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S1454: Two-Step Endoscopic Papillary Dilation With Large-Diameter Balloon After Endoscopic Sphincterotomy for Retained Bile Duct Stones
Abstracts vessels, mass lesions, nodules, ulcerations, and villous projections. Visually directed biopsies and standard brushings were obtained from the strictures. Results: In all 13 examinations, a dominant biliary stricture was directly visualized. In 11/13 patients, the stricture had signs of active inflammation, including erythema, edema and/or mild friability. 5/13 patients had ulcerated strictures, pre-defined as a malignant feature. No tortuous vessels, mass lesions, nodules or villous projections were identified in any of the strictures. Visually directed forceps biopsies were attempted in 11/13 patients; in 9/11 of these patients, the biopsy sample was satisfactory for histologic analysis (including all of the patients with ulcerated strictures). Malignant cells were not identified in any biopsy sample. All 13 patients underwent stricture brushings, all of which were non-malignant. Over a median follow up period of 10 months, no patient has developed signs of cholangiocarcinoma; 1 patient died from complications of end stage liver disease. Conclusion: Dominant biliary strictures in PSC patients can be successfully visualized with the Spyglass system with adequate tissue acquisition. Although 38% of our patients had ulcerative strictures, histology, cytology, and 10 months follow-up were negative for development of CCA. Based on our experience, unlike the situation in non-PSC patients, ulcerative strictures in PSC patients may not indicate malignancy. Therefore, other adjunct modalities (e.g. intraductal ultrasound, confocal endomicroscopy) may be necessary in conjunction with cholangioscopy when evaluating dominant strictures in PSC patients.
pancreatitis. However, the risk of severe complications, such as bleeding and perforation, are still remained. The aim of this study was to evaluate the safety and efficacy of two-step method of EPDLB after EST for retained bile duct stones. METHODS; Total 66 consecutive patients with CBD stones with cholangitis were randomized to two-step EPDLB after EST or conventional onestep EPDLB after EST. Included patients were failed in stone removal with conventional method using basket and/or balloon and treated with EPDLB (the diameter of balloon ⱖ12 mm). For two-step group, we performed EST and biliary drainage (BD) in 1st ERCP session and EPDLB with stone removal in 2nd session after clinical improvement of cholangitis. For conventional group, we performed EST and EPDLB with stone removal in 1st ERCP session. Additional stone fragmentation procedures were performed for complete stone extraction, if needed. RESULTS; The mean diameter of largest stone was similar between both groups (17.1 mm vs 18.0 mm). And the mean diameter of balloon dilation was also similar between both groups (15.1 mm vs 14.1 mm). Both procedures resulted in similar outcomes in terms of successful complete stone removal (100% vs 100%) and the use of additional lithotripsy (24.2% vs 24.2%). Complications were as follows for the two-step group and the conventional group: pancreatitis, 0% and 12.1 %, bleeding, 0% and 3.0 %, perforation, 0% and 3%, and overall complication rate, 0% and 7% (p ⬍0.01), respectively. CONCLUSIONS; Two-step EPDLB after EST may be a safer method compared with conventional EST and EPDLB. However, studies based on a large number of patients are needed.
S1453 Predictive Value of Noninvasive Imaging As a Precursor to ERCP in the Assessment of Early Complications Post-Orthotopic Liver Transplant (OLT) Joseph T. Merrill, John M. Iskander, Anil B. Seetharam, Christine E. Hovis, Gregory A. Cote, Abed Al-Lehibi, Dayna S. Early, Daniel Mullady, Sreenivasa S. Jonnalagadda, Steven A. Edmundowicz, Riad R. Azar
S1455 Endoscopic Small Sphincterotomy Followed by Large Balloon Sphincteroplasty Performed During the Same Procedure Versus Separate Procedures for Difficult Common Bile Duct Stones Paul S. Sepe, Mandeep Sawhney, Shyam J. Thakkar, Subhasish Sengupta, Tyler M. Berzin, Douglas K. Pleskow, RAM Chuttani
Background:Abnormal LFTs in post- OLT patients can be multi-factorial. Hepatocellular, vascular causes and biliary duct abnormalities should be considered in the differential diagnosis. Biliary complications including strictures, stones and bile leaks occur in 10-25% of those patients. Ultrasound (US) is often the initial imaging modality. CT scan or MRCP may help further clarify the diagnosis if needed. We sought to determine the diagnostic accuracy and the use of noninvasive imaging in patients with suspected biliary disease after OLT at one tertiary medical center.Methods: A retrospective analysis was performed of all patients who underwent ERCP for suspected biliary tract disease within one year of transplant from Jan 2003 to Dec 2008. Noninvasive imaging obtained no more than 30 days prior to ERCP were included. Results of noninvasive imaging were compared to findings on ERCP. If available, liver biopsies were reviewed.Results:Eighty-nine patients underwent ERCP within 12 months postOLT. 66/89 patients underwent non-invasive imaging less than 30 days prior to ERCP. Findings on ERCP were 46 anastomosis strictures (AS), 7 non-anastomosis common bile duct (CBD) strictures (NAS), 8 CBD stones and 9 bile leaks. Eighty imaging studies (54 US, 23 CT, and 3 MRCP) were obtained in 66 patients. Thirty imaging studies were positive for biliary disease (22 AS, 5 CBD stones, 2 bile leaks and 1 NAS) of which 29 (97%) were confirmed on ERCP. 50 imaging studies were normal. Of these 40/50(80%) were abnormal on ERCP (24 AS, 5 NAS, 3 CBD stones, 7 bile leaks).The positive predictive value (PPV) of all imaging was 97% (29/30). The negative predictive value (NPV) was 20% (10/50). PPV and NPV of US were 100% (21/21) and 16% (5/32), respectively. The PPV and NPV of CT were 86% (6/7) and 25% (4/16). All 3 MRCP were normal, with 2/3 having abnormal ERCPs. In patients who underwent liver biopsy within 3 months of ERCP, 14/36 (39%) had acute cellular rejection at histology. Biliary pathology was found in addition to rejection in 13/14 (93%) patients. In 89 patients undergoing ERCP, 7 developed mild pancreatitis (7.8%) and bleeding that required endoscopic intervention occurred in 2 patients (2.2%)Conclusion: While a positive US or CT scan is highly suggestive of biliary pathology in postOLT patients, a negative result is a poor predictor of findings on ERCP. ERCP is safe and should be considered early in the evaluation of abnormal LFTs in those patients even when acute rejection is noted on liver biopsy. Prospective studies comparing ERCP to MRCP and other noninvasive imaging studies in this setting are necessary to better define this issue.
Background: Endoscopic small sphincterotomy followed by large balloon sphincteroplasty has recently been shown to be safe and efficacious for large common bile duct stones. The aim of our study was to compare the safety and efficacy of concurrent endoscopic sphincterotomy (EST) and balloon sphincteroplasty during the same procedure with that of EST and balloon sphincteroplasty performed during separate procedures. Methods: All patients who underwent balloon sphincteroplasty at our institution from 2006 to 2009 were identified from a prospectively maintained database. The database, medical record, and procedure reports were reviewed to determine those who had EST and balloon sphincteroplasty during the same procedure (SPS), and those with EST and balloon sphincteroplasty during separate procedures (DPS). Primary outcomes were successful stone extraction achieving bile duct clearance on first attempt, and procedure related adverse events. Results: During the study period, 105 patients undergoing 114 procedures for difficult stones were identified. All patients had EST followed by balloon sphincteroplasty either during the same or separate procedures. Mean age was 73.2 ⫹/- 17.3 yrs and 57% were female. Mean CBD stone size was 12.8 ⫹/- 4.5 mm. Multiple stones were seen in 76% of patients. Successful bile duct clearance on first attempt was accomplished in 85.7% of patients. Final bile duct clearance was achieved in 99.0%. Complications were seen in 7.0% (95% CI 3.3 - 12.9) of procedures. Complications included pancreatitis (2.6%), cholangitis (0.9%), bleeding (0.9%), duodenal perforation (0.9%), CBD stricture (0.9%), and oral laceration (0.9%). Fifty-five patients had undergone SPS, while 50 patients had DPS. There were no significant differences between the two groups in regards to patient demographics, stone number and size, and other procedural factors. Successful bile duct clearance on first attempt was achieved in 83.6% of patients with SPS vs. 88.0% with DPS (p⫽0.7). Final duct clearance was achieved in 100% of patients with SPS vs. 98% with DPS (p⫽0.9). Complications were more common with SPS, occurring in 12.5% of procedures, compared to 1.7% with DPS (OR ⫽ 8.14; p⫽0.05). Pancreatitis occurred in 3.6% of SPS procedures vs. 1.7% with DPS. Increasing CBD stone size was associated with failure to achieve bile duct clearance on first attempt (OR 0.83, CI 0.71 - 0.98). Conclusion: Endoscopic small sphincterotomy followed by large balloon sphincteroplasty is highly successful for difficult CBD stones. Performing sphincterotomy and balloon dilation during separate procedures is equally effective and has fewer complications.
S1454 Two-Step Endoscopic Papillary Dilation With Large-Diameter Balloon After Endoscopic Sphincterotomy for Retained Bile Duct Stones Jong Chan Lee, Jong Ho Moon, Hyun Jong Choi, Hyun Cheol Koo, Jun Yong Bae, Jong Kyu Park, Young Koog Cheon, Young Deok Cho, Moon Sung Lee
S1456 Steroid-Responsive IgG4-Associated Hilar or Intrahepatic Sclerosing Cholangitis Hyoung-Chul Oh, Myung-Hwan Kim, Kyu_taek Lee, Jong Kyun Lee, Sung-Hoon Moon, Tae Jun Song, Junbum Eum, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee
BACKGROUND AND AIMS; Currently, endoscopic papillary dilation with largediameter balloon (EPDLB) after endoscopic sphincterotomy (EST) for removal of large bile duct stones might present lower incidence of post-procedure
AB166 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
Background: Hilar or intrahepatic biliary strictures are caused by diverse etiologies, varying from benign to malignant. A critical point in differential diagnosis is how to find out a subgroup of hilar/intrahepatic stricture that responds to steroid therapy. This study aimed to discriminate the characteristics
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pancreatitis. However, the risk of severe complications, such as bleeding and perforation, are still remained. The aim of this study was to evaluate the safety and efficacy of two-step method of EPDLB after EST for retained bile duct stones. METHODS; Total 66 consecutive patients with CBD stones with cholangitis were randomized to two-step EPDLB after EST or conventional onestep EPDLB after EST. Included patients were failed in stone removal with conventional method using basket and/or balloon and treated with EPDLB (the diameter of balloon ⱖ12 mm). For two-step group, we performed EST and biliary drainage (BD) in 1st ERCP session and EPDLB with stone removal in 2nd session after clinical improvement of cholangitis. For conventional group, we performed EST and EPDLB with stone removal in 1st ERCP session. Additional stone fragmentation procedures were performed for complete stone extraction, if needed. RESULTS; The mean diameter of largest stone was similar between both groups (17.1 mm vs 18.0 mm). And the mean diameter of balloon dilation was also similar between both groups (15.1 mm vs 14.1 mm). Both procedures resulted in similar outcomes in terms of successful complete stone removal (100% vs 100%) and the use of additional lithotripsy (24.2% vs 24.2%). Complications were as follows for the two-step group and the conventional group: pancreatitis, 0% and 12.1 %, bleeding, 0% and 3.0 %, perforation, 0% and 3%, and overall complication rate, 0% and 7% (p ⬍0.01), respectively. CONCLUSIONS; Two-step EPDLB after EST may be a safer method compared with conventional EST and EPDLB. However, studies based on a large number of patients are needed.
S1453 Predictive Value of Noninvasive Imaging As a Precursor to ERCP in the Assessment of Early Complications Post-Orthotopic Liver Transplant (OLT) Joseph T. Merrill, John M. Iskander, Anil B. Seetharam, Christine E. Hovis, Gregory A. Cote, Abed Al-Lehibi, Dayna S. Early, Daniel Mullady, Sreenivasa S. Jonnalagadda, Steven A. Edmundowicz, Riad R. Azar
S1455 Endoscopic Small Sphincterotomy Followed by Large Balloon Sphincteroplasty Performed During the Same Procedure Versus Separate Procedures for Difficult Common Bile Duct Stones Paul S. Sepe, Mandeep Sawhney, Shyam J. Thakkar, Subhasish Sengupta, Tyler M. Berzin, Douglas K. Pleskow, RAM Chuttani
Background:Abnormal LFTs in post- OLT patients can be multi-factorial. Hepatocellular, vascular causes and biliary duct abnormalities should be considered in the differential diagnosis. Biliary complications including strictures, stones and bile leaks occur in 10-25% of those patients. Ultrasound (US) is often the initial imaging modality. CT scan or MRCP may help further clarify the diagnosis if needed. We sought to determine the diagnostic accuracy and the use of noninvasive imaging in patients with suspected biliary disease after OLT at one tertiary medical center.Methods: A retrospective analysis was performed of all patients who underwent ERCP for suspected biliary tract disease within one year of transplant from Jan 2003 to Dec 2008. Noninvasive imaging obtained no more than 30 days prior to ERCP were included. Results of noninvasive imaging were compared to findings on ERCP. If available, liver biopsies were reviewed.Results:Eighty-nine patients underwent ERCP within 12 months postOLT. 66/89 patients underwent non-invasive imaging less than 30 days prior to ERCP. Findings on ERCP were 46 anastomosis strictures (AS), 7 non-anastomosis common bile duct (CBD) strictures (NAS), 8 CBD stones and 9 bile leaks. Eighty imaging studies (54 US, 23 CT, and 3 MRCP) were obtained in 66 patients. Thirty imaging studies were positive for biliary disease (22 AS, 5 CBD stones, 2 bile leaks and 1 NAS) of which 29 (97%) were confirmed on ERCP. 50 imaging studies were normal. Of these 40/50(80%) were abnormal on ERCP (24 AS, 5 NAS, 3 CBD stones, 7 bile leaks).The positive predictive value (PPV) of all imaging was 97% (29/30). The negative predictive value (NPV) was 20% (10/50). PPV and NPV of US were 100% (21/21) and 16% (5/32), respectively. The PPV and NPV of CT were 86% (6/7) and 25% (4/16). All 3 MRCP were normal, with 2/3 having abnormal ERCPs. In patients who underwent liver biopsy within 3 months of ERCP, 14/36 (39%) had acute cellular rejection at histology. Biliary pathology was found in addition to rejection in 13/14 (93%) patients. In 89 patients undergoing ERCP, 7 developed mild pancreatitis (7.8%) and bleeding that required endoscopic intervention occurred in 2 patients (2.2%)Conclusion: While a positive US or CT scan is highly suggestive of biliary pathology in postOLT patients, a negative result is a poor predictor of findings on ERCP. ERCP is safe and should be considered early in the evaluation of abnormal LFTs in those patients even when acute rejection is noted on liver biopsy. Prospective studies comparing ERCP to MRCP and other noninvasive imaging studies in this setting are necessary to better define this issue.
Background: Endoscopic small sphincterotomy followed by large balloon sphincteroplasty has recently been shown to be safe and efficacious for large common bile duct stones. The aim of our study was to compare the safety and efficacy of concurrent endoscopic sphincterotomy (EST) and balloon sphincteroplasty during the same procedure with that of EST and balloon sphincteroplasty performed during separate procedures. Methods: All patients who underwent balloon sphincteroplasty at our institution from 2006 to 2009 were identified from a prospectively maintained database. The database, medical record, and procedure reports were reviewed to determine those who had EST and balloon sphincteroplasty during the same procedure (SPS), and those with EST and balloon sphincteroplasty during separate procedures (DPS). Primary outcomes were successful stone extraction achieving bile duct clearance on first attempt, and procedure related adverse events. Results: During the study period, 105 patients undergoing 114 procedures for difficult stones were identified. All patients had EST followed by balloon sphincteroplasty either during the same or separate procedures. Mean age was 73.2 ⫹/- 17.3 yrs and 57% were female. Mean CBD stone size was 12.8 ⫹/- 4.5 mm. Multiple stones were seen in 76% of patients. Successful bile duct clearance on first attempt was accomplished in 85.7% of patients. Final bile duct clearance was achieved in 99.0%. Complications were seen in 7.0% (95% CI 3.3 - 12.9) of procedures. Complications included pancreatitis (2.6%), cholangitis (0.9%), bleeding (0.9%), duodenal perforation (0.9%), CBD stricture (0.9%), and oral laceration (0.9%). Fifty-five patients had undergone SPS, while 50 patients had DPS. There were no significant differences between the two groups in regards to patient demographics, stone number and size, and other procedural factors. Successful bile duct clearance on first attempt was achieved in 83.6% of patients with SPS vs. 88.0% with DPS (p⫽0.7). Final duct clearance was achieved in 100% of patients with SPS vs. 98% with DPS (p⫽0.9). Complications were more common with SPS, occurring in 12.5% of procedures, compared to 1.7% with DPS (OR ⫽ 8.14; p⫽0.05). Pancreatitis occurred in 3.6% of SPS procedures vs. 1.7% with DPS. Increasing CBD stone size was associated with failure to achieve bile duct clearance on first attempt (OR 0.83, CI 0.71 - 0.98). Conclusion: Endoscopic small sphincterotomy followed by large balloon sphincteroplasty is highly successful for difficult CBD stones. Performing sphincterotomy and balloon dilation during separate procedures is equally effective and has fewer complications.
S1454 Two-Step Endoscopic Papillary Dilation With Large-Diameter Balloon After Endoscopic Sphincterotomy for Retained Bile Duct Stones Jong Chan Lee, Jong Ho Moon, Hyun Jong Choi, Hyun Cheol Koo, Jun Yong Bae, Jong Kyu Park, Young Koog Cheon, Young Deok Cho, Moon Sung Lee
S1456 Steroid-Responsive IgG4-Associated Hilar or Intrahepatic Sclerosing Cholangitis Hyoung-Chul Oh, Myung-Hwan Kim, Kyu_taek Lee, Jong Kyun Lee, Sung-Hoon Moon, Tae Jun Song, Junbum Eum, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee
BACKGROUND AND AIMS; Currently, endoscopic papillary dilation with largediameter balloon (EPDLB) after endoscopic sphincterotomy (EST) for removal of large bile duct stones might present lower incidence of post-procedure
AB166 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
Background: Hilar or intrahepatic biliary strictures are caused by diverse etiologies, varying from benign to malignant. A critical point in differential diagnosis is how to find out a subgroup of hilar/intrahepatic stricture that responds to steroid therapy. This study aimed to discriminate the characteristics
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