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Wire guided papillotomes increase the selective bile duct cannulation rate
ERCP-BILIARY 7"413
7415
BILIARY STENTING WITH SELF-EXPANDABLE NITINOL SPRING STENT J.-F.Rey~, D.Duforest~, T A M a r e k 2. Institut Amault Tzanck, Saint Laurent du Var, France I and Silesian Medical Academy, Katowme, Poland2.
EEFFECT OF ENDOSCOPIC BALLOON SPHINCTEROPLASTY (EBS) ON SPHINCTER OF ODDI -EVALUATION FROM THE VIEW POINT OF ENDOSCOPIC MANOMETRYH.Sato, S. Mitsufuji, J. Takaaki, Y. Tatsumi, T. Maeda, S. Fujita, H. Ogasawara, K. Tokita, T. Kodama, K. Kashima. Third Department of Inteenal Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan. EBS has been reported as a safe and effective technique alternative to papillotomy in the management of common bile duct (CBD) stones, although its effect on papillary function remains to be elucidated. In this study, we studied the papillary function of the patients with CBD stones, before and after EBS. Methods: Sphincter of Oddi manometry (SOM) was performed in 21 patients (11-F,10-M : mean age 55 yrs) with CBD stones and 8 controls (4-F,4-M : mean age 53 yrs), using a 4-French microtransducer catheter (Galtec Ltd) inserted into the CBD. lntraluminal pressure in the CBD and the sphincter of Oddi (SO) was measured by means of stationary pull-through method: Parameters measured were basal SO pressure (BSOP : mmHg), phasic pressure (PP : mmHg), phasic frequency (PF : per minute), and contraction pattern (CP). 5 patients underwent SOM before and one week after EBS for CBD stone removal. EBS was performed, using a balloon tipped billiary catheter (Meadox) inflated across the papilla to a diameter of 10mm (lmin x 2-3). Results: Expressed as Mean + SEM Subjects BSOP PP PF CP Normal (n=8) 8.0-1-1.1 98.3 4-1.5 4.84-0.4 regular
Introduction: Biliary stenting with self-expandable metal stents is gaming increasingly wider acceptance as a palliative treatment of pancreatic and bile duct cancer. Recently, a new kind of metal stem has been developed, which structure could better prevent tumor ingrowth. Stent description: The stent (EndoCoil, InStent, USA) is made from a nickel and tttanium alloy, in shape of coil spring. The stent is introduced constricted over a 12F catheter, hold by a wire. During three-phase (proximal end, distal end, cente0 delivery stent shortens (closmg spaces between spring coils) and widens rapidly, up to 24F Patients: Between January 1994 and November 1995 stent insertion was aRempted in 27 patients (11 M, 16 F; age range: 47 - 91) with obstructive jaundice due to non-reseetable cancer. The tumor was located in the pancreatic head in 20 cases, in 4 cases in the upper CBD, and in 3 in the papilla of Vater. Insertion: Steats were correctly placed in 19 / 27 (70%) pati~ts. In 6 cases we were net able to pass the introduction catheter through the stricture. In 2 cases stents initially did not expand completely, what resulted in the entrapment of the delivery catheter. In both cases steats had to be removed. Occlusion of the stent occurred in 12 (6 - overgrowth, 6 - sludge) cases aPter median time of 213 (range: 145 - 255) days. This was managed by cleaning with Donnia basket (6), additional steat placeme~at (4) or s t ~ t replacement (2 cases). No tumor ingrowth into the tight stenting section was observed. Removal: We were able to withdrawn the stem by pulling the distal end using Domua baskct/polypectomy snare in 4 cases (in 2 due to tumor overgrowth, in 2 due to inadequate expansion), with 1 conrplication. Complii:ations occurred in 3 cases (14%) with one fatality (5~ The removal of the stem with emrapped delivery system resulted in perforatico of the distal CBD and severe bleeding, leading to death. In additional 2 eases clinically asymptomatic Perforation of the CBD occurred, as a consequence of CBD wall pinching between neighboring coils of the stent helix during delivery. Conclusions: The new self-expandable stent offers several advantages; the ingrowth prevention and.the possibility of ren~val are the most waportant. However, the insertion system should be hrq~roved, to avoid CBD injury during stem's shortening and the possible entrapment of delivery catheter. The removal of the stent should be carefully monitored endoscopically and radiolngically.
CBDstones(n=21)
11.94-0.9 124.85=4.4 7.24-0.7 irregular
Before EBS (n=5)
9.6-1-0.7
111.6"1-7.1 7.2-1-0.7 irregular
1 weekafterEBS(n=5) 7.6_---/-0.7 45.3-t-6.5 2.8-t-0.4 irregular PP,PF and the incidence of irregular phasic wave pattern were relatively higher in patients with CBD stones than those in controls. EBS and removal of CBD stones were successfully performed with no associated complications such as severe papillary hemorrhage, pancreatitis or perforation. SOM data showed reducing SO pressure at least one week after the procedure.Coathtsion: The persistent reduction of SO pressure by EBS suggested that congestive bile flow could be improved at least one week after this procedure. Further investigation will be necessary to evaluate the long-term sequela of the function of SO.
7"414
7"416
EXPERIENCE WITH 300 CASES OF PANCREATO-BILIARY ASCARIASlS. F. Sandouk, S. Haffar, M M Zada. Departments of Medicine, AI-Asad & AI-Mouassat University Hospitals, Damascus, Syda.
WIRE GUIDED PAPILLOTOMES INCREASE THE SELECTIVE BILE DUCT CANNULATION RATE. GD Schaniro~ D Jaffe, D Ryder, W Brugge, P B Kelsey, RH Schapiro. Massachusetts General Hospital, Boston, M A . Introduction: Pancreatitis associated with E R C P may be rchted to contrast injected into the pancreatic duct. Wire guided carmulation may improve the selective biliary calmulafion rate and decrease the frequency of panercatitis. Purpose: We sought to determine if wire guided cannulation increases the speed and success rate of biliary eannulation while reducing complications. Methods: 104 patients in whom selective eannulation of the bile duct was desired were randomized to either a standard catheter (STD) or a triple lumen papinotome and soft tipped guidewire (WGC). An experienced fellow was allowed 10 minutes to cannulate; if unsuccessful a staffphysician could use the primary catheter for up to 10 minutes or opt to change eannulation technique. Results: 52 patients were randomized to each ann of the study. Cannulation rate was 80% .0W) with the initial device and 96% q ~overall. Feilow ' Ave time to suee Selective bilmry " " to *p<005 Ave"ttme Cannula success(%) calm.(rain.) cannulafion (%) pap.(rain) STD 38/52(73) 3:25 61 19:57 WGC 32/52(62) 4:10 81" 13:56" Time to papillotomy and percent selective biliary cannulation significantly favored WGC. There was no difference in time to cannulation, overall fellow success rate, and number of attempted cannulations. There was no difference in overall success (fellow and staff) with either method. 6 cases were successful aRer c h a n ~ 8 from STD->WGC i 2 cases from WGC->STD.
Background: Pancreato-biliary ascadasis is an uncommon problem in most countries but is frequent in endemic areas. Pancreaticbiliary ascariasis is amenable to endoscopic therapy. Methods and Results: Over a pedod of 6 years 1730 endoscopic retrograde cholangio-pancreaticograms (ERCP) have been done in Damascus University Hospitals. 333 cases were referred for possible pancreato-biliary ascariasis; 300 cases (18%) had worms demonstrated at ERCP. In seven (2.3%) the worm was present in the pancreatic duct. 24% were men and the median age was 42 years. The presenting symptoms were severe upper abdominal pain (98%), cholangitis (16%) and pancreatitis (4.3%). Obstructive jaundice was present in 4 cases. Most of the cases had past history of sphincterotomy (77.3%) and 25.3% had history of previously vomiting a worm. 20 patients had a previous history of pancreatobiliary ascariasis. Worms were commonly associated with a dilated common bile duct. The presence of worms in the pancreatico-biliary tract was associated with visible laceration remarks of the orifice of the ampulla of Vater in 85.6% of the cases. The worms were successfully removed endoscopicelly in 98.5% of the cases with prompt reversal of symptoms. Conclusion: One should have a high index of suspicion for pancreato-biliary ascadasis in patients from endemic areas presenting with biliary tract disease especially if there is common duct dilatation or a history of previous sphincterotomy. High risk patients should probably receive piperazine routinely every 3 months.
394
GASTROINTESTINAL ENDOSCOPY
1 4* 4 complications oceurred: there was 1 perforation of the pancreatic duct by the gnidewire with resultant severe ponereatitis. There were 3 eases of mild panercatitis, reqmring hospitalization for <2 days. 2/4 patients (both mild) reqmred more than 10 minutes to cannulute. 3/4 (2 mild) had pupillotomies; 2 of these (both mild) had prolonged cautery (>30 see) d~ibg p a p i l | ~ m y . Conclusions: While WGC had a higher rate of selective biliaa3' cannulation and a faster time to papiUotomy, this did not confer an advantage in time to cannulation or overall success rate. WGC resulted in a increased complication rate. WGC is an effective cannulaling method but the increased complication rate should limit its use as a primary caunulating device to situations where a papiUotomy is anticipated. Research was funded in part by the Wilson-Cook Corp., Winston-Salem, NC.
VOLUME 43, NO. 4, 1996
7415
BILIARY STENTING WITH SELF-EXPANDABLE NITINOL SPRING STENT J.-F.Rey~, D.Duforest~, T A M a r e k 2. Institut Amault Tzanck, Saint Laurent du Var, France I and Silesian Medical Academy, Katowme, Poland2.
EEFFECT OF ENDOSCOPIC BALLOON SPHINCTEROPLASTY (EBS) ON SPHINCTER OF ODDI -EVALUATION FROM THE VIEW POINT OF ENDOSCOPIC MANOMETRYH.Sato, S. Mitsufuji, J. Takaaki, Y. Tatsumi, T. Maeda, S. Fujita, H. Ogasawara, K. Tokita, T. Kodama, K. Kashima. Third Department of Inteenal Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan. EBS has been reported as a safe and effective technique alternative to papillotomy in the management of common bile duct (CBD) stones, although its effect on papillary function remains to be elucidated. In this study, we studied the papillary function of the patients with CBD stones, before and after EBS. Methods: Sphincter of Oddi manometry (SOM) was performed in 21 patients (11-F,10-M : mean age 55 yrs) with CBD stones and 8 controls (4-F,4-M : mean age 53 yrs), using a 4-French microtransducer catheter (Galtec Ltd) inserted into the CBD. lntraluminal pressure in the CBD and the sphincter of Oddi (SO) was measured by means of stationary pull-through method: Parameters measured were basal SO pressure (BSOP : mmHg), phasic pressure (PP : mmHg), phasic frequency (PF : per minute), and contraction pattern (CP). 5 patients underwent SOM before and one week after EBS for CBD stone removal. EBS was performed, using a balloon tipped billiary catheter (Meadox) inflated across the papilla to a diameter of 10mm (lmin x 2-3). Results: Expressed as Mean + SEM Subjects BSOP PP PF CP Normal (n=8) 8.0-1-1.1 98.3 4-1.5 4.84-0.4 regular
Introduction: Biliary stenting with self-expandable metal stents is gaming increasingly wider acceptance as a palliative treatment of pancreatic and bile duct cancer. Recently, a new kind of metal stem has been developed, which structure could better prevent tumor ingrowth. Stent description: The stent (EndoCoil, InStent, USA) is made from a nickel and tttanium alloy, in shape of coil spring. The stent is introduced constricted over a 12F catheter, hold by a wire. During three-phase (proximal end, distal end, cente0 delivery stent shortens (closmg spaces between spring coils) and widens rapidly, up to 24F Patients: Between January 1994 and November 1995 stent insertion was aRempted in 27 patients (11 M, 16 F; age range: 47 - 91) with obstructive jaundice due to non-reseetable cancer. The tumor was located in the pancreatic head in 20 cases, in 4 cases in the upper CBD, and in 3 in the papilla of Vater. Insertion: Steats were correctly placed in 19 / 27 (70%) pati~ts. In 6 cases we were net able to pass the introduction catheter through the stricture. In 2 cases stents initially did not expand completely, what resulted in the entrapment of the delivery catheter. In both cases steats had to be removed. Occlusion of the stent occurred in 12 (6 - overgrowth, 6 - sludge) cases aPter median time of 213 (range: 145 - 255) days. This was managed by cleaning with Donnia basket (6), additional steat placeme~at (4) or s t ~ t replacement (2 cases). No tumor ingrowth into the tight stenting section was observed. Removal: We were able to withdrawn the stem by pulling the distal end using Domua baskct/polypectomy snare in 4 cases (in 2 due to tumor overgrowth, in 2 due to inadequate expansion), with 1 conrplication. Complii:ations occurred in 3 cases (14%) with one fatality (5~ The removal of the stem with emrapped delivery system resulted in perforatico of the distal CBD and severe bleeding, leading to death. In additional 2 eases clinically asymptomatic Perforation of the CBD occurred, as a consequence of CBD wall pinching between neighboring coils of the stent helix during delivery. Conclusions: The new self-expandable stent offers several advantages; the ingrowth prevention and.the possibility of ren~val are the most waportant. However, the insertion system should be hrq~roved, to avoid CBD injury during stem's shortening and the possible entrapment of delivery catheter. The removal of the stent should be carefully monitored endoscopically and radiolngically.
CBDstones(n=21)
11.94-0.9 124.85=4.4 7.24-0.7 irregular
Before EBS (n=5)
9.6-1-0.7
111.6"1-7.1 7.2-1-0.7 irregular
1 weekafterEBS(n=5) 7.6_---/-0.7 45.3-t-6.5 2.8-t-0.4 irregular PP,PF and the incidence of irregular phasic wave pattern were relatively higher in patients with CBD stones than those in controls. EBS and removal of CBD stones were successfully performed with no associated complications such as severe papillary hemorrhage, pancreatitis or perforation. SOM data showed reducing SO pressure at least one week after the procedure.Coathtsion: The persistent reduction of SO pressure by EBS suggested that congestive bile flow could be improved at least one week after this procedure. Further investigation will be necessary to evaluate the long-term sequela of the function of SO.
7"414
7"416
EXPERIENCE WITH 300 CASES OF PANCREATO-BILIARY ASCARIASlS. F. Sandouk, S. Haffar, M M Zada. Departments of Medicine, AI-Asad & AI-Mouassat University Hospitals, Damascus, Syda.
WIRE GUIDED PAPILLOTOMES INCREASE THE SELECTIVE BILE DUCT CANNULATION RATE. GD Schaniro~ D Jaffe, D Ryder, W Brugge, P B Kelsey, RH Schapiro. Massachusetts General Hospital, Boston, M A . Introduction: Pancreatitis associated with E R C P may be rchted to contrast injected into the pancreatic duct. Wire guided carmulation may improve the selective biliary calmulafion rate and decrease the frequency of panercatitis. Purpose: We sought to determine if wire guided cannulation increases the speed and success rate of biliary eannulation while reducing complications. Methods: 104 patients in whom selective eannulation of the bile duct was desired were randomized to either a standard catheter (STD) or a triple lumen papinotome and soft tipped guidewire (WGC). An experienced fellow was allowed 10 minutes to cannulate; if unsuccessful a staffphysician could use the primary catheter for up to 10 minutes or opt to change eannulation technique. Results: 52 patients were randomized to each ann of the study. Cannulation rate was 80% .0W) with the initial device and 96% q ~overall. Feilow ' Ave time to suee Selective bilmry " " to *p<005 Ave"ttme Cannula success(%) calm.(rain.) cannulafion (%) pap.(rain) STD 38/52(73) 3:25 61 19:57 WGC 32/52(62) 4:10 81" 13:56" Time to papillotomy and percent selective biliary cannulation significantly favored WGC. There was no difference in time to cannulation, overall fellow success rate, and number of attempted cannulations. There was no difference in overall success (fellow and staff) with either method. 6 cases were successful aRer c h a n ~ 8 from STD->WGC i 2 cases from WGC->STD.
Background: Pancreato-biliary ascadasis is an uncommon problem in most countries but is frequent in endemic areas. Pancreaticbiliary ascariasis is amenable to endoscopic therapy. Methods and Results: Over a pedod of 6 years 1730 endoscopic retrograde cholangio-pancreaticograms (ERCP) have been done in Damascus University Hospitals. 333 cases were referred for possible pancreato-biliary ascariasis; 300 cases (18%) had worms demonstrated at ERCP. In seven (2.3%) the worm was present in the pancreatic duct. 24% were men and the median age was 42 years. The presenting symptoms were severe upper abdominal pain (98%), cholangitis (16%) and pancreatitis (4.3%). Obstructive jaundice was present in 4 cases. Most of the cases had past history of sphincterotomy (77.3%) and 25.3% had history of previously vomiting a worm. 20 patients had a previous history of pancreatobiliary ascariasis. Worms were commonly associated with a dilated common bile duct. The presence of worms in the pancreatico-biliary tract was associated with visible laceration remarks of the orifice of the ampulla of Vater in 85.6% of the cases. The worms were successfully removed endoscopicelly in 98.5% of the cases with prompt reversal of symptoms. Conclusion: One should have a high index of suspicion for pancreato-biliary ascadasis in patients from endemic areas presenting with biliary tract disease especially if there is common duct dilatation or a history of previous sphincterotomy. High risk patients should probably receive piperazine routinely every 3 months.
394
GASTROINTESTINAL ENDOSCOPY
1 4* 4 complications oceurred: there was 1 perforation of the pancreatic duct by the gnidewire with resultant severe ponereatitis. There were 3 eases of mild panercatitis, reqmring hospitalization for <2 days. 2/4 patients (both mild) reqmred more than 10 minutes to cannulute. 3/4 (2 mild) had pupillotomies; 2 of these (both mild) had prolonged cautery (>30 see) d~ibg p a p i l | ~ m y . Conclusions: While WGC had a higher rate of selective biliaa3' cannulation and a faster time to papiUotomy, this did not confer an advantage in time to cannulation or overall success rate. WGC resulted in a increased complication rate. WGC is an effective cannulaling method but the increased complication rate should limit its use as a primary caunulating device to situations where a papiUotomy is anticipated. Research was funded in part by the Wilson-Cook Corp., Winston-Salem, NC.
VOLUME 43, NO. 4, 1996