Infection with Helicobacter bilis but not Helicobacter hepaticus was Associated with Extrahepatic Cholangiocarcinoma.

BACKGROUND AND AIMS: The biliary tract cancer or cholangiocarcinoma (CCA) represents the sixth leading cause of gastrointestinal tumors in the Western world, and mortality varies across the world, with regions such as Chile, Thailand, Japan, and northeastern India presenting the highest rates. CCA may develop in the bile duct, gallbladder, or ampulla of Vater; and risk factors include obesity, parity, genetic background, geographical and environmental factors. Inflammation induced by bacterial infections might play a role in the pathogenesis of CCA. In this work, we investigated whether there is an association between extrahepatic cholangiocarcinoma (ECCA) and infection with S. typhi, H. hepaticus, or H. bilis in a Mexican population. METHODS: A total of 194 patients were included and divided into 91 patients with benign biliary pathology (controls) and 103 with ECCA (cases). Tumor samples were taken during endoscopic retrograde cholangiopancreatography by biliary brushing, followed by DNA extraction and PCR testing for infections. RESULTS: We found that 44/103 cases were positive for H. bilis, compared with 19/91 controls (p = 0.002; OR 2.83, 95% CI 1.49-5.32), and when analyzed by sub-site, H. bilis infection was significantly more associated with cancer in the common bile duct (p = 0.0005; OR 3.56, 95% CI 1.77-7.17). In contrast, H. hepaticus infection was not different between cases (17/103) and controls (13/91) (p = 0.82; OR 1.19, 95% CI 0.54-2.60). None of the samples were positive for S. typhi infection. CONCLUSION: In conclusion, infection with H. bilis but neither H. Hepaticus nor S. typhi was significantly associated with ECCA, particularly with tumors located in the common bile duct.

[Complications in diagnostic and therapeutic endoscopic cholangiopancreatography. Prospective study]. / Complicaciones en colangiopancreatografía endoscópica diagnóstica y terapéutica. Estudio prospectivo.

BACKGROUND: Studies of ERCP-related morbidity seldom include a sufficient patient follow-up. The complication rate is variable. AIM: To characterize and to evaluate the frequency of complications in patients after Diagnostic and Therapeutic ERCP. PATIENTS AND METHODS: All patients undergoing ERCP during a 2-year period were included in this prospective study. Complications were assessed at time of ERCP and by personal or telephone contact at 1st, 7, 14 and 30-days after the procedure. RESULTS: A total of 897 ERCPs were included in the analysis, of which 93.9% were therapeutic procedures. 640 were female with age of 49.68 (+/-18.59) and 257 male with age 58.80 (+/-16.67). The 30-day complications rate was 3.19%; the procedure-related mortality rate was 0.11%. Mild hemorrhage occurred in 1.48% and moderate hemorrhage in 0.11%. Post-ERCP pancreatitis occurred in 0.79% and duodenal perforation in 0.45%. The 30-day procedure-no related mortality was 1.14%. CONCLUSION: This prospective study confirms the complications rate of ERCP including therapeutic procedures is low in our experience.

[Endoscopic mechanical lithotripsy in choledocholithiasis of difficult extraction handling]. / Litotripsia mecánica vía endoscópica en el manejo de coledocolitiasis de difícil extracción.

BACKGROUND: Large stones are difficult to remove in block through a small papillotomy, a relative narrowed distal bile duct, periampular diverticula or in those who have undergone only balloon sphincteroplasty prior to stone extraction. Extending the papillotomy is not always possible, and may carry, an increased risk of bleeding and perforation. Lithotripsy facilitates stone extraction and clearance of the common bile duct. AIM: This study investigated the predictors of successful or unsuccessful mechanical lithotripsy. PATIENTS AND METHODS: A series of 100 consecutive patients who underwent mechanical lithotripsy was evaluated retrospectively and a large number of variables tested for their association with successful outcome. RESULTS: The procedure was safe (morbidity rate 4.4%) and effective (68% stone clearance rate). The statistic analysis showed that lithotripter type was the only outcome predictor (p = 0.044). The other factors analyzed were not statistically significance. CONCLUSION: Mechanical lithotripsy is successful in about 70% of patients with difficult bile duct stones. The only significant factor that predicts failure of mechanical lithotripsy is lithotripter type.

[Therapeutic endoscopy in pancreas]. / Endoscopia terapéutica en páncreas.

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreatic disease is continuing to evolve. In view of increasingly noninvasive diagnostic imaging modalities for pancreatic disease, ERCP should be mainly restricted to therapeutic indications. This article reviews recent publications spanning a wide range of topics related to therapeutic pancreatic endoscopy: This review article will be focused on the technical and therapeutic aspects of the following topics: 1. Post-ERCP pancreatitis and preventive methods for this entity, 2. Recurrent severe pancreatitis, 3. Oddi sphincter dysfunction, 4. Pancreatic duct stenosis and lithiasis in chronic pancreatitis, 5. Hereditary pancreatitis, 6. Pseudocysts and pancreatic abscesses, and 7. Pancreatic duct fistulae. Pancreatic endotherapy is technically demanding and potentially hazardous; these interventions should be restricted to high-volume centers with options for an interdisciplinary team approach. Methods that have not yet been established should be evaluated in carefully designed prospective trials.

[Endoscopic treatment of idiopathic recurrent chronic pancreatitis in children and adolescents]. / Tratamiento endoscópico de la pancreatitis crónica idiopática recidivante en niños y adolescentes.

BACKGROUND: The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. AIM: Report our experience with ERCP in the management of chronic recurrent idiopathic pancreatitis in children. PATIENTS AND METHODS: Over a 12-year period we performed 56 ERCP for the treatment of chronic recurrent idiopathic pancreatitis in 20 patients which clinical status was assessed six months before the first ERCP and six months after the last ERCP. RESULTS: There were 12 girls and eight boys with a mean age of 11.36 in girls (range 4-17) and 12.77 in boys (range 9-16). Abdominal pain was the main presenting symptoms with hiperamylasemia. Clinical diagnoses included two pancreas divisum, chronic calcifying pancreatitis in two and 16 non-calcifying chronic pancreatitis with dilated and irregular pancreatic duct. The mean follow-up was 24 months. Twenty patients underwent a total of 56 therapeutic ERCP procedures included pancreatic and biliary sphincterotomy, pancreatic endoprosthesis placement, stone extraction and hydrostatic or mechanical dilation in pancreatic strictures. There were four complications of 56 procedures (7.14%), both being mild pancreatitis after endoprosthesis placement (n = 1), pancreatic sphincterotomy (n = 1) and hydrostatic dilation with endoprosthesis placement (n = 2). There were no deaths. There was a significant reduction in frequency and severity of pain after intervention (p < 0.001). One patient with calcifying pancreatitis required surgical intervention. CONCLUSION: ERCP is safety and useful diagnostic and therapeutic procedure in children and adolescents with chronic recurrent idiopathic pancreatitis.

[Transpapillary and transmural drainage of pancreatic pseudocysts]. / Drenaje de pseudoquistes pancreáticos por vía transpapilar o transmural.

BACKGROUND: Endoscopic treatment of pancreatic pseudocysts via cystoenterostomy or transpapillary stenting has been recognized as a successful treatment options in carefully selected patients. Transpapillary stenting is an option in patients with pancreatic pseudocysts directly communicating with the main duct. AIM: The aim of this study was to assess the safety and usefulness of transpapillary pancreatic endoprosthesis and transmural drainage in the treatment of symptomatic pancreatic pseudocysts. PATIENTS AND METHODS: After preliminary endoscopic retrograde pancreatography (ERCP) in 22 patients, transpapillary drainage was attempted in 8 patients with pseudocysts that communicated with the main pancreatic duct, transmural drainage of pseudocysts in contact with the stomach or duodenal wall was attempted in 12 patients and 2 patients were selected for combined transpapillary and transmural drainage. RESULTS: Endoscopic drainage was technically successful in 18 patients (81.8%) of whom 16 had complete pseudocyst resolution. Complications occurred in 9% and included bleeding (n = 1) after transmural drainage, and pancreatitis (n = 1) after transpapillary drainage. Mean follow-up was 12 months (range, 2 to 21); pseudocysts recurred in 2 patients (11%), whom required surgical intervention. No mortality was observed. CONCLUSION: Both transpapillary and transmural pseudocysts drainage are highly effective in patients with pseudocysts demonstrating suitable anatomy for these endoscopic techniques.

[Self-expandable metallic biliary endoprosthesis in malignant obstructive jaundice]. / Endoprótesis metálicas biliares autoexpandibles en ictericia obstructiva maligna.

BACKGROUND: Implantation of metallic stents for malignant biliary strictures has been recognized to be effective alternatives. AIM: To show our experience in metallic stents for palliation of malignant biliary strictures. PATIENTS AND METHODS: Seventy three patients (38 males, 35 females, mean age 64.26) with malignant biliary strictures have been treated by implantation of metallic stents. Causes of obstruction were pancreatic carcinoma (23/73, 31.5%), bile duct carcinoma (31/73, 42.5%), carcinoma of ampula of Vater (11/73, 15%) and Klatskin tumor (3/73, 4.1%). RESULTS: Endoscopic procedure was successful in all cases. Neither procedure-related morbidity nor mortality was observed. Life surviving curve was 9 months and showed significant difference (p < 0.0071) in patients with carcinoma of ampula of Vater. CONCLUSION: Self-expanding metal endoprosthesis is a recognized method of palliation in malignant biliary obstruction. It efficiently relieves jaundice and generally improves comfort and nutritional status during the patient's remaining lifetime. The metallic stents are advantageous in patients surviving 6 months or less.

Association between Helicobacter spp. infections and hepatobiliary malignancies: a review.

Hepatobiliary cancers are highly lethal cancers that comprise a spectrum of invasive carcinomas originating in the liver hepatocellular carcinoma, the bile ducts intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, the gallbladder and the ampulla of Vater (collectively known as biliary tract cancers). These tumors account for approximately 13% of all annual cancer-related deaths worldwide and for 10%-20% of deaths from hepatobiliary malignancies. Cholangiocarcinoma (CCA) is a devastating disease that displays a poor survival rate for which few therapeutic options are available. Population genetics, geographical and environmental factors, cholelithiasis, obesity, parity, and endemic infection with liver flukes have been identified as risk factors that influence the development of biliary tract tumors. Other important factors affecting the carcinogenesis of these tumors include chronic inflammation, obstruction of the bile ducts, and impaired bile flow. It has been suggested that CCA is caused by infection with Helicobacter species, such as Helicobacter bilis and Helicobacter hepaticus, in a manner that is similar to the reported role of Helicobacter pylori in distal gastric cancer. Due to the difficulty in culturing these Helicobacter species, molecular methods, such as polymerase chain reaction and sequencing, or immunologic assays have become the methods of choice for diagnosis. However, clinical studies of benign or malignant biliary tract diseases revealed remarkable variability in the methods and the findings, and the use of uniform and validated techniques is needed.

[Conservative management of duodenal perforation following endoscopic sphincterotomy of papilla of Vater]. / Manejo conservador de la perforación duodenal secundaria a esfinterotomía endoscópica (EE) de la papila de vater.

BACKGROUND: Endoscopic sphincterotomy (ES) is an established procedure in treatment of diseases of the biliary tract; management of serious complications such as duodenal perforation remains controversial. Because mortality is high if sepsis is inadequately treated by no use of operative means, many surgeons advocate routine operative repair and drainage upon diagnosis. In surveys of large experiences, however, the majority patients initially were treated non-surgically, and the majority recovered. OBJECTIVE: To evaluate our experience with non-surgical management in patients with duodenal perforation after ES. PATIENTS AND METHODS: Retrospective chart review from January 1991 to December 2000 identified 12 instances of duodenal perforation. We reviewed endoscopic cholangiopancreatography (ERCP) findings, diagnostic methods, time to diagnosis, methods of management, length of patient stay, and outcome. RESULTS: Twelve patients with diagnosis of choledocholithiasis (5) papillary stenoses (4) and carcinoma of pancreas (3) had duodenal perforation among 1,510 ES performed (0.79%). In all cases during ES, retroperitoneal air on fluoroscopic examinations was observed and diagnosis was made. One patient was managed initially by surgery and death occurred due to pulmonary complications. Eleven patients were treated conservatively with nasogastric aspiration, none by mouth intravenous fluids, antibiotics, and somatostatin analog without mortality. Median length of stay was 6.7 days. CONCLUSIONS: Duodenal perforation after ES may be treated conservatively with success if identified during ES or early stage. Early diagnosis of duodenal perforation is essential for optimum outcome.

[Selection criteria for endoscopic cholangiopancreatography before laparoscopic cholecystectomy]. / Criterios de selección para la realización de colangiopancreatografía endoscópica previo a colecistectomía laparoscópica.

BACKGROUND: The unexpected detection of stones in common bile duct during laparoscopic cholecystectomy is a concern for laparoscopic surgeons. Immediate laparoscopic removal may not always be feasible due to inadequate operating facilities, surgeons, and assistants. Attempts have been made to identify clinical and biochemical predictor of common bile duct stones, the results of which have not been consistent. OBJECTIVE: The aim of this study was to define patients with risk for common bile duct stones based on history, abdominal ultrasound, and biochemical derangements, as well as to evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) for diagnosis and duct clearance if necessary. PATIENTS AND METHODS: This is a prospective cross sectional analysis of 82 patients (66 females and 16 males) with gallstones on whom were performed clinical examination, laboratory test, and abdominal ultrasound to identify predictors of common bile duct stones. Preoperative ERCP was carried out and patients underwent ES for stone retrieval. RESULTS: Clinical evidence of jaundice or pancreatitis, elevated serum amylase, and ultrasonographic evidence of biliary tree dilation or common bile duct stone were considered risk factors. In 45 patients, common bile duct stones were identified at preoperative ERCP patients underwent ES, and stones were removed with 100% success. All patients were scheduled for laparoscopic cholecystectomy 24 h later. There was no mortality in this series. CONCLUSIONS: Clinical evidence of jaundice or pancreatitis, elevation of serum amylase and dilated common bile duct or presence of common bile duct stones were considered risk factors for choledocholithiasis. Use of such a model rather than individual criteria would improve selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.

[Postoperative biliary stenosis: long-term results of endoscopic treatment]. / Estenosis biliar postoperatoria: resultados del tratamiento endoscópico a largo plazo.

BACKGROUND: Endoscopic stent placement is often the initial therapy in symptomatic patients with postoperative strictures because patients are usually diagnosed at the time of ERCP. Although stent insertion rapidly relieves symptoms of biliary obstruction and can even be live-saving in patients with cholangitis, all stents eventually clog, necessitating regular stent changes every 3 to 4 months. Results from several groups suggested that placing multiple stents for months to years could dilate the stricture permanently and thus also treat patients with postoperative biliary strictures palliatively. OBJECTIVE: The outcome of temporary biliary stent placement for postoperative bile duct stenosis was retrospectively evaluated. This is a review of our experience with endoscopic dilation and stent placement in postoperative biliary strictures. PATIENTS AND METHODS: Thirty patients with postoperative strictures diagnosed with ERCP were treated with long-term endoscopic stent placement. One 10 Fr stent was placed at first whenever possible, and stents were exchanged every 3 months for a total of 18 months as median. RESULTS: Four men and 26 women with mean age 42 years (range 16-69 years), and laparoscopic cholecystectomy in six and cholecystectomy (open procedure) in 24; surgical history was reviewed retrospectively. Five patients were lost to follow-up and 25 patients were followed for a median of 18 months. In all 25 patients, previous to stent placement, 8.5 or 10 Fr, a mechanical or hydrostatic dilation was necessary. Stents were exchanged every 3 months to avoid cholangitis caused by clogging. Three 10 Fr stents were inserted in one patient, two 10 Fr stents in 14 patients, one 10 Fr and one 8.5 Fr stent in nine patients, and in one patient, one 10 Fr stent. Six patients (24%) developed recurrent stenosis and required surgery. CONCLUSIONS: Endoscopic treatment with mechanical or hydrostatic dilation and stent insertion may improve long-term results for patients with postoperative biliary strictures.

[Endoscopic sphincterotomy as an out-patient procedure: is it safe?]. / Esfinterotomía endoscópica (EE) como procedimiento ambulatorio: es seguro?

BACKGROUND: Patients have been routinely admitted for observation for potential complications after therapeutic ERCP; however, in this era of cost containment it may be more cost-effective to perform these procedures on an out-patient basis. AIM: The purpose of this study was to determine safety and complication rates of endoscopic sphincterotomy in out-patients. MATERIALS AND PATIENTS: Over an 11-month period, 124 consecutive patient undergoing endoscopic sphincterotomy for biliary and pancreatic disease were enrolled in a prospective and randomized manner. Sixty patients (Group A) were observed 1-3 h post procedure before discharge with follow-up at 5 days. The other 62 patients (Group B) were admitted for observation. The statistical method was Fisher test and chi 2. RESULTS: Successful endoscopic sphincterotomy was achieved in 98.3% (122/124) of patients. Eighty five patients were female and 37 male. There were 60 outpatients and 62 in-patients; endoscopic sphincterotomy was performed by choledocholithiasis in 59.9% (70 cases) and papillary stenoses in 16.4% (20 cases). Complication rates were 3.27% (four patients): three pancreatitis and one bleeding. There were three in-patients and one outpatient (p. 313). We reduce costs $324,120.00 M.N. (Mexican pesos) without compromising patient safety and outcome. CONCLUSIONS: Endoscopic sphincterotomy may be performed safely on an outpatient basis, realizing significant savings in costs.

[Endoscopic management of choledocholithiasis during pregnancy]. / Manejo endoscópico de la coledocolitiasis durante el embarazo.

BACKGROUND: Gallstones and extrahepatic biliary obstruction is a difficult management problem during pregnancy. Choledocholithiasis may cause cholangitis or pancreatitis, potentially life-threatening conditions. As surgery may result in significant fetal mortality when performed on these patients. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are preferred and could be performed safely in pregnant women provided suitable precautions are taken to minimize exposure to radiation. OBJECTIVE: To show our experience in ERCP and ES for symptomatic choledocholithiasis during pregnancy. MATERIAL AND PATIENTS: We described our experience in seven young women (mean age, 27.4 years) who presented with symptoms caused by choledocholithiasis, one in first trimester of pregnancy, four in second trimester, and two in third month. All had obstructive jaundice corroborated by abnormal liver function test and dilation of biliary tree on abdominal ultrasound. RESULTS: All had ERCP, ES, and stone extraction without complication and went on to deliver healthy babies at term. A lead apron was positioned over the abdomen of the mother to shield the fetus during roentgenographic fluoroscopy. Mean fluoroscopy time was 26 (range, 5-60 sec). CONCLUSIONS: Endoscopic management should be considered in women presenting with choledocholithiasis during pregnancy.

[Endoscopic diagnosis and treatment of non-traumatic bilhemia. A case report]. / Diagnóstico endoscópico y tratamiento de bilhemia de origen no traumática. Reporte de un caso.

Biliovascular fistulas are abnormal communications with two types of clinical manifestations depending on type of flow in fistulous tract: 1) hemorrhage into biliary tract known as hemobilia, or 2) bile into bloodstream, known as bilhemia. Historically, this complication has been treated with surgery; however, technological progress at present allows treatment with intervention techniques without surgery being mandatory. In 1975, Clemens and Wittrin introduced the term bilhemia, a rare complication of hepatic damage producing excessively high levels of serum bilirubin and moderate rise of hepatic enzymes secondary to post-traumatic intrahepatic biliovenous fistula. Although this pathology is rare, it is considered dangerous; of 50 patients reported in the literature, 25 died due to this problem. The main purpose of treatment is to release tract obstruction by endoscopic sphincterotomy of Vater's papilla or, if the process is localized in proximal areas of biliary tract, through percutaneous biliary drainage or preferably nasobiliary drainage with continuous suction. This procedure can at least produce temporary relief and occasionally fistula closure. A longer effect can be achieved with biliary stent placement. We describe what is, to our knowledge, the first case of diagnosis and successful treatment of non-traumatic bilhemia with endoscopic sphincterotomy and nasobiliary catheter placement.

Endoprótesis biliares: utilidad terapéutica en ictericia obstructiva / Biliary endoprothesis: its therapeutic usefulness in obstructive jaundice

Entre octubre de 1990 y diciembre de 1994, se valoraron 200 pacientes en quienes se colocó endoprótesis en la vía biliar. La distribución por sexo fue de 102 mujeres y 98 hombres, con rangos de edad entre los 18 y los 94 años. Las indicaciones para el procedimiento fueron: obstrucción biliar maligna en 96 casos, coledocolitiasis de difícil manejo en 47, estenosis iatrogénica de la vía biliar en 27, fístula biliar en 12, compresión de colédoco por pancreatitis crónica en nueve, por pancreatitis aguda en seis, colangitis supurativa en dos y un paciente con estenosis de la papila de Vater. Inmediatamente después de la colocación de las prótesis se observó drenaje adecuado de bilis al duoneno. Como complicaciones, se presentaron cinco migraciones, 14 cuadros de obstrucción de las prótesis con colangitis subsecuente, una hemorragia secundaria a esfinterotomía y una prancreatitis grave con defunción. Se concluye que la colocación de endoprótesis es de gran utilidad para mantener permeable la vía biliar. Las pocas complicaciones en manos esperimentadas, su bajo costo y mínima morbimortalidad, la hacen el método de primera elección en los procesos obstructivos de la vía biliar.