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Mo1460 Endoscopic Snare Papillectomy for Early Invasive Cancer of the Papilla of Vater: A Clinico-Pathological Analysis
Abstracts
Mo1458 Patients, Endoscopist’s and Nursing Staff Radiation Exposure During Interventional ERCP Procedures John A. Karagiannis1, Virginia Tsapaki2, Konstantina D. Paraskeva1, Nicoletta G. Mathou1, Charikleia Triantopoulou2 1 Gastroenterology Unit, “Konstantopoulio” Hospital, Athens, Greece; 2 Radiology, ”Konstantopoulio” Hospital, Athens, Greece Background: Although the number of various therapeutic procedures during ERCP are increasing exponentially almost yearly, information regarding the levels of radiation dose, and thus the safety for both the patient and the endoscopist, are inadequately studied. Aim of the study: To investigate radiation exposure dose levels for the endoscopist, nursing staff and the patient during several interventional procedures performed under ERCP. Patients and Methods: Data were collected for 987 patients-procedures in terms of patient age (A), KermaArea Product (KAP), fluoroscopy time (T) and total number of films (F) for a time period of 24 months. Six hundred thirty one (631) patients underwent endoscopic sphincterotomy (ES) plus balloon clearance of the common bile duct (Group A) and 356 had several other procedures (dilatations, plastic or metallic stent insertion, nasobiliary drainage) performed during ERCP (Group B). The Xray machine used was a conventional (non-digital) overcouch X-ray Philips Essenta system with automatic exposure control and with a KAP meter installed in the X-ray tube. Both the endoscopist and nursing staff were protected through a lead apron with collar, lead glasses and two articulated, ceiling-mounted, lead shields. Both endoscopist and nursing staff were radiation-monitored through a thermoluminescent dose-meter placed over the lead apron. Results: A large variation in KAP was observed in both Groups. Median radiation dose was 18.4 Gy/cm2 (range 8-371 Gy/cm2) for Group A and 31.0 Gy/cm2 (range 5.9-354 Gy/ cm2) for Group B (p⬍0.05, 95% CI). Corresponding median A, T and F values were 72 years, 1.5 min (range 0.5-13.7) and 1 X-ray film (range 1-3) for Group A and 75 years (p: ns), 2.5 min (range 1.2-8.2) (p⬍0.05, 95% CI) and 2 X-ray films (range 1-3) (p: ns) for Group B.Endoscopist and nursing staff monthly radiation was negligible (⬍0.0003 mSv), well below the 0.02 mSv monthly limit. Conclusions: a) With appropriate protective measures patient’s, endoscopist’s and nursing staff radiation can be minimal, even in complex interventional ERCP procedures, b) there is a relatively large variation in patient’s radiation dose in both less and more complex procedures with greater absolute values in the more complex ones.
Mo1459 Evaluation of a Fully Covered Self-Expanding Metal Stent in Malignant Biliary Obstruction: Follow-Up of a Multi-Center Study Jayant P. Talreja1, David E. Loren2, Thomas E. Kowalski2, Peter D. Stevens3, John M. Poneros3, Marisa A. Chow3, Isaac Raijman4, Divyesh V. Sejpal5, Sandeep Patel6, Laura Rosenkranz6, Kevin N. McNamara6, Alan Brijbassie1, Andrew Y. Wang1, Monica Gaidhane1, Amrita Sethi3, Michel Kahaleh1 1 Digestive Health, University of Virginia, Charlottesville, VA; 2 Gastroenterology, Thomas Jefferson, Philadelphia, PA; 3 Gastroenterology, Columbia University Medical Center, New York, NY; 4 Gastroenterology, Digestive Associates of Houston, Houston, TX; 5 Gastroenterology, Mount Sinai, New York, NY; 6Gastroenterology, University of Texas Health Science Center, San Antonio, TX Background and Aims: Limited data is available regarding fully covered metal stents in the management of malignant distal biliary strictures since its availability. The aim of this study was to evaluate the safety of a fully covered self-expanding metal stent (FCSEMS) in treating malignant biliary strictures at multiple institutions. We report our long term retrospective analysis from six centers. Methods: Between June 2007 and November 2010, 260 patients (142 males, median age 68 years) underwent ERCP with placement of FCSEMS (WallFlex, Boston Scientific, Natick, MA) for the palliation of obstructive jaundice in the setting of pancreatic adenocarcinoma (169), metastatic disease (36), cholangiocarcinoma (23), ampullary cancer (19), or other (13). Patients were evaluated clinically in follow-up and biochemical tests of liver function were obtained. Data was recorded for the following variables: patient survival, duration of stent patency, the need for subsequent biliary intervention and complications. Results: A total of 266 fully covered WallFlex stents were placed in 260 patients. There was a median survival of 100 days (range 7-531 days). There was a mean follow-up of 128 ⫾ 118 days (range 2-519 days). Biliary decompression was successful in 252 patients (97%). At the end of the study period, 121 were alive with a patent stent, 70 patients died with a patent stent, 40 patients were successfully bridged to surgery, 8 patients had their patent stent removed and no need for further stenting, 18 patients were lost to follow-up. Eight patients who had a successfully placed FCSEMS were considered a failure due to the following reason: migration (2), cholecystitis necessitating cholecystostomy placement (1), cholangitis (1), stent occlusion (1) intolerable pain (1), cystic duct obstruction (1), and removal for management of proximal biliary obstruction (1). Two additional patients experienced migration that did
not require FCSEMS removal or replacement. Stent replacement was required in 10 patients, of whom 6 had a second Wallflex placed. The remaining 4 were in the failure group and underwent replacement with either uncovered stents or plastic stents. Other complications, managed conservatively, included pain (2), post-ERCP pancreatitis (4), fever (1), retroperitoneal perforation (1) and postsphincterotomy bleeding (1). The mean patency duration was 328 days (SE 19.04). The patency percentage was 83% at 3 months, 63% at 6 months and 48.5% at 12 months. Conclusion: In the management of malignant distal biliary strictures, the fully covered Wallflex stent has acceptable patency and complication rates and achieves adequate biliary decompression in the majority of patients. Further long term prospective data are required to confirm this observation.
Mo1460 Endoscopic Snare Papillectomy for Early Invasive Cancer of the Papilla of Vater: A Clinico-Pathological Analysis Pietro Familiari1, Gianluigi Petrone2, Mika Matsuoka1, Massimiliano Mutignani1, Riccardo Ricci2, Vincenzo Perri1, Andrea Tringali1, Ivo Boskoski1, Cristiano Spada1, Paola Cesaro1, Guido Rindi2, Guido Costamagna1 1 Digestive Endoscopy Unit, Universita’ Cattolica del Sacro Cuore, Rome, Italy; 2Department of Pathology, Universita’ Cattolica del Sacro Cuore, Rome, Italy Background: Endoscopic Snare Papillectomy (ESP) is the standard of care for ampullary adenomas and in-situ carcinomas. Pancreaticoduodenectomy (PD) is performed for the treatment of invasive cancer, even if limited to the papilla of Vater (T1), because of the risk of local recurrences, nodal and distant metastases.PD is associated with significant morbidity and mortality, and may be precluded to many patients. Aim of the study is to evaluate the role of ESP in the management early stage invasive cancers of the papilla of Vater. Patients & Methods: Between 2000 and June 2009, 25 patients (mean age 68 years, range 36-87; 15 males) with an invasive adenocarcinoma apparently limited to the papilla of Vater (Tis excluded) underwent ESP in a single academic endoscopy center. After ESP, some patients underwent additional surgery (PD). Others, unfit-for-surgery, were followed-up. The findings of the pathological on ESP specimens (including tumor dimensions, grading, depth of infiltration, lymphovascular invasion, analysis of the margins of the resection) were compared with the findings after PD or with the outcomes of follow-up. Mean follow-up after ESP was 25.3 months. Results: Mean tumor diameter was 20.6 mm (range 460mm). Twenty patients underwent enbloc resection. Eight tumors were well-, 13 moderately- and 4 poorly- differentiated. Eight cancer invaded the lamina propria, 6 the submucosa, 11 the sphincter of Oddi or the duodenal wall. Only 4 specimens had disease-free margins, 15 were not assessable, 6 were clearly invaded. Lympho-vascular invasion was seen in 3 specimens.Ten patients underwent additional PD. Residual disease was seen on 7 of the surgical specimens (70%); lymph nodes were positive in 2 cases. Perioperative mortality was 20%. Fifteen patients, unfit for surgery, underwent follow-up (mean 27.7 months, 1-81 months). Nine (60%) had recurrent/residual adenomas or cancer and were re-treated by endoscopy; 1 patient (6.7%) was lost at follow-up; 2 patients (13.3%) are alive with local recurrences, 31 months after ESP; 7 (46.7%), included two re-treatments, are disease-free, 28.8 months after ESP; 4 patients (26.6%) died for disease progression, 17 months after ESP; 1 patient died for mammalian cancer, 81 months after ESP. Including the re-treated patients and 3
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Abstracts
patients who were found to be disease-free at the pathological evaluation after PD, ESP had been curative for 11/25 patients (44%). No correlations between nodal metastases or local recurrence and the pathological analysis of the specimens were observed. Conclusion: Patients who are diagnosed with an invasive T1 ampullary carcinoma after ESP are better treated surgically. ESP can be curative in part of the patients with invasive cancer, and thus should be always considered for patients unfit for surgery with small ampullary cancers.
Mo1461 Biliary-Enteric Anastomotic Stricturoplasty Using OvertubeAssisted Enteroscopy ERCP in Patients With Long Limb Surgical Biliary Bypass Raj J. Shah, Maximiliano Smolkin, James R. Burton, Brian C. Brauer Medicine, University of Colorado Denver, Aurora, CO BACKGROUND: Limited data exists on ERCP in long limb surgical biliary bypass (LLSBB) patients. A subset of Roux-Y liver transplant and other LLSBB develop benign biliary-enteric anastomotic strictures (AS). Conventionally, patients undergo PTC and multiple drain exchanges. Surgical revision may be required. Only case reports exist on ERCP techniques to treat AS in patients with LLSBB. AIM: Evaluate the technical and clinical success of ERCP treatment of AS in patients with LLSBB. METHODS: Consecutive patients from one referral center were retrospectively identified from a prospectively maintained database. Rotational overtube (Spirus Medical)-assisted enteroscopy (Olympus) ERCP (RoE) was used. AS was defined as hepaticojejunal anastomotic stenosis associated with upstream ductal dilatation plus elevated cholestatic hepatic enzymes (LFTs) and/or cholangitis episodes. AS Stricturoplasty: either cautery (needle-knife or pull-type sphincterotome) and/or dilation (passage catheter or balloon). Primary Endpoint: Greater than 50% reduction in LFTs at minimum one month follow-up and/or resolution of cholangitis episodes. RESULTS: From September 2008 to September 2010, 41 pts had RoE of whom 11 had AS identified. Prior nonovertube assisted ERCP attempts 2/11 (18%). Anatomy was Roux-Y hepaticojejunostomy: liver transplant (live donor, N⫽5; cadaveric, N⫽1), cholecystectomy injury revision (N⫽3), other (N⫽2). Indications: Elevated LFTs ⫹/- pain (N⫽4), cholangitis (N⫽3), jaundice (N⫽2), AS by PTC (N⫽2). Stricturoplasty was performed in 11 patients, 4 of whom had ⱖ 2 anastomoses treated. Technique included dilation (N⫽4), cautery (N⫽2), or both (N⫽5). Cautery techniques were free hand needle-knife (N⫽5), pull-type sphincterotome (N⫽1), or both (N⫽1). Stents were placed in 4/11 (36%) and failed in 1/11 (9%). Two patients had biliary stones removed. Complications: needle-knife perforation treated with endoclip alone (N⫽1). Follow-up obtained in 11/11 (100%) for a median of 12 months (range 2-21). Primary Endpoint reached in 100%: improvement in LFTs (N⫽6), LFTs and pain (N⫽3), or resolution of cholangitis episodes (N⫽2). However, repeat stricturoplasty was performed in 2/11 (18%) at 4 and 10 months, respectively, with the former requiring subsequent PTC. An additional three patients had repeat RoE for stent/ stone removal (N⫽3). The two patients with PTC drains prior to RoE and stricturoplasty have not required further PTC. No patients have required surgical revision. CONCLUSIONS: 1) In expert hands, given its high technical success, biliary-enteric stricturoplasty for anastomotic strictures in patients with LLSBB using overtube-assisted ERCP may be a preferred alternative to PTC or surgery. 2) In most patients at one-year of follow-up, the technique resulted in sustained improvement of elevated LFTs or cholangitis episodes after a single stricturoplasty session.
Mo1462 The Effect of Endoscopic Gallbladder Drainage for Management of Acute Cholecystitis Natsuyo Yamamoto1, Hiroyuki Isayama1, Kazumichi Kawakubo1, Saburo Matsubara1, Kenji Hirano1, Tsuyoshi Hamada1, Rie Nagano1, Koji Miyabayashi1, Dai Mohri1, Hirofumi Kogure1, Takashi Sasaki1, Naoki Sasahira1, Takeshi Tsujino1, Minoru Tada1, Masao Omata2, Kazuhiko Koike1 1 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 2Yamanashi Prefectural Hospital Organization, Kohu, Japan Background & Aim: Recently endoscopic gallbladder drainage (EGD) for management of acute cholecystitis has been reported as salvage therapy which was received for surgically high-risk patients or technically contraindicated of percutaneous approach. Though the numbers of cases were small, technical success rates of EGD which have been reported were lower than that of percutaneous transhepatic gallbladder drainage (PTGBD). However the risk factors of failure have not been well studied. Patients & Methods: Between 2004 and 2010, EGD for acute cholecystitis was attempted in 55 patients with a median age of 75 (from 49 to 93). After selective deep cannulation of the cystic duct, a 7Fr pigtail-type naso-biliary tube or a 7Fr double pigtail-type plastic stent was placed. Drainage tube was removed after symptom and laboratory data were improved. The rate of success, clinical response and early complication
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(within a week) were evaluated. Results: The 55 patients included 23 patients of taking anticoagulation or antiplatelet agents, 5 patients of hepatic cirrhosis with ascites, and 32 patients at high risk for surgical treatment. EGD was technically successful in 41(74.5%) patients. Clinical improvement was achieved in 40 of 41(97.6%) patients. One patient underwent PTGBD within 5 days because cholecystitis was not improved by EGD. In 14 failed patients, PTGBD was undergone subsequently. The causes of failure were difficult bile duct annulation in 3, an undetectable orifice of cystic duct in 3, and failure to pass guidewire or catheter into the cystic duct in 7 patients. Biliary stenosis at the orifice of cystic duct was observed in 6 of 11(54.5%) of failed patients. The rate of biliary stenosis was higher in the cases of failure than in the cases of success (8/ 41(19.5%)).Five of 55(9.1%) patients experienced early complications; post-ERCP pancreatitis in 3 and perforation of cystic duct during procedure in 2 patients, all of which were treated conservatively. The 23 patients who had not undergone cholecystectomy after successful EGD were followed for a median time of 14 months (from 1 to 70 months). Biliary-related event was observed in 4(17.4%) patients. Acute cholecystitis was observed in one and acute cholangitis was occurred in 3 patients. Conclusion: EGD was technically safe and effective for the management of acute cholecystitis. Biliary stenosis may affect the rate of technical success.
Mo1463 Is Liquid-Based Cytopathology Superior Than Conventional Smear Method in Preparation Method of Endoscopic Biliary Brushing Cytology? Jae Woo Kim1, Hyo Keun Jeon1, Hyun-Soo Kim1, Hong Jun Park1, So Yeon Park1, Bo Ra Kim1, Mee-Yon Cho2 1 Department of internal medicine, Yonsei university wonju college of medicine, Wonju, Republic of Korea; 2Departement of pathology, Yonsei university wonju colleg of medicine, Wonju, Republic of Korea Background: The use of endobiliary brush cytology to definitely diagnose malignant biliary strictures has been shown to be useful during ERCP. Liquidbased cytology decreases technical problems due to poor fixation, air drying, and interpretive problems caused by cell overlap. The objective of this study was to assess the accuracy of brush cytology in biliary strictures and the efficacy of conventional smear method and liquid-based technology. Methods: From a total of 2,236 endoscopic retrograde cholangiopancreatography performed between August 2006 and February 2010 at our center, all biliary brushing cytologies were reviewed. A total of 121 patients met the inclusion criteria for the study. The mean age was 66 (24-90) with 68.6% male. The subjects were 61 patients with biliary stricture who underwent brushing cytology with conventional smear method between August 2006 and August 2008 and 60 patients with liquid cytopathology, such as ThinPrep®, between September 2008 and February 2010. In our study, positive biliary brushing cytology was defined as suspicious for malignancy or positive for malignancy. In the absence of histopathological diagnosis, criteria for a final clinical diagnosis of malignant disease were clinical deterioration and progression of malignancy on subsequent imaging studies, and the criterion for a final clinical diagnosis of benign disease was the absence of features of malignancy during a minimal follow up of 6 months. Results: The 102 patients (84.3%) had malignant and 19 (15.7%) patients had benign strictures. The 29 patients had pancreatic cancer, 49 had extrahepatic cholangiocarcinoma, 17 had gallbladder cancer, 5 had intrahepatic cholangiocarcinoma, and 2 had metastatic lymphadenopathy. Cytological brushing confirmation was obtained in 75.5% (77/102) of patients with malignant strictures. Nineteen patients had benign disease, commonly strictures secondary to chronic pancreatitis and biliary stones. Overall, the diagnostic sensitivity, specificity, positive predictive value(PPV), and negative predictive value(NPV) of brush cytology by conventional smear method were 79.5%, 100%, 100%, and 65.4%, respectively. In the contrary, the diagnostic sensitivity, specificity, PPV, and NPV of brush cytology by liquid cytopathology were 72.4%, 100%, 100%, and 11.1%, respectively. Among all variables studied including age, length of stricture, laboratory results, type of stricture, and preparation method of brushing cytology, only age more than 60 years (p⫽0.026) is associated with positive yield on biliary brushing cytology. Preparation method of brushing cytology was not found to be associated with a higher cytology yield. Conclusion: Our results showed a high sensitivity (75.5%) for biliary brushing cytology, but didn’t showed that the liquid based cytopathology, such as ThinPrep, was superior than the conventional smear method.
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Mo1458 Patients, Endoscopist’s and Nursing Staff Radiation Exposure During Interventional ERCP Procedures John A. Karagiannis1, Virginia Tsapaki2, Konstantina D. Paraskeva1, Nicoletta G. Mathou1, Charikleia Triantopoulou2 1 Gastroenterology Unit, “Konstantopoulio” Hospital, Athens, Greece; 2 Radiology, ”Konstantopoulio” Hospital, Athens, Greece Background: Although the number of various therapeutic procedures during ERCP are increasing exponentially almost yearly, information regarding the levels of radiation dose, and thus the safety for both the patient and the endoscopist, are inadequately studied. Aim of the study: To investigate radiation exposure dose levels for the endoscopist, nursing staff and the patient during several interventional procedures performed under ERCP. Patients and Methods: Data were collected for 987 patients-procedures in terms of patient age (A), KermaArea Product (KAP), fluoroscopy time (T) and total number of films (F) for a time period of 24 months. Six hundred thirty one (631) patients underwent endoscopic sphincterotomy (ES) plus balloon clearance of the common bile duct (Group A) and 356 had several other procedures (dilatations, plastic or metallic stent insertion, nasobiliary drainage) performed during ERCP (Group B). The Xray machine used was a conventional (non-digital) overcouch X-ray Philips Essenta system with automatic exposure control and with a KAP meter installed in the X-ray tube. Both the endoscopist and nursing staff were protected through a lead apron with collar, lead glasses and two articulated, ceiling-mounted, lead shields. Both endoscopist and nursing staff were radiation-monitored through a thermoluminescent dose-meter placed over the lead apron. Results: A large variation in KAP was observed in both Groups. Median radiation dose was 18.4 Gy/cm2 (range 8-371 Gy/cm2) for Group A and 31.0 Gy/cm2 (range 5.9-354 Gy/ cm2) for Group B (p⬍0.05, 95% CI). Corresponding median A, T and F values were 72 years, 1.5 min (range 0.5-13.7) and 1 X-ray film (range 1-3) for Group A and 75 years (p: ns), 2.5 min (range 1.2-8.2) (p⬍0.05, 95% CI) and 2 X-ray films (range 1-3) (p: ns) for Group B.Endoscopist and nursing staff monthly radiation was negligible (⬍0.0003 mSv), well below the 0.02 mSv monthly limit. Conclusions: a) With appropriate protective measures patient’s, endoscopist’s and nursing staff radiation can be minimal, even in complex interventional ERCP procedures, b) there is a relatively large variation in patient’s radiation dose in both less and more complex procedures with greater absolute values in the more complex ones.
Mo1459 Evaluation of a Fully Covered Self-Expanding Metal Stent in Malignant Biliary Obstruction: Follow-Up of a Multi-Center Study Jayant P. Talreja1, David E. Loren2, Thomas E. Kowalski2, Peter D. Stevens3, John M. Poneros3, Marisa A. Chow3, Isaac Raijman4, Divyesh V. Sejpal5, Sandeep Patel6, Laura Rosenkranz6, Kevin N. McNamara6, Alan Brijbassie1, Andrew Y. Wang1, Monica Gaidhane1, Amrita Sethi3, Michel Kahaleh1 1 Digestive Health, University of Virginia, Charlottesville, VA; 2 Gastroenterology, Thomas Jefferson, Philadelphia, PA; 3 Gastroenterology, Columbia University Medical Center, New York, NY; 4 Gastroenterology, Digestive Associates of Houston, Houston, TX; 5 Gastroenterology, Mount Sinai, New York, NY; 6Gastroenterology, University of Texas Health Science Center, San Antonio, TX Background and Aims: Limited data is available regarding fully covered metal stents in the management of malignant distal biliary strictures since its availability. The aim of this study was to evaluate the safety of a fully covered self-expanding metal stent (FCSEMS) in treating malignant biliary strictures at multiple institutions. We report our long term retrospective analysis from six centers. Methods: Between June 2007 and November 2010, 260 patients (142 males, median age 68 years) underwent ERCP with placement of FCSEMS (WallFlex, Boston Scientific, Natick, MA) for the palliation of obstructive jaundice in the setting of pancreatic adenocarcinoma (169), metastatic disease (36), cholangiocarcinoma (23), ampullary cancer (19), or other (13). Patients were evaluated clinically in follow-up and biochemical tests of liver function were obtained. Data was recorded for the following variables: patient survival, duration of stent patency, the need for subsequent biliary intervention and complications. Results: A total of 266 fully covered WallFlex stents were placed in 260 patients. There was a median survival of 100 days (range 7-531 days). There was a mean follow-up of 128 ⫾ 118 days (range 2-519 days). Biliary decompression was successful in 252 patients (97%). At the end of the study period, 121 were alive with a patent stent, 70 patients died with a patent stent, 40 patients were successfully bridged to surgery, 8 patients had their patent stent removed and no need for further stenting, 18 patients were lost to follow-up. Eight patients who had a successfully placed FCSEMS were considered a failure due to the following reason: migration (2), cholecystitis necessitating cholecystostomy placement (1), cholangitis (1), stent occlusion (1) intolerable pain (1), cystic duct obstruction (1), and removal for management of proximal biliary obstruction (1). Two additional patients experienced migration that did
not require FCSEMS removal or replacement. Stent replacement was required in 10 patients, of whom 6 had a second Wallflex placed. The remaining 4 were in the failure group and underwent replacement with either uncovered stents or plastic stents. Other complications, managed conservatively, included pain (2), post-ERCP pancreatitis (4), fever (1), retroperitoneal perforation (1) and postsphincterotomy bleeding (1). The mean patency duration was 328 days (SE 19.04). The patency percentage was 83% at 3 months, 63% at 6 months and 48.5% at 12 months. Conclusion: In the management of malignant distal biliary strictures, the fully covered Wallflex stent has acceptable patency and complication rates and achieves adequate biliary decompression in the majority of patients. Further long term prospective data are required to confirm this observation.
Mo1460 Endoscopic Snare Papillectomy for Early Invasive Cancer of the Papilla of Vater: A Clinico-Pathological Analysis Pietro Familiari1, Gianluigi Petrone2, Mika Matsuoka1, Massimiliano Mutignani1, Riccardo Ricci2, Vincenzo Perri1, Andrea Tringali1, Ivo Boskoski1, Cristiano Spada1, Paola Cesaro1, Guido Rindi2, Guido Costamagna1 1 Digestive Endoscopy Unit, Universita’ Cattolica del Sacro Cuore, Rome, Italy; 2Department of Pathology, Universita’ Cattolica del Sacro Cuore, Rome, Italy Background: Endoscopic Snare Papillectomy (ESP) is the standard of care for ampullary adenomas and in-situ carcinomas. Pancreaticoduodenectomy (PD) is performed for the treatment of invasive cancer, even if limited to the papilla of Vater (T1), because of the risk of local recurrences, nodal and distant metastases.PD is associated with significant morbidity and mortality, and may be precluded to many patients. Aim of the study is to evaluate the role of ESP in the management early stage invasive cancers of the papilla of Vater. Patients & Methods: Between 2000 and June 2009, 25 patients (mean age 68 years, range 36-87; 15 males) with an invasive adenocarcinoma apparently limited to the papilla of Vater (Tis excluded) underwent ESP in a single academic endoscopy center. After ESP, some patients underwent additional surgery (PD). Others, unfit-for-surgery, were followed-up. The findings of the pathological on ESP specimens (including tumor dimensions, grading, depth of infiltration, lymphovascular invasion, analysis of the margins of the resection) were compared with the findings after PD or with the outcomes of follow-up. Mean follow-up after ESP was 25.3 months. Results: Mean tumor diameter was 20.6 mm (range 460mm). Twenty patients underwent enbloc resection. Eight tumors were well-, 13 moderately- and 4 poorly- differentiated. Eight cancer invaded the lamina propria, 6 the submucosa, 11 the sphincter of Oddi or the duodenal wall. Only 4 specimens had disease-free margins, 15 were not assessable, 6 were clearly invaded. Lympho-vascular invasion was seen in 3 specimens.Ten patients underwent additional PD. Residual disease was seen on 7 of the surgical specimens (70%); lymph nodes were positive in 2 cases. Perioperative mortality was 20%. Fifteen patients, unfit for surgery, underwent follow-up (mean 27.7 months, 1-81 months). Nine (60%) had recurrent/residual adenomas or cancer and were re-treated by endoscopy; 1 patient (6.7%) was lost at follow-up; 2 patients (13.3%) are alive with local recurrences, 31 months after ESP; 7 (46.7%), included two re-treatments, are disease-free, 28.8 months after ESP; 4 patients (26.6%) died for disease progression, 17 months after ESP; 1 patient died for mammalian cancer, 81 months after ESP. Including the re-treated patients and 3
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Abstracts
patients who were found to be disease-free at the pathological evaluation after PD, ESP had been curative for 11/25 patients (44%). No correlations between nodal metastases or local recurrence and the pathological analysis of the specimens were observed. Conclusion: Patients who are diagnosed with an invasive T1 ampullary carcinoma after ESP are better treated surgically. ESP can be curative in part of the patients with invasive cancer, and thus should be always considered for patients unfit for surgery with small ampullary cancers.
Mo1461 Biliary-Enteric Anastomotic Stricturoplasty Using OvertubeAssisted Enteroscopy ERCP in Patients With Long Limb Surgical Biliary Bypass Raj J. Shah, Maximiliano Smolkin, James R. Burton, Brian C. Brauer Medicine, University of Colorado Denver, Aurora, CO BACKGROUND: Limited data exists on ERCP in long limb surgical biliary bypass (LLSBB) patients. A subset of Roux-Y liver transplant and other LLSBB develop benign biliary-enteric anastomotic strictures (AS). Conventionally, patients undergo PTC and multiple drain exchanges. Surgical revision may be required. Only case reports exist on ERCP techniques to treat AS in patients with LLSBB. AIM: Evaluate the technical and clinical success of ERCP treatment of AS in patients with LLSBB. METHODS: Consecutive patients from one referral center were retrospectively identified from a prospectively maintained database. Rotational overtube (Spirus Medical)-assisted enteroscopy (Olympus) ERCP (RoE) was used. AS was defined as hepaticojejunal anastomotic stenosis associated with upstream ductal dilatation plus elevated cholestatic hepatic enzymes (LFTs) and/or cholangitis episodes. AS Stricturoplasty: either cautery (needle-knife or pull-type sphincterotome) and/or dilation (passage catheter or balloon). Primary Endpoint: Greater than 50% reduction in LFTs at minimum one month follow-up and/or resolution of cholangitis episodes. RESULTS: From September 2008 to September 2010, 41 pts had RoE of whom 11 had AS identified. Prior nonovertube assisted ERCP attempts 2/11 (18%). Anatomy was Roux-Y hepaticojejunostomy: liver transplant (live donor, N⫽5; cadaveric, N⫽1), cholecystectomy injury revision (N⫽3), other (N⫽2). Indications: Elevated LFTs ⫹/- pain (N⫽4), cholangitis (N⫽3), jaundice (N⫽2), AS by PTC (N⫽2). Stricturoplasty was performed in 11 patients, 4 of whom had ⱖ 2 anastomoses treated. Technique included dilation (N⫽4), cautery (N⫽2), or both (N⫽5). Cautery techniques were free hand needle-knife (N⫽5), pull-type sphincterotome (N⫽1), or both (N⫽1). Stents were placed in 4/11 (36%) and failed in 1/11 (9%). Two patients had biliary stones removed. Complications: needle-knife perforation treated with endoclip alone (N⫽1). Follow-up obtained in 11/11 (100%) for a median of 12 months (range 2-21). Primary Endpoint reached in 100%: improvement in LFTs (N⫽6), LFTs and pain (N⫽3), or resolution of cholangitis episodes (N⫽2). However, repeat stricturoplasty was performed in 2/11 (18%) at 4 and 10 months, respectively, with the former requiring subsequent PTC. An additional three patients had repeat RoE for stent/ stone removal (N⫽3). The two patients with PTC drains prior to RoE and stricturoplasty have not required further PTC. No patients have required surgical revision. CONCLUSIONS: 1) In expert hands, given its high technical success, biliary-enteric stricturoplasty for anastomotic strictures in patients with LLSBB using overtube-assisted ERCP may be a preferred alternative to PTC or surgery. 2) In most patients at one-year of follow-up, the technique resulted in sustained improvement of elevated LFTs or cholangitis episodes after a single stricturoplasty session.
Mo1462 The Effect of Endoscopic Gallbladder Drainage for Management of Acute Cholecystitis Natsuyo Yamamoto1, Hiroyuki Isayama1, Kazumichi Kawakubo1, Saburo Matsubara1, Kenji Hirano1, Tsuyoshi Hamada1, Rie Nagano1, Koji Miyabayashi1, Dai Mohri1, Hirofumi Kogure1, Takashi Sasaki1, Naoki Sasahira1, Takeshi Tsujino1, Minoru Tada1, Masao Omata2, Kazuhiko Koike1 1 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 2Yamanashi Prefectural Hospital Organization, Kohu, Japan Background & Aim: Recently endoscopic gallbladder drainage (EGD) for management of acute cholecystitis has been reported as salvage therapy which was received for surgically high-risk patients or technically contraindicated of percutaneous approach. Though the numbers of cases were small, technical success rates of EGD which have been reported were lower than that of percutaneous transhepatic gallbladder drainage (PTGBD). However the risk factors of failure have not been well studied. Patients & Methods: Between 2004 and 2010, EGD for acute cholecystitis was attempted in 55 patients with a median age of 75 (from 49 to 93). After selective deep cannulation of the cystic duct, a 7Fr pigtail-type naso-biliary tube or a 7Fr double pigtail-type plastic stent was placed. Drainage tube was removed after symptom and laboratory data were improved. The rate of success, clinical response and early complication
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(within a week) were evaluated. Results: The 55 patients included 23 patients of taking anticoagulation or antiplatelet agents, 5 patients of hepatic cirrhosis with ascites, and 32 patients at high risk for surgical treatment. EGD was technically successful in 41(74.5%) patients. Clinical improvement was achieved in 40 of 41(97.6%) patients. One patient underwent PTGBD within 5 days because cholecystitis was not improved by EGD. In 14 failed patients, PTGBD was undergone subsequently. The causes of failure were difficult bile duct annulation in 3, an undetectable orifice of cystic duct in 3, and failure to pass guidewire or catheter into the cystic duct in 7 patients. Biliary stenosis at the orifice of cystic duct was observed in 6 of 11(54.5%) of failed patients. The rate of biliary stenosis was higher in the cases of failure than in the cases of success (8/ 41(19.5%)).Five of 55(9.1%) patients experienced early complications; post-ERCP pancreatitis in 3 and perforation of cystic duct during procedure in 2 patients, all of which were treated conservatively. The 23 patients who had not undergone cholecystectomy after successful EGD were followed for a median time of 14 months (from 1 to 70 months). Biliary-related event was observed in 4(17.4%) patients. Acute cholecystitis was observed in one and acute cholangitis was occurred in 3 patients. Conclusion: EGD was technically safe and effective for the management of acute cholecystitis. Biliary stenosis may affect the rate of technical success.
Mo1463 Is Liquid-Based Cytopathology Superior Than Conventional Smear Method in Preparation Method of Endoscopic Biliary Brushing Cytology? Jae Woo Kim1, Hyo Keun Jeon1, Hyun-Soo Kim1, Hong Jun Park1, So Yeon Park1, Bo Ra Kim1, Mee-Yon Cho2 1 Department of internal medicine, Yonsei university wonju college of medicine, Wonju, Republic of Korea; 2Departement of pathology, Yonsei university wonju colleg of medicine, Wonju, Republic of Korea Background: The use of endobiliary brush cytology to definitely diagnose malignant biliary strictures has been shown to be useful during ERCP. Liquidbased cytology decreases technical problems due to poor fixation, air drying, and interpretive problems caused by cell overlap. The objective of this study was to assess the accuracy of brush cytology in biliary strictures and the efficacy of conventional smear method and liquid-based technology. Methods: From a total of 2,236 endoscopic retrograde cholangiopancreatography performed between August 2006 and February 2010 at our center, all biliary brushing cytologies were reviewed. A total of 121 patients met the inclusion criteria for the study. The mean age was 66 (24-90) with 68.6% male. The subjects were 61 patients with biliary stricture who underwent brushing cytology with conventional smear method between August 2006 and August 2008 and 60 patients with liquid cytopathology, such as ThinPrep®, between September 2008 and February 2010. In our study, positive biliary brushing cytology was defined as suspicious for malignancy or positive for malignancy. In the absence of histopathological diagnosis, criteria for a final clinical diagnosis of malignant disease were clinical deterioration and progression of malignancy on subsequent imaging studies, and the criterion for a final clinical diagnosis of benign disease was the absence of features of malignancy during a minimal follow up of 6 months. Results: The 102 patients (84.3%) had malignant and 19 (15.7%) patients had benign strictures. The 29 patients had pancreatic cancer, 49 had extrahepatic cholangiocarcinoma, 17 had gallbladder cancer, 5 had intrahepatic cholangiocarcinoma, and 2 had metastatic lymphadenopathy. Cytological brushing confirmation was obtained in 75.5% (77/102) of patients with malignant strictures. Nineteen patients had benign disease, commonly strictures secondary to chronic pancreatitis and biliary stones. Overall, the diagnostic sensitivity, specificity, positive predictive value(PPV), and negative predictive value(NPV) of brush cytology by conventional smear method were 79.5%, 100%, 100%, and 65.4%, respectively. In the contrary, the diagnostic sensitivity, specificity, PPV, and NPV of brush cytology by liquid cytopathology were 72.4%, 100%, 100%, and 11.1%, respectively. Among all variables studied including age, length of stricture, laboratory results, type of stricture, and preparation method of brushing cytology, only age more than 60 years (p⫽0.026) is associated with positive yield on biliary brushing cytology. Preparation method of brushing cytology was not found to be associated with a higher cytology yield. Conclusion: Our results showed a high sensitivity (75.5%) for biliary brushing cytology, but didn’t showed that the liquid based cytopathology, such as ThinPrep, was superior than the conventional smear method.
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
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