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Choledochoscopy in the diagnosis and management of biliary complications after orthotopic liver transplant (OLT)
ERCP.BILIARY 481
1"483
CHOLEIX.X~CY~'OPY IN THE DIAGNOSIS A N D MANAGEMENT OF BILIARY COMPLICATIONS AFTER ORTHOTOPIC LIVER TRANSPLANT (OLT). I Raiiman" H Monsour, J Galati, C Osaki, P Wood. University of Texas in Houston. The most commonly reported complications after OLT include anastomotic stricture, papillary dysfunction, and ductai stones. There are no data regarding the use of choledochoscopy in the diagnosis or m a n a g e m e n t of these complications after OLT. We report on o u r initial experience w i t h 4 patients w h o u n d e r w e n t choledochoscopy (Olympus and Pentax) after OLT for anastomotic stricture in 2, filling defects in 1, and inability to drain the left hepatic system in 1. In aO patients, standard cholangiogram w a s performed by ERCP (3) or PTC (1). Choledochoscopy w a s performed 9 months to 8 years after OLT. There w e r e 2 male, 2 female, ages range 3- 51 yrs old. In the 2 patients w i t h stricture, plevinusly unidentified anastomotic ulcers and severe inflammatory changes w e r e noted. Brushings revealed fungel elements in I and w e r e negative in the other~ In the patient with adherent filling defects at the level of the anastomosis, choledochoscopy revealed 2 yellowish stones attached to suture material. After stone-suture r e m o v a l the cholangiogram and choledechoscopy were normal. In these 3 patients, the epithelium of the d o n o r bile duct w a s pink and shiny compared to a grayish and duller epithelium of the recipient bile duct. Biopsies in 1 w e r e non-revealing. In the patient with left hepatic drainage problem, a Roux-en-Y biliojejunal anastomosis had been performed. Three attempts at percutaneous drainage had failed. Percutaneous choledochoscopy s h o w e d severe inflammation and a stricture proximal to the bilioenteral anastomosis. A wire was advanced under direct visualization into the left system for subsequent drainage. In conclusion, while this experience is limited a n d in progress, and the clinical significance of s o m e of the findings is unknown, choledochoscopy may provide additional information to routine cholangiography both in the diagnosis and m a n a g e m e n t of biliery complications after OLT.
ENDOSCOPIC M A N A G E M E N T OF BILIARY T R A C T C A N C E R W I T H THE WALLSTENT: EXPERIENCE IN 121 PATIENTS. I Raijman, [ Siddique,P Lynch, Y Patt,M Rob, S Curley, J Lee, P Pisters,D Evans, J Abbruzzese. M D Anderson Cancer Center,Universityof Texas, Houston. The treatment of choice for malignant biliary strictures is endoscopic stenting, either plastic or metallic. Eventhough metallic stents have shown a longer potency rate and easier placement, their use is stili not widely accepted. We report our experience with the Walistont (Schneider, Minneapolis). From Jan 1994 to Oct 1996, we treated 121 pts with b/liar), strictures. There were 80 men, 41 women, mean age 66.8 y (range 21-905. The strictures were due to pancreatic cancer (45), gallbladder (17), choisngiocarcinoma (16), ampulla (10), colorertai (11), hepatoma (5), breast (7), lung (4), ovarian (1), gaatric (2), lymphoma (2), and adrenal (1). h~dex stent placement was successful in 100% (4 l~ltmx.~d a second stent for initial mJsplacemen 0. Previous Rx included plastic stents (82), surgery (34), and chemoXRT (91). The mean stricture length was 2.5 cms and the location was CBD/CHD in 91, and C H D / I H D in 30. Nine pts had >1 strictures and required 2 stsnts. During a mean follow-up of 127 days (29-377), overgrowth occured in 3, ingrowth in 10, cholangifis in 14, tissue hyperplasia in 22, migration in 1, and hemobilia in 1. All pts with luminal stent occlusion were successfully treated with plastic stents. The patient with migration of the stent underwent surgery. The patient with heraobilm was treated with Nd-YAG laser during choledochoscopy. Four pts required choledochoscopy for laser therapy to allow passage of the plastic stent. In all choledochoscopy showed tumor ingrowth. One pt required a second stant to avoid occlusion of the stent opening by the wall of the CBD and 1 for "extension" of the stent beyond a CHB-duodenal anastomosis to bypass a duodenal stricture. In 1, the stont was placed using the rendezvous technique. Overall, jaundice resolved in 108/121 pts (90%) and the mean stent patency rate was 9.25 months (6 weeks-14 months). All pts with residual jaundice had metastatic liver disease. There was no stent-related mortality. Fourteen pts are alive, the rest have died of disease progression. In conclusion, biliary Wallstents have a longer patency rate compared to that reported for plastic s~nts, provide significant relief of jaundice (90%), and are associated with nunimal morbidity and no mortality. Coating of the stent may prevent tumor ingrowth. A prospective evaluation and comparison to various plastic stents is underway.
482 COMPARISON BEI'WI~EN MEI'ASTATIC VS PRIMARY BILIARY TRACT C A N C E R IN THEIR RESPONSE T O THE WALLSTENT. I Raijman, l Siddique,P Lynch, Y Part,M Rob, S Curley, J Lee, P Pisters, D Evans, J Abbruzlmse. M D Anderson Cancer Center,and Universityof Texas, Houston. The treatment of clioice for malignant biliary strictures is endoscopic stenting, either plastic or expandable. Data regarding the outcome after stenting for bfliary strictures are limited regarding metastatic (M) vs primary (P) disease. We report our experience with 88 pts (P) and 33 pts (M) treated with the bfliary Wallsient (Schneider, Minneapolis). Them were 80 men, mean age 66.8 y (range 21-90). In P, the stricture was due to: pancreas 45, cholangio 16, gallbladder 17,ampulla 10. In M, h-'aestricture was due to:coiorectal 11,hepatoma 5, breast 6, lung 4, ovaxian 1, gastric 2, lymphoma 2, adl~nal 1, unknown 1. Index stent placement was 100% successful (4 required a second strait for initial misplacement). Previous Rx included plastic stsnts in 82 (72 P, 10 M) and chemoXRT in 91 (61 P, 30 M). The mean stricture length was 2.3 cuts (P) and 2.8 cms (M). The location in P was: CBD/CHD in 88; in M: CBD/CHD in 3 and CHD/1HD in 30. Nine pts (1 P, 8 M) had >1 stricture and reqmred 2 stents, During a mean follow up of 120 days (P) and 132 days (M), overgrowth occured in 3 (1 P, 2 M ), ingrowth in 10 (4 P, 6 M), cholangitis in 14 (5 P, 9M), tissue hyperplasia in 22 (10 P, 12M), migration in 1 (P), and hemobilin in 1 (M). Jaundtce resolved in 81/88 pts (92%) in P and 29/33 (88%) in M (NS). Mean stent petency rate was 9.7 months (P) and 8.7 months (M) (iNS). All pts with residual jaundice had metastatic liver disease. Them was no mortality related to the stant. Choledochoecopy/Nd-YAG laser was required in 4 pts (4 M) for correction of hemobilia (1) or plastic stent placement (3). There are 14 surviving patients (6 P, 8 M), the rest have died of disease progression. Conclusion: the response to Walletent among pts with P vs M biliary stricture is similar regarding resolution of jaundice, patency rate, and complication rata.Additionai "invasive" therapy (choledochoscopy) may be needed more often in M. A prospective comparison to various plas~c stents is under evaluation.
?484
VOLUME 45, NO. 4, 1997
NEEDLE KNIFE FISTULOTOMY (NKF): RESULTS METHOD OF PRECUT FOR BILIARY CANNULATION
OF A N O T H E R
RS Raymond, TH Baron. Div. Gastroenterology & Hepatology, University of Alabama at Birmingham. Birmingham, AL. INTRO: The term precut sphincterotomy is loosely applied to many types of precut for biliary cnnnulation. One technique of needle knife precut papillotomy starting the incision at the papillary orifice has been described by Howell et al (Gastrointest Endosc 1996;A371). We describe in detail the technique and results using precut fistulotomy; complications were compared to routine endoscopic bilisry sphincterotomy (ES) as defined by Cotton et al. PATIENTS: From 1/95-12/96, 889 ERCPs were performed by one endoscopist. 148 underwent standard ES. In another 130 pts. (14.6%), deep cnnnulation of the common bile duct (CBD) failed and NKF was performed. INDICATIONS
c..--i
,NKF _ .(n=1305 38 (29.2% 5
.oo i .-t i -.. i
28 (21.5%) 33 (25.4%) 24 (18% 5 ES (n=1485 72 (48.6% 5 30 {20.3%) 31 (21.0%e) 12 (8.1%) METHODS: NKF (HPC-2. Wilson-Cook) was performed by applying stroking movements in the 11 o'clock position along the intrnduodenal portion of the CBD starting above the papillary orifice. Following deep cannulation, the incision was then extended cephalad using a standard sphincterotome, when appropriate, avoiding the papillary opening. Pancreatic duct (PD) stents were not placed. RESULTS: In the NKF group, cannulation was achieved in 121/130 (93%) during the initial procedure. Two pts. underwent a second ERCP to achieve cannulation with an overall success rate of 94.6%. There were 12 episodes of pancreatitis (7 mild, 5 moderate), 4 episodes of bleeding (2 mild, I moderate, I severe), I infection (mild), and 4 perforations (2 moderate, 2 severe including one death - both with periampullary diverticula). Statistical analysis revealed no significant differences between the two groups (Fisher's exact test). Therapeutic results were achieved in 76% of NKF and 90% of ES. Teehnlque Bleedin= I Pancreatitls [ Perforation [ Infection [ Death [ NKF(n=I305 4 (3.0%) I 12 (9.2% 5 4 (3.0%) [ 1 (0.8%) 1 (0.8%)1 ES (n=148) 3 (2.0%) I 8(5.4%) I I (0.7%) I 3 (2.0%) I 1 (0.7%)1 CONCLUSIONS: 1) Needle knife fistulotomy is an effective method for obtaining biliary cannulation when standard techniques fail. 2) The complication rate after NKF is comparable to ES and the risk of severe pancreatitis is low such that PD stent placement is unnecessary. 3) The perforation risk using a NKF is higher than ES; a periampullary diverticulum may be a relative contraindication to this technique. 4) Prospective studies are needed to compare outcomes between different precut techniques.
GASTROINTESTINAL ENDOSCOPY
AB145
1"483
CHOLEIX.X~CY~'OPY IN THE DIAGNOSIS A N D MANAGEMENT OF BILIARY COMPLICATIONS AFTER ORTHOTOPIC LIVER TRANSPLANT (OLT). I Raiiman" H Monsour, J Galati, C Osaki, P Wood. University of Texas in Houston. The most commonly reported complications after OLT include anastomotic stricture, papillary dysfunction, and ductai stones. There are no data regarding the use of choledochoscopy in the diagnosis or m a n a g e m e n t of these complications after OLT. We report on o u r initial experience w i t h 4 patients w h o u n d e r w e n t choledochoscopy (Olympus and Pentax) after OLT for anastomotic stricture in 2, filling defects in 1, and inability to drain the left hepatic system in 1. In aO patients, standard cholangiogram w a s performed by ERCP (3) or PTC (1). Choledochoscopy w a s performed 9 months to 8 years after OLT. There w e r e 2 male, 2 female, ages range 3- 51 yrs old. In the 2 patients w i t h stricture, plevinusly unidentified anastomotic ulcers and severe inflammatory changes w e r e noted. Brushings revealed fungel elements in I and w e r e negative in the other~ In the patient with adherent filling defects at the level of the anastomosis, choledochoscopy revealed 2 yellowish stones attached to suture material. After stone-suture r e m o v a l the cholangiogram and choledechoscopy were normal. In these 3 patients, the epithelium of the d o n o r bile duct w a s pink and shiny compared to a grayish and duller epithelium of the recipient bile duct. Biopsies in 1 w e r e non-revealing. In the patient with left hepatic drainage problem, a Roux-en-Y biliojejunal anastomosis had been performed. Three attempts at percutaneous drainage had failed. Percutaneous choledochoscopy s h o w e d severe inflammation and a stricture proximal to the bilioenteral anastomosis. A wire was advanced under direct visualization into the left system for subsequent drainage. In conclusion, while this experience is limited a n d in progress, and the clinical significance of s o m e of the findings is unknown, choledochoscopy may provide additional information to routine cholangiography both in the diagnosis and m a n a g e m e n t of biliery complications after OLT.
ENDOSCOPIC M A N A G E M E N T OF BILIARY T R A C T C A N C E R W I T H THE WALLSTENT: EXPERIENCE IN 121 PATIENTS. I Raijman, [ Siddique,P Lynch, Y Patt,M Rob, S Curley, J Lee, P Pisters,D Evans, J Abbruzzese. M D Anderson Cancer Center,Universityof Texas, Houston. The treatment of choice for malignant biliary strictures is endoscopic stenting, either plastic or metallic. Eventhough metallic stents have shown a longer potency rate and easier placement, their use is stili not widely accepted. We report our experience with the Walistont (Schneider, Minneapolis). From Jan 1994 to Oct 1996, we treated 121 pts with b/liar), strictures. There were 80 men, 41 women, mean age 66.8 y (range 21-905. The strictures were due to pancreatic cancer (45), gallbladder (17), choisngiocarcinoma (16), ampulla (10), colorertai (11), hepatoma (5), breast (7), lung (4), ovarian (1), gaatric (2), lymphoma (2), and adrenal (1). h~dex stent placement was successful in 100% (4 l~ltmx.~d a second stent for initial mJsplacemen 0. Previous Rx included plastic stents (82), surgery (34), and chemoXRT (91). The mean stricture length was 2.5 cms and the location was CBD/CHD in 91, and C H D / I H D in 30. Nine pts had >1 strictures and required 2 stsnts. During a mean follow-up of 127 days (29-377), overgrowth occured in 3, ingrowth in 10, cholangifis in 14, tissue hyperplasia in 22, migration in 1, and hemobilia in 1. All pts with luminal stent occlusion were successfully treated with plastic stents. The patient with migration of the stent underwent surgery. The patient with heraobilm was treated with Nd-YAG laser during choledochoscopy. Four pts required choledochoscopy for laser therapy to allow passage of the plastic stent. In all choledochoscopy showed tumor ingrowth. One pt required a second stant to avoid occlusion of the stent opening by the wall of the CBD and 1 for "extension" of the stent beyond a CHB-duodenal anastomosis to bypass a duodenal stricture. In 1, the stont was placed using the rendezvous technique. Overall, jaundice resolved in 108/121 pts (90%) and the mean stent patency rate was 9.25 months (6 weeks-14 months). All pts with residual jaundice had metastatic liver disease. There was no stent-related mortality. Fourteen pts are alive, the rest have died of disease progression. In conclusion, biliary Wallstents have a longer patency rate compared to that reported for plastic s~nts, provide significant relief of jaundice (90%), and are associated with nunimal morbidity and no mortality. Coating of the stent may prevent tumor ingrowth. A prospective evaluation and comparison to various plastic stents is underway.
482 COMPARISON BEI'WI~EN MEI'ASTATIC VS PRIMARY BILIARY TRACT C A N C E R IN THEIR RESPONSE T O THE WALLSTENT. I Raijman, l Siddique,P Lynch, Y Part,M Rob, S Curley, J Lee, P Pisters, D Evans, J Abbruzlmse. M D Anderson Cancer Center,and Universityof Texas, Houston. The treatment of clioice for malignant biliary strictures is endoscopic stenting, either plastic or expandable. Data regarding the outcome after stenting for bfliary strictures are limited regarding metastatic (M) vs primary (P) disease. We report our experience with 88 pts (P) and 33 pts (M) treated with the bfliary Wallsient (Schneider, Minneapolis). Them were 80 men, mean age 66.8 y (range 21-90). In P, the stricture was due to: pancreas 45, cholangio 16, gallbladder 17,ampulla 10. In M, h-'aestricture was due to:coiorectal 11,hepatoma 5, breast 6, lung 4, ovaxian 1, gastric 2, lymphoma 2, adl~nal 1, unknown 1. Index stent placement was 100% successful (4 required a second strait for initial misplacement). Previous Rx included plastic stsnts in 82 (72 P, 10 M) and chemoXRT in 91 (61 P, 30 M). The mean stricture length was 2.3 cuts (P) and 2.8 cms (M). The location in P was: CBD/CHD in 88; in M: CBD/CHD in 3 and CHD/1HD in 30. Nine pts (1 P, 8 M) had >1 stricture and reqmred 2 stents, During a mean follow up of 120 days (P) and 132 days (M), overgrowth occured in 3 (1 P, 2 M ), ingrowth in 10 (4 P, 6 M), cholangitis in 14 (5 P, 9M), tissue hyperplasia in 22 (10 P, 12M), migration in 1 (P), and hemobilin in 1 (M). Jaundtce resolved in 81/88 pts (92%) in P and 29/33 (88%) in M (NS). Mean stent petency rate was 9.7 months (P) and 8.7 months (M) (iNS). All pts with residual jaundice had metastatic liver disease. Them was no mortality related to the stant. Choledochoecopy/Nd-YAG laser was required in 4 pts (4 M) for correction of hemobilia (1) or plastic stent placement (3). There are 14 surviving patients (6 P, 8 M), the rest have died of disease progression. Conclusion: the response to Walletent among pts with P vs M biliary stricture is similar regarding resolution of jaundice, patency rate, and complication rata.Additionai "invasive" therapy (choledochoscopy) may be needed more often in M. A prospective comparison to various plas~c stents is under evaluation.
?484
VOLUME 45, NO. 4, 1997
NEEDLE KNIFE FISTULOTOMY (NKF): RESULTS METHOD OF PRECUT FOR BILIARY CANNULATION
OF A N O T H E R
RS Raymond, TH Baron. Div. Gastroenterology & Hepatology, University of Alabama at Birmingham. Birmingham, AL. INTRO: The term precut sphincterotomy is loosely applied to many types of precut for biliary cnnnulation. One technique of needle knife precut papillotomy starting the incision at the papillary orifice has been described by Howell et al (Gastrointest Endosc 1996;A371). We describe in detail the technique and results using precut fistulotomy; complications were compared to routine endoscopic bilisry sphincterotomy (ES) as defined by Cotton et al. PATIENTS: From 1/95-12/96, 889 ERCPs were performed by one endoscopist. 148 underwent standard ES. In another 130 pts. (14.6%), deep cnnnulation of the common bile duct (CBD) failed and NKF was performed. INDICATIONS
c..--i
,NKF _ .(n=1305 38 (29.2% 5
.oo i .-t i -.. i
28 (21.5%) 33 (25.4%) 24 (18% 5 ES (n=1485 72 (48.6% 5 30 {20.3%) 31 (21.0%e) 12 (8.1%) METHODS: NKF (HPC-2. Wilson-Cook) was performed by applying stroking movements in the 11 o'clock position along the intrnduodenal portion of the CBD starting above the papillary orifice. Following deep cannulation, the incision was then extended cephalad using a standard sphincterotome, when appropriate, avoiding the papillary opening. Pancreatic duct (PD) stents were not placed. RESULTS: In the NKF group, cannulation was achieved in 121/130 (93%) during the initial procedure. Two pts. underwent a second ERCP to achieve cannulation with an overall success rate of 94.6%. There were 12 episodes of pancreatitis (7 mild, 5 moderate), 4 episodes of bleeding (2 mild, I moderate, I severe), I infection (mild), and 4 perforations (2 moderate, 2 severe including one death - both with periampullary diverticula). Statistical analysis revealed no significant differences between the two groups (Fisher's exact test). Therapeutic results were achieved in 76% of NKF and 90% of ES. Teehnlque Bleedin= I Pancreatitls [ Perforation [ Infection [ Death [ NKF(n=I305 4 (3.0%) I 12 (9.2% 5 4 (3.0%) [ 1 (0.8%) 1 (0.8%)1 ES (n=148) 3 (2.0%) I 8(5.4%) I I (0.7%) I 3 (2.0%) I 1 (0.7%)1 CONCLUSIONS: 1) Needle knife fistulotomy is an effective method for obtaining biliary cannulation when standard techniques fail. 2) The complication rate after NKF is comparable to ES and the risk of severe pancreatitis is low such that PD stent placement is unnecessary. 3) The perforation risk using a NKF is higher than ES; a periampullary diverticulum may be a relative contraindication to this technique. 4) Prospective studies are needed to compare outcomes between different precut techniques.
GASTROINTESTINAL ENDOSCOPY
AB145