4626 Wire-guided intraductal ultrasound - an adjunct to ercp in the management of common bile duct...

*4623CLOSURE OF THE ACCESSORY PANCREATIC DUCT IS THERISK FACTOR FOR POST-DIAGNOSTIC ERCP PANCREATITIS.Hitoshi Sano, Hirotaka Ohara, Tamaki Yamada, Takahiro Nakazawa,Hakuji Ando, Shinichi Kajino, Takashi Hashimoto, Soichi Nakamura,Tomoaki Ando, Makoto Itoh, Yasutaka Okayama, Kazuo Goto, Nagoya CityUniv Med Sch, Nagoya, Japan; Gifu Prefectural Tajimi Hosp, Tajimi,Japan.Background: Acute pancreatitis is the most common complication of ERCP.Many risk factors such as direct mechanical trauma, hydrostatic forces,chemical effects of contrast agent injected under pressure, and microbialcontamination for post-diagnostic ERCP pancreatitis have been reported.However, whether patency of the accessory pancreatic duct (APD) influ-ences post-diagnostic ERCP pancreatitis is unknown. Aim: To evaluate theclosure of the APD and several other risk factors for post-diagnostic ERCPpancreatitis. Patients and Methods: This study was conducted on 536patients from 836 consecutive ERCPs over the past seven years. Serumpancreatic enzymes (amylase, lipase, elastase-1, trypsin, pancreatic secre-tary trypsin inhibitor {PSTI}) and neutrophil counts were evaluated at pre-, 5, 24, 48 and 72 hours after ERCP. Percent of increase compared with pre-ERCP value also estimated respectively. The severity of pancreatitis wasclassified into three groups (severe, moderate, or mild) according to theestablished criteria. By multivariate analysis, twelve factors: age, gender,cannulation frequency, bile duct cannulations, pancreatic contrast injec-tions, closure of the APD, pre-ERCP values of serum pancreatic enzymesand neutrophil counts were evaluated. Results: Overall, 14/536 (2.6%)patients developed pancreatitis; 6 mild, 6 moderate, 2 severe. Patency ofAPD was significantly lower in the pancreatitis group than that in thenon-pancreatitis group (pancreatitis vs. non-pancreatitis: 2/14, 14.3% vs.173/522, 33.1%, respectively). The rate of pancreatitis was significantlyhigher in the closed APD group than in the patent APD group and twocases with severe pancreatitis were documented only in the closed APDgroup (closed vs. patent: 12/246, 4.9% vs. 2/175, 1.1% and 2 severe, 5 mod-erate, 5 mild vs.1 moderate, 1 mild). In the non-pancreatitis group, serumpancreatic enzyme values at pre-ERCP were similar between closed andpatent APD groups, whereas the percent increases at 24 and 48 hours afterthe procedure in the closed group were higher than those in the patentgroup. By multivariate analysis, the significant risk factors were: femalesex, cannulation frequency, closure of APD, bile duct cannulations, andpancreatic contrast injections. Conclusion: Closure of APD also carries ahigh risk of developing post-diagnostic ERCP pancreatitis. The appropri-ate use of this new prognostic indicator may provide a significant benefitin the early diagnosis of post-ERCP pancreatitis.

*4624IS EUS USEFUL IN PREDICTING POST-ERCP PANCREATITIS? -AN ANALYSIS OF 509 PATIENTS.Rig S. Patel, Mohammad A. Eloubeidi, Hugh E. Mulcahy, Kenneth M.Payne, John T. Cunningham, Neven Hadzijahic, Robert Etemad, KojiMatsuda, Michael B. Wallace, Peter B. Cotton, Brenda J. Hoffman, RobertH. Hawes, Med Univ of South Carolina, Charleston, SC.BACKGROUND: EUS can provide detailed information regardingparenchymal and ductal changes in the pancreas. Other than prior histo-ry, there are no known pre-ERCP predictors of post-ERCP pancreatitis(PEP). The relationship between EUS features of pancreatitis and post-ERCP pancreatitis is unknown. AIM: Evaluate if the number or distribu-tion (ie : ductal Vs. parenchymal ) of EUS features of pancreatitis (parenchymal : foci, lobularity, stranding, cysts, and ductal : duct irregular-ity, hyperechoic margins, dilatation visible side-branchescalcification/stone) are associated with the incidence of post-ERCP pancre-atitis. METHOD: Consecutive patients who underwent EUS prior to ERCPat MUSC between 2/94 and 11/99 were evaluated. Patients who had anincomplete EUS, pancreatic cancer or prior pancreatic duct therapy (sur-gical or endoscopic), were excluded. Univariate analyses were performed toevaluate for any relationship between PEP and individual or groups of fea-tures seen on EUS. A multivariate analysis was also performed to includethe influence of interventions performed during ERCP. RESULTS: Datafrom 509 patients (mean age 46 yrs. range 13-84 yrs., M/F: 153/356) wereanalyzed. PEP occurred in a total of 40 (8%) patients. The incidence of PEPin patients with > 4 EUS features was 8% (22/275), and 8% (18/234) inthose who had <3 EUS features (p=1). PEP occurred in 9% (17/194) inthose with >5 EUS features compared to 7% (23/315) those with < 5 fea-tures (p=0.6). Of patients who had no EUS features of pancreatitis, 5%(3/67) developed PEP compared to 8% (37/442) in patients who had one ormore EUS criteria, (p=0.3). There was no association between the numberof ductal or parenchymal EUS features present and the incidence of PEP.Multivariate analysis showed that only pancreatic stenting significantly

(p=0.0015) influenced (reduced) the incidence of PEP. CONCLUSION:Endosonographic features of chronic pancreatitis do not help in predictingthe likelihood of post-ERCP pancreatitis.

*4625ENDOSCOPIC ULTRASOUND AND INTRADUCTAL ULTRASONO-GRAPHY ARE COMPLEMENTARY FOR THE MANAGEMENT OFAMPULLARY TUMORS.Bertrand Napoleon, Jean Christophe Saurin, Rosario Albis, Jean YvesScoazec, Thierry Ponchon, Jacques Fumex, Bertrand Pujol, Jean AlainChayvialle, Ste Anne Lumiere Clin, Lyon, France; Hosp E Herriot, Lyon,France.Whipple’s resection is the gold standard treatment of the ampullarytumors. Nevertheless endoscopic snare resection (ESR), which is less inva-sive, can be applied in a curative intent when some criteria are respected: -1- no risk of metastatic lymph node e.g. benign ampullomas or early car-cinomas respecting the submucosae -2- no tumoral extension inside thepancreatic and the bile ducts. While endoscopic ultrasound (EUS) stages,with a good accuracy, an ampullary tumor as respecting the muscularispropria (uT1), intraductal ultrasonography (IDUS) is very promising toappreciate the involvement of the submucosae and the existence of anintraductal extension. The combination of the two methods could thenallow optimizing the therapeutic choice. AIM: to estimate the clinicalimpact of EUS +/- IDUS in the management of ampullary tumorsPATIENTS AND METHODS: between Jan 99 and Nov 99, 10 patients withampullary tumors had a pretherapeutic staging. A radial EUS (GFUM20,Olympus Co) was systematically performed. When the staging was uT1 anIDUS (UM-G20-29R, Olympus Co) was done. A Whipple’s resection wasproposed when final staging was -1- lesion infiltrating the submucosae ormore ; -2- tumor extension inside the biliary or pancreatic ducts. An ESRwas proposed in the other cases. RESULTS: EUS concluded to a tumor >uT1 in 4 cases. Pathology (Whipple’s resection) confirmed the staging (3pT3; 1 pT2). EUS conclude to a tumor uT1 in 6 cases and IDUS was per-formed. - In 4 cases tumors were considered without intraductal involve-ment and respecting the submucosae. ESR was always curative (severedysplasia; resection margins free of tumor). – In 2 cases IDUS evidencedinvolvement of the submucosae. 1 with a tumor extension inside the ductswas operated on and diagnosed as pT2. 1 refused surgery and an ESR wasperformed confirming the involvement of the submucosae (positive resec-tion margins). A moderate pancreatitis was the only ESR complication.CONCLUSION: EUS and IDUS togheter allow an accurate T staging ofampullary tumors. The clinical impact is major: endoscopic snare resectioncan be applied in a curative intent in early tumors, Whipple’s resection inother cases or when ESR is not complete.

*4626WIRE-GUIDED INTRADUCTAL ULTRASOUND - AN ADJUNCT TOERCP IN THE MANAGEMENT OF COMMON BILE DUCTSTONES.A. Das, G. I. Isenberg, A. Chak, R. Ck Wong, M. V. Sivak Jr., Univ Hospitalsof Cleveland, Cleveland, OH.Introduction: Cholangiography (ERC) may misdiagnose CBD stones if airbubbles are introduced during contrast injections and it may also fail todiagnose stones in the presence of marked bile duct dilation. Aim:To deter-mine whether IDUS could be a useful adjunct in the management of CBDstones. Methods: IDUS using a wire-guided ultrasound probe(UMG2029R,Olympus)was performed after initial ERC in patients with suspectedCBD stones. The endoscopist noted the probability of CBD stones andsludge (definite, high, intermediate and low) after initial ERC and thennoted additional or change in diagnosis after IDUS. Results: ERC withIDUS was performed in 28 patients with suspected CBD stones. CBDstones were confirmed after sphincterotomy and stone extraction in 12patients. In these 12 patients, ERC classified 5 as definite stones and 5 ashigh probability. IDUS definitively identified CBD stones in 11 of 12patients with confirmed CBD stones (PPV 100%, NPV 94%). IDUS con-firmed stones in 9 of the 10 patients with high or definite probability ERC.In addition, IDUS identified stones in 1/13 patients classified as interme-diate and 1 patient classified as low probability at ERC. Both were con-firmed after sphincterotomy and extraction. In addition, IDUS demon-strated air bubbles in 2 patients and subsequent ballooon explorationconfirmed the absence of stones. Performance of wire-guided IDUSrequired a mean of 4.3 ±0.2 minutes. Additional diagnostic informationprovided by IDUS included identification of cystic duct stones in 3 patientsand choledochal varices in 1 patient. Conclusions: IDUS imaging wasfound to be a useful adjunct to ERC because it helped change managementin 4/28 (14%) patients with suspected CBD stones. Specifically, sphincter-otomy was performed in 2 patients with IDUS confirmed stones and wasavoided in 2 patients with injected air bubbles

AB186 GASTROINTESTINAL ENDOSCOPY VOLUME 51, NO. 4, PART 2, 2000