Complete Duct Research Articles

Sa1316 Long Term Results of Endoscopic Radiologic Rendez-Vous After Complete Biliary Duct Section

Sa1316 Long Term Results of Endoscopic Radiologic Rendez-Vous After Complete Biliary Duct Section

Role of endoscopic papillary balloon dilation in patients with recurrent bile duct stones after endoscopic sphincterotomy

BackgroundEndoscopic sphincterotomy (ES) is an established treatment for patients with choledocholithiasis or common bile duct stones (CBDS), but further management of patients after ES with recurrent CBDS remains controversial. Endoscopic papillary large balloon dilation (EPLBD) has been used safely and effectively for stone removal in patients after ES with recurrent CBDS. The aim of this study was to evaluate the clinical efficacy of EPLBD in patients after complete ES with recurrent CBDS. MethodsRecords of 891 patients with CBDS after complete ES from January 1991 to December 2008 were reviewed. Of 133 patients with recurrent CBDS, 122 had complete endoscopic bile duct clearance. Twenty-three patients (Group 1) underwent EPLBD and 99 (Group 2) underwent stone extraction without dilatation. Basic demographics and endoscopic findings at the first recurrence were recorded and analyzed. The primary end point was the second CBDS recurrence. ResultsNo statistical differences were observed between the two groups, except for larger CBDS size in Group 1. The bile duct clearance rate was 96% in Group 1 and 91% in Group 2. No complications such as pancreatitis, perforation, and bleeding were noted in Group 1, and one patient in Group 2 suffered from bleeding after stone extraction. The rate of second recurrent CBDS after endoscopic clearance for the first recurrent CBDS was 17% in Group 1 and 60% in Group 2 (p < 0.001). There were two independent factors for the second recurrence, including cirrhosis (odds ratio 4.734, p = 0.023) and stone extraction directly without major papilla expansion (odds ratio 6.050, p = 0.003). ConclusionEPLBD is a safe and effective endoscopic treatment for recurrent CBDS in patients after ES. It can also facilitate complete clearance of CBDS and prevent further CBDS recurrence.

Surgical reconstruction and endoscopic pancreatic stent for traumatic pancreatic duct disruption

Nonoperative management is acceptable treatment for minor pancreatic injuries. However, management of major pancreatic duct injury in children remains controversial. We present our experience in treating isolated pancreatic duct injury. We describe the cases of three male patients treated for complete pancreatic duct disruption in the past 5 years at our institution. We performed pancreatic duct repair to avoid distal pancreatectomy and to maintain normal pancreatic function. All patients underwent enhanced computed tomography and endoscopic retrograde cholangiopancreatography in the early period. The injuries were classified as grade III according to the American Association for the Surgery of Trauma classification. In two cases, we performed end-to-end anastomosis of the pancreatic duct during the delayed period. In the third case, we placed a stent across the disruption to the distal pancreatic duct. The patients' postoperative courses were uneventful, and the average hospitalization was 25.6 days after the procedure. At a median follow-up of 36 months (range 14-54 months), all patients remain asymptomatic, with normal pancreatic function, but with persistent distal pancreatic duct dilatation. We suggest that distal pancreatectomy should not be routinely performed in patients with isolated pancreatic duct injury.

Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones: a meta-analysis.

To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm). PubMed, Web of Knowledge, EBSCO, the Cochrane Library, and EMBASE were searched for eligible studies. Randomized controlled trials (RCTs) that compared EPLBD with EST were identified. Data extraction and quality assessment were performed by two independent reviewers using the same criteria. Any disagreement was discussed with a third reviewer until a final consensus was reached. Pooled outcomes of complete bile duct stone clearance, stone clearance in one session, requirement for mechanical lithotripsy, and overall complication rate were determined using relative risk and 95%CI. The separate post-endoscopic retrograde cholangiopancreatography complications were pooled and determined with the Peto odds ratio and 95%CI because of the small number of events. Heterogeneity was evaluated with the chi-squared test with P ≤ 0.1 and I(2) with a cutoff of ≥ 50%. A fixed effects model was used primarily. A random effects model was applied when significant heterogeneity was detected. Sensitivity analysis was applied to explore the potential bias. Five randomized controlled trials with 621 participants were included. EPLBD compared with EST had similar outcomes with regard to complete stone removal rate (93.7% vs 92.5%, P = 0.54) and complete duct clearance in one session (82.2% vs 77.7%, P = 0.17). Mechanical lithotripsy was performed less in EPLBD in the retrieval of whole stones (15.5% vs 25.2%, P = 0.003), as well as in the stratified subgroup of stones larger than 15 mm (24.2% vs 40%, P = 0.001). There was no statistically significant difference in the incidence of overall adverse events (7.9% vs 10.7%, P = 0.25), post-ERCP pancreatitis (4.0% vs 5.0%, P = 0.54), hemorrhage (1.7% vs 2.8%, P = 0.32), perforation (0.3% vs 0.9%, P = 0.35) or acute cholangitis (1.3% vs 1.3%, P = 0.92). EPLBD could be advocated as an alternative to EST in the retrieval of large common bile duct stones.

Postoperative Outcomes of Elective Pancreatic Surgery in a Low-Volume Academic Surgical Clinic

Summary According to the volume-outcome concept the postoperative outcome after major pancreatic surgery in high-volume institutions compares favorably to low- volume centers. However, it is not clear whether this is applicable to all low-volume institutions nowadays. The aim of the study was to evaluate the postoperative outcome after major elective pancreatic surgery in a low- volume academic surgical clinic. All consecutive elective major pancreatic cases operated within a 10-year period till October 2013 have been retrospectively reviewed. During the studied period, 36 patients (15 females, 21 males, mean age 54 years, age range 37-76) were scheduled for elective pancreatic surgery and underwent pancreatic resection (n=31, 18 proximal and 13 distal pancreatic resections) or complete pancreatic duct drainage procedure (n=5). Eleven patients had chronic pancreatitis and 25 patients had malignant or benign tumors. Vascular or adjacent organ resection was performed in 9 patients (29% of resections). The overall postoperative morbidity was 36% (n=13), and complications requiring re-operation occurred in 5 patients (14%). The median postoperative hospital stay was 11 days for patients without complications vs. 25 days for patients with any complication. There was no 60- day postoperative mortality or hospital readmission. Major elective pancreatic surgery can be safely performed today in a low-volume academic general surgical clinic, with postoperative outcomes similar to those reported by high-volume centers.

Surgeon-performed ultrasound and transfacial sialoendoscopy for complete parotid duct stenosis

A 57-year-old man presented with a 16-month history of right parotid swelling since undergoing a transoral sialolithotomy of the parotid duct. An ultrasound and a computed tomography scan showed a 6 cm-long dilated parotid duct without evidence of sialolithiasis or tumor mass. The complete Stensen's duct stenosis that was found was managed by a surgeon-performed ultrasound-guided transfacial needle catheterization of the dilated parotid duct, anterograde sialoendoscopy, recanalization of the duct, and stent placement. At 15 month follow-up, the patient reported no recurrent facial swelling or discomfort. Surgeon-performed ultrasound, combined with sialoendoscopy, can provide unique advantages for managing parotid duct stenosis and obstructive sialadenitis.

Endoscopic Ultrasound Examination of the Papilla and the Biliary System

Examination of the papilla of Vater and biliary system is feasible using radial or longitudinal scanning echoendoscopes, respectively. The complete extrahepatic bile duct may be followed from the papilla to liver hilum. Additionally, the gallbladder and intrahepatic biliary tree of the left liver can be visualized. Altered anatomy and juxtapapillary duodenal diverticulum may impede the evaluation of the papilla and distal common bile duct. Benign stenosis or adenomyomatous hyperplasia of the papilla are conditions occurring predominantly in older patients with a history of gallbladder stones. EUS is the procedure of choice in the evaluation of a dilated common bile duct or in suspected biliary pathology when transabdominal ultrasound fails. This article is part of an expert video encyclopedia.

Su1412 The Use of Intraductal Ultrasound for Non Fluoroscopic Bile Duct Clearance in Pregnancy: a Case Series

Biliary disease during pregnancy poses a unique challenge to gastroenterologists because conventional imaging and endoscopic therapies can expose the fetus to possible teratogenic radiation. We describe a method of complete endoscopic bile duct clearance without the use of fluoroscopy.

Hybrid Method of Transurethral Resection of Ejaculatory Ducts Using Holmium:Yttriumaluminium Garnet Laser on Complete Ejaculatory Duct Obstruction

A 32-year old single man presented with azoospermia and low semen volume which was noted one and half a year ago. Transrectal ultrasonography and seminal vesiculography were performed to evaluate ejaculatory duct obstruction, and transurethral resection of the ejaculatory duct was performed using a hybrid technique of holmium:yttriumaluminium garnet laser with monopolar transurethral resection to overcome the narrow prostatic urethra. To our knowledge, this is the first report on the successful outcome of a hybrid technique applied for transurethral resection of the ejaculatory duct.

Short- and long-term outcomes of endoscopic papillary large balloon dilation with or without sphincterotomy for removal of large bile duct stones

Objective. Removal of large bile duct stones by endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been proven safe and effective. Little evidence supports the benefits of a preceding EST in reducing complications. Recent studies suggest that large bile duct stone removal by EPLBD alone may be safe and effective. Material and methods. We removed large bile duct stones by EPLBD with EST from March 2008 to February 2010 and without EST from March 2010 to October 2011. Efficacy and safety of EPLBD with or without EST and late biliary complication outcomes were assessed. Results. Forty-two patients (men/women, 27/15; mean age, 76 years) underwent EPLBD: 14 underwent EPLBD with EST and 28 underwent EPLBD without EST. The mean stone size was 14 mm (9–30 mm). Overall complete stone removal rate was 98%, with 83% achieved in 1 session. Complete duct clearance by EPLBD alone was achieved in 79%. Mechanical lithotripsy was required in 4 (10%) patients. Extracorporeal shock wave lithotripsy and electrohydraulic lithotripsy were required in 4 (10%) and 1 (2%) patients, respectively. Pancreatitis and perforation occurred in 2 (5%) and 1 (2%) patients, respectively. Patients treated by EPLBD with EST and by EPLBD alone did not differ in complication outcomes. Six (14%) patients had recurrent bile duct stones, with a significant correlation to dilated common bile duct (p = 0.0351). Conclusions.EPLBD is safe and effective in patients with large bile duct stones. Preceding EST may be unnecessary.

Pediatric cardiology Less invasive percutaneous closure of persistent arterial duct in children below 10 kilos

IntroductionThere is quite high risk of vascular complications connected with arterial puncture – mainly in the group of the smallest patients weighing less than 10 kg.AimTo evaluate a new method of percutaneous closure of persistent arterial duct (PDA) in small children.Material and methodsSix patients were enrolled in this method of PDA closure at the age of 10.67 ±1.97 months. The mean weight was 8.85 ±0.66 kg. The occluders were implanted using only venous access. The position of the occluder was determined by angiography in the pulmonary artery through the delivery system and by echocardiography.ResultsThe procedure was effective in all six cases but we managed to proceed in the planned transvenous method in five cases. There was one case of complete duct constriction after introduction of the catheter, so precise measurements were impossible. After removal of the catheter the constriction remitted completely. The duct was closed in the standard manner. During echocardiographic examination we found complete closure of all six arterial ducts directly after the procedures and in the follow-up (9.17 ±3.02 months). No stenosis within the pulmonary arteries or aorta were found.ConclusionsTranscatheter arterial duct occlusion without arterial puncture is an effective and safe method of treatment allowing one to reduce the complications connected with arterial puncture. A possible complication of this method may be a constriction of the duct walls as a result of a larger amount of manipulations.

Management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit

To describe the aetiology and management of the symptom epiphora presenting to a specialist ophthalmic service. A retrospective case series and patient postal questionnaire of all new referrals seen in a specialist unit with primary symptoms of epiphora between January 2007 and December 2008. The study was begun in 2010 to allow a 2-year follow-up for this cohort. Two hundred thirty-seven patients were identified, of which 192 met the inclusion criteria. Fifty-seven were male, 135 were female, with a mean age of 60.7 (range 0-95) years. Patients were identified using a key word search of clinic letters and a search of primary care coding. Duration of symptoms, referral source, aetiology and subjective improvement of symptoms post treatment. At consultation, patients had experienced epiphora for a mean of 41.1 (range 0.066-360) months. A diagnosis of partial or complete nasolacrimal duct obstruction (31.8%), dry eye with secondary reflex tearing (29.2%), eyelid malposition (10.4%) and multi-factorial epiphora (28.7%) was made after follow-up and treatment. A postal questionnaire follow-up showed that 25% of patients no longer had any epiphora, with 67% reporting an improvement in their symptoms. Final follow-up was 30-54 months. This study highlights the protean aetiology of the symptom and sign, epiphora. Sparse data exist on the audited success in managing this common symptom and sign. This study helps introduce an example of a benchmark for evaluating the effectiveness of epiphora. The majority of patients were referred, usually by ophthalmologists for lacrimal surgery.

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)

An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality. To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS. A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs. Tertiary-care pancreatic referral center. Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN. Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods. EPF resolution and morbidity. Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths. Small, selected group of patients without a comparative group. The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.

Sp813 Pancreatic Necrosis Treated With Direct Endoscopic Debridement by Transpapillary Approach

The patient is a 33 year-old male with a recent history of severe alcohol-induced acute necrotizing pancreatitis who was transferred with dyspnea and abdominal pain. Chest x-ray showed a high amylase right-sided pleural effusion suggesting a pancreatico-pleural fistula. Adbominal CT showed multiple pancreatic fluid collections in addition to changes of severe necrotizing pancreatitis, with total loss of parenchyma in the head. Initial ERCP confirms a complete pancreatic duct disruption, and a pancreatic duct stent is placed. The patient does not improve, and he is scheduled for repeat ERCP.

Improvement of surgical treatment of intraoperative injuries of magistral bile ducts

Results of surgical treatment of 103 patients with intraoperative magistral bile ducts injuries were observed. Roux-enY hepaticojejunostomy was the main operati on in complete extrahepatic bile ducts (EHBD) transaction and excision; it was performed in 64 patients with following good remote results (95.3%). Restorative operation was indicated only in partial injury of the duct. Formation of bile-biliary anastomosis (BBA) in complete transaction of the duct in all cases resulted in stricture. Hepaticoduodenostomy also led to negative treatment results. Complications in the near postoperative period made 22.3% and in the remote one -35.9%. Repeated operative interven tions were performed in 32.3% of patients, lethal outcome made 5.8%.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

Background/AimsEndoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.MethodsBetween March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.ResultsSuccessful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.ConclusionsWithout preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.

Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos)

Scant data exist on the utility of the holmium:yttrium-aluminum-garnet laser for the treatment of biliary or pancreatic duct stones. To evaluate the efficacy and safety of fiberoptic probe and catheter system-guided holmium laser lithotripsy of difficult biliary and pancreatic duct stones. Prospective study. Tertiary-care referral center. This study involved 64 patients who underwent holmium laser stone fragmentation. A total of 64 patients (60 bile duct stones, 4 pancreatic duct stones) underwent endoscopic retrograde stone fragmentation with a holmium laser and a fiberoptic probe and catheter system. The inclusion criterion for bile duct stones was stones not amenable to retrieval by mechanical lithotripsy and/or balloon sphincteroplasty or standard techniques. Pancreatic duct stones included in this study were not amenable to removal by stone retrieval basket or balloon. Rates of ductal clearance and procedural complications. All 64 patients had successful fragmentation of biliary and pancreatic duct stones with the holmium laser. Fifty of 60 patients (83.3%) had complete biliary duct clearance after a single session; 10 patients required an additional session. All pancreatic duct stones were fragmented in a single session. Mean duration of ERCP sessions was 45.9 minutes (range 30-90 minutes). Complications were mild and were encountered in 13.5% of patients; fever (n = 3), transient abdominal pain (n = 4), and biliary stricture (n = 1). No comparative treatment group. The fiberoptic probe and catheter system facilitates transpapillary access for holmium laser fragmentation of difficult biliary and pancreatic duct stones. The technique is safe and highly effective for single-setting duct clearance. Complications are minimal and transient.

Cholestase

Cholestasis is a condition where too little bile gets to the duodenum. This delayed or stagnating bile flow may be caused by disturbances in bile formation, bile secretion or blocked bile drainage. The defect can be localised on different levels, from basolateral hepatocyte membrane to complete biliary duct to major duodenal papilla. Clinical signs of cholestasis include increased blood concentrations of bile acids as well as of certain enzymes typical in cholestasis, impacts on the intestine caused by less or lacking bile, and effects of bile stasis on the liver tissue. Typical symptoms include pruritus, jaundice as well as pale stool and dark urine. Sonography, CT, MRCP, ERCP, percutaneous transhepatic cholangiography (PTC) and liver biopsy are of outstanding importance for diagnosis and differential diagnosis.

Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos)

Complex biliary stones often require temporary stent placement before a repeat attempt at extraction. To date, covered self-expandable metal stents (CSEMSs) have not been formally investigated for this indication. To evaluate the efficacy and safety of CSEMSs in patients with retained complex biliary stones. Retrospective case series. Large quaternary-care center. Thirty-six patients (24 women) with complex biliary stones with incomplete stone clearance after endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy. Patients with incomplete stone clearance after ERC with biliary sphincterotomy underwent temporary placement of CSEMSs, with subsequent removal before repeat stone extraction. Success achieving immediate biliary drainage and eventual complete duct clearance. Procedure-related complications were also assessed. CSEMS placement was successful in establishing immediate biliary drainage in all 36 patients. Complete duct clearance at repeat ERC was achieved in 29 of 35 patients after a mean duration of 6.4 weeks. Four of the remaining 6 patients underwent sequential CSEMS placement, with eventual duct clearance after multiple ERCPs. There were no complications related to biliary obstruction. One patient died of a nonbiliary cause. Of the total 42 CSEMSs placed, there were 4 cases (9.5%) of clinically insignificant stent migration. Single-center experience, retrospective design. CSEMSs permit management of complex biliary stones, but require multiple sessions. The cost-effectiveness of this technique needs further investigation.

Use of udenafil is not associated with a reduction in post-ERCP pancreatitis: results of a randomized, placebo-controlled, multicenter trial

Udenafil, a phosphodiesterase-5 inhibitor, may decrease sphincter of Oddi tone and allow efficient cannulation. To determine whether prophylactic udenafil reduces the rates of occurrence of post-ERCP pancreatitis. Prospective, randomized, double-blind, placebo-controlled, multicenter study. Three academic medical centers. From November 2008 to November 2010, a total of 278 patients who underwent ERCP were analyzed. ERCP. Rate of post-ERCP pancreatitis. Demographic features, indications for ERCP, and therapeutic procedures were similar in each group. The overall rate of pancreatitis was 7.9% (22/278). There was no significant difference in the rate (8.0% [11/137] vs 7.8% [11/141], P = .944) and severity of post-ERCP pancreatitis between the udenafil and placebo groups. Severe pancreatitis developed in 1 patient in the placebo group. On both univariate and multivariate analyses, age 40 years or younger, suspected sphincter of Oddi dysfunction, complete pancreatic duct opacification, and failed cannulation were associated with post-ERCP pancreatitis. Only mild udenafil-related complications occurred, including flushing (n = 3) and headache (n = 3). Unselected patient group, overestimation of the rate of pancreatitis in the placebo group. Udenafil was not effective for prevention of post-ERCP pancreatitis in this study. ( KCT0000021.).