Deep Cannulation Research Articles

All-in-one sphincterotome with high rotation performance and freely bendable blade for endoscopic sphincterotomy in patients with surgically altered anatomy (a case series with video).

A new type of sphincterotome released to the market recently has high rotation performance and a freely bendable blade. It is devised to be singly capable of accommodating not only normal anatomy but also cases with surgically altered anatomy. This study was undertaken for clinical evaluation of the usefulness of this new sphincterotome. Eight cases in a reconstructed intestine for which cannulation or endoscopic sphincterotomy (EST) had been performed were extracted from 32 cases for which endoscopic retrograde cholangiopancreatography-related procedures were performed using the sphincterotome developed during November 2023 through February 2024. The cases were investigated retrospectively. Among these, EST was applied to six cases. Cannulation was performed using the developed sphincterotome in the native papilla in four cases. The primary endpoints were the success rate of cannulation in surgically altered anatomy and the success rate of EST. Secondary endpoints were complications and usability for operators. Usability for operators was evaluated by questionnaire for several items on a 5-point scale. EST was conducted successfully in all six cases subjected to EST. Mild hemorrhage was observed in one case (17%) as an adverse event after EST. Deep cannulation to the native papilla with the developed sphincterotome was conducted successfully in three cases (75.0%). Evaluation results by operators were 4.4 ± 0.55 for rotation performance, 4.00 ± 0.63 for incision performance, 4.29 ± 0.49 for deep cannulation performance, and 4.07 ± 0.19 for overall evaluation. In conclusion, this developed sphincterotome might be very useful for EST and cannulation in cases with surgically altered anatomy.

A prospective cohort study on rivaroxaban in the prevention of catheter-related thrombosis in breast cancer.

e12602 Background: Chemotherapy is an important treatment strategy for breast cancer. Catheter related thrombosis (CRT) is one of the most common complications of catheterization, affecting patients’ living quality and survival. It is thus of great practical significance for exploring how to prevent CRT. That’s why we carried out this study to provide evidence-based medical data for the prevention and treatment of thrombosis in breast cancer patients. Methods: A prospective cohort study approach was adopted. Breast cancer patients who received deep vein catheterization chemotherapy from July 2021 to July 2023 were selected. Cohort A included patients in the treatment group: they received prophylactic anticoagulation after catheterization: Rivaroxaban, 10 mg, orally once/d for 2 months; cohort B included patients in the control group, who did not receive prophylactic anticoagulation. The thrombosis was compared between the patients in the two groups within six months after catheterization. The comparison between groups was tested by X2 test, and logistic regression analysis was used to analyze the influencing factors of CRT. Results: A total of 402 breast cancer patients were enrolled. The incidence of CRT was 2.0% (4/201) in the treatment group of 201 cases and 12.4% (25/201) in the control group of 201 cases ( P=0.000). The thrombus was mainly located around the axillary vein, basilic vein and subclavian vein, the innominate vein, and the internal jugular vein. There were 44.8% (13/29) patients developed CRT within 30 days after catheterization, 20.7% (6/29) patients developed CRT within 30~<60days, and 34.5% (10/29) patients developed CRT within 60~<120 days. Patients diagnosed with CRT received anticoagulant therapy for 3 months. Within three months, the thrombus regression rate reached 100.0% (29/29). Univariate analysis showed that whether to receive prophylactic anticoagulation, whether hemoglobin is normal, patients whether to experience previous endocrine therapy, different Age group and chemotherapy regimens were actors for thrombosis, P<0.05 respectively. Multivariate analysis indicated that age and whether to receive prophylactic anticoagulation were independent factors for thrombosis ( P=0.019, P=0.006, respectively). Patients diagnosed with CRT received deep vein cannulation while anticoagulation therapy was administered, with smooth infusion. They all completed antitumor therapy as planned, and no abnormalities such as new thrombosis and pulmonary embolism were found. Conclusions: The prophylactic anticoagulation regimen with Rivaroxaban can reduce the incidence of CRT in breast cancer, showing good efficacy and safety. Therefore, medical staff should carry out early prevention, early detection and early treatment for CRT to improve the living quality of patients. Clinical trial information: ChiCTR2000031649.

A126 IMPACT OF TIME OF DAY ON PROCEDURAL OUTCOMES IN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP): ANALYSIS FROM A TERTIARY REFERRAL CENTER

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is an established diagnostic and therapeutic tool for hepatobiliary disease. Given its technical demands, it remains one of the highest-risk endoscopic procedures. Addressing modifiable factors, such as operator fatigue, may mitigate procedural risk. In colonoscopy, there is conflicting data on whether procedure time of day, as a surrogate of operator fatigue, affects outcomes, with some literature demonstrating decreased procedure completion and polyp detection rates in the afternoon. There is a paucity of data evaluating this potential relationship in ERCP. Aims To evaluate the impact of procedure time of day on procedural success and short-term adverse outcomes in patients undergoing ERCP. Methods A retrospective review of ERCP's performed on adult patients at our tertiary referral center from January 1, 2011 to December 31, 2020 was performed. The primary outcome was the procedural success rate, defined as successful navigation to the papilla, selective duct cannulation and cholangiography, and realization of the intended therapeutic goals. Secondary outcomes included procedure duration, rate of deep ductal cannulation, rate of sphincterotomy, and short-term (30-day) adverse events (immediate bleeding, delayed bleeding, pancreatitis, perforation). Statistical analysis was conducted using R. Categorical variables were compared using the Chi-square test of independence or Fisher’s exact test. Continuous variables were compared using T-tests or the Mann-Whitney-U test. Results A total of 5755 ERCP’s were performed between 8 AM – 6 PM; 2863 were performed before 12PM (AM group) and 2892 after 12PM (PM group). Baseline characteristics were similar between the two cohorts, with the exception of hypertension (33.7% AM vs 30.1% PM; p=0.003), and anticoagulation (20.3% AM vs 18.3% PM; p=0.05). In both groups, the most common ERCP indication was choledocholithiasis. The primary operators in both cohorts were clinical fellows. There was no difference in procedural success rate (87.0 % AM vs 86.7% PM; p = 0.72), procedure duration (33.6 minutes AM vs 32.9 minutes PM; p = 0.29), rates of deep cannulation (82.6% AM vs 83.0% PM; p = 0.81) and sphincterotomies (63.2% vs 62.7%; p = 0.68). Rate of adverse events were similar, with slightly higher rates of immediate bleeding in the AM group (5.0% AM vs 3.8% PM; p = 0.03). Results were similar in a subgroup analysis of patients with altered anatomy. Conclusions In this large retrospective review of ERCPs performed at a tertiary referral center, the procedure time of day did not impact procedural success rate. There were slightly higher rates of immediate bleeding in the AM group, though this may be explained by higher rates of anticoagulation in that group. Funding Agencies None

Analysis of the Effectiveness of Second Attempt Endoscopic Retrograde Cholangiopancreatography (ERCP) 24 Hours (Second Day) After Primary Failure.

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive intervention that has established itself as the gold standard therapeutic option for various pancreaticobiliary conditions. Deep cannulation of the common bile duct (CBD) is essential in ERCP. However, cannulation is not possible in approximately 20% of the cases with the usual techniqueseven when performed by highly trained professionals or at major healthcare institutions. In case of failure on the first attempt, alternative choices include redoing the procedure (on the secondattempt) or moving on to more proficient endoscopic methods such as endoscopic ultrasound (EUS) or radiology-aided techniques (rendezvous procedures), totally percutaneous approaches, or surgical treatments. To analyze the effectiveness of the second attempt ERCP24 hours (second day) after primary failure. This analytical study was conducted to check the outcomes of second attempt ERCP in patients with prior failed cannulation, from June 20, 2023, to November 20,2023, at the Department of Gastroenterology, Lady Reading Hospital, Peshawar. Patients of either sex, aged >16 years with failed biliary cannulation, and who were otherwise clinically stable were included in the study. Patients with surgically modified anatomy, an unidentified main duodenal papilla, or a history of sphincterotomy at another setup were excluded. Outcomes were assessed in terms of gaining deep biliary access (cannulation) using a therapeutic duodenoscope and endoscopy system supported by a fluoroscope while using a wire-guided sphincterotome. Factors linked to second ERCP cannulation success or failure were analyzed using SPSS version 24. Ninety-four patients were enrolled including 61 (64.9%) males and 33 (35.10%) females. The mean age of the participants was 39.01±14.831 years. The most common indication for the intervention was CBDstones, which were present in 70 (74.5%) patients. Successful cannulation on the second attempt was achieved in 72 (76.6%) patients. Experienced endoscopists achieved a greater proportion of successful cannulation (86.8%) compared to 33.3% by endoscopists with lower experience (p-value: <0.001). Logistic regression analysis was conducted to predict the outcomes (cannulation), which revealed an odds ratio for endoscopist experience of 33.604 (95% confidence interval: 6.948-162.52). A second ERCP attempt24 hours after the primary failed attempt appears to be the best course of action for the majority of clinically stable patients.

Optimal dilation duration of 10 mm diameter balloons after limited endoscopic sphincterotomy for common bile duct stones: a randomized controlled trial

Limited endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) is widely used. However, the optimal duration of small balloon dilation in choledocholithiasis remains controversial. We aimed to determine the optimal duration for 10 mm diameter balloon dilation after limited EST in choledocholithiasis. In this randomized controlled clinical trial, 320 patients were randomly assigned to receive small balloon dilation (10 mm in diameter) for 1 min (n = 160) or 3 min (n = 160) after deep bile duct cannulation. No significant difference in success rate of stone extraction between the two groups was observed. The incidence of post-ERCP pancreatitis (PEP) was higher in the 1 min group (10.6%) than in the 3 min group (4.4%) (P = 0.034). The logistic regression analysis showed that guidewire into the pancreatic duct, cannulation time > 5 min and 1 min balloon dilation were independent risk factors for PEP. There were no significant differences in other post-ERCP adverse events such as acute cholangitis, bleeding, perforation, etc. between the two groups. In conclusion, 3 min in duration was determined to be the optimal dilation condition for the removal of common bile duct stones.

Modified double-wire technique for deep cannulation of dorsal duct in incomplete pancreas divisum

Modified double-wire technique for deep cannulation of dorsal duct in incomplete pancreas divisum

Validity of a virtual reality endoscopic retrograde cholangiopancreatography simulator: can it distinguish experts from novices?

There is a lack of evidence regarding the effectiveness of virtual simulators as a means to acquire hands-on exposure to endoscopic retrograde cholangiopancreatography (ERCP). The present study aimed to assess the outcome and construct validity of virtual ERCP when training on the GI II Mentor simulator. A group of seven experienced endoscopists were compared with 31 novices. After a short introduction, they were requested to carry out three virtual ERCP procedures: diagnosing and removing a common bile duct (CBD) stone; diagnosing and taking brush cytology from a hilar stenosis; and, finally, diagnosing and treating a cystic leakage with a BD stent. For each task, the total time required to complete the task, time required to correctly view the papilla, total time of irradiation, time to deep cannulation, time to define diagnosis, time to complete sphincterotomy, and time to complete the respective intervention were measured. Cannulation of the BD, correct diagnosis, sphincterotomy, and time to complete intervention were assessed by an assessor blinded to the status of the endoscopist who performed the virtual ERCP. The time required to visualize the papilla and to cannulate deeply when removing the BD stone was significantly shorter for the experts (both p < 0.05). The time to visualize the papilla, cannulate deeply, reach a diagnosis, complete sphincterotomy, and complete the intervention was significantly shorter for the experts when managing cystic leakage (all p < 0.05). In diagnosing and taking brush cytology from a hilar stenosis, there was only a trend toward the experts needing less time for the deep cannulation of the BD (p = 0.077). The performance differed between experts and novices, especially in the management of cystic leakage. This corroborates the construct validity of the GI II Mentor simulator.

Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP

BackgroundDemonstration of access to the bile duct through Enlarged Papillary Fistulotomy, a method different from conventional fistulotomy.AimsDemonstration of the EFP technique with dissection in layers of the papilla for accessing the common bile duct, its efficiency and safety, rescue of cases of failure in cannulation and cases of access failure by EFP in the first attempt, facilitating cannulation in the second attempt.MethodsCross-sectional study, with retrospective data collection from 2233 ERCP exams with 528 EFP procedures, analysis of success and complications.Results528 patients underwent EFP on the first attempt, with success in 465 cases (88.06%) and 63 failures (11.94%). Of these failures, 33 patients (52.38%) returned for a second EFP attempt, with success in 30 cases (90.9%) and failure in 3 cases (9.1%). Deep bile duct cannulation was achieved in 93.75% of EFP procedures, and cannulation failure occurred in 33 cases (6.25%).ConclusionEFP showed efficiency in CBD cannulation, did not induce post-ERCP pancreatitis, no cases of perforation or false tract, but resulted in higher rates of minor bleeding, rescued cases of access failure by EFP, facilitated the posterior approach on the second attempt, it is safe, effective, low risk and associated with few comorbidities.

Can phrenic nerve injury be anticipated by larger cryoballoons?

Recently, a novel size-adjustable cryoballoon has been introduced in clinical practice, which can be inflated to two different diameters (28 and 31mm). The 31mm cryoballoon is specifically designed to achieve better contact with remodeled pulmonary veins (PVs) that have wider ostia while avoiding deep cannulation, thereby potentially reducing the risk of phrenic nerve injury (PNI) associated with deep balloon cannulation. However, we encountered two cases of PNI during cryoballoon ablation using the novel system among our initial 25 consecutive case series. Herein, we present two cases that exhibited PNI during freezing of the right superior PV with a size-adjustable balloon. While larger balloons are expected to create a larger area of isolation, the safety of this novel balloon system needs to be evaluated in a large-scale clinical study.

Does early application of needle-knife sphincterotomy (NKS) in patients with difficult biliary cannulation increase the risk of postERCP pancreatitis? A single centre study.

To determine that early needle-knife sphincterotomy does not increase post-ERCP pancreatitis in patients with difficult biliary cannulation as compared to standard cannulation. This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January 2021 to June 2021. Patients requiring ERCP were enrolled in the study (according to inclusion and exclusion criteria) and were subsequently allotted different groups according to the technique used for deep biliary cannulation. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and one way ANOVA test. The cohort included 114 patients with 52.6% male patients and predominance of relatively younger age group (31-45 years). The most common indication for ERCP was choledocholithiasis (36%) with an overall technical success rate of 96%. Deep cannulation was achieved either through standard cannulation (56%), double guidewire and/or pancreatic stent assisted (10.5%), use of early Needle-Knife Sphincterotomy (19%), NKS as a last resort (3.5%) or Transpancreatic Stenting and/or combined sphincterotomy (6%). Pancreatitis as a complication occurred in 4(3.5%) patients, bleeding in 2(1.8%), on-table desaturation in 2(1.8%) and perforation in 1(0.9%) patient. The occurrence of pancreatitis was only related significantly to inadvertent PD cannulation through univariate and logistic regression analysis whereas, multiple cannulations (>5), gender, age, classification of papilla and the use of early NKS had no impact on pancreatitis or the occurrence of other complications. NKS is an effective and safe modality for deep biliary cannulation and achieving technical success where cannulation is deemed difficult and does not increase the risk of PEP if done by experienced endoscopists in high volume centres.

Does patient's position count during Endoscopic Retrograde Cholangio-pancreatography? Left lateral decubitus versus prone position.

To compare the efficacy and safety of left lateral decubitus versus prone position during endoscopic retrograde cholangio-pancreaticography (ERCP). This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January to June 2021. Patients requiring ERCP were subsequently allotted LL or PP group randomly (unequal randomization) except patients with recent abdominal surgery, in-dwelling catheters, raised intra-abdominal pressure, cervical spine abnormalities and limb contractures. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and student T or Mann Whitney U-test. A total of 114 patients were enrolled according to the inclusion criteria with 62(54%) males and majority of the patients (42%) belonging to the age group 31-45 years. The most common ERCP indication was choledocholithiasis (36%). Technical success was achieved in 109(96%) patients with no statistically significant difference between the two groups. The total time of procedure, time for deep cannulation, time for acquiring therapeutic goal and ERCP complexity level were all similar between the two groups. The rate of inadvertent PD cannulation and PEP were relatively higher for the PP group but were statistically non-significant through univariate and logistic regression analyses and the only outcome measure that showed significance was multiple cannulations in the PP group. The study concludes that LL is non-inferior to PP and both positions have comparable outcomes with non-significant differences in terms of technical success rate, complications (specifically PEP), total procedure time, time required for deep cannulation and attainment of goal, ERCP complexity level and inadvertent PD cannulation.

Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center

IntroductionSelective biliary cannulation is a prerequisite for a successful endoscopic retrograde cholangiopancreatography (ERCP). However, conventional biliary access can be difficult. The aims of our study were to determine the prevalence of difficult biliary cannulation (DBC) and its associated factors and to describe the efficiency and safety of used standard and advanced cannulation techniques. MethodsWe conducted a single-center retrospective study including all patients with naïve papilla who had an ERCP procedure in Gastroenterology department of Mohamed Taher Maamouri Hospital from June 2019 to December 2021. Efficiency was defined as successful selective deep biliary cannulation. DBC was defined based on the presence of one or more of the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1): more than five cannulation attempts, more than 5 min before cannulation and more than one accidental passage in the wirsung. Prevalence was measured using ESGE 5-5-1 cutoffs and chinese set cutoffs 15-10-2. Predictors of DBC were sought by univariate and multivariate analysis (SPSS software, p significant if < 0.05). ResultsWe included 664 patients (mean age 62 years and sex ratio M/W = 0.8). Main indication for ERCP was choledocholithiasis (67%, n = 442) followed by malignant biliary stenosis (21%, n = 138). Based on ESGE criteria, prevalence of DBC was 42.62% (n = 283). Prevalence was 21.15% when 15-10-2 cutoffs are applied in trainee-involved procedure. Cumulative biliary success rate was 96.46%. Standard cannulation method achieved access in 98.2% while advanced methods permitted success in 92.2% in fistulotomy, 94.1% in papillotomy and 77.3% in transpancreatic sphincterotomy. Independent predictive factors of DBC in multivariate analysis were: Trainee presence OR 1.80 [1.24–2.65], SOD OR 4.71 [1.11–19.88], biliary stenosis found on imaging examinations (OR 2.53 [1.63–3.92], small papilla OR 4.09 [1.82–9.17] and difficult orientation of the papilla OR 14.90 [3.28–67.62]. ConclusionDBC is a frequent endoscopic situation. Predictors of DBC can be related to trainee involvement in the procedure, anatomical and clinical factors. A thorough understanding of these factors can actively contribute to ERCP management plans.

Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: Real life experience from a referral center.

During ERCP for biliary indication, when a difficult bile duct (BD) cannulation occurs, with unintended access to the main pancreatic duct (PD), both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed. We aimed to compare the technical success and adverse events (AEs) rate of these techniques. A retrospective analysis of patients with naïve papillae referred to the Pancreas Institute of Verona from January 2016 and July 2021 to undergo ERCP for biliary indications was performed. Overall, 202 patients (53.5% males, mean age 67.2 years) were evaluated (96 DGW, 106 TPBS). Malignant biliary stricture was the most common ERCP indication (78.2%). The rate of success in deep biliary cannulation was significantly higher in the DGW group (94.8%) compared to TPBS (79.2%) at the first attempt (p=0.001). This result was also confirmed in the subgroup of patients with malignant distal stricture (72/77, 93.5% vs 63/80, 78.8%, p=0.01). No significant difference in AEs rate, particularly in PEP incidence was found between the two groups. DGW demonstrated a higher success rate and similar safety profile compared with TPBS in difficult biliary cannulation. Based on this retrospective study, DGW should be preferred over TPBS in case of unintended PD cannulation. Further prospective studies are needed to confirm our results.

S1730 ERCP in a Patient With Situs Inversus Totalis

Introduction: Situs inversus (SI) is a congenital anomaly resulting in transposition of thoracic and abdominal organs. SI is often found incidentally. We present a case of choledocholithiasis in a patient with situs inversus totalis (SIT). We highlight some technical considerations in performing ERCP for these patients which may increase procedural success. In addition, we included images showing the unique orientation of bile duct to the pancreatic duct. Case Description/Methods: An 89-year-old man presented to the emergency department with progressive epigastric abdominal pain for one month associated with nausea and non-bloody, non-bilious vomiting. In the emergency department, the patient was found to have elevated lipase 1903 U/L, total bilirubin 1.7 mg/dL, and a CT abdomen showed changes of acute pancreatitis with a 7 mm obstructing stone at the ampulla (Figure A). The CT also incidentally detected situs inversus totalis. After treatment of acute pancreatitis, patient underwent ERCP for removal of the common bile duct (CBD) stone. The patient was positioned in right semiprone position with the endoscopist positioned on the right side of the table. The side-viewing duodenoscope was advanced into the stomach, the gastric folds were followed with slight clockwise rotation of the scope until reaching the antrum. Long scope position was used to visualize and access the papilla. The major papilla was visualized in the upper right quadrant of the screen (Figure B). Deep biliary cannulation was challenging so a pancreatic duct stent was placed first to aid in biliary cannulation. Subsequently, biliary cannulation was achieved with biliary sphincterotomy and balloon sweep performed (Figure C shows the orientation of CBD to the right of the pancreatic duct). Clearance of the common bile duct was achieved (Figure D). The patient tolerated the procedure well and underwent laparoscopic cholecystectomy during the same hospitalization. Discussion: SI is found in approximately 1 in 10,000 which can obscure the diagnosis of abdominal pathology. Often imaging is necessary to fully determine organ position and existing anatomy. In our case SIT was noted on CT along with the culprit CBD stone that caused acute pancreatitis. Performing ERCP in this setting can be very challenging. In such patients, careful planning for ERCP to minimize adverse events and maximize success is essential.Figure 1.: CT scan demonstrating situs inversus with pancreatitis and visible stone (A), major papilla (B), CBD to the right of the pancreatic duct (C), confirmed clearance of common bile duct (D).

S1733 Exceedingly Rare Coexistence of Metamorphosis of Tubulovillous Adenoma of the Ampulla to Adenocarcinoma with Small Bowel Gastrointestinal Stromal Tumor - Case Report and Review of the Literature

Introduction: This is a unique case of a patient with 3 tumors, which include one benign tumor, tubulo-villous adenoma of the ampulla of Vater (TVAoA), and 2 extremely rare malignant tumors, adenocarcinoma of the ampulla of Vater arising from TVAoA and gastrointestinal stromal tumor (GIST) involving the jejunum. Based on literature review, this is the first case of ampullary adenocarcinoma coexisting with GIST. Distal duodenal polyps are uncommon and have preponderance to occur in and around the ampulla of Vater. We report a case of a 77-year-old male who was admitted for painless obstructive jaundice with a 40-pound weight loss over a 2-month period, and who was subsequently diagnosed with 3 tumors. Case Description/Methods: A 77-year-old man was admitted for generalized weakness with associated weight loss of 40 pounds in the previous 2 months and was noted to have painless obstructive jaundice. Computed tomography (CT) of the abdomen and pelvis and magnetic resonance cholangiopancreatography were consistent with a polypoid mass at the level of the common bile duct (CBD) and ampulla of Vater with CBD dilatation. The same lesions were visualized by endoscopic retrograde cholangiopancreatography. Histopathology of endoscopic forceps biopsy showed tubulo-villous AoA (TVAoA). Histopathology of the surgical specimen of the resected ampulla showed adenocarcinoma arising from the TVAoA. Abdominal and pelvic CT also showed a coexisting heterogeneously enhancing, lobulated mass in the posterior pelvis originating from the jejunum (Figure). The patient underwent resection of the mass and jejunojejunal anastomosis. The histopathology of the resected mass confirmed it as a high-grade GIST. Discussion: AoA can occur sporadically and in a familial inheritance pattern in the setting of FAPS. We emphasize screening and surveillance colonoscopy when one encounters AoA in upper endoscopy to check for FAPS. AoA is a premalignant lesion, particularly in the setting of FAPS, that carries a high risk of metamorphism to ampullary adenocarcinoma. Final diagnosis should be based on a histopathologic study of the surgically resected ampullary specimen, and not on endoscopic forceps biopsy.This case is unique because he had 3 tumors and rare coexistence, which included one premalignant TVAoA and 2 malignant tumors: ampullary adenocarcinoma arising from the TVAoA and coexisting jejunal GIST.Figure 1.: Figure1A: CT abdomen and pelvis with contrast. Obstructed distal common bile duct due to a 9 mm polypoid intraluminal (pointed yellow arrows) lesion in the distal CBD. Figure1B: CT of the abdomen and pelvis with contrast. Heterogeneously enhanced lobulated mass with punctate calcifications (pointed yellow arrows) in the posterior pelvis originating from the serosal surface of the pelvic small bowel. Figure1C: Endoscopic retrograde cholangiopancreatography (ERCP) showed abnormal papilla with polypoid mass. Sphincterotomy and deep cannulation procedures were performed and confirmed by fluoroscopy. It showed common bile duct dilatation, and there was an abrupt cutoff at the distal aspect. Figure1D: High-power photomicrograph showing high-grade glandular dysplasia (hematoxylin and eosin stain, 200 X original magnification) Figure1E: A broad base ampullary mass with red fogerty cath was advanced from the cystic duct down through the ampulla to the duodenum. Figure1F: Pedunculated GIST arising from the small bowel approximately 150 cm proximal to the ileocaecal valve.

S2551 Gone to Guts: A Case of Osteosarcoma With Metastasis to Upper and Lower Gastrointestinal Tract Presenting as Recurring Bleeding

Introduction: Osteosarcomas are the most common bone tumors in children and adolescents. They are notoriously known to metastasize to lungs, however metastasis to gastrointestinal tract is extremely rare and only reported in sparse case reports.1–5 To our knowledge, we present one of the first cases of osteosarcoma that metastasized to the upper and lower GI tract presenting as recurrent bleeding. Case Description/Methods: A 43-year-old man with medical history of metastatic osteosarcoma to the lungs and brain, initially diagnosed at the age of 20 years in the femur, presented to the hospital after a syncopal episode. Patient had been having intermittent melena for a month prior to presentation. Oncological treatments included ifosfamide, doxorubicin, carboplatin, and etoposide. On presentation, his vitals were significant for HR 102, and BP 85/40 mmHg. Physical exam revealed a non-tender abdomen and rectal exam was positive for melena. His labs are outlined in Table. Chest X-ray revealed metastatic lung nodules. Enteroscopy showed no bleeding up to proximal jejunum. A 2cm ulcerated nodule was noted in the jejunum which was not actively bleeding (Figure A). Colonoscopy with deep cannulation of terminal ileum (40 cm) revealed old blood throughout. Again, similar 2-3 cm ulcerated transverse and hepatic colon nodules were noted which were biopsied (Figure B). Pathology revealed spindle-shaped cells with marked nuclear atypia with poor immunoreactions indicating poorly differentiated sarcoma. CT angiography of the abdomen showed evidence of metastatic nodules in the small and large bowel. Patient’s family opted for comfort measures given his poor surgical candidacy and overall prognosis. Discussion: In line with other sparsely reported cases, our case presented with luminal bleeding from multiple ulcerated nodules.1,3,4 To our understanding, this was one of the first cases that had simultaneous involvement of both upper and lower GI tract. With the growing incidence of osteosarcoma, it would aid gastroenterologists in understanding clinical presentation and endoscopic appearance to timely recognize this condition and thereby impact outcomes.Figure 1.: A) EGD image showing a 2cm ulcerated jejunal nodule. B,C) Colonoscopy images showing 2-3cm ulcerated nodules in the hepatic and transverse colon. Table 1. - Laboratory values with reference range on presentation Lab parameter Value Units Reference range WBC count 17.70 X 1000 cells/uL 4-10 RBC count 2.28 Million/uL 3.5-5.5 Hemoglobin 5.3 g/dL 12-16 Hematocrit 18.3 % 35-45 MCV 80.3 fL 84-96 Platelet count 257 X 1000/uL 150-400 RDW 19.40 % 12-15 Sodium 135 mmol/L 132-143 Potassium 4.2 mmol/L 3.5-5.1 Chloride 102 mmol/L 98-107 Carbon dioxide 26 mmol/L 21-31 BUN 33 mg/dL 7-25 Creatinine 0.8 mg/dL 0.7-1.3 BUN/Cr ratio 34 6-22 AST 22 IU/L 13-39 ALT 10 IU/L 7-52 ALP 49 IU/L 34-104 Albumin 3.0 g/dL 3.7-4.9 Total Bilirubin 1.1 mg/dL 0.2-1.2 INR 1.32 0.90-1.10 Lactic acid 3.07 mmol/L 0.5-1.99

Side-Viewing Duodenoscope versus Forward-Viewing Gastroscope for Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is still a challenging procedure. The optimal approach, namely the type of endoscope and sphincter management, has yet to be defined. Aim: To compare the efficacy and safety of forward-viewing gastroscope and the side-viewing duodenoscope in ERCP of patients with Billroth II gastrectomy. Methods: We conducted a retrospective, single-center cohort study of consecutive patients with Billroth II gastrectomy submitted to ERCP in an expert center for ERCP between 2005 and 2021. The outcomes assessed were: papilla identification, deep biliary cannulation, and adverse events (AEs). Multivariate analysis was performed to evaluate potential associations and predictors of the main outcomes. Results: We included 83 patients with a median age of 73 (IQR 65–81) years. ERCP was performed using side-viewing duodenoscope in 52 and forward-viewing gastroscope in 31 patients. Patients’ characteristics were similar in the two groups. The global rate of papilla identification was 66% (n = 55). The rate of deep cannulation was 58% considering all patients and 87% in the subgroup of patients in which the papilla major was identified. Cannulation was performed with standard methods in 65% of cases and with needle-knife fistulotomy in 35%. AEs occurred in 4 patients. There was no difference between duodenoscope and gastroscope in papilla identification (64% [95% CI: 51–77] vs. 71% [55–87]). Although not statistically significant, duodenoscope had a lower deep cannulation rate when considering all patients (52% [15–39] vs. 68% [7–35]) and a higher AEs rate (8% [1–15] vs. 0% [0–1]). In a multivariate analysis, the use of gastroscope significantly increased the deep cannulation rate (OR = 152.62 [2.5–9,283.6]). Conclusion: This study demonstrates that forward-viewing gastroscope is at least as effective and safe as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Moreover, our study showed that gastroscope is an independent predictor of successful cannulation.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists’ experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists’ experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

Post-ERCP Bile Leak

AbstractA 37-year-old female with no underlying comorbidities was referred for the evaluation of biliary stricture. Her magnetic resonance cholangiopancreatography showed a focal lesion in the left hepatic duct close to primary confluence causing a stricture and bilateral intrahepatic biliary radicle dilatation. Spyglass cholangioscopy was done and SpyBite biopsy was taken from the stricture. Repeated attempts at attaining deep cannulation of the right duct were unsuccessful. Patient developed right-sided abdominal pain the next day. Computed tomographic scan of the abdomen showed intra-abdominal fluid in the perihepatic region. Fluid was drained under ultrasound guidance. Though patient improved transiently, she had recurrence of pain after drain removal. A repeat endoscopic retrograde cholangiopancreatography (ERCP) was done and a leak was noted at the junction of right anterior and posterior hepatic ducts. Stenting was done to right anterior, right posterior, and left hepatic ducts. Over the next few days, she improved symptomatically. Though complications are inherent during ERCP, bile duct injury leading to bile leak is rare. Special caution has to be taken in high-risk cases to prevent bile duct injury. Though post-ERCP bile leak is a rare complication, early recognition with a high index of clinical suspicion and prompt management are the key factors in minimizing morbidity and mortality.

Patient-related post-ERCP pancreatitis (PEP) risk factors between two groups of patients: Prophylactic pancreatic stent and rectal indomethacin.

Pancreatitis is one of the most crucial complications following endoscopic retrograde cholangiopancreatography (ERCP). The purpose of the current study was to investigate patient-related post-ERCP pancreatitis (PEP) risk factors in two groups of patients: prophylactic pancreatic stent and rectal indomethacin. Two different prophylactic modalities were planned and complications were assessed based on the defined inclusion criteria. In this study, the patients were evaluated for the procedure and patient-related risk factors in post-ERCP pancreatitis in the recipient groups of the prophylactic pancreatic stent and rectal indomethacin. Pancreatitis was confirmed in 27 of all 170 selected patients after ERCP. By univariate analysis, two variables were significant with the development of PEP. Regarding the patient-related risk factors, unique subjects with common bile duct (CBD) dilated 10mm were more exposed to an increased chance of PEP (P=0. 015); meanwhile, other factors did not correlate with the increased possibility of PEP in both groups. The only procedure-related risk factor for PEP was the deep cannulation of the pancreatic duct in both groups during the procedure with an incremental significant incidence of pancreatitis (P=0.005). Comparison of prophylactic pancreatic stent and rectal indomethacin showed no effects in term of post ERCP pancreatitis reduction. Additionally, there was no significant difference between these two strategies in the rate of PEP. Prophylactic pancreatic duct stents and administration of rectal indomethacin cannot have particular approaches for reducing the possible occurrence of PEP. The increase in time of deep cannulation and the presence of CBD dilation <10mm could be considered as important risk factors.