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Physician Controlled Wire Guided Cannulation of the Minor Papilla
Abstracts
Results: EUS-FNA and ERCP were performed under general anesthesia. The median procedure time was 75 minutes. A histological proof of cancer was obtained in 88% of patients after the initial EUS-FNA (100% after a second EUS-FNA). Biliary stent placement was successful in 98% and 5% had a biliary stent dysfunction and needed to undergo a second ERCP. All (5) patients with duodenal stenting had a soft or normal diet 48 hours. Procedure-related morbidity was 7% (1 case of pancreatitis, 2 cases of hemobilia, 1 case of sepsis and 5 cases of respiratory distress), but 4% (4 patients) died within 10 days of procedure from post-anesthesia complications. The mean hospitalization time after endoscopy was 13 days, including the first chemotherapy in 14% of patients. 64% of patients underwent chemotherapy within a median timespan of 20 days after endoscopic procedures. Conclusions: Combined EUS-FNA and stenting is feasible in nearly all patients with non-operable pancreatic cancer, with a high histological yield and rapid clinical recovery, allowing for prompt chemotherapy. However, a lengthy procedure and anesthesia can be harmful in the most-severely-ill patients.
Primary site of MPD lesions: head (NZ19), neck (NZ8), body (NZ2), tail (NZ2), diffuse (NZ1); POP failed to reach site of interest in the body in 1 pt. At index POP there were 17 tissue sampling events in 14 pts: 12 POP-directed biopsies, 3 POPassisted biopsies, 2 POP-assisted brush cytologies; 1 sample was inadequate. Mean follow up was 29.4 mo (range 1.7-82.3). Final diagnoses: 13 MPD neoplasm (4 adenocarcinoma, 7 MPD-IPMN, 1 mixed type IPMN, 1 malignant MPD-IPMN); 24 with no MPD neoplasm. Two adenocarcinomas were missed by POP (One Dx by EUS-FNA, one Dx at time of Puestow procedure). See table for sensitivity, specificity, PPV, NPV and accuracy of POP visualization, tissue sampling, and combined results. There were 8 complications (14.3%) after 56 POP: Pancreatitis (nZ6), pain exacerbation (nZ2); rates did not differ between those with and without neoplasia. Conclusions: In expert hands, pancreatoscopy with and without tissue sampling has overall excellent predictive value for suspected/indeterminate main pancreatic duct neoplasia. Operating Characteristics of Index Peroral Pancreatoscopy Sensitivity
T1327 Physician Controlled Wire Guided Cannulation of the Minor Papilla Tarek Ammar, John T. Maple, Michael Ansstas, Basem M. Abdeen, Gregory A. Cote, Riad R. Azar Objective: Cannulation of the minor papilla (MiP) can be challenging. Historically, specialty accessories and small caliber guidewires have been advocated for approaching the MiP. New short-wire ERCP platforms allow physicians to control the guidewire, and have facilitated wire-guided ductal cannulation via the major papilla. The aim of this study is to describe the efficacy and safety of MiP cannulation using standard accessories and a wire-guided technique. Methods: All patients who underwent attempted MiP cannulation by 2 endoscopists (RA, JM) at 2 tertiary care medical centers between July 2005 and November 2008 were identified using institutional databases. These endoscopists exclusively employed the following cannulation technique. The MiP is identified, with or without the aid of secretin, and generally approached using a ‘‘long scope’’ position. Cannulation is attempted with a 4.4Fr tip sphincterotome loaded with a 0.035", 260cm guidewire. With the sphincterotome hovering in the duodenum, the physician-controlled guidewire is used to cannulate the orifice of the MiP, and then gently advanced 15-20 mm or until any resistance is met, using fluoroscopic guidance. The wire is secured and the sphincterotome advanced until it enters or abuts the MiP. Contrast is injected to delineate the dorsal duct anatomy. The wire is advanced more deeply into the dorsal duct and re-secured. The sphincterotome is passed deep into the dorsal duct. However, if the orifice doesn’t permit passage of the sphincterotome, a needle knife is used to perform an access sphincterotomy alongside the guidewire. Electronic medical records were reviewed to assess for complications. Results: 24 patients were identified (14 women, mean age 46, 18 performed by RA). Procedure indications included recurrent acute pancreatitis in 17 patients (71%), idiopathic acute pancreatitis in 3 (13%), chronic pancreatitis in 1 (4%), and 3 patients had other indications. Pancreas divisum was suspected prior to the ERCP in 10 of 16 patients with prior imaging. Secretin was used in 9 patients (38%). MiP cannulation was successful in 23 patients (96%). Sphincterotomy followed by pancreatic stent placement (5-7 Fr) was performed in 20 patients (83%). The median procedure time (recorded in 18 patients) was 31 minutes. Complications occurred in 3 patients (13%), who developed mild post-ERCP pancreatitis. Conclusion: Physician-controlled wire-guided cannulation of the MiP using a 4.4Fr sphincterotome and 0.035" guidewire is an effective and safe technique that may obviate the need for specialty MiP accessories and small caliber guidewires. Further prospective evaluation of this technique is warranted.
T1328 Role of Peroral Pancreatoscopy (POP) in the Evaluation of Main Pancreatic Duct (MPD) Neoplasia Daniel A. Ringold, Raj J. Shah, Roy Yen, Brian C. Brauer, Norio Fukami, Yang K. Chen Background: POP has been used to assess MPD lesions in pts with known intraductal papillary mucinous neoplasms (IPMN) and to treat MPD stones. Its usefulness in the evaluation of indeterminate MPD strictures and/or dilatation and suspected IPMN remains unclear. We sought to determine the role of POP in pts with suspected MPD neoplasia. Methods: Retrospective review of all POP cases in our endoscopy database. Data collection included demographics, POP indications and findings, pathology, final diagnoses, complications, and follow-up. POP diagnosis was based on direct visualization and/or results of index POP tissue sampling. Final diagnosis was based on tissue confirmation of neoplasm or R 12 months of follow-up. Primary endpoint was presence or absence of MPD neoplasm. Chi square was used to compare proportions and t-test to compare means. Results: Of 75 POP performed from 1/00 to 6/07, 18 POP for stone therapy alone and 1 failed POP were excluded. 56 POP were performed in 37 pts to rule out MPD neoplasia (mean 1.5/pt); mean age 62.1 yr, 22 F, pts had a mean of 2.4 ERCP/EUS prior to index POP. Scopes: CHF BP30 (nZ30), SpyGlassTM (NZ4), CHF BP160 (nZ2) & FCP9P (nZ1). POP indications: 20 indeterminate strictures, 17 duct dilatation and suspected MPD IPMN. POP findings: 32 had discrete MPD lesions and 5 did not.
AB268 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
Pancreatoscopy-directed and -assisted Tissue Sampling Pancreatoscopy Visualization Combined
NPV
Accuracy
70%
Specificity PPV 100%
100%
57.1%
78.6%
76.9% 84.6%
100% 100%
100% 100%
88.9% 92.3%
91.8% 94.6%
T1329 The Results of the Tokyo Trial of Prevention of Post-ERCP Pancreatitis with Risperidone (Tokyo P3R) Hiroyuki Isayama, Takeshi Tsujino, Yukiko Ito, Yousuke Nakai, Suguru Mizuno, Keisuke Yamamoto, Hiroshi Yagioka, Yoko Yashima, Kazumichi Kawakubo, Takashi Sasaki, Hirofumi Kogure, Osamu Togawa, Toshihiko Arizumi, Saburo Matsubara, Kenji Hirano, Naoki Sasahira, Nobuo Toda, Minoru Tada, Takao Kawabe, Masao Omata Background and Aims: Pancreatitis remains the major complication of endoscopic retrograde cholangiopancreatography (ERCP), and hyperenzymemia after ERCP is common. We had reported that ulinastatin, a protease inhibitor, was effective to prevent post ERCP pancreatitis (PEP) and hyper amylasemia (PEA) (Clinical Gastroenterology and Hepatology 2005; 3: 376-383.). Risperidone is a serotonin (5-HT) antagonist, especially selectively blocks 5-HT2A, has been reported the efficacy in the prevention and treatment of cerulean-induced pancreatitis in mice (J Pharmacol Sci. 2007; 105: 240-50.). The aim of this study was to assess the additional effect of risperidone on ulinastatin for the prevention of post-ERCP pancreatitis and hyperenzymemia. Methods: In a multicenter, randomized, parallelgroup controlled trial, patients undergoing a therapeutic-ERCP were randomly assigned to risperidone (1 mg) and ulinastatin (150,000 U) or urinastatin alone. Risperidone tablet was taken orally per 30-60 minutes before ERCP and ulinastatin was infused by intravenous route for 10 minutes just prior to ERCP. All patients were hospitalized at least 24 hours after ERCP for evaluation of clinical symptoms. Serum pancreatic enzymes (Amylase and lipase) levels were measured at baseline, 4 and 18 hours after ERCP. The primary end point was the incidence of post-ERCP pancreatitis and others were severity, hyperenzymemia and levels of enzymes. Results: A total of 300 patients were enrolled (150 in the risperidone and ulinastatin (RU) group and 150 in the ulinastatin alone (U) group). There were no differences between the 2 groups regarding baseline characteristics, details of fluoroscopic findings, or endoscopic procedure. The comparison between RU group and U group were as follows; hyper-amylasemia (18.2% vs 20.7%; 0.6437) and mean amylase level after 18 hours (239.7 vs 345.4; pZ0.0651), hyper-lipasemia (27.7% vs 37.0%; pZ0.0806) and 18 hours (219.8 vs 395.5; pZ0.0 425). Six patients in RU group and 9 patients in U group developed pancreatitis (4.1% vs. 6.2%, pZ0.5975). The incidence of severe/moderate pancreatitis in RU group (1/147; 0.7%) was lower than U group (5/146; 3.3%), but there was no significant difference between 2 groups (pZ0.1205). There was no complication in both groups. Conclusions: Prophylactic risperidone revealed additional effect to ulinastatin showing lower incidence of pancreatitis, its severity and hyperenzymemias, and decrease the level of enzymes, especially lipase. Patients may have benefits with risperidone as the adjunctive therapy to avoid the ERCP-related pancreatitis, but further placebocontrolled studies are needed to confirm the present results.
T1330 EUS Guided Methylene Blue Pancreatography Facilitates Pancreatic Duct Cannulation in Patients with Restenosis of Prior Endoscopic Sphincterotomy or Surgical Sphincteroplasty and in Patients with Pancreas Divisum Olga Barkay, Byung Moo Yoo, Lee McHenry, Evan L. Fogel, James L. Watkins, Stuart Sherman, John M. DeWitt, Glen A. Lehman Background and Aims: Endoscopic retrograde pancreatography (ERP) is an important tool in the management of a variety of pancreatic diseases. However, localization of the pancreatic duct (PD) orifice may be difficult in patients with
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Results: EUS-FNA and ERCP were performed under general anesthesia. The median procedure time was 75 minutes. A histological proof of cancer was obtained in 88% of patients after the initial EUS-FNA (100% after a second EUS-FNA). Biliary stent placement was successful in 98% and 5% had a biliary stent dysfunction and needed to undergo a second ERCP. All (5) patients with duodenal stenting had a soft or normal diet 48 hours. Procedure-related morbidity was 7% (1 case of pancreatitis, 2 cases of hemobilia, 1 case of sepsis and 5 cases of respiratory distress), but 4% (4 patients) died within 10 days of procedure from post-anesthesia complications. The mean hospitalization time after endoscopy was 13 days, including the first chemotherapy in 14% of patients. 64% of patients underwent chemotherapy within a median timespan of 20 days after endoscopic procedures. Conclusions: Combined EUS-FNA and stenting is feasible in nearly all patients with non-operable pancreatic cancer, with a high histological yield and rapid clinical recovery, allowing for prompt chemotherapy. However, a lengthy procedure and anesthesia can be harmful in the most-severely-ill patients.
Primary site of MPD lesions: head (NZ19), neck (NZ8), body (NZ2), tail (NZ2), diffuse (NZ1); POP failed to reach site of interest in the body in 1 pt. At index POP there were 17 tissue sampling events in 14 pts: 12 POP-directed biopsies, 3 POPassisted biopsies, 2 POP-assisted brush cytologies; 1 sample was inadequate. Mean follow up was 29.4 mo (range 1.7-82.3). Final diagnoses: 13 MPD neoplasm (4 adenocarcinoma, 7 MPD-IPMN, 1 mixed type IPMN, 1 malignant MPD-IPMN); 24 with no MPD neoplasm. Two adenocarcinomas were missed by POP (One Dx by EUS-FNA, one Dx at time of Puestow procedure). See table for sensitivity, specificity, PPV, NPV and accuracy of POP visualization, tissue sampling, and combined results. There were 8 complications (14.3%) after 56 POP: Pancreatitis (nZ6), pain exacerbation (nZ2); rates did not differ between those with and without neoplasia. Conclusions: In expert hands, pancreatoscopy with and without tissue sampling has overall excellent predictive value for suspected/indeterminate main pancreatic duct neoplasia. Operating Characteristics of Index Peroral Pancreatoscopy Sensitivity
T1327 Physician Controlled Wire Guided Cannulation of the Minor Papilla Tarek Ammar, John T. Maple, Michael Ansstas, Basem M. Abdeen, Gregory A. Cote, Riad R. Azar Objective: Cannulation of the minor papilla (MiP) can be challenging. Historically, specialty accessories and small caliber guidewires have been advocated for approaching the MiP. New short-wire ERCP platforms allow physicians to control the guidewire, and have facilitated wire-guided ductal cannulation via the major papilla. The aim of this study is to describe the efficacy and safety of MiP cannulation using standard accessories and a wire-guided technique. Methods: All patients who underwent attempted MiP cannulation by 2 endoscopists (RA, JM) at 2 tertiary care medical centers between July 2005 and November 2008 were identified using institutional databases. These endoscopists exclusively employed the following cannulation technique. The MiP is identified, with or without the aid of secretin, and generally approached using a ‘‘long scope’’ position. Cannulation is attempted with a 4.4Fr tip sphincterotome loaded with a 0.035", 260cm guidewire. With the sphincterotome hovering in the duodenum, the physician-controlled guidewire is used to cannulate the orifice of the MiP, and then gently advanced 15-20 mm or until any resistance is met, using fluoroscopic guidance. The wire is secured and the sphincterotome advanced until it enters or abuts the MiP. Contrast is injected to delineate the dorsal duct anatomy. The wire is advanced more deeply into the dorsal duct and re-secured. The sphincterotome is passed deep into the dorsal duct. However, if the orifice doesn’t permit passage of the sphincterotome, a needle knife is used to perform an access sphincterotomy alongside the guidewire. Electronic medical records were reviewed to assess for complications. Results: 24 patients were identified (14 women, mean age 46, 18 performed by RA). Procedure indications included recurrent acute pancreatitis in 17 patients (71%), idiopathic acute pancreatitis in 3 (13%), chronic pancreatitis in 1 (4%), and 3 patients had other indications. Pancreas divisum was suspected prior to the ERCP in 10 of 16 patients with prior imaging. Secretin was used in 9 patients (38%). MiP cannulation was successful in 23 patients (96%). Sphincterotomy followed by pancreatic stent placement (5-7 Fr) was performed in 20 patients (83%). The median procedure time (recorded in 18 patients) was 31 minutes. Complications occurred in 3 patients (13%), who developed mild post-ERCP pancreatitis. Conclusion: Physician-controlled wire-guided cannulation of the MiP using a 4.4Fr sphincterotome and 0.035" guidewire is an effective and safe technique that may obviate the need for specialty MiP accessories and small caliber guidewires. Further prospective evaluation of this technique is warranted.
T1328 Role of Peroral Pancreatoscopy (POP) in the Evaluation of Main Pancreatic Duct (MPD) Neoplasia Daniel A. Ringold, Raj J. Shah, Roy Yen, Brian C. Brauer, Norio Fukami, Yang K. Chen Background: POP has been used to assess MPD lesions in pts with known intraductal papillary mucinous neoplasms (IPMN) and to treat MPD stones. Its usefulness in the evaluation of indeterminate MPD strictures and/or dilatation and suspected IPMN remains unclear. We sought to determine the role of POP in pts with suspected MPD neoplasia. Methods: Retrospective review of all POP cases in our endoscopy database. Data collection included demographics, POP indications and findings, pathology, final diagnoses, complications, and follow-up. POP diagnosis was based on direct visualization and/or results of index POP tissue sampling. Final diagnosis was based on tissue confirmation of neoplasm or R 12 months of follow-up. Primary endpoint was presence or absence of MPD neoplasm. Chi square was used to compare proportions and t-test to compare means. Results: Of 75 POP performed from 1/00 to 6/07, 18 POP for stone therapy alone and 1 failed POP were excluded. 56 POP were performed in 37 pts to rule out MPD neoplasia (mean 1.5/pt); mean age 62.1 yr, 22 F, pts had a mean of 2.4 ERCP/EUS prior to index POP. Scopes: CHF BP30 (nZ30), SpyGlassTM (NZ4), CHF BP160 (nZ2) & FCP9P (nZ1). POP indications: 20 indeterminate strictures, 17 duct dilatation and suspected MPD IPMN. POP findings: 32 had discrete MPD lesions and 5 did not.
AB268 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
Pancreatoscopy-directed and -assisted Tissue Sampling Pancreatoscopy Visualization Combined
NPV
Accuracy
70%
Specificity PPV 100%
100%
57.1%
78.6%
76.9% 84.6%
100% 100%
100% 100%
88.9% 92.3%
91.8% 94.6%
T1329 The Results of the Tokyo Trial of Prevention of Post-ERCP Pancreatitis with Risperidone (Tokyo P3R) Hiroyuki Isayama, Takeshi Tsujino, Yukiko Ito, Yousuke Nakai, Suguru Mizuno, Keisuke Yamamoto, Hiroshi Yagioka, Yoko Yashima, Kazumichi Kawakubo, Takashi Sasaki, Hirofumi Kogure, Osamu Togawa, Toshihiko Arizumi, Saburo Matsubara, Kenji Hirano, Naoki Sasahira, Nobuo Toda, Minoru Tada, Takao Kawabe, Masao Omata Background and Aims: Pancreatitis remains the major complication of endoscopic retrograde cholangiopancreatography (ERCP), and hyperenzymemia after ERCP is common. We had reported that ulinastatin, a protease inhibitor, was effective to prevent post ERCP pancreatitis (PEP) and hyper amylasemia (PEA) (Clinical Gastroenterology and Hepatology 2005; 3: 376-383.). Risperidone is a serotonin (5-HT) antagonist, especially selectively blocks 5-HT2A, has been reported the efficacy in the prevention and treatment of cerulean-induced pancreatitis in mice (J Pharmacol Sci. 2007; 105: 240-50.). The aim of this study was to assess the additional effect of risperidone on ulinastatin for the prevention of post-ERCP pancreatitis and hyperenzymemia. Methods: In a multicenter, randomized, parallelgroup controlled trial, patients undergoing a therapeutic-ERCP were randomly assigned to risperidone (1 mg) and ulinastatin (150,000 U) or urinastatin alone. Risperidone tablet was taken orally per 30-60 minutes before ERCP and ulinastatin was infused by intravenous route for 10 minutes just prior to ERCP. All patients were hospitalized at least 24 hours after ERCP for evaluation of clinical symptoms. Serum pancreatic enzymes (Amylase and lipase) levels were measured at baseline, 4 and 18 hours after ERCP. The primary end point was the incidence of post-ERCP pancreatitis and others were severity, hyperenzymemia and levels of enzymes. Results: A total of 300 patients were enrolled (150 in the risperidone and ulinastatin (RU) group and 150 in the ulinastatin alone (U) group). There were no differences between the 2 groups regarding baseline characteristics, details of fluoroscopic findings, or endoscopic procedure. The comparison between RU group and U group were as follows; hyper-amylasemia (18.2% vs 20.7%; 0.6437) and mean amylase level after 18 hours (239.7 vs 345.4; pZ0.0651), hyper-lipasemia (27.7% vs 37.0%; pZ0.0806) and 18 hours (219.8 vs 395.5; pZ0.0 425). Six patients in RU group and 9 patients in U group developed pancreatitis (4.1% vs. 6.2%, pZ0.5975). The incidence of severe/moderate pancreatitis in RU group (1/147; 0.7%) was lower than U group (5/146; 3.3%), but there was no significant difference between 2 groups (pZ0.1205). There was no complication in both groups. Conclusions: Prophylactic risperidone revealed additional effect to ulinastatin showing lower incidence of pancreatitis, its severity and hyperenzymemias, and decrease the level of enzymes, especially lipase. Patients may have benefits with risperidone as the adjunctive therapy to avoid the ERCP-related pancreatitis, but further placebocontrolled studies are needed to confirm the present results.
T1330 EUS Guided Methylene Blue Pancreatography Facilitates Pancreatic Duct Cannulation in Patients with Restenosis of Prior Endoscopic Sphincterotomy or Surgical Sphincteroplasty and in Patients with Pancreas Divisum Olga Barkay, Byung Moo Yoo, Lee McHenry, Evan L. Fogel, James L. Watkins, Stuart Sherman, John M. DeWitt, Glen A. Lehman Background and Aims: Endoscopic retrograde pancreatography (ERP) is an important tool in the management of a variety of pancreatic diseases. However, localization of the pancreatic duct (PD) orifice may be difficult in patients with
www.giejournal.org