ABSTRACTS FOR VIDEO HONORABLE MENTIONS VH1 Direct Through-The-Needle Pancreaticocystoscopy in the Evaluation of a Side-Branch Intraductal Papillary Mucinous Cyst S. Ian Gan Background: The case involves a 47 year old man with recurrent acute pancreatitis. The gentleman had his first episode at age 15 and has had repeated severe episodes approximately every 5 years and milder episodes more sporadically. EUS and ERCP were performed at an outside institution 14 years ago, showing parenchymal changes of chronic pancreatitis and an 11mm cyst that communicated with the main duct. More recent CT scan showed a 2cm cyst in the neck of the pancreas with clear communication with the main duct. EUS was performed to rule out an IPMN. Changes of chronic pancreatitis were seen and fluid sampling by FNA yielded clear viscous fluid and CEA 900ng/ml highly suggestive of IPMN. Given the growth, symptoms, and possible main duct involvement, resection was advised but the patient refused unless there was further “proof” of IPMN. Direct pancreaticocystoscopy was first described by our group in 2009. This involves off-label use of a fiber optic probe through a 19 gauge FNA needle. Endoscopic Methods: EUS is performed and the cyst is visualized. A 19 gauge needle is advanced into the cyst and fluid is withdrawn and sent for analysis. Sterile saline is injected into the cyst and the fiber optic probe is advanced through the needle into the cyst. The cyst wall is visualized. Finally the cyst is completely decompressed by aspiration and the needle is withdrawn. Clinical Implications: Reliable preoperative diagnosis of pancreatic cystic lesions has proven difficult. Further means of differentiation between benign, premalignant and malignant cysts is required. Direct pancreaticocystoscopy appears safe and can provide diagnostic information about the underlying nature of pancreatic cysts. Further studies are required to determine the accuracy and the role that cystoscopy may play in diagnostic algorithms. VH2 Endoscopic Antegrade Pancreatography (EAP): EUS Rendezvous to Facilitate Pancreatic Duct Therapy in Postoperative Anatomy Gregory A. Cote, Michael House, John DeWitt Background: EUS rendezvous has been reported in cases of failed ERCP. Most case reports and series highlight EUS to facilitate access to the biliary tree. We present a case of EUS rendezvous to facilitate access to the pancreatic duct in a patient who had previously undergone pancreatoduodenectomy five years prior. She presented with recurrent abdominal pain and CT evidence of a retained pancreatic duct stent from the time of her surgery. Endoscopic Methods: EUS FNA access to the pancreatic duct, EUS guided pancreatogram, EUS and fluoroscopy guided antegrade wire access to the pancreatic duct. Rendezvous access to the pancreatojejunal anastomosis. Clinical Implications: EAP is a feasible technique in failed cases of ERP, particularly in cases of postoperative anatomy. Larger studies/experience is needed to define its role. VH3 EUS-Guided Choledochoduodenostomy With Metal Stent Placement. Tyler Berzin, Zhigang Song, Ram Chuttani, Niravkumar Patel Background: A 76 year old woman presented with a 20lb weight loss, epigastric discomfort, and abnormal LFTs. RUQ ultrasound and cross-sectional imaging revealed biliary dilation, a pancreatic head mass, and liver masses concerning for metastases. ERCP was attempted for biliary drainage and cytologic sampling. The ampulla was identified and cannulated, however there was complete obstruction at the distal CBD, and wire passage was not possible. Biopsies confirmed pancreatic adenocarcinoma. The patient later developed worsening jaundice and biliary dilation, and the decision was made to proceed with EUS-guided choledochoduodenostomy with metal stent placement. Endoscopic Methods: A therapeutic linear echoendoscope was introduced. The dilated common bile duct was identified from the duodenal bulb. A single puncture was made into the bile duct using 19g FNA needle. Bile aspiration was confirmed with a syringe, and a transduodenal cholangiogram was performed confirming severe dilation of the common bile duct with minimal intrahepatic dilation. A needle knife was then used over the wire to create the choledochoduodenostomy and a 4mm biliary balloon was passed over the wire to dilate under fluoroscopic visualization. A 4cm x 10mm fully covered self-expanding metal stent was inserted and deployed successfully. Clinical Implications: Prior to 2011, EUS-guided biliary access techniques were described largely in case reports and case series. Two important studies in 2011 establish EUS-guided biliary access procedures as effective and safe alternatives when ERCP fails (Shah et al. Gastrointest Endosc 2011 Oct 19; Park et al. Gastrointest Endosc 2011 Sept 11). The technical success rate for direct EUS-guided biliary therapy is 80% in recently published studies. Complication rates are comparable to percutaneous approaches, with the advantage accomplishing internal drainage with a single stage procedure. EUS- guided biliary drainage procedures, including choledochoduodenostomy (EUS- CDS) can be completed successfully using a therapeutic channel linear EUS scope. There are opportunities for further refinements in linear echoendoscope design and the development of dedicated devices for EUS-guided biliary access. VH4 EUS Guided Biliary Drainage of Distal Biliary Obstruction Serag Dredar, Harry Aslanian Background: 80 year old man presented with pancreatic cancer with CBD obstruction. ERCP failed. We performed EUS biliary rendezvous and were able to perform ERCP with metal stent placement. Endoscopic Methods: EUS with 19g FNA needle to puncture CBD, pass guidewire antegrade with wire passing through papilla. ERCP then performed alongside the guidewire. The strictured region is dilated and a metal stent is placed across the stricture. Clinical Implications: This technique may obviate the need of sending patients to IR for failed ERCP and allow for patients that have failed ERCP to have single session interventions. May also be more cost effective. VH5 A Novel Endoscopic Treatment of Pancreas Divisum Everson L.A. Artifon, Flavio C. Ferreira Background: Pancreas divisum is the most common congenital anomaly of the pancreas. It occurs in approximately 7% of autopsy. Pancreas divisum develops prenatally by a failure of the ducts of the dorsal and ventral buds to fuse during embryologic development. In more than 90% of patients, the proximal one third of the dorsal pancreatic duct regresses as it fuses with the ventral duct, forming the main pancreatic duct.We present here a 51 year-old female with two episodes of acute pancreatitis in a short period of two months. She had a previous history of colecistectomy six months earlier. A MRCP was performed after surgery and demonstrated dilation of the intrahepatic bile duct, without evidence of stones or strictures. Dilation of main pancreatic duct with communication between dorsal and ventral pancreas was seen. Laboratory findings included a high direct bilirubin of 2.8 and amylase of 290. Endoscopic Methods: The present case demonstrates the feasibility of a novel technique for treatment of pancreas divisum by using an antegrade access through the major papilla and after the guidewire passed through the major papilla, into the communication duct, then through the minor papilla and deeply into the duodenal lumen. The dilation of the minor papilla was performed antegradely , over the guidewire after the balloon catheter had passed through the major papilla in this patient with incomplete pancreas divisum. Radiologic images of the balloon’s passage and posterior dilation with a 6mm x 30mm hydrostatic balloon was obtained. During procedure was observed a slow enlargement of balloon’s waist until its complete disappearance. The radiologic control showed good drainage of the contrast injected inside the pancreatic ducts. No immediate or late complications were observed. The laboratory exams demonstrated to be normal at 7 and 30 days after the procedure. Clinical Implications: Because this anomaly usually is asymptomatic, treatment is offered to symptomatic patients after conducting a complete workup for other causes of pancreatitis and abdominal pain. Patients with mild symptoms can be managed conservatively. On the other hand, patients with recurrent episodes of pancreatitis or chronic pain may need intervention, which can be performed endoscopically or surgically. The potential adverse effects of prolonged pancreatic stenting, such as pancreatitis, stent occlusion or migration, pancreatic duct perforation, and pseudocyst formation, are determinant to the use of stents after the procedure. If during the exam it is clear that there is good clearence of the contrast injected, so we must avoid pancreatic stenting. We demonstrated here a novel technique of endoscopic treatment of incomplete pancreas divisum . VH6 EUS Guided Rendezvous for Biliary Access for Bile Duct Stone in Small Duct, After Outside Failed ERCP with Post ERCP Pancreatitis and Perforation Rajeev Attam, Mustafa Arain, Martin L Freeman Background: In this video we will show management of a 77 year old with recent cholecystectomy at an outside hospital. Intraoperative cholangiogram www.giejournal.org Volume 75, No. 4S : 2012 GASTROINTESTINAL ENDOSCOPY AB113