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Sa1518 Precut Sphincterotomy At a Tertiary Referral Center for Pancreatic Diseases: A Prospective Study
Abstracts
Table 1. Interim results
Gender M:F Median age years (range) Median time of AS diagnosis post OLT months (range) Median time since treatment protocol commenced months (range) Number of ERCPs Stricture resolution Stricture recurrence ERCP related hospitalization days
RCSEMS
Plastic
3:4 53.5(38-66) 6 (1-30) 11.5 (8-16)
3:3 51.5(23-68) 3.5 (1-204) 21 (11-25)
15 6/7 (86%) 1/6 (17%) 24
28 5/6 (84%) 1/5 (20%) 48
Sa1515 Efficacy of Wire-Guided Cannulation of the Bile Duct in the Treatment of Acute Cholangitis Saburo Matsubara1,2, Hiroyuki Isayama2 1 Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan; 2 Gastroenterology, Tokyo University, Tokyo, Japan Objective: Rapid biliary decompression is important in the treatment of acute cholangitis. Because of nonuse of contrast medium injection, wire-guided cannulation (WGC) is considered to avoid enlarging intrabiliary pressure. WGC during endoscopic biliary drainage might reduce the duration of acute cholangitis compared to standard cannulation (SC). Methods: We retrospectively analyzed patients with acute cholangitis underwent urgent biliary drainage using WGC or SC successfully. Patients with normal body temperature, acute pancreatitis, hepatic abscess, hilar biliary obstruction, and biliary metallic stent, whose distal end was in the duodenum, were excluded. The duration of fever, the time of procedure, and complications were compared between both cannulation methods. The timing of injection of contrast medium was: after fully aspiration of bile juice in WGC, before aspiration in SC. Severity of cholangitis was based on Tokyo Guideline. Either endoscopic nasobiliary drainage (ENBD) tube or plastic stent (PS) was used as drainage device. Results: Eighty-three patients (32 in WGC, 51 in SC) were eligible between April 2007 and April 2010. The baseline characteristics did not show significant differences in following parameters: median age, 77y vs. 76y; male, 66% vs. 49%; causative diseases (common bile duct stone, 25 vs. 40; cholangiocarcinoma, 4 vs. 6; pancreatic cancer, 2 vs. 3; hepatocellular carcinoma, 1 vs. 1; and chronic pancreatitis, 0 vs. 1); severity (mild, 7 vs. 8; moderate, 19 vs. 27; and severe, 6 vs. 16); and diabetes mellitus, 8 vs. 10. There was significant difference in ASA score (1/2/3/ 4, 2/17/13/0 vs. 10/32/8/1, P ⫽ 0.03). There was no significant differences in drainage devices (ENBD/PS, 28/4 vs. 46/5). The duration of fever was significantly shorter in WGC than SC (1 day [interquartile range, 1-2.75] vs. 2 days [2-4], P ⫽ 0.01). The median time of procedure (16.5min. vs. 25min.), postERCP pancreatitis (0% vs. 5.9%), and hyperamylasemia (15.6% vs. 21.6%) were not significantly different, but WGC exceeded SC in all these subjects. Subset analysis of the duration of fever according to severity revealed significant difference in severe group (1 [1-4] vs. 3.5 [2-4.75], P ⫽ 0.048), but no significant difference in mild (2 [1-3] vs. 1.5 [1-2.75]) and moderate group (1 [1-2] vs. 2 [1-3]). Conclusions: WGC during endoscopic biliary drainage reduced the duration of acute cholangitis compared to SC, especially in severe cases.
used was 15mm]. Larger balloon diameter size was not associated with a higher rate of complications. Complications, including post procedural hemorrhage, perforation, and cholangitis occurred in 7.9% [Total of 3 pts: 1 hemorrhage, 1 mild pancreatitis that resolved with conservative management, 1 cholangitis in a patient with unsuccessful stone extraction]. Mechanical lithotripsy was required in 7 of the patients [19%] with subsequent successful clearance. Lithotripsy was associated with a trend towards an increased complication rate. In addition, oozing of blood was seen in 2 of the 38 patients (5.3%), but resolved with the injection of epinephrine during the endoscopy. There were no perforations or deaths in any of the patients. Conclusions: Large-diameter balloon dilation of the sphincterotomy site appears to be a safe and valuable adjunct for the removal of large common bile duct stones. Mechanical lithotripsy may be associated with a higher complication rate and can be avoided in the majority of patients using this approach. Further large scale studies are needed to confirm the safety and efficacy of large-diameter balloon dilation of the sphincterotomy site for large common bile duct stones.
Sa1517 Outcome of Repeat ERCP Following Initial Failed Needle Knife Precut for Biliary Access Fergal Donnellan1,2, Michael F. Byrne2, Edward Y. Kim2, Jack Amar1, Jennifer J. Telford1, Eric C. Lam1, Robert A. Enns1 1 Gastroenterology, St. Paul’s Hospital, Vancouver, BC, Canada; 2 Gastroenterology, Vancouver General Hospital, Vancouver, BC, Canada Introduction: Needle knife precut is often used to gain bile duct access when standard techniques have failed. If unsuccessful, the next step usually involves radiological-guided biliary access. However, a repeat endoscopic procedure may be an option if the patient’s clinical condition permits. Aims: To determine the success of repeat ERCP following failed needle knife precut for biliary access. Methods: Retrospective analysis of all patients who underwent initial unsuccessful biliary cannulation following needle knife precut between January 2007 and August 2010. Results: 42 patients were identified in total. Of these, 27(64%) underwent a repeat ERCP, of which biliary cannulation was successful in 21 (78%). Choledocholithiasis was diagnosed in 13 (72%) patients, malignancy in 4 (22%) patients and a bile leak in the remaining patient. In the 5 patients in whom repeat cannulation was unsuccessful, choledocholithiasis was diagnosed in 2 (40%) patients, malignancy in 2 (40%) patients and a bile leak in the remaining patient. In the 15 patients in whom repeat ERCP was not performed following initial failure, 5 (33%) patients underwent radiological-guided biliary access, 8 (53%) patients were managed conservatively and 2 (14%) patients underwent surgical resection for malignancy.Median time to repeat ERCP was 7.5 days (range 1 - 28 days). The same endoscopist performed the repeat procedure in 17 patients, with successful cannulation occurring in 13 of these patients (77%). 2 patients developed complications, a wire-guided perforation in one and pancreatitis in the other. Conclusions: Our data demonstrates that repeat ERCP within a few days following failed needle knife precut for biliary access is associated with acceptable success and complication rates, and thereby obviates the need for radiological-guided access in some patients.
Sa1516 Large-Diameter Balloon Dilation for the Removal of Large Common Bile Duct Stones Bani Chander, Harry R. Aslanian, Uzma D. Siddiqui, Priya A. Jamidar Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
Sa1518 Precut Sphincterotomy At a Tertiary Referral Center for Pancreatic Diseases: A Prospective Study Giorgio Talamini1, Federica Damini2, Claudio Bassi2, Giampaolo Angelini3, Paolo Pederzoli2, Italo Vantini4 1 Pancreatic Endoscopy Unit, policlinico g. rossi, verona, Italy; 2 General Surgery, policlinico g. rossi, verona, Italy; 3Digestive Endoscopy Unit, policlinico g. rossi, verona, Italy; 4Gastroenterology, policlinico g. rossi, verona, Italy
Background: Endoscopic sphincterotomy followed by extraction using a basket or an extraction balloon is typically used for the removal of common bile duct (CBD) stones. However, this procedure is associated with a significant rate of post procedural hemorrhage, pancreatitis, and perforation and is not successful in all patients. Few studies have looked at outcomes using large-diameter balloon dilation for the removal of large common bile duct stones. Aims: The aims of this study were: 1) To determine the efficacy of large diameter balloon dilation of the sphincterotomy site for the removal of large common bile duct stones and 2) To evaluate the risks and complication rate associated with this procedure. Methods: A single center, retrospective chart review of 38 consecutive patients who underwent large-diameter (12-18mm) balloon dilation for common bile duct stones between April 2008 through October of 2010. Following partial biliary sphincterotomy, all patients had balloon dilation of the biliary orifice performed [balloon diameter size ranged from 12-18mm]. Results: Common bile duct stones could be removed in all the patients using large-diameter balloon technique. Complete stone extraction was achieved in 34 of the 38 patients (89%). Stone size varied from ⬍15 mm to 25 mm. The average balloon diameter size used in successful clearance was 14.14 ⫾ 1.69 mm [The most common size
Background: Precutting is sometimes needed to facilitate deep cannulation of the biliary/pancreatic ducts during the course of endoscopic retrograde cholangiopancreatography (ERCP). Objectives: To identify the precut-related success and complication rates, and the treatments used in the event of ERCP failing. Design: Observational study on prospectively collected data. Setting: A tertiary referral university hospital. Patients: Patients with papillae with no prior endoscopic treatment who underwent precutting between January 2007 and April 2010. Main Outcome Measurements: Success and complication rates after precutting and after invasive radiological procedures used after ERCP had failed. Results: ERCP was performed in 783 patients, and 755 of these procedures were implemented with a therapeutic intent; a precut was made in 131 (17.3%): 64 were males (48.9%) and 67 were females (51.1%); their mean age was 65.5 ⫾ 13.7 years. The overall success rate was 73.3% (96/131) with an inter-operator range of 63.1% to 83.3%. Among all the variables considered, uni- and multivariate analysis showed that only the “operator” variable was significant.The complication rate was 5.3% (7/131) with: 4 cases of mild pancreatitis (3%); 1 of severe pancreatitis (0.8%); 2 perforations (1.5%); and no hemorrhage or deaths. The difficulty encountered in performing the ERCP correlated inversely with the
AB194 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
success rate (p⬍0.01), but not with the complication rate.The 35 patients whose ERCP was unsuccessful underwent: percutaneous transhepatic biliary drainage (PTBD) in 18 cases (51.4%); medical treatment and radiological follow-up in 11 (31.4%); and surgery in 6 (17.2%). PTBD carried a 22.2% rate of infectious/ bleeding complications. Conclusion: Papilla precutting is useful in deep duct cannulation, with an acceptable complication rate, although the method is operator-dependent.
Group A within first 36 hours, in Group B after 72 hours. The data of age, sex, leucocyte levels before treatment, the falling time of leucocyte and duration of hospital stay were recorded and analised in SPSS 17.0 version. The mean values were calculated due to Mann-Whitney U and Chi-square tests. There were 46 male and 68 female patients. ERCP was performed to 63 patients within first 36 hours (Group A) and 51 patients afer 72 hours of application (Group B). There was no statistical difference of the number stones in the choledochus and diameter of the choledochus between two groups. Three patients in Group A and 1 patient in Group B were died from sepsis. The mean age was 68⫾15 years, leucocyte count was 17⫾5,8 /mm3, the mean day of leucocyte count turning into normal level was 4,3⫾4,1 days, number of days antibiotics used were 5,4⫾ 2,8 days, the duration of hospital stay was 6,2⫾4,7 days in Group A. The mean age was 70⫾13 years, leucocyte count was 17⫾6,7 /mm3, the mean day of leucocyte count turning into normal level was 5,3⫾2,6 days, number of days antibiotics used were 7,2⫾3,1 days, the duration of hospital stay was 9,2⫾4,6 days in Group B. There were significant difference on duration of hospital stay, leucocyte decreasing time and the days of antibiotics used between two groups. There was no bleeding, perforation and bacterial septicemia in each group during and after ERCP. According to our results, clinical recovery is provided in a shorter time in early ERCP applied patients. This situation reduces the duration of hospital stay and number of days of antibiotics used. Early ERCP has no significant effect on mortality and morbidity.
Success rate of precutting by grade of difficulty of the ERCP and by operator (the number of patients is indicated at the top of each column)
Sa1519 Carbon Dioxide Insufflation Versus Conventional Saline Irrigation for PerOral Video Cholangioscopy Shinpei Doi1, Ichiro Yasuda1, Masanori Nakashima1, Takuji Iwashita1, Katsuhisa Toda1, Tsuyoshi Mukai2, Keisuke Iwata2, Hisataka Moriwaki1 1 First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan; 2Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan Background: Recent studies have evaluated the efficacy of peroral cholangioscopy (POCS) for diagnosis of biliary diseases. During POCS, saline is irrigated to replace yellow bile. In order to obtain clear images, a lengthy saline irrigation is required. Aim: To evaluate the feasibility of replacing saline irrigation with CO2insufflation during POCS. Methods: We enrolled 36 patients with bile duct lesions for POCS. Among these, 18 patients underwent POCS using saline irrigation followed by CO2 insufflation, while the remaining 18 patients received the reverse approach. We compared the time required to obtain a clear endoscopic image as well as the quality of the images. Results: The time required to obtain a clear endoscopic image in CO2insufflation (4 min) was significantly shorter than that in saline irrigation (24 min, p ⬍ 0.001). The quality of the endoscopic images obtained was similar in 27 cases. However, CO2 insufflation provided better images in 4 cases that showed an abundance of mucin or biliary sludge. In contrast, saline irrigation was superior to CO2 insufflation in 5 cases that showed severe stricture with bleeding and tall papillary lesions. Conclusions: CO2insufflation during POCS can reduce procedure time and simplify cholangioscopy. Overall image quality was similar to the conventional saline irrigation.
Sa1520 Early ERCP Is Safe and Cost-Effective in the Treatment of Mild to Moderate Acute Cholangitis Emrah Alper2, Belkis Unsal2, Zafer Buyraç2, BehlüL Baydar1, Fatih Aslan2, Serdar Akça1, Yucel Ustundag3 1 Gastroenterology and Surgery, Memorial Antalya Hospital, Antalya, Turkey; 2Gastroenterology, Ataturk Training and Research Hospital, Izmir, Turkey; 3Gastroenterology, Karaelmas University, Zonguldak, Turkey Acute cholangitis has high mortality and morbidity if left untreated. Acute cholangitis can be treated effectively with biliary decompression and antibiotics. But the timing of biliary decompression is still unclear. Aim is to analize the effect of early ERCP on duration of hospital stay, antibiotic use, mortality and morbidity of the patients with mild to moderate acute cholangitis. The study is done prospectively in a gastroenterology clinic in a tertier center. One hundred and fourteen acute cholangitis patients diagnosed with laboratory and screening methods applied with Charcoat triad were included in the study between May 2008 and May 2010. The patients randomly divided into two groups. Wide spectrum antibiotics were initiated to all patients in their first application. Under anestesia, the ERCP was performed with standard Olympus duodenoscope in
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Sa1521 Endoscopic Large-Balloon Sphincteroplasty Without Preceding Sphincterotomy Versus Endoscopic Sphincterotomy Plus LargeBalloon Sphincteroplasty for the Removal of Large Bile Duct Stones: A Retrospective Cross-Sectional Study Jin Hong Kim, Jae Chul Hwang, Byung Moo Yoo, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea Background and Aim: Recently, several studies have been reported in which large-balloon sphincteroplasty (LBS) was conducted for the removal of large bile duct stones. Endoscopic sphincterotomy (EST) is usually performed before LBS because of the high risk of pancreatitis. The aim of this study was to compare the therapeutic effectiveness and complications between LBS without preceding EST and EST plus LBS for the treatment of large bile duct stones. Patients and Methods: Fifty three patients (M:F ⫽ 18:35, mean age 69.6) with large bile duct stones (ⱖ 12mm) had LBS without preceding EST from March 2008 to April 2009. Seventy patients (M:F ⫽ 33:37, mean age 68.2) with large bile duct stones who underwent EST plus LBS between July 2005 and February 2008, served as a historical control. Balloon sphincteroplasty was done with a 12- to 20-mm diameter balloon. After ballooning for 1minute, stone removal was done with a basket or a retrieval balloon. If stone removal failed with standard methods, endoscopic mechanical lithotripsy (EML) was performed. Efficacy of stone removal and complications related to the procedure were analyzed. Results: LBS without EST compared with EST plus LBS resulted in similar outcomes in terms of overall successful stone removal (96.2% vs. 95.7, P ⫽ 0.887), mean transverse stone diameter in the success group (15.4mm vs. 16.2mm, P ⫽ 0.254), and the use of EML (15.1% vs. 24.3%, P ⫽ 0.261). Complications were as follows for the LBS without EST group and the EST plus LBS group: pancreatitis (7.5% vs. 5.7%, P ⫽ 0.725); impaction of the basket and stone (0% vs. 1.4%, P ⫽ 1.000), and perforation (0% vs. 2.9%, P ⫽ 0.506). There was one death due to pancreatitis and perforation in the EST plus LBS group. Conclusions: LBS without a preceding EST showed no significant complications and resulted similar to those with EST plus LBS for the removal of large bile duct stones. Therefore, LBS without EST could be an effective alternative for the treatment of large bile duct stones. Prospective, large-scale, randomized, comparative studies are needed to support our study.
Sa1522 Neosquamous Epithelium After Radiofrequency and Cryoablation of Barrett’s Esophagus Displays Genetic Abnormalities: FISH Analysis Sofiya Reicher1, Fatih Z. Boyar3, Vivek S. Ramanathan1, Patricia Chan3, Vladimira Sulcova3, Samuel W. French2, David S. Chung1, Binh V. Pham1, Viktor E. Eysselein1, Arturo L. Anguiano3 1 Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA; 2 Pathology, Harbor-UCLA Medical Center, Torrance, CA; 3Quest Diagnostics Nichols Institute, San Juan Capistrano, CA Background & Aim: Barrett’s esophagus (BE) progression to cancer is associated with accumulation of genetic abnormalities. Recently, promising ablative techniques such as radiofrequency ablation (RFA) and cryoablation have been increasingly applied for BE eradication. Our study aimed to evaluate chromosomal changes in BE before and after RFA and cryoablation by using
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB195
Table 1. Interim results
Gender M:F Median age years (range) Median time of AS diagnosis post OLT months (range) Median time since treatment protocol commenced months (range) Number of ERCPs Stricture resolution Stricture recurrence ERCP related hospitalization days
RCSEMS
Plastic
3:4 53.5(38-66) 6 (1-30) 11.5 (8-16)
3:3 51.5(23-68) 3.5 (1-204) 21 (11-25)
15 6/7 (86%) 1/6 (17%) 24
28 5/6 (84%) 1/5 (20%) 48
Sa1515 Efficacy of Wire-Guided Cannulation of the Bile Duct in the Treatment of Acute Cholangitis Saburo Matsubara1,2, Hiroyuki Isayama2 1 Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan; 2 Gastroenterology, Tokyo University, Tokyo, Japan Objective: Rapid biliary decompression is important in the treatment of acute cholangitis. Because of nonuse of contrast medium injection, wire-guided cannulation (WGC) is considered to avoid enlarging intrabiliary pressure. WGC during endoscopic biliary drainage might reduce the duration of acute cholangitis compared to standard cannulation (SC). Methods: We retrospectively analyzed patients with acute cholangitis underwent urgent biliary drainage using WGC or SC successfully. Patients with normal body temperature, acute pancreatitis, hepatic abscess, hilar biliary obstruction, and biliary metallic stent, whose distal end was in the duodenum, were excluded. The duration of fever, the time of procedure, and complications were compared between both cannulation methods. The timing of injection of contrast medium was: after fully aspiration of bile juice in WGC, before aspiration in SC. Severity of cholangitis was based on Tokyo Guideline. Either endoscopic nasobiliary drainage (ENBD) tube or plastic stent (PS) was used as drainage device. Results: Eighty-three patients (32 in WGC, 51 in SC) were eligible between April 2007 and April 2010. The baseline characteristics did not show significant differences in following parameters: median age, 77y vs. 76y; male, 66% vs. 49%; causative diseases (common bile duct stone, 25 vs. 40; cholangiocarcinoma, 4 vs. 6; pancreatic cancer, 2 vs. 3; hepatocellular carcinoma, 1 vs. 1; and chronic pancreatitis, 0 vs. 1); severity (mild, 7 vs. 8; moderate, 19 vs. 27; and severe, 6 vs. 16); and diabetes mellitus, 8 vs. 10. There was significant difference in ASA score (1/2/3/ 4, 2/17/13/0 vs. 10/32/8/1, P ⫽ 0.03). There was no significant differences in drainage devices (ENBD/PS, 28/4 vs. 46/5). The duration of fever was significantly shorter in WGC than SC (1 day [interquartile range, 1-2.75] vs. 2 days [2-4], P ⫽ 0.01). The median time of procedure (16.5min. vs. 25min.), postERCP pancreatitis (0% vs. 5.9%), and hyperamylasemia (15.6% vs. 21.6%) were not significantly different, but WGC exceeded SC in all these subjects. Subset analysis of the duration of fever according to severity revealed significant difference in severe group (1 [1-4] vs. 3.5 [2-4.75], P ⫽ 0.048), but no significant difference in mild (2 [1-3] vs. 1.5 [1-2.75]) and moderate group (1 [1-2] vs. 2 [1-3]). Conclusions: WGC during endoscopic biliary drainage reduced the duration of acute cholangitis compared to SC, especially in severe cases.
used was 15mm]. Larger balloon diameter size was not associated with a higher rate of complications. Complications, including post procedural hemorrhage, perforation, and cholangitis occurred in 7.9% [Total of 3 pts: 1 hemorrhage, 1 mild pancreatitis that resolved with conservative management, 1 cholangitis in a patient with unsuccessful stone extraction]. Mechanical lithotripsy was required in 7 of the patients [19%] with subsequent successful clearance. Lithotripsy was associated with a trend towards an increased complication rate. In addition, oozing of blood was seen in 2 of the 38 patients (5.3%), but resolved with the injection of epinephrine during the endoscopy. There were no perforations or deaths in any of the patients. Conclusions: Large-diameter balloon dilation of the sphincterotomy site appears to be a safe and valuable adjunct for the removal of large common bile duct stones. Mechanical lithotripsy may be associated with a higher complication rate and can be avoided in the majority of patients using this approach. Further large scale studies are needed to confirm the safety and efficacy of large-diameter balloon dilation of the sphincterotomy site for large common bile duct stones.
Sa1517 Outcome of Repeat ERCP Following Initial Failed Needle Knife Precut for Biliary Access Fergal Donnellan1,2, Michael F. Byrne2, Edward Y. Kim2, Jack Amar1, Jennifer J. Telford1, Eric C. Lam1, Robert A. Enns1 1 Gastroenterology, St. Paul’s Hospital, Vancouver, BC, Canada; 2 Gastroenterology, Vancouver General Hospital, Vancouver, BC, Canada Introduction: Needle knife precut is often used to gain bile duct access when standard techniques have failed. If unsuccessful, the next step usually involves radiological-guided biliary access. However, a repeat endoscopic procedure may be an option if the patient’s clinical condition permits. Aims: To determine the success of repeat ERCP following failed needle knife precut for biliary access. Methods: Retrospective analysis of all patients who underwent initial unsuccessful biliary cannulation following needle knife precut between January 2007 and August 2010. Results: 42 patients were identified in total. Of these, 27(64%) underwent a repeat ERCP, of which biliary cannulation was successful in 21 (78%). Choledocholithiasis was diagnosed in 13 (72%) patients, malignancy in 4 (22%) patients and a bile leak in the remaining patient. In the 5 patients in whom repeat cannulation was unsuccessful, choledocholithiasis was diagnosed in 2 (40%) patients, malignancy in 2 (40%) patients and a bile leak in the remaining patient. In the 15 patients in whom repeat ERCP was not performed following initial failure, 5 (33%) patients underwent radiological-guided biliary access, 8 (53%) patients were managed conservatively and 2 (14%) patients underwent surgical resection for malignancy.Median time to repeat ERCP was 7.5 days (range 1 - 28 days). The same endoscopist performed the repeat procedure in 17 patients, with successful cannulation occurring in 13 of these patients (77%). 2 patients developed complications, a wire-guided perforation in one and pancreatitis in the other. Conclusions: Our data demonstrates that repeat ERCP within a few days following failed needle knife precut for biliary access is associated with acceptable success and complication rates, and thereby obviates the need for radiological-guided access in some patients.
Sa1516 Large-Diameter Balloon Dilation for the Removal of Large Common Bile Duct Stones Bani Chander, Harry R. Aslanian, Uzma D. Siddiqui, Priya A. Jamidar Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
Sa1518 Precut Sphincterotomy At a Tertiary Referral Center for Pancreatic Diseases: A Prospective Study Giorgio Talamini1, Federica Damini2, Claudio Bassi2, Giampaolo Angelini3, Paolo Pederzoli2, Italo Vantini4 1 Pancreatic Endoscopy Unit, policlinico g. rossi, verona, Italy; 2 General Surgery, policlinico g. rossi, verona, Italy; 3Digestive Endoscopy Unit, policlinico g. rossi, verona, Italy; 4Gastroenterology, policlinico g. rossi, verona, Italy
Background: Endoscopic sphincterotomy followed by extraction using a basket or an extraction balloon is typically used for the removal of common bile duct (CBD) stones. However, this procedure is associated with a significant rate of post procedural hemorrhage, pancreatitis, and perforation and is not successful in all patients. Few studies have looked at outcomes using large-diameter balloon dilation for the removal of large common bile duct stones. Aims: The aims of this study were: 1) To determine the efficacy of large diameter balloon dilation of the sphincterotomy site for the removal of large common bile duct stones and 2) To evaluate the risks and complication rate associated with this procedure. Methods: A single center, retrospective chart review of 38 consecutive patients who underwent large-diameter (12-18mm) balloon dilation for common bile duct stones between April 2008 through October of 2010. Following partial biliary sphincterotomy, all patients had balloon dilation of the biliary orifice performed [balloon diameter size ranged from 12-18mm]. Results: Common bile duct stones could be removed in all the patients using large-diameter balloon technique. Complete stone extraction was achieved in 34 of the 38 patients (89%). Stone size varied from ⬍15 mm to 25 mm. The average balloon diameter size used in successful clearance was 14.14 ⫾ 1.69 mm [The most common size
Background: Precutting is sometimes needed to facilitate deep cannulation of the biliary/pancreatic ducts during the course of endoscopic retrograde cholangiopancreatography (ERCP). Objectives: To identify the precut-related success and complication rates, and the treatments used in the event of ERCP failing. Design: Observational study on prospectively collected data. Setting: A tertiary referral university hospital. Patients: Patients with papillae with no prior endoscopic treatment who underwent precutting between January 2007 and April 2010. Main Outcome Measurements: Success and complication rates after precutting and after invasive radiological procedures used after ERCP had failed. Results: ERCP was performed in 783 patients, and 755 of these procedures were implemented with a therapeutic intent; a precut was made in 131 (17.3%): 64 were males (48.9%) and 67 were females (51.1%); their mean age was 65.5 ⫾ 13.7 years. The overall success rate was 73.3% (96/131) with an inter-operator range of 63.1% to 83.3%. Among all the variables considered, uni- and multivariate analysis showed that only the “operator” variable was significant.The complication rate was 5.3% (7/131) with: 4 cases of mild pancreatitis (3%); 1 of severe pancreatitis (0.8%); 2 perforations (1.5%); and no hemorrhage or deaths. The difficulty encountered in performing the ERCP correlated inversely with the
AB194 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
success rate (p⬍0.01), but not with the complication rate.The 35 patients whose ERCP was unsuccessful underwent: percutaneous transhepatic biliary drainage (PTBD) in 18 cases (51.4%); medical treatment and radiological follow-up in 11 (31.4%); and surgery in 6 (17.2%). PTBD carried a 22.2% rate of infectious/ bleeding complications. Conclusion: Papilla precutting is useful in deep duct cannulation, with an acceptable complication rate, although the method is operator-dependent.
Group A within first 36 hours, in Group B after 72 hours. The data of age, sex, leucocyte levels before treatment, the falling time of leucocyte and duration of hospital stay were recorded and analised in SPSS 17.0 version. The mean values were calculated due to Mann-Whitney U and Chi-square tests. There were 46 male and 68 female patients. ERCP was performed to 63 patients within first 36 hours (Group A) and 51 patients afer 72 hours of application (Group B). There was no statistical difference of the number stones in the choledochus and diameter of the choledochus between two groups. Three patients in Group A and 1 patient in Group B were died from sepsis. The mean age was 68⫾15 years, leucocyte count was 17⫾5,8 /mm3, the mean day of leucocyte count turning into normal level was 4,3⫾4,1 days, number of days antibiotics used were 5,4⫾ 2,8 days, the duration of hospital stay was 6,2⫾4,7 days in Group A. The mean age was 70⫾13 years, leucocyte count was 17⫾6,7 /mm3, the mean day of leucocyte count turning into normal level was 5,3⫾2,6 days, number of days antibiotics used were 7,2⫾3,1 days, the duration of hospital stay was 9,2⫾4,6 days in Group B. There were significant difference on duration of hospital stay, leucocyte decreasing time and the days of antibiotics used between two groups. There was no bleeding, perforation and bacterial septicemia in each group during and after ERCP. According to our results, clinical recovery is provided in a shorter time in early ERCP applied patients. This situation reduces the duration of hospital stay and number of days of antibiotics used. Early ERCP has no significant effect on mortality and morbidity.
Success rate of precutting by grade of difficulty of the ERCP and by operator (the number of patients is indicated at the top of each column)
Sa1519 Carbon Dioxide Insufflation Versus Conventional Saline Irrigation for PerOral Video Cholangioscopy Shinpei Doi1, Ichiro Yasuda1, Masanori Nakashima1, Takuji Iwashita1, Katsuhisa Toda1, Tsuyoshi Mukai2, Keisuke Iwata2, Hisataka Moriwaki1 1 First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan; 2Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan Background: Recent studies have evaluated the efficacy of peroral cholangioscopy (POCS) for diagnosis of biliary diseases. During POCS, saline is irrigated to replace yellow bile. In order to obtain clear images, a lengthy saline irrigation is required. Aim: To evaluate the feasibility of replacing saline irrigation with CO2insufflation during POCS. Methods: We enrolled 36 patients with bile duct lesions for POCS. Among these, 18 patients underwent POCS using saline irrigation followed by CO2 insufflation, while the remaining 18 patients received the reverse approach. We compared the time required to obtain a clear endoscopic image as well as the quality of the images. Results: The time required to obtain a clear endoscopic image in CO2insufflation (4 min) was significantly shorter than that in saline irrigation (24 min, p ⬍ 0.001). The quality of the endoscopic images obtained was similar in 27 cases. However, CO2 insufflation provided better images in 4 cases that showed an abundance of mucin or biliary sludge. In contrast, saline irrigation was superior to CO2 insufflation in 5 cases that showed severe stricture with bleeding and tall papillary lesions. Conclusions: CO2insufflation during POCS can reduce procedure time and simplify cholangioscopy. Overall image quality was similar to the conventional saline irrigation.
Sa1520 Early ERCP Is Safe and Cost-Effective in the Treatment of Mild to Moderate Acute Cholangitis Emrah Alper2, Belkis Unsal2, Zafer Buyraç2, BehlüL Baydar1, Fatih Aslan2, Serdar Akça1, Yucel Ustundag3 1 Gastroenterology and Surgery, Memorial Antalya Hospital, Antalya, Turkey; 2Gastroenterology, Ataturk Training and Research Hospital, Izmir, Turkey; 3Gastroenterology, Karaelmas University, Zonguldak, Turkey Acute cholangitis has high mortality and morbidity if left untreated. Acute cholangitis can be treated effectively with biliary decompression and antibiotics. But the timing of biliary decompression is still unclear. Aim is to analize the effect of early ERCP on duration of hospital stay, antibiotic use, mortality and morbidity of the patients with mild to moderate acute cholangitis. The study is done prospectively in a gastroenterology clinic in a tertier center. One hundred and fourteen acute cholangitis patients diagnosed with laboratory and screening methods applied with Charcoat triad were included in the study between May 2008 and May 2010. The patients randomly divided into two groups. Wide spectrum antibiotics were initiated to all patients in their first application. Under anestesia, the ERCP was performed with standard Olympus duodenoscope in
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Sa1521 Endoscopic Large-Balloon Sphincteroplasty Without Preceding Sphincterotomy Versus Endoscopic Sphincterotomy Plus LargeBalloon Sphincteroplasty for the Removal of Large Bile Duct Stones: A Retrospective Cross-Sectional Study Jin Hong Kim, Jae Chul Hwang, Byung Moo Yoo, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea Background and Aim: Recently, several studies have been reported in which large-balloon sphincteroplasty (LBS) was conducted for the removal of large bile duct stones. Endoscopic sphincterotomy (EST) is usually performed before LBS because of the high risk of pancreatitis. The aim of this study was to compare the therapeutic effectiveness and complications between LBS without preceding EST and EST plus LBS for the treatment of large bile duct stones. Patients and Methods: Fifty three patients (M:F ⫽ 18:35, mean age 69.6) with large bile duct stones (ⱖ 12mm) had LBS without preceding EST from March 2008 to April 2009. Seventy patients (M:F ⫽ 33:37, mean age 68.2) with large bile duct stones who underwent EST plus LBS between July 2005 and February 2008, served as a historical control. Balloon sphincteroplasty was done with a 12- to 20-mm diameter balloon. After ballooning for 1minute, stone removal was done with a basket or a retrieval balloon. If stone removal failed with standard methods, endoscopic mechanical lithotripsy (EML) was performed. Efficacy of stone removal and complications related to the procedure were analyzed. Results: LBS without EST compared with EST plus LBS resulted in similar outcomes in terms of overall successful stone removal (96.2% vs. 95.7, P ⫽ 0.887), mean transverse stone diameter in the success group (15.4mm vs. 16.2mm, P ⫽ 0.254), and the use of EML (15.1% vs. 24.3%, P ⫽ 0.261). Complications were as follows for the LBS without EST group and the EST plus LBS group: pancreatitis (7.5% vs. 5.7%, P ⫽ 0.725); impaction of the basket and stone (0% vs. 1.4%, P ⫽ 1.000), and perforation (0% vs. 2.9%, P ⫽ 0.506). There was one death due to pancreatitis and perforation in the EST plus LBS group. Conclusions: LBS without a preceding EST showed no significant complications and resulted similar to those with EST plus LBS for the removal of large bile duct stones. Therefore, LBS without EST could be an effective alternative for the treatment of large bile duct stones. Prospective, large-scale, randomized, comparative studies are needed to support our study.
Sa1522 Neosquamous Epithelium After Radiofrequency and Cryoablation of Barrett’s Esophagus Displays Genetic Abnormalities: FISH Analysis Sofiya Reicher1, Fatih Z. Boyar3, Vivek S. Ramanathan1, Patricia Chan3, Vladimira Sulcova3, Samuel W. French2, David S. Chung1, Binh V. Pham1, Viktor E. Eysselein1, Arturo L. Anguiano3 1 Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA; 2 Pathology, Harbor-UCLA Medical Center, Torrance, CA; 3Quest Diagnostics Nichols Institute, San Juan Capistrano, CA Background & Aim: Barrett’s esophagus (BE) progression to cancer is associated with accumulation of genetic abnormalities. Recently, promising ablative techniques such as radiofrequency ablation (RFA) and cryoablation have been increasingly applied for BE eradication. Our study aimed to evaluate chromosomal changes in BE before and after RFA and cryoablation by using
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
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