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Complications Following Endoscopic Stent Placement for Malignant Biliary Obstruction: Preliminary Analysis
Abstracts
W1466 Endoscopic Management of Biliary Strictures After Living Donor Liver Transplantation in Adults Jimin Han, Sung Koo Lee, Jong Cheol Kim Kim, Eun Kwang Choi, Dong Wan Seo, Sang Soo Lee, Myung-Hwan Kim, Kyu-Bo Sung, Sung-Gyu Lee Background: Biliary stricture is one of the most common biliary complications after liver transplantation and requires early diagnosis and prompt adequate treatment. So far, treatment modalities for this complication had been transpapillary approach using endoscopic retrograde cholangiography (ERCP), percutaneous transhepatic approach, and surgery. Aims: We attempted to assess the role of ERCP in diagnosis and management of biliary strictures following living donor liver transplantation in adults and to evaluate the safety and efficacy of transpapillary endoscopic intervention. Methods: From March 2004 to May 2005, 63 out of 505 adult living donor liver transplantation recipients had been diagnosed with biliary stricture by ERCP at Asan Medical Center. Medical records of these recipients were retrospectively reviewed. The strictures were dilated and stented as deemed necessary by the dedicated endoscopists. If transpapillary endoscopic intervention failed or was inadequate, percutaneous intervention was done. Endoscopic success was defined as endoscopic management resulting in resolution of clinical manifestations. Results: Of the recipients with biliary stricture, 79.4% was male. The median age was 52 years. Median time interval between liver transplantation and first ERCP was 111.0 days. Biliary reconstructions consisted of duct-to-duct anastomoses in 79.4% (n Z 50) and duct-to-duct plus hepaticojejunostomy in 20.6% (n Z 13). Locations of biliary strictures were anastomotic site (55.6%), intrahepatic ducts (23.8%), and hilum (15.9%). Total 139 sessions (mean: 2.2 sessions, range: 1-11 sessions) of ERCP were done. Strictures were dilated in 34.5% and stent was placed in 43.2%. For stricture dilation, bougination was used in 39.6%, balloon dilation in 52.1% and both in 8.3%. ERCP-related complications occurred in 6 cases. Sphincterotomy site bleeding occurred in 5 and perforation after needle knife infundibulotomy in 1 case. Immediate success was achieved in 71.2%. Transpapillary endoscopic intervention was successful in 26 recipients. Of 43 recipients who underwent percutaneous intervention, 40 are undergoing periodic dilation and tube exchange. There was no statistically significant difference between endoscopic success and percutaneous intervention groups in regard to age, gender, time from liver transplantation to first endoscopic intervention, type of living donor liver transplantation, and stricture site. Conclusion: Transpapillary approach is not so successful in managing biliary strictures in living donor liver transplantation recipients with duct-to-duct anastomoses. Complete resolution is difficult to achieve despite multidisciplinary approach.
W1467 Clinicopathological Differentiation Between Primary Sclerosing Cholangitis and Sclerosing Cholangitis with Autoimmune Pancreatitis Takayoshi Nishino, Etsuko Hashimoto, Fumitake Toki, Makiko Taniai, Hiroyasu Oyama, Itaru Oi, Makio Kobayashi, Keiko Shiratori Background and Aim: Sclerosing cholangitis with autoimmune pancreatitis (SC-AIP) resembles primary sclerosing cholangitis (PSC) in terms of the cholangiographic findings, but since the only the former responds to steroid therapy, it is necessary to differentiate between these two diseases. The present study was undertaken to investigate the clinicopathological differences between SC-AIP and PSC. Methods: We retrospectively compared the clinical findings, cholangiographic findings, liver biopsy findings, and clinical course between 27 cases of PSC (M:F Z 14:13) and 25 cases of SC-AIP (M:F Z 17:8). Results: Patient age at the time of the clinical onset was significantly lower in the PSC cases (14-69 years, median 37) than in the SC-AIP (45-83 years, median 65)(p ! 0.0001). The peripheral blood eosinophil count was significantly higher in the PSC cases than the SC-AIP patients cases, but the serum IgG4 level was significantly higher in the SC-AIP cases. Cholangiography revealed a band-like stricture, beaded appearance, and pruned-tree appearance significantly more frequently in PSC, whereas segmental stricture and stricture of the distal third of the common bile duct was significantly more common in SC-AIP. Subsequent cholangiography showed no improvement in any of the PSC cases, but most SC-AIP patients responded to steroid therapy, and improvement in the strictures was observed cholangiographically. Liver biopsy revealed fibrous tissue around the bile duct in both the SC-AIP patients and the PSC patients, but the degree of fibrosis was less severe in the SC-AIP patients. IgG4-positive plasma cell infiltration of the liver was significantly more severe in SC-AIP than in PSC. PSC was significantly more frequently complicated by ulceratice colitis (p ! 0.0001), whereas SC-AIP was significantly more frequently complicated by diabetes mellitus. Conclusions: Based on the patients’ ages, blood chemistry findings, complications, cholangiographic findings, and liver biopsy findings SC-AIP and PSC are different clinical entities.
AB306 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
W1468 Complications Following Endoscopic Stent Placement for Malignant Biliary Obstruction: Preliminary Analysis David H. Goetz, Jeffrey H. Lee, Marta L. Davila, Norio Fukami, William Ross Background: Endoscopic stent placement is first line therapy for treatment for malignant obstructive jaundice. Several stent types are available yet the relative complication profiles are incompletely defined. Methods: This was a retrospective study of patients who had malignant obstructive jaundice treated with an endoscopically placed stent from July 2001 to May 2005. Endoscopic reports and the electronic medical records were reviewed for procedural details and complications as well as development of subsequent cholangitis. Statistical analysis was performed using Student’s t test. Results: A total of 191 patients had 309 stent placement procedures. There were 93 patients with pancreatic cancer, 30 with cholangiocarcinoma, 17 with metastatic colorectal cancer, 9 with gallbladder cancer and 42 with other cancers. Plastic stents (P) were placed in 152, uncovered metal stents (U) in 102 and covered metal stents (C) in 55. Twenty-five patients had needle knife sphincterotomies and 78 more had standard papillotomies. There were 101 episodes of cholangitis or worsening jaundice following stent placement (32.9%). The incidence of stent occlusion was comparable between stent types. However, occlusion occurred an average of 73.24 days after P stent, 143.05 days after U stents, and 197.67 days after C stents. The difference between P stents and each metal stent type was significant with p ! .001. The difference between metal stent types did not reach significance with p O .20. There were 25 procedurerelated complications for an overall rate of 8.09%. There were no significant differences in overall complication rates between stent types. There was no difference between stent types in the incidence of the two most common complications, pancreatitis and migration. Pancreatitis accounted for half of procedure-related complications with an overall incidence of 3.9%. There were eight episodes of stent migration. No statistical difference between patients with sphincterotomy and those without in terms of stent migration, p Z .41. There were two episodes of hemobilia and one post-sphincterotomy bleed. In addition, two patients developed cholecystitis one had a covered metal stent for 17 days and the other had a series of plastic stents for a total of 120 days. Conclusions: Metal stents have longer patency times than plastic endobiliary stents in malignant strictures. The incidence of procedure-related complications is comparable between stent types.
W1469 Leukocytosis As a Predictor of Choledocholithiasis in Hispanic and African-American Patients Undergoing ERCP Andrew K. Sanderson, Ioannis Giannikopoulos, Grace Tee, Magda Shaheen Background: Clinical symptoms and accurate non-invasive testing are integral factors in determining which patients would benefit from endoscopic retrograde cholangio-pancreatography (ERCP). Radiologic imaging techniques; such as ultrasound (US), computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), have improved the diagnosis of common bile duct (CBD) stones. However, they are not available at all hospitals (MRCP) or have limited visualization at the ampulla (CT, US). Aim: We chose to evaluate the relationship between an elevated white blood cell (WBC) count and CBD stones found at ERCP, given the low cost, wide availability, and ease of interpretation of complete blood cell counts. Methods: A retrospective review of over 300 ERCPs performed at a single urban hospital was conducted. These were all initial, in-patient exams for indications including liver function test (LFT) abnormalities, obstructive jaundice, and gallstone pancreatitis. Patients with leukocytosis and without leukocytosis were divided into groups. Patients with leukocytosis from a non-biliary cause (pneumonia, steroids) and patients found to have gastrointestinal malignancies were excluded. Demographic data, such as age, sex, race, and body mass index were recorded, as well as pertinent radiologic and laboratory data. The two groups were then compared to determine if significant correlations could be made for the presence of CBD stones found during ERCP. Results: A total of 247 patients (83% Hispanic, 14% African-American, 76% Female) were included in the study. The mean age was 43.8 G 17 years (range 17-88) and the mean WBC count 11.2 G 4.9. There was no difference between the groups with and without leukocytosis in regards to LFTs, including serum bilirubin or alkaline phosphatase, nor was there a difference in indications for ERCP. CBD stones were found in 90 of 247 patients (36.4%). Pearson Chi-Square analysis was performed and revealed a significant difference between patients with elevated WBC counts and patients with normal WBC counts, and the presence of CBD stones during ERCP (46% vs. 28%, respectively, p Z .004; Odds Ratio 2.172, 95% confidence interval 1.282-3.681). Conclusion: This study demonstrates that leukocytosis, in patients with clinical syndromes suggesting the need for ERCP, does indicate the presence of CBD stones in approximately 1.6 times more patients than those in which no leukocytosis is found.
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W1466 Endoscopic Management of Biliary Strictures After Living Donor Liver Transplantation in Adults Jimin Han, Sung Koo Lee, Jong Cheol Kim Kim, Eun Kwang Choi, Dong Wan Seo, Sang Soo Lee, Myung-Hwan Kim, Kyu-Bo Sung, Sung-Gyu Lee Background: Biliary stricture is one of the most common biliary complications after liver transplantation and requires early diagnosis and prompt adequate treatment. So far, treatment modalities for this complication had been transpapillary approach using endoscopic retrograde cholangiography (ERCP), percutaneous transhepatic approach, and surgery. Aims: We attempted to assess the role of ERCP in diagnosis and management of biliary strictures following living donor liver transplantation in adults and to evaluate the safety and efficacy of transpapillary endoscopic intervention. Methods: From March 2004 to May 2005, 63 out of 505 adult living donor liver transplantation recipients had been diagnosed with biliary stricture by ERCP at Asan Medical Center. Medical records of these recipients were retrospectively reviewed. The strictures were dilated and stented as deemed necessary by the dedicated endoscopists. If transpapillary endoscopic intervention failed or was inadequate, percutaneous intervention was done. Endoscopic success was defined as endoscopic management resulting in resolution of clinical manifestations. Results: Of the recipients with biliary stricture, 79.4% was male. The median age was 52 years. Median time interval between liver transplantation and first ERCP was 111.0 days. Biliary reconstructions consisted of duct-to-duct anastomoses in 79.4% (n Z 50) and duct-to-duct plus hepaticojejunostomy in 20.6% (n Z 13). Locations of biliary strictures were anastomotic site (55.6%), intrahepatic ducts (23.8%), and hilum (15.9%). Total 139 sessions (mean: 2.2 sessions, range: 1-11 sessions) of ERCP were done. Strictures were dilated in 34.5% and stent was placed in 43.2%. For stricture dilation, bougination was used in 39.6%, balloon dilation in 52.1% and both in 8.3%. ERCP-related complications occurred in 6 cases. Sphincterotomy site bleeding occurred in 5 and perforation after needle knife infundibulotomy in 1 case. Immediate success was achieved in 71.2%. Transpapillary endoscopic intervention was successful in 26 recipients. Of 43 recipients who underwent percutaneous intervention, 40 are undergoing periodic dilation and tube exchange. There was no statistically significant difference between endoscopic success and percutaneous intervention groups in regard to age, gender, time from liver transplantation to first endoscopic intervention, type of living donor liver transplantation, and stricture site. Conclusion: Transpapillary approach is not so successful in managing biliary strictures in living donor liver transplantation recipients with duct-to-duct anastomoses. Complete resolution is difficult to achieve despite multidisciplinary approach.
W1467 Clinicopathological Differentiation Between Primary Sclerosing Cholangitis and Sclerosing Cholangitis with Autoimmune Pancreatitis Takayoshi Nishino, Etsuko Hashimoto, Fumitake Toki, Makiko Taniai, Hiroyasu Oyama, Itaru Oi, Makio Kobayashi, Keiko Shiratori Background and Aim: Sclerosing cholangitis with autoimmune pancreatitis (SC-AIP) resembles primary sclerosing cholangitis (PSC) in terms of the cholangiographic findings, but since the only the former responds to steroid therapy, it is necessary to differentiate between these two diseases. The present study was undertaken to investigate the clinicopathological differences between SC-AIP and PSC. Methods: We retrospectively compared the clinical findings, cholangiographic findings, liver biopsy findings, and clinical course between 27 cases of PSC (M:F Z 14:13) and 25 cases of SC-AIP (M:F Z 17:8). Results: Patient age at the time of the clinical onset was significantly lower in the PSC cases (14-69 years, median 37) than in the SC-AIP (45-83 years, median 65)(p ! 0.0001). The peripheral blood eosinophil count was significantly higher in the PSC cases than the SC-AIP patients cases, but the serum IgG4 level was significantly higher in the SC-AIP cases. Cholangiography revealed a band-like stricture, beaded appearance, and pruned-tree appearance significantly more frequently in PSC, whereas segmental stricture and stricture of the distal third of the common bile duct was significantly more common in SC-AIP. Subsequent cholangiography showed no improvement in any of the PSC cases, but most SC-AIP patients responded to steroid therapy, and improvement in the strictures was observed cholangiographically. Liver biopsy revealed fibrous tissue around the bile duct in both the SC-AIP patients and the PSC patients, but the degree of fibrosis was less severe in the SC-AIP patients. IgG4-positive plasma cell infiltration of the liver was significantly more severe in SC-AIP than in PSC. PSC was significantly more frequently complicated by ulceratice colitis (p ! 0.0001), whereas SC-AIP was significantly more frequently complicated by diabetes mellitus. Conclusions: Based on the patients’ ages, blood chemistry findings, complications, cholangiographic findings, and liver biopsy findings SC-AIP and PSC are different clinical entities.
AB306 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
W1468 Complications Following Endoscopic Stent Placement for Malignant Biliary Obstruction: Preliminary Analysis David H. Goetz, Jeffrey H. Lee, Marta L. Davila, Norio Fukami, William Ross Background: Endoscopic stent placement is first line therapy for treatment for malignant obstructive jaundice. Several stent types are available yet the relative complication profiles are incompletely defined. Methods: This was a retrospective study of patients who had malignant obstructive jaundice treated with an endoscopically placed stent from July 2001 to May 2005. Endoscopic reports and the electronic medical records were reviewed for procedural details and complications as well as development of subsequent cholangitis. Statistical analysis was performed using Student’s t test. Results: A total of 191 patients had 309 stent placement procedures. There were 93 patients with pancreatic cancer, 30 with cholangiocarcinoma, 17 with metastatic colorectal cancer, 9 with gallbladder cancer and 42 with other cancers. Plastic stents (P) were placed in 152, uncovered metal stents (U) in 102 and covered metal stents (C) in 55. Twenty-five patients had needle knife sphincterotomies and 78 more had standard papillotomies. There were 101 episodes of cholangitis or worsening jaundice following stent placement (32.9%). The incidence of stent occlusion was comparable between stent types. However, occlusion occurred an average of 73.24 days after P stent, 143.05 days after U stents, and 197.67 days after C stents. The difference between P stents and each metal stent type was significant with p ! .001. The difference between metal stent types did not reach significance with p O .20. There were 25 procedurerelated complications for an overall rate of 8.09%. There were no significant differences in overall complication rates between stent types. There was no difference between stent types in the incidence of the two most common complications, pancreatitis and migration. Pancreatitis accounted for half of procedure-related complications with an overall incidence of 3.9%. There were eight episodes of stent migration. No statistical difference between patients with sphincterotomy and those without in terms of stent migration, p Z .41. There were two episodes of hemobilia and one post-sphincterotomy bleed. In addition, two patients developed cholecystitis one had a covered metal stent for 17 days and the other had a series of plastic stents for a total of 120 days. Conclusions: Metal stents have longer patency times than plastic endobiliary stents in malignant strictures. The incidence of procedure-related complications is comparable between stent types.
W1469 Leukocytosis As a Predictor of Choledocholithiasis in Hispanic and African-American Patients Undergoing ERCP Andrew K. Sanderson, Ioannis Giannikopoulos, Grace Tee, Magda Shaheen Background: Clinical symptoms and accurate non-invasive testing are integral factors in determining which patients would benefit from endoscopic retrograde cholangio-pancreatography (ERCP). Radiologic imaging techniques; such as ultrasound (US), computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), have improved the diagnosis of common bile duct (CBD) stones. However, they are not available at all hospitals (MRCP) or have limited visualization at the ampulla (CT, US). Aim: We chose to evaluate the relationship between an elevated white blood cell (WBC) count and CBD stones found at ERCP, given the low cost, wide availability, and ease of interpretation of complete blood cell counts. Methods: A retrospective review of over 300 ERCPs performed at a single urban hospital was conducted. These were all initial, in-patient exams for indications including liver function test (LFT) abnormalities, obstructive jaundice, and gallstone pancreatitis. Patients with leukocytosis and without leukocytosis were divided into groups. Patients with leukocytosis from a non-biliary cause (pneumonia, steroids) and patients found to have gastrointestinal malignancies were excluded. Demographic data, such as age, sex, race, and body mass index were recorded, as well as pertinent radiologic and laboratory data. The two groups were then compared to determine if significant correlations could be made for the presence of CBD stones found during ERCP. Results: A total of 247 patients (83% Hispanic, 14% African-American, 76% Female) were included in the study. The mean age was 43.8 G 17 years (range 17-88) and the mean WBC count 11.2 G 4.9. There was no difference between the groups with and without leukocytosis in regards to LFTs, including serum bilirubin or alkaline phosphatase, nor was there a difference in indications for ERCP. CBD stones were found in 90 of 247 patients (36.4%). Pearson Chi-Square analysis was performed and revealed a significant difference between patients with elevated WBC counts and patients with normal WBC counts, and the presence of CBD stones during ERCP (46% vs. 28%, respectively, p Z .004; Odds Ratio 2.172, 95% confidence interval 1.282-3.681). Conclusion: This study demonstrates that leukocytosis, in patients with clinical syndromes suggesting the need for ERCP, does indicate the presence of CBD stones in approximately 1.6 times more patients than those in which no leukocytosis is found.
www.giejournal.org