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Vanishing Bile Duct Syndrome and Sclerosing Cholangitis in Patients with Critical Illness and Long Term Intensive Care Treatment
Abstracts
T1260 Percutaneous Transhepatic Cholangioscopy Versus Open Choledochotomy in Treatment of Difficult Common Bile Duct Stones Jimin Han, Sang Soo Lee, Tae Joon Song, Myung-Hwan Kim, Dong Wan Seo, Sung Koo Lee, Do Hyun Park, Sung Jo Bang, Kyu-Bo Sung, Sung-Gyu Lee Background: Most of common bile duct stones can be effectively treated by endoscopic sphincterotomy and stone extraction using baskets or balloon catheters. However, endoscopic stone extraction can be very difficult or even impossible in patients with large and/or multiple stones, bile duct stricture, peripapillary diverticula, and previous gastric surgery. Open choledochotomy has played a major role in the treatment of such patients. On the other hand, laparoscopic choledochotomy is relatively expensive, more technically demanding, and takes longer to perform than laparoscopic cholecystectomy. Percutaneous transhepatic cholangioscopy (PTCS) has been used successfully for diagnosis and treatment of various biliary tract diseases. We compared treatment outcome of PTCS with that of open choledochotomy in patients with difficult common bile duct stones. Patients and Methods: Medical records of 98 patients who underwent either PTCS (nZ64) or open choledochotomy (nZ34) for difficult common bile duct stones from January 1998 to December 2003 were evaluated retrospectively. Results: Mean age of the 98 patients was 66.2 years (range: 31-89 years) and 58 patients (59.2%) were men. Mean number of stones was 2.5 (range 1-8) and mean size of the stones was 23.5 mm (range 8-56 mm). Between PTCS and open choledochotomy groups, there were statistically significant differences in mean age (68.3 vs. 62.4 years, pZ0.012), AST at the time of diagnosis (241 vs. 110 IU/dL, pZ0.019), history of cholecystectomy (39.1 vs. 11.8%, pZ0.005), and presence of fever at presentation (60.7 vs. 38.2%, pZ0.032). However, there were no statistically significant differences between two group regarding gender, number and size of stones, presence of comorbidity, and duration of hospital stay. Complications occurred in 8 patients (12.5%) of PTCS group and 11 (32.4%) of open choledochotomy group (pZ0.002). In PTCS group, 3 cases of bleeding (4.7%) and 2 cases of bile duct injury (3.1%) had occurred. In open choledochotomy group, 3 cases of bile duct injury (8.8%) and 7 cases of wound infection (20.6%) were reported. Also, there was one perioperative death in open choledochotomy group. No statistically significant difference in recurrence rate was observed during the follow-up (pZ0.31). Conclusions: PTCS is an effective and safe method in patients with difficult common bile duct stones. It may be a useful alternative treatment modality in such patients.
T1261 Vanishing Bile Duct Syndrome and Sclerosing Cholangitis in Patients with Critical Illness and Long Term Intensive Care Treatment Harald Hofer, Arnulf Ferlitsch, Ludwig Kramer, Christian Madl, Edward Penner, Rainer Schoefl, Andreas Puespoek Background: Sepsis associated cholestasis in intensive care patients usually subsides with treatment of the underlying cause. However, in a subgroup of these patients a progressive destruction of intrahepatic bile ducts and sclerosing cholangitis with the typically appearance of segmental strictures and cholangiectasies develops. In this respect, a progressive form of sclerosing cholangitis after septic shock and long term intensive care treatment has been described. We herein report the clinical course and endoscopic treatment in patients with sclerosing cholangitis due to critical illness. Patients: Twelve patients (6 male, age: 48.8C12.7, (mean, yearsCSD)) with sclerosing cholangitis, diagnosed by endoscopic retrograde cholangiopancreaticography were identified. No patient had evidence of preexisting hepato-biliary disease or inflammatory bowel disease. Transfer to the ICU was necessary because of sepsis in 2, extensive surgery in 4, polytrauma in 2, cardiopulmonary resuscitation in 2 and respiratory failure in 2 patients, respectively. All patients needed mechanical ventilation, had a preexisting pulmonary disease and/or developed a severe adult respiratory distress syndrome. Results: Cholestasis or jaundice developed 60 [13-110] days (median[range]) after transfer to the ICU. The laboratory findings were: Bilirubin: 7.5[0.4-62.1], Alkaline Phosphatase: 10.6[2.6-22.5], GGT: 34.0[10.3-91.4], ALT: 2.0[0.8-18.7], AST: 3.6[0.8-34.0],(xULN, median[range]). ERCP demonstrated sclerosing cholangitis in all patients. Severe ductopenia was seen in two patients. In 9 patients endoscopic sphincterotomy was performed. Casts and sludge were extracted in 5 patients. Biliary stenting was performed in one patient with a dominant stenosis. Two patients were lost for follow up. During a median follow up of 11 [4–46] months 7 patients (58%) progressed to liver cirrhosis. Two patients died of liver failure and 2 patients underwent orthotopic liver transplantation. Stabilization or biochemical improvement of cholestasis was achieved in 3 patients. Discussion: Reduced hepatic oxygen delivery may lead to initial bile duct injury in ICU patients. As a second hit septicemia, ischemia, translocation of endotoxins from the gut may further lead to progressing sclerosing cholangitis. Long term outcome of endoscopic treatment is poor as a high proportion of these patients develop liver cirrhosis, for whom liver transplantation should be considered.
AB206 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1262 Use of a Temporary Plastic Stent to Facilitate Multiple Self Expanding Metal Stents Placement in Malignant Biliary Hilar Strictures Lawrence C. Hookey, Olivier Le Moine, Jacques Deviere Although endoscopic palliation of malignant biliary hilar obstruction is preferable over surgery or percutaneous drainage, it remains technically challenging. This is especially true when multiple self expanding metal stents (SEMS) are placed, as difficulty is commonly encountered in passing the subsequent SEMS at the level of the previously deployed initial stent. We have devised a method of deploying multiple metal stents using a temporary plastic stent, which makes deployment of the subsequent SEMS much easier.After guidewire placement, a plastic stent is deployed in a sub-hilar position. The initial SEMS is deployed with the plastic stent maintaining a passage for the second SEMS. After the second SEMS is deployed, the plastic stent is retrieved. This technique has been used successfully in 6/7 patients, all of whom presented with symptomatic jaundice secondary to malignant hilar obstruction of various etiologies (cholangiocarcinoma, nZ3, metastatic disease, nZ3, and hepatocellular carcinoma, nZ1). Drainage was successful in all cases, with significant improvement in symptoms and cholestasis.
T1263 Precut Sphincterotomy Using Triple Lumen Needle-Knife for Cannulation of Biliary and Pancreatic Ducts in Patients with Choledocholithiasis Noriyuki Horiki, Noriko Watanabe, Ayumi Ogura, Mikito Kuroda, Megumi Nakamura, Gabazza C. Esteban, Ichiro Imoto, Yukihiko Adachi Aim: Precut technique is very useful when cannulation of obstructed biliary duct is not possible using standard methods. The use of this technique may avoid the occurrence of fatal cholangitis or septicemia. Precut sphincterotomy using needleknife is an effective method but extremely difficult. The success rate is low, and complications with acute pancreatitis are frequent. We designed a new precut technique of pancreatic sphincterotomy using a triple lumen needle-knife (TLN, Olympus) for selective access to the common bile duct. Methods: The study comprised 171 patients (mean age 69.1G17.4 yrs, male : femaleZ 80 : 91) that underwent standard endoscopic sphincterotomy (EST) including endoscopic papillary balloon dilatation (EPBD) or precut sphincterotomy for obstructed biliary disease with choledocholithiasis at our hospital from July 2001 through April 2004. We performed precutting in all patients showing difficulty for catheter insertion into the bile duct. Upward pancreatic sphincter precutting (PSP) was performed in patients in whom the papillotome was possible to insert into thin pancreatic duct. We used a TLN or a standard needle precut knife (NK) when the tip of papillotome could not be inserted into the pancreatic orifice deep enough to precut. Serum amylase was measured in all patients before and after (the next morning) the procedure and comparison between groups was performed. Result: Standard lithotomy (EST: EPBDZ 118:26) was successful in 84% (144 out of 171). Precutting was necessary in 27 patients in whom standard method failed. PSP was successful in 12 out of 14 patients. TLN was successful in 6 out of 8 patients; NK was successful in 1 out of 5 patients. The level of serum amylase was slightly lower in TLN than in NK. Conclusion: TLN is an effective procedure cases in which cannulation of biliary and pancreatic duct is difficult.
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T1260 Percutaneous Transhepatic Cholangioscopy Versus Open Choledochotomy in Treatment of Difficult Common Bile Duct Stones Jimin Han, Sang Soo Lee, Tae Joon Song, Myung-Hwan Kim, Dong Wan Seo, Sung Koo Lee, Do Hyun Park, Sung Jo Bang, Kyu-Bo Sung, Sung-Gyu Lee Background: Most of common bile duct stones can be effectively treated by endoscopic sphincterotomy and stone extraction using baskets or balloon catheters. However, endoscopic stone extraction can be very difficult or even impossible in patients with large and/or multiple stones, bile duct stricture, peripapillary diverticula, and previous gastric surgery. Open choledochotomy has played a major role in the treatment of such patients. On the other hand, laparoscopic choledochotomy is relatively expensive, more technically demanding, and takes longer to perform than laparoscopic cholecystectomy. Percutaneous transhepatic cholangioscopy (PTCS) has been used successfully for diagnosis and treatment of various biliary tract diseases. We compared treatment outcome of PTCS with that of open choledochotomy in patients with difficult common bile duct stones. Patients and Methods: Medical records of 98 patients who underwent either PTCS (nZ64) or open choledochotomy (nZ34) for difficult common bile duct stones from January 1998 to December 2003 were evaluated retrospectively. Results: Mean age of the 98 patients was 66.2 years (range: 31-89 years) and 58 patients (59.2%) were men. Mean number of stones was 2.5 (range 1-8) and mean size of the stones was 23.5 mm (range 8-56 mm). Between PTCS and open choledochotomy groups, there were statistically significant differences in mean age (68.3 vs. 62.4 years, pZ0.012), AST at the time of diagnosis (241 vs. 110 IU/dL, pZ0.019), history of cholecystectomy (39.1 vs. 11.8%, pZ0.005), and presence of fever at presentation (60.7 vs. 38.2%, pZ0.032). However, there were no statistically significant differences between two group regarding gender, number and size of stones, presence of comorbidity, and duration of hospital stay. Complications occurred in 8 patients (12.5%) of PTCS group and 11 (32.4%) of open choledochotomy group (pZ0.002). In PTCS group, 3 cases of bleeding (4.7%) and 2 cases of bile duct injury (3.1%) had occurred. In open choledochotomy group, 3 cases of bile duct injury (8.8%) and 7 cases of wound infection (20.6%) were reported. Also, there was one perioperative death in open choledochotomy group. No statistically significant difference in recurrence rate was observed during the follow-up (pZ0.31). Conclusions: PTCS is an effective and safe method in patients with difficult common bile duct stones. It may be a useful alternative treatment modality in such patients.
T1261 Vanishing Bile Duct Syndrome and Sclerosing Cholangitis in Patients with Critical Illness and Long Term Intensive Care Treatment Harald Hofer, Arnulf Ferlitsch, Ludwig Kramer, Christian Madl, Edward Penner, Rainer Schoefl, Andreas Puespoek Background: Sepsis associated cholestasis in intensive care patients usually subsides with treatment of the underlying cause. However, in a subgroup of these patients a progressive destruction of intrahepatic bile ducts and sclerosing cholangitis with the typically appearance of segmental strictures and cholangiectasies develops. In this respect, a progressive form of sclerosing cholangitis after septic shock and long term intensive care treatment has been described. We herein report the clinical course and endoscopic treatment in patients with sclerosing cholangitis due to critical illness. Patients: Twelve patients (6 male, age: 48.8C12.7, (mean, yearsCSD)) with sclerosing cholangitis, diagnosed by endoscopic retrograde cholangiopancreaticography were identified. No patient had evidence of preexisting hepato-biliary disease or inflammatory bowel disease. Transfer to the ICU was necessary because of sepsis in 2, extensive surgery in 4, polytrauma in 2, cardiopulmonary resuscitation in 2 and respiratory failure in 2 patients, respectively. All patients needed mechanical ventilation, had a preexisting pulmonary disease and/or developed a severe adult respiratory distress syndrome. Results: Cholestasis or jaundice developed 60 [13-110] days (median[range]) after transfer to the ICU. The laboratory findings were: Bilirubin: 7.5[0.4-62.1], Alkaline Phosphatase: 10.6[2.6-22.5], GGT: 34.0[10.3-91.4], ALT: 2.0[0.8-18.7], AST: 3.6[0.8-34.0],(xULN, median[range]). ERCP demonstrated sclerosing cholangitis in all patients. Severe ductopenia was seen in two patients. In 9 patients endoscopic sphincterotomy was performed. Casts and sludge were extracted in 5 patients. Biliary stenting was performed in one patient with a dominant stenosis. Two patients were lost for follow up. During a median follow up of 11 [4–46] months 7 patients (58%) progressed to liver cirrhosis. Two patients died of liver failure and 2 patients underwent orthotopic liver transplantation. Stabilization or biochemical improvement of cholestasis was achieved in 3 patients. Discussion: Reduced hepatic oxygen delivery may lead to initial bile duct injury in ICU patients. As a second hit septicemia, ischemia, translocation of endotoxins from the gut may further lead to progressing sclerosing cholangitis. Long term outcome of endoscopic treatment is poor as a high proportion of these patients develop liver cirrhosis, for whom liver transplantation should be considered.
AB206 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1262 Use of a Temporary Plastic Stent to Facilitate Multiple Self Expanding Metal Stents Placement in Malignant Biliary Hilar Strictures Lawrence C. Hookey, Olivier Le Moine, Jacques Deviere Although endoscopic palliation of malignant biliary hilar obstruction is preferable over surgery or percutaneous drainage, it remains technically challenging. This is especially true when multiple self expanding metal stents (SEMS) are placed, as difficulty is commonly encountered in passing the subsequent SEMS at the level of the previously deployed initial stent. We have devised a method of deploying multiple metal stents using a temporary plastic stent, which makes deployment of the subsequent SEMS much easier.After guidewire placement, a plastic stent is deployed in a sub-hilar position. The initial SEMS is deployed with the plastic stent maintaining a passage for the second SEMS. After the second SEMS is deployed, the plastic stent is retrieved. This technique has been used successfully in 6/7 patients, all of whom presented with symptomatic jaundice secondary to malignant hilar obstruction of various etiologies (cholangiocarcinoma, nZ3, metastatic disease, nZ3, and hepatocellular carcinoma, nZ1). Drainage was successful in all cases, with significant improvement in symptoms and cholestasis.
T1263 Precut Sphincterotomy Using Triple Lumen Needle-Knife for Cannulation of Biliary and Pancreatic Ducts in Patients with Choledocholithiasis Noriyuki Horiki, Noriko Watanabe, Ayumi Ogura, Mikito Kuroda, Megumi Nakamura, Gabazza C. Esteban, Ichiro Imoto, Yukihiko Adachi Aim: Precut technique is very useful when cannulation of obstructed biliary duct is not possible using standard methods. The use of this technique may avoid the occurrence of fatal cholangitis or septicemia. Precut sphincterotomy using needleknife is an effective method but extremely difficult. The success rate is low, and complications with acute pancreatitis are frequent. We designed a new precut technique of pancreatic sphincterotomy using a triple lumen needle-knife (TLN, Olympus) for selective access to the common bile duct. Methods: The study comprised 171 patients (mean age 69.1G17.4 yrs, male : femaleZ 80 : 91) that underwent standard endoscopic sphincterotomy (EST) including endoscopic papillary balloon dilatation (EPBD) or precut sphincterotomy for obstructed biliary disease with choledocholithiasis at our hospital from July 2001 through April 2004. We performed precutting in all patients showing difficulty for catheter insertion into the bile duct. Upward pancreatic sphincter precutting (PSP) was performed in patients in whom the papillotome was possible to insert into thin pancreatic duct. We used a TLN or a standard needle precut knife (NK) when the tip of papillotome could not be inserted into the pancreatic orifice deep enough to precut. Serum amylase was measured in all patients before and after (the next morning) the procedure and comparison between groups was performed. Result: Standard lithotomy (EST: EPBDZ 118:26) was successful in 84% (144 out of 171). Precutting was necessary in 27 patients in whom standard method failed. PSP was successful in 12 out of 14 patients. TLN was successful in 6 out of 8 patients; NK was successful in 1 out of 5 patients. The level of serum amylase was slightly lower in TLN than in NK. Conclusion: TLN is an effective procedure cases in which cannulation of biliary and pancreatic duct is difficult.
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