Treatment Of Dominant Strictures Research Articles

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting Udayakumar Navaneethan, Ramprasad Jegadeesan*, Jeffrey Hammel, Madhusudhan R. Sanaka, John J. Vargo, Mansour A. Parsi Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; Cleveland2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Dominant biliary strictures occur commonly in patients with primary sclerosing cholangitis (PSC). The optimal endoscopic management of dominant strictures remains unclear and the comparative risk of adverse events associated with balloon dilation alone versus balloon dilation and short term stenting remains unknown. Aim: Our aim was to compare the rate of adverse events associated with balloon dilation alone versus balloon dilation followed by short term stenting (! 7 days) in PSC patients with dominant strictures. Methods: In this retrospective study, 298 patients with PSC were evaluated. Among these, patients who had undergone biliary balloon dilation and/or short term stent placement (! 7 days) for endoscopic treatment of dominant strictures were identified. Adverse events associated with endoscopic biliary balloon dilatation with and without short term stenting for management of dominant strictures were determined. Results: A total of 72 PSC patients (median age 52.6 years; interquartile range 42.5-64) with dominant strictures were identified. Fifteen patients (20.8%) were treated with endoscopic balloon dilation alone and 57 patients (79.2%) were treated with balloon dilation and stent placement. Both groups had comparable baseline characteristics such as age, symptoms, bilirubin levels and severity of PSC as determined by the Mayo PSC risk score. The median duration of follow-up after intervention was similar in both groups (49 months). The overall risk of adverse events with endoscopic retrograde cholangiopancreatography (ERCP) was 15.3% (nZ11). Six patients developed cholangitis which was the most common adverse event. None of the patients in the balloon dilation alone group developed adverse events in contrast to 19.3% of patients (nZ11) who had undergone balloon dilation and short term stenting. (p! 0.01) On multivariate analysis, only stent placement increased the risk of adverse event development. (Hazard ratio 1.86; 95% confidence interval [1.3-2.2], pZ0.02). Conclusions: In this study, even short term stenting after balloon dilation appeared to increase the overall risk of adverse events associated with treatment of dominant strictures in PSC patients. Randomized controlled trials are required to clarify the appropriate management of dominant strictures in PSC patients.

Su1649 Algorithmic Approach Including Bile Aspiration to Decrease ERCP Associated Adverse Events in Primary Sclerosing Cholangitis

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting Udayakumar Navaneethan, Ramprasad Jegadeesan*, Jeffrey Hammel, Madhusudhan R. Sanaka, John J. Vargo, Mansour A. Parsi Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; Cleveland2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Dominant biliary strictures occur commonly in patients with primary sclerosing cholangitis (PSC). The optimal endoscopic management of dominant strictures remains unclear and the comparative risk of adverse events associated with balloon dilation alone versus balloon dilation and short term stenting remains unknown. Aim: Our aim was to compare the rate of adverse events associated with balloon dilation alone versus balloon dilation followed by short term stenting (! 7 days) in PSC patients with dominant strictures. Methods: In this retrospective study, 298 patients with PSC were evaluated. Among these, patients who had undergone biliary balloon dilation and/or short term stent placement (! 7 days) for endoscopic treatment of dominant strictures were identified. Adverse events associated with endoscopic biliary balloon dilatation with and without short term stenting for management of dominant strictures were determined. Results: A total of 72 PSC patients (median age 52.6 years; interquartile range 42.5-64) with dominant strictures were identified. Fifteen patients (20.8%) were treated with endoscopic balloon dilation alone and 57 patients (79.2%) were treated with balloon dilation and stent placement. Both groups had comparable baseline characteristics such as age, symptoms, bilirubin levels and severity of PSC as determined by the Mayo PSC risk score. The median duration of follow-up after intervention was similar in both groups (49 months). The overall risk of adverse events with endoscopic retrograde cholangiopancreatography (ERCP) was 15.3% (nZ11). Six patients developed cholangitis which was the most common adverse event. None of the patients in the balloon dilation alone group developed adverse events in contrast to 19.3% of patients (nZ11) who had undergone balloon dilation and short term stenting. (p! 0.01) On multivariate analysis, only stent placement increased the risk of adverse event development. (Hazard ratio 1.86; 95% confidence interval [1.3-2.2], pZ0.02). Conclusions: In this study, even short term stenting after balloon dilation appeared to increase the overall risk of adverse events associated with treatment of dominant strictures in PSC patients. Randomized controlled trials are required to clarify the appropriate management of dominant strictures in PSC patients.

ERCP-related adverse events in patients with primary sclerosing cholangitis

ERCP is frequently used in patients with primary sclerosing cholangitis (PSC) for cancer surveillance and treatment of dominant strictures. To evaluate the prevalence and risk factors for ERCP-related adverse events in patients with PSC. Retrospective analysis of ERCPs performed from 1998 to 2012. Referral center. A total of 294 consecutive patients with PSC who underwent a total of 657 ERCPs. ERCP. ERCP-related adverse events and predictive factors were determined by univariate and multivariate analyses. ERCP use in patients with PSC showed a significant increase during the second half of the study period (2006-2012) compared with the first half (1998-2005) (437 vs 220 procedures; P = .04). Primary cannulation was successful in 634 procedures (96.6%) or in 271 of 294 patients (92.2%). Access to the bile duct was achieved with a needle-knife in 19 procedures (2.9%), whereas ERCP was unsuccessful in 4 of 657 procedures (0.6%), and successful percutaneous drainage was performed. Post-ERCP pancreatitis (PEP) was diagnosed in 8 (1.2%), cholangitis in 16 (2.4%), and bleeding in 4 (0.7%) procedures. Overall, risk of any adverse event was 28 of 657 (4.3%) procedures. On multivariate analysis, performing biliary sphincterotomy (odds ratio [OR] 5.04; 95% confidence interval [CI], 2.01-12.60; P = .001) and passage of a guidewire into the pancreatic duct (OR 4.54; 95% CI, 1.44-14.30; P = .010) were independently associated with an increased risk of any adverse event. Retrospective study. Cholangitis appears to be the most common adverse event despite intraprocedural antibiotic use. There was a low risk of adverse events in patients with PSC undergoing ERCP.

Treatment of Dominant Strictures in PSC: Balloon Dilation, Stent, or Both?

Significant clinical, laboratory, and radiographic improvements have been reported after endoscopic and percutaneous treatment of dominant biliary

Balloon dilation compared to stenting of dominant strictures in primary sclerosing cholangitis

OBJECTIVE: In some patients with primary sclerosing cholangitis (PSC), a localized, high-grade (dominant) stricture may be the principal cause of symptoms and hyperbilirubinemia. The aim of this retrospective study was to compare the beneficial effects and risk of balloon dilation alone versus dilation followed by stenting in PSC patients with dominant strictures. METHODS: Charts from a group of 1009 patients with PSC seen over 10 yr were reviewed to identify those patients who had undergone endoscopic or percutaneous therapeutic intervention. Procedural and clinical data were recorded. RESULTS: A total of 71 PSC patients, median age of 49 yr (range 18–78 yr) were identified. Thirty-four patients were treated with endoscopic balloon dilation alone, and 37 patients were treated with balloon dilation plus stent placement. Stents were placed percutaneously (n = 19), endoscopically (n = 14), or using both interventions (n = 4). Both groups were comparable at baseline with regards to age, symptoms, and bilirubin level. The median duration of follow-up after intervention was similar in both groups. The number of intervention-related complications (30 vs 6, p = 0.001) as well as the incidence of acute cholangitis ( p = 0.004) were more common in the stent group compared to the balloon dilation group. There were more complications related to percutaneous stent placement than endoscopic placement (23 vs 7, p = 0.001). There was no significant difference between the two groups with regards to improving cholestasis. CONCLUSIONS: There was no additional obvious benefit from stenting after balloon dilation in the treatment of dominant strictures in PSC patients. Stenting was associated with more complications, and its role after dilation should be assessed in a randomized trial rather than being accepted as routinely indicated in this setting.