- Email: [email protected]
Prostheses Protected Sphincterotomy - A Safe Way for Therapeutic ERCP in Billroth II-Patients
Abstracts
W1438 Techniques for Cannulation of the Bile Duct During Endoscopic Retrograde Cholangiopancreatography (ERCP) Hiroshi Imaizumi, Mitsuhiro Kida, Hidehiko Kikuchi, Miyoko Takezawa, Yoshiki Kida, Katsunori Saigenji Introduction: Techniques for deep cannulation of the bile duct or pancreatic duct are essential for endoscopic transpapillary treatment. However, deep cannulation of the bile duct is sometimes difficult, resulting in a prolonged treatment time or even the abandonment of therapy. Expedient deep cannulation of the bile duct is considered to have a key role in therapeutic ERCP. We compared the usefulness of a guide wire used with a standard catheter with that of a guide wire used with a papillotome for deep cannulation of the bile duct during ERCP. Aims & Methods: We studied 89 patients who underwent ERCP to permit cholangiography. Patients who had undergone a Billroth II gastrectomy or who had papillary tumors were excluded. Patients were randomly assigned to undergo deep cannulation of the bile duct by means of a guide wire used with a standard catheter (catheter group) or a guide wire used with a papillotome (papillotome group) before ERCP. Cannulation with the assigned procedure was performed within 5 minutes. If the bile duct was not deeply cannulated within 5 minutes by means of the assigned procedure, the operator switched to an appropriate technique for cannulation. The rate of successful cannulation of the bile duct and the incidences of hyperamylasemia and pancreatitis were compared between the groups. Results: A total of 89 patients were enrolled. The mean age of the patients was 64.7 years. The male:female ratio was 47:42. The overall rate of successful cannulation of the bile duct was 95.5%. The failure rate was 4.5% (4 patients). Before ERCP 40 were assigned to the catheter group and 49 to the papillotome group. Cannulation of the bile duct by the randomly assigned cannulation technique was accomplished within 5 minutes in 44 patients (49%). The rate of successful cannulation of the bile duct did not significantly differ between the catheter group (43%, 17/40) and the papillotome group (55%, 27/49). The incidences of hyperamylasemia and pancreatitis were respectively 17% and 1.1% in the catheter group as compared with 22% and 1.4% in the papillotome group. These differences were not significant. Conclusion: The rate of successful cannulation of the bile duct and the incidence of complications did not differ significantly between the catheter group and papillotome group. Cannulation of the bile duct before diagnostic ERCP is usually done with a procedure familiar to the operator. When ERCP is performed before endoscopic sphincterotomy, however, the bile duct should be cannulated with a papillotome to avoid the need for changing devices and to shorten the treatment time.
W1439 Endoscopic Treatment for Common Bile Duct Stricture Due to Blunt Abdominal Trauma Do Hyun Park, Myung-Hwan Kim, Sang Soo Lee, Tae-Nyun Kim, Hyun-Young Son, Jong Cheol Kim, Dong Wan Seo, Sung Koo Lee, Jung Sik Choi Background/Aims: Common bile duct stricture associated with blunt abdominal trauma is extremely rare. Therefore, definite treatment modality for this stricture was unclear. To evaluate the efficacy of endoscopic treatment for common bile duct stricture due to blunt abdominal trauma, we undertook this study. Materials and Methods: Medical record, ERCP, and CT findings were reviewed in all cases which collected from a database of 19,048 ERCP between January 1994 and December 2004. The diagnosis of biliary stricture due to blunt abdominal trauma was based on the following criteria: a proved history of blunt abdominal trauma, absence of biliary symptoms before trauma, onset of biliary symptoms after trauma, and confirmation of biliary stricture at ERCP. Results: A total 12 patients (9 males, and 3 females) were with a median age 34.5 years (Interquartile range (IQR) 25-50 years) were included in this study. Most common causes of blunt abdominal trauma was automobile accident associated steering injury (8/12, 67%). others causes were fall in two, blow injury in one, and slip down in one, respectively. All included patients showed jaundice as the initial symptoms due to biliary stricture. The interval between initial trauma and onset of symptoms was 15-390 days (median, 26 days). Median length of biliary stricture was 1cm (IQR 0.6-1.8 cm). The location of stricture was suprapancreatic portion in ten, and intranpancreatic portion in two, respectively. Endoscopic plastic stent placement was performed in all included patients. Duration of stent placement was 2-12 months (median, 2.5 months). Two patients who had delayed onset (115 days in one, and 390 days in one, respectively) of symptoms could be needed longer stent placement (6 months, and 12 months, respectively) because of residual strictures. Follow-up ERCP showed improved or resolved biliary stricture in all patients. There was no recurrence of symptoms after removal of the stents, therefore, surgery was completely avoided in these patients. Conclusions: Our study suggested that endoscopic placement for biliary stricture due to blunt abdominal trauma may be feasible and effective.
www.giejournal.org
W1440 Endoscopic Biliary Brush Microsatellite Loss Analysis in Primary Sclerosing Cholangitis and Associated Cholangiocarcinoma Asif Khalid, Laurentia Nodit, Stephen Raab, Ahmad Jawad, Debra Brody, Kathy Bauer, Kevin Mcgrath, David Whitcomb, Adam Slivka, Sydney Finkelstein Background: Early and accurate detection of cholangiocarcinoma (CC) in primary sclerosing cholangitis (PSC) with currently available tools is challenging. The role of molecular analysis in this area remains unclear. Methods: 25 patients with prior extra-hepatic biliary brushings of a dominant stricture and surgically proven diagnosis were studied (10 PSC associated CC [PSC-CC], 5 PSC, and 10 controls; 7 CC without PSC and 3 strictures due to chronic pancreatitis [CP]). Only 3 PSC-CC and 1 CC brush cytology was positive for cancer. Multiple sequential brushings from 3 cases of PSC-CC (11 brushings over 65 months) and 3 cases of PSC (8 brushings over 180 months) are included to detect a possible trend in accumulating DNA damage. Representative cells were microdissected from each brush sample and surgical correlate. Following PCR amplification the products were subjected to allelic loss analysis (targeting 15 microsatellites situated at 1p, 3p, 5q, 9p, 9q, 10q, 17p, 17q, 21q and 22q) utilizing fluorescent capillary electrophoresis. Fractional allelic loss (FAL) was calculated and compared for each group. Results: (see table) DNA from 1 case with PSC-CC failed to amplify. 9/9 PSC-CC and 7/7 CC cases carried multiple losses (FAL-0.32 and 0.33 respectively), regardless of cytology interpretation. Microsatellite losses were seen in 3/5 PSC cases (FAL-0.16) and none of the CP cases. Sequential brushings from the 6 cases showed near perfect concordance. MB-LOH from the brushings correlated well with that of the surgical specimens. PSC-CC and CC can be differentiated from CP (p ! 0.01) using this technique. Although the mean FAL for the PSC cases is lower than PSC-CC cases, this did not reach statistical significance. Conclusions: MB-LOH can be reliably performed on biliary brushings and differentiates malignant and non-PSC benign strictures. Similar to CC and PSC-CC, abundant mutational damage was seen in histological benign PSC. It is unclear if the PSC cases with LOH would have gone on to develop CC. This raises the unique possibility of using these markers to guide the timing of liver transplantation. Large prospective studies however are required to detect a degree or pattern of mutational damage that aids in the early and accurate diagnosis of CC in PSC. Pathology
Cases
Cytology
FAL-Brush
FAL-Surgery
PSC-CC
9
PSC
5
PositiveZ3 InconclusiveZ2 NegativeZ4 InconclusiveZ1 NegativeZ4
CC
7
PositiveZ1 InconclusiveZ6
CP
3
InconclusiveZ1 NegativeZ2
0.32 C/ 0.12 0.16 C/ 0.2 0.32 C/ 0.08 0
0.38 C/ 0.10 0.17 C/ 0.10 0.44 C/ 0.11 0
W1441 Prostheses Protected Sphincterotomy - A Safe Way for Therapeutic ERCP in Billroth II-Patients Michael Bertullies, Rolf Drossel, Frank Kinzel, Hans Joachim Schulz Endoscopic sphincterotomy (EST) is difficult in patients who have undergone partial gastrectomy with Billroth II anastomoses. This study describes our experience using prostheses protected sphincterotomy in Billroth II patients. Methods: Prospective Study of 729 patients with Billroth II anastomoses undergoing ERCP including therapeutic interventions between 01/88-12/04. Details noted included indications for ERCP, therapeutic interventions, causes of failure and complications. Results: Success rate of diagnostic ERCP was 75,8% (553/729). Major indications for ERCP were common bile duct stones (52%), jaundice of unknown origin (19%), chronic pancreatitis (9%) and malignant tumors (9%). Interventional endoscopy was performed in 271 patients. Since 1993 we performed prostheses protected sphincterotomy . In comparison to conventional EST we could increase the efficiency of EST from 92,6% (1988-1992, n Z 95) to 96,8% (1993-2004; n Z 189). Complete extraction of bile duct stones was achieved in 79,3% (249/314;1988-1992 73,5%, n Z 83; 1993-2004 81,4%, n Z 231). Sufficient bile drainage was achieved by placement of transpapillary endoprostheses in 98% (183/ 186). The overall complication rate was 5,1% (37/729). The major complication of the procedure was perforation (1,8%, 1/729). 8 perforations occurred in the small bowel while the endoscope was being manipulated through the afferent loop, 5 patients had retroduodenal perforations. 9 patients suffered from bleeding after sphincterotomy (9/314 , 2,9%), 8 (1,1%) patient developed acute pancreatitis and 7 (1%) patients acute cholangitis. Conclusion: Prostheses protected sphincterotomy is a safe and useful technique in treatment of biliary obstructions in Billroth II patients. It can increase the success rate and reduce potential risks.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB299
W1438 Techniques for Cannulation of the Bile Duct During Endoscopic Retrograde Cholangiopancreatography (ERCP) Hiroshi Imaizumi, Mitsuhiro Kida, Hidehiko Kikuchi, Miyoko Takezawa, Yoshiki Kida, Katsunori Saigenji Introduction: Techniques for deep cannulation of the bile duct or pancreatic duct are essential for endoscopic transpapillary treatment. However, deep cannulation of the bile duct is sometimes difficult, resulting in a prolonged treatment time or even the abandonment of therapy. Expedient deep cannulation of the bile duct is considered to have a key role in therapeutic ERCP. We compared the usefulness of a guide wire used with a standard catheter with that of a guide wire used with a papillotome for deep cannulation of the bile duct during ERCP. Aims & Methods: We studied 89 patients who underwent ERCP to permit cholangiography. Patients who had undergone a Billroth II gastrectomy or who had papillary tumors were excluded. Patients were randomly assigned to undergo deep cannulation of the bile duct by means of a guide wire used with a standard catheter (catheter group) or a guide wire used with a papillotome (papillotome group) before ERCP. Cannulation with the assigned procedure was performed within 5 minutes. If the bile duct was not deeply cannulated within 5 minutes by means of the assigned procedure, the operator switched to an appropriate technique for cannulation. The rate of successful cannulation of the bile duct and the incidences of hyperamylasemia and pancreatitis were compared between the groups. Results: A total of 89 patients were enrolled. The mean age of the patients was 64.7 years. The male:female ratio was 47:42. The overall rate of successful cannulation of the bile duct was 95.5%. The failure rate was 4.5% (4 patients). Before ERCP 40 were assigned to the catheter group and 49 to the papillotome group. Cannulation of the bile duct by the randomly assigned cannulation technique was accomplished within 5 minutes in 44 patients (49%). The rate of successful cannulation of the bile duct did not significantly differ between the catheter group (43%, 17/40) and the papillotome group (55%, 27/49). The incidences of hyperamylasemia and pancreatitis were respectively 17% and 1.1% in the catheter group as compared with 22% and 1.4% in the papillotome group. These differences were not significant. Conclusion: The rate of successful cannulation of the bile duct and the incidence of complications did not differ significantly between the catheter group and papillotome group. Cannulation of the bile duct before diagnostic ERCP is usually done with a procedure familiar to the operator. When ERCP is performed before endoscopic sphincterotomy, however, the bile duct should be cannulated with a papillotome to avoid the need for changing devices and to shorten the treatment time.
W1439 Endoscopic Treatment for Common Bile Duct Stricture Due to Blunt Abdominal Trauma Do Hyun Park, Myung-Hwan Kim, Sang Soo Lee, Tae-Nyun Kim, Hyun-Young Son, Jong Cheol Kim, Dong Wan Seo, Sung Koo Lee, Jung Sik Choi Background/Aims: Common bile duct stricture associated with blunt abdominal trauma is extremely rare. Therefore, definite treatment modality for this stricture was unclear. To evaluate the efficacy of endoscopic treatment for common bile duct stricture due to blunt abdominal trauma, we undertook this study. Materials and Methods: Medical record, ERCP, and CT findings were reviewed in all cases which collected from a database of 19,048 ERCP between January 1994 and December 2004. The diagnosis of biliary stricture due to blunt abdominal trauma was based on the following criteria: a proved history of blunt abdominal trauma, absence of biliary symptoms before trauma, onset of biliary symptoms after trauma, and confirmation of biliary stricture at ERCP. Results: A total 12 patients (9 males, and 3 females) were with a median age 34.5 years (Interquartile range (IQR) 25-50 years) were included in this study. Most common causes of blunt abdominal trauma was automobile accident associated steering injury (8/12, 67%). others causes were fall in two, blow injury in one, and slip down in one, respectively. All included patients showed jaundice as the initial symptoms due to biliary stricture. The interval between initial trauma and onset of symptoms was 15-390 days (median, 26 days). Median length of biliary stricture was 1cm (IQR 0.6-1.8 cm). The location of stricture was suprapancreatic portion in ten, and intranpancreatic portion in two, respectively. Endoscopic plastic stent placement was performed in all included patients. Duration of stent placement was 2-12 months (median, 2.5 months). Two patients who had delayed onset (115 days in one, and 390 days in one, respectively) of symptoms could be needed longer stent placement (6 months, and 12 months, respectively) because of residual strictures. Follow-up ERCP showed improved or resolved biliary stricture in all patients. There was no recurrence of symptoms after removal of the stents, therefore, surgery was completely avoided in these patients. Conclusions: Our study suggested that endoscopic placement for biliary stricture due to blunt abdominal trauma may be feasible and effective.
www.giejournal.org
W1440 Endoscopic Biliary Brush Microsatellite Loss Analysis in Primary Sclerosing Cholangitis and Associated Cholangiocarcinoma Asif Khalid, Laurentia Nodit, Stephen Raab, Ahmad Jawad, Debra Brody, Kathy Bauer, Kevin Mcgrath, David Whitcomb, Adam Slivka, Sydney Finkelstein Background: Early and accurate detection of cholangiocarcinoma (CC) in primary sclerosing cholangitis (PSC) with currently available tools is challenging. The role of molecular analysis in this area remains unclear. Methods: 25 patients with prior extra-hepatic biliary brushings of a dominant stricture and surgically proven diagnosis were studied (10 PSC associated CC [PSC-CC], 5 PSC, and 10 controls; 7 CC without PSC and 3 strictures due to chronic pancreatitis [CP]). Only 3 PSC-CC and 1 CC brush cytology was positive for cancer. Multiple sequential brushings from 3 cases of PSC-CC (11 brushings over 65 months) and 3 cases of PSC (8 brushings over 180 months) are included to detect a possible trend in accumulating DNA damage. Representative cells were microdissected from each brush sample and surgical correlate. Following PCR amplification the products were subjected to allelic loss analysis (targeting 15 microsatellites situated at 1p, 3p, 5q, 9p, 9q, 10q, 17p, 17q, 21q and 22q) utilizing fluorescent capillary electrophoresis. Fractional allelic loss (FAL) was calculated and compared for each group. Results: (see table) DNA from 1 case with PSC-CC failed to amplify. 9/9 PSC-CC and 7/7 CC cases carried multiple losses (FAL-0.32 and 0.33 respectively), regardless of cytology interpretation. Microsatellite losses were seen in 3/5 PSC cases (FAL-0.16) and none of the CP cases. Sequential brushings from the 6 cases showed near perfect concordance. MB-LOH from the brushings correlated well with that of the surgical specimens. PSC-CC and CC can be differentiated from CP (p ! 0.01) using this technique. Although the mean FAL for the PSC cases is lower than PSC-CC cases, this did not reach statistical significance. Conclusions: MB-LOH can be reliably performed on biliary brushings and differentiates malignant and non-PSC benign strictures. Similar to CC and PSC-CC, abundant mutational damage was seen in histological benign PSC. It is unclear if the PSC cases with LOH would have gone on to develop CC. This raises the unique possibility of using these markers to guide the timing of liver transplantation. Large prospective studies however are required to detect a degree or pattern of mutational damage that aids in the early and accurate diagnosis of CC in PSC. Pathology
Cases
Cytology
FAL-Brush
FAL-Surgery
PSC-CC
9
PSC
5
PositiveZ3 InconclusiveZ2 NegativeZ4 InconclusiveZ1 NegativeZ4
CC
7
PositiveZ1 InconclusiveZ6
CP
3
InconclusiveZ1 NegativeZ2
0.32 C/ 0.12 0.16 C/ 0.2 0.32 C/ 0.08 0
0.38 C/ 0.10 0.17 C/ 0.10 0.44 C/ 0.11 0
W1441 Prostheses Protected Sphincterotomy - A Safe Way for Therapeutic ERCP in Billroth II-Patients Michael Bertullies, Rolf Drossel, Frank Kinzel, Hans Joachim Schulz Endoscopic sphincterotomy (EST) is difficult in patients who have undergone partial gastrectomy with Billroth II anastomoses. This study describes our experience using prostheses protected sphincterotomy in Billroth II patients. Methods: Prospective Study of 729 patients with Billroth II anastomoses undergoing ERCP including therapeutic interventions between 01/88-12/04. Details noted included indications for ERCP, therapeutic interventions, causes of failure and complications. Results: Success rate of diagnostic ERCP was 75,8% (553/729). Major indications for ERCP were common bile duct stones (52%), jaundice of unknown origin (19%), chronic pancreatitis (9%) and malignant tumors (9%). Interventional endoscopy was performed in 271 patients. Since 1993 we performed prostheses protected sphincterotomy . In comparison to conventional EST we could increase the efficiency of EST from 92,6% (1988-1992, n Z 95) to 96,8% (1993-2004; n Z 189). Complete extraction of bile duct stones was achieved in 79,3% (249/314;1988-1992 73,5%, n Z 83; 1993-2004 81,4%, n Z 231). Sufficient bile drainage was achieved by placement of transpapillary endoprostheses in 98% (183/ 186). The overall complication rate was 5,1% (37/729). The major complication of the procedure was perforation (1,8%, 1/729). 8 perforations occurred in the small bowel while the endoscope was being manipulated through the afferent loop, 5 patients had retroduodenal perforations. 9 patients suffered from bleeding after sphincterotomy (9/314 , 2,9%), 8 (1,1%) patient developed acute pancreatitis and 7 (1%) patients acute cholangitis. Conclusion: Prostheses protected sphincterotomy is a safe and useful technique in treatment of biliary obstructions in Billroth II patients. It can increase the success rate and reduce potential risks.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB299