- Email: [email protected]
Temporary and long term biliary stenting for retained common bile duct stones in an irish cohort
ERCP-BILIARY
"~429
I'431
UTILITY OF SPHINCTER OF ODDI MANOMETRY (SOM) IN CHRONIC PANCREATITIS (CP). E.L. Fogel, D. Eversman, S. Sherman and G.A. Lehman. Indiana University Medical Center, Indianapolis, IN. BACKGROUND: Sphincter of Oddi dysfunction (SOD) may play a causal role in acute panereatitis, but its relationship with CP is unclear. In 20% of CP eases, no cause is identified. Our goal was to review the frequency of SOD in patients with CP. METHODS: A diagnosis of CP was made in 102 patients based: oh clinical .history, CT fmdirrgs and ERCP. All patients underwent d0uble~duet (bi!~a~ and pancreatic)SOM Using a ~ple2!umen water-perfnsed catheter with I hmenused for aspii"ation;pressures w~re me~ured by station pull-through. SOD was diagnosed when the basal sphincter pressure was > 40ram Hg. Patients were classified as Pancreas type (P) I, II, III according to the Sherman-Lehmen classification (Am J Gastro 1991;86:586). RESULTS: (i) 47 of 102 patients had received no prior sphincter therapy. The majority of these patients were P-lI (35/47; 74%). Overall, 14/47 (30%) had elevations of both B and P pressures, 13 (28%) had isolated elevations of 1 sphincter only (8 P, 5 B), end 20 (43%) had normal SOM. (ii) A prior biliary sphincterotomy alone was found in 37 patients. Twenty-eight (76%) were P-II. Seven of the 37 patients (19%) had persistently high B pressures, in association with elevated P pressures. Of the remaining 30 patients, 16 (43%) had elevated P pressure alone and 14 (38%) had normal SOM. (iii) Nineteen of the 102 patients had prior dual (B and P) sphincter therapy. Of these, 14 (74%) were P-ll. No patients had residual elevated B pressures, with only 1 patient (5%) demonstrating elevated P pressures. In the entire group of 102 patients, the frequency of SOD in mild CP was 62% (40/65), moderate CP 27% (6/22), end severe CP 27% (4/15). SUMMARY: In our series ofCP pts undergoing SOM, 49% (50/102) had evidence of SOD: 57%, 62% and 5% in pts with intact sphincters, B sphineterotomy and dual sphineterotomy, respectively. The frequency of SOD in CP is similar to that seen in our referral population without CP. CONCLUSION: SOD is a frequent Finding in pts with CP. Further trials are needed to determine whether (1) SOD causes CP or results from the generalized scarfing process, and (2) biliary or dual sphmeterotomy will alter the course of this disease in patients with SOD.
NEEDLE KNIFE SPHINCTEROTOMY: A Geller, BT Petersen, CJ Gostout, RW Hughes, N Geller. Mayo Clinic, Rochester, Minnesota. Introduction: Bile duct cannulation fails in 5-10% of ERCPs. The use of needle knife sphincterotomy (NKS)in such cases is controversial because of the perceived risk and the experience required. Aim: To assess the efficacy, safety and outcome of NKS in a tertiary referral center. ~lethods: All cases of NKS from 2/94-10/96 were reviewed for indication, success of access, findil)gs, and outc0me. :Complication s were classified according to established criteria (Cotton, 199!) Results:.NKS .was performed in :! 19 Of 937 Sphincter0tomies(12:7 %)-among 24,16 total ERCP's (5%). The mean age was 57 yrs ( range 4-95); 55% were female. Most NKS were used only after failure with a variety of accessories. The papilla appeared normal in 55 (47%), small in 12 (10%), bulging 26 (22%), neoplastic 8 (7%), fractured in 6 and edematous in 6. NKS was used for anticipated diagnostic studies in 27 (23%), for cholangiography with anticipated therapy in 59 (49%), and for therapy after cholangiography in 25 (21%). Bile duct access was achieved via NKS in 100 pts (85%), including 94 (80%) at the first ERCP and 6/6 at a second ERCP. Of 19 pts. with failed access 8 underwent diagnostic (2) or therapeutic (6) PTC, and 11 were not further studied. Standard sphincterotomy was completed in 58 pts. Final diagnoses were: bile duct stricture 41(34%) (malignant 20, ampullary ca 8, PSC 7, benign 6), biliary stones 30(25%), non-malignant pancreatic diagnoses 20(20%) and normal or not pursued 28 (24%). Complications occurred in 28 pts. (23.5%). Mild (%) Mod~ratp (%) Sevar~ (%) TotAl (v/~)
t430 T E C H N I C A L F A I L U R E S AND C O M P L I C A T I O N S O F D I A G N O S T I C (Dx) AND T H E R A P E U T I C (Tx) E R C P : I M P A C T ON RESOURCE UTILIZATION. ML Freeman. DB Nelson, HW Snady, JA DiSario, CS Overby, ME Ryan, RV Erickson, JP Moore, MS Shaw, MB Fennerty, GS Bochna, JG Lee, AM Pheley, and the ERCP Outcome Study (ERCOST) group, Hennepin County Medical Center, Minneapolis MN In an ongoing prospective study involving ERCP in a wide spectrum of practice settings, we are examining technical success and complication rates, and their relative impact on utilization of resources. METHODS: Consecutive ERCP's attempted at 11 centers (6 private, 5 university) were enrolled. Procedure data were recorded at time of ERCP, and outcomes assessed at 30 days. Complications were defined by consensus criteria (Cotton et al), but included all procedure-related events. ERCP-related hospital days (=hosp-days) were defined as nights in hospital for observation, treatment of complications (=complic's), or for additional unplanned endoscopic, radiological, and surgical interventions due to failures or complic's of ERCP (=addt'l proc). RESULTS: Data are shown for the 486 cases (of 804 ERCP) which were performed on "virgin" papillae (no prior sphincterotomy or stent) and were done for "traditional" indications (Dx or biliary Tx only, without pancreatic sphincter or ductal Tx). "VIRGIN P A P I L L A " E R C P (n=486) Diagnostic !Technical Complete Partial Fail
432
intended only
(n=142) therapy intended
(n=344)
Success
86 %
Complic's :6% Addt'lproc 2% Hosp-days 0.8 + 0.2 Technical Complete Success
87 %
Complic's Addt'lproc
14% 4%
IHosp-days 11.5+0.1
8%
6%
0% 18%*
22% 22%*
! 0.5 + 0.2 Partial 5%
3.6* + 1.9 Fail 8%
17% 44%* 2.7 + 1.0
12% 62%* 6.2* -+ 1.8
eta CONCLUSIONS: For both Dx and Tx ERCP, complication rates were similar regardless of whether ERCP was a technical success or failure. However, failed ERCP resulted in a marked excess of unplanned endoscopic, radiological, and surgical interventions, and significant prolongation of hospital stay (about 4 days). Resource utilization related to ERCP is primarily related to technical success.
AB132
GASTROINTESTINAL ENDOSCOPY
Pl~ner~titis
6 (5)
6 (5)
I (0 8)
17 (14 2)
nh~lin~ 6 (~;3" | (0.~)# 0 7 (5.g) eerfarftfiqn 1 ([I 8) 1 (0.8) 0 2 (1 6) Chnlan~ifi~ 1(O 8) 1 (0.g) fl 2 (1.6) Bleeding(*) was limited to observed oozing with universal response to injection therapy at the initial ERCP. One pt(#) had no evidence of bleeding but Hgb fell 2g and he received 3 U pRBC. Mean hospital stay attributable to NKS complications was 3.8 days (range 0-24). One pt required surgery for complications. There was no procedure-related mortality. Conclusions: 1. NKS is an effective method for gaining bile duct access in pts with failed cannalation. 2. Though not infrequent, most complications were minor, 3. The proportion of complications due to prior failed cannulation is unknown, 4. Decisions to utilize NKS should consider the indication, expected intervention, experience, and availabilityand risks of alternative modalities.
TEMPORARY AND LONG TERM BILIARY STENTING FOR RETAINED COMMON BILE DUCT STONES IN AN IRISH COHORT J.Goh, S.Pathmakanthan, G.Harewood, E.Clarke, J.Leunon, P.MacMathuna and J.Crowe. Department of Gastroenterology, Mater Miserionrdiae Hospital, Dublin, Ireland. Common bile duct (CBD) stones that are not amenable to extraction at ERCP, so called "defiant stones', can be managed by temporary biliary stenting. In selected patients, repeated biliary stenting may be an alternative to definitive surgical procedures. We aimed to evaluate retrospectively the safety and clinical outcome of Ursodeoxycholate, temporary and long-term stenting in the management of defiant CBD stones. 42 patients (M:F=19:23; Mean age 77.5; range 56-95) underwent temporary biliary stenting for defiant CBD stones over a four-year period (1991-95) and were followed up for a mean period of 20 months. Of these, 4 anderwent surgical CBD clearance; Of the remaining non-surgical group (n=38), 16 (42.1%) were treated with Ursodeoxycholate for a mean of 4.3 months. 87.5% (n= 14) of the treatment group underwent successful duct clearance after a median of one additional ERCP. Of the 22 patients who did not receive Ursodeoxycholate, only 3 underwent successful duct clearance after one additional ERCP. A total of 21 patients (Mean age 77, range 68-95) had unsuccessful duct clearance with or without Ursodeoxychnlato and were managed by longterm biliary stenting with stent change 3 to 6 monthly. In this long-term stenting group, 6 died fxom non-biliary causes and the renminder have not experienced any biliary-related symptoms during a mean follow-up of 20 months. Complications of biliary stenting comprised cholangiris due to stent migration or occlusion in 3 (including one hepatic abscess) and cesuphageal laceration during stent removal in one. No side affects were reported with the use of Ursodeoxycholate. Conclusion: Biliary stenting for non-extractable CBD stones at the first attempt is safe and allows further attempts at duct clearance to be performed alectively. This may be facilitated by Ursodeoxycholate. Long-term biliary stenting with elective stent change is a safe management option in the frail and elderly.
VOLUME 45, NO. 4, 1997
"~429
I'431
UTILITY OF SPHINCTER OF ODDI MANOMETRY (SOM) IN CHRONIC PANCREATITIS (CP). E.L. Fogel, D. Eversman, S. Sherman and G.A. Lehman. Indiana University Medical Center, Indianapolis, IN. BACKGROUND: Sphincter of Oddi dysfunction (SOD) may play a causal role in acute panereatitis, but its relationship with CP is unclear. In 20% of CP eases, no cause is identified. Our goal was to review the frequency of SOD in patients with CP. METHODS: A diagnosis of CP was made in 102 patients based: oh clinical .history, CT fmdirrgs and ERCP. All patients underwent d0uble~duet (bi!~a~ and pancreatic)SOM Using a ~ple2!umen water-perfnsed catheter with I hmenused for aspii"ation;pressures w~re me~ured by station pull-through. SOD was diagnosed when the basal sphincter pressure was > 40ram Hg. Patients were classified as Pancreas type (P) I, II, III according to the Sherman-Lehmen classification (Am J Gastro 1991;86:586). RESULTS: (i) 47 of 102 patients had received no prior sphincter therapy. The majority of these patients were P-lI (35/47; 74%). Overall, 14/47 (30%) had elevations of both B and P pressures, 13 (28%) had isolated elevations of 1 sphincter only (8 P, 5 B), end 20 (43%) had normal SOM. (ii) A prior biliary sphincterotomy alone was found in 37 patients. Twenty-eight (76%) were P-II. Seven of the 37 patients (19%) had persistently high B pressures, in association with elevated P pressures. Of the remaining 30 patients, 16 (43%) had elevated P pressure alone and 14 (38%) had normal SOM. (iii) Nineteen of the 102 patients had prior dual (B and P) sphincter therapy. Of these, 14 (74%) were P-ll. No patients had residual elevated B pressures, with only 1 patient (5%) demonstrating elevated P pressures. In the entire group of 102 patients, the frequency of SOD in mild CP was 62% (40/65), moderate CP 27% (6/22), end severe CP 27% (4/15). SUMMARY: In our series ofCP pts undergoing SOM, 49% (50/102) had evidence of SOD: 57%, 62% and 5% in pts with intact sphincters, B sphineterotomy and dual sphineterotomy, respectively. The frequency of SOD in CP is similar to that seen in our referral population without CP. CONCLUSION: SOD is a frequent Finding in pts with CP. Further trials are needed to determine whether (1) SOD causes CP or results from the generalized scarfing process, and (2) biliary or dual sphmeterotomy will alter the course of this disease in patients with SOD.
NEEDLE KNIFE SPHINCTEROTOMY: A Geller, BT Petersen, CJ Gostout, RW Hughes, N Geller. Mayo Clinic, Rochester, Minnesota. Introduction: Bile duct cannulation fails in 5-10% of ERCPs. The use of needle knife sphincterotomy (NKS)in such cases is controversial because of the perceived risk and the experience required. Aim: To assess the efficacy, safety and outcome of NKS in a tertiary referral center. ~lethods: All cases of NKS from 2/94-10/96 were reviewed for indication, success of access, findil)gs, and outc0me. :Complication s were classified according to established criteria (Cotton, 199!) Results:.NKS .was performed in :! 19 Of 937 Sphincter0tomies(12:7 %)-among 24,16 total ERCP's (5%). The mean age was 57 yrs ( range 4-95); 55% were female. Most NKS were used only after failure with a variety of accessories. The papilla appeared normal in 55 (47%), small in 12 (10%), bulging 26 (22%), neoplastic 8 (7%), fractured in 6 and edematous in 6. NKS was used for anticipated diagnostic studies in 27 (23%), for cholangiography with anticipated therapy in 59 (49%), and for therapy after cholangiography in 25 (21%). Bile duct access was achieved via NKS in 100 pts (85%), including 94 (80%) at the first ERCP and 6/6 at a second ERCP. Of 19 pts. with failed access 8 underwent diagnostic (2) or therapeutic (6) PTC, and 11 were not further studied. Standard sphincterotomy was completed in 58 pts. Final diagnoses were: bile duct stricture 41(34%) (malignant 20, ampullary ca 8, PSC 7, benign 6), biliary stones 30(25%), non-malignant pancreatic diagnoses 20(20%) and normal or not pursued 28 (24%). Complications occurred in 28 pts. (23.5%). Mild (%) Mod~ratp (%) Sevar~ (%) TotAl (v/~)
t430 T E C H N I C A L F A I L U R E S AND C O M P L I C A T I O N S O F D I A G N O S T I C (Dx) AND T H E R A P E U T I C (Tx) E R C P : I M P A C T ON RESOURCE UTILIZATION. ML Freeman. DB Nelson, HW Snady, JA DiSario, CS Overby, ME Ryan, RV Erickson, JP Moore, MS Shaw, MB Fennerty, GS Bochna, JG Lee, AM Pheley, and the ERCP Outcome Study (ERCOST) group, Hennepin County Medical Center, Minneapolis MN In an ongoing prospective study involving ERCP in a wide spectrum of practice settings, we are examining technical success and complication rates, and their relative impact on utilization of resources. METHODS: Consecutive ERCP's attempted at 11 centers (6 private, 5 university) were enrolled. Procedure data were recorded at time of ERCP, and outcomes assessed at 30 days. Complications were defined by consensus criteria (Cotton et al), but included all procedure-related events. ERCP-related hospital days (=hosp-days) were defined as nights in hospital for observation, treatment of complications (=complic's), or for additional unplanned endoscopic, radiological, and surgical interventions due to failures or complic's of ERCP (=addt'l proc). RESULTS: Data are shown for the 486 cases (of 804 ERCP) which were performed on "virgin" papillae (no prior sphincterotomy or stent) and were done for "traditional" indications (Dx or biliary Tx only, without pancreatic sphincter or ductal Tx). "VIRGIN P A P I L L A " E R C P (n=486) Diagnostic !Technical Complete Partial Fail
432
intended only
(n=142) therapy intended
(n=344)
Success
86 %
Complic's :6% Addt'lproc 2% Hosp-days 0.8 + 0.2 Technical Complete Success
87 %
Complic's Addt'lproc
14% 4%
IHosp-days 11.5+0.1
8%
6%
0% 18%*
22% 22%*
! 0.5 + 0.2 Partial 5%
3.6* + 1.9 Fail 8%
17% 44%* 2.7 + 1.0
12% 62%* 6.2* -+ 1.8
eta CONCLUSIONS: For both Dx and Tx ERCP, complication rates were similar regardless of whether ERCP was a technical success or failure. However, failed ERCP resulted in a marked excess of unplanned endoscopic, radiological, and surgical interventions, and significant prolongation of hospital stay (about 4 days). Resource utilization related to ERCP is primarily related to technical success.
AB132
GASTROINTESTINAL ENDOSCOPY
Pl~ner~titis
6 (5)
6 (5)
I (0 8)
17 (14 2)
nh~lin~ 6 (~;3" | (0.~)# 0 7 (5.g) eerfarftfiqn 1 ([I 8) 1 (0.8) 0 2 (1 6) Chnlan~ifi~ 1(O 8) 1 (0.g) fl 2 (1.6) Bleeding(*) was limited to observed oozing with universal response to injection therapy at the initial ERCP. One pt(#) had no evidence of bleeding but Hgb fell 2g and he received 3 U pRBC. Mean hospital stay attributable to NKS complications was 3.8 days (range 0-24). One pt required surgery for complications. There was no procedure-related mortality. Conclusions: 1. NKS is an effective method for gaining bile duct access in pts with failed cannalation. 2. Though not infrequent, most complications were minor, 3. The proportion of complications due to prior failed cannulation is unknown, 4. Decisions to utilize NKS should consider the indication, expected intervention, experience, and availabilityand risks of alternative modalities.
TEMPORARY AND LONG TERM BILIARY STENTING FOR RETAINED COMMON BILE DUCT STONES IN AN IRISH COHORT J.Goh, S.Pathmakanthan, G.Harewood, E.Clarke, J.Leunon, P.MacMathuna and J.Crowe. Department of Gastroenterology, Mater Miserionrdiae Hospital, Dublin, Ireland. Common bile duct (CBD) stones that are not amenable to extraction at ERCP, so called "defiant stones', can be managed by temporary biliary stenting. In selected patients, repeated biliary stenting may be an alternative to definitive surgical procedures. We aimed to evaluate retrospectively the safety and clinical outcome of Ursodeoxycholate, temporary and long-term stenting in the management of defiant CBD stones. 42 patients (M:F=19:23; Mean age 77.5; range 56-95) underwent temporary biliary stenting for defiant CBD stones over a four-year period (1991-95) and were followed up for a mean period of 20 months. Of these, 4 anderwent surgical CBD clearance; Of the remaining non-surgical group (n=38), 16 (42.1%) were treated with Ursodeoxycholate for a mean of 4.3 months. 87.5% (n= 14) of the treatment group underwent successful duct clearance after a median of one additional ERCP. Of the 22 patients who did not receive Ursodeoxycholate, only 3 underwent successful duct clearance after one additional ERCP. A total of 21 patients (Mean age 77, range 68-95) had unsuccessful duct clearance with or without Ursodeoxychnlato and were managed by longterm biliary stenting with stent change 3 to 6 monthly. In this long-term stenting group, 6 died fxom non-biliary causes and the renminder have not experienced any biliary-related symptoms during a mean follow-up of 20 months. Complications of biliary stenting comprised cholangiris due to stent migration or occlusion in 3 (including one hepatic abscess) and cesuphageal laceration during stent removal in one. No side affects were reported with the use of Ursodeoxycholate. Conclusion: Biliary stenting for non-extractable CBD stones at the first attempt is safe and allows further attempts at duct clearance to be performed alectively. This may be facilitated by Ursodeoxycholate. Long-term biliary stenting with elective stent change is a safe management option in the frail and elderly.
VOLUME 45, NO. 4, 1997