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Endoscopic management of dominant strictures in primary sclerosing cholangitis (PSC)
ERCP-BILIARY ?'357
359
ENDOSCOPIC TREATMENT OF BENIGN BILIARY DUCT STRICTURES (BBDS) : LONG-TERMRESULTS. J.-M. Dumonoeau, J. Deviere, M. Delhaye, M. Cremer. Department of Gastroentero(ogy,Erasme University Hospital, Universite Libre de Bruxeltec,Brucsels.
ENDOSCOPIC MANAGEMENT OF DOMINANT STRICTURES IN PRIMARY SCLEROSING CHOLANGITIS 0PSC). _E Elton and M.J. Goldberg. The University of Chicago, Chicago IL.
The endoscopic treatmentof BSD,~is safe and can provide good immediatedrainage. Aim : To assess long-term results after endoscopic treatment of BSDS not related to chronic panoreatitis. Patie#!s a0d methods : Follow-~Jpdata (biliary symptoms and bilirubinemia) were obtained in a~{of 35 consecutiveeases of BBDS (male : 20, age : 57 • 16 years) where the absence of further endoscopic treatment had been recommended because of a calibration of the 88DS judged to be sufficient. BBDS, mainly attributable to chobcystectsmy (N=22) and OLTX (N=6) were located on the ma}n bib duct (N=32), the hilum (N=I), the left bile duct (N=I) and the hepaticojejunostorny (N=I). The management had consisted of dilation, alone (N=3), or associated with metallic (Waistefit) (N=6) or plastic stents (these latter for a total of 6.8 • 5.1 months). All patiehtc wi~ abnormalfollow-up data underwent ERCP in order to confirm a recurrent BBDS.. Result.s:
|!' e
20 I
13
25
9M o n t h s
37 after
49
61
73
85
97
109
121
removal of plas~k: stents [ A ) o~ inse~on of Wa~tentr, (B).
The delay before 88DS recurred was significantly shorter in patients treated with metallic stents. In this group, recurrent stenoses required hepafbojejunostomy(N=2) or continuous plasfic stenfing (N=2). One of the 2 single cases who did not develop recurrent stenoseswas the patientwith previous local radiotherapy. Conqlusio0 ~These results chow that dilation and plastic stenting is a safe and efficient treatment of BBDS. Self expandandable stents not only offer no advantage but are followed by rapid restenosis and should be considered as contraindicated in this indication..
t358
Methods: We retrospectively reviewed the charts of the 12 patiertts with PSC and dominant strictures who were referred to our service for endoscopic int~on over a 4-year period. Serum values for total bilirubin, alkaline phosphatase, alanme aminotransferase (ALT), and 7-gltS,amyl transpeptidase (GGT) were recorded for the period preceding the initial therapeutic ERCP, at I month after the final intervention, and for the most rector period a~aitable. Results: The twelve patients underwent a toter of 18 therapeutic ERCPs (range, 1 to 4 per patient). Endoscopic interventions were successful in I t patients (92%), a guidewire could not be successfully placed beyond a tight dominant stricture in the final patient. Two patients underwent ES alone; 2 had ES plus st~tmg~ 2 had ES, Soehendra catheter dilation, and stating; I had ES plus stone extraction, 1 had onsobiliary drain placement followed by ES and stenting; 1 had ES plus catheter dilation; I had catheter dilation alone; and 1 had nasobiliary drain placement atone. No major complications of hemnrdmge, cholangitis, pancreatitis, or perforation were noted. However, one patient required a percutanenusly-placed bihary drain, as adequate drainage could not be obtained through the endoscopicaUy-placed stent Mean values for serum liver chemistries are shown in the table below. B/~'.bln Pre-therapy 4.9 I month post-therapy 1.7" fo~ow-a~t t .5" "!9<0.05 compared wi$ pr~therapy,
AIk Phns ALT GGT 482 109 416 352* 73 381 314" 72 330* tMean 22 months (range, 7 ~ 49),
Conclusion: Endoscopic'intervention for dominant strictures in PSC r e s ~ in significant improvement in obstructive liver function tests. This improvement perfis~ over an e~ended ~ilow-up period ~ere, a mean period of 22 months; range, 7 ~ 49 months).
H360
THE RISK OF BLEEDING AFrER ENDOSCOPIC BILIARY SPHINCTEROTOMY (EBS) IN PATIENTS WITH PERI-AMPULLARY DIVERTICULA (PAD): A PROSPECTIVE TRIAL. ABELFANT. GB HABER, MJ BOURKE,A ALHALEL, PP KORTAN. THE WELLESLEY HOSPITAL, TORONTO, CANADA Baekan'mmd: Whether there is an increased bleeding risk after EBS in pts with PAD is controversial. Several small series support this association. Pur uese:Determine the risk of immediate and delayed hemorrhage following EBS in patients with PAD. Methods:From 10/94-6/95,patients requiring EBS at The Wellesley Hospital were enrolled in this open trial. Data consisting of age, sex, diagnosis, NSAID use, cholangiographic findings was obtained. Bleeding was absent or insignificant (no treatment) or active (oozing or spurting) requiring endoscopic control, transfusion or surgery. Telephone follow-up occurred in all subjects at 10 days. Chi-square test of association was used for statistical analysis. Results'Diagnostic/Therapentic ERCP was performed on 1627 subjects with 494 receiving an EBS. Indications: Presumed Choledochotithiasis (274), Benign Biliary stricture (31). PAD were noted in 106 subjects (6.5%), 77 of whom had an EBS. Mean age was 69.5 ~rc.~(Range 28-95, 36M), NSAID use was noted in 6(7.8%)PAD patients and in 26(6.2%) non-PAD patients undergoing EBS. Post-EBS hemorrhage requiring epinephrine injection occurred in 15 subjects (19.5%) with PAD, while only IS subjects (4.3%) without PAD had post-EBS hemorrhage requiring epinephrine injection. There was a statistically significant association between PAD and post-EBS hemorrhage (chi-squsre=21.6, p<0.01). One subject (1.3%) with PAD required transfusion with 2 units of pRBC with a 2 day hospital stay. One subject (0.29~) without PAD had a late bleed requiring transfusion of 4 units of pRBC with a 3 day hospital stay. CBD diameter > 10ram was seen in 43/77 subjects (55.85) with PAD having an EBS. There was no difference in post-EBS hemorrhage between those with (60%) or without (54%) ductal dilation. CBD diameter > 10ram was noted in 7/18 (38.8%) subjects without PAD who had post-EBS hemorrhage. No patients required surgery and there was no procedure related mortality. Condusion:Post-EBS hemorrhage occurs significantly more often in patients with PAD. However, aggressive endoscopic hemostasis may minimize the clinical severity in patients with this anatomic variant.
380
Background: Dominant strictures in PSC patters can lead to rapid elevations in serum bitirubin levels, recurrent ch~tangitis, or pruritus. Endoscopic methods used to treat these strictures have included endoscopic sphincterotomy (ES), catheter Or hydrostatic haUonn dilation, placeme~ of endoprostheses, nasobiliary drainage, and biliary ravage. Here, we report our experience with endoscopic therapy of.dominant strictures in patients with PSC,
GASTROINTESTINAL ENDOSCOPY
MICROBZOLOGY OF BILE CULTURES IN PATIENTS WITH CHOLANGITIS OR CHOLESTASIS AND PLASTIC BILIARY ENDOPROSTHESIS. Ed Esber, Stuart Sherman, Dee Earle, James Pezzi, Klaus Gottlieb, Glen Lehman, Indiana University Medical Center. ChoZan~itis is a freqllent comDli~ation of biliary stents. Empiric antibiotic seleckion is based primarily on the results of bile cultures obtained ~rom surgical patients and limited data from the ERCP era. This stud Z was undertaken to analyze the microbiology of 5ile and the sensitivities of the orqanisms identified in stented patients D r e s e n t i n g wiEh clinical cholanqitis or cholestasis. METHODS: We reviewed all bile cultures collected durinq ERCP from 11/93 to 8/95. Specimens were collected wit~ a sterile catheter prior to the injection of contrast. DuodenoscoDes were washed for 20 minutes in 2% ~lutaraldehyde just prior to use. RESULTS: Seventy~hree cultures from 57 patients ranging in age from 12-85 (mean 60) were identified. Thirty-eight patients (50 cultures) had indwelling plastic miliary stents at the time of culture (Grl3 I) and 23 patients (23 cultures) had no previous history of biliary stents (Grp 2). Four patients initially included in G rp 2 subsequently had a repeat bile culture while a biliary sten~ was in place. The primary diac~%osis for patients in GrDs ~,2 were: malignant ~ile duct obstruction (n=30,10), choledocholi~hiasis (n=0,8), benign stricture from chronic pancreatitis (n=4,2), anastomotic stricture after liver transplantation (n=4,3). G r D l(n=50) GrD2~ Positive Cultures 48~96%) (p
VOLUME 43, NO. 4, 1996
359
ENDOSCOPIC TREATMENT OF BENIGN BILIARY DUCT STRICTURES (BBDS) : LONG-TERMRESULTS. J.-M. Dumonoeau, J. Deviere, M. Delhaye, M. Cremer. Department of Gastroentero(ogy,Erasme University Hospital, Universite Libre de Bruxeltec,Brucsels.
ENDOSCOPIC MANAGEMENT OF DOMINANT STRICTURES IN PRIMARY SCLEROSING CHOLANGITIS 0PSC). _E Elton and M.J. Goldberg. The University of Chicago, Chicago IL.
The endoscopic treatmentof BSD,~is safe and can provide good immediatedrainage. Aim : To assess long-term results after endoscopic treatment of BSDS not related to chronic panoreatitis. Patie#!s a0d methods : Follow-~Jpdata (biliary symptoms and bilirubinemia) were obtained in a~{of 35 consecutiveeases of BBDS (male : 20, age : 57 • 16 years) where the absence of further endoscopic treatment had been recommended because of a calibration of the 88DS judged to be sufficient. BBDS, mainly attributable to chobcystectsmy (N=22) and OLTX (N=6) were located on the ma}n bib duct (N=32), the hilum (N=I), the left bile duct (N=I) and the hepaticojejunostorny (N=I). The management had consisted of dilation, alone (N=3), or associated with metallic (Waistefit) (N=6) or plastic stents (these latter for a total of 6.8 • 5.1 months). All patiehtc wi~ abnormalfollow-up data underwent ERCP in order to confirm a recurrent BBDS.. Result.s:
|!' e
20 I
13
25
9M o n t h s
37 after
49
61
73
85
97
109
121
removal of plas~k: stents [ A ) o~ inse~on of Wa~tentr, (B).
The delay before 88DS recurred was significantly shorter in patients treated with metallic stents. In this group, recurrent stenoses required hepafbojejunostomy(N=2) or continuous plasfic stenfing (N=2). One of the 2 single cases who did not develop recurrent stenoseswas the patientwith previous local radiotherapy. Conqlusio0 ~These results chow that dilation and plastic stenting is a safe and efficient treatment of BBDS. Self expandandable stents not only offer no advantage but are followed by rapid restenosis and should be considered as contraindicated in this indication..
t358
Methods: We retrospectively reviewed the charts of the 12 patiertts with PSC and dominant strictures who were referred to our service for endoscopic int~on over a 4-year period. Serum values for total bilirubin, alkaline phosphatase, alanme aminotransferase (ALT), and 7-gltS,amyl transpeptidase (GGT) were recorded for the period preceding the initial therapeutic ERCP, at I month after the final intervention, and for the most rector period a~aitable. Results: The twelve patients underwent a toter of 18 therapeutic ERCPs (range, 1 to 4 per patient). Endoscopic interventions were successful in I t patients (92%), a guidewire could not be successfully placed beyond a tight dominant stricture in the final patient. Two patients underwent ES alone; 2 had ES plus st~tmg~ 2 had ES, Soehendra catheter dilation, and stating; I had ES plus stone extraction, 1 had onsobiliary drain placement followed by ES and stenting; 1 had ES plus catheter dilation; I had catheter dilation alone; and 1 had nasobiliary drain placement atone. No major complications of hemnrdmge, cholangitis, pancreatitis, or perforation were noted. However, one patient required a percutanenusly-placed bihary drain, as adequate drainage could not be obtained through the endoscopicaUy-placed stent Mean values for serum liver chemistries are shown in the table below. B/~'.bln Pre-therapy 4.9 I month post-therapy 1.7" fo~ow-a~t t .5" "!9<0.05 compared wi$ pr~therapy,
AIk Phns ALT GGT 482 109 416 352* 73 381 314" 72 330* tMean 22 months (range, 7 ~ 49),
Conclusion: Endoscopic'intervention for dominant strictures in PSC r e s ~ in significant improvement in obstructive liver function tests. This improvement perfis~ over an e~ended ~ilow-up period ~ere, a mean period of 22 months; range, 7 ~ 49 months).
H360
THE RISK OF BLEEDING AFrER ENDOSCOPIC BILIARY SPHINCTEROTOMY (EBS) IN PATIENTS WITH PERI-AMPULLARY DIVERTICULA (PAD): A PROSPECTIVE TRIAL. ABELFANT. GB HABER, MJ BOURKE,A ALHALEL, PP KORTAN. THE WELLESLEY HOSPITAL, TORONTO, CANADA Baekan'mmd: Whether there is an increased bleeding risk after EBS in pts with PAD is controversial. Several small series support this association. Pur uese:Determine the risk of immediate and delayed hemorrhage following EBS in patients with PAD. Methods:From 10/94-6/95,patients requiring EBS at The Wellesley Hospital were enrolled in this open trial. Data consisting of age, sex, diagnosis, NSAID use, cholangiographic findings was obtained. Bleeding was absent or insignificant (no treatment) or active (oozing or spurting) requiring endoscopic control, transfusion or surgery. Telephone follow-up occurred in all subjects at 10 days. Chi-square test of association was used for statistical analysis. Results'Diagnostic/Therapentic ERCP was performed on 1627 subjects with 494 receiving an EBS. Indications: Presumed Choledochotithiasis (274), Benign Biliary stricture (31). PAD were noted in 106 subjects (6.5%), 77 of whom had an EBS. Mean age was 69.5 ~rc.~(Range 28-95, 36M), NSAID use was noted in 6(7.8%)PAD patients and in 26(6.2%) non-PAD patients undergoing EBS. Post-EBS hemorrhage requiring epinephrine injection occurred in 15 subjects (19.5%) with PAD, while only IS subjects (4.3%) without PAD had post-EBS hemorrhage requiring epinephrine injection. There was a statistically significant association between PAD and post-EBS hemorrhage (chi-squsre=21.6, p<0.01). One subject (1.3%) with PAD required transfusion with 2 units of pRBC with a 2 day hospital stay. One subject (0.29~) without PAD had a late bleed requiring transfusion of 4 units of pRBC with a 3 day hospital stay. CBD diameter > 10ram was seen in 43/77 subjects (55.85) with PAD having an EBS. There was no difference in post-EBS hemorrhage between those with (60%) or without (54%) ductal dilation. CBD diameter > 10ram was noted in 7/18 (38.8%) subjects without PAD who had post-EBS hemorrhage. No patients required surgery and there was no procedure related mortality. Condusion:Post-EBS hemorrhage occurs significantly more often in patients with PAD. However, aggressive endoscopic hemostasis may minimize the clinical severity in patients with this anatomic variant.
380
Background: Dominant strictures in PSC patters can lead to rapid elevations in serum bitirubin levels, recurrent ch~tangitis, or pruritus. Endoscopic methods used to treat these strictures have included endoscopic sphincterotomy (ES), catheter Or hydrostatic haUonn dilation, placeme~ of endoprostheses, nasobiliary drainage, and biliary ravage. Here, we report our experience with endoscopic therapy of.dominant strictures in patients with PSC,
GASTROINTESTINAL ENDOSCOPY
MICROBZOLOGY OF BILE CULTURES IN PATIENTS WITH CHOLANGITIS OR CHOLESTASIS AND PLASTIC BILIARY ENDOPROSTHESIS. Ed Esber, Stuart Sherman, Dee Earle, James Pezzi, Klaus Gottlieb, Glen Lehman, Indiana University Medical Center. ChoZan~itis is a freqllent comDli~ation of biliary stents. Empiric antibiotic seleckion is based primarily on the results of bile cultures obtained ~rom surgical patients and limited data from the ERCP era. This stud Z was undertaken to analyze the microbiology of 5ile and the sensitivities of the orqanisms identified in stented patients D r e s e n t i n g wiEh clinical cholanqitis or cholestasis. METHODS: We reviewed all bile cultures collected durinq ERCP from 11/93 to 8/95. Specimens were collected wit~ a sterile catheter prior to the injection of contrast. DuodenoscoDes were washed for 20 minutes in 2% ~lutaraldehyde just prior to use. RESULTS: Seventy~hree cultures from 57 patients ranging in age from 12-85 (mean 60) were identified. Thirty-eight patients (50 cultures) had indwelling plastic miliary stents at the time of culture (Grl3 I) and 23 patients (23 cultures) had no previous history of biliary stents (Grp 2). Four patients initially included in G rp 2 subsequently had a repeat bile culture while a biliary sten~ was in place. The primary diac~%osis for patients in GrDs ~,2 were: malignant ~ile duct obstruction (n=30,10), choledocholi~hiasis (n=0,8), benign stricture from chronic pancreatitis (n=4,2), anastomotic stricture after liver transplantation (n=4,3). G r D l(n=50) GrD2~ Positive Cultures 48~96%) (p
VOLUME 43, NO. 4, 1996