- Email: [email protected]
426 Ocular Radiation Threshold Projection Based on Fluoroscopy Time During ERCP
Abstracts
test for proportional data, with p!0.05 denoting significance. Results: Of 1400 patients with BE, 196 (14%) met criteria for inclusion at a mean follow up of 86.8 months. Of these, 112 (57%) were untreated and 84 (43%) underwent RFA. Of these 84, complete eradication was accomplished in 54 (64%) and 9 patients progressed despite therapy, compared with 33 (29.5%) of the untreated patients (pZ0.01). Allcause mortality in treated patients was 13% compared to 29.7% in untreated patients (27.8% for those who did not progress and, 35.5% for those who did) (pZ0.004). Table 1 depicts these findings. Mean age, interval from BE to LGD diagnosis, short versus long-segment BE rates, and anatomical distribution of LGD were comparable between stable LGD and progression cohorts. Progression was associated with a higher mean BE segment length (8.6 cm vs. 10 cm, pZ0.46). Conclusion: Compared to clinical trials, our experience with RFA in a large BE cohort with LGD demonstrates lower complete eradication rates, and higher rates of dysplastic/malignant progression. However, untreated patients showed significantly higher rates of progression to HGD or EAC and higher all-cause mortality rates, strongly supporting the existing recommendation to treat LGD with RFA. Despite long-term follow up, we were unable to identify risk factors associated with progression from LGD, other than longer BE segment. We noted substantial heterogeneity in time to progression independent of endoscopic treatment, suggesting the presence of as-yet unidentified factors for risk stratification. Further studies are needed to develop a more comprehensive and predictive risk assessment paradigm for patients with BE.
Characteristics of LGD in patients with or without RFA treatment
Follow up (months) Interval from BE to LGD (months) Interval from LGD to HGD/EAC (months) Progression to HGD/EAC (n, %) All-cause mortality (n, %)
RFA (n [ 84)
Untreated (n [ 112)
Pvalue
75.7 37.3 32.5 9 (10.7%) 11 (13%)
94.9 42.6 33.8 33 (29.5%) 33 (29.5%)
0.03 0.49 0.94 0.01 0.04
345 Transepithelial Brush Biopsy With Computer-Assisted Tissue Analysis Increases Detection of Residual or Recurrent Intestinal Metaplasia and Dysplasia Following Endoscopic Ablation of Barrett’s Esophagus Natalya Iorio*1, Brandon Sprung2, Vivek Kaul2, Danielle Marino2, Shivangi Kothari2, Truptesh H. Kothari2, Rahul D. Kataria4, Seth A. Gross3, Michael S. Smith1 1 Medicine/Gastroenterology, Temple University School of Medicine, Philadelphia, PA; 2Medicine/Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester, NY; 3Medicine/Gastroenterology, NYU Langone Medical Center, New York, NY; 4Medicine, Jackson Memorial Hospital, Miami, FL Background: Radiofrequency ablation (RFA) and liquid nitrogen spray cryotherapy (SCT) are ablative techniques used to eradicate Barrett’s esophagus (BE). Residual or recurrent intestinal metaplasia (IM) can be present without endoscopically visible disease. Post-ablation surveillance using forceps biopsies (FB) leaves significant mucosa unsampled, which creates a risk of missing IM or dysplasia. Wide Area Transepithelial Sampling with Computer-Assisted 3-Dimensional Tissue Analysis (WATS3D) has been shown to increase detection of metaplasia and dysplasia when used in addition to FB. Our aim was to better characterize the incremental benefit of adding WATS3D to FB for detection of residual or recurrent IM and dysplasia following BE ablation, using data from 2 high-volume centers. Methods: Patients undergoing surveillance following RFA or SCT between June 2012 and October 2014 were included if there was no visual evidence of BE during endoscopy. WATS3D biopsies were obtained using a 2 brush technique within the original BE segment and were analyzed at a central laboratory using a neural network to identify abnormal cells. Following WATS3D, FB were obtained in the same segment using a modified Seattle Protocol, with 4 quadrant biopsies every 1 centimeter (cm). These biopsies were read by expert GI pathologists at each site. Demographic and endoscopic data were added to pathology and de-identified prior to data aggregation and analysis. Results: Our study included 208 procedures and 110 patients. There was a slight male predominance (53%), with a mean age of 63 years (37-88) and BMI of 30.1. Seventy patients (63.6%) were current or former smokers. Pre-ablation histology included high grade dysplasia or intramucosal adenocarcinoma (55.5%), low grade dysplasia (20.9%) and non-dysplastic BE (23.6%). The mean pre-treatment BE length was 3.88 cm. Prior BE treatments included RFA (90%), SCT (26%) and endoscopic mucosal resection (26%). FB identified post-ablation residual or recurrent IM in 37 cases (17.8%), and dysplasia or neoplasia in 7 cases (3.37%). Adjunctive use of WATS3D identified another 24 cases of BE and 4 cases of dysplasia missed by FB. Therefore, the incremental yield of adding WATS3D to FB for these post-ablation patients was 64.9% for IM and 57.1% for dysplasia and neoplasia. No complications from WATS3D use were reported. Conclusions: In the post-ablation setting, adjunctive use of WATS3D with FB increases detection of residual or recurrent IM and dysplasia in the absence of endoscopically visible disease. Our multi-center experience, the largest cumulative post-ablation data set to date, confirms the benefit of
www.giejournal.org
adding WATS3D to FB with incremental yield around 60%. Further studies are needed to determine the target population in whom WATS3D will be most beneficial, and if this technology ultimately can replace laborious 4 quadrant FB.
426 Ocular Radiation Threshold Projection Based on Fluoroscopy Time During ERCP Mrinal S. Garg*1, Pikul Patel1, Margaret Blackwood2, Satish Munigala3, Elie Aoun1, Abhijit Kulkarni1, Manish K. Dhawan1, Katie Farah1, Shyam Thakkar1 1 Department of Gastroenterology, Allegheny Health Network, Pittsburgh, PA; 2Department of Radiation Safety, Allegheny Health Network, Pittsburgh, PA; 3Department of Gastroenterology, Washington University, St. Louis, MO Purpose: International Commission on Radiological Protection (ICRP) guidelines suggest a threshold of ocular radiation exposure of 20 millisieverts (mSv) per year averaged over five years not to exceed 50 mSv in any one year. We analyzed the lens exposure during endoscopic retrograde cholangiopancreatography (ERCP) for attending and fellow endoscopists to determine the time of fluoroscopy needed to warrant using lens protection during ERCP. Methods: Prospective analysis of 197 patients who underwent ERCP from January - July of 2013 at one tertiary care center endoscopy room. The fluoroscopy equipment included a GE OECTM 9800 C-arm with room setup shown in Figure 1. Patient characteristics (age/gender), anterior-posterior diameter (APD) and indications for ERCP were documented. ERCP interventions, procedure characteristics, fluoroscopy time, dose, and attending +/- fellow involvement were recorded to demonstrate the variety of cases and for comparisons to other practices. Radiation exposure was collected by three body Landauer InLightÒ Whole Body Basic dosimeters (BD) which calculated a projected eye lens exposure and three Landauer nanoDotÒ dosimeters (LD) placed directly between the eyes to accurately represent true eye exposure. Cumulative radiation doses were obtained from the dosimeters at the completion of the study and averaged over the total fluoroscopy time to determine the mSv/hour exposure. Results: After initial calibration, 187 cases were included in the study, of which attendings wore lens dosimeters (ALD) in 178 cases and body dosimeters (ABD) in 174 cases. Fellows wore lens dosimeters (FLD) in 126 cases and body dosimeters (FBD) in 128 cases. Patient and procedural characteristics were documented (Table 1). Attendings wore ALDs throughout 15.89 hours of fluoroscopy and fellows wore FLDs throughout 11.24 hours. The cumulative radiation dose absorbed was 5.35 mSv by the ALDs and 2.55 mSv by the FLDs. The projected lens absorption by the body dosimeters was 19.03 mSv by the ABDs and 5.21 mSv by the FBDs. The body dosimeters overestimated the lens dose by 13.68 mSv for the attendings and 2.66 mSv for the fellows. The hourly fluoroscopy lens exposure was 0.34 mSv/hour for attendings and 0.23 mSv/hour for fellows. Conclusions: ERCP procedures involve increased radiation exposure to physicians. Current body radiation exposure recommendations such as the use of lead apron shielding do not account for ocular radiation exposure to endoscopists as protective eye wear is optional. This study shows the amount of fluoroscopy hours needed in this model to reach the ICRP suggested lens radiation limit of 20 mSv/year was 59.41 hours for attendings and 88.17 hours for fellows. We recommend the use of radioprotective eye wear by physicians with yearly fluoroscopy times in similarly structured practices that meet or exceed these thresholds.
Table 1. Demographic and procedural data for each group of dosimeter collection
Age (yr) (Mean +/- SD) Gender: Male Female Unknown APD (cm) (Mean +/- SD) Indications: CBD Stone CBD Stricture Cholangitis SOD Acute Recurrent Pancreatitis Acute Pancreatitis Chronic Pancreatitis Pancreas Divisum Pancreatic Stricture PD Disruption Ampullary Neoplasm
ALD (178)
ABD (174)
FLD (126)
FBD (128)
Num
Num
Num
Num
%
63(16.2) 84 47% 92 52% 2 1% 22(4.3) 63 35% 61 34% 12 7% 13 7% 16 9% 8 4% 10 6% 5 3% 8 4% 2 1% 9 5%
%
63(16.2) 82 47% 90 52% 2 1% 22(4.2) 62 36% 60 34% 11 6% 12 7% 16 9% 8 5% 10 6% 5 3% 9 5% 2 1% 8 5%
%
%
62(15.7) 58 46% 68 54%
62(15.7) 58 45% 70 55%
22(3.8) 44 35% 43 34% 7 6% 9 7% 14 11% 8 6% 6 5% 3 2% 5 4% 1 1% 9 7%
22(3.8) 45 35% 43 34% 7 5% 9 7% 14 11% 8 6% 6 5% 3 2% 5 4% 1 1% 9 7%
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB141
Abstracts
Bile Leak Other Procedures: Balloon Sweep Sphincterotomy Dilation Cholangioscopy Plastic Stent Metal Stent Lithotripsy SOD Manometry Ampullectomy
ALD (178)
ABD (174)
FLD (126)
FBD (128)
Num
%
Num
%
Num
%
Num
%
8 27 109 86 43 17 80 19 3 5 2
4% 15% 61% 48% 24% 10% 45% 11% 2% 3% 1%
8 27 107 83 41 17 79 19 3 5 2
5% 16% 61% 48% 24% 10% 45% 11% 2% 3% 1%
7 19 80 64 25 12 54 16 0 6 0
6% 15% 63% 51% 20% 10% 43% 13% 0% 5% 0%
7 20 81 65 26 13 54 16 0 6 0
5% 16% 63% 51% 20% 10% 42% 13% 0% 5% 0%
ALD, attendings wearing lens dosimeters; ABD, attendings wearing body dosimeters; FLD, fellows wearing lens dosimeters; FBD, fellows wearing body dosimeters; yr, years; SD, standard deviation; APD , anterior-posterior patient diameter; cm, centimeters; CBD, common bile duct; SOD, Sphincter of Oddi; PD, pancreatic duct
Figure 1. Endoscopy Room Setup
427 Effectiveness of Cholecystectomy to Prevent Recurrent Acute Biliary Pancreatitis Ayesha Kamal*, Venkata S. Akshintala, Elie S. Al Kazzi, Vikesh K. Singh, Anthony N. Kalloo, Susan Hutfless Gastroenterology, Johns Hopkins Hospital, Baltimore, MD Background: Cholecystectomy during or within 4 weeks of the first hospitalization for acute biliary pancreatitis (ABP) is the guideline recommended standard of care. Clinical trials have demonstrated that early cholecystectomy prevents future episodes of pancreatitis. We examined the prevalence of hospitalizations for ABP following cholecystectomy compared with individuals with ABP who did not undergo cholecystectomy. Methods: The MarketScanÒ Commercial Claims & Encounters database includes individual-level clinical utilization data for inpatient and outpatient encounters paid for by employer sponsored fee-for-service, fully capitated or partially capitated plans. All individuals with at least one hospitalization associated with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 577.0 for acute pancreatitis and gallstone disease (ICD-9-CM 574.x) during 2008 were eligible. Follow up continued through 2009. Individuals with and without a CPT code of 47600, 47605, 47562, 47563 or 47564 for cholecystectomy during the initial hospitalization for ABP were compared for subsequent hospitalization for pancreatitis (ICD-9-CM 577) within 1 year after the index hospitalization. Logistic regression was used to compare the groups with adjustment for age, sex, alcohol abuse, smoking and obesity. Results: Of the 76,188 patients admitted for ABP, 11.1% underwent cholecystectomy within 4 weeks of the initial hospitalization, 4% never underwent cholecystectomy, 0.4% had a cholecystectomy O 4 weeks and less than 1 year after the initial hospitalization and 83% had a cholecystectomy greater than 1 year after the initial hospitalization. Among those who underwent cholecystectomy, the median age was 46.4 years and 57.1% were female compared with a median age of 47.0 year and 46.8% female in the group without cholecystectomy. Of those who underwent cholecystectomy during the guideline recommended period, 3.4% were hospitalized for pancreatitis in the subsequent year compared with a 9.0% prevalence of hospitalization for pancreatitis in the subsequent year among those who did not undergo cholecystectomy within 30 days of the initial hospitalization and never underwent cholecystectomy (p! 0.001). The remaining 83% of the cohort required additional hospitalizations during
AB142 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
which a cholecystectomy was performed. Conclusion: Compliance with management guidelines for ABP is less than 10%. Despite the decrease in subsequent hospitalizations for ABP among those who underwent cholecystectomy, not all patients undergo cholecystectomy during their initial hospitalization for ABP resulting in more than 80% of patients undergoing unnecessary future hospitalizations affecting costs and patient quality of life.
428 Benefits of Early ERCP in Patients With Gallstone Pancreatitis With Biliary Obstruction in Absence of Cholangitis Raxitkumar Jinjuvadia*1, Ahmed Saeed1, Adrienne Lenhart2, Suthat Liangpunsakul3,4, Cyrus R. Piraka1 1 Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI; 2 Internal Medicine, Henry Ford Hospital, Detroit, MI; 3Gastroenterology and Hepatology, Roudebush Veterans Administration Medical Center, Indianapolis, IN; 4Gastroenterology and Hepatology, Indiana University, Indianapolis, IN Background: Current ASGE guidelines for the role of endoscopy in the evaluation of suspected choledocholithiasis recommend early endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute biliary pancreatitis and clinical evidence of biliary obstruction without cholangitis. However, this is a low quality evidence guideline and further research has been recommended. We aim to study the differences in outcomes based on early versus late ERCP among patients presenting acute gallstone pancreatitis with biliary obstruction without cholangitis using large national sample database. Methods: The National Inpatient Sample (NIS) databases year 2011 was utilized. It contains around 8 million hospitalizations from approximately 1000 hospitals in the United States. The patients presented with acute pancreatitis, choledocholithiasis, biliary obstruction and cholangitis were identified using the various ICD-9 diagnosis codes. Hospitalizations with cholangitis were excluded from the study cohort. ERCP procedures were captured using various ICD-9 codes. Early ERCP was defined as being performed within 1 day of hospitalization. Various outcomes such as inpatient mortality, septicemia, length of stay (LOS), and total hospitalization cost were evaluated. Multivariate logistic regression modeling adjusted for age, sex, race and Elixhauser comorbidities were used, and adjusted odds ratios (aOR) are reported. SAS 9.3 was used for analyses. Results: Our study included 10,364 hospitalizations related to acute pancreatitis with choledocholithiasis/biliary obstruction without cholangitis. The mean age of the cohort was 57.2 years with 66.4% white and 62.2% female. Overall 58.9% had ERCP performed during the hospitalizations. Rate of early ERCP among those who had ERCP during hospitalization was 48.6%. Inpatient mortality was significantly lower among patients who had ERCP during the hospitalization (0.5% vs 1.7%, p!.001) though no significant difference in mortality noted among early vs late ERCP groups (0.5% vs 0.5%, pZ0.846). The rate of septicemia was significantly lower among those with early ERCP (4.0% vs 7.2%, p!.001). Multivariate logistic regression showed age, septicemia and Elixhauser comorbidities as predictors of increase in inpatient mortality (table 1). Apart from clinical outcomes, overall hospitalization LOS and costs were significantly lower among those with early ERCP. (mean LOS: 5.2 vs 8.0 days, p !.001; cost: $52,400 vs $71,736, p!.001). Conclusion: Early ERCP should be encouraged for hospitalizations related to acute pancreatitis and biliary obstruction without cholangitis as it is associated with significantly lower rate of septicemia, reduced LOS and financial cost. Our study further strengthens and adds high quality evidence to current ASGE guideline by utilizing a large nationally representative hospitalization sample. Table 1. Independent risk factors associated with inpatient mortality among hospitalizations with acute pancreatitis and biliary obstruction in absence of cholangitis Risk factor
Adjusted Odds ratio* (95% CI)
Age Elixhauser comorbidities ERCP during hospitalization Septicemia
1.04 (1.03 - 1.06) 1.17 (1.06 - 1.29) 0.30 (0.19 - 0.47) 13.5 (8.75 - 20.75)
*multivariate model included age, sex, race, septicemia, ERCP during hospitalization, Elixhauser comorbidities and early vs late ERCP
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test for proportional data, with p!0.05 denoting significance. Results: Of 1400 patients with BE, 196 (14%) met criteria for inclusion at a mean follow up of 86.8 months. Of these, 112 (57%) were untreated and 84 (43%) underwent RFA. Of these 84, complete eradication was accomplished in 54 (64%) and 9 patients progressed despite therapy, compared with 33 (29.5%) of the untreated patients (pZ0.01). Allcause mortality in treated patients was 13% compared to 29.7% in untreated patients (27.8% for those who did not progress and, 35.5% for those who did) (pZ0.004). Table 1 depicts these findings. Mean age, interval from BE to LGD diagnosis, short versus long-segment BE rates, and anatomical distribution of LGD were comparable between stable LGD and progression cohorts. Progression was associated with a higher mean BE segment length (8.6 cm vs. 10 cm, pZ0.46). Conclusion: Compared to clinical trials, our experience with RFA in a large BE cohort with LGD demonstrates lower complete eradication rates, and higher rates of dysplastic/malignant progression. However, untreated patients showed significantly higher rates of progression to HGD or EAC and higher all-cause mortality rates, strongly supporting the existing recommendation to treat LGD with RFA. Despite long-term follow up, we were unable to identify risk factors associated with progression from LGD, other than longer BE segment. We noted substantial heterogeneity in time to progression independent of endoscopic treatment, suggesting the presence of as-yet unidentified factors for risk stratification. Further studies are needed to develop a more comprehensive and predictive risk assessment paradigm for patients with BE.
Characteristics of LGD in patients with or without RFA treatment
Follow up (months) Interval from BE to LGD (months) Interval from LGD to HGD/EAC (months) Progression to HGD/EAC (n, %) All-cause mortality (n, %)
RFA (n [ 84)
Untreated (n [ 112)
Pvalue
75.7 37.3 32.5 9 (10.7%) 11 (13%)
94.9 42.6 33.8 33 (29.5%) 33 (29.5%)
0.03 0.49 0.94 0.01 0.04
345 Transepithelial Brush Biopsy With Computer-Assisted Tissue Analysis Increases Detection of Residual or Recurrent Intestinal Metaplasia and Dysplasia Following Endoscopic Ablation of Barrett’s Esophagus Natalya Iorio*1, Brandon Sprung2, Vivek Kaul2, Danielle Marino2, Shivangi Kothari2, Truptesh H. Kothari2, Rahul D. Kataria4, Seth A. Gross3, Michael S. Smith1 1 Medicine/Gastroenterology, Temple University School of Medicine, Philadelphia, PA; 2Medicine/Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester, NY; 3Medicine/Gastroenterology, NYU Langone Medical Center, New York, NY; 4Medicine, Jackson Memorial Hospital, Miami, FL Background: Radiofrequency ablation (RFA) and liquid nitrogen spray cryotherapy (SCT) are ablative techniques used to eradicate Barrett’s esophagus (BE). Residual or recurrent intestinal metaplasia (IM) can be present without endoscopically visible disease. Post-ablation surveillance using forceps biopsies (FB) leaves significant mucosa unsampled, which creates a risk of missing IM or dysplasia. Wide Area Transepithelial Sampling with Computer-Assisted 3-Dimensional Tissue Analysis (WATS3D) has been shown to increase detection of metaplasia and dysplasia when used in addition to FB. Our aim was to better characterize the incremental benefit of adding WATS3D to FB for detection of residual or recurrent IM and dysplasia following BE ablation, using data from 2 high-volume centers. Methods: Patients undergoing surveillance following RFA or SCT between June 2012 and October 2014 were included if there was no visual evidence of BE during endoscopy. WATS3D biopsies were obtained using a 2 brush technique within the original BE segment and were analyzed at a central laboratory using a neural network to identify abnormal cells. Following WATS3D, FB were obtained in the same segment using a modified Seattle Protocol, with 4 quadrant biopsies every 1 centimeter (cm). These biopsies were read by expert GI pathologists at each site. Demographic and endoscopic data were added to pathology and de-identified prior to data aggregation and analysis. Results: Our study included 208 procedures and 110 patients. There was a slight male predominance (53%), with a mean age of 63 years (37-88) and BMI of 30.1. Seventy patients (63.6%) were current or former smokers. Pre-ablation histology included high grade dysplasia or intramucosal adenocarcinoma (55.5%), low grade dysplasia (20.9%) and non-dysplastic BE (23.6%). The mean pre-treatment BE length was 3.88 cm. Prior BE treatments included RFA (90%), SCT (26%) and endoscopic mucosal resection (26%). FB identified post-ablation residual or recurrent IM in 37 cases (17.8%), and dysplasia or neoplasia in 7 cases (3.37%). Adjunctive use of WATS3D identified another 24 cases of BE and 4 cases of dysplasia missed by FB. Therefore, the incremental yield of adding WATS3D to FB for these post-ablation patients was 64.9% for IM and 57.1% for dysplasia and neoplasia. No complications from WATS3D use were reported. Conclusions: In the post-ablation setting, adjunctive use of WATS3D with FB increases detection of residual or recurrent IM and dysplasia in the absence of endoscopically visible disease. Our multi-center experience, the largest cumulative post-ablation data set to date, confirms the benefit of
www.giejournal.org
adding WATS3D to FB with incremental yield around 60%. Further studies are needed to determine the target population in whom WATS3D will be most beneficial, and if this technology ultimately can replace laborious 4 quadrant FB.
426 Ocular Radiation Threshold Projection Based on Fluoroscopy Time During ERCP Mrinal S. Garg*1, Pikul Patel1, Margaret Blackwood2, Satish Munigala3, Elie Aoun1, Abhijit Kulkarni1, Manish K. Dhawan1, Katie Farah1, Shyam Thakkar1 1 Department of Gastroenterology, Allegheny Health Network, Pittsburgh, PA; 2Department of Radiation Safety, Allegheny Health Network, Pittsburgh, PA; 3Department of Gastroenterology, Washington University, St. Louis, MO Purpose: International Commission on Radiological Protection (ICRP) guidelines suggest a threshold of ocular radiation exposure of 20 millisieverts (mSv) per year averaged over five years not to exceed 50 mSv in any one year. We analyzed the lens exposure during endoscopic retrograde cholangiopancreatography (ERCP) for attending and fellow endoscopists to determine the time of fluoroscopy needed to warrant using lens protection during ERCP. Methods: Prospective analysis of 197 patients who underwent ERCP from January - July of 2013 at one tertiary care center endoscopy room. The fluoroscopy equipment included a GE OECTM 9800 C-arm with room setup shown in Figure 1. Patient characteristics (age/gender), anterior-posterior diameter (APD) and indications for ERCP were documented. ERCP interventions, procedure characteristics, fluoroscopy time, dose, and attending +/- fellow involvement were recorded to demonstrate the variety of cases and for comparisons to other practices. Radiation exposure was collected by three body Landauer InLightÒ Whole Body Basic dosimeters (BD) which calculated a projected eye lens exposure and three Landauer nanoDotÒ dosimeters (LD) placed directly between the eyes to accurately represent true eye exposure. Cumulative radiation doses were obtained from the dosimeters at the completion of the study and averaged over the total fluoroscopy time to determine the mSv/hour exposure. Results: After initial calibration, 187 cases were included in the study, of which attendings wore lens dosimeters (ALD) in 178 cases and body dosimeters (ABD) in 174 cases. Fellows wore lens dosimeters (FLD) in 126 cases and body dosimeters (FBD) in 128 cases. Patient and procedural characteristics were documented (Table 1). Attendings wore ALDs throughout 15.89 hours of fluoroscopy and fellows wore FLDs throughout 11.24 hours. The cumulative radiation dose absorbed was 5.35 mSv by the ALDs and 2.55 mSv by the FLDs. The projected lens absorption by the body dosimeters was 19.03 mSv by the ABDs and 5.21 mSv by the FBDs. The body dosimeters overestimated the lens dose by 13.68 mSv for the attendings and 2.66 mSv for the fellows. The hourly fluoroscopy lens exposure was 0.34 mSv/hour for attendings and 0.23 mSv/hour for fellows. Conclusions: ERCP procedures involve increased radiation exposure to physicians. Current body radiation exposure recommendations such as the use of lead apron shielding do not account for ocular radiation exposure to endoscopists as protective eye wear is optional. This study shows the amount of fluoroscopy hours needed in this model to reach the ICRP suggested lens radiation limit of 20 mSv/year was 59.41 hours for attendings and 88.17 hours for fellows. We recommend the use of radioprotective eye wear by physicians with yearly fluoroscopy times in similarly structured practices that meet or exceed these thresholds.
Table 1. Demographic and procedural data for each group of dosimeter collection
Age (yr) (Mean +/- SD) Gender: Male Female Unknown APD (cm) (Mean +/- SD) Indications: CBD Stone CBD Stricture Cholangitis SOD Acute Recurrent Pancreatitis Acute Pancreatitis Chronic Pancreatitis Pancreas Divisum Pancreatic Stricture PD Disruption Ampullary Neoplasm
ALD (178)
ABD (174)
FLD (126)
FBD (128)
Num
Num
Num
Num
%
63(16.2) 84 47% 92 52% 2 1% 22(4.3) 63 35% 61 34% 12 7% 13 7% 16 9% 8 4% 10 6% 5 3% 8 4% 2 1% 9 5%
%
63(16.2) 82 47% 90 52% 2 1% 22(4.2) 62 36% 60 34% 11 6% 12 7% 16 9% 8 5% 10 6% 5 3% 9 5% 2 1% 8 5%
%
%
62(15.7) 58 46% 68 54%
62(15.7) 58 45% 70 55%
22(3.8) 44 35% 43 34% 7 6% 9 7% 14 11% 8 6% 6 5% 3 2% 5 4% 1 1% 9 7%
22(3.8) 45 35% 43 34% 7 5% 9 7% 14 11% 8 6% 6 5% 3 2% 5 4% 1 1% 9 7%
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB141
Abstracts
Bile Leak Other Procedures: Balloon Sweep Sphincterotomy Dilation Cholangioscopy Plastic Stent Metal Stent Lithotripsy SOD Manometry Ampullectomy
ALD (178)
ABD (174)
FLD (126)
FBD (128)
Num
%
Num
%
Num
%
Num
%
8 27 109 86 43 17 80 19 3 5 2
4% 15% 61% 48% 24% 10% 45% 11% 2% 3% 1%
8 27 107 83 41 17 79 19 3 5 2
5% 16% 61% 48% 24% 10% 45% 11% 2% 3% 1%
7 19 80 64 25 12 54 16 0 6 0
6% 15% 63% 51% 20% 10% 43% 13% 0% 5% 0%
7 20 81 65 26 13 54 16 0 6 0
5% 16% 63% 51% 20% 10% 42% 13% 0% 5% 0%
ALD, attendings wearing lens dosimeters; ABD, attendings wearing body dosimeters; FLD, fellows wearing lens dosimeters; FBD, fellows wearing body dosimeters; yr, years; SD, standard deviation; APD , anterior-posterior patient diameter; cm, centimeters; CBD, common bile duct; SOD, Sphincter of Oddi; PD, pancreatic duct
Figure 1. Endoscopy Room Setup
427 Effectiveness of Cholecystectomy to Prevent Recurrent Acute Biliary Pancreatitis Ayesha Kamal*, Venkata S. Akshintala, Elie S. Al Kazzi, Vikesh K. Singh, Anthony N. Kalloo, Susan Hutfless Gastroenterology, Johns Hopkins Hospital, Baltimore, MD Background: Cholecystectomy during or within 4 weeks of the first hospitalization for acute biliary pancreatitis (ABP) is the guideline recommended standard of care. Clinical trials have demonstrated that early cholecystectomy prevents future episodes of pancreatitis. We examined the prevalence of hospitalizations for ABP following cholecystectomy compared with individuals with ABP who did not undergo cholecystectomy. Methods: The MarketScanÒ Commercial Claims & Encounters database includes individual-level clinical utilization data for inpatient and outpatient encounters paid for by employer sponsored fee-for-service, fully capitated or partially capitated plans. All individuals with at least one hospitalization associated with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 577.0 for acute pancreatitis and gallstone disease (ICD-9-CM 574.x) during 2008 were eligible. Follow up continued through 2009. Individuals with and without a CPT code of 47600, 47605, 47562, 47563 or 47564 for cholecystectomy during the initial hospitalization for ABP were compared for subsequent hospitalization for pancreatitis (ICD-9-CM 577) within 1 year after the index hospitalization. Logistic regression was used to compare the groups with adjustment for age, sex, alcohol abuse, smoking and obesity. Results: Of the 76,188 patients admitted for ABP, 11.1% underwent cholecystectomy within 4 weeks of the initial hospitalization, 4% never underwent cholecystectomy, 0.4% had a cholecystectomy O 4 weeks and less than 1 year after the initial hospitalization and 83% had a cholecystectomy greater than 1 year after the initial hospitalization. Among those who underwent cholecystectomy, the median age was 46.4 years and 57.1% were female compared with a median age of 47.0 year and 46.8% female in the group without cholecystectomy. Of those who underwent cholecystectomy during the guideline recommended period, 3.4% were hospitalized for pancreatitis in the subsequent year compared with a 9.0% prevalence of hospitalization for pancreatitis in the subsequent year among those who did not undergo cholecystectomy within 30 days of the initial hospitalization and never underwent cholecystectomy (p! 0.001). The remaining 83% of the cohort required additional hospitalizations during
AB142 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
which a cholecystectomy was performed. Conclusion: Compliance with management guidelines for ABP is less than 10%. Despite the decrease in subsequent hospitalizations for ABP among those who underwent cholecystectomy, not all patients undergo cholecystectomy during their initial hospitalization for ABP resulting in more than 80% of patients undergoing unnecessary future hospitalizations affecting costs and patient quality of life.
428 Benefits of Early ERCP in Patients With Gallstone Pancreatitis With Biliary Obstruction in Absence of Cholangitis Raxitkumar Jinjuvadia*1, Ahmed Saeed1, Adrienne Lenhart2, Suthat Liangpunsakul3,4, Cyrus R. Piraka1 1 Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI; 2 Internal Medicine, Henry Ford Hospital, Detroit, MI; 3Gastroenterology and Hepatology, Roudebush Veterans Administration Medical Center, Indianapolis, IN; 4Gastroenterology and Hepatology, Indiana University, Indianapolis, IN Background: Current ASGE guidelines for the role of endoscopy in the evaluation of suspected choledocholithiasis recommend early endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute biliary pancreatitis and clinical evidence of biliary obstruction without cholangitis. However, this is a low quality evidence guideline and further research has been recommended. We aim to study the differences in outcomes based on early versus late ERCP among patients presenting acute gallstone pancreatitis with biliary obstruction without cholangitis using large national sample database. Methods: The National Inpatient Sample (NIS) databases year 2011 was utilized. It contains around 8 million hospitalizations from approximately 1000 hospitals in the United States. The patients presented with acute pancreatitis, choledocholithiasis, biliary obstruction and cholangitis were identified using the various ICD-9 diagnosis codes. Hospitalizations with cholangitis were excluded from the study cohort. ERCP procedures were captured using various ICD-9 codes. Early ERCP was defined as being performed within 1 day of hospitalization. Various outcomes such as inpatient mortality, septicemia, length of stay (LOS), and total hospitalization cost were evaluated. Multivariate logistic regression modeling adjusted for age, sex, race and Elixhauser comorbidities were used, and adjusted odds ratios (aOR) are reported. SAS 9.3 was used for analyses. Results: Our study included 10,364 hospitalizations related to acute pancreatitis with choledocholithiasis/biliary obstruction without cholangitis. The mean age of the cohort was 57.2 years with 66.4% white and 62.2% female. Overall 58.9% had ERCP performed during the hospitalizations. Rate of early ERCP among those who had ERCP during hospitalization was 48.6%. Inpatient mortality was significantly lower among patients who had ERCP during the hospitalization (0.5% vs 1.7%, p!.001) though no significant difference in mortality noted among early vs late ERCP groups (0.5% vs 0.5%, pZ0.846). The rate of septicemia was significantly lower among those with early ERCP (4.0% vs 7.2%, p!.001). Multivariate logistic regression showed age, septicemia and Elixhauser comorbidities as predictors of increase in inpatient mortality (table 1). Apart from clinical outcomes, overall hospitalization LOS and costs were significantly lower among those with early ERCP. (mean LOS: 5.2 vs 8.0 days, p !.001; cost: $52,400 vs $71,736, p!.001). Conclusion: Early ERCP should be encouraged for hospitalizations related to acute pancreatitis and biliary obstruction without cholangitis as it is associated with significantly lower rate of septicemia, reduced LOS and financial cost. Our study further strengthens and adds high quality evidence to current ASGE guideline by utilizing a large nationally representative hospitalization sample. Table 1. Independent risk factors associated with inpatient mortality among hospitalizations with acute pancreatitis and biliary obstruction in absence of cholangitis Risk factor
Adjusted Odds ratio* (95% CI)
Age Elixhauser comorbidities ERCP during hospitalization Septicemia
1.04 (1.03 - 1.06) 1.17 (1.06 - 1.29) 0.30 (0.19 - 0.47) 13.5 (8.75 - 20.75)
*multivariate model included age, sex, race, septicemia, ERCP during hospitalization, Elixhauser comorbidities and early vs late ERCP
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