- Email: [email protected]
Abscess Drainage: A Systematic Review of Prospective Studies
Abstracts
36, abscess 15, necrosis 9). Technical success was 95% (57/60): failures were due to inability to drain thick necrotic PFC in 2 and inability to visualize PFC in 1. Treatment success was 93% (53/57): 3 abscesses and 1 necrosis required surgery. No complications were encountered. There were no significant differences in patient/ clinical characteristics between group A and B patients. While there was no difference in technical or clinical outcomes, median procedural duration was significantly shorter for group B than group A patients (25 vs.70 min; p ! 0.001). After 25 procedures, procedural duration for performing EUS-D of PFC was more likely to be ! 30 minutes (adj. OR Z 11.6; p Z 0.01) even after adjusting for patient age, serum albumin, type/location/size of PFC, drainage modality (stent vs. stent plus drainage catheter) and site of endoscopic access in GI tract for establishing drainage. Conclusions: In this study, the largest reported to-date, EUSguided drainage of PFC was performed safely using the graded dilation technique with a successful outcome in a majority of patients. Learning curve, with regard to procedural duration, improved significantly after the first 25 cases.
[range, 5-16]) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent EUS-guided cyst-gastrostomy. There were no significant differences in demographic data, comorbidity, and clinical characteristics between both groups. While there were no significant differences in rates of treatment success (100% vs. 95%; p Z 0.36), procedural complications (none in both groups) or reinterventions (10% vs. 0%; p Z 0.13) between surgery vs. EUS-guided cystgastrostomy, the mean length of hospital stay for EUS-guided cyst-gastrostomy was significantly shorter than for surgical cyst-gastrostomy (2.6 vs. 6.5 days; p Z 0.008). The average total cost per case for the EUS-guided cyst-gastrostomy approach was significantly less when compared to surgical cyst-gastrostomy ($7943 vs. $14,815, p Z 0.01) with the total cost savings being $6872 per patient. Conclusions: When available, EUS-guided cyst-gastrostomy should be the first-line treatment approach for patients with uncomplicated pancreatic pseudocysts as the procedure is less costly and is associated with shorter length of hospital stay than surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities.
M1494 EUS-Guided Drainage: An Alternative to Surgical and Percutaneous Approaches for Management of Multiple, Non-Communicating Peripancreatic Fluid Collections Shyam Varadarajulu, Jeanetta Blakely
M1496 One-Step, EUS-Guided Drainage of Pancreatic Pseudocysts: Experience in 52 Patients Colin Mckay, Simon Denley, Ross Carter
Background: Management of multiple peripancreatic fluid collections (PFC) is a therapeutic challenge, particularly in patients with disrupted main pancreatic duct as pancreatic stenting is not feasible. Also, endoscopic trans-mural drainage may not be feasible as none or only few of the PFC may cause definitive luminal compression (LC). Under such circumstances, management is relegated to percutaneous/surgical drainage. Although the role of EUS for drainage of PFC without LC is well known, there are no published reports on use of this modality for drainage of multiple PFC. Aim: Evaluate the role of EUS in drainage of multiple, non-communicating PFC. Methods: Prospective study of all patients who underwent EUS-guided drainage of PFC over a 42-month period. Prior to EUS, all patients underwent contrast enhanced abdomen CT and ERCP was attempted for pancreatic stenting. In symptomatic patients with multiple PFC that were noncommunicating, not causing LC, and large (O 6 cm), EUS-guided drainage of PFC in all locations was undertaken. At EUS, the PFC were accessed using a 19-gauge needle and after passage of a 0. 035 inch guidewire, sequential dilation of the tract was performed and 7 Fr/10 Fr stents or drainage catheters were deployed. Clinical follow-up and CT was undertaken at 6-weeks to assess treatment response. Results: Multiple, large, non-communicating PFC was encountered in 6 (3 pseudocyst, 2 abscess, 1 necrosis) of 60 patients (10%; 95% CI [4.3%, 20.4%]) who underwent EUS-guided drainage. Etiology of pancreatitis in the 6 patients (3 female, mean age 60.5yrs [range, 41-70]) were idiopathic in 4, gallstone 1 and ETOH 1. ERCP revealed complete duct disruption in all 6 patients. Three patients with pseudocyst had PFC at 3 locations and others at 2 locations. The procedure was technically successful in all patients (100%). A total of 15 PFC sites were drained under EUS-guidance in these 6 patients. Sites of access were GE junction in 1, gastric cardia/fundus (6), greater curvature (2), antrum (2), duodenum (3), and Roux-en-Y loop in (1). The mean procedural duration was 60 minutes (range, 47-76). No complications were encountered. At follow-up, 4 (3 pseudocyst, 1 abscess) of 6 patients (66%) had complete symptom relief and resolution of PFC; others experienced persistent symptoms with residual fluid collection requiring surgical drainage. Conclusions: EUS-guided drainage of multiple, non-communicating peripancreatic fluid collections is technically feasible, safe, obviates the need for surgery or placement of multiple percutaneous drainage catheters, and leads to a successful clinical outcome in two-thirds of patients.
M1495 EUS Versus Surgical Cyst-Gastrostomy for Management of Pancreatic Pseudocysts Shyam Varadarajulu, Tercio Lopes, Charles M. Wilcox, Ernesto R. Drelichman, Meredith L. Kilgore, John D. Christein Background: Although EUS-guided cyst-gastrostomy is increasingly performed, there are no studies comparing the clinical outcomes and cost-effectiveness of this approach with ‘gold standard’ surgical cyst-gastrostomy. Aim: Compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for management of patients with pancreatic pseudocysts and perform a cost analysis of each treatment modality. Methods: This is a retrospective case-control study of consecutive patients with uncomplicated pancreatic pseudocysts who underwent either surgical or endoscopic cyst-gastrostomy over a 3-yr period at a tertiary referral center. Individual patients who underwent surgical cyst-gastrostomy were matched with two patients who underwent EUS-guided cyst-gastrostomy during the same time period for age, etiology of pancreatitis, and size of the pseudocyst. All procedures were performed by one experienced pancreaticobiliary surgeon and one experienced endosonographer. Patients with pancreatic abscess or necrosis were excluded. Main outcome measures were rates of treatment success, complications and reinterventions, length of hospital stay (post-procedure), and cost associated with each treatment modality. Treatment success was defined as resolution of clinical symptoms and pseudocyst on follow-up imaging at 6-weeks. Results: Ten patients (6 male, median age 41yrs, mean pseudocyst size 6.2 cm
AB226 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Introduction: In the treatment of pancreatic pseudocysts endoscopic treatment is now standard. Increasingly, trans-gastric drainage is being used in patients with acute pancreatitis and patients with more complex cysts containing debris. We report our experience in 52 patients using a one-step, two stent procedure under EUS guidance. Methods: All patients had persistent, symptomatic cysts. Aetiology was acute pancreatitis in 34 and chronic pancreatitis in 18 patients. 17 cysts were infected. ERCP or duct stent placement was either unsuccessful (8 cases) or demonstrated no communication (31 cases). In 10 cases ERCP was not attempted. In the remaining 3 cases, cysts persisted despite pancreatic duct stenting. Cyst drainage was carried out under EUS control using a therapeutic echoendoscope (Pentax EG-3830UT) with a 3.8 mm working channel and bridge. Two or more pigtail stents were inserted after entering the cyst with a Wilson-Cook CystotomeTM and performing balloon dilatation (oesophageal balloon) of the cystgastrostomy to 12-15 mm. Results: Cysts resolved at the first procedure in 37 cases, with one patient undergoing 24h of lavage via a naso-cyst catheter. A further 5 patients underwent a second procedure, 3 for placement of a naso-cyst catheter and lavage, 2 for further dilatation of the cyst-gastrostomy. All 5 resolved after a second procedure. One patient underwent 4 procedures, a naso-cyst catheter at the first followed by 3 further dilatations. In 3 patients formal open surgery was required, one 2 months later for incomplete drainage, the other two for procedure related complications. Two patients died following surgery for persistent, infected cysts. A third death occurred due to liver failure following successful cyst drainage and a fourth died approximately 1 year after successful cyst drainage from a pancreatic tumour. Conclusions: One-step EUS-guided drainage with the deployment of two or more stents is an effective treatment with 43 of 52 patients having complete cyst resolution by endoscopic means only. Complications all occurred early in this study indicating a learning curve, but these can be minimised by appreciating the need for further intervention and the use of naso-cyst lavage in more complex cysts.
M1497 Effectiveness and Safety of EUS Guided Pancreatic Pseudocyst/ Abscess Drainage: A Systematic Review of Prospective Studies Priyanka Tiwari, Nadim S. Jafri, Praveen K. Roy, Mainor R. Antillon Background: EUS guided pseudocyst and abscess drainage has been reported since it was first described in 1992. Overall success rates and complications of this procedure are however not known and it is unclear if this treatment is definitive. We conducted a systematic review to evaluate the effectiveness and safety of EUS guided drainage of pancreatic pseudocysts and abscesses. Method: We performed a systematic search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials without language restriction for prospective studies evaluating the role of EUS guided drainage of pancreatic pseudocysts/abscess. We also hand searched grey literature from major gastrointestinal meetings. Standard forms were used to extract data regarding study design, cyst/abscess size, success rates, recurrence, surgical intervention, mortality and complications by two independent reviewers. Result: Six studies (156 patients) met our predefined eligibility criteria. The sample size of the studies ranged from 8 to 46 patients. Patient age ranged from 9-81 years. Time of intervention from time of diagnosis was less than 4 weeks. The length of follow-up period after the therapeutic intervention ranged from 3-468 weeks among the studies. The etiology of cyst/abscess formation reported in the studies were: alcohol, acute pancreatitis, gallstones and other causes. The size of the pseudocysts/abscess ranged from 4-14 cm in all the studies. The pancreatic body was the most common location (22-76% of patients), followed by the head of the pancreas (12-52%) and pancreatic tail (8-34%). In two prospective studies, 3-8% patients were also found to have gastric varices at the time of endoscopy. An endoscopic bulge was seen in 3-12% patients (3 studies). Overall, the success rate for EUS guided drainage of pancreatic pseudocysts and abscesses varied from 82%-100% among the studies. The most common complications from the endoscopic intervention were bleeding, perforation, stent migration and stent occlusion. The rate of recurrence of the pesudocyst/abscess
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Abstracts
varied from 0-11% of patients in the studies. Subsequent surgical intervention was needed in 0-10% of the patients. There were no deaths related to the procedure at the end of the follow up period in any of the studies. Conclusion: EUS guided pancreatic drainage is an effective and safe definitive procedure.
M1498 Therapeutic Endoscopic Ultrasound (EUS) Access and/Or Stenting of Pancreaticobiliary System After Failed Conventional Endoscopic Retrograde Cholangiopancreatography (ERCP) H. Nguyen Thomas Thong, Christopher E. Lee, Charles S. Whang, Patrick B. Truong, Raman Muthusamy, Kenneth Chang, John G. Lee Background: Pancreaticobiliary access during ERCP can fail due to duodenal obstruction, surgically altered anatomy or unsuccessful cannulation. We used EUS to obtain pancreatic or biliary access and/or stent after conventional ERCP failed. Method: Retrospective review of 18 consecutive patients undergoing EUS guided access during 12 months. We assessed outcomes from medical records and referring physicians. Results: We imaged the desired duct with linear EUS and injection of radiographic contrast. A 0.035 inch guidewire was advanced through the 19g needle and manipulated across the stricture, ampulla or intrahepatics. The EUS scope was removed and a conventional endoscope was advanced to the wire, which was grasped and pulled out. The duct was accessed retrograde over the wire if possible; if not the stent was placed through an endoscopically created choledochoduodenostomy (CD). ERCP failed in 18 (8 men, mean age Z 68y, range 30-94y) due to malignant duodenal obstruction resistant to dilation (6), prior duodenal metal stent (2), malignant choledochojejunal stenosis post Whipple (4) or roux en Y (1), benign choledochojejunal stenosis post roux en Y (1), benign pancreaticojejunal stenosis post Whipple (1), ampulla inside diverticulum (2) and failed deep cannulation (1). We stented retrograde over a guidewire if possible (9); otherwise through an endoscopically created CD with the distal end of the stent in the bulb (3) or the ampulla (1). The patient with stones had duct clearance and jaundice resolved in all with technical success. The patient with pancreaticojejunal stenosis and recurrent pancreatitis resolved the stenosis and remains asymptomatic. Two with CD underwent planned stent exchange uneventfully and one had successful planned Whipple. Initial attempt at wire passage failed in 5/18; reattempt was successful in 1 and switching back to ERCP was successful in another (83% technical success). Percutaneous biliostomy was successful in 2. We used EUS to puncture and dilate a tract to the proximal end of the afferent limb in a patient with recurrent cholangiocarcinoma after choledochojejun-ostomy, but still could not locate the anastamosis even after direct intubation of the limb using a colonoscope; gastrojejunostomy was clipped closed without complications. Further attempts at radiographic and surgical biliary access also failed. One complication of pain occurred in a patient who had antegrade metal stent placement via CD; urgent laparoscopy was unremarkable and the patient recovered uneventfully. Conclusion: Therapeutic EUS guided access and stenting of the pancreaticobiliary system is a reasonable alternative when conventional ERCP fails.
M1499 No Cytopathologist? No Problem Maintaining Yield While Minimizing EUS Guided FNA Passes in a Community Hospital Setting Mukul Arya, Siddharth Mathur, Niket Sonpal, Philip Mathew, William L. Thelmo, Yashpal Arya Traditionally, EUS guided FNA is performed in the presence of a cytopathologist in an effort to maximize yield and reduce the number of passes. The majority of these procedures are performed in tertiary care centers with access to a cytopathologist. Previous studies have reported that a minimum of 7 passes for solid pancreatic lesions and 5 passes for lymph nodes provides a sensitivity of 83% and 77%, respectively. As this modality spreads to community hospitals where services of a cytopathologist are not readily available, there may be significant reduction in specimen yield. The purpose of our study was to maintain adequate sensitivity in the absence of a cytopathologist in a community hospital setting. In our trial, all samples obtained were placed directly into a fixative solution eliminating the preparation of slides. A cell block was created and examined by a pathologist. We hypothesized that initial passes provided the greatest yield and specimen may be lost in the preparation of slides. This would potentially reduce the number of required passes while still maintaining and possibly enhancing our overall yield. Limiting passes provides obvious clinical and procedural benefits with an overall reduction in cost per. A prospective study in which all patients underwent linear echoendoscopy and FNA using a 22 g , 25 g or 19 g quick core needle. A maximum number of 3 passes was made regardless of the site of the lesion. The specimen was immediately placed into 20 cc of a methanol based fixative solution and sent for cell block preparation. The specimens were spun and the resultant cell block was sectioned and placed on slides for histopathologic interpretation. A total of 27 lesions in 27 patients were sampled. Solid lesions numbered 22 and 5 were cystic. A mean number of 2.2 passes was made. The lesions by locality were 11 pancreatic, 4 lymph nodes, 3 gastric, 2 biliary, 1 esophageal and 6 cystic lesions. Overall yield on solid lesions was 90.9% (20/22) and 100% on cysts. For pancreatic lesions the sensitivity was found to be 90.8%. These preliminary results suggest yield and sensitivity can be maintained especially in solid pancreatic tumors despite the
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absence of a cytopathologist. By eliminating slides we were able to limit the number of passes (mean -2.2) which translated into a reduction in procedure time, anesthesia requirement and overall cost without compromising sensitivity. In fact, our study is the only one to date that imposes a limit of 3 passes irrespective of the target lesion. Larger series have reported a range of passes with maximal numbers of 18. Data is still being collected with hopes of a larger series in the near future.
T1479 Diagnosis of Intraductal Papillary-Mucinous Neoplasm of the Pancreas By Using Peroral Pancreatoscopy (POPS)- the Usefulness of POPS with Narrow -Band Imaging (NBI) Taro Hara, Taketo Yamaguchi, Kentaro Sudo, Kazuyoshi Nakamura, Tadamichi Denda, Takeshi Ishihara Backgroud &Aim : Peroral pancreatoscopy (POPS) contribute useful information for the diagnosis of intraductal papillary-mucinous neoplasm (IPMN) , and we have reported the efficary of POPS with special reference to the type of protruding lesion as well as vascular image (Gastroenterology 2002). Recently, Narrow -Band Imaging (NBI) has been used in clinical procedure as new diagnostic techniques for GI-tract diseases. POPS with NBI has made it possible to increase the visibility of capillaries and other delicate tissue surface structures The aims of this study are to determine the usefulness of POPS (with NBI) in IPMN for differentiation of malignant from benign disease, and to evaluate the significance of these techniques as preoperative examination. Subjects and Methods: One hundred and twenty-one histopathologically confirmed patients with IPMN underwent POPS preoperatively.; POPS with NBI in 9 patients. Findings of POPS were compared with histopathology of resected specimens. The postoperative follow-up data were analyzed. Results: Protruding lesions were detected by POPS in 73 patients. They were classified into 5 groups. ;granular type (type1), fish-egg-like type without vascular images (type2), fish-egg- like type with vascular images (type3), villous type (type4), and vegetative type (type 5). Fish-egg-like type with vascular images, villous type and vegetative type were considered to be malignant. The sensitivity, specificity, and accuracy of POPS in differentiating these 3 types as malignant were 65%, 78%, and 73%, respectively. Protruding lesions were detected in 8 out of 9 patients with NBI , and emphasized image features such as mucosal structures and capillary vessels in all these patients. The 3-year cumulative survival rate and disease-free survival rate were extremely high at 95%, 92%. Conclusions: POPS (with NBI) results in a considerably improved differential diagnosis between malignant and benign IPMN and useful for determining an effective therapeutic approach. Especially, NBI facilitated easy recognition of vascular image in the protruding lesion, enhancing diagnostic value of POPS. This technique can contribute to improvements in postoperative results.
T1480 Intraluminal Implantation of Radioactive Stents for Treatment of Unresectable Pancreatic Cancer, Extrahepatic Bile Duct Carcinoma and Ampullary Carcinoma: A Pilot Trial Yan Liu, Zheng Lu Purpose: The aim of this study was to evaluate the potential curative efficacy and safety of intraluminal brachytherapy through radioactive stents in the palliative treatment of bile duct, pancreatic head and ampullary carcinomas. Materials and Methods: Patients with inoperable extrahepatic bile duct (n Z 2), pancreatic head (n Z 6) or ampullary (n Z 3) carcinomas were treated by intraluminal implantation of radioactive stents designed according to a computerized treatment planning system. Both radioactive stents and commonly used self-expand metal (two patients) or plastic stents (nine patients) were placed in the common bile duct (CBD) of all patients except one pancreatic cancer patient in whom the stents with radioactive seeds were placed in both CBD and the pancreatic duct. The primary measures for the efficacy included abdominal pain and Karnofsky performance status. Survival, tumor status, and global quality of life (QOL) and symptoms were also assessed during the period of follow-up. Results: All 11 patients were successively placed with a total of 16 radioactive stents. There were no lifethreatening complications. Three (27.3%) patients were classified as clinical benefit
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB227
36, abscess 15, necrosis 9). Technical success was 95% (57/60): failures were due to inability to drain thick necrotic PFC in 2 and inability to visualize PFC in 1. Treatment success was 93% (53/57): 3 abscesses and 1 necrosis required surgery. No complications were encountered. There were no significant differences in patient/ clinical characteristics between group A and B patients. While there was no difference in technical or clinical outcomes, median procedural duration was significantly shorter for group B than group A patients (25 vs.70 min; p ! 0.001). After 25 procedures, procedural duration for performing EUS-D of PFC was more likely to be ! 30 minutes (adj. OR Z 11.6; p Z 0.01) even after adjusting for patient age, serum albumin, type/location/size of PFC, drainage modality (stent vs. stent plus drainage catheter) and site of endoscopic access in GI tract for establishing drainage. Conclusions: In this study, the largest reported to-date, EUSguided drainage of PFC was performed safely using the graded dilation technique with a successful outcome in a majority of patients. Learning curve, with regard to procedural duration, improved significantly after the first 25 cases.
[range, 5-16]) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent EUS-guided cyst-gastrostomy. There were no significant differences in demographic data, comorbidity, and clinical characteristics between both groups. While there were no significant differences in rates of treatment success (100% vs. 95%; p Z 0.36), procedural complications (none in both groups) or reinterventions (10% vs. 0%; p Z 0.13) between surgery vs. EUS-guided cystgastrostomy, the mean length of hospital stay for EUS-guided cyst-gastrostomy was significantly shorter than for surgical cyst-gastrostomy (2.6 vs. 6.5 days; p Z 0.008). The average total cost per case for the EUS-guided cyst-gastrostomy approach was significantly less when compared to surgical cyst-gastrostomy ($7943 vs. $14,815, p Z 0.01) with the total cost savings being $6872 per patient. Conclusions: When available, EUS-guided cyst-gastrostomy should be the first-line treatment approach for patients with uncomplicated pancreatic pseudocysts as the procedure is less costly and is associated with shorter length of hospital stay than surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities.
M1494 EUS-Guided Drainage: An Alternative to Surgical and Percutaneous Approaches for Management of Multiple, Non-Communicating Peripancreatic Fluid Collections Shyam Varadarajulu, Jeanetta Blakely
M1496 One-Step, EUS-Guided Drainage of Pancreatic Pseudocysts: Experience in 52 Patients Colin Mckay, Simon Denley, Ross Carter
Background: Management of multiple peripancreatic fluid collections (PFC) is a therapeutic challenge, particularly in patients with disrupted main pancreatic duct as pancreatic stenting is not feasible. Also, endoscopic trans-mural drainage may not be feasible as none or only few of the PFC may cause definitive luminal compression (LC). Under such circumstances, management is relegated to percutaneous/surgical drainage. Although the role of EUS for drainage of PFC without LC is well known, there are no published reports on use of this modality for drainage of multiple PFC. Aim: Evaluate the role of EUS in drainage of multiple, non-communicating PFC. Methods: Prospective study of all patients who underwent EUS-guided drainage of PFC over a 42-month period. Prior to EUS, all patients underwent contrast enhanced abdomen CT and ERCP was attempted for pancreatic stenting. In symptomatic patients with multiple PFC that were noncommunicating, not causing LC, and large (O 6 cm), EUS-guided drainage of PFC in all locations was undertaken. At EUS, the PFC were accessed using a 19-gauge needle and after passage of a 0. 035 inch guidewire, sequential dilation of the tract was performed and 7 Fr/10 Fr stents or drainage catheters were deployed. Clinical follow-up and CT was undertaken at 6-weeks to assess treatment response. Results: Multiple, large, non-communicating PFC was encountered in 6 (3 pseudocyst, 2 abscess, 1 necrosis) of 60 patients (10%; 95% CI [4.3%, 20.4%]) who underwent EUS-guided drainage. Etiology of pancreatitis in the 6 patients (3 female, mean age 60.5yrs [range, 41-70]) were idiopathic in 4, gallstone 1 and ETOH 1. ERCP revealed complete duct disruption in all 6 patients. Three patients with pseudocyst had PFC at 3 locations and others at 2 locations. The procedure was technically successful in all patients (100%). A total of 15 PFC sites were drained under EUS-guidance in these 6 patients. Sites of access were GE junction in 1, gastric cardia/fundus (6), greater curvature (2), antrum (2), duodenum (3), and Roux-en-Y loop in (1). The mean procedural duration was 60 minutes (range, 47-76). No complications were encountered. At follow-up, 4 (3 pseudocyst, 1 abscess) of 6 patients (66%) had complete symptom relief and resolution of PFC; others experienced persistent symptoms with residual fluid collection requiring surgical drainage. Conclusions: EUS-guided drainage of multiple, non-communicating peripancreatic fluid collections is technically feasible, safe, obviates the need for surgery or placement of multiple percutaneous drainage catheters, and leads to a successful clinical outcome in two-thirds of patients.
M1495 EUS Versus Surgical Cyst-Gastrostomy for Management of Pancreatic Pseudocysts Shyam Varadarajulu, Tercio Lopes, Charles M. Wilcox, Ernesto R. Drelichman, Meredith L. Kilgore, John D. Christein Background: Although EUS-guided cyst-gastrostomy is increasingly performed, there are no studies comparing the clinical outcomes and cost-effectiveness of this approach with ‘gold standard’ surgical cyst-gastrostomy. Aim: Compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for management of patients with pancreatic pseudocysts and perform a cost analysis of each treatment modality. Methods: This is a retrospective case-control study of consecutive patients with uncomplicated pancreatic pseudocysts who underwent either surgical or endoscopic cyst-gastrostomy over a 3-yr period at a tertiary referral center. Individual patients who underwent surgical cyst-gastrostomy were matched with two patients who underwent EUS-guided cyst-gastrostomy during the same time period for age, etiology of pancreatitis, and size of the pseudocyst. All procedures were performed by one experienced pancreaticobiliary surgeon and one experienced endosonographer. Patients with pancreatic abscess or necrosis were excluded. Main outcome measures were rates of treatment success, complications and reinterventions, length of hospital stay (post-procedure), and cost associated with each treatment modality. Treatment success was defined as resolution of clinical symptoms and pseudocyst on follow-up imaging at 6-weeks. Results: Ten patients (6 male, median age 41yrs, mean pseudocyst size 6.2 cm
AB226 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Introduction: In the treatment of pancreatic pseudocysts endoscopic treatment is now standard. Increasingly, trans-gastric drainage is being used in patients with acute pancreatitis and patients with more complex cysts containing debris. We report our experience in 52 patients using a one-step, two stent procedure under EUS guidance. Methods: All patients had persistent, symptomatic cysts. Aetiology was acute pancreatitis in 34 and chronic pancreatitis in 18 patients. 17 cysts were infected. ERCP or duct stent placement was either unsuccessful (8 cases) or demonstrated no communication (31 cases). In 10 cases ERCP was not attempted. In the remaining 3 cases, cysts persisted despite pancreatic duct stenting. Cyst drainage was carried out under EUS control using a therapeutic echoendoscope (Pentax EG-3830UT) with a 3.8 mm working channel and bridge. Two or more pigtail stents were inserted after entering the cyst with a Wilson-Cook CystotomeTM and performing balloon dilatation (oesophageal balloon) of the cystgastrostomy to 12-15 mm. Results: Cysts resolved at the first procedure in 37 cases, with one patient undergoing 24h of lavage via a naso-cyst catheter. A further 5 patients underwent a second procedure, 3 for placement of a naso-cyst catheter and lavage, 2 for further dilatation of the cyst-gastrostomy. All 5 resolved after a second procedure. One patient underwent 4 procedures, a naso-cyst catheter at the first followed by 3 further dilatations. In 3 patients formal open surgery was required, one 2 months later for incomplete drainage, the other two for procedure related complications. Two patients died following surgery for persistent, infected cysts. A third death occurred due to liver failure following successful cyst drainage and a fourth died approximately 1 year after successful cyst drainage from a pancreatic tumour. Conclusions: One-step EUS-guided drainage with the deployment of two or more stents is an effective treatment with 43 of 52 patients having complete cyst resolution by endoscopic means only. Complications all occurred early in this study indicating a learning curve, but these can be minimised by appreciating the need for further intervention and the use of naso-cyst lavage in more complex cysts.
M1497 Effectiveness and Safety of EUS Guided Pancreatic Pseudocyst/ Abscess Drainage: A Systematic Review of Prospective Studies Priyanka Tiwari, Nadim S. Jafri, Praveen K. Roy, Mainor R. Antillon Background: EUS guided pseudocyst and abscess drainage has been reported since it was first described in 1992. Overall success rates and complications of this procedure are however not known and it is unclear if this treatment is definitive. We conducted a systematic review to evaluate the effectiveness and safety of EUS guided drainage of pancreatic pseudocysts and abscesses. Method: We performed a systematic search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials without language restriction for prospective studies evaluating the role of EUS guided drainage of pancreatic pseudocysts/abscess. We also hand searched grey literature from major gastrointestinal meetings. Standard forms were used to extract data regarding study design, cyst/abscess size, success rates, recurrence, surgical intervention, mortality and complications by two independent reviewers. Result: Six studies (156 patients) met our predefined eligibility criteria. The sample size of the studies ranged from 8 to 46 patients. Patient age ranged from 9-81 years. Time of intervention from time of diagnosis was less than 4 weeks. The length of follow-up period after the therapeutic intervention ranged from 3-468 weeks among the studies. The etiology of cyst/abscess formation reported in the studies were: alcohol, acute pancreatitis, gallstones and other causes. The size of the pseudocysts/abscess ranged from 4-14 cm in all the studies. The pancreatic body was the most common location (22-76% of patients), followed by the head of the pancreas (12-52%) and pancreatic tail (8-34%). In two prospective studies, 3-8% patients were also found to have gastric varices at the time of endoscopy. An endoscopic bulge was seen in 3-12% patients (3 studies). Overall, the success rate for EUS guided drainage of pancreatic pseudocysts and abscesses varied from 82%-100% among the studies. The most common complications from the endoscopic intervention were bleeding, perforation, stent migration and stent occlusion. The rate of recurrence of the pesudocyst/abscess
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Abstracts
varied from 0-11% of patients in the studies. Subsequent surgical intervention was needed in 0-10% of the patients. There were no deaths related to the procedure at the end of the follow up period in any of the studies. Conclusion: EUS guided pancreatic drainage is an effective and safe definitive procedure.
M1498 Therapeutic Endoscopic Ultrasound (EUS) Access and/Or Stenting of Pancreaticobiliary System After Failed Conventional Endoscopic Retrograde Cholangiopancreatography (ERCP) H. Nguyen Thomas Thong, Christopher E. Lee, Charles S. Whang, Patrick B. Truong, Raman Muthusamy, Kenneth Chang, John G. Lee Background: Pancreaticobiliary access during ERCP can fail due to duodenal obstruction, surgically altered anatomy or unsuccessful cannulation. We used EUS to obtain pancreatic or biliary access and/or stent after conventional ERCP failed. Method: Retrospective review of 18 consecutive patients undergoing EUS guided access during 12 months. We assessed outcomes from medical records and referring physicians. Results: We imaged the desired duct with linear EUS and injection of radiographic contrast. A 0.035 inch guidewire was advanced through the 19g needle and manipulated across the stricture, ampulla or intrahepatics. The EUS scope was removed and a conventional endoscope was advanced to the wire, which was grasped and pulled out. The duct was accessed retrograde over the wire if possible; if not the stent was placed through an endoscopically created choledochoduodenostomy (CD). ERCP failed in 18 (8 men, mean age Z 68y, range 30-94y) due to malignant duodenal obstruction resistant to dilation (6), prior duodenal metal stent (2), malignant choledochojejunal stenosis post Whipple (4) or roux en Y (1), benign choledochojejunal stenosis post roux en Y (1), benign pancreaticojejunal stenosis post Whipple (1), ampulla inside diverticulum (2) and failed deep cannulation (1). We stented retrograde over a guidewire if possible (9); otherwise through an endoscopically created CD with the distal end of the stent in the bulb (3) or the ampulla (1). The patient with stones had duct clearance and jaundice resolved in all with technical success. The patient with pancreaticojejunal stenosis and recurrent pancreatitis resolved the stenosis and remains asymptomatic. Two with CD underwent planned stent exchange uneventfully and one had successful planned Whipple. Initial attempt at wire passage failed in 5/18; reattempt was successful in 1 and switching back to ERCP was successful in another (83% technical success). Percutaneous biliostomy was successful in 2. We used EUS to puncture and dilate a tract to the proximal end of the afferent limb in a patient with recurrent cholangiocarcinoma after choledochojejun-ostomy, but still could not locate the anastamosis even after direct intubation of the limb using a colonoscope; gastrojejunostomy was clipped closed without complications. Further attempts at radiographic and surgical biliary access also failed. One complication of pain occurred in a patient who had antegrade metal stent placement via CD; urgent laparoscopy was unremarkable and the patient recovered uneventfully. Conclusion: Therapeutic EUS guided access and stenting of the pancreaticobiliary system is a reasonable alternative when conventional ERCP fails.
M1499 No Cytopathologist? No Problem Maintaining Yield While Minimizing EUS Guided FNA Passes in a Community Hospital Setting Mukul Arya, Siddharth Mathur, Niket Sonpal, Philip Mathew, William L. Thelmo, Yashpal Arya Traditionally, EUS guided FNA is performed in the presence of a cytopathologist in an effort to maximize yield and reduce the number of passes. The majority of these procedures are performed in tertiary care centers with access to a cytopathologist. Previous studies have reported that a minimum of 7 passes for solid pancreatic lesions and 5 passes for lymph nodes provides a sensitivity of 83% and 77%, respectively. As this modality spreads to community hospitals where services of a cytopathologist are not readily available, there may be significant reduction in specimen yield. The purpose of our study was to maintain adequate sensitivity in the absence of a cytopathologist in a community hospital setting. In our trial, all samples obtained were placed directly into a fixative solution eliminating the preparation of slides. A cell block was created and examined by a pathologist. We hypothesized that initial passes provided the greatest yield and specimen may be lost in the preparation of slides. This would potentially reduce the number of required passes while still maintaining and possibly enhancing our overall yield. Limiting passes provides obvious clinical and procedural benefits with an overall reduction in cost per. A prospective study in which all patients underwent linear echoendoscopy and FNA using a 22 g , 25 g or 19 g quick core needle. A maximum number of 3 passes was made regardless of the site of the lesion. The specimen was immediately placed into 20 cc of a methanol based fixative solution and sent for cell block preparation. The specimens were spun and the resultant cell block was sectioned and placed on slides for histopathologic interpretation. A total of 27 lesions in 27 patients were sampled. Solid lesions numbered 22 and 5 were cystic. A mean number of 2.2 passes was made. The lesions by locality were 11 pancreatic, 4 lymph nodes, 3 gastric, 2 biliary, 1 esophageal and 6 cystic lesions. Overall yield on solid lesions was 90.9% (20/22) and 100% on cysts. For pancreatic lesions the sensitivity was found to be 90.8%. These preliminary results suggest yield and sensitivity can be maintained especially in solid pancreatic tumors despite the
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absence of a cytopathologist. By eliminating slides we were able to limit the number of passes (mean -2.2) which translated into a reduction in procedure time, anesthesia requirement and overall cost without compromising sensitivity. In fact, our study is the only one to date that imposes a limit of 3 passes irrespective of the target lesion. Larger series have reported a range of passes with maximal numbers of 18. Data is still being collected with hopes of a larger series in the near future.
T1479 Diagnosis of Intraductal Papillary-Mucinous Neoplasm of the Pancreas By Using Peroral Pancreatoscopy (POPS)- the Usefulness of POPS with Narrow -Band Imaging (NBI) Taro Hara, Taketo Yamaguchi, Kentaro Sudo, Kazuyoshi Nakamura, Tadamichi Denda, Takeshi Ishihara Backgroud &Aim : Peroral pancreatoscopy (POPS) contribute useful information for the diagnosis of intraductal papillary-mucinous neoplasm (IPMN) , and we have reported the efficary of POPS with special reference to the type of protruding lesion as well as vascular image (Gastroenterology 2002). Recently, Narrow -Band Imaging (NBI) has been used in clinical procedure as new diagnostic techniques for GI-tract diseases. POPS with NBI has made it possible to increase the visibility of capillaries and other delicate tissue surface structures The aims of this study are to determine the usefulness of POPS (with NBI) in IPMN for differentiation of malignant from benign disease, and to evaluate the significance of these techniques as preoperative examination. Subjects and Methods: One hundred and twenty-one histopathologically confirmed patients with IPMN underwent POPS preoperatively.; POPS with NBI in 9 patients. Findings of POPS were compared with histopathology of resected specimens. The postoperative follow-up data were analyzed. Results: Protruding lesions were detected by POPS in 73 patients. They were classified into 5 groups. ;granular type (type1), fish-egg-like type without vascular images (type2), fish-egg- like type with vascular images (type3), villous type (type4), and vegetative type (type 5). Fish-egg-like type with vascular images, villous type and vegetative type were considered to be malignant. The sensitivity, specificity, and accuracy of POPS in differentiating these 3 types as malignant were 65%, 78%, and 73%, respectively. Protruding lesions were detected in 8 out of 9 patients with NBI , and emphasized image features such as mucosal structures and capillary vessels in all these patients. The 3-year cumulative survival rate and disease-free survival rate were extremely high at 95%, 92%. Conclusions: POPS (with NBI) results in a considerably improved differential diagnosis between malignant and benign IPMN and useful for determining an effective therapeutic approach. Especially, NBI facilitated easy recognition of vascular image in the protruding lesion, enhancing diagnostic value of POPS. This technique can contribute to improvements in postoperative results.
T1480 Intraluminal Implantation of Radioactive Stents for Treatment of Unresectable Pancreatic Cancer, Extrahepatic Bile Duct Carcinoma and Ampullary Carcinoma: A Pilot Trial Yan Liu, Zheng Lu Purpose: The aim of this study was to evaluate the potential curative efficacy and safety of intraluminal brachytherapy through radioactive stents in the palliative treatment of bile duct, pancreatic head and ampullary carcinomas. Materials and Methods: Patients with inoperable extrahepatic bile duct (n Z 2), pancreatic head (n Z 6) or ampullary (n Z 3) carcinomas were treated by intraluminal implantation of radioactive stents designed according to a computerized treatment planning system. Both radioactive stents and commonly used self-expand metal (two patients) or plastic stents (nine patients) were placed in the common bile duct (CBD) of all patients except one pancreatic cancer patient in whom the stents with radioactive seeds were placed in both CBD and the pancreatic duct. The primary measures for the efficacy included abdominal pain and Karnofsky performance status. Survival, tumor status, and global quality of life (QOL) and symptoms were also assessed during the period of follow-up. Results: All 11 patients were successively placed with a total of 16 radioactive stents. There were no lifethreatening complications. Three (27.3%) patients were classified as clinical benefit
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB227