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Su1374 Risk Factors for Stent Occlusion After Endoscopic Metallic Stent Placement in Patients With Unresectable Malignant Biliary Stricture
Abstracts
Su1373 Management of Self-Expanding Metal Stent Occlusion in Patients With Malignant Biliary Obstruction Amanpal Singh*1, William A. Ross1, Somashekar G. Krishna2, Abhik Bhattacharya1, Harshad S. Ladha1, Graciela M. Nogueras Gonzalez3, Gauri R. Varadhachary4, Jason B. Fleming5, Gottumukkala S. Raju1, Jeffrey H. Lee1 1 Division of Gastroenterology, Hepatology & Nutrition, University of Texas MD Anderson Cancer Center, Houtson, TX; 2Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Medical Center, Columbus, OH; 3Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX; 4Department of GI Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; 5Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX Background: The management of patients with obstruction of self-expanding metal stents (SEMS) placed for malignant biliary obstruction can be challenging. Limited data is available as to the optimal approach to such patients. The objective of this study is to compare the patency rate and overall survival among patients with occluded SEMS who undergo second stent placement. Methods: We included patients with malignant biliary obstruction and SEMS placement who presented with recurrent obstruction during 2000-2011. Only patients who underwent repeat ERCP were included. Data were collected on the type of second stent placed (covered (CSEMS), uncovered (USEMS) or plastic), development of recurrent obstruction, mechanism of obstruction and follow up duration. Overall survival (OS) was calculated from date of second stent placement to death or last date of follow up. Recurrent obstruction free survival (ROFS) was calculated from date of second stent placement to the date of obstruction, death, lost to follow up, or surgery, whichever came first. Result: A total of 131 patients (mean age 62.6 ⫾ 11 years; 56.5% males) developed SEMS occlusion and underwent repeat ERCP procedures. 98/131 (74.8%) patients had pancreatic cancer. The first SEMS was covered among 27 patients and uncovered among 104 patients. The indications for repeat procedure were abnormal liver function tests with or without cholangitis, 21.4% and 78.6% respectively. A second CSEMS and USEMS were placed among 20 and 84 patients respectively. Plastic stent was placed among 15 patients and only mechanical cleaning was performed among 12 patients. The median OS for the second CSEMS and USEMS were 5.7 months and 6.9 months (p-value 0.312), respectively. The median ROFS for the second CSEMS and USEMS were 5.26 months and 5.49 months (p-value 0.444), respectively. Tissue ingrowth and stricture formation was the most common cause of recurrent obstruction among patients with second USEMS and in patients with CSEMS sludge formation and food debris were the most common. The OS and ROFS among patients who underwent plastic stent placement for drainage of occluded SEMS were 9.4 months and 2.99 months respectively. Conclusion: No significant difference was noted in the outcomes among patients with second CSEMS or USEMS for drainage of occluded SEMS. Depending upon the mechanism of recurrent obstruction of first SEMS and overall prognosis, decision can be made between second SEMS (CSEMS or USEMS) or plastic stent placement.
Kaplan-Meier Analysis of ROFS in patients with second USEMS, CSEMS and Plastic Stents
Su1374 Risk Factors for Stent Occlusion After Endoscopic Metallic Stent Placement in Patients With Unresectable Malignant Biliary Stricture Takahisa Ogawa*, Naotaka Fujita, Kei Ito, Yutaka Noda, Go Kobayashi, Jun Horaguchi, Shinsuke Koshita, Yoshihide Kanno, Kaori Masu, Shinichi Hashimoto Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan Background and Aim: Endoscopic metallic stent (MS) placement is widely accepted as a palliative therapy in patients with unresectable malignant biliary stricture. Although stent occlusion is a major complication of MS placement, there have been few reports regarding its risk factors. The aim of this study was to investigate risk factors for stent occlusion after endoscopic MS placement in unresectable malignant biliary stricture. Patients and Methods: Between April 2005 and October 2012, 139 patients with unresectable malignant biliary stricture (mean age, 75 ⫾ 11 yrs.; 70 males, 69 females) who successfully underwent endoscopic MS placement were included in this study. Patients with hilar bile duct stricture and those with insufficient data were excluded from the study. Main outcome measurements were stent patency and risk factors for stent occlusion. Stent occlusion was defined as bile duct dilation associated with elevation of serum total bilirubin. Cholangitis was defined according to the Tokyo Guidelines for the management of acute cholangitis and cholecystitis. Stent patency was analyzed by the Kaplan-Meier method and risk factors were assessed by Cox regression analysis. Results: Seventy-nine patients had pancreatic cancer, 38 had bile duct cancer, 9 had lymph node metastases from other cancers, 8 had gallbladder cancer, 3 had ampullary cancer, and 2 had cystic duct cancer. The stents used were uncovered MS in 31 patients, partially covered MS in 69, and fully covered MS in 39. Cholangitis as the time of stenting was seen in 26% (36/139). At a mean follow-up period of 272 days, stent occlusion occurred in 32% (45/139). The causes of stent occlusion were tumor ingrowth in 12 patients, tumor overgrowth in 12, sludge in 9, stones in 4, food impaction in 3, and unknown factors in 5. Mean stent patency was 527 days (median, 306 days). Univariate analysis including 15 factors revealed that sex (male, p ⫽ 0.04) and cholangitis at the time of stent placement (P ⫽ 0.0005) were risk factors for stent occlusion. Multivariate analysis showed that cholangitis was the only significant risk factor for stent occlusion (HR 2.8, 95% CI 1.5-5.2, p ⫽ 0.001). Conclusion: Endoscopic MS placement for unresectable malignant stricture should be considered after improvement of cholangitis due to the high risk of stent occlusion.
Su1375 Role of Usid in the Assessment of Cholangiocarcinoma Experience of a Romanian Tertiary Referral Center Marcel Tantau*1,2, Teodora Atena Pop1,2, Ofelia Mosteanu1,2, Alina I. Tantau1 1 University of Medicine and Pharmacy Iuliu Hatieganu Cluj-Napoca, Cluj-Napoca, Romania; 2Institute of Gastroenterology and Hepatology “Prof.Dr.O.Fodor” Cluj-Napoca, Cluj-Napoca, Romania Background: Although computer tomography and magnetic resonance greatly improved in performance regarding the diagnosis of malignant biliary strictures, two major problems have not been completely solved yet: first, the differentiation of malignant and benign bile duct strictures, and, second, the assessment of the resectability of carcinomas underlying biliary strictures. Aim: The prospective assessment of intraductal ultrasonography (IDUS) accuracy in the malignant biliary strictures diagnosis. Methods: 227 consecutive patients were referred to our institution with cholangiocarcinoma between September 2007 and December 2011. In 56 patients we used USID for the further assessment of the biliary stricture. USID probes were advanced in a transampullary fashion under fluoroscopic control, or over a guidewire. The histopathological diagnosis was established using transpapillary biopsy during ERCP. The differential diagnosis was achieved using immunohistochemistry. CT or MRCP were used for as comparative methods for staging. Results: From the 56 patients with biliary stricture, the histopathology came back as benign in 4 patients (7.14%) and as malignant in 52 (92.85%) patients (cholangiocarcinoma). We performed endoscopic sphincterotomy for IDUS examination in 20.43% of cases. The mean time for probe insertion and intraductal ultrasonography (IDUS) was 6.3⫾0.7 mins. The diagnostic accuracy ranged between 76 and 92% according to the nature of the biliary stricture, benign or malignant, respectively. The parameters and the characteristics asssociated with a malignant stricture were: thickness of the biliary duct wal, hypoechoic mass, inomogenous pattern and vascular invasion. Conclusions: Intraductal ultrasonography is feasible, easy to perform and in selected cases can bring useful data for the management of the biliary pathology. Yet, it is still a technique reserved for specialised centers with a high volume of specialized cases.
AB302 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Su1373 Management of Self-Expanding Metal Stent Occlusion in Patients With Malignant Biliary Obstruction Amanpal Singh*1, William A. Ross1, Somashekar G. Krishna2, Abhik Bhattacharya1, Harshad S. Ladha1, Graciela M. Nogueras Gonzalez3, Gauri R. Varadhachary4, Jason B. Fleming5, Gottumukkala S. Raju1, Jeffrey H. Lee1 1 Division of Gastroenterology, Hepatology & Nutrition, University of Texas MD Anderson Cancer Center, Houtson, TX; 2Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Medical Center, Columbus, OH; 3Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX; 4Department of GI Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; 5Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX Background: The management of patients with obstruction of self-expanding metal stents (SEMS) placed for malignant biliary obstruction can be challenging. Limited data is available as to the optimal approach to such patients. The objective of this study is to compare the patency rate and overall survival among patients with occluded SEMS who undergo second stent placement. Methods: We included patients with malignant biliary obstruction and SEMS placement who presented with recurrent obstruction during 2000-2011. Only patients who underwent repeat ERCP were included. Data were collected on the type of second stent placed (covered (CSEMS), uncovered (USEMS) or plastic), development of recurrent obstruction, mechanism of obstruction and follow up duration. Overall survival (OS) was calculated from date of second stent placement to death or last date of follow up. Recurrent obstruction free survival (ROFS) was calculated from date of second stent placement to the date of obstruction, death, lost to follow up, or surgery, whichever came first. Result: A total of 131 patients (mean age 62.6 ⫾ 11 years; 56.5% males) developed SEMS occlusion and underwent repeat ERCP procedures. 98/131 (74.8%) patients had pancreatic cancer. The first SEMS was covered among 27 patients and uncovered among 104 patients. The indications for repeat procedure were abnormal liver function tests with or without cholangitis, 21.4% and 78.6% respectively. A second CSEMS and USEMS were placed among 20 and 84 patients respectively. Plastic stent was placed among 15 patients and only mechanical cleaning was performed among 12 patients. The median OS for the second CSEMS and USEMS were 5.7 months and 6.9 months (p-value 0.312), respectively. The median ROFS for the second CSEMS and USEMS were 5.26 months and 5.49 months (p-value 0.444), respectively. Tissue ingrowth and stricture formation was the most common cause of recurrent obstruction among patients with second USEMS and in patients with CSEMS sludge formation and food debris were the most common. The OS and ROFS among patients who underwent plastic stent placement for drainage of occluded SEMS were 9.4 months and 2.99 months respectively. Conclusion: No significant difference was noted in the outcomes among patients with second CSEMS or USEMS for drainage of occluded SEMS. Depending upon the mechanism of recurrent obstruction of first SEMS and overall prognosis, decision can be made between second SEMS (CSEMS or USEMS) or plastic stent placement.
Kaplan-Meier Analysis of ROFS in patients with second USEMS, CSEMS and Plastic Stents
Su1374 Risk Factors for Stent Occlusion After Endoscopic Metallic Stent Placement in Patients With Unresectable Malignant Biliary Stricture Takahisa Ogawa*, Naotaka Fujita, Kei Ito, Yutaka Noda, Go Kobayashi, Jun Horaguchi, Shinsuke Koshita, Yoshihide Kanno, Kaori Masu, Shinichi Hashimoto Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan Background and Aim: Endoscopic metallic stent (MS) placement is widely accepted as a palliative therapy in patients with unresectable malignant biliary stricture. Although stent occlusion is a major complication of MS placement, there have been few reports regarding its risk factors. The aim of this study was to investigate risk factors for stent occlusion after endoscopic MS placement in unresectable malignant biliary stricture. Patients and Methods: Between April 2005 and October 2012, 139 patients with unresectable malignant biliary stricture (mean age, 75 ⫾ 11 yrs.; 70 males, 69 females) who successfully underwent endoscopic MS placement were included in this study. Patients with hilar bile duct stricture and those with insufficient data were excluded from the study. Main outcome measurements were stent patency and risk factors for stent occlusion. Stent occlusion was defined as bile duct dilation associated with elevation of serum total bilirubin. Cholangitis was defined according to the Tokyo Guidelines for the management of acute cholangitis and cholecystitis. Stent patency was analyzed by the Kaplan-Meier method and risk factors were assessed by Cox regression analysis. Results: Seventy-nine patients had pancreatic cancer, 38 had bile duct cancer, 9 had lymph node metastases from other cancers, 8 had gallbladder cancer, 3 had ampullary cancer, and 2 had cystic duct cancer. The stents used were uncovered MS in 31 patients, partially covered MS in 69, and fully covered MS in 39. Cholangitis as the time of stenting was seen in 26% (36/139). At a mean follow-up period of 272 days, stent occlusion occurred in 32% (45/139). The causes of stent occlusion were tumor ingrowth in 12 patients, tumor overgrowth in 12, sludge in 9, stones in 4, food impaction in 3, and unknown factors in 5. Mean stent patency was 527 days (median, 306 days). Univariate analysis including 15 factors revealed that sex (male, p ⫽ 0.04) and cholangitis at the time of stent placement (P ⫽ 0.0005) were risk factors for stent occlusion. Multivariate analysis showed that cholangitis was the only significant risk factor for stent occlusion (HR 2.8, 95% CI 1.5-5.2, p ⫽ 0.001). Conclusion: Endoscopic MS placement for unresectable malignant stricture should be considered after improvement of cholangitis due to the high risk of stent occlusion.
Su1375 Role of Usid in the Assessment of Cholangiocarcinoma Experience of a Romanian Tertiary Referral Center Marcel Tantau*1,2, Teodora Atena Pop1,2, Ofelia Mosteanu1,2, Alina I. Tantau1 1 University of Medicine and Pharmacy Iuliu Hatieganu Cluj-Napoca, Cluj-Napoca, Romania; 2Institute of Gastroenterology and Hepatology “Prof.Dr.O.Fodor” Cluj-Napoca, Cluj-Napoca, Romania Background: Although computer tomography and magnetic resonance greatly improved in performance regarding the diagnosis of malignant biliary strictures, two major problems have not been completely solved yet: first, the differentiation of malignant and benign bile duct strictures, and, second, the assessment of the resectability of carcinomas underlying biliary strictures. Aim: The prospective assessment of intraductal ultrasonography (IDUS) accuracy in the malignant biliary strictures diagnosis. Methods: 227 consecutive patients were referred to our institution with cholangiocarcinoma between September 2007 and December 2011. In 56 patients we used USID for the further assessment of the biliary stricture. USID probes were advanced in a transampullary fashion under fluoroscopic control, or over a guidewire. The histopathological diagnosis was established using transpapillary biopsy during ERCP. The differential diagnosis was achieved using immunohistochemistry. CT or MRCP were used for as comparative methods for staging. Results: From the 56 patients with biliary stricture, the histopathology came back as benign in 4 patients (7.14%) and as malignant in 52 (92.85%) patients (cholangiocarcinoma). We performed endoscopic sphincterotomy for IDUS examination in 20.43% of cases. The mean time for probe insertion and intraductal ultrasonography (IDUS) was 6.3⫾0.7 mins. The diagnostic accuracy ranged between 76 and 92% according to the nature of the biliary stricture, benign or malignant, respectively. The parameters and the characteristics asssociated with a malignant stricture were: thickness of the biliary duct wal, hypoechoic mass, inomogenous pattern and vascular invasion. Conclusions: Intraductal ultrasonography is feasible, easy to perform and in selected cases can bring useful data for the management of the biliary pathology. Yet, it is still a technique reserved for specialised centers with a high volume of specialized cases.
AB302 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org