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Reactive papillary changes secondary to plastic endoprostheses may mimic villous neoplasm
ERCP-BILIARY 497
t499
REACTIVE PAPILLARY CHANGES SECONDARY TO PLASTIC ENDOPROSTHESES MAY MIMIC VILLOUS NEOPLASM. SG Silva. GB Haber, PP Kortan, JA Martin, M Abedi, GA DuVall, JA Dorais, R Saidi. The Wellesley Hospital, University of Toronto, Ontario, Canada.
TRANSPAPILLARY STENTS EFFECTIVELY TREAT TRAUMATIC INTRAHEPATIC BILIARY LEAKS. A Slivka JA Martin WB Silverman WG Parsons DL Carr-Locke. University of Pittsburgh Medical Center, Pittsburgh PA, Brigham and Women's Hospital, Boston, MA, and Northwestern University Medical School, Chicago, IL.
BACKGROUND: Inthe course of stent exchange for benign and malignant disease, we have observed enlargement and villiform changes to the papilla. These changes may closely mimic the macroscopic appearance of ampullary neoplasm. This study was undertaken to characterize the nature of these changes, which has not been previously addressed. PATIENTSAND METHODS: We undertook a retrospective chart review of all 270 patients who underwent transpapillary placement of a polyethylene (261) or Teflon (9) endoprosthesis between 1/92 and 7/96. Excluding patients with ampullary tumors and with stonts placed for the sole purpose of guiding sphinctarotomy, 21 of these patients were noted on followup duodenoacopy to have new vitiiform (10) or bulbous (11) change in the endoscopic appearance of the papilla. 12 of these underwent multiple biopsies of the papilla and are the focus of this study. 17 patients had undergone stenting for benign indications (oholedooholithiasis (5), papillary stenosis (3), benign CBD stricture (3), OBD stricture and choledocholithiasis (1), chronic pancreatitis (4), and pancreas divisum (1)), and 4 for malignant indioations (malignant CBD stricture (1), pancreatic CA (3)). Histology was interpreted by an anatomical pathologist. RESULTS: In this review, 21/270 (7.8%) patients were identified with new macroscopic changesofthepapillastthetimeofstentremovalorexchange. Ofthe 12whohad biopsies, all showed consistent histopathologic features of inflammation (11), and normal muoosa with compression artefact (1). None had features consistent with or suggestive of neoplasm. The mean duration of stenfing prior to these observations was 14 months (villous 17, bulbous 8). The mean aggregate stent diameter (ASD) was 32 (villous 40, bulbous 17). CONCLUSIONS: When villous or bulbous macroscopic change is identified as a new finding in patients who have undergone transpapillary stanting, it is unlikely to be malignant. This finding, and villous change in particular, is associated with prolonged duration of stent placement, as often occurs with benign sh'ictures, and with a larger aggregate diameter of the indwelling endoprosthesis.
Introduction: Short transpapillary biliary stents placed during ERCP have been shown to be effective treatment for cystic duct leaks following laparoscopic cholecystectomy (Bjorkman et al Am J Gastroen~rol 1995). The efficacy of this therapy for traumatic intrahepatic biliary leaks has not been evaluated. We report our experience in 6 patients with bile leaks following abdominal trauma who were managed with endoscopically placed short biliary stents. Results: 6 patients mean age=24.5 yrs (range 17-34yrs) presented with bile leaks an average of 21 days (range 4-40 days) following motor vehicle accident in 4/6 or gunshot wound in 2/6. The leaks presented as bilious output from peritoneal drains in 3/6, from a chest robe in 1/6, from diagnostic paracentesis in 1/6, and based on a HIDA scan only in 1/6. One patient underwent unsuccessful hcpatorrhaphy prior to endoscopy. At ERCP, leaks were demonstrated from R hepatic duct in 3/6, L hepatic duct in 2/6, and both ducts in 1/6. 5/6 patients were treated successfully at index endoscopy with a transpapillary stcnt placed without papillotomy (3/6 10Fr 3cm, 1/6 10Fr 2cm, 1/6 7Fr 5cm). The sixth patient had a biliary sphincterotomy and 8.5Fr 15cm stent placed beyond the leak. This therapy was unsuccessful as judged by paracentesis and HIDA scan 7 days later. The patient then had successful treatment with a 10Fr 5cm stent 9Leak closure was documented in 5 patients at a mean of 5.6 days (range 1-14 days). Stents were removed at endoscopy at 31 days (range 18-54 days). There were no procedure related complications. Condusions: Similar to cystic duct leaks, traumatic intrahcpatic biliary leaks can be safely and effectively treated with short transpapiliary biliary stents. The presumed mechanism of action is equilibration of biliary pressure to that of the duodenum. Short stents have better flow characteristics compared with long stents, and mechanical bridging of the leak is not necessary.
T498
t500
A CLINICALLY FRIENDLY CLASSIFICATION OF S P H I N C T E R OF ODDI D Y S F U N C T I O N (SOD) BASED ON SIMPLIFIED MILWAUKEE CRITERIA WB Silyerman. A Slivka, M Rabinovitz, University of Pittsburgh, Pittsburgh, PA. l n t r o d u e t i o n : l . V a r i o u s studies have examined the frequency of abnormal sphincter of Oddi manometry (SOM) relative to SOD type (using the Milwaukee criteria.). Certain criteria (duct drainage time; phasic frequency, duration & propagation) may no longer be valid, and are often omitted in clinical practice. Therefore, we omitted them from this analysis, 2. The vexing problem of how to classify patients with maroinal elevations in lab tests remains unanswered. A i m : 1)To determine the frequency of elevated basal sphincter pressure (BSP) in patients using a simplified Type II and III SOD; 2) To determine whether to classify "hybrid" patients (i.e. with marginal elevations in lab tests) as type II or as type Ill. Methods: From 1/93 to 10/96, 114 consecutive patients w/o prior sphincterotomy were evaluated for SOD 1I / III. All had rigorous eval. to R/O other etiologies. There were 82 F and 31 M; ages 12 to 87 yrs. SOD II was defined as pain + lab elevation (TB, ALl', AST, ALP, Amylase, or Lipase) :,. i .5 x ULN or dilated ducts (CBD > 12mm or PD >5mm). HYBRID patients had pain + lab elevation < 1.5 x ULN. SODHI patients had pain only, with normal lab tests and duct diameters. Drainage times, frequency, duration & propagation were not assessed. Abnormal SOM was defined as BSP in CBD or PDL~O mmHg. Results: Successful SOM of the CBD or PD was obtained in 113/114 )atients: SOD t},pe #patients %abnl. SOM 9 5 ~ C.I. Total 113 63 ~71/i 13) (53,72)
ENDOSCOPIC MANAGEMENT OF SIMPLE & COMPLICATED BILIARY LEAKS BR Stotland, ML Kochman, Long WB, DO Faigel, GG Ginsberg, Gastroenterology Division, University of Pennsylvania, Phila., PA
II
83
65 (54/83)
(53,75)
HYBRID Ill
9 21
89 (8/9 / 43 (9/21)
(52, 99) (22, 67)
Parwise Test Significant ? p : (Fisher's Exact) SOD II vs HYBRID no p=0.26 SOD HI vs HYBRID yes p=0.04 SOD II vs SOD III yes 13=0.08 Test of Homogeneity yes p=0.05 -ondusions: 1 ]y selective referrs center, the incidence o r abnormal SOM (using elevated BSP only) in simplified SOD lI and Ill is similar to other recently published data. 2. There was no significant difference in abnormal frequency of SOD II vs HYBRID. 3. HYBRID SOD patients should be considered as type II SOD. Study is ongoing.
VOLUME 45, NO. 4, 1997
Most "simple" biliary leaks are successfully managed by transpapiltary stenting [TPS] and/or endoscopic sphincterotomy [ES]. Biliary leaks with concomitant obstruction to flow by stricture or stone have been termed "complex"; and typically require adjunctive therapies. We have identified a subgroup of bile leaks distinguished by being "complicated" by a local organized fluid collection and their poor response to "simple" management. We define these complicated bile leaks in the context of all leaks and describe specific management strategies. Methods: We reviewed all bile duct leaks identified and managed endoscopically over a 40 month period. We reviewed the etiology, site of ductal injury, presence of focal fluid collection, type of endoscopic intervention and clinical outcome. Results: Among 36 patients, the etiologies were: taparoscopic cholecystectomy(12), open cholecystectomy(3), T-tube removal after orthotopic liver transplantation JOLT](12), biliary anastomosis after OLT(3), abdominal trauma(3), partial hepatectomy for malignancy(2), and other abdominal surgery(I). Endoscopic management included TPS (21), ES(I), combined TPS and ES(12), and 7Fr nasobiliary [NB] tube(2) (both for OLT T-tube tract leaks). Of those with TPS, 3 of the stems were preferentially placed to bridge the leak. Transpapillary stent diameters were 10 Fr(12) and 7 Fr(20). Follow up ERCP was performed to confirm leak healing (mean interval = 4.5 wk) except after NB tube placement. At follow up ERCP 28 patients(78%) had resolution of the leak. Eight patients had persistant leaks: i)Two post-taparescopic cholecystectomy cystic duct leaks initially treated with 7 Fr TPS had persistant catheter drainage at 1 week, prompting repeat TPS with 12Fr stent fascillitating resolution at 4 weeks follow up. ii) Three patients with focal flud collections at the leak site (biloma=2, hematoma=l) failed to respond to 7F TPS's at 2,4, and 6 wks respectively. In these three cases two large diameter (> 10Fr) TPS's were placed in parallel bridging the leak site, and follow up ERCP at 5 to 9 wk confirmed resolution, iii) One post-OLT T-tube tract leak was repaired surgically 3 days after ERCP.iv) Two patients had non-biliary sepsis and died of septic complications. Among patients who responded to initial therapy, local fluid collection at the leak site was only documented in 6 patients. Conclusions: (1) "Simple" bile leaks are effectivly managed by TPS, ES, TPS + ES, or NB tube in the majority of cases. (2) TPS with large diameter (> 10 Fr) stent alone achieves high success and avoids the risks of ES. (3) "Complicated" bile leaks may be effectivly managed by placing two stents in parallel, bridging the leak.
GASTROINTESTINAL ENDOSCOPY AB149
t499
REACTIVE PAPILLARY CHANGES SECONDARY TO PLASTIC ENDOPROSTHESES MAY MIMIC VILLOUS NEOPLASM. SG Silva. GB Haber, PP Kortan, JA Martin, M Abedi, GA DuVall, JA Dorais, R Saidi. The Wellesley Hospital, University of Toronto, Ontario, Canada.
TRANSPAPILLARY STENTS EFFECTIVELY TREAT TRAUMATIC INTRAHEPATIC BILIARY LEAKS. A Slivka JA Martin WB Silverman WG Parsons DL Carr-Locke. University of Pittsburgh Medical Center, Pittsburgh PA, Brigham and Women's Hospital, Boston, MA, and Northwestern University Medical School, Chicago, IL.
BACKGROUND: Inthe course of stent exchange for benign and malignant disease, we have observed enlargement and villiform changes to the papilla. These changes may closely mimic the macroscopic appearance of ampullary neoplasm. This study was undertaken to characterize the nature of these changes, which has not been previously addressed. PATIENTSAND METHODS: We undertook a retrospective chart review of all 270 patients who underwent transpapillary placement of a polyethylene (261) or Teflon (9) endoprosthesis between 1/92 and 7/96. Excluding patients with ampullary tumors and with stonts placed for the sole purpose of guiding sphinctarotomy, 21 of these patients were noted on followup duodenoacopy to have new vitiiform (10) or bulbous (11) change in the endoscopic appearance of the papilla. 12 of these underwent multiple biopsies of the papilla and are the focus of this study. 17 patients had undergone stenting for benign indications (oholedooholithiasis (5), papillary stenosis (3), benign CBD stricture (3), OBD stricture and choledocholithiasis (1), chronic pancreatitis (4), and pancreas divisum (1)), and 4 for malignant indioations (malignant CBD stricture (1), pancreatic CA (3)). Histology was interpreted by an anatomical pathologist. RESULTS: In this review, 21/270 (7.8%) patients were identified with new macroscopic changesofthepapillastthetimeofstentremovalorexchange. Ofthe 12whohad biopsies, all showed consistent histopathologic features of inflammation (11), and normal muoosa with compression artefact (1). None had features consistent with or suggestive of neoplasm. The mean duration of stenfing prior to these observations was 14 months (villous 17, bulbous 8). The mean aggregate stent diameter (ASD) was 32 (villous 40, bulbous 17). CONCLUSIONS: When villous or bulbous macroscopic change is identified as a new finding in patients who have undergone transpapillary stanting, it is unlikely to be malignant. This finding, and villous change in particular, is associated with prolonged duration of stent placement, as often occurs with benign sh'ictures, and with a larger aggregate diameter of the indwelling endoprosthesis.
Introduction: Short transpapillary biliary stents placed during ERCP have been shown to be effective treatment for cystic duct leaks following laparoscopic cholecystectomy (Bjorkman et al Am J Gastroen~rol 1995). The efficacy of this therapy for traumatic intrahepatic biliary leaks has not been evaluated. We report our experience in 6 patients with bile leaks following abdominal trauma who were managed with endoscopically placed short biliary stents. Results: 6 patients mean age=24.5 yrs (range 17-34yrs) presented with bile leaks an average of 21 days (range 4-40 days) following motor vehicle accident in 4/6 or gunshot wound in 2/6. The leaks presented as bilious output from peritoneal drains in 3/6, from a chest robe in 1/6, from diagnostic paracentesis in 1/6, and based on a HIDA scan only in 1/6. One patient underwent unsuccessful hcpatorrhaphy prior to endoscopy. At ERCP, leaks were demonstrated from R hepatic duct in 3/6, L hepatic duct in 2/6, and both ducts in 1/6. 5/6 patients were treated successfully at index endoscopy with a transpapillary stcnt placed without papillotomy (3/6 10Fr 3cm, 1/6 10Fr 2cm, 1/6 7Fr 5cm). The sixth patient had a biliary sphincterotomy and 8.5Fr 15cm stent placed beyond the leak. This therapy was unsuccessful as judged by paracentesis and HIDA scan 7 days later. The patient then had successful treatment with a 10Fr 5cm stent 9Leak closure was documented in 5 patients at a mean of 5.6 days (range 1-14 days). Stents were removed at endoscopy at 31 days (range 18-54 days). There were no procedure related complications. Condusions: Similar to cystic duct leaks, traumatic intrahcpatic biliary leaks can be safely and effectively treated with short transpapiliary biliary stents. The presumed mechanism of action is equilibration of biliary pressure to that of the duodenum. Short stents have better flow characteristics compared with long stents, and mechanical bridging of the leak is not necessary.
T498
t500
A CLINICALLY FRIENDLY CLASSIFICATION OF S P H I N C T E R OF ODDI D Y S F U N C T I O N (SOD) BASED ON SIMPLIFIED MILWAUKEE CRITERIA WB Silyerman. A Slivka, M Rabinovitz, University of Pittsburgh, Pittsburgh, PA. l n t r o d u e t i o n : l . V a r i o u s studies have examined the frequency of abnormal sphincter of Oddi manometry (SOM) relative to SOD type (using the Milwaukee criteria.). Certain criteria (duct drainage time; phasic frequency, duration & propagation) may no longer be valid, and are often omitted in clinical practice. Therefore, we omitted them from this analysis, 2. The vexing problem of how to classify patients with maroinal elevations in lab tests remains unanswered. A i m : 1)To determine the frequency of elevated basal sphincter pressure (BSP) in patients using a simplified Type II and III SOD; 2) To determine whether to classify "hybrid" patients (i.e. with marginal elevations in lab tests) as type II or as type Ill. Methods: From 1/93 to 10/96, 114 consecutive patients w/o prior sphincterotomy were evaluated for SOD 1I / III. All had rigorous eval. to R/O other etiologies. There were 82 F and 31 M; ages 12 to 87 yrs. SOD II was defined as pain + lab elevation (TB, ALl', AST, ALP, Amylase, or Lipase) :,. i .5 x ULN or dilated ducts (CBD > 12mm or PD >5mm). HYBRID patients had pain + lab elevation < 1.5 x ULN. SODHI patients had pain only, with normal lab tests and duct diameters. Drainage times, frequency, duration & propagation were not assessed. Abnormal SOM was defined as BSP in CBD or PDL~O mmHg. Results: Successful SOM of the CBD or PD was obtained in 113/114 )atients: SOD t},pe #patients %abnl. SOM 9 5 ~ C.I. Total 113 63 ~71/i 13) (53,72)
ENDOSCOPIC MANAGEMENT OF SIMPLE & COMPLICATED BILIARY LEAKS BR Stotland, ML Kochman, Long WB, DO Faigel, GG Ginsberg, Gastroenterology Division, University of Pennsylvania, Phila., PA
II
83
65 (54/83)
(53,75)
HYBRID Ill
9 21
89 (8/9 / 43 (9/21)
(52, 99) (22, 67)
Parwise Test Significant ? p : (Fisher's Exact) SOD II vs HYBRID no p=0.26 SOD HI vs HYBRID yes p=0.04 SOD II vs SOD III yes 13=0.08 Test of Homogeneity yes p=0.05 -ondusions: 1 ]y selective referrs center, the incidence o r abnormal SOM (using elevated BSP only) in simplified SOD lI and Ill is similar to other recently published data. 2. There was no significant difference in abnormal frequency of SOD II vs HYBRID. 3. HYBRID SOD patients should be considered as type II SOD. Study is ongoing.
VOLUME 45, NO. 4, 1997
Most "simple" biliary leaks are successfully managed by transpapiltary stenting [TPS] and/or endoscopic sphincterotomy [ES]. Biliary leaks with concomitant obstruction to flow by stricture or stone have been termed "complex"; and typically require adjunctive therapies. We have identified a subgroup of bile leaks distinguished by being "complicated" by a local organized fluid collection and their poor response to "simple" management. We define these complicated bile leaks in the context of all leaks and describe specific management strategies. Methods: We reviewed all bile duct leaks identified and managed endoscopically over a 40 month period. We reviewed the etiology, site of ductal injury, presence of focal fluid collection, type of endoscopic intervention and clinical outcome. Results: Among 36 patients, the etiologies were: taparoscopic cholecystectomy(12), open cholecystectomy(3), T-tube removal after orthotopic liver transplantation JOLT](12), biliary anastomosis after OLT(3), abdominal trauma(3), partial hepatectomy for malignancy(2), and other abdominal surgery(I). Endoscopic management included TPS (21), ES(I), combined TPS and ES(12), and 7Fr nasobiliary [NB] tube(2) (both for OLT T-tube tract leaks). Of those with TPS, 3 of the stems were preferentially placed to bridge the leak. Transpapillary stent diameters were 10 Fr(12) and 7 Fr(20). Follow up ERCP was performed to confirm leak healing (mean interval = 4.5 wk) except after NB tube placement. At follow up ERCP 28 patients(78%) had resolution of the leak. Eight patients had persistant leaks: i)Two post-taparescopic cholecystectomy cystic duct leaks initially treated with 7 Fr TPS had persistant catheter drainage at 1 week, prompting repeat TPS with 12Fr stent fascillitating resolution at 4 weeks follow up. ii) Three patients with focal flud collections at the leak site (biloma=2, hematoma=l) failed to respond to 7F TPS's at 2,4, and 6 wks respectively. In these three cases two large diameter (> 10Fr) TPS's were placed in parallel bridging the leak site, and follow up ERCP at 5 to 9 wk confirmed resolution, iii) One post-OLT T-tube tract leak was repaired surgically 3 days after ERCP.iv) Two patients had non-biliary sepsis and died of septic complications. Among patients who responded to initial therapy, local fluid collection at the leak site was only documented in 6 patients. Conclusions: (1) "Simple" bile leaks are effectivly managed by TPS, ES, TPS + ES, or NB tube in the majority of cases. (2) TPS with large diameter (> 10 Fr) stent alone achieves high success and avoids the risks of ES. (3) "Complicated" bile leaks may be effectivly managed by placing two stents in parallel, bridging the leak.
GASTROINTESTINAL ENDOSCOPY AB149