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Mechanisms of stent occlusion in malignant biliary strictures
ERCP-BILIARY +477 MECHANISMS OF STENT OCCLUSION IN M A L I G N A N T B I L I A R Y S T R I C T U R E S . F. prat, O. Chapat, C. Cosson, D. Fompeydie, N. Nassar, J, Fritsch, G. Pelletier, C. Buffet. H6patogastroenterology, Biochemistry and Bacteriology, CHU Bic~tre. Dept of chemistry, Univ. of Paris, France. The major drawback of plastic stents is their frequent occlusion by sludge deposition. Studies on occluded prostheses have not allowed the full understanding of obstruction mechanisms. We have studied both occluded and permeable prostheses in order to clarify the role of proteins, microrganisms and minerals in sludge formation. During a prospective randomized study comparing plastic stents exchanged prophylactically every 3 months or only in case of symptomatic dysfunction, 58 polyethylene stents (ll.5Fr, WilsonCook) were collected and analyzed. The stents were sectioned and classified macroscopically as permeable or occluded. The analysis included infra-red spectrophotometry of stent contents, 15% polyacrylamide gel electrophoresis (SDS-PAGE), electron microscopy scanning and a bacteriological analysis with identification of bacterial species and determination of [3-glycuronidase-producing strains. 38 stents were macroscopically occluded and 20 were permeable. Calcium bilimbinate and palmitate were the main Constituents of stent contents in 74% of occluded stents, while the inner biofilm of permeable stents was essentially composed of proteins in 75% of cases. Proteic spectra of permeable and occluded stents were not different. On electron microscopy, the stent lumen was covered with a conglomerate of filamentous material, mineral sediment and microorganisms. E. coli was the most commonly identified bacteria in both groups of stents. 30.2% of bacterial strains were [3glycuronidase-positive in occluded prostheses, as against 6.6% in permeable stents. The initial mechanism of obstruction is apparently the deposition of a proteic biofilm on the inner stent wall, thus stimulating mineral precipitation, in which the facilitating role of bacterial contamination requires more investigation. Forthcoming trials of stent obstruction prophylaxis should be oriented towards prevention of protein deposition and/or proteolysis.
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PRIMARY COMMON BILE DUCT STONES WITHOUT CHOLELITHIASIS: ARE JUXTAPAPILLARY DUODENAL DIVERTICULA THE CAUSE? T.Qaseem= E.Elton, B.L. Hanson, D.A.HoweU. Division of Gastroenterology, Maine Medical Center, Portland, ME. Background: Most clinicians would agree that the presence of stones within the common duct when none exist in an intact gallbladder represents primary common duct stone formation. The etiology of this unusual clinical finding has been unexplained. A strong statistical association between juxtapapillary duodenal diverticula and common bile duct stone disease in patients who have had cholecystectomy for cholelithiasis has been reported by several authors. We sought to investigate the association ofjuxtapapillary duodenal diverticula with the presence of such primary common bile duct stones. Methods: Between 1/91 and 5/96, 1916 patients undergoing ERCP at Maine Medical Center had the details of their procedures prospectively entered into a data base. Of these, 295 patients had an intact gallbladder and no stones in the gallbladder by ultrasound. After excluding the 17 patients with equivocal common duct findings, we included the remaining 278 patients in our study. We then compared the incidence of primary common duct stones in the subset with JDD to that in those without JDD. Results: Primary common duct stones were visualized at ERCP in 47 patients (17%). Of these patients, 11 (23.4%) had JDD. In comparison, in the 231 patients without primary common duct stones, only 7 (3.0%) had JDD (p<0.000001). Of note, the mean age of those with primary CBD stones was 64.8, and of those without primary CBD stones was 60.0 (p--0.003), while the mean age of patients with JDD was 68.1, and of those without JDD was 60.3 (p<0.000001). Conclusions: The presence of primary common bile duct stones is highly correlated with the presence ofjuxtaampullary duodenal diverticula. This association strongly supports the hypothesis that duodenal diverticula involving the papilla in some way contribute to the formation of primary common duct stones. However, part of this association may be due to age, as older patients are more likely to have both primary common duct stones and JDD.
+478
480
ENDOSCOPIC SPHINCTEROTOMY (ES) VS ENDOSCOPIC BALLOON DILATATION (EBD) FOR BILE DUCT STONES (BDSI .RESULTS IN 28 PATIENTS(PTS)UNDER 56 YEARS OF AGE. V. Pugliese. Dept.of Digestive Endoscopy and Gastroenterology Nat. Inst.for Cancer Research, Genoa, Italy. Method. Consecutive pts were randc~ly asslgned to ES or EBD after the diagnosis of BDS was made at ERC.Excluded were pts with suones larger than 20 mm, acute pancreatitis (AP), acute cholangitis, coagulation disorders or previous ES. ES was carried out according to standard technique. EBD was performed by using hydrostatic balloon (Max Force, Microvasive, Boston).If necessary, mechanical lithotripsy could be employed uo fragment stones before extraction.A final occlusive ERC was obtained and an ES was performed in case of failure of previous EBD. Medical examination and blood tests were performed daily on the subsequent 3 days,at the time of discharge from hospital and during follow-up(FU).The success rate of BDS clearing, the incidence of post-ERCP complications and the results of FU studies were compared. Results. ES(N=I5) EBD(N=I3)_ Median no.of BDS(range) i(i-ii) i(1-9) Median BDS diameter(nan) 7(5-15) 7(3-15) Cholelithiasis 12 8 Mechanical lithotripsy 1 Procedure successful 16 12 Final occlusive ERC negative 1512 Complications l* Median FUmo. 14(11-24) 19(10-24) ~Jnegative 15 12
THE "ANCHORING" TECHNIQUE: A NEW METHOD FOR PLACE-MENT OF LARGE BORE PLASTIC BILIARY STENTS. I Raijman. MD Anderson Cancer Center and University of Texas~ Houston. Placement of large bore plastic stents may prove difficult and sometimes tmpossible in both distal and proximal biliary strictures, whether benign or malignant. A new technique is described that has been successfully used in 10 consecutive patients. The strictures were malignant and located at the bifurcation (4), common hepatic duct (2), and common bile duct (4). The strictures were due to pancreatic cancer (4), gallbla-dder cancer (1), cholangiocarcmoma (1), colon cancer (3), and breast cancer (1). In all, the strictures had a lumen of 1 m m or less. Stricture dilation was not performed in any patient. ] h e new technique is as follows: Alter visualization of the stricture, a small papillotomy is performed and a hydrophyl/c guidewtre is passed beyond the stricture. An 11.5 Fr push catheter that accepts a 7 Fr guide catheter (Wilson-Cook) is accomodated on an 8.5 m m extractor balloon with a 7 Fr. Shaft (Microvasive). An 11.5 Fr plastic stent is then placed on the balloon shaft against the pusher catheter. The tapered tip of the stent is tan-gentially cut to allow passage of the balloon shaft. Silicone lubrication facilitates advancing the balloon both through the pusher catheter and the stent Once the balloonpusher-stent apparatus is assembled, it is advanced over the guidewire. Care must be taken to keep the balloon catheter and the pusher catheter closed together outside the endoscope while advancing the entire apparatus over the wire. Once the balloon catheter is beyond the stricture, it is pushed into the intrahepatic ducts and then maximally insufflated. This allows anchoring of the balloon intrahepatically. By doing so, the balloon catheter is tugged creating opposing forces and a stable anchored position that facilitates pushing of the stent into the bile duct and through the stricture. This tecnique has proved to be easily and successfully accomplished in patients with very difficult strictures that would otherwise reqture biliary dilation a n d / o r placement of smaller stents. This new technique is curronfly being evalu-ated and compared to standard methods in a larger number of patients.
9 1 residual intrahepatic BDS; *mild AP. Conclusion. ES and EBD seem to be comparable basis of the 3 parameters considered.
AB144
GASTROINTESTINAL ENDOSCOPY
on
the
VOLUME 45, NO. 4, 1997
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PRIMARY COMMON BILE DUCT STONES WITHOUT CHOLELITHIASIS: ARE JUXTAPAPILLARY DUODENAL DIVERTICULA THE CAUSE? T.Qaseem= E.Elton, B.L. Hanson, D.A.HoweU. Division of Gastroenterology, Maine Medical Center, Portland, ME. Background: Most clinicians would agree that the presence of stones within the common duct when none exist in an intact gallbladder represents primary common duct stone formation. The etiology of this unusual clinical finding has been unexplained. A strong statistical association between juxtapapillary duodenal diverticula and common bile duct stone disease in patients who have had cholecystectomy for cholelithiasis has been reported by several authors. We sought to investigate the association ofjuxtapapillary duodenal diverticula with the presence of such primary common bile duct stones. Methods: Between 1/91 and 5/96, 1916 patients undergoing ERCP at Maine Medical Center had the details of their procedures prospectively entered into a data base. Of these, 295 patients had an intact gallbladder and no stones in the gallbladder by ultrasound. After excluding the 17 patients with equivocal common duct findings, we included the remaining 278 patients in our study. We then compared the incidence of primary common duct stones in the subset with JDD to that in those without JDD. Results: Primary common duct stones were visualized at ERCP in 47 patients (17%). Of these patients, 11 (23.4%) had JDD. In comparison, in the 231 patients without primary common duct stones, only 7 (3.0%) had JDD (p<0.000001). Of note, the mean age of those with primary CBD stones was 64.8, and of those without primary CBD stones was 60.0 (p--0.003), while the mean age of patients with JDD was 68.1, and of those without JDD was 60.3 (p<0.000001). Conclusions: The presence of primary common bile duct stones is highly correlated with the presence ofjuxtaampullary duodenal diverticula. This association strongly supports the hypothesis that duodenal diverticula involving the papilla in some way contribute to the formation of primary common duct stones. However, part of this association may be due to age, as older patients are more likely to have both primary common duct stones and JDD.
+478
480
ENDOSCOPIC SPHINCTEROTOMY (ES) VS ENDOSCOPIC BALLOON DILATATION (EBD) FOR BILE DUCT STONES (BDSI .RESULTS IN 28 PATIENTS(PTS)UNDER 56 YEARS OF AGE. V. Pugliese. Dept.of Digestive Endoscopy and Gastroenterology Nat. Inst.for Cancer Research, Genoa, Italy. Method. Consecutive pts were randc~ly asslgned to ES or EBD after the diagnosis of BDS was made at ERC.Excluded were pts with suones larger than 20 mm, acute pancreatitis (AP), acute cholangitis, coagulation disorders or previous ES. ES was carried out according to standard technique. EBD was performed by using hydrostatic balloon (Max Force, Microvasive, Boston).If necessary, mechanical lithotripsy could be employed uo fragment stones before extraction.A final occlusive ERC was obtained and an ES was performed in case of failure of previous EBD. Medical examination and blood tests were performed daily on the subsequent 3 days,at the time of discharge from hospital and during follow-up(FU).The success rate of BDS clearing, the incidence of post-ERCP complications and the results of FU studies were compared. Results. ES(N=I5) EBD(N=I3)_ Median no.of BDS(range) i(i-ii) i(1-9) Median BDS diameter(nan) 7(5-15) 7(3-15) Cholelithiasis 12 8 Mechanical lithotripsy 1 Procedure successful 16 12 Final occlusive ERC negative 1512 Complications l* Median FUmo. 14(11-24) 19(10-24) ~Jnegative 15 12
THE "ANCHORING" TECHNIQUE: A NEW METHOD FOR PLACE-MENT OF LARGE BORE PLASTIC BILIARY STENTS. I Raijman. MD Anderson Cancer Center and University of Texas~ Houston. Placement of large bore plastic stents may prove difficult and sometimes tmpossible in both distal and proximal biliary strictures, whether benign or malignant. A new technique is described that has been successfully used in 10 consecutive patients. The strictures were malignant and located at the bifurcation (4), common hepatic duct (2), and common bile duct (4). The strictures were due to pancreatic cancer (4), gallbla-dder cancer (1), cholangiocarcmoma (1), colon cancer (3), and breast cancer (1). In all, the strictures had a lumen of 1 m m or less. Stricture dilation was not performed in any patient. ] h e new technique is as follows: Alter visualization of the stricture, a small papillotomy is performed and a hydrophyl/c guidewtre is passed beyond the stricture. An 11.5 Fr push catheter that accepts a 7 Fr guide catheter (Wilson-Cook) is accomodated on an 8.5 m m extractor balloon with a 7 Fr. Shaft (Microvasive). An 11.5 Fr plastic stent is then placed on the balloon shaft against the pusher catheter. The tapered tip of the stent is tan-gentially cut to allow passage of the balloon shaft. Silicone lubrication facilitates advancing the balloon both through the pusher catheter and the stent Once the balloonpusher-stent apparatus is assembled, it is advanced over the guidewire. Care must be taken to keep the balloon catheter and the pusher catheter closed together outside the endoscope while advancing the entire apparatus over the wire. Once the balloon catheter is beyond the stricture, it is pushed into the intrahepatic ducts and then maximally insufflated. This allows anchoring of the balloon intrahepatically. By doing so, the balloon catheter is tugged creating opposing forces and a stable anchored position that facilitates pushing of the stent into the bile duct and through the stricture. This tecnique has proved to be easily and successfully accomplished in patients with very difficult strictures that would otherwise reqture biliary dilation a n d / o r placement of smaller stents. This new technique is curronfly being evalu-ated and compared to standard methods in a larger number of patients.
9 1 residual intrahepatic BDS; *mild AP. Conclusion. ES and EBD seem to be comparable basis of the 3 parameters considered.
AB144
GASTROINTESTINAL ENDOSCOPY
on
the
VOLUME 45, NO. 4, 1997