transfusion via one of the lumina of the catheter.The anes-thetist who had placed the catheter did not notice any ab-normalities during the procedure,and there were neither signs of spontaneous upper GI bleeding despite the connec-tion between the superior caval vein and the esophagus before blood transfusion nor any signs of infection.
Further convalescence of the patient was uneventful,and 2weeks after cardiovascular surgery,he left the hos-pital in good condition for further rehabilitation.DISCLOSURE
The authors disclosed no financial relationships rele-vant to this publication.
REFERENCES
1.Chen CY,Chen KY,Taso SL,et al.Perforation of the right innominate vein by pulmonary artery catheter introducer sheath:a case report.J Clin Anesth 2009;21:206-8.
2.Bossert T,Gummert JF,Bittner HB,et al.Swan-Ganz catheter-induced severe complications in cardiac surgery:right ventricular perforation,knotting,and rupture of a pulmonary artery.J Card Surg 2006;21:292-5.
3.Procaccini B,Clementi G.Pulmonary artery catheterization in 9071car-diac surgery patients:a review
of complications.Ital Heart J 2004;5(Suppl)5:891-9.
4.Harvey S,Harrison DA,Singer M,et al,PAC-Man Study Collaboration.Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man):a randomised con-trolled trial.Lancet 2005;366:472-7.
Department of Internal Medicine,Albertinenkrankenhaus Hamburg,Ham-burg,Germany.
Reprint requests:Guntram Lock,MD,Department of Internal Medicine,Al-bertinenkrankenhaus,Süntelstr.11a,D-22457Hamburg,Germany.Copyright ©2012by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00
doi:10.1016/j.gie.2011.02.006
Fully endoscopic removal of migrated mesh after laparoscopic fundoplication
the gastroesophageal junction:a case report (with video)
Gianfranco Donatelli,Dallemagne,MD,Silvana Perretta,MD,Parag Dhumane,MD,Jacques Marescaux,MD,FRCS,FACS Strasbourg,France
Diaphragmatic crural mesh reinforcement signifi-cantly reduces recurrence after laparoscopic hiatal her-nia repair.1Complications,including esophageal mesh erosion and stenosis requiring surgical resection,are known.Endoscopic removal of migrated intraluminal mesh has been described.2We report the successful endoscopic retrieval of migrated intraluminal mesh fol-lowed by stenting.
CASE REPORT
A 70-year-old man presented with new-onset dyspha-gia and weight loss 7months after Nissen-Rossetti fun-doplication with crural mesh repair (Parietex;Covidien-Sofradim,Trevoux,France)for hiatal hernia.Endoscopy showed mesh eroding into the lower esophageal wall at the gastroesophageal junction.The mesh could not be ablated with argon plasma coagulation.A CT scan re-vealed a small cavity lateral to the gastroesophageal junction.At our center,using a single-channel endo-scope,after an initial unsuccessful attempt with argon plasma coagulation,we grasped the mesh with foreign-body forceps,partially cut with a polypectomy snare,and completely removed it in 2parts by exerting trac-tion and cutting the sutures with endoscopic scissors (Fig.1)(Video 1,available online at )
.Fluoroscopy showed a small,contained per-iesophageal cavity with hiatal hernia (Fig.2).A 12cm ϫ22-mm covered self-expandable metal stent (SEMS)with an antireflux valve (HANAROSTENT;Life Partner Eu-rope,Bagnolet,France)was placed to bypass the cavity and prevent stenosis.After a swallow study the follow-ing day (Fig.3),the patient resumed a liquid diet.Five weeks later,at SEMS removal,endoscopy showed de-creased cavity volume.A similar SEMS was placed again for 5additional weeks.At SEMS removal,there was no stricture and no residual cavity.The patient was symp-tom free at 3-month follow-up.
DISCUSSION
Of prosthetic hiatal hernia repairs,2.3%have mesh erosion,3mainly because of infection,ischemia,and friction between the mesh and the esophagus.Biologi-Brief Reports
Volume 75,No.2:2012GASTROINTESTINAL ENDOSCOPY 455
cal meshes can alternatively be used to decrease erosion risk.4An eroded mesh needs surgical excision with or without esophagectomy or gastrectomy.Use of a stent to cover the migrated-eroded m
esh after failed endo-scopic removal was reported.5We demonstrate that endoscopic removal can be more aggressively used in such cases if it is combined with antireflux stent place-ment,allowing rapid patient recovery and excellent long-term results without major surgery.SEMS migra-tion is expected to be minimal because of a physiolog-ical high-pressure zone at the lower esophageal sphinc-ter after fundoplication.Difficulty in SEMS removal because of mucosal ingrowth can be avoided by keep-ing the SEMS in place for a maximum of 5weeks.
CONCLUSION
Prosthetic reconstruction of the hiatus should be con-sidered with extreme caution,given the known rate of erosion.Total endoscopic removal is a promising modality to treat intraesophageal mesh migration.SEMS placement may improve the outcome of organ-sparing endoscopic management of this complication.DISCLOSURE
The authors disclosed no financial relationships rele-vant to this publication.
Abbreviation:SEMS,self-expandable metal stent.
REFERENCES
1.Dallemagne B,Kohnen L,Perretta S,et al.Laparoscopic repair of para-esophageal hernia:long-term follow-up reveals good clinical outcome despite high radiological recurrence rate.Ann Surg 2011;253:291-6.
2.Rumstadt B,Kähler G,Mickisch O,et al.Gastric mesh erosion after hiato-plasty for recurrent paraesophageal hernia.Endoscopy 2008;40:E70.
3.Targarona EM,Bendahan G,Balague C,et al.Mesh in the hiatus:a contro-versial issue.Arch Surg 2004;139:1286-96;discussion 1296.
4.Sheff SR,Kothari SN.Repair of the giant hiatal hernia.J Long Term Eff Med Implants
2010;20:139-48.
Figure 2.Fluoroscopy revealed a hiatal hernia,and a right-sided 3ϫ4-cm subdiaphragmatic cavity without communication with the medias-tinum or the peritoneal
space.
Figure 1.A c omplete specimen of the hiatal mesh (in 2pieces)and the suture material removed endoscopically are shown.Small holes caused by argon plasma coagulation can be seen on left
side.
Figure 3.Upper GI contrast study on day 1after placement of the first SEMS demonstrating excellent transit of contrast into stomach and com-plete exclusion of the perioesophageal cavity with the SEMS in place.
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456GASTROINTESTINAL ENDOSCOPY Volume 75,No.2:2012
5.Griffith PS,Valenti V,Qurashi K,et al.Rejection of goretex mesh used in prosthetic curoplasty:a case series.Int J Surg 2008;6:106-9.
IRCAD/EITS,Department of Gastrointestinal and Endocrine Surgery,Univer-sity of Strasbourg,Strasbourg,France.
Reprint requests:Gianfranco Donatelli,MD,IRCAD/EITS,Department of Gas-trointestinal and Endocrine Surgery,University of Strasbourg;1,Place de l’hopital -F-67091.Strasbourg,France.
Copyright ©2012by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00
doi:10.1016/j.gie.2011.04.007
Endoscopic full-thickness resection of a gastric subepithelial tumor by using the submucosal tunnel
with the patient under conscious sedation (with video)
Chang Kyun Lee,MD,Suck-Ho Lee,MD ,MD,Tae Hoon Lee,MD,Sang-Heum Park,MD,Eun Ok Kim,RN,Myung Soon Chung,RN,Hyun Deuk Cho,MD,Sun-Joo Kim,MD Cheonan,Korea
Recently,several investigators have reported the feasibility of endoscopic full-thickness resection (EFTR)of gastric lesions with a hybrid technique involv-ing laparoscopic assistance and general anesthesia in humans.1-3Here,we present a case of EFTR by using the submucosal tunnel technique in a patient with a gastric subepithelial tumor,with the patient under conscious sedation.
CASE REPORT
A 47-year-old woman was referred to our hospital for evaluation of a gastric subepithelial tumor.EUS re-vealed a 16.0ϫ11.2–mm,intraluminal growing,heter-ogeneous,hypoechoic mass originating from the mus-cularis propria.We planned an EFTR of the lesion for the dual purpose of obtaining a histopathological diag-nosis and performing definite treatment.The institu-tional review board approved the human trial,and in-formed consent was obtained from the patient.
All procedures were performed with the patient un-der sedation with midazolam and propofol in the en-doscopy unit.Aseptic preparation and prophylaxis with broad-spectrum antibiotics were carried out.The pro-cedure was done by using a cap-fitted therapeutic gas-troscope (GIF-Q260J,D-201-11804;Olympus,Tokyo,Japan),with room-air insufflation after gastric lavage (Fig.1;Video 1,available online at ).1After submucosal injection of a hyaluronic acid mixture,a 20-mm transverse incision was made by using a flex knife (KD-630L;Olympus).2A 40-mm submucosal tunnel was created by using the endoscopic submucosal dissection (ESD)technique.3After the endoscope reached the tumor,a small puncture was made in the
uneventful
proximal seromuscular layer of the tumor.4A full-thickness incision around three-fourths of the circum-ference of the tumor was made by using an IT-2knife (KD-611L;Olympus).5Then,the tumor was resected with a snare,and it was suctioned into the cap.6The mucosal defect in the tunnel was closed
successfully by using the endoloop-clips technique,by using a two-channel gastroscope (GIF-2TQ260M;Olympus).4
The retrieved specimen was identified as a gastric schwannoma.On the second hospital day,the luminal patency of the stomach was confirmed in an EGD and water-soluble contrast study,and the patient was dis-charged the following day.
DISCUSSION
This case clearly demonstrated that EFTR by using the submucosal tunnel technique enables the en bloc,whole-layer resection of gastric subepithelial tumors without laparoscopic assistance.All procedures can be performed with the patient under procedural sedation in an endos-copy unit,as in our previous report.5The submucosal tunnel technique was originally described by Sumiyama et al 6as a method for obtaining safe access and closure.Our experience suggests that the submucosal tunnel is a novel route for the diagnosis and treatment of subepithe-lial tumors.The essential element of our method is suffi-cient exposure of the intraluminal side of the tumor within the submucosal tunnel with ESD.This allows endoscopic visibility for the following two critical steps,thereby avoid-ing accidental injury to adjacent viscera:the full-thickness incision of the seromuscular layer and the final tumor resection with a snare.However,our technique appears to
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Volume 75,No.2:2012GASTROINTESTINAL ENDOSCOPY 457

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