1. Advanced Endoscopy Techniques Jayant P.Talreja, M.D. Gastrointestinal Specialists, Inc. Bon Secours St. Mary’s Hospital

2. How We Do It

3. Procedural Details Fiducials placed at time of outpatient staging EUS in anticipation of XRT Fiducials placed at time of outpatient staging EUS in anticipation of XRT Demarcate proximal/distal borders Demarcate proximal/distal borders 2 linear gold fiducials (0.35 mm x 1.0 cm) preloaded separately into one 22 ga FNA exchangeable needle with delivery system and one single 22g FNA needle 2 linear gold fiducials (0.35 mm x 1.0 cm) preloaded separately into one 22 ga FNA exchangeable needle with delivery system and one single 22g FNA needle Fig 1: Preloaded FNA platform with fiducials (inset: magnified view of fiducial)

4. Key Features of Procedure Total delivery time 4-6 minutes Total delivery time 4-6 minutes Exchangeable needles allow for rapid and accurate deployment without scope/catheter repositioning Exchangeable needles allow for rapid and accurate deployment without scope/catheter repositioning Preloading multiple sterile needles ensures clinical staff safety by avoiding sequential loading of “dirty” needles Preloading multiple sterile needles ensures clinical staff safety by avoiding sequential loading of “dirty” needles

5. Obstructing Cancer Obstructing esophageal cancer may preclude EUS delivery Obstructing esophageal cancer may preclude EUS delivery This requires direct visualized delivery with fluoroscopic guidance This requires direct visualized delivery with fluoroscopic guidance

11. Baseline Characteristics Characteristic Total No. patients 31 Age, y (mean [range]) 63 [41 – 79] Gender 20 male (67%) Type (no. [%])  Adenocarcinoma  Squamous Cell Carcinoma 24 (77%) 7 (23%) Location of Tumor  Mid esophagus  Distal esophagus / GEJ  Gastric involvement 5 (17%) 18 (56%) 8 (28%) Obstruction Preventing Echoendoscope Passage 6 (22%) Number of Fiducials Placed (mean)  Proximal/Superior Border  Distal/Inferior Border 1.2 [1-2] 1.3 [1-2] GA or IVCS 19 IVCS (61%)

12. Procedural Characteristics Characteristic Immediate Complications (pain, bleeding, perforation requiring admission) 0/31 (0%) Delayed Complications (procedure related admission within 30 days) 0/31 (0%) Technical Success (both distal/proximal fiducials placed) 30/31 (97%) Time for Fiducial Placement (mean) Time for Fiducial Placement (mean, per fiducial) 5.6 min (2 min – 28 min) 2.8 min (1.7 min – 6.5 min)

13. Fiducials & XRT Planning Characteristic Fiducial Retention at Time of XRT Simulation 72/75 (96%) Fiducial Retention at Completion of XRT30/32 (94%) Fiducial Alignment with FDG activity on PET, superior (max tolerance 5 mm) 31/35 (89%) Fiducial Alignment with FDG activity on PET, inferior (max tolerance 5 mm) 33/40 (83%)

14. Summary Fiducials potentially enhance accuracy and precision of tumor delineation, thereby enhancing planning and delivery of XRT Fiducials potentially enhance accuracy and precision of tumor delineation, thereby enhancing planning and delivery of XRT No extra procedure- done at staging EUS No extra procedure- done at staging EUS Minimal extra time, particularly using multiple preloaded exchangeable needles Minimal extra time, particularly using multiple preloaded exchangeable needles Fiducials for esophageal cancer has high technical success rate and is safe Fiducials for esophageal cancer has high technical success rate and is safe Similar success and feasibility with rectal lesions Similar success and feasibility with rectal lesions

15. Case Presentation PATIENT: HM MRN: 28208668 HPI: 40yM history of laparoscopic sleeve gastrectomy on 4/22/13 40yM history of laparoscopic sleeve gastrectomy on 4/22/13 Post-op UGI series showed a leak proximal to stomach body with pooling in LUQ Post-op UGI series showed a leak proximal to stomach body with pooling in LUQ Returned to OR on 4/27/13 – found to have old clot in upper abdomen 1 cm distal to esophagus on left side of pouch along seamguard line – irrigated and suctioned, not patched or oversewn. Returned to OR on 4/27/13 – found to have old clot in upper abdomen 1 cm distal to esophagus on left side of pouch along seamguard line – irrigated and suctioned, not patched or oversewn. CT 5/8 showed 4 X 6 cm foci of gas near suture line. CT 5/8 showed 4 X 6 cm foci of gas near suture line. 5/9 an 8 Fr drain was placed in the fluid collection producing 40cc of purulent bloody fluid/gas 5/9 an 8 Fr drain was placed in the fluid collection producing 40cc of purulent bloody fluid/gas CT 5/13 showed decrease in size of collection. CT 5/13 showed decrease in size of collection. Transferred to BWH for endoscopic management of sleeve gastrectomy leak Transferred to BWH for endoscopic management of sleeve gastrectomy leak On broad spectrum antibiotics and receiving J tube feeding On broad spectrum antibiotics and receiving J tube feeding

16. Case Presentation EGD 5/20/13: Sleeve gastrectomy anatomy Instilled sterile saline colored with methylene blue through the previously placed percutaneous drain Contrast filled fundus but did not extravasate Blue saline was seen entering the cardia Gastric fistula at cardia about 1 cm below Z-line on the suture line

17. Case Presentation EGD 5/20/13: Abraded the aperture of the fistula with a cytology brush One Aponos over the scope padlock clip was successfully placed Limited contrast injection confirmed proper placement and no contrast extravasation was seen.

18. Case Presentation UGI Series 5/21: Persistent fistula between the gastric cardia and the perigastric abscess. The fistulous track appears to be just inferior to the new clip

19. Case Presentation EGD 5/22/13: Previously placed Aponos clip in place No evidence of contrast extravasation Entire gastric pouch filled with contrast