ERCP Outcomes in Nonagenarians: Experience At a Tertiary Referral Center

ERCP Outcomes in Nonagenarians: Experience At a Tertiary Referral Center

Abstracts W1420 Endoscopist Administered Sedation During ERCP: Dosing Requirements and Need for Reversal Agents Georgios I. Papachristou, Ferga Glees...

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W1420 Endoscopist Administered Sedation During ERCP: Dosing Requirements and Need for Reversal Agents Georgios I. Papachristou, Ferga Gleeson, Gavin C. Harewood, Todd H. Baron Background: Endoscopists administer moderate/deep sedation during ERCP. Problems encountered during sedation include difficulty in adequately sedating patients on narcotics or benzodiazepines (N/B) and oversedation. Oversedation often requires the use of reversal agents. Aims: 1) To determine dosages of i.v. sedatives in patients with and without a history of N/B use. 2) To assess the use of reversal agents. Methods: Data were retrospectively collected through a computerized endoscopy database from 01/04 to 12/04. Results: In 1,111 therapeutic ERCPs, sedation was provided by the endoscopist. 995 patients (mean age: 58, 8-101; 49% male) were not using N/B. They received predominantly meperidine (95%) and midazolam (99%) at median doses (MD) of 125 mg (12.5-400) and 7 mg (1-22) respectively. Promethazine was administered in 22% (MD: 25 mg). Mean procedure duration (intubation to extubation - ITET) was 44 min (3-179). 116 patients (10%) were using N/B. These patients were younger (mean age 55; p Z 0.04), predominantly female (60%; p Z 0.05), required higher doses of meperidine (MD: 125, p Z 0.04), midazolam (MD: 8, p ! 0.01) and 34% received promethazine (NS). Reversal agents (naloxone or flumazenil) were given in 57 patients (6%) in the non-N/B group and in 5 (4%) in the N/B group (NS). Patients requiring reversal agents received higher doses of meperidine (MD:150, p ! 0.001) and midazolam (MD: 8, p Z 0.003), 47% received promethazine (p ! 0.00001) and had similar ITET (49 min, NS) compared to the non-reversed group. Median sedation dosages for different age and ITET groups are presented in Table 1. The MD of meperidine and midazolam was approximately 25 mg and 1 mg higher in the reversed group, respectively, when compared to the non-reversed group, regardless of age and duration of procedure. Conclusions: 1. ERCP patients using N/B are more likely to be younger, female and require significantly higher doses of i.v. sedatives. 2. Patients requiring reversal agents received significantly higher doses of sedation compared to non-reversed patients. Also, dose thresholds appeared to be lower in older patients. A future potential model to guide safe sedation would need to recommend varying sedation doses according to patient age. 3. Administration of promethazine during sedation may increase the need for reversal agents. !70 years Age Non-reversed ITETR45 min ITET!45 min Reversed ITETR45 min ITET!45 min

followup (n Z 16), and pancreatic pseudocyst (n Z 1). Successful cannulation in 93%. Findings: choledocholithiasis 17(63%), pancreatic cancer 2(7%), cholangiocarcinoma 3(11%), papillary stenosis 2(7%), pancreatic pseudocyst 1(4%), normal 1(4%). Six patients (22%) had duodenal diverticula, and 3 had Billroth II anatomy. Endoscopic therapy, including biliary and pancreatic sphincterotomy, stone extraction, and stent placement was performed in 39 of 43 (91%) procedures. There were two complications (4.7%); both respiratory distress due to volume overload, which rapidly resolved with diuresis. There were no ERCP-associated pancreatitis, perforation, bleeding, or mortality in this series. Conclusions: ERCP in the very elderly appears to be safe and efficacious for management of pancreaticobiliary diseases, despite the significantly higher comorbidity in this population. We suspect that the morbidity and mortality will prove to be less than comparable surgical interventions for management of similar pancreaticobiliary diseases in this age group.

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W1421 ERCP Outcomes in Nonagenarians: Experience At a Tertiary Referral Center Kourosh F. Ghassemi, Rahul Verma, Harry Rodriguez, Liana Vesga, Mary Jo Mcmahon, Karen C. Bagatelos, James W. Ostroff Background: With the aging of the population an increased prevalence of pancreaticobiliary disease in the elderly is expected. Given the high incidence of concomitant chronic diseases in this age group, surgical management carries substantial risk of morbidity and mortality. Endoscopic approach to management, i.e. ERCP, has been proposed as a safer alternative to surgical therapy. Despite the increasing use of ERCP in the evaluation of very elderly patients (90 years of age or older) with pancreaticobiliary disorders, data on the efficacy and safety in this age group is scarce. Methods: A search of the computerized endoscopy database at our institution from 1/00 to 9/05 revealed a total of 5375 ERCP procedures. Of these, 43 (0.8%) were performed for patients 90 years of age and older, and a retrospective review of the medical records for this cohort was completed. Outcomes, including interventions, success rates, and complications (defined in a standard manner) were summarized. Results: Forty three ERCP procedures were performed (1-12 procedures per patient) in 27 patients (mean age 92.5 years, range 90-102), female 70.4%: male 29.6%. Over three fourths (78%) had at least one major comorbidity (cardiovascular 44%, pulmonary 15%, neurologic 30%, renal 26%, and nonpancreaticobiliary malignancy 22%). Twenty nine procedures were done with conscious sedation; 14 with general anesthesia. Indications: suspected biliary obstruction (n Z 14), biliary pancreatitis (n Z 7), cholangitis (n Z 5), planned


W1422 ERCP in Patients with Prior Billroth II Gastrectomy: A 22-Year Experience Pietro Familiari, Federico Iacopini, Massimiliano Mutignani, Andrea Tringali, Cristiano Spada, Vincenzo Perri, Michele Marchese, Lucio Petruzziello, Guido Costamagna Background and Aim: ERCP in Billroth II patients (BII) is difficult due to anatomical changes. Afferent loop intubation, reaching the papilla, selective cannulation and sphincterotomy (ES) are the main issues. The ERCP experience of a tertiary referring endoscopy centre is reported. Patients and Methods: From 1982 to 2004, 537 patients with prior BII gastrectomy (418 males, mean age 67C/11 years) were retrospectively identified from a prospectively collected database. Main indications of ERCP were: biliary stones (44.5%), malignant biliary strictures (25.9%), chronic pancreatitis (9.9%), acute cholangitis (9.7%), acute biliary pancreatitis (3.2%), biliary fistulas (2.8%), benign biliary strictures (1.7%), asymptomatic bile duct dilation (1.1%), anicteric cholestasis (0.7%) and pancreatic fistula (0.5%). The procedures were always started with an operative duodenoscope with the patient on left side/supine decubitus. ES was usually performed using a home-made long nose sigmoid inverted sphincterotome over a guidewire. Results: A total of 855 ERCP were performed. Papilla of Vater was reached and identified in 477 patients (88.8%), in 97.9% of cases at the first attempt. In 7 patients duodenal intubation was obtained using a gastroscope after failure with the duodenoscope. In 4 cases the papilla was reached over the guidance of a percutaneously placed transhepatic and transpapillary guidewire. Failure in duodenal intubation was due to jejunal loop perforation in 11 out 855 procedure (1.3%) and to angled and/or long jejunal loop in 49 patients. Biliary or pancreatic cannulation and opacification was successfully performed 93.1% of patients in whom the papilla had been identified. Purely diagnostic ERCP were performed only in 76 cases (17.1%). Most of the ERCP were therapeutic; biliary and/or pancreatic ES were performed in 75.2% and 4.3% of patients respectively, including 5 who underwent minor papilla ES. Precut ES was necessary in 29 cases (6.5%). Plastic and/or metallic stents were inserted in 29.1% of patients. One patient underwent endoscopic ampullectomy. Morbidity and mortality per procedure were 3.4% and 0.1% respectively. One patient died because of complications related to the jejunal perforation. Conclusions: ERCP in BII patients is as safe and almost as effective as in non-gastrectomized patients. The use of duodenoscope is recommended and allows successful endoscopic treatment of most patients in whom the papilla is reachable.