Role of percutaneous transhepatic cholangioscopy in biliary papillomatosis: Can it change treatment modality?

Letters to the Editor

Role of percutaneous transhepatic cholangioscopy in biliary papillomatosis: Can it change treatment modality? To the Editor:

Figure 2. Endoscopic view showing the intussusception and a dusky appearing mucosa.

ally misdiagnosed as the more common rectal prolapse. Colonoscopy is helpful to confirm the diagnosis and may also be useful in assessing the presence or absence of ischemia, in diagnosing an underlying condition such as polyps, cancer, lipomas, etc., and in reducing the intussusception if no ischemia is suspected and the patient appears to be clinically stable. Ziad H. Younes, MD David A. Johnson, MD, FACP, FACG Lara Dimick, MD Eastern Virginia Medical School Norfolk, Virginia

REFERENCES 1. Schuster MM, Ratych RE. Anorectal disease. In: Haubrich WS, Shaffner F, Berk JE, editors. Bockus gastroenterology. Philadelphia: Saunders; 1995. p. 1773-89. 2. Nesbakken A, Haffner J. Colo-anal intussusception. Acta Chir Scand 1989;155:201-4. 3. Nelson TM, Pearl RK, Prasad ML, Abcarian H. Perineal sigmoidectomy for sigmoid providentia: report of a case. Am Surg 1995;61:320-1. 4. Forde KA, Gold RP, Holck S, Goldberg MD, Kaim PS. Giant pseudopolyposis in colitis with colonic intussusception. Gastroenterology 1978;75:1142-6. 5. Goldin E, Libson E. Intussusception in intestinal lymphoma: the role of colonoscopy. Postgrad Med J 1986;62:1139-40. 6. Kitamura K, Kitagawa S, Mori M, Haraguchi Y. Endoscopic correction of intussusception and removal of a colonic lipoma. Gastrointest Endosc 1990;36:509-11. 7. Hurwitz LM, Gertler SL. Colonoscopic diagnosis of ileocolic intussusception. Gastrointest Endosc 1986;32:217-8. 8. Ghang FY, Cheng JT, Lai KH. Colonoscopic diagnosis of ileocolic intussusception in an adult. SAMJ 1990;77:313-4.

We read with interest the recent article by D'Abrigeon et a\.l They reported five cases of multiple biliary papillosmatosis (MBP) with typical endoscopic retrograde cholangiographic (ERC) findings. Two patients had undergone surgical treatment, and we speculated that the choice of surgical procedure was made on the basis of conventional radiologic findings including ERC and computed tomography (CT). However, tumors recurred in both patients with a mean delay of 7.5 months. The mean survival time of surgically treated patients was shorter than that of those treated nonsurgically. From the 1990 until now, over 5300 cases ofERCP were performed at our institute. Eight cases ofMBP were found during this period. The ERC findings in our patients were similar to those of D'Abrigeon et a\. In addition to routine radiologic examinations, we performed cholangioscopy in six of the eight patients. In four patients, the lesion sites identified by cholangioscopy were identical to those of ERCP. However, in two patients, intrahepatic lesions, not evident by ERCP, were disclosed by cholangioscopy (Fig. n In these patients, Whipple's operation was initially planned for resection of the extrahepatic lesion, but this plan was changed to hepatico-pancreato-duodenectomy because cholangioscopic findings revealed the additional unilateral intrahepatic ductal involvement. No recurrence of tumor was observed for 20 months and 6 months after operation, respectively. To date, complete excision of tumor~ or liver transplantation:! is the recommended therapy for cure of MBP. If not, recurrence occurs in most cases and patients will die of complications such as recurrent cholangitis, liver fail-

Figure 1. Multiple velvety, papillary projections observed by cholangioscopic examination in a patient with biliary papillomatosis. VOLUME 47, NO.6, 1998

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Letters to the Editor

ure, or cancerous change. In our cases, the lesions were noted in extrahepatic and intrahepatic bile duct sites and intervening mucosa between the papillomatous lesions revealed nearly normal findings on pathologic examination. Conventional radiologic techniques such as abdominal CT, ultrasound, or ERCP for evaluation of MBP may not be adequate to detect these subtle mucosal lesions. There is a possibility that these lesions unidentified by conventional radiologic techniques could be the foci of tumor recurrence.1.4 and one of the most important causes of incomplete resection of poor postoperative prognosis. We suggest that, in cases of biliary papillomatosis, cholangioscopic examination be strongly recommended to identify concomitant subtle mucosal lesions and to decide whether hepatic resection may be required. Yeon Suk Kim, Seung Jae Myung, Sung Koo lee, Myung Hwan Kim,

MD MD MD MD

Asan Medical Center Seoul, Korea

REFERENCES 1. D'Abrigeon G, Blanc P, Bauret P, Diaz D, Durand L, Michel J, et al. Diagnostic and therapeutic aspects of endoscopic retrograde cholangiography in papillomatosis of the bile ducts: analysis of five cases. Gastrointest Endosc 1997;46:237-43. 2. Lam CM, Yuen ST, Yeun WK, Fan ST. Biliary papillomatosis. Br J Surg 1996;83:1712-5. 3. Rambaud S, Nores JM, Meeus F. Malignant papillomatosis of the bile ducts: A new indication for liver transplantation? Am J Gastroenterol 1989;84:448-9. 4. Taguchi J, Yasunaga M, Kojiro M, Arita T, Nakayama T, Simokobe T. Intrahepatic and extrahepatic biliary papillomatosis. Arch Pathol Lab Med 1993;117:944-7.

Post-cholecystectomy bile leaks and their management To the Editor: The article by Barkun et al. 1 has shown that intraoperative complications can predispose to a postoperative bile leak after cholecystectomy and that many if not most of these bile leaks can be managed by endoscopic sphincterotomy or stent placement. This has already been established by recent publications. 2 .:J The authors claim that they have made a demographic study of patient populations undergoing laparoscopic and open surgery, and yet, on careful study of the data, the size of the database is not clear. Sixty-four cases have been culled from an unknown number of patients, and the cases from only one of the hospitals (n == 2200) have been included. Of sixty-four patients, 15 underwent a planned open cholecystectomy and 12 others were converted to open surgery (making 27 in all; 42'1(). These data are pxtremely confusing. The authors say that 79 ERCP examinations were performed in 50 patients (see Table 2 in article), of which 40 showed a biloma or leak. Yet they have also said that "ERCP was 564

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carried out successfully in 46 patients" and "There were six failures of ERCP," making 52 in all. Also, only some patients were included in the database; thus, we have conflicting figures such as "7 out of 1184" and "81 out of 1276." The authors have gone on to observe that the incidence of bile leaks is higher among those patients undergoing open surgery than in those where laparoscopic surgery alone had been done. Our observation is the opposite; most (87'1() of our bile leaks have occurred in patients where difficult cholecystectomies were performed laparoscopically. When open surgery was resorted to, a more definitive procedure such as T-tube drainage or a biliary-enteric anastomosis was invariably performed and no bile leaks occurred in these patients. It is also probably misleading to compare the conversion rates among those patients with and without leak; it is probably more accurate to compare the leak rates overall in those patients undergoing laparoscopic cholecystectomy (LC) versus those undergoing open cholecystectomy (OC). The former may only serve to indicate that difficult cholecystectomies may have higher postoperative leak rates than easy ones. In the authors' experience, operative drainage or repair failed to prevent a leak in as many as 71 '1(. of patients. This is extremely surprising, and there is evidence in the literature as well as our own experience that suggests that the best opportunity for repair of biliary trauma is at the time of the first operation. Even in situations where distortion of anatomy or friability of tissues precludes primary repair, a controlled biliary drainage can usually be achieved in most cases. Hariharan Ramesh, MS, MCh, FACS Digestive Diseases Centre P. V. S. Memorial Hospital Kerala, India

REFERENCES 1. Barkun AN, Rezieg M, Mehta SN, Pavone E, Landry S, Barkun JS, et al. Postcholecystectomy leaks in the laparoscopic era: risk factors, presentation, and management. Gastrointest Endosc 1997;45:277-83. 2. Himal HS. The role of ERCP in laparoscopic cholecystectomyrelated cystic duct stump leaks. Surg Endosc 1996;10:653-5. 3. Kupferschmidt H, Havelka J, Schwery S, Bernardi M, Buhler H. Endoscopic therapy of bile leakage following laparoscopic cholecystectomy. Schweiz Med Wochenschr 1997;79:898-93S.

Response: We thank Dr. Ramesh for his comments and are eager to clarify the presented data and correct some misinterpretations. Indeed, as we discussed previously, other groups have reported their experience with the endoscopic treatment of post-cholecystectomy bile leaks. However, the only English language reference cited by Dr. Ramesh is a small case series (14 patients) that included only patients with cystic duct leaks. lOur report is one of the largest series published to date, encompassing different types of leaks. Furthermore, for the first time, we highlight specific risk factors related to the development of bile leaks that should raise the level of suspicion among VOLUME 47, NO.6, 1.Y98