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Randomized Trial Comparing the Tip of the Hydrophilic Guide Wire for Successful Deep Cannulation of the Common Bile Duct
Abstracts
T1286 Biliary Bezoar: A Rare Cause of Bile Duct Obstruction in Metallic Stent Patients Helio Medina, Rama P. Venu, Russell D. Brown Background: In patients with biliary obstruction secondary to malignancy, metallic stents (MS) have been shown to provide good palliation. Common causes of MS obstruction include: tumor ingrowth or overgrowth, stent migration, sludge/stone and hemobilia. We have observed that duodenal choledochal reflux of solid food may cause a ‘‘biliary bezoar’’ and lead to obstruction of MS. Aim: To describe the presentation and treatment of four patients in whom solid food debris lead to recurrent obstruction of the MS. Methods: Pts with MS obstruction were studied retrospectively. Data analyzed included: Pt demographics, lab data, initial diagnosis, stricture location, type of stent, cause of MS blockage, presence/absence of duodenal narrowing, and readmission dx after therapy. Criteria for the diagnosis of obstruction from biliary bezoar were: (1) Cholangiography showing multiple filling defects, (2) Visualization of solid food debris at endoscopic extraction, and (3) the absence of other causes of MS obstruction. Results: Four patients in over 200 that have undergone MS placement at our center from 1998-2004 were determined to have obstruction from duodenal choledochal reflux. All 4 patients initially presented with hyperbilirubinemia, 3 with cholangitis. All 4 developed recurrent obstruction w/ cholangitis following initial successful endotherapy. UGI study confirmed duodenal choledochal reflux in 2 of 3 studied, with partial narrowing of the duodenum noted in all 3. Three patients were ultimately treated with gastrojejunostomy (GJ), one with PEG and modified diet. Conclusions: Duodenal choledochal reflux of solid food causing a ‘‘biliary bezoar’’ is a rare but treatable cause of MS obstruction. Partial stenosis of the duodenum may be a contributing factor by favoring retrograde flow. Recognition of this condition is important as obstruction occurs early, recurrence is common, and treatment may require operation or alternative feeding methods.
T1287 Randomized Trial Comparing the Tip of the Hydrophilic Guide Wire for Successful Deep Cannulation of the Common Bile Duct Spyros Michopoulos, Georgios Stamatis, Georgios Manthos, Stefanos Karayiannis, Emmanouel Archavlis, Lambros Vlachakis, Athanasios Archimandritis Selective cannulation of the common bile duct (CBD) is one of the most difficult features of therapeutic ERCP. The aim of our study was to evaluate if the tip of the hydrophilic guide wire can influence the success rate of the deep cannulation of the CBD. Patients and Methods: 367 patients (175 men) without a history of previous ERCP were enrolled in the study. Difficult cannulation for this study was considered when a sphincterotome (Flow-cut, 0,035, Olympus, Japan) could not be inserted into the CBD after 3 attempts. An attempt was counted any time the sphincerotome touched the ampulla. All ERCPs were performed by a single senior operator. Deep cannulation was verified by the position of the sphincterotome under fluoroscopy and bile aspiration. No opacification was permited. Cannulation was unsuccessful by single sphincterotome for 46 patients (21 men). These patients were randomly assigned for the use of a hydrophilic guide wire (GW) (Jackwire, 0,035, Microvasive, USA) through the sphincterotome with either a J shape (GWJ) or a straight type (GWS) of the 5 cm tip. Five attempts were allowed for each GW. In case of impassability into the CBD a crossover interchange with the other type of GW was performed for 5 new attempts. If cannulation was unsuccessful again we considered it to be a failure of the method. Results: Age: 66,2G14,3 (MeanGSD) years. Indications for ERCP: 30 lithiasis, 14 neoplasias, 1 sump syndrome, 1 post-op stenosis of CBD. Initial guide wire tip: 24 GWS and 22 GWJ. Impossibility to cannulate with the first GW: 4GWS and 3GWJ (85% of success). The change of the GW led to one successful cannulation in each group. The mean number of attempts for CBD cannulation was 2,9G1,3 for GWS and 2,4G1,5 for GWJ (pZ0,21). Insertion into the pancreatic duct: 10 with GWS and 5 with GWJ (pZ0,29). Conclusions: 1) The use of a hydrophilic GW with a sphincterotome has a high success rate for the deep cannulation of the CBD 2) The type of the tip of the GW seems not to influence the success rate of cannulation or the insertion of the GW into the pancreatic duct 3) A change of the tip of the GW can add to small additional gain for successful cannulation.
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T1288 Small Sphincterotomy Combined with Papillary Dilation with Large Balloon Permits Retrieval of Large Stones without Lithotripsy Second Report Atsushi Minami, Takao Okuyama, Shinji Hirose Background: Endoscopic sphincterotomy (ES) has become an established therapeutic procedure, predominantly in the treatment of choledocholithiasis. In patients who have large stones, stone retrieval is technically difficult, particularly when a mechanical lithotriptor is required to crush them. This problem may be solved by a new method we call ‘‘Endoscopic Papillary Large Balloon Dilation (EPLBD) combined with ES’’ which we herein present. Patients and Methods: Retrieval of large biliary stones was performed in 35 patients including 2 B-II reconstruction cases. Mean stone size was 14C/ÿ3 mm and mean number of stones was 2.8C/ÿ1.5. Firstly, ES with a small incision up to the pancreatic orifice was performed over a wire guide. Next, endoscopic papillary dilation was performed with a large balloon (20 mm max in diameter) to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket. After stone retrieval, the bile duct was washed with normal saline to check for remaining stones. Our comparison of ES vs EPD (endoscopic papillary dilation) suggested that a small incision prevents pancreatic injury after EPD. We therefore performed EPLBD with a small ES. Results: Stone retrieval was successful in all cases without the need to crush large stones. Mean procedure time was 37C/ÿ5 minutes. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. This also helped to make confirmation of remaining stones easy. After dilation with the large balloon, there were some instances of oozing, but no perforations. No post-procedural pancreatitis and no cholangitis occurred. Two pneumobilia cases on CT scan were recognized in 7 cases on long-term follow up over 6 months. Discussion: EPLBD combined with a small ES was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy. Although ES with a large incision may be effective in reducing the indication of mechanical lithotripsy, a large incision has a higher risk of perforation and bleeding than a normal ES. Our new method, incorporating a slow dilation of the papilla up to a large diameter, could provide a larger opening than a large ES and could prevent perforation and bleeding. This method of stone retrieval is easy to perform and may be able to play a role in the treatment of large and multiple bile duct stones.
T1289 Diagnosis of Primary Sclerosing Cholangitis (PSC): A Blinded Comparative Study Using Magnetic Resonance Cholangiography (MRC) and Endoscopic Retrograde Cholangiography (ERC) Stephen L. Moff, Ihab R. Kamel, Jospeh Eustace, Leo P. Lawler, Sergey Kantsevoy, Anthony N. Kalloo, Paul J. Thuluvath ERC remains the gold standard for diagnosing PSC, however, MRC is being used increasingly by many physicians to diagnose or exclude PSC because it is less invasive. Based on our experience, we hypothesized that MRC may have less accuracy than ERC for PSC. In this study, we aimed to assess the diagnostic accuracy and interobserver agreement of both ERC and MRC in patients with PSC. Methods: We studied 36 PSC cases and 51 controls (normal/other biliary pathology) who had both ERC and MRC within 6 months of each other. MRCs and ERCs were read in an independent, blinded, randomized fashion by 2 MR radiologists (readers 1 & 2) and 2 interventional endoscopists (readers 3 & 4), respectively. No readers had access to the paired study. Readers did not have access to clinical history, laboratory results, or patient mix. The study organizers (SLM, PJT) did not participate in reading the images. Readers independently recorded ductal visualization, presence and severity of strictures, and scored the biliary ductal system using a classification system validated for PSC patients. Readers recorded the presence or absence of PSC and their level of certainty in this diagnosis. Results: Extra- and intrahepatic ductal (EHD, IHD) visualization was excellent in 64% and 66% of MRC and 86% and 74% of ERC cases and controls, respectively. For diagnosing PSC, the sensitivities for readers 1–4 were 91%, 88%, 81%, and 83% (pZ0.36), and the specificities for readers 1–4 were 85%, 90%, 96%, 96% (pZ0.12), respectively. Interobserver agreement for the diagnosis of PSC was very good (k MRC 0.83, ERC 0.73). Agreement on the presence and severity of EHD strictures was good for ERC (k 0.55) and poor for MRC (k 0.36), while on the presence of IHD strictures, agreement was very good for both (k MRC 0.64, ERC 0.86). When analysis was limited to the 36 PSC cases only, interobserver agreement was poor when determining disease severity [k 0.23 (EHD), 0.07 (IHD) for MRC and 0.24 (EHD), 0.34 (IHD) for ERC]. Conclusions: ERC and MRC were comparable for diagnosing PSC. Both modalities showed very good interobserver agreement for diagnosing PSC and for IHD strictures, but only ERC had good agreement for EHD strictures. Agreement was poor for both techniques when assessing disease severity.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB213
T1286 Biliary Bezoar: A Rare Cause of Bile Duct Obstruction in Metallic Stent Patients Helio Medina, Rama P. Venu, Russell D. Brown Background: In patients with biliary obstruction secondary to malignancy, metallic stents (MS) have been shown to provide good palliation. Common causes of MS obstruction include: tumor ingrowth or overgrowth, stent migration, sludge/stone and hemobilia. We have observed that duodenal choledochal reflux of solid food may cause a ‘‘biliary bezoar’’ and lead to obstruction of MS. Aim: To describe the presentation and treatment of four patients in whom solid food debris lead to recurrent obstruction of the MS. Methods: Pts with MS obstruction were studied retrospectively. Data analyzed included: Pt demographics, lab data, initial diagnosis, stricture location, type of stent, cause of MS blockage, presence/absence of duodenal narrowing, and readmission dx after therapy. Criteria for the diagnosis of obstruction from biliary bezoar were: (1) Cholangiography showing multiple filling defects, (2) Visualization of solid food debris at endoscopic extraction, and (3) the absence of other causes of MS obstruction. Results: Four patients in over 200 that have undergone MS placement at our center from 1998-2004 were determined to have obstruction from duodenal choledochal reflux. All 4 patients initially presented with hyperbilirubinemia, 3 with cholangitis. All 4 developed recurrent obstruction w/ cholangitis following initial successful endotherapy. UGI study confirmed duodenal choledochal reflux in 2 of 3 studied, with partial narrowing of the duodenum noted in all 3. Three patients were ultimately treated with gastrojejunostomy (GJ), one with PEG and modified diet. Conclusions: Duodenal choledochal reflux of solid food causing a ‘‘biliary bezoar’’ is a rare but treatable cause of MS obstruction. Partial stenosis of the duodenum may be a contributing factor by favoring retrograde flow. Recognition of this condition is important as obstruction occurs early, recurrence is common, and treatment may require operation or alternative feeding methods.
T1287 Randomized Trial Comparing the Tip of the Hydrophilic Guide Wire for Successful Deep Cannulation of the Common Bile Duct Spyros Michopoulos, Georgios Stamatis, Georgios Manthos, Stefanos Karayiannis, Emmanouel Archavlis, Lambros Vlachakis, Athanasios Archimandritis Selective cannulation of the common bile duct (CBD) is one of the most difficult features of therapeutic ERCP. The aim of our study was to evaluate if the tip of the hydrophilic guide wire can influence the success rate of the deep cannulation of the CBD. Patients and Methods: 367 patients (175 men) without a history of previous ERCP were enrolled in the study. Difficult cannulation for this study was considered when a sphincterotome (Flow-cut, 0,035, Olympus, Japan) could not be inserted into the CBD after 3 attempts. An attempt was counted any time the sphincerotome touched the ampulla. All ERCPs were performed by a single senior operator. Deep cannulation was verified by the position of the sphincterotome under fluoroscopy and bile aspiration. No opacification was permited. Cannulation was unsuccessful by single sphincterotome for 46 patients (21 men). These patients were randomly assigned for the use of a hydrophilic guide wire (GW) (Jackwire, 0,035, Microvasive, USA) through the sphincterotome with either a J shape (GWJ) or a straight type (GWS) of the 5 cm tip. Five attempts were allowed for each GW. In case of impassability into the CBD a crossover interchange with the other type of GW was performed for 5 new attempts. If cannulation was unsuccessful again we considered it to be a failure of the method. Results: Age: 66,2G14,3 (MeanGSD) years. Indications for ERCP: 30 lithiasis, 14 neoplasias, 1 sump syndrome, 1 post-op stenosis of CBD. Initial guide wire tip: 24 GWS and 22 GWJ. Impossibility to cannulate with the first GW: 4GWS and 3GWJ (85% of success). The change of the GW led to one successful cannulation in each group. The mean number of attempts for CBD cannulation was 2,9G1,3 for GWS and 2,4G1,5 for GWJ (pZ0,21). Insertion into the pancreatic duct: 10 with GWS and 5 with GWJ (pZ0,29). Conclusions: 1) The use of a hydrophilic GW with a sphincterotome has a high success rate for the deep cannulation of the CBD 2) The type of the tip of the GW seems not to influence the success rate of cannulation or the insertion of the GW into the pancreatic duct 3) A change of the tip of the GW can add to small additional gain for successful cannulation.
www.mosby.com/gie
T1288 Small Sphincterotomy Combined with Papillary Dilation with Large Balloon Permits Retrieval of Large Stones without Lithotripsy Second Report Atsushi Minami, Takao Okuyama, Shinji Hirose Background: Endoscopic sphincterotomy (ES) has become an established therapeutic procedure, predominantly in the treatment of choledocholithiasis. In patients who have large stones, stone retrieval is technically difficult, particularly when a mechanical lithotriptor is required to crush them. This problem may be solved by a new method we call ‘‘Endoscopic Papillary Large Balloon Dilation (EPLBD) combined with ES’’ which we herein present. Patients and Methods: Retrieval of large biliary stones was performed in 35 patients including 2 B-II reconstruction cases. Mean stone size was 14C/ÿ3 mm and mean number of stones was 2.8C/ÿ1.5. Firstly, ES with a small incision up to the pancreatic orifice was performed over a wire guide. Next, endoscopic papillary dilation was performed with a large balloon (20 mm max in diameter) to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket. After stone retrieval, the bile duct was washed with normal saline to check for remaining stones. Our comparison of ES vs EPD (endoscopic papillary dilation) suggested that a small incision prevents pancreatic injury after EPD. We therefore performed EPLBD with a small ES. Results: Stone retrieval was successful in all cases without the need to crush large stones. Mean procedure time was 37C/ÿ5 minutes. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. This also helped to make confirmation of remaining stones easy. After dilation with the large balloon, there were some instances of oozing, but no perforations. No post-procedural pancreatitis and no cholangitis occurred. Two pneumobilia cases on CT scan were recognized in 7 cases on long-term follow up over 6 months. Discussion: EPLBD combined with a small ES was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy. Although ES with a large incision may be effective in reducing the indication of mechanical lithotripsy, a large incision has a higher risk of perforation and bleeding than a normal ES. Our new method, incorporating a slow dilation of the papilla up to a large diameter, could provide a larger opening than a large ES and could prevent perforation and bleeding. This method of stone retrieval is easy to perform and may be able to play a role in the treatment of large and multiple bile duct stones.
T1289 Diagnosis of Primary Sclerosing Cholangitis (PSC): A Blinded Comparative Study Using Magnetic Resonance Cholangiography (MRC) and Endoscopic Retrograde Cholangiography (ERC) Stephen L. Moff, Ihab R. Kamel, Jospeh Eustace, Leo P. Lawler, Sergey Kantsevoy, Anthony N. Kalloo, Paul J. Thuluvath ERC remains the gold standard for diagnosing PSC, however, MRC is being used increasingly by many physicians to diagnose or exclude PSC because it is less invasive. Based on our experience, we hypothesized that MRC may have less accuracy than ERC for PSC. In this study, we aimed to assess the diagnostic accuracy and interobserver agreement of both ERC and MRC in patients with PSC. Methods: We studied 36 PSC cases and 51 controls (normal/other biliary pathology) who had both ERC and MRC within 6 months of each other. MRCs and ERCs were read in an independent, blinded, randomized fashion by 2 MR radiologists (readers 1 & 2) and 2 interventional endoscopists (readers 3 & 4), respectively. No readers had access to the paired study. Readers did not have access to clinical history, laboratory results, or patient mix. The study organizers (SLM, PJT) did not participate in reading the images. Readers independently recorded ductal visualization, presence and severity of strictures, and scored the biliary ductal system using a classification system validated for PSC patients. Readers recorded the presence or absence of PSC and their level of certainty in this diagnosis. Results: Extra- and intrahepatic ductal (EHD, IHD) visualization was excellent in 64% and 66% of MRC and 86% and 74% of ERC cases and controls, respectively. For diagnosing PSC, the sensitivities for readers 1–4 were 91%, 88%, 81%, and 83% (pZ0.36), and the specificities for readers 1–4 were 85%, 90%, 96%, 96% (pZ0.12), respectively. Interobserver agreement for the diagnosis of PSC was very good (k MRC 0.83, ERC 0.73). Agreement on the presence and severity of EHD strictures was good for ERC (k 0.55) and poor for MRC (k 0.36), while on the presence of IHD strictures, agreement was very good for both (k MRC 0.64, ERC 0.86). When analysis was limited to the 36 PSC cases only, interobserver agreement was poor when determining disease severity [k 0.23 (EHD), 0.07 (IHD) for MRC and 0.24 (EHD), 0.34 (IHD) for ERC]. Conclusions: ERC and MRC were comparable for diagnosing PSC. Both modalities showed very good interobserver agreement for diagnosing PSC and for IHD strictures, but only ERC had good agreement for EHD strictures. Agreement was poor for both techniques when assessing disease severity.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB213