Long-term biliary endoscopic sphincterotomy restenosis: incidence, endoscopic management, and complications of retreatment.

BACKGROUND: Ampullary restenosis is a late complication of biliary endoscopic sphincterotomy. Long-term data are limited regarding both the rate of restenosis and complications resulting from repeat therapy. AIMS: To determine the incidence of post sphincterotomy restenosis and the effectiveness of endoscopic therapy in the management of this entity. METHODS: A retrospective review of medical charts and the endoscopic retrograde cholangiopancreatography (ERCP) database to identify patients with ERCP and biliary endoscopic sphincterotomy during the period 1998-2002 at the University of Iowa Hospitals was conducted. All subjects were contacted by phone and asked about the recurrence of their pancreatobiliary symptoms after the first ERCP and whether they sought any medical treatment for these symptoms. The primary outcome was restenosis of the sphincterotomy site and the secondary outcome was complications of endoscopic treatment of sphincterotomy restenosis. RESULTS: A total of 202 patients underwent ERCP and biliary endoscopic sphincterotomy on an intact major papilla. Of these, n = 80 patients (54.7 +/- 19 years of age, 76% female) consented and enrolled in the study. Among these, n = 13 (16%) developed ampullary restenosis in 1-62 (median 16) months after the index ERCP. These 13 patients underwent a total of 24 ERCPs (range 1-4 for each patient) for repeat biliary sphincterotomy and biliary stenting, if needed. Repeat biliary endoscopic sphincterotomy was successful in 12/13 (92%) patients. Complications of repeat biliary endoscopic sphincterotomy were seen in three patients: mild pancreatitis (n = 1), severe bleeding (n = 1), and severe duodenal perforation (n = 1). CONCLUSIONS: Long-term restenosis is an important sequella of biliary endoscopic sphincterotomy. Repeat biliary endoscopic sphincterotomy is an effective treatment modality, but complications are not negligible.

Biliary sphincter of Oddi dysfunction type I versus occult biliary microlithiasis in post-cholecystectomy patients: are they both part of the same clinical entity?

We speculate that biliary sphincter of Oddi dysfunction type I and symptomatic migrating biliary microlithiasis may be part of the same disease process. A retrospective analysis of prospectively collected data was carried out using procedure and diagnosis codes during the period of 1997-2006. Seventeen patients (age 51 +/- 17; 94% women) with prior cholecystectomy, right upper quadrant/epigastric abdominal pain, elevated liver enzymes, dilated biliary ducts seen on ultrasound/CT scan were identified. The patients underwent ERCP with biliary endoscopic sphincterotomy. Nine (53%) had biliary microlithiasis and eight (47%) had biliary sphincter of Oddi dysfunction type I. They were followed for 2-108 weeks (median 9 weeks). 6/8 (75%) in biliary sphincter of Oddi dysfunction type I and 6/9 (67%) in biliary microlithiasis group had resolution of abdominal pain (P = 1.00). We conclude that the clinical improvement with biliary sphincterotomy for biliary sphincter of Oddi dysfunction type I versus occult biliary microlithiasis was not significantly different.

Outcome of ERCP in the management of duct-to-duct anastomotic strictures in orthotopic liver transplant.

This study sought to determine the efficacy of endoscopic treatment of duct-to-duct anastomotic stricture in orthotopic liver transplant. A retrospective chart and database review was carried out using procedure and diagnosis codes during the period of 1997-2001. One hundred ninety-eight adult patients underwent orthotopic liver transplantation from 1997 to 2001. Fifteen patients (age 52+/-9 years; 60% women) with duct-to-duct anastomotic strictures were identified. They underwent a total of 53 endoscopic retrograde cholangiopancreatographies (ERCPs) and received different endoscopic treatments including biliary dilation, stent placement, and sphinctrerotomy. Thirteen of these patients (87%) had complete resolution of stricture. Of the remaining two patients, one had partial resolution of stricture and underwent long-term self-expanding metal stenting, while the other had no resolution after two ERCPs. We conclude that ERCP was effective in treating 87% of the duct-to-duct anastomotic strictures in this series.

Nasobiliary tube management of postcholecystectomy bile leaks.

BACKGROUND: Endobiliary stenting is the traditional form of endoprosthetic drainage for biliary leaks. Nasobiliary tubes offer the advantage of easy removal and interval tube cholangiograms to assess leak resolution. AIM: To determine the efficacy of nasobiliary tube drainage in patients with postcholecystectomy biliary leaks and provide our experience with management of biliary leak using nasobiliary drains. MATERIALS AND METHODS: Retrospective study of 24 patients who were treated for postcholecystectomy biliary leaks in a tertiary referral center from 1998 to 2002. These patients were managed with either nasobiliary tube (NBT) alone or NBT + endoscopic sphincterotomy (ES). RESULTS: Twenty-four patients (mean age, 57.5 years; 50% women) had postcholecystectomy leak noted on ERCP. Twenty patients were managed by NBT+ES and 4 patients had NBT placement alone. In the NBT+ES group, 2 patients pulled their NBT out, but 18 patients had complete leak resolution in 3 to 9 days. In the NBT group, all patients had complete leak resolution in 4 to 12 days. Using an intention-to-treat analysis, 22 of 24 (92%) patients were successfully treated with NBT treatment over 3 to 12 days. CONCLUSIONS: ERCP with NBT placement is an effective and safe treatment modality in the management of postcholecystectomy biliary leaks.

Hemosiderosis is associated with accelerated decompensation and decreased survival in patients with cirrhosis.

AIM: Although hepatic iron deposition unrelated to hereditary hemochromatosis is commonly observed in cirrhosis, its clinical significance is unclear. The aim of this study was to examine the outcomes of cirrhotic patients with and without hemosiderosis. METHODS: Patients with an initial liver biopsy demonstrating cirrhosis between January 1993 and December 1997 were identified using the Department of Pathology database. Based on iron staining, patients were characterized as siderotic or nonsiderotic. Charts were reviewed to determine outcomes. RESULTS: Siderotic patients had significantly higher Child-Pugh (CP) and model for end-stage liver disease (MELD) scores. Their median survival without transplant was 23 months vs. 85 months in the nonsiderotics (P<0.0001, confidence interval: 95%). On univariate analysis, siderosis was associated with a hazard ratio of 2.74 (P<0.0001). On multivariate analysis, the effect of siderosis was reduced but remained significant after correction for the CP or MELD score (hazard ratios 1.82 and 2.06, P=0.05 and 0.02, respectively). Child's A cirrhotics with hemosiderosis decompensated more rapidly and had shorter median survival than those without siderosis (P=0.007 and P=0.01, respectively). CONCLUSIONS: The presence of siderosis is associated with more advanced liver dysfunction. Even when the effects of baseline liver function are taken into account, siderosis is associated with decreased survival and more rapid decompensation in cirrhosis.