Mo1675 Learning Curve of Direct PerOral Cholangioscopy Using Ultra Slim Gastroscopes

Abstract

Mo1675 Learning Curve of Direct PerOral Cholangioscopy Using Ultra Slim Gastroscopes Jochen Weigt*, Arne Kandulski, Peter Malfertheiner Gastroenterology, Hepatology and Infectious Diseases, University Magdeburg, Magdeburg, Germany Direct peroral cholangioscopy (POCS) is an emerging technique complementing ERCP. Unless several data show the feasibility and clinical relevance of POCS, only few data about the learning process of this technique are available. Aim: To investigate the technical success rate and learning process of POCS in a tertiary center. Methods: All patients were investigated with standard ERCP and biliary sphincterotomy directly prior to cholangioscopy. After removal of the duodenoscope, an ultra slim gastroscope was directly advanced to the duodenum. The common bile duct was intubated using the balloon anchor technique. All POCS procedures were performed with water irrigation. Histology was taken from suspicious lesions. The investigation times and the success rates were calculated. Special caution was given to the time from oral intubation until visualization of the bile ducts, that served as a key technical parameter. Results: A total of 28 POCS were performed. Intubation was successful in 24/28 (86%). Reasons for failed intubation were small caliber bile ducts, duodenal diverticulum and papillary adenoma. The mean intubation time was 9.5 min (3-23 min). The average intubation time did not change significantly over time (R*2 -0.05). The variance of intubation times changed over time and was 35,7 min in the first half of investigations and 13,5 min in the second half. Complications did not occur. Conclusions: The technique of direct peroral cholangioscopy using the balloon anchor technique in combination with ultra-slim gastroscopes is technically demanding but learning does not show a long learning period at last in a tertiary center. However the technical measures present signs of adaptation and learning of the technique.Nevertheless, as POCS is not yet a standard technique, we suggest that POCS may only be performed by experienced endoscopists. Mo1676 Evaluated Experimental Model of Gallstone Cholecystitis Available for Miniinvasive Surgical Procedures Ondrej Ryska*, Zuzana Serclova, Jan Martinek, Radek Dolezel, Stefan Juhas, Jana Juhasova, Bohus Bunganic, Miroslav Ryska Department of Surgery and 2nd Medical Faculty, Central Military Hospital, Prague 6, Czech Republic; Hepatogastroenterology Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Internal Medicine, Central Military Hospital, Prague, Czech Republic; Institute of Animal Physiology and Genetics, Academy of Sciences, Libechov, Czech Republic Background: Natural orifice transluminal endoscopic surgery (NOTES), single port laparoscopy (SILS) and other miniinvasive surgical techniques are recently under the experimental investigation. Cholecystectomy as a most frequent laparoscopic procedure is usually the subject of evaluation where the clear benefits of new approaches should be proved. Experimental studies using healthy animals with physiological finding on gallbladder are lacking for the clinical relevance. The aim of the experimental study was to create and evaluate surgical model of gallstone cholecystitis in large animal. Material And Method: Model creation: 14 pigs weighing 40.3 10.0 kg were included. Laparoscopy (3 ports) was performed under general anesthesia. Bile from the gallbladder was aspirated and cholecystotomy was done. Three to five gallstones obtained by human cholecystectomy were inserted and incision was closed. Evaluation: 11 pigs with artificial cholelithiasis the laparoscopic cholecystectomy (3-port access) was performed. This group was compared to 10 cholecystemies in pigs without lithiasis. All pigs were euthanized 30th postoperative day (POD) and the autopsy performed. The protocol was approved by committee for the protection of the animals. Results: All animals survived without severe complications. Model procedure took 42 (35-150) minutes. White blood cells (WBC) count increased 1.POD and 2.POD markedly; 18.7 (10.4-23.7)x109/l and 16.7 (8.3-27.8)x109/l); and remained slightly higher till 7.POD 15.4 (9.2-22.8)x109/l. CRP levels were higher on 1st, 2nd and 3rd POD 12.4 (6.9-21.4, 13.3 (1.4-35.7) and 13.0 (8.117.8)mg/l) and decreased to normal levels till 7.POD. Levels of interleukin 6 were the highest 2 hours after surgery 472.7 (50.9-1286) and decreased the 1.POD 80.8 (36.4-153) and the 2.POD 35.6 (8.257.2) pg/ml. The ultrasound signs of chronic gallstone cholecystitis were observed 4 weeks after intervention, which was also confirmed by histology. Laparoscopic cholecystectomy in gallstone model took longer time compare to healthy animals: 63 (42-91) minutes vs. 46 (31-62) minutes (p 0,0182). The perioperative gallbladder perforation was significantly less more frequent in healthy pigs 1/10 vs. 8/11 (RR: 7,27; CI95%: 1,09-48,3; p 0,04) as well as postoperative complications rate nonsignificantly lower 0/10 vs. 2/11 (2 abscesses in gallbladder bed) at autopsy (RR: 4,58; Cl95%: 0,25-85,3; p 0,307). Conclusion: Simple surgical model of gallstone cholecystitis was created as a reliable tool for accurate evaluation of NOTES and other miniinvasive procedures. Sonographic and histological signs of inflammation with no elevation of inflammatory markers were observed 4 weeks after intervention. The laparoscopic cholecystectomy was technically more difficult in cholecystitis model than in healthy animals. Supported by a grant from IGA NT12250-4