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M1475: The Necessity of Pancreatic Duct Visualization in the Treatment of Pancreatic Fluid Collections Complicating Acute Pancreatitis
Abstracts M1473 Transgastrostomy Therapeutic ERCP in Patients With Roux-en-Y Anatomy: Long Term Experience Bezawit D. Tekola, Andrew Y. Wang, Madhuri Ramanath, Brent Burnette, Michele E. Rehan, Kristi Ellen, Bruce D. Schirmer, Peter T. Hallowell, Bryan G. Sauer, Michel Kahaleh Background: Roux-en-Y gastric bypass (RYGB) surgery is the most commonly performed bariatric surgery in the US. Surgical gastrostomy (SG) tube placement enables transgastrostomy ERCP (TG-ERCP) using conventional duodenoscopes. Our aim was to determine the efficacy and safety of TG-ERCP in patients who undergo SG tube placement for therapeutic ERCP.Patients and Methods: Ten patients with RYGB anatomy and pancreatobiliary disease underwent Stamm gastrostomy. The gastrostomy tube tract was allowed to mature over a median of 46 days (range: 29-135) prior to be dilated to allow duodenoscope passage and therapeutic ERCP.Results: Ten patients (median age 52 years, range: 37-61 years) with prior RYGB underwent TG-ERCP. Patients had gallstone pancreatitis (n⫽4), ampullary strictures (n⫽4), pancreas divisum (n⫽1), and common bile duct clipping (n⫽1). Open gastrostomy with Malecot tube placement was successful in all patients. Three patients developed post surgical complication at the gastrostomy site (2 infections and 1 bleeding). TG-ERCP with therapeutic intervention was successfully performed in all ten patients. Interventions included stone extractions (n⫽10), biliary stricture dilation (n⫽10), biliary sphincterotomy (n⫽10), biliary (n⫽2) and pancreatic (n⫽1) stent placement, ampullary biopsies (n⫽3), and pseudocyst drainage (n⫽1). Complications included post-ERCP pancreatitis (n⫽2), post-sphincterotomy bleeding (n⫽1), gastrostomy site bleed (n⫽1), and contained gastric perforation (n⫽1). The total number of ERCP for the ten patients was 13 (range: 1-2). The median follow-up was 3.25 months (range: 0.3-48 months).Conclusion: TG-ERCP is a effective technique for patients requiring therapeutic ERCP but is associated with relevant complications and is limited by the time needed for the gastrostomy tract maturation.
M1474 Is Spiral Enteroscopy Superior to Single Balloon Assisted ERCP in Patients With Altered Anatomy? Anne Marie Lennon, Sumit Kapoor, Vikesh K. Singh, Mouen Khashab, Vinay Chandrasekhara, Anthony N. Kalloo, Marcia I. Canto, Patrick I. Okolo Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) can be technically challenging in patients with postsurgical anatomy. Recent advances in enteroscopy have made it possible to access the pancreaticobiliary limb allowing diagnostic and therapeutic intervention. METHODS: Consecutive patients with altered gastrointestinal anatomy referred to a single tertiary referral center between 10/2007 and 8/2009, who underwent single balloon (SBE-ERCP) or spiral (SE-ERCP) assisted ERCP were evaluated. Only patients with Roux-en-y (R-en-Y) anatomy or those with other altered anatomy who had failed conventional ERCP were included. Success in reaching the native ampulla (NA) or surgical anastomosis (SA), selective cannulation, completion of an intervention, and type and incidence of complications were compared for SBEERCP and SE-ERCP. RESULTS: 27 patients (21 female; mean age 53.4 (range 2788)) underwent 44 ERCP procedures (24 SBE, 20 SE). 34 procedures were performed in R-en-Y (77.3%) anatomy (20 or 46% had gastric bypass). 7(16%) procedures were performed in patients with Billroth II (B-II), and 3 (6.7%) in other anatomy (choledochoenterostomy, duodenal switch). Overall, patients with NA (n⫽20) or SA (n⫽24) was successfully reached in 23/44(52.3%) of all procedures (44% with R-en-Y anatomy, 85.7% of B-II, and 66.7% of other
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anatomy). There was no significant difference between the ability of SE (10/20 OR 50%) or SBE (13/24 OR 54.2%) to reach the NA or SA (p⫽0.783). When the NA/SA was reached by either method, the bile duct and pancreatic duct were successfully cannulated in 87% and 4/4(100%) when indicated. Therapeutic intervention was successful in 13/14 patients (balloon dilation (n⫽5), biliary sphincterotomy (n⫽4), balloon sphincteroplasty (n⫽2), sphincterotomy/balloon sphincteroplasty (n⫽1), stent insertion(n⫽2). In 21 patients with either unsuccessful SE or SBE, 3/11 (27.3%) were successful at second enteroscopyERCP. Operator experience increased success in SBE but not SE. The median procedure time for all enteroscopy-ERCP (median 81 mins, range 32-135), with no difference between SE-ERCP and SBE-ERCP (median 77 range 32-135 vs.93 min, range 58-130, respectively, p⫽0.26) There was one perforation in a patient with R-en-Y anatomy who had SE-ERCP. CONCLUSION: SBE-ERCP and SE-ERCP have similar success rates in patients with altered anatomy. Operator experience appears to be important in SBE but not SE.
M1475 The Necessity of Pancreatic Duct Visualization in the Treatment of Pancreatic Fluid Collections Complicating Acute Pancreatitis Erienne M. De Cuba, Rogier P. Voermans, Erik Rauws, Paul Fockens BACKGROUND: Pancreatic fluid collections (PFCs) communicating with the pancreatic duct (PD) tend to recur more often after endoscopic drainage than non-communicating collections. It is still subject of debate whether early visualization of PD anatomy and subsequent treatment of the PD disruption favors outcome of endoscopic drainge. AIM: To evaluate whether visualization of the PD and subsequent treatment reduces recurrence rate of PFCs after endoscopic drainage.METHODS: We performed a retrospective study on our prospective database with all patients who underwent endoscopic drainage of PFCs complicating acute pancreatitis from 2001 until January 2009. Primary endpoint was recurrence of PFCs post endoscopic drainage. Secondary endpoints included number of additional interventions. During the study period it was standard of care to visualize the PD only in case of complicated PFCs.RESULTS: We identified 147 patients with PFCs complicating acute pancreatitis that underwent endoscopic drainage. 115 of 147 patients (78%) did not have their PD visualized during treatment. In 13% of these patients the PFC recurred (15 of 115 patients). In 32 of 147 patients(22%) the PD was visualized (ERCP⫽ 29, MRCP⫽3) and shown to be disrupted. Nine of these 32 patients(28%)suffered from a recurring PFC after PD visualization(p⫽0.06). In 10 patients knowledge of the PD abnormality did not alter treatment of a recurrent PFC. Six of these PFCs were treated transgastrically (TG), 3 conservatively and 1 percutaneously. Three of 10(33%) had recurrence. In the remaining 22 cases the PFC and PD disruption was treated either endoscopically (14 transpapillary (TP), 3 TG and TP) or surgically(5). Six of 22 (27%) had recurring PFCs, despite treatment of the PD disruption. Looking at timing of ERCP/MRCP, in 10 patients the PD was visualized before initial drainage of PFC (4 TP, 2 TP&TG, 3 TG and 1 other). Four of 10 patients 40% showed recurrence, despite knowledge of PD anatomy. The PD was visualized after initial endoscopic drainage in 22 patients, all because of recurrent PFC. Ten of these patients were treated TP, 1 TP and TG, 3 TG, 5 surgically and 3 conservatively. Five of 22 patients(23%)showed a second recurrence.CONCLUSIONS: Recurrence rate after endoscopic drainage of uncomplicated PFCs without visualization of the PD is acceptable(13%). In complicated cases the recurrence rate was 28%. It remains unclear whether PD visualization could reduce recurrence rate in these difficult patients and what timing should be. Prospective studies are needed to assess whether the diagnosis and treatment of PD abnormalities improves outcome of PFCs complicating acute pancreatitis.
M1476 ERCP Catheter Based Intraductal Endoscopy: Indications and Initial Experience Gennadiy Bakis, Douglas A. Howell, Eric Wright, Jay J. Bosco, Andreas M. Stefan Background: Intraductal endoscopy of the CBD (IE-CBD) and pancreatic duct (IE-PD) has been available for selected cases but, in the past, limited by fragile endoscopes, therapeutic potential, duct size, procedure time and expense. Recent introduction of a 10F disposable baby endoscope with a 1 mm reusable optical bundle (SpyGlass, Boston Scientific) effectively addresses breakage and increases therapeutic options. Early experience with placing the Spyglass optical bundle through standard ERCP devices may address the latter three issues. Patients and Methods: Pts undergoing ERCP who might benefit from intraductal endoscopy with small ducts (less than 10Fr/3.3 mm) and/or simple diagnostic questions were identified. After appropriate ERCP access and, when warranted, initial therapy, the 1mm Spyglass fiber bundle was simply inserted into the .035” guidewire lumen of the device being used. Coaxial injection to clear the view was carefully hand-injected by the physician without the use of a foot pump in the setting of small ducts. Position of the device and probe was monitored by fluoroscopy. Additional therapy was then performed or arranged depending upon findings. Patients: 12 pts, aged 33 to 71, M:7, F:5 were studied for the
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB231
M1474 Is Spiral Enteroscopy Superior to Single Balloon Assisted ERCP in Patients With Altered Anatomy? Anne Marie Lennon, Sumit Kapoor, Vikesh K. Singh, Mouen Khashab, Vinay Chandrasekhara, Anthony N. Kalloo, Marcia I. Canto, Patrick I. Okolo Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) can be technically challenging in patients with postsurgical anatomy. Recent advances in enteroscopy have made it possible to access the pancreaticobiliary limb allowing diagnostic and therapeutic intervention. METHODS: Consecutive patients with altered gastrointestinal anatomy referred to a single tertiary referral center between 10/2007 and 8/2009, who underwent single balloon (SBE-ERCP) or spiral (SE-ERCP) assisted ERCP were evaluated. Only patients with Roux-en-y (R-en-Y) anatomy or those with other altered anatomy who had failed conventional ERCP were included. Success in reaching the native ampulla (NA) or surgical anastomosis (SA), selective cannulation, completion of an intervention, and type and incidence of complications were compared for SBEERCP and SE-ERCP. RESULTS: 27 patients (21 female; mean age 53.4 (range 2788)) underwent 44 ERCP procedures (24 SBE, 20 SE). 34 procedures were performed in R-en-Y (77.3%) anatomy (20 or 46% had gastric bypass). 7(16%) procedures were performed in patients with Billroth II (B-II), and 3 (6.7%) in other anatomy (choledochoenterostomy, duodenal switch). Overall, patients with NA (n⫽20) or SA (n⫽24) was successfully reached in 23/44(52.3%) of all procedures (44% with R-en-Y anatomy, 85.7% of B-II, and 66.7% of other
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anatomy). There was no significant difference between the ability of SE (10/20 OR 50%) or SBE (13/24 OR 54.2%) to reach the NA or SA (p⫽0.783). When the NA/SA was reached by either method, the bile duct and pancreatic duct were successfully cannulated in 87% and 4/4(100%) when indicated. Therapeutic intervention was successful in 13/14 patients (balloon dilation (n⫽5), biliary sphincterotomy (n⫽4), balloon sphincteroplasty (n⫽2), sphincterotomy/balloon sphincteroplasty (n⫽1), stent insertion(n⫽2). In 21 patients with either unsuccessful SE or SBE, 3/11 (27.3%) were successful at second enteroscopyERCP. Operator experience increased success in SBE but not SE. The median procedure time for all enteroscopy-ERCP (median 81 mins, range 32-135), with no difference between SE-ERCP and SBE-ERCP (median 77 range 32-135 vs.93 min, range 58-130, respectively, p⫽0.26) There was one perforation in a patient with R-en-Y anatomy who had SE-ERCP. CONCLUSION: SBE-ERCP and SE-ERCP have similar success rates in patients with altered anatomy. Operator experience appears to be important in SBE but not SE.
M1475 The Necessity of Pancreatic Duct Visualization in the Treatment of Pancreatic Fluid Collections Complicating Acute Pancreatitis Erienne M. De Cuba, Rogier P. Voermans, Erik Rauws, Paul Fockens BACKGROUND: Pancreatic fluid collections (PFCs) communicating with the pancreatic duct (PD) tend to recur more often after endoscopic drainage than non-communicating collections. It is still subject of debate whether early visualization of PD anatomy and subsequent treatment of the PD disruption favors outcome of endoscopic drainge. AIM: To evaluate whether visualization of the PD and subsequent treatment reduces recurrence rate of PFCs after endoscopic drainage.METHODS: We performed a retrospective study on our prospective database with all patients who underwent endoscopic drainage of PFCs complicating acute pancreatitis from 2001 until January 2009. Primary endpoint was recurrence of PFCs post endoscopic drainage. Secondary endpoints included number of additional interventions. During the study period it was standard of care to visualize the PD only in case of complicated PFCs.RESULTS: We identified 147 patients with PFCs complicating acute pancreatitis that underwent endoscopic drainage. 115 of 147 patients (78%) did not have their PD visualized during treatment. In 13% of these patients the PFC recurred (15 of 115 patients). In 32 of 147 patients(22%) the PD was visualized (ERCP⫽ 29, MRCP⫽3) and shown to be disrupted. Nine of these 32 patients(28%)suffered from a recurring PFC after PD visualization(p⫽0.06). In 10 patients knowledge of the PD abnormality did not alter treatment of a recurrent PFC. Six of these PFCs were treated transgastrically (TG), 3 conservatively and 1 percutaneously. Three of 10(33%) had recurrence. In the remaining 22 cases the PFC and PD disruption was treated either endoscopically (14 transpapillary (TP), 3 TG and TP) or surgically(5). Six of 22 (27%) had recurring PFCs, despite treatment of the PD disruption. Looking at timing of ERCP/MRCP, in 10 patients the PD was visualized before initial drainage of PFC (4 TP, 2 TP&TG, 3 TG and 1 other). Four of 10 patients 40% showed recurrence, despite knowledge of PD anatomy. The PD was visualized after initial endoscopic drainage in 22 patients, all because of recurrent PFC. Ten of these patients were treated TP, 1 TP and TG, 3 TG, 5 surgically and 3 conservatively. Five of 22 patients(23%)showed a second recurrence.CONCLUSIONS: Recurrence rate after endoscopic drainage of uncomplicated PFCs without visualization of the PD is acceptable(13%). In complicated cases the recurrence rate was 28%. It remains unclear whether PD visualization could reduce recurrence rate in these difficult patients and what timing should be. Prospective studies are needed to assess whether the diagnosis and treatment of PD abnormalities improves outcome of PFCs complicating acute pancreatitis.
M1476 ERCP Catheter Based Intraductal Endoscopy: Indications and Initial Experience Gennadiy Bakis, Douglas A. Howell, Eric Wright, Jay J. Bosco, Andreas M. Stefan Background: Intraductal endoscopy of the CBD (IE-CBD) and pancreatic duct (IE-PD) has been available for selected cases but, in the past, limited by fragile endoscopes, therapeutic potential, duct size, procedure time and expense. Recent introduction of a 10F disposable baby endoscope with a 1 mm reusable optical bundle (SpyGlass, Boston Scientific) effectively addresses breakage and increases therapeutic options. Early experience with placing the Spyglass optical bundle through standard ERCP devices may address the latter three issues. Patients and Methods: Pts undergoing ERCP who might benefit from intraductal endoscopy with small ducts (less than 10Fr/3.3 mm) and/or simple diagnostic questions were identified. After appropriate ERCP access and, when warranted, initial therapy, the 1mm Spyglass fiber bundle was simply inserted into the .035” guidewire lumen of the device being used. Coaxial injection to clear the view was carefully hand-injected by the physician without the use of a foot pump in the setting of small ducts. Position of the device and probe was monitored by fluoroscopy. Additional therapy was then performed or arranged depending upon findings. Patients: 12 pts, aged 33 to 71, M:7, F:5 were studied for the
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB231