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Su1413 Usefullness of Intraductal US in Patients With Highly Suspected Choledocholithiasis Without Definite Bile Duct Stone on ERCP
Abstracts
Su1413 Usefullness of Intraductal US in Patients With Highly Suspected Choledocholithiasis Without Definite Bile Duct Stone on ERCP Dong Choon Kim*, Jong Ho Moon, Hyun Jong Choi, Tae Hoon Lee, Sang-Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Republic of Korea Background and Aims: ERCP has been a first-line management strategy for choledocholithiasis. However, small bile duct stones can be missed to diagnose during ERCP. The aim of this study was to prospectively evaluate the accuracy of intraductal US (IDUS) for detecting small choledocholithiasis in patients with highly suspected bile duct stones without definite bile duct stone on ERC. Patients and Methods: 123 consecutive patients who underwent ERCP within 48 hours after admission for highly suspected choledocholithiasis without stone on ERC were evaluated with intraductal US (20 MHz) for the presence of stones or sludge or not. Patients showing any filling defect on biliary tree on ERCP excluded. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge. Results: Of 123 patients, IDUS found bile duct stone in 48 (39.0%) patients. IDUS findings were confirmed by endoscopic extraction of stone in 46 of 48 (95.8%) patients. IDUS showed contour of biliary sludge in 28 (22.8%) patients and confirmed by extraction of sludge in 26 (92.9%) patients. Mean diameter of CBD stones detected by IDUS was 2.89 mm (range: 1-7 mm). In dilated bile ducts (⬎10mm), detection rate of bile duct stone/sludge which were missing on ERC were significantly higher than that of non-dilated bile duct (p⬍0.001). Conclusions: In patients with highly suspected bile duct stones without definite bile duct stone on ERCP, intraductal US is useful for detection of bile duct stones.
Su1414 Combined Treatment of Irretrievable Intra-Hepatic Stones by Extracorporeal Shock Wave Lithotripsy and ERCP Ivo Boskoski*1, Andrea Tringali1, Vincenzo Bove1, Clelia Marmo1, Pietro Familiari1, Vincenzo Perri1, Massimiliano Mutignani2, Guido Costamagna1 1 Catholic University, Rome, Italy; 2Ospedale Niguarda, Milano, Italy Introduction: Intrahepatic stones (IHS) are rare in western countries and may cause recurrent cholangitis leading to liver abscess and impairment of liver function. Liver resection is the treatment of choice for primary HIS associated with atrophy of the parenchyma, but endoscopic treatment may be tried in the majority of cases. Conventional extraction during ERCP may fail because of obstructing stones. We evaluated the results of Extracorporeal Shock Wave Lithotripsy (ESWL) as an adjunct to ERCP in patients with irretrievable HIS. Material and Methods: Patients with IHS treated by ERCP and ESWL during a 20year period were retrospectively identified from a prospectively collected database. After ERCP and insertion of a naso-biliary drain, ESWL was performed with an electro-hydraulic lithotripter with radiological focusing (Siemens LITHOSKOP®). ERCP was repeated to extract stone fragments. Results: 128 patients, out of 350 with HIS, who underwent ESWL were identified and analyzed (male 74, mean age 57,9). A total of 376 ERCP (mean 2.9/patient, range 1-10) and 238 ESWL (mean 1.9/patient, range 1-7) were performed (including retreatments). IHS were located in the left liver in 57 patients (44.5%), in the right liver in 42 (32.8%), at the hepatic hilum in 16 (12.5%) and in 13 (10.2%) patients were bilateral. Follow-up data were available for 96 (75%) patients. Mean follow up was 10.4 yrs (range 0.2-20 yrs). Seven patients died after a mean of 7.4 yrs (range 0.2-16 yrs). Five died from unrelated causes, 1 due to acute cholangitis and 1 from cholangiocarcinoma. Thirty-one (32%) patients had recurrence of cholangitis on average after 4 yrs (range 3-8 yrs) from the first treatment. Residual/recurrent IHS were found in 23 (74%) patients while 8 (26%) had bile duct strictures. Nineteen (61.2%) patients were successfully re-treated endoscopically, 11 (35.6%) required hepatic resection and 1 (3.2%) patient with Caroli’s disease underwent liver transplantation. Adverse events of ESWL were pain in 13%, extrasystoles in 9.2% and nausea and vomiting 1.2% of patients respectively. There were no ERCP/ESWL-related deaths. Limitations: retrospective, single center trial. Conclusions: A multidisciplinary approach to IHS should be always considered. In our series multiple sessions of ERCP/ESWL were necessary to obtain IHS clearance. Procedure related morbidity was low but a high rate of recurrent cholangitis due to residual/recurrent IHS was found during follow-up. Retreatment by ERCP ⫹/⫺ ESWL is feasible with good results. Patients requiring re-treatment should undergo surgical re-evaluation.
Su1415 Choledocholithiasis Refractory to Conventional Endoscopic Extraction: Treatment With SPYGLASS®-Guided Holmium LASER Lithotripsy Dimitrios Xinopoulos1, Stefanos P. Bassioukas1, Dimitrios Kypraios*1, Apostolos S. Poulakis1, Apostolos Malachias1, Panagiotis Katerinis1, Georgios Psanis2, Efstratios P. Kouskos3, Antonios Vezakis4 1 Gastroenterology, Hellenic Anticancer Institute, Saint Savvas Hospital, Athens, Greece, Athens, Greece; 2Gastroenterology, Vostanio Hospital, Mytilene, Greece; 3Surgery, Vostanio Hospital, Mytilene, Greece; 4 Surgery, University of Athens, Aretaieion Hospital, Athens, Greece Background: Endoscopic retrograde cholangiography (ERC), implemented with balloon or dormia basket extraction or/and mechanical lithotripsy, remains the standard of care for the treatment of chelodocholithiasis. In case of failure, insertion of removable biliary stents offers temporary relief, but this approach normally requires repeated ERC sessions. Surgical therapy is generally reserved for patients who fail to achieve long-term clinical success. In these cases, a newly developed peroral cholangioscopy system could guide a salvage treatment by means of laser lithotripsy under direct visualization. Aim: To assess the efficacy and safety of SpyGlass®-assisted intracorporeal laser lithotripsy for difficult-to-treat biliary stones. Methods: Patients suffering from biliary stones refractory to conventional ERC extraction techniques, due to stone impaction or/ and co-existing biliary stricture, underwent SpyGlass® (Boston Scientific, Natick, MA)-guided Holmium-YAG Laser (Auriga, StarMedetch, Germany) lithotripsy. Holmium laser energy was set at 1200mJ, 9.6W in lithotripsy mode. Laser beam energy was applied from the center of the stone in small bursts to multiple areas in a radial fashion. Stone fragments were removed with the use of balloon or basket. All patients underwent plastic stent insertion as a precaution to biliary micro-leakage. Technical and clinical success of the procedure was evaluated on the basis of complete biliary stone clearance, safety and number of sessions required. Results: Seventeen patients (10 female, 7 male, mean age 65.9 years) were treated from April 2011 to October 2012. The average size of the stones was 2.7cm (range 1.5-4), number of stones 1.5 (1-4) and the mean number of prior ERC sessions was 1.9 (1-3). Stones were located in the extrahepatic biliary system in 13 patients (76.5%); intrahepatic biliary system in 3 patients (17.6%) and cystic duct in 1 patient (5.9%). In 2 patients a co-existing, histologicallyproved, benign biliary stenosis was revealed and boogie dilation was performed to pass the SpyGlass catheter. In the remaining patients biliary stone impaction was detected. Technical success, in terms of complete stone extraction in one session, was achieved in 15 patients (88.2%) confirmed by a second-look cholangioscopy. Two patients required 2 and 3 sessions each for complete stone removal. The mean number of interventions, per patient, was 1.2 (1-3). No major complications (bleeding, perforation, pancreatitis) were encountered. Minor complications occurred in 3 patients (17.7%), two experiencing transient fever and one abdominal pain, which were controlled by antibiotics and analgesics. Conclusion: Our preliminary results indicate that Spyglass guided Holmium-YAG lithotripsy is a safe and effective salvage therapy for difficult to treat biliary stones, which may spare futile surgical procedures.
Su1416 Risk Factors for Acute Cholangitis Caused by Common Bile Duct Stone: a Single-Center Study Ryuichi Yamamoto*1, Shuko Ishida1, Yasuyo Osafune1, Masatomo Takahashi1, Maiko Harada1, Shingo Kato1, Sumiko Nagoshi1, Ko Nishikawa2, Koji Yakabi1 1 Gastroenterology and Hepatology, Saitama medical center, Saitama medical university, Kawagoe city, Japan; 2Gastroenterology, Ageo central general hospital, ageo, Japan Background and Aim: Acute cholangitis caused by common bile duct (CBD) stones is a life-threatening complication that must be treated appropriately without delay. The purpose of this study was to identify the factors that predispose patients to acute cholangitis caused by CBD stones. Patient And Methods: A retrospective analysis was performed among 258 patients who underwent endoscopic retrograde cholangiopancreatogram to remove the CBD stones at the Saitama medical center of Saitama medical university between January 2005 and December 2011. 258 patients were divided into two groups: Group 1, 127 patients who were presented with acute cholangitis, and Group 2, 131 patients without acute cholangitis. To identify the risk factors developing acute cholangitis, we compared the following characteristics of two groups: gender, age, gallstones, presence of periampullary diverticulum, presence of CBD dilatation, size and number of CBD stones, and prior cholecystectomy. Multivariate logistics regression analyses were performed to define the risk factors associated with acute cholangitis. A p values⬍0.05 was considered statistically significant. Results: In multivariate analysis, the following factors were found to be independent risk factors for the development of acute cholangitis: CBD dilatation(⬎10mm) (p ⫽0.011, OR 2.20, 95% CI 1.19-4.05) and large size of CBD stones(⬎10mm) (p ⫽0.045, OR 1.73, 95% CI 1.01-2.95). Conclusion: CBD dilatation and large CBD stones were identified as independent risk factors for
AB316 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Su1413 Usefullness of Intraductal US in Patients With Highly Suspected Choledocholithiasis Without Definite Bile Duct Stone on ERCP Dong Choon Kim*, Jong Ho Moon, Hyun Jong Choi, Tae Hoon Lee, Sang-Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Republic of Korea Background and Aims: ERCP has been a first-line management strategy for choledocholithiasis. However, small bile duct stones can be missed to diagnose during ERCP. The aim of this study was to prospectively evaluate the accuracy of intraductal US (IDUS) for detecting small choledocholithiasis in patients with highly suspected bile duct stones without definite bile duct stone on ERC. Patients and Methods: 123 consecutive patients who underwent ERCP within 48 hours after admission for highly suspected choledocholithiasis without stone on ERC were evaluated with intraductal US (20 MHz) for the presence of stones or sludge or not. Patients showing any filling defect on biliary tree on ERCP excluded. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge. Results: Of 123 patients, IDUS found bile duct stone in 48 (39.0%) patients. IDUS findings were confirmed by endoscopic extraction of stone in 46 of 48 (95.8%) patients. IDUS showed contour of biliary sludge in 28 (22.8%) patients and confirmed by extraction of sludge in 26 (92.9%) patients. Mean diameter of CBD stones detected by IDUS was 2.89 mm (range: 1-7 mm). In dilated bile ducts (⬎10mm), detection rate of bile duct stone/sludge which were missing on ERC were significantly higher than that of non-dilated bile duct (p⬍0.001). Conclusions: In patients with highly suspected bile duct stones without definite bile duct stone on ERCP, intraductal US is useful for detection of bile duct stones.
Su1414 Combined Treatment of Irretrievable Intra-Hepatic Stones by Extracorporeal Shock Wave Lithotripsy and ERCP Ivo Boskoski*1, Andrea Tringali1, Vincenzo Bove1, Clelia Marmo1, Pietro Familiari1, Vincenzo Perri1, Massimiliano Mutignani2, Guido Costamagna1 1 Catholic University, Rome, Italy; 2Ospedale Niguarda, Milano, Italy Introduction: Intrahepatic stones (IHS) are rare in western countries and may cause recurrent cholangitis leading to liver abscess and impairment of liver function. Liver resection is the treatment of choice for primary HIS associated with atrophy of the parenchyma, but endoscopic treatment may be tried in the majority of cases. Conventional extraction during ERCP may fail because of obstructing stones. We evaluated the results of Extracorporeal Shock Wave Lithotripsy (ESWL) as an adjunct to ERCP in patients with irretrievable HIS. Material and Methods: Patients with IHS treated by ERCP and ESWL during a 20year period were retrospectively identified from a prospectively collected database. After ERCP and insertion of a naso-biliary drain, ESWL was performed with an electro-hydraulic lithotripter with radiological focusing (Siemens LITHOSKOP®). ERCP was repeated to extract stone fragments. Results: 128 patients, out of 350 with HIS, who underwent ESWL were identified and analyzed (male 74, mean age 57,9). A total of 376 ERCP (mean 2.9/patient, range 1-10) and 238 ESWL (mean 1.9/patient, range 1-7) were performed (including retreatments). IHS were located in the left liver in 57 patients (44.5%), in the right liver in 42 (32.8%), at the hepatic hilum in 16 (12.5%) and in 13 (10.2%) patients were bilateral. Follow-up data were available for 96 (75%) patients. Mean follow up was 10.4 yrs (range 0.2-20 yrs). Seven patients died after a mean of 7.4 yrs (range 0.2-16 yrs). Five died from unrelated causes, 1 due to acute cholangitis and 1 from cholangiocarcinoma. Thirty-one (32%) patients had recurrence of cholangitis on average after 4 yrs (range 3-8 yrs) from the first treatment. Residual/recurrent IHS were found in 23 (74%) patients while 8 (26%) had bile duct strictures. Nineteen (61.2%) patients were successfully re-treated endoscopically, 11 (35.6%) required hepatic resection and 1 (3.2%) patient with Caroli’s disease underwent liver transplantation. Adverse events of ESWL were pain in 13%, extrasystoles in 9.2% and nausea and vomiting 1.2% of patients respectively. There were no ERCP/ESWL-related deaths. Limitations: retrospective, single center trial. Conclusions: A multidisciplinary approach to IHS should be always considered. In our series multiple sessions of ERCP/ESWL were necessary to obtain IHS clearance. Procedure related morbidity was low but a high rate of recurrent cholangitis due to residual/recurrent IHS was found during follow-up. Retreatment by ERCP ⫹/⫺ ESWL is feasible with good results. Patients requiring re-treatment should undergo surgical re-evaluation.
Su1415 Choledocholithiasis Refractory to Conventional Endoscopic Extraction: Treatment With SPYGLASS®-Guided Holmium LASER Lithotripsy Dimitrios Xinopoulos1, Stefanos P. Bassioukas1, Dimitrios Kypraios*1, Apostolos S. Poulakis1, Apostolos Malachias1, Panagiotis Katerinis1, Georgios Psanis2, Efstratios P. Kouskos3, Antonios Vezakis4 1 Gastroenterology, Hellenic Anticancer Institute, Saint Savvas Hospital, Athens, Greece, Athens, Greece; 2Gastroenterology, Vostanio Hospital, Mytilene, Greece; 3Surgery, Vostanio Hospital, Mytilene, Greece; 4 Surgery, University of Athens, Aretaieion Hospital, Athens, Greece Background: Endoscopic retrograde cholangiography (ERC), implemented with balloon or dormia basket extraction or/and mechanical lithotripsy, remains the standard of care for the treatment of chelodocholithiasis. In case of failure, insertion of removable biliary stents offers temporary relief, but this approach normally requires repeated ERC sessions. Surgical therapy is generally reserved for patients who fail to achieve long-term clinical success. In these cases, a newly developed peroral cholangioscopy system could guide a salvage treatment by means of laser lithotripsy under direct visualization. Aim: To assess the efficacy and safety of SpyGlass®-assisted intracorporeal laser lithotripsy for difficult-to-treat biliary stones. Methods: Patients suffering from biliary stones refractory to conventional ERC extraction techniques, due to stone impaction or/ and co-existing biliary stricture, underwent SpyGlass® (Boston Scientific, Natick, MA)-guided Holmium-YAG Laser (Auriga, StarMedetch, Germany) lithotripsy. Holmium laser energy was set at 1200mJ, 9.6W in lithotripsy mode. Laser beam energy was applied from the center of the stone in small bursts to multiple areas in a radial fashion. Stone fragments were removed with the use of balloon or basket. All patients underwent plastic stent insertion as a precaution to biliary micro-leakage. Technical and clinical success of the procedure was evaluated on the basis of complete biliary stone clearance, safety and number of sessions required. Results: Seventeen patients (10 female, 7 male, mean age 65.9 years) were treated from April 2011 to October 2012. The average size of the stones was 2.7cm (range 1.5-4), number of stones 1.5 (1-4) and the mean number of prior ERC sessions was 1.9 (1-3). Stones were located in the extrahepatic biliary system in 13 patients (76.5%); intrahepatic biliary system in 3 patients (17.6%) and cystic duct in 1 patient (5.9%). In 2 patients a co-existing, histologicallyproved, benign biliary stenosis was revealed and boogie dilation was performed to pass the SpyGlass catheter. In the remaining patients biliary stone impaction was detected. Technical success, in terms of complete stone extraction in one session, was achieved in 15 patients (88.2%) confirmed by a second-look cholangioscopy. Two patients required 2 and 3 sessions each for complete stone removal. The mean number of interventions, per patient, was 1.2 (1-3). No major complications (bleeding, perforation, pancreatitis) were encountered. Minor complications occurred in 3 patients (17.7%), two experiencing transient fever and one abdominal pain, which were controlled by antibiotics and analgesics. Conclusion: Our preliminary results indicate that Spyglass guided Holmium-YAG lithotripsy is a safe and effective salvage therapy for difficult to treat biliary stones, which may spare futile surgical procedures.
Su1416 Risk Factors for Acute Cholangitis Caused by Common Bile Duct Stone: a Single-Center Study Ryuichi Yamamoto*1, Shuko Ishida1, Yasuyo Osafune1, Masatomo Takahashi1, Maiko Harada1, Shingo Kato1, Sumiko Nagoshi1, Ko Nishikawa2, Koji Yakabi1 1 Gastroenterology and Hepatology, Saitama medical center, Saitama medical university, Kawagoe city, Japan; 2Gastroenterology, Ageo central general hospital, ageo, Japan Background and Aim: Acute cholangitis caused by common bile duct (CBD) stones is a life-threatening complication that must be treated appropriately without delay. The purpose of this study was to identify the factors that predispose patients to acute cholangitis caused by CBD stones. Patient And Methods: A retrospective analysis was performed among 258 patients who underwent endoscopic retrograde cholangiopancreatogram to remove the CBD stones at the Saitama medical center of Saitama medical university between January 2005 and December 2011. 258 patients were divided into two groups: Group 1, 127 patients who were presented with acute cholangitis, and Group 2, 131 patients without acute cholangitis. To identify the risk factors developing acute cholangitis, we compared the following characteristics of two groups: gender, age, gallstones, presence of periampullary diverticulum, presence of CBD dilatation, size and number of CBD stones, and prior cholecystectomy. Multivariate logistics regression analyses were performed to define the risk factors associated with acute cholangitis. A p values⬍0.05 was considered statistically significant. Results: In multivariate analysis, the following factors were found to be independent risk factors for the development of acute cholangitis: CBD dilatation(⬎10mm) (p ⫽0.011, OR 2.20, 95% CI 1.19-4.05) and large size of CBD stones(⬎10mm) (p ⫽0.045, OR 1.73, 95% CI 1.01-2.95). Conclusion: CBD dilatation and large CBD stones were identified as independent risk factors for
AB316 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org