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Therapeutic Endoscopic Retrograde Cholangiopancreaticography (ERCP) for Bile Duct Stones in Patients with a Prior Billroth II Gastrectomy
Abstracts
M1302 Therapeutic Endoscopic Retrograde Cholangiopancreaticography (ERCP) for Bile Duct Stones in Patients with a Prior Billroth II Gastrectomy Kazunari Nakahara, Jun Horaguchi, Naotaka Fujita, Yutaka Noda, Go Kobayashi, Kei Ito, Osamu Takasawa, Takashi Obana, Takuro Endo Background and Aim: Recently, endoscopic treatment of bile duct stones in patients with a prior Billroth II gastrectomy is increasing. We evaluated the usefulness and safety of therapeutic ERCP for bile duct stones in patients who had undergone a prior Billroth II gastrectomy. Patients and methods: 30 patients with bile duct stones after Billroth II gastrectomy (20 men, 10 women; median age, 76.4 years; range, 58-93) who underwent therapeutic ERCP from January 1998 to October 2006 at our center were included in this study. The average number of bile duct stones was 2.5 (1-15) and their mean diameter was 12.0 mm (4-20). Success rates of access to the papilla of Vater and selective cannulation of the bile duct, complete stone removal ratio, and incidence of complications were evaluated. For evaluation of the incidence of complications, 550 patients without gastrectomy who underwent ERCP and endoscopic sphincterotomy (EST) for bile duct stones in the same period were studied as a control. Front oblique-viewing endoscopes (GIF XK 200,240; Olympus) we used for procedures. Results: Access to the papilla of Vater was successful in 86.7% (26/30) of the patients. As to the other four patients, two underwent surgical treatment, one underwent PTCS with complete stone removal, and the remaining patient did not receive, additional treatment due to advanced age and poor general condition. Selective cannulation of the bile duct was achieved in 96.2% (25/26) of the patients with successful access to the papilla of Vater. One in whom deep cannulation of the bile duct was not achieved underwent surgical treatment. Among the patients in whom the approach to the papilla of Vater was successful, the complete stone removal ratio was 84.6% (22/26). Because of his poor general status and advanced age, one patient did not undergo stone removal and was treated only by endoscopic biliary drainage. The ratio of complete stone removal was 95% (20/21) by EST and 67% (2/3) by EPBD. Two patients without complete stone removal underwent surgical treatment. The incidence of complications was 3.3% (1/30) in the patients with a prior Billroth II gastrectomy and 6.5% (43/662) in the control group (n.s.). One patient with prior Billroth II gastrectomy suffered from acute cholecystitis and was treated by PTGBD. Neither pancreatitis, bleeding, nor perforation was seen in the patients with a prior Billroth II gastrectomy. Conclusions: The safety of therapeutic ERCP for removal of bile duct stones in patients with a prior Billroth II gastrectomy is comparable to that in patients with normal anatomy. Improvement of the rate of complete stone removal is necessary to avoid additional surgery.
M1304 Performance of Covered vs. Uncovered Metal Stents in Malignant Strictures of the Common Duct David H. Goetz, Jeffrey H. Lee, Marta L. Davila, Suyu Liu, Norio Fukami, William A. Ross Background: Obstruction of the common bile duct is a frequent complication of pancreatic and other malignancies. Metal biliary stents are commonly used to reestablish biliary patency. The efficacy and complications of the two types of metal biliary stents, covered and uncovered, in treating malignant strictures are incompletely defined. Our goal is to compare their performance in a tertiary cancer center. Methods: Patients referred from August 2002 to March 2006 for metal biliary stent placement in strictures involving the common bile duct were studied retrospectively. Only those patients who received their initial metal stent and in whom the proximal aspect of the stent was below the hepatic bifurcation were included. Results: Uncovered metal stents were placed in 112 patients for an average stricture length of 2.7 cm. The underlying malignancy was pancreatic in 74, metastatic colon in 8, duodenal/ampullary in 5 and various others in 25. There were 12 acute complications with pancreatitis in 8, migration in 2, hemobilia and fever in 1 each. The episodes of pancreatitis required an average of 3 days of hospitalization. Stent occlusion was seen in 39 (34.8%) of patients at an average of 140.4 days (SD 131d and median 122d). Of the remaining patients 9 had resection an average of 122.6 days after stent placement and 5 remained alive an average of 241.6 days. The remaining 59 died at a mean of 197.9d after stent placement (median 152.5d). One hundred patients had covered metal stents placed for an average stricture length of 2.4 cm. The underlying malignancy was pancreatic in 78, ampullary in six and other in 16. There were 15 acute complications including pancreatitis (9), persistent fever (3) and migration (2). The episodes of pancreatitis required an average of 4.5 hospital days. Late complications were stent occlusion in 23 and one case of cholecystitis 30 days after stent placement. Stent occlusions occurred at a mean of 245.5 days (SD 149.6, median 201). The remaining patients had Whipple resection (16) on an average of 122.6d, were alive (6) an average of 323 days, or died (58) on average 157.7 days after stent placement. The difference in proportion of occluded stents between groups trended toward statistical significance (p Z . 059). The difference in time to occlusion was statistically significant (p Z . 05). Differences in rates of pancreatitis and other complications were not statistically significant. Conclusions: Early and late complication rates are comparable between stent types although a trend toward less occlusion with covered stents was noted. The time to occlusion is significantly greater with covered stents.
M1305 Biliary Complications Following Hepatic Trauma: The Importance of ERCP David R. Lichtenstein, Brian C. Jacobson, Suresh Agarwal, Peter Burke, Erwin Hirsch
M1303 Sphinterotomy Plus Large Balloon Papillary Dilatation for Large Bile Duct Stones Sang Wook Park, Kang Suk Seo, Gun Young Hong, Dong Hyun Oh Backgraound: One of the main problems in removing CBD stone is large stone size (O15 mm). It requires prolonged time and repeated procedure to remove large CBD stone. And there is higher risk of bleeding during wide EST. The aim of this study was to determine the utility of paillary dilatation with large balloon after EST. Method: Seventy patients with large (O15 mm) CBD stone were enrolled for this study. The patients underwent papillary dilatation with a 15 mm or 20 mm diameter balloon after EST (mid-incisoin). Then, stones were extracted by basket. And additional mechanical lithotripsy was done when stone removal was unsuccessful. Result: The maximum stone diameter was 21.5 mm. Average number of stones was 1.4. Periampullary diverticulum was found in 16 patient. Complete stone removal was achieved in all patient. We used 15 mm balloon in 25 patient, 20 mm balloon in 45 patient. And we needed mechanical lithotripsy in 11 patients in whom stone removal was unsuccessful by basket extraction. After the procedure, the serum amylase and/or lipase levels were elevated in 9 patients (12%). But, true pancreatitis was noted in only three patient (4%). Minor bleeding was encountered in 10 patients (14%) and was controlled spontaneously or by balloon compression. There was no critical complication such as perforation, severe pancreatitis, active bleeding or death. Conclusion: Large balloon papillary dilatation after EST is safe and effective method for treatment of large CBD stones. And this method can reduce the procedure time or repeated ERCP.
AB222 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Purpose: The purpose of the study was to describe our experience with traumatic biliary complications and in particular define the efficacy, safety and outcomes of ERCP in the management of bile leaks following liver injury. Methods: A prospective analysis of liver injuries from October, 2001 to April, 2006 was performed. Information recorded included demographic, radiologic and operative interventions. A bile leak was diagnosed if there was bile noted in a surgical wound, bile leakage from an intra-abdominal drain, or a leak noted on hepatobiliary scintigraphy (HIDA). ERCPs were performed in all patients with bile leaks. Characteristics of the leak and endoscopic treatment of the injury were assessed. Clinical outcomes measured included healing of the leak, post-treatment biliary anatomy, and associated complications. Results: 225 patients experienced major hepatic trauma (145 blunt and 80 penetrating). Twenty-eight patients (12.4%; 13 blunt, 15 penetrating) underwent ERCP for biliary injury diagnosed by HIDA (26 pts.) and/or by clinical suspicion from previously noted surgical findings or percutaneous biliary drainage (10 pts.). The average AAST liver injury grade was 3.25. The mean time to diagnosis of biliary injury was hospital day 7 (range 3-18). Laparotomy was performed in 18 (64%) and surgical or CT drainage of bilomas in 10 pts. (36%). All leaks identified on nuclear scintigraphy were confirmed at ERCP. However, HIDA scanning underestimated the extent of the injury in 8 patients where the leak was characterized as contained but found to be freely extravasating on ERCP. ERCP was performed at a mean of hospital day 7.5 (range 2-28). The total number of ERCPs performed was 50. Endoscopic therapy included biliary sphincterotomy (n Z 6), stent placement (n Z 16) or combined therapy (n Z 6). All bile leaks resolved after ERCP. Cholangiography was normal in all 16 patients who received a follow-up ERCP. The average hospital length of stay was 25.8 days (range 3-70). There was one (3.5%) ERCP-related complication which was moderate pancreatitis. There were no deaths noted. Conclusion: Bile leaks commonly occur in individuals with liver trauma (12.4%). ERCP is a safe and effective strategy for diagnosing and managing biliary complications following blunt and penetrating hepatic trauma. Although biliary scintigraphy has a high positive predictive value for diagnosing biliary leaks, ERCP better distinguishes the extent of injury and eliminates the need for more invasive surgical treatment.
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M1302 Therapeutic Endoscopic Retrograde Cholangiopancreaticography (ERCP) for Bile Duct Stones in Patients with a Prior Billroth II Gastrectomy Kazunari Nakahara, Jun Horaguchi, Naotaka Fujita, Yutaka Noda, Go Kobayashi, Kei Ito, Osamu Takasawa, Takashi Obana, Takuro Endo Background and Aim: Recently, endoscopic treatment of bile duct stones in patients with a prior Billroth II gastrectomy is increasing. We evaluated the usefulness and safety of therapeutic ERCP for bile duct stones in patients who had undergone a prior Billroth II gastrectomy. Patients and methods: 30 patients with bile duct stones after Billroth II gastrectomy (20 men, 10 women; median age, 76.4 years; range, 58-93) who underwent therapeutic ERCP from January 1998 to October 2006 at our center were included in this study. The average number of bile duct stones was 2.5 (1-15) and their mean diameter was 12.0 mm (4-20). Success rates of access to the papilla of Vater and selective cannulation of the bile duct, complete stone removal ratio, and incidence of complications were evaluated. For evaluation of the incidence of complications, 550 patients without gastrectomy who underwent ERCP and endoscopic sphincterotomy (EST) for bile duct stones in the same period were studied as a control. Front oblique-viewing endoscopes (GIF XK 200,240; Olympus) we used for procedures. Results: Access to the papilla of Vater was successful in 86.7% (26/30) of the patients. As to the other four patients, two underwent surgical treatment, one underwent PTCS with complete stone removal, and the remaining patient did not receive, additional treatment due to advanced age and poor general condition. Selective cannulation of the bile duct was achieved in 96.2% (25/26) of the patients with successful access to the papilla of Vater. One in whom deep cannulation of the bile duct was not achieved underwent surgical treatment. Among the patients in whom the approach to the papilla of Vater was successful, the complete stone removal ratio was 84.6% (22/26). Because of his poor general status and advanced age, one patient did not undergo stone removal and was treated only by endoscopic biliary drainage. The ratio of complete stone removal was 95% (20/21) by EST and 67% (2/3) by EPBD. Two patients without complete stone removal underwent surgical treatment. The incidence of complications was 3.3% (1/30) in the patients with a prior Billroth II gastrectomy and 6.5% (43/662) in the control group (n.s.). One patient with prior Billroth II gastrectomy suffered from acute cholecystitis and was treated by PTGBD. Neither pancreatitis, bleeding, nor perforation was seen in the patients with a prior Billroth II gastrectomy. Conclusions: The safety of therapeutic ERCP for removal of bile duct stones in patients with a prior Billroth II gastrectomy is comparable to that in patients with normal anatomy. Improvement of the rate of complete stone removal is necessary to avoid additional surgery.
M1304 Performance of Covered vs. Uncovered Metal Stents in Malignant Strictures of the Common Duct David H. Goetz, Jeffrey H. Lee, Marta L. Davila, Suyu Liu, Norio Fukami, William A. Ross Background: Obstruction of the common bile duct is a frequent complication of pancreatic and other malignancies. Metal biliary stents are commonly used to reestablish biliary patency. The efficacy and complications of the two types of metal biliary stents, covered and uncovered, in treating malignant strictures are incompletely defined. Our goal is to compare their performance in a tertiary cancer center. Methods: Patients referred from August 2002 to March 2006 for metal biliary stent placement in strictures involving the common bile duct were studied retrospectively. Only those patients who received their initial metal stent and in whom the proximal aspect of the stent was below the hepatic bifurcation were included. Results: Uncovered metal stents were placed in 112 patients for an average stricture length of 2.7 cm. The underlying malignancy was pancreatic in 74, metastatic colon in 8, duodenal/ampullary in 5 and various others in 25. There were 12 acute complications with pancreatitis in 8, migration in 2, hemobilia and fever in 1 each. The episodes of pancreatitis required an average of 3 days of hospitalization. Stent occlusion was seen in 39 (34.8%) of patients at an average of 140.4 days (SD 131d and median 122d). Of the remaining patients 9 had resection an average of 122.6 days after stent placement and 5 remained alive an average of 241.6 days. The remaining 59 died at a mean of 197.9d after stent placement (median 152.5d). One hundred patients had covered metal stents placed for an average stricture length of 2.4 cm. The underlying malignancy was pancreatic in 78, ampullary in six and other in 16. There were 15 acute complications including pancreatitis (9), persistent fever (3) and migration (2). The episodes of pancreatitis required an average of 4.5 hospital days. Late complications were stent occlusion in 23 and one case of cholecystitis 30 days after stent placement. Stent occlusions occurred at a mean of 245.5 days (SD 149.6, median 201). The remaining patients had Whipple resection (16) on an average of 122.6d, were alive (6) an average of 323 days, or died (58) on average 157.7 days after stent placement. The difference in proportion of occluded stents between groups trended toward statistical significance (p Z . 059). The difference in time to occlusion was statistically significant (p Z . 05). Differences in rates of pancreatitis and other complications were not statistically significant. Conclusions: Early and late complication rates are comparable between stent types although a trend toward less occlusion with covered stents was noted. The time to occlusion is significantly greater with covered stents.
M1305 Biliary Complications Following Hepatic Trauma: The Importance of ERCP David R. Lichtenstein, Brian C. Jacobson, Suresh Agarwal, Peter Burke, Erwin Hirsch
M1303 Sphinterotomy Plus Large Balloon Papillary Dilatation for Large Bile Duct Stones Sang Wook Park, Kang Suk Seo, Gun Young Hong, Dong Hyun Oh Backgraound: One of the main problems in removing CBD stone is large stone size (O15 mm). It requires prolonged time and repeated procedure to remove large CBD stone. And there is higher risk of bleeding during wide EST. The aim of this study was to determine the utility of paillary dilatation with large balloon after EST. Method: Seventy patients with large (O15 mm) CBD stone were enrolled for this study. The patients underwent papillary dilatation with a 15 mm or 20 mm diameter balloon after EST (mid-incisoin). Then, stones were extracted by basket. And additional mechanical lithotripsy was done when stone removal was unsuccessful. Result: The maximum stone diameter was 21.5 mm. Average number of stones was 1.4. Periampullary diverticulum was found in 16 patient. Complete stone removal was achieved in all patient. We used 15 mm balloon in 25 patient, 20 mm balloon in 45 patient. And we needed mechanical lithotripsy in 11 patients in whom stone removal was unsuccessful by basket extraction. After the procedure, the serum amylase and/or lipase levels were elevated in 9 patients (12%). But, true pancreatitis was noted in only three patient (4%). Minor bleeding was encountered in 10 patients (14%) and was controlled spontaneously or by balloon compression. There was no critical complication such as perforation, severe pancreatitis, active bleeding or death. Conclusion: Large balloon papillary dilatation after EST is safe and effective method for treatment of large CBD stones. And this method can reduce the procedure time or repeated ERCP.
AB222 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Purpose: The purpose of the study was to describe our experience with traumatic biliary complications and in particular define the efficacy, safety and outcomes of ERCP in the management of bile leaks following liver injury. Methods: A prospective analysis of liver injuries from October, 2001 to April, 2006 was performed. Information recorded included demographic, radiologic and operative interventions. A bile leak was diagnosed if there was bile noted in a surgical wound, bile leakage from an intra-abdominal drain, or a leak noted on hepatobiliary scintigraphy (HIDA). ERCPs were performed in all patients with bile leaks. Characteristics of the leak and endoscopic treatment of the injury were assessed. Clinical outcomes measured included healing of the leak, post-treatment biliary anatomy, and associated complications. Results: 225 patients experienced major hepatic trauma (145 blunt and 80 penetrating). Twenty-eight patients (12.4%; 13 blunt, 15 penetrating) underwent ERCP for biliary injury diagnosed by HIDA (26 pts.) and/or by clinical suspicion from previously noted surgical findings or percutaneous biliary drainage (10 pts.). The average AAST liver injury grade was 3.25. The mean time to diagnosis of biliary injury was hospital day 7 (range 3-18). Laparotomy was performed in 18 (64%) and surgical or CT drainage of bilomas in 10 pts. (36%). All leaks identified on nuclear scintigraphy were confirmed at ERCP. However, HIDA scanning underestimated the extent of the injury in 8 patients where the leak was characterized as contained but found to be freely extravasating on ERCP. ERCP was performed at a mean of hospital day 7.5 (range 2-28). The total number of ERCPs performed was 50. Endoscopic therapy included biliary sphincterotomy (n Z 6), stent placement (n Z 16) or combined therapy (n Z 6). All bile leaks resolved after ERCP. Cholangiography was normal in all 16 patients who received a follow-up ERCP. The average hospital length of stay was 25.8 days (range 3-70). There was one (3.5%) ERCP-related complication which was moderate pancreatitis. There were no deaths noted. Conclusion: Bile leaks commonly occur in individuals with liver trauma (12.4%). ERCP is a safe and effective strategy for diagnosing and managing biliary complications following blunt and penetrating hepatic trauma. Although biliary scintigraphy has a high positive predictive value for diagnosing biliary leaks, ERCP better distinguishes the extent of injury and eliminates the need for more invasive surgical treatment.
www.giejournal.org