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Endoscopic palliation of primary and secondary malignant proximal bile duct obstruction
ERCP-BILIARY 473
475
ENDOSCOPIC PALLIATION OF PRIMARY AND SECONDARY MALIGNANT PROXIMAL BILE DUCT OBSTRUCTION. J.C. Pereira-Lima, R. Jnkobs, M. Maler, C. Beaz, H. Adamek, J.F. Rlemnna. Department of
THE PRE-CUT PAPILLOTOMY IS NOT AS SAFE AS ADVERTISED. ~ R. Jakobs, H. Adamek,
Gastroenterology,
Pre-cut papillotomy is increasingly used to approach the biliary tree, when the endoscopist is faced with a failed cholangiogram. The frequency ofpre-cut procedures in reported series varies from 3.9 to 35%. We report here our experience with needle-knife pre-cut "accnssotomy" in the management of bile duet stones. Methods: During a 2.5 year period, 223 patients with choledueholithiasis (149 female, median age 72 (38-79)) were referred to our department. We prospectively analysed the immediate complications of biliary sphineterotomy with those, which happened when a pre-cut procedure was performed. Results: 217 of the 223 were freed from their calculi endoscopically. 342 ERCPs were necessary (1.53 per patient) to achieve these results. A pre-cut papillotomy was perform~ in 15 patients (6.72%) at index ERCP, 7 of whom (46.7%) suffered from a complication thereafter (pancreatitis in 5, bleeding in 2), with 1 death. Of the 208 patients in whom a standard biliary sphineterotomy was performed, 15 (7.2%) presented some complication, with 1 death (odds-ratio = 5.28 (CI = 1.56-17.88), p<0.005 Fisher's exact test). The hospital mortality was not affected by the pre-cut approach. Conclusion: The pre-cut procedure in a prospective study carries a high complication rate, even in patients with known choledocholithiasis. We would recommend caution with its liberal use, because its high complication rate is not justifiable for a purely diagnostic purpose.
Klinikum Ludwigshnfen,
Ludwigsliafen,
Germany. Endoscopic stenting of proximal bile duct malignant strictures is considered less sueessfol than the palliatiou of distal obstruction. 30-day mortality of 43% and successful stenting in only 53% were already reported. In this gudy we intend to expose our experience with the endoscopic palliation of malignant hilas obstruction due to umeseetable Kiatskin tumors (K-Tu), gallbladder tumors (GB-Tu) and metastatic malignancy due to tumors which primary site is far from the biliary tree (S-Tu). Methods: We treated 93 patients with proximal malignant biliary obstruction between 1990 and 1994. Patient's outcome were determined retrospectively by the clinical records and a standardized questionnaire answered by the patient's general practitioner, Results: A complete follow-up until death was achieved in 68 (median age 74 (46-93), 40 females and 28 males). The cause of icterus was K-Tu in 26 (I = 11, II = 7, HI = 8), GB-Tu in 18, S-Tu in 24 (colon tumor in 15 of these). Medium serum bilirubin (BR) before therapy scored 13.6 rag% for patients with biliary tumors and 16 mg% with S-Tu. After steuting, median BR droped to 1.5 mg% lathe former group and 2.6 mg% in the latter. In 75% of the cases, stentiog reduced the BR to less than 3 rag%. An improvement in the quality of life was judged to occur in 72%. Procedure-related mortality was 3.2%. Stent dysfunction occurred in 41% in the longterm ru~ Median survival reached 3 months in patients with noncolon S-Tu, 4 months in colonic S-Tu, 6 months in K-Tu (9 months in K-Tu I) and 6 months in GB-Tu. Conclusion: As expected, the survival and benefits were greater among patients in the early stage of the disease (K-Tu I), Even in patients with end-stage disease (S-Tu, K-Tu III) a remarkable benefit from the therapy in terms ofjaundice relief and improvement in the quality of life could be perceived.
U. Winter, J.F. Riemaaa. Department of Gastroenterology, Kilaikum Ludwigshafen, Ludwigshafen, Germany.
1"474
476
LONG-TERM FOLLOW-UP AFTER ENDOSCOPIC SPHINCTEROTOMY (ES). MULTIVARIATE ANALYSIS OF PREDICTIVE FACTORS FOR THE RECURRENCE
A 7 YEAR EXPERIENCE IN ERCP FOR COMPLICATIONS OF
OF BILIARY SYMPTOMS. J ~ U. Winter, IL Jakobs, C. Benz, J.F. Riemana. Department of Gastroenterology, Klinikum Ludwi@hafen, Ludwipliafen, Germany. Although the long-term results of ES are well-known, the risk factors for recurrence of biliary symptoms are poorly determined. We aim to investigate which factors are associated with biliary symptomatic recurrence after ES. Methods: Between 4/1985 and 6/1988, 223 patients underwent ES for bile duct stones. Long-term data were obtained from the patients and general practitioners. Results: Long-term data (7 to 10 years, mean 8.8) were analyzed for 201 patients (mean age 68.8 years, 140 (70%) women). The 30-day mortality was 0.89% (2 patients) with 6 procedure failures and 14 cases were lost to follow-up. 93 patients were left with tbek gallbladder in sttu and 108 were cholecystr Blliary symptoms recurrence occured in 31 (15%) patients during follow-up (16 with choledocholithiasis, acute cholacystitis in 8, papillary stcnosis in 2, 5 with biliery cholic without cholecystitis ). Bile duct diameter prior to ES was the most important factor for symptomatic recurrence. Biliery symptoms relapse OCCuredin 29% of the patients with bile duct gauge > 15ram and in 10O/oof those with bile duct <__10ram (RR = 2.65, p< 0.03, Cox's proportional hazards model). When the gallbladder was left in situ after ES, 20% relapsed and reccurence was experienced by 11% of those cholecystectomized (RR = 2.18, p< 0.05, Cox's model). All other parameters evaluated were not statistically significant. Conclusion: Chol~ochal diameter and gallbladder left in situ are the risk factors associated with biliary recurrence. Surveillance ERCP or surgery may be contemplated in these groups of patients.
VOLUME 45, NO. 4, 1997
LAPAROSCOPIC CHOLECYSTECTOMY P. Pe=catore. W. Lorenz, B.C. Manegold, DepammsR of Surgical Endoscopy, Klinikum Mannheim, University of Heidelberg, Germany The aim of this stadv was to assessthe value of ERCP in diasnosis and treat~R of complicatmnsof laparo~w~piccholecystectomy(i~). Methode: Retrospective rewew of a university hospital experience cr 120 patients (82 women, 38 men; mean age 52 years) referred between 1990 and 1996. Results: The principal indications to ERCP were: abdominal pain (n = 37), anicteric cholestnsis (n = 21), jaundice (n = 19), common bile duct (CBD) stones seen intraoperatively (n = I I) or by postoperative ultrasound (n = 12), billary pancreatitis (n = 9), bilomas or bile fistulas (n = 8) and gall bladder carcinoma (n = 3). ERCP failed m 5 patierd~ (4 %). In 37 cases ERCP was normal. The 83 pathological results were'. 45 CBD stonu, I I CBD strictures, 8 bile leakages associated with CBD stones, 6 isolated bile leakages, 3 anastometic strictures alter CBD tranesection and mediate end-to-and reconstruction, I complete CBD transsection and 9 others (2 cholaagioearcmoma, 2 chronic pancreatitis, 2 bmign papillary stanosos, 1 pancreas divisum, I primary sclermmg cholangitiz, I hemobilia). Endoscopic therapy was succossfid in 56 of 60 tmtatives: 93 % of CBD stones, lO0 % of leakages associated with stones and 66 % of isolated leakages could be treated by endoscopic sphmcterotomy (ES) +/- nnsobiliary drainage. In 3 patimts CBD stone extraction failed because of their size, 1 patient was lost to follow-up In the 3 patiants with choledochal anastomotic stricture a balloon dilation (n = I) or a permanent dilation by endopmstheses (n = 2) was undertaken. In 12 patients no endoscopic therapy was attempted (8 strictures, 2 CBD carcinomas, 1 CBD leakage, 1 transseetion). 9 patiants eventually underwent reconstructive surgery or bilio-digeetive anastomoses. They remain symptrom-free after a mean follow-up of 2,5 years. Complications of ERCP were 2 pancreatitis and 1 bleeding after ES, all treated conservatively. I patient died one day after ES due to pulmonary embolism. Conclusions: ERCP is an excellent diagnomc method for suspected complications aRer LC Residual stones and mmor bile leakages can easily be treated andoscopically. Strictures may be managed by endoscopic dilation, but lung-term results are still lacking. We advocate a surgical revision in case of severe CBD lesions.
GASTROINTESTINAL ENDOSCOPY
AB143
475
ENDOSCOPIC PALLIATION OF PRIMARY AND SECONDARY MALIGNANT PROXIMAL BILE DUCT OBSTRUCTION. J.C. Pereira-Lima, R. Jnkobs, M. Maler, C. Beaz, H. Adamek, J.F. Rlemnna. Department of
THE PRE-CUT PAPILLOTOMY IS NOT AS SAFE AS ADVERTISED. ~ R. Jakobs, H. Adamek,
Gastroenterology,
Pre-cut papillotomy is increasingly used to approach the biliary tree, when the endoscopist is faced with a failed cholangiogram. The frequency ofpre-cut procedures in reported series varies from 3.9 to 35%. We report here our experience with needle-knife pre-cut "accnssotomy" in the management of bile duet stones. Methods: During a 2.5 year period, 223 patients with choledueholithiasis (149 female, median age 72 (38-79)) were referred to our department. We prospectively analysed the immediate complications of biliary sphineterotomy with those, which happened when a pre-cut procedure was performed. Results: 217 of the 223 were freed from their calculi endoscopically. 342 ERCPs were necessary (1.53 per patient) to achieve these results. A pre-cut papillotomy was perform~ in 15 patients (6.72%) at index ERCP, 7 of whom (46.7%) suffered from a complication thereafter (pancreatitis in 5, bleeding in 2), with 1 death. Of the 208 patients in whom a standard biliary sphineterotomy was performed, 15 (7.2%) presented some complication, with 1 death (odds-ratio = 5.28 (CI = 1.56-17.88), p<0.005 Fisher's exact test). The hospital mortality was not affected by the pre-cut approach. Conclusion: The pre-cut procedure in a prospective study carries a high complication rate, even in patients with known choledocholithiasis. We would recommend caution with its liberal use, because its high complication rate is not justifiable for a purely diagnostic purpose.
Klinikum Ludwigshnfen,
Ludwigsliafen,
Germany. Endoscopic stenting of proximal bile duct malignant strictures is considered less sueessfol than the palliatiou of distal obstruction. 30-day mortality of 43% and successful stenting in only 53% were already reported. In this gudy we intend to expose our experience with the endoscopic palliation of malignant hilas obstruction due to umeseetable Kiatskin tumors (K-Tu), gallbladder tumors (GB-Tu) and metastatic malignancy due to tumors which primary site is far from the biliary tree (S-Tu). Methods: We treated 93 patients with proximal malignant biliary obstruction between 1990 and 1994. Patient's outcome were determined retrospectively by the clinical records and a standardized questionnaire answered by the patient's general practitioner, Results: A complete follow-up until death was achieved in 68 (median age 74 (46-93), 40 females and 28 males). The cause of icterus was K-Tu in 26 (I = 11, II = 7, HI = 8), GB-Tu in 18, S-Tu in 24 (colon tumor in 15 of these). Medium serum bilirubin (BR) before therapy scored 13.6 rag% for patients with biliary tumors and 16 mg% with S-Tu. After steuting, median BR droped to 1.5 mg% lathe former group and 2.6 mg% in the latter. In 75% of the cases, stentiog reduced the BR to less than 3 rag%. An improvement in the quality of life was judged to occur in 72%. Procedure-related mortality was 3.2%. Stent dysfunction occurred in 41% in the longterm ru~ Median survival reached 3 months in patients with noncolon S-Tu, 4 months in colonic S-Tu, 6 months in K-Tu (9 months in K-Tu I) and 6 months in GB-Tu. Conclusion: As expected, the survival and benefits were greater among patients in the early stage of the disease (K-Tu I), Even in patients with end-stage disease (S-Tu, K-Tu III) a remarkable benefit from the therapy in terms ofjaundice relief and improvement in the quality of life could be perceived.
U. Winter, J.F. Riemaaa. Department of Gastroenterology, Kilaikum Ludwigshafen, Ludwigshafen, Germany.
1"474
476
LONG-TERM FOLLOW-UP AFTER ENDOSCOPIC SPHINCTEROTOMY (ES). MULTIVARIATE ANALYSIS OF PREDICTIVE FACTORS FOR THE RECURRENCE
A 7 YEAR EXPERIENCE IN ERCP FOR COMPLICATIONS OF
OF BILIARY SYMPTOMS. J ~ U. Winter, IL Jakobs, C. Benz, J.F. Riemana. Department of Gastroenterology, Klinikum Ludwi@hafen, Ludwipliafen, Germany. Although the long-term results of ES are well-known, the risk factors for recurrence of biliary symptoms are poorly determined. We aim to investigate which factors are associated with biliary symptomatic recurrence after ES. Methods: Between 4/1985 and 6/1988, 223 patients underwent ES for bile duct stones. Long-term data were obtained from the patients and general practitioners. Results: Long-term data (7 to 10 years, mean 8.8) were analyzed for 201 patients (mean age 68.8 years, 140 (70%) women). The 30-day mortality was 0.89% (2 patients) with 6 procedure failures and 14 cases were lost to follow-up. 93 patients were left with tbek gallbladder in sttu and 108 were cholecystr Blliary symptoms recurrence occured in 31 (15%) patients during follow-up (16 with choledocholithiasis, acute cholacystitis in 8, papillary stcnosis in 2, 5 with biliery cholic without cholecystitis ). Bile duct diameter prior to ES was the most important factor for symptomatic recurrence. Biliery symptoms relapse OCCuredin 29% of the patients with bile duct gauge > 15ram and in 10O/oof those with bile duct <__10ram (RR = 2.65, p< 0.03, Cox's proportional hazards model). When the gallbladder was left in situ after ES, 20% relapsed and reccurence was experienced by 11% of those cholecystectomized (RR = 2.18, p< 0.05, Cox's model). All other parameters evaluated were not statistically significant. Conclusion: Chol~ochal diameter and gallbladder left in situ are the risk factors associated with biliary recurrence. Surveillance ERCP or surgery may be contemplated in these groups of patients.
VOLUME 45, NO. 4, 1997
LAPAROSCOPIC CHOLECYSTECTOMY P. Pe=catore. W. Lorenz, B.C. Manegold, DepammsR of Surgical Endoscopy, Klinikum Mannheim, University of Heidelberg, Germany The aim of this stadv was to assessthe value of ERCP in diasnosis and treat~R of complicatmnsof laparo~w~piccholecystectomy(i~). Methode: Retrospective rewew of a university hospital experience cr 120 patients (82 women, 38 men; mean age 52 years) referred between 1990 and 1996. Results: The principal indications to ERCP were: abdominal pain (n = 37), anicteric cholestnsis (n = 21), jaundice (n = 19), common bile duct (CBD) stones seen intraoperatively (n = I I) or by postoperative ultrasound (n = 12), billary pancreatitis (n = 9), bilomas or bile fistulas (n = 8) and gall bladder carcinoma (n = 3). ERCP failed m 5 patierd~ (4 %). In 37 cases ERCP was normal. The 83 pathological results were'. 45 CBD stonu, I I CBD strictures, 8 bile leakages associated with CBD stones, 6 isolated bile leakages, 3 anastometic strictures alter CBD tranesection and mediate end-to-and reconstruction, I complete CBD transsection and 9 others (2 cholaagioearcmoma, 2 chronic pancreatitis, 2 bmign papillary stanosos, 1 pancreas divisum, I primary sclermmg cholangitiz, I hemobilia). Endoscopic therapy was succossfid in 56 of 60 tmtatives: 93 % of CBD stones, lO0 % of leakages associated with stones and 66 % of isolated leakages could be treated by endoscopic sphmcterotomy (ES) +/- nnsobiliary drainage. In 3 patimts CBD stone extraction failed because of their size, 1 patient was lost to follow-up In the 3 patiants with choledochal anastomotic stricture a balloon dilation (n = I) or a permanent dilation by endopmstheses (n = 2) was undertaken. In 12 patients no endoscopic therapy was attempted (8 strictures, 2 CBD carcinomas, 1 CBD leakage, 1 transseetion). 9 patiants eventually underwent reconstructive surgery or bilio-digeetive anastomoses. They remain symptrom-free after a mean follow-up of 2,5 years. Complications of ERCP were 2 pancreatitis and 1 bleeding after ES, all treated conservatively. I patient died one day after ES due to pulmonary embolism. Conclusions: ERCP is an excellent diagnomc method for suspected complications aRer LC Residual stones and mmor bile leakages can easily be treated andoscopically. Strictures may be managed by endoscopic dilation, but lung-term results are still lacking. We advocate a surgical revision in case of severe CBD lesions.
GASTROINTESTINAL ENDOSCOPY
AB143