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Pulse Fluoroscopy in ERCP: Reducing Radiation Exposure
Abstracts
W1442 Clinical Utility of Pre-Operative Hemostatic Screening Tests (PHSTs) in Patients Undergoing Outpatient ERCP Evan L. Fogel, Waleed Alazmi, Suzette Schmidt, Thomas F. Imperiale, Stuart Sherman, James L. Watkins, Lee Mchenry, Glen A. Lehman
W1444 Is ERCP Success Rate Affected By the Presence of Periampullary Diverticulum in Patients with Suspected Choledocholithiasis? Philippos Georgopoulos, Angelos Mastrangelis, Georgios Malgarinos, Eva Georgopoulou, John K. Triantafillidis
Background: Pre-operative laboratory testing is done to detect disorders that might alter patient (pt) management. Surgical data has questioned the need for routine PHSTs (INR, platelets), suggesting selective screening is adequate, but endoscopic data are lacking. ASGE guidelines suggest extrapolation from this surgical data. However, routine PHSTs prior to ERCP and sphincterotomy (ES) are still obtained in many institutions. Aims: To determine: 1) the frequency of clinically significant coagulation abnormalities noted on testing pre-ERCP; 2) how often these abnormalities are predicted from the history/physical examination; 3) how frequently PHST results alter performance of outpt ERCP; 4) the test characteristics of physician predictions. Methods: This prospective study evaluated consecutive outpts undergoing ERCP/ES. Exclusion criteria included in-pt status, use of oral anticoagulants or known hematological disorder, failure to obtain PHSTs or record the physician’s assessment pre-ERCP, and no ES performed. Pre-procedure assessment included a history/physical examination, validated Wahlberg index assessing likelihood of coagulopathy, and PHSTs. Endoscopists stated whether they predicted any of these test results might be abnormal, and would be reluctant to proceed without these results. Abnormal results were defined as: 1) INR R 1.4; 2) platelets % 75,000/mm3. Pts then underwent ERCP, with appropriate precautions (eg. transfusion, vitamin K) when needed. All bleeding complications were noted. Results: From 9/01-8/03, 1444 pts were included; 1433 (99%) had normal PHSTs. Clinicians correctly identified 1289/1433 pts with normal PHSTs (specificity 90%) and 6/11 pts with abnormal PHSTs (sensitivity 55%). Positive and negative predictive values were 4.0% and 99.6%, respectively. In the 5 pts unsuspected to have hemostatic abnormalities, no bleeding episodes occurred, despite no blood products given. Five patients (0.3%) had bleeding complications (3 mild, 2 moderate, based on consensus criteria). All 5 had normal PHSTs, correctly predicted by physicians. Summary: A ‘‘test-all’’ strategy requires 1444 PHSTs, identifies 11/16 (69%) pts who bled or were high-risk to do so, and requires a ‘‘number needed to test’’ (NNT) of 131. In contrast, selective testing based on MD assessment requires 150 PHSTs (a 90% reduction) and has a higher yield (NNTZ25) but identifies only 6/16 (38%) high-risk patients. Conclusions: Neither routine PHSTs nor MD assessment identifies all pts at risk of bleeding during ERCP/ES. Selective testing based on MD assessment reduces PHSTs by 90% but identifies fewer pts who are at increased risk of bleeding.
Background/Aim: Duodenal diverticulum is a known cause of choledocholithiasis although the majority of them remain asymptomatic. The aim of this study was to evaluate the overall success rate of ERCP in patients with suspected common bile duct (CBD) stones. Methodology: We reviewed the data from 221 consecutive ERCPs performed within 19 months from a single endoscopy center. We specifically report the cannulation and CBD clearance rate and procedure related morbidity in relation to the presence of a periampullary diverticulum. Difficult cannulation of CBD was reported when more than three attempts were necessary or when using guide wire or when dye was injected into the pancreatic duct. Results: Twenty-eight ERCPs were excluded from the analysis due to repeated procedures necessary for retained CBD stones. Forty-four patients (22.8%) out of the remaining 193 patients were found to have periampullary diverticula. Three of them had undergone previous sphincterotomy. In 7 patients (17,07%) cannulation of CBD was difficult and in 3 patients (7.3%) failed with total success rate of 92.7%. CBD clearance was successful in 40 out of the 44 patients (91%). Pancreatitis occurred in 2 patients and cholangitis in 1 patient. Of the remaining patients without diverticula 115 out of the 193 had intact papilla of Vater. In 25 patients (21.7%) cannulation was difficult and in 13 patients (11.3%) impossible with overall success rate in 88.7%. Selective cannulation was successful in 90% in both groups of patients with and without duodenal diverticula. Common bile duct stones were removed in 103 patients (89%). Complications occurred in 7 patients (6%) (4 had pancreatitis, 2 cholangitis and 1 minor bleeding). Neither cannulation success nor CBD clearance nor complication rate were statistically significant in both groups of patients. Conclusion: Therapeutic ERCP in patients with periampullary diverticulum is as safe as in patients without it.
W1443 Pulse Fluoroscopy in ERCP: Reducing Radiation Exposure Amit Singhal, Gillian Rowe, Riyaz Faizallah Background: Endoscopic Retrograde Choloangio Pancreatography (ERCP) poses significant radiation risk to patients and health professionals. Radiation exposure depends mainly on fluoroscopy time which theoretically may be decreased by using pulsed fluoroscopy instead of traditional method of continuous x-ray screening. Aim: To study the fluoroscopy time and radiation exposure to patients undergoing ERCP using pulsed fluoroscopy. Methods: Three hundred consecutive ERCPs performed from January to November 2003 at a single centre in UK were retrospectively studied. Siemens Siremobil Compact mobile intensifier system was used on the endoscopy unit. A Dose Area product (DAP) meter was fitted to the Xray tube and DAP reading and fluoroscopy time was recorded for each patient. Results: A total of 300 ERCPs on 225 consecutive patients were studied during 11 month period. 278 procedures were performed and ERCP was abandoned in 22 (7.3%) cases mainly because of poor access to papillary area. The biliary ducts were adequately visualized in 262 (94.2%) cases. Out of 278 ERCPs that were performed, thirty one (11.2%) ERCPs were diagnostic and 247 (88.8%) were therapeutic. Therapeutic procedures performed were mainly sphincterotomy in 159 (64.4%), duct clearance in 163 (66%) and stent insertion or exchange in 89 (36%) cases. There were in all 13 (4.3%) complications recorded. Of which 4 (1.3%) were mild and 9 (3%) were of moderate severity. The mean fluoroscopic time was 60.19 seconds (95% C.I 46.6-73.7 sec) for diagnostic and 97.09 seconds (95% C.I 88.4-105.8 sec) for the therapeutic ERCP (p ! 0.001). Average DAP was 471.3 cGraycm2 (95% C.I 358.3-584.3) for diagnostic and 808.9 cGray-cm2 (95% C.I 730.4-887. 3) for the therapeutic ERCP (p ! 0.0001). DAP showed a linear correlation with fluoroscopy time (pearson correlation 0.947). Conclusion: Use of pulsed radiation in this study resulted in smaller fluoroscopy time and radiation dose compared to published data using traditional non pulsed fluoroscopy 1. Our success rates in therapeutic procedures as well as complication rates compare favourably to most published series2. We conclude that pulse fluoroscopy can considerably reduce the screening time and radiation dose without loss of efficacy or additional risk to patients. References: 1. Larkin CJ et al. Radiation doses to patients during ERCP. Gastrointest Endosc 2001;53(2):161-4. 2. Loperfido S et al. Major early complications from diagnostic and therapeutic ERCP: A prospective multicentre study. Gastrointest Endosc 1998;48:1-16
AB300 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
W1445 Does Endoscopic Sphincterotomy Reduce the Rate of Subsequent Cholangitis Or Development of Common Bile Duct Stones in Patients with Highly Suspicious Common Bile Duct Stones, Not Documented On ERCP? Kiyoung Yang, Jin-Hyeok Hwang, Young Soo Park, Kwang-Hyuck Lee, Ji Kon Ryu, Yong Tae Kim, Yong Bum Yoon Background: In patients who have cholangitis and common bile duct (CBD) stones, endoscopic stones removal and biliary decompression is standard treatment of choice. However, when CBD stones were not documented on endoscopic retrograde cholangiopancreatography (ERCP) in patients with highly suspicious CBD stones, endoscopic sphincterotomy (ES) to prevent subsequent cholangitis or occurrence of CBD stones is not well known. Aims: To investigate effectiveness of ES to prevent subsequent cholangitis or development of CBD stones in patients with highly suspected CBD stones, not demonstrated on ERCP. Methods: The medical records of 172 patients who had been diagnosed cholangitis and/or high probability of CBD stones at Seoul National University Hospital and Seoul National University Bundang Hospital from January 2000 to June 2005 were reviewed. All of them were not demonstrated CBD stones on ERCP. Results: Ninety one patients underwent ES (ES group) and 81 patients did not (non-ES group). There were no statistically significant differences in demographic factors and laboratory findings between two groups. The mean follow-up was 449 days (10-1663 days) in ES group and 537 days (5-1889 days) in non-ES group. During the follow-up, four cases of cholangitis and 10 cases of CBD stones developed in ES group, and three cases of cholangitis and seven cases of CBD stones developed in non-ES group. The cumulative rates of cholangitis or development of CBD stones were 2.2% (vs 2.7%) at 1 year, 8.4% (vs 8.5%) at 3 years and 9.4% (vs 12,5%) at 5years in ES group (vs non-ES group), respectively (p Z 0.47). By univariate analysis, the presence of gallbladder stones, juxtapapillary duodenal diverticulum, cholangitis, or CBD diameter(O10 mm vs ! 10 mm) at initial manifestation didn’t effect on the rate of subsequent cholangitis or development of CBD stones in both groups. In ES group, six patients (6/91, 6.6%) developed post ERCP complications compared to only one patient (1/81, 1.2%) in non-ES group (p Z 0.045). Conclusions: ES does not seem to reduce the rate of subsequent cholangitis or development of choledocholithiasis in patients who had highly suspicious CBD stones without documentation of CBD stones on ERCP.
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W1442 Clinical Utility of Pre-Operative Hemostatic Screening Tests (PHSTs) in Patients Undergoing Outpatient ERCP Evan L. Fogel, Waleed Alazmi, Suzette Schmidt, Thomas F. Imperiale, Stuart Sherman, James L. Watkins, Lee Mchenry, Glen A. Lehman
W1444 Is ERCP Success Rate Affected By the Presence of Periampullary Diverticulum in Patients with Suspected Choledocholithiasis? Philippos Georgopoulos, Angelos Mastrangelis, Georgios Malgarinos, Eva Georgopoulou, John K. Triantafillidis
Background: Pre-operative laboratory testing is done to detect disorders that might alter patient (pt) management. Surgical data has questioned the need for routine PHSTs (INR, platelets), suggesting selective screening is adequate, but endoscopic data are lacking. ASGE guidelines suggest extrapolation from this surgical data. However, routine PHSTs prior to ERCP and sphincterotomy (ES) are still obtained in many institutions. Aims: To determine: 1) the frequency of clinically significant coagulation abnormalities noted on testing pre-ERCP; 2) how often these abnormalities are predicted from the history/physical examination; 3) how frequently PHST results alter performance of outpt ERCP; 4) the test characteristics of physician predictions. Methods: This prospective study evaluated consecutive outpts undergoing ERCP/ES. Exclusion criteria included in-pt status, use of oral anticoagulants or known hematological disorder, failure to obtain PHSTs or record the physician’s assessment pre-ERCP, and no ES performed. Pre-procedure assessment included a history/physical examination, validated Wahlberg index assessing likelihood of coagulopathy, and PHSTs. Endoscopists stated whether they predicted any of these test results might be abnormal, and would be reluctant to proceed without these results. Abnormal results were defined as: 1) INR R 1.4; 2) platelets % 75,000/mm3. Pts then underwent ERCP, with appropriate precautions (eg. transfusion, vitamin K) when needed. All bleeding complications were noted. Results: From 9/01-8/03, 1444 pts were included; 1433 (99%) had normal PHSTs. Clinicians correctly identified 1289/1433 pts with normal PHSTs (specificity 90%) and 6/11 pts with abnormal PHSTs (sensitivity 55%). Positive and negative predictive values were 4.0% and 99.6%, respectively. In the 5 pts unsuspected to have hemostatic abnormalities, no bleeding episodes occurred, despite no blood products given. Five patients (0.3%) had bleeding complications (3 mild, 2 moderate, based on consensus criteria). All 5 had normal PHSTs, correctly predicted by physicians. Summary: A ‘‘test-all’’ strategy requires 1444 PHSTs, identifies 11/16 (69%) pts who bled or were high-risk to do so, and requires a ‘‘number needed to test’’ (NNT) of 131. In contrast, selective testing based on MD assessment requires 150 PHSTs (a 90% reduction) and has a higher yield (NNTZ25) but identifies only 6/16 (38%) high-risk patients. Conclusions: Neither routine PHSTs nor MD assessment identifies all pts at risk of bleeding during ERCP/ES. Selective testing based on MD assessment reduces PHSTs by 90% but identifies fewer pts who are at increased risk of bleeding.
Background/Aim: Duodenal diverticulum is a known cause of choledocholithiasis although the majority of them remain asymptomatic. The aim of this study was to evaluate the overall success rate of ERCP in patients with suspected common bile duct (CBD) stones. Methodology: We reviewed the data from 221 consecutive ERCPs performed within 19 months from a single endoscopy center. We specifically report the cannulation and CBD clearance rate and procedure related morbidity in relation to the presence of a periampullary diverticulum. Difficult cannulation of CBD was reported when more than three attempts were necessary or when using guide wire or when dye was injected into the pancreatic duct. Results: Twenty-eight ERCPs were excluded from the analysis due to repeated procedures necessary for retained CBD stones. Forty-four patients (22.8%) out of the remaining 193 patients were found to have periampullary diverticula. Three of them had undergone previous sphincterotomy. In 7 patients (17,07%) cannulation of CBD was difficult and in 3 patients (7.3%) failed with total success rate of 92.7%. CBD clearance was successful in 40 out of the 44 patients (91%). Pancreatitis occurred in 2 patients and cholangitis in 1 patient. Of the remaining patients without diverticula 115 out of the 193 had intact papilla of Vater. In 25 patients (21.7%) cannulation was difficult and in 13 patients (11.3%) impossible with overall success rate in 88.7%. Selective cannulation was successful in 90% in both groups of patients with and without duodenal diverticula. Common bile duct stones were removed in 103 patients (89%). Complications occurred in 7 patients (6%) (4 had pancreatitis, 2 cholangitis and 1 minor bleeding). Neither cannulation success nor CBD clearance nor complication rate were statistically significant in both groups of patients. Conclusion: Therapeutic ERCP in patients with periampullary diverticulum is as safe as in patients without it.
W1443 Pulse Fluoroscopy in ERCP: Reducing Radiation Exposure Amit Singhal, Gillian Rowe, Riyaz Faizallah Background: Endoscopic Retrograde Choloangio Pancreatography (ERCP) poses significant radiation risk to patients and health professionals. Radiation exposure depends mainly on fluoroscopy time which theoretically may be decreased by using pulsed fluoroscopy instead of traditional method of continuous x-ray screening. Aim: To study the fluoroscopy time and radiation exposure to patients undergoing ERCP using pulsed fluoroscopy. Methods: Three hundred consecutive ERCPs performed from January to November 2003 at a single centre in UK were retrospectively studied. Siemens Siremobil Compact mobile intensifier system was used on the endoscopy unit. A Dose Area product (DAP) meter was fitted to the Xray tube and DAP reading and fluoroscopy time was recorded for each patient. Results: A total of 300 ERCPs on 225 consecutive patients were studied during 11 month period. 278 procedures were performed and ERCP was abandoned in 22 (7.3%) cases mainly because of poor access to papillary area. The biliary ducts were adequately visualized in 262 (94.2%) cases. Out of 278 ERCPs that were performed, thirty one (11.2%) ERCPs were diagnostic and 247 (88.8%) were therapeutic. Therapeutic procedures performed were mainly sphincterotomy in 159 (64.4%), duct clearance in 163 (66%) and stent insertion or exchange in 89 (36%) cases. There were in all 13 (4.3%) complications recorded. Of which 4 (1.3%) were mild and 9 (3%) were of moderate severity. The mean fluoroscopic time was 60.19 seconds (95% C.I 46.6-73.7 sec) for diagnostic and 97.09 seconds (95% C.I 88.4-105.8 sec) for the therapeutic ERCP (p ! 0.001). Average DAP was 471.3 cGraycm2 (95% C.I 358.3-584.3) for diagnostic and 808.9 cGray-cm2 (95% C.I 730.4-887. 3) for the therapeutic ERCP (p ! 0.0001). DAP showed a linear correlation with fluoroscopy time (pearson correlation 0.947). Conclusion: Use of pulsed radiation in this study resulted in smaller fluoroscopy time and radiation dose compared to published data using traditional non pulsed fluoroscopy 1. Our success rates in therapeutic procedures as well as complication rates compare favourably to most published series2. We conclude that pulse fluoroscopy can considerably reduce the screening time and radiation dose without loss of efficacy or additional risk to patients. References: 1. Larkin CJ et al. Radiation doses to patients during ERCP. Gastrointest Endosc 2001;53(2):161-4. 2. Loperfido S et al. Major early complications from diagnostic and therapeutic ERCP: A prospective multicentre study. Gastrointest Endosc 1998;48:1-16
AB300 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
W1445 Does Endoscopic Sphincterotomy Reduce the Rate of Subsequent Cholangitis Or Development of Common Bile Duct Stones in Patients with Highly Suspicious Common Bile Duct Stones, Not Documented On ERCP? Kiyoung Yang, Jin-Hyeok Hwang, Young Soo Park, Kwang-Hyuck Lee, Ji Kon Ryu, Yong Tae Kim, Yong Bum Yoon Background: In patients who have cholangitis and common bile duct (CBD) stones, endoscopic stones removal and biliary decompression is standard treatment of choice. However, when CBD stones were not documented on endoscopic retrograde cholangiopancreatography (ERCP) in patients with highly suspicious CBD stones, endoscopic sphincterotomy (ES) to prevent subsequent cholangitis or occurrence of CBD stones is not well known. Aims: To investigate effectiveness of ES to prevent subsequent cholangitis or development of CBD stones in patients with highly suspected CBD stones, not demonstrated on ERCP. Methods: The medical records of 172 patients who had been diagnosed cholangitis and/or high probability of CBD stones at Seoul National University Hospital and Seoul National University Bundang Hospital from January 2000 to June 2005 were reviewed. All of them were not demonstrated CBD stones on ERCP. Results: Ninety one patients underwent ES (ES group) and 81 patients did not (non-ES group). There were no statistically significant differences in demographic factors and laboratory findings between two groups. The mean follow-up was 449 days (10-1663 days) in ES group and 537 days (5-1889 days) in non-ES group. During the follow-up, four cases of cholangitis and 10 cases of CBD stones developed in ES group, and three cases of cholangitis and seven cases of CBD stones developed in non-ES group. The cumulative rates of cholangitis or development of CBD stones were 2.2% (vs 2.7%) at 1 year, 8.4% (vs 8.5%) at 3 years and 9.4% (vs 12,5%) at 5years in ES group (vs non-ES group), respectively (p Z 0.47). By univariate analysis, the presence of gallbladder stones, juxtapapillary duodenal diverticulum, cholangitis, or CBD diameter(O10 mm vs ! 10 mm) at initial manifestation didn’t effect on the rate of subsequent cholangitis or development of CBD stones in both groups. In ES group, six patients (6/91, 6.6%) developed post ERCP complications compared to only one patient (1/81, 1.2%) in non-ES group (p Z 0.045). Conclusions: ES does not seem to reduce the rate of subsequent cholangitis or development of choledocholithiasis in patients who had highly suspicious CBD stones without documentation of CBD stones on ERCP.
www.giejournal.org