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Benign biliary stricture frequency and management at ERCP
ERCP--BILIARY t413
t415
ENDOSCOPIC THERAPY FOR COMMON BILE DUCT ICBD) STONES: LONGTERM OUTCOMES GE Harmsten, JA DiSario, r'lJ Bjorkman University of Utah Health Sciences Center, Salt Lake City, Utah. Endoscopic therapy is the treatment of choice for removal of CBD stones. However, there are few data on outcomes beyond 30 days. Aim." To determine the long-term outcomes of patients treated with endoscopic CBD stone extraction. Metheds: 67 consecutive patients who had endoscopic removal of C80 stones between 1981 and 1994 were retrospectively evaluated. Follow-up was possible in 63 (94%) patients: all had medical record review and 54 (86%) were interviewed. Complications were defined and graded in a standard format (Cotton et aL, Gasttointest Endosc 1991 37:363-393). I~linieal outcomes were determined in a standardized fashion by the resolution of symptoms and signs, and the need for further medical care for biliary and/or pancreatic problems. Results: There were 32 men and 31 women with a mean age of 63 years (range, 18-94 years). The mean duration of follow-up was 2.6 years (range, 0.213.5 years). 46 (73%) patients had cholecystectomy: 35 (56%) before ERCP and 11 (17%) electively after ERCP. 61 (97%) patients were treated with sphincteratomy, and 2 (3.2%) with papillary balloon dilation. The CBD was cleared with one procedure in 47 (75%) patients. 16 (25%) patients required subsequent endoscopic procedures (median= I, range 13): 7 had repeat stone extraction, 4 had mechanical lithetripsy and 5 had stent replacement or removal. There were 9 (14%) short-term ( < 3 0 days) complications: 1 (1.6%) had moderate bleeding and 8 (13%) had pancreatitis, 2 (3.2%) of which were severe. After clearance of the CBD and completion of the elective cholecystectomies, 60 (95%) patients remained free of biliary or pancreatic symptoms and signs. 3 (4.8%) patients experienced delayed complications: 2 (3.2%) developed papillary stenosis at 2 and 8 months, and 1 (1.6%) developed recurrent stones at 2 years, despite previous chalecystectamy. These patients were successfully treated with repeat ERCP. There was no relation between immediate and late occurring complications. No other patient required further pancreatobibary-related medical care, surgery or radiographic intervention. There was no procedure related mortality. Conclusions: Endoscopic therapy for CBD stones has good long-term outcomes and few late complications.
BENIGN BILIARY STRICTURES: OUTCOME OF ENDOSCOPIC THERAPY Ammar Hmeidan, James Jacob, Stuart Sherman, and Glen A. Lehman, Division of Gastroanterology/blepatology,Indiana University Medical Center, Indianapolis, IN The outcome of benign biliary stricture management was reviewed from 1987-1993. Stricture etiologies were sclarosing cholangitis, postoperative, stones, and miscellaneous. Chronic pancreatitis patients were excluded. Methods: Strictures involving any portion of the intrahepatic or extrahepatic biliary tree were included, except cystic duct, gallbladder, or sphincter. Out of 6,017 ERCPs, 115 cases were diagnosed as benign stricture. Fifteen were treated medically, 6 surgically, and 94 by ERCP. The patients were treated with Soehendra catheter dilation, balloon dilation (4-10 ram.), or stent placement (10-11 French). Follow-up (FU) was available on 83 patients. Two additional patients died of unrelated causes. Five patients required 2 series of treatment; 3 of these 83 were referred for surgery. Patients had FU for 1-4 years after initial treatment. Tallied parameters are listed below. An emergency room visit was considered a I-day hospital stay. Results:
*Number of episodes and/or days in 12-month interval pre-treatment **A 1-3 day interval of lever, RUQ pain, + jaundice The mean number of endoscopic interventions was 3.8. Summary: ERCP treatment for benign strictures is a moderately effective treatment and leads to a 51-70% reduction (but not elimination) in frequency of cholangitis, a 45-64 % reduction in hospital stay, and a 52-81% improvement in functional status over a 1- to 4-year FU.
414
t416
BENIGN BILIARY STRICTURE FREQUENCY AND MANAGEMENT AT ERCP Ammar Hmeidan, James A. Jacob. Stuart Sherman. and Glen A. Lehman. Division of Gastroenterology, Indiana University Medical Center, Indianapolis, IN To determine the frequency, etiology, and management of benign biliary strictures identified during ERCP at our institution, records from the last 8 years were reviewed and summarized. 6,953 ERCPs were performed on 5,257 patients (pts.). Strictures were considered benign if no evidence of malignancy was found by ductography, brushings, biopsies, or clinical follow-up of at least 1 year in all pts. (except those done in 1994). Strictures involving any portion of the intra- or extra.hepatic biliary tree were included (except cystic duct, gallbladder, or sphincter). Results: Benign biliary strictures were identified in 225 pts, (4.28%). TREATMENT
ETIOLOGY
N
Medical
Surgical
Endoscopic
Chronic Pancreatitis
87
38
20
29
Sclerosing Cholang
54
12
0
42
Post-Operative
51
,1
5
45
Liver Transplant
16
1
0
15
Lap Chole
12
0;-
2
l0
Open Chole
12
0
2
I0
CBD/Enteric
lI
0
1
l0
Stone
19
2
1
Other
14
l
1
12
225
54
27
144
TOTAL
16
Pts. undergoing endoscopic therapy had a mean of 3.2 ERCPs. Technical success of interventions, including Soehendra catheter dilation, balloon dilation, end stent placement was overall 80%, 91%, and 94% respectively. The maximal number of l0 or 11.5 French stents placed par session was 1 in 51 pts. and 2 in 19 pts. The maximal diameter of balloon dilation was 4 ram. in 7 pts., 6 ram. in 29 pts., 8 mm. in 37 pts., l0 ram. in 13 pts., 12 ram. in 5 pts., and 15 nun. in 2 pts. Medically treated pts. were generally those with selerosing eholangitis without major stricture of the hilum or extrahepatic ducts or those with chronic pancreatitis and low-grade strictures. The outcome of therapy will be reported elsewhere. Major complications of endoscopic treatment were bleeding (1 pt.), pancreatitis (3 pts.), choleeystitis (2 pts.), and perforation (1 pt.). Summary: (1) Benign biliary strictures are a relatively infrequent finding at ERCP; (2) chronic pancreatitis, sclerosing cholangitis, and postoperative are the most common etiologies; (3) 76 % of strictures were invasively treated - 64 % via endoscopy and 12 % via surgery; and (4) multiple endoscopic sessions are required.
VOLUME 41, NO. 4, 1995
Mean n Below
1-Year Pre-TX*
FU Year:l
FU Year2
FU Year3
FU Year4
Patients (n)
83
83
59
34
14
Cholangitis Episodes**
8.6
2.5
2.9
3.4
3.6
Antibiotic Courses IV
6.2
1.6
1.7
2
2.2
Oral
4.3
2.4
2.3
2.4
3.3
Continuous
3.3
1.2
1.4
1.8
1.9
Hospital Visits
5.2
1.8
1.9
2.3
2.5
Inpatient Days
39.7
11.6
14.4
17.9
20
Days Without Normal Activity (Hospital Days Excluded)
59.2
12.1
14.6
15.7
19.5
Work Absent Days
21.6
4.3
6.3
8.t
8.9
PROGNOSTIC FACTORS [:OR THE P A L L I A T I V E TREATMENT OF MALIGNANT BILIARY OBSTRUCTION WITH W A L L S T E N T S TM N. Hoepffner, E.C. Foerster, D. Eil3ing, W. Domschke, Dept. of Medicine B, University of Muenster, Muenster, Germany The endoscopic implantation of prostheses for the palliative treatment of malignant biliary obstruction is admittedly the best suitable method. Patients with an expected long time of survival benefit from the implantation of self-expanding mesh stents (WallstentrM). A short time of survival after implantation reduces the benefit of mesh stents because of their high costs. In these cases the implantation of cheaper plastic prostheses would be the better choice of treatment. So we tried to find out prognostic factors which indicate the probable time of survival after implantation and thus, may determine selection of the appropriate treatment device (stent vs. plastic prosthesis). Between May 1989 and Octob e r 1994, 210 patients with malignant bile duct obstruction were treated with 250 self-expanding mesh stents (Wallstent TM, Schneider ]Europe[ AG, 30 F diameter, 34 - 111 mm length). The clinical data of 154 patients (87 females, mean age 70,5 ]range 36-97] years / 67 males, mean age 68,6 [range 39-92] years ) were retrospectively analysed with regard to clinical, biochemical, endoscopical and histological charakteristics. 51 patients (32%) died within the first three months after implantation. Relative to the time of survival, the patients'age and gender as well as the GOT, GPT, y-GT, AP and LDH levels turned out to be insignificant. By constrast, the presence of liver metastases, bilirubin level > 3,2 mg/dl, location of the stenoses in the middle or proximal common bilde duct, length of the stenoses > 20 mm and leukocytosis ( more than 10.000 / ul ) showed significant differences. Significant differences were also found between tumors of the bile duct or the pancreas and obstructions caused by lymphatic metastases of the lig. teres hepatis. These results indicate that the absence of liver metastases, serum bilirubin level less than 3,2 mg/dl, location of the stenosis in the distal common bilde duct, length of the stenosis less than 20 mm and the absence of leukocytosis are favorable prognostic factors for the decision of implanting Wallstents TM for the palliative treatment of malignant biliary obstruction. Patients with these characteristics, and in whom the diagnosis of malignant biliary obstruction has been established without doubt and provided there is no surgical opportunity of treatment, should be treated by the implantation of a Wallstent TM prosthesis.
GASTROINTESTINAL ENDOSCOPY
399
t415
ENDOSCOPIC THERAPY FOR COMMON BILE DUCT ICBD) STONES: LONGTERM OUTCOMES GE Harmsten, JA DiSario, r'lJ Bjorkman University of Utah Health Sciences Center, Salt Lake City, Utah. Endoscopic therapy is the treatment of choice for removal of CBD stones. However, there are few data on outcomes beyond 30 days. Aim." To determine the long-term outcomes of patients treated with endoscopic CBD stone extraction. Metheds: 67 consecutive patients who had endoscopic removal of C80 stones between 1981 and 1994 were retrospectively evaluated. Follow-up was possible in 63 (94%) patients: all had medical record review and 54 (86%) were interviewed. Complications were defined and graded in a standard format (Cotton et aL, Gasttointest Endosc 1991 37:363-393). I~linieal outcomes were determined in a standardized fashion by the resolution of symptoms and signs, and the need for further medical care for biliary and/or pancreatic problems. Results: There were 32 men and 31 women with a mean age of 63 years (range, 18-94 years). The mean duration of follow-up was 2.6 years (range, 0.213.5 years). 46 (73%) patients had cholecystectomy: 35 (56%) before ERCP and 11 (17%) electively after ERCP. 61 (97%) patients were treated with sphincteratomy, and 2 (3.2%) with papillary balloon dilation. The CBD was cleared with one procedure in 47 (75%) patients. 16 (25%) patients required subsequent endoscopic procedures (median= I, range 13): 7 had repeat stone extraction, 4 had mechanical lithetripsy and 5 had stent replacement or removal. There were 9 (14%) short-term ( < 3 0 days) complications: 1 (1.6%) had moderate bleeding and 8 (13%) had pancreatitis, 2 (3.2%) of which were severe. After clearance of the CBD and completion of the elective cholecystectomies, 60 (95%) patients remained free of biliary or pancreatic symptoms and signs. 3 (4.8%) patients experienced delayed complications: 2 (3.2%) developed papillary stenosis at 2 and 8 months, and 1 (1.6%) developed recurrent stones at 2 years, despite previous chalecystectamy. These patients were successfully treated with repeat ERCP. There was no relation between immediate and late occurring complications. No other patient required further pancreatobibary-related medical care, surgery or radiographic intervention. There was no procedure related mortality. Conclusions: Endoscopic therapy for CBD stones has good long-term outcomes and few late complications.
BENIGN BILIARY STRICTURES: OUTCOME OF ENDOSCOPIC THERAPY Ammar Hmeidan, James Jacob, Stuart Sherman, and Glen A. Lehman, Division of Gastroanterology/blepatology,Indiana University Medical Center, Indianapolis, IN The outcome of benign biliary stricture management was reviewed from 1987-1993. Stricture etiologies were sclarosing cholangitis, postoperative, stones, and miscellaneous. Chronic pancreatitis patients were excluded. Methods: Strictures involving any portion of the intrahepatic or extrahepatic biliary tree were included, except cystic duct, gallbladder, or sphincter. Out of 6,017 ERCPs, 115 cases were diagnosed as benign stricture. Fifteen were treated medically, 6 surgically, and 94 by ERCP. The patients were treated with Soehendra catheter dilation, balloon dilation (4-10 ram.), or stent placement (10-11 French). Follow-up (FU) was available on 83 patients. Two additional patients died of unrelated causes. Five patients required 2 series of treatment; 3 of these 83 were referred for surgery. Patients had FU for 1-4 years after initial treatment. Tallied parameters are listed below. An emergency room visit was considered a I-day hospital stay. Results:
*Number of episodes and/or days in 12-month interval pre-treatment **A 1-3 day interval of lever, RUQ pain, + jaundice The mean number of endoscopic interventions was 3.8. Summary: ERCP treatment for benign strictures is a moderately effective treatment and leads to a 51-70% reduction (but not elimination) in frequency of cholangitis, a 45-64 % reduction in hospital stay, and a 52-81% improvement in functional status over a 1- to 4-year FU.
414
t416
BENIGN BILIARY STRICTURE FREQUENCY AND MANAGEMENT AT ERCP Ammar Hmeidan, James A. Jacob. Stuart Sherman. and Glen A. Lehman. Division of Gastroenterology, Indiana University Medical Center, Indianapolis, IN To determine the frequency, etiology, and management of benign biliary strictures identified during ERCP at our institution, records from the last 8 years were reviewed and summarized. 6,953 ERCPs were performed on 5,257 patients (pts.). Strictures were considered benign if no evidence of malignancy was found by ductography, brushings, biopsies, or clinical follow-up of at least 1 year in all pts. (except those done in 1994). Strictures involving any portion of the intra- or extra.hepatic biliary tree were included (except cystic duct, gallbladder, or sphincter). Results: Benign biliary strictures were identified in 225 pts, (4.28%). TREATMENT
ETIOLOGY
N
Medical
Surgical
Endoscopic
Chronic Pancreatitis
87
38
20
29
Sclerosing Cholang
54
12
0
42
Post-Operative
51
,1
5
45
Liver Transplant
16
1
0
15
Lap Chole
12
0;-
2
l0
Open Chole
12
0
2
I0
CBD/Enteric
lI
0
1
l0
Stone
19
2
1
Other
14
l
1
12
225
54
27
144
TOTAL
16
Pts. undergoing endoscopic therapy had a mean of 3.2 ERCPs. Technical success of interventions, including Soehendra catheter dilation, balloon dilation, end stent placement was overall 80%, 91%, and 94% respectively. The maximal number of l0 or 11.5 French stents placed par session was 1 in 51 pts. and 2 in 19 pts. The maximal diameter of balloon dilation was 4 ram. in 7 pts., 6 ram. in 29 pts., 8 mm. in 37 pts., l0 ram. in 13 pts., 12 ram. in 5 pts., and 15 nun. in 2 pts. Medically treated pts. were generally those with selerosing eholangitis without major stricture of the hilum or extrahepatic ducts or those with chronic pancreatitis and low-grade strictures. The outcome of therapy will be reported elsewhere. Major complications of endoscopic treatment were bleeding (1 pt.), pancreatitis (3 pts.), choleeystitis (2 pts.), and perforation (1 pt.). Summary: (1) Benign biliary strictures are a relatively infrequent finding at ERCP; (2) chronic pancreatitis, sclerosing cholangitis, and postoperative are the most common etiologies; (3) 76 % of strictures were invasively treated - 64 % via endoscopy and 12 % via surgery; and (4) multiple endoscopic sessions are required.
VOLUME 41, NO. 4, 1995
Mean n Below
1-Year Pre-TX*
FU Year:l
FU Year2
FU Year3
FU Year4
Patients (n)
83
83
59
34
14
Cholangitis Episodes**
8.6
2.5
2.9
3.4
3.6
Antibiotic Courses IV
6.2
1.6
1.7
2
2.2
Oral
4.3
2.4
2.3
2.4
3.3
Continuous
3.3
1.2
1.4
1.8
1.9
Hospital Visits
5.2
1.8
1.9
2.3
2.5
Inpatient Days
39.7
11.6
14.4
17.9
20
Days Without Normal Activity (Hospital Days Excluded)
59.2
12.1
14.6
15.7
19.5
Work Absent Days
21.6
4.3
6.3
8.t
8.9
PROGNOSTIC FACTORS [:OR THE P A L L I A T I V E TREATMENT OF MALIGNANT BILIARY OBSTRUCTION WITH W A L L S T E N T S TM N. Hoepffner, E.C. Foerster, D. Eil3ing, W. Domschke, Dept. of Medicine B, University of Muenster, Muenster, Germany The endoscopic implantation of prostheses for the palliative treatment of malignant biliary obstruction is admittedly the best suitable method. Patients with an expected long time of survival benefit from the implantation of self-expanding mesh stents (WallstentrM). A short time of survival after implantation reduces the benefit of mesh stents because of their high costs. In these cases the implantation of cheaper plastic prostheses would be the better choice of treatment. So we tried to find out prognostic factors which indicate the probable time of survival after implantation and thus, may determine selection of the appropriate treatment device (stent vs. plastic prosthesis). Between May 1989 and Octob e r 1994, 210 patients with malignant bile duct obstruction were treated with 250 self-expanding mesh stents (Wallstent TM, Schneider ]Europe[ AG, 30 F diameter, 34 - 111 mm length). The clinical data of 154 patients (87 females, mean age 70,5 ]range 36-97] years / 67 males, mean age 68,6 [range 39-92] years ) were retrospectively analysed with regard to clinical, biochemical, endoscopical and histological charakteristics. 51 patients (32%) died within the first three months after implantation. Relative to the time of survival, the patients'age and gender as well as the GOT, GPT, y-GT, AP and LDH levels turned out to be insignificant. By constrast, the presence of liver metastases, bilirubin level > 3,2 mg/dl, location of the stenoses in the middle or proximal common bilde duct, length of the stenoses > 20 mm and leukocytosis ( more than 10.000 / ul ) showed significant differences. Significant differences were also found between tumors of the bile duct or the pancreas and obstructions caused by lymphatic metastases of the lig. teres hepatis. These results indicate that the absence of liver metastases, serum bilirubin level less than 3,2 mg/dl, location of the stenosis in the distal common bilde duct, length of the stenosis less than 20 mm and the absence of leukocytosis are favorable prognostic factors for the decision of implanting Wallstents TM for the palliative treatment of malignant biliary obstruction. Patients with these characteristics, and in whom the diagnosis of malignant biliary obstruction has been established without doubt and provided there is no surgical opportunity of treatment, should be treated by the implantation of a Wallstent TM prosthesis.
GASTROINTESTINAL ENDOSCOPY
399