Endoscopic Sphincterotomy Versus Endoscopic Papillary Balloon Dilatation for Choledocholithiasis in Liver Cirrhosis with Coagulopathy

Abstract

Endoscopic Sphincterotomy Versus Endoscopic Papillary Balloon Dilatation for Choledocholithiasis in Liver Cirrhosis with Coagulopathy Do Hyun Park, Myung-Hwan Kim, Sung Koo Lee, Sang Soo Lee, Moon Hee Song, Jung Sik Choi, Dong Wan Seo, Young Il Min Background/Aim: To determine whether endoscopic papillary balloon dilatation (EPBD) actually decreases the risk of hemorrhage without increasing risk of acute pancreatitis, we compared the results of EPBD with those of endoscopic biliary sphincterotmy (EST) in cirrhotic patients with coagulopathy. Methods: Twentyone liver cirrhosis patients with coagulopathy were treated with EBPD for choledocholithiasis from January 2001 to September 2003. Twenty liver cirrhosis patients with coagulopathy who underwent EST from January 1998 to December 2000 served as a historical control group. Coagulopathy was defined as a prothrombin time below 50% of normal or a platelet count below 80,000 / mm3.Hemorrhagewas recorded onlywhen therewas clinical (not just endoscopic) evidence of bleeding such asmelena or hematemesis, with an associated decrease of at least 2 g per deciliter in the hemoglobin concentration, or the need for a blood transfusion. Results: Hemorrhage occurred in 6 (30%) of 20 patients in the EST group, but there was no case of hemorrhagic complications in the EPBD group (p = 0.009). With regard to the hemorrhagic rates according to Child-Pugh class in the EST group, the hemorrhagic complications mostly occurred in Child-Pugh class C patients. Moreover, three of five Child-Pugh class C cirrhotic patients with EST-related hemorrhage bled to death. In the EPBD group, however, there was not any hemorrhagic complication inChild-Pugh class C patients. Therefore, there was significant difference in the hemorrhagic complications of Child-Pugh class C patients between EST and EPBD group (5/14, 35.7% vs. 0/16, 0%; p = 0.014). On the contrary, in Child-Pugh class B, there was no significant difference in hemorrhagic complications between EST and EPBD groups (1/6, 16.6% vs. 0/4, 0%; p = NS). There was also no significant difference between EST and EPBD groups in the rate of procedure-related pancreatitis (2/20, 10 % vs. 1/21, 4.7 %; p = NS). Conclusions: EPBD may significantly reduce the risk of bleeding compared with EST in advanced cirrhotic patients with coagulopathy such as Child-Pugh class C. In these patients, EPBD should replace EST as a treatment modality for removal of choledocholithiasis. *T1476 ERCP with Sphincter of Oddi Manometry (SOM) at an Ambulatory Endoscopy Center (AEC): An Assessment of Complications Erik Springer, Yang K. Chen, Daus Mahnke, Mainor R. Antillon, Raj J. Shah BACKGROUND: Patients (pts) with suspected sphincter of Oddi dysfunction (SOD) are known to be at increased risk for post-ERCP pancreatitis. At our tertiary referral center, outpatients undergo ERCP at a multi-specialty AEC and recover in a post-anesthesia care unit.We assessed the safety of performingERCP/ SOM at an AEC. METHODS: Consecutive pts undergoing SOM over a one-yr period were identified by prospective collection and computer database. All pts had propofol administered by anesthesiology. The standard station pull-through technique was performed using the aspiration manometry catheter. Pts were transferred by ambulance to the hospital 6 miles away for 23hr observation. 30d complication rate was assessed by clinic/telephone contact and record review. Complications were defined by consensus (CONS) criteria, and by comprehensive (COMP) criteria which included unplanned ER/MDvisits,>23 hr observation, or admission for symptoms. SOD was defined by modified Milwaukee criteria. RESULTS: Between 10/02 and 10/03, 595 ERCPs were performed. 53 pts (7M, 46F, mean age 40) underwent 59 SOM procedures providing the cohort for this study. 31 SOMs were biliary, 11 were pancreatic, and 17 were biductal. SOM results: SOD Type II (29), SOD Type III (21), or normal (9). 48 pts had sphincterotomies: 32 biliary, 7 pancreatic, and 15 biductal. 31 pancreatic stents were placed prophylactically. CONS: Total 7 complications (11.9%); 6 pancreatitis, 1 bleed (mild). Pancreatitis severity: 1 mild (SOD III), 2 moderate (SOD II), and 3 severe (2 SOD II, 1 normal). COMP: Total 24 complications (41%) including 13 cases of pain requiring>23hr hospital admission, 1 abdominal pain requiring po analgesics, 1 IV site infiltration, and 2 infection. CONCLUSIONS: 1) SOM can be performed safely in an AEC provided there is on-site anesthesia support and mechanisms for hospital transfer. 2) Our pancreatitis rate is comparable to previously published series. 3) One-fifth of SOM pts without pancreatitis required >23 hr stay for pain management, thus, routine admission post-SOM is recommended. 4) Future studies reporting endoscopy-related complications should incorporate comprehensive criteria as defined for a more accurate assessment of morbidity.