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Su1540 Rates of Post-ERCP Pancreatitis in the Pediatric Population: a Single Center Experience
Abstracts
Su1538 A Novel Ex Vibo Training Model for Colorectal Endoscopic Submucosal Dissection Using a Bovine Rectum Joichiro Horii*1, Toshio Uraoka1, Osamu Goto1, A. I. Fujimoto1, Yasutoshi Ochiai1, Koji Takahashi1, Shimoda Masayuki2, Naohisa Yahagi1 1 Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; 2Department of pathology, Keio University School of Medicine, Tokyo, Japan Background: The colorectal ESD (CR-ESD) procedure is highly technically demanding due to the inherent histological and anatomical features of the human colorectum, and has a steep learning curve. Endoscopists clinically should start to perform CR-ESD on rectum because of the lower risk of perforation and less difficulty. Training using animal model is generally recommended before starting CRESD in human. However, we often experienced discrepancy of technical difficulty between an animal model and a human colorectum due to the different thickness of submucosal layer and the excessive fat tissue in submucosal layer. Very few reports have assessed the suitability of animal organ as training model for CR-ESD based on histological examination. Aim: To assess the similarity of histological characteristics of animal colorectum to human rectum and create a new animal training model for CR-ESD. Methods: Study1; The comparison of histology were investigated between 6 isolated animal organs (1. Bovine (B)/ Cecum (C); 2. B/Sigmoid Colon (S); 3. B/ Rectum (R); 4. Porcine (P)/C; 5. P/S; 6. P/R) and resected human rectal specimen. Thicknesses of submucosal layer were evaluated between above-mentioned 6 animal organs (nZ1) and human rectum (nZ3). Study2; Distribution of the fat tissue was evaluated in bovine rectum and porcine rectum by using oil red o staining. Study3; Create a new animal training model based on the result of study1 and study2. Results: Study1; Thickness of the submucosal layer of isolated animal organs were as follows; 1. B/C: 1750mm, 2. B/S: 312mm, 3. B/R: 667mm, 4. P/C: 538mm, 5. P/S: 250mm, 6. P/R: 1250mm. On the other hand, the average thickness of the submucosal layer of 3 human rectum was 666 mm. Thickness of submucosal layer of B/R was almost same as human rectum, in contrast, that of B/S and P/S were obviously thinner, and that of B/C and P/R were obviously thicker than human rectum. Study2; Abundant fat tissue was shown in the submucosal layer of porcine rectum, in contrast, very little fat tissue was shown in that of bovine rectum. Study3; In study 1 and 2, it was shown that B/R was most approximate to human rectum histologically. A model which reproduced colorectal shape and elasticity of the human colorectum was made using a sponge, and a B/R which regulated to appropriate length was fitted in a model. The maneuverability and feeling of ESD procedure in this model were extremely similar to that in human CR-ESD. In addition, anatomical features of human colorectum, such as the thinner wall, the narrow lumen, the presence of angulations and haustra folds were reproduced in this model. Conclusions: An ex vibo animal training model using B/R has a potential to simulate CR-ESD with extremely similarity to that in human.
Su1539 A Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis in Patients With Sphincter of Oddi Dysfunction Type 3 Jeremy H. Kaplan1, Andrew H. Zabolotsky1, Thomas E. Kowalski1, David E. Loren1, Jason Korenblit1, Douglas G. Adler2, Mohamad a. Eloubeidi3, Ali Siddiqui*1 1 Thomas Jefferson University Hospital, Philadelphia, PA; 2 Gastroenterology, University of Utah, Salt Lake City, UT; 3 Gastroenterology, American Univesity of Beruit, Beruit, Lebanon Introduction: Prophylactic pancreatic duct (PD) stenting is an established means to prevent post-ERCP pancreatitis(PEP) in patients with suspected sphincter of Oddi dysfunction (SOD) who undergo manometry. Recent data has suggested that rectal indomethacin can also reduce the incidence of PEP in high risk patients. Aim: The aim of this study was to determine whether prophylactic rectal indomethacin combined with PD stenting alone would reduce the incidence and severity of PEP compared to PD stenting also in patients undergoing manometry for suspected SOD type 3. Methods: A retrospective review of patients who underwent an ERCP with manometry for suspected SOD type 3 from 2006 to 2013 was performed. Patients were divided into two groups: a) those who underwent an ERCP with manometry between 2006 and September 2012 received a prophylactic PD stent (nZ285) and b) beginning October 2012, patients received a prophylactic PD stent along with a single dose of 100-mg indomethacin suppositories after ERCP (nZ57). The following data were recorded: demographics, basal manometry results, trainee involvement, if pancreatography was performed, biliary or pancreatic sphincterotomy, and number of patients in whom pancreatitis developed. Pancreatitis was defined as abdominal pain combined with an increase in pancreatic enzymes R 3 times the upper limit of normal within 24 hours of the procedure. The rate of PEP was compared between the 2 groups. Results: We identified 342 patients who underwent an ERCP with manometry for suspected SOD 3 (82% females, mean age 49 1.9(SE) years). The two groups were similar with regard to patient demographics and procedure risk factors for PEP. Elevated biliary or pancreatic manometry pressures were found in 182 (53.3%) patients. Post-ERCP pancreatitis developed in 22% patients. There was no statistically significant difference in the incidence of PEP in
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the PD stent group compared to the PD stent and indomethacin group (23% vs. 18% respectively; OR 0.71: 95% CI [0.34, 1.47], p Z 0.39). Moderate-to-severe pancreatitis developed in 21 (7%) patients in the PD stent group compared to 5 (9%) patients the PD stent and indomethacin group (pZ0.78). Among patients with PEP, the median length of hospital stay was longer in the PD stent group compared to the PD stent and indomethacin group (6 vs. 4 days respectively; pZ0.11). Age, sex, performing pancreatography, trainee involvement and a pancreatic sphincterotomy were not independently associated with PEP. Discussion: Prophylactic rectally administered indomethacin with PD stenting did not affect the incidence nor severity of post-ERCP pancreatitis when compared to PD stenting alone in patients with suspected SOD 3.
Su1540 Rates of Post-ERCP Pancreatitis in the Pediatric Population: a Single Center Experience Maia Kayal*, Sophia M. Jagroop, Woojin Kim, Amrita Sethi, Tamas a. Gonda, Frank G. Gress, Mercedes Martinez, John M. Poneros Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY Background and Objective: Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP) in the adult population. Our aim was to assess the prevalence and severity of post-ERCP pancreatitis in the pediatric population of a single institution. Materials and Methods: A retrospective review of all pediatric patients (21 years old and younger) undergoing ERCP at our institution in the inpatient and outpatient setting between 2000 and 2013 was conducted. Cases of post-ERCP pancreatitis were defined according to the 1991 consensus statement. Post-ERCP pancreatitis severity was determined according to established criteria: mild pancreatitis requiring unplanned admission or prolongation of planned admission 2-3 days, moderate pancreatitis requiring unplanned admission or prolongation of admission 4-10 days, and severe pancreatitis requiring hospitalization greater than 10 days, intervention, development of necrosis or pseudocyst. Patients with chronic pancreatitis were evaluated separately. Results: From 2000-2013, a total of 170 patients (mean age 14.4 years, range 10 months to 21 years) underwent 242 ERCP procedures. The most common ERCP indications included choledocholithiasis (33.5%), suspected biliary obstruction (22.7%), stent exchange (11.2%), pancreatitis (10.7%), biliary type abdominal pain (9.9%), primary sclerosing cholangitis (4.5%), and bile leak (2.5%). The most common ERCP findings included choledocholithiasis (34.2%), biliary stricture (11.2%), biliary sludge (7.02%), chronic pancreatitis, biliary papillary stenosis and pancreas divisum (each 3.7%), bile leak (2.5%) and choledochal cyst (2.5%). The post-ERCP pancreatitis rate for the 157 patients without chronic pancreatitis was 5.9% (13/220) and 18.2% (4/22) for the 13 patients with chronic pancreatitis. With regards to interventions, 8/17 (47.1%) post-ERCP pancreatitis cases involved biliary sphincterotomy, 8/17 (47.1%) pancreatic duct stent placement, 4/17 (23.5%) biliary stent placement, 4/17 (23.5%) pancreatic sphincterotomy, and 2/17 (11.8%) minor papilla sphincterotomy. In terms of the severity of post-ERCP pancreatitis, 6/17 were mild (35.3%), 10/17 were moderate (58.8%) and 1/17 (5.9%) was severe. Mean age, amylase level, lipase level, and hospitalization length for all patients with post-ERCP pancreatitis were 11.8 years, 931.1 U/L, 2291.2 U/L, and 5.5 days, respectively. Conclusion: The most common ERCP indication and finding in our single center pediatric population is choledocholithiasis. When performed by experienced endoscopists, the overall prevalence of post-ERCP pancreatitis in this single center study is 7.0%, and even less, 5.9%, when excluding patients with chronic pancreatitis.
Su1541 Interobserver Agreement Between Trainers and Trainees: Results From a Multicenter Study Evaluating Learning Curves and Competency in ERCP Sachin Wani*1,2, V. Raman Muthusamy5, Andrew Y. Wang4, Christopher J. Dimaio3, Brian C. Brauer1, Jeffrey J. Easler6, Roy D. Yen1, Ihab El Hajj1, Norio Fukami1, Kourosh F. Ghassemi5, Susana Gonzalez3, Lindsay Hosford1, Thomas G. Hollander6, Vladimir M. Kushnir6, Jawad Ahmad3, Faris Murad6, Anoop Prabhu3, Rabindra R. Watson5, Daniel S. Strand4, Stuart K. Amateau1, Raj J. Shah1, Steven a. Edmundowicz6, Daniel Mullady6 1 University of Colorado, Centennial, CO; 2Veterans Affairs Medical Center, Denver, CO; 3Mount Sinani, New York, NY; 4University of Virginia, Chalottesville, VA; 5David Geffen School of Medicine at UCLA, Los Angeles, CA; 6Washington University School of Medicine, St. Louis, MO Background: There are limited data regarding factors that define competency in performing ERCP. The ASGE recommends a minimum of 180 total procedures before competency can be achieved. These guidelines have not been validated, and studies on learning curves do not account for all skills essential to performance of ERCP. In the era of competency-based medical education, development of a standardized data collection tool to assess competency based on technical and cognitive skills is
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB207
Su1538 A Novel Ex Vibo Training Model for Colorectal Endoscopic Submucosal Dissection Using a Bovine Rectum Joichiro Horii*1, Toshio Uraoka1, Osamu Goto1, A. I. Fujimoto1, Yasutoshi Ochiai1, Koji Takahashi1, Shimoda Masayuki2, Naohisa Yahagi1 1 Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; 2Department of pathology, Keio University School of Medicine, Tokyo, Japan Background: The colorectal ESD (CR-ESD) procedure is highly technically demanding due to the inherent histological and anatomical features of the human colorectum, and has a steep learning curve. Endoscopists clinically should start to perform CR-ESD on rectum because of the lower risk of perforation and less difficulty. Training using animal model is generally recommended before starting CRESD in human. However, we often experienced discrepancy of technical difficulty between an animal model and a human colorectum due to the different thickness of submucosal layer and the excessive fat tissue in submucosal layer. Very few reports have assessed the suitability of animal organ as training model for CR-ESD based on histological examination. Aim: To assess the similarity of histological characteristics of animal colorectum to human rectum and create a new animal training model for CR-ESD. Methods: Study1; The comparison of histology were investigated between 6 isolated animal organs (1. Bovine (B)/ Cecum (C); 2. B/Sigmoid Colon (S); 3. B/ Rectum (R); 4. Porcine (P)/C; 5. P/S; 6. P/R) and resected human rectal specimen. Thicknesses of submucosal layer were evaluated between above-mentioned 6 animal organs (nZ1) and human rectum (nZ3). Study2; Distribution of the fat tissue was evaluated in bovine rectum and porcine rectum by using oil red o staining. Study3; Create a new animal training model based on the result of study1 and study2. Results: Study1; Thickness of the submucosal layer of isolated animal organs were as follows; 1. B/C: 1750mm, 2. B/S: 312mm, 3. B/R: 667mm, 4. P/C: 538mm, 5. P/S: 250mm, 6. P/R: 1250mm. On the other hand, the average thickness of the submucosal layer of 3 human rectum was 666 mm. Thickness of submucosal layer of B/R was almost same as human rectum, in contrast, that of B/S and P/S were obviously thinner, and that of B/C and P/R were obviously thicker than human rectum. Study2; Abundant fat tissue was shown in the submucosal layer of porcine rectum, in contrast, very little fat tissue was shown in that of bovine rectum. Study3; In study 1 and 2, it was shown that B/R was most approximate to human rectum histologically. A model which reproduced colorectal shape and elasticity of the human colorectum was made using a sponge, and a B/R which regulated to appropriate length was fitted in a model. The maneuverability and feeling of ESD procedure in this model were extremely similar to that in human CR-ESD. In addition, anatomical features of human colorectum, such as the thinner wall, the narrow lumen, the presence of angulations and haustra folds were reproduced in this model. Conclusions: An ex vibo animal training model using B/R has a potential to simulate CR-ESD with extremely similarity to that in human.
Su1539 A Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis in Patients With Sphincter of Oddi Dysfunction Type 3 Jeremy H. Kaplan1, Andrew H. Zabolotsky1, Thomas E. Kowalski1, David E. Loren1, Jason Korenblit1, Douglas G. Adler2, Mohamad a. Eloubeidi3, Ali Siddiqui*1 1 Thomas Jefferson University Hospital, Philadelphia, PA; 2 Gastroenterology, University of Utah, Salt Lake City, UT; 3 Gastroenterology, American Univesity of Beruit, Beruit, Lebanon Introduction: Prophylactic pancreatic duct (PD) stenting is an established means to prevent post-ERCP pancreatitis(PEP) in patients with suspected sphincter of Oddi dysfunction (SOD) who undergo manometry. Recent data has suggested that rectal indomethacin can also reduce the incidence of PEP in high risk patients. Aim: The aim of this study was to determine whether prophylactic rectal indomethacin combined with PD stenting alone would reduce the incidence and severity of PEP compared to PD stenting also in patients undergoing manometry for suspected SOD type 3. Methods: A retrospective review of patients who underwent an ERCP with manometry for suspected SOD type 3 from 2006 to 2013 was performed. Patients were divided into two groups: a) those who underwent an ERCP with manometry between 2006 and September 2012 received a prophylactic PD stent (nZ285) and b) beginning October 2012, patients received a prophylactic PD stent along with a single dose of 100-mg indomethacin suppositories after ERCP (nZ57). The following data were recorded: demographics, basal manometry results, trainee involvement, if pancreatography was performed, biliary or pancreatic sphincterotomy, and number of patients in whom pancreatitis developed. Pancreatitis was defined as abdominal pain combined with an increase in pancreatic enzymes R 3 times the upper limit of normal within 24 hours of the procedure. The rate of PEP was compared between the 2 groups. Results: We identified 342 patients who underwent an ERCP with manometry for suspected SOD 3 (82% females, mean age 49 1.9(SE) years). The two groups were similar with regard to patient demographics and procedure risk factors for PEP. Elevated biliary or pancreatic manometry pressures were found in 182 (53.3%) patients. Post-ERCP pancreatitis developed in 22% patients. There was no statistically significant difference in the incidence of PEP in
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the PD stent group compared to the PD stent and indomethacin group (23% vs. 18% respectively; OR 0.71: 95% CI [0.34, 1.47], p Z 0.39). Moderate-to-severe pancreatitis developed in 21 (7%) patients in the PD stent group compared to 5 (9%) patients the PD stent and indomethacin group (pZ0.78). Among patients with PEP, the median length of hospital stay was longer in the PD stent group compared to the PD stent and indomethacin group (6 vs. 4 days respectively; pZ0.11). Age, sex, performing pancreatography, trainee involvement and a pancreatic sphincterotomy were not independently associated with PEP. Discussion: Prophylactic rectally administered indomethacin with PD stenting did not affect the incidence nor severity of post-ERCP pancreatitis when compared to PD stenting alone in patients with suspected SOD 3.
Su1540 Rates of Post-ERCP Pancreatitis in the Pediatric Population: a Single Center Experience Maia Kayal*, Sophia M. Jagroop, Woojin Kim, Amrita Sethi, Tamas a. Gonda, Frank G. Gress, Mercedes Martinez, John M. Poneros Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY Background and Objective: Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP) in the adult population. Our aim was to assess the prevalence and severity of post-ERCP pancreatitis in the pediatric population of a single institution. Materials and Methods: A retrospective review of all pediatric patients (21 years old and younger) undergoing ERCP at our institution in the inpatient and outpatient setting between 2000 and 2013 was conducted. Cases of post-ERCP pancreatitis were defined according to the 1991 consensus statement. Post-ERCP pancreatitis severity was determined according to established criteria: mild pancreatitis requiring unplanned admission or prolongation of planned admission 2-3 days, moderate pancreatitis requiring unplanned admission or prolongation of admission 4-10 days, and severe pancreatitis requiring hospitalization greater than 10 days, intervention, development of necrosis or pseudocyst. Patients with chronic pancreatitis were evaluated separately. Results: From 2000-2013, a total of 170 patients (mean age 14.4 years, range 10 months to 21 years) underwent 242 ERCP procedures. The most common ERCP indications included choledocholithiasis (33.5%), suspected biliary obstruction (22.7%), stent exchange (11.2%), pancreatitis (10.7%), biliary type abdominal pain (9.9%), primary sclerosing cholangitis (4.5%), and bile leak (2.5%). The most common ERCP findings included choledocholithiasis (34.2%), biliary stricture (11.2%), biliary sludge (7.02%), chronic pancreatitis, biliary papillary stenosis and pancreas divisum (each 3.7%), bile leak (2.5%) and choledochal cyst (2.5%). The post-ERCP pancreatitis rate for the 157 patients without chronic pancreatitis was 5.9% (13/220) and 18.2% (4/22) for the 13 patients with chronic pancreatitis. With regards to interventions, 8/17 (47.1%) post-ERCP pancreatitis cases involved biliary sphincterotomy, 8/17 (47.1%) pancreatic duct stent placement, 4/17 (23.5%) biliary stent placement, 4/17 (23.5%) pancreatic sphincterotomy, and 2/17 (11.8%) minor papilla sphincterotomy. In terms of the severity of post-ERCP pancreatitis, 6/17 were mild (35.3%), 10/17 were moderate (58.8%) and 1/17 (5.9%) was severe. Mean age, amylase level, lipase level, and hospitalization length for all patients with post-ERCP pancreatitis were 11.8 years, 931.1 U/L, 2291.2 U/L, and 5.5 days, respectively. Conclusion: The most common ERCP indication and finding in our single center pediatric population is choledocholithiasis. When performed by experienced endoscopists, the overall prevalence of post-ERCP pancreatitis in this single center study is 7.0%, and even less, 5.9%, when excluding patients with chronic pancreatitis.
Su1541 Interobserver Agreement Between Trainers and Trainees: Results From a Multicenter Study Evaluating Learning Curves and Competency in ERCP Sachin Wani*1,2, V. Raman Muthusamy5, Andrew Y. Wang4, Christopher J. Dimaio3, Brian C. Brauer1, Jeffrey J. Easler6, Roy D. Yen1, Ihab El Hajj1, Norio Fukami1, Kourosh F. Ghassemi5, Susana Gonzalez3, Lindsay Hosford1, Thomas G. Hollander6, Vladimir M. Kushnir6, Jawad Ahmad3, Faris Murad6, Anoop Prabhu3, Rabindra R. Watson5, Daniel S. Strand4, Stuart K. Amateau1, Raj J. Shah1, Steven a. Edmundowicz6, Daniel Mullady6 1 University of Colorado, Centennial, CO; 2Veterans Affairs Medical Center, Denver, CO; 3Mount Sinani, New York, NY; 4University of Virginia, Chalottesville, VA; 5David Geffen School of Medicine at UCLA, Los Angeles, CA; 6Washington University School of Medicine, St. Louis, MO Background: There are limited data regarding factors that define competency in performing ERCP. The ASGE recommends a minimum of 180 total procedures before competency can be achieved. These guidelines have not been validated, and studies on learning curves do not account for all skills essential to performance of ERCP. In the era of competency-based medical education, development of a standardized data collection tool to assess competency based on technical and cognitive skills is
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB207