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T1541: Short and Long Term Safety of ERCP During Pregnancy
Abstracts malignant hilar strictures is difficult but safe procedure, which improves the life expectancy rate.
to those of EST alone. Risk factors for stone recurrence were acute CBD angle and presence of pneumobilia.
T1541 Short and Long Term Safety of ERCP During Pregnancy Oscar M. Laudanno, Pablo Gollo, Anibal Rondan, Gabriel E. Ahumaran, Jose M. Garrido, Alberto R. Ferreres
T1543 Usefulness of Cross Wired Metallic Stents for Endoscopic Bilateral Stent in Stent Placement and Revision in Patients With Malignant Hilar Biliary Strictures Jong Ho Moon, Jong Hyeok Kim, Hyun Jong Choi, Kyo-Sang Yoo, Young Koog Cheon, Young Deok Cho, Moon Sung Lee
Background: ERCP is an important therapeutic tool in the management of biliopancreatic diseases. Data regarding its usefulness and mother-fetal safety in the resolution of biliar pathology and its complications during pregnancy are scarce. Literature on long term follow-up is not available, particularly in concern to fetal radiation exposure safety. Aim: report the short and long term safety of ERCP during pregnancy.Methods: between june 1998 and june 2009, 1560 ERCPs were performed, including 18 pregnants (1.1%). Indications included: acute cholangitis (n⫽6), obstructive jaundice (n⫽8) and gallstones pancreatitis (n⫽4). The procedures were performed during the first trimester in one case, during the second in 6 and in the last one, in the remaining 11. Propofol was used as sedation agent in all cases; the pelvis was lead-shielded, fluoroscopy was minimized, hard copy radiographs avoided and the fetus was always monitored by an obstetrician. Long term follow- up was attained in the 18 mothers and their children , with a mean follow up period of 6.8 years ( range 11.2-0,6 years).Results: 16 out of 18 procedures were therapeutic (15 sphincterotomies with bile duct stone extraction, one sphincterotomy with temporary plastic stent placing due to giant stone).Stones were not found in 2 patients (suspicion of migration).There were two complications: 1 mild acute pancreatitis and 1 acute cholecystitis, which resolved with no need of emergency surgery.Ten patients required laparoscopic cholecistectomy during pregnancy, 7 during the puerperium and one was already cholecystectomized. Newborns were healthy with an average APGAR score above 8, except in one with low weight who required intensive care admission. No futher episodes of billiary complications happened during long term follow-up of mothers. The growth, development and neurological maturation of the children were normal. Conclusions: ERCP seems to be a safe procedure for the mother- fetus binomium during pregnancy. Safety measures are required during the procedure. Long term outcomes in children were unremarkable.
T1542 Late Complications and Stone Recurrence Rate After Endoscopic Removal of Large Bile Duct Stones by Endoscopic Sphincterotomy and Large Balloon Dilatation Are Similar to Those of Endoscopic Sphincterotomy Alone Jimin Han, Ka Young Kim, Ho Gak Kim, Byung Seok Kim, Jin Tae Jung, Chang Hyeong Lee, Joong Goo Kwon, Eun Young Kim Background: Combined endoscopic sphincterotomy and endoscopic large balloon dilatation (EST-LBD) is a safe alternative treatment for removing large bile duct stones that cannot be extracted by endoscopic sphincterotomy (EST) alone. But, long-term complications or stone recurrence rate after EST-LBD is unknown yet. Aim: The aim of this study was to compare efficacy and long-term complications, difference in bile duct stone recurrence rate, and risk factors of stone recurrence in EST alone and EST-LBD groups. Methods: The medical records of patients who underwent ERCP for bile duct stone were retrospectively reviewed. Patients with dilated CBD ⱖ11mm and follow up longer than 6 months were included. Exclusion criteria were patients with previous EST, precut, infundibulotomy, previous Billroth II operation, and uncorrected coagulopathy. EST-LBD group underwent 50% EST and LBD using CRE® balloon larger than 11 mm. EST alone group underwent up to 80% EST Late complications(⬎72 hr after procedure) included recurrent cholangitis, biliary pancreatitis, CBD stricture, and cholecystitis. Stone recurrence rate was studied also. Results: From February 2005 to April 2009, 222 patients were included. There were 121 patients in EST alone group and 101 patients in EST-LBD group. Mean follow-up duration was similar in EST alone and EST-LBD groups (22.0⫾13.2 vs. 19.0⫾11.7 months, p⫽0.082). In EST-LBD group, presence of periampullary diverticulum and mean age were higher (45 vs. 67%, p⫽0.001; 67.0⫾12.2 vs. 71.7⫾11.4 years, p⫽0.004). And CBD stones were greater in number (2.1⫾1.4 vs. 2.7⫾1.7, p⫽0.004) and larger (10.5⫾2.3 vs. 13.7⫾3.0 mm, p⬍0.001). Also, mean CBD diameter after stone extraction (12.0⫾1.9 vs. 13.1⫾1.5 mm, p⬍0.001) and ERCP session number (1.1⫾0.4 vs. 1.3⫾0.5, p⫽0.037) were greater. There was no difference in stone type, angle between mid and distal CBD, and lithotripsy rate. Complete retrieval success rate were excellent in both groups (100 vs. 99%). Early complication rate was low (total, 5 vs. 4%; major bleeding, 2 vs. 2%; pancreatitis 2 vs. 1%; perforation 1 vs. 0%). But, one patient in EST-LBD group expired from delayed bleeding. During long-term follow up (⬎1year), late complication rate (3.3 vs. 5.9 %) and stone recurrence rate (5.8 vs. 7.9%) were low and similar in both groups. Significant risk factors of stone recurrence were acute CBD angle(⬍135°) and pneumobilia (60 vs. 31%, p⫽0.02; 27 vs. 4.8%, p⫽0.001, respectively). Conclusion: EST-LBD for large bile duct stone showed similar long-term complication rate and stone recurrence rate
AB304 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
BACKGROUND AND AIMS; Endoscopic bilateral drainage with metal stents for inoperable malignant hilar biliary strictures is considered technically difficult, especially for second stenting. Furthermore, bilateral metal stenting can be difficult to revise endoscopically when stent is obstructed by tumor ingrowth. Cross wired metal stent can facilitate contralateral second stenting and allow to access bilaterally after stent obstruction. The aim of this study was to evaluate the efficacy of endoscopic bilateral stent-in-stent placement with cross wired metallic stents for the patients with high-grade malignant hilar biliary strictures during initial trial and revision. PATIENTS AND METHODS; From July 2007 and May 2009, a total of 62 patients with Inoperable malignant hilar biliary strictures of Bismuth type II or higher were enrolled. Endoscopic bilateral metal stenting by a stent-in-stent placement was performed. Cross wired metal stent (BONA-M Hilar, Standard Sci.Tech, KOREA) was inserted as a first stent. Second stent was placed into the contralateral hepatic duct through the central crossed mesh of the primary stent. Second stent was another cross wired metal stent in group 1 and conventional Zilver or Wallstent in group 2. RESULTS; The technical success rate of endoscopic bilateral stent in stent placement using cross wired metallic stents was 93.5% (58/62) in patients with high-grade malignant hilar strictures. Functional success rate was 100% (58/58). Median stent patency was 213 days. Late complications occurred in 34.5% (20/58) including stent obstruction with 24.1% (14/58). The technical success rate of endoscopic bilateral stent placement for occluded initial stent was 64.3% (9/14). However, the success rate of endoscopic revision was significantly higher in patients with group 1 having bilateral stenting with cross wired metallic stents (87.5% (7/8)). CONCLUSIONS; Endoscopic bilateral stent in stent placement using cross wired metallic stents was effective in patients with high-grade malignant hilar biliary strictures. Bilateral stenting with dual cross wired metallic stents may be the most effective for the endoscopic revision after stent obstruction.
T1544 Endoscopic Retrograde Cholangiopancreatography After Recent Myocardial Infarction: 10-Year Experience From a Large Tertiary Care Hospital System Borko Nojkov, Mitchell S. Cappell Aim: There is little data on the safety and outcome of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent myocardial infarction (MI), with only 3 published reports including a total of 7 patients. Methods: Review of 4,200 ERCPs at the 3 William Beaumont Hospitals during the past 10 years revealed 9 cases of ERCP performed within 30 days after MI. Results: Mean age of the patients was 76.0 ⫾ 12.6 years. Six were female. ERCP was performed a mean of 6.5 ⫾ 7.6 days after the MI (range 1-26 days). All patients had cardiac symptoms, abnormal cardiac enzyme levels, and new EKG changes with the MI (Table). ERCP indications included: suspected choledocholithiasis or cholangitis, pancreatic mass, and billiary stent removal. Serum bilirubin was elevated in 7 pts, and alkaline phosphatase was elevated in 9 pts. ERCP revealed choledocholithiasis in 6 pts and no abnormality in 3 pts. Sphincterotomy was performed in 6 pts, balloon pull-through in 9, and stones were extracted in 6 pts. Billiary stent was placed in 1 pt, and 1 pt had a preexisting stent removed. There were 2 ERCP complications: transient hypotension during ERCP successfully treated by epinephrine; and biliary obstruction from a blood clot at the ampulla after sphincterotomy successfully treated by repeat ERCP. The cholestasis improved in all pts. Nine patients were able to be discharged 3.1 ⫾ 1.9 days post ERCP. One pt had an extended hospitalization unrelated to the ERCP or gallstone disease.Conclusion: This data suggests that ERCP appears to be relatively safe to perform soon after MI when strongly indicated. CLINICAL PARAMETERS Mean age (range) Female Mean days ERCP performed after MI (range) Mean CK with MI EKG changes with MI Mean Alkaline Phosphatase Mean Bilirubin
76.0 ⫾ 12.6 (48 - 87) years 6 6.5 ⫾ 7.6 (1 - 26) 397.6 ⫾ 352.4 u/l 4 ST-segment changes 4 T-wave alterations 2 Q-waves 1 poor R-wave progression 363 ⫾ 281.2 u/l 3.9 ⫾ 3.2 mg/dl
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to those of EST alone. Risk factors for stone recurrence were acute CBD angle and presence of pneumobilia.
T1541 Short and Long Term Safety of ERCP During Pregnancy Oscar M. Laudanno, Pablo Gollo, Anibal Rondan, Gabriel E. Ahumaran, Jose M. Garrido, Alberto R. Ferreres
T1543 Usefulness of Cross Wired Metallic Stents for Endoscopic Bilateral Stent in Stent Placement and Revision in Patients With Malignant Hilar Biliary Strictures Jong Ho Moon, Jong Hyeok Kim, Hyun Jong Choi, Kyo-Sang Yoo, Young Koog Cheon, Young Deok Cho, Moon Sung Lee
Background: ERCP is an important therapeutic tool in the management of biliopancreatic diseases. Data regarding its usefulness and mother-fetal safety in the resolution of biliar pathology and its complications during pregnancy are scarce. Literature on long term follow-up is not available, particularly in concern to fetal radiation exposure safety. Aim: report the short and long term safety of ERCP during pregnancy.Methods: between june 1998 and june 2009, 1560 ERCPs were performed, including 18 pregnants (1.1%). Indications included: acute cholangitis (n⫽6), obstructive jaundice (n⫽8) and gallstones pancreatitis (n⫽4). The procedures were performed during the first trimester in one case, during the second in 6 and in the last one, in the remaining 11. Propofol was used as sedation agent in all cases; the pelvis was lead-shielded, fluoroscopy was minimized, hard copy radiographs avoided and the fetus was always monitored by an obstetrician. Long term follow- up was attained in the 18 mothers and their children , with a mean follow up period of 6.8 years ( range 11.2-0,6 years).Results: 16 out of 18 procedures were therapeutic (15 sphincterotomies with bile duct stone extraction, one sphincterotomy with temporary plastic stent placing due to giant stone).Stones were not found in 2 patients (suspicion of migration).There were two complications: 1 mild acute pancreatitis and 1 acute cholecystitis, which resolved with no need of emergency surgery.Ten patients required laparoscopic cholecistectomy during pregnancy, 7 during the puerperium and one was already cholecystectomized. Newborns were healthy with an average APGAR score above 8, except in one with low weight who required intensive care admission. No futher episodes of billiary complications happened during long term follow-up of mothers. The growth, development and neurological maturation of the children were normal. Conclusions: ERCP seems to be a safe procedure for the mother- fetus binomium during pregnancy. Safety measures are required during the procedure. Long term outcomes in children were unremarkable.
T1542 Late Complications and Stone Recurrence Rate After Endoscopic Removal of Large Bile Duct Stones by Endoscopic Sphincterotomy and Large Balloon Dilatation Are Similar to Those of Endoscopic Sphincterotomy Alone Jimin Han, Ka Young Kim, Ho Gak Kim, Byung Seok Kim, Jin Tae Jung, Chang Hyeong Lee, Joong Goo Kwon, Eun Young Kim Background: Combined endoscopic sphincterotomy and endoscopic large balloon dilatation (EST-LBD) is a safe alternative treatment for removing large bile duct stones that cannot be extracted by endoscopic sphincterotomy (EST) alone. But, long-term complications or stone recurrence rate after EST-LBD is unknown yet. Aim: The aim of this study was to compare efficacy and long-term complications, difference in bile duct stone recurrence rate, and risk factors of stone recurrence in EST alone and EST-LBD groups. Methods: The medical records of patients who underwent ERCP for bile duct stone were retrospectively reviewed. Patients with dilated CBD ⱖ11mm and follow up longer than 6 months were included. Exclusion criteria were patients with previous EST, precut, infundibulotomy, previous Billroth II operation, and uncorrected coagulopathy. EST-LBD group underwent 50% EST and LBD using CRE® balloon larger than 11 mm. EST alone group underwent up to 80% EST Late complications(⬎72 hr after procedure) included recurrent cholangitis, biliary pancreatitis, CBD stricture, and cholecystitis. Stone recurrence rate was studied also. Results: From February 2005 to April 2009, 222 patients were included. There were 121 patients in EST alone group and 101 patients in EST-LBD group. Mean follow-up duration was similar in EST alone and EST-LBD groups (22.0⫾13.2 vs. 19.0⫾11.7 months, p⫽0.082). In EST-LBD group, presence of periampullary diverticulum and mean age were higher (45 vs. 67%, p⫽0.001; 67.0⫾12.2 vs. 71.7⫾11.4 years, p⫽0.004). And CBD stones were greater in number (2.1⫾1.4 vs. 2.7⫾1.7, p⫽0.004) and larger (10.5⫾2.3 vs. 13.7⫾3.0 mm, p⬍0.001). Also, mean CBD diameter after stone extraction (12.0⫾1.9 vs. 13.1⫾1.5 mm, p⬍0.001) and ERCP session number (1.1⫾0.4 vs. 1.3⫾0.5, p⫽0.037) were greater. There was no difference in stone type, angle between mid and distal CBD, and lithotripsy rate. Complete retrieval success rate were excellent in both groups (100 vs. 99%). Early complication rate was low (total, 5 vs. 4%; major bleeding, 2 vs. 2%; pancreatitis 2 vs. 1%; perforation 1 vs. 0%). But, one patient in EST-LBD group expired from delayed bleeding. During long-term follow up (⬎1year), late complication rate (3.3 vs. 5.9 %) and stone recurrence rate (5.8 vs. 7.9%) were low and similar in both groups. Significant risk factors of stone recurrence were acute CBD angle(⬍135°) and pneumobilia (60 vs. 31%, p⫽0.02; 27 vs. 4.8%, p⫽0.001, respectively). Conclusion: EST-LBD for large bile duct stone showed similar long-term complication rate and stone recurrence rate
AB304 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
BACKGROUND AND AIMS; Endoscopic bilateral drainage with metal stents for inoperable malignant hilar biliary strictures is considered technically difficult, especially for second stenting. Furthermore, bilateral metal stenting can be difficult to revise endoscopically when stent is obstructed by tumor ingrowth. Cross wired metal stent can facilitate contralateral second stenting and allow to access bilaterally after stent obstruction. The aim of this study was to evaluate the efficacy of endoscopic bilateral stent-in-stent placement with cross wired metallic stents for the patients with high-grade malignant hilar biliary strictures during initial trial and revision. PATIENTS AND METHODS; From July 2007 and May 2009, a total of 62 patients with Inoperable malignant hilar biliary strictures of Bismuth type II or higher were enrolled. Endoscopic bilateral metal stenting by a stent-in-stent placement was performed. Cross wired metal stent (BONA-M Hilar, Standard Sci.Tech, KOREA) was inserted as a first stent. Second stent was placed into the contralateral hepatic duct through the central crossed mesh of the primary stent. Second stent was another cross wired metal stent in group 1 and conventional Zilver or Wallstent in group 2. RESULTS; The technical success rate of endoscopic bilateral stent in stent placement using cross wired metallic stents was 93.5% (58/62) in patients with high-grade malignant hilar strictures. Functional success rate was 100% (58/58). Median stent patency was 213 days. Late complications occurred in 34.5% (20/58) including stent obstruction with 24.1% (14/58). The technical success rate of endoscopic bilateral stent placement for occluded initial stent was 64.3% (9/14). However, the success rate of endoscopic revision was significantly higher in patients with group 1 having bilateral stenting with cross wired metallic stents (87.5% (7/8)). CONCLUSIONS; Endoscopic bilateral stent in stent placement using cross wired metallic stents was effective in patients with high-grade malignant hilar biliary strictures. Bilateral stenting with dual cross wired metallic stents may be the most effective for the endoscopic revision after stent obstruction.
T1544 Endoscopic Retrograde Cholangiopancreatography After Recent Myocardial Infarction: 10-Year Experience From a Large Tertiary Care Hospital System Borko Nojkov, Mitchell S. Cappell Aim: There is little data on the safety and outcome of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent myocardial infarction (MI), with only 3 published reports including a total of 7 patients. Methods: Review of 4,200 ERCPs at the 3 William Beaumont Hospitals during the past 10 years revealed 9 cases of ERCP performed within 30 days after MI. Results: Mean age of the patients was 76.0 ⫾ 12.6 years. Six were female. ERCP was performed a mean of 6.5 ⫾ 7.6 days after the MI (range 1-26 days). All patients had cardiac symptoms, abnormal cardiac enzyme levels, and new EKG changes with the MI (Table). ERCP indications included: suspected choledocholithiasis or cholangitis, pancreatic mass, and billiary stent removal. Serum bilirubin was elevated in 7 pts, and alkaline phosphatase was elevated in 9 pts. ERCP revealed choledocholithiasis in 6 pts and no abnormality in 3 pts. Sphincterotomy was performed in 6 pts, balloon pull-through in 9, and stones were extracted in 6 pts. Billiary stent was placed in 1 pt, and 1 pt had a preexisting stent removed. There were 2 ERCP complications: transient hypotension during ERCP successfully treated by epinephrine; and biliary obstruction from a blood clot at the ampulla after sphincterotomy successfully treated by repeat ERCP. The cholestasis improved in all pts. Nine patients were able to be discharged 3.1 ⫾ 1.9 days post ERCP. One pt had an extended hospitalization unrelated to the ERCP or gallstone disease.Conclusion: This data suggests that ERCP appears to be relatively safe to perform soon after MI when strongly indicated. CLINICAL PARAMETERS Mean age (range) Female Mean days ERCP performed after MI (range) Mean CK with MI EKG changes with MI Mean Alkaline Phosphatase Mean Bilirubin
76.0 ⫾ 12.6 (48 - 87) years 6 6.5 ⫾ 7.6 (1 - 26) 397.6 ⫾ 352.4 u/l 4 ST-segment changes 4 T-wave alterations 2 Q-waves 1 poor R-wave progression 363 ⫾ 281.2 u/l 3.9 ⫾ 3.2 mg/dl
www.giejournal.org