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Clinical Impact of Bile and Pancreatic Fluid Cultures At ERCP in Patients with Suspected Pancreaticobiliary Sepsis
Abstracts
sequentially reduce and pleat the bowel over a standard enteroscope. SBE may enable diagnostic and therapeutic ERCP in patients with surgically altered anatomy. Aim: To determine the effectiveness of SBE in performing ERC in patients with surgically altered anatomy. Methods: Patients with surgically altered anatomy, in whom standard ERCP techniques had failed or were not possible, underwent ERC using SBE with initial therapeutic intent. Results: Seven patients (2 men, 5 women) with a median age of 57 years (range: 28-81 years) underwent SBE to perform ERC. Patient anatomy consisted of Whipple (nZ2), hepaticojejunostomy (HJ) (nZ2), Billroth II with a long afferent limb (nZ1) or roux-en-Y gastric bypass (RYGB, nZ2). Diagnostic ERC was successful in all six patients in whom the biliary orifice was reached. In one patient with HJ after bile duct injury, SBE failed to reach the HJ. Cholangiography was performed using a modified extraction balloon catheter (nZ3), irrigation catheter (nZ2), or a modified triple-lumen needle-knife cannula (nZ1). Therapeutic ERC was required in four patients, and it was successful in three cases (two balloon dilations, one stone extraction, and one needle-knife biliary sphincterotomy over a 5 F x 7 cm plastic stent were performed). One patient had stenosis of the HJ after living-donor liver transplantation that could not be treated due to inability to pass a guidewire through the stenosed anastomosis. Two patients sustained pancreatitis following therapeutic ERC; one of whom developed a pseudocyst. Median procedure length was 89 min (range: 30-151 min). Median procedure time was 91 min for therapeutic ERC and 68 min for diagnostic ERC. Median follow-up was 177 days (range: 5-340 days). Conclusions: SBE enables diagnostic and therapeutic ERC in most patients with altered surgical anatomy. SBEassisted therapeutic ERC may be associated with longer procedure times and increased risk of pancreatitis. Improvement in the available equipment is necessary to perform safer and more efficient ERC using SBE.
Pt Surgical PostERC ERC # etiology surgical indication success Procedure(s) anatomy 1 2
Cholangio- Whipple carcinoma PSC LDLT-HJ
3
PUD
Billroth II
4
Obesity
RYGB
5
Cholangitis
Yes
ERC (irrigation cath)
47
No
Cholangitis, Yes lost PTC access CBD stones, Yes PTC removal
ERC (irrigation cath)
89
No
ERC (modified balloon cath), stone extraction, ampullary dilation (13.5 mm), PTC removal ERC (modified balloon cath), ampullary dilation (7 mm), failed 7 F x 10 cm stent placement
63
No
151
Yes
Unable to reach the 92 hepaticojejunostomy 91 ERC (modified 3-lumen needle-knife cath), 5 F x 7 cm stent placement, needle-knife biliary sphincterotomy, removal of biliary stent ERC (modified balloon cath) 30
No
Ampullary Yes sclerosis, biliary dilation, failed PTC c/ b biloma Cholangitis No
CBD injury Hepaticojejunostomy RYGB Biliary Yes pancreatitis
6
Obesity
7
Ampullary Whipple carcinoma
Proc. Posttime ERC (min) panc.
Pain, jaundice
Yes
Yes
No
S1361 Wire-Guided Cannulation for Therapeutic Biliary ERCP: The Learning Curve and a Matched Case Control Study with Conventional Contrast-Assisted Cannulation Yousuke Nakai, Hiroyuki Isayama, Suguru Mizuno, Keisuke Yamamoto, Yoko Yashima, Hiroshi Yagioka, Kazumichi Kawakubo, Hirofumi Kogure, Takashi Sasaki, Toshihiko Arizumi, Osamu Togawa, Yukiko Ito, Saburo Matsubara, Naoki Sasahira, Kenji Hirano, Takeshi Tsujino, Minoru Tada, Takao Kawabe, Masao Omata Purpose: Wire-guided cannulation (WGC) without contrast injection was reported to reduce post-ERCP pancreatitis (PEP). The aims of this study were to evaluate the learning curve of WGC introduced in our institution in December 2007 and to compare clinical outcomes of WGC with conventional contrast-assisted cannulation (CC). Methods: Data on consecutive 250 therapeutic biliary ERCP by WGC between December 2007 and October 2008 were prospectively collected and clinical outcomes (primary and final success rates of biliary cannulation, time to biliary cannulation, procedure time, and complication rates) were compared among 5 chronological groups of each 50 cases (Group1-5). Then, a matched case-control study was performed evaluating the clinical outcomes between WGC and CC. The 250 therapeutic ERCP cases performed by CC, matched for age (þ/- 5 years), gender and indication for ERCP, were extracted from the ERCP database in our institution.
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Results: The mean age was 67.2 years, 176 cases (70.4%) were male. Indications for ERCP were bile duct stones (49.2%), malignant biliary stricture (38.0%), and benign biliary stricture (12.8%). Primary success rates of cannulation by WGC were 96%, 90%, 94%, 96%, and 80% in Group 1 to Group 5. In cases cannulation by WGC were difficult, other cannulation methods including CC were attempted at discretion of the experienced endoscopists, and the final success rates of cannulation were 98%, 96%, 98%, 100%, and 100% in Group 1 to Group 5. The rates of PEP were 4% in Group 1 and 2% in Group2-5 (pZ1.00), and the rates of hyperamylasemia were 10%, 14%, 6%, 8%, and 6% in Group1 to Group 5 (pZ0.75). In the subsequent casecontrol study between WGC and CC, there were no differences in the proportion of the initial ERCP (31.2% vs. 31.2%, pZ1.00), experience of endoscopists (30.4% vs. 28.4% by trainee, pZ0.69), periampullary diverticula (21.2% vs. 19.6%, pZ0.74), history of PEP (8.4% vs. 5.6%, pZ0.29). Clinical outcomes of WGC were similar to that of CC in the final success rates of cannulation (98.4% vs. 99.2%, pZ0.69), cannulation time (8.2min vs. 7.9min, pZ0.83), procedure time (38.6min vs. 40.0min, pZ0.59), and rates of PEP (2.4% and 3.2%, pZ0.79). The rates of hyperamylasemia (8.8% vs. 14.4%, pZ0.07) and the mean increase in amylase level (62.8IU/L vs. 169.5IU/L, pZ0.04) were lower in WGC than in CC. Conclusion: High success rates of biliary cannulation and low complication rates were achieved immediately after introduction of WGC. WGC was similar to CC in biliary cannulation rate and time. Hyperamylasemia was reduced in WGC.
S1362 Clinical Impact of Bile and Pancreatic Fluid Cultures At ERCP in Patients with Suspected Pancreaticobiliary Sepsis Douglas A. Howell, Daniel P. Hammond, Ramesh Srinivasan, Jennifer Lewis, Michele B. Delenick, Burr J. Loew, Ramu Raju Background: We reported a successful technique of pancreaticobiliary fluid sampling for bacteriologic culture at ERCP (Raju. GIE 2008: 67;AB234). In the era of increasing antibiotic resistance and the increasing complexity of ERCP procedures, this technique revealed an unexpected number of drug resistant organisms (DRO). We report an expanded experience emphasizing the clinical impact of ERCP fluid culture. Patients: 62 pts (aged 35 to 90þ) with symptoms of biliary (nZ55) or pancreatic infection (nZ7) underwent ERCP employing the prior described technique. Biliary indications for ERCP included cholangitis, sclerosing cholangitis, intrahepatic abscess and biliary fistula. Pancreatic indications included chronic pancreatitis with fever and stricture/stone disease. Results: 44/62 (71%) of specimens collected for culture were positive for pathologic organisms with 31/44 (70%) having more than one. Antibiotic resistance was noted in 13/44 (30%) cultures to at least one common antibiotic for gram-negative infection: Extended Spectrum Beta Lactamase E.coli (nZ2), Vancomycin-resistant Enterococcus (nZ4), Klebsiella (nZ2), Pseudomonas (nZ1), Methicillin-resistant Staph Aureus (nZ1) and cultures containing multiples of these resistant organisms (nZ3). 2/44 (5%) proved to be on an inappropriate antibiotic (Clostridium perfringens (nZ2). Antibiotic changes were indicated in all of these 15/44 (35%). Of the remaining 29/ 44 (66%), correct antibiotic therapy was confirmed or selected. Of 37 pts having had blood cultures, only 19/37 (51%) had positive results, and only 10/19 (53%) had complete correspondence to the ERCP culture results. Mucosal contaminates were cultured in only 4/62 (6.5%). Of the remaining 14 cases, all were bile cultures during treatment for clinical cholangitis and were negative documenting effective therapy in all. A major change in therapy resulting from culture data was recorded in 3/62 (5%) including ERCP stricture release, resumption of pancreatic duct stenting, and a surgical revision of a choledochoduodenostomy. Several hospital fever work-up were truncated as a result of the discovery of resistant organisms. Conclusion: The previously described pancreaticobiliary fluid aspiration technique for bacterial culture at ERCP produced evidence of antibiotic resistance or incorrect therapy in 15/62 (24%) of cases. Culture results caused a significant modification of empiric antibiotic treatment in these patients, and changed major treatment plans in an additional 5% of cases. Important changes in treatment and clinical outcome supports adding this technique of bacterial culture in cases of suspected infected pancreaticobiliary fluids during ERCP.
S1363 Factors Predicting Patency of Stents Placed for Malignant Biliary Strictures: A Cox Regression Analysis Petra G. Van Boeckel, Frank P. Vleggaar, Ewout W. Steyerberg, Ben J. Witteman, Marcel J. Groenen, Han Geldof, Peter D. Siersema Background: Stent placement is an effective and widely accepted treatment for the palliation of malignant biliary strictures. One of the main drawbacks is the limited stent patency resulting in recurrent symptoms of jaundice and cholangitis. The aim of this study was to establish factors that affect stent patency. Methods: A retrospective multicentre study was conducted in 4 Dutch (1 university and 3 general) hospitals. Data were collected from patient and endoscopy records, and information provided by patients’ general practitioners (patient characteristics, and stent-, procedure-, and underlying disorder-related features). The cumulative incidence of stent occlusion was analyzed with Kaplan-Meier curves and log rank
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB153
sequentially reduce and pleat the bowel over a standard enteroscope. SBE may enable diagnostic and therapeutic ERCP in patients with surgically altered anatomy. Aim: To determine the effectiveness of SBE in performing ERC in patients with surgically altered anatomy. Methods: Patients with surgically altered anatomy, in whom standard ERCP techniques had failed or were not possible, underwent ERC using SBE with initial therapeutic intent. Results: Seven patients (2 men, 5 women) with a median age of 57 years (range: 28-81 years) underwent SBE to perform ERC. Patient anatomy consisted of Whipple (nZ2), hepaticojejunostomy (HJ) (nZ2), Billroth II with a long afferent limb (nZ1) or roux-en-Y gastric bypass (RYGB, nZ2). Diagnostic ERC was successful in all six patients in whom the biliary orifice was reached. In one patient with HJ after bile duct injury, SBE failed to reach the HJ. Cholangiography was performed using a modified extraction balloon catheter (nZ3), irrigation catheter (nZ2), or a modified triple-lumen needle-knife cannula (nZ1). Therapeutic ERC was required in four patients, and it was successful in three cases (two balloon dilations, one stone extraction, and one needle-knife biliary sphincterotomy over a 5 F x 7 cm plastic stent were performed). One patient had stenosis of the HJ after living-donor liver transplantation that could not be treated due to inability to pass a guidewire through the stenosed anastomosis. Two patients sustained pancreatitis following therapeutic ERC; one of whom developed a pseudocyst. Median procedure length was 89 min (range: 30-151 min). Median procedure time was 91 min for therapeutic ERC and 68 min for diagnostic ERC. Median follow-up was 177 days (range: 5-340 days). Conclusions: SBE enables diagnostic and therapeutic ERC in most patients with altered surgical anatomy. SBEassisted therapeutic ERC may be associated with longer procedure times and increased risk of pancreatitis. Improvement in the available equipment is necessary to perform safer and more efficient ERC using SBE.
Pt Surgical PostERC ERC # etiology surgical indication success Procedure(s) anatomy 1 2
Cholangio- Whipple carcinoma PSC LDLT-HJ
3
PUD
Billroth II
4
Obesity
RYGB
5
Cholangitis
Yes
ERC (irrigation cath)
47
No
Cholangitis, Yes lost PTC access CBD stones, Yes PTC removal
ERC (irrigation cath)
89
No
ERC (modified balloon cath), stone extraction, ampullary dilation (13.5 mm), PTC removal ERC (modified balloon cath), ampullary dilation (7 mm), failed 7 F x 10 cm stent placement
63
No
151
Yes
Unable to reach the 92 hepaticojejunostomy 91 ERC (modified 3-lumen needle-knife cath), 5 F x 7 cm stent placement, needle-knife biliary sphincterotomy, removal of biliary stent ERC (modified balloon cath) 30
No
Ampullary Yes sclerosis, biliary dilation, failed PTC c/ b biloma Cholangitis No
CBD injury Hepaticojejunostomy RYGB Biliary Yes pancreatitis
6
Obesity
7
Ampullary Whipple carcinoma
Proc. Posttime ERC (min) panc.
Pain, jaundice
Yes
Yes
No
S1361 Wire-Guided Cannulation for Therapeutic Biliary ERCP: The Learning Curve and a Matched Case Control Study with Conventional Contrast-Assisted Cannulation Yousuke Nakai, Hiroyuki Isayama, Suguru Mizuno, Keisuke Yamamoto, Yoko Yashima, Hiroshi Yagioka, Kazumichi Kawakubo, Hirofumi Kogure, Takashi Sasaki, Toshihiko Arizumi, Osamu Togawa, Yukiko Ito, Saburo Matsubara, Naoki Sasahira, Kenji Hirano, Takeshi Tsujino, Minoru Tada, Takao Kawabe, Masao Omata Purpose: Wire-guided cannulation (WGC) without contrast injection was reported to reduce post-ERCP pancreatitis (PEP). The aims of this study were to evaluate the learning curve of WGC introduced in our institution in December 2007 and to compare clinical outcomes of WGC with conventional contrast-assisted cannulation (CC). Methods: Data on consecutive 250 therapeutic biliary ERCP by WGC between December 2007 and October 2008 were prospectively collected and clinical outcomes (primary and final success rates of biliary cannulation, time to biliary cannulation, procedure time, and complication rates) were compared among 5 chronological groups of each 50 cases (Group1-5). Then, a matched case-control study was performed evaluating the clinical outcomes between WGC and CC. The 250 therapeutic ERCP cases performed by CC, matched for age (þ/- 5 years), gender and indication for ERCP, were extracted from the ERCP database in our institution.
www.giejournal.org
Results: The mean age was 67.2 years, 176 cases (70.4%) were male. Indications for ERCP were bile duct stones (49.2%), malignant biliary stricture (38.0%), and benign biliary stricture (12.8%). Primary success rates of cannulation by WGC were 96%, 90%, 94%, 96%, and 80% in Group 1 to Group 5. In cases cannulation by WGC were difficult, other cannulation methods including CC were attempted at discretion of the experienced endoscopists, and the final success rates of cannulation were 98%, 96%, 98%, 100%, and 100% in Group 1 to Group 5. The rates of PEP were 4% in Group 1 and 2% in Group2-5 (pZ1.00), and the rates of hyperamylasemia were 10%, 14%, 6%, 8%, and 6% in Group1 to Group 5 (pZ0.75). In the subsequent casecontrol study between WGC and CC, there were no differences in the proportion of the initial ERCP (31.2% vs. 31.2%, pZ1.00), experience of endoscopists (30.4% vs. 28.4% by trainee, pZ0.69), periampullary diverticula (21.2% vs. 19.6%, pZ0.74), history of PEP (8.4% vs. 5.6%, pZ0.29). Clinical outcomes of WGC were similar to that of CC in the final success rates of cannulation (98.4% vs. 99.2%, pZ0.69), cannulation time (8.2min vs. 7.9min, pZ0.83), procedure time (38.6min vs. 40.0min, pZ0.59), and rates of PEP (2.4% and 3.2%, pZ0.79). The rates of hyperamylasemia (8.8% vs. 14.4%, pZ0.07) and the mean increase in amylase level (62.8IU/L vs. 169.5IU/L, pZ0.04) were lower in WGC than in CC. Conclusion: High success rates of biliary cannulation and low complication rates were achieved immediately after introduction of WGC. WGC was similar to CC in biliary cannulation rate and time. Hyperamylasemia was reduced in WGC.
S1362 Clinical Impact of Bile and Pancreatic Fluid Cultures At ERCP in Patients with Suspected Pancreaticobiliary Sepsis Douglas A. Howell, Daniel P. Hammond, Ramesh Srinivasan, Jennifer Lewis, Michele B. Delenick, Burr J. Loew, Ramu Raju Background: We reported a successful technique of pancreaticobiliary fluid sampling for bacteriologic culture at ERCP (Raju. GIE 2008: 67;AB234). In the era of increasing antibiotic resistance and the increasing complexity of ERCP procedures, this technique revealed an unexpected number of drug resistant organisms (DRO). We report an expanded experience emphasizing the clinical impact of ERCP fluid culture. Patients: 62 pts (aged 35 to 90þ) with symptoms of biliary (nZ55) or pancreatic infection (nZ7) underwent ERCP employing the prior described technique. Biliary indications for ERCP included cholangitis, sclerosing cholangitis, intrahepatic abscess and biliary fistula. Pancreatic indications included chronic pancreatitis with fever and stricture/stone disease. Results: 44/62 (71%) of specimens collected for culture were positive for pathologic organisms with 31/44 (70%) having more than one. Antibiotic resistance was noted in 13/44 (30%) cultures to at least one common antibiotic for gram-negative infection: Extended Spectrum Beta Lactamase E.coli (nZ2), Vancomycin-resistant Enterococcus (nZ4), Klebsiella (nZ2), Pseudomonas (nZ1), Methicillin-resistant Staph Aureus (nZ1) and cultures containing multiples of these resistant organisms (nZ3). 2/44 (5%) proved to be on an inappropriate antibiotic (Clostridium perfringens (nZ2). Antibiotic changes were indicated in all of these 15/44 (35%). Of the remaining 29/ 44 (66%), correct antibiotic therapy was confirmed or selected. Of 37 pts having had blood cultures, only 19/37 (51%) had positive results, and only 10/19 (53%) had complete correspondence to the ERCP culture results. Mucosal contaminates were cultured in only 4/62 (6.5%). Of the remaining 14 cases, all were bile cultures during treatment for clinical cholangitis and were negative documenting effective therapy in all. A major change in therapy resulting from culture data was recorded in 3/62 (5%) including ERCP stricture release, resumption of pancreatic duct stenting, and a surgical revision of a choledochoduodenostomy. Several hospital fever work-up were truncated as a result of the discovery of resistant organisms. Conclusion: The previously described pancreaticobiliary fluid aspiration technique for bacterial culture at ERCP produced evidence of antibiotic resistance or incorrect therapy in 15/62 (24%) of cases. Culture results caused a significant modification of empiric antibiotic treatment in these patients, and changed major treatment plans in an additional 5% of cases. Important changes in treatment and clinical outcome supports adding this technique of bacterial culture in cases of suspected infected pancreaticobiliary fluids during ERCP.
S1363 Factors Predicting Patency of Stents Placed for Malignant Biliary Strictures: A Cox Regression Analysis Petra G. Van Boeckel, Frank P. Vleggaar, Ewout W. Steyerberg, Ben J. Witteman, Marcel J. Groenen, Han Geldof, Peter D. Siersema Background: Stent placement is an effective and widely accepted treatment for the palliation of malignant biliary strictures. One of the main drawbacks is the limited stent patency resulting in recurrent symptoms of jaundice and cholangitis. The aim of this study was to establish factors that affect stent patency. Methods: A retrospective multicentre study was conducted in 4 Dutch (1 university and 3 general) hospitals. Data were collected from patient and endoscopy records, and information provided by patients’ general practitioners (patient characteristics, and stent-, procedure-, and underlying disorder-related features). The cumulative incidence of stent occlusion was analyzed with Kaplan-Meier curves and log rank
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB153