Mo1457Surgical Gastrostomy to Access the Bypassed Stomach: SameDay or Delayed ERCP?Carlos R. Gonzalez*1, James L. Watkins2, Lee Mchenry2, Evan L. Fogel2,Glen A. Lehman2, Nicholas J. Zyromski11Surgery, IU school of medicine, Indianapolis, IN; 2Gastroenterology,Indiana University Hospital, Indianapolis, INBackground: Endoscopic access to the pancreatobiliary system following Roux-en-Y gastric bypass is challenging. Double balloon enteroscopy can beperformed, however cannulation of the native papilla is suboptimal. ERCP viathe gastric remnant is preferred but requires surgical gastrostomy placement intothe gastric remnant. This analysis compared patients having same day (SD-ERCP)versus delayed (D-ERCP) endoscopic retrograde cholangiopancreatographyfollowing surgical access to the gastric remnant. Methods: 24 consecutivepatients requiring open surgical gastrostomy into the gastric remnant wereanalyzed: 13 patients had SD-ERCP and 11 had D-ERCP. Demographic andclinical data were compared. Appropriate statistics were applied; p � 0.05 wasconsidered statistically significant. Results: The majority of patients were female(96%) and Caucasian (83%). The median age was 47 years (range 30 to 60).ERCP indications included suspected sphincter of Oddi dysfunction vs chronicpancreatitis (83%); cholangitis, common bile duct stricture, bile leak, andretained bile duct stent (4% each). In D-ERCP group, ERCP was performed 41�/� 4 days after gastrostomy. The duration of gastrostomy tube maintenancewas 42 �/� 3 days in SD-ERCP compared to 51 �/� 4 days in D-ERCP(p�0.02). Following surgical gastrostomy, hospital length of stay was 5 �/� 1days in SD-ERCP and 5 �/� 1 days in D-ERCP (p�0.88). Two patients (8%)developed superficial surgical site infection (SD-ERCP � 1, D-ERCP � 1), onewas severe. One patient (4%) in the D-ERCP group developed delayedabdominal wall hematoma. Successful ERCP was achieved in 23 patients (96%).No mortality occurred in either group. Conclusions: After gastrostomy placementin the gastric remnant, same day ERCP decreased length of time required forgastrostomy tube maintenance compared to delayed ERCP. Similar perioperativeoutcomes, (including a similar minor complication profile) were observed inboth same day and delayed ERCP groups. In the bypassed stomach, same dayERCP after surgical gastrostomy provides safe and practical access to thepancreatobiliary system.

Mo1458The Incidence of Post ERCP Pancreatitis, Bleeding, Perforationand ERCP Related Mortality, and Clinical Risk Factors for PostERCP Pancreatitis: a Population Based StudyDana C. Moffatt*, Yichun Wei, B. Nancy Yu, Charles N. BernsteinDepartment of Medicine, University of Manitoba, Winnipeg, MB,CanadaObjectives: Risk factors for post ERCP pancreatitis (PEP) have been well definedusing prospective data from large volume and tertiary centers around the world,however the “real world” risks of PEP and other procedural complications havenever been fully explored. Methods: All residents of Manitoba have a uniquepersonal health identification number through which every health system contactis registered in the admin databases of Manitoba Health, the single health insurerof all individuals in the province. All ERCPs and hospital admissions wereidentified using MD billing tariffs and ICD-9 (1984-2004) and ICD-10 (2004-2009)codes. Data were analyzed to define the incidence of PEP, post sphincterotomyhemorrhage (PSH) and perforations requiring admission to hospital within 7 daysof an ERCP. Severity of PEP, PSH and perforation were defined by consensuscriteria based on length of stay in hospital (mild�1-3days, moderate�4-9days,severe��9 days or mortality). Mortality rates due to PEP were adjusted bysequestering deaths in patients undergoing ERCP for malignancy. Patient,procedure and physician variables were evaluated using univariate andmultivariate logistic regression to define risk factors for PEP. Results: In total31,607 ERCPs in 21,556 individuals were performed between 1984-2009 andwere included in the analysis. Complications requiring hospitalization occurredafter 3140 ERCPs (9.9%). PEP was most common, accounting for 94.1% of allcomplications. PEP was graded as mild, moderate and severe in 80.6%, 13.0%and 6.4% respectively with a trend towards an increase in moderately severe PEPand no change in severe PEP (p�0.05) (Figure 1). Mortality occurring after PEPoccurred in a total of 31 cases (1.5% of PEP events and 0.09% of all ERCPs).Rates of PEP decreased between 1984-1990, and have plateaued from 1990-2010(Figure 1). Significant risk factors for PEP include female sex (OR1.15 95% CI1.04-1.23), age �50 (OR 1.22 CI 1.10-1.39), residence in the south rural area (OR1.22 CI 1.08-1.38), and undergoing ERCP performed by a surgeon (OR 1.32 CI1.24-1.39)(Table 1). The type of hospital (tertiary v. community), and type ofERCP was not associated with an increased risk of PEP (Table1). Perforation andPSH occurred rarely after ERCP and required hospitalization after 0.17% and0.40% of cases respectively. Conclusions: Complications requiring hospitalizationpost ERCP occur frequently, with the vast majority being PEP. PEP ratesdecreased from 1984-1990, but have been stable ever since. Mortality post ERCPis rare, occurring within 90 days of 0.09% of all ERCPs. Patient related risk factorsfor PEP include female sex, younger age and possibly the location of residence.The only modifiable patient risk factor for PEP was having a surgeon performthe ERCP, although this might be confounded by procedure indication.

Crude and Adjusted Odds Ratio of Risk Factors for Post ERCP Pancreatitis

Risk Factors RateUnadjusted

ORLow

CIHigh

CI P valueAdjusted

ORLow

CIHigh

CI P value

Male 4.94 refFemale 5.99 1.22 1.10 1.35 �0.001 1.15 1.04 1.28 �0.01Age 0-19 7.91 refAge 20-39 6.66 0.83 0.58 1.19 �0.05 0.84 0.59 1.21 �0.05Age 40-59 7.01 0.88 0.62 1.25 �0.05 0.68 0.47 0.97 �0.05Age 60-79 5.13 0.63 0.45 0.90 �0.05 0.68 0.47 0.97 �0.05Age 80� 3.13 0.38 0.26 0.55 �0.001 0.41 0.28 0.60 �0.0001Region - Urban 5.32 refRegion - Rural Mid 5.64 1.06 0.92 1.23 �0.05 1.05 0.90 1.22 �0.05Region - RuralNorth

5.14 0.96 0.79 1.18 �0.05 0.88 0.71 1.08 �0.05

Region - RuralSouth

6.66 1.27 1.13 1.43 �0.0001 1.22 1.08 1.37 �0.01

Tertiary Care Hosp 5.21 refCommunity Hosp 6.72 1.29 1.18 1.45 �0.001 1.10 0.98 1.23 �0.05Therapeutic ERCP 5.44 refDiagnostic ERCP 5.81 1.07 0.98 1.18 �0.05 0.94 0.85 1.04 �0.05Surgeonperforming ERCP

7.07 red

Gastro performingERCP

4.64 0.64 0.58 0.71 �0.0001 1.22 1.08 1.37 �0.00001

Mo1459Post ERCP Pancreatitis Risk Factors and Prognosis in ElderlyErhan Ergin, Nevin Oruc, Galip Ersoz, Oktay Tekesin,Omer A. Ozutemiz*Ege University, Faculty of Medicine, Gastroenterology Department,Bornova, Izmir, TurkeyERCP indications in elderly are increasing nowadays. Post ERCP pancreatitis isthe most important complication of ERCP. We aimed to study the risk factors andprognosis of post ERCP pancreatitis in elderly. Material Method: Patient admittedto ERCP unit between April 2008-2012 and admitted to the hospital at least 1 dayafter the ERCP procedure were evaluated. Patient’s demographics, prediagnosis,imaging findings, biochemical analysis, and the procedure related details wererecorded. Severity of post ERCP pancreatitis was determined with Ranson andAPACHE II scores. Results: Totally 1372 ERCP patients were evaluated. Patientswith periampullary tumor, post operation stenosis, biliary injury or perforation,pre ERCP pancreatitis in last 30 days, intrahepatic biliary disease were excludedand 988 patients were included to the further analysis. Patients were divided intotwo groups as �65 years old (494 patients, 274 F, 220 M) and �65 years old(494 patients, 259 F, 235 M). Analysis showed that 21 patients (4,3%) �65 yearsold developed post ERCP pancreatitis. Similarly 21 patients (4,3%) � 65 years olddeveloped post ERCP pancreatitis. Patients divided into their age decades andcompared for post ERCP pancreatitis ratio. Patients between 20-30 years old agehad highest risk for post ERCP pancreatitis with the prevalence of 7,7% ,whilepatients at 6th decade 4,2%, 7th decade 4,7%, 8th decade 4,1% and 17 patients at9th decade 0% pancreatitis ratio detected respectively. Further univariate andmultivariate regression analysis for patients �65 years old were performed todetermine the risk factors for post ERCP pancreatitis in elderly. Female genderand Juxstapapillary diverticula (JPD), were found to be a risk factor for postERCP pancreatitis. Female gender increased the risk of post ERCP pancreatitis OR

Abstracts

AB390 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013 www.giejournal.org

8,1 (95% CI 1,7-37,7) p�0,001) and JPD increased the risk of post ERCPpancreatitis OR 1,1. ERCP diagnosis of SOD was more prevalant in elderly withpost ERCP pancreatitis compared to without pancreatitis (14,3% vs 3,8%respectively, p�0,05) When prognosis of patients evaluated patients with postERCP pancreatitis at 7th decade had higher Ranson (median 2) and APACHE IIscores (median 6) then other decades. However the post ERCP pancreatitisrelated complications and mortality ratio were similar in patients �65 oryounger. Conclusions: This is one of the largest series evaluating the rate andrisk factors for post ERCP pancreatitis in elderly. We found that risk of post ERCPpancreatitis does not increase with age. Female gender is the most important riskfactor for post ERCP pancreatitis in elderly. JPD and SOD also slightly increasesthe risk of post ERCP pancreatitis in elderly. Altough risk of post ERCPpancreatitis does not increase with age, its severity detected with Ranson andAPACHE II scores were higher in elderly.

Mo1460Quality Assurance in ERCP: Results of a Prospective Follow upof Selective Prophylactic PD Stent Placement in a TertiaryCenter Endoscopy UnitAkash Ajmera*, Ramnath Hebbar, Shervin Shafa, Ma AI Thanda Han,Nicholas Szary, Firas H. AL-KawasMedicine/Gastroenterology, Georgetown University Hospital,Washington, DCPlacement of prophylactic pancreatic duct stents (PPS) in high risk patients hasbeen reported to significantly reduce the risk of post ERCP pancreatitis (PEP).Questions remain about proper patient selection and risk of pancreatitisfollowing failed PPS placement. Since 2011, a Quality Assurance initiative wasinitiated at our unit requiring a statement in each ERCP report indicating if a PPSwas placed and why not. All patients with suspected SOD, prior H/Opancreatitis, difficult cannulation or access sphincterotomy were considered highrisk . Data was collected prospectively. All patients were called within 48 hoursof their procedure and any negative outcomes were recorded . Methods: Allpatients who underwent ERCP at our institution from Oct 2011 to Oct 2012 werefollowed prospectively. The patients were categorized into: I) No PD cannulationand no PPS was placed (NCNS). II) Pancreatic duct cannulation and PPSplacement (PCPS). III) Pancreatic duct cannulation with failed stent (PCFS) andIV) Pancreatic duct cannulation without an attempt to place a PPS (PCNS).Pancreatitis was defined as new upper abdominal pain with a lipase �3 timesthe upper limit of normal. Severity of pancreatitis was defined using Cottoncriteria. Groups were compared in reference to the frequency and severity ofPEP. Results were analyzed using logistic regression analysis odd ratio. Results: Atotal of 948 ERCP procedures were performed from Oct 2011 to Oct 2012.Complete data in reference to PD stent placement was available on 531 patients.A PPS was successfully placed in 139/150 (93%) presumed high risk patients(PCPS). In 11 patients (7%) we could not re-enter the pancreatic duct (PCFS) andin 13 patients, the PD was either injected or entered but PD stent was not placed(PCNS) as they were considered low risk (Pancreas divisum 4, Pancreaticmalignancy 3, gallbladder malignancy 1, CBD stone 4 and CBD stricture 1)Theoverall incidence of pancreatitis was 4.7%. The rate of pancreatitis in thedifferent subgroups was as follows: NCNS: 10/ 368 (2.7%). PCPS: 12/139 (8.6%).PCFS: 2/11 (18.2%). PCNS 1/13 (7.7%). The rate and severity of pancreatitis ineach of the four groups is summarized in Table 1. Odds ratio analysis indicatedthat the presumed high risk group(PCPS) was 3.38 times more likely to developPEP relative to the low risk group(NCNS) despite PPS placement (p�0.006). ThePCFS group had more PEP, however, this was statistically not significant.(Table 1and 2). Conclusions: Our data confirm that clinical risk analysis is very helpfulwhen deciding about the need for PPS and that in expert hands; PPS issuccessfully placed in the majority of patients. In the PCPS the risk of PEP waslower than previously published data. Failure to place a PPS in a presumed highrisk individual did result in a significant increase in PEP. Further data is needed.Rate of pancreatitis with severity in different groups.

Pancreatitis/Total no. (%) Severity

All patients 25/531 (4.7) Mild 19; Severe 6NCNS 10/368 (2.7) Mild 7; Severe 3PCPS 12/139 (8.6) Mild 9; Severe 3PCFS 2/11 (18.2) Mild 2PCNS 1/13 (7.7) MIld 1

NCNS: No cannulation No prophylactic pancreatic stent (PPS) PCPS: Pancreatic

cannulation with PPS PCFS: Pancreatic cannulation failure to place PPS PCNS:

Pancreatic cannulation without PPS

Odds ratio comparison between different groups

Odds ratio (CI) P-value

PCPS vs. NCNS 3.38 (1.43-8.02) 0.006PCNS vs. NCNS 2.98 (0.35-25.2) 0.3PCPS vs. PCFS 0.43 (0.08-2.2) 0.3

Mo1461Oral NSAIDs and Statins (Simvastatin or Atorvastatin) MightDecrease the Incidence and Severity of Post-ERCP PancreatitisMohamed M. Abdelfatah*1, Markus Agito1, Andrew Lee2,Nairmeen Haller21Gastroenterology, AGMC, Akron, OH; 2Internal medicine, northeastohio medical universty(NEOMED), Akron, OHBackground: Pancreatitis stills the most common complication of endoscopicretrograde cholangiopancreatography (ERCP). may occur in up to 10% ofpatients with estimated health care expenditure of approximately 150 millionannually in USA and mortality rates may range from 0.2 - 0.6%, Manymedications have been used to prevent this complication with only preliminaryevidence that rectal Diclofenac and/or rectal indomethacin have prophylacticrole in decrease the incidence of post-ERCP pancreatitis (PEP), to date nomedication had been constantly used in wide clinical practice. Objective: Todetermine whether or not Statins (Simvastatin or Atorvastatin) and/or oralNSAIDs (Ibuprofen) use as prophylaxis decreases the incidence, severity andcomplications of (PEP). Methods: After obtaining IRB approval of our institution,All patients had ERCP were retrospectively analyzed from 2/2007 to 2/2011According to the prior use of statins, oral NSAIDS or non on those medications.Patients were divided into 3 groups. The definition of (PEP) in our study is acuteupper abdominal pain, an elevation in pancreatic enzymes to at least three timesthe upper limit of the normal range 48 hours after the procedure, andhospitalization for at least 2 nights. Indications, incidence and severity and lengthof hospitalization, subsequent complications of acute PEP were analyzed andcompared between groups. Results: A total of 124 patients (29male, 75female)median age 57, (BMI) 32, 30 patients had previous history of pancreatitis.(group1) 32 patients had received statins (simvastatin17, Atorvastatin15),(group2) 15 patients had used oral NSAID (Ibuprofen), and (group3) 77 patientshad none of these medications. Over all 10 patients developed (PEP), 2 patients(6.2%) on (group 1) [the 2 patients used Atorvastatin, no patients on simvastatinhad PEP], in NSAIDs (group2) no patient had PEP, in (no Statins no NSAIDs)(group3) 8 patients (10.3%) had PEP.In patients who underwentpancreatography with or without cholangiography, incidence and severity of(PEP) were lower in the (group1 and 2) than (group 3) (P�0.66) and (P�0.27)respectively. Moderate to severe pancreatitis in 5 patients (group3) with nomortality, no moderate/sever pancreatitis in (group 1, 2). Conclusions: Our studysuggests that Statins (Simvastatin or Atorvastatin) and oral NSAIDs may reducethe severity and incidence of (PEP), further randomized prospective studiesneeded in the future.

Mo1462Intravenous Ketorolac Does Not Prevent Post-ERCP PancreatitisPeter Junwoo Lee*, Rocio Lopez, Walter G. Maurer, John Tetzlaff,Sunguk Jang, Madhusudhan R. Sanaka, Mansour A. Parsi,Gregory Zuccaro, John J. Vargo, Tyler StevensCleveland Clinic Foundation, Cleveland Heights, OHBackground: Post-ERCP pancreatitis (PEP) is a feared complication of ERCP, andoccurs in up to 20% of high-risk patients. In a randomized trial, rectalindomethacin significantly reduced the rate and severity of PEP. Intravenousketorolac has potential advantages over other NSAIDs due to its high andpredictable bioavailability, ease of administration, and potency. At our center,ketorolac is sometimes given as an analgesia adjunct before or during anesthesiaassisted sedation for ERCP. We sought to evaluate the effectiveness of ketorolacin preventing PEP in high-risk patients. Methods: A single-center retrospectivecase-control study was conducted. Patients who underwent ’high risk’ ERCPbetween January 2008 and August 2012 were included. A high risk ERCP wasdefined based on the presence of any of the following risk factors: suspectedsphincter of Oddi dysfunction, performance of precut, ampullectomy, balloondilation of intact biliary sphincter, pancreatic sphincterotomy, pancreatic ductbrushing, previous PEP, or if patients had �2 of the following risk factors:female sex with age �50, history of recurrent acute pancreatitis, pancreatogramand difficult cannulation. PEP was defined based on new onset abdominal painrequiring hospitalization for at least 2 nights and elevation of lipase and/oramylase �3 times the upper limit of normal at least 24 hours after the procedure.Univariable and multivariable analyses were performed to compare rates ofketorolac use in subjects with and without post-ERCP pancreatitis, adjusting forpotential confounding factors. Results: Out of 3929 ERCPs done during the study

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www.giejournal.org Volume 77, No. 5S : 2013 GASTROINTESTINAL ENDOSCOPY AB391