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Mo1484 Direct Per Oral Cholangioscopy (DPOC) Using an Intraductal Balloon Anchoring System
Abstracts
complications. In 89 of 193 patients, EST had been used prior to stenting. The remaining 590 patients were referred to endoscopic stone removal after EST. Kaplan-Meier estimates of survival and time to recurrence of cholangitis were calculated for clinical variables using the Cox model for multivariate analysis. RESULTS: Successful biliary drainage was achieved in all patients regardless of stone removal. Early complications occurred in 2.3% of stent patients and 7.1% of EST patients. Most of them were trivial except for a few with serious pancreatitis and duodenal perforation requiring surgery in EST patients. The mean hospital stay after treatment was significantly shorter in stent patients (5.7 days) than EST patients (9.7 days)(p⬍0.01), and than EST patients with stone removal at once (7.9 days)(p⬍0.01). Late complication of cholangitis occurred more frequently in stent patients (61.0%) than in EST patients (18.7%) within five-year observation (p⬍0.01, log-rank test). The mean duration to clinical presentation of cholangitis after treatment was 3.3 years (Median: 2.5 years) in stent patients and 8.1 years in EST patients. All patient in need tolerated retreatment adequately, without biliary tract-related mortality. In stent patients, only the number of stones was significantly correlated with occurrence of cholangitis (p⬍0.05), but addition of EST was ineffective to prevent recurrence. CONCLUSIONS: This study confirmed the usefulness and safety of long-term biliary stenting as an alternative to endoscopic common duct stone removal and in shortening the hospital stay in CBDS patients. Although recurrence of cholangitis is frequent, this method can be repeated safely, providing a feasible option for selected patients, such as the elderly and or debilitated patients with short life expectancy. Additional EST to this method did not to prevent late occurrence of cholangitis.
Mo1484 Direct Per Oral Cholangioscopy (DPOC) Using an Intraductal Balloon Anchoring System Marios Efthymiou1,2, Juan Antonio Chirinos Vega1, Naoki Muguruma1, Alan Moss1, Spiro C. Raftopoulos1, Gabor Kandel1, Norman E. Marcon1, Paul P. Kortan1, Gary R. May1 1 Gastroenterology, St Michael’s Hospital, Toronto, ON, Canada; 2 Gastroenterology, St Vincent’s Hospital, Melbourne, VIC, Australia Although cholangioscopy is possible using dedicated instruments, these instruments are expensive and accessibility is limited. Direct cholangioscopy may be valuable in the investigation of biliary strictures and in the management of complex biliary stones. In the latter lithotripsy may be performed under direct vision potentially improving technical success. In this series we report the outcomes of six patients undergoing DPOC using a 15mm intraductal balloon anchoring system and the Olympus GFXP-160 slim gastroscope.METHODS: Ductal access was obtained with either wide biliary sphincterotomy (1/6) or sphincteroplasty (5/6). The DPOC balloon (Pilot balloon, Cook Medicalm, Winston-Salem, NC) was then anchored in the right or left hepatic duct. This balloon has a detachable hub allowing the duodenoscope to be withdrawn while maintaining balloon inflation. The GFXP-160 endoscope was then backloaded over the guidewire and under endoscopic and fluoroscopic guidance was advanced into the common bile duct (CBD).RESULTS: DPOC was attempted in six patients (Table 1). 5/6 had complex choledocholithiasis with previous failed attempts at duct clearance and one patient an indeterminate biliary stricture. Successful intubation of the distal CBD was achieved in all patients (100%). In 3/6 cases deep cannulation of the CBD failed due to distal CBD stones limiting advancement of the endoscope. In two cases direct electrohydraulic lithotripsy (EHL) was successfully performed and in one case the biliary stricture was well visualised and appeared benign. There was one major adverse event observed in the patient with the biliary stricture. This was acute desaturation during the procedure requiring the procedure to be aborted. Post procedure a stroke and patent foramen ovale were diagnosed. The suspected diagnosis in the absence of other cardiovascular risk factors was air embolism.SUMMARY: DPOC is facilitated using a balloon anchoring system. This approach was beneficial in the treatment of complex choledocholithiasis involving the mid or proximal CBD. Like other modalities of DPOC, the balloon anchoring system is limited in patients with distal CBD pathology due to inability to establish and maintain CBD cannulation. It is unclear whether the rare complication observed in one of our patients is related to this method or is coincidental. Table 1 -Summary of cases Age Sex 1 2 3 4 5 6
73 62 80 70 51 38
F F M F F F
Indication
Deep CBD intubation
Treatment
Adverse event(s)
Choledocholithiasis Biliary stricture Choledocholithiasis Choledocholithiasis Choledocholithiasis Choledocholithiasis
Y Y Y N N N
EHL ⫺ EHL ⫺ ⫺ ⫺
N Y N N N N
Mo1485 Cholangitis Is Common in Cancer Survivors With Metal Biliary Stents Suresh Pola, Ramya Muralimohan, Benjamin L. Cohen, Syed M Abbas Fehmi, Thomas J. Savides University California San Diego, San Diego, CA BACKGROUND: Patients with malignant biliary obstruction are living longer now due to improved oncologic therapy. The purpose of this study was to assess the impact of longer patient survival on metal biliary stent complications such as cholangitis. METHODS: Retrospective review of endoscopy database for patients who underwent placement of biliary self-expanding metal stents (SEMS) for malignant biliary obstruction at a single academic medical center. Medical records were used to assess patient follow up including episodes of cholangitis, subsequent procedures, and survival. Death registries were used to assess for survival. RESULTS: 101 patients had endoscopically placed SEMS for malignant biliary obstruction between 2001-2010. Survival data was successfully obtained for 96 patients. The median survival following metal stent placement was 214 days (range 1-1112 days). 56% (53/95) and 26% (23/90) of patients with malignant biliary obstruction were living at 6 months and 1 year, respectively. 20 patients (22%) developed at least 1 episode of cholangitis requiring inpatient admission. 9/20 (45%) patients had recurrent episodes of cholangitis (range 2-5 total episodes per patient, median 2 total episodes) during the follow up period. 25/36 (69%) of hospitalizations for cholangitis were treated with ERCP guided therapies plus antibiotics and 11/36 (31%) were treated with antibiotics alone. The cumulative risk of having at least 1 hospitalization for cholangitis was 13% (7/56) at 3 months, 20% (9/45) at 6 months, 40% (8/20) at 1 year, and 75% (3/4) at 2 years. CONCLUSIONS: Cholangitis is common in patients with SEMS for malignant biliary obstruction, especially as they usually live longer than 6 months after stent placement. Further studies are needed to investigate interventions to reduce cholangitis rates such as prophylactic antibiotics or prophylactic balloon sweeping of stents in at-risk groups.
Percentage of patients with at least one prior episode of cholangitis requiring inpatient hospitalization at specified time points following SEMS for malignant biliary obstruction.
Mo1486 Risk Stratification for the Development of Post-ERCP Pancreatitis by Sphincter of Oddi Dysfunction Classification Sara K. Beltz1, Avik Sarkar1, David E. Loren1, Thomas E. Kowalski1, Jocelyn A. Andrel2, Ali A. Siddiqui1 1 Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA; 2Division of Biostatistics, Thomas Jefferson University Hospital, Philadelphia, PA Background: Patients with SOD who undergo manometry are at substantially higher risk (20-30%) for developing post-ERCP pancreatitis compared with patients undergoing ERCP for other disease states (2%-5%). The risk stratification for developing this complication is currently not available. Aim: To explore if there is a difference in the frequency of post-ERCP pancreatitis in patients with manometrically confirmed SOD 1, 2 and 3. Methods: A retrospective review of all patients who underwent an ERCP with manometrically confirmed SOD (mean basal sphincter pressure ⬎40 mm Hg) from 2006 to 2010 was performed. Patients were classified into 3 groups: SOD 1, 2 or 3 according to the modified
AB360 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
complications. In 89 of 193 patients, EST had been used prior to stenting. The remaining 590 patients were referred to endoscopic stone removal after EST. Kaplan-Meier estimates of survival and time to recurrence of cholangitis were calculated for clinical variables using the Cox model for multivariate analysis. RESULTS: Successful biliary drainage was achieved in all patients regardless of stone removal. Early complications occurred in 2.3% of stent patients and 7.1% of EST patients. Most of them were trivial except for a few with serious pancreatitis and duodenal perforation requiring surgery in EST patients. The mean hospital stay after treatment was significantly shorter in stent patients (5.7 days) than EST patients (9.7 days)(p⬍0.01), and than EST patients with stone removal at once (7.9 days)(p⬍0.01). Late complication of cholangitis occurred more frequently in stent patients (61.0%) than in EST patients (18.7%) within five-year observation (p⬍0.01, log-rank test). The mean duration to clinical presentation of cholangitis after treatment was 3.3 years (Median: 2.5 years) in stent patients and 8.1 years in EST patients. All patient in need tolerated retreatment adequately, without biliary tract-related mortality. In stent patients, only the number of stones was significantly correlated with occurrence of cholangitis (p⬍0.05), but addition of EST was ineffective to prevent recurrence. CONCLUSIONS: This study confirmed the usefulness and safety of long-term biliary stenting as an alternative to endoscopic common duct stone removal and in shortening the hospital stay in CBDS patients. Although recurrence of cholangitis is frequent, this method can be repeated safely, providing a feasible option for selected patients, such as the elderly and or debilitated patients with short life expectancy. Additional EST to this method did not to prevent late occurrence of cholangitis.
Mo1484 Direct Per Oral Cholangioscopy (DPOC) Using an Intraductal Balloon Anchoring System Marios Efthymiou1,2, Juan Antonio Chirinos Vega1, Naoki Muguruma1, Alan Moss1, Spiro C. Raftopoulos1, Gabor Kandel1, Norman E. Marcon1, Paul P. Kortan1, Gary R. May1 1 Gastroenterology, St Michael’s Hospital, Toronto, ON, Canada; 2 Gastroenterology, St Vincent’s Hospital, Melbourne, VIC, Australia Although cholangioscopy is possible using dedicated instruments, these instruments are expensive and accessibility is limited. Direct cholangioscopy may be valuable in the investigation of biliary strictures and in the management of complex biliary stones. In the latter lithotripsy may be performed under direct vision potentially improving technical success. In this series we report the outcomes of six patients undergoing DPOC using a 15mm intraductal balloon anchoring system and the Olympus GFXP-160 slim gastroscope.METHODS: Ductal access was obtained with either wide biliary sphincterotomy (1/6) or sphincteroplasty (5/6). The DPOC balloon (Pilot balloon, Cook Medicalm, Winston-Salem, NC) was then anchored in the right or left hepatic duct. This balloon has a detachable hub allowing the duodenoscope to be withdrawn while maintaining balloon inflation. The GFXP-160 endoscope was then backloaded over the guidewire and under endoscopic and fluoroscopic guidance was advanced into the common bile duct (CBD).RESULTS: DPOC was attempted in six patients (Table 1). 5/6 had complex choledocholithiasis with previous failed attempts at duct clearance and one patient an indeterminate biliary stricture. Successful intubation of the distal CBD was achieved in all patients (100%). In 3/6 cases deep cannulation of the CBD failed due to distal CBD stones limiting advancement of the endoscope. In two cases direct electrohydraulic lithotripsy (EHL) was successfully performed and in one case the biliary stricture was well visualised and appeared benign. There was one major adverse event observed in the patient with the biliary stricture. This was acute desaturation during the procedure requiring the procedure to be aborted. Post procedure a stroke and patent foramen ovale were diagnosed. The suspected diagnosis in the absence of other cardiovascular risk factors was air embolism.SUMMARY: DPOC is facilitated using a balloon anchoring system. This approach was beneficial in the treatment of complex choledocholithiasis involving the mid or proximal CBD. Like other modalities of DPOC, the balloon anchoring system is limited in patients with distal CBD pathology due to inability to establish and maintain CBD cannulation. It is unclear whether the rare complication observed in one of our patients is related to this method or is coincidental. Table 1 -Summary of cases Age Sex 1 2 3 4 5 6
73 62 80 70 51 38
F F M F F F
Indication
Deep CBD intubation
Treatment
Adverse event(s)
Choledocholithiasis Biliary stricture Choledocholithiasis Choledocholithiasis Choledocholithiasis Choledocholithiasis
Y Y Y N N N
EHL ⫺ EHL ⫺ ⫺ ⫺
N Y N N N N
Mo1485 Cholangitis Is Common in Cancer Survivors With Metal Biliary Stents Suresh Pola, Ramya Muralimohan, Benjamin L. Cohen, Syed M Abbas Fehmi, Thomas J. Savides University California San Diego, San Diego, CA BACKGROUND: Patients with malignant biliary obstruction are living longer now due to improved oncologic therapy. The purpose of this study was to assess the impact of longer patient survival on metal biliary stent complications such as cholangitis. METHODS: Retrospective review of endoscopy database for patients who underwent placement of biliary self-expanding metal stents (SEMS) for malignant biliary obstruction at a single academic medical center. Medical records were used to assess patient follow up including episodes of cholangitis, subsequent procedures, and survival. Death registries were used to assess for survival. RESULTS: 101 patients had endoscopically placed SEMS for malignant biliary obstruction between 2001-2010. Survival data was successfully obtained for 96 patients. The median survival following metal stent placement was 214 days (range 1-1112 days). 56% (53/95) and 26% (23/90) of patients with malignant biliary obstruction were living at 6 months and 1 year, respectively. 20 patients (22%) developed at least 1 episode of cholangitis requiring inpatient admission. 9/20 (45%) patients had recurrent episodes of cholangitis (range 2-5 total episodes per patient, median 2 total episodes) during the follow up period. 25/36 (69%) of hospitalizations for cholangitis were treated with ERCP guided therapies plus antibiotics and 11/36 (31%) were treated with antibiotics alone. The cumulative risk of having at least 1 hospitalization for cholangitis was 13% (7/56) at 3 months, 20% (9/45) at 6 months, 40% (8/20) at 1 year, and 75% (3/4) at 2 years. CONCLUSIONS: Cholangitis is common in patients with SEMS for malignant biliary obstruction, especially as they usually live longer than 6 months after stent placement. Further studies are needed to investigate interventions to reduce cholangitis rates such as prophylactic antibiotics or prophylactic balloon sweeping of stents in at-risk groups.
Percentage of patients with at least one prior episode of cholangitis requiring inpatient hospitalization at specified time points following SEMS for malignant biliary obstruction.
Mo1486 Risk Stratification for the Development of Post-ERCP Pancreatitis by Sphincter of Oddi Dysfunction Classification Sara K. Beltz1, Avik Sarkar1, David E. Loren1, Thomas E. Kowalski1, Jocelyn A. Andrel2, Ali A. Siddiqui1 1 Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA; 2Division of Biostatistics, Thomas Jefferson University Hospital, Philadelphia, PA Background: Patients with SOD who undergo manometry are at substantially higher risk (20-30%) for developing post-ERCP pancreatitis compared with patients undergoing ERCP for other disease states (2%-5%). The risk stratification for developing this complication is currently not available. Aim: To explore if there is a difference in the frequency of post-ERCP pancreatitis in patients with manometrically confirmed SOD 1, 2 and 3. Methods: A retrospective review of all patients who underwent an ERCP with manometrically confirmed SOD (mean basal sphincter pressure ⬎40 mm Hg) from 2006 to 2010 was performed. Patients were classified into 3 groups: SOD 1, 2 or 3 according to the modified
AB360 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org