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Clinical: Other ERCP Biliary Tuesday, May 21, 2002
*T1857 THE NEED FOR REPEAT PROCEDURES WITHIN 30 DAYS IN PATIENTS STENTED FOR MALIGNANT DISTAL BILIARY STRICTURES (MDBS): EXPERIENCE OF 508 PATIENTS AT A US REFERRAL CENTER Michael F. Byrne, Helen L. Stiffler, Malcolm S. Branch, Paul Jowell, John Baillie, Durham, NC
*T1859 FREQUENCY OF LAPAROSCOPIC CHOLECYSTECTOMY INJURIES DETECTED AT ERCP: EIGHT-YEAR EXPERIENCE AT A TERTIARY REFERRAL CENTER Mario Debellis, Evan L. Fogel, Stuart Sherman, James L. Watkins, Joyce Flueckiger, Anne Kochell, Donna Cox, Gaylyn Alexander, Glen A. Lehman, Indianapolis, IN
Introduction: Endoscopic stenting is regarded as highly effective for palliating malignant biliary strictures. However, occlusion, kinking and migration may cause stent failure, necessitating a second procedure. Failure of stents placed for palliation of MDBS has not previously been studied in detail. We set out to determine the rate of biliary stent failure within 30 days of the index procedure in a large tertiary center population. Patients and Methods: Retrospective analysis of ERCP was undertaken to determine the number of patients (pts) who were stented for presumed or known malignant distal biliary strictures (MDBS) between 7/93 and 11/01. Pts who required repeat stenting within 30 days were identified, as well as the reason for their stent exchange. Prolongation of inpatient stay resulting from stent failure was also looked for. Results: 508 pts were stented for MDBS during the 8+ year study period. 29/508 (5.7%) pts had repeat stenting procedures within 30 days. 18/29 (62.1%) stents were occluded and 3/29 (10.4%) had migrated out of their original position. In 2/29 (6.9%) cases, the original stent was replaced as part of a repeat ERCP needed to make a tissue diagnosis (i.e. repeat cytology). In 2/29 (6.9%) cases, kinking of a plastic stent was the presumed problem, as no other cause of occlusion was identified. In 4/29 (13.8%) cases, plastic stents were electively changed for expandable metal mesh ones. Of the 29 stents involved in failures, 27/29 were plastic and 2/29 were metal. Metal stent failure was treated primarily by placing a plastic stent through the “failed” metal one. In 6/29 cases (20.7%), at least 3 additional hospital days resulted from failure of the index stent. Conclusion: Our data show that the problem is not negligible, even in a major referral center, where technical skill is expected to be high. 5.7% of pts in our retrospective series of 508 cases required a second ERCP within 30 days. Early repeat procedures add to the potential procedure-related morbidity and mortality. They also have significant economic implications, especially when hospitalization is prolonged as a result. Despite their higher cost, increasing use of expandable metal stents as the initial therapy in suitable cases may reduce the frequency of stent failure, and be a cost-effective strategy.
Background: The risk of bile duct injury during laparoscopic cholecystectomy has been a concern since this procedure became available. It has generally been anticipated over the years that the incidence of bile duct injury should decrease with technical advances and increased surgical experience with this technique. Aim: To review our ERCP experience over the last 8 years to define the frequency and type of biliary complications encountered after laparoscopic cholecystectomy. Methods: From January 1994 to November 2001, ERCP identified a bile duct injury after laparoscopic cholecystectomy in 143 patients (M:F 53:90; age range 18-91): bile leak, ductal stricture or duct transection. Patients with postlaparoscopic cholecystectomy symptoms, which were due to choledocholithiasis, sphincter of Oddi dysfunction or malignant strictures were excluded from the analysis. Results: See table. Summary: Complication rates after laparoscopic cholecystectomy vary annually without a definite downward trend in our experience. Conclusions: To date, bile duct injuries are still documented at ERCP. The number of patients referred for postlaparoscopic cholecystectomy injuries has not decreased despite the fact that this procedure is currently considered the gold standard for surgical treatment of cholelithiasis. However, referral bias cannot be excluded and its influence on our data is unknown. Indeed, postlaparoscopic injuries may be declining overall, with more patients being referred to our tertiary referral center. Longer-term follow-up of all patients undergoing laparoscopic cholecystectomy is required in order to assess the final procedure complication rate, including low–grade strictures with delayed clinical presentation. Individual institutions must monitor “in-house” injuries to determine local injury rates.
*T1858 CLINICAL SIGNIFICANCE OF A LONG COMMON CHANNEL Terumi Kamisawa, Kozue Amemiya, Yuyang Tu, Naoto Egawa, Nobuhiro Sakaki, Masakatsu Matsukawa, Tokyo, Japan; Hirosaki, Japan Background: Only 19 (11%) of 173 patients identified to have a long common channel at the junction of the pancreatic and bile ducts were found to be 6 mm or longer. Pancreaticobiliary maljunction (PBM) is defined as an anomaly with a markedly long common channel with the junction located outside the duodenal wall, so action of the sphincter of Oddi does not functionally affect the junction. As two-way regurgitation, reflux of pancreatic juice into the bile duct, or of bile juice into the pancreatic duct occurs, various pathologic conditions occur in the biliary tract and the pancreas. Aim: We defined high confluence of pancreaticobiliary ducts (HCPBD) as a case with a common channel longer than 6 mm, in which communication between the pancreatic and bile ducts was occluded when the sphincter was contracted. This study aims to investigate the clinical significance of HCPBD. Patients and Methods: Almost consecutive 2980 cases of adequate ERCP were reviewed. PBM and HCPBD was diagnosed according to the above definitions. Other cases were used as controls, and radiologic and clinical features were studied. PBM was divided into two groups; with or without biliary dilatation. Results: PBM and HCPBD was detected in 63 (2.1%) and 50 cases (1.7%), respectively. Biliary dilatation was detected in 30 cases of PBM. There was no difference among gender in the patients with HCPBD. The average age at the time of diagnosis was significantly younger in the patients with PBM with biliary dilatation (49.8 years) in comparison to those with HCPBD (61.4 years) and controls (57.6 years) (p < 0.05). The average length of common channel in the patients with HCPBD was 8.5 mm, which was significantly shorter than 22.6 mm in PBM (p < 0.01). The incidence of gallbladder carcinoma associated with PBM with or without biliary dilatation, and HCPBD was 13%, 67%, 12%, being significantly higher than 3% of controls (p < 0.05, p < 0.01, p < 0.05). The incidence of gallbladder stones in conjunction with gallbladder carcinoma associated with HCPBD or PBM was 17% and 12%, which was significantly lower, compared with 62% with gallbladder carcinoma in the absence of these maljunctions (p < 0.01). Pancreatic ductal reflux was detected in 11 (85%) of 13 patients with HCPBD by postoperative T-tube cholangiograms, and the amylase level in the bile was elevated in all 6 patients with HCPBD examined. Acute pancreatitis occurred in 24% of 50 patients with HCPBD. Conclusions: HCPBD may be an intermediate variant of PBM. It is necessary to pay attention to associated gallbladder carcinoma in the patients with HCPBD, like as PBM.
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*T1860 BILIARY POLYETHYLENE STENT PATENCY: INTEREST OF THE SIDE HOLES Francois Cessot, Alain Menudier, Christian Moesch, Maryline Debette Gratien, Nicolas Pichon, Denis Sautereau, Limoges, France Late biliary stent blockage is an important clinical problem. In vitro experiments have shown that plastic stents with side holes showed a maximal occlusion at the side holes. However, benefits of stents without side holes has not be clinically confirmed. We therefore conducted from 1990 to 2000, a prospective, nonrandomized study comparing 46 biliary stents with side holes (SH) with 44 without side holes (NSH). All prostheses studied (10F: polyethylene stent) were inserted endoscopically for palliative management of malignant or benign biliary strictures. Patients with gallstones were excluded. After stent blockage, occluded biliary stents were removed endoscopically and analyzed: section into 5 mm segments, stereomicroscopic quantification of the luminal obstruction (from 0 = no obstruction to 5 = total obstruction), scanning electron microscopic study, Fourier transform infrared spectrometric analysis of the deposits (KBr disc) and identification of aerobic and anaerobic bacteria in sterile saline injected through the lumen of the stent. In spite of a more important clogging of the prostheses in the presence of side holes (p = 0.0003), these side holes allow a statistically longer stent patency (p = 0.0002). This result is consolidated by the comparison of the frequencies of premature clogging (p = 0.0068 ). In the SH group, the presence of compounds of later formation (calcium bilirubinate and palmitate) is more frequent (p < 0.05) and the importance of deposits correlated with the stent patency (p = 0.0013). In this SH group: bacteriological flora is statistically richer than in the NSH group with more anaerobes (p < 0.05); Klebsiella is less present because of a longer stent patency. These results suggest that the presence of side holes increases the patency and decreases premature clogging of the biliary stents.
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*T1861 A PILOT STUDY FOR SELECTIVE GALL BLADDER STENTING AS A TEMPORIZING MEASURE IN CIRRHOTICS WITH CHOLECYSTITIS AWAITING LIVER TRANSPLANTATION Khoa Do, Sanjay Agrawal, Ajay Batra, Wahid Wassef, Kanishka Bhattacharya, Savant Mehta, Worcester, MA
*T1863 HIGH INCIDENCE OF ANOMALOUS PANCREATICOBILIARY DUCTAL JUNCTION IN GALLBLADDER CARCINOMA: AN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) STUDY IN CHINA Bing Hu, Biao Gong, Dai-Yun Zhou, Shanghai, China
Objectives: Patients with acute cholecystitis and underlying severe liver disease (Child’s class C) pose a management challenge. In this group of patients, cholecystectomy carries high mortality and morbidity and percutaneous cholecystostomy has high morbidity due to extensive collaterals around the gall bladder from portal hypertension. Selective endoscopic stenting of the gall bladder offers an alternative to managing these patients by interrupting the essential pathophysiological step in the development of acute cholecystitis, namely cystic duct obstruction. Methods: Patients with advanced decompensated liver disease who were considered poor surgical risk were offered endoscopic stenting. Those who accepted underwent ERCP with selective gall bladder stenting with double pig-tail plastic stents. Two of the 3 patients had spincterotomy and balloon sweep prior to stenting. The patients were then followed prospectively for complicatons and recurrence. Results: Three patients with advanced decompensated liver disease (Child’s class C) awaiting orthotopic liver transplantation presented with clinical and radiologic evidence of acute cholecystitis. The mean age was 39 years and etiology of liver disease included hepatitis C, alcohol, and primary sclerosing cholangitis associated with ulcerative colitis. The patients failed antibiotic therapy alone and all of them were successfully managed by selective gall bladder stenting. One patient underwent successful orthotopic liver transplantation approximately four months post stent placement while a second patient had his stent changed about six months after the initial stent and continues to do well. The third patient is 2 months after stent placement and also is doing well. Conclusion: Selective gall bladder stenting is a safe and reasonable alternative to cholecystectomy and cholecystostomy in Child’s C cirrhotics presenting with acute cholecystitis. The procedure is not technically difficult to perform and should be considered as a temporizing measure in Child’s C cirrhotics with high risk of morbidity and mortality from cholecystectomy and a safer alternative to cholecystostomy. The optimal interval between stent changes and long term outcomes remains to be determined.
Background: Anomalous pancreaticobiliary ductal junction (APBDJ) is a rare congenital anomaly, which is considered recently to be high risk of developing carcinoma of the gallbladder. The reported frequency of the APBDJ in gallbladder cancer was 12.8%-17.2% in Japan. Our study aimed to clarify the incidence of APBDJ in Chinese patients with gallbladder carcinoma. Methods: Between Apr. 2000 and Sep. 2001, 1876 consecutive patients underwent ERCP in our center. Among them both biliary and pancreatic ducts were opacified in 1082 cases. The study included 54 patients with gallbladder carcinoma (histologically proven or confirmed at laparotomy). APBDJ was defined radiologically as a common channel longer than 15 mm. Results: Overall 10 patients (0.9%) had APBDJ. Among them, gallbladder cancer was identified in 7 cases (Male 3: Female 4), choledochal cyst in 1 case and normal biliary tract in 2 cases. Of the 7 patients with gallbladder cancer, the anomalies were P-B union in 3, B-P union in 3 and a complex type in 1 patient respectively. The mean common channel was 20.6 mm in length (range 15 to 34 mm) with no associated cystic dilation of bile duct or gallstones. The incidence of APBDJ was significantly higher in patients with gallbladder carcinoma (7 of 54 compared with 3 of 1025 patients, p < 0.001; OR, 51; 95% CI 12.7-203). Conclusions: The presence of APBDJ among Chinese patients is strongly associated with gallbladder carcinoma.
*T1862 IMPROVED SERUM CHOLESTEROL FOLLOWING BILIARY SPHINCTEROTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION (SOD): A NOVEL THERAPY FOR HYPERCHOLESTEROLEMIA? Evan L. Fogel, Stuart Sherman, James L. Watkins, Linda Laetz, Glen A. Lehman, Indianapolis, IN
*T1864 WHAT IS THE CLINICAL IMPLICATION OF PAPILLITIS OF THE AMPULLA OF VATER? Js Park, Myung-Hwan Kim, Sung-Koo Lee, Dw Seo, Sang Soo Lee, HyeSook Chang, Jimin Han, Jung Sun Kim, Young Il Min, Seoul, South Korea
Background: The sphincter of Oddi regulates bile flow into the small intestine. Biliary sphincterotomy (BES) disrupts this mechanism, increasing bile delivery. If the absorptive capacity of the terminal ileum is exceeded, cholesterol excretion may increase, potentially leading to a decrease in serum cholesterol concentration. Our preliminary data in SOD patients with hypercholesterolemia suggests that BES may reduce total cholesterol levels. This study updates our earlier experience. Methods: From 5/9810/01, patients with Type III SOD (disabling pain, normal LFTs and CBD diameter) who underwent BES were identified retrospectively from the ERCP database. Baseline (pre-ERCP) total serum cholesterol levels were obtained in all patients. In those patients who returned for a subsequent procedure (for temporary pancreatic stent removal or recurrent symptoms), the effect of BES on total serum cholesterol was noted. Results: 620 Type III SOD patients who underwent BES were identified; follow-up cholesterol levels were available in 132 patients (see Table). Summary: (1) Performance of ES in patients without evidence of biliary obstruction was associated with a decrease in serum total cholesterol concentration. This was statistically significant in patients with baseline hypercholesterolemia (≥200 mg/dL). (2) Possible confounding effects of lipid-lowering medications, exercise and dietary changes were not accounted for in this study. Conclusion: Biliary sphincterotomy may potentially be an alternative or adjuvant therapy to medications in patients with hypercholesterolemia. A prospective controlled study is required.
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Purpose: We prospectively performed this study to reveal the clinical implication of papillitis in patients with various biliary or pancreatic disorders. Methods: Total 87 consecutive patients (M:F = 44:43, mean age = 58 years) and 12 controls (M:F = 6:6, mean age = 51 years) were enrolled in this study. The classification of the endoscopic papillitis and the scoring of its severity, which were adopted from those of duodenitis in the Sydney system, were performed by 2 blinded endoscopists. Biopsies for histologic papillitis were taken at the papilla. Various factors were analyzed to find out the factors associated with the severity of endoscopic papillitis. We also analyzed the correlation between endoscopic and histologic papillitis. Results: Mild endoscopic papillitis was noted in 47 (54%) of 87 patients with various biliary or pancreatic disorders and was also found in 6 (50%) of 12 normal healthy volunteers. Moderate and severe endoscopic papillitis were noted in 33 (38%) of 87 patients in biliary or pancreatic disorders, whereas they were not observed at all in normal healthy volunteers. In univariate analysis, the presence of a clinically acute inflammatory condition (i.e., the presence of one of the following disorders: acute cholangitis, acute pancreatitis, or acute exacerbation of chronic pancreatitis) and serum transaminase level were significantly associated with moderate and severe endoscopic papillitis (p < 0.05). On the other hand, the anatomic location of underlying diseases, benign vs. malignant disease, alkaline phosphatase, bilirubin, pancreatic enzymes, presence of periampullary diverticulum and H pylori infection were not associated with moderate and severe endoscopic papillitis (p > 0.05). In multivariate analysis, however, only a clinically acute inflammatory condition was significantly associated with moderate and severe endoscopic papillitis (p < 0.001). The severity of endoscopic papillitis showed poor correlation with that of monocyte infiltration but good correlation with that of neutrophil infiltration. Conclusions: Moderate and severe endoscopic papillitis were significantly more common in biliary or pancreatic disorders with a clinically acute inflammatory condition than in those without it, whereas they were not observed at all in normal healthy volunteers. Moderate and severe endoscopic papillitis are, therefore, considered as a characteristic finding to suggest that the patients with biliary or pancreatic disorders are accompanied with a clinically acute inflammatory condition.
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*T1865 OUTCOME OF ENDOSCOPIC TREATMENT OF BILIARY COMPLICATIONS IN LIVER TRANSPLANT PATIENTS Prashanthi Thota, Madhusudhan Sanaka, John Dumot, Gregory Zuccaro, John Vargo, Cleveland, OH Endoscopic treatment is gaining acceptance in the management of biliary complications in liver transplant patients. However, the long term efficacy after a successful initial ERCP is uncertain. Aim: To determine the initial success and long term results of ERCP in diagnosing and treating biliary complications in liver transplant patients. Methods: 280 patients underwent 298 OLT in our institution over a 5-yr period (19952000). A total of 42 pts were referred for ERCP. Follow–up data until Nov 15, 2001 is included. We reviewed the indications, diagnostic findings and the initial and long term success rates of ERCP. The initial ERCP is defined as successful if there was adequate drainage established or there was no immediate need for percutaneous drainage or surgery. Long-term success is defined as resolution of the leak or stricture without percutaneous drainage or surgery for up to one year after the last ERCP or until the end of follow-up period. Results: Biliary leaks and strictures were the most common findings. ERCP had a diagnostic accuracy of 97.6%. 10 patients had normal cholangiograms. Initial ERCP was successful in the treatment of 75% of biliary complications. Among the 8 pts in whom the initial ERCP failed to treat, 7 pts went for percutaneous drainage and 1 went directly for surgery. On a mean follow-up period of 22.5 months (range 0.5 to 77 months), 50% of the pts that were successfully treated initially by ERCP remained free of biliary complications. 25% of pts are currently undergoing treatment. Among the subset of pts in whom the initial ERCP failed, 62.5% underwent surgical treatment. There was a trend towards decreased need for surgery in pts in whom initial ERCP was successful (25% vs. 62.5%; p value = 0.088). Conclusions: (1) Endoscopic treatment is effective in the diagnosis and management of biliary complications. (2) A successful initial ERCP is associated with a low need for surgery in the long term basis.
Biliary fistulas were treated with 4 week drainage with either stent or a naso-biliary tube. Stones and casts were extracted. Results: A mean of 1.7 (1-9) ERCPs had to be performed in these 85 patients, median follow-up period was 16 months after ERCP, 76% of the patients were still alive at the end of the study. Biliary pathologies were stenoses of the anastomosis in 50%, intrahepatic strictures in 21%, bile duct leaks in 17%, casts in 6%, bile duct stones in 3% and others in 3%. Significant reduction of cholestasis (decrease of bilirubin >5 mg/dL) was seen in 80% of our patients after ERCP, a reduction to normal bilirubin levels was seen in 30%. 11% of these patients had to be retransplanted, in 22% of these patients surgical biliodigestive anastomosis had to be performed. Conclusion: In more than 30% biliary complications could be treated with ERCP alone, more than 2⁄3 of the patients improved partially or for a certain amount of time due to endoscopic intervention alone and did not need surgical intervention or retransplantation. Prospective trials are needed to prove its value in comparison with primary surgical interventions.
*T1867 WHAT IS THE YIELD OF ERCP FOR INVESTIGATING FOCAL OR DIFFUSE INTRAHEPATIC DUCTAL DILATION (IHDD) IN THE SETTING OF NORMAL LFTS? Jorge V. Obando, Helen L. Stiffler, John Baillie, Paul Jowell, Malcolm S. Branch, Burlington, MA; Durham, NC Background: Given the omnipresent concern that serious pathology might be present, ERCP is usually recommended when the intrahepatic ducts appear dilated on CT scanning, even when the LFTs are normal. We reviewed our experience of 14 patients seen at a tertiary care center over the last 8 years with IHDD ± mild extrahepatic ductal dilation (EHDD) to determine how often pathology was identified. Patients and Methods: From endoscopic databases, we identified 14 patients referred for ERCP between 11/93 and 11/01 who had IHDD ± EHDD. IHDD was any degree of dilatation of the intrahepatic ducts. EHDD was defined as CBD diameter >7 mm and <12 mm, to avoid overlap with possible SOD. Patients with suspected choledochal cysts, known biliary pathology or history of biliary sphincterotomy were also excluded. Results: 8 patients had IHDD alone, 6 had IHDD and mild EHDD. None of the 14 patients had intra- or extrahepatic biliary stones or strictures to explain their ductal dilatation. One patient had a solitary small gallstone identified. 1/6 patients with IHDD and mild EHDD was felt to have papillary stenosis or SOD based on history and cholangiography, and underwent sphincterotomy without manometry. Conclusion: The yield of ERCP for serious biliary pathology in patients with normal LFTs and IHDD was zero (0/8). 1/6 patients with IHDD and mild EHDD underwent empiric sphincterotomy for suspected papillary stenosis or SOD. No stone, stricture or tumor was found in any of these 14 patients with normal LFTs. Modern high-resolution CT scanning may show normal caliber IH bile ducts which are erroneously interpreted as dilated. Another explanation is that mild IHDD may have little significance. ERCP appears to be a low-yield procedure in such cases.
*T1866 LONG-TERM RESULTS OF ENDOSCOPIC THERAPY OF BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION Arnulf Ferlitsch, Astrid Gupper, Andreas Puespoek, Markus PeckRadosavljevic, Felix Langer, Alfred Gangl, Ferdinand Mühlbacher, Rainer Schoefl, Vienna, Austria Introduction: Biliary complications after liver transplantation (OLT) occur with a frequency of 10% to 50% and are a major reason for follow-up surgical interventions. Aim of the study was the evaluation of endoscopic treatment in these patients. Methods: From January 1985 to November 2001 OLT was performed in 916 patients. 115 of them were referred for ERCP with suspected biliary complications and 85 (63m, 22f, mean age 50 (16-68)) were treated endoscopically a mean period of 107 days (7-3964 days) after OLT. Reason for ERCP was cholestasis in 78 patients and others in 7, complicated by cholangitis in 18. Stenoses were treated initially with balloon dilatation and with dilatation and plastic stent implantation in case of recurrent stenosis. Stents were exchanged routinely after 6 months, for a total of 12 months.
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*T1868 COMPARISON OF MRCP AND ERCP IN THE DIAGNOSIS OF BILIARY AND PANCREATIC DISEASES Kiyoshi Mizuno, Kazuyuki Itoh, Makoto Itoh, Nagoya, Japan; Kasugai, Japan Background: An increasing number of studies have shown that magnetic resonance cholangiopancreatography (MRCP) has good potential for differential diagnosis of diseases. Aims: To evaluate the diagnostic accuracy of MRCP for biliary and pancreatic diseases and to clarify possible reasons for misdiagnosis with this approach. Methods: We examined clinical indications for MRCP in 203 patients (104 males, 99 females; mean age, 61 years old, range from 15 to 94) in comparison with ERCP. Clinical presentation was categorized as being of biliary (n = 149), pancreatic (n = 38), nonspecific (n = 8), or normal type (n = 8). MRCP images were obtained as coronal thick single slices (50 mm) and multiple thin slices (4 mm) using SSFSE techniques (1.5T GE Medical Systems). Results: Biliary diseases encountered were cholelithiasis (81 cases), choledocholithiasis (40), cholangiocarcinoma (14), gallbladder adenomyomatosis (8), and ampulla of Vater cancer (3). Pancreatic presentations included cancer (13), chronic pancreatitis (11), pancreatic cysts (8), and cystic neoplasms (3). For the patients with choledocholithiasis, the MRCP values for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91.9%, 96.2%, 87.2%, and 98.1%, respectively. The false negative result was due to nonrecognition of small stones (<4 mm). The false positives were caused by debris in the common bile duct or flow void effects. In the patients with cholangiocarcinomas, the values for sensitivity, specificity, PPV, and NPV were 88.6%, 99.5%, 91.7%, and 98.4%, respectively, whereas those for pancreatic cancer were 92.3%, 98.9%, 85.7%, and 99.5%. Conclusions: (1) MRCP is a valuable noninvasive diagnostic modality for pancreatobiliary disease. (2) MRCP suffers from low sensitivity for detection of CBD stones less than 4 mm in diameter. (3) MRCP can provide useful additional information on bile duct or pancreatic duct proximal to strictures.
*T1869 EFFICACY OF ENDOSCOPIC AND PERCUTANEOUS TREATMENTS OF THE BILIARY COMPLICATIONS AFTER CADAVER AND LIVING DONOR LIVER TRANSPLANTATIONS Js Park, Myung-Hwan Kim, Sung-Koo Lee, Dw Seo, Sang Soo Lee, Jimin Han, Young Il Min, Shin Hwang, Kwang Min Park, Young Joo Lee, Seung Gyu Lee, Gyu Bo Sung, Seoul, South Korea Purpose: Recently, transpapillary endoscopic treatment and percutaneous transhepatic radiologic intervention have been used in treatment of various biliary complications after liver transplantation. We performed this study to evaluate the efficacy of these medical treatments for the biliary complications in patients who received cadaver donor liver transplantation (CDLT) and living donor liver transplantation (LDLT). Methods: We conducted this retrospective study to reveal the prevalence and the type of the biliary complications after CDLT and LDLT. We also assessed the success rate of transpapillary endoscopic treatment (i.e., ERCP) and percutaneous transhepatic radiologic procedure (PTRP) for the biliary complications. Results: Among 429 adult patients who underwent the liver transplantation, total 39 cases of the biliary complications developed in enrolled 25 patients (25/429, 5.8%): biliary stricture (n = 20), biliary stones (n = 10), and bile leaks (n = 9). The prevalence rate (5.8%, 6/103) of the biliary complications after CDLT was not significantly different when compared with that (5.8%, 19/326) after LDLT (p > 0.05). The success rates of ERCP and PTRP for the biliary stricture, biliary stone, and bile leak were 100% (3/3) and 75% (9/12), 100% (3/3), and 86% (6/7), and 100% (5/5), and 75% (3/4), respectively, and were not significantly different between each complication (p > 0.05). Conclusions: Transpapillary endoscopic treatment and percutaneous transhepatic radiologic intervention are equally effective and useful therapies for the biliary complications associated with liver transplantation. Moreover, they are not competitors but reciprocal companions in therapeutic modalities because the choice of the medical treatment mainly depends on the type of biliary reconstruction and the accessibility to the complication site.
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*T1859 FREQUENCY OF LAPAROSCOPIC CHOLECYSTECTOMY INJURIES DETECTED AT ERCP: EIGHT-YEAR EXPERIENCE AT A TERTIARY REFERRAL CENTER Mario Debellis, Evan L. Fogel, Stuart Sherman, James L. Watkins, Joyce Flueckiger, Anne Kochell, Donna Cox, Gaylyn Alexander, Glen A. Lehman, Indianapolis, IN
Introduction: Endoscopic stenting is regarded as highly effective for palliating malignant biliary strictures. However, occlusion, kinking and migration may cause stent failure, necessitating a second procedure. Failure of stents placed for palliation of MDBS has not previously been studied in detail. We set out to determine the rate of biliary stent failure within 30 days of the index procedure in a large tertiary center population. Patients and Methods: Retrospective analysis of ERCP was undertaken to determine the number of patients (pts) who were stented for presumed or known malignant distal biliary strictures (MDBS) between 7/93 and 11/01. Pts who required repeat stenting within 30 days were identified, as well as the reason for their stent exchange. Prolongation of inpatient stay resulting from stent failure was also looked for. Results: 508 pts were stented for MDBS during the 8+ year study period. 29/508 (5.7%) pts had repeat stenting procedures within 30 days. 18/29 (62.1%) stents were occluded and 3/29 (10.4%) had migrated out of their original position. In 2/29 (6.9%) cases, the original stent was replaced as part of a repeat ERCP needed to make a tissue diagnosis (i.e. repeat cytology). In 2/29 (6.9%) cases, kinking of a plastic stent was the presumed problem, as no other cause of occlusion was identified. In 4/29 (13.8%) cases, plastic stents were electively changed for expandable metal mesh ones. Of the 29 stents involved in failures, 27/29 were plastic and 2/29 were metal. Metal stent failure was treated primarily by placing a plastic stent through the “failed” metal one. In 6/29 cases (20.7%), at least 3 additional hospital days resulted from failure of the index stent. Conclusion: Our data show that the problem is not negligible, even in a major referral center, where technical skill is expected to be high. 5.7% of pts in our retrospective series of 508 cases required a second ERCP within 30 days. Early repeat procedures add to the potential procedure-related morbidity and mortality. They also have significant economic implications, especially when hospitalization is prolonged as a result. Despite their higher cost, increasing use of expandable metal stents as the initial therapy in suitable cases may reduce the frequency of stent failure, and be a cost-effective strategy.
Background: The risk of bile duct injury during laparoscopic cholecystectomy has been a concern since this procedure became available. It has generally been anticipated over the years that the incidence of bile duct injury should decrease with technical advances and increased surgical experience with this technique. Aim: To review our ERCP experience over the last 8 years to define the frequency and type of biliary complications encountered after laparoscopic cholecystectomy. Methods: From January 1994 to November 2001, ERCP identified a bile duct injury after laparoscopic cholecystectomy in 143 patients (M:F 53:90; age range 18-91): bile leak, ductal stricture or duct transection. Patients with postlaparoscopic cholecystectomy symptoms, which were due to choledocholithiasis, sphincter of Oddi dysfunction or malignant strictures were excluded from the analysis. Results: See table. Summary: Complication rates after laparoscopic cholecystectomy vary annually without a definite downward trend in our experience. Conclusions: To date, bile duct injuries are still documented at ERCP. The number of patients referred for postlaparoscopic cholecystectomy injuries has not decreased despite the fact that this procedure is currently considered the gold standard for surgical treatment of cholelithiasis. However, referral bias cannot be excluded and its influence on our data is unknown. Indeed, postlaparoscopic injuries may be declining overall, with more patients being referred to our tertiary referral center. Longer-term follow-up of all patients undergoing laparoscopic cholecystectomy is required in order to assess the final procedure complication rate, including low–grade strictures with delayed clinical presentation. Individual institutions must monitor “in-house” injuries to determine local injury rates.
*T1858 CLINICAL SIGNIFICANCE OF A LONG COMMON CHANNEL Terumi Kamisawa, Kozue Amemiya, Yuyang Tu, Naoto Egawa, Nobuhiro Sakaki, Masakatsu Matsukawa, Tokyo, Japan; Hirosaki, Japan Background: Only 19 (11%) of 173 patients identified to have a long common channel at the junction of the pancreatic and bile ducts were found to be 6 mm or longer. Pancreaticobiliary maljunction (PBM) is defined as an anomaly with a markedly long common channel with the junction located outside the duodenal wall, so action of the sphincter of Oddi does not functionally affect the junction. As two-way regurgitation, reflux of pancreatic juice into the bile duct, or of bile juice into the pancreatic duct occurs, various pathologic conditions occur in the biliary tract and the pancreas. Aim: We defined high confluence of pancreaticobiliary ducts (HCPBD) as a case with a common channel longer than 6 mm, in which communication between the pancreatic and bile ducts was occluded when the sphincter was contracted. This study aims to investigate the clinical significance of HCPBD. Patients and Methods: Almost consecutive 2980 cases of adequate ERCP were reviewed. PBM and HCPBD was diagnosed according to the above definitions. Other cases were used as controls, and radiologic and clinical features were studied. PBM was divided into two groups; with or without biliary dilatation. Results: PBM and HCPBD was detected in 63 (2.1%) and 50 cases (1.7%), respectively. Biliary dilatation was detected in 30 cases of PBM. There was no difference among gender in the patients with HCPBD. The average age at the time of diagnosis was significantly younger in the patients with PBM with biliary dilatation (49.8 years) in comparison to those with HCPBD (61.4 years) and controls (57.6 years) (p < 0.05). The average length of common channel in the patients with HCPBD was 8.5 mm, which was significantly shorter than 22.6 mm in PBM (p < 0.01). The incidence of gallbladder carcinoma associated with PBM with or without biliary dilatation, and HCPBD was 13%, 67%, 12%, being significantly higher than 3% of controls (p < 0.05, p < 0.01, p < 0.05). The incidence of gallbladder stones in conjunction with gallbladder carcinoma associated with HCPBD or PBM was 17% and 12%, which was significantly lower, compared with 62% with gallbladder carcinoma in the absence of these maljunctions (p < 0.01). Pancreatic ductal reflux was detected in 11 (85%) of 13 patients with HCPBD by postoperative T-tube cholangiograms, and the amylase level in the bile was elevated in all 6 patients with HCPBD examined. Acute pancreatitis occurred in 24% of 50 patients with HCPBD. Conclusions: HCPBD may be an intermediate variant of PBM. It is necessary to pay attention to associated gallbladder carcinoma in the patients with HCPBD, like as PBM.
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*T1860 BILIARY POLYETHYLENE STENT PATENCY: INTEREST OF THE SIDE HOLES Francois Cessot, Alain Menudier, Christian Moesch, Maryline Debette Gratien, Nicolas Pichon, Denis Sautereau, Limoges, France Late biliary stent blockage is an important clinical problem. In vitro experiments have shown that plastic stents with side holes showed a maximal occlusion at the side holes. However, benefits of stents without side holes has not be clinically confirmed. We therefore conducted from 1990 to 2000, a prospective, nonrandomized study comparing 46 biliary stents with side holes (SH) with 44 without side holes (NSH). All prostheses studied (10F: polyethylene stent) were inserted endoscopically for palliative management of malignant or benign biliary strictures. Patients with gallstones were excluded. After stent blockage, occluded biliary stents were removed endoscopically and analyzed: section into 5 mm segments, stereomicroscopic quantification of the luminal obstruction (from 0 = no obstruction to 5 = total obstruction), scanning electron microscopic study, Fourier transform infrared spectrometric analysis of the deposits (KBr disc) and identification of aerobic and anaerobic bacteria in sterile saline injected through the lumen of the stent. In spite of a more important clogging of the prostheses in the presence of side holes (p = 0.0003), these side holes allow a statistically longer stent patency (p = 0.0002). This result is consolidated by the comparison of the frequencies of premature clogging (p = 0.0068 ). In the SH group, the presence of compounds of later formation (calcium bilirubinate and palmitate) is more frequent (p < 0.05) and the importance of deposits correlated with the stent patency (p = 0.0013). In this SH group: bacteriological flora is statistically richer than in the NSH group with more anaerobes (p < 0.05); Klebsiella is less present because of a longer stent patency. These results suggest that the presence of side holes increases the patency and decreases premature clogging of the biliary stents.
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*T1861 A PILOT STUDY FOR SELECTIVE GALL BLADDER STENTING AS A TEMPORIZING MEASURE IN CIRRHOTICS WITH CHOLECYSTITIS AWAITING LIVER TRANSPLANTATION Khoa Do, Sanjay Agrawal, Ajay Batra, Wahid Wassef, Kanishka Bhattacharya, Savant Mehta, Worcester, MA
*T1863 HIGH INCIDENCE OF ANOMALOUS PANCREATICOBILIARY DUCTAL JUNCTION IN GALLBLADDER CARCINOMA: AN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) STUDY IN CHINA Bing Hu, Biao Gong, Dai-Yun Zhou, Shanghai, China
Objectives: Patients with acute cholecystitis and underlying severe liver disease (Child’s class C) pose a management challenge. In this group of patients, cholecystectomy carries high mortality and morbidity and percutaneous cholecystostomy has high morbidity due to extensive collaterals around the gall bladder from portal hypertension. Selective endoscopic stenting of the gall bladder offers an alternative to managing these patients by interrupting the essential pathophysiological step in the development of acute cholecystitis, namely cystic duct obstruction. Methods: Patients with advanced decompensated liver disease who were considered poor surgical risk were offered endoscopic stenting. Those who accepted underwent ERCP with selective gall bladder stenting with double pig-tail plastic stents. Two of the 3 patients had spincterotomy and balloon sweep prior to stenting. The patients were then followed prospectively for complicatons and recurrence. Results: Three patients with advanced decompensated liver disease (Child’s class C) awaiting orthotopic liver transplantation presented with clinical and radiologic evidence of acute cholecystitis. The mean age was 39 years and etiology of liver disease included hepatitis C, alcohol, and primary sclerosing cholangitis associated with ulcerative colitis. The patients failed antibiotic therapy alone and all of them were successfully managed by selective gall bladder stenting. One patient underwent successful orthotopic liver transplantation approximately four months post stent placement while a second patient had his stent changed about six months after the initial stent and continues to do well. The third patient is 2 months after stent placement and also is doing well. Conclusion: Selective gall bladder stenting is a safe and reasonable alternative to cholecystectomy and cholecystostomy in Child’s C cirrhotics presenting with acute cholecystitis. The procedure is not technically difficult to perform and should be considered as a temporizing measure in Child’s C cirrhotics with high risk of morbidity and mortality from cholecystectomy and a safer alternative to cholecystostomy. The optimal interval between stent changes and long term outcomes remains to be determined.
Background: Anomalous pancreaticobiliary ductal junction (APBDJ) is a rare congenital anomaly, which is considered recently to be high risk of developing carcinoma of the gallbladder. The reported frequency of the APBDJ in gallbladder cancer was 12.8%-17.2% in Japan. Our study aimed to clarify the incidence of APBDJ in Chinese patients with gallbladder carcinoma. Methods: Between Apr. 2000 and Sep. 2001, 1876 consecutive patients underwent ERCP in our center. Among them both biliary and pancreatic ducts were opacified in 1082 cases. The study included 54 patients with gallbladder carcinoma (histologically proven or confirmed at laparotomy). APBDJ was defined radiologically as a common channel longer than 15 mm. Results: Overall 10 patients (0.9%) had APBDJ. Among them, gallbladder cancer was identified in 7 cases (Male 3: Female 4), choledochal cyst in 1 case and normal biliary tract in 2 cases. Of the 7 patients with gallbladder cancer, the anomalies were P-B union in 3, B-P union in 3 and a complex type in 1 patient respectively. The mean common channel was 20.6 mm in length (range 15 to 34 mm) with no associated cystic dilation of bile duct or gallstones. The incidence of APBDJ was significantly higher in patients with gallbladder carcinoma (7 of 54 compared with 3 of 1025 patients, p < 0.001; OR, 51; 95% CI 12.7-203). Conclusions: The presence of APBDJ among Chinese patients is strongly associated with gallbladder carcinoma.
*T1862 IMPROVED SERUM CHOLESTEROL FOLLOWING BILIARY SPHINCTEROTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION (SOD): A NOVEL THERAPY FOR HYPERCHOLESTEROLEMIA? Evan L. Fogel, Stuart Sherman, James L. Watkins, Linda Laetz, Glen A. Lehman, Indianapolis, IN
*T1864 WHAT IS THE CLINICAL IMPLICATION OF PAPILLITIS OF THE AMPULLA OF VATER? Js Park, Myung-Hwan Kim, Sung-Koo Lee, Dw Seo, Sang Soo Lee, HyeSook Chang, Jimin Han, Jung Sun Kim, Young Il Min, Seoul, South Korea
Background: The sphincter of Oddi regulates bile flow into the small intestine. Biliary sphincterotomy (BES) disrupts this mechanism, increasing bile delivery. If the absorptive capacity of the terminal ileum is exceeded, cholesterol excretion may increase, potentially leading to a decrease in serum cholesterol concentration. Our preliminary data in SOD patients with hypercholesterolemia suggests that BES may reduce total cholesterol levels. This study updates our earlier experience. Methods: From 5/9810/01, patients with Type III SOD (disabling pain, normal LFTs and CBD diameter) who underwent BES were identified retrospectively from the ERCP database. Baseline (pre-ERCP) total serum cholesterol levels were obtained in all patients. In those patients who returned for a subsequent procedure (for temporary pancreatic stent removal or recurrent symptoms), the effect of BES on total serum cholesterol was noted. Results: 620 Type III SOD patients who underwent BES were identified; follow-up cholesterol levels were available in 132 patients (see Table). Summary: (1) Performance of ES in patients without evidence of biliary obstruction was associated with a decrease in serum total cholesterol concentration. This was statistically significant in patients with baseline hypercholesterolemia (≥200 mg/dL). (2) Possible confounding effects of lipid-lowering medications, exercise and dietary changes were not accounted for in this study. Conclusion: Biliary sphincterotomy may potentially be an alternative or adjuvant therapy to medications in patients with hypercholesterolemia. A prospective controlled study is required.
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Purpose: We prospectively performed this study to reveal the clinical implication of papillitis in patients with various biliary or pancreatic disorders. Methods: Total 87 consecutive patients (M:F = 44:43, mean age = 58 years) and 12 controls (M:F = 6:6, mean age = 51 years) were enrolled in this study. The classification of the endoscopic papillitis and the scoring of its severity, which were adopted from those of duodenitis in the Sydney system, were performed by 2 blinded endoscopists. Biopsies for histologic papillitis were taken at the papilla. Various factors were analyzed to find out the factors associated with the severity of endoscopic papillitis. We also analyzed the correlation between endoscopic and histologic papillitis. Results: Mild endoscopic papillitis was noted in 47 (54%) of 87 patients with various biliary or pancreatic disorders and was also found in 6 (50%) of 12 normal healthy volunteers. Moderate and severe endoscopic papillitis were noted in 33 (38%) of 87 patients in biliary or pancreatic disorders, whereas they were not observed at all in normal healthy volunteers. In univariate analysis, the presence of a clinically acute inflammatory condition (i.e., the presence of one of the following disorders: acute cholangitis, acute pancreatitis, or acute exacerbation of chronic pancreatitis) and serum transaminase level were significantly associated with moderate and severe endoscopic papillitis (p < 0.05). On the other hand, the anatomic location of underlying diseases, benign vs. malignant disease, alkaline phosphatase, bilirubin, pancreatic enzymes, presence of periampullary diverticulum and H pylori infection were not associated with moderate and severe endoscopic papillitis (p > 0.05). In multivariate analysis, however, only a clinically acute inflammatory condition was significantly associated with moderate and severe endoscopic papillitis (p < 0.001). The severity of endoscopic papillitis showed poor correlation with that of monocyte infiltration but good correlation with that of neutrophil infiltration. Conclusions: Moderate and severe endoscopic papillitis were significantly more common in biliary or pancreatic disorders with a clinically acute inflammatory condition than in those without it, whereas they were not observed at all in normal healthy volunteers. Moderate and severe endoscopic papillitis are, therefore, considered as a characteristic finding to suggest that the patients with biliary or pancreatic disorders are accompanied with a clinically acute inflammatory condition.
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*T1865 OUTCOME OF ENDOSCOPIC TREATMENT OF BILIARY COMPLICATIONS IN LIVER TRANSPLANT PATIENTS Prashanthi Thota, Madhusudhan Sanaka, John Dumot, Gregory Zuccaro, John Vargo, Cleveland, OH Endoscopic treatment is gaining acceptance in the management of biliary complications in liver transplant patients. However, the long term efficacy after a successful initial ERCP is uncertain. Aim: To determine the initial success and long term results of ERCP in diagnosing and treating biliary complications in liver transplant patients. Methods: 280 patients underwent 298 OLT in our institution over a 5-yr period (19952000). A total of 42 pts were referred for ERCP. Follow–up data until Nov 15, 2001 is included. We reviewed the indications, diagnostic findings and the initial and long term success rates of ERCP. The initial ERCP is defined as successful if there was adequate drainage established or there was no immediate need for percutaneous drainage or surgery. Long-term success is defined as resolution of the leak or stricture without percutaneous drainage or surgery for up to one year after the last ERCP or until the end of follow-up period. Results: Biliary leaks and strictures were the most common findings. ERCP had a diagnostic accuracy of 97.6%. 10 patients had normal cholangiograms. Initial ERCP was successful in the treatment of 75% of biliary complications. Among the 8 pts in whom the initial ERCP failed to treat, 7 pts went for percutaneous drainage and 1 went directly for surgery. On a mean follow-up period of 22.5 months (range 0.5 to 77 months), 50% of the pts that were successfully treated initially by ERCP remained free of biliary complications. 25% of pts are currently undergoing treatment. Among the subset of pts in whom the initial ERCP failed, 62.5% underwent surgical treatment. There was a trend towards decreased need for surgery in pts in whom initial ERCP was successful (25% vs. 62.5%; p value = 0.088). Conclusions: (1) Endoscopic treatment is effective in the diagnosis and management of biliary complications. (2) A successful initial ERCP is associated with a low need for surgery in the long term basis.
Biliary fistulas were treated with 4 week drainage with either stent or a naso-biliary tube. Stones and casts were extracted. Results: A mean of 1.7 (1-9) ERCPs had to be performed in these 85 patients, median follow-up period was 16 months after ERCP, 76% of the patients were still alive at the end of the study. Biliary pathologies were stenoses of the anastomosis in 50%, intrahepatic strictures in 21%, bile duct leaks in 17%, casts in 6%, bile duct stones in 3% and others in 3%. Significant reduction of cholestasis (decrease of bilirubin >5 mg/dL) was seen in 80% of our patients after ERCP, a reduction to normal bilirubin levels was seen in 30%. 11% of these patients had to be retransplanted, in 22% of these patients surgical biliodigestive anastomosis had to be performed. Conclusion: In more than 30% biliary complications could be treated with ERCP alone, more than 2⁄3 of the patients improved partially or for a certain amount of time due to endoscopic intervention alone and did not need surgical intervention or retransplantation. Prospective trials are needed to prove its value in comparison with primary surgical interventions.
*T1867 WHAT IS THE YIELD OF ERCP FOR INVESTIGATING FOCAL OR DIFFUSE INTRAHEPATIC DUCTAL DILATION (IHDD) IN THE SETTING OF NORMAL LFTS? Jorge V. Obando, Helen L. Stiffler, John Baillie, Paul Jowell, Malcolm S. Branch, Burlington, MA; Durham, NC Background: Given the omnipresent concern that serious pathology might be present, ERCP is usually recommended when the intrahepatic ducts appear dilated on CT scanning, even when the LFTs are normal. We reviewed our experience of 14 patients seen at a tertiary care center over the last 8 years with IHDD ± mild extrahepatic ductal dilation (EHDD) to determine how often pathology was identified. Patients and Methods: From endoscopic databases, we identified 14 patients referred for ERCP between 11/93 and 11/01 who had IHDD ± EHDD. IHDD was any degree of dilatation of the intrahepatic ducts. EHDD was defined as CBD diameter >7 mm and <12 mm, to avoid overlap with possible SOD. Patients with suspected choledochal cysts, known biliary pathology or history of biliary sphincterotomy were also excluded. Results: 8 patients had IHDD alone, 6 had IHDD and mild EHDD. None of the 14 patients had intra- or extrahepatic biliary stones or strictures to explain their ductal dilatation. One patient had a solitary small gallstone identified. 1/6 patients with IHDD and mild EHDD was felt to have papillary stenosis or SOD based on history and cholangiography, and underwent sphincterotomy without manometry. Conclusion: The yield of ERCP for serious biliary pathology in patients with normal LFTs and IHDD was zero (0/8). 1/6 patients with IHDD and mild EHDD underwent empiric sphincterotomy for suspected papillary stenosis or SOD. No stone, stricture or tumor was found in any of these 14 patients with normal LFTs. Modern high-resolution CT scanning may show normal caliber IH bile ducts which are erroneously interpreted as dilated. Another explanation is that mild IHDD may have little significance. ERCP appears to be a low-yield procedure in such cases.
*T1866 LONG-TERM RESULTS OF ENDOSCOPIC THERAPY OF BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION Arnulf Ferlitsch, Astrid Gupper, Andreas Puespoek, Markus PeckRadosavljevic, Felix Langer, Alfred Gangl, Ferdinand Mühlbacher, Rainer Schoefl, Vienna, Austria Introduction: Biliary complications after liver transplantation (OLT) occur with a frequency of 10% to 50% and are a major reason for follow-up surgical interventions. Aim of the study was the evaluation of endoscopic treatment in these patients. Methods: From January 1985 to November 2001 OLT was performed in 916 patients. 115 of them were referred for ERCP with suspected biliary complications and 85 (63m, 22f, mean age 50 (16-68)) were treated endoscopically a mean period of 107 days (7-3964 days) after OLT. Reason for ERCP was cholestasis in 78 patients and others in 7, complicated by cholangitis in 18. Stenoses were treated initially with balloon dilatation and with dilatation and plastic stent implantation in case of recurrent stenosis. Stents were exchanged routinely after 6 months, for a total of 12 months.
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*T1868 COMPARISON OF MRCP AND ERCP IN THE DIAGNOSIS OF BILIARY AND PANCREATIC DISEASES Kiyoshi Mizuno, Kazuyuki Itoh, Makoto Itoh, Nagoya, Japan; Kasugai, Japan Background: An increasing number of studies have shown that magnetic resonance cholangiopancreatography (MRCP) has good potential for differential diagnosis of diseases. Aims: To evaluate the diagnostic accuracy of MRCP for biliary and pancreatic diseases and to clarify possible reasons for misdiagnosis with this approach. Methods: We examined clinical indications for MRCP in 203 patients (104 males, 99 females; mean age, 61 years old, range from 15 to 94) in comparison with ERCP. Clinical presentation was categorized as being of biliary (n = 149), pancreatic (n = 38), nonspecific (n = 8), or normal type (n = 8). MRCP images were obtained as coronal thick single slices (50 mm) and multiple thin slices (4 mm) using SSFSE techniques (1.5T GE Medical Systems). Results: Biliary diseases encountered were cholelithiasis (81 cases), choledocholithiasis (40), cholangiocarcinoma (14), gallbladder adenomyomatosis (8), and ampulla of Vater cancer (3). Pancreatic presentations included cancer (13), chronic pancreatitis (11), pancreatic cysts (8), and cystic neoplasms (3). For the patients with choledocholithiasis, the MRCP values for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91.9%, 96.2%, 87.2%, and 98.1%, respectively. The false negative result was due to nonrecognition of small stones (<4 mm). The false positives were caused by debris in the common bile duct or flow void effects. In the patients with cholangiocarcinomas, the values for sensitivity, specificity, PPV, and NPV were 88.6%, 99.5%, 91.7%, and 98.4%, respectively, whereas those for pancreatic cancer were 92.3%, 98.9%, 85.7%, and 99.5%. Conclusions: (1) MRCP is a valuable noninvasive diagnostic modality for pancreatobiliary disease. (2) MRCP suffers from low sensitivity for detection of CBD stones less than 4 mm in diameter. (3) MRCP can provide useful additional information on bile duct or pancreatic duct proximal to strictures.
*T1869 EFFICACY OF ENDOSCOPIC AND PERCUTANEOUS TREATMENTS OF THE BILIARY COMPLICATIONS AFTER CADAVER AND LIVING DONOR LIVER TRANSPLANTATIONS Js Park, Myung-Hwan Kim, Sung-Koo Lee, Dw Seo, Sang Soo Lee, Jimin Han, Young Il Min, Shin Hwang, Kwang Min Park, Young Joo Lee, Seung Gyu Lee, Gyu Bo Sung, Seoul, South Korea Purpose: Recently, transpapillary endoscopic treatment and percutaneous transhepatic radiologic intervention have been used in treatment of various biliary complications after liver transplantation. We performed this study to evaluate the efficacy of these medical treatments for the biliary complications in patients who received cadaver donor liver transplantation (CDLT) and living donor liver transplantation (LDLT). Methods: We conducted this retrospective study to reveal the prevalence and the type of the biliary complications after CDLT and LDLT. We also assessed the success rate of transpapillary endoscopic treatment (i.e., ERCP) and percutaneous transhepatic radiologic procedure (PTRP) for the biliary complications. Results: Among 429 adult patients who underwent the liver transplantation, total 39 cases of the biliary complications developed in enrolled 25 patients (25/429, 5.8%): biliary stricture (n = 20), biliary stones (n = 10), and bile leaks (n = 9). The prevalence rate (5.8%, 6/103) of the biliary complications after CDLT was not significantly different when compared with that (5.8%, 19/326) after LDLT (p > 0.05). The success rates of ERCP and PTRP for the biliary stricture, biliary stone, and bile leak were 100% (3/3) and 75% (9/12), 100% (3/3), and 86% (6/7), and 100% (5/5), and 75% (3/4), respectively, and were not significantly different between each complication (p > 0.05). Conclusions: Transpapillary endoscopic treatment and percutaneous transhepatic radiologic intervention are equally effective and useful therapies for the biliary complications associated with liver transplantation. Moreover, they are not competitors but reciprocal companions in therapeutic modalities because the choice of the medical treatment mainly depends on the type of biliary reconstruction and the accessibility to the complication site.
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