- Email: [email protected]
Mo1344 Implementation of Diagnostic and Therapeutic Algorithm for Biliary Candidiasis
Abstracts
EPLBD vs 55-102 months in EST, p⫽0.489). However, complete biliary stone removal at one session was more frequent with EPLBD than with EST (78% vs. 50%, p⫽0.016). Conclusions: EPLBD was not superior to EST in preventing bile duct stone recurrence. However, EPLBD would be preferred than EST because EPLBD is more likely to remove large stone at one session than EST.
Mo1341 The Significance of Ballooning Time in Endoscopic Papillary Large Balloon Dilation for the Treatment of Difficult Choledocholithiasis Yeonsuk Kim*, Yunjeong Jo, Yangsuh Koo, Kwang an Kwon, Jung Ho Kim, Joo Hyun Kim, Yun Soo Kim, Yoonjae Kim, Dongkyun Park, Chung Jun Won Gachon Gil Medical Center, Incheon, Republic of Korea Background: Endoscopic papillary large balloon dilation(EPLBD) using CRE balloon (12-20mm) has been used as an alternative method of endoscopic sphinterotomy (EST) for difficult bile duct stone with condiserable success rate and low complication rate. However, little is known about proper ballooning time for EPLBD. Aim: Our study was aimed to evaluate the efficacy and safety of immediate balloon deflation method compared to conventional method. Patients: From Jan 2010 to Dec 2010, a total of 133 patients who underwent difficult bile duct stone therapy with EPLBD ⫹/⫺ limited EST were enrolled. Stones above the benign stricture, concomitant pancreatico-biliary malignancy or stones with choledochoduodenal fistula were excluded. Method: Enrolled patients were divided into two groups (immediate deflation group: immediate CRE balloon dilation after achieving full ATM, N ⫽ 57 vs. conventional deflation group: maintain inflation at least over 45 seconds until waist of balloon was disappeared, N⫽76). CRE balloon size was chosen according to stone size and CBD diameter. Limited EST was performed if necessary. When stone extraction was difficult, mechanical lithotripsy was performed. Result: Gender, age, balloon size, stone diameter, bile duct diameter presence of periampullary diverticulum were not different in both group. Distal CBD arm, CBD angle and presence of previous EST showed no statistical significance. Mean ERCP session was 1.21⫹/ ⫺ 0.4 in immediate inflation group and 1.59⫹/⫺ 0.5 in conventional group (p ⫽ 0.001). Overall success rate was 56/57(98.2%) and 70/76(92.1%) in each group (P ⫽ 0.073), respectively. Success rate at 1st attempt was similar.( 78.2% vs 71.1%, p ⫽ 0.662). No. of mechanical lithotripsy used was also similar(0 vs 5, p ⫽ 0.065). Overall complication rate was not different in both groups (24.5% vs 25%, p ⫽ 0.954). PostERCP pancreatitis rate was 3/57(5.2%) vs 6/76(7.8%) (p⫽0.86). In conventional group, one severe postERCP pancreatitis occurred. Other major complications such as bleeding and perforation were not statistically different in both groups. One mortality due to perforation was revealed in conventional group. Conclusion: Immediate deflation method showed similar success rate and complication rate compared to conventional inflation method. Therefore, it is our precautious conclusion that immediate deflation method is safe and feasible for difficult bile duct stone therapy using with EPLBD. Shorter procedure time and lesser pain could be additional benefits of immediate deflation method. However, large prospective study is needed to elucidate our conclusion.
Mo1342 In Vitro Magnifying Endoscopic Observation of Non-Neoplastic Bile Duct Mucosa: Comparison of Endoscopic Findings With Histopathology Yusuke Ishida*1, Yoshinobu Okabe1, Makiko Yasumoto2,1, Gen Sugiyama1, Tomoyuki Ushijima1, Yuu Sasaki1, Ryohei Kaji1, Yuhei Kitazato3, Hiroyuki Horiuchi3, Hisafumi Kinoshita3, Atsushi Toyonaga4, Osamu Tsuruta1, Michio Sata1 1 Medicine, Division of Gastroenterology, Kurume Universiy of Medicine, Kurume, Japan; 2Pathology, Kurume University of Medicine, Kurume, Japan; 3Surgery, Kurume University of Medicine, Kurume, Japan; 4Yasumoto Hospital, Kurume, Japan Background and Aim: The utility of peroral cholangioscopy (POCS) has been reported since a new video POCS was developed. However, endoscopic findings of non-neoplastic bile duct mucosa using POCS with NBI have not yet been established. This is a fundamental study in vitro to compare magnifying endoscopic findings and histopathological findings. Patients and Methods: 32 common bile ducts which were surgically resected were enrolled in this study. These specimens included non-neoplastic bile duct mucosa obtained from 32 patients who underwent pancreatoduodenectomy, bile duct resection, or hepatectomy. We cut each common bile duct open for in vitro endoscopic observation of its mucosa. We used a magnifying endoscope (FH-260AZI or H260Z; Olympus Medical Systems, Tokyo, Japan) commonly used for the gastrointestinal tract, and we utilized both conventional white light imaging (WLI) and narrow band imaging (NBI) (CV-260SL processor, CVL-260SL light source; Olympus). After histological diagnosis, the 32 specimens were classified into two categories based on the absence or presence of histological
inflammation. Normal to mild inflammatory mucosa was assigned to group A and moderate to severe inflammatory mucosa was to group B. Then we examined the relationship between the magnifying endoscopic findings (using WLI and NBI) and microscopic histopathology. Result: 15 specimens of bile duct mucosa were classified as group A and 17 specimens as group B. In the 15 cases of group A, many oval-shaped, depressed areas and a fine, regular network of microvessels were observed using magnifying endoscopy. In the 17 cases of group B, we could not clearly see these oval-shaped, depressed areas and the network. In four cases of histologically confirmed severe inflammatory mucosa in group B, the depressed areas and network could not be found and only irregular mucosa and microvessels were observed. Additionally, these bile duct mucosa cases looked like petechial hemorrhaging, scales, or villous structures. In only one case with mild inflammation but with regenerative change, irregular mucosal structure was observed and likely to be mistaken for neoplastic mucosa. In all cases, we could see these findings more clearly when magnifying endoscopy with NBI was used. Conclusion: Oval-shaped, depressed areas and a fine, regular network of microvessels are the characteristic features of normal bile duct mucosa. Inflammation obscures these features. However, it is very difficult to distinguish between severe inflammatory or regenerative mucosa and neoplastic mucosa.
Mo1343 Multiple Plastic Stents to Treat Post-Cholecystectomy Biliary Strictures: 20 Year Experience on 183 Patients Rosario Landi, Andrea Tringali*, Ivo Boskoski, Pietro Familiari, Massimiliano Mutignani, Vincenzo Perri, Guido Costamagna Digestive Endoscopy Unit - Catholic University, Rome, Italy Background and Aims: Endotherapy of benign biliary strictures with multiple plastic stents has excellent long term results. Endoscopic treatment of postcholecystectomy biliary strictures (PCBS) was evaluated during long term followup.Design and setting: Single center, follow-up study performed in a tertiarycare, academic referral center. Patients and Methods: ERCP was performed in patients with suspected PCBS by insertion of an increasing number of plastic stents at each stent exchange (planned every 3 months), until complete morphological disappearance of the stricture. After stent removal systematic follow-up was done by liver function tests and assessment of occurrence of biliary symptoms (mainly cholangitis). Last telephone follow-up was done in October 2011. Results: From December 1988 to June 2010, 183 patients with PCBS underwent multiple plastic biliary stenting. A median of 3 (1-7) ERCP/ patient, with median placement of 4 (2-12) plastic biliary stents and a median treatment period of 12 months (2-179) were necessary to complete the treatment. Nineteen patients (10.4 %) were lost to follow-up. The overall median follow-up on 164 evaluable patients was 7 yrs (range 0.08-21.83 yrs); 13/164 (7.9%) died from unrelated causes after a median of 6.08 yrs (range 0.08-13.37 yrs) from the end of treatment, without further biliary symptoms. From the remaining 151 patients, 22 (14.6%) experienced recurrent acute cholangitis after a median of 0.95 yrs (range 0.08-11.75 yrs) from the end of treatment. Of these 14 (9.3%) had stricture recurrence and were retreated endoscopically with placement of multiple stents, and the other 8 (5.3%) had newly formed common bile duct stones that were extracted. No stricture or stone recurrences after retreatment were recorded after a mean follow-up of further 4.4 yrs (range 0.05-14.08 yrs). One hundred and forty-two (85.4%) patients remained asymptomatic with normal liver function test after a median follow-up of 7.12 years (range 0.0821.83 yrs). Conclusion: Endotherapy of PCBS by multiple plastic stents has effective and satisfactory results in this large cohort after long-term follow-up. Stricture recurrence rate is low and can be successfully retreated endoscopically.
Mo1344 Implementation of Diagnostic and Therapeutic Algorithm for Biliary Candidiasis Philipp Lenz1, Franziska Eckelskemper1, Andreas Uekoetter2, Torsten Beyna1, Hansjoerg Ullerich1, Andre Schmedt1, Frank Lenze1, Dirk Domagk*1 1 Department of Medicine B, University of Muenster, Muenster, Germany; 2Institute of Medical Microbiology, University of Muenster, Muenster, Germany Introduction: Biliary obstruction and cholangitis are common problems in gastroenterology and need specific therapeutic interventions. Infections of the biliary tract with Candida and other fungal species have increasingly been reported in the last few years. Aim of this study is to develop an algorithm for clinical diagnostics and treatment of biliary candidiasis. Patients and Methods: Since July 2011, 50 patients were included in the study (ClinicalTrials.gov Identifier: NCT01109550). During ERCP bile samples were taken and microbiologically analyzed. If appropriate, endoscopic transpapillary bile duct biopsies were taken for diagnosing an invasive fungal infection. Smears of the endoscope working channel were taken before and after the examination. Buccal smears and stool samples were supposed to show the individual transient
AB395 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
Abstracts
flora. Additionally, candida-antigen-serology and blood-cultures were gained. The different clinical information were integrated in a treatment algorithm to define an indication for antifungal treatment (figure 1). Results: Microbiological
cholangiocarcinoma (128 patients with B-C type III-IV tumors) who had undergone unilateral ENBD between January 2007 and December 2010. The success and efficacy of this procedure and the risk factors for post-ENBD cholangitis and pancreatitis were retrospectively evaluated. Results: The ENBD was successful in 153 (93.3%) of the 164 patients. Of these 164 patients, 65 had total serum bilirubin (TB) levels ⬎ 2.0 mg/dL prior to the drainage. The first unilateral ENBD was successfully performed in 60 of the 65 patients, and the TB level decreased to ⬍ 2.0 mg/dL after the ENBD in 50 of these 60 patients (83.3%). The significant predictive factors for ENBD efficacy included the preENBD TB level (P ⫽ 0.032, 95% CI: 1.01-1.23) and post-ENBD cholangitis (P ⫽ 0.012, 95% CI: 1.61-43.2). Post-ENBD cholangitis occurred in 47 (28.8%) of the 163 patients, and a previous endoscopic sphincterotomy (EST) was found to be a significant risk factor for post-ENBD cholangitis (P ⫽0.008, 95% CI: 1.30-5.46). Post-ENBD pancreatitis occurred in 33 (20.1%) of the 164 patients (26 mild patients, 4 moderate patients, and 3 severe patients). The significant risk factors included undergoing pancreatography (P ⬍0.001, 95% CI: 2.44-31.1) and the absence of previous endoscopic biliary stenting (EBS) or ENBD (P ⬍0.001, 95% CI: 3.03-29.2). Conclusions: Unilateral ENBD of the future remnant lobe(s) exhibited a high success rate, suggesting that it is an effective and suitable preoperative drainage method for perihilar cholangiocarcinoma, even in patients with B-C type III-IV tumors. To reduce the post-procedural complications, ENBD should be performed without EST or pancreatography.
Mo1346 Is Endoscopic Sphincterotomy (EST) Unnecessary as an Urgent Treatment for Acute Obstructive Suppurative Cholangitis (AOSC)? Soichiro Morikawa*, Azumi Suzuki, Kenjiro Yasuda Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
Figure 1 Suggested diagnostic and therapeutic algorithm for biliary candidiasis.
analysis data were fully available in 44 of 50 patients. In 13 of 44 patients, we found Candida species in the bile (30%). As potential risk factor for biliary candidiasis long-term antibiotic therapy (⬎ 7 days) could be identified (p ⬍ 0.05). Two of these 13 patients were treated with echinocandins according to our treatment algorithm; one patient with progressive gallbladder cancer and liver metastasis and the other with biliary cast syndrome after cardiopulmonary resuscitation. No invasive mycosis could be identified histologically. In 27 of 44 patients we found candida in the buccal smears (61,4 %). Only in 2 of 44 cases we found candida at the endoscope channel before the endoscopic examination; these findings were only achieved after enhancement of mycological cultures. Remarkably, the species were different from those found in the bile. No significant associations of prior endoscopic sphincterotomy (p ⫽ 0.557) or prior ERCP (p ⫽ 0.561) and biliary candidiasis were found. No positive fungal culture of blood samples was obtained. Conclusion: This ongoing study offers interesting clinical information about the microbiological flora of the bile in patients with biliary disease. The preliminary data indicate that the suggested therapeutic algorithm for biliary candidiasis seems to be appropriate in daily routine. Whether transpapillary biopsies are necessary in the diagnosis of biliary candidiasis remains controversial.
Mo1345 The Efficacy and Complications of Preoperative Endoscopic Nasobiliary Drainage (ENBD) in Perihilar Cholangiocarcinoma Patients Hiroki Kawashima*1, Akihiro Itoh1, Eizaburo Ohno2, Yuya Itoh1, Yosuke Nakamura2, Takeshi Hiramatsu1, Hiroyuki Sugimoto1, Hajime Sumi1, Ryoji Miyahara2, Naoki Ohmiya1, Hidemi Goto1, Yoshiki Hirooka2 1 Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Endoscopy, Nagoya University Hospital, Nagoya, Japan Background/Aims: The advantages of endoscopic nasobiliary drainage (ENBD) have been previously reported. However, no studies to date have examined a large number of subjects, including those with Bismuth-Corlette (B-C) type III-IV tumors. Additionally, sufficient data on the risk factors associated with ENBD complications are not available. This study’s aims are to assess the clinical benefits of preoperative ENBD in patients with perihilar cholangiocarcinoma. Methods: This study involved 164 consecutive patients with suspected perihilar
www.giejournal.org
Background: Because AOSC sometimes rapidly progress to a severe form accompanied by organ dysfunction, caused by the systemic inflammatory response syndrome (SIRS) and/or sepsis, prompt urgent treatment including EST and endoscopic biliary stenting (EBS) is necessary. However an additional procedure such as EST sometimes lead to a complication. Objectives: To assess the technical success, complications and clinical outcomes of urgent ERCP related procedure for AOSC. Patients and Methods: Data was collected retrospectively on patients who underwent urgent ERCP related procedure for AOSC by reviewing hospital charts from January 2006 to December 2011. Main outcome measurements are technical success, complications, and clinical outcome. A total of 334 patients underwent urgent ERCP related procedure for AOSC. Median patient age was 79 years (range, 19-101 years) and 208 patients were male. AOCS was caused by common bile duct stone in 220 (65.9%), malignant biliary stricture in 100 (29.9%), benign biliary stricture in 12 (3.6%), choledochal cyst in 1 (0.3%), primary sclerosing cholangitis in 1 (0.3%). Nine patients were associated with pancreatitis due to common bile duct stone. We classified the severity of all patients with AOSC except for nine patients associated with pancreatitis into three grades, mild, moderate, and severe using Japanese Guideline. We classified 56 patients (17.2%) in severe, 224 (68.9%) in moderate, and 45 (13.8%) in mild. Of the 334 patients, 160 (47.9%) have a past history of EST and the remaining 184 (52.1%) have a naive papilla. There were 31 patients (9.3%) on oral anticoagulants and/or antiplatelet agent. We performed EST on 99 patients and EBS without EST on 62 patients with naive papilla. Results: The urgent ERCP related procedure was successful in 328 patients (98.2%). All of 6 patients whom urgent ERCP related procedure finished unsuccessfully have a naive papilla. An urgent percutaneous transhepatic biliary drainage was required only for one patient of these 6. The other 5 patients were treated conservatively. There were no severe complications. The post-ERCP pancreatitis arose in 8 patients (2.8%), but all of these patients recovered conservatively. Seven of these 8 patients underwent EST. There were no complications in EBS without EST group. Among the patients with a naive papilla, the incidence of post-ERCP pancreatitis of EST group and EBS without EST group were 7.1% (7/99) and 0% (0/62)(p⬍0.05) respectively. All the patients recovered and were able to leave our hospital. Conclusions: Urgent ERCP related procedure for AOSC were safe and effective. But in our series, incidence of postERCP pancreatitis was more frequent in EST group. In the case of urgent treatment for AOSC, especially for the patients with a naive papilla, we should consider to perform EBS without EST.
Mo1347 The Intramucosal Incision Technique: Converting Complication Into Success Ashish K. Jha, Mahesh Goenka*, Pranav K. Mandal, Sanjeev Kumar Institute of Gastroscience, Apollo Gleneagles Hospital, Kolkata, India Background: The precut sphincterotomy is used to facilitate selective biliary access in difficult procedures. Needle-knife precut papillotomy is standard of care but is associated with high rate of complications. Formation of false tract
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB396
EPLBD vs 55-102 months in EST, p⫽0.489). However, complete biliary stone removal at one session was more frequent with EPLBD than with EST (78% vs. 50%, p⫽0.016). Conclusions: EPLBD was not superior to EST in preventing bile duct stone recurrence. However, EPLBD would be preferred than EST because EPLBD is more likely to remove large stone at one session than EST.
Mo1341 The Significance of Ballooning Time in Endoscopic Papillary Large Balloon Dilation for the Treatment of Difficult Choledocholithiasis Yeonsuk Kim*, Yunjeong Jo, Yangsuh Koo, Kwang an Kwon, Jung Ho Kim, Joo Hyun Kim, Yun Soo Kim, Yoonjae Kim, Dongkyun Park, Chung Jun Won Gachon Gil Medical Center, Incheon, Republic of Korea Background: Endoscopic papillary large balloon dilation(EPLBD) using CRE balloon (12-20mm) has been used as an alternative method of endoscopic sphinterotomy (EST) for difficult bile duct stone with condiserable success rate and low complication rate. However, little is known about proper ballooning time for EPLBD. Aim: Our study was aimed to evaluate the efficacy and safety of immediate balloon deflation method compared to conventional method. Patients: From Jan 2010 to Dec 2010, a total of 133 patients who underwent difficult bile duct stone therapy with EPLBD ⫹/⫺ limited EST were enrolled. Stones above the benign stricture, concomitant pancreatico-biliary malignancy or stones with choledochoduodenal fistula were excluded. Method: Enrolled patients were divided into two groups (immediate deflation group: immediate CRE balloon dilation after achieving full ATM, N ⫽ 57 vs. conventional deflation group: maintain inflation at least over 45 seconds until waist of balloon was disappeared, N⫽76). CRE balloon size was chosen according to stone size and CBD diameter. Limited EST was performed if necessary. When stone extraction was difficult, mechanical lithotripsy was performed. Result: Gender, age, balloon size, stone diameter, bile duct diameter presence of periampullary diverticulum were not different in both group. Distal CBD arm, CBD angle and presence of previous EST showed no statistical significance. Mean ERCP session was 1.21⫹/ ⫺ 0.4 in immediate inflation group and 1.59⫹/⫺ 0.5 in conventional group (p ⫽ 0.001). Overall success rate was 56/57(98.2%) and 70/76(92.1%) in each group (P ⫽ 0.073), respectively. Success rate at 1st attempt was similar.( 78.2% vs 71.1%, p ⫽ 0.662). No. of mechanical lithotripsy used was also similar(0 vs 5, p ⫽ 0.065). Overall complication rate was not different in both groups (24.5% vs 25%, p ⫽ 0.954). PostERCP pancreatitis rate was 3/57(5.2%) vs 6/76(7.8%) (p⫽0.86). In conventional group, one severe postERCP pancreatitis occurred. Other major complications such as bleeding and perforation were not statistically different in both groups. One mortality due to perforation was revealed in conventional group. Conclusion: Immediate deflation method showed similar success rate and complication rate compared to conventional inflation method. Therefore, it is our precautious conclusion that immediate deflation method is safe and feasible for difficult bile duct stone therapy using with EPLBD. Shorter procedure time and lesser pain could be additional benefits of immediate deflation method. However, large prospective study is needed to elucidate our conclusion.
Mo1342 In Vitro Magnifying Endoscopic Observation of Non-Neoplastic Bile Duct Mucosa: Comparison of Endoscopic Findings With Histopathology Yusuke Ishida*1, Yoshinobu Okabe1, Makiko Yasumoto2,1, Gen Sugiyama1, Tomoyuki Ushijima1, Yuu Sasaki1, Ryohei Kaji1, Yuhei Kitazato3, Hiroyuki Horiuchi3, Hisafumi Kinoshita3, Atsushi Toyonaga4, Osamu Tsuruta1, Michio Sata1 1 Medicine, Division of Gastroenterology, Kurume Universiy of Medicine, Kurume, Japan; 2Pathology, Kurume University of Medicine, Kurume, Japan; 3Surgery, Kurume University of Medicine, Kurume, Japan; 4Yasumoto Hospital, Kurume, Japan Background and Aim: The utility of peroral cholangioscopy (POCS) has been reported since a new video POCS was developed. However, endoscopic findings of non-neoplastic bile duct mucosa using POCS with NBI have not yet been established. This is a fundamental study in vitro to compare magnifying endoscopic findings and histopathological findings. Patients and Methods: 32 common bile ducts which were surgically resected were enrolled in this study. These specimens included non-neoplastic bile duct mucosa obtained from 32 patients who underwent pancreatoduodenectomy, bile duct resection, or hepatectomy. We cut each common bile duct open for in vitro endoscopic observation of its mucosa. We used a magnifying endoscope (FH-260AZI or H260Z; Olympus Medical Systems, Tokyo, Japan) commonly used for the gastrointestinal tract, and we utilized both conventional white light imaging (WLI) and narrow band imaging (NBI) (CV-260SL processor, CVL-260SL light source; Olympus). After histological diagnosis, the 32 specimens were classified into two categories based on the absence or presence of histological
inflammation. Normal to mild inflammatory mucosa was assigned to group A and moderate to severe inflammatory mucosa was to group B. Then we examined the relationship between the magnifying endoscopic findings (using WLI and NBI) and microscopic histopathology. Result: 15 specimens of bile duct mucosa were classified as group A and 17 specimens as group B. In the 15 cases of group A, many oval-shaped, depressed areas and a fine, regular network of microvessels were observed using magnifying endoscopy. In the 17 cases of group B, we could not clearly see these oval-shaped, depressed areas and the network. In four cases of histologically confirmed severe inflammatory mucosa in group B, the depressed areas and network could not be found and only irregular mucosa and microvessels were observed. Additionally, these bile duct mucosa cases looked like petechial hemorrhaging, scales, or villous structures. In only one case with mild inflammation but with regenerative change, irregular mucosal structure was observed and likely to be mistaken for neoplastic mucosa. In all cases, we could see these findings more clearly when magnifying endoscopy with NBI was used. Conclusion: Oval-shaped, depressed areas and a fine, regular network of microvessels are the characteristic features of normal bile duct mucosa. Inflammation obscures these features. However, it is very difficult to distinguish between severe inflammatory or regenerative mucosa and neoplastic mucosa.
Mo1343 Multiple Plastic Stents to Treat Post-Cholecystectomy Biliary Strictures: 20 Year Experience on 183 Patients Rosario Landi, Andrea Tringali*, Ivo Boskoski, Pietro Familiari, Massimiliano Mutignani, Vincenzo Perri, Guido Costamagna Digestive Endoscopy Unit - Catholic University, Rome, Italy Background and Aims: Endotherapy of benign biliary strictures with multiple plastic stents has excellent long term results. Endoscopic treatment of postcholecystectomy biliary strictures (PCBS) was evaluated during long term followup.Design and setting: Single center, follow-up study performed in a tertiarycare, academic referral center. Patients and Methods: ERCP was performed in patients with suspected PCBS by insertion of an increasing number of plastic stents at each stent exchange (planned every 3 months), until complete morphological disappearance of the stricture. After stent removal systematic follow-up was done by liver function tests and assessment of occurrence of biliary symptoms (mainly cholangitis). Last telephone follow-up was done in October 2011. Results: From December 1988 to June 2010, 183 patients with PCBS underwent multiple plastic biliary stenting. A median of 3 (1-7) ERCP/ patient, with median placement of 4 (2-12) plastic biliary stents and a median treatment period of 12 months (2-179) were necessary to complete the treatment. Nineteen patients (10.4 %) were lost to follow-up. The overall median follow-up on 164 evaluable patients was 7 yrs (range 0.08-21.83 yrs); 13/164 (7.9%) died from unrelated causes after a median of 6.08 yrs (range 0.08-13.37 yrs) from the end of treatment, without further biliary symptoms. From the remaining 151 patients, 22 (14.6%) experienced recurrent acute cholangitis after a median of 0.95 yrs (range 0.08-11.75 yrs) from the end of treatment. Of these 14 (9.3%) had stricture recurrence and were retreated endoscopically with placement of multiple stents, and the other 8 (5.3%) had newly formed common bile duct stones that were extracted. No stricture or stone recurrences after retreatment were recorded after a mean follow-up of further 4.4 yrs (range 0.05-14.08 yrs). One hundred and forty-two (85.4%) patients remained asymptomatic with normal liver function test after a median follow-up of 7.12 years (range 0.0821.83 yrs). Conclusion: Endotherapy of PCBS by multiple plastic stents has effective and satisfactory results in this large cohort after long-term follow-up. Stricture recurrence rate is low and can be successfully retreated endoscopically.
Mo1344 Implementation of Diagnostic and Therapeutic Algorithm for Biliary Candidiasis Philipp Lenz1, Franziska Eckelskemper1, Andreas Uekoetter2, Torsten Beyna1, Hansjoerg Ullerich1, Andre Schmedt1, Frank Lenze1, Dirk Domagk*1 1 Department of Medicine B, University of Muenster, Muenster, Germany; 2Institute of Medical Microbiology, University of Muenster, Muenster, Germany Introduction: Biliary obstruction and cholangitis are common problems in gastroenterology and need specific therapeutic interventions. Infections of the biliary tract with Candida and other fungal species have increasingly been reported in the last few years. Aim of this study is to develop an algorithm for clinical diagnostics and treatment of biliary candidiasis. Patients and Methods: Since July 2011, 50 patients were included in the study (ClinicalTrials.gov Identifier: NCT01109550). During ERCP bile samples were taken and microbiologically analyzed. If appropriate, endoscopic transpapillary bile duct biopsies were taken for diagnosing an invasive fungal infection. Smears of the endoscope working channel were taken before and after the examination. Buccal smears and stool samples were supposed to show the individual transient
AB395 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
Abstracts
flora. Additionally, candida-antigen-serology and blood-cultures were gained. The different clinical information were integrated in a treatment algorithm to define an indication for antifungal treatment (figure 1). Results: Microbiological
cholangiocarcinoma (128 patients with B-C type III-IV tumors) who had undergone unilateral ENBD between January 2007 and December 2010. The success and efficacy of this procedure and the risk factors for post-ENBD cholangitis and pancreatitis were retrospectively evaluated. Results: The ENBD was successful in 153 (93.3%) of the 164 patients. Of these 164 patients, 65 had total serum bilirubin (TB) levels ⬎ 2.0 mg/dL prior to the drainage. The first unilateral ENBD was successfully performed in 60 of the 65 patients, and the TB level decreased to ⬍ 2.0 mg/dL after the ENBD in 50 of these 60 patients (83.3%). The significant predictive factors for ENBD efficacy included the preENBD TB level (P ⫽ 0.032, 95% CI: 1.01-1.23) and post-ENBD cholangitis (P ⫽ 0.012, 95% CI: 1.61-43.2). Post-ENBD cholangitis occurred in 47 (28.8%) of the 163 patients, and a previous endoscopic sphincterotomy (EST) was found to be a significant risk factor for post-ENBD cholangitis (P ⫽0.008, 95% CI: 1.30-5.46). Post-ENBD pancreatitis occurred in 33 (20.1%) of the 164 patients (26 mild patients, 4 moderate patients, and 3 severe patients). The significant risk factors included undergoing pancreatography (P ⬍0.001, 95% CI: 2.44-31.1) and the absence of previous endoscopic biliary stenting (EBS) or ENBD (P ⬍0.001, 95% CI: 3.03-29.2). Conclusions: Unilateral ENBD of the future remnant lobe(s) exhibited a high success rate, suggesting that it is an effective and suitable preoperative drainage method for perihilar cholangiocarcinoma, even in patients with B-C type III-IV tumors. To reduce the post-procedural complications, ENBD should be performed without EST or pancreatography.
Mo1346 Is Endoscopic Sphincterotomy (EST) Unnecessary as an Urgent Treatment for Acute Obstructive Suppurative Cholangitis (AOSC)? Soichiro Morikawa*, Azumi Suzuki, Kenjiro Yasuda Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
Figure 1 Suggested diagnostic and therapeutic algorithm for biliary candidiasis.
analysis data were fully available in 44 of 50 patients. In 13 of 44 patients, we found Candida species in the bile (30%). As potential risk factor for biliary candidiasis long-term antibiotic therapy (⬎ 7 days) could be identified (p ⬍ 0.05). Two of these 13 patients were treated with echinocandins according to our treatment algorithm; one patient with progressive gallbladder cancer and liver metastasis and the other with biliary cast syndrome after cardiopulmonary resuscitation. No invasive mycosis could be identified histologically. In 27 of 44 patients we found candida in the buccal smears (61,4 %). Only in 2 of 44 cases we found candida at the endoscope channel before the endoscopic examination; these findings were only achieved after enhancement of mycological cultures. Remarkably, the species were different from those found in the bile. No significant associations of prior endoscopic sphincterotomy (p ⫽ 0.557) or prior ERCP (p ⫽ 0.561) and biliary candidiasis were found. No positive fungal culture of blood samples was obtained. Conclusion: This ongoing study offers interesting clinical information about the microbiological flora of the bile in patients with biliary disease. The preliminary data indicate that the suggested therapeutic algorithm for biliary candidiasis seems to be appropriate in daily routine. Whether transpapillary biopsies are necessary in the diagnosis of biliary candidiasis remains controversial.
Mo1345 The Efficacy and Complications of Preoperative Endoscopic Nasobiliary Drainage (ENBD) in Perihilar Cholangiocarcinoma Patients Hiroki Kawashima*1, Akihiro Itoh1, Eizaburo Ohno2, Yuya Itoh1, Yosuke Nakamura2, Takeshi Hiramatsu1, Hiroyuki Sugimoto1, Hajime Sumi1, Ryoji Miyahara2, Naoki Ohmiya1, Hidemi Goto1, Yoshiki Hirooka2 1 Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Endoscopy, Nagoya University Hospital, Nagoya, Japan Background/Aims: The advantages of endoscopic nasobiliary drainage (ENBD) have been previously reported. However, no studies to date have examined a large number of subjects, including those with Bismuth-Corlette (B-C) type III-IV tumors. Additionally, sufficient data on the risk factors associated with ENBD complications are not available. This study’s aims are to assess the clinical benefits of preoperative ENBD in patients with perihilar cholangiocarcinoma. Methods: This study involved 164 consecutive patients with suspected perihilar
www.giejournal.org
Background: Because AOSC sometimes rapidly progress to a severe form accompanied by organ dysfunction, caused by the systemic inflammatory response syndrome (SIRS) and/or sepsis, prompt urgent treatment including EST and endoscopic biliary stenting (EBS) is necessary. However an additional procedure such as EST sometimes lead to a complication. Objectives: To assess the technical success, complications and clinical outcomes of urgent ERCP related procedure for AOSC. Patients and Methods: Data was collected retrospectively on patients who underwent urgent ERCP related procedure for AOSC by reviewing hospital charts from January 2006 to December 2011. Main outcome measurements are technical success, complications, and clinical outcome. A total of 334 patients underwent urgent ERCP related procedure for AOSC. Median patient age was 79 years (range, 19-101 years) and 208 patients were male. AOCS was caused by common bile duct stone in 220 (65.9%), malignant biliary stricture in 100 (29.9%), benign biliary stricture in 12 (3.6%), choledochal cyst in 1 (0.3%), primary sclerosing cholangitis in 1 (0.3%). Nine patients were associated with pancreatitis due to common bile duct stone. We classified the severity of all patients with AOSC except for nine patients associated with pancreatitis into three grades, mild, moderate, and severe using Japanese Guideline. We classified 56 patients (17.2%) in severe, 224 (68.9%) in moderate, and 45 (13.8%) in mild. Of the 334 patients, 160 (47.9%) have a past history of EST and the remaining 184 (52.1%) have a naive papilla. There were 31 patients (9.3%) on oral anticoagulants and/or antiplatelet agent. We performed EST on 99 patients and EBS without EST on 62 patients with naive papilla. Results: The urgent ERCP related procedure was successful in 328 patients (98.2%). All of 6 patients whom urgent ERCP related procedure finished unsuccessfully have a naive papilla. An urgent percutaneous transhepatic biliary drainage was required only for one patient of these 6. The other 5 patients were treated conservatively. There were no severe complications. The post-ERCP pancreatitis arose in 8 patients (2.8%), but all of these patients recovered conservatively. Seven of these 8 patients underwent EST. There were no complications in EBS without EST group. Among the patients with a naive papilla, the incidence of post-ERCP pancreatitis of EST group and EBS without EST group were 7.1% (7/99) and 0% (0/62)(p⬍0.05) respectively. All the patients recovered and were able to leave our hospital. Conclusions: Urgent ERCP related procedure for AOSC were safe and effective. But in our series, incidence of postERCP pancreatitis was more frequent in EST group. In the case of urgent treatment for AOSC, especially for the patients with a naive papilla, we should consider to perform EBS without EST.
Mo1347 The Intramucosal Incision Technique: Converting Complication Into Success Ashish K. Jha, Mahesh Goenka*, Pranav K. Mandal, Sanjeev Kumar Institute of Gastroscience, Apollo Gleneagles Hospital, Kolkata, India Background: The precut sphincterotomy is used to facilitate selective biliary access in difficult procedures. Needle-knife precut papillotomy is standard of care but is associated with high rate of complications. Formation of false tract
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB396