- Email: [email protected]
Su1660 Endoscopic Treatment of Non-Stricture Related Benign Biliary Diseases Using Covered Self-Expandable Metal Stents (CSEMS)
Abstracts
Su1657 Endoscopic Parameters and Clinical Factors Impacting the Success of ERCP in Resolution of Biliary Anastomotic Strictures in Patients After Liver Transplantation Salvatore Francesco Vadala’ Di Prampero*1, Giacomo Faleschini1, Milutin M. Bulajic1,2, Loris Mario Zoratti1, Maurizio Zilli1 1 Gastroenterology and GI Endoscopy, University Hospital of Udine, Udine, Italy; 2Center for Digestive Endoscopy, Faculty of Medicine, Belgrade University, Belgrade, Serbia Introduction and aims: The most frequent biliary complication following liver transplantation (LT) is biliary anastomotic stricture (BAS). To define possible impacting factors of BAS appearance and resolution we analyzed different epidemiological, clinical and endoscopic features in patients undergoing ERCP. Material and methods: We evaluated 171 consecutive liver transplanted recipients recruited in our Centre from 2004 to 2010 (133 males, median age 56 years), with at least one year of follow-up. All patients with clinical or radiologic suspicion of obstructive jaundice and cholestasis underwent ERCP. The concept of ERCP was based on biliary sphyncterotomy followed by stricture dilation and placement of at least one plastic stent, exchangeable every 3-6 months until the final stricture resolution. There have been examined clinical and endoscopic risk factors predicting the success or failure of endoscopic treatment (ERCP). Results: During post-operative follow-up 40 patients presented BAS. The median number of ERCP per patient was 3, median number of stents inserted per patient per procedure was 1 and median period until stricture resolution was 9 months. Stricture resolution was obtained in 83%. Occurrence of BAS was strongly associated with use of Kehr T tube (12/23 Vs 28/148, p!0.01) and with use of cyclosporine as immunosuppressive therapy (18/54 Vs 22/ 117, p!0.05). Independent predictors of BAS development at logistic regression analysis were use of Kehr T tube (O. R. 5.46, p!0.01) and donor male gender (O. R. 2.61, p!0.01). The univariate logistic analysis showed that elevated number of repeated ERCP (OR 0,659; 95% CI 0,522-0,832; pZ0,000), combined stenting with dilation (OR 0,197; 95% CI 0,074-0,525; pZ0,001), increasing number of inserted stents per procedure (OR 0,896; 95% CI 0,782-1,026; pZ0,112) and longer period of warm ischemia (OR 0,966; 95% CI 0,938-0,995; pZ0,023) were associated with successful endoscopic treatment. On the contrary, longer period of stent in place (OR 1,034; 95% CI 1,005-1,064; pZ0,021), elevated MELD score (OR 1,104; 95% CI 1,035-1,178; pZ0,003), elevated Child-Pugh score (OR 1,679; 95% CI 1,089-2,591; pZ0,019) and high pre-transplantation bilirubin values (OR 1,104; 95% CI 1,0071,210; pZ0,035) were associated with endoscopic treatment failure. Conclusions: Endoscopic treatment of BAS requires detailed clinical assessment and skilled equipe. Understanding clinical and endoscopic risk factors may help in predicting of more appropriate regimen of treatment of patients undergoing ERCP for BAS post-LT.
Su1658 Complex Biliary Leak Post-Hepatectomy: Is Endoscopic Treatment Effective? Marco Alburquerque*1,2, Montserrat Figa1,3, Joan Figueras1,3, Santiago LóPez Ben3, Marcela Perez Contreras3, Ferran GonzáLez-Huix1 1 Gastroenterology, Clínica Girona, Girona, Spain; 2Gastroenterology, Hospital de Palamós, Palamós, Spain; 3Gastroenterology, Hospital Universitario Dr. Josep Trueta, Girona, Spain Introduction: The ERCP (papillotomy and/or stent) has become the elective treatment for post-cholecystectomy biliary leak (PCBL). Nowadays is unknown if this treatment is equally effective for post-hepatectomy biliary leak (PHBL). Aims: To compare the efficacy between endoscopic treatment for PHBL and PCBL. Methods: From January 2002 to October 2012 were recorded in a prospective database all patients with post-surgical biliary leak (PSBL) that underwent to ERCP. The database included demographic data: age and sex; type of surgery and indication; PSBL features: localization, debit and associated findings (strictures, biloma/abscess, lithiasis, etc); endoscopic treatment; papillotomy and/or stent, diagnostic success, technical success, efficacy and safety. We defined as Diagnostic success: localization of PSBL by ERCP and as Technical success: Endoscopic drainage of PSBL. The sealing of PSBL was confirmed by ERCP and/or clinical evaluation. The data were analyzed using the SPSS 15.0 software. Results: Between 3785 ERCPs (2002 - 2012) there were 67 patients with PSBL (1,7%): 51 PCBL (67%) and 16 PHBL (33%). Age: 64,79 15,07 years. Women: 20 (29,9%). In PCBL the surgical indication was cholelithiasis (100%), while in PHBL were liver metastases: 12 (75%), hepatic hydatid disease: 2 (12,5%), traumatism: 1 (6,25%) and gallbladder cancer:1 (6,25%). Cystic duct stump and common bile duct/common hepatic duct were the most frequents localization of PCBL: 58,82 vs. 0,00% (pZ0,000) and 25,49 vs. 18,75% (pZ0,000), respectively. In PHBL, primary and secondary intrahepatic bile ducts were the most frequents: 31,25 vs. 5,88% (pZ0,000) and 37,5 vs. 5,88% (pZ0,000), respectively. For PCBL, diagnostic success was higher than PHBL: 96,08 vs. 87,5% (pZ0,000). There was not difference in PSBL debits. Strictures (57,14 vs. 22%, pZ0,000) and biloma/abscess (87,5 vs. 26%, pZ0,000) were more associated to PHBL than lithiasis (7,14 vs. 48%, pZ0,000). In regard to endoscopic treatment, there was not difference between both groups: papillotomy and stent was the most frequent procedure and technical success was above 93%. The endoscopic treatment efficacy for PHBL was much
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lower than for PCBL (25 vs. 84,31%, pZ0,000). The complication rate was similar between both groups. Conclusions: The endoscopic treatment efficacy (papillotomy and/or stent) for post-hepatectomy biliary leak is much lower than for post-cholecystectomy biliary leak. This is related to their greater complexity: frequently intrahepatic and associated to strictures and biloma/abscess.
Su1659 The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Hepatic Hydatid Disease: a Single Center Experience Sait Bagci*, Cemal Nuri Ercin, ZüLfikar Polat, Mustafa Gulsen, Ahmet Uygun, Ahmet Tuzun, Hakan Demirci, Ahmet Alper Gastroenterology, Gulhane Military Medical Academy, Ankara, Turkey Background: Hydatid disease is a parasitic infection caused by Echinococcus granulosus. The liver is the most frequent site of involvement. Endoscopic retrograde cholangiopancreatography (ERCP) can be used in both the diagnosis and treatment of biliary complications of hepatic hydatid cyst. In this retrospective study, we evaluated the efficacy of ERCP in patient with hepatic hydatid disease in the preoperative and postoperative period. Materials and methods: 69 patients diagnosed with liver hydatid cyst and underwent ERCP in the clinic between 1993 and 2013 were assessed retrospectively. Out of patients 51 were male while 18 women and the mean age was 37,1. Results: 62 patients had hydatid cyst in the liver only while 7 had liver and lung hydatid cysts. Out of patients with liver cyst 28 had Type I, 11 Type II, 23 Type III, 6 Type IV and 1 Type V hydatid cyst according to Gharbi classification. The number of patients who were operated on pre-ERCP was 46, post-ERCP was 15, non-operated was 7 and lung operation was 1. The number of days between the operation and the ERCP was 20.6 on average in patients who underwent ERCP following the operation. Fourty seven patients underwent ERCP once, 18 patients twice, 4 patients five times, which amounted to 103 times in total. Out of patients 31 (44,9%) had bilocutaneous and/or bronchobiliary fistula (external fistula), 25 (36,2%) cholestasis and/or cholangitis, 12 (17,3%) cyst related to the biliary tract (internal fistula). ERCP in a patient (1.4%) having a cyst without complication was normal. Among those with external fistula, 12 patients were applied nasobiliary drainage catheter (NBDC), 11 patients sphincterotomy (ST) + NBDC, 6 patients ST, 1 patient ST+stent application and 1 patient ST+NBDC. The fistula closed in 93.5% of the patients by means of endoscopic methods. Average closing time for fistula was 13 days in 25 of the patients, excluding four patients whose fistula closed on the 40th, 45th, 63rd and 92nd (5 procedures were applied) days. The fistula didn’t close in one patient (in 5 year follow-up) and another patient died on the 60th day. ST were carried out successfully in 9 patients with cholestasis and/or cholangitis, ST+balloon extraction in 8, ST+NBDC in 4, ST+NBDC+balloon extraction in 1, ST+NBDC+ stent application in 1, ST+ stent application in 1 and NBDC in another patient. With regard to patients with internal fistula, 7 underwent successfully ST+NBDC, 4 ST and 1 balloon extraction. Conclusion: ERCP is a highly effective, successful and reliable method which must be preferred in the first place in the pre and post-operational period in the treatment of liver hydatid disease.
Su1660 Endoscopic Treatment of Non-Stricture Related Benign Biliary Diseases Using Covered Self-Expandable Metal Stents (CSEMS) Shayan Irani*1, Todd H. Baron2, Ryan Law2, Ali Akbar2, Andrew S. Ross1, Otto S. Lin1, Michael Gluck1, S. Ian Gan1, Richard a. Kozarek1 1 Gastroenterology, Virginia Mason Medical Center, Seattle, WA; 2 gastroenterology and hepatology, Mayo Clinic, rochester, MN Background & Aims: Non-stricture, benign biliary diseases (BBD) such as leaks, perforations, and bleeding have traditionally been managed with the placement of one or more plastic stents (PS). However, emerging data support the use of covered selfexpandable metal stents (CSEMS). We sought to assess outcome of endoscopic temporary placement of CSEMS in patients with non-stricture BBD. Methods: Retrospective study of CSEMS placement for BBD between 5/2005-8/2013 from two tertiary care centers. 87 patients (47 males, median age 62 years) were identified; 35 (40%) had bile leaks, 27 (31%) had bleeding, 18 (21%) had perforations and 7 (8%) had other conditions. Main outcome measures were resolution of perforation, bleeding, leak, and adverse events (AEs) due SEMS-related therapy. Results: Fully covered and partially covered 8-10mm diameter CSEMS were placed and subsequently removed in all 87 patients (100%). Resolution of bile leaks occurred in 33/35 (94%) patients, bleeding in 25/27 (93%) patients, perforation in 18/18 (100%) patients, and in 3/7 (43%) patients with other indications. Median duration of stenting was 9 weeks in patients with biliary leak, 3 weeks for bleeding, and 9.5 weeks for perforations. Median follow-up was 58 weeks after stent removal. Seven AEs occurred, including cholangitis in 6 (7%) patients, and tissue hyperplasia leading to difficulty with removal of a partially-covered SEMS in 1 patient. Conclusions: Nonstricture BBD can be effectively and safely treated with the short-term placement of CSEMS. Patient characteristics and indications for placement of covered selfexpandable metal stents in patients with non-stricture benign biliary diseases (nZ87)
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB249
Abstracts
INDICATION 1) Biliary Leak a) Post-cholecystectomy b) Abscess/Pancreatic necrosis c) Post-EUS-Biliary rendezvous 2) Bleeding a) Post-sphincterotomy b) Bile duct varices c) Bleeding Neuro-endocrine tumor 3) Perforation a) Post-sphincterotomy b) Biliary-enteric anastomotic 4) Other a) Removal of partially covered self-expandable stent b) Facilitate biliary stone removal c) Sump Syndrome d) Choledochogastric fistula
35 24 10 1 27 23 3 1 18 12 6 7 3 2 1 1
Post-procedural details of patients undergoing covered selfexpandable metal stent placement in non-stricture related benign biliary diseases (n[87) Prior plastic stent use, n (%) Type of stent, n (%) 1) Wallstent 2) Wallflex (10mm) 3) Viabil Median duration of stent placement (weeks) 1) Biliary Leak 2) Bleeding 3) Perforation Biliary leak resolved, n (%) Bleeding resolved, n (%) Perforation resolved, n (%) a) Removal of partially covered self-expandable metal stent b) Facilitate biliary stone removal c) Sump Syndrome d) Choledochogastric fistula
32 (37%) 87 12 (14%) 29 (33%) 46 (53%) 9 (2 - 115) 3 (1 - 11) 9.5 (4- 14) 33/35 (94%) * 25/27 (93%) ** 18/18 (100%) 2/3 (67%) 1/2 (50%) 0/1 (0%) 0/1 (0%)
* 1 patient died from sepsis from infected biloma and another patient failed. ** 1 patient rebled after being restarted on Coumadin, and another while on clopidogrel.
Su1662 Smart Atlas for Supporting the Interpretation of Probe-Based Confocal LASER Endomicroscopy (pCLE) of Biliary Strictures: First Classification Results of a Computer-Aided Diagnosis Software Based on Image Recognition Marzieh Kohandani Tafreshi*1,2, Virendra Joshi3, Alexander Meining4, Charles J. Lightdale5, Marc Giovannini6, Julien Dauguet2, Nicholas Ayache1, Barbara André2 1 INRIA, Sophia Antipolis, France; 2Mauna Kea Technologies, Paris, France; 3Ochsner Medical Center Kenner, Kenner, LA; 4Klinikum rechts der Isar, München, Germany; 5Columbia University Medical Center, New York, NY; 6Institut Paoli-Calmettes, Marseille, France Background and Aims: pCLE enables microscopic imaging of biliary strictures, in vivo and in real time, during an ERCP procedure. Results of a multicentric study (Meining et al., GIE 2011) have shown that pCLE allows endoscopists to differentiate benign from malignant strictures in real time with high sensitivity and NPV. A computer-aided diagnosis software called Smart Atlas has been developed to assist endoscopists with the interpretation of pCLE sequences. This study aims at evaluating the performance of this software for the differentiation of benign and malignant strictures. Methods: Several high quality pCLE sequences were retrospectively collected from pCLE procedures performed in multiple clinical centers. These sequences, along with their annotated final diagnosis, were used to train a classification software that uses a content-based image retrieval algorithm to predict the diagnosis of a query video based on the diagnoses of the most visually similar atlas videos. For all cases, final diagnosis was based on histology, positive tissue sampling, or one year follow-up. All evaluations were performed using leave-one-patient-out cross-validation to avoid bias. To evaluate binary classification, a receiver operating curve was generated, allowing optimization of the trade-off between false positives and negatives. Results: Among the 60 pCLE sequences collected from 30 patients, 14 were representative of healthy bile duct, 10 of inflammatory strictures and 36 of malignant strictures. The resulting receiver operating curve shows two points of interest: the first (reps. second) point has a high sensitivity of 88.9% (reps. high specificity of 91.7%), an acceptable specificity of 70.8% (reps. acceptable sensitivity of 69.4%), an accuracy of 81.7% (resp. 78.3%), a PPV of 82.1% (resp. 92.6%) and a NPV of 81.0% (resp. 66.7%). In comparison, Meining et al. reported that, for in vivo pCLE diagnosis of malignant stricture, endoscopists achieve overall sensitivity, specificity, accuracy, PPV and NPV of 98%, 67%, 81%, 71% and 97%, respectively. Limitations: Small and unbalanced sample size, restricted to high quality videos. Conclusions: These first results demonstrate that benign and malignant strictures can be automatically discriminated by the Smart Atlas software using only the image content of pCLE sequences of high quality, with an accuracy comparable to that achieved in real-time by endoscopists. The software is also able to achieve high specificity and PPV to help reduce false positives caused by inflammatory strictures. Future work will focus on improving the software to handle pCLE sequences of various quality. The resulting case-based reasoning software could be used as an educational tool to train non-expert endoscopists, but also as a second-reader tool to assist any endoscopist in real-time diagnosis of biliary strictures using pCLE.
Su1661 Risk Factors for Technical Failure of Endoscopic Multiple SelfExpandable Metallic Stent Placement by Stent-in-Stent Method Kazumichi Kawakubo*, Hiroshi Kawakami, Masaki Kuwatani, Yoko Abe, Taiki Kudo, Kimitoshi Kubo, Yoshimasa Kubota, Naoya Sakamoto Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan Background: Endoscopic multiple self-expandable metallic stent (SEMS) placement by the stent-in-stent (SIS) method has been reported to be useful for the management of unresectable hilar malignant biliary obstruction. However, it is technically challenging, and the optimal SEMS for the procedure has remained unknown. The aim of this study was to identify the risk factors for technical failure of endoscopic multiple SEMS placement for unresectable malignant hilar biliary obstruction (MHBO). Methods: Between December 2009 and May 2013, 50 consecutive patients with MHBO underwent endoscopic multiple SEMS placement by the SIS method. We retrospectively evaluated the rate of successful multiple SEMS placement and identified the risk factors for technical failure. Results: The technical success rate for multiple SEMS placement was 82.0% (95% confidence interval [CI]: 69.2-90.2). On univariate analysis, the rate of technical failure was high in patients with metastatic disease and unilateral placement. Multivariate analysis revealed that metastatic disease was a significant risk factor for technical failure (odds ratio: 9.63, 95% CI: 1.11105.5). Subgroup analysis after multiple guidewire insertion showed that the rate of technical success was higher in the laser-cut than in the braided type SEMS. Conclusions: Metastatic disease was a significant risk factor for technical failure of multiple SEMS placement for unresectable MHBO. A laser-cut SEMS might be preferable for the SIS procedure. (UMIN-CTR; No. UMIN000011879)
Receiver operating characteristic curve for the binary classification between benign and malignant biliary strictures.
AB250 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
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Su1657 Endoscopic Parameters and Clinical Factors Impacting the Success of ERCP in Resolution of Biliary Anastomotic Strictures in Patients After Liver Transplantation Salvatore Francesco Vadala’ Di Prampero*1, Giacomo Faleschini1, Milutin M. Bulajic1,2, Loris Mario Zoratti1, Maurizio Zilli1 1 Gastroenterology and GI Endoscopy, University Hospital of Udine, Udine, Italy; 2Center for Digestive Endoscopy, Faculty of Medicine, Belgrade University, Belgrade, Serbia Introduction and aims: The most frequent biliary complication following liver transplantation (LT) is biliary anastomotic stricture (BAS). To define possible impacting factors of BAS appearance and resolution we analyzed different epidemiological, clinical and endoscopic features in patients undergoing ERCP. Material and methods: We evaluated 171 consecutive liver transplanted recipients recruited in our Centre from 2004 to 2010 (133 males, median age 56 years), with at least one year of follow-up. All patients with clinical or radiologic suspicion of obstructive jaundice and cholestasis underwent ERCP. The concept of ERCP was based on biliary sphyncterotomy followed by stricture dilation and placement of at least one plastic stent, exchangeable every 3-6 months until the final stricture resolution. There have been examined clinical and endoscopic risk factors predicting the success or failure of endoscopic treatment (ERCP). Results: During post-operative follow-up 40 patients presented BAS. The median number of ERCP per patient was 3, median number of stents inserted per patient per procedure was 1 and median period until stricture resolution was 9 months. Stricture resolution was obtained in 83%. Occurrence of BAS was strongly associated with use of Kehr T tube (12/23 Vs 28/148, p!0.01) and with use of cyclosporine as immunosuppressive therapy (18/54 Vs 22/ 117, p!0.05). Independent predictors of BAS development at logistic regression analysis were use of Kehr T tube (O. R. 5.46, p!0.01) and donor male gender (O. R. 2.61, p!0.01). The univariate logistic analysis showed that elevated number of repeated ERCP (OR 0,659; 95% CI 0,522-0,832; pZ0,000), combined stenting with dilation (OR 0,197; 95% CI 0,074-0,525; pZ0,001), increasing number of inserted stents per procedure (OR 0,896; 95% CI 0,782-1,026; pZ0,112) and longer period of warm ischemia (OR 0,966; 95% CI 0,938-0,995; pZ0,023) were associated with successful endoscopic treatment. On the contrary, longer period of stent in place (OR 1,034; 95% CI 1,005-1,064; pZ0,021), elevated MELD score (OR 1,104; 95% CI 1,035-1,178; pZ0,003), elevated Child-Pugh score (OR 1,679; 95% CI 1,089-2,591; pZ0,019) and high pre-transplantation bilirubin values (OR 1,104; 95% CI 1,0071,210; pZ0,035) were associated with endoscopic treatment failure. Conclusions: Endoscopic treatment of BAS requires detailed clinical assessment and skilled equipe. Understanding clinical and endoscopic risk factors may help in predicting of more appropriate regimen of treatment of patients undergoing ERCP for BAS post-LT.
Su1658 Complex Biliary Leak Post-Hepatectomy: Is Endoscopic Treatment Effective? Marco Alburquerque*1,2, Montserrat Figa1,3, Joan Figueras1,3, Santiago LóPez Ben3, Marcela Perez Contreras3, Ferran GonzáLez-Huix1 1 Gastroenterology, Clínica Girona, Girona, Spain; 2Gastroenterology, Hospital de Palamós, Palamós, Spain; 3Gastroenterology, Hospital Universitario Dr. Josep Trueta, Girona, Spain Introduction: The ERCP (papillotomy and/or stent) has become the elective treatment for post-cholecystectomy biliary leak (PCBL). Nowadays is unknown if this treatment is equally effective for post-hepatectomy biliary leak (PHBL). Aims: To compare the efficacy between endoscopic treatment for PHBL and PCBL. Methods: From January 2002 to October 2012 were recorded in a prospective database all patients with post-surgical biliary leak (PSBL) that underwent to ERCP. The database included demographic data: age and sex; type of surgery and indication; PSBL features: localization, debit and associated findings (strictures, biloma/abscess, lithiasis, etc); endoscopic treatment; papillotomy and/or stent, diagnostic success, technical success, efficacy and safety. We defined as Diagnostic success: localization of PSBL by ERCP and as Technical success: Endoscopic drainage of PSBL. The sealing of PSBL was confirmed by ERCP and/or clinical evaluation. The data were analyzed using the SPSS 15.0 software. Results: Between 3785 ERCPs (2002 - 2012) there were 67 patients with PSBL (1,7%): 51 PCBL (67%) and 16 PHBL (33%). Age: 64,79 15,07 years. Women: 20 (29,9%). In PCBL the surgical indication was cholelithiasis (100%), while in PHBL were liver metastases: 12 (75%), hepatic hydatid disease: 2 (12,5%), traumatism: 1 (6,25%) and gallbladder cancer:1 (6,25%). Cystic duct stump and common bile duct/common hepatic duct were the most frequents localization of PCBL: 58,82 vs. 0,00% (pZ0,000) and 25,49 vs. 18,75% (pZ0,000), respectively. In PHBL, primary and secondary intrahepatic bile ducts were the most frequents: 31,25 vs. 5,88% (pZ0,000) and 37,5 vs. 5,88% (pZ0,000), respectively. For PCBL, diagnostic success was higher than PHBL: 96,08 vs. 87,5% (pZ0,000). There was not difference in PSBL debits. Strictures (57,14 vs. 22%, pZ0,000) and biloma/abscess (87,5 vs. 26%, pZ0,000) were more associated to PHBL than lithiasis (7,14 vs. 48%, pZ0,000). In regard to endoscopic treatment, there was not difference between both groups: papillotomy and stent was the most frequent procedure and technical success was above 93%. The endoscopic treatment efficacy for PHBL was much
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lower than for PCBL (25 vs. 84,31%, pZ0,000). The complication rate was similar between both groups. Conclusions: The endoscopic treatment efficacy (papillotomy and/or stent) for post-hepatectomy biliary leak is much lower than for post-cholecystectomy biliary leak. This is related to their greater complexity: frequently intrahepatic and associated to strictures and biloma/abscess.
Su1659 The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Hepatic Hydatid Disease: a Single Center Experience Sait Bagci*, Cemal Nuri Ercin, ZüLfikar Polat, Mustafa Gulsen, Ahmet Uygun, Ahmet Tuzun, Hakan Demirci, Ahmet Alper Gastroenterology, Gulhane Military Medical Academy, Ankara, Turkey Background: Hydatid disease is a parasitic infection caused by Echinococcus granulosus. The liver is the most frequent site of involvement. Endoscopic retrograde cholangiopancreatography (ERCP) can be used in both the diagnosis and treatment of biliary complications of hepatic hydatid cyst. In this retrospective study, we evaluated the efficacy of ERCP in patient with hepatic hydatid disease in the preoperative and postoperative period. Materials and methods: 69 patients diagnosed with liver hydatid cyst and underwent ERCP in the clinic between 1993 and 2013 were assessed retrospectively. Out of patients 51 were male while 18 women and the mean age was 37,1. Results: 62 patients had hydatid cyst in the liver only while 7 had liver and lung hydatid cysts. Out of patients with liver cyst 28 had Type I, 11 Type II, 23 Type III, 6 Type IV and 1 Type V hydatid cyst according to Gharbi classification. The number of patients who were operated on pre-ERCP was 46, post-ERCP was 15, non-operated was 7 and lung operation was 1. The number of days between the operation and the ERCP was 20.6 on average in patients who underwent ERCP following the operation. Fourty seven patients underwent ERCP once, 18 patients twice, 4 patients five times, which amounted to 103 times in total. Out of patients 31 (44,9%) had bilocutaneous and/or bronchobiliary fistula (external fistula), 25 (36,2%) cholestasis and/or cholangitis, 12 (17,3%) cyst related to the biliary tract (internal fistula). ERCP in a patient (1.4%) having a cyst without complication was normal. Among those with external fistula, 12 patients were applied nasobiliary drainage catheter (NBDC), 11 patients sphincterotomy (ST) + NBDC, 6 patients ST, 1 patient ST+stent application and 1 patient ST+NBDC. The fistula closed in 93.5% of the patients by means of endoscopic methods. Average closing time for fistula was 13 days in 25 of the patients, excluding four patients whose fistula closed on the 40th, 45th, 63rd and 92nd (5 procedures were applied) days. The fistula didn’t close in one patient (in 5 year follow-up) and another patient died on the 60th day. ST were carried out successfully in 9 patients with cholestasis and/or cholangitis, ST+balloon extraction in 8, ST+NBDC in 4, ST+NBDC+balloon extraction in 1, ST+NBDC+ stent application in 1, ST+ stent application in 1 and NBDC in another patient. With regard to patients with internal fistula, 7 underwent successfully ST+NBDC, 4 ST and 1 balloon extraction. Conclusion: ERCP is a highly effective, successful and reliable method which must be preferred in the first place in the pre and post-operational period in the treatment of liver hydatid disease.
Su1660 Endoscopic Treatment of Non-Stricture Related Benign Biliary Diseases Using Covered Self-Expandable Metal Stents (CSEMS) Shayan Irani*1, Todd H. Baron2, Ryan Law2, Ali Akbar2, Andrew S. Ross1, Otto S. Lin1, Michael Gluck1, S. Ian Gan1, Richard a. Kozarek1 1 Gastroenterology, Virginia Mason Medical Center, Seattle, WA; 2 gastroenterology and hepatology, Mayo Clinic, rochester, MN Background & Aims: Non-stricture, benign biliary diseases (BBD) such as leaks, perforations, and bleeding have traditionally been managed with the placement of one or more plastic stents (PS). However, emerging data support the use of covered selfexpandable metal stents (CSEMS). We sought to assess outcome of endoscopic temporary placement of CSEMS in patients with non-stricture BBD. Methods: Retrospective study of CSEMS placement for BBD between 5/2005-8/2013 from two tertiary care centers. 87 patients (47 males, median age 62 years) were identified; 35 (40%) had bile leaks, 27 (31%) had bleeding, 18 (21%) had perforations and 7 (8%) had other conditions. Main outcome measures were resolution of perforation, bleeding, leak, and adverse events (AEs) due SEMS-related therapy. Results: Fully covered and partially covered 8-10mm diameter CSEMS were placed and subsequently removed in all 87 patients (100%). Resolution of bile leaks occurred in 33/35 (94%) patients, bleeding in 25/27 (93%) patients, perforation in 18/18 (100%) patients, and in 3/7 (43%) patients with other indications. Median duration of stenting was 9 weeks in patients with biliary leak, 3 weeks for bleeding, and 9.5 weeks for perforations. Median follow-up was 58 weeks after stent removal. Seven AEs occurred, including cholangitis in 6 (7%) patients, and tissue hyperplasia leading to difficulty with removal of a partially-covered SEMS in 1 patient. Conclusions: Nonstricture BBD can be effectively and safely treated with the short-term placement of CSEMS. Patient characteristics and indications for placement of covered selfexpandable metal stents in patients with non-stricture benign biliary diseases (nZ87)
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB249
Abstracts
INDICATION 1) Biliary Leak a) Post-cholecystectomy b) Abscess/Pancreatic necrosis c) Post-EUS-Biliary rendezvous 2) Bleeding a) Post-sphincterotomy b) Bile duct varices c) Bleeding Neuro-endocrine tumor 3) Perforation a) Post-sphincterotomy b) Biliary-enteric anastomotic 4) Other a) Removal of partially covered self-expandable stent b) Facilitate biliary stone removal c) Sump Syndrome d) Choledochogastric fistula
35 24 10 1 27 23 3 1 18 12 6 7 3 2 1 1
Post-procedural details of patients undergoing covered selfexpandable metal stent placement in non-stricture related benign biliary diseases (n[87) Prior plastic stent use, n (%) Type of stent, n (%) 1) Wallstent 2) Wallflex (10mm) 3) Viabil Median duration of stent placement (weeks) 1) Biliary Leak 2) Bleeding 3) Perforation Biliary leak resolved, n (%) Bleeding resolved, n (%) Perforation resolved, n (%) a) Removal of partially covered self-expandable metal stent b) Facilitate biliary stone removal c) Sump Syndrome d) Choledochogastric fistula
32 (37%) 87 12 (14%) 29 (33%) 46 (53%) 9 (2 - 115) 3 (1 - 11) 9.5 (4- 14) 33/35 (94%) * 25/27 (93%) ** 18/18 (100%) 2/3 (67%) 1/2 (50%) 0/1 (0%) 0/1 (0%)
* 1 patient died from sepsis from infected biloma and another patient failed. ** 1 patient rebled after being restarted on Coumadin, and another while on clopidogrel.
Su1662 Smart Atlas for Supporting the Interpretation of Probe-Based Confocal LASER Endomicroscopy (pCLE) of Biliary Strictures: First Classification Results of a Computer-Aided Diagnosis Software Based on Image Recognition Marzieh Kohandani Tafreshi*1,2, Virendra Joshi3, Alexander Meining4, Charles J. Lightdale5, Marc Giovannini6, Julien Dauguet2, Nicholas Ayache1, Barbara André2 1 INRIA, Sophia Antipolis, France; 2Mauna Kea Technologies, Paris, France; 3Ochsner Medical Center Kenner, Kenner, LA; 4Klinikum rechts der Isar, München, Germany; 5Columbia University Medical Center, New York, NY; 6Institut Paoli-Calmettes, Marseille, France Background and Aims: pCLE enables microscopic imaging of biliary strictures, in vivo and in real time, during an ERCP procedure. Results of a multicentric study (Meining et al., GIE 2011) have shown that pCLE allows endoscopists to differentiate benign from malignant strictures in real time with high sensitivity and NPV. A computer-aided diagnosis software called Smart Atlas has been developed to assist endoscopists with the interpretation of pCLE sequences. This study aims at evaluating the performance of this software for the differentiation of benign and malignant strictures. Methods: Several high quality pCLE sequences were retrospectively collected from pCLE procedures performed in multiple clinical centers. These sequences, along with their annotated final diagnosis, were used to train a classification software that uses a content-based image retrieval algorithm to predict the diagnosis of a query video based on the diagnoses of the most visually similar atlas videos. For all cases, final diagnosis was based on histology, positive tissue sampling, or one year follow-up. All evaluations were performed using leave-one-patient-out cross-validation to avoid bias. To evaluate binary classification, a receiver operating curve was generated, allowing optimization of the trade-off between false positives and negatives. Results: Among the 60 pCLE sequences collected from 30 patients, 14 were representative of healthy bile duct, 10 of inflammatory strictures and 36 of malignant strictures. The resulting receiver operating curve shows two points of interest: the first (reps. second) point has a high sensitivity of 88.9% (reps. high specificity of 91.7%), an acceptable specificity of 70.8% (reps. acceptable sensitivity of 69.4%), an accuracy of 81.7% (resp. 78.3%), a PPV of 82.1% (resp. 92.6%) and a NPV of 81.0% (resp. 66.7%). In comparison, Meining et al. reported that, for in vivo pCLE diagnosis of malignant stricture, endoscopists achieve overall sensitivity, specificity, accuracy, PPV and NPV of 98%, 67%, 81%, 71% and 97%, respectively. Limitations: Small and unbalanced sample size, restricted to high quality videos. Conclusions: These first results demonstrate that benign and malignant strictures can be automatically discriminated by the Smart Atlas software using only the image content of pCLE sequences of high quality, with an accuracy comparable to that achieved in real-time by endoscopists. The software is also able to achieve high specificity and PPV to help reduce false positives caused by inflammatory strictures. Future work will focus on improving the software to handle pCLE sequences of various quality. The resulting case-based reasoning software could be used as an educational tool to train non-expert endoscopists, but also as a second-reader tool to assist any endoscopist in real-time diagnosis of biliary strictures using pCLE.
Su1661 Risk Factors for Technical Failure of Endoscopic Multiple SelfExpandable Metallic Stent Placement by Stent-in-Stent Method Kazumichi Kawakubo*, Hiroshi Kawakami, Masaki Kuwatani, Yoko Abe, Taiki Kudo, Kimitoshi Kubo, Yoshimasa Kubota, Naoya Sakamoto Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan Background: Endoscopic multiple self-expandable metallic stent (SEMS) placement by the stent-in-stent (SIS) method has been reported to be useful for the management of unresectable hilar malignant biliary obstruction. However, it is technically challenging, and the optimal SEMS for the procedure has remained unknown. The aim of this study was to identify the risk factors for technical failure of endoscopic multiple SEMS placement for unresectable malignant hilar biliary obstruction (MHBO). Methods: Between December 2009 and May 2013, 50 consecutive patients with MHBO underwent endoscopic multiple SEMS placement by the SIS method. We retrospectively evaluated the rate of successful multiple SEMS placement and identified the risk factors for technical failure. Results: The technical success rate for multiple SEMS placement was 82.0% (95% confidence interval [CI]: 69.2-90.2). On univariate analysis, the rate of technical failure was high in patients with metastatic disease and unilateral placement. Multivariate analysis revealed that metastatic disease was a significant risk factor for technical failure (odds ratio: 9.63, 95% CI: 1.11105.5). Subgroup analysis after multiple guidewire insertion showed that the rate of technical success was higher in the laser-cut than in the braided type SEMS. Conclusions: Metastatic disease was a significant risk factor for technical failure of multiple SEMS placement for unresectable MHBO. A laser-cut SEMS might be preferable for the SIS procedure. (UMIN-CTR; No. UMIN000011879)
Receiver operating characteristic curve for the binary classification between benign and malignant biliary strictures.
AB250 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
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