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691 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic SNARE Papillectomy; Prospective, Randomized Multicenter Study
Abstracts
(96.6%) in valve group, 25/27 (92.6%) in non-valve group (pZ0.525). In valve group, only two patients (6.9%) were observed partial reflux of barium on barium meal examination, but all patients were occurred to reflux of barium in non-valve group (p!0.001). The mean duration of stent patency was 198 (39-507) days in valve group and 146 (27-376) days in non-valve group, respectively (pZ0.008). The mean survival of patients was 302 (92-507) and 281 (125-707) days, respectively (pZ0.792). Conclusions: A new anti-reflux valve SEMS was effective to prevent for duodenobiliary reflux and may be prolong stent patency in patient with unresectable distal MBS.
691 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic SNARE Papillectomy; Prospective, Randomized Multicenter Study Sang-Woo Cha*1, Eun Taek Park2, Kyo-Sang Yoo3, Tae Hoon Lee1, Soung Won Jeong1, Jae Young Jang1, Young Deok Cho1, Sang-Heum Park1, Sun-Joo Kim1 1 Department of Internal Medicine, Institute for Digestive Research, Digestive Disease center, Soonchunhyang University College of Medicine, Seoul, Republic of Korea; 2Department of Gastroenterology, Kosin University Hospital, Busan, Republic of Korea; 3Department of Gastroenterology, Hanyang University Guri Hospital, Guri, Republic of Korea Background and Aims: Endoscopic snare papillectomy (ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, acute pancreatitis is the most common and serious complication following an ESP. The aim of this study was to compare the rate of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic stent placement after ESP. Patients and Methods: From March 2010 to October 2013, consecutive patients who were to undergo ESP were randomized to pancreatic stent placement group or to no pancreatic stent placement group. The overall outcomes after ESP including complications were compared between two groups. Results: The 42 patients who received ESP for the treatment of major duodenal papillary tumors were enrolled. Twenty one patients were assigned to the stent group and 21 patients to the no stent group. Post-ESP pancreatitis developed in 9 patients (21.4 %, 9/42), 5 cases occurred in the stent group and 4 cases occurred in the no stent group. One case in the stent group was considered moderate grade pancreatitis and the others were considered mild grade pancreatitis. The overall incidence of post-EPS pancreatitis were 23.8% (5/21) in the stent group and 19.0% (4/21) in the no stent group (pZ1.000). The rates of hyperamylasemia were 9.5% (2/21) in the stent group and 9.5% (2/21) in the no stent group (pZ1.000). Conclusions: The development of post-ESP pancreatitis and hyperamylasemia were not significantly different in patients with prophylactic pancreatic stent placement compared to those without it. Our data suggest that the effectiveness of prophylactic pancreatic stent placement after ESP may be doubtful. Therefore, more large scaled prospective, randomized controlled studies are needed. Keywords: Endoscopic snare papillectomy, Pancreatitis, Prophylactic pancreatic stent
692 Safety and Efficacy of a Combined Endoscopic Approach Using ERCP and EUS for the Management of Complete Bile-Duct Transections: Mid-Term Results Nestor Aleman, Alba L. Vargas, Irene PeñAs*, Carlos De, La Serna, Carolina Almohalla Alvarez, Felix Garcia-Pajares, Gloria Sanchez-Antolin, Manuel Perez-Miranda Endoscopy Unit. Department of Gastroenterology and Hepatology, Hospital Universitario Río Hortega, Valladolid, Spain Background: Postoperative Bile-duct Transections (POBT) are not amenable to endoscopic therapy. Preliminary data from combined percutaneous-endoscopic approaches are encouraging. Isolated reports of successful retrograde canalization are intriguing. We hypothesized that aggressive retrograde (ERCP) and/or antegrade (EUS) attempts at recanalization may salvage POBTs for endotherapy, and subsequent serial stenting would induce remodeling and durable resolution as seen in partial strictures. Aim: To assess the feasibility, safety and efficacy of an endoscopic treatment algorithm of POBTs and to characterize the heterogeneous techniques used to attempt recanalization. Patients & Methods: Since September 2010, 248 consecutive ERCPs were performed at a tertiary Unit for postoperative complications (strictures/leaks) in 150 patients (69 Liver Transplant, 81 Other). POBTs were identified in 17 patients (9 Female; ageZ 59.6 [43-79] years) following liver transplant (LT) /cholecystectomy (CCx) /Other in 7/7/3. Records were retrospectively reviewed for procedural data (success, antegrade Vs retrograde, technique) and clinical outcome (immediate POBT remodeling and mid-term clinical resolution). Results: Recanalization was achieved in 12/17 POBT (70%), by means of ERCP alone in 5 (4 LT, 1CCx), of ERCP combined with EUS-guided antegrade approach in 6 (2 LT, 3CCx, 1 Other), and EUS alone in 1. Lack of upstream biliary dilation precluded EUS attemps in 4, and recanalization failed in 1 despite EUS-hepaticogastrostomy (EUS-HG). 5 initial failures underwent surgical repair with/without interval external
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PTBD. 10/12 recanalizations required forced antegrade/retrograde techniques: using the hard end of a stiff guidewire, needle-knife, puncture with intraductal hollow needles, transhepatic peritoneoscopy or magnetic compression anastomosis. A mean (range) of 1.5 (1-5) ERCPs were needed to achieve recanalization. Coincidental bilomas were drained in 2 POBTS (one transpapillary by ERCP and one transmural by EUS each). 11 Patients have completed 12 treatment courses of serial stenting (2 plastic alone & 10 covered metal with/without plastic) after 323(180-503) days of stents in place. After a mean follow-up of 353(30-900) days, there were 3 recurrences (1 surgery, 1 currently undergoing stenting, 1 successfully remodeled endoscopically). Post-procedural or stent related mild cholangitis ensued in 4, and moderate post-sphincterotomy bleeding in 1. Conclusions: 70% of POBTs can successfully be recanalized endoscopically by means of forced mechanical (guidewires, needles), thermal or magnetic techniques. Antegrade EUS approaches allow salvage of 60% of ERCP failures. Mid-term treatment ouctomes using this algorithm for POBTs appear comparable to those seen with partial postoperative strictures.
728 Clinical Results of 500 POEM Cases for Esophageal Achalasia and Related Diseases in a Single Institute Haruhiro Inoue*, Manabu Onimaru, Haruo Ikeda, Chiaki Sato, Hiroki Sato, Shin-Ei Kudo Showa University Northern Yokohama Hospital, Digestive Disease Center, Yokohama, Japan Introduction: To clarify clinical impact of POEM for esophageal achalasia and related disease, single insttitue registered prospective study was conducted. Study design: Prospective registered study (UMIN 1901) at university hospital. Technical details of POEM were already reported (Inoue H et al. Endoscopy 2010; 42: 265-71). Patients: All types of stenotic motility disorder of the esophagus (achalasia, diffuse spasm, Nutcracker esophagus, Hypertensive LES and others) were included in this study. From September 2008 to October 2013, 500 consecutive cases of esophageal stenotic motility disorder received POEM procedure. Gender was 171 Males and 229 Females. Age distributes from 3 to 87 (45.2 on average). Suffered period from the disease was from 0.4 to 62.4 years (average 10.9). 52 sigmoid achalasia cases were involved. Clinical results: 1. Results of procedureOperating time was 97.7 min (35 to 245). Myotomy length was 13.9 cm in total (2.8 on gastric side and 11.1 cm in esophageal side). No patient was converted to open surgery. 2. Post POEM complications No major adverse event occurred. Minor complication in 3.2% ( Mucosal injury 8 cases, localized submucosal hematoma 3 cases, pleural effusion 2 cases, pneumothorax 1 case, local peritonitis 1 case, mass bleeding during procedure which required transfusion 1 case). Mean hospital stay was 4.72 .3. Overall success rateOverall success rate was 94.7% (Eckerdt score was less than 3), 97% (Eckerdt score reduced more than 3 points).4. Symptom scoreEckerdt score improved from 6.0 (before POEM) to 1.3 (two month later) (P!0.01) and 1.5 (one year later) (P! 0.01).5. Resting pressure reduced from 28.8 to 13.2 mmHg (P!0.01).6. Application of POEM to sigmoid achalasiaEffectiveness of POEM procedure in sigmoid achalasia was equal to non-sigmoid achalasia. Eckerdt score recovered from 5.34 to 1.11 in sigmoid achalasia (6.07 to 1.37 in non-sigmoid group).7. Rescue POEM for surgical failure Rescue POEM was done in 10 cases with previous surgical failure. Eckerdt score improved from 6.5 to 1.1. Generally clinical results of redo surgery were not excellent, then excellent result of POEM suggests that POEM is better indicated to surgical cases.8. Chest painChest pain was controlled in 96. 7% by POEM. Eckerdt chest pain score was significantly improved 2.49 to 0.66.9. Post POEM GERD. Symptomatic GERD was observed in 16% and only 5% received PPI. There were no severe GERD cases. This result is relevant to surgical Heller-Dor procedure.10. Middle-term results.36 cases were followed more than 3 years.. Eckerdt score was improved from 6.58 to 2.27. This result suggests that patients keep excellent control of symptoms more than 3 years after POEM. Conclusion: Based on these results POEM is considered to be a standard treatment for esophageal achalasia and related dislease.
729 Predictive Values of Impedence Planimetry (Endo-FLIP) for Clinical Outcomes of Endoscopic Esophageal Myotomy (POEM) Procedures Ahmed M. Sharata*1, Christy M. Dunst1, Radu Pescarus2, Eran Shlomovitz2, Kevin M. Reavis1, Lee L. Swanstrom1 1 GMIS, Oregon Clinic, Portland, OR; 2Forgut Surgery/GMIS, Providence Portland Medical Center, Portland, OR Background: Endolumenal Functional Lumen Imaging Probe (Endo-FLIP) is a new modality to assess the physiologic charateristics of the GI tract. It measures multiple parameters of the GI tract and has been particularly useful at characterizing the lower esophageal sphincter (LES). It has already been used intraoperatively to predict successful outcomes after fundoplication. We analyzed pre and post myotomy LES characteristics during POEM surgery for achalasia and correlate the parameters of the final myotomized LES with the clinical and objective outcomes at 6 months. Based on this data we hypothesize that EndoFLIP may be a valuable tool to allow surgeons to modify POEM myotomies during surgery in order to maximize
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB165
(96.6%) in valve group, 25/27 (92.6%) in non-valve group (pZ0.525). In valve group, only two patients (6.9%) were observed partial reflux of barium on barium meal examination, but all patients were occurred to reflux of barium in non-valve group (p!0.001). The mean duration of stent patency was 198 (39-507) days in valve group and 146 (27-376) days in non-valve group, respectively (pZ0.008). The mean survival of patients was 302 (92-507) and 281 (125-707) days, respectively (pZ0.792). Conclusions: A new anti-reflux valve SEMS was effective to prevent for duodenobiliary reflux and may be prolong stent patency in patient with unresectable distal MBS.
691 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic SNARE Papillectomy; Prospective, Randomized Multicenter Study Sang-Woo Cha*1, Eun Taek Park2, Kyo-Sang Yoo3, Tae Hoon Lee1, Soung Won Jeong1, Jae Young Jang1, Young Deok Cho1, Sang-Heum Park1, Sun-Joo Kim1 1 Department of Internal Medicine, Institute for Digestive Research, Digestive Disease center, Soonchunhyang University College of Medicine, Seoul, Republic of Korea; 2Department of Gastroenterology, Kosin University Hospital, Busan, Republic of Korea; 3Department of Gastroenterology, Hanyang University Guri Hospital, Guri, Republic of Korea Background and Aims: Endoscopic snare papillectomy (ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, acute pancreatitis is the most common and serious complication following an ESP. The aim of this study was to compare the rate of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic stent placement after ESP. Patients and Methods: From March 2010 to October 2013, consecutive patients who were to undergo ESP were randomized to pancreatic stent placement group or to no pancreatic stent placement group. The overall outcomes after ESP including complications were compared between two groups. Results: The 42 patients who received ESP for the treatment of major duodenal papillary tumors were enrolled. Twenty one patients were assigned to the stent group and 21 patients to the no stent group. Post-ESP pancreatitis developed in 9 patients (21.4 %, 9/42), 5 cases occurred in the stent group and 4 cases occurred in the no stent group. One case in the stent group was considered moderate grade pancreatitis and the others were considered mild grade pancreatitis. The overall incidence of post-EPS pancreatitis were 23.8% (5/21) in the stent group and 19.0% (4/21) in the no stent group (pZ1.000). The rates of hyperamylasemia were 9.5% (2/21) in the stent group and 9.5% (2/21) in the no stent group (pZ1.000). Conclusions: The development of post-ESP pancreatitis and hyperamylasemia were not significantly different in patients with prophylactic pancreatic stent placement compared to those without it. Our data suggest that the effectiveness of prophylactic pancreatic stent placement after ESP may be doubtful. Therefore, more large scaled prospective, randomized controlled studies are needed. Keywords: Endoscopic snare papillectomy, Pancreatitis, Prophylactic pancreatic stent
692 Safety and Efficacy of a Combined Endoscopic Approach Using ERCP and EUS for the Management of Complete Bile-Duct Transections: Mid-Term Results Nestor Aleman, Alba L. Vargas, Irene PeñAs*, Carlos De, La Serna, Carolina Almohalla Alvarez, Felix Garcia-Pajares, Gloria Sanchez-Antolin, Manuel Perez-Miranda Endoscopy Unit. Department of Gastroenterology and Hepatology, Hospital Universitario Río Hortega, Valladolid, Spain Background: Postoperative Bile-duct Transections (POBT) are not amenable to endoscopic therapy. Preliminary data from combined percutaneous-endoscopic approaches are encouraging. Isolated reports of successful retrograde canalization are intriguing. We hypothesized that aggressive retrograde (ERCP) and/or antegrade (EUS) attempts at recanalization may salvage POBTs for endotherapy, and subsequent serial stenting would induce remodeling and durable resolution as seen in partial strictures. Aim: To assess the feasibility, safety and efficacy of an endoscopic treatment algorithm of POBTs and to characterize the heterogeneous techniques used to attempt recanalization. Patients & Methods: Since September 2010, 248 consecutive ERCPs were performed at a tertiary Unit for postoperative complications (strictures/leaks) in 150 patients (69 Liver Transplant, 81 Other). POBTs were identified in 17 patients (9 Female; ageZ 59.6 [43-79] years) following liver transplant (LT) /cholecystectomy (CCx) /Other in 7/7/3. Records were retrospectively reviewed for procedural data (success, antegrade Vs retrograde, technique) and clinical outcome (immediate POBT remodeling and mid-term clinical resolution). Results: Recanalization was achieved in 12/17 POBT (70%), by means of ERCP alone in 5 (4 LT, 1CCx), of ERCP combined with EUS-guided antegrade approach in 6 (2 LT, 3CCx, 1 Other), and EUS alone in 1. Lack of upstream biliary dilation precluded EUS attemps in 4, and recanalization failed in 1 despite EUS-hepaticogastrostomy (EUS-HG). 5 initial failures underwent surgical repair with/without interval external
www.giejournal.org
PTBD. 10/12 recanalizations required forced antegrade/retrograde techniques: using the hard end of a stiff guidewire, needle-knife, puncture with intraductal hollow needles, transhepatic peritoneoscopy or magnetic compression anastomosis. A mean (range) of 1.5 (1-5) ERCPs were needed to achieve recanalization. Coincidental bilomas were drained in 2 POBTS (one transpapillary by ERCP and one transmural by EUS each). 11 Patients have completed 12 treatment courses of serial stenting (2 plastic alone & 10 covered metal with/without plastic) after 323(180-503) days of stents in place. After a mean follow-up of 353(30-900) days, there were 3 recurrences (1 surgery, 1 currently undergoing stenting, 1 successfully remodeled endoscopically). Post-procedural or stent related mild cholangitis ensued in 4, and moderate post-sphincterotomy bleeding in 1. Conclusions: 70% of POBTs can successfully be recanalized endoscopically by means of forced mechanical (guidewires, needles), thermal or magnetic techniques. Antegrade EUS approaches allow salvage of 60% of ERCP failures. Mid-term treatment ouctomes using this algorithm for POBTs appear comparable to those seen with partial postoperative strictures.
728 Clinical Results of 500 POEM Cases for Esophageal Achalasia and Related Diseases in a Single Institute Haruhiro Inoue*, Manabu Onimaru, Haruo Ikeda, Chiaki Sato, Hiroki Sato, Shin-Ei Kudo Showa University Northern Yokohama Hospital, Digestive Disease Center, Yokohama, Japan Introduction: To clarify clinical impact of POEM for esophageal achalasia and related disease, single insttitue registered prospective study was conducted. Study design: Prospective registered study (UMIN 1901) at university hospital. Technical details of POEM were already reported (Inoue H et al. Endoscopy 2010; 42: 265-71). Patients: All types of stenotic motility disorder of the esophagus (achalasia, diffuse spasm, Nutcracker esophagus, Hypertensive LES and others) were included in this study. From September 2008 to October 2013, 500 consecutive cases of esophageal stenotic motility disorder received POEM procedure. Gender was 171 Males and 229 Females. Age distributes from 3 to 87 (45.2 on average). Suffered period from the disease was from 0.4 to 62.4 years (average 10.9). 52 sigmoid achalasia cases were involved. Clinical results: 1. Results of procedureOperating time was 97.7 min (35 to 245). Myotomy length was 13.9 cm in total (2.8 on gastric side and 11.1 cm in esophageal side). No patient was converted to open surgery. 2. Post POEM complications No major adverse event occurred. Minor complication in 3.2% ( Mucosal injury 8 cases, localized submucosal hematoma 3 cases, pleural effusion 2 cases, pneumothorax 1 case, local peritonitis 1 case, mass bleeding during procedure which required transfusion 1 case). Mean hospital stay was 4.72 .3. Overall success rateOverall success rate was 94.7% (Eckerdt score was less than 3), 97% (Eckerdt score reduced more than 3 points).4. Symptom scoreEckerdt score improved from 6.0 (before POEM) to 1.3 (two month later) (P!0.01) and 1.5 (one year later) (P! 0.01).5. Resting pressure reduced from 28.8 to 13.2 mmHg (P!0.01).6. Application of POEM to sigmoid achalasiaEffectiveness of POEM procedure in sigmoid achalasia was equal to non-sigmoid achalasia. Eckerdt score recovered from 5.34 to 1.11 in sigmoid achalasia (6.07 to 1.37 in non-sigmoid group).7. Rescue POEM for surgical failure Rescue POEM was done in 10 cases with previous surgical failure. Eckerdt score improved from 6.5 to 1.1. Generally clinical results of redo surgery were not excellent, then excellent result of POEM suggests that POEM is better indicated to surgical cases.8. Chest painChest pain was controlled in 96. 7% by POEM. Eckerdt chest pain score was significantly improved 2.49 to 0.66.9. Post POEM GERD. Symptomatic GERD was observed in 16% and only 5% received PPI. There were no severe GERD cases. This result is relevant to surgical Heller-Dor procedure.10. Middle-term results.36 cases were followed more than 3 years.. Eckerdt score was improved from 6.58 to 2.27. This result suggests that patients keep excellent control of symptoms more than 3 years after POEM. Conclusion: Based on these results POEM is considered to be a standard treatment for esophageal achalasia and related dislease.
729 Predictive Values of Impedence Planimetry (Endo-FLIP) for Clinical Outcomes of Endoscopic Esophageal Myotomy (POEM) Procedures Ahmed M. Sharata*1, Christy M. Dunst1, Radu Pescarus2, Eran Shlomovitz2, Kevin M. Reavis1, Lee L. Swanstrom1 1 GMIS, Oregon Clinic, Portland, OR; 2Forgut Surgery/GMIS, Providence Portland Medical Center, Portland, OR Background: Endolumenal Functional Lumen Imaging Probe (Endo-FLIP) is a new modality to assess the physiologic charateristics of the GI tract. It measures multiple parameters of the GI tract and has been particularly useful at characterizing the lower esophageal sphincter (LES). It has already been used intraoperatively to predict successful outcomes after fundoplication. We analyzed pre and post myotomy LES characteristics during POEM surgery for achalasia and correlate the parameters of the final myotomized LES with the clinical and objective outcomes at 6 months. Based on this data we hypothesize that EndoFLIP may be a valuable tool to allow surgeons to modify POEM myotomies during surgery in order to maximize
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB165