Abstracts

S1531

Endoscopic Bilateral Metal Stent Placement with a Y-Configured

Stent for Advanced Hilar CholangiocarcinomaJae Sup Eum, Dae Hwan Kang, Chan Ho Park, Kyung Yeob Kim,Tae in Ha, Cheol Woong Choi, Hyoung Yoel Park, Il Doo Kim,Gwang Ha Kim, Jeong Heo, Geun-Am Song, Mong ChoBackground/Aims: Palliative endoscopic or percutaneous internal drainage iswidely used for treating hilar cholangiocarcinoma. Yet unilateral biliary drainagedoes not completely improve jaundice and it can induce cholangitis by theundrained bile or contrast media. We evaluated the technical feasibility andclinical efficacy of a newly designed Y-configured stent for palliation of advancedhilar cholangiocarcinoma. Methods: From May 2005 to August 2007, thirtypatients with hilar cholangiocarcinoma (men:women Z 11:19, age Z 71.5 yr)that were not suitable for surgical resection were included in this study. Forbilateral metal stent placement, a biliary stent with a wide open central mesh (Ystent) was first inserted. After this, another stent without a hole was insertedinto the contralateral hepatic duct through the open central mesh of the firststent. Results: Bilateral metal stent insertion was done in 24 of 30 patients.Among the 24 patients in whom bilateral stents were successfully placed, therate of functional success was 100%. There were no early complications. Asa late complication, stent occlusion occurred in 6 of 24 patients (25%), and twoof these patients had a plastic stent inserted. The other 4 patients were treatedwith percutaneous transhepatic biliary drainage. The median stent patencyperiod was 188 days. Conclusion: The bilateral metal stent method using the Ystent is safe and effective for bilateral biliary drainage in patients with advancedhilar cholangiocarcinoma. Key words: Hilar cholangiocarcinoma, Biliary stent,Endoscopic retrograde biliary drainage

S1532

Endoscopic Management of Biliary Tract Complications

in the Liver Transplant PatientVictor Torres, Glenn W. Gross, Sandeep PatelBackground: Biliary tract complications (BTC) are a significant source of morbidityafter orthotopic liver transplantation (OLT) and fall into four main categories: (a)strictures, (b) leaks, (c) stones and (d) sphincter of Oddi dysfunction (SOD). This isthe largest study to our knowledge evaluating the efficacy of endoscopic treatmentof BTC in the post liver transplantation patient. Methods: A total of 996 charts ofpatients who underwent OLT from 1992 to 2006 were reviewed retrospectively.Patients with a T-tube or a choledochojejunostomy were excluded. BTC wereclassified as stones, suspected SOD, leaks and strictures based on endoscopicretrograde cholangiopancreatography (ERCP) findings. Leaks and strictures werefurther classified as anastomotic (AS) or non-anastomotic (NAS) and as early (%3month post OLT) or late (O3 month post OLT). 365 ERCPs were performed in 223patients. ERCP modalities included: sphincterotomy, balloon dilation and single vsmultiple stent use. Successful response to endoscopic therapy was defined aspatients with: (1) liver profile normalization, (2) resolution of cholangiographicabnormalities, and (3) no further need for intervention. Results: Of the 223 patientspresenting for ERCP, 189 patients were found to have a BTC (Incidence 21.0%, PPV84.8%). Stones and suspected SOD were found on 10 (5.3%) and 6 (3.2%) patientsrespectively with all responding to one endoscopic intervention. Biliary leaks werefound in 36 (19%) patients, of which 23 (63.9%) were AS and 13 (36.1%) were NAS.Endoscopic intervention was performed on 33/36 patients. Overall response toendoscopic therapy in this group was found to be 69.7 %, 80% in AS vs 53.8% inNAS (P Z 0.110). The median intervention required for both AS leaks and NASleaks was 1.0. Leaks found after 3 months of OLT tended to be NAS (p Z 0.012).137 (72.5%) patients were found to have strictures (118 AS, 5 NAS, and 14 both).120/137 of these patients underwent endoscopic intervention. Overall response toendoscopic therapy in this group was found to be 82.5 %, 86.8% in AS vs 50% inNAS (P!0.001). Median interventions required for AS strictures were 1.0 vs 4.5 forNAS strictues (p ! 0.001). As with leaks, NAS strictures tended to present later thanAS strictures (p Z 0.029). Conclusion: ERCP offers multiple therapeutics optionsfor the management of BTC. Based on our large retrospective review, ERCP iseffective in the diagnosis and management of BTC after OLT, and should beconsidered as a first line of therapy.

S1533

Jackson Pratt Drain Fluid to Serum Bilirubin Concentration

Ratio for the Diagnosis of Bile LeaksPeter E. Darwin, Eric M. Goldberg, Lance T. UradomoBackground: Jackson Pratt (JP) fluid bilirubin levels are often assayed in theevaluation of possible bile leaks. While fluid color and bilirubin level may promptadditional evaluation, there are no reference data available. Objective: To assess theJP drain fluid to serum bilirubin ratio in patients with documented bile leaks.Design: Prospective case series Setting: Tertiary referral center Methods: Patientsreferred for ERCP for the management of documented bile leaks with a JP drainin place were included. Demographic data, bile leak etiology and serum bilirubin

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levels were recorded. JP fluid was sent for color evaluation and bilirubinconcentration. Control subjects included both post-operative patients with non-biliary surgery and a JP drain in place and medical patients with ascitesundergoing paracentesis. Results: JP drain to serum bilirubin concentration andfluid color evaluation were performed on 23 patients with documented bileleaks by ERCP and compared to 16 surgical and 10 medical controls. The JPdrain/ascites to serum bilirubin ratio was significantly higher in those with bileleaks (mean ratio 45.6) compared to combined controls (mean ratio 0.9; p-valueof the difference between groups !0.0001). Utilization of a cutoff JP drain toserum bilirubin ratio of 5 would be 100% sensitive and specific for theprediction of a bile leak. There was overlap in fluid color evaluation betweenthe groups. Limitations: Controls did not include those with suspected bile leaksand negative HIDA or ERCP. Conclusions: JP drain fluid to serum bilirubinconcentration ratio greater than 5 appears to be highly sensitive and specific fordetection of a bile leak. In combination with fluid volume output, this ratiocould be utilized to select patients to proceed directly to ERCP.

S1534

A Comparative Study of Outcomes Between Endoscopic

Papillary Large Balloon Dilatation (EPLBD) and Endoscopic

Mechanical Lithotripsy (EML) in Patients with Difficult CBD

StonesDongyoub Cha, Byungmoo YooBackground/Aims : A new procedure, endoscopic papillary large balloon dilatation(EPLBD) with a large-diameter balloon after EST has been recently introduced assubstitute to the role of conventional endoscopic mechanical lithotripsy (EML)in removing difficult extra hepatic duct stones. The aim of this study was toevaluate the clinical outcomes of Endoscopic Papillary Large Balloon Dilatation(EPLBD) in patients with difficult extrahepatic bile duct stones, in comparison toconventional EML. Method : In 109 patients whose stones were difficult to beremoved using a standard basket/balloon technique, were successfully removedby EML, 84.6% (33/39) and EPBLD 74.3%(52/70). If stone removal failed by usingEPLBD alone, additional EML was performed, then 88.9% (16/18) successfullymanaged with EML. We reviewed in 101 patients with successfully removeddifficult extra hepatic duct stones. In the EPLBD group, the ampulla was dilatedwith a 12- to 20-mm diameter balloon for pyloric use (CRETM wire-guidedballoon dilator, Boston Scientific, U.S.A) after EST. After ballooning for about 1min, stone removal was attempted with a standard basket/balloon technique. Ifstone removal failed using EPLBD, EML was then performed. Result: 1) In 101patients with successfully removed extra hepatic duct stones, EML wasperformed in 33 patients (mean age: 64.4 years, M:F Z 14:19), EPLBD after ESTwas performed in 68 patients (mean age: 70.0 years, M:F Z 27:41). 2) The meandiatmeter of stones were 15.9 � 3.9mm (range, 9w24mm) in the EML groupand 17.0 � 4.8mm (range, 10w34mm) in the EPLBD group (p Z 0.225). 3) Themean number of stones were 2.3 � 1.6 (range, 1w6) in the EML group and 2.5� 1.5 (range,1w6) in the EPLBD group (p Z 0.676). 4) The mean duration ofprocedure was 35.0 � 22.0 min (range 14w104 min) in the EML group and 28.8� 14.9min (range 5w73min) (p Z 0.097). 5) The mean sessions of EML were1.3 � 0.7 sessions (range 1w5 session) in the EML group, in 16 failed patientsby EPLBD, the mean sessions of EML was 1.2 � 0.4 session (range 1w2sessions) (p Z 0.807). Conclusion: The mean duration of procedure and themean sessions of EML had no significant difference between both groups.Prospective and multi-center based studies are needed to investigate the clinicaloutcome between both groups.

S1535

SHORT (SHOrt Rendezvous Technique): A New ERCP

Rendezvous TechniqueJuan C. Ayala, Ricardo Labbe, Juan E. VeraIntroduction: Most complications in Endoscopic RetrogradeCholangiopancreatography present during cannulation of the desired duct. Whenendoscopic technique fails, a percutaneous approach is the next option. TheRendezvous Technique is a fluoroscopic and endoscopic maneuver in which thereis a "meeting" at the papilla between a wire guide that enters througha percutaneous tract and the duodenoscope that it is placed in front the papilla.During this encounter, when the wire guide exits through the papilla, it is caughtwith a snare and is withdrawn through the accessory channel of the duodenoscope.Then the papillotome can be slid over-the-wire to gain access into the CommonBile Duct (CBD) and avoid complications. Many changes to the original techniquehave been described and also many advances have been made to reducecomplications and to improve success rates, with various degrees of complexity intheir implementation. Objectives: To introduce a new Rendezvous Technique,which is shorter and faster compared to existing techniques and with a similar rateof success. Materials and Methods: In 14 patients with percutaneous access to theCBD, we performed SHORT using a Loop Tip Wire Guide (LTWG) (Cook Medical,Winston-Salem, NC, USA), which has a closed loop at the tip. The LTWG is advanced

lume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB159

Abstracts

into the duodenum through the percutaneous tract. When the LTWG exits throughthe papilla, a papillotome with a regular wire guide is waiting for the closed loop atthe distal end of the LTWG. The regular wire guide is then placed through theclosed loop. The LTWG is then pulled back, bringing the regular wire guide into theCBD. The papillotome can then be slid over the regular wire guide to achieve deepcannulation. Results: The SHORT rendezvous technique was successful in 14/14patients (100%), with no complications and with a handling time of less than 60seconds per case. No additional operator was needed to perform this maneuver.Conclusion: The Short Rendezvous Technique is fast and effective. Compared topreviously described RT techniques, it requires less fluoroscopic and endoscopictime, fewer steps, less staff, and less manipulation of the papilla and CBD. It is theshortest and fastest Endoscopic Retrograde CholangiopancreatographyRendezvous technique thus far presented in the literature.

S1536

Efficacy of the Endoscopic Therapy of Biliary Fistulas Secondary

to Complex Liver ResectionsAnne Bourrier, Ariane Chryssostalis, Marianne Gaudric,Stanislas Chaussade, FreDeRic PratThe role and efficacy of endoscopy for the treatment of biliary fistulas of thecommon bile duct are well documented. On the contrary, results of endoscopicprocedures for fistulas arising from peripheral bile ducts after liver resections arepoorly studied, although more complex hepatectomies are increasingly performed, incase of oncologic surgery. We analyzed retrospectively the results of these proceduresin order to identify their specific features. Seventeen patients (men: 9) aged from 10to 74 years were included. Seven patients had a right hepatectomy, 1 a lefthepatectomy, 1 a single segmentectomy, 6 had more than a single segmentectomy,and 2 had a bi partition liver transplantation (cystic fibrosis and hepato cell carcinomapost C viral hepatitis) . The liver diseases were primitive liver tumor in 7 patients,hepatic location of a metastatic cancer in 8 patients (colorectal carcinoma, n Z 4,pharyngeal squamous cell carcinoma, n Z 1, corticosurrenaloma, n Z 2, breastcancer, n Z 1), liver abscess in 1 patient, and cirrhosis in 1 patient. Bile outflow beforeendoscopy was measured at 300 to 2000ml/24h (median 400). A biloma was presenton CT-scan in 15/17 patients (88%). Percutaneous drainage of the bilioma failed in allcases. Endoscopy Retrograde Cholangio Pancreatography was performed aftera median time of 15 days after the diagnosis of fistula (range 10–488 days). Asphincterotomy was requiered in 94% of the patients. An 8.5 to 10F polyethylene stentbypassing the leaking bile duct was implanted in 13/17 patients (76%). 2 naso biliarydrips, and 2 internal-external naso biliary drips were added to the procedure to accessa good drainage. In one patient, application of histoacryl� glue in the leaking ductswas needed.The treatment of fistulas required 1 to 3 ERCP (median 2 ERCP perpatient). No procedure-related complications was observed. Fistulas were dried upcompletely in 13/17 patients (76%). Among the 4 failures, 3 were observed in patientswith intra hepatic tumors. The time from initial ERCP to running dry of the leaks was 6to 201 days (median 21 days, mean 48 days). Biliary fistulas arising from intra-hepaticducts after complex liver resections are more difficult to treat than distal fistulasarising from the common bile duct, in part as a consequence of the associated sepsis.Failure of the drying up was mostly observed in patients with intra hepatictumors.Therapeutics options are largers than before (NBD, IENBD, Prothesis,Embolization) However, despite a longer time for cure and the need for repeatedERCP, endoscopic therapy appears efficient and does not induce additional morbidity.

S1537

Single-Operator Cholangioscopy Enhances Diagnostic

and Therapeutic Applications of Endoscopic Retrograde

CholangiopancreatographyUdayakumar Navaneethan, Joseph B. Palascak, Mayar Al Mohajer,Shailendra S. Chauhan, Andres GelrudBackground: Peroral cholangioscopy is useful for direct visualization of bile ducts,tissue sampling and therapeutic applications. The Spyglass single-operator biliaryvisualization system (Boston Scientific, MA) consists of an optical probe ina disposable access and delivery catheter with a 1.2 mm accessory channel plusdedicated irrigation channels. The aim of the study was to evaluate the efficacy andpracticality of this single operator cholangioscope for diagnosis and therapy ofbiliary disorders as compared to conventional ERCP. Methods: Our endoscopicdatabase was utilized to identify patients who underwent cholangioscopy betweenNovember 2006 and November 2007. Retrospective chart review was performed todetermine patient demographics, medical history, procedural success, clinicaloutcomes and procedure related complications. A procedure was consideredsuccessful if diagnostic and / or therapeutic objectives were achieved. Results: Atotal of 19 cholangioscopic examinations were performed after conventional ERCPin 17 patients (10 men and 7 women; mean age 55.2 þ 5.7 years). Indications forthe procedures included previously failed treatment for large biliary stones (N Z 9,47.4%) and indeterminate biliary stricture (N Z 10, 52.6%); one patient had bothstones and stricture. One patient underwent removal of a migrated intraductalmetal coil (previously placed to embolize a hepatic artery aneurysm). The overallprocedural success rate was 94.7 %. Cholangioscopic stone removal withelectrohydraulic lithotripsy (EHL) was successful in 8 of 9 procedures (88.9%); oneof the successful procedures required a combination of EHL and mechanical

AB160 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008

lithotripsy. One patient failed mechanical lithotripsy and EHL and required surgicalreferral. All biopsy specimens obtained during 10 procedures were adequate forpathological evaluation. Pathology was positive for malignancy in one patient andnegative in nine. Cholangioscopy altered patient management as compared to theinitial ERCP in 8 procedures (42.1%). EHL allowed successful stone extraction in 7patients who failed conventional ERCP therapy. One patient with indeterminatestricture by conventional ERCP was found to have cholangiocarcinoma. Only oneprocedure related complication occurred (Aspiration) with uneventful recovery.Conclusion: In our series, single operator cholangioscopy provided a safe means ofexpanding diagnostic and therapeutic biliary applications as compared toconventional ERCP. Our early experience is similar to recent publications by othertherapeutic endoscopists using this innovative technology.

S1538

Gallbladder Carinoma Associated with Pancreatobiliary Reflux:

A Hint for Early Diagnosis of Gallbladder CarcinomaJin Kan Sai, Masafumi Suyama, Yoshihiro Kubokawa, Yuji Matsumura,Kei Kato, Masayasu Chikamori, Koichi Inami, Kei Anno, Jitsuko Maruki,Sumio WatanabeBackground: Pancreatobiliary reflux can occur in patients with and withoutpancreaticobiliary maljunction (PBM), and it may be associated with gallbladdercarcinoma. One of the imaging findings that suggest mucosal changes accompaniedby pancreatobiliary reflux is diffuse thickening of the hypoechoic inner layer of thegallbladder wall on abdominal ultrasonography that might reflect cellularproliferation of the gallbladder epithelium. The aim of the present study was todetect the patients with gallbladder carcinoma associated with pancreatobiliaryreflux at an early stage by examining ultrasonography and bile sampling. Methods:From March 1995 to September 2007, among 186 patients, who had diffusethickness (O 3mm) of the inner layer of the gallbladder wall and were suspected ofhaving PBM on ultrasonography in our outpatient clinic, 95 patients were subjectedto endoscopic retrograde cholangiopancreatography and bile in the common bileduct was sampled. Among them, patients, who had extremely high biliary amylaselevels (O 10,000 IU/L), underwent cholecystectomy, and the clinicopathologicalfindings of those patients were examined. Results: Fifty-two patients had biliaryamylase levels in the common bile duct above 10,000 IU/L, including 32 with PBMand 20 without PBM. The occurrence of gallbladder carcinoma and that limitedwithin the mucosa was 31% (10/32), 13% (4/32) in patients with PBM, and 40% (8/20), 15% (3/20) in those without PBM. The occurrence of mucosal hyperplasia anddysplasia was 81% (26/32), 53% (17/32) in patients with PBM, and 85% (17/20), 65%(13/21) in those without PBM. Conclusion: Earlier detection of the diffusethickening of the hypoechoic inner layer of the gallbladder wall associated withpancreatobiliary reflux could lead to earlier management of gallbladder carcinoma,and might improve the poor prognosis of this tumor.

S1539

Spyglass: Comparison of a New Choledochoscope to Other

Established Choledochoscope in Biliary Tract DiseaseIsaac Raijman, Douglas S. FishmanIntroduction: Choledochoscopy is an integral part of the evaluation and therapy inbiliary tract disease. Available choledochoscopes can be difficult to maneuver andhave limitations. We evaluated Spyglass, a new single operator choledochoscopeand directly compared it to an established choledochoscope (FCP-9P, Pentax, USA)with which we have ample experience with. Patients and Methods: We evaluated 5pts with various bile duct diseases and directly compared the Spyglass vs FCP-9P.Spyglass is a single operator device with separate water irrigation and therapeuticchannels. There were 4 women, median age 67 years. Indications included largecholedocholithiasis in 3, choledocholithiasis with bile duct stricture in 1 and biliarystricture in 1 . All pts underwent peroral choledochoscopy through the therapeutic4.6 mm channel Pentax duodenoscope. All pts underwent a biliary sphincterotomy,were done under propofol, all performed on an outpatient basis and all receivedantibiotics. Spyglass was performed by a single operator while FCP-9P wasperformed by 2 physicians. Both methods were performed during the samesession. Factors evaluated included ease in setting up, ease of advancementthrough the scope, time to complete the choledochoscopic procedure, visualclarity, intraductal cannulation and maneuverability, irrigation and ability to providetherapy. Results: Both FCP-9P and Spyglass were successfully performed in all pts.There was no difference in ease of set up, in ease of advancement through thescope, in ductal cannulation or in time to perform and complete the procedure.Advancement of lithotripsy probes (EHL) was possible in all FCP-9P while it was notpossible in one Spyglass case. Ductal irrigation was superior with Spyglass.Intraductal maneuverability was equal when performed without a guidewire. Visualclarity was superior with FCP-9P. The intended outcome was possible in 4/5 withSpyglass and 5/5 with FCP-9P. Conclusions: Spyglass is a first generation, singleoperator miniature endoscope that is effective in the evaluation and treatment ofvarious biliary tract diseases. Compared to the existing FCP-9P, its major advantageis that is single operator and has an independent irrigation channel. Futurerefinement of the Spyglass scope is needed.

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