Faculty Bibliography

Introduction: Metastases to the stomach from various primary malignancies is rare. Renal cell carcinoma (RCC) metastasis to the stomach is even more uncommon and should be suspected in patients complaining of the slightest of gastrointestinal symptoms. Here, we explore a rare case of gastric metastases from RCC, eleven years after radical nephrectomy diagnosed by endoscopy. Case Description/Methods: We report the case of a 71-year-old Hispanic female, medical history pertinent for RCC and left nephrectomy, who presented with persistent left lower quadrant abdominal pain and normal bloodwork. Repeat imaging reveals a gastric mass, unseen on CT scans 3 weeks prior (Figure a). Endoscopy (Figure b), histopathological findings, and immunohistochemical staining (Figure c) were consistent with metastatic RCC. Given the poor prognosis, patient chose to undergo targeted systemic chemotherapy.
Discussion(s): In the past two decades, there have been a limited number of case reports in the literature of RCC metastatic to the stomach (Table) Although gastric metastasis is a late finding in the course of renal malignancy, detection can come from a thorough evaluation of presenting symptoms followed by appropriate diagnostic imaging. Additionally, this case also emphasizes the need for targeted treatment modalities for patients with poor prognoses

Background: Lumen-apposing self-expandable metal stents (LAMS) have transformed the management of pancreatic fluid collections over the last two decades. There has since been significant interest in expanding the utility of LAMS for additional therapies such as the management of benign luminal strictures. However, there remains little data on their efficacy and safety when used for this indication. The goal of this study was to define the technical success, clinical success, and complication rates of LAMS when used in the management of benign strictures Methods: This was a retrospective multicenter evaluation of the safety, efficacy, and long-term clinical durability of LAMS in the treatment of benign strictures. The study took place between June 2018 and November 2019. Data collection included demographic information, indication, stent size, use of concurrent balloon dilation including dilation diameter, stent stabilization technique, intra-procedure and post-procedure complications, clinical improvement, and post-procedure follow up outcomes.
Result(s): 30 patients underwent placement of LAMS for a benign luminal stricture, with one having two stents placed during the index procedure at separate areas of stenoses resulting in a total of 31 stents placed. In total, 19 stents were 15 x 10 mm and 12 stents were 20 x 10 mm. No intra-procedural complications were noted. The technical success of deployment was 100%. Clinical resolution of symptoms was present in 25 (83%) patients. Of the patients who experienced clinical improvement, 17 underwent stent removal after an average of 6.4 weeks, and clinical recurrence occurred in 7 (41%) patients. The mean time to recurrence of symptoms after stent removal was 7 weeks. Univariate subgroup analysis revealed 15 x 10 mm stents were associated with clinical improvement (OR 12.86, 95% CI: 1.27-130.57, p 0.031). Each patient who did not clinically improve developed pain (3) or stent migration (2). In total 11 (37%) patients developed minor post-procedure adverse event. Stent migration was seen in 5 (17%) cases. Bleeding and pain were noted in 1 (3%) and 7 (23%) patients, respectively. Ulceration was found in 4 patients.
Conclusion(s): LAMS is a durable, safe option for patients with benign luminal strictures. Overall technical success was 100% and clinical success was 83%. The data also suggests better clinical outcomes with 15 x 10 mm stents, when compared to 20 x 10 mm stents. Pain is the most common adverse event but easily managed. [Formula presented]
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BACKGROUND:Heterotopic tissue can be found throughout the GI tract, most commonly being gastric tissue. The finding of ectopic salivary tissue located in the GI tract is an exceedingly rare finding. We present a case of an otherwise healthy 30-year-old male with rectal bleeding who underwent biopsy of a submucosal rectal lesion with pathologic findings of ectopic salivary gland tissue. CASE PRESENTATION/METHODS:Our patient is a 30-year-old male who presented with rectal bleeding. During his workup, he underwent colonoscopy and subsequent endoscopic ultrasound after discovery of a submucosal mass in the rectum measuring approximately 2 × 1 cm. Biopsies were sent which returned showing ectopic salivary gland tissue superimposed on hyperplastic rectal mucosa. The patient's symptoms resolved and he has not had recurrence of bleeding. CONCLUSIONS:Ectopic salivary gland tissue is a rare pathological finding in the rectum. It can present as a symptomatic lesion or be found incidentally. There is no clear reason for its presence, but it is felt to be due to metaplasia, developmental anomalies, or idiopathic in nature. Treatment includes excision and monitoring.

BACKGROUND:To assess the safety and efficacy of the Instinct clip in the acute endoscopic treatment of upper gastrointestinal bleeding (UGIB). MATERIALS AND METHODS/METHODS:This is the first large series reporting this clip in achieving hemostasis. A retrospective descriptive chart review was performed on patients presenting with recent overt GI bleeding treated with endoclip therapy at Mount Sinai Beth Israel Medical Center between May 2013 and January 2016. Results are expressed in absolute numbers, percentages, and trends. RESULTS:In total, 178 consecutive patients with UGIB were included. Source of bleeding was identified as duodenal ulcer (29.2%), gastric ulcer (22.5%), gastro-esophageal junction tear (8.4%), anastomosis (5.6%), erosive gastropathy (5.6%), Dieulafoy (5.1%), gastric polyp (4.5%), postendoscopic procedure (3.9%), angioectasia (3.4%), esophageal ulcer (2.8%), benign duodenal mass (2.8%), peg tube site (2.3%), gastric neoplasm (1.7%), esophagitis (1.1%), and small bowel ulcer (1.1%). Lesions demonstrated active bleeding in 47.5% (11.3% spurting and 36.2% oozing) and nonbleeding lesions in 52.5% (25.0% visible vessel, 11.9% hematin in ulcer base, 10.0% adherent clot, 5.6% flat spot). Initial hemostasis was achieved in 96.6%. Additional methods were used in 24.1% (argon plasma coagulation and epinephrine injection in 21.3%, surgery in 0.6%, and interventional radiology in 2.2%). There were no adverse events. In-hospital rebleeding was 7.3% and 3.9% presented with rebleeding within 30 days. Average procedure duration was 22.9 minutes and average length of hospital stay was 11.3 days. CONCLUSIONS:The Instinct clip, when used for UGIB, seems to be safe and effective with similar rebleeding rates compared with other modalities.

BACKGROUND AND AIMS/OBJECTIVE:Gastric per-oral endoscopic myotomy (G-POEM) recently has been reported as minimally invasive therapy for gastroparesis. The aims of this study were to report on the first multicenter experience with G-POEM and to assess the efficacy and safety of this novel procedure for patients with gastroparesis with symptoms refractory to medical therapy. METHODS:All patients with gastroparesis who underwent endoscopic pyloromyotomy (G-POEM) at 5 medical centers were included. Procedures were performed following the same principles as esophageal POEM. Clinical response was defined as improvement in gastroparetic symptoms with absence of recurrent hospitalization. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS:A total of 30 patients with refractory gastroparesis (11 diabetic, 12 postsurgical, 7 idiopathic) underwent G-POEM. Previous therapies included Botox injection in 12, transpyloric stenting in 3, and PEG with jejunal extension (PEGJ) in 1. Nausea/vomiting were the predominant symptoms in 25 patients. Weight loss was present in 27 patients with an average of 10% loss of body weight. G-POEM was completed successfully in all 30 (100%) patients with a mean procedure time of 72 minutes (range, 35-223 min). The mean myotomy length was 2.6 ± 2.3 cm. The mean length of hospital stay was 3.3 days (range, 1-12 days). Two adverse events occurred in 2 (6.7%) patients, including 1 capnoperitoneum and 1 prepyloric ulcer, rated as mild and severe, respectively. Clinical response was observed in 26 (86%) patients during a median follow-up of 5.5 months. Four patients (2 diabetic, 1 postsurgical, 1 idiopathic cause) did not respond to G-POEM. Repeat gastric emptying scan was obtained in 17 patients, normalized in 8 (47%), and improved in 6 (35%) patients. CONCLUSION/CONCLUSIONS:G-POEM is a technically feasible procedure. This small non-randomized study suggests the effectiveness of G-POEM for the treatment of patients with gastroparesis refractory to medical therapy. It concomitantly results in normalization of GES in a significant proportion of treated patients.