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T1549: Management of Patients With Biliary Sphincter of Oddi Disorder Without Sphincter of Oddi Manometry
Abstracts the study period (CPMC-5; HCS-3). Patients presented with elevated liver enzymes (8), jaundice (8), pain (7) and cholangitis (1). Prior abdominal US failed to demonstrate CBD stones in 5. EUS revealed stones in 7, and was normal in 1. A total of 13 CBD stones (median 1, range 1-5) were identified. Selective biliary cannulation and non-radiation endoscopic therapy was performed in seven patients. Sphincterotomy was performed using a traction sphincterotome (6) or needle knife (1). Stones were removed with a balloon (4) or basket (3). The number removed matched the number seen on EUS in all cases. Cholangioscopy was performed in 1 to confirm clearance. There were no complications. No clinical suspicion for recurrence was reported over a mean follow up of 7.5 months. Conclusions:EUS is an effective tool to evaluate bile duct stones and to determine the need for endoscopic therapy in pregnant women. The number of stones can be documented and matched with the number of stones removed. Fluoroscopy is not required if selective bile duct cannulation can be achieved.
T1549 Management of Patients With Biliary Sphincter of Oddi Disorder Without Sphincter of Oddi Manometry Evangelos Kalaitzakis, Tim Ambrose, Jane Phillips-Hughes, Jane D. Collier, Roger W. Chapman The paucity of controlled data for the treatment of most biliary Sphincter of Oddi disorder (SOD) types and the incomplete response to therapy seen in clinical practice as well as in several trials, has generated controversy as to the best course of management of these patients. We aimed to assess the outcome of patients with SOD managed without sphincter of Oddi manometry. Methods A total of 59 patients (53 female, median age 46 years, 26 with previous cholecystectomy) with biliary SOD (14% type I, 51% type II, 35% type III) were prospectively enrolled. All patients with a dilated common bile duct were offered endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy whereas all others were offered medical treatment alone. Patients were followed up for a median of 15 months and were assessed clinically for response to treatment.Results Thirty-three patients (56%) has a dilated common bile duct on imaging at presentation. At follow-up 15.3% of patients reported complete symptom resolution, 59.3% improvement, 22% unchanged symptoms, and 3.4% symptom deterioration. Fifty-one percent experienced symptom resolution/ improvement on medical treatment only, 12% after sphincterotomy, and 10% after both medical treatment/sphincterotomy. Twenty percent experienced at least one recurrence of symptoms after initial response to medical and/or endoscopic treatment. Fifty ERCP procedures were performed in 24 patients with an 18% (9/50) complication rate (16% post-ERCP pancreatitis). Seven out of nine complications were mild and all patients with complications were treated conservatively; no post-ERCP mortality was observed. The proportions of patients reporting symptom resolution/improvement during follow-up did not differ significantly (p⬎0.05) among patients with SOD type I (63%), type II (77%), or type III (76%). Among patients undergoing ERCP, the proportion of patients experiencing a post-ERCP complication did not differ significantly between patients reporting symptom resolution/improvement (35%) and those reporting stable or deteriorating symptoms (50%) at the end of follow-up (p⬎0.05). Age, gender, comorbidity (psychiatric or other), dilated common bile duct, presence of intact gallbladder, or opiate use were not related to the effect of treatment at the end of follow-up (p⬎0.05 for all). Conclusion Patients with biliary SOD may be managed with a combination of endoscopic sphincterotomy (performed in those with dilated common bile duct) and medical therapy without utilization of manometry. The results of this approach with regards to symptomatic relief and ERCP complication rate are comparable to those previously published in the literature.
T1550 EPLBD With or Without Needle Knife Fistulotomy Is Safe and Effective for the Treatment of CBD Stones in Cases of Billroth II Anastomosis With Subtotal Gastrectomy Hui Won Jang, Semi Park, Jeong Youp Park, Seung Woo Park, Si Young Song, Jae Bock Chung, Seungmin Bang (1)Background: In patients with Billroth II (B-II) anastomosis with subtotal gastrectomy, endoscopic treatment of CBD stone requires more precise technique. Especially, endoscopic sphincterotomy in that situation is frequently troublesome. Endoscopic papillary large balloon dilation (EPLBD) is emerging as an effective alternative to conventional EST.(2)Aims & Methods: We evaluated the efficacy and safety of EPLBD with or without needle knife fistulotomy (NKF) in CBD stone patients with B-II anastomosis and subtotal gastrectomy. From June 2006 to August 2009, the patients with CBD stone, who had received subtotal gastrectomy and B-II anastomosis previously, were included for this study. For the procedure, conventional side-view duodenoscopy was used. EPLBD was performed with 10 -18 mm balloon catheter (CRE wire-guided dilator, Boston Scientific Corp. Natick, MA, USA). The balloon dilation was done after NKF in cases of failure to cannulate CBD selectively. (3)Results: Total 30 patients (24 of male) underwent EPLBD for the retrieval of CBD stones, 11 patients with
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concurrent NKF. The mean diameter of CBD was 13.3⫾2.7 mm (range 9-18) and the balloon was 11.8⫾1.4 mm (range 10-14). Eleven patients had gallbladder stones in initial diagnosis. Bile duct stones were successfully removed in all patients. Complete removal of bile duct stones was achieved by repeated ERCP in three patients (10%). Interestingly, mechanical lithotripsy was not required in all cases. In the aspect of acute complications, post-EPLBD pancreatitis was developed only in one patient (3.3%), which were mild grade. Perforation and bleeding was not developed. In the late complications, stone recurrence and cholangitis were not seen. Cholecystitis occurred in two of 11 patients with gallbladder stone.(4)Conclusions: In cases of B-II anastomosis, EPLBD is a safe and highly effective technique for the retrieval of CBD stones. Although this study has some limitations, EPLBD should be considered as an alternative tool to conventional EST.
T1551 Limited Endoscopic Sphincterotomy Plus Large Balloon Sphincteroplasty for Removal of Bile Duct Stones According to the Types of Periampullary Diverticulum Cheol Woong Choi, Hyung Wook Kim, Dae Hwan Kang, Kee Tae Park, Gyoun Hong Kwon, Su Bum Park, Yong Wan Sung, Jae Hyung Lee Background and study aims: Endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) is a useful method to remove bile duct stones, but the effectiveness and safety of this procedure is not well known in patients with periampullary diverticula (PAD) which are reportedly associated with difficulties and complications associated procedures. We conducted this trial to evaluate the effectiveness and safety of limited EST plus LBD for removal of bile duct stones in patients with PAD.Patients and methods: A total of 139 patients with bile duct stones were treated with LBD (10⬃20 mm balloon diameter) after limited EST. Out of them, 73 patients had PAD and 66 patients did not have PAD (controls). Stone removal and complications were retrospectively evaluated.Results: There were no significant differences between groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complication (11.0% vs 7.6%). Clinical outcomes were also similar among PAD types, but the rate of stone removal in first session and the numbers of session was significantly lower and more frequent in type B PAD (papilla located near the diverticulum) than controls respectively (23/38 [60.5%] vs 54/66 [81.8%], P ⫽.021; and 1 [1⬃2] vs 1 [1⬃3], P⫽.037, respectively) and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than controls (16.1% vs 3.0%, P ⫽.047). Conclusions: Limited EST plus LBD was effective and safe treatment modality for removing bile duct stones in patients with PAD. However, this procedure requires caution to remove stone successfully and prevent complications in some types of PAD.
T1552 Clinical Outcome of a Progressive Stenting Protocol in Patients With Anastomotic Strictures After Orthotopic Liver Transplantation Marius N. Lekkerkerker, Jan-Werner Poley, Herold J. Metselaar, Jelle Haringsma, Geert Kazemier, Casper H. Van Eijck, Ernst J. Kuipers, Marco J. Bruno Background: Anastomotic strictures are an important cause of morbidity after orthotopic liver transplantation (OLT). Endoscopic dilation has emerged as a primary treatment modality for benign biliary strictures. In benign anastomotic strictures due to orthotopic liver transplantation the outcome and complications of a progressive stenting protocol, inserting a cumulative number of plastic endoprosthesis with each successive intervention, is largely unknown. Methods: Longitudinal cohort study. Treatment was considered successful if there was stricture resolution at cholangiography, a balloon could be passed without resistance and liver enzymes returned to normal values. Results: Between May 2000 and June 2009, 375 orthotopic liver transplantations were performed in which a duct-to-duct anastomosis was created in 304 cases (81,1%). In 63 patients (20.7%) an anastomotic stricture developed. Of these patients, a progressive stenting protocol was started in 35. During treatment 1 patient died of a non-treatment-related cause (intra-abdominal bleeding). Two patients underwent a second OLT while still being stented, one because of ischemic biliary complications and 1 because of liver failure due to a hepatitis C reinfection. One patient was still being stented at the time of follow-up. After excluding these patients, 31 patients were available for the present analysis (male: female 21: 10, median age 61 years, range: 28 - 75). A progressive stenting protocol in these patients required a median number of 5 ERCP procedures (range: 2 - 11). A median of maximal 3 plastic stents (range: 2 - 8) were inserted during treatment. Twenty-one patients (67.7%) required hospital admission because of treatment-related complications. In 33 out of a total of 155 ERCPs (21.3%) a complication occurred: 12 events of cholangitis, 11 events of cholestasis, 7 events of (mild) post-ERCP pancreatitis and 3 events of treatment-
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T1549 Management of Patients With Biliary Sphincter of Oddi Disorder Without Sphincter of Oddi Manometry Evangelos Kalaitzakis, Tim Ambrose, Jane Phillips-Hughes, Jane D. Collier, Roger W. Chapman The paucity of controlled data for the treatment of most biliary Sphincter of Oddi disorder (SOD) types and the incomplete response to therapy seen in clinical practice as well as in several trials, has generated controversy as to the best course of management of these patients. We aimed to assess the outcome of patients with SOD managed without sphincter of Oddi manometry. Methods A total of 59 patients (53 female, median age 46 years, 26 with previous cholecystectomy) with biliary SOD (14% type I, 51% type II, 35% type III) were prospectively enrolled. All patients with a dilated common bile duct were offered endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy whereas all others were offered medical treatment alone. Patients were followed up for a median of 15 months and were assessed clinically for response to treatment.Results Thirty-three patients (56%) has a dilated common bile duct on imaging at presentation. At follow-up 15.3% of patients reported complete symptom resolution, 59.3% improvement, 22% unchanged symptoms, and 3.4% symptom deterioration. Fifty-one percent experienced symptom resolution/ improvement on medical treatment only, 12% after sphincterotomy, and 10% after both medical treatment/sphincterotomy. Twenty percent experienced at least one recurrence of symptoms after initial response to medical and/or endoscopic treatment. Fifty ERCP procedures were performed in 24 patients with an 18% (9/50) complication rate (16% post-ERCP pancreatitis). Seven out of nine complications were mild and all patients with complications were treated conservatively; no post-ERCP mortality was observed. The proportions of patients reporting symptom resolution/improvement during follow-up did not differ significantly (p⬎0.05) among patients with SOD type I (63%), type II (77%), or type III (76%). Among patients undergoing ERCP, the proportion of patients experiencing a post-ERCP complication did not differ significantly between patients reporting symptom resolution/improvement (35%) and those reporting stable or deteriorating symptoms (50%) at the end of follow-up (p⬎0.05). Age, gender, comorbidity (psychiatric or other), dilated common bile duct, presence of intact gallbladder, or opiate use were not related to the effect of treatment at the end of follow-up (p⬎0.05 for all). Conclusion Patients with biliary SOD may be managed with a combination of endoscopic sphincterotomy (performed in those with dilated common bile duct) and medical therapy without utilization of manometry. The results of this approach with regards to symptomatic relief and ERCP complication rate are comparable to those previously published in the literature.
T1550 EPLBD With or Without Needle Knife Fistulotomy Is Safe and Effective for the Treatment of CBD Stones in Cases of Billroth II Anastomosis With Subtotal Gastrectomy Hui Won Jang, Semi Park, Jeong Youp Park, Seung Woo Park, Si Young Song, Jae Bock Chung, Seungmin Bang (1)Background: In patients with Billroth II (B-II) anastomosis with subtotal gastrectomy, endoscopic treatment of CBD stone requires more precise technique. Especially, endoscopic sphincterotomy in that situation is frequently troublesome. Endoscopic papillary large balloon dilation (EPLBD) is emerging as an effective alternative to conventional EST.(2)Aims & Methods: We evaluated the efficacy and safety of EPLBD with or without needle knife fistulotomy (NKF) in CBD stone patients with B-II anastomosis and subtotal gastrectomy. From June 2006 to August 2009, the patients with CBD stone, who had received subtotal gastrectomy and B-II anastomosis previously, were included for this study. For the procedure, conventional side-view duodenoscopy was used. EPLBD was performed with 10 -18 mm balloon catheter (CRE wire-guided dilator, Boston Scientific Corp. Natick, MA, USA). The balloon dilation was done after NKF in cases of failure to cannulate CBD selectively. (3)Results: Total 30 patients (24 of male) underwent EPLBD for the retrieval of CBD stones, 11 patients with
AB306 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
concurrent NKF. The mean diameter of CBD was 13.3⫾2.7 mm (range 9-18) and the balloon was 11.8⫾1.4 mm (range 10-14). Eleven patients had gallbladder stones in initial diagnosis. Bile duct stones were successfully removed in all patients. Complete removal of bile duct stones was achieved by repeated ERCP in three patients (10%). Interestingly, mechanical lithotripsy was not required in all cases. In the aspect of acute complications, post-EPLBD pancreatitis was developed only in one patient (3.3%), which were mild grade. Perforation and bleeding was not developed. In the late complications, stone recurrence and cholangitis were not seen. Cholecystitis occurred in two of 11 patients with gallbladder stone.(4)Conclusions: In cases of B-II anastomosis, EPLBD is a safe and highly effective technique for the retrieval of CBD stones. Although this study has some limitations, EPLBD should be considered as an alternative tool to conventional EST.
T1551 Limited Endoscopic Sphincterotomy Plus Large Balloon Sphincteroplasty for Removal of Bile Duct Stones According to the Types of Periampullary Diverticulum Cheol Woong Choi, Hyung Wook Kim, Dae Hwan Kang, Kee Tae Park, Gyoun Hong Kwon, Su Bum Park, Yong Wan Sung, Jae Hyung Lee Background and study aims: Endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) is a useful method to remove bile duct stones, but the effectiveness and safety of this procedure is not well known in patients with periampullary diverticula (PAD) which are reportedly associated with difficulties and complications associated procedures. We conducted this trial to evaluate the effectiveness and safety of limited EST plus LBD for removal of bile duct stones in patients with PAD.Patients and methods: A total of 139 patients with bile duct stones were treated with LBD (10⬃20 mm balloon diameter) after limited EST. Out of them, 73 patients had PAD and 66 patients did not have PAD (controls). Stone removal and complications were retrospectively evaluated.Results: There were no significant differences between groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complication (11.0% vs 7.6%). Clinical outcomes were also similar among PAD types, but the rate of stone removal in first session and the numbers of session was significantly lower and more frequent in type B PAD (papilla located near the diverticulum) than controls respectively (23/38 [60.5%] vs 54/66 [81.8%], P ⫽.021; and 1 [1⬃2] vs 1 [1⬃3], P⫽.037, respectively) and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than controls (16.1% vs 3.0%, P ⫽.047). Conclusions: Limited EST plus LBD was effective and safe treatment modality for removing bile duct stones in patients with PAD. However, this procedure requires caution to remove stone successfully and prevent complications in some types of PAD.
T1552 Clinical Outcome of a Progressive Stenting Protocol in Patients With Anastomotic Strictures After Orthotopic Liver Transplantation Marius N. Lekkerkerker, Jan-Werner Poley, Herold J. Metselaar, Jelle Haringsma, Geert Kazemier, Casper H. Van Eijck, Ernst J. Kuipers, Marco J. Bruno Background: Anastomotic strictures are an important cause of morbidity after orthotopic liver transplantation (OLT). Endoscopic dilation has emerged as a primary treatment modality for benign biliary strictures. In benign anastomotic strictures due to orthotopic liver transplantation the outcome and complications of a progressive stenting protocol, inserting a cumulative number of plastic endoprosthesis with each successive intervention, is largely unknown. Methods: Longitudinal cohort study. Treatment was considered successful if there was stricture resolution at cholangiography, a balloon could be passed without resistance and liver enzymes returned to normal values. Results: Between May 2000 and June 2009, 375 orthotopic liver transplantations were performed in which a duct-to-duct anastomosis was created in 304 cases (81,1%). In 63 patients (20.7%) an anastomotic stricture developed. Of these patients, a progressive stenting protocol was started in 35. During treatment 1 patient died of a non-treatment-related cause (intra-abdominal bleeding). Two patients underwent a second OLT while still being stented, one because of ischemic biliary complications and 1 because of liver failure due to a hepatitis C reinfection. One patient was still being stented at the time of follow-up. After excluding these patients, 31 patients were available for the present analysis (male: female 21: 10, median age 61 years, range: 28 - 75). A progressive stenting protocol in these patients required a median number of 5 ERCP procedures (range: 2 - 11). A median of maximal 3 plastic stents (range: 2 - 8) were inserted during treatment. Twenty-one patients (67.7%) required hospital admission because of treatment-related complications. In 33 out of a total of 155 ERCPs (21.3%) a complication occurred: 12 events of cholangitis, 11 events of cholestasis, 7 events of (mild) post-ERCP pancreatitis and 3 events of treatment-
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