- Email: [email protected]
Sa1438 Long Term Outcomes of Self Expandable Metal Stents in the Palliation of Malignant Biliary Obstruction
Abstracts
of the disease; however, this treatment is associated with complications that could increase morbidity and mortality. It is not yet agreed in the literature whether early ERCP provides better results in the treatment of acute biliary pancreatitis compared to conservative treatment. Objective: To evaluate whether the use of early ERCP in the treatment of acute biliary pancreatitis reduces local and / or systemic complications, onset of cholangitis, mortality, time of pain relief and axillary temperature recovery, hospitalization time and cost compared to conservative treatment. Method: Systematic review was performed in Pubmed, Lilacs, Embase, Cochrane, Bireme of randomized clinical trials comparing early endoscopic treatment with conservative treatment in the initial approach of acute biliary pancreatitis. For the analysis, the risk difference (RD) and the Higgins test were used to evaluate the heterogeneity, with fixed effects (FE) and random (RE), through the software in Review Manager 5.3. Results: We analyzed 10 randomized clinical trials involving 1091 patients comparing early ERCP in the treatment of acute biliary pancreatitis versus conservative treatment. The outcomes that presented a statistically significant difference were the analysis of the local complications reported in the studies in general and favored the group submitted to ERCP (RD 0.74, 95%CI 0.55 to 0.99). The time of pain relief and axillary temperature recovery also favored the group submitted to ERCP with significant statistical difference (RD -5.01, 95%CI -6.98 to -3.04; RD - 0.70, 95%CI -2.33 to -1.08), as well as in relation to the hospitalization time. The patients undergoing ERCP stayed less time in the hospital (RD -11.04, 95% CI -15.15to -6.93). In the cost analysis the study that evaluated pancreatitis in general and the study that evaluated the subgroup with severe acute pancreatitis showed that the cost was lower in the patients submitted to ERCP. Discussion: Although this study shows that in only a few outcomes ERCP brings benefits, it is still not recommended as an ideal in the early treatment of acute biliary pancreatitis since more randomized studies, with homogeneous inclusion and exclusion criteria, are needed for the analysis of the real benefits of ERCP in the early treatment of acute biliary pancreatitis. Key words: (Retrograde Cholangiopancreatography, Endoscopic Cholangiopancreatographies, Endoscopic Retrograde, Endoscopic Retrograde Cholangiopancreatographies, Retrograde Cholangiopancreatographies, Endoscopic Retrograde Cholangiopancreatography, ERCP) AND Pancreatitis. PROSPERO database (CRD42016047001).
Sa1438 Long Term Outcomes of Self Expandable Metal Stents in the Palliation of Malignant Biliary Obstruction Ahmad Najdat Bazarbashi*, Christian Brooks, Amit P. Desai, Sunil Amin, Amrita Sethi, John M. Poneros, Frank G. Gress, Tamas Gonda Columbia University Medical Center, New York, NY Introduction: Many studies have evaluated the use of self-expandable metal stents (SEMS) and their advantage to plastic stents in the palliation of malignant biliary obstruction. Less is known about their long term durability in patients receiving palliative treatment and the need for stent re-evaluation in the absence of complications. Our goal was to identify the time frame of stent complications and the factors associated with need for reintervention. Methods: We conducted a singlecenter retrospective cohort study of patients with known pancreatic cancer, cholangiocarcinoma or metastatic disease. Patients who underwent palliative stenting and were alive for > 3 months after placement of a SEMS were included. Data were collected on age, gender, type of cancer, type of first stent placed (fully covered self expandable metal stent [FCSEM] vs uncovered self expandable metal stent [UCSEM]), indication and frequency for reintervention after stent placement and the mean time to re-intervention. We also collected data on concomitant chemotherapy, radiotherapy, duodenal stenting, the presence of a gallbladder and cholelithiasis. Statistical analysis was performed with the Chi square and Fisher exact tests. Results: We reviewed the records of 146 patients who underwent ERCP with placement of SEMS for malignant obstruction at our institution and identified 34 patients who received palliative treatment and were alive for >3 months after stent placement. Mean age was 71.6 years, 65% were male and 85% had pancreatic cancer. The average survival after stent placement was 325 (51) days. 41% of patients required re-intervention at an average time of 263 (254) days (76% for biliary obstruction and 24% for stent migration). Only 6/34 patients required a reintervention less then 6 months from metal stent placement and 3 of these were due to stent migration in patients with a FCSEMS. All patients who presented with cholangitis (38%) had UCSEMS placed and the average time since placement was 277 days. In a univariate analysis, the use of uncovered metals stents (OR 7.8; 95%CI 1.5-39.2; pZ0.008) was the only factor predictive of need for re-intervention. Treatment with chemotherapy or radiation therapy, the presence of gallbladder or stone disease or concurrent duodenal obstruction or prior plastic stent placement was not predictive of reintervention. Conclusions: In this cohort of palliative long-term metal stenting, we show an overall high patency rate. Our data also supports the use of fully covered metal stents with a significantly lower reintervention rate. Based on the type and timing of complications, it appears that patients with FCSEMS would not benefit from prophylactic reintervention, whereas patients with UCSEMS may benefit from a reintervention 6-9 months after stent placement to prevent the development of biliary obstruction or cholangitis.
AB242 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Sa1439 To Evaluate of Comparison Between Short-Type SingleBalloon and Double-Balloon Enteroscope Assisted Ercp in Postsurgical Altered Anatomy Yoshinobu Okabe*1, Kei Kuraoka1, Hiroya Terabe2, Yusuke Ishida1, Makiko Yasumoto1, Tomoyuki Ushijima1, Osamu Tsuruta1, Takuji Torimura1 1 Department of Gastroenterology, Kurume University School of Medicine, Kurume, Japan; 2Center for Gastroenterology, Tobata kyouritsu hospital, Kitakyusyu, Japan Background and aim: Recently, two new types of short-type balloon enteroscope were developed for ERCP procedure for pancreatobiliary disease with postsurgical altered anatomy. We examined between the results of ERCP using short-type single balloon enteroscope (sSBE) and short-type double balloon enteroscope (sDBE) experienced at two facilities. Methods: During the same period, we studied 27 cases of 32 sSBE (SIF-H290S, Olympus Medical Systems, Tokyo) assisted ERCP at our hospital and 15 cases of 20 sDBE (EI-530BT, Fujinon, Osaka) assisted ERCP at Tobata Kyouritsu Hospital for the patients with postoperative gastrointestinal reconstruction (excluding Billroth I reconstruction). Reconstruction procedures included, 12 cases and 4 case of Billroth II (B2), 9 cases and 13 cases of Roux-en Y (RY), 11 cases and 3 case of post-pancreatoduodenectomy (or post-choledochojejunostomy), in groups sSBE and sDBE, respectively. We investigated retrospectively about the rate of reaching the blind end, cannulation success rate, procedure completion rate, and adverse events in both groups. Results: The rate of reaching the blind end were 96.9% (31/32) [B2: 100%(12/12), RY: 88.9%(8/9), Others: 100%(11/11)] and 90.0% (18/20) [B2: 100%(4/4), RY: 84.6% (11/13), Others: 100%(3/3)] in groups sSBE and sDBE (pZ0.309). The average time of reaching the blind end was significantly higher in group sSBE (21.8 min vs. 38.9 min; pZ0.014). The cannulation success rates were 90.3% (28/31) and 77.8% (14/18) in groups sSBE and sDBE (pZ0.226). The procedure completion rates and average time were significantly higher in group sSBE (87.5%(28/32) vs. 60.0%(12/20); pZ0.022, 83.2 min vs. 107.5 min; pZ0.019). Adverse events rates were 3.1%(1/32: intestinal perforation due to overtube) and 5.0%(1/10: mild post-ERCP pancreatitis) in groups sSBE and sDBE. Conclusion: The rate of reaching the blind end of sSBE and sDBE were almost the same, but the procedure completion rate was significantly higher in sSBE. The limitation of this study was small size, it is necessary to investigate by increasing the number of cases in the future.
Sa1440 Preoperative Biliary Drainage in Resectable Pancreatic Cancer: A Systematic Review and Network Meta-Analysis Peter Junwoo Lee*1, Amareshwar Podugu2, Dong Wu3, Arier Chi Lun Lee4, Tyler Stevens6, John A. Windsor5 1 Gastroenterology, University Hospitals, Cleveland, OH; 2 Gastroenterology, Cleveland Clinic Florida, Weston, FL; 3 Gastroenterology, Peking Union Medicall College Hospital, Beijing, China; 4University of Auckland, Auckland, New Zealand; 5Department of Surgery, University of Auckland, Auckland, New Zealand; 6 Gastroenterology, Cleveland Clinic, Cleveland, OH Background: There is controversy about the best pre-operative management in patients with resectable pancreatic cancer (RPC) undergoing planned pancreaticoduodenectomy (PD). The aim of this study was to systematically review the evidence to compare four pre-operative approaches (POA) to obstructive jaundice in RPC in relation to post-operative complication rates: preoperative biliary drainage with plastic stent, metal stent, and percutaneous transhepatic drain (PBD-PS, PBD-MS and PBD-PT respectively), or no pre-operative biliary drainage (NPBD). Methods: Literature search of English language studies regarding preoperative management of obstructive jaundice from MEDLINE, EMBASE and the Cochrane databases between 1945 and April 2016 was performed. Strength of evidence was assessed using GRADE. Endpoints were rate of any post-operative complication, wound infection, intra-abdominal infection and post-operative bleeding. Network meta-analysis (NMA) was performed using direct and indirect evidence from pairwise comparisons. Odds ratios and probability scores were calculated to rank the 4 management approaches. Results: The search identified 7232 studies, out of which 32 met the inclusion criteria. All studies were observational in design except two randomized controlled trials. Only sixteen studies compared different management approaches. Drainage period and proportion of RPC varied widely between 32 studies. Only 3 studies reported outcomes using Clavien-Dindo Classification. Data from 8 studies were pooled for NMA for three endpoints, and data from 5 studies were pooled for post-operative bleeding. The calculated odds ratios and probabilities ranked NPBD as the best approach, followed by PBD-PS, PBD-MS and PBD-PT (Table). Conclusion: The available evidence indicates that no preoperative biliary drainage is the best way to manage preoperative jaundice in patients with RPC before PD. If patients are to be stented then PBD-PS appear to be superior to PBD-MS and PBD-PT.
www.giejournal.org
of the disease; however, this treatment is associated with complications that could increase morbidity and mortality. It is not yet agreed in the literature whether early ERCP provides better results in the treatment of acute biliary pancreatitis compared to conservative treatment. Objective: To evaluate whether the use of early ERCP in the treatment of acute biliary pancreatitis reduces local and / or systemic complications, onset of cholangitis, mortality, time of pain relief and axillary temperature recovery, hospitalization time and cost compared to conservative treatment. Method: Systematic review was performed in Pubmed, Lilacs, Embase, Cochrane, Bireme of randomized clinical trials comparing early endoscopic treatment with conservative treatment in the initial approach of acute biliary pancreatitis. For the analysis, the risk difference (RD) and the Higgins test were used to evaluate the heterogeneity, with fixed effects (FE) and random (RE), through the software in Review Manager 5.3. Results: We analyzed 10 randomized clinical trials involving 1091 patients comparing early ERCP in the treatment of acute biliary pancreatitis versus conservative treatment. The outcomes that presented a statistically significant difference were the analysis of the local complications reported in the studies in general and favored the group submitted to ERCP (RD 0.74, 95%CI 0.55 to 0.99). The time of pain relief and axillary temperature recovery also favored the group submitted to ERCP with significant statistical difference (RD -5.01, 95%CI -6.98 to -3.04; RD - 0.70, 95%CI -2.33 to -1.08), as well as in relation to the hospitalization time. The patients undergoing ERCP stayed less time in the hospital (RD -11.04, 95% CI -15.15to -6.93). In the cost analysis the study that evaluated pancreatitis in general and the study that evaluated the subgroup with severe acute pancreatitis showed that the cost was lower in the patients submitted to ERCP. Discussion: Although this study shows that in only a few outcomes ERCP brings benefits, it is still not recommended as an ideal in the early treatment of acute biliary pancreatitis since more randomized studies, with homogeneous inclusion and exclusion criteria, are needed for the analysis of the real benefits of ERCP in the early treatment of acute biliary pancreatitis. Key words: (Retrograde Cholangiopancreatography, Endoscopic Cholangiopancreatographies, Endoscopic Retrograde, Endoscopic Retrograde Cholangiopancreatographies, Retrograde Cholangiopancreatographies, Endoscopic Retrograde Cholangiopancreatography, ERCP) AND Pancreatitis. PROSPERO database (CRD42016047001).
Sa1438 Long Term Outcomes of Self Expandable Metal Stents in the Palliation of Malignant Biliary Obstruction Ahmad Najdat Bazarbashi*, Christian Brooks, Amit P. Desai, Sunil Amin, Amrita Sethi, John M. Poneros, Frank G. Gress, Tamas Gonda Columbia University Medical Center, New York, NY Introduction: Many studies have evaluated the use of self-expandable metal stents (SEMS) and their advantage to plastic stents in the palliation of malignant biliary obstruction. Less is known about their long term durability in patients receiving palliative treatment and the need for stent re-evaluation in the absence of complications. Our goal was to identify the time frame of stent complications and the factors associated with need for reintervention. Methods: We conducted a singlecenter retrospective cohort study of patients with known pancreatic cancer, cholangiocarcinoma or metastatic disease. Patients who underwent palliative stenting and were alive for > 3 months after placement of a SEMS were included. Data were collected on age, gender, type of cancer, type of first stent placed (fully covered self expandable metal stent [FCSEM] vs uncovered self expandable metal stent [UCSEM]), indication and frequency for reintervention after stent placement and the mean time to re-intervention. We also collected data on concomitant chemotherapy, radiotherapy, duodenal stenting, the presence of a gallbladder and cholelithiasis. Statistical analysis was performed with the Chi square and Fisher exact tests. Results: We reviewed the records of 146 patients who underwent ERCP with placement of SEMS for malignant obstruction at our institution and identified 34 patients who received palliative treatment and were alive for >3 months after stent placement. Mean age was 71.6 years, 65% were male and 85% had pancreatic cancer. The average survival after stent placement was 325 (51) days. 41% of patients required re-intervention at an average time of 263 (254) days (76% for biliary obstruction and 24% for stent migration). Only 6/34 patients required a reintervention less then 6 months from metal stent placement and 3 of these were due to stent migration in patients with a FCSEMS. All patients who presented with cholangitis (38%) had UCSEMS placed and the average time since placement was 277 days. In a univariate analysis, the use of uncovered metals stents (OR 7.8; 95%CI 1.5-39.2; pZ0.008) was the only factor predictive of need for re-intervention. Treatment with chemotherapy or radiation therapy, the presence of gallbladder or stone disease or concurrent duodenal obstruction or prior plastic stent placement was not predictive of reintervention. Conclusions: In this cohort of palliative long-term metal stenting, we show an overall high patency rate. Our data also supports the use of fully covered metal stents with a significantly lower reintervention rate. Based on the type and timing of complications, it appears that patients with FCSEMS would not benefit from prophylactic reintervention, whereas patients with UCSEMS may benefit from a reintervention 6-9 months after stent placement to prevent the development of biliary obstruction or cholangitis.
AB242 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Sa1439 To Evaluate of Comparison Between Short-Type SingleBalloon and Double-Balloon Enteroscope Assisted Ercp in Postsurgical Altered Anatomy Yoshinobu Okabe*1, Kei Kuraoka1, Hiroya Terabe2, Yusuke Ishida1, Makiko Yasumoto1, Tomoyuki Ushijima1, Osamu Tsuruta1, Takuji Torimura1 1 Department of Gastroenterology, Kurume University School of Medicine, Kurume, Japan; 2Center for Gastroenterology, Tobata kyouritsu hospital, Kitakyusyu, Japan Background and aim: Recently, two new types of short-type balloon enteroscope were developed for ERCP procedure for pancreatobiliary disease with postsurgical altered anatomy. We examined between the results of ERCP using short-type single balloon enteroscope (sSBE) and short-type double balloon enteroscope (sDBE) experienced at two facilities. Methods: During the same period, we studied 27 cases of 32 sSBE (SIF-H290S, Olympus Medical Systems, Tokyo) assisted ERCP at our hospital and 15 cases of 20 sDBE (EI-530BT, Fujinon, Osaka) assisted ERCP at Tobata Kyouritsu Hospital for the patients with postoperative gastrointestinal reconstruction (excluding Billroth I reconstruction). Reconstruction procedures included, 12 cases and 4 case of Billroth II (B2), 9 cases and 13 cases of Roux-en Y (RY), 11 cases and 3 case of post-pancreatoduodenectomy (or post-choledochojejunostomy), in groups sSBE and sDBE, respectively. We investigated retrospectively about the rate of reaching the blind end, cannulation success rate, procedure completion rate, and adverse events in both groups. Results: The rate of reaching the blind end were 96.9% (31/32) [B2: 100%(12/12), RY: 88.9%(8/9), Others: 100%(11/11)] and 90.0% (18/20) [B2: 100%(4/4), RY: 84.6% (11/13), Others: 100%(3/3)] in groups sSBE and sDBE (pZ0.309). The average time of reaching the blind end was significantly higher in group sSBE (21.8 min vs. 38.9 min; pZ0.014). The cannulation success rates were 90.3% (28/31) and 77.8% (14/18) in groups sSBE and sDBE (pZ0.226). The procedure completion rates and average time were significantly higher in group sSBE (87.5%(28/32) vs. 60.0%(12/20); pZ0.022, 83.2 min vs. 107.5 min; pZ0.019). Adverse events rates were 3.1%(1/32: intestinal perforation due to overtube) and 5.0%(1/10: mild post-ERCP pancreatitis) in groups sSBE and sDBE. Conclusion: The rate of reaching the blind end of sSBE and sDBE were almost the same, but the procedure completion rate was significantly higher in sSBE. The limitation of this study was small size, it is necessary to investigate by increasing the number of cases in the future.
Sa1440 Preoperative Biliary Drainage in Resectable Pancreatic Cancer: A Systematic Review and Network Meta-Analysis Peter Junwoo Lee*1, Amareshwar Podugu2, Dong Wu3, Arier Chi Lun Lee4, Tyler Stevens6, John A. Windsor5 1 Gastroenterology, University Hospitals, Cleveland, OH; 2 Gastroenterology, Cleveland Clinic Florida, Weston, FL; 3 Gastroenterology, Peking Union Medicall College Hospital, Beijing, China; 4University of Auckland, Auckland, New Zealand; 5Department of Surgery, University of Auckland, Auckland, New Zealand; 6 Gastroenterology, Cleveland Clinic, Cleveland, OH Background: There is controversy about the best pre-operative management in patients with resectable pancreatic cancer (RPC) undergoing planned pancreaticoduodenectomy (PD). The aim of this study was to systematically review the evidence to compare four pre-operative approaches (POA) to obstructive jaundice in RPC in relation to post-operative complication rates: preoperative biliary drainage with plastic stent, metal stent, and percutaneous transhepatic drain (PBD-PS, PBD-MS and PBD-PT respectively), or no pre-operative biliary drainage (NPBD). Methods: Literature search of English language studies regarding preoperative management of obstructive jaundice from MEDLINE, EMBASE and the Cochrane databases between 1945 and April 2016 was performed. Strength of evidence was assessed using GRADE. Endpoints were rate of any post-operative complication, wound infection, intra-abdominal infection and post-operative bleeding. Network meta-analysis (NMA) was performed using direct and indirect evidence from pairwise comparisons. Odds ratios and probability scores were calculated to rank the 4 management approaches. Results: The search identified 7232 studies, out of which 32 met the inclusion criteria. All studies were observational in design except two randomized controlled trials. Only sixteen studies compared different management approaches. Drainage period and proportion of RPC varied widely between 32 studies. Only 3 studies reported outcomes using Clavien-Dindo Classification. Data from 8 studies were pooled for NMA for three endpoints, and data from 5 studies were pooled for post-operative bleeding. The calculated odds ratios and probabilities ranked NPBD as the best approach, followed by PBD-PS, PBD-MS and PBD-PT (Table). Conclusion: The available evidence indicates that no preoperative biliary drainage is the best way to manage preoperative jaundice in patients with RPC before PD. If patients are to be stented then PBD-PS appear to be superior to PBD-MS and PBD-PT.
www.giejournal.org