Abstracts

(49.5�1.23 vs. 37.17�2.05, p!0.05). When the results were stratified according tothe level of ERCP experience (!100 versus O 100), the difference in pre and postunderstanding, confidence, and credibility scores were significantly higher for theless experienced endoscopists than that for the experienced endoscopistsregardless of the type of simulator (Table). The scores for realism, usefulness as aninstructional tool, and applicability were higher among the less experiencedendoscopists for both types of simulators, but were only statistically significant forthe CS when compared to the experienced. There was no statistical difference inthe scores for the MS between the two groups. Conclusion: Endoscopists at varyinglevels of experience evaluated the MS as superior to CS for ERCP practice, whichwas more significant among less experienced endoscopists.

Table. Difference in scores based on ERCP experience

Computer simulator Mechanical simulator

www.giejournal.org

Survey question

!100 ERCPexperience

Oe

100 ERCPxperience

!e

100 ERCPxperience

Oe

100 ERCPxperience

Understanding(differencebetween pre and post)

3.07 � 0.84y -

0.75 �0.75y

5

.23 � 0.99 1 .25�1.70

Confidence(differencebetween pre and post)

3.07 � 0.90 0

.75 � 0.75 6 .15 � 1.12 3 .0 � 2.12

Credibility(differencebetween pre and post)

1.71 � 1.92 -

6.0 � 5.73 7 .54 � 2.17 3 .75 � 2.59

Realism compared tohuman ERCP

45.29 �2.04y

38

1.75 �.64y

5

9.57 � 2.29 5 4.0 � 5.80

Usefulness as aninstructional tool &applicability

39.79 �1.59y

2

8.0 � 5.67y 5 0.5 � 1.26 4 6.0 � 3.11

Data expressed as mean � SEM (standard error of mean). For endoscopists with!100 ERCP experience, NZ14 except for mechanical understanding/confidence/credibility scores where NZ13. For endoscopists with O100 ERCP experience,NZ4 for computer and mechanical. y p value significant.

S1345

Outcomes in Lymphoma Patients with Obstructive JaundiceChukwuma I. Egwim, Michael J. Wallace, Michael Wang, Jeffrey H. Lee,David C. Madoff, William A. RossIntroduction: Obstructive jaundice is a rare complication of lymphoma. There isscant literature to guide the management of these patients. Methods: Medicalrecords from June 2002 to October 2008 were reviewed to find all lymphomapatients that developed obstructive jaundice and underwent endoscopic (ERCP) orpercutaneous biliary (PBD) decompression to determine outcomes. FINDINGSThirty-five patients (23 males) with mean age of 57.6 were identified. Large B celllymphoma was the diagnosis in 24. Hodgkin’s lymphoma and follicular lymphomawere each responsible for 4 cases. Jaundice was part of the initial lymphomapresentation in 13. Twenty-five patients were treated with ERCP. Nine had PTC, 5 ofwhom had prior attempts at ERCP. One patient had both ERCP and PTC. Onepatient had 7 ERCPs and two others had 7 and 11 PBD procedures. Stents wereplaced in all patients but one with CBD stones. Plastic stents were used in 38 of the42 ERCPs where stents were placed. This percentage of plastic stents usage issignificantly higher than in other patients treated with ERCP for malignant jaundiceat our institution (90% vs. 55%, p!.0001). Only plastic stents were used in PBD. Allpatients with stents had documented stricture but one who was ultimatelydiagnosed with intrahepatic cholestasis. Of the 33 patients with stricture, 28achieved normal bilirubin after stent placement in an average of 18.5 days frommean bilirubin of 8.3mg/dl. Four others died without normalization but had anaverage decline in bilirubin of 77%. One patient failed to respond to stentplacement and died of bile peritonitis 28 days after PTC. There were 4 episodes ofpancreatitis after ERCP. Three were mild but one was complicated by bacteremiaand prolonged hospitalization by 14 days. Of the 13 patients whose initialpresentation of lymphoma included obstructive jaundice, 7 are alive at an averageof 30 mos and 6 died an average of 14.3 mos after stent placement. Only 2 of the 22developing jaundice after presentation are alive. One of these survivors had CBDstones as etiology of obstruction. Overall mean survival is significantly higher inthose presenting with jaundice than those who develop it later in the course of thedisease (20.4 vs. 5.6mo, pZ.001). Conclusions: Obstructive jaundice in the settingof lymphoma responds well to stent placement. Plastic biliary stents are advisedinitially in all lymphoma patients due to the responsiveness to first linechemotherapy and the limited survival in those developing jaundice after initialpresentation. However, metal stent usage may reduce the number of proceduresrequired in a select group of patients.

S1346

The Effectiveness and Safety of Minor Endoscopic

Sphincterotomy Plus Large Balloon Dilation for Removal of Bile

Duct Stones in Patients with Periampullary DiverticulaHyung Wook Kim, Dae Hwan Kang, Cheol Woong Choi, Dong UK Kim,Min Dae Kim, Jin Ho Lee, Jae Seung Lee, Yong Mock Bae, Jeung Ho Heo

Vo

Background: Endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) isa useful method to remove bile duct stones. PAD have been reported to beassociated with the risk of complications and difficulty of stone removal. However,the effectiveness and safety of minor EST plus LBD in patients with PAD for removalof bile duct stones is not well known. Objective: The aim of this study is to evaluatethe effectiveness and safety of minor EST plus LBD for removal of bile duct stonesin patients with PAD. Patients and Intervention: Total one hundred thirty ninepatients with bile duct stones were included. Among them, 73 patients (median age70 years (40w89); 37 men, 36 women) had PAD and 66 patients (median age 64years (23w89); 39 men, 27 women) had normal papilla. PAD were classified in 3different types according to the position of the major duodenal papilla; type1,inside the diveticulum; type2, in the margin of the diverticulum; type3, near thediverticulum. LBD (10 to 20 mm balloon diameter) was performed after minor EST.Main outcome measurements: Successful stone removal and complications such aspancreatitis, bleeding. Results: The mean age was significantly increased in PADgroup compared with normal group (69.9 vs 62.1, P! 0.001). PAD group comparedwith normal group resulted in similar outcomes in terms of overall complete stoneremoval (94.5% vs 93.9%), complete stone removal in single session (69.9% vs81.8%), mechanical lithotripsy (12.3% vs 13.6%). Complications were similarbetween the 2 groups (11.0% vs 7.6%, PZ0.497). Clinical outcomes according totypes of PAD were similar. Conclusions: Minor EST plus LBD was effective and safetreatment modality for removing bile duct stones in patients with PAD. The types ofPAD did not influence clinical outcome.

S1347

Plastic Stents May Be Superior to Self-Expandable Metallic

Stents (SEMS) in Palliating the Very Complex Malignant Hilar

StricturesMichael Schafer, Laith H. Jamil, Simon K. LoIntroduction: SEMS are rapidly becoming the preferred method to palliatemalignant hilar biliary obstruction despite limited data regarding their superiorityover plastic stents. We believe that SEMS are not appropriate for complex stricturesin the liver hilum. Aim: Evaluate the outcomes of patients treated with plastic stentsfor complex malignant biliary obstruction. Methods: Retrospective review of allpatients treated with plastic stenting for complex (Bismuth III & IV) hilar stricturesbetween January 2001 and October 2008. Results: 210 ERCPs were performed on 37patients. An average of 5.7 procedures were performed per patient (range 1-15).The median number of procedures was 4. The majority (78%) of patients hadcholangiocarcinoma. The remaining had either liver metastases (19%) or gallbladder cancer (3%). The median survival was 7.3 months (range 0-70.8) (fig. 1).The average length of time between procedures per patient was 12.4 weeks. Threepatients had only one procedure performed prior to their death. When thosepatients were excluded, the median survival increased to 8.0 months. A therapeuticendoscopist blinded to the outcome of the procedure reviewed eachcholangiogram. Adequate (at least 25%) drainage was deemed impossible usinga single metal stent in 33% of cases. Of those where a single metal stent wasa possibility, most would drain only one-third of the liver. Conclusions: Comparedwith published data (Freeman ML GIE 2003), our Bismuth III/IV patients seem tohave slight survival advantage over those treated with single metallic stents. Thisadvantage, if confirmed by larger studies, may be offset by the increased costs andinconvenience of every three-months plastic stent exchanges. Nonetheless, there isa subset population that cannot technically be treated by metal stents who shouldbe offered plastic stents as the sole means of palliation.

S1348

A Protocol of Multiple Side By Side Stenting of Symptomatic

Common Bile Duct Strictures Secondary to Pancreatitis - Long

Term OutcomeMichael P. Swan, Michael J. Bourke, Adam A. Bailey, Stephen J. WilliamsBackground: Common bile duct strictures occur in 1/3 of patients with chronicpancreatitis. Although often asymptomatic, they may be associated with jaundice,abdominal pain or cholangitis. Early symptomatic stricture recurrence occurs with singlebiliary stent treatment. Operative management is advocated but carries potential

lume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB149