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Tu1459 Factors Associated With Positive and Negative Findings of Choledocholithiasis in Endoscopic Retrograde Cholangiography
Abstracts
Univariate
EPLBD EST secondary stones migrated from GB any symptom*
Multivariate
HR
95% CI
P value
0.81 2.05 0.88
0.11-5.97 0.49-8.69 0.42-1.86
0.84 0.33 0.74
0.60
0.28-1.31
0.20
HR
95% CI
P value
0.56
0.25-1.23
0.15
(*) in first recurrence, CBDS: common bile duct stone, EML: endoscopic mechanical lithotripsy, GB: gallbladder, CCx: cholecystectomy, EPBD: endoscopic papillary balloon dilation, EST: sphincterotomy, EPLBD: endoscopic papillary large balloon dilation, EST: endoscopic, HR: hazard ratio, CI: confidence interval
Tu1457 The Friction Effect of Plastic Stents for Biliary Stone Fragmentation Chang Il Kwon*1, Gwangil Kim1, Seok Jeong2, Sung Hoon Choi1, Kwang Hyun Ko1, Don Haeng Lee2 1 Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea (the Republic of); 2Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea (the Republic of) Background/Aims: In patients with irretrievable or intractable common bile duct stone (CBDS), short-term insertion of plastic stents (PS) followed by further ERCP or surgery has been recommended as a “bridge” therapy to prevent stone impaction and cholangitis. The reason for the short-term insertion of PS is not only to achieve adequate biliary drainage, but also to fragment CBDS to some degree. However, exact mechanism of stone fragmentation has not been discovered. The aim of this study was to evaluate whether PS shape can improve stone fragmentation. Methods: Using an in vitro bile flow phantom model, we compared the friction effect among the three different PS groups (straight-shaped PS group; double pigtail-shaped PS group, and screw-shaped PS group) and control group. All stones were hard and obtained from patients with cholecystectomy. Each group had 10 silicon tube rooms that contained one stone and two PS. The stone was located between the proximal head of two overlapped PS. The control group had 10 rooms each with only a stone and no PS. To reflect special actions like human breathing movements, all the silicon tubes were fixed on a special shaker to let the tubes swing continuously (20/min). We performed an analysis of the degree of friction effect by weight and volume change. Results: Eight weeks after the PS and stones insertion in the phantom model, all the stones were retrieved and analyzed. Complete fragmentation was noted in one stone of 34 cholesterol stones (2.9%), and four stones of six pigmented stones (66.7%). After exclusion of those fragmented stones, % of volume change and weight change were analyzed among the groups. Volume change and weight change were more prominent in the screw-shaped PS group than they were in the straightshaped PS group, double pigtail-shaped group, and control group (volume change: -10.13%, 7.94%, 5.06%, and 2.05%, respectively; weight change: -8.05%, 0.71%, -0.35%, and -1.23%, respectively). Conclusion: Stone fragmentation can be induced by PS friction effect. Also, special shape of plastic stent could improve friction effect. These results may help guiding future PS development and clinical decisions.
Tu1458 Occlusion Cholangiography Does Not Impact the Rate of Recurrent Choledocholithiasis in Patients Who Undergo ERCP With Stone Extraction Matthew J. Skinner*, Christopher C. Thompson Brigham & Women’s Hospital, Boston, MA Background: Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP) in the United States. Occlusive cholangiography is commonly used to ensure that all stones are removed from the common bile duct (CBD); however, employment of this technique and documentation varies widely between practitioners. Currently there is no evidence to suggest occlusion cholangiography improves outcomes following ERCP. Furthermore, it is unclear whether endoscopists should pursue an alternative imaging modality in cases of cholangitis where an occlusion cholangiogram is a relative contraindication. Aim: Determine if occlusion cholangiography decreases the rate of recurrent choledocholithiasis at 30 days in patients treated with ERCP for an initial choledocholithiasis event. Methods: A prospective multicenter registry was queried to find all patients who underwent ERCP for choledocholithiasis between 7/2014 and 7/2016 with records abstracted for chart review. Inclusion criteria required that choledocholithiasis was confirmed on ERCP or imaging study (MRCP, CT, US, cholangiogram). Patients were excluded if they had: known retained choledocholithiasis at conclusion of ERCP, biliary stricture, pancreaticobiliary or liver malignancy, cystic fibrosis, prior hepaticojejunostomy, or a choledochal cyst. Collected data included age, sex, whether or not the patients had cholangitis, prior or index cholecystectomy, cholelithiasis, required lithotripsy, or had a biliary stent left in place. The outcome of recurrent choledocholithiasis was established if choledocholithiasis was noted on repeat ERCP or imaging test. Results: The initial database returned 442 patients, with 99 meeting all criteria. 78 patients underwent an occlusion cholangiogram and 21 did not. There were two cases of recurrent choledocholithiasis, and both occurred in the group that received the occlusion cholangiogram (2.6%). Patient 1 had undergone an index cholecystectomy, and after the procedure was noted to have “at least 10 stones” in the CBD. Patient 2 was noted to have cholelithiasis and choledocholithiasis on US; however, repeat ERCP did not demonstrate a stone. Conclusions: These findings suggest that there is no difference in the rate of recurrent choledocholithiasis following ERCP weather or not an occlusion cholangiogram is performed. As such, occlusion cholangiography may not be necessary following sphincterotomy and balloon sweep of choledocholithiasis, and can potentially be reserved for difficult cases when clearance of the CBD is uncertain.
Table 1 – Patient characteristics Percent Male Age (Years) Prior Cholecystectomy Index Cholecystectomy Cholelithiasis Sphincterotomy Cholangitis
Occlusion Cholangiogram
None
44.8 11.3 67.0 4.4 .328 .118 .526 .133 .745 .119 .98 .030 .128 .076
52.3 23.3 66.3 9.3 .143 .163 .277 .229 .667 .241 1.000 0 .714 .211
Tu1459 Factors Associated With Positive and Negative Findings of Choledocholithiasis in Endoscopic Retrograde Cholangiography Romulo D. Vargas, Diego M. Guerrero, Carlos A. Espinosa*, Gerardo A. Puentes, Raul A. Cañadas, Reinaldo A. Rincon, Alberto Rodriguez, Paola Roa, Alvaro A. Gomez, Diego A. Bonilla, Andrea Velasquez Hospital Universitario San Ignacio, Bogota, Colombia Background: Cholelithiasis is a common disease worldwide and Latin America is one of the regions with highest prevalence. Predictive scales are currently used to estimate risk of choledocholithiasis. When patients have high probability of common bile duct stones (CBDS), guidelines recommend performing endoscopic retrograde cholangiography (ERCP) as a minimal- invasive first choice strategy to remove stones. However, there is a significant proportion of patients classified as high risk that have no stones on ERCP. Aim: To evaluate and compare the positive and negative ERCP findings in patients with suspected high risk for choledocholithiasis, and determine any association with demographic features, clinical and non-invasive diagnostic tests. Methods: A retrospective analysis was performed at Hospital universitario San Ignacio in Bogota, Colombia. We evaluated 771 consecutive patients who underwent ERCP, and were classified in 2 groups: ERCP positive and negative findings for CBDS. Patients before performing ERCP were classified using ASGE
AB636 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org
Abstracts
criteria in high risk for choledocholithiasis or intermediate risk with demonstrated CBDS by any diagnostic image as transabdominal ultrasound, biliary magnetic resonance (MRI) and biliopancreatic endoscopic ultrasonography (EUS). Results: We identified CBDS in 571 patients post ERCP (74,05%). We performed a bivariate analysis by age, classifying patients in 2 groups: those over 50 years (nZ499) and those under 50 years (nZ272). Also, we identified CBDS in 69% of patients under 50 years old and 77% in those over 50 years old. Other variables evaluated were: time of performing ERCP since emergency admission, jaundice, pancreatitis, cholangitis, prior cholecystectomy. Patients with positive ERCP findings have twice jaundice and more rates of acute cholangitis. Patients with acute pancreatitis, low alkaline phosphatase levels had more rates of ERCP negative findings. Patients with previous cholecystectomy had more rates of ERCP negative findings. (25% positive CBDS). 126 patients (63%) with ERCP negative findings were previously classified as high risk for choledocholithiasis based on liver enzymes and CBD diameter (non- MRI, non-EUS). Conclusion: Time between admission and ERCP findings could influence in CBDS probability. Acute pancreatitis and total bilirubin were not a strong predictor for CBSD. Some patients with ERCP negative findings were classified in high risk CBSD without confirmatory images. Maybe in these cases, the most significant criteria used to perform ERCP were bilirubin levels. Current criteria to predict CBDS using only laboratory tests and CBD diameter, overestimates risk, especially patients with previous cholecystectomy. So we propose in this scenario perform confirmatory image tests.
Tu1460 Revision of Bilateral Self-Expandable Metallic Stents for Malignant Hilar Biliary Obstruction Jun Hyuk Son*1, Sang Hyub Lee1, Hee Seung Lee2, Seungmin Bang2, Jinwoo Kang1, Jae Woo Lee1, Ji Kon Ryu1, Yong-Tae Kim1 1 Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea (the Republic of); 2 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
trials and in clinical practice. Free DNA may be found in the cellular environment of neoplastic tissues due to rapid cell turn over and as a consequence of progressive mutational acquisition. However, the ability to obtain DNA from the supernatant of extracted stents and the performance of mutational analysis in distinguishing benign from malignant strictures has not been described. Methods: This study is an ongoing, prospective, controlled, single-blinded trial. An interim analysis was prespecified at accrual of 4 patients in each arm. Patients with known benign (post liver transplant anastomotic strictures) and known malignant strictures were enrolled. Plastic biliary stents extracted from patients during ERCP were sent for evaluation (Interpace Diagnostic, Pittsburgh, PA). The reference laboratory was blinded to the clinical history of the patient and the characterization of the stricture as benign or malignant. DNA was extracted from aliquots (supernatant, supernatant plus cells, cells, supernatant from stent) (Qiagen, Valencia, CA) and was quantified by optical density (NanoDrop, Thermo Scientific, Wilmington, DE). Quantitative PCR was used to establish the diagnostic yield. A validated panel included DNA markers for KRAS oncogene mutations and tumor suppressor gene loss-of-heterozygosity (LOH) mutations at 10 genomic loci. The presence or absence of KRAS mutations was examined in codons 12 and 13. Tumor suppressor gene LOH mutations were assessed at 10 loci via capillary gel electrophoresis: 1p (CMM1, Lmyc), 3p (VHL, OGG1), 5q (MCC, APC), 9p (CDKN2A, CDKN2B), 10q (PTEN, MXI1), 17p (TP53), 17q (NME1, RNF34), 18q (SMAD4, DCC), 21q (TFF1, PSEN2), and 22q (NF2). Results: Eight patients were included in the pre-specified interim analysis. Four patients with orthotropic liver transplantation had a known benign biliary anastomotic stricture and four patients had malignant biliary stricture. Mean age was 70.8+/-5.3 yrs. There were two male and six female patients. Mean AST was 112.2+/- 82.1U/L, mean ALT was 146.4+/-178.8 U/L, mean ALP was 452.7+/-334.7 U/L and total bilirubin was 8+/7.9 mg/dl. The supernatant and the KRAS performed with a very high specificity (100%) and a moderate sensitivity (50%); complete mutational analysis (Table 1). Conclusion: Stent supernatant fluid contains analyzable material, which is suitable for molecular characterization. The supernatant and the KRAS mutation analyses performed with very high specificity (100%) and moderate sensitivity (50%) in a small cohort. This interim analysis suggests that the stent supernatant analysis may be a promising adjunct to the low discriminatory capability of brush cytology for biliary strictures.
Background/Aims: Endoscopic biliary decompression using bilateral self-expandable metallic stents (SEMS) is considered as a favorable procedure for unresectable malignant hilar biliary obstruction. However occlusion of the bilateral SEMS is frequently occurred and revision can be challenging. This study was performed to evaluate the efficacy and the long-term patency of revision of bilateral SEMS and to investigate which revision method had better patency, endoscopic or percutaneous in patients with malignant hilar biliary obstruction. Methods: From January 2011 to July 2016, ninety-one patients with hilar biliary obstruction underwent endoscopic bilateral SEMS insertion in two tertiary hospitals located in South Korea. Among 91 patents, 74 patients were followed-up more than 30 days. We retrospectively reviewed the medical records. Results: Of the seventy-four patients, 38 experienced occlusion of previously inserted SEMS and underwent revision. Mean age of the patients was 69.2 years. The most common etiology of hilar biliary obstruction was cholangiocarcinoma (52.6%), followed by gallbladder cancer (34.2%) and the other metastatic cancer (13.2%). The mean patent duration of previously inserted SEMS was 170.6 days. Endoscopic revision (76.3%) or percutaneous revision (23.7%) was performed to resolve the occlusion. Clinical success rate of the primary revision was 44.7% and the mean patent duration was turned out to be 50.8 days. Twenty-four patients received second revision and 15 patients underwent third revision thereafter. Mean follow-up duration was 281.6 days after bilateral SEMS insertion and 120.2 days after primary revision. Comparing the revision method, clinical success rate was comparable between endoscopic revision and percutaneous revision (44.8% vs. 44.4%, pZ0.577). The patent duration after revision was 49.1 days in the endoscopic revision group and 56.3 days in the percutaneous revision group (pZ0.774). Conclusions: Palliative bilateral SEMS insertion was effective for unresectable malignant hilar biliary obstruction, however the efficacy and patency of occluded bilateral SEMS was not satisfactory. Endoscopic revision is preferred for the convenience of patients.
Tu1461 Prospective Molecular Mutational Analysis of Stent Supernatant in the Characterization of Benign and Malignant Biliary Strictures, an Interim Analysis Sunil Dacha*1, Jennifer Sprague3, Nicole Toney2, Steven Keilin1, Qiang Cai1, Field F. Willingham1 1 Dept. of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA; 2Interpace Diagnostics, Pittsburgh, PA; 3 Interpace Diagnostics, Pittsburgh, PA Introduction: The sensitivity of traditional modalities such as brush cytology in differentiating benign from malignant biliary strictures has been low in reported
www.giejournal.org
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB637
Univariate
EPLBD EST secondary stones migrated from GB any symptom*
Multivariate
HR
95% CI
P value
0.81 2.05 0.88
0.11-5.97 0.49-8.69 0.42-1.86
0.84 0.33 0.74
0.60
0.28-1.31
0.20
HR
95% CI
P value
0.56
0.25-1.23
0.15
(*) in first recurrence, CBDS: common bile duct stone, EML: endoscopic mechanical lithotripsy, GB: gallbladder, CCx: cholecystectomy, EPBD: endoscopic papillary balloon dilation, EST: sphincterotomy, EPLBD: endoscopic papillary large balloon dilation, EST: endoscopic, HR: hazard ratio, CI: confidence interval
Tu1457 The Friction Effect of Plastic Stents for Biliary Stone Fragmentation Chang Il Kwon*1, Gwangil Kim1, Seok Jeong2, Sung Hoon Choi1, Kwang Hyun Ko1, Don Haeng Lee2 1 Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea (the Republic of); 2Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea (the Republic of) Background/Aims: In patients with irretrievable or intractable common bile duct stone (CBDS), short-term insertion of plastic stents (PS) followed by further ERCP or surgery has been recommended as a “bridge” therapy to prevent stone impaction and cholangitis. The reason for the short-term insertion of PS is not only to achieve adequate biliary drainage, but also to fragment CBDS to some degree. However, exact mechanism of stone fragmentation has not been discovered. The aim of this study was to evaluate whether PS shape can improve stone fragmentation. Methods: Using an in vitro bile flow phantom model, we compared the friction effect among the three different PS groups (straight-shaped PS group; double pigtail-shaped PS group, and screw-shaped PS group) and control group. All stones were hard and obtained from patients with cholecystectomy. Each group had 10 silicon tube rooms that contained one stone and two PS. The stone was located between the proximal head of two overlapped PS. The control group had 10 rooms each with only a stone and no PS. To reflect special actions like human breathing movements, all the silicon tubes were fixed on a special shaker to let the tubes swing continuously (20/min). We performed an analysis of the degree of friction effect by weight and volume change. Results: Eight weeks after the PS and stones insertion in the phantom model, all the stones were retrieved and analyzed. Complete fragmentation was noted in one stone of 34 cholesterol stones (2.9%), and four stones of six pigmented stones (66.7%). After exclusion of those fragmented stones, % of volume change and weight change were analyzed among the groups. Volume change and weight change were more prominent in the screw-shaped PS group than they were in the straightshaped PS group, double pigtail-shaped group, and control group (volume change: -10.13%, 7.94%, 5.06%, and 2.05%, respectively; weight change: -8.05%, 0.71%, -0.35%, and -1.23%, respectively). Conclusion: Stone fragmentation can be induced by PS friction effect. Also, special shape of plastic stent could improve friction effect. These results may help guiding future PS development and clinical decisions.
Tu1458 Occlusion Cholangiography Does Not Impact the Rate of Recurrent Choledocholithiasis in Patients Who Undergo ERCP With Stone Extraction Matthew J. Skinner*, Christopher C. Thompson Brigham & Women’s Hospital, Boston, MA Background: Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP) in the United States. Occlusive cholangiography is commonly used to ensure that all stones are removed from the common bile duct (CBD); however, employment of this technique and documentation varies widely between practitioners. Currently there is no evidence to suggest occlusion cholangiography improves outcomes following ERCP. Furthermore, it is unclear whether endoscopists should pursue an alternative imaging modality in cases of cholangitis where an occlusion cholangiogram is a relative contraindication. Aim: Determine if occlusion cholangiography decreases the rate of recurrent choledocholithiasis at 30 days in patients treated with ERCP for an initial choledocholithiasis event. Methods: A prospective multicenter registry was queried to find all patients who underwent ERCP for choledocholithiasis between 7/2014 and 7/2016 with records abstracted for chart review. Inclusion criteria required that choledocholithiasis was confirmed on ERCP or imaging study (MRCP, CT, US, cholangiogram). Patients were excluded if they had: known retained choledocholithiasis at conclusion of ERCP, biliary stricture, pancreaticobiliary or liver malignancy, cystic fibrosis, prior hepaticojejunostomy, or a choledochal cyst. Collected data included age, sex, whether or not the patients had cholangitis, prior or index cholecystectomy, cholelithiasis, required lithotripsy, or had a biliary stent left in place. The outcome of recurrent choledocholithiasis was established if choledocholithiasis was noted on repeat ERCP or imaging test. Results: The initial database returned 442 patients, with 99 meeting all criteria. 78 patients underwent an occlusion cholangiogram and 21 did not. There were two cases of recurrent choledocholithiasis, and both occurred in the group that received the occlusion cholangiogram (2.6%). Patient 1 had undergone an index cholecystectomy, and after the procedure was noted to have “at least 10 stones” in the CBD. Patient 2 was noted to have cholelithiasis and choledocholithiasis on US; however, repeat ERCP did not demonstrate a stone. Conclusions: These findings suggest that there is no difference in the rate of recurrent choledocholithiasis following ERCP weather or not an occlusion cholangiogram is performed. As such, occlusion cholangiography may not be necessary following sphincterotomy and balloon sweep of choledocholithiasis, and can potentially be reserved for difficult cases when clearance of the CBD is uncertain.
Table 1 – Patient characteristics Percent Male Age (Years) Prior Cholecystectomy Index Cholecystectomy Cholelithiasis Sphincterotomy Cholangitis
Occlusion Cholangiogram
None
44.8 11.3 67.0 4.4 .328 .118 .526 .133 .745 .119 .98 .030 .128 .076
52.3 23.3 66.3 9.3 .143 .163 .277 .229 .667 .241 1.000 0 .714 .211
Tu1459 Factors Associated With Positive and Negative Findings of Choledocholithiasis in Endoscopic Retrograde Cholangiography Romulo D. Vargas, Diego M. Guerrero, Carlos A. Espinosa*, Gerardo A. Puentes, Raul A. Cañadas, Reinaldo A. Rincon, Alberto Rodriguez, Paola Roa, Alvaro A. Gomez, Diego A. Bonilla, Andrea Velasquez Hospital Universitario San Ignacio, Bogota, Colombia Background: Cholelithiasis is a common disease worldwide and Latin America is one of the regions with highest prevalence. Predictive scales are currently used to estimate risk of choledocholithiasis. When patients have high probability of common bile duct stones (CBDS), guidelines recommend performing endoscopic retrograde cholangiography (ERCP) as a minimal- invasive first choice strategy to remove stones. However, there is a significant proportion of patients classified as high risk that have no stones on ERCP. Aim: To evaluate and compare the positive and negative ERCP findings in patients with suspected high risk for choledocholithiasis, and determine any association with demographic features, clinical and non-invasive diagnostic tests. Methods: A retrospective analysis was performed at Hospital universitario San Ignacio in Bogota, Colombia. We evaluated 771 consecutive patients who underwent ERCP, and were classified in 2 groups: ERCP positive and negative findings for CBDS. Patients before performing ERCP were classified using ASGE
AB636 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org
Abstracts
criteria in high risk for choledocholithiasis or intermediate risk with demonstrated CBDS by any diagnostic image as transabdominal ultrasound, biliary magnetic resonance (MRI) and biliopancreatic endoscopic ultrasonography (EUS). Results: We identified CBDS in 571 patients post ERCP (74,05%). We performed a bivariate analysis by age, classifying patients in 2 groups: those over 50 years (nZ499) and those under 50 years (nZ272). Also, we identified CBDS in 69% of patients under 50 years old and 77% in those over 50 years old. Other variables evaluated were: time of performing ERCP since emergency admission, jaundice, pancreatitis, cholangitis, prior cholecystectomy. Patients with positive ERCP findings have twice jaundice and more rates of acute cholangitis. Patients with acute pancreatitis, low alkaline phosphatase levels had more rates of ERCP negative findings. Patients with previous cholecystectomy had more rates of ERCP negative findings. (25% positive CBDS). 126 patients (63%) with ERCP negative findings were previously classified as high risk for choledocholithiasis based on liver enzymes and CBD diameter (non- MRI, non-EUS). Conclusion: Time between admission and ERCP findings could influence in CBDS probability. Acute pancreatitis and total bilirubin were not a strong predictor for CBSD. Some patients with ERCP negative findings were classified in high risk CBSD without confirmatory images. Maybe in these cases, the most significant criteria used to perform ERCP were bilirubin levels. Current criteria to predict CBDS using only laboratory tests and CBD diameter, overestimates risk, especially patients with previous cholecystectomy. So we propose in this scenario perform confirmatory image tests.
Tu1460 Revision of Bilateral Self-Expandable Metallic Stents for Malignant Hilar Biliary Obstruction Jun Hyuk Son*1, Sang Hyub Lee1, Hee Seung Lee2, Seungmin Bang2, Jinwoo Kang1, Jae Woo Lee1, Ji Kon Ryu1, Yong-Tae Kim1 1 Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea (the Republic of); 2 Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
trials and in clinical practice. Free DNA may be found in the cellular environment of neoplastic tissues due to rapid cell turn over and as a consequence of progressive mutational acquisition. However, the ability to obtain DNA from the supernatant of extracted stents and the performance of mutational analysis in distinguishing benign from malignant strictures has not been described. Methods: This study is an ongoing, prospective, controlled, single-blinded trial. An interim analysis was prespecified at accrual of 4 patients in each arm. Patients with known benign (post liver transplant anastomotic strictures) and known malignant strictures were enrolled. Plastic biliary stents extracted from patients during ERCP were sent for evaluation (Interpace Diagnostic, Pittsburgh, PA). The reference laboratory was blinded to the clinical history of the patient and the characterization of the stricture as benign or malignant. DNA was extracted from aliquots (supernatant, supernatant plus cells, cells, supernatant from stent) (Qiagen, Valencia, CA) and was quantified by optical density (NanoDrop, Thermo Scientific, Wilmington, DE). Quantitative PCR was used to establish the diagnostic yield. A validated panel included DNA markers for KRAS oncogene mutations and tumor suppressor gene loss-of-heterozygosity (LOH) mutations at 10 genomic loci. The presence or absence of KRAS mutations was examined in codons 12 and 13. Tumor suppressor gene LOH mutations were assessed at 10 loci via capillary gel electrophoresis: 1p (CMM1, Lmyc), 3p (VHL, OGG1), 5q (MCC, APC), 9p (CDKN2A, CDKN2B), 10q (PTEN, MXI1), 17p (TP53), 17q (NME1, RNF34), 18q (SMAD4, DCC), 21q (TFF1, PSEN2), and 22q (NF2). Results: Eight patients were included in the pre-specified interim analysis. Four patients with orthotropic liver transplantation had a known benign biliary anastomotic stricture and four patients had malignant biliary stricture. Mean age was 70.8+/-5.3 yrs. There were two male and six female patients. Mean AST was 112.2+/- 82.1U/L, mean ALT was 146.4+/-178.8 U/L, mean ALP was 452.7+/-334.7 U/L and total bilirubin was 8+/7.9 mg/dl. The supernatant and the KRAS performed with a very high specificity (100%) and a moderate sensitivity (50%); complete mutational analysis (Table 1). Conclusion: Stent supernatant fluid contains analyzable material, which is suitable for molecular characterization. The supernatant and the KRAS mutation analyses performed with very high specificity (100%) and moderate sensitivity (50%) in a small cohort. This interim analysis suggests that the stent supernatant analysis may be a promising adjunct to the low discriminatory capability of brush cytology for biliary strictures.
Background/Aims: Endoscopic biliary decompression using bilateral self-expandable metallic stents (SEMS) is considered as a favorable procedure for unresectable malignant hilar biliary obstruction. However occlusion of the bilateral SEMS is frequently occurred and revision can be challenging. This study was performed to evaluate the efficacy and the long-term patency of revision of bilateral SEMS and to investigate which revision method had better patency, endoscopic or percutaneous in patients with malignant hilar biliary obstruction. Methods: From January 2011 to July 2016, ninety-one patients with hilar biliary obstruction underwent endoscopic bilateral SEMS insertion in two tertiary hospitals located in South Korea. Among 91 patents, 74 patients were followed-up more than 30 days. We retrospectively reviewed the medical records. Results: Of the seventy-four patients, 38 experienced occlusion of previously inserted SEMS and underwent revision. Mean age of the patients was 69.2 years. The most common etiology of hilar biliary obstruction was cholangiocarcinoma (52.6%), followed by gallbladder cancer (34.2%) and the other metastatic cancer (13.2%). The mean patent duration of previously inserted SEMS was 170.6 days. Endoscopic revision (76.3%) or percutaneous revision (23.7%) was performed to resolve the occlusion. Clinical success rate of the primary revision was 44.7% and the mean patent duration was turned out to be 50.8 days. Twenty-four patients received second revision and 15 patients underwent third revision thereafter. Mean follow-up duration was 281.6 days after bilateral SEMS insertion and 120.2 days after primary revision. Comparing the revision method, clinical success rate was comparable between endoscopic revision and percutaneous revision (44.8% vs. 44.4%, pZ0.577). The patent duration after revision was 49.1 days in the endoscopic revision group and 56.3 days in the percutaneous revision group (pZ0.774). Conclusions: Palliative bilateral SEMS insertion was effective for unresectable malignant hilar biliary obstruction, however the efficacy and patency of occluded bilateral SEMS was not satisfactory. Endoscopic revision is preferred for the convenience of patients.
Tu1461 Prospective Molecular Mutational Analysis of Stent Supernatant in the Characterization of Benign and Malignant Biliary Strictures, an Interim Analysis Sunil Dacha*1, Jennifer Sprague3, Nicole Toney2, Steven Keilin1, Qiang Cai1, Field F. Willingham1 1 Dept. of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA; 2Interpace Diagnostics, Pittsburgh, PA; 3 Interpace Diagnostics, Pittsburgh, PA Introduction: The sensitivity of traditional modalities such as brush cytology in differentiating benign from malignant biliary strictures has been low in reported
www.giejournal.org
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB637