792 ERCP in the Pediatric Population Is Successful and Efficacious

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outpatient colonoscopy were randomized in a 1:1 fashion to consume either a low residual diet (LR) of specified foods for breakfast, lunch, and snack (Table 1) or clear liquid diet (CL) the day before colonoscopy. All patients received Suprep according to manufacturer’s split dosing instructions. The quality of the bowel prep was assessed by 8 experienced gastroenterologists who were blinded to the type of diet patients received using the Boston Bowel Prep Scale. Patients reported their satisfaction with the bowel prep, diet, overall preparation process, and side effects using a 20mm visual analog scale. Wilcoxon Rank sum test was used to analyze the prep quality based upon diet consumed, Fisher’s exact test to analyze cancellation rate associated with diet, and t-test to analyze side-effect profile. Results: A total of 230 subjects were recruited 116 LR/114 CL. There was no difference in the segmental or total cleanliness of the colon between the two groups. The mean cleanliness scores with standard error of the mean were the following: LR 2.5⫾0.06 vs. CL 2.6⫾0.06 (p⫽0.210) in the right colon, LR 2.8⫾0.05 vs. CL 2.7⫾0.06 (p⫽0.358) in the transverse, LR 2.7⫾0.04 vs. CL 2.7⫾0.09 (p⫽0.509) in the left, and LR 8.0⫾0.12 vs. CL 7.9⫾0.17 (p⫽0.815) in total score. Subjects on LR reported significantly higher satisfaction with bowel prep 11.3⫾0.41 vs. 9.36⫾0.51 (p⫽ 0.008), higher satisfaction with diet 13.4⫾0.36 vs. 9.7⫾0.43 (p ⬍0.001), and higher satisfaction with the entire bowel preparation process 12.4⫾0.38 vs. 9.6⫾0.49 (p⬍0.001). Observed rates of sideeffects were low and there was no statistical difference between the two groups. On a 0-20 scale, subjects reported a mean score of abdominal discomfort LR 5.8⫾0.38 vs. CL 6.3⫾0.51 (p⫽0.27), bloating LR 3.9⫾0.39 vs. CL 3.7⫾0.45 (p⫽0.93), cramping LR 2.79⫾0.39 vs. CL 2.43⫾0.39 (p⫽0.52), nausea LR 2.62⫾0.41 vs. CL 2.9⫾0.50 (p⫽0.48), and vomiting LR 0.29⫾0.27 vs. 0.44⫾0.39 (p⫽0.44). The rates of procedural cancellation by patients were significantly lower in the LR group 11/116 (9%) vs. in the CL group 23/114(20%) (p⫽ 0.026). Summary: Low residual diet the day before colonoscopy did not affect the quality of bowel preparation. The cancellation rate was 50% lower among patients on LR. Patient satisfaction was higher with the entire bowel prep process on LR. Table. Low Residual Diet Plan

Easy to Prepare

Healthy

Restaurant

Breakfast

2 eggs (fried, over easy, or scrambled)

1 cup Yogurt (No seeds, berries, or nuts) 1 banana

1 Egg McMuffin with Canadian bacon taken off 1 plain bagel with cream cheese, jelly, or butter

1 chicken breast pan fried or baked

1 plain chicken or turkey sandwich on white bread with condiments only - no lettuce or tomato OR

Lunch

2 white bread slices or 1 plain bagel with butter or jelly 1 plain chicken or turkey sandwich on white bread with condiments only - no lettuce or tomato OR

1 cup cottage cheese

1 cup Macaroni & Cheese

Snack

OR Baked Potato with butter and/or sour cream 1 handful pretzels

5 chicken tenders or 10 nuggets with condiments OR 1 cup Macaroni & Cheese

1 cup Yogurt (No seeds, berries, or nuts)

1 handful pretzels

791 Good Agreement Between Endoscopic Findings and Biopsy Reports Supports Limited Tissue Sampling During Pediatric Colonoscopy Lawrence F. Borges1, Amanda J. Deutsch1, Hongyu Jiang2, Jeffrey D. Goldsmith3, Jenifer R. Lightdale1, Michael A. Manfredi*1 1 Medicine, Children’s Hospital Boston, Boston, MA; 2Clinical Research Center, Children’s Hospital Boston, Boston, MA; 3Pathology, Children’s Hospital Boston, Boston, MA Standard biopsy practices during pediatric colonoscopy involve routine sampling of normal appearing colonic mucosa, stemming in large part from historic

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concern that pathology may be missed if biopsies are not obtained. Aim: To investigate whether an improved understanding of agreement between endoscopist assessments of colonic appearance and pathologist evaluations of tissue samples could support a reduction in biopsies during colonoscopy in children. Methods: Institutional approval was granted to correlate findings documented in procedure notes and pathology reports of 524 consecutive unique patients undergoing colonoscopy at our institution from 6/1/10-12/31/10. We excluded all procedures with no biopsies obtained proximal to the splenic flexure, as well as those performed for dysplasia screening and/or in surgical anatomy. Agreement was defined as normal colon/terminal ileum (TI) and normal biopsies; or abnormal endoscopic findings and an abnormal biopsy report. Descriptive and ␬-statistics (with 95% CI) were used to assess agreement, and regression models were used to explore potential predictors (including colonic region of findings (TI, right, left, rectum), patient size, procedure indication, endoscopist and pathologist experience). Results: Of 390 colonoscopies that met inclusion criteria, endoscopists (n⫽26) reported abnormal gross findings in 218 (55%) and pathologists (n⫽4) found clinically significant histology in 195 (50%). Inter-provider agreement between endoscopists and pathologists was high, with discordant findings in only 16% of procedures. (␬ ⫽.68 (95% CI: 0.60, 0.75)). More disagreement occurred when endoscopists reported abnormalities and biopsies were normal, vs. when normal colon was reported and biopsies were abnormal (11% vs. 5%, p⫽0.004). Endoscopists took a total of 5033 biopsies overall, with a median 12.9 (IQR: 10.6, 14.4) per procedure. 20/172 (12%) patients with endoscopically normal appearing colons had abnormal biopsies; 8 had a prior diagnosis of IBD, which was a strong risk factor for abnormal histopathology (p⬍.0001). Among normal colons, there was no difference in the numbers of biopsies obtained in procedures associated with histopathology vs. not (median 6 (IQR 5-7) vs. 6 (4, 7) p⫽.2). A total of 1695 biopsies were obtained from normal appearing colons with no pathology findings. For the 154 non-IBD patients with normal appearing colons, pathology findings had almost perfect agreement if tissue sampling was performed solely from the left and right colon vs. 4 colonic regions (␬ ⫽.95 (95% CI: 0.86, 1.00). Discussion: Our large sample size study shows strong agreement between endoscopist assessments of pediatric colons and pathologist findings on tissue biopsies. It also supports the pursuit of an evidence-basis for limited tissue sampling strategies in children with endoscopically normal appearing colons.

792 ERCP in the Pediatric Population Is Successful and Efficacious Brintha K. Enestvedt*1, Christina Tofani3, Dale Y. Lee2, Pari M. Shah1, Gregory G. Ginsberg1, William B. Long1, Nuzhat A. Ahmad1, David L. Jaffe1, Vinay Chandrasekhara1, Petar Mamula2, Michael L. Kochman1 1 Gastroenterology, University of Pennsylvania, Philadelphia, PA; 2 Gastroenterology, Children’s Hospital of Philadelphia, Philadelphia, PA; 3Medicine, University of Pennsylvania, Philadelphia, PA Background: The safety and utility of endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation and management of pancreaticobiliary disease is established. However, the literature on safety and efficacy in a pediatric population (under 21 years old) is limited by relatively small sample sizes. We hypothesize that ERCP is safe and useful in the pediatric population in the management of pancreaticobiliary disease. We aimed to review the pediatric ERCP experience at a single tertiary care institution and describe the indications, findings and prevalence of technical success and immediate complications. Methods: A retrospective review was performed of endoscopic reports of pediatric patients who underwent ERCP for any indication at a single tertiary care center between 6/17/93-9/7/2011. Data collected were demographic information, indication of ERCP, findings and final diagnosis, technical details of the procedure including use of a therapeutic intervention (defined as sphincterotomy, dilation, stone extraction or stent placement). Outcomes evaluated included the prevalence of a complication recognized at ERCP and technical success (defined as successful deep cannulation of the desired duct). Data were analyzed using univariate statistics. Results: A total of 429 ERCPs were performed on 296 unique patients. The mean age of the patients was 14.9 ⫾ 4.8 years (range 3 months to 21 years) and 51.1% (151) were male. The majority of ERCPs evaluated inpatients (75.8%). The distribution of indications for ERCP and final diagnosis (clinical and radiographic) are contained within Tables 1 and 2. Of all ERCPs, 35.9% (154) had only a diagnostic cholangiogram or pancreatogram performed. The remainder of ERCPs contained a therapeutic intervention. Sphincterotomy was performed on 63.2% (187) of the 296 unique patients. Precut sphincterotomy was performed on 9.8% (29) of all patients. Stone extraction or stent placement was performed in 26.1% and 27.5% of ERCPs, respectively. Cannulation of the desired duct was not achieved in 4.4% (17) of ERCPs. Cannulation was not attempted in an additional 1.6% (7) due to a combination of endoscopist (3) and non-endoscopist related (4) factors. Overall ERCP technical success rate was 95.3% (409/429). Patients with a history of prior liver transplant comprised 13.1% (56) of all ERCPs. An immediate complication recognized at endoscopy was present in 3 cases (0.7%) (bleeding). Conclusions: To date, this is the largest pediatric ERCP experience to be reported. ERCP in the pediatric population is technically highly successful and efficacious. Therapeutic

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interventions are performed in the majority of cases (65%) There is a low risk of immediate complications. The overall efficacy and safety support the performance of ERCP in this population by experienced endoscopists. Table 1. Distribution of indications for pediatric ERCP Indication Abnormal liver associated enzymes Suspected or established CBD stone Follow up ERCP1 Recurrent pancreatitis Suspected bile or pancreatic duct leak Cholangitis Jaundice Abdominal pain Cyst drainage Pancreatic duct endotherapy planned Total 1

N

% of total

109 107 52 47 45 27 23 12 4 3 429

25.4% 24.9% 12.1% 10.9% 10.5% 6.3% 5.4% 2.8% 0.9% 0.7% 100.0%

landmarks were used to assess the area of interest. Monopolar pure-cut electrocautery was applied to the shelf, until either tension was relieved or the native wall was reached in 1 to 3mm increments. (Image 1). Results: Isolated needle knife was performed in four cases and four combined cases with either esophageal dilatation or stent placement. Two patients had stricturoplasty as part of a staged procedure due to the complexity of the defect. (Image 2) Shelf obliteration was complete in 3 cases and partial in 5 cases at time of procedure. Two of four patients had improvements in endoscopic appearance of shelf at follow-up. 75% (n⫽3) patients had improvements in symptoms, radiographic appearance, and overall improvement. Two patients continue to receive periodic esophageal dilatation. Complications included progressive respiratory distress secondary to stent placement (n⫽1) and post-procedure fever (n⫽1) that did not result in hospitalization. (Image 2). Conclusions: Needle knife stricturoplasty was effective in relieving symptoms in the majority of patients, however most had residual anatomic defects still present. The procedure was most effective in obliterating a simple shelf or cleft, rather than complex defects. This technique is a useful adjunct to standard therapy and combined techniques are necessary in a subset of patients to maintain patency.

Follow up for biliary stricture, bile leak, pancreatic duct leak, cholangitis

Table 2. Diagnosis (clinical and ERCP radiographic) N

% of total

Biliary stone Biliary stricture Normal cholangiogram or pancreatogram Bile leak Pancreatic duct leak Chronic pancreatitis1 Primary sclerosing cholangitis Biliary dilation without other pathology Choledochocele Pancreatic duct dilation without other pathology Pancreas divisum Cholelithiasis Pancreatic duct stricture Other (foreign body in intrahepatics, intraduodenal cyst in communication with pancreatic duct)

105 94 90 22 17 13 12 12 11 9 6 6 4 2

24.5% 21.9% 21.0% 5.1% 4.0% 3.0% 2.8% 2.8% 2.6% 2.1% 1.4% 1.4% 0.9% 0.5%

Cannulation not achieved2 Cannulation not attempted Cannulation not attempted: endoscopist related factorx Cannulation not attempted: non-endoscopist related factoro Total

19 7 [3] [4]

4.4% 1.6%

429

100.0%

Diagnosis

Needle-knife with esophageal bridge

1Pancreatic duct changes consistent with chronic pancreatitis; 2Cannulation of desired duct not achieved; xEndoscopist related factors: bleeding from precut sphincterotomy precluded

cannulation, unable to identify ampulla or advanced beyond gastric body due to altered anatomy; oNon-endoscopist related factors: inability to sedate patient, significant nose bleeding

793 Needle-knife Esophageal Stricturoplasty in Pediatric Patients Douglas S. Fishman*1, Isaac Raijman2, Mark A. Gilger1 1 Pediatric Gastroenterology, Texas Children’s Hospital, Houston, TX; 2 Digestive Associates of Houston, Houston, TX Introduction: Multiple modalities are available to treat esophageal strictures in children. A unique problem in esophageal strictures is the development of an esophageal shelf or cleft, difficult to treat with standard balloon dilatation. Similar to our experience in Zenker’s diverticula, we describe a series of pediatric patients, in which mucosal shelves in the esophagus were ablated using a needle-knife technique.Patients and Methods: Retrospective review of eight cases performed in four patients. Mean follow-up time was 24 months (6-38). All patients were female, age 2-17 (median 14) and had a distinct shelf or cleft in the proximal esophagus. 3 of 4 pts had developmental delay and prior feeding difficulties. The etiology for stricture and related shelf were retained foreign body (n⫽2) and tracheo-esophageal atresia (n⫽2). The primary complaint was dysphagia in all patients. Procedures were performed under general endotracheal anesthesia with a 9.2mm endoscope and a 5mm needle knife (Wilson-Cook, NC or Boston Scientific, MA). Three out of four patients had prior balloon dilatation to relieve the obstruction. Endoscopic and/or fluoroscopic

AB165 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012

Complex esophageal shelf

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