ray machine used was a conventional (non-digital) overcouch X-ray Philips ... a lead apron with collar, lead glasses and two articulated, ceiling-mounted, lead.
Abstracts
Mo1458 Patients, Endoscopist’s and Nursing Staff Radiation Exposure During Interventional ERCP Procedures John A. Karagiannis1, Virginia Tsapaki2, Konstantina D. Paraskeva1, Nicoletta G. Mathou1, Charikleia Triantopoulou2 1 Gastroenterology Unit, “Konstantopoulio” Hospital, Athens, Greece; 2 Radiology, ”Konstantopoulio” Hospital, Athens, Greece Background: Although the number of various therapeutic procedures during ERCP are increasing exponentially almost yearly, information regarding the levels of radiation dose, and thus the safety for both the patient and the endoscopist, are inadequately studied. Aim of the study: To investigate radiation exposure dose levels for the endoscopist, nursing staff and the patient during several interventional procedures performed under ERCP. Patients and Methods: Data were collected for 987 patients-procedures in terms of patient age (A), KermaArea Product (KAP), fluoroscopy time (T) and total number of films (F) for a time period of 24 months. Six hundred thirty one (631) patients underwent endoscopic sphincterotomy (ES) plus balloon clearance of the common bile duct (Group A) and 356 had several other procedures (dilatations, plastic or metallic stent insertion, nasobiliary drainage) performed during ERCP (Group B). The Xray machine used was a conventional (non-digital) overcouch X-ray Philips Essenta system with automatic exposure control and with a KAP meter installed in the X-ray tube. Both the endoscopist and nursing staff were protected through a lead apron with collar, lead glasses and two articulated, ceiling-mounted, lead shields. Both endoscopist and nursing staff were radiation-monitored through a thermoluminescent dose-meter placed over the lead apron. Results: A large variation in KAP was observed in both Groups. Median radiation dose was 18.4 Gy/cm2 (range 8-371 Gy/cm2) for Group A and 31.0 Gy/cm2 (range 5.9-354 Gy/ cm2) for Group B (p⬍0.05, 95% CI). Corresponding median A, T and F values were 72 years, 1.5 min (range 0.5-13.7) and 1 X-ray film (range 1-3) for Group A and 75 years (p: ns), 2.5 min (range 1.2-8.2) (p⬍0.05, 95% CI) and 2 X-ray films (range 1-3) (p: ns) for Group B.Endoscopist and nursing staff monthly radiation was negligible (⬍0.0003 mSv), well below the 0.02 mSv monthly limit. Conclusions: a) With appropriate protective measures patient’s, endoscopist’s and nursing staff radiation can be minimal, even in complex interventional ERCP procedures, b) there is a relatively large variation in patient’s radiation dose in both less and more complex procedures with greater absolute values in the more complex ones.
Mo1459 Evaluation of a Fully Covered Self-Expanding Metal Stent in Malignant Biliary Obstruction: Follow-Up of a Multi-Center Study Jayant P. Talreja1, David E. Loren2, Thomas E. Kowalski2, Peter D. Stevens3, John M. Poneros3, Marisa A. Chow3, Isaac Raijman4, Divyesh V. Sejpal5, Sandeep Patel6, Laura Rosenkranz6, Kevin N. McNamara6, Alan Brijbassie1, Andrew Y. Wang1, Monica Gaidhane1, Amrita Sethi3, Michel Kahaleh1 1 Digestive Health, University of Virginia, Charlottesville, VA; 2 Gastroenterology, Thomas Jefferson, Philadelphia, PA; 3 Gastroenterology, Columbia University Medical Center, New York, NY; 4 Gastroenterology, Digestive Associates of Houston, Houston, TX; 5 Gastroenterology, Mount Sinai, New York, NY; 6Gastroenterology, University of Texas Health Science Center, San Antonio, TX Background and Aims: Limited data is available regarding fully covered metal stents in the management of malignant distal biliary strictures since its availability. The aim of this study was to evaluate the safety of a fully covered self-expanding metal stent (FCSEMS) in treating malignant biliary strictures at multiple institutions. We report our long term retrospective analysis from six centers. Methods: Between June 2007 and November 2010, 260 patients (142 males, median age 68 years) underwent ERCP with placement of FCSEMS (WallFlex, Boston Scientific, Natick, MA) for the palliation of obstructive jaundice in the setting of pancreatic adenocarcinoma (169), metastatic disease (36), cholangiocarcinoma (23), ampullary cancer (19), or other (13). Patients were evaluated clinically in follow-up and biochemical tests of liver function were obtained. Data was recorded for the following variables: patient survival, duration of stent patency, the need for subsequent biliary intervention and complications. Results: A total of 266 fully covered WallFlex stents were placed in 260 patients. There was a median survival of 100 days (range 7-531 days). There was a mean follow-up of 128 ⫾ 118 days (range 2-519 days). Biliary decompression was successful in 252 patients (97%). At the end of the study period, 121 were alive with a patent stent, 70 patients died with a patent stent, 40 patients were successfully bridged to surgery, 8 patients had their patent stent removed and no need for further stenting, 18 patients were lost to follow-up. Eight patients who had a successfully placed FCSEMS were considered a failure due to the following reason: migration (2), cholecystitis necessitating cholecystostomy placement (1), cholangitis (1), stent occlusion (1) intolerable pain (1), cystic duct obstruction (1), and removal for management of proximal biliary obstruction (1). Two additional patients experienced migration that did
not require FCSEMS removal or replacement. Stent replacement was required in 10 patients, of whom 6 had a second Wallflex placed. The remaining 4 were in the failure group and underwent replacement with either uncovered stents or plastic stents. Other complications, managed conservatively, included pain (2), post-ERCP pancreatitis (4), fever (1), retroperitoneal perforation (1) and postsphincterotomy bleeding (1). The mean patency duration was 328 days (SE 19.04). The patency percentage was 83% at 3 months, 63% at 6 months and 48.5% at 12 months. Conclusion: In the management of malignant distal biliary strictures, the fully covered Wallflex stent has acceptable patency and complication rates and achieves adequate biliary decompression in the majority of patients. Further long term prospective data are required to confirm this observation.
Mo1460 Endoscopic Snare Papillectomy for Early Invasive Cancer of the Papilla of Vater: A Clinico-Pathological Analysis Pietro Familiari1, Gianluigi Petrone2, Mika Matsuoka1, Massimiliano Mutignani1, Riccardo Ricci2, Vincenzo Perri1, Andrea Tringali1, Ivo Boskoski1, Cristiano Spada1, Paola Cesaro1, Guido Rindi2, Guido Costamagna1 1 Digestive Endoscopy Unit, Universita’ Cattolica del Sacro Cuore, Rome, Italy; 2Department of Pathology, Universita’ Cattolica del Sacro Cuore, Rome, Italy Background: Endoscopic Snare Papillectomy (ESP) is the standard of care for ampullary adenomas and in-situ carcinomas. Pancreaticoduodenectomy (PD) is performed for the treatment of invasive cancer, even if limited to the papilla of Vater (T1), because of the risk of local recurrences, nodal and distant metastases.PD is associated with significant morbidity and mortality, and may be precluded to many patients. Aim of the study is to evaluate the role of ESP in the management early stage invasive cancers of the papilla of Vater. Patients & Methods: Between 2000 and June 2009, 25 patients (mean age 68 years, range 36-87; 15 males) with an invasive adenocarcinoma apparently limited to the papilla of Vater (Tis excluded) underwent ESP in a single academic endoscopy center. After ESP, some patients underwent additional surgery (PD). Others, unfit-for-surgery, were followed-up. The findings of the pathological on ESP specimens (including tumor dimensions, grading, depth of infiltration, lymphovascular invasion, analysis of the margins of the resection) were compared with the findings after PD or with the outcomes of follow-up. Mean follow-up after ESP was 25.3 months. Results: Mean tumor diameter was 20.6 mm (range 460mm). Twenty patients underwent enbloc resection. Eight tumors were well-, 13 moderately- and 4 poorly- differentiated. Eight cancer invaded the lamina propria, 6 the submucosa, 11 the sphincter of Oddi or the duodenal wall. Only 4 specimens had disease-free margins, 15 were not assessable, 6 were clearly invaded. Lympho-vascular invasion was seen in 3 specimens.Ten patients underwent additional PD. Residual disease was seen on 7 of the surgical specimens (70%); lymph nodes were positive in 2 cases. Perioperative mortality was 20%. Fifteen patients, unfit for surgery, underwent follow-up (mean 27.7 months, 1-81 months). Nine (60%) had recurrent/residual adenomas or cancer and were re-treated by endoscopy; 1 patient (6.7%) was lost at follow-up; 2 patients (13.3%) are alive with local recurrences, 31 months after ESP; 7 (46.7%), included two re-treatments, are disease-free, 28.8 months after ESP; 4 patients (26.6%) died for disease progression, 17 months after ESP; 1 patient died for mammalian cancer, 81 months after ESP. Including the re-treated patients and 3
AB352 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
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