the gastroscope, verifying a perforation. It was possible to pass the gastroscopeoutside the duodenum into the subomental area under the liver. The gastroscopewas retrieved and passed down the real duodenal lumen. A guide wire wasplaced into the distal portion of the duodenum. A 9 cm partially coveredduodenal stent (Hanarostent, M.I Tech, Korea) was placed over the wire,through the scope with the covered portion reaching into the stomach. No airbubbles were seen at laparoscopy, indicating sealing of the perforation. Anabdominal drain was placed. We believe that covered metal stents can be usedas a treatment alternative for perforated duodenal ulcers, especially in patientswith comorbidities. This treatment option has recently been used in severalpatients at our department with good results. Simultaneous drainage of theabdominal cavity at the site of leakage seems to be crucial in most cases. Stenttreatment together with percutaneous drainage may even be a future alternativeto surgery in all patients with perforated duodenal ulcers.

Sp711Emergency Endoscopic Diagnosis and Hemostasis for DelayedBleeding of Submucosal Tunnel after Peroral EndoscopicMyotomy (POEM)Quan-Lin Li*, Ping-hong Zhou, Li-Qing YaoPostoperative delayed bleeding of submucosal tunnel is a rare complication afterperoral endoscopic myotomy (POEM) for esophageal achalasia. However, onceit occurs it can be fatal. Thus, early diagnosis and managements are most criticalfor patient outcome. Here, we showed emergency endoscopic diagnosis andhemostasis for delayed bleeding of submucosal tunnel after POEM in a 25-year-old male. This patient did not have any coagulation disorder before POEM andunderwent POEM successfully. After discharge, he complained of progressiveserious retrosternal pain from the first day after surgery and also suddenly hadvomiting of fresh blood on the third day. Emergency gastroscopy was performedimmediately for exploration. Hematoma was found along the submucosal tunneland the covering mucosa was very swelling. After removing the metal clips ofmucosal entry, a large number of blood clots were discovered in the submucosaltunnel, and were removed. The active bleeding points were identified andcoagulated with hemostatic forceps. However, on the third day after firstendoscopic hemostasis, there was major blood drainage from nasogastric tuble.A Sengstaken–Blakemore tube was placed into the stomach and lower part ofthe esophagus to compress the bleeding spot. Intermittence deflation of theballoons was done every 24 hours. The gastric balloon of Sengstaken–Blakemoretube was finally deflated on the first day after placement, and the esophagealballoon was finally released on the second day. Successful hemostasis wasachieved and no blood transfusion was necessary. This case may provide a

better understanding of delayed bleeding after POEM with an emphasis on itsearly features and effective managements. Vomiting of fresh blood andprogressive serious retrosternal pain were the major early manifestations inpatients with delayed bleeding of submucosal tunnel. Emergency endoscopicdiagnosis and hemostasis should be taken as early as possible. It should beworth mentioning that a Sengstaken–Blakemore tube is particularly effective forhemostasis by compression.

Sp712Two Hands do More Than One: Controllable Traction toFacilitate Safety And Efficacy of ESD in Porcine ModelHyunsoo Chung*, Bernard Dallemagne, Keng-Hao Liu, Michele Diana,Silvana Perretta, Yoshihiro Nagao, Jacques MarescauxColorectal endoscopic submucosal dissection (ESD) is technically morechallenging than gastric ESD and results in a higher perforation rate (5-20%).Consequently, this technique is not yetwidely performed. Proper traction toimprove the dissection plane may allow for an easier and safer colorectal ESD.Several traction methods have been reported, but most of them cannot controlthe direction and strength of the traction intraoperatively. ESD with a newtraction method using a steerable grasper may overcome this issue. The aim ofthis randomized animal study was to compare steerable grasper ESD (SG-ESD)with conventional ESD (C-ESD) in the porcine colon. A single-channelgastroscope with a transparent cap were used. ESDs were performed at 20, 27,34 and/or 40cm from the anus (3-4 ESDs/pig). ESD steps included the following:1) marking; 2) submucosal injection and circumferential mucosal incision (pre-cut), and 3) submucosal dissection. In the SG-ESD group, the 3.7mm diametersteerable grasper with 2-directional 100-degree bending distal end was used tograb and lift up the edge of the incised mucosa to expose the dissection plane.During ESD, the strength and the direction of traction were changed to get theefficient traction and the optimal dissection plane by pushing, pulling, rotatingand bending the steerable grasper. A total of 28 ESDs were performed in 8 pigs(14 ESDs in each group). Mean specimen size was 1320.0 � 207.8 vs. 1251.8 �183.3mm2 (p�ns), mean total procedure time was 63.9 � 10.0 vs. 42.8 � 7.8min (p�0.021), and mean dissection speed was 22.0 � 6.0 vs. 39.7 � 12.4mm2/min (p�0.031) in the C-ESD and SG-ESD group respectively. Perforation rate ofC-ESD group was 28.6% (4/14) whereas no perforation occurred in SG-ESDgroup. All perforations in the C-ESD group occurred at proximal sites such as 34and 40cm. In conclusion, controllable traction ensured faster and safer colonicESD in the porcine model. We expect this method could reduce the technicaldifficulty of colonic ESD in humans, and that it could well be helpful to noviceand intermediate level endoscopists, and even experts on certain occasions.

Abstracts

www.giejournal.org Volume 77, No. 5S : 2013 GASTROINTESTINAL ENDOSCOPY AB119