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Stent Removability and Mid-Term Stricture Resolution After Multi-Month Metal Stenting of Benign Biliary Strictures: Interim Report From an International Prospective Trial in 187 Patients Guido Costamagna*, D. Nageshwar Reddy, Andreas Puspok, Thierry Ponchon, Marco J. Bruno, Michael J. Bourke, Horst Neuhaus, Andre Roy, FerraN GonzaLez-Huix, Alan N. Barkun, Paul P. Kortan, Claudio Navarrete, Jacques M. Deviere Digestive Endoscpy Unit Universita Cattolica del Sacro Cuore, Rome, Italy; Asian Institute of Gastroenterology, Hyderabad, India; Medical University of Vienna, Vienna, Austria; Hopital Edouard Herriot, Lyon, France; Erasmus Medical Center, Rotterdam, Netherlands; Westmead Hospital, Westmead, NSW, Australia; EVK Krankenhaus Dusseldorf, Dusseldorf, Germany; Montreal-Saint-Luc Hospital, Montreal, QC, Canada; Hospital Universitari Doctor Josep Trueta, Girona, Spain; McGill University Hospital, Montreal, QC, Canada; St. Michael’s Hospital, Toronto, ON, Canada; Clinica Alemana de Santiago, Santiago, Chile; Erasme Hospital, Brussels, Belgium Background and Aims: Use of fully-covered self-expanding metal stents (FCSEMS) for treatment of benign biliary strictures is becoming more broadly adopted but long term prospective effectiveness data are needed. Methods: FCSEMS (WallFlex Biliary RX Fully Covered Stent, Boston Scientific, Natick, MA) were placed in 187 patients (pts) with benign biliary strictures associated with chronic pancreatitis (CP, 127), liver transplantation (OLT, 42), and post-operative complications (PO, 18). Strictures could be naive or previously dilated using plastic stents. Per protocol (PP) FCSEMS indwell was 11 months in CP and PO pts and 5 months in OLT pts, with a planned 5 year post removal follow-up (f/ u). Endpoints include stent removability (primary) defined as ability to remove FCSEMS endoscopically without stent-removal-related adverse event (AE), stricture resolution and AEs. This report includes removability results for all pts and stricture resolution for subset of pts with at least 1 year of f/u based on enrollment dates. Results and Discussion: Mean age 54 years, 145/187 (78%) male. At least 1 prior plastic stent in 139 (74%) pts. Removability could be assessed in 171 (91%) pts as 16 pts were discontinued early due to unrelated death or progression to cancer (9) or to loss to f/u (7). All 171 stents were removed endoscopically (154) or passed spontaneously (17). Five endoscopic removals required a stent-in-stent technique. Removability was confirmed in 164 (96%) pts. There were 7 stent-removal-related AEs: cholangitis (4), pancreatitis (1), self-limiting bleed (1) and RUQ pain (1). To-date, of the 171 pts, 95 have at least 1 year f/u (53 CP, 33 OLT and 9 PO). PP stent removal took place in 72 (76%) pts (44 CP, 22 OLT, 6 PO). Early stent removal (15) or complete distal migration (8) occurred in 23 (24%) pts (9 CP, 11 OLT, 3 PO) with stricture resolution in 6 pts and immediate restenting in 17 pts. In total stent-related AEs were cholangitis (14), cholestasis (5), RUQ pain (3), pancreatitis (3), biliary leaks (1) with no stent-related deaths. After PP FCSEMS removal with mean f/u to date of 569 days ( 103), there was overall stricture resolution in 55 (76%) pts, namely in 35 (80%) CP pts, 15 (68%) OLT pts and 5 (83%) PO pts. F/u is ongoing. Updated results will be presented. Conclusion: Endoscopic FCSEMS removal after up to a year of indwell in benign biliary strictures was possible with acceptable complication profile. Preliminary stricture resolution rates with mean f/u of 18 months appears promising, particularly in CP related and PO biliary strictures. Longer follow-up is required.

Therapeutic Gastrointestinal Endoscopy in Pediatric Patients Carmen G. Rostion, Cecilia Castillo, Roque Saenz, Carlos Harz, Carlos Reyes, Raul Prieto, Eduardo Valdivieso, Hugo Richter, Claudio Navarrete Introduction: Pediatric gastrointestinal disorders, occasionally require interventional gastrointestinal endoscopy procedures, to solve congenital or acquired clinical conditions. Its use has increased considerably, due to the development of new and better technological resources and cares, usually extrapolated not only from diagnostic, but also therapeutic endoscopic resources in adult population. Biliary atresia, pancreatic cystic fibrosis, Hirschprung disease and congenital disorders (imperforated anus and esophageal atresia v.g), demand new diagnostic and therapeutic skills. Aim: To evaluate our cumulative experience, in minimally invasive treatment among children. Patients and Method: We present a consecutive series of therapeutic endoscopic procedures in pediatric population (0 to 15 years) recruited from January 2003 to November 2005., in our Unit located at Santiago Chile. After informed consent was obtained from parents, under general anesthesia or titrated sedation with propofol, the endoscopic procedure was performed, utilizing pediatric Olympus instruments. Clinical and endoscopic data, were collected using an Epi Info 2002 computerized database, which includes besides photo images and video-records. Results: 82 therapeutic endoscopic procedures, among 75 patients (40 women and 35 men), aged between 0 and 15 years, refered from Primary Care Hospitals, were done. ERCP in 22 cases (2 liver transplant patients), 12 percutaneous gastrostomies, 8 endoscopic treatment of esophageal varices (6 band ligations and 2 variceal sclerosis), esophageal dilatation in 8 cases (1 achalasia and 7 benign estenosis), intra gastric baloon in 4 obese patients, 6 colonic polypectomies (juvenile polyps). APC in 3 cases of congenital tracheoesophageal fistulae, 3 foreign bodies extraction only, (this procedure is usually performed in the urgency department), positioning of nasoyeyunal tube in 3 cases, endoscopic drainage of 2 gastro-duodenal duplications and 1 pancreatic pseudocyst. 73 patients did well. One patient had recurrence of the tracheoesophageal fistulae, after application of APC and went to surgery. There was a casualty, as consequence of air embolism. Discussion: Minimally invasive gastrointestinal endoscopy procedures appear like complex interventions, but they are becoming a necessary therapeutic resource in the pediatric population. We present our experience in highly selected pediatric patients, referred to our Unit from several Primary Care Hospitals. 97,5% of the cases were solved endoscopically. There was a casualty in this series.

Inverted Colonic Diverticulum: An Infrequent and Dangerous Endoscopic Finding R. Merino, T. Kinney, R. Santander, R. Yazigi, C. Navarrete, M. Saenz, R. Saenz Background: Inverted Colonic Diverticula (ICD) can be misinterpreted as elevated polypoid lesions, and biopsy or endoscopic resection of these lesions can lead to severe complications. These important lesions are rarely reported in the medical literature and marginally mentioned in classic texts. The aim of this study is to describe the endoscopic characteristics of ICD to avoid misdiagnosis and to report the frequency of these lesions in a large endoscopic series. Materials and Methods: A retrospective analysis was performed of all patients undergoing colonoscopy at our institution between July 2001 and July 2004 using Medicaps 2.0 InfoCYS endoscopic database and selecting patients diagnosed with ICD. Patient characteristics as well as lesion characteristics were recorded, including location, endoscopic characteristics, and the presence of synchronous polypoid lesions.The following endoscopic characteristics were considered in diagnosing ICD: 1) elevated sessile appearance with fine concentric folds surrounding the lesion, 2) mucosal pattern on lesion is similar to surrounding mucosa, 3) umbilicated appearance, 4) found in an area of diverticula, 5) surrounding fine concentric folds enhance with Methylene Blue, and 6) lesion reverts to typical diverticular appearance with direct water infusion, air insufflation, or gentle pressure with biopsy forceps. Results: Among 4508 colonoscopies performed in the selected period, 33 (0.7%) were diagnosed with ICD according to the endoscopic criteria above. Mean patient age was 62.3 years, with 7/9 male/female ratio. 89% of ICD were in an area of multiple colonic diverticula, and 75% were located in the sigmoid colon. One had active bleeding from the inverted diverticulum and was treated with injection therapy. 2 cases required gentle pressure with the biopsy forceps for diagnosis and the remaining were diagnosed according to the other referred endoscopic criteria. No biopsies or resections were performed. There were no complications in this series. Conclusion: ICD is a rare endoscopic finding (0.7%) that is occasionally complicated by local bleeding. Misdiagnosis could be dangerous as these lesions appear similar to sessile polyps, and biopsy or endoscopic resection could lead to serious complications. The endoscopic criteria described should be considered to avoid complications.

Is There a Different Outcome Between Endoscopic Treatment of Intrahepatic (IHBL) Versus Extrahepatic Biliary Leak (EHBL)? Susana Escalante-Glorsky, Hashim Khandawalla, Claudio Navarrete, Marc Catalano, Isaac Raijman Sr. Introduction: Endoscopic stenting with or without sphincterotomy is the optimal non-surgical therapy for BL. Placing a short stent in the bile duct without bypassing the leak may be enough for healing. The validity of this statement in IHBL is unknown. We compared the outcome of pts with IHBL with that of EHBL after endoscopic therapy. Patients andMethods: EHBLwas defined as that located below the biliary confluence. A total of 233 pts with BLwere treated. In the IHBL group, there were 27 pts: 3 with right hepatic duct (RHD) leak, 12 duct of Luschka leak, 4 left hepatic duct (LHD) leak, and 8 intrahepatic leaks posttrauma. Of the post-traumatic BL (5 left lobe, 3 right lobe). The mean time from injury to diagnosis of the BL was 4 days. In the EHBL, there were 206 pts. The BL was at the cystic stump in 198 and from an OLT anastomosis in 8. The mean time from surgery to diagnosis of the BL was 4 days. Treatment included a biliary sphincterotomy and placement of a 7-10 Fr straight polyethylene stent bypassing the site of leakage or in the leaking intrahepatic duct. A 7 Fr stent was used in 3 pts with peripheral IHDL and the stent was placed just above the ampulla. Results: Of the pts with EHBL, the BL resolved in 194 of 206, for an overall success rate of 94%. Failures included 1 post-OLT and 11 post-LC. Complications occurred in 1 pt after OLT who developed cholangitis that resolved promptly after therapy, acute pancreatitis in 1 pt after LC, and stent migration in 1 after LC. In the IHBL group, the BL resolved in 23 of 27 pts, for an overall success rate of 85%. Failures included 1 pt after right hepatectomy and 3 post-trauma BL who received 7 Fr stents placed just above the ampulla. After the stent was replaced for a 10 Fr into the leaking branch, the BL leak resolved. Thus, overall 26 of 27 pts resolved (96%). During a mean follow up of 23 months, there has been no recurrence of the BL in either patient’s group. Conclusion: 1. Endoscopic therapy with biliary sphincterotomy and stent placement is successful in the majority of pts with IHBL and EHBL; 2. for pts with IHBL, it is recommended that a stent be placed in the feeding bile duct of the leak; 3. Large bore stents (10 Fr) are preferred over smaller stents (7 Fr); 4. Endoscopic therapy is the intervention of first choice in pts with IHBL or EHBL; 5. Surgery is needed when BL does not resolve after endoscopic therapy; 6. A prospective multicenter trial would be useful in establishing the best possible treatment in these pts.