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Su1631 Needle-knife Sphincterotomy vs. Guidewire-Assisted Transpancreatic Sphincterotomy for Difficult Biliary Cannulation
Abstracts
underwent ERCP between May 2010 and September 2014 at our institution (average age 50; 1321/559 female/male); data collected were demographics, procedure indication, biliary cannulation technique used, cannulation success rate, and complications. Guidewire-assisted (GA) cannulation with no contrast injection until deep biliary cannulation was considered a standard technique. Double wire-guided (DWG) cannulation, transpancreatic papillary septotomy (TPS), and needle knife sphincterotomy (NKS) were considered advanced cannulation techniques. With DWG, the bile duct is cannulated alongside a pancreatic duct (PD) wire, using PD wire as a guide for biliary cannulation. In TPS-assisted biliary cannulation, a partial septotomy is performed after sphinctertome is introduced into the common channel of the papilla, and GA cannulation then reattempted. We applied a stepwise approach: when GA cannulation failed, DWG cannulation was usually attempted first if PD wire was in place; if that failed, TPS or NKS was performed. Alternatively, TPS or NKS were performed alone. Prophylactic pancreatic stent was placed in case of repeated PD cannulation or PD contrast injection. Indomethacin suppositories were given to all patients with advanced cannulation techniques during the last two years of the review. Results: Overall biliary cannulation success rate was 98% (1837/1880). Advanced cannulation techniques were used in 12% of ERCPs (234/1880), with 88% (207/234) success rate. DWG technique alone was used in 99/234, TPS alone in 34/234, and NKS alone in 50/234; multiple techniques, in 51/234. Success rate was 95%(94/ 99) for DWG alone, 85% (29/34) for TPS alone, 78% (39/50) for NKS, and 88% (45/51) for cases with multiple techniques. Overall, the DWG technique was used in 137/234 procedures (99 alone, 38 in combination with other techniques). TPS was used as a rescue technique in 27/38 cases where DWG cannulation failed, and resulted in 96% (26/27) success rate. There was a trend towards increased use of TPS in the last two years reviewed. Of the 43 patients who failed advanced techniques on the first attempt, 34 were successfully cannulated with standard technique during repeat procedure. The overall rate of post-ERCP pancreatitis was 0.3% (7/1880), with all cases being mild and treated with supportive care; there was one microperforation. Conclusion: In our experience, the proposed stepwise approach to biliary cannulation using the double wire-guided technique followed, if necessary, by transpancreatic papillary septotomy or needle knife sphincterotomy is both safe and effective.
Su1631 Needle-knife Sphincterotomy vs. Guidewire-Assisted Transpancreatic Sphincterotomy for Difficult Biliary Cannulation Yoshiaki Kawaguchi*, Tetsuya Mine Tokai University School of Medicine, Isehara, Japan Aim: Needle-knife sphincterotomy (NKS) is a commonly used precut technique for difficult biliary cannulation. Guidewire-assisted transpancreatic sphincterotomy (GATS), as an alternative method for bile duct entry when conventional biliary cannulation failed, has been debated on its success rate of cannulation and its complications, such as increased incidence of pancreatitis. This study was aimed to compare success rate, and complications of NKS and GATS for difficult biliary cannulation. Methods: This was a retrospective study conducted between April 2006 and November 2014 in a single university hospital in Japan. We defined difficult cannulation as biliary cannulation failure by conventional, wire-guided and pancreatic guidewire technique. A total of 32 difficult cannulation patients, were divided into NKS (n Z 10) and GATS (n Z 22) groups. NKS or GATS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation and procedure related complications. Results: Both groups were comparable in baseline characteristics. Successful cannulation rate in NKS and GATS groups were 90.0% vs. 90.9%, P Z 0.732, respectively. There was no significant difference between both groups. The overall incidence of post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis was 20.0% vs. 13.6%, PZ 0.0211 in NKS and GATS group; post-procedure pancreatitis was significantly higher in NKS group. The overall incidence of post-ERCP hyperamylasemia was no significant difference between both groups; NKS vs. GATS group: 40.0% vs. 36.4%, PZ0.235. Pancreatic stent was inserted to prevent post-ERCP pancreatitis 60.0% vs. 100%, PZ 0.0142 in NKS and GATS group. Conclusion: In difficult cannulation cases, NKS and GATS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis was significantly higher in NKS group. Pancreatic stent insertion may be needed to prevent post-ERCP pancreatitis in NKS.
Su1632 Factors Involved in Post-ERCP Pancreatitis in a Terciary Level Hospital Maria J. Garcia Garcia, Susana Llerena Santiago, Carmen Alonso Martín, Maria Teresa Arias-Loste, Luis Martín Ramos, Alvaro Teran, Joaquin De La Peña* Gastroenterology, Marqués De Valdecilla Hospital, Santander, Spain Acute pancreatitis (AP) is the most frequent complication after an endoscopic retrograde cholangio-pancreatography (ERCP). Different factors are involved in the risk of developing a post-ERCP pancreatitis (PEP). Two interventions, namely nonsteroidal anti-inflammatory drugs (NSAIDs) and pancreatic stents, have demonstrated to reduce its incidence. Aim of the Study: Evaluate demographical, pharmacological and technical factors involved in the incidence of PEP at our institution. Methods: We designed a retrospective cohorts study analyzing all consecutive ERCPs performed between
www.giejournal.org
December of 2011 and November of 2013. We took two 12-months periods, before and after starting our protocol with rectal indomethacin 100 mg immediately before every ERCP, excluding medical contraindications. Patients with previous biliary sphincterotomy and pancreatic therapeutic procedures were also excluded. Results: 514 ERCPs were performed, of which 358 (69.6%) fulfilled the inclusion criteria. PEP global incidence was 5.6% (nZ20). There was no statistically significant difference in PEP incidence for any recorded variable (Table 1). PEP incidence seemed to be influenced by personal history of previous AP, pancreatic duct cannulation and/or contrast injection, and use of pancreatic stents. However our results didn’t reached statistical signification probably due to a small sample size. Conclusion: Prophylactic pancreatic stents following pancreatic duct cannulation show a protector effect against PEP, particularly after contrast injection.In our study, universal use of rectal indomethacin has not demonstrated to reduce PEP incidence and its use may be restricted to high risk patients or situations.Randomized control trials comparing these two methods, pancreatic stents and NSAIDs, are needed.
FACTOR PRESENT PEP % (n/N)
FACTOR ABSENT PEP % (n/N)
Age ! 50 years
11.1% (3/27)
5.1% (17/331)
Female
7.2% (12/166)
4.2% (8/192)
15% (3/20)
5% (17/338)
Indomethacin
5.8% (9/155)
5.4% (11/203)
Bilirrubin !3 mg/dL
5.9 (12/205)
3.2 (4/125)
Biliary sphincterotomy
6% (17/285)
4.1% (3/73)
Biliary sphincteroplasty with balloon.
9.5% (2/21)
5.3% (18/337)
Pre-cut sphincterotomy
4.3% (4/94)
6.1% (16/264)
Pancreatic duct cannulation
7.8% (9/116)
4.5% (11/242)
Pancreatic stent after pancreatic cannulation Pancreatic duct contrast injection
5.3% (4/75)
12.2% (5/41)
9.0% (7/78)
4.6% (13/280)
7.7% (4/52)
13.6% (3/22)
Previous AP
Pancreatic stent after contrast injection
OR (IC: 95%) 2.163 (0.6766.922) 1.735 (7.274.142) 2.982 (0.9529.339) 1.059 (0.4502.493) OR: 1.881 (0.59-5.96) 1.451 (0.4374.820) 1.783 (0.4437.179) 0.702 (0.2412.047) 1.707 (0.7284.004) 0.437 (0.1241.539) 1.933 (0.7994.678) 0.564 (0.1382.314)
p 0.184
0.251
0.092
1
0.429 0.776
0.331
0.610
0.226
0.276
0.163
0.418
Su1633 Holmium LASER Lithotripsy Versus Electrohydraulic Lithotripsy in Patients With Difficult Bile Duct Stones Ji Wan Kim*, Tae Yoon Lee, Hyun A. H. Chung, Young Koog Cheon, Chan Sup Shim Departments of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea (the Republic of) Background: Although large biliary stones often require electrohydraulic lithotripsy (EHL), or holmium laser lithotripsy (LL), there have been few studies comparing two methods. The purpose of this study was to compare the efficacy and safety of LL and EHL with choledochoscopic guidance. Methods: Between 2009 and 2014, we enrolled 64 patients with bile duct stones who underwent LL or EHL. All patients included had failed endoscopic retrograde cholangiopancreatography (ERCP) and performed percutaneous transhepatic choledochoscopy (PTCS); large stone (nZ6), impacted stone (nZ1), inaccessible main duodenal papilla (nZ23), intrahepatic duct (IHD) stone (nZ32), and poor general condition (nZ2). Stone was located in extrahepatic (nZ29) and IHD (nZ35). Furthermore, 19 people (29.7%) had single stone, 45 (70.3%) had multiple stones. Main outcome measures included complete
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB359
underwent ERCP between May 2010 and September 2014 at our institution (average age 50; 1321/559 female/male); data collected were demographics, procedure indication, biliary cannulation technique used, cannulation success rate, and complications. Guidewire-assisted (GA) cannulation with no contrast injection until deep biliary cannulation was considered a standard technique. Double wire-guided (DWG) cannulation, transpancreatic papillary septotomy (TPS), and needle knife sphincterotomy (NKS) were considered advanced cannulation techniques. With DWG, the bile duct is cannulated alongside a pancreatic duct (PD) wire, using PD wire as a guide for biliary cannulation. In TPS-assisted biliary cannulation, a partial septotomy is performed after sphinctertome is introduced into the common channel of the papilla, and GA cannulation then reattempted. We applied a stepwise approach: when GA cannulation failed, DWG cannulation was usually attempted first if PD wire was in place; if that failed, TPS or NKS was performed. Alternatively, TPS or NKS were performed alone. Prophylactic pancreatic stent was placed in case of repeated PD cannulation or PD contrast injection. Indomethacin suppositories were given to all patients with advanced cannulation techniques during the last two years of the review. Results: Overall biliary cannulation success rate was 98% (1837/1880). Advanced cannulation techniques were used in 12% of ERCPs (234/1880), with 88% (207/234) success rate. DWG technique alone was used in 99/234, TPS alone in 34/234, and NKS alone in 50/234; multiple techniques, in 51/234. Success rate was 95%(94/ 99) for DWG alone, 85% (29/34) for TPS alone, 78% (39/50) for NKS, and 88% (45/51) for cases with multiple techniques. Overall, the DWG technique was used in 137/234 procedures (99 alone, 38 in combination with other techniques). TPS was used as a rescue technique in 27/38 cases where DWG cannulation failed, and resulted in 96% (26/27) success rate. There was a trend towards increased use of TPS in the last two years reviewed. Of the 43 patients who failed advanced techniques on the first attempt, 34 were successfully cannulated with standard technique during repeat procedure. The overall rate of post-ERCP pancreatitis was 0.3% (7/1880), with all cases being mild and treated with supportive care; there was one microperforation. Conclusion: In our experience, the proposed stepwise approach to biliary cannulation using the double wire-guided technique followed, if necessary, by transpancreatic papillary septotomy or needle knife sphincterotomy is both safe and effective.
Su1631 Needle-knife Sphincterotomy vs. Guidewire-Assisted Transpancreatic Sphincterotomy for Difficult Biliary Cannulation Yoshiaki Kawaguchi*, Tetsuya Mine Tokai University School of Medicine, Isehara, Japan Aim: Needle-knife sphincterotomy (NKS) is a commonly used precut technique for difficult biliary cannulation. Guidewire-assisted transpancreatic sphincterotomy (GATS), as an alternative method for bile duct entry when conventional biliary cannulation failed, has been debated on its success rate of cannulation and its complications, such as increased incidence of pancreatitis. This study was aimed to compare success rate, and complications of NKS and GATS for difficult biliary cannulation. Methods: This was a retrospective study conducted between April 2006 and November 2014 in a single university hospital in Japan. We defined difficult cannulation as biliary cannulation failure by conventional, wire-guided and pancreatic guidewire technique. A total of 32 difficult cannulation patients, were divided into NKS (n Z 10) and GATS (n Z 22) groups. NKS or GATS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation and procedure related complications. Results: Both groups were comparable in baseline characteristics. Successful cannulation rate in NKS and GATS groups were 90.0% vs. 90.9%, P Z 0.732, respectively. There was no significant difference between both groups. The overall incidence of post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis was 20.0% vs. 13.6%, PZ 0.0211 in NKS and GATS group; post-procedure pancreatitis was significantly higher in NKS group. The overall incidence of post-ERCP hyperamylasemia was no significant difference between both groups; NKS vs. GATS group: 40.0% vs. 36.4%, PZ0.235. Pancreatic stent was inserted to prevent post-ERCP pancreatitis 60.0% vs. 100%, PZ 0.0142 in NKS and GATS group. Conclusion: In difficult cannulation cases, NKS and GATS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis was significantly higher in NKS group. Pancreatic stent insertion may be needed to prevent post-ERCP pancreatitis in NKS.
Su1632 Factors Involved in Post-ERCP Pancreatitis in a Terciary Level Hospital Maria J. Garcia Garcia, Susana Llerena Santiago, Carmen Alonso Martín, Maria Teresa Arias-Loste, Luis Martín Ramos, Alvaro Teran, Joaquin De La Peña* Gastroenterology, Marqués De Valdecilla Hospital, Santander, Spain Acute pancreatitis (AP) is the most frequent complication after an endoscopic retrograde cholangio-pancreatography (ERCP). Different factors are involved in the risk of developing a post-ERCP pancreatitis (PEP). Two interventions, namely nonsteroidal anti-inflammatory drugs (NSAIDs) and pancreatic stents, have demonstrated to reduce its incidence. Aim of the Study: Evaluate demographical, pharmacological and technical factors involved in the incidence of PEP at our institution. Methods: We designed a retrospective cohorts study analyzing all consecutive ERCPs performed between
www.giejournal.org
December of 2011 and November of 2013. We took two 12-months periods, before and after starting our protocol with rectal indomethacin 100 mg immediately before every ERCP, excluding medical contraindications. Patients with previous biliary sphincterotomy and pancreatic therapeutic procedures were also excluded. Results: 514 ERCPs were performed, of which 358 (69.6%) fulfilled the inclusion criteria. PEP global incidence was 5.6% (nZ20). There was no statistically significant difference in PEP incidence for any recorded variable (Table 1). PEP incidence seemed to be influenced by personal history of previous AP, pancreatic duct cannulation and/or contrast injection, and use of pancreatic stents. However our results didn’t reached statistical signification probably due to a small sample size. Conclusion: Prophylactic pancreatic stents following pancreatic duct cannulation show a protector effect against PEP, particularly after contrast injection.In our study, universal use of rectal indomethacin has not demonstrated to reduce PEP incidence and its use may be restricted to high risk patients or situations.Randomized control trials comparing these two methods, pancreatic stents and NSAIDs, are needed.
FACTOR PRESENT PEP % (n/N)
FACTOR ABSENT PEP % (n/N)
Age ! 50 years
11.1% (3/27)
5.1% (17/331)
Female
7.2% (12/166)
4.2% (8/192)
15% (3/20)
5% (17/338)
Indomethacin
5.8% (9/155)
5.4% (11/203)
Bilirrubin !3 mg/dL
5.9 (12/205)
3.2 (4/125)
Biliary sphincterotomy
6% (17/285)
4.1% (3/73)
Biliary sphincteroplasty with balloon.
9.5% (2/21)
5.3% (18/337)
Pre-cut sphincterotomy
4.3% (4/94)
6.1% (16/264)
Pancreatic duct cannulation
7.8% (9/116)
4.5% (11/242)
Pancreatic stent after pancreatic cannulation Pancreatic duct contrast injection
5.3% (4/75)
12.2% (5/41)
9.0% (7/78)
4.6% (13/280)
7.7% (4/52)
13.6% (3/22)
Previous AP
Pancreatic stent after contrast injection
OR (IC: 95%) 2.163 (0.6766.922) 1.735 (7.274.142) 2.982 (0.9529.339) 1.059 (0.4502.493) OR: 1.881 (0.59-5.96) 1.451 (0.4374.820) 1.783 (0.4437.179) 0.702 (0.2412.047) 1.707 (0.7284.004) 0.437 (0.1241.539) 1.933 (0.7994.678) 0.564 (0.1382.314)
p 0.184
0.251
0.092
1
0.429 0.776
0.331
0.610
0.226
0.276
0.163
0.418
Su1633 Holmium LASER Lithotripsy Versus Electrohydraulic Lithotripsy in Patients With Difficult Bile Duct Stones Ji Wan Kim*, Tae Yoon Lee, Hyun A. H. Chung, Young Koog Cheon, Chan Sup Shim Departments of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea (the Republic of) Background: Although large biliary stones often require electrohydraulic lithotripsy (EHL), or holmium laser lithotripsy (LL), there have been few studies comparing two methods. The purpose of this study was to compare the efficacy and safety of LL and EHL with choledochoscopic guidance. Methods: Between 2009 and 2014, we enrolled 64 patients with bile duct stones who underwent LL or EHL. All patients included had failed endoscopic retrograde cholangiopancreatography (ERCP) and performed percutaneous transhepatic choledochoscopy (PTCS); large stone (nZ6), impacted stone (nZ1), inaccessible main duodenal papilla (nZ23), intrahepatic duct (IHD) stone (nZ32), and poor general condition (nZ2). Stone was located in extrahepatic (nZ29) and IHD (nZ35). Furthermore, 19 people (29.7%) had single stone, 45 (70.3%) had multiple stones. Main outcome measures included complete
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB359