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Patients with Atypical Sphincter of Oddi Dysfunction Symptoms Can Benefit from Endoscopic Biliary Manometry
Abstracts
stenting and UDCA is an easy and effective method for difficult CBD stones and may not necessitate long-term care. However, this study was conducted using a limited number of patients and further prospective randomized controlled trials should be conducted.
S1387 Effect of Opium Consumption On the Incidence of Post ERCP Pancreatitis At a Large Tertiary Center Javad S. Shirvany, Neda Meftah, Hassan Taheri, Ali Bijani, Mahmoud Hajiahmadi, Shahriar Savadkohi Background: Suspected SOD is a known risk factor for post ERCP pancreatitis, chronic use of opium has spastic effect on sphincter of Oddi, it has not been established whether post ERCP pancreatitis is increased in this group of patients. Objective: this prospective study was conducted to investigate the incidence of post ERCP pancreatitis in patients with high probability of having SOD due to opium addiction in north east of Iran with high rate of opium consumption. In these patients we did not use pancreatic duct stent for prevention of pancreatitisMethod: a total of 474 patients referred to our hospital for ERCP between January 2005 and March 2008 were enrolled in this study, of whom 110 patients were chronic user of opium using it as oral or inhalational at least 3 days of week for more than one year and 364 patients have no history of using opium. Then post ERCP pancreatitis was compared in these two groups. Results: 110 (23.2%) patients were addicted to opium (group 1) and 364 (76.8%) patients were not addicted to opium (group 2). overall post ERCP pancreatitis rate were 4.6% in group 1 and 6.6% in group 2 (pZ 0.3) the incidence of hyperamylasemia was 12.8% in group 1 and 21.9% in group2 (pZ.09) mean CBD diameter was 12.3þ/- in group 1 and 10 þ/- 4.3 in group 2 (p!.001). by multivariate analysis after adjusting for age and sex there was no difference in incidence of post ERCP pancreatitis in these two groups of patients. Conclusion: there is no association between chronic use of opiates and increased risk of post ERCP pancreatitis contradicting the overall hypothesis that narcotics has excitatory effect on SO. This study revealed a statistically nonsignificant reduction in overall rate of post ERCP pancreatitis in non stented patients, probably owing to unknown mechanism such as CBD dilation in chronic user of opiate and protective material in opium. Further study is needed to clarify the reason for this result.
S1388 EMS Removing Had Caused No Bile Duct Stenosis. Long Term Follow Up About Removal of Bile Duct Stones with An Expandable Metallic Stent Atsushi Minami, Shinichi Hirata Background: Recently expandable metallic stent (EMS) removing has been becoming little popular. But the long term results after removing EMS have not been published even now. We had published the new method using removable EMS for lithotripsy at 2003(1). This time we would like to show the long term result of EMS removing about our experience. EMS-Lithotripsy method was developed by us but this method could not become popular because we could not develop original stent for removing bile duct stones and the cost of EMS is relatively high. This presentation might give us the opportunity to develop the removable EMS and so we present long term results. Methods: Forty-six patients (18 women, 28 men; median age 68 þ/- 10) with bile duct stones underwent ERCP. The median stone size was 11þ/-4mm and the number was 3 þ/- 3. A EMS was inserted over a guide wire into the major duodenal papilla. Papillary dilation was performed with a metallic stent. Stones were extracted with an 8-wire spiral basket after endoscopic mechanical lithotripsy through expanded EMS. The metallic stent was subsequently removed with a snare. On two cases choledochoscopy was performed to check the bile duct before and after the stent removing. 35 cases could be followed (mean 7.4 þ/- 1.0 years). Result: Duct clearance was 44/46(96%). Lithotripsy was performed safely in 3 patients who had undergone partial gastrectomy with a Billroth II anastomosis. Two stent migration was occurred. These failed cases were caused by stent figure. After removing the stent reddening like meshes of stent was seen by choledochoscopy. 2 cases (6%) have occurred stone recurrence for over 5 years. One of them was B-II reconstruction case. We have not recognized the bile duct stenosis after metallic stent removing for over 5 years. Discussion: EMS removing was not so severe damage to the normal bile duct because bile duct stenosis case was none. The reduction of bile duct columnar epithelium by removing was suspected but sever injury to the fibromuscular layer was rare. So we suspect the removable metallic stent for the benign disease (bile duct stenose and formation of route to bile duct) should be developed. If original stent is established as a method of treatment and the shape of the stent is improved, then both the cost of the stent and the risk of migration may gradually decline. This method is not suitable for treatment of most stones. However, once the method is established as safe, it might play a greater role as a safe for diverticulum and bile duct stenosis case. A Minami et al. A new technique for removal of bile duct stones with an expandable metallic stent Gastrointest Endosc 2003;57: 945-948(1)
AB160 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
S1389 Patients with Atypical Sphincter of Oddi Dysfunction Symptoms Can Benefit from Endoscopic Biliary Manometry Aruna Dias, Nafeesa Ali, Colin Ainley Introduction: Sphincter of Oddi dysfunction (SOD) is a clinical syndrome of biliary or pancreatic obstruction related to mechanical or functional abnormalities of the sphincter of Oddi. Diagnosis of SOD is usually established by endoscopic biliary manometry (EBM) performed at the time of ERCP and measures the biliary and pancreatic sphincter pressures. Depending on the results it can determine which treatments such as endoscopic sphincterotomy or Botulinum toxin injection should be given. However, the Rome III guidelines, developed for the investigation of patients with SOD, propose that unless patients meet all the criteria then they should not undergo invasive investigations such as EBM. These patients may present with a variety of symptoms which may be biliary, pancreatic, mixed or atypical in nature and this may make diagnosis difficult without doing EBM. Aims and Methods: The Royal London Hospital is a tertiary referral centre for this condition and this study was a retrospective audit of patients referred here for the investigation of SOD and who underwent EBM. It involved patients who had EBM from 1st January 2004 to 31st July 2008 and looked at the long term outcomes and complication rates. Results: 131 patients (104 females) underwent EBM during this period. 60 patients had biliary symptoms, 21 had pancreatic, 23 had mixed biliary and pancreatic and 27 had atypical abdominal symptoms. Overall 63% of patients had some improvement and long term no-one had worsening of symptoms post EBM. The Rome III guidelines do not include atypical patients for the investigation of SOD. However in our study, 11 patients in the atypical group had elevated biliary or pancreatic duct pressure (O40 mm Hg) of which 6 underwent sphincterotomy and 9 patients had ampullary Botulinum toxin injection. 11 of the atypical patients showed some improvement following EBM. In the atypical group 2 patients developed post-ERCP pancreatitis and 1 patient suffered a fatal guide wire perforation. In total 19 patients developed post-ERCP pancreatitis (12 following sphincterotomy and 5 post-Botulinum toxin injection) and 5 patients developed perforation. Conclusions: Rome III guidelines for the diagnosis of SOD are unnecessarily restrictive and therefore may lead to the under-diagnosis and treatment of this condition. Many patients, who may not fit these criteria, including those with atypical symptoms, may potentially benefit from undergoing EBM and endoscopic treatments. References: 1. Behar J, Corazziari E, Guelrud M et al. Functional Gallbladder and Sphincter of Oddi Disorders. Gastroenterology 2006; 130: 1498-1509
S1390 Long Term Biliary Endoscopic Sphincterotomy (B-ES) Restenosis: Incidence, Endoscopic Management & Complications of Re-Treatment Farshad Elmi, William B. Silverman Background: Restenosis is a late complication of B-ES. Long term data are limited regarding both the rate of restenosis and complications resulting from repeat therapy. Methods: Medical charts & our ERCP data base were searched for patients with ERCP & B-ES during 1998 - 2002 at our university hospital. This allowed O 5 years of post B-ES clinical follow up on each patient. Each patient received a letter describing the study and was invited to participate. All consented patients were contacted by phone and asked about the recurrence of their pancreatobiliary symptoms after the first ERCP and whether they sought any medical treatment for these symptoms. Next of kin were contacted if the subject was deceased. Referring physician was contacted if the subjects were treated elsewhere. Restenosis of B-ES was defined as scarring of sphincterotomy site seen on ERCP. The primary outcome was restenosis of sphincterotomy site and secondary outcome was complications of endoscopic treatment of sphincterotomy restenosis. Results: A total of 202 patients underwent ERCP & B-ES on an intact major papilla. Of these, nZ80 patients (54.7 19 year, 76% female) consented & enrolled in the study; nZ117 lost to follow up (phone/address no longer valid) & nZ5 refused to participate. Among the 80 patients, nZ13 (16%) developed restenosis of B-ES in 1 to 60 (22 20) months after the index ERCP/B-ES. Indications for index ERCP/B-ES in these 13 patients include: cholangitis (nZ3), Sphincter of Oddi Dysfunction (nZ2 type I, nZ5 type II), symptomatic bile duct stone (nZ1) and biliary pancreatitis (nZ2). These 13 patients underwent total of 24 ERCPs (range 1-4 for each patient) for repeat B-ES and biliary stenting if needed. Repeat B-ES was successful in 12/13 (92%) patients. One patient had a non ERCP related mid common bile duct stricture which did not respond to stenting and underwent choledochojejunal bypass but died of cardiac arrhythmia 3 days after surgery. COMPLICATIONS OF REPEAT B-ES: 3/13 patients (23%); nZ1 patients had bleeding (severe, requiring surgery), nZ1 patient had mild pancreatitis and nZ1 patient developed severe duodenal perforation & abscess requiring surgical drainage. Conclusions: Long term restenosis is an important & perhaps underestimated sequella of B-ES. Repeat B-ES is a logical & effective treatment modality, but complications from doing this are not negligible.
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stenting and UDCA is an easy and effective method for difficult CBD stones and may not necessitate long-term care. However, this study was conducted using a limited number of patients and further prospective randomized controlled trials should be conducted.
S1387 Effect of Opium Consumption On the Incidence of Post ERCP Pancreatitis At a Large Tertiary Center Javad S. Shirvany, Neda Meftah, Hassan Taheri, Ali Bijani, Mahmoud Hajiahmadi, Shahriar Savadkohi Background: Suspected SOD is a known risk factor for post ERCP pancreatitis, chronic use of opium has spastic effect on sphincter of Oddi, it has not been established whether post ERCP pancreatitis is increased in this group of patients. Objective: this prospective study was conducted to investigate the incidence of post ERCP pancreatitis in patients with high probability of having SOD due to opium addiction in north east of Iran with high rate of opium consumption. In these patients we did not use pancreatic duct stent for prevention of pancreatitisMethod: a total of 474 patients referred to our hospital for ERCP between January 2005 and March 2008 were enrolled in this study, of whom 110 patients were chronic user of opium using it as oral or inhalational at least 3 days of week for more than one year and 364 patients have no history of using opium. Then post ERCP pancreatitis was compared in these two groups. Results: 110 (23.2%) patients were addicted to opium (group 1) and 364 (76.8%) patients were not addicted to opium (group 2). overall post ERCP pancreatitis rate were 4.6% in group 1 and 6.6% in group 2 (pZ 0.3) the incidence of hyperamylasemia was 12.8% in group 1 and 21.9% in group2 (pZ.09) mean CBD diameter was 12.3þ/- in group 1 and 10 þ/- 4.3 in group 2 (p!.001). by multivariate analysis after adjusting for age and sex there was no difference in incidence of post ERCP pancreatitis in these two groups of patients. Conclusion: there is no association between chronic use of opiates and increased risk of post ERCP pancreatitis contradicting the overall hypothesis that narcotics has excitatory effect on SO. This study revealed a statistically nonsignificant reduction in overall rate of post ERCP pancreatitis in non stented patients, probably owing to unknown mechanism such as CBD dilation in chronic user of opiate and protective material in opium. Further study is needed to clarify the reason for this result.
S1388 EMS Removing Had Caused No Bile Duct Stenosis. Long Term Follow Up About Removal of Bile Duct Stones with An Expandable Metallic Stent Atsushi Minami, Shinichi Hirata Background: Recently expandable metallic stent (EMS) removing has been becoming little popular. But the long term results after removing EMS have not been published even now. We had published the new method using removable EMS for lithotripsy at 2003(1). This time we would like to show the long term result of EMS removing about our experience. EMS-Lithotripsy method was developed by us but this method could not become popular because we could not develop original stent for removing bile duct stones and the cost of EMS is relatively high. This presentation might give us the opportunity to develop the removable EMS and so we present long term results. Methods: Forty-six patients (18 women, 28 men; median age 68 þ/- 10) with bile duct stones underwent ERCP. The median stone size was 11þ/-4mm and the number was 3 þ/- 3. A EMS was inserted over a guide wire into the major duodenal papilla. Papillary dilation was performed with a metallic stent. Stones were extracted with an 8-wire spiral basket after endoscopic mechanical lithotripsy through expanded EMS. The metallic stent was subsequently removed with a snare. On two cases choledochoscopy was performed to check the bile duct before and after the stent removing. 35 cases could be followed (mean 7.4 þ/- 1.0 years). Result: Duct clearance was 44/46(96%). Lithotripsy was performed safely in 3 patients who had undergone partial gastrectomy with a Billroth II anastomosis. Two stent migration was occurred. These failed cases were caused by stent figure. After removing the stent reddening like meshes of stent was seen by choledochoscopy. 2 cases (6%) have occurred stone recurrence for over 5 years. One of them was B-II reconstruction case. We have not recognized the bile duct stenosis after metallic stent removing for over 5 years. Discussion: EMS removing was not so severe damage to the normal bile duct because bile duct stenosis case was none. The reduction of bile duct columnar epithelium by removing was suspected but sever injury to the fibromuscular layer was rare. So we suspect the removable metallic stent for the benign disease (bile duct stenose and formation of route to bile duct) should be developed. If original stent is established as a method of treatment and the shape of the stent is improved, then both the cost of the stent and the risk of migration may gradually decline. This method is not suitable for treatment of most stones. However, once the method is established as safe, it might play a greater role as a safe for diverticulum and bile duct stenosis case. A Minami et al. A new technique for removal of bile duct stones with an expandable metallic stent Gastrointest Endosc 2003;57: 945-948(1)
AB160 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
S1389 Patients with Atypical Sphincter of Oddi Dysfunction Symptoms Can Benefit from Endoscopic Biliary Manometry Aruna Dias, Nafeesa Ali, Colin Ainley Introduction: Sphincter of Oddi dysfunction (SOD) is a clinical syndrome of biliary or pancreatic obstruction related to mechanical or functional abnormalities of the sphincter of Oddi. Diagnosis of SOD is usually established by endoscopic biliary manometry (EBM) performed at the time of ERCP and measures the biliary and pancreatic sphincter pressures. Depending on the results it can determine which treatments such as endoscopic sphincterotomy or Botulinum toxin injection should be given. However, the Rome III guidelines, developed for the investigation of patients with SOD, propose that unless patients meet all the criteria then they should not undergo invasive investigations such as EBM. These patients may present with a variety of symptoms which may be biliary, pancreatic, mixed or atypical in nature and this may make diagnosis difficult without doing EBM. Aims and Methods: The Royal London Hospital is a tertiary referral centre for this condition and this study was a retrospective audit of patients referred here for the investigation of SOD and who underwent EBM. It involved patients who had EBM from 1st January 2004 to 31st July 2008 and looked at the long term outcomes and complication rates. Results: 131 patients (104 females) underwent EBM during this period. 60 patients had biliary symptoms, 21 had pancreatic, 23 had mixed biliary and pancreatic and 27 had atypical abdominal symptoms. Overall 63% of patients had some improvement and long term no-one had worsening of symptoms post EBM. The Rome III guidelines do not include atypical patients for the investigation of SOD. However in our study, 11 patients in the atypical group had elevated biliary or pancreatic duct pressure (O40 mm Hg) of which 6 underwent sphincterotomy and 9 patients had ampullary Botulinum toxin injection. 11 of the atypical patients showed some improvement following EBM. In the atypical group 2 patients developed post-ERCP pancreatitis and 1 patient suffered a fatal guide wire perforation. In total 19 patients developed post-ERCP pancreatitis (12 following sphincterotomy and 5 post-Botulinum toxin injection) and 5 patients developed perforation. Conclusions: Rome III guidelines for the diagnosis of SOD are unnecessarily restrictive and therefore may lead to the under-diagnosis and treatment of this condition. Many patients, who may not fit these criteria, including those with atypical symptoms, may potentially benefit from undergoing EBM and endoscopic treatments. References: 1. Behar J, Corazziari E, Guelrud M et al. Functional Gallbladder and Sphincter of Oddi Disorders. Gastroenterology 2006; 130: 1498-1509
S1390 Long Term Biliary Endoscopic Sphincterotomy (B-ES) Restenosis: Incidence, Endoscopic Management & Complications of Re-Treatment Farshad Elmi, William B. Silverman Background: Restenosis is a late complication of B-ES. Long term data are limited regarding both the rate of restenosis and complications resulting from repeat therapy. Methods: Medical charts & our ERCP data base were searched for patients with ERCP & B-ES during 1998 - 2002 at our university hospital. This allowed O 5 years of post B-ES clinical follow up on each patient. Each patient received a letter describing the study and was invited to participate. All consented patients were contacted by phone and asked about the recurrence of their pancreatobiliary symptoms after the first ERCP and whether they sought any medical treatment for these symptoms. Next of kin were contacted if the subject was deceased. Referring physician was contacted if the subjects were treated elsewhere. Restenosis of B-ES was defined as scarring of sphincterotomy site seen on ERCP. The primary outcome was restenosis of sphincterotomy site and secondary outcome was complications of endoscopic treatment of sphincterotomy restenosis. Results: A total of 202 patients underwent ERCP & B-ES on an intact major papilla. Of these, nZ80 patients (54.7 19 year, 76% female) consented & enrolled in the study; nZ117 lost to follow up (phone/address no longer valid) & nZ5 refused to participate. Among the 80 patients, nZ13 (16%) developed restenosis of B-ES in 1 to 60 (22 20) months after the index ERCP/B-ES. Indications for index ERCP/B-ES in these 13 patients include: cholangitis (nZ3), Sphincter of Oddi Dysfunction (nZ2 type I, nZ5 type II), symptomatic bile duct stone (nZ1) and biliary pancreatitis (nZ2). These 13 patients underwent total of 24 ERCPs (range 1-4 for each patient) for repeat B-ES and biliary stenting if needed. Repeat B-ES was successful in 12/13 (92%) patients. One patient had a non ERCP related mid common bile duct stricture which did not respond to stenting and underwent choledochojejunal bypass but died of cardiac arrhythmia 3 days after surgery. COMPLICATIONS OF REPEAT B-ES: 3/13 patients (23%); nZ1 patients had bleeding (severe, requiring surgery), nZ1 patient had mild pancreatitis and nZ1 patient developed severe duodenal perforation & abscess requiring surgical drainage. Conclusions: Long term restenosis is an important & perhaps underestimated sequella of B-ES. Repeat B-ES is a logical & effective treatment modality, but complications from doing this are not negligible.
www.giejournal.org