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Mo1453 Single Center Experience With Spyglass for Biliary Disease
Abstracts
the remaining 115 patients with long term follow-up, the most common etiologies of common bile duct stricture were adenocarcinoma followed by primary sclerosing cholangitis. (see table). Conclusions Most of the patients with initial presentation of ”idiopathic” common bile duct stricture had malignancy or primary sclerosing cholangitis on long term follow up in this study. Long term follow up of patients with ”idiopathic” common bile duct stricture is necessary. Outcome Malignant: Pancreatic Adenocarcinoma Cholangiocarcinoma Ampullary Adenocarcinoma Metastatic Disease Lymphoma Other Adenocarcinoma Pancreatic Neuroendocrine Tumor Non-Malignant: Primary Sclerosing Cholangitis Chronic Pancreatitis Biliary Stone Acute Pancreatitis Choledochal Cyst Benign without identified etiology1 Other2
Number
Percent of Total
57 32 11 4 4 3 2 1 58 20 9 5 2 2 12 8
49.6 27.6 9.5 3.4 3.4 2.6 1.7 0.9 50.4 17.4 7.8 4.3 1.7 1.7 10.4 7.0
1. Average follow-up 45.8 months, range 6-120 months 2. Single cases of cardiac cirrhosis, periampullary diverticulum, drug-induced cholestatic liver failure, graftversus-host disease, sarcoid pancreatitis, trauma, benign variant ductal system, and radiation changes.
Mo1452 Differences in ERCP Practice Preferences Among Physicians Who Perform ERCP With Varying Frequency: A National Survey Gregory A. Cote1, Rajesh N. Keswani2, Lee McHenry1, Tina M. Jackson1, Evan L. Fogel1, Glen A. Lehman1, James L. Watkins1, Stuart Sherman1 1 Gastroenterology, Indiana University, Indianapolis, IN; 2 Gastroenterology, Northwestern University, Chicago, IL Background: Differences in practice patterns between gastroenterologists who perform ERCP at varying frequency are largely unknown. Our objective was to compare self-reported utilization of specific ERCP maneuvers and devices based on annual ERCP volume. Methods: We conducted an online survey of U.S. gastroenterologists who are active members of the ASGE. The survey was a 32question, self-administered instrument. Based on self-reported annual volume, physicians were classified into high (HV, ⬎ 200 cases/year), moderate (MV, 50200) and low (LV, ⬍ 50) volume ERCP practitioners. We compared the utilization of ERCP techniques and device preferences: approach to common bile duct (CBD) cannulation including wire-guided cannulation (WGC) and short wire (260mm) systems; use of prophylactic pancreatic duct stenting (PDS), and needle knife sphincterotomy (NKS). Results: We contacted 5,429 physicians, of which 1,006 (18.5%) responded. Responders who perform ERCP and provided data on individual annual volume (n⫽669) were categorized into HV (n⫽131), MV (n⫽284) and LV (n⫽254). For CBD cannulation, short wire devices were more commonly the preferred cannulation device for LVs (50.0%) and MVs (53.2%) vs. HVs (39.4%, p⫽0.03). While WGC (vs. conventional insert-and-inject) was the cannulation technique preferred by 75.5% of all physicians, HVs were less likely (65.9%) than MVs (80.8%) and LVs (74.4%) to use WGC as their initial approach (p⫽0.004). HVs were more likely to persist longer and with greater attempts at CBD cannulation before terminating the procedure: only 6.5% of LVs would attempt for ⬎ 60 minutes, vs. 9.7% (MVs) and 13.2% (HVs) (p⬍0.04). Similarly, 19.3% of HVs would attempt CBD cannulation ⬎ 30 times prior to termination vs. 5.5% (MV) and 6.6% (LV) (p⫽0.001). For failed CBD cannulation, 71.5% of HVs repeat ERCP themselves, vs. 40.2% (MVs) and 17.8% (LVs); LVs are more likely to refer to an academic center (39.8%) or ask a partner to repeat the ERCP (32.5%, p⬍0.001).The probability of using prophylactic PDS increased with annual ERCP volume: 46.1% of LVs performed PDS vs. 77.1% (MVs) and 96.0% (HVs) (p ⬍ 0.0001, each pairwise comparison). Similarly, 57.1% of LVs reported being at least “somewhat comfortable” with PDS, vs. 92.3% (MVs) and 98.3% (HVs) (pⱕ 0.02, each pairwise comparison).34.1% of LVs reported being at least “somewhat comfortable” with freehand NKS, vs. 60.7% (MVs) and 90.2% (HVs) (p ⬍ 0.0001, each pairwise comparison). Self-reported comfort level with NKS was not different among LVs who perform prophylactic PDS (37.7%) and those who do not (30.9%, p⫽0.28). Conclusions: While the use of WGC and short wire devices is common among LV practitioners, fewer are comfortable with placing prophylactic PDS. Education on the appropriate use of these preventive (PDS) and higher risk (NKS) techniques in lower volume practitioners is needed.
Mo1453 Single Center Experience With Spyglass for Biliary Disease Isaac Raijman, Dang Nguyen, Douglas S. Fishman Digestive Associates of Houston, Houston, TX Introduction: Spyglass (BSC, Natick, MA, USA) is a disposable choledochoscope that has been available since early 2007. We report our experience in a single center of 322 patients. Methods: From 3/2007 until 11/2010, 322 biliary Spyglass procedures were performed at our institution, representing 16.7% of the biliary ERCP volume during the same period (322/1927). Most common indications for the procedure included difficult biliary stone disease in 164/322 (51%), primary sclerosing cholangitis/indeterminate strictures in 125/322 (39%) and other in 33/ 322 (10%). All procedures were performed under monitored anesthesia, all received prophylactic antibiotics, and the majority performed on an outpatient basis. The procedure was performed per-orally in 315 and percutaneously in 7. In the per-oral group, all underwent or had a biliary sphincterotomy. In patients requiring lithotripsy, electrohydraulic (Northech autolithNorthgate, Elgin, IL) and holmium laser (Versapulse, slimline GI, Santa Clara, CA) were used. Percutaneous Spyglass was performed on a mature tract after dilatation to 12 Fr and all were performed with the assistance of the interventional radiologist. Results: The procedure was successful in all patients. Of the patients with biliary stones, ductal clearance was achieved in 150/164 patients (92%) after one session, with 14 (7%) of the group requiring more than one procedure. Of the patients with indeterminate biliary strictures, a malignant diagnosis was established in 67% and benign in 33% by combination of visual characteristics and directed biopsies (4 biopsies per patient) (Spybite, BSC, Natick, MA, USA). Spyglass confirmed the suspected diagnosis of malignant stricture in 65 patients (40%) while changed the diagnosis in 57/164 (35%) to benign. The suspected benign diagnosis in 42 (25%) was confirmed. Other indications included liver transplant patients (13), hemobilia (1), choledochal cyst (3), and staging of cholangiocarcinoma (5), and indeterminate filling defects (11). In the liver transplant group, a diagnosis of stricture was modified by recognizing cast-like stones in 6, thus modifying the management in 46% of these patients. In the cholangiocarcinoma patients, Spyglass upstaged the diagnosis in 2/5 patients (40%) thus avoiding surgery. Overall, Spyglass modified the original diagnosis in 40% of the patients, and completed desired therapy in 100% of the patients. Morbidity occurred in 4/322 patients (1.2 %), perforation in 1 and cholangitis in 3. The perforation required surgical drainage. There was no mortality. Conclusions: Spyglass is a useful adjuvant to ERCP in the management of difficult stone disease, determining the nature of biliary strictures and modifying the overall diagnosis in 40% of the patients. The associated morbidity is acceptable.
Mo1454 Randomized Controlled Study of Endoscopic Sphincterotomy With Endocut Mode or Conventional Blended Cut Mode Yoshiki Tanaka1, Ken Sato1, Hiroyuki Tsuchida1, Masafumi Mizuide1, Katsutoshi Ishida2, Hidetoshi Yasuoka2, Motoyasu Kusano3, Masatomo Mori1 1 Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan; 2Department of Internal Medicine, Tone Chuo Hospital, Numata, Japan; 3Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Japan Background: Although the potential advantages of Endocut mode of endoscopic sphincterotomy (EST) have been reported, the problems including the small sample size, retrospective analysis in previous studies makes it difficult to conclude the advantage of efficacy and safety of Endocut mode. Aim: To evaluate whether Endocut mode surpasses conventional blended cut mode in efficacy and safety. Patients and Methods: The patients with choledocholithiasis or stenosis of the bile duct were randomly assigned to one of the modes. We restricted only one experienced operator to avoid technical bias. We used the success rate and the real operating time of EST for the assessment of efficacy and serum amylase level and complications for the assessment of safety. Results: There were no significant differences on background such as age, sex, the ratio between the two underlined diseases and serum amylase level before EST between the two groups. A total of 326 patients (M:F ⫽ 187:139, averaged 73.3 years old) were randomly assigned to EST with Endocut mode (n ⫽ 164) or conventional blended cut mode (n ⫽ 162). Because of various reasons such as pre-cut sphincterotomy or EST not appropriate, 305 patients were finally randomized to EST with endocut mode (n ⫽ 152) or conventional blended cut mode (n ⫽ 153). There was no significant difference of the success rate of EST or the real operating time between the two groups. The mean serum amylase levels at 24 hours after EST were significantly lower in the Endocut mode group (p⫽0.03). However, complications were founded in 27 (17.8%) patients of the Endocut mode group: hyperamylasemia in 21 (13.8%), mild pancreatitis in 5 (3.3%),moderate pancreatitis in 1 (0.7%), whereas they were founded in 35 (22.9%) patients of the conventional blended cut mode: hyperamylasemia in 29 (19.0%), mild pancreatitis in 6 (4.0%). There was no significant difference of incidence of hyperamylasemia or pancreatitis between the two groups. There were no severe complications such as clinical bleeding or severe pancreatitis
AB350 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
the remaining 115 patients with long term follow-up, the most common etiologies of common bile duct stricture were adenocarcinoma followed by primary sclerosing cholangitis. (see table). Conclusions Most of the patients with initial presentation of ”idiopathic” common bile duct stricture had malignancy or primary sclerosing cholangitis on long term follow up in this study. Long term follow up of patients with ”idiopathic” common bile duct stricture is necessary. Outcome Malignant: Pancreatic Adenocarcinoma Cholangiocarcinoma Ampullary Adenocarcinoma Metastatic Disease Lymphoma Other Adenocarcinoma Pancreatic Neuroendocrine Tumor Non-Malignant: Primary Sclerosing Cholangitis Chronic Pancreatitis Biliary Stone Acute Pancreatitis Choledochal Cyst Benign without identified etiology1 Other2
Number
Percent of Total
57 32 11 4 4 3 2 1 58 20 9 5 2 2 12 8
49.6 27.6 9.5 3.4 3.4 2.6 1.7 0.9 50.4 17.4 7.8 4.3 1.7 1.7 10.4 7.0
1. Average follow-up 45.8 months, range 6-120 months 2. Single cases of cardiac cirrhosis, periampullary diverticulum, drug-induced cholestatic liver failure, graftversus-host disease, sarcoid pancreatitis, trauma, benign variant ductal system, and radiation changes.
Mo1452 Differences in ERCP Practice Preferences Among Physicians Who Perform ERCP With Varying Frequency: A National Survey Gregory A. Cote1, Rajesh N. Keswani2, Lee McHenry1, Tina M. Jackson1, Evan L. Fogel1, Glen A. Lehman1, James L. Watkins1, Stuart Sherman1 1 Gastroenterology, Indiana University, Indianapolis, IN; 2 Gastroenterology, Northwestern University, Chicago, IL Background: Differences in practice patterns between gastroenterologists who perform ERCP at varying frequency are largely unknown. Our objective was to compare self-reported utilization of specific ERCP maneuvers and devices based on annual ERCP volume. Methods: We conducted an online survey of U.S. gastroenterologists who are active members of the ASGE. The survey was a 32question, self-administered instrument. Based on self-reported annual volume, physicians were classified into high (HV, ⬎ 200 cases/year), moderate (MV, 50200) and low (LV, ⬍ 50) volume ERCP practitioners. We compared the utilization of ERCP techniques and device preferences: approach to common bile duct (CBD) cannulation including wire-guided cannulation (WGC) and short wire (260mm) systems; use of prophylactic pancreatic duct stenting (PDS), and needle knife sphincterotomy (NKS). Results: We contacted 5,429 physicians, of which 1,006 (18.5%) responded. Responders who perform ERCP and provided data on individual annual volume (n⫽669) were categorized into HV (n⫽131), MV (n⫽284) and LV (n⫽254). For CBD cannulation, short wire devices were more commonly the preferred cannulation device for LVs (50.0%) and MVs (53.2%) vs. HVs (39.4%, p⫽0.03). While WGC (vs. conventional insert-and-inject) was the cannulation technique preferred by 75.5% of all physicians, HVs were less likely (65.9%) than MVs (80.8%) and LVs (74.4%) to use WGC as their initial approach (p⫽0.004). HVs were more likely to persist longer and with greater attempts at CBD cannulation before terminating the procedure: only 6.5% of LVs would attempt for ⬎ 60 minutes, vs. 9.7% (MVs) and 13.2% (HVs) (p⬍0.04). Similarly, 19.3% of HVs would attempt CBD cannulation ⬎ 30 times prior to termination vs. 5.5% (MV) and 6.6% (LV) (p⫽0.001). For failed CBD cannulation, 71.5% of HVs repeat ERCP themselves, vs. 40.2% (MVs) and 17.8% (LVs); LVs are more likely to refer to an academic center (39.8%) or ask a partner to repeat the ERCP (32.5%, p⬍0.001).The probability of using prophylactic PDS increased with annual ERCP volume: 46.1% of LVs performed PDS vs. 77.1% (MVs) and 96.0% (HVs) (p ⬍ 0.0001, each pairwise comparison). Similarly, 57.1% of LVs reported being at least “somewhat comfortable” with PDS, vs. 92.3% (MVs) and 98.3% (HVs) (pⱕ 0.02, each pairwise comparison).34.1% of LVs reported being at least “somewhat comfortable” with freehand NKS, vs. 60.7% (MVs) and 90.2% (HVs) (p ⬍ 0.0001, each pairwise comparison). Self-reported comfort level with NKS was not different among LVs who perform prophylactic PDS (37.7%) and those who do not (30.9%, p⫽0.28). Conclusions: While the use of WGC and short wire devices is common among LV practitioners, fewer are comfortable with placing prophylactic PDS. Education on the appropriate use of these preventive (PDS) and higher risk (NKS) techniques in lower volume practitioners is needed.
Mo1453 Single Center Experience With Spyglass for Biliary Disease Isaac Raijman, Dang Nguyen, Douglas S. Fishman Digestive Associates of Houston, Houston, TX Introduction: Spyglass (BSC, Natick, MA, USA) is a disposable choledochoscope that has been available since early 2007. We report our experience in a single center of 322 patients. Methods: From 3/2007 until 11/2010, 322 biliary Spyglass procedures were performed at our institution, representing 16.7% of the biliary ERCP volume during the same period (322/1927). Most common indications for the procedure included difficult biliary stone disease in 164/322 (51%), primary sclerosing cholangitis/indeterminate strictures in 125/322 (39%) and other in 33/ 322 (10%). All procedures were performed under monitored anesthesia, all received prophylactic antibiotics, and the majority performed on an outpatient basis. The procedure was performed per-orally in 315 and percutaneously in 7. In the per-oral group, all underwent or had a biliary sphincterotomy. In patients requiring lithotripsy, electrohydraulic (Northech autolithNorthgate, Elgin, IL) and holmium laser (Versapulse, slimline GI, Santa Clara, CA) were used. Percutaneous Spyglass was performed on a mature tract after dilatation to 12 Fr and all were performed with the assistance of the interventional radiologist. Results: The procedure was successful in all patients. Of the patients with biliary stones, ductal clearance was achieved in 150/164 patients (92%) after one session, with 14 (7%) of the group requiring more than one procedure. Of the patients with indeterminate biliary strictures, a malignant diagnosis was established in 67% and benign in 33% by combination of visual characteristics and directed biopsies (4 biopsies per patient) (Spybite, BSC, Natick, MA, USA). Spyglass confirmed the suspected diagnosis of malignant stricture in 65 patients (40%) while changed the diagnosis in 57/164 (35%) to benign. The suspected benign diagnosis in 42 (25%) was confirmed. Other indications included liver transplant patients (13), hemobilia (1), choledochal cyst (3), and staging of cholangiocarcinoma (5), and indeterminate filling defects (11). In the liver transplant group, a diagnosis of stricture was modified by recognizing cast-like stones in 6, thus modifying the management in 46% of these patients. In the cholangiocarcinoma patients, Spyglass upstaged the diagnosis in 2/5 patients (40%) thus avoiding surgery. Overall, Spyglass modified the original diagnosis in 40% of the patients, and completed desired therapy in 100% of the patients. Morbidity occurred in 4/322 patients (1.2 %), perforation in 1 and cholangitis in 3. The perforation required surgical drainage. There was no mortality. Conclusions: Spyglass is a useful adjuvant to ERCP in the management of difficult stone disease, determining the nature of biliary strictures and modifying the overall diagnosis in 40% of the patients. The associated morbidity is acceptable.
Mo1454 Randomized Controlled Study of Endoscopic Sphincterotomy With Endocut Mode or Conventional Blended Cut Mode Yoshiki Tanaka1, Ken Sato1, Hiroyuki Tsuchida1, Masafumi Mizuide1, Katsutoshi Ishida2, Hidetoshi Yasuoka2, Motoyasu Kusano3, Masatomo Mori1 1 Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan; 2Department of Internal Medicine, Tone Chuo Hospital, Numata, Japan; 3Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Japan Background: Although the potential advantages of Endocut mode of endoscopic sphincterotomy (EST) have been reported, the problems including the small sample size, retrospective analysis in previous studies makes it difficult to conclude the advantage of efficacy and safety of Endocut mode. Aim: To evaluate whether Endocut mode surpasses conventional blended cut mode in efficacy and safety. Patients and Methods: The patients with choledocholithiasis or stenosis of the bile duct were randomly assigned to one of the modes. We restricted only one experienced operator to avoid technical bias. We used the success rate and the real operating time of EST for the assessment of efficacy and serum amylase level and complications for the assessment of safety. Results: There were no significant differences on background such as age, sex, the ratio between the two underlined diseases and serum amylase level before EST between the two groups. A total of 326 patients (M:F ⫽ 187:139, averaged 73.3 years old) were randomly assigned to EST with Endocut mode (n ⫽ 164) or conventional blended cut mode (n ⫽ 162). Because of various reasons such as pre-cut sphincterotomy or EST not appropriate, 305 patients were finally randomized to EST with endocut mode (n ⫽ 152) or conventional blended cut mode (n ⫽ 153). There was no significant difference of the success rate of EST or the real operating time between the two groups. The mean serum amylase levels at 24 hours after EST were significantly lower in the Endocut mode group (p⫽0.03). However, complications were founded in 27 (17.8%) patients of the Endocut mode group: hyperamylasemia in 21 (13.8%), mild pancreatitis in 5 (3.3%),moderate pancreatitis in 1 (0.7%), whereas they were founded in 35 (22.9%) patients of the conventional blended cut mode: hyperamylasemia in 29 (19.0%), mild pancreatitis in 6 (4.0%). There was no significant difference of incidence of hyperamylasemia or pancreatitis between the two groups. There were no severe complications such as clinical bleeding or severe pancreatitis
AB350 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org