Cases and Techniques Library (CTL) E217

Video 1 An alternative endoscopic treatment for massive gastric bezoars: Ho:YAG laser fragmentation

Gastrointestinal (GI) bezoars are aggre- gy (Lumenis VersaPulse PowerSuite 100W gates of indigestible material that occur lithotripter, 10 –30Hz, 3000mJ), resulting mainly in patients with altered GI anatomy in a shorter procedure time (24 minutes). (i.e. bariatric surgery, partial gastrectomy) In both procedures, complete bezoar frag- and/or motility disorders (i.e. gastro- mentation was achieved in a single endos- paresis, drug-induced delayed gastric copy session. Holmium:YAG laser treatment (frequency emptying). Other risk factors are high fiber No postprocedural complications were 4– 8Hz, pulse energy 2000 mJ) of a 10-cm intake, psychiatric diseases, and severe registered in the patients and they were phytobezoar in a 73-year-old man with Billroth I constipation [1]. discharged 1 day after the endoscopic anatomy (procedure time 60 minutes). Treatment strategies for bezoar fragmen- treatment. tation include pharmacological, endo- In conclusion, Ho:YAG laser fragmenta- scopic, and surgical approaches. Endo- tion represents a safe, effective, and rapid Video 2 scopic treatment of gastric bezoar consists endoscopic approach for the treatment of of attempted fragmentation by using dif- massive gastric bezoars. ferent devices such as snares, forceps, baskets, lithotripters, argon plasma coag- Endoscopy_UCTN_Code_TTT_1AO_2AL ulation, and needle-knife [2,3]. The use of a laser-ignited mini-explosive technique Competing interests: None with neodymium-doped yttrium alumi- nium garnet (Nd:YAG) laser has also been described [4]. To date, only one article Giuseppe Grande, Mauro Manno, from China (original language) has de- Claudio Zulli, Carmelo Barbera, scribed the use of holmium:YAG (Ho: Santi Mangiafico, Nadia Alberghina, YAG) laser lithotripsy in this field [5]. Rita Luisa Conigliaro Holmium:YAG laser treatment (Lumenis Versa- Pulse PowerSuite 100 W lithotripter, 10–30Hz, We present two video cases of massive Gastrointestinal Endoscopy Unit, NOCSAE gastric phytobezoar, which were irre- 3000 mJ) of an 8-cm phytobezoar in the proxi- Baggiovara Hospital, Modena, Italy mal gastric pouch of a 58-year-old woman with sponsive to pharmacological approaches a gastric band (procedure time 24 minutes). and were successfully treated with Ho: YAG laser (Lumenis Ltd., Yokneam, Israel). References The first patient was a 73-year-old man 1 Iwamuro M, Okada H, Matsueda K et al. Re- view of the diagnosis and management of with a history of Billroth I partial gastrec- Bibliography gastrointestinal bezoars. World J Gastro- DOI http://dx.doi.org/ tomy for gastric cancer, who had endo- intest Endosc 2015; 7: 336–345 scopic evidence of a massive, hard, phyto- 2 Kuo JY, Mo LR, Tsai CC et al. Nonoperative 10.1055/s-0042-109057 Endoscopy 2016; 48: E217 bezoar, 10cm in diameter (●" Video 1). The treatment of gastric bezoars using electro- © Georg Thieme Verlag KG phytobezoar was successfully treated with hydraulic lithotripsy. Endoscopy 1999: 31; 386–388 Stuttgart · New York 200 micron laser fiber (Lumenis Versa- 3 Iwamuro M, Tanaka S, Shiode J et al. Clinical ISSN 0013-726X Pulse P20 lithotripter, frequency 4–8Hz, characteristics and treatment outcomes of pulse energy 2000 mJ) The procedure nineteen Japanese patients with gastro- time was 60 minutes. intestinal bezoars. Intern Med 2014; 53: Corresponding author – Giuseppe Grande, MD The second patient was a 58-year-old 1099 1105 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 4 Mao Y, Qiu H, Liu Q et al. Endoscopic litho- Gastrointestinal Endoscopy Unit woman with a gastric band for treatment tripsy for gastric bezoars by Nd:YAG laser- NOCSAE Hospital of obesity, who showed a large phyto- ignited mini-explosive technique. Lasers via Pietro Giardini 1355 bezoar (8cm in diameter) in the proximal Med Sci 2014; 29: 1237–1240 Baggiovara di Modena 41126 Xu C Li PY Qin H gastric pouch (●" Video 2). In this case, we 5 , , et al. Curative effect of en- Italy doscopic holmium laser lithotripsy in man- used a 550 micron laser fiber, which Fax: +39-059-3961216 agement of gastric bezoars. World Chinese J [email protected] allowed the diffusion of higher pulse ener- Digestol 2015; 23: 3277

Grande Giuseppe et al. Endoscopic Ho:YAG laser fragmentation of massive gastric bezoars… Endoscopy 2016; 48: E217