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⁎4677 Endoscopic treatment of 64 patients with mirizzi`s syndrome.
*4674 ENDOSCOPIC MANAGEMENT OF BILIARY COMPLICATIONS IN 369 LIVER TRANSPLANT RECIPIENTS. Shea O. Ross, Stephen T. Amann, Christopher E. Forsmark, Univ of Florida, Gainesville, FL; North Mississippi Med Ctr, Tupelo, MS. Background: Biliary tract complications occur in approximately 15-35% of patients following OLT. We report our experience with the endoscopic management of a variety of post-OLT biliary complications. Methods: The records of 369 patients receiving 407 grafts from 1/1/94 to 1/1/99 were retrospectively reviewed. Endoscopic retrograde cholangiography (ERC) was performed in 122 patients for cholestasis or suspected bile leak. Mean follow up is 38 mo(range 11-70 mo). Results: ERC was successfully completed in 118/122 (97%). The endoscopic findings, management, and results are presented in the table. Overall, endoscopic therapy was successful in 79/91(87%) of patients with abnormalities. The success rate was highest for isolated biliary leaks (95%) followed by strictures (89%) and was lowest for combined stricture and leak (60%). On average, 2.4 and 2.0 ERC s were required for successful management of strictures and leaks, respectively. Endoscopic therapy of stones/ sludge was successful in 100%. Suspected papillary stenosis was successfully treated in 5/5 patients, although only 2 of these patients had a normalization of liver chemistries. Conclusion: Biliary strictures and leaks were the most common biliary complications at our institution occurring in 19.9% of grafts during the study period. Endoscopic therapy was most successful in isolated bile leak and strictures and least successful in combined stricture and leak. Although multiple endoscopic procedures are required to treat these complications, the vast majority can be successfully managed endoscopically.
ERC
N
Findings
(%)†
Biliary Stricture Biliary Leak Stricture and Leak Stones/ Sludge Papillary Stenosis Normal
45 21 15 5 5 27
(38%) (18%) (13%) (4%) (4%) (23%)
Balloon
Stent or
Sphincterotomy‡
dilation‡
NB Tube‡
78% 62% 93% 60% 100% 26%
69% —— 27% —— —— ——
73% 86% 80% —— 40% ——
Endoscopic Success
40 20 9 5 5
(89%) (95%) (60%) (100%) (100%) ——
†Percentage of finding in 118 pts w/successful ERC ‡Percentages exceed 100% because many pts had ≥ 1 maneuver
*4675 PERIAMPULLARY CHOLEDOCHODUODENAL FISTULA: INDICATION FOR ENDOSCOPIC SPHINCTEROTOMY? Takao Ohtsuka, Masao Tanaka, Ken Inoue, Toshinaga Nabae, Kazunori Yokohata, Graduate Sch of Med Sci, Kyushu Univ, Fukuoka, Japan. Background and aim: PCDF mostly caused by duodenal penetration of common bile duct (CBD) stones has been recognized more frequently with the prevalence of ERCP. Most patients undergo ES for CBD stone removal, but appropriate treatment for PCDF without stones is unknown. Longterm outcome was analyzed in this context. Methods: Follow-up was obtained in 157 (95%) of 165 patients with benign PCDF. 19 patients with hepatolithiasis were excluded from analysis, since migrating intrahepatic stones might be indistinguishable from recurrent stones. Fistulotomy by ES (76) or papilloplasty (6) was performed in 82 patients (Group 1), but not in 53 (Group 2). The other 3 patients underwent various surgical procedures. CBD stones were initially present in 96% of Group 1 and 30% of Group 2. Incidence of late complications was compared between the two groups. Results: During a median period of 130 months (range, 1 months to 28 years), 28 (21%) of a total of 135 patients developed late complications including recurrence of CBD stones (17 patients, 13%), acute cholangitis (9 patients, 7%), and biliary carcinoma (2 patients, 1.5%). The rate of stone recurrence tended to be higher in Group 1 (16%) than in Group 2 (8%), but the difference was not significant (P=0.15). In Group 2, four patients (8%) had one to three episodes of chills, fever and liver dysfunction suggesting reflux cholangitis, which resolved quickly by conservative treatment. Two patients developed a CBD carcinoma and an early gallbladder carcinoma 2 and 7 years, respectively, after the diagnosis of PCDF. Conclusions: Reflux cholangitis sometimes occurs in patients with a PCDF even without recurrent stones. However, the incidence and frequency of cholangitis are low and the symptoms can be easily managed. PCDF may be left untreated as judged by the long-term outcome.
AB200
GASTROINTESTINAL ENDOSCOPY
Group 1 No. of patients Recurrence of stones Cholangitis with recurrent stones Cholangitis with residual stones Cholangitis without stones Biliary carcinoma
82 13 (16%) 3 0 0 0
Group 2
P-value
53 4 (8%) 0 2 4 2
0.15 — — 0.02 —
*4676 THERAPEUTIC ERCP IN OUTPATIENTS: A SERIES OF 530 CONSECUTIVE CASES. Nelson Vieira Coelho, Julio Pereira-Lima, Claudio Rolim Teixeira, Ronaldo Spinatto Torresini, Rosane Cirne, Fugast, Porto Alegre, Brazil; Fugast, Porto Alegre, Brazil. The aim of the study was to determine the safety of discharge following therapeutic ERCP. We assessed 530 patients undergoing outpatient therapeutic ERCP from a cohort of 1,227 consecutive ERCP procedures from 1994 to 1999. Patient selection was based on relative good health (ASA I or II). Patients were observed for a minimum of 4 hours before discharge and were told to contact the service if any symptoms developed. Plastic stents were inserted in 43 patients (giant stones n=8; malignancy n = 20; cystic duct leak n =8; chronic pancreatitis n = 4; stricture without confirmed etiology n = 3); biliary sphincterotomy was performed in 515 cases. The majority of this group was treated for coledocholithiasis and stone extraction (n=491). Ten patients were treated for ampulary tumor and 5 for sphincter of Oddi dysfunction. Admission was required in 32 cases (6,03%), 25 during the four-hour postERCP observation period, and 7 after a median time of 24 hours following discharge (range 5-72 hours). Reasons for admission were pancreatitis in 25 patients, post-sphincterotomy bleeding in 2, cholangitis in 3, and abdominal pain in 2. The overall median hospital stay was 3 days (range 1-17 days). One patient (HIV-positive) developed cholangitis, sepsis and died 14 days after the procedure. Another patient with cirrhosis presented severe bleeding and died 72 hours after successful stone extraction. In this selected series of 530 consecutive cases, endoscopic sphincterotomy and stent placement were safely performed in an ambulatory setting. A randomized comparative trial between outpatient and inpatient ERCP is necessary prior to recommending a generalized change in the current practice. *4677 ENDOSCOPIC TREATMENT OF 64 PATIENTS WITH MIRIZZI`S SYNDROME. Uwe Seitz, Erik Debes, Sabine Bohnacker, Christian Weise, Parupudi Vj Sriram, Frank Thonke, Stefan Jaeckle, Nib Soehendra, Univ Hosp Eppendorf, Hamburg, Germany. Background: Mirizzi`s syndrome is defined as extrinsic compression of the common bile duct by an impacted stone in the cystic duct or the neck of the gallbladder. Surgery is often difficult due to extensive inflammation. Aim: Evaluation of endoscopic treatment of Mirizzi`s syndrome in the largest series reported yet. Methods: Retrospective evaluation of patients (pts) presenting with Mirizzi`s syndrome between 1990 and 1999. For initial stabilisation or safe transport to our center, temporary stents or nasobiliary drainage (NBD) were placed. If the stone could be caught into the Dormia basket, mechanical lithotripsy (ML) was performed. Otherwise electrohydraulic lithotripsy (EHL) using the Mother-Baby scope system (Olympus Co.,Tokyo, Japan) and the Walz lithotriptor (Fa. Walz, Rohrdorf, Germany) was performed to fragment stones under cholangioscopic view. Results: 48 f and 16 m pts with a median age of 71years (14-94y) were included. Median duration of biliary symptoms was 22 days (1 d-5 y). Patients presented with pain in 64%, obvious jaundice in 66% and painless jaundice in 22%. 19% were in poor general condition. 9 pts had undergone cholecystectomy median 3 y before (0.1-23 y). An initial endoscopic stent or NBD was placed in 30 pts (47%). Median size of stones was 2cm (0.75cm). In 8 pts ML was performed. 52 pts required EHL. Complete duct clearance was achieved in 59 pts (92%). A single lithotripsy session was sufficient in 54 pts. 4 pts were treated by stenting or nasobiliary drainage only. A complicated course was observed in 4 pts: 2 pts with cystic duct leak at the site of pressure necrosis recovered conservatively. A 71y male not sent for the 2nd session of lithotripsy was treated with long term stenting in another hospital and developed small bowel perforation by the dislodged stent. A 90 y female with septicemia treated by NBD, had myocardial infarction after 2 d and died after 3 d. Subsequently, 12 pts underwent cholecystectomy. 4 of them were symptomatic after endoscopy due to cholelithiasis (3 patients had cholecystitis after 7 d, 7 d and 56 d, respectively; 1 pt had biliary colics after 2 y). 39 pts did not undergo surgery and have remained asymptomatic over a median follow up of 28 months (2-82). None of the pts developed biliary malignancy over a median follow up of 24 (0-85) months. Conclusion: Mirizzi`s syndrome, being considered a clear indication for surgical management, can be safely and effectively treated by endoscopy even in elderly and severely ill pts. Coincidence of gallbladder malignancy with Mirizzi`s syndrome was not observed.
VOLUME 51, NO. 4, PART 2, 2000
ERC
N
Findings
(%)†
Biliary Stricture Biliary Leak Stricture and Leak Stones/ Sludge Papillary Stenosis Normal
45 21 15 5 5 27
(38%) (18%) (13%) (4%) (4%) (23%)
Balloon
Stent or
Sphincterotomy‡
dilation‡
NB Tube‡
78% 62% 93% 60% 100% 26%
69% —— 27% —— —— ——
73% 86% 80% —— 40% ——
Endoscopic Success
40 20 9 5 5
(89%) (95%) (60%) (100%) (100%) ——
†Percentage of finding in 118 pts w/successful ERC ‡Percentages exceed 100% because many pts had ≥ 1 maneuver
*4675 PERIAMPULLARY CHOLEDOCHODUODENAL FISTULA: INDICATION FOR ENDOSCOPIC SPHINCTEROTOMY? Takao Ohtsuka, Masao Tanaka, Ken Inoue, Toshinaga Nabae, Kazunori Yokohata, Graduate Sch of Med Sci, Kyushu Univ, Fukuoka, Japan. Background and aim: PCDF mostly caused by duodenal penetration of common bile duct (CBD) stones has been recognized more frequently with the prevalence of ERCP. Most patients undergo ES for CBD stone removal, but appropriate treatment for PCDF without stones is unknown. Longterm outcome was analyzed in this context. Methods: Follow-up was obtained in 157 (95%) of 165 patients with benign PCDF. 19 patients with hepatolithiasis were excluded from analysis, since migrating intrahepatic stones might be indistinguishable from recurrent stones. Fistulotomy by ES (76) or papilloplasty (6) was performed in 82 patients (Group 1), but not in 53 (Group 2). The other 3 patients underwent various surgical procedures. CBD stones were initially present in 96% of Group 1 and 30% of Group 2. Incidence of late complications was compared between the two groups. Results: During a median period of 130 months (range, 1 months to 28 years), 28 (21%) of a total of 135 patients developed late complications including recurrence of CBD stones (17 patients, 13%), acute cholangitis (9 patients, 7%), and biliary carcinoma (2 patients, 1.5%). The rate of stone recurrence tended to be higher in Group 1 (16%) than in Group 2 (8%), but the difference was not significant (P=0.15). In Group 2, four patients (8%) had one to three episodes of chills, fever and liver dysfunction suggesting reflux cholangitis, which resolved quickly by conservative treatment. Two patients developed a CBD carcinoma and an early gallbladder carcinoma 2 and 7 years, respectively, after the diagnosis of PCDF. Conclusions: Reflux cholangitis sometimes occurs in patients with a PCDF even without recurrent stones. However, the incidence and frequency of cholangitis are low and the symptoms can be easily managed. PCDF may be left untreated as judged by the long-term outcome.
AB200
GASTROINTESTINAL ENDOSCOPY
Group 1 No. of patients Recurrence of stones Cholangitis with recurrent stones Cholangitis with residual stones Cholangitis without stones Biliary carcinoma
82 13 (16%) 3 0 0 0
Group 2
P-value
53 4 (8%) 0 2 4 2
0.15 — — 0.02 —
*4676 THERAPEUTIC ERCP IN OUTPATIENTS: A SERIES OF 530 CONSECUTIVE CASES. Nelson Vieira Coelho, Julio Pereira-Lima, Claudio Rolim Teixeira, Ronaldo Spinatto Torresini, Rosane Cirne, Fugast, Porto Alegre, Brazil; Fugast, Porto Alegre, Brazil. The aim of the study was to determine the safety of discharge following therapeutic ERCP. We assessed 530 patients undergoing outpatient therapeutic ERCP from a cohort of 1,227 consecutive ERCP procedures from 1994 to 1999. Patient selection was based on relative good health (ASA I or II). Patients were observed for a minimum of 4 hours before discharge and were told to contact the service if any symptoms developed. Plastic stents were inserted in 43 patients (giant stones n=8; malignancy n = 20; cystic duct leak n =8; chronic pancreatitis n = 4; stricture without confirmed etiology n = 3); biliary sphincterotomy was performed in 515 cases. The majority of this group was treated for coledocholithiasis and stone extraction (n=491). Ten patients were treated for ampulary tumor and 5 for sphincter of Oddi dysfunction. Admission was required in 32 cases (6,03%), 25 during the four-hour postERCP observation period, and 7 after a median time of 24 hours following discharge (range 5-72 hours). Reasons for admission were pancreatitis in 25 patients, post-sphincterotomy bleeding in 2, cholangitis in 3, and abdominal pain in 2. The overall median hospital stay was 3 days (range 1-17 days). One patient (HIV-positive) developed cholangitis, sepsis and died 14 days after the procedure. Another patient with cirrhosis presented severe bleeding and died 72 hours after successful stone extraction. In this selected series of 530 consecutive cases, endoscopic sphincterotomy and stent placement were safely performed in an ambulatory setting. A randomized comparative trial between outpatient and inpatient ERCP is necessary prior to recommending a generalized change in the current practice. *4677 ENDOSCOPIC TREATMENT OF 64 PATIENTS WITH MIRIZZI`S SYNDROME. Uwe Seitz, Erik Debes, Sabine Bohnacker, Christian Weise, Parupudi Vj Sriram, Frank Thonke, Stefan Jaeckle, Nib Soehendra, Univ Hosp Eppendorf, Hamburg, Germany. Background: Mirizzi`s syndrome is defined as extrinsic compression of the common bile duct by an impacted stone in the cystic duct or the neck of the gallbladder. Surgery is often difficult due to extensive inflammation. Aim: Evaluation of endoscopic treatment of Mirizzi`s syndrome in the largest series reported yet. Methods: Retrospective evaluation of patients (pts) presenting with Mirizzi`s syndrome between 1990 and 1999. For initial stabilisation or safe transport to our center, temporary stents or nasobiliary drainage (NBD) were placed. If the stone could be caught into the Dormia basket, mechanical lithotripsy (ML) was performed. Otherwise electrohydraulic lithotripsy (EHL) using the Mother-Baby scope system (Olympus Co.,Tokyo, Japan) and the Walz lithotriptor (Fa. Walz, Rohrdorf, Germany) was performed to fragment stones under cholangioscopic view. Results: 48 f and 16 m pts with a median age of 71years (14-94y) were included. Median duration of biliary symptoms was 22 days (1 d-5 y). Patients presented with pain in 64%, obvious jaundice in 66% and painless jaundice in 22%. 19% were in poor general condition. 9 pts had undergone cholecystectomy median 3 y before (0.1-23 y). An initial endoscopic stent or NBD was placed in 30 pts (47%). Median size of stones was 2cm (0.75cm). In 8 pts ML was performed. 52 pts required EHL. Complete duct clearance was achieved in 59 pts (92%). A single lithotripsy session was sufficient in 54 pts. 4 pts were treated by stenting or nasobiliary drainage only. A complicated course was observed in 4 pts: 2 pts with cystic duct leak at the site of pressure necrosis recovered conservatively. A 71y male not sent for the 2nd session of lithotripsy was treated with long term stenting in another hospital and developed small bowel perforation by the dislodged stent. A 90 y female with septicemia treated by NBD, had myocardial infarction after 2 d and died after 3 d. Subsequently, 12 pts underwent cholecystectomy. 4 of them were symptomatic after endoscopy due to cholelithiasis (3 patients had cholecystitis after 7 d, 7 d and 56 d, respectively; 1 pt had biliary colics after 2 y). 39 pts did not undergo surgery and have remained asymptomatic over a median follow up of 28 months (2-82). None of the pts developed biliary malignancy over a median follow up of 24 (0-85) months. Conclusion: Mirizzi`s syndrome, being considered a clear indication for surgical management, can be safely and effectively treated by endoscopy even in elderly and severely ill pts. Coincidence of gallbladder malignancy with Mirizzi`s syndrome was not observed.
VOLUME 51, NO. 4, PART 2, 2000