S1447: Pancreatic Guide-Wire Placement Assisting Biliary Cannulation (Double Guide-Wire) Versus Precut Sphincterotomy in Difficult Biliary Cannulation: A Prospective Randomized Study

Abstracts and those meeting criteria for difficult cannulation enrolled. Difficult cannulation was defined as either inability to achieve deep CBDC within 6 minutes (min) (12 min for trainee involvement) or inadvertent cannulation of the PD three consecutive times. In the PDS group, the endoscopist deployed a 4 or 5Fr PDS over a guidewire, and then resumed CBDC attempts. In the PDW group, a 0.025” or 0.035” guidewire was left in the PD, then attempts at CBDC resumed. Patients in the PDW group could be crossed over to the PDS group if deep CBDC was not achieved within 6 min or if the PDW fell out during the cannulation effort. Precut could be performed after 6 min of cannulation effort following PDS deployment. Success was defined as deep CBDC. Using intention to treat (ITT) and per protocol (PP) analyses, we compared the rate of CBDC. Secondarily, we measured differences in cannulation times and rate of CBDC within 6 min of PDS or PDW placement.Results: Among 276 patients with native papillae, 69 (25.0%) met criteria for difficult cannulation. 32 were randomized to PDW, 37 to PDS. Deep PD cannulation was unsuccessful in 21 of 69, 11 (52%) of whom had successful CBDC with persistent effort (cannulation time 21.1⫾14.6 min). Per protocol, 8 patients crossed over from the PDW to PDS group. By ITT, CBDC rate was higher in the PDS group (83%) compared to the PDW group (61%) (p⬍0.04). By PP, CBDC rate was significantly higher in the PDS group (89% v. 67%, p⬍0.05). 27% of PDS patients underwent precut sphincterotomy, with subsequent CBDC in 75%. Mean cannulation time (min) following PDW or PDS deployment were similar (PDW, 4.1⫾4.8 v. PDS, 13.0⫾28.4, p⫽0.26). Similarly, cannulation rates within 6 min of PDW (59%) or PDS (60%) placement were not significantly different (p⫽0.94). Among 8 patients who crossed over from the PDW to the PDS group, deep CBDC was successfully achieved in 5 (63%). There were 4 cases of mild post-ERCP pancreatitis, 3 in the PDS and 1 in the PDW group.Conclusion: Among cases of difficult CBDC, use of a PDS leads to a higher rate of CBDC compared to a PDW, while maintaining a low (27%) rate of precut sphincterotomy. Larger sample sizes are needed to confirm these findings.

S1446 Predicting Difficult Bile Duct Cannulation: Accuracy of Endoscopic Visualization of the Papilla to Predict Cannulation Difficulty Gregory A. Cote, Christine E. Hovis, Steven A. Edmundowicz, Sreenivasa S. Jonnalagadda, Daniel Mullady, Riad R. Azar Background: Predicting difficult cannulation of the common bile duct (CBD) may impact the approach to CBD cannulation. Objective: Compare the rate of successful CBD cannulation among cases of anticipated difficult v. not difficult cannulation. Methods: Patients with native papillae undergoing first-time ERCP were prospectively enrolled. Prior to attempting cannulation, endoscopists rated the difficulty of cannulation based on visual inspection of the papilla. The length of the intraduodenal CBD segment (long v. short) and the relationship of the papilla to a diverticulum (present v. absent) were also reported. A long intraduodenal segment was classified as ⬎5mm. A true difficult cannulation was defined as ⬎6 minutes of effort. After 6 minutes, patients were enrolled in a trial comparing alternatives for difficult CBD cannulation (data presented in separate abstract). Results: 278 patients with native papillae were enrolled. 72 of 278(26%) were anticipated to be difficult. In addition, papillae were classified as long in 60% and involved in a diverticulum (17%). The overall cannulation rate was 96% and ⬍6 minutes in 72%. The cannulation rate declined over time (Kaplan-Meier method, figure). Cannulation rates within 6 minutes were similar among cases anticipated to be difficult (67% [95%CI,56-78]) versus not difficult (74%[6880],p⫽0.25). Rates were also similar among patients with a periampullary diverticulum (74% v. 67%,p⫽0.42) and a long intraduodenal segment (68% v. 78%,p⫽0.11). Conclusion: Among experienced endoscopists, the cannulation rate progressively declines over time. Physicians are not accurate in predicting cannulation difficulty by visual inspection of the papilla.

S1447 Pancreatic Guide-Wire Placement Assisting Biliary Cannulation (Double Guide-Wire) Versus Precut Sphincterotomy in Difficult Biliary Cannulation: A Prospective Randomized Study Phonthep Angsuwatcharakon, Wiriyaporn Ridtitid, Rungsun Rerknimitr, Pradermchai Kongkam, Sombat Treeprasertsuk, Pinit Kullavanijaya Background: Precut sphincterotomy (PS) is usually indicated after difficult biliary cannulation. However, this technique requires a steep learning curve and may contain a significant rate of complications. Recently, a pancreatic guide-wire placement assisting biliary (double guide-wire) cannulation (PG) has been reported to be useful after a failed standard biliary cannulation.Objective: To compare the success rate, cannulation time, post ERCP serum amylase level, and complication rate between PG and PS in difficult biliary cannulation. Methods: Patients who failed biliary cannulation within 10 minutes by the expert endoscopist were randomized into PG or PS groups. Patients with altered surgical anatomy, obstructed pancreatic duct, and history of pancreatitis were excluded. If biliary cannulation was not achieved within 10 minutes, we switched to the other technique.Results: From June 2008- October 2009, there were 442 ERCPs performed on virgin ampulla at the Chulalongkorn Endoscopy Unit. Forty eligible (difficult cannulation) patients who underwent ERCP were randomized. Demographic data and results are shown in the table. PG had significantly shorter duration of biliary cannulation than PS. Two patients from each group had a failed ERCP after swapping the technique. However, all achieved a success biliary access during the second ERCP. All acute bleedings were controlled during endoscopy and no blood transfusion was required. Neither delayed bleeding nor perforation occurred. Conclusion: PG provides similar success rate and significant shorter duration of biliary cannulation when compared with PS. Post-ERCP serum amylase level in the PG group is significantly higher than that in the PS group, however, no clinically significant difference in post-ERCP pancreatitis rate is found. Demogarphic data and outcomes Technique Gender (M:F) Age (years) Indications Obstructive Jaundice Suspected CBD stone Others First technique (%) After swapping the technique Median cannulation time after failed standard cannulation(sec) Serum amylase at 24 hr (mg/dL) Pancreatitis (mild/moderate/ severe) Acute bleeding NS⫽ Not significant

Double guide-wire (nⴝ22)

Precut (nⴝ18)

P value

12:10 65.9

7:11 65.5

NS NS

7 11 0

NS NS NS

83.3% 88.9% 309

NS NS 0.001

239

⬍0.001

0/1/0

NS

0

NS

8 12 2 Success rate 72.7% 90.9% 108 1173 Complications 4/0/0 2

S1448 EUS-Guided Biliary Access and Drainage (EBAD) At a Tertiary Care Center Murtaza Arif, Hazem T. Hammad, Nicholas M. Szary, Abhishek Choudhary, Matthew L. Bechtold, Mainor R. Antillon BACKGROUND: Percutaneous biliary drainage may be used in patients who have a failed ERCP. EUS-guided biliary access and drainage (EBAD) has recently been shown to be useful after unsuccessful ERCP. Given the lack of clinical experience with the EBAD and traditional EUS-guided rendezvous procedures, we report our EUS-guided biliary drainage experience at a tertiary care center.METHODS: A retrospective study was performed on all patients who underwent EBAD after failed ERCP at the University of Missouri from 1/07-5/09. Patients were identified by searching our endoscopy database with all procedures performed by a single experienced endoscopist (MRA). Each patient was evaluated for the following parameters: Demographics, indications for ERCP and EBAD, desired duct access rates, success rates for rendezvous procedure versus transgastric/transduodenal drainage, interventions performed at time of procedure, complications, and clinical outcomes.RESULTS: 20 cases of EBAD were identified with the mean age of 68 ⫾ 10 years. The indications included: Obstructive jaundice/abnormal LFTs (17), cholangitis (2), and CBD dilation (1). 29 unsuccessful ERCPs were performed on these 20 patients (1.5 ERCPs/patient) prior to EBAD. Reasons for ERCP failure included distorted anatomy due to tumor invasion (12), inability to cannulate due to complete obstruction or distortion of CBD (7), and periampullary diverticulum (1). EUS-guided access to the desired duct was achieved in all cases. Traditional rendezvous procedure

AB164 GASTROINTESTINAL ENDOSCOPY

Volume 71, No. 5 : 2010

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