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Endoscopic Sphincterotomy Using the Heiss-Device Endoscopic Scissor in Patients with a Billroth II Gastrectomy
Abstracts
possible with M-scope. Conclusion: The therapeutic approaches using M-scope were successfully possible. M-scope seems to be helpful to selective cannulation during ERCP in patients with a Billroth II gastrectomy, although larger and comparative study will be required.
T1505 Can We Reduce the Radiation Exposure During ERCP Procedure By Using a Novel Protective Lead Shield? Toshio Kurihara, Takao Itoi, Atsushi Sofuni, Fumihide Itokawa, Shujiro Tsuji, Kentarou Ishii, Nobuhito Ikeuchi, Fuminori Moriyasu Background: One of big issues of the ERCP-related procedure is a radiation exposure of patients and medical staffs. However, there are few reports reviewed in detail of radiation exposure. Recently, we developed a novel protective lead shield which was attached around the fluoroscopy generator. The purpose of this study was to examine levels of radiation exposure to patients, endoscopists and assistants and to evaluate the usefullness of protective lead shield. Methods: ERCP procedures were performed on Shimazus DAR-3000B type fluoroscopic unit. This unit can make pulse fluoroscopy frequency 30 and 15. Our protective shield made from 0.025 Pb equivalence clothes. Fluoroscopy generator was hung with 3-sides protective lead shield like a curtain approximatery 120 cm. At first, experimentally we mapped radiation dose in our fluoroscopy room, putting acrylic phantom in fluoroscopy field. We compared the radiation dose of consecutive fluoroscopy condition with pulse fluoroscopy 15. And more we compared the radiation dose with and without protective lead shield. Next, clinically using pulse 15 and protective lead shield, we measured the radiation exposure of endoscopists and assistants monitored by digital dosimeter during ERCP. Consecutive 40 patients undergoing ERCP were selected for this study from April to July 2005. Result: 1) Experimental results: The radiation dose was the most highest at the 45 degree direction. Using pulse 15, radiation dose of patients and endoscopist position decreased in about half times. Using both pulse 15 and protective shield, radiation dose at the endoscopists position was reduced up to 97% of those without shield. 2) Clinical results: The total fluoroscopy time was 483 minutes in 40 ERCP cases. Using pulse 15 and protective lead shield, radiation exposure of one endoscopists and two assistants were 203, 112 and 216 uSv respectively. There are less enough radiation exposure than the safety exposure level that ICRP recommends. Conclusion: We could significantly reduce the radiation exposure with a novel protective lead shield in combination with pulse fluoroscopy. It is very useful for patients and medical staffs to use this shield to avoid unnecessary radiation exposure.
T1506 Echogenicities in Intraductal Ultrasonography Are Real Biliary Microlithiasis? Pung Kang, Jong Kyun Lee, Beom Jin Kim, Dong Hyun Sinn, Kyu Taek Lee, Jong Chul Rhee Aim: Intraductal ultrasonography (IDUS) is effective in the diagnosis of clinically suspected biliary microlithiasis with normal cholangiogram but it’s so difficult to differentiate tiny echogenicity from real microlithiasis. We compared echogeniciities in IDUS with bile microscopy whether those are real microlithiasis and found out the characteristics of echogenicity in IDUS correlated with bile microscopic findings. Methods: From June 2006 and August 2007, a total of 30 patients who experienced biliary pain, acute cholecystitis, idiopathic pancreatitis, with abnormal liver function test without jaundice and no filling defect or obstruction in the bile duct on ultrasonography(USG) or computed tomography(CT) were enrolled. During IDUS, we observed the findings of microlithiasis based on the size, echogenicity, number and margin. After IDUS and bile collected from CBD was centrifuged and examined under direct and polarized microscope. Results: Of 30 patients underwent IDUS, 23(77%) were revealed to have echogenic materials in the CBD. 14 patients underwent bile microscopy found biliary crystals. Of 23 patients identified echogenic materials in IDUS, 13(57%) found biliary crystals by bile microscopy. Size in IDUS was only significant factor associated with BM positivity. The optimal level of size of the echogenicity in IDUS using receiver operation characteristic (ROC) was 1.4 mm with resulting sensitivity and specificity of 71% and 75%. Conclusion: Size in IDUS was a significant factor associated with bile microscopy positivity. When the size of microlithiasis was more than 1.4 mm, the most optimal accordance between IDUS and BM. It is useful in the decision for indication of EST
T1507 Bacteriologic Culture During ERCP: Technique, Results and Clinical Impact Ramu Raju, Daniel P. Hammond, Michele B. Delenick, Burr J. Loew, Andreas M. Stefan, Arathi Rao, Douglas A. Howell Background: Sampling for bacteriologic culture has rarely been reported at ERCP. In the era of increasing antibiotic resistance to common organisms and the increasing complexity of ERCP procedures, a technique to reliably sample pancreaticobiliary secretions is needed. We report our initial experience with a new technique. Patients and Methods: 20 pts with symptoms of biliary (n Z 16) or pancreatic infection (n Z 4) underwent 23 indicated ERCPs. Pts were aged 35 to 90þ. Biliary indications for ERCP: cholangitis, sclerosing cholangitis
AB234 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
and biliary fistula. Pancreatic indications: chronic pancreatitis with fever, stricture and stone disease. Technique: Deep access was confirmed with minimal contrast injection and sphincterotomy, if indicated, was performed. The biopsy channel of the endoscope was then filled with 5-10 cc of 95% ethanol and care was used not to suction the channel. A sterile cannulating catheter was then placed and directed into the appropriate duct without touching mucosa. Effort was then made to advance the catheter up into the duct, above any installation of contrast material. 3 to 10 cc of fluid was aspirated into a sterile syringe and instilled into a transport tube for both anaerobic and aerobic culture. The ERCP was then completed as appropriate. Results: 19 of 24 (79%) specimens collected for culture were positive for pathological organisms with 11/19 (58%) having more than one organism present. Antibiotic resistance was noted in 5/19 (26%) cultures to at least one commonly used antibiotic for gram-negative infection: E.coli (n Z 2), Enterococcus (VRE), Klebsiella, Pseudomonas. Negative cultures were confirmed to be true negatives, ruling out cholangitis (n Z 4) or confirming effective therapy (n Z 1). Antibiotic change was indicated in 6/19 (32%). A major change in therapy resulting from culture data included ERCP stricture release, resumption of pancreatic duct stenting, and surgical revision of a choledochoduodenostomy (n Z 1 each). A single oropharyngeal contaminant was noted. Of 14 pts with blood cultures, only 5/14 (36%) had positive results, all of which corresponded to the ERCP culture organism. Conclusion: The technique of ERCP intraductal aspiration for bacteriologic culture described produces accurate, contamination-free specimens, simply and inexpensively. Unexpected serious antibiotic resistance was discovered in 1/4 of cases, all of whom had received prior antibiotic treatment. Culture results caused a significant modification of empiric antibiotic treatment in 1/3 of patients, and changed major treatment plans in a minority. ERCP bacteriologic culture should be part of therapeutic ERCP in all appropriate clinical settings.
T1508 Endoscopic Sphincterotomy Using the Heiss-Device Endoscopic Scissor in Patients with a Billroth II Gastrectomy Hyun Jong Choi, Jong Ho Moon, Hyun Cheol Koo, Young Koog Cheon, Young Deok Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim Background and Aims: Endoscopic sphincterotomy (EST) is generally difficult and hazardous in patients with a Billroth II gastrectomy because of anatomical change. Heiss-device flexible endoscopic scissor (TeleMed system, Inc., USA) is a biliary sphincter scissor for pre-cut access with advantages of improved control, simplicity of operation, and avoidance of thermal injury. We conducted this study to evaluate the usefulness and safety of performing EST using the Heiss-device endoscopic scissor in patients with a Billroth II gastrectomy. Patients and Methods: From September 2005 to September 2007, 21 patients with a Billroth II gastrectomy underwent EST using the biliary scissor for biliary diseases. After selective cannulation and guidewire insertion into the bile duct using forwardviewing endoscope, the biliary scissor was located on papilla and performed EST along with the guidewire. After EST, additional therapeutic procedures were performed. Overall success rate, clinical usefulness and procedure related complications were assessed. Results: 21 patients were 15 common bile duct stones, 3 gallstone pancreatitis, 1 cholangiocarcinoma, 1 ampullary cancer, and 1 bile duct leak after laparoscopic cholecystectomy. EST using the biliary scissor was successfully performed in all patients (100%). Additional therapeutic procedures, stone removal or biliary drainage catheter insertion, were possible after EST using the biliary scissor. No procedure related complication was occurred. Conclusions: Heiss-device flexible endoscopic scissor may be a useful instrument for a sphincterotomy for therapeutic procedures of patients with a Billroth II gastrectomy. Further study is warranted to compare with currently used devices.
T1509 Radiation Exposure During ERCP: Critical Determinants Edward Y. Kim, Mark Mcloughlin, Eric C. Lam, Jack Amar, Michael F. Byrne, Jennifer J. Telford, Robert A. Enns Background: Fluoroscopy during ERCP carries a known risk of radiation exposure to patients and staff. The radiation dose has been shown to have a direct linear relationship with fluoroscopy time. Many factors including diagnosis, complexity of the case, physician training, and the number and type of interventions interact to determine the total duration of fluoroscopy during ERCP. Objectives: To determine if there were specific patient/ physician factors that are associated with fluoroscopy duration. Methods: We performed a retrospective analysis of 1071 ERCPs at 2 tertiary referral hospitals over an 18 month period. Information including fluoroscopy time, patient characteristics, indication for ERCP, biliary procedures performed, endoscopist and diagnosis was collected from data sheets which had been completed at the time of the procedure. When these data sheets were incomplete, an electronic chart review was performed. Results: From this retrospective database of 1071 records, a total of 969 procedures were suitable for analysis in the final model. The average fluoroscopy time (95% Confidence Interval) was 4.66 (4.38 - 4.93) minutes. A multivariable analysis showed the following variables to be significant: endoscopist, diagnosis, number of procedures, basket, biopsies, papillotomy (all
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possible with M-scope. Conclusion: The therapeutic approaches using M-scope were successfully possible. M-scope seems to be helpful to selective cannulation during ERCP in patients with a Billroth II gastrectomy, although larger and comparative study will be required.
T1505 Can We Reduce the Radiation Exposure During ERCP Procedure By Using a Novel Protective Lead Shield? Toshio Kurihara, Takao Itoi, Atsushi Sofuni, Fumihide Itokawa, Shujiro Tsuji, Kentarou Ishii, Nobuhito Ikeuchi, Fuminori Moriyasu Background: One of big issues of the ERCP-related procedure is a radiation exposure of patients and medical staffs. However, there are few reports reviewed in detail of radiation exposure. Recently, we developed a novel protective lead shield which was attached around the fluoroscopy generator. The purpose of this study was to examine levels of radiation exposure to patients, endoscopists and assistants and to evaluate the usefullness of protective lead shield. Methods: ERCP procedures were performed on Shimazus DAR-3000B type fluoroscopic unit. This unit can make pulse fluoroscopy frequency 30 and 15. Our protective shield made from 0.025 Pb equivalence clothes. Fluoroscopy generator was hung with 3-sides protective lead shield like a curtain approximatery 120 cm. At first, experimentally we mapped radiation dose in our fluoroscopy room, putting acrylic phantom in fluoroscopy field. We compared the radiation dose of consecutive fluoroscopy condition with pulse fluoroscopy 15. And more we compared the radiation dose with and without protective lead shield. Next, clinically using pulse 15 and protective lead shield, we measured the radiation exposure of endoscopists and assistants monitored by digital dosimeter during ERCP. Consecutive 40 patients undergoing ERCP were selected for this study from April to July 2005. Result: 1) Experimental results: The radiation dose was the most highest at the 45 degree direction. Using pulse 15, radiation dose of patients and endoscopist position decreased in about half times. Using both pulse 15 and protective shield, radiation dose at the endoscopists position was reduced up to 97% of those without shield. 2) Clinical results: The total fluoroscopy time was 483 minutes in 40 ERCP cases. Using pulse 15 and protective lead shield, radiation exposure of one endoscopists and two assistants were 203, 112 and 216 uSv respectively. There are less enough radiation exposure than the safety exposure level that ICRP recommends. Conclusion: We could significantly reduce the radiation exposure with a novel protective lead shield in combination with pulse fluoroscopy. It is very useful for patients and medical staffs to use this shield to avoid unnecessary radiation exposure.
T1506 Echogenicities in Intraductal Ultrasonography Are Real Biliary Microlithiasis? Pung Kang, Jong Kyun Lee, Beom Jin Kim, Dong Hyun Sinn, Kyu Taek Lee, Jong Chul Rhee Aim: Intraductal ultrasonography (IDUS) is effective in the diagnosis of clinically suspected biliary microlithiasis with normal cholangiogram but it’s so difficult to differentiate tiny echogenicity from real microlithiasis. We compared echogeniciities in IDUS with bile microscopy whether those are real microlithiasis and found out the characteristics of echogenicity in IDUS correlated with bile microscopic findings. Methods: From June 2006 and August 2007, a total of 30 patients who experienced biliary pain, acute cholecystitis, idiopathic pancreatitis, with abnormal liver function test without jaundice and no filling defect or obstruction in the bile duct on ultrasonography(USG) or computed tomography(CT) were enrolled. During IDUS, we observed the findings of microlithiasis based on the size, echogenicity, number and margin. After IDUS and bile collected from CBD was centrifuged and examined under direct and polarized microscope. Results: Of 30 patients underwent IDUS, 23(77%) were revealed to have echogenic materials in the CBD. 14 patients underwent bile microscopy found biliary crystals. Of 23 patients identified echogenic materials in IDUS, 13(57%) found biliary crystals by bile microscopy. Size in IDUS was only significant factor associated with BM positivity. The optimal level of size of the echogenicity in IDUS using receiver operation characteristic (ROC) was 1.4 mm with resulting sensitivity and specificity of 71% and 75%. Conclusion: Size in IDUS was a significant factor associated with bile microscopy positivity. When the size of microlithiasis was more than 1.4 mm, the most optimal accordance between IDUS and BM. It is useful in the decision for indication of EST
T1507 Bacteriologic Culture During ERCP: Technique, Results and Clinical Impact Ramu Raju, Daniel P. Hammond, Michele B. Delenick, Burr J. Loew, Andreas M. Stefan, Arathi Rao, Douglas A. Howell Background: Sampling for bacteriologic culture has rarely been reported at ERCP. In the era of increasing antibiotic resistance to common organisms and the increasing complexity of ERCP procedures, a technique to reliably sample pancreaticobiliary secretions is needed. We report our initial experience with a new technique. Patients and Methods: 20 pts with symptoms of biliary (n Z 16) or pancreatic infection (n Z 4) underwent 23 indicated ERCPs. Pts were aged 35 to 90þ. Biliary indications for ERCP: cholangitis, sclerosing cholangitis
AB234 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
and biliary fistula. Pancreatic indications: chronic pancreatitis with fever, stricture and stone disease. Technique: Deep access was confirmed with minimal contrast injection and sphincterotomy, if indicated, was performed. The biopsy channel of the endoscope was then filled with 5-10 cc of 95% ethanol and care was used not to suction the channel. A sterile cannulating catheter was then placed and directed into the appropriate duct without touching mucosa. Effort was then made to advance the catheter up into the duct, above any installation of contrast material. 3 to 10 cc of fluid was aspirated into a sterile syringe and instilled into a transport tube for both anaerobic and aerobic culture. The ERCP was then completed as appropriate. Results: 19 of 24 (79%) specimens collected for culture were positive for pathological organisms with 11/19 (58%) having more than one organism present. Antibiotic resistance was noted in 5/19 (26%) cultures to at least one commonly used antibiotic for gram-negative infection: E.coli (n Z 2), Enterococcus (VRE), Klebsiella, Pseudomonas. Negative cultures were confirmed to be true negatives, ruling out cholangitis (n Z 4) or confirming effective therapy (n Z 1). Antibiotic change was indicated in 6/19 (32%). A major change in therapy resulting from culture data included ERCP stricture release, resumption of pancreatic duct stenting, and surgical revision of a choledochoduodenostomy (n Z 1 each). A single oropharyngeal contaminant was noted. Of 14 pts with blood cultures, only 5/14 (36%) had positive results, all of which corresponded to the ERCP culture organism. Conclusion: The technique of ERCP intraductal aspiration for bacteriologic culture described produces accurate, contamination-free specimens, simply and inexpensively. Unexpected serious antibiotic resistance was discovered in 1/4 of cases, all of whom had received prior antibiotic treatment. Culture results caused a significant modification of empiric antibiotic treatment in 1/3 of patients, and changed major treatment plans in a minority. ERCP bacteriologic culture should be part of therapeutic ERCP in all appropriate clinical settings.
T1508 Endoscopic Sphincterotomy Using the Heiss-Device Endoscopic Scissor in Patients with a Billroth II Gastrectomy Hyun Jong Choi, Jong Ho Moon, Hyun Cheol Koo, Young Koog Cheon, Young Deok Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim Background and Aims: Endoscopic sphincterotomy (EST) is generally difficult and hazardous in patients with a Billroth II gastrectomy because of anatomical change. Heiss-device flexible endoscopic scissor (TeleMed system, Inc., USA) is a biliary sphincter scissor for pre-cut access with advantages of improved control, simplicity of operation, and avoidance of thermal injury. We conducted this study to evaluate the usefulness and safety of performing EST using the Heiss-device endoscopic scissor in patients with a Billroth II gastrectomy. Patients and Methods: From September 2005 to September 2007, 21 patients with a Billroth II gastrectomy underwent EST using the biliary scissor for biliary diseases. After selective cannulation and guidewire insertion into the bile duct using forwardviewing endoscope, the biliary scissor was located on papilla and performed EST along with the guidewire. After EST, additional therapeutic procedures were performed. Overall success rate, clinical usefulness and procedure related complications were assessed. Results: 21 patients were 15 common bile duct stones, 3 gallstone pancreatitis, 1 cholangiocarcinoma, 1 ampullary cancer, and 1 bile duct leak after laparoscopic cholecystectomy. EST using the biliary scissor was successfully performed in all patients (100%). Additional therapeutic procedures, stone removal or biliary drainage catheter insertion, were possible after EST using the biliary scissor. No procedure related complication was occurred. Conclusions: Heiss-device flexible endoscopic scissor may be a useful instrument for a sphincterotomy for therapeutic procedures of patients with a Billroth II gastrectomy. Further study is warranted to compare with currently used devices.
T1509 Radiation Exposure During ERCP: Critical Determinants Edward Y. Kim, Mark Mcloughlin, Eric C. Lam, Jack Amar, Michael F. Byrne, Jennifer J. Telford, Robert A. Enns Background: Fluoroscopy during ERCP carries a known risk of radiation exposure to patients and staff. The radiation dose has been shown to have a direct linear relationship with fluoroscopy time. Many factors including diagnosis, complexity of the case, physician training, and the number and type of interventions interact to determine the total duration of fluoroscopy during ERCP. Objectives: To determine if there were specific patient/ physician factors that are associated with fluoroscopy duration. Methods: We performed a retrospective analysis of 1071 ERCPs at 2 tertiary referral hospitals over an 18 month period. Information including fluoroscopy time, patient characteristics, indication for ERCP, biliary procedures performed, endoscopist and diagnosis was collected from data sheets which had been completed at the time of the procedure. When these data sheets were incomplete, an electronic chart review was performed. Results: From this retrospective database of 1071 records, a total of 969 procedures were suitable for analysis in the final model. The average fluoroscopy time (95% Confidence Interval) was 4.66 (4.38 - 4.93) minutes. A multivariable analysis showed the following variables to be significant: endoscopist, diagnosis, number of procedures, basket, biopsies, papillotomy (all
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