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Tu1564 Double-Balloon Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Anatomy: A Single Center Experience
Abstracts
Tu1564 Double-Balloon Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Anatomy: A Single Center Experience Jan-Erick Nilsson*, Montano-Loza Aldo, Sergio Zepeda-Gomez Gastroenterology, University of Alberta, Edmonton, AB, Canada
patients presenting with acute cholangitis, utilization of ERCP and PTC have increased over the last decade while that of surgical drainage and cholecystectomy have decreased. In comparison, the likelihood of getting an ERCP for acute cholangitis is lower in South than Northeast region.
Background: Balloon assisted enteroscopy has improved our ability to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. We reviewed the experience with double-balloon ERCP (DBE-ERCP) in patients with altered anatomy and suspicion of biliary obstruction in a tertiary center. Methods: Retrospective analysis of all patients who underwent DBE-ERCP at the University of Alberta hospital between September 2011 and August 2015. Results: A total of 57 DBE-ERCPs were performed in 28 patients (16 males) with a mean age of 51 19 years (range: 20-81) using a short-type double balloon enteroscope. Twenty-seven patients had a Roux-en-Y reconstruction (25 hepatico-jejunostomies) and one patient had a prior Billroth-II gastro-jejunostomy. There were 19 patients that had previous liver transplantation (9 cadaveric, 10 living donor). There was a trend to earlier DBEERCP in living related vs cadaveric transplants [519 619 vs 1826 1907 days (pZ 0.06)]. The main indications for all procedures were suspicion of stricture at the hepatico-jejunostomy [nZ25 (44%)], recurrent cholangitis [nZ21 (37%)] and stent retrieval [nZ8 (14%)]. Therapeutic maneuvers included: stricture dilation (nZ31), extraction of stones (nZ10), stent placement (nZ10) and stent retrieval (nZ8). The hepatico-jejunostomy or major papilla was reached in 46 of 57 procedures (81%). Bile duct cannulation was successful in 40 of 46 procedures (87%). The mean number of procedures per patient was 2 1.5 (range: 1-7 procedures). The number of procedures was higher in those with liver transplantation compared to other surgeries [mean: 2.5 1.7 vs 1.3 0.48(pZ0.04)]. There were two patients with mild cholangitis after biliary manipulation that resolved with intravenous antibiotic therapy. Fourteen patients required stenting and dilation of the hepatico-jejunostomy. No subsequent intervention was required in ten of these patients after a mean of 3.1 1.9 (range 1-7) procedures. In 4 patients (14%), subsequent percutaneous drainage (PTC) was required for failure of endoscopic therapy, mean time to PTC was 136 days 104 (30-274). Conclusions: DBE-ERCP allows for successful therapy in patients with surgically altered anatomy of the upper-GI tract. Our single center study suggests this is a safe, and effective first line option at managing post-surgical biliary obstruction/strictures, however more than one session is generally required to achieve good outcomes.
Tu1566 Real-Time Transabdominal Ultrasound-Guided ERCP in Pregnancy Callum Dargavel*1, Jeffrey D. Mosko1, Derek Muradali2, Tareq Alomani1, Sujievvan Chandran1, Niroshan Muwanwella1, Yuto Shimamura1, Christopher W. Teshima1, Gabor Kandel1, Paul P. Kortan1, Norman E. Marcon1, Gary R. May1 1 Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada; 2Department of Medical Imaging, St Michael’s Hospital, Toronto, ON, Canada
Tu1565 Acute Cholangitis: Procedural Intervention,Temporal Trends and Regional Variation: 10-Year Analysis of the National Inpatient Sample 2003-2012 Kalpit Devani*1, Nazir Ahmed2, Nilay Patel2, Achint Patel3, Chirag Savani4, Apurva Badeka5, Dhruvan Patel6, Pranav Patel7, Balaji Yegneswaran2, Chakradhar M. Reddy7, Mark Young7 1 Department of Internal Medicine, East Tennessee State University, Johnson City, TN; 2Department of Internal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ; 3Public Health Department, Icahn School of Public Health at Mount Sinai, New York, NY; 4Public Health Department, New York Medical College, Valhalla, NY; 5 Cardiology, University of Miami - Miller School of Medicine, Miami, FL; 6 Internal Medicine, Mercy Catholic Medical Center, Philadelphia, PA; 7 Department of Gastroenterology, East Tennessee State University, Johnson City, TN Introduction: Acute cholangitis occurs secondary to partial or complete biliary obstruction and management requires relief of biliary obstruction by various procedural interventions.The objective of this study was to identify inpatient admissions for cholangitis and compare different interventions including endoscopic retrograde cholangiopancreatography (ERCP), Percutaneous Transhepatic Cholangiography and Biliary Drainage (PTC), surgical drainage and cholecystectomy and report on the trends in utilization and their regional variation. Methods: From the Nationwide Inpatient Sample (NIS), which is a 20% representative of all hospital discharges in the US, we identified all adult (18 years of age) patients admitted with a primary diagnosis of acute cholangitis using ICD-9 codes during a 10 year period between 2003 to 2012. Temporal trends were assessed using Cochran-Armitage statistical analysis. Results: A weighted sample of 102,433 admissions were for acute cholangitis, of which 43,313 (42.3%) had undergone ERCP which was significantly more than PTC [4880, 4.8%, (P<0.0001)], surgical drainage [816, 0.8% (P<0.0001)], and cholecystectomy [2079, 2.03% (P<0.0001)], while 50.1% were managed conservatively. Patients undergoing ERCP and PTC have significantly increased from 41.4% to 44.7% (P<0.0001 for trends) and 4.7% to 5.2% (PZ0.04 for trends) respectively during the 10-year study period. In comparison, surgical drainage and cholecystectomy for acute cholangitis has significantly decreased from 0.9% to 0.2% (P<0.001 for trends) and 2.7% to 1.3% (P<0.001 for trends) respectively during the same period. On comparing regional variation in ERCP utilization between Northeast, Midwest, South and West regions, the likelihood of getting an ERCP for acute cholangitis was significantly lower in Southern part of the US [OR 0.86, CI 0.79-0.98] compared to Northeast. Conclusion: Among
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Background: Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography [ERCP] in pregnancy. Despite current guidelines recommending limited radiation exposure to the fetus and mother during ERCP, there is a paucity of literature describing methods for stone extraction and bile duct exploration without fluoroscopy. Real-time transabdominal ultrasound [US]-guided ERCP is a radiation-free technique that facilitates direct confirmation of biliary cannulation, equipment exchange and stone clearance. We describe a prospective case series utilizing this modality in pregnant patients. Methods: Between May and October 2015, three pregnant patients were referred to our tertiary academic center with symptomatic choledocholithiasis. All three were treated with trans-abdominal ultrasound assisted ERCP without fluoroscopy, performed by two expert endoscopists [GM, JM]. The US was operated and interpreted in real-time by a radiologist [DM]. Successful ERCP was defined as biliary cannulation confirmed by US-visualization of the guidewire in the common bile duct [CBD], followed by successful sphincterotomy and achievement of definitive biliary drainage. Results: Three patients underwent ERCP guided by real-time US for symptomatic choledocolithiasis [average age 35 years]. The gestational ages [GA] of the fetuses were 5, 9, and 25 weeks. Two patients had choledocholithiasis visualized on referring US. The third patient had a high pre-test probability of choledocholithiasis without a calculi visualized on referring US, based on elevated liver enzymes [ALT 413 U/L; ALP 668 U/ L], elevated direct bilirubin [18 umol/L] and a dilated CBD [12 mm]. Real-time US confirmed the referral US findings, demonstrating intra-ductal calculi in two cases and a dilated CBD in all cases. ERCP success rate was 100% without any use of fluoroscopy. All patients experienced clinical and biochemical resolution, without any maternal complications. One patient who was at 5 weeks GA suffered a spontaneous abortion four weeks post-procedure felt to be unrelated to her ERCP. Another patient at 25 weeks GA went into spontaneous labor two weeks post-procedure, delivering a baby who remains alive and well. There were no occurrences of post-ERCP pancreatitis or other procedural complications. Conclusion: Real-time transabdominal US-guided ERCP is a technically feasible and safe modality to obtain biliary access in a radiation-free fashion. In pregnant patients with suspected or documented choledocholithiasis, this technique should be strongly considered as a first-line modality to avoid radiation exposure.
Image 1. Ultrasound shows guidewire (small arrow) in the CBD (long arrows).
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB609
Tu1564 Double-Balloon Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Anatomy: A Single Center Experience Jan-Erick Nilsson*, Montano-Loza Aldo, Sergio Zepeda-Gomez Gastroenterology, University of Alberta, Edmonton, AB, Canada
patients presenting with acute cholangitis, utilization of ERCP and PTC have increased over the last decade while that of surgical drainage and cholecystectomy have decreased. In comparison, the likelihood of getting an ERCP for acute cholangitis is lower in South than Northeast region.
Background: Balloon assisted enteroscopy has improved our ability to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. We reviewed the experience with double-balloon ERCP (DBE-ERCP) in patients with altered anatomy and suspicion of biliary obstruction in a tertiary center. Methods: Retrospective analysis of all patients who underwent DBE-ERCP at the University of Alberta hospital between September 2011 and August 2015. Results: A total of 57 DBE-ERCPs were performed in 28 patients (16 males) with a mean age of 51 19 years (range: 20-81) using a short-type double balloon enteroscope. Twenty-seven patients had a Roux-en-Y reconstruction (25 hepatico-jejunostomies) and one patient had a prior Billroth-II gastro-jejunostomy. There were 19 patients that had previous liver transplantation (9 cadaveric, 10 living donor). There was a trend to earlier DBEERCP in living related vs cadaveric transplants [519 619 vs 1826 1907 days (pZ 0.06)]. The main indications for all procedures were suspicion of stricture at the hepatico-jejunostomy [nZ25 (44%)], recurrent cholangitis [nZ21 (37%)] and stent retrieval [nZ8 (14%)]. Therapeutic maneuvers included: stricture dilation (nZ31), extraction of stones (nZ10), stent placement (nZ10) and stent retrieval (nZ8). The hepatico-jejunostomy or major papilla was reached in 46 of 57 procedures (81%). Bile duct cannulation was successful in 40 of 46 procedures (87%). The mean number of procedures per patient was 2 1.5 (range: 1-7 procedures). The number of procedures was higher in those with liver transplantation compared to other surgeries [mean: 2.5 1.7 vs 1.3 0.48(pZ0.04)]. There were two patients with mild cholangitis after biliary manipulation that resolved with intravenous antibiotic therapy. Fourteen patients required stenting and dilation of the hepatico-jejunostomy. No subsequent intervention was required in ten of these patients after a mean of 3.1 1.9 (range 1-7) procedures. In 4 patients (14%), subsequent percutaneous drainage (PTC) was required for failure of endoscopic therapy, mean time to PTC was 136 days 104 (30-274). Conclusions: DBE-ERCP allows for successful therapy in patients with surgically altered anatomy of the upper-GI tract. Our single center study suggests this is a safe, and effective first line option at managing post-surgical biliary obstruction/strictures, however more than one session is generally required to achieve good outcomes.
Tu1566 Real-Time Transabdominal Ultrasound-Guided ERCP in Pregnancy Callum Dargavel*1, Jeffrey D. Mosko1, Derek Muradali2, Tareq Alomani1, Sujievvan Chandran1, Niroshan Muwanwella1, Yuto Shimamura1, Christopher W. Teshima1, Gabor Kandel1, Paul P. Kortan1, Norman E. Marcon1, Gary R. May1 1 Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada; 2Department of Medical Imaging, St Michael’s Hospital, Toronto, ON, Canada
Tu1565 Acute Cholangitis: Procedural Intervention,Temporal Trends and Regional Variation: 10-Year Analysis of the National Inpatient Sample 2003-2012 Kalpit Devani*1, Nazir Ahmed2, Nilay Patel2, Achint Patel3, Chirag Savani4, Apurva Badeka5, Dhruvan Patel6, Pranav Patel7, Balaji Yegneswaran2, Chakradhar M. Reddy7, Mark Young7 1 Department of Internal Medicine, East Tennessee State University, Johnson City, TN; 2Department of Internal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ; 3Public Health Department, Icahn School of Public Health at Mount Sinai, New York, NY; 4Public Health Department, New York Medical College, Valhalla, NY; 5 Cardiology, University of Miami - Miller School of Medicine, Miami, FL; 6 Internal Medicine, Mercy Catholic Medical Center, Philadelphia, PA; 7 Department of Gastroenterology, East Tennessee State University, Johnson City, TN Introduction: Acute cholangitis occurs secondary to partial or complete biliary obstruction and management requires relief of biliary obstruction by various procedural interventions.The objective of this study was to identify inpatient admissions for cholangitis and compare different interventions including endoscopic retrograde cholangiopancreatography (ERCP), Percutaneous Transhepatic Cholangiography and Biliary Drainage (PTC), surgical drainage and cholecystectomy and report on the trends in utilization and their regional variation. Methods: From the Nationwide Inpatient Sample (NIS), which is a 20% representative of all hospital discharges in the US, we identified all adult (18 years of age) patients admitted with a primary diagnosis of acute cholangitis using ICD-9 codes during a 10 year period between 2003 to 2012. Temporal trends were assessed using Cochran-Armitage statistical analysis. Results: A weighted sample of 102,433 admissions were for acute cholangitis, of which 43,313 (42.3%) had undergone ERCP which was significantly more than PTC [4880, 4.8%, (P<0.0001)], surgical drainage [816, 0.8% (P<0.0001)], and cholecystectomy [2079, 2.03% (P<0.0001)], while 50.1% were managed conservatively. Patients undergoing ERCP and PTC have significantly increased from 41.4% to 44.7% (P<0.0001 for trends) and 4.7% to 5.2% (PZ0.04 for trends) respectively during the 10-year study period. In comparison, surgical drainage and cholecystectomy for acute cholangitis has significantly decreased from 0.9% to 0.2% (P<0.001 for trends) and 2.7% to 1.3% (P<0.001 for trends) respectively during the same period. On comparing regional variation in ERCP utilization between Northeast, Midwest, South and West regions, the likelihood of getting an ERCP for acute cholangitis was significantly lower in Southern part of the US [OR 0.86, CI 0.79-0.98] compared to Northeast. Conclusion: Among
www.giejournal.org
Background: Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography [ERCP] in pregnancy. Despite current guidelines recommending limited radiation exposure to the fetus and mother during ERCP, there is a paucity of literature describing methods for stone extraction and bile duct exploration without fluoroscopy. Real-time transabdominal ultrasound [US]-guided ERCP is a radiation-free technique that facilitates direct confirmation of biliary cannulation, equipment exchange and stone clearance. We describe a prospective case series utilizing this modality in pregnant patients. Methods: Between May and October 2015, three pregnant patients were referred to our tertiary academic center with symptomatic choledocholithiasis. All three were treated with trans-abdominal ultrasound assisted ERCP without fluoroscopy, performed by two expert endoscopists [GM, JM]. The US was operated and interpreted in real-time by a radiologist [DM]. Successful ERCP was defined as biliary cannulation confirmed by US-visualization of the guidewire in the common bile duct [CBD], followed by successful sphincterotomy and achievement of definitive biliary drainage. Results: Three patients underwent ERCP guided by real-time US for symptomatic choledocolithiasis [average age 35 years]. The gestational ages [GA] of the fetuses were 5, 9, and 25 weeks. Two patients had choledocholithiasis visualized on referring US. The third patient had a high pre-test probability of choledocholithiasis without a calculi visualized on referring US, based on elevated liver enzymes [ALT 413 U/L; ALP 668 U/ L], elevated direct bilirubin [18 umol/L] and a dilated CBD [12 mm]. Real-time US confirmed the referral US findings, demonstrating intra-ductal calculi in two cases and a dilated CBD in all cases. ERCP success rate was 100% without any use of fluoroscopy. All patients experienced clinical and biochemical resolution, without any maternal complications. One patient who was at 5 weeks GA suffered a spontaneous abortion four weeks post-procedure felt to be unrelated to her ERCP. Another patient at 25 weeks GA went into spontaneous labor two weeks post-procedure, delivering a baby who remains alive and well. There were no occurrences of post-ERCP pancreatitis or other procedural complications. Conclusion: Real-time transabdominal US-guided ERCP is a technically feasible and safe modality to obtain biliary access in a radiation-free fashion. In pregnant patients with suspected or documented choledocholithiasis, this technique should be strongly considered as a first-line modality to avoid radiation exposure.
Image 1. Ultrasound shows guidewire (small arrow) in the CBD (long arrows).
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB609