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Endoscopic Retrograde Cholangiography in Post Orthotopic Liver Transplant Population with Roux-En-Y Biliary Reconstruction: Six-Year Single Institute Experience
Abstracts
T1236 Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Kamil Obideen, Maarouf Hoteit, John Affronti, Qiang Cai Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a gastrointestinal endoscopic procedure that requires fluoroscopy. The radiation dose of fluoroscopy is much higher than that of routine X-ray examinations, such as a chest X-ray. A few studies regarding radiation exposure of patients and ERCP staff during ERCP have been published in recent years. However, information about radiation exposure during each step of the procedure is not well known.AIMS: This study aimed to provide data regarding radiation exposure during specific components of ERCP, such as during the deep cannulation of the common bile duct (CBD). Methods: In the last several months, patients referred to us for their first ERCP were enrolled in this study. The fluoroscopy time before, during and post deep cannulation of the CBD in each ERCP were recorded. Results: We analyzed 46 successful ERCP procedures during the study period. Those procedures can be divided into two groups: 18 were diagnostic ERCPs and 28 were therapeutic ERCPs. The latter included obtaining cytology, performing sphincterotomy, balloon extraction, and stent insertion, etc. The mean FT before deep cannulation of the CBD was minimal, less than 0.1 minutes for each procedure in both groups. The mean FTs during the deep cannulation of the CBD were 4.5G4.1 minutes and 6.4G7.9 minutes for the diagnostic group and the therapeutic group respectively. The mean FTs for the whole procedure were 6.1G5.0 minutes and 16.2G11.0 minutes for the diagnostic group and the therapeutic groups respectively. The FT during deep cannulation of the CBD accounted for a significant portion of the whole FT in both the diagnostic group (4.5/6.1, about 74%) and the therapeutic group (6.4/16.2, about 40%). Conclusions: The radiation dose of one-minute FT is approximately 15 mGy at skin entrance which is equal to almost 100 routine chest X-rays. If the cannulation time can be reduced thereby shortening the FT during deep cannulation of the CBD, it will significantly reduce the radiation exposure during ERCP.
T1238 Repeat Sphincter of Oddi Manometry in Patients with Post Cholecystectomy Syndrome and Acute Recurrent Pancreatitis After Initial Normal Study Marc F. Catalano, Urooj Ahmed, Shailendra Chauhan, Sandeep Patel, Joseph E. Geenen Sphincter of Oddi dysfunction is believed to be the cause of biliary colic-type pain following cholecystectomy in up to 1% of pts (‘‘Post Cholecystectomy Syndrome’’). SOM in these pts during ERCP can establish the diagnosis and provide immediate, effective treatment. Similarly ARP may be caused by sphincter dysfunction and sphincterotomy may be curative in a subset of pts. Accuracy of SOM in establishing a diagnosis in PCS and ARP, particularly specificity is largely unknown. AIM: 1) To determine value of repeat SOM in pts presenting with PCS and ARP after initial normal study. 2) To determine clinical response to endotherapy in these pts. Methods: Over a 16-year period, 2497 pts underwent SOM.1873 pts presented with PCS, while 624 pts presented with ARP. Ninety-seven pts with normal SOM presented for follow-up ERCP and SOM and are the subject of this study. This included 41 pts with PCS and 56 pts with ARP. SOM was performed in standard fashion using a perfusion manometry catheter with 3 ports. SO pressure R40 mmHg, high frequency contractions, or high amplitude contractions and/or paradoxical response to CCK was considered an abn study. Sphincterotomy was undertaken by first carrying out biliary sphincterotomy followed by pancreatic sphincterotomy. Over the last 5 years of this study, modified pancreatic stents were left in the PD following pancreatic SO sphincterotomy to prevent for ERCP pancreatitis. Results: Of the 41 pts with PCS presenting for repeat SOM, 16 of 41 (39%) had abn SOM, including 13 with CBD SOD, 1 with PD SOD, and 2 with dual SOD. Following ES, 10 of 16 (63%) had good long-term resolution of symptoms. Thirty-six of 56 pts (64%) in the ARP group had abn SOM, including 12 with PD SOD, 4 with CBD SOD, and 8 with dual SOD. After ES, this group had 26/36 (72%) clinical response. Conclusion: Pts with documented PCS and ARP caused by SOD may occasionally have normal sphincter of Oddi manometry. Repeat SOM may reveal abn studies in up to two-thirds of pts. ES in these pts Results in resolution of pain and/or episodes of acute pancreatitis in the majority of pts.
T1237 Risk Factor Assessement Predisposing To Recurrent CBD Stones Following Duct Clearance: New Insights Marc F. Catalano, Urooj Ahmed, Shailendra S. Chauhan, Sandeep N. Patel, Joseph E. Geenen Endoscopic sphincterotomy and stone extraction is the therapeutic treatment of choice in pts presenting with common bile duct stones. A common post sphincterotomy complication in this setting is recurrent CBD stones. The reported rate of recurrence has been described to be up to 25%. Risk factors have predominately been limited to presence of biliary ductal dilation, ampullary diverticula, and presence of non cholesterol stones. The underlying mechanism therefore suggests biliary stasis. Few other ductal anatomic variants contributing to recurrent stones have been critically evaluated. AIM: To determine by multivariate analysis the anatomic variants contributing to recurrent CBD stones. Methods: Over a 10-yr period, 1267 presented with CBD stones and underwent endoscopic extraction by ES. Of these, 43 pts were identified with recurrent CBD stones, 6 month-4yrs following initial presentation. Diagnosis of CBD stones was established by ERCP and bile duct clearance. Pts with biliary strictures were excluded from evaluation. Definition of recurrent stones was the development of stones not earlier than 3 months after complete initial stone clearance. Data collection included standard demographics (sex, age, race), presence of GB (with or w/o stones), duct diameter and angulation deviation (from vertical), number and size of stones, use of mechanical lithotripsy, and presence of diverticulum. Results: Recurrence of CBD stones was noted in 3.4% (43/1267) over a 10-yr period. Independent risk factors predisposing to recurrence of stones were as follows: 1) Presence of diverticulum (55% vs 26%), 2) Multiple stones (47% vs 18%), 3) Duct diameter R15 mm (46% vs 17%), 4) Mechanical lithotripsy (57% vs 25%), and 5) Angulation of CBD from vertical (57% vs 18%). Sex, age, presence of gallbladder, and cholangitis were not shown to increase recurrence of stones. Conclusion: Our overall Results delineate specific risk factors contributing to recurrence of CBD stones. These risk factors support the theory of biliary stasis and bacterial overgrowth as underlying mechanism. Careful follow-up and, perhaps, scheduled repeat cholangiography is recommended in pts with high risk variables presented herein.
AB200 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1239 Endoscopic Retrograde Cholangiography in Post Orthotopic Liver Transplant Population with Roux-En-Y Biliary Reconstruction: Six-Year Single Institute Experience Prabhleen Chahal, Todd Baron, Charles B. Rosen, John J. Poterucha Background and Aim: Endoscopic retrograde cholangiography (ERC) is a wellestablished modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with post-surgical anatomy like Roux-en-Y anastomoses. Its effectiveness in post orthotopic liver transplant (OLT) patients with Roux-en-Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population.Patients and Methods: 116 OLT with Roux-en-Y biliary reconstruction were performed at our institution from June 1998-October 2004. Data from consenting patients who underwent ERCP were reviewed once they were identified through computerized medical index system. Results: Of the 116 OLT patients with Roux-en-Y biliary reconstruction, 23 patients, 6 females & 17 males underwent ERC. Median age was 57 years and range was 11 months –70 years. The indication for liver transplant was primary sclerosing cholangitis in 22 and hepatitis C virus in one patient. Variable stiffness pediatric colonoscope was used in majority of patients. ERC indications were both diagnostic & therapeutic and included dilation of anastomotic biliary stricture in 8 patients, evaluation of elevated liver biochemistries and fever in 7 patients, removal of fractured biliary tube in 5, retrieval of biliary stone in 1, endoscopic management of biliary leak in post operative period via stent placement in 1, jejunal tube extension placement for nutritional purpose in 1. ERC was successful in 17 (74%) patients and failure to advance through afferent limb of Roux-en-Y anastomoses was encountered in 6 patients. There were no post procedure complications. Conclusion: Although ERC is technically more difficult in OLT patients with Roux-en-Y anastomoses, this data suggests that ERC is an effective and safe diagnostic and therapeutic modality with minimal or no complications when performed by experienced endoscopists. ERC was successful in majority of the patients and allowed successful treatment of post-operative biliary leak and anastomotic strictures, thus averting the need for possible surgical approach for management of these complex issues.
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T1236 Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Kamil Obideen, Maarouf Hoteit, John Affronti, Qiang Cai Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a gastrointestinal endoscopic procedure that requires fluoroscopy. The radiation dose of fluoroscopy is much higher than that of routine X-ray examinations, such as a chest X-ray. A few studies regarding radiation exposure of patients and ERCP staff during ERCP have been published in recent years. However, information about radiation exposure during each step of the procedure is not well known.AIMS: This study aimed to provide data regarding radiation exposure during specific components of ERCP, such as during the deep cannulation of the common bile duct (CBD). Methods: In the last several months, patients referred to us for their first ERCP were enrolled in this study. The fluoroscopy time before, during and post deep cannulation of the CBD in each ERCP were recorded. Results: We analyzed 46 successful ERCP procedures during the study period. Those procedures can be divided into two groups: 18 were diagnostic ERCPs and 28 were therapeutic ERCPs. The latter included obtaining cytology, performing sphincterotomy, balloon extraction, and stent insertion, etc. The mean FT before deep cannulation of the CBD was minimal, less than 0.1 minutes for each procedure in both groups. The mean FTs during the deep cannulation of the CBD were 4.5G4.1 minutes and 6.4G7.9 minutes for the diagnostic group and the therapeutic group respectively. The mean FTs for the whole procedure were 6.1G5.0 minutes and 16.2G11.0 minutes for the diagnostic group and the therapeutic groups respectively. The FT during deep cannulation of the CBD accounted for a significant portion of the whole FT in both the diagnostic group (4.5/6.1, about 74%) and the therapeutic group (6.4/16.2, about 40%). Conclusions: The radiation dose of one-minute FT is approximately 15 mGy at skin entrance which is equal to almost 100 routine chest X-rays. If the cannulation time can be reduced thereby shortening the FT during deep cannulation of the CBD, it will significantly reduce the radiation exposure during ERCP.
T1238 Repeat Sphincter of Oddi Manometry in Patients with Post Cholecystectomy Syndrome and Acute Recurrent Pancreatitis After Initial Normal Study Marc F. Catalano, Urooj Ahmed, Shailendra Chauhan, Sandeep Patel, Joseph E. Geenen Sphincter of Oddi dysfunction is believed to be the cause of biliary colic-type pain following cholecystectomy in up to 1% of pts (‘‘Post Cholecystectomy Syndrome’’). SOM in these pts during ERCP can establish the diagnosis and provide immediate, effective treatment. Similarly ARP may be caused by sphincter dysfunction and sphincterotomy may be curative in a subset of pts. Accuracy of SOM in establishing a diagnosis in PCS and ARP, particularly specificity is largely unknown. AIM: 1) To determine value of repeat SOM in pts presenting with PCS and ARP after initial normal study. 2) To determine clinical response to endotherapy in these pts. Methods: Over a 16-year period, 2497 pts underwent SOM.1873 pts presented with PCS, while 624 pts presented with ARP. Ninety-seven pts with normal SOM presented for follow-up ERCP and SOM and are the subject of this study. This included 41 pts with PCS and 56 pts with ARP. SOM was performed in standard fashion using a perfusion manometry catheter with 3 ports. SO pressure R40 mmHg, high frequency contractions, or high amplitude contractions and/or paradoxical response to CCK was considered an abn study. Sphincterotomy was undertaken by first carrying out biliary sphincterotomy followed by pancreatic sphincterotomy. Over the last 5 years of this study, modified pancreatic stents were left in the PD following pancreatic SO sphincterotomy to prevent for ERCP pancreatitis. Results: Of the 41 pts with PCS presenting for repeat SOM, 16 of 41 (39%) had abn SOM, including 13 with CBD SOD, 1 with PD SOD, and 2 with dual SOD. Following ES, 10 of 16 (63%) had good long-term resolution of symptoms. Thirty-six of 56 pts (64%) in the ARP group had abn SOM, including 12 with PD SOD, 4 with CBD SOD, and 8 with dual SOD. After ES, this group had 26/36 (72%) clinical response. Conclusion: Pts with documented PCS and ARP caused by SOD may occasionally have normal sphincter of Oddi manometry. Repeat SOM may reveal abn studies in up to two-thirds of pts. ES in these pts Results in resolution of pain and/or episodes of acute pancreatitis in the majority of pts.
T1237 Risk Factor Assessement Predisposing To Recurrent CBD Stones Following Duct Clearance: New Insights Marc F. Catalano, Urooj Ahmed, Shailendra S. Chauhan, Sandeep N. Patel, Joseph E. Geenen Endoscopic sphincterotomy and stone extraction is the therapeutic treatment of choice in pts presenting with common bile duct stones. A common post sphincterotomy complication in this setting is recurrent CBD stones. The reported rate of recurrence has been described to be up to 25%. Risk factors have predominately been limited to presence of biliary ductal dilation, ampullary diverticula, and presence of non cholesterol stones. The underlying mechanism therefore suggests biliary stasis. Few other ductal anatomic variants contributing to recurrent stones have been critically evaluated. AIM: To determine by multivariate analysis the anatomic variants contributing to recurrent CBD stones. Methods: Over a 10-yr period, 1267 presented with CBD stones and underwent endoscopic extraction by ES. Of these, 43 pts were identified with recurrent CBD stones, 6 month-4yrs following initial presentation. Diagnosis of CBD stones was established by ERCP and bile duct clearance. Pts with biliary strictures were excluded from evaluation. Definition of recurrent stones was the development of stones not earlier than 3 months after complete initial stone clearance. Data collection included standard demographics (sex, age, race), presence of GB (with or w/o stones), duct diameter and angulation deviation (from vertical), number and size of stones, use of mechanical lithotripsy, and presence of diverticulum. Results: Recurrence of CBD stones was noted in 3.4% (43/1267) over a 10-yr period. Independent risk factors predisposing to recurrence of stones were as follows: 1) Presence of diverticulum (55% vs 26%), 2) Multiple stones (47% vs 18%), 3) Duct diameter R15 mm (46% vs 17%), 4) Mechanical lithotripsy (57% vs 25%), and 5) Angulation of CBD from vertical (57% vs 18%). Sex, age, presence of gallbladder, and cholangitis were not shown to increase recurrence of stones. Conclusion: Our overall Results delineate specific risk factors contributing to recurrence of CBD stones. These risk factors support the theory of biliary stasis and bacterial overgrowth as underlying mechanism. Careful follow-up and, perhaps, scheduled repeat cholangiography is recommended in pts with high risk variables presented herein.
AB200 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1239 Endoscopic Retrograde Cholangiography in Post Orthotopic Liver Transplant Population with Roux-En-Y Biliary Reconstruction: Six-Year Single Institute Experience Prabhleen Chahal, Todd Baron, Charles B. Rosen, John J. Poterucha Background and Aim: Endoscopic retrograde cholangiography (ERC) is a wellestablished modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with post-surgical anatomy like Roux-en-Y anastomoses. Its effectiveness in post orthotopic liver transplant (OLT) patients with Roux-en-Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population.Patients and Methods: 116 OLT with Roux-en-Y biliary reconstruction were performed at our institution from June 1998-October 2004. Data from consenting patients who underwent ERCP were reviewed once they were identified through computerized medical index system. Results: Of the 116 OLT patients with Roux-en-Y biliary reconstruction, 23 patients, 6 females & 17 males underwent ERC. Median age was 57 years and range was 11 months –70 years. The indication for liver transplant was primary sclerosing cholangitis in 22 and hepatitis C virus in one patient. Variable stiffness pediatric colonoscope was used in majority of patients. ERC indications were both diagnostic & therapeutic and included dilation of anastomotic biliary stricture in 8 patients, evaluation of elevated liver biochemistries and fever in 7 patients, removal of fractured biliary tube in 5, retrieval of biliary stone in 1, endoscopic management of biliary leak in post operative period via stent placement in 1, jejunal tube extension placement for nutritional purpose in 1. ERC was successful in 17 (74%) patients and failure to advance through afferent limb of Roux-en-Y anastomoses was encountered in 6 patients. There were no post procedure complications. Conclusion: Although ERC is technically more difficult in OLT patients with Roux-en-Y anastomoses, this data suggests that ERC is an effective and safe diagnostic and therapeutic modality with minimal or no complications when performed by experienced endoscopists. ERC was successful in majority of the patients and allowed successful treatment of post-operative biliary leak and anastomotic strictures, thus averting the need for possible surgical approach for management of these complex issues.
www.mosby.com/gie