Initial ERCP Research Articles

Surgical results of modified Blumgart anastomosis in our institution

Pancreatodigestive tract anastomotic site stenosis is a problematic complication after pancreatoduodenectomy.We evaluated the feasibility and efficacy of endoscopic treatments for a stenotic pancreatodigestive tract anastomosis.Retrospective study.Endoscopic units of a university-affiliated hospital and a general hospital.Fourteen patients with recurrent pancreatitis (n = 10) and pancreatic fluid fistula (n = 4) after anatomy-altering surgery with pancreatodigestive tract anastomosis.The initial ERCP included obtaining a pancreatogram, introducing a 0.025-inch guidewire through the anastomosis, along which a 5F plastic stent or nasopancreatic drain was inserted. If initial ERCP failed, we attempted EUS-guided rendezvous, with a guidewire passed antegrade from the main pancreatic duct across the stenotic anastomosis.Rates of successful intervention and clinical relief.The initial intervention was successfully achieved in 6 of 14 patients (38%). Of the 6 patients with successful therapeutic endoscopies, 4 (66.7%) and 2 (25.0%) had undergone a previous pancreatogastrostomy or pancreatojejunostomy, respectively. Eight patients with an initial unsuccessful intervention successfully underwent a second intervention using an EUS-guided or US-guided rendezvous method. Finally, stenosis was relieved in all patients with either the retrograde placement of a pancreatic duct stent across the stenosis of an anastomotic site or antegrade percutaneous bougienage of the stenotic anastomosis.Small sample size and lack of control patients.Endoscopic treatment of stenotic pancreatodigestive tract anastomosis for transanastomotic pancreatic juice drainage is safe and feasible.

PWE-015 Radiofrequency ablation for management of malignant biliary obstruction

Introduction Malignant biliary obstruction is usually treated using metal stents at ERCP but some patients can develop stent dysfunction. Radiofrequency ablation (RFA) causes coagulative necrosis of tissue using thermal energy which may reduce tumour volume prior to biliary stenting or can be used to ablate ingrowth of tumour in previously placed stents. Improving stent patency has the potential to reduce morbidity, reduce reintervention rate and possibly improve survival. We report our experience in the use of RFA for malignant biliary obstruction. Method Retrospectively analysis of clinical and procedure related data of all patients undergoing RFA for malignant biliary obstruction over the last two years at Aberdeen Royal Infirmary. Age, sex and procedure/disease stage matched controls were selected from patients undergoing ERCP prior to the commencement of this service. Each RFA application delivers 10 watts of energy for 90 s via a specific probe passed through the lesion over a wire during ERCP. Technical success rates, complications, time to reintervention and date of death were recorded following the initial ERCP with RFA and Kaplan-Meier survival analysis performed. Results 12 patients underwent biliary 13 RFA applications during the study period (median age 78 years, 7 females). 5 patients had cholangiocarcinoma, 5 had pancreatic cancer, 1 had ampullary carcinoma and 1 had metastatic colorectal cancer. In 8 patients RFA was applied prior to biliary metallic stenting and good drainage was achieved. RFA was given in 1 – 3 applications with a median of 1 application. 4 patients underwent RFA for a blocked metal stent resulting in adequate biliary drainage in all cases. Post procedure complications included acute pancreatitis in 2 (mild) and Klebsiella bacteraemia and 30 day mortality rate was 0/12 (0%). 2 controls required reintervention within 30 days compared to none who received RFA. Median time to death or reintervention was 220 days in those receiving RFA compared o 131 in controls (Hazard ratio 0.59, 95% CI 0.25–1.4, p = 0.23). Conclusion Biliary RFA is a safe, useful adjunct in the management of malignant biliary obstruction or blocked metal stents. Time to death or reintervention was longer in those receiving RFA but a larger, prospective study is required to show a significant survival benefit. Disclosure of interest None Declared.

EUS-FNA During Initial ERCP for Obstructive Jaundice From Pancreatic Head Adenocarcinoma Results in Fewer Subsequent Invasive Procedures

Introduction: Patients with pancreatic masses presenting with obstructive jaundice often need both tissue diagnosis and biliary decompression prior to initiation of treatment. Where available, EUS-FNA for tissue diagnosis is often performed during the same session as the initial ERCP with stenting. The aim of this study is to determine whether performing EUS-FNA with the initial ERCP leads to patients undergoing fewer diagnostic and therapeutic invasive procedures. Methods: Patients with pancreatic head adenocarcinoma presenting with jaundice referred to a comprehensive cancer hospital between Feb 2005 and Sep 2013 were identified by chart review. Patients were classified into two groups based on initial endoscopic procedure; 1) combined EUS-FNA plus ERCP with biliary stenting (combined group) or 2) ERCP with brushings and biliary stenting (ERCP group). The primary outcome was the number of subsequent invasive procedures for tissue diagnosis and biliary decompression patients needed to have prior to initiation of cancer treatment. Statistical analyses were done using Fisher’s exact test to compare categorical variables and Wilcoxon rank sum test to compare numeric variables. All associations were considered statistically significant at an alpha error <0.05 (P value 0.05). Results: Overall, 161 patients met study criteria (combined = 57, ERCP = 104). Cytology was diagnostic for adenocarcinoma in 82.5% of the combined group vs. 19.8% in the ERCP group (p<0.0001). The combined group required fewer subsequent diagnostic interventions (10 vs. 100, p<0.001). Biliary cannulation rates were similar in both groups (82.1% vs. 71.2%, p=0.18). Due to information gained from rapid on-site cytologic evaluation of FNA specimens and EUS staging, more patients in the combined group received metal biliary stents than in the ERCP group (74.5% vs. 40.5%, p=0.004). The combined group required fewer subsequent biliary drainage procedures (19 vs. 47, p=0.03). Complications were similar in both groups (6 vs. 9, p=0.18). The type of initial cancer therapy was not statistically different between the two groups. Median time to treatment (in days) between the two groups was 28 vs. 49 for chemotherapy (p<0.001), 25 vs. 34 for surgery (p=0.917) and 7 vs. 31 for hospice referral (p=0.002). Conclusion: Pancreatic cancer patients presenting with obstructive jaundice who undergo EUS-FNA with the initial ERCP are subjected to fewer subsequent invasive diagnostic and therapeutic procedures resulting in sooner initiation of cancer treatment. Further studies are needed to determine if this expedited treatment influences survival.

Young Nepalese Male With Jaundice

Introduction: Pancreatic acinar cell carcinoma is a rare malignancy accounting for less than 1% of all pancreatic tumors. Given its rarity, diagnosis is often difficult and delayed. There are no current standard treatment protocols and surgical resection is the only curative measure. This cancer is primarily seen in older males. However, we report a case of acinar cell carcinoma in a young male from Nepal who presented with jaundice. Case Report: A 30-year-old Nepalese male with no significant past medical history who presented with jaundice, generalized pruritus, dark urine, and a 34-pound weight loss in 1.5 months. He presented with elevated serum liver enzymes. An abdominal ultrasound was performed, which showed fatty liver, distended gallbladder containing large amounts of sludge, and dilated common bile duct with sludge. A subsequent MRCP confirmed a dilated distal common bile duct along with a filling defect, 2.0 cm from ampulla of Vater with no other significant abnormalities. His initial ERCP showed a stricture in the common bile duct, a sphincterotomy was performed, and a stent was placed. Cytology was nondiagnostic and only showed atypical glandular cells. A CT did not show any other lesions or gross abnormalities. Subsequent endoscopic ultrasound (EUS) showed a well-demarcated mass in the lower third of the common bile duct with no significant pathology in the pancreas. Another ERCP was performed, which showed a dilated common bile duct with distal stricture that was restented and nondiagnostic biopsies. The patient’s laboratory values showed a slightly elevated CA 19-9, normal CEA, negative ANA, and normal IgG4, making autoimmune pancreatitis unlikely. The patient underwent a pylorus-sparing pancreaticoduodenectomy (partial Whipple resection), abdominal lymphadenectomy, and cholecystectomy. Pathology showed a 3-cm high-grade acinar cell carcinoma in the pancreatic head. The final staging of the tumor was T3N1M0 with 2 out of 5 resected abdominal lymph nodes being positive for metastasis. All resection margins were negative. Tumor cells were positive for Cam 5.2, AE1/AE3 and anti-chymotrypsin, making it consistent with acinar cell carcinoma in addition to positive PAS (periodic acid-Schiff-diastase) staining of cytoplasmic granules. The patient was started on a course of radiation with 5 fluorouracil, 3 months after surgery, followed by chemotherapy with Gemzar. After 1 month post-adjuvant radiation and chemotherapy, the patient’s CA 19-9 decreased. At 12 months’ follow-up, the patient is doing well and is on oral medications for brittle diabetes. The patient’s follow-up PET scan was negative.

Analysis of risk factors for post-ERCP pancreatitis

Objective To investigate the risk factors of post-ERCP pancreatitis( PEP). Methods Data of 4,234 patients who underwent ERCP in Nanjing Drum Tower Hospital were retrospectively analysed. Information of patients and operations,including age,gender,operation history,major disease history,labora-tory examination before operation,abdominal ultrasound,CT,MRCP,detailed ERCP operation process,com-plications and treatment were carefully recorded. Then Chi-square test was used for univariate analysis,and stepwise multivariate Logistic regression for variate analysis. Linear correlations between risk factors were de-tected. Results There were totally 226 PEPs,with 5. 3% incidence rate. Univariate analysis showed that the female(χ2 =9. 715,P=0. 002),young( <60 years)(χ2 =6. 108,P=0. 013),chronic pancreatitis(χ2 =14. 703,P=0. 001),initial ERCP(χ2 =14. 899,P=0. 000),hypertension(χ2 =4. 489,P=0. 034),nor-mal bilirubin levels before operation(χ2 =19. 159,P =0. 000 ),difficult cannulation(χ2 =45. 824,P =0. 000),pancreatic guide wire(χ2 =30. 223,P=0. 000),papillary pre cut(χ2 =45. 928,P=0. 000),pan-creatography(χ2 =20. 170,P=0. 000)may be risk factors for PEP. Non conditional Logistic regression analy-sis showed that female(OR=1. 449,P=0. 011),initial ERCP(OR=1. 745,P=0. 003),normal bilirubin levels before operation(OR=1. 917,P=0. 000),difficult cannulation(OR=3. 317,P=0. 000)and pancre-atography(OR=1. 823,P=0. 004)were independent risk factors for PEP. Linear correlation analysis sugges-ted that pancreatic duct guide wire and papillary precut were related to the difficult cannulation,and the corre-lation coefficients were -0. 788 and -0. 699. Conclusion Female,young(<60 years),chronic pancreati-tis,initial ERCP,hypertension,normal bilirubin levels,difficult cannulation,pancreatic duct guide wire,pa-pillary precut,pancreatography may induce PEP. Female,normal bilirubin levels before operation,initial ER-CP,difficult cannulation and pancreatography are independent risk factors for PEP,while pancreatic duct guide wire,papillary precut are not,as they were linear correlated to difficult cannulation. Key words: Cholangiopancreatography,endoscopic retrograde ; Pancreatitis ; Risk factor ; Uni-variate analysis ; Independent risk factor ;

Primary Sclerosing Cholangitis in the Setting of Normal Liver Function Tests Can Be Associated with Severe Ductal Disease and Even Cholangiocarcinoma

Purpose: Primary sclerosing cholangitis (PSC) is a chronic progressive disease characterized by inflammation, fibrosis and stricturing within the intra and extrahepatic biliary ducts. It is commonly associated with abnormal liver function tests such as alkaline phosphatase, AST, ALT and total bilirubin. The aim of this study is to evaluate patients with PSC with normal liver function tests. Methods: Retrospective cohort study. Results: Of 101 PSC patients, 10 (seven males and three females) had normal LFTs. The mean age was 47.1 years (range 18-69). Five patients had IBD disease (three CD, two UC), four patients did not have IBD, and one patient's IBD status was unknown. One patient had a previous biliary sphincterotomy. Three patients had prior cholecystectomies and one patient had a previous cholecystectomy and choledochoduodenostomy for papillary adenocarcinoma of the gallbladder. On ERCP, five patients had mild to moderate ductal disease, two patients had moderate disease, two patients had moderate to severe disease, and one patient had severe disease. One of the patients was diagnosed with cholangiocarcinoma at time of initial ERCP, and one patient was found to have cholangiocarcinoma 8 months later by biliary brushings on surveillance ERCP. Conclusion: Although PSC patients commonly have abnormal LFTs, there is a subset of PSC patients with normal LFT's. Despite normal labs, these patients can have severe ductal disease and even cholangiocarcinoma. These findings may have significant importance for screening and surveillance for malignancy in patients with PSC. Normal ducts do not appear correlate to quiescent disease.

One- and two-step self-expandable metal stent placement for distal malignant biliary obstruction: a propensity analysis

Although self-expandable metal stents (SEMS) are widely used for distal malignant biliary obstruction, one-step SEMS (direct placement without a prior plastic stent) and two-step SEMS (placement at second endoscopic retrograde cholangiopancreatography [ERCP] following plastic stent placement) have not been fully compared. In this multicenter retrospective study, patients were included who underwent first-time endoscopic SEMS placement between September 1994 and December 2010. We compared the one-step and two-step strategies using a propensity analysis. In total, 370 patients were identified and one-step SEMS was performed in 59 patients. After adjustment using propensity scores, the median times to dysfunction were 116 and 219 days, respectively, for one-step and two-step SEMS (P = 0.058). Stent migration was more frequently observed in one-step SEMS as compared with two-step SEMS (25 vs. 11 %, P = 0.031). In one-step SEMS, the number of days of hospitalization associated with first-time SEMS placement was shorter compared with that in two-step SEMS (21 vs. 30 days, P = 0.001), and the total costs of SEMS-related interventions within 6 months were lower (6510 and 8100 USD, P = 0.004). The pathological diagnosis rates for pancreatic and biliary tract cancer at initial ERCP were 52 and 61 %. After failed diagnosis at initial ERCP, pathological diagnosis rates for pancreatic cancer were 32 versus 76 % (P = 0.005) by repeated ERCP versus endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). One-step SEMS was associated with increased stent migration, despite having potential cost-effectiveness. The additional yield of pathological diagnosis at repeated ERCP was low compared with that yielded by EUS-guided FNA.

Sp813 Pancreatic Necrosis Treated With Direct Endoscopic Debridement by Transpapillary Approach

The patient is a 33 year-old male with a recent history of severe alcohol-induced acute necrotizing pancreatitis who was transferred with dyspnea and abdominal pain. Chest x-ray showed a high amylase right-sided pleural effusion suggesting a pancreatico-pleural fistula. Adbominal CT showed multiple pancreatic fluid collections in addition to changes of severe necrotizing pancreatitis, with total loss of parenchyma in the head. Initial ERCP confirms a complete pancreatic duct disruption, and a pancreatic duct stent is placed. The patient does not improve, and he is scheduled for repeat ERCP.

Use of probe-based confocal laser endomicroscopy (pCLE) in the diagnosis of cholangiocarcinoma.

281 Background: Despite technologic advances in endoscopy and new cytologic techniques, cholangiocarcinoma is a challenging diagnosis for the endoscopist and oncologists. Current sampling techniques include cytology brushing, biopsy, and fine needle aspiration but are limited in their sensitivity. Confocal laser endomicroscopy (CLE) is a relatively new modality that offers in-vivo imaging of the gastrointestinal tract with microscopic detail in living cells. Methods: This was an observational study of 10 patients with indeterminate biliary strictures who were evaluated with ERCP, cholangioscopy, and CLE to determine the sensitivity and specificity of tissue biopsy compared to virtual biopsy using this new technology, CLE. All cases were confirmed to be cholangiocarcinoma by histopathology. Fluorescein 10% was used as a contrast agent. Results: The 10 ERCP cases that were reviewed demonstrated biliary strictures that were suspicious for malignancy based on history and clinical presentation. Nearly all initial brushings and traditional biopsies were inconclusive. Subsequent ERCP and cholangioscopy with CLE imaging was performed. The biliary architecture was concerning for malignancy according to the Miami Criteria. Images were reviewed by 2 independent physicians. Every case demonstrated thick bands &gt;20 µm and dark clumps of glands. Bright vessels ( &gt;20 µm) with tortuosity were visualized in seven cases. Other findings include reticular networks of dark bands and small, fine branching bands &lt;20 µm, but these patterns were infrequent. Conclusions: 1.CLE is a novel tool to investigate indeterminate biliary strictures and potentially diagnose cholangiocarcinoma in conjunction with other diagnostic modalities during the initial ERCP and cholangioscopy. 2. Our early experience found sensitivity 90% , specificity of 100% , NPV 90% 3. CLE gives the opportunity to obtain en-vivo targeted biopsies during cholangioscopy as well as reduce repeat procedures and cost.

Acute pancreatitis after removal of retained prophylactic pancreatic stents

Prophylactic pancreatic stents (PPSs) are used to decrease the risk of post-ERCP pancreatitis (PEP) in high-risk patients. The risk associated with PPS removal is unknown. To describe the rate of PEP in patients undergoing PPS removal without pancreatogram or other manipulation of the major or minor papilla. Retrospective, cohort study. Tertiary care academic center. This study involved 230 patients undergoing removal of PPSs from 1997 to 2010. PPS removal. Rate of acute pancreatitis associated with removal of PPS alone. Acute pancreatitis occurred after PPS removal in 7 of 230 (3.0%) cases. PEP was graded as mild, moderate, and severe in 2, 5, and 0 cases, respectively. Statistically significant risk factors of PEP after PPS removal include use of a 5F stent (P=.001), use of a stent with an internal flange (P<.01), and occurrence of PEP after the initial ERCP (P<.01). Longer duration of stent within the pancreatic duct before removal was of borderline significance (P=.06). Patient age; sex; indication for initial procedure; the presence of pancreas divisum, ansa loop, or chronic pancreatitis; and history of pancreatic or biliary sphincterotomy or orifice dilation were not significant risk factors for pancreatitis after PPS removal. Retrospective analysis of prospectively collected data. Small number of events. Removal of retained PPSs may cause mild or moderate acute pancreatitis. This risk of acute pancreatitis may diminish the overall efficacy of PPS use by delaying the occurrence of PEP rather than eliminating it. This implies that PPSs should be used only in patients at high risk for PEP.

Su1429 Frozen Section of ERCP Forceps Biopsy Specimens Permits Efficient Intraprocedural Diagnosis

Same Session, Single-Operator EUS-Assisted Cholangiopancreatography (EUSCP) After Failed ERCP: Expanded Experience Jay P. Babich, James H. Grendell, Stavros N. Stavropoulos Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, Mineola, NY ERCP fails to access the biliary or pancreatic ductal systems in 1-2% of patients. EUSCP is being increasingly employed at expert centers as an alternative to surgery or interventional radiology, modalities which until recently provided the only alternatives to failed ERCP access. Methods: All patients had EUSCP after initial ERCP attempt at our center by one of the investigators with a career ERCP volume of 3000 ERCPs(SS). The EUSCP was performed at the same session as failed ERCP in the majority of cases. Technical success was defined as successful access of the desired duct as a result of EUSCP. Clinical success was defined as lack of need for alternative intervention. Results: From 1/2004 to 11/2010, 30 patients (22F,mean age 61) underwent EUSCP for biliary access (n 23) or pancreatic access (n 7). EUSCP was performed at the same session as failed ERCP attempt in 21/23 (91%)biliary patients and 5/7 (71%) pancreatic patients. Biliary indications: periampullary diverticulum (n 2), periampullary tumor infiltration (n 12), hilar metal stent obstructing the L system (n 1), post-surgical complications/altered anatomy (n 7), duodenal malrotation (n 1). Pancreatic indications: post Whipple stricture (n 2), unsuccessful minor papilla cannulation (n 2), migrated pancreatic stent (n 2), pancreatogastric anastomosis stricture (n 1).BD interventions included: Transgastric hepatic stent placement (n 8), transduodenal stent placement (n 3), rendezvous (n 8), antegrade transpapillary stent placement (n 1), cholangiography guided retrograde stent placement (n 2), cholangiography to map biliary tree prior to biliary surgery for transected CHD (n 1). Pancreatic interventions included: Rendezvous for post Whipple stricture (n 2), minor papilla rendezvous (n 1), antegrade rendezvous to assist retrieval of embedded stent (n 1), Direct EUS guided transgastric extraction of migrated PD stent in OR with laparoscopic assistance (n 1), pancreatography guided minor papilla cannulation (n 1), other (n 1). Biliary intervention technical success was 22/23 (96%) with clinical success in 21/22 pts (92%). Pancreatic intervention technical and clinical success was 3/7 (43%). Biliary complications (2/23; 9%)were; self-limited hemobilia after successful rendezvous and pneumoperitoneum after transgastric hepatic plastic stent. Pancreatic complications (2/7; 29%) were mild pancreatitis after successful pancreatic rendez-vous. Conclusions: 1) EUSCP by a single operator at the same session as failed ERCP appears feasible, with a high success rate and a low complication rate. Technical success appears higher for biliary cases. 2) Prospective multicenter data collection would be useful in confirming the results of single center expert series. 3) Complications tend to occur early in operator experience consistent with the high level of expertise required for EUSCP.

Therapeutic endoscopy for stenotic pancreatodigestive tract anastomosis after pancreatoduodenectomy (with videos)

Pancreatodigestive tract anastomotic site stenosis is a problematic complication after pancreatoduodenectomy. We evaluated the feasibility and efficacy of endoscopic treatments for a stenotic pancreatodigestive tract anastomosis. Retrospective study. Endoscopic units of a university-affiliated hospital and a general hospital. Fourteen patients with recurrent pancreatitis (n=10) and pancreatic fluid fistula (n=4) after anatomy-altering surgery with pancreatodigestive tract anastomosis. The initial ERCP included obtaining a pancreatogram, introducing a 0.025-inch guidewire through the anastomosis, along which a 5F plastic stent or nasopancreatic drain was inserted. If initial ERCP failed, we attempted EUS-guided rendezvous, with a guidewire passed antegrade from the main pancreatic duct across the stenotic anastomosis. Rates of successful intervention and clinical relief. The initial intervention was successfully achieved in 6 of 14 patients (38%). Of the 6 patients with successful therapeutic endoscopies, 4 (66.7%) and 2 (25.0%) had undergone a previous pancreatogastrostomy or pancreatojejunostomy, respectively. Eight patients with an initial unsuccessful intervention successfully underwent a second intervention using an EUS-guided or US-guided rendezvous method. Finally, stenosis was relieved in all patients with either the retrograde placement of a pancreatic duct stent across the stenosis of an anastomotic site or antegrade percutaneous bougienage of the stenotic anastomosis. Small sample size and lack of control patients. Endoscopic treatment of stenotic pancreatodigestive tract anastomosis for transanastomotic pancreatic juice drainage is safe and feasible.

Role of ERCP in Evaluation of Post-stem Cell Transplantation Patients with Hepatobiliary Disease

Purpose: Patients with hematopoietic stem cell transplantation (HSCT) may develop hepatobiliary disease. The role of ERCP in evaluating this group of patients is being defined. The aim was to review our experience with ERCP in HSCT patients. Methods: All patients who had ERCP following HSCT from 2002-2009 were identified. Clinical data were extracted from the electronic medical record. Results: During the study period 8,010 HSCTs were performed (53% allogeneic). Thirty patients (13 male) who had 37 ERCPs were identified. Average age was 50 years and 24 patients were white. There were 19 allogeneic HSCT. Indications for HSCT were: lymphoma (9), acute leukemia (9), breast cancer (3), MDS (2), CLL (2), ovarian cancer (2) and other malignancies (3). Nine patients had biopsy proven graft-versus-host disease (GVHD), 7 with GI tract involvement. Mean and time to ERCP was 640 (S.D. 808) days post transplant with a range of 20 to 3805 days. Indications for initial ERCP were: obstructive jaundice (12), suspected choledocholithiasis (CBD stones) (11), dilated bile ducts (3), stent removal/revision (3), and bile leak (1). Findings on ERCP were: stricture (14), CBD stones (10), resolved stricture/normal (3), leak (1), sludge (1), and dilated duct without stricture or stone (1). The stricture group had 10 females and the mean age was 50.6 (SD 13.2) years. Eight patients had autologous and 6 had allogeneic HSCT with two having GI GHVD. ERCP occurred at a mean of 1088 days after HSCT (SD 980). Etiologies of the strictures were: recurrent malignancy (11), pancreatic cancer (1), gallbladder compressing bile duct (1) and unclear etiology (1). This latter patient had mild duodenal GVHD, negative biliary brushings and sludge on EUS. The stent was removed after 2 wks and 4 wks later CT scan showed resolution of ductal dilation. None of the stricture patients with recurrent disease had GI GVHD. The CBD stone group had a mean age of 45.9 (SD 9.0) years and 6 were female. All patients had allogeneic HSCT and two had GI GVHD. ERCP occurred at a mean of 362 days after HSCT (SD 310). Overall there were 20 deaths, 16 from recurrent disease. Other deaths were from pneumonia (2), pancreatic cancer (1), and GVHD induced liver failure (1). All 14 patients with strictures died in a mean time of 139 days after ERCP. Three of 10 with CBD stones died at a mean of 164 days post ERCP. The seven survivors in the stone group have been followed a mean of 951 days without recurrence of biliary disease. Conclusion: ERCP is uncommonly performed in the post HSCT patient. The most common indication is obstructive jaundice from either recurrent disease or CBD stones. Inflammatory strictures possibly related to GHVD are rare in our experience.

Failed biliary access following needle knife fistulotomy: is repeat interval ERCP worthwhile?

Objective. Needle knife fistulotomy is a useful alternative in gaining access to the biliary system when standard cannulation techniques have been exhausted. Where access cannot be achieved following fistulotomy the convention has been to abandon further endoscopic attempts. Recent experience at our center suggests that repeat ERCP is frequently successful. This study assesses the utility of repeat ERCP in a cohort of patients for whom biliary access could not be achieved despite needle knife fistulotomy during the initial procedure. Materials and methods. Patients who had undergone needle knife fistulotomy without successful biliary access were identified over a 3-year period. Primary endpoint was success of repeat ERCP in gaining biliary access without further intervention. Secondary endpoints were repeat ERCP time interval and findings and interventions at repeat ERCP. Results. Thirty-six patients were identified (mean age 60.2 years; 47% male). ERCP indications were: jaundice 60%, dilated biliary system 32%, choledocholithiasis 35%, gallstone pancreatitis 3%, bile leak 3%. 53% (19 of 36 patients) had a repeat ERCP and 68% (13 of 19) of repeat ERCPs were successful. Median time to repeat ERCP was 6 days (range 1–21 days). Repeat ERCP findings were: choledocholithiasis 46%, pancreatic cancer 15% and cholangiocarcinoma 39%. Interventions at repeat ERCP were as follows: plastic stent insertion 46%, metal stent insertion 39% and balloon trawl 15%. Conclusion. Follow-up ERCP after a short interval is worthwhile in patients for whom initial ERCP and fistulotomy is unsuccessful as biliary access is frequently obtained without further intervention and definitive management is facilitated in the majority of cases.

Biliary stenting in the management of large or multiple common bile duct stones

Endoscopic biliary stenting with a plastic stent is often performed to prevent impaction of common bile duct (CBD) stones. The therapeutic effect of a plastic stent placement in terms of reduction in stone size and number has not been established. The aim of this study was to study the effect of biliary stenting as therapy for CBD stones. Retrospective study. Municipal hospital outpatients. Patients with large (> or = 20 mm) and/or multiple (> or = 3) stones had placement of a 7F double-pigtail plastic stent without stone extraction at the initial ERCP. Approximately 2 months later, stone removal was attempted. The number and size of CBD stones before and after stent placement, stone clearance, complications, and 180-day mortality were evaluated. Forty patients were studied. Stent placement averaged 65 days (range, 50-82 days). The median number (interquartile range) of stones per patient fell after stent placement (4.0 [3.0] before vs. 2.0 [1.0] after; P < .0001). Characteristically, larger stones became smaller and small stones disappeared (ie, the median stone index decreased from 4.6 [3.0] to 2.0 [1.5]; P < .0001). Stone clearance at the second ERCP was achieved in 37 out of 40 patients (93%). Complications included cholangitis (13%) and pancreatitis (5%) after the second ERCP. No 180-day mortality occurred. A retrospective, single-center study. Stent placement for 2 months was associated with large and/or multiple CBD stones becoming smaller and/or disappearing without any complications. Stenting followed by a wait period may assist in difficult CBD stone removal.

VHM07: Combined Cholangioscopy and Confocal Endomicroscopy of An Indeterminant Biliary Stricture

48 year old male with a history of chronic alcohol abuse presented with painless jaundice. CT scan and EUS revealed biliary dilation without an associated mass lesion. Initial ERCP showed a CBD stricture, however cytology brushings were non-diagnostic. The patient was then then referred to our institution for ERCP with cholangioscopy for further management of this indeterminant biliary stricture.

Successful Use of Single-Balloon Enteroscopy Assisting ERCP in Patients with Altered Small Bowel Anatomy

Purpose: ERCP becomes challenging and often unsuccessful in patients with altered small bowel anatomy. Single-balloon enteroscopy (SBE) allows deep intubation of the small bowel by using a single-balloon overtube to reduce and pleat the bowel over a standard enteroscope. We present a case of successful diagnostic and therapeutic ERC in a patient with Roux-en-Y anastomosis, with the use of SBE. A 66 y/o female presented to the ER with jaundice, fever, ascites and abdominal pain with similar episodes during the past year. She had history of breast cancer status post mastectomy in 1993, with right hepatectomy for metastasis. She also had a Roux-en-Y hepaticojejunostomy for presumed delayed complications from the segmental resection of the liver. Physical exam showed jaundice, and stigmata of chronic liver disease. Labs on admission revealed leukocytosis of 13.1 bil/L [4.8-11.8], platelets 135,000 bil/L [130-460], protein 7.3 gr/dL [6.3-8.2], albumin 3.4 gr/dL [3.8-5.2], AST 59 U/L [0-30], ALT 43 U/L [0-37], total bilirrubin 12.4 mg/dL [0-1.0], alkaline phosphatase 268 U/ L [37-132]. Abdominal US showed mild ascites, liver 12.7 cm, spleen 13.5 cm, and dilated intrahepatic ducts. Abdominal CT could not be performed due to allergy to Iodine, and a pacemaker precluded patient from having an MRCP. Based on the above data, patient was thought to have secondary biliary cirrhosis decompensated by ascites and complicated by recurrent episodes of cholangitis, likely due to narrow anastomosis vs. biliary stones. An initial ERCP attempt using a pediatric colonoscope was unsuccessful. ERCP assisted with single-balloon enteroscopy was performed. Using a pleating technique while inflating and deflating the balloon, the jejunum was carefully examined as the enteroscope was advanced. The scope was then advanced into the afferent limb and the biliary-enteric anastomosis was found. A cannula was advanced and cholangiogram showed an anastomosis consistent with choledocho-jejunostomy, dilated intrahepatic ducts, and multiple filling defects. The anastomosis was dilated with a 6-7-8 mm CRE balloon, followed by an 8-9-10 mm CRE balloon. A memory basket was then used to remove multiple large black pigmented stones. Finally, the anastomosis was dilated with a 10-11-12 mm CRE balloon, and an occlusion cholangiogram revealed no filling defects. SBE can be used to assist diagnostic and therapeutic ERCP in patients with altered anatomy. It was especially helpful in our patient, as cirrhosis and ascites excluded the possibility of elective surgery or percutaneous drain.

Bilious Ascites After Liver Transplantation Due to Duodenal Perforation from Biliary Stent

Purpose: A 51-year-old female with chronic hepatitis C underwent orthotopic liver transplantation with bile duct-to-bile duct anastomosis. Her surgery was complicated by native hepatic artery dissection that was repaired using a supra-celiac conduit. Initial post-operative liver ultrasound showed elevated hepatic artery indices, this improved on repeat ultrasound on post-operative day (POD) 4. Bile ducts were normal caliber, however liver chemistries remained elevated (aspartate aminotransferase 6 times the upper limit of normal, alanine aminotransferase 3 times the upper limit of normal, alkaline phoshatase 445 IU/L, direct bilirubin 2.6 mg/dl). On POD 4, endoscopic retrograde cholangiogram revealed mild stenosis at the biliary anastomosis. An 8.5 French 10 cm plastic biliary stent was placed traversing the anastomosis. Liver chemistries began to normalize after 6 days. Patient later developed significant ascites and underwent paracentesis on POD 15. Culture of ascitic fluid grew enterococcus which was treated with intravenous vancomycin. The patient developed worsening ascites and abdominal pain. On POD 17, repeat paracentesis revealed bilious appearing fluid; ascitic bilirubin level was 34.3 mg/dl. Patient was taken emergently for surgical repair of bile leak and presumed bile duct disruption; however, the biliary system was intact. Exploration disclosed a 1 cm defect in the lateral wall of the second duodenum, just opposite the major papilla and the biliary stent. The duodenal defect was repaired with an omental patch. Patient improved and was discharged home after 10 days. Eight weeks later, endoscopy showed a normal appearing duodenum. At ERCP the biliary stent was removed. Cholangiogram showed moderate stenosis at the biliary anastomosis. The anastomosis was dilated with a 6 mm dilating balloon. A shorter plastic stent, 10 French 7 cm, was placed in the bile duct across the anastomosis. This case demonstrates a biliary prosthesis perforating through the small intestine, presenting with bilious ascites. The stent served as a conduit for bile to drain directly into the abdominal cavity. We suspect that the use of immunosuppressive therapy, a requisite after organ transplant, may have lead to increased fragility of the intestinal wall. It is plausible that the perforation resulted from endoscope trauma during the ERCP, though one might expect such an injury to be apparent earlier in her course. CT scans 2 and 10 days after the initial ERCP showed the distal end of biliary stent did approximate the lateral duodenal wall, though perforation was not apparent. Perhaps the use of a shorter stent or single pigtail design would prevent this complication in the early post-transplant setting.

Failed Cannulation After Initial ERCP: Benefit of a Tertiary Referral ERCP Service

Background: Competent biliary endoscopists fail selective biliary cannulation between 5 and 10% of cases and unsuccessful cannulation is reported in up to 20% of published series. Published data confirms that patients with previously failed cannulation at ERCP are often referred for alternative therapeutic techniques with inferior safety and accuracy profiles. Prospective data on outcomes after referral to a tertiary high volume ERCP center with greater experience is absent, however if this clinical pathway was confirmed as viable and effective then substantial cost savings and improved clinical outcomes might be anticipated. Methods: Prospective recruitment of patients with previously failed ERCP cannulation referred by other specialist biliary endoscopists. Prospective data collection included initial procedural indication, reason (if any) for failed cannulation, along with detailed cannulation parameters at the tertiary center. This group was compared to all other ERCP procedures performed at the same institution during the same period. 24 hour and 30 day follow up was obtained in all patients. Results In the 24 months to November 2008, a total of 1676 ERCP procedures were performed. 35 patients (20 female, mean age 68(range 40-88)) were referred after previous failed ERCP cannulation. Indications were biliary stones(16), pancreatic malignancy(6), biliary strictures(5), bile leak(2) and cholangitis(2). Successful cannulation was achieved in 100% of cases, 10(29%) requiring needle knife sphincterotomy (NKS). Identifiable reasons for initial failed cannulation included long intraduodenal papilla(5), peripapillary diverticulum(5), difficult/unstable duodenal position(4) and small papilla(4). There was one episode of mild post ERCP pancreatitis. There were no deaths or perforations. In the non-tertiary referral procedural group (1676) the cannulation rate for naïve papilla (651) was 97.8% with a NKS rate of 12.9%. Conclusions: Referral to a high volume centre following an initial unsuccessful ERCP procedure is associated with high technical success and a favorable complication rate compared to routine ERCP procedures. This data suggests that this type of clinical pathway should be developed as a part of an ERCP treatment algorithm. Tabled 1 Number Cannulation success NKS rate Post ERCP pancreatitis Other ERCP complications Non tertiary referral naïve papilla procedures 651 97.8% 12.9% 6.3% Perforation 0.15% Bleeding 0.6% Tertiary referral ERCP procedures 35 100% 29% 2.9% 0% p value 0.15 0.01 0.71 Open table in a new tab

Rescue ERCP and insertion of a small-caliber pancreatic stent to prevent the evolution of severe post-ERCP pancreatitis: a case-controlled series

Recently prophylactic placement of a trans-sphincteric pancreatic stent has successfully been applied to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Rescue ERCP and emergency application of small-caliber pancreatic stents during the early course of post-ERCP pancreatitis as a possible endoscopic therapy has not been reported yet. All patients who underwent ERCP were hospitalized for at least 24 h, with routine laboratory testing of amylase levels. Out of 1,225 ERCPs, evolution of severe post-ERCP pancreatitis was anticipated in six consecutive patients, based on severe pancreatic pain attack, more than tenfold elevation of serum amylase levels at 8 and 24 h, and moderate rise of white blood cell (WBC) and C-reactive protein (CRP) levels. Rescue ERCP and emergency application of small-caliber (4-5F, 4-cm, Geenen stent) pancreatic stents were successfully performed in all patients within 8-20 h after the initial ERCP. Moderate to severe papillary oedema was observed in all patients during the rescue ERCP. Pancreatic pain was promptly reduced after the rescue pancreatic drainage procedure and completely diminished within 24 h after pancreatic stenting. Serum amylase levels were exponentially reduced and normalized within 72 h in all patients; no pancreatic necrosis or any other late complications were observed. Pancreatic stents could be safely removed a few days later. Rescue pancreatic stenting with small-caliber prophylactic pancreatic stents seems to be a safe and effective procedure that might be feasible to stop the evolution of severe post-ERCP pancreatitis, but prospective controlled studies are clearly demanded to support this innovative approach.