Plastic Biliary Stent Research Articles

Successful endoscopic retrograde cholangiopancreatography and bilateral stenting in a patient with situs inversus totalis

A 60-year-old man with situs inversus totalis (SIT) presented with jaundice. Two years earlier, he had been diagnosed with unresectable hepatocellular carcinoma (HCC) and treated with transcatheter arterial chemoembolization thrice. Computed tomography and magnetic resonance cholangiopancreatography revealed intrahepatic duct (IHD) dilatation caused by extrinsic compression from the large HCC (Fig. 1). During endoscopic retrograde cholangiopancreatography (ERCP), the patient was placed in the prone position, with the endoscopist on the patient's right side (Fig. 2). Because of SIT, the duodenoscope was rotated through 180° clockwise in the stomach. At the second portion of the duodenum, the duodenoscope was adjusted slightly to visualize the ampulla. For better and easier access, cannulation, sphincterotomy, and selective wire placement in both IHDs were performed by a physician-controlled wire-guided cannulation (PCWGC) technique using a rotatable sphincterotome (Autotome Sphincterotome, Boston Scientific, Marlborough, MA, USA). After wire-guided cannulation, cholangiography showed IHD obstruction by extrinsic compression from the large mass. Two plastic stents were placed in both IHDs without any complications, and the patient was discharged in a good condition.Fig. 2Endoscopic retrograde cholangiopancreatography in our patient with situs inversus totalisShow full caption(a) Endoscopy showing duodenal luminal narrowing due to ischemic damage after transcatheter arterial chemoembolization.(b) Endoscopic view showing the papilla oriented to the right side after adjustment of the left and up angles of the duodenoscope.(c) Successful cannulation and endoscopic sphincterotomy are easily performed using a rotatable sphincterotome.(d) The duodenoscope is rotated 180° clockwise in the stomach and advanced to the second portion of the duodenum.(e) Initial cholangiography showing a non-visible intrahepatic duct and a large mass with lipiodol uptake.(f) Final cholangiography showing two biliary plastic stents (arrowheads; 7Fr. single pig-tail, 12 and 15 cm) in the right and left intrahepatic ducts.View Large Image Figure ViewerDownload Hi-res image Download (PPT)With limited ERCP cases in patients with SIT, several technical tips for successful cannulation have been reported [[1]Lee J.M. Lee J.M. Hyun J.J. et al.Successful access to the ampulla for endoscopic retrograde cholangiopancreatography in patients with situs inversus totalis: a case report.BMC Surg. 2017; 17: 112Crossref PubMed Scopus (9) Google Scholar]. Our experience is that positional and technical changes are not necessary. Additionally, 180° clockwise rotation in the stomach, a rotatable sphincterotome, and a PCWGC technique help achieve successful procedure. A 60-year-old man with situs inversus totalis (SIT) presented with jaundice. Two years earlier, he had been diagnosed with unresectable hepatocellular carcinoma (HCC) and treated with transcatheter arterial chemoembolization thrice. Computed tomography and magnetic resonance cholangiopancreatography revealed intrahepatic duct (IHD) dilatation caused by extrinsic compression from the large HCC (Fig. 1). During endoscopic retrograde cholangiopancreatography (ERCP), the patient was placed in the prone position, with the endoscopist on the patient's right side (Fig. 2). Because of SIT, the duodenoscope was rotated through 180° clockwise in the stomach. At the second portion of the duodenum, the duodenoscope was adjusted slightly to visualize the ampulla. For better and easier access, cannulation, sphincterotomy, and selective wire placement in both IHDs were performed by a physician-controlled wire-guided cannulation (PCWGC) technique using a rotatable sphincterotome (Autotome Sphincterotome, Boston Scientific, Marlborough, MA, USA). After wire-guided cannulation, cholangiography showed IHD obstruction by extrinsic compression from the large mass. Two plastic stents were placed in both IHDs without any complications, and the patient was discharged in a good condition. (a) Endoscopy showing duodenal luminal narrowing due to ischemic damage after transcatheter arterial chemoembolization. (b) Endoscopic view showing the papilla oriented to the right side after adjustment of the left and up angles of the duodenoscope. (c) Successful cannulation and endoscopic sphincterotomy are easily performed using a rotatable sphincterotome. (d) The duodenoscope is rotated 180° clockwise in the stomach and advanced to the second portion of the duodenum. (e) Initial cholangiography showing a non-visible intrahepatic duct and a large mass with lipiodol uptake. (f) Final cholangiography showing two biliary plastic stents (arrowheads; 7Fr. single pig-tail, 12 and 15 cm) in the right and left intrahepatic ducts. With limited ERCP cases in patients with SIT, several technical tips for successful cannulation have been reported [[1]Lee J.M. Lee J.M. Hyun J.J. et al.Successful access to the ampulla for endoscopic retrograde cholangiopancreatography in patients with situs inversus totalis: a case report.BMC Surg. 2017; 17: 112Crossref PubMed Scopus (9) Google Scholar]. Our experience is that positional and technical changes are not necessary. Additionally, 180° clockwise rotation in the stomach, a rotatable sphincterotome, and a PCWGC technique help achieve successful procedure. No conflicts of interest have been declared.

S2370 A Unique Case of Ampulla of Vater Metastasis From Breast Cancer Without Hepatic/Pancreatic Involvement

INTRODUCTION: Breast cancer is a leading cause of malignancy and death in women worldwide. It usually metastasizes to the brain, bones, lymph nodes, lungs, and liver but may rarely involve the GI tract (in 10%). Bile duct involvement from breast cancer without liver involvement is uncommon. We report an exceptionally uncommon case of ampullary metastasis from breast cancer without liver metastases who presented with nausea and vomiting. CASE DESCRIPTION/METHODS: A 59-year-old female with PMH of ER-/PR-Her2+ breast cancer (invasive ductal carcinoma-diagnosed in 2007) s/p lumpectomy, adjuvant chemoradiotherapy followed by local in-breast recurrence in 2013 with a metastasis to CNS/pleura s/p chemoradiotherapy presented from a rehabilitation center with persistent nausea, vomiting, RUQ pain, clay-colored stools and dark urine. Physical examination revealed RUQ abdominal tenderness. Routine laboratory tests were significant for abnormal liver blood tests (Tbil 2.9, ALP 462, AST 598, ALT 931, Lipase 558). She was resuscitated with iv fluids and was started on antibiotics and antiemetic. RUQ US showed dilatation of CBD and intrahepatic ducts. CT abdomen/pelvis with IV contrast confirmed US findings and the pancreas was unremarkable. Subsequent ERCP showed erythematous major papilla with severe and diffuse dilatation of the common bile duct, left main hepatic duct and right main hepatic duct with friable major papillary mucosa. Cells for cytology were obtained by brushing lower biliary and ampullary areas. A 10 Fr x 7 cm plastic biliary stent was placed 6 cm into the common bile duct. Her symptoms improved after the stenting and she started tolerating food. Liver blood tests also improved(Tbil 0.8, ALP 388, AST 80, ALT 558, Lipase 76). The pathology from the biopsy of the ampullary area showed poorly differentiated carcinoma consistent with metastasis of the patient's metastatic breast cancer which was ER/PR/HER2 +ve. She was discharged from the hospital back to the rehabilitation center, however, she succumbed to breast cancer. DISCUSSION: Biliary tract involvement by metastatic cancer is uncommon in general, colon cancer being the most common. Metastasis to the biliary tract and ampulla of Vater from isolated breast cancer without liver involvement is rare. Clinically, it is important to recognize this group of patients as relief of biliary obstruction using surgical bypass or biliary stenting may extend survival to over 1 year, in comparison to those with liver metastasis, whose mean survival is usually 1 month.Figure 1.: Area of Papilla in the 2nd Portion of the Duodenum showing erythematous major papilla, Congested major papilla.Figure 2.: Fluoroscopy image of stent placement.Figure 3.: Poorly differentiated carcinoma cells in intestinal mucosa with positive GATA-3 staining consistent with metastasis from breast primary.

S1603 Ampullary Mass from Metastatic Renal Cell Carcinoma Presenting as Acute Pancreatitis

INTRODUCTION: Renal cell carcinoma (RCC) is a heterogenous group of cancers that originate from renal tubular epithelial cells. Metastatic disease most commonly affects the lungs or bone. In rare cases, there may be metastasis to the ampulla of Vater, which can result in acute pancreatitis. Although there have been few case reports of recurrent RCC presenting as a periampullary mass, none have presented with acute pancreatitis. CASE DESCRIPTION/METHODS: A 61-year old male presented with a 1-day history of periumbilical and epigastric pain radiating to the back, nausea, and vomiting. Past medical history was notable for clear cell carcinoma of the left kidney with pulmonary metastasis. Physical examination revealed tenderness in periumbilical and epigastric regions without rebound or guarding. Liver function tests were significant for a bilirubin of 3.2 mg/dL, alkaline phosphatase of 777 U/L, and an ALT of 659 U/L. Serum lipase was 5,862 U/L. Gallbladder ultrasound revealed sludge and common bile duct dilation to 12 mm. An abdominal CT scan showed pancreatic tail edema and peripancreatic fat infiltration. Endoscopic retrograde cholangiopancreatography (ERCP) showed ulceration of the major papilla and a large, periampullary mass. A stricture of distal common bile duct at the ampulla was also present. A sphincterotomy was performed and a temporary, plastic biliary stent was placed. The lower one-third of the common bile duct and ampulla were biopsied and cytology was consistent with metastatic renal cell carcinoma. DISCUSSION: Although RCC appears to have a predilection for certain organs, metastatic disease can present in many places. Metastasis to the ampulla of Vater is rare, and there are very few reported cases. Despite limited data, it is believed that renal cell carcinoma with metastasis to the ampulla of Vater has a more favorable prognosis compared to other sites. Of the reported cases, symptoms of biliary obstruction such as nausea, vomiting, abdominal pain, and jaundice were the most common presentations. To our knowledge, this is the first reported case of an ampullary mass from renal cell carcinoma resulting in acute pancreatitis. Treatment of these patients should focus on fluid resuscitation and pain control, ERCP with sphincterotomy and stent placement, and coordination with oncology services. It is difficult to provide absolute estimates of patient prognosis, although relative ones can be made when comparing to other sites of RCC metastasis.Figure 1.: H&E (×400): At high magnification, the atypical cells have round to oval nuclei with prominent nucleoli and voluminous clear cytoplasm. They are separated by delicate blood vessels with associated extravasated red cells and inflammatory cells.

S2604 Acute Severe Cholestatic Hepatitis B Infection in an Immune-Competent Patient

INTRODUCTION: Acute severe cholestatic hepatitis B is uncommon and usually reported in organ transplant recipients. We report a unique case of acute HBV infection with severe cholestasis in an immune-competent patient whose symptoms were initially felt to be secondary to complications from choledocholithiasis. CASE DESCRIPTION/METHODS: A 67-year-old female presented with right upper quadrant (RUQ) pain, vomiting, fatigue & jaundice for 2 weeks. She had a new sexual partner with unknown hepatitis status. The patient had no history of alcohol, drug use or new medications. RUQ tenderness & scleral icterus were noted on exam. Labs showed AST-629u/l (Normal[N]: 10–40 u/l), ALT-497u/l (N: 12–78 u/l), ALP-294u/l (N: 33–138 u/l), T. Bili-8.4mg/dl (N: 0.0–1.5 mg/dl), D. Bili-7.5mg/dl (N: 0.0 −1.5mg/dl), INR-1. On ultrasound of the abdomen cholelithiasis with gall bladder wall thickening with normal biliary ducts was noted. Endoscopic ultrasound revealed a 2.5 mm filling defect without shadowing in distal common bile duct (CBD) & Endoscopic retrograde pancreatic duodenoscopy showed a small filling defect in mid CBD and a distal CBD stricture about 1–2 cm in length. Biopsy of CBD stricture showed inflammation. A plastic biliary stent was deployed with good drainage. Her liver tests did not improve, and additional investigations performed were positive for Hepatitis B surface antigen (HbsAg), core antibody Total (Anti HBc Total) & core IgM, Hepatitis e antigen (HBeAg). She was negative for Hepatitis B e antibody (HBeAb) and Hepatitis B surface antibody (HBsAb). HBV PCR was 765,000,000 IU/ml. She was discharged with a follow up scheduled in liver clinic, but was readmitted 2 weeks later with worsening fatigue & liver tests. A liver biopsy showed active hepatitis without evidence of bridging fibrosis or cirrhosis & positive HBV staining. Anti-viral therapy with Tenofovir was initiated with improvement in symptoms. DISCUSSION: Although several case reports describe severe cholestasis with HBV post-liver transplantation, it has rarely been described in immunocompetent patients. Our patient's presentation was initially concerning for biliary obstruction. Despite biliary drainage patient's symptoms worsened, & further investigations revealed acute HBV infection with high replication which was confirmed by biopsy. Prompt therapy with antivirals improved the clinical course. Given these findings one should have high index of suspicion to evaluate for HBV infection in unusual presentation with cholestasis.Figure 1.: Immunohistochemical stain highlights Hepatitis B surface antigen within the cytoplasm of hepatocytes (200X magnification).Figure 2.: Hepatic parenchyma with dense mixed acute and chronic inflammation throughout the hepatic lobule and intermixed ceroid-laden macrophages removing dead hepatocytes (100x magnification).Figure 3.: Hepatic parenchyma with dense mixed acute and chronic inflammation throughout the hepatic lobule and intermixed ceroid-laden macrophages removing dead hepatocytes (200 X magnification).

S1406 Right Hepatic Artery Pseudoaneurysm Causing Hemobilia: A Rare Complication of Laparoscopic Cholecystectomy

INTRODUCTION: Laparoscopic cholecystectomy is considered the gold standard for cholecystitis and symptomatic cholelithiasis. However, it poses a risk of bile duct injury and injury to the right (R) hepatic artery when compared to the open operation. While injuries including bile leakage of aberrant ducts, cystic stump injury, or main bile duct injury have been documented, hemobilia secondary to hepatic artery pseudoaneurysm is a rare complication of laparoscopic cholecystectomy. This case represents delayed gastrointestinal bleeding sustained from laparoscopic cholecystectomy with injury to the common bile duct (CBD). CASE DESCRIPTION/METHODS: An 82 year-old male presented to the hospital with mid-epigastric abdominal pain and melena beginning two months after a cholecystectomy that was converted to an open procedure secondary to complications from a gangrenous gallbladder. During that procedure, a leak within the Duct of Luschka noted and closed with placement of a T-tube (draining tube). This would stay in until two weeks prior to admission. On initial presentation, the patient had an elevated temperature of 100.3 F. Initial hemoglobin (Hgb) was 13 g/dL, which dropped to 9 g/dL after 24 hours. Liver enzymes were elevated (total bilirubin 5.4, AST 194, ALT 149, and alkaline phosphatase 188). Computed tomography revealed dilation of both the intra and extrahepatic bile ducts and hyperdense material within an 18 mm dilated common bile duct. Magnetic resonance cholangiopancreatography confirmed the findings above. Endoscopic retrograde cholangiopancreatography revealed blood emanating from the ampullary orifice. A small sphincterotomy was performed and a 10 french × 5 cm plastic biliary stent was placed. Interventional radiology was consulted and angiography revealed a large pseudoaneurysm of a branch of the R hepatic artery in the region of the cystic artery communicating with the bile duct. This was subsequently embolized. The patient’s Hgb stabilized and he was subsequently discharged home. DISCUSSION: R hepatic artery pseudoaneurysm is an uncommon complication from laparoscopic cholecystectomy, however, the incidence is increased if there is injury to the bile duct during the operation. This case raises the awareness of hemobilia secondary to right hepatic artery pseudoaneurysm as an important bile duct injury that can predispose the patient to long-term complications. Prompt recognition using radiographic and endoscopic modalities helped make a diagnosis which lead to the appropriate management.Figure 1.: Endoscopic view with side-viewing duodenoscope showing hemobilia.Figure 2.: CT abdomen and pelvis showing the hepatic artery pseudoaneurysm communicating with the biliary system.Figure 3.: Another view of the right hepatic artery pseudoaneurysm communicating with the biliary system on CT abdomen and pelvis.

S1571 A Case of Cholangiocarcinoma Causing Severe Hyperlipidemia That Improved With Biliary Decompression

INTRODUCTION: Cholestasis causes disturbances to cholesterol homeostasis in the epithelium of the biliary tract and also to the composition and metabolism of plasma lipoproteins, which can manifest as hyperlipidemia. However extreme degree of hyperlipidemia with high levels of lipoprotein-X is unusual outside the setting of primary biliary cholangitis. We present a patient with cholangiocarcinoma (CCA) who was noted to have severe hyperlipidemia that resolved with biliary stenting. CASE DESCRIPTION/METHODS: A 70 year-old man with a past medical history of hypertension and diabetes mellitus presented with abdominal pain, jaundice, and pruritus. Computed tomography (CT) scan revealed severe intrahepatic biliary ductal dilatation with abrupt cut-off at the level of the common hepatic duct (CHD). In addition to markedly elevated liver tests with a total bilirubin of 26.2 mg/dL, his labs revealed severe hyperlipidemia with low-density lipoprotein (LDL) > 1600 mg/dL. The patient underwent endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP) and was found to have two distinct biliary strictures, one at the distal common bile duct (CBD) and another at the CHD, without any pancreatic mass. A plastic biliary stent was placed. Biliary brushings were positive for malignant cells and the patient was deemed fit for surgical resection based on imaging criteria. Endocrinology was consulted to optimize lipids and for consideration of plasmapheresis prior to surgery. A lipoprotein electrophoresis was sent to confirm the diagnosis. The patient subsequently underwent cardiac work-up, including stress testing, which was normal. He required an additional plastic stent placement 7 days after the initial ERCP and his lipid levels improved rapidly with biliary stenting over a span of 2 weeks. Later at exploratory laparotomy, his disease was found to be more extensive and unsuitable for complete resection. The patient is currently receiving chemotherapy and is in stable condition with plans to reassess for resection following treatment. DISCUSSION: Hyperlipidemia may occur in the setting of cholestasis and is often secondary to the accumulation of abnormal lipoprotein particles such as lipoprotein-X. Such particles are unlikely to be atherogenic and seldom require therapy other than treatment of the underlying cholestatic condition. In our case, a patient with cholangiocarcinoma had dramatic improvement in his cholesterol upon biliary decompression coinciding with a decrease in his cholestasis and pruritus.Figure 1.: CT showing ill-defined partially cystic CBD lesion, and stricture of the common hepatic duct.Figure 2.: Decrease in total bilirubin and LDL after stents placed on April 28 and May 5.Figure 3.: Cholangiogram showing biliary strictures (arrows).

S3334 No Fluoroscopy, No Problem: Non-Fluoroscopic, Non-Sonographic Biliary Drainage

INTRODUCTION: Acute cholangitis (AC) is classically associated with fever, right upper quadrant pain, and jaundice. Severe AC is a gastrointestinal (GI) emergency that requires urgent intervention. The most common cause of AC is biliary obstruction due to gallstones. The management of severe AC involves early initiation of antibiotics, aggressive resuscitation, and endoscopic retrograde cholangiopancreatography (ERCP). We present a case of severe AC requiring an urgent ERCP that was complicated by fluoroscopy malfunction with successful stent placement. CASE DESCRIPTION/METHODS: A 27-year-old man with a past medical history of autism presented with jaundice and fever. The patient is nonverbal and developed nausea and emesis for 3 days prior to presentation. The patient developed jaundice which prompted medical evaluation. On evaluation, the patient was tachycardic and febrile and was directed to the emergency department (ED). In the ED, abdominal ultrasound showed a CBD measuring 15mm. Initial labs were notable for WBC 21.8k, AST 171, ALT 254, and direct bilirubin >10. The patient was given antibiotics and underwent urgent ERCP. Upon biliary cannulation, pus and bile was released from the papilla. Following cannulation however, the fluoroscopy equipment malfunctioned and was no longer available. Given severe AC and aspiration of pus/bile, one plastic biliary stent was placed under endoscopic guidance. The patient’s labs and vital signs rapidly improved, and he was discharged on oral antibiotics. DISCUSSION: Severe AC requires antibiotics, fluids, and timely ERCP. Although endoscopic ultrasound (EUS) is accurate in diagnosing choledocholithiasis, it is unclear whether EUS-guided biliary drainage is as effective as ERCP. One randomized trial of patients with malignant biliary obstruction showed similar success rates among those undergoing EUS-guided drainage compared to ERCP. Another randomized trial of patients with choledocholithiasis found EUS-guided ERCP without fluoroscopy to be inferior to ERCP with fluoroscopy. In our patient, ERCP with fluoroscopy was unavailable due to a technical malfunction. Although EUS was not attempted, we successfully decompressed the biliary tree with blind stent placement after confirming pus and bile on aspiration. Although ERCP with fluoroscopy is preferred, EUS-guided drainage may be a safe alternative. Biliary decompression without EUS or fluoroscopy may be a viable bedside option in patients too sick for transfer, or in situations where fluoroscopy is unavailable.

S1479 Cystic Duct Stump Stone: A Diagnostic Dilemma of Post Cholecystectomy Syndrome

INTRODUCTION: Post-cholecystectomy syndrome (PCS) is defined as persistent dyspepsia, upper abdominal pain, pancreatitis, or jaundice after cholecystectomy. The symptoms of PCS can be caused by a wide variety of conditions, including biliary, pancreatic, or hepatic, while the rest are extra-intestinal. PCS can be described as early: occurring in the postoperative period or late: occurring months to years later. Here we will focus on endoscopic management of retained biliary stones within the cystic duct stump. CASE DESCRIPTION/METHODS: We present a 72-year-old male with new post-prandial epigastric pain with mild tenderness on deep palpation. Cholecystectomy completed six months prior. Lipase: 82, AST: 72, ALT: 47, Total Bilirubin: 0.7, Direct bilirubin: 0.2. CT Abdomen Pelvis with Contrast: Calculus in the remnant cystic duct stump without any intra or extrahepatic biliary dilation. Endoscopic retrograde cholangiopancreatography (ERCP) and fluoroscopy were performed, without visualization of stone. Therefore, Direct Visualization Cholangioscopy was performed, where an impacted stone was noted in the proximal tip of the cystic duct stump. Electrohydraulic Lithotripsy (EHL) was completed, and fragments of the stone were flushed with biliary plastic stent placement. On a three-month follow-up, the patient remained asymptomatic with the removal of the plastic stent. DISCUSSION: It has been demonstrated that ERCP is an adequate alternative to laparoscopic therapy for the diagnosis and treatment of cystic duct stump stones, causing PCS. However, without any head-to-head trials comparing surgical versus endoscopic therapies, selection of therapy becomes anecdotal and based on institutional expertise. We demonstrate a case whereby traditional fluoroscopy with ERCP could not visualize the impacted stone at the proximal tip of the cystic duct stump. Therefore, we question whether the accuracy of diagnostic biliary fluoroscopy decreases in the setting of cystic duct stump. Without cholangioscopy and lithotripsy, the stone likely would have remained, and the patient symptomatic. Therefore, gastroenterologists should recognize the difficulty of fluoroscopic diagnosis of remnant cystic duct stump stones. Additionally, cholangioscopy facilitates selective cannulation of the cystic duct in comparison to contrast fluoroscopy on its own. We are highlighting the importance of the diagnostic and therapeutic role of direct visualization cholangioscopy, in patients with PCS and a suspected cystic duct stump stones.Figure 1.: ERCP and Fluroscopy of cystic duct stump without visualization of cystic duct stump stone.Figure 2.: Direct Visualization Cholangioscopy of impacted stone at the proximal tip of the cystic duct stump.Figure 3.: Clearance of impacted cystic duct stump stone after use of Electrohydraulic Lithotripsy.

S3484 A Case of Ulcerative Proctitis in a Patient With Recent Diagnosis of Autoimmune Pancreatitis

INTRODUCTION: The association between autoimmune pancreatitis (AIP) and inflammatory bowel disease (IBD) is extremely rare and poorly understood. Autoimmune pancreatitis presenting in patients with IBD poses a diagnostic dilemma, as it is difficult to differentiate between AIP and primary sclerosing cholangitis. The relationship between IBD and AIP is mostly limited to UC. The following is a rare case of a patient with AIP and UC. CASE DESCRIPTION/METHODS: A 28-year-old man presented to our office for evaluation of abnormal liver function tests. Symptoms included jaundice and an episode of generalized abdominal pain two weeks before, which resolved spontaneously. Remarkable laboratory results included AST 158, ALT 355, ALP 281 and total bilirubin 4.76. MRCP revealed CBD dilation. Subsequent ERCP with cholangioscopy revealed a distal CBD stricture. A directed biopsy was obtained with deployment of a plastic biliary stent for relief of obstruction. Due to his young age and presentation with biliary stricture and a history of abdominal pain, AIP was suspected. IgG4 serology was found to be positive confirming the diagnosis. He was started on steroid therapy and presented later with rectal bleeding prompting colonoscopy evaluation revealing distal inflammation in the rectum with biopsies consistent with ulcerative proctitis. He was treated with oral and rectal mesalamine and a tapering dose of steroids. Two months later his symptoms resolved, and repeat ERCP revealed resolution of the CBD stricture. Follow-up liver enzymes normalized. DISCUSSION: While an association between AIP and concurrent immune/inflammatory diseases, especially UC has been reported, an exact relationship has not been ascertained. Type 2 AIP was recently identified to be associated with IBD. However, Type 2 usually presents in young patients with IgG4 negative serology. This case is unique as our patient is young but presented with IgG4 positive AIP.

S2333 Management of a Bile Leak Status Post Cholecystectomy in a Patient With Roux-en-Y Anatomy

INTRODUCTION: Surgically altered anatomy renders ERCP challenging. Depending on the surgical reconstruction, a multitude of endoscopic approaches has been developed in order to gain access to the ampulla of Vater. This case describes our experience with a challenging transgastrostomy ERCP performed through a surgically placed gastrostomy in the excluded gastric remnant. CASE DESCRIPTION/METHODS: Case Description: A 48-year-old African American Woman with hx of Roux-en-Y presented to the emergency room approximately 12 days post-cholecystectomy with abdominal pain and low-grade fever. Physical examination showed normal cardiopulmonary exam and diffuse abdominal tenderness. Laboratory testing revealed elevated WBC 15.9 and alkaline phosphatase 179 with normal bilirubin. IV Contrasted CT showed focal fluid collection localized to the right lobe of the liver, confirming a bile leak. A laparoscopic facilitated ERCP revealed a cystic duct leak and common bile duct stone treated with a sphincterotomy, stone extraction, and placement of a plastic biliary stent to reestablish proper bile flow. Following the ERCP, percutaneous 24 French gastrostomy tube was placed. On interval evaluation, the gastrostomy site was too narrow to allow the therapeutic duodenoscope to pass. A novel technique was employed to retrieve the biliary stent and perform occlusion cholangiography via gastrostomy tube site. A 5.8mm diameter pediatric upper-endoscope was passed through the gastrostomy site into the stomach and beyond to the 2nd portion of the duodenum. A 1.8 mm cholangioscopic forceps was used to grasp and retrieve the stent percutaneously. Subsequently, the same forceps were used to grasp a sphincterotome by a 3mm vicryl surgical knot attached to the tip of the sphincterotome. The sphincterotome was manipulated using the forceps and standard handle operation to cannulate the common bile duct and pass a .035 insulated guide wire. Following cannulation of the biliary tree, the same technique was used to pass a 9-12mm biliary balloon to achieve a proper cholangiogram and balloon sweep with sludge extraction. The patient was discharged and recovered uneventfully after this outpatient procedure. DISCUSSION: The tandem delivery system enabled us to successfully perform ERCP utilizing an end-viewing, 5.8mm endoscope in a patient with altered gastrointestinal anatomy, rendering repeat surgical intervention or more aggressive gastrostomy site dilation unnecessary.

S1854 Endoscopic Retrograde Cholangiopancreatography in Patient With Roux-en-Y Gastric Bypass and High-Grade Duodenal Stricture Across Dual Lumen Apposing Metal Stents

INTRODUCTION: Endoscopic ultrasound-guided lumen-apposing metal stents (LAMS) is a minimally invasive modality that has not only been used for drainage of pancreatic fluid collection but also other off-label indications. We demonstrated a case with multiple applications of LAMS for management of both choledocholithiasis and enteric stricture in a patient with Roux-en-Y Gastric Bypass (RYGB) anatomy. CASE DESCRIPTION/METHODS: An 82-year-old woman with a history of RYGB, multiple abdominal surgeries and choledocholithiasis, which was treated with laparoscopic-assisted ERCP (LA-ERCP) and complicated by duodenal perforation and repaired by open surgery, was admitted for right upper quadrant abdominal pain. MRCP revealed choledocholithiasis with biliary dilatation. After discussion of various options for accessing biliary system, EDGE procedure was pursued. For the initial stage, LAMS was deployed to obtain access to gastric remnant under endosonographic and fluoroscopic guidance. The patient returned in 3 weeks after the tract was mature for ERCP. However, high-grade duodenal stricture, which is likely due to post-surgical scarring or peptic stricture, was unexpectedly found before reaching the biliary system. The stricture was treated with 20 mm by 10 mm LAMS placement under endosonographic and fluoroscopic guidance. She returned in 2 weeks for subsequent ERCP through dual transluminal connection consisted of gastrogastrostomy and duodenal LAMS. The duodenoscope was advanced through gastrogastrostomy and duodenal LAMS to the major papilla without difficulty. Biliary sphincterotomy and plastic biliary stent placement were performed. A large amount of sludge and stone was extracted. She was discharged the same day with improvement in symptoms. All stents were removed 6 weeks after the ERCP without complications. DISCUSSION: With application of LAMS, we described a novel case of EDGE procedure in patient with RYGB anatomy in conjunction with benign enteric stricture, which was performed through dual transluminal conduit comprised of gastrogastrostomy and duodenal LAMS. Other biliary access options were also considered. However, given the high likelihood of extensive adhesions from prior abdominal surgery, LA-ERCP posed a higher risk of complications, and balloon-assisted enteroscopy ERCP (BA-ERCP) has limited maneuverability which often leads to suboptimal success rates. This highly effective approach should be considered for situations where BA-ERCP is technically challenging, and when LA-ERCP is not feasible.

Endoscopic closure of a duodenal perforation caused by early migration of a biliary plastic stent with an over-the-scope-clip

Endoscopic closure of a duodenal perforation caused by early migration of a biliary plastic stent with an over-the-scope-clip

Sigmoid colon perforation caused by migrated plastic biliary stents: a case report

Endoscopic migration of plastic biliary stents is performed by endoscopic retrograde cholangiopancreatography (ERCP) for biliary and pancreatic diseases. This plays an increasingly important role. Intestinal perforation caused by stent migration is one of the complications. Although sigmoid colon perforation caused by stent migration is rare, it can be life-threatening. This case shows us that we should increase awareness of sudden abdominal pain after ERCP. We provide a review of the clinical manifestations, imaging data of this case, and the literature related to the perforation caused by stent migration. A male patient had a history of choledocholithiasis, cholecystolithiasis, and biliary pancreatitis treated with ERCP and a pancreatic stent. After the operation, the patient developed cholangitis and was treated with ERCP and a plastic biliary stent. This patient was admitted to the emergency department with sudden lower abdominal pain. A CT scan showed sigmoid colon perforation by a foreign body and infra-diaphragmatic free air. An emergency surgery confirmed that the stent had caused the perforation. The patient was then treated with sigmoid colectomy and sigmoidostomy. Biliary stent migration after ERCP is rare, but intestinal perforation caused by migration should be considered in cases of abdominal pain of unknown cause.

Retained biliary plastic stents - lest we forget.

Prolonged indwelling of endoscopically placed biliary plastic stents may lead to complications. We conducted a retrospective analysis of patients who underwent endoscopic retrograde cholangio-pancreaticography (ERCP) at our centre in 2017 and were noted to have retained biliary plastic stents ( > 3 months after an index ERCP). A total of 127 patients had previously placed biliary plastic stents, out of which 45 (35.4%) were retained. The median age of the latter was 52 years (range = 22-79 years) with 27 (60%) patients being men. The median duration of the retained stents was 144 days (range = 94-3292 days). The majority of the patients were asymptomatic. However, 9 (20%) patients had cholangitis, 2 (4.4%) had choledocholithiasis, 2 (4.4%) had cholangitic abscess and 1 (2.2%) developed septicaemia. Fortunately, all these complications could be managed medically and endoscopically. Retention of biliary plastic stents is a problem often overlooked and underestimated in clinical practice. Various measures need to be instituted to create awareness of this entity to prevent undesirable outcomes.

Percutaneous transhepatic placement of plastic biliary stents: technical description and preliminary results.

To describe a novel technique of percutaneous transhepatic (PTH) placement of a plastic biliary stent (PBS), report the feasibility and safety of the technique, and present the preliminary results of a pilot study that included 32 patients with symptomatic obstructive jaundice (SOJ) treated with the technique. This was a prospective, single-arm, single-center, pilot study of a cohort of patients with the diagnosis of benign or malignant obstructive jaundice that underwent PTH placement of a PBS to relieve the obstruction. Thirty-two patients were included, 16 men and 16 women (age range, 35-88 years). There were 26 malignant and six benign lesions. Cholangiocarcinoma was the most common tumor (n=13, 40.6%), followed by pancreatic adenocarcinoma (n=6, 18.75%) and metastasis (n=5, 15.6%). A total of 35 PBSs were placed in 32 procedures. The bile duct was accessed and drained to the right side in 18 cases, to the left side in 14 cases, and bilaterally in three cases. Technical success was achieved in 100% and clinical success in 93.7% of cases. Using a modified Bismuth-Cortelle classification system, type I was observed in nine patients, type II in nine patients, type III in six patients, and type IV in eight patients. The mean follow-up was 426.1 days for the total sample, and 349.4 days for patients with malignancy. Two complications were observed: transient hemobilia and cholangitis. PTH placement of a PBS in patients with SOJ is feasible, safe, and effective.

Tu1048 PREVALENCE AND RISK FACTORS FOR DUODENAL PERFORATION DUE TO MIGRATED BILIARY PLASTIC STENTS

Transpapillary biliary drainage by stent placement through endoscopic retrograde cholangiography (ERC) is a well-established treatment for bile duct obstruction. Migrated-stent-induced duodenal perforation (MSDP) can be a life-threatening complication. The actual prevalence of MSDP is however unknown and risk factors are unclear. We aimed to analyze the prevalence, risk factors and clinical course of MSDP. All patients who underwent an ERC with biliary plastic stent placement between January 1st 2014 and December 31st 2017 in our centre were retrospectively analysed. General patient characteristics, ERC indication and biliary stricture and stent characteristics were collected. For patients with a MSDP, date of perforation, clinical presentation, type of treatment and outcome were reviewed. A total of 2487 ERCs were performed in 1228 patients (mean age 59 years, 59% male). In 630 patients (51%) a biliary plastic stent was placed; in 304 patients (25%) one or more stents were placed for perihilar strictures. A total of 14 MSDPs were diagnosed in 13 patients (mean age 63 years, 79% male). All MSDPs occurred in patients with a perihilar stricture. The overall prevalence was 1,1% in all patients, 2,1% for patients with biliary stent placement and 4,3% for patients with a stent for perihilar stricture. Perforation did not occur with stents shorter than 12 cm (median length 15 cm, IQR 12-15 cm). Perforation occurred both with 7 and 10 French stents (21% and 79% resp.) and with either centre or duodenal bend type stents (42% and 58% resp.). Etiology of stenosis was malignant in 8 patients (57%). In 57% of patients the proximal tip was deployed in the left intrahepatic ducts. Median time to diagnosis of MSDP was 12 days (IQR 4-66 days). In 9/13 patients MSDP was clinically suspected due to presentation with abdominal pain, fever and/or laboratory abnormalities. 4/13 patients were asymptomatic and were diagnosed at elective stent retrieval. Treatment was either by stent removal (n=4), endoscopic closure with an over the scope clip (n=8) or surgery (n=1). 4/13 patients died due to abdominal sepsis despite repeated interventions. This is the first study to report on the prevalence of MSDP in patients who undergo ERC. Despite the overall low risk of MSDP, it represents a potentially life threatening complication of ERC after transpapillary drainage for perihilar biliary strictures. The risk of MSDP needs to be acknowledged for this indication and warrants consideration in symptomatic patients after ERC.

Su1575 DISTAL BILIARY STENT MIGRATION IN PATIENTS WITH IRRETRIEVABLE COMMON BILE DUCT STONES: A RETROSPECTIVE COMPARISON BETWEEN STRAIGHT AND DOUBLE-PIGTAIL STENTS

Migration of biliary stents is a well-documented problem. Different types of plastic stents (straight or double-pigtail) are used for biliary drainage in patients with irretrievable common bile duct stones (ICBDS). Due to their physical characteristics, double-pigtail stents are expected to migrate less frequently; however, comparisons remain scarce. We aimed to compare the distal migration rate between patients who received either straight or double-pigtail stents in the biliary drainage of ICBDS. Consecutive patients with ICBDS who received plastic biliary stents at the Venizeleio General Hospital between 2009 and 2019 were retrospectively reviewed. Distal migration was confirmed on follow-up endoscopy when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Among 4524 ERCPs, a total of 618 biliary plastic stent placement procedures (410 patients) were performed for ICBDS: 289 (46.8%) with a straight stent (Group A) and 329 (53.2%) with a double-pigtail stent (Group B). No significant differences were observed between the two groups concerning age, gender, bile duct diameter, placement of single vs multiple biliary stents, as well as use of endoscopic sphincterotomy and balloon sphincteroplasty. The median time period of repeated endoscopy was 7 months (IQR 4-12 months). The rate of distal stent migration was 17.3% (50/289) in group A and 27.4% (90/329) in group B (p=0.003). By Kaplan-Meier analysis (Figure), freedom from distal stent migration was 91.6% and 82.7% at 6 months, 78.6% and 72.3% at 12 months, and 73% and 55% at 18 months, for groups A and B respectively (P=0.004, log-rank). Contrary to common perception, pigtail stents are more likely to migrate distally compared with straight stents in patients with ICBDS.

Endoscopic Management of Postlaparoscopic Sleeve Gastrectomy Leaks: A Single-Center Experience

Abstract Introduction Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Sleeve leak is the most important complication, with an incidence of 1.9 to 2.4%. Various endoscopic approaches to LSG have been used, including self-expanding metal stents (SEMSs), glue injection, and clipping along with percutaneous drainage. This study was aimed to study the role of endotherapy in the management of post-LSG leaks. Methods This study included patients referred for endotherapy for post-LSG leak between January 2016 and December 2018. We maintained data prospectively, which included the location and type of leak, type of endotherapy, adverse events, and time for leak closure. Primary endotherapy included mega SEMS placement; if it failed, then secondary endoscopic therapy was performed. Results Seven patients (four females, with a mean age of 45.2 years) with a preoperative body mass index of mean 38.5 kg/m2 underwent endotherapy for post-LSG leaks. Two were acute, four were early, and the remaining one was late leak. Five were located proximally near gastroesophageal junction and two at the midsleeve level. In four (57.1%) patients, the leak was resolved by primary therapy. Three patients underwent secondary therapy that included overlapping SEMS placement (in one patient), SEMS replacement (in one patient), and short plastic biliary stent placement with Argon plasma coagulation (APC) to create a raw surface and induce granulation tissue. The median duration for leak closure was 12 weeks (range: 8–24 weeks). One patient who had partial distal migration underwent overlapping SEMS placement. Three patients had nonbleeding ulcers at the distal end of SEMS at removal. Conclusion Endotherapy is effective and safe for the management of post-LSG leaks. Additional endotherapy can be used if primary therapy is not successful for resolution of the leak.

1170 ENDOSCOPIC TRANSPAPILLARY GALLBLADDER STENT PLACEMENT TO PREVENT ACUTE CHOLECYSTITIS IN PATIENTS RECEIVING FULLY COVERED SELF EXPANDING METAL STENTS FOR BENIGN BILIARY STRICTURE

Treatment of benign biliary strictures (BBS) with fully covered self-expanding metal stents (FCSEMS) has become common practice due to its deceased number of endoscopic sessions and its efficacy in resolution of benign strictures. However, placement of FCSEMS for BBS poses intrinsic risk, including stent migration, pancreatitis and acute cholecystitis at a rate of 2.9% to 12%. Prophylactic endoscopic transpapillary gallbladder stenting (ETPGBS) during the same ERCP session can allow continuous gallbladder drainage and prevent acute cholecystitis from occlusion of cystic duct orifice by the FCSEMS. The aim of this study was to assess the technical feasibility, efficacy, and safety of ETPGBS prior to placement of FCSEMS for BBS for prevention of acute cholecystitis. This is a retrospective analysis of a prospectively collected database at a single tertiary-care referral center of all patients who underwent FCSEMS for BBS with prophylactic endoscopic transpapillary gallbladder stent placement between 12/1/2016 and 11/30/2019. Demographic, endoscopic, imaging, clinical management, and follow-up data was abstracted and analyzed. A total of 46 transpapillary GB stents were placed during the study period. Selective cystic duct and gallbladder wire cannulation was achieved followed by successful placement of ETPGBS in all patients (technical success 100%). 10 patients underwent ETPGBS prior to biliary FCSEMS during the same endoscopic session. (Figure) The mean age was 69 ± 21.83 years, and the majority of patients were male (80%). A 7 Fr by 22 cm low-profile, soft, plastic double-pigtail gallbladder stent with larger inner lumen was used in all cases. In all cases, a 10 mm diameter FCSEMS (length ranging from 40 mm to 100 mm; 60 mm being the most common) was placed in the common bile duct. There was significant improvement in total bilirubin level (pre-procedural 4±3.08 vs post-procedural 1.27±1.1 gm/dL with mean reduction of 2.73±1.27; p=0.04). FCSEMS were left in place (stent dwell time) for a median of 139 (range: 87-291; mean 164±68) days with resolution of BBS and successful removal of ETPGBS and FCSEMS in all patients. No episodes of acute cholecystitis or any other post-procedural complications were noted during the median follow-up of 126 (range: 3-380; mean 169±147) days. Treatment of BBS with FCSEMS has become an increasingly common alternative therapy to plastic biliary stents. However, rates of acute cholecystitis have been documented as high as 12%. Endoscopic transpapillary gallbladder stent placement prior to FCSEMS in our study demonstrated an effective treatment of BBS without an increase in procedural or post-procedural complications. ETPGBS prevented post-procedural acute cholecystitis with continued efficacy of FCSEMS.

Su1446 TRANSPAPILLARY GALLBLADDER STENT PLACEMENT: EXPANDING TREATMENT OPTIONS FOR SYMPTOMATIC GALLSTONE DISEASE IN PATIENTS WITH CIRRHOSIS AWAITING LIVER TRANSPLANTATION

OBJECTIVES: The aim of this study was to evaluate clinical outcomes in patients with cirrhosis awaiting liver transplantation who underwent transpapillary gallbladder stent (TGS) placement for symptomatic gallstone disease. This retrospective study included patients with Child-Turcotte-Pugh class B or C cirrhosis with symptomatic gallstones causing biliary colic or acute cholecystitis. All patients were deemed to be high risk for cholecystectomy. The patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with attempted TGS placement using a double pigtail plastic biliary stent. The database included patients from July 2008 to August 2019. Demographic variables, including age, sex, etiology of cirrhosis, number of procedures, Charlson Comorbidity Index (CCI), Model End Stage Liver Disease Sodium (MELD-Na) score were analyzed. A total of 20 patients with cirrhosis awaiting liver transplantation underwent ERCP for symptomatic gallstone disease (Table 1). Transpapillary biliary stent placement was technically successful in 90% (18 of 20) of patients. 13 of the 18 (72.2%) patients experienced complete resolution or clinical improvement in symptoms of gallbladder disease. Just over half (55%) of the patients developed recurrent symptoms at an average of 6.8 months, which were successfully managed with biliary stent exchange. Following TGS placement, 83% of patients had fewer emergency room visits for symptomatic gallstones (average decrease of 1.8 visits). 11% (2 of 18) patients ultimately required cholecystectomy due to persistent symptoms after TGS placement. Post-procedural complications were seen in 3 of the 18 (16.7%) patients including severe abdominal pain necessitating stent removal (n=1) and sepsis requiring hospitalization and antibiotics (n=2). There was no significant difference in age, burden of co-morbidities, MELD-Na score, or number of stent exchanges between patients who did not experience symptom improvement compared to those who did (p>0.05). Transpapillary gallbladder stent placement is safe and effective in managing symptomatic gallstone disease in patients with cirrhosis awaiting liver transplantation. Gallbladder stenting can be considered as an alternative treatment option in these patients who are at high surgical risk for cholecystectomy.