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Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients 80 years of Age and Older: Safe and Effective
*T1488 Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients 80 years of Age and Older: Safe and Effective Eva Fritz, Andreas Kirchgatterer, Dietmar Hubner, Gerhard Aschl, Maximilian Hinterreiter, Bernhard Stadler, Peter Knoflach Background: Biliary disease commonly occurs in the elderly but there is limited data on ERCP in the very old population. Aims/Methods: To evaluate endoscopic findings, interventions, success and complication rates of ERCP in patients $80 years (yr) of age in comparison to patients <80 yr old. All consecutive ERCPs performed between 2000-2002 at our institution were retrospectively reviewed for patients $80 yr and were compared to all ERCPs performed in the year 2000 in patients <80 yr. Results: 135 ERCPs were performed in 98 patients $80 yr (21 males, 77 females; mean age 84.6 6 0.5 yr). Clinical presentations were cholestasis (122), abdominal pain (71), acute pancreatitis (12), cholangitis (38), cholecystitis (14), and sepsis (3). Main endoscopic findings were common bile duct stones (64), stenosis by pancreatic cancer (20), cholangiocarcinoma (6), hepatocellular carcinoma (2), papillary adenoma (2), and benign stenosis (6). Stone extraction was successful on the first attempt in 59 cases, early re-ERCP was necessary in 8 patients for retained stones. In the <80 yr group 133 patients (59 males, 74 females; mean age 62.3 6 1.3 yr) underwent 175 ERCPs. Successful biliary cannulation was achieved in 86.7% in the $80 yr group vs 84.6% in the <80 yr group (p= 0.604) and sphincterotomies were performed in 61.5% vs 55.4% (p= 0.284), respectively. In the $80 yr group 27 plastic and 5 metal stents were inserted for malignancy (20) and benign disease (12) and in the <80 yr group as well 32 stents were used for benign (8) and malign (24) stenosis. The number of important chronic concomitant diseases was significantly higher in the older group (1.3 60.1 vs 0.9 6 0.08; p=0.006). There was no significant difference in the complication rate between the $80 and the <80 yr group (5.9 vs 2.9%; p=0.109; 3 vs 1 mild post-ERCP pancreatitis, 2 vs 1 bleedings, 2 vs 0 perforations, 1 vs 1 respiratory insufficiency during ERCP, and 1 vs 2 cholangitis, respectively). Conclusions: ERCP is a safe and effective intervention in the old as complication and success rates are comparable to younger patients although comorbidity is significantly higher.
*T1489 Early Complication of Endoscopic Biliary Stenting in Patients with Inoperable Malignant Biliary Stricture Sang Woo Cha, Jong Ho Moon, Young Deok Cho, Bong Min Ko, Young Koog Cheon, Young Seok Kim, Yun Soo Kim, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Lee BACKGROUND/AIM: Early complication rates and relative risk factor after endoscopic biliary stenting in patients with inoperable malignant biliary stricture has not yet been established. The aim of this study was to evaluate the occurrence rates of important early complication and it’s relative risk factors after endoscopic biliary stenting in patients with inoperable malignant biliary stricture. METHODS: From Feb. 2001 to Aug. 2003, total 132 patients (men 90, women 42, mean age: 65.5 years) with inoperable malignant biliary stricture were performed endoscopic biliary stenting. Membrane covered self-expandable metal stent (MCSEMS) in 33 patients, membrane uncovered SEMS (UCSEMS) in 14 patients and plastic stent (PS) in 85 patients were inserted. Patients were retrospectively investigated the occurrence rates of cholecystitis and pancreatitis and it’s relative risk factors. RESULTS: 1) Causes of malignant biliary stricture were Klatskin tumor; 44, pancreatic ca; 32, distal CBD ca; 23, AV ca; 14, GB ca; 13, and metastatic ca; 6 cases. 2) As an early complication (within 30 days), pancreatitis and cholecystitis were occurred in 11 (8.3%) and 5 (3.8%) cases, respectively. Pancreatitis and cholecystitis were developed in 9/85 (10.6%) and 4/85 (4.7%) cases of PS group and 2/33 (6.1%) and 1/33 (3.0%) cases of MCSEMS group, respectively. In UCSEMS group, pancreatitis and cholecystitis were not developed. Pancreatitis and cholecystitis were was developed in 4/ 44 (9.1%) and 2/44 (4.5%) cases of Klatskin tumor, 3/32 (9.4%) and 0 cases of pancreatic ca, 2/23 (8.7%) and 2/23 (8.7%) cases of distal CBD ca, 1/14 (7.1%) and 0 case of AV ca, 0 and 1/13 (7.7%) case of GB ca, 1/6 (16.7%) and 0 case of metastatic ca, respectively. The occurrence rate of pancreatitis or cholecystitis was not significantly different between the types of inserted stent and primary tumor. 3) Pancreatitis was significantly increased in the younger than 55 years old patients (p=0.009). 4) Cystic duct invasion of primary tumor significantly increased the occurrence rate of cholecystitis (p=0.01). CONCLUSIONS: Occurrence rate of pancreatitis or cholecystitis after endoscopic biliary stenting is not related to the types of stent and causes of malignant biliary stricture. Cystic duct invasion of tumor and patients with younger than 55 years old were relative risk factors for development of acute cholecystitis and pancreatitis, respectively. Further prospective studies with large number of cases will be needed.
VOLUME 59, NO. 5, 2004
*T1490 Post-ERCP Pancreatitis: Does Prophylactic Pancreatic Duct Stent Placement Reduce the Risk? David J. Novak, Lotika Sharma, Franca B. Barton, Firas Al-Kawas Background: Recently published data suggests that prophylactic placement of pancreatic duct stents (PS) can reduce the incidence and severity of post-ERCP pancreatitis in high-risk patients. Purpose: To describe the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk patients with or without placement of PS. Methods: A retrospective chart review was performed over an 18- month period at a tertiary care university hospital. All patients who underwent ERCP and were deemed at high-risk (HR) for post-ERCP pancreatitis were included the analysis. HR patients were defined as those who underwent sphincter of Oddi mannometry (SOM), had a history of post-ERCP or recurrent pancreatitis, or had pancreatic duct manipulation. Severity of pancreatitis was defined using length of stay (LOS); mild <3 days, moderate 3-7 days, and severe $ 7 days. In our unit all endoscopy complications are recorded prospectively in the endoscopy unit data- base. All Patients with persistent post-procedure abdominal pain were admitted and had serum amylase and lipase measured. PEP was defined by the presence of abdominal pain and serum amylase and lipase of $ 33 the upper normal (33UL). As of 07/01/03, prophylactic PS were routinely placed in all HR patients (Stent Group-SG). Data from patients prior to 07/03 (reference group- RG) was compared to SG group. Results: 461 ERCPs were performed from 07/01/02- 12/01/03. 63 patients were considered high risk (HR), 45 of which had SOM. There were 43/63 patients in the SG, and 20/63 patients in the RG. The incidence of PEP in the RG was 40%, and 28% in the SG. Mean LOS was 2.7 days 6 0.4 in the SG, and 2.4 days 6 0.5 (p>0.05). The median amylase/lipase for the SG was 214/195 and 335/471 for the RG, respectively (p>0.05). Moderate /severe pancreatitis was seen in 6/43 (14%) of SG and 6/20 (30%) in the RG (p=0.13) with an OR=0.45 (p>0.05). Conclusions: The risk of PEP is higher than reported when data is recorded prospectively. However, most cases were mild. Prophylactic pancreatic stents are associated with a trend toward decreased incidence and severity of post-ERCP pancreatitis in high-risk patients. The risk of moderate/severe PEP in the RG was nearly twice that of the SG. Prospective studies of larger groups of patients will be needed to confirm these trends.
*T1491 Recurrent Pyogenic Cholangitis (RPC): Characteristics and Outcomes from Patients Undergoing Endoscopic Retrograde Cholangiograms Robert Enns, Jack Amar, Donald Carr Recurrent pyogenic cholangitis (RPC) is an uncommon problem of unknown etiology characterized by recurrent biliary tract infections. Objective: We evaluated our endoscopic retrograde cholangiogram (ERC) database to determine a) The characteristics of patients with this condition b) the outcomes of ERC. Methods: All ERCs from 10/98 to 10/03 were evaluated. Only those patients determined to have had recurrent episodes of cholangitis (with or without biliary tract structural disease), documented by repeated ERC were included. At least one of the ERCs had to be performed at our institutions for inclusion. Another subset of patients with cholangitis was also evaluated and subsequently included within a control group for comparison purposes. All patients were placed on antibiotics pre/post procedure for a minimum of 72 hours. Results: A total of 45 ERCs (range 2-5/pt) were performed in 24 patients (18 females) with a mean age of 54.7 (SD 18.7 years (range 21-85). Only one was Canadian born (French Canadian) and the others were all born in Southeast Asia. All patients underwent ERC/sphincterotomy with 30% (7/24) of the group having stones within the intrahepatic ducts and 57% (4/7) of this group requiring $3 ERCs. Only 7 patients had ERC diagnosed strictures (all benign) of which 2 involved the common bile duct and 5 the intrahepatic ducts. Only 4 patients were frankly jaundiced, however, 32% had an elevated bilirubin and 92% (22/24) had abnormal transaminases. When compared to a control group ofcholangitis patients, RPC patients tended to be younger (54.7 vs 65.3 yrs, p=0.04), more commonly female (75% vs 46%, p=0.035) and more likely to be from Southeast Asia (92% vs 35%, p=0.001). Only one RPC patient had evidence of clonorchis within stool samples. Only one patient underwent surgery for a segmental hepatic resection. No cases of cholangiocarcinoma have occurred (mean follow up 24 months). Conclusion: In our center, RPC occurs more commonly in young women who were born in Southeast Asia. It typically presents with signs of cholangitis (primarily elevated liver enzymes). ERC is a very effective method to diagnose and treat this condition. Surgery, even for strictures of intrahepatic ducts, may be reserved for very select patients.
GASTROINTESTINAL ENDOSCOPY
P195
*T1489 Early Complication of Endoscopic Biliary Stenting in Patients with Inoperable Malignant Biliary Stricture Sang Woo Cha, Jong Ho Moon, Young Deok Cho, Bong Min Ko, Young Koog Cheon, Young Seok Kim, Yun Soo Kim, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Lee BACKGROUND/AIM: Early complication rates and relative risk factor after endoscopic biliary stenting in patients with inoperable malignant biliary stricture has not yet been established. The aim of this study was to evaluate the occurrence rates of important early complication and it’s relative risk factors after endoscopic biliary stenting in patients with inoperable malignant biliary stricture. METHODS: From Feb. 2001 to Aug. 2003, total 132 patients (men 90, women 42, mean age: 65.5 years) with inoperable malignant biliary stricture were performed endoscopic biliary stenting. Membrane covered self-expandable metal stent (MCSEMS) in 33 patients, membrane uncovered SEMS (UCSEMS) in 14 patients and plastic stent (PS) in 85 patients were inserted. Patients were retrospectively investigated the occurrence rates of cholecystitis and pancreatitis and it’s relative risk factors. RESULTS: 1) Causes of malignant biliary stricture were Klatskin tumor; 44, pancreatic ca; 32, distal CBD ca; 23, AV ca; 14, GB ca; 13, and metastatic ca; 6 cases. 2) As an early complication (within 30 days), pancreatitis and cholecystitis were occurred in 11 (8.3%) and 5 (3.8%) cases, respectively. Pancreatitis and cholecystitis were developed in 9/85 (10.6%) and 4/85 (4.7%) cases of PS group and 2/33 (6.1%) and 1/33 (3.0%) cases of MCSEMS group, respectively. In UCSEMS group, pancreatitis and cholecystitis were not developed. Pancreatitis and cholecystitis were was developed in 4/ 44 (9.1%) and 2/44 (4.5%) cases of Klatskin tumor, 3/32 (9.4%) and 0 cases of pancreatic ca, 2/23 (8.7%) and 2/23 (8.7%) cases of distal CBD ca, 1/14 (7.1%) and 0 case of AV ca, 0 and 1/13 (7.7%) case of GB ca, 1/6 (16.7%) and 0 case of metastatic ca, respectively. The occurrence rate of pancreatitis or cholecystitis was not significantly different between the types of inserted stent and primary tumor. 3) Pancreatitis was significantly increased in the younger than 55 years old patients (p=0.009). 4) Cystic duct invasion of primary tumor significantly increased the occurrence rate of cholecystitis (p=0.01). CONCLUSIONS: Occurrence rate of pancreatitis or cholecystitis after endoscopic biliary stenting is not related to the types of stent and causes of malignant biliary stricture. Cystic duct invasion of tumor and patients with younger than 55 years old were relative risk factors for development of acute cholecystitis and pancreatitis, respectively. Further prospective studies with large number of cases will be needed.
VOLUME 59, NO. 5, 2004
*T1490 Post-ERCP Pancreatitis: Does Prophylactic Pancreatic Duct Stent Placement Reduce the Risk? David J. Novak, Lotika Sharma, Franca B. Barton, Firas Al-Kawas Background: Recently published data suggests that prophylactic placement of pancreatic duct stents (PS) can reduce the incidence and severity of post-ERCP pancreatitis in high-risk patients. Purpose: To describe the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk patients with or without placement of PS. Methods: A retrospective chart review was performed over an 18- month period at a tertiary care university hospital. All patients who underwent ERCP and were deemed at high-risk (HR) for post-ERCP pancreatitis were included the analysis. HR patients were defined as those who underwent sphincter of Oddi mannometry (SOM), had a history of post-ERCP or recurrent pancreatitis, or had pancreatic duct manipulation. Severity of pancreatitis was defined using length of stay (LOS); mild <3 days, moderate 3-7 days, and severe $ 7 days. In our unit all endoscopy complications are recorded prospectively in the endoscopy unit data- base. All Patients with persistent post-procedure abdominal pain were admitted and had serum amylase and lipase measured. PEP was defined by the presence of abdominal pain and serum amylase and lipase of $ 33 the upper normal (33UL). As of 07/01/03, prophylactic PS were routinely placed in all HR patients (Stent Group-SG). Data from patients prior to 07/03 (reference group- RG) was compared to SG group. Results: 461 ERCPs were performed from 07/01/02- 12/01/03. 63 patients were considered high risk (HR), 45 of which had SOM. There were 43/63 patients in the SG, and 20/63 patients in the RG. The incidence of PEP in the RG was 40%, and 28% in the SG. Mean LOS was 2.7 days 6 0.4 in the SG, and 2.4 days 6 0.5 (p>0.05). The median amylase/lipase for the SG was 214/195 and 335/471 for the RG, respectively (p>0.05). Moderate /severe pancreatitis was seen in 6/43 (14%) of SG and 6/20 (30%) in the RG (p=0.13) with an OR=0.45 (p>0.05). Conclusions: The risk of PEP is higher than reported when data is recorded prospectively. However, most cases were mild. Prophylactic pancreatic stents are associated with a trend toward decreased incidence and severity of post-ERCP pancreatitis in high-risk patients. The risk of moderate/severe PEP in the RG was nearly twice that of the SG. Prospective studies of larger groups of patients will be needed to confirm these trends.
*T1491 Recurrent Pyogenic Cholangitis (RPC): Characteristics and Outcomes from Patients Undergoing Endoscopic Retrograde Cholangiograms Robert Enns, Jack Amar, Donald Carr Recurrent pyogenic cholangitis (RPC) is an uncommon problem of unknown etiology characterized by recurrent biliary tract infections. Objective: We evaluated our endoscopic retrograde cholangiogram (ERC) database to determine a) The characteristics of patients with this condition b) the outcomes of ERC. Methods: All ERCs from 10/98 to 10/03 were evaluated. Only those patients determined to have had recurrent episodes of cholangitis (with or without biliary tract structural disease), documented by repeated ERC were included. At least one of the ERCs had to be performed at our institutions for inclusion. Another subset of patients with cholangitis was also evaluated and subsequently included within a control group for comparison purposes. All patients were placed on antibiotics pre/post procedure for a minimum of 72 hours. Results: A total of 45 ERCs (range 2-5/pt) were performed in 24 patients (18 females) with a mean age of 54.7 (SD 18.7 years (range 21-85). Only one was Canadian born (French Canadian) and the others were all born in Southeast Asia. All patients underwent ERC/sphincterotomy with 30% (7/24) of the group having stones within the intrahepatic ducts and 57% (4/7) of this group requiring $3 ERCs. Only 7 patients had ERC diagnosed strictures (all benign) of which 2 involved the common bile duct and 5 the intrahepatic ducts. Only 4 patients were frankly jaundiced, however, 32% had an elevated bilirubin and 92% (22/24) had abnormal transaminases. When compared to a control group ofcholangitis patients, RPC patients tended to be younger (54.7 vs 65.3 yrs, p=0.04), more commonly female (75% vs 46%, p=0.035) and more likely to be from Southeast Asia (92% vs 35%, p=0.001). Only one RPC patient had evidence of clonorchis within stool samples. Only one patient underwent surgery for a segmental hepatic resection. No cases of cholangiocarcinoma have occurred (mean follow up 24 months). Conclusion: In our center, RPC occurs more commonly in young women who were born in Southeast Asia. It typically presents with signs of cholangitis (primarily elevated liver enzymes). ERC is a very effective method to diagnose and treat this condition. Surgery, even for strictures of intrahepatic ducts, may be reserved for very select patients.
GASTROINTESTINAL ENDOSCOPY
P195