Noor Bekkali

Pancreatoscopy-Directed Electrohydraulic Lithotripsy for Pancreatic Ductal Stones in Painful Chronic Pancreatitis Using SpyGlass.

Objective Painful chronic pancreatitis is often associated with main duct obstruction due to stones. Approaches to management are challenging, including surgery, extracorporeal shock wave lithotripsy, or endoscopic approaches. Here, we report our experience of pancreatoscopy + electrohydraulic lithotripsy (EHL) for pancreatic duct (PD) stones using SpyGlass. Methods We retrospectively audited the use of SpyGlass (Legacy and DS) + EHL. Indication, procedural details, and clinical outcomes were assessed. Results A total of 118 SpyGlass + EHL procedures for stones were performed, of which 8 (7%) for pancreatic stones, in 6 patients (3 female; mean [standard deviation] age, 45 [7] years). All patients had painful chronic pancreatitis, with radiological evidence of a dilated PD, and main duct stone disease. Surgical options had been considered in all cases. Stone fragmentation and PD decompression were achieved in 83% (n = 5) without complications. Two patients required 2 EHL procedures to achieve clearance. In 1 patient with failed clearance, pancreatoscopy revealed a stone in the adjacent parenchyma and not in PD. All patients with successful EHL had pain relief/marked improvement at clinical review (mean [standard deviation] follow-up, 2.7 [1.1] years). Conclusions Pancreatoscopy + EHL may have a valuable role in treating obstructing PD stones, possibly avoiding the need for surgery in some patients.

Training in ERCP and EUS in the UK anno 2017

In the last 20u2005years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a diagnostic procedure to being almost exclusively therapeutic. Similarly, endoscopic ultrasound (EUS) is developing into ever-increasing therapeutic roles. Operator technique is central to diagnostic accuracy in EUS, as is effective and safer therapy for both ERCP and therapeutic EUS. Hence, effective training and robust standards for certification and revalidation are required to ensure ERCP and EUS in the UK are as effective and as safe as possible.

Efficacy and Safety of Digital Single-Operator Cholangioscopy for Difficult Biliary Stones

BACKGROUND & AIMS: It is not clear whether digital single‐operator cholangioscopy (D‐SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D‐SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D‐SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D‐SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26–21.2; P = .02). Procedure time increased odds of more than 1 session of D‐SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01–1.03; P < .001). CONCLUSIONS: In a multicenter, international, retrospective analysis, we found D‐SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.

The role of multidisciplinary meetings for benign pancreatobiliary diseases: a tertiary centre experience

Multidisciplinary meetings are central to the management of chronic and complex diseases and they have become widely established across the modern healthcare. Patients with pancreatobiliary diseases can often present with complex clinical dilemmas, which fall out with the scope of current guidelines. Therefore, these patients require a personalised management approach discussed in a multidisciplinary meeting.

Cholangioscopy-directed lithotripsy for a large bile duct stone: the “donut technique”

Conventionally, choledocholithiasis is managed by endoscopic retrograde cholangiopancreatography (ERCP), and it accounts for at least 50% of the approximately 52000 ERCPs performed in the UK each year [1–5]. Bile duct stone clearance traditionally involves the performance of ERCP with biliary sphincterotomy (or sphincteroplasty), followed by the removal of stones from the biliary tree using an extraction balloon, with or without the use of a basket or mechanical lithotripter. Stones may be difficult to remove at ERCP owing to a range of factors, including size (e. g. stones > 15mm), number, location (e. g. intrahepatic or within the cystic duct), and other anatomical factors (e. g. stones above strictures). Cholangioscopy was first introduced in 1975 as a dual-operator “mother–baby” technique and allowed direct visualization of intraductal stones and fragmentation of stones with laser or electrohydraulic lithotripsy (EHL). The technique fell out of widespread use because of technical and endoscopic limitations. In 2006, a single-operator cholangioscope was introduced (Spyglass; Boston Scientific Inc., Natick Massachusetts, USA), which reinvigorated the use of cholangioscopy in the management of difficult bile duct stones. In 2015, a second-generation Spyglass cholangioscope (Spyglass DS; Boston Scientific Inc.) was developed, with improved visualization and scope movement, and a larger (1.3mm) working channel. Here we report the case of a 46-year-old woman who underwent cholangioscopy for an impacted 3-cm common bile duct stone after three failed conventional ERCPs at her local hospital. We elected to perform an ERCP combined with cholangioscopy. Despite visually directed EHL, the stone could not be cracked, and therefore a tunnel was created through the stone (▶Fig. 1), as shown in ▶Video1. This allowed a wire to be passed through the stone, which was then cracked using a dilating balloon. Subsequent uncomplicated stone clearance followed, with successful bile duct clearance.

PWE-161 Preventing Post-ERCP Pancreatitis (PEP): The Role of Prophylactic Pancreatic Duct Stenting In The Rectal NSAID era

Introduction Post ERCP pancreatitis (PEP) is an important complication. Rectal NSAIDs at ERCP is the standard of care to reduce the risk. Pancreatic duct (PD) stenting also reduces the risk of PEP in high risk patients, but placement can be technically challenging. Failed PD stenting carries reported PEP rates of at least 35%. We aimed to assess whether prophylactic pancreatic stenting is still justified in the current rectal NSAID era. Methods Between January 2013 and June 2015, we retrospectively evaluated the use of PD stents in a UK tertiary referral centre. Rectal NSAIDs were used universally for all cases post-ERCP, except in those contraindicated to NSAIDs. Prophylactic PD stenting (unflanged 5Fr 5–7 cm single pigtail stents, Cook Medical) was attempted in predicted high risk PEP cases. Indications for therapeutic PD stents included patients with chronic pancreatitis. Data was collected from our prospective database, completed following each ERCP. Follow-up information was reviewed through electronic records and telephone enquiry. Results 1633 ERCPs were performed during the study period. Pancreatic stenting was attempted in 324 cases (20%); successful placement was achieved in 307 cases (95%). Prophylactic PD stenting failed in 12 cases, one case developed PEP (1/12 = 8%). This patient had sphincter of Oddi dysfunction (SOD) and a contraindication to NSAIDs. 65% (201/307), of successfully placed pancreatic stents were inserted prophylactically, in whom 9% (18/201) developed PEP. PEP occurred in 1.4% (18/1309) of cases who did not undergo attempted PD stenting. The relative risk of PEP was 8.4 (p = 0.04) in the stented group. Conclusion PEP rates in failed PD stenting were low (8%) compared to past studies, and comparable to PEP rates in successful prophylactic PD stenting. This suggests a protective role of rectal NSAIDs, as previously shown by Choksi et al.1 The higher rate of PEP in the PD stenting/attempted stenting group, compared to the unstented group, likely reflects the higher perceived risk of PEP in the PD stenting group. The low rate of recorded PEP in the unstented group may, in part, be due to under-reporting. Our data suggests that increased rates of PEP continue to be seen in perceived high risk cases, even in a universal NSAID use setting. The overall risk appears lower than in the pre-NSAID era, and in our series a lack of difference in the PEP rate between successful and failed PD stenting suggests there is less need for prophylactic PD stenting in the NSAID era. Reference 1 Choksi, et al. The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement Gastrointest Endosc 2015;81(1):150–155. Disclosure of Interest None Declared

OC-009 Spyglass DS™ Cholangioscopy for Difficult Stones: Early Experience of Two UK Centres

Introduction Endoscopic clearance of bile duct stones is achievable in >90% with conventional ERCP (ASGE 2015). Additional techniques may be necessary for those patients with difficult stones, which may be due to stone location, size, or number. Cholangioscopy and intraductal lithotripsy may have a specific role in treating difficult stones. The Spyglass DS™ peroral cholangioscopy system was introduced in mid-2015, and here we report our early experience with this technique. Methods Spyglass DS cholangioscopy was available in the UK from May 2015. Cases referred to our 2 centres were assessed within a specialist HPB multidisciplinary meeting, and all cases deemed appropriate for Spyglass DS were prospectively followed. Patient demographics, indication for cholangioscopy, technical outcome and complications were recorded. Results Eight-four patients (54% female, median age 61 years (range 25–90)) underwent ERCP with plan for cholangioscopy. Indications were stones (83%), strictures (14%) and other (3%). The stones were extrahepatic (62%), intrahepatic (15%), cystic duct (15%), and intra + extrahepatic (8%). The total number of stones was <5 in 58%, 5–10 in 18%, 11–15 in 9%, 16–20 in 9% and >20 stones in 6%. The 70 patients with stones had undergone a median 2 ERCPs (range 1–7) prior to referral. At our centres duct clearance was achieved in 30% (n = 21/70) without need for cholangioscopy, using combinations of extraction balloon (100%), sphincteroplasty (69%) and mechanical lithotripsy (ML) (54%). Cholangioscopy was needed for 49 cases, in 46 patients. Cholangioscopy with electrohydraulic lithotripsy (EHL) led to complete stone clearance in 72% of patients (33/46), of whom 3 on second EHL. The remaining patients await a second EHL procedure. In the 18 patients with unsuccessful stone clearance to date, reasons included: stone size + density (n = 8 with stones >15 mm); intrahepatic stones (n = 9); inability to apply EHL (n = 1). Overall, stone clearance was achieved in 54/67 (81%) of patients undergoing ERCP +/- cholangioscopy with EHL. The mean (SD) duration of ERCP + cholangioscopy + EHL was 93 (±28) minutes; 90% had propofol sedation, and 10% conscious sedation. No complications were observed. Conclusion In patients who have failed multiple attempts at endoscopic stone clearance, referral to a centre with availability of Spyglass DS cholangioscopy and EHL results in definitive stone clearance in 81% of patients. This success includes further conventional ERCP. Stone clearance with cholangioscopy may be achieved irrespective of site or size of stones, but failure of complete fragmentation with EHL may contribute to need for repeat procedures, and occasional failure. Disclosure of Interest None Declared

PWE-035 Early experience of pancreatoscopy-directed electrohydraulic lithotripsy for pancreatic ductal stones in painful chronic pancreatitis

Introduction Painful chronic pancreatitis is often associated with main duct obstruction due to stones. Approaches to management are challenging, including surgery, extracorporeal shock wave lithotripsy (ESWL), or endoscopic approaches. All have their limitations. Electrohydraulic lithotripsy (EHL) using Spyglass™ directed visualisation is highly effective for treating difficult bile duct stones, and is increasingly used in the UK. Here we report our early experience of Spyglass ™ pancreatoscopy and EHL for pancreatic duct stones. Method We retrospectively audited our unit’s use of Spyglass™EHL in the period February 2013–February 2015, with a focus on those patients undergoing pancreatic EHL. Indication, procedural details, and clinical outcome were assessed. Results Eighty-five procedures for Spyglass™and EHL for stones were performed, of which 5 (6%) were carried out for pancreatic stones in 4 patients (3 female, mean age 46 years ±16 years). All patients had painful chronic pancreatitis, with radiological evidence of a dilated pancreatic duct, and main duct stone disease within 2 cm of the ampulla. Surgical options had been considered in all cases. Prior to EHL all patients had undergone pancreatic sphincterotomy and pancreatic duct stenting. Stone fragmentation and duct decompression was achieved in 75% (3/4) of cases. One patient required two EHL procedures to achieve clearance. In the patient with failed clearance, pancreatoscopy revealed that the stone was not in the main duct, but in the adjacent parenchyme. There were no procedure related complications. All patients with successful EHL had pain relief/marked improvement at clinical review (mean follow up - 6.8 ± 5 months).Abstract PWE-035 Table 1 Patient Aetiology of Chronic Pancreatitis Age (years) Sedation Main duct stone location Stone Size (cm) Number of EHL sessions Success Follow up (months) Previous ERCPs 1 Idiopathic 57 Conscious Head 1.2 2 Yes 13.5 4x 2 Spink1-mutation 43 Propofol Head 1.5 1 Yes 5.9 1x 3 Spink1-mutation 19 Propofol Head and tail 2.2 1 Yes 1.2 1x 4 Biliary 53 Conscious Head 1.0 1 No - 1x Conclusion Pancreatoscopy with EHL may have a valuable role in treating obstructing pancreatic duct stones, possibly avoiding the need for surgery in some patients. However, careful patient selection is mandatory, and more studies are needed to better define treatment approaches. Disclosure of interest None Declared.

Idiopathic esophageal ulceration is nearly forgotten in an era of controlled human immunodeficiency virus

Obstruction due to esophageal ulceration is usually caused by gastroesophageal reflux disease, malignancy, or eosinophilic esophagitis. In patients infected with the human immunodeficiency virus (HIV), another specific cause of obstruction should not to be forgotten. A 43-year-old HIV-infected man with low CD4 cell count and high viral load was admitted with odynophagia and dysphagia. Esophagogastroduodenoscopy showed severe esophagitis with strictures (● Fig.1 and● Fig.2), and normal histology on repeat endoscopy. Multiple dilations and subsequent high-dose proton pump inhibitors and ganciclovir did not improve the symptoms. Serology for herpes simplex virus and cytomegalovirus was negative. Meanwhile, viral loads and CD4 cell count improved, as a result of adjustment to antiretroviral therapy. Finally, a gastroenterologist who was experienced in HIV problems suggested the diagnosis of HIV-associated idiopathic esophageal ulceration (IEU). The patient was treated with liquid steroids (beclomethasone), which resulted in clinical and endoscopic improvement (● Fig.3). In the early days of the acquired immunodeficiency syndrome epidemic, gastroenterologists frequently encountered complications. IEU was typically seen in patients with uncontrolled HIV, as in the current patient. With increasingly wellmonitored HIV treatment, IEU has become rare. Current gastroenterologists and internists are less familiar with diagnosing IEU, which should also be considered in other immunocompromised patients (e.g. stem cell or renal transplantation) [1,2]. In addition, fragmentation of care may further delay proper treatment. In the 1990s, one group reported an IEU prevalence of 15% in HIV patients [3]. Typical symptoms were chest pain and odynophagia; dysphagia was less common. Histology is mandatory to exclude malignancy and infection. The treatment of choice is steroids, with response in 90% of patients [4–6]. With thalidomide, a success rate of 71% was reported [7]. The current patient was successfully treated with orally administered enema steroids (beclomethasone). The influence of better viral control with interventions other than steroids is unknown. No data exist comparing the latter. Budesonide inhalers, prescribed for eosinophilic esophagitis, might be newadditions to the armamentarium. In summary, early recognition of IEU is warranted in order to start treatment.