Carlos A. Macías Gomez

Prophylaxis of post-ERCP pancreatitis: a practice survey

BACKGROUND Prophylactic pancreatic stenting is widely used by expert biliary endoscopists to prevent post-ERCP pancreatitis (PEP); nonsteroidal anti-inflammatory drugs (NSAIDs) are thought to prevent PEP. OBJECTIVE To assess the use of pancreatic stenting and NSAIDs for PEP prophylaxis among endoscopists and its determinants. DESIGN A survey was distributed to 467 endoscopists attending a course on therapeutic digestive endoscopy. INTERVENTION Completed surveys were collected from 141 endoscopists performing ERCP in 29 countries (answer rate 30.2%); practices were most often located in community hospitals with an annual hospital volume of < or = 500 ERCPs (in Belgium, Spain, Italy, and France in about half of cases). For all conditions listed, including needle-knife precut, previous PEP, suspected sphincter of Oddi dysfunction, and ampullectomy, less than half of the endoscopists reported attempting prophylactic pancreatic stenting in > or = 75% of cases. Thirty (21.3%) survey respondents did not perform prophylactic pancreatic stenting in any circumstance; this was mainly ascribed to lack of experience. Measurement of PEP incidence and an annual hospital volume of > 500 ERCPs were independently associated with the use of prophylactic pancreatic stenting (P = .005 and P = .030, respectively). Most survey respondents (n = 118, 83.7%) did not use NSAIDs for PEP prophylaxis. This was mainly ascribed to lack of scientific evidence of its benefits. MAIN OUTCOME MEASUREMENTS Proportion of cases in which pancreatic stenting is attempted during ERCP; reasons for not using prophylactic pancreatic stenting or NSAIDs. LIMITATIONS Survey, not an audit of practice. CONCLUSIONS Despite scientific evidence of its benefits, use of prophylactic pancreatic stenting is not as widely adopted as previously thought; use of NSAIDs for PEP prophylaxis is marginal.

Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation.

Background. Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting. Methods. We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively. Results. Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS). Conclusions. Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.

Grasp or brush for biliary sampling at endoscopic retrograde cholangiography? A blinded randomized controlled trial.

OBJECTIVES Brushing, the standard sampling method at endoscopic retrograde cholangiography (ERC), lacks sensitivity for cancer detection. We assessed a novel sampling method using a grasping basket.METHODS Fifty-six patients with a suspected malignant biliary stricture were randomized to biliary sampling at ERC using a basket (basket group, N = 30) or a brush (brush group, N = 26), followed by the alternate device. When deemed necessary, strictures were dilated (using 6-mm balloons exclusively). The primary end point was sensitivity for cancer detection at cytopathological examination of the first sample collected in each patient; the cytopathologist was blinded to clinical details and sampling method. All analyses followed an intention-to-treat principle.RESULTS All 56 patients had successful sampling with both techniques; 50 (89%) had a final diagnosis of malignant stricture. Sensitivity for cancer detection with the first sample collected in each patient was significantly higher in the basket compared to brush group (20/25 [80%] vs 12/25 [48%], respectively, P = 0.018, OR 4.33, 95% CI 1.24–15.21). Seventeen (34%) of the 50 sample pairs collected from malignant cases showed discordant cytopathological results: 15 patients had a positive basket and a negative brush result while two had the inverse association (P = 0.002, OR 7.5, 95% CI 1.65–47.44). Basketting more frequently yielded positive samples from malignant strictures in case of presampling balloon dilation (27/32 [84%] vs 10/18 [56%], respectively, P = 0.043, OR 4.32, 95% CI 1.14–16.37). Specificity was 100% (both methods).CONCLUSION Biliary sampling at ERC using a dedicated basket provided a significantly higher sensitivity for cancer detection than brushing; presampling stricture dilation significantly increased sensitivity.

Successful Endoscopic Management of Late Biliary Cast Syndrome in a Liver Transplant Recipient: A Case Report

Biliary cast syndrome (BCS) is an unusual complication of liver transplantation (LT). The pathophysiology is not known, and it is thought to develop because of mucosal damage in the bile duct related to obstruction, ischemia, or bacterial infection. It occurs in 2.5–18% of LT patients and is associated with increased graft failure, need for retransplantation, and mortality. Here we report on a case of BCS of late appearance after LT who was successfully treated by endoscopic means.

Su1247 Postcolonoscopy Colorectal Cancer (PCCRC) in a Population of a Closed System of Health Care Provision

BACKGROUND: Previous studies have demonstrated that patients post cholecystectomy have had no definitive association with colorectal adenomatous polyps. It is thought that chronic inflammation from bile acids may lead to increase development of colorectal polyps. Post cholecystectomy chronic diarrhea is likely from bile acid exposure. Additionally chronic constipation is thought to be an risk factor for colorectal cancer. The purpose of this study is to investigate for an increased risk for colorectal adenomas in post cholecystectomy patients and to look for the association of polyps with chronic diarrhea in these patients. METHODS: We performed a retrospective chart review of the patients who underwent cholecystectomy between 01/200112/2012 who also had a colonoscopy following surgery. Patients without a personal history of IBD, colorectal polyps and/or family history of colorectal cancer were included in the study. Patients were further divided into two groups, those with and without chronic diarrhea. Polyps were further classified based on histology and location. RESULTS: A total of 395 patients were included in the study (63% female, with a mean age of 50 y). The average number of years between the cholecystectomy and a colonoscopy was 2.6 years. An increased risk for colorectal polyps 151(38%) (95% confidence interval (CI)-0.33-0.43) was found among these patients when compared to an average risk in general population aged 50 y (20%). A total of 28% patients in the study were found to have proximal colon polyps (0.28, 95% CI 0.21 to 0.36) and no significant difference was found when compared to the average risk population (13-37%). In contrast an increased risk of polyps in distal colon 48% (0.48, 95% CI: 0.40 to 0.56) was found when compared to the average risk population (25-40%). Twenty five percent of patients had polyps in both proximal and distal colon 37/151 (0.25; 95% CI 0.18 to 0.32), statistics were not compared to the general population. Hyper plastic polyps were found in 37% (0.37, 95%CI: 0.29 to 0.45) patients, which were not found to be at increased risk when compared to average risk (20-40%). Adenomas, 55% (0.55, 95% CI: 0.46 to 0.63), were found to be at increased risk when compared to average risk (25-30%). Additionally an increased risk was found for serrated polyps, 9% (0.09, 95% CI 0.05 to 0.15), when compared to average risk (1-7%). In patients with chronic diarrhea the proportion of polyps was 0.26 compared to 0.43 in those without chronic diarrhea. (Odds ratio=0.47, 95% CI 0.29-0.75, P=0.002), revealing a negative association of polyps with chronic diarrhea in this set of patients. CONCLUSIONS: Cholecystectomy was found to increase the risk for distal colorectal adenomas/polyps. Chronic diarrhea was found to be negatively associated with colorectal polyps in this set of patients.

S1022 Prevalence of Colorectal Premalignant Lesions Detected By Colonoscopy in Different Risk Groups for Colorectar Cancer

BACKGROUND: Colorectal cancer (CRC) is the second most frequent cancer and the second cause of mortality related to cancer in Argentina. The detection of premalignant lesions (PML) through colonoscopy has been demonstrated to be effective in the prevention of CRC. It is important to be aware of the prevalence of these lesions to estimate their impact on the prevention of CRC in our population. The aim of this study was to assess the prevalence of PML in asymptomatic subjects with different levels of risk of CRC. METHODS: A cross-sectional analysis was performed based on the colonoscopy records of asymptomatic subjects screened for CRC in a General Hospital of Buenos Aires City, Argentina, between July 2004 and March 2007. The prevalence of PML was assessed in 2 groups: 1) average risk and 2) first-degree relatives with CRC. Patients with incomplete colonoscopy, poor preparation or second-degree relatives with CRCwere excluded. PMLwas defined as polyps or flat adenomaswith low or high-grade dysplasia.Multivariate logistic analysis was performed to establish the association between individual characteristics and PML. RESULTS: Data from 1233 subjects was collected (female= 733, mean age= 67.6 years SD= ±11.2). We found a global prevalence of 24.1% for PML and 1.1% for CRC. Average risk group (n=476; female= 246; mean age=61.8 years SD= ±9,06) showed a prevalence of 22.1% for PML (CI 95%= 18.3-25.8), in which 19.2% had low-grade and 2.5% high-grade dysplasia. The prevalence of CRC was 1.05%. First-degree relatives group (n=757; female =487; mean age= 54.9 years SD= ±11.53) showed a prevalence of 25.2% (CI 95%=22.1-28.3), in which 20% had lowgrade and 4.8% high-grade dysplasia. The prevalence of CRC in this group was 1.2%. In the validation set a logistic regressionmodel showed that family history of CRCwas independently associated with increased risk of PML (odds ratio=1.54; CI 95%= 1.15-2.05; P=0.004). This difference was greater in younger subjects (table 1). Male sex was also independently associated with an increased risk of PML (odds ratio=1.50; IC 95%= 1.15-1.97; P=0.003). CONCLUSION: Approximately a quarter of this population presented at least one PML and a significantly increased risk in first-degree relatives with CRC and male sex was observed. These results may contribute to issue local guidelines for CRC prevention. Table 1. Prevalence in different age groups