Mo1491 SPY Cholangioscopy Guided Laser Lithotripsy for Extraction of Difficult Bile Duct Stones

Abstracts

remaining 100 with an AS, etiologies of liver failure included hepatitis C (51), non-alcohol and alcohol fatty liver disease (31), autoimmune hepatitis (7), other (11). Median duration from OLT to first ERCP and from first to last ERCP were 10.5 (interquartile range 7 - 32) and 168 (99 - 379) days respectively. Among 86 patients who have completed endoscopic therapy, 81 of 86 (94.2%) were successfully treated via ERCP without recurrence of AS, having a median followup of 763 days (31-1382). 5 patients had an AS recurrence requiring repeat stenting. The remaining 14 patients have ongoing stents.Patients required a median of 3.5 ERCPs (IQR, 3-5) with a median maximal number of stents of 3 (2-6). Alternatively, the median cumulative stent diameter was 20 Fr (range 754.6 Fr). The median total number of plastic stents was 3 (1-20). The median physician-specific charges per patient were $16,149 (10,223 - 23,071) and facilityspecific $23,067 (7,343 - 87,176) for facility charges specific to ERCP. The median total charges (physician ⫹ facility) per patient, per procedure were $10,735 (5,856 - 18,899). Conclusion: Endoscopic treatment of post-OLT AS is effective but requires multiple procedures and plastic stents, increasing health care costs. An alternative device such as a fully covered metallic stent may offer a less expensive alternative if stricture dilation can be achieved with fewer procedures.

Mo1490 A Head-to-Head Hands-On Comparison of ERCP Mechanical Simulator (EMS) and Ex-Vivo Porcine Stomach Model (PSM) Joseph W. Leung1,2, Dong Wang3, Bing Hu4, Brian S. Lim5, Felix W. Leung6 1 Gastroenterology, UC Davis Medical Center, Sacramento, CA; 2 Gastroenterology, Sacramento VA Medical Center, Mather, CA; 3 Gastroenterology, Changhai Hospital, Shanghai, China; 4 Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Shanghai, China; 5Gastroenterology, Riverside Kaiser Permanente Medical Center, Riverside, CA; 6Gastroenterology, Sepulveda ACC, VAGLAHS and David Geffen School of Medicine at UCLA, North Hills, CA Background: ERCP mechanical simulator (EMS) and Ex-vivo porcine stomach model (PSM) have been described for ERCP practice. No head-to-head comparison has been reported to reflect perception of trainees and trainers regarding the efficacy for incorporation into a training program. Objective: Comparative assessment of the EMS and PSM. Design: Questionnaire survey before and after practice with each simulator. Setting: Hands-on ERCP practice workshops. Subjects: 22 endoscopists with varying ERCP case experience (mean⫾SEM 111⫾225) participated. A minimum of 106⫾70 cases was rated necessary to gain basic ERCP experience. Interventions: Participants performed scope insertion, selective deep bile duct cannulation with a guide wire and insertion of a single biliary stent using the Olympus TJF-240 duodenoscope with accessories from Olympus. To monitor the guide wire and accessories in the bile duct, simulated fluoroscopy (external pin-hole camera) for EMS; and additional bright light transillumination for PSM, were used,Main outcome measure: Participants rated their confidence in performance the above ERCP techniques before and after simulator practice and the credibility (logical, improve skills, recommend, willing to practice and useful for other procedures) of the two methods in training. Comparative efficacy (based on pre and post survey responses 1⫽not, 10⫽very) of EMS and PSM for basic ERCP education was scored based on assessment of realism (tissue pliability, papilla anatomy, visual and cannulation realism, wire manipulation, simulated fluoroscopy, overall experience); usefulness (assessment of results e.g. stent placement, supplementing clinical ERCP experience, easy for trainees to learn new skills) and applicability (overall ease of use, prepare trainees to use real scope and accessories and ease of incorporating in training). Results: Before hands-on practice, both EMS and PSM received high scores. After practice, there was a significantly greater increase in confidence score for EMS in performing ERCP compared with PSM (Table 1). Participants also found EMS more useful for training but no significant difference between EMS and PSM in realism or application as an instructional tool for trainee education (Table 2). Limitations: Subjective scores. Conclusions: Based on head-to-head hands-on comparison, endoscopists considered both EMS and PSM credible options for improving performance of the ERCP procedure and in supplementing clinical ERCP training. They had greater confidence that the EMS is more useful than the PSM for the learning process. Table 1. Evaluation scores for simulators practice (Nⴝ22) Before Hands-on Practice Survey question Confidence (max⫽15) Credibility (max⫽50)

After Hands-on Practice

Change After Practice

PSM

EMS

PSM

EMS

PSM

EMS

P**

9.7⫾3.1

9.4⫾3.3

3.4⫾3.4

0.0202

40.0⫾9.0

12.8⫾2.0 P ⫽ 0.0001* 43.0⫾7.0 P ⫽ 0.1377*

2.0⫾2.5

39.2⫾7.0

11.6⫾2.2 P ⫽ 0.0013* 42.6⫾5.7 P ⫽ 0.0187*

3.5⫾6.4

3.0⫾9.0

0.8067

Data are mean⫾SD. *Versus baseline, paired t test **Change after practice, paired t test, PSM vs. EMS.

Table 2. Evaluation of PSM and EMS after hands-on practice Survey question Realism (max⫽70), N⫽22 Usefulness (max⫽30 ), N⫽20 Applicability (max⫽ 30), N⫽22

PSM

EMS

P*

52.6⫾8.7 22.2⫾2.9 22.8⫾3.8

48.7⫾11.4 24.5⫾2.2 24.0⫾2.8

0.1677 0.0013 0.1448

Data are mean⫾SD, *paired t test, PSM vs. EMS.

Mo1491 SPY Cholangioscopy Guided Laser Lithotripsy for Extraction of Difficult Bile Duct Stones Suryaprakash Bhandari, Mukta Bapat, Praveen Mathew, Andrew Kwek, Vinay Dhir, Amit P. Maydeo Institute of Advanced Endoscopy, Mumbai, India Background: Endoscopic extraction of difficult bile duct stones (DBDS) continue to pose a therapeutic challenge. Surgery continues to the definitive treatment modality. Recent reports indicate that spy cholangioscopy assisted laser lithotripsy could be a minimal invasive alternative. Aims: To evaluate safety, efficacy and success rate of SPY cholangioscopy (Boston Scientific) guided laser lithotripsy in selected patients having difficult bile duct stones. Materials and methods: Between January 2009 to November 2010, 25 patients (Male 10, Female 15) with difficult bile duct stones (failed mechanical lithotripsy/balloon sphincteroplasty) were recruited in the study. Difficult bile duct stones were defined as large bile duct stones measuring ⱖ 2.5cms in size, impacted stones, Mirizzi’s syndrome, patients having distal CBD inflammatory stricture (stone to duct size discrepancy) and intrahepatic stones. SPY cholangioscopy was done after doing a complete biliary sphincterotomy. Laser lithotripsy was done using HOLMIUM laser (Dornier Medtech, Germany) . End point was multiple small stone fragments measuring 8-10mms in size. Results: 7 patients had large stones measuring ⬎2.5cms size (single 3 patients, multiple 4 patients) , 8 patients had impacted stone in the bile duct, 5 patients had Mirrizzi’s syndrome, 4 patients had duct to stone size discrepancy and 1 patient had intrahepatic stones. Laser lithotripsy could be done in all patients. Fragmentation could be achieved in all patients (one sitting in 20 patients and two sittings in 5 patients). Mean procedure time was 45minutes (range 30 min-1.1hour). Complications were seen in two patients (cholangitis in 2 patients and transient hypoxia during the procedure in 2 patients).Floating bile duct stones and stones in lower bile duct were technically difficult to fragment. Impacted bile duct stones could be fragmented easily. Conclusions: SPY guided laser lithotripsy is highly effective with 100 % success rate for extraction of DBDS and could be a minimal invasive alternative for CBD exploration.

Mo1492 Diagnostic and Therapeutic Utility of Spyglass PerOral Cholangioscopy for Indeterminate Biliary Lesions and Bile Duct Stones Evangelos Kalaitzakis1, George Webster2, Panagiotis Vlavianos3, Kofi W. Oppong4, Richard Burnham2, Muhammad F. Dawwas4, Mazin R. Aljabiri2, Adrian R. Hatfield2, Yiannis Kallis3, David Westaby3, Richard Sturgess1 1 Department of Gastroenterology, Aintree University Hospital, Liverpool, United Kingdom; 2Department of Gastroenterology, University College Hospital, London, United Kingdom; 3Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, United Kingdom; 4HPB unit, Freeman Hospital, Newcastle, United Kingdom Peroral cholangioscopy (POC) enables direct visual examination of bile ducts, tissue sampling and therapeutic interventions. We aimed to evaluate the diagnostic utility of Spyglass POC for indeterminate biliary lesions and its usefulness in electrohydraulic lithotripsy (EHL) of bile duct stones not amenable to conventional endoscopic therapy.Methods A total of 163 consecutive patients (mean age 61yr (SD14); 71 female), undergoing 174 attempted Spyglass POC procedures, in four UK tertiary referral centers between 2008 and 2010 were retrospectively enrolled. We estimate that ⬎90% of all Spyglass procedures performed for indeterminate biliary lesions or EHL of bile duct stones in the UK are included in the cohort. Brush cytology or POC-directed biopsies were obtained as clinically indicated. Patients were followed up for a mean of 9 months (7). The operating characteristics of POC for detecting malignant biliary lesions were calculated using a composite reference standard that included surgical confirmation, tissue sampling and follow-up. Bile duct clearance after POC-EHL was also determined using stone recurrence at follow-up as a reference standard.Results Indications for Spyglass procedures included 122/ 174(70%) stricture assessment, 22/174(13%) intraluminal mass assessment, and 30/174 (17%) EHL for bile duct stones. The Spyglass cholangioscope could be inserted in the bile duct in 162/174 (93%) and adequate mucosal visualization was achieved in 134/174 (77%). A diagnosis of cancer was made in 38 out of 174

AB362 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011

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