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709 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic snare Papillectomy; Prospective, Randomized Single Center Study
Abstracts
CS was 6.7 times more likely if the larger stent diameter (15mm) was used, even after adjusting for adverse events, cyst length, ERCP, necrosectomy and number of sessions (OR 6.7, 95% 1.3-34; pZ0.02). Conclusions: Endoscopic therapy of WOPN using LAMS is a safe and feasible concept. Creation of a large and sustained cystenterostomy tract provides a more efficient window for extraction of necrotic material with reduced number of sessions compared to prior studies. Table 1. Predictors of cyst resolution in WOPN Variables Axios Diameter 10 mm 15 mm Cyst length Adverse Events Sessions Age
Univariate Ref 3.25 (0.88-12.0) 0.99 (0.98-1.02) 0.18 (0.02-1.44) 0.59 (0.4-0.86) 0.98 (0.94-1.02)
Multivariable Analysis 6.7 1.02 0.09 0.47 0.99
Ref (1.3-34.9) (0.99-1.02) (0.01-0.97) (0.28-0.77) (0.24-24.7)
P-value 0.02 0.4 0.05 0.003 0.92
709 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic snare Papillectomy; Prospective, Randomized Single Center Study Young Deok Cho*, Yong Sub Lee, Sang-Woo Cha, Tae Hoon Lee, Soung Won Jeong, Jae Young Jang, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Soon Chun Hyang University Hosptial, Seoul, Korea (the Republic of) 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. Methods: From March 2010 and November 2014, consecutive patients who were to undergo ESP were randomized to pancreatic stent placement group (stent group) after ESP or to no pancreatic stent placement group (no stent group). The overall outcomes after ESP including complications were compared between the two groups. Results: The 50 patients who received ESP for the treatment of major duodenal papillary tumors were enrolled. 25 patients were assigned to the stent group and 25 patients to the no stent group. Post-ESP pancreatitis developed in 8 patients (16.0%, 8/50), The overall incidence of post-ESP pancreatitis were 20.0% (5/25) in the stent group and 12.0% (3/25) in the no stent group (pZ0.702). Although there was no statistic significance, post-ESP pancreatitis was higher in the stent group. Conclusions: The development of postESP pancreatitis were not significantly different in patients with prophylactic pancreatic stent placement compared the 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 regarding the effectiveness of pancreatic duct stent placement to reduce incidence of post-ESP pancreatitis are needed. Keywords: Endoscopic snare papillectomy, Pancreatitis, Prophylactic pancreatic stent
710 Use and Perceived Effectiveness of Endoscopic Therapies in Recurrent Acute Pancreatitis (RAP) Patients Treated At US Referral Centers Andres Gelrud*1, Timothy B. Gardner2, John Baillie3, Adam Slivka4, Michelle A. Anderson5, Michele D. Lewis6, Stephen Amann8, Peter A. Banks7, Stuart Sherman9, Robert Hawes10, Samer Al-Kaade11, Michael R. O’Connell4, Gregory A. Cote12, Joseph Romagnuolo12, David C. Whitcomb4, Dhiraj Yadav4 1 Gastroenterology, University of Chicago, Chicago, IL; 2Dartmouth Hitchcock Medical Center, New London, NH; 3Carteret Medical Groupd, Forehead City, NC; 4University of Pittsburgh Medical Center, Pittsburgh, PA; 5University of Michigan, Ann Arbor, MI; 6Mayo Clinic, Jacksonville, FL; 7Brigham and Women’s Hospital, Boston, MA; 8Digestive Health Specialists, Tupelo, MS; 9Indiana University, Indianapolis, IN; 10Florida Hospital, Orlando, FL; 11Saint Louis Medical Center, Saint Louis, MO; 12 Medical University South Carolina, Charleston, SC Background: Most studies on RAP (R2 documented episodes of AP and no abdominal imaging evidence of Chronic Pancreatitis) are small and have focused on specific subsets (sphincter of oddi dysfunction, pancreas divisum) or therapy (sphincterotomy). The aim of our study was to describe the demographics, etiologic profile, therapies utilized and their perceived effectiveness in a large cohort of well-phenotyped RAP patients treated at US referral centers. Method: From 2001-2006, 454 patients with RAP were prospectively enrolled from 19 US centers in the North American Pancreatitis Study (NAPS2). With assistance of a trained coordinator, patients completed a detailed questionnaire on demo-
AB162 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
graphics, clinical and family history and risk factors (smoking, alcohol). In a separate questionnaire, physicians provided information on disease phenotype, etiology, treatments received until enrollment and their perceived effectiveness (91%, 411/454). Results: Of the 454 patients, 44% were male and 90% were White. The mean age of first AP episode was 4116 yrs. About half (53%) were enrolled from two and about three-fourth (78%) from six centers. The three most common etiologies were idiopathic, alcohol and obstructive (most commonly pancreas divisum and SOD), accounting for about one-fourths of the cohort each (Table 1). Men were more likely to have alcohol (OR 4.9, 95% CI 3.0-7.9) while women were more likely to have obstructive (OR 2.3, 95% CI 1.3-3.8) or idiopathic etiologies (2.6, 95% CI 1.7-4.2). Patients with alcoholic RAP were more likely (p!0.05) to be ever or heavy (R1 ppd) smokers (80%, 47%) when compared with idiopathic (46%, 23%) and obstructive (42%, 26%) RAP, and they had a higher prevalence of pseudocyst formation (17% vs. 7% idiopathic, 4% obstructive, p!0.05). The most common therapies utilized were biliary sphincterotomy, stent placement in the bile or pancreatic ducts and oral pancreatic enzyme supplementation (Table 2). Other medical (octreotide, antispasmodics, vitamins/antioxidants, celiac block) or surgical therapies (sphincterotomy, cyst or drainage operation, partial pancreas resection) were infrequently used (2-8%). Biliary sphincterotomy (72%) and pancreatic duct stenting (49%) were used more frequently in patients with obstructive etiology (vs. 34%, 32% others, p!0.05) while pancreatic enzymes were tried more often in young patients !35 yrs (50 vs. 35% others, p!0.05). Conclusions: In contrast to community setting most patients with RAP treated at US referral centers have non-alcoholic etiologies. About half undergo an endoscopic intervention and one-thirds of patients receive oral pancreatic enzyme supplements. The available endoscopic therapies for RAP are perceived to be effective only in subsets of patients.
Etiology of RAP in the NAPS2 cohort Alcohol Gallstones Obstructive Idiopathic Hyperlipidemia Others
All (454)
Female (254)
Male (200)
117 (26) 41 (9) 90 (20) 129 (28) 24 (5) 53 (12)
33 (13) 24 (9) 64 (25) 93 (37) 9 (4) 31 (12)
84 (42) 17 (9) 26 (13) 36 (18) 15 (8) 22 (11)
Select medical and endoscopic therapies tried and their perceived effectiveness in the NAPS2 cohort Treatment (N[411) Oral Pancreatic Enzymes Biliary Sphincterotomy Biliary Stent Pancreatic Stent
Tried - n (%) x 158 (38) 168 (41) 46 (11) 145 (35)
Perceived Effectiveness - n (%) U 64 80 14 72
(41) (48) (30) (50)
N Z Number of patients in whom physicians provided information on therapies n (%) represents patients in whom the therapy was x tried and U found effective
711 Comparison of Insertion Techniques for Luminal Distention for on-Demand Sedation Colonoscopy: Air Insufflation, Carbon Dioxide and Water-Aided Colonoscopy - a Two-Center Randomized Controlled Trial Sergio Cadoni*1, Premysl Falt2, Paolo Gallittu1, Mauro Liggi1, Donatella Mura1, Vit Smajstrla2, Matteo Erriu3, Felix W. Leung4 1 Digestive Endoscopy Unit, S. Barbara Hospital, Iglesias, Italy; 2Digestive Diseases Center, Vìtkovice Hospital, Ostrava, Czech Republic; 3 Department of Surgical Sciences, University of Cagliari, Cagliari, Italy; 4 Gastroenterology, VA Sepulveda Ambulatory Care Center, VAGLAHS and David Geffen School of Medicine at UCLA, Los Angeles, CA Background: The 2013 ASGE Technology Status Evaluation Report on methods of luminal distention for colonoscopy called for studies comparing carbon dioxide (CO2) insufflation and water-aided insertion techniques. We compared maximum real-time insertion pain of air insufflation (AI), CO2 insufflation, water immersion (WI) and water exchange (WE). Objectives: We aimed to determine which combination of methods would produce the lowest maximum real-time insertion pain score. Patients: Consecutive diagnostic colonoscopy patients who received splitdose bowel preparation. Methods: Patient-blinded, prospective, two-center randomized controlled trial. On-demand sedation based on patient request due to pain. Colonoscopy with (insertion modality-withdrawal modality) AI-AI, CO2-CO2, WI-AI, WE-AI, WI-CO2 or WE-CO2. Investigators were blinded to insufflation gas used. Main outcome: maximum real-time insertion pain. (NCT01954862)Main outcome measurements: Maximum real-time insertion pain (0Znone, 1-2Zdiscomfort 10Zworst) was recorded by an unblinded nurse assistant. At discharge a blinded
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CS was 6.7 times more likely if the larger stent diameter (15mm) was used, even after adjusting for adverse events, cyst length, ERCP, necrosectomy and number of sessions (OR 6.7, 95% 1.3-34; pZ0.02). Conclusions: Endoscopic therapy of WOPN using LAMS is a safe and feasible concept. Creation of a large and sustained cystenterostomy tract provides a more efficient window for extraction of necrotic material with reduced number of sessions compared to prior studies. Table 1. Predictors of cyst resolution in WOPN Variables Axios Diameter 10 mm 15 mm Cyst length Adverse Events Sessions Age
Univariate Ref 3.25 (0.88-12.0) 0.99 (0.98-1.02) 0.18 (0.02-1.44) 0.59 (0.4-0.86) 0.98 (0.94-1.02)
Multivariable Analysis 6.7 1.02 0.09 0.47 0.99
Ref (1.3-34.9) (0.99-1.02) (0.01-0.97) (0.28-0.77) (0.24-24.7)
P-value 0.02 0.4 0.05 0.003 0.92
709 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic snare Papillectomy; Prospective, Randomized Single Center Study Young Deok Cho*, Yong Sub Lee, Sang-Woo Cha, Tae Hoon Lee, Soung Won Jeong, Jae Young Jang, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Soon Chun Hyang University Hosptial, Seoul, Korea (the Republic of) 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. Methods: From March 2010 and November 2014, consecutive patients who were to undergo ESP were randomized to pancreatic stent placement group (stent group) after ESP or to no pancreatic stent placement group (no stent group). The overall outcomes after ESP including complications were compared between the two groups. Results: The 50 patients who received ESP for the treatment of major duodenal papillary tumors were enrolled. 25 patients were assigned to the stent group and 25 patients to the no stent group. Post-ESP pancreatitis developed in 8 patients (16.0%, 8/50), The overall incidence of post-ESP pancreatitis were 20.0% (5/25) in the stent group and 12.0% (3/25) in the no stent group (pZ0.702). Although there was no statistic significance, post-ESP pancreatitis was higher in the stent group. Conclusions: The development of postESP pancreatitis were not significantly different in patients with prophylactic pancreatic stent placement compared the 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 regarding the effectiveness of pancreatic duct stent placement to reduce incidence of post-ESP pancreatitis are needed. Keywords: Endoscopic snare papillectomy, Pancreatitis, Prophylactic pancreatic stent
710 Use and Perceived Effectiveness of Endoscopic Therapies in Recurrent Acute Pancreatitis (RAP) Patients Treated At US Referral Centers Andres Gelrud*1, Timothy B. Gardner2, John Baillie3, Adam Slivka4, Michelle A. Anderson5, Michele D. Lewis6, Stephen Amann8, Peter A. Banks7, Stuart Sherman9, Robert Hawes10, Samer Al-Kaade11, Michael R. O’Connell4, Gregory A. Cote12, Joseph Romagnuolo12, David C. Whitcomb4, Dhiraj Yadav4 1 Gastroenterology, University of Chicago, Chicago, IL; 2Dartmouth Hitchcock Medical Center, New London, NH; 3Carteret Medical Groupd, Forehead City, NC; 4University of Pittsburgh Medical Center, Pittsburgh, PA; 5University of Michigan, Ann Arbor, MI; 6Mayo Clinic, Jacksonville, FL; 7Brigham and Women’s Hospital, Boston, MA; 8Digestive Health Specialists, Tupelo, MS; 9Indiana University, Indianapolis, IN; 10Florida Hospital, Orlando, FL; 11Saint Louis Medical Center, Saint Louis, MO; 12 Medical University South Carolina, Charleston, SC Background: Most studies on RAP (R2 documented episodes of AP and no abdominal imaging evidence of Chronic Pancreatitis) are small and have focused on specific subsets (sphincter of oddi dysfunction, pancreas divisum) or therapy (sphincterotomy). The aim of our study was to describe the demographics, etiologic profile, therapies utilized and their perceived effectiveness in a large cohort of well-phenotyped RAP patients treated at US referral centers. Method: From 2001-2006, 454 patients with RAP were prospectively enrolled from 19 US centers in the North American Pancreatitis Study (NAPS2). With assistance of a trained coordinator, patients completed a detailed questionnaire on demo-
AB162 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
graphics, clinical and family history and risk factors (smoking, alcohol). In a separate questionnaire, physicians provided information on disease phenotype, etiology, treatments received until enrollment and their perceived effectiveness (91%, 411/454). Results: Of the 454 patients, 44% were male and 90% were White. The mean age of first AP episode was 4116 yrs. About half (53%) were enrolled from two and about three-fourth (78%) from six centers. The three most common etiologies were idiopathic, alcohol and obstructive (most commonly pancreas divisum and SOD), accounting for about one-fourths of the cohort each (Table 1). Men were more likely to have alcohol (OR 4.9, 95% CI 3.0-7.9) while women were more likely to have obstructive (OR 2.3, 95% CI 1.3-3.8) or idiopathic etiologies (2.6, 95% CI 1.7-4.2). Patients with alcoholic RAP were more likely (p!0.05) to be ever or heavy (R1 ppd) smokers (80%, 47%) when compared with idiopathic (46%, 23%) and obstructive (42%, 26%) RAP, and they had a higher prevalence of pseudocyst formation (17% vs. 7% idiopathic, 4% obstructive, p!0.05). The most common therapies utilized were biliary sphincterotomy, stent placement in the bile or pancreatic ducts and oral pancreatic enzyme supplementation (Table 2). Other medical (octreotide, antispasmodics, vitamins/antioxidants, celiac block) or surgical therapies (sphincterotomy, cyst or drainage operation, partial pancreas resection) were infrequently used (2-8%). Biliary sphincterotomy (72%) and pancreatic duct stenting (49%) were used more frequently in patients with obstructive etiology (vs. 34%, 32% others, p!0.05) while pancreatic enzymes were tried more often in young patients !35 yrs (50 vs. 35% others, p!0.05). Conclusions: In contrast to community setting most patients with RAP treated at US referral centers have non-alcoholic etiologies. About half undergo an endoscopic intervention and one-thirds of patients receive oral pancreatic enzyme supplements. The available endoscopic therapies for RAP are perceived to be effective only in subsets of patients.
Etiology of RAP in the NAPS2 cohort Alcohol Gallstones Obstructive Idiopathic Hyperlipidemia Others
All (454)
Female (254)
Male (200)
117 (26) 41 (9) 90 (20) 129 (28) 24 (5) 53 (12)
33 (13) 24 (9) 64 (25) 93 (37) 9 (4) 31 (12)
84 (42) 17 (9) 26 (13) 36 (18) 15 (8) 22 (11)
Select medical and endoscopic therapies tried and their perceived effectiveness in the NAPS2 cohort Treatment (N[411) Oral Pancreatic Enzymes Biliary Sphincterotomy Biliary Stent Pancreatic Stent
Tried - n (%) x 158 (38) 168 (41) 46 (11) 145 (35)
Perceived Effectiveness - n (%) U 64 80 14 72
(41) (48) (30) (50)
N Z Number of patients in whom physicians provided information on therapies n (%) represents patients in whom the therapy was x tried and U found effective
711 Comparison of Insertion Techniques for Luminal Distention for on-Demand Sedation Colonoscopy: Air Insufflation, Carbon Dioxide and Water-Aided Colonoscopy - a Two-Center Randomized Controlled Trial Sergio Cadoni*1, Premysl Falt2, Paolo Gallittu1, Mauro Liggi1, Donatella Mura1, Vit Smajstrla2, Matteo Erriu3, Felix W. Leung4 1 Digestive Endoscopy Unit, S. Barbara Hospital, Iglesias, Italy; 2Digestive Diseases Center, Vìtkovice Hospital, Ostrava, Czech Republic; 3 Department of Surgical Sciences, University of Cagliari, Cagliari, Italy; 4 Gastroenterology, VA Sepulveda Ambulatory Care Center, VAGLAHS and David Geffen School of Medicine at UCLA, Los Angeles, CA Background: The 2013 ASGE Technology Status Evaluation Report on methods of luminal distention for colonoscopy called for studies comparing carbon dioxide (CO2) insufflation and water-aided insertion techniques. We compared maximum real-time insertion pain of air insufflation (AI), CO2 insufflation, water immersion (WI) and water exchange (WE). Objectives: We aimed to determine which combination of methods would produce the lowest maximum real-time insertion pain score. Patients: Consecutive diagnostic colonoscopy patients who received splitdose bowel preparation. Methods: Patient-blinded, prospective, two-center randomized controlled trial. On-demand sedation based on patient request due to pain. Colonoscopy with (insertion modality-withdrawal modality) AI-AI, CO2-CO2, WI-AI, WE-AI, WI-CO2 or WE-CO2. Investigators were blinded to insufflation gas used. Main outcome: maximum real-time insertion pain. (NCT01954862)Main outcome measurements: Maximum real-time insertion pain (0Znone, 1-2Zdiscomfort 10Zworst) was recorded by an unblinded nurse assistant. At discharge a blinded
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