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Common Bile Duct Stones Associated with Pancreatobiliary Reflux and Disproportionate Bile Duct Dilatation
Abstracts
S1383 Removable Fully Covered Biliary Metal Stents in Benign Biliary Disease Donna M. Varela, Sofiya Reicher, David S. Chung, Binh V. Pham, Viktor E. Eysselein Background and Aims: Traditionally, benign biliary diseases, such as bile leaks and biliary strictures, are managed with plastic stents. However, plastic stents are often inadequate for large leaks and require frequent replacements due to limited longterm patency. Recently, fully covered metal stents have been increasingly used in benign biliary diseases. The aim of our study was to evaluate the safety and efficacy of removable fully covered biliary metal stents for benign indications. Methods: Fully covered biliary metal stents (Viabil, ConMed) were placed in 8 patients (sizes: 10 mm diameter, 6-10 cm length). Indications were bile leaks (nZ3) and biliary strictures (nZ5). Prior to placement, patients with bile leaks failed standard therapy (biliary sphincterotomy and plastic stents) and were poor surgical candidates. Biliary strictures were anastomotic (nZ1) or due to benign stone disease (nZ4). These strictures were refractory to prolong multiple plastic stenting. All strictures were located in the distal bile duct; leaks were from cystic duct take off. Removal of the fully covered metal stents was done with a snare device or grasping forceps. Clinical success was resolution of bile leak or stricture with normalization of laboratory values. Results: All stent placements were technically successful. The duration of stenting was 12 to 18 weeks. To date, 7 patients had stents removed with resolution of bile leak (nZ2) and stricture (nZ5). One patient with bile leak is awaiting stent removal. There were no procedure-related complications. In 1 patient, cholangioscopic evaluation of bile duct at the time of stent removal via choledochoscopy showed some mucosal irregularity, which completely resolved on repeat examination. Conclusion: Fully covered biliary metal stents offer a new approach to the management of benign biliary diseases, such as bile leaks and strictures, and are easy to use with an acceptable complication rate. Long term effects of extended fully covered metal stenting on bile duct mucosa should be further evaluated.
Indication Patient For Stent
Follow Up Time Since Stent Symptoms Stent Post Procedure Duration Removal
1
12 Weeks 10 Months
2
Anastomotic biliary stricture Persistent bile leak
3
Persistent bile leak
13 Weeks 5 Months
4
Benign biliary stricture
13 Weeks 2 Months
5
Benign biliary stricture
12 Weeks 2 Months
6
Benign biliary stricture
16 Weeks 1 Months
7
Benign biliary stricture
18 Weeks 1 Months
8
Persistent bile leak
16 Weeks Stent in place
14 Weeks 7 Months
No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice
S1384 Common Bile Duct Stones Associated with Pancreatobiliary Reflux and Disproportionate Bile Duct Dilatation Se-Joon Lee, Hyeyeon Park, Yonghan Paik, Dongki Lee, Kwan Sik Lee Introduction: The diameter of common bile duct (CBD) in CBD stone patients is usually increased more than 10mm, but peripheral bile duct dilatation is not commonly observed. In contrast, CBD and peripheral bile duct diameters show proportionate dilatation pattern in malignant CBD obstruction patients. This difference is frequently observed in radiologic findings, but the exact mechanism is not yet clear. Meanwhile, the theory that pancreatobiliary reflux could damage the bile duct and cause CBD dilatation is well accepted in choledochal cyst patients. We suggest that not only elevated hydrostatic pressure in CBD but also chemical irritation produced by pancreatobiliary reflux are responsible for this disproportionate bile duct dilatation. Aim: The aim of this study was to prospectively compare the dilatation pattern of bile duct and the degree of pancreatobiliary reflux in CBD stones patients (Group A) versus malignant CBD obstruction patients (Group B). Method: From November 2007 to August 2008, endoscopic retrograde cholangiopancreatography (ERCP) was performed in 33 patients of calculous cholangitis and 12 patients of malignant CBD obstruction. Before contrast dye injection, bile juice was aspirated at CHD level then sent for bile amylase and lipase measure. CBD and peripheral bile duct diameter were calculated after contrast injection. Patients with pancreatobiliary maljunction and gallstone pancreatitis were excluded. Result: In group A (15 males, 18 females, mean age 52.09 years, range 29-80), thirty patients (90.9%) showed disproportionate dilatation (i.e. peripheral duct not dilate) but in group B (4 males, 8 females, mean age 63.67 years, range 45-82), only four patients (33%) showed
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disproportionate dilatation pattern. Mean value of bile amylse and lipase level in group A were 1387 IU/L and 6737 IU/L respectively, which were significantly higher level than in group B 32 IU/L and 138 IU/L (p!0.05, both). Mean value of serum amylase and lipase showed no difference between both groups. Conclusion: This study suggests that patients with CBD stones exhibit pancreatobiliary reflux, which can cause disproportionate bile duct dilatation.
S1385 The Early Use of the Double-Wire Technique to Facilitate Difficult Biliary Cannulation and Its Impact On Post-ERCP Pancreatitis Sandeep Patel, Victor J. Torres, Glenn W. Gross Background: Common bile duct (CBD) cannulation can be difficult in up to 15% of ERCPs performed by experienced endoscopists. This situation leads to increased incidence of both unsuccessful procedures and post-ERCP pancreatitis. We report our outcomes using the double-wire technique early in accessing difficult biliary systems and the complication rates associated with this technique. Methods: 882 patients underwent ERCP at our institution from October 2006 to September 2008. Charts were reviewed retrospectively. During ERCP, the double-wire technique was instituted upon the third inadvertent passage of the guidewire into the pancreatic duct (PD). Upon leaving the guidewire in the PD, one of three scenarios ensued: (i) successful cannulation of the CBD with respective therapies; (ii) successful cannulation of the CBD with respective therapies and the placement of a modified PD stent; (iii) unsuccessful initial CBD cannulation with subsequent placement of a PD stent followed by a pre-cut papillotomy. 69 patients requiring this technique were identified and assessed for successful cannulation and complication rates. Success was characterized as selective CBD cannulation regardless of the number of ERCP attempts. The incidence of post-ERCP pancreatitis was then compared in all three groups. Results: The double-wire technique was utilized in 69 pts (35M, 34 F; mean age 51.8 years): 36 pts in (group i); 15 pts in (group ii); and 18 pts in (group iii). These 69 pts underwent a total of 78 ERCPs (mZ1.1). Indications included: biliary stricture in 28 pts (40.6%); choledocholithiasis in 24 pts (34.8%); bile leak in 12 pts (17.4%); and suspected sphincter of Oddi dysfunction in 5 pts (7.2%). CBD cannulation was achieved in 68/69 pts (98.5%) with 61 pts (88.4%) requiring only one ERCP session. Post-ERCP pancreatitis occurred in 5 pts (7.2%). The pancreatitis rates within the groups were as follows: 3/36 (8.3%) in group i; 2/15 (13.3%) in group ii; and 0/18 pts (0%) in group 3. Pancreatitis was mild in all cases with no procedure-related deaths. Conclusion: Early use of the double-wire technique is effective in achieving difficult biliary cannulation and does not appear to increase the risk of post-ERCP pancreatitis.
S1386 The Usefulness of Multiple Double Pigtail Stents and Oral Ursodeoxycholic Acid in the Treatment of Difficult Bile Duct Stones Tae Hoon Lee, Sang-Heum Park, Ji-Young Park, Chang Kyun Lee, Il Kwun Chung, Sun-Joo Kim Background: Large common bile duct (CBD) stones accompanied with risk factors can be difficult to extract by conventional techniques. When the extraction techniques have failed, temporary stenting is a technically easy and feasible method. Aim: Our study was to investigate the efficacy of combination therapy with multiple double pigtail stents and ursodeoxycholic acid (UDCA) as a prospective clinical trial. Materials and Methods: From September 2005 to September 2008, a total of 895 patients underwent attempted removal of CBD stones at our hospital. ERCP was performed using a video duodenoscope (TJF 240; Olympus, Japan). Difficult CBD stones were defined as those which could not be removed after sphincterotomy and/or balloon plasty by basket or balloon extraction, because of multiple or large stone (O 20 mm in diameter) accompanying with/without risk factors. Two or three double pigtail stents (7 or 10 Fr) were inserted into the bile duct over a guidewire with the proximal end above the stone and the distal end in the duodenum. The stents were left in place until endoscopic removal during a second attempt. All patients received oral UDCA (600 mg/day) during follow-up. Follow-up was performed every one or two months. Results: In 21 patients (2.34%), complete clearance was not achieved by the conventional method. There were 9 men and 12 women with a mean age of 73.8 years (range 38-88). Large (size O 20 mm, nZ11) and multiple (nO3 and size O 10mm; nZ16) stones, the presence of periampullary diverticulum limiting sphincterotomy (5), narrowing or stricture of distal CBD (3), and severe cardiopulmonary diseases (8) were found as limiting factors for stone removal in this study. Two stents were inserted in 13 patients and 3 stents in 8 patients. Complete endoscopic clearance was achieved in 12 patients (57.1%) and there was a statistically significant reduction in stone size (17.65 4.20 mm vs. 13.04 3.16 mm; p Z 0.002). The mean duration (SD) of stenting and medication was 73.9 ( 35.3) days. The outcomes for the remaining 9 patients were spontaneous migration of the stent with the stone (1), surgical operation (2), exchange of occluded stents (3), and remaining well with stents (3). There was no immediate complication related to the insertion of biliary stents. Conclusion: Our results suggest that combination therapy with multiple pigtail
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB159
S1383 Removable Fully Covered Biliary Metal Stents in Benign Biliary Disease Donna M. Varela, Sofiya Reicher, David S. Chung, Binh V. Pham, Viktor E. Eysselein Background and Aims: Traditionally, benign biliary diseases, such as bile leaks and biliary strictures, are managed with plastic stents. However, plastic stents are often inadequate for large leaks and require frequent replacements due to limited longterm patency. Recently, fully covered metal stents have been increasingly used in benign biliary diseases. The aim of our study was to evaluate the safety and efficacy of removable fully covered biliary metal stents for benign indications. Methods: Fully covered biliary metal stents (Viabil, ConMed) were placed in 8 patients (sizes: 10 mm diameter, 6-10 cm length). Indications were bile leaks (nZ3) and biliary strictures (nZ5). Prior to placement, patients with bile leaks failed standard therapy (biliary sphincterotomy and plastic stents) and were poor surgical candidates. Biliary strictures were anastomotic (nZ1) or due to benign stone disease (nZ4). These strictures were refractory to prolong multiple plastic stenting. All strictures were located in the distal bile duct; leaks were from cystic duct take off. Removal of the fully covered metal stents was done with a snare device or grasping forceps. Clinical success was resolution of bile leak or stricture with normalization of laboratory values. Results: All stent placements were technically successful. The duration of stenting was 12 to 18 weeks. To date, 7 patients had stents removed with resolution of bile leak (nZ2) and stricture (nZ5). One patient with bile leak is awaiting stent removal. There were no procedure-related complications. In 1 patient, cholangioscopic evaluation of bile duct at the time of stent removal via choledochoscopy showed some mucosal irregularity, which completely resolved on repeat examination. Conclusion: Fully covered biliary metal stents offer a new approach to the management of benign biliary diseases, such as bile leaks and strictures, and are easy to use with an acceptable complication rate. Long term effects of extended fully covered metal stenting on bile duct mucosa should be further evaluated.
Indication Patient For Stent
Follow Up Time Since Stent Symptoms Stent Post Procedure Duration Removal
1
12 Weeks 10 Months
2
Anastomotic biliary stricture Persistent bile leak
3
Persistent bile leak
13 Weeks 5 Months
4
Benign biliary stricture
13 Weeks 2 Months
5
Benign biliary stricture
12 Weeks 2 Months
6
Benign biliary stricture
16 Weeks 1 Months
7
Benign biliary stricture
18 Weeks 1 Months
8
Persistent bile leak
16 Weeks Stent in place
14 Weeks 7 Months
No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice No complaints, no jaundice
S1384 Common Bile Duct Stones Associated with Pancreatobiliary Reflux and Disproportionate Bile Duct Dilatation Se-Joon Lee, Hyeyeon Park, Yonghan Paik, Dongki Lee, Kwan Sik Lee Introduction: The diameter of common bile duct (CBD) in CBD stone patients is usually increased more than 10mm, but peripheral bile duct dilatation is not commonly observed. In contrast, CBD and peripheral bile duct diameters show proportionate dilatation pattern in malignant CBD obstruction patients. This difference is frequently observed in radiologic findings, but the exact mechanism is not yet clear. Meanwhile, the theory that pancreatobiliary reflux could damage the bile duct and cause CBD dilatation is well accepted in choledochal cyst patients. We suggest that not only elevated hydrostatic pressure in CBD but also chemical irritation produced by pancreatobiliary reflux are responsible for this disproportionate bile duct dilatation. Aim: The aim of this study was to prospectively compare the dilatation pattern of bile duct and the degree of pancreatobiliary reflux in CBD stones patients (Group A) versus malignant CBD obstruction patients (Group B). Method: From November 2007 to August 2008, endoscopic retrograde cholangiopancreatography (ERCP) was performed in 33 patients of calculous cholangitis and 12 patients of malignant CBD obstruction. Before contrast dye injection, bile juice was aspirated at CHD level then sent for bile amylase and lipase measure. CBD and peripheral bile duct diameter were calculated after contrast injection. Patients with pancreatobiliary maljunction and gallstone pancreatitis were excluded. Result: In group A (15 males, 18 females, mean age 52.09 years, range 29-80), thirty patients (90.9%) showed disproportionate dilatation (i.e. peripheral duct not dilate) but in group B (4 males, 8 females, mean age 63.67 years, range 45-82), only four patients (33%) showed
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disproportionate dilatation pattern. Mean value of bile amylse and lipase level in group A were 1387 IU/L and 6737 IU/L respectively, which were significantly higher level than in group B 32 IU/L and 138 IU/L (p!0.05, both). Mean value of serum amylase and lipase showed no difference between both groups. Conclusion: This study suggests that patients with CBD stones exhibit pancreatobiliary reflux, which can cause disproportionate bile duct dilatation.
S1385 The Early Use of the Double-Wire Technique to Facilitate Difficult Biliary Cannulation and Its Impact On Post-ERCP Pancreatitis Sandeep Patel, Victor J. Torres, Glenn W. Gross Background: Common bile duct (CBD) cannulation can be difficult in up to 15% of ERCPs performed by experienced endoscopists. This situation leads to increased incidence of both unsuccessful procedures and post-ERCP pancreatitis. We report our outcomes using the double-wire technique early in accessing difficult biliary systems and the complication rates associated with this technique. Methods: 882 patients underwent ERCP at our institution from October 2006 to September 2008. Charts were reviewed retrospectively. During ERCP, the double-wire technique was instituted upon the third inadvertent passage of the guidewire into the pancreatic duct (PD). Upon leaving the guidewire in the PD, one of three scenarios ensued: (i) successful cannulation of the CBD with respective therapies; (ii) successful cannulation of the CBD with respective therapies and the placement of a modified PD stent; (iii) unsuccessful initial CBD cannulation with subsequent placement of a PD stent followed by a pre-cut papillotomy. 69 patients requiring this technique were identified and assessed for successful cannulation and complication rates. Success was characterized as selective CBD cannulation regardless of the number of ERCP attempts. The incidence of post-ERCP pancreatitis was then compared in all three groups. Results: The double-wire technique was utilized in 69 pts (35M, 34 F; mean age 51.8 years): 36 pts in (group i); 15 pts in (group ii); and 18 pts in (group iii). These 69 pts underwent a total of 78 ERCPs (mZ1.1). Indications included: biliary stricture in 28 pts (40.6%); choledocholithiasis in 24 pts (34.8%); bile leak in 12 pts (17.4%); and suspected sphincter of Oddi dysfunction in 5 pts (7.2%). CBD cannulation was achieved in 68/69 pts (98.5%) with 61 pts (88.4%) requiring only one ERCP session. Post-ERCP pancreatitis occurred in 5 pts (7.2%). The pancreatitis rates within the groups were as follows: 3/36 (8.3%) in group i; 2/15 (13.3%) in group ii; and 0/18 pts (0%) in group 3. Pancreatitis was mild in all cases with no procedure-related deaths. Conclusion: Early use of the double-wire technique is effective in achieving difficult biliary cannulation and does not appear to increase the risk of post-ERCP pancreatitis.
S1386 The Usefulness of Multiple Double Pigtail Stents and Oral Ursodeoxycholic Acid in the Treatment of Difficult Bile Duct Stones Tae Hoon Lee, Sang-Heum Park, Ji-Young Park, Chang Kyun Lee, Il Kwun Chung, Sun-Joo Kim Background: Large common bile duct (CBD) stones accompanied with risk factors can be difficult to extract by conventional techniques. When the extraction techniques have failed, temporary stenting is a technically easy and feasible method. Aim: Our study was to investigate the efficacy of combination therapy with multiple double pigtail stents and ursodeoxycholic acid (UDCA) as a prospective clinical trial. Materials and Methods: From September 2005 to September 2008, a total of 895 patients underwent attempted removal of CBD stones at our hospital. ERCP was performed using a video duodenoscope (TJF 240; Olympus, Japan). Difficult CBD stones were defined as those which could not be removed after sphincterotomy and/or balloon plasty by basket or balloon extraction, because of multiple or large stone (O 20 mm in diameter) accompanying with/without risk factors. Two or three double pigtail stents (7 or 10 Fr) were inserted into the bile duct over a guidewire with the proximal end above the stone and the distal end in the duodenum. The stents were left in place until endoscopic removal during a second attempt. All patients received oral UDCA (600 mg/day) during follow-up. Follow-up was performed every one or two months. Results: In 21 patients (2.34%), complete clearance was not achieved by the conventional method. There were 9 men and 12 women with a mean age of 73.8 years (range 38-88). Large (size O 20 mm, nZ11) and multiple (nO3 and size O 10mm; nZ16) stones, the presence of periampullary diverticulum limiting sphincterotomy (5), narrowing or stricture of distal CBD (3), and severe cardiopulmonary diseases (8) were found as limiting factors for stone removal in this study. Two stents were inserted in 13 patients and 3 stents in 8 patients. Complete endoscopic clearance was achieved in 12 patients (57.1%) and there was a statistically significant reduction in stone size (17.65 4.20 mm vs. 13.04 3.16 mm; p Z 0.002). The mean duration (SD) of stenting and medication was 73.9 ( 35.3) days. The outcomes for the remaining 9 patients were spontaneous migration of the stent with the stone (1), surgical operation (2), exchange of occluded stents (3), and remaining well with stents (3). There was no immediate complication related to the insertion of biliary stents. Conclusion: Our results suggest that combination therapy with multiple pigtail
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB159