- Email: [email protected]
Needle knife papillotomy (NKP) without stent insertion for the difficult sphincterotomy (ES): A standardized technique explained
ERCP-BILIARY
./369
$37/
A NEW FREQUENCY-DOUBLED DOUBLE-PULSE Nd:YAG LASER (FREDDY) FOR LASERLITHOTRIPSY OF GALLSTONES - AN INTERESTING NEW PULSED SOLID-STATE LASER WITH AN AUTOMATIC PIEZO-ACOUSTIC STONE/TISSUE DETECTION SYSTEM (paSTDS) J. Hochberger, J. Tschepe*, R. Stein, J. Bayer, J. Helfmann*, P. Martus#, S. Tex, C. Ell, D. Schiidel*, E.G. Hahn Dept. of Medicine I, # Inst. Biomed. Statistics, Fr.-Alex.-Univ., Erlangen, *Laser-Medizin-Zentrum, Berlin, Germany Laserlithotripsy using dye laser systems has become a commonly accepted endoscopic treatment modality for the removal of difficult bile duct stones. To date its application is limited, however, to centers because of high costs. In the following we report on our preliminary preclinical experience using a new solid-state laser lithotriptor which seems to combine the advantages of dye and solid state lasers as concerns low price, reliability and effectiveness. A new piezo-acoustic stone/tissue detection system (paSTDS) is integrated in the laser for automatic pulse interruption in case of tissue contact ('smart laser'). Mat.& Meth.: 50 human gallstones (GS) of comparable chem. composition and size [d=9.321.4ram; 5 'mixed groups of 10 GS (10 families of 5 GS)] were disintegrated into sand-grain-like fragments (<4 ram). Three different settings of a frequency-doubled double-pulse Q-switched Nd:YAG laser (FREDDY; 532/1064nm, 10 Hz; Clyxon Corp. D-Berlin) with different green shares of the laser pulse (9.8%; 20.6%; 25.4% at 532 nm), different pulse lengths (1.0~ts; 1.4~s; 1.4,tts) and varying total pulse energy (80mJ;80mJ;65mJ) were compared to two standard settings of a rhodamine-6G dye laser (595nm, 2.5 ~ts, 120 and 80 mJ pp, 10 Hz; 'Lithognost', Baasel Corp. D-Starnberg) disintegrating one stone group at each setting. Results: All 50 concrements could be effectively disintegrated in vitro. FREDDY80/16.5mJ and Rh-6G-120mJ showed the fastest fragmentation and a .s~n.liar n of pulses required. (1315• resp. 1160~_415 pulses/cm ; p>0.1). Conclusions: FREDDY represents an interesting new pulsed laser system with integrated paSTDS which shows a fragmentation capacity comparable to conventional laser systems at 30% of the COSTS.Animal experiments for the paSTDS and first clinical applications are currently under investigation.
NEEDLE KNIFE PAPILLOTOMY (NKP) WITHOUT STENT INSERTION FOR THE DIFFICULT SPHINCTEROTOMY (ES): A STANDARDIZED TECHNIQUE EXPLAINED, D_.A.A::lowell, T. Qaseem, B.L. Hanson, W.G. Parsons,E. Elton, J.J. Bosco. Division of GI, Maine Medical Center, Portland, ME. We have reported the impact of needle knife papillotomy on our growing series of endoscopic sphincterotomy which has a very low overall complication rate of 1.1% (Gastrointest Endosc 1995;41:400A). A recent controlled study has suggested that stent placement into the pancreatic duct lowers the risk of pancreatitis for NKP. Many authors use the single term "precut" to describe many different procedures. P_AT.JE2LTS: From 1/91-I 1/95, 1000 consecutive patients (aged 4-97; 385M:615F) had ES performed for common bile duct stones-340, SOD/ampullary stenosis-233, stent placement-232, and others-195. Complications were recorded by published criteria (Gastrointest Endosc 1991;37-383-393). 154 patients (15.4%) could not be deeply cannulated to undergo standard sphincterotomy and underwent our technique of NKP. METHODS: An HKPT needle knife papiUotome (Wilson-Cook), with a minimum of 4 mm of exposed wire was inserted into the papillary orifice without a protective stent. Gentle traction on the endoscope, while applying blended current, permitted an upward incision towards the 1 l o'clock position while pulling the needle knife back into the duodenal lumen. Entry was then re-attempted with a wireguided papfllotome and the ES was completed, gESUJ.,X~ Entry followed immediately in 129/154 (84%) and after 1 additional procedure in 17 more (overall success 95%), There were 3 episodes (1.9%) of pancreatitis, none severe, with total complications of 6/154 (3.9%). In comparison, the 846 patients undergoing standard sphincterotomy experienced 3 episodes of pancreatitis (0.35%) (1 moderate and 2 severe) and total complications were 0.71%. No deaths or emergency surgery occurred. EDAS.CLI2SIQNS: Stent insertion into the pancreatic duct before NKP was unnecessary when using this technique. This technique of NKP produced few complications, all of which were mild or moderate. Since the majority of complications occur in patients who are difficult to cannulate, this technique prevents many complicafons.
"/370
./372
DIAGNOSTIC AND THERAPEUTIC ERCP USING A PUSH ENTEROSCOPE IN LONG LIMB SURGICAL GASTROENTEROSTOMY PATIENTS. D.A, Howell. T. Qaseem, W.G. Parsons, Division of Gl, Maine Medical Center, Portland, ME. Long limb surgical bypasses have in general not permitted access for retrograde cannulation, necessitating management by surgery or interventional radiology. We repoJt per early experience using push enteroscopy to gain access to the papilla for ERCP. P_ATAENTS: From 3/94 to 9/95.6 patients (M:3;F:3, mean age:59) presented with biliary obstruction (N=3), recurrent pancreatitis (N=2), or hemobilia (N=I). All 6 patients had undergone previous partial gastrectomy. The afferent limb was a Roux-en-Y in 4 and a long loop pancreatoduodenectomy in 2. 3 patients had had multiple previous preliminary operations leading to the final Roux-en-Y diversion. Three had prior percutaneous or endoscopic placed Wallstents or plastic stents in place. METHOD_S: The Olympus Evis SIP 100 push enteroscope was utilized to enter the jejuno-jejunostomy approximately 30 cm from the gastroemerostomy in the Roux-en-Y patients, or the afferent loop in the 1 patient status-post Whipple. RESULTS: In 5/6 (83%) it was possible to advance the enteroscope fully to the level of the papilla. In 1 patient, extensive surgical adhesions prevented full advancement. Selective cannulation was possible in 4, documenting an obstructing stone, an occluded stent. a strictured pancreatico-duodenal anastomosis and a bleeding varix of a surgical cholecystojejunostomy in 1 patient each. Therapeutic ERCP was possible in all 4 patients including 7 Fr plastic stem placement in 2, stent and stone removal in 1, and coagulation therapy of the bleeding vessel in I. Specially adapted or modified endoscopic accessories were used in some cases. Increased bleeding of the varix necessitating surgery was the only complication, CD_NCIJ I S ~ Patients with long loop gastroenterostomies can generally undergo successful examination of the arnpullary region using push enteroscopy. Therapeutic ERCP procedures can be accomplished in some, but specialized accessories need to be developed to improve the ability to cannulate and to canT out therapeutic procedures. Ideally a sideviewing push enteroscope would improve the overall success of therapy at the papilla.
ROLE OF SURVEILLANCE ERCP IN PREVENTING EPISODIC CHOLANG1TISIN PATIENTS WITH RECURRENT CBD STONES. Jafri, JE Gecnen, WJ Hogan, MF Catalano, GK Johnson, DJ Geenen, MJ Schmalz. Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, WL Recurrent CBD stones oeeu~ in 2-7% of pts who have undergone endoscopic or surgical extraction; a small percentage have multiple recurrences of CBD stones and present with recurrent episodes of ascending cholangitis. AIM: To define the characteristics of pts with multiple recurrences of CBD stones presenting with ascending eholangitis who may benefit from surveillance ERCP. METHODS: Forty-two of 2,096 pts were identified as having CBD stone recurrence following endoscopic sphincterotomy and clearance of the biliary tree. Thirteen of 42 pts (10M, 3F, ages 24-89, mean 67 yrs.) were identified with two or more recurrences without any predisposing factors. Following the second recurrence of stones with ascending cholengitls, pts underwent annual ERCP. ~,d~J_L...T$.:All 13 pts presented with recurrent episodes of ascending cholangitis; the majority of pts had more than one stone on each occasion. Unexpectedly, most of the stones were yellow and soft. All pts had dilated CBD's (range 15-25mm, mean 17ram). The sphincterotomy opening was measured by balloon pullthrough and appeared to be adequate in all pts. CBD drainage of contrast was delayed in 10 of 13 pts. Continuous Actigall therapy did not prevent recurrence of stone formation. The number of episodes of ascending cholangitis decreased significantly following surveillance ERCP. Episodes of Surveillance ERCP i Pts No. of stones Cholangitis (n) (n) per recurrence Pre-S-urv Post-Surv Stones Stones Total
VOLUME 43, NO. 4, 1996
(n)
(mean)
ERCP
ERCP
Present
absent
13
4 26 6* 25 "6 31 Range (1-12) 0.01 CONCLUSIONS.: In the subgroup of patients with multiple recurrent CBD stones, ascending cholangitis is the major clinical presentation. Despite adequate sphincterotomy, the findings of dilated CBD's and delayed drainage are suggestive of stasis as a causative factor in recurrent stone formation. Actigall does not seem to be effective in preventing recurrences. Survei/lance ERCP with prophylactic stone removal on an annual basis appears to prevent recurrent episodes of ascending cholangitis.
GASTROINTESTINAL ENDOSCOPY
388
./369
$37/
A NEW FREQUENCY-DOUBLED DOUBLE-PULSE Nd:YAG LASER (FREDDY) FOR LASERLITHOTRIPSY OF GALLSTONES - AN INTERESTING NEW PULSED SOLID-STATE LASER WITH AN AUTOMATIC PIEZO-ACOUSTIC STONE/TISSUE DETECTION SYSTEM (paSTDS) J. Hochberger, J. Tschepe*, R. Stein, J. Bayer, J. Helfmann*, P. Martus#, S. Tex, C. Ell, D. Schiidel*, E.G. Hahn Dept. of Medicine I, # Inst. Biomed. Statistics, Fr.-Alex.-Univ., Erlangen, *Laser-Medizin-Zentrum, Berlin, Germany Laserlithotripsy using dye laser systems has become a commonly accepted endoscopic treatment modality for the removal of difficult bile duct stones. To date its application is limited, however, to centers because of high costs. In the following we report on our preliminary preclinical experience using a new solid-state laser lithotriptor which seems to combine the advantages of dye and solid state lasers as concerns low price, reliability and effectiveness. A new piezo-acoustic stone/tissue detection system (paSTDS) is integrated in the laser for automatic pulse interruption in case of tissue contact ('smart laser'). Mat.& Meth.: 50 human gallstones (GS) of comparable chem. composition and size [d=9.321.4ram; 5 'mixed groups of 10 GS (10 families of 5 GS)] were disintegrated into sand-grain-like fragments (<4 ram). Three different settings of a frequency-doubled double-pulse Q-switched Nd:YAG laser (FREDDY; 532/1064nm, 10 Hz; Clyxon Corp. D-Berlin) with different green shares of the laser pulse (9.8%; 20.6%; 25.4% at 532 nm), different pulse lengths (1.0~ts; 1.4~s; 1.4,tts) and varying total pulse energy (80mJ;80mJ;65mJ) were compared to two standard settings of a rhodamine-6G dye laser (595nm, 2.5 ~ts, 120 and 80 mJ pp, 10 Hz; 'Lithognost', Baasel Corp. D-Starnberg) disintegrating one stone group at each setting. Results: All 50 concrements could be effectively disintegrated in vitro. FREDDY80/16.5mJ and Rh-6G-120mJ showed the fastest fragmentation and a .s~n.liar n of pulses required. (1315• resp. 1160~_415 pulses/cm ; p>0.1). Conclusions: FREDDY represents an interesting new pulsed laser system with integrated paSTDS which shows a fragmentation capacity comparable to conventional laser systems at 30% of the COSTS.Animal experiments for the paSTDS and first clinical applications are currently under investigation.
NEEDLE KNIFE PAPILLOTOMY (NKP) WITHOUT STENT INSERTION FOR THE DIFFICULT SPHINCTEROTOMY (ES): A STANDARDIZED TECHNIQUE EXPLAINED, D_.A.A::lowell, T. Qaseem, B.L. Hanson, W.G. Parsons,E. Elton, J.J. Bosco. Division of GI, Maine Medical Center, Portland, ME. We have reported the impact of needle knife papillotomy on our growing series of endoscopic sphincterotomy which has a very low overall complication rate of 1.1% (Gastrointest Endosc 1995;41:400A). A recent controlled study has suggested that stent placement into the pancreatic duct lowers the risk of pancreatitis for NKP. Many authors use the single term "precut" to describe many different procedures. P_AT.JE2LTS: From 1/91-I 1/95, 1000 consecutive patients (aged 4-97; 385M:615F) had ES performed for common bile duct stones-340, SOD/ampullary stenosis-233, stent placement-232, and others-195. Complications were recorded by published criteria (Gastrointest Endosc 1991;37-383-393). 154 patients (15.4%) could not be deeply cannulated to undergo standard sphincterotomy and underwent our technique of NKP. METHODS: An HKPT needle knife papiUotome (Wilson-Cook), with a minimum of 4 mm of exposed wire was inserted into the papillary orifice without a protective stent. Gentle traction on the endoscope, while applying blended current, permitted an upward incision towards the 1 l o'clock position while pulling the needle knife back into the duodenal lumen. Entry was then re-attempted with a wireguided papfllotome and the ES was completed, gESUJ.,X~ Entry followed immediately in 129/154 (84%) and after 1 additional procedure in 17 more (overall success 95%), There were 3 episodes (1.9%) of pancreatitis, none severe, with total complications of 6/154 (3.9%). In comparison, the 846 patients undergoing standard sphincterotomy experienced 3 episodes of pancreatitis (0.35%) (1 moderate and 2 severe) and total complications were 0.71%. No deaths or emergency surgery occurred. EDAS.CLI2SIQNS: Stent insertion into the pancreatic duct before NKP was unnecessary when using this technique. This technique of NKP produced few complications, all of which were mild or moderate. Since the majority of complications occur in patients who are difficult to cannulate, this technique prevents many complicafons.
"/370
./372
DIAGNOSTIC AND THERAPEUTIC ERCP USING A PUSH ENTEROSCOPE IN LONG LIMB SURGICAL GASTROENTEROSTOMY PATIENTS. D.A, Howell. T. Qaseem, W.G. Parsons, Division of Gl, Maine Medical Center, Portland, ME. Long limb surgical bypasses have in general not permitted access for retrograde cannulation, necessitating management by surgery or interventional radiology. We repoJt per early experience using push enteroscopy to gain access to the papilla for ERCP. P_ATAENTS: From 3/94 to 9/95.6 patients (M:3;F:3, mean age:59) presented with biliary obstruction (N=3), recurrent pancreatitis (N=2), or hemobilia (N=I). All 6 patients had undergone previous partial gastrectomy. The afferent limb was a Roux-en-Y in 4 and a long loop pancreatoduodenectomy in 2. 3 patients had had multiple previous preliminary operations leading to the final Roux-en-Y diversion. Three had prior percutaneous or endoscopic placed Wallstents or plastic stents in place. METHOD_S: The Olympus Evis SIP 100 push enteroscope was utilized to enter the jejuno-jejunostomy approximately 30 cm from the gastroemerostomy in the Roux-en-Y patients, or the afferent loop in the 1 patient status-post Whipple. RESULTS: In 5/6 (83%) it was possible to advance the enteroscope fully to the level of the papilla. In 1 patient, extensive surgical adhesions prevented full advancement. Selective cannulation was possible in 4, documenting an obstructing stone, an occluded stent. a strictured pancreatico-duodenal anastomosis and a bleeding varix of a surgical cholecystojejunostomy in 1 patient each. Therapeutic ERCP was possible in all 4 patients including 7 Fr plastic stem placement in 2, stent and stone removal in 1, and coagulation therapy of the bleeding vessel in I. Specially adapted or modified endoscopic accessories were used in some cases. Increased bleeding of the varix necessitating surgery was the only complication, CD_NCIJ I S ~ Patients with long loop gastroenterostomies can generally undergo successful examination of the arnpullary region using push enteroscopy. Therapeutic ERCP procedures can be accomplished in some, but specialized accessories need to be developed to improve the ability to cannulate and to canT out therapeutic procedures. Ideally a sideviewing push enteroscope would improve the overall success of therapy at the papilla.
ROLE OF SURVEILLANCE ERCP IN PREVENTING EPISODIC CHOLANG1TISIN PATIENTS WITH RECURRENT CBD STONES. Jafri, JE Gecnen, WJ Hogan, MF Catalano, GK Johnson, DJ Geenen, MJ Schmalz. Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, WL Recurrent CBD stones oeeu~ in 2-7% of pts who have undergone endoscopic or surgical extraction; a small percentage have multiple recurrences of CBD stones and present with recurrent episodes of ascending cholangitis. AIM: To define the characteristics of pts with multiple recurrences of CBD stones presenting with ascending eholangitis who may benefit from surveillance ERCP. METHODS: Forty-two of 2,096 pts were identified as having CBD stone recurrence following endoscopic sphincterotomy and clearance of the biliary tree. Thirteen of 42 pts (10M, 3F, ages 24-89, mean 67 yrs.) were identified with two or more recurrences without any predisposing factors. Following the second recurrence of stones with ascending cholengitls, pts underwent annual ERCP. ~,d~J_L...T$.:All 13 pts presented with recurrent episodes of ascending cholangitis; the majority of pts had more than one stone on each occasion. Unexpectedly, most of the stones were yellow and soft. All pts had dilated CBD's (range 15-25mm, mean 17ram). The sphincterotomy opening was measured by balloon pullthrough and appeared to be adequate in all pts. CBD drainage of contrast was delayed in 10 of 13 pts. Continuous Actigall therapy did not prevent recurrence of stone formation. The number of episodes of ascending cholangitis decreased significantly following surveillance ERCP. Episodes of Surveillance ERCP i Pts No. of stones Cholangitis (n) (n) per recurrence Pre-S-urv Post-Surv Stones Stones Total
VOLUME 43, NO. 4, 1996
(n)
(mean)
ERCP
ERCP
Present
absent
13
4 26 6* 25 "6 31 Range (1-12) 0.01 CONCLUSIONS.: In the subgroup of patients with multiple recurrent CBD stones, ascending cholangitis is the major clinical presentation. Despite adequate sphincterotomy, the findings of dilated CBD's and delayed drainage are suggestive of stasis as a causative factor in recurrent stone formation. Actigall does not seem to be effective in preventing recurrences. Survei/lance ERCP with prophylactic stone removal on an annual basis appears to prevent recurrent episodes of ascending cholangitis.
GASTROINTESTINAL ENDOSCOPY
388