- Email: [email protected]
Su1396 Endoscopic Retrograde Cholangiopancreatography in Patients With Altered Anatomy: Does Scope Choice and Experience Matter?
Abstracts
Responce Group II
n
Yes
No
%
Retreatment
CP Pain
17 14
10 5
7 9
59 36
4 3
Su1396 Endoscopic Retrograde Cholangiopancreatography in Patients With Altered Anatomy: Does Scope Choice and Experience Matter? Christopher W. Hammerle*, Vijay Jayaraman, Laith H. Jamil, Simon K. Lo Cedars-Sinai Medical Center, Los Angeles, CA Background: Endoscopic retrograde cholangiopancreatography (ERCP) is challenging in patients with surgically-altered anatomy. AIM: To assess overall success of rate of ERCP in patients with post-surgical anatomy, and to assess if experience or type of scope used influences success. Methods: An electronic medical records system was retrospectively evaluated to identify patients with altered anatomy who had an ERCP performed at our institution between January 2001 and November 2011. A successful ERCP was defined as the ability to complete the intended diagnostic or therapeutic intervention in its entirety. The scope type(s) used during each procedure was recorded, as well as the individual success and failure rate for each scope. Results: A total of 236 patients (157 male) with a mean age of 55.1 years (range 16-95) had 352 procedures. The numbers of procedures performed based on altered anatomy were: Billroth I (2), Billroth II (25), Roux-en-Y hepatico/choledochojejunostomy (157), Roux-en-Y gastric bypass (97), pancreaticoduodenectomy (59), hepaticodudenostomy (4), and total gastrectomy (8). The indications for ERCP included stones, cholangitis, cholestasis, pain and/or weight loss, biliary dilatation, and stent removal/ exchange. Our overall success rate was 82%. Success rate varied depending upon the type of altered anatomy. Therapeutic interventions were performed in most patients and included bilio-enteric stricturoplasty (65), bilio-enteric dilation (95), sphincterotomy (88), stone extraction (70) and stent exchange (133). The success rate increased with time, with 67% (44 patients) having a successful ERCP from the years 2001-2005 vs. 85% (244 patients) from 2006-2011 (Table 1). The scopes most commonly used per altered anatomy and their success rate are noted in Table 2. Complications occurred in 16 (4.5%) and included pancreatitis in 11 and perforation in 5 (two bowel perforations requiring surgery, 3 small retroperitoneal perforations that were managed conservatively). Conclusion: ERCP is a safe procedure in patients with post-surgical anatomy and has an overall success rate in 82% of cases. The success rate increases with experience in altered anatomy ERCP. The type of anatomy should influence scope choice. Table 1. Rate of Successful ERCP per Altered Anatomy Type Type of Anatomy Billroth I Billroth II Roux-en-Y hepaticojejunostomy Roux-en-Y gastric bypass Pancreaticoduodenectomy Hepaticoduodenostomy Total Gastrectomy Total Overall Success
Success 2001-2005
Success 20062011
Overall Success
1/1 (100%) 5/8 (63%) 33/42 (79%) 0/0 6/13 (46%) 0/0 1/2 (50%) 44/66 (67%)
1/1 (100%) 15/17 (88%) 99/115 (86%) 83/97 (86%) 38/46 (83%) 4/4 (100%) 4/6 (67%) 244/286 (85%)
2/2 (100%) 20/25 (80%) 132/157 (84%) 83/97 (86%) 44/59 (75%) 4/4 (100%) 5/8 (63%) 290/352 (82%)
Table 2. Most Used and Successful Scopes per Altered Anatomy Type Type of Anatomy (# procedures)
Most Used Scope
Billroth II (25)
2nd Most Used Scope
DuodenoscopeDeep 16/31 (68%) Enteroscopes 5/31 (16%) Push Deep Reoux-en-Y Enteroscopes Enteroscope hepaticojejunostomy 96/180 (53%) 72/180 (40%) (157) Push Roux-en-Y gastric bypass Deep (97) Enteroscopes Enteroscope 93/98 (95%) 4/98 (4%) Duodeoscopes Pancreaticoduodenectomy Deep (59) Enteroscopes 23/90 (26%) 32/90 (36%) Deep Total Gastrectomy (8) Push Enteroscope Enteroscopes 4/12 (33%) 5/12 (42%)
www.giejournal.org
Most Successful Scope Duodenoscope, 16/21 (76%) Deep Enteroscopes 76/ 96 (79%) Deep Enteroscopes 80/ 92 (87%) Deep Enteroscopes 19/ 32 (59%) Therapeutic Upper Endoscope 1/ 1 (100%)
2nd Most Successful Scope Deep Enteroscopes 3/ 5 (60%) Push Enteroscope 52/72 (72%) Push Enteroscopes 1/4 (25%) Therapeutic Upper Endoscope 7/ 14 (50%) Deep Enteroscopes 2/4 (50%)
Su1397 A Comparative Evaluation of Severity Among Patients With PostERCP Pancreatitis and Acute Biliary Pancreatitis Atoosa Rabiee*, Susan Hutfless, Rakesh Juneja, Katherine Kim, Vikesh K. Singh, Anne Marie Lennon, Anthony N. Kalloo, Mouen Khashab Johns Hopkins, Baltimore, MD Background: Acute pancreatitis is the most common complication of ERCP and occurs in 5-15% of procedures. Although post-ERCP pancreatitis (PEP) is most often mild, it is occasionally severe and can be a devastating illness resulting in pancreatic necrosis, multiorgan failure, permanent disability and even death. Aims: To compare morbidity rates in patients with acute biliary pancreatitis (ABP) and those with PEP. Methods: PEP was defined as a clinical illness associated with serum amylase or lipase at least 3 times normal at more than 24 hours after the procedure and requiring hospitalization or prolonging initial admission by more than one day. PEP patients admitted to Johns Hopkins Hospital between 1/2003 and 12/2010 were matched to ABP patients based on age, sex and admission date. Length of hospital stay (LOHS), pancreas necrosis, pseudocyst formation as well as mortality were obtained for the two groups of patients. We used a t test to compare LOHS and conditional logistic regression to compare the other variables. Results: We included 206 ABP patients (48.92 yrs, 50% female) and 149 PEP patients (48.34 yrs, 60.4% female). The mean length of hospital stay was 4.52 (range 1-22) days for PEP group and 9.17 (range 1-51) days for ABP (P ⬍ 0.0009). In the PEP group, LOHS was 1-2 days in 36%, 3-10 days in 56%, and ⬎10 days in less than 1% of patients. None of the patients in PEP group had pancreas necrosis but pancreas necrosis was identified in 3.88% of patients with ABP. Pseudocyst occurred in 6% of the PEP patients and 14% of ABP (OR⫽0.55, CI: 0.25-1.24, p⫽0.14). Finally, mortality rate was 0.7% in PEP and 1.9% in ABP group (OR⫽0.39, CI: 0.04-3.59, p⫽0.4). Conclusion: Patients with PEP have milder pancreatitis than ABP. Length of hospital stay was significantly shorter in PEP group compared with ABP.
Su1398 Fully Covered Self-Expanding Metal Stents for Remodeling of Refractory Pancreatic Duct Strictures: A Multicenter Experience David L. Diehl*1, Ali A. Siddiqui2, Stavros N. Stavropoulos3, Thomas E. Kowalski2, Viet-Nhan H. Nguyen4, Hashem J. Hashem1 1 Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA; 2Gastroenterology, Thomas Jefferson School of Medicine, Philadelphia, PA; 3Gastroenterology, Winthrop Medical Center, Mineola, NY; 4Gastroenterology, Womack Army Medical Center, Ft. Bragg, NC Temporary placement of fully covered self-expanding metal stents (FC-SEMS) for remodeling of benign biliary strictures is increasing. However, there is limited experience with use of FC-SEMS for main pancreatic duct (PD) strictures associated with chronic pancreatitis (CP) in terms of efficacy and safety. This is a multicenter retrospective review of 11 cases of benign PD strictures that were managed with FC-SEMS. Methods: This was a retrospective multicenter trial of 11 patients from 3 institutions. Procedures were performed by experienced endoscopists with extensive experience with placement of SEMS and pancreatic endotherapy. Data were collected on indication for the procedure, clinical presentation, etiology of stricture, presence of PD stones, stricture length and diameter, previous stenting, procedural details, complications, and clinical outcomes. Clinical Material: Alcohol abuse was the most common etiology of CP and PD strictures (8/11); 1 patient had pancreas divisum associated CP, and 2 idiopathic CP. Clinical presentations were recurrent acute pancreatitis in 6 and pancreatic-type pain in 5. 7 patients had previous plastic stents placed in the PD to try to manage the stricture. Mean length of PD stricture was 25mm (10-50). Stones in the main PD were present in 6. 8 patients had CBD strictures. FC-SEMS designed for biliary use were used (FC-Wallflex, Boston Scientific); either 10x40mm or 8x60mm. Placement was through the major papilla in all but 2 cases (1 divisum, 1 with stone obstructing major). 6 patients had concomitant CBD stent placement. Outcomes: Clinical follow-up was mean 16 months (range 6-32).Stents were left in for average 11 weeks (range 1-26), and all were easily removed. Decreased maximum upstream PD diameter was seen in every case immediately following stent removal (pre-stenting 12.6mm (8-18) and poststenting 7.8mm (5-13). 5 patients had clinical improvement (ablation of pancreatic pain and/or no further episodes of acute pancreatitis) and did not need stent replacement. One patient had partial improvement of pain. 6 patients required stent replacement (metal or plastic). Complications included mild acute pancreatitis in 1, and exacerbation of pancreatic pain in 4 (FC-SEMS removal required in 2 of these). Conclusions: FC-SEMS can be used for refractory pancreatic duct strictures. They appear safe although some patients may experience pain upon stent expansion. Removability was not a problem with stents left in for up to 6 months. Some strictures could be remodeled, and several patients are stent-free on follow-up. However, many PD strictures were refractory and require ongoing PD stenting. In the future, new stents should be developed that optimize stent diameter and length. In addition, a fenestrated
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB318
Responce Group II
n
Yes
No
%
Retreatment
CP Pain
17 14
10 5
7 9
59 36
4 3
Su1396 Endoscopic Retrograde Cholangiopancreatography in Patients With Altered Anatomy: Does Scope Choice and Experience Matter? Christopher W. Hammerle*, Vijay Jayaraman, Laith H. Jamil, Simon K. Lo Cedars-Sinai Medical Center, Los Angeles, CA Background: Endoscopic retrograde cholangiopancreatography (ERCP) is challenging in patients with surgically-altered anatomy. AIM: To assess overall success of rate of ERCP in patients with post-surgical anatomy, and to assess if experience or type of scope used influences success. Methods: An electronic medical records system was retrospectively evaluated to identify patients with altered anatomy who had an ERCP performed at our institution between January 2001 and November 2011. A successful ERCP was defined as the ability to complete the intended diagnostic or therapeutic intervention in its entirety. The scope type(s) used during each procedure was recorded, as well as the individual success and failure rate for each scope. Results: A total of 236 patients (157 male) with a mean age of 55.1 years (range 16-95) had 352 procedures. The numbers of procedures performed based on altered anatomy were: Billroth I (2), Billroth II (25), Roux-en-Y hepatico/choledochojejunostomy (157), Roux-en-Y gastric bypass (97), pancreaticoduodenectomy (59), hepaticodudenostomy (4), and total gastrectomy (8). The indications for ERCP included stones, cholangitis, cholestasis, pain and/or weight loss, biliary dilatation, and stent removal/ exchange. Our overall success rate was 82%. Success rate varied depending upon the type of altered anatomy. Therapeutic interventions were performed in most patients and included bilio-enteric stricturoplasty (65), bilio-enteric dilation (95), sphincterotomy (88), stone extraction (70) and stent exchange (133). The success rate increased with time, with 67% (44 patients) having a successful ERCP from the years 2001-2005 vs. 85% (244 patients) from 2006-2011 (Table 1). The scopes most commonly used per altered anatomy and their success rate are noted in Table 2. Complications occurred in 16 (4.5%) and included pancreatitis in 11 and perforation in 5 (two bowel perforations requiring surgery, 3 small retroperitoneal perforations that were managed conservatively). Conclusion: ERCP is a safe procedure in patients with post-surgical anatomy and has an overall success rate in 82% of cases. The success rate increases with experience in altered anatomy ERCP. The type of anatomy should influence scope choice. Table 1. Rate of Successful ERCP per Altered Anatomy Type Type of Anatomy Billroth I Billroth II Roux-en-Y hepaticojejunostomy Roux-en-Y gastric bypass Pancreaticoduodenectomy Hepaticoduodenostomy Total Gastrectomy Total Overall Success
Success 2001-2005
Success 20062011
Overall Success
1/1 (100%) 5/8 (63%) 33/42 (79%) 0/0 6/13 (46%) 0/0 1/2 (50%) 44/66 (67%)
1/1 (100%) 15/17 (88%) 99/115 (86%) 83/97 (86%) 38/46 (83%) 4/4 (100%) 4/6 (67%) 244/286 (85%)
2/2 (100%) 20/25 (80%) 132/157 (84%) 83/97 (86%) 44/59 (75%) 4/4 (100%) 5/8 (63%) 290/352 (82%)
Table 2. Most Used and Successful Scopes per Altered Anatomy Type Type of Anatomy (# procedures)
Most Used Scope
Billroth II (25)
2nd Most Used Scope
DuodenoscopeDeep 16/31 (68%) Enteroscopes 5/31 (16%) Push Deep Reoux-en-Y Enteroscopes Enteroscope hepaticojejunostomy 96/180 (53%) 72/180 (40%) (157) Push Roux-en-Y gastric bypass Deep (97) Enteroscopes Enteroscope 93/98 (95%) 4/98 (4%) Duodeoscopes Pancreaticoduodenectomy Deep (59) Enteroscopes 23/90 (26%) 32/90 (36%) Deep Total Gastrectomy (8) Push Enteroscope Enteroscopes 4/12 (33%) 5/12 (42%)
www.giejournal.org
Most Successful Scope Duodenoscope, 16/21 (76%) Deep Enteroscopes 76/ 96 (79%) Deep Enteroscopes 80/ 92 (87%) Deep Enteroscopes 19/ 32 (59%) Therapeutic Upper Endoscope 1/ 1 (100%)
2nd Most Successful Scope Deep Enteroscopes 3/ 5 (60%) Push Enteroscope 52/72 (72%) Push Enteroscopes 1/4 (25%) Therapeutic Upper Endoscope 7/ 14 (50%) Deep Enteroscopes 2/4 (50%)
Su1397 A Comparative Evaluation of Severity Among Patients With PostERCP Pancreatitis and Acute Biliary Pancreatitis Atoosa Rabiee*, Susan Hutfless, Rakesh Juneja, Katherine Kim, Vikesh K. Singh, Anne Marie Lennon, Anthony N. Kalloo, Mouen Khashab Johns Hopkins, Baltimore, MD Background: Acute pancreatitis is the most common complication of ERCP and occurs in 5-15% of procedures. Although post-ERCP pancreatitis (PEP) is most often mild, it is occasionally severe and can be a devastating illness resulting in pancreatic necrosis, multiorgan failure, permanent disability and even death. Aims: To compare morbidity rates in patients with acute biliary pancreatitis (ABP) and those with PEP. Methods: PEP was defined as a clinical illness associated with serum amylase or lipase at least 3 times normal at more than 24 hours after the procedure and requiring hospitalization or prolonging initial admission by more than one day. PEP patients admitted to Johns Hopkins Hospital between 1/2003 and 12/2010 were matched to ABP patients based on age, sex and admission date. Length of hospital stay (LOHS), pancreas necrosis, pseudocyst formation as well as mortality were obtained for the two groups of patients. We used a t test to compare LOHS and conditional logistic regression to compare the other variables. Results: We included 206 ABP patients (48.92 yrs, 50% female) and 149 PEP patients (48.34 yrs, 60.4% female). The mean length of hospital stay was 4.52 (range 1-22) days for PEP group and 9.17 (range 1-51) days for ABP (P ⬍ 0.0009). In the PEP group, LOHS was 1-2 days in 36%, 3-10 days in 56%, and ⬎10 days in less than 1% of patients. None of the patients in PEP group had pancreas necrosis but pancreas necrosis was identified in 3.88% of patients with ABP. Pseudocyst occurred in 6% of the PEP patients and 14% of ABP (OR⫽0.55, CI: 0.25-1.24, p⫽0.14). Finally, mortality rate was 0.7% in PEP and 1.9% in ABP group (OR⫽0.39, CI: 0.04-3.59, p⫽0.4). Conclusion: Patients with PEP have milder pancreatitis than ABP. Length of hospital stay was significantly shorter in PEP group compared with ABP.
Su1398 Fully Covered Self-Expanding Metal Stents for Remodeling of Refractory Pancreatic Duct Strictures: A Multicenter Experience David L. Diehl*1, Ali A. Siddiqui2, Stavros N. Stavropoulos3, Thomas E. Kowalski2, Viet-Nhan H. Nguyen4, Hashem J. Hashem1 1 Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA; 2Gastroenterology, Thomas Jefferson School of Medicine, Philadelphia, PA; 3Gastroenterology, Winthrop Medical Center, Mineola, NY; 4Gastroenterology, Womack Army Medical Center, Ft. Bragg, NC Temporary placement of fully covered self-expanding metal stents (FC-SEMS) for remodeling of benign biliary strictures is increasing. However, there is limited experience with use of FC-SEMS for main pancreatic duct (PD) strictures associated with chronic pancreatitis (CP) in terms of efficacy and safety. This is a multicenter retrospective review of 11 cases of benign PD strictures that were managed with FC-SEMS. Methods: This was a retrospective multicenter trial of 11 patients from 3 institutions. Procedures were performed by experienced endoscopists with extensive experience with placement of SEMS and pancreatic endotherapy. Data were collected on indication for the procedure, clinical presentation, etiology of stricture, presence of PD stones, stricture length and diameter, previous stenting, procedural details, complications, and clinical outcomes. Clinical Material: Alcohol abuse was the most common etiology of CP and PD strictures (8/11); 1 patient had pancreas divisum associated CP, and 2 idiopathic CP. Clinical presentations were recurrent acute pancreatitis in 6 and pancreatic-type pain in 5. 7 patients had previous plastic stents placed in the PD to try to manage the stricture. Mean length of PD stricture was 25mm (10-50). Stones in the main PD were present in 6. 8 patients had CBD strictures. FC-SEMS designed for biliary use were used (FC-Wallflex, Boston Scientific); either 10x40mm or 8x60mm. Placement was through the major papilla in all but 2 cases (1 divisum, 1 with stone obstructing major). 6 patients had concomitant CBD stent placement. Outcomes: Clinical follow-up was mean 16 months (range 6-32).Stents were left in for average 11 weeks (range 1-26), and all were easily removed. Decreased maximum upstream PD diameter was seen in every case immediately following stent removal (pre-stenting 12.6mm (8-18) and poststenting 7.8mm (5-13). 5 patients had clinical improvement (ablation of pancreatic pain and/or no further episodes of acute pancreatitis) and did not need stent replacement. One patient had partial improvement of pain. 6 patients required stent replacement (metal or plastic). Complications included mild acute pancreatitis in 1, and exacerbation of pancreatic pain in 4 (FC-SEMS removal required in 2 of these). Conclusions: FC-SEMS can be used for refractory pancreatic duct strictures. They appear safe although some patients may experience pain upon stent expansion. Removability was not a problem with stents left in for up to 6 months. Some strictures could be remodeled, and several patients are stent-free on follow-up. However, many PD strictures were refractory and require ongoing PD stenting. In the future, new stents should be developed that optimize stent diameter and length. In addition, a fenestrated
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB318