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Su1596 A Suggested Method for Preventing Post Palliative SEMS Cholecystitis in Selective Patients With Courvoisier's Gallbladder, a Preliminary Study
Abstracts
Su1596 A Suggested Method for Preventing Post Palliative SEMS Cholecystitis in Selective Patients With Courvoisier’s Gallbladder, a Preliminary Study Tariq A. Hammad*, Yaseen Alastal, Muhammad Ali Khan, Usman Ahmad, Muhammad Z. Bawany, Osama Alaradi, Ali Nawras Internal Medicine - Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH Background: Cholecystitis is a potential complication for self-expandable Metallic stents (SEMS) that occurs in about 2-12% of patients. Objective: This study suggests a method to minimize the risk of post palliative SEMS cholecystitis in very high risk group of patients. This method has been adapted at our institution after having few incidences on post SEMS cholecystitis requiring interventional treatment.Design: Single arm study and single center design.Setting: University tertiary medical center. Patients: Five consecutive patients with obstructive jaundice and Courvoisier’s gallbladder (GB) secondary to suspected malignant pancreatic-biliary tumor.Intervention: Endoscopic ultrasound guided decompression of the Courvoisier GB by fine needle aspiration. Patients underwent a single session of EUS-FNA for diagnosis and staging of the tumors, and ERCP for possible palliative SEMS. Once the patients were assigned to palliative SEMS based on the clinical, radiographic and cytopathologic findings (table 1); the need for GB decompression was carefully assessed based on several factors (Diagram). Patients with Courvoisier GB whom CD’s were not visualized during the ERCP underwent this procedure. Results: All patients had the procedure without complications. None of the patients developed any clinical symptoms or signs of post SEMS cholecystitis. Conclusion: Endosonographic guided Courvoisier GB decompression post simultaneous palliative SEMS placement and diagnostic EUS -FNA is a suggestive method for preventing cholecystitis. Larger studies are required to validate these results.
Patients’ Characteristics. Case
1
2
3
4
5
Age (year) Gender Cancer type
80 Male Ductal PAC
75 Female Ductal PAC
60 Male Ductal PAC
68 Female Ductal PAC
Un-resectability features
Locally advanced Mid - Distal CBD 10 x 60 Distended
Liver metastasis
Metastasis form lung 3 cm Mid Distal CBD 10 x 80 109 x 54.9
59 Male NSCLC to pancreas Metastasis form lung 2 cm Mid Distal CBD 10 x 80 94.1x 42.0
Site of stricture Length of stent (mm) Gallbladder size per EUS (mm) Amount of aspirated GB bile (ml) Cystic duct per ERCP
2 cm Mid Distal CBD 10 x 80 70.1 x 69.0
SMA invasion 2 cm Mid Distal CBD 10 x 80 Distended
75
250
150
100
130
Not visualized
Not visualized
Not visualized
Not visualized
Not visualized
PAC pancreatic adenocarcinoma, SCP sarcomatoid carcinoma of pancreas, NSCLC non-small cell lung cancer, SMA superior mesenteric artery, CBD common bile duct, EUS endoscopic ultrasound, GB gallbladder, ERCP endoscopic retrograde cholangiopancreatography.
Diagram -1. Algorithm showing when decompression of Courvoisier’s Gallbladder is required with Palliative metallic biliary stenting.
www.giejournal.org
Su1597 Predictive Factors for Percutaneous Drainage Placement in Patients Developing Bilomas From Bile Leaks Mari A. Rivera*1, Brian Rajca1, Christopher E. Forsmark1, Peter V. Draganov1, Mihir S. Wagh1, Anand Gupte1, Myron N. Chang2, Yunfeng Dai2, Shailendra Chauhan1 1 Department of Internal Medicine, Division of Gastroenterology, University of Florida, Gainesville, FL; 2Department of Biostatistics, University of Florida, Gainesville, FL Background: Patients who develop a bile leak from iatrogenic or traumatic injury can develop bilomas. Whereas endoscopic management of bile leaks is well described, the management of bilomas has not been well studied. Aim: To identify factors that predict the need for placement of a percutaneous drainage, in addition to endoscopic management of bile leaks, in patients who develop bilomas. Method: This was a single center study in which all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for an indication of bile leak between 2005 and 2013 were identified. Records were reviewed for demographic data, laboratory values, symptoms, timing of first ERCP, ERCP findings, endoscopic treatment, time to diagnosis of bile leak, and presence and management of biloma. Results: 107 pts (56 M, 51 F, 14-82 yrs, mean 53 yrs) with bile leaks were identified of which 62 (58%) developed a biloma. Of these, 37 (60%) had cholecystectomy (24 open, 17 lap), 13 (21%) had partial hepatectomy, 8 (13%) had traumatic injury, 7 (11%) had liver transplant, and 6 (10%) had exploratory laparotomy as the source of injury. The majority of bilomas were located in the peri-hepatic area (34%) and gallbladder fossa (32%). Percutaneous drains for biloma management were placed in 46/62 (74%) pts. Majority of these patients complained of abdominal pain upon presentation (28/46, 61%). Other symptoms included fever (11/46, 24%) and jaundice (6/46, 13%), and 8/46 (17%) were asymptomatic. In contrast, patients who did not require percutaneous drainage presented with abdominal pain (8/16, 50%), jaundice (4/16, 25%), fever (3/16, 19%), and 4/16 were asymptomatic (25%). When the covariates of age, gender, laboratory values (white count, total bilirubin, alkaline phosphatase), time to identification of leak, and time to first ERCP were individually analyzed for association with the status of percutaneous drain placement, only time to first ERCP (mean 21.9 +/- 18.7 days in pts with percutaneous drain vs 10.6 +/- 9.2 days in pts without percutaneous drain) and time to identification of leak (mean 12.6 +/- 13.4 days vs 6.4 +/- 5.7 days) were significantly associated with percutaneous drain placement (pZ0.0001 and pZ0.018 respectively). Endoscopic treatment of bile leaks was successful in 94% of patients in whom complete data was available (86/107). Conclusion: In our series, 58% of patients with bile leaks developed a biloma. 74% of these pts required percutaneous drainage. Patient demographics, symptoms, and laboratory values were similar between the groups that did and did not receive percutaneous drainage. Longer time to identification of bile leak and longer time to first ERCP were significantly associated with the need for percutaneous drain placement. Therefore, earlier detection and treatment of bile leaks could decrease the need for percutaneous drainage.
Su1598 Endoscopic or Combined Endoscopic/Percutaneous Management of Patients With Complex Bile Duct Injuries and Biliary Exclusion Simon Bouchard*1,2, Damien Tan2, Tarun Gupta2, Pierre Eisendrath2, Vincent Huberty2, Arnaud Lemmers2, Olivier Le Moine2, Jacques Deviere2 1 Gastroenterology, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada; 2Gastroenterology, Hepatopancreatology and Digestive Oncology, ULB Erasme Hospital, Brussels, Belgium Background and Aim: The most severe bile duct injuries, also known as complex bile duct injuries (BDI), are associated with significant morbidity and mortality. Although reconstructive biliary surgery is considered standard treatment for complex BDI, recent studies have suggested that an endoscopic or combined endoscopic/percutaneous approach might be an alternative to a surgical approach in selected patients. We report our experience with a variety of endoscopic or combined endoscopic/ percutaneous techniques to re-establish biliary drainage in patients with complex BDI and biliary exclusion. Methods: We performed a retrospective study of patients with complex BDI (complete biliary transections or complete biliary strictures) treated in our endoscopy unit between July 1998 and November 2013. The diagnosis was confirmed by reviewing radiologic or endoscopic images. Baseline characteristics, laboratory tests results, radiologic findings, procedural and follow-up data were collected by reviewing patient’s records, our endoscopic database and radiologic database. Results: We identified 12 symptomatic patients with complex BDI and biliary exclusion who were treated by various methods to repermeabilise the excluded bile ducts. Successful drainage of the excluded biliary ducts with resolution of symptoms was possible in all patients, either through recreation of bilio-biliary continuity (9 patients) or by creating a bilio-enteric drainage tract (3 patients). In 5 patients, biliary repermeabilisation was performed using a TIPSS-200 set. Mean duration of the biliary repermeabilisaiton procedure was 108 min (range 70-180). No immediate severe complication occured. Complete internalization of biliary drainage was possible in all 12 patients. An average of 4.6 additionnal ERCP procedures per patient were performed after the initial repermeabilisation procedure and an average of 7.8 biliary stents were placed per patients (range 1-18). Mean duration of follow-up was 52.2 months (range 5-159). During the follow-up period, six patients developed a biliary stricture at the level of the initial BDI,
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB345
Su1596 A Suggested Method for Preventing Post Palliative SEMS Cholecystitis in Selective Patients With Courvoisier’s Gallbladder, a Preliminary Study Tariq A. Hammad*, Yaseen Alastal, Muhammad Ali Khan, Usman Ahmad, Muhammad Z. Bawany, Osama Alaradi, Ali Nawras Internal Medicine - Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH Background: Cholecystitis is a potential complication for self-expandable Metallic stents (SEMS) that occurs in about 2-12% of patients. Objective: This study suggests a method to minimize the risk of post palliative SEMS cholecystitis in very high risk group of patients. This method has been adapted at our institution after having few incidences on post SEMS cholecystitis requiring interventional treatment.Design: Single arm study and single center design.Setting: University tertiary medical center. Patients: Five consecutive patients with obstructive jaundice and Courvoisier’s gallbladder (GB) secondary to suspected malignant pancreatic-biliary tumor.Intervention: Endoscopic ultrasound guided decompression of the Courvoisier GB by fine needle aspiration. Patients underwent a single session of EUS-FNA for diagnosis and staging of the tumors, and ERCP for possible palliative SEMS. Once the patients were assigned to palliative SEMS based on the clinical, radiographic and cytopathologic findings (table 1); the need for GB decompression was carefully assessed based on several factors (Diagram). Patients with Courvoisier GB whom CD’s were not visualized during the ERCP underwent this procedure. Results: All patients had the procedure without complications. None of the patients developed any clinical symptoms or signs of post SEMS cholecystitis. Conclusion: Endosonographic guided Courvoisier GB decompression post simultaneous palliative SEMS placement and diagnostic EUS -FNA is a suggestive method for preventing cholecystitis. Larger studies are required to validate these results.
Patients’ Characteristics. Case
1
2
3
4
5
Age (year) Gender Cancer type
80 Male Ductal PAC
75 Female Ductal PAC
60 Male Ductal PAC
68 Female Ductal PAC
Un-resectability features
Locally advanced Mid - Distal CBD 10 x 60 Distended
Liver metastasis
Metastasis form lung 3 cm Mid Distal CBD 10 x 80 109 x 54.9
59 Male NSCLC to pancreas Metastasis form lung 2 cm Mid Distal CBD 10 x 80 94.1x 42.0
Site of stricture Length of stent (mm) Gallbladder size per EUS (mm) Amount of aspirated GB bile (ml) Cystic duct per ERCP
2 cm Mid Distal CBD 10 x 80 70.1 x 69.0
SMA invasion 2 cm Mid Distal CBD 10 x 80 Distended
75
250
150
100
130
Not visualized
Not visualized
Not visualized
Not visualized
Not visualized
PAC pancreatic adenocarcinoma, SCP sarcomatoid carcinoma of pancreas, NSCLC non-small cell lung cancer, SMA superior mesenteric artery, CBD common bile duct, EUS endoscopic ultrasound, GB gallbladder, ERCP endoscopic retrograde cholangiopancreatography.
Diagram -1. Algorithm showing when decompression of Courvoisier’s Gallbladder is required with Palliative metallic biliary stenting.
www.giejournal.org
Su1597 Predictive Factors for Percutaneous Drainage Placement in Patients Developing Bilomas From Bile Leaks Mari A. Rivera*1, Brian Rajca1, Christopher E. Forsmark1, Peter V. Draganov1, Mihir S. Wagh1, Anand Gupte1, Myron N. Chang2, Yunfeng Dai2, Shailendra Chauhan1 1 Department of Internal Medicine, Division of Gastroenterology, University of Florida, Gainesville, FL; 2Department of Biostatistics, University of Florida, Gainesville, FL Background: Patients who develop a bile leak from iatrogenic or traumatic injury can develop bilomas. Whereas endoscopic management of bile leaks is well described, the management of bilomas has not been well studied. Aim: To identify factors that predict the need for placement of a percutaneous drainage, in addition to endoscopic management of bile leaks, in patients who develop bilomas. Method: This was a single center study in which all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for an indication of bile leak between 2005 and 2013 were identified. Records were reviewed for demographic data, laboratory values, symptoms, timing of first ERCP, ERCP findings, endoscopic treatment, time to diagnosis of bile leak, and presence and management of biloma. Results: 107 pts (56 M, 51 F, 14-82 yrs, mean 53 yrs) with bile leaks were identified of which 62 (58%) developed a biloma. Of these, 37 (60%) had cholecystectomy (24 open, 17 lap), 13 (21%) had partial hepatectomy, 8 (13%) had traumatic injury, 7 (11%) had liver transplant, and 6 (10%) had exploratory laparotomy as the source of injury. The majority of bilomas were located in the peri-hepatic area (34%) and gallbladder fossa (32%). Percutaneous drains for biloma management were placed in 46/62 (74%) pts. Majority of these patients complained of abdominal pain upon presentation (28/46, 61%). Other symptoms included fever (11/46, 24%) and jaundice (6/46, 13%), and 8/46 (17%) were asymptomatic. In contrast, patients who did not require percutaneous drainage presented with abdominal pain (8/16, 50%), jaundice (4/16, 25%), fever (3/16, 19%), and 4/16 were asymptomatic (25%). When the covariates of age, gender, laboratory values (white count, total bilirubin, alkaline phosphatase), time to identification of leak, and time to first ERCP were individually analyzed for association with the status of percutaneous drain placement, only time to first ERCP (mean 21.9 +/- 18.7 days in pts with percutaneous drain vs 10.6 +/- 9.2 days in pts without percutaneous drain) and time to identification of leak (mean 12.6 +/- 13.4 days vs 6.4 +/- 5.7 days) were significantly associated with percutaneous drain placement (pZ0.0001 and pZ0.018 respectively). Endoscopic treatment of bile leaks was successful in 94% of patients in whom complete data was available (86/107). Conclusion: In our series, 58% of patients with bile leaks developed a biloma. 74% of these pts required percutaneous drainage. Patient demographics, symptoms, and laboratory values were similar between the groups that did and did not receive percutaneous drainage. Longer time to identification of bile leak and longer time to first ERCP were significantly associated with the need for percutaneous drain placement. Therefore, earlier detection and treatment of bile leaks could decrease the need for percutaneous drainage.
Su1598 Endoscopic or Combined Endoscopic/Percutaneous Management of Patients With Complex Bile Duct Injuries and Biliary Exclusion Simon Bouchard*1,2, Damien Tan2, Tarun Gupta2, Pierre Eisendrath2, Vincent Huberty2, Arnaud Lemmers2, Olivier Le Moine2, Jacques Deviere2 1 Gastroenterology, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada; 2Gastroenterology, Hepatopancreatology and Digestive Oncology, ULB Erasme Hospital, Brussels, Belgium Background and Aim: The most severe bile duct injuries, also known as complex bile duct injuries (BDI), are associated with significant morbidity and mortality. Although reconstructive biliary surgery is considered standard treatment for complex BDI, recent studies have suggested that an endoscopic or combined endoscopic/percutaneous approach might be an alternative to a surgical approach in selected patients. We report our experience with a variety of endoscopic or combined endoscopic/ percutaneous techniques to re-establish biliary drainage in patients with complex BDI and biliary exclusion. Methods: We performed a retrospective study of patients with complex BDI (complete biliary transections or complete biliary strictures) treated in our endoscopy unit between July 1998 and November 2013. The diagnosis was confirmed by reviewing radiologic or endoscopic images. Baseline characteristics, laboratory tests results, radiologic findings, procedural and follow-up data were collected by reviewing patient’s records, our endoscopic database and radiologic database. Results: We identified 12 symptomatic patients with complex BDI and biliary exclusion who were treated by various methods to repermeabilise the excluded bile ducts. Successful drainage of the excluded biliary ducts with resolution of symptoms was possible in all patients, either through recreation of bilio-biliary continuity (9 patients) or by creating a bilio-enteric drainage tract (3 patients). In 5 patients, biliary repermeabilisation was performed using a TIPSS-200 set. Mean duration of the biliary repermeabilisaiton procedure was 108 min (range 70-180). No immediate severe complication occured. Complete internalization of biliary drainage was possible in all 12 patients. An average of 4.6 additionnal ERCP procedures per patient were performed after the initial repermeabilisation procedure and an average of 7.8 biliary stents were placed per patients (range 1-18). Mean duration of follow-up was 52.2 months (range 5-159). During the follow-up period, six patients developed a biliary stricture at the level of the initial BDI,
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB345