Kahaleh (*) Department of Medicine, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA e-mail: [email protected] H. Shahid Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 K. Esponda et al. (eds.), Guide to Complex Interventional Endoscopic Procedures, https://doi.org/10.1007/978-3-030-80949-2_8

131

132

C. Demone et al.

Endoscopic Submucosal Dissection A 69-year-old patient with known Barrett’s esophagus is referred for a 5 × 7 cm lesion above the EG junction, biopsy revealed a high grade dysplasia with malignant feature in the center of the lesion. An endoscopic ultrasound showed that the lesion is superficial and was classified T1a. After multidisciplinary meeting with surgery and oncology, the patient was referred to advanced endoscopy. Physical examination is normal. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. ESD is preferred to EMR since large flat lesions and to provide better chance of negative margins of resection, less risk of recurrence. Endoscopic Full Thickness Resection An 89-year-old patient with pain, nausea, and early satiety. Endoscopy done locally showed a 3 cm submucosal lesion in the antrum. Endoscopic ultrasound showed the lesion to be originating from the muscular layer, sitting on it. FNA confirmed a GIST (gastrointestinal stromal tumor) with no features of malignancy. After multidisciplinary meeting with surgery and oncology, the patient was referred to advanced endoscopy. Physical examination is normal. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. EFTR to permit full resection, followed by suturing if defect of the muscularis. Submucosal Tunneling Endoscopic Resection A 79-year-old patient with known CAD referred for dysphagia and weight loss. EGD demonstrated a 4 cm submucosal lesion in the upper esophagus. EUS showed the lesion sitting right above the aorta with FNA confirming leiomyoma with no sign of malignancy. After multidisciplinary meeting with surgery and oncology, the patient was referred to advanced endoscopy. Physical examination is normal. Plan:

8  Case Studies

133

1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. Cardiology consult. 3. STER since tunneling technique allows safe and complete resection with limited risk of bleeding and perforation. EPOEM A 34-year-old patient with significant weight loss (25 pounds) over 3 months, chest pain, regurgitation, and food stuck in the chest referred to clinic with barium esophagram showing dilated esophagus with barely any contrast passage in stomach. Manometry confirmed type II achalasia. Physical examination is unremarkable except for mild dehydration. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. Consider pneumatic dilation for temporizing measure. 3. EPOEM. GPOEM A 54-year-old patient with diabetes status postsurgical fundoplication complicated by Vagal nerve injury 3 years ago. Seen with severe bloating, nausea, vomiting, and mild weight loss (5 pounds). Physical examination shows severe gastric distension and diffuse abdominal pain. Gastric emptying study: severe delay in gastric emptying compatible with gastroparesis. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. GPOEM. ZPOEM A 78-year-old patient with recurrent admission for aspiration pneumonia, poor appetite, bad breath, and chronic cough. Barium swallow showed a Zenker’s diverticulum of 5 cm with poor passage of contrast in the esophagus. Physical examination unremarkable. Plan:

134

C. Demone et al.

1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. Consider pulmonary consult. 3. ZPOEM or septotomy (typically performed for smaller Zenker). Transpapillary ERCP A 45-year-old female patient s/p cholecystectomy complicated with bile duct injury. HIDA Scan positive for a high grade bile leak. CT of abdomen showed a gallbladder fossa collection of 8 cm, a drain was placed by IR and drained 2 L of bile in 5 h. Advanced endoscopy was consulted. Physical examination: Diffuse abdominal tenderness with pain at the site of the percutaneous drain. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. ERCP with biliary sphincterotomy and placement of a 10 mm × 8 cm large covered metal stent sealing the bile duct injury. Endoscopic Ultrasound Guided ERCP for Biliary Access A 37-year-old patient who underwent a left liver cyst resection 2 years ago and was referred for second opinion. Patient developed a left hepatic biliary dilation with pruritus and jaundice that was seen on CT abdomen. ERCP was attempted locally with inability to access or opacify the left hepatic duct. Patient was referred to advanced endoscopy and an MRI-MRCP was requested. MRI-MRCP showed a disconnected and severely dilation of left hepatic duct. Patient declined percutaneous drainage due to fear of pain and prefer internal drainage. Physical examination: Excoriation injury and jaundice. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies. 2. EUS guided ERCP with biliary drainage was performed from the stomach, the left hepatic duct was drained with a 10 cm × 10 mm fully covered metal stent with anchoring fins (to prevent migration). Endoscopic Ultrasound Guided ERCP for Pancreatic Access A 28-year-old patient was referred with recurrent pancreatitis, weight loss, and abdominal pain.

8  Case Studies

135

Past medical history includes a whipple procedure for a mucinous cyst in the head of the pancreas. MRI-MRCP was requested which showed a dilated main pancreatic duct compatible with an anastomotic stricture at the pancreaticojejunostomy site. ERCP with single balloon was attempted with no success, no ability to see the pancreatic anastomosis in the afferent limb. Physical examination: Epigastric pain on palpation, severe weight loss. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies, amylase, lipase, Ca 19/9. 2. EUS guided ERCP for pancreatic drainage from the stomach with a 7 French × 10 cm double pigtail placed between stomach and main pancreatic duct. Endoscopic Ultrasound Directed Transgastric ERCP A 65-year-old patient s/p Roux-en-Y gastric bypass with cholecystectomy 15 years ago. Patient is seen today with abdominal pain, mild jaundice, fever, and chills. MRI-MRCP demonstrate a 2 cm CBD stones with biliary dilation. Advanced endoscopy consulted by surgery since patient is status post-cholecystectomy. Patient declined any percutaneous drainage. Physical examination: RUQ pain, temperature of 103.1 °F, and mild jaundice. Plan: 1. Pre-procedure labs: Complete blood count, chemistry profile, coagulation studies, amylase, lipase. 2. EUS guided transgastric ERCP (EGDE) with placement of a 20  mm lumen-­ apposing stent connecting the pouch to the excluding stomach followed by ERCP through the axios, biliary sphincterotomy, stone extraction, and 10 French × 9 cm biliary stent placement. EUS-Guided Cystogastrostomy A 35-year-old male with past medical history of alcohol abuse and acute pancreatitis presents as a transfer from a community hospital for management of necrotizing pancreatitis with walled off necrosis. CT scan of the abdomen/pelvis at the community hospital revealed a 13 cm fluid collection involving the body and tail of the pancreas. Plan: Given ongoing pain and early satiety, patient underwent an EUS-guided cystgastrostomy (Figs. 8.1 and 8.2).

136

C. Demone et al.

Fig. 8.1  EUS image: deployment of internal flange of lumen-apposing metal stent within wall-off necrosis collection. (©Haroon Shahid)

Fig. 8.2 Endoscopic image: after deployment of lumen-apposing metal stent—necrosis seen within the pancreatic fluid collection. (©Haroon Shahid)

EUS-Guided Hepaticogastrostomy A 78-year-old female with past medical history of dementia, history of DVT, and locally advanced gastric cancer s/p chemotherapy and subtotal gastrectomy with Roux-en-Y reconstruction presents with concern for recurrent gastric cancer causing biliary obstruction. She is jaundiced and unable to get chemotherapy given her elevated liver function tests. Plan: Given her postsurgical altered anatomy, it is decided the patient will undergo EUS-hepaticogastrostomy for biliary drainage rather than percutaneous drainage (Figs. 8.3, 8.4 and 8.5).

8  Case Studies Fig. 8.3  EUS image— dilated left intrahepatic duct. (©Haroon Shahid)

Fig. 8.4  EUS image— dilation of the fistula tract between stomach and left intrahepatic duct. (©Haroon Shahid)

Fig. 8.5 Endoscopy image—placement of hepaticogastrostomy stent. (©Haroon Shahid)

137

138

C. Demone et al.

EUS-Guided Gastrojejunostomy An 85-year-old female with history of coronary artery disease, atrial fibrillation, hypertension, diabetes mellitus, and dementia presents with gastric outlet obstruction due to a large ulcerated lesion in the duodenum concerning malignancy. Plan: Given underlying comorbidities, patient not a candidate for surgery. Therefore patient underwent an EUS-guided gastrojejunostomy for the gastric outlet obstruction (Figs. 8.6 and 8.7).

Fig. 8.6  EUS image of dilated jejunum after injection of normal saline. (©Haroon Shahid)

Fig. 8.7 Endoscopic image after lumen-­ apposing metal stent (LAMS) placement. Small bowel can be seen through the LAMS. (©Haroon Shahid)