788i: Endo-Sonography-Guided Cholangio-Pancreatography (ESCP) As the Primary Approach for Ductal Drainage After Failed ERCP
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788i Endo-Sonography-Guided Cholangio-Pancreatography (ESCP) As the Primary Approach for Ductal Drainage After Failed ERCP Manuel Perez-Miranda, Carlos De La Serna, Pilar Diez-Redondo, Sara Gomez De La Cuesta, Paula Gil-Simon, Noelia Alcaide, Agustin Caro-Paton Background: ESCP is claimed an alternative to PTC after failed ERCP. The reported ESCP to PTC ratio for biliary drainage is 1:2 (Maranki’09). ESCP outcomes seem related to patient & approach selection.Aims: To assess technique, safety and efficacy of ESCP in patients with previously failed ERCP drainage.Methods: Between Nov03-Nov09, 168 pts out 5009 consecutive ERCPs had failed biliary or pancreatic duct (PD) drainage (3.3%). Salvage surgery/PTC in 4, clinical follow-up w/o further attempts in 62, and ESCP for the remaining 102 (M/F 43/59; age range 36-91 yr) using linear EUS & 19 or 22G needles (94/8) under fluoroscopy. During that period 16 pts underwent PTC (8 primarily, 2 after failed ERCP, 6 after failed ESCP), for a 10:2 ratio. Fisher’s test was used to compare outcomes between PD vs biliary, early vs late period, transhepatic vs transCBD, & cautery vs dilation for access. The number of ESCP relative to ERCP & approach used relative to pts’ anatomy were also analyzed.Results: PD drainage was attempted in 10/102 (3 Whipple’s, 7 chronic pancreatitis) and biliary drainage in 92 (23 duodenal stenosis/stent, 18 malignant papillary involvement, 27 contralateral duct access problems in hilar strictures, 17 Rouxen-Y & 7 miscellaneous). Malignancy in 80/92 pts (86.95%), and benign disease in 12/92. In 6/102, puncture precluded by nondilated ducts, ascites or other. Ductography obtained in 95/96 punctures, and single-step stent placement in 75 (42 metal & 33 7F-8.5F plastic). Thus, ESCP was technically successful in 75/96 punctures (78.12%): 61 transmural (43 hepaticogastrostomy; 11 choledochoduodenostomy, 7 pancreaticogastrostomy) & 14 transpapillary. Clinical success achieved in 62/75 (86.11%) and not available in 11 lost to follow-up/early non-related deaths. Complications 16/96, 7 mild (4 bile leaks, 2 bleeding, 1 pancreatitis) and 9 severe (2 pseudocyst, 2 abscess, 2 biloma, 2 perforations, 1 portal thrombosis), resulting in 3 deaths. Significant differences for success/complications between PD vs biliary (60/30% vs 79.3/12.6%) & early vs late (73/18.4% vs 88.8/12.06%), & for complications between cautery vs dilation (83.1% vs 7.4%). No differences between transhepatic vs transCBD. A 50% increase in ESCP use despite steady ERCP. Approach dictated in 92% by level of obstruction ⫾ gastrectomy, resulting in ⬎75% amenable to transhepatic access only.Conclusions: ESCP can salvage most failed ERCPs. Morbidity and learning curve make patient selection mandatory. Cautery is best avoided. With a high ESCP to PTC ratio, most patients will require transhepatic access, in turn associated with transmural stent placement.
788j Endoscopic Ultrasound-Guided Tattoo of Pancreatic Lesions Decreases Operative Time in Patients Undergoing Laparoscopic Distal Pancreatectomy Anne Marie Lennon, Naeem Newman, Samuel A. Giday, Christopher L. Wolfgang, Richard D. Schulick, Martin A. Makary, Marcia I. Canto, Barish H. Edil Background: Precise localization of small pancreatic tumors during laparoscopic distal pancreatectomy (LDP) can be difficult due to decreased tactile ability of laparoscopy and the homogenous appearance of the pancreas and surrounding retroperitoneal fat. Correct identification of the lesion is critical to achieving adequate margins of resection and preserving uninvolved pancreas. Endoscopic ultrasound fine needle aspiration (EUS-FNA) tattoo of the lesion allows for precise identification at the time of LDP improving operative outcomes. AIM: To determine the effect of EUS-FNA tattoo on surgical outcomes in patients undergoing LDP. METHODS: A retrospective chart review was performed of consecutive patients who underwent LDP at a tertiary referral center. EUS-guided tattoo was performed using 22 gauge needle with the needle inserted 3-5 mm proximal to the lesion and 2- 4 cc of sterile purified carbon particles (GI Spot, GI Supply) injected under direct visualization. Antibiotics were given just prior to the EUS and for 3 days post-procedure. Tattoo visibility was evaluated at the time of laparoscopy. Operative technique, operative times, estimated blood loss, conversion to open procedure, surgical margins, length of hospital stay,
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morbidity and mortality were compared for patients with and without prior tattoo. RESULTS: 31 consecutive patients underwent LDP between 2006-2009. Ten patients underwent preoperative EUS-FNA tattoo within a mean of 32.4 days (range 1-83). The EUS-FNA tattoo was clearly visible in all ten patients at laparoscopy. Compared to patients without prior tattoo, patients with prior tattoo had significantly decreased operative time (mean 126 minutes, range 53-180 minute, vs mean 170 minutes, range 120-210 minutes, respectively, p ⬍0.0091). Tattooed patients had 49% less blood loss compared with the non-tattooed (55 cc vs. 104 cc; p⫽1.0). None of the tattoo group required repeat surgery, while one patient who was not tattooed required re-resection for a lesion missed in the initial specimen. There were no complications associated with the EUS-FNA tattoo, including pancreatitis or pathologic evidence of abscess and peritonitis. CONCLUSION: EUS-FNA tattoo of distal pancreatic lesions prior to LDP is safe and associated with decreased operative time but not decreased blood loss. It may improve efficiency of LDP.
788k EUS-Guided Nd:YAG Laser Ablation on Normal Pancreatic Tissue: A Pilot Study in a Pig Model Francesco M. Di Matteo, Martino Margareth, Roberta Rea, Monica Pandolfi, Carla Rabitti, Maria Grazia Masselli, Sergio Silvestri, Claudio Maurizio Pacella, Enrico Papini, Francesco Panzera, Sergio Valeri, Roberto Coppola, Guido Costamagna Background and study aims: Laser Ablation with Neodymium:yttrium aluminum garnet lasers (Nd:YAG laser) can achieve a high rate of complete tissue necrosis and has been applied as a minimally invasive, palliative option in hepatocellular carcinoma, liver metastasis in colorectal cancer and malignant thyroid nodules.In this study, the in vivo feasibility of Endoscopic ultrasonography-guided laser ablation (EUS-LA) by Nd:YAG was assessed on normal pancreatic tissue of a porcine model. The secondary endpoint was the safety of Nd:YAG EUS-LA at 24 hours.Materials and Methods: A prospective investigation was performed on 8 pigs submitted to EUS-guided LA of the pancreas under general anaesthesia. EUS-guided puncture of the pancreatic tail allowed placement of a laser-beam fiber. A Nd:YAG laser (1.064 nm) was used, with output powers to 2 and 3 W and a total delivered energy of 500 and 1000 J in continuous mode. The 24-hour follow-up of the swine was focused on clinical and laboratory aspects. Results of histological studies on the pancreas were obtained 24 hours after the procedure on necroscopy tissue.Results: There were no technical limitations to perform the procedure. Tissue necrosis, localized in the pancreatic parenchyma, was observed in all animals upon histological examination. The ablation area ranged from a mean value of 49 (SD 19) mm2 to 80 mm2. Volume of ablation tissue ranged from a mean value of 314 (SD 173) mm3 to 483 mm3. No major postprocedure complications were recorded, and all the pigs survived at 24 hours.Conclusions: Nd:YAG EUS-LA of porcine pancreas is feasible, and was found to be safe, in the very short term, in a porcine model.
788l A Randomized Controlled Trial Comparing Tapered Catheter vs 6 Fr Cystostome for Safe EUS Guided Drainage of Non-Bulging Pseudocyst With Collaterals Sandeep Lakhtakia, Rajesh Gupta, Anupama Nagar, Nitesh Pratap, Mohan Ramchandani, Santosh Darisetty, D. Nageshwar Reddy Introduction: Endoscopic drainage of pseudocyst (PSC) carries a risk in patient having vessels in the wall of PSC or without prominent luminal bulge. Endoscopic Ultrasound (EUS) guided drainage of such pseudocyst has become the standard of care. Aim: To compare mechanical versus electro-cautery method of “initial track dilation” after EUS guided puncture of non-bulging pseudocyst with collaterals.Study type : Prospective randomized controlled trial.Patients & Methods: All patients with symptomatic PSC underwent EUS with Doppler study between July 2008 to Sept 2009 were enrolled. Patients with a single PSC having collaterals in the wall and/or absence of luminal bulge were selected for EUS guided drainage. Pseudocyst was first punctured with 19 gauge needle followed by passage of 0.035 inch 450cm guidewire which was allowed to coil inside the pseudocyst. The patients were randomized to undergo initial cysto-luminal track dilation over the wire guide using one of the two methods; (A) Mechanical tapered 5 Fr cannula or (B) Electro-cautery - 6Fr cytostome. The track was then uniformly dilated with CRE balloon (12-15mm). Complications occurring in periprocedure period or during one month follow up were recorded. Results: 47 patients (37 males; mean age 41 years, range 9-69) underwent EUS guided PSC drainage. Mean size of PSC was 9.5 cm (range 6 - 13). PSC were punctured via stomach (46) or esophagus (1). Single 10Fr double pigtail stent was placed in 27 and two 8.5 Fr stents in 20 patients. Technical success was achieved in 46 / 47 patients. Complications occurred in 5 patients, all occurring in patients having PSC with vessels in wall without a luminal bulge. One patient with post procedure bleed required vascular intervention, other patient improved with conservative management. Two patients who developed PSC infection required additional stent placement, and one subject with perforation required surgery.