Comparison of Biliary Stent versus Biliary Sphincterotomy Alone in the Treatment of Bile Leak.

BACKGROUND AND AIMS: Bile leaks are uncommon but are a painful postoperative complication of hepatobiliary interventions. Many authors advocate treating them with biliary stenting. We compared the outcomes in patients treated with endoscopic biliary sphincterotomy (EBS) alone versus EBS with biliary stenting. METHODS: We reviewed charts of patients treated endoscopically for bile leak from 2009 to 2015 at our tertiary care center. Based on endoscopists' practice preference, patients underwent EBS alone or with a biliary stent. Clinical resolution of bile leak and total number of endoscopic and nonendoscopic interventions were compared between patients treated with EBS alone versus EBS with a biliary stent. RESULTS: Fifty-eight patients were included; etiology was cholecystectomy (52), hepatic resection (5), and liver trauma (1). The leak was from the cystic duct (22), duct of Luschka (23), common bile, or hepatic duct (2), and intrahepatic duct (11). Thirty-seven patients had EBS alone (EBS group), and 21 had stents (stent group). Single intervention resolved the bile leak in 34 (92%) patients in EBS group and 19 (90%) in the stent group (p = 0.85). Resolution was slower (p = 0.02) and more patients required second intervention (p < 0.01) in the stent group. CONCLUSION: EBS with or without a biliary stent is highly effective in the management of bile leak. Clinical resolution of the bile leak is quicker with EBS alone, requires fewer interventions, and may cost less.

Clinical outcome of single plastic stent treatment of benign iatrogenic biliary strictures: is the outcome predetermined?

Endoscopic retrograde cholangiopancreatography (ERCP) is used for the management of benign iatrogenic biliary strictures after cholecystectomy and liver transplantation. Multiple stents can injure biliary circulation. If resolution of reversible ductal edema and/or ischemia is the mechanism for successful therapy then single stent placement for benign biliary stricture should work. Retrospectively reviewed ERCP records between November 1999 and 2012 provided 25 patients with repeat ERCPs performed at 10-week intervals or if symptoms of stent occlusion were present. If strictures did not improve between stent changes and if removal was not an option, hepaticojejunostomy was used. Strictures resolved in 72% of patients. Seven patients underwent hepaticojejunostomy. Three had ERCP-related complications. No stricture recurrence occurred during the follow-up period. Endoscopic single plastic stent treatment of benign biliary iatrogenic strictures has comparable success to multiple stenting. Many postsurgical strictures may have reversible ischemic/edematous component with stenting to maintain bile drainage.

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.

Improved oral intake after palliative duodenal stenting for malignant obstruction: a prospective multicenter clinical trial.

OBJECTIVES: We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet. METHODS: In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement. RESULTS: Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase > or =1. Resumption of solid food intake (GOOSS 2-3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2-3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients. CONCLUSIONS: Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2-3, the capacity for solid food intake endures until death or last follow-up.

Does obesity confer an increased risk and/or more severe course of post-ERCP pancreatitis?: a retrospective, multicenter study.

BACKGROUND: Pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). Recent studies have suggested that obesity may serve as a prognostic indicator of poor outcome in non-ERCP-induced acute pancreatitis. However, to our knowledge, no one has ever investigated the potential association of obesity and ERCP-induced pancreatitis. Thus, the purpose of our study was to determine whether obesity conferred an increased risk and/or more severe course of post-ERCP pancreatitis. METHODS: A 160 variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study, evaluating whether prophylactic corticosteroids reduces the incidence of post-ERCP pancreatitis. Body mass indices (BMIs) were available on 964 of the 1115 patients from the original study. A BMI > or = 30 kg/m2 was defined as obese (World Health Organization) and used as a cutoff point in this study. BMIs were analyzed in a retrospective fashion to determine whether obesity confers an increased risk and/or more severe course of post-ERCP pancreatitis. Data were collected before the ERCP, at the time of procedure, and 24 to 72 hours after discharge. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. RESULTS: Nine hundred sixty four patients were enrolled in the study. Pancreatitis occurred in 149 patients (15.5%) and was graded as mild in 101 (67.8%), moderate in 42 (28.2%), and severe in 6 (4.0%). The patients were categorized by BMI (kg/m2) using the following breakdowns: BMI < 20, 20 to < 25, 25 to < 30, and > or = 30, as well as BMI < 30 or > or = 30. The groups were similar with respect to the patient and procedure risk factors for post-ERCP pancreatitis except the group with BMI > or = 30 had a higher frequency of females, were younger, had less frequent chronic pancreatitis, a lower number of pancreatic duct injections, and fewer patients received more than 2 pancreatic duct injections. Of the patients with a BMI < 30, 119 (16.4%) developed post-ERCP pancreatitis compared with 30 (12.5%) of those with a BMI > or = 30 (P=0.14). There was no association between the presence of obesity and the severity of pancreatitis (P=0.74). Patients with a BMI < 20, 20 to < 25, 25 to < 30, and > or = 30 had a similar incidence of post-ERCP pancreatitis. CONCLUSIONS: Obesity did not seem to confer an increased risk for ERCP-induced pancreatitis. A statistically significant association between obesity and the severity of ERCP-induced pancreatitis was not apparent.

Cholecystectomy and the risk of recurrent colorectal adenomas.

Prior studies have shown an increased risk of colorectal cancer following cholecystectomy, but few studies have explored the association between cholecystectomy and the risk of colorectal adenomas. We used data from three large randomized adenoma chemoprevention trials to explore the association between cholecystectomy and the occurrence of adenomas. After adjusting for confounding factors, we found no increased risk for adenomas among individuals who had undergone cholecystectomy [risk ratio (RR), 1.02; 95% confidence interval (95% CI), 0.88-1.18]. There was a slight increase in the risk of advanced recurrent adenomas (RR, 1.28; 95% CI, 0.94-1.76) and multiple advanced recurrent adenomas (RR, 1.34; 95% CI, 0.97-1.85) but the 95% CIs included the null in both cases. We conclude that the increased risk for colorectal cancer following cholecystectomy seems to be due to a biological process occurring after the adenoma has developed.

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.

Percutaneous endoscopic gastrojejunostomy tube placement in healthy dogs and cats.

BACKGROUND: Pancreatitis, hepatobiliary disease, and proximal gastrointestinal tract disorders are clinical situations where delivery of nutrients via jejunostomy tube is preferable to a feeding gastrostomy. A thorough description of the percutaneous endoscopic gastrojejunostomy (PEG-J) technique and practical guidelines for its use in small animals have not been reported. HYPOTHESIS: That a simple technique of PEG-J tube placement in humans would be useful and safe in healthy dogs and cats. ANIMALS: Twelve healthy dogs and 5 healthy cats were included in the study. MATERIALS AND METHODS: Commercially prepared PEG-J tubes were modified for use in animals and positioned in the small intestine by endoscopic guidance. Eight dogs and 5 cats were bolus fed enteral diets for 14 days. Complications associated with the use of the PEG-J tube and responses to bolus feedings were assessed. RESULTS: Jejunostomy tubes were placed distal to the caudal duodenal flexure in all dogs and cats. Complications associated with PEG-J tubes occurred in 5/12 dogs and 4/5 cats and included J-tube removal, local pain/inflammation, retrograde tube migration, and diarrhea. Bolus feeding (daily maintenance energy requirement [MER] divided q8h) through the jejunostomy catheter was well tolerated, maintained normal body weight, and was not associated with adverse gastrointestinal signs. CONCLUSIONS AND CLINICAL IMPORTANCE: Placement of a PEG-J tube is an effective, noninvasive technique for providing enteral nutritional support of healthy dogs and cats. Bolus-feeding techniques via PEG-J tubes maintain normal nutritional status in healthy dogs and cats. This procedure for jejunostomy feeding may be easily adapted for use in clinical practice outside of an intensive care facility.

Palliative endoscopic ultrasound-guided drainage of a malignant pancreatic cyst causing gastric outlet obstruction.

BACKGROUND: Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has been well described but it is not an established therapy for malignant pancreatic cystic neoplasms. We report the first EUS-guided cystogastrostomy for the palliative treatment of a cystic pancreatic adenocarcinoma. CASE REPORT: We describe a 70-year-old male with a nonresectable cystic pancreatic adenocarcinoma causing partial gastric outlet obstruction treated successfully with palliative EUS-guided cystogastrostomy stent placement. The diagnosis was confirmed by EUS-guided fine needle aspiration. Computerized tomography (CT) and EUS staging revealed vascular invasion precluding the patient from surgical resection. Cystogastrostomy was performed entirely under EUS guidance utilizing a 10-Fr double pigtail stent. After cystogastrostomy stent placement, the patient developed dramatic symptomatic improvement of gastric outlet obstructive symptoms, although subsequent imaging did not reveal complete collapse of the cystic structure. CONCLUSION: EUS-guided cystogastrostomy can be considered in the palliative treatment of nonresectable pancreatic cystic neoplasms. Cyst decompression may result in significant symptomatic improvement, although the architecture of malignant cysts may prevent complete resolution.

The role of ERCP in patients with pancreatico-biliary problems in the setting of hematopoietic stem cell transplant.

BACKGROUND: Patients undergoing hematopoietic stem cell transplant may develop pancreatico-biliary complications that may require ERCP. Due to their immunocompromised state, these patients may be at higher risk of procedure-related complications. OBJECTIVE: To determine the role of ERCP in the diagnosis and treatment of patients who have undergone hematopoietic stem cell transplant and the patients' clinical outcomes. DESIGN: Retrospective analysis of patients with hematopoietic stem cell transplant who underwent ERCP from 1997 to 2004 evaluating ERCP indications, diagnosis, therapeutic interventions, and complications. SETTING: Tertiary referral center. RESULTS: Of the 16 patients identified, 9 were female, 15 had had allogeneic hematopoietic stem cell transplant, and 1 had an autologous hematopoietic stem cell transplant. Twenty-six ERCP procedures were performed in the 16 patients. Index ERCP findings included: extra hepatic bile duct obstruction in 12 patients, of which 7 had biliary lithiasis. Ampullary obstruction due to infiltration from graft versus host disease was seen in 3 of 12 patients, benign bile duct stricture in 1 of 12, and ampullary obstruction in the setting of a peri-ampullary diverticulum in 1 of 12. Index ERCP findings in the remaining 4 patients included: intrahepatic bile duct compression due to metastatic disease in 1 of 16 patients, bile duct leak in 1 of 16, pancreatic duct stone in 1 of 16, and normal ERCP in 1 of 16. Complications occurred in 4 patients: mild pancreatitis (1), mild bleeding (1), cholangitis due to late stent occlusion (1), and intermittent bradycardia (1). There were no ERCP-related deaths. LIMITATIONS: Single-center study. CONCLUSION: In patients with hematopoietic stem cell transplant, bile duct lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to graft versus host disease. ERCP yielded clinically relevant information in this particular group of patients.

Risk factors for post-ERCP pancreatitis: a prospective multicenter study.

OBJECTIVES: Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS: A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS: Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION: This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.