Abstracts

Table 1. Outcomes of weekday compared to weekend hospital

Sur-N EUS-N
admission for acute cholangitis. (n[35) (n[28) p value
Weekday Weekend
Bleeding (%) 1 (3) 5 (18) 0.11
admissions admissions
Chylos ascitis (%) 1 (3) 0 1
n[129 n[52 p-value
New onset organ failure (%) 4 (12) 3 (11) 1
ERCP performed, n (%) 101 (78.3%) 39 (75.0%) 0.64 Death (%) 2 (6) 4 (14) 0.47
Time to ERCP, mean 34.8  25.3 31.0  20.8 0.37 Fischer’s test; and non-parametric Wilcoxon’s test
hrs  SD
ERCPs within 24 hrs, n 51 (50.0%) 22 (56.4%) 0.50
(%)
Frequency, an type of delayed adverse events after treatment of
ERCPs within 48 hrs, n 79 (77.5%) 30 (76.9%) 0.95
patients with WOPN
(%)
Mortality, n (%) 6 (4.7%) 1 (1.9%) 0.36 Type of adverse events SUR-N EUS-N
LOS, mean days  SD 4.6  4.0 4.3  2.4 0.59 after the procedure (n[35) (n[28) p value
New onset Diabetes (%) 5 (15) 1 (4) 0.31
Pseudocysts (%) 5 (15) 2 (8) 0.62
Exocrine insuficiency (%) 10 (30) 4 (16) 0.29
Bowel obstruction (%) 7 (21) 0 0.04
Sa1403
Biliary obstruction 9 (27) 0 0.01
Endosonography-Guided Necrosectomy Versus Surgical Need of new Surgery because 12 (36) 2 (8) 0.02
Treatment of Infected Walled-Off Pancreatic Necrosis: A the adverse events (%)
Comparative Study
José C. Ardengh1,2, Eloy Taglieri2, Otávio Micelli-Neto2,
Juliana C. Barbosa*1, Débora Pacheco2, Ana C. Santaella2, Rafael Kemp1,
Jorge Elias-Júnior3, Jose Sebastiao S. Dos Santos1 Sa1404
1
Anatomy and Surgery, Hosp. Clin. Fac. Med. Ribeirão Preto - Non-Indicated Endoscopic Retrograde Cholangiopancreatography
Universidade de São Paulo, São Paulo, Brazil; 2Endoscopic Service, in Suspected Choledocholithiasis: Prevalence, Complication, and
Hospital 9 de Julho, São Paulo, Brazil; 3Radiology, Hosp. Clinicas da Diagnostic Yield
Faculdade de Medicina Ribeirão Preto, Ribeirão Preto, Brazil Parit Mekaroonkamol*, Mehul Parikh, Ravi Vora, Stephen H. Berger,
The surgical necrosectomy (SUR-N) of walled-off pancreatic necrosis (WOPN) has high
Emad S. Qayed
morbidity and mortality rates. The new options of treatments have been increasingly
used such as step-up approach and endoscopic drainage. The endoscopic approach is Gastroenterology, Emory University, Atlanta, GA
not yet defined as a first option for this treatment, but have been increasingly used for Gallstone diseases affect more than 20 million people in the United States. Endo-
its efficacy, safety and the possibility of necrosis approach in any situation with the aid scopic retrograde cholangiopancreatography (ERCP) is the diagnostic and thera-
of endoscopic ultrasonography (EUS). The objective was to study and compare the peutic intervention of choice for patients at high risk for choledocholithiasis
characteristics, clinical course, the immediate and late adverse events in patients with however, it is recommended to be deferred to less invasive modalities when the risk
WOPN treated by SUR-N and EUS-guided necrosectomy (EUS-N). 63 patients with for choledocholithiasis is intermediate due to its high complication rate. This study
WOPN were treated by SUR-N (35) and EUS-N (28) from Aug/90 to Jul/2014. The mean aims to evaluate diagnostic yield and risk associated with the procedure when it is
age was higher in the EUS-N (p !0.01). Sex, ASA index, diabetes, obesity, and car- performed outside of the current guideline’s recommendation. All ERCP performed
diovascular risk factor before treatment were similar to the SUR-N and EUS-N groups in our tertiary care public hospital after the publication of American Society of
(pO 0.05). Cause of AP (pZ0.06), infected necrosis (pZ0.13) and median time from Gastrointestinal Endoscopy (ASGE) guideline for endoscopic evaluation of sus-
onset of symptoms to treatment (pZ0.34) were similar for both groups. The Marshal pected choledocholithiasis in 2010 were reviewed. Majority of patients were African-
(p!0.01) and CT Balthazar score (p!0.01) were significantly higher for SUR-N. Acute American (73%) and female (76%) with a mean age of 41 years old. Out of 63
adverse events were statistically significant for the EUS-N vs SUR-N (71% vs 37%, p! procedures performed for suspected choledocholithiasis, 9 (14%) were non-indi-
0.01). The average length of stay of patients after the start of treatment (SUR-N vs EUS- cated according to the current guideline. All 9 procedures were performed for pa-
N) was 16.4 days (7-105) and 28.4 days (7-56), respectively. The average time between tients at intermediate risk for choledocholithiasis with the mean common bile duct
the first session and the last necrosectomy procedure (SUR-N vs EUS-N) was 37.5 days diameter of 7 mm and the mean bilirubin level of 1.4 mg/dL. The reason to proceed
(1-116 days) and 17.5 days (5-45 days), respectively. The average EUS-N sessions was with ERCP without obtaining magnetic resonance cholangiopancreatography
3.5 sessions per patient (1 to 9) and the average surgeries was 1.6 per patient (1 to 6). (MRCP) first was documented in 55% of the cases. All were because of surgeon’s
Twenty-three patients underwent a single surgery. Another needed six successive requests. Among non-indicated ERCPs, 67% found choledocholithiasis and suc-
reoperations. Despite the occurrence only in SUR-N group of sepsis, post-operative cessfully extracted the stones. There was no statistically significant difference be-
hernia, bowell obstruction, pneumonia, fistula (pancreatic and biliary) and chylous tween bilirubin level, common bile duct size, presence of biliary pancreatitis, age,
ascites there was no statistical difference compared to EUS-N group. The late adverse race, gender, or body mass index of ERCP with positive and negative findings.
events were statistically significant for patients undergoing SUR-N vs EUS-N in relation Overall rate of complication was 4.7%, similar to previous studies. Majority of
to bowell and biliary obstruction (21% vs 0%, pZ0.04 and 27% vs 0%, p Z 0.01, complications were post-ERCP pancreatitis with one case (1.5%) of post-sphincter-
respectively) and required surgery (36% vs. 8%, pZ0.02, respectively). The average otomy bleeding. When looking at only patients with intermediate risk for choledo-
follow-up was 493 days, there was no difference between patients who underwent cholithiasis who underwent an ERCP, only 47% received MRCP first as
SUR-N and EUS-N in relation to pancreatic sequelae, including pseudocyst (p Z 0.62), recommended by ASGE guideline. No discrepancy between MRCP and ERCP find-
cases of onset diabetes (pZ0.31) or need for pancreatic enzymes (pZ0.29). ings was observed. Even though 14% of ERCPs performed for suspected choledo-
Compared to SUR-N, the EUS-N showed a lower rate of adverse events. EUS-N appears cholithiasis were non-adherent to the current guideline, there was a substantial yield
to be a safe and effective procedure must be included in the therapeutic algorithm of 67% from the “non-indicated” procedures. The reasons for this unexpectedly high
patients with WOPN. diagnostic yield in our African-American predominate population remain unclear.
We found no predicting parameter of positive ERCP in this study. However, the
statistical analysis was likely underpowered due to the small number of non-indi-
Frequency, type of adverse events and mortality rate immediately cated procedures. ERCP may be considered as an initial diagnostic modality in
after treatment of patients with WOPN. population with high prevalence of choledocholithiasis among patients with inter-
Sur-N EUS-N mediate risk. Its cost-effectiveness should be further assessed with procedural risk
taken into consideration. Multi-specialty approach is essential in improving adher-
(n[35) (n[28) p value
ence to the guideline.
Patient with more than 1 adverse event 8 (23) 1 (4) 0.07
Total imediate adverse events 25 (71) 10 (37) !0.01
Septicemia (%) 7 (21) 5 (18) 0.45
Postoperative hernia (%) 6 (18) 0 0.06
Bowel obstruction (%) 4 (12) 0 0.18
Pneumonia (%) 3 (9) 0 0.32
Pancreatic fistula (all grades) [%] 2 (6) 0 0.57
Biliary Fistula (%) 1 (3) 0 1

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