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Mo1535 Clinical Usefulness of Contrast-Enhanced Harmonic EUS in the Diagnosis of Malignant Polypoid Lesions of Gallbladder
Abstracts
Mo1532 A Multicenter Retrospective Study of Endoscopic UltrasoundGuided Biliary Drainage (EUS-BD) for Malignant Biliary Obstruction in Japan Hiroyuki Isayama*1, Kazumichi Kawakubo1, Hironari Kato2, Takao Itoi3, Hiroshi Kawakami4, Keiji Hanada5, Hirotoshi Ishiwatari6, Ichiro Yasuda7, Hirofumi Kawamoto2, Fumihide Itokawa3, Masaki Kuwatani4, Tomohiro Iiboshi5, Tsuyoshi Hayashi6, Shinpei Doi7, Yousuke Nakai1 1 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 2Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Okayama, Japan; 3Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan; 4Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan; 5Center of Gastroenterology, Onomichi General Hospital, Onomichi, Japan; 6Fourth Department of Internal Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan; 7First Department of Internal Medicine, Gifu University Hospital School of Medicine, Gifu, Japan Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is considered as effective salvage procedure for failed ERCP in cases with unresectable malignant biliary obstruction, but most of the previous reports were based on a single center experience. The selection of drainage route, choledochoduodenostomy (CDS) vs. hepaticogastrostomy (HGS) or drainage type, plastic stents (PS) vs. covered metallic stents (CMS) is still to be clarified. We conducted this multicenter retrospective study to evaluate the current status of EUS-BD in Japan.Patients: A total of 64 patients who underwent EUS-BD for failed ERCP in 7 referral centers between November 2006 and May 2012 were retrospectively studied. Technical success rate, stent patency and procedurerelated complications were evaluated. Results: Median age was 72 years old and 35 patients were male. The cause of biliary obstruction was pancreatic cancer in 66%, bile duct cancer in 8%, gallbladder cancer in 2%, ampullary cancer in 14% and metastatic lymph node in 10%. The reason for EUS-BD was tumor invasion at periampulary region in 84%, inaccessible ampulla due to the surgical altered upper gastrointestinal tract in 6%, failed ERCP cannulation in 6% and refractory ascending cholangitis after transpapillary stent placement in 3%. Transmural stnet used in this study was straight type PS in 29, double pigtail PS in 8 and CMS in 26 patients. CDS was performed in 69% and HGS in 31%. A technical success rate in EUS-CDS and EUS-HGS was both 95%. The reasons for technical failure were 2 failed dilation of anastomosis in EUS-CDS and 1 puncture failure in EUSHGS. Stent dysfunction rate was 21% and 32% and the 3-months dysfunction free patency was 80% and 51% in EUS-CDS and in EUS-HGS, respectively. There were 12 (6 in EUS-CDS and 6 in EUS-HGS) procedure-related complications (19%): 5 bile-leak (3 and 2), 3 stent misplacement (1 and 2), 1 pneumoperitonium (1 and 0), 2 bleeding (1 and 1), 1 perforation (1 and 0) and 1 biloma (0 and 1). Bile-leak was more frequently observed in patients with PS placement than in those with CMS pacement (11% vs. 4%). Conclusion: This Japanese multicenter series of 64 EUS-BD for failed ERCP confirmed high technical success rate with acceptable complication rate. The use of CMS is preferred for EUS-BD to prevent bile leak. A prospective randomized controlled trial with percutaneous transhepatic biliary drainage is warranted.
Mo1533 Endoscopic Ultrasound Guided Rendezvous Procedure in Biliary Drainage-a Systematic Review Naga Swetha Samji*1, Rajan Kanth1, Anupama Inaganti1, Mainor R. Antillon2, Ramon E. Rivera2, Praveen K. Roy1 1 Internal Medicine, Marshfield clinic, Marshfield, WI; 2 Gastroeneterology, Oschner Clinic, New Orleans, LA Purpose- Endoscopic retrograde cholangio pancreaticography(ERCP) is the procedure of choice for biliary decompression. Endoscopic ultrasound(EUS) guided rendezvous procedure has been suggested as an alternative for patients who failed ERCP. Several studies have evaluated the role of EUS rendezvous procedure in biliary drainage. We performed a systematic review of the published studies to evaluate the safety and effectiveness of the EUS rendezvous procedure in biliary drainage. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (through 11/12). All the studies assessing the efficacy of EUS rendezvous procedure in biliary drainage are included. Standard forms were used to extract data by two independent reviewers. Data regarding the following outcomes were extractedsuccess rate of the procedure, site of puncture, failure rate, reasons for failure and complication rate.Summary effects were computed using comprehensive meta-analysis. Results- Eleven studies were included (n⫽ 307). Age ranged from 36 to 90 years. All the patients who had failed ERCP (defined as failure of biliary cannulation with up to 5 attempts of ERCP). Causes of ERCP failure include
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malignant obstruction in 210 patients (68.4%) and benign obstruction in 97 patients (31.5%). Transduodenal and transgastric were the sites of puncture depending on the site of obstruction .Either 19g/22 g needles were used for puncture of biliary duct. Success rate with transduodenal approach was 83.3% (95% CI 66.8-92.6%). Success rate with transgastric approach was 75% (95% CI 49.3% to 90.3%).Overall success rate of EUS guided rendezvous procedure in biliary drainage was 78.9% (95% CI 64.6-88.4%). Overall complication rate of EUS rendezvous procedure ranged from 0 to 21%. Complication rate with tranduodenal approach ranged from 0 to 21%.Complication rate with transgastric approach ranged from 0 to 16%.Complications included bile leak, pancreatitis, post procedural abdominal pain, peri-choledochal tracking of contrast , pneumoperitoneum and sepsis. Causes of failure of EUS rendezvous included failure to pass guide wire in most of the cases. Conclusion- EUS rendezvous procedure is 66.4-88.4% successful in biliary drainage. Sucess rate was similar with both transgastric and transduodenal approach . Overall complication rate ranged from 0 to 21%. EUS guided rendezvous procedure is an acceptable alternative option for patients who had failed ERCP.
Mo1534 Examination of Feasibility of a Novel EUS Imaging Technique (Reversed 3D Imaging) in Pancreatico-Biliary Field Yoshiki Hirooka*1, Akihiro Itoh2, Hiroki Kawashima2, Eizaburo Ohno1, Yuya Itoh2, Yosuke Nakamura1, Takeshi Hiramatsu2, Hiroyuki Sugimoto2, Hajime Sumi2, Daijuro Hayashi2, Takamichi Kuwahara2, Kohei Funasaka1, Masanao Nakamura2, Ryoji Miyahara2, Naoki Ohmiya2, Hidemi Goto2,1 1 Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan; 2Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan Background and AIM: Three-dimensional (3D) EUS imaging has been developed especially in combination with B-mode images and vasculature including color/ power Doppler flow mapping. Recently, 3D imaging in combination with contrast-enhanced EUS (CE-EUS) has been also proposed. 3D images produced by simple manipulation of an endosonoscope inevitably lack the positional information, which is a limitation of 3D imaging regardless of its comprehensibleness. Reversed 3D imaging (R3DI) is the reversed display method between anechoic area and echogenic area with adjusting the threshold of an echogenicity. The aim of this study was to clarify role and feasibility of R3DI in the pancreatico-biliary field. Patients and Methods: From November 2011 to October 2012, 35 patients who underwent R3DI-EUS were enrolled in this study. 35 patients consisted of 15 with pancreatic invasive ductal carcinoma (PC), 13 with intraductal papillary mucinous neoplasm: IPMNs (6 with an associated invasive carcinoma and 7 with low and intermediate-grade dysplasia), 7 with gallstone. 8 cases served as normal controls. R3DI-EUS was performed as follows: At first, target lesion was observed. Next, in order to acquire volume information (3D information), an endosonoscope was pulled from distal side of the lesion to the proximal side, that is, from anal side to oral side along the duodenum or stomach. Lastly, anechoic area was extracted from acquired volume data. The demonstration of the main pancreatic duct (MPD) and the common bile duct (CBD) was tested by R3DI-EUS in 8 normal controls. The apparatuses used were EG-3670URK (PENTAX, Tokyo, Japan) as an endosonoscope and Ascendus (HITACHI, Tokyo, Japan) as an ultrasound diagnostic machine. Results: PC: R3DI-EUS revealed the dilated upstream MPD to tumors in all cases mimicking MRCP (magnetic resonance cholangiopancreatography). IPMNs: R3DI-EUS demonstrated the whole 3D image of multilocular mass in all cases and communication between the lesion and the MPD in 10 out of 13 cases. Gallstone: R3DI-EUS depicted the stereoscopic image of gallbladder and CBD in all cases. Both MPD and CBD were illustrated by R3DI-EUS in all normal controls, furthermore, superior mesenteric vein and splenic vein were depicted stereoscopically in all cases. Conclusion: R3DI-EUS demonstrated the images mimicking MRCP and also surrounding vessels. Though R3DI-EUS images lack the positional information, the stereoscopic information of R3DI-EUS may be helpful in the diagnosis of pancreatico-biliary disorders.
Mo1535 Clinical Usefulness of Contrast-Enhanced Harmonic EUS in the Diagnosis of Malignant Polypoid Lesions of Gallbladder Jun-Ho Choi*, Dong Wan Seo, Do Hyun Park, Sang Soo Lee, Sung Koo Lee, Myung-Hwan Kim Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Background: The differential diagnosis between benign and malignant polypoid lesions of gallbladder (PLGs) is often difficult even by various examination methods. Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is a novel method that uses US contrast and depicts microvasculature in real time.
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB417
Abstracts
This study aims to evaluate whether CH-EUS might be an accurate method to discriminate malignant PLGs from benign PLGs with regard to the vessel and perfusion images. Methods: Between November 2010 and August 2012, a total of 76 patients with PLGs more than 10 mm in size who underwent CH-EUS and subsequent cholecystectomy were prospectively enrolled. SonoVue® (Bracco, Milan, Italy), a second-generation ultrasound contrast agent (UCA), was used as a contrast agent. CH-EUS was performed by using a radial echoendoscope and the extended pure harmonic detection mode. Two blinded reviewers classified the perfusion images into three categories as follows; diffuse enhancement, perfusion defect or nonenhancement. The vessel images were categorized as having a regular spotty vessel pattern, a irregular tortuous vessel pattern, or no vessels. Results: Irregular tortuous vessels were observed in 29 of 31 patients with malignant PLGs and 1 of 45 benign PLGs. Perfusion defects were found in 28 of 31 patients with malignant PLGs and 2 of 45 benign PLGs. A CH-EUSdetermined irregular tortuous vascular pattern could diagnose malignant PLG with a sensitivity and specificity of 96.6% and 95.6%, respectively. The presence of perfusion defects, determined by CH-EUS, was calculated to diagnose malignant PLG with a sensitivity and specificity of 93.3% and 93.4%, respectively. Defining biliary sludge by avascular-nonenhancement pattern showed a sensitivity and specificity of 100% and 100%, respectively. Conclusions: The presence of irregular tortuous vessels or perfusion defects on CH-EUS are sensitive and accurate predictors of malignant PLGs. CH-EUS can most accurately distinguish biliary sludge from other PLGs.
Mo1536 Endoscopic Ultrasound (EUS) Guided Pancreatic Duct Intervention: Outcomes of a Single Tertiary Referral Center Experience Larissa Fujii*1, Charles Lenz1, Barham K. Abu Dayyeh1, Todd H. Baron1, Suresh T. Chari1, Michael B. Farnell2, Ferga C. Gleeson1, Christopher J. Gostout1, Michael L. Kendrick2, Randall K. Pearson1, Bret T. Petersen1, Santhi Swaroop Vege1, Michael J. Levy1 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 2Division of General Surgery, Mayo Clinic, Rochester, MN Background: The role of EUS as a diagnostic and therapeutic modality is everexpanding for the management of pancreatic disorders. There is increasing use of EUS following failed endoscopic retrograde pancreatography (ERP) to access the main pancreatic duct (MPD). We aim to describe our experience and longterm outcomes for patients undergoing EUS-guided MPD intervention. Methods: A prospectively maintained EUS database was reviewed to identify all patients who underwent attempted EUS-guided MPD access. Presenting clinical, radiologic, endoscopic, and outcome data were analyzed. Results: Fifty-one patients (mean age 55 [SD 17], 25 men) underwent 57 EUS-guided procedures. Indications included recurrent acute pancreatitis (n⫽33), chronic pancreatitis (n⫽11), duct leak (n⫽3), retained surgical stent (n⫽2), cysts (n⫽1), and symptoms of weight loss (n⫽8), steatorrhea (n⫽6), or abdominal pain (n⫽26) with a dilated MPD. The intervention was necessitated by a failed ERP in 75% (n⫽38) and/or surgically altered anatomy (n⫽36), pancreas divisum (n⫽4), duodenal stricture (n⫽1), and ERCP-induced duodenal perforation (n⫽1). Median MPD measured 5 mm (0.8-8.5 mm). Among the 51 patients, 7 underwent EUS-guided pancreatography alone without stenting due to the absence of obstructive pathology. EUS was successful in removing 1 of 2 (50%) retained stents. In the remaining 42 patients, MPD stenting was the goal with technical success achieved in 32 (76%) with antegrade (n⫽17) or retrograde (n⫽15) insertion. Stenting was possible during the index exam in 30 (94%) patients. A total of 1 stent (n⫽30) or 2 stents (n⫽2) was placed during the initial exam. The maximum number of stents placed was 1, 2, 3, 4, or 5 stents in 18, 5, 6, 2, and 1 patient, respectively. Moderate-severe adverse events developed in 2 (4%) patients including acute pancreatitis (n⫽1) with an 11 day hospitalization and a peripancreatic abscess (n⫽1) that responded well to EUS-guided drainage. Abdominal pain requiring hospitalization of 2, 3, 4, and 5 days were reported in 8, 2, 1, and 2 patients, respectively. The guidewire coating was sheared and retained in one patient. Adequate follow-up was available for 31 of 32 stented patients. Complete clinical success with symptom resolution occurred in 17 (55%) at a mean of 17 months. Ten (32%) patients had partial clinical success with symptom recurrence at an average of 9.5 months. Four patients reported no symptom relief. Conclusions: EUS-guided MPD intervention following failed ERCP is safe and feasible in select patients and can obviate the need for percutaneous and surgical procedures. Our data suggest that many patients clinically benefit from such interventions, but that technical limitations and adverse events must be carefully considered. Additional clinical data are needed to define the long-term outcomes and role for these techniques.
Mo1537 Complications of Endoscopic Pancreatic Necrosectomy Jessica L. Abbott*1, Amy R. Welch1, Matthew T. Moyer2, Charles E. Dye2, Thomas J. Mcgarrity2, Brandy Dougherty-Hamod2, Raquel E. Davila2, Abraham Mathew2 1 Internal Medicine, Penn State Hershey Medical Center, Hershey, PA; 2 Gastroenterology-Hepatology, Penn State Hershey Medical Center, Hershey, PA Back ground: EUS-guided translumenal drainage and debridement is an accepted approach to the management of pancreatic abscesses and walled off pancreatic necrosis (WOPN) in severe necrotizing pancreatitis and carry lower rates of mortality and complications when compared with conventional surgical approaches. Further evidence of its efficacy and complications rates would be valuable. Objective: To investigate the immediate and delayed complications associated with endoscopic pancreatic necrosectomy.Patients: 48 patients with a history of pancreatitis and subsequent WOPN treated with endoscopic pancreatic necrosectomy at Penn State Hershey Medical Center. Methods: Electronic medical record of patients who had undergone endoscopic pancreatic necrosectomy from 2006 to current was reviewed and extracted. Patients were excluded if it had been less than 6 months since their necrosectomy to allow for at least 6 months of follow up. Complications were immediate if they occurred within 6 months of necrosectomy and delayed if after 6 months. Results: 48 patients underwent endoscopic evaluation of a WOPN. 45 procedures were successful (94%) and 3 failed attempts. Of those with successful endoscopic therapy, 4 patients had recurrence (3 with pancreatitis and 1 patient with new WOPN visualized on imaging), 16 patients had varying degrees of asymptomatic retained fluid post necrosectomy and 4 patients required surgery (2 patients with concerns for peritonitis, 1 to repair cyst gastrostomy bleeding, and 1 for placement of a davol drain to allow for further debridement). In those patients with successful necrosectomy, the most common complication within 6 months was bleeding. 4/45 or 9% of patients had procedural bleeding, with 1 patient requiring surgical intervention. One patient experienced a peritoneal leak and was managed conservatively. The six-month mortality rate was 2%. This patient had been re-admitted 20 days post-procedure at local hospital with sepsis after having missed his scheduled repeat procedure. The most common long-term complication was found to be diabetes at 48%. In those patients who survived after 6 months, mortality was 2/47 or 4%. One patient expired due to hemorrhagic shock from a retroperitoneal hematoma with concerns for a bowel perforation. This death was unrelated to necrosectomy as they were 2 years post procedure. The cause death is unknown in the second patient. Conclusion: The most common complication of pancreatic necrosectomy within 6 months of the procedure is bleeding; occurring in 9% of patients. Severe hemorrhage, requiring surgical intervention occurred in 2% of patients. 1 patient expired within 6 months of necrosectomy. Diabetes was observed as the most frequent (48%) delayed and overall complication. The overall mortality rate of WOPN treatment through endoscopic evaluation is 3/48 or 6%.
Mo1538 The Microbiome of Walled-off Pancreatic Necrosis (WOPN): Analysis of Blood and Direct WOPN Culture Results Nitin Kumar*, Darwin Conwell, Christopher C. Thompson Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA Background: The management of walled-off pancreatic necrosis (WOPN) is increasingly incorporating endoscopic techniques. WOPN culture is regularly obtained via EUS-guided needle aspiration prior to necrosectomy, but the character and significance of the WOPN microbiome remains unclear. Aim: To analyze and compare blood culture results and EUS-guided direct WOPN culture results in patients with symptomatic WOPN. Methods: Retrospective record review was conducted to identify patients who required endoscopic debridement of symptomatic WOPN between 2003 and 2012. Patients who had culture data from the endoscopic procedure were eligible for inclusion. Patients who had pseudocysts were excluded. WOPN culture data was obtained from the first endoscopic necrosectomy. Clinical success, defined as resolution of symptoms without need for further procedural intervention, was recorded. Results: 47 patients (27M/22F, 52.7 ⫾ 2.1 yr, Charlson comorbidity index 2.53 ⫾ 0.7, APACHE II 9.4 ⫾ 1.1 at admission) had DEN with microbiologic culture obtained from the WOPN. Two culture bottles had been inoculated in the procedure room during DEN in all patients. Blood cultures had been obtained on the inpatient floor within 7 days of DEN. Microbiologic data are reported in Table 1. Four cultures were polymicrobial. Gram positive organisms were most common, with the most common organism being alpha-hemolytic Streptococcus (6). The most common fungal organism was Candida albicans. WOPN culture was positive in 21/47 patients, versus 2/47 blood cultures (OR 18.2, 95% CI 3.9-83.8, p⬍0.001). Both blood cultures were later determined to be skin contaminants by the microbiology lab. 12 patients were on antibiotic therapy prior to DEN. There was no correlation between Gram positive, Gram negative, or fungal organisms and clinical failure of DEN. Conclusions: Patients undergoing DEN for symptomatic WOPN have diverse culture results with a variety of bacterial and fungal organisms. Blood cultures are insensitive for the detection of infected WOPN.
AB418 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
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Mo1532 A Multicenter Retrospective Study of Endoscopic UltrasoundGuided Biliary Drainage (EUS-BD) for Malignant Biliary Obstruction in Japan Hiroyuki Isayama*1, Kazumichi Kawakubo1, Hironari Kato2, Takao Itoi3, Hiroshi Kawakami4, Keiji Hanada5, Hirotoshi Ishiwatari6, Ichiro Yasuda7, Hirofumi Kawamoto2, Fumihide Itokawa3, Masaki Kuwatani4, Tomohiro Iiboshi5, Tsuyoshi Hayashi6, Shinpei Doi7, Yousuke Nakai1 1 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 2Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Okayama, Japan; 3Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan; 4Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan; 5Center of Gastroenterology, Onomichi General Hospital, Onomichi, Japan; 6Fourth Department of Internal Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan; 7First Department of Internal Medicine, Gifu University Hospital School of Medicine, Gifu, Japan Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is considered as effective salvage procedure for failed ERCP in cases with unresectable malignant biliary obstruction, but most of the previous reports were based on a single center experience. The selection of drainage route, choledochoduodenostomy (CDS) vs. hepaticogastrostomy (HGS) or drainage type, plastic stents (PS) vs. covered metallic stents (CMS) is still to be clarified. We conducted this multicenter retrospective study to evaluate the current status of EUS-BD in Japan.Patients: A total of 64 patients who underwent EUS-BD for failed ERCP in 7 referral centers between November 2006 and May 2012 were retrospectively studied. Technical success rate, stent patency and procedurerelated complications were evaluated. Results: Median age was 72 years old and 35 patients were male. The cause of biliary obstruction was pancreatic cancer in 66%, bile duct cancer in 8%, gallbladder cancer in 2%, ampullary cancer in 14% and metastatic lymph node in 10%. The reason for EUS-BD was tumor invasion at periampulary region in 84%, inaccessible ampulla due to the surgical altered upper gastrointestinal tract in 6%, failed ERCP cannulation in 6% and refractory ascending cholangitis after transpapillary stent placement in 3%. Transmural stnet used in this study was straight type PS in 29, double pigtail PS in 8 and CMS in 26 patients. CDS was performed in 69% and HGS in 31%. A technical success rate in EUS-CDS and EUS-HGS was both 95%. The reasons for technical failure were 2 failed dilation of anastomosis in EUS-CDS and 1 puncture failure in EUSHGS. Stent dysfunction rate was 21% and 32% and the 3-months dysfunction free patency was 80% and 51% in EUS-CDS and in EUS-HGS, respectively. There were 12 (6 in EUS-CDS and 6 in EUS-HGS) procedure-related complications (19%): 5 bile-leak (3 and 2), 3 stent misplacement (1 and 2), 1 pneumoperitonium (1 and 0), 2 bleeding (1 and 1), 1 perforation (1 and 0) and 1 biloma (0 and 1). Bile-leak was more frequently observed in patients with PS placement than in those with CMS pacement (11% vs. 4%). Conclusion: This Japanese multicenter series of 64 EUS-BD for failed ERCP confirmed high technical success rate with acceptable complication rate. The use of CMS is preferred for EUS-BD to prevent bile leak. A prospective randomized controlled trial with percutaneous transhepatic biliary drainage is warranted.
Mo1533 Endoscopic Ultrasound Guided Rendezvous Procedure in Biliary Drainage-a Systematic Review Naga Swetha Samji*1, Rajan Kanth1, Anupama Inaganti1, Mainor R. Antillon2, Ramon E. Rivera2, Praveen K. Roy1 1 Internal Medicine, Marshfield clinic, Marshfield, WI; 2 Gastroeneterology, Oschner Clinic, New Orleans, LA Purpose- Endoscopic retrograde cholangio pancreaticography(ERCP) is the procedure of choice for biliary decompression. Endoscopic ultrasound(EUS) guided rendezvous procedure has been suggested as an alternative for patients who failed ERCP. Several studies have evaluated the role of EUS rendezvous procedure in biliary drainage. We performed a systematic review of the published studies to evaluate the safety and effectiveness of the EUS rendezvous procedure in biliary drainage. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (through 11/12). All the studies assessing the efficacy of EUS rendezvous procedure in biliary drainage are included. Standard forms were used to extract data by two independent reviewers. Data regarding the following outcomes were extractedsuccess rate of the procedure, site of puncture, failure rate, reasons for failure and complication rate.Summary effects were computed using comprehensive meta-analysis. Results- Eleven studies were included (n⫽ 307). Age ranged from 36 to 90 years. All the patients who had failed ERCP (defined as failure of biliary cannulation with up to 5 attempts of ERCP). Causes of ERCP failure include
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malignant obstruction in 210 patients (68.4%) and benign obstruction in 97 patients (31.5%). Transduodenal and transgastric were the sites of puncture depending on the site of obstruction .Either 19g/22 g needles were used for puncture of biliary duct. Success rate with transduodenal approach was 83.3% (95% CI 66.8-92.6%). Success rate with transgastric approach was 75% (95% CI 49.3% to 90.3%).Overall success rate of EUS guided rendezvous procedure in biliary drainage was 78.9% (95% CI 64.6-88.4%). Overall complication rate of EUS rendezvous procedure ranged from 0 to 21%. Complication rate with tranduodenal approach ranged from 0 to 21%.Complication rate with transgastric approach ranged from 0 to 16%.Complications included bile leak, pancreatitis, post procedural abdominal pain, peri-choledochal tracking of contrast , pneumoperitoneum and sepsis. Causes of failure of EUS rendezvous included failure to pass guide wire in most of the cases. Conclusion- EUS rendezvous procedure is 66.4-88.4% successful in biliary drainage. Sucess rate was similar with both transgastric and transduodenal approach . Overall complication rate ranged from 0 to 21%. EUS guided rendezvous procedure is an acceptable alternative option for patients who had failed ERCP.
Mo1534 Examination of Feasibility of a Novel EUS Imaging Technique (Reversed 3D Imaging) in Pancreatico-Biliary Field Yoshiki Hirooka*1, Akihiro Itoh2, Hiroki Kawashima2, Eizaburo Ohno1, Yuya Itoh2, Yosuke Nakamura1, Takeshi Hiramatsu2, Hiroyuki Sugimoto2, Hajime Sumi2, Daijuro Hayashi2, Takamichi Kuwahara2, Kohei Funasaka1, Masanao Nakamura2, Ryoji Miyahara2, Naoki Ohmiya2, Hidemi Goto2,1 1 Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan; 2Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan Background and AIM: Three-dimensional (3D) EUS imaging has been developed especially in combination with B-mode images and vasculature including color/ power Doppler flow mapping. Recently, 3D imaging in combination with contrast-enhanced EUS (CE-EUS) has been also proposed. 3D images produced by simple manipulation of an endosonoscope inevitably lack the positional information, which is a limitation of 3D imaging regardless of its comprehensibleness. Reversed 3D imaging (R3DI) is the reversed display method between anechoic area and echogenic area with adjusting the threshold of an echogenicity. The aim of this study was to clarify role and feasibility of R3DI in the pancreatico-biliary field. Patients and Methods: From November 2011 to October 2012, 35 patients who underwent R3DI-EUS were enrolled in this study. 35 patients consisted of 15 with pancreatic invasive ductal carcinoma (PC), 13 with intraductal papillary mucinous neoplasm: IPMNs (6 with an associated invasive carcinoma and 7 with low and intermediate-grade dysplasia), 7 with gallstone. 8 cases served as normal controls. R3DI-EUS was performed as follows: At first, target lesion was observed. Next, in order to acquire volume information (3D information), an endosonoscope was pulled from distal side of the lesion to the proximal side, that is, from anal side to oral side along the duodenum or stomach. Lastly, anechoic area was extracted from acquired volume data. The demonstration of the main pancreatic duct (MPD) and the common bile duct (CBD) was tested by R3DI-EUS in 8 normal controls. The apparatuses used were EG-3670URK (PENTAX, Tokyo, Japan) as an endosonoscope and Ascendus (HITACHI, Tokyo, Japan) as an ultrasound diagnostic machine. Results: PC: R3DI-EUS revealed the dilated upstream MPD to tumors in all cases mimicking MRCP (magnetic resonance cholangiopancreatography). IPMNs: R3DI-EUS demonstrated the whole 3D image of multilocular mass in all cases and communication between the lesion and the MPD in 10 out of 13 cases. Gallstone: R3DI-EUS depicted the stereoscopic image of gallbladder and CBD in all cases. Both MPD and CBD were illustrated by R3DI-EUS in all normal controls, furthermore, superior mesenteric vein and splenic vein were depicted stereoscopically in all cases. Conclusion: R3DI-EUS demonstrated the images mimicking MRCP and also surrounding vessels. Though R3DI-EUS images lack the positional information, the stereoscopic information of R3DI-EUS may be helpful in the diagnosis of pancreatico-biliary disorders.
Mo1535 Clinical Usefulness of Contrast-Enhanced Harmonic EUS in the Diagnosis of Malignant Polypoid Lesions of Gallbladder Jun-Ho Choi*, Dong Wan Seo, Do Hyun Park, Sang Soo Lee, Sung Koo Lee, Myung-Hwan Kim Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Background: The differential diagnosis between benign and malignant polypoid lesions of gallbladder (PLGs) is often difficult even by various examination methods. Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is a novel method that uses US contrast and depicts microvasculature in real time.
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB417
Abstracts
This study aims to evaluate whether CH-EUS might be an accurate method to discriminate malignant PLGs from benign PLGs with regard to the vessel and perfusion images. Methods: Between November 2010 and August 2012, a total of 76 patients with PLGs more than 10 mm in size who underwent CH-EUS and subsequent cholecystectomy were prospectively enrolled. SonoVue® (Bracco, Milan, Italy), a second-generation ultrasound contrast agent (UCA), was used as a contrast agent. CH-EUS was performed by using a radial echoendoscope and the extended pure harmonic detection mode. Two blinded reviewers classified the perfusion images into three categories as follows; diffuse enhancement, perfusion defect or nonenhancement. The vessel images were categorized as having a regular spotty vessel pattern, a irregular tortuous vessel pattern, or no vessels. Results: Irregular tortuous vessels were observed in 29 of 31 patients with malignant PLGs and 1 of 45 benign PLGs. Perfusion defects were found in 28 of 31 patients with malignant PLGs and 2 of 45 benign PLGs. A CH-EUSdetermined irregular tortuous vascular pattern could diagnose malignant PLG with a sensitivity and specificity of 96.6% and 95.6%, respectively. The presence of perfusion defects, determined by CH-EUS, was calculated to diagnose malignant PLG with a sensitivity and specificity of 93.3% and 93.4%, respectively. Defining biliary sludge by avascular-nonenhancement pattern showed a sensitivity and specificity of 100% and 100%, respectively. Conclusions: The presence of irregular tortuous vessels or perfusion defects on CH-EUS are sensitive and accurate predictors of malignant PLGs. CH-EUS can most accurately distinguish biliary sludge from other PLGs.
Mo1536 Endoscopic Ultrasound (EUS) Guided Pancreatic Duct Intervention: Outcomes of a Single Tertiary Referral Center Experience Larissa Fujii*1, Charles Lenz1, Barham K. Abu Dayyeh1, Todd H. Baron1, Suresh T. Chari1, Michael B. Farnell2, Ferga C. Gleeson1, Christopher J. Gostout1, Michael L. Kendrick2, Randall K. Pearson1, Bret T. Petersen1, Santhi Swaroop Vege1, Michael J. Levy1 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 2Division of General Surgery, Mayo Clinic, Rochester, MN Background: The role of EUS as a diagnostic and therapeutic modality is everexpanding for the management of pancreatic disorders. There is increasing use of EUS following failed endoscopic retrograde pancreatography (ERP) to access the main pancreatic duct (MPD). We aim to describe our experience and longterm outcomes for patients undergoing EUS-guided MPD intervention. Methods: A prospectively maintained EUS database was reviewed to identify all patients who underwent attempted EUS-guided MPD access. Presenting clinical, radiologic, endoscopic, and outcome data were analyzed. Results: Fifty-one patients (mean age 55 [SD 17], 25 men) underwent 57 EUS-guided procedures. Indications included recurrent acute pancreatitis (n⫽33), chronic pancreatitis (n⫽11), duct leak (n⫽3), retained surgical stent (n⫽2), cysts (n⫽1), and symptoms of weight loss (n⫽8), steatorrhea (n⫽6), or abdominal pain (n⫽26) with a dilated MPD. The intervention was necessitated by a failed ERP in 75% (n⫽38) and/or surgically altered anatomy (n⫽36), pancreas divisum (n⫽4), duodenal stricture (n⫽1), and ERCP-induced duodenal perforation (n⫽1). Median MPD measured 5 mm (0.8-8.5 mm). Among the 51 patients, 7 underwent EUS-guided pancreatography alone without stenting due to the absence of obstructive pathology. EUS was successful in removing 1 of 2 (50%) retained stents. In the remaining 42 patients, MPD stenting was the goal with technical success achieved in 32 (76%) with antegrade (n⫽17) or retrograde (n⫽15) insertion. Stenting was possible during the index exam in 30 (94%) patients. A total of 1 stent (n⫽30) or 2 stents (n⫽2) was placed during the initial exam. The maximum number of stents placed was 1, 2, 3, 4, or 5 stents in 18, 5, 6, 2, and 1 patient, respectively. Moderate-severe adverse events developed in 2 (4%) patients including acute pancreatitis (n⫽1) with an 11 day hospitalization and a peripancreatic abscess (n⫽1) that responded well to EUS-guided drainage. Abdominal pain requiring hospitalization of 2, 3, 4, and 5 days were reported in 8, 2, 1, and 2 patients, respectively. The guidewire coating was sheared and retained in one patient. Adequate follow-up was available for 31 of 32 stented patients. Complete clinical success with symptom resolution occurred in 17 (55%) at a mean of 17 months. Ten (32%) patients had partial clinical success with symptom recurrence at an average of 9.5 months. Four patients reported no symptom relief. Conclusions: EUS-guided MPD intervention following failed ERCP is safe and feasible in select patients and can obviate the need for percutaneous and surgical procedures. Our data suggest that many patients clinically benefit from such interventions, but that technical limitations and adverse events must be carefully considered. Additional clinical data are needed to define the long-term outcomes and role for these techniques.
Mo1537 Complications of Endoscopic Pancreatic Necrosectomy Jessica L. Abbott*1, Amy R. Welch1, Matthew T. Moyer2, Charles E. Dye2, Thomas J. Mcgarrity2, Brandy Dougherty-Hamod2, Raquel E. Davila2, Abraham Mathew2 1 Internal Medicine, Penn State Hershey Medical Center, Hershey, PA; 2 Gastroenterology-Hepatology, Penn State Hershey Medical Center, Hershey, PA Back ground: EUS-guided translumenal drainage and debridement is an accepted approach to the management of pancreatic abscesses and walled off pancreatic necrosis (WOPN) in severe necrotizing pancreatitis and carry lower rates of mortality and complications when compared with conventional surgical approaches. Further evidence of its efficacy and complications rates would be valuable. Objective: To investigate the immediate and delayed complications associated with endoscopic pancreatic necrosectomy.Patients: 48 patients with a history of pancreatitis and subsequent WOPN treated with endoscopic pancreatic necrosectomy at Penn State Hershey Medical Center. Methods: Electronic medical record of patients who had undergone endoscopic pancreatic necrosectomy from 2006 to current was reviewed and extracted. Patients were excluded if it had been less than 6 months since their necrosectomy to allow for at least 6 months of follow up. Complications were immediate if they occurred within 6 months of necrosectomy and delayed if after 6 months. Results: 48 patients underwent endoscopic evaluation of a WOPN. 45 procedures were successful (94%) and 3 failed attempts. Of those with successful endoscopic therapy, 4 patients had recurrence (3 with pancreatitis and 1 patient with new WOPN visualized on imaging), 16 patients had varying degrees of asymptomatic retained fluid post necrosectomy and 4 patients required surgery (2 patients with concerns for peritonitis, 1 to repair cyst gastrostomy bleeding, and 1 for placement of a davol drain to allow for further debridement). In those patients with successful necrosectomy, the most common complication within 6 months was bleeding. 4/45 or 9% of patients had procedural bleeding, with 1 patient requiring surgical intervention. One patient experienced a peritoneal leak and was managed conservatively. The six-month mortality rate was 2%. This patient had been re-admitted 20 days post-procedure at local hospital with sepsis after having missed his scheduled repeat procedure. The most common long-term complication was found to be diabetes at 48%. In those patients who survived after 6 months, mortality was 2/47 or 4%. One patient expired due to hemorrhagic shock from a retroperitoneal hematoma with concerns for a bowel perforation. This death was unrelated to necrosectomy as they were 2 years post procedure. The cause death is unknown in the second patient. Conclusion: The most common complication of pancreatic necrosectomy within 6 months of the procedure is bleeding; occurring in 9% of patients. Severe hemorrhage, requiring surgical intervention occurred in 2% of patients. 1 patient expired within 6 months of necrosectomy. Diabetes was observed as the most frequent (48%) delayed and overall complication. The overall mortality rate of WOPN treatment through endoscopic evaluation is 3/48 or 6%.
Mo1538 The Microbiome of Walled-off Pancreatic Necrosis (WOPN): Analysis of Blood and Direct WOPN Culture Results Nitin Kumar*, Darwin Conwell, Christopher C. Thompson Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA Background: The management of walled-off pancreatic necrosis (WOPN) is increasingly incorporating endoscopic techniques. WOPN culture is regularly obtained via EUS-guided needle aspiration prior to necrosectomy, but the character and significance of the WOPN microbiome remains unclear. Aim: To analyze and compare blood culture results and EUS-guided direct WOPN culture results in patients with symptomatic WOPN. Methods: Retrospective record review was conducted to identify patients who required endoscopic debridement of symptomatic WOPN between 2003 and 2012. Patients who had culture data from the endoscopic procedure were eligible for inclusion. Patients who had pseudocysts were excluded. WOPN culture data was obtained from the first endoscopic necrosectomy. Clinical success, defined as resolution of symptoms without need for further procedural intervention, was recorded. Results: 47 patients (27M/22F, 52.7 ⫾ 2.1 yr, Charlson comorbidity index 2.53 ⫾ 0.7, APACHE II 9.4 ⫾ 1.1 at admission) had DEN with microbiologic culture obtained from the WOPN. Two culture bottles had been inoculated in the procedure room during DEN in all patients. Blood cultures had been obtained on the inpatient floor within 7 days of DEN. Microbiologic data are reported in Table 1. Four cultures were polymicrobial. Gram positive organisms were most common, with the most common organism being alpha-hemolytic Streptococcus (6). The most common fungal organism was Candida albicans. WOPN culture was positive in 21/47 patients, versus 2/47 blood cultures (OR 18.2, 95% CI 3.9-83.8, p⬍0.001). Both blood cultures were later determined to be skin contaminants by the microbiology lab. 12 patients were on antibiotic therapy prior to DEN. There was no correlation between Gram positive, Gram negative, or fungal organisms and clinical failure of DEN. Conclusions: Patients undergoing DEN for symptomatic WOPN have diverse culture results with a variety of bacterial and fungal organisms. Blood cultures are insensitive for the detection of infected WOPN.
AB418 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
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