Introduction: The intragastric balloon (IGB) is a non- surgical, short-term method for treatment of obesity. It functions by reducing the stomach’s capacity, thereby restricting food intake, and promoting early satiety. It is designed to remain tin the stomach for a limited period, ranging from a few months to one year, after which it is removed. Although less invasive than bariatric surgery, IGB insertion via endoscopy may lead to life threatening complications. These include gastric perforation, intestinal obstruction secondary to migration and in rare cases acute pancreatitis. Case Description/Methods: We describe a case of a 22-year-old woman with past medical history significant for obesity (BMI 33) and appendectomy who presented with severe epigastric pain, nausea, and vomiting 3 months after intragastric balloon insertion completed in a foreign country. Serum lipase was elevated to 2624 U/L (normal 73-393 U/L) and Computerized tomography (CT) abdomen and pelvis demonstrated stranding posterior to the pancreas without evidence of fluid collection or necrosis and a large IGB in the stomach without obstruction (Figure 1). She was initially treated conservatively with intravenous fluids, nil per os and pain control medication. When her symptoms failed to respond after 6 days of management, the balloon was deflated and removed via endoscopy. She was immediately able to tolerate a diet of liquids and solids and was discharged the following day from the hospital. Discussion: We describe a case of an intragastric balloon causing the rare complication of acute pancreatitis and the treatment of the condition with endoscopic removal. The pathogenesis of this complication has not been conclusively defined. It may be due to extrinsic compression of the body and tail of the pancreas by a dilated stomach containing the IGB, leading to mechanical trauma and inflammation. This is the first case report describing this complication in the silicone- based 350cc Silimed gastric balloon (Silimed Industria de Implantes Ltda Rio de Janeiro, Brazil). It serves as a reminder that patients with a history of intragastric balloon insertion and symptoms of epigastric pain, nausea and vomiting should be evaluated for pancreatitis and removal of IGB via endoscopy for resolution of their symptoms. Further research and surveillance are warranted to better understand the mechanisms and risk factors associated with this rare complication.Figure 1.: CT abdomen pelvis with contrast of intragastric balloon without obstruction in addition to stranding posterior to the pancreas extending inferiorly along the retroperitoneum and root of mesentery; and compression of the splenic vein likely due to the inflamed pancreas. Measurement of intragastric balloon was 10.0 x 8.0 x 9.9 cm.

Rishabh Khatri: NO financial relationship with a commercial interest | Jay Patel: NO financial relationship with a commercial interest | Jun Song: NO financial relationship with a commercial interest | Zachary Jurkowski: NO financial relationship with a commercial interest | Neil Nadpara: NO financial relationship with a commercial interest | Tiffany Lambrou: NO financial relationship with a commercial interest | Marlana Radcliffe: NO financial relationship with a commercial interest | Kamal Baig: NO financial relationship with a commercial interest | Woo Jung Lee: YES financial relationship with a commercial interest;Olympus:Consulting | Saraswathi Cappelle: NO financial relationship with a commercial interest | Stephen Heller: YES financial relationship with a commercial interest;Olympus:Consulting | Frank Friedenberg: NO financial relationship with a commercial interest

Introduction: Intrapancreatic accessory spleen (IPAS) is a congenital focus of healthy splenic tissue present outside of the splenic parenchyma. There are numerous locations for IPAS and they are usually found incidentally. The location of ectopic splenic tissue is important as it can often mimic as a neoplasm, most commonly neuroendocrine tumor (NET) due to similar imaging characteristics on nuclear imaging and computed tomography (CT) scan. We report on the finding of an IPAS in the tail of the pancreas for which fine needle aspiration was performed. Patient concerns: A 66-year-old man with past medical history of prostate cancer managed with brachytherapy presented to his urologist for workup of persistently elevated prostate specific antigen. He underwent a nuclear medicine whole body scan which revealed uptake in the pancreatic tail for which follow up CT was recommended. The patient was seen by the gastroenterology and a CT scan was obtained. CT revealed a 4 cm × 3 cm isoenhancing mass in the tail of the pancreas without invasion to surrounding structures nor communication with the pancreatic ducts. No lymphadenopathy was noted. Intervention: The patient subsequently underwent endoscopic ultrasound (EUS) with fine needle aspiration (FNA) of the mass. EUS revealed a hypoechoic, oval, mass-like structure in the distal pancreatic tail measuring ~20 mm × 20 mm in maximal cross-sectional diameter. FNA of the mass was performed. Diagnosis: Cytopathology of the specimen revealed small mature lymphocytes and vessels suggestive of IPAS. Outcome: The patient remained asymptomatic through the duration of the workup. Lessons: All enhancing pancreatic lesions require further workup to rule out malignancy. Typically, patients undergo scintigraphy for further evaluation or FNA biopsy via EUS for confirmation. Currently, there are no established serum markers or radiographic findings with adequate specificity for diagnosing IPAS. It is important to recognize the impact of incidental findings as they frequently require further testing and often result in procedural intervention. IPAS is often confused with NET, frequently necessitating tissue sampling. While the prevalence of intrapancreatic accessory spleen is higher than initially thought, contrary to NET it carries no inherent risk unless its location compromises vital structures. This highlights the importance of recognizing this anomaly.

INTRODUCTION: Colonic polypectomy (CP) is performed to remove precancerous or early cancerous polyps to decrease the risk of invasive colon cancer. The primary complications of CP are post-polypectomy bleeding and perforation. In the hope of decreasing the incidence of these complications, endoscopists may deploy temporary endoscopic clips at the CP site. However, data supporting the efficacy of this practice is mixed and clips are very expensive ranging $150–$200 per clip. The aims of this study were to investigate patterns of endoscopic clip placement at our institution and to assess factors which influence the placement of clips. METHODS: Retrospective analysis evaluated 3,283 CPs at our institution from 1/1/2019 to 12/31/2019. Variables recorded included polyp size, location, method of polyp removal, and antiplatelet use. In addition, the training level of the attending (general vs advanced) was noted as well as time of day (AM vs PM), presence of a fellow, and day of week. RESULTS: Among the 3,283 CPs analyzed, male patients comprised 50.4% of the cases, mean age 62.2y. Mean polyp size was 6 mm (range 1-40 mm). 40.7% of polyps were right sided. Overall, in 215 (6.5%) CPs a clip was placed. On univariate analysis only polyp size, method of removal (forceps v. cold snare v. hot snare v. mucosal lift endoscopic mucosal resection (EMR)), and role as an advanced endoscopist (9.8 v. 5.6% of cases) were associated with clip placement. However, on multivariate analysis there was no association with patient age, gender, presence of a fellow, anti-platelet use, location of polyp, day of the week, or time of day. Logistic regression modeling revealed that for each 1 mm increase in polyp size, OR = 1.18 (1.13- 1.23) for clip placement. Method of removal was highly associated with clip placement using forceps removal as the reference method; (cold snare, OR = 2.7 (1.5–4.7), hot snare, OR = 3.1 (1.6–6.0), mucosal lift EMR, OR = 16.2 (7.7–34.0)). Advanced endoscopist status was not associated with clip placement; OR = 1.4 (0.9–2.0). CONCLUSION: Increased polyp size and method of removal are significantly associated with clip placement. This makes sense in that the risk of injuring a submucosal artery is increased when a large amount of tissue is removed. Location of polyp, day of the week, anti-platelet use and advanced endoscopist status were not associated with clip placement.

INTRODUCTION: Subepithelial lesions (SELs) are a group of heterogenous tumors arising from layers below the gastrointestinal (GI) mucosa and are a common incidental finding on upper endoscopy. Although fewer than 15% of SELs are malignant, accurate diagnosis is essential to identify tumors that will need definitive management. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is an established technique frequently used to sample SELs, but diagnosis can still remain elusive in many instances. We present a case of a large gastric SEL where single incision needle knife (SINK) biopsy successfully produced a histopathologic diagnosis after multiple failed attempts with EUS-FNA. CASE DESCRIPTION/METHODS: A 66-year-old woman with epigastric pain, weight loss and early satiety underwent CT imaging that showed a 4.5 cm exophytic gastric mass. Initial EUS revealed a subepithelial, hypoechoic lesion with smooth borders and intraluminal convexity along the greater curvature of the stomach. It originated from the muscularis propria and measured 27 mm in depth. Two attempts with EUS-FNA at an outside hospital were non-diagnostic. At our center, EUS-FNA involving multiple passes with 22 and 25-gauge needles was also inconclusive. EUS was then repeated using the SINK biopsy technique. After exclusion of overlying vasculature and circumferential epinephrine injection, a 10 × 5 mm (length x depth) needle knife incision was made at the area of highest convexity over the lesion. A biopsy forceps was inserted into the defect for direct tissue sampling. Minor bleeding post-biopsy was treated with additional epinephrine and two hemostatic clips. A histologic diagnosis of GIST was made and the patient was referred for surgical resection as definitive management. DISCUSSION: This case highlights the limitations of EUS-FNA, while also providing further evidence to support SINK biopsy as a safe and effective technique. The reported yield for histologic diagnosis in upper GI SELs using SINK biopsy is between 81% and 92%. In cases with failed conventional biopsy or EUS-FNA, subsequent SINK biopsy has success rates ranging from 75% to 92%. No instances of perforation have been reported with SINK biopsy. As current ASGE guidelines do not endorse a standard biopsy method, the increased diagnostic yield and strong safety profile of SINK biopsy performed by experienced endoscopists suggests it should be the preferred technique over repeated EUS-FNA in cases of SELs with intraluminal convexity and prior non-diagnostic sampling.Figure 1.: Endoscopic Ultrasound (EUS) image of large gastric (greater curvature) subepithelial lesion arising from the muscularis propria with intraluminal convexity.Figure 2.: 10 × 5 mm (length x depth) incision of overlying mucosa using needle knife (Endo Cut).Figure 3.: Histology of sample obtained by SINK biopsy showing (A) proliferative and atypical spindle cells (hematoxylin and eosin, 20x), (B) positive DOG-1 staining (20x) and (C) positive C-KIT staining (20x).

Introduction: Esophagectomy following neoadjuvant chemoradiation therapy is the standard of care for locally advanced and node-positive esophageal cancer. Approximately one third of patients have no residual esophageal cancer at the time of esophagectomy.Aim: Investigate the outcome of patients who refused to undergo esophagectomy following complete clinical response of esophageal cancer. Methods: We retrospectively evaluated consecutive patients who underwent upper endoscopies and cross sectional imaging following neoadjuvant treatment for esophageal cancer at a tertiary cancer center between 2011 and 2017. Of 247 patients who underwent neoadjuvant treatment (mostly 50.4 Gy radiation dose and Paclitaxel/Carboplatin based chemotherapy), we included all patients (n=13) with complete clinical response of esophageal cancer, defined as absence of cancer on upper endoscopy with bite-on-bite biopsies and cross sectional imaging, whereas all other patients were excluded (progression and no surgery 98; in/complete response and had esophagectomy 100, lost to follow-up 36). Data was abstracted by chart review. The main outcome was the cancer free survival and the incidence rate of recurrent esophageal cancer. Results: 13 patients (mean age 71 years, SD 7, 85% male, mean Charlson comorbidity index 6) underwent surveillance following complete clinical response of esophageal cancer (10 adeno, 3 squamous cell cancer). Cancer stages included 1A (n=6), 2A (n=1); 2b (n=4), 3c (n=1), and 4 (n=1). Median follow-up was 40 months and included a median of 4 upper endoscopies and 4 PET CT scans per patient. 4 patients developed recurrent dysplasia during follow-up, including 1 patient with high-grade dysplasia, which were all treated endoscopically with a total of 3 endoscopic mucosal resection, 3 cryoablation and 1 radiofrequency ablation session, which all resulted eventually in complete remission of intestinal metaplasia. One patient developed recurrent cancer manifested as metastatic paratracheal lymph node 16 months following completion of neoadjuvant therapy. Calculated cancer incident rate was 1 case in 502 patient months. Limitations: retrospective, small sample size, single center experience Conclusion: In agreement with limited data most patients with complete clinical response of esophageal cancer following neoadjuvant therapy have acceptable survival rate. All patients with recurrent dysplasia were treated successfully with endoscopic measures and avoided esophagectomy.