Abstracts

cholangitis (4), papillary hemorrhage (2) and acute necrotizing pancreatitis (1). Latecomplications occurred in 18% due to either occlusion of the stent or extension ofthe biliary stricture outside the stent in 18% (18/89 pts) with a median stentpatency of 212 days in cases of stents placed entirely within the biliary system and184 days in cases of stent placement in a transpapillary position, p Z 0.78. Twopatients died with cholangitis post ERCP. This study shows that placement ofa single metallic stent is sufficient in patients with malignant hilar strictures. Theplacement of a single stent in the left lobe of patients with stages II to IV diseasewas particularly effective with regression of jaundice in 85% of patients. Aprospective study of these patients after attempt to preferentially place a stent inthe left duct is actually underway to confirm our results.

S1580

Multiple Sampling Method Increases the Diagnostic Yield in Non

Pancreatic Malignant Biliary Obstruction (MBO)John T. CunninghamBackground and Aim: The yield of brush cytology (Cyt) in malignant bile duct (BD)strictures is low, multiple sampling methods have given variable results. Ourdatabase has been prospectively recording our experience with intraductalsampling with biopsy block Cyt (B x C) and brush Cyt (BrC) as part of a QAexercise. We report our experience with our last 43 cases of non pancreaticMBO. Materials and Methods: Once a suspicious bilary stricture is identified @ERCP and a 0.035’’ guidwire inserted, a 9.6 French (Fr) biliary cannulation sleeve(Cook Medical, Winston Salem) with its 6 Fr inner guide catheter are advancedover the wire and through the stricture. The guide catheter and wire removed.Through the sleeve a pediatric Bx forceps (Boston Scientific, Boston) anda cytology brush with a 5 or 6 Fr covering catheter are inserted and the sleeverepositioned in the duct to allow sampling. 4 bx specimens from within thestricture and the brush are sent in preservative for Cyt evaluation. For this studypathology reading of malignancy is our only positive recording, while suspiciousand atypical diagnoses are considered negative. Results: 110 strictures wereevaluated, 16 were benign, 51 were primary pancreatic and 43 non pancreatic(cholangioCa-27, gallbladder-8, metastatic 8)and they are reported here. Eachsampling method was compared to both in combination using a Chi Squareanalysis in the table below. 37/43 cases were positive by @ least one sample. Ofthe 6 negatives (3 suspicious and 3 negative)were confimed cancers by EUS,PTC or surgery. After sampling is completed the sleeve system could be used toinsert a 10 Fr plastic stent, or a metal inserted over the wire. Combinedsampling was stastically superior to either method alone. Conclusions: 1).Combining BrC and BxC is statistically superior to either alone. 2). Using thesleeve system for multiple sampling gives a high overall yield. 3). This samplingmethod would not confer the risk of seeding the biopsy tract like percutaneousor EUS sampling in surgical candidates

Method # positive (%) cumulative (BrC D BxC) (%) P value

www.giejou

rnal.org

BrC

27/43 (63%) 37/43 (86%) p Z 0.01 BxC 29/43 (67%) 37/43 (86%) P Z 0.05

S1581

Aggressive Endoscopic Balloon Dilatation and Multiple Stents

for Can Lead to Resolution of Post Orthotopic Liver Transplant

Biliary StricturesBing Hu, Fenghai Yu, Yamin Pan, Like Bie, Tiantian Wang, Biao GongBackground: The biliary anastomosis has long been considered as the Achilles heelof Orthotopic liver transplantation (OLT) and anastomotic strictures (AS) accountfor more than half of biliary complications. We report our experience in theendoscopic management of anastomotic strictures following OLT. Method: FromJanuary 2001 to October 2007, 307 cases with post-OLT biliary complicationsunderwent 359 ERCPs. One hundred and ninety-eight patients were confirmed tohave biliary strictures. Eighty-three patients with dominant AS without other biliaryproblems (i.e. diffuse stricture, cast or biliary necrosis) were enrolled in currentstudy. A single stent (without dilatation) would be inserted in patients within 3months of surgery. This would be followed by serial balloon dilatation would becarried out followed by multiple stents placement until at least three stents weresuccessfully implanted. The stents were kept in place for six months and removed ifcholangiogram demonstrated no evidence of stricture and laboratory test revealedresolution of cholestasis. Results: The Mean (SD) age of 83 patients was 45.3 (11.2)yrs with M/F ratio of 70/13. Initial drainage with a single stent (n Z 16) andnasobiliary drain (n Z 17) were performed in patients early in post OLT period andwith associated bile leak. Other 50 patients underwent 65 procedures witha median of 3.7 stents (range: 2-6 10 Fr stents) with or without pre-dilatation.Thirty-three cases were re-evaluated after mean period of 6.8 (range 0.5-17.5)months and twelve patients (36.4%) showed stricture resolution after stentsremoval. Futher stents were inserted in remaining patients. Balloon dilatation (F 6-10 mm) led to 45.5% (10/22) of stricture resolution, but no dilation and catheter

Vo

dilation only 14.2% (1/7) and 25.0% (1/4) respectively. The relationships betweenthe number of stents and success rate are showed in the table 1. The mean stentingduration for stricture resolution group was 5.5 (range 1.5-9.1) months and 7.6(range 0.5-17.5) months for the unresolved group. Conclusion: Initial single stentdrainage followed by aggressive balloon dilatation and multiple stents (of at least21Fr) of more than 6 months can lead to resolution of AS.

The relationship between number of stents and outcome

AS resolution

lume 67, No.

5 : 2 008 GASTROIN TESTINAL ENDO

No. of stent

n Total size (Fr) Follow-up case n

SCOPY

%

2

16 14-17 16 3 18.8 3 29 21-25.5 9 2 22.2 4 17 29.5-34 6 6 100 5 2 35 1 1 100 6 1 42 0 0 - Total 65 33 12 36.4

M1286

Frequency of Distal Esophageal Landmark Identification and

Adherence to Biopsy Standards At Index Endoscopy in Patients

Referred for Ablative Therapy for Barrett’s EsophagusStephen Kucera, Sabo B. Tanimu, Jason B. Klapman, James S. BarthelIntroduction: A pay for performance program, which links performance and qualityto reimbursement, has been instituted, and it is anticipated that gastrointestinalendoscopy will soon be subject to this model. As a referral center for Barrett’sesophagus (BE) ablative therapy, we have observed the frequency of distalesophageal landmark identification and adequacy of mucosal biopsy sampling atindex endoscopy (IE) from referring gastroenterologists to be low. Methods: Aretrospective review of 49 patients treated with photodynamic therapy and Barrxfor BE with high grade dysplasia between 10/15/03 and 10/15/07 at a tertiary carereferral center was performed. IE reports were reviewed for identification of thefollowing esophageal landmarks 1) diaphragmatic hiatus, 2) gastroesophagealjunction (GEJ), and 3) squamocolumnar junction (SQJ). The number of biopsiestaken from the segment of BE at each IE was recorded. An IE report was consideredcomplete if all 3 esophageal landmarks were identified and adequate if both theGEJ and SQJ were identified. The IE was considered to contain an appropriatenumber of biopsies if 4 quadrant biopsies were obtained every 2 cm of the Barrett’ssegment. Confirmatory endoscopy at the referral institution provided landmarkswhen not obtainable from the IE. Results13 of 49 (26.5%) IE reports were completeand 25 of 49 (51%) were adequate. 14 of 49 (28.6%) IE contained an appropriatenumber of biopsies for the length of BE. Only 7 of 26 (26.9%) IE cases of longsegment BE (O 3 cm) contained appropriate biopsy sampling. 14 of 23 (60.9%) IEcases of short segment BE (!3 cm) contained appropriate biopsy sampling. Theaverage length and number of biopsies taken at IE for long segment BE was 6.8 cmand 9.6 biopsies compared to 1.70 cm and 3.4 biopsies for short segment BE.Contingency table analysis using Fisher’s Exact Test revealed P Z 0.022 forcomparison of biopsy sampling between short and long segment BE. Discussion:The percentage of IE reports which were complete or adequate, and thepercentage containing appropriate numbers of biopsies for the length of BE weresurprisingly low. We also observed a statistically significant difference between shortand long segment BE in regards to adequacy of biopsy sampling, which wespeculate may result from the length of time required to perform 4-quadrantbiopsies every 2 cm in long segment BE. As we move towards pay for performance,quality endoscopy will become increasingly important for reimbursement but hasthe benefit of improving patient care. Programs to further educate physicians in theimportance of improving endoscopy reporting and performance are needed.

M1287

Correlation of Barrett’s Histological Surveillance Biopsies

Versus Final Endoscopic Mucosectomy Resection (EMR)

Specimens: Are We Seeing the Forest Or Just the Trees?Jennifer S. Chennat, Vani J. Konda, Andrew S. Ross, Alberto Herreros DeTejada, Barbara M. Cislo, Lynne Stearns, Amy E. Noffsinger, John Hart,Charles E. Dye, Mitchell C. Posner, Mark K. Ferguson, Irving WaxmanBackground: Current guidelines advocate Barrett’s esophagus (BE) endoscopicsurveillance with random 4 quadrant biopsies from at least every 1-2 cm ofesophageal mucosa with additional targeted biopsies of any visible lesions.Sampling error may occur with conventional biopsies when measured againstdefinitive EMR specimens, leading to potential inadvertent mismanagement ofdysplasia. Given the current trend towards non-tissue acquiring endoscopicablation modalities, accurate pathological information is critical. AIM: Tohistologically compare Barrett’s surveillance biopsies obtained from patientsreferred for endoscopic therapy with the final EMR specimens. Methods:Retrospective chart review of all EMR patients who had pre-mucosectomysurveillance biopsies was done. Endoscopy was performed with white lightsupplemented by narrow band imaging (NBI) in some cases for more targeted

AB171