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Partially Covered Metal Stenting in Patients with Symptomatic Common Bile Duct Stenosis Secondary to Chronic Pancreatitis: A Pilot Study
*T1470 Prospective Assessment of Patient Outcome Following Photodynamic Therapy for Advanced Cholangiocarcinoma Gavin Harewood, Todd Baron, Ashwin Rumalla, Kenneth Wang, Gregory Gores, Linda Stadheim, Piet de Groen Introduction: Photodynamic therapy (PDT) demonstrates promise in the palliative treatment of advanced cholangiocarcinoma. The aim of this study was to prospectively assess the outcome of patients with unresectable cholangiocarcinoma following endoscopic application of PDT directly into the biliary tract. Methods: Sodium porfimer was administered intravenously to consecutive patients with histologically confirmed advanced cholangiocarcinoma (Bismuth type III, IV). Forty-eight hours later, a commercially available cylindrical diffusing laser fiber (1-2.5 cm in length, OptiGuide, FiberDirect) designed for esophageal use was advanced across the biliary strictures as previously described (Gastrointest Endosc 2001;53:500-4). Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm2 using an argon pumped tunable dye laser. Patients received endoscopic PDT every 3 months provided they maintained a favorable performance status. Plastic biliary stents were replaced following light application and maintained in all patients. Results: Using a preloaded catheter, adequate positioning of the laser fiber was achieved in all patients. Eight patients with advanced cholangiocarcinoma received a total of 18 PDT treatments, range 1 to 5 treatments/patient. There was no procedure related mortality; 2 patients developed acute cholangitis and 2 patients experienced phototoxicity. All 8 patients were followed until death; mean follow-up was 9.8 months. Median survival from the date of 1st PDT treatment was 276 days, range 90 to 804 (see Kaplan-Meier curve) which compares favorably with published series, where median survival times vary between 45 and 127 days for patients with Bismuth type III and IV tumors treated with stenting alone. Conclusions: Endoscopic application of PDT demonstrates promise in prolonging survival in patients with advanced cholangiocarcinoma. Additional randomized clinical trials using commercially available fibers are needed to fully evaluate the optimum frequency and treatment interval of PDT in the management of advanced cholangiocarcinoma.
analysis of variance. Results (means 6 SEM). A 40 mm (n=13) or 60 mm (n=1) PCM stent was placed depending on the length of the CBD stenosis (n=9 type I and n=5 type III, Caroli9s classification) and the level of the cystic duct bifurcation. PCM stent placement was successful except in one case (distal migration), treated with a plastic stent. Cholangitis resolved and cholestasis improved in all (see Table). During follow-up (median of 21 months) 2 patients required retreatment: further plastic stenting in one patient who had delayed migration of the stent and surgical biliary diversion in another patient for stent dysfunction. At 21 months, the stent patency rate was 85%. Conclusions. In symptomatic CBD stenoses secondary to CP, PCM stenting is safe and does not prevent further surgery. Medium-term results suggest that if dysfunction occurs, it is more related to migration than to hyperplasia. Longer follow-up or randomised controlled trials are mandatory to consider this treatment as an alternative also in patients fit for surgery.
*T1472 Additional p53 and K-ras Immunohistochemical Stain Can Not Enhance the Outcome of Brush Cytology During ERCP Ho Gak Kim, Joong Goo Kweon, Eun Young Kim, Chang Hyeong Lee, Jong Seok Bae, Sun Woo Park
*T1471 Partially Covered Metal Stenting in Patients with Symptomatic Common Bile Duct Stenosis Secondary to Chronic Pancreatitis: A Pilot Study Paolo Cantu, Alejandro Morales, Olivier Le Moine, Jacques Deviere Background. Surgery remains the gold standard for treatment of symptomatic common bile duct (CBD) stenosis associated with chronic pancreatitis (CP). Plastic stents and self-expandable open mesh stents have been proposed as alternative treatments but they are associated with dysfunctions mainly due to stent occlusion or inflammatory tissue hyperplasia, respectively. Aim. To evaluate safety and medium-term results of partially covered metal (PCM) stenting for CBD stenosis secondary to CP, previously treated with plastic protheses. Methods. We reviewed the records of 14 patients (12 men, 50 6 3 y.o.) who underwent PCM stent (Wallstent, Boston Scientific) insertion for CBD stenosis secondary to CP (12 alcohol-related, 2 idiopathic), previously treated with plastic protheses (3.1 6 0.6 replacements/patient). Two patients were not suitable for surgery (portal cavernoma and recent myocardial infarction respectively). Clinical and laboratory data were prospectively collected. Significance was tested by
P190
GASTROINTESTINAL ENDOSCOPY
Background and aims: Brush cytology at obstructed biliary tree during ERCP is the standard method for getting the tissue diagnosis in malignant biliary obstruction. K-ras and p53 mutation are common and early molecular events in biliary and pancreas cancer. We evaluate the outcome of brush cytology and study whether additional p53 and k-ras immunohistochemical (IHC) stain can enhance the outcome of brush cytology. Patients and Method: In 97 patients with biliary obstruction, we evaluate if the presence of 3-D cluster of cells on smeared slide, site of bushing (ampulla and distal CBD, mid CBD, proximal CBD), tightness of biliary obstruction (tight, intermediate, loose), and length of obstruction (=< 2 cm, >2 cm) can influence the result of brush cytology. In addition we did IHC stain for p53 and k-ras with brush cytology slides in 64 patients with biliary obstruction. Results: Among 97 patients with biliary obstruction, 78 obstructions was malignant stricture by final diagnosis after surgery and long-term follow up. For malignant biliary obstruction, the sensitivity and specificity of brush cytology during ERCP at stricture were 89.7% and 98.6% respectively. 3-D cluster was more common in malignant obstruction than benign obstruction {68/86 (79.1%) vs. 9/17 (52.9%), p < 0.05}. There were no differences in the sensitivities of brush cytology according to the level of obstruction in CBD, tightness of obstruction, and the length of obstruction. In 64 patients done additional p53 and k-ras IHC stain, sensitivity of brush cytology plus p53 in malignant obstruction was 96.8%, that of brush cytology plus k-ras was 93.7%, that of brush cytology plus p53 and kras was 98.4%. But there was no difference in sensitivity on adding p53 or k-ras IHC stain. Conclusion: The diagnostic accuracy of brush cytology at biliary obstruction during ERCP was very high, and 3D-cluster of cells on slide was more common in malignant obstruction. Additional p53 and k-ras IHC stain can not enhance the outcome of brush cytology.
VOLUME 59, NO. 5, 2004
analysis of variance. Results (means 6 SEM). A 40 mm (n=13) or 60 mm (n=1) PCM stent was placed depending on the length of the CBD stenosis (n=9 type I and n=5 type III, Caroli9s classification) and the level of the cystic duct bifurcation. PCM stent placement was successful except in one case (distal migration), treated with a plastic stent. Cholangitis resolved and cholestasis improved in all (see Table). During follow-up (median of 21 months) 2 patients required retreatment: further plastic stenting in one patient who had delayed migration of the stent and surgical biliary diversion in another patient for stent dysfunction. At 21 months, the stent patency rate was 85%. Conclusions. In symptomatic CBD stenoses secondary to CP, PCM stenting is safe and does not prevent further surgery. Medium-term results suggest that if dysfunction occurs, it is more related to migration than to hyperplasia. Longer follow-up or randomised controlled trials are mandatory to consider this treatment as an alternative also in patients fit for surgery.
*T1472 Additional p53 and K-ras Immunohistochemical Stain Can Not Enhance the Outcome of Brush Cytology During ERCP Ho Gak Kim, Joong Goo Kweon, Eun Young Kim, Chang Hyeong Lee, Jong Seok Bae, Sun Woo Park
*T1471 Partially Covered Metal Stenting in Patients with Symptomatic Common Bile Duct Stenosis Secondary to Chronic Pancreatitis: A Pilot Study Paolo Cantu, Alejandro Morales, Olivier Le Moine, Jacques Deviere Background. Surgery remains the gold standard for treatment of symptomatic common bile duct (CBD) stenosis associated with chronic pancreatitis (CP). Plastic stents and self-expandable open mesh stents have been proposed as alternative treatments but they are associated with dysfunctions mainly due to stent occlusion or inflammatory tissue hyperplasia, respectively. Aim. To evaluate safety and medium-term results of partially covered metal (PCM) stenting for CBD stenosis secondary to CP, previously treated with plastic protheses. Methods. We reviewed the records of 14 patients (12 men, 50 6 3 y.o.) who underwent PCM stent (Wallstent, Boston Scientific) insertion for CBD stenosis secondary to CP (12 alcohol-related, 2 idiopathic), previously treated with plastic protheses (3.1 6 0.6 replacements/patient). Two patients were not suitable for surgery (portal cavernoma and recent myocardial infarction respectively). Clinical and laboratory data were prospectively collected. Significance was tested by
P190
GASTROINTESTINAL ENDOSCOPY
Background and aims: Brush cytology at obstructed biliary tree during ERCP is the standard method for getting the tissue diagnosis in malignant biliary obstruction. K-ras and p53 mutation are common and early molecular events in biliary and pancreas cancer. We evaluate the outcome of brush cytology and study whether additional p53 and k-ras immunohistochemical (IHC) stain can enhance the outcome of brush cytology. Patients and Method: In 97 patients with biliary obstruction, we evaluate if the presence of 3-D cluster of cells on smeared slide, site of bushing (ampulla and distal CBD, mid CBD, proximal CBD), tightness of biliary obstruction (tight, intermediate, loose), and length of obstruction (=< 2 cm, >2 cm) can influence the result of brush cytology. In addition we did IHC stain for p53 and k-ras with brush cytology slides in 64 patients with biliary obstruction. Results: Among 97 patients with biliary obstruction, 78 obstructions was malignant stricture by final diagnosis after surgery and long-term follow up. For malignant biliary obstruction, the sensitivity and specificity of brush cytology during ERCP at stricture were 89.7% and 98.6% respectively. 3-D cluster was more common in malignant obstruction than benign obstruction {68/86 (79.1%) vs. 9/17 (52.9%), p < 0.05}. There were no differences in the sensitivities of brush cytology according to the level of obstruction in CBD, tightness of obstruction, and the length of obstruction. In 64 patients done additional p53 and k-ras IHC stain, sensitivity of brush cytology plus p53 in malignant obstruction was 96.8%, that of brush cytology plus k-ras was 93.7%, that of brush cytology plus p53 and kras was 98.4%. But there was no difference in sensitivity on adding p53 or k-ras IHC stain. Conclusion: The diagnostic accuracy of brush cytology at biliary obstruction during ERCP was very high, and 3D-cluster of cells on slide was more common in malignant obstruction. Additional p53 and k-ras IHC stain can not enhance the outcome of brush cytology.
VOLUME 59, NO. 5, 2004