IV) Pancreas / Biliary

Section：Pancreas / Biliary ⑯

TRANSPANCREATIC SPHINECTEROTOMY IS EFFECTIVE AND SAFE PROCEDURE IN DIFFICULT BILIARY ACCESS: A RETROSPECTIVE STUDY IN A SOUTHERN TAIWAN MEDICAL CENTER

Fai-Meng Sou, Yi-Chun Chiu, Lung-Sheng Lu, Cheng-Kun Wu, Chung-Mou Kuo, Chih-Ming Liang Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan 經胰括約肌切開術在困難膽道進接的 病人是安全既有效的：南台灣教學醫院 的回朔性研究

蘇輝明 邱逸群 盧龍生 吳鎮琨 郭仲謀 梁志明 高雄長庚紀念醫院胃腸肝膽科系 Background: Endoscopic retrograde cholangiopancreatography (ERCP) is used for diagnosing and treating pancreatobiliary disease. ESGE suggested guidewire-assisted cannulation for patients with naïve papilla, but about 10-20% of patients failed to achieve biliary cannulation 2. Different techniques were developed for difficult cannulation, including transpancreatic sphincterotomy (TPS), double guidewire technique, needle knife papillotomy (NKP), and needle knife fistulotomy (NKF). Little data was found to compare the efficacy and complications inTPS. Aims: Compared the CBD cannulation rates and complications between standard NKP and TPS. Methods: A total of 1904 patients received ERCP between Jan 2018 and Feb 2021. There were 1129 naïve papilla. 171 (15.1%) cases with difficult biliary cannulation (cannulation time >10 mins) treated with endoscopic papillotomy. Patients who received NKP and TPS were enrolled in this study after excluding the patients who had successful cannulation using traditional guidewire-assisted cannulation (n = 958) or NKF techniques (n = 54). Results: Among 117 patients enrolled in this study, 100 patients received NKP and 17 patients received TPS. The mean age was 63.8 years old. 43 patients (36.8%) received ERCP due to bile duct stone, 27 patients (23.1%) were liver-related malignancy, 9 patients (7.7%) were pancreatic malignancy. There was no difference in biliary cannulation successful rate between NKP and TPS groups (75% vs. 64.7%, p = 0.383), TPS group had higher percentage in receiving more than 5 cannulation attempts (70.6% vs. 37%, p = 0.016) and more than 1 pancreatic attempt (94.1% vs. 55%, p = 0.002) than the NKP group. TPS group had more patients who received rectal NSAID for post-ERCP pancreatitis (PEP) (70.6% vs. 39%, p = 0.019). There was no difference in cannulation time (17 min vs. 22.2 min, p = 0.249) and procedure time (32 min vs 36 min, p = 0.358) between NKP and TPS groups. Total 10 (8.5%) patients complicated with PEP, 5 (4.27%) patients with bleeding, 2 (1.7%) patients with perforation. There were no significant differences in complication rates between the two groups. Conclusions: Both NKP and TPS had acceptable cannulation rate and complication rate in patients with difficult cannulation.

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THE EXPERIENCE OF EUS-FNB IN A MEDICAL CENTER OF CENTRAL TAIWAN

Yen-Chih Lin, Kue-Yu Chen, Chia-Wei Yang, Kai-Lun Shih, Hsu-Heng Yen Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan 中部一醫學中心使用 EUS-FNB 之經驗

林彥至 陳奎佑 楊佳偉 施凱倫 顏旭亨 彰化基督教醫院胃腸肝膽科 Background: The usefulness of EUS-FNA has been established. In recent years, FNB needle become more popular due to its high diagnostic ability on histology evaluation. Aims: To compare the diagnostic ability of FNA needle and FNB needle in a tertiary referral hospital of central Taiwan. Methods: From the summer of 2020, we used FNB needle to all the patients who received EUS guided biopsy in our hospital except those for fluid analysis. We retrospectively enrolled 22 cases from 2020.8 to 2021.1 and compared the outcome to the historic record in our hospital. Most FNB needles we used have franseen tip, and we sent the tissue to our lab for both histology evaluation and cytology evaluation in all patients. ROSE was not available in our constitution. The final diagnosis was based on the surgical pathology or imaging follow-up 6 months later. Results: In 22 patients who received EUS-FNB, the sensitivity was 89%, specificity was 100%, and accuracy was 91%. MCV (macroscopic visible core) was obtained in 55% patient. When compared to the outcome of FNA era in our hospital, no significant difference was observed in termed of sensitivity, specificity. However, there is a trend that more MCV was obtained when we used FNB needle (55% v.s 36%, p = 0.226). Interestingly, when we confined the diagnosis to PDAC (pancreatic ductal adenocarcinoma), the accuracy of EUS-FNB is 100%, while 2 cases which didn’t have definite diagnosis by EUS-FNB was finally diagnosed as small pNET (pancreatic neuroendocrine tumor). Conclusions: In our experience, FNB needles have good performance on histology evaluation for higher MVC yield rate. However, the diagnosis of small pNET is still challenging.

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ENDOSCOPIC AMPULLECTOMY IS SAFE AND EFFECTIVE IN TREATING PAPILLARY NEOPLASM: A SINGLE CENTER EXPERIENCE SHARING

Hsueh-Chien Chiang, Meng-Ying Lin, Yao-Sheng Wang, Jui-Wen Kang, Chiao-Hsiung Chuang, Chiung-Yu Chen Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan 內視鏡壺腹部腫瘤切除的安全性與療 效：單一醫學中心經驗

姜學謙 林孟穎 王堯生 康瑞文 莊喬雄 陳炯瑜 成大醫院內科部 Background: Endoscopic ampullectomy is a safe and reliable method for resecting papillary neoplasm in selected cases. Variable rates of technique success (46% to 92%) and adverse event (0% to 25%) were reported in the previous literatures. Aims: We aim to evaluate the performance of endoscopic ampullectomy in a tertiary center of Taiwan. Methods: From April, 2019 to April, 2021, total 12 patients with ampullary neoplasm underwent endoscopic ampullectomy at the National Cheng Kung University Hospital. The rates of technical success and adverse events were recorded. Results: Among the 12 patients, the baseline characteristics and tumor related features were recorded in Table 1. Most of the target lesion was small (<3 cm) and proved to be adenoma prior to ampullectomy. Ten patients (83.3%) had pretreatment EUS examination with 8 (80%) of them showed an intra-luminal invasion less than 1 cm. The successful rates of endoscopic resection and complete tumor resection were 100% and 83.3% (10), respectively. Five patients (41.7%) had post procedure bleeding event and all of them were successfully treated by using endoscopic methods. One (8.3%) patient failed to have prophylactic pancreatic stenting and was complicated with

pancreatitis. The mean procedure time was 38 minutes and median hospital stay was 5 days (Table 2). Conclusions: With careful patient selection, endoscopic ampullectomy has a high successful resection rate and can be accomplished in a short time. Its adverse event rate is high, however, it is all manageable with endoscopy.

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MANUAL CLEANING BY SOAKING ENZYME DETERGENT IMPROVES DISINFECTION EFFICACY OF DUODENOSCOPES: EXPERIENCES FROM A TERTIARY CENTER IN NORTHERN TAIWAN

I-Fang Tsai1 , Cheng-Shuan Chung2,3 , I-Hua Lee2, Chun-Hsing Liao4, Mai-Yu Wu4 , Ya-Ching Huang4, Fang-Chen Hung4 Occupational Safety and General Affairs, Far Eastern Memorial Hospital, New Taipei City, Taiwan1 Ultrasonography and Endoscopy Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan2 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan3 Infection Control Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan4 膽胰鏡人工清洗效能之改善 ─ 以北部 某醫學中心為例

蔡宜芳1 鍾承軒2,3 李依樺2 廖俊星4 吳美玉4 黃雅卿4 洪芳禎4 亞東紀念醫院職業安全暨總務處1 亞東紀念醫院超音波暨內視鏡中心2 亞東紀念醫院肝膽胃腸內科3 亞東紀念醫院感染管制中心4

Background: The structures of duodenoscopes are complex and reprocessing is challenging. The elevator which facilitates cannulation is always contaminated with blood and tissue debris and wire channel cannot be brushed. There have been many reports of cluster infection and deaths due to inadequate disinfection of duodenoscopes worldwide. Some studies have shown that the manual cleaning process can prevent the residual biofilm on the surface of the endoscope and in the lumens. The soaking of enzyme detergent to improve the cleaning performance is the most important part of the disinfection process of flexible endoscopes. However, manual cleaning in soaking method is not recommended in every international society. Aims: This study aimed to compare the efficacy of manual cleaning between under running water

and detergent soaking. Methods: Selection basis and target: From January to March 2020, an experienced technician in the Ultrasonography and Endoscopy Center in Far Eastern Memorial Hospital performed manual cleaning of the duodenoscopes. Control group: manual cleaning under running water. Experimental group: manual cleaning under soaking in enzyme detergent. Sampling method: using ATP detection (standard value: <200 RLU). The tested area included: 1) the surface of bending part of distal duodenoscope (10 cm from the proximal part), 2) working channel, 3) elevator channel, 4) forceps elevator, and 5) distal cover. Statistical analysis method: Mann-Whitney U test, α: 0.05. Results: 3 dedicated duodenoscope were used to perform endoscopic retrograde cholangiopancreatography in 193 patients. The positive rate of microbial culture: 0%. A total of eight patients (4.1%) developed post-ERCP pancreatitis and no procedure related infections was reported. Conclusions: Manual cleaning through submerge the scope under the enzyme detergent can improve the efficiency of manual cleaning of the duodenoscopes. Meanwhile, the situation of difficult cleaning of the elevator and the elevator channel is also improved by soaking method. The results show that distal cover of duodenoscope has not been significantly improved. Since distal cover has irregular surface, using brushes with matched size to enhance physical cleaning is still needed. It is recommended that endoscopes with complex structures (such as the elevator and the elevator channel) must be submerged and cleaned in order to improve the efficiency of manual cleaning and reduce the risk of potential infection of the endoscope.

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COMPARISON OF STRICTURE DILATION BEFORE OR AFTER MULTIMODAL TISSUE-SAMPLING, INCLUDING BRUSH CYTOLOGY, INTRADUCTAL SUCTION AND FORCEPS BIOPSY FOR THE DIAGNOSIS OF INDETERMINATE BILIARY STRICTURE: A PROSPECTIVE COHORT STUDY

Yu-Ting Kuo1,2, Weng-Fai Wong1,2 , Ming-Lun Han1,2, Chieh-Chang Chen1 , Wei-Chih Liao1, Hsiu-Po Wang1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan1 Division of Endoscopy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan2 比較膽道擴張前與擴張後針對膽道不 明原因的狹窄做膽道切片及細胞刷取 準確度的前瞻性研究

郭雨庭1,2 黃永輝1,2 韓明倫1,2 陳介章1 廖偉智1 王秀伯1 台大醫院消化內科1 台大醫院綜合診療部內視鏡科2

Background: Biliary strictures present a diagnostic and therapeutic challenge to clinicians due to unsatisfied accuracy of sampling modality. Limited data are available on the impact of dilation of biliary strictures for tissue sampling. Aims: In our study, we aimed to compare the diagnostic accuracy of triple tissue-sampling for indeterminate biliary stricture, including intraductal suction, forceps biopsy and brush cytology before or after dilation of biliary strictures. Methods: In this prospective study, patients with biliary obstruction with a clinical suspicion of malignancy underwent triple-tissue sampling before and after dilation of biliary strictures at one ERCP session. Final diagnosis was based on all sampling methods plus surgery and clinical followup. Tissue specimens were reported as normal, atypia, or malignant. Results: From February 2016 and October 2019, total 60 consecutive patients with a mean age of