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Metal vs plastic stents for malignant distal common bile duct stenosis: A prospective, controlled, randomized clinical trial
Vol. 9, No. 4 2005
etodolac groups, respectively, and there was no significant difference in the incidence of adenoma between the two groups. Biliary carcinomas developed in 15 of 17 (88%) hamsters in control group, and only 6 of 18 (33%) in etodolac group (P ⬍ 0.05). Severe cholangitis was evident in control hamsters, and the number and incidence of developing biliary carcinomas was well correlated with the degree of cholangitis. The cell kinetic study demonstrated that the average of proliferating cell nuclear antigen labeling index (PCNA LI) of the biliary epithelium was 9.67% and 5.14% in control and etodolac groups, respectively (P ⬍ 0.05). Selective COX-2 inhibitor suppressed the occurrence of persistent cholangitis and acceleration of cell kinetic activity of the biliary epithelium after biliary reconstruction, resulting a prevention of BOP-induced biliary carcinogenesis in hamsters.
233 ENDOSCOPIC RESECTION OF AMPULLARY NEOPLASIA Giuseppe Aliperti, MD, Kirsten Boessneck, Mandeep Sawhney, MD, Saint Louis University School of Medicine, St. Louis, MO; Midwest Therapeutic Endoscopy Consultants, St. Louis, MO; University of Minnesota, Minneapolis, MN Ampullary neoplasia has a well-established malignant potential. Pancreaticoduodenectomy (Whipple) is standard therapy; however, some patients are not fit or refuse that procedure. This series reports our experience with endoscopic resection in such patients; 41 patients with ampullary neoplasia underwent endoscopic resection with snares. In one case a hook-shaped needle-knife was used after saline lift injections. Dual sphincterotomy and protective dual stenting were performed in all but one patient. Thermal ablation with Nd-YAG laser or argon plasma coagulator was utilized for incomplete resections. Further therapy, if needed, was performed at 1-2 mo until completion. Of 41 patients (mean age 66.5 y, r 31-90 y) 7 (mean age 43.3 y) had familial adenomatous polyposis; 8 (mean age 70.4 y) had adenocarcinoma (CA) or high-grade dysplasia (HGD) in the resection specimen and were reconsidered for surgery. Three of 8 with CA/HGD underwent Whipple. Five were treated with endoscopic debulking, stenting, and/or thermal ablation (2 with complete CA/HGD resection). An average of 4.5 endoscopic procedures were required for 24 patients diagnosed prior to 2000, or with CA/HGD, and/or with complications; 2.1 were required for the other 17. Fifteen of the 24 (62.5%) and only 3 of the 17 (17.6%) underwent thermal ablation (P ⭐ 0.0035). One (without CA/HGD) had residual adenoma, treated to completion over 48 mo and remained free of disease 12 mo later. Three (without CA/HGD) had recurrent adenoma at mean followup of 40 mo (r 19-60 mo); one had a second recurrence. All were retreated and no recurrence occurred at mean follow-up of 6.3 mo. Four of 41 developed complications. The very first patient underwent protective pancreatic but not biliary stenting and developed cholangitis, resolved after subsequent stenting. Two developed delayed bleeding requiring 2 and 4 transfusions. Hemostasis was attained with bipolar electrocautery. One developed duodenal perforation with abscess and was treated with surgical abscess evacuation and duodenal T-tube. (1) Endoscopic management of ampullary adenomas is safe and often effective therapy for poor surgical candidates, however further experience and longer follow-up are necessary. (2) Addition of thermal therapy after resection appears to be useful to ablate residual adenomatous tissue (3) Such therapy should not be used in place of Whipple resection in patients with CA/HGD who are fit for surgery. (4) Resection attains highly adequate histologic specimens. (5) It is important during therapy to preserve biliary and pancreatic drainage and to conduct careful endoscopic follow-up to detect recurrences.
Abstracts
593
234 LIVER CYST OF ECHINOCOCCUS GRANULOSUS WITH RUPTURE INTO THE BILIARY TREE— SUCCESSFUL ENDOSCOPIC AND PHARMACEUTICAL TREATMENT Larisa Dzirlo, Michael Wasilewski, Elisabeth Poeschl, Brigitte Hellmich, Susanne Bach, Erich Hoffmann, Michael Gschwantler, Wilheminen Hospital, Vienna, Austria Rupture of hepatic cysts into the biliary tree with biliary obstruction is a common complication of hepatic hydatid disease (HHD) occurring in 5-10% of patients. Established treatment options include surgical resection, percutaneous drainage, diagnostic and therapeutic ERCP and adjuvant medical therapy. In the literature, there are only a few case reports about successful treatment of complicated HHD by a combination of endoscopic techniques and pharmaceutical therapy. A 28-year-old Serbian man was admitted to our hospital with jaundice, fever, and right-sided abdominal pain. He had a 2-year history of uncomplicated HHD. Abnormal laboratory results included elevation of liver function tests and CRP. Abdominal ultrasound and CT scan showed a 5 × 4 cm hydatid liver cyst in the right lobe of the liver. Endosonograpy revealed amorph material obstructing the common bile duct (CBD). After ERCP with endoscopic sphincterotomy daughter cysts drained into the duodenum spontaneously. During ERCP no direct communication of the cyst with the biliary tree could be demonstrated. After extraction of cyst material from the CBD a nasobiliary tube was inserted into the intrahepatic bile duct next to the cyst. Examination of extracted material revealed characteristic hooklets of Echinococcus granulosus. For 14 days 15 ml of 23% hypertonic saline solution were installed into the cyst three times a day. The patient received antibiotics and albendazole 400 mg bid. Clinical symptoms and liver function tests improved. However, there was no significant shrinking of the hydatid cyst. Two months later, the patient was admitted once again with jaundice. ERCP was performed and cyst material was removed from the CBD. This time a direct communication between cyst and biliary tree could be demonstrated and a nasobiliary tube could be placed directly into the cyst cavity. The cyst was irrigated with 15 ml of 23% hypertonic saline solution three times a day for two weeks. The patient improved rapidly. One month later, a CT scan showed disappearance of the liver cyst with calcification. Nine months after the procedure the patient is completely asymptomatic. Our case shows that the combination of pharmaceutical therapy and ERCP with local lavage of the cyst with hypertonic saline solution via a nasobiliary tube is a safe and effective method for treatment of complicated HHD. However, placement of the nasobiliary tube directly into the cyst seems to be essential for the success of the method.
235 METAL VS PLASTIC STENTS FOR MALIGNANT DISTAL COMMON BILE DUCT STENOSIS: A PROSPECTIVE, CONTROLLED, RANDOMIZED CLINICAL TRIAL Claes Soderlund V, MD, PhD, Stefan Linder V, MD, Department of Surgery, South Hospital, Stockholm, Sweden Only about 20% of patients with pancreatic head cancer are suitable for curative resection. Palliation of jaundice by placement of a polyethylene (PE) stent with ERC technique is well established. Stent occlusion typically occurs in 3-5 months, while wide bore metal (ME) stents are reported to remain open twice as long. The initial higher cost of the ME-stent might thus be balanced by less need for reintervention. Our aim was to compare the patency of endoscopically inserted 10F plastic PE stents vs. covered steel stents (Wallstent, Boston Scientific Nordic AB) in a RCT, in patients with malignant distal bile duct
594
Journal of Gastrointestinal Surgery
Abstracts
strictures not suitable for radical surgery. Endpoints were uneventful follow-up for 10 months, death or “failure,” defined as proven occluded stent at reintervention. Inclusion was terminated at 100 patients. Currently 97 patients are evaluable, 49 in the PE-group and 48 MEpatients. 54 patients died without (proven) stent failure within 10 months, after a median of 2.6 months. 35 patients had hepatic or pulmonary metastasis at inclusion, with a median survival of 2.5 months. 21 PE-patients and 10 ME-patients (P ⬍ 0.05) experienced proven stent failure, 8 more (6 PE, 2 ME) had clinical (no ERC) failure. Failure appeared after a median of 1.1 and 3.2 months, respectively. Overall median survival was 4.3 months, 40 patients did not survive 3 months. 9 patients (2 PE, 7 ME) survived 10 months without stent failure. This is the first RCT to compare plastic PE stents and covered steel stents. Our results indicate fewer patients with stent failure in the ME-group, and longer patency time in those ME-patients in which occlusion occurred. These results were significant despite a remarkably short overall survival.
236 METALLIC STENT FOR TREATMENT OF DORSAL DUCT STRICTURE IN PANCREAS DIVISUM: REPORT OF A CASE Franck Vandenbroucke, MD, Marylene Plasse, MD, Claude Saint Jean, Andre´ Roy, MD, CHUM Hopital Saint Luc, Montreal, PQ, Canada; CH Gramby, Gramby, PQ, Canada We report the first case of a stent of the dorsal pancreatic duct with a metallic stent for treatment of a patient with symptomatic pancreas divisum and secondary chronic pancreatitis. A 72-year-old patient, with medical history of lymphoma, was referred for recurrent acute pancreatitis. In 1999, an endoscopic retrograde cholangio-pancreatography (ERCP) revealed a pancreas divisum with a short cephalic dorsal duct stricture and in 2001, a double endoscopic sphincterotomy of the major and minor papilla was done. An endoscopic ultrasound showed a moderate chronic pancreatitis with a predominant dorsal duct. In January 2003, after a new bout of acute pancreatitis, an ERCP showed a short persistent cephalic stricture of the dorsal duct. A plastic stent (10 fr × 5 cm) was successfully inserted through the minor papilla with adequate decompression of the dorsal duct. No subsequent procedure was needed until June 2003, when the patient had a new episode of acute pancreatitis. At the same time, a recurrent lymphoma of the right breast was diagnosed. Chemotherapy was re-instituted. ERCP showed a stable stricture of the dorsal duct. The pancreatic stent was changed for an uncovered metallic stent (8 mm × 4 cm) (Wallstent endoprothesis endoscopic biliary with unistep plus delivery system; Boston Scientific, Natick - USA) allowing drainage of side pancreatic branches. We decided to use a metallic stent in the context of his recurrent lymphoma in order to avoid a radical surgery, delay the patient’s treatment for his lymphoma and prevent any further acute pancreatitis. The patient has since then been symptom-free in regard to his pancreas divisum. He also had a complete response after chemotherapy for his lymphoma without any recurrence. In our patient’s situation, there was a persistent stricture of the dorsal duct. Treatment of this stricture could not be achieved by sphincteroplasty alone and surgical drainage procedures were not indicated because of the absence of significant duct dilatation and the general condition of the patient. Thus, insertion of a wallstent for correction of the dorsal duct stricture was then considered a good option. In conclusion, the use of metallic stent for correction of a dorsal pancreatic duct stricture in the context of a pancreas divisum is an effective procedure. This treatment can be a valuable alternative to surgical procedures in selected cases.
237 TREATMENT OF BILIARY STENOSIS AFTER LIVER TRANSPLANTATION USING WALLSTENTS Franck Vandenbroucke, MD, Marylene Plasse, MD, Andre´ Roy, MD, CHUM Hopital Saint-Luc, Montreal, PQ, Canada Biliary stenosis are common after orthotopic liver transplantation (OLT), with a 15% reported incidence. Endoscopic treatment with dilatation and plastic stent is now a valuable therapeutic option. However, the use of metallic stents (Wallstents) to treat this condition is debated. The aim of this study was to report our experience using Wallstents to treat biliary stenosis after OLT. From January 1999 to July 2004, 279 patients underwent 306 whole-liver transplantations in our center. Among the 222 (73%) OLT performed with choledochocholedochostomy, 100 (45%) biliary stenosis were diagnosed and treated by endoscopic retrograde cholangio-pancreatography (ERCP) or percutaneous procedures. Primary hepaticojejunostomy (HJ) were excluded. Twenty-one patients (mean age 57.0 ⫾ 5.6 years) treated by a Wallstent were retrospectively studied. Stent was considered obstructed when insertion of a plastic or a second metallic stent was required or when surgical HJ was needed. The operative time, cold and warm ischemic time for the 21 studied cases were, respectively, 225 ⫾ 60, 460 ⫾ 158, and 40 ⫾ 9 minutes. Mean blood losses were 1420 ⫾ 1100 (400-3500) ml. Donors mean age was 45.5 ⫾ 16.2 (1770) years. Proximal and anastomotic stenosis were diagnosed in 4 and 17 patients and a Wallstent was placed by ERCP or percutaneous approach in 18 and 3 patients, respectively. A bile leak was identified in 4 (19%) patients. The mean interval between diagnosis and Wallstent insertion was 179.7 ⫾ 292.8 (0-1113) days. Total number of procedures for treatment was 7.4 ⫾ 5.5, with 3.7 ⫾ 3.9 and 2.7 ⫾ 3.4 procedures before and after Wallstent insertion. The mean duration of patency was 10.8 ⫾ 7.8 (0.9-25.1) months with 12, 18, and 24 month-patency rates of 64%, 51%, and 26%, respectively, after a mean follow-up of 37.8 ⫾ 17.2 months. An HJ was performed in 5 (24%) patients and two (10%) patients underwent a second transplant for ischemic cholangitis and chronic rejection after a mean intervall of 782.1 ⫾ 638.2 days after diagnosis. No graft was lost because of the use of a Wallstent. Overall complication rate was 29% including 3 pancreatitis, 2 cholangitis and one case of aeroportia. Treatment of post-transplant biliary stenosis using a Wallstent is a valuable option allowing to delay or to avoid surgery in 70% of patients. Endoscopic cleaning of the stent is simple with a low complication rate. Proximal stenosis can be treated this way in selected patients with major comorbidities. No technical problem was encountered during the removal of the stent when HJ was needed. The use of a temporary Wallstent in order to dilate post-transplant stenosis can also be considered and is actually under study.
238 HEPATOBILIARY AND PANCREATIC SURGICAL PUBLISHING IN TEN LEADING SURGICAL JOURNALS Shahzeer Karmali, MD, Charles M Vollmer, Jr., MD, FRCP, Oliver Bathe, MD, FRCP, Janice L. Paseika, MD, FRCP, Francis Sutherland, MD, FRCP, Elijah Dixon, MD, FRCP, University of Calgary, Calgary, AB, Canada; Beth Israel Deaconess Medical Center, Boston, MA A rapidly growing knowledge base about recently developed diagnostic and therapeutic modalities in the management of hepatic-pancreaticbiliary (HPB) disease has emerged. With such advancement it is expected that the literature of the current day should reflect the emerging and evolving field of HPB surgery. We sought to review the surgical literature in the past 4 years to examine the predominance and scope of HPB topics in publication. Ten leading surgical journals over two
etodolac groups, respectively, and there was no significant difference in the incidence of adenoma between the two groups. Biliary carcinomas developed in 15 of 17 (88%) hamsters in control group, and only 6 of 18 (33%) in etodolac group (P ⬍ 0.05). Severe cholangitis was evident in control hamsters, and the number and incidence of developing biliary carcinomas was well correlated with the degree of cholangitis. The cell kinetic study demonstrated that the average of proliferating cell nuclear antigen labeling index (PCNA LI) of the biliary epithelium was 9.67% and 5.14% in control and etodolac groups, respectively (P ⬍ 0.05). Selective COX-2 inhibitor suppressed the occurrence of persistent cholangitis and acceleration of cell kinetic activity of the biliary epithelium after biliary reconstruction, resulting a prevention of BOP-induced biliary carcinogenesis in hamsters.
233 ENDOSCOPIC RESECTION OF AMPULLARY NEOPLASIA Giuseppe Aliperti, MD, Kirsten Boessneck, Mandeep Sawhney, MD, Saint Louis University School of Medicine, St. Louis, MO; Midwest Therapeutic Endoscopy Consultants, St. Louis, MO; University of Minnesota, Minneapolis, MN Ampullary neoplasia has a well-established malignant potential. Pancreaticoduodenectomy (Whipple) is standard therapy; however, some patients are not fit or refuse that procedure. This series reports our experience with endoscopic resection in such patients; 41 patients with ampullary neoplasia underwent endoscopic resection with snares. In one case a hook-shaped needle-knife was used after saline lift injections. Dual sphincterotomy and protective dual stenting were performed in all but one patient. Thermal ablation with Nd-YAG laser or argon plasma coagulator was utilized for incomplete resections. Further therapy, if needed, was performed at 1-2 mo until completion. Of 41 patients (mean age 66.5 y, r 31-90 y) 7 (mean age 43.3 y) had familial adenomatous polyposis; 8 (mean age 70.4 y) had adenocarcinoma (CA) or high-grade dysplasia (HGD) in the resection specimen and were reconsidered for surgery. Three of 8 with CA/HGD underwent Whipple. Five were treated with endoscopic debulking, stenting, and/or thermal ablation (2 with complete CA/HGD resection). An average of 4.5 endoscopic procedures were required for 24 patients diagnosed prior to 2000, or with CA/HGD, and/or with complications; 2.1 were required for the other 17. Fifteen of the 24 (62.5%) and only 3 of the 17 (17.6%) underwent thermal ablation (P ⭐ 0.0035). One (without CA/HGD) had residual adenoma, treated to completion over 48 mo and remained free of disease 12 mo later. Three (without CA/HGD) had recurrent adenoma at mean followup of 40 mo (r 19-60 mo); one had a second recurrence. All were retreated and no recurrence occurred at mean follow-up of 6.3 mo. Four of 41 developed complications. The very first patient underwent protective pancreatic but not biliary stenting and developed cholangitis, resolved after subsequent stenting. Two developed delayed bleeding requiring 2 and 4 transfusions. Hemostasis was attained with bipolar electrocautery. One developed duodenal perforation with abscess and was treated with surgical abscess evacuation and duodenal T-tube. (1) Endoscopic management of ampullary adenomas is safe and often effective therapy for poor surgical candidates, however further experience and longer follow-up are necessary. (2) Addition of thermal therapy after resection appears to be useful to ablate residual adenomatous tissue (3) Such therapy should not be used in place of Whipple resection in patients with CA/HGD who are fit for surgery. (4) Resection attains highly adequate histologic specimens. (5) It is important during therapy to preserve biliary and pancreatic drainage and to conduct careful endoscopic follow-up to detect recurrences.
Abstracts
593
234 LIVER CYST OF ECHINOCOCCUS GRANULOSUS WITH RUPTURE INTO THE BILIARY TREE— SUCCESSFUL ENDOSCOPIC AND PHARMACEUTICAL TREATMENT Larisa Dzirlo, Michael Wasilewski, Elisabeth Poeschl, Brigitte Hellmich, Susanne Bach, Erich Hoffmann, Michael Gschwantler, Wilheminen Hospital, Vienna, Austria Rupture of hepatic cysts into the biliary tree with biliary obstruction is a common complication of hepatic hydatid disease (HHD) occurring in 5-10% of patients. Established treatment options include surgical resection, percutaneous drainage, diagnostic and therapeutic ERCP and adjuvant medical therapy. In the literature, there are only a few case reports about successful treatment of complicated HHD by a combination of endoscopic techniques and pharmaceutical therapy. A 28-year-old Serbian man was admitted to our hospital with jaundice, fever, and right-sided abdominal pain. He had a 2-year history of uncomplicated HHD. Abnormal laboratory results included elevation of liver function tests and CRP. Abdominal ultrasound and CT scan showed a 5 × 4 cm hydatid liver cyst in the right lobe of the liver. Endosonograpy revealed amorph material obstructing the common bile duct (CBD). After ERCP with endoscopic sphincterotomy daughter cysts drained into the duodenum spontaneously. During ERCP no direct communication of the cyst with the biliary tree could be demonstrated. After extraction of cyst material from the CBD a nasobiliary tube was inserted into the intrahepatic bile duct next to the cyst. Examination of extracted material revealed characteristic hooklets of Echinococcus granulosus. For 14 days 15 ml of 23% hypertonic saline solution were installed into the cyst three times a day. The patient received antibiotics and albendazole 400 mg bid. Clinical symptoms and liver function tests improved. However, there was no significant shrinking of the hydatid cyst. Two months later, the patient was admitted once again with jaundice. ERCP was performed and cyst material was removed from the CBD. This time a direct communication between cyst and biliary tree could be demonstrated and a nasobiliary tube could be placed directly into the cyst cavity. The cyst was irrigated with 15 ml of 23% hypertonic saline solution three times a day for two weeks. The patient improved rapidly. One month later, a CT scan showed disappearance of the liver cyst with calcification. Nine months after the procedure the patient is completely asymptomatic. Our case shows that the combination of pharmaceutical therapy and ERCP with local lavage of the cyst with hypertonic saline solution via a nasobiliary tube is a safe and effective method for treatment of complicated HHD. However, placement of the nasobiliary tube directly into the cyst seems to be essential for the success of the method.
235 METAL VS PLASTIC STENTS FOR MALIGNANT DISTAL COMMON BILE DUCT STENOSIS: A PROSPECTIVE, CONTROLLED, RANDOMIZED CLINICAL TRIAL Claes Soderlund V, MD, PhD, Stefan Linder V, MD, Department of Surgery, South Hospital, Stockholm, Sweden Only about 20% of patients with pancreatic head cancer are suitable for curative resection. Palliation of jaundice by placement of a polyethylene (PE) stent with ERC technique is well established. Stent occlusion typically occurs in 3-5 months, while wide bore metal (ME) stents are reported to remain open twice as long. The initial higher cost of the ME-stent might thus be balanced by less need for reintervention. Our aim was to compare the patency of endoscopically inserted 10F plastic PE stents vs. covered steel stents (Wallstent, Boston Scientific Nordic AB) in a RCT, in patients with malignant distal bile duct
594
Journal of Gastrointestinal Surgery
Abstracts
strictures not suitable for radical surgery. Endpoints were uneventful follow-up for 10 months, death or “failure,” defined as proven occluded stent at reintervention. Inclusion was terminated at 100 patients. Currently 97 patients are evaluable, 49 in the PE-group and 48 MEpatients. 54 patients died without (proven) stent failure within 10 months, after a median of 2.6 months. 35 patients had hepatic or pulmonary metastasis at inclusion, with a median survival of 2.5 months. 21 PE-patients and 10 ME-patients (P ⬍ 0.05) experienced proven stent failure, 8 more (6 PE, 2 ME) had clinical (no ERC) failure. Failure appeared after a median of 1.1 and 3.2 months, respectively. Overall median survival was 4.3 months, 40 patients did not survive 3 months. 9 patients (2 PE, 7 ME) survived 10 months without stent failure. This is the first RCT to compare plastic PE stents and covered steel stents. Our results indicate fewer patients with stent failure in the ME-group, and longer patency time in those ME-patients in which occlusion occurred. These results were significant despite a remarkably short overall survival.
236 METALLIC STENT FOR TREATMENT OF DORSAL DUCT STRICTURE IN PANCREAS DIVISUM: REPORT OF A CASE Franck Vandenbroucke, MD, Marylene Plasse, MD, Claude Saint Jean, Andre´ Roy, MD, CHUM Hopital Saint Luc, Montreal, PQ, Canada; CH Gramby, Gramby, PQ, Canada We report the first case of a stent of the dorsal pancreatic duct with a metallic stent for treatment of a patient with symptomatic pancreas divisum and secondary chronic pancreatitis. A 72-year-old patient, with medical history of lymphoma, was referred for recurrent acute pancreatitis. In 1999, an endoscopic retrograde cholangio-pancreatography (ERCP) revealed a pancreas divisum with a short cephalic dorsal duct stricture and in 2001, a double endoscopic sphincterotomy of the major and minor papilla was done. An endoscopic ultrasound showed a moderate chronic pancreatitis with a predominant dorsal duct. In January 2003, after a new bout of acute pancreatitis, an ERCP showed a short persistent cephalic stricture of the dorsal duct. A plastic stent (10 fr × 5 cm) was successfully inserted through the minor papilla with adequate decompression of the dorsal duct. No subsequent procedure was needed until June 2003, when the patient had a new episode of acute pancreatitis. At the same time, a recurrent lymphoma of the right breast was diagnosed. Chemotherapy was re-instituted. ERCP showed a stable stricture of the dorsal duct. The pancreatic stent was changed for an uncovered metallic stent (8 mm × 4 cm) (Wallstent endoprothesis endoscopic biliary with unistep plus delivery system; Boston Scientific, Natick - USA) allowing drainage of side pancreatic branches. We decided to use a metallic stent in the context of his recurrent lymphoma in order to avoid a radical surgery, delay the patient’s treatment for his lymphoma and prevent any further acute pancreatitis. The patient has since then been symptom-free in regard to his pancreas divisum. He also had a complete response after chemotherapy for his lymphoma without any recurrence. In our patient’s situation, there was a persistent stricture of the dorsal duct. Treatment of this stricture could not be achieved by sphincteroplasty alone and surgical drainage procedures were not indicated because of the absence of significant duct dilatation and the general condition of the patient. Thus, insertion of a wallstent for correction of the dorsal duct stricture was then considered a good option. In conclusion, the use of metallic stent for correction of a dorsal pancreatic duct stricture in the context of a pancreas divisum is an effective procedure. This treatment can be a valuable alternative to surgical procedures in selected cases.
237 TREATMENT OF BILIARY STENOSIS AFTER LIVER TRANSPLANTATION USING WALLSTENTS Franck Vandenbroucke, MD, Marylene Plasse, MD, Andre´ Roy, MD, CHUM Hopital Saint-Luc, Montreal, PQ, Canada Biliary stenosis are common after orthotopic liver transplantation (OLT), with a 15% reported incidence. Endoscopic treatment with dilatation and plastic stent is now a valuable therapeutic option. However, the use of metallic stents (Wallstents) to treat this condition is debated. The aim of this study was to report our experience using Wallstents to treat biliary stenosis after OLT. From January 1999 to July 2004, 279 patients underwent 306 whole-liver transplantations in our center. Among the 222 (73%) OLT performed with choledochocholedochostomy, 100 (45%) biliary stenosis were diagnosed and treated by endoscopic retrograde cholangio-pancreatography (ERCP) or percutaneous procedures. Primary hepaticojejunostomy (HJ) were excluded. Twenty-one patients (mean age 57.0 ⫾ 5.6 years) treated by a Wallstent were retrospectively studied. Stent was considered obstructed when insertion of a plastic or a second metallic stent was required or when surgical HJ was needed. The operative time, cold and warm ischemic time for the 21 studied cases were, respectively, 225 ⫾ 60, 460 ⫾ 158, and 40 ⫾ 9 minutes. Mean blood losses were 1420 ⫾ 1100 (400-3500) ml. Donors mean age was 45.5 ⫾ 16.2 (1770) years. Proximal and anastomotic stenosis were diagnosed in 4 and 17 patients and a Wallstent was placed by ERCP or percutaneous approach in 18 and 3 patients, respectively. A bile leak was identified in 4 (19%) patients. The mean interval between diagnosis and Wallstent insertion was 179.7 ⫾ 292.8 (0-1113) days. Total number of procedures for treatment was 7.4 ⫾ 5.5, with 3.7 ⫾ 3.9 and 2.7 ⫾ 3.4 procedures before and after Wallstent insertion. The mean duration of patency was 10.8 ⫾ 7.8 (0.9-25.1) months with 12, 18, and 24 month-patency rates of 64%, 51%, and 26%, respectively, after a mean follow-up of 37.8 ⫾ 17.2 months. An HJ was performed in 5 (24%) patients and two (10%) patients underwent a second transplant for ischemic cholangitis and chronic rejection after a mean intervall of 782.1 ⫾ 638.2 days after diagnosis. No graft was lost because of the use of a Wallstent. Overall complication rate was 29% including 3 pancreatitis, 2 cholangitis and one case of aeroportia. Treatment of post-transplant biliary stenosis using a Wallstent is a valuable option allowing to delay or to avoid surgery in 70% of patients. Endoscopic cleaning of the stent is simple with a low complication rate. Proximal stenosis can be treated this way in selected patients with major comorbidities. No technical problem was encountered during the removal of the stent when HJ was needed. The use of a temporary Wallstent in order to dilate post-transplant stenosis can also be considered and is actually under study.
238 HEPATOBILIARY AND PANCREATIC SURGICAL PUBLISHING IN TEN LEADING SURGICAL JOURNALS Shahzeer Karmali, MD, Charles M Vollmer, Jr., MD, FRCP, Oliver Bathe, MD, FRCP, Janice L. Paseika, MD, FRCP, Francis Sutherland, MD, FRCP, Elijah Dixon, MD, FRCP, University of Calgary, Calgary, AB, Canada; Beth Israel Deaconess Medical Center, Boston, MA A rapidly growing knowledge base about recently developed diagnostic and therapeutic modalities in the management of hepatic-pancreaticbiliary (HPB) disease has emerged. With such advancement it is expected that the literature of the current day should reflect the emerging and evolving field of HPB surgery. We sought to review the surgical literature in the past 4 years to examine the predominance and scope of HPB topics in publication. Ten leading surgical journals over two