Abstracts

diagnosis of AIP, since narrowing of the main pancreatic duct in AIP was notvisualized on MRCP. MRCP findings of segmental or skipped non-visualized mainpancreatic duct accompanied by a less dilated upstream main pancreatic duct maysuggest the presence of AIP. MRCP is useful for following AIP patients.

T1493

Mechanical Simulator Practice Speeds Up Selective Cannulation

Time of Novice Trainees in ‘‘Standard’’ but not ‘‘Distorted’’

Simulator SettingsJoseph W. Leung, Brian S. Lim, Robert E. Wilson, Wei-Chih Liao, Jaw-Town Lin, Zhao-Shen Li, Khean-Lee Goh, Felix W. LeungBackground: We previously reported that ERCP skills and experience can bereflected by the speed of cannulation using a mechanical simulator. Aim: Todetermine if simulator practice can improve (speed up) selective cannulation bynovice trainees. Method: As a preparatory step to participation in an internationalmulti-center prospective randomized controlled trial, novice trainees (!10 ERCPexperience) performed simulated cannulation practice using a mechanicalsimulator. They received hands-on one-on-one training by the trainer (JWL). Theylearned to perform selective cannulation of bile and pancreatic ducts usinga catheter, guide wire, and simulated fluoroscopy. Practice included selectivecannulation using 5 simulator settings. These include use of ‘‘standard’’ (S) settingsof flat (2 mm thick) papilla with single opening and papilla (10 mm thick) withsingle opening but dual channels; and ‘‘distorted’’ (D) settings of (10 mm thick)papilla with separate bile duct and pancreatic duct orifices, rotated papilla androtated duodenum. Trainees performed 3 practice sessions with each setting. Initialpractice involved verbal and hands-on instructions by the trainer in order to enabletrainees to understand the mechanics of the practice. For the second and finalpractices, trainer assistance was given only if the trainees encountered problems.Time taken for selective cannulation during the second practice was compared withthat for the final practice using paired t-test. Results: There was significantimprovement (shorter cannulation time) for 2 of the 5 settings (see Table).Conclusion: Given appropriate instructions, novice trainees can execute thetechniques of selective cannulation using a mechanical simulator. With a limitednumber of only 3 practice sessions, selective cannulation time was significantlyshortened for the ‘‘standard’’ settings but not for the ‘‘distorted’’ settings. Theobservations support use of simulator practice in novice trainee education. Morethan 3 sessions may be necessary for the impact of repeated practice in ‘‘distorted’’settings to be demonstrated.

Cannulation Time with Various Simulator Settings

Cannulation Time in Seconds

www.giejournal.org

Simulator Setting

Second Practice Final Practice p-value

Flat papilla (S)

92 (12) 60 (15) ! 0.05 Papilla with single opening(S) 129 (31) 59 (9) ! 0.05 Papilla with 2 separate orifices (D) 65 (12) 61 (10) NS Rotated papilla (D) 78 (20) 91 (37) NS Rotated duodenum (D) 84 (18) 134 (23) NS

Number of Trainees Z 12 Data are expressed as mean (SEM)

T1494

The Effect of Sildenafil on Sphincter of Oddi Pressure in

Patients Undergoing ERCP for Suspected Sphincter of Oddi

DysfunctionKevin C. Ruff, Stuart L. Triester, Michael D. Crowell, M. Edwyn HarrisonBackground: Acute pancreatitis is a common complication of endoscopicretrograde cholangiopancreatography (ERCP) with no reliable way to prevent post-ERCP acute pancreatitis. Nitric oxide (NO) donors show benefit in reducingsphincter of Oddi (SO) tone and the incidence of post-ERCP acute pancreatitits.Sildenafil is a phosphodiesterase-5 (PDE-5) inhibitor whose effects are mediatedthrough a NO messenger pathway, a major inhibitory pathway in the smoothmuscle of the gastrointestinal tract. Aim: Determine if sildenafil reduces SOpressure in patients undergoing ERCP for evaluation of suspected SO dysfunction.Methods: Adults referred for ERCP with sphincter of Oddi manometry to evaluatesuspected SO dysfunction were recruited for the study. SO pressures weremeasured using a hydraulic capillary infusion system. Initial readings of biliarysphincter pressures were obtained using the 10-station pull-through technique.Fifty milligrams of sildenafil dissolved in 20 mL of water was injected through thetherapeutic channel of the duodenoscope into the duodenum after removing themanometry catheter. Repeated pressure measurements were obtained with thesame technique, after allowing 30 minutes for absorption of the medication.Results: A total of seven patients completed the study ranging in age from 31 to57 years old. Six of the seven participants were women and three of the sevenparticipants were hospitalized at the time of the testing. Six out of sevenpatients had sphincter of Oddi dysfunction, as defined by basal biliary sphincterpressures O40 mmHg: the average pre-treatment SO pressure for the group was

Vo

81.96 þ/� 51.78 mm Hg. After instillation of sildenafil, the average SO diminishedto 29.12 þ/� 26.99 mm Hg. The mean change in SO pressures was found to be52.84 þ/� 40.62 mm Hg (95% CI, 10.21 mm Hg to 95.46 mm Hg, p Z 0.02).Conclusions: Sildenafil administration into the duodenum during ERCP significantlydecreased the basal biliary pressure of the SO in individuals undergoing SOmanometry for the evaluation of SO dysfunction.

Basal Biliary Sphincter Pressures

Pre-Treatment

lume 67, No. 5 : 2008 GASTROINTESTINAL ENDO

81.96 þ/- 51.78 mm Hg

Post-treatment

y z

29.12 þ/- 26.99 mm Hg

Mean Change ,

52.84 þ/- 40.62 mm Hg

y95% CI 10.21 mm Hg to 95.46 mm Hgzp Z 0.02

T1495

Evaluation of a New, Mechanical ERCP SimulatorJoe Healy, James Kimberly, John Baillie, Stan Remiszewski,Jeffrey Radziunas, Ronald L. Green, Barbara WilkesBackground: ERCP is arguably the most technically demanding endoscopicprocedure. Many attempts at ex-vivo ERCP simulation have been made over theyears. Both computer and animal models have advantages, but cost and anatomicdifferences are significant limitations. If proven to be realistic and affordable,a reusable, mechanical model may provide the most cost efficient simulation.Hypothesis: A simple mechanical model can be used to familiarize inexperiencedbiliary endoscopists with the complexities of side-viewing endoscopy and ERCP.Methods: Four GI fellows (subjects A-D) with no prior experience of usinga duodenoscope or performing ERCP were compared to a third year fellow (subjectE) with experience of approximately 150 ERCPs. A prototype static desktop ERCPsimulator developed by an American endoscopy accessory manufacturer wasemployed, using a standard 3.8 mm channel duodenoscope and commercially-available papillotomes. Times to deep cannulation from a variety of positions (easy,difficult, partially obstructed view) were recorded. After their experience, thefellows were polled for their opinions regarding the usefulness of the simulator fororienting to the duodenoscope and cannulating the papilla. Results: Noviceendoscopists required significantly longer to achieve biliary cannulation (mean:1min 21secs) when compared to experienced endoscopists (mean: 28secs). Overfive repetitions of each challenge, the novices significantly decreased their time tobiliary cannulation. All novices had initial difficulty understanding elevator function.In the novice group, some cannulation attempts were rapidly successful due tofortunate pre-positioning of the scope (‘‘dumb luck.’’) Extreme deflections of thescope tip required significant time to regain effective positioning. The experiencedsubject (E) felt strongly that the simulation of cannulation was realistic. The novicesuniformly found the device a useful tool for understanding scope function and themechanics of cannulation. They also found the experience enjoyable and a stimulusto learning ERCP in patients. Conclusion: This basic desktop device appears toprovide a realistic simulation of basic duodenoscope movements and cannulationmechanics. Inability to put the scope in a ‘‘long’’ position is a limitation, buta minor one. Advantages include ease of set-up and operation, and ability topresent different cannulation challenges (a variety of anatomic variants of thepapilla are available and interchangeable.) The device is ideal for repetitive practiceof basic skills with evaluation and feedback from mentors. Preliminary data areencouraging and further studies are planned.

T1496

A UK National Survey Into Safety Awareness and Practice in

Diagnostic and Therapeutic ERCPNeil Rajoriya, Anthony S. MeeBackground: Endoscopic Retrograde Cholangiopancreatography (ERCP) relies onthe use of ionizing radiation, however risks and awareness of the safety aspects of theprocedure are often not appreciated by the ERCP’ist. Aim: The aim of this survey wasto assess the safety practices and awareness of the radiation aspect of ERCP by doctorsin the United Kingdom carrying out the procedure. Methods: An electronicquestionnaire was sent via email to members of the British Society ofGastroenterology and Scottish Society of Gastroenterology. Professors, Consultantsand trainees (Specialist Registrars - SPRs) were included. The survey questionnairewas returned electronically to a base website (www.surveymonkey.com) and theinformation collated thereafter. Results: 172 responses (92.4% male) were collectedover a 2 month period. 93.5% were Consultants, 4.8 % trainees, and 1.8% Professors.51.5% were between the ages of 45-65, 42.7% between 36-45 and the rest below 36years of age. 85.5% were Gastroenterologists, 9.3% Surgeons and 5.2% Radiologists.Most (48%) have been practicing ERCP for 11-20 years, 21.7% O 20 years, and 30.4%! 10 years. 73.4% do 1 session per week, 17% do 2 sessions, 1.2% do 3 sessions and7.6% do on average less than 1 session on a weekly basis. In the last 12 months 2.4%have done O250 ERCPs, 7.6% between 200-250, 19.4% between 150-200, 37.6%

SCOPY AB231