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Tu1477 Single Session Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) Replaces Perioperative ERCP for Treating Choledocholithiasis
Abstracts
improved clinically after ERCP and were discharged home for follow up. Conclusions: LFT patterns including elevation or decline are not helpful in predicting post-cholecystectomy bile duct injuries. When clinical suspicion for a bile leak is present, ERCP should be performed despite the LFT patterns. ERCP is highly successful in diagnosing, localizing, and managing bile duct leaks.
ERCP FINDINGS ———> Mean AST (Units/L) Median/range of AST (Units/L) Mean ALT (Units/L) Median/range of ALT (Units/L) Mean Alkaline Phosphatase (Units/L) Median/ range of Alkaline Phosphatase (Units/L) Mean Total bilirubin (mg/dL) Median/range Total bilirubin (mg/dL)
BILE DUCT INJURY (N[59)
NORMAL DUCT (N[20)
75 489 (12 – 503) 86 368 (5 – 373) 183 309 (53 – 362)
116 371 (9 – 380) 158 921 (14 – 935) 209 569 (88 – 657)
0.36
1.2 4.6 (0.2 – 4.8)
1.3 2.4 (0.5 – 2.9)
0.81
P VALUE
0.37 0.67
Tu1477 Single Session Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) Replaces Perioperative ERCP for Treating Choledocholithiasis John M. Bozdech*, John T. Barbagiovanni Quincy Medical Group, Quincy, IL No major society includes single session laparoscopic cholecystectomy and ERCP (SSCE) in guidelines for the treatment of choledocholithiasis (CDL). We have found this safe and effective.Working with our surgical and anesthesia colleagues we attempted to replace split session cholecystectomy and ERCP with SSCE.We reviewed sucess rate, complications, length of hospitalization,and outcomes Methods: Retrospective review of ERCP performed 4/1/2014-10/15/16 at community hospital in small rural city. All ERCP done by authors. Informed consent was obtained for ERCP prior to cholecystectomy. SSCE ERCP performed after laparoscopic cholecystectomy in prone position under general anesthesia with portable fluoroscopy. Endoscopic ultrasound was not available. Advanced endoscopy referral centers are more than 130 miles distant. Results: 175 ERCP performed during study period for all indications. 49 patients had SSCE. Median age 68, ASA 3, bilirubin 2.2. Emergency department admission 35, hospital transfer 7. Preoperative imaging included ultrasound (38), CT (24) and MRCP (6). Imaging demonstrated CDL (16) or dilated duct (22). Preoperative diagnosis was acute cholecystitis (9), acute cholecystitis with CDL (19), gallstone pancreatitis (9), CDL (9), cholelithiasis (3). Intraoperative cholangiogram (IOC) attempted in 37, CDL found in 29, no drainage in 5. All patients had a biliary sphincterotomy. ERCP found CDL( 38), sludge (3), stricture (2), normal or small amount of debris (2) and unsuccessful access (2). Successful stone clearance at initial session 37/38. Pancreatic wire assistance (3), balloon dilation of papilla (1) and biliary stent placement (bleeding-2, residual stone,debris or edema-5,bile leak-1) were performed. There was no use of transcystic wire, pancreatic stent or precut sphincterotomy. Indomethacin was given to 4 patients. Room time both procedures 131+41 med 124 minutes. Median start time 1551. Complications: Minor bleeding-2. No pancreatitis or perforation. There were unrelated deaths (dementia,ischemic colitis) at 2 and 4 weeks. Both unsuccessful ERCP sent to tertiary care center, one with stone, 1 with sludge. 4 unplanned ERCP for stent migration, stone migration from gallbladder remnant, residual stone (2) including one from tertiary care salvage ERCP. Followup: LOS entire stay 3.9+2.3 median 3d. LOS after ERCP 2.8+4.7 median 1d. 30 patients discharged day after SSCE, 36 1-2 days after SSCE. Patient followup 17+4 median 8 weeks. 2 lost to followup. Perioperative ERCP for CDL (not SSCE) during study period: ERCP for CDL within 7 d of LC-8, IOC done in 6. ERCP for CDL > 7d after LC-7, IOC not done in 5. Conclusions: Single session laparoscopic cholecystectomy and ERCP for choledocholithiasis can replace the majority of perioperative ERCP with high success rate, low complications, and short hospital stay.
Tu1478 Comparison of Standard and Pig-Tail Plastic Stents in the Treatment of Residual Common Bile Duct Stones Mustafa Kartal, Hakan Camyar, Cem Cekic, Fatih Aslan, Sezgin Vatansever, Zehra Akpinar*, Emrah Alper, Belkis Unsal Gastroenterology, Izmir Ataturk Research And Training Hospital, Izmir, Turkey
study was to compare the effectivity of pig-tail plastic and standard plastic stents in the treatment of patients with dilated common bile duct and large stones which cannot be extracted with balloon and basket. Methods: Between January 2012 September 2015 patients who had undergone endoscopic retrograde cholangiopancreatography (ERCP) and despite adequate endoscopic sphincterotomy at least 1 common bile duct stone 10 mm could not be extracted with balloon/basket and 10F diameter pig-tail or standard plastic stent were placed in the common bile duct were taken into the study. Patients with cholangitis, benign or malignant biliary strictures, pancreatic- peripancreatic or periampullary mass lesions, chronic pancreatitis, postoperative bile leak or stricture were excluded. Patients in both groups (pig-tail or standard plastic stent group) cholestatic enzymes at 3rd -6 th months, ERCP results at 3rd or 6th month, need for recurrent ERCP due to stent occlusion or stent migration after the first procedure or number of repetitive ERCPs, and the frequency of complete extraction of the residual stones were evaluated. Results: In the standard plastic stent group (group1) there were 70 patients (33M/ 37F) with mean age 67.6 years and in the pig-tail stent group (group2) there were 50 patients (26 M/24 F) with mean age 64.2 years. There was no statistical difference between the groups in regards of demographic data and initial laboratory findings. Cholangitis developed in 25.7% (nZ18) of patients in group 1 and 6% (nZ3) of patients in group 2 (pZ0.006). Stent occlusion was seen in 35.7% (nZ25) of patients in group 1 whereas 10% (nZ5) in group 2 (pZ0.001). The rate of residual stone extraction in the second ERCP was 37.1%(nZ26) in the first and 42% (nZ21) in the second group (pZ0.71). The stent fell off in 28.6% (nZ20) of patients in group1 and 6% (nZ3) of patients in group2 (pZ0.0001) and stent migration in the common bile duct was seen in 17.1% (nZ12) and 2% (nZ1) in group 1 and 2, respectively (pZ0.0001). Discussion: In this study standard plastic and pig-tail plastic stents seem to be equally effective in treatment of residual common bile duct stone extraction. However cholangitis and stent complications like migration or occlusion are more common in the standard plastic stent group. We think that pigtail plastic stent is superior to standard plastic stent in regards to effectivity and stent dysfunction.
Tu1479 Predictors of Migration of Self-Expandale Metal Stent in Malignant Biliary Stricture Sunguk Jang*, Mansour A. Parsi, Tyler Stevens, Madhusudhan R. Sanaka, Amit Bhatt, Prabhleen Chahal, John J. Vargo Gastroenterology, Cleveland Clinic, Cleveland, OH Background: Self-expandable metal stent (SEMS) has been widely used in treatment of malignant biliary stricture. Despite its effectiveness, SEMS suffers from untimely migration requiring costly re-intervention. We aimed to identify factors associated with increased risk of SEMS migration. Methods: A retrospective cohort study was conducted using a registry of consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary SEMS placement at the Cleveland Clinic Foundation. Those with SEMS insertion for the treatment of malignant biliary stricture were identified. Variables including patient demographic, BMI, diagnosis, indication, stricture location, stricture length (if available), status of chemotherapy, gallbladder status were collected. Stent brand, type (covered vs. uncovered SEMS), length and diameter were also included in analysis. SEMS migration was defined as endoscopic confirmation of SEMS displacement from original location, requiring further intervention. The rates of technical and clinical success (defined as ability to achieve prompt biliary decompression resulting in significant symptomatic relief without the need to re-intervene within 14 days of SEMS deployment) were also measured. Univariable and multi-variable analyses were performed to identify factors that are associated with statistically significant hazard rate (HR) of SEMS migration. Result: There were 463 cases of SEMS placement for the management of malignant biliary stricture between 2010 and 2016 (Table 1). Technical success was achieved in 458 cases (98.9%). Clinical success was achieved in 444 cases (95.9%). Median follow-up duration was 78 days [25th, 75th percentiles: 30.3, 154]. Total of 24 cases of stent migration were observed: 20 cases with fully covered SEMS use and 4 cases with uncovered SEMS use. Both univariable and multivariable analyses revealed proximal (peri-hilar) location of malignant stricture and the use of fully covered SEMS were associated with statistically significant increase in hazard rate (HR) of stent migration (HR Z 8.2, P <0.001, with covered SEMS use and HR Z 4.35, P Z 0.008 with proximal location of stricture in multivariable analysis). No other variables investigated showed statistically significant HR. Conclusion: Although highly successful in management of malignant biliary stricture, the use of SEMS is also associated with several clinically significant complications including stent migration. This large cohort study identified proximal location of extrahepatic biliary stricture and the use of covered SEMS as statistically significant factors associated with SEMS migration. Identifying modifiable factors of SEMS migration can impact in patient outcome by equipping endoscopists with evidence-based information to judiciously select the type of SEMS to be used for their patients.
Background and Aim: In the palliative treatment of residual common bile duct stones, stenting is a treatment option. For this purpose standard plastic (Amsterdam type) or pig-tail plastic stents are commonly available. The aim of this
www.giejournal.org
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB643
improved clinically after ERCP and were discharged home for follow up. Conclusions: LFT patterns including elevation or decline are not helpful in predicting post-cholecystectomy bile duct injuries. When clinical suspicion for a bile leak is present, ERCP should be performed despite the LFT patterns. ERCP is highly successful in diagnosing, localizing, and managing bile duct leaks.
ERCP FINDINGS ———> Mean AST (Units/L) Median/range of AST (Units/L) Mean ALT (Units/L) Median/range of ALT (Units/L) Mean Alkaline Phosphatase (Units/L) Median/ range of Alkaline Phosphatase (Units/L) Mean Total bilirubin (mg/dL) Median/range Total bilirubin (mg/dL)
BILE DUCT INJURY (N[59)
NORMAL DUCT (N[20)
75 489 (12 – 503) 86 368 (5 – 373) 183 309 (53 – 362)
116 371 (9 – 380) 158 921 (14 – 935) 209 569 (88 – 657)
0.36
1.2 4.6 (0.2 – 4.8)
1.3 2.4 (0.5 – 2.9)
0.81
P VALUE
0.37 0.67
Tu1477 Single Session Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) Replaces Perioperative ERCP for Treating Choledocholithiasis John M. Bozdech*, John T. Barbagiovanni Quincy Medical Group, Quincy, IL No major society includes single session laparoscopic cholecystectomy and ERCP (SSCE) in guidelines for the treatment of choledocholithiasis (CDL). We have found this safe and effective.Working with our surgical and anesthesia colleagues we attempted to replace split session cholecystectomy and ERCP with SSCE.We reviewed sucess rate, complications, length of hospitalization,and outcomes Methods: Retrospective review of ERCP performed 4/1/2014-10/15/16 at community hospital in small rural city. All ERCP done by authors. Informed consent was obtained for ERCP prior to cholecystectomy. SSCE ERCP performed after laparoscopic cholecystectomy in prone position under general anesthesia with portable fluoroscopy. Endoscopic ultrasound was not available. Advanced endoscopy referral centers are more than 130 miles distant. Results: 175 ERCP performed during study period for all indications. 49 patients had SSCE. Median age 68, ASA 3, bilirubin 2.2. Emergency department admission 35, hospital transfer 7. Preoperative imaging included ultrasound (38), CT (24) and MRCP (6). Imaging demonstrated CDL (16) or dilated duct (22). Preoperative diagnosis was acute cholecystitis (9), acute cholecystitis with CDL (19), gallstone pancreatitis (9), CDL (9), cholelithiasis (3). Intraoperative cholangiogram (IOC) attempted in 37, CDL found in 29, no drainage in 5. All patients had a biliary sphincterotomy. ERCP found CDL( 38), sludge (3), stricture (2), normal or small amount of debris (2) and unsuccessful access (2). Successful stone clearance at initial session 37/38. Pancreatic wire assistance (3), balloon dilation of papilla (1) and biliary stent placement (bleeding-2, residual stone,debris or edema-5,bile leak-1) were performed. There was no use of transcystic wire, pancreatic stent or precut sphincterotomy. Indomethacin was given to 4 patients. Room time both procedures 131+41 med 124 minutes. Median start time 1551. Complications: Minor bleeding-2. No pancreatitis or perforation. There were unrelated deaths (dementia,ischemic colitis) at 2 and 4 weeks. Both unsuccessful ERCP sent to tertiary care center, one with stone, 1 with sludge. 4 unplanned ERCP for stent migration, stone migration from gallbladder remnant, residual stone (2) including one from tertiary care salvage ERCP. Followup: LOS entire stay 3.9+2.3 median 3d. LOS after ERCP 2.8+4.7 median 1d. 30 patients discharged day after SSCE, 36 1-2 days after SSCE. Patient followup 17+4 median 8 weeks. 2 lost to followup. Perioperative ERCP for CDL (not SSCE) during study period: ERCP for CDL within 7 d of LC-8, IOC done in 6. ERCP for CDL > 7d after LC-7, IOC not done in 5. Conclusions: Single session laparoscopic cholecystectomy and ERCP for choledocholithiasis can replace the majority of perioperative ERCP with high success rate, low complications, and short hospital stay.
Tu1478 Comparison of Standard and Pig-Tail Plastic Stents in the Treatment of Residual Common Bile Duct Stones Mustafa Kartal, Hakan Camyar, Cem Cekic, Fatih Aslan, Sezgin Vatansever, Zehra Akpinar*, Emrah Alper, Belkis Unsal Gastroenterology, Izmir Ataturk Research And Training Hospital, Izmir, Turkey
study was to compare the effectivity of pig-tail plastic and standard plastic stents in the treatment of patients with dilated common bile duct and large stones which cannot be extracted with balloon and basket. Methods: Between January 2012 September 2015 patients who had undergone endoscopic retrograde cholangiopancreatography (ERCP) and despite adequate endoscopic sphincterotomy at least 1 common bile duct stone 10 mm could not be extracted with balloon/basket and 10F diameter pig-tail or standard plastic stent were placed in the common bile duct were taken into the study. Patients with cholangitis, benign or malignant biliary strictures, pancreatic- peripancreatic or periampullary mass lesions, chronic pancreatitis, postoperative bile leak or stricture were excluded. Patients in both groups (pig-tail or standard plastic stent group) cholestatic enzymes at 3rd -6 th months, ERCP results at 3rd or 6th month, need for recurrent ERCP due to stent occlusion or stent migration after the first procedure or number of repetitive ERCPs, and the frequency of complete extraction of the residual stones were evaluated. Results: In the standard plastic stent group (group1) there were 70 patients (33M/ 37F) with mean age 67.6 years and in the pig-tail stent group (group2) there were 50 patients (26 M/24 F) with mean age 64.2 years. There was no statistical difference between the groups in regards of demographic data and initial laboratory findings. Cholangitis developed in 25.7% (nZ18) of patients in group 1 and 6% (nZ3) of patients in group 2 (pZ0.006). Stent occlusion was seen in 35.7% (nZ25) of patients in group 1 whereas 10% (nZ5) in group 2 (pZ0.001). The rate of residual stone extraction in the second ERCP was 37.1%(nZ26) in the first and 42% (nZ21) in the second group (pZ0.71). The stent fell off in 28.6% (nZ20) of patients in group1 and 6% (nZ3) of patients in group2 (pZ0.0001) and stent migration in the common bile duct was seen in 17.1% (nZ12) and 2% (nZ1) in group 1 and 2, respectively (pZ0.0001). Discussion: In this study standard plastic and pig-tail plastic stents seem to be equally effective in treatment of residual common bile duct stone extraction. However cholangitis and stent complications like migration or occlusion are more common in the standard plastic stent group. We think that pigtail plastic stent is superior to standard plastic stent in regards to effectivity and stent dysfunction.
Tu1479 Predictors of Migration of Self-Expandale Metal Stent in Malignant Biliary Stricture Sunguk Jang*, Mansour A. Parsi, Tyler Stevens, Madhusudhan R. Sanaka, Amit Bhatt, Prabhleen Chahal, John J. Vargo Gastroenterology, Cleveland Clinic, Cleveland, OH Background: Self-expandable metal stent (SEMS) has been widely used in treatment of malignant biliary stricture. Despite its effectiveness, SEMS suffers from untimely migration requiring costly re-intervention. We aimed to identify factors associated with increased risk of SEMS migration. Methods: A retrospective cohort study was conducted using a registry of consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary SEMS placement at the Cleveland Clinic Foundation. Those with SEMS insertion for the treatment of malignant biliary stricture were identified. Variables including patient demographic, BMI, diagnosis, indication, stricture location, stricture length (if available), status of chemotherapy, gallbladder status were collected. Stent brand, type (covered vs. uncovered SEMS), length and diameter were also included in analysis. SEMS migration was defined as endoscopic confirmation of SEMS displacement from original location, requiring further intervention. The rates of technical and clinical success (defined as ability to achieve prompt biliary decompression resulting in significant symptomatic relief without the need to re-intervene within 14 days of SEMS deployment) were also measured. Univariable and multi-variable analyses were performed to identify factors that are associated with statistically significant hazard rate (HR) of SEMS migration. Result: There were 463 cases of SEMS placement for the management of malignant biliary stricture between 2010 and 2016 (Table 1). Technical success was achieved in 458 cases (98.9%). Clinical success was achieved in 444 cases (95.9%). Median follow-up duration was 78 days [25th, 75th percentiles: 30.3, 154]. Total of 24 cases of stent migration were observed: 20 cases with fully covered SEMS use and 4 cases with uncovered SEMS use. Both univariable and multivariable analyses revealed proximal (peri-hilar) location of malignant stricture and the use of fully covered SEMS were associated with statistically significant increase in hazard rate (HR) of stent migration (HR Z 8.2, P <0.001, with covered SEMS use and HR Z 4.35, P Z 0.008 with proximal location of stricture in multivariable analysis). No other variables investigated showed statistically significant HR. Conclusion: Although highly successful in management of malignant biliary stricture, the use of SEMS is also associated with several clinically significant complications including stent migration. This large cohort study identified proximal location of extrahepatic biliary stricture and the use of covered SEMS as statistically significant factors associated with SEMS migration. Identifying modifiable factors of SEMS migration can impact in patient outcome by equipping endoscopists with evidence-based information to judiciously select the type of SEMS to be used for their patients.
Background and Aim: In the palliative treatment of residual common bile duct stones, stenting is a treatment option. For this purpose standard plastic (Amsterdam type) or pig-tail plastic stents are commonly available. The aim of this
www.giejournal.org
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB643