PD Stent Research Articles

S2563 Upper GI Bleed Caused by Ampullary AVM

Introduction: GI bleed (GIB) is responsible for 1,000,000+ hospitalizations every year, and a mortality rate of 2-10%. Ampullary AVMs are an uncommon etiology of GIB and difficult from a diagnostic standpoint. We present a case of 77-year-old man presenting to emergency department (ED) with acute shortness of breath (SOB) and chest pain (CP), and dark stools for 4 days, found to have acute GIB caused by ampullary AVM. Case Description/Methods: 77-year-old white male presented to ED with acute SOB and CP. Past medical history included aortic regurgitation s/p valve replacement, atrial fibrillation s/p ablation and watchman, chronic anemia with baseline Hgb of 9, HTN, HFpEF, and ulcerative colitis s/p curative total proctocolectomy and ileostomy with modified Kock pouch procedure. Physical exam was unremarkable aside from dark-appearing ileal pouch output. He was not on anticoagulation and denied Pepto-Bismol use. Abnormal labs included Hgb/Hct of 5.1/16.4, BUN:Cr 37:1.93, and hemoccult positive stool from ileal pouch. Presenting symptoms of anemia (CP, SOB) were consistent with lab findings, concerning for GIB in setting of hemoccult positive stool. He received IV Protonix, Rocephin, and 1u pRBCs for acute blood loss anemia secondary to suspected GIB and was admitted to hospitalist. GI was consulted to do EGD, which showed active bleeding around major papilla, suggesting hemobilia. Subsequent CT A/P with contrast showed no clear etiology of bleed, so nuclear medicine bleeding scan was performed. The scan was unremarkable, and he continued to have melena, requiring 2u of pRBCs. Finally, ERCP was pursued to evaluate for potential biliary source. A normal bile duct (BD) was identified via cholangiogram, measuring 10mm without filling defect. Sphincterotomy was performed, followed by BD sweeping using a stone extraction balloon. No blood clots were noted, making hemobilia less likely. However, slow bleeding from inferior aspect of ampulla was visualized. The site was lavaged and appeared to be ampullary AVM (see Figure). Before ablation of AVM, a PD stent was placed to reduce likelihood of post-ERCP pancreatitis. Following procedure, his Hgb normalized, and he stopped having melenic stools. He continued PPI treatment outpatient and is doing well. Discussion: To our knowledge, no case of GIB caused by ampullary AVM is found in the literature. Thus, this case reports a rare finding of ampullary AVM and provides support for endoscopy as diagnostic approach in such patients.Figure 1.: Ampullary AVM.

S0921 Pancreatitis Following Endoscopic Resection of Ampullary Masses: A Single Center Retrospective Study

INTRODUCTION: Endoscopic resection of ampullary masses has emerged as an effective and first line treatment approach compared to surgery. Post-ampullectomy pancreatitis is a potential significant adverse outcome of endoscopic resection. The effectiveness of prophylactic pancreatic duct stent during ampullectomy is unclear, however it is considered widely. We aim to evaluate factors associated with post-ampullectomy pancreatitis and the role of prophylactic pancreatic duct stenting. METHODS: A retrospective review was performed of patients who underwent endoscopic ampullectomy of ampullary masses using craniocaudal snare technique 2003–2019 at Georgetown University Hospital. Z-test and descriptive statistics were used. RESULTS: 90 patients underwent ampullectomy for ampullary mass. 11.1% (10/90) developed pancreatitis. 5.6% (3/54) of patients with adenomas developed pancreatitis, compared to 19.4% (7/36) of patients with non-adenomas (P = 0.04). Of the 10 patients who developed pancreatitis compared to those that did not develop pancreatitis, average age was 58.2 y (vs 59 y, P = 0.89). Average adenoma size was 1.19 cm (vs. 1.36 cm, P = 0.5). 50% were male. 100% had PD stents placed (P = 0.17), and 10% underwent APC (vs. 14.4%, P = 0.67). Pathology of the masses showed 3 adenoma, 1 carcinoma, 1 gangliocytic paraganglioma, 3 normal mucosa, 1 adenomyoma, and 1 granulation tissue. CONCLUSION: Ampullectomy offers patients with ampullary masses an intervention with high success rates and decreased morbidity and mortality, compared to surgery. However, ampullectomy confers increased risk for postoperative pancreatitis. We observed a pancreatitis rate of 11.1%, similar to reported rates ranging from 4.5% to 33%. Our use of craniocaudal snare technique, compared to caudocranial, may explain our relatively lower pancreatitis rates. Identifying risk factors for post ampullectomy pancreatitis is challenging and the literature is sparse. In our cohort, we observed a statistically significant increase in pancreatitis among patients with non-adenomas. There was no significant difference by age, mass size, use of PD stent, or use of APC between patients who developed pancreatitis and those that did not. All patients in our cohort who developed pancreatitis had prophylactic PD stents placed. Ultimately, our single-center study is limited by a small sample size and selection bias, and there is a need for further studies to determine which factors contribute the most to post-ampullectomy pancreatitis.Table 1.: Patient CharacteristicsGraph 1.: Pancreatitis in Patients with Adenoma vs. Non-Adenoma.

Impact of disconnected pancreatic duct on recurrence of fluid collections and new-onset diabetes: do we finally have an answer?

Disconnected pancreatic duct (DPD) is a frequent occurrence in cases with walled-off necrosis (WON). The impact of DPD on recurrence of collection after removal of metal stents is not clear....

Su1578 POST ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS PREVENTION USING TOPICAL EPINEPHRINE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Multiple drugs and techniques have been studied for the prevention of PEP. Topical epinephrine has recently been studied for the prevention of PEP and theoretically should work similarly as a PD stent. Topical epinephrine sprayed on the ampulla can reduce edema by arteriolar vasoconstriction and therefore improve pancreatic outflow. Evidence regarding the use of topical epinephrine in the prevention of PEP is inconsistent with some studies favoring their use while other studies did not show any benefit. We, therefore, conducted a systematic review and meta-analysis to delineate if topical epinephrine is useful in the prevention of PEP. A comprehensive literature review was conducted by searching multiple databases until August 2019, to identify all studies that evaluated the use of topical epinephrine alone or in conjunction with other agents for the prevention of PEP. The characteristics of the participants and outcome measurements (incidence of PEP) were analyzed. All analysis was conducted using Revman 5.3. Eight studies, including 6 randomized controlled trials (RCTs) and 2 observational studies with 4123 patients, were included in the meta-analysis. Our overall results included two types of studies. Some studies evaluated both topical epinephrine and rectal indomethacin therapy together and some studies compared topical epinephrine with placebo therapy. Five RCTs are of good quality while one was of fair quality. Both the observational studies were of good quality. Overall, there was no difference in the incidence of PEP in patients who underwent ERCP and were treated with epinephrine spray versus those who were not, OR=0.62 (CI 0.30-1.25) with heterogeneity (I2=72%). In a subgroup analysis, topical epinephrine, when compared to placebo significantly decreases the risk of PEP, OR=0.30 (0.16-0.55). However, in a subgroup analysis, addition of topical epinephrine to rectal indomethacin did not provide any additional advantage in decreasing the incidence of PEP, when compared to rectal indomethacin alone OR=1.15 (0.58-2.28). Topical epinephrine does not provide any additional advantage in combination with rectal indomethacin in the prevention of PEP in patients who underwent ERCP. However, topical epinephrine alone is associated with lower odds of PEP compared to placebo and can be considered if rectal indomethacin is unavailable or there is any contraindication to its use. It may also be considered as a suitable alternative to prophylactic pancreatic stenting. Future studies comparing topical epinephrine versus PD stenting can be considered to evaluate if topical epinephrine provides a similar advantage in decreasing PEP as compared to PD stenting.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

OUTCOME OF ERCP (ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY) IN MILITARY HOSPITAL RAWALPINDI.

To describe the indications, endoscopic findings and complications of Endoscopic retrograde cholangiopancreatography (ERCP) in a tertiary care hospital. Study Design: Retrospective analysis of data collected from all patients underwent ERCP in the year 2015. Setting: Gastroenterology department, Military Hospital Rawalpindi. Period: From 1st January 2015 to 31ST December 2015. Materials and Methods: The main outcomes were technical success, safety and complications. Results: Total 469 patients underwent ERCP inmilitary hospital Rawalpindi in year 2015. Common bile duct (CBD) cannulation was achieved in 437 (93.1%) patients. CBD stones were found in 182 (38%) and CBD stricture in 79 (16.8%). Sphincteroplasty was needed for extraction of large stones in 13 (2.7%) cases. CBD stricture with co-existing stones above was seen in 25 cases (5.3%). Large stones not amenable to endoscopic extraction were seen in 24 cases (5.1%). Total 25 cases of ampullary growth (5.3%) and 15 cases (3.1%) of CBD leak post cholecystectomy were noted. 6 cases (1.27%) were identified as choledochal cyst with CBD Stones. PD stones with dilated PD identified in 5 cases (1.06%) and post-cholecystectomy CBD clipped in 3 cases (0.63%). 3 cases of displaced PD stent ended up in successful retrieval. 21 cases developed acute pancreatitis (4.4%) out of which 3 were found to have severe pancreatitis having fluid collections. 3 cases (0.6%)had retroperitoneal perforation (2 were managed conservatively and 1 through surgery). 4 cases (0.8%)had significant post procedure bleed requiring re-scope with adrenal injection at bleeding site, and hemostasis achieved. Conclusions: ERCP in Combined Military Hospital Rawalpindi hospital was associated with a high degree of technical success and a low risk of complications.

Impact of ERCP Timing on the Incidence of Post-ERCP Pancreatitis

Introduction: Post-ERCP pancreatitis (PEP) is a potential major complication of endoscopic retrograde cholangiopancreatography (ERCP). The impact of ERCP timing on PEP is not known. Methods: A retrospective, cohort study was conducted to elucidate the relationship between BMI and PEP in all patients who underwent ERCP in a tertiary referral center from January 2009 to October 2016. Patient characteristics and procedure details were collected. PEP was defined by consensus criteria. Multivariable logistic regression was used to determine the association between ERCP timing and PEP. Results: PEP was diagnosed in 84 out of 1789 (4.7%) ERCP performed during the regular working hours (7AM-5 PM) and in 23 out of 447 (5.2%) RR 1.1 (0.67-1.7) p=0.69. Multivariate analysis showed that female < 40 years of age, contrast injection into the pancreatic duct, biliary sphincterotomy, pancreatic sphincterotomy, failed PD stent placement, and difficult cannulation were associated with PEP. In the multivariate model timing of the ERCP was not associated with PEP OR 1.2 (0.7-2.0) p=0.42 Conclusion: Timing of the ERCP does not increase the the risk of PEP.

A Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis in Patients with Suspected Type 3 Sphincter of Oddi Dysfunction.

Recent data have suggested that rectal indomethacin can also reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The aim of this study was to determine whether prophylactic rectal indomethacin with PD stenting would reduce the incidence and severity of PEP compared to PD stenting alone in patients undergoing manometry for suspected SOD type 3. A retrospective review of consecutive patients who underwent an ERCP with manometry for suspected SOD type 3 was performed. Patients were divided into two groups: (a) those who received a prophylactic PD stent (n=285) and (b) those who received a prophylactic PD stent and a single dose of 100-mg indomethacin suppositories after ERCP (n=57). The rate of PEP was compared between the two groups. The two patient groups were similar with regard to patient and procedure risk factors for PEP. Post-ERCP pancreatitis developed in 22% patients. There was no significant difference in the incidence of PEP in the PD stent group compared to the PD stent and indomethacin group (23 vs. 18%, respectively; p=0.39). Moderate-to-severe pancreatitis developed in 21 (7%) patients in the PD stent group compared to 5 (9%) patients in the PD stent and indomethacin group (p=0.78). Among patients with PEP, the median length of hospital stay was not significantly longer in the PD stent group compared to the PD stent and indomethacin group (6 vs. 4days, respectively; p=0.11). In patients with suspected SOD type 3, prophylactic rectally administered indomethacin with PD stenting was not observed to affect the incidence or severity of post-ERCP pancreatitis when compared to PD stenting alone.

PTU-002 Ercp Cannulation; Evaluation Of A Wire-led Technique For Biliary Access In A Training Centre

IntroductionA range of techniques have been described to achieve successful cannulation at ERCP, and when training in ERCP it is often difficult to select the optimum approach.1 There are potential...

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

581 Predicting All-Cause 30-Day Mortality Following First ERCP: External Validation of a Model in a Swedish Population-Based First ERCP Cohort

among high-risk patients. However, it is unknown if pancreatic duct stent type, diameter, and presence of flanges affects the rate of post-ERCP pancreatitis. Since there have been few randomized controlled trials (RCT) evaluating PD stents, network meta-analysis can be used to evaluate the existing RCTs to determine if any PD stent features affect rates of PEP among high-risk patients. Aim: To perform a network meta-analysis of RCTs evaluating pancreatic stents for the prevention of PEP in high-risk patients. Methods: The MEDLINE, EMBASE and Cochrane Library databases were searched for RCTs evaluating the efficacy of PD stents in preventing post-ERCP pancreatitis from 9/93-9/12. Trials which reported the incidence of PEP in high-risk patients randomized to one versus another type of PD stent or no stent were included in the analysis. RCTs that did not compare PD stents or compared pharmacologic agents to stents were excluded. The predictive probability of ranking best was calculated for all the different stents. The network meta-analysis was performed using Winbugs statistical software. Results: A total of 987 studies were reviewed and 6 RCTs with 561 patients were included in this analysis. Four RCTs compared PD stents with no stents and 2 RCTs compared different types of PD stents head to head. Three RCTs evaluated 5 Fr straight PD stents, 2 RCTs evaluated 5 Fr single pigtail PD stents, and 3 RCTs evaluated 3 Fr single pigtail PD stents (see figure 1). The probability of ranking best was 0.503 for 5Fr single pigtail unflanged PD stent, 0.465 for 5Fr straight flanged PD stent, and 0.031 for 3Fr single pigtail unflanged PD stents (see figure 2). Conclusion: 5 Fr PD stents are superior to 3 Fr PD stents in preventing PEP among high-risk patients. 5 Fr single pigtail, unflanged PD stents and 5 Fr straight, flanged PD stents performed similarly but both performed better than the 3 Fr PD stents in preventing PEP, suggesting that stent diameter is more critical for the prevention of PEP than type of stent or the presence of flanges. Further studies are needed to verify these results. 581 Predicting All-Cause 30-Day Mortality Following First ERCP: External Validation of a Model in a Swedish Population-Based First ERCP Cohort Evangelos Kalaitzakis* Department of Gastroenterology, Skane University Hospital, Lund, Sweden Identifying predictors of 30-day mortality following endoscopic retrograde cholangiopancreatography(ERCP) could facilitate patient selection and the informed consent process. Recently, a 30-day mortality risk estimator following first ERCP was developed based on administrative data from England & Wales (Bodger et al GIE 2011;74:825-33). The estimator incorporates age, underlying cancer, comorbidity, and mode of admission (urgent/elective), and produces the probability of 30-day mortality. The aim of the current study was to externally validate the estimator in a population-based cohort of patients undergoing a first ERCP in Sweden. Methods All patients having had a first in-/out-patient ERCP between 04/2005-06/2008 in Sweden were identified from the Hospital Discharge Register. Data on indication, admission method(urgent/elective), and co-morbid illness were extracted from diagnostic fields(ICD-10 codes) in the register. Patients were linked to the National Death Register to define dead/alive status and the National Cancer Register. The probability of 30-day mortality of each patient according to the published estimator was calculated. Discriminant validity was estimated with the c-statistic, and goodness-to fit with the calibration plot between predicted(estimator) and the observed death probabilities and the Hosmer-Lemeshow test. Results A total of 16478 patients with a first ERCP performed in 66 hospitals were identified (mean age 68(17); 57% female; urgent admission 57%; diagnostic profile: gallstone-related 55.2%, cancer 22.5%, gallstone and cancer 1.4%, other 20.9%). All-cause 30-day mortality was 5%(14.9% in cancer and 1.9% in non-cancer cases). No major differences were observed in case mix or mortality between the original(English) and the current(Swedish) cohorts, apart from a higher proportion of cancer cases in the latter (14.6% vs23.9%). Discriminant validity was very good with a c-statistic of 0.82 (95% CI 0.81-0.83) in the Swedish cohort. However, the Hosmer-Lemeshow test was significant(p 0.001) indicating lack of fit. The calibration plot suggested that the model tended to overestimate mortality(figure 1). Re-calibration was performed with slope adjustment(figure 2) without compromising discriminant validity (c-statistic of new model 0.81, 95% CI 0.80-0.82). However, the HosmerLemeshow test continued to be significant(p 0.001) indicating lack of fit (figure 2). Conclusion A model of 30-day mortality following first ERCP recently developed from administrative data in England and Wales was validated in a Swedish population-based cohort of patients with a first ERCP. Despite adequate discriminant validity, there was lack of fit which remained after re-calibration with slope adjustment. These findings indicate that different factors may be of importance for 30-day mortality prediction following first ERCP in different populations.

A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video)

Fully-covered self expandable metal stents (fcSEMSs) are an alternative to progressive plastic stenting for the treatment of benign biliary strictures (BBS) with the prospect of a higher treatment efficacy and the need for fewer ERCPs, thereby reducing the burden for patients and possibly costs. Key to this novel treatment is safe stent removal. To investigate the feasibility and safety of stent removal of a fcSEMS with a proximal retrieval lasso: a long wire thread integrated in the proximal ends of the wire mesh that hangs freely in the stent lumen. Pulling it enables gradual removal of the stent inside-out. A secondary aim was success of stricture resolution. Non-randomized, prospective follow-up study with 3 sequential cohorts of 8 patients with BBS. Academic tertiary referral center. Eligible patients had strictures either postsurgical (post-cholecystectomy (LCx) or liver transplantation (OLT)), due to chronic pancreatitis (CP), or papillary stenosis (PF). Strictures had to be located at least 2 cm below the liver hilum. All patients had one plastic stent in situ across the stricture and had not undergone previous treatment with either multiple plastic stents or fcSEMS. The first cohort of patients underwent stent placement for 2 months, followed by 3 months if the stricture had not resolved. The second and third cohort started with 3 months and 4 months, respectively, both followed by another 4 months if indicated. Treatment success was defined by stricture resolution at cholangiography, the ability to pass an inflated extraction balloon and clinical follow-up (at least 6 months). safety of stent removal. Secondary outcomes were complications and successful stricture resolution. A total of 23 patients (11 female; 20-67 yrs) were eligible for final analysis. One patient developed a malignant neuroendocrine tumor in the setting of CP. Strictures were caused by CP (13), OLT (6), LCx (3) and PF (1). In total 39 fcSEMS were placed and removed. Removals were easy and without complications. Transient pain after insertion was common (13 of 23/56%) but was easily managed by analgesics in all patients. Other complications were cholecystitis (1), cholangitis due to stent migration (1, stent replaced) or stent clogging (2, managed endoscopically) and worsening of CP (2). In these patients, the fcSEMS was removed and replaced after pancreatic sphincterotomy and PD stent placement. Median follow-up was 15 months (range 11-25). Overall treatment success was 61% (14/23); in the CP group 46%, in the remaining patients 80% (p = 0.11). Patients with stricture resolution after removal of the first stent (n = 7; success 6/7) showed a trent towards a more sustained treatment success than patients who needed a 2nd stent placement (n = 16; success 8/16); p = 0.12). Small number of patients with regard to secondary outcomes. Removal of a new type of fcSEMS with a proximal retrieval lasso in patients with BBS proved easy and uncomplicated. Treatment success for CP strictures was higher compared to what is known from results of progressive plastic stenting protocols. For other indications treatment success was comparable to progressive plastic stenting, but with the prospect of fewer ERCP procedures.

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.

The Association of a Polydioxanone Tent Without a Guided Tissue Regeneration Membrane to a Coronal Sliding Flap for Root Coverage

This study verifies clinical results of using a polydioxanone (PDS) tent without a guided tissue regeneration (GTR) membrane for root coverage. Forty-nine gingival recessions (in 16 patients) were treated with a PDS tent inserted under the coronally positioned gingival flap. The recession level (RL), probing depth (PD), and keratinized mucosa width (KMW) were registered. Statistical analysis was performed with the Wilcoxon test. In 48 cases, there was a significant reduction in the RL (2.55 +/- 1.11 mm on day 0 and 0.34 +/- 0.65 mm on day 120; P = 0.0001). PD showed the same values at the beginning and end of treatment in 47 cases (0.99 +/- 0.71 mm on days 0 and 120; z = 0.000). There was a significant increase of KMW in 46 cases (2.38 +/- 0.76 mm on day 0 and 3.18 +/- 0.90 mm on day 120; P = 0.0001). The association of the PDS tent without the GTR membrane to a coronal sliding flap for root coverage of Miller Class I and II gingival recessions allows root coverage, gain of attachment level, and an increase of keratinized mucosa. For root coverage, it is not necessary to use the GTR membrane associated to the PDS tent, thereby reducing surgical costs. Future studies should be conducted to assess the sole performance of the PDS as an alternative method to a connective tissue graft and coronal sliding flap, thus decreasing risks and post-surgery discomfort.

Diagnostic and Therapeutic ERCP in Long-Limb Surgical Bypass Patients Using a New Single-Balloon Assisted Enteroscope

Background: Successful per-oral ERCP has been reported in long-limb surgical bypass patients, including Roux-en-Y cases, using standard push enteroscopes (Howell, GIE 1996;43: 383AB). Newer bypass procedures have resulted in increased length of bypass limbs preventing endoscopic access with standard equipment. The single-balloon overtube assisted enteroscope (SBAE)(Olympus America) has recently been released. We report initial experience performing per-oral ERCP using SBAE. Patients and Methods: 10 procedures were attempted in 8 pts, with the following long-limb bypasses: Pylorus preserving Whipple (PPW) (n=2) and bariatric laparoscopic Roux-en-Y gastric bypass (RNYGB) (n=8). Four pts (2 PPW and 2 RNYGB) had a previous failed attempt with other endoscopes, including variable stiffness colonoscopes and standard-push enteroscopes with non-balloon overtubes. Indications: All procedures were carried out with the new Olympus Q180 200cm SBAE. Cannulation and therapy was performed with special enteroscope length accessories supplied by various companies. Indications included: common duct stone (n=1), ampullary stenosis/SOD Type I (n=1), recurrent pancreatitis (n=2), severe right upper quadrant (RUQ) pain with dilated ducts (n=2), chronic pancreatitis (n=2), and PD stent removal (n=2). Results: 8/10 (80%) procedures were successful in reaching the RUQ and assessing the desired duct. Two failures were due to adhesions in one PPW patient and inability to advance beyond the ligament of Treitz in a RNYGB patient. Two diagnostic ERCPs noted a normal cholangiogram in one and extensive pyloric channel ulcer disease in the other. Six therapeutic ERCPs included biliary sphincterotomy (n=1), pancreatic sphincterotomy with stent placement (n=2), biductal sphincterotomy with nasopancreatic drainage (n=1), and pancreatic stent removal (n=2). Complications included a single episode of delayed mild pancreatitis. Both barbless pancreatic duct stents failed to pass after 3 weeks requiring a second SBAE ERCP with successful removal. Experience is ongoing. Conclusions: Single-balloon assisted enteroscopy permitted access to the RUQ in most patients in this initial experience. Diagnostic and therapeutic ERCP was accomplished in all cases where the RUQ was reached. Technical challenges include the front-viewing nature of the enteroscope, the absence of an elevator and the limited selection of therapeutic accessories. Routine per oral ERCP in post-operative long-limb bypass patients should be routinely possible, at least in specialized centers of excellence.

Multimodality Treatment of Chronic Pancreatitis: Can We Prevents Hospital Admission?

Background & Aims: Efficacy of endoscopic therapy for chronic pancreatitis (CP) has typically been evaluated by improvement in pain score. Unfortunately accurate evaluation of pain is difficult since most patients are already on pain medication when undergoing endoscopic therapy. Our aim is to determine the efficacy of multimodality treatment of chronic pancreatitis on the rate of hospitalization. Methods: 247 patients (174 male, mean age 51 ± 13 y/o) with CP associated with pain were endoscopically treated between December 2001 and November 2006 and followed prospectively. Therapy offered included ERCP with pancreatic duct stenting (PD stent), extracorporeal shock wave lithotripsy (ESWL), and celiac plexus block (CPB). Long term efficacy of therapy was based on the absence of recurrent admissions for abdominal pain or pancreatitis after therapy, excluding post-procedural admission. Multivariate analysis were effected on the following factors to assess prediction of successful treatment (Age (<55 versus ≥55 y/o), gender, etiology (alcoholic or not), PD stent (yes versus no), ESWL, CPB). Results: Therapy included a mean of 3.6 ± 2.9 ERCPs in 240 (97%) patients with 166 (67%) patients receiving a PD stent, 37 (15%) patients underwent a mean of 1.2 ± 0.7 ESWL (range 1-4) and 42 (17%) patients received a mean of 2.2 ± 2 CPB (range: 1-8). A total of 154 (62%) patients did not require further admission post therapy over a median period of three years (range:1-5). Multivariate logistic regression analysis identified only PD stent as a predictor of long term success (see table). Conclusions: Endoscopic treatment of chronic pancreatitis is efficacious in 62% of patients undergoing multimodality therapy. PD stent placement appears to be a predictor of success in preventing long -term hospitalization post therapy. Tabled 1Predictive factor of successful treatment Factors P value Odds ratio 95% CI Gender 0.970 1.01 0.53-1.93 Age 0.051 1.77 1.00-3.13 Etiology 0.292 0.72 0.38-1.33 PD stent 0.007 0.43 0.24-0.79 ESWL 0.807 0.91 0.44-1.90 CPB 0.293 0.68 0.33-1.40 Open table in a new tab

A factor predictive of post-ERCP pancreatitis?

The authors conclude that elevation of the serum amylase levels 2 hours after SOM predicts development of post-SOM pancreatitis exclusively in patients who do not receive a PD stent. An elevated 2-hour serum amylase level that occurs in patients with a PD stent, however, predicts subsequent findings that "may occur because of attenuated pancreatitis."

Application of Prototype Duodenoscopes in an ERCP Referral Practice

Application of Prototype Duodenoscopes in an ERCP Referral Practice Richard A. Kozarek, Tamara H. Harrison Background: Current duodenoscopes are excellent technical tools whose limitations are related to working channel size and operator experience. Potential modifications to include image enlargement, enhancement (addition of pixels), modifications of the duodenscope shaft and modifications of the scope elevator may improve procedural success rate or decrease procedure time. Materials and Methods: Two new FDA approved Olympus Inc. (New Hyde Park, NY) therapeutic duodenoscopes were prospectively studied in 335 pts. Scope modifications included: 1.) a variably stiff scope shaft meant to hold the duodenoscope in place and improve ease of stent placement, and 2.) adaptation of the Q-scope electronic image with enlargement of the image size and the addition of 100,000 pixels to enhance image quality. Data collected included procedural success, therapy undertaken, time to initial cannulation, and whether the scope modification improved procedural ease because of improved vision, guidewire fixation, or ability to modify shaft stiffness. Results: 98% procedures were technically successful: Qscope 218, and variable stiffness scope 117 uses. Median time to cannulation was 6 minutes (range 1–30). Therapy was undertaken in 332 of the 335 pts and included CBD or PD sphincterotomy (159), stone extraction (116), stricture dilation (68), stent placement (188) or extraction (33), and miscellaneous (158). Forty-one patients underwent brush cytologies as an additional diagnostic procedure. The stiffening function of the variable stiffness duodenoscope was used in 58 cases of stent placement and felt to facilitate stent passage through an extremely tight malignant stenoses in 1 and preclude repeated scope fallback into the stomach in another. The Q-duodenoscope was associated with a dramatically improved image and was felt to facilitate the procedure in 213/218 cases (98%). Conclusions: Design changes in the current Olympus duodenoscopes may facilitate ease and success of ERCP procedures. Image enlargement and enhancement appear to be the most important modification, but prospective studies comparing these scopes to currently utilized JF-160 duodenoscopes will be required for definitive conclusions. T1280 The Relationship Between Juxtapapillary Duodenal Diverticula (JPDD) and Biliary Stone Disease Seung-Ok Lee, Hyun Chul Kim, In Hee Kim, Sang Wook Kim, Soo Teik Lee, Dae Ghon Kim Background/Aims: Juxtapapillary duodenal diverticula (JPDD) are acquired lesions and their incidence increases with age. The prevalence of JPDD in the general population is around 20%. JPDD does not usually provoke symptoms by itself but the possibility of an association with bile duct stones was suggested. The aims of the study were to investigate the frequency of JPDD in the patients with biliary stone disease or non-biliary stone diseases, and to determine the type of JPDD according to the relationship of the papilla with the diverticulum, and to assess the association between types of JPDD and biliary stone disease. Methods: 270 patients who underwent ERCP were analyzed retrospectively and divided into two groups: biliary stone disease group (group I, nZ196) and non-biliary stone disease group (group II, nZ74). Additionally, we performed side-view duodenoscopy to agematched 40 healthy subjects for a control group (group III). The type of JPDD was classified as follows: papilla adjacent to the diverticulum (type I), papilla on the margin of the diverticulum (type II), papilla within the diverticulum (type III). All groups were investigated the frequency and the type of JPDD. Results: The frequencies of JPDD in group I, group II, and group III were 49.5%, 17.5%, 25.0%, respectively. The increment of frequencies of JPDD with aging was observed in all groups and was statistically significant in the group I. In biliary stone disease group, bile duct diameter was greater in the patients with JPDD than in the patients without JPDD (15.7 mm vs. 13.7 mm, PZ0.006). The frequencies of JPDD according to the type were as follows: type I, type II, and type III were 50.5%, 27.8%, 21.6% in group I, 53.8%, 15.4%, 30.7% in group II, 100%, 0%, 0% in group III, respectively. The distribution of JPDD according to the type was not significantly different between group I and group II. In biliary stone disease group, bile duct diameter in the patients with type I, type II, and type III JPDD were 14.6 mm, 15.8 mm, 17.2 mm, respectively, but did not show statistically significant difference. Conclusions: The frequency of JPDD was higher in the patients with biliary stone disease and increased with aging. In biliary stone disease, bile duct diameter was greater in the patients with JPDD than in the patients without JPDD. These results suggest that JPDD develops with aging and causes biliary stone formation through the bile stasis and bile duct dilatation.

Role of ERCP in Patients with Pancreatico-Biliary (PB) Disease in the Setting of Hematopoietic Stem Cell Transplant (HSCT)

Background: Patients (pts) undergoing HSCT may develop PB complications that may need to be evaluated by ERCP. These pts are immunocompromised and may be at higher risk of procedure related complication than average risk pts. Surprisingly, few data have been published regarding ERCP findings/benefits/risks in this population. Aim: To determine the role of ERCP in the diagnosis, treatment, and outcome ERCP in the setting of HSCT. Materials &Methods: Retrospective analysis of HSCT pts who underwent ERCP from 1997-2004. We examined ERCP indications, diagnosis, therapeutic interventions, and complication rates. Results: Of the pts who received HSCT, 16 pts (7M/9F) were identified who had undergone ERCP; 15/16 had allogeneic HSCT & 1/16 had autologous HSCT. Indications for HSCT were: AML (6),CML (3), ALL (1), NHL (2), myeloma (1), met breast ca (2). 26 ERCP procedures were performed in these 16 pts. 10/16 pts were >100days post HSCT. 8/26 had a platelet count< 50x103/L. ERCP indications: obstructive jaundice (4); possible ascending cholangitis (7); post cholecystectomy bile leak (1); relapsing pancreatitis (4).ERCP Findings were: BD lithiasis (7), Ampullary infiltration from GVHD (3), BD stricture(1), BD leak (1),cholangitis (1), Mirrizzi (1), PD stone (1), normal (1). ERCP interventions were: BD sphincterotomy (8), BD lithiasis removal (11), BD stents (13), NB tube(4), PD stent for drainage(1), prophylactic temporary PD mini stents (6), Transpapillary endoscopic GB drain (2). Complications occurred in 3 pts: bleed (1), cholangitis due to late stent occlusion (1), mild pancreatits (1). No deaths. Conclusion: In patients with HSCT, BD lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to GVHD. ERCP was safe and successful in this population. Background: Patients (pts) undergoing HSCT may develop PB complications that may need to be evaluated by ERCP. These pts are immunocompromised and may be at higher risk of procedure related complication than average risk pts. Surprisingly, few data have been published regarding ERCP findings/benefits/risks in this population. Aim: To determine the role of ERCP in the diagnosis, treatment, and outcome ERCP in the setting of HSCT. Materials &Methods: Retrospective analysis of HSCT pts who underwent ERCP from 1997-2004. We examined ERCP indications, diagnosis, therapeutic interventions, and complication rates. Results: Of the pts who received HSCT, 16 pts (7M/9F) were identified who had undergone ERCP; 15/16 had allogeneic HSCT & 1/16 had autologous HSCT. Indications for HSCT were: AML (6),CML (3), ALL (1), NHL (2), myeloma (1), met breast ca (2). 26 ERCP procedures were performed in these 16 pts. 10/16 pts were >100days post HSCT. 8/26 had a platelet count< 50x103/L. ERCP indications: obstructive jaundice (4); possible ascending cholangitis (7); post cholecystectomy bile leak (1); relapsing pancreatitis (4).ERCP Findings were: BD lithiasis (7), Ampullary infiltration from GVHD (3), BD stricture(1), BD leak (1),cholangitis (1), Mirrizzi (1), PD stone (1), normal (1). ERCP interventions were: BD sphincterotomy (8), BD lithiasis removal (11), BD stents (13), NB tube(4), PD stent for drainage(1), prophylactic temporary PD mini stents (6), Transpapillary endoscopic GB drain (2). Complications occurred in 3 pts: bleed (1), cholangitis due to late stent occlusion (1), mild pancreatits (1). No deaths. Conclusion: In patients with HSCT, BD lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to GVHD. ERCP was safe and successful in this population.

Utilization of EUS for Endoscopic Drainage of Pancreatic Pseudocysts: Results of a National and an International Survey

Utilization of EUS for Endoscopic Drainage of Pancreatic Pseudocysts: Results of a National and an International Survey Tony E. Yusuf, Todd H. Baron Introduction: Pancreatic pseudocysts are a type of pancreatic fluid collection that can complicate acute and chronic pancreatitis. Pancreatic pseudocysts can be drained endoscopically via the transpapillary or the transmural (transgastric or transduodenal) routes. Aim: The aim of this study was to assess the endoscopic approach and techniques of pancreatic pseudocyst drainage as performed by endoscopists in the United States and internationally. Methods: A web-based survey was designed to assess the type of practice and the endoscopic techniques used in drainage of pancreatic pseudocysts. Questions that addressed imaging modalities used prior to or during drainage were included. An initial electronic message with a link to the web survey followed by a reminder message was sent to endoscopists in the United States and internationally. E-mail addressees were obtained from the ASGE membership directory. Results: The survey was sent to 3,054 endoscopists of whom 266 (8.7%) replied. Of the responders, 198 performed endoscopic drainage of pancreatic pseudocysts. Each endoscopist performed a mean of 69 cases (range, 1-364 cases). The transgastric route was the most commonly used drainage route (98%) versus transduodenal (72%). Transmural entry was performed using a needle knife in 53% of the non EUS-guided transmural drainage. The number of stents placed was 1-4 stents for a period of 2-24 weeks. Imaging studies to guide drainage included CT scan alone (60%) or in combination with other radiographic imaging (35%). EUS imaging was used prior to drainage by 72 of 103 (70%) endoscopists in the US compared to 56 of 95 (59%) international endoscopists (pZ0.1). EUSguided drainage was used by 56% of endoscopists in the US compared to 43% international endoscopists (pZ0.06). Conclusions: The transgastric route is the most common route for transmural endoscopic drainage of pancreatic pseudocysts. Computed tomography is the most commonly used pre-drainage imaging modality. The majority of endoscopists in both the US and abroad utilize EUS prior to and during transmural drainage of pancreatic pseudocysts. The practice of EUS prior to drainage is not significantly different among endoscopist in the United States and internationally. T1226 Role of ERCP in Patients with Pancreatico-Biliary (PB) Disease in the Setting of Hematopoietic Stem Cell Transplant (HSCT) Majed Al Nusair, Margarida C. de Magalhaes-Silverman, William B. Silverman Background: Patients (pts) undergoing HSCT may develop PB complications that may need to be evaluated by ERCP. These pts are immunocompromised and may be at higher risk of procedure related complication than average risk pts. Surprisingly, few data have been published regarding ERCP findings/benefits/risks in this population. Aim: To determine the role of ERCP in the diagnosis, treatment, and outcome ERCP in the setting of HSCT. Materials M 15/ 16 had allogeneic HSCT & 1/16 had autologous HSCT. Indications for HSCTwere: AML (6),CML (3), ALL (1), NHL (2), myeloma (1), met breast ca (2). 26 ERCP procedures were performed in these 16 pts. 10/16 pts were O100days post HSCT. 8/26 had a platelet count! 50x103/L. ERCP indications: obstructive jaundice (4); possible ascending cholangitis (7); post cholecystectomy bile leak (1); relapsing pancreatitis (4).ERCP Findings were: BD lithiasis (7), Ampullary infiltration from GVHD (3), BD stricture(1), BD leak (1),cholangitis (1), Mirrizzi (1), PD stone (1), normal (1). ERCP interventions were: BD sphincterotomy (8), BD lithiasis removal (11), BD stents (13), NB tube(4), PD stent for drainage(1), prophylactic temporary PD mini stents (6), Transpapillary endoscopic GB drain (2). Complications occurred in 3 pts: bleed (1), cholangitis due to late stent occlusion (1), mild pancreatits (1). No deaths. Conclusion: In patients with HSCT, BD lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to GVHD. ERCP was safe and successful in this population.

IN SITU PANCREATIC DUCT STENT IN PANCREATICOJEJUNOSTOMY AFTER PARTIAL PANCREATODUODENECTOMY IS ASSOCIATED WITH COMPLICATIONS

Purpose: Pancreaticojejunal anastamosic leakage is a major complication after partial pancreatoduodenectomy. To reduce this complication rate anastamosis over a pancreatic duct stent (PD stent) either left in situ or with temporary external drainage has been recommended and practiced by some surgeons. There are several well-recognized PD stent related complications such as stent occlusion, stent migration, infection, duodenal erosions, ductal perforation, clinical pancreatitis and morphologic changes resembling those of chronic pancreatitis. Keeping these significant complications in mind the potential therapeutic benefits of PD stents must be weighed against the potential complications. We looked at the complications from use of in situ PD stents in pancreatojejunostomy (PJ) after pancreatoduodenectomies at our institution. Methods: This is a retrospective observational study. Records of 110 patients who underwent pancreatoduodenectomies with duct to mucosa PJ for locally advanced pancreatic head cancers, periampullary cancers and other benign pancreatic conditions, between 1997 and 2003 at Fox Chase Cancer Center were reviewed. Out of these, 29 patients with retained Geenan PD stent (Wilson-Cook Medical INc., Winston-Salem, N.C) were followed after surgery. Median follow-up period was 26months (range 1–41) depending on the time of surgery. Results: Of the 29 patients with PD stent left in situ after pancreatoduodenectomy, 6 patients had complications requiring endoscopic retrieval of the stent. Four patients had unexplained fevers requiring multiple hospital admissions with no recurrence of fever after stent removal, and 2 patients had unexplained upper abdominal pain relieved after stent removal. The median time of onset of symptoms was 19 months (2–31). These complications were likely from occluded PD stent and resultant infectious complications. Conclusions: We conclude that PJ with PD stent in situ after pancreatoduodenectomy is associated with several stent related complications causing significant long-term postoperative morbidity. We believe that PD stent design modification may be warranted to ensure spontaneous passage of stent. Patients with PD stents placed at the time of PJ should be monitored for potential complications of the stent with rigorous attempts at endoscopic removal, should these occur.