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Mo1536 Endoscopic Ultrasound (EUS) Guided Pancreatic Duct Intervention: Outcomes of a Single Tertiary Referral Center Experience
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
www.giejournal.org
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
www.giejournal.org