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P.14.19 THE CLINICAL IMPACT OF EARLY ENDOSCOPIC ULTRASOUND (EUS) IN SUSPECTED CHOLEDOCHOLITHIASIS: A PROSPECTIVE PILOT STUDY
S182
Abstracts of the 18th National Congress of Digestive Diseases / Digestive and Liver Disease 44S (2012) S55–S220
2009 to December 2010. Patients undergoing EUS were sedated with one of two different protocols: conscious sedation with midazolam or deep sedation with propofol. Results: 74 consecutive patients (mean age 73.4±10 years; 62 men) underwent esophageal resection with previous EUS stadiation for adenocarcinoma of the EGJ. 34 patients were sedated with midazolam and 40 patients were sedated with propofol. The mean dose of midazolam and propofol was, respectively, of 4.3 mg (range 2-6 mg) and 300 mg (range 180-400 mg).The overall accuracy for EUS in identifying the correct T stage was 74%. The overall accuracy of EUS for the diagnosis of N1 was 73%. The overall accuracy of EUS in differentiating T2 from T3 was 85% and in differentiating N0 from N1 was 90%. When analyzing the accuracy in stadiation between the two groups sedated with different protocols (midazolam vs propofol) the accuracy in identifying the correct T stage was 70% in the midazolam group and 78% in the propofol groups (p=0.07), the accuracy in diagnosis of N1 was 68% and 75% respectively (p=0.12). The accuracy in differentiating T2 stage from T3 and N0 stage from N1 was respectively 82% vs 87% and 85% vs 94% (p<0.05). Conclusions: The diagnostic accuracy of EUS in staging patients with cancer of the EGJ is still unsatisfactory. Our data show a trend towards a better performance of EUS when performed under deep sedation with propofol.
P.14.18
Group B: the stent removal occured after 2 months. The separation into to group permit us to evaluate if the different time of stent placement may influence the patients outcome. We define as treatment success when the patients don’t need others endoscopic treatment, for almost 12 months, with biliary strictures and cholestasis resolution. Results: Patients included were divided in two groups (A and B). We obtain a treatment success in 22/25 patients (88%). In the Group A (12 pat.) we observed 1 insuccess (8.3%). In the Group B (13 pat.) we observed 2 insuccess (15.4%) and in this group we observed the sole complication (ischemic anastomotic necrosis) after stent removal. Conclusions: The endoscopic placement of self-expanding metal stents in the treatment of biliary complications post OLTx is easy, safety and efficacy. Only one major complication occurred probably related to stent enlargement with vascular anastomosis compression and subseguent ischemia. Finally this is the first observation in which we found no difference in biliary stricture resolution between the two groups of patients, with different stent removal time. However to establish the optimal stent removal time is required randomized controlled trial for a longer period.
P.14.19 THE CLINICAL IMPACT OF EARLY ENDOSCOPIC ULTRASOUND (EUS) IN SUSPECTED CHOLEDOCHOLITHIASIS: A PROSPECTIVE PILOT STUDY
ENDOSCOPIC TREAMENT OF BILIARY ANASTOMOTIC STRICTURES AFTER LIVER TRANSPLANTATION WITH COVERED SELF-EXPANDABLE METALLIC STENTS
A. Anderloni ∗ , M. Ballarè, M. Galeazzi, M. Pagliarulo, S. Andorno, M. Del Piano
G. Zanasi ∗ , A. Tringali, C. Grosso, A. Rossi
Ospedale “Maggiore della Carità”, Novara, Italy
Ospedale Niguarda, Milano, Italy Background and aim: Biliary complications continue to be a major cause of morbidity in liver transplant recipients with an incidence of 10-30%. The most frequent complications are anastomotic biliary tract strictures, bile leaks, and bile duct stones. The aim of this prospective observational study was to treat the anastomotic strictures with fully covered self-expandable stents (HANAROSTENT), and analyze the necessary stents time placement to obtain the dilation of strictures. Material and methods: We included all patients with anastomotic biliary stricture with or without leak after OLTx from 6/2008 to 11/2010 to obtain a minimum follow-up time of 12 months. We included 25 patients of whom 7 were previous treated with plastic multistenting therapy without strictures resolution and 18 were treated for the first time with metallic stents. Three of these patient had biliary strictures with leak. These patients were randomly divided into two groups: Group A: the stent removal occured after 1 month.
Background and aim: EUS has been consistently shown to be accurate, safe and cost effective in diagnosing biliary obstructive disease compared with MRCP and ERCP and therefore in preventing unnecessary ERCP and its related complications. Aim: to investigate the clinical impact of early EUS in the management of suspected acute biliary obstructive disease caused by choledocholithiasis. Material and methods: From January 2010 to November 2011 all patients presenting to the A&E with clinical, biochemical or US suspicion of common bile duct (CBD) stone were prospectively included in the study and were categorized into low, moderate, and high probability of CBD stones. Exclusion criteria was gastrectomy. All the included patients underwent EUS within 48 hours from the admission. ERCP was performed immediately afterward if a biliary stone was identified. All patients were closely monitored after undergoing EUS and ERCP and early (1-month) and late (6-month) follow-up details were obtained by telephone. The following predictors were investigated: age, sex, dilated CBD, bilirubin, AST, ALT, gGT, ALP, amylase, and fever. Predictors significantly associated with CBD stones (p<0.05) were entered in a multivariate logistic regression model. Results: 149 patients (87 female), mean age 58,3 years (SD + 19,2), were prospectively included in the study. 36 patients were classified as low probability of CBD stones, 55 as moderate probability and 58 as high probability. 77 (51,7%) patients had CBD stones identified at EUS (11 with low probability, 26 with moderate probability and 40 with high probability) and confirmed at ERCP. 31% of patients with low risk were EUS positive and 31% of patients with high risk were EUS negative. Only CBD diameter was an independent predictor of CBD stones at multivariate analysis. None of the 72 patients with negative EUS had any biliary event during 6-month follow up.
Neg Pos Total
Low
Moderate
High
Total
25 11 36
29 26 55
18 40 58
72 77 149
Conclusions: Our results suggest that commonly used biochemical and radiological predictors of the presence of choledocholithiasis are unreliable. EUS seems to be safe and accurate in identifying CBD stones allowing immediate endoscopic treatment at the same session and avoiding unnecessary ERCP. An early EUS could be also used to select patients who don’t need ERCP for an early discharge.
Abstracts of the 18th National Congress of Digestive Diseases / Digestive and Liver Disease 44S (2012) S55–S220
2009 to December 2010. Patients undergoing EUS were sedated with one of two different protocols: conscious sedation with midazolam or deep sedation with propofol. Results: 74 consecutive patients (mean age 73.4±10 years; 62 men) underwent esophageal resection with previous EUS stadiation for adenocarcinoma of the EGJ. 34 patients were sedated with midazolam and 40 patients were sedated with propofol. The mean dose of midazolam and propofol was, respectively, of 4.3 mg (range 2-6 mg) and 300 mg (range 180-400 mg).The overall accuracy for EUS in identifying the correct T stage was 74%. The overall accuracy of EUS for the diagnosis of N1 was 73%. The overall accuracy of EUS in differentiating T2 from T3 was 85% and in differentiating N0 from N1 was 90%. When analyzing the accuracy in stadiation between the two groups sedated with different protocols (midazolam vs propofol) the accuracy in identifying the correct T stage was 70% in the midazolam group and 78% in the propofol groups (p=0.07), the accuracy in diagnosis of N1 was 68% and 75% respectively (p=0.12). The accuracy in differentiating T2 stage from T3 and N0 stage from N1 was respectively 82% vs 87% and 85% vs 94% (p<0.05). Conclusions: The diagnostic accuracy of EUS in staging patients with cancer of the EGJ is still unsatisfactory. Our data show a trend towards a better performance of EUS when performed under deep sedation with propofol.
P.14.18
Group B: the stent removal occured after 2 months. The separation into to group permit us to evaluate if the different time of stent placement may influence the patients outcome. We define as treatment success when the patients don’t need others endoscopic treatment, for almost 12 months, with biliary strictures and cholestasis resolution. Results: Patients included were divided in two groups (A and B). We obtain a treatment success in 22/25 patients (88%). In the Group A (12 pat.) we observed 1 insuccess (8.3%). In the Group B (13 pat.) we observed 2 insuccess (15.4%) and in this group we observed the sole complication (ischemic anastomotic necrosis) after stent removal. Conclusions: The endoscopic placement of self-expanding metal stents in the treatment of biliary complications post OLTx is easy, safety and efficacy. Only one major complication occurred probably related to stent enlargement with vascular anastomosis compression and subseguent ischemia. Finally this is the first observation in which we found no difference in biliary stricture resolution between the two groups of patients, with different stent removal time. However to establish the optimal stent removal time is required randomized controlled trial for a longer period.
P.14.19 THE CLINICAL IMPACT OF EARLY ENDOSCOPIC ULTRASOUND (EUS) IN SUSPECTED CHOLEDOCHOLITHIASIS: A PROSPECTIVE PILOT STUDY
ENDOSCOPIC TREAMENT OF BILIARY ANASTOMOTIC STRICTURES AFTER LIVER TRANSPLANTATION WITH COVERED SELF-EXPANDABLE METALLIC STENTS
A. Anderloni ∗ , M. Ballarè, M. Galeazzi, M. Pagliarulo, S. Andorno, M. Del Piano
G. Zanasi ∗ , A. Tringali, C. Grosso, A. Rossi
Ospedale “Maggiore della Carità”, Novara, Italy
Ospedale Niguarda, Milano, Italy Background and aim: Biliary complications continue to be a major cause of morbidity in liver transplant recipients with an incidence of 10-30%. The most frequent complications are anastomotic biliary tract strictures, bile leaks, and bile duct stones. The aim of this prospective observational study was to treat the anastomotic strictures with fully covered self-expandable stents (HANAROSTENT), and analyze the necessary stents time placement to obtain the dilation of strictures. Material and methods: We included all patients with anastomotic biliary stricture with or without leak after OLTx from 6/2008 to 11/2010 to obtain a minimum follow-up time of 12 months. We included 25 patients of whom 7 were previous treated with plastic multistenting therapy without strictures resolution and 18 were treated for the first time with metallic stents. Three of these patient had biliary strictures with leak. These patients were randomly divided into two groups: Group A: the stent removal occured after 1 month.
Background and aim: EUS has been consistently shown to be accurate, safe and cost effective in diagnosing biliary obstructive disease compared with MRCP and ERCP and therefore in preventing unnecessary ERCP and its related complications. Aim: to investigate the clinical impact of early EUS in the management of suspected acute biliary obstructive disease caused by choledocholithiasis. Material and methods: From January 2010 to November 2011 all patients presenting to the A&E with clinical, biochemical or US suspicion of common bile duct (CBD) stone were prospectively included in the study and were categorized into low, moderate, and high probability of CBD stones. Exclusion criteria was gastrectomy. All the included patients underwent EUS within 48 hours from the admission. ERCP was performed immediately afterward if a biliary stone was identified. All patients were closely monitored after undergoing EUS and ERCP and early (1-month) and late (6-month) follow-up details were obtained by telephone. The following predictors were investigated: age, sex, dilated CBD, bilirubin, AST, ALT, gGT, ALP, amylase, and fever. Predictors significantly associated with CBD stones (p<0.05) were entered in a multivariate logistic regression model. Results: 149 patients (87 female), mean age 58,3 years (SD + 19,2), were prospectively included in the study. 36 patients were classified as low probability of CBD stones, 55 as moderate probability and 58 as high probability. 77 (51,7%) patients had CBD stones identified at EUS (11 with low probability, 26 with moderate probability and 40 with high probability) and confirmed at ERCP. 31% of patients with low risk were EUS positive and 31% of patients with high risk were EUS negative. Only CBD diameter was an independent predictor of CBD stones at multivariate analysis. None of the 72 patients with negative EUS had any biliary event during 6-month follow up.
Neg Pos Total
Low
Moderate
High
Total
25 11 36
29 26 55
18 40 58
72 77 149
Conclusions: Our results suggest that commonly used biochemical and radiological predictors of the presence of choledocholithiasis are unreliable. EUS seems to be safe and accurate in identifying CBD stones allowing immediate endoscopic treatment at the same session and avoiding unnecessary ERCP. An early EUS could be also used to select patients who don’t need ERCP for an early discharge.