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Su1497 MRCP is Not a Cost Effective Strategy in Management of Common Bile Duct Stones
squamous cells (EPC1) form a 10-11 layered stratified epithelium when grown on polyester trans-well filters apically and basally supplemented with keratinocyte serum-free media with 0.6mM Ca+2. This stratified epithelium shows epithelial barrier function and expresses squamous specific genes like GRHL-1, K10, KDAP, DSG1, and IVL. Moreover, when exposed to bile acids at pH5 in short pulses, EPC1 cells demonstrate reduction in the stratification layers and in the expression of squamous specific genes. The epithelium also exhibits loss of barrier function possibly due to disruption of desmosomal junctions and phosphorylationactivation of epidermal growth factor receptor (EGFR) and down-stream pathways. In addition, the epithelium starts expressing columnar specific transcription factor CDX2 as early as day 3 of treatment. These results indicate that bile acid at low pH is responsible for skewing the differentiation status of stratified squamous esophageal epithelium In Vitro to a more columnar type possibly by initiating a mucosal restitution response through activation of EGFR signaling.
its clinical utility to MRCP in order to evaluate -their impact on patients management. Methods: All the laparoscopic cholecystectomy (LC) procedures performed during the period of January 2008 to 2010 were retrieved from computerized database. We examined the indications and findings of IOF and MRCP and their impact on the treatment strategy. Results: A total of 700 consecutive cases of LCs were performed. Liver enzymes were elevated in 273 of 700 (39%) patients. MRCP was carried out in 139 of 700 (20%) patients. A hundred and eighteen patients (118) had pre operative MRCP, while 21 patients had postoperative MRCP. Forty two (42) patients (6%) underwent ERCP, half of these (21/42) were performed before surgery and other half was performed after it. A total of 182 (26%) underwent IOF during LC. Choledocholithiasis was noted in 46 patients (6.6%), 70% of the 46 were detected by MRCP and 30 % by IOC. MRCP reported common bile duct stones (CBDS) in 32 (27%). IOC was performed in 21 patients who had a negative MRCP revealing a stone in a single case. A hundred and three ((18.4%) of 558 patients who did not undergo MRCP had IOF and stones were seen in 13/103 patients (2.3%). Eleven patients out of the 13 went on to have a successful single-stage laparoscopic clearance. Conclusions: MRCP is an accurate non-invasive diagnostic and triaging modality while IOF remains to be the gold standard when CBD stones are suspected. IOF document site and size of known CBD stones and detect unsuspected ones in patients, who may benefit from a single stage laparoscopic common bile duct clearance. A leaner preoperative choledocholithiasis predictability criterion is desirable to reduce the redundancy in MRCP and IOF utilization.
Su1497 MRCP is Not a Cost Effective Strategy in Management of Common Bile Duct Stones Irene Epelboym, Megan Winner, John D. Allendorf Background: Few formal cost effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches in the management of choledocholithiasis. Methods: Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case we assumed a 10% probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal MRCP, universal ERCP, laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables. Results: The most effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10% risk of asymptomatic choledocholithiasis was LCIOC. This was followed closely by MRCP, LC alone, and ERCP; expected values of success in each strategy did not differ in a clinically meaningful way. Varying the prevalence of asymptomatic choledocholithaisis or the probability that retained stones would eventually cause symptomatic biliary obstruction did not affect the optimal strategy. When procedure and hospitalization costs were taken into consideration, LCIOC was the most cost effective approach, followed by laparoscopic cholecystectomy. LC was preferred when the prevalence of asymptomatic choledocholithiasis fell below 9%, or when the probability that a retained CBD stone would eventually become symptomatic was less than 60%. Similarly, if the sensitivity, specificity, or technical success of an IOC fell below 78%, 54%, or 80%, LC alone was the preferred strategy. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost effective than universal MRCP or ERCP, irrespective of presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome. Conclusions: LC with routine IOC is the preferred strategy in a cost effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.
Su1499
AIM: The aim of this study was to clarify the risk factors, the pattern of occurrence and the results of treatment of recurrence in patients affected by cholangiocarcinoma submitted to surgical resection for peri-hilar (PCC) and intrahepatic cholangiocarcinoma (ICC). METHODS: We retrospectively analyzed the clinicopathologic data of 132 patients submitted to liver resection with curative intent from January 1990 to July 2011, 71 of whom affected by PCC and 61 withICC. Thirty-two patients for both groups developed recurrence during the follow-up period (45% and 52.5%, respectively). We estimated the risk factors, the onset pattern of recurrence and the impact of treatment on survival in these patients. RESULTS: The 3- and 5-year disease-free survival was 41% and 21% for both groups (p= 0.35). Among the patients affected by PCC, 11 (34%) developed intrahepatic recurrence, 5 (15%) developed peritoneal carcinomatosis, 4 (13%) anastomotic and 4 (13%) lymph-nodal recurrence. Percutaneous transhepatic biliary drainage catheter tract recurrence occurred in 3 patients (9%). At univariate analysis, the tumor size, the macroscopical portal involvement and elevated serum level of Ca 19.9 were significantly associated with recurrence. In the intrahepatic cholangiocarcinoma group, 19 patients (59%) developed intrahepatic recurrence. Five factors were significantly associated with recurrence at univariate analysis in this group: tumor size, serum level of Ca 19.9 and CEA, multifocal disease at resection and grading. The overall 3-year survival after recurrence was 17%. The type of treatment was different between two groups. In patients with PCC, 5 (9%) patients were submitted to surgical treatment of recurrence followed by chemotherapy, 19 (60%) underwent only chemotherapy, while 8 (25%) received supportive care. In patients affected by ICC, Five patients (16%) received surgical treatment, 13 (41%) chemo- or radiotherapy and 14 (43%) only supportive care. Regarding the impact of treatment on survival, the median survivals in patients submitted to surgery, chemotherapy or supportive care were 45.5, 12.5, and 2.9 months respectively (p<0.05). CONCLUSIONS: Recurrence after liver resection with curative intent is correlated to a poor prognosis. When feasible, aggressive treatment with radical resection of recurrence can improve the prognosis in these patients. Su1500 Experiences From the use of PerOral Cholangio-Pancreaticoscopy as a Routine Diagnostic Work up Tool in a Tertiary Referral Center Lars Enochsson, Lars R. Lundell, Fredrik Swahn, Matthias Loehr, Urban Arnelo Background: Although there are a variety of modalities to diagnose pathology within the pancreatobiliary ductal tract the introduction of the single-operator peroral cholangio-pancreaticoscopy (SOPOC), SpyGlass Direct Visualization System has added a significant contribution to the diagnostic arsenal. At Karolinska University Hospital we have since 2007 used the system as an integrated part of the diagnostic work up programme. The aim of this paper is to describe our experiences and define its role in clinical practice Methods Between 2007 and 2010, 167 SOPOC examinations have been performed using the SpyGlass system. As we got more familair with the system there was a gradual increase in the number of examinations over the years (19(2007); 45(2008); 50(2009); 53(2010)). In all 28% of the patients were referred to us from other centers. In 145 (91.8%) of the examinations the complete system including the optical probe (SpyGlass) and the access and delivery catheter (SpyScope) was used. In the remaining 8.2% the SpyGlass was introduced through a sphincterotome catheter. Results 167 examinations were completed in 161 patients. Among these were 56.3% males (mean age 58.4; range 21-87) and 43.7% females (mean age 61.5; range 23-89). There were 104 (62.3 %) examinations of the biliary, 45 (26.9%) of the pancreatic duct system and in 18 cases (10.8%) the ampullary tract. The optical quality of the examination was considered to be good in 90.8%, fair in 6.1% and inadequate in the remaining 3.1%. The overall postoperative complication rate of the ERCP examinations with SpyGlass was 13.3%. Postoperative complications, however, differed significantly depending on which tract that was investigated since postop complication rates were 12.6% in the biliary, 20.0% in the pancreatic and 0% in the ampullary region. The diagnostic gain was in the biliary system 82.7%, in the pancreatic duct system 68.9% and 100% in the ampullary region. Conclusion The single-operator SpyGlass Direct Visualization System offers a valuable diagnostic aid with significant gains in both the biliary as well as the pancreatic duct system. The large variation in postprocedural complication rates suggests the room for preventive measures which requires further studies.
Su1498 The Role of Intraoperative Fluorocholangiography During the Advance Laparoscopic Cholecystectomy Era Harsha Jayamanne, Jonathan Lloyd-Evans, Ashraf M. Rasheed Introduction Intra-operative fluorocholangiography (IOF) allows real time demonstration of biliary anatomy and identification of common bile duct stones irrespective of size or site of the stones. However, routine use of IOF for detection of unsuspected choledocholithiasis ignited a debate during the open era that continued into the current laparoscopic era. Absence of conclusive preoperative predictors of choledocholithiasis, rise in the number of preoperative endoscopic retrograde cholangiography pancreatography (ERCP) /endoscopic sphincterotomy (ES) and availability of laparoscopic ductal stones clearance rekindled the interest and re-ignited the debate in the clinical utility of pre-operative magnetic resonance cholangiography (MRCP) and laparoscopic IOF. Aims To assess indications and utilization of IOF during laparoscopic cholecystectomy at Aneurin Bevan Health Board and to compare
S-1049
SSAT Abstracts
SSAT Abstracts
Risk Factors, Pattern of Onset and Result of Treatment of Recurrence After Liver Resection of Peri-Hilar and Intrahepatic Cholangiocarcinoma Andrea Ruzzenente, Alessandro Valdegamberi, Tommaso Campagnaro, Simone Conci, Elisabeth Baldiotti, Calogero Iacono, Alfredo Guglielmi
its clinical utility to MRCP in order to evaluate -their impact on patients management. Methods: All the laparoscopic cholecystectomy (LC) procedures performed during the period of January 2008 to 2010 were retrieved from computerized database. We examined the indications and findings of IOF and MRCP and their impact on the treatment strategy. Results: A total of 700 consecutive cases of LCs were performed. Liver enzymes were elevated in 273 of 700 (39%) patients. MRCP was carried out in 139 of 700 (20%) patients. A hundred and eighteen patients (118) had pre operative MRCP, while 21 patients had postoperative MRCP. Forty two (42) patients (6%) underwent ERCP, half of these (21/42) were performed before surgery and other half was performed after it. A total of 182 (26%) underwent IOF during LC. Choledocholithiasis was noted in 46 patients (6.6%), 70% of the 46 were detected by MRCP and 30 % by IOC. MRCP reported common bile duct stones (CBDS) in 32 (27%). IOC was performed in 21 patients who had a negative MRCP revealing a stone in a single case. A hundred and three ((18.4%) of 558 patients who did not undergo MRCP had IOF and stones were seen in 13/103 patients (2.3%). Eleven patients out of the 13 went on to have a successful single-stage laparoscopic clearance. Conclusions: MRCP is an accurate non-invasive diagnostic and triaging modality while IOF remains to be the gold standard when CBD stones are suspected. IOF document site and size of known CBD stones and detect unsuspected ones in patients, who may benefit from a single stage laparoscopic common bile duct clearance. A leaner preoperative choledocholithiasis predictability criterion is desirable to reduce the redundancy in MRCP and IOF utilization.
Su1497 MRCP is Not a Cost Effective Strategy in Management of Common Bile Duct Stones Irene Epelboym, Megan Winner, John D. Allendorf Background: Few formal cost effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches in the management of choledocholithiasis. Methods: Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case we assumed a 10% probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal MRCP, universal ERCP, laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables. Results: The most effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10% risk of asymptomatic choledocholithiasis was LCIOC. This was followed closely by MRCP, LC alone, and ERCP; expected values of success in each strategy did not differ in a clinically meaningful way. Varying the prevalence of asymptomatic choledocholithaisis or the probability that retained stones would eventually cause symptomatic biliary obstruction did not affect the optimal strategy. When procedure and hospitalization costs were taken into consideration, LCIOC was the most cost effective approach, followed by laparoscopic cholecystectomy. LC was preferred when the prevalence of asymptomatic choledocholithiasis fell below 9%, or when the probability that a retained CBD stone would eventually become symptomatic was less than 60%. Similarly, if the sensitivity, specificity, or technical success of an IOC fell below 78%, 54%, or 80%, LC alone was the preferred strategy. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost effective than universal MRCP or ERCP, irrespective of presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome. Conclusions: LC with routine IOC is the preferred strategy in a cost effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.
Su1499
AIM: The aim of this study was to clarify the risk factors, the pattern of occurrence and the results of treatment of recurrence in patients affected by cholangiocarcinoma submitted to surgical resection for peri-hilar (PCC) and intrahepatic cholangiocarcinoma (ICC). METHODS: We retrospectively analyzed the clinicopathologic data of 132 patients submitted to liver resection with curative intent from January 1990 to July 2011, 71 of whom affected by PCC and 61 withICC. Thirty-two patients for both groups developed recurrence during the follow-up period (45% and 52.5%, respectively). We estimated the risk factors, the onset pattern of recurrence and the impact of treatment on survival in these patients. RESULTS: The 3- and 5-year disease-free survival was 41% and 21% for both groups (p= 0.35). Among the patients affected by PCC, 11 (34%) developed intrahepatic recurrence, 5 (15%) developed peritoneal carcinomatosis, 4 (13%) anastomotic and 4 (13%) lymph-nodal recurrence. Percutaneous transhepatic biliary drainage catheter tract recurrence occurred in 3 patients (9%). At univariate analysis, the tumor size, the macroscopical portal involvement and elevated serum level of Ca 19.9 were significantly associated with recurrence. In the intrahepatic cholangiocarcinoma group, 19 patients (59%) developed intrahepatic recurrence. Five factors were significantly associated with recurrence at univariate analysis in this group: tumor size, serum level of Ca 19.9 and CEA, multifocal disease at resection and grading. The overall 3-year survival after recurrence was 17%. The type of treatment was different between two groups. In patients with PCC, 5 (9%) patients were submitted to surgical treatment of recurrence followed by chemotherapy, 19 (60%) underwent only chemotherapy, while 8 (25%) received supportive care. In patients affected by ICC, Five patients (16%) received surgical treatment, 13 (41%) chemo- or radiotherapy and 14 (43%) only supportive care. Regarding the impact of treatment on survival, the median survivals in patients submitted to surgery, chemotherapy or supportive care were 45.5, 12.5, and 2.9 months respectively (p<0.05). CONCLUSIONS: Recurrence after liver resection with curative intent is correlated to a poor prognosis. When feasible, aggressive treatment with radical resection of recurrence can improve the prognosis in these patients. Su1500 Experiences From the use of PerOral Cholangio-Pancreaticoscopy as a Routine Diagnostic Work up Tool in a Tertiary Referral Center Lars Enochsson, Lars R. Lundell, Fredrik Swahn, Matthias Loehr, Urban Arnelo Background: Although there are a variety of modalities to diagnose pathology within the pancreatobiliary ductal tract the introduction of the single-operator peroral cholangio-pancreaticoscopy (SOPOC), SpyGlass Direct Visualization System has added a significant contribution to the diagnostic arsenal. At Karolinska University Hospital we have since 2007 used the system as an integrated part of the diagnostic work up programme. The aim of this paper is to describe our experiences and define its role in clinical practice Methods Between 2007 and 2010, 167 SOPOC examinations have been performed using the SpyGlass system. As we got more familair with the system there was a gradual increase in the number of examinations over the years (19(2007); 45(2008); 50(2009); 53(2010)). In all 28% of the patients were referred to us from other centers. In 145 (91.8%) of the examinations the complete system including the optical probe (SpyGlass) and the access and delivery catheter (SpyScope) was used. In the remaining 8.2% the SpyGlass was introduced through a sphincterotome catheter. Results 167 examinations were completed in 161 patients. Among these were 56.3% males (mean age 58.4; range 21-87) and 43.7% females (mean age 61.5; range 23-89). There were 104 (62.3 %) examinations of the biliary, 45 (26.9%) of the pancreatic duct system and in 18 cases (10.8%) the ampullary tract. The optical quality of the examination was considered to be good in 90.8%, fair in 6.1% and inadequate in the remaining 3.1%. The overall postoperative complication rate of the ERCP examinations with SpyGlass was 13.3%. Postoperative complications, however, differed significantly depending on which tract that was investigated since postop complication rates were 12.6% in the biliary, 20.0% in the pancreatic and 0% in the ampullary region. The diagnostic gain was in the biliary system 82.7%, in the pancreatic duct system 68.9% and 100% in the ampullary region. Conclusion The single-operator SpyGlass Direct Visualization System offers a valuable diagnostic aid with significant gains in both the biliary as well as the pancreatic duct system. The large variation in postprocedural complication rates suggests the room for preventive measures which requires further studies.
Su1498 The Role of Intraoperative Fluorocholangiography During the Advance Laparoscopic Cholecystectomy Era Harsha Jayamanne, Jonathan Lloyd-Evans, Ashraf M. Rasheed Introduction Intra-operative fluorocholangiography (IOF) allows real time demonstration of biliary anatomy and identification of common bile duct stones irrespective of size or site of the stones. However, routine use of IOF for detection of unsuspected choledocholithiasis ignited a debate during the open era that continued into the current laparoscopic era. Absence of conclusive preoperative predictors of choledocholithiasis, rise in the number of preoperative endoscopic retrograde cholangiography pancreatography (ERCP) /endoscopic sphincterotomy (ES) and availability of laparoscopic ductal stones clearance rekindled the interest and re-ignited the debate in the clinical utility of pre-operative magnetic resonance cholangiography (MRCP) and laparoscopic IOF. Aims To assess indications and utilization of IOF during laparoscopic cholecystectomy at Aneurin Bevan Health Board and to compare
S-1049
SSAT Abstracts
SSAT Abstracts
Risk Factors, Pattern of Onset and Result of Treatment of Recurrence After Liver Resection of Peri-Hilar and Intrahepatic Cholangiocarcinoma Andrea Ruzzenente, Alessandro Valdegamberi, Tommaso Campagnaro, Simone Conci, Elisabeth Baldiotti, Calogero Iacono, Alfredo Guglielmi