A Comparative Study of Outcomes Between Endoscope Sphincterotomy Plus Endoscope Papillary Large Balloon Dilatation and Endoscopic Sphincterotomy Alone in Patients with Large Extrahepatic Bile Duct Stones

Abstracts

Table 1. Treatment Outcomes Complete Stone Clearance After Laser Session(s) Persons Requiring Additional Therapy) Final Stone Clearance Procedure Complications Nausea/Pain Wire perforation

8/16 (50%) 8/16 (50%) 16/16 (100%) 211

)Additional therapy included CBD stenting with subsequent ERCP with balloon/ basket retrieval and/or mechanical lithotripsy.

S1371 Unilateral vs Bilateral Metallic Stents for Malignant Hilar Obstruction: A Meta-Analysis and Systematic Review of Risks Srinivas R. Puli, Matthew L. Bechtold, Jyotsna Bk Reddy, Mainor R. Antillon, David L. Carr-Locke Background: Metallic stents are used for palliating inoperable malignant hilar obstruction. It is not clear if bilateral metallic stenting provides any advantage over unilateral stenting in these patients. Aim: Compare bilateral to unilateral metallic stenting in malignant hilar obstruction. Method: Study Selection Criteria: Studies using metallic stents for palliation in patients with malignant hilar obstruction Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement. Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran’s Q test based upon inverse variance weights. Results: Initial search identified 1640 reference articles, of which 169 were selected and reviewed. 13 studies (NZ340) for bilateral metallic stents and 10 studies (NZ575) for unilateral metallic stents which met the inclusion criteria were included in this analysis. Pooled data are shown in table 1. The pooled estimated by fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was O 0.10. Conclusions: Bilateral metallic stenting seems to have lower odds of overall complications when compared to unilateral metallic stenting. But, unilateral metallic stenting has no increased odds of cholangitis or 30 day mortality when compared to bilateral stenting. Unilateral metallic stenting seems to be comparable to bilateral stenting in patients with malignant hilar strictures with respect to adverse events.

Table 1. Comparison of bilateral metallic vs. unilateral metallic stents for malignant hilar obstruction Odds Ratio with 95% CI

p (tests if odds ratio is different from 1)

Success of Placement

0.33 (0.16 to 0.69)

0.01

Decrease in Bilirubin

2.25 (1.29 to 3.90)

0.01

Overall Complications

0.53 (0.32 to 0.86)

0.01

Early Complications

0.11 (0.04 to 0.28)

! 0.01

Late Complications

0.23 (0.07 to 0.75)

0.01

Overall Cholangitis

0.90 (0.59 to 1.38)

0.67

Early Cholangitis

0.89 (0.47 to 1.70)

0.85

Late Cholangitis

0.78 (0.29 to 2.07)

0.79

30 Day Mortality

4.34 (0.74 to 25.56)

0.19

S1372 Utility of Endoscopic Naso-Gallbladder Drainage (ENGBD) for Acute Cholecystitis Akira Kurita, Manabu Osanai, Akio Katanuma, Kuniyuki Takahashi, Hiroyuki Maguchi Aim: The efficacy of endoscopic naso-gallbladder drainage (ENGBD) as a drainage for acute cholecystitis has been reported. In this study, we evaluated the effectiveness and problems of using ENGBD from the results achieved in our center. Subjects and Methods: Endoscopic procedure was performed as follows. Firstly, cannulation of the bile duct was achieved using standard ERCP techniques, and then an 0.035’’ angled hydrophilic guidewire was passed though the cystic duct. Finally, a ENBD tube (5Fr. or 6Fr. pig tail type) was inserted into the gallbladder. Ninety one patients underwent ENGBD for acute cholecystitis between April 1997 to October 2008. ENGBD was indicated as follows; medication of anti-coagulant, bleeding tendency, advanced age or complications, the presence of bile duct stones or cholangitis, or suspicion of gallbladder cancer. Evaluating points were 1) success rates of the technique, 2)drainage effects, 3)complications Results:

AB156 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009

1) ENGBD tube was successfully placed in 81.3% (74/91) of all patients; its breakdown by the disease degree was 81.6% (31/38) in mild cases, 80.5% (33/41) in moderate cases and 83.3% (10/12) in serious cases, showing no significant difference among them respectively. 2) Effective drainage was achieved in 98.6% (73/74) of the cases where drainage placement was successful; in 1 case, ENGBD was changed to percutaneous transhepatic gallbladder drainage (PTGBD). 3) Complications developed in 8.8% (8/91); cholangitis in 3, pancreatitis in 3, and injury to the cystic duct in 2. Conclusion: ENGBD was thought to be an effective treatment for acute cholecystitis. However, there are some cases difficult to treat using this method, and thus advancement in technique and improvement of tools are necessary.

S1373 A Comparative Study of Outcomes Between Endoscope Sphincterotomy Plus Endoscope Papillary Large Balloon Dilatation and Endoscopic Sphincterotomy Alone in Patients with Large Extrahepatic Bile Duct Stones Tae Hyeon Kim, Hyo Jeong Oh, Chong Ju Im, Chang Soo Choi, Ji Hye Kweon, Young Woo Sohn Introduction: Endoscopic sphincterotomy(EST) has become an standard procedure for removal of extrahepatic bile duct stones, but it carries risks, such as bleeding, pancreatitis, and perforation, and ascending cholangitis. Additionally, in patients who have large biliary stones with or without periampullary diverticulum, stone removal is technically difficult, and time consuming when mechanical lithotriptor is reqiuired. Recently, small endoscopic sphincterotomy(EST) combined with endoscopic papillary large balloon dilatation(EPLBD) seem to be a promising alternative in the patients with difficult bile duct stones that could not be extracted by EST. Aim: To compare the therapeutic benefits and complication rates of EST plus EPBLD with that of EST alone. Methods: We investigated 204 patients with the treatment of stones (O10 mm) and multiple stones in the extrahepaic bile duct. with compared small EST plus EPLBD (group A, nZ104) with conventional EST (group B, nZ100). Small EST plus EPLBD method was as follow; first of all EST with a minor incision up to middle part of papilla was performed over a guidewire, and then endoscopic balloon dilation for about 20 or 30 sec was performed with large balloon (12-20 mm in diameter) matched the diameter of the bile duct. A standard conventional EST was performed over a guidewire. When stone could not be removed by normal basket, mechanical lithotripter was performed. Results: The mean age of each group were 69.811.7 years in group A and 69.411.7 years in group B (M: FZ63: 51 vs. 49: 51). There was no significant difference of the mean bile duct diameter (A: 16.45.0, B: 18.85.2, and presence of periampullary diverticulum (A;46.7%, B;39%). EST plus EPBD compared with EST alone resulted in similar outcomes in terms of complete stone removal in one session (85.6% vs 81.7%, pZ0.19) and overall successful stone removal (95.6% vs 92.0%, pZ0.24), but use of mechanical lithotripsy have a significant difference (8.0% vs. 16.5%, p! 0.05). Complications were as follows for the EST plus EPBD group and EST group: pancreatitis (9.6% vs. 9%, pZ0.871), perforation (0% vs. 1.0%), and delayed bleeding (0.8% and 0%). No fatal complication occurred in either the EPBD or the EST group. Conclusions: Based on the similar rates of successful stone removal and complications, EST plus LBD is a safe and effective alternative to EST for endoscopic removal of large common bile duct stones and can reduce use of mechanical lithotripsy as comopared to EST only.

S1374 Biliary Orifice Balloon Dilation (BD) After Prior Biliary Sphincterotomy (BES) in Patients with Sphincter of Oddi Dysfunction (SOD): Is Pancreatic Duct (PD) Stent Placement Necessary to Prevent Post-ERCP Pancreatitis (PEP)? Byung Moo Yoo, Olga Barkay, Lee Mchenry, James L. Watkins, Stuart Sherman, Glen A. Lehman, Evan L. Fogel Background: Patients (pts) with recurrent symptoms following BES for suspected or documented SOD typically undergo repeat sphincter of Oddi manometry (SOM). Therapy is usually guided by SOM results. However, if SOM is normal, or if no further cutting space is available following prior BES, we often balloon dilate the biliary orifice, particularly in pts who achieved benefit from prior sphincter therapy. BD of an intact papilla is a high-risk maneuver for the development of PEP, with a reduction in pancreatitis rates when a protective PD stent is placed. However, there are no data in SOD pts with prior BES who undergo biliary orifice BD. Aims: 1. to determine the frequency and severity of PEP in SOD patients undergoing biliary orifice BD with prior BES; 2. to determine whether PD stent placement in these pts reduces the frequency and severity of PEP. Patients and Methods: From 1994-10/2008, our ERCP database was reviewed for pts with prior BES who were referred for SOM. Only pts who underwent BD of the biliary orifice with a 6-10mm balloon were evaluated. Pts who received any other endoscopic therapy (except protective PD stent placement), done at the discretion of the endoscopist, were excluded. Patient- and procedure-related risk factors for PEP were also evaluated. Results: 201 pts were identified (M: F 19: 182, mean age: 4513). A PD stent was inserted in 93 pts (Group 1: stent; Group 2: no stent). Biliary and pancreatic SOM was completely successful in 191 pts; pancreatic SOM failed in 9 pts, biliary SOM failed in one. There was no difference between the 2 groups with respect to age, gender, history of recurrent pancreatitis or PEP, degree of PD duct filling or changes of chronic pancreatitis identified at ERCP (pZNS). Trainee participation was greater

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