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Endoscopic stenting for malignant biliary obstruction: Assessment of clinical outcome and quality of life
ERCP--BILIAR Y -}'465
467
THE PRECUT-TECHNIQUE IS A SAFE P R O C E D U R E AND DOES NOT INCREASE THE OVERALL COMPLICATION RISK OF SPHINCTEROTOMY.
ACCESSORY GALLBLADDER BED (SUBVESICAL DUCT OR DUCT OF LUSCHKA'S) BILIARY LEAKS AFTER LAPAROSCOPIC .C.HOLECYS.'I'E.CTOMY. ~ , . Cunningham J.T, ' Marsh W H. PIOTTman t~j, .arnasKv t'H.L~p.nze rx, taryoosKI UM, Jameson ~L~ .H.awes RH, .Cotton ..PB...Division pf Gasts Medica, university o~ ~outh Carodna, ~naneston, ~outh Carolina. 9 Baqkoround: .Biliary leaks after laparoscopic c holepystectomy naveoeen well documented. The e~tectiveness oT enaoscopicallv placed biliary stents in .treat.ing the.se I.eaks i~ approximately 90.% ,n most series~/~ peripheral Drench ot t , e Olliary tree termed me subvesical d uC..t^~r duct of Luschka's has Seen reported in approximately ou ~o OT patients in autopsy series, w e now report a s.eres 0 t perip.hera! duct injur,es .during. I.aparoscop!c cnolecystectomy an(/tecnniques to more e~ectively eemonstrate gallblapder bed ,e.aks: All bile ~eaKs a~ler ,aparoscopic cno~ecystect.omv reterred ~o our nstitution dyer the pasl; 4 years were rev ewe.o. All ERCPs were rev ewed to eeterm ne the location ot the leak and the success of bi!iarv s.tent ng . . z] oi,e leaks were seen atter laparoscopic pno.lecys~ec.tomy qve.r a 4 year period..The, location, the use of o.a,oon occtusio.n cno!angiograpny, and me c,osure rate drier stem 31acement are listed oelow:
T. Rabenstein, T. Ruppert, S. M~hldorfer, J. Hochberger, W.E. Fieig, E.G. Hahn, C. Ell. I. Department of Medicine, University of Erlangen-Nuremberg
Aims and Methods From January 1973 to December 1993 2752 endoscopic sphincterotomies (EST) were performed at the Medical Department I o f the University of Erlangen-Nuremberg. Since 1981 the precut-technique has been used alone or in combination with standard sphincterotomy. Indications, success and complications of precut techniques (PRE) were analyzed retrospectively.
Results 1. FreQuency of PRE: Between 1981 and 1993 PRE were used in exactly one third of all patients, where a diagnostic or therapeutic access to the duct systems was intended (694/2105). 2. PRE without EST: Depending on the indication PRE were sufficient to achieve the therapeutic aim without EST in 7,2 % (151 cases). Malignant bile duct obstruction (n = 63) and chronic pancreatitis (n -= 31 were the main indications of this limited cutting procedure. 3. PRE to allow EST: In 30 % of all cases (632/2105) PRE was performed prior to EST, since standard canulation with the sphincterotome was not possible. After PRE EST was successful in a second attempt in 83,5 % (528/632). 4. PRE to allow diagnostic imaging of the duct systems: For diagnostic purposes PRE was used in 86 cases, when ERCP failed. After pRE the intended duct imaging was successful in 73,3 % (63/86). Complications after PRE: The complication rate was 4.6 % for PRE without following EST and 7.6 % for PRE in combination with EST. Compared to the complication rate of the standard EST (6,1 %) there was no significant statistical difference. Summary and Conclusion: The precut technique increases the success of diagnostic and therapeutic precedures at the papilla of Vateri. The technique is safe and does not increase the overall complication risk of sphincterotomy.
466 Treatment of malignant duodeno-biliary obstruction with double-endoscopic stenting. Isaac Raii m a n , Gardiner Roddey. Div of Gastroenterology, University of Texas Health Science Center and The MD Anderson Cancer Center, Houston, Texas Background: Palliation of biliary obstruction by endoscopic stent placement is the treatment of choice. Gastric outlet obstruction (GO0) may complicate advanced cancer and is traditionally treated with surgical bypass. We report here the use of endoscopically placed stents for the treatment of malignant GOD in patients with late stage disease considered poor surgical candidates. Patients/Methods: 3 women, mean age 53 years (38-68). One pancreatic cancer, 1 leiomyosarcoma, and 1 adenocarcinoma of unknown primary. All had undergone endoscopic biliary decompression (1 plastic stent, 2 expandable). All had intractable vomiting and weight loss. Barium studies demonstrated the obstruction proximal to the ampulla. Endoscopic balloon dilation (using a 15 n u n TI;S balloon) was performed in all patients prior to steui placement. A 12 m m Wallstent (Schneider) was placed in 2 and an 18 ram Ultraflex (Microvasive) was attempted in 1. The latter could not be placed due to the stiff part of the delivery system adjacent to the stent which could not negotiate a pyloro-duodenal angle created by the stricture. Results: The 2 patients with successful stent placement had resolution of their GOD. One developed gastric bleeding 2 wks after stent placement that resolved spontaneously. She is alive after 4 months without obstructive symptoms. One died 6 wks later of tumor progression. The patient in w h o m the stent could not be placed died 3 days later of sepsis (present prior to attempted stent placement). No procedural complications occured. Conclusion: Endoscopic placement of duodenal stents provides a non-surgical alternative in the treatment of GOD in patients with late stage malignant disease considered poor surgical candidates. Flexible stent-delivery systems are necessary to achieve successful stent placement.
412
GASTROINTESTINAL ENDOSCOPY
Type of Leak
Leak Location
Peripheral duct
5/21
5 5
Cystic duct
11/21
3/11
aKS
aKS Maior duct
(24%) (52%) /21
] Balloon Occl. [ Closed with I Needed [ Stenting
1~(00%1 (27%)
4 5
1~0%1 10/11
(91%)
iniur Y ~14%} Undetermined 1/21 1 1 1 1 location (5%) (/00%) 1/00%) Failure to 1/21 n/a n/a demonstrate (5%) u t tne penpner~l leaks ,aent,t eo, all aopeare i to De in in( r~gion of the gallbladder bed= Four. of. ~he five c used. with placement or a oi,iary stent. Une releaKea out resolved drier sphineterotomy and nasobiliary tube placement. One went directly to sur ery. Conc~us,on: Accessory ga. b adder bed leaks are an mpor~nt potential complication o r laoaroscopic cnolecystectomy. /ne prob.ability of.this siteshould be cons,tiered in any p.atient with a oi,e ,eak..Fai,ure to aemonstratea cystic duct leaF on routi,ne injection snould s.uggest using balloon occlusion pnolangiograpny above the cystic auct stump to properw ieentifv tl~e source. MOSt accessory duct leaks seal with bihary stents (80%).
468 ~ ] ' ~ s ' ~ o p l c stehtlng for m-aIFgn~tqJil[a]'y-obs-t~ct~6n~ Assessment of clinical outcome and quality of life. Gardiner Roddey, Michael Paolucci, Isaac Raiiman: Div of Gastroenterology, University of Texas, Houston. Background: Endoscopic stenting is the preferred therapy for the relief of malignant bihary obstruction. Besides the relief of pruritus and jaundice, little is known regarding the outcome of other associated symptoms and the quality of life of patients after biliary stenting. Methods & patients: We reviewed retrospectively the charts of 37 patients in whom a standard questionnaire regarding symptomatology and quality of life could be completed. There were 21 women, 16 men, mean age 63 y (38-91). Fourteen had pancreatic cancer, :2 cholangiocarcinoma, 1 gallbladder cancer, 18 metastatic cancer, 2 other: A:standard questionnafre assessing pruritus, abdominal pain, anorexia, indiges9tion, level of activity, and perception of their physical health was u~O~.r ~li#~i~//t~h~!@bee~On~lCCe/tlelth~diJ~i~gntc~/~ne folI0w- f ~ 8~rlaWOt~Scoh~di~d tk~'~z ~k,~relcsfatttl ~3~r ~ ~ r n t h s after stent plack~l~n'~J~tiittli~01r~lh~1~dci~lrp~tients. Results: Tabl~.YL3'lf~i~ :O'ltfOblille~ i ~ l l t y : ~sltfevalt o~ b l l ~ , d ~ a t i n g Stenting Symptoms* Pruritus Anorexia Abd Pain Indigestion Well being" Before 2.2 2.5 2.0 1.8 1.0 After 0.0 1.0 1.0 1.0 4.0 *meanscoms.Scale0=notatall; 3=verymuch ~ scorel=bad,5==verygood Improvement in pruritus, anorexia, a n d patient's perception of well being were statistically significant (<0.05). Patients who had improve-ment within the first two weeks continued to have improvement 3-4 months later. There were 2 patients who required a repeat procedure 3 days after the initial one for continued pruritus and jaundice9 Both did well after the second procedure. Conclusion: Endoscopic stenting for malignant biliary stricture resolves not only jaundice and pruritus, but also improves associated anorexia. In addition, patient's perception ~of well being is improved
VOLUME 41, NO. 4, 1995
467
THE PRECUT-TECHNIQUE IS A SAFE P R O C E D U R E AND DOES NOT INCREASE THE OVERALL COMPLICATION RISK OF SPHINCTEROTOMY.
ACCESSORY GALLBLADDER BED (SUBVESICAL DUCT OR DUCT OF LUSCHKA'S) BILIARY LEAKS AFTER LAPAROSCOPIC .C.HOLECYS.'I'E.CTOMY. ~ , . Cunningham J.T, ' Marsh W H. PIOTTman t~j, .arnasKv t'H.L~p.nze rx, taryoosKI UM, Jameson ~L~ .H.awes RH, .Cotton ..PB...Division pf Gasts Medica, university o~ ~outh Carodna, ~naneston, ~outh Carolina. 9 Baqkoround: .Biliary leaks after laparoscopic c holepystectomy naveoeen well documented. The e~tectiveness oT enaoscopicallv placed biliary stents in .treat.ing the.se I.eaks i~ approximately 90.% ,n most series~/~ peripheral Drench ot t , e Olliary tree termed me subvesical d uC..t^~r duct of Luschka's has Seen reported in approximately ou ~o OT patients in autopsy series, w e now report a s.eres 0 t perip.hera! duct injur,es .during. I.aparoscop!c cnolecystectomy an(/tecnniques to more e~ectively eemonstrate gallblapder bed ,e.aks: All bile ~eaKs a~ler ,aparoscopic cno~ecystect.omv reterred ~o our nstitution dyer the pasl; 4 years were rev ewe.o. All ERCPs were rev ewed to eeterm ne the location ot the leak and the success of bi!iarv s.tent ng . . z] oi,e leaks were seen atter laparoscopic pno.lecys~ec.tomy qve.r a 4 year period..The, location, the use of o.a,oon occtusio.n cno!angiograpny, and me c,osure rate drier stem 31acement are listed oelow:
T. Rabenstein, T. Ruppert, S. M~hldorfer, J. Hochberger, W.E. Fieig, E.G. Hahn, C. Ell. I. Department of Medicine, University of Erlangen-Nuremberg
Aims and Methods From January 1973 to December 1993 2752 endoscopic sphincterotomies (EST) were performed at the Medical Department I o f the University of Erlangen-Nuremberg. Since 1981 the precut-technique has been used alone or in combination with standard sphincterotomy. Indications, success and complications of precut techniques (PRE) were analyzed retrospectively.
Results 1. FreQuency of PRE: Between 1981 and 1993 PRE were used in exactly one third of all patients, where a diagnostic or therapeutic access to the duct systems was intended (694/2105). 2. PRE without EST: Depending on the indication PRE were sufficient to achieve the therapeutic aim without EST in 7,2 % (151 cases). Malignant bile duct obstruction (n = 63) and chronic pancreatitis (n -= 31 were the main indications of this limited cutting procedure. 3. PRE to allow EST: In 30 % of all cases (632/2105) PRE was performed prior to EST, since standard canulation with the sphincterotome was not possible. After PRE EST was successful in a second attempt in 83,5 % (528/632). 4. PRE to allow diagnostic imaging of the duct systems: For diagnostic purposes PRE was used in 86 cases, when ERCP failed. After pRE the intended duct imaging was successful in 73,3 % (63/86). Complications after PRE: The complication rate was 4.6 % for PRE without following EST and 7.6 % for PRE in combination with EST. Compared to the complication rate of the standard EST (6,1 %) there was no significant statistical difference. Summary and Conclusion: The precut technique increases the success of diagnostic and therapeutic precedures at the papilla of Vateri. The technique is safe and does not increase the overall complication risk of sphincterotomy.
466 Treatment of malignant duodeno-biliary obstruction with double-endoscopic stenting. Isaac Raii m a n , Gardiner Roddey. Div of Gastroenterology, University of Texas Health Science Center and The MD Anderson Cancer Center, Houston, Texas Background: Palliation of biliary obstruction by endoscopic stent placement is the treatment of choice. Gastric outlet obstruction (GO0) may complicate advanced cancer and is traditionally treated with surgical bypass. We report here the use of endoscopically placed stents for the treatment of malignant GOD in patients with late stage disease considered poor surgical candidates. Patients/Methods: 3 women, mean age 53 years (38-68). One pancreatic cancer, 1 leiomyosarcoma, and 1 adenocarcinoma of unknown primary. All had undergone endoscopic biliary decompression (1 plastic stent, 2 expandable). All had intractable vomiting and weight loss. Barium studies demonstrated the obstruction proximal to the ampulla. Endoscopic balloon dilation (using a 15 n u n TI;S balloon) was performed in all patients prior to steui placement. A 12 m m Wallstent (Schneider) was placed in 2 and an 18 ram Ultraflex (Microvasive) was attempted in 1. The latter could not be placed due to the stiff part of the delivery system adjacent to the stent which could not negotiate a pyloro-duodenal angle created by the stricture. Results: The 2 patients with successful stent placement had resolution of their GOD. One developed gastric bleeding 2 wks after stent placement that resolved spontaneously. She is alive after 4 months without obstructive symptoms. One died 6 wks later of tumor progression. The patient in w h o m the stent could not be placed died 3 days later of sepsis (present prior to attempted stent placement). No procedural complications occured. Conclusion: Endoscopic placement of duodenal stents provides a non-surgical alternative in the treatment of GOD in patients with late stage malignant disease considered poor surgical candidates. Flexible stent-delivery systems are necessary to achieve successful stent placement.
412
GASTROINTESTINAL ENDOSCOPY
Type of Leak
Leak Location
Peripheral duct
5/21
5 5
Cystic duct
11/21
3/11
aKS
aKS Maior duct
(24%) (52%) /21
] Balloon Occl. [ Closed with I Needed [ Stenting
1~(00%1 (27%)
4 5
1~0%1 10/11
(91%)
iniur Y ~14%} Undetermined 1/21 1 1 1 1 location (5%) (/00%) 1/00%) Failure to 1/21 n/a n/a demonstrate (5%) u t tne penpner~l leaks ,aent,t eo, all aopeare i to De in in( r~gion of the gallbladder bed= Four. of. ~he five c used. with placement or a oi,iary stent. Une releaKea out resolved drier sphineterotomy and nasobiliary tube placement. One went directly to sur ery. Conc~us,on: Accessory ga. b adder bed leaks are an mpor~nt potential complication o r laoaroscopic cnolecystectomy. /ne prob.ability of.this siteshould be cons,tiered in any p.atient with a oi,e ,eak..Fai,ure to aemonstratea cystic duct leaF on routi,ne injection snould s.uggest using balloon occlusion pnolangiograpny above the cystic auct stump to properw ieentifv tl~e source. MOSt accessory duct leaks seal with bihary stents (80%).
468 ~ ] ' ~ s ' ~ o p l c stehtlng for m-aIFgn~tqJil[a]'y-obs-t~ct~6n~ Assessment of clinical outcome and quality of life. Gardiner Roddey, Michael Paolucci, Isaac Raiiman: Div of Gastroenterology, University of Texas, Houston. Background: Endoscopic stenting is the preferred therapy for the relief of malignant bihary obstruction. Besides the relief of pruritus and jaundice, little is known regarding the outcome of other associated symptoms and the quality of life of patients after biliary stenting. Methods & patients: We reviewed retrospectively the charts of 37 patients in whom a standard questionnaire regarding symptomatology and quality of life could be completed. There were 21 women, 16 men, mean age 63 y (38-91). Fourteen had pancreatic cancer, :2 cholangiocarcinoma, 1 gallbladder cancer, 18 metastatic cancer, 2 other: A:standard questionnafre assessing pruritus, abdominal pain, anorexia, indiges9tion, level of activity, and perception of their physical health was u~O~.r ~li#~i~//t~h~!@bee~On~lCCe/tlelth~diJ~i~gntc~/~ne folI0w- f ~ 8~rlaWOt~Scoh~di~d tk~'~z ~k,~relcsfatttl ~3~r ~ ~ r n t h s after stent plack~l~n'~J~tiittli~01r~lh~1~dci~lrp~tients. Results: Tabl~.YL3'lf~i~ :O'ltfOblille~ i ~ l l t y : ~sltfevalt o~ b l l ~ , d ~ a t i n g Stenting Symptoms* Pruritus Anorexia Abd Pain Indigestion Well being" Before 2.2 2.5 2.0 1.8 1.0 After 0.0 1.0 1.0 1.0 4.0 *meanscoms.Scale0=notatall; 3=verymuch ~ scorel=bad,5==verygood Improvement in pruritus, anorexia, a n d patient's perception of well being were statistically significant (<0.05). Patients who had improve-ment within the first two weeks continued to have improvement 3-4 months later. There were 2 patients who required a repeat procedure 3 days after the initial one for continued pruritus and jaundice9 Both did well after the second procedure. Conclusion: Endoscopic stenting for malignant biliary stricture resolves not only jaundice and pruritus, but also improves associated anorexia. In addition, patient's perception ~of well being is improved
VOLUME 41, NO. 4, 1995