7163 Endoscopic treatment of post-liver transplant biliary leaks with stent placement across the leak site.

7162 ELECTROCAUTERY IN ENDOSCOPIC SPHINCTEROTOMY - A RANDOMISED PROSPECTIVE TRIAL COMPARING COMBINED CURRENT VS. CUT OR BLEND. Sanjiv Mahadeva, James Connelly, Pulak Sahay, Pontefract Gen Infirmary, Pontefract, United Kingdom. Recent evidence suggests that the type of electrocautery used in endoscopic sphincterotomy(ES) can affect the complication rate. Although ‘pure cut’ current has been associated with less post-procedure pancreatitis when compared to ‘blended current’1, the combined effect has not been studied. Aims. To compare the complication rates and the effect on cholestasis by three types of electrocautery current in ES - pure cut(C), blended(B) and combined cut and blend(C&B). Methods. As a pilot study, all patients requiring ES from November 1998 to August 1999 were randomised to C, B or C&B in a sequential manner. The same, single endoscopist performed all procedures during the period of study and ward-based clinicians observing for complications were blinded to the type of current used. All ES procedures were wire-guided (including bile duct recannulation) while laboratory parameters of full blood count, coagulation profile, serum amylase and liver function tests were examined pre/ post ES. Results. 50 patients had ES with B(n=15), C(n=17) and C&B(n=18). The mean age was 70(±23 years). Clinical indications for ES, use of needleknife papillotomy and the coagulation profile were similar in all three groups. The total complication rate was 4%. There was only one episode of significant bleeding requiring transfusion (B group), 1 severe pancreatitis (C&B group) and two further episodes of hyperamylasaemia (one each in B and C). There was no significant difference in haemoglobin decrease in all three groups (95% CI=-0.47 to +0.31 g/dl, Student’s t-test). Although the mean decrease in alkaline phosphatase was greatest in the C group,this was not stastically significant (95%CI=-49.3 to +96.1 U/l). Conclusions. Our overall complication rate was lower than most studies. The preliminary data showed no significant difference either in complication rates or cholestatic improvement between the three types of electrocautery current, although we accept that this pilot study is underpowered. To show a power of 90% in this study, we calculated that each group would require 247 patients. We are currently recruiting more patients into each arm as part of an ongoing trial. References. 1.Elta GH et al.Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current. Gastrointest Endosc 1998;47:149-153. 2. Pasricha PJ et al. Pure cutting vs blended current for endoscopic sphincterotomy: a prospective blinded controlled trial. Gastrointest Endosc 1994;40:66

7163 ENDOSCOPIC TREATMENT OF POST-LIVER TRANSPLANT BILIARY LEAKS WITH STENT PLACEMENT ACROSS THE LEAK SITE. Joseph Morelli, Hugh E. Mulcahy, Ira R. Willner, Prabhakar Baliga, Kenneth M. Payne, Peter B. Cotton, Adrian Reuben, John T. Cunningham, Med Univ of South Carolina, Charleston, SC; Med Univ of South Carolina, Chaleston, SC. Introduction: Biliary tract leaks occur in up to 26% of patients undergoing choledocho-choledochostomy (CDCD) during lever transplantation (OLT), but there is no consensus on optimum treatment. Surgical repair, radiological drainage, endoscopic biliary sphincterotomy, nasobiliary drain placement and trans-papillary stenting have been used with success, but the role of ERCP with placement of a “leak bridging” stent has not been well examined. Aim: To assess biliary stent placement across the leak site as a primary treatment for post OLT biliary disruption. Methods: 292 OLT’s were performed between Oct 1990 and Oct 1999, 215 with CDCD anastomosis. 32 CDCD cases (15%) were complicated by biliary leaks, of which 6 underwent primary surgical repair. The remaining 26 patients (median age 47; range 29-69; 19 male) were treated endoscopically. Results: The median time from OLT to ERCP was 43 days (range 10-193). 11 patients had related symptoms (fever, abdominal pain, clinically evi-

VOLUME 51, NO. 4, PART 2, 2000

dent jaundice) and 19 had abnormal liver biochemistry. Endoscopic retrograde cholangiography was successfully performed in all cases. The leak was situated at the anastomosis in 11 cases, T-tube site in 11, donor cystic duct in 2 and at both anastomosis and cystic duct in 2 cases. 6 patients had had a T-tube removed within the previous 48 hours. Primary treatment was with stenting (7fr-11.5fr) to bridge the leak in 24 cases (92%), papillary stenting alone in 1 and nasobiliary tube placement in 1. Initial treatment was successful in 23 cases (91%), but unsucessful in 3 cases (2 cases with leak-bridging stents and the single patient with a transpapillary stent). 4 patients died during follow-up, all from unrelated causes. Conclusion. ERCP with placement of a leak bridging stent has a high success rate in the treatment of post OLT cystic duct, T-tube and anastomotic biliary leaks. 7164 ENDOSCOPIC SPHINCTEROTOMY IS SAFE AND WELL TOLERATED IN ORTHOTOPIC LIVER TRANSPLANTATION (OLT) PATIENTS. Peter M. Oshin, Russell D. Brown, Allan G. Halline, Rama P. Venu, Univ of Illinois at Chicago, Chicago, IL. Introduction Biliary complications such as bile leak (BL) and anastomotic strictures (AS) occurs in 15-20% of patients undergoing orthotopic liver transplant(OLT), and can be treated successfully by endoscopic techniques of stent placement and dilation, respectively. Endoscopic sphincterotomy (ES) is commonly performed during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to facilitate repeated cannulation and stent placement. Given concerns for bacterial contamination and stasis at the anastomotic site, some endoscopists avoid ES in these immunocompromised patients. Aim To determine the safety and clinical outcome of ES in OLT patients(“ES Group”) and to compare their course to OLT patients who underwent ERCP without ES (“No ES Group”) Methods Patients who received OLT between 1994-98 and required ERCP were included in the study. Patient demographics, ERCP indications, complications and postERCP course were analyzed. Complications of ERCP were catagorized as procedure-related and delayed(≤30 days). Late adverse events recorded were related to biliary tract disease. Results Twenty-seven post OLT patients(17M, 10F, mean age 49 yrs, range 31-68) who required ERCP were studied. Mean follow up was 30 mos. in the ES group, and 35 mos. in the No ES group. ERCP indications, complications and clinical course are noted in the table below. Most (14/15) patients in the ES group underwent multiple ERCPs with stents and dilation for AS as per our protocol. Delayed ERCP complications occurred in 3 of 15 in the ES group(20%); all 3 had stones or sludge which predated ERCP/ES. The 3 patients who suffered late adverse events had recurrence of AS without new stones or sludge. No deaths were attributable to ES. Conclusion Endoscopic sphincterotomy in orthotopic liver transplant patients undergoing ERCP is safe, with a complication rate comparable to published data for non-OLT patients. Delayed complications and late adverse events (Stent occlusion, restenosis, death) in these patients appear to be unrelated to sphincterotomy per se, but common to all OLT patients. Patient No. of Group Patients

ERCP Indication

# of ERCP

Proced. compl.

ES

15

No ES

12

14 AS, Mean 3, 1 BL, 1 BL Range 1-5 1 Panc. 2 AS, Mean 1.5, 1 Panc. ↑10 LFTs Range1-3

Delayed Compl.

Late Adverse

1 Chol†, 2 AS→ 2 EO* ERCP 2 EO* 1 AS → Surgery

† Cholangitis,*EO = Early Stent Occlusion (≤ 4 weeks) requiring early stent ∆.

GASTROINTESTINAL ENDOSCOPY

AB283