- Email: [email protected]
Deep Cannulation of the Common Bile Duct at Endoscopic Retrograde Cholangiopancreatography: How Challenging Is It?
*T1454 Occult Pancreatobiliary Reflux and Associated Mucosal Changes of the Gallbladder Jin Kan Sai, Masafumi Suyama, Yoshihiro Kubokawa, Hiroyuki Tadokoro, Nobuhiro Sato Purpose: To investigate pancreatobiliary reflux in individuals with a normal pancreatobiliary junction and assoicated mucosal changes of the gallbladder. Methods: A total of 108 patients, who had diffuse thickness of the gallbladder wall detected by ultrasonography and normal pancreatobiliary junction on ERCP, were examined for their pathological findings and biliary amylase levels. Results: Nine patients showed biliary amylase levels more than 10,000 IU/L, in whom 4 patients had carcinoma, 2 patients had dysplasia, and 2 patients had hyperplasia of the gallbladder. In contrast, none of the patients with biliary amylase levels less than 1,000 IU/L, had dysplasia nor hyperplasia of the gallblader. Conclustion: Pancreatobiliary reflux can occur in patients with a normal pancreatobiliary junction and induce cancerous and pre-cancerous lesion of the gallbladder.
*T1455 Post-ERCP Radiology Interpretation of Cholangio-pancreatograms Appears To Be of Limited Benefit and May Be Inaccurate Nitin Khanna, Gary May, Marty Cole, Syd Bass, Joe Romagnuolo Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is an endoscopic procedure facilitated by the use of fluoroscopy. Radiologists review, report, and bill on the fluoroscopic images generated from the ERCP. With increasing ERCPist experience in reading ERCPs without a radiologist, and with the increasing therapeutic nature of ERCP (needing interpretation at the time of the procedure), whether post-ERCP radiologist reporting is necessary is questionable. The purpose of this study was to determine the rate of discrepancy of results between the ERCP procedure report and the radiology report, and to determine whether radiology reports add clinically relevant information. Methods: To date, we have reviewed 61 consecutive charts from our ERCP database that contained ERCP reports from both the endoscopist and radiologist. The reports were reviewed for choledocholithiasis, strictures, common bile duct (CBD) dilatation and biliary leaks. An a priori list of what was felt to be potentially clinically relevant discrepancies was made. Follow-up for 6 months is being undertaken to resolve discrepancies. Ninety-five percent confidence intervals (95%CI) were calculated. Kappa statistics will be calculated. Results: The overall rate of discrepancy among ERCP reports was 25 of 61 (41.0%; 95%CI: 29-53%). When discrepancies in the subjective descriptions of CBD size were excluded from the analysis, the rate of discrepancy was 32.8% (21-45%). In 12 of 23 cases of CBD stone removal at ERCP, the radiology reports did not report a stone or filling defect (sensitivity 52% (32-73%)). The radiologist did not report 3 of 5 biliary leaks (sensitivity 40%). In 4 (6.6% (0-13%)) radiology reports, there were findings of potential clinical relevance not reported by the endoscopist: possible primary sclerosing cholangitis, a filling defect in the CBD, a CBD stricture and a filling defect in the pancreatic duct. Conclusions: There appears to be significant discrepancy between the ERCP procedure reports and post-endoscopy interpretation of fluoroscopic images by radiologists. Radiologist interpretation does not appear to add a significant amount of information and often misses clinically important findings. With completion of follow-up, discrepancies will be more reliably classified.
*T1456 Success of Endoscopic Therapy in Traumatic Bile Duct Lesions Andreas Adler, Winfried Veltzke, Hassan Abou-Rebyeh, Bertram Wiedenmann, Peter Neuhaus, Rainer Hintze Introduction: For endoscopic diagnosis and treatment of bile duct lesions due to blunt abdominal traumata especially in cases of traffic accidents (e.g. by steeringwheel or belt) there are no standardized guidelines. The delimitation from surgical procedures is unclear. Methods: From 8598 ERCPs performed in the time between November 1st, 1998 and October 31st, 2003 in our endoscopic unit in 12 patients (8m, 4f, mean age: 47 years, min. 12 to max.79 years) retrograde bile duct opacifications due to blunt abdominal traumata were performed. The indication was biliary leakage with peritonitis or cholestasis and cholangitis. Results: By ERC in 6 patients a rupture of the common bile duct or a main hepatic branch with a diameter less than 5 mm was found and in 3 patients with a diameter more than 5 mm. In further 3 patients stenoses in the central bile duct system occured. The leakages less than 5 mm were primarily splinted and stented after sphincterotomy. Stenoses resulting from scarification processes were balloondilatated. Afterwards parallelstenting with three 10 F stents over one year as a prolonged dilatation procedure was performed. In the long term follow-up period (32 months in the mean, min. 14 to max. 45 months) these patients were symptom-free. In the 3 patients with leakages wider than 5 mm surgery had to be performed at once. These patients had longer stays at the intensive care unit also due to septic complications or other severe organ failures. In the meantime they
P186
GASTROINTESTINAL ENDOSCOPY
are also symptom-free. Conclusions: In bile duct injuries due to blunt abdominal traumata endoscopic retrograde cholangiography should be performed at once to define the type of lesion. In short leakages and scarred stenoses an endoscopic therapy should be intended. In leakages with diameters more than 5 mm initial surgery is indicated.
*T1457 Dilated Ducts: Is It a Reliable Sign for Choledocholithiasis in Patients with Acute Calculous Cholecystitis (ACC)? Affan Quadri, Marc F. Catalano, Joseph E. Geenen BACKGROUND: In patients presenting with ACC common bile duct (CBD) stones need to be ruled out prior to surgery. Besides other variables, the degree of CBD dilation may be a predictive factor for presence of CBD stones and may help decide need for pre-operative ERCP. AIMS: To study the correlation between the size of the common bile duct and presence of CBD stones in patients with ACC. METHODS: All cases with ACC and cholelithiasis undergoing ERCP were studied. Size of the CBD as measured during ERCP was used to calculate the probability of CBD stones (Chi square and T tests). Balloon sweep was used as gold standard to check for the presence or absence of stones. RESULTS: Three hundred and forty-five patients with ACC undergoing ERCP for presumed CBD stones during last 5 years were studied. Of the 345 patients (male=200, female=145, mean age=49) 218 were found to have CBD stones while 127 did not have the stones. Using the Chi square test there was no correlation found between the duct diameter and presence of CBD stones (table). Using the T test analysis CBD, size was not found to be a reliable predictor of CBD stones (table). CONCLUSIONS: In patients with acute calculus cholecystitis and non dilated CBD, CBD size alone cannot be used to rule out the presence of CBD stones. In patients with dilated ducts, CBD size alone may not be a good predictor of presence of CBD stones and other variables should be taken into consideration for decisions for ERCP prior to cholecystectomy.
*T1458 Deep Cannulation of the Common Bile Duct at Endoscopic Retrograde Cholangiopancreatography: How Challenging Is It? Mohammad Wehbi, Kamil Obideen, Amaar Ghazale, Aasma Shaukat, Qiang Cai Background: A key step in endoscopic retrograde cholangiopancreatography (ERCP) is to cannulate the common bile duct (CBD) and/or pancreatic duct (PD). Despite the advances in endoscopic techniques, cannulation remains an invariably technical challenge at times. A review of the literature revealed that no studies have been carried out to document the degree of difficulty in cannulation. Aim: To provide data to document the degree of difficulty in cannulation at ERCP. Methods: A prospective study to precisely document the time spent on each step during ERCP, including position time (the time from esophageal intubation to the time of appropriate positioning in order to attempt the cannulation of the ampulla), PD cannulation time (the time from initiating cannulation to the time of obtaining a pancreatogram), initial common bile duct (ICBD) cannulation time (the time from initiating cannulation to the time of obtaining an initial cholangiogram) and deep common bile duct (DCBD) cannulation time (the time from initiating cannulation to the time of the positioning of a cannulator deep inside the CBD). Results: Fifty-eight consecutive successful ERCP procedures were enrolled in the study. PD and ICBD cannulation rates were 96% and 90% respectively. DCBD cannulation rate was 78% (45 cases). The average time to complete an ERCP procedure was 46.65 minutes. The average position time was 3.9 minutes. The average time taken to perform PD cannulation was 2.66 minutes (6% of the entire procedure time). The average times taken to perform initial and deep cannulation of the CBD were 12.2 and 30.2 minutes respectively. This constituted 26% and 65% of the entire procedure time respectively. The degree of difficulty of DCBD cannulation was defined by three categories: failure to cannulate (22% of the cases), significant difficulty to cannulate defined as longer than thirty minutes to achieve that end point (31% of the cases), and easy/relative easy to cannulate (47% of the cases). There was a statistically significant difference when comparing PD or ICBD cannulation times to that of the DCBD (p value<0.001). Conclusion: DCBD cannulation was the longest step in ERCP. DCBD cannulation is still a technical challenge in some cases even in experienced hands. Hence, Solutions resulting in a shortening of the DCBD cannulation time will significantly shorten the ERCP procedure time.
VOLUME 59, NO. 5, 2004
*T1455 Post-ERCP Radiology Interpretation of Cholangio-pancreatograms Appears To Be of Limited Benefit and May Be Inaccurate Nitin Khanna, Gary May, Marty Cole, Syd Bass, Joe Romagnuolo Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is an endoscopic procedure facilitated by the use of fluoroscopy. Radiologists review, report, and bill on the fluoroscopic images generated from the ERCP. With increasing ERCPist experience in reading ERCPs without a radiologist, and with the increasing therapeutic nature of ERCP (needing interpretation at the time of the procedure), whether post-ERCP radiologist reporting is necessary is questionable. The purpose of this study was to determine the rate of discrepancy of results between the ERCP procedure report and the radiology report, and to determine whether radiology reports add clinically relevant information. Methods: To date, we have reviewed 61 consecutive charts from our ERCP database that contained ERCP reports from both the endoscopist and radiologist. The reports were reviewed for choledocholithiasis, strictures, common bile duct (CBD) dilatation and biliary leaks. An a priori list of what was felt to be potentially clinically relevant discrepancies was made. Follow-up for 6 months is being undertaken to resolve discrepancies. Ninety-five percent confidence intervals (95%CI) were calculated. Kappa statistics will be calculated. Results: The overall rate of discrepancy among ERCP reports was 25 of 61 (41.0%; 95%CI: 29-53%). When discrepancies in the subjective descriptions of CBD size were excluded from the analysis, the rate of discrepancy was 32.8% (21-45%). In 12 of 23 cases of CBD stone removal at ERCP, the radiology reports did not report a stone or filling defect (sensitivity 52% (32-73%)). The radiologist did not report 3 of 5 biliary leaks (sensitivity 40%). In 4 (6.6% (0-13%)) radiology reports, there were findings of potential clinical relevance not reported by the endoscopist: possible primary sclerosing cholangitis, a filling defect in the CBD, a CBD stricture and a filling defect in the pancreatic duct. Conclusions: There appears to be significant discrepancy between the ERCP procedure reports and post-endoscopy interpretation of fluoroscopic images by radiologists. Radiologist interpretation does not appear to add a significant amount of information and often misses clinically important findings. With completion of follow-up, discrepancies will be more reliably classified.
*T1456 Success of Endoscopic Therapy in Traumatic Bile Duct Lesions Andreas Adler, Winfried Veltzke, Hassan Abou-Rebyeh, Bertram Wiedenmann, Peter Neuhaus, Rainer Hintze Introduction: For endoscopic diagnosis and treatment of bile duct lesions due to blunt abdominal traumata especially in cases of traffic accidents (e.g. by steeringwheel or belt) there are no standardized guidelines. The delimitation from surgical procedures is unclear. Methods: From 8598 ERCPs performed in the time between November 1st, 1998 and October 31st, 2003 in our endoscopic unit in 12 patients (8m, 4f, mean age: 47 years, min. 12 to max.79 years) retrograde bile duct opacifications due to blunt abdominal traumata were performed. The indication was biliary leakage with peritonitis or cholestasis and cholangitis. Results: By ERC in 6 patients a rupture of the common bile duct or a main hepatic branch with a diameter less than 5 mm was found and in 3 patients with a diameter more than 5 mm. In further 3 patients stenoses in the central bile duct system occured. The leakages less than 5 mm were primarily splinted and stented after sphincterotomy. Stenoses resulting from scarification processes were balloondilatated. Afterwards parallelstenting with three 10 F stents over one year as a prolonged dilatation procedure was performed. In the long term follow-up period (32 months in the mean, min. 14 to max. 45 months) these patients were symptom-free. In the 3 patients with leakages wider than 5 mm surgery had to be performed at once. These patients had longer stays at the intensive care unit also due to septic complications or other severe organ failures. In the meantime they
P186
GASTROINTESTINAL ENDOSCOPY
are also symptom-free. Conclusions: In bile duct injuries due to blunt abdominal traumata endoscopic retrograde cholangiography should be performed at once to define the type of lesion. In short leakages and scarred stenoses an endoscopic therapy should be intended. In leakages with diameters more than 5 mm initial surgery is indicated.
*T1457 Dilated Ducts: Is It a Reliable Sign for Choledocholithiasis in Patients with Acute Calculous Cholecystitis (ACC)? Affan Quadri, Marc F. Catalano, Joseph E. Geenen BACKGROUND: In patients presenting with ACC common bile duct (CBD) stones need to be ruled out prior to surgery. Besides other variables, the degree of CBD dilation may be a predictive factor for presence of CBD stones and may help decide need for pre-operative ERCP. AIMS: To study the correlation between the size of the common bile duct and presence of CBD stones in patients with ACC. METHODS: All cases with ACC and cholelithiasis undergoing ERCP were studied. Size of the CBD as measured during ERCP was used to calculate the probability of CBD stones (Chi square and T tests). Balloon sweep was used as gold standard to check for the presence or absence of stones. RESULTS: Three hundred and forty-five patients with ACC undergoing ERCP for presumed CBD stones during last 5 years were studied. Of the 345 patients (male=200, female=145, mean age=49) 218 were found to have CBD stones while 127 did not have the stones. Using the Chi square test there was no correlation found between the duct diameter and presence of CBD stones (table). Using the T test analysis CBD, size was not found to be a reliable predictor of CBD stones (table). CONCLUSIONS: In patients with acute calculus cholecystitis and non dilated CBD, CBD size alone cannot be used to rule out the presence of CBD stones. In patients with dilated ducts, CBD size alone may not be a good predictor of presence of CBD stones and other variables should be taken into consideration for decisions for ERCP prior to cholecystectomy.
*T1458 Deep Cannulation of the Common Bile Duct at Endoscopic Retrograde Cholangiopancreatography: How Challenging Is It? Mohammad Wehbi, Kamil Obideen, Amaar Ghazale, Aasma Shaukat, Qiang Cai Background: A key step in endoscopic retrograde cholangiopancreatography (ERCP) is to cannulate the common bile duct (CBD) and/or pancreatic duct (PD). Despite the advances in endoscopic techniques, cannulation remains an invariably technical challenge at times. A review of the literature revealed that no studies have been carried out to document the degree of difficulty in cannulation. Aim: To provide data to document the degree of difficulty in cannulation at ERCP. Methods: A prospective study to precisely document the time spent on each step during ERCP, including position time (the time from esophageal intubation to the time of appropriate positioning in order to attempt the cannulation of the ampulla), PD cannulation time (the time from initiating cannulation to the time of obtaining a pancreatogram), initial common bile duct (ICBD) cannulation time (the time from initiating cannulation to the time of obtaining an initial cholangiogram) and deep common bile duct (DCBD) cannulation time (the time from initiating cannulation to the time of the positioning of a cannulator deep inside the CBD). Results: Fifty-eight consecutive successful ERCP procedures were enrolled in the study. PD and ICBD cannulation rates were 96% and 90% respectively. DCBD cannulation rate was 78% (45 cases). The average time to complete an ERCP procedure was 46.65 minutes. The average position time was 3.9 minutes. The average time taken to perform PD cannulation was 2.66 minutes (6% of the entire procedure time). The average times taken to perform initial and deep cannulation of the CBD were 12.2 and 30.2 minutes respectively. This constituted 26% and 65% of the entire procedure time respectively. The degree of difficulty of DCBD cannulation was defined by three categories: failure to cannulate (22% of the cases), significant difficulty to cannulate defined as longer than thirty minutes to achieve that end point (31% of the cases), and easy/relative easy to cannulate (47% of the cases). There was a statistically significant difference when comparing PD or ICBD cannulation times to that of the DCBD (p value<0.001). Conclusion: DCBD cannulation was the longest step in ERCP. DCBD cannulation is still a technical challenge in some cases even in experienced hands. Hence, Solutions resulting in a shortening of the DCBD cannulation time will significantly shorten the ERCP procedure time.
VOLUME 59, NO. 5, 2004