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Su1458 Pancreatic Endoscopic Therapy Through the Major vs Minor Ampulla: Feasibility and Comparative Study
Abstracts
informative results. The cytologic diagnosis was positive (class V or class IV) in 6, and negative (class I, II, III, and non-informative) in 6. The sensitivity and specificity of the cytologic diagnosis were 86 % and 100 %, respectively. Procedure induced mild pancreatitis occurred in 1 patient (8%). Conclusion: Pancreatic duct lavage cytology with cell block method may be useful for the differentiation between benign and malignant IPMN of the branch duct type. Further studies in a larger population are required to confirm our results.
balloon dilatation of minor papilla (guidewire cut method), ENPD was placed into pseudocyst and abscess. One week later they disappeared and her conditions improved greatly. Case b. 56 y/o male ; a non-calcified chronic pancreatitis case. ERP showed marked narrowing of the Wirsung duct. When the guide wire was inserted through major papilla, it couldn’t go deeply and came back into duodenum via Santorini duct and minor papilla. So minor papilla was cut by needle knife (Rendezvous precut method) and dilatated by balloon, then EPS was placed. After this procedure his symptoms were relieved. Conclusions: The treatment of pancreatic diseases via minor papilla is a safe and useful method when the treatment via major papilla is difficult in such cases as above. In these cases, pancreatic juice is drained mainly through Santorini duct, so careful procedures for minor papilla are necessary.
Su1456 Therapeutic ERCP Using Short Double-Balloon Enteroscopy in Patients With Surgically Altered Anatomy Hirofumi Kogure1, Hirotsugu Watabe1, Atsuo Yamada1, Hiroyuki Isayama1, Takeshi Tsujino1, Rie Nagano1, Tsuyoshi Hamada1, Koji Miyabayashi1, Keisuke Yamamoto1, Dai Mohri1, Kazumichi Kawakubo1, Takashi Sasaki1, Yukiko Ito1, Natsuyo Yamamoto1, Kenji Hirano1, Naoki Sasahira1, Minoru Tada1, Masao Omata2, Kazuhiko Koike1 1 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 2Yamanashi Prefectural Hospital Organization, Kofu, Japan
Su1458 Pancreatic Endoscopic Therapy Through the Major vs Minor Ampulla: Feasibility and Comparative Study Juan J. Vila, Silvia GoñI, Miriam Ostiz, Marcos Kutz, Jesus Urman, Federico Bolado, Ignacio Fernandez-Urien, Javier Jiménez-Pérez Endoscopy Unit. Gastroenterology Dpt, Hospital de Navarra, Pamplona, Spain
Background: Although ERCP is technically challenging in patients with surgically altered anatomy, with the advent of double-balloon enteroscopy (DBE), endoscopic access to the pancreaticobiliary system can be more effectively achieved in such patients, so various therapeutic interventions have become possible. Methods: Between February 2006 and November 2010, we performed endoscopic pancreaticobiliary interventions in 46 patients (82 sessions) using a short DBE (152 cm in length with a 2.8 mm working channel; EC-450BI5, Fujifilm Medical Co. Ltd., Tokyo, Japan), enabling conventional ERCP accessories. Previous surgeries included pancreaticoduodenectomy (n ⫽ 17), Roux-en-Y gastrectomy (n ⫽ 10), hepaticojejunostomy (n ⫽ 9), Billroth II gastrectomy (n ⫽ 6), living donor liver transplantation with hepaticojejunostomy (n ⫽ 3), and gastrectomy with jejunal interposition (n ⫽ 1). Indication for biliary interventions were bile duct stones (n ⫽ 26), anastomotic stricture (n ⫽ 16; with bile duct stones [n ⫽ 10]), obstructive jaundice (n ⫽ 2), cholangitis (n ⫽ 1), and pancreatic duct stones (n ⫽ 1). Results: Access to the papilla or anastomosis was successful in 74 of 82 sessions (90%), with the mean time required to the target orifice being 38 min (4-116 min). Successful cannulation was achieved in 69 of 82 sessions (84%). Pancreaticobiliary interventions were successful in 63 of 82 sessions (77%). Therapeutic procedures included stone extraction (n ⫽ 46), balloon dilation of anastomotic stricture (n ⫽ 25), biliary plastic stent placement (n ⫽ 14), endoscopic naso-biliary drainage (n ⫽ 12), papillary balloon dilation (n ⫽ 9), papillary large balloon dilation (n ⫽ 7), and electrohydraulic lithotripsy (n ⫽ 1). The mean overall procedure time was 119 min (20-280 min). Complications occurred in 8 (10%) patients, including retroperitoneal and/or intraperitoneal air (n ⫽ 4), cholangitis (n ⫽ 2), tension pneumothorax (n ⫽ 1), and esophageal hemorrhage (n ⫽ 1). Conclusions: Pancreaticobiliary interventions using short DBE are effective and safe in patients with surgically altered anatomy.
Su1457 How to Treat Pancreatic Diseases by Endoscopy via “Minor Papilla”- Our Experiences of 72 Cases; Its Safety and Efficacy Tadao Tsuji Gastroenterology, Saitama City Hospital, Saitamashi, Japan Introduction: In the past 16 years, we have experienced 72 cases of pancreatic diseases treated via minor papilla endoscopically. They consisted of 57 pancreatic stone (47 alcoholic, 3 idiopathic, 4 divisum, 2 hereditary, 1 hyperparathyroidism), 7 non-calcified chronic pancreatitis with Wirsung duct narrowing, 2 symptomatic noncalcified divisum, 3 IPMC, 1 ventral pancreas dysplasia, 1 hereditary pancreatitis, and 1 carcinoma in Wirsung duct. In these cases, treatments via major papilla were unsuccessful; however treatments via minor papilla were successful. So we would like to show how to treat these cases via minor papilla and the safety and efficacy of this method. Aims and Methods: Evaluation of the safety and efficacy of endoscopic treatment via minor papilla. The indications for this procedure were in such conditions as severe narrowing of the Wirsung duct-56 cases, continuous pain by re-impaction of fragments after ESWL-2 cases, divisum-5 cases, and stones in the Santorini duct-4 cases, dilatation of the orifice of minor papilla(IPMC)-3 cases, and continuous pain due to primary stone impaction-2 cases. The procedures for the minor papilla consisted of guide-wire(⫹)EPST-57 cases, guide-wire(-)EPST-1 case, EPDBD(balloon dilatation) alone-3 cases, Rendezvous method-5 cases, Rendezvous precut method-4 cases, and free hand method-2 cases. Results: These procedures were successful in all 72 cases and no major problems occurred after this treatment. In 57 pancreatic stone cases, stone-free-rate was 98%(56/57), pain-free-rate 100%(53/ 53). In other 15 cases, the results were good and symptoms disappeared in all cases. Case presentation-Case a. 29 y/o female ; an alcoholic pseudocyst and abscess case. Her complaints were dyspnea, high fever and abdominal pain due to pancreatic pleural effusion and pseudocyst and abscessin the abdominal cavity. ERP showed obstruction of Wirsung duct by inflammation and stone impaction. After EPST and
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Introduction: Endoscopic pancreatic therapy through the minor papilla (MiP) as a salvage procedure after failed therapy through the major papilla (MaP) has been described. Comparative studies of both approaches are lacking. AIMS: Compare the outcomes of endoscopic therapy through the MiP with therapy through the MaP. Methods: Patients who underwent transpapillary endoscopic pancreatic therapy in our endoscopy unit from Jan/2009 until Aug/2010 were eligible for inclusion in the study. Our policy is to perform the endoscopic treatment through the MaP (Major Group). When this is not possible we try to perform the endoscopic treatment through the MiP (Minor Group). Technical success (successful endoscopic treatment), therapeutic manoeuvres performed, clinical success (resolution of symptoms after ERCP) and complications were compared between both groups using 2 test. Results: 8 patients were included in the Minor Group and 12 in the Major Group. In the Minor Group, ERCP was performed for complications of chronic pancreatitis in 4 patients (pancreatolithiasis in 2, pseudocyst in 1, pancreatic duct stenosis in 1), acute pancreatitis in 2 patients (pancreatic duct stenosis in 1, recurrent pancreatitis in 1 patient with pancreas divisum), carcinoid tumor located in the MiP in 1 patient and pancreatic type pain in another one with pancreas divisum. In the Major Group, ERCP was indicated for complications of chronic pancreatitis in 7 patients (pancreatic duct stenosis in 4, pseudocyst in 1, pancreatolithiasis in 2) and complications of acute pancreatitis in 4 patients (pseudocyst in 3, pancreaticopleural fistula in 1). Technical success was achieved in 5 patients of the Minor Group vs 10 patients of the Major Group (62,5% vs 83%; p⬎0.05). Pancreatic sphincterotomy was performed in 4 patients from the Minor Group and in 8 patients from the Major Group (p⬎0.05). Cannulation of the MiP was achieved after needle knife precut in 2 patients, and sphincterotomy was followed by pancreatic sphincteroplasty in 1 patient of the Major Group. In the patient with the carcinoid tumor, minor papilla ampullectomy was performed. Clinical success was achieved in 5 patients of the Minor Group vs 10 patients of the Major Group (p⬎0.05). One mild post-ERCP pancreatitis ocurred in the Minor Group and 1 case of pancreatitis and 1 infectious complication were diagnosed after ERCP in the Major Group (p⬎0.05), all of them managed conservatively. Conclusions: Pancreatic access through the minor papilla is a feasible salvage alternative for pancreatic cannulation, it allows performance of endoscopic therapy, achieves a similar technical and clinical success and it does not entail a higher complication rate than access through the major papilla. Therefore it should be take into account whenever major papilla cannulation or therapy is not possible.
Su1459 EUS Should Be Performed Prior to ERCP in Patients With Gallstone Pancreatitis Kian Makipour, Mandeep Singh, Anil K. Vegesna, Larry S. Miller Temple University, Philadelphia, PA Background: In the past ERCP was performed for all patients with suspected gallstone pancreatitis. In the past 3 years EUS was performed more frequently prior to ERCP for the diagnosis of gallstone pancreatitis than in previous years at Temple University Hospital in Philadelphia PA. Purpose: To determine the number of patient’s with gallstone pancreatitis who have retained CBD stones and who have passed CBD stones prior to endoscopic intervention (ERCP or EUS). Methods: This is a retrospective review of patients with gallstone pancreatitis between Jan. 1st, 2008 and Nov. 29th, 2010. The diagnosis of gallstone pancreatitis was based on the presence of an elevated amylase or lipase in the setting of documented CBD stones on imaging other than ERCP or EUS, or in the setting of a transient elevation in transaminases. Results: Thirty patients (50 Yrs, 9M, 21F) with gallstone pancreatitis underwent ERCP or EUS at Temple University Hospital between Jan. 1st, 2008 and Nov. 29th, 2010. Of these 30 patients with gallstone pancreatitis 13 (43%) were found to have CBD stones at the time of EUS or ERCP and 17 (57%) had no stones at the time of ERCP or
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB271
informative results. The cytologic diagnosis was positive (class V or class IV) in 6, and negative (class I, II, III, and non-informative) in 6. The sensitivity and specificity of the cytologic diagnosis were 86 % and 100 %, respectively. Procedure induced mild pancreatitis occurred in 1 patient (8%). Conclusion: Pancreatic duct lavage cytology with cell block method may be useful for the differentiation between benign and malignant IPMN of the branch duct type. Further studies in a larger population are required to confirm our results.
balloon dilatation of minor papilla (guidewire cut method), ENPD was placed into pseudocyst and abscess. One week later they disappeared and her conditions improved greatly. Case b. 56 y/o male ; a non-calcified chronic pancreatitis case. ERP showed marked narrowing of the Wirsung duct. When the guide wire was inserted through major papilla, it couldn’t go deeply and came back into duodenum via Santorini duct and minor papilla. So minor papilla was cut by needle knife (Rendezvous precut method) and dilatated by balloon, then EPS was placed. After this procedure his symptoms were relieved. Conclusions: The treatment of pancreatic diseases via minor papilla is a safe and useful method when the treatment via major papilla is difficult in such cases as above. In these cases, pancreatic juice is drained mainly through Santorini duct, so careful procedures for minor papilla are necessary.
Su1456 Therapeutic ERCP Using Short Double-Balloon Enteroscopy in Patients With Surgically Altered Anatomy Hirofumi Kogure1, Hirotsugu Watabe1, Atsuo Yamada1, Hiroyuki Isayama1, Takeshi Tsujino1, Rie Nagano1, Tsuyoshi Hamada1, Koji Miyabayashi1, Keisuke Yamamoto1, Dai Mohri1, Kazumichi Kawakubo1, Takashi Sasaki1, Yukiko Ito1, Natsuyo Yamamoto1, Kenji Hirano1, Naoki Sasahira1, Minoru Tada1, Masao Omata2, Kazuhiko Koike1 1 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 2Yamanashi Prefectural Hospital Organization, Kofu, Japan
Su1458 Pancreatic Endoscopic Therapy Through the Major vs Minor Ampulla: Feasibility and Comparative Study Juan J. Vila, Silvia GoñI, Miriam Ostiz, Marcos Kutz, Jesus Urman, Federico Bolado, Ignacio Fernandez-Urien, Javier Jiménez-Pérez Endoscopy Unit. Gastroenterology Dpt, Hospital de Navarra, Pamplona, Spain
Background: Although ERCP is technically challenging in patients with surgically altered anatomy, with the advent of double-balloon enteroscopy (DBE), endoscopic access to the pancreaticobiliary system can be more effectively achieved in such patients, so various therapeutic interventions have become possible. Methods: Between February 2006 and November 2010, we performed endoscopic pancreaticobiliary interventions in 46 patients (82 sessions) using a short DBE (152 cm in length with a 2.8 mm working channel; EC-450BI5, Fujifilm Medical Co. Ltd., Tokyo, Japan), enabling conventional ERCP accessories. Previous surgeries included pancreaticoduodenectomy (n ⫽ 17), Roux-en-Y gastrectomy (n ⫽ 10), hepaticojejunostomy (n ⫽ 9), Billroth II gastrectomy (n ⫽ 6), living donor liver transplantation with hepaticojejunostomy (n ⫽ 3), and gastrectomy with jejunal interposition (n ⫽ 1). Indication for biliary interventions were bile duct stones (n ⫽ 26), anastomotic stricture (n ⫽ 16; with bile duct stones [n ⫽ 10]), obstructive jaundice (n ⫽ 2), cholangitis (n ⫽ 1), and pancreatic duct stones (n ⫽ 1). Results: Access to the papilla or anastomosis was successful in 74 of 82 sessions (90%), with the mean time required to the target orifice being 38 min (4-116 min). Successful cannulation was achieved in 69 of 82 sessions (84%). Pancreaticobiliary interventions were successful in 63 of 82 sessions (77%). Therapeutic procedures included stone extraction (n ⫽ 46), balloon dilation of anastomotic stricture (n ⫽ 25), biliary plastic stent placement (n ⫽ 14), endoscopic naso-biliary drainage (n ⫽ 12), papillary balloon dilation (n ⫽ 9), papillary large balloon dilation (n ⫽ 7), and electrohydraulic lithotripsy (n ⫽ 1). The mean overall procedure time was 119 min (20-280 min). Complications occurred in 8 (10%) patients, including retroperitoneal and/or intraperitoneal air (n ⫽ 4), cholangitis (n ⫽ 2), tension pneumothorax (n ⫽ 1), and esophageal hemorrhage (n ⫽ 1). Conclusions: Pancreaticobiliary interventions using short DBE are effective and safe in patients with surgically altered anatomy.
Su1457 How to Treat Pancreatic Diseases by Endoscopy via “Minor Papilla”- Our Experiences of 72 Cases; Its Safety and Efficacy Tadao Tsuji Gastroenterology, Saitama City Hospital, Saitamashi, Japan Introduction: In the past 16 years, we have experienced 72 cases of pancreatic diseases treated via minor papilla endoscopically. They consisted of 57 pancreatic stone (47 alcoholic, 3 idiopathic, 4 divisum, 2 hereditary, 1 hyperparathyroidism), 7 non-calcified chronic pancreatitis with Wirsung duct narrowing, 2 symptomatic noncalcified divisum, 3 IPMC, 1 ventral pancreas dysplasia, 1 hereditary pancreatitis, and 1 carcinoma in Wirsung duct. In these cases, treatments via major papilla were unsuccessful; however treatments via minor papilla were successful. So we would like to show how to treat these cases via minor papilla and the safety and efficacy of this method. Aims and Methods: Evaluation of the safety and efficacy of endoscopic treatment via minor papilla. The indications for this procedure were in such conditions as severe narrowing of the Wirsung duct-56 cases, continuous pain by re-impaction of fragments after ESWL-2 cases, divisum-5 cases, and stones in the Santorini duct-4 cases, dilatation of the orifice of minor papilla(IPMC)-3 cases, and continuous pain due to primary stone impaction-2 cases. The procedures for the minor papilla consisted of guide-wire(⫹)EPST-57 cases, guide-wire(-)EPST-1 case, EPDBD(balloon dilatation) alone-3 cases, Rendezvous method-5 cases, Rendezvous precut method-4 cases, and free hand method-2 cases. Results: These procedures were successful in all 72 cases and no major problems occurred after this treatment. In 57 pancreatic stone cases, stone-free-rate was 98%(56/57), pain-free-rate 100%(53/ 53). In other 15 cases, the results were good and symptoms disappeared in all cases. Case presentation-Case a. 29 y/o female ; an alcoholic pseudocyst and abscess case. Her complaints were dyspnea, high fever and abdominal pain due to pancreatic pleural effusion and pseudocyst and abscessin the abdominal cavity. ERP showed obstruction of Wirsung duct by inflammation and stone impaction. After EPST and
www.giejournal.org
Introduction: Endoscopic pancreatic therapy through the minor papilla (MiP) as a salvage procedure after failed therapy through the major papilla (MaP) has been described. Comparative studies of both approaches are lacking. AIMS: Compare the outcomes of endoscopic therapy through the MiP with therapy through the MaP. Methods: Patients who underwent transpapillary endoscopic pancreatic therapy in our endoscopy unit from Jan/2009 until Aug/2010 were eligible for inclusion in the study. Our policy is to perform the endoscopic treatment through the MaP (Major Group). When this is not possible we try to perform the endoscopic treatment through the MiP (Minor Group). Technical success (successful endoscopic treatment), therapeutic manoeuvres performed, clinical success (resolution of symptoms after ERCP) and complications were compared between both groups using 2 test. Results: 8 patients were included in the Minor Group and 12 in the Major Group. In the Minor Group, ERCP was performed for complications of chronic pancreatitis in 4 patients (pancreatolithiasis in 2, pseudocyst in 1, pancreatic duct stenosis in 1), acute pancreatitis in 2 patients (pancreatic duct stenosis in 1, recurrent pancreatitis in 1 patient with pancreas divisum), carcinoid tumor located in the MiP in 1 patient and pancreatic type pain in another one with pancreas divisum. In the Major Group, ERCP was indicated for complications of chronic pancreatitis in 7 patients (pancreatic duct stenosis in 4, pseudocyst in 1, pancreatolithiasis in 2) and complications of acute pancreatitis in 4 patients (pseudocyst in 3, pancreaticopleural fistula in 1). Technical success was achieved in 5 patients of the Minor Group vs 10 patients of the Major Group (62,5% vs 83%; p⬎0.05). Pancreatic sphincterotomy was performed in 4 patients from the Minor Group and in 8 patients from the Major Group (p⬎0.05). Cannulation of the MiP was achieved after needle knife precut in 2 patients, and sphincterotomy was followed by pancreatic sphincteroplasty in 1 patient of the Major Group. In the patient with the carcinoid tumor, minor papilla ampullectomy was performed. Clinical success was achieved in 5 patients of the Minor Group vs 10 patients of the Major Group (p⬎0.05). One mild post-ERCP pancreatitis ocurred in the Minor Group and 1 case of pancreatitis and 1 infectious complication were diagnosed after ERCP in the Major Group (p⬎0.05), all of them managed conservatively. Conclusions: Pancreatic access through the minor papilla is a feasible salvage alternative for pancreatic cannulation, it allows performance of endoscopic therapy, achieves a similar technical and clinical success and it does not entail a higher complication rate than access through the major papilla. Therefore it should be take into account whenever major papilla cannulation or therapy is not possible.
Su1459 EUS Should Be Performed Prior to ERCP in Patients With Gallstone Pancreatitis Kian Makipour, Mandeep Singh, Anil K. Vegesna, Larry S. Miller Temple University, Philadelphia, PA Background: In the past ERCP was performed for all patients with suspected gallstone pancreatitis. In the past 3 years EUS was performed more frequently prior to ERCP for the diagnosis of gallstone pancreatitis than in previous years at Temple University Hospital in Philadelphia PA. Purpose: To determine the number of patient’s with gallstone pancreatitis who have retained CBD stones and who have passed CBD stones prior to endoscopic intervention (ERCP or EUS). Methods: This is a retrospective review of patients with gallstone pancreatitis between Jan. 1st, 2008 and Nov. 29th, 2010. The diagnosis of gallstone pancreatitis was based on the presence of an elevated amylase or lipase in the setting of documented CBD stones on imaging other than ERCP or EUS, or in the setting of a transient elevation in transaminases. Results: Thirty patients (50 Yrs, 9M, 21F) with gallstone pancreatitis underwent ERCP or EUS at Temple University Hospital between Jan. 1st, 2008 and Nov. 29th, 2010. Of these 30 patients with gallstone pancreatitis 13 (43%) were found to have CBD stones at the time of EUS or ERCP and 17 (57%) had no stones at the time of ERCP or
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB271