Abstracts

stent cases, 26 (27%) in plastic stent cases, and 15 (15%) in cases with no stents.
Logistic regression was conducted to evaluate the predictive factors for
successful outcome and complications (Table 1). No factors were significantly
associated with improved successful outcomes or low complication rates.
Conclusion: Successful outcomes and safety profile are not different for gender,
stricture type, extrahepatic or intrahepatic technique or stent placement route.
Different techniques and approaches may be employed based on etiology,
stricture location, and eventual altered anatomy emphasizing the need to
individualize treatment for every case.
achieve PP resolution in 9/11 subjects. Complications included abdominal pain
(n⫽3), spontaneous stent migration and back/shoulder pain (n⫽1), and access-
site infection and stent dislodgement (n⫽1). Conclusions: ACSEMS was
successfully placed in 91% of subjects. In ACSEMS subjects, PP resolution of 93%
is comparable to plastic pigtail stent data with the distinct advantage of single-
step stent deployment and the ability to perform endoscopic necrosectomy
through the stent. Optimizing the delivery system and increased operator
experience will improve technical success.

Table 1. Predictive Factors for Successful outcome and Complications (281 n)

142
Adjusted OR* Adjusted OR*
[95%CI] For [95%CI] For Diagnostic Yield and Safety of EUS-Guided Single-Incision
N (%) Safety Outcome Complications Needle-knife (SINK) Biopsy for Cyto-Histological Tissue
Diagnosis in Upper Gastrointestinal Subepithelial Lesions
Predictor 1 Male 152 (54 %) 1.00 [Reference] 1.00 [Reference]
Carlos De La Serna*, Pilar Diez-Redondo, Irene PeñAs, Henar NuñEz,
Female 129 (46 %) 1.69 [0.53-5.38] 1.00 [0.59-1.69]
Paula Gil-Simon, Lorena Sancho Del Val, Noelia Alcaide,
Predictor 2 Benign 45 (16 %) 2.71 [0.43-17.02] 0.52 [0.25-1.11]
Manuel Perez-Miranda
Malignant 236 (84 %) 1.00 [Reference] 1.00 [Reference]
Endoscopy, Rio Hortega Hospital, Valladolid, Spain
Predictor 3 Altered 54 (19 %) 0.33 [0.09-1.17] 0.82 [0.41-1.62] Background: Subepithelial tumors (SETs) frequently lack distinct EUS features, so
Normal 227 (81%) 1.00 [Reference] 1.00 [Reference] final diagnosis demands adequate methods of acquisition of tissue. However,
Predictor 4 Intrahepatic 152 (54%) 0.31 [0.05-2.21] 2. 07 [0.71-6.04] histologic disgnosis of SETs is challenging: EUS-guided FNA is limited by low
Extrahepatic 129 (46%) 1.00 [Reference] 1.00 [Reference] yield for samller lesions and often fails to provide sufficient tissue for
Predictor 5 Yes 26 (9%) 1.00 [Reference] 1.00 [Reference] immunohistochemistry (IH). EUS-guided SINK biopsy is a novel method for
No 255 (91%) 0.09 [0.003-3.26] 0.35 [0.09-1.39] tissue sampling with promising preliminary results in a previous pilot study (De
Predictor 6 Transpapillary 74 (26%) 1.00 [Reference] 1.00 [Reference] la Serna et al, GIE 74(3)2011) Aim: To prospective assess tissue sampling yield,
efficacy & safety of SINK biopsy for upper GI SETs Patients and Methods: All
Transenteric 114 (41%) 0.06 [0.006-0.66] 1.84 [0.63-5.40]
consecutive patients from April 2010 to October 2012 undergoing EUS evaluation
Hepaticogastrostomy 89 (32%) 0.17 [0.08-1.31] 0.41 [0.19-0.87] of upper GI SETs were included in a prospective database. SETs were previously
None 4 (1%) 0.01 [⬍0.001-0.61] 2.29 [0.19-26.93] evaluated using EUS for size management, morphological characterization and
Adjusted for Gender, Stricture Type, Anatomy, Technique, Rendezvous, Stent pulsed-Doppler scanning to scan the area for vessels. A needle-knife was used in
blended current at 30-60W, to perform a 6-12 mm linear incision over the
Placement, Stent Type
hoghest convexity area of the lesion. Then, a conventional biopsy forceps was
deeply introduced through the hole and 3 to 5 tissue samples were retrieved and
placed in formalin. Mitotic index (MI) and IH analysis were perfromed when it
was feasible. Eight patients out the first thirteen underwent both 22G-EUS FNA
141 and SINK. Prophylactic hemostatic procedures (endoclips) were used only in the
EUS-Guided Drainage of Pancreatic Pseudocysts (PP) Utilizing a first 15 cases. Results: 41 patients (M/F:20/21) were included (mean age: 59.60;
Novel Anchoring, Covered Self-Expanding Metal Stent (Acsems): range 22-87).On EUS, mean diameter of the SETS was 2.77 cm (0.65-9.3).Layer
location: 4th/3th/2nd: 19/17/5. Organ location: Esophagus (2), Stomach (24),
Results From a Prospective, Multi-Center Study Duodenum (5). Yield of biopsies after SINK: 38/41 (92.68%). There were no
Raj J. Shah2, Janak N. Shah3, Irving Waxman4, Thomas E. Kowalski5, cautery artifacts. FNA was diagnostic in only 1 of 8 cases (12.5%). Biopsies
Andres Sanchez-Yague6, Jose Nieto7, Brian C. Brauer2, reveales GIST (17), heterotopic pancreas (7), lipoma (5),inflammatory fibroid
Monica Gaidhane1, Michel Kahaleh*1 polyp (3) leiomyoma (2), gangliocytic paraganglioma (1),neuroendocrine tumor
1 (1), duplication cyst (1), splenic rest (1) and non-diagnostic (3).IH analyses (CD-
Division of Gastroenterology and Hepatology, Weill Cornell Medical
College, New York, NY; 2University of Colorado Anschutz Medical 17) was positive in 16/17 GISTs (94.11%) and MI determination was feasible in
Campus, Aurora, CO; 3California Pacific Medical Center (CPMC), San 13/17 (76.47%). There were no procedural related immediate or late
complications. Conclusions: 1: SINK-biopsy of upper GI SETs appears to be an
Francisco, CA; 4University of Chicago Medical Center (UCMC), easy and safe technique even without prophylactic hemostatic methods. 2: The
Chicago, IL; 5Thomas Jefferson University, Philadelphia, PA; 6Hospital histologic yield of SINK biopsy is quite high 3: SINK may represent a reliable
Costa del Sol, Marbella, Spain; 7Borland-Groover Clinic (BGC), alternative to EUS-FNA specially for smaller SETs
Jacksonville, FL
Background: Placement of double pigtail plastic stents, with limited lumen size,
for endoscopic pancreatic pseudocyst (PP) drainage requires repeat wire access
of the cystenterostomy after initial stent deployment. Conventional covered self- 143
expanding metal stents (CSEMS) are larger in diameter and permit single-step
insertion but carry a risk for stent migration. The AXIOSTM (XLUMENA, Inc) Role of Endoscopic Ultrasound in Patients Presenting for Open
stent (ACSEMS), a fully-covered Nitinol stent, has a dual-flange design allowing Access Sphincter of Oddi Monometry (SOD) Including Acute
an anchoring effect to maintain a cystenterostomy tract. Our objective was to Recurrent Pancreatitis (ARP), Post Cholecystectomy Syndrome
evaluate the safety and efficacy of ACSEMS for PP drainage. Methods: 7 tertiary (PCS) and Chronic Abdominal Pain
care centers (6 US, 1 EU) utilized the following inclusion criteria: symptomatic
PP requiring drainage and adherence to GI lumen that was ⱖ 6 cm with ⱖ 70%
Marc F. Catalano*1,2, Naser M. Khan1, Joseph B. Henderson1,2,
fluid content determined by EUS and/or CT. Technique of cystenterostomy Shahid Ali1, Joseph E. Geenen1,2, Nalini M. Guda1,2
1
creation and diameter of AXIOSTM stent (10 or 15 mm) was based on GI Associates, LLC, Milwaukee, WI; 2Pancreatic Biliary Center,
endoscopist preference. Safety outcomes: access site-related bleeding, infection, Aurora St. Luke’s Medical Center, Milwaukee, WI
perforation, tissue injury, and stent migration. Efficacy endpoints: successful Endoscopic Ultrasound (EUS) has an evolving role in the evaluation of patients
insertion and/or removal of ACSEMS, PP resolution defined as ⱖ 50% reduction with undetermined abdominal pain, and idiopathic recurrent pancreatitis. These
in size, and lumen patency. Follow-up: EUS, and/or CT for PP status at 30 and/ patients exhaust medical services, including voluminous laboratory studies, cross
or 60 days, and 1 week post-stent removal. Results: From Oct ‘11 to June ‘12, 33 sectional imaging, and standard endoscopy (upper and lower endoscopy).
patients (18M; mean age 53 ⫾ 14 yrs) were enrolled with 28 (85%) having Advanced endoscopic procedures ultimately may be recommended including
underlying chronic pancreatitis. Median PP size was 9.7 ⫾ 4.0 cm. ACSEMS was Sphincter of Oddi Manometry (SOM) and EUS in limited tertiary centers. While
successfully placed via endoscopic ultrasound (EUS) guidance in 30/33 (91%) these procedures are often done during separate encounters, it may be cost
patients, with remaining 3 receiving double pigtail stents. Unsuccessful effective to perform simultaneously leading to a more accurate and expedient
deployment was due to stent malposition (n⫽2) and delivery handle malfunction diagnosis. Aim: To determine the role of EUS in patients with ARP, PCS and
(n⫽1). Procedure time was 64 ⫾ 38 minutes. PP resolution was achieved in 31/ chronic abdominal pain during the evaluation of SOM. Methods: Over a 6 year
33 (94%); and 28/30 (93%) receiving ACSEMS with93% lumen patency at stent period, 522 patients underwent simultaneous SOM and EUS at St. Luke’s Medical
removal. In ACSEMS subjects, PP size decreased significantly (6.7cm, 95% CI [5.6 Center, Pancreatic Biliary Center, Milwaukee, WI. This included 207 patients with
- 7.8], p⬍0.0001) from baseline (10.1 ⫾ 4.0 cm) to 30 days post-stent placement PCS, 150 with ARP and 165 patients with chronic pain with intact gallbladders.
(3.4 ⫾ 3.9 cm). For 10 subjects, the PP size was 1.9 ⫾ 1.6 cm at 60 days. One All patients had negative laboratory, cross sectional imaging and routine
failure required surgical necrotic debridement and 1 required stent removal post- endoscopy. EUS was performed with Olympus radial echoendoscope. SOM was
stent dilation due to debris partially occluding the stent. 11 subjects underwent performed during ERCP using a triple lumen perfusion catheter with evaluation
direct endoscopic necrotic debridement through the indwelling ACSEMS to of the appropriate sphincter. Sedation was performed under general anesthesia.

www.giejournal.org Volume 77, No. 5S : 2013 GASTROINTESTINAL ENDOSCOPY AB128

Abstracts
Results: In the patients presenting with ARP (n⫽150), 87 (58%) had abnormal
studies, including 66 with features suggestive or diagnostic of chronic
pancreatitis (Rosemont Criteria) and 6 patients with pancreatic neoplasm
(adenocarcinoma, neuroendocrine tumors, lymphoma), pancreatic cysts (9). In
patients presenting with PCS (n⫽207), only 27 (13%) had abnormal studies
including 15 with features suggestive of Chronic Pancreatitis, 6 with bile duct
stones and 6 with dilated ducts (pancreatic and or biliary). In patients presenting
with pain only (n⫽165), 33 (20%) had abnormal studies including 22 with
features suggestive of Chronic Pancreatitis, 1 each with pancreatic neoplasm and
bile duct stone, 3 with pancreatic cysts and 5 with dilated ducts. CONSLUSION:
Patients presenting with ARP or obscure abdominal pain with or without prior
cholecystectomy may benefit from Endoscopic Ultrasound. Advanced endoscopic
procedures such as ERCP with SOM are often requested in this group of patients.
Simultaneous ERCP/SOM and EUS results in establishing a final diagnosis much
superior than either study alone. This results in more expedient completion of
medical testing and institution of appropriate management in these challenging
groups of patients. The group most likely to benefit from both studies are those
presenting with ARP.
EUS EUS Findings
Patient
Category (n) NL (%) ABN (%) CP PN BDS DBD/PD PC SMT
ARP 150 63 (42%) 87 (58%) 66 6 2 4 9
PCS 207 180 (87%) 27 (13%) 15 0 6 6 0
Pain 165 132 (80%) 33 (20%) 22 1 1 5 3
Total 522 375 (72%) 147 (28%) 103 7 9 15 12
CP⫽ Chronic pancreatits; PN⫽ Pancreatc Neoplasm; BDS⫽ Bile Duct Stones DBD/
PD⫽ Dialted Biliary Buct/Pancreatic Duct; PC⫽ Pancreatic Cyst; SMT⫽ Submucosal
Tumor
144
Quality in Pediatric Colonoscopy: Results From a Multi-Center
Consortium
Kalpesh H. Thakkar*1, Douglas S. Fishman1, Jennifer L. Holub2,
Mark a. Gilger1
1
GI, Baylor College of Medicine, Houston, TX; 2GI, Oregon Health &
Science University, Portland, OR
Background: Currently, there are no quality measures specific to children
undergoing gastrointestinal endoscopy. To determine the baseline quality of
pediatric colonoscopy reports, key quality indicators must be monitored and
analyzed. The consortium of the Pediatric Endoscopy Database System-Clinical
Outcomes Research Initiative (PEDS-CORI) use a structured computerized
endoscopy report generator, which includes fields for specific quality indicators.
Methods: We conducted prospective data collection using a standard
computerized report generator and central registry (PEDS-CORI) to examine key
quality indicators from 14 pediatric centers between Jan 2000 and Dec 2011.
Reports were queried to determine if specific quality indicators were recorded.
Specific endpoints, including quality of bowel prep, cecal intubation rate, ileal
intubation rate, documentation of ASA class, and procedure time were compared
in practices with more than 100 colonoscopy procedures during the study
period. Results: We analyzed 21, 807 colonoscopy procedures performed in
patients with mean age of 11.9 (SD 4.8). Of the 21, 807 reports received during
the study period, 56% did not include bowel prep quality and 12.7% did not
include ASA classification. When bowel prep was reported, the quality was
described as excellent, good or fair in 80.2%. The overall ileal intubation rate
was 69.4%, and 15.6% reported cecal intubation. Thus, 15% of colonoscopy
procedures did not include complete examination (i.e., reach the cecum or
ileum). When considering the proportion of procedures not intended to reach
the cecum (17.3%), the overall rate of complete examination increases to 89%.
The rate of complete examination varied from 85% to 95% depending on
procedure indication. Colonoscopy time was documented in 69.2% of cases.
Conclusions: Significant variations in the practice of pediatric endoscopy are
apparent, despite the use of a computerized report generator. Measurement of
quality indicators in clinical practice can identify areas for quality improvement.
145
Pediatric Gastroenterologists Can Safely and Effectively Perform
ERCP
David Troendle*, Bradley a. Barth
UT Southwestern, Dallas, TX
Background: Use of endoscopic retrograde cholangiopancreatography (ERCP) is
increasing in pediatrics for biliary and pancreatic disorders. To date, all experiences of
ERCP in children have been published by adult providers or surgeons. There is
controversy over whether pediatric gastroenterologists should perform ERCP due to
lower case volume and lack of formal training programs. The purpose of this study was
AB129 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
to demonstrate that appropriately trained pediatric gastroenterologists can perform ERCP
for at least basic indications (Grade 1 and 2), safely and effectively as defined by ASGE
practice standards. Methods: With IRB approval, ERCP experience at Children’s Medical
Center Dallas (CMCD) from November 2006 to May 2012 was reviewed. All ERCPs were
performed independently by a pediatric gastroenterologist with initial training of 200
supervised ERCPs (70% on children) followed by approximately 45 ERCPs annually at
multiple sites for the past 6 years. Only ERCPs on pediatric patients at CMCD for
suspected choledocholithiasis were included for chart review. Outcomes were compared
to accepted ASGE quality indicators for ERCP in adults. Results: 154 ERCPs were
performed, of which 65 (42%) were performed for the indication of suspected
choledocholithiasis. Suspicion was based on clinical presentation in 46 (72%) patients,
intraoperative cholangiogram in 18 (28%), and cholangiogram through cholecystostomy
tube in 1 patient. Median age was 15.2 years (1 month -18.4 years). Median weight was
65kg (4kg-127kg). Forty-six (71%) were female, 20 (31%) were obese, 9 (14%) had sickle
cell disease, and 1 had repaired cyanotic congenital heart disease. All cases were
performed under general anesthesia. Biliary cannulation was successful in 65 (100%,
ASGE threshold ⫽ 90%). All 65 patients underwent biliary sphincterotomy. Bile duct
clearance was achieved in 63 patients (97%, ASGE threshold 85%) during the initial
session with subsequent clearance in the two remaining patients at follow-up ERCP.
Adverse events included mild pancreatitis in 3 patients (5%, ASGE threshold 7%), and 1
episode of moderate bleeding (ASGE threshold 2%). In addition there was 1 episode of
sphincterotomy clot adherence leading to biliary obstruction requiring repeat ERCP
0 within 1 week. Overall, 5 (8%) patients experienced a complication. Interestingly, 3
0 (60%) of these 5 had sickle cell disease. Conclusions: This study demonstrates that
1 pediatric gastroenterologists can perform ERCP for choledocholithiasis, a grade 2 ERCP,
1 with acceptable cannulation and stone extraction rates and acceptable adverse event
rates as defined by ASGE. The same is likely true for more complex procedures given
appropriate experience, but additional research is needed.
146
Validation of a Part-Task Training Box for Endoscopic Skill
Assessment in Pediatric Gastroenterology
Sarah Kadzielski*1, Pichamol Jirapinyo2, Christopher C. Thompson3
1
Pediatric Gastroenterology, Massachusetts General Hospital, Boston,
MA; 2Yale, New Haven, CT; 3Division of Gastroenterology, Brigham &
Women’s Hospital, Boston, MA
Background: There is no standardized method for teaching endoscopy in pediatric
gastroenterology. Acquisition of skills may vary widely among institutions,
depending on the instruction styles of attending endoscopists, amount of endoscopy
exposure for fellows, and availability of additional training tools (i.e. simulators).
Aim: To validate a part-task training box for the objective assessment of endoscopic
proficiency in pediatric gastroenterology providers. Methods: The training box was
developed based on our prior work in kinematic analysis of maneuvers and
deconstruction of the colonoscopic examination. The training box contains 5 tasks:
polypectomy, retroflexion, torque, tip deflection, and navigation/loop reduction.
Each task was scored using a system previously developed from repeated trials with
a 5 minute time limit per task. Training levels included novices, pediatric
gastroenterology fellows, and pediatric gastroenterology attendings from 2 academic
institutions. No participant had prior experience with the training box beforehand.
Data was collected on years of experience and total number of procedures
performed. Several subjects of different experience levels participated in multiple
sessions with the training box to assess the learning curve on this particular mode of
training. Results: A total of 36 subjects were enrolled in the study: 10 novices, 12
fellows (2-1st years, 5-2nd years, and 5-3rd years), and 14 attendings. Novices
(including 1st year fellows) had a mean total score of 52.5 ⫾ 10.2. Senior fellows
(2nd and 3rd year) had a mean score of 248.5 ⫾ 32.0. Attendings had a mean score
of 212.1 ⫾ 20.2. Senior fellows scored significantly higher than novices (p⬍0.001).
Senior fellows’ scores were not significantly different from attendings (p⫽0.97).
Score results are shown in Table 1. Individual scores were highest on the
polypectomy task. However, this study was not powered to detect differences in
performance on individual tasks. Several participants repeated the box trainer more
than once, most of whom demonstrated improvement in scores, suggesting that
there is a learning curve for this training modality. Conclusion: This part-task
endoscopic training box differentiated novices from those with more pediatric
endoscopic experience. Additionally, the similarity between senior fellows’ and
attendings’ scores suggests that there is not a major decay of procedural skills over
time, despite a lack of intensive exposure to endoscopy after fellowship. These
results suggest that this part-task training box may provide an opportunity to
develop basic endoscopic skills in a non-clinical setting, and may be a valuable
teaching tool at the start of training. Further studies are needed to evaluate the
training box as a tool to teach beginners, maintain proficiency, or increase
performance of endoscopic skills.
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