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Tu1582 Biliary Stenosis Extreme Endoscopy Treatment - Very Large Balloon Dilation: Case Series (EBD)
Abstracts
DSs in patients with PSC, clinical perceptions vary widely among faculty and also between advanced endoscopists and non-advanced endoscopists. Further studies are needed to address these variations, develop uniform practice patterns, and increase adherence to societal guidelines.
Tu1582 Biliary Stenosis Extreme Endoscopy Treatment - Very Large Balloon Dilation: Case Series (EBD) Eduardo T. de Moura*, Gustavo L. Silva, Marina Lordello Passos, Julio Cesar M. Aquino, Vinicius L. Castro, Diogo T. de Moura, Eduardo T. de Moura, Tomazo Franzini, Paulo Sakai Gastroenterology, University of São Paulo Medical School, São Paulo, São Paulo, Brazil
Figure 2. X-ray view of the two slim metal stents after insertion in a 82year-old man.
Tu1581 Dominant Strictures in Primary Sclerosing Cholangitis: A Multi-Center Survey of Clinical Perceptions and Practices James H. Tabibian*1,2, Moira Hilscher2, Elizabeth J. Carey2, Christopher Gostout2, Keith D. Lindor2,3 1 University of Pennsylvania, Philadelphia, PA; 2Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 3 Executive Vice Provost and Dean, College of Health Solutions, Arizona State University, Phoenix, AZ Introduction: Dominant strictures (DSs) of the biliary tree occur in approximately 50% of patients with primary sclerosing cholangitis (PSC) and are a potentially lethal complication. Nevertheless, the definition and management of DSs lacks consensus among clinical providers. The objective of this study was to better understand current definitions and practices in the management of PSC-associated DSs. Methods: After obtaining institutional review board approval, an anonymous 22-question survey of definitions, perceptions, and practices as well as participant demographics was electronically distributed to 131 faculty in the division of gastroenterology and hepatology, including advanced endoscopists, hepatologists, and gastroenterologists, at the 3 major Mayo Clinic campuses (MN, AZ, and FL) as well as the Mayo affiliated practice network. Responses were securely downloaded from the Surveymonkey server for descriptive analyses. Results: A total of 54 faculty (41.2%) completed the study survey, of whom 26 (48.1%) were from the main Mayo Clinic campus in Rochester, MN, a major referral center for patients with PSC. Of these 54 faculty, 9 (16.7%) were advanced endoscopists, 24 (44.4%) were hepatologists, and 21 (38.9%) were gastroenterologists. The major findings of the study included: i) with respect to elements necessary to consider a biliary stenosis a DS, “Upstream (i.e. proximal) bile duct dilatation”, “New or worsening cholestatic serum liver tests”, and “Stenosis diameter of < 1.5 mm in the common bile duct or < 1 mm in a hepatic duct” were the only choices to be selected by >50% of participants (58.7%, 58.7%, and 52.1%, respectively); ii) 61.7% of participants answered “yes” to the question, “Should PSC patients with incidental(i.e. asymptomatic) DSs on crosssectional imaging undergo initial management with ERC?”, while among advanced endoscopists, the “yes” rate was 85.7%; iii) in response to “Should biliary brush cytology and/or endoscopic biopsy be obtained before or after biliary balloon dilation during ERC?”, 28.2% responded “before”, 15.2% “after”, and 56.5% “There is insufficient evidence to support one over the other”; iv) lastly, regarding a proposed DS definition of “An extrahepatic, hilar, or intrahepatic duct stenosis, regardless of length or diameter, with upstream bile duct dilatation and new or worsening cholestatic serum liver tests”, 84.8% of all participants responded that this would be a reasonable definition, although among advanced endoscopists, only 57.1% responded in the affirmative. Conclusions: Despite the prevalence and morbidity of
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Background: One of the most relevant biliary complications after liver transplantation (LT) is the biliary anastomotic stricture (BAS), which occurs in about 8-20% of LT patients follow-up. Endoscopic retrograde cholangiopancreatography (ERCP) is the current gold standard for diagnosis and treatment of biliary complications after LT, and balloon dilation with or without stent placement is the current standard endoscopic interventions. Extreme Balloon Dilation (EBD) of anastomotic strictures was first described by Moura at al in 2015, and comprises of agressive balloon dilation from 10mm on, until the stricture waist disappears on fluoroscopy (FIGURE 1). Methods: We reviewed the medical records and database of a tertiary center, from January 2013 until November 2015, to report a case series of post-LT patients who underwent EBD after unsuccessful conventional treatment according to the ROME protocol. The outcomes analyzed were the number of EBD sessions necessary to obtain adequate anastomotic diameter (<3 or >3 sessions), the number of patients in whom stents were placed, the length of the stricture segment, the number of patients with proximal biliary stones – and the success rate in treating this associated complication, and complications. Results: A total of 20 patients were included. The mean number of EBD session was 2.25 1.52. Seven patients (35%) required less than 3 sessions, and 3 patients (15%) required more than 3 sessions to obtain adequate anastomosis remodeling; the remaining 10 patients (50%) are still under endoscopic follow-up with repeated 3-month apart EBD sessions. A total of 18 patients (90%) required stent placement (metallic Z 2, plastic Z 16). Three patients (15%) had anastomotic strictures with a length 10mm. The number of patients with proximal biliary stones was 6 (30%), and the success rate in extracting these stones with either extraction balloon or basket following EBD was 83,3% (5 of 6 patients). As for complications, one patient developed immediate hemorrhage, which was treated with sustained balloon insufflation for five minutes, and in one patient the fully covered metallic stent migrated to the duodenum; none of the plastic stents migrated, and there were no perforations. Conclusion: This is the first case series that reports experience in treating refractory biliary anastomosis strictures with EBD, in LT patients. EBD required few dilation sessions to obtain satisfactory results in patients with a stenotic length shorter than 10mm, facilitating the removal of proximal biliary stones, and with a low rate of complications. These results serve as a guide in tayloring future prospective randomized trials, to determine the efficacy of this promising novel approach.
Figure 1. Illustration (A) and Fluoroscopic images (B) of EBD performed on a biliary anastomosis stricture following LT.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB615
DSs in patients with PSC, clinical perceptions vary widely among faculty and also between advanced endoscopists and non-advanced endoscopists. Further studies are needed to address these variations, develop uniform practice patterns, and increase adherence to societal guidelines.
Tu1582 Biliary Stenosis Extreme Endoscopy Treatment - Very Large Balloon Dilation: Case Series (EBD) Eduardo T. de Moura*, Gustavo L. Silva, Marina Lordello Passos, Julio Cesar M. Aquino, Vinicius L. Castro, Diogo T. de Moura, Eduardo T. de Moura, Tomazo Franzini, Paulo Sakai Gastroenterology, University of São Paulo Medical School, São Paulo, São Paulo, Brazil
Figure 2. X-ray view of the two slim metal stents after insertion in a 82year-old man.
Tu1581 Dominant Strictures in Primary Sclerosing Cholangitis: A Multi-Center Survey of Clinical Perceptions and Practices James H. Tabibian*1,2, Moira Hilscher2, Elizabeth J. Carey2, Christopher Gostout2, Keith D. Lindor2,3 1 University of Pennsylvania, Philadelphia, PA; 2Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 3 Executive Vice Provost and Dean, College of Health Solutions, Arizona State University, Phoenix, AZ Introduction: Dominant strictures (DSs) of the biliary tree occur in approximately 50% of patients with primary sclerosing cholangitis (PSC) and are a potentially lethal complication. Nevertheless, the definition and management of DSs lacks consensus among clinical providers. The objective of this study was to better understand current definitions and practices in the management of PSC-associated DSs. Methods: After obtaining institutional review board approval, an anonymous 22-question survey of definitions, perceptions, and practices as well as participant demographics was electronically distributed to 131 faculty in the division of gastroenterology and hepatology, including advanced endoscopists, hepatologists, and gastroenterologists, at the 3 major Mayo Clinic campuses (MN, AZ, and FL) as well as the Mayo affiliated practice network. Responses were securely downloaded from the Surveymonkey server for descriptive analyses. Results: A total of 54 faculty (41.2%) completed the study survey, of whom 26 (48.1%) were from the main Mayo Clinic campus in Rochester, MN, a major referral center for patients with PSC. Of these 54 faculty, 9 (16.7%) were advanced endoscopists, 24 (44.4%) were hepatologists, and 21 (38.9%) were gastroenterologists. The major findings of the study included: i) with respect to elements necessary to consider a biliary stenosis a DS, “Upstream (i.e. proximal) bile duct dilatation”, “New or worsening cholestatic serum liver tests”, and “Stenosis diameter of < 1.5 mm in the common bile duct or < 1 mm in a hepatic duct” were the only choices to be selected by >50% of participants (58.7%, 58.7%, and 52.1%, respectively); ii) 61.7% of participants answered “yes” to the question, “Should PSC patients with incidental(i.e. asymptomatic) DSs on crosssectional imaging undergo initial management with ERC?”, while among advanced endoscopists, the “yes” rate was 85.7%; iii) in response to “Should biliary brush cytology and/or endoscopic biopsy be obtained before or after biliary balloon dilation during ERC?”, 28.2% responded “before”, 15.2% “after”, and 56.5% “There is insufficient evidence to support one over the other”; iv) lastly, regarding a proposed DS definition of “An extrahepatic, hilar, or intrahepatic duct stenosis, regardless of length or diameter, with upstream bile duct dilatation and new or worsening cholestatic serum liver tests”, 84.8% of all participants responded that this would be a reasonable definition, although among advanced endoscopists, only 57.1% responded in the affirmative. Conclusions: Despite the prevalence and morbidity of
www.giejournal.org
Background: One of the most relevant biliary complications after liver transplantation (LT) is the biliary anastomotic stricture (BAS), which occurs in about 8-20% of LT patients follow-up. Endoscopic retrograde cholangiopancreatography (ERCP) is the current gold standard for diagnosis and treatment of biliary complications after LT, and balloon dilation with or without stent placement is the current standard endoscopic interventions. Extreme Balloon Dilation (EBD) of anastomotic strictures was first described by Moura at al in 2015, and comprises of agressive balloon dilation from 10mm on, until the stricture waist disappears on fluoroscopy (FIGURE 1). Methods: We reviewed the medical records and database of a tertiary center, from January 2013 until November 2015, to report a case series of post-LT patients who underwent EBD after unsuccessful conventional treatment according to the ROME protocol. The outcomes analyzed were the number of EBD sessions necessary to obtain adequate anastomotic diameter (<3 or >3 sessions), the number of patients in whom stents were placed, the length of the stricture segment, the number of patients with proximal biliary stones – and the success rate in treating this associated complication, and complications. Results: A total of 20 patients were included. The mean number of EBD session was 2.25 1.52. Seven patients (35%) required less than 3 sessions, and 3 patients (15%) required more than 3 sessions to obtain adequate anastomosis remodeling; the remaining 10 patients (50%) are still under endoscopic follow-up with repeated 3-month apart EBD sessions. A total of 18 patients (90%) required stent placement (metallic Z 2, plastic Z 16). Three patients (15%) had anastomotic strictures with a length 10mm. The number of patients with proximal biliary stones was 6 (30%), and the success rate in extracting these stones with either extraction balloon or basket following EBD was 83,3% (5 of 6 patients). As for complications, one patient developed immediate hemorrhage, which was treated with sustained balloon insufflation for five minutes, and in one patient the fully covered metallic stent migrated to the duodenum; none of the plastic stents migrated, and there were no perforations. Conclusion: This is the first case series that reports experience in treating refractory biliary anastomosis strictures with EBD, in LT patients. EBD required few dilation sessions to obtain satisfactory results in patients with a stenotic length shorter than 10mm, facilitating the removal of proximal biliary stones, and with a low rate of complications. These results serve as a guide in tayloring future prospective randomized trials, to determine the efficacy of this promising novel approach.
Figure 1. Illustration (A) and Fluoroscopic images (B) of EBD performed on a biliary anastomosis stricture following LT.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB615