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Sa1424 Endoscopic Dilation of Pancreatic Duct Strictures in Chronic Pancreatitis With Multiple Plastic Stents: Results in 48 Patients
Abstracts Table 2: Univariate Analysis for Factors Associated with Technical Success and Complications for ERCP in Billroth II Patients Technical Success Factors Associated with Clinical Success Age >60 BMI >25 Indication Pancreatic vs Biliary *Prior Sphincterotomy Endoscope Type Duodenoscope vs Forward Viewer *Therapuetic Duodenoscope *Anesthesia, General
Complications
OR
p value
OR
p Value
1.203 1.414 0.396 21
0.701 0.534 0.16 0.003
0.701 0.889 1.41 2.67
0.638 0.891 0.725 0.192
1.89 4.165 4.19
0.463 0.008 0.004
0.353 3.696 1.27
0.364 0.118 0.753
Multivariate Analysis of Significant Factors: *General Anesthesia, OR Z 3.22, p value Z 0.032 *Prior Sphincterotomy, OR Z 16.9, p value Z 0.007 *Therapeutic Duodenoscope, OR Z 1.614, p value Z 0.433.
Sa1421 Endoscopic Retrograde Cholangiopancreatography Safety in End Stage Renal Disease in the National Inpatient Sample Tarek Sawas*, Fateh Bazerbachi, Barham K. Abu Dayyeh Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN Background: Chronic kidney disease (CKD) is an increasing, high prevalence public health problem. The aim of our study is to evaluate the safety of performing ERCP in end stage renal disease using a large national cohort. Methods: We used the Nationwide Inpatient Sample (NIS) 2012 database to perform a cross sectional study. The NIS is the largest inpatient database in the US and contains a sample of inpatient admissions at the participating US community hospitals. We included hospitalized patients from the NIS 2012 age 18 years or older who underwent ERCP during their hospital stay. Patients were identified using International Classification of Diseases 9th Revision (ICD-9-CM) for the ERCP procedure codes. Included patients were divided into two groups. The study group was those who had a concomitant discharge diagnosis of end stage renal disease ESRD. We used ICD-9-CM code 585.6 to identify patients who had end stage renal disease who required dialysis. The control group was the hospitalized patients who underwent ERCP and did not have renal disease in their discharge diagnosis. Complications were compared using distribution and multivariate logistic regression analysis controlling for age and gender for all the outcomes. We isolated complication from indication by considering the primary and secondary diagnosis as an indication and the subsequent diagnoses as complications. Results: 526 patients had ESRD requiring HD and 33,662 represented the control group. The mean age was 59.4 19.7 (range 18-90 years). 48 patients developed post ERCP pancreatitis in the ESRD group (9.13%) compared to 1,530 in the control group (4.49%) with adjusted odd ratio aOR: 2.1 (95% CI: 1.56 – 2.86, P<0.001). 11 patients (2.1%) developed Post ERCP Hemorrhage in the ESRD group compared to 266 (0.8%) in the control group with aOR: 2.5 (95% CI: 1.38 - 4.7, PZ0.003). Post ERCP perforation was rare in both groups but still significantly higher in the ESRD 0.38 % compared to the control 0.06% with aOR: 6.8 (95% CI: 1.6 – 29.7, PZ0.01). Overall length of hospital stay in patients who underwent ERCP was 6.40 7.18 days. The mean length of hospital stay was longer in the ESRD group 12.9 13.95 days compared to 6.3 6.98 (P<0.001). In Hospital mortality was also significantly higher in the in the ESRD group. 32 patients (6%) died compared to the control group (1.3%) aOR: 4.4 (95% CI: 3 – 6.4, P<0.001). ESRD patients also incurred higher hospitalization charges ($163,948 vs $62,849, P<0.001) compared to the control group. Conclusion: ESRD is associated with a significant health care burden in hospitalized patients requiring ERCP because of higher rate of post procedure complications, longer hospital stay, and higher mortality. Closer monitoring and peri-procedural special intervention should be considered to decrease complications.
Sa1422 The Use of Fully Covered Metal Stents in the Management of Benign Refractory Pancreatic Ductal Strictures Akit Patel, Obinna C. Ukabam, Sreedevi Atluri, Hendrikus Vanderveldt, Laura Rosenkranz, Sandeep N. Patel* University of Texas Health Sciences, San Antonio, TX
agement of refractory benign PD strictures. Our objective was to evaluate the feasibility, safety, and outcomes of FCSEMS for therapeutic intervention in refractory benign pancreatic ductal strictures in patients with chronic pancreatitis. Methods: A retrospective chart review was conducted on consecutive adult subjects who underwent ERCP with stenting of the PD performed between February 2008 and September 2016 at our institution. All subjects who had FCSEMS placed for main pancreatic ductal strictures were included in the study. Results: 245 patients underwent ERCP with main pancreatic duct stenting during the study period. Twenty patients underwent ERCP with FCSEMS placement. The patients median age was 42.5 (range 15 - 75). Forty-six percent were male. The most common location of the PD stricture was at the head of the pancreas (NZ16, 80%). Strictures were also located in the neck (NZ1) and the body of the pancreas (NZ1). Five patients (25%) had pancreas divisum. Ten patients (50%) had PD stones. FCSEMS were successfully placed in all twenty patients. Prior to FCSEMS placement, all patients had undergone sphincterotomy, balloon or catheter stricture dilation and plastic stent placement. The average number of plastic stents placed prior to FCSEMS placement was 2.2 (range 1-6). The average number of FCSEMS placed before stricture resolution was 1.4 (range 1-8) with the mode being just 1 metal stent (eighteen out of twenty patients, 90%). PD stricture resolution was achieved in sixteen patients (80%). Three of the twenty patients (15%) who had stricture resolution with FCSEMS later redeveloped a PD stricture requiring an additional endotherapy. Complications of FCSEMS placement occurred in 10%: mild post-ERCP pancreatitis (NZ1) and pain requiring stent removal (NZ1). Conclusions: Endotherapy using fully cover self-expanding metal stents in the management of refractory benign PD strictures appears to be safe and provides reasonable stricture resolution.
Sa1424 Endoscopic Dilation of Pancreatic Duct Strictures in Chronic Pancreatitis With Multiple Plastic Stents: Results in 48 Patients Vincenzo Bove*1, Andrea Tringali1, Giorgio Valerii1, Rosario Landi1, Pietro Familiari1, Ivo Boskoski1,2, Vincenzo Perri1, Guido Costamagna1,3 1 Digestive Endoscopy Unit, Gemelli University Hospital, Rome, Italy, Italy; 2Service de Chirurgie Digestive & Endocrinienne, IHU Strasbourg, Strasbourg, France; 3USIAS Strasbourg University, Strasbourg, France Background and Aims: Main Pancreatic Duct (MPD) strictures located in the head of the pancreas often occur in the course of Chronic Pancreatitis (CP). Common management of these strictures is endoscopic placement of a single plastic stent. Refractory strictures require repeated stent replacement or surgical pancreaticojejunostomy. Insertion of Multiple Plastic Stents (MPS) obtained, in a series of 19 patients, symptomatic MPD stricture resolution in 84% of the cases, after 3-year follow-up (1) The aim of this study was to evaluate the results of the MPS strategy in a larger series of CP patients. Patients and Methods: Forty-eight patients (34 men; mean age 44 years, range 5-86) with severe CP and a symptomatic dominant MPD stricture located in the head of the pancreas, were evaluated. All the patients experienced pain resolution following MPD drainage with a single plastic stents. The MPD stricture was refractory to single plastic stent placement in all cases and patients underwent insertion of MPS according to the following protocol: balloon dilation of the stricture if necessary, insertion of the maximum number of plastic stents allowed by the stricture tightness and pancreatic duct diameter, stents removal after 6 months. Results: The median number of stents placed through the major or minor papilla was 3 (range 2-5), 8.5 to 11.5 Fr in diameter and 3 to 7 cm in length. MPS were removed after a mean time of 6.7 months (range 2-18). Eight patients (16.6 %) had persistence of the MPD stricture after MPS removal and underwent replacement of an increased number of stents; 3/8 patients had a dilation of the stricture after further multistent placement (overall success 89.5%). Following a mean follow up of 9.5 years (range 0.3-15.5) after MPS removal, 77.1% of patients were asymptomatic. Symptomatic MPD stricture recurrence was reported in 11 patients (22.9%), after a mean time of 26.4 months (range 5-108) from MPS removal. No major complications were recorded. Conclusion: Endoscopic dilation of CPrelated dominant MPD strictures seems possible with the MPS technique. According to this experience on 48 patients, MPS is highly effective even at long-term follow-up in the majority of patients. Reference 1. Costamagna G, Bulajic M, Tringali A et al. Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results. Endoscopy 2006;38:254-9.
Background: Chronic pancreatitis (CP) is characterized by long-standing inflammation of the pancreas potentially leading to structural damage such as pancreatic duct strictures and the formation of stones. The endoscopic placement of small caliber plastic stents has been increasingly utilized to improve panceatic outflow and improve symptoms in these patients. Endotherapy offers the potential of treatment in a less invasive manner than surgery. Literature is scarce on the outcomes of pancreatic fully cover self-expanding metal stent (FCSEMS) placement in the man-
AB236 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org
Complications
OR
p value
OR
p Value
1.203 1.414 0.396 21
0.701 0.534 0.16 0.003
0.701 0.889 1.41 2.67
0.638 0.891 0.725 0.192
1.89 4.165 4.19
0.463 0.008 0.004
0.353 3.696 1.27
0.364 0.118 0.753
Multivariate Analysis of Significant Factors: *General Anesthesia, OR Z 3.22, p value Z 0.032 *Prior Sphincterotomy, OR Z 16.9, p value Z 0.007 *Therapeutic Duodenoscope, OR Z 1.614, p value Z 0.433.
Sa1421 Endoscopic Retrograde Cholangiopancreatography Safety in End Stage Renal Disease in the National Inpatient Sample Tarek Sawas*, Fateh Bazerbachi, Barham K. Abu Dayyeh Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN Background: Chronic kidney disease (CKD) is an increasing, high prevalence public health problem. The aim of our study is to evaluate the safety of performing ERCP in end stage renal disease using a large national cohort. Methods: We used the Nationwide Inpatient Sample (NIS) 2012 database to perform a cross sectional study. The NIS is the largest inpatient database in the US and contains a sample of inpatient admissions at the participating US community hospitals. We included hospitalized patients from the NIS 2012 age 18 years or older who underwent ERCP during their hospital stay. Patients were identified using International Classification of Diseases 9th Revision (ICD-9-CM) for the ERCP procedure codes. Included patients were divided into two groups. The study group was those who had a concomitant discharge diagnosis of end stage renal disease ESRD. We used ICD-9-CM code 585.6 to identify patients who had end stage renal disease who required dialysis. The control group was the hospitalized patients who underwent ERCP and did not have renal disease in their discharge diagnosis. Complications were compared using distribution and multivariate logistic regression analysis controlling for age and gender for all the outcomes. We isolated complication from indication by considering the primary and secondary diagnosis as an indication and the subsequent diagnoses as complications. Results: 526 patients had ESRD requiring HD and 33,662 represented the control group. The mean age was 59.4 19.7 (range 18-90 years). 48 patients developed post ERCP pancreatitis in the ESRD group (9.13%) compared to 1,530 in the control group (4.49%) with adjusted odd ratio aOR: 2.1 (95% CI: 1.56 – 2.86, P<0.001). 11 patients (2.1%) developed Post ERCP Hemorrhage in the ESRD group compared to 266 (0.8%) in the control group with aOR: 2.5 (95% CI: 1.38 - 4.7, PZ0.003). Post ERCP perforation was rare in both groups but still significantly higher in the ESRD 0.38 % compared to the control 0.06% with aOR: 6.8 (95% CI: 1.6 – 29.7, PZ0.01). Overall length of hospital stay in patients who underwent ERCP was 6.40 7.18 days. The mean length of hospital stay was longer in the ESRD group 12.9 13.95 days compared to 6.3 6.98 (P<0.001). In Hospital mortality was also significantly higher in the in the ESRD group. 32 patients (6%) died compared to the control group (1.3%) aOR: 4.4 (95% CI: 3 – 6.4, P<0.001). ESRD patients also incurred higher hospitalization charges ($163,948 vs $62,849, P<0.001) compared to the control group. Conclusion: ESRD is associated with a significant health care burden in hospitalized patients requiring ERCP because of higher rate of post procedure complications, longer hospital stay, and higher mortality. Closer monitoring and peri-procedural special intervention should be considered to decrease complications.
Sa1422 The Use of Fully Covered Metal Stents in the Management of Benign Refractory Pancreatic Ductal Strictures Akit Patel, Obinna C. Ukabam, Sreedevi Atluri, Hendrikus Vanderveldt, Laura Rosenkranz, Sandeep N. Patel* University of Texas Health Sciences, San Antonio, TX
agement of refractory benign PD strictures. Our objective was to evaluate the feasibility, safety, and outcomes of FCSEMS for therapeutic intervention in refractory benign pancreatic ductal strictures in patients with chronic pancreatitis. Methods: A retrospective chart review was conducted on consecutive adult subjects who underwent ERCP with stenting of the PD performed between February 2008 and September 2016 at our institution. All subjects who had FCSEMS placed for main pancreatic ductal strictures were included in the study. Results: 245 patients underwent ERCP with main pancreatic duct stenting during the study period. Twenty patients underwent ERCP with FCSEMS placement. The patients median age was 42.5 (range 15 - 75). Forty-six percent were male. The most common location of the PD stricture was at the head of the pancreas (NZ16, 80%). Strictures were also located in the neck (NZ1) and the body of the pancreas (NZ1). Five patients (25%) had pancreas divisum. Ten patients (50%) had PD stones. FCSEMS were successfully placed in all twenty patients. Prior to FCSEMS placement, all patients had undergone sphincterotomy, balloon or catheter stricture dilation and plastic stent placement. The average number of plastic stents placed prior to FCSEMS placement was 2.2 (range 1-6). The average number of FCSEMS placed before stricture resolution was 1.4 (range 1-8) with the mode being just 1 metal stent (eighteen out of twenty patients, 90%). PD stricture resolution was achieved in sixteen patients (80%). Three of the twenty patients (15%) who had stricture resolution with FCSEMS later redeveloped a PD stricture requiring an additional endotherapy. Complications of FCSEMS placement occurred in 10%: mild post-ERCP pancreatitis (NZ1) and pain requiring stent removal (NZ1). Conclusions: Endotherapy using fully cover self-expanding metal stents in the management of refractory benign PD strictures appears to be safe and provides reasonable stricture resolution.
Sa1424 Endoscopic Dilation of Pancreatic Duct Strictures in Chronic Pancreatitis With Multiple Plastic Stents: Results in 48 Patients Vincenzo Bove*1, Andrea Tringali1, Giorgio Valerii1, Rosario Landi1, Pietro Familiari1, Ivo Boskoski1,2, Vincenzo Perri1, Guido Costamagna1,3 1 Digestive Endoscopy Unit, Gemelli University Hospital, Rome, Italy, Italy; 2Service de Chirurgie Digestive & Endocrinienne, IHU Strasbourg, Strasbourg, France; 3USIAS Strasbourg University, Strasbourg, France Background and Aims: Main Pancreatic Duct (MPD) strictures located in the head of the pancreas often occur in the course of Chronic Pancreatitis (CP). Common management of these strictures is endoscopic placement of a single plastic stent. Refractory strictures require repeated stent replacement or surgical pancreaticojejunostomy. Insertion of Multiple Plastic Stents (MPS) obtained, in a series of 19 patients, symptomatic MPD stricture resolution in 84% of the cases, after 3-year follow-up (1) The aim of this study was to evaluate the results of the MPS strategy in a larger series of CP patients. Patients and Methods: Forty-eight patients (34 men; mean age 44 years, range 5-86) with severe CP and a symptomatic dominant MPD stricture located in the head of the pancreas, were evaluated. All the patients experienced pain resolution following MPD drainage with a single plastic stents. The MPD stricture was refractory to single plastic stent placement in all cases and patients underwent insertion of MPS according to the following protocol: balloon dilation of the stricture if necessary, insertion of the maximum number of plastic stents allowed by the stricture tightness and pancreatic duct diameter, stents removal after 6 months. Results: The median number of stents placed through the major or minor papilla was 3 (range 2-5), 8.5 to 11.5 Fr in diameter and 3 to 7 cm in length. MPS were removed after a mean time of 6.7 months (range 2-18). Eight patients (16.6 %) had persistence of the MPD stricture after MPS removal and underwent replacement of an increased number of stents; 3/8 patients had a dilation of the stricture after further multistent placement (overall success 89.5%). Following a mean follow up of 9.5 years (range 0.3-15.5) after MPS removal, 77.1% of patients were asymptomatic. Symptomatic MPD stricture recurrence was reported in 11 patients (22.9%), after a mean time of 26.4 months (range 5-108) from MPS removal. No major complications were recorded. Conclusion: Endoscopic dilation of CPrelated dominant MPD strictures seems possible with the MPS technique. According to this experience on 48 patients, MPS is highly effective even at long-term follow-up in the majority of patients. Reference 1. Costamagna G, Bulajic M, Tringali A et al. Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results. Endoscopy 2006;38:254-9.
Background: Chronic pancreatitis (CP) is characterized by long-standing inflammation of the pancreas potentially leading to structural damage such as pancreatic duct strictures and the formation of stones. The endoscopic placement of small caliber plastic stents has been increasingly utilized to improve panceatic outflow and improve symptoms in these patients. Endotherapy offers the potential of treatment in a less invasive manner than surgery. Literature is scarce on the outcomes of pancreatic fully cover self-expanding metal stent (FCSEMS) placement in the man-
AB236 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org