- Email: [email protected]
Diagnostic and Therapeutic ERCP in Long-Limb Surgical Bypass Patients Using a New Single-Balloon Assisted Enteroscope
Abstracts
Conclusions: Viabil stent is an excellent option for the management of pancreatic pseudocysts. A large stoma lumen can be accomplished with one single stent. It appears that 6 weeks of observation suffices to resolve the pseudocyst and remove the stent. Removal of the stent was simple. A larger number of patients is needed.
T1338 Increased Fat in Pancreas: A Risk Factor for Post-ERCP Pancreatitis? Omer Khalid, Henry A. Pitt, Kumar Sandrasegaran, Lee McHenry, Evan L. Fogel, Stuart Sherman, James L. Watkins, Paul Kwo, Glen A. Lehman Background: Pancreatitis complicates 1% to 22% of ERCP procedures. Attempts to prevent post-ERCP pancreatitis continue to be studied and one way to partially prevent this is by patient(pts) selection. In our recent study, pts with Sphincter of Oddi Dysfunction (SOD) and a history of pancreatitis had more fat in their pancreas than those with SOD and no history of pancreatitis (Gastrointest Endosc2008;67;5; AB328). This observation suggests that increased fat in the pancreas may lower the threshold for the development of pancreatitis, including post-ERCP pancreatitis. It has become fairly common for pts, suspected to have hepatobiliary pain, to have an MRI with MRCP followed later by an ERCP for further evaluation. Aim: To determine if increased fat content of the pancreas as seen by MRI is a contributing factor in the development of post-ERCP pancreatitis. Methods: Retrospective case controlled review. Pts who had an abdominal MRI followed by an ERCP within 60 days from 01/02 to 08/08 were identified. Pts with post-ERCP pancreatitis(nZ23) were selected for further analysis. Age, sex and disease matched cohort of controls(nZ52) was included. Fat in the abdominal wall, pancreatic head, body and tail was measured by MRI. Pts with chronic pancreatitis, pseudocysts, necrotizing pancreatitis and/or those having an ERCP for malignancy were excluded from the analysis. The percentage fat was determined by recording the signal intensity in the in-phase (Sin) and out-ofphase (Sout) T1-weighted gradient echo sequences and subsequently calculating the fat fraction as (Sin- Sout)/(Sin 2). Statistics: Analysis was performed in SAS version 9 and statistical tests were performed as two-sided at the alphaZ0.05 significance level and 0.10 marginal level. Ranked data transformation was used for analysis of pancreas fat. Generalized Linear Mixed Models with match as the random effect was used to compare body, tail and head fat and BMI between case and control groups. Results: ERCP-controls and post ERCP- pancreatitis pts did not differ with respect to age (38.0 vs 38.20 years), gender (73.2% vs 73.2% female), and BMI (28.7 vs 24.9). There was no difference in body fat, tail fat, head fat or BMI between cases and controls (pvaluesZ0.640, 0.243, 0.418, and 0.179 respectively). Conclusions: These data suggest that increased fat content of pancreas does not increase the risk of post-ERCP pancreatitis.
Type
Variable
Median
Minimum Maximum
Case NZ23 Head %Fat(a) Body %Fat(c) Tail %Fat(e) 2.1 0.9 2.1 0.0 0.0 0.0 Control NZ52 Head %Fat(b) Body %Fat(d) Tail %Fat(f) 0.0 1.7 2.5 0.0 0.0 0.0
32.3 30.4 35.4 17.5 20.9 19.0
a vs b Z p-value 0.418; c vs d Z p-value 0.640; e vs f Z p-value 0.243
K-ras point mutation developed pancreatic cancer 4 and 12 years after the examination. Conclusions: The incidence of pancreatic cancer associated with chronic pancreatitis was 4%. It is reported that smoking habits, diabetes mellitus, alcohol drinking continuation are risk factors of developing pancreatic cancers in patients with chronic pancreatitis, but they were not risk factors in our study. Only examination of K-ras point mutation in pancreatic juice seem to be a useful tool setting of high risk group developing pancreatic cancer in chronic pancreatitis.
T1340 Cocktail Sedation Containing Propofol Versus Conventional Sedation for ERCP: A Prospective, Randomized Controlled Study Phonthep Angsuwatcharakon, Yuwadee Ponauthai, Rungsun Rerknimitr, Wiriyaporn Ridtitid, Pradermchai Kongkam, Narongrit Prempracha, Sombat Treeprasertsuk, Pinit Kullavanijaya Background: The usage of propofol for endoscopic procedures has been increasing because of its ultra-short onset and rapid offset of sedation with quick recovery. ERCP generally requires moderate to deep sedation. Because propofol has a narrow therapeutic window, therefore propofol alone may cause over sedation. A combination of propofol, meperidine and midazolam (cocktail) may reduce the dosage of propofol and may result in a less number of over sedation. Aims: To compare the efficacy, recovery time, patient satisfactory and side effect including desaturation rate between cocktail and conventional sedations for patients undergoing ERCP. Methods: Patients (nZ205) who underwent ERCP were randomed prospectively into 2 groups; the cocktail and conventional sedations (103 and 102 patients). Initially, 25 mg of meperidine and 2.5 mg of midazolam were injected in both groups. Then, 1 mg/kg of propofol bolus was given intravenously in the cocktail group, and followed by infusion rate of 1 mg/kg/hour. To control patient into moderate level of sedation, 0.5 mg/kg was added as needed. In the conventional group, 0.5 mg/kg of meperidine and 0.05 mg/kg of midazolam were administered to maintain the moderate level of sedation. Oxygen supplement was not given unless desaturation occurred. Results: Both groups had no statistically significant difference regarding to gender, age, BMI and duration of procedures. In the cocktail group, the average amount and administration rate of propofol were 172.1 (92.2) mg, 6.2 (3.0) mg/kg/hr. In the conventional group; average amount and administration rate of meperidine were 58.3 (24.5) mg, 2.4 (2.5) and dosages for midazolam were 6.8 (2.1), 0.3 (0.4), respectively. Cocktail group had a significant shorter recovery time; higher patients’ satisfaction score; and higher proportion of desaturation than conventional group (table). All desaturation events in both groups were corrected with temporary oxygen supplementation without any apnea or serious hemodynamic instabilityConclusions: Cocktail sedation containing propofol provides faster recovery time and better patients’ satisfaction for patients undergoing ERCP. However, desaturation is common but can be corrected by oxygen supplementation without serious side effects. Results of cocktail vs. conventional sedations
T1339 High Risk Group Developing Pancreatic Cancer in Patients with Chronic Pancreatitis Yujin Kudo, Terumi Kamisawa, Hajime Anjiki, Naoto Egawa Background/Aims: Pancreatic cancer sometimes occurs during the course of chronic pancreatitis. However, as most pancreatic cancers associated with chronic pancreatitis are diagnosed in an advanced stage, it is necessary to recognize high risk group developing pancreatic cancer in patient with chronic pancreatitis. To make a strategy detecting pancreatic cancer associated with chronic pancreatitis in an early stage, we analyzed the clinical features of pancreatic cancer associated with chronic pancreatitis. Methods: We retrospectively examined incidence and clinical features of extrapancreatic and pancreatic malignancies in 218 patients (192 males and 26 females, average age of 56.8 years old) with definite chronic pancreatitis. Etiologies of chronic pancreatitis were alcoholic (nZ157), idiopathic (nZ47), malformation (nZ14), and others (i.e. biliary, radiation, trauma) (nZ8). Average period of follow-up was 6.5 years (0-33 years). We collected pancreatic juice of 15 patients with chronic pancreatitis during ERCP and investigated K-ras point mutation. Results: Nine patients developed pancreatic cancer. They were 7 males and 2 females, and average age was 63.3 years old. Etiologies of the chronic pancreatitis were alcoholic (nZ5), idiopathic (nZ3), and papillary stenosis (nZ1). Period from onset of chronic pancreatitis to diagnosis of pancreatic cancer was average 9.6 years (0-30 years). All pancreatic cancers were diagnosis in an advanced stage, and 8 patients died within 8 months. There were no significant differences between chronic pancreatitis patients developing pancreatic cancer and those non-developing pancreatic cancer, in smoking habits (70.7% vs. 62.5%), diabetes mellitus (77.8% vs. 54.4%), and alcohol drinking continuation (37.5% vs. 53.1%). K-ras point mutation was observed in pancreatic juice of 10 patients with chronic pancreatitis (2þ; nZ2, 1þ; nZ5, ; nZ3). In them, the 2 patients with 2þ
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Gender(F: M) Age (year) Duration of procedure (min) Recovery time (min) Patient satisfaction score (%) Number of patients with desaturation (O2 saturation !90%)
Meperidine/ midazolam N Z 102
Cocktail N Z 103 P value
51: 51 57.5 31.6 12.9 87.6 32 (31.3%)
51: 52 1.000 59.9 0.257 27.9 0.099 9.7 0.045 93.1 ! 0.01 60 (58.3%) ! 0.01
T1341 Diagnostic and Therapeutic ERCP in Long-Limb Surgical Bypass Patients Using a New Single-Balloon Assisted Enteroscope Douglas A. Howell, Ramesh Srinivasan, Andreas M. Stefan Background: Successful per-oral ERCP has been reported in long-limb surgical bypass patients, including Roux-en-Y cases, using standard push enteroscopes (Howell, GIE 1996;43: 383AB). Newer bypass procedures have resulted in increased length of bypass limbs preventing endoscopic access with standard equipment. The single-balloon overtube assisted enteroscope (SBAE)(Olympus America) has recently been released. We report initial experience performing peroral ERCP using SBAE. Patients and Methods: 10 procedures were attempted in 8 pts, with the following long-limb bypasses: Pylorus preserving Whipple (PPW) (nZ2) and bariatric laparoscopic Roux-en-Y gastric bypass (RNYGB) (nZ8). Four pts (2 PPW and 2 RNYGB) had a previous failed attempt with other endoscopes, including variable stiffness colonoscopes and standard-push enteroscopes with non-balloon overtubes. Indications: All procedures were carried out with the new
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB271
Abstracts
Olympus Q180 200cm SBAE. Cannulation and therapy was performed with special enteroscope length accessories supplied by various companies. Indications included: common duct stone (nZ1), ampullary stenosis/SOD Type I (nZ1), recurrent pancreatitis (nZ2), severe right upper quadrant (RUQ) pain with dilated ducts (nZ2), chronic pancreatitis (nZ2), and PD stent removal (nZ2). Results: 8/ 10 (80%) procedures were successful in reaching the RUQ and assessing the desired duct. Two failures were due to adhesions in one PPW patient and inability to advance beyond the ligament of Treitz in a RNYGB patient. Two diagnostic ERCPs noted a normal cholangiogram in one and extensive pyloric channel ulcer disease in the other. Six therapeutic ERCPs included biliary sphincterotomy (nZ1), pancreatic sphincterotomy with stent placement (nZ2), biductal sphincterotomy with nasopancreatic drainage (nZ1), and pancreatic stent removal (nZ2). Complications included a single episode of delayed mild pancreatitis. Both barbless pancreatic duct stents failed to pass after 3 weeks requiring a second SBAE ERCP with successful removal. Experience is ongoing. Conclusions: Single-balloon assisted enteroscopy permitted access to the RUQ in most patients in this initial experience. Diagnostic and therapeutic ERCP was accomplished in all cases where the RUQ was reached. Technical challenges include the front-viewing nature of the enteroscope, the absence of an elevator and the limited selection of therapeutic accessories. Routine per oral ERCP in post-operative long-limb bypass patients should be routinely possible, at least in specialized centers of excellence.
T1342 ERCP in Pregnancy- Is It Safe? Adel Y. Daas, Amir Agha, Haim Pinkas, Jay J. Mamel, Patrick G. Brady Background: Although rare, pancreaticobiliary disease during pregnancy can pose a serious risk to both the mother and fetus. Gallstones may be present in up to 12% of pregnancies and are the most common cause of acute pancreatitis in pregnancy with a 70% antepartum relapse rate. Data regarding the relative safety of ERCP during pregnancy is sparse. Methods: We performed a retrospective review of 15 cases performed in 8 pregnant patients in which ERCP was utilized as a therapeutic modality. Procedures were performed at a single center tertiary care referral center between January 2005 and October 2008. Records were reviewed for ERCP indication, endoscopic interventions, use and extent of fluoroscopy, post-procedure complications, and pregnancy outcomes including APGAR scores. Results: The mean patient age was 23.5 years (18-30) years; mean duration of gestation was 20 weeks (8-34 weeks). 5 cases were performed during the first trimester, 4 cases in the second trimester, and 8 in the third trimester. Indications were cholangitis (nZ1), gallstone pancreatitis (nZ3), obstructive jaundice (nZ4), stent service (nZ5) and cystic dilation of biliary tree (nZ2). Biliary sphincterotomy was performed in 8 cases. Balloon extraction of biliary stones/ sludge was performed in 7 cases. There were no reports of any acute complications in any of the cases. Fetal heart monitoring was performed throughout each procedure. Limited use of fluoroscopy was performed in 5 cases with a mean exposure time of 8 seconds. Lead shielding to the pelvis was performed in all cases involving fluoroscopy to reduce radiation exposure to the fetus. Aspiration of bile was used to confirm selective bile duct cannulation when fluoroscopy was not used. There were no pregnancy related complications. Mean gestational age at delivery was 38 weeks (36-41 weeks) with mean APGAR O8 at 1 and 5 minutes. Conclusions: ERCP in pregnancy appears to be a safe, therapeutic option for patients with pancreaticobiliary disease. Although the use of fluoroscopy was generally avoided, certain situations such as inability to confirm selective biliary cannulation with aspiration techniques alone necessitated its use in some cases. Our data demonstrates not only the safety of ERCP, but additionally the safety of therapeutic interventions such as stent placement, sphincterotomy and balloon stone extraction. Therapeutic ERCP during pregnancy appears to be safe when performed in experienced hands and with judicious use of fluoroscopy.
patients were identified who had undergone double balloon ERCP (DBE-ERCP). In 89% of the patients previously performed ERCP using a conventional duodenoscope had failed (25/28). In these patients DBE-ERCP was successful in 60 percent (15/25). In three patients DBE-ERCP was performed primarily. In four patients ERCP was done by DBE-ERCP combined with PTC in rendezvous-technic. Overall success rate of DBE-ERCP in all patients was 61% (17/28 patients). In those patients interventions such as papillotomy, balloon dilation, calculus extractions as well as stent placement could be performed even though tools for DBE-ERCP are still very limited. Despite most of the DBE-ERCPs having included therapeutic interventions in only one patient edematous post-ERCP pancreatitis occurred. No other major complications occurred in our case series and minor side effects were restricted to meteorism and mild to moderate abdominal pain. Conclusions: DBEERCP is an alternative method for diagnostic as well as therapeutic interventions in the biliary as well pancreatic system in the operated patient. In the majority of cases more invasive procedures such as PTC and surgery could be prevented. However, it should be limited to selected patients, as it is a time consuming as well as a cost intensive procedure.
T1344 Applications and Outcomes of Single User Cholangiopancreatoscopy in a Community Hospital James A. Disario, Maydeen M. Ogara, Daniel G. Luba The Spyglass (Boston Scientific, Inc.) is a single-user cholangioscope (SUC) for visual diagnosis, aimed biopsy, and lithotripsy. Purpose: Describe the applications and outcomes of SUC use in a community hospital. Methods: Prospective cohort series of initial consecutive cases. Results: From 9/20/2007-10/10/2008, SUC was used in 50 cases (47 biliary, 3 pancreatic) by 3 experienced endoscopists (JD 42, DL 5, OT 3) on 40 patients (26 women, 14 men) with a mean age of 67 (27 - 88) years. There were 57 indications: 24 stone, 21 abnormal imaging, 8 stricture, 2 ampullary and 2 fistulas. Mean ERCP duration was 89 (28-185) and fluoroscopy 8.3 (0.9-37) minutes. SUC use required a mean of 37 (12-83) minutes in 39 cases and fluoroscopy took a mean of 2 (0.1-11) minutes in 36 cases. SUC cannulation was adequate free-hand in 25/26 (96%) and wire-guided in 22/24 (92%). Successful applications: 48/50 (96%) visual diagnosis, 13 guided 1 mm forceps biopsies [11 (85%) adequate tissue; pathology: 8 indeterminate, 3 normal with 2 (18%) false negative for cancer]; 8/10 (80%) aimed guidewire placement, 13/13 (100%) stone extractions, 2/3 (66%) Holmium laser lithotripsy for impacted CBD stones and 2/2 (100%) fibrin glue injections via the channel for cystic duct fistula closure. Complications occurred in 8 (16%) cases: 3 cardiopulmonary (1 severe, 2 mild), 1 severe perforation, 1 moderate cholangitis and bleeding, 1 mild pancreatitis, 2 pain (1 moderate, 1 mild). Two (4%) events were possibly SUC-related. 30 day mortality was 3 (6%): 1 unknown cause 3 days post-ERCP deemed cardiopulmonary, 2 cancer. SUC use led to a diagnosis in 31 (62%) and added to patient management in 30 (60%) cases beyond conventional ERCP. There were no statistically significant differences in the mean procedure times or scores for visualization, ease of use and utility for the first and last 10 procedures. Conclusions: SUC use in a community hospital: 1. Contributed to patient management beyond conventional ERCP in most cases; 2. Was often difficult in the ampullary and pancreatic segments; 3. Required additional maneuvers and time; 4. May have false negative biopsies; 5. Involved morbidity reflecting pre-existing illnesses; 6. Had no significant learning curve, by key indicators, with experienced endoscopists.
Duct
N
Diam, mm
Right intrahepatic Left intrahepatic Extrahepatic Cystic Pancreatic duct Ampulla segment
26 27 47 13 3 43
8(2-18) 9(3-18) 13(4-20) 7(3-15) 6(4-8) NA
Stones 1 2 11 2 0 3
Inflam 2 2 9 )) 3 0 3
Tumor 0 0 1 0 1 1
) View
Ease
4 4 4 4 3 3
4 4 4 4 3 3
(2-6) (2-5) (1-6) (2-5) (2-3) (1-6)
)
(2-6) (2-5) (1-6) (2-5) (2-5) (1-6)
)1Z none - 6Z excellent ))1 eroded clip, 2 fistulas
T1343 Usefulness of Double Balloon Enteroscopy for Diagnostic and Therapeutic ERCP in Postoperatively Altered Anatomy A Retrospective Analysis Frank Lenze, Christian Maaser, Tobias Meister, Dirk Domagk, Torsten F. Kucharzik, Wolfram W. Domschke, Hansjoerg Ullerich
T1345 Failure Rate of Peroral Cholangiopancreatoscopy in Clinical Practice Shahzad Iqbal, Anuj Kapoor, Peter D. Stevens
Objectives: Diagnostic and therapeutic interventions in the biliary and pancreatic system in the previously operated patient, such as BII-situation and biliodigestive anastomosis, by conventional ERCP are difficult and in many cases unsuccessful. We describe our experience of ERCP performed with a double balloon enteroscope (DBE) as an alternative examination technique for these patients. Methods: Double balloon enteroscopy was introduced in the Department of Medicine B in November 2004. From November 2004 until the end of March 2008 1080 double balloon enteroscopies and 2050 ERCP’s have been performed. In a retrospective analysis examinations which combined ERCP with double balloon enteroscopy in previously abdominally operated patients were reviewed. Results: A total of 28
Background: Peroral cholangiopancreatoscopy (CP) is an ERCP technique that uses a fiberoptic cholangioscope passed through a therapeutic duodenoscope directly into the biliary and pancreatic ducts. The primary aim of this study was to analyze the failure rate of CP in clinical practice. The secondary aims were to analyze the complication rate, clinical applications and diagnostic yield of CP forceps bite. Methods: It was a retrospective review of all CP procedures performed between 11/ 01/05 to 11/30/08 at Columbia University Medical Center, NYC by a single experienced endoscopist. The failure was defined as inability to achieve the primary goal that was set before starting the procedure. The diagnostic yield of CP forceps was defined as either positive for malignancy or benign with 6 months follow-up.
AB272 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
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Conclusions: Viabil stent is an excellent option for the management of pancreatic pseudocysts. A large stoma lumen can be accomplished with one single stent. It appears that 6 weeks of observation suffices to resolve the pseudocyst and remove the stent. Removal of the stent was simple. A larger number of patients is needed.
T1338 Increased Fat in Pancreas: A Risk Factor for Post-ERCP Pancreatitis? Omer Khalid, Henry A. Pitt, Kumar Sandrasegaran, Lee McHenry, Evan L. Fogel, Stuart Sherman, James L. Watkins, Paul Kwo, Glen A. Lehman Background: Pancreatitis complicates 1% to 22% of ERCP procedures. Attempts to prevent post-ERCP pancreatitis continue to be studied and one way to partially prevent this is by patient(pts) selection. In our recent study, pts with Sphincter of Oddi Dysfunction (SOD) and a history of pancreatitis had more fat in their pancreas than those with SOD and no history of pancreatitis (Gastrointest Endosc2008;67;5; AB328). This observation suggests that increased fat in the pancreas may lower the threshold for the development of pancreatitis, including post-ERCP pancreatitis. It has become fairly common for pts, suspected to have hepatobiliary pain, to have an MRI with MRCP followed later by an ERCP for further evaluation. Aim: To determine if increased fat content of the pancreas as seen by MRI is a contributing factor in the development of post-ERCP pancreatitis. Methods: Retrospective case controlled review. Pts who had an abdominal MRI followed by an ERCP within 60 days from 01/02 to 08/08 were identified. Pts with post-ERCP pancreatitis(nZ23) were selected for further analysis. Age, sex and disease matched cohort of controls(nZ52) was included. Fat in the abdominal wall, pancreatic head, body and tail was measured by MRI. Pts with chronic pancreatitis, pseudocysts, necrotizing pancreatitis and/or those having an ERCP for malignancy were excluded from the analysis. The percentage fat was determined by recording the signal intensity in the in-phase (Sin) and out-ofphase (Sout) T1-weighted gradient echo sequences and subsequently calculating the fat fraction as (Sin- Sout)/(Sin 2). Statistics: Analysis was performed in SAS version 9 and statistical tests were performed as two-sided at the alphaZ0.05 significance level and 0.10 marginal level. Ranked data transformation was used for analysis of pancreas fat. Generalized Linear Mixed Models with match as the random effect was used to compare body, tail and head fat and BMI between case and control groups. Results: ERCP-controls and post ERCP- pancreatitis pts did not differ with respect to age (38.0 vs 38.20 years), gender (73.2% vs 73.2% female), and BMI (28.7 vs 24.9). There was no difference in body fat, tail fat, head fat or BMI between cases and controls (pvaluesZ0.640, 0.243, 0.418, and 0.179 respectively). Conclusions: These data suggest that increased fat content of pancreas does not increase the risk of post-ERCP pancreatitis.
Type
Variable
Median
Minimum Maximum
Case NZ23 Head %Fat(a) Body %Fat(c) Tail %Fat(e) 2.1 0.9 2.1 0.0 0.0 0.0 Control NZ52 Head %Fat(b) Body %Fat(d) Tail %Fat(f) 0.0 1.7 2.5 0.0 0.0 0.0
32.3 30.4 35.4 17.5 20.9 19.0
a vs b Z p-value 0.418; c vs d Z p-value 0.640; e vs f Z p-value 0.243
K-ras point mutation developed pancreatic cancer 4 and 12 years after the examination. Conclusions: The incidence of pancreatic cancer associated with chronic pancreatitis was 4%. It is reported that smoking habits, diabetes mellitus, alcohol drinking continuation are risk factors of developing pancreatic cancers in patients with chronic pancreatitis, but they were not risk factors in our study. Only examination of K-ras point mutation in pancreatic juice seem to be a useful tool setting of high risk group developing pancreatic cancer in chronic pancreatitis.
T1340 Cocktail Sedation Containing Propofol Versus Conventional Sedation for ERCP: A Prospective, Randomized Controlled Study Phonthep Angsuwatcharakon, Yuwadee Ponauthai, Rungsun Rerknimitr, Wiriyaporn Ridtitid, Pradermchai Kongkam, Narongrit Prempracha, Sombat Treeprasertsuk, Pinit Kullavanijaya Background: The usage of propofol for endoscopic procedures has been increasing because of its ultra-short onset and rapid offset of sedation with quick recovery. ERCP generally requires moderate to deep sedation. Because propofol has a narrow therapeutic window, therefore propofol alone may cause over sedation. A combination of propofol, meperidine and midazolam (cocktail) may reduce the dosage of propofol and may result in a less number of over sedation. Aims: To compare the efficacy, recovery time, patient satisfactory and side effect including desaturation rate between cocktail and conventional sedations for patients undergoing ERCP. Methods: Patients (nZ205) who underwent ERCP were randomed prospectively into 2 groups; the cocktail and conventional sedations (103 and 102 patients). Initially, 25 mg of meperidine and 2.5 mg of midazolam were injected in both groups. Then, 1 mg/kg of propofol bolus was given intravenously in the cocktail group, and followed by infusion rate of 1 mg/kg/hour. To control patient into moderate level of sedation, 0.5 mg/kg was added as needed. In the conventional group, 0.5 mg/kg of meperidine and 0.05 mg/kg of midazolam were administered to maintain the moderate level of sedation. Oxygen supplement was not given unless desaturation occurred. Results: Both groups had no statistically significant difference regarding to gender, age, BMI and duration of procedures. In the cocktail group, the average amount and administration rate of propofol were 172.1 (92.2) mg, 6.2 (3.0) mg/kg/hr. In the conventional group; average amount and administration rate of meperidine were 58.3 (24.5) mg, 2.4 (2.5) and dosages for midazolam were 6.8 (2.1), 0.3 (0.4), respectively. Cocktail group had a significant shorter recovery time; higher patients’ satisfaction score; and higher proportion of desaturation than conventional group (table). All desaturation events in both groups were corrected with temporary oxygen supplementation without any apnea or serious hemodynamic instabilityConclusions: Cocktail sedation containing propofol provides faster recovery time and better patients’ satisfaction for patients undergoing ERCP. However, desaturation is common but can be corrected by oxygen supplementation without serious side effects. Results of cocktail vs. conventional sedations
T1339 High Risk Group Developing Pancreatic Cancer in Patients with Chronic Pancreatitis Yujin Kudo, Terumi Kamisawa, Hajime Anjiki, Naoto Egawa Background/Aims: Pancreatic cancer sometimes occurs during the course of chronic pancreatitis. However, as most pancreatic cancers associated with chronic pancreatitis are diagnosed in an advanced stage, it is necessary to recognize high risk group developing pancreatic cancer in patient with chronic pancreatitis. To make a strategy detecting pancreatic cancer associated with chronic pancreatitis in an early stage, we analyzed the clinical features of pancreatic cancer associated with chronic pancreatitis. Methods: We retrospectively examined incidence and clinical features of extrapancreatic and pancreatic malignancies in 218 patients (192 males and 26 females, average age of 56.8 years old) with definite chronic pancreatitis. Etiologies of chronic pancreatitis were alcoholic (nZ157), idiopathic (nZ47), malformation (nZ14), and others (i.e. biliary, radiation, trauma) (nZ8). Average period of follow-up was 6.5 years (0-33 years). We collected pancreatic juice of 15 patients with chronic pancreatitis during ERCP and investigated K-ras point mutation. Results: Nine patients developed pancreatic cancer. They were 7 males and 2 females, and average age was 63.3 years old. Etiologies of the chronic pancreatitis were alcoholic (nZ5), idiopathic (nZ3), and papillary stenosis (nZ1). Period from onset of chronic pancreatitis to diagnosis of pancreatic cancer was average 9.6 years (0-30 years). All pancreatic cancers were diagnosis in an advanced stage, and 8 patients died within 8 months. There were no significant differences between chronic pancreatitis patients developing pancreatic cancer and those non-developing pancreatic cancer, in smoking habits (70.7% vs. 62.5%), diabetes mellitus (77.8% vs. 54.4%), and alcohol drinking continuation (37.5% vs. 53.1%). K-ras point mutation was observed in pancreatic juice of 10 patients with chronic pancreatitis (2þ; nZ2, 1þ; nZ5, ; nZ3). In them, the 2 patients with 2þ
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Gender(F: M) Age (year) Duration of procedure (min) Recovery time (min) Patient satisfaction score (%) Number of patients with desaturation (O2 saturation !90%)
Meperidine/ midazolam N Z 102
Cocktail N Z 103 P value
51: 51 57.5 31.6 12.9 87.6 32 (31.3%)
51: 52 1.000 59.9 0.257 27.9 0.099 9.7 0.045 93.1 ! 0.01 60 (58.3%) ! 0.01
T1341 Diagnostic and Therapeutic ERCP in Long-Limb Surgical Bypass Patients Using a New Single-Balloon Assisted Enteroscope Douglas A. Howell, Ramesh Srinivasan, Andreas M. Stefan Background: Successful per-oral ERCP has been reported in long-limb surgical bypass patients, including Roux-en-Y cases, using standard push enteroscopes (Howell, GIE 1996;43: 383AB). Newer bypass procedures have resulted in increased length of bypass limbs preventing endoscopic access with standard equipment. The single-balloon overtube assisted enteroscope (SBAE)(Olympus America) has recently been released. We report initial experience performing peroral ERCP using SBAE. Patients and Methods: 10 procedures were attempted in 8 pts, with the following long-limb bypasses: Pylorus preserving Whipple (PPW) (nZ2) and bariatric laparoscopic Roux-en-Y gastric bypass (RNYGB) (nZ8). Four pts (2 PPW and 2 RNYGB) had a previous failed attempt with other endoscopes, including variable stiffness colonoscopes and standard-push enteroscopes with non-balloon overtubes. Indications: All procedures were carried out with the new
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB271
Abstracts
Olympus Q180 200cm SBAE. Cannulation and therapy was performed with special enteroscope length accessories supplied by various companies. Indications included: common duct stone (nZ1), ampullary stenosis/SOD Type I (nZ1), recurrent pancreatitis (nZ2), severe right upper quadrant (RUQ) pain with dilated ducts (nZ2), chronic pancreatitis (nZ2), and PD stent removal (nZ2). Results: 8/ 10 (80%) procedures were successful in reaching the RUQ and assessing the desired duct. Two failures were due to adhesions in one PPW patient and inability to advance beyond the ligament of Treitz in a RNYGB patient. Two diagnostic ERCPs noted a normal cholangiogram in one and extensive pyloric channel ulcer disease in the other. Six therapeutic ERCPs included biliary sphincterotomy (nZ1), pancreatic sphincterotomy with stent placement (nZ2), biductal sphincterotomy with nasopancreatic drainage (nZ1), and pancreatic stent removal (nZ2). Complications included a single episode of delayed mild pancreatitis. Both barbless pancreatic duct stents failed to pass after 3 weeks requiring a second SBAE ERCP with successful removal. Experience is ongoing. Conclusions: Single-balloon assisted enteroscopy permitted access to the RUQ in most patients in this initial experience. Diagnostic and therapeutic ERCP was accomplished in all cases where the RUQ was reached. Technical challenges include the front-viewing nature of the enteroscope, the absence of an elevator and the limited selection of therapeutic accessories. Routine per oral ERCP in post-operative long-limb bypass patients should be routinely possible, at least in specialized centers of excellence.
T1342 ERCP in Pregnancy- Is It Safe? Adel Y. Daas, Amir Agha, Haim Pinkas, Jay J. Mamel, Patrick G. Brady Background: Although rare, pancreaticobiliary disease during pregnancy can pose a serious risk to both the mother and fetus. Gallstones may be present in up to 12% of pregnancies and are the most common cause of acute pancreatitis in pregnancy with a 70% antepartum relapse rate. Data regarding the relative safety of ERCP during pregnancy is sparse. Methods: We performed a retrospective review of 15 cases performed in 8 pregnant patients in which ERCP was utilized as a therapeutic modality. Procedures were performed at a single center tertiary care referral center between January 2005 and October 2008. Records were reviewed for ERCP indication, endoscopic interventions, use and extent of fluoroscopy, post-procedure complications, and pregnancy outcomes including APGAR scores. Results: The mean patient age was 23.5 years (18-30) years; mean duration of gestation was 20 weeks (8-34 weeks). 5 cases were performed during the first trimester, 4 cases in the second trimester, and 8 in the third trimester. Indications were cholangitis (nZ1), gallstone pancreatitis (nZ3), obstructive jaundice (nZ4), stent service (nZ5) and cystic dilation of biliary tree (nZ2). Biliary sphincterotomy was performed in 8 cases. Balloon extraction of biliary stones/ sludge was performed in 7 cases. There were no reports of any acute complications in any of the cases. Fetal heart monitoring was performed throughout each procedure. Limited use of fluoroscopy was performed in 5 cases with a mean exposure time of 8 seconds. Lead shielding to the pelvis was performed in all cases involving fluoroscopy to reduce radiation exposure to the fetus. Aspiration of bile was used to confirm selective bile duct cannulation when fluoroscopy was not used. There were no pregnancy related complications. Mean gestational age at delivery was 38 weeks (36-41 weeks) with mean APGAR O8 at 1 and 5 minutes. Conclusions: ERCP in pregnancy appears to be a safe, therapeutic option for patients with pancreaticobiliary disease. Although the use of fluoroscopy was generally avoided, certain situations such as inability to confirm selective biliary cannulation with aspiration techniques alone necessitated its use in some cases. Our data demonstrates not only the safety of ERCP, but additionally the safety of therapeutic interventions such as stent placement, sphincterotomy and balloon stone extraction. Therapeutic ERCP during pregnancy appears to be safe when performed in experienced hands and with judicious use of fluoroscopy.
patients were identified who had undergone double balloon ERCP (DBE-ERCP). In 89% of the patients previously performed ERCP using a conventional duodenoscope had failed (25/28). In these patients DBE-ERCP was successful in 60 percent (15/25). In three patients DBE-ERCP was performed primarily. In four patients ERCP was done by DBE-ERCP combined with PTC in rendezvous-technic. Overall success rate of DBE-ERCP in all patients was 61% (17/28 patients). In those patients interventions such as papillotomy, balloon dilation, calculus extractions as well as stent placement could be performed even though tools for DBE-ERCP are still very limited. Despite most of the DBE-ERCPs having included therapeutic interventions in only one patient edematous post-ERCP pancreatitis occurred. No other major complications occurred in our case series and minor side effects were restricted to meteorism and mild to moderate abdominal pain. Conclusions: DBEERCP is an alternative method for diagnostic as well as therapeutic interventions in the biliary as well pancreatic system in the operated patient. In the majority of cases more invasive procedures such as PTC and surgery could be prevented. However, it should be limited to selected patients, as it is a time consuming as well as a cost intensive procedure.
T1344 Applications and Outcomes of Single User Cholangiopancreatoscopy in a Community Hospital James A. Disario, Maydeen M. Ogara, Daniel G. Luba The Spyglass (Boston Scientific, Inc.) is a single-user cholangioscope (SUC) for visual diagnosis, aimed biopsy, and lithotripsy. Purpose: Describe the applications and outcomes of SUC use in a community hospital. Methods: Prospective cohort series of initial consecutive cases. Results: From 9/20/2007-10/10/2008, SUC was used in 50 cases (47 biliary, 3 pancreatic) by 3 experienced endoscopists (JD 42, DL 5, OT 3) on 40 patients (26 women, 14 men) with a mean age of 67 (27 - 88) years. There were 57 indications: 24 stone, 21 abnormal imaging, 8 stricture, 2 ampullary and 2 fistulas. Mean ERCP duration was 89 (28-185) and fluoroscopy 8.3 (0.9-37) minutes. SUC use required a mean of 37 (12-83) minutes in 39 cases and fluoroscopy took a mean of 2 (0.1-11) minutes in 36 cases. SUC cannulation was adequate free-hand in 25/26 (96%) and wire-guided in 22/24 (92%). Successful applications: 48/50 (96%) visual diagnosis, 13 guided 1 mm forceps biopsies [11 (85%) adequate tissue; pathology: 8 indeterminate, 3 normal with 2 (18%) false negative for cancer]; 8/10 (80%) aimed guidewire placement, 13/13 (100%) stone extractions, 2/3 (66%) Holmium laser lithotripsy for impacted CBD stones and 2/2 (100%) fibrin glue injections via the channel for cystic duct fistula closure. Complications occurred in 8 (16%) cases: 3 cardiopulmonary (1 severe, 2 mild), 1 severe perforation, 1 moderate cholangitis and bleeding, 1 mild pancreatitis, 2 pain (1 moderate, 1 mild). Two (4%) events were possibly SUC-related. 30 day mortality was 3 (6%): 1 unknown cause 3 days post-ERCP deemed cardiopulmonary, 2 cancer. SUC use led to a diagnosis in 31 (62%) and added to patient management in 30 (60%) cases beyond conventional ERCP. There were no statistically significant differences in the mean procedure times or scores for visualization, ease of use and utility for the first and last 10 procedures. Conclusions: SUC use in a community hospital: 1. Contributed to patient management beyond conventional ERCP in most cases; 2. Was often difficult in the ampullary and pancreatic segments; 3. Required additional maneuvers and time; 4. May have false negative biopsies; 5. Involved morbidity reflecting pre-existing illnesses; 6. Had no significant learning curve, by key indicators, with experienced endoscopists.
Duct
N
Diam, mm
Right intrahepatic Left intrahepatic Extrahepatic Cystic Pancreatic duct Ampulla segment
26 27 47 13 3 43
8(2-18) 9(3-18) 13(4-20) 7(3-15) 6(4-8) NA
Stones 1 2 11 2 0 3
Inflam 2 2 9 )) 3 0 3
Tumor 0 0 1 0 1 1
) View
Ease
4 4 4 4 3 3
4 4 4 4 3 3
(2-6) (2-5) (1-6) (2-5) (2-3) (1-6)
)
(2-6) (2-5) (1-6) (2-5) (2-5) (1-6)
)1Z none - 6Z excellent ))1 eroded clip, 2 fistulas
T1343 Usefulness of Double Balloon Enteroscopy for Diagnostic and Therapeutic ERCP in Postoperatively Altered Anatomy A Retrospective Analysis Frank Lenze, Christian Maaser, Tobias Meister, Dirk Domagk, Torsten F. Kucharzik, Wolfram W. Domschke, Hansjoerg Ullerich
T1345 Failure Rate of Peroral Cholangiopancreatoscopy in Clinical Practice Shahzad Iqbal, Anuj Kapoor, Peter D. Stevens
Objectives: Diagnostic and therapeutic interventions in the biliary and pancreatic system in the previously operated patient, such as BII-situation and biliodigestive anastomosis, by conventional ERCP are difficult and in many cases unsuccessful. We describe our experience of ERCP performed with a double balloon enteroscope (DBE) as an alternative examination technique for these patients. Methods: Double balloon enteroscopy was introduced in the Department of Medicine B in November 2004. From November 2004 until the end of March 2008 1080 double balloon enteroscopies and 2050 ERCP’s have been performed. In a retrospective analysis examinations which combined ERCP with double balloon enteroscopy in previously abdominally operated patients were reviewed. Results: A total of 28
Background: Peroral cholangiopancreatoscopy (CP) is an ERCP technique that uses a fiberoptic cholangioscope passed through a therapeutic duodenoscope directly into the biliary and pancreatic ducts. The primary aim of this study was to analyze the failure rate of CP in clinical practice. The secondary aims were to analyze the complication rate, clinical applications and diagnostic yield of CP forceps bite. Methods: It was a retrospective review of all CP procedures performed between 11/ 01/05 to 11/30/08 at Columbia University Medical Center, NYC by a single experienced endoscopist. The failure was defined as inability to achieve the primary goal that was set before starting the procedure. The diagnostic yield of CP forceps was defined as either positive for malignancy or benign with 6 months follow-up.
AB272 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
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