Sphincterotomy In Patients Research Articles

MANAGEMENT OF BLEEDING AFTER ENDOSCOPIC BILIARY SPHINCTEROTOMY IN PATIENTS WITH OR WITHOUT COAGULOPATHY DEFECTS

Background: Post Endoscopic sphincterotomy (ES) bleeding is a common complication, and it can be challenging to manage post ES bleeding through a side-viewing endoscope. Objective: To establish a well-accepted clinical strategy for management of bleeding after endoscopic biliary sphincterotomy in patients with or without coagulopathy defects. Patients and Methods: This prospective interventional selective study was carried out on 100 consecutive patients with jaundice at General Surgery Department, Al- Azhar University Hospitals (Cairo) Egypt. All patients underwent ERCP during the period between January 2016 and August 2019. Patients were divided into 2 equal groups according to presence or absence of coagulopathy: Group A without coagulopathy defect, and group B with coagulopathy defect. Results: Among 100 patients with endoscopic retrograde cholangiopancreatography (ERCP), post ES bleeding was recorded in 33 patients. Only 1 of 33 was among group A which represented 3% of bleeding cases, and 1% of the total. The cause was vigorous sphincterotomy. Of 33 patients, 32 were among group B, and represented 97% of bleeding cases, and 32% of total cases in our study. The arrangement of the use of different hemostatic measures in our study was based on accessibility of the facilities and also severity of bleeding. In mild cases, bleeding stopped simply with balloon tamponade. If not, adrenaline spray was used. Endoclip was used for difficult and recurrent cases. Delayed bleeding occurred (1±7 days -mean, 2.5 days) following the procedures. Among the 9 patients with delayed bleeding, 7 patients were managed by endoscopic intervention. The other 2 patients managed conservatively by drugs and intravenous fluids with. No patient required angiography or surgery for delayed bleeding. Conclusion: Patients must be carefully assessed and prepared pre procedure. Centers must be equipped with all hemostatic measures and facilities. Endoscopists must be well trained and qualified. Bleeding was controlled in all patients easily without morality.

MANAGEMENT OF BLEEDING AFTER ENDOSCOPIC BILIARY SPHINCTEROTOMY IN PATIENTS WITH OR WITHOUT COAGULOPATHY DEFECTS

Background: Post Endoscopic sphincterotomy (ES) bleeding is a common complication, and it can be challenging to manage post ES bleeding through a side-viewing endoscope. Objective: To establish a well-accepted clinical strategy for management of bleeding after endoscopic biliary sphincterotomy in patients with or without coagulopathy defects. Patients and Methods: This prospective interventional selective study was carried out on 100 consecutive patients with jaundice at General Surgery Department, Al- Azhar University Hospitals (Cairo) Egypt. All patients underwent ERCP during the period between January 2016 and August 2019. Patients were divided into 2 equal groups according to presence or absence of coagulopathy: Group A without coagulopathy defect, and group B with coagulopathy defect. Results: Among 100 patients with endoscopic retrograde cholangiopancreatography (ERCP), post ES bleeding was recorded in 33 patients. Only 1 of 33 was among group A which represented 3% of bleeding cases, and 1% of the total. The cause was vigorous sphincterotomy. Of 33 patients, 32 were among group B, and represented 97% of bleeding cases, and 32% of total cases in our study. The arrangement of the use of different hemostatic measures in our study was based on accessibility of the facilities and also severity of bleeding. In mild cases, bleeding stopped simply with balloon tamponade. If not, adrenaline spray was used. Endoclip was used for difficult and recurrent cases. Delayed bleeding occurred (1±7 days -mean, 2.5 days) following the procedures. Among the 9 patients with delayed bleeding, 7 patients were managed by endoscopic intervention. The other 2 patients managed conservatively by drugs and intravenous fluids with. No patient required angiography or surgery for delayed bleeding. Conclusion: Patients must be carefully assessed and prepared pre procedure. Centers must be equipped with all hemostatic measures and facilities. Endoscopists must be well trained and qualified. Bleeding was controlled in all patients easily without morality.

Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: a meta-analysis

BackgroundEndoscopic sphincterotomy (ES) is the standard treatment for common bile duct stones. The reported findings regarding complications, such as biliary pancreatitis and cholangitis, differ between cholecystectomy after ES. The purpose of this study is to compare cholecystectomy outcomes after endoscopic treatment of common bile duct stones whether or not the incidence of recurrent pancreatitis and cholangitis is reduced, especially in high-risk patients.MethodsWe analyzed 8 studies, including 7 randomized controlled trials retrieved from the PubMed (1990–2019), Embase (1990–2019), and Cochrane (1990–2019) databases for trials comparing the two strategies for treatment of gallstones after ES. A related study on gallbladder removal after ES was acquired, followed by analysis of each group using RevMan. Risk ratios (RRs) were calculated for categorical variables and differences in means were calculated for continuous variables.ResultsWe retrieved a total of 8 studies, including seven randomized controlled trials and one retrospective study. A total of 12,717 patients were included in the study (4922 in the early cholecystectomy group and 7795 in the gallbladder in situ group). During the follow-up period, 41 patients had pancreatitis after ES in the cholecystectomy group and 177 patients in the wait-and-see group. The incidence of pancreatitis in the cholecystectomy group was significantly reduced (RR, 0.38; 95% CI, 0.27–0.53; P < 0.00001; I2 = 0%). The incidence of cholangitis and jaundice in the cholecystectomy group was also less than the preserved gallbladder group (RR, 0.31; 95% CI, 0.26–0.38; P < 0.00001; I2 = 0%). There was no significant difference in mortality between the two groups (RR, 0.73; 95% CI, 0.52–1.02; P = 0.07; I2 = 14%). There was a significant difference in cholecystitis and biliary colic (RR, 0.28; 95% CI, 0.24–0.32; P < 0.00001; I2 = 17%).ConclusionEarly cholecystectomy after removal of common bile duct stones can effectively reduce biliary complications. This is still true for high-risk patients and has no significant effect on the mortality of patients. Laparoscopic cholecystectomy is recommended after ES.

Prospective Randomized Study between Open Vs Closed Lateral Anal Internal Sphincterotomy in Patients with Chronic Fissure in Ano

Background: One of the the most common cause of pain during defecationin young patientsis chronic fissure in ano. Surgical treatment of choice for chronic fissure in ano is internal sphincterotomy. This procedure can be performed by open or closed method. The aim of the study was to compare the closed and open anal internal sphincterotomy in patients admitted in our hospital with chronic anal fissure. Subjects and Methods: 105 patients admitted in department of general surgery with chronic fissure in ano were divided into two groups. 50 patients (Group A) who were treated by closed method and 55 patients (Group B) who were managed by open lateralanal sphincterotomy method. A 3 months follow up done in both post-surgery to observe for pain, bleeding, infection, incontinence, and recurrence. Results: Significant difference was observed in postoperative acute complications between the two methods of internal anal sphincterotomy. Conclusion: Lateral anal sphincterotomy is the treatment of choice for chronic anal fissure, either open or closed method. However, the closed method was observed to have lesserpost operative complication compared to the open method.

Self-expandable metallic stent placement above the papilla without endoscopic sphincterotomy in patients with distal malignant biliary obstruction.

Background and study aims The best method for endoscopic placement of self-expandable metallic stents (SEMS) for distal malignant biliary obstruction (MBO) has not yet been determined. The aim of this study was to evaluate how SEMS placement above the papilla and without endoscopic sphincterotomy (EST) impacts the time to recurrent biliary obstruction (RBO) in patients with distal MBO. Patients and methods We retrospectively reviewed data for 73 consecutive patients with unresectable distal MBO who underwent endoscopic SEMS placement for the first time at our institution between April 2014 and March 2016. We compared time to RBO of SEMS placement above the papilla (intraductal placement) with SEMS placement across the papilla (transpapillary placement). In the intraductal placement group, we also compared time to RBO of placement without EST with placement with EST. Results Endoscopic SEMS placement was performed in 30 patients with intraductal placement and in 43 patients with transpapillary placement. The median time to RBO was significantly longer with intraductal placement (307 days) than with transpapillary placement (161 days) ( P = 0.022). Complication rates did not differ between the two groups. In both univariate and multivariate analysis, intraductal placement was an independent factor contributing to prolonged time to RBO. In intraductal placement, time to RBO was significantly longer in SEMS placement without EST than with EST (363 days vs. 227 days, respectively; P = 0.026). Conclusions Intraductal SEMS placement, especially without EST for distal MBO contributed to longer time to RBO.

906 To Cut or Not to Cut – Clinical Efficacy of Endoscopic Sphincterotomy in Recurrent Acute Pancreatitis From Functional Biliary Sphincter of Oddi Disorder: A Systematic Review and Meta-Analysis

INTRODUCTION: Functional biliary Sphincter of Oddi disorder, previously referred to as Sphincter of Oddi Dysfunction, is an established cause of recurrent acute pancreatitis which is defined as two or more episodes of documented acute pancreatitis per year. Data on the efficacy of endoscopic sphincterotomy in preventing future episodes of pancreatitis is limited. We performed a systematic review and meta-analysis to evaluate the clinical efficacy of index endoscopic sphincterotomy in patients with Recurrent Acute Pancreatitis secondary to manometrically proven functional biliary Sphincter of Oddi disorder. Our goal was to assess reduction in episodes of pancreatitis following sphincterotomy, and not to assess chronic pain in these patients. METHODS: We conducted a search of several databases including PubMed, EMBASE, Google-Scholar, Scopus and Cochrane Review (from 1960 to October 2018). Random-effects model was used for analysis. Heterogeneity between study-specific estimates was calculated using Cochran Q statistical test, 95% confidence interval (CI) and I2 statistics. Publication bias was ascertained, qualitatively, by visual inspection of funnel plot and quantitatively, by the Egger test. RESULTS: Our initial search yielded 3201 results. Of 1936 studies screened, 12 met inclusion criteria. A total of 396 patients with recurrent acute pancreatitis and abnormal manometry findings were included from these studies in the final analysis. The interventions performed were as follows: Endoscopic biliary sphincterotomy in 212 (53.5%), endoscopic pancreatic sphincterotomy in 19 (4.8%) and dual biliary and pancreatic sphincterotomy in 165 (41.6%) patients. Technical success ranged from 99 to 100%.The pooled estimate for clinical success following index sphincterotomy was 68.4% (95% CI 57.6-77.4; I2 = 71.4%). Lone endoscopic biliary sphincterotomy was successful in 43/60 (71.6%) patients. The pooled estimate for proportion of patients with post-ERCP pancreatitis was 23.2% (95% CI 16.6-31.4; I2 = 44.4%). The follow up duration ranged from 6 to 120 months. There was no evidence of publication bias, based on funnel plot analysis and Egger’s test. CONCLUSION: Our study highlights the utility and clinical efficacy of endoscopic sphincterotomy in patients with recurrent acute pancreatitis secondary to Functional biliary Sphincter of Oddi disorder. We conclude that 68.4% of patients improved after endoscopic sphincterotomy and that it can be considered in patients with recurrent acute pancreatitis.

44 Trends in ERCP Utilization for Sphincter of Oddi Dysfunction: The Real World Impact of EPISOD and Rome IV

INTRODUCTION: The widespread clinical adaptation of landmark clinical trials and practice guidelines is often unclear. The EPISOD trial, a randomized, sham-controlled trial, demonstrated that endoscopic sphincterotomy in patients with Type III Sphincter of Oddi dysfunction (SOD) did not result in clinical improvement. The results of this study were presented at the 2013 National Meeting of the American College of Gastroenterology and published in May 2014. Subsequently, the updated 2016 Rome IV criteria removed Type III SOD from the functional biliary disorder classification. Though patients with Type III SOD make up a minority of all SOD patients, we aimed to assess the utilization of ERCP for patients with SOD in a large population database from 2012–2017. METHODS: We searched electronic health record (EHR)-based disparate data from a cloud-based dataset which incorporates over 300 individual hospitals in the United States (Explorys Inc, Cleveland, OH). Using Systematized Nomenclature of Medicine (SNOMED) codes we identified patients with a first-ever diagnosis of “disorder of Sphincter of Oddi” or “spasm of Sphincter of Oddi” annually from 2012–2017. Because the dataset uses SNOMED codes, it was not feasible to sub-classify the types of SOD. Stratified by year, we identified the proportion of patients undergoing ERCP with sphincterotomy and those receiving tricyclic antidepressants (TCA). A Mantel-Haenszel test was used. RESULTS: The number of index cases of SOD and rates of ERCP utilization are outlined in Table 1. From 2013 (the presentation of EPISOD data) to 2016, there was a significant trend demonstrating lower rates of ERCP for newly-diagnosed SOD (P = 0.018). A divergent increase in TCA utilization was concomitantly seen from 2013–2015, but the trend was not statistically significant (P = 0.29). Following the publication of the ROME IV criteria, rates of ERCP utilization for newly-diagnosed SOD significantly increased (P = 0.048) (Figure 1). CONCLUSION: Following the presentation of the EPISOD data, there was a significant 3-year linear decrease in ERCP utilization for all-comers newly-diagnosed with SOD. Concomitantly, a divergent yet insignificant increase in TCA usage was observed. In 2016, after the Rome IV criteria narrowed the diagnosis of SOD, an expected increase in ERCP utilization was observed. These findings call for ongoing observation to see if these trends are durable.

Comparison of Open Versus Closed Lateral Internal Sphincterotomy in the Management of Chronic Anal Fissure

An anal fissure is a longitudinal split in the anoderm of the distal anal canal, extending from the anal verge proximally towards, but not beyond, the dentate line. Various surgical methods of treatment of chronic anal fissure (CAF) are available, including anal dilatation, fissure excision, fissure excision with sphincterotomy, open lateral anal internal sphincterotomy and closed lateral anal internal sphincterotomy. This prospective study compared the results and complications of the open and closed techniques of lateral internal anal sphincterotomy in patients with CAF. A total of 60 patients with CAF were enrolled in this study, of which 30 underwent open lateral sphincterotomy and 30 underwent closed lateral sphincterotomy. Post-operative complications (pain, bleeding, constipation, perianal abscess, incontinence) were compared between the two groups. Postoperative pain, bleeding, and constipation were significantly less in the group undergoing closed surgery (p > 0.05). Perianal abscess and incontinence did not occur in any study subject. Closed lateral anal sphincterotomy is the treatment of choice for CAF. It can be performed effectively and safely, with a low rate of complications and a reduced cost burden.

Safety of endoscopic sphincterotomy in patients undergoing antithrombotic treatment: a retrospective study

Background:This study investigated the safety of endoscopic sphincterotomy in patients undergoing antithrombotic treatment.Methods:From January 2014 to December 2016, a single-center retrospective study was conducted. Of the 80 patients with naïve papilla receiving antithrombotic treatment who underwent endoscopic sphincterotomy, 76 patients were retrospectively analyzed. We divided the participants into two groups as follows: 45 patients who discontinued antithrombotic treatment (discontinuation group) and 31 patients who continued antithrombotic treatment (continuation group). We evaluated the safety of endoscopic sphincterotomy in patients with naïve papilla who received antithrombotic treatment.Results:The percentage of patients requiring emergency endoscopic retrograde cholangiopancreatography in the continuation group was significantly higher than that in the discontinuation group (55% vs 11%; p = 0.001). The incidence of adverse events did not differ significantly between the two groups. Neither bleeding nor perforation occurred in either group. The length of hospital stay did not differ significantly between the two groups.Conclusions:Endoscopic sphincterotomy in patients undergoing antithrombotic treatment may be safe if the guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment are followed.

Study on surgical outcome and complications of lateral anal sphincterotomy in patients suffering from anal fissure

Study on surgical outcome and complications of lateral anal sphincterotomy in patients suffering from anal fissure

Effect of lateral internal sphincterotomy in patients undergoing excisional hemorrhoidectomy.

Background:Excisional hemorrhoidectomy (EH) is the major surgical option for high-grade symptomatic hemorrhoids, but it has some shortcomings, especially postoperative pain. This study was performed to assess the effect of lateral internal sphincterotomy (LIS) in patients undergoing excisional hemorrhoidectomy.Methods:A systematic literature search (Medline, Embase, Cochrane Library, Science Citation Index, Science Direct, Springer Link, Ovid Journals, and EBSCO) was performed to identify all eligible articles. Randomized controlled trials (RCTs) published until July 7, 2017 comparing EH combined with LIS (experimental group) with EH only (control group) were eligible for inclusion. The primary outcome of interest was postoperative pain.Results:Ten RCTs involving 1560 patients were identified for inclusion. The pooled analysis revealed that patients undergoing EH and LIS were associated with lower pain score [standardized mean difference (SMD), −0.75; 95% confidence interval (CI), −1.14 to −0.36; z = 3.76; P = .0002] and resting anal pressure [odds ratio (OR), −17.19; 95% CI, −25.66 to −8.72; z = 3.98; P < .0001], and lower incidence of anal stricture (OR, 0.12; 95% CI, 0.03–0.53; z = 2.85; P = .004). However, the differences of urinary retention, bleeding and length of hospital stay were similar between the 2 methods.Conclusion:Our meta-analysis suggests that LIS effectively relieves postoperative pain and reduces patient's postoperative analgesic requirements. LIS also reduces the incidence of anal stenosis but increases the incidence of fecal incontinence.

Assessing Quality of Precut Sphincterotomy in Patients With Difficult Biliary Access: An Updated Meta-analysis of Randomized Controlled Trials.

It is generally accepted that precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of pancreatitis. However, patients with difficult biliary access may be different. We implemented a meta-analysis to explore the effects of early and delayed precut sphincterotomy on post-ERCP pancreatitis in patients with difficult biliary access. We searched studies in PubMed, EMBASE, and the Cochrane Central Register of Randomized Controlled Trials for meeting requirement in which precut sphincterotomy was compared with persistent standard cannulation during ERCP. The primary outcomes included the overall cannulation success rate and the incidence of post-ERCP pancreatitis. The secondary outcomes included primary cannulation success and the overall complication rate. Six studies (898 patients) were included. The present meta-analysis found no significant difference in overall cannulation success rate and overall complication rate between early precut sphincterotomy and persistent standard cannulation. However, early precut sphincterotomy not only increased the primary cannulation success rate [Mantel Haenszel test relative risk, 1.87; 95% confidence interval (CI), 1.15-3.04] but also decreased the overall risk of pancreatitis (Peto odds ratio, 0.49; 95% CI, 0.30-0.80). For persistent standard cannulation, no significant difference was observed in the pancreatitis rate between no salvage precut and delayed salvage precut sphincterotomy (Peto odds ratio, 0.96; 95% CI, 0.49-1.85). Compared with persistent standard cannulation, an early precut sphincterotomy exhibited a reduced risk of pancreatitis. In addition, a delayed precut sphincterotomy after persistent attempts did not increase the occurrence of pancreatitis and this is the first meta-analysis to present this conclusion.

Long‐term urodynamic follow‐up after external sphincterotomy in patients with spinal cord injury

External sphincterotomy (ES) is a therapeutic option for male spinal cord injury patients with detrusor sphincter dyssynergia. However, some patients need to change their voiding management after ES. One of the potential causes of failure is reportedly detrusor dysfunction, but long-term urodynamic follow-up data after ES is limited. In the present study, we reviewed the urodynamic data before and after ES and analyzed it for possible causes of ES failure. A total of 37 patients who were followed up at our center for at least 5 years after ES were included. Mean follow-up period was 16.5 years. Urodynamic assessment was routinely performed every 2 or 3 years after ES, and the data were reviewed and analyzed. Of the 37 patients, 27 are still managed with reflex voiding to a condom catheter (success group), while 10 needed to change their bladder management. Mean maximum bladder pressure (MBP) was preserved at a low level after ES. However, after ES, there was a gradual increase over time in both the mean bladder volume at first neurogenic detrusor overactivity (NDO) and the percentage of patients without NDO. The mean preoperative MBP in the success group was significantly higher than that in the failure group. MBP is maintained at a low level over 20 years after ES. However, NDO gradually decreases over time, which might be one of the reasons for failure after ES. In addition, low preoperative MBP would be a poor prognostic factor for ES.

Optimal time of resuming anticoagulant after endoscopic sphincterotomy in patients at risk for thromboembolism: a retrospective cohort study.

One major adverse event of endoscopic sphincterotomy (EST) is bleeding, which could be more common and severe in patients receiving anticoagulant therapy. However, the cessation of anticoagulants for long periods could lead to thromboembolic events. We aimed to evaluate the optimal timing of resumption of anticoagulants after EST in patients at risk for thromboembolism. From January 2010 through October 2017, a retrospective cohort at risk for thromboembolism who had taken warfarin and bridging therapy with heparin around EST from three tertiary hospitals in South Korea was investigated. The primary outcome was to compare the incidence of post-EST delayed bleeding according to the resumption time of anticoagulant. The secondary outcome was to investigate any thromboembolic adverse events related to interruption of the anticoagulant. A total of 96 patients (46 males and 50 females; median age 75years [range, 24-91years]) were enrolled. Overall, the patient numbers of very early (< 24h), early (24-48h), and late resumption (> 48h) of anticoagulant after EST were 56, 23, and 17, respectively. The baseline characteristics were similar between groups except resumption time of anticoagulant. There was no significant difference in the rate of post-EST delayed bleeding (5% in very early group vs. 9% in early group vs. 0 in late group, p = 0.47). The rate of thromboembolic adverse events was significantly higher in the late resumption of anticoagulant group (0 vs. 0 vs. 24%, p < 0.001). There was no significant difference in the incidence of post-EST delayed bleeding according to the resuming time of anticoagulant. Since long cessation of anticoagulant could increase the risk of thrombotic adverse events, the early resumption of anticoagulant seems to be preferred.

Endoscopic biliary sphincterotomy in patients under antithromboembolic therapy.

Background Endoscopic sphincterotomy (EST) carries several risks (e. g., pancreatitis and bleeding). The risk of bleeding is increased in patients with a compromised coagulation system, often due to antithromboembolic therapy. Recent guidelines caution to perform endoscopic procedures that carry a high risk of bleeding in these patients. However, data to support current recommendations are scarce, and EST frequently has to be performed as an emergency procedure. Therefore, it was the aim of our retrospective study to evaluate the rate of procedural bleeding in patients undergoing EST in our endoscopy unit while on antithromboembolic therapy. Methods Between March 2005 and August 2015, 1798 consecutive patients underwent EST at HELIOS Hospital in Pforzheim, Germany. Concomitant therapy with anticoagulants and/or antiplatelet agents was noted, and bleeding following sphincterotomy was recorded. Results We observed 54 bleeding events in 1482 patients (3.6 %) without and 20 events in 316 patients (6.3 %) with antithromboembolic therapy. Bleeding was recorded in 7 out of 123 patients (5.7 %) taking aspirin, in one out of 34 patients (2.9 %) taking clopidogrel, and in 12 out of 209 patients under heparin (5.7 %). Compared to controls, no statistically significant increase in the bleeding rate was seen. However, we observed an association between a lower physical health score and increased bleeding rate. If precut was necessary for biliary tract access, the bleeding rate increased significantly (p < 0.01). Conclusion Bleeding following EST is neither increased in patients taking clopidogrel and/or aspirin or heparin and rarely requires transfusion of packed red blood cells nor does it lead to an increased mortality. However, bleeding following EST seems to occur more frequently in patients with a compromised health status or following precut of the papilla.

Long-term consequences of young patients undergoing endoscopic sphincterotomy: a cohort study

BackgroundAn estimated 15% of the UK population has gallstones. Gallstones in the biliary tree can result in complications such as cholangitis and pancreatitis, which have high morbidity and mortality rates. To prevent such complications, patients can undergo endoscopic sphincterotomy. In our centre, an initial study was undertaken in 2002 to examine outcomes of endoscopic sphincterotomy in patients under the age of 50 years. The aim of our current project was to examine the long-term outcomes until Nov 30, 2015. MethodsData from the study in 2002 were used to identify patients who had undergone endoscopic sphincterotomy between 1984 and 1992. The case notes for these patients were examined to identify outpatient hepatobiliary appointments, serial liver function tests, further investigations or procedures, and development of upper gastrointestinal malignancy or death. Data available included letters and scan reports. In the case of patient death, patients' general practitoners and the coroner's office were contacted. Findings42 patients (32 women [76%]) had undergone endoscopic sphincterotomy between 1984 and 1992. At data collection in November, 2015, mean age was 55 years (SD 6·49), and mean follow-up since endoscopic sphincterotomy was 25 years (SD 2·40). Eight patients (19%) had died, two during the 2002 study, and six between 2002 and 2016. Two deaths were due to pancreatic adenocarcinoma at 8 months and 19 years after endoscopic sphincterotomy. One patient died from hepatocellular carcinoma; no other deaths were due to hepatobiliary or pancreatic disease or malignancy. Ten patients had no follow-up scans, imaging, or outpatient appointments. Of the 32 patients who had follow-up or investigations, two required further endoscopic sphincterotomy for recurrent stone disease at 22 and 25 years after their initial endoscopic sphincterotomy. Three patients had abnormal liver function tests but had no further investigations; three patients underwent further imaging but had no further interventions. InterpretationTo our knowledge this is the first cohort study with such lengthy follow-up after endoscopic sphincterotomy. Our results suggest that endoscopic sphincterotomy is generally a safe and effective long-term treatment option that is not associated with major levels of recurrent disease or malignancy. This was a small single-centre cohort study and future population based studies should be conducted to better evaluate these findings in a larger cohort of patients. FundingNone.

PWE-250 Clinical usefulness and safety of performing manometric guided sphincterotomy in patients with suspected type ii sphincter of oddi dysfunction: Abstract PWE-250 Table 1

Introduction Persistent biliary pain following cholecystectomy can be a challenging symptom to manage and the role of sphinterotomy has been questioned. Manometry during ERCP has been available in our unit since 2013 for patients with suspected type II sphincter of Oddi dysfunction (SOD). The aim of this study was to assess the response to sphincterotomy following manometric confirmation of a hypertensive sphincter and to assess the safety of this procedure. Method Patients fulfilling criteria for type II SOD underwent ERCP and manometry with the Cook long nose catheter. Pressure was zeroed in the duodenum prior to insertion into the common bile duct and a minimum of 2 pull-throughs performed. A persistent trough pressure ≥40 mmHg was considered hypertensive and an indication to perform sphincterotomy. All patients had rectal Diclofenac and an attempt at insertion of a prophylactic stent. Primary outcomes were reduction in abdominal pain and post-procedural complication rate. Coexistent anxiety, depression and functional disorders were also noted. Results 20 patients (mean age 42yrs and 18 females) were included (shown in Table 1). 4/20 did not receive a stent due to concomitant pancreas divisum (PD) and there were no complications during the procedure. 4/20 had acute pancreatitis post ERCP (3 mild, 1 moderate). Patients were followed-up at a mean of 10.9 weeks with the majority of patients finding benefit post sphincterotomy. 3/9 responders v 2/4 non-responders had a history of anxiety/depression and 6/10 responders v 2/4 non-responders had other functional disorders. 6 patients are awaiting follow-up. Conclusion Manometry is helpful in predicting response to sphincterotomy in patients with type II SOD with 71% having significantly improved or abolished pain at early follow up. Pancreatitis occurred in 20%, consistent with previous reports in the literature of up to 24%. 1 There was a higher proportion of anxiety/depression in non-responders but no difference in the proportion with functional disorders between groups. However, study numbers are too small to assess these parameters accurately. Disclosure of interest None Declared. Reference Toouli et al . Functional Gallbladder and Sphincter of Oddi Disorders. Gastroenterology 2006;130:1498–1509

A meta-analysis of preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones

To compare the safety and efficiency of preoperative endoscopic sphincterotomy (POES) versus intraoperative endoscopic sphincterotomy (IOES) in patients with gallbladder and common bile duct stones. Multiple electronic databases were searched for prospective, randomized, controlled trials on the safety and effectiveness of POES versus IOES. And the outcome parameters of clearance rate, post-procedural complications and hospital stay were analyzed. Five trials with 631 patients (POES, n=318; IOES, n=313) were analyzed. Although the overall rates of common bile duct stone clearance were similar between POES and IOES (RR 0.96, 95% CI: 0.91-1.01; P=0.13), the failure rate of CBD cannulation was significantly higher for IOES (RR 2.54, 95% CI: 1.23-5.26; P=0.01) during endoscopic retrograde cholangiopancreatography (ERCP). The pooled RR after POES for overall complication rates was similar to that for IOES (RR 1.56, 95% CI: 0.94-2.59; P=0.09). However, as compared with IOES, the RR risk of ERCP-related complications was significantly higher for POES (RR 2.27, 95% CI: 1.18-4.40, P=0.01). No significant inter-group differences existed in morbidity after laparoscopic cholecystectomy or subsequent conversion into open surgery. In subgroup analyses, the rates of hemorrhage, perforation, cholangitis, cholecystitis, and gastric ulceration showed no significant inter-group differences. With regards to stone clearance and overall complication rate, POES is comparable to IOES in patients with gallbladder and common bile duct stones. However, IOES has a lowered incidence of ERCP-related pancreatitis and a shorter hospital stay.

Su1624 Early Precut Sphincterotomy for Patients With Difficult Biliary Access: a Meta-Analysis of Randomized Controlled Trials.

Su1624 Early Precut Sphincterotomy for Patients With Difficult Biliary Access: a Meta-Analysis of Randomized Controlled Trials.

Is there a safer electrosurgical current for endoscopic sphincterotomy in patients with liver cirrhosis?

Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients. The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1). Group 1 included 15 patients (six women, nine men, mean age: 62.2±12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6±16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p=0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis. Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.