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Development of a Biliary Stricture Model in Yucatan Miniature Swine
*T1446 Yield of Repeat ERCP for Persistently Elevated LFTs After a Previously Normal Cholangiogram in Liver Transplant Patients with Choledochocholedochostomy Anastomosis Evan L. Fogel, Lee McHenry Jr., James L. Watkins, Suzette Schmidt, A. J. Tector, Jonathan A. Fridell, Stuart Sherman, Glen A. Lehman Background: Biliary tract complications occur in 20-30% of patients after orthotopic liver transplantation (OLT), with bile leaks and anastomotic strictures most often identified. ERCP is generally the preferred method of evaluation, and is usually performed for persistently elevated or rising LFTs post-OLT. A normal ERC suggests an alternative explanation for the abnormal LFTs (eg. rejection). However, exclusion of other causes may prompt a repeat ERCP. This study examines the yield of a 2nd ERCP, performed after a previously normal exam, in the evaluation of persistently abnormal or rising LFTs. Methods: From 1/99-10/ 03, patients who had a previously normal post-OLT ERC (with or without prior endoscopic intervention) and underwent repeat evaluation for the above indications were identified from our ERCP database. The biliary anastomosis had been established by choledochocholedochostomy in all patients. Complications were graded according to consensus criteria. Results: Overall, 34 patients (who underwent 46 follow-up ERCPs) were identified, 31 of which had biliary continuity established without a T-tube. Twenty-seven ERCPs were performed in 22 patients who had no prior therapy (Group 1), while 19 ERCPs were performed in 12 patients who had prior intervention but had subsequently normalized their cholangiograms (Group 2). The mean interval between the initial normal ERC and the follow-up study was 5.5 months (range 0.5-24.0) in Group 1 and 5.3 months (range 0.3-29) in Group 2. The findings at the 2nd ERC are as noted in the Table. In both groups, 63% of patients had a persistently normal study, while 37% had new pathology identified. Two patients developed pancreatitis (4.3%; 1 mild, 1 moderate) and one patient had a mild post-sphincterotomy bleed (overall complication rate 6.5%). Summary: In over one-third of patients with a previously-normal post-OLT ERC, new findings (strictures, most often) were identified at repeat ERC performed for persistently elevated or rising LFTs. Conclusion: Repeat ERC can identify the cause of persistently abnormal LFTs in a subset of OLT patients despite a previously normal ERC, and should be considered when an alternative explanation is not identified.
*T1448 Evaluation of Mucosa in Early Gallbladder Carcinoma by Using Double Contrast Cholangiography Koji Yoshida Currently, elevated mucosae of gallbladder have been often detected by ultrasonography (US). Most of them are benign but some caces make it difficult to diagnose accurately and need further examination. Endoscopic ultrasonography (EUS) is considered to have the intrinsic potential to becoming standard image modality for differential diagnosis gallbladder polyps. The suggestion of gallbladder malignancy on EUS is essential to the choice of surgical resection. The presence of superficial tumor without polypoid component is considered a major problem in the diagnosis gallbladder malignancies in the early stage. So using ERCP technique, we developed the double contrast cholangiography to detect superficial flat tumors of the gallbladder. For 2 years, US revealed gallbladder disorder in 511 of 9251 cases. In 295 cases EUS was performed and in 82 cases which were suspected early gallbladder cancer double contrast study was performed. Reticular mucosa represent the normal mucosa. Granular and irregular mucosa corresponded to gallbladder carcinoma. We can diagnose 15 cases of early gallbladder carcinoma including 3 flat mucosal type. Double contrast cholangiography is valuable in the early detection of gallbladder cancer, especially in superficial flat tumors of the gallbladder.
*T1449 Development of a Biliary Stricture Model in Yucatan Miniature Swine Scott W. Grisolano, Bret T. Petersen, Lori J. Herman, Jodie L. Deters, Thomas C. Smyrk
*T1447 Peroral Cholangioscopy in Combination with Endoscopic Transpapillary Bile Duct Biopsy in the Diagnosis of Extrahepatic Bile Duct Cancer Yasuhiro Nakano, Satoshi Tanno, Manabu Osanai, Kazuya Koizumi, Yusuke Mizukami, Toshikatsu Okumura, Yutaka Kohgo Background/Aims: Peroral cholangioscopy (POCS) is a less invasive examination and its preparation is extremely simple. Further, POCS requires shorter time in the hospital compared with percutaneous transhepatic cholangioscopy. In addition, endoscopic transpapillary bile duct biopsies (ETB) to obtain the bile duct mucosa can be sequentially performed following POCS. The aim of this study is to evaluate the usefulness of POCS and ETB for the assessment of longitudinal tumor extension in extrahepatic bile duct cancer. Methods: Twenty-five patients with malignant extrahepatic bile duct stricture underwent POCS and ETB. POCS was carried out by using a baby scope (CHF-B20 and XCHF-B240, Olympus) and a mother scope (TJF-200, Olympus). ETB was performed by using Howell biliary system following POCS. In each patient, three specimens were taken from the lesion with biopsy forceps. Results: Prior to POCS, endoscopic biliary stentings were performed in 21 (84%) patients for the biliary drainage and dilation. In all cases, a baby scope was introduced to the papilla of Vater and the proximal of the bile duct stricture. Proximal tumor extension was evaluated in all POCS cases, and the longitudinal tumor extension was accurately diagnosed in 18 (72%) bile duct cancers. An electronic baby scope (XCHF-B240) demonstrated clearly mucosal changes and tumor vessels than conventional POCS (CHF-B20). The accuracy of diagnosis for longitudinal tumor extension was higher in the cases combined with ETB than POCS alone (72% vs 84%). No major complications related to procedures occurred. Conclusions: Transpapillary approach with the combination of POCS and ETB is useful for preoperative diagnosis to assess the tumor extension in the diagnosis of extrahepatic bile duct cancer.
P184
GASTROINTESTINAL ENDOSCOPY
Background: A large animal model of biliary strictures would allow for development and testing of novel biliary endoprostheses and provide a means for prospective comparison of various endoscopic treatment modalities. We have described initial efforts toward development of such a model in standard farm pigs (Gastrointest Endosc 2003;57:73). The aim of this study was to further develop this model in Yucatan miniature swine. Methods: This study was reviewed and approved by the Mayo Clinic Institutional Animal Care and Use Committee. Standard side-viewing duodenoscopes and biliary accessories were used. Twelve Yucatan miniature swine (7 male, median weight 43 kg) had thermal injury applied to the extrahepatic bile duct with a 7 French heater probe (2 animals 15 J, 4 animals 20 J, 6 animals 25 J). Antibiotic prophylaxis was administered prior to all cholangiograms. Serial liver chemistries and cholangiograms were performed at week 2, 3, and 6, then monthly. Strictures were defined as Grade 1 (G1) for luminal diameters < 25% pre-injury diameter, Grade 2 (G2) for luminal diameters between 25-50% pre-injury diameter, and Grade 3 (G3) for luminal diameters > 50% pre-injury diameter. If a G1 or G2 stricture did not develop by week 6, the extrahepatic bile duct was re-injured at the same site using a thermal energy 5 J higher than the initial injury. Results: Overall, 60 cholangiograms were performed, all without immediate complication. Median follow-up was 21 weeks (range 1051). At week 6 cholangiogram, 4 animals had a G1 stricture and 2 animals a G2 stricture. Six animals were re-injured; one animal apiece developed G1 and G2 strictures, while four had persistent G3 strictures. Overall, 5/12 animals developed a G1, 3/12 animals G2, and 4/12 animals G3. Transient cholestasis (median 3 weeks) developed in 4 animals (3 with G1 stricture, 1 with G2 stricture) but did not persist despite ongoing biliary stricture by cholangiography. Median time to best stricture development was 3 weeks (range 2-10). Initial bile duct diameter and change in animal weight did not correlate with stricture development. One animal died of cholangitis. Conclusions: 1) Yucatan miniature swine appear to be a good animal for performance of ERC studies utilizing standard clinical equipment. 2) Yucatan growth characteristics allow for performance of long-term follow-up procedures. 3) 67% of animals developed a G1 or G2 stricture. 4) Cholestasis was transient even with persistent biliary stricturing. 5) This model will enable endoprosthesis testing and development.
VOLUME 59, NO. 5, 2004
*T1448 Evaluation of Mucosa in Early Gallbladder Carcinoma by Using Double Contrast Cholangiography Koji Yoshida Currently, elevated mucosae of gallbladder have been often detected by ultrasonography (US). Most of them are benign but some caces make it difficult to diagnose accurately and need further examination. Endoscopic ultrasonography (EUS) is considered to have the intrinsic potential to becoming standard image modality for differential diagnosis gallbladder polyps. The suggestion of gallbladder malignancy on EUS is essential to the choice of surgical resection. The presence of superficial tumor without polypoid component is considered a major problem in the diagnosis gallbladder malignancies in the early stage. So using ERCP technique, we developed the double contrast cholangiography to detect superficial flat tumors of the gallbladder. For 2 years, US revealed gallbladder disorder in 511 of 9251 cases. In 295 cases EUS was performed and in 82 cases which were suspected early gallbladder cancer double contrast study was performed. Reticular mucosa represent the normal mucosa. Granular and irregular mucosa corresponded to gallbladder carcinoma. We can diagnose 15 cases of early gallbladder carcinoma including 3 flat mucosal type. Double contrast cholangiography is valuable in the early detection of gallbladder cancer, especially in superficial flat tumors of the gallbladder.
*T1449 Development of a Biliary Stricture Model in Yucatan Miniature Swine Scott W. Grisolano, Bret T. Petersen, Lori J. Herman, Jodie L. Deters, Thomas C. Smyrk
*T1447 Peroral Cholangioscopy in Combination with Endoscopic Transpapillary Bile Duct Biopsy in the Diagnosis of Extrahepatic Bile Duct Cancer Yasuhiro Nakano, Satoshi Tanno, Manabu Osanai, Kazuya Koizumi, Yusuke Mizukami, Toshikatsu Okumura, Yutaka Kohgo Background/Aims: Peroral cholangioscopy (POCS) is a less invasive examination and its preparation is extremely simple. Further, POCS requires shorter time in the hospital compared with percutaneous transhepatic cholangioscopy. In addition, endoscopic transpapillary bile duct biopsies (ETB) to obtain the bile duct mucosa can be sequentially performed following POCS. The aim of this study is to evaluate the usefulness of POCS and ETB for the assessment of longitudinal tumor extension in extrahepatic bile duct cancer. Methods: Twenty-five patients with malignant extrahepatic bile duct stricture underwent POCS and ETB. POCS was carried out by using a baby scope (CHF-B20 and XCHF-B240, Olympus) and a mother scope (TJF-200, Olympus). ETB was performed by using Howell biliary system following POCS. In each patient, three specimens were taken from the lesion with biopsy forceps. Results: Prior to POCS, endoscopic biliary stentings were performed in 21 (84%) patients for the biliary drainage and dilation. In all cases, a baby scope was introduced to the papilla of Vater and the proximal of the bile duct stricture. Proximal tumor extension was evaluated in all POCS cases, and the longitudinal tumor extension was accurately diagnosed in 18 (72%) bile duct cancers. An electronic baby scope (XCHF-B240) demonstrated clearly mucosal changes and tumor vessels than conventional POCS (CHF-B20). The accuracy of diagnosis for longitudinal tumor extension was higher in the cases combined with ETB than POCS alone (72% vs 84%). No major complications related to procedures occurred. Conclusions: Transpapillary approach with the combination of POCS and ETB is useful for preoperative diagnosis to assess the tumor extension in the diagnosis of extrahepatic bile duct cancer.
P184
GASTROINTESTINAL ENDOSCOPY
Background: A large animal model of biliary strictures would allow for development and testing of novel biliary endoprostheses and provide a means for prospective comparison of various endoscopic treatment modalities. We have described initial efforts toward development of such a model in standard farm pigs (Gastrointest Endosc 2003;57:73). The aim of this study was to further develop this model in Yucatan miniature swine. Methods: This study was reviewed and approved by the Mayo Clinic Institutional Animal Care and Use Committee. Standard side-viewing duodenoscopes and biliary accessories were used. Twelve Yucatan miniature swine (7 male, median weight 43 kg) had thermal injury applied to the extrahepatic bile duct with a 7 French heater probe (2 animals 15 J, 4 animals 20 J, 6 animals 25 J). Antibiotic prophylaxis was administered prior to all cholangiograms. Serial liver chemistries and cholangiograms were performed at week 2, 3, and 6, then monthly. Strictures were defined as Grade 1 (G1) for luminal diameters < 25% pre-injury diameter, Grade 2 (G2) for luminal diameters between 25-50% pre-injury diameter, and Grade 3 (G3) for luminal diameters > 50% pre-injury diameter. If a G1 or G2 stricture did not develop by week 6, the extrahepatic bile duct was re-injured at the same site using a thermal energy 5 J higher than the initial injury. Results: Overall, 60 cholangiograms were performed, all without immediate complication. Median follow-up was 21 weeks (range 1051). At week 6 cholangiogram, 4 animals had a G1 stricture and 2 animals a G2 stricture. Six animals were re-injured; one animal apiece developed G1 and G2 strictures, while four had persistent G3 strictures. Overall, 5/12 animals developed a G1, 3/12 animals G2, and 4/12 animals G3. Transient cholestasis (median 3 weeks) developed in 4 animals (3 with G1 stricture, 1 with G2 stricture) but did not persist despite ongoing biliary stricture by cholangiography. Median time to best stricture development was 3 weeks (range 2-10). Initial bile duct diameter and change in animal weight did not correlate with stricture development. One animal died of cholangitis. Conclusions: 1) Yucatan miniature swine appear to be a good animal for performance of ERC studies utilizing standard clinical equipment. 2) Yucatan growth characteristics allow for performance of long-term follow-up procedures. 3) 67% of animals developed a G1 or G2 stricture. 4) Cholestasis was transient even with persistent biliary stricturing. 5) This model will enable endoprosthesis testing and development.
VOLUME 59, NO. 5, 2004