Joyce Flueckiger

Triple-tissue sampling at ERCP in malignant biliary obstruction

BACKGROUND Procurement of cytologic samples by brushing is common practice at endoscopic retrograde cholangiopancreatography (ERCP) but has low sensitivity for cancer detection. Limited data are available on other techniques, including endoluminal fine-needle aspiration and forceps biopsy. This series reviews the yield of these three stricture sampling methods. METHODS In this prospective study, patients with biliary obstruction with a clinical suspicion of malignancy underwent triple-tissue sampling at one ERCP session. Final cancer diagnosis was based on all sampling methods plus surgery, autopsy, and clinical follow-up. Tissue specimens were reported as normal, atypia, or malignant. RESULTS A total of 133 patients were evaluated: 104 had cancer and 29 had benign strictures. Tissue sampling sensitivity varied according to the type of cancer; the highest yield was seen in ampullary cancers (62% to 85%). The cumulative sensitivity of triple-tissue sampling in the cancer patients was as follows: sensitivity was 52% if atypia was considered benign and 77% if it was considered malignant. The addition of a second or third technique increased sensitivity rates in most instances. No serious complications occurred from the tissue sampling methods. CONCLUSIONS Tissue sampling sensitivity varied according to the type of cancer. Combining a second or third method increased sensitivity; general use of at least two sampling methods is therefore recommended.

Predicting the Insertion Distance for Placing Gastric Tubes

Approximately 1 million enteral tubes are placed through the nose or mouth in adults and children in the United States annually. Previous studies found gastric tube placement errors to be common. A primary issue in ensuring safe and effective gastric feeding by tube is achieving optimal tube position on insertion. The purpose of this study is to use 24 variables to develop a clinical prediction rule for gastric tube insertion distance in adults, using the internal-nares-to-distallower esophageal-sphincter distance. A three-variable model using gender, weight, and nose-umbilicus-flat was selected. This new model, validated using nonparametric bootstrap cross-validation, correctly predicted gastric tube insertion distance 85.3% of the time. This new model is compared to two other methods, one evidence based and one commonly used in practice, and was found to be superior. Two nomograms, one for each gender, are drawn to make this new model easier to use.

Evaluating Adults With Idiopathic Pancreatitis for Genetic Predisposition: Higher Prevalence of Abnormal Results With Use of Complete Gene Sequencing

Objectives In adults with unexplained pancreatitis, the yield of complete gene versus select exosome sequencing on mutation detection and distinguishing clinical characteristics associated with mutations requires clarification. We sought to (1) compare frequency of mutations identified using different techniques and (2) compare clinical characteristics between adults with and without mutations. Methods This is a cohort study of adults with unexplained pancreatitis who underwent genetic testing between January 2008 and December 2012. We compare probabilities of having a positive mutation with complete gene sequencing versus alternatives and describe differences in characteristics among patients with and without mutations. Results Of the 370 patients, 67 (18%) had a genetic mutation; 24 (6%) were of high risk. Mutations were significantly more prevalent with use of complete sequencing (42%) versus other approaches (8%, P < 0.0001). Most (44/67, 66%) with a mutation had no family history. Those with high-risk mutations were more likely to have a family history of chronic pancreatitis (21% vs 4%, P = 0.002). Patients with pancreas divisum were more likely to have mutations (27% vs 14%, P = 0.0007). Conclusion Among individuals with adult-onset pancreatic disease, the probability of finding any mutation, including high risk, is significantly higher using complete gene sequencing. The impact on patients and providers requires further investigation.

4603 Spontaneous dislodgment rates of long length, small diameter, “unflanged” pancreatic stents placed partially up the duct.

Pancreatic duct (PD) stent placement reduces pancreatitis rates following precut biliary sphincterotomy (ES) or pancreatobiliary ES in pts with sphincter of Oddi dysfunction (SOD). To limit ductal injury and need for endoscopic removal, spontaneous dislodgment is desirable after 1-2 weeks. Short (=3cm) unflanged stents dislodge 80% of the time. However, post- ERCP pancreatitis rates remain relatively high, ~10-15% in SOD pts. We hypothesized that these short stents might dislodge too quickly (ie

3566 Endoscopic therapy of biliary and pancreatic disorders in children.

There is limited data on the role of ERCP in the pediatric population. We report our experience in this group during the last 5 years. Pts and Methods: From 1/94-9/99, 126 pediatric pts were evaluated by ERCP. There were 47 boys and 79 girls with a mean age of 12.1 yrs (range 0.1-17). There were 170 ERCPs performed (43 diagnostic and 127 therapeutic). Ninetytwo procedures were performed under general anesthesia and the remainder were under conscious sedation. A pediatric endoscope (diameter 8.5 mm) was used in 9 pts(all less than 2 yr)and a standard adult diagnostic endoscope (diameter 11 mm) was used in the remainder. Indications for ERCPs were: Idiopathic acute pancreatitis (n=15), recurrent acute pancreatitis (n=31), chronic pancreatitis (n=8), obstructive jaundice (n=40), suspected sphincter of Oddi dysfunction (SOD) (n=22), and miscellaneous (n=10). The desired duct was visualized in 116 of 126 pts (92.1%). Results: Therapeutic techniques from 170 sessions are shown on the table. Disease findings were (some pts had more than one finding): bile duct stone(s) (n=18), SOD (n=24), biliary atresia (n=1), anomalous P-B junction (n=3), choledochal cyst (n=4), biliary fistula (n=5), PSC (n=5), chronic pancreatitis with strictures and stones (n=11) or without stones (n=5), pancreas divisum (n=18), pancreatic duct leak (n=5), benign biliary stricture (n=7), malignant biliary stricture (n=1) and normal (n=12). Twenty-four complications occurred in 21 pts (16.6% of 126 pts). Twenty pts developed acute pancreatitis graded mild in 14, moderate in 3, and severe in 3. Conclusion: ERCP is an effective diagnostic tool in the evaluation of biliary and pancreatic disorders in the pediatric population. It offers therapeutic application that can obviate surgery with an acceptable complication rate similar to the adult population.

⁎⁎3801 Complete disruption of main pancreatic duct: short and long term results of endoscopic management.

Historically, surgical management has been the definitive treatment in pts with CPDD.We report short and long term results of ERx in this group of pts. Pts and Methods: From 4/94-10/99 153 pts (91 men, 62 women; mean age 51 yrs, range 9-89) were found to have a pancreatic duct leak at ERP. 37 pts had a CPDD. Indications for ERP were: pseudocyst (n=14), pancreatic ascites (n=6), unresolving pancreatitis (n=11), pancreaticocutaneous fistula (n=6). CT findings were: pseudocyst (n=14), ascites (n=6), disconnected tail (n= 3), pancreatic edema/necrosis (n=9). Five pts were sent directly to surgery. Thirty-two pts underwent 84 sessions of ERx which included endoscopic sphincterotomy, pancreatic duct stricture dilation if needed, and stent or nasopancreatic catheter placement. Pts with an associated accessible pseudocyst had endoscopic drainage by transpapillary stenting (n=6), cystogastrostomy (n=3), cystoduodenostomy (n=1), or combined procedures (n=1). Long-term follow-up was obtained by CT, ERP, clinical evaluation, and phone calls. Results: Twenty pts initially sealed their leaks at a mean duration of 1.6 month (range 0.2-4.5). Twelve pts required surgery after failed ERx. Pts with an initial sealed leak were evaluated at follow-up ERP with or without CT scan and categorized into 1) Successful upstream duct (UD) reconnection (SUR) and 2) Duct obstruction (DO) at prior leak site. Results of a 30-month follow-up are shown on table. Pts were asymptomatic (n=9), had recurrent pancreatitis (n=3), chronic pain (n=2), recurrent fistula (n=2), or were unable to be contacted (n=4). Summary: CPDD closure rate was 63% (20/32); 10% had a confirmed recurrent duct leak (fistula) 2) 25% continue to have pancreatic symptoms. Conclusion: ERx appears to be an acceptable alternative to surgery for a subset of pts with CPDD. Long-term results of pts with SUR are excellent. In pts with DO, the undrained segment may remain asymptomatic, become atrophic, or be associated with recurrent pancreatitis or recurrent fistulization. Better methods are needed to select the subset of pts with CPDD who will respond to ERx.

⁎4682 Post orthotopic liver transplantation bile leak: results of endoscopic management.

Bile leak is one of the most common biliary complications after OLT. Because of the relatively high morbidity and mortality rates associated with surgical intervention, nonsurgical methods of treatment are being investigated. Endoscopic drainage has become a popular approach in OLT pts with a duct-to-duct anastomosis (DDA).We report our results of endoscopic therapy (ERx) in these pts. Patients and Methods: From 5/88-8/99, 408 OLTs were performed at our institution and 4 pts who had OLT at another hospital were followed by us. Twenty-two were referred for evaluation of a suspected bile leak. ERx included endoscopic sphincterotomy (ES), stent or nasobiliary tube (NBT) placement. Resolution of the bile leak was confirmed either by repeat ERCP or NBT cholangiogram. Results: A bile leak was diagnosed in 22 pts (15 men, 7 women; mean age 37.8 years, range 9-51 years). The mean interval between the OLT and endoscopic intervention was 9.8 weeks (range, 1-20 weeks). This complication occurred in 6.0% of the total number of pts who received transplants and had a DDA during this period. ERCP demonstrated a leak in all 22 pts arising from the T-tube tract (n=13), anastomosis (n=7), intrahepatic radicle (n=1), donor cystic duct (n=1). Six pts had fever at presentation and another six showed evidence of leak per T-tube cholangiogram. Management of the bile leak is shown on the table. Pts undergoing stent therapy had repeat ERCP with stent removal (if the leak sealed) at a mean time of 32 days (range, 22-60 days). Two pts who underwent NBT had fistula closure on day 6 and 8. Two pts also had stones removed at the time of stenting. All leaks treated by endoscopy sealed clinically and confirmed by follow-up ERCP or cholangiogram via NBT. Endoscopic evaluation and Rx was associated with a 4.5% major complication rate and 0% mortality rate. Summary: ERCP demonstrated a biliary fistula in 22 of 22 pts (100%). Endosocpic management resolved biliary fistulae in all pts in whom it was attempted. Conclusion: Endoscopic management of bile leak in OLT pts with DDA is very effective and can obviate the need for surgical intervention. Choice of biliary decompression does not effect the outcome of this approach.

6993 Biliary intraductal pressure measurement has low sensitivity for diagnosis sphincter of oddi dysfunction (sod).

BACKGROUND: Intraductal biliary pressure measurement has been proposed as the substitute for basal sphincter pressure for diagnosis of SOD. Intraductal pressure measurement is technically easier to perform than station pull-through sphincter of Oddi (SO) manometry and may be appropriate since one mechanism of pain in patients with SOD is attributable to elevated intraductal pressure. This study evaluated the correlation of biliary basal sphincter pressure and intraductal biliary pressures. METHODS: 59 patients with suspected SOD were prospectively studied. Intraductal biliary pressure was measured in calmly sedated patients with the standard 5 Fr triple lumen SOM catheter passed 2-4 cm above the sphincter as confirmed on fluoroscopy. Thereafter the conventional pullthrough SOM was performed. Conscious sedation was achieved with combination diazepam and droperidol, (and meperidine, if needed). A subgroup of 20 patients with prior biliary sphincterotomy had separate analysis. RESULTS: Elevated SO basal pressure >40 mmHg was seen in 28 of 39 patients. In 9 of these 28 patients (32 %) intraductal pressure at greater than 12 mmHg. One of 11 patients with normal SO basal pressure had elevated intraductal pressure. Mean intrabiliary pressure was 9.7 ± 5.3 mmHg in patients with SOD and 8.8 ± 5.4 mmHg in patients with normal SO basal pressure (p=0.63). Stratification of patients according to presence or absence of intact gallbladder did not improve sensitivity. Patients with gallbladder intact (n=8) tended to have lower intraductal pressure than patients with gallbladder removed (6.5 ± 3.0 mmHg vs. 10.2 ± 5.5 mmHg; p=0.07). This phenomenon was independent of SOD diagnosis. Moreover intraductal pressure was strongly influenced by meperidine administration (n=21; 11.4 ± 5.0 mmHg vs. 7.0 + 4.6 mmHg: p 12 mmHg (presumed false positive). SUMMARY: Using >12 mmHg as a cut off, intraductal biliary pressure has low sensitivity for detection of SOD defined as basal biliary sphincter pressure of >40 mmHg. CONCLUSION: Intraductal biliary basal pressure is a poor substitute for the established standard of >40 mmHg basal sphincter pressure for diagnosis of SOD.