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Duct of Luschka injury — Does endoscopic therapy help?
ERCP-BILIARY 1"465
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Duct of Luschka Injury - Does Endoscopic Therapy Help? Kenneth Miller, John McKee, Andrew Marshall, Adam Barrison, Irving Waxman, Ram Chottani. Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA Aim: To analyze the role of endoscopic therapy for the treatment of postoperative bile leaks caused by injury to the accessory duct of Luschka. Methods: We conducted a retrospective review of all patients with postoperative bile leaks referred to a tertiary care center. 12 patients had ERCP documenting injury to the duct of Luschka and were treated by transpapillary stent placement +/- endoscopic sphincterotomy (ES); their records were reviewed. R e s ~ : Of 50 patients with postoperative bile leaks,12 had injury to the duct of Lnschka. All patients were symptomatic and with persistent bile leaks. All leaks resulted from complications of chnlecystectomy (laparoscopic 11/12) . 3/12 had pereotsneous (Pete) biloma drainage. All patients were treated with 10F stant placement +/- ES. 3/12 had retained CBD stones that were extracted. All patients had dramatic symptomatic improvement and follow-u ERCP confirmed resolution of all bile leaks. Age & Prior CBD Stent ES Stent Complication Success Sex Therapy S~nes Total Duration 22 F None No 1 No 3 weeks None Yes 74 F None No I Yes 12 weeks None Yes 40 F None Yes 2 Yes 10 weeks None Yes 56 M Percdrain No 2 Yes 3 weeks Pancrestitis Yes 23 F Surgery No 1 Yes 4 weeks None Yes 64 M Pert drain No I Yes 7 weeks None Yes 55 F None Yes 1 Yes 12 weeks None Yes 47 F None No I Yes 4 weeks None Yes 69 F Percdrain Yes 1 No 3 weeks None Yes 30 F None No I No 3 weeks None Yes 76 F None No 2 Yes 3 weeks None Yes 22 F None No I Yes 4 weeks None Yes S,nnmarv: All duct of Luschka leaks resolved after endoscopic therapy with minimal complications. Patients with or without ES had similar success. Injury to the accessory duct of Luschka is an important complication of cholecystectemy. Biliary decompression with transpapillary stem placement is a safe and highly effective therapy for patients with persistent bile leaks.
BILIARY MANOMETRY, SCINTIGRAPHY OR EMPIRIC SPHINCTEROTOMY FOR SUSPECTED SPHINCTER OF ODDI DYSFUNCTION: A DECISION ANALYSIS P. Okolo 111. HP Lchmann, AN Kalloo, DM Cromwell, PJ Pasricha. The Johns Hopkins University School of Medicine, Baltimore, Maryland Background. Patients with posteholecystectomy right upper quadrant/epigastric pain without objective evidence of paocreatobi!iary disease (so-called Type III patients) pose a major diagnostic and therapeutic dilemma. Although these patients are usually suspected as having sphincter of Oddi dysfunction (SOD), the clinical approach to this condition is fraught with many uncertainties. Biliary manometry, considered the "goldstandard" for the diagnosis, is a difficult and relatively high-risk procedure. The accuracy of alternative techniques such as bepatobiliary scintigraphy is debated. Finally, empiric sphincterotomy (EroS) may lead to too many unnecessary procedures with a high rate of complications. Methods. We performed decision analysis by pooling published estimates and by assigning utilities of outcomes. The following assumptions were used for our base case: prevalence of SOD = 0.3, scintigraphy sansitivity/spocificity = 0.75/0.95, manometry sansitivity/specificity= 1.0/1.0, response rate to EroS (if SOD was present) = 0.6, EroS complication rate = 0.10, EmS + manometry complication rate = 0.15. Utility values were assigned as follows: cure ffi 1.0, procedure without cure = 0.75, continued symptoms without procedure = 0.5 and complications ffi 0. Results. The overall values for our base case were as follows: scintigraphy ffi 0.73; EroS = 0.69 and manometry = 0.60. However, for SOD prevalence rates between 27 to 38%, EroS is the optimal decision unless associated with a complication rate > 10%, in which case scintigraphy is better. Conclusions, Our analysis suggests that the approach to these patients can be tailored to the prevalence of SOD in the clinical practice, and the local complication rates of sphiocterotomy. If a local center has sphincterotomy complication rates greater than I0%, initial sointigraphy is optimal at any prevalence of disease. Empiric sphincterotomy may be the preferred approach given a lower complication rate and a SOD prevalence of 27 to 38%. However, the decision may be further driven towards empiric sphiacterotomy if specificitias of scintigraphy are lower or if lower utility values are assigned to untreated disease. Biliary manometry appears to be the least valuable procedure in this group of patients in most clinical circumstances.
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468
INJECTION OF TRIAMCINOLONE IMPROVES OUTCOME OF BALLOON DILATION OF DEFIANT HILAR BILE DUCT STRICTURES. R Mollov. A Bohorfoush, M Mewisson, M Craln, J France, A Taylor, E Stewart. Medical College o f Wisconsin, Milwaukee, WI. Triamcinolone (TCN) injection was investigated for its potential benefit in the management of severe Idler bile duct strictures that were refractory ("defiant") to standard ~ t a u e o u s or endoscopic management with balloon dilation (B-DIL). METHODS: 8 patients with severe, defiant strictures, (4 post-liver transplant (LTX), 4 postlap. chole (LAP)) were treated with submucosai injections via a sclerotherepy needle with 10% TCN in 0.5cc increments within the stricture segment, for a total of 50 to 100mR per stricture. A total of 21 injections were performed, ranging from one to five per patient. All strictures were located in either the right hepatic duct, the left hepatic duct, the common hepatic duct, or combinations of two or three ducts. LTX patients were treated via pereutaueous catheter (PTC) or ERCP or combination procedure, whereas LAP patients were treated by ERCP only. B-DIL was then performed to 6, 8, or 10ram diameter for at least one minute at 12-14 atm pressure. Repeat cholangiography was conducted immediately afterward and at 3 week, 3 month, or 6 month intervals and stricture diameter measured. Episodes of cholangitis, biliary obstruction, serum chemistries, and jaundice were followed. RESULTS: In the LTX group, all patients improved so that the previously placed PTC could be removed. 2 patients listed for retransplant were taken off the list. In the LAP group, TCN made the stricture more pliable and allowed the use of larger balloons, thus achieving a larger stricture diameter. There were no clinical failures in either group and there was only one complication of an asymptometic trace bile duct leak in one patient. CONCLUSION: TCN injection is safe and improves the clinical outcome of B-DIL of defiant Idlar bile duct strictures. Successful endoscopic or percutaneons management can prevent the need for reconstructive biliary surgery in LAP patients or the need for retransplantation in LTX patients.
Can A Small Incision (Less than 5ram) Limited to the Papillary Orifice/Apex of the Ampulla Minimize Bleeding from the Needle Knife Papillotomy? Parasher. VK MD.Wtight A, Denadonoe AM. Bcebe Medical Canter, Lewes Delaware. The incidence of hemorrhage from Needle Knife Papinotomy varies from 5 to 12%. Vascular anatomy of the ampulla suggests that it is more vascular in the center and at the base when compared to the papillary orifice/apex. The ampulla of eater is supplied centrally by branches of 3 o'clock and 9 o'clock arteries, side branches of the retredondanal artery, superior and inferior branches of the anterior and posterior pancrentianduedanal arteries whose terminal branches anastamose to supply muscular pmpria. (GUT 1996:39;36-38). Therefore, a long incision or incisions involving the center and/or the base of the ampulla, may be associated with increased bleeding. Furthermore, insufficient coagulation in this vascular region because of a small area of tissue ContaCt by the needle knife may yet be another Contributing factor. Conceivably then, a small incision (less than 5ram) limited to the less vascular papillary orifice/apex of the ampulla only, should be associated with less or no bleeding. The present study was undertaken to test this hypothesis. Materials & Methods I I0 therapeutic ERCP's were performed between January 1995 and November 1996, needle knife papillotomy was performed in 14 pts. There were 6 males, 8 females, aged 44 to 80 years (mean age 60.5 yrs). A small incision (less than 5mm) was made in 11 o'clock direction, limited to the papillary orifice by Combination of various movemants which were previously described by us (Am J Gastroanterol 1996;91:1938). If canoulation was unsuccessful, a deeper incision was made at the same spot instead of extanding the incision. Sphincterotomy if indicuted was completed in the standard fashion. Results Cannulation was achieved in all patiants while one patient required a second attempt. No hamorrhage occurred while one patient had mild panereatitis. Conclusion 1. A small incision limited to the papillary orifice/apex of the ampulla is associated with no bleeding. 2. This occurs perhaps because of avoiding the center and the base of the ampulla which is more vascular than the papillary orifice or the apex.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY A B 1 4 1
t467
Duct of Luschka Injury - Does Endoscopic Therapy Help? Kenneth Miller, John McKee, Andrew Marshall, Adam Barrison, Irving Waxman, Ram Chottani. Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA Aim: To analyze the role of endoscopic therapy for the treatment of postoperative bile leaks caused by injury to the accessory duct of Luschka. Methods: We conducted a retrospective review of all patients with postoperative bile leaks referred to a tertiary care center. 12 patients had ERCP documenting injury to the duct of Luschka and were treated by transpapillary stent placement +/- endoscopic sphincterotomy (ES); their records were reviewed. R e s ~ : Of 50 patients with postoperative bile leaks,12 had injury to the duct of Lnschka. All patients were symptomatic and with persistent bile leaks. All leaks resulted from complications of chnlecystectomy (laparoscopic 11/12) . 3/12 had pereotsneous (Pete) biloma drainage. All patients were treated with 10F stant placement +/- ES. 3/12 had retained CBD stones that were extracted. All patients had dramatic symptomatic improvement and follow-u ERCP confirmed resolution of all bile leaks. Age & Prior CBD Stent ES Stent Complication Success Sex Therapy S~nes Total Duration 22 F None No 1 No 3 weeks None Yes 74 F None No I Yes 12 weeks None Yes 40 F None Yes 2 Yes 10 weeks None Yes 56 M Percdrain No 2 Yes 3 weeks Pancrestitis Yes 23 F Surgery No 1 Yes 4 weeks None Yes 64 M Pert drain No I Yes 7 weeks None Yes 55 F None Yes 1 Yes 12 weeks None Yes 47 F None No I Yes 4 weeks None Yes 69 F Percdrain Yes 1 No 3 weeks None Yes 30 F None No I No 3 weeks None Yes 76 F None No 2 Yes 3 weeks None Yes 22 F None No I Yes 4 weeks None Yes S,nnmarv: All duct of Luschka leaks resolved after endoscopic therapy with minimal complications. Patients with or without ES had similar success. Injury to the accessory duct of Luschka is an important complication of cholecystectemy. Biliary decompression with transpapillary stem placement is a safe and highly effective therapy for patients with persistent bile leaks.
BILIARY MANOMETRY, SCINTIGRAPHY OR EMPIRIC SPHINCTEROTOMY FOR SUSPECTED SPHINCTER OF ODDI DYSFUNCTION: A DECISION ANALYSIS P. Okolo 111. HP Lchmann, AN Kalloo, DM Cromwell, PJ Pasricha. The Johns Hopkins University School of Medicine, Baltimore, Maryland Background. Patients with posteholecystectomy right upper quadrant/epigastric pain without objective evidence of paocreatobi!iary disease (so-called Type III patients) pose a major diagnostic and therapeutic dilemma. Although these patients are usually suspected as having sphincter of Oddi dysfunction (SOD), the clinical approach to this condition is fraught with many uncertainties. Biliary manometry, considered the "goldstandard" for the diagnosis, is a difficult and relatively high-risk procedure. The accuracy of alternative techniques such as bepatobiliary scintigraphy is debated. Finally, empiric sphincterotomy (EroS) may lead to too many unnecessary procedures with a high rate of complications. Methods. We performed decision analysis by pooling published estimates and by assigning utilities of outcomes. The following assumptions were used for our base case: prevalence of SOD = 0.3, scintigraphy sansitivity/spocificity = 0.75/0.95, manometry sansitivity/specificity= 1.0/1.0, response rate to EroS (if SOD was present) = 0.6, EroS complication rate = 0.10, EmS + manometry complication rate = 0.15. Utility values were assigned as follows: cure ffi 1.0, procedure without cure = 0.75, continued symptoms without procedure = 0.5 and complications ffi 0. Results. The overall values for our base case were as follows: scintigraphy ffi 0.73; EroS = 0.69 and manometry = 0.60. However, for SOD prevalence rates between 27 to 38%, EroS is the optimal decision unless associated with a complication rate > 10%, in which case scintigraphy is better. Conclusions, Our analysis suggests that the approach to these patients can be tailored to the prevalence of SOD in the clinical practice, and the local complication rates of sphiocterotomy. If a local center has sphincterotomy complication rates greater than I0%, initial sointigraphy is optimal at any prevalence of disease. Empiric sphincterotomy may be the preferred approach given a lower complication rate and a SOD prevalence of 27 to 38%. However, the decision may be further driven towards empiric sphiacterotomy if specificitias of scintigraphy are lower or if lower utility values are assigned to untreated disease. Biliary manometry appears to be the least valuable procedure in this group of patients in most clinical circumstances.
"~466
468
INJECTION OF TRIAMCINOLONE IMPROVES OUTCOME OF BALLOON DILATION OF DEFIANT HILAR BILE DUCT STRICTURES. R Mollov. A Bohorfoush, M Mewisson, M Craln, J France, A Taylor, E Stewart. Medical College o f Wisconsin, Milwaukee, WI. Triamcinolone (TCN) injection was investigated for its potential benefit in the management of severe Idler bile duct strictures that were refractory ("defiant") to standard ~ t a u e o u s or endoscopic management with balloon dilation (B-DIL). METHODS: 8 patients with severe, defiant strictures, (4 post-liver transplant (LTX), 4 postlap. chole (LAP)) were treated with submucosai injections via a sclerotherepy needle with 10% TCN in 0.5cc increments within the stricture segment, for a total of 50 to 100mR per stricture. A total of 21 injections were performed, ranging from one to five per patient. All strictures were located in either the right hepatic duct, the left hepatic duct, the common hepatic duct, or combinations of two or three ducts. LTX patients were treated via pereutaueous catheter (PTC) or ERCP or combination procedure, whereas LAP patients were treated by ERCP only. B-DIL was then performed to 6, 8, or 10ram diameter for at least one minute at 12-14 atm pressure. Repeat cholangiography was conducted immediately afterward and at 3 week, 3 month, or 6 month intervals and stricture diameter measured. Episodes of cholangitis, biliary obstruction, serum chemistries, and jaundice were followed. RESULTS: In the LTX group, all patients improved so that the previously placed PTC could be removed. 2 patients listed for retransplant were taken off the list. In the LAP group, TCN made the stricture more pliable and allowed the use of larger balloons, thus achieving a larger stricture diameter. There were no clinical failures in either group and there was only one complication of an asymptometic trace bile duct leak in one patient. CONCLUSION: TCN injection is safe and improves the clinical outcome of B-DIL of defiant Idlar bile duct strictures. Successful endoscopic or percutaneons management can prevent the need for reconstructive biliary surgery in LAP patients or the need for retransplantation in LTX patients.
Can A Small Incision (Less than 5ram) Limited to the Papillary Orifice/Apex of the Ampulla Minimize Bleeding from the Needle Knife Papillotomy? Parasher. VK MD.Wtight A, Denadonoe AM. Bcebe Medical Canter, Lewes Delaware. The incidence of hemorrhage from Needle Knife Papinotomy varies from 5 to 12%. Vascular anatomy of the ampulla suggests that it is more vascular in the center and at the base when compared to the papillary orifice/apex. The ampulla of eater is supplied centrally by branches of 3 o'clock and 9 o'clock arteries, side branches of the retredondanal artery, superior and inferior branches of the anterior and posterior pancrentianduedanal arteries whose terminal branches anastamose to supply muscular pmpria. (GUT 1996:39;36-38). Therefore, a long incision or incisions involving the center and/or the base of the ampulla, may be associated with increased bleeding. Furthermore, insufficient coagulation in this vascular region because of a small area of tissue ContaCt by the needle knife may yet be another Contributing factor. Conceivably then, a small incision (less than 5ram) limited to the less vascular papillary orifice/apex of the ampulla only, should be associated with less or no bleeding. The present study was undertaken to test this hypothesis. Materials & Methods I I0 therapeutic ERCP's were performed between January 1995 and November 1996, needle knife papillotomy was performed in 14 pts. There were 6 males, 8 females, aged 44 to 80 years (mean age 60.5 yrs). A small incision (less than 5mm) was made in 11 o'clock direction, limited to the papillary orifice by Combination of various movemants which were previously described by us (Am J Gastroanterol 1996;91:1938). If canoulation was unsuccessful, a deeper incision was made at the same spot instead of extanding the incision. Sphincterotomy if indicuted was completed in the standard fashion. Results Cannulation was achieved in all patiants while one patient required a second attempt. No hamorrhage occurred while one patient had mild panereatitis. Conclusion 1. A small incision limited to the papillary orifice/apex of the ampulla is associated with no bleeding. 2. This occurs perhaps because of avoiding the center and the base of the ampulla which is more vascular than the papillary orifice or the apex.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY A B 1 4 1