1047Prospective Sequential Protocol Analysis to Facilitate SelectiveBiliary Access for Difficult Biliary Cannulation in ERCPTae Hoon Lee*1, Sang-Heum Park1, Hyun Jong Choi2, Jong Ho Moon2,Sang-Woo Cha3, Young Deok Cho3, Yunho Jung1, IL-Kwun Chung1,Sun-Joo Kim1

1Division of Gastroenterology, Department of Internal Medicine, SoonChun Hyang University Cheonan Hospital, Cheonan, Republic ofKorea; 2Soon Chun Hyang University School of Medicine, BucheonHospital, Bucheon, Republic of Korea; 3Soon Chun Hyang UniversitySchool of Medicine, Seoul Hospital, Seoul, Republic of KoreaBackgrounds/Aim: During ERCP, 5-20% of cases fail for successful biliarycannulation even when performed by experts. Various techniques have beenattempted to improve the cannulation success rate. However, standardizedguidelines are not yet in place. We therefore prospectively investigated asequential protocol analysis to facilitate selective biliary access for difficult biliarycannulation (DBC) in ERCP. Methods: An early precut fistulotomy (EPF), adouble wire-guided cannulation (DWC), and a precut following pancreatic stentplacement (PPS) were performed sequentially according to an algorithm (Figure1) in DBC criteria; papillary contacts � 5 or cannulation time � 5 min or hooknose shape papilla, and unintentional pancreatic duct cannulation � 3. Thetechnical success rate, procedure outcomes, and complications in each groupwere recorded prospectively from May 2010 to August 2012. Results: A total of711 patients with naïve papilla underwent therapeutic ERCP. The 140 patients(19.7%) failed under initial standard wire-guided biliary cannulation. The EPF,DWC, and PPS were performed in 71 (50.7%), 33 (23.6%), and 36 (25.7%)patients. Total success rate of biliary cannulation based on sequential protocolwas 97.1%. The primary technical success rates were 94.4% (67/71, EPF), 100%(DWC), and 100% (PPS), respectively (P � .135). Successful cannulation timewas short in the DWC group (P � .001, Table 1). Compared with previousresults of PF only, sequential protocol methods significantly reduced successfulcannulation time in DBC (9.2 � 7.3 min in sequential protocol vs. 16.9 � 9.1min in PF only, P � .05). Regarding complications, post-ERCP pancreatitisdeveloped in 14 (10%) patients, which was not statistically significant betweengroups (P � .870) or compared with the conventional group (P � .125). In themultivariate analysis, female gender was a risk factor for pancreatitis (odds ratio4.16, 95% CI 1.108-15.645, P � .035). Conclusions: Based on the protocolanalysis, EPF, DWC, and PPS were safe and feasible in DBC. We suggest EPFusing DBC criteria, and PPS following DWC in unintentional pancreatic ductcannulation based on sequential protocol analysis.

Table 1. Protocol outcomes and complications

No. (%) EPF (n�71)DWC

(n�33) PPS (n�36)Total

(n�140) P value

Age, yr (SD) 65.6 (14.3) 61.1 (15.4) 69.6 (12.8) 65.61 (13.9) 0.048Successful cannulation time,

sec559.4 (412.8) 314.8 (65.2) 706.0 (469.4) 559.7 (403.6) � 0.01

Total success rate 67 (94.4) 33 (100) 36 (100) 136/140 (97.1) 0.135Success in first attempt 63 (88.7) 32 (96.9) 30 (83.3) 125/140 (89.3) 0.183Asymptomatic

hyperamylasemia5 (7) 3 (9) 2 (5.6) 10 (7.1) 0.849

PEP (mild/moderate/severe) 6/1/0 (9.85) 4/0/0 (12) 3/0/0 (8.3) 14 (10) 0.870

PEP; post -ERCP pancreatitis, EPF; early precut fistulotomy, DWC; double wire-guided cannulation,PPS, precut following pancreatic stent placement

1048Prospective Evaluation of Bacteremia and Cholangitis RatesFollowing Single Operator CholedochoscopyRajan Kochar*1, Richard Zubarik2, Shivangi Kothari1, Neeraj Sardana2,Shai Friedland1, Ann M. Chen1, Tu Nguyen1, Subhas Banerjee1

1Division of Gastroenterology and Hepatology, Stanford University,Stanford, CA; 2Division of Gastroenterology and Hepatology, Universityof Vermont, Burlington, VTBackground: With the wide availability of the Single Operator Choledochoscopy(SOC) platform over recent years, SOC for direct bile duct visualization isincreasingly performed at ERCP. SOC necessitates irrigation of the bile duct withwater or saline and this may increase intra-biliary pressure and the risks ofbacteremia, cholangitis and sepsis. Although the rates of bacteremia andcholangitis following ERCP are well established, those following SOC are notknown. SOC is therefore not currently covered in the ASGE antibioticprophylaxis guidelines for endoscopy. Aim: To prospectively evaluate the rate ofbacteremia, cholangitis and other infectious complications following SOC usingthe Spyglass™ choledochoscope. Methods: Patients requiring ERCP with SOC attwo tertiary care centers were enrolled into this study. Patients were excluded ifthey had received antibiotics within the previous week, if there was anindication for pre-procedure antibiotics based on ASGE guidelines, or if evidenceof infection was found at ERCP. Blood cultures were obtained immediatelybefore the ERCP, after completion of the ERCP portion of the procedure (to r/oERCP related bacteremia), and after completion of SOC. All patients received asingle dose of intravenous antibiotic after the last blood culture was drawn. Allpatients received follow up phone calls 24h and 7d post-procedure to identifydelayed infectious complications. Patients with positive blood cultures receivedadditional follow up at 1 and 2 months post-procedure. Results: Forty patients(mean age: 62 yrs, 53% male) underwent ERCP with SOC. Blood cultures inthree asymptomatic patients grew coagulase negative Staphylococcus (n�2) andBacteroides thetaiotaomicron (n�1); these were considered contaminants. Threeasymptomatic patients (7.5%) had positive blood cultures in both post-ERCP andpost-SOC sets, due to transient ERCP related bacteremia and were not treated.Four patients (10%) had negative blood cultures following ERCP but positiveblood cultures after SOC, implying SOC related bacteremia: E. coli (n�2), K.pneumoniae and vancomycin resistant Enterococcus (VRE) (n�1) and K.pneumoniae and alpha hemolytic Streptococcus (n�1). Two of these patients(5%) developed cholangitis requiring hospitalization and IV antibiotics. The othertwo patients were asymptomatic and received PO antibiotics. All patientsrecovered completely. No significant difference was evident in demographic orprocedure related factors between patients who developed SOC relatedbacteremia and those who did not (Table 1). In particular there was nodifference in irrigation fluid volume or duration of SOC. Conclusion: ERCP withSOC is associated with a 17.5% bacteremia rate and SOC alone with a 10%bacteremia rate and a 5% cholangitis rate. Pre-procedure antibiotic prophylaxisshould be considered for patients undergoing SOC

Table 1. Patient and procedural characteristics in ERCP/SOC patients

ParameterPatients with

Bacteremia (n�4)Patients without

Bacteremia (n�36)

Mean Age 68 61Gender (% male) 100 47Indication for ERCP/SOCLarge stone: EHL/Laser, n(%) 2 (50%) 15 (42%)Biliary stricture, n(%) 1 (25%) 11 (32%)Abnormal imaging, n(%) 1 (25%) 7 (19%)Other, n(%) — 3 (9%)Mean Irrigation fluid volume (ml) 250 264Mean SOC procedure time (min) 22 23Mean ERCP procedure time (min) 36 37

1049Utility of Sildenafil for ERCP CannulationMartin A. Gomez*Internal Medicine, Universidad Nacional de Colombia, Bogota,ColombiaPancreatitis post ERCP is the most common complication of this procedure.Difficult cannulation (more than 10 attempts, � 10 minutes or more than 5pancreatic cannulations) has been associated as a risk factor for pancreatitis, forthis reason is important to implement measures that facilitate cannulation.Sildenafil is a very safe drug used in erectile dysfunction but has also been used

Abstracts

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